PPP ECD Programming

PPP ECD programming

CA AID-656-A-16-00002 (GDA ECD Programming)

Fiscal Year 2018 Year 3: April 2018–March 2019

Quarterly Report: Q3 October– December 2018

Submitted on: January 31, 2019 Submitted to: United States Agency for International Development Cooperative Agreement No. AID-656-A-16-00002

Submitted by: PATH Street address: 2201 Westlake Avenue, Suite 200 Seattle, WA 98121, USA Mailing address: PO Box 900922, Seattle, WA 98109, USA Tel: 206.285.3500; Fax: 206.285.6619 www.path.org

This work is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents of this document are the sole responsibility of PATH and do not necessarily reflect the views of USAID or the United States Government

Contents

Abbreviations...... 2 1. Overview of the reporting period ...... 3 2. Project objectives ...... 4 3. Results framework/Logical framework ...... 5 4. Indicators ...... 6 Indicator 1 ...... 6 Progress and issues ...... 6 Indicator 2 ...... 8 Progress and issues ...... 8 Indicator 3 ...... 8 Progress and issues ...... 9 Indicator 5 ...... 12 Progress and issues ...... 12 Indicator 6 ...... 15 Indicator 8 ...... 17 Indicator 9 ...... 18 Progress and issues ...... 18 Indicator 10 ...... 19 Progress and issues ...... 19 Indicator 12 ...... 23 Progress and issues ...... 23 Indicator 13 ...... 24 Progress and issues ...... 24 Indicator 14 ...... 25 Progress and issues ...... 25 Indicator 16 ...... 27 Progress and issues ...... 27 5. Monitoring and evaluation ...... 29 6. Upcoming plans ...... 31 7. Administrative update ...... 31 8. Financial information ...... 32 9. Appendices ...... 33 Appendix A. Success story ...... 33

Abbreviations

ANC antenatal care APE agente polivalente elementar (community health worker) ART antiretroviral therapy CBO community-based organization CCD Consulta da Criança Doente (sick-child consultation) CCR Consulta da Criança em Risco (child-at-risk consultation) CCS Consulta de Criança Sadia (child well-being consultation) CDC Centers for Disease Control and Prevention CHC child health committee CHW community health worker CPC child protection committee DPGCAS Direcção Provincial do Género, Criança e Acção Social (Provincial Directorate of Gender, Children and Social Welfare) DLI Disbursement Linked Indicators DPS Provincial Health Directorate ECD early childhood development EGPAF Elizabeth Glaser Pediatric AIDS Foundation GDA Global Development Alliance HF health facility IEC information, education, and communication IMCI Integrated Management of Childhood Illness IR intermediate result LOP life of project MCH maternal and child health MGCAS Ministry of Gender, Children and Social Action MOH Ministry of Health NGO nongovernmental organization OVC orphans and vulnerable children PEPFAR US President's Emergency Plan for AIDS Relief PES Plano Económico e Social (Social and Economic Plan) PNC postnatal care PPP public-private partnership PRN Programa de Reabilitação Nutricional (Nutrition Rehabilitation Program) S-ECD Scaling Up Early Childhood Development SDSMAS District Directorate of Health, Women and Social Welfare TDI Tratamento da Desnutrição em Internamento (in-patient treatment of malnutrition [TDI]) TWG technical working group UNICEF United Nations Children's Fund USAID United States Agency for International Development WEI World Education International WHO World Health Organization

1. Overview of the reporting period

The Integrating Early Childhood Development (ECD) Global Development Alliance (GDA) Programming is a public-private partnership (PPP) between the United States Agency for International Development (USAID), the Conrad N. Hilton Foundation, and PATH, which works to integrate early childhood development programming in Mozambique. This PPP focuses on improving child development outcomes for vulnerable children 0–3 years in targeted areas of Mozambique, through an integrated health, nutrition, sensitive care, and stimulation intervention for health and social services provided by government and partners. This PPP is a three-year cooperative agreement that started on April 6, 2016. This progress report summarizes the accomplishments of the project during the third quarter (October to December 2018) of the third year of project implementation. PATH has continued to support the Ministry of Health (MOH) and Ministry of Gender, Child and Social Action (MGCAS) in developing activities to reinforce the integration of ECD in health facilities (HFs) and communities with the objective to improve the life of children ages 0–3 years. To achieve these results, PATH combines innovation and provision of technical assistance for strengthening ECD service delivery through HFs and community-based organization (CBOs).

During this quarter, the PPP team continued working with the Child Health, Nutrition, and Health Promotion departments and technical working groups of the MOH to review and follow up on a range of relevant documents for integrating ECD.

In partnership with the World Health Organization (WHO) and UNICEF, PATH supported participation of both national and subnational participants in a seven-country regional meeting held in Kenya that introduced the new Nurturing Care Framework within the health sector and initiated the country planning process for its introduction.

Although PATH is not directly involved in the clinical treatment of malnutrition, nutritional counseling to caregivers of children 0–5 years was carried out in all HFs supported by the project as part of the ECD integration strategy. 13,207 children were reached with nutrition interventions by community health workers (agentes polivalentes elementares [APEs]).

At the HF level, data collected across all 55 target HFs of the eight target districts covered by the project indicated that 57,700 beneficiaries (caregivers of children under five) received ECD and nutrition counseling.

During the reporting period, 155 playbox sessions were conducted in the 12 target HFs, reaching a total of 9,481 caregivers of children under five.

During this reporting period, a total of 90 video sessions were conducted in HFs across the six intervention districts. A total of 4,810 caregivers attended these sessions. The playbox and the video sessions are part of the information, education, communication (IEC) activities facilitated by trained HF service auxiliary staff and HIV counselors and supported by maternal and child health (MCH) nurses. Playbox and video sessions are held in the early morning hours in HF waiting areas, while caregivers and their children wait to receive different MCH services—e.g., antenatal care (ANC), postnatal care (PNC), consultation of children at risk (Consulta de Criança Sadia [CCR]), child well-being consultation (Consulta de Criança Sadia [CCS]), and pediatric antiretroviral therapy (ART).

The PPP team in collaboration with the District Directorates of Health, Women and Social Welfare (Serviço Distrital de Saúde, Mulher e Acção Social [SDSMAS]) continues to provide direct support, mentoring, and supervision to APEs in the districts. During this quarter, the PPP team supported the Maputo Provincial Directorate of Health (Direcção Provincial de Saúde [DPS]) to train 30 new APEs. Through these mentoring and supervision visits and trainings, the PPP team is reinforcing specific ECD topics that have been integrated into the APEs training package. A total of 32 APEs were mentored during the period, 2 of whom reached the threshold score of 60 percent using the PATH mentoring tool for first time.

During this reporting period, a total of 39 health providers received mentoring visits, of which 33 achieved the desired score of at least 80 percent threshold for the first time.

During this reporting quarter, data collected across the 55 target HFs in the eight project districts indicate that 6,619 children ages 0–11 months attended CCS for the first time, which translates to 167 percent in relation to the quarter target.

A total of 466 monitored children across CCS, CCR, sick child consultation (Consulta da Criança Doente [CCD]), pediatric ART, PNC, and maternity consultations were suspected to have developmental delays. Of those, 313 were suspected during the first consultation and 153 during the follow-up consultations.

In December, the PPP Project Manager Jordi Fernandez left PATH. PATH was fortunate to be able to fill his position with existing staff member Melanie Picolo, who is completing her tenure as PATH Senior Nutrition Advisor for the Maternal and Child Survival Program. Melanie will assume the PPP Project Manager role from January 1, 2019 and will still retain her important technical functions within the team as Senior Nutrition Advisor. The PPP team has submitted the project closeout plan to USAID and has begun discussing the participant list and draft agenda for the closeout ceremony. In the next quarter, PATH will work with USAID, the Conrad N. Hilton Foundation, and the Maputo DPS to finalize the agenda and participant list for the closeout ceremony, develop a joint press release, and make logistical preparations for the closeout ceremony.

2. Project objectives

The goal of the Global Development Alliance PPP for integrating ECD programming is to improve development outcomes for children 0–3 years in targeted areas of Mozambique through an integrated health, nutrition, sensitive care, and stimulation project. The project has three objectives/result areas:  Result 1: Create an enabling environment at the national level for the integration of ECD interventions, which target the youngest vulnerable children, into social action and health systems and services.  Result 2: Improve care and stimulation behaviors of caregivers of vulnerable children aged 0–3 years through social action and health-sector partnerships with government and civil society that expand integrated ECD programs in the country.  Result 3: Expand the knowledge and evidence base on integrated ECD.

3. Results framework/Logical framework

The results framework included in Figure 1 represents the PPP project’s vision for achieving its objectives.

Figure 1. Results framework for the Integrating Early Childhood Development Global Development Alliance Programming

4. Indicators

In line with our performance monitoring plan, below we discuss project progress and achievements toward results and intermediate results (IRs) indicators. For a better understanding of the indicators and their figures, the following concepts are defined:

LOP: Life of Project. While the PPP lifetime is from April 2016 to March 2019, for indicator reporting purposes, LOP also includes the lifetime of the Scaling Up Early Childhood Development (S-ECD) project funded by the Conrad N. Hilton Foundation.

S-ECD project only: Refers to results obtained under S-ECD project between July 2015 and March 2016—i.e., immediately before the start of the PPP. These results are mentioned as “baseline” in the terminology utilized in the PPP performance monitoring plan and are included in the LOP target column.

PPP Year 1, 2, 3 achievements refer to results obtained in project Years running from April- March beginning April 2016.

Result 1: Create an enabling environment at the national level for the integration of ECD interventions, which target the youngest vulnerable children, into social action and health systems and services

IR 1.1: Improved adoption of orphans and vulnerable children (OVC), MCH, and community health worker (CHW) materials with integrated ECD content

Indicator 1

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Achievements Percent target only Achieve Achieve Y3 achieved of Indicator -ments -ments Annual Y3 annual target Q1 Q2 Q3 Q4 target

Number of PATH IEC materials approved 7 2 4 3 1 0 0 0 0% by provincial or national government

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year; IEC: information, education, and communication.

Progress and issues In this quarter, no new PATH IEC materials have been approved by provincial health directorates or the national MOH. However, a booklet containing recipes for children developed by PATH has been submitted to the MOH Nutrition department for approval and additional changes to the MCH supervision tool (which now includes items on playboxes and on developmental monitoring and Kangaroo Mother Care in maternity wards) have been approved by the DPS of Maputo Province and Nampula Province for use in implementation districts.

In this quarter, the PPP team continued to work with MOH Mental Health and Maternal Health departments to refine the terms of reference for piloting screening and counseling on maternal

depression as a part of postnatal consultations in selected HFs of Maputo Province. The workgroup designed the first draft of the protocol for screening and counseling, which will be presented to the Child Health Technical Working Group (TWG) later this year. Additionally, PATH conducted an assessment involving in-depth interviews with 15 postpartum mothers and presented findings to the TWG. The findings suggested several potential factors that could lead to depression in the postpartum period—e.g., young age, lack of support from husband or peers, stopping regular income-generating or leisure activities due to the arrival of a baby, and pressures to take care of the household while taking care of the baby. These findings have been used to draft key content and illustrations for counseling cards, which will also be presented to the Child Health TWG, as well as will be shared with the WHO team that developed the original Thinking Healthy package for managing maternal depression.

In terms of ECD integration into relevant policies and strategies, while the PPP team suggested specific ECD-related content to be integrated into the national Child Feeding Strategy in the last reporting quarter, no further updates regarding their inclusion have been received by the Nutrition team. Furthermore, although PATH and UNICEF jointly carried out extensive efforts to advocate for inclusion of stimulation counseling content into neonatal Integrated Management of Childhood Illness (IMCI), this was not accepted by the Child Health TWG as the suggestion came late in the process and the materials had already been submitted to the Minister for approval.

Outside of the health sector, MGCAS invited PATH to prepare and lead a discussion on ECD in its annual meeting of the multisectoral group for OVC (Núcleo Multissectorial para as Crianças Órfãs e Vulneráveis) in December 2018, where all Provincial Directorates of Gender, Children and Social Welfare (Direcção Provincial do Género, Criança e Acção Social [DPGCAS]) teams were present. PATH’s presentation allowed the provincial DPGCAS teams to reflect on the importance of ECD, especially in the context of OVC. Participants also debated questions related to coverage and quality of ECD programs for children and the need to introduce and scale up parenting programs for caregivers. At the end of the presentation the participants from the provinces expressed their desire to be trained on ECD-related issues, so that they are able to better support their provinces with expansion of ECD programs.

Additionally, in December, PATH further deepened its engagement with MGCAS by formally becoming a member of the MGCAS OVC TWG.

IR 1.2: Increased ECD content in district and provincial social action and health plans

Indicator 2

LOP S- PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target ECD Achieve- Achieve- Annual achieved of Indicator only ments ments target Y3 annual Q1 Q2 Q3 Q4 target

Number of targeted health and social action plans that 20 3 5 7 8* N/A 8 N/A 100% include ECD content and goals for ECD integration.

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. *Including Matola and Boane

Progress and issues On November 7–8, 2018, PATH attended and provided technical and financial support to the Maputo DPS for a provincial planning and stocktaking meeting. The meeting was attended by 104 participants from the DPS, the various SDSMAS, and nongovernmental partners and sought to evaluate the activities carried out by government and nongovernmental partners between January and September 2018. After all the SDSMAS had made their presentations, the DPS Director noted that some partner-supported activities had not made their way into the district annual plans. The DPS Director recommended all districts to conduct a district-level review meeting to ensure that these activities were included in the final district plans. As a result, these meetings took place in November 12–16, 2018. PATH attended these meetings and reinforced the inclusion of PATH-supported activities into each of the SDSMAS plans. In the next quarterly report, we will provide detailed information about ECD integration into the SDSMAS and DPS annual plans for 2019.

IR 1.3: Improved ECD content in existing health and social action curricula, guidelines, and data tools

Indicator 3

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Percent Y3 Achievements target only Achieve- Achieve Annual achieved of Indicator ments -ments target Y3 annual Q1 Q2 Q3 Q4 target

Number of government curricula, guidelines, and data tools revised by 4 1 1 2 1 5 1 0 600% PATH to include ECD content and adopted by government

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Progress and issues A. Review of MCH nurse pre-service training curricula During this quarter, PATH provided financial support for a five-day orientation meeting for the consultants who have been hired by UNFPA for developing the pre-service training curricula modules. In addition, PATH has worked with the MOH Training department to identify key modules that will be reviewed to ensure strong integration of ECD content. These modules include ANC, neonatal health, and child health (CCS and CCR). The review was supposed to end in December 2018, but as most of the consultants have not finished their work, the MOH gave them an extension. As agreed with the MOH, these modules will soon be shared with PATH by the consultants for technical review. The modules are expected to be ready for use in the second half of 2019. We will provide a more detailed update about the status of these modules in the next quarterly report.

B. Other technical assistance provided through participation in international forums and MOH/MGCAS TWGs Regional workshop on the Nurturing Care Framework During this quarter, WHO, UNICEF, and PATH organized a regional workshop on the Nurturing Care Framework in Nairobi, Kenya, with a view to bringing together key stakeholders from countries that are already working, or have committed to working, to strengthen the health system response to support nurturing care in the early years. PATH supported the participation of a delegation from Mozambique comprising two staff from the national MOH (representing the Nutrition and Planning departments), two staff from the Maputo DPS (representing the Public Health and APE departments), and one district-level staff member from the Moamba Nutrition department. During the workshop, the team developed a one-year work plan for presentation to the MOH. The work plan proposed the development of a multisectoral group within the MOH to coordinate ECD activities across various departments. The plan also described multiple opportunities for integrating ECD content into specific policy and technical documents spanning programming areas as diverse as MCH, nutrition, APEs, mental health, and monitoring and evaluation.

The plan has been formally presented to the Child Health TWG, several MCH-related activities have been included in the MOH 2019 child health annual plan. Similarly, nutrition and APE- related activities have been included in their respective departmental plans. Integrated activities include the following:  Ensure inclusion of developmental counseling and monitoring in national MCH supervision guide.  Reinforce developmental counseling and monitoring in CCS and CCR consultation norms that are currently under review.  Include relevant content related to developmental counseling and monitoring and responsive feeding in National Child Feeding Strategy.  Reinforce contents and IEC materials related to stimulation in a community nutrition program to be implemented in eight (8) provinces.  Carry out supervision of national nutrition program in five (5) provinces, with stimulation content integrated.

Currently PATH is working with UNICEF and WHO to promote the creation of the multisectoral coordination group to guide this work, with a view to operationalizing this group in early 2019.

HIV In this quarter, PATH was invited by the MOH to participate in a three-day workshop to validate the new guidelines on prevention of mother to child transmission. In this workshop, the team had the opportunity to advocate to other partners such as the Mozambican National AIDS Council, USAID, Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Fundação Ariel Glaser, ICAP, UNICEF, the Clinton Foundation, and WHO about the importance of integrating ECD in their respective HIV plans.

Nutrition In the previous quarter, PATH began collaborating with World Bank staff on integration of early stimulation and responsive feeding content into the implementation guide for community-based counseling on child feeding, to be used under Disbursement Linked Indicators 4 (DLI 4). DLI 4 is part of the new health sector funding package to Mozambique under the Global Financing Facility (GFF) in eight provinces starting in 2019. The MOH Nutrition department authorized PATH to revise and enrich the section on stimulation and to recommend the IEC materials to be used by the APEs and activistas in the communities.

During this quarter, PATH was given the opportunity to further revise ECD content in the Pacote Integrado Nutrição (integrated nutrition package) implementation guide and to provide ECD IEC materials to be integrated into the package for nutrition activistas. Discussions are currently underway with UNICEF about a potential role for PATH to revise the pedagogical approach of the entire training package to adapt the content to the level of the activistas. This would allow work designed and validated in Maputo Province under the PPP to be scaled up across eight provinces of the country.

APEs During this quarter, PATH actively participated in the APE TWG, which resulted in PATH being invited to comment on the new APE supervision manual and supervision forms. It is important to note that, due to intensive advocacy by PATH, the presented draft tools already included substantial content on ECD. The team provided further technical inputs on these tools and other content areas, including reinforcing nutritional counseling and interpersonal communication competencies of APEs. The proposed improvements will be reviewed by the APE TWG and subsequently sent to the next level of MOH for approval.

Result 2: Improve care and stimulation behaviors of caregivers of vulnerable children aged 0 to 3 years through social action and health-sector partnerships with government and civil society that expand integrated ECD programs in the country.

IR 2.1: Improved ECD knowledge and skills of service providers at HFs

Indicator 4

LOP S-ECD PPP Y1 PPP Y2 PPP Percent Y3 Achievements target only Achieve Achieve Y3 achieved of Y3 Indicator -ments -ments Annual annual target target Q1 Q2 Q3 Q4

Number of health providers 370 135 85 35 115** 23*** 93 28**** 125% trained on ECD by PPP project

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. ** 63 Health providers from Matola, 29 from Boane, and 23 new health providers from Marracuene *** In Q1 127 providers received ECD training in different components such as IMCI, nutrition in-patient treatment, etc. but only 23 of these providers were trained for first time **** These providers were already trained in ECD in the past but received complementary training in specific areas integrating ECD, such as IMCI, in-patient treatment of malnutrition, etc.

Progress and issues A. Trainings Partograph training PATH provided technical and financial support to the DPS to conduct a training of MCH nurses on correct recording of partograph data. The training, which took place on October 1–3, 2018, focused on the importance of partograph data, how to correctly record such data, provision of ECD counseling to caregivers, and recording the partograph data in the context of ANC, PNC, and CCR, as well as review of ANC, PNC, and CCR tools. Training evaluation results suggested improvement in participant knowledge levels. The training was attended by 28 nurses from all eight districts of Maputo Province, as shown in Table 1 below.

Table 1. Number of staff trained during the quarter (correct filling of partograph)

District Total trained Namaacha 3 Marracuene 3 Matutuine 2 Moamba 2 Magude 3 Manhica 5 Boane 2 Matola 8 Total 28

B. Technical and financial support for training on development monitoring in the new CCS and CCD registers During this reporting period, PATH, in partnership with Fundação Ariel Glaser, provided technical and financial support to the Maputo DPS to train health providers on the new CCS and CCD registers. The trainings took place between November 19 and December 14 and reached a total of 223 health providers. Training content included an orientation on the general package, and focused on the newly incorporated areas (e.g., around nutrition and developmental monitoring), daily and monthly recording of data, and data flow within the larger health system. The training also covered the new flowchart that is being introduced in HFs to attend to young children. Medical chiefs from the districts, along with the responsible persons for nutrition, MCH, and preventive medicine pledged their support for successful rollout and use of the new registers in their respective districts.

Indicator 5

Y3 Achievements Total Percent project PPP Y1 PPP Y2 PPP Y3 Q1 Q2 Q3 Q4 LOP S-ECD achieved accumula Indicator Achieve- Achieve Annual target only of annual -tive ments -ments target target Y3 achievement Percentage of health facility clinical providers 75% 75% reaching the 24 91 32 NA NA 33 45% 68% (265) (74) threshold score of 80% for ECD services (*) Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. (*)This is 75% of the number of health providers who are eligible for receiving mentoring sessions according to the new strategy: 99 providers of Matola (46), Boane (31) and Marracuene (22), in addition to the 191 accumulated until Y2.

Progress and issues Support SDSMAS teams to produce, implement, and evaluate quarterly specific action plans for priority health facilities to address challenges identified during supervision. A. Action plans During this reporting period quarter, the PPP team prioritized the follow-up of action plan activities identified during the previous supervision at the priority HFs of Motaze, Panjane, Facazissa, and Moíne in Magude District and Salamanga, Ponta D’Ouro, and Catuane in Matutuíne District. The PPP team and responsible persons for MCH, IMCI, Nutrition, and monitoring and evaluation from the two districts provided technical support on best practices in MCH and integration of care and stimulation into their routine services. In addition, the support focused on some of the gaps noted during previous supervision activities:  Completion of children’s health cards and conducting CCS consultations according to MOH norms.  Data collection and preparation of monthly summaries for ECD, MCH, and nutrition.

 Correct implementation of ECD and IMCI services.  Carrying out developmental monitoring, according to MOH norms.  Correct use of the new CCS and CCD registers and using them to reinforce child development monitoring and counseling.

B. Supervision—Magude, Moamba, Namaacha, and Manhiça During the reporting period, the PPP team and the SDSMAS teams from Magude, Moamba, Namaacha, and Manhiça conducted supervision visits to health providers in all the HFs in these districts. Supervision focused on the areas of MCH, IMCI, nutrition, development monitoring, and counseling on stimulation, as well as data collection and reporting. Areas in which notable improvement was observed include the following:  Correct monitoring of child development.  Correct assessment of nutritional status and treatment of malnutrition in children and pregnant women according to PRN standards.  Provision of quality nutrition and stimulation counseling and demonstration of knowledge of key concepts in these two areas.  Promoting participation of male partners in MCH services for pregnant women.  General compliance with MOH standards and protocols.

As the PPP Project is nearing its completion, the supervision activities have been designed to transfer capacity and ownership to the district teams—an approach that has been welcomed by district medical chiefs, chief medical officers, and the responsible persons for the various relevant programming areas. This transfer of skills will continue in the next quarter.

C. Mentoring activities to the new health providers in Matola, Boane, and Marracuene Following the ECD training of 93 providers from Matola, Boane, and Marracuene districts in this quarter, the PPP team conducted joint mentoring with SDSMAS. In the current mentoring model, each health provider is mentored three times after being trained, following which they are integrated into regular supervision processes. During this reporting period, a total of 39 health providers received mentoring visits, of which 33 achieved the desired score of at least 80 percent threshold for the first time. Table 2 disaggregates the figures by sex and district. During mentoring visits, service providers have been observed to:  Measure and record anthropometric data correctly.  Provide appropriate nutrition counseling and screening.  Correctly use the developmental monitoring poster.  Recommend age-appropriate stimulating activities to caregivers and explain the importance of play and communication.  Praise caregivers for practicing promoted behaviors and practices.

The team has observed that compared to previous quarters, trained health providers are responding better to mentoring efforts and reaching the 80 percent threshold faster. The team partially attributes this to the quality assurance efforts that are currently being implemented, which supplement routine mentoring with additional activities such as caregiver exit interviews.

Table 2: Number of health providers mentored, disaggregated by sex per district (Matola, Boane, and Marracuene) # HP mentoring visits # HP mentoring visits # HPs trained that Total # HP in the quarter that in the quarter that do received mentoring trained to date meet the 80% not meet the 80% visit in the quarter District threshold (1st time) threshold

Male Male Male Male

Total Total Total Total

Female Female Female Female Matola 41 37 4 29 29 0 27 27 0 2 2 0 Boane 29 27 2 4 2 2 2 1 1 2 1 1 Marracuene 23 17 6 6 6 0 4 4 0 2 2 0 Total 93 81 12 39 37 2 33 32 1 6 5 1

D. Provide technical and financial support to DPS supervision in child health During this reporting quarter, it was not possible to support DPS supervision in child health, as DPS was working on preparing and conducting trainings to health providers on the new CCS and CCD registers. However, the PPP team proposed updated supervision information and guides to the DPS, which have been approved and will be used moving forward. The PPP and DPS teams also prepared and reviewed the annual plan and prepared and conducted activities related to World Prematurity Day.

The PPP team supported events related to this commemorative day at both district and provincial levels; PATH provided two mannequins and 250 brochures. The provincial celebration was led by the Provincial Medical Chief and featured demonstrations of activities that can benefit a premature baby—e.g., massage, Kangaroo Mother Care, and group and individual counseling. Participants also discussed issues related to appropriate maternal nutrition, care during pregnancy, infant and young child nutrition, and developmental milestones.

E. Provide technical and financial support to district mobile brigades ensuring integration of ECD activities During this reporting period, the PPP team provided limited support to Marracuene District to carry out one mobile brigade exercise, in which ECD was integrated. As noted in previous reports, mobile brigades comprise several technicians and are an MOH strategy to provide different services such as vaccination, MCH, and medical consultations to remote communities with limited access to HFs.

F. Implementation of playboxes in target health facilities During the reporting period, 155 playbox sessions were conducted in the 12 target HFs, reaching a total of 9,481 caregivers of children under five. Playbox sessions are held in the early morning hours in the HF waiting areas, while caregivers and their children wait to receive health services (e.g., ANC, PNC, CCR, CCS, CCD, and pediatric ART). During this reporting period, the PPP team provided technical support to all the HFs with playboxes. The team observed playbox sessions and provided feedback to facilitators on ways to improve their facilitation skills and produce age-appropriate play and learning materials.

The number of sessions and participants are lower in this quarter compared to the previous quarter, due to many staff being on leave during the festive season. In Matutuíne, the counselor responsible for implementing playboxes stopped working due to the withdrawal of incentives as part of the end of project. The PPP team is undertaking efforts to restart the activity in this district, as well ensure that data is being collected and reported. Table 3 below summarizes the activities for the quarter.

Table 3. Number of playbox sessions and participants

District # of Sessions # of Participants

Namaacha 9 693 Marracuene 31 4,089 Matutuíne 29 512 Moamba 34 1,414 Magude 22 722 Manhiça 19 995 Boane 11 1,056 Total 155 9,481

IR 2.2: Improved ECD knowledge and skills of community-based health and social action providers

Indicator 6

LOP S- PPP PPP PPP Year 3 Achievements Percent target ECD Year 1 Year 2 Year 3 achieved Indicator only Achieve- Achieve- Annual of Y3 ments ments target Q1 Q2 Q3 Q4 annual target

Number of beneficiaries (caregivers or children under 5) 202,186 N/A 62,211 90,130 124,273 34,125 55,945 57,700 119% receiving ECD and nutrition counseling in HFs

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; HF: health facility; PPP: public-private partnership; Q: quarter; Y: year. Target per quarter = 31,068

During the reporting period, a total of 57,700 beneficiaries received ECD and nutrition counseling in all 55 HFs of the eight PPP project implementation districts. This translates to an achievement of 186 percent of the quarterly target and is due to the expansion of project activities to six additional HFs (three in Matola and three in Boane districts), of which the three HFs in Matola District have high client volumes. The trend has been generally upward during

the project’s lifespan and can be attributed not just to overall improvement in ECD service delivery, but also better reporting using the registers in HFs.

Table 4 below provides more detailed information, with beneficiaries disaggregated by district and service delivery touch-points.

Table 4. Number of beneficiaries (caregivers of children under five) receiving ECD and nutrition counseling in health facilities (targets and achievements by district during the quarter)

District

CCS PNC ANC

CCR CCD

CCS(*)

TOTAL

PED ARV PED

Target

MATERNITY

Age 0-11M 1-4Y 0-18M 0-4Y 0-14Y RN achieved Percent

Namaacha 366 747 92 1,860 17 294 326 425 4,127 2,507 165

Marracuene 1,097 682 247 356 0 974 766 1,204 5,326 6,526 82

Matutuíne 221 181 59 1,040 52 164 179 251 2,147 1,346 160

Moamba 627 463 196 4,578 34 538 619 806 7,861 2,303 341

Magude 322 289 67 993 7 216 200 349 2,443 1,079 226

Manhica 1,635 1,711 185 3,401 26 1,847 1,966 2,050 12,821 4,124 311

Boane 536 458 108 2,113 9 332 375 786 3,390 3,262 104

Matola 2,244 3,218 606 6,438 21 1,759 2,214 3,085 19,585 14,315 137

TOTAL 6,619 7,291 1,560 20,339 166 6,124 6,645 8,956 57,700 35,462 163

Indicator 7

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target only Achieve- Achieve Annual achieved of Indicator ments -ments target Y3 annual Q1 Q2 Q3 Q4 target

Number of

CHWs trained 166 58 108 NA 30 NA 30 NA 100% on ECD by

PPP project

Abbreviations: CHW: community health worker: LOP, Life of Project: ECD, early childhood development; PPP: public-private partnership; Q: quarter; Y: year.

During this quarter, the PPP team supported DPS by providing counseling cards to all newly trained APEs, supported APE supervisors to monitor home visits, and organized a closing event after the new batch of APEs were trained between June and November 2018. The event also saw participation from UNICEF, DPS, and SDSMAS teams from across Maputo Province. In addition, at the request of Namaacha District, PATH supported the presentation of seven new APEs to their communities in the district, which was welcomed by community leaders and members.

Indicator 8

S- PPP Y1 PPP Y2 PPP Y3 LOP Y3 Achievements Total project Indicator ECD Achieve- Achieve- Annual target accumulative only ments ments target Q1 Q2 Q3 Q4 achievement Percentage of CHWs reaching 75% 75% the threshold 7 55 69 13 2 2 110% (135) (135)* score of 60% for ECD services (*) Abbreviations: CHW: community health worker; LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. (*)This is 75% of all APEs of all districts including Boane and newly trained APEs (166+14=180)

Progress and issues As community interventions still require robust project support, the PPP team continued to provide direct mentoring and supervision to APEs in the districts. The following section will provide more detailed information regarding ways in which the PPP team supported APEs.

A. Supervision and mentoring of APEs During the reporting period, the PPP team provided financial and technical support to APE supervisors in Matutuíne, Boane, Magude, Marracuene, and Namaacha districts to support their APEs. The supervision activity reached a total of 32 APEs in all districts. APEs were observed to accurately screen for malnutrition using the mid-upper arm circumference tape, integrate counseling on stimulation into their household visits, correctly use the counseling cards, and collect and record data.

During this quarter, 32 APEs benefited from project-supported mentoring visits. Among them, 30 had already reached the threshold score of 60 percent in previous quarters. Two of the mentored APEs reached 60 percent for the first time during this quarter.

Table 5 shows the mentoring distribution across target districts, disaggregated by sex.

Table 5. Number of APEs mentored, disaggregated by sex per district

# APE # APE #APE # APEs trained mentoring visits mentoring visits mentoring visits Total # APEs that received in the quarter in the quarter in the quarter trained to date mentoring visit that meets the that meet that do not District in the quarter 60% threshold 60% 1st time in meet the 60% (not 1st time) the quarter threshold

Male Male Male Male Male

Total Total Total Total Total

Female Female Female Female Female Namaacha 16 11 5 9 7 2 9 7 2 0 0 0 0 0 0

Marracuene 41 32 9 7 6 1 6 5 1 1 1 0 0 0 0

Matutuíne 16 12 4 2 1 1 2 1 1 0 0 0 0 0 0

Moamba 27 18 9 0 0 0 0 0 0 0 0 0 0 0 0

Magude 25 16 9 7 3 4 6 3 3 1 0 1 0 0 0

Manhica 41 24 17 0 0 0 0 0 0 0 0 0 0 0 0

Boane 14 11 3 7 5 2 7 5 2 0 0 0 0 0 0

Total 180 124 56 32 22 10 30 21 9 2 1 1 0 0 0

B. Refresher training for APEs No refresher trainings took place during this quarter, as the district and provincial APE coordinators requested that the refresher trainings be postponed.

Indicator 9

Indicator LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target only Achieve- Achieve Annual achieved of Y3 ments -ments target annual target Q1 Q2 Q3 Q4

Number of nongovernmental partners receiving 7 2 2 3 0 NA NA NA NA technical assistance from PATH

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Progress and issues A. Other community partners—home visits, parenting education, and awareness building/sensitization activities In this quarter, PATH signed an agreement with a rural development nongovernmental organization (NGO) CESAL, which is operating in Matutuíne. In addition, the team has joined

with DPGCAS and SDSMAS to support the second training of agricultural association activists in parenting education. CESAL covered training costs, and PATH contributed trainers and parenting kits for the activists. During this quarter, 48 new activists were trained, who will join the 38 activists trained last year to conduct parenting education sessions in close to 30 communities, which are widely distributed across Matutuíne District. Parenting education sessions not only target agricultural association members but also families identified by associations as being nutritionally vulnerable/insecure. Parenting education sessions will complement CESAL’s and SDSMAS’s work to ensure that these vulnerable families are able to access nutrition rehabilitation and support services and have production skills to improve their wellbeing. From this partnership, PATH hopes to learn how to optimize nutrition-agriculture-ECD links at the community level to create better results for nutritionally insecure families with young children.

Three other NGOs—Catholic Relief Services, ChildFund, and Terres des Hommes—have contacted PATH, requesting to have access to the parenting education program materials or to be trained in their use. This would allow the program to be used in more districts in Maputo Province as well as to expand to Nampula and Sofala provinces. As this parenting education support to NGOs was not in PATH’s original plans or budget, the team is now carefully considering how to best respond to these requests.

IR 2.3: Increased developmental monitoring and referrals of developmental delays Indicator 10

LOP S- PPP Y1 PPP Y2 PPP Percent Y3 Achievements target ECD Achieve- Achieve- Y3 achieved Indicator only ments ments Annual of Y3 target Q1 Q2 Q3 Q4 annual target

Number of children monitored for 29,095 N/A 9,726 13,652 15,816 4,160 6,406 6,619 109% developmental delays

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. Target revised as result of Boane Inclusion. Quarterly targets = 3,954

Progress and issues A. ECD counseling and child development monitoring at health facilities This indicator is collected during the first CCS visit to avoid double counting, which may occur if collecting data from additional HF services as well. The indicator serves to assess the degree of compliance in conducting developmental monitoring in all children during their first year of life.

During this reporting quarter, data collected across all 55 project target HFs in the eight project districts indicate that 6,619 children ages 0–11 months were monitored for developmental delays for first time in the CCS consultation, which corresponds to an achievement of 167 percent of the target for this quarter. The cumulative number thus far corresponds to 109 percent of the Year 3 target.

A total of 466 children monitored out of 48,774 across CCS, CCR, CCD, pediatric ART, PNC, and maternity consultations (i.e., approximately 16 percent) were suspected to have developmental delays, of which, 313 were suspected from the first consultation and 153 from the following consultation. This number is a slight decrease from the previous quarter, but significantly higher compared to previous quarters. The team attributes this increase to the introduction of the new CCS and CCD registers and the integration of the indicator for developmental monitoring into the health information system, which motivates health providers to accurately track and report the indicator.

Table 6 below summarizes this information, disaggregated by district and by service delivery touch-point.

Table 6. Number of children suspected of developmental delays per service (first consultation and following first consultation)

Total

CCS PNC District CCR CCD

PED ARV

MATERNITY

first following first following first first following NB NB following first following Namaacha 2 12 2 5 9 0 0 4 1 0 18 17 Marracuene 0 16 3 0 6 0 0 44 1 0 54 16 Matutuíne 0 12 0 0 2 0 0 9 1 0 12 12 Moamba 1 21 3 2 2 0 0 11 0 0 17 23 Magude 2 0 4 0 4 0 0 5 0 5 15 5 Manhica 17 11 4 7 9 8 0 33 54 4 125 22 Boane 0 32 0 0 0 0 0 0 0 0 0 32 Matola 7 7 0 4 14 0 4 45 6 11 72 26 TOTAL 29 111 16 18 46 8 4 151 63 20 313 153

B. Follow-up of referrals of children identified with developmental delays by health providers During this quarter, the PPP team collected data on children suspected of developmental delays who were internally referred from CCD, PNC, CCS, and CCR consultations to other specialized providers in the HF for confirmation. The exercise sought to better understand referral pathways. Table 7 below notes the number of children with suspected developmental delays who are confirmed and transferred to specialist care.

Table 7. Number of children with suspected development delays, and confirmed and transferred to specialist care

Confirmed and District Suspected transferred

Namaacha 31 3 Marracuene 21 0 Matutuíne 23 1 Moamba 26 4 Magude 20 5 Manhica 16 7 Boane 0 0 Matola 88 22 TOTAL 225 42

C. Physiotherapist outreach visits and other supportive activities During the provincial planning meeting, the PPP team sensitized the district directors from Namaacha and Matutuíne districts to incorporate funds into their budgets that will permit them to hire dedicated physiotherapists, without having to depend on visiting provincial physiotherapists. This proposal was made on the basis of the fact that these are the two districts that have historically required the most physiotherapist outreach visits.

D. Other activities performed to ensure data capture and quality During this reporting quarter, the PPP monitoring and evaluation team and SDSMAS (district statistics staff and ECD focal points) conducted joint data collection and technical assistance visits to all eight project target districts to guarantee the quality of the data received from each district. This activity had a special focus on ECD, but included other aspects of MCH as well and consisted of reviewing HF data, register books, monthly and daily summaries, and patient observation checklists and referral booklets across all MCH services (ANC, PNC, CCR, CCS, CCD, maternity, and medical consultations). One of the key results was the verification of an improvement in recording of ECD counseling and monitoring data across all target HFs.

E. USAID team field visit On October 30–31, 2018, a team comprising representatives from USAID, PATH, and DPS conducted a two-day field visit to Matutuíne District. In addition to observing facility- and community-level integrated ECD implementation, the USAID delegation took stock of long-term sustainability and transition plans after the end of the PPP project. The SDSMAS strongly reiterated its ownership in integrated ECD and expressed its desire to continue activities even when not supported by PATH.

Result 3: Expand knowledge and evidence base on integrated ECD

IR 3.1: Increased demand for ECD materials and services among implementers and policymakers.

Indicator 11

Indicator LOP S- PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target ECD Achieve- Achieve- Annual achieved only ments ments target of Y3 Q1 Q2 Q3 Q4 annual target

Number of children referred by 25,716 NA NA 5,376 11,111 1,847 1,836 1,618 48% CHWs to health facility

During the reporting period, APEs made 1,618 referrals to HFs. This translates to an achievement of 58 percent of the planned target for the reporting period, and the cumulative figure over three quarters translates to 48 percent of the annual target. Of these referrals, 15 were due to malnutrition and 15 due to suspected developmental delays.

The number of referrals continues to be low. When probed further, APEs noted that community members often cite long distances to the HFs as a barrier to fulfilling referrals, while some community members simply refuse to carry out a referral. APEs also claim that they do not always register referrals that they make. The PPP team is working to sensitize APEs on improving referrals and to make a note when community members refuse referrals.

Unfortunately, the APE-level data cannot be disaggregated by sex because the APEs’ monthly summary tool does not record data in this manner. Table 8 below provides detailed information about ECD counseling and early detection of signs of development delays at the community level.

Table 8. ECD counseling and early detection of signs of development delays at the community level

old old

ons, in ons,

5 years old old years 5

5 years 5

–

28 days old) days28 old)

District –

APEs APEs

problems

5 years old referred to referred old 5 years

–

management)

and community case case community and

provided by the APEs APEs the by provided

stimulation and nutrition and stimulation

Women pregnant and in in and pregnant Women

al of children referred to HF to HF referred children al of

Newborn (0 Newborn

HFs due to developmental to developmental HFs due

malnutrition (DAM or DAG) or (DAM malnutrition

which ECD was integrated, integrated, was ECD which

Children referred to HF with with to HF referred Children

Health education sessi education Health

Children 1 month Children

monitored for development by by development for monitored by development for monitored

Children 1 month Children

attended by APEs (home visits visits (home APEs by attended Tot

postpartum period counseled in counseled period postpartum

Children 0 Children Namaacha 1,363 55 146 142 4 1 111 265

Marracuene 3,385 268 732 576 4 9 510 405 Matutuíne 850 20 548 37 0 2 56 204 Moamba 2,090 89 919 47 2 0 171 623

Magude 1,535 114 161 180 0 0 195 282 Manhiça 3,048 505 521 529 1 0 600 895 Boane 936 62 55 107 4 3 111 189 TOTAL 13,207 1,113 3,082 1,618 15 15 1,754 2,863 Abbreviations: APE, Agente Polivalente Elementar (community health worker); ECD, early childhood development; HF: health facility.

Indicator 12

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target only Achieve- Achieve Annual achieved Indicator ments -ments target of Y3 annual Q1 Q2 Q3 Q4 target

Number of partners using 7 2 4 6 1 0 2 1 300% PATH materials for programming

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Progress and issues As already mentioned, several partners have expressed interest in using PATH’s nutrition and ECD materials. These include Catholic Relief Services, ChildFund and Terres des Hommes, requesting to use PATH’s parenting education program, as well as local NGOs in Maputo and Gaza requesting materials and training on playbox sessions as a part of HF waiting rooms or nutrition rehabilitation program, respectively. Since PATH has no project funds for these activities, these requests will be negotiated with each partner on a case by case basis. During the reporting period, one local partner association in Moamba received training in the parenting education program.

Within Maputo Province, PATH continued distribution of IEC materials to key health services, such as CCS consultations, maternities, and pediatric wards. The objective is to reach 100 percent coverage with these IEC materials in all HFs in Maputo Province by the end of January 2019. The same materials have also been distributed to targeted HFs in Nampula Province, as part of the jointly-funded Conrad N. Hilton and UNICEF effort to facilitate collective action around the Nurturing Care Framework.

Additionally, MOH requested for more ECD posters for CCS consultations to be distributed nationally. However, since PATH has no additional printing funds, we have encouraged the MOH Child Health department to seek this support from UNICEF, which normally supports the MOH’s printing needs.

Finally, PATH materials developed in Mozambique are currently being analyzed by the MOH in both Zambia and Ethiopia, with the intention to adapting them for country use.

IR 3.2. Increased evidence base on high-quality ECD service provision and the impact of ECD services on care and stimulation behaviors in target communities.

Indicator 13

LOP S-ECD PPP Y1 PPP Y2 Y3 Y3 Achievements Percent target only Achieve- Achieve- Annual achieved of Indicator ments ments target annual target Q1 Q2 Q3 Q4 for Y3

Number of dissemination 24 6 11 8 6 5 4 6 250% instances

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Progress and issues As described above, a team from Mozambique representing MOH, UNICEF, WHO, and PATH participated in a regional stakeholder meeting on the operationalization of the Nurturing Care Framework, held in Nairobi, Kenya in October 2018. During the meeting, MOH Nutrition staff from Mozambique presented to MOH representatives from seven countries in the region regarding the Mozambique MOH’s experience working with PATH and other partners—such as UNICEF and the World Bank—to integrate early stimulation into existing programs and tools. Additionally, samples of MOH materials with integrated ECD content were exhibited during a “materials marketplace” session. As a result of the dissemination, several countries expressed interest in learning more about the integrated ECD work taking place in Mozambique and have asked for copies of materials developed in Mozambique, such as the posters used for ECD counseling and monitoring developmental milestones.

The PPP team continued to disseminate its work and the concept of ECD for the youngest children through different national events, including two commemorative days—a World Prematurity Day event in Maputo Province in November and a Day of People with Disabilities event in Maputo in December. At these events, PATH exhibited its materials and led discussions with partners and the public on the importance of practices that stimulate optimal development in newborns and children with disabilities.

Several dissemination events conducted in this quarter were related to the evaluation of the parenting education program “Caring for Children from Pregnancy to Five Years” that PATH, DPGCAS, and rural development NGOs VIDA and CESAL have piloted in Matutuíne District. In November, PATH jointly with MGCAS organized a meeting to disseminate evaluation results of the parenting program. The dissemination meeting was well attended by MGCAS, DPGCAS, academia, and NGO partners. The workshop also resulted in a commitment by MGCAS to organize a workshop in early 2019 with different partners working on parenting education, so that the Ministry could obtain an overview of existing programs and make a decision regarding a national parenting program.

Additionally, a researcher from Eduardo Mondlane University who participated in the parenting evaluation, was supported by the Africa Early Childhood Network to present the findings at the Africa Early Childhood Network Conference in Nairobi in November. He also organized a workshop on parenting education for students from Eduardo Mondlane University in their last year of studies in the Early Childhood Development and Education course, which was conducted by PATH staff.

The partnership with Eduardo Mondlane University received a further boost when several students from the same course came to visit PATH to learn about its promotion of homemade toys for early stimulation purposes. PATH will move ahead with signing a memorandum of understanding with the university in order to continue serving as an ECD learning site for this main public university in Mozambique. A draft memorandum of understanding already exists and is expected to be finalized in early 2019.

Indicator 14

Y2 Achievements Percent S- PPP Y1 PPP Y2 Y3 achieved LOP Indicator ECD Achieve- Achieve- Annual of annual target ments only ments target Q1 Q2 Q3 Q4 target for Y3

Number of publications 40 10 10 9 10 2 2 2 60% (newsflashes)

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Progress and issues During the reporting quarter, the PPP team continued to produce electronic newsflashes and briefs, where success stories and key project achievements were highlighted. In this quarter, one brief and one newsflash were produced and disseminated, with the brief focusing on maternal depression (in light of Mental Health Day in November) and the newsflash covering the parenting education dissemination meeting. In addition, PATH has produced a calendar promoting the concept of Nurturing Care and highlighting various commemorative days during the year related to the domains of Nurturing Care (i.e., protection, health, nutrition, early learning, and responsive care).

The produced newsflashes and the calendar are being distributed to a total of over 100 institutions and 250 recipients. PATH’s distribution list includes institutions such as USAID/PEPFAR, UNICEF, WHO, World Bank, MOH, MGCAS, Ministry of Education and Human Development, Eduardo Mondlane University, Maputo DPS, multiple SDSMAS, EGPAF, ICAP, FHI 360, World Vision, and Save the Children, among others.

IR 3.3: Improved caregiver knowledge, attitudes, and practices on ECD.

Indicator 15

LOP S- PPP Y1 PPP Y2 Y3 Y2 Achievements Percent target ECD Achieve- Achieve- Annual achieved Indicator only ments ments target of annual Q1 Q2 Q3 Q4 target for Y3

Number of caregivers receiving IEC messages 901,072 NA 281,585 207,517 348,414 59,088 58,725 58,783 51% through CHW-led community talks

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; IEC: information, education, communication; CHW: community health worker; PPP: public-private partnership; Q: quarter; Y: year; N/A, not applicable. Revised as result of inclusion of Boane Quarterly targets = 87,104

During the reporting period, APEs reached a total of 58,783 caregivers in their community educational talk activities—which covered a range of different topics such as ECD, nutrition, family planning, hygiene, water and sanitation, and prevention diseases. This figure corresponds to 67 percent of the planned target for this quarter and the cumulative figure for the three quarters corresponds to 51 percent of the annual target. The lower than expected figures are consistent with data from previous quarters and may be attributed to APEs spending more time in delivering curative services rather than disease prevention and health promotion activities. Table 9 disaggregates the number of caregivers by district.

Table 9. Number of caregivers receiving CHW IEC messages through community talks (targets and achievements by district during the quarter)

Indicator 3.3.1: Number of caregivers receiving IEC messages through APE-led community talks.

District Total of caregivers covered Target Percent achieved

Namaacha 5,412 7,513 72 Marracuene 11,359 19,881 57 Matutuíne 8,444 3,545 238 Moamba 9,288 18,374 51 Magude 4,783 7,711 62 Manhiça 15,764 23,932 66 Boane 3,733 6,148 61 Total 58,783 87,104 67

Indicator 16

LOP S- PPP Y1 PPP Y2 Y3 Y2 Achievements Percent target ECD Achieve- Achieve- Annual achieved Indicator only ments ments target of annual Q1 Q2 Q3 Q4 target for Y3

Number of beneficiaries attending Projecting 23,976 NA NA 25,423 11,704 6,658 6,642 4,810 151% Heath sessions at health facilities

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year; N/A, not applicable Quarterly targets = 3,194

Progress and issues A. Projecting Health: Facilitation of educational video sessions at health facilities Projecting Health video sessions are held during early morning hours in the waiting areas of 17 HFs of six districts, including the Matola Provincial Hospital, while caregivers and their children wait for different mother and child services (e.g., ANC, PNC, CCR, CCS, and pediatric ART). A total of 12 different videos addressing nutrition, children stimulation, and promotion of utilization of health services topics are currently in use in HFs.

During the reporting period, a total of 151 video sessions were conducted in HFs across all intervention districts, with the exception of Boane and Matola, and were attended by a total of

4,810 caregivers (968 male and 3,842 female). This figure translates to an achievement of 164 percent of the quarterly target, while the cumulative figures over three quarters corresponds to 155 percent of the annual target. Table 9 below provides more detailed information about projecting health sessions conducted and participants.

Table 10. Number of Projecting Health sessions and participants, by sex per district

Number of beneficiaries attending to Projecting Heath sessions at health facilities

District Male Female Total Target % Coverage # of sessions

Namaacha 26 314 340 338 100 17

Marracuene 311 731 1042 484 215 8

Matutuíne 184 225 409 66 621 22 Moamba 279 1,375 1,654 631 262 24 Magude 32 305 337 172 196 8 Manhiça 136 892 1,028 429 239 11 Boane 0 0 0 1,074 0 0 Total 968 3,842 4,810 3,194 151 90

In addition, the PPP team continued to provide technical support to health providers who were trained on Projecting Health, with the objective to improve the quality of facilitation during sessions. The team has noted improvements in facilitation skills and use of materials for demonstration, as well as improved caregiver understanding of topics discussed in video sessions.

B. Projecting Health: Expanding educational video sessions at community level The assessment of the acceptability and feasibility of Projecting Health as a tool for influencing behavior change in the Mozambican context showed that most facilitators are able to properly use the video equipment and that video sessions have expanded to include markets, churches, and other sites in the target communities. Participants who had been exposed to the videos reported improved skills in toy-making, as well as in practicing promoted care and stimulation and nutrition behaviors.

5. Monitoring and evaluation

A. Monitoring and evaluation plan During the reporting period, the PPP team submitted the revised monitoring and evaluation plan to USAID, which has been approved. The revisions to some indicators were necessitated by the addition of two new districts in the project.

B. Collaboration with World Education International. In the previous quarter, PATH provided support to World Education International (WEI) Girl’s Education project teams in Sofala and Zambézia provinces. During this reporting period, the PPP team and the WEI Girl’s Education project team conducted a meeting regarding the possibility of a similar support visit to Manica and Gaza provinces. However, with the PPP project ending in March 2019 and the lack of dedicated funding to provide technical assistance to WEI’s work in additional provinces, PATH advised WEI to present the idea to the donor and seek additional funding. Should the idea be approved, PATH is fully prepared to collaborate further with WEI.

C. Operations research and other assessments During this reporting period, data collection for the operations research has taken place per the approved schedule. Although there have been some delays, the PATH team has received a draft of the study report and is currently working with the consultant to improve the quality of the data analysis and reporting. The final report will be shared with USAID in the next quarter. The team also plans to host a meeting to disseminate study findings.

D. PEPFAR OVC indicators The OVC indicator will be reported next quarter, considering that it is a biannual indicator.

E. HL. 9-1 INDICATOR While the PPP project is not supporting clinical nutrition interventions or treatment of nutrition conditions, it has a strong component on nutritional counseling to caregivers to improve nutritional knowledge and practices for their children as part of the approach of integrating ECD into clinical and community services.

Table 10 reflects the number of children benefiting from nutrition counseling provided by APEs during the period October to December 2018. A total of 13,207 children (6,339 male and 6,868 female) were reached by APEs in all seven districts with APEs. Out of this figure, 2,746 children were under one year old (1,331 males and 1,415 female), and 10,460 children were between 1– 4 years old (5,008 males and 5,452 female). This quarter’s figures represent an increase from the previous quarter’s figures and are part of an upward trend over the previous four quarters, as more districts and communities have been covered by the PPP project’s activities.

Table 11. HL. 9-1: Number of children under five (0–59 months) reached with nutrition-specific interventions through United States Government-supported programs (October–December 2018)

Code Indicator Name HL. 9-1: Number of children under 5 (0-59 months) reached with nutrition- specific interventions through United States Government-supported

HL. 9-1 programs Male TOTAL Female TOTAL Total Target Achievement District <1 year 1-4 years <1 year 1-4 years Magude 155 582 737 164 634 798 1,535 1,030 149 Manhica 307 1,156 1,463 327 1,258 1,585 3,048 4,636 66 Marracuene 341 1,284 1,625 363 1,397 1,760 3,385 2,845 119 Matutuine 86 322 408 91 351 442 850 474 179 Moamba 211 793 1,003 224 863 1,087 2,090 2,094 100 Namaacha 137 517 654 146 563 709 1,363 1,114 122 Boane 94 355 449 100 386 487 936 1,937 48 TOTAL 1,331 5,008 6,339 1,415 5,452 6,868 13,207 14,128 93

F. Progress in implementation of environmental mitigation and monitoring plan (EMMP) As proposed in the approved EMMP, the PPP team has continued promoting the use of recycled materials for toy production in every training.

G. Progress of gender analysis issues With regard to promoting gender equality, as of 2019, PATH in Mozambique will be led by an all-female team, who will assume leadership of its various programs and components. In terms of technical work, the recently conducted parenting education training, for the first time, included 10 male activists. These male activists were trained to facilitate parenting education sessions, with a special focus on fathers. Additionally, the formative interviews conducted with postpartum mothers explored the topic of male partner support, and the data is now being used to design counseling cards for mothers with signs of depression.

6. Upcoming plans

The following are some major activities planned for the upcoming quarter: 1. In collaboration with MOH, continue support for the development of job aids, data collection mechanisms, and training materials for MCH nurses and mental health technicians on screening and counseling for maternal depression. 2. Provide technical and financial support to DPS and SDSMAS on monitoring the use of the new CCS and CCD registers in Maputo Province. 3. Provide technical and financial support for the training of mental health providers in Maputo Province. 4. Conduct monthly mentoring visits for new facility-based health workers trained on ECD in Matola, Marracuene, and Boane districts. 5. Implement an overall project quality improvement approach and support district supervision and facility-specific action plans around MCH, nutrition, and ECD. 6. Support quarterly refresher trainings for existing APEs. 7. Support district APE coordinators to conduct quarterly APE supervision visits with integrated ECD content. 8. Conduct a meeting with DPS and SDSMAS regarding with project closeout plan. 9. Disseminate results of operations research to key partners and stakeholders. 10. Conduct a closeout ceremony with different partners from government, NGOs, and donors.

For detailed activities of the upcoming quarter, refer to Appendix B, which is attached with this report submission.

7. Administrative update

Jordi Fernandez, Mozambique Country Program Manager and PPP Project Director, left PATH in December 2018. Melanie Picolo, Senior Nutrition Advisor on the USAID-funded Maternal and Child Survival Program, will be the new PPP Project Director, starting January 2019. In this capacity, she will be supported by Ndana Sande, Senior Site Administrator, and Svetlana K. Drivdale, Senior Regional ECD Specialist. The PPP team has submitted the project closeout plan to USAID, which includes (among other things) highlights of the major programmatic events and achievements during the implementation of the project, current financial status report, asset disposition plan, final audit timeline, personnel phaseout timeline, and program closeout timeline and procedures. USAID and PATH have also begun discussing the participant list and draft agenda for the closeout ceremony. In the next quarter, PATH will work with USAID, the Conrad N. Hilton Foundation, and the Maputo DPS to finalize the agenda and participant list for the closeout ceremony, develop a joint press release, and make logistical preparations for the closeout ceremony.

8. Financial information

A total of $127,354.63 was expended during the quarter October–December 2018. The table below shows the expenses for the quarter by categories and projected expenses for January– March 2019.

Total Expenditures Cumulative Total budget Projected expenses approved for Expenditures for remaining (1/1/19–3/31/19) budget current period project to date (10/1/18– (4/6/16– 12/31/18) 12/31/18) Direct labor 566,852 55,892.25 514,666.85 52,184.65 46,500.00 Fringe benefits 176,909 14,684.84 156,109.34 20,799.16 19,903.00 Travel 86,042 6,652.08 80,235.23 5,806.68 5,000.00 Supplies 4,364.09 - 4,364.09 0 0 Sub-awards 54,140 0 38,830.32 15,309.68 15,309.68 Other direct costs 282,949 21,561.25 258,013.34 24,935.66 24,398.00 Indirect costs 328,192 28,600.20 295,179.96 33,012.04 31,061.00 Total project costs 1,499,447 127,354.63 1,347,399.13 152,047.87 138,167.00

9. Appendices

Appendix A. Success story A health worker’s small act helps transform the life of an entire family Alcinda Maholela, with a big smile and arms prepared to embrace, is hurrying to greet Celeste Carlos and her family. One year ago, Alcinda, an APE in the Bobi community of Magude District, ensured that Celeste’s family was referred to social action services, so that they could benefit from the minimum basket of goods for vulnerable families. This year, the family which also includes two-year-old Laura, six-year-old Sergio, and eight-year-old Jose has received something even better than the food basket—they have been registered with the Basic Social Subsidy Program of the National Social Action Institute.

Celeste’s family was identified by Alcinda as eligible for social services, following the training conducted by PATH and the Magude District Directorate of Health, Women and Social Welfare in September 2016, which oriented APEs to identify and report orphans ad vulnerable children to social action services. Celeste is HIV positive, and while the boys were confirmed to be HIV negative, she is still waiting for Laura’s results.

A year ago, Celeste did not have any personal documents and her children did not have their birth registration documents. They were also not attending school. On some days, there was no food for the family, while on other days the family would eat only once to ensure that there was food left for the next day.

“This family has passed through many hardships… some neighbors have stopped talking to Celeste after they caught her children walking around hungry and stealing food,” described Alcinda.

Celeste now proudly shows her identity papers, her children’s birth certificates, and school registration documents, which social action services helped her obtain. Additionally, the family is now benefiting from a monthly subsidy of 840 meticais1 through the subsidy program.

“I am very happy, the money will help us a lot… I will buy food, soap, notebooks and pencils for children… we will not go to sleep hungry anymore,” tells Celeste with a big smile.

Having supported the family over a long time, Alcina feels that her hard work has been rewarded with the help that Celeste and her children now receive.

The social action technician, Cecilia Mutemba, assures that the support is meant to continue throughout the life of the family, depending on their circumstances.

1 Subsidy amount varies according to the family size, from MZN 540 for a family of one to MZN 1050 for a family of five or more members.

“If the mother for some reason passes away, the situation of the children will be analyzed and if the challenges continue, the name of the mother will be changed to the name of the oldest child, and they will continue receiving support.”

Alcina promises to continue supporting the family. In addition to checking on the health and nutrition of Celeste and her children, Alcina reminds her every month when she should go and receive her subsidy, so that she does not get dropped from the subsidy list.

Celeste is feeling joyful as she is sure that she will never Walking barefoot, Celeste is carrying on her head and in her again see her children going to bed hungry. She is pictured hands the guarantee that her children will have something to here with her daughter, Laura. eat this month.

Appendix B. January–March 2019 work plan Please refer to the work plan in the attached Excel spreadsheet that has been submitted separately with this report.