Guinea End of Project Report

Guinea Guinea Ebola Response and Recovery: Restoration and Improvement of Reproductive, Maternal, Newborn and Child Health Services (RHS)

End of Project Report July 2015 - December 2016

Submitted to: United States Agency for International Development under Cooperative Agreement #AID-OAA-A-14-00028

Submitted by: Jhpiego Corporation The Maternal and Child Survival Program (MCSP) is a global United States Agency for International Development (USAID) Cooperative Agreement to introduce and support high-impact health interventions with a focus on 24 high-priority countries with the ultimate goal of ending preventable child and maternal deaths within a generation. The Program is focused on ensuring that all women, newborns and children most in need have equitable access to quality health care services to save lives. MCSP supports programming in maternal, newborn and child health, immunization, family planning and reproductive health, nutrition, health systems strengthening, water/sanitation/hygiene, malaria, prevention of mother-to-child transmission of HIV, and pediatric HIV care and treatment. Visit www.mcsprogram.org to learn more.

This report is made possible by the generous support of the American people through USAID under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of MCSP and do not necessarily reflect the views of USAID or the United States Government.

2 Contents

Acronyms and Abbreviations ...... 4

Acknowledgments ...... 5

Executive Summary ...... 6

Introduction ...... 10

Major Accomplishments ...... 13 A- Rapid situation analysis of focus facilities ...... 13 B- Facility focused interventions ...... 14 Select service delivery data for project facilities ...... 28 C- Community-focused interventions ...... 32 Challenges and Opportunities ...... 35 Lessons Learned and Recommendations ...... 36

Annexes ...... 37 Annex 1: Number and type of facility by region/prefecture in the RHS intervention zone, and previous interventions ...... 37 Annex 2: MCSP RHS Monitoring Indicators Table ...... 38 Annex 3: Details for Indicator C1, Healthcare Cadre, Gender and Training Topic ...... 51 Annex 4: Terms of reference of IPC focal points and coaches ...... 52

3 Acronyms and Abbreviations

AI Apprentissage Individualisé (Individualized Learning) ASC/ CHW Agents de Santé Communautaire/ Community Health Worker CMC Communal Medical Center CNLEB National Ebola Response Coordinating Committee COASH Community Health Committee DPS Direction Préfectorale de la Santé (Prefecural Health Directorate) DRS Direction Régionale de la Santé (Regional Health Direcotrate) EmONC Emergency Obstetric and Newborn Care EVD Ebola Virus Disease FANC Focused antenatal care FP Family Planning HSC Health and Safety Committee (hospital level) HMIS Health Management Information Systems IEC Information, Education, Communication IPC Infection Prevention and Control IMCI Integrated Management of Childhood Illness LDHF Low-dose, high frequency (training methodology) MCHIP Maternal and Child Health Integrated Program MCSP Maternal and Child Survival Program MCSP RHS MCSP Restoration of Health Services Project MNH Maternal and Newborn Health MoH Ministry of Health NGO Nongovernmental Organization OFDA Office of Foreign Disaster Assistance (US Government) ORT Oral Rehydration Therapy PAC Post-abortion Care PMTCT Prevention of maternal to child transmission of HIV PNC Postnatal care PPFP Postpartum Family Planning PPH Postpartum Hemorrhage PPIUD Postpartum Intrauterine Device RMNCH Reproductive, Maternal, Newborn and Child Health RH/FP Reproductive Health/Family Planning SBCC Social and Behavior Change Communication SBM-R Standards-based Management and Recognition UNMEER United Nations Mission for Ebola Emergency Response WHO World Health Organization

4 Acknowledgments Key Partners • Maternal and Child Survival Program (MCSP) partner, Jhpiego, thank our collaborators and partners. • Ministry of Public Health and specifically, the Secretary General, the Coordination Nationale de Lutte contre la Maladie à virus Ebola, the National Directorate of Family Health and Nutrition, the National Directorate of Prevention and Community Health, the National Malaria Control Program, and the National Program on Integrated Management of Childhood Illness • Regional health offices of Conakry, Kankan, Kindia, Faranah, and N’zérékoré, and the prefectural and communal health offices in these regions • Health care workers in MCSP-supported facilities and community health workers engaged in bringing health information and services to their communities • World Health Organization, United Nations Fund for Population Activities, and UNICEF • Implementing partners of United States Agency for International Development, Office of U.S. Foreign Disaster Assistance, and the Centers for Disease Control and Prevention • Médecins Sans Frontières—Belgium, Action Contre la Faim, Alliance for International Medical Action, Women and Health Alliance International, and other nongovernmental organizations (NGOs) engaged in the Ebola response and in particular, infection prevention and control

The MCSP Team • In-country technical team: Professor Yolande Hyjazi, Dr. Mamadou Malal Diallo, Dr. Gassim Cissé, Dr. Bokar Dem, Dr. Havanatou Camara, Dr. Suzanne Austin, Bamba Mamady Camara, Jacqueline Aribot, Dr. Abdoulaye Diallo, Dr. Ibrahim Pita Bah, and Bakary Berete • Finance, administration, and operations team: Antoine Lamah, Ténin Sougoulé, Thierno Saidou Diallo, El Hadj Mamadou Saliou Bah, and Abbas Kourouma • Headquarters’ technical support team: Dr. Tsigue Pleah, Professor Blami Dao, Dr. Ruparelia Chandrakant, Dr. Willy Shasha • Headquarters’ program support team: Rachel Waxman, Laura Skolnik, Karine Nankam, Caroline Tran, Joan Peto, and Linda Benamor (for translation support)

5 Executive Summary

In order the contribute to the response to the Ebola Viral Disease (EVD) epidemic in Guinea and the severe effects on health services, including increased risks for healthcare providers, MCSP was requested to develop and implement several projects to reinforce Infection Prevention and Control in healthcare facilities and to assist the MOH to restore confidence in and use of health services. This report presents the Restoration of Health Services (RHS) project, which operated from July 2015 to December 2016 and was designed to address the second order impacts of the EVD epidemic in Guinea (Pillar 2), specifically the restoration of critical non-Ebola health services. The project was funded with resources from the Ebola Response and Preparedness Fund, and the support of the Global Health Ebola Team (GHET).

Interventions were concentrated on geographic areas most impacted by the EVD epidemic. These impacts include high numbers of EVD cases and deaths, loss of healthcare workers to EVD, transfers and mobilization for the EVD response; and dramatic reductions in health service utilization for routine prevention and treatment such as antenatal and delivery care for pregnant women, family planning, treatment of diarrheal disease, malaria and other communicable diseases. Community based health information and services delivered by Community Health Workers (CHW) were also impacted by the mobilization of CHWs to support EVD surveillance, contact tracing and monitoring, and community awareness building. The 20 focus prefectures for MCSP RHS included 221 facilities; 26 Hospitals and 195 health centers, and approximately 60% of the country’s population.

The goal of the RHS project was to expand the number of integrated and high-quality maternal, newborn and child health services (Emergency obstetric and newborn care, FP and Integrated Management of Newborn and Child Illness (IMNCI]) to an appreciable number of health facilities and communities, building upon the platform of previous USAID-supported work through MCSP and MCHIP and responding to the impacts of the Ebola outbreak. The four objectives to obtain this goal include:

• Strengthen Service Delivery • Creation of a favorable healthcare environment • Demand Creation (in collaboration w/ HC3) • Facilitate Community Engagement (w/HC3)

Prior to project implementation and in order to better adapt the interventions to the needs of the beneficiaries, a rapid analysis of the baseline situation was carried out in 109 health facilities in the eight prefectures in Boké and Kindia regions, as well as select facilities in Conakry. The general objective was to identify the needs of the health facilities to ensure the provision of quality RMNCH services at both clinical and community level. In N’zérékoré, Kissidougou, and several high-level facilities in Conakry, MCSP had supervision reports from previous RMNCH and IPC activities to inform the identification of needs for these facilities.

6 To support consistent and correct Infection Prevention and Control (IPC) practices, MCSP RHS provided institutional support for policy updating; supportive supervision and coaching for sustained performance of IPC; IPC training for healthcare providers; provision of IPC materials and supplies; minor rehabilitation of facility infrastructure; capacity building of health and safety committees (CHS); and ongoing monitoring of IPC performance. Key accomplishments include: training of 49 supervisors and coaches for IPC who along with IPC trainers carried out 519 facility visits for IPC coaching across the 221 facilities in the project zone. These visits allowed for 9,468 coaching contacts with healthcare workers and 1,366 with support staff. 99 health care providers from 26 facilities received training on IPC in Dubreka district which was fortunate not to have experienced cases of EVD but also had not received prior support to strengthen IPC. A package of IPC materials was provided to each facility upon completion of the IPC training. MCSP RHS supported minor rehabilitation at three hospitals in the project zone with a focus on access to and storage of water, repair of toilets, and back-up solar electricity for labor and delivery rooms, postpartum observation, operating theatre; services where maintaining IPC practices is essential for 24 availability of lifesaving services. The three hospitals included the regional hospitals in Kindia and Boké and the prefectural hospital Dubreka. The project worked with 143 CHS members across 10 hospitals to reinforce their capacity to monitor and manage IPC performance in these facilities.

Periodic assessments were conducted over the life of the project with feedback provided to staff. MCSP observed a decrease in IPC performance when the end of the EVD epidemic was declared in Guinea at the end of 2015, and supervision and coaching visits helped to address some of the fluctuation in performance levels, but changing behavior in IPC practices remains a fundamental challenge for health systems due to the challenges in changing behavior as well as challenges in assuring consistent availability of IPC supplies, water and power for instrument sterilization and waste management. Performance rates improved in almost all health facilities, with 46% of health facilities/services meeting the desired minimum performance of 75% of IPC standards compared to only 5% at baseline. 34% were performing between 50% and 74% versus 22% at baseline. The percentage of health facilities/services with less than 50% performance decreased from 70% to 19% between the initial and final evaluation.

To improve quality of care in RMNCH services, MCSP worked to reinvigorate and maintain the use of the nationally adopted quality improvement methodology Standards-based Management and Recognition (SBM-R®). Focusing on facilities where this process had previously been introduced by USAID funded projects ACCESS-FP and MCHIP, MCSP carried out a review of current performance and presence of trained SBM-R team members in order to determine needs. Orientations were provided for 24 providers and supervisors to reinforce SBM-R teams in eleven facilities in N’zérékoré and Conakry, while another 21 stakeholders from four facilities in Kindia were trained in the second and third modules of SBM-R to help reestablish SBM-R in these facilities. 50 supervision visits were carried out to support SBM-R reaching each of the 35 targeted facilities at least once.

Activities to strengthen the availability of maternal and newborn maternal health services focused on training, post-training follow-up and supervision, as well as the provision of key medical materials such as instruments and minor equipment to focus facilities. A total of 19 of 25 hospitals (76%) and 195 of 195 health centers (100%) benefited from support from MCSP RHS support to improve the availability of

7 services for pregnant women and newborns. Several different types of trainings for Basic and Comprehensive Emergency Obstetric Care (EmONC) were offered depending on the level of the facility with a total of 239 providers completed the competency-based trainings. To help validate skills acquisition and help providers to transfer learning to implementation at their worksites, trainers conduct post-training follow up 1-2 months after training reaching 84% of trained providers in their worksites.

Using the skills acquired and reinforced during training and post-training follow-up visit and supervision, treatment of the cases of severe pre-eclampsia and eclampsia with magnesium sulfate increased form 79% in the first quarter to 97% in the last quarter. The number of assisted deliveries increased from a monthly average of 2,487 deliveries in the project area (before interventions) to 6,242 in the last quarter of 2016. Improved application of active management of third stage labor with oxytocin likely contributed to the reduction in cases of postpartum hemorrhage even as the number of deliveries in facilities was increasing.

MCSP RHS also worked to reinforce the management of childhood illness beginning with training of a pool of 17 IMCI trainers who went on to train 177 providers from health centers and health posts in three districts. Trained providers were provided with job aids, management tools / monthly report templates and the IMCI reference booklet for the care of the sick child. MCSP also responded to a request from the national IMCI program to support supervision in three districts that did not have support of other partners.

Cases of treated pneumonia increased from an average of 328 per month in October-December 2015 to 2052 per month during the same period in 2016. Treatment for diarrhea also increased, although at lower overall numbers than for pneumonia, from an average of 114 cases per month in the last quarter of 2015 to 191 cases per month for the last quarter of 2016. 97% of all reported cases of pneumonia and 96% of cases of diarrhea were treated in health facilities.

Community focused interventions included support to reinvigorate the performance of Community Health Workers (CHW). 682 CHWs were trained in the project area (97% of target), 561 of whom trained on the integrated curriculum of community services and health messages and 121 on the dissemination of MNCH / FP / IMNCI/ PAC messages alone. MCSP worked closely with the District-level Community Health supervisors (Chargé SBC) and community educators of local NGOs to strengthen their capacity to facilitate CHW monitoring and supervision. 106 Chargé SBC supervisors from the health centers (Agent PEV or head of the health center) and NGO educators were trained on supportive supervision of CHWs. 21 were trained as trainers for the CHW curriculum. In terms of supervision, 85% (579/682) of new CHWs were reached during post-training visits across all prefectures. 20 peer educators of hair salons were also visited in Conakry. In the N’zérékoré region, 113 existing CHWs were reached by the first round of supervision and 188 at the second. CHW’s contributed to the conduct of 100,831 group educational sessions that reached 528,728 people (not disaggregated by CHW and provider led sessions).

Also at community level, MCSP introduced the community action cycle to assist communities to better understand beliefs and practices related to Ebola and healthcare seeking. 24 facilitators, including regional health managers and members of community organizations, were trained on the Community Action Cycle and knowledge of community health policies, strategies and protocols in order to align with national

8 priorities. MCSP was able to provide only the first step in the development of community mobilization teams, in part due to the fact the USAID-funded HC3 project was also engaged with communities. MCSP therefore ended up putting more effort into coordinating with HC3 than implementing this process as originally planned. At the national level, MCSP RHS provided technical support to several meetings to review the revised community mobilization strategy document and prepare it for submission to MOH for validation.

Challenges and lessons learned over the course of this project include: Behavior change for IPC is hard and requires fairly intensive effort to hold providers accountable and to ensure that IPC supplies are continuously available. At the same time, the EVD epidemic served to highlight the fundamental role of IPC in the quality and safety of health services in Guinea and investment is needed from the policy level all the way to facilities. There were many partners and a lot of resources available for the post-Ebola response, but coordination and poor planning created ongoing interference and interruption of activities as health managers often do not receive information from central level and from partners in a timely manner to organize the time of their staff. US Government support for Ebola Recovery may have been better served by integrating the health services and health systems interventions to be carried out over the same time period as they rely on each other to produce sustainable results for the countries impacted by the Ebola epidemic.

9 Introduction

The Maternal and Child Survival Program is a global U.S. Agency for International Development (USAID) cooperative agreement to introduce and support high-impact health interventions in 24 priority countries with the ultimate goal of ending preventable child and maternal deaths (EPCMD) within a generation. The Maternal and Child Survival Program engages governments, policymakers, private sector leaders, health care providers, civil society, faith-based organizations and communities in adopting and accelerating proven approaches to address the major causes of maternal, newborn and child mortality such as postpartum hemorrhage, birth asphyxia and diarrhea, respectively, and improve the quality of health services from household to hospital. The Program will tackle these issues through approaches that also focus on health systems strengthening, household and community mobilization, gender integration and eHealth, among others. The Maternal and Child Survival Program (MCSP) carries forward the momentum and lessons learned from the highly successful USAID-funded Maternal and Child Health Integrated Program (MCHIP), which has made significant progress in improving the health of women and children in over 50 developing countries throughout Africa, Asia, Latin America and the Caribbean.

MCSP interventions were designed to build on the development of local training capacity among healthcare providers in Guinea; a focus on competency-based training methods that work to improve both knowledge and skills; previous work specifically on infection prevention practices in health care facilities; and a commitment to quality improvement and supportive mentoring and supervision to assist healthcare providers to translate new skills into ongoing service delivery at their worksites.

In order the contribute to the response to the Ebola Viral Disease (EVD) epidemic in Guinea and the severe effects on health services, including increased risks for healthcare providers, in late 2014 USAID requested MCSP to develop a workplan to address the infection prevention and control (IPC) practices in facilities, as well as to work with communities to prevent disease transmission. The first intervention was designed for a period of nine-months from 17 November 2014 to 16 August 2015. MCSP Guinea has been very engaged in national level coordination of the Ebola Response and particularly the work of the IPC cluster to support healthcare services. Working in eight of the country’s 38 districts, the first IPC project completed the training of 2986 healthcare providers from 55 facilities in Conakry, including all services of the three university teaching hospitals, and three rural prefectures- Beyla, Forécariah and Kissidougou. The IPC training focuses on the knowledge and skills for Infection Prevention and Control including standard precautions in healthcare service delivery and waste management along with additional measures required to assess suspect cases of, and to prevent transmission of Ebola. Providers have received multiple follow-up supervision visits, to support correct and consistent implementation of IPC practices. At the community level, MCSP supported social and behavior change communication (SBCC) on EVD in coordination with 99 community health committees through a range of communication channels.

A second IPC project, also managed under MCSP and funded by USAID’s Office of Foreign Disaster Assistance (OFDA), operated from June 2015 through May 2016 in the another five prefectures: Boké, Dabola, Dinguiraye, Faranah, and Mandiana. These prefectures were selected based on coverage of IPC support across health partners (see map below of all prefectures with IPC support through MCSP). 1,345 health care providers from 249 healthcare facilities across the five prefectures were trained in IPC through this project. 62 providers also benefited from a three-day training specifically on setting up and managing triage of patients seeking care at health facilities in Boké, which experienced its first cases of Ebola just as the project was starting up. Supervision and coaching visits to support continued IPC performance were conducted to all facilities and reached 78% of trained providers. In addition, 67 staff who were posted to the focus facilities after the training sessions received onsite orientations on IPC during supervision visits. 271 support staff also received IPC orientation and coaching in local languages. MCSP also donated IPC materials and consumables to the MOH facilities in order to support correct and consistent practice of the skills

10 learned and reinforced during the IPC training. 29 autoclaves and seven incinerators were also purchased and installed to support instrument processing and waste management respectively.

Koundara Mali Siguiri Gaoual Dinguiraye Labe Tougue Boke* Telimele Pita Dabola Kouroussa Mamou Boffa Fria Kindia Faranah Kankan

Conakry Forekariyah Kissidougou Kerouane IPC training supported by Jhpiego Gueckedou Beyla Regional HQ in Bold Macenta MCSP Ebola 1 MCSP Ebola 2 (OFDA) N’zerekore WHO Lola *Alcoa funding also supporting Boke Yomou

An analysis of service delivery data from healthcare facilities previously supported by the Maternal and Child Health Integrated Program (MCHIP; October 2010 - March 2014) in the East and South of the country showed the drastic impact that the Ebola epidemic had on health service utilization. Quarterly data was compared for October-December 2013 (Q1) through October-December 2014 (Q5).As EVD surged toward the end of 2014, the use of MNH and FP services dropped steeply in the most affected regions of N’zérékoré and Conakry. Delivery care dropped 81% (n=2490 to n=463) in N’zérékoré and 74% (n=4890 to n=1724) in Conakry between Q1 and Q5. Cesarean deliveries also declined sharply. By comparison, delivery care stayed stable in Kankan and Faranah regions until the last quarter when community resistance arose to Ebola related interventions from health officials. For family planning services, average monthly users fell 75% in N’zérékoré (n=10703 to n=2580), 53% in Conakry, (n=6191 to n=2893) and 65% in Kankan (n=11660 to n=4082). In 2015, MCSP encountered a steep decrease in monthly data reporting by facilities to the Prefectural Health Directorates (DPS), further complicating capacity to assess the impact of EVD. For the quarter of January-March 2015, the reporting rate was only 26%.

With resources from the Ebola Response and Preparedness Fund, and the support of the Global Health Ebola Team (GHET), MCSP was requested to develop a third project to address the second order impacts of the EVD epidemic in Guinea (Pillar 2), specifically the restoration of critical non-Ebola health services. For the development of the present Restoration of Health Services (RHS) project, MCSP worked to leverage existing programs, such as USAID and OFDA investments in IPC, and previous achievements of MCHIP in strengthening MNCH and quality improvement, as well as the StopPalu malaria project (Jhpiego, the lead on MCSP, is a partner on this project).

Interventions were concentrated on geographic areas most impacted by the EVD epidemic (see map on next page). These impacts include high numbers of EVD cases and deaths, loss of healthcare workers to EVD, transfers and mobilization for the EVD response; and dramatic reductions in health service utilization for

11 routine prevention and treatment such as antenatal and delivery care for pregnant women, family planning, treatment of diarrheal disease, malaria and other communicable diseases. Community based health information and services delivered by Community Health Workers (CHW) were also impacted by the mobilization of CHWs to support EVD surveillance, contact tracing and monitoring, and community awareness building. The 20 focus prefectures for MCSP RHS included 221 facilities; 26 Hospitals and 195 health centers, and approximately 60% of the country’s population. The number of facilities and communities to be reached is specified for each target in this project. A table with the number of facilities by level per prefecture and previous interventions is provided in Annex 1.

This final report describes the activities conducted during the contractual period of the project from July 2015 through December 2016.

Goal and Objective

• Strengthen Service Delivery • Creation of a favorable healthcare environment • Demand Creation (in collaboration w/ HC3) • Facilitate Community Engagement (w/HC3)

12 Major Accomplishments

A- Rapid situation analysis of focus facilities

Prior to project implementation and in order to better adapt the interventions to the needs of the beneficiaries, a rapid analysis of the baseline situation was carried out in all health facilities in the eight prefectures in Boké and Kindia regions, as well as select facilities in Conakry. Data collection focused on facilities that had not received prior USAID support for health services. This analysis gathered essential data on services, inputs, human resources, tools and infrastructure at the clinical and community level. The general objective was to identify the needs of the health facilities to ensure the provision of quality RMNCH services at both clinical and community level. In N’zérékoré, Kissidougou, and several high-level facilities in Conakry, MCSP had supervision reports from previous RMNCH and IPC activities to inform the identification of needs for these facilities.

Specific objectives • Conduct an inventory of available services and facilities within health centers (materials, equipment, infrastructure, commodities) in order to establish current level of functioning; • Report on human resources and technical assistance received in the context of capacity-building in order to identify training needs • Review the status of community-based services in targeted areas to identify training needs (retraining or training of new CHWs), equipment and supervision to strengthen community-based services and community engagement for better access to care. • Identify the main challenges in service provision and their effective integration into health facilities

The study was conducted in 109 health facilities in the eight prefectures of the Boké (3), Kindia (5) and Conakry (5) regions, and included two regional hospitals (HR), six prefectural hospitals (HP), two communal medical centers (CMC), 37 urban health centers (CSU) and 62 rural health centers (CSR). Key findings include:

Community engagement and oversight: It was noted that the ten hospitals/CMCs each have a health and safety committee (HSC); however, the active membership was often limited to the treasurer and the president which is not enough to function well and perform their responsibilities to organize and mobilize the community and oversee facility sanitation. Although a health committee existed in every facility, the community is very poorly represented in the functioning of the health facilities because only two hospitals out of ten have a “user’s committee” and associated groups.

Community based services: 1,484 villages and neighborhoods had 1,488 community health workers (CHWs). The Kindia region has the most villages and community workers (1089/1214), while Boké (299/215) and Conakry (96/59) have fewer. More than 85% of CHWs provide malaria services, followed by more than 60% offering IMNCI services (respiratory illness, diarrhea) and, to a lesser extent, family planning. This aligns with previous support by the USAID-funded Stop Palu and UNICEF respectively for malaria and community IMNCI.

Facility based services: More than 80% of health facilities offer services related to maternal, neonatal and child health. The least available services are those that require referral to a higher level facility (respiratory distress and severe dehydration in children, cesarean section), yet 24 health structures reported referring to other facilities for unavailable or not offered services. The most frequently referred services are, in order: PMTCT, pregnancy complications and childhood illnesses. Among Emergency Obstetric Care (EmONC)

13 signal functions, the least commonly available include postabortion care (33% of facilities) and assisted vaginal delivery (38%). The most common means of travel to the health center is by foot (31%), followed by motorcycle (29%) and vehicle (27%). Methods of transport that require payment include motorcycle taxi (6%), canoe (3%) or taxi (2%).

Human Resources for Health: The 109 health facilities visited had 363 midwives (168 contractual), 302 nurses (173 contractual), 1,031 ATS (Auxiliary nurses; 559 contractual), and 226 physicians (118 contractual). Contractual personnel are government employees paid by the government, while the rest are often volunteers (often underemployed providers), students in training, including residents, and occasionally personnel paid for by another program. Thus, in these facilities, 53% of providers are not formally employed in the health sector, with most found at hospitals and urban health centers.

Infrastructure: As a source of power supply, the state electric company (EDG) is the main source, powering 44/109 facilities, followed by solar panels (22 facilities) and generators (7 facilities). 31 structures use a single source, EDG, and do not have a backup source in case of power outage. 40/109 (37%) of health facilities confirmed they do not have a water supply due to lack of or failure of the drilling and water supply systems of the state company (SEG).

Supervision: The number of supervision or joint supervision visits with partners received per structure varies from 10 to more than 20 in the previous six months, likely a function of the EVD risk in previous months. More specifically: • More than 20 supervision visits per facility were received by 12 facilities (6 in Boké, 4 in Kindia and 2 in Conakry). • Between 10 and 20 supervision visits per structure were carried out to 26 facilities (13 in Kindia, 10 in Boké and 3 in Conakry). • Less than 10 supervision visits per structure were carried out to 66 facilities (38 in Kindia, 16 in Conakry and 13 in Boké).

Health Partners and Donors: Several bilateral and multilateral partners cover all three regions and work in all areas of health (infrastructure, transport logistics, health products and technical support). Information was collected on what exactly they are doing where to help MCSP avoid duplication in its activities.

B- Facility focused interventions

1. Supporting consistent and correct Infection Prevention and Control (IPC) practices.

18-month target: At least 80% of MCSP supported hospitals and health centers (n=221) demonstrate improved performance of IPC standards

(Note: This target was revised from its initial formulation of: At least 80% of MCSP supported hospitals and health centers (n=221) meet minimum IPC standards. As discussed below, maintaining IPC performance and achieving such a high level of performance (75% of all standards is the minimum desired level) has multiple challenges, some within the scope of this project to address and others that were not.)

14 Institutional Support

MCSP RHS provided technical and financial support to the MOH for the development/revision of several policy documents including, the National Policy and Program for IPC, Norms and Procedures and the Monitoring and Evaluation Framework for IPC. Once the MCSP Health Services Strengthening (HSS) project began operating in mid-2016, support for these policy level activities transferred to that project. MCSP also regularly participated in the National Ebola Coordination (until dissolved following the declaration of the end of the epidemic) and the IPC Cluster specifically, in order to ensure that USAID- supported activities were well coordinated with MOH and partners.

Supportive supervision and coaching for sustained performance of IPC

During the Ebola epidemic, USAID, OFDA and others committed resources to reinforcing IPC practices in healthcare facilities as a means to protect both healthcare workers and patients and to stop transmission of the virus in routine health services. MCSP implemented two of these projects that trained and supported 4,330 providers from 304 facilities across 13 prefectures and communes on IPC for healthcare settings, with specific emphasis on additional procedures for Ebola. Of the 20 prefectures that are the focus of the MCSP RHS project, nine were previously supported by MCSP for IPC training while the remaining 11 had received IPC support from other health partners (three prefectures received the same training led by Jhpiego, funded by WHO).

A key lesson of the IPC training and support is that maintaining continuous and consistent performance requires ongoing attention through supervision and attention to supply chain for essential materials to bring about long term behavior change. Further, IPC is a foundational element of quality healthcare. Therefore, MCSP RHS planned to provide ongoing support for IPC through supervision and coaching including assistance to providers and managers to problem solve when issues arise.

MCSP technical advisors, national and regional IPC trainers (MOH staff) and the heads of services were all involved in providing supportive supervision. MCSP worked with the DPS to identify two IPC focal points from the prefectural health offices in each prefecture along with the team of trained providers from the region who were oriented as coaches based on their own consistent performance and roles within the health system (superintendent, head of service). A total of 49 coaches, including the DPS focal points, were engaged to support IPC across the four regions (9 in Boke, 13 in Kindia, 14 in Conakry and 23 in N’zérékoré.) MCSP worked to build capacity of MOH staff whose jobs include supervision rather than using project staff to conduct supervision in their place.

The objective of the coaching was to support healthcare providers and support staff to enable the provision of safe and quality health services by strengthening IPC through observation and feedback, on-site practical exercises and use of the IPC performance standards for self and peer assessment. Once the coaches were oriented, they worked with IPC trainers and project staff to carry out visits. MCSP RHS supported trainers and IPC focal points to carry out coaching visits on a quarterly basis in each prefecture and was able to conduct a total of 519 facility visits for IPC coaching across the 221 facilities in the project zone. These visits allowed for 9,468 coaching contacts with healthcare workers and 1,366 with support staff. In the five prefectures of Kindia, the coaching teams also provided on-site IPC orientation for 251 providers who had been recently assigned to the facility and had not participated in an IPC training course. This included student trainees.

Table 1: Distribution of supervision and coaching visits across the project zone Time period # of sites* # of providers # of support staff Prefectures (DPS) visited receiving reached by reached by coaching visits coaching visits coaching visits November 2015 53 1157 184 4 communes of Conakry December 2015 106 1330 202 Kindia, Forecariah, Boké, Fria, Beyla, Conakry February 2016 51 1064 171 DPS Kissidougou, Kindia, Forecariah et Conakry March 2016 10 424 94 Boffa and Kissidougou May 2016 57 1756 79 Conakry, Boffa and Macenta June 2016 51 1065 99 Kindia, Forecariah, Dubreka, Coyah et Telimele August 2016 59 703 126 Kindia, Coyah, Forecariah, Dubreka, Telimele. December 2016 132 1969 411 6 DPS of N’Zerekore, 3 DPS of Boke, and 5 DPS of Kindia *sites includes individual services within the large national and regional hospitals.

IPC Training for Healthcare Providers

MCSP RHS project planned a limited amount to IPC training to reach providers that had not been reached through previous IPC training efforts. It was identified that Dubreka prefecture had not received any IPC training, the only prefectures in the MCSP RHS zone, which was selected by the GHET specifically to focus on areas most affected by the epidemic. Therefore, four training sessions were held to train 99 providers from 26 facilities (including 16 private facilities) in the prefecture. Baseline IPC performance was assessed just prior to the training sessions. These trainings were held in February and March 2016, thus supervision and coaching was provided in Dubreka after this point.

Provision of IPC supplies and materials

Similar to the IPC training in previous MCSP projects, a package of IPC materials was provided to each facility upon completion of the IPC training. This included items from trashcans, hand washing stations, personal protective equipment such as gloves, goggles, aprons (for maternity and for cleaners), soap, bleach powder, etc. For consumable items, a quantity to last for one month was provided based on facility caseloads. The provision of these materials was provided to encourage providers to initiate and continue IPC skills learned in training and also to encourage facility manager to plan accordingly for the replacement of consumables.

In addition, a stock of 29 autoclaves that were purchased under the MCSP IPC2 project were distributed to facilities in the RHS focus area. RHS resources were used to support transport as well as an MOH maintenance team that visited each site and assisted staff to set up the autoclaves and provided training on how to correctly operate the autoclaves.

Minor rehabilitation of facility infrastructure

MCSP RHS supported minor rehabilitation at three hospitals in the project zone with a focus on access to and storage of water, repair of toilets, and back-up solar electricity for labor and delivery rooms, postpartum observation, operating theatre; services where maintaining IPC practices is essential for 24 availability of lifesaving services. The three hospitals included the regional hospitals in Kindia and Boké and the prefectural hospital Dubreka. While MCSP RHS hoped to be able to support up to ten facilities, the needs were greater

16 than expected and the budget could only be stretched to cover three facilities. MCSP’s support for rehabilitation was done in close coordination and complementarity with the HC3 project as well as USAID’s new Health Service Delivery (HSD) bilateral award which started operations in 2016. Before and after photos at Boké hospital are shown below.

Hospital Rehabilitation Completed HR Kindia Water storage and access points in service delivery areas Solar panels and light installation HR Boké Water storage, filtration for water coming from bore hole, and access points in service delivery areas Solar panel and light installation for pediatrics, surgery and emergency departments Repair of 12 latrines HP Dubreka Water storage and access points in service delivery areas Solar panels and light installation Repair of latrines

Also related to healthcare infrastructure, MCSP RHS participated in the WASH cluster at the national level and provided information from the baseline activities and IPC coaching visits to the cluster to inform planning of interventions by the main WASH partners.

At the time of donations and handover of rehabilitated facilities, an MOU was signed between the project and facility managers to acknowledge receipt of the materials at the facility and obtain their commitment to maintain and monitor the use of the materials, including identification of the person responsible for maintenance. Copies were also provided to district or regional health managers. MCSPs regional coordinators regularly checked on the functioning of the materials, which has continued been continued by the HSD award, in order to engage with managers on ongoing internal monitoring of inventory and maintenance procedures.

Capacity Building of Health and Safety Committees

MCSP RHS worked closely with Expertise France who were leading the strategy development for CHS to bring the experience from the facilities into considerations of capacity building needs, ensuring the availability and completeness of the committees and providing assessment tools to guide their support of health facilities. MCSP RHS also worked at the national level harmonize approaches with the Hygiene and Safety Committees across different donors and partners.

At facility level, MCPS RHS provided orientations to CHS and support to develop an action plan to respond to their new role. MCSP RHS reached 143 committee members at 10 facilities: 9 hospitals and one urban health center. The Committees are comprised of the facility director, representatives of the different services and professional categories, community representatives and local collectives, as well as representation from the DPS or DRS. One doctor on staff was designated as the contact point for accidental exposure incidents (blood, infected materials, needle sticks). The initial meeting was used to designate a president, vice president and rapporteur for the committee; to review national policy guiding the formation of the Hygiene and Safety Committees; a review of work conditions that can expose staff to infection risks and measures that can reduce risk; review of assessment methods for verifying performance of health and safety measures;

18 discussion of education/sensitization activities to be organized with facility staff; and review of the steps for reporting and managing accidental exposure incidents.

Monitoring of IPC performance

For prefectures and facilities where MCSP or Jhpiego (with funding from WHO) had previously provided IPC support, baseline IPC performance is based on the assessment conducted prior to training. In order to monitor IPC and provide coaching in all of the MCSP RHS focus prefectures, IPC assessments were conducted in 42 facilities in four prefectures – Coyah, Dubreka, Macenta and Boffa – to serve as their baseline for the project even though they may have received support to improve IPC from other health partners.

Macenta and Boffa were not assessed or monitored until about halfway through this project because another health partner was actively supporting IPC until mid-2016. Nevertheless, IPC performance was below desired standards. In Macenta, median performance was found to be 37%, with the highest score reaching 70% at Macenta Prefectural Hospital and the lowest was 10% at Watanka. In Boffa, IPC performance in hospital services ranged from 31 to 68% with an average of 49% and at the health centers, performance ranged from 27 to 54% with an average of 40%. During the assessments, the findings were presented to all staff in an effort to further engage them in performance improvement and an action plan was developed for each facility to address the problems and gaps in performance identified.

Periodic assessments were conducted over the life of the project with feedback provided to staff, and a final round of assessments was organized in November/December 2016. The number of assessments per facility varies with when the site was targeted for IPC training. MCSP observed a decrease in IPC performance when the end of the EVD epidemic was declared in Guinea at the end of 2015, and supervision and coaching visits helped to address some of the fluctuation in performance levels, but changing behavior in IPC practices remains a fundamental challenge for health systems due to the challenges in changing behavior as well as challenges in assuring consistent availability of IPC supplies, water and power for instrument sterilization and waste management. For the purposes of assessing progress in IPC performance, the baseline and final assessments are compared. Also of note, MCSP made the decision during the IPC projects to assess the different services in large hospitals individually as they function largely independently and IPC performance can vary widely.

Table 2: Evolution of IPC performance in health centers and hospital services Health centers Hospital services Performance Baseline Final assessment Baseline Final assessment score (%) n=165 % n=165 % n=174 % n=174 % 75% or higher 7 4% 60 36% 11 6% 91 57% 50–74% 38 23% 68 41% 36 21% 44 27% 25–49% 70 42% 34 21% 41 24% 21 13% 0–24% 42 25% 3 2% 77 44% 4 3% Not assessed 8 5% 9 5% 14 8%

Performance rates improved in almost all health facilities, with 46% of health facilities/services meeting the desired minimum performance of 75% of IPC standards compared to only 5% at baseline. 34% were performing between 50% and 74% versus 22% at baseline. The percentage of health facilities/services with less than 50% performance decreased from 70% to 19% between the initial and final evaluation. 11 hospital

19 services reached the threshold for desired IPC performance (75% or higher) at baseline, amongst which 7 maintained this level at final assessment. Moreover, 84 hospital services (48%) with low performance at baseline improved their performance rates meeting desired threshold at final assessment. The change in behavior required to maintain IPC performance and the need to ensure adequate availability of IPC supplies are persistent challenges in striving for consistent and correct performance of standard precautions.

Table 3: Evolution of IPC performance in health centers by region Health centers Conakry Kindia Kissidougou N’zérékoré Boke (n=30) Performance (n=22) (n=35) (n=17) (n=61) score (%) Base- Base- Base- Base- Base- line Final line Final line Final line Final line Final 75% and higher 23% 32% 0 49% 3% 33% 0 94% 2% 18% 50–74% 59% 41% 11% 37% 27% 57% 0 6% 21% 51% 25–49% 18% 27% 37% 14% 43% 10% 59% 0 49% 30% 0–24% 0 0 49% 0 20% 0 41% 0 20% 1% Not assessed 3% 6% 8%

Another way to visualize the information is found in the graph below.

Graph1: IPC score distribution for health centers at baseline and final IPC assessment by region

Final 11 31 18 1

Baseline 1 13 30 12 5 Nzerekore

Final 16 1

Baseline 10 7 Kissidougou Final 10 17 3

Boke Baseline 1 8 13 6 2

Final 17 13 5

Kindia Baseline 4 13 17 1

Final 7 9 6

Conakry Baseline 5 13 4

0 10 20 30 40 50 60 70 Number of facilities >75% 50–74% 25–49% 0–24% Not assessed

The Kindia and Boké regions and the Kissidougou district registered the greatest proportion of facilities that meet or exceed the desired performance of 75% or greater. The Kissidougou district also had the best

20 performance evolution with 94% of health centers obtaining the required score. It is difficult to tease out the sources of these variations, but some possible contributors include:

1) MCSP made a purposeful decision to focus on the districts in Kindia and Boké because they had the lowest levels of support from other partners in the Ebola response, therefore more coaching visits may have contributed to greater improvements in performance. MCSP, through RHS and previous projects, had also provided the five-day, skills-based IPC training to more districts in Kindia and Boke, thus providing more coaching and follow-up across the different project periods. N’zérékoré and the health centers in Conakry on the other hand received IPC training from other partners, in some cases a shorter course focused on a more limited set of information regarding hand hygiene, and PPE use. 2) The majority of health facility infrastructure in Guinee is old and in poor repair. Water is not consistently available, waste management is weak, electricity is not consistently available and buildings are old. MCSP RHS ended up supporting rehabilitation that had not originally been planned but was requested by the Mission to address some of the worst situations, however the project was not able to address all of the extensive infrastructure needs in Guinea, across more than half of the country. 3) Anecdotal observations by members of the National Ebola Response pointed out more rapid regression in IPC performance among providers trained using the shorter training course. This observation was a driving force for the MOH’s adoption of Jhpiego’s IPC training materials, with the Ebola addendum, as the nationally preferred curriculum.

2. Improving quality of care using the Standards-based Management and Recognition (SBM-R) methodology.

18-month target: 35 Facilities supported to reinvigorate and maintain the SBM-R process; with at least 80% achieving and/or maintaining recognition of performance

The target for this activity is based on facilities where the quality improvement methodology, Standards – Based Management and Recognition (SBM-R®), had previously been introduced. This includes facilities with previous USAID-funded project support as well as facilities where the methodology was introduced with support from UNFPA (see Annex 2). SBM-R has been adopted by the Guinean MOH as a preferred quality improvement methodology. The SBM-R process takes from nine months to a year to implement therefore the choice was made to focus on supporting facilities previously introduced to the process in order to reinvigorate its use to restore the quality of services and community confidence. The initial target for this activity was 36 SBM-R facilities, but with the closure for Donka National Hospital for major renovation, this site was removed from the target. Donka closed in November 2015 for extensive renovations funded by the government of Saudi Arabia, the Islamic Development Bank and the National Development Bank. It is expected to be completed by December 2017. A few specialty services moved to the military camp across the road, while services such as maternity and pediatrics closed entirely and other facilities in the city were expected to manage the caseload.

Review the current performance status and presence of trained team members in each facility; assess need to introduce additional performance standards such as obstetric surgery, IMNCI

Most of the SBM-R sites had recently received supervision visits from the MCSP RMNCH project (a small carryover between MCHIP and a pending bilateral) and this information was used to determine specific needs of the facilities. Baseline information showed that performance had dropped in the majority of facilities

21 compared to reviews conducted prior to the EVD epidemic, thus there was a long way to go to bring some facilities back up to desired performance levels to maintain or achieve recognition. For facilities that had previously obtained recognition, but current performance was below the threshold, they were advised that they would need to restore performance to recognition levels within a few months or risk losing their recognition star.

Orient/train new staff and managers SBM-R as needed to reinforce facility teams

In the case of six SBM-R facilities in N’zérékoré, MCSP provided on-site orientation for a total 12 providers in order to make them part of the facility SBM-R team and help to reinvigorate the internal review process.

In the five CMC of Conakry, 4-6 providers and 5-6 supervisors of the different services were identified to reconstitute the SBM-R teams, which included a member of the Hygiene committee. Presentations by a team of MCSP and Regional and Communal health managers emphasized the internal review and supervision of SBM-R performance. Providers were identified to lead the peer reviews and a review of the tools for managing and recording internal assessments was provided. Further, at CMC Flamboyant and CMC Coleah, 20 providers, including 7 students, received coaching and support in the utilization of performance standards for EmONC and FP, including on-site training using anatomic models to review the skills for normal delivery and active management of third stage labor.

For four facilities in Kindia prefecture, where there had been a long period between the introduction of SBM- R under a UNFPA project, as well as loss of staff to transfers and EVD, MCSP RHS opted to repeat the second and third modules and the interim monitoring visits of the SBM-R process in order to reinvigorate the process. A total of 21 stakeholders from the four facilities- CSU Wondy, CSR Friaguiabgé, CSU Kenende and CSU Manquepas- were trained.

Conduct introductions of additional performance standards based on findings of baseline review

The initial package of performance standards in Guinea includes 1) Delivery care and EmONC, 2) FP and 3) IPC. Additional standards have also been adapted for use in Guinea under the MCHIP project and introduced as appropriate for capacity building needs in the facilities. When the SBM-R process is already in place, new performance standards can be introduced through supervision visits and do not require a workshop. Performance standards for IMNCI services were introduced in two CSU in Kindia -Manquepas and Wondy. An additional four sites were planned for introduction of IMNCI standards but following repeated postponements due to National Vaccination Days (which make health managers unavailable for a week or more at a time), the activity was only able to be conducted for two CSU in Kindia- CSU Manquepas and CSU Wondy.

MCSP’s MNH team was also able to introduce the performance standards for Prevention of Mother to Child Transmission of HIV (PMTCT) in five facilities where these services were initially reinforced under the MCHIP project. The standards were validated near the end of the MCHIP project and were awaiting dissemination to support ongoing performance of PMTCT services in ANC.

Conduct joint visits with district (DPS) and regional (DRS) supervisors to review SBM-R implementation

All 35 SBM-R sites received at least one joint visit to review the status of implementation of the internal processes of peer review and action plan monitoring, as well as provide an external assessment of performance in order to provide feedback. Additional visits targeted facilities in need of further follow-up. A total of 50 supervision and review visits were conducted to the SBM-R sites in coordination with MOH staff from regional and prefectural or communal health offices. SBM-R sites in Conakry and Kindia in particular

22 received multiple visits to assist providers to reinvigorate use of the process and improve their performance with respect to clinical and management standards.

During these visits, SBM-R teams were supported to develop action plans to resolve gaps in performance. A logbook to record peer assessments was provided to help reinvigorate the internal use of the QI process in between periodic external visits and to encourage teams to work towards the recognition threshold where SBM-R teams request a validation visit by the National SBM-R Committee. These visits also served as coaching opportunities as specific issues were identified. In Dubreka, coaching was provided on two key EmONC skills- bimanual compression of the uterus for the management of postpartum hemorrhage (PPH), and the use of the active management of third stage of labor with an uterotonic for the prevention of PPH.

Three validation visits were requested by facilities early on in the project and were conducted under MCSP RHS, while later validation assessments by the National SBM-R Committee were conducted under the MCSP HSS project given the involvement of national level health managers. By the end of the project, five facilities had been validated for recognition and the ceremonies were to be organized through MCSP HSS.

MCSP RHS worked closely with the HC3 project, also funded by USAID GHET funding, and focused on communications and behavior change activities, to integrate their Gold Star quality improvement model with SBM-R. In particular the communication tools of Gold Star served to increase information made available to communities surrounding the facilities receiving recognition.

The target of 80% of the sites achieving or maintaining overall performance was not reached as only 21 of 35 health facilities, 60%, were able to improve or sustain performance with the support of the project. Of these 21 SBM-R sites, eight are at the level of recognition with an average score of 80% across the three core domains. 13 sites improved their performance from baseline to the end of the project, while 14 did not register improvements in the overall score, with average scores declining from 83% to 66% (see graphs below). Some possible contributors to lack of performance improvements in 14 facilities include: loss of staff due to Ebola deaths and transfers, including those trained on SBM-R; and recurrent stock-outs, particularly of IPC materials. MCSP could advocate with managers about filling positions, timely reordering and alerting the pharmacy about stock outs, but the actions to resolve these were outside of the project’s scope. Overall, this was an ambitious target for 18 months given the sharp decline in quality and utilization during the epidemic and the multitude of activities taking place in these prefectures post-Ebola to attempt to restore healthcare services and community trust. As noted previously, competing activities, from protests against the government to national vaccination days disrupted planned activities multiple times throughout the project. The graphs below present the range of scores for the baseline and final assessments for the different groups of facilities- at recognition level, improved, and unchanged/unimproved.

23 Graph 2: Evolution of overall performance (%) of eight SBM-R sites that achieved or maintained performance at recognition level of 80% or higher 100 97 93 85 85 80 80

60 64

0 Previous evaluation Latest evaluation Median Minimum Maximum

Graph 3: Evolution of the median overall performance of 13 SBM-R sites that improved performance between the last two evaluations 100

80 77 75 71 60 59 52 40 42

0 Previous evaluation Latest evaluation

Minimum Median Maximum

Graph 4: Evolution of the median overall performance of 14 SBM-R sites that did not register improvements in the overall score between the last two evaluations 100 89 83 80 78 67 66 60 45 40

0 Previous evaluation Latest evaluation

Minimum Median Maximum

24 Graph 5: Evolution of performance by domain for three CMC of Conakry 100% 90% 87% 88% 89% 90% 84% 85% 79% 80% 80% 67% 68% 69% 70% 64% 60% 62% 62% 60% 60% 45% 50% 42% 40% 30% 20% 10% 0% CMC Flamboayant CMC Ratoma CMC Coleah

IPC Nov '15 IPC Sept '16 EmONC Nov '15 EmONC Sept '16 FP Nov '15 FP Sept '16

3. Increasing the availability and improving the quality of MNH services through a focus on integration of services.

18-month target: 75% of target facilities in the 20 focus prefectures have increased capacity to offer RMNCH services (of 25 Hospitals and 195 health centers)

Provider training on obstetric and neonatal care skills (BEmONC and CEmONC)

Several different types of trainings were offered depending on the level of the facility. 239 providers completed the competency-based trainings; details by sex and region are provided in table 4 below. For hospitals and the CMCs of Conakry, the classic two week course on BEmONC skills was offered to 48 providers from 16 facilities to improve knowledge and skills to manage normal delivery and obstetric and newborn complications. In Conakry, providers who were new to the facility and had not previously been trained by USAID-funded projects were selected, while in Kindia and Boké facilities had not been part of previous projects to support capacity development for EmONC.

Two training sessions were also conducted for 44 providers primarily from 11 prefectural hospitals in Boké and Kindia on Comprehensive EmONC, which includes the package of BEmONC functions and adds skills for cesarean section and laparotomy for repair ruptures uterus and ectopic pregnancy.

To reach providers from health centers, without taking them out of their sites for extended periods and also to allow more time for practice of new skills, MCSP RHS adapted the classic BEmONC training into a series of three modules. This also allows trainers to adapt to lower skills levels of providers in health facilities where there are rarely doctors or midwives and the majority of care is providers by auxiliary nurses (ATS). Each

25 module is five days and is followed by post-training follow-up visits to assist providers to implement new skills in their worksites.

To launch this new BEmONC training model, supervision visits were conducted to 110 health centers with particular attention to antenatal care (ANC) and delivery care in order to understand the gaps in skills and practices in the care of pregnant and laboring women and newborns. MCSP RHS also identified 20 clinically active, experienced providers to be trained as trainers to support this new approach and trained them using the Clinical Training Skills (CTS) course materials. New trainers conduct a mentored training to be qualified as a trainer and then proceed to support training activities as requested. Using this team of new trainers along with some existing trainers, MCSP RHS proceeded to conduct module 1 of the BEmONC course for a total of 147 providers. Module 1 focuses on skills for normal childbirth, essential care of the newborn, postpartum care and dilution of magnesium sulfate to provide a loading dose prior to referral. Due to time and financial constraints of this project, MCSP RHS completed the first training module and first follow-up, and the remaining two modules were later provided by the HSD project for all regions except N’zérékoré, which is no longer supported by USAID.

Instruments and materials including delivery kits, newborn resuscitation equipment (penguin suction, newborn ambu bag), stethoscopes, thermometers, partograph cards, posters and flip charts were given to the facilities to support practice of new skills and knowledge and improve the quality of health services.

Table 4: Providers trained on the different EmONC courses by region and sex # of providers # of providers # of providers # of providers Région trained using trained in CEmONC trained used trained on CTS classic BEmONC phased BEmONC Women Men Women Men Women Men Women Men Conakry 14 2 2 0 6 2 Kindia 8 11 8 16 57 25 5 2 Boké 4 9 11 7 17 5 3 2 N’zérékoré 23 20 26 22 21 23 97 50 14 6 Total 48 44 147 20

Post-training follow-up and assessment of providers trained on EmONC In the training model used under MCSP, the classroom and practical sessions are not the end of training. To help validate skills acquisition and help providers to transfer learning to implementation at their worksites, trainers conduct post-training follow up 1-2 months after training. Six weeks after the trainings, the project organized post-training follow-up visits to improve the level of retention of health care providers. • Follow-up visits to BEmONC training participants reached 156/195 (80%) trained staff in the project area. Providers who could not be visited include those that were not present on the day of the visit and inaccessibility of facilities during the raining season. • Follow-up visits to CEmONC sites were able to observe 100% of providers in 11 hospitals in the Boké and Kindia regions. • These visits made it possible to identify gaps in the application of the skills acquired during the EmONC training sessions and in the implementation of the action plans. Through demonstrations and the management of real cases with a trainer, certain gaps could be corrected.

26 • The post training follow-up visits also provided an opportunity to provide supportive supervision to five facilities where prevention of maternal and child transmission of HIV (PMTCT) was introduced under the MCHIP project. It also served as an opportunity to introduce the performance standards for PMTCT that were developed near the end of MCHIP. The five sites are all SBM-R sites that would be able to integrate this set of performance standards into their self-assessments and peer reviews.

Graph 6: Evolution of average observed performance before and after training on Module 1 of the BEmONC phased training in Kindia, Boké and Nzérékoré regions

100% 92% 91% 90% 90% 80% 79% 80% 73% 70% 60% 50% 40% 30% 20% 10% 0% Kindia Boké Nzerekore

Avant la formation Après la formation

Integration of postpartum family planning (PPFP) counseling and services into antenatal care and maternity services

MCSP RHS developed a new approach to training to expand the number of providers capable of providing counseling on family planning, and access to methods in the immediate postpartum period, to pregnant and postpartum women. The antenatal and immediate postpartum period present an important opportunity to reach women with information about healthy timing and spacing of pregnancy. While contraceptive prevalence remains low at 9.5 for all women (Tack 20), 85% of women attend at least one antenatal visit and 57% complete at least four visits, and 45% deliver with a skilled attendant (Demographic and Health Survey, 2012), thus pregnancy and immediate postpartum represent an important opportunity to capitalize on interactions with healthcare providers. Building on efforts to expand access to postpartum family planning services under MCHIP, MCSP RHS adapted training materials into a series of smaller modules that can be completed on the job with support of a trainer. The course consisted of 28 modules and could be completed in a minimum of a month, but often extended out over an average of three months. While traditional training programs pick a few staff per facility to be trained, this approach helps to train all staff in large volume facilities to offer PPFP counseling across ANC and maternity services. Training on postpartum IUD (PPIUD) insertion is also part of the course. Once all of the modules are successfully completed, the provider’s skills are validated through observation in order to consider him/her a qualified PPFP/PPIUD provider.

Interventions were focused on Conakry, N’zérékoré and Kissidougou, where PPIUD had previously been introduced through training of a few staff, and there were already trained clinical trainers. A total of 28 trainers (15 in Conakry, 3 in Kissidougou, 9 in Kindia, 1 in N’zérékoré) were provided with a skills update on

27 PPFP/PPIUD to reinforce their skills followed by an orientation on the individualized, on-site training approach (AI). Trainers were also equipped with training materials, PPIUD insertion kits (instruments) and anatomical models, and the facilities were equipped with the PPFP stamp that is used to indicate counseling and method choice on a woman’s ANC card. Copies of the PPIUD register were also provided.

A total of 18 facilities were supported to facilitate the AI training and over the life of the project. 150 providers initiated the course, and by December 2016, 129 (86%) had completed all course modules and 111 (74%) providers had been qualified. The HSD project continues to support the AI training approach. The training approach allowed participants to insert 144 PPIUD, 14% of clients counseled (n=1045) on PPFP options.

Table 5: Distribution of AI participants by region and completion status Level of completion Conakry Kindia Faranah N’zérékoré Total region region region region Enrolled in training 88 35 18 9 150 Completed training modules 73 32 18 6 129 Qualified on PPFP/PPIUD 64 28 18 1 111

Select service delivery data for project facilities Using the skills acquired and reinforced during training and post-training follow-up visit and supervision, treatment of the cases of severe pre-eclampsia and eclampsia with magnesium sulfate increased form 79% in the first quarter to 97% in the last quarter. The number of assisted deliveries increased from a monthly average of 2,487 deliveries in the project area (before interventions) to 6,242 in the last quarter of 2016 (see Graph 7).

Graph 7: Evolution of the number of deliveries attended by skilled personnel per quarter 20000 18739 18000 16563 16444 16000 15641 14000 14876 12000 10000 8604 8000 7462 6000 4000 2000 0 avril-juin 15 juil-sept 15 oct-dec 15 janv-mars 16 avril-juin 16 juillet-sept 16 oct-dec16

28 Graph 8: Evolution of maternal health indicators: Deliveries with a skilled provider, Active Management of Third Stage of Labor and cases of postpartum hemorrhage by quarter 98 100 91 91 2.5 90 92 85 2.3 80 74 2 76 73 71 76 70 60 1.6 1.5 50 40 1 30 0.9 0.6 0.8 20 0.5 10 0 0 oct-déc 15 Janv-mars 16 Avril-juin 16 Juillet-Sept 16 Oct-Déc 16

% GATPA % Accouchement assisté % HPP sur Acc Asiste

Improved application of active management of third stage labor with oxytocin likely contributed to the reduction in cases of postpartum hemorrhage even as the number of deliveries in facilities was increasing.

Utilization of the telephone network for communication between providers To support improved communications for referral, consultations and coordination among providers and managers an extension of the Orange telephone network in operation in eastern regions was provided in the new prefectures of Kindia and Boke regions. 109 phones and sim cards were distributed to providers and managers in these prefectures along with orientations on their use and the monthly data collection form for recording the purpose of the calls.

8,492 telephone calls were made for referrals during the project period, 52% of which concerned child illnesses such as diarrhea/dehydration, fever or pneumonia (see Graph 9). The increase in referrals over time may relate to the overall resumption of care seeking at health facilities once the epidemic was over.

Graph 9: Use of the telephone by health workers for referrals by type of referral and semester

345 Labor/Delivery 462 777

265 Pregnancy 498 675

135 Newborn 192 279

642 Child 1421 Type of referral/ danger sign 2381

0 500 1000 1500 2000 2500

July-Dec 2015 Jan-June 2016 July-Dec 2016

4. Increasing the availability and improving the quality of IMCI services in facilities and in communities

18-month target: 30 Facilities supported to improve Integrated Management of Child Illness (IMCI)

While the child health component of the RHS project specifically targeted three DPS, namely Boké, Forécariah and Beyla, the MCSP project also helped the IMCI national program ensure follow-up of IMCI performance standards and strengthen its pool of trainers. As part of the start-up of the clinical integrated management of childhood illness (IMCI) activities, the MCSP team achieved the following: • Support for a specific request of IMCI program for supervision of the implementation of the IMCI performance standards in the prefectures of Guinea Dabola, Mandiana and Beyla, in north-eastern Guinea. A team composed by MCSP and MOH ensured a second follow-up visit to monitor the SBM-R standards in three health facilities and noted some declines in performance, mostly in terms of organization of IMCI services. The recommendations helped the DPS team and the national program adjust their supervision plans, better integrate community IMCI into their activities, and improve coordination across partners. • Recruitment of two technical advisors to support the implementation of IMCI activities. • A field visit in the Boké DPS, where it was observed that more than 50% of sick children are seen in health posts. Further assessments concluded that the situation is not unique to the prefecture of Boké. These findings allowed MCSP staff led to the revision of interventions to include additional focus on providers at health posts in MCSP’s three supported prefectures who were not originally part of the planned target.

Strengthening the pool of IMCI trainers at national and regional levels

The training of trainers in clinical IMCI supported by MCSP under the RHS project included one national trainer from the IMCI national program, 6 clinical instructors from Donka Hospital, Ignace Dean hospital, and the CMC Bernard Kouchner, as well as 10DPS managers from the prefectures of Boké, Forécariah, Beyla, N'Zérékoré, Kindia, Mamou and Labé. This new addition to the existing pool of trainers was used to build the skills of IMCI providers in MCSP’s three focus prefectures, who will be able to support IMCI beyond the lifetime of the project in pre-service and in-service training at the national level and in the regions.

Training of health workers to strengthen clinical IMCI

Overall, the MCSP RHS program reached well beyond its initial target, by supporting the implementation of IMCI in a total of 170 health facilities, including 55 health centers and 115 health posts in the prefectures of Boké, Forécariah and Beyla. After being trained with support from MCSP, the trainers went on to organize and facilitate eight training sessions on clinical IMCI skills that involved a total of 177 providers, among them are 57 providers from health centers, 112 providers from health posts and 8 supervisors from district hospitals and DPS staff.

MCSP also supported the IMCI trainers to ensure follow-up training of 100 trained providers in Boké and Forécariah, including 38 heads of health posts. These follow-up visits addressed remaining gaps in knowledge and skills and, more importantly, helped the providers better organize their services to facilitate the daily practice of IMCI in the local context and work environment.

During the supervision activities, additional set of job-aids and basic materials were provided, each consisting of: a set of 4 IMCI wall posters, a specific job-aid for general danger signs, a wall poster for the rehydration plan B displayed at the ORT (oral rehydration therapy) corner in each health center and health post visited during follow-up, and a consultation registry for a child under the age of 5 years. Each trained staff member was provided with job aids, management tools / monthly report templates and the IMCI reference booklet for the care of the sick child. MCSP helped the regional trainers plan further follow-up visits in the remaining health facilities that could not be reached during the RHS project. MCSP was not authorized to provide the medications or rapid tests used for management of sick children but was able to use the occasion of the trainings to advocate with district managers for provision of medications and to work with providers to review what they need to order and have available for treatment. Cases of treated pneumonia increased from an average of 328 per month in October-December 2015 to 2052 per month during the same period in 2016. Treatment for diarrhea also increased, although at lower overall numbers than for pneumonia, from an average of 114 cases per month in the last quarter of 2015 to 191 cases per month for the last quarter of 2016. 97% of all reported cases of pneumonia and 96% of cases of diarrhea were treated in health facilities. The jump in cases managed in the last two quarters coincides with the training provided by the project. (See graphs below). Factors that may contribute to the dramatic increase in the last two quarters include improved skills of providers to manage the cases, improved recording of services provided following training and distribution of registers, and increased care seeking with the end of the epidemic and renewed confidence in health facilities.

Graph 7: Evolution of the management of pneumonia cases in the health facilities of Forécariah and Boké districts. 7000 6384 6157 6000 5594 5502 5000

4000

3000

2000 985 985 752 748 1000 714 710

0 Oct-Dec 2015 Jan-March 2016 April-June 2016 July-Sept 2016 Oct-Dec 2016 # received # Treated

31 Graph 8: Evolution of the management of cases of diarrhea in health facilities in supported facilities by quarter 700 601 592 600 555 543 500 393 400 342 273 273 300 231 231 200

100

0 Octobre - décembre Janvier - mars 2016 avril - juin 2016 Juillet - Septembre Octobre - décembre 2015 2016 2016 Reçu traité

18-month target: Community health workers (ASC) are providing community IMNCI (c- IMNCI) in 175 communities in three prefectures

This target was annulled. A review of partner interventions identified that adequate support to community case management of childhood illness was well covered by UNICEF and other partners, including Stop-Palu and AACG (Association des Animateurs Communautaires en Guinée). At the same time it was noted that a significant proportion sick child consultations take place at health posts which were not part of the any projects targets for capacity building. Therefore MCSP RHS requested to reprogram activities to focus on the providers at health posts discussed above.

Instead of supporting the training of community health workers, MCSP collaborated with Stop-Palu to help the head of health centers better facilitate their existing monthly meetings. This activity helped solve operational problems such as stock-out of non-malaria commodities at the community level. In collaboration with the DPS team, MCSP provided support to monthly meetings in six health centers in Boké and five in Forécariah, in order to verify the quality of the data collected at both facility and community level, to review the management tools and to address the drug management system from the prefecture to the health center to the community. The model initiated by MCSP is expected to be continued by the DPS and its partners beyond the lifetime of the RHS project.

C- Community-focused interventions 1. Reinvigorate community health and mobilization activities of ASC to provide health information, accompaniment of pregnant women, FP services and key lifesaving interventions.

18-month target: 700 Community Health Workers (CHW) are supported to reinvigorate community health and mobilization to provide health information, accompaniment of pregnant women, FP services, as well as key life-saving interventions

32 While the original target for this activity was based on number to be trained, a total of 975 CHWs benefited from the project's support for the provision of health services at the community level, including the dissemination of messages and the provision of neonatal, infant and maternal health services because this included training and supportive supervision. These activities were intended to strengthen the link between communities and health facilities in order to increase the demand for health services. MCSP RHS also supported the revision of the data collection tools (register and logbook) taking into account the key messages of the integrated curriculum.

682 CHWs were trained in the project area (97% of target), 561 of whom trained on the integrated curriculum of community services and health messages and 121 on the dissemination of MNCH / FP / IMNCI/ PAC messages alone. Guinea’s community health strategy is to have two CHWs per village to provide services and health information, so the project focused on filling gaps that were created due to loss of CHWs due to Ebola, lack of motivation or taking up other opportunities.

MCSP worked closely with the District-level Community Health supervisors (Chargé SBC) and community educators of local NGOs to strengthen their capacity to facilitate CHW monitoring and supervision. 106 Chargé SBC supervisors from the health centers (Agent PEV or head of the health center) and NGO educators were trained on supportive supervision of CHWs. 21 were trained as trainers for the CHW curriculum.

Table 6: Training activities for community health, by region and sex # community # supervisors # CHWS trained on the # CHWs trained on health trainers trained on integrated community health messages Région trained supportive health curriculum supervision Women Men Women Men Women Men Women Men Kindia 5 8 22 37 20 197 10 61 Boké 2 4 13 9 17 153 0 0 N’Zérékoré 0 0 2 23 44 130 14 36 Total 7 12 37 69 81 480 24 97

In terms of supervision, 85% (579/682) of new CHWs were reached during post-training visits across all prefectures. 20 peer educators of hair salons were also visited in Conakry. In the N’zérékoré region, 113 existing CHWs were reached by the first round of supervision and 188 at the second. During the supervision of the newly trained CHWs, MCSP was able to provide supportive supervision to existing CHWs who have continued to function in some of the same communities thus exceeding the target of overall CHWs supported by the project. CHW’s contributed to the conduct of 100,831 group educational sessions that reached 528,728 people (not disaggregated by CHW and provider led sessions).

While MCSP RHS has hoped to be able to continue and possibly extend the distribution of misoprostol through ANC services and supported by CHWs for the prevention of postpartum hemorrhage at home births, it was not possible due to administrative procedures for MOH to request procurement of the medication by UNFPA. This initiative was successfully piloted in N’zérékoré under MCHIP and subsequently adopted into national policy thus paving the way for ongoing support for implementation.

2. Introduce the community action cycle to better understand beliefs and practices related to Ebola and to healthcare seeking.

33 18-month target: Increase community ownership and capacity to explore, plan, and act together for improved RMNCH outcomes in communities surrounding 20 MCSP supported health centers

In order to strengthen the capacity for community mobilization, 24 facilitators, including regional health managers and members of community organizations, were trained on the Community Action Cycle and knowledge of community health policies, strategies and protocols in order to align with national priorities. The training initiated the formation of community mobilization teams, three in Boké, three in Kindia and four in N’zérékoré, to be able to engage with communities to plan and act for improved health. MCSP was able to provide only the first step in the development of community mobilization teams, as this was an overambitious target for this workplan and implementation period as well as the fact that HC3 was also engaged with communities. MCSP therefore ended up putting more effort into coordinating with HC3 than implementing this process. Under the new USAID-funded Health Service Delivery project, Jhpiego has been able to complete the development of community mobilization committees and initiate activities.

Other community engagement activities included: • At the national level, MCSP RHS provided technical support to several meetings to review the revised community mobilization strategy document and prepare it for submission to MOH for validation. • A draft community mobilization strategy paper was presented to representatives of five local NGO partners (CAM, APIC, APIF, PRIDE) for discussion and revision. • In collaboration with HC3, the MCSP project accomplished the following:

o Participation in the workshop organized by HC3 for the preparation of radio messages (radio spot, radio magazines, round tables, public statements).

o Organization of two roundtables in community radio stations (Familia FM and Renaissance) to discuss the quality of health services.

o Participation in the preparation and validation of radio messages for their broadcasts on two stations (Familia FM and Renaissance FM).

o Participation in the process of identifying health centers, hospitals and CHWs for "Bridges of Hope” activities in four prefectures of the N’zérékoré region (N’zérékoré, Beyla, Yomou and Lola).

o Identification of trainers from three health facilities to be trained by HC3 on communication skills.

o Participation in the launch of the “Gold Star” campaign at the Coleah CMC and the Mine in Conakry, in order to support community engagement in the process of improving the quality.

o Organization of four forums to discuss the need for health care. o Participation in a caravan in the Gold Star Conakry sites, in recognition of the quality services available in its facilities, as well as the activities of the Bridge of Hope in N’zérékoré including a cultural event to promote the health services in Hamdallaye.

o Participation in the review and planning with NGO partners in Kindia. With the NGO OPALS in Kindia, a meeting was organized for the coordination of activities in the Télémélé DPS.

o Support was given to CHWs to conduct a census of pregnant women and to organize séances of IEC in the communities and health facilities.

34 Challenges and Opportunities • Behavior change for IPC is hard. A lot of coaching and more coaching as well as changing norms and expectations among providers and managers is needed to achieve sustained high quality IPC performance. Accountability and provider perception of risk remain weak and in need of further exploration of how to improve this in low-resource settings. This is evidenced by the decline in IPC performance after the end of the outbreak (hand hygiene, triage etc.) both because of reduced perception of risk and inconsistent availability of IPC supplies as partner support for materials ended. • The EVD epidemic served to highlight the fundamental role of IPC in the quality and safety of health services in Guinea. The investment toward improving IPC from the policy level down to the lowest level facility during the epidemic presents an opportunity to improve on the attention given to this aspect of health care quality, including protocols and practices of providers and support staff to consistent budgeting and logistics to ensure supply of needed commodities. • Interference of many other activities/actors and weak coordination. Planning of activities was often derailed by last minute changes in the availability of regional and district health managers to participate, particularly for supervision. National vaccination days were a frequent culprit. A good deal of this stems from poor planning at the central level and late notification down to the field. While the vaccination days usually occur over a week, and there is a set number of events per year, the period was often not designated until the last minute making it difficult to plan around this activity which required all DRS and DPS staff to participate. MCSP RHS was working in the prefectures most affected by the EVD epidemic so not surprisingly there were many other partners working in these areas to support recovery as well. MOH at national and subnational levels are unable to adequately coordinate activities and obligate partners to plan activities in a coordinated manner. MCSP prioritized coordination in its quarterly detailed work planning and was able to remain flexible on a number of activities (e.g. changing the IMCI targets to focus on health post providers) in order to avoid duplication of other partner’s efforts, and this was only possible with extraordinary efforts to reach out to partners to ask about their planned activities. MCSP through the HSS project is working to address this issue of coordination and management of partners and MOHs own activities. • Once the National Ebola Coordination was dissolved, the leadership for IPC returned to the National Directorate for Hospitals and Health Services (DNHES). A major challenge in working with the DNEHS is that the IPC team was quite small and while the new IPC Policy laid out an expanded staffing matrix for this unit, the posts were not created or filled during the project period. MCSP, along with IPC Cluster members, advocated for the importance of filling these positions, but could not take specific actions to resolve the problem within the MOH and civil service. The main implication for this is that national level engagement on IPC standards, functioning of the Health and Hygiene Committees, and resolving issues with supply chain and availability of supplies for IPC are needed to realize long term changes in how IPC is integrated into health system functioning. • The new USAID-funded health bilateral, HSD, which started at the beginning of calendar year 2016, is the opportunity to continue to support health services to maintain and expand on the achievements that were realized as a result of this project and US government funding to respond to the EVD epidemic.

35 Lessons Learned and Recommendations

To facilitate the support to the Ministry of Health of Guinea in the post-Ebola period, RHS and HSS funding should have been integrated rather than sequential, particularly if implemented under the same award/implementing partners as was the case for MCSP, but also when there are different implementing partners (i.e. the Health Financing and Governance project’s support for national level management capacity). Restoration of services following an epidemic or emergency can only go so far without systems improvements, and systems interventions are often hollow without helping managers link these improvements to actual healthcare services. RHS did successfully push the boundaries to be able to support the policy updates for IPC, as these were needed to help guide the IPC supervision and monitoring and the MOH was ready to move forward on this before the MCSP HSS project was in place. MCSP wanted to avoid providing facility level support that does not have a basis in current national policy and guidance as these are essential for consistent implementation and creating a sense of accountability for implementing health service improvements. MCSP RHS also continued to participate in the national coordinating mechanisms even though this was technically the mandate of the HSS funding. The utility of integrating these aspects of the post-Ebola recovery funding are also apparent in the MCSP HSS project, which is still operating and is limited in the reach of the activities it can support (HSS does not support facility-level supervision or monitoring of IPC). SBM-R is another example where MCHIP and then MCSP have worked to engage district, regional and national supervisors to continue the use of this QI methodology, with a continuum of activities divided across the two projects. Finally, as a development initiative rather than humanitarian response mechanism, MCSP’s global objectives include linking capacity building with policy and systems strengthening.

36 Annexes Annex 1: Number and type of facility by region/prefecture in the RHS intervention zone, and previous interventions Facility type

Communal

Region Préfecture National/ Medical Health Health R University Regional Prefectural Center (CMC Center- Center- - Hospital Hospital Hospital or CMS) Urban Rural Total StopPalu StopPalu prefectures MCHIP Prefectures SBM facilities IPC training Jhpiego Boke# 0 1 0 0 2 12 15 X X~ Boke Boffa 0 0 1 0 1 7 9 X Fria 0 0 1 0 3 3 7 X X~ Boke Region 0 1 2 0 6 22 31 Kindia 0 1 0 0 5 9 15 X~ Coyah 0 0 1 0 2 3 6 X Kindia Dubreka 0 0 1 1 1 8 11 X 2^ Forekariah 0 0 1 0 1 9 11 X X Telimele 0 0 1 0 1 13 15 2^ Kindia Region 0 1 4 1 10 42 58 Faranah Kissidougou 0 0 1 0 5 12 18 X 6 X Faranah Region 0 0 1 0 5 12 18 Beyla 0 0 1 1 1 14 17 X 3 X Gueckedou 0 0 1 1 3 9 14 X 2 Macenta 0 0 1 0 3 14 18 X 2 N'zerkore Lola 0 0 1 0 1 8 10 X 2 Yomou 0 0 1 0 1 6 8 X 2 N'Zerekore 0 1 0 0 6 10 17 X 8 N'zerekore Region 0 1 5 2 15 61 84 Matoto 0 0 0 0 6 0 6 X X X Dixinn 1* 0 0 1 3 0 4 X X 1 X Conakry Matam 0 0 0 2 1 0 3 X X 2 X Kaloum 1 0 0 0 4 0 5 X X 1 X Ratoma 1 0 0 3 8 0 12 X X 2 X Conakry Region 2 0 0 6 22 0 30 Total 20 2 3 12 9 58 137 221 11 12 35 11 # in Boke prefecture there is a second major hospital operated by ANAIM, an association of mining companies, that could be considered for inclusion in interventions *CHU Donka excluded in count as major construction/renovation to start soon; ^ Jhpiego was funded UNFPA to introduce SBM-R in these sites. ~ Jhpiego was funded by Alcoa Foundation to provide IPC training for providers from three health centers in Boke (others supported by USAID.OFDA) and by WHO for all facilities in Fria and Kindia. 37 Annex 2: MCSP RHS Monitoring Indicators Table GOAL: Restoration of Health Services to expand the number of integrated and quality maternal, newborn, and child health services (EmONC, FP, IMNCI) to an appreciable number of health facilities and communities, building upon the platform of previous USAID-supported work through MCSP and MCHIP and responding to the impacts of the Ebola outbreak

OBJECTIVE: Restoration of Health Services with a focus on quality improvement of maternal, newborn and child health services by: 1) Strengthening service delivery, 2) Creation of a favorable healthcare environment; 3) Demand Creation, and 4) Facilitating community engagement.

INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD IR1: Delivery and utilization of quality essential primary health care services is restored Sub IR 1.1: Restoration of Primary Health Services, including IPC Sub IR 1.2: Health Promotion and Fear Reduction through Successful Behaviour Change Communications Cross-Cutting Indicators CC Number of Number of people Training Monthly 350 71 HCW, 227 HCW, 78 HCW, 212 HCW 113 HCW 701HCW (200%) 1 people trained, including rosters providers; 99 CHWs, 196 CHWs, 316 CHWs 71 CHW (including training of trained those reached via 700 122 CHW trainers), 374 women onsite training CHWs, supervisor and 327 men Disaggregates: 335 CHWs s 682 CHWs (97%), 101 topics ; specific on IMNCI women, 581 men skills; cadre 122 CHW supervisors, (health care 32 women, 92 men worker, CHW); sex HCWs higher than expected because of change in target for IMNCI training, and modular BEmONC training for rural health center staff Detail by cadre and topic provided in Annex 3 CC Number of Number of new Training Monthly 20 0 0 20 0 NA 100% 2 new trainers trainers trained rosters trained and MNH qualified on Disaggregates: MNH function, sex 38 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD CC Percentage of Numerators: Supervisio Monthly 80% 30% 80% 58% 51% 93% 3 trained Number of trained n reports providers providers who who received received post post training training follow-up; follow up Denominator: supervision at total number of 6 week/3 providers trained month Disaggregated by : sex, cadre, period (6 week, 3 month), cadre (health care worker, CHW); Topics

CC Number of Number of Project Annual 3 1 NA NA 2 NA 1. Development of 4 National tools national tools and records Individual Learning and service service provision for PPFP provision guidelines related 2. Adaptation of developed/ to improve access BEmONC training adapted and to and use of into 3 modules validated health services 3. Community drafted with USG Mobilization Policy support, by program. (Eg : Not a primary objective IMNCI, MNH of this project, most service delivery, policy work supported referral system, under MCSP HSS etc.)

39 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD CC Number of Number of group Monthly Quarterly 16000 11,836 12,669 (FP: 16,918 23,205 (FP: 36203 100,831 (630% of 5 group educational report (FP=9736, 10605, (FP:14599, 20043; (FP:32259; target) educational sessions MNH=210 MNH:2064 MNH: MNH: 3162 MNH:3944 Likely underestimate of sessions conducted 0) ) 2319) ) original target conducted Disaggregates: Topic, location (facility, community) CC Number of Number of people Monthly Quarterly 128000 84,993 76,806 91,151 103,689 172,089 528,728 (413%) 6 people reached by group report (FP=74134, (FP: 67423 FP:80746, (FP: 89875, (FP:155,86 reached by educational MNH=108 , MNH: MNH: MNH: MN:16223) group session at facility 59) 9383) 10405 13814) educational Disaggregates: session Topic, sex CC Number of Number of Maternity Baseline, % over life NA 795,495 777,026 7 consultations consultations in /consultati Endline of project (5% increase compared (16% increase compared at health supported health on logbook (TBD). to same period in 2015) to same period in 2015) facilities facilities per month Disaggregated by: type of service/type of structure

40 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD Increase access and utilization of high quality of health services by delivering an integrated package of quality health services an appreciable number of health facilities and communities including Ebola-impacted areasç Supporting consistent and correct Infection Prevention and Control (IPC) practices Result 1: At least 80% of MCSP supported hospitals and health centers demonstrating improved IPC practices (n=221) 1. Number of Number of Training Quarterly 250 (in 10 231 70 0 0 0 301 (120%) 1 managers in managers in database districts) health facility health facility who who receive receive orientation orientation on on coaching coaching skill to skill to promote self- promote self- assessment assessment Disaggregated by : sex, cadre 1. Number of Number of Supervisio Quarterly 440 174 61 113 61 204 613 (140%) 2 monthly coaching visits n records coaching conducted on site visits at providers work conducted on site. site 1. Number/ Numerator: Supervisio Quarterly 80% 43/59 55/74 53/70 14/28 137/194 71% of health facilities, 3 proportion of Number of health n records health health health health health 60% of hospital health facilities that have facilities facilities facilities facilities facilities departments (from facilities that appropriate (64%) (74%) (76%) (50%) (71%) final assessment) have (standard and appropriate complementary) In 8 In 9 In 11 In 3 In 33 (and (and sufficient hospitals, hospitals, hospitals, hospitals, hospitals, sufficient quantity of) PPE 53/77 49/114 34/65 6/18 118/197 quantity of) Denominator: departmen departmen departme department departmen PPE for at total number of ts (69%) ts (43%) nts (52%) s (33%) ts (60%) least one health facilities month observed Disaggregated by : services type/facilities type

41 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD 1. Number/prop Numerators: Supervisio 80% 1/1 health 44/74 27/43 6/29 health 102/194 Final quarter is total 4 ortion of Number of health n records facilities health health facilities health achievement. Other health facilities that have (100%) facilities facilities (21%) facilities quarters only facilities facilities that access to clean (59%) (53%) (53%) reached during period have access water in each In 1 In 6 In 3 are reported to clean service delivery hospital, In 9 hospitals hospital, In 33 water in each point 2/29 hospital, 45/62 4/17 hospitals, Quarterly Service Denominator: departmen 73/114 departme department 132/199 delivery point total number of ts (6%) departmen nts (76%) (24%) departmen (SDP) health facilities ts (64%) t (66%) observed Disaggregated by : services type/ facilities type 1. Number/prop Numerator : Supervisio 80% 52/59 65/74 61/70 26/29 166/194 5 ortion of Number of health n records health health health health health health facilities that have facilities facilities facilities facilities facilities facilities that access to (88%) (88%) (87%) (90%) (86%) have access disinfecting agents to disinfecting Denominator: In 8 In 9 In 11 In 3 In 33 agents (and total number of hospital, hospital, hospitals hospitals, hospitals, sufficient health facilities Quarterly 67/77 98/114 61/66 17/18 168/191 quantity for observed departmen departmen departme department departmen at least one Disaggregated by : ts (87%) ts (86%) nts (92%) (94%) ts (88%) month) services type/ facilities type

42 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD 1. Number of Numerator: Supervisio Annual NA NA NA 7 NA NA 6 health Number of health n record facilities that facilities that have have fully fully functioning installed/reno incinerators to be vated and able to properly functioning dispose of the incinerators increased or waste pit quantities of (MCSP will disposable and advocate with potentially donors contaminated currently materials purchasing Denominator: incinerators total number of to place at health facilities focus Disaggregated by : facilities) facilities type

1. Number of Numerator: Supervisio Annual NA NA 29 NA NA NA Provision of autoclaves 7 health Number of health n record autoclaves not included in this facilities that facilities that have distributed project, indicator may have appropriate (no have accidently been appropriate autoclave additional carried over from IPC autoclave provided, to purchases) projects provided ensure proper instrument processing, with USG support Denominator: total number of health facilities

43 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD Improving quality of care using the Standards-based Management and Recognitions (SBM-R) Result 2: 35 Facilities supported to continue the SBM-R process and achieving or maintaining Recognition

2. Percentage of Numerator: Supervisio Annual 60% of NA NA NA 36% of NA 1 health Number of n record hospital; hospitals, facilities facilities achieving 45% of 14% of achieving/ / compliant with Health health compliant at least 80% of centers centers with at least performance 80% of standards through performance SBM-R process. standards Denominator: total number of health facilities observed Disaggregated by : facilities type, topic

2. Number of Number of Supervisio Quarterly 140 15 12 16 04 02 35% of target 2 quarterly quarterly joint n record joint visits visits with DPS to Difficult to coordinate with DPS to supervise SBM-R joint supervision due to supervise implementation competing activities SBM-R Disaggregate: type implementati of facilities on

44 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD Integrate and improve quality of maternal, newborn and child health services to an appreciable number of health facilities and communities in Ebola- impacted areas following the outbreak; Increasing the availability and improving the quality of MNH through a focus on integration of services Result 3: 26 Hospitals and 195 and health centers in 20 prefectures have increased capacity to offer RMNCH services6 3. Number of Numerator: Maternity Quarterly 60000 24,710/32, 22,087/30, 21,830/29 22,059/31, 27,593/28, 118,279/151,417 (78%) 1 women Number of women logbook 333 (76%) 174 (73%) ,438 (74%) 197(71%) 275 (98%) delivering delivering with with assistance of a assistance of skilled birth a skilled birth attendant* (in attendant health facilities with SBA). SBA is a trained nurse, or midwife or medical doctor Denominator: Number of birth registered at facilities.

45 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD 3. Percentage of The percentage of Maternity Quarterly 70% 20,476/ 19,676/ 18,916/ 20,216/ 26,580/ 102,864/116,297 2 women giving women who logbook 24,197 21,633 20,861 22,013 27,593 (88%) birth who received a (85%) (91%) (91%) (92%) (96%) received uterotonic uterotonics in immediately the third following birth, stage of labor may include through USG- women who supported delivered at the programs health facility normally or through cesarean birth and women who delivered at home Numerator: Number of women who received a uterotonic immediately following birth; Denominator: Number of women who deliveries in health facilities and at home Disaggregates: Type of uterotonic (misoprostol, oxytocin); location (facility, community)

46 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD 3. Number and Numerator: Maternity Quarterly 60% 9,228/24,7 8,986/23,0 8,230/21, 9,138/25,0 11,256/ 46,838/122,331 3 percentage of Number of women logbook 10 (37%) 87 (39%) 830 (38%) 98 (36%) 27,606 (38%) women delivering at (41%) delivering at MCSP-supported MCSP- facilities that are supported assisted during facilities with labor using a a completed partograph by a partograph in nurse or a doctor. their medical Denominator: All record women delivering at MCSP- supported facilities 3. Percentage of Numerator: Maternity Quarterly 90% 322/406 441/499 299/360 402/475 515/529 1979/2269 (87%) 4 cases of number of logbook (79%) (88%) (83%) (85%) (97%) severe pre- pregnant women eclampsia and diagnosed with eclampsia severe pre- treated with eclampsia/eclamp magnesium sia whose sulfate treatment included a full course of magnesium sulfate Denominator: number of pregnant women diagnosed with severe pre- eclampsia/eclamp sia

47 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD 3. Number and Numerator: Total Maternity Quarterly 60% 23,717/30 22,125/28, 20,391/28 21,276/29, 26,716/32, 114,225/148,805 (77%) 5 percentage of number of logbook 135 855 ,367(72%) 213 (73%) 235 (76%) newborns newborns put to (79%) (77%) breastfed the breast within within one one hour of birth hour of birth Denominator: Number of live births Disaggregates: Location (facility, community)

3. Couple Years Number of users Family annually NA NA NA NA NA 40,068 6 Protection of each method planning (CYP)* (FP method mix) logbook multiplied by a protection factor for each method from published sources.

3. Number of Number of Maternity Quarterly NA 982 (468 725 (350 647 ( 318 683 (357 823 (375 7 Stillbirths stillbirths by type logbook, fresh, 514 fresh, 375 Fresh , fresh, 326 fresh, 448 (fresh, macerated) macerated macerated 329 macerated) macerated at facility ) ) macerete ) d) 3. Number of Number of Maternity Quarterly NA 1092 890 964 1149 1236 5331 8 asphyxiated newborns not logbook, newborns crying or not successfully breathing at birth resuscitated successfully resuscitated

48 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD Increasing the availability and improving the quality of IMNCI services in facilities and in communities Result 4: 29 Facilities supported to improve Integrated Management of Newborn and Child Illness (IMNCI) Result 5: Community health workers (ASC) are providing community IMNCI (c-IMNCI) in 250 communities in three prefectures 4. Number of Number of Primary NA 985 714 748 4514 6157 13,118 1, children children < 5 years care 5. < 5 years with symptoms of consultatio 1 with pneumonia n logbook, symptoms of managed IMCI pneumonia Desegregation: logbook managed Facility, community 4. Number of Number of Primary NA 342 273 231 461 592 1899 2, children children < 5 years care 5. < 5 years with symptoms of consultatio 2 with diarrhea receiving n logbook, symptoms of care management IMCI diarrhea Desegregation: logbook receiving care Facility, management community Reinvigorate community health and mobilization activities of ASC to provide health information, accompaniment of pregnant women, FP services and key lifesaving interventions Result 6: 700 Community Health Workers (ASC) are supported to reinvigorate community health and mobilization to provide health information, accompaniment of pregnant women, FP services, as well as key life-saving interventions (advanced distribution of misoprostol for prevention of PPH) 6. Number of Total number of Health NA 475 496 443 887 586 2887 1 referrals referrals made facility made Disaggregates: reference Provenance logbook, (facility, CHW community); reference services (i.e., logbook pregnancy complications, newborn complications, child morbidity)

49 INDICATOR* DEFINITION** DATA FREQUENCY TARGET October – January - April – July – Sep October – Achievement AND SOURCE OF DATA December March June 2016 2016 December DISAGGREGATOR /COLLECTI COLLECTIO 2015 2016 2016 S ON N METHOD 6. Number and Numerator: Health NA Na Na Na na na 2 percentage of Number of cases facility follow-up given follow up reference referrals referrals after logbook, made receiving CHW treatment reference Denominator: logbook Number of cases Disaggregates: Level of facilities (health post, health center, prefectural hospital, regional hospital, national hospital); community

50 Annex 3: Details for Indicator C1, Healthcare Cadre, Gender and Training Topic Aux Nurse Training topic Doctor Midwife Nurse Biologist Other* Total (ATS) Provider skills training IPC 13 13 10 47 8 8 99 Basic EmONC 23 67 22 86 198

Comprehensive EmONC 18 23 1 2 44

IMNCI 10 2 27 146 8 193

Individualized Learning on PPFP/PPIUD 9 72 1 8 90

Training of trainers 0 0 0 0 0 0 0 Clinical Training Skills (trainers) 7 13 20

Training of trainers on individualized learning approach 15 14 29

Training of trainers on PPFP/PPIUD 3 7 10

Training of IMNCI trainers 18 18

Total 116 211 61 289 8 16 701

Gender of providers trained M F F M F M F M F M F M F 76 40 211 46 15 186 103 6 2 13 3 327 374 *Other includes: engineer (hygiene), health administrator, student, senior health technician, pharmacist and lab technician

Training type- Community Health M F Total Community health supervisors 90 32 122 Community health trainers 16 7 23 Community Health Workers 581 101 682 Total 687 140 827

51 Annex 4: Terms of reference of IPC focal points and coaches

TERME DE REFERENCES DES POINTS FOCAUX ET ENCADREURS PCI DANS LES STRUCTURES SANITAIRES POUR MCSP

Dans le cadre de la riposte contre l’épidémie de la maladie à virus Ébola survenue en Guinée depuis mars 2014, la coordination nationale de riposte contre l’épidémie de la Maladie à Virus Ebola et les partenaires de terrain (USAID, OMS, OFDA, ALCOA, et Jhpiego a organisé la formation du personnel de santé comprenant les prestataires de soins et le personnel de soutien des hôpitaux de Donka, Ignace Deen, Sino Guinéen, CMC Ratama, CMC Matam, CMC Minière, CMC Coleah, CMC Flamboyants, CMS Jean Paul II, les Districts sanitaires de Forécariah, Beyla, Kissidougou, Kindia, Boké, Fria, Faranah, Dabola, Mandiana et Dinguiraye. D’autres partenaires évoluant sur le terrain ont également planifié et réalisé des formations PCI dans certaines préfectures.

L’Objectif du programme d’intervention est de soutenir les prestataires et travailleurs des services de santé pour permettre une offre de services de santé sûrs et de qualité, en renforçant la PCI grâce à la formation pratique, l’encadrement sur site, et le suivi et l'évaluation des activités à l’aide des standards de performances.

Afin de renforcer la performance des prestataires dans les établissements sanitaires, et pour assurer le suivi du processus de pérennisation des acquis dans le domaine de la prévention et le contrôle des infections, le staff technique de MCSP, les formateurs et les responsables des services sont chargés d’apporter l’assistance technique aux structures sanitaires ciblées afin de mettre en place au niveau de chaque District sanitaire deux points focaux et une équipe d’encadreurs locaux.

Ces Points focaux auront pour taches : - Aider les chefs de services et chefs de centre de santé pour l’approvisionnement en fournitures et intrants PCI (Fiches standards de performance PCI, Fiche synthèse PCI, les listes de vérification, Affiches PCI, intrants PCI…) - Mobiliser les intrants et outils nécessaires qui seront utilisés par les encadreurs pour faire des démonstrations avec les prestataires ; - Planifier les encadrements mensuels avec les responsables des services et les encadreurs locaux avec l’appui du coordonnateur régional MCSP; - Impliquer le comité d’hygiène et de sécurité (CHS), les Comités de santé et d’Hygiène (COSAH) et les surveillants de services dans la réalisation des encadrements et l’évaluation des performances ; - Superviser la réalisation des encadrements dans les services concernés ; - Prendre des photos/ vidéos pour illustrer les constats effectués et enregistrer des témoignages ou des pratiques innovantes; - Analyser et rédiger le rapport mensuel des encadrements des prestataires en collaboration avec les encadreurs et le CHS/COSAH ; - Faire la restitution au responsable du site sur la base des lacunes identifiées et des propositions de résolution des lacunes ; - Acheminer le rapport de l’encadrement avec la liste des prestataires encadrés, la liste des personnels de soutien orientés, les fiches standards et de synthèse PCI remplies et tous autres documents utiles au Coordonnateur régional MCSP. - Organiser la restitution des résultats de l’encadrement lors des réunions mensuelles des DPS, au CTPS et au CTRS

Les encadreurs locaux auront les tâches suivantes : Avant la visite

52 - Rassembler/ organiser les documents (standards, les listes de vérification, formules de dilution) et réunir les intrants qui seront utilisés pour faire des démonstrations avec les bénéficiaires - Préparer et partager avec Jhpiego et responsables des services bénéficiaires, l’agenda avec un chronogramme précis des activités à réaliser, les cibles et les résultats attendus - Informer le service et le personnel bénéficiaire de la visite d’encadrement

Pendant la visite - Renforcer et améliorer les pratiques de prévention et de contrôle des infections (PCI) en utilisant les standards de performance (revoir la fiche synthèse de l’évaluation de base si disponible) en travaillant étroitement avec le personnel du service, - Discuter avec le personnel, des aspects précis sur lesquels portera la visite d’encadrement - Vérifier la disponibilité des : o intrants PI (fiche de stock, cahier d’inventaire, cahier/ou bon de commande) o outils de collecte PI o des points d’eau et de leur fonctionnalité o procédures PI affichées (formule de dilution chlore, lavage de mains, stérilisation, DHN, transmission-prévention de MVE) o unité fonctionnelle de dépistage et de triage - Collecter les données essentielles relatives aux stocks (antiseptiques, désinfectant, équipement de protection personnelle, matériel d’entretien) - Initier le personnel a l’utilisation des standards de performance de même que le processus d’auto- évaluation et d’auto-formation interne par le personnel du service bénéficiaire - Aider le personnel à résoudre les problèmes relatifs à l’approvisionnement - Faire la formation sur site des agents de soutien sur la PI - Assister le personnel pour l’évaluation interne et le remplissage de la fiche synthèse - Prendre des photos/ vidéos pour illustrer les constats effectués et enregistrer des témoignages ou des pratiques.

Après la visite - Faire le feedback au personnel pour améliorer la qualité des pratiques de PCI - Faire la restitution au responsable du site et sur la base des lacunes identifiées, formuler les objectifs à atteindre avec le personnel - Déterminer la date de la prochaine visite d’encadrement - Rédiger le rapport d’encadrement avec des recommandations à suivre