IFPP - Integrated Family Planning Program

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

Yearly Report:

October 2018 to September 2019 – 3rd Year of the Project

Table of Contents ACRONYM LIST ...... 4 PROJECT SUMMARY ...... 7 SUMMARY OF THE REPORTING PERIOD (OCTOBER 2018 TO SEPTEMBER 2019) ...... 8 IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services ...... 17 Sub-IR 1.1: Increased access to modern contraceptive methods and quality, facility-based FP/RH services ...... 17 Sub-IR 1.2: Increased access to modern contraceptive methods and quality, community- based FP/RH services...... 36 Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services ...... 46 IR 2: Increased demand for modern contraceptive methods and quality FP/RH services ...... 47 Sub-IR 2.1: Improved ability of individuals to adopt healthy FP behaviors ...... 47 Sub-IR 2.2: Improved community environment to support healthy FP behaviors ...... 48 Sub-IR 2.3: Improved systems to implement and evaluate (Social and Behavior Change Communication) (SBCC) interventions ...... 52 IR 3: Strengthened FP/RH health systems ...... 53 Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution ...... 53 Sub-IR 3.4: Improved government capacity to increase supply, distribution and retention of skilled workers ...... 62 Sub-IR 3.5: Improved generation, dissemination and use of FP data for more effective decision-making ...... 63 Project Performance Indicators ...... 70 IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services ...... 70 Sub- IR 1.1: Increased access to modern contraceptive methods and quality, facility-based ...... 74 Sub- IR 1.2: Increased access to modern contraceptive methods and quality, community- based ...... 74 Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services ...... 75 IR 2: Increased demand for modern contraceptive methods and quality FP/RH services ...... 75

Sub-IR 2.1: Improved ability of individuals to adopt healthy FP behaviors ...... 75 Sub-IR 2.3: Improved systems to implement and evaluate SBCC interventions ...... 76 IR 3: Strengthened FP/RH health systems ...... 76 Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution ...... 77 Sub-IR 3.2: Improved management of commodities to ensure availability at local levels .. 78 Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment ...... 78 Sub-IR 3.4: Improved government capacity to increase supply, distribution and retention of skilled workers ...... 79 Sub-IR 3.5: Improved generation, dissemination and use of FP data for more effective decision-making ...... 79 Collaboration with other donor projects ...... 80 Upcoming Plans...... 81 IR 1: ...... 81 IR 2: ...... 81 IR 3: ...... 82 Evaluation/Assessment Update ...... 82 Annexes ...... 83 Annex A - Success story ...... 84

ACRONYM LIST Acronym Description AC Accommodation Center ANC Antenatal Care ART Antiretroviral Treatment AYSRH Adolescent and youth sexual and reproductive health APE Agente Polivalente Elementar – Ministry of Health Approved Community Health Worker BL Baseline BTL Bilateral Tubal Ligation CACUM Cancro de Colo de Útero e da Mama – Cervical Cancer of the uterus and breast cancer CBOs Community Based Organizations CDCS Country Development Coordination Strategy CDFMP Cenário de Despesas Fiscal de Médio Prazo (Midterm Fiscal Review) CECAP Cervical Cancer Prevention CF Community Facilitator CHW Community Health Worker (including APEs, PTs, other health activists) CIHO Communication for Improved Health Outcomes CL Community Leader CLC Community Leader Council (at village level) – “Conselho de Lideres Comunitarios” CLL Locality’s local council (covering an area of approximately 20 villages) – “Conselho Local da Localidade” CMAM Central de Medicamentos e Artigos Médicos (National Drugs, Commodities and Supplies Warehouse) CMM Consumo Medio Mensal – Monthly Average Consumption CPR Contraceptive Prevalence Rate CR Community Radio CSC Community Score Card CYP Couple Year Protected CwS “Connect with Sarah” app DDM Depósito Distrital de Medicamentos (District Medicines Depot) DMPA-IM Medroxyprogesterone acetate – Injectable contraceptive DMPA-SC Sayana Press DP District profile DPM Depósito Provincial de Medicamentos (Provincial Medicines Depot) DPS Provincial Health Directorate E2A Evidence to Action FP Family Planning EMMP Environmental mitigation and monitoring plan EPC Escola Primaria Completa – Primary School - 6th and 7th grade FP/RH Family planning/reproductive health FS Field Supervisors FTP First Time Parents FY Fiscal Year GIS Geographic Information System

GRM Government of the Republic of Mozambique HCW Health Care Worker HF Health Facility HMIS Health Management Information System HP Health Provider HR Human Resources HRIS Human Resources Information System HSS Health Systems Strengthening HTSP Health Timing and Spacing of Pregnancy IEC Information, Education and Communication IEE Initial Environmental Examination IFPP Integrated Family Planning Program IMASIDA National Malaria and HIV Indicator Survey IPC Interpersonal Communication Agent ISL Implementation Science and Learning IT Information Technology IUD Intrauterine Device LARC Long Acting Reversible Contraceptive LOE Level of Effort LOP Life of Project LTM Long Term Method M&E Monitoring and Evaluation MB Mobile Brigade MCH Maternal and Child Health mCPR Modern Contraceptive Prevalence Rate MCSP Mother and Child Survival Program MINEDH Ministry of Education and Human Development MISAU Mozambican Ministry of Health MMEMS Mozambique Monitoring. and Evaluation Mechanism Services MOU Memorandum of Understanding MSC Management Standards Compliance NED District Statistical Nucleus NEP Provincial Statistical Nucleus NGOs Non-governmental Organizations NHS National Health System OC Oral Contraceptives OVC Orphans and Vulnerable Children PDSA Plan, Do, Study, Act PES Social and Economic Plan PESOD District Operational Social and Economic Plan PHD Provincial Health Directorate PMP Performance Monitoring Plan PPFP Post-Partum Family Planning PPIUD Post-Partum IUD PSI Population Services International QI Quality Improvement RDQA Routine Data Quality Audit

RH Reproductive Health SARA Service Availability, Readiness Assessment SAAJ Serviços Amigos dos Adolescentes e Jovens (Youth Friendly Services - YFS) SAPERS-CPF Sistema de Alerta Precoce para Evitar Roturas de Stock dos Consumíveis de Planeamento Familiar, or Early Warning System to Avoid Stock Outs of Family Planning Commodities SBCC Social and Behavioral Change Communication SDP Service Delivery Point SDSMAS District Health Welfare and Women Directorate SGBV Sexual and Gender-Based Violence SIFO Training Information System SISLOG Sistemas e Tecnologias - Gestão de Clientes (Local Digital Technology Company) SIS-MA Sistema de Informação em Saúde – Monitoria e Avaliação (HMIS) SMATG-CPF Sistema Móvel de Assistência Técnica para Gestão dos Consumíveis de Planeamento Familiar, or System for Mobile Management of Family Planning Commodities SOPs Standard Operating Procedures SRH Sexual and Reproductive Health SRHR Sexual and Reproductive Health Rights STM Short Term Method TA Technical Assistance TBA / “PT” Traditional Birth Attendant / “Parteira Tradicional” TBAs Traditional Birth Attendants TEM+ “TEM mais” – Private clinic network ToR Terms of Reference TOT Training of Trainers TSO Technical Support Officers USAID United States Agency for International Development USAID AOR Agreement Officer’s Representative (USAID) USG United States Government VIA Visual Inspection using Acetic Acid WHO World Health Organization WRA Women of Reproductive Age YFHS Youth-Friendly Health Services

PROJECT SUMMARY

Project Title: IFPP - Integrated Family Planning Program Duration: 5 years Start Date: June 2016 Life of project funding: $ 35,060,000 Geographic Focus: Nampula and Sofala provinces The Integrated Family Planning Program (IFPP) is a five-year USAID/Mozambique-funded initiative to increase use of modern contraceptive methods by target populations in all 36 districts in Nampula and Sofala provinces in Mozambique. IFPP responds to the United States Government (USG) strategy for development and foreign assistance in Mozambique through the Country Development Coordination Strategy (CDCS). USAID/Mozambique CDCS outlines an overarching development objective health goal to “Improve the Health Status of Target Populations” through three results: 1) Increased coverage of high impact health and nutrition services, 2) Increased adoption of positive health and nutrition behaviors, and 3) Strengthened systems to deliver health, nutrition, and social services (CDCS, 2013).

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

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

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

SUMMARY OF THE REPORTING PERIOD (October 2018 to September 2019)

During the third year of the project (FY3), IFFP had to cope with the aftermath of the tropical cyclone IDAI (14th of March) in the districts of Beira City, Dondo, Buzi and Nhamatanda in Sofala province. This resulted in redirecting the project’s community and clinical staffs focus on supporting these districts’ 41 accommodation centers for comprehensive emergency efforts led by the Government and strongly supported by the international community. The focus was primarily on reestablishing and increasing FP service access to displaced populations, while ensuring implementation of IFPP in the nine remaining districts. For this purpose, additional medical equipment and supplies, furniture, facility materials and monitoring and evaluation (M&E) logbooks were purchased and delivered. Within this context, the IFPP midterm evaluation (MTE) carried out by Monitoring and Evaluation Mechanism and Services (MMEMS) was canceled for the province however it was still implemented in Nampula province. The MTE findings and recommendations were discussed and reviewed by the USAID IFPP team in order to better understand where the project stands after two and a half years of implementation and what should be adjusted and strengthened in the second half of the project to successfully reach IFPP’s objective of increasing demand for and the utilization of FP service, as well as the strengthening health systems for FP programming and managing. Additionally, this was included under the Y4 workplan.

IFPP is on track to increase knowledge and awareness of modern contraceptive methods, including long-acting reversible contraceptives (LARCs) – e.g. accurate knowledge on intrauterine devices (IUDs) increased from 27% (baseline [BL]) to 52% (MTE) and ability to negotiate contraceptive use with partners/husbands increased from 44% (BL) to 64% (MTE) – and to address unmet need for FP in adolescents 15 - 19 years of age – e.g. knowledge among 15 – 19 year olds increased from 75% (BL) to 83% (MTE). IFPP has also contributed to enabling the socio- cultural environment – e.g. acceptance of FP by the household heads has increased from 53% (BL) to 64% (MTE) – and has laid the groundwork to increase FP services offered by training providers across various cadres through intensive cascade training given over eight days. The project has also achieved this by increasing awareness of District Health Women and Welfare Directorate (SDSMAS) and health facility (HF) teams about the importance of strengthening FP services offered through (i) FP integration into other consultations and at the maternity level; (ii) increase of mobile brigades (MBs); and (iii) the expansion of FP services in the community through Agente Polivalente Elementar (APEs, Ministry of Health Approved Community Health Worker). The MEMMS population-based survey, which took place in Nampula during the second half of March 2019, showed that the mCPR was unchanged from baseline, however issues with stockouts of injectable contraceptives may have been a significant contributing factor to this lack of progress. The percentage of HFs in Nampula suffering from DMPA shortage rose from 8% in December 2018 (Q1FY3) to 37% by March 2019 (Q2FY3) as the MTE was taking place. These issue of stock-out improved in Q3 and Q4 but continued to be prevalent as the level of supplies from the central level to the Depósito Provincial de Medicamentos (DPM) aren’t corresponding to the quantities requested by DPM to respond to the demand creation activities financed

8 through IFPP; indeed, the HF’s stock-out percentage in Q3FY3 was about 15%, fortunately less than the 37% of Q2 but, still unacceptably high to respond to the demand creation activities. To improve FP commodity supplies in Q3 and Q4, IFPP strengthen the existing coordination and communication mechanisms between DPM, PSM and IFPP at provincial level and CMAM, PSM and IFPP at central level. Note that this insufficient FP commodity supply from the central to the provincial level is also reflected through the DMPA CMM - Consumo Medio Mensal – Monthly Average Consumption – trends, which had increased steadily from 34,308 (based on July – Dec. 2017 distributions), to 50,796 (based on Jan – Jun 2018 distributions), to 64,916 (based on July – Dec. 2018 distributions), and then decreased to 59,083 (based on Jan – Jun 2019 distributions), disrupting the efforts carried out thru IFPP to create the demand and, even more, reducing commodities access for clients that acquired last semester. It’s one more lesson learned, more in-depth proactive analysis based on CMAM and PSM updated data and more coordination efforts between TWG’s partners (Pathfinder and others NGOs, FP commodities donors, CMAM, MISAU) must be carried out to prevent such fallbacks impacting the aligned efforts implemented through all partners to reach the GoM target of 34% of mCPR by end of 2020. While lack of progress in the midline mCPR rate for Nampula province was disappointing but not entirely unexpected given the substantial stock issues, IFPP has intensified efforts and increased the number of activities in the Y4 Annual Work Plan (FY4 AWP) to increase access and quality of FP services, in order to reduce unmet need for FP for WRA in Nampula and Sofala.

During FY3, the following accomplishments are worth mentioning under IR1. The project carried out two FP training of trainers (TOT) involving 50 district-based health providers (HPs) in Nampula, in order to strengthen the technical capacity of MoH staff in on-the-job training and mentoring of FPs in line with midterm review recommendations to ensure the sustainability of IFPP investments; additionally, the efforts to involve all eligible HPs in FP service delivery were continued as 604 additional HPs were trained in the eight-day FP facility-based curriculum and 485 HPs and health managers had the opportunity to participate in additional advanced technical and managerial trainings related to FP program; finally, efforts to improve the quality of the FP services delivered were strengthened as illustrated through the results of the mentorship activities; indeed, the rate of providers failing to achieve competency on various clinical skills for the entire cohort of HPs cumulatively enlisted in the mentorship App is gradually diminishing, confirming that HPs are bettering their abilities as Nampula province has decreased its PPIUD skill failure rate from 41% (46/111) in Q2FY2 (ending March 2018) to 10% (40/390) in Q4FY3 (ending September 2019) and Sofala from 11% (10/88) in Q2FY2 to 2% (4/203) in Q4FY3; more recently introduced activities, such as one week of experience exchange visits (learning visits) between HFs were carried out in Sofala province with low volume HF providers visiting Higher level or higher volume HFs to consolidate skill transfer, involving 67 HFs and 121 HPs in the last two quarters of FY3; to expand the method mix, since Q2FY2, the project has supported the introduction of mini-laparotomy bilateral tubal ligation (BTL) with local anesthesia as an option for permanent method (PM), responding to satisfying demand for limiting births; in FY3, 668 mini-laparotomy BTL were carried out in 19 different HFs against 225 mini-laparotomy BTL in 6

HFs during FY2 . To strengthen understanding and coordination, boost the quality of the sexual and reproductive health (SRH) services, as well as to lay foundations for self-reliance and sustainability of quality improvement initiatives, during FY3, IFPP focused on the involvement of the Provincial Health Directorate (DPS) and SDSMAS in HF’s joint supervision visits: 183 HF’s joint supervision visits were carried out in Q4FY3 against 110 in Q1FY3 and, a total of 612 joint supervisions were carried out in FY3.

Leveraging the opportunity presented by IFPP and in efforts to reduce morbidity and mortality from cervical cancer, USAID funded Pathfinder to support Cervical Cancer Prevention (CECAP) activities in country for FY3 by providing technical assistance (TA) across Mozambique at the central, provincial and district level, as well as providing direct support to HFs and district authorities through high-volume, PEPFAR-supported antiretroviral therapy clinics at district and higher-level hospitals in coordination and complementarity with PEPFAR partners. The detailed activities carried out are described in the corresponding section of this report but, during next FY, urgent investment is needed in training, supervision and mentorship, as on the one hand, MoH purchased one thousand additional cryotherapy machines (with GFF funds) to expand accessibility of CECAP services and, on the other hand, cervical cancer remains a public health emergency in Mozambique; indeed, whereas, on average, only 12% of the SRH consultations (in Nampula) and 19% (in Sofala) are coupled with Visual Inspection with Acetic Acid (VIA), 4% in Nampula and 5% in Sofala are identified as VIA+ and, out of these VIA+ on average, 19% are diagnosed with cervical lesion >75% in Nampula and 32% in Sofala, highlighting that far too many WRA already have extended cervical lesions at time of screening; and even more, in FY3, 357 WRA in Nampula and 527 in Sofala with advanced lesions were referred directly to the provincial level for suspected cervical cancer.

During FY3, MBs continued to be key in increasing access to FP, particularly for rural and hard to reach areas, like this, IFPP supported 3,303 MB maintaining the level reached in FY2 (3,383); to boost these specific activities, IFPP has during the last quarter of FY3, refined the strategy to be applied in Y4 by planning an increase in a suite of synchronized mobile brigades to reduce barriers to access for vulnerable populations such as youth and consistent access for those living far from health centers; four types of MBs were defined - continuation MBs, school-based MBs, targeted rural MBs, and community dialogue MBs linking MBs with sensitization community dialogue cycles; furthermore, in September 2019, IFPP supported specific MBs to enhance the MoH’s contraception month and the four types of MBs have started to be implemented.

During FY3, continuous support to APEs to increase their FP services offered was provided; the trends of the number of APEs reporting FP data is steadily increasing from 284 out of 366 reporting data (78%) in April 2018 to 922 out of 1083 (85%) in September 2019; the monthly average number of DMPA users served per APE is around 13 per month while the average number of oral contraceptive pill users served per APE is around 3 per month, totaling 16 users served per month and per APE, the goal of the MoH is to reach at least 25 clients per month; although it’s already a remarkable achievement, in FY4, IFPP will strengthen its support through

10 identifying poor performing APEs and working with them to better understand and address barriers such as lack of commodities, persistence of personal bias related to youth rights or FP methods myths and low knowledge around the different type of FP methods, existing weaknesses in their abilities to ensure increased male involvement, and accurate data registration. For Sofala province, at end September 2019, 316 APEs were reporting data out of 380 reported as active through the NHS against 231 out of 350 at end September 2018; the monthly average number of DMPA users served per APE is around 12 per month while the average number of pill users served per APE is around 10 per month; The May 2019 peak of reporting is related to the post-IDAI campaign in Sofala province, but these data should be taken in consideration very cautiously as data over-reporting is a recurrent issue during campaigns and the gain of users was not reflected in the following months.

For IR2.1, during FY3 a total of 524,166 contacts carried out through TBAs, CFs and IPC agents, were reported (378,098 in Nampula and 146,068 in Sofala) against 322,583 in FY2 and 174,531 in FY1.

In relation with the urban demand creation component, the intervention strategy has switched to a systematic mapping for all registered houses, blocks, units, neighbourhoods and administrative posts of the preselected urban area and covered during FY3, 33% of the predefined households (48% in Nampula urban area and 8% in Sofala urban area); 192,998 women contacts were reported. The mapping implemented by the FY3 recruited urban community assistants has strengthened IFPP’s objective of appointing each Interpersonal Communication Agents (IPC - Promotora de Saúde Comunitária) to a specific geographic area of about 2,000 - 2,500 households (HHs) to increase the mCPR through regular home visits. With the updated version of CwS App, IPC agents focus on the importance of FP client follow-up, reporting behavior change barriers met at each household visited and establishing male or mothers-in-law group sensitization with the support of the urban community assistant and CL involvement; in Nampula province, IFPP LOP target is to visit and register 212,500 WRA in predefined urban areas; during FY3, 102,211 (48% of coverage) were already visited and registered in CwS and, out of these, at the end of FY3, 62,476 are reported as FP users; of these, 6,772 were not a FP user at the moment of the visit and initiated or reinitiated a FP method as result of the community visits meaning that 6% of WRA visited at least once became users after IPC's intervention during FY3, illustrating the powerfulness of this newly introduced approach. In Sofala, due to IDAI and the post-emergency phase, this systematic mapping had to be carried out again in Q4FY3 to ensure coverage of WRA who, due to the cyclone, moved from one neighborhood to another and, the ones settling in new neighborhoods emerging after IDAI; therefore, IFPP reports only the data of the Q4FY3; the IFPP LOP target is to visit and register 125,000 WRA in predefined areas and 10,136 were (re)visited and (re)registered in CwS solely during Q4FY3; out of these, at the end of FY3, 4,841 are reported as FP users; of these, 421 were not a FP user at the moment of the visit and initiate or reinitiate a FP method through the community visits meaning that 4% of WRA visited at least once became users after IPC's intervention during FY3.

In relation with the rural demand creation, during FY3, a total of 300,459 contacts with women were carried out through community dialogues against 222,812 contacts in FY2 and 109,833 in FY1. This component is investing in reaching additional remote communities in order to provide FP information and knowledge as well as FP services to the most remote populations – most probably for the first time despite the serious constraints. 3,883 community dialogue groups attending each six different sessions have been carried out in FY3 against 3,226 in FY2; CFs (community facilitators) are facilitating two groups per day (one of CL and another of young couples) carrying out activities six days per week, covering three different villages in a period of three weeks and increasing like that their productivity, which is very important to cover more distant areas but also to reach IFPP LOP target of 13,056 (at end of FY3, IFPP reached 54% of the LOP target). Additionally, at end FY3, out of the 1,336 trained TBAs during the first three years of IFPP, approximately 800 are still active and implementing regular sensitization activities at the community level and reporting confirmed referral data monthly. Sensitization contacts reported by TBAs have increased from 1,129 (FY1) to 23,651 (FY2) and jumped to 39,785 by the end of FY3; in FY2 and FY3, IFPP has focused on operationalizing the monthly review meetings led by the HF MCH nurse to ensure more qualitative support resulting in more effective community mobilization from the involved TBAs; when analyzing the confirmed referrals by specific subgroups in Nampula province, it’s outstanding that 20% of the confirmed referrals, in Nampula and, 15% in Sofala represents ‘adolescents yet without children’ demystifying the idea that TBAs are not comfortable with delaying the first pregnancy in adolescent.

To improve community environment to support healthy FP behaviors (IR2.2), the rural demand creation component, as referred above, is implementing a systematic community dialogue process; half of the groups are targeting key community leaders (CLs) and influencers to address the social and gender norms and drivers behind the lack of use of modern FP and create like this a more enabling environment at the community level for adherence to modern FP methods; before entering in a new locality (localidade), in order to ease the work of the CFs with the village-based CLs groups, since FY2, IFPP sensitized the upper administrative structure, the locality’s local council (CLL - Conselho Local da Localidade) through a one-day meeting focused on the FP program and their important role as gatekeepers; during this FY3, 105 CLLs were gathered and sensitized against 64 in FY2. Also, 120 HF’s co-management committees were supported in FY3. In urban settings, 14,949 CLs were sensitized on FP through unique sessions, to ease the roll-out of the mapping and the IPC agent’s household visits.

As an integrated component of IFPP, twelve community radios have broadcasted FP podcasts, including for the first time on the Nampula Muslim radio “HAQ” which reaches the entire province of Nampula. The involvement of men and women champions in the community radio program was instrumental along the FY3; two trainings were carried out involving staff of the twelve usual CRs and staff of four additional CRs located in Cheringoma, Dondo, Chibabava and Buzi districts preparing like this the FY4 season; topics such as writing scripts to cover the monitoring of the CSC (community score cards) on quality of the HF FP services, mobile brigades,

12 community dialogue sessions and, more effective involvement of CL, APEs and men and women champions were taught.

Regarding IR3.1, over the last three years, IFPP worked closely with DPS, SDSMAS, HF and Partners in Nampula and Sofala provinces to strengthen FP health systems in the areas of planning and budgeting, human resources, FP commodities, FP/ MCH program management and HIS monitoring and evaluation by implementing a number of FP interventions; while IFPP HSS targeted fifteen districts (9 in Nampula and 6 in Sofala) in FY1, the coverage was extended to nine additional districts (6 in Nampula and 3 in Sofala) in FY2 and, twelve additional ones (8 in Nampula and 4 in Sofala) in FY3, totaling 100% of the districts targeted in the LOP: every district of the area of intervention has already received some HSS TA at the end of FY3, meanwhile, through the last MSC scoring, 19 had already reached 80% of satisfying scoring, 4 were scoring between 70 and 80%, 5 scoring between 60 and 70% and, 8 scoring 60% or less; it’s important to note that the electoral campaign, as a lot of civil servant were involved, have delayed part of the HSS activities initially planned for August-September 2019 to the next quarter. Along the FY3, specific performance gaps in the management SOPs were used to define and incorporate FP priority actions in the annual PES/PESOD and, in quarterly and monthly FP system strengthening actions plans drafted by DPS and SDSMAS managers with IFPP support. In FY3, 192 DPS and SDMAS health managers were mentored to consistently identify FP priorities, design and budget FP activities in the PES/PESOD annual health plans representing 126% achievement of the annual target (152).

Regarding IR3.2, while, during FY2 , there was, overall, a significant reduction of stock outs in the HFs assisted by the project thanks to a combination of factors contributing to these results, such as the large availability of FP commodities at the national level, and several IFPP supported interventions including weekly pro-active follow-up of imminent stock-out or stock outs, identified by IFPP staff and DDM and DPM responsible, during the FY3, the DPM of Nampula was confronted to serious difficulties - starting from December 2018 and lasting up at least to May 2019 - to receive from the regional and central level warehouses, the sufficient quantities of DMPA injectables to answer timely at the demand created; thus, the percentage of HFs with stock-out increase from 8% in Q1, to 37% in Q2, and then decrease to 15% in Q3 and 4% in Q4FY3, while in Sofala province, the percentage of HFs with stock-out was of 4%, 3%, 7% and 1% in Q4FY3. IFPP in FY3 focus in providing TA for SIGLUS functioning in 196 HF (132 in Nampula and 64 in Sofala) from 17 districts as district and HF depot managers were provided TA to improve their skills in operating tablets, understanding SIGLUS platform, entering data on FP commodities, reacting to stock outs alerts and timely saving and synchronization of SIGLUS data into SIMAM; meanwhile, more technical support from PSM and IFPP in addition to strengthened political and programmatic commitment of SDSMAS and DPS will be needed in FY4, specially for Nampula province, for the SIGLUS platform being used consistently by the HFs and district depot’s managers. In FY3, provincial and district depots managers, district medical chiefs, in Nampula and Sofala, were trained to track FP commodities inventory management at HF through SIGLUS portal and improve communication between the chain of logistics supply stakeholders.

IFPP provided TA in the institutionalization of district in service training centers, strengthening staff competencies in operating the MISAU’s human resource information system (HRIS) or SIFO.

To strengthen governance and civil society engagement around FP and contribute to stronger systems (IR3.3), IFPP is carrying out community score card (CSC) activities - a participatory, community-based tool for assessing the quality of health services. The community facilitators (IR2.1) and field supervisors facilitate the process of community assessment of FP/RH services, provider assessment on the same criteria, and support dialogues between community members and providers to agree on priorities for action and plan for improvement. While CSC process implementation was a sensitive subject when carried out for the first time in FY2, the process was more easily performed in FY3 and MISAU also committed itself to carry out CSC through the Global Financing Facility funding mechanism. When comparing the results of the FY3 against the FY2, by criteria, overall, the composition and the operationalization of the CMC remain the most difficult to be satisfied from the community’s point of view, inviting IFPP to further understand how these two criteria could be more positively perceived by the communities and what further processes could be proposed to improve the composition and the operationalization of the CMC, from the point of view of the users; the customer service’s criteria, are bettering but still need improvement while the service delivery quality and the FP commodities availability are perceived by the community as satisfactory.

Regarding IR3.4 (Improved government capacity to increase supply, distribution, and retention of skilled workers), the project has developed and distributed clear SOPs for the reporting and registration of in-service trainings using SIFO forms in the respective platform. Overall, this district support has decreased the volume of forms to be recorded at the provincial level. Most of the districts are recording the SIFO forms locally, thereby streamlining the training registration process and ensuring more complete data in SIFO. The use of the SIFO data base to identify the existing gaps and plan accordingly the HPs needs in training is still a challenge; the pro-active on- the-job training needs for managerial position handover is a serious weakness of the MoH health system jeopardizing the HSS wins. Regarding IR3.5 (Improved generation, dissemination, and use of FP data for more effective decision-making), the District Profile tool (DP), composed of 10 selected strategic FP program indicators was designed in FY1, tested and refined in FY2 and progressively introduced in all 36 districts in FY2 and FY3; the level of SDSMAS staff’s ability, to feed the district profile, at end FY3, is variable from one district to another but, overall, all districts have started to interpret the dashboard and use the data to define their next steps and quarterly activities, thus strengthening the SDSMAS to acquire strategic information and use it for evidenced-based decision making to improve FP program performance.

Regarding M&E, IFPP has boosted the number of activities to improve data quality such as RDQAs, Joint SDSMAS – IFPP supervision visits, HP trainings on register logbooks during this FY3 and has increased the number of IFPP M&E officers accordingly to the increase of the number of SDPs benefiting of IFPP support; Some shy progress is showing up as 10% of HFs improve their data quality in Nampula and 5% in Sofala (reducing the data discrepancy); taking in account the

14 training efforts carried out and the involvement of partners staff, the results are still minimal; IFPP in close collaboration with DPS and SDSMAS will continue to highlight the importance of accurate and consistent data and for more political and programmatic commitment from the leadership. The Evidence to Action (E2A) Project as a member of the Implant Removal Task Force conducted a study in close collaboration with IFPP to test the feasibility of including a set of six removal indicators for long-acting reversible contraceptives (LARCs) in Mozambique’s national family planning register. The first draft of the report is still being reviewed internally and by USAID and MISAU partners and will be disseminated after completion.

Major Implementation Issues Some implementation issues were faced by IFPP during FY3, there are as follow:

In Q1FY3 a regressive recommendation from MISAU, endorsed by MINEDH, with regards to school-based contraception activities carried out by HPs, emphasizing delivery of information and provision of condoms and oral contraceptives only, and limiting the previous provision of injectables, implants and IUD’s where possible, requiring an additional effort by IFPP to conduct MB to school surrounding areas.

In Q2FY3 Sofala faced a bigger issue, one that severely impacted Beira City, Dondo, Búzi, and Nhamatanda: the hit of Cyclone Idai in mid-March (March 14th and 15th), which impacted IFPP’s planned activities in multiple ways such on: Infrastructure: Over 40 HFs were damaged across the province of Sofala, with higher destruction levels affecting the roofs, reducing access to regular service provision; access: Roads and bridges were destroyed, cutting contact from Beira and Dondo to the rest of the province. Buzi was completely flooded and isolated, and Nhamatanda was surrounded by water without access to other districts; Service Delivery: Delivery of services was reduced, and activities were re-focused on emergency response only. Most of the surgical theaters were non-functional in Beira, Dondo, and Nhamatanda, as were FP rooms. Other MCH services, such as antenatal care (ANC), most at-risk child consultations, and immunizations, among others, were paused. Additionally, pharmacies and HF depots were flooded, causing damage to most of the commodities and supplies, as well as extensive damage to register logbooks of all other services, which had a huge implication in reporting; disease outbreak: The above-mentioned situations led to the creation of accommodation centers (ACs), with 26 established in Sofala for over 46,000 displaced people. Malaria cases peaked to over 14,800, and the cholerae outbreak reached over 6,000 cases.

Also during Q3FY3,Sofala continued to have most of the resources and attention on the Cyclone, draining the overall support and attention from DPS and partners heavily on this districts;The poor engagement and/or follow-up of implementation of SIGLUS by health providers and health authorities in the province (DPS Nampula and SDSMAS) in the districts implementing SIGLUS; therefore, Q2FY3 stockouts reflect only the months of January and February 2019 and the delays in contraceptive shipment arrival at all levels results in higher stockouts reported in Q3FY3.

During Q4FY3, electoral campaign started leading to poor availability of district managers for MSC assessment calendars, postponing most of the planed assessments and the use of the district profile strategic information, influencing as well availability of some of the HP to conduct MB within the catchment areas of the communities served by rural HF’s.

Goal: Increase use of modern contraceptive methods

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

Table 1. Project supported trainings at end of September 2019 FY1 FY2 FY3 Provinces TOTAL TOTAL To date Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

# of Facility based trainings per quarter and province Nampula 27 27 17 20 91 11 5 12 4 32 6 7 4 9 149 Sofala 0 30 24 8 62 6 12 8 4 30 3 2 1 2 100 TOTAL 27 57 41 28 153 17 17 20 8 62 9 9 5 11 249

# of unique Health Providers reached thru FP training per quarter and province 565 414 205 240 1424 132 72 183 121 508 132 115 55 169 2403 Nampula 26 * 0 463 347 81 891 107 213 139 65 524 57 34 16 26 1548 Sofala 64* 3 * 26 * TOTAL 565 877 552 321 2315 239 285 322 186 1032 189 149 71 195 3951

# of unique Health facilities reached thru FP training along quarters by province

Nampula 147/226 204/228 232/237 43 36 34 34 23 4 16 14 12 9 1 6 (cumulative %) (65%) (89%) (98%)

Sofala 112/157 150/157 157/162 55 43 14 24 13 1 0 0 3 4 0 (cumulative %) (71%) (95%) (97%)

TOTAL 43 134 211 259 68% 47 64 81 95 92% 12 24 29 34 98% (cumulative)

Cascade in-service training

During Q4FY3, a total of 11 eight-day FP facility-based trainings were carried out (nine in Nampula and two in Sofala), totaling 34 for the FY3 against 62 in FY2 and 153 in FY1. The trainings, in FY3, reached a total of 604 public health providers (471 in Nampula and 133 in Sofala). As summarized in Table 1, since the launch of the project, a total of 3,951 HPs has been trained (2,403 in Nampula and 1,548 in Sofala).

Prior to the training of HPs, HF needs assessments were conducted: in FY3, 51 HFs (3 in Sofala and 48 in Nampula) completed their need assessment totaling 149 on 162 HF (92%) in Sofala and 189 on 237 (80%) in Nampula. These baseline HF assessments focused on commodity management, infection prevention, client flow, adolescent and youth friendliness, and FP data collection and aggregation, with the objective of Table 2: Number of project-supported Health Facilities enrolled in FP trainings, by district to date identifying weaknesses to # of HF be addressed during the % of HF with # of HF % of HF with at # of HF per at least 1 HP with all HP with all HP eight-day facility-based DISTRICT least 1 HP district trained in FP trained in trained in trained in trainings. Based on these per district FP to date FP to date FP to date assessments, the project Beira 17 17 100% 1 6% mitigated the lack of Dondo 15 15 100% 12 80% supplies and equipment Nhamatand 18 17 94% 15 83% Buzi 15 15 100% 6 40% needed to improve work Chibabava 16 15 94% 6 38% conditions and apply the Machanga 11 10 91% 7 64% Caia 12 12 100% 11 92% skills acquired during Marromeu 10 9 90% 5 50% training for improving Chemba 9 9 100% 6 67% Gorongosa 14 14 100% 10 71% competency and sustaining Cheringoma 7 7 100% 4 57% behavior change. Maringue 10 9 90% 5 50% Muanza 8 8 100% 2 25% SOFALA Table 2 summarizes the 162 157 97% 90 56% PROVINCE number of project- Angoche 20 20 100% 13 65% supported HFs enrolled in Mogincual 6 6 100% 2 33% Liupo 4 4 100% 2 50% FP trainings with at least Npla Cid 25 23 92% 3 12% one HP trained by district Erati 11 11 100% 8 73% Memba 14 14 100% 6 43% and province. In Sofala, at Meconta 8 8 100% 5 63% end FY3, 97% (157/162) of Nacaroa 7 7 100% 4 57% Muecate 11 11 100% 4 36% the HFs already have “at Mogovolas 8 8 100% 7 88% least one HP trained in FP” Moma 11 11 100% 0 0% Lardes 7 7 100% 3 43% and 98% (232/237) in Monapo 17 17 100% 7 41% Nampula province. In Mossuril 10 10 100% 4 40% Ilha Moç. 5 5 100% 3 60% Sofala, one of the last N.Porto 14 12 86% 5 36% remaining facilities with no N.Velha 6 6 100% 5 83% Murrupula 6 6 100% 1 17% provider trained in FP, Rapale 7 7 100% 2 29% Chitengo located in the Mecuburi 13 13 100% 3 23% Ribaue 10 9 90% 1 10% National Park of Malema 10 10 100% 3 30% Gorongosa (NPG), finally Lalaua 7 7 100% 3 43% NAMPULA has one HP trained in FP 237 232 98% 94 40% PROVINCE during Q4FY3. The five remaining HFs with no HP yet trained in FP are related with the HFs opened this Q4FY3: Tucuta in Maringue district, Ngaze

18 in Marromeu district, Zimuala in Machanga district, Hamanba in Chibabava district and Ndeja in Nhamatanda district. In Nampula, IFPP still has five remaining HFs without a HP trained in FP, two of them are located in Nampula city -“the male penitentiary HP” for which the pertinency of having HP trained will rely mainly on male sensitization and the Mental HF, which refers the WRA to the CS anexo psiquiatrico located at 30 meters through accompanied referrals-, a recently opened HF (Lupi HC) in Ribaue district and two in Nacala Porto (CAMINA and Cimento health post). Note that Mental HC is led by Catholic Church and had several times declined the opportunity to integrate FP services within their HF and, CAMINA HC, a private Catholic HF focusing on preventative and curative care for children under five and attending to 800 children per month - refuses to promote FP services per religious conviction. In next FY, an activist will be mobilizing the mothers, at the exit door of the CAMINA HC to counsel and establish a one stop referral pathway for the women with FP unmet needs to FP services of the neighboring Akumi HC separated by a road and located 300 meters away. Comparatively, Table 2 illustrates the number of HFs with all HPs trained in FP. At end FY2, 170 HFs (79 HFs in Nampula and 91 in Sofala) reported having all their eligible HP trained on FP; at end FY3, this number increased to 184 HFs (94 in Nampula and 90 in Sofala), representing 46% of the 399 existing HFs. When compared to FY2 achievement (44% of the 385 existing HFs), it doesn’t seem very consistent but, it’s representing an increase of 15 HFs in Nampula province despite the weight of the HP recently-posted in Q2 and Q3 mainly in remote and small HFs; furthermore, Sofala succeed to maintain 90 HF with all HP trained, only losing one, despite the tremendous upset caused by cyclone IDAI in March 2019. The total number of eligible HP trained through IFPP, at end FY3 (3,951) is already surpassing IFPP LOP target (3,749), therefore for FY4, IFPP has reduced the range of eligible HP strictly to the HP pertaining to the areas of MCH, EPI and healthy child consultation, at risk child consultation, HIV integrated consultation and, adult and child curative consultations. In order to increase the technical sustainability of the MoH FP program and FP integration in other services, IFPP has trained in Q3&Q4FY3, 50 FP district trainers in Nampula province; one of the purposes of these district trainers is to scale up the eight-days-facility-based IFPP in-service FP training for the not-yet-trained or recently-posted eligible health providers and to address specifically the gaps identified through mentorship through two to three days advanced FP training modules. Note that, additionally, 25 district trainers will be trained in October 2019 in Sofala province to implement the same strategy. In FY4, with a strong involvement of these MoH district trainers, IFPP planned to carry out 23 HF-based trainings of 15 eligible HP each to narrow down the gap towards the project target (100% of HF with all eligible HP trained in FP).

Experience has shown that limiting the training to 15 trainees and multiplying the number of different HFs to hosting the training sessions, strengthen the overall institutional buy-in. Since the beginning of the intervention, 80 HFs in Nampula and 28 HFs in Sofala served as training centers, totaling to 108 out of 399 HFs (27%).

During FY3, the percentage of HPs in both provinces who completed the training on modern methods of contraception with passing scores on the written post-test was 90%.

Other FP related trainings In FY3, a total of 485 HPs and health managers had the opportunity to participate to additional technical trainings, an increase of 50% in comparison with FY2 (306). Even if FP compliance topic is integrated in IFPP initial 8-days FP training, still IFPP is carrying out one-day-facility-based compliance trainings directed to the HFs who are Table 3: Number of other trainings, by topic to not hosting the 8-days-HF-based trainings and, date therefore, has trained 127 additional HPs on FP # of unique Health Providers reached thru other compliance, in Y3. Also, in order to address trainings FY2 FY3 specific gaps, 112 additional HPs participated to Additional Nampula Sofala Nampula Sofala a shorter complementary training curriculum of Trainings three days focusing on the most common Implanon 58 143 28 weaknesses observed through the mentoring BTL 22 0 visits, and including: improving counselling skills, ISL 83 0 36 conducting values clarification exercises in FP relation to adolescents and LARCs, correct 86 41 Compliance management of side effects, proper steps to fill 3 days out the registration logbooks, proper advanced FP 112 updates management of contraceptive commodities CECAP 83 49 stocks at outpatient consultation rooms, practicums for IUD and implant insertion and FP TOT 50 163 143 367 118 removal (including Implanon) and, FP TOTAL 306 485 compliance. This activity was started in Q2FY3 involving 54 HPs from Monapo, Mossuril, and Ilha de Moçambique districts and continued this Q4FY3 involving 58 HPs from Nampula City and Mecuburi district.

To strengthen the technical sustainability of IFPP, the project has carried out a FP TOT involving 50 HPs who will support the eight-day-FP-facility-based trainings – one of the recommendations of the March 2019 IFPP midterm review – as well as HP’s mentoring. The trainees were selected based on their location, commitment to offer more qualitative FP services, skills for counselling and LARC insertion and removal. Through these trainings, 23 districts are now equipped with FP trainers. The average of the post-test was of 17.7/20 against 14/20 for the pre-test. Their newly acquired abilities as trainers will be used during the next FY as facilitators to train the HP recently posted.

Finally, 83 (Nampula province) and 49 HPs (Sofala province) coming from the different districts were trained for CECAP to reboot CECAP services, and in Sofala, 28 HPs were trained specifically for Implanon-NXT insertion and removal.

Implementation Science and Learning (ISL) During Q3FY3, an ISL workshop was carried out involving 36 participants among clinical responsible, gynecologist- obstetricians’ specialists and OBGYN Residents, Bachelor MCH nurses from the Central Hospital of Nampula (HCN), the Marrere General Hospital (GH) and the Nacala Porto District Hospital (DH). The aim was to provide participants with the latest FP technical updates on one side, to discuss – based on the opportunities, skills and motivations tool - how to Photo 1. ISL training in Nampula involving HCN, improve the quality and regularity of postpartum FP (PPFP) NPDH and Marrere GH gynecologist-obstetricians services in the gynecology and obstetrics department and and licensed MCH nurses draft action plans. The main points of the agenda included:

• Reflect on the causes of maternal death at HCN and how the offer of FP can influence their reduction (Dr. François Biombe and Dores Zaina); • Reflect on missed opportunities in providing PPFP methods and data analysis from January 2018 to January 2019 and part of healthcare providers in improving the delivery of FP methods in HCN maternity – Dr. Matos Chamussue; • Share experiences about PPFP offering at Nacala Porto DH (Dr. Emília Matola Selemane); • Presentation of the latest studies on PPFP provision (Dr. Momade Ustá – Head of OBGYN Association); • Share experiences about postpartum mini- laparotomy tubal bilateral ligation’s offer at the maternity ward of José Macamo General Hospital (Dr. Luis Walle – Maputo City); • Create strategies for improving the supply of long-term and permanent methods at HC Nampula, and how providers can influence offering improvement (workgroups).

Bilateral Tubal Ligation (Mini-Laparotomy) Trainings in Nampula province Since Q2FY2, the project has supported the Figure 1. Number of mini-laparotomy carried introduction of mini-laparotomy bilateral over, by FY in Nampula province - IFPP tubal ligation (BTL) with local anesthesia as a permanent method (PM) with the intent 800 to expand the method mix within the range 700 668 of available contraceptive methods in 600 country, responding to the increasing 500 demand for limiting births. In FY3, 668 mini- laparotomy BTL were carried out in 19 400 300 different HFs against 225 in FY2 in 6 225 different sites, making the mini-laparotomy 200 procedure more available as an option for 100 contraception; indeed, specific weeks for 0 FY2 FY3 referred clients who have chosen to receive

21 mini-laparotomy BTL were carried out, specifically at Malema and Murrupula HC ( Q2FY3), with involvement of the MCH bachelor nurses of Ribaue and Moma; at five additional peripheral HCs (Chalaua, Rapale, Namina, Mecua, Nacaroa) in Q3FY3; at four additional peripheral HFs (Marrere, Nihessiue, Namitatar, Nametil) in Q4FY3; note that the Central Hosp. of Nampula, Rural hospitals of Angoche and Ribaue, District hospitals of Moma and Monapo are offering the service on a regular basis. As there is a high demand for this method, clients were referred through the community dialogue sessions and by the peripheral HF nurses who provided comprehensive counseling.

One of the chief clinicians of the Sofala province – Dr Pita Tomás, gynecologist-obstetrician of the Central Hospital of Beira and Almija Pulseira, focal point for FP and CECAP at Sofala PHD - participated in the two-day BTL session at the Netia HC during which 30 BTLs were carried out. Dr. Tomás also later visited the Nampula Central Hospital where there was an opportunity to see FP integration in the pediatric and obstetric wards Table 4: # of joint MISAU-IFPP supervision at district level by as well as how methods are province - Q1FY3 offered in the maternity and District Health Facility HF receiving integrated supervision operating room. At the end of the FY3, the DPS of Sofala Existing Trained Q1 Q2 Q3 Q4 Angoche 20 20 5 7 5 5 didn’t agree to roll-out the Mogincual 6 6 6 4 3 4 Liupo 4 4 0 2 2 2 mini-laparotomy BTL Npla Cid 25 23 8 23 14 3 procedures being reluctant Erati 11 11 10 0 0 6 Memba 14 14 0 0 0 10 towards the possible Meconta 8 8 0 0 5 0 Nacaroa 7 7 7 0 7 0 complication (particularly Muecate 11 11 11 11 1 0 related to women with a Mogovolas 8 8 1 2 2 3 Moma 11 11 0 3 4 3 history of previous Lardes 7 7 0 3 4 7 Monapo 17 17 4 7 6 8 abdominal surgery) although Mossuril 10 10 7 2 1 0 in Nampula province, a strict Ilha Moç. 5 5 1 4 0 2 N.Porto 14 12 2 1 4 3 checklist focusing on the N.Velha 6 6 4 1 2 2 Murrupula 6 6 4 2 1 4 existing abdominal previous Rapale 7 7 0 6 1 3 invasive procedures in the Mecuburi 13 13 0 7 2 0 Ribaue 10 9 8 2 9 24 history of the clients is Malema 10 10 4 2 10 7 Lalaua 7 7 4 1 6 6 applied and these clients are Nampula 237 232 86 90 89 102 referred to the neighbor Beira 17 17 6 6 6 6 Dondo 15 15 0 3 7 7 referral hospital. Nhamatanda 18 17 3 5 8 8 Buzi 15 15 0 4 5 5 Chibabava 16 15 7 6 9 9 Joint MISAU-IFPP Machanga 11 10 7 5 8 8 supervision Caia 12 13 3 6 4 4 Marromeu 10 9 4 6 7 7 Chemba 9 9 2 3 7 7 Gorongosa 14 13 0 2 4 4 The IFPP technical team and Cheringoma 7 7 2 6 0 0 Maringue 10 9 0 3 8 8 SDSMAS/DPS staff carried Muanza 8 8 0 5 7 8 out technical support visits SOFALA 162 157 34 60 80 81

22 providing supervision to HFs as described in Table 4. This quarter, 183 joint supervisions were carried out (81 in Sofala and 102 in Nampula) in comparison with the 169 carried out in Q3FY3, with the 150 carried out in Q2FY3 and 110 in Q1FY3. This joint supervision serves to strengthen understanding and coordination, to boost the quality of the sexual and reproductive health (SRH) services, as well as to lay foundations for self-reliance and sustainability of quality improvement initiatives. The supervision includes the FP integration data aggregation tool, assessment of the quality of counseling, techniques for method Table 5: Mentoring visits received by HFs during at end FY3 insertion, cleanliness and HFs categorized according to the # of mentoring visits received at end FY3 organization of HF services, % HF with at least 1 HP trained which received a mentorship visit Health Facility FP commodities and at end FY3 # % of HF equipment management. District # HF # HF Mentorship % of HF mentored at Existing Trained mentored mentored visits mentored least once Integrated supervision visits along FY3 in FY3Q4 carried out in FY3Q4 along FY3 in FY3Q4 are important, as they boost Beira 17 17 17 17 73 100% 100% adoption of new Dondo 15 15 15 7 13 47% 100% Nhamatanda 18 17 17 17 55 100% 100% components and increase Buzi 15 15 15 14 36 93% 100% ownership of the MISAU’s FP Chibabava 16 15 14 11 22 73% 93% Machanga 11 10 10 10 17 100% 100% strategy and consequently Caia 12 12 9 9 19 75% 75% the sustainability of the FP Marromeu 10 9 9 8 33 89% 100% Chemba 9 9 9 9 11 100% 100% program. Gorongosa 14 14 11 3 6 21% 79% Cheringoma 7 7 7 6 11 86% 100% Maringue 10 9 9 8 28 89% 100% Quality Improvement and Muanza 8 8 6 6 10 75% 75% Total Sofala 162 157 148 125 334 80% 94% Mentoring Angoche 20 20 12 12 25 60% 60% Mogincual 6 6 6 6 12 100% 100% Liupo 4 4 3 3 7 75% 75% Quality improvement (QI) is Npla Cid 25 23 21 21 80 91% 91% key to project success in Erati 11 11 10 5 6 45% 91% Memba 14 14 12 8 8 57% 86% terms of achieving and Meconta 8 8 8 7 57 88% 100% maintaining a high quality of Nacaroa 7 7 7 6 23 86% 100% Muecate 11 11 11 9 47 82% 100% service provision, garnering Mogovolas 8 8 6 2 8 25% 75% institutional support and Moma 11 11 10 2 5 18% 91% Lardes 7 7 5 3 8 43% 71% buy-in to address systemic Monapo 17 17 14 7 27 41% 82% challenges and to support Mossuril 10 10 9 4 15 40% 90% Ilha Moç. 5 5 5 3 4 60% 100% the sustainability of FP N.Porto 14 12 11 9 19 75% 92% N.Velha 6 6 6 5 20 83% 100% integration efforts. Murrupula 6 6 6 4 15 67% 100% Rapale 7 7 7 5 0 71% 100% Mentorship drives the QI Mecuburi 13 13 13 11 18 85% 100% Ribaue 10 9 9 9 40 100% 100% cycle through regular visits Malema 10 10 10 10 43 100% 100% by project MCH nurses and Lalaua 7 7 6 6 24 86% 86% Total Nampula 237 232 207 157 511 68% 89% district coordinators. The Total Both 399 389 355 282 845 72% 91% objective of mentoring is provinces primarily to guarantee that

HPs trained by the project are engaged on a regular basis and supported to achieve and maintain clinical proficiency and Figure 2 and 3: # of unique Health Providers trained, registered in service quality. Mentoring the App, who received mentoring visit(s) per topic and by province includes direct observation at end FY3 of service quality provision, coupled with supplementary

2000 on-the-job training. A 1823 1800 secondary objective of the 1600 375 1444 1400 mentoring visits is to 1200 437 1167 566 1023 106 999 1000 cultivate institutional 217 200 767 800 437 471 106 600 356 361 engagement and ownership 323 400 882 624 536 450 among HF management and mentored HP additionalunique # of 200 438 338 0 staff to remove barriers to FP Counselling Implants Depo FP Counselling Implants Depo successful integration and NAMPULA SOFALA FY1 FY2 FY3 greater uptake of FP services. The first mentoring visit is scheduled 450 approximately 10 days after 406 390 400 330 the end of the initial training. 350 169 300 180 103 Subsequent mentoring visits 250 203 are scheduled depending on 200 147 124 150 136 90 the findings of the first visit, 100 43

# of additional unique HP mentored HP additionalunique # of 50 103 but the goal is to reach each 90 74 70 0 HF with trained HPs, if IUD PPIUD IUD PPIUD possible, once per quarter, NAMPULA SOFALA FY1 FY2 FY3 considering the high number of HFs with one already Figure 4: # of competency standards checklist observed in trained HP. FY1, FY2 and FY3 Table 5 summarizes the 4000 number of mentoring visits Implant Depo IUD PPIUD 3500 3407 received by HFs by province 3000 and district during Q4FY3, and the percent of HFs with 2500 2000 1873 at least one HP trained that 1639 1403 1500 1258 received a mentorship visit. 1145 1000 In Sofala, the number of HFs 654 638 471 471 500 visited for HP mentorship at 171 226 least once per quarter 0 increases from 97 (Q1FY3) to FY1 FY2 FY3 109 (Q2FY3), 117 (Q3FY3)

and 125 (Q4FY3) while the total number of mentorship visits per quarter was respectively 232 (Q1), 235 (Q2), 267 (Q3) and, 334 (Q4); in Nampula, the number of HFs mentored at least once per quarter stabilizes around 160 per quarter (157 in Q1FY3; 161 in Q2FY3; 151 in Q3FY3; 157 in Q4FY3 while the total number of mentorship visits per quarter was respectively 398 (Q1), 530 (Q2), 351 (Q3) and, 511 (Q4). Meanwhile, along the FY3, 94% of the HFs with at least one HP trained were mentored in Sofala and 89% in Nampula.

Mentorship App To ensure the consistency of mentorship and facilitate follow-up on action plans developed during mentoring visits, IFPP uses a mentorship digital app. It provides HP-specific electronic notetaking and follow-up action plans, which are discussed and shared before leaving the HF. The app provides prompts for mentors to guide them through each step of the mentorship process and sends reminders to mentors for the next mentoring visit to ensure providers who require additional support are mentored at appropriate intervals. As seen in Figure 2 and 3, at end of FY3, IFPP staff have mentored 2,990 unique health providers (1,823 in Nampula and 1,167 in Sofala) against 2,509 unique health providers (1,448 in Nampula and 1,061 in Sofala) at end FY2 and, against 1,506 (882 in Nampula and 624 in Sofala) at end FY1: all of the 2,990 were mentored on comprehensive FP counselling on existing method-mix; 1,790 (1,023 in Nampula and 767 in Sofala) were mentored for DMPA (against 1,467 at end FY2 and 788 at end FY1); 2,443 (1,444 in Nampula and 999 in Sofala) at end of FY3 against 1,806 at end of FY2 and 974 at end FY1, were mentored for implant insertion. As seen in Figure 4, specific attention was given to increase the number of HP mentored for Figure 5a: Trends per quarter of the rate of failure for the entire cohort of IUD insertion and HP cumulatively enlisted per method for Nampula province PPIUD insertion: 41% comparing FY3 and the number achieved in FY1 and 31% FY2, 272 additional

HP were mentored 23% 22% for IUD (169 in 20% 19% 18% Nampula and 103 in 16% 15% 15% 14% 14% 13% 13% Sofala) and 270 for 12% 12% 11% 10% PPIUD (180 in 9% 7% Nampula and 90 in 6% Sofala). As seen in Figure 4, during FY3, PPIUD IUD Implant Q2 FY2 Q3 FY2 Q4 FY2 Q1 FY3 Q2 FY3 Q3 FY3 Q4FY3 the total number of tasks observed by mentors increased from 1,873 in FY2 to 3,407 in FY3 for implants, from 471 in FY2 to 654 in FY3

25 for IUD and, from 471 in FY2 to 638 in FY3 for PPIUD highlighting the mentoring efforts to increase the quality of the different insertion techniques mainly for implants, IUD and PPIUD.

In total, 81% (3114 out of 3840) of the trained HP, still active and registered HPs were already mentored (85% in Nampula and 75% in Sofala) and 19% still need to be mentored for the first time. This gap is still considerable and will continue to be the focus during the upcoming quarters; the recently and upcoming trained district facilitators will support the intervention to achieve this goal. Of the 19% of providers not yet mentored, most of them fall into the “other provider” cadre. This category consists of health professionals in fields not traditionally associated with MCH or SRH services such as pharmacists, laboratorians, and more specialized health technicians including Figure 5b: Trends per quarter of the rate of failure for the entire cohort of HP cumulatively enlisted per method for Sofala province physiotherapists, ophthalmologists, 13% Q2 FY2 radiologists, and 11% 11% Q3 FY2 11% anesthesiologists. 10% Q4 FY2 These categories Q1 FY3 Q2 FY3 are trained to 8% 7% 7% enable the Q3 FY3 Q4FY3 5% 5% 5% 5% environment and 5% 5% for in-facility 4% 3% referral, therefore 3% 2% 2% 2% the clinical 1% mentorship is being conducted PPIUD IUD Implant to prioritize the ones providing Figure 6: Comparison of unique HP mentored for PPIUD at end FY2 and FY3 methods. Of the 600

MCH nurses 500 71 0 trained, 91% were 400 already mentored 300 593 while only 73% of 44 469 200 1 317 the HPs belonging 210 100 55 to the category 44 0 7 9 Mentored Passed Still need Failed Mentored Passed Still need Failed named “others” # of Unique Health Provider improvement improvement were mentored. 2018 2019

The mentorship Always "passed" Passed but previously "needed improvement" Passed but previously had failed Always "needed improvement" database was "Need improvement" but previously had failed Failed cleaned up by no more in NHS # of unique HP Mentored removing HPs who retired, went on

26 upgrading training from basic to medium, left the province, left the National Health System (NHS), and who passed away.

As seen in Figure 5a and 5b, the Figure 7: Comparison of unique HP mentored for IUD at rate of failure to achieve end FY2 and FY3 competency on various clinical skills for the entire cohort of HPs 800 cumulatively enlisted in the App is 700 gradually diminishing, confirming 600 77 that Nampula HPs are bettering 10 500 their abilities; this is calculated 400 46 736 dividing the total unique number 5 of HP still reported as failed for the 300 569 464 200 method, at the end of each quarter 335

# of Unique Health Providers of # Unique Providers Health 100 by the total number of unique HP 2 1 13 63 15 64 0 who have been mentored at least Mentored Passed Still need Failed Mentored Passed Still need Failed improvement improvement once, for that specific method, at 2018 2019 # of unique HP Mentored Failed the end of the same quarter. Still "need improvement" but previously had failed Always "needed improvement" Results (figure 5a) show us that Passed but previously had failed Passed but previously "needed improvement" Always "passed" Nampula province has decreased its PPIUD failure rate from 41% (46/111) in Q2FY2 (ending March 2018) to 10% (40/390) in Q4FY3 (ending September 2019), remarkable result considering Figure 8: Comparison of unique HP mentored for Implants that the total number of unique at end FY2 and FY3 HP mentored has jumped from 327 2000 111 to 390 over the time period. 24 Sofala province (figure 5b) also 1500 230 has decreased its PPIUD failure 13 rate from 11% (10/88) in Q2FY2 to 2443 1000 2% (4/203) in Q4FY3. Figure 6 1806 1964 illustrates the jump in competent 1381 500 (passed) providers for both

# of Unique # of Unique Health Provider 158 107 28 20 province between FY2 and FY3: 0 Mentored Passed Still need Failed Mentored Passed Still need Failed while the number of unique HP improvement improvement 2018 2019 mentored for PPIUD increases # of unique HP Mentored Failed Still "need improvement" but previously had failed Always "needed improvement" from 317 to 593, the number of Passed but previously had failed Passed but previously "needed improvement" Always "passed" HP who failed diminished from 55 to 44. 259 HP (469 less 210) passed straight away after their eight- days-facility-based FP training and 27 (71 less 44) passed but previously failed, confirming that the mentorship tool is indeed useful to supporting the development of abilities.

For interval IUDs, results (Figure 5a) show us that Nampula province has decreased its IUD failure rate from 19% (24/126) in Q2FY2 to 12% (47/406) in Q4FY3, while the total number of unique HP mentored has jumped from 126 to 406. Sofala province (Figure 5b) also has decreased its IUD failure rate from 13% (20/160) in Q2FY2 to 5% (17/330) in Q4FY3. Figure 7 illustrates the jump for both province between FY2 and FY3: while the number of unique HP mentored for IUD increases from 464 to 736, the number of HP who failed stabilized around 63-64, 234 HP (569 less 335) passed straight away after their 8-days-facility-based FP training and 31 (77 less 46) passed but previously had failed.

For implants, in comparison with IUD and PPIUD, IFPP target group expanded from MCH nurses to curative and preventative officers, therefore the number of mentored HP increases consequently; results show us that Nampula province (Figure 5a) has decreased its IUD failure rate from 14% (100/707) in Q2FY2 to 6% (80/1444) in Q4FY3, while the total number of unique HP mentored has jumped from 707 to 1444. Sofala province (Figure 5b) also has decreased its implant failure rate from 5% (32/598) in Q2FY2 to 3% (27/999) in Q4FY3. Figure 8 illustrates the jump for both province between FY2 and FY3: while the number of unique HP mentored for implant increases from 1,806 to 2,443 , the number of HP who failed diminished from 158 to 107, 583 HP (1,964 less 1,381) passed straight away after their 8-days-facility-based FP training and 97 (327 less 230) passed but previously had failed.

Nampula HPs have faced more technical challenges (such as confidence and skills in insertion techniques), particularly for PPIUDs and interval IUDs, than those in Sofala province. Therefore, IFPP had provided additional support to the mentors to increase their abilities to mentor high- need mentees during this FY3. The decreasing failure rates are encouraging, and further attention will be given during the next quarters to support providers who continue to struggle and ensure sustained competency. Consequent efforts will continue to be carried out in the next quarters for more frequent mentoring on Implant, IUD, and PPIUD techniques. The project will continue to increase mentorship visits during the shift changeover meeting that takes place between maternity ward nurses to maximize. The maternity daily meeting offers an important glimpse into the HFs’ client load and service flow. It also provides an opportunity to give parturient women counselling and immediate PPFP, including PPIUD insertions, and IFPP can catch night-shift workers who are otherwise missed for mentorship. This effort will be coupled with Government Trainers based at HF level. Finally, during this FY3, the MISAU SRH quality standard tool was applied as illustrated in figures 9a and 9b in 29 HFs in Nampula province and 26 in Sofala:

Figure 9 a and b: Results of the quality standard tool application by HFs in Nampula and Sofala provinces

Summary of the main observations and recommendations of the mentoring and supervision visits: • Technical skills: Difficulties persist in immediate postpartum counseling skills, especially for LARCs. The PPIUD insertion technique is the most difficult for HPs and they need more mentorship to improve their self-confidence. For low-volume HF providers, an internship approach will be implemented so that they have practicum opportunities at the main district- level HF.

• Offering of FP methods at maternity level: The PPFP counselling at antenatal care (ANC) still needs to be more consistent so that missed opportunities are diminished, specifically during ANC visits attended by the couple for HIV screening. • FP integration: In most of the trained HFs, FP methods are offered, but non-maternal and child health (non-MCH) providers need more follow-up with respect to FP method provision in order to decrease the missed opportunities and increase access to FP methods at HF’s level; When providers are transferred or on annual leave, the substitute tends to not follow up on the activity even though they were informed. It was recommended through integrated supervision and mentorship visits that FP focal points and HF directors increase their follow-up and support. The daily and weekly monitoring role of the HF’s director is particularly important and should be reinforced; in order to do that, IFPP planned to implement a management training in FY4 (please see section IR3). • M&E logbooks: More SRH/FP logbook daily summaries are correctly filled out when compared with previous quarters, even if challenges remain. Problems arise when the regular MCH nurse in charge of the FP/SRH consultation is absent and there is a substitute nurse or student who is not familiar with the process. Data follow-up on a weekly basis during the HF clinical review meetings was recommended. FP data will be reported by each HF responsible and discussed during the quarterly review data meeting at SDSMAS level. The 50 HPs, in Nampula, trained as district trainers for FP during this Q3&4FY3 were trained in the correct registration and aggregation of data in the different logbooks for use at national level. It’s expected that they will be able to strengthen the MISAU recommendations of using the daily summary. Additionally, a FP TOT is planned for the next quarter for Sofala.

Experience exchange visits between MCH nurses with low LARC volume and those with high volume In Beira city, Dondo, Caia, Marromeu and Chibabava district, one week of experience exchange visits (learning visits) between 28 HFs were carried out in Q3FY3 involving 67 HPs and resulting in insertion of 140 IUDs (interval and post-partum), 778 implants, offering of 482 injectables and 837 pills. In Q4FY3, the exchange visits were carried out in four districts (Dondo, Beira, Nhamatanda and Buzi), involved 16 different HFs and 54 HPs and, result in insertion of 277 IUDs, 647 Implants, offering of 411 injectables and 384 pills.

Strategies established for FY4 to continuously increase the uptake of FP services at HF level include: • Continue the innovative facility peer twinning strategy in Y4, enabling peer-to-peer learning and development as part of the quality improvement process • Increased night-shift mentoring activities involving the recently-trained district trainers • For low-volume HF providers, an internship approach will be implemented so that they have practicum opportunities at the main district-level HF mainly for implant, IUD and PPIUD • Implement a management training for HF’s responsible, led by the SDSMAS directors and district chief doctors (see IR3)

• Continue ISL optimization workshops with maternities that have low outcomes with the involvement of the DPS. • Organize additional specific in-service training for the providers, including addressing adolescent and youth issues, who have already been trained through IFPP but identified as poorly performing in post-training period through mentorship (3-days advanced FP updates). • Train the recently posted eligible HP as they are recruited by the DPS • Conduct an additional five-day TOT for the MCH district responsible and district FP focal points, in Sofala province, to increase their skills in PPFP in-service training and mentoring, including FP antenatal counseling, and on how to create demand among couples during immediate postpartum; improvement of their own PPIUD insertion technique; correct registration and aggregation of data in the different SRH/FP and maternity logbooks.

Strengthening Cervical Cancer Prevention (CECAP) through Integrated Prevention, Testing, and Treatment Leveraging the opportunity presented by IFPP, Pathfinder supported the CECAP activities in country during the FY3. The core of this intervention is built on providing technical assistance (TA) across Mozambique at the central, provincial and district level, as well as providing direct support to HFs and district authorities through high-volume, PEPFAR-supported antiretroviral therapy clinics at district and higher-level hospitals in coordination and complementarity with PEPFAR partners. This intervention has two main objectives: 1) support to update and strengthen the national CECAP training materials, clinical guidelines, and service demand generation tools and 2) strengthened referral network, service uptake, and treatment hubs in Nampula and Sofala provinces.

While the northern region technical assistant, based in Nampula, started her duties in March (Q2FY3), the two CECAP technical assistants recruited for the national level and central regions started their activities in April (Q3FY3). So, during the two last quarters of FY3, the following activities were carried out:

• At central level:

o In relation to the first objective, a hand-over meeting was carried out in May 2019 with Mother and Child Survival Program (MCSP) under USAID leadership.

o Regular coordination meetings with USAID and MISAU’s cancer technical working group focusing on clinical norms and M&E were carried out: the review of the training material including the manuals was updated to integrate new practices and clinical protocols; the following instruments were analyzed and revised: CACUM's individual registration form, provincial hospital logbook; review and updating of the referral and counter-referral form (ARV consultation to SRH/CECAP consultation).

o Participation in the February 2019 PEPFAR Cervical Cancer M&E and Reference meeting and the September 2019 CECAP Partner Meeting

o Participation in the CECAP national TOT organized led by MoH and, in the annual MISAU CECAP coordination meeting with provincial focal points and HIV program managers

o Technical support visits, jointly with the MoH central level, in Gaza and Maputo provinces in Q3FY3 and, in Manica and Inhambane, in Q4FY3; during these visits, the following main activities were, whenever possible, carried out: (i) meeting with DPS and PEPFAR clinical partner to discuss and strengthen the current CECAP provincial need assessment and plan; (ii) meeting with the provincial CECAP TWG focusing on better inclusion of the CECAP data analysis in the HIV/ART treatment regular follow-up meetings; (iii) Joint DPS- Clinical partner- Pathfinder HF’s supervision visits involving the respective SDSMAS and focusing on, among others aspects, the flowchart of HIV-positive women to routinely include CECAP screening services and standardize this activity across HFs, Technical support in performing VIA and its interpretation, in performing cryotherapy, in managing cryotherapy equipment, in correctly filling logbooks; (iv) support the review and update of the provincial training plan. During these four technical support visits in these four different provinces, 14 HFs were supervised.

o Two HP’s trainings were supported involving 25 HPs from 12 HFs of Matola city and 2 DPS officers of Maputo province in August 2019.

o Different orders for medical and non-medical equipment - mainly speculums, clocks, plastic bags and IEC materials were ordered to improve the quality of the CECAP activities at national level (350 logbooks, 2000 posters to support HPs in recognizing the different stages of the cervix lesions, 2000 posters related to the CECAP integrated SRH consultation)

• As IFPP areas of intervention a special attention was given to Nampula and Sofala provinces; outside the usual activities of coordination with the DPS, the clinical partner and the provincial TWG, the following activities were carried out:

• In Nampula province, it was urgent to train additional HPs as innumerous HFs foreseen to offer the CECAP services had no trained MCH nurses, as the province was

confronted to a high Photo 2: CECAP Training sessions in Nampula province level of turn-over during Q1 and Q2FY3, mainly due to the promotion courses required by MISAU for basic MCH level in order to upgrade to the medium MCH level; so IFPP, together with the clinical partner and the DPS, trained during FY3, carried out five trainings involving 183 HPs; In Sofala province, two trainings involving 49 HPs from all 13 districts were carried out. The last training has started on 30 of September and reached an additional 26 HPs which will be accounted in FY4. • Following the trainings, it’s crucial to carry out technical support to the recently trained nurses, so during Q3&4FY3, 60 prioritized HFs (33 in Nampula and 27 in Sofala), received either a joint supervision visit with SDSMAS and DPS, or a technical support visit. The project has supported the posting of recently trained MCH nurses to ensure the CECAP consultations and the existence of the CECAP logbook in the SRH/PF consultation rooms. During these visits, the following topics were strongly highlighted and discussed with the HFs’ HP and responsible: (i) the need to strengthen the correct registration of the logbooks as the number of Visual Inspection with Acetic Acid (VIA) reported (that’s our denominator) are over-registered as more daily VIA are reported than daily speculum available; (ii) the need to monitor on a daily basis and improve the efficiency of the reference and counter-referral operationality between the ART and CECAP services; (iii) the main recommendations are to promote CECAP services during ART and with HIV+ mothers during at-risk children consultations, regular outpatient consultations and SRH/FP consultations with referrals to the CECAP room; (iv) promote CECAP services through clinical update for all HF providers; (v) correctly registering the columns related to CECAP of the SRH/FP logbook; (vi) not over-reporting; and (vii) maintain the trained nurses in their CECAP post.

• Furthermore, during the FY3, the quality standard tool was applied in 19 HFs in Nampula province and in 17 in Sofala province which included specific standards for CECAP services, results of which are illustrated in figure 10a and 10b, highlighting the CECAP program’s needs for more intensive follow up and support from DPS and clinical partners next fiscal year. Figure 10a: % of CECAP standards achieved by HF assessed in Nampula province – Q3&Q4FY3

100% 100% 93% 93% 86% 73% 90% 85% 77% 80% 73% 73% 71% 75% 70% 60% 60% 60% 57% 57% 60% 56% 50% 47% 50% 45% 45% 40% 33% 30% 20% 10% 0%

1st Assessment 2nd Assessment

Figure 10b: % of CECAP standards achieved by HF assessed in Sofala province – Q3&Q4FY3

100% 93% 93% 93% 88% 90% 80% 80% 71% 74% 73% 71% 71% 70% 70% 70% 69% 67% 70% 60% 55% 60% 50% 50%50% 50% 43% 40% 30% 25% 20% 10% 10% 0%

1st Assessment 2nd Assessment

• Outcomes are illustrated in figures 11a and 11b for each province and highlight an increased CECAP program’s efficiency during the FY3 IFPP intervention, in Nampula, as the number of WRA identified as VIA + increased and, the % of VIA+ taken in charge – meaning receiving Figure 11a and 11b: trends of WRA number identified as cryotherapy and/or being VIA +, distributed by sub-categories and, # of WRA referred for extensive diagnosed and referred for cervical cancer suspicion in cervical lesion (>75%) - Nampula and Sofala increased also from 45% (Q1) to 53% (Q3) to 73% (Q4), showing once more that the CECAP program need more operational and consistent attention to increase its efficiency; In Sofala province the reduction in Q2 and Q3 is related to the promotion courses required by MISAU for basic MCH level nurse

in order to upgrade to the medium MCH level, resulting in an high turn-over of HP already trained. • During next FY, PEPFAR clinical partners should invest strongly in training, supervision and mentorship, as on one side, MoH purchased one thousand additional cryotherapy machines (with GFF funds) to expand accessibility of CECAP services and, on the other side, the CECAP program is a

public health emergency in Mozambique indeed, whereas, in average, only 12% of the SRH consultations (in Nampula) and 19% (in Sofala) are coupled with Visual Inspection with Acetic Acid (VIA), 4% in Nampula and 5% in Sofala are identified as VIA+ and, out of these VIA+ on average, 19% are diagnosed with cervical lesion >75% in Nampula and

32% in Sofala, highlighting that far too many WRA already have extended cervical lesions at time of screening; and even more, in FY3, 357 WRA in Nampula and 527 in Sofala with advanced lesions were referred directly to the provincial level for suspected cervical cancer.

Sub-IR 1.2: Increased access to modern contraceptive methods and quality, community-based FP/RH services Agente Polivalente Elementar trainings (APEs) IFPP support to APEs is a key activity that will increase FP access for the hard to reach, rural populations. During their initial training, APEs were trained on FP since 2016 before IFPP started. However, the MISAU perceived that APEs were not providing significant FP services by the end of 2016. As such, the MISAU requested that IFPP strengthen APEs skills and increase support and supervision to effectively integrate FP into their daily tasks. Therefore, IFPP included APEs working in IFPP HFs in the first two days of HF provider trainings to refresh their knowledge and to boost HF and APE coordination mechanisms, including FP commodities, supplies, referrals, and supportive supervision schedules. During FY3, 164 additional APEs were trained through IFPP (126 in Nampula and 38 in Sofala), in addition to 417 in FY2 and 287 in FY1, totaling 868 APEs trained (316 in Sofala and 552 in Nampula) and specific attention was given to intensively support the APE program. The number of women served through APEs has the potential to increase as APEs are still being trained or in process to be officially enrolled after training completion. Figure 12 illustrates the trends in the number of APEs reporting data, reporting FP data and the percent of APEs reporting FP data, per month, in Nampula province: the number of APEs reporting FP data is steadily increasing from 284 out of 366 reporting data (78%) in April 2018 to 452 out of 551 (82%) in September 2018 to 922 out of 1083 (85%) in September 2019; meanwhile, still, monthly data has the tendency to be incomplete as APEs are community based and represent the most peripheral FP service delivered and, therefore it is directly related to the number of monthly peripheral HF meetings carried out and also the number of APEs traveling from their communities to their catchment HFs every month to attend this meeting. Figure 13 illustrates the number of users served per month and per type of contraceptive method through the group of APE reporting FP data in Nampula. The monthly average number of DMPA- users served per APE is around 13 per month while the average number of oral contraceptive pill users served per APE is around 3 per month, totaling 16 users served per month and per APE, the goal of the MISAU is to reach at least 25; although it’s already an honorable achievement, in FY4, IFPP will strengthen its support through identifying poor performing APEs and working with them to better understand and address barriers such as lack of commodities, persistence of personal prejudices related to youth rights or myths related to FP and the different FP methods, existing weaknesses in their abilities to ensure increased male involvement, and accurate data registration. To accomplish this, IFPP will support provincial and district-level APE supervision— including one-on-one mentorship visits between APEs and MCH nurses from catchment area health facilities and district FP trainers, to address individual performance and challenges, and quarterly district-wide meetings among APEs, district supervisors, and HF focal points to analyze

36 data, improve reporting, share APEs’ experiences, and discuss wider issues impacting community service provision.

Figure 12: Trends of the # of APEs reporting data, reporting FP data, % of APE reporting FP data, per month, in Nampula province

1200 100% 1083 96% 90% 95% 81% 82% 993 1000 90% 931 89% 89% 88% 86% 87%86% 86%85%85% 80% 82% 81% 82% 801 803 78% 773 922 70% 800 742 745 700 703 720 705 844 800 60%

566 551 691 691 600 526 522 653 661 50% 621 627 625 441 603 # # APEs of 578 414 419 420 40% 366 501 400 489 305 452 452 275 274 30% 379 % of APEs reporting FP data 20% 200 284

10%

0 0%

Jul-18 Jul-19

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May-19 May-18 # of APEs reporting data # of APEs reporting FP data % of APE reporting FP data

Figure 13: # of users served per month and per type of contraceptive method for the group of APE reporting FP data in Nampula province

11535 11841 10837 8758 9730 9267 9101 8018 8827 8667 8312 8546 7665 5850 6594 6830 5407 5551 6169 5193 5626 4323 4841 4207 2840 2130 2415 2577 2063 1958 1344 1762 23502498 2103 1531 1548 1892 2031 1498 1937 1904 2208 2059

1274 1321 1270 1369

# of # Users served

Jul-18 Jul-19

Jan-19 Jan-18

Jun-18 Jun-19

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Apr-18 Apr-19

Feb-18 Sep-18 Feb-19 Sep-19

Dec-17 Dec-18

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Mar-18 Mar-19 May-19 # of PillsMay-18 users served # of Depo users served

In Nampula province, out of 1,083 APEs trained and reported as active, through the NHS, 922 have reported FP data, still 163 should be supported to initiate service delivery and report monthly data.

More mobility constraints are existing in Sofala province due to lower population density and huge distance between the communities and HFs. For Sofala province, as illustrated in Table 6, at end September 2019, 316 APEs are reporting data out of 380 reported as active through the NHS as trained and active, against 231 at end September 2018. Figure 14 illustrates the number of users served per month and per type of contraceptive method through the group of APE reporting FP data in Sofala. The monthly average number of DMPA users served per APE is around 12 per month while the average number of pill users served per APE is around 10 per month. The May 2019 peak of reporting is related to the post-IDAI campaign in Sofala province, but these data should be taken in consideration very cautiously as data over-reporting is usual during campaigns and the gain of users was not reflected in the following months.

Gorongosa district: IFPP district coordinator supporting APEs and Community Facilitators during a supervision meeting and participation of APEs in quarterly review meeting

Table 6: # of APEs reporting FP data per month in Sofala province

# of APEs reporting FP data per month # of existing FY2 (Jan 2019 to Sept 2019) FY3 (Oct 2018 to Sept 2019) Sofala APEs at end FY3 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

Beira 5 IDAI 0 0 2 3 19 27 Dondo 30 2 4 29 30 11 15 14 IDAI 7 2 25 16 32 32 Nhamatanda 44 37 37 37 37 37 37 41 41 45 45 45 40 43 15 40 38 39 41 20 20 Buzi 27 13 9 24 19 20 19 24 22 4 7 11 9 8 IDAI 5 7 26 20 12 18 Chibabava 32 22 18 19 17 27 31 32 32 29 30 25 25 26 31 31 25 24 26 30 30 Machanga 24 8 6 7 8 3 2 6 5 1 4 6 6 17 16 12 19 19 20 4 4 Caia 30 19 19 19 19 31 31 30 30 30 24 30 30 18 24 28 17 22 0 Marromeu 34 19 19 20 19 19 18 20 20 20 20 5 5 10 13 25 23 0 58 53 Chemba 20 10 10 9 10 8 5 9 19 17 16 15 15 16 17 13 14 14 10 20 20 Gorongosa 61 36 36 35 29 41 38 46 40 54 52 58 59 59 56 60 50 60 46 9 8 Cheringoma 20 12 14 12 12 17 21 11 16 25 19 19 19 9 35 35 Maringue 22 11 2 5 21 20 40 20 20 10 20 20 22 22 22 29 24 Muanza 31 28 38 13 14 18 22 13 44 45 Total 380 19 196 171 186 170 171 194 200 231 287 274 241 218 266 195 252 263 323 243 334 316

Figure 14: # of users served per month and per type of contraceptive method for the group of APE reporting FP data in Sofala 12,000 10778

10,000

8,000 7666

6,000 # ofusers served 4,000 3555 3507 3196 3229 2918 3000 3067 3001 37592639 2583 2412 2384 2317 2319 2072 2011 1680 1903 2,000 1345 2354 2360 2266 2186 2116 2238 2097 1832 1892 1962 1965 1661 1682 1799 1580 1804 1327 1479

Jul-19 Jul-18

Jan-19

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Oct-18

Apr-18 Apr-19

Feb-18 Sep-18 Feb-19 Sep-19

Dec-18

Aug-18 Aug-19

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Mar-18 Mar-19

May-18 May-19

# of Pills users served # of Depo users served

IFPP, in FY4, will strengthen its efforts to support SDSMAS and the APEs district responsible to carry out the district quarterly review meeting to highlight the relevancy of APEs involvement in FP delivery. Therefore the following activities, including those referred above, will continue to be carried out: 1) increase supervision visits of the IFPP technical team as well as support to APE supervisors at SDSMAS and DPS level for integrated supervision, focusing on counselling and the delivery of short term FP methods, FP registration in the APE logbook, referrals to HFs for long acting FP methods and management of traditional birth attendants (TBAs) FP referrals that are directed to APEs; 2) improve the supply of SAMs available to APEs in both provinces supporting the dissemination of MISAU’s recommendations for the distribution of MCH commodities for APEs, as well as the one clarifying that DMPA-IM injection can be provided by APEs as a substitution when DMPA-SC (Sayana Press) stocks are insufficient; 3) provide technical support at the monthly “APEs – HF” coordination meeting for data analysis, share experiences and restock FP methods and commodities; and 4) print register books and references slips when necessary.

Traditional Birth Attendant (TBA) Trainings IFPP’s rural supply-side strategy involves Table 7 – TBAs trained in FP methods and community identifying, training and supporting TBAs to conduct sensitization home visits and community-based FP counseling TBAs trained in FP methods and and referrals. It is expected that TBAs will generate community sensitization demand by improving knowledge of FP, countering To Grand FY1 FY2 FY3 prevailing misconceptions and biases, conveying date Total the importance of healthy timing and spacing of Nampula 762 79 152 993 pregnancy (HTSP), increasing self-efficacy and 1336 Sofala 92 179 72 343 promoting linkages with contraceptive service delivery points (IR1). TBAs are trained and

39 supervised by the HF trainers, in partnership with the IFPP district coordinators. TBAs are expected to reach all women and adolescents of reproductive age, specifically targeting first- time parents (FTPs) who are pregnant or postpartum and medium- and high-parity women (defined by IFPP as woman with three or more children). TBAs also engage household influencers and gatekeepers (for example, male partners and mothers-in-law). During the FY3 a total of 224 additional TBAs were trained against 258 in FY2 and 865 in FY1. In FY2 and FY3, IFPP has focused on operationalizing the monthly review meetings led by the HF MCH nurse to ensure more qualitative support resulting in more effective community mobilization from the involved TBAs. In Nampula province, these efforts were crowned with success as the confirmed referrals reported by TBAs has jumped from 537 (Q1FY2) and 425 (Q2FY2) to 5,847 (Q3FY2) to 9,786 (Q4FY2) totaling 16,595 confirmed referrals in FY2 and 29,238 in FY3; the 993 trained TBAs are concentrated in 83 rural HF catchment areas and are supported by the TBA’s HF MCH nurses trained by IFPP as a TBA trainer for FP. During FY3, in Nampula, an average of 60 out of the 83 HFs have reported confirmed references from TBAs, and 91 out of 98 in Sofala. Out of the 993 TBAs trained in Nampula, 545 unique TBAs have reported community referrals in Q4 against 563 in Q3FY3 and 404 in Q2FY3. Out of the 343 TBAs trained in Sofala, in average, 214 have reported data during FY3. When analyzing the confirmed referrals by specific subgroups in Nampula province, the adolescents yet without children appear also as a specific sub-group for referral: this number has steadily increased from 1,144 (Q2FY3) to 1522 (Q3FY3) and to 1,572 (Q4FY3) representing on average 20% of all confirmed referrals carried out by TBAs – that’s an outstanding result as it’s illustrating the impact that TBAs can have on adolescent yet without children; and, in Sofala, adolescent without children represents 15% of all referrals carried out by TBAs (409 in Q4FY3 against 297 in Q3FY3); the remaining confirmed referrals are evenly divided between WRA with 1-4 children and WRA with more than 4 children! In Sofala province, the 343 trained TBAs are spread over 98 rural HF catchment areas and not all HFs have a focal point trained as a TBA trainer, therefore the monthly review meeting between the HF MCH nurse and the TBAs is more difficult to organize. During Q2FY3, out of the 343 TBAs trained, only 91 reported referral data (negatively affected by rainy season) and referred 1,536 WRA for FP consultations, of which 1,199 were confirmed as arrived at HFs (78%), while during Q4FY3, 214 reported 2,851 confirmed referrals.

Interpersonal Communication Agent (IPC) Training The project’s urban demand creation strategy builds on the “TEM mais” or private clinic network (TEM+) model already used by PSI, which seeks to create informed demand for FP directly at the household and community level through home visits and community meetings. Table 8 illustrates the number of IPC agents trained along the three first fiscal years of the IFPP intervention illustrating the high number of trainees for Sofala province Table 8: # of IPC agents trained in FY1-FY3, by province in FY3 as, at the end of Q2, the IPCs agents were oriented to include FY1 FY2 FY3 additional priority activities such as NAMPULA 39 95 27 water and sanitation awareness and SOFALA 45 48 86 ended up in other post-emergency NGOs: 39 were trained in Q3 and 32 Table 9: # of IPC agents active during FY3, by province additional in Q4 to re-establish IFPP Nampula Q1 Q2 Q3 Q3 urban community component. During Province FY3 FY3 FY3 FY3 this Q4FY3, 106 IPCs (22 in Sofala and Angoche city 12 8 11 11 84 in Nampula) have carried out Nampula city 42 36 47 45 sensitization activities. In addition to Anchilo 5 5 5 5 the initial trainings, monthly updates Ilha de 4 3 3 3 are carried out to increase IPCs’ Moçambique abilities to use the updated version of Murrupula sede 5 3 8 5 the digital platform “Connect with Nacala Porto 19 16 21 15 Sarah” (CwS) which operates on a Total 87 71 95 84 more advanced cell phone model – the Sofala Province VODAFONE SMART E9 – and allow IPC Beira city 40 23 33 11 agents to follow-up with WRA and Dondo city 8 3 9 11 their families. Monthly technical Total 48 26 42 22 updates are also provided with focus on the importance of FP compliance, client follow-up, reporting behavior change barriers met at each household visited and the involvement of community leadership to conduct male group sensitization. As illustrated in Table 9, the urban community component worked in average with 135 IPC agents in Q1, 97 in Q2, 137 in Q3 and 106 in Q4.

“Connect with Sarah” App (CwS) The “Connect with Sarah” platform was introduced at the end of FY2 to strengthen client’s registration, the number of sessions, follow-up of references and identify families sub groups with similar barriers for family acceptance to design additional strategies for demand generation activities.

The IPCs register the client and document the different interactions carried out during the year which will strengthen the follow-up of clients, improve registration of clients’ FP needs, collect client feedback on the services provided and track the referrals. As this App works on

41 smartphones equipped with an android system, geo-localization of the households is required and eases IFPP’s internal audits and IPCs return visits. The App is being used by both IPCs and HPs.

Mapping of IPCs agents Furthermore, the urban community mobilization and counselling strategy redesigned in Q4FY2 has been implemented since beginning of FY3. The IPCs were redistributed in pre-selected neighborhoods with the mission to progressively reach 100% of WRA for FP counseling and further follow-up. Therefore, working meetings have been and will continue to be carried out with the community leaders (CLs) to define the mapping and sensitize them on FP myths, taboos, and challenges. In Nampula city, the IPC agents are distributed in six administrative posts and 14 boroughs; in Murrupula, in one administrative post and six boroughs; in Angoche city, in one administrative post and 15 boroughs; in Nacala Porto city, in one administrative post and in 10 boroughs; in Ilha de Moçambique, in two administrative post and 3 boroughs; in Beira city, in four administrative posts and 18 boroughs; in Dondo, in two administrative posts and six boroughs. Each IPC agent is covering a geographical area of about 10,000 inhabitants with the objective to cover all households with home-based visits, and, with the support of 15 community assistants and the community leadership, conduct male group sensitization for families presenting specific socio-cultural and religious barriers. The model is quite intensive but aims to

Table 10: Cumulative data for FY3, for the urban demand creation component

% of WRA % of WRA that # of WRA that became # of WRA became users % of WRA # of that users after that after IPC's Total # of # of WRA covered expected estimated # of WRA became IPC's became a intervention WRA registere thru IPC # of IPC WRA to be registere users after intervention LARC users during FY3 Province District registered d in CwS agent and agent covered in d in CwS IPC's during FY3 after IPC's (denominator in CwS not using registered active predefined using FP interventio (denominator interventio = WRA FY3 FP in CwS, in areas n during = WRA n during registered in FY3 FY3 registered in FY3 CwS using a FP CwS) method) Nampula 45 112,500 65,235 22,646 42,589 58% 3,987 6.1% 573 1.3% city Angoche 12 30,000 15,463 6,502 8,961 52% 867 5.6% 121 1.4% city Nampula Nacala 20 50,000 12,029 6,721 5,308 24% 421 3.5% 81 1.5% Porto Murrupula 4 10,000 7,484 3,343 4,141 75% 1,450 19.4% 156 3.8% Ilha Moc. 4 10,000 2,003 526 1,477 20% 47 2.3% 2 0.1% Total 85 212,500 102,214 39,738 62,476 48% 6,772 6.6% 933 1.5% Beira 40 100,000 7,486 4,001 3,485 7% 314 4% 116 3.3% Sofala Dondo 10 25,000 2,650 1,294 1,356 11% 107 4% 26 1.9% Total 50 125,000 10,136 5,295 4,841 8% 421 4% 142 2.9% create FP demand within the households presenting high level of barriers.

As seen In table 10, in Nampula province, IFPP planned to visit and register 212,500 WRA in predefined areas; during FY3, 102,211 (48% of coverage) were already visited and registered in

CwS and, out of these, at the end of FY3, 62,476 are reported as FP users; of these, 6,772 were not a FP user at the moment of the visit and initiate or reinitiate a FP method through the community visits; out of the number of current users at end FY3 (62,476), 993 initiate a LARC (629 among the WRA not yet users at the moment of the visit and 304 were switchers to LARC).

In Sofala, due to IDAI and the post-emergency phase, this systematic mapping had to be carried out again in Q4FY3; this action aimed to ensure coverage of WRA who, due to the cyclone, moved from one neighborhood to another and, the ones settling in new neighborhoods emerging after IDAI; therefore the table 10 reports only the data of the Q4FY3: IFPP planned to visit and register 125,000 WRA in predefined areas and 10,136 (8% of IFPP LOP target through intervention in the solely Q4FY3) were visited and registered in CwS ; out of these, at the end of FY3, 4,841 are reported as FP users; of these, 421 were not a FP user at the time of the visit and either initiated or reinitiated a FP method through the community visits; of the number of current users at end FY3 (4,841), 142 initiated a LARC (120 among the WRA not yet users at the moment of the visit and 12 were switchers to LARC).

For Angoche city (Nampula province), IFPP covered, by the end of FY3, 52% (15,463/30,000) of the WRA living in the predefined areas and produced an increase of the estimated mCPR by 5.6% (867/15,463) among WRA registered in CwS. Training on FP the leaders for community engagement and carrying out meetings with men presenting socio-cultural barriers and/or FP misconception were key activities to achieve this result; in FY4, an additional area - the Josina Machel corridor - will be invested to expand the area of intervention of the already involved IPC agents and continuous efforts will be focused on the Inguri neighborhood ensuring the FP continuation rate and increasing the mCPR through male involvement. Another action envisioned will be the integration of one of the best IPC agents to be resident mobilizer at the Rural Hospital of Angoche for group’s chats, individual counselling at waiting room and referrals to the different consultations having integrated the offering of FP services.

For Nampula city, IFPP covered, by the end of FY3, 58% (62,235/112,500) of the WRA living in the predefined areas and produced an increase of the estimated mCPR by 6.1% (3,987/65,235) among WRA registered in CwS. As a way forward to increase the mCPR in Y4, IFPP IPC agents will not only continue to visit the WRA not yet registered in the already predefined areas but will also request that 5 of the IPC agents carry out mobilization activities in five specific HFs with the largest client flow to diminish the lost opportunities at the HF’s level PSCs to support HF activities as a highlight mobilizer for the largest user flows (eg Military Hospital, Namutequeliua, Napipine, 25th of September, Muhala Expanão); the women's group sessions and sessions with men being reluctant to FP adoption for their families will continue to be carried out.

For the corridor of Murrupula sede locality, IFPP covered, by the end of FY3, 75% (7,484/10,000) of the WRA living in the predefined areas and produced an increase of the estimated mCPR by 19.4% (1,454/7,484) among WRA registered in CwS. This outstanding result was achieved as 80% of the IPC agents remained active since the beginning of the intervention, resulting in an high

43 level of consistency (greater mastery of subjects and good communication skills of the IPC agents, well-structured neighborhoods easing the roll-out of the intervention, training of the Community Leaders on FP community engagement, meetings with men who may be FP barriers, consistent referral of users in need of FP services and their follow-up. These results are satisfactory for the mapped area and it doesn’t seem necessary to the door-to-door activities carried out by the IPC agents. To ensure accountability, the most qualified of the four IPC agents will be resident mobilizer at the Murrupula HC for group’s chats, individual counselling at waiting room and referrals to the different consultations having integrated the offering of FP services.

For the district of Ilha de Moçambique, IFPP covered, by the end of FY3, 20% (2,003/10,000) of the WRA living in the predefined areas and produced an increase of the estimated mCPR by 2.3% (47/2,003) among WRA registered in CwS. This outcome is low compared to the other districts: although we anticipated working with 4 PSC, only 2 were active working in the continental area of the Island, namely Lumbo and Gembesse, leaving the island where strong FP socio-cultural barriers are prevalent impeding door-to-door activities; additional factors were the weakness of the Vodacom network and frequent absence of provider at the SRH/FP door of the ilha de Moçambique health center. For FY4, the community assistant will be clarifying through CL sessions and male involvement groups to create a more enabling environment and further planned together with the CL the door-to-door activities; furthermore, the IPC agents will carry out mobilization activities at the Ilha de Moçambique HC and referrals towards the consultations offering integrated FP services.

For the Nacala-Porto city, IFPP covered, by the end of FY3, 24% (12,091/50,000) of the WRA living in the predefined areas and produced an increase of the estimated mCPR by 3.5% (421/12,091) among WRA registered in CwS. These results are weak and related with the high turnover of the IPC agents, due mainly to the low incentive paid to the IPC agents when compared with Nacala Porto higher cost of living, myths related with FP and inconsistent referrals slips confirmation of the referred users diminishing further the incomes of the IPC agents paid on Performance Based Financing (PBF).

Community Facilitators (CF) training

During the FY3, a refresher training was done for 231 CFs and 24 supervisors and 42 CFs were initially trained (27 in Nampula and 15 in Sofala).

Targeted Mobile Brigades (MBs) for priority populations

MBs continue to be key in increasing access to FP, particularly for rural and hard to reach areas. During FY3, IFPP supported 3,303 MB (1,532 in Nampula and 1,771 in Sofala) against 3,383 in FY2 and 1,639 in FY1. During Q1FY3 alone, IFPP supported 423 in Nampula and 676 in Sofala, totaling 1,099 MBs. In Q2FY3, IFPP supported 276 in Nampula and 121 in Sofala, totaling 397 MBs, a decrease from Q1 due to the rainy season and the MOH’s new directive related to FP offerings in schools. During Q3FY3, IFPP supported 398 in Nampula and 752 in Sofala, totaling

1,150 MBs, an increase compared to Q2 mainly due to the emergency week in Sofala and, in Q4FY3, IFPP supported 435 in Nampula and 222 in Sofala, totaling 657 MBs. During Q4, specific MB were carried out for the contraception month. Available data on MB report that, on average, each MB served 36 WRA in Nampula and 20 in Sofala; furthermore, 10 to 15% of these clients are choosing a LARC. To enhance full access to the method-mix, MBs are carried out in the immediate surroundings of the schools and are directed to all WRA with a focus on out-of-school adolescent but still allow the in-school to have access to the LARC. On the other hand, as IFPP rural Community Facilitator (CFs) are targeting more and more remote and disperse areas, IFPP has and will continue to increase the coordination with the respective SDSMAS and HFs to synchronize the implementation of the rural MBs in phase with the timing of the 4th, 5th or 6th community dialogue’s sessions. The communities are sensitized on the FP benefits, LARC and STM, and the community facilitator, in coordination and with the support of the respective Community Leader Councils (CLCs), is mobilizing the population, distributing FP referrals for the MBs event during which specific attention will be given to access of LARCs. The community field supervisor is playing a key role in coordinating the programming and the implementation of these ‘one shot’ MBs with the peripheral HFs of first referral for these communities. In remote communities where an APE is already delivering FP services, close collaboration is carried out for the programming, as well as the implementation of the proper MB day. During the MB day, in communities where there is an APE present the STM clients should be served by the APE and registered in the APE’s logbook. This will help ensure STM users continue the use of their chosen STM. Whatever is the type of the MB, FP consultations inform the clients about their rights as well as the potential side-effects and complications of the FP methods and what are the next steps that the users should carried out, including in case of LARC removal need. To strengthen the information dissemination, efforts in FY4 will showed-off laminated posters – one highlighting the client’s rights and another focusing on LARC removals including (i) the gratuity of the services , (ii) the need to be carried out by a HP, (iii) in most cases, the removal can be offered at the setting of the MB, (iv) what is the ideal timing for removal but focusing their right to remove it earlier and the usual easiness of the procedure; to ensure the continuity of services in the specific case of the “one shot” community dialogue cycle MB, the different possible referral pathways will be clarified emphasizing the HF and the surroundings MB fixed point (close enough to previous one to ensure coverage) and their calendar. Celebration of Contraception Day in Nampula City and Netia Administrative Post in Monapo

Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services Figure 13 shows trends in the number of confirmed referrals by the type of CHWs, FY and province. The total number of confirmed referrals by HPs is 98,123 in FY3 against 108,204 in FY2, and 57,342 in FY1 when comparing FY3 and FY2, IFPP had a slight decrease of 9%; meanwhile, on the 15th of Figure 13: Number of confirmed referrals as 'attended at HF' by province, March, Sofala was from October 2016 to September 2019 hit by IDAI cyclone and this impacted 45,000 42,054 seriously the urban 40,000 IPC TBA CF community 35,000 component which 29,448 29,238 30,000 didn’t report 25,000 28,091 almost any 21,427 confirmed referrals 20,000 16,595 17,657 16,618 14,545 thru HP in Beira 15,000 9,413 and Dondo. 10,000 7,324 8,167 1,814 4,170 5,000 1,652 5,954 The red bars 486 8,676 - represent the FY1 FY2 FY3 FY1 FY2 FY3 confirmed referrals sent to HFs by Nampula Sofala TBAs. When comparing FY2 against FY3, TBAs increased their confirmed referrals from 20,765 in FY2 to 37,745 in FY3 (80% of increase), which is very encouraging. The FP cascade training for TBAs has been re-initiated in Q4FY2 as we can monitor their outputs and analyze data produced per HF catchment area. This data confirms the great opportunity TBAs represent for demand generation at the rural level.

The annual IPC confirmed referral’s trend is diminishing year after year (39,710 in FY1 against 30,360 in FY2, and 21,513 in FY3) which is mainly related to the field methodology applied across the years, amplified in FY3 by IDAI cyclone hitting Beira and Dondo: during FY1, activities were carried out dividing the IPC agents in groups to attend highly crowded places in specific neighborhood and their payment was based on the number of confirmed referrals (electronic or paper based) by HF’s HPs, favoring the IPC agents to focus on referrals whatever the status of the client was (FP initiator or FP continuer) inducting the reaching of most probably current FP users. This approach wasn’t favoring a systematic coverage approach of the predefined neighborhoods. At the end of FY2 and beginning of Y3, IFPP introduced the CwS digital platform focusing on door-to-door visits and requiring the geo-localization of the households, easing like that IFPP’s internal audits, IPCs return visits and, all referrals became electronic; each IPC agent received a predefined area in which an estimate of about 2,500 WRA were living. The IPC agents shift their focus on systematically covering the households and carrying out unique coded

46 registration for each WRA, first counselling visits as well as follow-up visits for further counselling and side-effects clarification and, identification of the peculiar barriers of the non-users; their incentive was no more only rewarding confirmed referrals but rewards also first counselling visits and follow-up visits.

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

Sub-IR 2.1: Improved ability of individuals to adopt healthy FP behaviors During Q4FY3, a total of 183,348 female contacts have been reported, a 56% increase when compared to Q3FY3. During FY3 a total of 524,166 contacts were reported (378,098 in Nampula and 146,068 in Sofala) against 322,583 in FY2 and 174,531 in FY1.

Rural Community Facilitators (CF) During FY3, a total of 300,459 contacts with women were carried out through community dialogues against 222,812 contacts in FY2 and 109,833 in FY1. In Q4FY3, sensitization contacts reported by CFs totaled up to 130,716 (39,305 in Sofala and 91,411 in Nampula) an increase of 70% when comparing with Q3FY3, related to the increasing of the numbers of groups facilitated by each CF’s pair: as we are reaching more far countryside villages, CFs are facilitating two groups per day (one of CL and another of young couples) carrying out activities six days per week, covering three different villages in a period of three weeks and increasing like that their productivity, which is very important to cover more distant areas.

A Community Leader’s group participating to the community dialogue sessions implemented by the community facilitators and youth couples participating to a work group exercise on choosing contraception methods

Traditional Birth Attendants (TBA) As mentioned above in Sub IR1.2, at end FY3, 1,336 TBAs have been trained and most of them are implementing regular sensitization activities at the community level with an average of 800 reporting data monthly. Sensitization contacts reported by TBAs have increased from 1,129 (FY1) to 23,651 (FY2) and jumped to 39,785 by the end of FY3, an increase of 59% when compared to FY2. When comparing Q3FY3 with Q4FY3 there was a increase of 26%.

Interpersonal Communication Agent (IPC) At the end of FY3, with the support of the 137 active IPC agents, cumulatively for FY3, IFPP reported 532,843 WRA contacts and of these IPC agents were responsible for 192,998 (36%).

Activities of urban demand creation: a young couple who accept a referral, door-to-door sensitization, a group session, a sensitization meeting with community leaders.

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

Fostering an enabling environment for demand creation In rural settings, to boost the local leadership involvement in the areas in which CFs are facing a deficit in community leadership involvement, IFPP rural community component (in coordination with the head of the Locality or Table 11: Distribution of the CLL meetings by province and quarter Chefe da PROVINCES Q2FY2 Q3FY2 Q4FY2 Q1FY3 Q2FY3 Q3FY3 Q4FY3 Localidade has Nampula 26 5 8 18 8 12 29 supported a Sofala 14 6 5 6 10 6 16 one-day Total 40 11 13 24 18 18 45 meeting focused on gathering the members of the Conselho Local da Localidade (CLL, Locality’s local council). This Leaders Council is a body of consultation for the local administration authorities in search of solutions to fundamental questions that affect the lives of local communities, as well as their well-being and sustainable development.

As illustrated in table 11, in FY3, IFPP carried out 105 CLL one-day meetings against 64 in FY2.

The main objective of these meetings is to strengthen the CLL abilities to led an enabling environment for FP behaviour change within their area where IFPP is carrying out the community dialogues sessions involving the Community Leaders (CL) sitting in the Community Leadership village Councils (CLCs), promoting social norms favorable to RH and HTSP; these meetings strengthen the CLL’s leadership to increase the community participation in community dialogues; the HF Director, the MCH responsible, as well as the provider in charge of the community involvement are invited to be the main orators in the facilitation. The main questions discussed included: In your opinion, what are the reasons for the low use of methods of contraception at community level? What could each of us do to improve the use of FP in your family circle and in your community?

The final exercise was mapping of the community, including highlighting the main roads, the schools, the health facilities, the APEs, the best-known PTs and the MBs concentration points.

Follow-up meetings are recommended to be carried out every six months and aim to review the progress of the locality plan increasing the accountability of the rural community component and the HF team.

The CLs expressed their satisfaction with regards to the meeting and the contents. Their understanding about the role of the CFs has dramatically increased and subsequently their support. Leaders committed themselves to more engagement in the program, to interact with the churches and mosques to spread the FP messages, and to disseminate FP messages in communities. Furthermore, 44 co-management committees (CMCs) in Q4FY3 against 35 HF in Q3FY3, 6 HF in Q2FY3 and 35 HF in Q1FY3received technical support from IFPP during this reporting quarter.

Additionally, the involvement of men and women champions in the community dialogue sessions for CLCs and in the community radio program was instrumental along the FY3. Six additional men champions and two women champions were involved this Q4FY3.

In the urban settings, while in Q2FY3, 11,975 CLs in Nampula province, 1,231 CLs in Beira City and 106 in Dondo administrative post were involved in the borough’s mapping and sensitized about FP and PPFP corresponding to 22 HF catchment areas in Nampula urban settings and 10 HF catchment areas in Sofala urban settings, during Q3FY3, an additional 1,011 CLs were involved of which 356 were trained and, in Q4FY3, 626 CL were sensitized and 690 trained. IFPP highlights the importance of FP and which families would most benefit from FP use, how FP is linked to the demographic dividend and the poverty reduction. The community mapping consists of registering all houses, blocks, units, neighbourhoods and administrative posts of the districts of Ilha de Moçambique, Nacala Porto city, Angoche city and Nampula City. This exercise was led by the Urban Community Assistants recruited during FY3; the Community Leaders of Angoche city objective is to appointed each IPC agent (Promotora de participating in a FP training having as focus Saúde Comunitária) to a specific geographic area of about male involvement 2,000 - 2,500 HHs and increases each specific area mCPR through regular home visits, identification of the proper barriers related to each non-FP adherent household (HH) and diminishing the influence of these existing barriers through small group discussions with husbands, partners, mother-in-law, religious leaders as appropriate. These small group talks will be led by the urban community assistants and progressively by the IPC agents.

Additionally, in the urban settings, this Q4FY3, IFPP Small men’s group unfavorable to identified men’s groups, through the IPC agents during FP in Angoche city the HH visits and / or CL, reported as limiting WRA’s access to FP services. Therefore, a male involvement guideline was finalized to guide three sessions focusing FP methods and male involvement; a total of 12 groups were set-up involving in total 82 men. During the meetings, it was noted that they are not unfavourable to the FP, as one might suppose. However, because they lack much information about modern contraceptive methods, the benefits of FP, and the type of services offered at US, some men persist with some distrust, discredit about FP and a deeply ingrained idea that FP is harmful to health, man’ sexual pleasure and is a women's exclusive matter. Many of them think of the man's role as authorizing or deciding that their partner should or shouldn’t use FP.

Also in the urban settings, this Q4FY3, IFPP carried out Small women’s group women’s group identified through the IPC agents during unfavorable to FP in Angoche the HH visits and / or CL and reported as the ones who and Nacala Porto cities limit WRA’s access to FP services; a total of 6 groups were set-up involving in total 51 women; these meetings highlight that the use of FP is powerfully shaped by social and gender norms, which limit women's autonomy and restrict communication and decision making between men and women; during the sessions, the myths and misconceptions regarding FP were addressed, and FP couple’s users sharing their experience about open communication and joint decision making was very much worth; women described partner support as an essential facilitator for FP use; it was also noted that initiation rites which are different in Sofala and Nampula also play an important role in their position regarding FP.

Leveraging community partnerships through CBOs Technical support visits continue to be carried out, targeting 88 community-based organizations (CBOs) to more qualitatively implement the agreement signed with IFPP by increasing their follow-up activities and including monitoring CF activities at the community and HF level. CBO representatives were involved in the community score card (CSC) process. The rural component continued their sensitization activities towards the expanded communities of forty-seven HF catchment areas added up past quarter. Some prevalent conflicts between CFs and their CBOs had to be intermediated and some of them resulted in discontinuance of the community facilitator activity.

Use of community radio to amplify the community dialogues focused on HTSP, FP and benefits for healthy families and communities IFPP is building on the community dialogues and working with eight community radios (CRs) in Nampula and five in Sofala to broadcasts dramas, interviews and radio programs to help to demystify and minimize barriers linked to FP at the community level. CR staff were prepared to broadcast 16 sexual and reproductive health rights (SRHR) and FP programs. Within IFPP’s communication and sensitization approach, the CRs complement the messages transmitted during community dialogue sessions with CFs promoting SRHR, FP rights and the duty of citizens to raise public awareness around SRHR and the benefits of FP services.

As illustrated in Table 12, this FY3, 429 radio programs were broadcasted focusing on the contents of the community dialogue sessions (277 in Nampula and 152 in Sofala) against 321 in FY2 and 323 in FY1.

Also, during this Q4FY3, two trainings were carried out involving staff of the twelve usual CRs and staff of four additional CRs located in Cheringoma, Dondo, Chibabava and Buzi districts preparing like this the FY4 season. In total, 48 CR’s staff and 16 IFPP field supervisor benefitted from a five-day training session on topics such as writing scripts to cover the monitoring of the CSC (community score cards) on quality of the HF FP services, mobile brigades, community dialogue sessions and, more effective involvement of CL, APEs and men and women champions.

All the radio programs had, during FY3, the active participation of Field Supervisors and the SDSMAS appointed HP. IFPP district coordinators joined as frequently as possible. IFPP signed a Memorandum of Understanding (MOU) with the Muslim radio HAQ (Arabic for Truth) based in Nampula City but covering the Table 12: Radio sessions by station Broadcasting entire province, Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 substituting the Province & district Radio name FY1 FY1 FY2 FY2 FY2 FY2 FY3 FY3 FY3 FY3 4 9 4 5 20 6 10 10 0 contract with Mossuril CR Mossuril Monapo CR Monapo 22 26 22 11 10 4 15 17 0 Radio Gemeas Meconta CRT Namialo 22 14 0 6 0 22 14 14 4 which was Memba CR Memba 12 16 0 0 0 10 22 0 0

Erati CR Namapa 10 16 0 0 26 8 32 5 0 extended terminated. It Nampula Ribaue CRT Ribaue 22 13 0 0 11 11 9 14 0

will be an added Angoche CR Parapato 18 16 2 0 12 4 2 26 0 MOU inMOU process be to value for IFPP as Nampula Radio Haq 12 15 0 0 0 0 12 6 0 its coverage is Sub-total 122 125 28 0 22 79 65 116 92 4 0 16 11 4 10 21 14 4 6 4 provincial and Nhamatanda CR Acordos de Paz Gorongoza CR Gorongoza 4 14 18 12 20 14 16 16 0 the radio is Caia CR Caia 8 8 9 4 12 17 16 15 10 2 reaching the Marromeu CR Marromeu 8 18 8 4 10 18 16 14 10 3

Muslim Sofala Cheringoma CR Cheringoma 6 Dondo CR Dondo

population Chibabava CR Chibabava this Q4FY3 more easily. Buzi CR Buzi Only trained Sub-total 20 56 46 24 52 70 62 49 32 9

The intervention Total 142 181 74 24 74 149 127 165 124 13 was confronted with some difficulties. The CR “Acordos de Paz” had a serious breakdown due to cyclone IDAI and still by end FY3 had not rehabilitated its equipment and station. Recorders were purchased this Q4FY3 to strengthen the capacities of CRs to carry out field recording activities with men and women champions, and during the community dialogues, the CSC and the CLL meetings.

Sub-IR 2.3: Improved systems to implement and evaluate (Social and Behavior Change Communication) (SBCC) interventions IFPP/PSI designed in close collaboration with OES designed an operational study “Increasing the Efficacy of Health Promoters for FP in Nampula and Sofala Provinces”, focusing specifically on the IPC agents. The design is completed and will be started as soon as the administrative authorization of the MoH bioethics committee will be received; it’s expected for next quarter.

IR 3: Strengthened FP/RH health systems During FY3 the IFPP HSS activities were focused on expansion but was impacted by cyclone IDAI (mainly in the immediate post-emergency phase, the month of April) and the electoral campaign, as a lot of civil servants were involved, delaying the HSS activities initially planned for August- September to the next quarter. Out of twelve MCS assessments planned for Q4FY3, ten did not take place. While IFPP HSS targeted fifteen districts (9 in Nampula and 6 in Sofala) in FY1, the coverage was extended to nine additional districts (6 in Nampula and 3 in Sofala) in FY2 and, twelve additional ones (8 in Nampula and 4 in Sofala) in FY3, totaling 100% of the districts targeted in the LOP: every district of the area of intervention has already received some HSS TA at the end of FY3

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

During Q1FY3, TA activities were focused on monitoring the implementation of activities included in the PES/PESOD 2018 for the MCH-FP component, including realignment taking into account the constraints and opportunities identified during the implementation of activities. In Q2FY3, IFPP team provided TA at the SDSMAS and DPS quarterly review meetings to systematically assess implementation of the FP program activities in order to determine the degree of compliance with the planned activities. Also, IFPP provided TA in the PES/PESOD2019 provincial meeting to identify PES/PESOD activities aligned with the disbursement-linked indicators 3 (DLI3) of the World Bank Primary Health Care Strengthening Program. Activities linked to the DLI3 could potentially be integrated into investment case for the World Bank program and therefore receive funding from that program. Potential activities identified included procurement of equipment and minor rehabilitation of infrastructure. During Q3FY3, special attention was given to the joint review of the Midterm Fiscal Review (Cenario de Despesas Fiscal de Medio Prazo - CDFMP) of the PES/PESOD activities (internal and external) including the submission of the final documents to the competent authorities. Likewise, workshops were held to consolidate the corrective planning of the CDFMP, for each health program at the district level, identifying the existing gaps. In Q4FY3, during the quarterly review meetings, TA was provided to both DPS and 22 SDSMAS (16 in Nampula and 6 in Sofala) to monitor and review progresses in the implementation of the 2019 PES/PESOD; activities with low performance or delayed were identified and analyzed; implementation’s constraints were staff workload, program agenda overlapping and insufficient government funds; HSS Team advocated for a more integrated approach to implement these activities taking benefit from mobile brigades, on-the- job-trainings (APEs, PTs and health providers), RDQA meetings and, TA for co-Management and Humanization Committees regular roll-out incorporating them in DPS and SDSMAS quarterly operational plans for October-December 2019.

During FY3, the HSS Table 12: MSC trends by district team provided TA to < or = 60% MSC District Scores Over Time >60% < or = 70% 192 Sofala and (Target: achieve satisfactory scores ?80%) >70% < or = 80% Nampula DPS and >80% < or = 90% FY1 (Oct. 16 - FY2 (Oct. 17 - Sept. 18) FY3 (Oct. 18 - Sept. 19) SDSMAS program >90% < or =100% Sept. 17) DISTRICT Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 unique individuals (141 Angoche 40% 92% 94% 85% 78% in Nampula and 51 in Mogincual 59% Liupo 60% Sofala) focusing on Nampula D. 39% 83% 90% 90% 90% Erati 37% 75% 84% 84% 84% managers from DPS and Memba 55% 79% 84% SDSMAS levels (HR, Meconta 68% 70% 84% 75% Nacaroa 65% NED, and Drug Muecate 47% Mogovolas 57% 56% 66% warehouse, MCH Moma 42% 85% 85% 88% 96% Lardes 25% district’s responsible). Monapo 50% 92% 91% 97% 96% This involved Mossuril 53% 86% 74% Ilha Moç. 36% 86% supporting the N.Porto 41% 66% 90% 98% 93%

NAMPULAPROVINCE N.Velha 56% 88% 84% preparation of monthly Murrupula 49% 83% 72% and quarterly work Rapale 60% Mecuburi 41% 81% 88% 86% 66% plans to guide Ribaue 41% 92% 96% 100% 98% Malema 38% 84% 85% implementation and Lalaua 41% 86% facilitate routine Beira 63% 86% 89% 90% 92% Dondo 60% 71% 82% 87% 84% monitoring of PES Nhamatanda 65% 83% 82% 85% 83% Buzi 74% 82% 82% performance. TA was Chibabava 60% 73% 79% 82% 82% Machanga 67% 85% 82% also provided in Caia 54% 66% 83% 83% planning and budgeting Marromeu 70% 62% Chemba 37% FP related activities to Gorongosa 66% 82% 83%

Cheringoma 59% SOFALAPROVINCE be included in the PES Maringue 62% and PESOD 2020. Muanza 53%

Table 12 illustrates the trends in MSC Figure 13: MSC results by FY and by management area focusing on the assessments carried out 5 districts of Nampula decreasing their overall scoring below 80% since the beginning of the IFPP intervention at SDSMAS and DPS level. The FY3 targets are to maintain satisfactory scores (≥80%) in FY1 and FY2 districts who graduated (21 districts) and support the three districts that had not yet

54 graduated in FY2 to achieve better results (Mogovolas, Memba and Marromeu). Twelve additional districts were enrolled for FY3 to receive regular MSC assessments (Mogincual, Liupo, Nacaroa, Muecate, Larde, Ilha de Moçambique, Rapale, Lalaua, Chemba, Cheringoma, Marringue and Muanza), totaling the 36 districts of both provinces. At end of FY3, results are somehow mitigated: three districts enter for the first time in the group of the ones scoring equal or superior to 80% (Memba, Ilha de Moçambique and Lalaua), but out of the 21 districts having already reached 80% of the MSC score at end FY2, five of them (Angoche, Meconta, Mossuril, Murrupula and Mecuburi) scored lower, on average, 12 percentual points (from 85% to 73%); as seen in figure 14, out of the 6 management areas assessed (Planning & Financing, Logistics, Human Resource, HIS monitoring, HIS evaluation, FP/MCH Program Management), Planning & Financing, Human Resource and, FP/MCH program management areas highlight the strongest decreases; whenever there is a decrease, it’s mostly related to the appointment of a new responsible in this area, highlighting the need to plan proactively and define specific handover’s activities at district level, as well as, induction of the recently appointed responsible at provincial level or weak SDSMAS leadership in following the different areas that has to be covered.

In any cases, IFPP HSS team also supported district managers to develop and update QI action plans to improve performance and guide follow-up TA in the implementation of corrective actions.

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

During FY2 , there was, overall, a significant reduction of stock outs in the HFs assisted by the project thanks to a combination of factors contributing to these results, such as the large availability of FP commodities at the national level, and several IFPP supported interventions including weekly proactive follow-up of imminent stock-out or stock outs, identified by IFPP district Figure 15: Monitoring of weekly DEPO-PROVERA stock level in Nampula provincial coordinators, HSS warehouse (DPM) and correlation with the percentage of HFs reporting at least one day provincial TA, DDM of stock-out per quarter - January 2018 to July 2019 and DPM responsible in their routine TA. During FY3, Nampula province DPM was confronted with serious difficulties - starting from December 2018 and lasting up to May 2019 - in receiving sufficient quantities of

DMPA injectables, to answer timely at the demand created from the regional and central level warehouses, as illustrated in the figure 15.

• The dark green bars represent the stock at the DPM level at end of every single week: levels of stock were excellent up to June 2018 as the levels of stock were superior to the maximum recommended level by the CMAM (5 months of stock); this 5 month level benchmark is represented in the graph by a fluo-green continuous line which is jumping from one level (171,000 injectables from December 2017 to June 2018) to another level (253,000 from July to December 2018), to the 324,000 level for January-June 2019 period and, unfortunately, is diminishing to 295,416 for the period July – December 2019, disrupting the efforts carried out thru IFPP to create the demand and, even more, reducing product access for customers acquired last semester; these levels are calculated based on the DMPA distributed to the DDMs and HFs during the previous 6 months. The dark blue line represents the minimum level (3 months of stock) that the DPM, per recommendation of CMAM, must possess at the provincial warehouse and, the orange line represents a single month of stock for the monthly necessities of the clients (the HFs and their users) • The red bulleted line represents the percentage of the HF assessed for stock-outs by the FP program staff (DPS, SDSMAS, IFPP): while in Jan-March 2018, the FP program reported zero percent of stock-outs at HF’s level, this percentage increase in the April – June 2018 period to 11% - mainly due to insufficient intra-provincial follow-up as the availability of DMPA was excellent – and then decrease at Figure 16: Total Demand and % met vs unmet 7% in July-September 2018 need period – mainly due to the proactive chase of the imminent stock-outs by the DDM and district IFPP staff – and, climb up again to 8% in October- December 2018, and raise dramatically to 37% in the period Jan-March 2019, to decrease again at 15% in April-June 2019. • When the DPM stocks are below the 3 months minimal stock the trend of stock-out percentage at HF level tends to increase. The

still unclear area is if the stock-out mitigation mechanisms between regional warehouses (Maputo, Beira, Nampula) and the DPM warehouse been enough efficient in redistribution of the DMPA regional stocks or, the national level of DMPA stock were

too low to maintain the level of the 11 DPMs at a minimum level of 3 months recommended by CMAM. • The FP service delivery efforts in Nampula province was seriously limited to answer the demand which, indeed, as the mid-term evaluation illustrated, increased from 42% to 52% between Jan-March 2017 and Jan-March 2019. Therefore, it’s important that PSM and CMAM give us an explanation in relation to what happened and how IFPP can help prevent it again. This graph analysis will be shared monthly by CMAM/PSM and shared with the MCH commodity’s technical group to prevent and or mitigate stock-outs.

Notwithstanding these stock-outs in Nampula province, comparing results at the end of each FY, cumulatively for both provinces, there was a reduction in SDPs with FP commodities stocked out from 14% at end of FY1 to 7% at end of FY2 and 3% at end of FY3.

To achieve this result, IFPP a) used MSC results to identify and close the gaps on FP commodities management and logistics implemented through FP system strengthening action plans; b) conducted in-service trainings and competence based TA visits to ensure that provincial, district and HFs depots managers have appropriate and updated skills to manage FP commodities stocks and correctly understand/use physical and electronic stock cards and requisitions, assess and act upon alerts of imminent stock out; and c) provided TA to 2 DPS and 36 SDSMAS task forces (23 in Nampula and 13 in Sofala) involving DPM, DDM and MCH health professionals to conduct monthly meetings to analyze consumption data and contraceptive commodity requisitions from each health facility to ensure enough stock is ordered to respond to the growing demand for FP commodities. Meanwhile, the DPM FP commodity requisitions sent to central level weren’t completely satisfied, as less quantities are sent by the central level mainly during FY3.

During the Q4FY3, six (3%) out of 206 SDP assessed (all in Nampula) registered stock outs.

During FY3, the supervision and TA visits in order to prevent stock-out focus on:

• Diminution of distribution of all FP commodities entering in HF depots to service delivery points/doors leaving the HF depots with falsely reported “stock-out”. • FP commodities entries and exits records updated in the physical and digital stock cards forms. • Technical skills of users to operate tablets and navigate through SIGLUS platform. • Diminishing delays in sending SIGLUS data to district depots to be synchronized into SIMAM (at least twice a week, HF depots managers are required to active mobile data in their tablets to store data in the SIGLUS server and synchronize with SIMAM). • Sensitizing about the misuse of tablets and data (megabytes are used for personal purposes) • Strengthening the leadership of the DPM and DDM managers in tracking FP commodities inventory management at HF through SIGLUS portal and their communication between logistic supply chain stakeholders (HF depot manager and responsible, district and DPS depot, RH-FP/MCH managers and implementing partners).

To report the HF’s stock-out indicator, IFPP used the CommCare and SIGLUS App as primary sources of information and then verify the physical stock cards for the stock-outs notified. A total of 137 HFs were assessed in Nampula province, which corresponds to 58% of the total HFs in the province (237 HFs); distributed among those implementing SIGLUS (132 HFs) in 12 districts (Monapo, Angoche, Nampula, Moma, Rapale, Nacala Porto, Nacala-a-Velha, Memba, Erati, Meconta, Muecate and Nacaroa), and those mentored through CommCare App (4 HFs) in three districts (Malema, Mecuburi, Mogovolas).

Table 13. results of FP commodity stock-out assessment in Nampula and Sofala

# of HFs reporting stock-out % de US's com Rotura Source / # of HFs App assessed Before stock After stock Before After cards card verification verification verification verification Nampula CommCare 4 0 0 0% 0% SIGLUS 132 45 6 34% 4.55% Total 136 45 6 33.1% 4.41% Sofala CommCare 6 0 0 0% 0% SIGLUS 64 5 0 8% 0% Total 70 5 0 7% 0% Total 206 50 6 24.3% 2.9%

As illustrated in table 13, overall, only six HFs in Nampula experienced a stock out of at least one method of contraception, corresponding to 4.4% of stock-out in Nampula, 0% in Sofala and 2,9% for both provinces in Q4FY3.

Meanwhile, if taking into consideration only the data reported thru SIGLUS, Nampula would have a 34% of HF with stock-out and Sofala a 7%, illustrating that SIGLUS App is still not used efficiently by the depots managers, and not sufficiently followed-up by the DDM supervisors and SDSMAS directors, despite TA efforts carried out during FY3 (training of the majority of the HF depots responsible, use of SIGLUS checklist during integrated supervision helping focusing on the most usual difficulties): the reasons for this low efficiency are quite diversified: during the last quarter, in Angoche district, for example, six HF had the tablets out of order and it took five weeks to get them back; in Sangage HF, the depot manager left on authorized leave, but his substitute – the MCH nurse – wasn’t sufficiently trained to use the tablet; in Napruma HF, the digital stock card was not updated because data synchronization wasn’t carried out on time due

58 to network issues, even if the usual previous invoked reasons, such as the lack of knowledge for tablet’s synchronization, the non-registration of the products in the digital stock card and the sending of all contraceptives to the MCH sector leaving the HF warehouse without stock, still continue to happen sometimes, and even if the abilities and knowledge of the deposit responsible have improved, the operating body improvement will be designed step by step and the way to manage it improved; in FY4, more attention will be focused on this bulk of constraints.

A set of measures for control, follow-up and reduction of stock outs were carried out by the IFPP staff with emphasis on: monthly assessment at provincial depot of the FP supplies provided to the district depots and sharing this information with the project team to ensure timely allocation and availability of contraceptives at the HFs; strengthening of the District and Provincial Task Forces to ensure the availability of consumables focusing on the correct quantification of needs and taking into account the consumption and expected demand; and intensification of communication among the actors involved in the logistics chain of medicines at all levels, from the Provincial Drug Depots (DPM), District Drug depots (DDM) and MCH district managers and HFs managers.

Trainings on FP Commodities stock management and SIGLUS in Nacala-a-Velha (2 pictures on the left side) and Nhamatanda , July- September 2019

In this reporting period the logistic maps were used for the design of routes for distribution of FP consumables. TA was provided in the implementation of logistics maps, route plans and monitoring of the preparation of requisitions and distribution of medicines to the HFs, and timely replacement of contraceptive stocks at the HFs and district warehouses

Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment

To strengthen governance and civil society engagement around FP and contribute to stronger systems, IFPP is carrying out community score card (CSC) activity - a participatory, community- based tool for assessing the quality of health services. The community facilitators (IR2.1) and field supervisors facilitate the process of community assessment of FP/RH services, provider assessment on the same criteria, and support dialogues between community members and providers to agree on priorities for action and plan for improvement. The aggregated results from facilities is discussed with SDSMAS and DPS during one of the PHD quarterly review

59 meetings and is used to inform district and provincial advocacy plans which are led by partner CSOs, with support from N’weti. They alsoinform IFPP capacity building and systems strengthening efforts at SDSMAS and DPS

While CSC process implementation was a sensitive subject when carried out for the first time in FY2, the process was more easily performed in FY3 as MISAU also committed itself to carry out CSC through the Global Financing Facility funding mechanism.

As illustrated in table 14, while the CSC process was carried out in 14 HFs in FY2, during FY3, the CSC process was carried out in 12 HFs, six previous and six new:

• The HFs were pre-selected based on the quality of their existing relationship with communities in their catchment area, favoring the HFs with weaker relationships based on the community dialogue’s sessions conducted. • In each province, the CSC process starts with a five-day training gathering members of the respective SDSMAS and DPS as well as the representatives of CBOs and the Community Facilitators (CF) involved in sensitization activities in these specific HF’s catchment areas, and the IFPP respective field supervisors; • After the training, 8 community groups per catchment HF were established - 4 in distant villages and 4 in more nearby villages - and 1 group of HPs; • Twelve interface meetings during which representatives of the community groups and members of the HP’s group debated the results of the ratings obtained at community level and at HF level were performed and, eleven restitution meetings which restitute the results and plan of action of the CSC process during a public meeting, were led by the district authorities. • Eight CSC were carried out in Nampula province and only four in Sofala province as two initially planned were cancelled due to IDAI and the post-emergency phase (Bandua HF in Buzi district and Vinho HF in Nhamatanda district, both in Sofala province); • Out of the 8 HF in Nampula province, four of them were repeating the process as they had already implemented it in FY2 - Barragem, Alua, Corrane and Mucoroge; comparing the results achieved in FY3 against FY2, the HF of Barragem and Alua improved dramatically all their CSC criteria as illustrated by the green color which is predominant in FY3 and two of them (Corrane and Mucoroge HFs) didn’t evolved; also, in Sofala province, two of them were repeaters of the process – Inhaminga and Marromeu and when comparing the results achieved in FY3 against FY2, the two HF improved the majority of their CSC criteria as illustrated by the green and yellow colors which are predominant in FY3 with the exception of the two CMC criteria (composition and operationalization of the CMC). • Out of the six HFs carrying out the CSC process for the first time in FY3 (Netia, Mecuburi, Nioce and Quinga in Nampula and Murraça and Chibabava sede in Sofala, five HFs reached fair scoring (Netia, Mecuburi, Nioce , Quinga and Chibabava sede), while one (Murraça) received poor scoring by the communities.

• When comparing the results of the FY3 against the FY2, by criteria, overall, the composition and the operationalization of the CMC remain the most difficult to be satisfied from the community’s point of view (see the last two lines of the table mostly painted in red), inviting IFPP to further better understand how these two criteria could be more positively perceived by the communities and what further processes could be proposed to improve the composition and the operationalization of the CMC, from the point of view of the users; the customer service’s criteria, are bettering but still need improvement; the service delivery and the FP commodities availability are perceived by the community as satisfactory. • It is worth highlighting that this process is strongly supporting the communities to identify and discuss “communities – HF” problems.

Table 14: Comparison of the results of the Community Score Card processes carried out in FY2 and FY3, per HF

CSC carried out in FY2 CSC carried out in FY3 HF repeating the CSC HF initiating the CSC HF initiating the CSC process in FY2 process in FY3 process in FY3 Province NAMPULA SOFALA NAMPULA NAMPULA SOFALA NAMPULA SOFALA

Assessment Criteria

Alua Alua

Iuluti

Vinho Vinho Netia Nioce

Function

Quinga

Goonda Bandua Corrane Corrane Bandua Chipene

"How do you rate…." Murraça

Namaita Catulene

Mecuburi

Barragem Mucoroge Barragem Mucoroge

Inhaminga Marromeu Inhaminga

Namaponda

Marromeu R.H.Marromeu Chibabava-sede HP's permanency at his post during working hours? HP's punctuality at HF? Existence of cases of illicit charges

on FP services? IDAI User's waiting time for FP

consultations Cancelled due to due Cancelled Customer service Customer HP's courtesy during consultation?

FP services availability at this HF? HP's information provided by the HP about the advantages and disadvantages of the different FP methods? User's freedom to choose the FP method of his choice?

Service DeliveryService HP's information given about FP method's side-effects? FP commodities availability at HF? CMC's operationalization?

CMC CMC's composition? < or = to 50% > 50% and < or = 70% > 70%

Sub-IR 3.4: Improved government capacity to increase supply, distribution and retention of skilled workers

Based on the system assessment, capacity building and systems strengthening action plans, IFPP supported DPS and district managers to Table 15: Comparative between trained HP and registered in SIFO at end September 2019 more effectively manage Nampula FY1 FY2 Q1 FY3 Q2 FY3 Q3 FY3 Q4FY3 FY3 TOTAL the supply, distribution Health Providers trained 1424 508 132 115 55 169 471 2403 and retention of skilled Health Providers registered in 1327 429 179 93 31 174 477 2233 SIFO FP workers. Health Providers still to be registered in SIFO 97 79 -47 22 24 -5 170 IFPP has conducted Sofala FY1 FY2 Q1 FY3 Q2 FY3 Q3 FY3 Q4FY3 FY3 TOTAL Health Providers trained 891 524 57 34 16 26 133 1548 countless in-services Health Providers registered in 584 430 57 435 16 13 521 1535 trainings and SIFO Health Providers still to be 307 94 0 -401 0 13 13 competence-based TA registered in SIFO visits to ensure that FP providers and managers at the facility level are well prepared and have appropriate skills to provide high quality FP services to meet client needs. The CSC scoring is used to show satisfactory delivery of services and the availability of FP commodities. Task shifting and sharing approaches were used to expand FP service delivery. TA visits were provided to human resource managers and in-service focal points to register in HRIS-SIFo platform health providers trained in FP, CECAP, MCH and commodity management fields while promoting the establishment and functioning of the district training nucleus.

In addition, IFPP, in Nampula, supported DPS and district managers to carry out an analysis targeting the 66 HFs out of 237 with high HRH turnover and low performance in FP services indicators to more effectively manage SDSMAS HR rotation and retention drafting strengthening of handover processes and submitting it to Nampula DPS for approval.

IFPP provided TA in the institutionalization of district in-service training centers, strengthening staff competencies in operating the MISAU’s human resource information system (HRIS) or SIFO. The project has developed and distributed clear SOPs for the reporting and registration of in- service trainings using SIFO forms in the respective platform. Overall, this district support has decreased the volume of forms to be recorded at the provincial level. Most of the districts are recording the SIFO forms locally, thereby streamlining the training registration process and ensuring more complete data in SIFo. Table 15 illustrated this: in Nampula, the district in-service training centers have gradually diminished the gap but still have a gap of 170 HP not yet registered, while Sofala during the Q2FY3, resorbed the registration deficit that had occurred during FY1 and FY2 and during Q4 FY3 there was 26 trained HP in Sofala, but only 13 were registered in SIFo.

For this specific result, while IFPP indicator is related specifically to the registration of the facility eight -day FP training, FSS Teams provided competence-based TA visits to record and report in SIFo health professionals who attended trainings on all RH-FP/CECAP and FP-MCH commodity stock management and SIGLUS. Quality checks on SIFo records were conducted and passwords provided to HR managers/in-service Focal Points to Log into SIFo platform.

Trained health professionals in SIFo platform by HR managers/in-service focal points still should improve:

• Their skills to access, interpret and operate SIFo - High staff turnover/rotation to pro-actively together with SDSMAS and the head of the human resources provincial department mitigate the impact of HP turnover on the service delivery. • Improve the SDSMAS internal communication for capturing all ongoing district trainings and use of HR in-service annual plan and print SIFo forms to record participants. • improve the quality of records in SIFo formats. • Manage the available credit for mobile data to access SIFo and the poor connectivity. • Some districts have no computers or other means to access SIFo. In this case recorded SIFo formats are piled and send to DPS or any closest district to be registered.

Sub-IR 3.5: Improved generation, dissemination and use of FP data for more effective decision- making A district profile tool composed of 10 selected strategic FP program indicators was designed in FY1, tested and refined in FY2 and progressively introduced in all 36 districts in FY2 and FY3; the level of SDSMAS staff’s ability, to feed the district profile, at end FY3, is variable from one district to another but, overall, all districts have started to interpret the dashboard and use the data to define their next steps and quarterly activities, thus strengthening the SDSMAS to acquire strategic information and use it for evidenced-based decision making to improve FP program performance. The quarterly indicators are percentages of new FP users, WRA 15-19 having their first SRH consultation, initiators of a LARC, new users receiving FP services through others consultations integrating FP services; numbers of parturient women who received a PPIUD , who received another FP method; number of WRA accessing FP services through APEs, through MB; the percentage of HF registering FP commodity stock-out and the percentage of compliance with the district MSC tool. In Q4FY3, 23 (64%) districts receiving IFPP support out of 36, conducted their data review meetings using District Profiles (DPs), 15 (65%) in Nampula (Nampula City, Angoche, Erati, Nacaroa, Muecate, Murrupula, Mecuburi, Mogovolas, Ribaue, Malema, Lalaua, Larde, Nacala Porto, Mossuril e Moma) and eight (62%) in Sofala (Beira, Dondo, Nhamatanda, Buzi, Machanga, Chemba, Caia, e Chibabava). This represents 96% achievement against the quarterly target to conduct 24 quarterly district data review meetings using DPs per quarter but less districts have used it when checked against Q3Y3 results.

Monitoring, evaluation and implementation research

During FY3, the M&E team continued implementing activities to strengthen the quality of project data. The main activities implemented were:

• Routine Data Quality Assurance (RDQA) • Supervision and technical support • Support HFs to analyse and present monthly statistics • Support the M&E community component • Follow up of the study “Assessing the feasibility of including Six removal Indicators for LARC” in Mozambique’s national FP registers and indirectly the reasons for LARC removals.

Summarizing the main efforts carried out since the onset of the IFPP intervention through training for improving quality of FP data collection, it’s worthful to remember that:

• Correct filling of the FP and Integrated FP logbooks as well as the monthly aggregation FP summary are

presented and discussed during one afternoon Photo 9. Technical support visit to the during the eight-day FP facility-based trainings in resettlement center of Guara Guara in Buzi District and Support to the elaboration of which all eligible HP are participating (FY1 to date). monthly statistics in Erati district • MCH and NED SDSMAS responsible were trained as facilitators to correctly fill in the FP logbooks and the HF and SDSMAS FP monthly data aggregation forms. (FY2). • 50 district FP trainers were trained in Q3 and Q4FY3 and the curriculum included the correct filling of the M&E forms. • In FY3, also, two trainings focused on HMIS data quality control procedures (one in Nampula city for Nampula province and another in Nhamatanda for Sofala province) were carried out. • IFPP also gathered all district and provincial M&E (NED, NEP) and MCH responsible to intensify the use of the simplified RDQAs. SDSMAS and DPS M&E corrective and support plans were draft and aligned with IFPP’s intervention plan to maximize RDQA implementation visits, supervision and post-audit technical support and increase data quality process ownership.

IFPP increases the M&E team with 4 Table 16: Main M&E activities implemented in FY3 and FY2 additional members in FY3 as the % of Total Q1 Q2 Q3 Q4 TOTAL supported service delivery sites FY2 FY3 FY3 FY3 FY3 Supervision visits 86 8 9 19 21 57 providing FP counselling and services RDQAs 55 51 48 53 77 229 Support to the monthly summary HF 33 5 7 15 4 31

increased from 68% at the end of FY1 data aggregation and discussion Nampula Support monthly discussion of Data at 7 0 2 1 1 4 to 98% at end FY3, totaling 389 HFs. district Supervision 52 7 3 28 38 76

RDQAs 83 29 43 64 60 167

Support to the monthly summary HF The table 16 illustrates the activities 12 10 6 26 29 71

data aggregation Sofala supported by the M&E team Support monthly discussion of Data at 1 1 0 1 1 2 district highlighting the focus on RDQAs performed; note that the table Table 17: Main M&E activities implemented in FY3 and FY2 illustrates only the efforts carried out by the M&E team, meanwhile the # of HF having completed at % of HF end FY3 the # of HF # of covered IFPP district’s coordinators and eligible unique District with at st nd rd More for HF with 1 2 3 officers (MCH nurses) are also least 1 than 3 RDQA a RDQA round round round participating in district quarterly M&E RDQA RDQA RDQA RDQA RDQA data analysis meetings, covering Angoche 12 10 83% 3 6 1 0 Mogincual 6 6 100% 2 3 1 0 additional districts as each team has Liupo 3 3 100% 1 2 0 0 Npla Cid 20 16 80% 10 6 0 0 in average 2 to 3 districts. Erati 11 10 91% 0 8 2 0 Memba 13 11 85% 6 4 1 0 Meconta 8 7 88% 0 4 2 1 Coverage and numbers of HFs Nacaroa 7 7 100% 0 4 3 0 prioritized for receiving RDQAs and Muecate 11 10 91% 3 5 1 1 Mogovolas 7 7 100% 1 5 1 0 distribution of the HFs per number of Moma 11 9 82% 4 3 2 0 Lardes 5 4 80% 2 2 0 0 RDQAs received are illustrated in table Monapo 17 12 71% 5 6 1 0 Mossuril 10 7 70% 2 4 1 0 17; note that, IFPP is prioritizing HC Ilha Moç. 5 5 100% 3 2 0 0 N.Porto 10 10 100% 6 3 1 0 and hospitals (212 on 237 HFs existing) N.Velha 5 5 100% 2 3 0 0 in Nampula provinces; 86% (321/374) Murrupula 6 5 83% 1 0 3 1 Rapale 8 7 88% 3 3 0 1 of the HFs have already received at Mecuburi 12 7 58% 6 0 1 0 Ribaue 9 10 111% 2 6 1 0 least one RDQA visit while 58% Malema 10 9 90% 2 2 5 0 Lalaua 6 4 67% 4 0 0 0 (218/374) have received at least two NAMPULA 212 180 85% 68 81 27 4 RDQAs visits, 19% (70/374) have PROVINCE Beira 17 16 94% 5 11 0 0 received at least three RDQAs visits Dondo 15 14 93% 5 8 1 0 Nhamatand 18 17 94% 3 14 0 0 and 3% have received more than three Buzi 15 14 93% 3 8 3 0 Chibabava 16 14 88% 3 3 7 1 RDQAs visits. The daily tally sheet of Machanga 11 10 91% 0 0 8 2 Caia 12 8 67% 1 5 1 1 the SRH/FP consultation continue to Marromeu 10 7 70% 1 2 3 1 be too frequently underutilized, FP Chemba 9 8 89% 1 4 0 3 Gorongosa 14 14 100% 6 3 5 0 integration monthly summary forms Cheringoma 7 5 71% 2 2 1 0 Maringue 10 8 80% 4 4 0 0 are not correctly aggregated and in Muanza 8 6 75% 1 3 2 0 SOFALA 162 141 87% 35 67 31 8 Sofala they are still challenges in PROVINCE BOTH aggregating APE data. Acceptable data 374 321 86% 103 148 58 12 PROVINCES quality, following MISAU scale is ≤ 10% for data discrepancy between data observed in primary logbook and data inserted in the HMIS

65 data base, medium data quality is between 10 and 20% and non-acceptable data quality is over 20% of discrepancy. The figures 17a and 17b illustrated the increases achieved between RDQA 1 and RDQA 2 for the HFs having Figure 17a and 17b: Data quality comparison received at least two RDQAs between HFs having received two RDQAs in Nampula respectively in Nampula and in Sofala and in Sofala provinces provinces; acceptable data quality, following MISAU scale is ≤ 10% for data discrepancy between data observed in primary logbook and data inserted in the HMIS data base, medium data quality is between 10 and 20% and non-acceptable data quality is over 20% of discrepancy. In case that data logbooks aren’t available at HF’s level, RDQA for this HF is considered as “not acceptable”. Despite efforts carried out, only 10% of HFs improve their data quality in

Nampula and 5% in Sofala; taking in account the training efforts carried out and the involvement of partners staff, the results are minimal even if improving: IFPP will discuss these results with each DPS and in the next quarterly DPS reviews asking for more involvement and political data commitment from the DPS and SDSMAS leadership; furthermore, as this problem is not the solely problem of Nampula and Sofala provinces, but exist also in several others provinces, the central SRH/FP TWG should propose to review the data logbooks to the MISAU, as data quality is hampering evidence-based decision for the FP program.

When crossing Figure 18: Percentage of Jadelle/Implanon distributed by DPM versus FP commodities Reported thru HMIS, per year, from Jan 2015 to Sept 2019 - Nampula supplied data – province meaning supplied thru DPM to the districts – and, the HMIS reported data, by contraceptive method type (e.g. implant is aggregating Jadelle and Implanon in the HMIS data), the data of injectables (DMPA , Sayana Press) and Pills (Microgynon, Microlut) supplied thru DPM and the data registered in the HMIS are roughly aligned; but, when comparing implants supplied thru DPM and data registered in the HMIS, the HMIS data are the double of the quantities supplied, this discrepancy is very concerning, even if the quantities supplied thru DPM increased from around 10,000 units in 2016 to around 30,000 units in 2018, already illustrating huge progress in service delivery in a period of two years; there is somewhere a double counting in the HMIS data chain, which should be the concern not only of IFPP but of all SRH/FP partners and MISAU, DPS, SDSMAS leadership in order to identify and correct this double counting. The figure 18 “Percentage of Jadelle/Implanon distributed by DPM versus reported thru HMIS, per year, from Jan 2015 to Sept 2019 - Nampula province” is illustrating the discrepancy and is highlighting that the percentage of discrepancy trends to diminish as it was around 145% in 2017, 124% in 2018 and 100% in the nine first months of 2019.

For the FY4, the M&E team will continue to strengthen the effort to improve data quality and start the graduation process of the health facilities with more than 2 RDQAs with acceptable data quality, focusing on these presenting more difficulties.

Support to the community component The M&E team in both provinces supported the community component along this FY3 to ensure reliability of records and reporting of data produced by the community component, better filing of the community referral forms, improve involvement of and coordination with APEs settled in the areas benefiting of community dialogues, focusing on APE’s and TBA’s participation to the community dialogue as well as increasing the number of community referrals towards APEs. In order to ease the data entry workload of the field supervisors and consequently diminish the

67 number of data entry errors, community data App was transitioned from DHIS2 to Commcare, therefore the following activities were implemented:

• Train the community supervisor in using the Commcare App, • M&E technical assistance followed up visits in subsequent quarters • Monthly and then quarterly data review and analysis meetings in subsequent quarters • Validation of referrals and confirmed referrals at HF level • Supervision visits to CF in the filling of the forms and the confirmed referral’s verification • Support to APEs through participation at the district’s APEs meetings and trainings to clarify the registration logs, the summary forms, explanation of the APE’s FP indicators and their analysis

Implementation research study to test the feasibility of including a set of six indicators for LARC in Mozambique’s national family planning register

The Evidence to Action (E2A) Project is USAID’s global flagship project for strengthening family planning and reproductive health service delivery. As a member of the Implant Removal Task Force and the lead of its data subgroup, E2A conducted a study in collaboration with the Integrated Family Planning Project (IFPP) to test the feasibility of including a set of six removal indicators for long-acting reversible contraceptives (LARCs) in Mozambique’s national family planning register. Therefore, the M&E team introduced an additional form to the existing register logbook of 17 HFs enrolled in the study; the additional columns proposed include i) Reason for seeking removal, ii) Date of insertion, iii) Date of removal, iv) Table 18: Reasons for removal Method removed, v) Removal outcome, vi) Reasons for referral. Indirectly, this study is documenting what are 1 Has expired 2 Change to another method the possible and most frequent reasons for implant and 3 Opted to get pregnant IUD removal as in the column “reason for seeking 4 Vaginal bleeding (spotting, heavy) 5 Vaginal discharge (severe) removal”, the HP had to enter a code number 6 Arm discomfort/pain corresponding to the following possible reasons as 7 Headache 8 Back pain detailed in the annexed table 18. 9 Husband/in-laws opposition The study was submitted to National IRB and approved, 10 Mother’s opposition 11 Infrequent or no sex launched, in October, (Q1FY3) with the stakeholder 12 Reduces sexual pleasure meeting attended by Nampula and Sofala DPS 13 Interferes with body natural processes representatives and conducted jointly by Fariyal Fikree, 14 IUD/Implant failed (got pregnant) Senior Research Adviser of E2A and MISAU; data 15 IUD expulsion/partial expulsion 16 Others (Specify) collection tools were piloted in two Maputo HFs; the selected HPs involved in the study data collection were trained in the first week of November

68 together with the respective DPS and, data collection started on the 21st of November for a 6 months period.

The first draft of the report is still being reviewed internally and by USAID and MISAU partners and will be disseminated after completion; meanwhile, some programmatic recommendation for IFPP can be already taken in account:

• Over the six-month study period, 795 LARC clients sought FP services for removals. A considerable proportion (14.1 percent) decided not to remove following the initial targeted counseling session offered per LARCs removal guideline to all removal clients; 83.5 percent were successfully removed, highlighting the importance to equip the HP with the required skills to performing a highly qualitative pre-removal counselling session. • Frequent reasons for seeking removals included side-effects particularly vaginal bleeding and desire to get pregnant. Quality of family planning services offered at three points of contact (pre-insertion, initial targeted counseling session, and post-removal FP session) illustrated topics for enhanced and/or refresher FP counseling training. These included appropriate assessment of clients’ desire to get pregnant within two years, particularly among nulliparous women (pre-insertion); balanced counseling for informed decision making; and strengthened counseling approaches, particularly for side-effects and misperceptions.

FP and Environmental Compliance During FY3, 227 HFs (139 HFs in Nampula and 88 HFs in Sofala) were assessed for environmental compliance. Only 5% of them were fully compliant. Most of the HFs are facing difficulties to segregate the different types of waste (waste biological such as placenta, infectious waste such as used needles and syringes, common waste) and difficulties in the decontamination process for medical equipment, such as temporarily immersing the medical equipment used (e.g. speculums, forceps, trawlers) in basins with chlorine solution, no appropriate incinerator, and no fence surrounding the sanitation area. IFPP has designed, together with the respective DPS, an action plan to support HFs in correcting the identified weaknesses and has purchased in Q3FY3 some of the missing materials such as basins, water reservoirs with tap for hand washing, trash buckets for correct segregation of waste and small water tanks to increase the quantity of water availability at HF level. In Q4FY3, IFPP has recruited a biosafety project officer improve this paradigm during next FY.

For FP compliance, 220 HFs were assessed (94 in Sofala and 126 in Nampula) and 28% were fully compliant. The non-compliant HFs are mainly non-compliant because a few HPs did not yet participate in the eight-day FP training. Therefore, to minimize this situation, IFPP is implementing a specific one afternoon module for the HPs recently posted. A total of 127 HPs were trained through this module in FY3.

Project Performance Indicators Goal: Increase use of modern contraceptive methods

IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services

Achieved Achieved FY3 Annual LOP Indicator FY1 FY2 Annual % Q1 Q2 Q3 Q4 Target Target Achieved 595,202 278,144 1,018,869 80,862 930% 210,348 177,416 199,942 164,593 Since April 2016, the MISAU “FP new user” indicator defined new users as “first time users in life.” For 1.A. # new the FY3, IFPP proposed the target of 80,862 defined taking in account the contraceptive prevalence rate users of (CPR) and the unmet need for FP (IFPP baseline). Categorizing a client as a first-time user in her life is modern dependent on information provided by the user. The reliability of this information depends on the HF contraceptive provider ability and time. Before April 2016, the concept of new user was “first time for the current methods year” and obviously, this indicator “first time user in life” doesn’t seems appropriate in Mozambican context. In this FY3 report, IFPP updates the data related to Q2 as DPS Sofala update its data for Q2 The total for FY3 is 752,299 new users reported against 80,862 planned, an annual percentage achieved of 930%. 3,045,547 544,230 1,159,123 698,036 134% 247,899 211,979 251,687 220,659 The IFPP suggested the inclusion of this new indicator, "Number of women initiating a contraceptive method", disaggregated by type of method as more reliable to monitor the trend of FP access in the # of women FY2. FY2 is probably overreported due to implementation of the MCH National health week and the initiating a SRH and CECAP “caravan” organized during July-August 2018. Until the end of Q3 IFPP reached 102% contraceptive of its annual target. In Sofala during the month of May was held an emergency health week and this method week contributed with 60,706 women initiating a contraceptive method representing 54% of what was reached by the whole province. The total for FY3 is 932,254 initiators reported against 698,036 planned, an annual percentage achieved of 134%. This indicator is more reliable that the one of new users, meanwhile the FP post-IDAI emergency campaign contribute to most probably overreporting, explaining why we are still above 120% of IFPP yearly target. 1.B. # 658,958 399,381 639,144 565,067 114% 158,619 149,149 166,219 168,651 continuers In coordination with the MISAU definition, a “continuer” user is a woman who used a FP method already users of in her life and should be registered only once in the FP logbook. The FY2 results were influenced by the modern National Health Week (NHW) and the CECAP caravan. IFPP surpassed the annual target by 14% The total contraceptive for FY3 is 642,638 continuers users reported against 565,067 planned, an annual percentage achieved methods of 114%. 2,963,877 591,722 1,233,514 1,282,855 81% 280,859 229,920 279,893 252,038 Data disaggregated by method are presented in the PMP in annex. The FY2 annual target was 615,391 CYP. At the end of FY2 the project had reached 200% of the annual target. This achievement was influenced by the NHW and the 2017 contraception week that occurred during Q1 as well as the SRH 1.C. Couple and CECAP “caravan” organized during the July-Sept 2018. The FY3 annual target proposed, based on Years of FY2 achievement, was 1,282,855. At the end of FY3, 1,042,710 CYP were reported thru the HMIS Protection corresponding to eighty one percent of the annual FY3 target. Meanwhile, the comparison between the number of commodities supplied through DPM and the FP services registered through HMIS, shows significant discrepancies, specifically for IUD and Implants which, in turn, over-estimated the FY2 CYP achieved. The magnitude of the discrepancy in FY3 has already diminished when comparing with FY2, explaining the 81% of achievement and illustrating the efforts carried out to improve data quality.

Achieved Achieved FY3 Annual LOP Indicator FY1 FY2 Annual % Q1 Q2 Q3 Q4 Target Target Achieved 18,465 3,136 10,000 16,622 66% 2,231 2,483 3,753 2,566 1.D. # During FY1, 3,136 WRA receiving contraceptive services in HIV services were reached, 10,000 in FY2 and women 11,033 in FY3 illustrating still an increase trend over the years, but the planned FY3 target was too receiving ambitious as IFPP reaches 66% of the annual target. One reason for this lower achievement is related contraceptive to the recent introduction of ART follow up consultations passing from quarterly to bi-annually. The services in other reason is that the WLHIV have the choice to access FP services in every outpatient consultation HIV services at HF level (Integration of FP services in all outpatient consultation). Furthermore, dedicated consultation room attending only ART patients is existing only in the biggest HFs while in smaller HF, the ART consultation is integrated in the common outpatient consultation room. Achieved Achieved FY3 Annual LOP Indicator FY1 FY2 Annual % Q1 Q2 Q3 Q4 Target Target Achieved 1.E. # 330,059 36,427 71,373 79,876 98% 18,097 17,412 20,885 21,563 postpartum During Q4FY3, 5,781 PPIUDs were inserted and 15,782 women accepted another modern contraceptive clients method, totaling 21,563 and representing 98% of IFPP FY3 annual target. Compared to the number of accepting a institutional deliveries registered in Q4FY3, 25% of the women who gave birth at an HF have accepted modern one of the eligible post-partum FP methods. The total for FY3 is 77,957 Immediate post-partum FP users contraceptive reported against 79,876 planned, an annual percentage achieved of 98%. method prior to or at discharge 1.F. # users 338,751 47,072 125,941 84,454 255% 46,017 52,818 60,535 55,871 receiving modern The total for FY3 is 215,241 WRA served by APEs against 84,454 planned, an annual percentage achieved contraceptive of 255%. Meanwhile this number integrated the FP post-IDAI emergency campaign data allocated to methods APEs which are overreported as the pick of WRA served in May drop down in the following months (see from APEs at detailed explanation in APE chapter). community level

Comments: Cyclone Idai affected the data being reported during Q2 in Sofala, but during this quarter the data from Q2 was updated in SISMA for CSR/PF indicators. In general, indicators show a sustained expansion of IFPP. The Q1FY2 and Q4FY2 data was strongly influenced by the MCH NHW and the contraception week. It was expected that some of the new SAM users and continuers reached during these two events will have difficulty refilling their methods in future quarters, which will increase the SAM discontinuation rate. Meanwhile, the initiators for LARCs are important contributors to the mCPR and these events have also increasing the IUD and implant additional user numbers.

Figure 15 shows the trend in women initiating a contraceptive method. Q1FY2 received a huge pull with the NHW that was also repeated during Q4FY2 with the CECAP “caravan” organized during the June-July 2018. During Q1 and Q2 FY3 the NHW was canceled and the data represents only routine HMIS data, but during Q3 an emergency health week was held in Sofala representing 54% of Sofala results which seems to be unlikely. A first verification with the HP in charge of data aggregation confirm us that the FP data produced at the HF level during the emergency week were reported two times as the instruction received from the DPS was to report the emergency data in the daily summary of the emergency health week and the same data were also aggregated in the HF monthly summary instead of being not aggregated.

Figure 15. Trends in women initiating a contraceptive method by type of method in Nampula and Sofala provinces - October 2016 to September 2019 (w/o PPFP at Maternity and minilap)

Pills Injectable Implant IUD 300000

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Nampula Sofala

Couple year protected (CYP) data (Figure 16): first, data for Q1FY1 are not comparable to the other quarters, as IFPP reported data from only 17 districts in Nampula compared to the 23 in the following quarters. For Q2FY1, data reported on a quarterly base are comparable. During Q4FY3 the CYP in Nampula increased by 8,5% compared to Q3Y3, with LARC being 63% of the CYP. In Sofala, the CYP decreased 29,4%, because in Q3FY#it was held to the emergency health week. Data from Q1FY2 and Q4FY2 were influenced by due to implementation of the MCH NHW and the SRH and CECAP “caravan” organized during the 2018 Russia football world championship.

Figure 16. Trends in CYP in Nampula and Sofala provinces - October 2016 to September 2019

Pills Injectable Implant IUD Pos Partum IUD T. Ligation 250000

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Nampula Sofala

IFPP is increasing access to immediate post-partum FP methods (IUD, implants and progestin pills). The percentage of the women who give birth at HFs and adopt PPIUD (Figure 17) is stabilizing along the FY2 quarters and FY3 reaching 7,6% in Nampula province and 4,9% in Sofala province. A specific strategy was designed together with DPS to give a second breath for PPFP in FY3. Figure 17. PP IUD and institutional deliveries by province from October 2016 to September 2019

PP IUD in IFPP district PP IUD in non IFPP district % of PPIUD 5000 15.0% 4500 13.0% 4000 11.0% 3500 7.7% 7.0%7.1% 7.6% 3000 6.4%6.9% 6.9% 9.0% 5.6% 2500 5.2% 5.2%5.4% 5.0%5.0%5.0% 4.9% 7.0% 4.3% 4.7% 4.7%4.3% 4.8% 2000 2.6% 2.7% 5.0% 1500 1.3% 3.0% 1000 500 1.0% 0 -1.0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 FY1 FY2 FY3 FY1 FY2 FY3 Nampula Sofala

When analyzing post-partum women accepting a modern contraceptive method at the maternity level (Figure 18 - PPIUD and other PP methods as captured and reported under HMIS-SISMA), Nampula province reached 27% and Sofala province 16% - these data seems over-reported through the HMIS when compared to the IUD and implants supplied through DPM.

Figure 18. % of women accepting Post-partum FP method at Maternity by quarter and province from October 2016 to September 2019 PP IUD Other methods % of women accepting a PPFP method

18000 100% 16000 90% 14000 80% 12000 70% 60% 10000 50% 8000 26% 26% 27%27% 40% 6000 23% 23%23%23% 25% 16% 15%16%18%19%18%18%17%16%16%16% 30% 4000 7% 9% 20% 2000 2% 10% 0 0% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 FY1 FY2 FY3 FY1 FY2 FY3

Nampula Sofala

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

FY3 LOP Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 1.1.1. # health 3,749 2,309 1,032 540 112% 189 149 71 195 providers trained on An accelerated start-up supported the MISAU to reach its 2020 FP targets. During the FY1 and modern methods of FY2 the IFPP trained 3,341 HPs. During FY3, IFPP trained 604 HPs reaching 112% of the annual contraception target of training (540 HPs). 1.1.2. % of health 80% 90% 93% 80% 99% 82% 93% 99% 93% providers who have A total of 93% of the HPs trained during Q4FY3 completed the post test of trainings completed the training successfully, reaching 116% of the annual target on modern methods of contraceptive with positive score in the post test 1.1.3. % of supported 100% 68% 92% 100% 98% 94% 97% 98% 98% service delivery sites providing family At end of FY3, 389 out of 399 HFs (98%) had already at least one HP trained in FP through planning counseling IFPP. During Q3FY3, 157 HFs in Sofala out of the 162 and 232 HFs out of the 237in Nampula and/or services had a trained HP.

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

Sub- IR 1.2: Increased access to modern contraceptive methods and quality, community-based FY3 LOP Achieve Achieve Annual % Indicator Annual Q1 Q2 Q3 Q4 Target d FY1 d FY2 Achieved Target 1.2.1. # of additional USG-assisted community 3,735 1,763 723 800 66% 168 57 128 190 health workers (CHWs) During FY3, 164 APE, 224 TBA, 113 IPC and 42 community facilitators were trained totaling providing family planning 543, reaching 66% of the annual target. The IDAI influenced this indicator as most of the information and/or services activities in Q3 were strongly impacted to respond to the post-IDAI emergency. 12,594 1,639 3,383 3,160 105% 1,099 397 1,150 657 1.2.2. # mobile brigades conducted including DuringFY3, IFPP supported 3,303 MBs (1532 in Nampula and 1771 in Sofala) reaching 105% of contraceptive services the annual target.

Comments The target for MBs in FY3 was calculated by considering the number of HFs receiving support from IFPP. IFPP will support one MB per month per supported HF. The life of project (LOP) target was changed to reflect this calculation from 47,306 to 12,594. The first LOP target was calculated under the assumption that the project could support at least three MBs per month per HF. Considering that in peripheral HFs only two HPs are available, and they oversee a lot of other public health programs and services, the target has been revised. Data from Q1FY2 was influenced by the MCH NHW and

the 2017 contraception week while data for Q4FY2 was influenced by the SRH and the 2018 contraception month which occurred in September 2018. Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services

FY3 LOP Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 44% 57% 68% 35% 182% 65% 67% 64% 62% 1.3.1. % confirmed With CwS platform, all IPC referrals are now electronic and are accountable. For clients receiving a referrals from paper slip from a triplicated referral copy-book from CFs and for client referred by TBAs whose referrals communities are confirmed thru the monthly HF-TBAs meetings. Out of 37,047 referrals made (paper and to facilities for electronic), health providers based at HFs have confirmed 22,851 referrals. When analyzing FY3, out of FP services the 152,202 referrals delivered thru CHW, health providers confirmed 97,274 corresponding to 64% of confirmation rate.

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

FY3 LOP Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 2.1.1. 1,147,520 174,531 322,583 188,160 283% 125,138 98,238 117,442 192,025 # contacts During Q4 FY3 192,025 contacts were conducted. The annual target of FY3 is 188,160 contacts, less than conducted by what was achieved during FY2. IFPP team has done the exercise of revising the annual target suggesting trained the new target of 459,804 contacts for FY3. By the end of FY3 the target was surpassed by 183% TBAs/activists corresponding to 532,843 contacts carried out during FY3. In relation with IFPP LOP target (1,147,520), to women at end of FY3, IFPP has already totaled 1,029,957 which correspond to 90% of the LOP target.

Comments The number of women contacted in Nampula during FY3 was about 386,775 (195,634 by CFs, 160,058 by IPC and 30,283 by TBAs) and 146,068 (104,825 by CF, 32,140 by IPC and 9.103 by TBAs) in Sofala.

Sub-IR 2.2: Improved community environment to support healthy FP behaviors FY3 LOP Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 13,056 0 3,226 3,600 108% 673 543 986 1,685 2.2.1. # community IFPP reached 108% (3,887/3,600) of the annual target; this Q4FY3 1,153 community dialogues were dialogues conducted in Nampula and 532 in Sofala and during FY3 a total of 2,501 community dialogues were conducted on FP conducted in Nampula and 1,386 in Sofala making a total of 3,887. In relation with IFPP LOP target (6 sessions (13,056), at end of FY3, IFPP has already totaled 7,113 community dialogues which correspond to completed) 54% of the LOP target. FY4 planning have already encompassed a serious increase in community dialogues to be carried out. 1,475 323 321 384 112% 127 165 124 13

2.2.2. # During FY3 a total of 429 radio sessions were broadcasted (277 in Nampula and 152 in Sofala) community radio sessions broadcasted on FP/HTSP

Sub-IR 2.3: Improved systems to implement and evaluate SBCC interventions FY3 LOP Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 2.3.1. # meetings NA 2 1 0 1 0 0 held with SBCC project to During the FY3 a meeting was held with IREX. plan/coordinate SBCC approaches 2.3.2. # capacity 10 2 2 2 100% 0 0 0 2 building sessions for community A capacity building session was held in both provinces radios and community groups in SBCC for FP

IR 3: Strengthened FP/RH health systems FY3 LOP Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 2 2 2 2 100% 2 2 2 2 The project provided TA to DPS Nampula and Sofala MCH division in the preparation and budgeting of PES 2020 (provincial) and PESOD (at district level) to include FP related 3.A. # DPS including activities considering the project intervention areas. FP interventions in Throughout the FY3, during AT visits to districts and DPS special attention was given to annual PES and the joint review of the CDFMP, the PES/PESOD activities (internal and external) that budget culminated in the submission of the final documents to competent authorities. Likewise, workshops were held to consolidate the planning exercise, considering the identified gaps in order to correctly fill the CDFMP for each health program at the district level.

36 7 21 25 76% 5 6 12 1 During the Q4FY3, district Management Standards Compliance (MSC) assessments were conducted in 2 districts, 1 Baseline (round1) in Chemba, Sofala and one round5 in 3.B. # SDSMAS/DPS Ribaue, Nampula. The overall compliance with the management standards in Chemba achieving achieved 37% with all areas scoring less than 60% and, in Ribaue, 98%. satisfactory scores in Over the time when there is a change of managers in the SDSMAS there is no delivery MSC assessment of service and orientation of the new managers hence happens these decreases in the score whenever there is a change of managers. Overall, IFPP reached 76% of the annual target by having 19 SDSMAS during FY3 achieving more that 80% in the last annual MSC assessment scored.

5% 14% 6% 10% 3% 7% 26% 12% 3%

3.C. % USG-assisted For reporting this indicator, the CommCare App and SIGLUS was used as the source of service delivery information to record the stock outs of the five main methods of contraception (IUD, points (SDPs) that Implant, progesterone -only oral contraceptives, combined oral contraceptives, and experience a stock DMPA-IM). A total of 137 HF were assessed in Nampula province, which corresponds to out at any time 58% of the total HF (237 HF), distributed among those implementing SIGLUS (132 HF) in during the reporting 12 districts (Monapo, Angoche, Nampula City, Moma, Rapale, Nacala Porto, Nacala-a- period of a Velha, Memba, Erati, Meconta, Muecate and Nacaroa), and those mentored through contraceptive CommCare App (5 HF) in 3 districts (Mecuburi, Malema and Mogovolas). In Sofala, a method that the SDP is expected to total of 70 HF were assessed, corresponding to 43% of the total HF (162), distributed provide between those implementing SIGLUS (64 HF) and those mentored through CommCare App (6 HF) and none reported stock-out. Overall 6 (3%) out of 206 SDP assessed (6 in Nampula and zero in Sofala) registered stock-outs

3.D. % of supported 100% 32% 45% 90% 46% 46% 45% 41% 46% SDPs with all eligible At the end FY3 46% of all HFs in both provinces (56% or 90 out of 162 HFs in Sofala, and health providers 40% in Nampula or 94 out of 237 HFs in Nampula) had all eligible health providers trained in a range of trained in a range of modern contraceptive methods. Although it’s important to note modern that 98% of the HFs in Sofala and in Nampula already have “at least one HP trained in contraceptive FP”. As a bunch of basic MCH nurses were required to enter in a middle level MCH methods promotion training, the expected coverage of 90% wasn’t achieved.

Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution FY3 LOP Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 139 126% 79 70 (46 114 (30 (51 Sof + (38 Nam + 152 52 128 152 (30 Sof, Sof, 41 141 Npla = Sof,84 109 24 192/ 152) Nam) Nam) Sof) Nam) 3.1.1. # DPS and IFPP during Q4 provided TA to 70 provincial and district managers (Nampula 46 in Nampula SDSMAS staff and 24 in Sofala) from Planning, FP/MCH, NED and depots to review progresses, update receiving and ensure the alignment of their quarterly operational plans with 2019 PES/PESOD TA/capacity- indicators and targets. Supervision visits were reframed to be more integrated and building in FP including mobile brigades, on-the-job-trainings for APEs, PTs and health providers in planning, integrated FP, RDQA meetings and TA to Co-Management and Humanization Committees. budgeting and implementation This is expected to lessen the costs and overcome delays in the implementation of PES/PESOD. From the 70 provincial and district health managers receiving TA in this quarter, 14 are been receiving capacity building sessions for the first time in the LOP (10 in Nampula and 4 in Sofala). Analyzing FY3, a total of 192 unique individuals received TA, 141 in Nampula and 51 in Sofala.

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

FY3 LOP Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 3.2.1. # of 38 28 36 36 100% 100% 100% 100% 100% supported This indicator has already been reached at 100% during Year 2 with all districts having logistics maps districts with a developed and implemented. Maps are being used and updated during HSS TA visits. documented FP logistics map to optimize commodity distribution, requisition and reporting

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

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

Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment FY3 LOP Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 3.3.1. # of HF 42 0 13 14 79% 0 0 8 3 that undergo Three CSC processes were finalized during Q4FY3 and 2 HF (Bandua, Vinho) in Sofala province had CSC feedback the planned CSC cancelled due to IDAI and post emergency and reconstruction activities; 1 CSC processes process (Chibabava sede) has nearly finished the CSC cycle with the public dissemination gathering through delayed to Q1FY4, most probably due to the organization of the general election. community discussions at least once per year

Comments There are no comments for this quarter on this activity.

Sub-IR 3.4: Improved government capacity to increase supply, distribution and retention of skilled workers FY3 LOP Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 47 528 187 236 (16 (435 (13 (57 Sof; Sofala 3.4.1. # DPS, 3,533 1,911 859 540 185% Sof; Sofala; 179 ; 31 SDSMAS & HF 93 174 Nam) Nam) staff trained in Nam) Nam) family planning that are During the Q4FY3, IFPP registered in SIFO 174 HP trained in Nampula province and 13 HP registered in e- trained in Sofala. During the FY3 a total of 998 HP trained in FP were registered (477 in SIFo (database) Nampula and 521 in Sofala) surpassing the annual target in 85%. In relation with IFPP LOP target (3,533), at end of FY3, IFPP has already totaled 3,768 which correspond to 107% of the LOP target.

Comments IFPP provided TA in the institutionalization of district in-service training nucleus, strengthening staff competencies in operating the MISAU’s HRIS or SIFO platform. The project also developed and distributed clear SOPs for the reporting and registration of in-service trainings using SIFO forms in the respective platform.

Sub-IR 3.5: Improved generation, dissemination and use of FP data for more effective decision-making

Indicator FY3 LOP Achieved Achieved Annual % Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 34 18 (12 23 (8 (12 in 36 16 16 24 96% 26 Sof: Sof; 6 Sof;15 22 Nam) Nam= 3.5.1. # of Nam) districts that hold In Q4FY3, 23 (64%) districts receiving IFPP support out of 36, conducted their data review quarterly data meetings using District Profiles (DPs), 15 (65%) in Nampula (Nampula City, Angoche, Erati, review meetings Nacaroa, Muecate, Murrupula, Mecuburi, Mogovolas, Ribaue, Malema, Lalaua, Larde, using district Nacala Porto, Mossuril e Moma) and 8 (62%) in Sofala (Beira, Dondo, Nhamatanda, Buzi, profiles Machanga, Chemba, Caia, e Chibabava). This represents 96% achievement against the quarterly target to conduct 24 quarterly district data review meetings using DPs per quarter and 32% reduction when checked against Q3Y3 results (impact of general election and very low availability of the SDSMAS staff).

Collaboration with other donor projects

During this reporting quarter, coordination meetings took place with government partners (MISAU, PHDs, and District Directorates of Health) and other partners such as MCSP, UNFPA, FP2020, Program-Procurement and Supply Management (PSM), Thinkwell, Health Policy Plus (HP+), WHO, ECHO Project and Mozambique Monitoring, Evaluation and Mechanism Services (MMEMS).

The main agenda items at the discussion with the MISAU, through three national technical working groups (adolescent and youth, FP and SRH commodities taskforce) include:

1) Discussion and review on recently piloted AY logbooks and tools; 2) SRH commodities forecasting for the quarter; 3) Preparation for Contraception day and week; 4) Joint supervision visits to provinces; 5) intensive work on DLI 2 with regards to service provision at secondary and technical schools; 6) FP2020 implementation plan; 7) A discussion on the preliminary results of service availability, readiness assessment (SARA); 8) Discussion on ECHO (Evidence for contraception and HIV options) study; 9) The start of costed implementation plan development with HP+ and Thinkwell; 10) Preparation of National FP Technical Meeting; 11) ECHO Trial results announcement and dissemination preparation; 12) The second phase discussion on transition to generics such as Zenia F for Microgynon, Triclofen for DMPA-IM, Fenipop for Microlut and Levoplant for Jadelle; 13) Revison on Injectables procurement plan considering the phase-in of Sayana Press; 14) Discussion on FP logbooks revision; 15) Discussion on FP estimation tool;

At the provincial and district level, regular meetings were held to coordinate and plan activities each month such as trainings, mentorship visits, supervision visits, MBs, commodities redistribution and data review and district profile meetings.

With MCSP main discussion were around fixed asset disposition (vehicles and motorbikes) for Nampula and Sofala Provinces. Additionally, the team attended two important meetings, one for the referral network and one during MCSP closeout in Nampula to ensure sustainability in core areas.

After the kickoff meeting held in December and field work conducted by MEMMS for MTE preliminary report was deeply discussed with the evaluators and USAID.

PSM was key partner to engage in discussion for contraceptive availability in-country and particularly in Nampula and Sofala, as well as to compare the distribution data and HMIS data, this analysis is still ongoing and will be used to present during National FP Meeting.

IFPP COP also attended the FP2020 workshop in Addis with country focal points and recently nominated Youth Focal Point, providing all the needed support and roll-out of the country plans.

With ECHO project discussions are being made to ensure collaboration in CECAP and Integration of FP services into HIV area.

Upcoming Plans

IR 1: • Continue the innovative facility peer twinning strategy in Y4, enabling peer-to-peer learning and development as part of the quality improvement process • Increased night-shift mentoring activities involving the recently-trained district trainers • For low-volume HF providers, an internship approach will be implemented so that they have practicum opportunities at the main district-level HF mainly for implant, IUD and PPIUD • implement a management training for HF’s responsible, led by the SDSMAS directors and district chief doctors (see IR3) • Continue ISL optimization workshops with maternities that have low outcomes with the involvement of the DPS. • Organize additional specific in-service training for the providers, including addressing adolescent and youth issues, who have already been trained through IFPP but identified as poorly performing in post-training period through mentorship (3-days advanced FP updates). • Train the recently posted eligible HP as they are recruited by the DPS • Conduct an additional five-day TOT for the MCH district responsible and district FP focal points, in Sofala province, to increase their skills in PPFP in-service training and mentoring, including FP antenatal counseling, and on how to create demand among couples during immediate post-partum; improvement of their own PPIUD insertion technique; correct registration and aggregation of data in the different SRH/FP and maternity logbooks. • Conduct remaining HF (including those recently built) assessments and support the provision of necessary medical equipment and supplies as identified. • Continue FP trainings and regular meeting’s support to enhance FP services delivered per APEs and TBAs. • Strengthen the availability of contraceptive methods at the HF level and for APEs by reinforcing the SRH commodities taskforce at the central, provincial and district level. • Support routine the synchronized MBs in urban and rural areas. • Continue to conduct FP and environmental compliance follow-up visits and monitor action plans for HFs previously visited and start the process for new HFs.

IR 2: • Continue to roll-out the six community dialogue sessions in additional community groups, increasing the number of groups to be carried out during FY4. • Continue the preparation, organization and realization of CLL meetings in alignment with the CFs areas of intervention. • Expand the Community Radios’ addendums to broadcast radio programs related to additional radios in Sofala province; • Continue to identify CL to boost male involvement in FP sensitization program.

• Continue to support the follow-up of the TBAs monthly meetings at peripheral HF level and ensure a more in-depth analysis based on the standardized TBA meeting forms. • Accelerate the coverage of the urban demand creation component accordingly with the strategy defined in FY3

IR 3: • Conduct 16 MSC assessments, 10 in Nampula (four round 2 in Nacaroa, Muecate, Rapale and Larde; four round 4 in Mossuril, Nacala Velha, Memba and Malema; one round 5 in Meconta and one round6-Monapo); and 6 in Sofala (three round2 in Muanza, Maringue and Cheringoma; one round 3 in Marromeu ; and two round 4 in Buzi and Machanga). • Provide TA to 36 districts (23 in Nampula and 13 in Sofala) to conduct their FP district profile dashboard. • Conduct regional capacity building workshops to ensure a more integrated and dynamic TA for health district managers in developing their district profiles, implement MSC quarterly internal assessment, identify persistent gaps and corrective action, develop/implement action plans and track progresses towards quality management practices. • Conduct district management peer-to-peer visits to strengthen knowledge and skills of those districts with non-satisfactory compliance/performance with MSC, PD tools, QI action plans and data review and Task Force meetings. • Prepare the contents of the health facility management TOT for district managers and the contents of the health facility managers training. • Contract SIGLUS help desk trainer and technical adviser, increase the number HR at DPS, PMD and DMD with skills to appropriate support HF and districts SIGLUS users as needed. • Provide specific TA follow up visits to strengthen district manager’s skills to timely track through SIGLUS portal FP commodities stocks at HF and take decision to prevent/manage eminent stock outs and over-and-under stock alerts. • Purchase within the budget allowance 3-5 computers-laptops, install SIFo and SIGLUS platforms and allocate to districts based on their need and QI management selected criteria.

Evaluation/Assessment Update

During Q3 IFPP had the protocol for the DPS operational research, supported by IFPP, approved by the bioethics committee in FP at the DPS Nampula: "Use of modern methods of contraception by Women of Fertile Age in nine districts of Nampula province" (Nampula City, Angoche, Erati, Ribaué, Moma, Mecuburi, Nacala Porto, Monapo, and Meconta).

IFPP and DPS team recruited and trained data inquirers in line with the training protocol; revised the data collection questionnaire and MagPi mobile android app was installed in the interviewer’s cellphones to deploy the updated questionnaires. Currently the team is finalizing logistical arrangements to proceed with field data collection visits.

In Sofala, the research protocol titled “Assessment of the knowledge, perceptions and influences of mothers, midwives and men on the use of family planning methods by women of childbearing age in Chibabava district”, submitted on Q3FY3 is still under DPS research nucleus scrutiny awaiting submission to the national bioethics committee for approval.

Evaluations, Assessments, Studies, and Audits Include any and all types of evaluations, financial or programmatic, internal or external. Planned: List evaluations, assessments, studies and/or audits planned o

Annexes

• Annex A - Success story • Annex B - PMP • Annex II - Workplan • Annex III - Financial information

Annex A - Success story

Improving access to long-term contraceptives: the story of Quixaxe Health Center’s maternal health nurse Clotilde Fábrica

In the district of Mongicul in Nampula province, Quixaxe Health Center has progressively increased its provision of long-term contraceptives over the most recent quarter thanks to the maternal health nurses’ commitment to providing counselling to woman in the community. In the mornings, Quixaxe Health Center’s nurses provide lectures to the woman who come to the health facility. They talk about family planning and show women how the methods work through demonstrations and posters.

Clotilde Fábrica is the nurse champion for Mogincual district. Her focus as a nurse champion is to raise awareness about family planning with the women in the community and her colleagues. She has been an advocate for family planning which has resulted in mobilization and demand creation within the district of Mognicual. Recently she held a lecture outside the health facility’s maternal ward to share information on long-term contraceptives. Clotilde passion and commitment to family planning goes beyond her role in the health facility, she has also improved mobilization for mobile brigades and health fairs.

Clotilde’s plays an essential role in IFPP. She not only helps plan and facilitate demand creation and information sharing events for the community, but she also ensures her colleagues are integrating family planning into other health services that are offered by the health facility.

In addition to Clotilde’s role as a nurse champion, the health facility also utilizes a community facilitator pair to raise community member’s awareness and access to information on long-term methods. The community facilitator pair, along with Clotilde’s advocacy efforts, have been successful in engaging community members in dialogues which have paved the for mobile brigades to visit more remote areas of Mogincual. This ensures that move people in the community can access essential health services, including long-term contraceptives. As a result of Clotilde and the community facilitators, providers from Quixaxe Health Center continue to increase long-term contraceptives offered in the maternity ward.

How one client’s satisfaction with her IUD led her to become an advocate for family planning within her community

Marina Luís is a 42-year old woman living with her partner and five children in the district of Nampula. She has been using an implant since August 2014. Marina is an advocate among the women in her community by sharing her own story during family planning lectures at the health facility. During a recent lecture at Muhala Expansion Health Facility, the maternal health nurse, Gilda Francisco, was discussing the myths and barriers of family planning. Nurse Francisco highlighted one of the myths she commonly hears during family planning consultations. Some women have expressed fear that after insertion of an implant or IUD it will move to other parts of their body, including the heart. Immediately, Marina spoke up during the lecture to attest to the how this is untrue and shared her experience with family planning in hopes of eliminating women’s doubts and misconceptions.

“I benefited from several lectures during my family planning consultation at Angoche Rural Hospital, where I had access to information on family planning and how it benefits me, my family and my community. I had the opportunity to learn about all the contraceptive methods offered through information provided by the nurse. I chose to have an implant and have felt comfortable with it for the last five years. I want to switch to the IUD now because I do not want to have any more children”.

Marina story is important not only because she is an advocate for family planning in her community, but because IFPP’s has given her the opportunity to learn about the IUD. Through conversations with an IFPP- trained maternal health nurse, Marina has opted to remove her implant and to insert an IUD. She has made the choice to not have any more children and she feel confident and secure in her choice to use this In the photo, Marina and the nurse are discussing importance of long-term methods with women at method. health facility and using the card to facilitate conversation. The photo was taken following verbal Marina will continue to encourage other women to consent, by Angelina Ferrão (IFPP-Nampula City Project learn more about family planning and provide her Officer). story so that other women can learn from her experiences. Marina is helping IFPP overcome myths and misconceptions, ensuring women have the information they need to make the right choice for their futures.