MCSP Madagascar Quarterly Report 01 January 2016– 31 March 2016
Submitted on: May 2, 2016
Submitted to: USAID Madagascar
Submitted by: MCSP Madagascar Team
Table of Contents
List of Figures and Tables i Acronyms and Abbreviations ii Executive Summary 1 Introduction 6 Major Accomplishments 8 Objective 1: Provide support and technical leadership in maternal and newborn health at the national level to the Ministry of Health 8 Objective 2: Increase access to and improve quality of maternal and newborn health services in USG priority regions 10 Objective 3: Increase access to long-acting Family Planning methods in USG priority regions 20 Objective 4: Improve prevention and treatment of MIP in the context of focused antenatal care 23 Objective 5: Strengthen the capacity of pre-service training institutions to educate midwives according to ICM standards and competencies 24 Management Updates 26 Challenges and Opportunities 27 Way Forward 28 Learning Agenda and Progress 29 Appendix 1: Performance Indicators 32
List of Figures and Tables Figure 1. MCSP coverage in End of March 2016...... 7 Figure 2. Average pre/post-test score of regional trainers per region, Jan-Mar 2016 ...... 11 Figure 3. Average Knowledge Pre-test and Post-test Participant Score during 3rd week of MNH Training per region, Quarter 2: Jan-Feb-March 2016 ...... 13 Figure 4. Average Practical Skills pre/post-test score of Participants in 3rd week of MNH Training per region, Quarter 2: Jan-Feb-March 2016 ...... 13 Figure 7. Overview of MNH quality dashboard in Alaotra Mangoro - Dec 2015- Jan-Feb 2016...... 17 Figure 8. MNH quality dashboard of CSB Tanambe-Amparafaravola in Alaotra Mangoro region, June 2015 - March 2016...... 18
Table 1. Distribution of Participants in 3rd week of MNH Training in Alaotra Mangoro and Melaky regions, Quarter 2: Jan-Feb-March 2016...... 12 Table 2. Distribution of Participants in 1st week of MNH Training in Analamanga and Vakinankaratra regions, Quarter 2: Jan-Feb-March 2016...... 14 Table 3. The 8 MNH quality dashboard indicators for public health facilities in 2015-2016...... 15 Table 4. MNH quality dashboard response rates for February 2016 in the 5 Y1 regions ...... 16 Table 5. Health providers trained in PPFP from Alaotra Mangoro and Menabe regions during ...... 21 Table 6. Learning activity and progress during Q2 of Year 2 ...... 29 Table 7. Status of the performance Indicators during the quarter 1 of Year 2...... 32
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Acronyms and Abbreviations AFD Agence Française de Développement- French agency for development ANC Antenatal Care CARMMA Campaign for Accelerating the Reduction of Maternal Mortality in Africa CG/QA Clinical Governance / Quality Assurance CHRD Centre Hospitalier de Reference de District (District reference hopsital) CHRR Centre Hospitalier Regional de Reference (Regional Reference Hospital) CHU Complexe Hospitalier Universitaire CHW Community Health Workers CSB Centre de Santé Base (Primary Health Center) DIFP Direction des instituts de formation des paramédicaux (Pre-service institution Division) DLP Direction Lutte contre le Paludisme DRSP Direction Régionale de la Santé Publique (Regional Health Division) DSFa Direction de la Santé Familiale (Family Health division) EMAD Equipe management de district (District Management team) EMAR Equipe Management Régional (Regional Management Team) FP Family Planning ICM International Confederation of Midwives IPTp Intermittent Preventive Treatment for pregnancy IUD Intrauterine device MCSP Maternal and Child Survival Program MIP Malaria In Pregnancy MNH Maternal and Newborn Health MOH Ministry of Health MSM Marie Stopes International Madagascar PEV Programme élargi de Vaccination (Immunization division) PNLP Programme National de Lutte contre le Paludisme (National Malaria Control Program) PPFP Postpartum Family Planning PPH Postpartum Hemorrhage PPIUD Postpartum Intrauterine Device PSI Population Services International RMA Rapport Mensuel d’Activités (Monthy Activities Report) RMNCH Reproductive, Maternal, Newborn and Child Health SFPP Service de la formation et perfectionnement du personnel SPSR Sécurisation des Produits de la Santé de la Reproduction (reproductive health integrated strategic plan) SSA Sites Strengthening Assessment
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SSME Semaine de la Santé de la mère et de l’enfant (week for maternal and newborn health) UHC Universal Heath Coverage UNFPA United Nations Population Fund UNICEF United Nations Children's Fund USAID United States Agency for International Development USG United States Government WHO World Health Organization
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Executive Summary The Maternal and Child Survival Program in Madagascar’s work plan for Year 2 (Y2) have the following objectives:
1. Provide support and technical leadership in Maternal and Newborn Health (MNH) and Family Planning (FP) at the national level to the Ministry of Health (MOH) 2. Increase access to and improve quality of maternal and newborn health services in USG priority regions 3. Increase access to long-acting postpartum family planning methods in USG priority regions 4. Improve prevention and treatment of malaria in pregnancy (MIP) in the context of focused antenatal care 5. Strengthen the capacity of pre-service training institutions to educate midwives according to International Confederation of Midwives (ICM) standards and competencies The key achievements for quarter 2 (January-February-March 2016) of PY2 are presented below:
Objective 1: Provide support and technical leadership in maternal and newborn health at the national level to the Ministry of Health
• Supported the dissemination and implementation of the CARMMA initiative - the Roadmap 2015-2019 (Activity 1.1.2).
o Conducted an orientation to the Roadmap for health providers from 2 regions: Analamanga and Vakinankaratra. This roadmap will help providers and local stakeholders prioritize and plan improvements to maternal and newborn health services. • Participated in the updating of the 2016-2020 reproductive health integrated strategic plan (SPSR) and the 2016-2017 operational plan (Activity 1.3).
o Supported the integration of a post-partum family planning (PPFP) component into two reference documents: the 2016-2020 SPSR and the 2016-2017 operational plan. These documents provides the framework for implementing partners and MOH and will help improve PPFP services for women and families. • Provided technical support to reproductive, maternal, newborn, and child health (RMNCH) technical working groups in developing misoprostol and CHX scale-up plans and a training curricula for misoprostol and chlorhexidine, and for RH at community level (Activities 1.4.2 and 1.8).
o Supported the validation of the misoprostol and CHX scale-up plan. This plan will be used by MOH and Implementing partners to implment misoprostol for the prevention and treatment of PPH and CHX for the reduction of newborn sepsis, thereby decreasing maternal and newborn mortality.
o Provided technical support to the development of a training curricula for reproductive health (RH) at the community level – including FP and Immunization components.
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Training at this level can help save lives by reaching vulnerable women and children through CHW in hard to reach areas.
• Provided technical support to the MOH for the development of a Universal Health Coverage strategy
• Strengthened USAID/MCSP visibility and presence with the Direction Régionale de la Santé Publique in Atsinanana, Melaky and Sofia regions, (Activity 1.7)
o In Atsinanana, MCSP introduced the innovative ‘’MNH Quality Dashboard” DURING A MEETING with facility administrators, local EMAR and EMAD representatives and local partners (i.e. the United Children’s Fund (UNICEF), Mikolo, etc.). The launch was also attended by the Minister of Public Health. The dashboard allows provdiers, hospital administrators, quality improvement committees and other key stakeholders to track key quality of care indicators and use the evaluation of the results to monitor progress against key health goals. o In Melaky and Sofia regions, official donations of key MNH basic equipment were organized for 2 CHRR and 2 CSB facilities, and the ceremonies were attended by the regional governors, town mayors, DRSP representatives, and the management team of hospitals. Basic equipment enables newly trained providers to use their skills in the health facility setting to improve health outcomes of women, children and families.
Objective 2: Increase access to and improve quality of maternal and newborn health services in USG priority regions
• Strengthened the existing pool of trainers by updating the technical skills of 36 regional trainers (Activity 2.2.2 and 2.2.3).
o 36 new regional trainers updated in clinical trainings skills, enabling them to begin training the health providers from Y2 regions. • Strengthened six (6) clinical training sites in Y1 and Y2 target regions (Activity 2.3.1).
o 6 clinical sites strengthened to support the upcoming training of health providers in Atsinanana, Haute-Matsiatra and Vakinankaratra o Conducted follow-up visits within sites strengthening –SSA activities in the Y1 region of Alaotra Mangoro.
• Improved quality of MNH services through the use of the MNH quality dashboard at 227 facilities, and MNH trainings reaching 100 providers.
o Increased health worker capacity to provide quality RMNH services: 33 providers from 2 Y1 regions completed the 3rd week of MNH training, and 67 providers from 2 Y2 regions completed their 1st week of MNH training (Activity 2.3.2). o Developed the formative supervision guide and tools for Y1 regions.
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o Improved collection, display and use of RMNCH data by health facilities for decision making to improve quality of care (Activities 2.5 and 2.6) . MNH quality dashboard: 227 health facilities Y1 regions are now collecting data and monitoring the 8 indicators with the SMS web-based platform system. . The 36 new regional trainers received orientations on the MNH quality dashboard package, including the data collection tools and the SMS and web platform system. . Clinical governance / quality assurance (CG/QA) at hospitals: 4 Centre Hospitalier Regional de Reference (CHHR, Regional Reference Hospital) of Ambatondrazaka, Antsohihy, Maintirano and Morondava are now implementing the CG/QA approach. o Supported the district MOH teams within the Mahefa and Mikolo intervention areas through formative supervision of providers and the revision of immunization job aids (Activity 2.9).
Objective 3: Increase access to long-acting Family Planning methods in USG priority regions
• Delivered ongoing advocacy on PPFP at national level through participation in an international conference and via local meetings with stakeholders (Activities 3.1 and 3.3).
o Supported a Malagasy delegation with 1 MOH representative to the international FP conference in Indonesia in January 2016, and continued advocacy efforts at the national level to include into the updated RH strategic plan and the communication tools for community health workers
• Strengthened the PPFP capacity of 64 health facilities by training thirty-two (32) new providers trained in PPFP (including PPIUD and implants), and donating basic equipment and supplies to those health facilities (Activities 3.2.5 and 3.2.6)
o 32 new providers were trained in PPFP from Alaotra Mangoro and Menabe regions, making a total of 64 health workers from 64 facilities trained in PPFP (including IUD and implants insertion and removal) within the 5 Y1 regions. All 64 facilities also received basic equipment for IUD and implants and 20 IUD kits as start-up lot.
• Prepared the field data collection of the First Time Parents Assessment (Activity 3.4)
o The formative research protocol was submitted to the local ethics committee in Madagascar and to the johns hopkins school of public health (JHSPH) internal review board (IRB). Final approval of local ethics committee and the MOH authorization letter for conducting the study at public health facilities was obtained in March 2016. Final JHSPH IRB approval is still pending. o a training of data collectors and a pre-test were conducted in march 2016 with the support of an MCSP senior sexual and reproductive health specialist and ASRH researcher. Preparation for field data collection is ongoing.
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• Progressed in the organization of the 2016 National Family Planning Conference (Activity 3.5)
o Two committees involving the MOH and partners are in place and meet every week – a Technical Committee and a Coordination Committee. o Two consultants and an agency were recruited to support the MOH in the planning and implementation of the conference. o Dates for the conference of July 19-22 given by the MOH and venue (Hotel Carlton) are secured
Objective 4: Improve prevention and treatment of MIP in the context of focused antenatal care
• Supported the Programme National de Lutte contre le Paludisme (PNLP, the National Malaria Control Program) and the Direction de la Santé Familiale (DSFa, Family Health division) with updates to MIP job aids, preparations for the training of national trainers, and the development of a malaria scorecard (Activities 4.1 and 4.3)
o 3 job aids for providers were validated by MOH and finalized for printing. o Participated in the budgeting and planning of training of the national trainers with MOH/DLP o Participated in the development of malaria scorecard, aimed at monitoring malaria fight progress across the country.
• Trained 67 providers in MIP during MNH trainings in Analamanga and Vakinankaratra regions
• Progressed in the development of a gestational age assessment tool (Activity 4.3)
o Development of the gestational age assessment tool is ongoing and will be field tested in quarter 3 2016 at 10 Centre de Santé Base (CSB, Primary Health Center) in Moramanga district in Alaotra Mangoro region.
Objective 5: Strengthen the capacity of pre-service training institutions to educate midwives according to ICM standards and competencies
• Provided technical support to the Faculty of Medicine’s midwifery pre-service department and the national association of midwives (Activities 5.1.1, 5.1.2, 5.1.3 and 5.1.5).
o MCSP provided technical support in preparing a workshop in April 2016 focused on the development and innovation of the pedagogy for midwifery pre-service. o MCSP also participated in the development of a strategic plan for the ‘’Association Nationale des Sages-femmes à Madagascar’’.
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Conclusion and Way Forward
Despite some delays experienced in q2, MCSP is on the track to extend programmatic coverage to the 15 USAID regions in Madagascar before the end of this Year 2. MCSP is doubling its efforts and is putting more resources from this q3 to achieve the year 2 targets.
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Introduction
The Maternal and Child Survival Program (MCSP) in Madagascar is supporting the national effort within the Campaign for Accelerating the Reduction of Maternal Mortality in Africa (CARMMA) initiative, which aims to accelerate the reduction of maternal and neonatal mortality across Africa. In order to achieve the goals of the Madagascar’s 2015-2019 CARMMA roadmap which targets to reduce, by 2019, the maternal mortality ratio from 478 to 300 deaths per 100,000 live births and the neonatal mortality rate from 26 to 17 deaths per 1,000 live births, the current MCSP work plan will contribute to the following objectives: 1. Provide support and technical leadership in Maternal and Newborn Health and Family Planning at the national level to the Ministry of Health 2. Increase access to and improve quality of maternal and newborn health services in USG priority regions 3. Increase access to postpartum long-acting family planning methods in USG priority regions 4. Improve prevention and treatment of MIP in the context of focused antenatal care 5. Strengthen the capacity of pre-service training institutions to educate midwives according to ICM standards and competencies.
Thus far in Year 2, MCSP has expanded its intervention regions, from 5 regions to 10 regions: Alaotra Mangoro, Analamanga, Atsinanana, Boeny (districts of Soalala and Mitsinjo), Diana, Haute Matsiatra, Melaky, Menabe, Sofia, Vakinankaratra and is preparing to enter 5 new regions in Q3 : Amoron’I Mania, Atsimo Andrefana Sava, Ihorombe and Vatovavy Fitovinany (see Figure 1). MCSP is on track to meet its workplan target of implementing activities in the 15 USG regions of Madagascar.
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Figure 1. MCSP coverage in End of March 2016.
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Major Accomplishments
Objective 1: Provide support and technical leadership in maternal and newborn health at the national level to the Ministry of Health
MCSP has committed to providing technical assistance to the Ministry of Health (MOH) in order to support improvements to quality of MNH efforts at the national level in Madagascar. To do this, MCSP is collaborating closely with the DSFa as well as other related MOH divisions (i.e. the PNLP for malaria, the Programme Élargi de Vaccination (PEV) for immunization, etc.) and regional management teams. Such close collaboration enables the sharing of updated information on policies and priority activities, and consequently helps MCSP to provide the adequate support to the MOH. MCSP has provided technical assistance in the dissemination of updated MNCH policies and directives in accordance with the latest international recommendations, as well as the development and dissemination of national strategic documents. During this quarter, MCSP also actively participated in the Universal Health Coverage (UHC) technical working group. The key achievements realized during Quarter 2 of Year 2 include the following: • Supported the dissemination and implementation of the CARMMA initiative’s Roadmap for 2015-2019 (Activity 1.1.2).
When initiating activities in a new programmatic region, it is standard practice for MCSP to provide an orientation on the Roadmap to the Regional and District Management Teams (EMAR and EMAD). In addition, a condensed version of Roadmap is also presented to the health providers who participated in the first week of the 5-week MNH training. The objective is that those local actors understand the importance of their contribution and get ownership of interventions supported by MCSP. During Q2, 67 health providers in Analamanga and Vakinankaratra regions received that orientation.
Next steps:
- Orientation on the Roadmap to EMARs and EMADs of Diana, Sava, Atsimo Andrefana, Ihorombe, Amoron’I Mania, and Vatovavy Fitovinany as a part of its expansion in new programmatic regions during the second semester of Y2:. - Approximately, 150 providers to receive an orientation on the roadmap During the MNH trainings in Analamanga, Atsinanana and Haute Matsiatra regions in this upcoming quarter,
• Participated in the updates to the 2016-2020 national reproductive health integrated strategic plan (SPSR) and the 2016-2017 operational plan (Activity 1.3).
MCSP actively participated in the updates of the reference documents for Family Planning: the 2016- 2020 SPSR and the 2016-2017 operational plan, ensuring that they included the postpartum family planning component in alignment with the FP2020 engagement.
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Next steps:
- MCSP is finalizing the PPFP component, in collaboration with the MOH/DSFa. - These updated documents will be validated by the MOH and key partners in Q3 of Y2.
• Provided technical support and key inputs to RMNCH technical working groups in developing misoprostol and CHX scale-up plan and community level RH training curricula (Activities 1.4.2 and 1.8).
In fostering efforts to contribute to the reduction of maternal and neonatal mortality at the national level, MCSP provided technical support in the development of the following national training curricula and national documents:
o The Scale-up plan for misoprostol and CHX, validated in January o A curriculum for RH at the community level, which includes Misoprostol, CHX, lifesaving gestures before referral, family planning and immunization components. The training curricula were developed in close partnership with MOH and other partners (i.e. UNICEF, Population Services International (PSI), Marie Stopes International Madagascar, Mikolo and Mahefa. Next steps:
- Follow up with partners the implementation of Misoprostol and CHX at community level - Support with the training of national trainers, who will conduct trainings on the new RH curricula at regional and district levels, planned for April 2016 in the Mikolo regions.
• Provided technical support to the MOH for the development of the Universal Health Coverage (UHC) strategy
The MOH has created a technical working group/committee to develop its Universal Health Coverage strategy. The committee/working group involves key stakeholders and partners, including USAID and its implementing partners. MCSP has been active in the sub-committee on health services/quality of care who developed the minimum package to be covered by the UHC. It has been decided that MNH services for women and children, emergencies including obstetrical and Neonatal emergencies, as well as services for seniors would be priority.
Next steps:
A national workshop is planned in April to involve the regions. MCSP will continue to participate in the sub-committee meetings along with USAID
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• Strengthened USAID/MCSP visibility and presence with the DRSP in Atsinanana, Melaky and Sofia regions (Activity 1.7)
In February 2016, MCSP participated in the quarterly review meeting organized by the DRSP in Atsinanana, which was attended by the Minister of Public Health, MOH key representatives, UNICEF, and Mikolo. MCSP presented its workplan activities for the region and also conduct an orientation on the innovative MNH Quality Dashboard. Using real data from the Alaotra Mangoro region, participants were able to experience interacting with the web platform and were able to see the practical use and importance of having real-time MNH data to support decision making at the facility level.
In Melaky and Sofia regions, official ceremonies for the donation of the key basic materials to MCSP- supported facilities were organized and attended by local authorities. These events provided opportunities to reinforce the support of USAID through MCSP to those regions.
Next steps:
- Introduction visits planned for the 5 new regions - Support one day of quarterly review meetings to orient all the EMAR and EMADs on the dashboard and its use for decision-making, and to review MCSP-supported activities
Objective 2: Increase access to and improve quality of maternal and newborn health services in USG priority regions
MCSP aims to strengthen the capacities of public health facilities to offer quality MNH and immunization services. The main MCSP interventions include strengthening capacity of providers, donation of key basic MNH equipment, strengthening the clinical sites used for training, reaching every district approach and an introduction to quality improvement dashboard for assessing the training outcomes. The innovative Clinical Governance/Quality Assurance (CG/QA) approach for implementing quality MNH services was launched in Quarter 4 of Y1, within 4 Centre Hospitalier Regional de Reference (CHRR, Regional Reference Hospital).
• Strengthened the existing pool of trainers with 36 regional trainers via updates in technical skills (Activity 2.2.2 and 2.2.3).
The 36 new regional trainers that received MNH technical updates in Q1 Y2 have also received updates in clinical training skills (CTS) to strengthen their capacity to train health providers in Y2 regions. A
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marked increase in pre— versus post-test scores, as well as the very high average post-test score of the regional trainers from Analamanga, Vakinankaratra, Atsinanana and Haute-Matsiatra, regions indicate the regional trainers are well-equipped to implement high quality provider trainings.
Figure 2. Average pre/post-test score of regional trainers per region, Jan-Mar 2016
Pre/Post-test Scores of Regional trainers, Y2 Q2 2016 .
Average prestest score training Average post test score training
99% 100% 99% 100%
84% 77% 73% 71%
Analamanga Vakinakaratra Haute Matsiatra Atsinanana
• Strengthened six (6) new clinical training sites in Y1 and Y2 target regions (Activity 2.3.1).
To ensure that clinical trainings are conducted within the required MCSP standards, sites strengthening activities (SSA) were implemented at all MCSP clinical sites. Such activities include an assessment followed by mentoring of facility staff to ensure quality improvement. This quality improvement approach has been standardized with the implementation of the CG/QA method, which requires the creation of a facility-based quality committee and the development of a corresponding action plan. In Quarter 2, 6 clinical training sites were strengthened to support the upcoming providers’ trainings in 4 Y2 regions of Analamanga, Atsinanana, Haute Matsiatra, and Vakinankaratra. Additionally, MCSP conducted follow-up site visits to build upon the Y1 SSA activities at 2 clinical sites in Alaotra Mangoro region. The DRSP and EMAR of Alaotra Mangoro who was involved in those supervision found beneficial the support provided by MCSP.
Next Steps:
- Training of 36 new regional trainers in Clinical Training skills-‘
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- 12 new clinical sites will be strengthened in the new regions Diana, Sava, Atsimo Andrefana, Vatovavy FitoVinany, Ihorombe and Amoron’I Mania. The findings of each region’s SSA assessment, as well as the ensuing action plans will be disemminated amongst all units of the hospitals targeted. - Monthly on-site supervision of clinical sites was recommended by the EMAD and clinicians in Moramanga to follow-up on the progress of the action plan for site strengthening, and to ensure sustainability. In the upcoming Quarter 3, MCSP will field-test a formative supervision guide with the support of Jhpiego’s Senior MNH Technical Advisor.
• Improved quality of MNH services at 217 facilities across five Y1 regions and 58 facilities across two Y2 regions.
In YR1, MCSP trained providers in 217 facilities across 5 regions due to the 2015 polio campaigns, the MNH trainings have been delayed in some Y1 regions. Consequently, the Y1 regions of Melaky and Alaotra Mangoro only received the 3rd week of MNH training in Q2: 33 providers from Y1 regions completed the 3rd week of MCH training... Additional details on the training participants, and their average pre-test and post-test scores in knowledge and competency skills are summarized in Table 1 and Figure 3 and 4 below.
Table 1. Distribution of Participants in 3rd week of MNH Training in Alaotra Mangoro and Melaky regions, Quarter 2: Jan-Feb-March 2016.
Region Participants
Health TOTAL Physicians Nurses Midwives Assistant M F M F M F M F M F Alaotra 0 2 1 6 0 8 0 0 1 16 Mangoro Melaky 2 3 4 2 0 5 0 0 6 10 TOTAL 2 5 5 8 0 13 0 0 7 26
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Figure 3. Average Knowledge Pre-test and Post-test Participant Score during 3rd week of MNH Training per region, Quarter 2: Jan-Feb-March 2016
Average prestest score training Average post test score training
100% 100% 84% 66%
Melaky Alaotra mangoro
Figure 4. Average Practical Skills pre/post-test score of Participants in 3rd week of MNH Training per region, Quarter 2: Jan-Feb-March 2016
Average score post training Average score training
100% 100%
98%
95%
Melaky Alaotra Mangoro
In addition, The Y2 regions of Analamanga and Vakinankaratra completed their 1st week of MNH training. Hence, 67 providers from Y2 regions completed the 1st week of MCH training. Due to large number of providers, these trainings were organized in 2 waves. In Q2, for the first wave of trainings, MCSP reached 38% (29/76) of the targeted facilities in Analamanga and 51% (29/57) of those in Vakinankaratra. Details of the MNH training participants, as well as their average pre-test and post-test scores in knowledge and technical skills are summarized in Table 2 and Figures 5 and 6 below.
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Table 2. Distribution of Participants in 1st week of MNH Training in Analamanga and Vakinankaratra regions, Quarter 2: Jan-Feb-March 2016.
Participants Region Health TOTAL Physicians Nurses Midwives Assistant M F M F M F M F M F Analamanga 4 16 1 0 0 13 0 0 5 29 Vakinakaratra 0 4 1 2 0 25 0 1 1 32 TOTAL 4 20 2 2 0 38 0 1 6 61
Figure 5. Average Knowledge Pre- and Post-test Score of Participants in 1st week of MNH Training per region, Quarter 2: Jan-Feb-March 2016
pre-test average score post-test average score
97% 99% 76% 67%
Analamanga Vakinankaratra
Figure 6. Average Practical Skills Pre- and Post-test Score of Participants in 1st week of MNH Training per region, Quarter 1: Jan-Feb-March 2016
pre-test average score post-test average score 97% 97%
90%
81%
Analamanga Vakinankaratra
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Next steps:
- The second wave of the 1st week of MNH trainings for Analamanga and Vakinankaratra regions will be conducted in April 2016. - Atsinanana and Haute-Matsiatra regions are planning their 1st week of MNH training in April. - The 3 weeks of MNH trainings for Analamanga, Vakinankaratra, Atsinanana and Haute- Matsiatra regions should be completed in Q3. - The new regions ( Diana, Sava, Vatovavy, A. Andrefana + Ihorombe/Ihosy, Amoron’I Mania) should start their 1st week of MNH training in June
• Developed the formative supervision plan and tools for Y1 regions.
Post-training supervision is required to maintain learned competencies. Post-training follow up were conducted after each week of training. Once the cycle of MNH+PPFP trainings are completed, however, regional trainers will need to follow up with their trainees with support from MCSP staff through mobile phone mentoring and on-site supervision visits.
During Q2, the technical team developed the supervision guide and tools for regional trainers who will be assigned 3-4 CSBs to which they will provide in-depth support. This closer mentor-type relationship between regional trainers and trainees will help promote retention of provider skills
. Next steps:
- Orientation of regional and district management team as well as regional trainers on supervision guide and tools in 5 Y1 regions - Joint planning of supervision activities with regional and district management team in 5 Y1 regions
• Improved collection, display and use of RMNCH data for decision making to improve quality of care (Activities 2.5 and 2.6).
MNH Quality Dashboard
The dashboard was rolled out in Q1 with trainings completed in December 2015. The 217 health facilities supported by MCSP in the five Y1 regions (Alaotra Mangoro, Menabe, Melaky, Sofia and 2 districts of Boeny-Soalala and Mitsinjo) are now collecting and sending data to measure and monitor the 8 indicators of the MNH quality dashboard (see table 3 for indicators).
Table 3. The 8 MNH quality dashboard indicators for public health facilities in 2015-2016.
Source of the INDICATORS indicator Service delivery indicators Indicator 1. Proportion of women who were screened for preeclampsia and WHO quality indicators eclampsia during antenatal care services in MCSP-supported areas Indicator 2. Proportion of women receiving uterotonic immediately after birth of the WHO quality indicators baby
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Indicator 3. Proportion of newborns who received all four elements of essential WHO quality indicators, newborn care: 1) immediate and thorough drying; 2) immediate skin-to-skin contact; 3) USAID delayed cord clamping ; 4) initiation of breastfeeding in the first hour Indicator 4. Proportion of women discharged after delivery with a family planning USAID modern method Outcome MNH indicators Indicator 5. Institutional maternal deaths rate MOH-RMA Indicator 6. Proportion of institutional fresh stillbirths MOH-RMA Indicator 7. Percentage of newborn not breathing/crying at birth resuscitated by WHO quality indicators stimulation or with bag & masks ( neonatal mask size 1 or 0) in the delivery areas Indicator 8. Proportion of newborns with umbilical cord infection MOH-RMA
The health providers send monthly SMS messages to toll-free numbers which transmit the data to the web-based DataWinners platform, which then automatically sends a SMS response to the provider with the value and color-code of the 8 indicators. This enables the health providers to complete the wall- displayed dashboard for their facility on a monthly basis. The MCSP team is able to view and monitor the MNH quality dashboard in real time and provide support directly to the health facilities facing difficulties in sending their monthly data via SMS. Thus far, MCSP asked providers to start sending their data from June 2015, and the response rate until February 2016 is about 52% with variation between 23% (Boeny) to 80% (Alaotra Mangoro) for the Y1 regions (see Table 4 for additional details). MCSP will reinforce support to the health facilities to improve the MNH quality dashboard response rate across the Y1 regions before expanding to Y2 regions. Table 4. MNH quality dashboard response rates for February 2016 in the 5 Y1 regions Number of MCSP- Number of SMS Region/District (Y 1) supported Health Response rate received (1/HF) Facilities (HF) ALAOTRA MANGORO 36 45 80% AMBATONDRAZAKA 10 14 71% AMPARAFARAVOLA 7 8 88% ANDILAMENA 5 7 71% ANOSIBE AN'ALA 5 6 83% MORAMANGA 9 10 90% BOENY 5 22 23% MITSINJO 5 13 38% SOALALA 0 9 0% MELAKY 20 41 49% AMBATOMAINTY 1 6 17% ANTSALOVA 5 7 71% BESALAMPY 5 8 63% MAINTIRANO 6 16 38% MORAFENOBE 3 4 75% MENABE 21 43 49% BELO SUR TSIRIBIHINA 3 7 43% MAHABO 7 7 100% MANJA 4 9 44% MIANDRIVAZO 5 14 36% MORONDAVA 2 6 33% SOFIA 29 63 46%
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Number of MCSP- Number of SMS Region/District (Y 1) supported Health Response rate received (1/HF) Facilities (HF) ANALALAVA 3 9 33% ANTSOHIHY 6 9 67% BEALANANA 5 7 71% BEFANDRIANA NORD 3 13 23% MAMPIKONY 3 5 60% MANDRITSARA 5 10 50% PORT BERGE 4 10 40% Grand Total 111 214 52%
Looking at the Alaotra Mangoro region, where MCSP piloted the MNH dashboard in 5 sites August- September 2015, an improvement in the quality indicators can be seen. An overview of Alaotra Mangoro’s MNH quality indicators results for the months of December 2015 – Februrary 2016 in regions is shown in Figure 7. Only three indicators (1, 3 and 7) still shows frequent red and yellow cells over the quarter. The overall improvement of the other five indicators directly reflect the adoption of the best practices influencing the provision of higher quality MNH quality services within public health facilities. In order to respect the Tiahrt amendment, a color-coded interpretation for indicator 4 is not used.
Figure 5. Overview of MNH quality dashboard in Alaotra Mangoro - Dec 2015- Jan-Feb 2016.
DECEMBRE 2015 (% ) JANVIER 2016 (% ) FEVRIER 2016 (% )
1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 Région District sanitaire Formation
1 N/A 100 100 0 0 2 83 0 18 100 100 0 0 ND 100 0 52 100 100 0 0 0 ND 0 2 N/A 100 100 N/A 0 0 ND 0 N/A 100 100 N/A 0 0 ND 0 100 100 100 N/A 0 0 ND 0 3 100 100 100 N/A 0 0 ND 0 100 95 95 N/A 0 0 ND 0 100 92 92 0 0 0 ND 0 AMBATONDRAZAKA 4 100 100 100 0 0 0 ND 0 100 100 100 0 0 0 100 0 100 100 100 8 0 0 ND 0 5 N/A 100 100 N/A 0 0 ND 0 N/A 100 100 N/A 0 0 ND 0 N/A 100 100 N/A 0 0 ND 0 6 100 100 100 N/A 0 0 100 0 100 100 100 50 0 0 100 0 100 ND ND ND ND ND ND ND 7 N/A 100 100 0 0 0 100 0 N/A 100 100 100 0 0 100 0 100 100 100 100 0 0 100 0 8 100 80 100 N/A 0 0 0 0 100 100 100 N/A 0 0 ND 0 100 100 100 0 0 0 100 0 9 N/A 100 100 90 0 0 0 0 N/A 100 100 100 0 0 100 0 36 100 100 100 0 0 86 0 AMPARAFARAVOLA 10 41 100 100 N/A 0 0 ND 0 N/A 100 100 N/A 0 0 ND 0 90 100 100 N/A 0 0 0 0 11 100 100 94 N/A 0 0 100 0 100 100 100 N/A 0 0 100 0 100 100 93 29 0 0 100 0 12 100 100 50 100 0 0 100 0 100 100 50 100 0 0 100 0 100 100 33 67 0 0 100 0 13 100 100 100 0 0 0 100 0 100 100 100 4 0 4 75 0 100 100 100 0 0 0 100 0 14 100 100 100 13 0 0 ND 0 100 100 100 0 0 0 ND 0 100 100 100 0 0 0 ND 0 15 100 100 60 0 0 0 0 0 100 100 100 0 0 0 0 0 100 100 100 0 0 0 0 0 ANDILAMENA 16 100 100 100 N/A 0 0 ND 0 100 100 100 N/A 0 0 ND 0 100 100 100 20 0 0 ND 0 17 100 100 100 0 0 0 ND 0 100 100 100 0 0 0 100 0 100 100 100 0 0 0 100 0 ALAOTRA MANGORO ALAOTRA 18 100 100 100 N/A 0 0 ND 0 100 100 100 N/A 0 0 ND 0 100 100 100 0 0 6 ND 0 19 100 100 100 100 0 0 ND 0 100 ND ND ND ND ND ND ND 100 ND ND ND ND ND ND ND ANOSIBE AN'ALA 20 62 100 15 8 0 ND 100 0 0 83 92 0 0 0 100 0 35 100 81 0 0 0 100 0 21 0 100 100 0 0 0 ND 0 0 100 100 0 0 0 ND 0 0 100 100 0 0 0 ND 0 22 100 100 100 100 0 0 ND 0 100 100 100 0 0 0 ND 0 100 100 100 0 0 0 100 0 23 100 100 100 10 0 0 ND 0 100 100 100 33 0 0 100 0 100 100 100 33 0 0 100 0 24 100 60 100 0 0 0 100 0 100 100 100 0 0 0 ND 0 100 100 100 N/A 0 0 N/A 0
MORAMANGA 25 0 100 100 0 0 0 ND 12 0 100 93 0 0 0 ND 4 100 100 100 6 0 0 ND 0 26 100 100 100 0 0 0 ND 0 100 100 100 0 0 0 ND 0 100 100 100 9 0 0 ND 0 27 100 100 100 0 0 0 ND 0 100 100 100 0 0 9 50 0 100 100 100 0 0 0 N/A 0 28 100 100 50 22 0 11 40 0 100 100 50 0 0 0 0 0 100 100 81 0 0 0 25 0
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* Green: quality standard / target achieved, Yellow: in progress / more effort required, Red: alarming / not on track, Grey: not applicable, White: no data / no interpretation provided.
Looking specifically at the CSB of Tanambe, which is one of 5 pilot sites in Alaotra Mangoro, tangible progress can be seen with the use of MNH quality dashboard (Figure 8). In June-July 2015, before the MNH training, 3 indicators were in the red and no data was available for newborn resuscitation, but starting from September 2015, most indicators have been in the green (aside from January 2016).
Figure 6. MNH quality dashboard of CSB Tanambe-Amparafaravola in Alaotra Mangoro region, June 2015 - March 2016.
EVOLUTION DES INDICATEURS DASHBOARD Juin 2015 à Mars 2016
CSB2 TANAMBE
Juin Juillet Aout Septembre Octobre Novembre Décembre Janvier Fevrier Mars 1. Proportion de femmes qui ont été dépistées pour la prééclampsie et N/A 0% 100% 100% 100% 100% 100% 100% 100% 100% l'éclampsie durant les consultations prénatales 2. Proportion de femmes ayant reçu de l'utérotonique immédiatement après la 67% 77% 90% 100% 100% 100% 100% 100% 100% 100% naissance du bébé 3. Proportion de nouveau-nés ayant reçu les 4 éléments essentiels des soins du nouveau- 0% 0% 90% 100% 100% 100% 100% 100% 100% 100% né 4. Proportion de femmes ayant accouchées sortant du centre avec une méthode 0% 0% 5% 6% 0% 0% 0% 4% 0% 0% moderne de planification familiale 5. Taux de décès maternels dans le centre 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 6. Proportion de mort-nés frais dans le 0% 0% 0% 0% 0% 0% 0% 4% 0% 0% centre 7. Pourcentage de nouveau-né n'ayant pas respiré/crié à la naissance ressuscitée N/A N/A 100% 100% 100% 100% 100% 75% 100% 100% après stimulation ou utilisation des ballons et masques 8. Proportion nouveau-nés avec Infection 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% ombilicale
During on-site supervision visits, the MCSP team monitored each facility’s MNH dashboard display and checked for completeness of the data. In general, the laminated dashboard tool has been consistently displayed and filled out regularly. However, MCSP has noted that health providers need additional support to learn how to analyze the dashboard data and identify corrective actions to improve the value of the indicators. Such support will be provided by the districts and regional trainers during periodic reviews or supervision visits.
Thirty-six (36) new regional trainers from Analamanga, Atsinanana, Haute Matsiatra and Vakinankaratra regions were trained on MNH quality dashboard package, which includes the data collection tools and the an orientation to the SMS datawinners system. The trainings on the dashboard for providers is usually conducted during the 2nd week for MNH training.
Next steps:
- Conduct follow-up of providers to increase the SMS response rate.
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- Plan a one-day orientation on the MNH quality dashboard of the chef CSB, EMAR and EMAD in all Y1 regions to support the use of the dashboard for decisions-making. - In new regions of Y2, conduct MNH quality dashboard training and plan the orientation of the chef CSB, EMAR and EMAD during Q3-Y2.
Clinical Governance/Quality Assurance at hospitals:
During this quarter, MCSP achieved the integration of clinical governance activiies in routine practice in the 4 targeted CHRR pilot sites in Ambatondrazaka, Antsohihy, Maintirano and Morondava. To begin, four (4) quality improvement objectives were defined, a quality improvement committee was set up within each hospital and the annual action plan was developed. The quality improvement objectives were:
i. Improvement of routine clinical care: post-partum care for mother and newborn, ii. Improvement of maternal emergency care: management of PPH cases, iii. Improvement of newborn emergency care: management of newborn asphyxia, and iv. A cross-cutting objective of the hospital’s choosing a. 3 out of the 4 hospitals chose an objective focusing on the hospital’s management b. 1 out of the 4 hospitals chose an objective focusing on the humanization of care
MCSP also successfully introduced an electronic dashboard in all 4 CHRRs to improve the collection and use of data, and to automatically measure indicators to support the CG/QA.
On-site CG/QA supervision visits were conducted at CHRR Ambatondrazaka and Morondava during Q2, and provided the opportunity to support both the hospital departments (maternity, surgery, management units), and the EMAR on the CG/QA approach and the critical activities of each facility’s quality improvement committee. MCSP noted that CHRR and EMAR staff are motivated and have great expectations for the CG/QA initiative but need more support to effectively implement their action plans.
Next steps:
- Follow-up of the CG/QA action plan and support its implementation. - Provide technical support to the periodic meeting of the quality improvement committees in the 4 CHRR.
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- Monitor in real-time the electronic dashboard of the 4 CHRR and will provide support to the CHRR and EMAR to use the data for decision-making and continuous improvement of quality in delivering services during this quarter.
• Supported the districts intervention areas of Mahefa and Mikolo through formative supervision of providers and revision of immunization job aids (Activity 2.9).
Immunization job aids have been revised, and MCSP is planning to do a pre-test of the updated job aids with community health workers and health providers. This will optimize its use in strengthening the current national immunization campaign. The immunization team also conducted meetings with Mikolo and Mahefa to discuss how to improve community linkages with immunization services and supportive supervision in priority regions/districts, based on immunization data analysis by MCSP
Next steps:
- Pre-test and printing of immunization job aids among CHW and health workers is planned in end of April. - MCSP will work closely with Mikolo to prepare the CHWs’ orientation on the jobaids
Objective 3: Increase access to long-acting Family Planning methods in USG priority regions
In 2014, MCSP successfully advocated to introduce the long-acting PPFP methods (PPIUD and implants) in Madagascar. A national PPFP coordinator within MOH/DSFa has been working closely with MCSP team to expand PPFP activities at regional and national level. MCSP’s strategy to strengthen the capacity of health facilities to offer quality PPFP services includes the training of health providers, donation of key basic equipment for IUD and implants insertion, and strengthening clinical training sites. A focus on adolescents will begin in Y2 with a formative research on first time parents; the findings of this study will guide future interventions on adolescent reproductive and sexual health. Additionally, MCSP has continued to lead preparations for the national FP conference during this quarter.
• Delivered ongoing advocacy on PPFP at national level through participation in international conference and local meetings with stakeholders (Activity 3.1 and 3.3).
In January 2016, MCSP supported the attendance of one MOH Staff, Dr. Haingo who is the head of FP unit, to the International Conference on Family Planning in Indonesia, who was accompanied by 2 MCSP staff, the Senior Technical Advisor and FP Technical Advisor. This was an opportunity to strengthen both MOH and MCSP technical competencies as well as deepen MCSP’s collaboration with MOH.
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MCSP has also attended in RH and FP meetings organized by MOH and partners. MCSP participated in the revision of RH strategic plan and operational plan that should now include the PPFP component. The final validation of the PPFP curricula (which is already used by the MOH now) was discussed with the MOH/SFPP service within MOH who recommended reformatting it. During a meeting focused on CHW communication tools), MCSP advocated for the integration of messages on immediate PPFP into The CHW flipchart which is an important communication tool.
Next steps:
- Format the PPFP training curricula to the MOH requirements for its final validation. - Conception of a page on immediate PPFP to be included in the CHW flipchart and validation with MOH.
• Strengthened capacity of health facilities in PPFP with thirty-two (32) new providers trained in PPFP: PPIUD and implants and provision of basic equipment and supplies for health facilities (Activities 3.2.5 and 3.2.6)
Thirty-two (32) health providers from Alaotra Mangoro and Menabe received the training on long-term PPFP methods, including IUD and implants in this quarter (4th week of the MNH training). When combined with the 32 providers from Boeny, Sofia and Melaky (only Besalampy district) that received technical updates last December, MCSP has trained a total of 64 providers across 5 regions in PPFP. Details of the most recent providers trained in PPFP, including the average pre-test and post-test scores in knowledge and competency skills are summarized in Table 6 and Figure 9. During the training, the health providers also received basic equipment for IUD and implants insertion and removal, along with 20 IUD kits as a start-up lot. Table 5. Health providers trained in PPFP from Alaotra Mangoro and Menabe regions during Q2-Y2.
Participants Region Health TOTAL Physicians Nurses Midwives Assistant M F M F M F M F M F Alaotra 1 2 1 5 0 7 0 0 2 14 Mangoro Menabe 0 0 1 2 0 13 0 0 1 15 TOTAL 1 2 2 7 0 20 0 0 3 29
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Figure 9. Average Competency Skills Pre- and Post-test Score of Participants in 4th week of MNH Training per region, Quarter 2: Jan-Feb-March 2016
Average prestest score training Average post test score training
100% 100%
98%
92%
Alaotra Mangoro Menabe
Next steps: - Conduct on-site supervision of PPFP activities with Anne Pfitzer, MCSP’s FP Team Lead, in May 2016 to evaluate the progress and potential adjustments in strategy or training approach. - Develop a strategy for improved data collection on PPFP within the USG supported facilities. - Piloting new approach of counseling and demand creation in PPFP
• Prepared the field data collection of the First Time Parents Assessment (Activity 3.4).
The protocol of the formative research on first-time parents in two regions, Menabe and Vakinankaratra was submitted for approval both to the local ethical committee and the JHSPH IRB. The approval of local ethics committee (MOH) and the authorization letter signed by the Minister are already available. JHSPH IRB final approval is still pending due to amendments to the data collection tools following the pre-test in March. A TA was conducted mid-March 2016 to support the preparation of the field data collection. Melanie Yahner, Senior Specialist for Sexual and Reproductive Health and Susan Igras, ASRH researcher provided support in the first phase of training for the data collectors, and the pre-test of the data collection tools in Itaosy (CHD and 2 CSBs). Following the pre-test and the training workshop, a slight modification was made to the data collection tools to better capture information from the first-time parents and to streamline the tools. This update to the study materials required the submission of an amendment process to the IRB application, for which final approval is pending. JHU approval is mandatory to start the field data collection. Next steps: - Field data collection when final approval of IRB is obtained in April 2016. - Data analysis using the software Atlas.ti in May and dissemination of preliminary results to partners in June 2016. - Preparing the next strategy/intervention on Adolescent reproductive health.
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• Supported the MOH in organizing the 2016 National Family Planning Conference on (Activity 3.5)
Significant progress was made in the preparation of the conference with the creation of a coordination committee and a scientific committee involving the MOH and the partners. Since February, weekly meetings of the coordination committee have been held and a meeting of partners was organized by the MOH in March 2016 to inform all the stakeholders and to present the terms of reference for the conference. To support the MOH, MCSP has recruited 2 consultants and an agency (BKG COM), who will respectively oversee the coordination of the both committees, and the logistics and communication for this event. The conference dates have been finalized and will occur on July 19th – 22nd at the Carlton hotel in Antananarivo.
The scientific committee has developed the main themes for the conference and the call for abstract. MCSP has collaborated with HQ communication team to develop a logo and a website. Next steps: Among other activities, the priorities in this quarter include: - Launching the call for abstracts - Finalize the communication materials around the conference with the agency: website, posters, advertising for both the call of abstract and participation to the conference, branded materials - Selection and review of submitted abstracts - Develop the agenda of the conference.
Objective 4: Improve prevention and treatment of MIP in the context of focused antenatal care
Following the last WHO recommendations on intermittent preventive treatment of malaria in pregnancy, MCSP has made it a priority to support the MOH in its integration t into the national policies, protocols and training curricula. In collaboration with MOH and Roll Back Malaria partners, MCSP is updating the knowledge and skills of health providers concerning malaria in pregnancy and focused antenatal care. Due to the difficulties many providers face in correctly determining the gestational age of a fetus during pregnancy, MCSP will be field-testing a gestational age tool to support the provision of SP early in the second trimester of pregnancy.
• Supported the MOH- PNLP and DSFa to update the job aids (activity 4.1) MCSP had developed with the Malaria division-DLP and partners 3 job aids on the following themes: intermittent preventive treatment of malaria in pregnancy, management of malaria in pregnant women and the evaluation of uterine height. All of which were validated in Q2. Their printing and dissemination is planned for April 2016.
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• Trained 67 health providers in MIP during MNH trainings in Analamanga and Vakinankaratra regions, and collaborated the PNLP and DSFa to prepare the training of the national trainers and for the malaria scorecard (Activity 4.3)
Sixty-seven (67) health providers from Analamanga and Vakinankaratra regions received updates in MIP during the 1st week of MNH trainings (see objective 2 for participant details).
Following a meeting with the President’s Malaria Initiative (PMI) and DLP, it was agreed that MCSP and DLP will collaborate in updating a maximum of providers, combining both IPTp trainings and case management training. MCSP supported the DLP in developing the budget for these updates which will use a cascade approach (training of national trainers and regional training of providers). The DLP has agreed to support the training of 2700 providers (with GFATM/NSA funds).
MCSP also participated in the workshop on the development of malaria scorecard and shared information about the dashboard. The MNH dashboard does not include a malaria indicator however, MCSP collect via sms data on the indicator “percentage of pregnant women receiving IPT3” among the MCSP- supported facilities. This was shared with the MOH/DLP.
• Field testing of a gestational age assessment tool The development of the tool is still ongoing, and its translation into French is planned in early Q3. During Q2, MCSP collected data from the regions to identify the regions and sites where the field testing will be conducted. Based on data on the rate of early ANC, it has been decided that the test will be done in 10 CSB of the district Moramanga, in Alaotra Mangoro region.
Next steps: - Printing the job aids and plan the orientation of providers - Field testing of the gestational age assessment tool to start in May- approval of the field test from the local ethics committee may need to be obtained. - MIP UPDTES integrated with MNH Trainings planned for approximately 150 providers in Analamanga, Vakinankaratra, Haute Matsiatra and Atsinanana. - Planning of the trainings to be conducted with the DLP.
Objective 5: Strengthen the capacity of pre-service training institutions to educate midwives according to ICM standards and competencies
After the revision of midwifery pre-service training curriculum to ensure adherence to ICM standards, MCSP has collaborated closely with UNFPA, the six (6) Faculties of Medicine in Madagascar, and MOH/DIFP to implement that new curricula. This revision coincides with the switch of the midwifery pre-service education into the License Masters Doctorate (LMD) system adopted recently by the Faculty of Medicine. Technical updates of the teachers/preceptors, the establishment of skills laboratories, and the strengthening of clinical practice sites are the main interventions planned by MCSP in Y2.
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• Provided technical support to the Medicine Faculty - midwifery pre-service department and the National Association of Midwives (Activities 5.1.1, 5.1.2, 5.1.3 and 5.1.5).
MCSP provided technical support for the preparation of a workshop focused the development and innovation of the pedagogy within midwifery department of the Faculty of Medicine. Deliverables of the meeting were the term of reference and the agenda of the workshop planned for April, 7th-8th. Expected deliverable of this workshop is an operational plan to support the 6 faculties of medicine. It is also expected that a joint schedule of activities involving MCSP, UNFPA, AFD and the Faculties of Medicine will be validated. MCSP also attended the workshop organized in Antsirabe by the National Association of Midwives to provide technical support during the development of their 3-year strategic plan. Next steps: - Participation in the April 2016 workshop in Antsirabe with UNFPA and representatives of the Faculties of Medicine from 6 regions. – MCSP will support the attendance of representatives from 3 regions not supported by UNFPA - Conduct follow-up activities in the 2 Faculties that have received technical updates from MCSP. - Joint planning of the other midwifery preservice activities. - Development of monitoring and evaluation tools for pre-service.
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Management Updates
To achieve the coverage of the 15 USAID regions in Madagascar by end of Y2, MCSP continues to expand its interventions regions. MCSP opened the office in Antsiranana (Diana region). In this quarter, MCSP prepared the opening of the additional MCSP offices in Atsimo Andrefana, Amoron’i mania, Sava and Vatovavy Fitovinany. Three (3) field technical advisors were hired for these new regions, as well as the program assistants necessary to support the field activities. New technical positions were also posted: an ASRH advisor, an immunization officer and a MNH advisor. To facilitate the implementation of the Yr2 workplan, a staff retreat was organized in January in Mantasoa. This was an opportunity for all staff and especially newly recruited staff, to learn about the work plan objectives and discuss how they can contribute to their achievements. STTA MCSP Madagascar received short-term technical support from Melanie Yahner, Senior Specialist for Sexual and Reproductive Health and Susan Igras, researcher, to support the formative research of adolescent/First time parents. (Both travelers were field funded) Richard Hughes, Jhpiego’s Acting Regional Director for Western Africa and Francophone Countries also provided programmatic and management support. (Rick was supported using jhpiego general funds)
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Challenges and Opportunities
The main challenges that MCSP has faced during the second quarter of Year 2 include:
• Planning the training schedule for MNH3 and MNH4 (PFPP session) within the Y1 regions was challenged by the frequent changes on polio campaigns dates and the rains, making difficult the movement of staff in the districts of Melaky region. The trainings in Y2 regions were also affected by the March polio campaign. • Field immunization technical staff members were also providing technical support on the global TOPV-BOPV vaccine switch which consumed much effort and time for planning and coordinating meetings with the national ministry of health • Regarding pre-service activities, the collaboration with UNFPA and Faculty of Medicine in Antananarivo has been challenging as MCSP could not carry-out any activities during this quarter. The Faculty in Antananarivo has requested to be involved in all trainings for the other Faculties in the regions, yet they could not move forward until their annual action plan with UNFPA was approved. Fortunately, a joint planning was validated during the workshop in Antsirabe
MCSP had several new opportunities in Q2:
• The Jhpiego retreat in January in Mantasoa allowed to present the work plan for Year 2 to the whole staff, including the new personnel hired. It was beneficial for the coordination and the planning of the activities during the first quarter. • Involvement of DRSP in supervision activities in Alaotra Mangoro was a great opportunity to showcase the progress made and obtain better adherence of clinical sites to their improvement action plans • Combined activities during on-site supervision in regions by MCSP: (supportive supervision clinical governance/quality assurance at CHRR and formative supervision of 2 or 3 neighboring health facilities) Allowed MCSP to refine its strategy for introducing CG/QA and dashboards at CSB level
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Way Forward
Despite some delays experienced in Q2, MCSP is on the right track to complete the trainings planned in the 15 USAID regions in Madagascar before the end of this Year 2, in September 2016. Experiences and lessons learned in the first year and the 2 quarters of Y2 were capitalized and used to guide the coordination and the planning of the activities to be carried-out as well as at central level and at regional level. With the expansion of interventions with adolescent reproductive health component and preparation of introduction of clinical governance/quality assurance in basic health centers, MCSP is doubling its efforts and putting more resources towards the achievements of the work plan targets.
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Learning Agenda and Progress
Table 6. Learning activity and progress during Q2 of Year 2
Activity Learning activity Progress Next steps Number
Activity 2.1 Assessment: Status of • Assessment report under finalization • Submission of the article Maternal, Newborn and • Briefs finalized and disseminated at national workshop in peer review journal Family Planning Service with MOH in October 2015. Delivery at Health Facilities in • AEJ article published1 in October 2015 15 Regions of Madagascar • Draft manuscript in EmONC under preparation for submission in peer reviewed journal Activity 3.2 Can a mentorship program • Launching of the mentoring system (mobile and on-site • Workshop for mentoring improve the mastery of MNH visit) as post-training supervision in 5 regionsY1. and supportive supervision and FP clinical skills post in mid-April in provider training? Moramanga. Activity 3.4 What are the influences that • Concept note approved by USAID • Data collection, analysis, affect access and use of facility • Approved by JHU (amendment is pending) and approved report, dissemination to services among young and by in-country IRB key stake holders, first time parents? intervention design
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IMPACT MADAGASCAR Improving the Quality of Health Services at a Rural Primary Health Centers Through the Use of a Dashboard
Photo: MCSP / Zo Harifetra
Noëline Ramananjanahary is a midwife at a primary
health center (in French, centre de santé base or CSB) in NAME the rural community of Andranomeva, in the Sofia region of northern Madagascar. Before the introduction Noëline Ramananjanahary of the dashboard to improve the quality of maternal and newborn health (MNH) services offered, the staff ROLE of CSB Andranomeva did not pay much attention to the importance of monitoring the proportion of Midwife newborns with umbilical infections.
LOCATION Through MNH training sessions implemented by MCSP, Noëline was able to strengthen her skills to Andranomeva, Sofia region, Madagascar provide care to mothers before and during childbirth as SUMMARY well as newborns, including the prevention of umbilical infection, which is a frequent complication in rural Noëline Ramananjanahary, a midwife at the areas like Andranomeva. Andranomeva primary health center in a rural The effective use of data and MNH indicators to guide community of northern Madagascar utilized a decision -making at primary health centers is an MNH dashboard – implemented to support important topic during the second week of MCSP’s health facilities with data-based decision making MNH training. Eight (8) quality indicators selected – to successfully reduce the number of umbilical among the WHO and national indicators compose the infections at her health center. By dashboard at CSB level. Data come from the existing institutionalizing a 48-hour observational period registers and reports and feed a system using for all women who recently delivered, Noëline information technologies, composed of: was able to strengthen the quality of services 1. A data collection system for indicators on a provided at her facility and used the dashboard DataWinners platform, which includes the transmission to track the drop infections from 40% to 0% in of health facility results via SMS and a web-based system of calculation and interpretation; just two months 2. A large poster mounted at every health facility which displays graphs of the monthly values of 8 MNH quality indicators, with color-coded results that correspond to the scorecard of the Ministry of Health’s (MOH) /Direction de la Santé Familiale ;
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3. A web application that allows the monitoring of dashboard data at the individual facility level and across all targeted health facilities.
After the training she received on data-based decision making and the MNH dashboard in November 2015, Noëline began systematically transmitting her facility’s data each month via SMS and receiving the color-coded results: green (within acceptable standard of performance), yellow (below acceptable standard of performance), or red (warning – low standard of performance). In December 2015, to her great astonishment, the dashboard revealed a result of 40% for the indicator tracking the proportion of umbilical infections at her health center, which merited a red color code, indicating poor performance. Recognizing the impact this indicator had on overall quality of newborn health services, Noëline immediately checked the management tools she was trained in to better assess the situation, and verify the number of cases of infection at the health center. She led the staff in a reorganization of the maternity ward’s procedures to ensure so that all women who deliver are monitored at the health center for at least 48 hours, in an effort to reduce the number of umbilical infections, and ensure the health of both the mother and newborn. As a result Noëline’s efforts, by January 2016 the number of infections had reduced by 15% and continued to drop until they reached 0% in February 2016, much to Noëline’s satisfaction.
“After seeing the proportion of umbilical infection at 40% in December 2015, with the red color, I decided to reorganize the [maternity ward] service to keep the mother and newborn for 48 hours after birth for more monitoring.” - Noëline Ramananjanahary
With visualization of health data through the Dashboard, health facilities have the ability to quickly address challenges to the provision of quality health services at their level, with the ability to refer more complex issues to higher level departments easily, if needed. The early successes of the introduction of the dashboard have generated interest from the local district health management team and Sofia’s regional health management team, both of which will soon be oriented on the use of the web platform to allow them to see the performance of CSBs within their catchment areas, and to discuss solutions to improve the quality of health services. The MNH dashboard system has been operational for 4 months in 4 regions of Madagascar thus far, and MCSP plans to extend this initiative to cover all health facilities in the project’s 15 targeted regions.
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Appendix 1: Performance Indicators
The key achievements of MCSP during the quarter 2of Year 2 (January2016 – March 2016), in terms of performance indicators, are summarized in Table 8 below. Table 7. Status of the performance Indicators during the quarter 1 of Year 2.
INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS 1.1 Number of national - 1 roadmap updated 1 Roadmap accelerating the reduction of In November 2014 policies drafted with MCSP maternal and neonatal mortality 2015-2019 support approved by the MOH and partners
- 1 RH norms and FP and RH strategic Updates of RH norms and procedures ongoing Still ongoing procedures updated plans completed and with the leadership of DSFa/MOH and validated disseminated in 15 regions - 1 Scaling -up Scaling-up strategic plan for misoprostol The validation of this strategic plan for developed and draft reviewed by strategic plan for the scaling- misoprostol MOH+partners up of misoprostol is planned developed and for 2016 validated
1.2 Percentage of regions 100% of 4 regions 100% of 10 regions Year 1: 100%,(5 regions Year 1) orientation on who have received the received the for Year 2 (to roadmap during the MNH training of the updated national policies and CARMMA Roadmap complete the 15 USG regional trainers that include representative of guidelines in MNH and all updated regions) received the EMAD and EMAR national policies and CARMMA Roadmap Year 2: Analamanga, Atsinanana, guidelines. and all updated Vakinankaratra, Haute-Matsiatra and Diana national policies and completed (5/10 regions) guidelines. 1.3 Number of health 250 providers 670 providers Year 1: 228 providers from the 4 working Year 1: 91% of achievement providers oriented on new regions and the 2 districts of Soalala and Mitsinjo national policies and (22 health providers missed the training) guidelines in MNH Year 2: 67 providers from the 2 regions Y2: Vakinakaratra and Analamanga 2.1 Number of studies 1 study on status of 1 study on status of MNH services completed Disseminated in completed MNH services international conferences MCSP Madagascar Y2 Quarter 2 Report (Jan – Mar 2016) Page 32 of 50
INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS completed and with 2 manuscripts for peer-review (1 published and 1 to be submitted). 1 desk review of the Data have been reviewed with the SV and the 1 desk review of the immunization data regions/districts and support is being outlined immunization data completed for the poorer performing districts completed
2.2 Number of articles 1 article submitted in TBD 1 article published in African Evaluation Journal 1 other draft manuscript submitted for publication in peer review journal in October 2015 under preparation before peer reviewed journals submission to peer review journal 2.3 Number of national 1 day of birth training 1 day of birth 1 day of birth training curriculum updated and policies drafted with MCSP curriculum validated curricula training approved by the MOH available support validated with MOH (MCSP global PMP, USAID indicator)
Combined training Combined curricula Combined training curriculum for PPH curriculum for PPH training for PPHP and prevention of PPH and PNI validated and neonatal infection PIN validated with validated MOH
Training tools, manuals and job aids: to be validated with the curricula training
2.4 Number of people 42 providers from 39 health providers from Vohemar trained in trained in MNH through Sava trained in PPH PPH and neonatal infections: USG-supported programs and neonatal 19 nurses: 14 male and 5 female (MCSP global PMP, USAID infections 19 female midwives indicator) 1 male health assistant
38 from Menabe 27 health providers from Mahabo trained in PPH trained in PPH and and neonatal infections: neonatal infections 9 physicians whose 1 surgeon: 6 male and 3
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INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS female 11nurses: 10 male, 1 female 7 female midwives
23 national trainers 10 national trainers in Year 1: 19 National Trainers in MNH: Percentage of achievement MNH MNH and 17 practitioners Year 1: 122% immunization 1 female midwife 1nurse. Percentage of achievement Year 2: 14 national trainers in MNH and Year 2: 140%. immunization: 3 male practitioners 9 female practitioners 1 male nurse 1 midwife 44 regional trainers 88 regional trainers Year 1: Percentage of achievement MNH and in MNH and 54 regional trainers MNH and immunization Y1: 122%. immunization immunization Year 2: 36 regional trainers: For Year 2, training of 10 from Analamanga: additional regional trainers 10 practitioners: 3 male, 7 female from the new MCSP regions 9 from Vakinankaratra: will be planned later (Q2- 4 practitioners: 3male, 1 female Q3) 5 midwives 9 from Atsinanana: 7 practitioners: 7 female, 1 female nurse 1 midwife 8 from Haute-Matsiatra: 7 practitioners: 1 male, 6 female 1 female nurse
250 providers trained 120 providers trained Year 1:228 health providers trained in Percentage of achievement in MNH in MNH (Y1regions) MNH: Y1: 91% (228/250). 550 providers trained 53 from Alaotra Mangoro: in MNH (Y2regions) 5 female practitioner
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INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS 3 male practitioner 29 midwives 12 female nurses 4 male nurses 17 from 2 districts of Boeny: 3 male practitioner 9 midwives 2 female nurses 3 male nurses 46 from Melaky: 2 female practitioner 8 male practitioner 19midwives 4 female nurses 13 male nurses 50 from Menabe: 1 female practitioner 1 male practitioner 27 midwives 5 female nurses 16 male nurses 62 from Sofia: 8 female practitioner 5 male practitioner 38 midwives 7 female nurses 4 male nurses Percentage of achievement Year 2:67 health providers trained in Y2: 12% (67/550) in Q2. MNH: 34 from Analamanga: 16 female physicians 4 male physicians 1 male nurse 13 female midwives
33 from Vakinakaratra: MCSP Madagascar Y2 Quarter 2 Report (Jan – Mar 2016) Page 35 of 50
INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS 4 female physicians 2 female nurses 1 male nurse 25 female midwives 1 female health assistant
195 providers trained 500 providers trained Year 1:132 health providers trained in The MNH quality dashboard in MNH quality in quality dashboard MNH quality dashboard: session is included in the dashboard MNH 53 from Alaotra Mangoro: second week of MNH 5 female practitioner training (week 2 out of the 5 3 male practitioner weeks of competency based 29 midwives approach) 12 female nurses 4 male nurses 17 from 2 districts of Boeny: 3 male practitioner 9 midwives 2 female nurses 3 male nurses 62 from Sofia: 8 female practitioner 5 male practitioner 38 midwives 7 female nurses 4 male nurses
Year 2: Dashboard session in SMN2 20 Mahefa/Mikolo 20 trainers oriented Not yet completed (only polio trainings Probably in Year 2 trainers in MNH and in targeted MNH conducted) immunization interventions for AC
45 trainers updated 45 trainers updated Planned in April (only polio training conducted Probably in Year 2 on immunization on immunization and coaches trained for immunization support) service delivery service delivery
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INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS 2.5 Number of antenatal 10,145 101,457 37,812 MCSP has only begun to care (ANC) visits by skilled work at the health facilities providers in USG-assisted level in the 4th quarter facilities 2.6 Number of deliveries 1,567 15,679 6,241 MCSP has only begun to with a skilled birth attendant work at the health facilities in USG-assisted programs level in the 4th quarter 2.7 Number of newborns 1,076 10,765 5,921 MCSP has only begun to receiving essential newborn work at the health facilities care through USG- level in the 4th quarter supported programs 2.8 Number of USG 2 interventions: 1 intervention: Year 1: program interventions development of GBV training of health 2 interventions : providing services, screening curricula: providers to screen GBV component integrated within MNH counseling to respond to completed GBV during ANC curricula training and/or reduce rates of gender-based violence training of health Training of 228 health providers in GBV screening during ANC visits completed. providers to screen
GBV during ANC Year 2: completed- 228 Training of 67 providers in GBV completed health providers trained
2.9 Number of USG- - 195 health centersa 500 health centers 195 health centers meeting minimum standards Year 1 achievement only supported service delivery to provide essential maternal and newborn care points meeting minimum (with trained provider and received basic standards to provide equipment from MCSP) essential maternal and newborn care - 8 clinical training 18 clinical training Year1 Provision of basic equipment sitesb sites 13 clinical training sites with trained provider in Year 1 completed and basic equipment from MCSP
Year 2 12 clinical training sites with trained provider but provision of basic equipment is ongoing 2.10 Number of children Data collection to Data collection to Data collection is still ongoing New PMP indicator added MCSP Madagascar Y2 Quarter 2 Report (Jan – Mar 2016) Page 37 of 50
INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS less than 12 months of age collect the baseline is collect the baseline for this Year 2 who received DPT3 from ongoing and to calculate the USG supported programs target is still ongoing
3.1 Number of national Training curriculum - Training curricula 1 training curriculum on postpartum family policies drafted with MCSP and learning resource and learning planning available support package validated resource package (MCSP global PMP, USAID validated with indicator) MOH
FP communication - FP communication FP communication strategy still ongoing Updates of communication strategy including strategy including strategy with the leadership PPFP updated and PFPP updated and of MOH/DSFa is ongoing validated validated with MOH
- My First Baby Still ongoing curriculum adapted into Malagasy context 3.2 Number of people 23 national trainers - 10 national Year 1: 22 national trainers: Percentage of achievement trained in RH/FP through trainers Year 1: 95%. USG-supported programs Year 2: 14 national trainers: (MCSP global PMP, USAID 3 male practitioners Percentage of achievement indicator) 9 female practitioners Year 2: 140%. 1 male nurse 1 midwife 44 regional trainers - 88 regional Year 1: 54 regional trainers in PPFP: Percentage of achievement trainers Year 1: 122%. Year 2: 36 regional trainers: 10 from Analamanga: For Year 2, training of 10 practitioners: 3 male, 7 female additional regional trainers 9 from Vakinankaratra: from the new MCSP regions 4 practitioners: 3male, 1 female will be planned later (Q2- 5 midwives Q3) 9 from Atsinanana:
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INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS 7 practitioners: 7 female, 1 female nurse 1 midwife 8 from Haute-Matsiatra: 7 practitioners: 1 male, 6 female 1 female nurse
250 providers trained 670 providers trained Year 1: Percentage of achievement: in PPFP and in PPFP and 228 health providers trained in MNH: 91% (228/250). counselling counselling 53 from Alaotra Mangoro: 5 female practitioner 3 male practitioner 29 midwives 12 female nurses 4 male nurses 17 from 2 districts of Boeny: 3 male practitioner 9 midwives 2 female nurses 3 male nurses 46 from Melaky: 2 female practitioner 8 male practitioner 19midwives 4 female nurses 13 male nurses 50 from Menabe: 1 female practitioner 1 male practitioner 27 midwives 5 female nurses 16 male nurses 62 from Sofia: 8 female practitioner 5 male practitioner MCSP Madagascar Y2 Quarter 2 Report (Jan – Mar 2016) Page 39 of 50
INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS 38 midwives 7 female nurses 4 male nurses
100 providers trained 365 providers trained Year 1: 64 providers trained: The 4th week of the 5 in PPIUD and implants in PPIUD and implants 6 from Boeny: weeks of competency based 2 male practitioner approach is the PPFP 1 male nurse training. Training in Alaotra 3 midwives Mangoro, Menabe and 23 from Sofia: Melaky will be planned in 4 male practitioner quarter 2-Y2. 4 nurses: 3 male, 1 female 15 midwives
3 from Besalampy-Melaky: 1female nurse 2 midwives
16 from Alaotra Mangoro: 2 female physicians 1 male physician 5 female nurses 1 male nurse 7 female midwives
16 from Menabe: 2 female nurse 1 male nurse 13 female midwives
3.3 Number of USG-assisted 75 health centers 400 health centers 64 health centers in Boeny, Sofia , Besalampy Year 1: percentage of service delivery points district (Melaky), Alaotra Mangoro, Menabe achievement: 85% (64/75) meeting minimum standards (trained provider and basic equipment) to support provision of long- MCSP Madagascar Y2 Quarter 2 Report (Jan – Mar 2016) Page 40 of 50
INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS acting and permanent methods of contraception 3.4 Percentage of maternal 100% 100% 100% health services clients at USG-assisted service delivery points who received counseling about postpartum family planning 3.5 Number of studies N/A - Formative N/A Submission of the protocol completed research on ARH: first time parents to the IRB first time parents. and the ethical committee- MOH. 4.1 Number of national - 1 national MIP - National MIP protocol updated integrated in MIP job aids will be finalized policies drafted with MCSP protocol updated the training curriculum, MIP job aids under in Q1 of PY2 support finalization 4.2 Number of people 23 national trainers - 10 national Year 1: Percentage of achievement trained through USG- trainers 19 National Trainers in MIP: Year 1: 83%. supported programs 17 practitioners (MCSP global PMP, USAID 1 female midwife Percentage of achievement indicator) 1 nurse Year 2: 140%
Year 2: 14 national trainers: 3 male practitioners 9 female practitioners 1 male nurse 1 midwife
44 regional trainers - 88 regional Year 1: 54 regional trainers in MIP Percentage of achievement: trainers 122%. Year 2: 36 regional trainers: For Year 2, training of 10 from Analamanga: additional regional trainers 10 practitioners: 3 male, 7 female from the new MCSP regions 9 from Vakinankaratra: will be planned later (Q2- 4 practitioners: 3male, 1 female Q3)
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INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS 5 midwives 9 from Atsinanana: 7 practitioners: 7 female, 1 female nurse 1 midwife 8 from Haute-Matsiatra: 7 practitioners: 1 male, 6 female 1 female nurse
250 providers 550 providers trained MIP training during the 1st in new MIP protocol Year 1: 228 health providers trained in MIP: week of the 5 weeks of 53 from Alaotra Mangoro: competency-based approach 5 female practitioner 3 male practitioner 29 midwives 12 female nurses 4 male nurses 17 from 2 districts of Boeny: 3 male practitioner 9 midwives 2 female nurses 3 male nurses 46 from Melaky: 2 female practitioner 8 male practitioner 19midwives 4 female nurses 13 male nurses 50 from Menabe: 1 female practitioner 1 male practitioner 27 midwives 5 female nurses 16 male nurses 62 from Sofia: 8 female practitioner MCSP Madagascar Y2 Quarter 2 Report (Jan – Mar 2016) Page 42 of 50
INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS 5 male practitioner 38 midwives 7 female nurses 4 male nurses
Year 2:67 health providers trained in MIP: 34 from Analamanga: 16 female physicians 4 male physicians 1 male nurse 13 female midwives
33 from Vakinakaratra: 4 female physicians 2 female nurses 1 male nurse 25 female midwives 1 female health assistant
4.3 Number of women 998 9,988 5,617 MCSP has only begun to receiving third dose of IPTp- work at the health facilities SP level in the 4th quarter 5.1 Number of MCSP MCSP Madagascar: 1 pre-service curriculum updated Curriculum updated now supported countries with 1 Pre-service used in the training pre-service education curriculum updated strengthened to improve RMNCH services with 40 teachers/tutors - 80 teachers/tutors 9 teachers and preceptors from PSE institutions MCSP support (MCSP global trained in MNH trained in MNH (collaboration with UNFPA): PMP) 1 gynaecological obstetrician (male from IFIRP Fianarantsoa) 8 female midwives (4 from IFIRP Antananarivo, 2 IFIRP Toamasina, 2 IFIRP Fianarantsoa)
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INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS
19 teachers/preceptors from CHU and IFIRP Fianarantsoa: 3 pratictioner : 2 female, 1 male 13 midwives 5 nurses: 4 female, 1 male
25 teachers/preceptors from IFIRP Toamasina: 9 practitioner: 3 male, 6 female 5 nurses: 2 male, 3 female 11 midwives 40 teachers/tutors - 80 teachers/tutors 19 teachers/preceptors from CHU and IFIRP The training of the trained in effective trained in effective Fianarantsoa: teacher/preceptors will teaching skills teaching 3 pratictioner : 2 female, 1 male continue in this quarter 1 13 midwives (Toamasina in October, 5 nurses: 4 female, 1 male Majunga in December).
20 teachers/preceptors from IFIRP Toamasina: 9 practitioner: 5 male, 4 female 2 nurses; 1 male, 1 female 9 midwives
2 skills lab at 2 IFIRPs - 6 skills lab in 6 1 skills lab: IFIRP Toamasina IFIRP
5.2 Number of institutes/ - 2 skills lab in 2 IFIRP - 6 skills lab in 6 1 skills lab: IFIRP Toamasina clinical training sites IFIRP strengthened - 2 clinical training - 6 clinical training 2 clinical training sites: 1 CHU Fianarantsoa, 1 sites sites CHU Toamasina 5.3 Number of midwife N/A N/A N/A No midwife graduates with students graduating with competencies that meet competencies that meet ICM standards in Year 1 and ICM standards Year 2: the new curriculum to ICM standards is just being implemented within
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INDICATOR TARGET YEAR 1 TARGET YEAR 2 ACHIEVEMENT COMMENTS the IFIRP/Fac Medicine. First graduates expected in 2017
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