MaMoni Health Systems Strengthening Activity (USAID Cooperative Agreement AID-388-LA-13-00004)
Annual Report October 1, 2015 – September 30, 2016
After watching a video program conducted in her village, Shilpi Begum became motivated to come to recently renovated Binoykathi UH&FWC in Jhalokathi Sadar sub-district for four ANC checkups, and returned again to give birth to a baby girl on August 23, 2016. Binoykathi is one of the 75 facilities where delivery and newborn service was introduced to bring lifesaving services closer to home.
Submitted October 30, 2016
Cover Photo Story: Binoykathi Union Health and Family Welfare Centre (UH&FWC) was renovated with MaMoni HSS support. It is one of the 75 UH&FWCs where MaMoni HSS supported MOH&FW to introduce normal vaginal delivery and essential newborn care services.
Photo Credit: Mr. Nizam Uddin, Partners in Health and Development/MaMoni Health Systems Strengthening Project
This document is made possible by the generous support of the American people through the support of the Office of Population, Health, Nutrition and Education, United States Agency for International Development (USAID), Bangladesh (USAID/Bangladesh), under the terms of Associate Cooperative Agreement No. AID-388-LA-13-00004 through Maternal and Child Health Integrated Program (MCHIP). The contents of this document are the responsibility of the MCHIP Project and do not necessarily reflect the views of USAID or the United States government. Table of Contents MaMoni Health Systems Strengthening Activity ...... 1 Table of Contents ...... i Abbreviations ...... ii Executive Summary...... 5 Introduction ...... 8 Program Results for the YeAr ...... 8 IR 1. Improve Service Readiness through Critical Gap Management ...... 8 IR 2: Strengthened Health Systems at District Level and Below ...... 29 IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems ...... 46 National level technical assistance ...... 46 IR 4. Identify and Reduce Barriers to Accessing Health Services ...... 48 Challenges, Solutions, and Action Taken ...... 51 Challenges ...... 51 Way Forward ...... 51 Appendix 1: Scope and Geographical coverage of Mamoni HSS project ...... 52 Appendix 2: Program Performance Indicators (October 2015–September 2016) ...... 53 Appendix 3: MNCH Essential Drugs Monitoring Report ...... 69 Appendix 4: Documentation and Dissemination of MaMoni Program Learning ...... 72 Appendix 5: Links to Safe Motherhood day Videos and Media Stories Published ...... 73 Appendix 6: Status of Health Facility Renovations ...... 76 Appendix 7: Mid Term Evaluation and How the Recommendations were incorporated ...... 78
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report i ABBREVIATIONS AHI Assistant Health Inspector AMTSL Active management of third stage of labor BCC Behavior Change Communication BEmONC Basic emergency obstetric and newborn care BNF Bangladesh Neonatology Forum BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CB Community-based CEmONC Comprehensive emergency obstetric and newborn care CHW Community Health Worker CHX Chlorhexidine CIPRB Center for Injury Prevention and Research, Bangladesh CMAM Community-based management of acute malnutrition cMPM Community microplanning meeting CNCP Comprehensive newborn care package CSBA Community Skilled Birth Attendants CV Community Volunteer CVRS Civil registration and vital statistical system CYP Couple years of protection DDFP Deputy Director Family Planning DDS Drugs and Dietary Supplements DGFP Directorate General Family Planning DGHS Directorate General Health Services DRS District Reserve Store EPCMD Ending Preventable Child and Maternal Deaths FPI Family Planning Inspector FWA Family Welfare Assistant FWV Female Welfare Visitor GOB Government of Bangladesh HA Health Assistant HBB Helping Babies Breathe HPNSDP Health, Population, and Nutrition Sector Development Program HS Health systems HSS Health systems strengthening
ii MaMoni Health Systems Strengthening Activity: FY’16 Annual Report IFA Iron plus Folic Acid IMCI Integrated Management of Childhood Illness IPHN Institute of public health nutrition IR Intermediate result JSV Joint supervisory visit LAPM Long-acting and permanent method LMIS Logistics management information system MAMA Mobile Alliance for Maternal Action mCPR Modern contraceptive prevalence rate MCWC Maternal and Child Welfare Center MNCH/FP/N Maternal, newborn and child health, family planning, and nutrition MNH Maternal and newborn health MOH&FW Ministry of Health and Family Welfare MOLGRD&C Ministry of Local Government Rural Development & Cooperatives MOU Memorandum of understanding MPDR Maternal and perinatal death review NIPORT National Institute of Population Research and Training NNS National nutrition services OGSB Obstetrics and Gynecology Society of Bangladesh PPIUCD Postpartum intra-uterine contraceptive device QA Quality assurance QI Quality improvement QPRM Quarterly performance review meeting RD Rural Dispensary RHIS Routine health information system RRQIT Regional roaming quality improvement team SACMO Sub-assistant Community Medical Officer SAM Severe Acute Malnutrition SBA Skilled Birth Attendant SBM-R Standards-Based Management and Recognition SC Save the Children SCANU Special care newborn unit SDP Service delivery point SIAPS Systems for improved access to pharmaceuticals and services SSN Senior Staff Nurse
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report iii STG Strategic thematic group TBA Traditional Birth Attendant TOT Training of trainers UEHFPSC Union Education Health and Family Planning Standing Committee UFPO Upazila Family Planning Officer UHC Upazila health complex UH&FPO Upazila Health and Family Planning Officer UH&FWC Union Health and Family Welfare Centers UP Union parishad USAID United States Agency for International Development USC Union sub-centers
iv MaMoni Health Systems Strengthening Activity: FY’16 Annual Report EXECUTIVE SUMMARY Key Accomplishments of the MaMoni Health Systems Strengthening Project (MaMoni HSS) In the third year of implementation, MaMoni Health Systems Strengthening Activity (MaMoni HSS) Project strengthened its focus to support the national level initiatives of the MOH&FW by supporting the development of an implementation plan of the fourth sector program, initiating new collaboration in human resource management and quality improvement. MaMoni HSS also consolidated its inputs at the district level to ensure integration of services and stronger demonstrable results in service readiness and utilization in MNCH-FP-N at all levels.
Of the many accomplishments in Year 3, of note are three major accomplishments: In collaboration with the Directorate General of Family Planning, MaMoni HSS has completed a nationwide facility assessment covering all 4,461 union level health facilities to determine their readiness to provide normal delivery care and essential newborn care services. The output was a comprehensive database of these facilities, which will be used to advocate for investments from MOHFW and development partners to strengthen these facilities. MaMoni HSS has also completed seven divisional level dissemination and advocacy events to prioritize this initiative as part of the new Health Nutrition and Population (HNP) sector program. MaMoni HSS has completed the initial roll out of 7.1% chlorhexidine application for newborn umbilical cord care through public sector health facilities in all 64 districts of the country. MOHFW is supporting the roll out by procuring and distributing the product, whereas the project has supported the training of 80,579 public sector health workers, supervisors and managers at all levels. The project has also supported integration of CHX into the routine monitoring systems of MOHFW, and has supported a Newborn and Child Health Cell within the Integrated Management of Childhood Illness (IMCI) section to monitor rollout. As part of the national scale up, MaMoni HSS has also mobilized the support of private sector providers, NGOs, and other development partners to promote the use of CHX as part of essential newborn care for babies in the country.
In partnership with icddr,b, MEASURE, and MSH/SIAPS, MaMoni HSS continued to support the implementation of a comprehensive automated Routine Health Information System (RHIS) in Habiganj district. MaMoni HSS implemented a population registration system in Madhabpur and Lakhai upazila of Habiganj, registering 342,200 people and 68,796 in Madhabpur upazila and 56,105 people and 10,215 households in Lakhai upazila. 278,313 health ID cards have been distributed in Madhabpur upazila, ensuring that the care-seeking information and service contact with these clients can be seamlessly shared between different service delivery points. MNH & FP e-registers have been introduced in Madhabpur upazila and 78 participants were trained. 263 deliveries, 3,444 ANC, and 523 postnatal newborn examinations were recorded in the first 11 months of implementation of the MNH module.
Challenges and Mitigation Strategies
The key challenges presented to MaMoni HSS in Year 3 were:
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 5 • Drug shortage: The Drugs and Dietary Supplements (DDS) kits of UH&FWCs and the drug supply of the community clinics have been interrupted since September 2015 due to procurement issues at DGHS and DGFP. This has severely affected the coverage and quality of essential services at the community level. MaMoni HSS has been closely monitoring the situation, and where appropriate, has been liaising with the Union Parishads, and Ministry of Social Welfare to leverage temporary support to meet the shortfall for drugs and supplements such as oxytocin, iron plus folic acid (IFA), and misoprostol. • The online DHIS2 MIS system of DGHS does not include reporting for chlorhexidine (CHX) yet. Thus, even though chlorhexidine has been made available in 64 districts, and the new EmOC registers rolled out by UNICEF has space for recording CHX use, utilization reports are not available. MaMoni worked with the IMCI section of DGHS, UNICEF and the Saving Newborn Lives program of Save the Children to organize a joint meeting with the Director of MIS, DGHS to speed up the revision process. A sub-committee was formed to address this, and the registers were finalized in September 2016. In the DGFP MIS system, chlorhexidine reports were included, but the MIS-4 combines service (MIS-3 and CSBA data) and information (FWA MIS-1) data, with potential for duplication. MaMoni HSS is working with local statisticians to understand the scale of duplication, with a plan to inform the MIS unit with the learning. • FWA vacancy has increased as more and more of them are in the process of retiring. New recruitment has been on hold because of a lawsuit against the recruitment of 2014. MaMoni HSS is working with the field service delivery unit of DGFP to deploy stipend based volunteers (women from community or previous NGO workers) to alleviate the staffing shortage. • Union Parishad (UP) election continued in this year in some parts of Habiganj, therefore, local government resources were not available in those unions. MaMoni is undertaking orientation on the newly elected Union Parishads.
Way Forward In the fourth year of implementation, the focus of the project will be on the following areas:
i. Consolidate the district models to achieve the optimal level of coverage and quality of MNCH/FP/N interventions ii. Improve the effectiveness of national scale up of newborn interventions, including management of sepsis, KMC, etc. iii. Strengthen quality improvement at district and national level, including strengthening divisional level engagement in QI activities, and improving QI stages in health facilities in MaMoni HSS districts. iv. Complete the design of e-MIS and expand implementation to all of Habiganj and Noakhali districts v. Support MOHFW efforts for strengthening union level facilities and tracking progress and results, and vi. Support MOHFW to generate evidence for HRH planning and management
In addition, the project will continue its active engagement with the Planning Wing, Program Preparation Team, PMMU and Line Directors to contribute to the development
6 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report of OPs and PIP for the fourth sector program. The project will also provide operational and administrative support to the PMMU. MaMoni HSS will use the data from the national UH&FWC assessment to inform the finalization of the different operational plans of the HPNSIP, and directory of UH&FWCs.
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 7 Introduction The MaMoni Health Systems Strengthening (HSS) project, a four-year USAID-funded award,1 has the goal of improving utilization of integrated maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) services delivered through a health systems strengthening lens. The project supports the Ministry of Health and Family Welfare (MOH&FW) to introduce and leverage support for the scale-up of evidence-based practices that have been applied and tested in Bangladesh. To support this scale-up, MaMoni HSS is actively engaging with local government structures and nongovernmental organizations (NGO) to improve delivery of health services, and strategically partner at the national level to build consensus on policies and standards that positively drive evidence-based interventions at all levels. The scope and geographical coverage of the MaMoni HSS Project has been included in Appendix 1 of the report.
PROGRAM RESULTS FOR THE YEAR
IR 1. Improve Service Readiness through Critical Gap Management
1.1 Introduction and Scale-up of MNCH/FP/N interventions
1.1.1 Maternal Health 1.1.1.a Increasing ANC coverage ANC is the gateway intervention where often a woman’s first contact in her life with a health facility occurs when she is pregnant. MaMoni HSS has taken a multipronged approach to address service provider shortage, ensure satellite clinics and ensure the equipment and logistics for the providers. In collaboration with OGSB and DGFP, MaMoni HSS developed a competency-based training package on ANC, PNC and labor room protocol to ensure that the service providers are competent to screen for complications, and motivate the mothers to adopt preventive behaviors. The national package was field tested in MaMoni HSS districts and will be sent to the DGFP and DGHS in November 2016 for endorsement of the national technical committee. At the district level, MaMoni steadily increased the ANC coverage, as evidenced by Figure 1. Figure 2 shows the ANC 4+ coverage also increased rapidly.
Figure 1: Trend of ANC coverage (ANC 1+) from medically trained providers (population based surveys)
1 MaMoni HSS is the result of an Associate Award under the Maternal and Child Health Integrated Program, with a period of performance from September 24, 2013 to September 23, 2017. MaMoni HSS is supported by Jhpiego—in partnership with Save the Children, John Snow, Inc., and The Johns Hopkins University Institute for International Programs—with national partners: International Centre for Diarrhoeal Disease Research, Bangladesh; Dnet; and Bangabandhu Sheikh Mujib Medical University (BSMMU). Save the Children serves as the lead operational partner for the Award in Bangladesh.
8 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 120 2012 2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016(Round-IV) 81 81 80 73 70 74 76 70 71 75 72 75 74 64 66 68 66 65 69 70 70 73 60 61 70 70 56 51 53 67 50 44 56 37
20
Habiganj Jhalokati Lakshmipur Noakhali Pirojpur Bhola -30
Figure 2: Trend of ANC 4+ by medically trained providers (population based surveys) 70 2012 2013 2014 (Round-I) 2015 (Round-II)
2016 (Round-III)44 2016 (Round-IV) EoP Target 50 41 42 50 40 39 39 38 34 35 36 37 30 30 36 26 30 25 26 23 22 21 20 26 19 26 26 17 24 14 15 14 9 12 10
Habiganj Jhalokati Lakshmipur Noakhali Pirojpur Bhola -10
1.1.1.b Pre-eclampsia/eclampsia management at community level MaMoni HSS, is rolling out pre- eclampsia/eclampsia (PE/E) management interventions in 45 unions in five upazilas of the high intensity districts: Nabiganj (Habiganj), Companyganj (Noakhali), Kamalnagar and Ramganj (Lakhsmipur), and Rajapur (Jhalokathi). 168 participants from these upazilas were trained this year, along with 124 with the help of 5 core trainers and 26 master trainers. In addition, 96 referral level providers were oriented on management of PE/E at the referral level facilities
(District hospitals and MCWC). Photo 1: PE/E training participants practice administration of injectable magnesium sulfate The current MIS Form 3 of DGFP, which is used at on a dummy model. the union level, only captures information on mothers who received magnesium sulfate, but not mothers who were screened and identified with pre-eclampsia/eclampsia. MaMoni HSS has introduced supplementary columns to collect this information, and will advocate to DGFP for revision after a few months based on the findings. The project has also introduced a state-of the art Microlife® Blood Pressure machine to accurately detect high blood pressure. The machines have digital readouts with sound indicators when a blood pressure is above the normal threshold. These machines were distributed to the 24/7 facilities (mostly UH&FWCs). The project also leveraged funding from KOICA funded Mamota Project of Save the Children to provide magnesium sulfate to the implementing unions.
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 9 Between October 2015 and March 2016, 3 cases of PE/E were identified in the 45 unions, which was much lower than expected number of 490 PE/E cases assuming a 2.8 PE/E cases among 100 live births, as estimated by EngenderHealth.
1.1.1.b Misoprostol to prevent postpartum hemorrhage in home births MaMoni HSS is supporting service providers (mostly FWVs) from high intensity districts to distribute misoprostol to mothers during third trimester ANC visits to prevent postpartum hemorrhage in home deliveries. In the HSCS upazilas, the national approach of distribution through FWA continued. Around 119,930 mothers in the six districts received misoprostol through union and community level providers this year.
Figure 4: Monthly misoprostol distribution beween October 2015 to September 2016 15000 2,949 10000 3,519 4,010 4,229 4,222 3,177 3,740 2,079 2,252 2,491 1,784 5000 8,803 8,451 10,349 8,679 8,777 8,125 7,760 8,185 7,463 6,161 1,113 2,827 4,519 0 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16
Number of Misoprostol Distribution (HI) Number of Misoprostol Distribution (SUS)
As depicted in Figure 4, supply of misoprostol has been uneven due to frequent stock- outs and occasional expiration of procured drug. District and upazila managers have limited funds to procure locally to meet temporary shortfall. DGFP has taken initiatives to address misoprostol stock-out, and provided three months supply of misoprostol to all the MaMoni upazilas. MaMoni HSS is working with the Faridpur and Patuakhali regional stores of DGFP to supply more misoprostol to Jhalokathi Sadar and Nalchiti upazilas. The third and latest population based survey, completed in February showed wide variation in misoprostol consumption pattern between upazilas. Among home births, 49% of mothers of Ajmiriganj upazila of Habiganj reported consuming misoprostol right after delivery, whereas the rate was five percent and six percent for Jhalokathi Sadar and Lakhsmipur Sadar upazilas. The district trends are summarized below.
Figure 5: Trend of misoprostol consumption among women who delivered at home (according to population based surveys)
70 2012 2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) EoP Target 47 55 50 42 4350 45 35 34 33 28 30 23 22 30 30 21 22 19 18 25 14 14 11 10 8 8 7 8 7 8 9 10 3 3 2
-10 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur Bhola
The project also supported DGFP in rolling out misoprostol in 22 additional districts in March 2014. MaMoni HSS recently analyzed the performance data from these 22
10 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report districts. All districts reported distribution of misoprostol within 8 months of TOT except Rangamati. Rangamati and Joypurhat were the worst performers in terms of distribution: Rangamati reported no misoprostol distribution 9 out of the last 12 months, Joypurhat reported 3 months for the same period. In the past 12 months, average monthly distribution of misoprostol was 17.4 in Rangamati, 431 in Joypurhat. MaMoni has contacted DGFP to monitor use of misoprostol, and reach out to the managers of the low performing districts. Anecdotal information points to inadequate follow up from the central level, budget to roll out training, availability of master trainers to conduct training on time and drug stockout as reasons for poor performance.
1.1.1.c Increasing SBA at the District Level In the six MaMoni HSS districts, the project is supporting MOH&FW to strengthen the UH&FWCs to provide the comprehensive package of MNCH/FP/N services, including normal delivery care through a combination of leveraging existing resources of MOH&FW; mobilizing local resources; and providing direct inputs to meet facility needs (i.e. training, infrastructure improvement). As of September 2016, a total of 106 out of 246 health facilities, including 75 UH&FWCs in the 23 high-intensity upazilas are providing 24/7 delivery services. Overall, as depicted in Figure 4 below, institutional deliveries at the facility level are increasing.
Figure 6: Number of deliveries with SBA in 6 MaMoni HSS districts between October 2015 and September 2016
10,000 2935 2932 3,500 3,023 3,052 2,502 3,026 2,799 2,961 5,000 1,745 1,774 1,600 5,524 5,931 5,747 6326 6313 3,936 3,927 3,972 4,349 4,601 4,646 4,989 - Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16
SBA HI SBA HSCS
*Note: includes delivery at home by p/CSBA, UH&FWC, UHC, DH, MCWC Delivery at the 75 union level facilities has also been increasing, as shown in Figure 10.
Figure 7: Number of Normal Vaginal Deliveries (NVD) conducted at 75 UH&FWCs between Oct 2015 and Sep 2016
1500 1241 1183 1043 915 905 993 938 872 879 919 898 972 1000
500
0 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16
Delivery at UH&FWC
The trend of skilled attendance at births at the population level has been steadily increasing in most districts, particularly in the four high intensity districts, as can be seen in Figure 11.
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 11 Figure 8: Trend of skilled attendance at birth (population based surveys)
80 2012 2013 2014 (Round-I) 2015 (Round-II)
60 2016 (Round-III) 2016 (Round-IV) EoP target 5351 51 52 51 50 45 4750 45 43 40 36 36 39 37 37 40 32 34 3240 35 35 30 29 28 28 26 24 2530 19 22 20
0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur Bhola
1.1.1d Private CSBAs (pCSBA) supported Private community SBAs (pCSBA) are non-salaried workers, who only earn income by charging for different services (ANC, deliveries, PNC) and selling essential commodities. 38 new pCSBAs from Noakhali (18) and Lakhmipur (20) were certified by the Bangladesh Nursing Council in March 2016. Subsequently, these pCSBAs completed 21 days of residential clinical attachment at the OB/GYN wards of the District Hospital and MCWC at their respective districts and were deployed in May 2016. MaMoni HSS also continued to support the 54 private CSBAs in Habiganj from previous years. Uptake in Noakhali and Lakshmipur has been slow, as seen in the graph below.
Figure 9: Number of deliveries by pCSBAs in three districts (Habiganj (Oct 2015 - Sep 2016), Noakhali and Lakshmipur (May-July 2016)) 100 90 74 71 74 80 52 60 48 47 48 39 35 38 36 40 20 0 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16
Delivery by PCSBA
1.1.1.e Supported Health Facility Preparedness for MNCH/FP/N Services In Year Two of MaMoni HSS, the MOH&FW requested the project to provide technical assistance to the DGFP to strengthen UH&FWCs across the entire country by training providers, strengthening commodity management, and establishing quality improvement mechanisms. As a starting point, the project completed a nationwide facility readiness assessment of 4,461 health facilities and assessed infrastructure, FWV residence, human resources, Photo 3: Mr. Md. Nasim, MP, Minister, MOH&FW at training, furniture, equipment and supplies. The the dissemination meeting project also conducted a validation of collected data in all 7 divisions by supervisors. The project data collectors physically visited unions where no UH&FWC was found to reconfirm the data.
12 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report A total 4,461 UH&FWCs were assessed. 3,349 of the facilities were UH&FWCs and 3,269 were found to be managed by DGFP. 987 Union Sub Centers (USCs) and 125 Rural Dispensaries (RD) were also assessed. Out of the total 4,550 unions in the country, a total of 358 unions do not have any health facilities. Among the 4,461 union level facilities included in this assessment, a total of 1,112 were USCs and RDs and hence were excluded from further analysis for readiness for normal delivery and essential newborn care services. For the 3,349 UH&FWCs, the assessment assigned scores against seven criteria to determine the overall readiness of each facility to provide normal delivery and essential newborn care services. Based on the cumulative scores, each facility was grouped into categories A, B and C. The categorization indicates the overall readiness of the facilities to provide normal delivery and essential newborn care services and the level of inputs required to make them fully ready. Overall, 20% UH&FWCs (n=711) are in “C” category, which means these facilities need major inputs in several areas, including physical renovation, staffing, supplies and equipment etc. with a total of 66% UH&FWCs (n=2,370) are in category “B” , which will need medium to major inputs. Only 14% of UH&FWCs (n=486) are in category “A”,, which are either already functional or need minimum resources to make them fully ready.
Figure 10: Human Resource Status of Union Level Facilities (Percentage)
100 72.4 71.1 60 59.8 50 31 24.8
0 FWV Posted SACMO Posted MO Posted Pharmacist Posted Aya Posted MLSS Posted
If the category A facilities (14% of total) were prioritized, 450 health facilities could be providing delivery services. MaMoni HSS organized a national dissemination meeting to share the findings with the minister and secretary of MOHFW. Figure 11: Distribution of Categories of union level facilities functioning as UH&FWCs in Bangladesh 80 69 60 40 14 17 20 0 Figure 12: FWV Residence Status of Union Level Facilities A B C (Percentage) 100 81 39.8 50 19.5 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 13 0 Residence available for Residence in good FWVs residing FWVs condition
1.1.2 Newborn Health 1.1.2a. National scale up of 7.1% chlorhexidine to prevent newborn infection As part of the national roll out of chlorhexidine, MaMoni HSS oriented 80,579 public sector providers in 64 districts on application of 7.1% chlorhexidine. Participants ranged from medical officers to CHCPs providing services in the districts. Job aids and IEC materials have also been provided. In addition to this, another 961 service providers (mostly doctors and nurses) from 9 medical colleges received orientation on chlorhexidine. MaMoni HSS also supported a newborn and child health cell within the IMCI section of DGHS Photo 4: A participant in Daudkandi to support the monitoring of the scale up. UHC, Comilla practicing chlorhexidine application 32 Independent Monitors (IMs) also conducted post training follow up of 3,488 providers at 256 UHCs, and 64 Civil Surgeon offices. 85% of MOH&FW providers assessed received training, 91% received orientation booklet, and 81% correctly demonstrated proper application of chlorhexidine. Information was also collected from 256 UHC, 64 Civil Surgeon’s office, selected private clinics & pharmacy. Result shows 52% of the facilities had chlorhexidine during the day of visit. Chlorhexidine was available in 54% of pharmacies.
Figure 13: Percentage of Pharmacies interviewed that sell 7.1% chlorhexidine (by Division)
100 73 80 61 61 54 55 54 60 50 37 40 20 0 Dhaka Chittagong Khulna Rajshahi Barisal Rangpur Sylhet Total
ACI Pharmaceuticals Ltd. began commercial production in June 2015. The following figure shows the monthly over the counter (OTC) sale of 7.1% chlorhexidine bottles across the country.
14 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report
Figure 14: Number of chlorhexidine bottles sold over the counter (Source: ACI) 26,985 30000 22,918 25000 17,548 17,627 18,705 15,09516,775 20000 12,367 13,18012,592 13,367 13,45812,838 13,403 15000 11,299 11,680 10000 5000 0
DGFP has begun tracking chlorhexidine through their online portal from January 2016. Between January and August 2016, 156,105 newborns received chlorhexidine in DGFP managed facilities (MCWCs and UH&FWCs). The district breakdown is shown in the figure below:
Figure 15: Chlorhexidine use by district between Jan-Aug 2016 in DGFP facilities
As the MIS4 Form of DGFP combines reports of FWAs (MIS1), CSBAs (MIS3) and FWVs (MIS3), there is a possibility of double counting chlorhexidine application. MaMoni HSS is working with the Saving Newborn Lives program of Save the Children to improve the quality of reporting. Data from DGHS managed facilities will become available after the revisions to the recording and reporting tools are fully implemented. DGHS has not integrated chlorhexidine reporting in their DHIS2 systems yet. MaMoni HSS and SNL supported the IMCI unit to revise the recording forms, and the reporting system is expected to be online in November. In the MaMoni HSS districts, application of 7.1% chlorhexidine as an intervention started as an early implementation in Bahubal upazila of Habiganj district. Later the intervention was gradually introduced in other upazilas of Habiganj district and also
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 15 other districts of the project area. The project leveraged non-USAID funding for the procurement of 7.1% chlorhexidine and supplied it through the existing supply chain for the public sector providers of project area. In year-3, 32,224 newborns received 7.1% chlorhexidine application from DGFP facilities.
Figure 16: Number of newborns who received Chlorhexidine (Oct '15 - Aug '16) 1750 1544 Habiganj Noakhali Lakshmipur1406 Jhalokati Pirojpur Bhola 1500 1341 1379 1342 1309 1256 1187 1185 1234 1250 1118 1130 1048 1001 998 1036 1000 723 750 663 526 469 425 500 346 270 257 201 252 227 247 250 182 0 0 0 0 0 Oct'15 Nov'15 Dec'15 Jan'16 Feb'16 Mar'16 Apr'16 May'16 June'16 July'16 Aug'16
1.1.2b. Newborn Sepsis Management
MaMoni HSS, this year, scaled-up provision of newborn sepsis management services at the 163 union level facilities in 23 high intensity upazilas2 through Sub-assistant Community Medical Officers (SACMOs) for newborns in situations where referral was not possible or acceptable. National Technical Committee, in September 2016 endorsed providing of 2nd dose of injectable gentamycin by Family Welfare Visitors (FWVs). The project will be facilitating training of FWVs on sepsis management for the project area in the following year. The following figure shows the quarterly trend of newborns who were managed by the 266 trained SACMOs.
Figure 17: Sick newborns managed by SACMOs between Oct 2015-Aug 2016
2 All eight upazilas of Habiganj, Ramganj upazila of Lakshmipur and Companyganj upazila of Noakhali district
16 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report
4,349 sick infants (<2 months) were managed between October 2015 and September 2016. The project provided intensive support and collected additional information of the intervention in Ramgonj upazila of Lakshmipur district. Routine MIS data shows that, during the period of October 2015 to August 2016, a total number of 582 sick children (<2month) were managed at 10 UH&FWCs of Ramgonj upazila. Of them, 9 (2%) were critical illness cases, 93 (16%) were clinical severe infection cases, 222 (38%) had isolated fast breathing as single sign of illness, 85 (14%) were classified as local bacterial infection, 173 (30%) were other. Among 93 CSI cases, 14 (2%) complied with referral while 79 (14%) did not comply with referral advice and were managed at UH&FWC following national protocol of simplified antibiotic regime. All of them received a second dose of Inj gentamycin and 78 cases was followed up on day 4 and also on day 8. None of them died. MaMoni HSS also ensured that all 9 critical illness cases were treated at the Upazila Health Complex and District Hospital, as per national protocol.
Figure 18 : Distribution of sick infant (0-59 day) by category managed at UH&FWCs of Ramgonj, Lakshmipur between October 2015 and August 2016
N=582 CI [VALUE] (30%) [VALUE](2%) IFB [VALUE] LBI (14%) [VALUE] (16%) [VALUE] (14%) Other [VALUE] CSI( refer compliance) (38%) CSI (refer failure) [VALUE](2%)
Half of cases were referred by CVs while a good number of cases were self- reported/referred by others. Figure 19: Source of referral of sick young infants (0-59days)
[VALUE]% N=582 8% (12) (46)
[VALUE]% (209) Self and other CV Village Doctor GoB staff
[VALUE]% (315)
Johns Hopkins University’s HRCI project conducted an evaluation of the intervention in Ramgonj upazila of Lakshmipur district. This operations research was part of a collaborative effort of MaMoni HSS with Johns Hopkins University (JHU), Saving Newborn Lives (SNL) program of Save the Children, and icddr,b. The SNL program is implementing a similar intervention using the same newborn sepsis management
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 17 protocol in Kushtia district, and JHU has been implementing one in two upazilas of Sylhet district. This study is expected to provide critical evidence to understand the feasibility of implementing the National Sepsis Management Guideline at union level facilities, exploring relevant barriers and demonstrating problem solving strategies. The study duration was for 12 months and results of 2nd quarter (February to May 2016) showed that overall there was an increasing trend in utilization of sick children management services from the UH&FWC from an average of 40/month in round 1 to 63/month in round 2. 100% of CSI cases received 1st dose of injectable gentamycin, 92% of referral failure CSI cases received a 2nd dose of inj. gentamycin, 92% cases were followed up on day 4 by SACMO over telephone while 64% of cases were followed up by Family Planning Inspector on Day 8. Caregiver knowledge about recognition of 3 danger signs increased from 54% to 80%.
1.1.2c. Kangaroo Mother Care (KMC) 14% of all births in Bangladesh are pre-term, and 45% newborn deaths are due to prematurity. Bangladesh recommends introduction and national scale-up of KMC at the facility with its continuation in the community. Following national guidelines, the project supported introduction of this intervention in 16 facilities which includes 1 District hospital, 1 MCWC from district level and 2 Upazila health complexes, a total of 4 facilities from 4 districts. 25 doctors and 46 nurses & FWV were trained. A KMC Photo 5: Prof. Abdul Mannan of BSMMU management tool, developed at national level was facilitating a KMC session supplied to the designated facilities. 14 out of 16 facilities are ready to provide services, although case admission has been low. The project also arranged sensitization meetings, learning visit for consultant pediatrics to KMC unit of BSMMU, mobilization of local resources for the establishment of a KMC unit of Nokhali district hospital. In total, 27 babies received KMC services from five facilities since February 2016. 21 of them were referred from the same facility, while records were not available in six cases. Adherence to standards, consistent admission of cases, completeness of documentation of services by providers, duration of stay of cases in the facility, and community follow up are some of the key concerns. Refresher orientations on technical content, documentation of services, community follow up monitoring, promoting referral for appropriate clients from community level are some of the initiatives planned to address the issues. Figure 20: Duration of stay of babies in the facility for KMC by number of day (Feb – Aug 2016)
N=27
10 9
5 3 3 3 3 2 2 1 1 0
1 day 2 day 3 day 4 day 5 day 7 day 8 day 9 day no record
18 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report An abstract entitled ‘overcoming health system bottlenecks in implementing Kangaroo Mother Care at district and sub-district level health facilities in Bangladesh’ has been accepted for poster presentation for the 11th congress of the International Network on KMC that will be held in Trieste, Italy, in November 2016. 1.1.2.d Antenatal corticosteroids for threatened preterm labor MaMoni HSS introduced antenatal corticosteroids for threatened preterm labor in Noakhali and Habiganj district hospitals. 113 cases received ACS since March 2016 from 2 district hospitals. Adherence to standards, completeness of documentation of services by provider, and follow-up are some of the key concerns. Refresher orientations on technical content, documentation of services, and establishment of a mechanism of community follow up are some of the initiatives planned to address the issues. 1.1.2e. Special Care Newborn Units (SCANUs) MaMoni HSS supported the MoHFW to introduce SCANUs at five district hospitals. Four SCANUs: Noakhali, Habiganj, Pirozepur and Bhola, are currently functional, with Lakhsmipur began in October 2016. The nurses who received Emergency Triage, Assessment and Treatment (ETAT) training from the IMCI section of DGHS have been managing these SCANUs. For Noakhali and Lakhsmipur, the project has provided six nurses in Noakhali and Lakhsmipur to strengthen the services. 465 cases in Noakhali, 77 cases in Habiganj and 13 cases in Pirojpur SCANUs were admitted since February 2016. 1.1.2e Comprehensive Newborn Care Package Training A total of 1,207 Community Health Workers (CHWs) from Habiganj and Jhalokathi districts were trained on the CNCP package in six districts. Outreach workers (HA, FWA, CHCP) and their supervisors (AHI, FPI, HI) also participated. Although the outreach workers are not expected to perform deliveries or provide immediate newborn care, they are expected to conduct PNC visits (at home or at community clinics), promote chlorhexidine use, identify preterm/low birth weight and sick newborns and refer them to appropriate facilities. They have received appropriate job aids, including IEC materials. MaMoni HSS plans to conduct post-training follow up in subsequent quarters. 1.1.2f. Helping Babies Breathe (HBB) training on neonatal resuscitation and its follow- on Nationally, 28,734 skilled birth attendants were trained on HBB prior to year 3. This year, BSMMU trained 704 service providers at the medical colleges and private hospitals, previously excluded from training. The trainers also revisited five districts this year (covering all 64 districts in the project period) and conducted 190 post-training follow up assessments. 16 Neonatalies, 2,254 Bags, Masks & Suckers, and 115 DVDs were distributed to OGSB, Plan International, BSMMU, and 64 district CS offices as buffer stock. Smiling Sun Clinics of NHSDP project received a replacement of 128 HBB equipment sets from the IMCI section of DGHS with facilitation from MaMoni HSS. During August 2016, 32 independent monitors conducted a post training follow up of the CHX orientation. During the review, they also collected selected information on HBB. Information was collected from approximately 3,488 MOHFW providers. Review of findings showed that 83% of SBAs had resuscitation devices, 81% of them were cleaned appropriately and 66% of the providers used one of the devices (bag/mask or sucker) in the previous week.
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 19 1.1.2g Promotion of Essential Newborn Care at the community MaMoni HSS continues to promote preventive essential newborn care services through training, community mobilization, BCC and other approaches. The following two graphs show the trend of PNC and early initiation of breastfeeding in MaMoni HSS districts.
Figure 24: Trend of Postnatal checkup within 48 hours (from population based surveys)
55 2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) EoP Target 45 42 39 38 34 34 35 29 33 28 24 25 32 22 25 19 19 19 20 15 20 20 18 15 12 11 11 7 7 6 7 10 4 3 5 3 5
-5 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur Bhola
Figure 25: Trend of early initiation of breastfeeding (within 1 hour) (from population based surveys)
130 2012 2013 2014 (Round-I) 2015 (Round-II) 2016 (Round-III) 2016 (Round-IV) EoP Target 83 77 7785 79 77 80 75 71 67 65 7264 62 62 70 52 70 53 54 52 48 48 44 63 37 42 40 42 38 41 38 41 42 30
Habiganj Jhalokati Lakshmipur Noakhali Pirojpur Bhola -20
1.1.3 Child Health MaMoni HSS has seconded staff to support National Newborn & Child Health Cell within the IMCI section of DGHS. The cell supported 19 performance reviews of IMCI services from 2014 and 2015 calendar years with the local health and family planning managers and statisticians from 26 districts.
32 Independent Monitors conducted 320 visits to Photo 6: IMCI performance review IMCI-N corners all over the country and assessed conducted by IMCI section of DGHS quality of health and nutrition services for U-5 children in IMCI-N corners. They also coordinated local managers to address the gaps for better functionality of those IMCI-N corners. Those activities were coordinated and monitored closely from the Cell. Continuous monitoring of the IMCI-N corners from the Cell, shows the impact in the DHIS2. In FY15, the online IMCI reporting rate (national) was 45.18% and on time reporting rate was 34.66%, which increased in FY16 to 57.35% and 41.89% respectively.
20 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report
Case Study: Results of monitoring visits by IMCI-N independent monitors Place Ramu UHC, Cox’s Bazar Daulatpur UHC, Manikganj Visit date June 2016 October 2015 The problem No IMCI register to record information. IMCI room used for storage, and no visible However, nearby Teknaf has excess signboard or service board. registers in their store The action Negotiation with UH&FPOs led to Negotiation with UH&FPO to move the transferring excess registers to Ramu UHC store and make the room functional Result 100% timely reporting from both upazilas Routine IMCI care provided and reported between July-August 2016 from this facility In general, there was increase in utilization of services from IMCI-N corner other than Noakhali district. In the MaMoni HSS districts, utilization of IMCI services increased year to year. Figure 21: Utilization of services at IMCI corner during 2014 and 2015 by district
Pirojpur-total case at IMCI-N corner 2015 68283 Pirojpur-total case at IMCI-N corner 2014 55587 Bhola-total case at IMCI-N corner 2015 55559 Bhola-total case at IMCI-N corner 2014 40384 Jhalokati-total case at IMCI-N corner 2015 31217 Jhalokati-total case at IMCI-N corner 2014 25464 Lakshmipur-total case at IMCI-N corner 2015 74411 Lakshmipur-total case at IMCI-N corner 2014 64691 Noakhali-total case at IMCI-N corner 2015 101890 Noakhali-total case at IMCI-N corner 2014 117017 Habiganj-total case at IMCI-N corner 2015 125416 Habiganj-total case at IMCI-N corner 2014 110882 0 50000 100000
There was a decrease in diarrhea and pneumonia cases in inpatient departments of the facility, except diarrhea cases of Pirojpur district. Fig 22 : Number of diarrhea and Pneumonia cases admitted at inpatient during 2014 and 2015
6000 5,600 5,669 5,903 5,883 5,2275,115 5000 4,564 4,429 3,9393,881 4,017 3,561 4000 3,414 3,286 3000 2,497 2,162 1,860 2000 1,407 1,440 1,422 1000 610 670 365 171 0
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 21
However there is variation in timeliness and completeness of reporting by district which is probably an understanding gap by statisticians. Regular reporting from DGFP facilities is another big challenge of the program. Based on feedback from these meetings, the IMCI section provided necessary feedback to the district authority to address these issues.
1.1.3a Community Case Management (CCM) 85 Community Health Care Providers from 82 existing Community Clinics (CC) in Jhalokathi district are now treating ARI, pneumonia, and diarrheal cases along with nutritional counseling following the CCM protocol. CHCPs provide daily reports online from the CC. The project, in collaboration with UNICEF, is facilitating performance monitoring through monthly meetings of CHCPs at upazila and district level. The following figure describes the performance of these CCs in the past two quarters.
Figure 23: Trend of CCM cases seen in Jhalokathi district
3000 2580 2500 2198 2259 2103 2020 2000 1622 1500 880 889 1000 614 500 23 25 31 53 119 61 15 24 5 0 Very Severe No Pneumonia Pneumonia Fever-No Malaria Fever-Malaria Diarrhoea Disease
Jan-Mar'16 Apr-Jun'16 Jul-Sep'16
The data shows a slight quarter-to-quarter increase in service contact. However, because of possible seasonal variations and effect of Ramadhan, it is premature to draw a conclusion at this point. 1.1.4 Family Planning At the national level, the project participated in the FP2020 Bangladesh Country Engagement Working Group (BCEWG) meeting chaired by DGFP and attended by GOB managers and development partners. The participants discussed the revised costed implementation plan of the FP programs and reviewed the current status of the PPFP action plan. Apart from this meeting, the project also adapted the FP counseling training curriculum and materials developed earlier in coordination with DGFP and EngenderHealth. In addition, the project coordinated with CCSDP for the provision of master trainers from the national level to facilitate training activities in PPFP counseling in the project districts. At the district level, MaMoni HSS undertook several initiatives to strengthen the family planning interventions with a focus on postpartum family planning. 59 master trainers from four districts received TOT on PPFP counseling, a subset of whom in turn trained 34 providers on IUCD insertion within FY16, prioritizing health facilities where high numbers of deliveries are conducted. In addition, MaMoni HSS trained 30 service providers on PPIUCD from Noakhali and Jhalokathi districts.
22 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Figure 26 shows the uptake of PPIUCD in four MaMoni HSS districts. Because of Ramadhan, the June performance was lower than previous months, but expected to increase in subsequent months.
Figure 26: PPIUCD insertion in High Intensity (HI) and Health Systems Capacity Strengthening (SUS) sub- districts, October 2015 – July 2016
160 140 35 21 120 35 14 3 100 1 18 80 3 60 1 117 117 107 107 12 101 40 94 83 86 60 20 45 0 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16
No. of PPIUD performed (HI) No. of PPIUD performed (SUS)
DGFP has re-introduced progestin-only pill (POP) as a short-term method for PPFP. MaMoni HSS counseling package addresses this new addition. 95 CSBAs of Habiganj district received training on all FP methods with a focus on PPFP services and PPFP counseling. Figure 4 shows women counseled on PPFP by CSBAs for the first 10 months.
Figure 27: Number of women counseled on PPFP by CSBAs in MaMoni project area between October 2015 and July 2016
1500
1000 484 407 211 235 214 210 360 500 800 637 712 743 722 622 783 113 47 53 203 211 0 163 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16
No. of PPFP counselling (HI) No. of PPFP counselling (SUS)
MaMoni HSS is supporting integration of FP services in all service delivery points of MOH&FW, particularly in the upgraded UH&FWCs. This year, the CYP for the high intensity upazilas was 488,453 (65% of target) and in the health systems capacity building upazilas was 409,061 .Figure 28 shows the trend of method mix compared to the previous years. The majority of clients chose oral contraceptives followed by injectables, across all districts.
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 23 Figure 28 : Trend of Family planning method mix FY14, FY15 & FY16
90 80 70 60
50 % 40 30 20 10 0 FY14 FY15 FY16 FY14 FY15 FY16 FY14 FY15 FY16 FY14 FY15 FY16 FY14 FY15 FY16 FY14 FY15 FY16 Standard Habiganj Bhola Pirojpur Jhalokati Noakhali Lakshmipur
Oral pill Condom Injectable IUD Implant NSV Tubectomy
In year 3, 22% of new LAPM acceptors were referred by community volunteers of MaMoni HSS. Figure 29 shows current progress in LAPM uptake in project districts.
Figure 29: LAPM acceptors referred by CV and GoB between October 2015 to July 2016 3561 4000 3067 3000 2025 1994 1817 2041 2111 1792 2099 2000 1207 552 741 1000 372 292 305 362 303 394 207 479 0 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16
LAPM by CV LAPM by GoB
MaMoni HSS also supported Family Planning Service Week from May 14-19, 2016. In the high intensity MaMoni HSS districts, the project supported the event by holding discussions, organizing video shows, and supporting additional service campaigns.
1.14a Promotion of FP services through community volunteers Engaging and linking the community with the formal health care system is one of MaMoni’s most successful initiatives. For each 250 people, the project has a CV position who leads and organizes a Community Action Group (CAG). These CVs contributed to around 20% of long-acting permanent method (LAPM) referrals in the project area. To strengthen the activity, in collaboration with DGFP, 20,547 CVs were oriented on LAPM referral. The project also supported the development of a national curriculum for orienting volunteers to FP counseling. During the past year, about 37.4% of all LAPM referrals in the Habiganj district were made by CVs.
Figure 30: Trend of modern CPR in MaMoni HSS districts (from population based surveys)
24 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 100 2012 2013 2014 (Round-I) 2015 (Round-II) 90 2016 (Round-III) 2016 (Round-IV) EoP Target 80 71 70 65 58 57 58 57 60 56 56 5554 55 54 54 53 51 52 50 53 52 53 58 48 48 49 47 49 50 45 53 41 41 42 40 42 40 30 20 10 0 Habiganj Jhalokati Lakshmipur Noakhali Pirojpur Bhola The figure 30 shows a stagnation in FP service uptake. High vacancy of FWA, FWV and MO-MCHFP positions are contributing to this trend.
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 25 1.1.5 Nutrition 1.1.5.1 Nutrition Counseling and BCC
MaMoni HSS efforts to strengthen communication skills of health center staff have emphasized counseling activities (built into existing nutrition training curriculum from IPHN) within its nutrition trainings. In project areas, extensive efforts has been undertaken with frontline health workers to provide critical feedback on how to improve the quality of individual and group infant Photo: Nutrition Counseling by FWV at UH&FWC, feeding counseling. Practical suggestions, along Noakhali with demonstrations and visual aids facilitate engaged interactions between the health personnel and mothers, which are important steps to enhancing women’s understanding of key nutritional messages. Side-by-side to elevate consciousness the BCC team has been rolling out their activities in the core of the community. Regularly monitoring weight and Hb% through ANC visits which is strictly monitored by the program itself as an extended hand of MOH&FW. During the reporting period (Oct’15 – Jul’16) the project reached 212,922 pregnant mothers in all HI areas by providing IFA (Iron-Folic Acid) supplementation and nutrition counseling. At the same time 149,913 parents/care givers received BCC interventions that promote IYCF practice in the same geographical areas for growth promotion under GMP activities.
Figure 31: Number of caretakers of children who received IYCF messages as part of the BCC intervention
34579 29011 27225
18330 17916 15881 13122 11590 9245 9269 6652 5520 4300 5316 2969 1997
Noakhali Lakshmipur Habiganj Jhalokathi
Oct-Dec'15 Jan-Mar'16 Apr-Jun'16 July'16
1.1.5.2 Growth Monitoring and Promotion At the district level, MaMoni HSS focuses on basic nutrition counseling by health workers, and screening, identifying, and referring children with Severe Acute Malnutrition (SAM) to Upazila Health Complexes (UHC). Evidence from low- and middle-income countries indicates that growth faltering on average begins during pregnancy and continues to about 24 months of age. This loss in linear growth is not recovered, and catch-up growth later
Photo: CHCP is screening for on in childhood is minimal. While the MaMoni HSS malnutrition by measuring MUAC, in a community clinic in Ramganj, Lakshmipur 26 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report conceptual framework reflected a focus on children of preschool age, there is now more emphasis on policies and programs that support action before the age of 2 years, especially on health and appropriate infant and young child feeding and care practices. Among children under the age of five years, in Noakhali a total of 11,031, in Lakshmipur 3,775, in Habiganj 22,826 and in Jhalakathi 7,721 were identified as suffering from different types of under-nutrition. At the same time in Noakhali there were 3,461, in Lakshmipur 581, in Habiganj 6,610 and in Jhalakathi 2,728 children under two years of age were identified with different categories of under-nutrition.
2919 580
2040 9022
998 440 2172 2884 335 5756 869 1325 2877 1759 727 436 1705 975 600 4272 1313 5129 1818 1036 3388 721 111 1066 990 3476360 Noakhali Lakshmipur Habiganj Jhalokathi Oct-Dec'15 Jan-Mar'16 Nk Lp Hg Jk Oct-Dec'15 Jan-Mar'16 Apr-Jun'16 July'16 Apr-Jun'16 July'16
Figure 32.a Children <5 years screened Figure 32.b Children <2 years screened
In FY’16, a total of 45,563 under 5 children were identified who were suffering from any kind of under-nutrition (Underweight; Stunting; Wasting; MAM and SAM) and among them 13,380 children were less than two years.
Among these children 13,580 children were categorized as underweight, 8,561 children were categorized as stunted and 7,936 children were categorized as wasted. The distribution of these children are shown below.
Figure 33: Number of malnourished under-5 children (identified between October '15-July '16)
7000 6000 5000 4000 3000 July'16 2000 Apr-Jun'16 1000 0 Jan-Mar'16 Oct-Dec'15 Wasting Wasting Wasting Wasting Stunting Stunting Stunting Stunting Underweight Underweight Underweight Underweight Noakhali Lakshmipur Habiganj Jhalokathi
1.1.5.3 Severe Acute Malnutrition (SAM) Management:
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 27 In childhood acute under-nutrition management, two types of acute malnutrition are identified as per national protocol. These types of children are categorized as Moderate Acute Malnutrition (MAM) who are traditionally domiciliary treated and Severe Acute Malnutrition are referred for facility based management (SAM Unit/Corner at Upazila Health Complexes and District Hospitals). During the reporting period (Oct 2015 – Aug 2016) a total of 125 SAM patients were admitted into 10 SAM units of Photo: SAM Corner, Ramganj UHC, Lakshmipur
MaMoni HSS supported project areas. The distribution shown in Figure 34.
Figure 34: Number of children with SAM treated at the SAM units (Oct 2015 - Aug 2016)
Oct-Dec'15 Jan-Mar'16 Apr-Jun'16 Jul-Aug'16
24 23
12 13 9 10 9 11 6 8 0 0
Noakhali Lakshmipur Habiganj
1.2 Management of Critical Human Resource Gaps of GOB Service Providers MaMoni HSS supported the Human Resource Management Unit (HRMU) of MOH&FW to undertake the implementation of the health workforce strategy (2016-2021). The support includes a study on workload and staffing needs assessments at the district and below, pilot implementation of the health human resource information system (HRIS) in Habiganj and Noakhali districts, and national rollout of the HRIS for planning and management decision support. In the six districts where implementation is in progress, the project is currently supporting 58 paramedics, one EmOC-trained Medical Officer, and 19 nurses to fill the critical human resource gaps.
Table 2. Summary trend of critical health workforce vacancies in high- intensity districts, as of Sep 30, 2016. FWA Vacancies FWV Vacancies Nurse Vacancies District FY 14 FY 15 FY 16* FY 14 FY 15 FY 16 FY 14 FY 15 FY 16
Habiganj 34 45 64 18 13 16 52 49 49
Noakhali 82 71 118 5 3 10 60 41 65
Lakshmipur 42 34 60 3 5 7 34 35 33
Jhalokathi 40 40 64 8 5 3 0 1 4
Total 198 190 306 34 26 36 144 126 151
28 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report
Table 2 shows the year to year change in vacancies in three critical cadres: FWA, FWV and nurses and highlights the effects of an aging workforce and attrition. Because of a lawsuit, FWA recruitment has been stalled since 2014. The DGFP has deployed contractual workers (volunteers deployed against vacant FWA units, paid volunteers for LAPM referral only) nationwide to address the FWA vacancies, but the number is quite small compared to the need. 45 volunteers have been deployed in Noakhali district in year 2, and 240 additional paid volunteers (for LAPM referral only) have been deployed this year. The MOH&FW is similarly in the process of recruitment and deployment of 9,000 nurses. MaMoni HSS is closely working with the Directorate of Nursing Services (DNS) and DGHS to ensure that a substantial number of them are deployed in MaMoni HSS districts to address the critical shortage.
IR 2: Strengthened Health Systems at District Level and Below
2.1 Strengthen District Planning and Performance Management With the aim to improve the maternal, newborn, child health, family planning and nutrition (MNCH/FP/N) situation in MaMoni HSS districts, the project supported the development of a plan through a very rigorous process of determining local level priorities from the union level to upazila and district levels. The whole process followed the analysis of current status Photo: Habiganj district planning workshop in February 2016 and bottlenecks using available data, identification of corrective action and resources needed with its availability and setting achievable targets with monitoring plan. Identification of critical gaps was under four domains which were service availability, accessibility, utilization, and quality index. A minimal set of tracer interventions like antenatal care, SBA delivery, newborn care, postnatal care and family planning which have the highest impact in reducing maternal & neonatal mortality and improving quality of life were analyzed during the whole planning process. Some other priority MNCH/FP/N interventions like EmOC, newborn care interventions (e.g., chlorhexidine, antenatal corticosteroids, Kangaroo Mother Care, sepsis management, HBB) and advanced newborn care (e.g., SCANU, referral system) were also considered during the discussion process.
In Year 3, the planning workshops were held in all districts with representation from upazila and union level staff. The districts have developed one plan for each upazila and also planned for two low performing unions from each upazila. A separate plan was developed for district hospitals. In total, four DH plans, 40 upazila plans and 48 union plans were developed in FY’16. These plans were monitored during JSV and reviewed in monthly upazila and district monthly meetings as well as in the 22 quarterly performance review meetings at district level.
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 29 In addition to the monthly and quarterly reviews, the teams conducted an annual review of the plans and to reset the targets and to revise the action plans to accommodate changed circumstances in the district. This local level planning helped the upazila and district GOB managers in decision-making by identifying critical gaps and resource mobilization both from public and private sectors. It is an ongoing process for improvement and availability of services with quality.
2.2 Strengthened Quality Improvement Initiatives 2.2.1 National Level Contributions In Year 3, MaMoni HSS expanded its support to the National Quality Improvement secretary (QIS), including boosting its human resources capacity and supporting a joint workplan for capacity building of staff at national, divisional, and district levels. The project continued to implement its generic strategy to improve the quality of clinical care in stages starting with improving basic cleanliness and infection prevention and incrementally progressing to improving MNCH/FP/N clinical services. The project is focusing on strengthening local leadership/ownership for QI through QI committees at all levels and encouraging the engagement of local government in resource mobilization and QI. It strengthened the supervision system and promoted the concepts of supportive supervision where supervisors are agents of capacity building, guidance, encouragement, gap identification, and problem solving. The project put a special emphasis on improving the quality of emergency obstetrics and newborn care through the specialized regional roaming quality improvement teams (RRQIT). In addition, the project implemented maternal and perinatal death review (MPDR) to strengthen death notification, identify gaps in health care seeking and service delivery, and share results to avoid future maternal and neonatal deaths. The project implemented SBM-R in selected facilities to build the capacity of service providers in assessing their own services and improve them. MaMoni HSS provided assistance to improving the management of MNCH/F/N essential drugs and supplies at the national and district levels. The project has established a regular system for measuring key QI indicators in sentinel health facilities, assessed every six months.
Supporting National Quality Improvement Secretariat:
MaMoni HSS has expanded its support to the MoHFW at the national level in several areas including improving quality of clinical care. During year 3, the project expanded its contribution to the development and implementation of the national QI strategy. The project signed a Letter of Collaboration (LOC) with the Quality Improvement Secretariat (QIS) of the MoHFW. The overall purpose of the LOC is to strengthen the capacity of the QIS in leading the national effort to develop and coordinate QI strategies and interventions to improve clinical services across the country. MaMoni HSS project’s support focuses on strengthening the institutional capacity of the QIS in providing technical leadership and management oversight for the implementation of the national QI strategy. The specific areas of the project’s support to the QIS includes: • Strengthening the technical and managerial capacity of the QI Secretariat: The project is recruiting staff to be seconded to the QIS at the national level. Staff include a National QI Advisor, a National QI Coordinator, MIS and administrative assistant staff. At the Divisional level, the project is seconding QI Coordinators and QI Monitors to facilitate the implementation of QI strategy at the district level across the country. In addition, the project is supporting the formation of a national pool of QI facilitators, who have been trained and assigned to support the QI
30 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report initiative at district and sub-district levels. During year 3, the project supported the capacity building of the QIS national pool of consultants through a national workshop, July 31 – August 3, 2016, in coordination with the global ASSIST project.
• Facilitating the establishment and functioning of the decentralized QI management structures at divisional, district and sub-district levels: MaMoni HSS is supporting selected divisional staff, seconded to the QIS to facilitate the formation of the divisional, district and sub-district level QI committee across the country. The project’s technical support also includes the development/ finalization of training manuals, facilitation tools and supervision/ monitoring tools for the national, QI facilitators, divisional and district level QI committees.
• Provide technical assistance to developing/ updating national guidelines, protocols and tools to support the implementation of the national QI strategy: In line with the strategic objectives 2 and 3 of the national QI strategy, MaMoni HSS provides support the QIS to develop/ modify/ finalize the standard operating procedures and benchmarks for various clinical and management practices.
• Supporting the development of a system for developing and monitoring QI indicators for various clinical services: MaMoni HSS is working with the QIS to select key clinical services QI indicators to monitor progress in improving the quality of services.
Leading the coordination of USAID QI efforts through Quality Improvement Council (QIC):
The project is acting as chair for the QIC, formed based on the request of USAID with the purpose to coordinate QI activities among USAID funded projects and to streamline support of USAID funded projects to the QIS of the MOHFW. The QIC includes representatives from all major USAID funded programs contributing to improving the quality of MNCH/FP/N in Bangladesh. On August 18, 2016, MaMoni HSS convened the first QIC meeting with all members. The meeting reviewed the purpose, objectives and modalities of the QIC. Members started the activity of developing Terms of Reference for the QIC. The group started mapping out the contribution of each program by health area and by district. In addition, the QIC started to collect an inventory of all QI guidelines and materials that will be available online for sharing with all members and with the QIS.
Improving Quality of Clinical Services in Stages: The project is supporting the MoHFW to improve the quality of clinical services at the district level. During year 3, the project continued to implement the new QI strategy aiming to improving the quality of clinical care provided at health facilities in stages.
Stage 1; to improve the cleanliness, infection prevention, and medical waste management;
Stage 2; to improve sterilization measures and compliance with antenatal care and newborn care services, and
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 31 Stage 3; to improve compliance with all range of MNCH/FP/N standards.
The project developed, in coordination with district level counterparts, specific district plan of action to ensure that health facilities apply interventions to complete the stages of QI. The following table summarizes the status of health facilities of QI stage by district.
Table 2: Number of Health Facilities at Different Stages of QI, by District
Stage of QI District
Habiganj Noakhali Lakshmipur Jhalokathi
Stage 1 58 35 50 29 Stage 2 16 8 8 4 Stage 3 4 0 0 0 Total number of health facilities 78 43 58 33
Challenges for completing Stage 1: Despite the improvement documented in several facilities, particularly in Hg district, several facilities are still at stage 1, i.e. have not completed the basic improvement in cleanliness and infection prevention. One of the main obstacles is ensuring acceptable medical waste management including the proper construction of waste management pits in the premises of the health facilities. This requires the engagement of local government for resource mobilization to construct the needed pits. In general, the improper medical waste management practices is not a priority for health officials at the national or district levels. Advocacy and creative thinking for resource mobilization is needed to improve medical waste management.
Case Study: Example of improved health facilities
Binoykathi UH&FWC, Jhalokathi Sadar Upazila, Jhalokathi District completed Stage 1 QI in this June 2016. The following table summarizes the improvements
Table 4: Binoykathi UH&FWC, Jhalokathi (before and after improvement)
Situation before improvement Situation after improvement Interventions that led to (Q1) (Q3) improvement Cleanness is absent in and outside The facility is clean inside and outside. Motivation by counselling of the facility. service provider through supervision. No medical waste dumping pits Medical waste dumping pits in place. Prepared by MaMoni HSS. exist in the premises of the facility. Chlorine solution for Chlorine solution prepared and used for Motivation by counselling of decontamination of used decontamination of used instruments. service provider through instrument not prepared. supervision. No color coded medical waste bins Color coded medical waste bins in place. Supplied by MaMoni HSS. in place. Partograph not used during labor. Partograph is used during labor Training given and partograph supplied by MaMoni HSS.
Binoykathi before improvement After improvement
32 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report
2.2.1b Recognition of staff and health facilities that achieved significant improvement
On May 11, 2016, the project organized a recognition event in Habiganj district for three health facilities that achieved significant QI of clinical standards (Murakuri, Shibpasha, and MCWC). The event was attended by several officials from national DGFP, DGHS, QIS, and Habiganj, MoHFW, and local government officials. The event contributed to raising the Photo 9: Recognition ceremony at Habiganj profile of QI activities in the district.
2.3 Increase Local Ownership Of Quality Improvement Through Establishing (QI) Committees One of the important challenges to improving the quality of clinical care is strengthen the MoHFW health managers and service providers to play a leadership role and take ownership of effort to improve the quality of clinical care. The project is increasing the local ownership of the QI process through the establishment of QI committees, as per the guidelines provided by the QIS. The project is facilitating the formation of the QI committees at district, upazila, and health facility levels and the meetings of the different committees. The project’s facilitation is focusing on making sure that while the counterparts from the MoHFW taking the lead and ownership of the process, the meetings of the QI committees are effective in identifying gaps in performance and action plan in response. The project is also facilitating the follow up for the implementation of the action plan and feedback to the QI committee on progress. The project is also providing facilitation to ensure the engagement of local government in the QI Committee meetings for increasing resources for replenishing supplies, conducting minor renovations, and building waste management pits with local resources.
The table below summarizes the status of the formation of QI Committees by district.
Table 5: Status of QI Committees in four high intensity districts (April-June 2016)
Number of QI Committees District Habiganj Noakhali Lakshmipur Jhalokathi
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 33 Total to be formed 86 43 54 40 Actually formed 73 42 54 35 Active (had at least 1 meeting in 42 41 49 25 the last 3 months)
Some of the QI committee meetings did not take place as members were engaged in training off site.
2.4 Strengthening routine supervision system and promoting supportive supervision: The project continues to provide support to strengthen the supervision system at the district level. Specifically, the project facilitates the establishment of a supervision visit schedule from first line supervisors, and union level staff such as Health Inspectors (HI) and Family Planning Inspectors (FPI), to the community level services provided by FWAs. The project also facilitates developing supervision plans for second line supervisors, from upazila level staff such as civil surgeon, DDFP, and MOCS to UH&FWCs. The facilitation includes developing monthly visit plans, joint supervisory visits (JSV) and ensuring the effectiveness of the supervisory visits through applying the concepts of supportive supervision where the supervisor plays a role in mentoring, capacity building, problem solving, and quality improvement. Supervisory visits are taking place using structured supervisory checklists in areas including: infection prevention measures, service delivery management, ANC, nutrition, FP, newborn and child health, IMCI, normal vaginal delivery, and postnatal care. The facilitation of the project ensures that each supervisory visit identifies gaps and action plans for improvement.
The table below includes the number of supervisory visits planned and conducted by district this year:
Table : JSVs conducted between Oct-Aug 2016
Districts 1st Line (Union) 2nd Line (Upazila/District) Planned Accomplished Planned Accomplished Habiganj 36 41 48 34 Jhalokathi 16 16 08 06 Lakshmipur 30 30 15 10 Noakhali 19 14 08 12 Total 101 101 79 62
Table : Example of Common Findings of JSV checklists, Lakshmipur District
JSV Findings Action Plan Developed During BCG period, ensure birth registration of Newborn birth registration not completed. newborn. Citizen Charter will be ensured by communicating Citizen Charter not found, FWC Management UFPO. Need to organize FWC Management Committee Committee meetings are not held regularly. in due time.
34 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report The Facility has no color coded bins for medical Shared with UP chairman to ensure three color coded waste management. bins. FWA register were not available in cMPM. Ensure FWA register at cMPM. Ensure misoprostol tab at pregnancy period and find No supply of misoprostol tablets. out the root cause of the stock-out. DDS kits are not available. Ensure DDS kits and other essential drug items. BCC materials are not used in service centre Ensure BCC materials for use in service centre during during counselling. counselling. The facility has no regular medicine supply for the Shared with DDFP and UFPO to ensure medicine last 4 months. supply regularly. UH&FWC Performance board was not up to date. Shared with FPI & UFPO for updating performance board. There is no infection prevention logistics, such as Shared with UP chairman to ensure the supply of chlorine solution. infection prevention logistics.
Photo: DDFP 2nd line JSV to a satellite clinic, Rampur Union, Companyganj Upazila, Noakhali District.
2.5 Maternal and Perinatal Death Review (MPDR): Maternal and Perinatal Death Review (MPDR) is one of the interventions endorsed by the MoHFW for implementation at a national scale to cover all districts. It has the objectives to improve maternal, newborn, and stillbirth death notification, map out death incidences to identify Unions with high numbers of deaths, conduct analysis of the causes and circumstances associated with mortality and use information to take action to avoid future mortality. MaMoni HSS is assisting the MoHFW in scaling up MPDR in one full district (NK) and initiated implementation in three other districts (Hg, Lp, JK). The operational guidelines for implementing MPDR have been finalized and the data collection Excel file has been developed to enable the district level staff to record and map Figure 10: Begumganj Upazilla, Noakhali District, mortality data. mapping of maternal, newborn deaths, and stillbirth, by Union from April 2015 to August 2016 The following map shows preliminary data from
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 35 Begumganj Upazila, NK on the distribution of notified mortality by Union.
Results of Verbal Case Autopsy (VCA), Begumganj (April 2015-June 2016)
Out of a total of 16 maternal deaths and 118 newborn deaths notified in Begumganj district in one year (April 2015 to June 2016), 10 and 40 VCAs were conducted respectively to investigate the causes of mortality. Preliminary results suggest that more than half of maternal mortality (60%) occurred during transportation to or from a health facility, 20% died at home, 20% died in a health facility. The place of delivery for maternal mortality cases were home (37.5%), UHFWC (25%), and private hospital (37.5%). The causes of death were postpartum hemorrhage (83.3%), eclampsia (33.3%), placenta retention (16.7%), other causes (16.7%).
For newborn death, results of VCA revealed that 33.3% of newborn mortality took place within 6 hours of delivery, 20.5% from 6 to 24 hours, 30.8% from 1 to 4 days, and 15.4% from 4 to 28 days of delivery. Place of delivery was: 45% at home, 27.5% at private clinic, 27.5% at a public facility. 28% of newborn death was associated with low birth weight (less than 2.5 kg).
Social Autopsy was performed with communities where maternal mortality has taken place to discuss the factors associated with the mortality and actions to avoid future mortality such as ensuring a delivery plan and organizing transport to a health facility in case of emergency for home deliveries.
MaMoni HSS Project’s effort to implement MPDR lies within the national strategy developed by the MoHFW to scale up MPDR in all districts of Bangladesh. The lessons learned from the early experience of introducing MPDR in Begumganj upazila will be useful in guiding the design of the technical and operational national implementation strategy. In general, the tools used for death notification, facility death review, and verbal and social autopsy, were easy to understand and use by MoHFW staff at all levels.
The results obtained from the verbal autopsy
Photo: Social Autopsy conducted at the confirm the major causes of maternal and newborn community level around a maternal death, mortality. While the coverage of antenatal care Kutubpur Union, Begamganj Upazila, Noakhali district (ANC) has generally increased across the country, many women still do not get ANC from appropriate sources, do not have a plan for delivery, and deliver at home. Mapping of maternal, newborn, and stillbirth to show the distribution of deaths by union has proved valuable in focusing the attention of policy makers to unions where most of mortalities take place. The designated staff could competently carry out the verbal and social autopsy confirming the technical feasibility of the intervention. However, on the operational side, there are several challenges to the implementation of MPDR at a large scale including:
• The need to strengthen local level data management and utilization. • There a need to strengthen follow up action identified at the social autopsy e.g. improve referral of cases and ensure identification of delivery plans at ANC services. • Sustainable source of funds need to be found at the local level to support basic travel cost for performing verbal and social autopsy.
36 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report • Leadership and motivation of local staff are needed to own the process of MPDR and ensure data utilization. Based on the early experience of Begumganj, MaMoni HSS Project is scaling up MPDR implementation in four additional Noakhali district upazilas, one upazila in each of Habiganj, Lakshmipur, and Jhalokathi. In addition, the project is participating in a working group at the national level, led by Quality Improvement Cell, to share experience and develop national guidelines.
2.6 Standards-based Management and Recognition (SBM-R): In year 3, the project continued the implementation of different steps of SBM-R implementation in 35 health facilities in Habiganj, Noakhali, Lakshmipur, Jhalokathi districts. SBM-R is a QI approach that focuses on building the capacity of the service providers to assess their own performance against set clinical standards and take action for improving performance and measuring impact. All facilities has completed the basic steps of SBM-R including baseline assessment, first internal assessment, second internal assessment, and external assessment. Based on the findings of each assessment, the staff of the heath facility implements an action plan for improvement. As mentioned above, the project conducted a recognition event in Hg district for three health facilities (Murakuri, Shibpasha, and MCWC). The three health facilities were selected as they were able to achieve a total score above 70% of SBM-R standards as documented by the external assessment conducted in the health facilities. The graphs below summarize the progress in improving compliance with standards of services for birth spacing and family planning, ANC, normal vaginal delivery, and infection prevention and facility management, in the three recognized facilities.
Figure 35: SBM-R scores of three facilities in Habiganj district Murakuri FWC
120% 100% 89% 87% 88%91% 100% 78% 78% 78% 79% 67%67% 71% 64%64% 68% 80% 57% 55% 57% 59% 54% 60% 44% 38% 42% 40% 19% 20% 0% BS & FP ANC Normal Labor & IP Facility Total Child birth management
Murakuri Murakuri Murakuri Murakuri
Shibpasha FWC
150% 100% 100%86% 100% 100% 67% 67% 78% 73%82% 76% 71% 80% 100% 57% 57% 46%63% 50% 29% 44% 27% 33% 30% 42% 42% 34%41% 50% 0% 0 0 17% 0%0% 0% BS & FP ANC PNC Normal Sick Obs IP Facility Total Labor & newborn Complication management Child birth care management
Baseline 1 st internal 2 nd internal External
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 37 MCWC 82%86% 89% 80% 88%91% 80% 100% 67% 78% 71% 78% 71% 57% 67% 55% 57% 59% 54% 64%64% 45% 44% 38% 50% 19% 25%25% 0% 0 0 0% BS & FP ANC PNC Normal Labor Obs IP Facility Total & Child birth Complication management management
Baseline 1 st internal 2 nd internal External
2.7 Establishing and supporting Regional Roaming Quality Improvement Team (RRQIT) to strengthen comprehensive emergency obstetric and newborn care RRQITs are considering specialized supervision teams to assess and improve the CEmONC services. The project continues to utilize the technical capacities available at the regional level, such as medical colleges and professional associations, to provide specialized technical support, through RRQIT, for improving CEmONC services. The project had developed RRQIT, in line with the national strategy for developing divisional quality improvement teams, in Sylhet and Barisal. Both teams had visited respective districts (Hg, Jk) and developed action plans for improvement of CEmONC services as well as general management of district hospitals and MCWCs.
To date, the project has formed RRQITs in Sylhet, Barisal, and Chittagong divisions. The Sylhet RRQIT conducted two visits to the Habiganj DH. The Barisal RRQIT visited Jhalokathi DH twice. The second RRQIT visits to Habiganj and Jhalokathi were held in May 2016. Plans are underway for the Chittagong RRQIT to visit Lakhsmipur and Noakhali.
In addition, the project followed up on the implementation of the findings and action plan developed based on the visit conducted by the Sylhet RRQIT to Habiganj district and the Barisal RRQIT to Jhalokathi district. The following table summarizes the action taken for improvement based on the RRQIT findings.
Table : Summary of RRQIT follow up findings and changes observed between the first and second visits to Jhalokathi and Habiganj district hospitals
Subject Positive Changes/ Area to Improve Comments/ observations suggestions
Jhalokathi District Hospital Infection Color coded medical waste Need dumping pits for Discuss in the QI prevention management bins in place waste disposal Committee & Zila parishad Human resource Anesthetist has joined Need regular monitoring management 4 cleaners have been provided from municipality
38 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Infrastructural Declared as 100-bedded Supplies are in-adequate Need national level Instruments hospital to increase allocation considering patient load. advocacy to increase Logistics supplies of supplies Additional needs include: allocation of supplies. . GA machine in OT, Phototherapy machine, Radiant warmer & incubator in neonatal ward, autoclave in labor room & X ray machine. Record keeping, As a tertiary facility, record Patient diagnosis & Need orientation on reporting keeping & reporting system is management information record keeping & not satisfactory should be improved for reporting. detail reporting Referral Good referral linkage & Downward linkage can be management improved QI committees Formed & started addressing Need regular meetings general cleanliness & Should address all infection prevention aspects of quality 24/7 service delivery. Habiganj District Hospital Infection Color coded bins are in place Discuss in the QI prevention & dumping pits for waste Committee & Zila disposal are arranged. parishad Cleaners wear protective cloths/ gloves/boots Human resource 2 more doctors joined. For No Anesthesiologist Advocate at national management emergency management of available. 2 RMO trained level to get the the hospital activity, Doctors in Anesthesia provide needed specialists. from union level and other Anesthesia during Upazila are placed at DH by operation. local/verbal order. One Junior Vacant post for Nurse Consultant (OB) joined. need to be filled immediately. Instruments All 5 GA machine in OT are 2 OT lights are needed. Engage local repaired. Autoclave machine needs government to 2 X-ray machine is functioning to be available at labor provided needed after repair from Dhaka. room. instruments. USG machine was taken to Dhaka for repair. Radiant warmer now functioning. SCANU service started operation. Logistics supplies 2 delivery tables of iron made It will be possible to are ensured. ensure the availability of For Pediatric ward, hand beds for every patient washing basin and hand when it will start its sanitizer/soap are ensured. activity as a 250 bed Medical College Hospital which is under process. Record keeping, Different service registers are History sheet/treatment Ensure regular reporting available and record keeping sheet are not properly monitoring is done for indoor patients of filled in indoor and record Pediatric and Gynecology keeping is not properly wards. done due to overburden of patients. Referral Patients are referred to As the anestheologist, SOMCH with proper OBG consultant and documents and after proper Pediatrician are not counseling. The patients who available for ensuring are referred to DH receive 24/7 emergency service,
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 39 immediate medical service many patients are because of MaMoni HSS referred to SOMCH who facilitation. got admitted to DH after 2:30 pm. QI committees Formed & following RRQIT Need regular meetings action plan, addressing Should address quality general cleanliness & IP service delivery for 24/7 CEmONC
2.7 Strengthening Logistics MIS National level activities 2.7.1 Coordination with SIAPS at the national level: National dissemination of assessment results and introduction of E-LMIS: MaMoni HSS Project collaborated with SIAPS in conducting national level dissemination of results of district level assessment conducted jointly in Lakshmipur district under the title: “District Level Assessment of Pharmaceutical Management of Life- saving Commodities” and discussion on Photo: Introduction of e-LMIS for priority MNCH “Introduction of e Logistics Management commodities under DGHS – April 4, 2016, MIS Systems (e-LMIS) for priority MNCH Conference Room, DGHS. commodities under DGHS”. The meeting took place on April 4, 2016 at MIS conference room, DDHS. The meeting was chaired by
Professor Abdul Kalam Azad, ADG (Planning and Development) and Director MIS DGHS, Chairperson of Technical Working Group (TWG) for logistics reporting and tracking systems for MNCH priority commodities, and M. Shahidullah, Professor Neonatology, BSMMU, Chairperson of the National Technical Working Group (NTWG) for Newborn (NB). Participants included the Director Primary Health Care, a representative from USAID, and international partner staff. Recommendations included dissemination of the maternal and newborn health Standard Operating Procedure (SOP)s at all levels of the system, improvement of the capacity of staff at the local level in pharmaceutical management including procurement, distribution and logistics management, strengthening pharmaceutical information systems to provide the data needed for forecasting and supply planning, documentation of the expiry date, and providing facilities with the infrastructure necessary to maintain cold chain storage conditions ( oxytocin).
Scaling-up of the National Uniform LMIS for DGHS: The project continued its coordination with SIAPS to scale up the National Uniform LMIS for DGHS stores. MaMoni HSS is taking the lead in introducing the Uniform LMIS ledgers in Noakhali, Habiganj, and Jhalokathi districts. The system has already been introduced in Lakshmipur district. Scale up activities includes printing and distribution of the Uniform ledgers and guidelines, training of store keepers and district managers, and follow up to support implementation. In addition, the project is supporting the implementation of the automated version of the Uniform LMIS (known as E-LMIS) in Lakshmipur district. The project conducted assessment of the obstacles to the
40 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report automated reporting of logistics data in Lakshmipur and shared information with SIAPS.
Coordination with National Warehouse Family Planning on essential drugs and commodities distribution to MaMoni HSS districts: The project conducted several visits to the national warehouse for DGFP and had discussions with Additional Director, National Warehouse (Family Planning). The purpose of the visits were to follow up on the distribution of misoprostol tablets and Microlife Blood Pressure Machine for facilitating diagnosis of pre-eclampsia and eclampsia by services providers. The visit facilitated the release of the micro blood pressure machines to project districts. The visit also revealed the presence of large quantities of misoprostol at the national level. 742,644 tablets were at the national store that were procured in June 2015, manufacturing date was May 2015 and expiration date is April 2017. The project facilitated the release of the stored misoprostol tablets to the project covered upazilas. Coordination of community distribution of misoprostol: On June 13, 2016, the project participated in a meeting organized jointly by DGFP and DGHS on the community distribution of misoprostol tablets. The meeting was chaired by the Director of MCH and attended by several development partners. The meeting discussed challenges in the availability and distribution of misoprostol, particularly the expiration of a lot of tablets currently at upazila stores on May 31, 2016. Participants recommended the issuing of a circular to the upazilas to collect the expired tablets and appropriately destroy them in the presence of the upazila committee. In addition, the new supply of misoprostol tablets will subsequently be distributed to the field. Improving availability of essential drugs at district level: The project provides support to the district and sub-district managers in monitoring the availability of 25 drugs essential for MNCH programs as well as essential FP commodities. Data are shared with local counterparts in simple color coded dashboards with red indicating stock out, green indicating item availability, and yellow indicating available stock with short expiration date (see examples below):
Stock status of Tab. Misoprostol in all the DGHS store at Noakhali district, December 2015-May 2016.
Name of the store Dec.15 Jan.16 Feb.16 Mar.16 Apr.16 May.16
CS store Senbag. Begumganj Companigonj Subornachar Hatiya Red = Stock-out. Green = Available stock.
Stock status of Inj. Oxytocin in stores of Lakshmipur district in last one year (June2015-May 2016)
Name Jun,1 Jul Aug,1 Sep,1 Oct,1 Nov,1 De Jan,1 Feb,1 Mar,1 Apr,1 May,1 of the 5 , 5 5 5 5 c, 6 6 6 6 6
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 41 store 15 15
CS
store District
Hos. Ramga
ti Kamal
Nagar Raipur Ramga
nj Red = Stock-out. Green = Available stock.
Availability status of Inj. Gentamycin in all the upazila store in Jhalokathi district in last six months (December 2015 –May 2016)
Name of the store Dec.15 Jan.16 Feb.16 Mar.16 Apr.16 May.16
CS store District Hospital Sadar Nalchity Kathalia Rajapur Red = Stock-out. Green = Available stock. Yellow = Available stock about to expire
Comparing quantities of available stock to essential drug requirement: The project conducted a comparison between the available stock of four essential items (inj. oxytocin, misoprostol tablets, magnesium sulphate injection, and iron/folic acid tablets) and the requirement based on estimation of the need.
Inj. oxytocin requirements were calculated by using the population data, Crude Birth Rate (CBR)-divisional (BDHS 2014), total number of births/year, percentage of deliveries at public facility (BDHS 2014) and number of injections needed for each delivery.
Tentative need for misoprostol tablets was calculated using the population data, Crude Birth Rate (CBR)-divisional (BDHS 2014), total number of births/year, percentage of deliveries at home (BDHS 2014) and number of tablets needed for each delivery.
The need for inj. magnesium sulphate was calculated by using the population data, Crude Birth Rate (CBR)-divisional (BDHS 2014), total number of births/year, percentage of pregnancies with pre-eclampsia(PE) (BDHS 2014) and number of injections needed for each case.
42 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Requirements for IFA were calculated by using the population data, Crude Birth Rate (CBR)-divisional (BDHS 2014), total number of births/year, percentage of ANC +4 coverage (BDHS 2014) and number of tablets needed for each delivery.
Results from Lakshmipur district are presented in the table below.
Table : Selected essential drugs annual need against annual supply – June 2015- May 2016, Lakshmipur district Essential Annual Annual supply by DGHS, DGFP, and local Percentage supplied versus drug Requirement procurement required Inj. Oxytocin 11,996 4,050 34% Tab. Misoprostol 57,212 17,100 30% Inj. MgS04 5,168 0 0 Tab. IFA 2,574,529 4,312,600 168%
Monitoring FP Commodities:
The project continues to monitor family planning commodities distributed at all service delivery points through UIMS2 V.7. MaMoni HSS staff at the district level assist the district level staff in downloading and summarizing data on availability of FP commodities and use results to take action to avoid stock outs. An example of data on FP commodities availability is presented in the table below.
Case Study: Examples of Utilization of Data for Minimizing Stock-out of Essential Drugs
• MaMoni contribution on moving misoprostol from national to district level: The project coordinated with the national level DGFP store to expedite the distribution of misoprostol tablets from the national level to MaMoni districts where there were a need for the tablets. • Re-distributing of chlorhexidine from Civil Surgeon Store to DGFP centers, Lakshmipur district: The project coordinated the re-distribution of 14,000 units of chlorhexidine 7.1% solution from the Civil Surgeon store at Lp district to the DFGP stores in five upazilas (Sadar, Raipur, Ramganj, Ramgoti, and Kamal Nagar) where it was in shortage. 5,500 units were subsequently distributed to MaMoni HSS 24/7 facilities. • Re-distribution of misoprostol from DGHS to DGFP facilities, Habiganj district: Data revealed the stock-out of misoprostol at DGFP stores, yet DGHS store had 5,000 tablets in stock. The project facilitated coordination between DGFP and DGHS and succeeded in transferring 2,790 tablets to 8 DGFP upazila stores for immediate distribution to 24/7 UH&FWCs. • Initiating local procurement of gentamycin and re-distribution of stock near expiration, Jhlokathi district: Using the color coded dashboard to monitor availability and expiration date of essential drugs revealed that the gentamycin inj. stock at Jhalokathi district is nearing expiration. Action was taken to expedite the distribution of the stock to service delivery point before expiration and to procure new stock locally.
2.8 Collaboration with Private Hospitals for Quality Improvement of Maternal and Newborn Services MaMoni HSS supported the Civil Surgeon offices to collect reports from private clinics. According to the agreement, only MCH data were collected and integrated into the
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 43 reporting mechanism of the DGHS system. Table 11 shows the performance reported by the private clinics. In the subsequent discussions, MaMoni HSS is also negotiating to collect information on postpartum tubectomy operations.
A rudimentary analysis uncovered that the admission data did not match the service data. C-section is also unusually high, in keeping with the national trend.
Table : Performance reported by the private clinics in three MaMoni HSS districts
Norm Mater Neona Admi al C- Live Still nal Referr District Month Total tal ssion delive Section birth birth Death al out death ry s April'16 266 17 187 204 204 0 0 0 8 Jhalokath May'16 357 67 252 319 319 0 3 0 12 i June'16 256 35 214 249 248 1 0 0 7 April'16 710 231 637 868 771 25 13 0 15 May'16 558 237 550 787 693 9 4 0 0 Noakhali June'16 510 247 533 780 717 13 2 0 13 April'16 22 208 Not Habiganj May'16 repor 20 225 Not collected/reported ted June'16 26 221
2.9 Monitoring Quality of Care Indicators Preliminary results from the first round The project conducted preliminary analysis of the first round of the quality of care (QoC) survey conducted in four districts (Habiganj, Noakhali, Lakshmipur, Jhalokathi). The survey included 10 sentinel sites in each district (1 DH, 1 UHC, 4 UH&FWC, and four satellite clinics). Data collection was performed by direct observation by trained surveyors. Highlights of the results of the first round of QoC are included below.
Table 12: Summary findings of QOC Survey • Preliminary results of assessing quality of ANC services show that, data from a total of 27 facilities in the 4 districts, Iron and Folic Acid tablets were available in 25 facilities (93%). Running water was available in 24/25 facilities (96%), soap for hand washing was available in 23/25 facilities (92%), and latex gloves were available in 25/24 facilities (96%). • Available results from Jhalokathi and Noakhali show that out of 14 facilities surveyed conducting normal vaginal deliveries, 10 (71%) had newborn resuscitation bag and mask, 12 (86 %) had resuscitation mask, and 11 (79%) had penguin sucker. • Out of a total of 26 facilities conducting normal vaginal deliveries surveyed in the four districts, 18 (69%) had partogragh paper and board, 11 (42%) had oxytocin injections, and 4 (15%) had magnesium sulfate 5 ml ampules. • Out of 122 deliveries observed in Lk district, all of them (100%) had oxytocin inj. administered within 1 minute of delivery and out of 172 deliveries observed in Jk district, due to shortage in stock, only 18% received oxytocin inj. within 1 minute of delivery. • Family planning data from Habiganj district shows that out of 272 clients, privacy was ensured in 13 cases (3%), client concerns where discussed in 56 cases (27%), a job aid was used with 142 clients (47%), and next date of visit was mentioned to 40 clients (15%).
44 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report
2.10 Routine Health Information Systems (RHIS)/eMIS Initiative
In partnership with icddr,b, MEASURE, and MSH/SIAPS, MaMoni HSS continued to support the implementation of a comprehensive automated Routine Health Information System (RHIS) in Habiganj district. MaMoni HSS implemented population registration system in Madhabpur and Lakhai upazila of Habiganj, registering 342,200 people and 68,796 in Madhabpur upazila and 56,105 people and 10,215 households in Lakhai upazila. 278,313 health ID cards have been distributed in Madhabpur upazila, ensuring that the care-seeking information and service contact with these clients can be seamlessly shared between different service delivery points.
Figure 36: E-register Service Statistics (Nov' 15 - Sep '16)
2500 30 26 2000 24 25 20 1500 18 16 15 1000 13 13 10 8 9 8 500 6 5 3 0 0 MAY JULY JUNE APRIL MARCH AUGUST JANUARY FEBRUARY DECEMBER NOVEMBER SEPTEMBER 2015 2015 2016 2016 2016 2016 2016 2016 2016 2016 2016
ANC TOTAL PNC mother (Total) PNC-Newborn (Total) DELIVERY LIVE-BIRTH MISOPROSTOL
MNH & FP e-registers have been introduced in Madhabpur upazila and 78 participants were trained. 263 deliveries, 3,444 ANC and 523 postnatal newborn examinations were recorded in the first 11 months of implementation of the MNH module.
Figure 37: Service Statistics by Union May - Sep, 2016
800 8000 700 7200 7000
6750 6699 6717 6456 600 6017 5822 6000 500 5222 5000 4510 400 4267 4000 300 3347 3000 437 ELCO IN UNION IN ELCO Service Delivery Service 200 373 2000 341 327 303 322 324 308 274 284 100 151 1000 0 0 CHOW SHAHJ BAGAS NOAPA DHARM JAGADI BAHAR CHHATI ANDIU MOHAN BULLA AHANP ADAIR URA RA AGHAR SHPUR A AIN RAUK I UR Delivery 47 54 23 21 16 17 32 16 29 8 0 PNC-N 137 79 94 23 63 22 26 35 33 11 0 PNC 140 90 95 27 70 50 23 37 34 16 0 ANC 373 341 327 437 303 322 324 308 274 284 151 Elco 6017 6750 7200 5822 3347 5222 6699 6717 4510 4267 6456
ANC PNC PNC-N Delivery Elco
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 45 The RHIS team presented their experiences in the Measurement and Accountability for Health (MA4 Health) Conference in Dhaka in April 2016. The development team presented the system in the Marketplace to the local and international visitors. After the conference, visitors from different countries visited Habiganj to observe the field level activities at RHIS piloting areas.
Photo 14: MaMoni HSS showcased their activities in MA4H conference stall
IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems National level technical assistance MaMoni HSS has been actively engaged in the national level consultations and discussions for developing the fourth Health Nutrition Population (HNP) Sector Program for the MOH&FW. MaMoni staff were represented in several Strategic Thematic Groups (STGs) that were constituted to draft the priorities for the Strategic Investment Plan (SIP). Subsequently, MaMoni HSS participated in a series of consultations organized by MOH&FW and The World Bank to identify the priorities for the Program Implementation Plan (PIP). The project staff also contributed to writing various sections of the PIP. The project has also been working with the respective Line Directors to ensure that the priority interventions and activities are incorporated in the Operational Plans and budgets.
Since July 2016, MaMoni HSS has also been providing technical and operational support to the Planning Wing to facilitate the development of the PIP. This includes operations support staff seconded to the Planning, Monitoring, and Management Unit (PMMU), support for organizing meetings and consultations, and routine logistics support. MaMoni HSS supported a divisional consultation meeting in Sylhet division to seek inputs from field level managers on the sector program priorities.
3.1 Journalist Engagement MaMoni HSS organized a number of journalist visits in different locations of its project area with a special focus to ensure optimum media coverage on Safe Motherhood Day. As a result of broader MaMoni HSS media advocacy, about 25 news stories were published by different media outlets. The news stories included issue-specific current situation, case studies, technical information with a call to action for required health systems improvement. Following the initial journalist training, a long-term follow up activity has been established to ensure that the trained journalist group put into practice what they have learned through this training. The reporters are well connected with the local project office personnel who always help them to improve reporting and troubleshoot ideas.
The media engagement and capacity building program has resulted in a significant increase in media coverage on MNCHFPN issues and increased engagement of involved stakeholders. Representatives from the multiple government ministries/directorates,
46 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report and non-governmental partners have been deeply involved in the program. This contributes immensely to facilitating closer collaborations across organizations and resulted in both increased dialogue and news coverage. Please refer to Annex 6 for published stories. 3.1.1 Observation of Safe Motherhood Day on May 28, 2016 MaMoni HSS conducted a community based review to identify causes of maternal deaths in their project districts. To mark the Safe Motherhood Day, MaMoni HSS deployed its volunteers and workers to go house to house and identify mothers who died in the last 12 months (May 2015-April 2016). In the month of May, MaMoni staff, government officials and local elected representatives jointly visited the household of every mother who was lost. The team expressed their sympathy to the family, and also discussed how the death could have been prevented. The findings were then shared at district level meetings in Habiganj, Noakhali, Lakshmipur and Jhalokathi to sensitize the different stakeholders. Each project district also organized a seminar on Safe Motherhood Day (SMD) in collaboration with the civil surgeon and District Family Planning Office. Participants from different backgrounds attended the seminar and created a scope of mutual sharing and understanding. At the end of the seminar, the participants came to a consensus that PPH along with the other causes of maternal death is preventable. Everyone also stressed that we can change the scenario of maternal death through our sincere effort and determination. The participants profile of the seminar included; Health and Family Planning officials, medical professionals, Social Welfare, Youths & Sports officials, Women’s Affairs officials, local government, NGOs, journalists, local elites, etc.
During the seminars, the following suggestions and recommendations were made:
1. Every pregnancy/pregnant-mother needs to be considered as potentially at risk 2. All SBAs need to be more focused on counseling the mother and the family 3. Health and Family Planning staff, as well as MaMoni volunteers/staff are asked to refer pregnant mothers with the complaint of swelling leg(s) to nearby Health Complex. Recognition of high performance of 24/7 facilities for conducting normal vaginal delivery at union level The MaMoni HSS project areas have a successful model of engaging UP at union level maternal and neonatal health services, which has been contributing to achieving number four and five of Millennium Development Goals. The project, in collaboration with the Health & Family Planning Department, took initiatives to recognize high performing 24/7 facilities for conducting normal vaginal delivery at union level, aimed at influencing the service providers to increase safe normal delivery with high quality services at union level facilities. The event involved participation of local people and leaders to build awareness among community members seeking health and family planning services. Through the event the Union Parishads were also recognized for their involvement. The recognition consisted of the following activities: • ANC campaign • BCC Video Show • Discussion session • Souvenir crest handover
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 47 • Sapling distribution.
3.2 Program learning initiatives undertaken and disseminated Program learning initiative on CHX in community- A program learning initiative was undertaken to understand the TBA’s role in the 7.1% chlorhexidine for newborn cord care scale-up process. A qualitative exploratory study was conducted to assess the role of TBAs as well as depot holders in CHX distribution at Bahubal, Habiganj. It was found that the TBAs who received orientation on chlorhexidine continued to encouraged families to purchase chlorhexidine and applied them on the umbilical cord.
Advocacy meeting with CCSDP, DGFP- MaMoni HSS supported an advocacy meeting with DGFP on June 2nd, with participation of major stakeholders such as EngenderHealth, Marie Stopes International, BRAC, RTM, SMC, and Population Council. CCSDP organized the workshop. Line directors of MIS, field service unit, IEM were present at the workshop. Workshops were chaired by the Line Director of CCSDP and Director General of Family Planning were present as the chief guests.
Findings from operations research on the permanent method of family planning completed by MaMoni HSS was presented at the meeting. The main objective of the workshop was to include the issues from the OR findings in the planning of CCSDP, as well as respective units of DGFP for enhancing the quality of permanent method services of family planning in the near future.
Development of two research briefs- The MaMoni HSS team has developed two research briefs from two completed operations research projects on partograph use, and pCSBA services. The briefs are currently being reviewed prior to publication. These materials would be useful to advocate to the stakeholders on these issues.
Workshop on documentation and program learning- The project organized a workshop for planning program learning initiatives and documentation areas for the next year in June. A four-day workshop included all technical leads of MaMoni HSS and icddr,b as the technical partner to decide how to initiate these activities. A series of follow-up initiatives was determined from this workshop around the documentation of project interventions and learnings.
Development of concept papers- The project has assisted the JHU team to develop an IRB proposal for documentation of national scale-up of chlorhexidine and follow-up study on income viability of private CSBA. Chlorhexidine documentation received an exemption and pCSBA study is under review.
IR 4. Identify and Reduce Barriers to Accessing Health Services
4.1 Community mobilization and BCC activities to remove barriers MaMoni HSS facilitated the monthly cMPM meetings involving community volunteers (CVs), frontline health workers (Health Assistants, FWAs, CHCP), and their supervisors (FPIs; AHIs), to update the information on eligible couples, mothers, and children, and to follow up on drop-outs. During April-June 2016, 95% of the cMPMs were held in 23 high-intensity upazilas. The project supported BCC teams to conduct targeted BCC campaigns on prioritized MNCH/FP/N messages, reaching 313,350 people. These
48 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report campaigns delivered a number of BCC messages through video shows and courtyard meetings.
4.2 Reaching mothers through Aponjon services Subscriber acquisition was higher in the fourth quarter compared to the previous quarters this year. A new agency, Spectrum, was hired, and contributed to acquisition from June 2016, boosting the subscriber base by 4% of average monthly acquisition. Cumulative count of subscribers stands at 1,978,061 on September 30, 2016.
Figure 38: Client Acquisition by Aponjon 148861 160000 131780 140000 120000 94074 100000 80000 58266 48994 60000 34096 31465 21047 40000 7674 9881 9146 20000 5603 0
Aponjon call center handled 5,949 subscriber queries on various purposes and helped 843 mothers to update the date of birth of their babies. The agreement with the call center has been extended up to September 2016.
Figure 39: Call Center Activities of Aponjon
14000 11769 11438 12000 10968 9564 10000 8719 7648 7341 8000 7133 5397 6000 4346 4224 3597 3928 2981 2962 4000 2459 2277 2251 2336 2019 1767 1774 1644 2000 948 0 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16
Total Incoming Total Outgoing Call from subscriber DoB update
Aponjon counseling line answered a total of 540 medical queries this year.
Mobile Apps
Aponjon Shogorbha:
The android version of Aponjon Shogorbha app was already up in Play store in April. The rest of the versions in Windows and IOS were made available as well. All three versions of Aponjon Shogorbha, along with a new app for adolescents, were nationally launched in a launching event in the presence of the US Ambassador, Mrs. Marcia Stephens Bloom Bernicat, and Honorable State Minister for ICT, Zunaid Ahmed Palak. Aponjon Shogorbha app statistics of Android version is provided below:
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 49 Table 13: Status of downloads of Aponjon Shogorbho application
App statistics App installs Android Windows iOS Apr-16 1043 27 213 May-16 779 13 204 Jun-16 927 19 167 Jul-16 939 2 183 Aug-16 850 1 211 Sep-16 756 2 138 TOTAL 5294 64 1116
Aponjon Koishor:
Aponjon Koishor is a novel mobile app in Bangla for adolescents that helps create awareness among adolescent boys and girls about physical and mental changes that they go through as well as about adolescent reproductive health. Both Android and Windows versions are available in the Play Store/App Store while the IOS version is yet to come. This app is not only for adolescents but their parents can also see by registering what information is being provided to the children from this app. Aponjon Koishor app statistics on Android and Windows versions is shown below. Table : Status of download of Aponjon Kaishor application
App statistics App installs Android Windows iOS Apr-16 329 0 0 May-16 128 506 0 Jun-16 2531 165 0 Jul-16 143 179 0 Aug-16 132 191 0 Sep-16 95 118 0 TOTAL 3,358 1,159 0
Dnet is introducing ‘Bridge’ to provide support on the technological platforms to fulfill internal as well as external demand. Aponjon is going to be a big beneficiary of this project in terms of reducing platform costs by about 90%. Hardware installation and quality assurance testing is done on Grameen Phone (GP) premises at Gazipur. Final integration with GP was completed. Here is the complete overview of the ‘Bridge’ project, integrated with GP initially. Other telecom operators will be reached in a similar process of integration one after another.
50 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report CHALLENGES, SOLUTIONS, AND ACTION TAKEN
Challenges Drug shortage: The DDS kits of UH&FWCs and the drug supply of the Community Clinics have been interrupted since September 2015 due to procurement issues at DGHS and DGFP. This has severely affected the coverage and quality of essential services at the community level. MaMoni HSS has been closely monitoring the situation, and where appropriate, has been liaising with the Union Parishads, and Ministry of Social Welfare funds to leverage temporary support to meet the shortfall for drugs and supplements such as oxytocin, IFA, and misoprostol. Union Parishad election: Several rounds of UP elections were held between December and May. Local government funds were not available because of this.
Way Forward In the upcoming quarter, the project will focus on the following areas: • Implementation of the HRH study to determine the workload and staffing needs at various levels of the health care delivery system. The study will be completed by the end of second quarter in year 4, and is expected to inform the health workforce planning for MOH&FW. • Deployment of quality improvement staff at subnational levels, including divisional and district level staff in five divisions to support the implementation of the national quality improvement strategy. The project will also work in collaboration with UNICEF, WHO and other stakeholders to start the implementation of the WHO framework for quality of care in MNH. • Expansion and scale up of the electronic MIS (e-MIS). The full roll out of the e- MIS has just started in Habiganj district. All union level facility modules will be deployed in Habiganj. The FWA electronic modules will also be introduced in Habiganj. The implementation of e-MIS will start in Noakhali district. • The follow up activities to institutionalize priority newborn interventions across the country will continue. One of the priority initiatives will be to nominate newborn focal points at each of the upazilas in the country and to develop their capacity. The work will start in 24 districts initially, in partnership with BSMMU. The newborn focal points will be supported to conduct upazila level NBH reviews on a monthly basis. • Program learning and documentation efforts will be intensified. The national documentation of the scale up of 7.1% chlorhexidine will be strengthened with the establishment of national stakeholder forum and a scale up dashboard. A new study is being designed to test effective approaches to reducing discontinuation rates for LARC and PMs.
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 51 APPENDIX 1: SCOPE AND GEOGRAPHICAL COVERAGE OF MAMONI HSS PROJECT
The project objective is well aligned with the GoB’s Health, Population, and Nutrition Sector Development Program (HPNSDP) for 2011–2016; and also directly supports the USAID/Bangladesh Development Objective 3 (DO 3: “Health Status Improved”), which is under the “Investing in People” objective of the Country Development Cooperation Strategy (CDCS) framework of USAID in Bangladesh. MaMoni HSS designed a two-pronged approach in which districts and upazilas were categorized into one of two groups—high-intensity intervention areas and health system capacity strengthening areas. The aim of the high-intensity areas is to demonstrate best-practice models of MNCH/FP/N health care delivery Figure 17: MaMoni geographical scope through intensive support to the Government of Bangladesh (GoB), and if needed, direct implementation to maximize learning and advocacy for scale-up nationally. Based on an analysis of gaps in coverage and equity of access to high-impact MNCH/FP/N services, the project identified a total of 23 upazilas across five districts to serve as the project’s high-intensity areas. Of the 23 upazilas, district saturation was achieved in Habiganj, Lakshmipur, and Jhalokathi districts, while in the Noakhali and Pirozpur districts, four and two upazilas were supported, respectively. The health systems (HS) capacity strengthening areas cover a total of 17 upazilas—all seven upazilas of Bhola, five upazilas of Noakhali, and five upazilas of Pirozpur (refer to Figure 1 and Table 1). Whereas the high-intensity areas focus on support for a complete package of MNCH/FP/N interventions, the HS capacity strengthening areas receive less intensive technical assistance on a selected set of interventions. Minimal support was provided to GoB health systems to scale up interventions such as 24/7 Union Health and Family Welfare Centers (UH&FWCs), chlorhexidine for cord care, and Helping Babies Breathe (HBB); instead, the focus was on supporting the strengthening of existing MNCH/FP/N services. MaMoni HSS has four intermediate results (IR): IR 1. Improve service readiness through critical gap management. IR 2. Strengthen health systems at district level and below. IR 3. Promote an enabling environment to strengthen health systems at the district level. IR 4. Identify and reduce barriers to accessing health services.
52 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Table 15. Summary of MaMoni HSS geographic scope
No. of Health Facilities Population No. of No. of Area (2015 Upazilas Unions District projection) Upazila Union Community (MCWC)
High- Intensity 23 26 7,355,822 5 20 208 619 Areas
Health Systems CB 17 151 4,870,933 5 13 121 488 Area
Total 40 377 12,226,755 10 33 329 1,107
Notes: (Community-Based), (Maternal and Child Welfare Center)
APPENDIX 2: PROGRAM PERFORMANCE INDICATORS (OCTOBER 2015–SEPTEMBER 2016)
Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Project Goal: Improve utilization of integrated maternal, newborn, child health, family planning and nutrition services Percent of women received at least one antenatal care visit from a medically trained provider High intensity areas Lakshmipur 69 74.8 70
Noakhali* 64 72 67
Habiganj 68 80.2 70
Jhalokathi 71 75.6 73
Pirozpur* 69 74.2 70 HSCS areas Pirozpur 65 - 67
Bhola 54 - 56
Noakhali 62 - 63
Percent of births receiving at least four antenatal care
(ANC) visits during pregnancy
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 53 Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
High intensity areas Lakshmipur 24 29.8 26
Noakhali* 24 26.4 26
Habiganj 25 40.9 26
Jhalokathi 48 44.4 50
Pirozpur* 35 37 36 HSCS areas Pirozpur 43 - 44
Bhola 22.5 - 23.5
Noakhali 20 - 21 Percent of Births Attended by a Skilled Doctor, Nurse or
Midwife High intensity area Lakshmipur 42 36.6 45.0
Noakhali* 36 35.1 40.0
Habiganj 37 35.9 40.0
Jhalokathi 50 51.9 53.0
Pirozpur* 48 49.7 50 HSCS areas Pirozpur 48.5 - 50.0
Bhola 29 - 30.0
Noakhali 37 - 38 Percent of women with home births who consumed misoprostol to prevent postpartum hemorrhage High intensity areas Lakshmipur 25 7 30
Noakhali* 25 18 30
Habiganj 46 46.5 50
Jhalokathi 52 22.2 55
54 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Pirozpur* 42 27.8 45
HSCS areas
Pirozpur 30.5 - 32
Bhola 23 - 25
Noakhali 18 - 20
Percent of newborns initiated breastfeeding within one hour after birth
High intensity areas Lakshmipur 73 54.2 75
Noakhali* 70 61.6 72
Habiganj 85 77.3 85
Jhalokathi 65 39.6 70
Pirozpur* 60 42.3 63
HSCS areas
Pirozpur 56 - 58
Bhola 68 - 70
Noakhali 75 - 76 Percent of newborns received chlorhexidine application on their umbilical cord immediately following birth High intensity areas Lakshmipur 40 0.5 60
Noakhali* 40 2.2 60
Habiganj 40 10.1 60
Jhalokathi 40 0.5 60
Pirozpur* 40 0.5 60
HSCS areas
Pirozpur NA - 35
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 55 Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Bhola NA - 35
Noakhali NA - 35 Percent of newborns receiving postnatal health check within two days of birth High intensity areas Lakshmipur: 19 25.1 20
Noakhali:* 19 33.5 20
Habiganj: 31 21.7 32
Jhalokathi: 32 42 33
Pirozpur:* 15 37.9 18 HSCS areas
Pirozpur: 9 - 10
Bhola: 9 - 10
Noakhali: 19 - 20 Modern contraceptive method prevalence rate High intensity areas Lakshmipur 53 50.8 55
Noakhali* 51.5 53.3 53
Habiganj 47 41.9 48
Jhalokathi 57 63.7 58
Pirozpur* 57 65.5 58
HSCS areas
Pirozpur 54.5 - 55
Bhola 57.5 - 58
Noakhali 50 - 51 Couple years of protection Source: DGFP MIS (CYP) in USG-supported Form 4 (accessed programs online) 488,453 795,396 High intensity areas 748,496
56 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
145,327 241,351 Lakshmipur 229,858 107,244 152,317 Noakhali* 138,470 144,825 233,071 Habiganj 221,972 58,027 112,537 Jhalokathi 107,178 33,028 56,120 Pirozpur* 51,018 409,061 HSCS areas
77,283 Pirozpur 227,445 Bhola 104,332 Noakhali
Source: SDP Percent of targeted facilities that are ready to provide essential assessment and newborn care training data
High intensity areas
Lakshmipur 35 71 90
Noakhali* 35 52 90
Habiganj 85 58 90
Jhalokathi 35 39 90
Pirozpur* 35 63 90
HSCS areas
Pirozpur 35 70 Source: SDP assessment and Bhola 35 70 training data (HI Noakhali 40 75 Upazilas only)
Percentage of public health facilities with functional bags and masks
(two neonatal size mask) in the delivery room
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 57 Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
High intensity areas
Lakshmipur 35 83 50 Noakhali* 35 83 50 Habiganj 35 81 50 Jhalokathi 35 80 50 Pirozpur* 35 81 50 HSCS areas
Pirozpur NA
Bhola 3 5
Noakhali NA
Source: SDP Percent of USG-assisted service delivery sites providing family planning assessment and (FP) counselling and/or services training data
High intensity areas
Lakshmipur 85 76 95 Noakhali* 85 75 95 Habiganj 99 77 99 Jhalokathi 85 90 95 Pirozpur* 85 88 95 HSCS areas
Pirozpur 10 17
Bhola NA NA
Noakhali 15 25
Source: SDP Number of targeted facilities ready to provide delivery services 24 hours assessment and a day, seven days a week (includes DH, MCWC, UHC and UH&FWC) training data
58 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Considering provider High intensity areas available and separate delivery room
Lakshmipur 25 41 25 Noakhali* 16 25 19 Habiganj 35 42 39 Jhalokathi 17 15 21 Pirozpur* 2 8 4 HSCS areas
Pirozpur 7 9
Bhola 30 32
Noakhali 7 7
Sub-IR 1.1: Increase availability of health service providers Number of vacant positions Doctor, Paramedic, filled by temporary non-GOB nurses health workers High intensity areas Lakshmipur 13 14 10 Noakhali* 17 23 15 Habiganj 43 37 10 Jhalokathi 16 0 10 Pirozpur* NA NA NA HSCS areas Pirozpur NA NA NA Bhola NA NA NA Noakhali NA NA NA
Sub-IR 1.2: Strengthen capacity of service providers to provide quality services Number of people trained in maternal/newborn health 82,090 73,659 2,149 Source: Project MIS through USG-supported programs
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 59 Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
High intensity areas
Lakshmipur NA 218 Women 124 Men 94 Noakhali* NA 375 Women 254 Men 121 Habiganj NA 533 Women 287 Men 246 Jhalokathi NA 254 Women 131 Men 123 Pirozpur* NA 106 Women 56
Men 50
trained on National level NA 72,153 CHX(71,945) Dhaka (208) HSCS areas
Pirozpur
Women
Men
Bhola NA 33 Women 22 Men 11 Noakhali 0
Number of people trained in 5,589 3,264 225 Source: Project MIS FP/RH with USG funds
High intensity areas 3,256
60 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Lakshmipur 0 173 Women 122
Men 51 Noakhali* 0 221 Women 171
Men 50 Habiganj 0 332 Women 268 Men 64 Jhalokathi 0 2,530 Women 2,472 Men 58 Pirozpur* Women Men National level 8 HSCS areas NA
Pirozpur NA
Bhola NA
Women
Men
Noakhali NA
Number of people trained in child health and nutrition 200 785 1,372 through USG-supported programs High intensity areas 760 1,305 Lakshmipur 178 Women 101 Men 77 Noakhali* 137 Women 78 Men 59 Habiganj 894 Women 672 Men 222 Jhalokathi 96 Women 62 Men 34
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 61 Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Pirozpur* Women Men National level 25 67 HSCS areas NA
Pirozpur NA
Bhola NA
Noakhali 0
Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization
Number of union level public Source: Monthly report health facilities that are from high intensity ready to provide normal upazilas delivery services
75 High intensity areas 16 Lakshmipur 11 Noakhali*
26 Habiganj 16 Jhalokathi 6 Pirozpur*
HSCS areas
Pirozpur
Bhola
Noakhali
Intermediate Result 2: Strengthen health systems at district level and below
Number of district level quarterly performance review meeting held for Source: QPRM data-driven performance review and planning meeting minutes
High intensity areas 20 20 20
62 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Lakshmipur 4 4 4 Noakhali* 4 4 4 Habiganj 4 4 4 Jhalokathi 4 4 4 Pirozpur* 4 4 4 Bhola NA NA NA Data expected from QI sentinel monitoring. Intra partum still birth rate in project assisted facilities The system is being established. <5/1000 High intensity areas <7/1,000
Lakshmipur <7/1,000 <5/1000
Noakhali* <7/1,000 <5/1000
Habiganj <7/1,000 <5/1000
Jhalokathi <7/1,000 <5/1000
Pirozpur* <7/1,000 <5/1000
Sub-IR 2.1: Improve leadership and management at district level and below
Number of GOB managers supported for leadership and management capacity development 5 Lakshmipur NA NA 3 Noakhali NA NA 8 Habiganj NA NA Source: Project MIS & 5 District team Jhalokathi NA NA 5 Pirozpur NA NA 3 Bhola NA NA Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs Number of upazilas with updated comprehensive Source: Project MIS annual MNCH/FP/N plan High intensity areas 23 36 23
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 63 Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Lakshmipur 5 5 5 Noakhali* 4 5 4 Habiganj 8 8 8 Jhalokathi 4 4 4 Pirozpur* 2 7 2 Bhola NA 7 NA Sub-IR 2.3: Strengthen local management information systems Percentage of community micro planning units conducting Source: Project MIS monthly meeting High intensity area Lakshmipur 95 99 100 Noakhali* 95 100 100 Habiganj 100 100 100 Jhalokathi 95 97 100 Pirozpur* 95 82 100
Sub-IR 2.4: Establish quality assurance system at district level and below Percent of planned supervision visit conducted where a supervision tool was Source: Project MIS used and findings shared with providers High intensity areas 90 90
39 Lakshmipur 90 90
131 Noakhali* 90 90 75 Habiganj 90 90 62 Jhalokathi 90 90 0 Pirozpur* 90 90
Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below
64 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Percent of USG-assisted service delivery points (SDPs) that experience a stock out at any time during the reporting period of a contraceptive method that the SDP is expected to provide High intensity areas <3 <2 <2 Lakshmipur <3 8 <2 *Some SDPs are enlisted which are not Noakhali* <3 17 eligible for specific methods <2 Habiganj <3 26 <2 Jhalokathi <3 7 <2 Pirozpur* <3 7
Sub-IR 2.6: Strengthen local government planning and engagement in health service provision The data was not available. Because of a server crash of CRVS Percentage of unions that online data. had at least 50 percent of Government online the estimated births system is not registered within 45 days of functioning and birth MaMoni HSS did not have access to the information. Therefor we are using EPI data. High intensity areas 40 Lakshmipur 40 62 60 It includes Three upazila ( Senbag, Noakhali* 40 26 60 Begumganj, Companigonj) Habiganj 40 97 60 Jhalokathi 40 34 60 Pirozpur* 40 26 60 Nazipur upazila only Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 65 Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Number of union parishads (UP) that spent funds to Source: Project MIS support MNCH/FP/N activities High intensity areas 226 118 226 Lakshmipur 58 33 58 Noakhali* 44 38 44
Habiganj 77 64 77 Jhalokathi 32 21 32 Pirozpur* 15 15
Intermediate Result 3: Promote enabling environment to strengthen district level health system Number of critical vacancies filled by GOB recruitment or Source: Project MIS redeployment in project areas High intensity areas 25 17 25 Lakshmipur 5 0 5 Noakhali* 5 1 5 Habiganj 5 11 5 Jhalokathi 5 3 5 4 FWV and 2 nurse Pirozpur* 5 2 5 3 FWV Sub-IR 3.1: Policy reforms in place to promote local planning and need-based human resource deployment in the public sector -PPFP counselling Number of policies/ guideline strategies/guidelines on 4 6 MNH developed/revised 4 -Infection prevention with MaMoni HSS support -MH strategy & SOP -PE/E guideline Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program -2 advocacy sharing meeting on UH&FWC assessment Number of program learning 15 initiatives completed and 10 12 -LPMP study finding disseminated sharing -LAPM& Partograph -study on PCSAB -KMC abstract Intermediate Result 4: Identify and reduce barriers to accessing health services
66 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Number of deliveries with a DGFP MIS, DHIS2, SBA in USG-assisted pCSBA programs High intensity areas 61,440 58,852 18,056 Lakshmipur 17,332 19,687 12,865 Noakhali* 11,622 12,288 20,307 Habiganj 23,580 25,896 5,412 Jhalokathi 6,362 7,054 2,212 Pirozpur* 2,544 2,658 31,521 HSCS areas 45,579
5,979 Pirozpur 10,796 12,148 13,455 Bhola 1,755 1,982 12,086 Noakhali* 33,028 37,848 Number of antenatal care
(ANC) visits by skilled DGFP MIS, DHIS2, 486,499 667,117 providers from USG-assisted pCSBA facilities
488,566 High intensity areas 303,839
109,977 Lakshmipur 48,846 53,730 119,751 Noakhali* 39,468 43,414 208,073 Habiganj 191,464 210,611 35,845 Jhalokathi 15,048 16,553 14,919 Pirozpur* 9,013 9,914 178,551 HSCS areas 182,660
28,236 Pirozpur 31,544 34,698 66,329 Bhola 62,314 68,546
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 67 Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
83,986 Noakhali 88,802 97,682
Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches
Number of people reached through project supported Source: Project MIS BCC activities High intensity areas 650,000 72,159 Lakshmipur 175,000 30,077 195,000 Women 20,045
Men 10,032
Noakhali* 135,556 15,454 135,556 Women 12,940
Men 2,514
Habiganj 195,000 18,954 210,000 Women 16,191
Men 2,763
Jhalokathi 113,587 7,674 120,000 Women 6,010
Men 1,664
Pirozpur* 30,857 39,444 Women Men Bhola Women Men
Sub-IR 4.2: Enhance community engagement in addressing health needs
Number of trained community volunteers Source: Project MIS promoting MNCHFPN through project support High intensity areas 24,925 Lakshmipur 6,710 6,278 6,710 Noakhali* 5,900 5,797 5,900 Habiganj 8,379 8,219 8,379
68 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Achievement Target (October2015- Target Remarks 2016 September) 2017 2016)
Jhalokathi 2,731 2,305 2,731 Pirozpur* 1,205 353 1,205 Number of Community Action Groups with an emergency transport system for Source: Project MIS maternal and newborn health care through USG-supported programs High intensity areas 20,001 Lakshmipur 6,461 6,056 6,461 Noakhali 3,876 4,115 3,876 Habiganj 4,369 8,071 4,369 Jhalokathi 3,746 1,778 3,746 Pirozpur* 1,549 353 1,549
APPENDIX 3: MNCH ESSENTIAL DRUGS MONITORING REPORT 1. Monitoring Quality of Care (QoC) Indicators: The project conducted preliminary analysis of the first round of the quality of care (QoC) survey conducted in four districts (Habiganj, Noakhali, Lakshmipur, Jhalokathi). The survey included 10 sentinel sites in each district ( 1 DH, 1 UHC, 4 UH&FWC, and 4 Satellite Clinics). Data collection was performed by direct observation by trained surveyors. Highlights of the results of the first round of QoC are included below.
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 69 Results of Quality of Care Survey
• Preliminary results of assessing quality of ANC services show that, data from a total of 27 facilities in the 4 districts, Iron and Folic Acid tablets were available in 25 facilities (93%). Running water was available in 24/25 facilities (96%), soap for hand washing was available in 23/25 facilities (92%), and latex gloves were available in 25/24 facilities (96%). • Available results from Jhalokathi and Noakhali show that out of 14 facilities surveyed conducting normal vaginal deliveries,, 10 (71% had newborn resuscitation bag and mask, 12 (86 %) had resuscitation mask, and 11 (79%) had penguin sucker. • Out of a total of 26 facilities conducting normal vaginal deliveries surveyed in the four districts, 18 (69%) had partogragh paper and board, 11 (42%) had Oxytocin injection, and 4 (15%) had magnesium sulphate 5 ml ampule. • Out of 122 deliveries observed in Lk district all of them (100%) had oxytocin inj. administered within 1 minute of delivery and out of 172 deliveries observed in Jk district, due to shortage in stock, only 18% received oxytocin inj. within 1 minute of delivery. • Family planning data from Habiganj district show that out of 272 clients, privacy was ensured in 13 cases (3%), client concerns where discussed in 56 clients (27%), job aid was used in 142 clients (47%), and next date of visit was mention to 40 clients (15%).
Table: IFA availability in surveyed facilities
District No. of Facilities Surveyed No. of Facilities IFA Tablets were available Lakshmipur 7 5 Habiganj 5 5 Jhalokathi 7 7 Noakhali 8 8 Total 27 25 (93%)
Table: Basic Infection prevention indicators in selected sites
District No. of facilities surveyed
Running Water Soap for Latex gloves hand washing Lakshmipur 7 7 6 7 Habiganj 3 3 3 3 Jhalokathi 7 6 6 6 Noakhali 8 8 8 8 Total 25 24 (96%) 23 (92%) 24 (96%)
Table:Availability of newborn resuscitation commodities
District No. of No. of facilities offering normal vaginal delivery with: facilities Functioning Newborn Newborn Penguin surveyed resuscitation resuscitation resuscitation sucker bag mask size 0 mask size 1 Jhalokathi 7 6 7 7 6 Noakhali 7 4 4 5 5 Total 14 10 (71%) 11 (79%) 12 (86%) 11 (79%)
70 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Table: Availability of essential maternal health drugs and supplies
District No. of No. of facilities offering normal vaginal deliveries with: facilities Partograph paper Inj. Oxytocin Inj. Magnesuim surveyed & board Sulphate 5 ml ampule. Lakshmipur 7 4 4 1 Habiganj 4 3 3 1 Jhalokathi 7 6 0 1 Noakhali 8 5 4 1 Total 26 18 (69%) 11 (42%) 4 (15%)
Table: Percent of timely use of Inj. Oxytocin after delivery, Lakshmipur district
Facility No. of No. and % of deliveries where Oxytocin Inj. was deliveries administered within 1 minute from delivery observed District Hospital 65 65 (100%) MCH-FP Unit of UHC 50 50 (100%) UH&FWC 7 7 (100%) Total 122 122 (100%)
Table: Percent of timely use of Inj. Oxytocin after delivery, Jhalokathi district
Facility No. of No. and % of deliveries where Oxytocin Inj. was deliveries administered within 1 minute from delivery observed District Hospital 124 1 (0.8%) MCH-FP Unit of UHC 30 30 (100%) UH&FWC 18 0 ( 0% ) Total 172 31 (18 %)
Level of Facility No. of clients No. & % Client Used Job Aid Informed observed with privacy concerns client about discussed date of next visit MCH-FP Unit of UHC 30 8 (27%) 6 (20%) 30 (100%) 12 (40%) UH&FWC 123 1 (0.8%) 18 (15%) 56 (46% ) 18 (15%) Satellite Clinics 119 4 (3%) 32 (27% 56 (27%) 10 (8%) Total 272 13 (5%) 56 (21%) 142 (52%) 40 (15%) Table: Quality of counseling, Jhalokathi district
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 71 APPENDIX 4: DOCUMENTATION AND DISSEMINATION OF MAMONI PROGRAM LEARNING
Table: Forums where MaMoni HSS lessons were disseminated
Title Forum Month Type of Dissemination Quality of LAPM Services Marie Stopes May 2016 Oral Presentation Quality of LAPM Services DGFP Jun 2016 Oral Presentation
Table: Summary of program learning activities Topic Status 1. Quality of LAPM Services (USAID) IRB waived Data collection complete Final presentation shared with USAID, GOB and key partners 2. Use of partograph at peripheral level facilities and IRB waived at community level Data collection complete, summary brief (USAID) prepared Selected for poster presentation at FIGO 2016 Shared with USAID, GOB and key partners 3. Quality of ANC at satellite clinics Data collection completed (USAID) Preliminary findings shared with project team, USAID 4. Viability of private community skilled birth Data collection completed attendants Report summary prepared (USAID) Poster presentation at FIGO 2016 5. Country case study of national scale up of 7.1% IRB waiver received chlorhexidine application for newborn umbilical cord Data collection in progress care 6. Process documentation of strengthening UH&FWCs IRB waived for improved birth outcomes Baseline assessment completed Findings shared at national level 7. Implementation Research on management of JHU IRB received infections among young infants at union level Partnership with HRCI/JHU Evaluation done by JHU Implementation in progress 8. Measurement and validation of selected chronic Led by UNC, JHU, Measure, Fistula Care II maternal morbidities: IRB approval completed Household data collection to be completed by Nov 2016 Validation to begin on November 14
72 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report APPENDIX 5: LINKS TO SAFE MOTHERHOOD DAY VIDEOS AND MEDIA STORIES PUBLISHED
Table: Links to media reports related to MaMoni HSS Media Date Article Title and Link YouTube May 28 Videos on Safe Motherhood Day Jahanara Alam, Captain of National Female Cricket Team https://youtu.be/WD5QP2IAQv4 Elita Karim, Singer and Journalist https://youtu.be/qyS3sznNV1c Rubana Haq, first lady of Dhaka North City, and MD of Mohammadi Group https://www.youtube.com/watch?v=7ZUFITn7g5c Mehzabeen Khaled, MP, member of Standing Committee of Foreign Affairs Ministry https://www.youtube.com/watch?v=PyhrK0vcy88 Char King Union Parishad engagement https://www.youtube.com/watch?v=b3CnyHa1v5o Synopsis: Community Engagement (presentation by Imteaz Mannan) Y-3: Q-1
Media Date Article Title and Link Daily Naya Oct 17, http://www.dailynayadiganta.com/detail/news/62438 Diganta 2015 Daily Naya Nov 07, http://www.dailynayadiganta.com/detail/news/67530 Diganta 2015 Daily Nov 17, http://www.prothomalo.com/bangladesh/article/685852 Prothom Alo 2015 Daily Nov 22, http://www.prothom-alo.com/bangladesh/article/690841/ Prothom Alo 2015 Daily Nov 17, http://www.prothom-alo.com/we-are/article/685621/ Prothom Alo 2015 Daily Nov 20, http://www.prothom-alo.com/bangladesh/article/688642/ Prothom Alo 2015 Daily Nov 23, http://www.prothom-alo.com/bangladesh/article/691855/ Prothom Alo 2015 Daily Nov 12, http://www.prothom-alo.com/bangladesh/article/681493/ Prothom Alo 2015 Daily Nov 22, http://www.prothom-alo.com/bangladesh/article/690742 Prothom Alo 2015 Daily Nov 22, http://www.prothom-alo.com/bangladesh/article/690799/ Prothom Alo 2015 Daily Star Nov 17, Roundtable on World Prematurity Day 2015 2015 http://www.thedailystar.net/round-tables/world-prematurity-day/world-prematurity-day-2015- 173440 BDnews24 Nov 16, Bangladesh to introduce Kangaroo Care to save premature babies .com 2015 http://bdnews24.com/health/2015/11/16/bangladesh-to-introduce-kangaroo-care-to-save- premature-babies BSS Nov 16, Bangladesh witnesses 4,39,000 preterm births every year
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 73 2015 http://www.bssnews.net/newsDetails.php?cat=0&id=532698&date=2015-11-16 Daily Sun Nov 17, Preterm Birth poses threat to child survival 2015 http://daily-sun.com/printversion/details/91659/Preterm-birth-poses-threat-to-child-survival News Today Nov 17, 4,39,000 preterm births a year in country 2015 http://www.newstoday.com.bd/index.php?option=details&news_id=2427467&date=2015-11- 17 Asian Age Nov 17, Preterm birth high in Bangladesh 2015 http://dailyasianage.com/news/2588/preterm-birth-high-in-bangladesh
Naya Nov 17, http://www.dailynayadiganta.com/detail/news/70257 Diganta 2015 Bdnews24.c Nov 17, Campaigners encourage Bangladesh government to invest more in women newborn care for om 2015 triple return. http://bdnews24.com/health/2015/11/18/campaigners-encourage-bangladesh-government- to-invest-more-in-women-newborn-care-for-triple-return Kaler Nov 18, http://www.kalerkantho.com/print-edition/news/2015/11/18/291741 Kantho 2015 Prothom Alo Nov 18, http://www.prothom-alo.com/bangladesh/article/686695/ 2015 Bdnews24.c Dec 19, Usage of tabs revolutionises health services in Bangladesh om 2015 http://bdnews24.com/health/2015/12/19/usage-of-tabs-revolutionises-health-services-in- bangladesh
Naya Dec 20, http://www.dailynayadiganta.com/detail/news/78752 Diganta 2015 Y-3: Q-2
Media Date Article Title and Link
’ﶟKaler March �সূিতেসবা-হাওর-কন뷍ারা এখন ‘ডা�ার েব Kantho 08, http://www.kalerkantho.com/print-edition/last- 2016 page/2016/03/08/333488#sthash.yNmK2F2m.dpuf Independent January Ashar Bangladesh: Durgapur UH&FWC TV 23, 2016 https://www.youtube.com/watch?v=x_Y1dX-Qktg
কানাﶠ Prothom Alo February শিনবােরর িবেশষ �িতেবদন; �সূিতেদর আপন 05, 2016 http://www.prothom-alo.com/bangladesh/article/761524/%E0%A6% BDNews24. January Breastfeeding is a smart investment in people and economies com 30, http://bdnews24.com/health/2016/01/30/breastfeeding-is-a-smart-investment-in-people- 2016 and-economies-the-lancet
BDNews24. March Bend the health curve with efficiency and quality, says Save the Children director com 23, http://bdnews24.com/health/2016/03/23/bend-the-health-curve-with-efficiency-and-quality- 2016 says-save-the-children-director
Daily March মাধবপুের �া�뷍 ক া ড쇍 িবতরণ Khowai 17, http://www.dailykhowai.com/news/2016/03/17/53903 2016
Madhabpur March �া�뷍 ক া ড쇍 িবতরণ News 16, http://www.madhabpurnews24.com/?p=15303 24.com 2016
74 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Daily Feb 14, মাধবপুের ইউিনয়ন �া�뷍 ও পিরবার কল뷍াণ েকে� ৫মােস ৪শ িনরাপদ �সব Probhakar 2016 http://dailyprobhakar.com/%E0%A6%AE%E0%A6%BE%E0%A6%A7%E0%A6%AC%E0%A6%AA% E0%A7%81%E0%A6%B0%E0%A7%87- %E0%A6%87%E0%A6%89%E0%A6%A8%E0%A6%BF%E0%A7%9F%E0%A6%A8- %E0%A6%B8%E0%A7%8D%E0%A6%AC%E0%A6%BE%E0%A6%B8%E0%A7%8D%E0%A6%A5% E0%A7%8D Kaler েদেশ �িতিদন ২২৭ মৃত স�ান �সব Kantho http://www.kalerkantho.com/print-edition/last-page/2016/01/20/315427
Prothom Alo Jan 20, মৃত স�ান �সেবর তািলকায় বাংলােদশ স�ম 2016 http://www.prothom-alo.com/bangladesh/article/745285 The Daily Jan 22, STILLBIRTH IN BANGLADESH: Rate halved in 15 years Star 2016 http://www.thedailystar.net/frontpage/rate-halved-15-years-205471 Dainandin Feb 12, Workshop and training on Chlorhexidine use completed (Cox’s 2016 Bazar) Online link not available Y-3: Q-3
Media Date Article Title and Link YouTube May 28 Videos on Safe Motherhood Day Jahanara Alam, Captain of National Female Cricket Team https://youtu.be/WD5QP2IAQv4 Elita Karim, Singer and Journalist https://youtu.be/qyS3sznNV1c Rubana Haq, first lady of Dhaka North City, and MD of Mohammadi Group https://www.youtube.com/watch?v=7ZUFITn7g5c Mehzabeen Khaled, MP, member of Standing Committee of Foreign Affairs Ministry https://www.youtube.com/watch?v=PyhrK0vcy88 Char King Union Parishad engagement https://www.youtube.com/watch?v=b3CnyHa1v5o Kaler May 22, �া�뷍েসবা :অনন뷍 নিজর বদলপুের Kantho 2016 http://www.kalerkantho.com/print-edition/last-page/2016/05/22/361183 Kaler May 28, িব� �া�뷍 সং�ার িনেদ쇍িশকা উেপি�ত �সবকােজ Kantho 2016 http://www.kalerkantho.com/print-edition/last-page/2016/05/28/363235 Kaler May 29, িনরাপদ মাতৃ ে�র কােজ ছু েট েবড়ান লাভলীরা Kantho 2016 http://www.kalerkantho.com/online/miscellaneous/2016/05/28/363424 Bdnews24. Jun 05, Unnecessary C-sections done in Bangladesh com 2016 http://bdnews24.com/health/2016/06/05/unnecessary-c-sections-done-in- bangladesh-says-save-the-children-director-ishtiaq-mannan Bdnews24. Jun 20, Clinical Appeal’ creates new appeal in Bangladesh rural health com 2016 http://bdnews24.com/health/2016/06/20/clinical-appeal-creates-new-appeal-in- bangladesh-rural-health BSS Jun 20, Experts for safe delivery to prevent maternal deaths 2016 http://www.bssnews.net/newsDetails.php?cat=0&id=584146&date=2016-06-20
Prothom May 05, মাতৃ মৃতু 뷍-কমােত-িমডওয়াইফাির-েসবার-িবক�-েনই Alo 2016 http://www.prothom-alo.com/bangladesh/article/849826/
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 75 Prothom May 31, 0মা-িশশর �া�뷍 উ�য়েন বাড়ােত হেব বােজট Alo 2016 http://www.prothom-alo.com/bangladesh/article/873868
Y-3: Q-4
Media Date Article Title and Link Daily Naya July 20, Feature on Gestional Diabetic: identification, prevention and management Digonto 2016 Writer: Dr. Jebun Rahman http://www.enayadiganta.com/news.php?nid=262954
Daily July 27, News Title: েগালেটিবল ৈবঠেক বক্তারা: িকেশারীেদর জন� িবিনেয়াগ বাড়ােত হেব Prothom 2016 http://www.prothom- Alo alo.com/bangladesh/article/926878/%E0%A6%95%E0%A6%BF%E0%A6%B6%E0%A 7%87%E0%A6%BE%E0%A6%B0%E0%A7%80%E0%A6%A6%E0%A7%87%E0%A6%B0 -%E0%A6%9C%E0%A6%A8%E0%A7%8D%E0%A6%AF- %E0%A6%AC%E0%A6%BF%E0%A6%A8%E0%A6%BF%E0%A7%9F%E0%A7%87%E0% A6%BE%E0%A6%97- %E0%A6%AC%E0%A6%BE%E0%A7%9C%E0%A6%BE%E0%A6%A4%E0%A7%87- %E0%A6%B9%E0%A6%AC%E0%A7%87 Daily Star July 27, Give special attention to teenage girls 2016 http://www.thedailystar.net/city/give-special-attention-teenage-girls-1260040 Bdnews24. August Calls to regulate Horlicks advertisements in Bangladesh maligning breastfeeding com 09, campaign 2016 http://bdnews24.com/bangladesh/2016/08/19/calls-to-regulate-horlicks- advertisements-in-bangladesh-maligning-breastfeeding-campaign Bdnews24. August Small inputs can make a big difference in Bangladesh’s maternal, neonatal health, com 16, finds study 2016 http://bdnews24.com/health/2016/08/16/small-inputs-can-make-a-big-difference- in-bangladeshs-maternal-neonatal-health-finds-study
Daily Sun August Promote breastfeeding to cut child mortality 18, http://www.daily-sun.com/printversion/details/160306 2016 Daily Kaler Jun 20, মােয়র দুধব�ঞ্চত িশশুেদর ম ত�ৃ � ঝু ঁ ি ক ১৪% েবিশ Kantho 2016 http://www.kalerkantho.com/print-edition/last-page/2016/08/19/395135 Daily Kaler August েটকসই উন্নয়ন ল��মা�া অজ�েন মাতৃ দুেগ্ধর িবকল্প েনই Kantho 22, http://www.kalerkantho.com/print-edition/goltable/2016/08/22/396204 2016 Daily Star August OP-ED: Finishing the unfinished agenda 22 Writer: Joby George, COP, MaMoni HSS http://www.thedailystar.net/op-ed/politics/finishing-the-unfinished-agenda-1273339
APPENDIX 6: STATUS OF HEALTH FACILITY RENOVATIONS Table: Summary of status of renovation activities supported by MaMoni HSS
District Upazila Name of Facility Progress to date Remarks Noakhali Begumganj Aleyarpur UH&FWC Completed Handed Over Begumganj Gopalpur UH&FWC Completed Handed Over
76 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Hatiya Sonadia UH&FWC 25% Hatiya Char King UH&FWC Completed Handed Over Lakshmipur Sadar Sadar Hospital Completed Handed Over Sadar Dalal Bazar UH&FWC Completed Handed Over Sadar Uttor Joypur UH&FWC Bidding initiated Ramganj Dorbespur UH&FWC Completed Handed Over Kamal Nagar Char Falcon UH&FWC Bidding initiated Roypur Char Mohona UH&FWC Bidding initiated Jhalokathi Kathalia Chesrirampur UH&FWC Completed Handed Over Rajapur Saturia UH&FWC Completed Handed Over Sadar Binoykathi UH&FWC Completed Handed Over Nachity Siddhokathi UH&FWC Completed Handed Over
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 77 APPENDIX 7: MID TERM EVALUATION AND HOW THE RECOMMENDATIONS WERE INCORPORATED
Recommendations and Actions from MaMoni HSS Responses Proposed Actions by the Project Timeline MTR Report
Recommendation 1: Develop and 1. Since the project is nested within • A core package of EPCMD July 2016 – enhance the core project strengths for the existing health care delivery interventions will be defined for September sustainability. system, it has the potential to enhanced focus in project 2017 contribute to HSS in a areas during the final year of sustainable manner. the project. Using the data from 2. The project implementation at the assessment of UH&FWCs, Action: Consolidate and prioritize the district level will give greater category A and B facilities will emphasis on service availability, efforts on the most promising be prioritized for delivering and especially at union level and integrated package of components of the integrated service below, and quality of care. MNCH/FP/N services at union package and explicitly define the 3. A core package of EPCMD level and below. desired endpoints and sustainability interventions will be identified for • Consolidate the community October 2016 plans for the Project. the final year of implementation mobilization activities, with a September for enhanced focus in project special focus on providing a 2017 districts platform for implementing 4. The assessment of UH&FWCs social and behavior change across the country has been communication for increasing completed. The focus in the next demand and utilization of 2 years would be on developing services. District-specific BCC and strengthening the UH&FWCs strategies will be developed for increased coverage, both and implemented in high within the project districts, as intensity areas well as at a national scale by Septembe supporting MOHFW 2016 5. Efforts for building management and leadership capacity and • ownership of MOHFW managers Year 4&5 workplans will include at district and sub-district levels exit strategies for various will continue. components, with a strategy to 6. Reinforce Habiganj as the hand over to MOHFW and local learning lab of MaMoni HSS government model & develop an exit/ sustainability plan with GOB (DGFP). Recommendation 2: Develop a 1. At this stage of the project, there • Streamline MaMoni to support July 2016- composite, replicable model of is a need to streamline efforts to for district planning and September MaMoni HSS Project strengthen health systems at the reviews, MIS strengthening, 2017 district level in an integrated and quality improvement and local Action: Streamline the district systems replicable model. government engagement, with strengthening activities in planning, 2. There is a need to establish and mutually reinforcing linkages nurture the inter-connectedness information, supervision, and quality • Develop at least two districts October 2016 of the various health systems improvement into one composite and into comprehensive HSS September strengthening efforts at the models, including key elements replicable HSS Model, which others 2017 district level – such as planning of EPCMD and health systems can adopt. reviews, quality improvement, strengthening routine health information • Monitor trends in key health Six-monthly systems, logistics tracking and coverage and quality indicators surveys/ qua management, supervision of care
78 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report systems and local government assessments engagement and oversight 3. The key elements of district level • Undertake capacity building October 2016 health systems strengthening, initiatives focusing on efficient September that are suitable for replication use of data. 2017 through national level efforts, will • Scale up RHIS initiatives for be documented from MaMoni seamless use of data in two HSS districts and shared districts • Share project experience in the March 2017 integrated model with national level decision makers, development partners and other stakeholders Recommendation 3: Keep sight of 1. This recommendation is in line • MaMoni HSS will be actively July 2016 - and align with national goals for scale- with the project’s evolving role at engaged in the development of December 20 up action. the national level. The project has Program Implementation Plan recently signed several Letters of (PIP) for the fourth HNP sector Collaboration with different program and the Operational MoHFW departments, such as Plans Action: Within the project’s finite Planning Wing, Human • Strengthen the National October 2016 Resources Management Unit and timespan, it now needs to shift focus Newborn and Child Health Cell to September Quality Improvement Secretariat. from the district to the national level in provide technical and 2017 The project has recently been managerial leadership for the terms of alignment, engagement and engaged in discussions for scale up of newborn and child advocacy. developing the national new health interventions at national health and population sector scale and to monitor quality. plan. • The project will develop policy 2. Project has been actively briefs based on the project’s September engaged in evidence generation, experiences to advocate for 2016 -June advocacy and policy support in specific policy change and to several areas – such as promote adoption of project 2017 integration of maternal and approaches by other donors and newborn health interventions, implementing partners strengthening UH&FWCs, routine • Provide national level technical health information systems and assistance to key departments quality improvement, integration of MOHFW to strengthen the of FP services in DGHS facilities, implementation and human resources planning and management of EPCMD and deployment etc health systems interventions. July 2016 – 3. MaMoni HSS has completed the This will include the Quality September initial roll out of several Improvement Secretariat, 2017 interventions at national scale – Human Resources Management HBB and CHX. More emphasis Unit, MNCAH and MCRAH required in ensuring effective Operational Plans and the scale up Planning Wing
Recommendation 4: Strengthen 1. MaMoni agrees that efforts to • Consolidate the support for October 2016 community involvement in seeking strengthen maternal, newborn, Community Volunteers (CVs) September and getting quality health care. child health, family planning, and and community mobilization, 2017 nutrition services (Supply side) with a clear strategy for lining must be jointly implemented with them with the frontline health efforts to improve community workers. Action: Support, motivate, and sustain utilization of services so that coverage of interventions Community Volunteers (CVs) to increases (Demand side). • Develop and implement a multi- September promote grassroots awareness of better healthcare services, improve level BCC strategy, specific to 2016 – each district context. Leverage September
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 79 care-seeking behavior, and increase 2. The project feels the need to on the community mobilization 2017 involvement with the health system. strengthen the service availability platform for BCC and for and quality at all levels of care, strengthening the linkages with alongside the creation of the health systems through demand. In the final year of the community microplanning. project, the relative emphasis • Project will continue to December 20 needs to be in filling the gaps in implement the pilot to health systems and service demonstrate CV-CAG delivery rather than in community adaptation within the context of mobilization. Community Clinics and Community Groups/ 3. The project accepts the Community Support Groups. recommendation on the need for The project will document and fine tuning the community share the pilot experience with mobilization strategy and to MOHFW and other stakeholders document the success. However, and decide on the expansion to the project will not work on other areas. strategies for income generation by the community volunteers
4. MaMoni HSS will continue with the pilot to link the community mobilization model with the existing CG and CAG structure of MOHFW. In addition, more emphasis will be given to strengthening the linkage between community volunteers and the frontline health workers for sustainability of the model. A decision on the expansion of this model will be made, jointly with the MOHFW, only after the pilot implementation and documentation is completed by December 2016. • Continue to engage the print August 2016 and electronic media in September advocating for health system 2017 The project recognizes the need to changes, to highlight key increase the frequency of field visits successes and project’s Recommendation 5: Leverage Media by key government officials to support models engagement for Promotion of Project our advocacy efforts at the national • Facilitate field visits by key September Successes and Advocacy level. In addition, the project will work MOHFW officials as well as 2016-June with various national and local media influential media personnel to 2017 Action. Enlarge the scope of media to highlight key project successes the project locations to observe engagement to cover reporting of including availability and use of 24/7 the successes from MaMoni more stories from the project, maternal and newborn services. The HSS’ efforts • August 2016 especially case studies of women who successes from the engagement of Mobilize media to generate enthusiasm and support have been referred to 24/7 Clinics local government institutions for their September and the involvement of UP Chairmen. among local leaders and 2017 oversight role and to provide local elected representatives for resource mobilization will be strengthening UH&FWCs prioritized for dissemination through • Develop communication August 2016 media. products (such as videos) to September showcase successes and for 2017 advocacy, including videos on local government engagement
80 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report Recommendation 6: Showcase the • Project will revise the October 2016 Project as Representative of USAID Hi- documentation and program Tech Contribution in EPCMD, with learning plan to include a GOB. stronger dissemination strategy • Project will document October 2016 1. Project is supporting for experiences and share lessons June 2017 demonstration of evidence based learned that will contribute to Action: Even in the limited time left, maternal and newborn survival national scale up process. the project’s role in providing the interventions i.e., KMC, ACS, • Project continue support for December 20 highest technical resources available Community based national scale up of critical intervention and work with to improve health systems SPE/Eclampsia prevention with national stakeholder group to strengthening, integrated MNCH/FP/N MgSO4 etc. 2. Projecting is supporting national position appropriately in in services, Essential Newborn Care and Scale up of critical life-saving upcoming sector plan EPCMD needs to be iterated with GOB. newborn interventions i.e., HBB, • Aponjon will develop and August 2016 implement new strategies for CHX September 3. Documentation and free, embedded messaging, 2017 interactive platforms along with dissemination of results, experiences and lessons learned subsidies, cost-sharing and need to be strengthened partnerships. More emphasis
to be given to customer acquisition involving public and
private sector health service providers. New applications for adolescents and families of young children will be integrated within the Aponjon message delivery and interactive services.
Recommendation 7: Let the Future 1. The project’s engagement in • Engage in dialogue with June 2017 Lead national level discussions related national policy makers at to planning for the next MoH&FW, DGFP, DGHS to population and health sector is envision the future health Action: Envision a future of attaining an important venue to predict the policies and align the project healthy outcomes for mothers, future policies and strategies. At strategies accordingly newborns, and children in Bangladesh, this final stage of the project will • Continue to engage in September align its interventions to fit the 10 years from now – then consider discussion with USAID mission 2017 future health strategies. what changes might enhance project on the future priorities and the 2. Some of the newer initiatives for long-term vision of the project efforts to better attain that vision. supporting the development of the new sector program, the
technical assistance in national level health systems strengthening have provided new opportunities for the MaMoni HSS team to better understand envision the goals and directions of the health sector in the run up to achieving Universal Health Care
3. The project team, Save the Children and other consortium partners, will develop a long-term vision for strengthening the health systems in Bangladesh and share ideas with USAID mission.
MaMoni Health Systems Strengthening Activity: FY’16 Annual Report 81
82 MaMoni Health Systems Strengthening Activity: FY’16 Annual Report