MCSP Madagascar Annual Report Y4 01 October 2017 – 30 September 2018

Submitted: 19 November 2018

Submitted to: USAID Madagascar

Submitted by: MCSP Madagascar Team Table of Contents Acronyms and Abbreviation ...... ii Executive Summary ...... 5 Introduction ...... 9 Major Accomplishments ...... 10 Objective 1: Provide support and technical leadership in maternal and newborn health, immunization and family planning at the national level to the Ministry of Health...... 10 Objective 2: Increase access to and improve quality of maternal, newborn and immunization health services in USG priority regions ...... 15 Objective 3: Increase access to long-acting family planning methods in USG priority regions ...... 21 Objective 4: Improve prevention and treatment of MIP in the context of focused antenatal care and malaria case management of children and adults at primary care level ...... 24 Objective 5: Strengthen the capacity of pre-service training institutions to educate midwives according to international Confederation of Midwives (ICM) standards and competencies...... 28 Addendum: Improve the capacity of providers to respond to the pneumonic plague outbreak ...... 30 Challenges and Opportunities ...... 37 Success Story ...... 38 Appendix 1: Data from Plague/IPC Trainings ...... 40 Appendix 2: Performance Indicators ...... 42

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Acronyms and Abbreviation

ACT Artemisinin-based combination therapy ANC Antenatal care ANSFM Association Nationale des Sages-Femmes de Madagascar (National Association of Midwives of Madagascar) ASRH Adolescent sexual and reproductive health BCS+ Balanced Counseling Strategy Plus BDS Bureau de Santé de District (district health office) BEmONC Basic emergency obstetrical and newborn care BSR Bureau de Santé Regional (regional health office) CARMMA Campaign on Accelerated Reduction of Maternal Mortality in Africa CCI Comité de Coordination Inter-agences CG/QI Clinical Governance / Quality Improvement CHRD Centre Hôpital de Reference du District (District referral hospital) CHRR Centre Hospitalier Regional de Reference (Regional referral hospital) CHU Centre Hospitalier Universitaire (University hospital) cMYP comprehensive multi-year strategic plans CSB Centre de Santé de Base (Primary Health Centre) CSO Civil society organization CSU Couverture Santé Universelle DDDS Direction du Développement des districts sanitaire (Heath District Development Department) DEP Direction des Etudes et Planification DGEHU Direction générale des établissements hospitaliers Universitaires (Department of University Hospitals) DGS Direction Générale de Santé DHIS2 District Health Information Software 2 DHRD Direction des Hôpitaux de Reference des Districts DIFP Direction des instituts de formation des paramédicaux (department of pre-service institutions) DLP Direction de la Lutte contre le Paludisme (National Malaria Control Program) DPEV Direction de Programme Elargi de Vaccination (Expanded Program on Immunization department) DQS Data Quality Survey DRSP Direction Régionale de la Santé Publique (regional health office) DSFa Direction de la Santé Familiale (Family Health division) DSI Direction du Système d’Information (the MOH’s Information System Department)

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EMAD Equipe management de district de la Santé (District Management team) EMAR Equipe Management Régional de la Santé (Regional Management Team) ENAP Every Newborn Action Plan EPI Expanded Program for Immunization FTP First-time parent FP Family planning GBV Gender-based violence HMIS Health management information system HP+ Health Policy Plus ICM International Confederation of Midwives IFIRP Institut public de Formation Interrégionale des Paramédicaux (public pre-service institution) IPC Infection prevention and control IPM Institut Pasteur de Madagascar IPTp Intermittent preventive treatment for pregnancy IPTp-SP Intermittent preventive treatment in pregnancy using sulfadoxine-pyrimethamine INSTAT Institut National de la Statistique IUD Intrauterine device LDHF Low-dose high-frequency MCSP Maternal and Child Survival Program MIP Malaria In Pregnancy MNH Maternal and Newborn Health MOH Ministry of Health ONM Ordre National des Médecins (National Council of Physicians) ONSFM Ordre National des Sages-Femmes de Madagascar (National Council of Midwives of Madagascar) OPV Oral polio vaccine PAQD Plan d’Amélioration de la Qualité des Données (data quality improvement plan) PE/E Pre-eclampsia/eclampsia PFI Planification Familiale Intégrée (integrated family planning training package) PPFP Postpartum family planning PPIUD Postpartum intrauterine device PPH Postpartum hemorrhage PSBI possible severe bacterial infection PSE Pre-service Education PSI Population Services International PSM Global Health Supply Chain Program – Procurement and Supply Management RBM Roll Back Malaria RDT Rapid diagnostic test

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REC Reaching Every Child RI Routine immunization RMA Rapport mensuel d’activités (monthly activities report) RH Reproductive health RMNCH Reproductive, maternal, newborn and child health SDSP Service de District de Santé Publique (district public health department) SFP Service de la Formation du Personnel (vocational training department) SMQ Service de Management de la Qualité (quality management department) TOT Training-of-trainers UNFPA United Nations Population Fund UNICEF United Nations International Children's Fund USAID United States Agency for International Development USG United States Government WHO World Health Organization

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Executive Summary The Maternal and Child Survival Program’s (MCSP) work plan in Madagascar for its fourth programmatic year (PY4) contains the following objectives: 1. Provide support and technical leadership in maternal and newborn health (MNH), immunization and family planning (FP) at the national level to the Ministry of Health (MOH) 2. Increase access to and improve quality of MNH and immunization services in USG priority regions 3. Increase access to long-lasting postpartum family planning (PPFP) methods in USG priority regions 4. Improve prevention and treatment of malaria in pregnancy (MIP) in the context of antenatal care (ANC) and improve malaria case management of children and adults at the primary care level 5. Strengthen the capacity of pre-service training institutions to educate midwives according to International Confederation of Midwives (ICM) standards and competencies • Addendum: Improve the capacity of providers to respond to the pneumonic plague outbreak

Key achievements through PY4 are summarized below. Objective 1: Provide support and technical leadership in MNH, immunization and FP at the national level to the MOH

• Provided technical support to MOH to monitor progress on the CARMMA Roadmap and ENAP milestones visa routine data collection at the central, regional and district levels, and via support of data use for decision-making. • MCSP supported the revision of the MNH and FP training curricula and job aids following the validation of the RH Norms and Protocols – which were then inserted in to the Planification Familiale Intégrée (PFI, the integrated family planning training package) – as well as the develop of the 2018-2020 ASRH National Strategic Plan Budgeted Operational Plan to ensure improved access of adolescents and youth to family planning services. • Supported the MOH and partners to develop and implement key national policies via participation in technical working groups (TWGs), including: the national Plan for Improved Essential Surgery Services; the Health Management Information System (HMIS) guidelines; and an action plan and budget for activities related to possible severe bacterial infection (PSBI). • Provided technical guidance to strengthen routine immunization and polio eradication via participation in the immunization data quality committee, and support for the development of the drafts of the 2018-2020 immunization cMYP and the 2018 DPEV workplan. • Supported the EPI to prepare the documentation required to obtain its Certification of Polio Eradication from the AFRO Regional Certification Commission, which was received June 2018. Objective 2: Increase access to and improve quality of MNH and immunization services in USG priority regions.

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• Supported capacity-building for 620 providers across 539 facilities and 59 members of Equipes Management de District (EMADs, or district management teams) to provide and maintain quality MNH services. The Staff and regional trainers reached are now independently leading training and supervision • Continued to monitor CG/QI initiative in two centres hôpital de référence du district (CHRDs, district referral hospitals) and 10 centres de santé de base (CSBs, primary health centers) in Vakinankaratra region, which have supported consistently high adherence to best practices as measured via key indicators. • Continued to support the capacity of district managers and health facilities to use data for decision-making via the MNH quality dashboard, which contributed to sustained improvements in key indicators: o The percentage of women who received blood pressure measurements during ANC – as part of early detection of pre-eclampsia/eclampsia (PE/E) – rose from 41% at the baseline assessment in Y1 to 96% in Q3 of PY4, staying above 90% since Q4 of PY3. o The percentage of women that received a uterotonic immediately after birth of the baby rose from 89% at baseline to 99% in PY2 and has remained steady through Q2 of PY2. o The percentage of newborns not breathing/crying at birth who were successfully resuscitated rose from 78% at baseline to 90% in Q3 of PY4. • Supported microplanning workshops and EPI performance review workshops in all six priority districts, resulting in a total number of 169 microplans developed and 167 people trained in the implementation of the Reaching Every Child (REC) approach.

Objective 3: Increase access to long-acting postpartum family planning (PPFP) methods in USG priority regions

• Provided technical support to the MOH to harmonize the FP training materials and tools, including the documentation and use of BCS+ counseling cards for providers to improve FP counseling. 98% of the providers using the tool attested to its usefulness. • Strengthened the PFPP skills of 620 providers across 538 facilities through supportive supervision, contributing to an increase from 8% in March 2018 to 21% in June 2018 in the percentage of postpartum women discharged with a FP method of choice in 513 project- supported CSBs. • Supported ongoing monitoring of the Tanora Mitsinjo Taranaka (TMT) initiative, including a periodic review reaching 73 community health workers and 21 health providers, to assess the quality of TMT activities and sharing experiences MCSP also initiative a qualitative and quantitative assessment of the project which will be completed in tandem with the project end-line assessment.

Objective 4: Improve prevention and treatment of malaria in pregnancy (MIP) in the context of antenatal care, and improve malaria case management of children and adults at the primary care level

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• Strengthened capacity of providers to provide evidence-based malaria prevention and treatment care via training of 179 providers and 65 Chefs CSB. 620 providers from 538 facilities benefitted from onsite and remote supervision (or mMentoring) • Support to the EMADs/EMARs in ten regions to continue malaria technical updates of new providers and conduct supportive supervision • The percentage of women who have received the third dose of intermittent preventive treatment in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP) in targeted facilities rose from 14% at baseline to 37% in March 2018 but reduced to 28% due to stock-outs. • Supported the MOH’s monitoring of availability of malaria commodities at 192 health facilities using a low-cost, web-based mapping system to track and map key malaria stock-outs. • Supported the MOH in the implementation of a study on malaria care-seeking behavior in pregnant women and children to assess care-seeking behavior for fever in caretakers of children under 15 years of age and in pregnant women in rural and urban areas throughout four different malaria-endemic zones of Madagascar. The final report will be disseminated in PY5. • Finalized the protocol and tools for two malaria assessments: a malaria health facility readiness survey and an elimination readiness assessment, which will be implemented in PY5.

Objective 5: Strengthen the capacity of pre-service training institutions to educate midwives according to ICM standards and competencies • Strengthened pre-service midwifery institutions (public and private) by supporting MNH/FP technical updates, and effective teaching for 17 teachers/tutors from 14 private midwifery education institutions. • Supported the establishment of skills labs in two public midwifery institutions • Conducted joint supervision of MCSP-supported private midwifery institution, which revealed that teachers/tutors trained are not adequately applying skills covered during training. • Supported the ONSFM in building their capacity to conduct technical updates for members by donating with MNH and PPFP training materials

Addendum: Improve the capacity of providers to respond to the pneumonic plague outbreak • Provided technical support to the national plague response and case management TWG to develop/adapt training materials, including nine IPC and plague case management job aids • Developed a pool of 17 national trainers and 275 regional trainers from 80 districts to support the cascade of provider trainings at the sub-regional level • Supported EMARs/EMADs to conduct provider IPC and plague case management trainings in five priority regions, resulting in 505 providers from 219 health facilities in 31 districts trained to date. • Collaborated with partners to train 429 providers in four regions most affected by the epidemic – Analamanga, Atsinanana, Vakinankaratra, and Haute Matsiatra. • Supported the implementation of IPC measures in 12 major hospitals in the five priority regions:

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o Conducted a rapid assessment in 10 major hospitals in Antananarivo, Fianarantsoa and Toamasina o Completed the training of the hospital clinical health works in the five priority regions by training of remaining untrained 20 clinical workers in the Centre Hospitalier Régional de Reference (CHRR, regional referral hospital) of Vakinankaratra. • In April 2018, completed the training of the hospital clinical workers in the priority regions to increase capacity to respond to the plague outbreak.

Conclusions and Way Forward: PY1-PY3 focused on critical service delivery and health system challenges and with a strong emphasis on transferring ownership to the MOH in order to institutionalize key interventions and sustain gains beyond the life of the project. In PY4, MCSP continued to support the institutionalization of activities and approaches at all levels of the MOH, consolidate advocacy and technical support of policy at the national level, as well as the operationalization of policies at the subnational level. All field activities were finalized during the third quarter, so MCSP has shifted its focus during the closeout period to documentation of its results and lessons learned, including the implementation of the malaria assessments and end-of-project evaluation.

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Introduction

The Maternal and Child Survival Program (MCSP) is a global U.S. Agency for International Development (USAID) cooperative agreement to introduce and support high-impact health interventions in 26 countries, implementing 45 country programs. The program supports USAID’s commitment to prevent child and maternal deaths, and the goals of several important maternal, newborn, and child health (MNCH) global strategies.

To achieve its goals, MCSP Madagascar has organized its programming around five principal Figure 1. MCSP Coverage during PY4 objectives:

1. Provide support and technical leadership in maternal and newborn health, INTERVENTION REGIONS immunization and family planning at the YEAR 3 national level to the Ministry of Health 2. Increase access to and improve quality of maternal and newborn health and immunization services in USG priority regions 3. Increase access to long-lasting postpartum family planning methods in USG priority regions 4. Improve prevention and treatment of malaria in pregnancy in the context of antenatal care, and improve malaria case management of children and adults at the primary care level 5. Strengthen the capacity of pre-service training institutions to educate midwives according to international Confederation of Midwives (ICM) standards and competencies

Addendum: During Q1 of PY4, MCSP’s scope of work was expanded to include technical support to the plague outbreak response. MCSP has planned and initiative specific activities aimed at strengthening the capacity of providers in infection prevention and control measures in targeted regions, to enable them to accurately diagnose and manage plague cases.

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Major Accomplishments Objective 1: Provide support and technical leadership in maternal and newborn health, immunization and family planning at the national level to the Ministry of Health.

MCSP provided technical assistance to the (MOH, particularly the Direction de la Santé Familiale (DSFa, Division of Family Health) which is responsible for reproductive, maternal, newborn and child health (RMNCH) at the national level. MCSP supported the development and dissemination of RMNCH policies, strategy documents and reference documents through the provision of technical leadership, the support of technical workshops and the dissemination of key documents. Within USG regions, MCSP provided technical support to the MOH’s Equipes Management Régional (EMARs, or regional management teams), and the Equipes Management de District (EMADs, or district management teams) to disseminate and implement the national 2015-2019 Roadmap for the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA), and strengthened routine immunization and polio eradication activities. • Provided technical support to MOH and partners to implement and monitor progress on the CARMMA Roadmap and ENAP milestones MCSP continued to support the MOH to implement priority national MNCH strategies – including the Roadmap for the CARMMA and the Every Newborn Action Plan (ENAP) – and participated in the monthly meeting of the H6+ technical committee tasked with reviewing and planning MNCH activities/interventions, including progress on ENAP. In Q3, MCSP contributed to the development of the 2017 ENAP report for Madagascar, which included newborn data collected at MCSP-supported health facilities via the MNH dashboard MCSP also supported the creation of a technical working group (TWG) on (PSBI), and in collaboration with the Mahefa Miaraka project, supported a follow-on workshop in Antsirabe to develop an action plan and budget for PSBI-related activities. In subsequent months this led to the development of the terms of reference of a PSBI technical committee, and to the integration of PSBI components in the existing national MNH, integrated management of childhood illness (IMCI), and preservice curricula.

• Supported the MOH and partners to disseminate the RH Norms and Protocols, and to develop ASRH strategic documents The Reproductive Health (RH) Norms and Protocols guide the practice of all cadres of providers at every level of the health system and though it is mentioned as a priority in the CARMMA 2015-2019 Roadmap for the reduction of maternal and neonatal mortality, it had not been updated since 2006. Providing technical and financial support for updates to this document was a key MCSP activity in PY3 to improve quality of care and ensuring that providers routinely offer high-impact evidence-based interventions. MCSP ensured that updates to the document aligned with global evidence and recommendations from the World Health Organization (WHO), in collaboration with several MOH departments and RH partners, including Health Policy Plus (HP+), Fianakaviana Sambatra (FISA), United Nations Population Fund (UNFPA), the Global Health Supply Chain Program – Procurement

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and Supply Management (PSM), Mahefa Miaraka, and Population Services International (PSI). In PY4, upon the DSFa’s request, MCSP supported the dissemination of the finalized document and developed an accompanying PowerPoint presentation synthesizing its contents, which was disseminated across the 16 project intervention regions. Following the update of the RH Norms and Protocols, MCSP supported the MOH in updating national MNH and family planning (FP) training curricula and job aids for alignment. To that end, MCSP revised ten MNH and FP job aids and developed two new FP job aids on the management of side effects after the insertion of intrauterine devices (IUDs) and Implanon, which have since been validated and inserted into the Planification Familiale Intégrée (PFI, the integrated family planning training package). In Q3, following the launch of the national Adolescent Sexual and Reproductive Health (ASRH) Strategic Plan, MCSP provided technical inputs to the development of the ASRH National Strategic Plan Budgeted Operational Plan. MCSP was also asked by the MOH to participate in the design of a National Adolescent and Youth Health curriculum and supported its finalization, which is still ongoing. During the MOH Grand Staff Meeting in Toliara, MCSP distributed to participants 300 USB memory sticks containing digital versions of the FP law, the ASRH National Strategic Plan, and the RH Norms and Protocols.

• Supported national Technical Working Groups (TWGs) and MOH MNCH policies and activities in program priority areas

MCSP participated in the TWG tasked with the revision of the Health Management Information System (HMIS), and supported two workshops on the District Health Information Software (DHIS2) for administrators and national trainers, organized in collaboration with Direction du Système d’Information (DSI, the MOH’s Information System Department), MEASURE Evaluation and partners. The objective of the workshop series was to implement a national data warehouse, centralized at DSI and accessible to all partners. MCSP also participated in the development and validation of the HMIS tools for hospitals, including the rapport mensuel d’activités (RMA, monthly facility activities report) and successfully advocated for the inclusion of two MNH quality of care indicators into the system: (i) the number of newborns successfully resuscitated and (ii) the number of women who receive a uterotonic after delivery. The RH/FP law was promulgated in January 2018 by the President of the Republic of Madagascar, formalizing a legal framework for those working to increase access to FP via demand creation activities and direct services, including for the youth. During PY4, MCSP continued to provide technical support to the FP TWG for the elaboration of the decree, which provides recommendations for the operationalization of the law. The FP TWG also developed key messages for the dissemination of the FP Law to different target audiences. Starting in PY3, MCSP provided technical support to the national TWG developing the National Plan for Improved Essential Surgery Services. The TWG developed a draft of the plan in PY3; however, due to frequent unavailability of members for meetings the document was not finalized. In PY4 the TWG updated the Plan and developed a presentation for the National Surgical Care in the Eastern Mediterranean and African Regions workshop in Dubai in March 2018, which was attended by a member of the MOH’s Directeur du Partenariat supported by MCSP funds. By the end of PY4, the National Plan for Improved Essential Surgery Services was finalized, and is awaiting formal validation.

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• Supported capacity-building of professional associations to provide regular technical updates and continuing professional education for members

As part of the collaboration with the Ordre National des Sages-Femmes de Madagascar (ONSFM, National Council of Midwives of Madagascar), MCSP supported the development of an implementation plan for an online MNH course for midwifery training to increase midwifery students’ access to MNH training and support the standardization service provision, starting with training modules on gender- based violence (GBV) and respectful maternity care. MCSP also contributed technical and financial support to the Association Nationale des Sages-Femmes de Madagascar (ANSFM, National Association of Midwives of Madagascar) for the celebration of International Midwives Day, which was held in Toliara in May 2018. As part of the celebration, several events were organized, including a workshop to strengthen the competencies of 29 midwives on newborn resuscitation skills, prevention of postpartum hemorrhage (PPH) and GBV using new MNH validated job aids.

• Provided senior-level immunization technical guidance to the MOH/DSMER, DPEV and DDS to strengthen routine immunization and polio eradication

In PY4 MCSP continued to support the Direction du Programme Elargi de Vaccination (DPEV, Expanded Program on Immunization [EPI] department), which included participation in the national-level data quality committee tasked with monitoring, analyzing, and managing routine immunization data. MCSP also contributed to updating the national comprehensive multi-year strategic plan (cMYP) for immunization, which will guide the DPEV’s activities over the next five years. Additionally, the project provided technical assistance to the DPEV and partners to achieve the global polio eradication initiative indicators, including support for the planning, implementation and validation of national polio campaigns and improving routine oral polio vaccine (OPV) coverage in USG-supported areas. o Provided technical support to periodic immunization data review and analysis meetings at national level MCSP has supported monthly EPI data analysis meetings to support district and regional focal points in effective decision making. These meetings focused on district performance in routine EPI, surveillance of vaccine preventable diseases (VPDs), the number of unvaccinated children and the dropout rate, as well as monitoring the two main polio indicators: the rates of non-polio acute flaccid paralysis and stool adequacy rate. MCSP also contributed to the preparation for the national vaccination coverage survey, including the development of the protocol and collection tools. This included capacity building with the USAID bilateral projects to assist with data collection in each project’s zone. The coverage survey will be implemented in early 2019 in collaboration between the MOH, the Institut National de la Statistique (INSTAT), and partners, with anticipated cost share with Gavi funding. In Q3, in collaboration with the EPI, MCSP provided technical support to the national immunization data quality TWG to improve routine immunization data quality and use. The DPEV approved the TWG terms of reference and action plan and issued national recommendations for the improvement of data quality, including at the regional and district levels. Furthermore, as part of the country’s efforts to improve data quality nationwide, MCSP conducted data quality self-assessments (DQS) in select priority districts, whose results were incorporated into the MOH’s Plan d’Amélioration de la Qualité des Données (PAQD, the national data quality improvement plan). A draft of the PAQD was finalized in May 2018 and will be validated after an additional DQS is completed in combination with a supervision visit in PY5.

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o Provided technical support for the coordination and implementation of polio- related activities MCSP contributed to updates of management tools, information education and communication (IEC) materials, and the identification of programmatic approaches and inter-campaign activities related to the polio supplementary immunization activities. MCSP participated in the 11th, 12th and 13th rounds of the FAV (polio subnational campaigns) in priority districts and also supported two joint supervision missions – with the MOH and Mahefa Miaraka project—covering Ambanja, Ambilobe, Mampikony and Bealanana districts. The steering committees in the districts were operational, and included the EMADs, Circonscription Scolaire (CISCO), the church, local leaders, and civil society organizations (CSOs). The supervision also revealed that the other districts needed additional attention to follow vaccine requirements in their respective microplans, with a reminder sent by the DPEV central office. The vaccine coverage rate in the last three campaigns exceeded the 95% benchmark in the focus districts (see Table 1 below), with the exception of Ambanja, where there were rumors of side effects and refusals. Vaccine refusal in Ambanja may be linked to an anti-bilharzia campaign run by the Ministry of Education in 2017, during which two pupils were reported to have fainted. Parents have since been reluctant to have people administer drugs or vaccines to their children. To address this potential resistance, MCSP worked with partners prior to the polio campaigns to raise awareness with the communities. Additionally, in Ambanja, MCSP supported EMAD staff to conduct a Q&A session with parents. This session highlighted the reasons for repeated polio vaccination campaigns and aimed to assuage parents’ concerns about vaccination to ensure their participation in the campaign. Ambanja, Ambilobe and Antsiranana were not involved in the 12th campaign because it was not a national campaign. However, the coverage rate was maintained above 90% for each of the 9th – 13th campaigns. Table 1. Results of the FAV POLIO Campaign for 6 priority districts Vaccine Coverage Rate (%) District 9th 10th 11th 12th 13th Campaign Campaign Campaign Campaign Campaign Mampikony 110.8% 102% 118.7% 116% 99% Bealanana 100.7% 103% 97.7% 105% 98% Port Berger 112% 96% 101.5% 99% 98% Ambanja 97.4% 97% 93.3% N/A 97% Ambilobe 100.7% 101% 97.2% N/A 98% Antsiranana II 102.2% 103% 99% N/A 98%

*Some coverage rates are over 100% because some of the children recorded during the campaign do not live in the targeted districts, and have therefore not been included in the target population calculations (skewing the denominator for the calculations). As such, the campaigns vaccinated more children than targeted, resulting in coverage rates that are over 100%.

MCSP also supported the EPI in preparing the documentation required to obtain its Certification of Polio Eradication. This included providing technical input into analysis of the polio eradication indicators and strategic insight into country plans post-certification, which included continuing efforts to strengthen routine immunization and AFP surveillance through REC. In 2018, Madagascar received its Certification of Polio Eradication, a major milestone for the country and region. The development

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of a plan to maintain the country’s "Polio free status" is planned for the first quarter of PY5.

O Provided technical assistance to and participate in meetings with international partner agencies to provide support to the EPI for improved RI services To implement the recommendations following the Gavi audit in November 2017, MCSP participated in the identification of immunization priority activities, led by the Direction du Développement des Districts Sanitaire (DDDS, the Health District Development Department) and DPEV. The activities included: building the capacity of providers in vaccine management and the development of the priority district EPI microplans; determining targets by fokontany; ensuring the regular supply of vaccines and immunization supplies; provision of fuel; supportive supervision; provision of management tools; and the organization of district-level quarterly reviews. MCSP also participated in periodic meetings organized with all stakeholders with the goal of monitoring the effective implementation of both technical and financial activities linked with the Gavi assistance. MCSP supported the development of the drafts of the immunization cMYP 2018-2020 and the 2018 DPEV workplan, which are awaiting validation by the Comité de Coordination Inter-agences (CCIA, Interagency Coordinating Committee). The cMYP and the 2018 annual workplan are aligned with the Global Vaccination Action Plan and the Regional Strategic Plan for Immunization, including new guidance on the introduction of new vaccines and the use of technology for data collection.

• Supported selected MOH events in program priority areas Among the interventions to improve the quality of health services are respectful maternity care and prevention and management of GBV. During the celebration of International Women's Day in March 2018, MCSP and other USAID partners supported the events organized by the Ministry of Population, in collaboration with the MOH, for the promotion of women's rights. Over the course of four days, an MCSP booth presented program interventions and related provider services, and included the participation of four midwives testifying to the importance of training on respectful care and GBV as a means to improve quality of care. In addition, the online GBV module developed by MCSP was launched during the International Women’s Day celebrations. MCSP also participated in a debate and "talk show" session on women's rights in health, which including showings of a video on GBV and women's rights around pregnancy (in Malagasy). MCSP’s activities at the celebration reached nearly 400 people and provided an important opportunity for advocacy amongst providers and MOH officials about the importance of women's rights and its impact on quality of care. MCSP supported the MOH in the organization of the Grand Staff meeting and joint review from April 30 to May 4, 2018 in Toliara. The annual event attended by all MOH key staff is an opportunity for the MOH to share its vision and for partners to share their interventions and results. Like other partners, MCSP had an exhibition booth with over 100 people visiting the booth and benefiting from an introduction to MCSP’s objectives and results, simulation sessions (which included newborn resuscitation, the condom tamponade, and the PPIUD), the distribution of MNH and FP job aids and key national polices.

• Promote incorporation of evidence-based training best practices into national policy

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Capitalizing on its experience in trainings and the pool of regional trainers developed by MCSP, the program supported the Service de la Formation du Personnel (SFP, vocational training department) with the establishment of the Bureaux Régionaux de Formation (BRF, regional training offices), a major component of the basis of the training policy. The role of the BRF is to plan and coordinate the capacity building for health providers and MOH staff at regional level. In PY4, MCSP provided financial and technical assistance for the establishment of a BRF in the Alaotra Mangoro region, as well as the development of its action plan which was bolstered by coaching and remote monitoring by MCSP. Key achievements of the BRF include a standalone office, official members nominated by the MOH, and an executive board set up to manage the BRF. The first regular meeting of Alaotra Mangoro’s board occurred in July 2018.

• Promoted MOH technical leadership of clinical governance/quality improvement (CG/QI) as a core function of the Madagascar health system

Given the important gains obtained by MCSP in introducing the CG/QI approach in project- supported regions, the MOH expressed an interest in expanding the CG/QI approach throughout the health system to achieve a broader coverage of quality improvement results. In order to transfer leadership of CG/QI activities to the central MOH level, MCSP advocated for a MOH quality body at the national and local levels to inform the decision-making of MOH managers. During Q1, in collaboration with Service de Management de la Qualité (SMQ, the Quality Management Department), which is under the MOH’s Direction Générale des Etablissements Hospitaliers Universitaires (DGEHU, the Department of University Hospitals), MCSP initiated a process to set up a new central quality coordination mechanism within the MOH, starting with the development of a draft of terms of reference. The draft document was submitted to the SMQ for their input and feedback. However, the recent changes in MOH leadership have impeded further progress.

Objective 2: Increase access to and improve quality of maternal, newborn and immunization health services in USG priority regions

MCSP, in close collaboration with DSFa, the EMARs and the EMADs, strengthened the capacity of public health facilities to provide quality services in maternal, newborn and immunization health. The main interventions under this objective included capacity-building for health providers, the donation of key basic equipment for delivering MNH services, post-training supervision and mentorship to help providers maintain newly-acquired skills, and quality improvement activities the implementation of the MNH quality dashboard and clinical governance approach. In PY4, MCSP focused on consolidating previous years’ gains, with a particular focus on strengthening the continuum of MNCH care from the community level through CSBs to district level facilities, including the centres hôpital de référence du district (CHRDs, district referral hospitals). • Supported capacity building of providers and the EMADs

During PY4, MCSP has prioritized support to districts to plan and implement training and supervision best practices in a sustainable manner. Provider trainings were organized to: i) ensure continuous quality of services by training the second provider in CSBs that already had a trained provider, and ii) ensure equity by increasing the coverage of health facilities that have trained providers across USG

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regions. o Skills of 620 providers at 538 facilities skills strengthened through onsite training and supportive supervision Due to the focus on the plague epidemic in September to November 2017, training and supervision activities were significantly slowed down during Q1, though remote supervision activities (via mobile mentoring or mMentoring) were conducted by regional trainers via telephone calls to trained providers. The content of each interaction during mobile supervision was based on the MNH dashboard data from the providers’ facilities; the regional trainers analyzed each facility’s results to determine how to support the facilities through targeted action plans. During Q2, MCSP was able to resume joint onsite supervision and continue mMentoring to enhance and strengthen trained providers’ competencies. In total, 620 providers received supportive supervision, and supervision reports revealed that providers maintained a high level of performance. In Analamanga for example, supervisors noted a successful newborn resuscitation conducted by trained providers using the proper equipment – a penguin, balloon and mask – and worked with the facility’s managers to reorganize the facility’s service structure, and update the ANC and birth registers. Due to the phasing-out process in the regions, MCSP's supervision activities decreased during the latter half of PY4. Table 2 details the number of providers and facilities reached via supportive supervision in PY4. Discussions between providers and regional trainers/supervisors during the review of action plans or dashboard results enabled providers to find realistic and immediate solutions to problems related to infection prevention, data consistency issues, and the appropriate use of tools and equipment, to name a few. Additionally, supervisors were able to support providers in real time, while dealing with real cases. Using this approach, MCSP has noted an improvement not only in the technical skill of providers but also in the organization of facility services.

o Strengthened the skills of 59 regional EMAR/EMAD staff members to sustain supervision and trainings activities at regional and district levels

In all regions of interventions, MCSP conducted capacity-building workshops for the EMARs and EMADs to continue MNH and malaria trainings and supervision activities after the life of the project. MCSP focused on supporting the EMADs specifically to incorporate best practices into their daily practice through a transfer of a specific set of prioritized skills/tools that they can eventually implement without the help of partners. This transfer of skills focused the following topics: - Comprehensive summary of the baseline data from health centers supported by MCSP. - Using data collected via the monthly health facility report and MNH dashboard for decision- making - Effective use of the pool of regional trainers: MCSP shared the directory of trained regional trainers and their fields of competence with the EMARs and EMADs to serve as the foundation for the establishment of a Human Resources Information System. - Management of the laboratory skills: equipment verification and maintenance, regular inventory checks, organization of services, etc. - Implementation of a multidimensional supervision approach to strengthen providers' capacity for performance and excellence - Implementation of the CG/QI approach at CSB and CHRD levels

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- Commodity management by supervisors and coaches assigned to facilities to monitor possible stock-outs and respond accordingly. - The low-dose high-frequency (LDHF) training approach paired with blended training. The capacity-building of the EMADs was conducted in two stages and began with an orientation of MOH staff at the central level – including members of the DSFa, the DDS, the Service de la Formation du Personnel (SFP, vocational training department), the Direction des Etudes et Planification, and the DSI. The orientation was developed to deepen the MOH staff’s understanding of the approaches and activities taking place in the MCSP-supported regions, and to enable them to adequately support the EMADs. In total, 59 members from local EMARs and EMADs have benefited from MCSP’s capacity building activities in the regions of Alaotra Mangoro, Analamanga, Atsimo Andrefana, Atsinanana, Diana, Haute Matsiatra, Menabe, Melaky, Sofia, Vakinankaratra and Vatovavy-Fitovinany. These regions each developed an action plan to ensure the implementation of provider trainings, as well as the gradual transfer and of the improved service delivery activities initiated by MCSP. The EMADs and regional trainers in those regions are now leading training and supervision related activities identified in their action plans independently of MCSP. After MCSP’s technical support, several EMADs began conducting some of the activities listed in their respective action plans, including: - 105 Chefs CSB – from the three regions of Analamanga, Haute Matsiatra and Atsinanana – benefitted from BEmONC and malaria case management refresher sessions during the quarterly reviews - 77 providers in the Sofia and Diana regions received refresher sessions in infections prevention and control, and in plague case management - The CG/QI approach was introduced into three (3) new CSBs in Alaotra Mangoro and Sofia regions, and included the creation of quality committees and quality improvement plans. - In Vakinankaratra and Atsinanana regions, 19 new clinical providers were trained in BEmONC at the district skills labs donated by MCSP. - In Analamanga and Vakinankaratra region, 17 newly recruited health providers were trained in BEmONC before taking up their post; - In the Analamanga region, district trainers provided on-site coaching sessions for 13providers - In Vakinankaratra region, one of the EMADs is training a Chef CSB2 to become clinical trainer These initial gains stemming from MCSP’s capacity building activities with targeted EMADs/EMARs show the effectiveness of the transfer and appropriation of skills to MOH staff under MCSP’s sustainability plan. MCSP’s blended learning approach, building off of the LDHF strategy, the training curricula and the established district skills labs are all being utilized by the EMADs and EMARs. The MOH health teams are also proactively identifying complementary resources, in collaboration with the community and local associations, to acquire training materials, including small medical or surgical equipment. Through this approach, the subnational MOG offices strengthen their ability to respond to local training needs and extend their geographical coverage by disseminating best practices in key technical domains including MNH/FP, plague prevention and case management, and malaria prevention and case management.

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• Strengthened the skills of EMADs and regional trainers to support the technical implementation of Reaching Every Child (REC) in priority districts

In PY4, immunization and REC microplanning began with MCSP supporting the DPEV and partners with the development of tools for the reorientation of district managers in EPI microplanning. MCSP then supported microplanning workshops and EPI performance review workshops in six districts – Ambanja, Ambilobe, Antsiranana II, Mampikony, Port Berger and Bealanana – increasing the total number of microplans developed by/for each health facility to 159 by the end of the year. In addition, two new districts – Antsiranana II and Bealanana – benefited from a reorientation of the REC approach, resulting in 167 people trained in total (159 service providers and 08 CSO members). The immunization technical support over the last two years has contributed to increases in the numbers of infants vaccinated as well as reductions in dropout, as shown in Figures 2 and 3 below.

Figure 2. Target and Number of children vaccinated for Penta3

Target and number vaccinated for Penta3, 3 MCSP-supported districts in Sofia

16,341 16,806 16,144 17,281 17,189 13,195

2015 2016 2017 Target Number vaccinated (Penta3)

*Source: Madagascar HMIS

Figure 3. Penta1 to 3 dropout rates in three MCSP districts, 2015-2017 Penta 1 to 3 drop-out rate in MCSP-supported districts 25% 21% 18% 15% 16% 2015 2016 10% 9% 2017 7% 7%

Boriziny (Port-Berger) BEALANANA MAMPIKONY Source: Madagascar HMIS

For PY4, MCSP planned to train 50 CSB providers in two districts on data management and data quality self-assessments (DQS) during district quarterly review meetings. However, the approach was changed due to unavailability of providers and instead, during Q3, MCSP decided to strengthen the

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capacity of 6 members of EMAD from Ambanja and Mampikony districts to conduct DQS, thereby enabling them to conduct DQS in the CSBs, beyond the life of the project. MCSP also carried out joint supportive supervision sessions with USAID bilateral, Mahefa Miaraka, in Ambanja and Mampikony, during which local partners shared their appreciation for MCSP technical support, particularly as it relates to the community engagement strategies highlighted in the REC approach.

• Continued to support capacity of district managers and health facilities to use data for decision-making via the MNH Quality Dashboard

The MNH quality dashboard’s monthly tracking of key indicators enabled MOH staff to visualize CSB results and facilitate decision-making to improve performance. MCSP institutionalized the use of the MNH quality dashboard in 815 facilities, and the percentage of target districts that utilized a systematic approach to track, display, and use priority indicators increased from 82% of districts in PY3 to 100% of districts in PY4 (target was 70%), although ensuring consistent and prolonged use in individual health facilities remains a challenge. At the 513 CSBs that received additional support to use data for decision-making, monitoring of the quality of care indicators revealed the following measured results from October 2015 to June 2018: - Women screened for pre-eclampsia and eclampsia (PE/E) via routine blood pressure measurement during ANC visits increased from 41% in October 2015 to 96% in June 2018 (N = 1,002,989 total ANC visits in which a woman’s blood pressure was measured) (see Figure 4). - Women receiving an immediate postpartum uterotonic to reduce PPH increased from 85% in October 2015 to 99% in June 2018 (N = 188,264 total postpartum women receiving an immediate postpartum uterotonic) - Newborns not breathing or crying at birth who were successfully resuscitated increased from 71% in October 2015 to 90% in June 2018 (N = 12,169 total newborns with asphyxia who were successfully resuscitated). Figure 4. Increasing percent of women screened for PE/E with a blood pressure check during ANC visits (N = 1,002,989 total ANC visits in 513 CSBs)

97 92 92 92 95 94 96 96 87 74 63

41 % of women of %

Aug Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun 2015 2016 2017 2018 Month

Figure 5. Improving the Quality of Birth Care in CSBs, PY1-Q3 PY4

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MCSP contributed to a sustained improvement in PPH prevention for mothers, as well as resuscitation of newborns (n= 188,264 postpartum women who received uterotonic, n= 12, 169 newborns with asphyxia who were successfully resuscitated

96% 97% 97% 98% 100% 99% 99% 99% 99% 98% 99% 85%

90% 90% 90% 90% 91% 90% 85% 83% 87% 88% 88% 71%

Baseline Q1Y2 Q2Y2 Q3Y2 Q4Y2 Q1Y3 Q2Y3 Q3Y3 Q4Y3 Q1Y4 Q2Y4 Q3Y4 2015 2016 2017 2018

Percentage of newborn not breathing at birth who were resuscitated using stimulation or a bag and mask (size 0 or 1) in delivery room or maternity ward Percentage of women giving birth who received a uterotonic immediately after birth

Data use for decision-making is an integral part of the capacity building of EMADs as well as data quality control efforts. During the capacity-building workshops in Q2, the EMADs were oriented on the use of the dashboard data as well as the standard HMIS report data, in order to appropriately plan for and implement its support activities for health facilities. In February 2018, MCSP also participated in a workshop on the development and dissemination of standard monitoring and analysis dashboards for key health indicators. MCSP presented on its MNH dashboard, including the overall framework and programmatic approach within which the dashboard is used to improve quality of care. An analysis and subsequent discussions on the dashboard led to a revision of performance indicators after which the following were retained: number of ANC appointments, number of deliveries, number of childbirth, and number of women who delivered in a facility and adopted a contraceptive method. This workshop proved to be an important step in the process of transferring ownership of best practices to improve facility-level quality of services to the MOH via the establishment of a simplified dashboard.

• Supported EMAD teams, CSBs and CHRDs region to implement district-level CG/QI activities to strengthen a continuum of high-impact RMNCH services

o Continued to monitor CG/QI initiatives in the 2 CHRDs and 10 CSBs In PY4, MCSP continued to support CG/QI activities in a subset of targeted facilities to improve quality of childbirth services for both routine care and for women and newborns with complications at two district hospitals, and increased community engagement at 10 CSBs. During Q1, MCSP was unable to conduct follow-up visits due to the plague epidemic, but onsite and remote supervision visits to 12 facilities were conducted in PY4. These onsite joint supervision visits were critical in building the capacity of EMADs to provide quality supervision, and supported the CG/QI data collected via dashboard indicators.

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o Supported capacity building of EMARs/EMADs to sustain CG/QI activities MCSP conducted capacity-building workshops for the EMAR/EMAD to strengthen their capacity to continue MCSP activities beyond the life of the project, including the CG/QI intervention. This effort was conducted in collaboration with MOH central staff from the SFP, DEGHU, DDS, and DSFa. During the workshops, the EMAR and EMAD teams in the regions of Sofia, Alaotra Mangoro, Haute Matsiatra, Atsinanana, Analamanga, Menabe, Boeny and Atsimo Andrefana developed action plans to continue key initiatives, including the supervision of CG/QI activities, and future expansion of the CG/QI initiative to additional facilities using MOH’s own initiative and resources. As part of its capacity-building initiative, MCSP reviewed and updated all CG/QI technical tools and documents to optimize the transfer of ownership to the EMARs/EMADs during district-level workshops and during on-site supervision visits. Technical capacity building, including the transfer of CG/QI skills and monitoring tools to EMADs, was carried out starting in Q2. As a result, the EMADs of Antsirabe II and Mandoto are now empowered to integrate into their respective action plans the continuation of the CG/QI activities. Elsewhere, the introduction of CG/ QI to Ambohibary CSB2 (Moramanga district), and Bealalana CSB2 (Sofia region) demonstrated the feasibility of extending the approach with the district's own resources. For example, CSB2 Ambohibary’s QI committee was able to renovate the lodging for patient families and conduct regular cleanup activities around the CSB, thus improving the environment Despite these gains, MCSP noted that the norms of internal or external monitoring/supervision were not consistently observed, nor had the QI committees and the EMAD yet been able to share formal monitoring reports. According to the EMAD and the providers, this was due to competing priorities, but MCSP A midwife uses the standard MNH indicator dashboard in an redoubled its efforts to sensitize the MCSP-supported CSB. Photo: Karen Kasmauski/MCSP EMADs to the importance of consistent supervision and documentation to maintain the provision of high quality services.

Objective 3: Increase access to long-acting family planning methods in USG priority regions

MCSP focused on introducing and expanding long-acting family planning methods (implants and intrauterine devices) during the postpartum period. Advocacy for PPFP, led by MCSP, will contribute to the Roadmap priority to increase the use of long-acting FP methods across the country. In USG regions, MCSP trained health providers in PPFP counseling and insertion of postpartum implants and intrauterine devices (IUD), and strengthens the capacity of the health facilities to deliver PPFP services through the provision of materials for insertion of postpartum intrauterine devices (PPIUD) and implants.

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• Provided technical support to the MOH to harmonize the FP training materials and tools (Activity 3.1)

o Disseminated results of field-testing on BCS+ counseling cards for providers to improve FP counseling (Activity 3.1.2)

During PY3, MCSP supported the development and field-testing of adapted Balanced Counseling Strategy Plus (BCS+) counseling cards for providers in order to improve FP counseling. In PY4, the counseling cards (in French and Malagasy) were field-tested in eight CSBs by 16 providers in the districts of Atsimondrano and Ambohidratrimo in Analamanga region, with support from the EMAR/EMAD. MCSP then disseminated the field-testing results to the national FP Committee in April 2018, revised the counseling cards based on recommendations and officially remitted the electronic version to the MOH, which has included the counseling cards as part of the virtual library for future use by partners working in family planning.

• Strengthened the PPFP skills of 620 providers through supportive supervision In PY4, MCSP strengthened the PPFP skills of a total of 620 providers across 538 facilities (66% of Y4 target), despite a focus on the plague epidemic response in Q1 which slowed training and supervision activities. 380 remote supervisions were conducted by regional trainers via telephone calls to trained providers in 14 regions. In addition, 240 providers received on-site supervision. These supportive supervision activities were conducted by EMAR/EMAD members with support from MCSP; the EMAD/EMAR teams are expected to continue the activities with their own resources after project closeout.

Figure 6. Increasing percent of postpartum women discharged with a FP method of choice in CSBs (N = 28,204 total postpartum women discharged with a FP method of choice in 513 CSBs; does not include lactation amenorrhea method)

25 22 21 20 19 20 16 15

8 8 % of postpartum women postpartum of % Mar Jun Sep Dec Mar Jun Sep Dec Mar June 2016 2017 2018 Month

• Improved quality of services by supporting commodity management

The availability of commodities plays a critical role in PPFP uptake. During supervision visits, MCSP monitored commodities stock level and followed up with the district management to ensure availability of contraceptives. In collaboration with the DSFa, MCSP also followed-up on the

MCSP Madagascar PY4 Annual Report Page 22 of 48 availability of products at the Centrale d'Achats de Médicaments Essentiels et de Matériel Médical de Madagascar (also known as SALAMA). MCSP also collaborated with the Direction Régionale de la Santé Publique (DRSP, regional public health department) to monitor FP commodities in Analamanga, as well as the eight facilities at which the BCS+ counseling cards were piloted. The exercise revealed that all FP product types, including PPFP, were available and in sufficient quantity at the SDSP and at visited health facilities. Recommendations for improvements were shared with relevant MOH managers and follow-up for improvement of commodity management is ongoing, and the monitoring will be transferred to the MOH EMAR/EMAD staff.

• Supported ongoing monitoring of TMT activities In PY3, based on results of the First–Time Parents (FTP) study, MCSP developed and implemented a proof-of-concept intervention, Tanora Mitsinjo Taranaka (TMT), aimed at improving the sexual and reproductive health (SRH) of young mothers and their husbands/partners in two districts in Menabe region. During Q1 of PY4, MCSP and the MOH conducted a joint supervision of TMT stakeholders within five health centers and several CHWs sites within Miandrivazo district to support participants to improve performance and share achievements and challenges. In Q2, MCSP held periodic review meetings in February 2018 with 73 community health workers (31 in Morondava and 42 in Miandrivazo) and 21 health providers (7 in Morondava and 14 in Miandrivazo) to monitor the quality of TMT activities, and provide an opportunity for participants to share best practices and improve TMT interventions in prenatal care, delivery, FP and postnatal care. During Q3, MCSP conducted the last joint supervision of TMT activities with the MOH at Morondava district. Besides the review of stakeholder’s performances, this was an opportunity to discuss the continuation of activities beyond the end of project, and ensure sustainability. The TMT stakeholders promised to continue the TMT activities with their own resources.

“Thanks to TMT [intervention] which gave us clues on what to improve within our health center and how to make things happen. You could see that we had no boundary fence before TMT, but we negotiated with the Mayor to help us construct what you now see. We even thought to provide acceptable shade for waiting patients. Young patients wouldn’t be embarrassed to stay on our benches anymore. Moreover, we added an orientation sign for them to indicate the way where to go… we learned through TMT that [these changes] make a difference. We are still keeping in mind other unachieved projects!”

- TMT-trained health providers at CSB2 Bemanonga, Dr Céline Raharisoa and Midwife Maria Soafarahanitra

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Weekly sensitization on health services for all patients performed by health providers observed during joint supervision at CSB2 Morondava Photo credit : Haingo Ralaison

o Conducted evaluation qualitative of the TMT proof-of-concept In April/May 2018, MCSP conducted the qualitative evaluation on TMT activities from 11 TMT health centers (CHRR, CHRD2 and CSB2) within the districts of Morondava and Miandrivazo in Menabe region. Through 36 interviews or focus group discussions to a total of 107 persons including 73 representative of TMT-trained actors (11 health workers, 46 Community Health Workers and 5 national and 11 regional MOH staff), a sample of 34 young parents have been interviewed. Early results show that the intervention was successful in increasing MNH and FP indicators and can be recommended for scale-up. The TMT quantitative data collection was conducted jointly with MCSP end-line assessment to enable a comparison of common RMNH indicators before and after TMT, with particular attention to patients 10 and 24 years old. Both quantitative and qualitative results are being analyzed together to withdraw and enrich lessons from TMT interventions and recommendations at local, regional and national level.

Objective 4: Improve prevention and treatment of MIP in the context of focused antenatal care and malaria case management of children and adults at primary care level Despite a relatively high rate of ANC attendance, only 37.4% of pregnant women received at least one dose of IPTp-SP during their last pregnancy, 22.3% reported taking two or more doses of IPTp-SP and only 10.3% took three or more doses during ANC (MIS 2016). In PY2-PY3, MCSP provided technical support to the Direction de la Lutte contre le Paludisme (DLP, National Malaria Control Program) to update national MIP documents, as well as supported the strengthening of providers’ capacities by developing pools of national, regional and district trainers through which 1,289 ANC providers and 1,713 Chefs CSB were trained. In PY4, MCSP continued to support updates to national documents to ensure alignment with global recommendations. MCSP also supported provider trainings in 10 regions (46 districts) on MIP and case management, including treatment of uncomplicated and complicated/severe malaria for all adults and pregnant women.

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• Provided technical support to the finalization of the RH Norms and Protocols and the 2018-2022 National Strategic Plan to ensure consistency and alignment with global recommendations Following the validation of the RH Norms and Protocols and the national malaria strategic plan, MCSP collaborated with the DLP and DSFa to update the MNH training curriculum and job aids, which included the integration of MCSP’s Toolkit to Improve Early and Sustained IPTp Uptake.

• Strengthened the capacity of 179 providers and 65 Chefs CSBs to provide evidence-based malaria prevention and treatment care During PY4, MCSP prioritized support to districts to plan and implement training and supervision best practices in a sustainable manner. 179 providers were trained in MIP and malaria case management in nine regions. These trainings were integrated into MCSP’s MNH training and were conducted during supervision visits of previously trained providers. The adapted approach to supportive supervision of trained health providers combined on-site supervisory visits with mobile mentoring, including SMS messaging and structured phone calls. Both onsite and remote supervision which revealed that providers have maintained a high level of performance. The supervision visits are also opportunities to identify and solve issues impeding service delivery including the stock-outs of commodities.

o Strengthened the capacity of ten regions to continue malaria technical updates of new providers and conduct supportive supervision During PY4, MCSP focused on the transfer of competencies and evidence-based best practices to the MOH in order to sustain activities beyond the life of the program. In all regions of interventions, MCSP conducted capacity-building workshop for the EMARs and EMADs to continue MNH and malaria trainings and supervision activities, and supported the EMADs to ensure the completion of those activities in PY4, by building on the existing pool of regional trainers. See results under Objective 2 of this report for additional details on the capacity-building of EMARs/EMADs.

• Strengthened the capacity of health facilities to monitor and use data for decision-making to support service delivery. MCSP integrated a MNH dashboard to monitor the quality of services at all project-supported facilities following provider trainings. The data are collected via SMS were also visually presented at the facility level on a poster, and made accessible to district and regional-level MOH staff to monitor via a web platform. In October 2017, MCSP integrated a small number of additional malaria, FP and immunization indicators into the MNH quality dashboards at program-supported CSBs. The project has since noted an improvement in the rate of women receiving the third dose of intermittent preventive treatment in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP), which is higher than the national rate of 22% (Source GESIS). The project noted an increase from 14% at baseline up to 37% in Q2, which dropped down to 23% in Q3 due mainly to SP stock-outs in many CSBs, but increased once again in Q4.

Figure 7. Proportion of pregnant women who received at least three doses of IPTp-SP in 160 MCSP supported facilities

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37% 33% 31% 28% 27% 28% 28% 26% 26% 24% 21% 23%

14%

GESIS Aug Sep Oct Nov Dec Jan Febr March Apr May June 2015 2017 2018

*Source: 2015 (GESIS), Aug 2017-June 2018 (MCSP supported quality dashboard) ** 2015 GESIS data is national average for all facilities in Madagascar

• Supported the monitoring of malaria commodities at 192 health facilities The availability of SP at the facility level has a direct impact on IPTp uptake. Historically, MCSP has shared data collected from its supervision visits with the district MOH teams as well as the DLP and PSM. In PY4, MCSP took this a step further by closely monitoring stock level during supervision visits, and by collaborating with districts and PSM to reduce the occurrence of stock-outs. The SP stock level – ascertained from facilities’ monthly reports – is one indicator collected via SMS as part of the MNH dashboard. Data collected from facilities in Q1 showed a high level of stock-outs; 63% of facilities reported at least 1 month of SP stock-out and 18% reported 3 months of stock-out for the quarter. Based on anecdotal evidence, providers were prescribing SP and referring pregnant women to the local pharmacies when there was a stock-out at the facility. MCSP noted that the current reporting system is not reactive enough to provide a real-time overview of monthly stock at facility level, and to address this concern, set up an innovative low cost system to track and map key malaria stock outs by using data sent by providers via text. Malaria commodities – SP, ACT, and RDTs – were tracked in MCSP interventions regions. Providers, even in remote areas, sent SMS information on monthly stock of commodities (at $0.10 per SMS), the texts are collated in a web server, and a web-based mapping tool on Google Maps updates the map each time a text is submitted.

Figure 8. Percentage of health facilities reporting stock outs on the last day of the month of key malaria commodities among 138 heath facilities submitting data via SMS, January-June 2018.

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

Percentagefacilities of healthreporting 0% Jan Feb March April May June

ART ACT ITN

• Supported the MOH in the implementation of a study on malaria care-seeking behavior in pregnant women and children MCSP supported the DLP in the development and implementation of a study to assess care-seeking behavior for fever in caretakers of children under 15 years of age and in pregnant women in rural and urban areas throughout eight different malaria-endemic zones of Madagascar. The data collection for the study began in October 2017, and the final report has been finalized. The study results will be shared during several keys malaria sector events, including the RBM meetings, and the MOH’s scientific conference. This dissemination will focus on study recommendations to ensure it is integrated into the 2019 Malaria Operational Plan and into the national strategic plan. Key results from the study include: study participants perceived malaria treatment to be of high cost, they tend to practice self-medication, and they site the frequent absence of providers and medications as impediments to seeking care.

• Supported the MOH in conducting two malaria assessments: a health facility readiness survey and an elimination readiness assessment In PY4, MCSP began to conduct an assessment of the operational capacity of health facilities and malaria elimination readiness in eight (08) targeted districts for elimination. The study protocol was finalized and was approved by the Malagasy Ethics Committee. The protocol and accompanying tools were also shared with the PMI for review before submission to John Hopkins University’s Internal Review Board (IRB). Data collection began during the last month of PY4 and study report will be finalized and distributed in Y5.

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Objective 5: Strengthen the capacity of pre-service training institutions to educate midwives according to international Confederation of Midwives (ICM) standards and competencies

Strengthening preservice institutions to train competent midwives is a priority investment towards improvement of MNH services. MCSP supports public education institutions by building the technical capacity of teachers/instructors and the implementation of skills lab. In PY4, MCSP plans to consolidate the technical support provided to the midwifery institutions in previous programmatic years and promote the sustainability of program gains by advocating for a legal framework to support the quality of midwifery education.

• Strengthened public and private pre-service midwifery institutions MCSP continued to support the quality of the teaching in public and private midwifery training institutes. The skills laboratory for the Majunga and Diego Institut public de Formation Interrégionale des Paramédicaux (IFIRP, public pre-service institution) were finally completed after significant delays due to coordination issues with the Faculty of Medicine. MCSP donated training equipment such as anatomical models and office equipment (i.e. anatomical models, delivery kits, newborn resuscitation kits, PPFP kits, infection prevention kits, PPH kits and eclampsia kits), and also provided a training for 15 tutors and teachers on skills lab management so that all students can practice on models and master the clinical skills. In total, MCSP directly supported the implementation of four (04) skills lab at four IFIRPs. For the two IFIRPs in Antananarivo and Toliara, it was agreed upon with UNFPA and the Faculty of Medicine that MCSP will support the technical updates of teachers/tutors while they would support the renovation and donation of equipment. In May 2018, the Toliara IFIRP’s skills Lab, at which MCSP had trained the 12 teachers in MNH and effective teaching, was inaugurated as part of International Day for Midwives.

In March 2018, MCSP also conducted a joint supervision visit with the IFIRP in Toamasina, reaching seven teachers/tutors, eight third-year students, and five students ending their midwifery training cycle. The IFIRP in Toamasina has enforced adoption of training supervision and evaluation approach marketed by MCSP, and starting in 2018, all students in Toamasina have to practice competencies in gynecology in obstetrics and in nursing in the skills labs before clinical practice. MCSP’s skills evaluation scoring have been adopted by the IFIRP and now the 90% skills validation MCSP rule is applied and only students who scored 90% on skills can start clinical practice. The IFIRPs are now convinced of the usefulness of the skill lab set up and equipped by MCSP.

o Supported MNH/FP technical updates and supervision for teachers/tutors from private midwifery education institutions Under the leadership of the DIFP and ONSFM – and upon request from private midwifery education institutions – MCSP supported technical updates in MNH/FP and effective teaching skills for 17 teachers/tutors from 14 private midwifery education institutions. These 17 teachers/tutors are now able to improve the quality of education in the private schools in Ambositra, Fianarantsoa, Ambatolampy, Toamasina, and Antananarivo by using interactive participative training approach, coupled with simulation and demonstration. MCSP was also able to coach two (02) trainers to strengthen the existing pool of trainers for private institutions in order to ensure the sustainability of

MCSP Madagascar PY4 Annual Report Page 28 of 48 the activities. In total, 27 private institutes were supported by MCSP in collaboration with ONSFM. In collaboration with the Faculty of Medicine, MCSP conducted joint supervision of supported private midwifery institutions to evaluate to what extent teachers/tutors trained in PY2-3 are applying their newly acquired skills and are using the revised curriculum in March 2018. The supervision visits reached 12 teachers/tutors, 12 first year students, 27 second-year students and 22 third-year students from 08 supported private midwifery institutions in Ambatolampy and Antananarivo. The key takeaway from this supervision activity is that trained teachers/tutors have not proactively shared their acquired knowledge and skills among their respective midwifery institutions and this has caused delayed adoption of the training and supervision approach within these training institutions. Supervision also revealed that the absence of a functioning skills lab at these private midwifery training institutions is a considerable impediment to strengthening pre-service midwifery institutions. MCSP took advantage of the opportunity posed by the supervision visits to share results for the first evaluation experimented in PY3, to outline the importance of skills labs, and to disseminate the latest ICM recommendations on MNH and FP. During Q3, MCSP supported the training of 17 teachers from seven (07) private institutes in Antsirabe, Antsohihy, Antsiranana and Antananarivo, as requested by DIFP and ONSFM. During this training, MCSP also ensured the monitoring and supervision of the quality of the teaching of supported midwifery institutions. In PY4, two (02) private institutions were supervised. After the supervision which showed gaps in following teaching standards, private institutions recognized the importance of teacher capacity building and the need for setting up skills lab, a major challenge since none of them have a skills lab.

o Supported supervision of public midwifery institutions and documented improvements in quality of education In PY4, the three IFIRPs of Fianarantsoa, Antsiranana and Mahajanga were also supervised by MCSP. A total of 19 teachers were interviewed, 28 students in the 3rd year (L3) and 10 graduate students were assessed. During supervision visits, MCSP observed improvements from the use of skill lab on student competences. As such, the students at IFIRP Fianarantsoa performed better because they were using the skill lab and MCSP’s standard checklists. However, MCSP has also noted the importance of more frequent internal or external supervision to sustain the quality of education, which should be conducted by the Faculty of Medicine and the DIFP.

• Supported the ONSFM to build capacity and advocate for a provider certification process based on continuing professional education MCSP collaborated closely with the ONSFM and professional associations for midwifery training. A key activity in PY4 was to support the ONSFM to initiate a provider certification process based on continuing professional education, which did not currently exist in Madagascar and yet is necessary for providers to maintain and update their competencies and knowledge throughout their career. MCSP supported the development of online courses and supervision visits for private schools. The ONSFM’s website is now in place, and MCSP provided technical support to make available training materials on the website in Q2. Students can access those online. The ONSFM was able to negotiate a room within the IFIRP Tananarive to set up a skill lab, and MCSP provided anatomic models. This allowed OSFM members to practice ahead of the MOH national exam to recruit midwives.

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Addendum: Improve the capacity of providers to respond to the pneumonic plague outbreak

During the plague epidemic, which started in August 2017, health providers were most at risk and many were infected when handling cases due to gaps in infection prevention and control (IPC), including the use of personal protective equipment (PPE). The outbreaks occurred in regions that were not traditionally plague endemic, thus most providers were not prepared for managing cases. In response to the epidemic, MCSP’s mandate and objective was to improve the capacity of providers in priority regions to respond to the plague emergency. The priority regions for MCSP’s interventions were: Analamanga, Atsinanana, Haute Matsiatra, Vakinankaratra, and Alaotra Mangoro, where the highest numbers of cases were recorded. Three of these regions – Analamanga, Alaotra Mangoro, and Vakinankaratra – have a few plague endemic districts, where cases appear annually. To achieve project objectives, MCSP collaborated closely with the MOH at central and regional levels, and actively participated in the national TWG to coordinate interventions with organizational partners

Figure 9. Technical Strategy for plague response

Theory of Change

Public Outbreaks of plague in non-traditional areas (major urban areas); Health systems overwhelmed; health need Frontline health personnel exposed; providers not trained in IPC and plague case management Project Project rationale

Inputs Activities Outputs Outcome Impacts • USAID funding, • Assessment, • National training • Decreased • Decreased • MCSP • Training of materials, number of number of experience in trainers and • pool of trainers infected cases, training, supervisors, and supervisors, providers, • epidemic halted • TWG, • Training of • increased • improved case Results chain • Training providers in knowledge/ management, materials: hospitals and competencies of • improved (manuals, CSBs, providers, preparedness equipment, Job • advocacy, • district/hospital aids) • TA for districts in action plans • PPE materials developing action plans

• Provided technical sport to the national TWG coordinating response to the plague outbreak MCSP actively participated in the TWGs coordinating plague response and case management, in addition to various weekly meetings at the height of the epidemic. More specifically, MCSP was a key member of the subcommittee in charge of capacity building which includes representatives from the MOH’s Service de Formation et Perfectionnement du Personnel (SFPP) and the Division Peste (plague department), the WHO, Médecins du Monde, the International Federation of Red Cross, and the

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Ordre National des Médecins (ONM, National Council of Physicians). MCSP hosted the subcommittee’s meetings to develop a training curriculum and training materials, which were subsequently validated and used by all partners for provider trainings. MCSP also liaised with the PSM to ensure the availability of PPE and supplies for facilities by relaying facility needs to PSM and conducting subsequent follow-up on the delivery of IPC commodities to confirm that requests were addressed. Within the plague response TWG that coordinated provider trainings at public and private facilities, MCSP committed to facilitating provider trainings with a focus on frontline CSB, primary health center staff. As diagnostic and treatment components were integrated into the training curriculum, MCSP collaborated with Institut Pasteur de Madagascar (IPM) and the MOH central laboratory to provide technical support for trainings on RDTs.

• Strengthened the health system to sustain the national plague response From the early stages of the epidemic, MCSP prioritized collaboration not only with the MOH’s Plague Division but also with the SFPP via the TWG to develop a standardized training approach and curriculum for all cadres of health providers. The goal was to promote the MOH’s ownership and build its capacity to support and implement effective trainings in the future. The approach, which capitalized on MCSP’s experience working in the 16 USAID priority regions, centered on the development of a pool of national and regional trainers who can roll-out the training of providers through cascade trainings to reach more health facilities and providers in a short time. The national trainers included MCSP staff but the majority were MOH staff. The regional trainers are members of the EMAR and EMADs who had previously received MCSP’s competency-based MNCH/FP training. These regional trainers were designated by the DRSP based on the regional and deistical needs and on the available human resources capacities. As MCSP supported cascade trainings of providers at the CSB level for the five priority regions most impacted by the plague – Analamanga, Atsinanana, Haute Matsiatra, Vakinankaratra, and Alaotra Mangoro – it also conducted training-of-trainers (TOT) sessions in 15 USG regions, thus building the capacity of the other regions to actively update their providers during quarterly reviews or other training opportunities.

Figure 10. IPC and plague management competency-based training model

Facility level training at CSB, National trainers trained regional and district hospitals • MOH, MCSP, in • National trainers • Better IPC practices collaboration with facilitate a 3-day in health facilities in 5 WHO, USAID partners • National trainers hold training for regional • Regional trainers priority regions in TWG supported 3-days trainers facilitate training this process comprehensive sessions for CSB and training for people. hospitals providers IPC and plague Improve IPC and case managementguidelines Régional trainers trained management knowledge and updated and trainers guide practice developed

Supervise training sessions and technical support during sessions

• Adapted training materials and job aids on IPC and plague case management

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o Developed a 3-day training curriculum for providers MCSP utilized Jhpiego program learning gathered from the global response to the 2014-2016 Ebola epidemic in West Africa to support the MOH in the development of a 3-day training curriculum for health providers on plague case management and IPC, which included a reference manual, facilitator guide and participant book. The comprehensive 3-day curriculum was validated by the MOH and was utilized for all the trainings conducted by MOH, MCSP and other partners.

o Developed and disseminated nine (9) IPC and plague case management job aids in 5 regions To strengthen MOH staff capacity and support the Figure 11. Topics covered in MCSP’s trainings, MCSP also developed job aids for providers, plague case management and IPC targeting frontline providers at public health facilities, as training well as staff at the Bureaux de Santé de District (BSDs, 1) General information on plague district health offices) and the Bureaux de Santé Régional 2) Triage and isolation of plague cases (BSRs, regional health offices). In November, 2017, The 3) Introduction to IPC 4) Practice of standard IPC measures to MOH and the TWG validated three (3) job aid posters protect providers (hand washing, correct in French and Malagasy – on IPC donning and removal of PPE) precautions/standards, the use of PPE, and the 5) Additional IPC measures for plague preparation of disinfecting solution – which were epidemic printed and disseminated to all trainees. In December 6) Safe disposal of sharps 2017, MCSP and partners developed three (3) additional 7) Sampling and transport of samples 8) Waste management in hospitals case management job aids – adapted from WHO and 9) Respectful care applied to plague case MOH plague materials – to boost implementation of the management updated training curriculum: 10) Management of deceased bodies - 1 flipchart on the treatment protocol algorithm (dignified and secure burial of bodies) 11) Diagnosis and testing (including use of - 1 poster on sampling and testing procedures the RDTs), and for bubonic plague (pus samples from buboes) 12) Case management - 1 poster on sampling and testing procedures for pneumonic plague (sputum samples) To support the training session on humanized care during plague case management, MCSP also developed a short video to demonstrate the best practices.

• Developed a pool of 17 national trainers and 275 regional trainers from 80 districts (including the five priority regions) to support the cascade of provider trainings at the sub-regional level MCSP initiated a TOT for 17 national trainers from the MOH, the ONM, and the ONSFM to support trainings in Haute Matsiatra, Atsinanana, and Vakinankaratra funded by WHO, as wells as future trainings. In November 2017, these national trainers were deployed to support TOTs in 16 regions, including the five priority regions. Two-hundred seventy-five (275) regional trainers were trained – 113 from the five priority regions and 162 from 11 other USG regions. Most of those regional trainers were from the EMAR/EMAD that MCSP has already trained and utilized for previous MNH trainings, thus were skilled in conducting trainings. Appendices 4 and 5 provides details of average scores from pre- and post-training tests per region, and shows an increase in knowledge from below

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65% to above 90%, indicating that regional trainers did gain knowledge and competencies in IPC and plague case management.

• Supported EMARs/EMADs to conduct provider IPC and plague case management trainings in five priority regions MCSP planned to reach 450 providers from 150 health facilities with IPC/plague training. In collaboration with the EMADs/EMARs in the five priority regions - Alaotra Mangoro, Atsinanana, Vakinankaratra, Haute Matsiatra and Analamanga - MCSP identified all the health facilities prioritized for training based on the following criteria: • Facilities located within the areas most affected by the plague epidemic • Facilities with health worker who have not yet received IPC training • Remote/rural facilities where people do not have access to a district hospital MSCP supported the trainings of 505 providers (112% of the target) from 219 selected health facilities (CSB and district hospitals) in 31 districts in the five priority regions. All providers who received training (i.e., medical doctors, midwives, and nurses) completed pre- and post- training assessments to evaluate change in their knowledge about IPC and plague case management. Appendix 5 provides details of average scores pre-test and post-test scores for providers in Atsinanana region for illustration, and shows increases in knowledge retention scores for four training topics (general information on plague, practice of IPC measures, triage and isolation of plague cases, waste management).

o Collaborated with partners to train 429 providers from major hospitals in 4 regions on IPC

When the epidemic started, in October 2018, Figure 12. Distribution of provider trainings the TWG urged to conduct IPC trainings in the major urban treatment centers. Thus, a first wave of provider trainings was conducted in 12 major hospitals in the four regions most affected by the epidemic – Analamanga, Atsinanana, Vakinankaratra, and Haute Matsiatra – through which 429 providers from major hospitals in 4 regions were trained.

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MCSP provided technical support in developing the IPC “The [MCSP] training gave me a better training curriculum, in conducting the trainings with its understanding of the appropriate measures staff participating as facilitators/trainers and logistical support – and by providing PPE samples for simulation, to take when managing patients suffering printing of training manuals for trainers, and printed job from the plague.” aids for the facilities. The WHO covered the expenses related to the per diem and travel of MOH staff (see - Dr. Fanja Ny Aina Andrianjaka, a clinical Table 3 for additional information on providers trained doctor at a hospital in Antananarivo with WHO funding).

o Supported EMADs in other MCSP regions to plan and implement the cascade training of providers, resulting in 105 providers trained independently During the regional TOTs for plague, those same trainers were selected and trained in IPC and plague case management. Then, MCSP supported the EMADs in planning provider trainings for subsequent months. In the five priority regions, MCSP financially supported the training of providers, while in the non-priority regions, the trainings of providers had to be organized by the EMADs using their own resources. As a result, in Sofia, Diana and Atsimo Andrefana regions, the EMADs trained 105 providers by April 2018 using their own resources taking advantage of quarterly review meetings or supervision visits.

• Supported the implementation of IPC measures in 12 major hospitals in the five priority regions

o Conducted a rapid assessment of hospitals in the five priority regions Key results of the rapid assessment: • Proportion of hospital workers trained in IPC: 78% of clinical workers have received IPC training compared to only 22% of supporting staff (see Figure 4 for additional details). To address this disparity, MCSP and PSI agreed on a plan to have MCSP train the remaining health workers at the major hospitals and PSI to train the supporting staff at those same institutions.

• Utilization of IPC training modules: Figure 13. Proportion of providers trained in IPC by Generally, most health workers have received the full package of IPC training modules covering the four major themes: RDTs, colleting pus samples, diagnosis and infection prevention (IP). However, under IP, the topics of health education for patients and their family, vaccination, laundry, and disinfection were not consistently touched upon. To address this issue, during the training session MCSP decided to highlight the importance of these topics. • Availability of IPC documents and job aids: Half of the facilities assessed do not have any available IPC job aids or other reference documents, and only 20% of health facilities use them

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systematically. To improve the availability of IPC tools, MCSP planned to print more and disseminate the basic IPC job aids in upcoming months. • Availability of IPC materials and equipment: 60% of hospital have personal protective equipment (surgical and examination gloves, gowns, masks, boots / clogs, etc.) but in insufficient quantities for all staff members. This finding was shared with PSI and they have committed to providing health facilities with the missing equipment. The results of this assessment were shared with MOH, PSI and WHO in order to coordinate interventions in the hospitals. These were the hospitals where the IPC trainings were conducted at the beginning of the epidemics and the results showed that they needed further support in implementing IPC standards. It was also important to train both clinical and non-clinical (supporting) staff. In response, MCSP was assigned the responsibility of conducting the trainings of remaining clinical workers and PSI was assigned the trainings of non-clinical staff.

o Completed the training of 173 clinical health workers in eight major hospitals in the five priority regions MCSP completed the training of the remaining clinical health workers in the major hospitals of the five priority regions, resulting in additional 173 health providers trained. This was also an opportunity to conduct follow-up on action plans established during the IPC trainings conducted in October 2017, and to develop facility action plans to address noted gaps in the implementation of IPC standards. For example, at the CHRR in Antsirabe, after receiving the training, hospital management has committed to include a review of IPC practices during their morning staff meetings, and ensuring that the proper preparation of chlorine solution – a key IPC practice – becomes systematic.

Table 2. Hospitals and providers trained by MCSP in five priority regions Region Hospitals Number of providers Haute Matsiatra CHRR Tambohobe 48 Atsinanana CHU Analakininina 45 Vakinankaratra CHRR Antsirabe 43 Analamanga CHAPA 6 CHRD Itaosy 2 CHRD Anosy Avaratra 7 CHU Fenoarivo 10 Alaotra Mangoro CHRR Ambatondrazaka 12 TOTAL 8 173

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Reinforcing IPC standards in major hospitals Noeline Alice Ravololoniaina is responsible for hospital hygiene, safety and sanitation at the CHUJRB. Following MCSP’s IPC/plague training, Noeline and her colleagues are now empowered to respond quickly to future epidemics. She states: "The fact that they have faced the plague, and that they have acquired good practices such as systematic handwashing before and after care, wearing gloves and the mask… as well as the availability of personal protective equipment provided by partners, have all led to a change in staff hygiene behavior. […] these good practices have really made my job as hospital hygiene manager easier. " MCSP/ Agnes Ramananarivo IPC/plague training for providers at CHUJRB

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Challenges and Opportunities Continuation of activities by districts: Ahead of project closeout, MCSP has built the capacity of EMADs/EMARs to sustain training and supervision activities beyond the life of project. However, this is a challenge as most districts clearly need support in continuing those activities. When MCSP phased out from the regions in April, a significant drop in supervision visits, mobile mentoring and SMS reporting was noted. Nonetheless, there are a few regions that have shown strong leadership and ownership, and have been able to maintain the activities.

Data Collection: MCSP addressed the reduction in the response rate for SMS quizzes and data transmission from facilities via strengthened onsite and remote supervision, which led to improvements in data collection and reporting. Data Quality: MCSP continues to support data verification both nationally and regionally through technical support for onsite supervision visits. This work will ensure robust data even during the close out process, and after the life of the project. Program Learning – Malaria Assessments and Final Evaluation: Two assessments are currently underway: (i) final evaluation of the program, and (ii) a health facilities assessment and malaria elimination assessment among public and private facilities. The first will provide ample data about the impact of MCSP in Madagascar, and the second support national strategic planning for malaria. Institutionalization of the MNH facility dashboard: The MOH has decided to standardize a dashboard tool, and during a recent workshop focused on the elaboration and dissemination of standard dashboards in February 2018, MOH staff expressed interest in modeling the dashboard on MCSP’s as well as integrating several of MCSP’s quality indicators. This is an excellent opportunity to have indicators on quality of care recognized at national level and taken into consideration in strategic planning Importance of supervision: MCSP has found that when supervision activities are consistently and effectively applied, it facilitates and eases the handover of such activities to MOH staff at regional, district and the local levels. Health providers have been much more actively engaged since they set up their CG/QI committees and MCSP is observing a positive trend that shows that the quality of services and results are sustained in health facilities with an active CG/QI committee, even without MCSP supervision.

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Success Story MADAGASCAR Effective formative supervision on vaccine preventable disease surveillance helps Madagascar become ‘polio free’

Dr. Lucie Famamesamtsoa is the head of the Antsatsaka centre de santé de base (CSB or primary health center) II, located in Ambanja district of northern Madagascar.

With a CSB to manage, vaccine preventable disease (VPD) surveillance—including surveillance for acute flaccid paralysis Photo: MCSP/Kate Bagshaw (AFP) has sometimes fallen through the cracks. “I didn’t really care about surveillance; I didn’t understand how important it NAME was,” she explained. Dr. Lucie Famamezamtsoa However, AFP surveillance is fundamental to eradicating polio, ROLE and was identified as a key intervention needed to interrupt the Head of Antsatsaka CSB II circulating vaccine-derived poliovirus (VDPV) first discovered in Madagascar in 2014. AFP surveillance helps to identify children LOCATION who may have symptoms of polio and can assist health teams in Ambanja district, Diana Region, Madagascar determining if additional polio campaign or routine immunization strengthening efforts are needed. And, countries depend on

SUMMARY networks of community members who are in close proximity to Between 2014 and 2015, Madagascar had 11 and trusted by the people—including health workers, like Dr. Lucie, local leaders, teachers, and parents—to identify at-risk confirmed cases of vaccine- derived communities and children showing signs of paralysis. Dr. Lucie poliovirus, signifying challenges with the was not the only one who didn’t understand the importance of routine immunization system that urgently surveillance. needed attention. In response to this polio outbreak, the national Expanded Program on In recognition of this gap, MCSP implemented a series of Immunization and partners implemented a formative supervision visits on AFP and VPD surveillance at series of polio campaigns and increased district and health facility levels, including the Antsatsaka CSB II. community-based polio surveillance efforts. With training on vaccine preventable disease Since the formative supervision on AFP and VPD surveillance, surveillance provided by MCSP, Dr. Lucie is Dr. Lucie has been active with surveillance, including reporting a contributing to national polio eradication suspected AFP case to the district level in April 2018. She followed the necessary steps to ensure the stool samples arrived efforts by identifying children who may have in good condition for testing at the Institute Pasteur of symptoms of polio in her home district, Madagascar and remained engaged with the family until the test Ambanja, located in northern Madagascar results were available, which showed that the case was negative for vaccine-derived polio virus.

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As a result of these efforts and increased “Before the training, I did not take the time to community and polio surveillance activities, identify AFP cases. After learning how important the Madagascar has not had further cVDPV cases and AFP surveillance component is to make Madagascar the country achieved Certification of Polio Eradication in June 2018. The certification by the a polio-free country, I am motivated to actively Regional Certification Committee is a major search for cases.” milestone for the country and region. - Dr. Lucie Famamezamtsoa

The photos below show the 2017 and 2018 vaccine preventable disease monitoring sheets for the Antsatsaka CSB II, which indicate zero polio-related acute flaccid paralysis (PFA) cases reported in 2017 and one AFP case reported in 2018, after receiving formative supervision on AFP and VPD surveillance from MCSP.

Photo 2. Number of VPD cases notified in Photo 1. Number of VPD cases notified in 2017 from Antsatsaka CSB II. 2018 from Antsatsaka CSB II.

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Appendix 1: Data from Plague/IPC Trainings Knowledge pre- and post-test scores of regional trainers in 5 priority regions

89% 93% 92% 93% 90% 84% 73% 71% 71% 68% 63% 62%

Knowledge retention Knowledge retention Knowledge retention Knowledge retention Knowledge retention Knowledge retention Vakinankaratra Alaotra Mangoro Analamanga Haute Matsiatra Atsinanana TOTAL Average prestest score Average post test score

Pre- and post-test knowledge scores of regional trainers in non-priority regions

96% 94% 93% 92% 93% 94% 89% 91% 91% 86% 86% 83%

69% 70% 66% 68% 68% 67% 67% 66% 65% 64% 63% 60%

Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge Knowledge retention retention retention retention retention retention retention retention retention retention retention retention Analanjirofo Vatovavy Atsimo Ihorombe Amoron'i Menabe Melaky Diana Boeny Sofia SAVA TOTAL Fitovinany Andrefana Mania Average prestest score Average post test score

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Average pre-test and post-test score for knowledge retention of providers by training topics (Atsinanana region).

91% 86% 88% 89% 89% 79% 67% 63% 61% 64%

General information on plague Practice on IPC measures Triage and isolation of plague cases Waste management Knowledge retention by topics

Average prestest score

Providers trained and facilities reached via MCSP’s IPC training in priority regions, Oct-Apr 2018

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Appendix 2: Performance Indicators

BASELINE/ ACHIEVEMENT Y1-Y3 INDICATOR PY4 TARGET ACHIEVEMENTS PY4 COMMENTS Y1-Y3 TARGETS 1.1 Number of national Baseline: N/A - CARMMA Roadmap 2015- - NA (achieved during PY3) policies drafted with 2019 validated and MCSP support*,** Targets: disseminated -1 roadmap updated - Roadmap operational plan - 1 RH norms and developed procedures updated - Scaling-up strategic plan for and validated misoprostol developed - 1 Scaling -up strategic - RH Norms and Protocols plan for misoprostol update ongoing developed and validated - FP and RH strategic plans - FP and RH strategic updated plans completed and - ASRH National Strategic disseminated in 15 Plan developed regions - National EPI workplan for 2018 being finalized - National FP law adopted - RH Norms and protocols updated and validated - 1.2 Percentage of regions Baseline: N/A Year 1: 100%, (5 regions) - NA (achieved during PY3) who have received oriented on Roadmap the updated national Targets PY1/2: Year 2: 100% (10 regions) policies and guidelines 100% oriented on Roadmap in MNH Year 3: 100% (16 regions) oriented on Roadmap 1.3 Number of people 20 midwives ONSFM - NA (achieved during PY3) trained through USG- members on MNH supported standardization. programs*,** - 22 coaches updated in REC, data for decision-making 2.1 Number of pre- Baseline: N/A -1 day of birth training - 3 curricula: - Ongoing (ICM and service or in-service curriculum updated and -Low Dose High Frequency Faculty of Medicine curricula developed Targets PY1/2: approved by the MOH approach curriculum available finalized this or updated to meet -1 day of birth curricula available -MNH immunization curriculum curricula) national standards training validated with - Combined curricula training updated and guidelines§ MOH for PPHP and PIN validated - PFPP curriculum -Combined curricula with MOH training for PPHP and Justification: These are the PIN validated with curricula that MCSP plans to MOH develop for Y4, prioritized

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BASELINE/ ACHIEVEMENT Y1-Y3 INDICATOR PY4 TARGET ACHIEVEMENTS PY4 COMMENTS Y1-Y3 TARGETS through meetings with stakeholders and the MOH

2.2 Number of people Baseline: N/A - 66 providers from Sava and - 179 providers trained in 244 providers trained in MNH In seven regions trained through USG- Menabe trained in PPH and MNH at health facilities (Atsimo Andrefana, supported Targets PY1/2: neonatal infections supported to ensure high- Atsinanana, DIANA, programs*,** - 80 providers in PPH, - 59 trainers updated in quality MNH services. Haute Matsiatra, PIN targeted MNH interventions Sofia, Vatovavy - 33 national trainers in - 37 national trainers in MNH Fitovinany and MNH - 276 regional trainers in Vakinankaratra) - 44+88 regional MNH trainers in MNH - 262 regional trainers - 920 providers in oriented in blended learning MNH (adapted LDHF) for MNH - 500 providers in - 1321 health providers in MNH quality dashboard MNH - 20 trainers oriented in - 1357 providers in MNH targeted MNH quality dashboard interventions for AC

2.3 Number of antenatal Baseline: 55,340 558 693 224,749 in 815 HF 321,245 in 332 HF care (ANC) visits by skilled providers in Targets PY1/2: USG-assisted 10,145 (Y1)

facilities**‡ 101,457 (Y2) 2.4 Number of deliveries Baseline: 8,552 18,278 in 513 HF 43,898 in 815 HF 60,901 in 332 HF with a skilled birth Targets PY1/2: attendant in USG- 1,567 (Y1) in 214 HF assisted programs**‡ 15,679 (Y2) in 513 HF 2.5 Number and Baseline: 5,872 101,382 PY4: 42,471 in 815 HF 59,142 percentage of PY1-2: 16,441, newborns receiving Targets PY1/2: PY3: 84, 941 99% (59142/59948) essential newborn 1,076 (Y1)

care through USG- 10,765 (Y2)

supported programs**,‡ 2.6 Number and Baseline: 356 6,959 2,880 3,810 (132%) percentage of PY1-2: 1,198, newborns not Targets PY1/2: Y3:5,761 breathing at birth Y1: 52 who were Y2: 521 successfully Y3: 1,250 resuscitated in USG supported programs§

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BASELINE/ ACHIEVEMENT Y1-Y3 INDICATOR PY4 TARGET ACHIEVEMENTS PY4 COMMENTS Y1-Y3 TARGETS 2.7 Number of women Baseline: 7,188 103,204 43,622 60,197 (138%) giving birth who received uterotonic Targets Y1-Y3: in the third stage of Y1: 1,317 labor or immediately Y2: 13,178 after birth through Y3 : 21,348 USG supported programs§ 2.8 Percentage of health Baseline: N/A 42.6% (89/209) 100% 66% (538/815) health facilities On-site visits were facilities receiving received supervision (on site and suspended during supportive Targets PY1/2: Supervision visits started in remote supervision) plague emergency supervision visits in N/A Q3 of PY2 the last quarter§ 2.9 Number of USG- Baseline: N/A 673 HF+29 clinical sites 815 HF 815 HF supported service PY1 13 clinical training delivery points Targets PY1-3: meeting minimum Y1: 195 HF + 8 clinical PY2 195 HF standards to provide training sites 16 clinical training essential maternal and Y2: 500 HF + 18 clinical newborn care** training sites PY3: 478 HF Y3: 420 HF + 20 clinical training sites 2.10 Number of people Baseline: N/A - 100 Participants from 6 - 25 participants/district (150 - 159 providers trained in REC trained to support districts participants) and 8 members of CSO. the technical Targets PY1-3: N/A - 100 CSB microplans implementation of developed REC in priority - 100 providers trained on districts and to data management, DQS, monitor and AFP surveillance immunization services 2.11 Percentage of target Baseline: N/A Districts in 62 regions: 82% Districts: 100% 75/75 districts have a systematic districts and health (62/75) approach to track, display and facilities that have a Targets PY1-3: Health Facilities: 70% use priority indicators. systematic approach N/A Health facilities in 14 regions: to track, display, and 73% (656/690) Health Facilities: 59% (458/773) use priority indicators§

2.12 Number of MCSP- Baseline: N/A 10 CSB2 - 10 CSBs in Vakinankaratra - 10 CSBs in Vakinankaratra supported health Targets region region facilities actively PY1-2: N/A - 2 district hospitals in 2 - 2 district hospitals in 2 regions implementing a PY3: 30 CSB2 regions quality improvement - 5 CHRRs approach

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BASELINE/ ACHIEVEMENT Y1-Y3 INDICATOR PY4 TARGET ACHIEVEMENTS PY4 COMMENTS Y1-Y3 TARGETS 3.1 Number of pre- Baseline: N/A 1 training curriculum on - Integrated FP/PPFP service or in-service Targets PY1/2: postpartum family planning curriculum for the country - Integrated FP/PPFP curriculum curricula developed -PPFP training curricula available - Curriculum for Young for the country or updated to meet and learning resource - FP communication strategy Mothers/Young Parents - Curriculum for Young national standards package validated and my first baby curriculum: developed Mothers/Young Parents and guidelines§ - FP communication ongoing developed strategy including PFPP updated and validated - My First Baby curriculum adapted into Malagasy context 3.2 Number of people Baseline: N/A - 36 national trainers PPFP 179 new providers trained 4 providers trained in PFPP in trained through USG- - 276 regional trainers PFPP Atsimo Andrefana. supported Targets PY1/2: counselling programs*,** - 33 national trainers - 211 regional trainers in - 132 regional trainers PPIUD and implants - 670 providers trained - 1012 providers trained in in PPFP counselling PPIUD and implants -365 providers trained in PPIUD and implants 3.3 Number of USG- Baseline: N/A 459 Health Facilities 100 HFs equipped to provide 39 health facilities equipped in assisted service LARC services SAVA region delivery points Targets PY1-3: meeting minimum Y1: 75 HF standards to support Y2: 400 HF provision of long- Y3: 300 HF acting and permanent methods of contraception ** 3.4 Percentage of Baseline: N/A 100% 100% 100% maternal health services clients at Targets PY1/2: USG-assisted service 100% delivery points who received counselling about postpartum family planning** 3.5 Baseline: N/A 21% (11852/56647) 25% 15% (9186/60276) Percentage of women Targets discharged after Y1-2: N/A Justification: Adjusted based on delivery with a Y3: 50% PY3 achievement. modern method of This indicator was (Target PY4 is based on the PY3 family planning introduced in PY3. results of 21%)

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BASELINE/ ACHIEVEMENT Y1-Y3 INDICATOR PY4 TARGET ACHIEVEMENTS PY4 COMMENTS Y1-Y3 TARGETS 3.6 Number of studies Baseline: N/A - National workshop to 4 studies: - Malaria Care seeking study - End-line evaluation completed* disseminate FTP study - Malaria Care seeking study finalized on going Targets PY1/2: findings in October 2016 - Supervision program - Supervision PL ongoing - HFAMER study 1 formative assessment - Pretesting PFPP learning - Testing indicator on going on first time parents Counselling card during - End-line evaluation on going ANC conducted by - HFAMER study on going providers

4.1 Number of national National MIP protocol - National MIP protocol - Summary briefs on latest - National MIP protocol updated policies drafted with updated updated and integrated WHO ANC guidelines and integrated into training MCSP support*,** into training curriculum disseminated curriculum - MIP job aids developed - Job aids updated with latest - MIP job aids developed - MOH technical note on WHO ANC guidelines - MOH technical note on new new MIP protocol - Use of Toolkit to Improve MIP protocol disseminated disseminated Early and Sustained Intermittent Preventive Treatment in Pregnancy (IPTp) Uptake validated and integrated into national standards 4.2 Number of people Baseline: N/A - 33 national trainers in MIP - 179 providers trained in - 179 providers trained in MIP trained through USG- - 265 regional trainers in MIP MIP - 73 providers including 65 Chefs supported Targets PY1-2: - 1289 providers in MIP - 60 Chefs CSB trained in MIP CSB trained in MIP and case programs*,** - 33 national trainers - 1713 Chefs CSB trained in and case management management and 8 hospital staff. MIP MIP and case management - 132 regional trainers MIP - 700 providers trained in MIP Targets PY3: - 700 providers trained in MIP 4.3 Percentage of Baseline: 15% N/A 25% 26% (10988/42754) pregnant women (90.8/600) receiving IPTp3 by Justification: Based on dose Targets PY1/2: estimate as this will be part of N/A data started to be collected in end of PY3

4.4 Number of women Baseline: 5,448 46,888 17,950 10,988 (61%) receiving third dose of IPTp-SP† Targets PY1-PY3: Y1: 999 Y2: 9,988

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BASELINE/ ACHIEVEMENT Y1-Y3 INDICATOR PY4 TARGET ACHIEVEMENTS PY4 COMMENTS Y1-Y3 TARGETS Y3 : 35,901

4.5 Number of studies Baseline: N/A - Field test of gestational age - NA (finished in PY3) completed* toolkit: ongoing Targets PY1/2: - Field testing of gestational age toolkit 4.6 Percentage of severe Baseline: 7% (6/84) N/A 5% 29% (105/362) malaria cases referred Targets PY1/2: N/A 5.1 Number of people Baseline: N/A PY1-2: - 40 teachers in effective - 17 teachers/Tutors updated in trained through USG- Targets PY1-2: - 103 teachers trained in teaching and MNH MNH. and effective teaching supported - 80 teachers in MNH MNH programs*,** - 80 teachers in - 100 teachers in effective Justification: These include the effective teaching teaching teachers in the MCSP focus PY3: PY3: institutions - 20 teachers in MNH 18 teachers/Tutors in - 80 teachers in Mahajunga updated in effective teaching MNH. and effective teaching 5.2 Number of pre- Baseline: N/A National pre-service - NA (finished during PY3) service or in-service midwifery education curricula developed Targets PY1/2: curriculum for or updated to meet - 1 pre-service curricula MNH/FP/immunizations national standards updated developed and adopted for and guidelines public and private school 5.3 Number of clinical Baseline: N/A 10 clinical training sites - NA (achieved during PY3) training sites strengthened strengthened for Targets PY1/2: training students of - 8 clinical training sites pre-service institutions 5.4 Number of skills Baseline: N/A -3 skills labs strengthened in - NA (finished during PY3) laboratories pre-service institution strengthened in pre- Targets PY1/2: (Fianarantsoa, Antsiranana service institution - 6 skills lab in 6 IFIRP and Mahajanga).

Target PY3: -1 skill lab equipped by -4 skills lab in 4 IFIRP UNFPA, training by MCSP -1 skill lab equipped by UNFPA, training by Delayed due to coordination MCSP with UNFPA and faculty of medicine

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Indicators for plague activities

DEFINITION AND INDICATOR PROJECT TARGET ACHIEVEMENT DISAGGREGATORS A.1 Number of people trained This indicator will be disaggregated by - 20 core national trainers - 17 core national trainers through USG-supported technical or cross-cutting area, training - 100 regional trainers from 5 priority - 113 regional trainers in priority regions programs*,** topic, sex, region and type of personnel. regions o Alaotra Mangoro: 15 • Personnel may include: health care - 200 regional trainers from 10 other o Haute Matsiatra: 16 workers (doctors, nurses, midwives); USG regions o Atsinanana: 18; community health workers, community - 450 Providers in 5 priority regions o Vakinankaratra: 17 health volunteers, non-health personnel trained in IPC and case management o Analamanga: 47 - 180 providers in major hospitals - 162 regional trainers in other MCSP regions from 11 trained in IPC regions o Sofia:11 o Atsimo Andrefana: 20 o Diana: 16 o Melaky: 15 o Amoron’I Mania :14 o Analanjirofo: 17 o Boeny: 14 o Vatovavy Fitovinany: 14. o Sava: 17 o Ihorombe: 12 and o Menabe: 12 - 505 health providers trained - 173 clinical providers from major hospitals trained

Cost-shared with WHO - 30 regional trainers in Analamanga region - 429 providers trained in infection prevention and control A.2 Number of pre-service or Number of curricula developed or - Comprehensive plague curriculum - Comprehensive plague curriculum for providers in-service curricula updated to meet national standards and for providers developed including developed including IPC and case management developed or updated to guidelines in IPC for pre-service or in- case management, - IPC curriculum developed meet national standards and service training through USG support. - IPC curriculum developed - 6 job aids developed and disseminated guidelines

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