MaMoni Health Systems Strengthening Activity USAID Cooperative Agreement AID-388-LA-13-00004 Quarterly Report October 01, 2017– December 31, 2017
Submitted
February 07, 2018
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 1 Cover Photo Story: Paramedic Kirtonia recognized for her work
The Union Health and Family Welfare Centre at Putijuri union in Bahubal Upazila, Habiganj was in bad shape when Smriti Kirtonia, a paramedic supported by the MaMoni HSS project, joined the facility in May 2016. The facility infrastructure was inadequate and there was little interest in the community to seek health services from the facility. Over the next year and a half, the situation improved considerably, thanks to the efforts of Kirtonia.
Kirtonia started conducting eight satellite sessions a month in her catchment area to provide maternal, newborn, child health, family planning and nutrition services and used the platform to encourage mothers to visit the health facility to access services. In the union follow-up meetings, she entreated health workers to keep contact with expectant mothers over the phone. Like many paramedics or FWVs, she did not limit her services to only the official timeline (8:30 am to 2:30 pm). Instead, she started living in the FWV quarter and would readily extend her services around the clock with a smile on her face, effectively making the facility a 24/7 service delivery point.
Very soon her reputation spread in the community and to villages even further out and mothers from the neighboring unions started coming to her. The service utilization in her facility started to soar - ANC visits rose from counts of about 30-40 to around 200, while the number of deliveries conducted at the facility increased from 3-5 per month to 18-20 per month.
Kirtonia’s skill and dedication - reflected in the ever-growing flow of health service seekers - earned her official recognition in December 2017. Amarillo Kibria Keya Chowdhury, a Member of the Parliament from Bahubal, handed over the best service provider award to Kirtonia. “If I can help people and serve them, that’s what I consider as my biggest achievement,” says Kirtonia upon her receipt of the award.
Photo credit: Md. Johirul Alam Sikder, Upazila Facilitator, Bahubal
This document is made possible by the generous support of the American people through the support of the Office of Population, Health, Nutrition and Education, United States Agency for International Development (USAID), Bangladesh (USAID/Bangladesh), under the terms of Associate Cooperative Agreement No. AID-388-LA-13-00004 through Maternal and Child Health Integrated Program (MCHIP). The contents of this document are the responsibility of the MCHIP Project and do not necessarily reflect the views of USAID or the United States government.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 2 TABLE OF CONTENTS
Abbreviations ...... 4 Executive summary ...... 7 Introduction ...... 10 Data Sources ...... 11 Program results of the year ...... 11 IR 1. Improve service readiness through critical gap management ...... 11 IR 2: Strengthen health systems at the district level and below ...... 36 IR 3. Promote an enabling environment to strengthen district level health systems ...... 58 IR 4. Identify and reduce barriers to accessing health services ...... 61 Challenges, Solutions and Action taken ...... 65 Appendix 1: Scope and Geographical coverage of MaMoni HSS program ...... 69 Appendix 2: Data Sources ...... 70 Appendix 3: Program Performance Indicators (Oct–Dec 2017) ...... 71 Appendix 4: Forums where MaMoni HSS lessons were disseminated ...... 82 Appendix 5: List of process documentation activities ...... 83
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 3 ABBREVIATIONS
5S Sort, Set, Shine, Standardize and Sustain AHI Assistant Health Inspector AMTSL Active Management of Third Stage of Labor ANC Antenatal Care APK Android Package Kit BCC Behavior Change Communication BIRDEM Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders BNF Bangladesh Neonatal Forum BPA Bangladesh Paediatric Association BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CBHC Community-based Health Care CC Community Clinic CCSDP Clinical Contraceptive Service Delivery Program CCU Coronary Care Unit CDCS Country Development Cooperation Strategy CEmONC Comprehensive Emergency Obstetric and Newborn Care CHCP Community Health Care Provider CHW Community Health Worker CHX Chlorhexidine cMPM Community Microplanning Meeting CNCP Comprehensive Newborn Care Package CS Civil Surgeon CSA Community Sales Agent CSBA Community-skilled Birth Attendant CSG Community Support Group CSI Clinical Severe Infection CV Community Volunteer DC District Commissioner DDFP Deputy Director- Family Planning DG Director General DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DH District Hospital DHIS-2 District Health Information System-2 DMCH Dhaka Medical College Hospital DQA Data Quality Assessment EDD Expected Date of Delivery eLMIS Electronic Logistics Management Information System eMIS Electronic Management Information System ENC Essential Newborn Care EPCMD Ending Preventable Child and Maternal Deaths FGD Focus Group Discussion FP Family Planning FPI Family Planning Inspector FSO Field Support Officer FTC Field Training Centre FWA Family Welfare Assistant FWV Family Welfare Visitor FWVTI Family Welfare Visitor Training Institute GMP Growth Monitoring and Promotion GOB Government of Bangladesh GPS Global Positioning System HA Health Assistant MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 4 HBB Helping Babies Breathe HI High Intensity HID Health Identity Document HNN Healthy Newborn Network HPNSP Health, Population and Nutrition Sector Program HR Human Resource HRD Human Resources and Development HRIS Human Resource Information System HSCS Health Systems Capacity Strengthening HSM Hospital Services Management Icddr,b International Centre for Diarrhoeal Disease Research, Bangladesh ICHW Improving Community Health Worker program performance through harmonization and community engagement to sustain effective coverage at scale ICU Intensive Care Unit ID Identity Document IDD Iodine Deficiency Disorder IFB Fast Breathing as a Single Sign of Illness IMCI Integrated Management of Childhood Illness IMCI-N Integrated Management of Childhood Illness-Nutrition IP Infection Prevention IPC Infection Prevention and Control IPD Inpatient Department IR Intermediate Result ISQua International Society for Quality in Health Care IUCD Intra Uterine Contraceptive Device JHU Johns Hopkins University JSV Joint Supervisory Visit KII Key Informant Interview KMC Kangaroo Mother Care KSH Khulna Shishu Hospital LARC Long-Acting Reversible Contraceptive LARC&PM Long-Acting Reversible Contraceptive and Permanent Method M&E Monitoring and Evaluation MAM Moderate Acute Malnutrition MCHTI Maternal and Child Health Training Institute MCRAH Maternal, Child, Reproductive and Adolescent Health MCWC Maternal and Child Welfare Center MEC Medical Eligibility Criteria MFSTC Mohammadpur Fertility Services and Training Centre MgSO4 Magnesium Sulfate MIS Management Information System MNCH/FP/N Maternal, Newborn and Child Health, Family Planning, and Nutrition MO Medical Officer MOHFW Ministry of Health and Family Welfare MO-MCH/FP Medical Officer-Maternal, Child Health and Family Planning MP Member of Parliament MPDSR Maternal and Perinatal Death Surveillance and Response MSH Management Sciences for Health NGO Nongovernmental Organization NIPORT National Institute of Population Research and Training NIPSOM National Institute of Preventive and Social Medicine NNHP National Newborn Health Program NNS National Nutrition Services NHSDP NGO Health Service Delivery Project NSU Newborn Stabilization Unit OBGYN Obstetrics and Gynecology OGSB Obstetrical and Gynecological Society of Bangladesh MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 5 OP Operational Plan OPD Outpatient Department OPHNE Office of Population, Health, Nutrition, and Education ORT Oral Rehydration Therapy OT Operation Theatre pCSBA Private Community-Skilled Birth Attendant PDCA Plan-Do-Check-Act PE/E Pre-eclampsia/Eclampsia PHC Primary Health Care PHD Partners in Health and Development PM Program Manager PPFP Postpartum Family Planning PPH Postpartum Hemorrhage PPIUCD Postpartum Intra-Uterine Contraceptive Device PSBI Possible Severe Bacterial Infection QI Quality Improvement QIC Quality Improvement Committee QIS Quality Improvement Secretariat QoC Quality of Care QPRM Quarterly Performance Review Meeting RD Rural Dispensary RMNCAH Reproductive, Maternal, Newborn, Child and Adolescent Health RMO Resident Medical Officer RRQIT Regional Roaming Quality Improvement Team RTC Regional Training Center SACMO Sub-Assistant Community Medical Officer SAM Severe Acute Malnutrition SBA Skilled Birth Attendant SBCC Social and Behavioral Change Communication SBM-R Standards-Based Management and Recognition SCANU Special Care Newborn Unit SCI Save the Children International SCMP Supply Chain Management Portal SDG Sustainable Development Goal SDP Service Delivery Point ShSMCH Shaheed Suhrawardy Medical College Hospital SIAPS Systems for Improved Access to Pharmaceuticals and Services SIP Sector Improvement Plan SMC Social Marketing Company SNL Saving Newborn Lives SOP Standard Operating Procedure SSMCH Sir Salimullah Medical College Hospital ToT Training of Trainers UFPO Upazila Family Planning Officer UH&FPO Upazila Health and Family Planning Officer UH&FWC Union Health and Family Welfare Center UHC Upazila Health Complex UK United Kingdom UN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UP Union Parishad USAID United States Agency for International Development USC Union Sub-Center WHO World Health Organization WISN Workload Indictors of Staffing Need WIT Work Improvement Team MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 6 EXECUTIVE SUMMARY
During the reporting period, the MaMoni Health Systems Strengthening (MaMoni HSS) project continued to partner with the Ministry of Health and Family Welfare (MOHFW) to strengthen health systems at the national and district levels. Previously, in Year Four, the program’s technical assistance at the national level and implementation at the district level were under consolidation; following this adjustment, the project currently supports 40 upazilas in 6 districts, 23 of which are designated as high intensity (HI) areas and 17 of which are health systems capacity strengthening (HSCS) areas. At the district level, MaMoni HSS continued to support the scale-up of priority interventions to prevent child and maternal deaths and improve the quality of facility-based care.
Key accomplishments
Key accomplishments for this reporting period are as follows:
• There is an increasing trend in all maternal health indicators on service utilization including antenatal care (ANC), skilled birth attendance and deliveries through private community skilled birth attendants (SBA).
• The revisit of implementation for priority newborn interventions (helping babies breathe (HBB), and essential newborn care (ENC)) has been completed in 64 districts. Through the process, a nationwide quick assessment of preparedness for newborn interventions with respect to human resources, skills retention, facility readiness, and medicine and supply stocks is now available. The findings from the revisit assessment will be ready in Q2.
• A day-long Kangaroo Mother Care (KMC) Community of Practice meeting was held under the leadership of the MOHFW. The objectives of the meeting were to provide an update on the status of KMC introduction and scale up in Bangladesh, share implementation experiences, challenges and opportunities for KMC practice, explore national and local models of best practices to inspire and increase motivation, to utilize a unique platform at the national level to mobilize KMC under the National Newborn Health Program (NNHP) and build consensus for KMC within the newborn health community in Bangladesh. The meeting came up with some recommendations for the successful implementation of KMC in facilities and it was decided that the NNHP will follow up with key recommendations from the meeting.
• Two-day Client Fairs were organized in all MaMoni intervention districts under direct guidance from the Clinical Contraceptive Service Delivery Program (CCSDP), Directorate General of Family Planning (DGFP). The ‘Client Fair-2017’ was a big push for building awareness, creating demand, and increasing performance as well as disseminating proper messages on long acting reversible contraceptives and permanent methods (LARC & PM). The Fair also created enthusiasm among the FP field staff and the community which will be a positive contribution towards utilization and clear understanding of FP methods.
• During the reporting quarter, the focus was to facilitate the initiation of Human Resource Information System (HRIS) implementation at DGFP where more than MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 7 fifty five thousand staff are working in more than five thousand service delivery facilities throughout the country. MaMoni HSS supported capacity building through providing Training of Trainers (ToT) to relevant central level DGFP staff who will subsequently provide training to the relevant district and upazila level DGFP staff on HRIS.
• Three Paramedics have been deployed by the local government (Union Parishads) to fill-in the positions that were supported by MaMoni HSS to fill-in critical human resource gaps.
• An assessment on capacity of NIPORT and its Regional Training Centers (RTCs) was conducted through a structured questionnaire. A short term technical expert from, India assisted the process. The report is being finalized in consultation with NIPORT and will be available in Q2.
Challenges and mitigation strategies . PE/E case detection: Though the number of total cases increased due to increased number of intervention areas, the PE/E case detection is quite far from the estimated number and only 10% of the reported cases were identified and provided with a loading dose of MgSO4 at UH&FWCs. The project is working with the local level health managers and service providers to create awareness among pregnant mothers and their families on the signs and consequences of severe PE/E and the importance of ANC during pregnancy. . Misoprostol distribution: Despite multipronged efforts of the project, misoprostol distribution coverage is still low in the project areas - only 54 percent of the pregnant women received misoprostol in the reporting quarter. The main reasons are vacant FWA positions, inadequate home visits, lack of a need-based distribution system and occasional stock outs. The project has taken several initiatives and will explore other strategies to address the issue. . Lack of coordination between QIS and implementing wings of DGHS and DGFP: Lack of coordination between the Quality Improvement Secretariat and Hospital Services Management (HSM) unit of DGHS and service delivery units of DGFP has remained a constant challenge for the implementation of QoC in Bangladesh. MaMoni HSS has initiated working with HSM and will involve HSM/DGHS and MCRAH/DGFP in QIS activities. . Continuity of services provided by paramedics: MaMoni HSS has been filling HR gaps through recruitment of paramedics, but as the project is nearing its end, dialogue with local health & FP managers, as well as with the local government, has been initiated for absorbing these staff. So far, three paramedics have been taken over by the Union Parishad. The district teams are working hard to engage more UPs and motivate them to take over the responsibility of deploying service providers (paramedics) to the UH&FWCs in their respective union centers. . Shortage of manpower in NIPORT: A shortage of NIPORT faculty members has presented itself as a challenge for conducting trainings. However, a pool of national
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 8 trainers are being identified through both government and non-government sectors. NIPORT is developing the capacity of the pool and will prepare selected candidates.
Way Forward During the 2nd quarter of Y-5, the project will initiate close-out activities in all districts and focus primarily on national activities. Continuation of MaMoni interventions through government systems will be facilitated at all levels and documentation of lessons learned and dissemination of results will be completed in a systemic manner. Some of the major focus areas are as follows: . The last round of the tracer survey will be conducted. This survey will serve as an end line assessment for the MaMoni HSS project. . The implementation of the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) QI framework by adapting WHO guidelines for pilot implementation in Narshingdi district hospitals - two UHCs and MCWCs. The expected duration of the pilot is one and a half years, which will begin in January 2018. . Bangladesh and Ethiopia are the two leading countries implementing outpatient treatment for possible severe bacterial infections (PSBI) in newborns and young infants. To deepen the cross-program learning on community based PSBI implementation, scale up, and sustainability and to put it in a long-term context, a global initiative has been undertaken and MaMoni HSS is a part of this global initiative. The aim of this initiative is to contribute information on the implementation of country-led transformation of newborn health within child health and other health systems. A consultant has been hired for this purpose. . MaMoni HSS is supporting the development of SCANU in MFSTC, MCHTI and two hospitals under DGFP. Gradually, these locations will also be equipped to provide Comprehensive Newborn Care Package (CNCP) training. Additionally, a SCANU will be developed in Khulna Shishu Hospital, located in the southwest corner of Bangladesh and far away from the city of Dhaka. . A “National Assessment of Facility Based Sick Newborn Care” will be conducted in collaboration with UNICEF. It is expected that this assessment will inform and guide policymakers regarding best practices and bottlenecks for improving facility-based sick newborn care. . Dhaka Medical College Hospital and Sir Salimullah Medical College Hospital will be developed as centers of excellence for providing CNCP trainings. . Revisit priority newborn interventions completed in 64 districts. Data is being compiled and a report will be published and disseminated in the next quarter. . MaMoni HSS district staff will continue coordinating with the local government (mainly UP) to deploy paramedics to fill in critical HR gaps. Three paramedics have been deployed so far. . As part of the DGFP operational plan, eMIS will be rolled out in five districts this year. In collaboration with MEASURE Evaluation, eMIS in Noakhali and Natore will also be initiated in next quarter.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 9 . MaMoni HSS is supporting QIS to develop an infection prevention manual, patient safety strategic plan and patient centered communication strategy. These documents will be finalized through stakeholder consultation. . MaMoni HSS initiated a process of supporting the Hospital Services Management (HSM) unit of DGHS to draft an act for hospital accreditation. A national consultant has been hired and a legal consultant and two international consultants will be recruited in next quarter. . In collaboration with WHO Bangladesh, the project will support the HSM unit of DGHS to develop a referral care guideline - a key activity in the operational plan. . NIPORT: Leadership and management training will be initiated. This will start with a first line supervisor’s training on supervision, and monitoring and follow up will be developed from there. Additionally, a training management system and an asset management system will be digitalized and a group of training quality monitors will be developed.
INTRODUCTION The MaMoni Health Systems Strengthening project, is a five-year USAID-funded award1 aimed at improving utilization of integrated maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) services in Bangladesh. The project’s objective is to increase availability and quality of high-impact interventions through strengthening district-level local management and health systems. This objective is well-aligned with the Government of Bangladesh’s (GOB) Health, Population, and Nutrition Sector Program (HPNSP) 2017-2022 and its Sector Improvement Plan (SIP) 2016-2021. MaMoni HSS provides support and assistance to the Ministry of Health and Family Welfare (MOHFW) at national and district levels, and directly supports the “USAID/Bangladesh- Health Status Improved” Activity under the Investing in People Objective, Health Project Area of the U.S. Foreign Assistance Framework. The four Intermediate Results (IR) of the project are to: • Improve service readiness through critical gap management • Strengthen health systems at the district level and below • Promote an enabling environment to strengthen district-level health systems • Identify and address barriers to accessing health services The project has expanded the technical assistance role at the national level, while consolidating the implementation at the district level. The project supports 40 upazilas in six districts, 23 of which are designated high intensity (HI) areas, and the remaining 17 of which are designated health systems capacity strengthening (HSCS) areas. The scope and geographical coverage of the MaMoni HSS project has been summarized in Table 1. Detailed coverage has been included in Appendix 1. Table 1: Summary of the geographic scope of MaMoni HSS
1MaMoni HSS is implemented through an Associate Award under the Maternal and Child Health Integrated Program, which is led by Jhpiego, with a period of performance from September 24, 2013 to September 23, 2018. MaMoni HSS is led by Save the Children in Bangladesh, in partnership with Jhpiego, John Snow, Inc., and The Johns Hopkins University Institute for International Programs—with national partners: International Centre for Diarrhoeal Disease Research, Bangladesh; Dnet; and Bangabandhu Sheikh Mujib Medical University (BSMMU). MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 10 Number Population Number of Health Facilities Area Number of (2017 of UH&FWC/ Upazilas Projection) DH MCWC UHC CC Unions USC High Intensity 23 (Habiganj-8, 226 6,662,456 4 7 20 213 619 Areas (HI) Noakhali-4, Lakshmipur-5, Jhalokathi-4, Pirojpur-2) Health Systems 17 (Bhola-7, 151 4,870,933 2 5 14 126 488 Capacity Noakhali-5, Strengthening Pirojpur-5) (HSCS) Areas
Total 40 377 10,718,274 6 12 34 339 1,107
DATA SOURCES This report uses data from various sources, including: sentinel surveys in selected facilities in MaMoni HSS districts; Service Delivery Point (SDP) assessments in selected facilities2; re-visitation of specific newborn interventions in 14 districts; and routine Management Information System (MIS) from the Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP). The complete list and scope of the surveys are attached as Appendix 2.
Program results of the year
IR 1. Improve service readiness through critical gap management 1.1 Increase availability of health service providers 1.1.1 Management of critical human resource gaps of GOB service
providers
MaMoni HSS only recruits technical positions such as paramedics, nurses, and doctors in hard to reach and strategically located areas. For field-based positions, such as Family Welfare Assistants (FWAs), the project will negotiate with the government to post newly recruited volunteers in project areas. In year five, MaMoni HSS continued support by providing 12 Community Health Workers (CHWs) as substitutes for FWAs, 50 paramedics, 21 nurses, and one obstetrics and gynecology (OBGYN) consultant for managing the critical human resource gaps of GOB service providers. Of the 50 paramedics, 22 are to fill-in Family Welfare Visitors (FWV) vacancies in hard to reach and strategically located union facilities and the remaining paramedics will be deployed depending on patient flow and overload. Community health workers in Habiganj were appointed in vacant positions of FWAs. Considering patient loads for round the clock delivery service, as well as for newborn care, especially at the Special Care Newborn Unit (SCANU), nurses were placed in Habiganj and Lakshmipur District Hospitals. The OBGYN consultant was posted in Hatiya as before.
The MaMoni district team is continuing its advocacy with the local government, parliamentarians and local level stakeholders to determine a longer-term solution of
2 DH, MCWC, UHC, UH&FWC and USC in 21 high intensity areas in 4 districts (Habiganj, Noakhali, Lakshmipur and Jhalokathi)
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 11 filling vacancies after the project is phased out. In Q1Y5, UP has already deployed one paramedic in Lakshmipur and two paramedics in Noakhali. Current gap management staff status is shown in Table 2.
Table 2 Critical human resource gaps filled-in by MaMoni HSS
District FWA FWV/Paramedics Nurses OBGYN Consultant
Posts
Vacant Vacancy filled up by GOB Vacancy filled up by (CHW) MaMoni Vacant Posts Vacancy filled up by GOB Vacancy filled up by (Paramedic) MaMoni Vacant Posts Vacancy filled up by GOB Vacancy filled up by (Nurse) MaMoni Vacant Posts Vacancy filled up by GOB Vacancy filled up by MaMoni
Habiganj 99 0 12 27 0 11 80 0 13 2 1 0 Jhalokathi 81 0 0 7 0 1 8 0 0 0 0 0 Noakhali 167 0 0 19 0 6 102 0 0 4 2 1 Lakshmipur 112 0 0 17 0 4 62 0 0 2 0 0 Total 459 0 12 70 0 22 252 0 13 8 3 1
1.2 Strengthen capacity of service providers to provide quality services 1.2.1 Introduction and scale-up of MNCH/FP/N interventions 1.2.1. a. Maternal health The program’s major interventions in maternal health are pregnancy identification and registration through frontline health workers; the provision of at least four antenatal care (ANC) contacts with Quality of Care (QoC) from a trained provider; birth planning; promotion of, and increased availability and accessibility to quality skilled birth attendants, including active management of the third stage of labor (AMTSL); distribution of misoprostol for home-based deliveries; and ensuring four postnatal visits, including the promotion of post-partum family planning. There are also special interventions in selected areas, such as the management of severe pre-eclampsia and eclampsia through the administration of magnesium sulfate (MgSO4).
i. Antenatal care coverage Antenatal care (ANC) is the gateway intervention wherein a woman makes what might be the first contact in her life with a health facility or health care provider, as a result of her pregnancy. MaMoni HSS has taken a multipronged approach to address the shortage of service providers, to ensure satellite clinics, and to confirm the availability of equipment and provide logistical support for providers. Figure 1 shows upward trends in use of ANC from a medically trained provider in MaMoni HSS areas. During the reporting period, 34,325 pregnant women in HI areas received at least one ANC visit, which was 79 percent of the total number of estimated pregnant women in the area. During the same period, 14,938 pregnant women in HSCS areas received at least one ANC visit, which was 56 percent of the total number of estimated pregnant women in the area.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 12
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 13 Figure 1: Number of pregnant women who received at least one antenatal care visit from a medically trained provider in MaMoni High Intensity (HI) and Health Systems Capacity Strengthening (HSCS) areas
50000 45000 40000 35000 43672 30000 34781 25000 34325 31818 30608
Number 20000 15000 26586 10000 14938
5000 13807 13715 10894 0 Estimated Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 number of pregnant women
HI HSCS
Source: MIS-4, CSBA and EmOC report of DHIS-2, pCSBA report of project MIS
Coverage of four or more ANC visits also shows increasing trends (Figure 2). During the reporting period, 27,342 pregnant women in HI areas received four or more ANC visits, which was 63 percent of the total number of estimated pregnant women in the area. During the same period, 7,718 pregnant women in HSCS areas received four or more ANC visits, which was 29 percent of the total number of estimated pregnant women in the area. An increase in the number of satellite clinics was one of the major contributing factors for the increased coverage of ANC. 3,834 satellite clinics were organized in the first quarter of year-5, compared to 3,680 in the preceding quarter.
Figure 2: Number of women who received four or more antenatal care visits from a medically trained provider in MaMoni High Intensity (HI) and Health Systems Capacity Strengthening (HSCS) areas
50000 45000 40000 35000
30000 43672 25000 20000 Number 15000 27342 26634 26580 23685 10000 23368
5000 6054 5353 6052 7718 0 Estimated Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 number of pregnant women
HI HSCS
Source: MIS-4, CSBA and EmOC report of DHIS-2, pCSBA report of project MIS
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 14 ii. Severe pre-eclampsia/eclampsia (PE/E) management at union level facilities PE/E is the second leading cause of maternal death in Banglades and accounts for 24 percent of all maternal deaths (BMMS 2016 Preliminary Report). Magnesium sulfate
(MgSO4) injections are considered to be an appropriate, and potentially affordable, drug to prevent and manage severe PE/E. Since FY 2015, MaMoni HSS has been rolling out severe PE/E management interventions at 140 Union Health and Family Welfare Centers (UH&FWC) in 16 upazilas in four MaMoni HSS districts (Habiganj, Noakhali, Lakshmipur, and Jhalokati) in collaboration with Obstetrics and Gynecological Society of Bangladesh (OGSB). During the reporting period, the intervention has been extended to another 57 union level facilities in seven upazilas in Noakhali district. A ToT was held on PE/E case identification and management for Consultant-Gynae and Obs, Medical Officer (MO), Resident Medical Officer (RMO), Upazila Health and Family Planning Officer (UH&FPO), Medical Officer- Clinic (MO-Clinic), Medical Officer- Maternal, Child Health and Family Planning (MO- MCH/FP) from the Ministry of Health and Family Welfare (MOHFW) and Manager- Quality Improvement and Field Coordinator- Quality Assurance (FC-QA) from MaMoni HSS project working in Noakhali. Following the ToT, these trainers trained 89 service providers (FWV, female SACMO and paramedics) working at the UH&FWCs in seven upazilas (Begumganj, Chatkhil, Kabirhat, Sadar, Senbagh, Subarnachar, Sonaimuri) of Noakhali.
Photo: Practical session on PE/E case identification and management
Through DGFP’s routine MIS, MaMoni HSS tracks PE/E case identification and management. Figure 3 shows that the number of severe PE/E case identification and referral after administering the loading dose of injected MgSO4 from UH&FWCs is rising gradually. The number of intervention areas also increased in this quarter, which has contributed to the increase of PE/E case identification and management. However, the PE/E case detection is quite far from the estimated number3, as only 10% of the cases have been identified and managed from UH&FWCs. The project is working with local level health managers and service providers to increase awareness of the consequences of severe PE/E and importance of ANC during pregnancy among pregnant mothers and their families. The service providers were also informed about the importance of severe PE/E case detection and management. During visits, supervisors follow up with service
3 2.8% of live births
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 15 providers on whether counseling is provided to the pregnant mother about the danger signs of PE/E.
Figure 3: Number of pregnant women with severe PE/E that received pre-referral loading dose of injectable MgSO4 at UH&FWCs
1400 1163 1163 1163 1163 1200 1000 800 600 Number 400 95 113 200 72 68 0 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5
Number of PE/E cases identified and managed Estimated number of PE/E cases
Source: MIS-3, DGFP
iii. Misoprostol to prevent postpartum hemorrhage (PPH) for home births MaMoni HSS facilitated the distribution of misoprostol tablets to pregnant women in their third trimester in order to prevent postpartum hemorrhage (PPH) following home deliveries. There were noticeable increases in the distribution of misoprostol tablets to pregnant women in MaMoni HSS high intensity (HI) areas. Figure 4 shows that in quarter-1 year-5, 22,754 pregnant women in HI areas received misoprostol tablets, compared to 21,158 in the previous quarter. However, the misoprostol distribution coverage is still low, as only 52 percent of the estimated number of pregnant women received the tablets in HI areas.
Figure 4: Number of pregnant women who received misoprostol tablets
50000 45000 40000 35000 43672 30000 25000
Number 20000 15000 26586 22754 21158 20699 10000 20019 5000 7209 7895 8255 8722 0 Estimated Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 number of pregnant women
HI HSCS
Source: MIS-4, DGFP
Misoprostol tablets are distributed by FWAs during their routine household visits, as well as by the FWVs during ANC3 visits for pregnant women who did not get the tablets from
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 16 the FWAs. Some of the primary contributors to the low distribution coverage of misoprostol were:
• Vacancies of FWAs (34%) and FWVs (23%) positions in MaMoni HI districts • Inadequate home visits by FWAs • Lack of a need-based distribution system • Stock out of misoprostol tablets. The project has taken several initiatives to address these issues. These are: . Sharing the misoprostol distribution status with upazila mangers and subsequently reinforcing this status throughout quarterly performance review meetings at the district level . Working with the MOHFW to develop a need-based system of misoprostol distribution, including monitoring the stock and distribution status, as well as focusing on increasing the ANC3 coverage . Developing a pilot study in Lakshmipur district for the distribution of misoprostol and 7.1% CHX together in a zip lock bag both at the community and facility levels during the third trimester of pregnancy . Continuing advocacy at national level for new recruitment of FWAs and FWVs to fill vacant positions . Increasing the availability of misoprostol among community sales agents . Initiating discussions with local NGOs to explore the distribution of misoprostol through NGO community health workers iv. Deliveries assisted by skilled birth attendants (SBAs) SBA deliveries have been increasing gradually in MaMoni HSS areas. Figure 5 shows that 20,799 deliveries were assisted by SBAs in the reporting period in HI areas, which was 55 percent of the total number of estimated deliveries in the area. In the previous quarter, the number of SBA deliveries was 19,408 in the HI areas, which was 51 percent of the total number of estimated deliveries. The coverage was also higher in HI areas than HSCS areas (48%).
Figure 5: Number of SBA deliveries in MaMoni HSS districts
40000 35000 30000 37976 25000 20000
Number 15000 23118 20799
10000 19408 17968 17688 5000 13333 11001 10052 10992 0 Estimated Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5 number of live birth
HI area HSCS area
Source: DGFP MIS 2 & 4; CSBA and EmOC report of DHIS-2, pCSBA report of project MIS
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 17 The major contributing factors in increasing SBA deliveries include comprehensive social and behavior change communication (SBCC) with targeted groups focusing on SBA delivery, community gathering, quality improvement initiatives at district hospitals, and increasing the number of UH&FWCs (Figure 6) providing round the clock delivery services in project areas. There were also noticeable increases in the number of deliveries at the union level facilities (Figure 6). During the reporting quarter, the number of 24/7 UH&FWCs increased from 94 facilities to 103 facilities in four HI districts that conducted a total number of 5,317 deliveries (26 percent of total number of SBA deliveries in the HI areas). This shows that the average number of deliveries has increased from about 37 per facility to 52 per facility.
Figure 6: Trends in deliveries in 24/7 UH&FWCs in MaMoni HSS HI areas
110 103 100 94 90 81 81 80 75 75 70 65 65 60 50 52 46 45 42 42 44 40 37 39 30 20 10 0 Q2 Y-3 Q3 Y-3 Q4 Y-3 Q1 Y-4 Q2 Y-4 Q3 Y-4 Q4 Y-4 Q1 Y-5
Number of 24/7 UH&FWCs Average number of deliveries per facility
Source: MIS-3, DGFP
v. Private community skilled birth attendants (pCSBA) assisted deliveries MaMoni HSS continued supporting 69 private CSBAs in Habiganj, Noakhali and Lakshmipur districts through facilitating supplies and regular monitoring and supervision. Figure 7 shows an increasing trend in deliveries by pCSBAs.
Figure 7: Trends in deliveries by MaMoni HSS supported pCSBAs
400 7069 7069 7069 7185 7185 7185 7185 8000 357 7000 300 309 314 6000 276 288 246 5000 200 3243 3306 4000 147 158 3000 100 112 2000 1000 52 52 91 89 64 71 68 68 69 0 0 Y3-Q1 Y3-Q2 Y3-Q3 Y3-Q4 Y4-Q1 Y4-Q2 Y4-Q3 Y4-Q4 Y5-Q1
Number of pCSBA Number of deliveries by pCSBAs Estimated number of delivery
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 18 Source: Project MIS
During the reporting quarter, 357 deliveries were conducted by the pCSBAs. On average, five deliveries were conducted by each pCSBA per quarter. In order to increase performance, the project facilitated the linkage of pCSBAs with the community, local government and formal health systems through BCC and local level advocacy.
1.2.1.b Newborn health
A. Newborn health national support i. Scale-up of priority newborn health interventions
MaMoni HSS has continued to support the MOHFW in the national scale-up of newborn interventions and in improving the quality of facility based care. The project has also continued to support the National Newborn and Child Health Cell, which provides management support for the national newborn and child health program activities, as well as coordinates national scale-up, which includes monitoring the interventions through post-training follow-up led by DGHS. MaMoni HSS provides technical assistance to the MOHFW through this cell. In this quarter, a Facebook group named ‘Revisit on Priority Newborn Interventions’ was introduced, where all the field coordinators posted their daily activities with photographs. This helped the National Newborn Health Program (NNHP) to monitor the field level activities of the revisit program. The ‘Cell’ also supported NNHP and IMCI to organize a ‘National Newborn Health Program (NNHP) Implementation Design Workshop’ where more than 200 participants participated in finalizing NNHP implementation design. ii. Re-visitation of priority newborn interventions
• This three-pronged activity included: a) identification of newborn focal persons from each upazila, divisional and district to help local level managers in implementing priority newborn health intervention; b) refresher training of SBAs on ENC, including HBB and use of 7.1% CHX on the umbilical stump; and c) a quick assessment of preparedness for newborn interventions with respect to human resources, skills retention, facility readiness, medicine and supply stocks (including 7.1% CHX). The revisit also included the replacement/ or provision of supplies for newborn resuscitation equipment (bag, mask and sucker) in the facilities. The National Newborn and Child Health Cell supported by MaMoni HSS provided management support for this activity. Data collectors from partner organizations (Partners in Health and Development (PHD) and Bangabandhu Sheikh Mujib Medical University (BSMMU)) conducted the revisits and gathered data using a standard checklist.
• During the first quarter of Y5, the project facilitated revisits in 1,613 facilities and 7,291 service providers in 18 districts of phase four and phase five. Thus all 64 districts have been covered through the Photo: Trainer is demonstrating hand washing in a refresher training in Dinajpur sadar hospital MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 19 revisits. List of facilities visited is shown in Table 3.
Table 3 Facility visited and districts completed during phase 4 and 5
Facility visited
Phase 4
Total CWC ospital istrict M UHC UH&FWC (DGFP) UH&FWC (DGHS) USC RD Others District visited District D H
Phase 4 7 6 11 78 587 24 71 77 13 867 (Aug-Dec 2017) Phase 5 11 11 15 74 523 40 11 58 14 746 (Oct-Dec 2017) Total 18 17 26 152 1110 64 82 135 27 1613
• Due to the Rohingya crisis, doctors and other providers in Cox’s Bazar were engaged in providing health care to Rohingya women and children. Therefore, the refresher training could not be done at the respective facilities of the affected district.
• The findings of the revisit data are shown in Table 4. It is revealed that 87 percent of the facilities offered delivery services, 7.1% CHX was available in 54 percent of the facilities, and HBB kits were available in 74 percent of the facilities. 69 percent of the service providers were found to be trained on 7.1% CHX and 53 percent were found to be trained on HBB. Table 4 Findings of revisit in 18 districts (phase 4 and phase 5)
Offer Amoxicillin delivery 7.1% pediatric Facility Type service CHX HBB Kit MgSO4 drop Gentamicin N (%) (%) (%) (%) (%) (%) DH 100 18 82 29 59 82 17 MCWC 100 81 88 15 81 8 26 UHC 91 20 76 14 23 55 152 UH&FWC-FP 93 62 81 7 73 0 1110 UH&FWC-H 78 47 48 3 81 0 64 USC 18 7 7 0 28 0 82 RD 85 54 72 1 66 0 135 Others 56 22 30 4 52 4 27
Total 87 54 74 7 65 6 1613
Service provider trained % N
7.1% CHX 69 7291 HBB 53 61575
4 Nursing institute, Community clinic etc. 5 Excluding SACMO; SACMOs does not get HBB training MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 20 There is a buffer stock of HBB kits in every Civil Surgeon (CS) office, but sometimes it is not collected by the facilities immediately when there is a need for replacement. That is why the HBB kits were not available in 26 percent of the facilities. During the revisit, it was ensured that the facilities collect the kits from CS office. It can be mentioned here that union level facilities (UH&FWC, USC, RD) are not in the supply chain for Inj. Gentamycin. The MaMoni HSS project takes a special initiative for the supply of Inj. Gentamycin at the union level facilities in project areas where there is PSBI intervention.
iii. Situation analysis of inpatient care for newborn and young infant at district and upazila level facilities District hospitals and a small number of medical college hospitals in Bangladesh do not have adequate service provision for the management of sick newborn as per the Standard Operating Procedures (SOPs). Sick newborns are mostly managed in the pediatric ward without proper quality and safety procedures leading to high case fatality rates. There is also lack of compliance with standards for sick newborn care at hospitals largely due to non-availability of Special Care Newborn Unit (SCANU). The situation at Upazila Health Complex (UHC) is also very unsatisfactory. The National Newborn Health Strategy recommends the establishment of SCANU in secondary and tertiary level hospitals and recommends Newborn Stabilization Unit (NSU) at Upazila Health Complex (UHC) and Mother and Child Welfare Center (MCWC). MaMoni HSS project, UNICEF, and other development partners have been supporting MOHFW for the establishment of SCANU. So far, 42 SCANUs have been established in 42 district hospitals. UNICEF and MaMoni HSS project of Save the Children will support MOHFW to conduct a “National Assessment of Facility Based Sick Newborn Care” in Q2. UNICEF will provide assistance to conduct the assessment of SCANU services at district hospitals and medical college hospitals, while MaMoni HSS will provide support for the assessment of the SCANUs at the UHC, MCWC and selected private sector facilities. icddr,b will conduct the assessment for MaMoni HSS project. UNICEF is in the process of hiring a different firm to conduct the assessment they are supporting. A joint dissemination will be organized to share the report with a broader stakeholder group. The entire process will be completed under the guidance of MOHFW. As SCANU and NSU are new interventions introduced in Bangladesh for facility based sick children management, it is expected that this assessment will inform and guide the policymakers regarding best practices and bottlenecks for improving facility-based sick newborn care.
iv. Establishment of SCANU For the first time, the Directorate General of Family Planning (DGFP) has incorporated a newborn health component in the Maternal, Child, Reproductive and Adolescent Health (MCRAH) operation plan with dedicated manpower for newborn health, medicine and commodity procurement, and capacity building of providers. The Operational Plan for MCRAH has a target to establish 32 Special Care Newborn Units (SCANU) at secondary and tertiary level health care facilities.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 21 DGFP has requested MaMoni HSS to support the establishment of comprehensive newborn care units at national level facilities. This will not only provide services to sick newborns, but will also serve as a center of excellence for training of different level providers of DGFP on priority newborn interventions. In response to the request, the project is supporting the establishment of a comprehensive newborn care unit at Mohammadpur Fertility Services and Training Centre (MFSTC) and Maternal and Child Health Training Institute (MCHTI) at Azimpur. MaMoni HSS is also supporting the establishment of a comprehensive newborn care unit in Khulna Shishu Hospital (KSH). At present, this service is lacking in the region. It is expected that establishing the comprehensive newborn care unit at KSH will contribute to newborn survival in the region and also serve as a training institute for the development of skills and competency for providers on priority newborn interventions. The comprehensive newborn care unit will consist of SCANU, KMC, provision of ENC, including 7.1% CHX, and PNC. v. Kangaroo Mother Care (KMC) Community of Practice A day-long KMC Community of Practice meeting was held under the leadership of MOHFW to celebrate World Prematurity Day 2017. MaMoni HSS and Saving Newborn Lives (SNL), projects of Save the Children and UNICEF, jointly supported the event. A broad group of stakeholders from MOHFW, DGHS, DGFP, professional bodies, and development partners attended the meeting. Objectives of the meeting were to update the status of KMC introduction and scale up in Bangladesh, share implementation experiences, challenges and opportunities for KMC practice, explore national and local models of best practices to inspire and increase motivation, utilize a unique platform at the national level to mobilize KMC under NNHP, and build a common consensus of KMC community in Bangladesh. Key note presentations were made by Director, PHC and Program Manager, NNHP and IMCI, DGHS and Deputy Director (Services) and Program Manager (NBCH), and MCH Services unit, DGFP.
Photo: Dignitaries Photo: A mother sharing her KMC experience
Facility managers and service providers of 32 KMC implementing facilities shared their implementation experiences. One mother also shared her experience of providing KMC to her baby. Participants were divided into four groups to discuss experiences of KMC implementation at tertiary, district and sub-district levels, including a discussion of barriers to ensure quality during scale up at policy and implementation levels. Key recommendations were to:
• Maintain the national guidelines and standards , • Record KMC data at all KMC facilities through the national register, MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 22 • Submit the KMC report through the national reporting form, • Synchronize DGHS and DGFP online reporting systems .
It was decided in the meeting that the National Newborn and Health Program (NNHP) will follow up with the key recommendations from the meeting.
vi. Design workshop on National Newborn Health Program (NNHP) NNHP and IMCI units within MOHFW convened a design workshop for the NNHP in October 2017. MOHFW, DGHS, DGFP, USAID, UN Agencies, development partners, professional organizations, and NGOs participated in the workshop. The objective of the workshop was to share and review the program implementation plan (PIP) of NNHP and determine recommendations.
Photo: National Newborn Health Program (NNHP) Implementation Design Workshop
The NNHP Program Manager presented the NNHP program implementation package. Participants were divided into four groups. The groups worked on guideline and capacity building, procurement and supply, SBCC, communication and campaign, coordination, and monitoring and supervision. Key recommendations from the group were discussed. This will be utilized for NNHP implementation.
MaMoni HSS, SNL and icddr,b jointly supported the design workshop.
vii. 20th National Conference and Scientific Session of Bangladesh Paediatric Association MaMoni HSS supported the 20th National Conference and Scientific Session organized by the Bangladesh Pediatric Association (BPA). More than 700 participants consisting of pediatricians, researchers and public health workers from Bangladesh and abroad joined the conference. Dr. Sabbir Ahmed, Program Director NB&CH at MaMoni HSS, presented a paper on the introduction and scale up of
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 23 management of infections among young infants at peripheral level facilities when referral is not possible.
viii. Synthesizing learning from early implementation of new WHO guideline for management of Possible Serious Bacterial Infection (PSBI) among young infant when referral is not feasible Bangladesh and Ethiopia are the two leading countries implementing outpatient treatment for possible severe bacterial infections (PSBI) in newborns and young infants. Results from trials conducted in these countries have been instrumental in the development of WHO guidelines on managing possible severe bacterial infection in young infants when referral is not feasible. Bangladesh’s national guidelines for the management of sick children (<2 month) from union level facilities has been developed through adaptation of the WHO protocol. Since 2015, MOHFW has been implementing the PSBI national guideline in multiple districts, with support from partners such as SNL/Save the Children, MaMoni HSS/USAID and Prohjohnnmo/JHU. Three implementation research studies were conducted concurrently in Kushtia, Lakhsmipur and Sylhet districts with support from partners. The PSBI implementation is now at scale in four MaMoni HSS districts. Both Bangladesh and Ethiopia have strong policies and plans to continue implementation and scale up of newborn health interventions as part of a five-year health systems plan, the Call to Action on Child Survival and Development, and movement towards SDGs. To deepen the cross-program learning on community based PSBI implementation, scale up, and sustainability, and to put it in a long-term context, a global initiative has been undertaken and MaMoni HSS is a part of this initiative. The aim of this initiative is to contribute information on the implementation of country-led transformation of newborn health within child health and other health systems more broadly. Exploring and synthesizing information learned from these two countries will structure initial descriptions of the environment, longer term aims for newborn health, and emerging implementation-related themes. A meeting with stakeholders will be convened tentatively in May 2018 to share the report.
ix. Other national activities
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 24 The project continues to provide technical support for the publication of the National Newborn Health Bulletin. The 4th issue of the bulletin was published during the last quarter. The purpose of this quarterly bulletin is to provide regular updates on the progress made by various initiatives by MOHFW, development partners, professional associations, and other stakeholders to improve the survival and wellbeing of newborns in the country. The bulletin primarily focuses on the evidence-based interventions prioritized by the Government of Bangladesh for accelerating the reduction of newborn mortality in the country. This issue presents the performance analysis of essential newborn care indicators from DHIS -2 and data received during the revisit program for the newborn interventions. Inspiring case studies of new newborn interventions such as KMC and HBB and the experience of child birth in urban slums were included in this issue. Project updates from NNHP and IMCI are also shared, along with social media activities. The bulletin was shared with all stakeholders and posted on the Healthy Newborn
Network (HNN) web page.52T
B. Newborn health district interventions Project initiatives during the reporting period focused not only on increasing coverage, but also on improving the quality of service delivery through building the capacity of service providers on priority newborn interventions, including record keeping and reporting, availability of logistics, job aids, and on-the-job coaching, as well as community awareness.
i. Helping Babies Breathe (HBB) MaMoni HSS has been supporting the HBB intervention in all 64 districts under national scale-up activities. The project supported the training of new and untrained doctors, nurses and midwives on priority newborn interventions, including record keeping and reporting in 18 districts (Pabna, Chittagong, Comilla, Kishoreganj, Rangpur, Dinajpur, Gaibandha, Cox’s Bazar, Feni, Chandpur, Kurigram, Lalmonirhat, Nilphamari, Panchagarh, Thakurgaon, Brahmanbaria, Jamalpur, Netrokona). The training was also conducted for new and untrained doctors of BSMMU and was facilitated by trainers from BSMMU and PHD. In Quarter 1, Year 5, 5,946 newborns were resuscitated in facilities across the country using a bag and mask. Figure 8 shows the number of newborns resuscitated using bag and mask by divisions. The figure shows that there is over use of bag and mask for newborn resuscitation in public health facilities throughout the country. Figure 8: Number of newborns for whom resuscitation actions were initiated in public health facilities, using a bag and mask, in seven divisions of Bangladesh
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 25 3000 2886
2500 Y4-Q1 1958
2000 1798 Y4-Q2 1694 1348 1311 1500 1293 1232 Y4-Q3 1081 Number 989 817 1000 801 737
704 Y4-Q4 676 646 644 579 576 569 547 502 502 479 449 436 377 369 352
500 281 215 208 Y5-Q1 127 113 100
0 Estimated number of newborns needing resuscitation
Source: MIS-3 and EmOC report of DHIS-2
ii. Application of 7.1% Chlorhexidine (CHX) for newborn cord care The application of 7.1% CHX to the umbilical cord stump is one of the major interventions to prevent newborn sepsis for all newborns, irrespective of their place of delivery. As a part of the essential newborn care (ENC) package, the projects supports implementation of 7.1% CHX application in six project districts, including implementation in public facilities and small-scale implementation in private facilities. In addition to GOB supply chain, the project coordinates with the manufacturing company to ensure availability of 7.1% CHX in local level pharmacies. MOHFW’s routine MIS tracks the application of 7.1% CHX for all SBA assisted deliveries, both at the facility and in the community. Figure 9 shows an increasing trend in the application of 7.1% CHX. The application of 7.1% CHX for newborn cord care increased from 24,425 in Q4 Y-4 to 30,416 in Q1 Year 5. Figure 9: Number of newborns that received 7.1% CHX on their umbilical cords immediately following birth in MaMoni HSS districts
70000
60000
50000 61094 61094 61094 61094 59486 40000
30000 32882
20000 31791 31301 30416 29458 28689 25133 10000 24425 15891 17201 0 Y4-Q1 Y4-Q2 Y4-Q3 Y4-Q4 Y5-Q1
Number of estimated live birth Number of SBA delivery Application of 7.1% chlorhexidine
Source: DGFP MIS 2 & 4, CSBA and EmOC report of DHIS-2, pCSBA report of project MIS
iii. Facility based care for sick children
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 26 a. Management of sick children (<2 months of age) in union level facilities MaMoni HSS has been supporting the implementation of national guidelines for management of sick young infants (<2 months of age) from 148 UH&FWCs in four project districts by injectable antibiotics where a trained Sub-Assistant Community Medical Officer (SACMO) is available. At the beginning of the program, all the SCAMOs received a two-day competency based training in addition to CNCP training. The project organized refresher trainings for the SACMOs during the reporting quarter. As per national protocol, Family Planning Inspector (FPI) of respective unions also received the refresher training on “Day 8 follow up” at the household level. During the reporting period a total of 1,706 cases were identified and managed by trained SACMOs. Among them 37 were classified as CI, 101 CSI and 518 IFB.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 27 Figure 10: Number of sick children (<2 months of age) treated at 148 UH&FWCs in 4 MaMoni HSS districts
700 601 573 600 544 532 497 494 486 472 500 431 424 442 376 400
300 247 228 227 215 211 204 196 194 194 190 186 176 175 174 172 168 157 148 145
200 131 125 124 124 124 116 112 112 110 102 100 97 93 91 90 80 76 42 39
100 34 29 27 27 25 25 23 23 22 20 19 19 19 16 11 10 8 7 4 3 3 3 0 Jan'17 Feb'17 Mar'17 Apr'17 May'17 Jun'17 Jul'17 Aug'17 Sep'17 Oct'17 Nov'17 Dec'17
CI CSI IFB LBI Other Total
Source: Project MIS
b. Management of sick children from Special Care Newborn Units (SCANUs) All five SCANUs at district hospitals in project areas continue to provide services for critically sick newborns. SCANU data from the facilities is entered into DHIS 2. However, the completeness and quality of data reported in DHIS 2 is a major issue. The project continues to work to improve the timeliness and completeness of SCANU reports. Figure 11 shows the number of admissions of sick newborns in five project supported SCANUs. The figure shows that in this quarter, 1,066 newborns were admitted for getting special care and treatment. Twenty-two percent of these newborns were referred from the same facilities and the average length of stay at the hospital was 4.4 days. Eleven percent of these sick newborns died from severe condition or complication.
Figure 11: Trends in admissions of sick newborns at 5 project supported SCANUs
1200 1066
1000 875 900
800
600 Number 400 310 273
200
0 Y4-Q1 Y4-Q2 Y4-Q3 Y4-Q4 Y5-Q1
Source: DHIS-2 MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 28 iv. Kangaroo Mother Care (KMC) at district and upazila level facilities Fifteen facilities in four MaMoni HSS districts have been providing KMC services. By the end of Q1, Y5, another fourteen facilities were prepared to provide KMC services for low birth weight babies following national guidelines. All of these facilities have at least one doctor and two nurses trained, resources available for five cases, and necessary job aids with record keeping and reporting tools for documentation. The project also initiated establishing KMC units at Khulna Shishu Hospital, Dhaka Medical College Hospital and Sir Salimullah Medical College Hospital. Fifteen doctors and fifteen nurses were trained from these facilities. As per national guidelines, the respective Assistant Health Inspector (AHI) is responsible for community follow up of post discharge cases. All the AHIs and their line supervisors (HI) in these four districts received training during this quarter on community follow up of post discharge cases. During this period, 114 (Habiganj-41, Noakhali-35, Lakshmipur-28 and Jhalokati-10) low birth weight newborns received KMC services from project area.
1.2.1.c Family Planning (FP) Major achievements in Q1 of Y5 are the following: i. Supported development of Postpartum Family Planning (PPFP) Counseling training modules for trainers and trainees ii. Oriented district level managers of MOHFW in MaMoni HSS areas on newly developed Post-Partum Family Planning (PPFP) Counseling Training modules
Orientation on PPFP module
iii. Organized basic training on PPFP with special focus on PPIUCD for FWVs, SACMOs and Nurses at MFSTC, Dhaka where sixteen FWVs, two SACMOs and seven Nurses received training
PPIUCD training
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 29 iv. Facilitated celebration of client fair with CCSDP, DGFP in Habiganj, Lakshmipur, Jhalokati and Pirojpur districts Two-day Client Fairs were organized by Family Planning (FP) department in all districts. With the support from USAID and MaMoni HSS and direct guidance from CCSDP and DGFP, the client fairs were held in four MaMoni HSS districts (Habiganj, Lakshmipur, Jhalokathi and Pirojpur). The Client Fair was organized in three different stages: - District advocacy workshop - Upazila advocacy workshop - Client Fair Invited stakeholders included DC Office, CS Office, related NGOs, local elected bodies, and elites. The objective of this meeting was to disseminate the information of the ‘Client Fair’ for enhancing interpersonal communication and to find out the strategies and techniques employed to observe the client fair successfully. The meeting with through the commitment of all stakeholders for successfully holding the ‘Client Fair 2017’ at the district and upazila level. The MaMoni-HSS program provided comprehensive support for organizing the meeting and the event throughout the district.
All Deputy Directors of Family Planning (DDFPs) ensured effective upazila level planning as well as direct supervision. The main purpose of the upazila meeting was to execute the client fair successfully. All field-based staff at the Health & Family Planning Department, NGOs, local elected bodies, and related stakeholders were present at the meeting and contributed to the planning session.
Client orientation for Court yard meeting with Client preparation in OT potential clients demand raising
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 30 The ‘Client Fair 2017’ was focused on building awareness, creating demand and increasing performance, as well as disseminating proper messages on Long Acting Reversible Contraceptives (LARC) & Permanent Methods (PM). The Fair also developed enthusiasm among the FP field staff and in the community, which has the potential to improve utilization and develop a clear understanding of FP methods in the near future. v. Developed a brochure on FP methods and service-related myths and misconceptions. The fair also printed a Medical Eligibility Criteria (MEC) wheel for supporting the orientation of field level service providers of DGFP and DGHS on recent FP Policy changes and Medical Eligibility Criteria (MEC) by district level administration.
Family planning performance in MaMoni HSS districts i. Postpartum family planning (PPFP) PPIUCD performance shows decreasing trends in Noakhali and Jhalokati districts, as shown in Figure 12. During the quarter, in Noakhali district, in one of the UH&FWCs, one paramedic left the job and another paramedic was on maternity leave. There was also a stock out of IUCD in certain districts because of a fire in a central warehouse. Figure 12: Trends in postpartum IUCD performance in MaMoni HSS districts
400 308 300 249 192199 200 130 112119117 Number 100 63 61 63 49 5 14 1 0 0 0 0 8 0 Habiganj Noakhali Lakshmipur Jhalokati Pirojpur
Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5
Source: MIS-4, DGFP
ii. Long acting and reversible contraceptive and permanent method During the reporting quarter, a special service week for LARC&PM was observed by DGFP. While the LARC performance shows increasing trends (Figure 13), the permanent method performance shows a slight decreasing trend (Figure 14) in MaMoni HSS districts. As shown in Figure 13 and Figure 14, LARC & PM performances in HI areas were 5,815 and 1,177 respectively during the reporting quarter. Figure 13: Trends in LARC performance in MaMoni HSS districts
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 31 10000
5921 5726 5815 4983 4476 4822 5000 3911 3469
0 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5
HI area HSCS area
Source: MIS-4, DGFP
Figure 14: Trend in PM performance in MaMoni HSS districts
2000
1200 1177 927 1000 803 733 728 784 600
0 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5
HI area HSCS area
Source: MIS-4, DGFP
•
• iii. Promotion of FP services through community volunteers
• In Q1 Y5, 23 percent of new LARC & PM users were referred by community volunteers of the MaMoni HSS project. Figure 15 shows the contribution of community volunteers to LARC & PM in project districts. Figure 15: Contribution of community volunteers (CVs) to LARC&PM performance in MaMoni HSS districts
100%
80%
60% 76% 77% 73% 76% 77%
40%
20% 24% 23% 27% 24% 23% 0% Q1-Y4 Q2-Y4 Q3-Y4 Q4-Y4 Q1-Y5
% referred by CVs % referred by GoB staff
Source: MIS-4, DGFP and Project MIS MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 32 1.2.1.d. Nutrition The MaMoni HSS project aims to reduce the prevalence of underweight children under five years old and to reduce child mortality from malnutrition by strengthening communities and government facilities’ capacity to identify, treat, and prevent malnutrition. This project also aims to prove that a holistic, decentralized, community- based approach to malnutrition eradication will have better health outcomes, be more inclusive for children under five and will be more cost-effective in the long-run compared to more centralized approaches – especially for rural and marginalized communities. This project empowers communities through health literacy and connects rural communities with available government health and nutrition services. MaMoni HSS does not just act as a catalyst for mobilizing communities to the resources available, but also works on a more intimate level with government health and nutrition workers to help build their capacity towards social mobilization, referrals, and provision of effective nutrition counseling. In year five, the project supported the National Nutrition Services (NNS) operational plan to develop skilled front-line community health workers on nutrition screening (basic nutrition) and counseling, which will help to expand the coverage by active-case-findings and ultimately mitigate the burden of the problem.
Data from DGFP MIS, DHIS-2 and project MIS showed the following results in MaMoni implementation areas in last quarter:
. 364,327 mothers and children (62,136 mothers & 302,191 children) were reached with nutrition interventions from different service delivery points from the community to the district level (Community Clinics, UH&FWCs, UHCs and DHs from where IMCI & nutrition services are being provided).
. 95,705 caregivers were reached with BCC interventions to promote essential infant and young feeding practices, hand washing, IDD, Vit-A, etc. 62,136 pregnant mothers received iron & folic acid (IFA) supplementation during ANC visits.
. 3,459 children were identified who had been suffering from MAM. 693 children were identified as SAM patients and were subsequently referred.
. Among all children who were reached, 20,436 (6.76%) children had been suffering from different forms of under nutrition. The data shows that among the reached children, 5,201 (2.29% ) children were identified as stunted, 4,769 (1.58% ) were wasted and 8,750 (2.90% ) were under weight (Figure 16).
Figure 16 Distribution of under nourished children
Under- Stunting weight 33% 44%
Wasting 23%
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 33 . Management of children with SAM: During the reporting period, 51 children afflicted with SAM were enrolled at 16 SAM units of District Hospitals (4) & upazila health complexes (12) across the project areas. Among them, 41 were newly admitted and the remaining 10 were under treatment from the previous month (September 2017). Among those patients, 46 were discharged. The treatment outcomes are shown in the Figure 17.
Figure 17 SAM Management Outcomes
Dischrged Cure Stabilized 42% 30%
Defaulter 28% Death 0%
1.3 Strengthen infrastructure preparedness to improve MNCH service utilization
1.3.1 Upgrading UH&FWCs to provide 24/7 delivery services
In Q1 Y5, nine more UH&FWCs were upgraded in the six project districts to provide 24/7 delivery services. Currentl, a total of 120 UH&FWCs are providing 24/7 services. Local government bodies at Hatiya built two facilities which function as interim UH&FWCs both at Chanondi and Nijhum dwip union. At Nijhum dwip, part of a cyclone shelter center was converted to a UH&FWC. With these two facilities, four UH&FWCs have been built by the Union Parishad in Hatiya. According to UH&FWC assessment data, 65 UH&FWC were designated as “Category A” in MaMoni districts and among them, 56 UH&FWCs are now functioning as 24/7 facilities.
Table 5 Number of UH&FWCs upgraded in MaMoni HSS districts
District Number of UH&FWCs Total number of UH&FWCs upgraded in Q1Y5 upgraded till to date
Habiganj 00 38 Jhalokati 01 15 Lakshmipur 01 24 Noakhali 05 23 Bhola 00 10 Pirojpur 02 10 Total 09 120
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 34 Nijhum Dwip looks forward to a healthy future
“I would deliver at home as I did before,” Shaheena said when she was asked what she would do if the health center were not there. Shaheena had her second baby at the Nijhum Dwip (an island in Hatiya Upazila on the south of Bangladesh) Union Health and Family Welfare Centre (UH&FWC) on the day the facility started functioning.
For Shaheena, delivering at a health facility was hardly an option. Shaheena lives in Madina Gram (village) in Nijhum Dwip Union of Hatiya Upazila and traveling to the nearest health Shaheena with her baby boy. She facility in Jahajmara takes at least 2-3 hours’ journey that can be happens to be the first mother to rough and expensive. For about 30,000 people who call Nijhum have delivered at a health facility in Nijhum Dwip. Dwip their home, ‘delivery at home’ had therefore been the only choice.
On November 1, the remote island union got its first health centre equipped with a range of basic healthcare provisions including normal delivery services. Six weeks later, the Nijhum Dwip UH & FWC started providing 24/7 delivery services. Now the people of Nijhum Dwip, one of the hardest-to-reach areas in Bangladesh, have the option to access safe and free delivery services by trained service providers around-the-clock.
Inauguration of the 24/7 delivery service at the Nijhum Dr. Md Sharif, Director, Maternal and Dwip UH&FWC on 12 December, 2017 Child Health, DGFP, inaugurated the 24/7 delivery service in the presence of Dr. Sukumar Sarker, Senior Technical and Policy Advisor, OPHNE, USAID and Joby George, Chief of Party of MaMoni HSS.
The establishment of Nijhum Dwip UH&FWC represents a novel initiative undertaken by the District family planning and local government departments of MaMoni Health Systems Strengthening (MaMoni HSS) Project. Instead of constructing a new building, they converted part of a shelter center to house this health facility.
MaMoni HSS Project has strived to engage the local government institutions as a means to strengthen the union health facilities, and the establishment of Nijhum Dwip UH&FWC has been part of that initiative. The project has actively motivated and advocated for the Union/Upazila Parishads to play an oversight role to ensure accountability of the health service providers in addition to mobilizing resources for strengthening of the facilities. In Hatiya, local government authorities had supported the establishment six 24/7 delivery centers, contributing to a significant increase in deliveries conducted by SBAs.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 35 IR 2: Strengthen health systems at the district level and below 2.1 Improve leadership and management at district level and below
In Q1 Y5, all six districts have conducted quarterly performance review meetings (QPRM) that are jointly organized by DGHS and DGFP. District and Upazila level managers, other officials, NGO representatives, and MaMoni HSS staff attended the QPRM. Upazila wise MNCH/FP/N performance indicators were reviewed and further actions were planned accordingly. District action plans, joint supervisory visits (JSV) and data quality assessment (DQA) findings, local government engagement, challenges, and up-coming priorities were also shared in the meeting. Based on the participatory review and discussions, action points were taken to improve the coverage and quality of program activities. Key findings on DQA visits are mentioned under section 2.3.2. Examples of JSV findings are shown under section 2.5.2.
In addition to QPRM, Upazila Health and FP department and MaMoni HSS jointly conducted coordination meetings at the upazila level each month. Respective UH&FPO, UFPO and MOMCH organized the meeting with service providers, statisticians and first line supervisors of both DGHS and DGFP to analyze union performances, review action plans and discuss the findings of joint supervisory visits and DQA.
2.2 Improve district level comprehensive planning (including human resources) to meet local needs
2.2.1. Health Workforce Management: Workload and staffing needs assessment study
Key findings and recommendations of the study on “Workload and Staffing Needs Assessment at Public Sector Healthcare Facilities” were shared in the USAID implementing partners’ meeting in October 2017. Bangladesh’s experience of applying the Workload Indicators of Staffing Need (WISN) method was also presented in the 4th Global Forum on Human Resources for Health held in November 2017 in Dublin, Ireland. The WISN study conducted in another two districts supported by WHO Bangladesh has also recently completed. Both reports share similar findings and recommendations. WHO and MaMoni HSS agreed to collaborate with each other along with HRD Unit, MOHFW for a joint dissemination of the key findings and recommendations of these two studies. A small group comprising of Principal Investigators of the two studies and technical persons from MaMoni HSS and WHO Bangladesh are working to develop policy briefs based on these studies.
2.2.2 Implementation of Central HRIS: Support DGHS and DGFP to implement central Human Resource Information System (HRIS) The MaMoni HSS project continued supporting the DGHS and DGFP in implementing a central Human Resource Information System (HRIS). During the reporting quarter, focus was to facilitate initiation of HRIS implementation at DGFP where more than 55,000 staff are working in more than 5,000 service delivery facilities and administrative offices throughout the country. Several discussions were held with the Director and Program Manager of MIS unit of DGFP and Activation Ltd. for planning, conceptualizing and implementing HRIS in DGFP. In line with the MIS Operational Plan (OP), MaMoni HSS supported capacity building through providing a three-day Training of Trainers (ToT) to
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 36 relevant central level DGFP staff who will subsequently provide training to the relevant district and upazila level DGFP staff on HRIS. ToT was organized in collaboration with MIS unit and Activation Ltd. Thirty-eight central level staff including Deputy Directors, Program Managers, Deputy Program Managers, Statisticians, and Assistant Maintenance Engineers, etc. were trained in two batches. MaMoni HSS is working with MIS unit, DGFP for initial inputs to HRIS’s facility and sanctioned post registries. 2.3 Strengthen local management information systems 2.3.1 Development and scale-up of Electronic Management Information System (eMIS) Key activities in this quarter include the implementation of the Community Modules (FWA and HA) and preparation for the supervisory e-register (FPI, AHI, HI) in new districts. Introduction of new tools and enhancement of the existing TAB based e-registers and monitoring tools as feedback from the field users and field level GOB supervisors ensures greater acceptability of the eMIS platform. Table 6 shows eMIS trainings conducted during the reporting quarter.
No of Sl Event Participants Category Districts Resources Person Part. UFPO, MO (MCH-FP), HIS ToT on Community module Noakhali, Director-MIS, DD-MIS, 1 54 Coordinators and M&E Persons (FWA) e-register Lakshmipur DGFP from partners and SCI
Line Director- MNC&AH, UH&FPO, MO, HIS Coordinators ToT on Community module Director-PHC, Deputy 2 35 and M&E Persons from partners Noakhali (HA) e-Register Director and PM-MNH, and SCI DGHS
UFPO, MO (MCH-FP), HIS ToT on Supervisory Module Director-MIS, DD-MIS, 3 28 Coordinators and M&E Persons Habiganj (FPI) e-Register DGFP from partners and SCI
Line Director- MNC&AH, UH&FPO, MO, HIS Coordinators ToT on Supervisory Module Director-PHC, Deputy 4 29 and M&E Persons from partners Habiganj ( AHI and HI) e-Register Director and PM-MNH, and SCI DGHS
DD-FP, UFPO and 5 Training on FWA e-Register 186 FWA Noakhali MO(MCH-FP), DGFP
DD-FP, UFPO and 6 Training on FWA e-Register 208 FWA Lakshmipur MO(MCH-FP), DGFP
Training on HI, AHI e- 7 38 HI, AHI Habiganj CS, UH&FPO,DGHS Register
DD-FP, UFPO and 8 Training on FPI e-Register 41 FPI Habiganj MO(MCH-FP), DGFP
CS, DD-FP, UH&FPO, MO- 9 Training on Monitoring Tool 12 Jhalokati Clinic, UFPO, MO (MCH-FP)
Table 6 eMIS ToT and Trainings conducted in October-December 2017
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 37 i. Implementation and Support In Noakhali, the e-register is also being introduced to FWV, SACMO-DGHS and SACMO- DGFP. The e-MIS design team is helping to resolve implementation issues of the FWA e- register throughout Noakhali and Lakshmipur. Before releasing the tool into the field, team members testing APK in TAB are also continuously monitoring e-MIS reports from unions currently using the monitoring tool. All Health ID cards have been printed for Madhabpur (excluding municipality) and almost 95 percent of the registered population have received HID cards. In Lakhai upazila, 73 percent of the population is registered and of those individuals, 93 percent have HID cards and 92 percent of the HID cards have been distributed. The GOB field workers are distributing the HID cards during their household visits in addition to counseling individuals on bringing the HID cards during facility visits.
ii. Development Activities: During this quarter, major work has been initiated for the child care register, Integrated Management of Childhood Illness and PSBI. The team is discussing with the partners and relevant GOB stakeholders about the possibility and scope of merging the existing registers in the electronic format so that the reporting format is unified and consistent with the record keeping. A rule-based decision support system (DSS) has been developed for efficient decision making in selection of dosage and categorizing the illness. To reduce dropout from LARC method, it was proposed to DGFP that an electronic notification for follow-up services be used. The team developed the dashboard at the provider end so that such client/patients are identified and the provider can initiate necessary follow-up action. Although the follow-up dashboard was initially designed for implant and IUCD clients, it was realized that similar follow-up notification is very effective for maternal health services such ANC, delivery, etc. These services are now included in the dashboard.
In the monitoring tool, live GPS integration has been introduced where every provider’s login location can be traced. This will enable national and (sub) district level managers to monitor service availability and identify the coverage gap. A number of new features have also been added for managers and M&E officers to effectively monitor the situation. A dashboard for low birth weight babies, location and login tracking, synchronization, and server health check has been added for better monitoring the provider’s activity. An integrated TAB view with a map, grid and graph can potentially provide better data accessibility.
Photo: Live GPS Coverage The UH&FWC assessment task of MaMoni HSS was a highly appreciated work and there are queries from the respective agencies about ways to keep the information up to date and integrate it with service statistics. The integration of UH&FWC assessments into eMIS TAB achieves both purposes. The first draft has been prepared and the previous assessment data has already been entered into the new system.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 38 iii. Launching Ceremony for Scale up of eMIS: A launching Ceremony for the National Scale-up of Electronic Management Information System (eMIS) was organized on 11 October, 2017. The Honorable Minister for Health and Family Welfare, Mr. Mohammed Nasim, MP, was the Chief Guest of this event. Kazi Mustafa Sarwar, Director General, DGFP, chaired the program. The eMIS scale-up will be in five new districts (Noakhali, Jhenaidah, Natore, Moulvibazar and Madaripur). Grassroots level health and family planning workers and their supervisors shared the experience of eMIS use. There were also booths where they could demonstrate the use of eMIS using TAB.
Hon’ble Minister for Health and Family Welfare Mr. Noorjahan Begum, FWV, Poil UH&FWC, Habiganj Mohammed Nasim, MP delivering his speech sharing her experiences on eMIS
Nupuri Das, FWV, Char Kakra UH&FWC Received TAB DD-eMIS, MaMoni HSS, demonstration the eMIS systems from Honb'l Minister, Ministry of Health and Family to the spectators
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 39
iv. Others activities The e-MIS team participated in Digital World 2017 (Dec 6 – Dec 9) at BICC organized by the ICT Division. Mamoni HSS, through the eMIS initiative, received a lot of appreciation from the respective agencies of the Government of Bangladesh and other international and local participants/visitors. MaMoni actively supported the Directorate General of Family Planning of MOHFW to organize the event and provided logistical support (food, caps, X stand banner) for the event. Throughout the event, the eMIS/MIS team actively participated in showcasing different ICT applications developed for the DGFP/DGHS in the presence of senior government officials and discussed other potential ideas.
2.3.2 Data Quality Assessment DQA is a routine activity in order to improve data quality in the project even though most of the data is from MIS, MOHFW. MIS and program staff in each district conducted DQA on a monthly basis. A total of 69 DQA were conducted in Q1 Y5. There are structured formats to document DQA and record the findings and the findings from DQA were shared with the concerned managers and corrected accordingly. Photo: DQA conducted by USAID team at Sadar Upazila family planning office in Habiganj One example of such findings was in Hatiya- the report of delivery was over reported because of inclusion of upazila health complex delivery in DGFP MIS-3, which are not supposed to be reported in MIS-3. The finding was shared with the respective upazila statistician of family planning and it was corrected accordingly. In addition to the the district level staff, DQA was also conducted at the national level as well as through USAID. During the reporting quarter, two DQAs were conducted at the national level in Noakhali and Lakshmipur on family planning data in a very systematic manner. Injectables and tubectomy data were verified from district, upazila, union, unit, and household levels. In Noakhali, the data was consistent across all tiers from upazila to community level. The data was also consistent from upazil to union level in Lakshmipur. One discrepancy identified was in the documentation of referral of tubectomy clients by community volunteers. The findings were shared with the district and upazila teams and corrective measures have been taken.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 40 In the previous quarter, another DQA as conducted by USAID in Habiganj on newborn and nutrition data. Most of the data from the field level was accurate, but in the web report, resuscitation of babies using bag and mask information was not updated and was duplicated for each month throughout the entire country. Based on these findings, the issue was raised at the national level. A meeting was conducted with the DGFP, MIS team in Dhaka to share the findings. MIS department of DGFP was able to identify the problem and take corrective actions accordingly.
2.4 Establish a quality assurance system for MNCHFP-N services at district level and below 2.4.1 Updates on MaMoni HSS Project staff seconded to QIS During this period, the project lost four staff (Dhaka and Barisal divisional QI coordinator; and divisional QI monitor of Sylhet and Barisal). To fill up the position of Dhaka divisional coordinator, the divisional coordinator of Mymensingh has been transferred to Dhaka. Also, the MaMoni HSS project agreed to provide two staff (district QI coordinator and district QI monitor) in Narsingdi to facilitate the implementation of the RMNCAH pilot. 2.4.2. Workshop on Implementing Quality Improvement Initiatives through Plan-Do-Check-Act (PDCA) Two batches of Plan-Do-Check-Act (PDCA) trainings were organized during this quarter. The overall objective of the training was to enhance the understanding and skills of the participants to resolve day-to-day hospital problems using the PDCA approach. In total, 53 participants (28 in the first batch and 25 in the second batch) attended the training. They were from 15 model district hospitals (Chuadanga, Bhola, Laksmipur, Sirajgonj, Tangail, Kurigram, Netrokona, Gopalgonj, Narail, Joypurhat, Natore, Chandpur, Khagrachari, Bandarbon, and Moulavibazar) from all divisions. The participants from the model hospitals were mostly Consultants (OBGYN), Resident Medical Officers, Medical Officers, Nursing Supervisors, and Nurses. The workshops were organized by QIS with support from UNICEF and MaMoni staff members who facilitated the sessions. The major areas identified by the participants to solve through PDCA approach were: a) Improve assessment of diarrhea patients for clinical management to prevent severe dehydration; b) Improve timely checking of capillary blood sugar to prevent neonatal convulsion; c) Improve hand washing in OT; d) Improve evening rounds by doctors/consultants; e) Reduce wound infection in surgical units; f) Improve infection control in delivery rooms; and g) Improve cleanliness of toilets. The trained divisional QI staff will follow up the implementation status through monitoring visits. The following graphs show the achievements after PDCA training in Narsingdi and Noakhali district hospitals.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 41 Figure 18 Percentage of staff washed hands before conducting delivery at delivery room, Narsingdi District Hospital, 2017
75
60 55
30
Percentage 25
JUNE JULY AUGUST SEPTEMBER OCTOBER Month, 2017
Figure 19 Percentage of newborns referred from SCANU and OBGYN ward to KMC corner, Noakhali District Hospital
60
50 50 46.15 40
30 27.27 20 16.7 20 10
0 May June July August September
2.4.3. Implementation of 5S in district hospitals During this reporting period, 5S was introduced (or a refresher training was provided) in six district hospitals/Medical College Hospitals in Khulna, Rangpur, Rajshahi, Sylhet, and Chittagong divisions. The district/medical college hospitals are: Magura, Shatkhira, Natore, Joypurhat, Bandarban, Sylhet MAG Osmani MCH, and Rangpur MCH. A one- day orientation was provided (in batches) to the WIT members. The total number of district facilities currently practicing 5S is 41 facilities (28 in four divisions supported by the MaMoni HSS Project). The overall objective of the workshop was to improve the understanding of the participants on 5S and develop WIT wise action plans to implement 5S activities for the improvement of the working environment, which is the gateway for quality improvement. The 5S award ceremony was organized by QIS at the Shaheed Suhrawardy Medical College Hospital (ShSMCH) and Dhaka Medical College Hospital (DMCH). The purpose of the ceremony was to reward the staff for their achievements on 5S and to motivate them to generate breakthroughs. ShSMCH received five awards for OPD, IPD, and OT complex. The director of the hospital also received the leadership award from the QIS. In DMCH, eight awards were given to the WITs (two for OPD; two for IPD; one for cabin and
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 42 paying wards; one for specialized units such as ICU, CCU, labor room, dialysis, bone marrow transplantation; one for all OTs; and one for other areas such as lab, blood bank, radiology, kitchen, drug administration etc.) for best performance. In addition, awards were also given to six individual staff (four Nurse and two doctors) as champions of change. Both the ceremonies were attended by high level officials from the MOHFW.
2.4.4. Maternal and perinatal death surveillance and response (MPDSR) During this quarter, facility based MPDSR was introduced in five district hospitals in Chittagong and Barisal divisions supported by the MaMoni HSS Project. The district hospitals include: Chandpur, Bhola, Khagrachari, Brahman Baria and Comilla. MPDSR sub-committees were formed in all the facilities, and the staff working in OBGYN and pediatrics departments along with the sub-committee members were oriented on facility- based MPDSR. A total if 129 staff were oriented and the total number of facilities where MPDSR is introduced in three MaMoni supported divisions is now at 16 (out of 21).
Three cause of death analysis workshops were conducted to review the community-based deaths (maternal and perinatal) during this period. The workshops were organized in Dhaka, Rajshahi and Rangpur. The objective of theses workshops was to review all the community-level maternal and perinatal deaths to identify the medical and social causes of deaths. The workshops were organized by QIS. In these workshops, every death was reviewed by a variety of experts (gynecologists, obstetricians & pediatricians) and the most probable causes of death were identified and recorded on death review forms. QIS is compiling the probable causes of deaths and the report will be shared with respective district level managers in Q2. Based on the report on the causes of deaths, district and upazila level MPDSR committees will develop action plans for implementation in their respective areas.
2.4.5 Piloting of RMNCAH QI framework QIS has developed the RMNCAH (reproductive, maternal, neonatal, child and adolescent health) QI framework by adapting the WHO guideline. The framework will be piloted in Narsingdi and Tangail districts. In both the districts, the indicators will be piloted in four facilities (district hospital, MCWC, and two UHCs in each district). MaMoni HSS project will collaborate with QIS to implement the pilot in Narsingdi. The expected duration of the pilot is one and a half years, which will commence from January 2018. icddr,b has been assigned to evaluate the pilot through baseline, midterm and endline data collections. A joint field visit was organized at Narsingdi to observe the health facilities and discuss the pilot activities with the district managers and senior officials. A draft implementation and documentation framework has been developed. To finalize the tools and methodology for the survey, three meetings were held with QIS and representatives from Narsingdi (UH&FPO of both UHCs and representatives from CS office). The baseline data collection will be initiated in the next quarter as soon as the tools are finalized.
2.4.6 Quality improvement committee and district resource pool The divisional and district QI committees have been formed and district resource pools have been developed. Continuous efforts are being given to activate the divisional and district QICs. Table 7 shows the number of districts where QIC and district resource pools have been formed and the number of district hospital QI committee meetings held.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 43 Table 7 Information about quality improvement committees (QIC)
Dist. QIC District District hospital District QIC No. of formed# resource pool QIC meeting Division meetings held districts developed held (Oct-Nov (Oct-Nov 17)# (cumulative) (cumulative) 17)#
Chittagong 11 11 11 5 8 Sylhet 4 4 4 3 4 Barisal 6 6 6 3 4 Khulna 10 10 10 7 9 Dhaka 13 13 13 6 9 Rajshahi 8 8 8 3 6 Rangpur 8 8 8 4 5 Mymensingh 4 3 3 2 3 Total 64 63 63 33 48 #: No. of districts; NI: No information;
2.4.7 Infection prevention and control (IPC) manual development The manual for Infection Prevention and Control (IPC) is being developed under the guidance of QIS and with support from the MaMoni HSS Project. The fourth meeting to update the manual was held during this quarter. Participants were from medical college hospitals (DMCH, SSMCH, ShSMCH, and BSMMU), DGHS, DGFP, DG Nursing, NIPSOM, and the National Institute of Neuroscience, and also included representatives from UNFPA and NGOs (SCI, Marie Stopes, NSDP). The manual is currently being revised based on the recommendations. It will be shared with all the stakeholders once completed.
2.4.8 Development of ICU QI standards QIS has initiated the development of a QI framework for ICU (Intensive Care Unit). In order to develop the framework, QIS has involved the eminent professionals of the country to develop the document. Three meetings have been held during this quarter. The meetings were attended by anesthesiologists, obstetricians and surgeons from BSMMU, BIRDEM, SSMC, DMCH, and ShSMCH. QIS is currently incorporating the feedback of the participants. MaMoni HSS staff are providing technical support to QIS in developing this framework.
2.4.9. Technical support to QIS (Development of technical materials)
MaMoni HSS is supporting QIS for developing (a) QI Communication Strategy, (b) PDCA training manual, (c) documentation on “Quality Improvement Secretariat Activities and Achievements” and (d) Patient Safety Strategic plan. (b) and (c) have been finalized after incorporation of stakeholder feedback and have been sent to printers. The remaining documents are still under development process.
2.4.10. Printing support to QIS During this period, MaMoni HSS project printed 100,000 copies of the safe surgery checklist and 1,000 copies of the guideline for distribution to the model hospitals and
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 44 medical college hospitals. Most of the checklists have been distributed by the QIS to the divisional QI coordinators to introduce the checklist at the model hospitals through QIC. The printed posters on 5S and patient-centered care have been handed over to the divisional QI coordinators for distribution as per the distribution plan developed by QIS. The posters are being distributed at the model hospitals.
2.4.11 Participation in QOC workshop in Tanzania The QoC network workshop was organized by WHO in Tanzania during 11-14 December, 2017. MaMoni HSS supported four participants, including three from the government, to attend the workshop. The staff participating in the workshop included MO-Clinic (MCWC Narsingdi), UH&FPO Shibpur, Narsingdi, Consultant OBGYN, Narsingdi DH and Divisional QI coordinator, Dhaka. The country team was led by the QIS.
2.4.12 Initiation of the process of healthcare institution accreditation system: MaMoni HSS extended support to the Hospital Services Management unit of DGHS for developing a “hospital accreditation act” in Bangladesh as per their Operation Plan. A Consultant has been hired to review the existing accreditation systems in Bangladesh and in the neighbouring countries, as well as to facilitate the process. One workshop was held at the Hospital Services Management unit of DGHS to review an existing draft act. It was decided that HSM Unit will prepare a revised draft of the Act and incorporate the inputs received. HSM will also engage a legal expert to help with the drafting of the Act. The MaMoni HSS project will assist in hiring the legal expert. USAID will provide support by involving two international experts on accreditation (with experience in the region) to review the past efforts and assist with the preparation of the Draft Accreditation Act. The consultants will be available in late January 2018. A wider consultation will be organized after re-drafting the Act to seek inputs from all relevant stakeholders. MaMoni HSS project will support the consultation process.
2.5 Improving delivery of MNCH/FP/N services in MaMoni HSS districts 2.5.1 Increasing local ownership of QI by establishing and supporting Quality Improvement Committees (QIC) and through the engagement of local government
The project continues to support the establishment and facilitation of QIC at district, upazila, and health facility levels. Major areas of support includes organizing QIC meetings, summarizing action points, and following up on the planned actions.
The table below includes an update on the status of the formation and activation of QI Committees at district and upazila levels by district. Table 8 Status of Quality Improvement Committee Formation and Activation by District
District Number of QI Committees Habiganj Noakhali Lakshmipur Jhalakati Total to be formed 18 19 11 10
Actually formed 18 19 11 10 Active (had at least 1 meeting in the 18 19 11 10 last 3 months)
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 45 2.5.2 Strengthening routine supervision system and promoting supportive supervision through Joint Supervisory Visits (JSV) The project supports joint supervisory visits (JSV) by second line government supervisors using structured checklists in areas including: infection prevention, service delivery management, ANC, nutrition, FP, newborn and child health, IMCI, normal vaginal delivery, and postnatal care. This facilitates gap identification, action plans for improvement, and follow up of results. Table 9 Examples of JSV finding and follow up action in Noakhali
Facility Observations Recommendation Last Status Parkote - Facility readiness for - On the job training - In place UH&FWC delivery service is good (OJT) provided - (Chatkhil) EDD list is not placed properly South Sarifpur - The premise is not - All the concerned - Better UH&FWC clean persons are requested than before - (Sadar) Documentation is not to make it happen and up to the mark SACMO/FWV will follow up it - OJT provided Neazpur - Registers are not filled - OJT provided - Improved UH&FWC up properly (Sadar) Sonapur - Updated EDD list is - OJT provided - Updated UH&FWC not available Kankirhat - Autoclave, Spot light - Requisition sent to - Follow up UH&FWC and Oxygen flow miter DDFP and once going on are damaged. available will be - No savlon supply confirmed Subarnochar - Not plotting the GMP - OJT has provided to UH&FWC card GMP potting - No IP logistic - Manager informed - Facility is not neat & Clean - Performance board was not updated - PW and EDD List not updated
2.5.3 Improving the quality of clinical care in stages
The project continues to provide support to the district health managers to improve the quality of clinical care provided by health facilities in stages:
. Stage 1: to improve cleanliness, infection prevention, and medical waste management;
. Stage 2: to improve sterilization measures and compliance with antenatal care and newborn care services, and
. Stage 3: to improve compliance with all range of MNCH/FP/N standards.
A total of 264 facilities are under continuous monitoring and stages are determined accordingly. Among these facilities, 158 facilities are in Stage-01, 70 facilities are in Stage-02 and only 36 facilities are under Stage-03.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 46 Table 10 Status of facilities in by stage Stages Facility Habiganj Jhalakathi Noakhali Lakshmipur Total (N=264) (n= 79) (n=35) (n=93) (n=59) Stage – 01 UH&FWC 32 22 67 18 139 UHC 07 03 07 00 17 MCWC 00 00 01 01 02 DH 01 00 01 00 02 Total 40 25 76 19 158 Stage – 02 UH&FWC 24 02 11 27 64 UHC 00 00 00 03 03 MCWC 00 01 01 00 02 DH 00 01 00 00 01 Total 24 04 12 30 70 Stage – 03 UH&FWC 14 06 05 07 32 UHC 00 00 00 01 01 MCWC 01 00 00 01 02 DH 00 00 00 01 01 Total 15 06 05 10 36
Figure 20 Distribution of facilities by stages
13.96
26.04 60
Stage1 Stage2 Stage3
2.5.4. Monitoring quality of care at sentinel facilities MaMoni HSS monitors the quality of care in selected facilities through a sentinel survey. Figures 21-23 display the comparisons of phase 1 and phase 2 survey findings on the quality of care of ANC and FP services. The total number of clients observed for ANC counseling was 1,237 in 2016 and 1,204 in 2017 in four MaMoni HSS districts. The graphs show considerable improvement in all areas observed during the provision of services. Counseling practices showed marked improvement in the importance of breastfeeding, PPFP, and complications during pregnancy, including the importance of four ANC visits. The total number of clients observed for FP counseling was 1,196 in 2016 and 1,202 in 2017 in four MaMoni HSS districts. The graphs show marked improvement in using job aid during counseling, including asking the client for feedback (which was very poor last year).
During the reporting quarter, the project completed conducting the third round of the QoC Sentinel Survey. Data collection started in Habiganj, Noakhali, Lakshmipur, and Jhalokati districts. In addition to direct observation of services, a new tool for exit interviews with a sample of postpartum women who delivered in the health facility will be conducted to assess the client’s experience of childbirth services.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 47 Figure 21 Percentage of pregnant women received ANC as per protocol
96 100 95 92 96 99 100 91 86 80 80 74 60 40 20 0 BP measured Weight measured Hemoglobin test Urine albumin test Iron folic acid given conducted conducted
Phase 1 (2016) Phase 2 (2017)
Figure 22 Percentage of women received counselling during ANC service
100 82 74 73 76 76 80 64 66 68 60 51 38 39 40 34 21 22 20 0 4 ANC Danger signs Institutional/safe PPFP Breastfeeding Exclusive Iron Folic Acid during pregnancy delivery within 1 hour of breastfeeding birth
Phase 1 (2016) Phase 2 (2017)
Figure 23 Percentage of women received counselling during Family Planning Service
100 96 99 77 80 70 69 55 56 59 60 40 30 20 9 0 Audio/visual privacy Exploring client's Discussion on side Receiving client's Job aid used experience effects feedback
Phase 1 (2016) Phase 2 (2017)
2.5.5 Supporting the implementation of Maternal and Perinatal Death Surveillance and Response (MPDSR)
During the reporting period, MaMoni HSS continued to support the QIS in the implementation of MPDSR at the facility level in Habiganj, Noakhali, Lakshmipur, and Jhalokati districts. In the project areas, community level MPDSR (i.e. death notification, verbal autopsy and social autopsy) are conducted only in the Begumganj Upazila of Noakhali district. The Facility level MPDSR has been rolled out in all districts and upazila level facilities (i.e., District/Sadar Hospital, MCWC & Upazila Health Complex) in MaMoni districts. MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 48
MaMoni HSS has been trying to develop at least one facility in each district where MPDSR is implemented as a model against set criteria. In response to the initiative, each district has set District Hospital/Sadar Hospital as the model facility for MPDSR. Table 11 shows the data for community MPDSR.
Table 11 Community level MPDSR at Begumganj upazila, Noakhali
Death Verbal Social Deaths Notification Autopsy Autopsy Maternal Death 03 03 03
Newborn Death 17 03 03
Total 20 06 06
2.5.6 Standard Based Management & Recognition (SBM-R): Standards-based Management and Recognition (SBM-R) is a practical management approach for improving the performance and quality of health services. This includes facility management that consists of the systematic utilization of performance standards as the basis for the organization and the functioning of these services in addition to the rewarding of compliance with standards through recognition mechanisms. SBM-R follows four basic steps: • Setting standards of performance in an operational way • Implementing the standards through a streamlined and systemic methodology • Measuring progress (one baseline [external assessors] followed by two internal [peer review] and one external assessment [external assessor]) to guide the improvement process towards these standards • Recognizing the achievement of the standards
This process begins with the development of evidence-based operational standards in a specific area of health service delivery. The performance standards developed are included in an assessment tool that can be used for self, peer, internal, and external assessments at the facility level.
During the reporting period, the 2nd cycle of SBM-R has completed in Noakhali and Lakshmipur and the 1st cycle has completed in Jhalakathi. The Habiganj team has completed the 2nd cycle of Phase-01. After assessment, all observations are being compiled and action plans will be developed through a joint meeting between the observer and the observant. Key findings and action plans will be shared in next quarterly report. Table 12 shows the SBM-R implementation status by district.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 49 Table 12 SBM-R implementation status by districts
Cycle-01 Cycle-02 Remarks Districts Baseline 1st 2nd 1st 3rd 4th 2nd Internal Internal External Internal Internal External
Habiganj
Jhalakathi
Noakhali
Lakshmipur
Legend Complete
2.5.7. Implementing status of ‘5S’:
‘5S’ has been implemented at different facilities at district and upazila levels. As per protocol, the five components (sort, set, shine, standardize, and sustain) of ‘S’ have been implemented through different ‘Work Improvement Teams (WITs)’. MaMoni HSS has been trying to facilitate local level managers to introduce the ‘5S’ which will in turn ensure overall quality. Initially, the facilities are trying to keep in place the 3Ss (sort, set and shine) in situ at facility level. Required capacity building has done accordingly across the districts. Some examples (photographs) are below from Lakshmipur district hospital:
Before applying ‘5S’ After applying ‘5S’
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 50 2.5.8 Supporting CEmONC through Regional Roaming QI Teams (RRQIT)
MaMoni HSS project has been working closely with DGHS and DGFP in six districts to develop a comprehensive QI framework at district level and below. MaMoni HSS mobilizes professionals from OGSB, BPA, and BNF to develop a Regional Roaming Quality Improvement Team (RRQIT), as a technical team consisting of DGHS, DGFP and professional organizations in the MaMoni HSS project area. The 5th visit in Jhalokathi and the 3rd visits in Lakshmipur and Noakhali were organized in this quarter.
Observations in Jhalokathi: Main observations in the district hospital and MCWC were as follows:
District Hospital • Bed occupancy rate was 168% • 12% of beds were allocated for pediatric patients. Among them only two beds were allocated for KMC corner, where eight neonates were admitted during visit • 24/7 ambulance service was available • Laboratory service was not available • Most of the MOs are on deputation and some positions are still vacant • No gate keeper present for controlling visitors
MCWC • No FWV, sweeper, cleaner and aya position. Some were attached for supporting. • Only one autoclave with low capacity. Need more autoclave or a larger one.
Observations in Lakshmipur:
District Hospital
• Bed occupancy was more than 100% • 18 beds were allocated for children patients (on the day of visit, 41 child patients were admitted for 18 beds (Bed Occupancy Rate: 227%). Need more beds for neonates, KMC & In SCANU & SAM • The IMCI-N Corner was functional • The facility had a functional breastfeeding corner/ORT corner • The facility had an isolated ward for infectious diseases • Uninterrupted power supply. Power back up was available • Running water supply exists • 24/7 ambulance service was available • 24/7 laboratory service was not available • Neonatal Death Review was taking place on a regular basis
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 51 Table 13 Progress in implementing RRQIT initiative in Districts
Major findings from previous visits Improvement
Jhalokati
Lack of cleanliness at district hospital Improved cleanliness at district hospital premises premises and inadequate visible signboards and arrangement of visible of health message providing health messages providing signboards.
No functional QI Committee at DH & MCWC. Functional QI Committee at DH & MCWC.
No dumping pit at MCWC. Dumping pit construction at MCWC is ongoing.
Partograph & AMTSL practice at DH & Partograph use & AMTSL practice improved at MCWC was not regular DH & MCWC
Digital X-Ray & USG Machine non-functioning Functioning Digital X-Ray & USG Machine at DH at DH
Delivery room utilization increased
Formal debriefing session Dumping pit for MCWC under construction Lakshmipur
Major findings from previous visits Improvement
For uninterrupted power supply there was No 24 hours power backup has been arranged power backup.
Limited practice of Maternal and Neonatal • MPDSR Sub Committee formed Death review • Death notification was in full swing • All nurses of DH are trained in MPDSR • All physician in Gynecology and Pediatrics ward were trained MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 52 Two radiant warmer were malfunctioning in Radiant warmer repaired with the support from SCANU MaMoni-HSS
Tiahrt chart was not available in the at the Tiahrt chart has been provided (DH & MCWC) service delivery point (DH & MCWC)
QI Committee was inactive at DH & MCWC QI Committee is now functional at DH & MCWC
Less use of partograph for NVD at DH & Regular use of partograph for NVD at DH & MCWC and lack of staff motivation MCWC has been started.
Temperature chart was not being maintained Temperature chart is now being maintained in all the wards of DH regularly in all the wards of DH
Haphazard filing and documentation in the Filing and documentation maintained properly in Gynecology ward and SCANU the Gynecology ward and SCANU by following 5S Kaizen
Signage for wards were not present in DH Adequate and proper Signage for wards are present in DH
Well-functioning SCANU Improved Filing system
At the end of the visit, a formal debriefing session was conducted in presence of CS & DDFP with key officials from respective departments. The group discussed the observations, changes, achievements, and problems and also developed a comprehensive action plan to improve the situation for ensuring health and family planning services at the district hospital and MCWC.
2.5 Develop comprehensive logistic management systems for essential MNCH/FP/N commodities at the district level 2.5.1 Monitoring and improving the availability of essential MNCH/FP/N drugs
2.5.1.a Coordination with SIAPS, MSH
MaMoni HSS is implementing eLMIS in Noakhali, Habigonj and Jhalokathi districts with support from SIAPS/MSH. Monthly reporting in DHIS-2 started from August, 2017 from Community Clinics, Union Sub Centers, Upazila Health Complexes, District Hospitals and District Reserve Stores.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 53 Figure 24 Reporting rate of e-LMIS in DHIS 2 after scale up in Noakhali, Habiganj and Jhalokathi district
120% 100% 100% 97% 95% 100% 88% 85% 87% 75% 74% 80% 72% 68% 60% 60%
40%
20%
0% 2017 2017 2017 2017 August, September October November
Habigonj Jhalokathi Noakhali
2.5.2 District level activity for improving availability of MNCH essential drugs and family planning commodities
2.5.2 a. Trouble-shooting meeting on electronic-Logistics Management Information System (eLMIS) for priority Maternal, Newborn and Child Health Medicines reporting in DHIS-2: Trouble shooting meetings were arranged in order to improve the data quality of eLMIS and to reduce the number of facilities that do not report in eLMIS. The one-day meetings were arranged at the upazila level to reduce knowledge gaps and ensure correct e-LMIS reports from each provider through hands on technical sessions. GOB managers were present in the meeting and will follow up on eLMIS reporting in the future. During the reporting quarter, troubleshooting meetings were completed in all upazilas of Lakshmipur district, two upazilas of Habiganj and two upazilas of Jhalokati district. All the upazilas of Habiganj, Noakhali and Jhalokati district will be completed in the next quarter.
Pictured above: Trouble shooting meetings for eLMIS use.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 54 2.5.2.b. Improved store maintenance at Kathalia UHC store following technical assistance from MaMoni HSS:
Program staff visited the Kathalia UHC store and found that the store condition shown significant improvements after technical support from the MaMoni HSS program.
Photo: Store keeper Rajapur UHC is maintaining temparure chart in the store by using temparature monitoring device and the medicines are well arranged to show the expiration date and use of BIN card for individual medicines. 2.5.2.c. Meeting with statisticians and store keepers of MOHFW on record keeping, reporting, and data utilization of LMIS including e-LMIS Meetings with statisticians and store keepers of the MOHFW were arranged on record keeping, reporting, and data utilization of LMIS - including e-LMIS - in Lakshmipur, Habigonj and Jhalokathi districts. The objective of the meeting was to share an overview of the e-LMIS reporting system in DHIS2 and the use of data to prevent stock-out in DGHS supply chain management. An overview of the Supply Chain Management Portal (SCMP) of the MOHFW was also shared to show how data can be used from the Portal to improve the availability of essential MNCH medicines and FP commodities in DGFP supply chain management.
Photo: Meeting with statistician and store keepers of MOH&FW at Habigonj and Jhalokathi district respectively.
The findings from color coded reporting were shared to improve record keeping, reporting, and data use for better distribution, utilization, stock out prevention, and to reduce misuse of MNCH essential medicines in upazila stores and facilities that provide MNCH services.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 55 Figure 25: Monthly availability of misoprostol tablets at selected DGFP upazila stores in Lakshmipur district
Sl Name of the Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec No store 17 17 17 17 17 17 17 17 17 17 17 17 1 Sadar 2 Kamalangar 3 Ramgonj 4 Ramgoti 5 Raipur
Item is available Item is not available (Stock Out) Item is available but has a stock that will expires within 6 month
Figure 25 shows the availability of Tab. Misoprostol 200 µGM (2 tabs = 1 dose) at DGFP stores of Lakshmipur district. It shows the short dated Tab. Misoprostol (with an expiration date of less than six months) was available in January and February, 2017 (marked with yellow color) and was distributed to the providers. Then the new lot of medicine was available from March to December, 2017 in all DGFP stores of Lakshmipur district except Ramgonj where it was not available in April –May, 2017.
Figure 26: Monthly availability of 7.1% Chlorhexidine at selected DGHS medical stores in Jhalokati district
Sl. No. Name of the store Jul. 17 Aug.17 Sep.17 Oct.17 Nov.17 Dec.17 1 CS store 2 District Hospital 3 Nalchiti 4 Kathalia 5 Rajapur
Figure 26 shows the availability of 7.1% Chlorhexidine at DGHS stores of Jhalokati district from July to December, 2017. The figure shows that it was available in all the upazila stores of DGHS except Civil Surgeon store. The yellow color is used to indicate that the expiry date of the medicine is February 2018 and needs immediate action to be taken to prevent misuse.
Use of color coded reports for prevention of stock out:
In Habiganj: • Through the use of the color coded report it was identified that Ajmeriganj & Chunarughat upazila had a stock out starting from the third week of November. The Regional Ware House in Sylhet also had a stock out. MaMoni HSS facilitated the process of distribution of 200 pcs of Tab. Misoprostol to Ajmeriganj from Nabiganj. In Chunarughat upazila, the redistribution between unions was facilitated for uninterrupted service delivery. • There was a stock of 840 pcs of 7.1% Chlorhexidine in Habiganj Sadar upazila store with an expiry date of February 2018 which Sadar upazila would not be able to
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 56 consume. The project facilitated the process of redistribution of the 840 pcs from Sadar upazila store to the District Hospital, Habiganj so that they could be used properly before expiration. • The Deputy Director of Family Planning (DDFP), Habiganj generated a report to the regional warehouse in Sylhet and follow up is on-going. As a result, Habiganj will receive 10,000 pcs of Tab. Misoprostol by end of January, 2018. • DRS, Habiganj has also planned to procure 1,40,000 pcs of Tab. Misoprostol in this financial year. • MaMoni is facilitating a proposal from DDFP to all Upazila Parishads of Habiganj to mobilize local government funds to purchase misoprostol. • Madhabpur upazila parishad allocated a budget of Taka 1,26,000 for Tab. Misoprostol.
In Jhalokati:
• The District Reserve store initiated the process to procure 1000 bottles of 7.1% CHX from the local market. • 2,000 pcs of Tab. Misoprostol were collected by Patuakhali RWH for use in Nalchity upazila. • 30 sachet of SAM food (F-100) were collected from Kawkhali UHC for use in the Rajapur SAM unit. • The program facilitated local redistribution of 40 bottles of 7.1% CHX from Shekherhat and Nobogram Union to Kirtipasa Union FWC.
2.6 Improve local governance and oversight for MNCH/FP/N The MaMoni HSS project along with DGHS and DGFP participated in ward level meetings of union parishads to facilitate budget allocations for MNCH/FP/N services. Advocacy and planning meetings were conducted with all union parishads in MaMoni districts to engage them in quality service delivery from the UH&FWCs. The Union Parishad (UP) has deployed two paramedics (in Charbhata UH&FWC of Subarnachar Upazila and Rajganj UH&FWC of Begumganj Upazila) in Noakhali and one paramedic in Vatra (Dolta) UH&FWC of Ramganj upazila in Lakhsmipur. The district teams worked to engage more UP’s to motivate them to take on the responsibility of deploying service providers (paramedics) in the UH&FWCs of their respective union centers. A remarkable achievement was made by involving the UPs to take the lead and also to mobilize funds to upgrade and/or maintain the services at 24/7 UH&FWCs. The community and UP of Nijhum Dwip started round the clock delivery services from a cyclone shelter of Nijhum Dwip, the isolated island of Hatiya. A seventy seven foot road has been constructed with community participation for easy access to services in this facility. The below table shows the fund allocation and utilization status by local government bodies for MNCH/FP/N activities for the period of July 2017 to Sept 2017. These funds were mainly used for the construction, repair, and maintenance of facilities as well as to purchase emergency medicine (especially during stock-outs), purchase small medical and MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 57 non-medical equipment and logistics; provide financial support to temporary support staff; and construct approaching roads.
Table 14 Upazila Parishad budget allocation and utilization, July 2017 to Sept 2017 Number of Percentage of Total budget Total budget Percentage Number unions unions District allocated FY-17- utilized (BDT) of budget of unions allocated allocated 18) (BDT) up to Nov 17 utilization budget budget Habiganj 77 77 100 9,941,350 1,50,595 15 Jhalokati 32 31 97 4,054,000 657,500 16 Lakshmipur 58 56 97 1,60,17,505 9,86,437 6 Noakhali 91 90 99 9610000 1212750 12 Total 258 254 392 23605350 1870250 49
IR 3. Promote an enabling environment to strengthen district level health systems 3.2 Strengthen advocacy and coordination for adoption of evidence-based learning in national policy and program 3.2.1 Participate in national and district level campaign activities on various national days MaMoni HSS supported the MOHFW at the national as well as at the district level to observe the following national and international days related to MNCH/FP/N issues:
• Family Planning Service and Campaign Week • World Prematurity Day
For the FP service week, MaMoni HSS supported the printing of Information, Education and Communication (IEC) materials to commemorate the event. MaMoni HSS also participated in roundtable discussion on World Prematurity day
At the district level, the project supported the Civil Surgeons and Deputy Directors of Family Planning by organizing collaborative meetings for presenting district situation and performance; participating in rallies; organizing volunteers to refer community members to the health facilities; and holding special SBCC events, such as development fairs in hard to reach areas.
3.3 Conduct and disseminate operations research and program learning / documentation activities
MaMoni HSS collaborated with various partners to document MaMoni HSS lessons on various issues. Four of the MaMoni HSS program issues were shared in international forums in two countries (UK and Vietnam) through oral and poster presentations. At the time of submission of this report, two manuscripts have been prepared for peer reviewed journals, and are undergoing review. Appendix 4 summarizes the topics that have been presented in different global forums. MaMoni continued three program learning initiatives during the reporting period. The program learning topics initiated are:
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 58 • A national case study on the nationwide scale up of 7.1% CHX
• A competency assessment of FWVs to effectively screen for pre-eclampsia/eclampsia
• Implementation research to reduce the discontinuation of LARCs (IUCD and implants) Data collection on this program learning is ongoing. MaMoni HSS also supported MEASURE DHS to conduct the Bangladesh Health Facility Survey 2017, a validation study on select chronic maternal morbidities, and the project is conducting routine process documentation on 25 other topics. A summary of these process documentation activities has been provided in Appendix 5.
3.4 Strengthening NIPORT to deliver a capacity-building program for community level health workers to deliver community-based interventions of the essential services package
a) Rapid assessment of the institutional and managerial capacity of NIPORT and its RTCs
An assessment on the capacity of NIPORT and its Regional Training Centers was conducted through a structured questionnaire. A short term technical expert assisted the process. Throughout the assessment, NIPORT officials were involved with the MaMoni HSS team in analyzing the data and suggesting recommendations for sustainable development of NIPORT and its RTCs. A directory with information for each RTC is attached with the assessment report. This report is being finalized in consultation with NIPORT and will be shared soon.
b) Mapping of potential collaborating institutions to manage large- scale training of CHWs A structured questionnaire was developed in consultation with NIPORT and MaMoni HSS to collect information on potential collaborating institutes in all 64 districts to manage large scale training of community health workers (CHWs), supervisors and managers. This data collection involved all the training quality monitoring officers of MaMoni HSS. Data collection has been completed and data analysis and report writing are ongoing.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 59
c) Rapid assessment of FWVTI and FTC A sustainable capacity development approach to NIPORT must be inclusive of capacity development for its Family Welfare Visitor’s Training Institute (FWVTIs) and Field Training Centre (FTC) along with the RTCs. With this in mind, NIPORT and MaMoni HSS conducted a rapid assessment of 12 FWVTI and 31 FTCs. Data collection was done by the Training Quality Monitoring Officers from MaMoni HSS along with continuous assistance from NIPORT and its FWVTIs and FTCs. Both data analysis and report writing are ongoing. Training Curriculum Development: d) Update on Team Training for HA, FWA and CHCP
After a series of Core Committee meetings and Technical Committee meetings, the participants’ hand book and trainer’s manual were developed. A consultation meeting for reviewing the revised curriculum will be held with the concerned USAID funded program representatives. A ToT and a series of trainings will be organized in the next quarter.
e) Revision of supervision, monitoring, and follow up training for first line supervisors The contents for the training curriculum were finalized after a core committee meeting and approval of the technical committee. Finalization of the content is ongoing through active participation of core committee members. Following a review of the curriculum by multiple stakeholders through a consultative meeting, the technical committee will approve the curriculum. A ToT will be organized in the following quarter.
f) Leadership and management training for upazila level managers The content of the leadership and management training for upazila level managers was identified after consultation with selected upazila level managers. The core committee for this curriculum development is comprised of members from DGHS, DGFP, BSMMU, NIPORT, John Hopkin’s university and MaMoni HSS. This technical committee reviewed and approved the contents. A national level consultant has been hired to develop the curriculum. Testing of the curriculum will be done in January 2018 after which a ToT will be planned.
g) Digitalized information system of NIPORT: Based on the NIPORT and RTC assessment findings it was revealed that the management information system of NIPORT and its RTCs need upgrading. This will be done by establishing a digitalized system of training management, asset management and effective linkages with the existing human resource and management information systems (MIS) of MOHFW, especially DGHS and DGFP.
In consultation with NIPORT, the software development team of MaMoni HSS is developing a digitalized system for NIPORT asset management (AMS). In-house testing of the software is on-going and will be installed in NIPORT by next quarter.
The training management system and the establishment of a linkage with the MIS of MOHFW is also in progress. In collaboration with MEASURE Evaluation, the initial planning and designing has been done and consultation with DGHS and DGFP has been
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 60 completed. The development team is now working for the process of software development.
Achievements:
. A good rapport has been made with the NIPORT officials . Strong coordination between DGHS, DGFP & NIPORT has been re-established . The collaboration between CBHC & NIPORT has been developed and CHCPs were successfully incorporated in the team training . Coordination between NIPORT and other training/academic institutes (such as NIPSOM, BSMMU) has started to develop. . Good coordination with other USAID funded projects like ICHW, Ujjiban has been established.
IR 4. Identify and reduce barriers to accessing health services
4.1 Reaching the community through Aponjon services Aponjon continues to provide critical maternal, newborn, child health, nutrition and family planning messages to pregnant and lactating mothers during pregnancy and the postpartum period through the subscription-based Shogorbha program. As of December 31, a cumulative total of 2,029,248 women have subscribed to the messaging service, an increase of 14,123 in this quarter. A prepaid model was launched and was designed to ensure timely revenue for Aponjon and to ensure subscribers will not miss content due to an insufficient balance. Currently nine local NGOs partner with Aponjon to promote its services and acquire subscribers. Figure 27 Aponjon Shogorbha acquisition trend Jan-Dec 2017
7000 6000 5000 4000 3000 2000 1000 0 1-Jan 1-Feb 1-Mar 1-Apr 1-May 1-Jun 1-Jul 1-Aug 1-Sep 1-Oct 1-Nov 1-Dec
Brac Tothyokollyani VPKA Foundation Janasheba MUK MKS PADMA-JHENIDAH Prattasha Shimantik Prepaid Others
Aponjon also targeted smartphone users and maintains an interactive Shogorbha app through Android, iOS and Windows mobile platforms. 12,696 women downloaded the app in this quarter. An average of 40,000 blog readers visit the Aponjon blog every month. The social media reach of Aponjon is 1.5 million.
During the last fiscal year Aponjon worked to revamp the website to become more service oriented and to fit the future plans for products and services. The development of phase two has been going on during this quarter focusing on adding new tools (i.e. ovulation MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 61 calendar) and mother’s forum. The initial launch of f-commerce has commenced in January.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 62 Table 15 Cumulative mobile app downloads of Aponjon Shogorbha and Koishor
Shogorbha App Koishor App OS Android Windows iOS Android Windows iOS April 3405 155 40 2035 155 25 May 1517 151 29 1333 180 4 June 2040 117 26 2196 130 3 July 5256 136 36 59 127 1 August 7144 125 50 41 88 0 September 8469 106 214 84 92 20 October 5484 105 48 64 105 4 November 2357 98 13 29 98 0 December 4515 64 12 39 64 0 Grand Total 40187 1057 468 5880 1039 57
APONJON CALL CENTER Aponjon manages a call center as a customer facing live interface and provides support for general service related issues and queries as well as for medical related issues. The call center agents and medical professionals provide service on a 24/7 basis with varying capacity through voice call and chat services. Below are the call summary of the 1st quarter. Table 16: Inbound and outbound call summary for call center and counseling line
INBOUND CALL OUTBOUND CALL
MONTH Call Counseling Call Counseling Date of birth QA- center line center line update QC
OCTOBER 876 810 21 103 1,352 21,830
NOVEMBER 859 683 186 99 445 13,794 DECEMBER ****** 817 1003 162 150 547 TOTAL 2,552 2,496 369 352 2,344 35,624
4.2 Enhanced community engagement in addressing health needs
Community mobilization
4.2.1 Community mobilization in high intensity districts; Habiganj, Lakshmipur and Hatiya Community Action Group (CAG) meetings and Community Microplanning Meetings (cMPM) were facilitated by HAs and FWAs (front line MOHFW field workers). Field Support Officers (FSOs) supervised CAG meetings, cMPM and union follow-up meetings in two unions. The upazila level facilitators for service delivery monitored all activities in the upazilas. At present there are 23,929 community volunteers/CAGs active in high intensity upazilas in MaMoni HSS districts.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 63 4.2.2 Community mobilization in other districts; Noakhali and Jhalokati CAG meetings and cMPMs were facilitated by frontline MOHFW field workers – HAs and FWAs. Health Assistants took over the responsibility of cMPM facilitation and reporting. The cMPM report includes CAG meeting information from the area. Eighty-eight percent of cMPMs are regularly conducted by HA and FWAs in MaMoni HSS areas. Table 17, Table 18 and Table 19 show CAG and cMPM related performance of Habiganj, Lakshmipur, 5 upazilas of Noakhali and Jhalokathi districts during the reporting quarter. Table 17 Percentage of community action group meetings held against plan Name of the District CAG planned CAGM held % of CAG against plan Habiganj 25000 20859 83 Lakshmipur 19141 12757 67 Noakhali 20510 10722 52 Jhalokati 6915 2415 35 Total 71566 46753 65
Table 18 Percentage of community microplanning meetings held against plan
% of cMPM against Name of the District cMPM planned cMPM held plan Habiganj 2744 2691 98 Lakshmipur 2040 2023 99 Noakhali 1857 1357 73 Jhalokati 1118 794 71 Total 7759 6865 88
Table 19 Percentage of community microplanning meetings where both HA and FWA attended
# cMPM where both % cMPM where both Name of the District # cMPM held HA and FWA HA and FWA attended attended Habiganj 2691 2147 80 Lakshmipur 2023 1494 74 Noakhali 1357 799 59 Jhalokati 794 373 47 Total 6865 4813 70
Table 20 Number of pregnant women identified and LAPM referred
# of pregnant women Name of the District # of LAPM Referred by CVs identified Habiganj 8347 765 Lakshmipur 7336 533 Noakhali 5244 228 Jhalokati 1553 77 Total 22480 1602
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 64
4.2.3 Piloting community microplanning meetings through Community Support Group (CSG) In project year 4, MaMoni HSS initiated community micro planning meetings (cMPMs) through the community mobilization structures of government - community support groups (CSGs) - in 3 unions of 3 districts: Noakhali, Habiganj and Jhalokathi. In Year 5, cMPMs through CSGs scaled up in another 4 unions of Habiganj, Lakshmipur and Jhalokathi. During Oct-Nov 2017, 55 CSG-based cMPMs were held in the unions where it is rolled out. A total 167 pregnant women and 138 child births were notified throug the cMPMs. Based on the experience of these unions, this initiative will be scaled in selected upazilas through CBHC.
4.2.4 Transformation of MaMoni Community Volunteer (CV) to Community Sales Agent (CSA) In the project year 4, MaMoni HSS initiated the transformation of selected MaMoni CVs to CSAs in 3 unions of 3 districts. This activity was designed in collaboration with the Social Marketing Company (SMC). The experience of developing women entrepreneurs as CSAs – following the “Notun Din” project of SMC – has been replicated in MaMoni HSS. Based on the experience of these 3 unions, this model has been scaled up in 6 unions of Noakhali, Lahshmipur and Habiganj in quarter 1 of year 5. In this quarter, a total of 37 CSAs started selling commodities in 9 unions of 3 districts; Habiganj, Noakhali and Lakshmipur. In addition to selling commodities, CSAs sold a total of 34 Hexicort (7.1% CHX) and ensured application in newborns’ umbilical cord.
Challenges, Solutions and Action taken Challenges and Mitigation Strategies . PE/E case detection: Though number of total cases increased due to increased number of intervention areas, the PE/E case detection is quite far from the estimated number, only 10% of the cases have been identified and managed from UH&FWCs. The project is working with the local level health managers and service providers to aware pregnant mothers and their families on the consequences of severe PE/E and importance of ANC during pregnancy.
. Misoprostol distribution: Despite of multipronged efforts of the project, misoprostol distribution coverage is still low in the project areas, only 54 percent of pregnant women received misoprostol in the reporting quarter. The main reasons are vacant positions of FWAs, inadequate home visits, lack of a need-based distribution system, and occasional stock outs. The project has taken several initiatives to address the issue such as reinforcing its importance through quarterly performance review meetings at the district level, working with the MOHFW to develop a need-based distribution system - including monitoring the stock and distribution status - as well as focusing on increasing the ANC3 coverage. A pilot is underway in Lakshmipur district for distribution of misoprostol and 7.1% CHX together in a packet both at community and facility level during third trimester of pregnancy. Misoprostol has been made available
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 65 to community sales agents and the project will initiate a discussion with local NGOs to explore the distribution of misoprostol through NGO community health workers. . Lack of coordination between QIS and implementing wings of DGHS and DGFP: The lack of coordination between the Quality Improvement Secretariat and Hospital Services Management (HSM) unit of DGHS and the service delivery units of DGFP has remained as a constant challenge for implementation of QoC in Bangladesh. MaMoni HSS has initiated working with the Hospital Services Management , and also ensures the involvement of HSM/DGHS and MCRAH/DGFP in QIS activities. . Continuity of services provided by Paramedics: MaMoni HSS has been filling the HR gaps through recruitment of Paramedics, but as the project is nearing its end, dialogue with local health and family planning managers as well as local government has been initiated so that these staff may be absorbed and MNCHFP services continued through the paramedics. Advocacy and planning meetings were conducted with all union parishads in MaMoni districts to engage them in quality service delivery from the UH&FWCs. So far 3 Paramedics have been taken over by the Union Parishad. The district teams are working hard to engage more UPs and motivate them to taking over the responsibilities of deploying service providers (paramedics) in the UH&FWCs of their respective union centers. . Shortage of manpower in NIPORT: Shortage of faculty members in NIPORT is a challenge for conducting trainings. However, resource pools are being identified from government and non-government sectors. NIPORT will develop the capacity of the resource pool and engage them in conducting the trainings, while the sessions will be monitored by training quality monitoring staff. Another challenge is developing collaboration of NIPORT with other government or non-government training institutes for conduction of large scale trainings. NIPORT’s policy doesn’t support this kind of coordination, and MaMoni HSS is exploring ways for developing this type of collaboration.
Way Forward In the second quarter of year five, the project will initiate close-out activities in all districts while focusing more on national activities. Technical assistance to NNHP implementation and HSM OP implementation will be strengthened. Continuation of MaMoni interventions through government systems will be facilitated at all levels. Also documentation of lessons learned and dissemination of results will be done in a systematic manner. Some of the major focus areas are as follows: . The last round of the tracer survey will be conducted. This survey will work as the endline assessment for the MaMoni HSS project. . The implementation of the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) QI framework by adapting WHO guidelines for pilot implementation in Narshingdi district hospitals - two UHCs and MCWCs. The expected duration of the pilot is one and a half years, which will begin in January 2018.
. Bangladesh and Ethiopia are the two leading countries implementing outpatient treatment for possible severe bacterial infections (PSBI) in newborns and young infants. Results from trials conducted in these countries were instrumental in the
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 66 development of the WHO guideline Managing possible severe bacterial infection in young infants when referral is not feasible. To deepen the cross-program learning on community based PSBI implementation, scale up, and sustainability, and to put it in a long-term context, a global initiative has been undertaken which MaMoni HSS is a part of. The aim of the initiative is to contribute information on the implementation of country-led transformation of newborn health within child health and other health systems more broadly. . MaMoni HSS is supporting the development of SCANUs in MFSTC and MCHTI - 2 hospitals under DGFP – and will gradually equip them to provide Comprehensive Newborn Care Package (CNCP) training. Also a SCANU will be developed in Khulna Shishu Hospital, located in the southwest corner of Bangladesh which is far away from Dhaka city. MaMoni HSS is developing this hospital as a center of excellence to serve the newborns in that area as well as to work as a regional training center for staff capacity building in the region.
. To support the MOHFW for a “National Assessment of Facility Based Sick Newborn Care”, a joint collaboration of UNICEF and MaMoni HSS has been undertaken. A joint dissemination will be organized to share the report with a broader stakeholder group. It is expected that this assessment will inform and guide policymakers regarding best practices and bottlenecks for improving facility-based sick newborn care. . Dhaka Medical College Hospital and Sir Salimullah Medical College Hospital will be developed as centers of excellence for providing CNCP trainings. . Revisit of priority newborn interventions completed in 64 districts. Data is being compiled and a report will be published and disseminated in the next quarter. . MaMoni HSS district staff will continue coordinating with local government (mainly union parishads) to deploy paramedics where the project had been filling critical human resource gaps. Three paramedics have been deployed by UPs so far. . As part of DGFP operational plan, eMIS will be rolled out in 5 districts in this year. In collaboration with MEASURE Evaluation, eMIS in Noakhali and Natore will be initiated in the next quarter. . MaMoni HSS is supporting the QIS to develop an infection prevention manual, patient safety strategic plan and patient centered communication strategy. These documents will be finalized through stakeholder consultation.
. MaMoni HSS initiated a process of supporting Hospital Services Management (HSM) unit of DGHS to draft an act for hospital accreditation. A national consultant has been hired. A legal consultant and 2 international consultants will be recruited for this work in the next quarter.
. In collaboration with WHO Bangladesh, the project will support the HSM unit of DGHS to develop a referral care guideline which is a key activity in the operational plan. . Upcoming activities in the next quarter related to NIPORT:
Digitalization of training management system and asset management system through establishing an effective linkage with DGHS and DGFP
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 67 Leadership and management training roll out for upazila level managers and team training roll out for community health workers
The first line supervisor’s training on supervision, monitoring and follow up.
An expert group of training quality monitors will be developed with representatives from DGHS, DGFP, NIPORT and MaMoni HSS. Quality of training will be ensured through capacity development and continuous monitoring.
A capacity building package on harmonized job description for CHW (both public and private) to ensure an optimum level care.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 68 APPENDIX 1: SCOPE AND GEOGRAPHICAL COVERAGE OF MAMONI HSS PROGRAM
The program’s objectives are well aligned with the GOB’s Health, Population, and Nutrition Sector Development Program (HPNSDP) for 2011–2016; and also directly support the USAID/ Bangladesh Development Objective 3 (DO 3: “Health Status Improved”), which is under the “Investing in People” objective of the Country Development Cooperation Strategy (CDCS) framework of USAID in Bangladesh. MaMoni HSS designed a two-pronged approach in which districts and upazilas were categorized into one of two groups—high-intensity intervention areas and health system capacity strengthening areas. The aim of the high-intensity High areas is to demonstrate best-practice models of Health System MNCH/FP/N health care delivery through intensive support to the GOB, and if needed, direct implementation to maximize learning and advocacy for scale-up nationally. Based on an analysis of gaps in coverage and equity of access to high-impact MNCH/FP/N services, the project identified a total of 23 upazilas across five districts to serve as the project’s high-intensity areas. Of the 23 upazilas, district saturation was achieved in Habiganj, Lakshmipur, and Jhalokathi districts, while in the Noakhali and Pirojpur districts, four and two upazilas were supported, respectively. The health systems (HS) capacity strengthening areas cover a total of 17 upazilas—all seven upazilas of Bhola, five upazilas of Noakhali, and five upazilas of Pirojpur (refer to Figure 1 and Table 1). While the high-intensity areas focus on support for a complete package of MNCH/FP/N interventions, the HS capacity strengthening areas receive less intensive technical assistance on a selected set of interventions. Minimal support was provided to GOB health systems to scale-up interventions such as 24/7 UH&FWCs, CHX for cord care, and HBB; instead, the focus was on supporting the strengthening of existing MNCH/FP/N services. MaMoni HSS has four intermediate results (IR): IR 1. Improve service readiness through critical gap management. IR 2. Strengthen health systems at district level and below. IR 3. Promote an enabling environment to strengthen health systems at the district level. IR 4. Identify and reduce barriers to accessing health services.
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 69 APPENDIX 2: DATA SOURCES Assessment Assessment Frequency Geographical Coverage Name Type Population Independent 2 rounds in 23 high intensity upazilas of 5 MaMoni districts based tracer cross sectional a year. (Habiganj, Jhalokathi, Noakhali, Lakshmipur, survey assessment by Each round and Pirojpur). In addition, during the initial third party is for six stages of program – starting from October 2013 – (icddr,b) months this population based assessment was also conducted for Bhola District along with Noakhali and Lakshmipur. This included a baseline assessment and two rounds of the population- based survey. In October 2014, there was a major shift in the MaMoni HSS program strategy and the scale of program activities were reduced in Bhola. Accordingly, the project monitoring plan (PMP) was revised and the population based survey no longer covers Bhola, with the exception of conducting an end line survey in 2017. Sentinel Selected Twice in a Selected DH, MCWC, UHC, UH&FWC and survey sentinel site year satellite clinics in Habiganj, Jhalokathi, assessments Noakhali and Lakshmipur district. using structured tool Service Periodic facility Twice in a 21 high intensity upazilas of Habiganj, delivery assessment by year Jhalokathi, Noakhali and Lakshmipur district. point using assessment structured tool Newborn Nationwide Once in All over the country revisit assessment by project life upazila on HBB and 7.1% CHX using structured questionnaire Routine MIS, Routine MIS Monthly All over the country MOHFW forms of DGHS and DGFP Project MIS Routine MIS Monthly Only in high intensity project areas reports
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 70 APPENDIX 3: PROGRAM PERFORMANCE INDICATORS (OCT–DEC 2017) Achievement Target (October- Target Indicator Remarks 2017 December 2018 2017) Project Goal: Improve utilization of integrated maternal, newborn, child health, family planning and nutrition services Percent of women received at least one Will be reported antenatal care visit from a medically in final report trained provider High intensity areas Lakshmipur 70 NA 77 Noakhali* 67 NA 85 Habiganj 70 NA 85 Jhalokathi 73 NA 83 Pirojpur* 70 NA 72 HSCS areas Pirojpur 67 NA 67 Bhola 56 NA 56 Noakhali 63 NA 63 Percent of births receiving at least four Will be reported antenatal care (ANC) visits during in final report pregnancy
High intensity areas Lakshmipur 26 NA 32 Noakhali* 26 NA 45 Habiganj 26 NA 45 Jhalokathi 50 NA 46 Pirojpur* 36 NA 36 HSCS areas Pirojpur 44 NA 44 Bhola 24 NA 24 Noakhali 21 NA 21 Percent of Births Attended by a Skilled Will be reported
Doctor, Nurse or Midwife in final report High intensity area Lakshmipur 45 NA 45 Noakhali* 40 NA 45 Habiganj 40 NA 40 Jhalokathi 53 NA 55 Pirojpur* 50 NA 50 HSCS areas Pirojpur 50 NA 50 Bhola 30 NA 30 Noakhali 38 NA 38 Percent of women with home births who Will be reported consumed misoprostol to prevent post- in final report partum hemorrhage
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 71 Achievement Target (October- Target Indicator Remarks 2017 December 2018 2017) High intensity areas Lakshmipur 30 NA 20 Noakhali* 30 NA 23 Habiganj 50 NA 40 Jhalokathi 55 NA 25 Pirojpur* 45 NA 25 HSCS areas Pirojpur 32 NA 32 Bhola 25 NA 25 Noakhali 20 NA 20 Percent of newborns initiated Will be reported breastfeeding within one hour after birth in final report High intensity areas Lakshmipur 75 NA 65 Noakhali* 72 NA 60 Habiganj 85 NA 80 Jhalokathi 70 NA 55 Pirojpur* 63 NA 55 HSCS areas Pirojpur 58 NA 58 Bhola 70 NA 70 Noakhali 76 NA 76 Percent of newborns received CHX Will be reported application on their umbilical cord in final report immediately following birth
High intensity areas Lakshmipur 60 NA 25 Noakhali* 60 NA 30 Habiganj 60 NA 20 Jhalokathi 60 NA 10 Pirojpur* 60 NA 10 HSCS areas Pirojpur 35 NA 10 Bhola 35 NA 10 Noakhali 35 NA 10 Percent of newborns receiving postnatal Will be reported health check within two days of birth in final report
High intensity areas Lakshmipur: 20 NA 36 Noakhali:* 20 NA 47 Habiganj: 32 NA 32 Jhalokathi: 33 NA 48 Pirojpur:* 18 NA 41 HSCS areas Pirojpur: 10 NA 10 MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 72 Achievement Target (October- Target Indicator Remarks 2017 December 2018 2017) Bhola: 10 NA 10 Noakhali: 20 NA 20 Modern contraceptive method prevalence Will be reported rate in final report High intensity areas Lakshmipur 55 NA 55 Noakhali* 53 NA 53 Habiganj 48 NA 48 Jhalokathi 58 NA 58 Pirojpur* 58 NA 58 HSCS areas Pirojpur 55 NA 55 Bhola 58 NA 58 Noakhali 59 NA 59 Couple years of protection (CYP) in USG- supported programs Overall 1087492 220055 901298 Lakshmipur 163,817 31,081 138942 From DGFP MIS
Noakhali 235128 51696 217475 Habiganj 191,852 37,403 149475 From DGFP MIS Jhalokathi 77,389 13,098 51762 From DGFP MIS Pirojpur 139069 30145 113933
Bhola 263,795 51,222 229711
Intermediate Result 1: Improve service readiness through critical gap management Percent of targeted facilities that are Frequency of ready to provide essential newborn care reporting is semiannually. Will be reported in next quarter High intensity areas Lakshmipur 90 NA 90 Noakhali* 90 NA 90 Habiganj 90 NA 90 Jhalokathi 90 NA 90 Pirojpur* 90 NA 90 HSCS areas Pirojpur 70 NA 70 Bhola 70 NA 70 Noakhali 70 NA 70 Percentage of public health facilities with Frequency of functional bags and masks (two neonatal reporting is size mask) in the delivery room semiannually. Will be reported in next quarter High intensity areas MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 73 Achievement Target (October- Target Indicator Remarks 2017 December 2018 2017) Lakshmipur 50 NA 70 Noakhali* 50 NA 70 Habiganj 50 NA 70 Jhalokathi 50 NA 70 Pirojpur* 50 NA 70 Percent of USG-assisted service delivery Frequency of sites providing family planning (FP) reporting is counselling and/or services semiannually. Will be reported in next quarter High intensity areas Lakshmipur 95 NA 95 Noakhali* 95 NA 95 Habiganj 99 NA 99 Jhalokathi 95 NA 95 Pirojpur* 95 NA 95 HSCS areas Pirojpur 17 NA 17 Bhola NA NA NA Noakhali 25 NA 25 Number of targeted facilities ready to Frequency of provide delivery services 24 hours a day, reporting is seven days a week semiannually. Will be reported in next quarter High intensity areas Lakshmipur 25 NA 32 Noakhali* 19 NA 30 Habiganj 39 NA 42 Jhalokathi 21 NA 21 Pirojpur* 4 NA 5 HSCS areas Pirojpur 9 NA 13 Bhola 32 NA 18 Noakhali 7 NA 7 Sub-IR 1.1: Increase availability of health service providers Number of vacant positions filled by Only GOB temporary non-GOB health workers service provider positions are included High intensity areas Lakshmipur 10 4 10 FWV-4 Noakhali* 15 7 15 (FWV-6, MO-1) (FWA-12, FWV- 10 36 10 Habiganj 11, Nurse-13) Jhalokathi 10 1 10 FWV-1 Pirojpur* NA NA NA
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 74 Achievement Target (October- Target Indicator Remarks 2017 December 2018 2017) Sub-IR 1.2: Strengthen capacity of service providers to provide quality services Number of people trained in 2,149 6977 16519 (2604 maternal/newborn health through USG- for MaMoni supported programs 4 districts and 13915 for national scale-up initiatives) Number of people trained in FP/RH with 225 44 70 USG funds Number of people trained in child health 200 - 0 and nutrition through USG-supported programs Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization Number of union level public health 75 129 101 facilities that are ready to provide normal delivery services High intensity areas Lakshmipur 29 25 Noakhali* 34 23 Habiganj 57 35 Jhalokathi 15 15 Pirojpur* NA 3 Intermediate Result 2: Strengthen health systems at district level and below Number of district level quarterly 24 4 12 performance review meeting held for data-driven performance review and planning High intensity areas Lakshmipur 1 2 Noakhali* 1 2 Habiganj 1 2 Jhalokathi 1 2 Pirojpur* NA 1 Bhola NA 1 Intra partum still birth rate in project assisted facilities High intensity areas <5/1000 NA NA Lakshmipur <5/1000 NA NA Noakhali* <5/1000 NA NA Habiganj <5/1000 NA NA Jhalokathi <5/1000 NA NA Pirojpur* <5/1000 NA NA Sub-IR 2.1: Improve leadership and management at district level and below
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 75 Achievement Target (October- Target Indicator Remarks 2017 December 2018 2017) Number of GOB managers supported for leadership and management capacity development Lakshmipur NA NA NA Noakhali NA NA NA Habiganj NA NA NA Jhalokathi NA NA NA Pirojpur NA NA NA Bhola NA NA NA Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs Number of upazilas with updated 23 NA 23 Frequency of comprehensive annual MNCH/FP/N plan reporting is annually.
High intensity areas Lakshmipur 5 NA 5 Noakhali 4 NA 9 Habiganj 8 NA 8 Jhalokathi 4 NA 4 Pirojpur 2 NA NA Sub-IR 2.3: Strengthen local management information systems Percentage of community micro planning units conducting monthly meeting High intensity area Lakshmipur 95 98 90 Noakhali* 95 71 90 Habiganj 100 99 95 Jhalokathi 95 73 85 Pirojpur* 95 NA NA Sub-IR 2.4: Establish quality assurance system at district level and below Percent of planned supervision visit conducted where a supervision tool was used and findings shared with providers High intensity areas Lakshmipur 90 47 90 Noakhali* 90 108 90 Habiganj 90 217 90 Jhalokathi 90 108 90 Pirojpur* 90 NA 90 Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below Percent of USG-assisted service delivery points (SDPs) that experience a stock out at any time during the reporting period of
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 76 Achievement Target (October- Target Indicator Remarks 2017 December 2018 2017) a contraceptive method that the SDP is expected to provide High intensity areas Lakshmipur <3 5 <2 Noakhali <3 2 <2 Habiganj <3 1 <2 Jhalokathi <3 1 <2 Pirojpur <3 0 <2 Sub-IR 2.6: Strengthen local government planning and engagement in health service provision Percentage of unions that had at least 50 percent of the estimated births registered within 45 days of birth High intensity areas Lakshmipur 60 NA NA Noakhali* 60 NA NA Habiganj 60 NA NA Jhalokathi 60 NA NA Pirojpur* 60 NA NA Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N Number of Union Parishads (UP) that spent funds to support MNCH/FP/N activities High intensity areas Lakshmipur 58 12 58 Noakhali* 44 14 44 Habiganj 77 26 77 Jhalokathi 32 12 32 Pirojpur* 15 NA NA Intermediate Result 3: Promote enabling environment to strengthen district level health system Number of critical vacancies filled by GOB recruitment or redeployment in project areas High intensity areas Lakshmipur 5 0 5 (Conslt. 5 2 5 Noakhali Gyn/Obs-2) (Conslt. Gyn/Obs- 5 1 5 Habiganj 1) Jhalokathi 5 0 5 Pirojpur* 5 NA 5 Sub-IR 3.1: Policy reforms in place to promote local planning and need- based human resource deployment in the public sector
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 77 Achievement Target (October- Target Indicator Remarks 2017 December 2018 2017) Number of policies/ strategies/guidelines on MNH developed/revised with MaMoni 4 1 4 HSS support Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program Number of program learning initiatives 10 1 15 completed and disseminated Intermediate Result 4: Identify and reduce barriers to accessing health services Number of deliveries with a SBA in USG- assisted programs High intensity areas Lakshmipur 19,687 6254 19,687 Noakhali* 12,288 4380 12,288 Habiganj 25,896 7132 25,896 Jhalokathi 7,054 2421 7,054 Pirojpur* 2,658 612 2,658 HSCS areas Pirojpur 12,148 3148 12,148 Bhola 1,982 4878 1,982 Noakhali 37,848 2966 37,848 Number of antenatal care (ANC) visits by skilled providers from USG-assisted facilities High intensity areas Lakshmipur 53,730 38,291 53,730 Noakhali* 43,414 30,065 43,414 Habiganj 210,611 50,170 210,611 Jhalokathi 16,553 10,687 16,553 HSCS areas Pirojpur 44,612 10,172 44,612 Bhola 68,546 24,949 68,546 Noakhali 97,682 23,172 97,682 Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches Number of people reached through 666,143 308676 999215 project supported BCC activities High intensity areas Lakshmipur 200,000 28238 300000 Women 16035 Men 12203 Noakhali* 145,556 439365 218334 Women 190213 Men 249152 Habiganj 205,000 12848 307500 Women 10724 Men 2124 Jhalokathi 115,587 3939 173381
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 78 Achievement Target (October- Target Indicator Remarks 2017 December 2018 2017) Women 2617 Men 1322 Sub-IR 4.2: Enhance community engagement in addressing health needs Number of trained community volunteers 28,371 23,929 28,371 promoting MNCHFPN through project support High intensity areas Lakshmipur 6,710 6375 6,710 Noakhali* 5,900 6782 5,900 Habiganj 8,379 8356 8,379 Jhalokathi 2,731 2305 2,731 Pirojpur* 1,205 0 1,205 Number of Community Action Groups 24,355 20,261 24,355 with an emergency transport system for maternal and newborn health care through USG-supported programs
High intensity areas Lakshmipur 6,461 6205 6,461 Noakhali 3,876 4367 3,876 Habiganj 4,369 8076 4,369 Jhalokathi 3,746 1613 3,746 Pirojpur* 1,549 0 1,549 * High intensity upazilas
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 79 ADDITIONAL NATIONAL LEVEL INDICATORS Achieve Target Target Indicator ment Remarks FY 17 2018 2017 Percentage of newborns receiving Source: DGFP MIS-3 and CHX application at birth in MOHFW EmOC report of DHIS-2 facilities National 50 71 60 Barisal 50 78 60 Chittagong 50 81 60 Dhaka 50 65 60 Khulna 50 89 60 Rajshahi 50 71 60 Rangpur 50 52 60 Sylhet 50 78 60 Number of upazilas where a review Source: Project report of Newborn interventions held
Total 326 165 165 Barisal 42 0 Chittagong 100 100 Dhaka 124 16 Khulna 53 7 7 Rajshahi 68 0 Rangpur 58 58 Sylhet 39 0 Number of Newborn for whom resuscitation actions using bag and Source: DGFP MIS-3,EOC mask were initiated (31% of annual target, Total 14,817 10618 16272 within range) Barisal 640 1082 7,03 Chittagong 3,137 1363 3,445 Dhaka 4,453 4318 4,890 Khulna 1,952 1574 2,144 Rajshahi 1,995 886 2,191 Rangpur 1,716 753 1,885 Sylhet 924 642 1,015 Number of Union Health and Family Welfare Centers (UH&FWCs) in the Source: Project report project area using electronic MIS tools Noakhali implementation to begin in April, delayed Total 130 168 84 because of Measure procurement Lakshmipur 55 Noakhali 69 83 84 Habiganj 61 - Jhalokati 30 Pirojpur NA NA NA Bhola NA NA
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 80 Achieve Target Target Indicator ment Remarks FY 17 2018 2017 Number of districts having an active
Quality Improvement (QI) committee Total 32 34 64 Barisal 3 4 6 QI committees were just Chittagong 6 5 11 formed in Khulna, Sylhet and Chittagong divisions Dhaka 9 8 17 Khulna 5 7 10 Rajshahi 4 3 8 Rangpur 3 4 8 Sylhet 2 3 4
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 81
APPENDIX 4: FORUMS WHERE MAMONI HSS LESSONS WERE DISSEMINATED
Title Forum Month Type of Dissemination
Electronic Health Record of London, e-MIS Links Routine Service United ISQUA Nov Oral Data to Decision Making for Kingdom Conference 2017 Presentation Improved Quality of Care in Bangladesh
Implementation Experience of Mamoni HSS Project to London, ISQUA Nov Poster Improve Quality of Care United Conference 2017 Presentation (QoC) in Public Sector Kingdom Facilities in Bangladesh
Service Readiness and Provision of Quality London, ISQUA Nov Poster Antenatal Care in Satellite United Conference 2017 Presentation Clinics: Findings from Kingdom Remote Areas of Bangladesh
Asia Pacific Development of community Regional Ha Long skilled birth attendants in Conference on Nov Poster Bay, Viet hard-to-reach areas of Reproductive & 2017 Presentation Nam Bangladesh Sexual Health and Rights
Ensuring Quality of Maternal Health Care in OGSB Sylhet, Oral Dec 2017 three districts: Lessons from conference Bangladesh Presentation MaMoni HSS Project
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 82 APPENDIX 5: LIST OF PROCESS DOCUMENTATION ACTIVITIES
MaMoni HSS will contribute to the following learning priorities over the life of the project: Learning Item Study Type Lead Expected Progress Partner Time made in Y4 Line and current status 1. CHX Scale-Up Implementation Prospective / MaMoni FY 2018 Stakeholder Case Study: Ambispective HSS, workshop Documentation of process, Documentation with conducted in results and lessons of national Multiple sources: routine JHU/II January scale-up by all partners and implementation data, P stakeholders including MOHFW, stakeholder meetings NGOs, and the private sector. and reviews, Newborn and Child Health Cell records, tracer surveys 2. Changes in Skilled Birth Prospective / MaMoni FY 2018 Protocol Attendance rates as a result of Ambispective HSS developed improvements at the UHFWC’s: Documentation Data - To what extent and how did collection the approach of advocacy and Source of Data ongoing assessment lead to Tracer surveys improvements at UHFWC HFS/SPA through sector plans and local District Planning government budget outputs allocations? Routine program data on - Did improved service UP budget utilization provision at UHFWC lead to increased utilization of UHFWC for delivery and increased coverage of SBA (MaMoni Areas)? 3. Case Study of the PCSBA Retrospective MaMoni FY 2018 Program Program and their income Documentation of HSS, in brief viability Habiganj and collabor developed, Prospective ation manuscript Documentation in with ongoing Noakhali JHU/II IRB required P 4. Case Study of MaMoni Program Retrospective MaMoni FY 2018 Six rounds Impact on Service Equity: Documentation; tracer HSS of tracer - ANC, SBA, and PNC in indicator surveys survey Habiganj – geographic and conducted, social equity final endline - Coverage of MNH, FP and survey to be nutrition across program completed in districts February 2018 5. Quality of service delivery for Cross-sectional Mixed MaMoni Manuscri Data Permanent Sterilization Method Study HSS pt FY analysis Methods of Family Planning with 2018 completed icddr,b
MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 83 Learning Item Study Type Lead Expected Progress Partner Time made in Y4 Line and current status One manuscript drafted
6. Quality Improvement: Routine Documentation Mamoni FY 2018 First draft Document the QI framework through project MIS, HSS prepared (process), outputs (improvement Data from QI sentinel Documentati in performance standards) and sites on ongoing overlay that data with quality performance indicators (health outcomes) 7. Newborn Sepsis (PSBI) Routine Documentation JHU/II FY 2018 Draft brief Management in MaMoni Data source P ongoing Supported Areas: • Routine MaMoni . Has/how has the community implementation data HSS platform improved care- • Tracer surveys seeking? • KII with SACMOs, . How are upazilas maintaining pharmacists, village records for newborn sepsis doctors cases? Can outcomes be • FGD with community traced? members 8. Misoprostol Implementation in Routine Documentation MaMoni FY 2018 Two rounds MaMoni HSS Supported Areas HSS of tracer Update: MaMoni HSS is Data source survey piloting a new model Tracer Survey completed packaging misoprostol and Routine implementation with CHX together in Lakshmipur data (DGFP reports) additional district KII with service questions . Whether an integrated providers Endline distribution increases survey to be coverage completed in . What are the barriers in Feb 2018 service delivery and demand side? 9. Nutrition: Routine Documentation MaMoni FY 2018 Data Update: Scope limited to HSS collection Jhalokathi district where Source of Data complete MaMoni HSS strengthened 82 Routine Implementation Data community clinics to identify (including training) data analysis malnutrition Key Informant interview ongoing, . How is growth monitoring and (KII) expected in promotion implemented? Dec 2017 . Did the intervention result in improved screening, referral and case management for MAM and SAM? 10 Postpartum Family Planning: Routine Documentation MaMoni FY 2017 Data . What has been the HSS collection contribution of MaMoni at Source of data ongoing community level to increasing Training data demand for LAPM? Routine utilization data from DGFP MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 84 Learning Item Study Type Lead Expected Progress Partner Time made in Y4 Line and current status . Did PPFP uptake increase in KII of service providers project areas? FGD with communities 11 Decentralized planning: Routine Documentation MaMoni FY 2017 Draft . Documentation of process and HSS presentation outputs with standing prepared, committee meetings, open brief being budget meetings, spending developed data . Stories of how MaMoni achieved success in increased government engagement and MNCH spending 12 Leadership Management: Routine Documentation JHU/II FY 2017 Conceptual . Did decentralized district P framework planning help managers be Routine implementation MaMoni developed more proactive and efficient data HSS Data for planning, other managerial Record review of collection practices? planning process and initiated . How has the program review meetings management practices – data- Key Informant Interview driven planning, supervision, FGD of providers in program reviews, functional three upazilas integration and collaboration – changed? 13 PE/E Management at union level Prospective icddr,b FY 2018 Protocol facilities using loading dose documentation MaMoni finalized magnesium sulfate HSS Data Source of data collection Update: Scope limited to 30 Record review at referral ongoing unions in 4 districts facilities Prospective documentation of whether FWVs can properly screen and identify women with SPE 14 Quality of ANC at Satellite Source of Data MaMoni FY 2018 GOB Clinics Structured assessment HSS (data approval Assessing the physical of facilities collection received. preparedness of satellite clinics Direct observation of complete) Study ANC at SC completed. Key informant Program interviews brief drafted 15 Use of partograph to inform Record review MaMoni FY 2018 Program referral decision-making KII HSS brief Were partograph effective in completed identifying complications? Manuscript drafted 16 Introducing Special Care Units KII MaMoni FY 2018 Data in 3 district hospitals Record review HSS, analysis icddr,b completed Program brief being drafted MaMoni Health Systems Strengthening Activity: FY18 Q1 Quarterly Report 85 Learning Item Study Type Lead Expected Progress Partner Time made in Y4 Line and current status 17 Introduction of KMC in 14 Record Review KII FGD MaMoni FY 2018 Draft brief facilities of mothers HSS prepared icddr,b 18 Intervention to reduce Record review MaMoni FY 2018 Formative discontinuation of Implant and Follow-up with clients HSS, study IUCD KII of providers icddr,b completed, intervention started 19 Use of Antenatal Corticosteroid Routine documentation MaMoni FY 2018 Data in two district hospitals Record review HSS, analysis - Are providers able to KII icddr,b ongoing administer a complete dose FGD with community of dexamethasone (12 hour) - Estimation of gestational age 20 Evolution of community Record review MaMoni Fy 2018 Draft report mobilization model in ACCESS, KII HSS prepared MaMoni ISMNC, and MaMoni HSS project 21 Use of WISN tools to estimate WISN tools BUHS, FY 2018 Study workload of government health Record review MaMoni completed workers Stakeholder consultation HSS by BUHS
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