MaMoni Health Systems Strengthening Activity (USAID Cooperative Agreement AID-388-LA-13-00004)

Quarterly Report April 1 – June 30, 2016

Razia Begum with her 12 day old daughter after being discharged from the newly installed Special Care Newborn Unit at Hospital (SCANU) with support from MaMoni HSS Project. 320 newborns were admitted to the SCANU Noakhali District Hospital since its introduction in March 2016

Submitted August 6, 2016

Cover Photo Story: Razia Begum with her 12 day old daughter after being discharged from the newly installed Special Care Newborn Unit at Noakhali District Hospital (SCANU) with support from MaMoni HSS Project. 320 newborns were admitted to the SCANU Noakhali District Hospital since its introduction in March 2016. MaMoni HSS has supported installation of five SCANUs in this quarter: , Noakhali, Lakhsmipur, Pirozepur and Bhola districts. Photo Credit: Marufa Aziz Khan, Save the Children/MaMoni HSS Project

This document is made possible by the generous support of the American people through the support of the Office of Population, Health, Nutrition and Education, United States Agency for International Development (USAID), (USAID/Bangladesh), under the terms of Associate Cooperative Agreement No. AID-388-LA-13-00004 through Maternal and Child Health Integrated Program (MCHIP). The contents of this document are the responsibility of the MCHIP Project and do not necessarily reflect the views of USAID or the United States government. Table of Contents MaMoni Health Systems Strengthening Activity ...... 1 Table of Contents...... i Abbreviations ...... ii Executive Summary ...... 5 Introduction ...... 7 Program Results for the Quarter ...... 7 IR 1. Improve Service Readiness through Critical Gap Management ...... 7 IR 2: Strengthened Health Systems at District Level and Below ...... 19 2.9 Monitoring Quality of Care Indicators ...... 31 IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems 32 IR 4. Identify and Reduce Barriers to Accessing Health Services ...... 35 Challenges, Solutions, and Action Taken ...... 35 Challenges ...... 37 Opportunities ...... Error! Bookmark not defined. Appendix 1: Scope and Geographical coverage of Mamoni HSS project ...... 39 Appendix 2: Case Studies ...... 41 Appendix 3: Program Performance Indicators (October–December 2015) ...... 43 Appendix 4: MNCH Essential Drugs Monitoring Report ...... 43 Appendix 5: Documentation and Dissemination of MaMoni Program Learning ...... 59 Appendix 6: Environmental Compliance Report ...... Error! Bookmark not defined. Appendix 7: Links to Media Stories Published ...... 60 Appendix 8: Update on USAID Abortion and FP Requirement 2016 Training ...... 61 Appendix 9: Status of Health Facility Renovations ...... 64

MaMoni Health Systems Strengthening Activity: FY’16 Q3 Quarterly Report i ABBREVIATIONS AHI Assistant Health Inspector AMTSL Active management of third stage of labor BCC Behavior Change Communication BEmONC Basic emergency obstetric and newborn care BNF Bangladesh Neonatology Forum BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CB Community-based CEmONC Comprehensive emergency obstetric and newborn care CHW Community Health Worker CHX Chlorhexidine CIPRB Center for Injury Prevention and Research, Bangladesh CMAM Community-based management of acute malnutrition cMPM Community microplanning meeting CNCP Comprehensive newborn care package CSBA Community Skilled Birth Attendants CV Community Volunteer CVRS Civil registration and vital statistical system CYP Couple years of protection DDFP Deputy Director Family Planning DGFP Directorate General Family Planning DGHS Directorate General Health Services DRS District Reserve Store EPCMD Ending Preventable Child and Maternal Deaths FPI Family Planning Inspector FWA Family Welfare Assistant FWV Female Welfare Visitor GOB Government of Bangladesh HA Health Assistant HBB Helping Babies Breathe HPNSDP Health, Population, and Nutrition Sector Development Program HS Health systems HSS Health systems strengthening IFA Iron plus Folic Acid

ii MaMoni Health Systems Strengthening Activity: FY’16 Q3 Quarterly Report IMCI Integrated Management of Childhood Illness IPHN Institute of public health nutrition IR Intermediate result JSV Joint supervisory visit LAPM Long-acting and permanent method LMIS Logistics management information system MAMA Mobile Alliance for Maternal Action mCPR Modern contraceptive prevalence rate MCWC Maternal and Child Welfare Center MNCH/FP/N Maternal, newborn and child health, family planning, and nutrition MNH Maternal and newborn health MOH&FW Ministry of Health and Family Welfare MOLGRD&C Ministry of Local Government Rural Development & Cooperatives MOU Memorandum of understanding MPDR Maternal and perinatal death review NIPORT National Institute of Population Research and Training NNS National nutrition services OGSB Obstetrics and Gynecology Society of Bangladesh PPIUCD Postpartum intra-uterine contraceptive device QA Quality assurance QI Quality improvement QPRM Quarterly performance review meeting RHIS Routine health information system RRQIT Regional roaming quality improvement team SACMO Sub-assistant Community Medical Officer SAM Severe Acute Malnutrition SBA Skilled Birth Attendant SBM-R Standards-Based Management and Recognition SC Save the Children SCANU Special care newborn unit SDP Service point SIAPS Systems for improved access to pharmaceuticals and services SSN Senior Staff Nurse STG Strategic thematic group TBA Traditional Birth Attendant

MaMoni Health Systems Strengthening Activity: FY’16 Q3 Quarterly Report iii TOT Training of trainers UEHFPSC Union Education Health and Family Planning Standing Committee UFPO Family Planning Officer UHC Upazila health complex UH&FPO Upazila Health and Family Planning Officer UH&FWC Union Health and Family Welfare Centers UP Union parishad USAID United States Agency for International Development USC Union sub-centers

iv MaMoni Health Systems Strengthening Activity: FY’16 Q3 Quarterly Report EXECUTIVE SUMMARY Key Accomplishments of the MaMoni Health Systems Strengthening Project (MaMoni HSS) In the third quarter of Year Three, the key accomplishments of the project include the following: • In collaboration with the Directorate General of Family Planning, MaMoni HSS has completed an assessment of all 4,461 union level health facilities to determine their readiness to provide normal delivery care and essential newborn care services. A comprehensive database of these facilities has been prepared, which will be used for advocating for investments from MOHFW and development partners to strengthen these facilities. MaMoni HSS has also completed seven divisional level dissemination and advocacy events to prioritize this initiative as part of the new Health Nutrition and Population (HNP) sector program. • MaMoni HSS has completed the initial roll out of 7.1% chlorhexidine application for newborn umbilical cord care through public sector health facilities in all 64 districts of the country. MOHFW is supporting the roll out by procuring and distribution of the product, whereas the project has supported the training of all public sector health workers, supervisors and managers at all levels. The project has also supported integration of CHX into the routine monitoring systems of MOHFW. As part of the national scale up, MaMoni HSS has also mobilized the support of private sector providers, NGOs, and other development partners to promote the use of CHX as part of essential newborn care for babies in the country. • MaMoni HSS has signed three important letters of collaboration (LOC) with different units of MOHFW at the national level. The first LOC aims to support the Planning Wing of MOHFW to coordinate the development of the fourth HNP sector program; the second LOC supports the Health Economics Unit (HEU) to strengthen the role and capacity of the Quality Improvement Secretariat (QIS) to nationally roll out the National Quality Improvement Strategic Plan; and the third supports the Human Resources Management Unit (HRMU) to implement the national Health Workforce Strategy (2016-2021).

Challenges and Mitigation Strategies • Drug shortage: The Drugs and Dietary Supplements (DDS) kits of UH&FWCs and the drug supply of the community clinics have been interrupted since September 2015 due to procurement issues at DGHS and DGFP. This has severely affected the coverage and quality of essential services at the community level. MaMoni HSS has been closely monitoring the situation, and where appropriate, has been liaising with the Union Parishads, and Ministry of Social Welfare to leverage temporary support to meet the shortfall for drugs and supplements such as oxytocin, iron plus folic acid (IFA), and misoprostol. • The online DHIS2 MIS system of DGHS does not include reporting for chlorhexidine (CHX) yet. Thus, even though chlorhexidine has been made available in 64 districts, and the new EmOC registers rolled out by UNICEF has space for recording CHX use, utilization reports are not available. MaMoni worked with the Integrated Management of Childhood Illnesses (IMCI) section of DGHS, UNICEF and the Saving Newborn Lives program of Save the Children to organize a joint meeting with the Director of MIS, DGHS to speed up the revision process. A sub-committee has been

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 5 formed to address this. In DGFP MIS system, chlorhexidine reports are included, but the MIS-4 combines service (MIS-3 and CSBA data) and information (FWA MIS-1) data, with potential for duplication. MaMoni HSS is working with local statisticians to understand the scale of duplication, with a plan to inform MIS unit with the learning. • Union Parishad (UP) election continued in this quarter in some parts of Habiganj, therefore, local government resources were not available in those unions. MaMoni is undertaking orientation on the newly elected Ups.

Way Forward • In the upcoming quarter, the focus of the project will be on consolidating implementation components as per the recommendation of the MaMoni mid-term evaluation. • Active engagement with the Planning Wing, Program Preparation Team, PMMU and Line Directors to contribute to the development of OPs and PIP for the fourth sector program. The project will also provide operational and administrative support to the PMMU. • MaMoni HSS will organize a high level advocacy meeting and national dissemination meeting on the assessment findings of UH&FWC strengthening at divisional levels. The final report and directory of UH&FWCs will be published. • MaMoni will work with HRMU, WHO, and a national consultant agency to conduct an assessment of workload of all levels of workers at district level and below in a few selected districts. • MaMoni will provide technical and managerial support to the Quality Improvement Secretariat. This includes deployment of a Senior QI Consultant and a National Consultant at the national level. The project will support a national level training of a national resource pool on QI. Additional administrative support to the QIS is planned. • The expansion of RHIS to the entire district of Habiganj will be initiated in the next quarter. The PRS and deployment of community health worker modules and MNH modules will start in an additional three by the end of next quarter. • MaMoni will introduce unified LMIS in all high intensity upazilas.

6 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 Introduction The MaMoni Health Systems Strengthening (HSS) project, a four-year USAID-funded award,1 has the goal of improving utilization of integrated maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) services delivered through a health systems strengthening lens. The project supports the Ministry of Health and Family Welfare (MOH&FW) to introduce and leverage support for the scale-up of evidence-based practices that have been applied and tested in Bangladesh. To support this scale-up, MaMoni HSS is actively engaging with local government structures and nongovernmental organizations (NGO) to improve delivery of health services, and strategically partner at the national level to build consensus on policies and standards that positively drive evidence-based interventions at all levels. The scope and geographical coverage of the MaMoni HSS Project has been included in Appendix 1 of the report.

PROGRAM RESULTS FOR THE QUARTER

IR 1. Improve Service Readiness through Critical Gap Management

1.1 Introduction and Scale-up of MNCH/FP/N interventions

1.1.1 Maternal Health MaMoni HSS, is rolling out pre- eclampsia/eclampsia (PE/E) management interventions in 45 unions in five upazilas of the high intensity districts: Nabiganj (Habiganj), Companyganj (Noakhali), Kamalnagar and Ramganj (Lakhsmipur), and Rajapur (Jhalokathi). 168 participants from these upazilas were trained in this quarter. In addition, 95 referral level providers were oriented on management of PE/E at the referral level facilities (District hospitals and MCWC).

The current MIS Form 3 of DGFP, which is used at Photo 1: PE/E training participants practice administration of injectable magnesium sulfate the union level, only captures information on on a dummy model. mothers who received magnesium sulfate, but not mothers who were screened and identified with pre- eclampsia/eclampsia. MaMoni HSS is including supplementary columns to collect this information, and will advocate to DGFP for revision after a few months based on the findings.

1 MaMoni HSS is the result of an Associate Award under the Maternal and Child Health Integrated Program, with a period of performance from September 24, 2013 to September 23, 2017. MaMoni HSS is supported by Jhpiego—in partnership with Save the Children, John Snow, Inc., and The Johns Hopkins University Institute for International Programs—with national partners: International Centre for Diarrhoeal Disease Research, Bangladesh; Dnet; and Bangabandhu Sheikh Mujib Medical University (BSMMU). Save the Children serves as the lead operational partner for the Award in Bangladesh.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 7 The project has also introduced a state-of the art Microlife® Blood Pressure Machine to accurately detect high blood pressure. The machines have digital readouts with sound indicators when a blood pressure is against the normal threshold. These machines were distributed to the 24/7 facilities (mostly UH&FWCs). The project also leveraged funding from KOICA funded Mamota Project of Save the Children to provide magnesium sulfate to the implementing unions.

MaMoni HSS is supporting service providers (mostly FWVs) from high intensity districts to distribute misoprostol to mothers during third trimester ANC visits to prevent postpartum hemorrhage in home deliveries. In the HSCS upazilas, the national approach of distribution through FWA continued. Around 44,614 mothers in the six districts received misoprostol through union and community level providers in this quarter. DGFP has taken initiatives to address misoprostol stockout, and provided three months supply of misoprostol to all the MaMoni upazilas. In Jhalokathi and Pirozepur, the districts most affected, 2,720 misoprostol tablets were provided from the regional store against a projected demand of 3,266 doses for the July-September quarter. MaMoni HSS is working with the Faridpur and Patuakhali regional stores of DGFP to supply more misoprostol to Jhalokathi Sadar and Nalchiti upazilas. The third and latest population based survey, completed in February showed wide variation in misoprostol consumption pattern between upazilas. Among home births, 49% of mothers of Ajmiriganj upazila of Habiganj reported consuming misoprostol right after delivery, whereas the rate was five percent and six percent for Jhalokathi Sadar and Lakhsmipur Sadar upazilas.

The project also supported DGFP in rolling out misoprostol in 22 additional districts in March 2014. MaMoni HSS recently analyzed the performance data from these 22 districts. All districts reported distribution of misoprostol within 8 months of TOT except Rangamati. Rangamati and Joypurhat were the worst performers in terms of distribution: Rangamati reported no misoprostol distribution 9 out of the last 12 months, Joypurhat reported 3 months for the same period. In the past 12 months, average monthly distribution of misoprostol was 17.4 in Rangamati, 431 in Joypurhat. MaMoni has contacted DGFP to monitor use of misoprostol, and reach out to the managers of the low performing districts. Anecdotal information points to inadequate follow up from the central level, budget to roll out training, availability of master trainers to conduct training on time and drug stockout as reasons for poor performance.

1.1.1a. Increasing SBA at the District Level In the six MaMoni HSS districts, the project is supporting MOH&FW to strengthen the UH&FWCs to provide the comprehensive package of MNCH/FP/N services, including normal delivery care through a combination of leveraging existing resources of

MOH&FW; mobilizing local resources; and providing Photo 2: Clinical Attachment of FWVs direct inputs to meet facility needs (i.e. training, in Habiganj MCWC infrastructure improvement). As of June 2016, a total of 58 out of 193 UH&FWCs in the high-intensity upazilas are providing 24/7 delivery services. Overall, as depicted in Figure 1 below, institutional deliveries at the facility level are increasing.

8 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 Figure 1 . Trend of SBA deliveries in MaMoni HSS high intensity areas* 25000 21653 20000 18838 17370 1732516820 15252 16100 14433 15000 1350713039

Number 10000

4136 5000 35783637 3476 1520 240 144 147 110 147 0 Facility Delivery CSBA PCSBA Total SBA

FY 15 Q3 FY 15 Q4 FY 16 Q1 FY 16 Q2 FY 16 Q3

*Note: includes delivery at home by p/CSBA, UH&FWC, UHC, DH, MCWC

1.1.1b Private CSBAs (pCSBA) supported Private community SBAs (pCSBA), are non-salaried workers, who only earn income by charging for different services (ANC, deliveries, PNC) and selling essential commodities. 38 new pCSBAs from Noakhali (18) and Lakhmipur (20) were certified by the Bangladesh Nursing Council in March 2016. Subsequently, these pCSBAs completed 21 days of residential clinical attachment at the OB/GYN wards of the District Hospital and MCWC at their respective districts and were deployed in May 2016. In May and June 2016, these CSBAs conducted 16 deliveries in Noakhali and 41 deliveries in Lakhsmipur districts. MaMoni HSS also continued to support the 54 private CSBAs in Habiganj. These CSBAs conducted 96 deliveries in this quarter.

1.1.1.c Supported Health Facility Preparedness for MNCH/FP/N Services In Year Two of MaMoni HSS, the MOH&FW requested the project to provide technical assistance to the DGFP to strengthen UH&FWCs across the entire country by training providers, strengthening commodity management, and establishing quality improvement mechanisms. As a starting point, the project completed a nationwide facility readiness assessment of 4,461 health facilities and assessed infrastructure, FWV residence, human resources, Photo 3: UH&FWC Divisional Advocacy training, furniture, equipment and supplies. In this meeting in quarter, the project is conducting a validation of collected data in all 7 divisions by supervisors. In , and divisions, the project data collectors physically visited unions where no UH&FWC was found to reconfirm the data. The same process will be replicated in the remaining four divisions in the following quarters. Two final divisional advocacy meetings (Dhaka and ) were organized in this quarter. Divisional Directors, DDFPs, representatives from DGHS from central level, CSs, Divisional Commissioners, HED representatives, representatives from local

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 9 government, NGO representatives and other stakeholders participated. The Director of MCH-FP of DGFP and other directors of DGFP co-hosted the meetings. In total 4,461 UH&FWCs have been assessed. 3,349 of the facilities were UH&FWCs and 3,269 were found to be managed by DGFP. 987 Union Sub Centers (USCs) and 125 Rural Dispensaries (RD) were also assessed. Among the 4,461 union level facilities included in this assessment, a total of 1,112 were USCs and RDs and hence were excluded from further analysis for readiness for normal delivery and essential newborn care services. For the 3,349 UH&FWCs, the assessment assigned scores against seven criteria to determine the overall readiness of each facility to provide normal delivery and essential newborn care services. Based on the cumulative scores, each facility was grouped into categories A, B and C. The categorization indicates the overall readiness of the facilities to provide normal delivery and essential newborn care services and the level of inputs required to make them fully ready. Overall, 20% UH&FWCs (n=711) are in “C” category, which means these facilities need major inputs in several areas, including physical renovation, staffing, supplies and equipment etc. with a total of 66% UH&FWCs (n=2,370) are in category “B” category, which will need medium to major inputs. Only 11% of UH&FWCs (n=486) are in category “A” categories, which are either already functional or need minimum resources to make them fully ready.

Figure 2: UH&FWCs categorized by their readiness to provide delivery services

100 73 80 67 71 65 63 67 62 66 60

40 26 21 21 20 18 19 15 17 20 15 14 11 14 14 13 14 14

0 Barisal Chittagong Dhaka Khulna Rajshahi Rangpur Sylhet Total

A B C

If the category A facilities (14% of total) were prioritized, 450 health facilities could be providing delivery services.

1.1.2 Newborn Health 1.1.2a. National scale up of 7.1% chlorhexidine to prevent newborn infection As part of the national roll out of chlorhexidine, MaMoni HSS oriented 25,839 participants in 1,086 groups in 39 districts on application of 7.1% chlorhexidine. Participants ranged from medical officers to CHCPs providing services in the districts. Job aids and IEC materials have also been provided. In addition to this, another 961 service providers (mostly

10 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 Photo 4: A participant in Daudkandi UHC, practicing chlorhexidine application doctors and nurses) from 9 medical colleges received orientation on chlorhexidine in 32 groups. 39 Independent Monitors (IMs) have monitored 516 training sessions among rounds in 39 districts, 48% of the training conducted this quarter. They also filled in a standardized check list and shared their observation and recommendations. In addition to supervising the training session the independent monitor also visited the IMCI-N corners of the concerned UHCs to assess the readiness of the facilities to introduce newborn interventions. DGFP has begun tracking chlorhexidine through their online portal from January 2016. The following figure shows the trend of chlorhexidine use over the first five months. Data from DGHS managed facilities will become available after the revisions to the recording and reporting tools are fully implemented.

Figure 3: Use of chlorhexidine at DGFP facilities in MaMoni HSS districts and nationally

10000 25000

9000 20981

8000 19295 20000 17184 7000 6000 14576 15000 12557 5000 4000 10000 3000 2000 5000 1000 0 0 Jan-16 Feb-16 Mar-16 Apr-16 May-16 National Bhola Pirojpur Noakhali Habiganj

There is a clear increasing trend nationally as more and more districts are oriented on application of chlorhexidine. However, as the MIS4 Form of DGFP combines reports of FWAs (MIS1), CSBAs (MIS3) and FWVs (MIS3), there is a possibility of double counting chlorhexidine application. MaMoni HSS is working with the Saving Newborn Lives program of Save the Children to improve the quality of reporting. DGHS has not integrated chlorhexidine reporting in their DHIS2 systems yet. Between April-May 2016, 3,949 newborns received chlorhexidine in four high intensity districts (Habiganj, Noakhali, Lakhsmipur, Jhalokathi) as reported by the UHCs.

1.1.2b. Newborn Sepsis Management

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 11 MaMoni HSS, in this quarter, scaled-up provision of newborn sepsis management services at the 153 union level facilities in 23 high intensity upazilas2 through Sub- assistant Community Medical Officers (SACMOs) for newborns in situations where referral was not possible or acceptable. In this quarter, SACMOs from of Pirozepur, which was not cover earlier, received training on newborn sepsis management using simplified antibiotic therapy treatment regimen. 1,253 cases of newborn sepsis were identified by the SACMOs (520 in Habiganj, 297 in Noakhali, and 487 in Lakhsmipur, 218 in Jhalokathi). Figure 4, below, shows the total number of cases disaggregated by types of infection.

Figure 4: Category of 1,253 sick newborn/infants (0-59 days) treated at UH&FWCs during this quarter

Critical Clinically Severe Infection, Infection, 107 34

Other, 532 Isolated Fast breathing, 378

Local Bacterial Infection, 471

In the case of 34 critical infection cases, first doses of antibiotics were provided and the sick infants were referred to higher level facilities. MaMoni followed up with each of the infants and found that treatment completion was high. However, MaMoni facilitation, including follow up with SACMOs and families over the phone and in-person within the treatment period, was critical to ensure this. MaMoni HSS, in collaboration with Johns Hopkins University’s HRCI project, has been conducting an implementation research on newborn sepsis management in of Lakhsmipur to inform the national policymakers. The study has two objectives: to work in partnership with MaMoni HSS to support the MOH&FW to operationalize their guideline for management of young infant infections at the union level health facilities when referral is not accepted by caregivers, and to evaluate the implementation of the new guidelines within the existing health structure. Based on the findings from the baseline study, 27 non-formal providers (village doctors and pharmacy owners) were oriented in this upazila to identify infection cases and facilitate appropriate referrals.

1.1.2c. Kangaroo Mother Care (KMC)

2 All eight upazilas of Habiganj, Ramganj upazila of Lakshmipur and Companyganj upazila of Noakhali district

12 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3

Photo 5: Prof. Abdul Mannan of BSMMU facilitating a KMC session MaMoni HSS planned to introduce KMC services in 16 health facilities (DH, UHC) this year. Noakhali District Hospital started providing the services in December, 2015. In this quarter, 11 doctors and 31 nurses from 9 additional health facilities were trained at BSMMU and these facilities have received the logistics and recordkeeping forms necessary to provide KMC services. 7 babies received KMC in Noakhali DH in this quarter, up from 3 the previous quarter. Average duration of stay was 2 days for these babies, and the birth weight on admission ranged from 1.2 kg to 2 kg. MaMoni HSS conducted a follow up in Noakhali District Hospital and Companyganj UHC in June to explore the low utilization of KMC and assess the barriers experienced by the providers. Table 1 summarized the findings from this assessment.

Table 1: Provider perception on challenges of implementing KMC Barriers to introduce KMC cited by providers at Noakhali District Hospital and Companiganj UHC • HR and workload: 40% doctor and 30% nurse positions are vacant at the DH. Bed occupancy rate is around 200%. Providers think dedicated beds for KMC would be difficult. • Unavailability of adequate trained manpower to cover all three shifts. • Risks of cross infection: Pediatricians mentioned that they are hesitant to keep low birth weight babies in the general pediatric ward, even with dedicated beds. • Family resistance: Mothers who deliver at the facility are keen to return to home if no visible complication is present. • SCANU presence: Newborns from the obstetric ward are directly referred to SCANU, and discharged from there without counseling to introduce KMC. MaMoni has taken steps to address this and is promoting KMC services after discharge from SCANU.

However, provider confidence seems to be increasing. In Companyganj UHC, the providers mentioned that they used to directly refer all low birth-weight babies to higher level facilities. Now they feel confident to provide KMC. They expect number of facility deliveries to increase after the rainy season and are willing to implement KMC. An abstract on the readiness of the facilities has been submitted to the 11th International Workshop and Congress on KMC being held in Italy in November 2016.

1.1.2.d Antenatal corticosteroids for threatened preterm labor MaMoni HSS introduced antenatal corticosteroid for threatened preterm labor in Noakhali and Habiganj district hospitals in this quarter. The orientation of doctors and nurses from Lakhsmipur district hospital were also completed, and will begin intervention in July. MaMoni HSS is collecting supplementary information to monitor these interventions. During the months of April and May 2016, ACS were administered in 19 cases in Noakhali District Hospital. Two doses of dexamethasone, 12 hours apart were administered in all cases, and the gestational age ranged from 24-34 weeks. Out of the 19, two were cases of preterm birth, and 17 had premature rupture of membrane (PROM). 7 mothers required C-section, and normal vaginal delivery was recorded for one mother. However, no delivery information was recorded in 11 cases. The weight of the children were recorded in 11 cases, with the weight ranging from 2kg to 4.5kg. Based on these data, MaMoni HSS is working with the district hospital team to strengthen the recordkeeping and ensuring complete data.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 13

1.1.2e. Special Care Newborn Units (SCANUs) MaMoni HSS supported the MoHFW to introduce SCANUs at five district hospitals. Four SCANUs: Noakhali, Habiganj, Pirozepur and Bhola, are currently functional, with Lakhsmipur expected to begin in July. The nurses who received Emergency Triage, Assessment and Treatment (ETAT) training from the IMCI section of DGHS have been managing these SCANUs. For Noakhali and Lakhsmipur, the project has provided six nurses in Noakhali and Lakhsmipur to strengthen the services. The IMCI section of DGHS is organizing a two-week attachment to BSMMU’s neonatology unit in late July/early August to further enhance the skills of these providers. In this quarter, 6 newborns were admitted to the newly installed SCANU in Pirozepur. Around 320 babies between 0 to 59 days of age were admitted in Noakhali district since its introduction in March.

1.1.2e Comprehensive Newborn Care Package Training 368 Community Health Workers (CHWs) from Habiganj and Jhalokathi districts were trained this quarter on the CNCP package for a cumulative number of 1,207 in six districts. Outreach workers (HA, FWA, CHCP) and their supervisors (AHI, FPI, HI) participated in 17 batches in this quarter. Although the outreach workers are not expected to perform deliveries or provide immediate newborn care, they are expected to conduct PNC visits (at home or at community clinics), promote chlorhexidine use, identify preterm/low birth weight and sick newborns and refer them to appropriate facilities. They have received appropriate job aids, including IEC materials. MaMoni HSS plans to conduct post-training follow up in subsequent quarters.

1.1.2f. Helping Babies Breathe training on neonatal resuscitation and its follow-on The national scale-up of HBB resuscitation training previously excluded medical colleges. A demand was placed to BSMMU to train the doctors and nurses at the medical colleges. 119 doctors and 259 nurses from four medical colleges (Faridpur, , Rajshahi and Rangpur) were trained. Nationally, 28,734 skilled birth attendants have now been trained on HBB. The Smiling Sun Clinics of NHSDP project received a replacement of 128 HBB equipment sets from the IMCI section of DGHS with facilitation from MaMoni HSS.

1.1.3 Child Health The National Newborn & Child Health Cell within the IMCI section of DGHS supported a performance review of IMCI data from 2014 and 2015 calendar years and reporting in four districts: Habiganj, Noakhali, Lakhsmipur and Bhola. District and Upazila level managers and statisticians participated in these review meetings. The review uncovered big gaps in the online reporting system and database, and an understanding gap by statisticians. In Photo 6: IMCI performance review Noakhali district, service contact with newborns (0- conducted by IMCI section of DGHS

14 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 28 days) went down from 4,369 to 1,898, which reflected an overall downward decline of 117,017 to 101,896 for all children under five years of age. However, counseling went from 3,296 in 2014 to 66,145 in 2014, which is unrealistic. The database also showed more patients referred than total patients seen, wrong patients referred (MAM patients instead of SAM, cold/cough instead of very severe disease, etc.), which was due to a database coding problem. Based on feedback from these meetings, the IMCI section is working with the statisticians to address these issues, both offline and online.

1.1.3a Community Case Management (CCM) 85 CHCPs from 82 existing Community Clinics (CC) in Jhalokathi district are now treating ARI, pneumonia, and diarrheal cases along with nutritional counseling following the CCM protocol. CHCPs provide daily reports online from the CC. The project, in collaboration with UNICEF, is facilitating performance monitoring through monthly meetings of CHCPs at upazila and district level. The following figure describes the performance of these CCs in the past two quarters.

Figure 5: Number of children treated by IMCI providers by category of disease in Jhalokathi district between January and June 2016

2500 2020 2103 2198

2000 1622 1500 880 1000 614 Number 500 25 23 15 24 53 119 0 Very severe Fever-no malaria Fever-malaria Diarrhea No_pneumonia Pneumonia disease with cold

Jan to Mar 2016 April to Jun 2016

The data shows a slight quarter-to-quarter increase in service contact. However, because of possible seasonal variations and effect of Ramadhan, it is premature to draw a conclusion at this point.

1.1.4 Family Planning At the national level, the project participated in the FP2020 Bangladesh Country Engagement Working Group (BCEWG) meeting chaired by DGFP and attended by GOB managers and development partners. The participants discussed the revised costed implementation plan of the FP programs and reviewed current status of the PPFP action plan. Apart from this meeting, the project also adapted FP counseling training curriculum and materials developed earlier in coordination with DGFP and EngenderHealth. In addition, the project coordinated with CCSDP for the provision of master trainers from the national level to facilitate training activities in PPFP counseling in the project districts. At the district level, MaMoni HSS undertook several initiatives to strengthen the family planning interventions with a focus on postpartum family planning. 59 trainers from four districts received TOT on PPFP counseling

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 15 Photo 7: TOT on PPFP counseling in Jhalokathi district this quarter. In addition, MaMoni HSS trained 12 service providers on PPIUCD from Noakhali and Jhalokathi districts. Figure 3 shows the uptake of PPIUCD in four MaMoni HSS districts. Because of Ramadhan, the June performance was lower than previous months, but expected to increase in subsequent months.

Figure 6: Number of PPIUCD insertions in four MaMoni HSS districts 90 83 77 72 80 68 70 60 50 50 43 40 29 29 30 15 20 13 11 14 9 7 7 10 21 2 02 0 3 0 0 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

Habiganj Noakhali Lakshmipur Jhalokati

DGFP has re-introduced Progestin-only pill (POP) as a short-term method for PPFP. MaMoni HSS counseling package addresses this new addition. In this quarter, 75 CSBAs of Habiganj district received training on all FP methods with a focus on PPFP services and PPFP counseling. Figure 4 shows PPFP counseling conducted by CSBAs between January and May 2016.

Figure 7: Number clients counseled on PPFP by CSBAs between January and June 2016 300 252 250

200 148 150 134 118 117 108 106 103 94 98 100 51 43 50 20 17 5 15 15 11 0 January 2016 February 2016 March 2016 April 2016 May 2016 June 2016

Habiganj Noakhali Laksmipur

MaMoni HSS is supporting integration of FP services in all service delivery points of MOH&FW, particularly in the upgraded UH&FWCs. During the quarter, the CYP for the high intensity upazilas was 116,219 (almost the same as previous quarter’s 116,634), and in the health systems capacity building upazilas was 97,840 (slightly lower than 99,964 in the previous quarters). Figure 5 shows the current method mix

16 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 as of June 2016 compared to the previous quarters. The majority of clients chose oral contraceptives followed by injectables, across all districts.

Figure 8: FP method mix in March and June 2016. 90 80 7 5 6.5 6.6 7.3 7.3 7.0 7.1 5.1 70 4 3.8 3.8 4.6 4.6 5.11.4 1.3 4 2.1 2.2 5.2 5.5 1.31.9 1.32.0 2.9 3.1 60 3.0 3.0 2.9 2.9 3.0 3.0 17 4.6 4.6 11.8 11.8 18.0 18.0 50 15.8 15.9 22.7 22.6 6 6.6 6.7 40 7.6 7.6 5.7 5.8 4.9 5.1 30 20 42 42.9 43.1 35.6 35.9 36.1 36.1 33.5 33.6 10 0 Mar-16 Jun-16 Mar-16 Jun-16 Mar-16 Jun-16 Mar-16 Jun-16 Standard Habiganj Jhalokati Noakhali Lakshmipur

Oral pill Condom Injectable IUD Implant NSV Tubectomy

During the quarter, 22% of new LAPM acceptors were referred by community volunteers of MaMoni HSS. Figure 6 shows current progress in LAPM uptake in project districts.

Figure 9: Number of LAPM acceptors and CV contribution in four high intensity districts

8000 6896 7000 5631 5703 6000 5350 4989 5000 4000

Number 3000

2000 1426 1268 1276 1078 970 1000 0 Total CV Total CV Total CV Total CV Total CV FY15 Q3 FY15 Q4 FY16 Q1 FY16 Q2 FY16 Q3

MaMoni HSS also supported Family Planning Service Week from May 14-19, 2016. In the high intensity MaMoni HSS districts, the project supported the event by holding discussions, organizing video shows, and supporting additional service camps.

1.1.5 Nutrition

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 17 At the district level, MaMoni HSS focuses on basic nutrition counseling by health workers, and screening, identifying, and referring children with Severe Acute Malnutrition (SAM) to Upazila Health Complexes (UHC). MaMoni trained 391 service providers and outreach workers on basic nutrition for establishment of nutrition units in three upazilas this quarter, namely Madhabpur (Habiganj, Hatiya (Noakhali) and Rajapur (Jhalokathi). Photo 8: Basic Nutrition training in Madhabpur 19 Medical Officers and Senior Staff Nurses upazila of Habiganj from four districts were also trained on SAM management, and developed as trainers for conducting CMAM training in their respective UHCs. Some of the participants have been part of established SAM corners but did not receive the training earlier. A two bed SAM corner was introduced in Rajapur UHC of Jhalokathi following the training.

1.2 Management of Critical Human Resource Gaps of GOB Service Providers MaMoni HSS is planning to support Ministry of Health and Family Welfare (MoH&FW) for improving human resources planning and management at healthcare facilities at district level and below, thereby contributing to district level health systems strengthening. A Letter of Collaboration (LoC) was signed between the Human Resources Management Unit (HRMU) of MoH&FW and MaMoni on 30th June 2016. Specific areas of collaboration were identified and agreed upon through series of meetings. Major areas of collaboration include conducting assessments on workload and staffing needs at districts and below level services, piloting and national scale up of a Human Resources Information System. Discussions also held with WHO Bangladesh to work together to extend the support to MOH&FW on HRH issues particularly workload assessment. Terms of Reference for assessment of workload and staffing needs were finalized and the consultant hiring process was initiated during the reporting quarter. In the six districts where implementation is in progress, the project is currently supporting 58 paramedics, one EmOC-trained Medical Officer, and 19 nurses to fill the critical human resource gaps. There have been changes from quarter to quarter in the number of paramedics deployed in Habiganj, Noakhali, and Jhalokathi—largely a result of frequent staff turn-over. The status of vacancies and MaMoni HSS gap management will be expected to undergo changes in December when new FWVs are deployed (refer to Table 1).

Table 2. Summary of critical health workforce gap management provided by MaMoni Health Systems Strengthening (HSS) in high-intensity districts, as of June 30, 2016.

FWV Nurses

District Vacant New MOH&FW Paramedics Vacant New Nurses Posts Jun deployment in deployed by Posts as of MOH&FW deployed by 2016 this quarter MaMoni HSS Jun 2016 deployment MaMoni HSS in this

18 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 quarter

Habiganj 13 0 24 28 1** 12

Noakhali 09 0 16 46 0 3

Lakhsmipur 0 0 8 36 0 7

Jhalokathi 7 4 5 2 1** 0

Total 27 4 53 129 2 22

IR 2: Strengthened Health Systems at District Level and Below

2.1 Strengthen District Planning and Performance Management In the second quarter, the project supported the development of decentralized MNCH/FP/N action plans at district and upazila levels, using local level data and analysis. The data from tracer indicator surveys on priority MNH/FP indicators, along with health systems bottlenecks analysis, helped prioritize interventions as well as geographic areas. The district plans for four high intensity upazilas were finalized in this quarter. Quarterly performance review meetings (QPRM), held jointly by DGFP and DGHS staff with project facilitators, were also held in all six districts. A total of 6 QPRMS were held, leading to management decision-making and action plans for program improvement.

2.2 Strengthened Quality Improvement Initiatives 2.2.1 National Level Contributions The project continued to collaborate with the MoH&FW Quality Improvement Secretariat (QIS). In the reporting quarter, the project participated in a national mapping exercise conducted by the QIS to record the geographic coverage of different projects and organizations and their capacity to support the implementation of various aspects of the national QI strategy. MaMoni HSS Project is covering six districts (Habiganj, Noakhali, Lakhsmipur, Jhalokathi, Bhola, and Pirozepur) and will play a leading role in supporting the formation and facilitation of the functions of quality improvement committees in these districts according to the guidelines provided by QIS. The project participated in a “Workshop on Quality Improvement Initiative for Health Care Service Delivery” conducted at DGFP on June 20, 2016. The workshop reviewed national progress in FP program implementation and the latest data on main FP indicators such as total fertility rate, contraceptive prevalence rate, unmet need for FP, and proportion of FP method use. The workshop identified challenges to providing quality FP services and the national strategy to improve quality of FP services. MaMoni HSS shared its experience in implementing the QI strategy in 4 districts and the lessons learned to be applied for improving quality of FP services. The workshop was chaired by the Director General of FP, and participants included the Director of MCH Services and Line Director of MCRAH, Director Clinical Contraception Services Delivery Program (CCSDP), Director General Health Economics Unit, Coordinator QIS, senior staff from DGFP, and representatives from international partners.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 19 The project contributed to discussions with QIS to identify input to further contribute to the capacity of the QIS. This included identifying national level staff to strengthen the technical capacity of QIS to coordinate the implementation of the national QI strategy and monitor progress as well as division staff to facilitate the implementation of QI interventions at the district level. A Letter of Collaboration (LoC) between the Health Economics Unit and Save the Children was signed specifying the objectives and the input of the project to provide further support to QIS. The project has been included in the recently developed Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) working groups, formed by the QIS, to update guidelines and develop tools for monitoring quality of RMNCAH services.

2.2.1a. Implementation of a new QI paradigm for improving quality of service in stages The project continued to implement the new QI strategy aiming at improving the quality of clinical care provided at health facilities in stages. Stage 1: to improve the cleanliness, infection prevention, and medical waste management; Stage 2: to improve sterilization measures and compliance with antenatal care and newborn care services, and Stage 3: to improve compliance with all range of MNCH/FP/N standards. The project developed, in coordination with district level counterparts, specific district plan of actions to ensure that health facilities apply interventions to complete the stages of QI. The following table summarizes the status of health facilities by QI Stage by District.

Table 3: Number of health facilities at different stages of QI, by district

Stage of QI District Habiganj Noakhali Lakhsmipur Jhalokathi Stage 1* 58 35 50 29 Stage 2** 16 8 8 4 Stage 3 4 0 0 0 Total number of health 78 43 58 33 facilities * Improved basic cleanliness, waste management, minimum infection prevention ** Improved organization of services, crowd management, infection prevention, apply basic clinical standards

Case Study: Example of improved health facilities in the reporting quarter

Binoykathi UH&FWC, Jhalokathi Sadar Upazila, Jhalokathi District completed Stage 1 QI in this quarter. The following table summarizes the improvements

Table 4: Binoykathi UH&FWC, Jhalokathi (before and after improvement)

Situation before improvement Situation after improvement Interventions that led to (Q1) (Q3) improvement Cleanness is absent in and outside The facility is clean inside and outside. Motivation by counselling of the facility. service provider through supervision. No medical waste dumping pits Medical waste dumping pits in place. Prepared by MaMoni HSS. exist in the premises of the facility. Chlorine solution for Chlorine solution prepared and used for Motivation by counselling of decontamination of used decontamination of used instruments. service provider through instrument not prepared. supervision. No color coded medical waste bins Color coded medical waste bins in place. Supplied by MaMoni HSS.

20 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 in place. Partograph not used during labor. Partograph is used during labor Training given and partograph supplied by MaMoni HSS.

Binoykathi before improvement After improvement

2.2.1b Recognition of staff and health facilities that achieved significant improvement

On May 11, 2016, the project organized a recognition event in Habiganj district for three health facilities that achieved significant QI of clinical standards (Murakuri, Shibpasha, and MCWC). The event was attended by several officials from national DGFP, DGHS, QIS, and Photo 9: Recognition ceremony at Habiganj Habiganj, MoHFW, and local government officials. The event contributed to raising the profile of QI activities in the district.

2.3 Increase Local Ownership of Quality Improvement through establishing (QI) Committees As part of the new paradigm adopted by the project, the project is increasing the local ownership of the QI process through the establishment of QI committees, as per the guidelines provided by the QIS. The project is facilitating the formation of the QI committees at district, upazila, and health facility levels and the meetings of the different committees. The project’s facilitation is focusing on making sure that while the counterparts from the MoH&FW take the lead and ownership of the process, the meetings of the QI committees are effective in identifying gaps in performance and creating action plans in response. The project is also facilitating the follow up for the implementation of the action plan and feedback to the QI committee on progress. The project is also providing facilitation to ensure the engagement of local government in the QI Committee meetings for increasing resources for replenishing supplies, conducting minor renovations, and building waste management pits with local resources. The table below summarizes the status of the formation of QI Committees by district.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 21 Table 5: Status of QI Committees in four high intensity districts (April-June 2016) Number of QI Committees District

Habiganj Noakhali Lakhsmipur Jhalokathi

Total to be formed 86 43 54 40

Actually formed 73 42 54 35

Active (had at least 1 meeting in 42 41 49 25 the last 3 months)

Some of the QI committee meetings did not take place as members were engaged in training off site.

2.4 Strengthening routine supervision system and promoting supportive supervision: The project continues to provide support to strengthen the supervision system at the district level. Specifically, the project facilitates the establishment of a supervision visit schedule from first line supervisors, and union level staff such as Health Inspectors (HI) and Family Planning Inspectors (FPI), to the community level services provided by FWAs. The project also facilitates developing supervision plans for second line supervisors, from upazila level staff such as civil surgeon, DDFP, and MOCS to UH&FWCs. The facilitation includes developing monthly visit plans, jointsupervisory visits (JSV) and ensuring the effectiveness of the supervisory visits through applying the concepts of supportive supervision where the supervisor plays a role in mentoring, capacity building, problem solving, and quality improvement. Supervisory visits are taking place using structured supervisory checklists in areas including: infection prevention measures, service delivery management, ANC, nutrition, FP, newborn and child health, IMCI, normal vaginal delivery, and postnatal care. The facilitation of the project ensures that each supervisory visit identifies gaps and action plans for improvement.

The table below includes the number of supervisory visits planned and conducted by district in this quarter:

Table 6: JSVs conducted between April-June 2016

Districts 1st Line (Union) 2nd Line (Upazila/District) Planned Accomplished Planned Accomplished Habiganj 36 41 48 34 Jhalokathi 16 16 08 06 Lakhsmipur 30 30 15 10 Noakhali 19 14 08 12 Total 101 101 79 62

22 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 Table 7: Example of Common Findings of JSV checklists, Lakhsmipur District

JSV Findings Action Plan Developed During BCG period, ensure birth registration of Newborn birth registration not completed. newborn. Citizen Charter will be ensured by communicating Citizen Charter not found, FWC Management UFPO. Need to organize FWC Management Committee Committee meetings are not held regularly. in due time. The Facility has no color coded bins for medical Shared with UP chairman to ensure three color coded waste management. bins. FWA register were not available in cMPM. Ensure FWA register at cMPM. Ensure misoprostol tab at pregnancy period and find No supply of misoprostol tablets. out the root cause of the stock-out. DDS kits are not available. Ensure DDS kits and other essential drug items. BCC materials are not used in service centre Ensure BCC materials for use in service centre during during counselling. counselling. The facility has no regular medicine supply for the Shared with DDFP and UFPO to ensure medicine last 4 months. supply regularly. UH&FWC Performance board was not up to date. Shared with FPI & UFPO for updating performance board. There is no infection prevention logistics, such as Shared with UP chairman to ensure the supply of chlorine solution. infection prevention logistics.

Photo 10: DDFP 2nd line JSV to a satellite clinic, Rampur Union, Companyganj Upazila, Noakhali District.

2.5 Maternal and Perinatal Death Review (MPDR): MPDR is one of the interventions endorsed by the MoH&FW for implementation at a national scale to cover all districts. The objectives are to reduce maternal deaths, newborn deaths, and improve stillbirth notification, map out death incidences to identify unions with high numbers of deaths, conduct analysis of the causes and circumstances associated with mortality and use information to take action to avoid future mortality. MaMoni HSS is assisting the MoH&FW in scaling up MPDR in one full district (NK) and initiate implementation

Figure 10: Begumganj Upazilla, Noakhali District, mapping of maternal, newborn mortality, and MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 23 stillbirth, by Union from April 2015 to February 2016. Maternal Death = 12; Newborn Death = 95; Stillbirth = 56 in three other districts (Hg, Lp, JK). During the reporting quarter, the project has scaled up the implementation of MPDR in three additional upazilas in NK district (Companiganj, Senbagh, and Hatiya). In addition, the project has supported the implementation of MPDR in Nabiganj uUpazila of Hg, of Lp, and in Rajapur upazila of Jk. The operational guidelines for implementing MPDR have been finalized and the data collection Excel file has been developed to enable the district level staff to record and map mortality data.

Table 8: Capacity Building in MPDR during the reporting quarter:

Training of the Trainers (TOT) : TOT on Facility Death Review (FDR) was conducted in Jhalokathi. During these TOT, 18 (13 Male and 5 Female) master trainers were developed. And in Habiganj, 14 personnel (11 Male and 03 Female) were trained on Social Autopsy (SA) as a follow-on activity of MPDR, technically supported by CIPRB.

Training of GOB staff: As follow-on activities in Habiganj, the master trainers that are developed during the TOT act as facilitators for next stage field level training on Death Notification (DN), Verbal Autopsy (VA), Social Autopsy (SA) and Facility Death Review (FDR). Those master trainers trained 175 GOB, project & other NGO staff on Death Notification, Verbal & Social Autopsy and Facility Death Review (FDR) by batches.

Preliminary results for neonatal data collected between April and September, 2015 (6 months) revealed that place of delivery for most of the neonatal deaths was home (43.9%), NGO/private hospital (34.1%) and the place of death was NGO/private hospital (34.1%), home (22%). Governmental health facilities (District Hospital, UHC, UH&FWC) were the place of delivery and death for 19.5% of cases. The analysis from 12 neonatal death verbal autopsies is summarized in the graph below.

Figure 11: Analysis of verbal autopsy of 12 neonatal deaths

Figure 12: Analysis of verbal autopsy of 12 neonatal deaths: mode of delivery and the neonates weight at birth

24 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3

Figure 13: Analysis of verbal autopsy of 12 neonatal deaths: complications that took place to the mother and the neonates before the neonatal deaths

Photo 11: Social Autopsy conducted at the community level around a maternal death, Kutubpur Union, , Noakhali district.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 25 2.6 Standards-based Management and Recognition (SBM-R): The project continued the implementation of different steps of SBM-R implementation, as per workplan, in 35 health facilities in Hg, Nk, LP, Jk districts. This quarter, external assessment has been completed in 8 and 7 facilities in Lk and Nk districts respectively. As mentioned above, the project conducted a recognition event in Hg district for three health facilities (Murakuri, Shibpasha, and MCWC). The three health facilities were selected as they were able to achieve a total score above 70% of SBM-R standards as documented by the external assessment conducted in the health facilities. The graphs below summarize the progress in improving compliance with standards of services for birth spacing and family planning, ANC, normal vaginal delivery, and infection prevention and facility management, in the three recognized facilities.

The following table summarizes the overall implementation of SBM-R and the expected time frame for completing all SBM-R steps in 35 facilities implementing SBM-R in four districts. Implementation of SBM-R will continue in these facilities, along with other initiatives to strengthen QI under the national QI strategic framework.

Table 9: Cumulative number of facilities completing SBM-R steps and time frame for completion

District SBM-R Implementation Steps Baseline 1st Internal 2nd Internal External Recognition Assessment Assessment Assessment Habiganj 12 12 12 5 (7 facilities 3 planned next quarter) Noakhali 7 7 7 4 (3 facilities Yr4 Q1 planned next quarter) Lakhsmipur 8 8 8 5 (3 facilities Yr4 Q1 planned next quarter) Jhalokathi 8 8 Yr3 Q4 Yr4 Q1 Yr4 Q3

2.7 Establishing and supporting Regional Roaming Quality Improvement Team (RRQIT) to strengthen comprehensive emergency obstetric and newborn care RRQITs are considering specialized supervision teams to assess and improve the CEmONC services. The project continues to utilize the technical capacities available at the regional level, such as medical colleges and professional associations, to provide specialized technical support, through RRQIT, for improving CEmONC services. The project had developed RRQIT, in line with the national strategy for developing divisional quality improvement teams, in Sylhet and Barisal. Both teams had visited respective districts (Hg, Jk) and developed action plans for improvement of CEmONC services as well as general management of district hospitals and MCWCs.

To date, the project has formed RRQITs in Sylhet, Barisal, and Chittagong divisions. The Sylhet RRQIT conducted two visits to the Habiganj DH. The Barisal RRQIT visited Jhalokathi DH twice. The second RRQIT visits to Habiganj and Jhalokathi were held during the reporting quarter (May 2016). Plans are underway for the Chittagong RRQIT to visit Lakhsmipur and Noakhali.

26 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 In addition, the project followed up on the implementation of the findings and action plan developed based on the visit conducted by the Sylhet RRQIT to Habiganj district and the Barisal RRQIT to Jhalokathi district. The following table summarizes the action taken for improvement based on the RRQIT findings.

Table 10: Summary of RRQIT follow up findings and changes observed between the first and second visits to Jhalokathi and Habiganj district hospitals

Subject Positive Changes/ Area to Improve Comments/ observations suggestions

Jhalokathi District Hospital Infection Color coded medical waste Need dumping pits for Discuss in the QI prevention management bins in place waste disposal Committee & Zila parishad Human resource Anesthetist has joined Need regular monitoring management 4 cleaners have been provided from municipality Infrastructural Declared as 100-bedded Supplies are in-adequate Need national level Instruments hospital to increase allocation considering patient load. advocacy to increase Logistics supplies of supplies Additional needs include: allocation of supplies. . GA machine in OT, Phototherapy machine, Radiant warmer & incubator in neonatal ward, autoclave in labor room & X ray machine. Record keeping, As a tertiary facility, record Patient diagnosis & Need orientation on reporting keeping & reporting system is management information record keeping & not satisfactory should be improved for reporting. detail reporting Referral Good referral linkage & Downward linkage can be management improved QI committees Formed & started addressing Need regular meetings general cleanliness & Should address all infection prevention aspects of quality 24/7 service delivery. Habiganj District Hospital Infection Color coded bins are in place Discuss in the QI prevention & dumping pits for waste Committee & Zila disposal are arranged. parishad Cleaners wear protective cloths/ gloves/boots Human resource 2 more doctors joined. For No Anesthesiologist Advocate at national management emergency management of available. 2 RMO trained level to get the the hospital activity, Doctors in Anesthesia provide needed specialists. from union level and other Anesthesia during Upazila are placed at DH by operation. local/verbal order. One Junior Vacant post for Nurse Consultant (OB) joined. need to be filled immediately. Instruments All 5 GA machine in OT are 2 OT lights are needed. Engage local repaired. Autoclave machine needs government to 2 X-ray machine is functioning to be available at labor provided needed after repair from Dhaka. room. instruments.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 27 USG machine was taken to Dhaka for repair. Radiant warmer now functioning. SCANU service started operation. Logistics supplies 2 delivery tables of iron made It will be possible to are ensured. ensure the availability of For Pediatric ward, hand beds for every patient washing basin and hand when it will start its sanitizer/soap are ensured. activity as a 250 bed Medical College Hospital which is under process. Record keeping, Different service registers are History sheet/treatment Ensure regular reporting available and record keeping sheet are not properly monitoring is done for indoor patients of filled in indoor and record Pediatric and Gynecology keeping is not properly wards. done due to overburden of patients. Referral Patients are referred to As the anestheologist, SOMCH with proper OBG consultant and documents and after proper Pediatrician are not counseling. The patients who available for ensuring are referred to DH receive 24/7 emergency service, immediate medical service many patients are because of MaMoni HSS referred to SOMCH who facilitation. got admitted to DH after 2:30 pm. QI committees Formed & following RRQIT Need regular meetings action plan, addressing Should address quality general cleanliness & IP service delivery for 24/7 CEmONC

2.7 Strengthening Logistics MIS National level activities 2.7.1 Coordination with SIAPS at the national level: MaMoni HSS project collaborated with SIAPS in conducting national level dissemination of results of district level assessments conducted jointly in Lakhsmipur district under the title: “District Level Assessment of Pharmaceutical Management of Life- saving Commodities” and discussion on “Introduction of e Logistics Management Systems (e-LMIS) for priority MNCH Photo 12: Introduction of e-LMIS for priority MNCH commodities under DGHS”. The meeting commodities under DGHS – April 4, 2016, MIS took place on April 4, 2016 at MIS Conference Room, DGHS. conference room, DGHS. The meeting was chaired by Professor Abul Kalam Azad, ADG (Planning and Development) and

Director of MIS, DGHS, Chairperson of Technical Working Group (TWG) for logistics reporting and tracking systems for MNCH priority commodities, and M. Shahidullah,

28 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 Professor of Neonatology, BSMMU, Chairperson of the National Technical Working Group (NTWG) for Newborn (NB). Participants included the Director of Primary Health Care, a representative from USAID, and other development partners. Recommendations included dissemination of the maternal and newborn health Standard Operating Procedure (SOP)s at all levels of the system, improving the capacity of staff at the local level in pharmaceutical management including procurement, distribution and logistics management, strengthening pharmaceutical information systems to provide the data needed for forecasting and supply planning, documentation of the expiry dates, and provide facilities with the infrastructure necessary to maintain cold chain storage conditions (oxytocin). The project continued its coordination with SIAPS to scale up the national Uniform LMIS for DGHS stores. MaMoni HSS is taking the lead in introducing the Uniform LMIS ledgers in Noakhali, Habiganj, and Jhalokathi districts. The system has already been introduced in Lakhsmipur district. Scale up activities include printing and distribution of the Uniform ledgers and guidelines, training of store keepers and district managers, and follow up to support implementation. In addition, the project is supporting the implementation of the automated version of the Uniform LMIS (known as E-LMIS) in Lakhsmipur district. The project conducted an assessment of the obstacles to the automated reporting of logistics data in Lakhsmipur and shared information with SIAPS.

Coordination with National Warehouse for Family Planning on essential drugs and commodities distribution to MaMoni HSS districts: The project conducted several visits to the national warehouse for DGFP and had discussions with the Additional Director, National Warehouse (Family Planning). The purpose of the visits were to

follow up on the distribution of misoprostol Photo 13: Review of Misoprostol Stock Level at tablets and Micro life blood pressure National DGFP Warehouse, May 25, 2016 machine for facilitating diagnosis of pre-

eclampsia and eclampsia by services providers. The visit facilitated the release of the Micro life blood pressure machines to project districts. The visit also revealed the presence of large quantities of misoprostol at the national level. 742,644 tablets were at the national store that were procured in June 2015, manufacturing date was May 2015 and expiration date is April 2017. The project facilitated the release of the stored misoprostol tables to the project covered upazilas.

On June 13, 2016, the project participated in a meeting organized jointly by DGFP and DGHS on the community distribution of misoprostol tablets. The meeting was chaired by the Director of MCH and attended by several development partners. The meeting discussed challenges in the availability and distribution of misoprostol, particularly the expiration of a lot of tablets currently at upazila stores on May 31, 2016. Participants recommended issuing a circular to the upazilas to collect the expired tablets and appropriately destroy them in the presence of the upazila committee. In addition, the new supply of misoprostol tablets will subsequently be distributed to the field.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 29 2.7.2 Monitoring and improving availability of essential drugs at district level The project continued supporting the district and sub-district managers in monitoring the availability of 25 essential drugs for MNCH programs as well as essential FP commodities. Data are shared with local counterparts in a simple color coded dashboard with red indicating stock-outs and green indicating item availability (see examples below). Please see Annex 4 for more results. Case Study: Examples of Utilization of Data for Minimizing Stock-out of Essential Drugs

• MaMoni contribution on moving misoprostol from national to district level: The project coordinated with the national level DGFP store to expedite the distribution of misoprostol tablets from the national level to MaMoni districts where there were a need for the tablets. • Re-distributing of chlorhexidine from Civil Surgeon Store to DGFP centers, Lakhsmipur district: The project coordinated the re-distribution of 14,000 units of chlorhexidine 7.1% solution from the Civil Surgeon store at Lp district to the DFGP stores in five uUpazilas (Sadar, Raipur, Ramganj, Ramgoti, and Kamal Nagar) where it was in shortage. 5,500 units were subsequently distributed to MaMoni HSS 24/7 facilities. • Re-distribution of misoprostol from DGHS to DGFP facilities, Habiganj district: Data revealed the stock-out of misoprostol at DGFP stores, yet DGHS store had 5,000 tablets in stock. The project facilitated coordination between DGFP and DGHS and succeeded in transferring 2,790 tablets to 8 DGFP upazila stores for immediate distribution to 24/7 UH&FWCs. • Initiating local procurement of gentamycin and re-distribution of stock near expiration, Jhlokathi district: Using the color coded dashboard to monitor availability and expiration date of essential drugs revealed that the gentamycin Inj. stock at Jhalokathi district is nearing expiration. Action was taken to expedite the distribution of the stock to service delivery point before expiration and to procure new stock locally.

2.8 Collaboration with Private Hospitals for Quality Improvement of Maternal and Newborn Services: MaMoni HSS supported the Civil Surgeon offices to collect reports from private clinics. According to the agreement, only MCH data were collected and integrated into the reporting mechanism of the DGHS system. Table 11 shows the performance reported by the private clinics. In the subsequent discussions, MaMoni HSS is also negotiating to collect information on postpartum tubectomy operations.

A rudimentary analysis uncovered that the admission data did not match the service data. C-section is also unusually high, in keeping with the national trend.

Table 11: Performance reported by the private clinics in three MaMoni HSS districts

Norm Mater Neona Admi al C- Live Still nal Referr District Month Total tal ssion delive Section birth birth Death al out death ry s April'16 266 17 187 204 204 0 0 0 8 Jhalokath May'16 357 67 252 319 319 0 3 0 12 i June'16 256 35 214 249 248 1 0 0 7 April'16 710 231 637 868 771 25 13 0 15 May'16 558 237 550 787 693 9 4 0 0 Noakhali June'16 510 247 533 780 717 13 2 0 13 Habiganj April'16 Not 22 208 Not collected/reported

30 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 May'16 repor 20 225 ted June'16 26 221

2.9 Monitoring Quality of Care Indicators Preliminary results from the first round The project conducted preliminary analysis of the first round of the quality of care (QoC) survey conducted in four districts (Habiganj, Noakhali, Lakhsmipur, Jhalokathi). The survey included 10 sentinel sites in each district (1 DH, 1 UHC, 4 UH&FWC, and four satellite clinics). Data collection was performed by direct observation by trained surveyors. Highlights of the results of the first round of QoC are included below.

Table 12: Summary findings of QOC Survey • Preliminary results of assessing quality of ANC services show that, data from a total of 27 facilities in the 4 districts, Iron and Folic Acid tablets were available in 25 facilities (93%). Running water was available in 24/25 facilities (96%), soap for hand washing was available in 23/25 facilities (92%), and latex gloves were available in 25/24 facilities (96%). • Available results from Jhalokathi and Noakhali show that out of 14 facilities surveyed conducting normal vaginal deliveries, 10 (71%) had newborn resuscitation bag and mask, 12 (86 %) had resuscitation mask, and 11 (79%) had penguin sucker. • Out of a total of 26 facilities conducting normal vaginal deliveries surveyed in the four districts, 18 (69%) had partogragh paper and board, 11 (42%) had oxytocin injections, and 4 (15%) had magnesium sulfate 5 ml ampules. • Out of 122 deliveries observed in Lk district, all of them (100%) had oxytocin inj. administered within 1 minute of delivery and out of 172 deliveries observed in Jk district, due to shortage in stock, only 18% received oxytocin inj. within 1 minute of delivery. • Family planning data from Habiganj district shows that out of 272 clients, privacy was ensured in 13 cases (3%), client concerns where discussed in 56 cases (27%), a job aid was used with 142 clients (47%), and next date of visit was mentioned to 40 clients (15%).

2.10 Routine Health Information Systems (RHIS) Initiative

In Madhabpur upazila of Habiganj, the population registry system was completed in earlier quarters. Health ID Cards, with unique ID numbers and bar codes, were distributed in two unions (Bahara & Noapara). FWVs have reported receiving clients with Health ID cards in the facilities. The tablet‐based population registry survey is going on in Lakhai upazila. Fifty three GoB outreach workers (HA-23,FWA-30) were engaged in the PRS activity. From April 01, 2016 to June 25, 2016 they were able to visit 4,966 households and registered 27,245 members. The following chart shows the monthly service statistics in different unions of Madhabpur upazila. The data is now available for review in real time in the server, with the aim to lead to better supportive supervision and management as the program matures.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 31 Figure 14: Monthly Service Statistics using RHIS (June, 2016), by union, Madhabpur upazila, Habiganj 200

150

100

50 71 63 61 71 38 51 41 35 52 47 40 0

ANC PNC PNC-N Delivery

The e-Register for the general patient register is finalized will be field tested shortly. This e-Register combined the paper-based register for both SACMO (DGHS and DGFP) and FWV. TOT for FWA registers were completed in this quarter, the training will be rolled out in the final quarter of FY’16 The monitoring tool for the UH&FWC is under development. In the first phase, live data feed for MIS-3 from all 11 unions from Madhabpur uUpazila is enabled. The tool was demonstrated in the meeting with the officials from DGHS and DGFP and the USAID review meeting. In the future, more qualitative indicators will be added. The RHIS team presented their experiences in the Measurement and Accountability for Health (MA4 Health) Conference in Dhaka in April 2016. The development team presented the system in the Marketplace to the local and international visitors. After the conference, visitors from different countries visited Habiganj to observe the field level activities at RHIS piloting areas.

Photo 14: MaMoni HSS showcased their activities in MA4H conference stall

IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems 3.1 Journalist Engagement In this quarter, MaMoni HSS organized a number of journalist visits in different locations of its project area with a special focus to ensure optimum media coverage on Safe Motherhood Day. As a result of broader MaMoni HSS media advocacy, about 25 news stories were published by different media outlets. The news stories included issue- specific current situation, case studies, technical information with a call of action for required health systems improvement. Following the initial journalist training, a long-term follow up activity has been established to ensure that the trained journalist group put into practice what they have

32 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 learned through this training. The reporters are well connected with local project office personnel who always help them to improve reporting and troubleshoot ideas.

The media engagement and capacity building program has resulted in a significant increase in media coverage on MNCHFPN issues and increased engagement of involved stakeholders. Representatives from the multiple government ministries/directorates, and non-governmental partners have been deeply involved in the program. This contributes immensely to facilitating closer collaborations across organizations and resulted in both increased dialogue and news coverage. Please refer to Annex 6 for published stories.

3.1.1 Observation of Safe Motherhood Day on May 28, 2016 MaMoni HSS conducted a community based review to identify causes of maternal deaths in their project districts. To mark the Safe Motherhood Day, MaMoni HSS deployed its volunteers and workers to go house to house and identify mothers who died in the last 12 months (May 2015-April 2016). In the month of May, MaMoni staff, government officials and local elected representatives jointly visited the household of every mother who was lost. The team expressed their sympathy to the family, and also discussed how the death could have been prevented. The findings were then shared at district level meetings in Habiganj, Noakhali, Lakhsmipur and Jhalokathi to sensitize the different stakeholders. Each project district also organized a seminar on Safe Motherhood Day (SMD) in collaboration with the civil surgeon and District Family Planning Office. Participants from different backgrounds attended the seminar and created a scope of mutual sharing and understanding. At the end of the seminar, the participants came to a consensus that PPH along with the other causes of maternal death is preventable. Everyone also stressed that we can change the scenario of maternal death through our sincere effort and determination.

The participants profile of the seminar included; Health and Family Planning officials, medical professionals, Social Welfare, Youths & Sports officials, Women’s Affairs officials, local government, NGOs, journalists, local elites, etc.

During the seminars, the following suggestions and recommendations were made:

1. Every pregnancy/pregnant-mother needs to be considered as potentially at risk 2. All SBAs need to be more focus on counselling the mother and the family 3. Health and Family Planning staff, as well as MaMoni volunteers/staff are asked to refer pregnant mothers with the complaint of swelling leg(s) to nearby Health Complex. Recognition of high performance of 24/7 facilities for conducting normal vaginal delivery at union level The MaMoni HSS project areas have a successful model of engaging UP at union level maternal and neonatal health services, which has been contributing in achieving number four and five of Millennium Development Goals. The Project in collaboration with the Health & Family Planning department took initiatives to recognize high performing 24/7 facilities for conducting normal vaginal delivery at union level, aimed at influencing the service provider to increase safe normal delivery with high quality at union level facilities. The event involved participation of local people and leaders to

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 33 build awareness among community members seeking health and family planning services. Through the event the Union Parishads were also recognized for their involvement. The recognition consisted of the following activities: • ANC campaign • BCC Video Show • Discussion session • Souvenir crest handover • Sapling distribution.

3.2 Program learning initiatives undertaken and disseminated Program learning initiative on CHX in community- A program learning initiative was undertaken to understand the TBA’s role in the 7.1% chlorhexidine for newborn cord care scale-up process. A qualitative exploratory study was conducted to assess the role of TBAs as well as depot holders in CHX distribution at Bahubal, Habiganj. It was found that the TBAs who received orientation on chlorhexidine continued to encouraged families to purchase chlorhexidine and applied them on the umbilical cord.

Advocacy meeting with CCSDP, DGFP- MaMoni HSS supported an advocacy meeting with DGFP on June 2nd, with participation of major stakeholders as EngenderHealth, Marie Stopes International, BRAC, RTM, SMC, and Population Council. CCSDP organized the workshop. Line directors of MIS, field service unit, IEM were present at the workshop. Workshops were chaired by the Line Director of CCSDP and Director General of Family Planning were present as the chief guests.

Findings from operations research on the permanent method of family planning completed by MaMoni HSS in last quarter had been presented at the meeting. The main objective of the workshop was to include the issues from the OR findings in the planning of CCSDP, as well as respective units of DGFP for enhancing the quality of permanent method services of family planning in the near future.

Development of two research briefs- The MaMoni HSS team has developed two research briefs from two completed operations research projects on partograph use, and pCSBA services. The briefs are currently being reviewed prior to publication. These materials would be useful to advocate to the stakeholders on these issues.

Workshop on documentation and program learning- The project organized a workshop for planning program learning initiatives and documentation areas for the next year in June. A four-day workshop included all technical leads of MaMoni HSS and icddr,b as the technical partner to decide how to initiate these activities. A series of follow-up initiatives was determined from this workshop around the documentation of project interventions and learnings.

Development of concept papers- The project has assisted the JHU team to develop an IRB proposal for documentation of national scale-up of CHX and follow-up study on income viability of private CSBA. Both of the proposals are now ready for submissionfor ethics review through JHU.

34 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3

IR 4. Identify and Reduce Barriers to Accessing Health Services

4.1 Community mobilization and BCC activities to remove barriers MaMoni HSS facilitated the monthly cMPM meetings involving community volunteers (CVs), frontline health workers (Health Assistants, FWAs, CHCP), and their supervisors (FPIs; AHIs), to update the information on eligible couples, mothers, and children, and to follow up on drop-outs. During April-June 2016, 97% of the cMPMs were held in 23 high-intensity upazilas. The project supported BCC teams to conduct targeted BCC campaigns on prioritized MNCH/FP/N messages, reaching 17,036 people, which was lower than previous quarters because of Ramadhan. These campaigns delivered a number of BCC messages through video shows and courtyard meetings.

4.2 Reaching mothers through Aponjon services Subscriber acquisition was higher in this quarter compared to the previous quarter. A new agency, Spectrum, was hired, and contributed to acquisition from June 2016, boosting the subscriber base by 4% of average monthly acquisition. Cumulative count of subscribers stands at 15,76,593 on 15th June 2016.

Figure 15: Monthly Client acquisition by Aponjon

21800

7763 4632

April May June (Upto 15th)

Aponjon call center handled 2,799 subscriber queries on various purposes and helped 103 mothers to update the date of birth of their babies. The agreement with the call center has been extended up to September 2016.

Figure 16: Call Center Activities of Aponjon

4346 3597

2134 2158 1182 1560 1139 928 478 48 38 17 0 0 0

Call from subscriber Incoming call Outgoing call DOB update Data Entry

April May till 15th june

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 35 Aponjon counselling line answered a total of 5,618 medical queries during the third quarter. The agreement with the counseling line has been extended up to September 2016 as well.

Mobile Apps

Aponjon Shogorbha:

The android version of Aponjon Shogorbha app was already up in Play store during the previous quarter. The rest of the versions in Windows and IOS were made available in this quarter. All three versions of Aponjon Shogorbha, along with a new app for adolescents, was nationally launched in a launching event in the presence of the US Ambassador, Mrs. Marcia Stephens Bloom Bernicat, and Honorable State Minister for ICT, Zunaid Ahmed Palak. Aponjon Shogorbha app statistics of Android version is provided below:

Table 13: Status of downloads of Aponjon Shogorbho application

App statistics App installs Android Windows IOS April 1043 235 17 May 779 175 0 Till June 15th 630 76 0

Aponjon Koishor:

Aponjon Koishor is a novel mobile app in Bangla for adolescents that helps create awareness among adolescent boys and girls about physical and mental changes that they go through as well as about adolescent reproductive health. Both Android and Windows versions are available in the Play Store/App Store while the IOS version is yet to come. This app is not only for adolescents but their parents can also see by registering what information is being provided to the children from this app. Aponjon Koishor app statistics on Android and Windows versions is shown below.

Table 14: Status of download of Aponjon Kaishor application

App statistics App installs Android Windows iOS April 329 0 0 May 128 459 0 Till June 15th 2477 80 0

Dnet is introducing ‘Bridge’ to provide support on the technological platforms to fulfill internal as well as external demand. Aponjon is going to be a big beneficiary of this project in terms of reducing platform costs by about 90%. Hardware installation and quality assurance testing is done on Grameen Phone (GP) premises at Gazipur. Final integration with GP is under process and expected to be done in July 2016. Here is the

36 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 complete overview of the ‘Bridge’ project, integrated with GP initially. Other telecom operators will be reached in a similar process of integration one after another.

The first mobile apps in Bangla language, Aponjon Shogorbha and Aponjon Koishor were nationally launched in a prestigious ceremony.

Photo 15: US Ambassador Ms. Marcia Bernicat announcing the official launch of the two healthcare mobile apps

The launch of these two new applications has given additional mileage for Aponjon to reach new clients, who were not reached earlier. From the earlier experiences, it can be concluded that the uptake of the two applications is good. Aponjon hopes to be able to expand the service reach to a wide range of audiences in rural and urban areas in the coming years.

CHALLENGES, SOLUTIONS, AND ACTION TAKEN

Challenges • Drug shortage: The DDS kits of UH&FWCs and the drug supply of the Community Clinics have been interrupted since September 2015 due to procurement issues at DGHS and DGFP. This has severely affected the coverage and quality of essential services at the community level. MaMoni HSS has been closely monitoring the situation, and where appropriate, has been liaising with the Union Parishads, and Ministry of Social Welfare funds to leverage temporary support to meet the shortfall for drugs and supplements such as oxytocin, IFA, and misoprostol. • Union Parishad election: Several rounds of UP elections were held this quarter. Local government funds were not available because of this.

Way Forward • In the upcoming quarter, the focus of the project will be on consolidating implementation components as per the recommendation of the MaMoni mid-term evaluation.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 37 • Active engagement with the Planning Wing, Program Preparation Team, PMMU and Line Directors to contribute the development of OPs and PIP for the fourth sector program. The project will also provide operational and administrative support to the PMMU. • MaMoni HSS will organize a high level advocacy meeting and national dissemination meeting on the assessment findings of UH&FWC strengthening at divisional levels. The final report and directory of UH&FWCs will be published. • MaMoni will work with HRMU, WHO and a national consultant agency to conduct an assessment of workload of all levels of workers at district level and below in a few select districts. • MaMoni will provide technical and managerial support to the Quality Improvement Secretariat. This includes deployment of a Senior QI consultant and a National consultant at the national level. The project will support a national level training of a national resource pool on QI. Additional administrative support to the QIS is planned. • The expansion of RHIS to the entire district of Habiganj will be initiated in the next quarter. The PRS and deployment of community health worker modules and MNH modules will start in three additional upazilas by the end of next quarter. • MaMoni will introduce unified LMIS in all high intensity upazilas.

38 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 APPENDIX 1: SCOPE AND GEOGRAPHICAL COVERAGE OF MAMONI HSS PROJECT

The project objective is well aligned with the GoB’s Health, Population, and Nutrition Sector Development Program (HPNSDP) for 2011–2016; and also directly supports the USAID/Bangladesh Development Objective 3 (DO 3: “Health Status Improved”), which is under the “Investing in People” objective of the Country Development Cooperation Strategy (CDCS) framework of USAID in Bangladesh.

MaMoni HSS designed a two-pronged approach in which districts and upazilas were categorized into one of two groups—high-intensity intervention areas and health system capacity strengthening areas. The aim of the high-intensity areas is to demonstrate best-practice models of MNCH/FP/N health care delivery through intensive support to the Government of Bangladesh (GoB), and if needed, direct implementation to maximize learning and advocacy for scale-up nationally. Based on an analysis of gaps in coverage and equity of access to high-impact MNCH/FP/N services, the project identified a total of 23 upazilas across five districts to serve as the project’s high-intensity areas. Of the 23 upazilas, district saturation was Figure 17: MaMoni geographical scope achieved in Habiganj, Lakhsmipur, and Jhalokathi districts, while in the Noakhali and Pirozpur districts, four and two upazilas were supported, respectively. The health systems (HS) capacity strengthening areas cover a total of 17 upazilas—all seven upazilas of Bhola, five upazilas of Noakhali, and five upazilas of Pirozepur (refer to Figure 1 and Table 1). Whereas the high-intensity areas focus on support for a complete package of MNCH/FP/N interventions, the HS capacity strengthening areas receive less intensive technical assistance on a selected set of interventions. Minimal support was provided to GoB health systems to scale up interventions such as 24/7 Union Health and Family Welfare Centers (UH&FWCs), chlorhexidine for cord care, and Helping Babies Breathe (HBB); instead, the focus was on supporting the strengthening of existing MNCH/FP/N services. MaMoni HSS has four intermediate results (IR): IR 1. Improve service readiness through critical gap management. IR 2. Strengthen health systems at district level and below. IR 3. Promote an enabling environment to strengthen health systems at the district level. IR 4. Identify and reduce barriers to accessing health services.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 39 Table 15. Summary of MaMoni HSS geographic scope

No. of Health Facilities Population No. of No. of Area (2015 Upazilas Unions District projection) Upazila Union Community (MCWC)

High- Intensity 23 26 7,355,822 5 20 208 619 Areas

Health Systems CB 17 151 4,870,933 5 13 121 488 Area

Total 40 377 12,226,755 10 33 329 1,107

Notes: (Community-Based), (Maternal and Child Welfare Center)

40 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 APPENDIX 2: CASE STUDIES

A.1.1. Sulata Rani of Kathalia upazila of Jhalokathi accepts PPIUCD after repeat counseling Sulata Rani, 28, was pregnant for a third time. She lives with her husband, Swapan Sikder, 48, in the Chechrirampur village of Kathalia sub-district, Jhalokathi. Her first two children were born at home, as the UH&FWC was around four kilometers away, and requires a boat ride. When she was around seven months pregnant, she received a visit from the paramedic of the union, and a MaMoni volunteer. She learned Photo 16: Sulata Rani about the benefits of a facility delivery, and the importance of after receiving PPIUCD postpartum family planning. The paramedic, Nazma, insertion continued to talk to her by phone regularly during the rest of

her pregnancy. Sulata decided to take a boat to deliver her third baby at the UH&FWC on May 15, 2016. She also consented to use an IUCD just after delivery. She was provided an IUCD 10 minutes after birth. It was so comfortable, upon discharge, she mentioned that she didn’t feel anything. She hopes to now focus on raising her three children rather than worrying about another pregnancy. MaMoni HSS has been actively promoting postpartum family planning through the volunteers. MaMoni is trying to ensure that in the 58 UH&FWC, where round the clock delivery services are available, PPIUCD services and logistics are also available. Although, nationally IUCD is the least popular method, initial trends in MaMoni districts are encouraging, and point to an opportunity to avoid unplanned pregnancy.

A.1.2 SAM baby treated in Ramganj, Lakhsmipur after community identification and referral Shahnaz is a two year old baby girl from Ramganj sub-district of Lakhsmipur. She was born at home as the third child of Jesmin and Shafiq. Shafiq is a teacher, and did not allow his wife to receive antenatal care for any of their children. Just seven days after birth, Shahnaz contracted pneumonia, and has been sick on and off since then. After hearing about nutrition services in Ramganj UHC from their nearby community clinic, the parents brought their daughter in as a last resort. They were pleasantly surprised by the

Photo 17: SAM baby in Ramganj UHC, treatment offered there. Lakshmipur MaMoni HSS introduced SAM services in Ramganj UHC in September 2015. Two doctors and two nurses were trained. Two beds are allocated for SAM, and a separate examination room has been set up with digital weighing machine, room heater and supply of therapeutic foods such as F100 and F75 . After sensitizing community level providers and supervisors in March 2016, 13 babies were referred to this UHC, and were successfully treated. The doctors are hopeful that by detecting and managing more children like Shahnaz, they will be able to decrease malnutrition significantly in their upazila.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 41

A.1.3. Initiative of Government staff in promoting services via social media Atiqur Rahman is a young Family Planning Inspector in charge of Bamoi union of Lakhai upazila, Habiganj. He started a social media movement by opening a Facebook group where he uploads the photos of the union activities, meeting minutes, and visit findings. Currently 800 people subscribe to this page, and follow the union activities daily, including government workers, local government members, NGO partners and young people of Lakhai. Because of this forum, it has been easier for him to mobilize support for his union. After posting the challenges experienced by the satellite clinic, and online discussion and subsequent meetings, DDFP provided additional support for an additional four satellite clinics, doubling the coverage of the union. Because of his leadership, average monthly ANC contacts increased from 130 in 2013 to 218 in 2016, and average monthly facility delivery increased from 8 to 30. Bamoi union’s Facebook Page can be found in the following link: http://www.facebook.com/groups/1493529710970553

42 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 APPENDIX 3: PROGRAM PERFORMANCE INDICATORS (OCTOBER–JUNE 2016) Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) Project Goal: Improve utilization of integrated maternal, newborn, child health, family planning and nutrition services Percent of women received at least one antenatal care visit from a medically Source: Tracer surveys trained provider High intensity areas

Lakhsmipur 67 NA 71 NA Noakhali* 61 NA 66 NA Habiganj 66 NA 81 NA Jhalokathi 69 NA 74 NA Pirozepur* 67 NA 75 NA HSCS areas

Pirozepur 63 NA NA NA

Bhola 51 NA NA NA

Noakhali 60 NA NA NA

Percent of births receiving at least four antenatal care (ANC) visits during Source: Tracer surveys pregnancy High intensity areas

Lakhsmipur 24 NA 21 NA Noakhali* 24 NA 23 NA Habiganj 25 NA 39 NA Jhalokathi 48 NA 39 NA Pirozepur* 35 NA 38 NA HSCS areas

Pirozepur 43 NA NA NA

Bhola 22.5 NA NA NA

Noakhali 20 NA NA NA

Percent of Births Attended by a Skilled Doctor, Nurse or Midwife Source: Tracer surveys High intensity area

Lakhsmipur 42.0 NA 37 NA Noakhali* 36 NA 35 NA Habiganj 37.0 NA 32 NA Jhalokathi 50.0 NA 51 NA Pirozepur* 48 NA 51 NA HSCS areas

Pirozepur 48.5 NA NA NA

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 43 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) Bhola 29 NA NA NA

Noakhali 37 NA NA NA

Percent of women with home births who consumed misoprostol to prevent Source: Tracer surveys postpartum hemorrhage High intensity areas

Lakhsmipur 25 NA 8 NA Noakhali* 25 NA 10 NA Habiganj 46 NA 33 NA Jhalokathi 52 NA 11 NA Pirozepur* 42 NA 22 NA HSCS areas

Pirozepur 30.5 NA NA NA

Bhola 23 NA NA NA

Noakhali 18 NA NA NA

Percent of newborns initiated breastfeeding within one hour after birth Source: Tracer surveys High intensity areas

Lakhsmipur 73 NA 48 NA Noakhali* 70 NA 64 NA Habiganj 85 NA 79 NA Jhalokathi 65 NA 42 NA Pirozepur* 60 NA 41 NA HSCS areas

Pirozepur 56 NA NA NA

Bhola 68 NA NA NA

Noakhali 75 NA NA NA

Percent of newborns received chlorhexidine application on their umbilical cord Source: Tracer surveys immediately following birth High intensity areas

Lakhsmipur 40 NA 1 NA Noakhali* 40 NA 1 NA Habiganj 40 NA 4 NA Jhalokathi 40 NA 1 NA Pirozepur* 40 NA 2 NA HSCS areas

Pirozepur NA NA NA NA - Bhola NA NA NA NA - Noakhali NA NA NA NA - Percent of newborns receiving postnatal health check within two days of birth Source: Tracer surveys

44 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) High intensity areas

Lakhsmipur: 19 NA 7 NA Noakhali:* 19 NA 11 NA Habiganj: 31 NA 19 NA Jhalokathi: 32.0 NA 39 NA Pirozepur:* 15.0 NA 34 NA HSCS areas

Pirozepur: 9 NA NA NA

Bhola: 9 NA NA NA

Noakhali: 19 NA NA NA

Modern contraceptive method prevalence rate Source: Tracer surveys High intensity areas

Lakhsmipur 53 NA 54 NA Noakhali* 51.5 NA 55 NA Habiganj 47 NA 45 NA Jhalokathi 57 NA 56 NA Pirozepur* 57 NA 53 NA HSCS areas

Pirozepur 54.5 NA NA NA

Bhola 57.5 NA NA NA

Noakhali 50 NA NA NA

Couple years of protection (CYP) Source: DGFP MIS Form 4 in USG-supported programs (accessed online) High intensity areas 748,496 133,134 116,634 116,219

Lakhsmipur 229,858 38,062 35,890 35,119 * Reason for underperformance: Noakhali* 138,470 30,814 23,389 25,962 * Reliance on short term methods by clients, limited number of LAPM Habiganj 221,972 39,607 35,799 32,494 * camps due to lack of MO-MCH-FP Jhalokathi 107,178 15,728 13,669 14,638 * positions Pirozepur* 51,018 8,924 7,887 8,006 * HSCS areas 106,936 99,964 97,840 Pirozepur 20,744 18,326 18,684 Bhola 59,242 57,164 55,642

Noakhali 26,950 24,474 23,515

Source: SDP assessment and Percent of targeted facilities that are ready to provide essential newborn care training data High intensity areas NA

Lakhsmipur 35 NA 44 NA

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 45 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) Noakhali* 35 NA 35 NA Habiganj 85 NA 78 NA Jhalokathi 35 NA 59 NA Pirozepur* 35 NA 19 NA HSCS areas

Pirozepur 35 NA NA NA Source: SDP assessment and Bhola 35 NA NA NA training data (HI Upazilas only) Noakhali 40 NA NA NA Percentage of public health facilities with functional bags and masks (two neonatal

size mask) in the delivery room High intensity areas

Lakhsmipur 35 NA 66 NA Noakhali* 35 NA 75 NA Habiganj 35 NA 87 NA

Jhalokathi 35 NA 61 NA Pirozepur* 35 NA 63 NA HSCS areas

Pirozepur NA NA NA NA

Bhola 35 NA NA NA

Noakhali NA NA NA NA

Percent of USG-assisted service delivery sites providing family planning (FP) Source: SDP assessment and counselling and/or services training data High intensity areas

Lakhsmipur 85 NA 87 NA Noakhali* 85 NA 81 NA

Habiganj 99 NA 88 NA

Jhalokathi 85 NA 74 NA Pirozepur* 85 NA 100 NA HSCS areas

Pirozepur 10 NA NA

Bhola NA NA NA

Noakhali 15 NA NA

Number of targeted facilities ready to provide delivery services 24 hours a day, Source: SDP assessment and seven days a week (includes DH, MCWC, UHC and UH&FWC) training data High intensity areas NA NA

Lakhsmipur 25 NA 31 NA

Noakhali* 16 NA 18 NA

Habiganj 35 NA 36 NA

46 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) Jhalokathi 17 NA 16 NA Pirozepur* 2 NA 5 HSCS areas NA

Pirozepur 7 NA NA Bhola 30 NA NA

Noakhali 7 NA NA Sub-IR 1.1: Increase availability of health service providers Number of vacant positions filled by temporary non-GOB Paramedic, nurses health workers High intensity areas

Lakhsmipur 13 11 0 7 Noakhali* 17 20 0 3 Habiganj 43 54 42 45 Jhalokathi 16 4 0 5 Reason for variation: Provided Pirozepur* NA NA NA 0 according to government consultation HSCS areas

Pirozepur NA NA Bhola NA NA Noakhali NA NA

Sub-IR 1.2: Strengthen capacity of service providers to provide quality services Number of people trained in maternal/newborn health 82090 * Source: Project MIS through USG-supported programs High intensity areas 1906 349

Lakhsmipur NA 404 81 Women 215 53

Men 189 28

Noakhali* NA 483 179 Women 285 125

Men 198 54 Reason for variation: Training Habiganj NA 135 334 41 conducted in scale up areas Women 51 186 31

Men 84 148 10

Jhalokathi NA 164 45 Women 68 29

Men 96 16

Pirozepur* NA 720 15

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 47 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) Women 441 7

Men 279 8

National level NA 17070 22073 18698 trained on CHX HSCS areas 665 616

Pirozepur 255

Women 158 Men 97 Bhola NA 665 361 Women 320 199

Men 345 162

Noakhali 0 Number of people trained in Source: Project MIS FP/RH with USG funds High intensity areas 5,589 NA 277 216 * Lakhsmipur 0 55 23 Women 55 7

Men 0 16

Noakhali* 0 115 17 Women 104 3

Men 11 14

Habiganj 0 107 172 Women 107 131

Men 0 41 Reason for variation: Need for Jhalokathi 0 4 additional training reassessed Women 0

Men 4

Pirozepur*

Women

Men

National level NA 8

HSCS areas NA NA 0 Pirozepur NA

Bhola NA

Women

Men

Noakhali NA

Number of people trained in child health and nutrition Source: Project MIS through USG-supported programs

48 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) High intensity areas 760 0 356 949 On track

Lakhsmipur 120 58

Women 66 35

Men 54 23

Noakhali* 137

Women 78

Men 59

Habiganj 52 842

Women 27 645

Men 25 197

Jhalokathi 47 49

Women 29 33

Men 18 16

Pirozepur*

Women

Men

National level 25 0 21 18 HSCS areas NA 0 Pirozepur NA Bhola NA Noakhali 0

Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization Number of union level public Source: Monthly report from high health facilities that are ready to intensity upazilas provide normal delivery services High intensity areas 82 75 75 75 Lakhsmipur 26 16 16 16 Noakhali* 14 11 11 11

Habiganj 28 26 26 26 Jhalokathi 10 16 16 16 Pirozepur* 4 6 6 6 HSCS areas 0 0

Pirozepur 0 0 Bhola 0 0

Noakhali 0 0 Intermediate Result 2: Strengthen health systems at district level and below Number of district level quarterly performance review meeting held for data-driven Source: QPRM meeting minutes performance review and planning High intensity areas 24 5 6

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 49 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) Lakhsmipur 4 1 1 0

Noakhali* 4 1 1 0

Habiganj 4 1 1 0

Jhalokathi 4 1 1 0

Pirozepur* 4 1 1 0 Bhola NA 0 1 0 Intra partum still birth rate in project assisted facilities

Comment: Because of small <7/1,00 High intensity areas NA sample, quality of data may not 0 be representative <7/1,00 Lakhsmipur NA 10.4 4.5 0 <7/1,00 Noakhali* NA 4.6 4.9 0 <7/1,00 Habiganj NA 7.1 6.9 0 <7/1,00 Jhalokathi NA 2.7 2 0 <7/1,00 Pirozepur* NA NA NA 0 Sub-IR 2.1: Improve leadership and management at district level and below Number of GOB managers supported for leadership and management capacity

development NA NA NA Lakhsmipur 5

NA NA NA Noakhali 3 Not part of Year 3 activity plan NA NA NA Habiganj 8

NA NA Jhalokathi NA 5

NA NA Pirozepur NA 5

NA NA Bhola NA 3

Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs Number of upazilas with updated comprehensive annual Source: Project MIS

MNCH/FP/N plan High intensity areas 23 36 Lakhsmipur 5 0 5 NA Noakhali* 4 0 5 NA Habiganj 8 0 8 NA

50 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) Jhalokathi 4 0 4 NA Pirozepur* 2 0 7 NA Bhola NA 0 7 NA Sub-IR 2.3: Strengthen local management information systems Percentage of community micro planning units conducting monthly meeting Source: Project MIS High intensity area On track

Lakhsmipur 95 99 99 98

Noakhali* 95 99 99 100

Habiganj 100 100 100 99

Jhalokathi 95 99 96 99

Pirozepur* 95 81 83 83 Sub-IR 2.4: Establish quality assurance system at district level and below Percent of planned supervision visit conducted where a On track Source: Project MIS supervision tool was used and findings shared with providers High intensity areas 90 122 67 72

Lakhsmipur 90 47 60 73

Noakhali* 90 108 179 117

Habiganj 90 183 59 64

Jhalokathi 90 108 25 108

Pirozepur* 90 0 0 0 Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below Percent of USG-assisted service delivery points (SDPs) that experience a stock out at any time during the reporting period of a contraceptive method that the SDP is expected to provide High intensity areas <3 7 5.5

Lakhsmipur <3 3 1.7 3.4 Reason for variation: Some SDPs are enlisted which are not eligible Noakhali* <3 6 6.1 3.7 for specific methods (Habiganj district hospital, etc.) 11.9 Habiganj <3 10 9.8 *

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 51 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016)

Jhalokathi <3 1 3.4 2.5

Pirozepur* <3 2 2.7 2.4

Sub-IR 2.6: Strengthen local government planning and engagement in health service provision The data was not available. Because of a server crash of CRVS Percentage of unions that had online data. Government online at least 50 percent of the system is not functioning and estimated births registered MaMoni HSS did not have access within 45 days of birth to the information. Therefor we are using EPI data. High intensity areas 40 NA On track Lakhsmipur 40 NA 75 62 NA 25 It includes Three upazila (Senbag, Noakhali* 40 96 Begumganj, Companiganj) Habiganj 40 NA 161 76 Jhalokathi 40 NA 28 50 Pirozepur* 40 NA 58 96 only Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N Number of union parishads (UP) that spent funds to support Source: Project MIS

MNCH/FP/N activities High intensity areas 226 67 100 74 Lakhsmipur 58 4 11 17 Noakhali* 44 17 30 21 Reason for variation: Because of UP elections spilling into May Habiganj 77 33 46 29 2016, funds were not available. Jhalokathi 32 13 13 7 Pirozepur* 15 0 0 0 Intermediate Result 3: Promote enabling environment to strengthen district level health system Number of critical vacancies filled by GOB recruitment or Source: Project MIS redeployment in project areas High intensity areas 25 Lakhsmipur 5 0

Noakhali* 5 0 Habiganj 5 3 3 0 Jhalokathi 5 2 6 4 FWV and 2 nurse Pirozepur* 5 2 3 3 FWV Sub-IR 3.1: Policy reforms in place to promote local planning and need-based human resource deployment in the public sector

52 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) Number of policies/ strategies/guidelines on MNH -PPFP counselling guideline 4 0 2 2 developed/revised with MaMoni -Infection prevention HSS support Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program Number of program learning -2 advocacy sharing meeting on initiatives completed and 10 3 2 3 UH&FWC assessment disseminated -LAPM study finding sharing Intermediate Result 4: Identify and reduce barriers to accessing health services Number of deliveries with a SBA DGFP MIS, DHIS2, pCSBA in USG-assisted programs 61,440 10,985 12,894 14882 High intensity areas

17,332 3,940 3,121 4555 Lakhsmipur

11,622 1,991 3212 3798 Noakhali*

23,580 4,082 5263 4869 Habiganj

6,362 607 634 1148 Jhalokathi

2,544 365 664 512 Pirozepur*

45,579 5,115 5,337 6771 HSCS areas

10,796 1,595 1,531 1233 Pirozepur

1,755 2,229 3,235 3460 Bhola

33,028 1,291 571 2078 Noakhali*

Number of antenatal care (ANC) 486,499 150,691 155,192 170798 visits by skilled providers from DGFP MIS, DHIS2, pCSBA USG-assisted facilities 303,839 106,244 110,895 132750 High intensity areas

48,846 26,655 20,697 28440 Lakhsmipur

39,468 23,012 30,034 33981 Noakhali*

191,464 45,969 48,405 57326 Habiganj

15,048 7,974 7,331 8940 Jhalokathi

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 53 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) 4063 Pirozepur* 9,013 2,634 4,428

38048 HSCS areas 182,660 44,447 44,297

5803 Pirozepur 31,544 7,528 7,519

15879 Bhola 62,314 16,311 15,634

16366 Noakhali 88,802 20,608 21,144

Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches Number of people reached through project supported BCC Source: Project MIS activities High intensity areas 650,000 223,488 16,528 17036 Lakhsmipur 175,000 54,111 5,636 6519 Women 28348 4047 4467

Men 25763 1589 2052 Reason for variation: The project modified the reporting criteria to Noakhali* 135,556 160,584 4,331 4305 exclude miking as a BCC method. Women 71927 3505 3678 This change resulted in lower number of beneficiaries reached Men 88657 826 627 in second and third quarter Habiganj 195,000 5,855 4,217 4935 Women 4983 3678 4239

Men 872 539 696

Jhalokathi 113,587 2,938 2,344 1277

Women 2139 1946 1036

Men 799 398 241

Pirozepur* 30,857 0 0

Women 0 0

Men 0 0

Bhola Women Men Sub-IR 4.2: Enhance community engagement in addressing health needs Number of trained community volunteers promoting MNCHFPN (Not cumulative) Source: Project MIS through project support High intensity areas 24,925 23,168 23,181 23817 Lakhsmipur 6,710 6,409 6,485 6214 Noakhali* 5,900 5,664 5,693 5586 Habiganj 8,379 8,265 8,345 8319

54 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 Achieve Achieve Achievemen ment ment Target Variation t (Oct–Dec (Jan-Mar (April- Remarks 2016 (%) 2015) 2016) June) 2016) Jhalokathi 2,731 2,300 2,304 2304 Pirozepur* 1,205 530 354 354

Number of Community Action Groups with an emergency transport system for maternal and newborn health care through USG-supported Source: Project MIS programs High intensity areas 20,001 18,999 20,081 20177 Lakhsmipur 6,461 6,056 6,102 5945 Noakhali 3,876 3,586 3,871 4076 Habiganj 4,369 8,136 8,060 8065 Jhalokathi 3,746 1,221 1,694 1737 354 BRAC mechanism followed in Pirozepur* 1,549 0 354 Pirozepur

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 55 APPENDIX 4: MNCH ESSENTIAL DRUGS MONITORING REPORT Table 16: Stock status of Tab. misoprostol in all the DGHS store at Noakhali district, December 2015-May 2016.

Name of the store Dec.15 Jan.16 Feb.16 Mar.16 Apr.16 May.16

CS store Sebbag. Begumganj Companigonj Subornachar Hatiya Red = Stock-out. Green = Available stock.

Table 17: Stock status of Inj. oxytocin in stores of Lakhsmipur district in last one year (June2015- May 2016)

Jul Jun, Aug Sep Oct, Nov Dec Jan, Feb Mar, Apr, May, Name of the store , 15 ,15 ,15 15 ,15 , 15 16 ,16 16 16 16 15 CS store District Hos. Ramgati Kamal Nagar Raipur Ramganj Red = Stock-out. Green = Available stock.

Table 18: Availability status of Inj. gentamycin in all the upazila store in Jhalokathi district in last six months (December 2015 –May 2016)

Name of the store Dec.15 Jan.16 Feb.16 Mar.16 Apr.16 May.16

CS store District Hospital Sadar Kathalia Rajapur Red = Stock-out. Green = Available stock. Yellow = Available stock about to expire

Tracking availability of family planning commodities at different upazila of Habigonj district

56 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 1. Monitoring Quality of Care (QoC) Indicators: The project conducted preliminary analysis of the first round of the quality of care (QoC) survey conducted in four districts (Hg, Nk, Lp, Jk). The survey included 10 sentinel sites in each district ( 1 DH, 1 UHC, 4 UH&FWC, and 4 Satellite Clinics). Data collection was performed by direct observation by trained surveyors. Highlights of the results of the first round of QoC are included below. Results of Quality of Care Survey

• Preliminary results of assessing quality of ANC services show that, data from a total of 27 facilities in the 4 districts, Iron and Folic Acid tablets were available in 25 facilities (93%). Running water was available in 24/25 facilities (96%), soap for hand washing was available in 23/25 facilities (92%), and latex gloves were available in 25/24 facilities (96%). • Available results from Jhalokathi and Noakhali show that out of 14 facilities surveyed conducting normal vaginal deliveries,, 10 (71% had newborn resuscitation bag and mask, 12 (86 %) had resuscitation mask, and 11 (79%) had penguin sucker. • Out of a total of 26 facilities conducting normal vaginal deliveries surveyed in the four districts, 18 (69%) had partogragh paper and board, 11 (42%) had Oxytocin injection, and 4 (15%) had magnesium sulphate 5 ml ampule. • Out of 122 deliveries observed in Lk district all of them (100%) had oxytocin inj. administered within 1 minute of delivery and out of 172 deliveries observed in Jk district, due to shortage in stock, only 18% received oxytocin inj. within 1 minute of delivery. • Family planning data from Habiganj district show that out of 272 clients, privacy was ensured in 13 cases (3%), client concerns where discussed in 56 clients (27%), job aid was used in 142 clients (47%), and next date of visit was mention to 40 clients (15%).

Table 19: IFA availability in surveyed facilities

District No. of Facilities Surveyed No. of Facilities IFA Tablets were available Lakhsmipur 7 5 Habiganj 5 5 Jhalokathi 7 7 Noakhali 8 8 Total 27 25 (93%)

Table 20: Basic Infection prevention indicators in selected sites

District No. of facilities surveyed

Running Water Soap for Latex gloves hand washing Lakhsmipur 7 7 6 7 Habiganj 3 3 3 3 Jhalokathi 7 6 6 6 Noakhali 8 8 8 8 Total 25 24 (96%) 23 (92%) 24 (96%)

Table 21:Availability of newborn resuscitation commodities

District No. of No. of facilities offering normal vaginal delivery with: facilities Functioning Newborn Newborn Penguin

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 57 surveyed resuscitation resuscitation resuscitation sucker bag mask size 0 mask size 1 Jhalokathi 7 6 7 7 6 Noakhali 7 4 4 5 5 Total 14 10 (71%) 11 (79%) 12 (86%) 11 (79%)

Table 22: Availability of essential maternal health drugs and supplies

District No. of No. of facilities offering normal vaginal deliveries with: facilities Partograph paper Inj. Oxytocin Inj. Magnesuim surveyed & board Sulphate 5 ml ampule. Lakhsmipur 7 4 4 1 Habiganj 4 3 3 1 Jhalokathi 7 6 0 1 Noakhali 8 5 4 1 Total 26 18 (69%) 11 (42%) 4 (15%)

Table 23: Percent of timely use of Inj. Oxytocin after delivery, Lakipur district

Facility No. of No. and % of deliveries where Oxytocin Inj. was deliveries administered within 1 minute from delivery observed District Hospital 65 65 (100%) MCH-FP Unit of UHC 50 50 (100%) UH&FWC 7 7 (100%) Total 122 122 (100%)

Table 24: Percent of timely use of Inj. Oxytocin after delivery, Jhalokathi district

Facility No. of No. and % of deliveries where Oxytocin Inj. was deliveries administered within 1 minute from delivery observed District Hospital 124 1 (0.8%) MCH-FP Unit of UHC 30 30 (100%) UH&FWC 18 0 ( 0% ) Total 172 31 (18 %)

Level of Facility No. of clients No. & % Client Used Job Aid Informed observed with privacy concerns client about discussed date of next visit MCH-FP Unit of UHC 30 8 (27%) 6 (20%) 30 (100%) 12 (40%) UH&FWC 123 1 (0.8%) 18 (15%) 56 (46% ) 18 (15%) Satellite Clinics 119 4 (3%) 32 (27% 56 (27%) 10 (8%) Total 272 13 (5%) 56 (21%) 142 (52%) 40 (15%) Table 25: Quality of counseling, Jhalokathi district

58 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 APPENDIX 5: DOCUMENTATION AND DISSEMINATION OF MAMONI PROGRAM LEARNING

Table 26: Forums where MaMoni HSS lessons were disseminated

Title Forum Month Type of Dissemination Quality of LAPM Services Marie Stopes May 2016 Oral Presentation Quality of LAPM Services DGFP Jun 2016 Oral Presentation

Table 27: Summary of upcoming program learning activities Topic Status Expected results by FY’16 1. Quality of LAPM Services IRB waived Final dissemination and (USAID) Data collection complete publication Findings shared with USAID, GOB and key partners 2. Use of partograph at peripheral IRB waived Final report and possible level facilities and at community Data collection complete, publication level summary brief prepared (USAID) Selected for poster presentation at FIGO Shared with USAID, GOB and key partners 3. Quality of ANC at satellite Data collection completed Final report clinics Preliminary findings shared with (USAID) project team, USAID 4. Viability of private community • IRB waived Final report skilled birth attendants • Data collection completed (USAID) • Preliminary findings shared Accepted for poster presentation at FIGO 2016 5. Country case study of national IRB waiver received Due for completion in FY 4 scale up of 7.1% chlorhexidine Implementation in progress application for newborn umbilical cord care 6. Process documentation of IRB waived Due for completion in FY 4 strengthening UH&FWCs for Baseline assessment completed improved birth outcomes 7. Implementation Research on JHU IRB received Due for completion in FY 4 management of infections among Partnership with HRCI/JHU young infants at union level Evaluation done by JHU Implementation in progress 8. Measurement of selected Led by UNC, JHU, Measure, Completion of data collection chronic maternal morbidities: Fistula Care II Pending IRB approval

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 59 APPENDIX 6: LINKS TO SAFE MOTHERHOOD DAY VIDEOS AND MEDIA STORIES PUBLISHED

Table 28: Links to media reports related to MaMoni HSS Media Date Article Title and Link YouTube May 28 Videos on Safe Motherhood Day Jahanara Alam, of National Female Team https://youtu.be/WD5QP2IAQv4 Elita Karim, Singer and Journalist https://youtu.be/qyS3sznNV1c Rubana Haq, first lady of Dhaka North City, and MD of Mohammadi Group https://www.youtube.com/watch?v=7ZUFITn7g5c Mehzabeen Khaled, MP, member of Standing Committee of Foreign Affairs Ministry https://www.youtube.com/watch?v=PyhrK0vcy88 Char King Union Parishad engagement https://www.youtube.com/watch?v=b3CnyHa1v5o Kaler May 22, �া�뷍েসবা :অনন뷍 নিজর বদলপুের Kantho 2016 http://www.kalerkantho.com/print-edition/last-page/2016/05/22/361183 Kaler May 28, িব� �া�뷍 সং�ার িনেদ쇍িশকা উেপি�ত �সবকােজ Kantho 2016 http://www.kalerkantho.com/print-edition/last-page/2016/05/28/363235 Kaler May 29, িনরাপদ মাতৃ ে�র কােজ ছু েট েবড়ান লাভলীরা Kantho 2016 http://www.kalerkantho.com/online/miscellaneous/2016/05/28/363424 Bdnews24. Jun 05, Unnecessary C-sections done in Bangladesh com 2016 http://bdnews24.com/health/2016/06/05/unnecessary-c-sections-done-in- bangladesh-says-save-the-children-director-ishtiaq-mannan Bdnews24. Jun 20, Clinical Appeal’ creates new appeal in Bangladesh rural health com 2016 http://bdnews24.com/health/2016/06/20/clinical-appeal-creates-new-appeal-in- bangladesh-rural-health BSS Jun 20, Experts for safe delivery to prevent maternal deaths 2016 http://www.bssnews.net/newsDetails.php?cat=0&id=584146&date=2016-06-20

Prothom May 05, মাতৃ মৃতু 뷍-কমােত-িমডওয়াইফাির-েসবার-িবক�-েনই Alo 2016 http://www.prothom-alo.com/bangladesh/article/849826/

Prothom May 31, 0মা-িশশ‍র �া�뷍 উ�য়েন বাড়ােত হেব বােজট Alo 2016 http://www.prothom-alo.com/bangladesh/article/873868

60 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 APPENDIX 7: APONJON UPDATE Expectant mothers, new mothers and gatekeepers were signed up for the service in the ratio 4:5:1 respectively. Following is a distribution of registered subscribers by source of acquisition:

Table 29: Distribution of registered subscribers by source of acquisition

Source Subscriber Aponjon 2802 BRAC 8518 Call Center 568 IMS 1 MCC 19 Smiling Sun 106 Spectrum 19673 TothyoKollyani 2349

Figure 18: Acquisition by Source

BRAC 8518

TothyoKollyani 2349 Outreach IMS 1

MCC 19 Agency Spectrum 19673

Aponjon 2802

Other Call Center 568

The proportion of SMS recipients is higher than that of IVR. 94% of them are SMS subscribers whereas only 6% received the service via IVR. Almost all subscribers acquired by Spectrum were SMS recipients based on the nature of contract with Dnet.

Call Center Activity:

Table 30: Summary of call center activities of Aponjon

Month Call from Incoming Outgoing call DOB update Data Entry subscriber call April 1139 2158 4346 48 N/A May 1182 2134 3597 38 N/A Till 15th June 478 928 1560 17 N/A

Promotional materials

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 61 Around 30,000 leaflets were published along with 2,600 wristbands to enhance brand footprints among the youth. 600K Aponjon forms were published during the quarter among which 300K was sent to Spectrum and 30,000 to BRAC. The remaining were used by Aponjon Brand Promoters.

Incentive disbursement

Community agents (CA)/ Stand-alone agents (SA) or Aponjon brand promoters (BP) were given incentives according to their contribution in acquisition. A total of 144,944 taka was disbursed among 1,382 beneficiaries for acquisition of 2,396 valid registrations.

Table 31: Summary of disbursement of incentives for customer acquisition by Aponjon

Incentive (In BDT) Beneficiary (CA/SA/BP) Acquisition (Subscriber) June Organization June (up June (up April May April May April May (up to to 15) to 15) 15) Brac 25,640 30,430 15,830 421 466 355 2,564 3,043 1,583 Infolady 22,305 26,685 4,785 14 9 5 1487 1779 319 Smiling Sun 550 0 0 1 0 55 0 0 Aponjon BP 18,719 0 0 52 59 1,640 0 756 Total 67,214.00 57,115.00 20,615.00 488 475 419 5,746 4,822 2,658

Table 32: Status of Rollout of own platform, Bridge

Component Status Comment Project Plan Signing Complete Hardware Installation Complete QAT of Installation Complete Site accepted without snag Network Integration Complete VPN Integration Commencing Will be complete before EiD Core Telecom Integration Commencing Will be complete before EiD UAT Pending After Eid, UAT and Cut-over

In an interview after the launching announcement she talked about how far Bangladesh has come regarding its digital vision and how these two apps will help people to have access to healthcare information, which is a milestone for the digital healthcare sector around the world. According to her, these apps have great potential to be launched in developed countries in different forms and capacities.

62 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3

Photo 18: State Minister for ICT Zunaid Ahmed Palak delivering his speech on the innovative initiative

According to State Minister Zunaid Ahmed Palak, both Shogorbha and Koishor apps align with the digital Bangladesh vision of the government by making healthcare information more accessible in bite sizes. He also expressed his expectation from Aponjon to continue its good work in the ICT based healthcare sector.

The Dhaka Tribune featured Aponjon on the app launching, the link is given below- http://www.dhakatribune.com/bangladesh/2016/apr/09/2-health-information- mobile-apps-launched

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3 63 APPENDIX 8: STATUS OF HEALTH FACILITY RENOVATIONS Table 35: Summary of status of renovation activities supported by MaMoni HSS

District Upazila Name of Facility Progress to date Remarks Noakhali Begumganj Aleyarpur UH&FWC Completed Handed Over Begumganj Gopalpur UH&FWC Completed Handed Over Hatiya Sonadia UH&FWC 25% Hatiya Char King UH&FWC Completed Handed Over Lakhsmipur Sadar Sadar Hospital 95% Sadar Dalal Bazar UH&FWC Completed Handed Over Sadar Uttor Joypur UH&FWC Bidding initiated Ramganj Dorbespur UH&FWC Completed Handed Over Kamal Nagar Char Falcon UH&FWC Bidding initiated Roypur Char Mohona UH&FWC Bidding initiated Jhalokathi Kathalia Chesrirampur UH&FWC Completed Handed Over Rajapur Saturia UH&FWC Completed Handed Over Sadar Binoykathi UH&FWC Completed Handed Over Nachity Siddhokathi UH&FWC Completed Handed Over

64 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q3