IFPP - Integrated Family Planning Program

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

Quarterly Report:

January 2019 to March 2019 – Q2 FY3

Table of Contents ACRONYM LIST ...... 4 PROJECT SUMMARY ...... 8 SUMMARY OF THE REPORTING PERIOD (JANUARY 2019 TO MARCH 2019) ...... 9 IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services 14 Sub- IR 1.1: Increased access to modern contraceptive methods and quality, facility-based FP/RH services...... 14 Sub- IR 1.2: Increased access to modern contraceptive methods and quality, community-based FP/RH services ...... 28 Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services...... 34 IR 2: Increased demand for modern contraceptive methods and quality FP/RH services ...... 36 Sub IR2.1: Improved ability of individuals to adopt healthy FP behaviors...... 36 Rural Community Facilitators (CF) ...... 36 Traditional Birth Attendants (TBA) ...... 36 Interpersonal Communication Agent (IPC) ...... 37 Sub-IR 2.2: Improved community environment to support healthy FP behaviors ...... 38 Sub-IR 2.3: Improved systems to implement and evaluate (Social and Behavior Change Communication) (SBCC) interventions ...... 41 IR 3: Strengthened FP/RH health systems ...... 41 In addition, the project provided TA to strengthen the capacity for management, coordination and monitoring of continuing training activities at Nampula DPS In-service Training and HR Divisions (District Focal Points) at the district level in recording and reporting all in-service training using SIFO...... 43 Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution ...... 43 Sub-IR 3.2: Improved management of commodities to ensure availability at local levels ...... 44 Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment ...... 46 Sub-IR 3.4: Improved government capacity to increase supply, distribution and retention of skilled workers ...... 46

Sub-IR 3.5: Improved generation, dissemination and use of FP data for more effective decision- making ...... 47 Project Performance Indicators ...... 54 Goal: Increase use of modern contraceptive methods ...... 54 IR 1: Increased access to a wide range of modern contraceptive methods and quality FP/RH services 54 Sub- IR 1.1: Increased access to modern contraceptive methods and quality, facility-based ...... 58 Sub- IR 1.2: Increased access to modern contraceptive methods and quality, community-based ..... 59 Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services ...... 59 IR 2: Increased demand for modern contraceptive methods and quality FP/RH services ...... 60 Sub-IR 2.1: Improved ability of individuals to adopt healthy FP behaviors ...... 60 Sub-IR 2.3: Improved systems to implement and evaluate SBCC interventions ...... 60 IR 3: Strengthened FP/RH health systems ...... 61 Sub-IR 3.1: Improved FP financial management, strategic planning, and budget execution ...... 62 Sub-IR 3.2: Improved management of commodities to ensure availability at local levels ...... 62 Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment ...... 63 Sub-IR 3.4: Improved government capacity to increase supply, distribution and retention of skilled workers ...... 64 Sub-IR 3.5: Improved generation, dissemination and use of FP data for more effective decision-making ...... 64 Collaboration with other donor projects ...... 65 Upcoming Plans ...... 66 IR 1: ...... 66 IR 2: ...... 66 IR 3: ...... 66 Annexes ...... 67

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 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) 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 Medications Depot) DEPO/DMPA- Depo-Provera IM DMPA-SC Sayana Press DP District profile DPM Depósito Provincial de Medicamentos (Provincial Medications Depot) DPS Provincial Health Directorate 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 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/reproductive health (FP/RH) services, 2) Increased demand for modern contraceptive methods and quality FP/RH services and 3) Strengthened FP/RH health systems. Under IFPP, the three 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 family planning (FP), namely: postpartum women; women living with HIV; adolescents, including orphans and vulnerable children (OVC); medium- and high-parity women; and post-abortion women. Additionally, IFPP recognizes that increasing the uptake of contraception in Mozambique requires shifting inequitable gender norms. Therefore, men and boys, alongside other key influencers, are meaningfully and systematically engaged throughout all intervention areas and intervention packages.

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

SUMMARY OF THE REPORTING PERIOD (JANUARY 2019 TO MARCH 2019)

During the second quarter of the third year of the project (Q2FY3), the project’s intervention met unexpected adverse conditions. First, the enormously destructive Cyclone Idai struck Sofala province in March, which disrupted the planned activities for IFPP in the four most populated districts of the project’s thirteen (Beira City, Dondo, Buzi and Nhamatanda). The cyclone damaged most of the health facilities (HFs), destroyed some of the HFs’ equipment including, medicines, commodities and register logbooks and impacted the central and provincial drug warehouses. Second, a national shortage of DPMA-IM occurred when international supply shipments arrived later than planned at the central level, leading to stock-outs in 37% of the HFs assessed in Nampula province. Third, the regressive recommendation from MoH – endorsed by the Ministry of Education and Human Development (MINEDH) and emphasizes delivery of information and provision of condoms and oral contraceptives only and restricts the previous provision of injectables, implants and intrauterine devices (IUDs) by health providers (HPs) in schools– has jeopardized the usual school-based mobile brigades as school-based activities are now perceived as low- priority by HPs. In-depth analysis of quarterly data from the health information management system (HMIS) and yearly commodities supplied through the provincial drug warehouses confirmed that, in Nampula province, data reported through the HMIS is far overreported for IUDs and implants even though the annual commodities supplied have increased from 9,796 (2015) to 12,430 (2018) for IUDs and from 13,061 (2015) to 31,318 (2018) for implants. IUD and implant HMIS data reported by HFs is therefore more difficult to interpret and consequently less meaningful to tailor IFPP technical assistance. To correct this situation, IFPP has recruited more IFPP monitoring and evaluation (M&E) officers to work towards improving quality and reliability in data reporting. A similar scenario also holds true for Sofala province, as data reported through the HMIS for IUDs and implants are much higher than those reported by the drug warehouse’s even though the annual commodities reported by the warehouses also point to increases from 11,770 (2015) to 29,578 (2018) for implants and from 8,711 (2015) to 10,914 on average (2017 and 2018) for IUDs. One reason the HMIS appears to be overreporting the data in Sofala province is the directive the Provincial Health Directorate (PHD) has given to the District Health Welfare and Women Directorate (SDSMAS) to aggregate post-partum FP (PPFP) maternity ward data within the RH/FP consultation HMIS sheet even though PPFP maternity data has its own HMIS sheet.

Meanwhile, most of IFPP’s planned activities for this quarter have been carried out. A few accomplishments worth mentioning under IR1: nine additional HP trainings took place and reached 149 additional HPs, resulting in 97% of coverage for the indicator “HFs already having at least 1 HP trained in FP”; consolidation of the offering for bilateral tubal ligation (BTL) ‘mini-lap’ as one of the FP method mix options in Nampula province; increased involvement of the Provincial Health Directorate (DPS) and SDSMAS in the FP program with 150 joint supervision visits carried out this quarter at the HF level; increased focus on quality service with 530 mentorship visits implemented, reaching 72% of the HFs with at least one HP trained in FP; cervical cancer prevention (CECAP) activities were integrated in the daily scope of work in the Nampula province; and the FP service delivery by Agentes Polivalente Elementar

(APEs) – MoH-approved community health workers (CHWs) –expanded to reach 50,711 women of reproductive age (WRA) this quarter.

For IR2, the urban demand creation component has carried out most of the systematic mapping for all registered houses, blocks, units, neighbourhoods and administrative posts in the urban area. The mapping is being implemented by the recently recruited urban community assistants who will strengthen the IFPP objective of appointing each Promotora de Saúde Comunitária agent (IPC) to a specific geographic area of about 2,000 - 2,500 households (HH) to increase the modern contraceptive prevalence rate (mCPR) through regular home visits. IPC agents will identify and tackle barriers for each HH that has shown less interest to FP through small group discussions gathering husbands, partners, mothers-in-law and religious leaders, as appropriate. This component is investing in reaching additional remote communities in order to provide FP information and knowledge to an isolated population for the first time despite the serious constraints. 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. Also, contracts were signed with five additional community radios in Sofala province for further broadcasting.

Regarding IR3, during Q2FY3, IFPP’s health system strengthening (HSS) activities were focused on expansion of activities to two new districts in Nampula province (Larde and Rapale) and one district in Sofala (Maringue). These activities were also carried out during the third round of evaluations in the districts of Mossuril, Memba and Nacala a Velha in Nampula, and the fifth round of evaluations in the districts of Beira City, Dondo, Nhamatanda and Chibabava.

IFPP provided technical assistance (TA) in the implementation of the quality action plans based on the improvement opportunities identified during the previous management standards compliance (MSC) evaluation that IFPP conducted in the areas of human resources (HR), planning, M&E, pharmacy and FP/RH services. The project carried out monitoring of logistics activities for the control of imminent or contraceptive stock-outs in the HFs that are monitored through the CommCare App, as well as for the HFs implementing the health information, management and logistics system (SIGLUS) in 12 districts of Nampula and five districts of Sofala. IFPP also provided TA in the implementation of logistics maps and route plans during the drug distribution process to ensure safe transportation of medicines in consideration of the rainy season. IFPP also provide TA for the use of these tools in planning and calculating the fuel needed for mobile brigades and distribution of medicines. IFPP provided TA to DPS Nampula maternal and child health (MCH) division in preparation for the FP logistics trainings for 80 MCH nurses recently hired and to ensure assignments were based on personnel needs identified in the situational assessment that were drawn up based upon the MSC evaluations carried out in the districts. In addition, the project provided TA to strengthen the capacity for management, coordination, and monitoring of continuing training activities at Nampula DPS in-service training and HR divisions (District Focal Points) at district level in recording and reporting all in-service training using the training information system (SIFO).

Major Implementation Issues During this reporting period 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:

1) Infrastructure: Over 70 HFs were damaged across three provinces, with higher destruction levels affecting the roofs in Sofala province, reducing access to regular service provision. 2) 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. 3) 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. 4) 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.

IFPP was instrumental to support the first layer of coordination, assessment, and immediate response to Cyclone Idai, having intervened with a multi-pronged approach:

1) Coordination: Immediately after Idai, the whole IFPP team in Sofala, supported by key personnel from Maputo, joined DPS and other partners such as FHI360, PSM, and Jhpiego to quickly establish a response team and hold regular coordination meetings that were later co-chaired by the World Health Organization (WHO). This was crucial to ensure that duplication of efforts would be minimized and that resources targeted priority areas. IFPP was an active member of the health clusters at the provincial and central (Maputo) level.

2) Assessments: The IFPP team, jointly with DPS, established the taskforce to assess damage caused by Idai at HF level and ACs to better prepare the response and coordinate the support that could be given considering the available resources within the first two weeks.

3) Restoring service delivery: Restoring minimum service delivery was a priority, and IFPP provide took a three-fold approach: i) support of minimal conditions at HFs by providing solar lamps, gloves, blankets, and other supplies; ii) support outreach teams to provide services in ACs that included contraceptive service delivery, adolescent- and youth-friendly services as well as integration of services, such as oral cholerae vaccine (OCV) campaign; and iii) mobilizing the community network to incorporate messaging to prevent water-borne diseases and to distribute water purifiers such as chlorine (certeza).

4) Printing of Materials: In order to return to normal operations and be able to report on health service delivery, a quick response was needed to ensure availability of logbooks and summary forms. These were printed, and the first batch was delivered within the first week, while the second batch, including a whole MCH component, will be delivered in the next quarter.

Another challenge that appears minor compared to the damage from Cyclone Idai but has been extremely impactful is the regressive recommendation from MISAU, endorsed by MINEDH, for school-based contraception activities carried out by HPs to emphasize information and provision of condoms and oral contraceptives only, restricting the previous provision that included injectables, implants, and IUDs, which can now only be delivered at the HF level. Other minor implementation issues being faced by IFPP include: • Absence of some district program managers during TA visits and MSC assessments (attending other missions or district government activities), resulting in some areas not being evaluated and negative reflection on the HSS activities. • Weak follow-up of the quality improvement action plans developed during the MSC assessments, by DPS and district managers, due to their constant mobility, which influences the scores obtained on the MSC assessments.

Photos of damage to Sofala province HFs and IFPP’s emergency response: FP service delivery and USAID visits to accommodation centers in Beira and Dondo; roof of Macurungo HC in Beira

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 March 2019

FY1 FY2 FY3 To Provinces TOTAL TOTAL Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 date

# of Facility based trainings per quarter and province Nampula 27 27 17 20 91 11 5 12 4 32 6 7 136 Sofala 0 30 24 8 62 6 12 8 4 30 3 2 97 TOTAL 27 57 41 28 153 17 17 20 8 62 9 9 233

# of unique Health Providers reached thru FP training per quarter and province 565 414 205 240 1424 132 72 183 121 508 132 115 2179 Nampula 26

*** 463 347 81 891 107 213 139 65 524 57 34 1506 Sofala 64 26 3 *** *** *** TOTAL 565 877 552 321 2315 239 285 322 186 1032 189 149 3685

# of unique Health facilities reached thru FP training along quarters by province Nampula 36 34 147/226 204/228 225/231 cumulative 43** 34 * 23 * 4 * 16 * 14 * 12 * 9 * * * (65%) (89%) (97%) % Sofala 55 43 112/157 150/157 153/157 cumulative 14 * 24 * 13 * 1 * 0 * 0 * 3 * ** * (71%) (95%) (97%) % TOTAL 43 134 211 259 68% 47 64 81 95 92% 12 12 97% cumulative * Additional HF **HF involved *** TC training Institutions of Nhamatanda (Sofala) & Alua (Nampula)

Cascade in-service training

During the second quarter of the third year of the project (Q2FY3), a total of nine additional eight-day FP facility-based trainings were carried out (seven in Nampula and two in Sofala). The trainings included staff from 71 HFs (13 in Sofala and 58 in Nampula), of which nine were hard-to-reach facilities involved for the

14 first time since the project’s inception. The trainings reached a total of 149 public Table 2: Number of project-supported Health Facilities enrolled in FP trainings, by district to date health providers (115 in Nampula and 34 in # HF # HF with at % HF already % HF with Sofala). As summarized in Table 1, since the per least 1 HP involved thru all HP DISTRICT district trained in training per trained in launching of the project, a total of 3,685 HPs FP to date district FP to date have been trained (2,179 in Nampula and Beira 17 16 94% 29% 1,506 in Sofala). Dondo 15 15 100% 87% Prior to the training of HPs, HF needs Nhamatanda 17 17 100% 82% assessments were conducted. During the Buzi 15 15 93% 73% reporting period, three additional HF Chibabava 15 15 100% 60% Machanga 10 10 100% 50% assessments were carried out in Nampula Caia 12 12 92% 92% (Mucova, Naholoco, and Napruma). These Marromeu 9 9 89% 67% baseline HF assessments focused on Chemba 9 9 100% 78% commodity management, infection Gorongosa 14 13 93% 64% Cheringoma 7 7 100% 57% prevention, client flow, adolescent and Maringue 9 8 89% 78% youth friendliness, and FP data collection Muanza 8 7 88% 38% and aggregation, with the objective of SOFALA 157 153 97% 66% identifying weaknesses to be addressed Angoche 19 18 95% 37% during the eight-day facility-based trainings. Mogincual 6 6 100% 50% Based on these assessments, the project Liupo 3 3 100% 33% Npla Cid 25 23 92% 12% mitigated the lack of supplies and Erati 11 11 100% 18% equipment needed to upgrade work Memba 14 14 100% 14% conditions and apply the skills acquired Meconta 8 8 100% 50% Nacaroa 7 7 100% 71% during training for improving competency Muecate 11 11 100% 27% and sustaining behavior change. Mogovolas 7 7 100% 43% Cumulatively, 322 HFs (173 in Nampula and Moma 11 11 100% 18% 149 in Sofala) were assessed, representing Lardes 6 6 100% 83% Monapo 17 17 100% 12% 77% (Nampula – 173/225) and 98% (Sofala Mossuril 10 9 90% 10% – 149/153) of the HFs with at least one HP Ilha Moç. 5 5 100% 40% already trained in FP. N.Porto 14 12 86% 43% N.Velha 6 6 100% 83% Table 2 summarizes the number of project- Murrupula 6 6 100% 33% supported HFs enrolled in FP trainings with Rapale 7 7 100% 71% Mecuburi 13 13 100% 38% at least one HP trained by district and Ribaue 9 9 100% 11% province. In Sofala and Nampula provinces, Malema 10 10 100% 20% 97% of the HFs already have “at least one HP Lalaua 6 6 100% 0% trained in FP”, respectively. In Sofala, out of NAMPULA 231 225 97% 31% the four missing HFs, three were recently built and are not yet operational (Inhamizua in Beira, Nhamatanda HC in Caia, Wiriquize HC in Chemba);

15 the two remaining HF are Chipengo located in the NPG of Gorongosa and Palama HC in Maringue district. In Nampula, out of the 16 Q1FY3 missing HFs, nine were covered this Q2FY3; out of the six remaining HFs, two of them are located in Nampula district (“the penitentiary HP” and Mental HC), one in Angoche district’s island (“Catamoio”), one in Mossuril (“Cabeceira grande HC”), two in Nacala Porto (“CAMINA HC” and “Cimento HP”). CAMINA HC - a private Catholic HF – is focusing on preventative and curative care for children under five and attends to 800 children per month. CAMINA HC refuses to offer FP services and therefore is denying the IFPP/SDSMAS’ offer for FP training and will remain mostly untrained throughout the life of the project intervention. Comparatively, Table 2 illustrates the number of HFs with all HPs trained in FP: 66% (103/157) of the HFs in Sofala and 31% (71/231) in Nampula have already had all their eligible providers trained in FP.

Whenever possible, all clinical and technical staff in each HF were trained to fully integrate FP activities into the work of all wards, and to promote active FP integration as a key objective for each HF. Support staff (including cleaners) from each HF participated in selected theoretical sessions for non-clinical provider training to sensitize them in removing possible barriers to access quality FP service. For example, they were trained to ensure proper sterilization and storage of IUD or implant insertion and removal kits. They also were trained on how to help create an enabling environment, especially for youth and other vulnerable populations.

Class sizes during the clinical trainings continued to be limited to 15 to offer more personalized attention to trainees and to link them with future mentorship visits. Experience has shown that hosting training sessions often strengthens overall institutional buy-in. Since the beginning of the intervention, 80 HFs in Nampula and 28 HFs in Sofala served as training centers, totaling to 108 out of 377 HFs (29%) with at least one HP trained. This balanced the need for high-volume practicums while maximizing the overall project coverage, resulting in high-quality trainings with rapid and sustained integration of FP services in all outpatient consultations and at the maternity ward.

During Q2FY3, 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 93%.

Photo 1,2. Meeting with TBL minilap’s clients at Murrupula HC Photo 3. FP training in Mogovolas district

Other FP related trainings

As nearly all HFs were covered through the IFPP eight-day standard FP training, a shorter complementary training curriculum of three days was wrapped up focusing on the most common weaknesses observed through the mentoring visits: improving counselling skills, conducting values clarification exercises in relation to adolescents and long-acting reversible contraceptives (LARCs), correct management of side effects, proper steps to fill out registration logbooks, proper management of contraceptive commodities stocks at outpatient consultation rooms, practicums for IUD and implant insertion and removal (including Implanon). This activity was started in Monapo, Mossuril, and Ilha de Moçambique districts and involved 54 HPs. In Sofala, 14 HPs were trained in Cheringoma specifically for Implanon insertion.

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

Since Q2FY2, the project has supported the introduction of mini-laparotomy bilateral tubal ligation (BTL) with local anesthesia as a permanent method (PM) with the intent to expand the method-mix pool, responding to the unmet need for limiting births. During Q2FY3, IFPP has organized specific weeks for enlisted clients to receive BTL mini-laps at Malema and Murrupula HC with the involvement of the MCH bachelor nurses of Ribaue and Moma. Enlisted clients were mobilized through the community dialogue sessions and the peripheral HF nurses, as there is a high demand. Some SDSMAS have requested to plan ahead for the weeks when BTL mini-laps will be offered. Therefore, for next quarter, mini-lap weeks are foreseen for Rapale HC, Chalaua HC, Malema HC, Murrupula HC, and Mecuburi HC. In Sofala, IFPP worked with the PHD to plan to launch the training for next quarter, though this will depend on whether the post- Idai situation normalizes.

Figure 1. Number of mini-laparotomy carried over , by site and quarter - IFPP 80 76 training of 2 70 MD of Monapo 60 2nd & 3rd 53 Specific weeks TOTs planned ahead 50 1st TOT

40 34

30 28 24 24 22 22 2021 20 17 20 15 16 12 13 8 10 6 6 7 3 3 3 0 HD Nacala HD Moma HR Angoche HD Monapo HR Ribaue HC Nampula CS Malema CS Murrupula Porto FY2 Q2 FY2 Q3 FY2 Q4 FY3 Q1 FY3 Q2

Joint MOH-IFPP supervision: The IFPP technical team and SDSMAS/DPS Table 3: # of joint MOH-IFPP supervision at district level by staff carried out technical support visits province - Q1FY3 providing supervision to HFs as described in HF receiving integrated Table 3. This quarter, 150 joint supervisions District Health Facility supervision were carried out (60 in Sofala and 90 in Existing Trained Q1 Q2 Nampula) in comparison with the 110 Angoche 19 18 5 7 carried out last quarter. This joint Mogincual 6 6 6 4 supervision serves to strengthen Liupo 3 3 0 2 understanding and coordination, to boost Npla Cid 25 23 8 23 Erati 11 11 10 0 the quality of the sexual and reproductive Memba 14 14 0 0 health (SRH) services, as well as to lay Meconta 8 8 0 0 foundations for self-reliance. The Nacaroa 7 7 7 0 Muecate 11 11 11 11 supervision includes the FP integration data Mogovolas 7 7 1 2 aggregation tool, assessment of the quality Moma 11 11 0 3 of counseling, techniques for method Lardes 6 6 0 3 Monapo 17 17 4 7 insertion, cleanliness and organization of HF Mossuril 10 9 7 2 services, FP commodities and equipment Ilha Moç. 5 5 1 4 management. Integrated supervision visits N.Porto 14 12 2 1 are important, as they boost adoption of N.Velha 6 6 4 1 Murrupula 6 6 4 2 new components and increases ownership Rapale 7 7 0 6 of the MISAU’s FP strategy and Mecuburi 13 13 0 7 consequently the sustainability of the FP Ribaue 9 9 8 2 Malema 10 10 4 2 program. Lalaua 6 6 4 1 Nampula 231 225 86 90 Beira 17 16 6 6 Dondo 15 15 0 3 Nhamatanda 17 17 3 5 Buzi 15 15 0 4 Chibabava 15 15 7 6 Machanga 10 10 7 5 Caia 12 12 3 6 Marromeu 9 9 4 6 Chemba 9 9 2 3

Gorongosa 14 13 0 2 Cheringoma 7 7 2 6 Maringue 9 8 0 3 Muanza 8 7 0 5 SOFALA 157 153 34 60

Quality Improvement and Mentoring Quality improvement (QI) is key to project success in terms of achieving and maintaining a high quality of service provision, garnering institutional support and buy-in to address systemic Table 4: Mentoring visits received by HFs during Q2FY3 challenges and to support the HFs categorized according to the # of mentoring visits received - Q2FY3 sustainability of FP integration efforts. % HF with at least 1 HP trained Health Facility which received a mentorship visit Mentorship drives the QI cycle through District # # HF regular visits by project MCH nurses and Existing Trained Mentorship % mentored district coordinators. The objective of visits Beira 17 16 15 32 94% mentoring is primarily to guarantee that Dondo 15 15 10 13 67% HPs trained by the project are engaged on Nhamatanda 17 17 15 32 88% a regular basis and supported to achieve Buzi 15 15 8 17 53% Chibabava 15 15 11 23 73% and maintain clinical proficiency and Machanga 10 10 6 14 60% service quality. Mentoring includes direct Caia 12 12 7 27 58% Marromeu 9 9 8 21 89% observation of service quality provision, Chemba 9 9 5 13 56% coupled with supplementary on-the-job Gorongosa 14 13 7 17 54% Cheringoma 7 7 7 13 100% training. A secondary objective of the Maringue 9 8 3 6 38% mentoring visits is to cultivate institutional Muanza 8 7 7 7 100% engagement and ownership among HF Total Sofala 157 153 109 235 71% management and staff to remove barriers Angoche 19 18 8 14 44% to successful integration and greater Mogincual 6 6 6 9 100% Liupo 3 3 3 6 100% uptake of FP services. The first mentoring Npla Cid 25 23 18 167 78% visit is scheduled approximately 10 days Erati 11 11 8 14 73% after the end of the initial training. Memba 14 14 5 8 36% Meconta 8 8 8 13 100% Subsequent mentoring visits are scheduled Nacaroa 7 7 7 8 100% depending on the findings of the first visit, Muecate 11 11 11 15 100% Mogovolas 7 7 3 15 43% but the goal is to reach each HF with Moma 11 11 5 12 45% trained HPs, if possible once per quarter, Lardes 6 6 3 7 50% considering the high number of HFs with Monapo 17 17 10 30 59% Mossuril 10 9 3 21 33% one already trained HP. Ilha Moç. 5 5 3 19 60% N.Porto 14 12 8 19 67% Table 4 summarizes the number of N.Velha 6 6 6 16 100% mentoring visits received by HFs by Murrupula 6 6 6 25 100% Rapale 7 7 7 15 100% province and district during Q2FY3, and the Mecuburi 13 13 12 28 92% percent of HFs with at least one HP trained Ribaue 9 9 9 30 100% that received a mentorship visit. This Malema 10 10 9 26 90% Lalaua 6 6 3 13 50% quarter, 72% - compared to 65% last Total Nampula 231 225 161 530 72%

19 quarter – (109 HFs out of 152 HFs with at least one HP trained) in Sofala and 72% (161 HFs out of 225) in Nampula province received at least one mentorship visit. Figure 2: # of unique Health Providers trained, registered in the App, who During Q2FY3, 530 received mentoring visit(s) per topic and by province mentorship visits – 1600 compared to 398 last quarter 1470 1400 – were carried out in 1200 1099 Nampula province, and 235 1000 876 mentorship visits – 827 800 676 compared to 232 last quarter 548 600 – were carried out in Sofala 400 272 257 province, totaling 765 212 200 102 mentorship visits. 0 counselling in Implants Depo IUD PPIUD Mentorship App FP Nampula Sofala To ensure the consistency of mentorship and facilitate follow-up on action plans Figure 3: # of unique HP trained, registered in the App, distributed per category and per mentoring status, by province, at end Q2FY3 developed during mentoring visits, IFPP uses a mentorship 700 digital app. It provides HP- 49 600 specific electronic Already Mentored notetaking and follow-up 500 Not yet mentored action plans, which are 400 64 39 discussed and shared before 41 leaving the HF. The app 300 provides prompts for 29 71 mentors to guide them 200 72 30 310 38 through each step of the 100 20 11 7 mentorship process and 579 335 209 106 33 342 182 157 100 37 30 sends reminders to mentors 0

for the next mentoring visit

Others Others Doctor

to ensure providers who Doctor MCH Nurse MCH

require additional support Nurse MCH

clinicalofficer clinicalofficer

GeneralNurse GeneralNurse

are mentored at appropriate Preventative officer Preventative intervals. As seen in Figure 2, officer Preventative at end Q2FY3, IFPP staff had mentored 2,297 unique - still active - HPs (1,470 in Nampula and 827 in Sofala). All of the 2,297 were mentored on comprehensive FP counselling for the existing method-mix, 1,424 (876 in Nampula and 548

20 in Sofala) were mentored for DMPA-IM injection, 1,775 (1,099 in Nampula and 676 in Sofala) were mentored for implant insertion, 484 (272 in Figure 4: ‘not meeting competency standards’ rate per FY and per province for Implants, IUD and PPIUD Nampula and 212 in Sofala) were mentored for interval 40% IUD and 359 (257 in Nampula Nampula Sofala and 102 in Sofala) were 31% mentored for post-partum 25% 20% 19% IUD (PPIUD). As seen in 17% 15% 15% Figure 3, the number of 13% 11% 12% 9% 10% unique HPs trained and 6% 6% 5% 6% registered in the app is 0%

distributed per category and observation task's at rate Failure per mentoring status by FY1 FY2 FY3 FY1 FY2 FY3 FY1 FY2 FY3 Q1,Q2 Q1,Q2 Q1,Q2 province. Implant IUD PPIUD In total, 84% - compared to

72% last quarter - of the trained and registered HPs were already mentored (85% compared to 74% for past quarter in Nampula and 81% compared to 69% for past quarter in Sofala) and 16% - compared to 28% last quarter - still need to be mentored for the first time. This gap is still considerable and will continue to be the focus during the next quarters. The category named “others” is other health professionals, such as pharmacists, laboratorians, and more specialized health technicians including physiotherapists, ophthalmologists, Figure 5: Trends per quarter of the rate of failure for the entire cohort of HP radiologists, and cumulatively enlisted per method for Nampula province anesthesiologists (these 41% categories are trained to enable the environment and 31% for in-facility referral, 23% 22% 20% therefore the clinical 18% 19% 16% 15% 15% mentorship is being 14% 14% 12% 11% conducted to prioritize the 9% ones providing methods). Of the MCH nurses trained, 91% - compared to 82% last PP IUD Interval IUD Implant quarter - were already Q2 FY2 Q3 FY2 Q4 FY2 Q1 FY3 Q2 FY3 mentored while only 63% - compared to 60% past quarter - of the HPs belonging to the category named “others” were mentored. The mentorship database was cleaned up, taking out the HPs who retired, went on upgraded training

21 from basic level to medium level, left the province, left the NHS, and those who passed away -resulting in some declines.

As seen in Figure 4, the ‘not meeting competency standards’ rate for implant insertion, interval IUD and PPIUD has decreased from FY1 to FY2 and further in Q1&2FY3 in both provinces. In Nampula province, the most difficult technique to be learned remains the PPIUD and IUD insertion, although the failure rates for PPIUD are steadily Figure 5: Unique HP mentored for PPIUD to date, by province. decreasing from 40% in FY1, to 31% in FY2 and 10% in 250

Q1&2FY3. As seen in Figure 200 5, the rate of failure for the 42 0 150 entire cohort of HPs 257 cumulatively enlisted in the 100 9 0 App is gradually diminishing, 160

# of Unique Health Provider Health of Unique # 50 102 confirming that Nampula 91 47 HPs are bettering their 0 0 2 8 Mentored Passed Still need Failed Mentored Passed Still need Failed abilities. improvement improvement Sofala Nampula Figure 2 above illustrates Always "passed" Passed but previously "needed improvement" the number of unique HPs Passed but previously had failed Always "needed improvement" "Need improvement" but previously had failed Failed trained and registered in the # of unique HP Mentored app who received mentoring visit(s) per topic Figure 6: Unique HP mentored for IUD to date, by province. and province. Figures 5, 6 and 7 show the distribution, 300 per province of how many HPs have “always passed”, 250 “passed but previously 18 200 6 needed improvement”, 31 1 150 “passed but previously had 272 212

failed”, “always needed 100 193 # of # UniqueProvidersHealth improvement”, “still need 162 50 improvement but previously 2 0 11 42 2 16 had failed” and “failed”. 0 Mentored Passed Still need Failed Mentored Passed Still need Failed improvement improvement Sofala Nampula Nampula HPs have faced Always "passed" Passed but previously "needed improvement" more technical challenges, Passed but previously had failed Always "needed improvement" Still "need improvement" but previously had failed Failed particularly for PPIUDs and # of unique HP Mentored interval IUDs, than those in Sofala province. Therefore, IFPP had provided additional support to the mentors to increase their abilities

22 to mentor high-need mentees. The decreasing failure rate for PPIUD is encouraging and further attention will be given to this during the next quarters.

The number of unique HPs mentored for IUD jumped from 86 (Q1FY2) to 272 (Q2FY3) in Nampula. Nevertheless, the number of mentees requesting further Figure 7: Unique HP mentored for Implants. to date, by province. assistance remains relatively high 1200 in Nampula, with 47 of 257 for PPIUD, 42 of 272 for interval IUD 1000 148 and 95 of 1,099 for implant, 9 800 compared respectively to 2 of

102, 16 of 212 and 25 of 676 in 600 97 Sofala province. Consequent 9 1099 efforts will continue to be carried 400 832 676

out in the next quarters for more of # UniqueProviderHealth 539 frequent mentoring on Implant, 200 IUD, and PPIUD techniques. The 6 13 95 0 25 project will continue to increase Mentored Passed Still need Failed Mentored Passed Still need Failed improvement improvement opportunities and take Sofala Nampula Always "passed" Passed but previously "needed improvement" advantage of the shift Passed but previously had failed Always "needed improvement" changeover meeting that takes Still "need improvement" but previously had failed Failed # of unique HP Mentored place between maternity ward nurses. The maternity daily meeting offers an important glimpse into the HFs’ client load and service flow, provides an opportunity to give parturient women counselling and immediate PPFP, including PPIUD insertions, and allows IFPP to catch night-shift workers who are otherwise missed for mentorship.

Summary of the main observations and recommendations of the mentoring and supervision visits: • Technical skills: Difficulties persist in immediate postpartum counseling skills, especially for LARC. 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 ANC still needs to be more consistent so that missed opportunities are diminished, specifically during ANC visits attended by the couple for HIV screening. • Family Planning integration: In most of the trained HFs, FP methods are offered, but non-MCH providers need more mentorship and follow-up with respect to long-term method provision, particularly implant insertion, since clients usually ask about FP to providers who are not MCH providers. When providers are transferred or on annual leave, the substitute tends to not follow up follow up the activity even

though they were informed. It was recommended through integrated supervision and mentorship visiyts that FP focal points and HF directors increase their follow-up and support. • 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.

Experience exchange visits between MCH nurses with low LARC performance and these with high performance In Beira city and Chibabava district, one week of experience exchange visits (learning visits) between several HFs were carried out from the 10th to 13th of March in Beira and from the 4th to 8th of February in Chibabava, involving six low performing nurses and three high performing nurses in Beira city and another group of six low performing and two high performing nurses in Chibabava. All together the low performing nurses inserted 29 PPIUD and 70 implants during this exchange visit, which doesn’t include the 14 PPIUD and 23 implants inserted by the high performing nurses to demonstrate the insertion techniques. The low performing nurses were proceeding from Beira CH, Muxungue RH, Chingussura, Nhaconjo, Macurungo, Panja, Machanga, Divinhe, and Nhango health centers.

Implementation Science and Learning (ISL) Every HF that had participated in the past quarter’s implementation learning workshops benefitted from follow-up visits. The HFs were categorized according to their ability to implement their follow-up action plans and their results in offering LARC at consultations and maternity ward level; the below paragraph illustrates the three categories and summarized the findings:

• HFs which did not follow up on the action plan and did not have any significant improvement in the offer of long-term methods: HD Moma, Chalaua, Muatuca, HD Namapa, Monapo Rio, Rapale, Monapo Sede and Natete; the main constraint identified was the weak involvement of the HF’s leadership; • HFs which implemented their action plan, had improvement in the LARC offering but still need improvement: Micane, Alua, Marrere HD, HD Monapo, Mirrote, Carapira, Namaita, 25 de Setembro, HC Nampula; in these HF, the leadership is involved but more mentorship is needed to increase the self-confidence of the HP. • HFs which implemented their action plan and had significant improvement for the LARC offering including for PPFP: HD Nacala Porto, Murrupelane, Urbano, Nhahupo Rio and Netia. Those HFs have increased their LARC offer at the outpatient consultations and at the maternity ward level. Some of them have also improved their abilities of couple FP counselling at their ANC consultation level.

Strategies established for FY3 to continuously increase the uptake of PPFP include: • Continue ISL optimization workshops with maternities that have low outcomes with the involvement of the PHD. • Organize additional specific in-service training for the providers who have already been trained through IFPP but identified as poorly performing in post-training period through mentorship. • Conduct a five-day TOT for the 34 MCH district responsible to increase their skills in PPFP in-service training and mentoring, including FP antenatal counseling, and on how to create demand among the couples with no FP demand in immediate post-partum; improvement of their own PPIUD insertion technique and how to proactively include the recently available mini-laparotomy method in the method-mix; and challenging the trainees (MCH district responsible) to identify three HFs with maternities to benefit from their active support during FY3.

Strengthening Cervical Cancer Prevention (CECAP) through Integrated Prevention, Testing, and Treatment Leveraging the opportunity presented by IFPP, Pathfinder is supporting the CECAP activities in country for FY19. The core of this intervention is built on providing 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.

During this quarter, the recruitment of the three CECAP technical assistants was finalized: Nampula TA already initiated her activities in March 2019 while the Sofala and the central positions will initiate their activities on 22nd and 9th of April.

In relation with the first objective, a hand-over meeting was requested with Mother and Child Survival Program (MCSP) under the USAID leadership and hopefully will take place early next quarter. Meanwhile, several coordination meetings with USAID and MISAU’s cancer technical working group including the support on the roadmap for cancer prevention and treatment strategy were carried out; IFPP participated at the USAID-led APR 2018 review meeting held on 7th of February gathering PEPFAR clinical implementers and Pathfinder; and financial support was given for the launching the national 2019 – 2029 plan for cancer mitigation on the 27th of February, held at the Joaquim Chissano conference complex. IFPP provincial coordinators and technical director held several meetings with the Sofala and Nampula PHDs to present the activity plan and share the IFPP CECAP additional responsibilities. During this quarter, IFPP has supported a joint supervision visit to the 23 main city-level HFs focusing on four main activities: 1) HP’s observation of technical and practical skills for counselling and provision of CECAP services; 2) verification, analysis, and comparison between the logbook data and the monthly aggregated data sent to the national

25 level for the January period; 3) providing in-service training for HP with difficulties to offer SRH / FP / CECAP services; 4) verification of existing equipment and commodities related to CECAP offering and existing sterilization equipment: acetic acid, speculums, carbon dioxide bottles, cryotherapy unit, resulting in the identification of the following programmatic key challenges illustrated in table 5. Three additional technical support visits were carried out for Muhala expansao, 25 de Setembro and 1° de Maio HFs focusing on the awareness chat at the waiting room, the proactive referrals flow of HIV+ women attending antiretroviral treatment (ART) services to the SRH/PF/CECAP consultation, the confirmation that MCH nurses were correctly applying the screening protocol, interpreting the white-acetic spots observed and verifying the existence of sufficient equipment and commodities. Finally, in coordination with the PHD and International Center for AIDS Care and Treatment Programs (ICAP), IFPP has fully supported the CECAP training of 26 HP to increase the number of trained MCH nurses for the 31 CECAP HFs.

The main challenge, in Nampula province, according to data collected during April 2018, is around the poor access of HIV positive women for annual screening with less than 1% of HIV+ women on ART were reported as screened; new strategies such as specific CECAP hubs in a HF with a high volume of ART clients will be organized and tested during the next quarter comprising among other the following strategies: one-stop model during ART clinical visits, clients literacy on cervical cancer and its preventability.

Table 5: Key programmatic challenges identified for the roll-out of the CECAP program in Nampula province – Q2FY3

District HF offering cryotherapy services Key programmatic challenges identified

Angoche 1 Angoche RH cryotherapy unit not working Mogincual 1 Mogincual HC without cryotherapy unit Liupo 1 Liupo HC without cryotherapy unit Nampula CH 25 de Setembro HC 1° de Maio HC Npla Cid 6 Muhala Expansão HC Psiquiatrico HC Marrere RH Erati 1 Namapa HC screening activities poorly implemented

Memba 1 Memba HC without cryotherapy unit Cryotherapy unit needs constant Meconta 1 Meconta HC manutention Nacaroa 1 Nacaroa HC Cryotips are missing Muecate 1 Muecate HC Mogovolas 1 Nametil HC cryotherapy unit poorly working Moma 1 Moma HC screening activities poorly implemented

screening activities poorly implemented Lardes 1 Lardes HC and cryotherapy unit poorly working cryotherapy unit poorly working; the Monapo 1 Monapo HC trained nurse need more support

Mossuril 1 Mossuril HC Ilha Moç. 1 Ilha HC

Nacala Porto GH N.Porto 3 Nacala Porto HC

Nacala Porto DH N.Velha 1 Nacala Velha HC

Murrupula 1 Murrupula HC screening activities poorly implemented Rapale 1 Rapale HC Mecuburi 1 Mecuburi HC screening activities poorly implemented

Ribaue RH Ribaue 2 Iapala HC screening activities poorly implemented

screening activities poorly implemented Malema 1 Malema HC and cryotherapy unit poorly working

without cryotherapy unit and dyoxide Lalaua 1 Lalaua HC carbon cylinder

Total Npla 31

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 Figure 8: Trends of the # of APEs reporting data, reporting FP data, % of APE is a key activity that reporting FP data, per month, in Nampula province will increase FP 1200 100% access for the hard to 90% 1000 95% 96% 90% 89% 80% reach, rural 86% 89% 87% 86%801 88% 82% 81%742 745 70% populations. During 800 78% 700 703 720 60% 566 their initial training, 526 551 522 600 691 691 50% APEs were trained on 414 419 441 621 420 627 653 366 603 40% 400 305 501 FP since 2016 before 275 274 489 452 452 30% IFPP started. 379 20% 200 284 However, the MISAU 10% 0 0%

perceived that APEs data FP reporting APEs of %

# of APEsof #

Jul-18

Jan-18 Jan-19

Jun-18

Oct-17 Oct-18

Apr-18

Feb-18 Sep-18 Feb-19

Dec-17 Dec-18

Aug-18

Nov-17 Nov-18

Mar-18 Mar-19 were not providing May-18 significant FP # of APEs reporting data # of APEs reporting FP data % of APE reporting FP data services by the end of 2016. As such, the Figure 9: # of users served per month and per type of contraceptive method for the MISAU requested group of APE reporting FP data in Nampula province 10837 that IFPP strengthen 9730 9101 8667 8312 APEs skills and 7665 8018 6830 increase support and 6594 6169 5407 5551 5850 5626 5193 4841 supervision to 4207 4323 2577 effectively integrate 2103 2031 2130 2415 2208 1531 1548 1892 1498 1762 1937 1904 FP into their daily 1274 1321 1344 1270 1369 tasks. Therefore, served Users of #

IFPP included APEs

Jul-18

Jan-18 Jan-19

Jun-18

Oct-17 Oct-18

Apr-18

Feb-18 Sep-18 Feb-19

Dec-17 Dec-18

Aug-18

Nov-17 Nov-18

Mar-18 Mar-19 working in IFPP HFs May-18 # of Pills users served # of Depo users served

Table 6: detailed example of APEs status for Angoche district in Nampula province # of existing ANGOCHE Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 APE at end Q2FY3 # of APE reporting data 22 13 45 45 45 33 33 41 46 75 36 58 Total Distrito 99 22 13 45 45 41 24 28 34 46 75 36 58 # of APE reporting FP data 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

28 schedules. During Q2FY3, no additional APEs were trained through IFPP but 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. The figure 8 illustrates the trends of the # of APEs reporting data, reporting FP data and the % of APE reporting FP data, per month, in Nampula province: the number of APEs reporting data are steadily increasing although monthly data has the tendency to be incompletely reported as APEs are community based and represent the most peripheral FP service delivered and, therefore 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 HF Table 7: # of APEs reporting FP data per month in Sofala province every month to attend # of APEs reporting FP data per month this meeting which is # of existing partly explaining why Sofala APEs at end 2018 2019 Q1FY3 February and March data Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar reported tended to be Beira 5 Dondo 30 lower than January. The Nhamatanda 44 2 4 29 30 11 15 14 figure XXX illustrates the Buzi 27 Chibabava 32 22 18 19 17 27 31 32 32 29 30 25 25 26 31 number of users served Machanga 24 8 6 7 8 3 2 6 5 1 4 6 6 17 16 per month and per type Caia 30 19 19 19 19 31 31 30 30 30 24 30 30 of contraceptive method Marromeu 34 19 19 20 19 19 18 20 20 20 20 5 5 10 Chemba 20 10 10 9 10 8 5 9 19 17 16 15 15 16 17 through the group of APE Gorongosa 61 36 36 35 29 41 38 46 40 54 52 58 59 59 56 reporting FP data; the Cheringoma 20 12 14 12 12 17 21 11 16 25 monthly average number Maringue 22 11 2 5 21 20 40 20 20 10 20 Muanza 31 28 38 13 of Depoprovera users Total 380 19 146 125 125 114 114 138 135 168 238 222 185 169 215 180 served per APE is around 15 per month while the Figure 10: # of users served per month and per type of contraceptive method for average number of oral the group of APE reporting FP data in Sofala contraceptive pill users served per APE is around 3759 3067 3196 2918 3000 3001 4 per month. The table 7, 2639 as an example, is 2412 2384 2317 2072 1903 2011 illustrating the variation 1680 2266 2354 2186 2116 2238 1345 2097 in the number of APEs 1832 1799 1892 1661 1682 1479 reporting monthly for 1327

Angoche district. served of # users

More mobility

Jul-18

Jan-19

Jun-18

Oct-18

Apr-18

Feb-18 Sep-18 Feb-19

Dec-18

Aug-18

Nov-18

Mar-18 Mar-19 constraints are existing in May-18 Sofala province due to # of Pills users served # of Depo users served lower population density

29 and huge distance between the communities and their HF of first reference. In Nampula province, out of 1,071 APEs trained and reported as active, through the NHS, an average of 755 – compared to 655 past quarter - are reporting FP data, which means that an additional 316 should still be IFPP focus to support them reporting FP services in following quarters. For Sofala province, an average of 226 – compared to 267 past quarter – have reported FP data on a total of 380 reported through the NHS as trained and active past quarter, this decrease is mainly related to IDAI cyclone and the heavy rainy season hitting Sofala province this quarter. The figure 10 illustrated the number of users served per month and per type of contraceptive method through the group of APE reporting FP data; the monthly average number of depoprovera users served per APE is around 13 per month while the average number of pill’s users served per APE is around 10 per month.

IFPP will continue to support SDSMAS and the APEs district responsible to carry out the district quarterly review meeting at the district’s level to highlight the relevancy of APEs involvement for FP delivery; therefore the following activities will continue to be carried out: 1) Increasing supervision visits of the IFPP technical team as well as supporting the APE supervisors at SDSMAS and DPS level for integrated supervision, focusing on counselling and the delivery of short term FP methods, FP registration in the APE logbook, referrals to HFs for long acting FP methods and management of traditional birth attendants (TBAs) FP referrals that are directed to APEs, 2) Improve the supply of short term contraceptive methods (STMs) available to APEs in both Photo 4. Marromeu district: IFPP district coordinator supporting APEs and Community Facilitators during a provinces supporting the dissemination of the MOH supervision meeting 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, experience sharing and restocking FP methods and commodities and 4) Printing of register books and references slips when necessary.

Traditional Birth Attendant (TBA) Trainings IFPP’s rural supply-side strategy involves Table 8 – 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 Grand demand by improving knowledge of FP, countering FY1 FY2 FY3 To date prevailing misconceptions and biases, conveying Total Nampula 762 79 37 878 the importance of healthy timing and spacing of 1202 Sofala 93 179 52 324 pregnancy (HTSP), increasing self-efficacy and

30 promoting linkages with contraceptive service delivery points (IR1). TBAs are trained and 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). This Q2FY3, IFPP in Nampula province has trained an additional 37 TBAs from Mossuril district. During Q3&4FY2, IFPP in Nampula has focused on the monthly review meetings led by the HF MCH nurse and supported by the IFPP technical teams, but in Q2FY3, the training of additional TBAs will re-initiated. In Nampula province, these efforts were crowned with success as the referrals reported by TBAs has jumped from 425 (Q2FY2) to 5,847 (Q3FY2) to 9,786 (Q4FY2) to 8,583 (Q1FY3) and 6,113 in Q2FY3. In Nampula, the 878 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. This quarter, 63 out of the 83 HFs have carried out TBAs monthly review meetings in Nampula, and 86 out of 97 in Sofala. Out of the 878 TBAs trained in Nampula, 404 (46%) unique TBAs have reported community references this Q2FY3, which is less than past quarter as lesser TBA succeed to arrive at their HF of reference (rainy season). When analyzing the referrals by specific subgroups in Nampula province, 1,268 (1,144 confirmed at the HF) were made for adolescents without children; 2,747 (2,565 confirmed) were made for WRA with one to four children; and 2,098 (1,889 confirmed) were made to WRA with more than four children. In Sofala, no training was held during Q2FY3. The 324 trained TBAs in the previous quarters 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. Out of the 324 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%).

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 Table 9: # of IPC agents active during Q2FY3, by province create informed demand for FP directly at the household and community level through home Nampula Province Q1 FY3 Q2 FY3 visits and community meetings. Angoche city 12 8 36 During this Q2FY3, 97 IPCs (26 in Sofala and 71 Nampula city 42 5 in Nampula) have carried out sensitization Anchilo 5 Ilha de Moçambique 4 3 activities. Of them, 20 have received and Murrupula sede 5 3 concluded their initial training as IPCs in Nacala Porto 19 16 Nampula province. Additionally, monthly Total 87 71 updates are carried out to increase IPCs’ Sofala Province abilities in using the recently introduced (June Beira city 40 23 2018) digital platform “Connect with Sarah”. Dondo city 8 3 Monthly technical updates are also provided Total 48 26 and focus on the importance of FP client follow- up, reporting behavior change barriers met at each household visited and the involvement of community leadership to conduct male group sensitization.

“Connect with Sarah” App (CwS)

The “Connect with Sarah” platform was introduced 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 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.

During Q2FY3 on the job training was given to eight IPCs in Angoche district, 33 IPCs in Nampula city, three IPCs in Ilha de Mozambique, five IPCs in Murrupula and seven IPCs in Nacala in Nampula province and 25 in Sofala province. Additionally, 52 MCH nurses (37 in Nampula and 15 in Sofala) benefited from on the job training sessions to address the CwS challenges related to the delivered FP method’s registration and the referral’s validation.

Mapping of IPCs agents

Furthermore, the urban community mobilization and counselling strategy redesigned in Q4FY2 is being implemented since beginning of FY3. The IPCs were redistributed in pre-selected neighborhoods with the mission to reach progressively 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. Community Facilitators (CF) training During the Q2FY3, no refreshment training was carried out as 231 CFs and 24 supervisors attended past quarter. Targeted Mobile Brigades (MBs) for priority populations As MBs continue to be key in increasing access to FP, particularly for rural and hard to reach areas during 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. To enhance full access to the method-mix MBs will be carried out in the immediate surroundings of the schools during the next quarters. On the other hand, as IFPP rural CFs are targeting more and more remote and disperse areas, IFPP will increase, during the next quarter, 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 and 6th community dialogue’s sessions. The communities will be already partly sensitized on the FP benefits, LARC and STM, and the community facilitator, in coordination and with the support of the respective CLCs, can mobilize the population, distribute FP referrals for the MBs event during which specific attention will be given to access of LARCs. The field supervisor will play 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 should be foreseen 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.

Sub-IR 1.3: Improved and increased active and completed referrals between community and facility for FP/RH services Figure 8 shows trends in the number of confirmed referrals by type of CHWs by FY and province. The total number of confirmed referrals by HPs is 22,402 for Q2FY3, a decrease of 26% mainly due to the heavy rainy season and the Figure 8: Number of confirmed referrals as 'attended at HF' by province, from October 2016 to March. 2019 unrolling of the community 45,000 42,054 IPC TBA CF score card (CSC) 40,000 activities, as 35,000 29,448 well as the 30,000 16,595 21,427 losses of the 25,000 vouchers and 20,000 16,618 registers due to 14,178 14,545 15,000 13,606 the cyclone in 11,347 9,413 8,545 10,000 7,324 some districts 4,170 5,000 3,354 of Sofala 1,652 486 1,814 1,887 province, when - FY1 FY2 FY3 (Q1&Q2) FY1 FY2 FY3 (Q1&Q2) compared to the 30,511 Nampula Sofala confirmed 18 referrals of Q1FY3.

The red bars in the graph above represent the confirmed referrals sent to HFs by TBAs. When comparing FY2 with the referrals made during Q1 and Q2 Figure 9: IPC agent’s trend of the # of sessions (with or without referrals) carried FY3, TBAs reported in two out and % of confirmed referrals - July to March 2019 (both provinces) quarter of FY3 about 84% of the referrals reported 60,000 70% in entire FY2, which is 50,000 60% 26,728 46% 50% very encouraging. The 40,000 40% 44% results illustrate an 40% 30,000 17,878 increase in the use of a 18,189 30% 20,000 more adequate system 20% 26,303 for TBA referrals for data 10,000 18,181 20,942 10% reporting compared to - 0% the Movercado digital Q4 FY2 Q1 FY3 Q2 FY3 system used until the Simple session Session with referral % of confirmed referrals middle of FY2. It is now worthwhile to re-initiate

34 the FP cascade training for TBAs as we can monitor their outputs and analyze data produced per HF catchment area. This data confirms the great opportunity TBAs represent for demand generation at the rural level. From Q1FY3 onwards IPCs agents reports referral data only through the “Connect with Sarah” digital platform while CFs referral data is reported through the MISAU referral paper form. When comparing Q1 and Q2 FY3 with FY2, the total number of confirmed referrals generated by IPCs already represents 55% of the entire FY2 (19,892 versus 35,972) which also is an encouraging result testifying to IPCs familiarity for the use of the CwS digital platform. Figure 9 shows the trend of the number of sessions carried out quarterly by the IPCs. During Q2FY3, a total of 38,820 sessions were carried out, of which 46% resulted in an accepted referral. Figure 10 shows IPC result cascades illustrating the number of sessions carried out during FY3, disaggregated by Q1 (bottom part of the bars) and Q2 (upside part of the bars), the number of sessions

Figure 10: IPC agent result’s cascade illustrating the # of sessions, the # of unique WRA ‘not currently using a FP method’, but referred to HF, confirmed as arrived, receiving a FP method, receiving a LARC method – Q1FY3 and Q2FY3 (both provinces)

90665

81290

38820

34253

38171

24719 15375 51,845 46,937 10112 11550 22,796 3540 5460 14,607 1544 1,996 6,090

# of contacts or # of unique WRA # of WRA 'not # of WRA not # of WRA 'not # of WRA 'not sessions reached currently FP user' currently FP user currently FP user' currently FP user', and referred at HF confirmed as arrived confirmed as arrived at HF and receiving at HF and, accepting a FP method a LARC method

carried out, the number of unique WRA reached (whatever they were current user or not at the time of the visit), the number of WRA “not currently using a FP method”, the WRA “not currently using a FP

35 method” accepting a referral from the IPC, the WRA “not currently using a FP method” confirmed as arrived at the HF, the WRA “not currently using a FP method” receiving a FP method (30% of the unique WRA “not currently using a FP method” reached) and the number of WRA “not currently using a FP method” who choose a LARC method (31% of the WRA who received a method at HF). In relation to the confirmed referrals generated by the rural CFs, 6,910 confirmed referrals were reported in Q2FY3, representing a decrease of 19,5% of the results achieved during Q1FY3, as less community dialogue sessions were carried out at the community level due to rainy season and CSC activity running in eight HFs in Nampula and six HFs in Sofala.

IR 2: Increased demand for modern contraceptive methods and quality FP/RH services

IFPP prioritizes high impact demand generation activities at the individual (Sub IR 2.1) and social level (Sub IR 2.2) to be implemented in line with the phased roll-out of the project’s IR1.

Sub IR2.1: Improved ability of individuals to adopt healthy FP behaviors During Q2FY3 a total of 87,669 female contacts have been reported. This was a 24% decrease when compared to Q1FY3, as Q2 was affected by the rainy season and additionally CPC activities has involved the rural CFs in eight HFs in Nampula and six HFs in Sofala.

Rural Community Facilitators (CF) In Q2FY3, sensitization contacts reported by CFs totaled up to 41,705 (14,468 in Sofala and 27,237 in Nampula).

Traditional Birth Attendants (TBA) As mentioned above in Sub IR1.2, by the end of Q2FY3, 1,202 TBAs have been trained and implemented sensitization activities at the community level. To date, sensitization contacts reported by TBAs have increased from 1,129 (FY1) to 23,651 (FY2) and jumped to 10,880 for the first quarter of FY3. During Q2 there was a decrease to 7,144 but cumulatively still representing 76% of all contacts produced during FY2.

Interpersonal Communication Agent (IPC)

At the end of Q2FY3, with the support of 97 active IPC agents, cumulatively for FY3, IFPP reported 90,665 WRA contacts reaching 81,290 unique WRA -whether they were currently users or not of a FP method at

Figure 11: IPC agent cumulative result’s cascade for the WRA ‘currently FP users', but referred to HF, confirmed as arrived and, switching to another FP method - Q1FY3 and Q2FY3 (both provinces)

100000 90,665 90000 81,290

80000

70000 38820 34253 60000

50000 43,019

40000 18878 30000 16,364 51845 6,106 46937 20000 35 6958 10000 24141 2500 3606 9406 14 0 21 # of contacts or # of Unique WRA # of Unique WRA # of WRA 'currently # of WRA 'currently # of WRA 'currently sessions reached reached 'currently FP user' and FP user' confirmed FP user' confirmed FP user' referred to HF as arrived at HF as arrived at HP and switching to another method

the time of their first contact during FY3. Of these 81,2 90 unique WRA reached, 43,019 were ‘current FP users’ representing 53% of all WRA reached. A total of 16,364 were nevertheless referred to a HF whether it was for re-supply of a STM or for additional information related to their current FP method. It is important to reach the current users to check if their FP and reproductive needs are still optimally covered with a high degree of personnel satisfaction (potential FP method switchers, need for side effects clarification, etc.).

Figure 11 shows IPCs results cascade illustrating the number of sessions carried out during Q1 (bottom part of the bars) and Q2FY3 (upside part of the bars), the number of unique WRA reached, the number of WRA ‘currently using a FP method’, of those currently using an FP method the number accepting a referral from IPCs, the WRA confirmed as arrived at the HF and the WRA who are switching to another FP method. During Q2 a total of 6,958 WRA out of 18,878 accepted a HF referral voucher and 2,500 (13% of the unique

WRA using a FP at the time of the visit) were confirmed as arrived. Of those, 14 WRA switched to another FP method, strengthening the principle of free choice of FP method.

Sub-IR 2.2: Improved community environment to support healthy FP behaviors To contribute to the IR2, IFPP and N’weti are 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 Table 10: Distribution of the CLL meetings by province and drivers behind the lack of use of modern FP. district The rationale also is to create a more DISTRICT Q2FY2 Q3FY2 Q4FY2 Q1FY3 Q2FY3 enabling environment at the community Beira NA NA NA NA NA Dondo 0 0 1 1 0 level for adherence to modern FP methods. Nhamatanda 3 1 0 2 3 CLs are important gate keepers and Buzi 1 0 1 0 1 Chibabava 2 0 0 3 3 educators. Machanga 1 1 0 0 2 Caia 1 0 0 0 0 Fostering an enabling environment for Marromeu 2 1 0 0 0 demand creation Chemba 2 2 0 0 0 Gorongosa 0 0 1 0 1 Cheringoma 0 1 0 0 0 In rural settings, to boost the local Maringue 2 0 2 0 0 leadership involvement in the areas in Muanza 0 0 0 0 0 which CFs are facing a deficit in community SOFALA PROVINCE 14 6 5 6 10 leadership involvement, IFPP (in Angoche 3 0 2 2 2 Mogincual 1 0 1 5 2 coordination with the head of the Locality Liupo 2 0 1 2 0 Npla Cid NA NA NA NA NA “Chefe da Localidade”) has supported a Erati 0 1 1 2 0 one-day meeting focused on gathering the Memba 0 0 1 2 0 Meconta 1 1 1 0 0 members of the CLL. This Leaders Council is Nacaroa 0 0 0 0 0 a body of consultation for the local Muecate 0 0 0 1 0 Mogovolas 3 1 0 1 0 administration authorities in search of Moma 1 0 0 0 0 solutions to fundamental questions that Lardes 0 0 0 0 0 Monapo 4 0 0 0 0 affect the lives of local communities, as Mossuril 3 0 0 0 0 well as their well-being and sustainable Ilha Moç. 3 0 0 0 0 N.Porto NA NA NA NA 1 development in which participate the N.Velha 2 0 0 0 0 community authorities. authorities in Murrupula 0 0 0 1 0 Rapale 0 1 0 0 1 search of solutions to fundamental Mecuburi 0 1 0 0 0 Ribaue 2 0 1 2 2 questions that affect the lives of local Malema 0 0 0 0 0 communities, as well as their well-being Lalaua 1 0 0 0 0 NAMPULA and sustainable development in which 26 5 8 18 8 PROVINCE participate the community authorities.

This Q2FY3, ten meetings were held in five districts in Sofala province and eight meetings in five districts in Nampula province. The main objective is to create a more enabling environment for FP behaviour

38 change within their communities, promoting social norms favorable Table 11: Result of the urban mapping to RH and HTSP and to strengthen # Administrative # of # of CL # of Blocks # of Houses their leadership to increase the Posts boroughs involved Maiaia 6 101 5,208 101 community participation in Nacala Porto Mutava 6 207 11,559 207 community dialogues. These Angoche Angoche sede 16 160 19,914 169 Ilha de meetings included participation 8 24 1,798 24 Ilha de Moçambique Moçambique from the HF Director, the MCH Lumbo 4 4 3,844 4 responsible, as well as the Namicopo 2 205 20,614 99 Napipine 2 264 19,800 264 Nampula provider in charge of the Muhala 3 260 32,816 82 community involvement. The Anchilo 1 25 7,470 25 TOTAL Nampula 9 48 1,250 123,023 975 main questions discussed included: In your opinion, what are # Administrative # of # of "unidades # of CL # of Blocks the reasons for the low use of Posts boroughs comunais" involved methods of contraception at Urbano1 - 5 29 149 42 community level? What could Chiveve Urbano2 - each of us do to improve the use of 5 30 186 45 Munhava FP in your family circle and in your Beira Urbano3 - Manga 3 14 59 26 community? Urbano 4 - 5 33 181 36 The final exercise was mapping of Inhamizua TOTAL Beira 4 18 106 575 1,231 the community, including Dondo 1 5 30 6 1 10 50 58 highlighting the main roads, the Dondo 1 7 30 10 schools, the health facilities, the 1 5 31 32 APEs, the best-known PTs and the TOTAL DONDO 4 4 27 141 106

MBs concentration points.

Follow-up meetings are recommended to be carried out every six months.

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

In the urban settings, during Q2FY3, as illustrated in table 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. IFPP highlights the importance of FP and which families would

39 most benefit from FP use, how FP is linked to the demographic dividend and the poverty reduction. The community mapping consists in 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 implemented by the recently Urban Community Assistants recruited; the objective is to appointed each IPC agent (Promotora de Saúde Comunitária) to a specific geographic area of about 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 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 talking will be led by the urban community assistants.

Leveraging community partnerships through CBOs

Technical support visits continue to be carried out, targeting the 88 community-based organizations (CBOs) to more qualitatively implement the agreement signed with IFPP by increasing their follow-up activities and including monitoring CF activities at the community and HF level. CBO representatives were involved in the 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 four in Sofala to broadcast 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 14, During Q2FY3, 165 radio programs were broadcasted focusing on the contents of the Community Dialogue sessions (116 in Nampula and 49 in Sofala).

All the radio programs had the active participation of Field Supervisors and the SDSMAS appointed HP. IFPP district coordinators join as frequently as possible. IFPP signed a MOU with the Muslim radio HAQ (Arabic - Truth) based in Nampula City but covering the entire province, substituting the contract with Radio Gemeas which was extinguished. It will be an Table 12: Radio sessions by station added value for IFPP as its Broadcasting Q3 Q4 Q1 Q2 Q3 FY1 Q4 FY1 Q1 FY2 Q2 FY2 coverage is provincial and Province & district Radio name FY2 FY2 FY3 FY3 the radio is reaching more Mossuril CR Mossuril 4 9 4 5 20 6 10 easily the Muslim Monapo CR Monapo 22 26 22 11 10 4 15 Meconta CRT Namialo 22 14 0 6 0 22 14 population. The Memba CR Memba 12 16 0 0 0 10 22

intervention was Erati CR Namapa 10 16 0 0 26 8 32 extended confronted to some Nampula Ribaue CRT Ribaue 22 13 0 0 11 11 9

difficulties: Angoche CR Parapato 18 16 2 0 12 4 2 MOU in process to be The community radio (CR) Nampula Radio Haq 12 15 0 0 0 0 12 Sub-total 122 125 28 0 22 79 65 116 “Acordos de Paz” was Nhamatanda CR Acordos de Paz 0 16 11 4 10 21 14 4 confronted to Gorongoza CR Gorongoza 4 14 18 12 20 14 16 16

innumerous power cuts Sofala Caia CR Caia 8 8 9 4 12 17 16 15 delaying the broadcasting Marromeu CR Marromeu 8 18 8 4 10 18 16 14 and damaging the voice Sub-total 20 56 46 24 52 70 62 49 Total 142 181 74 24 74 149 127 165 mixer; the CR of Caia needs additional recorders to accompany IFPP field activities such as community dialogues and CLL meetings.

Sub-IR 2.3: Improved systems to implement and evaluate (Social and Behavior Change Communication) (SBCC) interventions No specific activities were planned for Q2FY3. IR 3: Strengthened FP/RH health systems During this quarter IFPP HSS activities were focused on the expansion of activities in two new districts in Nampula province (Larde and Rapale) and in one district in Sofala (Maringue). The project was not able to visit the districts of Liupo and Mongicual in Nampula, and Chemba in Sofala, due to scheduling overlap of district managers, and will reschedule these visits for next quarter. IFPP also carried out the baseline assessments of the FP MSC in three expansion districts and the third round of evaluations in the districts of Mossuril, Memba and Nacala a Velha in Nampula and the fith round of evaluations in the districts of Beira City, Dondo, Nhamatanda and Chibabava. During this Q2FY3 the project continued to monitor the logistics activities for the control of imminence and contraceptive stock outs in the HFs mentored through the CommCare App in 11 districts of Nampula and eight districts of Sofala, HFs implementing the Health Information, Management and Logistics System (SIGLUS) in 12 districts of Nampula province and 5 districts in Sofala, and HFs implementing the pilot phase

41 of mobile contraceptive inventory control and management systems (SAPERS -CPF and SMATAG-CPF) in the districts of Erati, Mogovolas, Ribaue and Lalaua in Nampula.

IFPP provided TA in the implementation of the quality action plans based on the improvement opportunities identified during the previous MSC evaluation in the areas of HR, planning, M&E, commodities supply and management and, FP and RH services for Nampula City and Muecate SDSMAS in Nampula. Table 13: MSC trends by district < or = 60% MSC District Scores Over Time TA to strengthen the >60% < or = 70% (Target: achieve satisfactory scores ?80%) implementation of logistics maps >70% < or = 80% >80% < or = 90% FY1 (Oct. 16 - Sept. and route plans for FP FY2 (Oct. 17 - Sept. 18) FY3 >90% < or =100% 17) commodities distribution was also DISTRICT Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 provided, with the objective of Angoche 40% 92% 94% 85% Mogincual pre-locating enough FP Liupo commodities before the rainy Nampula D. 39% 83% 90% 90% Erati 37% 75% 84% 84% season but, unfortunately, the Memba 55% 79% 84% levels of depoprovera stocks at Meconta 68% 70% 84% national level being below the Nacaroa 65% Muecate 47% needs, 16% of HF experienced Mogovolas 57% 56% stock-outs. Additionally, TA was Moma 42% 85% 85% 88% Lardes 25% given for MB and drug distribution Monapo 50% 92% 91% 97% planning to rationalize fuel’s Mossuril 53% 86% 74%

NAMPULAPROVINCE Ilha Moç. 36% consumption. N.Porto 41% 66% 90% 98% IFPP provided TA to DPS Nampula N.Velha 56% 88% 84% maternal and child health (MCH) Murrupula 49% 83% Rapale 60% division in preparation for the FP Mecuburi 41% 81% 88% 86% logistics trainings for 80 MCH Ribaue 41% 92% 96% 100% Malema 38% 84% nurses recently hired and to Lalaua 41% ensure assignments were based Beira 63% 86% 89% 90% 92% Dondo 60% 71% 82% 87% 84% on personnel needs identified in Nhamatanda 65% 83% 82% 85% 83% the situational assessment that Buzi 74% 82% Chibabava 60% 73% 79% 82% 82% were drawn up during the MSC Machanga 67% 85% evaluations carried out in the Caia 54% 66% 83% districts. Marromeu 70% Chemba SOFALAPROVINCE Gorongosa 66% 82% Cheringoma 59% Maringue 62% Muanza 53%

In addition, the project provided TA to strengthen the capacity for management, coordination and monitoring of continuing training activities at Nampula DPS In-service Training and HR Divisions (District Focal Points) at the district level in recording and reporting all in-service training using SIFO. 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.

IFPP provided TA at the quarterly review meetings with the SDSMAS of Beira, Dondo, Nhamatanda, Chibabava, Cheringoma, Maringue and DPS Sofala in the systematic evaluation of the implementation of the FP program activities in order to determine the degree of compliance with the planned activities. Participation in the PES/PESOD 2019 provincial meeting for harmonization with the intervention strategies of the Primary Health Care Strengthening Program – MISAU/FP component, represented in the DLI 3 (Disbursement-Linked Indicators 3), with the objective of integrating relevant activities described in the technical notes of the DLIs in the investment case, in the provincial (PES) and district (PESOD) in Nampula;

During Q2FY3, the HSS team provided TA to 79 Sofala and Nampula DPS and SDSMAS program including 28 new individuals receiving TA (15 in Nampula; 13 in Sofala) and 51 (26 in Nampula; 25 in Sofala) who had received it before. These individuals receiving TA were from Sofala and Nampula DPS, SDSMAS and other FP related program managers (HR, NED, and Pharmacy) (6 districts and DPS in Sofala, and 7 districts and DPS in Nampula). This involved supporting the preparation of monthly and quarterly work plans to guide implementation and facilitate routine monitoring of PES performance.

Table 13 illustrates the trends in MSC assessments carried out 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 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, Marringu and Muanza).

During Q2FY3, District Management Standards Compliance (MSC) assessments were conducted in 10 districts during the Jan-Mar 2019 quarter, including two baseline assessment (R1) in Nampula (Larde and Rapale), one baseline assessment (R1) in Sofala (Maringue); and three round 3 assessments in Nampula province (Memba, Nacala-à-Velha and Mossuril); four round 5 assessments in Sofala (Beira City, Dondo, Nhamatanda and Chibabava). Of these 10 MSC evaluations, seven districts assessed in R3 and R5 maintained their greater than 80% score achieved in R3 and R5 respectively, Memba reached the score of 80% for the first time, and none of the baseline districts reach the minimum score of 80%. There was a slight decrease in the score in Nacala-à-Velha, reduced from 88% to 84%, and significant decrease in

Mossuril from 86% to 74%, Dondo reduced from 87% to 84% and Nhamatanda also from 85% to 83%. This decrease was due to the high turnover in both DPS which resulted in the change of some key staff in the management of the SDSMAS. All 10 districts where MSCs were conducted in the Jan-Mar quarter the IFPP HSS team also supported district managers to develop and update quality improvement (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 Overall during year two there was a significant reduction of stock outs in the HFs assisted by the project. A combination of factors contributed to these results, most notably the availability of FP commodities at the national level, as well as several IFPP supported interventions. These interventions include project- supported weekly follow-up of any imminent or total stock outs identified by IFPP district coordinators in their routine TA.

During the Q2FY3, IFPP’s TA teams provided routine TA to ensure each HF’s pharmacy manager and SDP focal point correctly and systematically used the MISAU stock cards and requisition forms to properly manage contraceptive stocks in site depots and internally within SDPs.

To report the indicator used for HF reporting stock out, the CommCare App and SIGLUS were used as sources of information to record stock outs of the main five methods of contraception (IUD, implant, progesterone-only oral contraceptives, combined oral contraceptives and DMPA - IM). A total of 148 HFs were assessed in Nampula province, which corresponds to 64% of the total HFs in the province (231 HFs); distributed among those implementing SIGLUS (140 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 (8 HFs) in 5 districts (Malema, Mecuburi, Mogovolas, Mossuril and Murrupula.

Table 14. Nampula: Source: No. HFs evaluated No. HFs that experienced % of HFs with stock stock out out CommCare App 8 1 12% SIGLUS 140 54 38% Total 148 55 37% Overall, 55 HFs in Nampula experienced a stock out of at least one method of contraception, which corresponds to 37%. In Sofala, for the reporting period, IFPP had available information only for January and February for reporting of the five districts implementing SIGLUS to record stock outs (Beira, Dondo, Nhamatanda, Buzi and Marromeu). There is no data available for March due to the partial and complete destruction of HFs depots associated with the lack of electricity due to the cyclone.

Table 15. Sofala: Source: No. HFs evaluated No. HFs that experienced % of HFs with stock out stock out CommCare App 10 0 0% SIGLUS 65 2 3% Total 75 2 2.6% Overall, two HFs in Sofala experienced stock outs of at least one method of contraception which corresponds to 3%. To address the 24% of HFs that registered stock outs, 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; TA in the implementation of the logistics maps and route plans for rational use of scarce resources available in the districts; TA on the establishment and strengthening of the District and Provincial Task Force to ensure the availability of consumables in the area of MCH and FP, in particular with focus 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), MCH district managers and HFs managers.

In this reporting quarter the logistic maps were used for the design of routes for distribution of FP consumables, as well as the use before departing for activities in the peripheries in order to identify the transitable and safe routes for transportation of consumables, especially during the rainy season. In Nampula for instance a map signed with a marker on the route map for the identification of alternative access routes to the main ones, which were interrupted due to the Photo 5 .Provincial focal point chechking the collapsing of bridges (Eg: Via linking Mossuril headquarters strock cards at Cheringoma DDM Sofala to Nampula City and Namitatar HF), allowed the vehicles of province partners and SDSMAS to travel safely and as quickly as possible during the distribution of medicines to the HFs.

Sub-IR 3.3: Strengthened governance, including civil society engagement, for an improved FP enabling environment In February, IFPPstarted with the second CPC cycle in 14 HF of Nampula. Of these, only eight, were able to carry out the community scoring within the quarter .. To that end, 896 people (448 M & 448F) from the community were mobilized to score. Organized in groups of 14 people, the process was initiated in March and is ongoing in the districts of Liúpo, Moma, Mecuburi, Nacala à Velha, Erati, Meconta, Malema and Monapo. In Sofala, only 35 groups were formed from the 56 predicted and only 12 community groups scored in three HF, representing 34% of the groups foreseen. The districts involved in the CSC process in Sofala - Buzi, Nhamatanda and Chibabava were hit by heavy rains and then by the cyclone IDAI, which disrupted the normal course of the teams as the communities were relocated in accommodation centers.

Sub-IR 3.4: Improved government capacity to increase supply, distribution and retention of skilled workers Based on the system assessment, capacity building Table 16: Comparative between trained HP and registered in SIFO at and systems strengthening end Dec. 2018 Nampula FY1 FY2 Q1 FY3 Q2 FY3 TOTAL action plans, IFPP supported DPS and district managers to Health Providers trained 1424 508 132 115 2179 more effectively manage the Health Providers registered in SIFO 1327 429 179 93 2028 supply, distribution and Health Providers still to be registered in SIFO 97 79 -47 22 151 retention of skilled FP workers. Sofala FY1 FY2 Q1 FY3 Q2 FY3 TOTAL IFPP provided TA in the Health Providers trained 891 524 57 34 1506 institutionalization of district in Health Providers registered in SIFO 584 430 57 435 1506 service training centers, Health Providers still to be registered in SIFO 307 94 0 -401 0 strengthening staff competencies in operating the MISAU’s human resource information system (HRIS) or training information system (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. All 13 districts in Sofala province and 13 in Nampula province are recording the SIFO forms locally, thereby streamlining the training registration process and ensuring more complete data in SIFO. Table 16 illustrated this: in Nampula, the in-service training centers have gradually diminished the gap but still have a gap of 151 HP not yet registered, while Sofala during the Q2FY3, resorbed the registration deficit that had occurred during FY1 and FY2.

Sub-IR 3.5: Improved generation, dissemination and use of FP data for more effective decision-making The use of district profiles to guide quarterly data analysis meetings has strengthened the FP program’s capacity to acquire strategic information and use it for evidenced-based decision making to improve program performance. In Q2FY3, 18 districts held data review meetings guided by District Profiles (DPs) developed and analyzed with IFPP support. Specific sites including 12 SDSMAS in Sofala (Beira, Dondo, Nhamatanda, Gorongosa, Machanga, Chibabava, Caia, Marromeu, Cheringoma, Muanza and Maringue) and 6 districts in Nampula (Memba, Nacarôa, Nampula City, Ribaué, Malema and Nacala-à-Velha,). This represents 75% achievement against the quarterly target to conduct 24 quarterly district data review meetings using DPs per quarter, which compared to last quarter is a decrease from the 26 achieved. The reason for this decrease is related to Nampula province where only five SDSMAS used the DPs compared to 15 last quarter. This was due to overloading of the agendas at the district level, associated with the constant absence of the SDSMAS Directorates and respective program managers to attend meetings and Photo 6: Technical support to Nhango HF, Chibabava trainings at the Province level, as well as the frequent district in Sofala province. change of the district officials in the NED and MCH programs in some districts that already had the dominion in the preparation of the DP and presentation in the monthly statistics meetings and/or quarterly review meetings (Nacala Porto, Moma, Mogovolas and Nampula City). One positive aspect of the use of the DP in the review meetings during Y3Q2 was the continued sharing of experiences and improvement actions between HFs with good and poor performance of the FP indicators, whenever possible between the Directors and MCH staff of the peripheral HFs and district program managers.

Monitoring, evaluation and implementation research During Q2FY3, 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 “Reasons that take users of IUD and Implants to remove the IUD and Implants”

Supervision and technical support During Q2FY3, 17 districts (eight in Nampula and nine in Sofala) received supervision and technical support visits including RDQA and TA participation at the HFs’ monthly statistics meeting. Although, some progress was observed throughout the quarters, the main findings Photo 7, 8. Technical support at Machanga district in Sofala and –Presentation of RDQA results in Erati District continue to be the inconsistent use of the daily summary form and consequently frequent errors in the monthly summary aggregation. Furthermore, there is still a weakness persisting with regards to the registration and monthly aggregation of the MB activities.

Support to district monthly meetings and elaboration of HF monthly statistics

During the reporting period in Nampula, the M&E team participated in the SDSMAS monthly data discussion meeting in Mongicual, attended by all the HFs responsibles and supported the elaborarion of HF monthly statistics in 22 HFs in the districts of Ribaue, Nacala Vela, Nacala Porto, Nampula city, Monapo, Angoche, Mome, Erati and Muecata. In Sofala, the team supported the districts of Machanga, Chibabava and Buzi.

Routine Data Quality Assurance (RDQA) During the Q2FY3, RDQA tools were applied to 92 HFs (49 in Nampula and 43 HF in Sofala). The main findings are summarized below:

1) Continuation of not using the daily tally sheet; 2) FP integration monthly summary forms are not correctly aggregated and in Sofala they are still challenges in aggregating APE data

To address both problems, HFs have been included as part of continued mentorship visits and support. During this quarter, the tool was upgraded to monitor overall HF quality data reporting as illustrated in the Figure 12 Acceptable data quality, following MISAU scale is ≤ Figure 12: RDQA results using the upgraded tool - Q2FY3 10% for data discrepancy between data observed in primary logbook 70% 63% and data inserted in the HMIS data 60% HF with acceptable data base, medium data quality is 50% quality aggregation between 10 and 20% and non- 40% 35% acceptable data quality is over 20% HF with medium data 30% quality aggregation of discrepancy. 20% HF with non acceptable In Nampula, out of the 49 HFs, 24 10% data quality aggregation HFs received the first RDQA visit, 20 0% HF received a second visit, four Sofala Nampula received a third RDQA visit and one received a fourth RDQA visits. In Sofala, out of the 43 HFs, nine HFs received the first RDQA visit, 27 HF received a second visit and even HF received a third RDQA visit. The below table’s flow illustrates the data quality improvement of Beia-Peia HF in Machanga district:

In summary, data quality continues out of the MISAU’s acceptable range despite efforts carried out. In Nampula, the magnitude of the discrepancy was discussed with the highest DPS representatives and resulted in the decision to intensify RDQAs by mobilizing the DPS and SDSMAS MCH and M&E staff. Main errors identified are: proper characterization and register of FP user by type (“new” or first time user in her life and “continuer” or has already used a FP method before in her life); not registering data immediately at the time of the FP consultation; high turn-over of MCH nurses as a bunch of recently

50 graduated ones were admitted while the former ones went on a additional one year training enabling them to jump from a basic administrative level to a medium one; daily data aggregation’s tally sheets not being consistently fulfilled at FP consultation room as the usual HP is temporarily moved or the usual MCH nurse has no pressure from her management to do so.

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

• Commcare App training for the community supervisors to improve their abilities in using the App followed up with TA. • Support the field supervisors to better manage the different tablet’s application (scan, email and general use). • Validation of referrals and confirmed referrals at HF level. • Support to APEs. Photo 9. Support to the APE in Mucheve – Machanga During this quarter the community database was district transitioned from DHIS2 to Commcare for more friendly data insertion. A training was held in Nampula and in Sofala reachingSupport to the all APE field in Mucheve supervisors, – Machanga Community district

Technical Support Officers (OAT), M&E team and a follow up meeting was held in the last week of the quarter to ensure that data was completely and correctly registered and to clarify remaining doubts.

Also, in Nampula the monitoring team participated in four technical updates targeting the rural CFs clarifying the flow-related aspects, discussing the frequent registration errors observed in the Community Dialogues registration forms.

The M&E team also supported the SDSMAS APEs meetings to analyse the performance of each APE, to discuss the data quality of APE data logbook and monthly HF data aggregation forms.

Implementation research study to explore the reasons behind IUD and implant removal IFPP, in collaboration with E2A, is conducting a study aiming better understanding of the possible and most frequent reasons for implant and IUD removal. To improve LARC removal records – the objective of this operational study, the M&E team introduced new indicators in the existing register logbook. This study is being implemented in Nampula province in the district of Nampula (central hospital and 25 de Setembro HF), in Moma district (Micane and Chalaua HFs) and in Nacala porto district (Nacala Porto DH, Nacala Porto HF, Akumi and Murrupulane HFs). In Sofala province: in Beira City (central hospital and

Munhava HF), in Buzi district (Buzi RH, Chissinguana, Grudja, Table 17: distribution, per selected HF, of the # of WRA involved in Guara-Guara HFs and Rio Buzi the study health post) and in Caia district # Sofala Dec Jan Feb March TOTAL 1 Central Hospital Beira 2 10 4 3 19 (Caia DH and Sena HF). 2 Buzi RH 9 12 6 0 27 3 Caia DH 9 14 9 0 32 Data from December to March 4 Chissinguana/Buzi 0 3 0 0 3 5 Grudja/Buzi 0 0 0 0 0 shows that 551 women came to 6 Guara-Guara/Buzi 3 3 0 0 6 the selected HFs for implant 7 Rio Buzi/Buzi 5 0 0 0 5 8 Deve/Caia 2 2 4 3 11 removal in Nampula and Sofala 9 Sena/Caia 5 0 7 5 17 10 Munhava/Beira 52 62 68 41 223 as presented in the table 17. TOTAL 87 106 98 52 343 # Nampula Dec Jan Feb March TOTAL Out of the 208 WRA, in 1 Central Hospital/Nampula 10 3 4 0 17 2 Moma HD 0 3 0 0 3 Nampula, 26 decided to keep 3 Nacala Porto DH 2 0 4 0 6 the implant following HP 4 Micane 2 3 2 2 9 5 Chalaua 3 3 1 0 7 counselling and 182 decided to 6 Nacala Porto 20 15 36 12 83 7 Akumi 4 4 15 6 29 remove their implant. In Sofala, 8 Murrupulane 3 1 3 3 10 out of the 343 WRA, 64 decided 9 25 de Setembro 17 10 9 8 44 Total 61 42 74 31 208 to keep the implant after counselling and 278 removed their implant. In both provinces, the most common reasons mentioned for removal were bleeding, desire to become pregnant and expired date of an implant.

FP and Environmental Compliance

During Q2FY3, 99 HFs (39 HF in Table 18 FP and environmental trained HP in Q2FY3

Nampula and 67 HF in Sofala) # HP trained in # HP trained in FP Distrito US environmental were assessed for compliance compliance environmental compliance; HF focal point for environmental only 3% of them were fully 20 20 compliance compliant. Most of the HFs are Monapo Carapira, Natete, Metocheria, facing difficulties to segregate Mecuco, Ramiane, Murruto, 111 111 the different type of waste Chihiri, Netia e Itoculo (waste biological such as Ilha de Moç. Ilha de Moçambique e Lumbo 85 85 Mossuril Nacuxa 17 17 placenta, infectious waste such Imala, Muculuone, Kavula, 0 42 as used needles and syringes, Muecate Minicane, Napala e Xinamane common waste) and difficulties Community facicilator 4 Mecua 0 10 in the decontamination process Meconta for medical equipment such as Community facicilator 2 2 Total 235 289 temporarily immersing the medical equipment used, such

52 as speculum, forceps, trawler 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 Q2FY3 part of the missing material 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. IFPP has furthermore initiated the recruitment of a biosafety project officer who is foreseen to initiate his activities in May 2019.

For FP compliance, 95 HFs were assessed (53 in Sofala and 42 in Nampula) and 44% were fully compliant. The non-compliant HFs are mainly non-compliant because a few of 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 235 HP was trained through this module in 19 HFs this quarter. The table 18 illustrated the number of HP and CFs trained in compliance.

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 80,862 479% 210,348 177,202 Since April 2016, the MOH “FP new user” indicator defined new users as “first time users in 1.A. # new users life.” For the FY3, IFPP proposed the target of 80,862 defined taking in account the of modern contraceptive prevalence rate (CPR) and the unmet need for FP (IFPP baseline). Categorizing contraceptive a client as a first-time user in her life is dependent on information provided by the user. The methods reliability of this information depends on the HF provider ability and time. Before April 2016, the concept of new user was “first time for the current year” and obviously, this indicator “first time user in life” doesn’t seems appropriate in Mozambican context. 3,045,547 544,230 1,159,123 698,036 66% 247,899 211,415 # of women The IFPP suggested the inclusion of this new indicator, "Number of women initiating a initiating a contraceptive method", disaggregated by type of method as more reliable to monitor the contraceptive trend of FP access in the FY2. FY2 is probably overreported due to implementation of the method MCH National health week and the SRH and CECAP “caravan” organized during July-August 2018. The data of the Q1&Q2FY3 is reaching 66% of IFPP annual target. 658,958 399,381 639,144 565,067 54% 158,619 148,799 1.B. # continuers users of modern In coordination with the MOH definition, a “continuer” user is a woman who used a FP contraceptive method already in her life and should be registered only once in the FP logbook. The FY2 methods results were influenced by the National Health Week (NHW) and the CECAP caravan. The Q1&Q2FY3 data are on track to reach the annual target. 2,963,877 591,722 1,233,514 1,282,855 39% 280,859 217,581 Data disaggregated by method are presented in the PMP in annex. The FY2 annual target proposed is 615,391. At the end of FY2 the project 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 and CECAP “caravan” organized during the July-Sept 2018. The FY3 annual target proposed, based on FY2 achievement, was 1,282,855. At the end of Q2FY3, thirty nine percent of the annual FY3 target was reached at the end of Q2FY3. Meanwhile, 1.C. Couple the comparison between the number of commodities supplied through DPM and the FP Years of services registered through HMIS, shows significant discrepancies, specifically for IUD and Protection Implants which, in turn, over-estimated the FY2 CYP achieved. In this context the achievement of only 39% of the FY3 target is an encouraging data as it’s probably the result of a lesser untwisted data collection and reporting at HF level.

Achieved Achieved FY3 Annual LOP Indicator FY1 FY2 Annual % Q1 Q2 Q3 Q4 Target Target Achieved

18,465 3,136 10,000 16,622 28% 2,231 2,483

Reaching 28% of the annual target. One reason for this lower achievement is related to the 1.D. # women recent introduction of ART follow up consultations passing from quarterly to bi-annually. The receiving other reason is that the WLHIV have the choice to access FP services in every outpatient contraceptive consultation at HF level (Integration of FP services in all outpatient consultation). services in HIV Furthermore, dedicated consultation room attending only ART patients is existing only in the services 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 45% 18,097 17,560 postpartum During Q2FY3, 4,813 PPIUDs were inserted and 12,747 women accepted another modern clients accepting contraceptive method, totaling to 17,560 and reaching 45% of the annual target. Compared a modern to the number of institutional deliveries registered in Q2FY3, 23% of the women who gave contraceptive birth at a HF have accepted one of the eligible post-partum FP methods. method prior to or at discharge 1.F. # users 338,751 47,072 125,941 84,454 115% 46,017 50,771 receiving modern Q2FY3 data shows that IFPP reached 115% of the annual target. contraceptive methods from APEs at community level

Comments: Cyclone Idai affected the data being reported Table 19: diminution of the HF # reporting data during this quarter in Sofala. Table 19 shows the due to the cyclone number of HF reporting data in SISMA during Health facilities in Sofala reporting in SISMA this reporting period (only 105 reported data Districts Existing HF January February March during March 2019). Beira 17 17 17 12

Dondo 15 15 4 10 In general, indicators show a sustained Nhamatanda 18 17 17 11 expansion of IFPP. The Q1FY2 and Q4FY2 data Búzi 15 15 15 0 was strongly influenced by the MCH NHW and Chibabava 15 15 15 0 the contraception week. It was expected that Machanga 10 10 9 8 some of the new STM users and continuers Caia 12 11 12 12 reached during these two events will have Marromeu 9 9 9 9 difficulty refilling their methods in future Chemba 9 9 9 9 quarters, which will increase the STM discontinuation rate. Meanwhile, the initiators Gorongosa 14 14 14 14 for LARCs are important contributors to the Cheringoma 7 7 7 7 modern contraceptive prevalence rate (mCPR) Marigué 9 8 8 8 and these events were also increasing the IUD Muanza 7 6 6 5 and implant additional user numbers. Total 157 153 142 105

Figure 13 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.

Couple year protected (CYP) data (figure 14): firstly, 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

Figure 13. Trends in women initiating a contraceptive method by type of method in Nampula and Sofala provinces - October 2016 to March 2019 (w/o PPFP at Maternity and minilap)

300000 Pills Injectable Implant IUD 250000

200000

150000

100000

50000

0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 FY1 FY2 FY3 FY1 FY2 FY3 Nampula Sofala

56 quarters. For Q2FY1, data reported on a quarterly base are comparable. During Q2FY3 the CYP in Nampula decreased by 4% compared to Q1Y3, with LARC being 63% of the CYP. In Sofala, the CYP decreased 42,4%, due to data not being entered in the HMIS. 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.

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 15) is stabilizing along the FY2

Figure 14. Trends in CYP in Nampula and Sofala provinces - October 2016 to March 2019

Pills Injectable Implant IUD Pos Partum IUD T. Ligation 250000

200000

150000

100000

50000

0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 FY1 FY2 FY3 FY1 FY2 FY3 Nampula Sofala

Figure 15, PP IUD and institutional deliveries by province from October 2016 to March 2019

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

quarters and Q1FY3 reaching 7% in Nampula province and 5% in Sofala province. A specific strategy was designed together with DPS to give a second breath for PPFP in FY3.

Figure 16. % of women accepting Post-partum FP method at Maternity by quarter and province from October 2016 to March 2019

PP IUD Other methods % of women accepting a PPFP method 16000 100%

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

When analyzing post-partum women accepting a modern contraceptive method at the maternity level (Figure 16 - PPIUD and other PP methods as captured and reported under HMIS-SISMA), Nampula province reached 25% and Sofala province 19% - these data seems over-reported through the HMIS when compared to the IUD and implants supplied through DPM.

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 providers 3,749 2,309 1,032 540 63% 189 149 trained on modern An accelerated start-up supported the MoH to reach its 2020 FP targets. During the FY1 and FY2 the methods of IFPP trained 3,341 HPs. During Q2FY3, IFPP trained 149 HPs reaching 63% of the annual target of contraception training (540 HPs). 1.1.2. % of health 80% 90% 93% 80% 87% 82% 93% providers who have A total of 93% of the HPs trained during Q2FY3 completed the training successfully, reaching 87% of completed the training the annual target on modern methods of contraceptive with positive score in the post test 100% 68% 92% 100% 97% 94% 97%

1.1.3. % of supported At end of Q2FY3, 376 out of 388 HFs (97%) had already at least one HP trained in FP through IFPP. service delivery sites During Q2FY3, 150 HFs in Sofala out of the 157 and 225 HFs out of the 231 in Nampula had a providing family trained HP. planning counseling and/or services

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 Achieved Achieved Annual % Indicator Annual Q1 Q2 Q3 Q4 Target FY1 FY2 Achieved Target 1.2.1. # of additional USG- assisted community health 3,735 1,763 723 800 28% 168 57 workers (CHWs) providing During Q2FY3, 37 TBA and 20 IPC were trained reaching at end of Q2FY3, 28% of the annual target. family planning information and/or services 12,594 1,639 3,383 3,160 47% 1,099 397 1.2.2. # mobile brigades conducted including During Q2FY3, IFPP supported 397 MBs (276 in Nampula and 121 in Sofala) reaching 47% of the contraceptive services 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) 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 1.3.1. % 44% 57% 68% 35% 67% 66% 69% confirmed referrals from With CwS platform, all IPC referrals are now electronic and are accountable. For clients receiving a paper slip communities to from a triplicated referral copy-book from CFs and for client referred by TBAs whose referrals are confirmed

59 facilities for FP thru the monthly HF-TBAs meetings. Out of 32,650 referrals made (paper and electronic), health providers services based at HFs have confirmed 22,402 referrals.

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 Achieved Achieved Annual % Indicator LOP Target Annual Q1 Q2 Q3 Q4 FY1 FY2 Achieved Target 2.1.1. 1,147,520 174,531 322,583 188,160 108% 115,351 87,669 # contacts conducted by During Q2 FY3 87,669 contacts were conducted. The annual target of FY3 is 188,160 contacts, less than what trained was achieved during FY2. IFPP team has done the exercise of revising the annual target suggesting the new TBAs/activists target of 459,804 contacts. This decrease of contacts was mainly due to the rainy season and to CPC activity. to women

Comments The number of women contacted in Nampula was about 62,837 (27,237 by CFs, 29,992 by IPC and 5,608 by TBAs) and 24,832 (14,468 by CF, 8,828 by IPC and 1,536 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 2.2.1. # community 13,056 0 3,226 3,600 34% 673 543 dialogues conducted on FP (6 IFPP reached 34% of the annual target; this quarter 2 only 355 community dialogues were conducted in sessions Nampula and 188 in Sofala. completed) 2.2.2. # community 1,475 323 321 384 76% 127 165 radio sessions broadcasted on During this quarter,165 CR sessions were broadcasted. IFPP reached 76% of the annual target. 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 held with SBCC project to A meeting was held with H2N plan/coordinate SBCC approaches 2.3.2. # capacity 10 2 2 2 0% 0 0 building sessions No capacity building trainings for CRs were carried out this quarter, this activity is planned for the last for community quarter of FY3.

60 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 Provided TA at the quarterly review meetings with the SDSMAS of Beira, Dondo, Nhamatanda, Chibabava, Cheringoma, Maringue and DPS Sofala in the systematic evaluation 3.A. # DPS including of the implementation of the FP program activities to determine the degree of compliance FP interventions in with the planned activities. annual PES and Provided TA in the PES/PESOD 2019 provincial meeting to help identify PES/PESOD activities budget that align with the disbursement-linked indicators 3 (DLI3) of the GFF 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. 36 7 21 25 44% 5 6 District MSC assessments were conducted in 10 districts during the Jan-Mar 2019 quarter, including two baseline assessment (R1) in Nampula (Larde and Rapale), one baseline assessment (R1) in Sofala (Maringue); and three round three assessments in Nampula province (Memba, Nacala-à-Velha and Mossuril); four round five assessments in Sofala (Beira City, Dondo, Nhamatanda and Chibabava). Of these 10 MSC evaluations, six districts assessed 3.B. # SDSMAS/DPS in R3 and R5 maintained their greater than 80% score achieved in R3 and R5 respectively, achieving satisfactory Memba reached the score of 80% for the first time, and none of the baseline districts reach scores in MSC the minimum score of 80%. There was a slight decrease in the score in Nacala-à-Velha, assessment reduced from 88% to 84%, and significant decrease in Mossuril from 86% to 74%, Dondo reduced from 87% to 84% and Nhamatanda also from 85% to 83%. This decrease was due to the high turnover in both DPS which resulted in the change of some key staff in the management of the SDSMAS. All 10 districts where MSCs were conducted in the Jan-Mar quarter the IFPP HSS team also supported district managers to develop and update quality improvement (QI) action plans to improve performance and guide follow-up TA in the implementation of corrective actions. 3.C. % USG-assisted 5% 14% 6% 10% 26% 7% 26% service delivery points For reporting this indicator the CommCare App and SIGLUS was used as the source of (SDPs) that experience a stock information to record the stock outs of the five main methods of contraception (IUD, out at any time during Implant, progesterone -only oral contraceptives, combined oral contraceptives, and DMPA- the reporting period IM). A total of 148 HFs were assessed in Nampula province, which corresponds to 64% of the of a contraceptive total HFs in the province (231 HFs); distributed among those implementing SIGLUS (140 HFs) method that the SDP located in 12 districts (Monapo, Angoche, Nampula, Moma, Rapale, Nacala Porto, Nacala-a- is expected to provide Velha, Memba, Erati, Meconta, Muecate and Nacaroa), and those mentored through

CommCare App (8 HFs from 5 different districts), 37% of HFs assessed (55/148) registered stock outs, mainly due to the shortage of DPMA at national level. For the reporting period, IFPP used the available January and February information for reporting of the 5 districts implementing SIGLUS (65 HF) to record stock outs (Beira, Dondo, Nhamatanda, Buzi and Marromeu) as no data was available for March due to the partial and complete destruction of HFs depots associated with the lack of electricity due to cyclone IDAI. 10 additional HFs were assessed for stock-out through the CommCare App; thus IFPP used data from 75 of 157 (47%) to report stock-out and 3% of the HF assessed report stock-out (2 on 75). 3.D. % of supported 100% 32% 45% 90% 45% 46% 45% SDPs with all eligible health providers At the end Q2FY3 45% of all HFs in both provinces (66% or 103 out of 157 HFs in Sofala, and trained in a range of 31% in Nampula or 71 out of 231 HFs in Nampula) had all eligible health providers trained in modern contraceptive a range of modern contraceptive methods. Although it’s important to note that 97% of the methods HFs in Sofala and in Nampula already have “at least one HP trained in FP”.

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 93% 114 79 (43 Sof + 99 (38 Sof, 152 52 128 152 (30 3.1.1. # DPS and Npla = 142 Sof,84 41 SDSMAS staff / 152) Nam) Nam) receiving IFPP provided TA on the implementation of FP activities within the 2018 PES work plan to plan to 79 TA/capacity- individuals, including 28 new individuals receiving TA (15 in Nampula; 13 in Sofala) and 51 building in FP already reached in Q1FY3 (26 in Nampula; 25 in Sofala).These individuals from HR, NED, and planning, budgeting and Pharmacy areas and are working at DPS and SDSMAS level (6 districts and DPS in Sofala, and 7 implementation districts and DPS in Nampula). This involved supporting the preparation of monthly and quarterly work plans to guide implementation and facilitate routine monitoring of PES performance.

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 38 28 36 36 100% 100% 100%

3.2.1. # of This indicator has already been reached at 100% during Year 2 with all districts having logistics maps supported districts developed and implemented. with a documented FP IFPP TA teams will continue to build capacity of DDM managers in both provinces during FY3 by logistics map to supporting the correct usage and maintenance of logistics maps to optimize supply chain management optimize of FP commodities. 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 that 42 0 13 14 0% 0 0 undergo CSC The activity was not planned for this quarter. feedback processes through 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

LOP Achieved Achieved FY3 Annual Annual % Indicator Q1 Q2 Q3 Q4 Target FY1 FY2 Target Achieved 236 528 (435 3,533 1,911 859 540 141% (57 Sof; 179 Sof; 93 3.4.1. # DPS, Nam) Nam) SDSMAS & HF staff During the Jan-Mar quarter, IFPP trained 149 health care providers at HF level in the integrated trained in family provision of family planning services and 189 in Q1FY3, with almost all participants recorded in planning that are the MOH’s SIFO HR training information system (HRIS). During these two quarters, the registered in e-SIFo continuous training division of Sofala DPS succeeded to fill completely the existing gap in SIFO (database) registration and the Nampula DPS succeeded to minimize its gap; this represents a 141% achievement against the annual target once non-previously registered HPs were registered. In Sofala this update was possible due to the special task force organized through IFPP DPS TA.

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 18 (12 36 16 16 24 75% 26 Sof; 6 Nam) 12 SDSMAS in Sofala (Beira, Dondo, Nhamatanda, Gorongosa, Machanga, Chibabava, Caia, Marromeu, Cheringoma, Muanza and Maringue) and 6 districts in Nampula (Memba, Nacarôa, 3.5.1. # of districts Nampula City, Ribaué, Malema e Nacala-à-Velha,). This represents 75% achievement against the that hold quarterly quarterly target to conduct 24 quarterly district data review meetings using DPs per quarter. data review This represents 75% achievement against the quarterly target to conduct 24 quarterly district meetings using data review meetings using DPs per quarter. Compared to last quarter, Y3 Q1, there was 33% district profiles decrease, this was due to overloading of the agendas at the district level, associated with the constant absence of the SDSMAS Directors and respective program managers, to attend meetings and trainings at the Province level. The mobility of personnel and frequent change of the district officials in the NED and MCH programs in some districts that already had mastered the preparation of the DP and presentation in the monthly statistics meetings and/or quarterly review meetings (Nacala Porto, Moma, Mogovolas, and Nampula City) also affected this indicator.

A positive aspect of the use of the DP in the review meetings during Y3 Q2 was the continued sharing of experiences and improvement actions between HFs with good and poor performance of the FP indicators, whenever possible between the Directors and MCH staff of the peripheral HFs and district program managers.

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 UNFPA, Program-Procurement and Supply Management (PSM), Thinkwell, Health Policy Plus (HP+) 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) The transition to generics such as Zenia F for Microgynon, Triclofen for DMPA-IM, Fenipop for Microlut and Levoplant for Jadelle 2) FP2020 implementation plan 3) SRH commodities forecasting for the quarter 4) A discussion on the preliminary results of service availability, readiness assessment (SARA) 5) The inclusion of DMPA-SC under the method-mix at HF’s level (currently offered by APE’s) 6) Preparation of National FP Meeting to be held in May 7- 9th, 7) Discussion on ECHO (Evidence for contraception and HIV options) study 8) The start of costed implementation plan development with HP+ and Thinkwell.

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.

After the kickoff meeting held in December with MEMMS and USAID, field work was held in Nampula covering 16 districts and targeted 816 households, and the qualitative component was conducted in three districts. Sofala province was excluded due to the cyclone, and the preliminary report is expected to be available during next quarter.

For MCSP the main discussion was around fixed asset disposition (vehicles and motorbikes) for Nampula and Sofala Provinces, with transfer of two vehicles and fifteen motorbikes by the end of this reporting period.

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.

Upcoming Plans

IR 1:

• Conduct remaining HF (including those recently built) assessments and support the provision of necessary medical equipment and supplies as identified. • Continue FP trainings at HF level and subsequent mentoring visit with emphasis on gaps mentioned under mentorship section, particularly for PPFP. • Continue FP trainings and regular meeting’s support to enhance FP services delivered per APEs and TBAs. • Support district MCH nurse to provide quarterly supportive supervision on FP/RH services to HFs. • 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 MBs in urban and rural areas, including schools. • Continue coordination meetings with other implementing partners to leverage support to HFs and directorates, and for the MB planning to increase access to FP commodities to remote communities including CECAP activities. • 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. • Continue to implement ISL PPIUD workshops. • Meeting with USAID and MCSP to establish CECAP materials repository (information, education and communication [IEC] materials, tools and SOP's).

IR 2: • Continue to mobilize the FY1 groups to complete sessions four through six of the community dialogues and roll-out the six community dialogue sessions in additional community groups. • Continue the preparation, organization and realization of CLL meetings in alignment with the CFs areas of intervention. • Draft and implement the CRs’ contract addendums to broadcast radio programs related to sessions four through six of the community dialogues. • TA team to continue monitoring and evaluating of the community component. • Continue to support the follow-up of the TBAs monthly meetings at peripheral HF level and ensure a more in-depth analysis based on the standardized TBA meeting forms.

IR 3: • Finalize the expansion of HSS activities for the remaining districts not yet covered during Q2 in Nampula province, namely Liúpo and Mongicual and Chemba in Sofala.

• Provide TA for the implementation and strengthening of SIGLUS in selected districts: Moma, Rapale, Naca-a-Velha, Nacala Porto, Memba, Angoche, Nampula city, Monapo, Nacaroa, Meconta, Erati and Muecate; Beira, Dondo, Nhamatanda, Buzi and Marromeu in Sofala

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

Evaluation/Assessment Update

During Q2 IFPP discussed and finalized the final version of the operational research protocol in FP at the DPS Nampula: Determining factors for adherence to SRH services/FP "Use of modern methods of contraception by Women of Fertile Age in nine districts of Nampula province during the year 2018" SDSMAS (Nampula City, Angoche, Erati, Ribaué, Moma, Mecuburi, Nacala Porto, Monapo, and Meconta).

During the next quarter IFPP will start the data collection, processing and present the results of the operational research in FP, and based on the results draw up the intervention plan, since the protocol has already been approved by the Committee of Bioethics in Health.

In Sofala, IFPP will complete the operational research protocol in FP “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” and submit to the International Committee of Bioethics in Health (CIOB) to obtain approval and start with the process of data collection, processing and production of the research results.

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 Mid Term evaluation conducted by MMEMS

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

Annex A - Success stories

“Now we can live our sexual life without the fear of getting pregnant”

AT is 29-year-old, and RM is 19 years old. They are young couple living in Siluvo, Nhamatanda district of Sofala province, with two children. The couple lives in a community with limited information on family planning and LARC. It is in this context that the IFPP project through the community dialogues reached them, a young couple who participated, learned and adopted family planning to limit the births.

“We heard about this project in the church through the peer facilitator who gave a talk about family planning and we liked it. In fact, there was coincidence with what happened to us, since our second child was not in the plans and with the lack of information we ended up having an unwanted pregnancy. With the community dialogues, we listened to all the information, we reflected and decided to adhere to the family planning methods and the implant was the method of our choice” ….” We are very happy with the family planning because it helps us a lot and so far, we don’t want to have another child and we can have sex without fear of becoming pregnant. "

As a way of ensuring that other families are covered by the message they have learned from the IFPP rural community strategy of the community dialogues, they have sensitized others in their community by sharing their own story as an example ... “by meeting my friends, I have advised them to do family planning in order to be able to better care for our children ... "

“With family planning, we can better plan our life”

RJ is 40 years old, and RM is 45 years old. They have 8 children and live in Siluvo, in the Nhamatanda District, Sofala province.

During the delivery of her last child, she had complications and after the birth, the couple adopted sexual abstinence for 2 years, a behaviour that generated some discomfort for them.

Aware of the importance of his wife’s health, they engaged in the community dialogue sessions where they learned and decided to adopt a contraceptive method. Their enrolment happened after he became aware of the community dialogues that were being held in his community.

"After community dialogues sessions, we discussed and decided to adhere to family planning methods, considering the complication we faced in the last childbirth. So, I accompanied my wife to the health facility, so she could have a method.”

"... in our lives, we must plan what we want to do with our lives. Family planning helps with child spacing and financial management of school costs. When a child is older and another one is born, she or he can help to care for the youngest one, if not, it is too much difficult for the mother to nurture them and still fulfil with daily tasks”.

"... Our life is more organized in terms of expenses, as well as in our marital relationship, since we can already have sex without any worry about getting pregnant, even with a smaller child," the couple says.

They have shared their story in their community and have talked about the advantages of family planning, influencing many women who have also adopted to methods of their choice, a fact that is witnessed by the local community leader, who affirmed that the life of community has greatly improved because of the IFPP.