MaMoni Health Systems Strengthening Activity

(USAID Associate Cooperative Agreement No. AID-388-LA-13-00004)

Quarterly Report April 1 – June 30, 2015

Submitted August 7, 2015

MaMoni HSS – Year Two Third Quarterly Report July 2015 1

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, Bangladesh (USAID/Bangladesh) under the terms of Associate Cooperative Agreement No. AID-388-LA-13-00004 through MCHIP, managed by Jhpiego Corporation. The contents of this document are the responsibility of Jhpiego Corporation and do not necessarily reflect the views of USAID or the United States Government.

Cover Photo Credit: Mr. Syed Monjurul Islam, Honorable Secretary, MOH&FW, at the national launch of the national initiative to strengthen UH&FWCs to increase access to skilled attendance at birth, held at the Spectra Convention Center. MaMoni HSS has been supporting the MOH&FW by providing technical assistance to assess facility readiness of all UH&FWCs in Bangladesh. Photo Credit: Save the Children.

MaMoni HSS – Year Two Third Quarterly Report July 2015 2 TABLE OF CONTENTS Acronyms and Abbreviations ...... 5 1. Introduction ...... 8 2. Program Objectives and Key Activities...... 9 3. Program Results for Quarter Three ...... 12 3.1 Summary of Major Accomplishments ...... 12 3.2 Narrative Report of Major Accomplishments ...... 13 3.2.1 Improve service readiness through critical gap management ...... 13 3.2.2 Strengthen health systems at district level and below ...... 19 Discussion with UFPO & FP monthly meeting for carrying combined register ...... 27 Promote an enabling environment to strengthen district-level health systems ...... 28 3.2.3 Identify and reduce barriers to accessing health services ...... 30 3.2.4 Challenges, Solutions and Action Taken ...... 31 4. The Way Forward ...... 33 5. Appendix...... 34 Annex 1. Photos from key events ...... 34 Annex 2: Performance Indicators (October 2014-June 2015) ...... 35 Annex 3: Success Stories ...... 54 Annex 4: Key Achievements of Aponjon/MAMA initiative ...... 58 Annex 5: An Update on Routine Health Information System ...... 61 Post training follow-up activities: ...... 62 Software Development Activity: ...... 62 Platform Unification: ...... 64 Guide and Facilitate Software Development: ...... 64 Data Ownership: ...... 64 Platform Evaluation: ...... 64 Annex 6: An update on national UH&FWC strengthening initiative ...... 66 Annex 7: Media Stories Published this Quarter ...... 70 Annex 8: National Newborn Scale-Up Initiatives ...... 73 Annex 9: Summary of Behavior Change Communication materials produced during the quarter ...... 80 Annex 10: Stakeholder consultation meeting on strengthening Union Health & Family Planning Centers - UH&FWCs to increase SBA Coverage ...... 81 Annex 11: Summary of pending activities of Year 2 workplan (Quarter 4) ...... 84

MaMoni HSS – Year Two Third Quarterly Report July 2015 3 MaMoni HSS – Year Two Third Quarterly Report July 2015 4 Acronyms and Abbreviations

AO Agreement Officer AMTSL Active Management of Third Stage Labor BCC Behavior Change Communication BEmONC Basic Emergency Obstetric and Newborn Care BNF Bangladesh Neonatology Forum BPS Bangladesh Perinatal Society BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CEmONC Comprehensive Emergency Obstetric and Newborn Care CHX Chlorhexidine CIPRB Center for Injury Prevention and Research, Bangladesh cMPM Community Microplanning Meeting CNCP Comprehensive Newborn Care Package CS Civil Surgeon CSBA Community Skilled Birth Attendants CV Community Volunteer CVRS Civil Registration and Vital Statistical System CYP Couple Years of Protection DDFP Deputy Director Family Planning DGFP Directorate General Family Planning DGHS Directorate General Health Services ECEB Essential Care for Every Baby EM Environmental Manual FAOPS Federation of Asia and Oceania Perinatal Societies FWA Family Welfare Assistant FWV Female Welfare Visitor GOB Government of Bangladesh HA Health Assistant HBB Helping Babies Breathe HMIS Health Management Information System HPNSDP Health, Population and Nutrition Sector Development Program HRCI Health Research Challenge for Impact HSS Health System Strengthening icddr,b International Centre for Diarrheal Disease Research, Bangladesh IMNCS Improving Maternal, Neonatal, and Child Survival IR Intermediate Result J&J Johnson and Johnson JHU/IIP Johns Hopkins University, Institute for International Programs JSI John Snow, Inc. JSV Joint Supervisory Visit

MaMoni HSS – Year Two Third Quarterly Report July 2015 5 LAPM Long Acting and Permanent Method LMIS Logistics Management Information System MCHIP Maternal and Child Health Integrated Program MCRAH Maternal, Child, Reproductive and Adolescent Health MEO Mission Environmental Officer MNCAH Maternal, Newborn, Child and Adolescent Health 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 OGSB Obstetrics and Gynecology Society of Bangladesh OP Operational Plan OR Operations Research PFM Physical Facilities Management PNGO Partner nongovernmental organization PPH Postpartum Hemorrhage PPIUCD Postpartum Intra-uterine Contraceptive Device QA Quality Assurance QI Quality Improvement QPRM Quarterly Performance Review Meeting RCHCIB Revitalizing Community Health Care in Bangladesh RHIS Routine Health Information System RRQAT Regional Roaming Quality Assurance Team SACMO Sub-Assistant Community Medical Officer 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 SMC Social Marketing Company SOP Standard Operating Procedure SSN Senior Staff Nurse TBA Traditional Birth Assistant TIS Tracer Indicator Surveys TOT Training of Trainers UDCC Union Development Coordination Committee UEHFPSC Union Education Health and Family Planning Standing Committee UFPO Upazila Family Planning Officers UH&FPO Union Health and Family Planning Officer

MaMoni HSS – Year Two Third Quarterly Report July 2015 6 UH&FWC Union Health and Family Welfare Centers UP Union Parishad USAID United States Agency for International Development

MaMoni HSS – Year Two Third Quarterly Report July 2015 7 1. Introduction

The MaMoni Health Systems Strengthening (HSS) project is a four-year Associate Award under the Maternal and Child Health Integrated Program (MCHIP), with a period of performance from September 24, 2013 to September 23, 2017. MaMoni HSS builds upon MaMoni’s previous work in Bangladesh and focuses on strengthening the systems and standards for maternal, newborn and child health, family planning and nutrition (MNCH/FP/N) that will result in declines in maternal, newborn and child mortality within seven districts in Bangladesh. The project supports the Ministry of Health and Family Welfare (MOH&FW) to introduce and leverage support for scale-up of evidence-based practices proven effective in Bangladesh.

MaMoni HSS is primed by Jhpiego in partnership with Save the Children (SC), John Snow, Inc. (JSI), and Johns Hopkins University, Institute for International Programs (JHU/IIP), with national partners International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dnet, and Bangabandhu Sheikh Mujib Medical University (BSMMU). SC serves as the functional operational lead partner for the Award in Bangladesh. MaMoni HSS engages with local government structures and non-governmental organizations (NGO) to improve delivery of health services and strategically partner at the national level to build consensus around policies and standards that positively drive evidence-based interventions at all levels.

Beginning the second year of implementation, Figure 1: Map of MaMoni HSS project areas the project is using a differential approach to implementation at the district level. Districts and upazilas are categorized into two groups based on the intensity of implementation support. This categorization will be maintained through the life of the project.

High-intensity areas: MaMoni HSS supports high-intensity interventions in a total of 23 upazilas. These areas include all upazilas of Habiganj, Lakhsmipur and Jhalokathi districts, four upazilas of Noakhali, and two upazilas of Pirozepur district.

Health system (HS) capacity strengthening areas: All remaining areas will receive support for implementing selected program components. These areas will also benefit from the district-level support for HS capacity strengthening. This covers a total of 17 upazilas – all seven upazilas of Bhola, five upazilas of Noakhali, and five upazilas of Pirozepur.

The map depicted in Figure 1 shows the geographic focus of the project from the second year of implementation. Table 1 below shows a summary of the geographic scope of the program.

MaMoni HSS – Year Two Third Quarterly Report July 2015 8

Table 1: Summary profile of MaMoni HSS program areas

Population No. of Health Facilities No. of No. of Area (2015 District Upazilas Unions Upazila Union Community projection) (MCWC) High-Intensity 23 226 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

2. Program Objectives and Key Activities

The goal of MaMoni HSS is to improve utilization of integrated MNCH/FP/N services and will be achieved through the project objective to increase availability and quality of high-impact interventions through strengthening district-level local management of health systems. This objective is well-aligned with the Government of Bangladesh’s (GOB) Health, Population, and Nutrition Sector Development Program (HPNSDP) for 2011–2016. MaMoni HSS will also directly support the USAID/Bangladesh Development Objective 3 (DO 3) “Health Status Improved” under the “Investing in People” Objective of the Country Development Cooperation Strategy (CDCS) Framework of USAID in Bangladesh.

MaMoni HSS has four intermediate results (IR). Shown below is a summary of the project’s IRs, sub-IRs, and the major activities included in the second year workplan.

IR1: Improve service readiness through critical gap management Sub-IR 1.1: Increase availability of health service providers • Support MOH&FW to develop a human resources information system (HRIS) for the country, including plans for recruitment and deployment of health workforce • Advocate GOB to expedite the recruitment of relevant staff and deploy them to fill all vacant positions, prioritizing positions in Union Health and Family Planning Welfare Centers (UH&FWC), Basic Emergency Obstetric and Newborn Care (BEmONC) and Comprehensive Emergency Obstetric and Newborn Care (CEmONC) facilities • Support temporary gap management of critical service provider positions in strategically-located facilities in high-intensity areas

Sub-IR 1.2: Strengthen capacity of service providers to provide quality services • Adapt or develop training package for different providers for integrated MNCH/FP/N skill development • Establish mechanism for development of trainers pool to conduct training of trainers (TOT)/training on MNCH/FP/N packages • Support training of service providers on integrated package(s) of MNCH/FP/N clinical service delivery and quality improvement areas • Continue technical support for national scale-up of Helping Babies Survive (HBS) • Support MOH&FW to ensure availability of logistics, and supplies for the roll-out of new newborn care interventions

MaMoni HSS – Year Two Third Quarterly Report July 2015 9

Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization • Support MOH&FW to maintain upgraded UH&FWCs to provide MNCH/FP/N services, including 24/7 delivery services • Support secondary and tertiary-level referral facilities of MOH&FW for integrated MNCH/FP/N services • Strengthen referral systems at the community level and at facilities • Upgrade facilities to be prepared for delivering the minimum essential package of MNCH/FP/N services • Support Directorate General Family Planning (DGFP) to scale up skilled birth attendant (SBA) deliveries by strengthening union level facilities

IR2: Strengthen health systems at district level and below Sub-IR 2.1: Improve leadership and management at district level and below • Build leadership and management capacity of MOH&FW managers at district and upazila levels through Strategic Leadership and Management Training Program (SLMTP) • Establish mentorship program for the district and upazila level managers

Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs • Facilitate MOH&FW decentralized MNCH/FPN planning and review systems • Facilitate regular review by MOH&FW of MNCH/FP/N performance against annual plans at upazila and district levels • Support the use of local data to track progress and make decisions on course corrections • Support MOH&FW to institutionalize community microplanning meetings (cMPMs) and union follow-up meetings

Sub-IR 2.3: Strengthen local management information systems • Support MOH&FW at the national level to design and pilot an automated comprehensive routine health information system (RHIS) • Support MOH&FW to roll out paper-based RHIS in high intensity areas until the automation is completed • Train managers and other key personnel on utilizing data for decision-making and for facilitative supervision

Sub-IR 2.4: Establish quality assurance (QA) system at district level and below • Support MOH&FW to strengthen national level QA initiatives • Support MOH&FW to strengthen supervision systems at all levels • Support improved infection prevention/ bio-waste management practices at health facilities • Support MOH&FW for the training of service providers on quality improvement and Standards- based Management and Recognition (SBM-R) • Support MOH&FW to activate and support Regional Roaming Quality Assurance Teams • Support MOH&FW to scale up Maternal and Perinatal Death Reviews (MPDR)

Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below • Scale up UIMS/ Service Delivery Point (SDP) dashboard module in high intensity areas

MaMoni HSS – Year Two Third Quarterly Report July 2015 10 • Support Directorate General Health Services (DGHS) to pilot and scale up a logistic management system for essential RMNCH commodities • National-level advocacy and support for the procurement of essential MNCH commodities for life-saving interventions

Sub-IR 2.6: Strengthen local government planning and engagement in health service provision • Build capacity of local government institutions to actively contribute to MNCH/FP/N • Strengthen the Vital Registration Systems (VRS) through improved coordination between MOH&FW and the Ministry of Local Government Rural Development & Cooperatives (MOLGRD&C) • Enhance the role of Union Parishads (UP) in MNCH/FP/N budgeting and problem-solving

Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N (in high intensity areas) • Facilitate activation of Union Education Health and Family Planning Standing Committees (UEHFPSC) in areas where they are not functional • Strengthen Union Parishad’s bi-monthly Union Development Coordination Committee (UDCC) meetings

IR3: Promote enabling environment to strengthen district-level health systems Sub-IR 3.1: Policy reforms in place to promote local planning and need-based human resource deployment in the public sector • National-level advocacy initiatives for policy reform • Provide national advocacy and technical support to MOH&FW to scale up SBA delivery by strengthening UH&FWCs to provide 24/7 services

Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidence-based learning in national policy and program • National-level advocacy to address barriers to utilization of budget allocated to MNCH/FP/N related Operational Plans (OP) • Promote program learning and documentation of lessons learned and accomplishments • Advocate for the scale-up of evidence-based maternal and newborn interventions in support of the Ending Preventable Child and Maternal Deaths (EPCMD) activities in Bangladesh

IR4: Identify and reduce barriers to accessing health services Sub-IR 4.1: Promote awareness of MNCH through innovative Behavior Change Communication (BCC) approaches • Develop and implement a mixed-methods communication campaign designed to catalyze behavior change in target groups • Contribute to the development of a national BCC campaign to support the scale-up of priority EPCMD interventions • Use technology from Aponjon, the local initiative of Mobile Alliance for Maternal Action (MAMA), to disseminate health messages to target populations

Sub-IR 4.2: Enhance community engagement in addressing health needs • Recruit, train, and support community volunteers (CV) • Support CVs to provide FP counseling and referrals

MaMoni HSS – Year Two Third Quarterly Report July 2015 11 • Facilitate Community Action Group (CAG) meetings and establish emergency transport systems for referral transport

3. Program Results for Quarter Three 3.1 Summary of Major Accomplishments

This report focuses on the period from April 1 to June 30, 2015. Key highlights for this reporting period include:

Programmatic Activities • The project facilitated decentralized district and sub-district level planning for MNCH/FP/N in four high intensity districts. National program review meeting was held in June and quarterly performance review meeting in four districts in May 2015 where both DGFP and DGHS staff jointly reviewed data and generated action plans. • A comprehensive, fully automated routine health information system for the MOH&FW was introduced in Madhabpur upazila of Habiganj district. Between March 15 and June 30, information on 108,096 individuals and 20,755 households were entered into the national registry. MaMoni is supporting the initiative by creating an FWV service module where ANC and FP services can be recorded and shared between service providers. • Facilitated referral of 1,188 maternal and 333 newborn cases in three districts to receive care at a higher level facility. • Established a Technical Assistance Cell in DGFP for strengthening the UH&FWCs with dedicated team members assigned from MaMoni HSS as well as from DGFP. Assessment of 739 UH&FWCs in Sylhet, Chittagong and Barisal Divisions completed. • Commenced scale-up of 7.1% chlorhexidine (CHX) to cover all sub-districts of Habiganj after six months of introduction in Bahubal sub-district. The project has completed the procurement of CHX for scale-up in another 10 upazilas in the third quarter. A detailed implementation plan has also been developed for supporting the MOH&FW at national scale. • Aponjon service added 49,321 subscribers in the past quarter, reaching a total of 1,281,951 subscribers by the quarter’s end. Because of funding uncertainty, customer acquisition was significantly affected in May 2015. Aponjon website also developed. The demo version can be seen at http://www.aponjon.com.bd/demo • A total of 51,779 persons were reached with BCC through primarily video shows and meetings with pregnant women. Trainings • Trained 1,205 GOB workers on various MNCH/FP/N topics. • The roll-out of comprehensive newborn care package (CNCP) modules has started with 100 trainers developed and 790 providers trained at national level. Project-supported Results • Supported the GOB to ensure provision of round-the-clock services through 35 UH&FWCs in project areas, a total of 1,819 deliveries were conducted in these facilities during this quarter. • A total of 372 (72% against quarterly target) joint supervisory visits (JSV) were initiated with local government staff at union and upazila levels in Habiganj, Lakshmipur, and Noakhali. Achieved coverage for 14,930 deliveries conducted by SBAs in six districts, of which, 12,944 were conducted at health facilities. This total represents approximately 18 percent of all projected deliveries for the quarter for those six districts.

MaMoni HSS – Year Two Third Quarterly Report July 2015 12 Generated 224,448 couple-years of protection (CYP), in six focus districts where the implementation started in the first year, including 54,235 who accepted Long Acting and Permanent Method (LAPM), which represents 24 percent of the total CYP in these districts.

3.2 Narrative Report of Major Accomplishments

3.2.1 Improve service readiness through critical gap management

Management of critical human resource gaps of GOB service providers: During the quarter, the project supported the high-intensity areas with critical human resource gap management through temporary NGO service provider recruitment. MaMoni HSS continued to provide temporary staff to address the vacancies in nurses and Female Welfare Visitor (FWV) positions in selected facilities in Habiganj, Noakhali, and Lakhsmipur districts, while continuing to advocate for long-term solutions by filling the vacancies through GOB recruitment. In the six districts where implementation is in progress, the project is currently supporting 58 paramedics, and 19 nurses to fill critical human resource gaps.

Table 2: Summary of critical health workforce gap management provided by MaMoni HSS in six districts, as of June 30, 2015

FWV Nurses Total District Paramedics Nurses Vacant Vacant Vacant MaMoni HSS deployed by deployed by Posts Posts Posts Support MaMoni HSS MaMoni HSS Habiganj 9 33 75 14 84 47 Noakhali 10 12 80 2 90 14 Lakshmipur 0 8 64 3 68 11 Jhalokathi 4 5 0 0 40 5 Total 23 58 219 19 282 87

As MaMoni HSS completed health workforce assessment and validated the sanctioned posts, some districts e.g Habiganj and Lakshmipur are reporting higher number of vacancies. In the previous quarter Habiganj reported 40 nurse vacancies, whereas after complete assessment it was found to be 84, a much higher number. Changes from the previous quarter in paramedics deployed in Habiganj, Noakhali, and Jalokathi are a result of staff turn-over. Otherwise the contextual factors affecting the critical gap management have not changed since the last quarter. The status of vacancies and MaMoni gap management will be expected to undergo changes in December when new FWV’s are deployed.

Supported health facility preparedness for MNCH/FP/N services: In the project districts, MaMoni HSS facilitated a systematic process to identify health facilities that are strategically located and have the potential to provide a comprehensive package of services, including 24/7 delivery care, with some additional elements such as renovated physical infrastructure, filled vacant positions, deployment of additional paramedics, training of staff, and provision of essential equipment and supplies. The project is supporting the MOH&FW to identify and upgrade strategically-located UH&FWCs. As of June 2015, there are 39 of 193 UH&FWCs in the 21 high-intensity upazilas that are providing 24/7 delivery services,.

MaMoni HSS – Year Two Third Quarterly Report July 2015 13 Only Char Falcon UH&FWC started conducting deliveries this quarter. MaMoni HSS has received USAID approval to renovate 14 health facilities and is finalizing the selection of contractors at this point.

USAID has approved renovation plan for a select number of health facilities in Noakhali, Lakshmipur and Jhalokathi districts. Bids were invited from contractors in June, and the renovation work will commence in the fourth quarter.

The following section briefly shows the delivery performance of the UH&FWCs

Figure 2: Normal Vaginal Delivery at UH&FWCs (April-Jun 2015) 50 43 45 3841 a. Habiganj38 40 34 34 29 31 30 23 26 24 2423 24 24 21 20 22 19 18 18 18 16 17 15 16 20 12 12 13 13 1412 13 8 7 10 9 8 8 6 5 4 5 6 6 4 5 6 3 4 3 3 10 2 0 0 3 2 1 2 0

Apr-15 May-15 Jun-15

b. Noakhali 60 51 48 50 47 45 41 40 35

30 21 21 20 18 20 15 17 17 14 14 12 14 8 10 2 2 1 0 Alyerapur Durgapur Gopalpur Char Kakra Sirajpur Char King Sonadia

Apr-15 May-15 Jun-15

MaMoni HSS – Year Two Third Quarterly Report July 2015 14 70 c. Lakshmipur 60 60 56 46 50 43 40 30 30 30 26 30 25 24 23 23 20 17 15 20 12 10 9 9 10 6 6 6 6 6 0 Dalal Bazar Chandraganj Bhadur Darbeshpur Char Mohana Sonapur Keroa Bamni Apr-15 May-15 Jun-15

MaMoni HSS has attempted to determine the cause of the wide variation of performance among the facilities. Three factors accounted for the variation in the performance of the health facilities 1. Some health facilities are located at the intersection of multiple unions, and thus serve a larger population beyond the respective union. Murakuri UH&FWC serves Fandauk union of Brahmanbaria, as well as clients from Bamoi and Muriauk unions of Lakhai since those health facilities are not functional. Kakailseo and Daulatpur unions of Habiganj are near Sunamganj, and serves clients from Shalla and Derai upazila for Sunamganj district. Population of Char Kakra union of Noakhali is around 70,000, so even though a lower proportion of mothers might be delivering, in absolute numbers it is high performing facility. 2. The facilities in the Haor (wetland) area are more accessible in the rainy season, thus clients come more via boat during the rainy season, in the mud season (October-December), utilization is low as the clients would have to walk. In comparison, some roads of Lakshmipur and the tea gardens of Habiganj are not paved, and makes it difficult for clients to access during rainy season. 3. A performance lag is common in new facilities, as the provider returns from training/attachment, the community awareness and trust is built, and mothers build rapport with the providers through ANC visits. The project experience in Habiganj is that a six month time is required for a facility to reach optimum service coverage.

Strengthening UH&FWCs for increasing skilled attendance at birth at the national level

MaMoni HSS is supporting DGFP to assess all UH&FWCs managed by DGFP in the country, a total of roughly 3,860 centers, to provide integrated MNCH/FP/N services, including 24/7 delivery services. The DGFP has already budgeted additional funds in their revised operational plan to reflect this activity. Using data collection tools programmed into tablet computers, 14 data collectors working for the project have received training and begun visiting UH&FWCs to record the current status of basic amenities and physical infrastructure. As of June 15, 541 UH&FWCs from Sylhet and Barisal division were assessed (all 10 except Barguna district). Out of 541, a total of 97 facilities were included in Category A, which indicates they are ready for immediate expansion of NVD services round the clock. Similarly, 87 facilities fell under Category C, which indicates they will require significant renovation and staffing deployment to make them functional.

At the national level, MaMoni HSS facilitated a stakeholder consultation workshop to enlist the support of other partners and stakeholders for the UH&FWC strengthening initiative. The workshop was

MaMoni HSS – Year Two Third Quarterly Report July 2015 15 attended by the Secretary, MOHW, the Director General of Family Planning and a large number of stakeholders. Please refer to Annex 10 for a more detailed report on this event.

National scale-up of newborn care interventions Major accomplishments during this quarter included the introduction of two different packages of Comprehensive Newborn Care Package (CNCP) (Upazila and union level packages; a third community package to be launched in next quarter) training in six MaMoni HSS Project districts, HBB refresher training under district revisit program, TOT for TBA orientation on application of 7.1% Chlorhexidine, and HBB & Surveillance data jointly reviewed with BSMMU senior faculties. 100 doctors were developed as trainers and 790 health provider at different levels and categories received training on CNCP, 11 doctors received TOT for TBA orientation on 7.1% Chlorhexidine and 20 providers received HBB refresher training. Annex 8 described MaMoni initiatives on Newborn sepsis management and KMC as well.

MaMoni HSS hosted the Asia Regional Helping Babies Survive (HBS) workshop to launch the new HBS training materials, including the Essential Care for Every Baby (ECEB) and Essential Care for Small Babies (ECSB). The workshop was organized jointly by the Ministry of Health and Family Welfare, with support from USAID, Maternal and Child Survival Project (MCSP), UNICEF, American Academy of Pediatrics, Laerdal Foundation and USAID/ASSIST project. A total of 110 delegates from 11 countries attended the five-day workshop held in Dhaka from April 8-13, 2015. The workshop was funded by USAID through MCSP.

Strengthened Family Planning services: MaMoni HSS Project participated in the global meeting for “Accelerating Access to Postpartum Family Planning” held in Thailand. The meeting initiated a series of interactions to catalyze country progress toward FP2020’s goal of providing additional 120 million women and girls access to lifesaving contraceptive information, services, and supplies by 2020. A key principle of FP2020 is to support the integration of family planning within the continuum of care for women and children.

The global action-oriented meeting brought together experts from FP/RH and MNCH communities, and country delegates to identify and expand access to voluntary family planning to meet the needs of postpartum women. Throughout this meeting, country delegations developed context-specific action plans to initiate or adapt postpartum family planning (PPFP) initiatives in light of country strategies. The Bangladesh team, including representatives from MoH&FW, UNFPA, USAID, and implementing partners (see the team’s composition below), has developed a draft national action plan for acceleration access to postpartum family planning. MaMoni HSS will be incorporating this action plan in its FP strengthening efforts, particularly in integrating PPFP services through the UH&FWCs. Also, MaMoni HSS will advocate for PPFP services to be provided through DGHS facilities, which is one of the gaps identified. MaMoni is in discussion with GOB to determine additional role.

MaMoni trained Community volunteers in high intensity districts in the prior quarter on family planning referral, the CV contribution to referral for LAPM in Lakshmipur has increased significantly since the comparable quarter in the previous year.

Table 2: Community volunteer contribution to referral for LAPM services (April-June 2015).

District LAPM referral by CV LAPM referral by CV

MaMoni HSS – Year Two Third Quarterly Report July 2015 16 GoB contribution% Habiganj 798 1691 47.2 Lakhsmipur 710 2029 35.0 Noakhali 50 789 6.3 Jhalokathi 4 911 0.4 Pirojpur 0 362 0.0 Total 1,562 5,782 27.0

It may be noted that the CVs in Habiganj have been referring clients for FP services since the MaMoni phase. The CVs in Noakhali, Lakhsmipur and Jhalokathi have received the orientation during the last quarter and the referrals have just started. Also, the record keeping systems for tracking of referrals have recently been established in these three districts.

Figure 3: Number of LAPM Referrals Performed by Community Volunteers (CV) and Government of Bangladesh (GOB) Providers in Habiganj Upazilas (Jan – May 2015)

100% 90% 80% 82 45 62 70% 77 68 1047 60% 164 208 50% 341 40% 30% 175 50 87 20% 41 48 554 10% 49 86 0% 18 Ajmiriganj Baniachang Chunarughat Nabiganj Bahubal Sadar Lakhai Madhabpur District CV/CAG GoB

Strengthened Nutrition Services:

MaMoni HSS conducted consultation meetings with the Institute of Public Health Nutrition (IPHN) to agree on the priority nutrition focus areas for MaMoni HSS to support. Based on the action plans agreed, MaMoni HSS will support 2-3 selected upazilas to strengthen the following nutrition interventions:

• Strengthening growth monitoring and promotion (GMP) through Community Clinics, UH&FWCs and Satellite Clinics. This will also include routine screening for acute malnutrition, referral of severe acute malnutrition cases to Upazila Health Complexes for management of SAM as per the national guidelines • Strengthening the IMCI and Nutrition Corners at Upazila health Complexes to manage children with acute malnutrition. This will also include training and capacity-strengthening of clinicians and nurses responsible for SAM at upazila and district levels.

MaMoni HSS – Year Two Third Quarterly Report July 2015 17 • Strengthening of behavior change communication on infant and young child feeding, using the platform of Community Action Groups • Strengthening the maternal nutrition interventions, particularly focusing on counseling during antenatal and postnatal periods, antenatal and post-partum iron folic acid supplementation and dietary diversification.

MaMoni has already began severely acute malnutrition (SAM) and community management of acute malnutrition (CMAM activities) in Madhabpur upazila of Habiganj, and will introduce the similar packages in Jhalokathi Sadar upazila where UNICEF has already provided SAM training and introduced SAM corner at district hospital.

Between Nov 2014 and June 2015, 63 children were admitted to Habiganj District Hospital due to severe acute malnutrition. Out of them 42 were successfully treated and released. 2 children died, 1 was absent, 8 dropped out, and for 8 children, no information was found beyond admission information during follow- up. MaMoni HSS is supporting the Habiganj district hospital to properly provide service to these children.

Competency-based training of GOB service providers

MaMoni HSS facilitated and supported the competency-based training of GOB service providers in selected technical areas. The details of the training program and the number of participants are presented in Annex 8. A summary of the types technical training supported by the project during the Figure 4: F-100 therapeutic food and an admitted child quarter are shown in Table 4 below: with SAM at Habiganj District Hospital

Table 3: Competency-based trainings and orientations undertaken by MaMoni HSS in the third quarter of FY15 (April-June 2015)

Training Type Training Batches Participants Level of Trainees Duration A. Competency based clinical training ANC, PNC and Labor Room Protocol Three days One 25 Master trainers from (Package 2) (TOT Only) OGSB, DGHS, DGFP, MaMoni HSS QI managers

MaMoni HSS – Year Two Third Quarterly Report July 2015 18 Master trainers from Infection prevention and medical Two Days One 23 OGSB, DGHS, DGFP, waste management (Package 3) (TOT) MaMoni HSS QI managers Infection prevention and medical Two Days 13 255 Sr. Staff Nurse, Nurse, waste management (Package 3) FWV, Paramedics, MOs (Training) Malnutrition Management (TOT) Five days One 19 MO and Staff Nurse Habiganj (SAM and CMAM) (Habiganj only) HBB Refresher Training One day one 20 Doctors, nurses, FWVs, CSBAs Comprehensive Newborn Care Package Five days 40 790 Doctors, Nurse, FWV, Training SACMO Private CSBA training Six months Two 40 Women from community (Noakhali and Lakshmipur) B. Other trainings/orientations Online reporting of IMCI data using Three days One 10 Statisticians DHIS2 (Noakhali) TOT on Chlorhexidine Orientation of One day 13 259 FWV, CSBA TBAs Orientation on Chlorhexidine One day One 30 TBAs

Basic Commodities (contraceptives, One day 28 826 Depot Holders ORS, IFA )and Chlorhexidine

During the quarter, a total of 2,297 persons, including GOB workers, CVs and project staff were trained on various MNCH/FP/N topics.

3.2.2 Strengthen health systems at district level and below

National program review meeting on MNCH/FP/N and Quarterly Performance Review Meetings On June 15, MaMoni HSS facilitated a national level program review of MaMoni HSS districts. The review was organized jointly by DGHS and DGFP. Several senior national level officials, Divisional Directors and district managers (Civil Surgeons and DDFPs) attended this review meeting, along with the national and district level staff of MaMoni HSS. Dr. Md. Sharif, Director (MCH), DGFP chaired the event. MNH/FP/N performance of the districts were shared by CS and DDFP and discussed. This review also provided a forum for CS and DDFP, to raise several programmatic and managerial issues requiring the attention of MOH&FW at the national level. Also, the participants had the opportunity to closely review the data related to the performance of each district against key MNCH/FP/N indicators. Several key issues were discussed, including: ensuring availability of the surgeon-anesthetist “pair” at CEmOC facilities, ensuring that DGHS doctors placed at DGFP UH&FWCs (currently the doctors do not have access to DDS kits of DGFP), and changing the reporting cycle of FWAs.

Four districts conducted quarterly performance review meetings in this quarter.

MaMoni HSS – Year Two Third Quarterly Report July 2015 19 Logistics Management Systems: The project has already introduced the Upazila Information Management System, called UIMS2 V.7 s in Lakshmipur district. This included the orientation of relevant staff on the preparation of monthly reports by the fifth working day of the month. It has been observed that the monthly reports adhere to the pre-conditions for successful reporting which are: completeness, correctness, and timeliness. MaMoni HSS project’s staff reviewed the logistics reports and prepared a summary report outlining the specific actions required to improve availability of commodities, by their very nature, the single most important measure of an efficient logistics management systems. This data was shared with GOB counterparts, and shown how this can improve decision making. Because of the continuous monitoring and follow-up, out of 347 service delivery points in Lakshmipur district, only one reported a stock out in FP commodities. The MNH commodities are provided through DDS kits, uniform across all SDPs, such as FWV and SACMO, therefore, usage is not tracked yet.

Recently, the MoHFW and SIAPS have decided to further upgrade the FP LMIS software from UIMS2 V.7 to UMIS3 and open its access online. The system is being implement in 10 districts, one of them is Lakhsmipur. The project is facilitating the training of the UMIS3 in Lakhsmipur.

In addition, the project supported the MoHFW in developing materials on basic logistics management and facilitated the five batches of trainings (2 in Habiganj, 1, in Jhalokathi, 1, in Noakhali, and 1 in Lakhsmipur). To date, a total of 133 participants have received logistics management training.

Table 4: Family Planning Commodities Stock in Service Delivery Points in Lakshmipur as of May, 2015

Upazila Contraceptives Overstock Satisfactory Under Potential Stock-out (3 + (1.7 – 3.0 stock Stock-out (0 Months) Months) Months) (0.7 – 1.6 (0.1 – 0.6 Months) Months) Kamal Nagar Condom 05 27 02 00 00 GoB:34 Pill 02 28 04 00 00 NGO:01 IUD 05 01 00 00 00 Total:35 Injectable 04 10 14 06 00 Implant 02 00 00 00 00 Lakshmipur Condom 47 84 07 03 00 Sadar Pill 06 32 97 06 01 GoB:140 IUD 04 08 06 04 00 NGO:03 Injectable 11 54 68 10 00 Total:143 Implant 01 00 02 00 00 Raipur Condom 09 07 01 00 00 GoB:58 Pill 05 13 01 00 00 NGO:00 IUD 01 04 04 00 00 Total:58 Injectable 03 08 03 00 00 Implant 00 01 00 00 00 Ramganj Condom 13 06 02 01 00 GoB:70 Pill 12 11 00 00 00 NGO:01 IUD 12 00 00 00 00 Total:71 Injectable 13 08 02 00 00 Implant 01 00 00 00 00 Ramgati Condom 13 06 02 01 00 GoB:45 Pill 12 11 00 00 00

MaMoni HSS – Year Two Third Quarterly Report July 2015 20 NGO:01 IUD 12 00 00 00 00 Total:46 Injectable 13 08 02 00 00 Implant 01 00 00 00 00 Total Service Delivery Points = 353; GoB SDPs = 347; NGO SDPs = 06

Improving LMIS for MNCH Tracer Drugs:

MaMoni HSS tracks eight tracer drugs to monitor stock-out of essential drugs within DGHS. The DGFP supply chain is supported by SIAPS, and is simpler because of single centralized procurement and distribution and uniform reporting at SDPs. In DGHS, there are procurements at national level (CC), regional level (CS) as well as local purchase. Therefore inventory control and reporting has been too complex for effective decision making. The following steps were undertaken

a. Developing a standardized inventory control and reporting tools for use at all DGHS service delivery points:

The DGHS does not have a uniform LMIS reporting system for monitoring the availability of tracer MNCH drugs. For this reason, Uniform LMIS Reporting System has been developed by DGHS, with technical assistance of SIAPS and the contribution of MaMoni HSS Project. The new system has been recently approved, including a set of standard tools and Registers, by DGHS for introduction nationwide. The project is supporting its implementation in Lakshmipur district.

b. Developing a user-friendly dashboard system to monitor availability of tracer MNCH drugs: MaMoni HSS project is assisting the district level decision-makers in monitoring and improving the availability of a list of essential (tracer) MNCH drugs. Starting in Lakshmipur, the project has introduced a system to extract basic data reflecting the availability of tracer MNCH in all the district’s stores and display the data in a color-coded dashboard to assist decision-makers in monitoring the availability of essential drug items and the incidence of stockouts. Once compiled and displayed in the dashboard, this information is discussed with the decision-makers to consider local actions needed to improve the availability of essential items.

The figures displayed below in Figures 5 and 6 summarize the availability of selected essential MNCH drugs (in green) and the stock-outs (in red) in Lakshmipur district Civil Surgeon Store and for Misoprostol tablets in all district stores.

Figure 5: Stock-out in Civil Surgeon Office store in Lakshmipur

MaMoni HSS – Year Two Third Quarterly Report July 2015 21

Figure 6: Stock out of misoprostol tablet at different levels of Lakshmipur

MaMoni HSS identified that all misoprostol supplies were due to expire in June 2015. As a result, MaMoni HSS collaborated with DGFP to ensure that each upazila received fresh supplies of misoprostol. On June 25, each upazila of MaMoni HSS districts received 1,800 misoprostol tablets. Even though a population based projection was used to supply misoprostol tablets, since ANC coverage was lower than national average in MaMoni HSS districts, there was “leftover” tablets. Once misoprostol becomes part of routine supply chain, ad-hoc purchase will be minimized, and demand based forecasting and distribution will be more reliable.

Strengthening information systems at national level: MaMoni HSS is collaborating with several other USAID collaborating partners, such as Measure DHS, icddr,b, and SIAPS under the RHIS project to design, test and roll out a paperless reporting system in Madhabpur upazila of Habiganj. A population-based

MaMoni HSS – Year Two Third Quarterly Report July 2015 22 registration survey tool has been developed, revised and finalized with RHIS initiative. The tab-based program for this survey has been finalized and tested at Madhabpur. Data collectors commenced data collection on March 15 and until June 30, they were able to visit 20,755 households, registering 108,096 individuals. Population registration was completed in two unions, and data collection was ongoing in two more unions as of June 2015. All 11 unions of Madhabpur will be covered by October 2015.

Annex 5 describes the RHIS initiative in greater detail, including status of the different modules being developed for service providers.

Strengthened planning and coordination through community microplanning and union follow-up meetings

In this quarter, 7,317 cMPM meetings out of a planned 7,534 (97%) took place in high intensity upazila. The cMPMs are helping frontline health workers, i.e. FWAs and HAs, to enroll eligible couples and pregnant women into the program early on and to track and follow up for the provision of services. These meetings also help to improve the quality of information collected by the DGHS and DGFP. During this quarter, a total of 576 out of planned 633 (91%) union follow-up meetings were held in Habiganj, Noakhali, Lakhsmipur and Jhalokathi district.

MaMoni HSS conducted structured district reviews in four districts, part of which examined the effect of cMPM and Union Follow Up meetings. The program review found that while the cMPM was attended by CVs, HA and FWA regularly, there was a gap in transmitting this information and ensuring that pregnant women received follow-up visits from FWVs during their satellite clinic visits. MaMoni HSS has taken steps to update the FWVs in the monthly meetings on how to better use the information and ensure ANC services are utilized. Because CMPM is linked to EPI sessions, FWAs were also found not to bring registers to the session. This has been raised with DDFP and UFPOs, and in specific cases, joint supervision visits were undertaken to address this gap.

Quality Improvement Initiative: National Level Activities: MaMoni HSS Project supported the National QI Secretariat in developing a national QI Strategic Frame work including the vision, mission statement, purpose and goal. The strategic objectives of the national QI Frame work are to improve patient-centered services, improve patient safety, improve clinical practice, improve leadership management system, ensure necessary input for QI, ensure necessary support services for QI, and develop effective outcome measure system for QI. In addition, the framework describes the organizational structure for QI implementation as follows:

• National level: National Steering Committee, National level Technical Committee (for setting standards and implementation modalities) • Divisional level: Divisional QI Committee (coordination, monitoring and support from RRQIT) • District level: District QI Committee (implementation of QI initiatives and performance tracking) • Upazilla level: Upazilla QI Committee (implementation of QI initiatives at all levels)

As part of the “Every Mother and Every Newborn” global initiative, MaMoni HSS contributed to the national technical committee in reviewing the national standards for maternal and newborn health.

MaMoni HSS – Year Two Third Quarterly Report July 2015 23 Based on the developed national Standard Operating Procedures for maternal health, the national technical committee specified ten major standards:

Every Mother and Every Newborn (EMEN) Standards Clinical Care 1. Evidence-based safe antenatal care is provided. 2. Evidence-based safe care is provided during labor and childbirth. 3. Evidence-based safe postnatal care is provided for all mothers and the newborns.

Patients’ Rights 4. Human rights are observed and the experience of care is dignified and respectful for every woman and newborn.

Crosscutting 5. A governance system is in place to support the provision of quality maternal and newborn care. 6. The physical environment of the health facility is safe for providing maternal and newborn care. 7. Qualified and competent staff are available in adequate numbers to provide safe, consistent and quality maternal and newborn care. 8. Essential drugs, supplies and functional equipment and diagnostic services are consistently available for maternal and newborn care. 9. Health information systems are in place to manage patient clinical records and service data. 10. Services are available to ensure continuity of care for all pregnant women, mothers and newborns.

MaMoni HSS Quality Improvement initiative will continue to advocate for incorporation of EMEN standards in the national quality assurance framework, and will provide TA to the QA cell to facilitate implementation.

Implementing Standards-based Management and Recognition

The implementation of SBM-R is advancing as planned in four districts: Habiganj, Noakhali, Lakshmipur, and Jhalokati. To date, the numbers of facilities applying SBM-R are Habiganj (12), Noakhali (11), Lakshmipur (8), and Jhalokathi (8). The table below presents the number of health facilities applying SBM-R in each district by the step of implementation reached.

Table 5: Cumulative Number of Facilities Applying SBM-R by District and by Step of Implementation

District SBM-R Implementation Steps Baseline 1st Internal 2nd Internal External Recognition Assessment Assessment Assessment Habiganj 12 12 5 Noakhali 11 11 Lakshmipur 8 8 Jhalokati 8

Habiganj district:

MaMoni HSS – Year Two Third Quarterly Report July 2015 24 The graph below presents a comparison between the level of applying SBM-R standards at the baseline and at the first internal assessment for seven health facilities newly applying SBM-R in Habiganj district

Figure 7: Compliance with QI (SBM-R) standards in 7 new health facilities, Habiganj

70 61.4 59.64 61.4 60 53.65 52.72 50 50 41.81

40 36.36 29.82 30 26.31 25.45 18.18 20

in Percentage 20 12.72 10

0 Mirpur Khagaura Devpara Poil Deorgach Daulatpur Madhoppur UHC baseline internal assessment

Noakhali District: The graph below depicts the baseline level of applying SBM-R standards at 11 health facilities in Noakhali

Figure 8: Baseline data of QI (SBM-R) implementation in Noakhali health facilities

Jhalokathi District: After completion of Module 1 training baseline assessment was conducted in eight facilities of Jhalokathi district, which included one MCWC, three UHCs, and four UH&FWCs. In this quarter the assessment and action plan was completed by the GOB mangers. The district is currently implementing the action plan to meet the standards.

MaMoni HSS – Year Two Third Quarterly Report July 2015 25

Table 6: Baseline scores for meeting the standards in Jhalokathi district

Facility Facility Infection FP ANC NVD Management Prevention MCWC 43% 55% -Not 71% 67% assessed Binoykathi 8% 36% 33% 43% - UH&FWC Amua UHC, 29% 09% -Not 29% 33% Kathalia Assessed Chenchrirampur 08% 36% 33% 43% - UH&FWC Rajapur UHC 29% 18% -Not 57% 33% Assessed Saturia 23% 36% 33% 43% - UH&FWC Nalchity UHC 29% 9% -Not 43% 33% Assessed Shiddhukathi 15% 36% 43% 43% - UH&FWC

Joint Supervisory Visits and RRQIT:

During the reporting period, MaMoni HSS continued to support the MOH&FW’s district level supervision system. The project facilitated the implementation Joint Supervisory Visits (JSVs) in the four districts and ensured the application of supportive supervision to identify performance gaps and action to address them. The following table shows the number of planned and conducted JSV by district:

Table 7: Joint Supervisory visits conducted against target in the third quarter of FY15

April 2015 May 2015 June 2015 Districts Planned Conducted Planned Conducted Planned Conducted Habiganj 32 37 32 45 32 41 Jhalokathi 31 28 31 31 6 6 Lakshmipur 39 35 60 30 51 37 Noakhali 39 14 55 10 54 14 Total 141 114 178 116 143 98

MaMoni HSS also compiled the issues identified by the JSVs and following up on the action items. Table 6 illustrates some of the issues identified in Noakhali district and action items that MaMoni HSS is following up on.

Table 8: Illustrative examples of JSV issues and action plan in Noakhali district in this quarter

Findings Action plan Not practicing proper hand washing before & after Motivated service provider for importance of hand washing

MaMoni HSS – Year Two Third Quarterly Report July 2015 26 providing the ANC & PNC services (further follow-up planned) Misoprostol expiring within the next month and not Ensure new supply from DRS within one week (completed in distributed due to lack of supply. July, due to shortage in June) BCC materials not used in counseling at Satellite Motivated service provider for using BCC materials Clinics, CCs. Family Health card & ANC card out of stock and not Both cards re-supplied (completed) given to mothers FWA absent in designated Satellite clinic session Discussed with UFPO & in FP monthly meeting, closer monitoring in next month’s schedule FWA not carrying register during Community clinic Discussion with UFPO & FP monthly meeting for carrying visit (thus mother’s names not recorded properly) FWA register Combined register not taken at SC Discussion with UFPO & FP monthly meeting for carrying combined register

RRQIT (changed from RRQAT because of Ministry focus change) is a Quality Improvement approach to complement the supervision system. Members of the team will be composed of specialized experts in maternal and newborn care and will focus on improving care at district level hospitals, particularly emergency obstetric and newborn care. During the reporting period the project obtained the official approval for forming the RRQIT in Sylhet. The composition and scope of work of the RRQIT in Sylhet were endorsed by the Divisional Director Family Planning and Divisional Director Health. The endorsement specifies the composition of the RRQIT as follows: • Assistant Director-Health. • FPCST-QAT Regional Supervisor. • Assistant Director- Nursing. • Representative from Obstetrics and Gynecology Society of Bangladesh (OGSB). • Representative from Bangladesh Pediatric Association. One visit per quarter is planned by the Sylhet RRQIT to Habiganj and an update of the results of the visits will be shared with district level decision-makers with a particular focus on actions for QI.

Maternal and Perinatal Death Review (MPDR): MaMoni HSS introduced MPDR in Begumganj sub- district of Noakhali district in collaboration with Center for Injury Prevention and Research, Bangladesh (CIPRB) and in coordination with MOH&FW and UNICEF for scaling up MPDR as a quality improvement approach. Different levels of staff were trained on specific facility and community focused modules as shown in the following Table:

Table 9: Components of MPDR introduced in Begumganj, Noakhali

Training Type Duration Batches No. Participants Level of Trainees TOT One day One 34 MO, Nurses, FWV, HS Death Notification One day Two 202 Statistician, SI, MT-EPI, pNGO Training staff

MaMoni HSS – Year Two Third Quarterly Report July 2015 27 Verbal Autopsy Two days One 51 A/HI, FPI, SI, UFPA, NGO staff Social Autopsy One day Four 53 A/HI, FPI, SI, UFPA, NGO staff Facility Death Two days One 19 Doctor, Nurse, FWV, Review Paramedics

Promote an enabling environment to strengthen district-level health systems

Capacity-building of media In this quarter, MaMoni HSS organized a numbers of journalist visit in different locations of its project area with a special focus to ensure optimum earned media coverage on Safe Motherhood Day. As a result of broader MaMoni HSS media advocacy, 35 news articles (Annex 7) were published by different media outlets. The news stories included issue-specific overviews of the current situation, case studies, and technical information with suggestions for health system improvement.

Following the initial journalist training, the reporters were connected with a local project staff who is responsible for providing information, linking the journalists with government sources, and providing a balanced perspective for improved reporting and generate story ideas. Media coverage on MNCH/FP/N issues and increased engagement of involved stakeholders have been observed. MaMoni HSS is focusing on improving the quality of the news reports at this point.

Observation of Safe Motherhood Day (May 28) MaMoni designed the national poster for Safe Motherhood Day on behalf of the Reproductive Health Department of DGHS. Annex 7 describes the newspaper articles, TV coverage and social media engagement leading to the Safe Motherhood Day observation.

At the district level, MaMoni organized a drive to make every maternal death count for the third year in a row. In four districts, MaMoni HSS supported the MOH&FW and Union Parishads to identify every mother who died between May 2014 and April 2015, and visit them to learn about how these deaths could have been prevented. On the week of the Safe Motherhood Day, MaMoni supported the Civil Surgeon to organize a seminar to discuss these deaths and sensitize stakeholders on their roles and responsibilities.

Engagement of the Parliament:

The bi-monthly meeting of Parliamentary Caucus on Child Rights (PCCR) was held on June 28, 2015 with the participation of nine PCCR members. The meeting was held in the IPD conference center of the parliamentary house. The honorable Deputy speaker of the Bangladesh National Parliament, Advocate Fazle Rabbi Miah, MP, chaired the meeting while Mr. Mir Sowkat Ali Badsha, MP moderated the meeting session as PCCR chair. Dr. Ishtiaq Mannan, Director, Health, Nutrition and HIV/AIDS for Save the Children international in Bangladesh made the key presentation at the PCCR titled ”Ending preventable child and maternal deaths: Parliamentarians role and responsibilities”. In his presentation he urged the

MaMoni HSS – Year Two Third Quarterly Report July 2015 28 parliamentarians to be a champion for children and mothers, allocation of human resources and facilities and strengthening primary health care by ensuring accountability of doctors and nurses.

The Caucus agreed to organize a hearing meeting with MOH&FW with the presence of Health Minister and Secretary after Eid holidays, and also organize a consultation meeting in Sylhet division to understand the disparity between the health indicators in this region compared with those of the rest of the country.

Program Learning Initiatives: The following learning initiatives are underway:

(i) Operations Research (OR): Under USAID’s TRAction research initiative, two research initiatives have completed the following:

• 24/7 delivery and EmONC services in public facilities through health systems strengthening in Bangladesh: This OR is being conducted in two district-level facilities in Habiganj district and looks at impact of non-financial incentive on availability of service in DH and MCWC. Areas covered in the analysis include availability of infrastructure, essential drugs and equipment for MNH services, availability of human resources based on sanctioned post, quality of care, and availability of different service providers for MNH care. During the quarter, icddr,b conducted a prospective 30-day observation of availability of staff in three shifts, and compared them with the result from the same period in 2014. Although availability of doctors at the night shift at the district hospital has increased since last year, vacancy among nurses has increased from 28 to 31, affecting the HR availability. Based on OR, MaMoni HSS and icddr,b has initiated discussion with Nursing Directorate to deploy additional nurses. • Community-based prevention and treatment of severe pre-eclampsia and eclampsia in a low resource setting of Bangladesh: This OR tested feasibility of identifying and managing PEE cases at the community level through FWV and CSBAs. Analysis of baseline and program data collection has been completed by icddr,b and presented to USAID in June 2015. Out of the 59 mothers who received the loading dose of magnesium sulfate, none of them died. There was, however, no difference in stillbirth or neonatal deaths for mothers who received magnesium sulfate. MaMoni HSS is planning to use this information to scale up PE/E management in Year 3 in coordination with Population Council and others.

(ii) OR Studies within MaMoni workplan: USAID approved five OR proposals for the second year of implementation, which will investigate quality of service delivery for LAPM; use of partographs as a decision-making tool for identifying and referring complicated pregnancies; viability of private CSBAs; community behavior on application of CHX; and quality of ANC at satellite clinics and challenges. For OR on LAPM and ANC, MaMoni has submitted research protocol to JHU IRB for ethical clearance.

Partograph study has been completed and quantitative findings were shared with USAID and WHO internally. The findings were used to adapt the training content, and all paramedics at the union level has been trained on partograph in the last two quarters.

A field visit was conducted in May 2015 to pre-test the tools for LAPM data collection. Based on that visit, MaMoni HSS plans to hire experienced medical doctors to observe the activities in the month of August and September.

MaMoni HSS – Year Two Third Quarterly Report July 2015 29

MaMoni HSS also received an approval letter from DGFP on May 11 granting permission to observe quality of satellite clinics for the OR.

3.2.3 Identify and reduce barriers to accessing health services

Community mobilization

MaMoni HSS has selected, trained, and supported a cumulative total of 22,763 CVs to facilitate CAGs, promote MNCH/FP/N behaviors, and serve as interfaces between the communities and the frontline health service providers through cMPMs. 77 percent of these CAGs have their own locally managed transport fo r referring mothers and children, 56 percent CAGs have their own fund.

Behavior Change Communication The implementing NGO partners of MaMoni HSS have dedicated BCC units in each of the project districts, with the purpose of conducting focused BCC. A total of 51,779 people were reached through video shows and meetings. MaMoni HSS is in the process of recruiting BCC Manager to review and support these activities for maximum impact. The incumbent will be on board in September 2015.

MaMoni HSS is also collaborating with the Saving Newborn Lives initiative (SNL) of Save the Children to air a television commercial on newborn care on behalf of the IMCI department of DGHS. Between April and June, SNL has aired the TVC in BTV, ATN Bangla and Channel i. MaMoni HSS will support the broadcasting for the months of August and September.

Please refer to Annex 9 for a detailed listing of BCC materials developed or reproduced by the project during the last quarter.

Engagement of local government MaMoni HSS has been working to strengthen the birth and death registrations, as well as leverage support for improving quality of care at union-level health facilities. MaMoni HSS organized a national- level meeting with the Mr. K M Mozammel Hoq, Additional Secretary of the LGD, MOLGRD&C and Shamima Nargis, Joint Secretary (UP), Abu Tahir Muhammad Zaber, Deputy Secretary (Up-2), Sharifa Ahmed, Senior Assistant Secretary (Up-I) of Local Government Division, to update them on MaMoni HSS activities, including birth registration. A joint work plan between MOH&FW and MOLGRD&C was proposed to strengthen the birth and death registrations, as well as leverage support for introducing delivery service at union‐level health facilities and to discuss on potential areas of collaboration.

Between January and May 2015, 44,628 newborns were registered in the high intensity districts by the SVRS system. Because of a server crash, MaMoni currently does not have real time update on birth registration from MOLGRD&C.

MaMoni HSS has been piloting an EPI based birth registration system in Begumganj upazila of Noakhali and Kamalnagar upazila of Lakshmipur district.

Figure 10: Birth registration against BCG in Begumganj and Kamalnagar upazilas between Mar-May 2015

MaMoni HSS – Year Two Third Quarterly Report July 2015 30 1400 1215 1200 1000 800 584 600 501 361 400 235 200 107 0 Begumganj, NK Kamalnagar, LP

Child Receiving BCG vaccine BR form filled by HA BR certificate distributed

The data shows that even though HA has service contact with children during EPI, s/he is not filling up forms and sending them to the Union Parishads. MaMoni has initiated discussion with UP Chairs on how to motivate HA to fill up birth registration forms, and how to ensure that the birth certificates are distributed. Another limitation of relying on HA is that the newborns are not tracked by the Union Parishad, therefore, newborn death notification mechanism is not entered into the SVRS system. MaMoni is in discussion to identify the solution for this.

During the past quarter, MaMoni HSS continued the active engagement of local government institutions, especially the UPs, to improve MNCH/FP/N services in their communities and allocate budget for MNCH/FP/N. Through ward shabhas (meetings), MaMoni CVs promoted open budget process. 120 out of 175 UPs in high intensity districts reported allocation of budget for MNCH-FP-N. Only 7 out of 27 UP of Jhalokathi allocated budget, since MaMoni community engagement rollout was not complete yet in that district.

MaMoni HSS has also facilitated the bi-monthly meetings of UDCCs in Noakhali district, where MNCH/FP/N issues are discussed and progress reviewed.

Continuation of Aponjon Services through 2017 MaMoni HSS received additional obligation from USAID to continue supporting the Aponjon mHealth initiative beyond April 2015 as was agreed in the original agreement. The promotional campaign, including bus branding and addition of more partners was rolled out during this quarter. Annex 4 describes Aponjon activities in greater detail.

In the current quarter, 49,321 new clients, mostly pregnant and lactating women signed up for Aponjon services. The original USAID funding for Aponjon ended in April, and the new obligation was received in May. Therefore, subscriber acquisition activities and brand promotion was interrupted during those months. Aponjon expects to reach 2 million subscribers by December 2015.

3.2.4 Challenges, Solutions and Action Taken

Pending Activities

The remaining Activities of the year 2 has been included in the Annexure 11 with a plan to outline the steps MaMoni is taking to complete them.

MaMoni HSS – Year Two Third Quarterly Report July 2015 31 Challenges • MaMoni HSS eliminated half of the Field Support Officer positions in Habiganj district as of March 2015 as part of the phase out plan. However, new interventions, RHIS and CNCP interventions are being scaled up at this point. This made supervision a bit of a challenge. MaMoni has overcome this challenge now. • The Director, Primary Health Care and Director, IPHN positions have undergone several changes because of retirement. MaMoni HSS oriented the new Director (PHC), and that person also left to become Director, IPHN after a few months. The Program Manager, Reproductive Health position was also vacant for a while due to retirement. Maintaining continuity and momentum amidst such turnover has been a consistent challenge for MaMoni HSS.

Opportunities

• The HRM Unit of MOH&FW has indicated that they would like technical assistance from MaMoni HSS project for manpower planning and assessment. MaMoni HSS has recently received a go ahead from USAID to work with the HRMU to provide technical assistance for the roll out of the new Health Workforce Strategy for Bangladesh. • The Director General of Health Services has requested USAID to provide technical and financial support for the national scale up of 7.1% chlorhexidine application for newborn umbilical cord care. USAID has agreed to provide this support through MaMoni HSS, opening up an exciting opportunity to scale up the intervention across the country.

MaMoni HSS – Year Two Third Quarterly Report July 2015 32 4. The Way Forward

Below are the highlights of major activities planned for the fourth quarter:

• Intensive roll-out of all newborn care interventions in 10 upazilas, includes newborn sepsis management and roll out of the Comprehensive Newborn Care Package and 7.1% chlorhexidine for newborn umbilical cord care • Begin the national scale up of 7.1% chlorhexidine application for newborn umbilical cord care. During the next quarter, the intervention will be rolled out in 20 districts in the first phase of implementation • Finalize the contractors for all renovation work and begin the UH&FW and district hospital renovations as per the approved workplan • National technical support to Human resources Management Unit (HRMU) for the roll out of the new Health Workforce Strategy • Support of facility preparedness initiatives in four new divisions for UH&FWCs • Develop a national master plan for strengthening of UH&FWCs based on the assessment and categorization of UH&FWCs in two divisions • Support IMCI Unit of DGHS in the establishment of SCANUs in three other districts • Pilot implementation of RHIS in Madhabpur sub-district of Habiganj district • Strengthen post-training follow up and implementation of the modified QI strategy in all HI areas • Identify TA needs for the design process of the follow on to HPNSDP sector program

MaMoni HSS – Year Two Third Quarterly Report July 2015 33 5. Appendix

Annex 1. Photos from key events

Infection Prevention Training in Noakhali district National program review at BSMMU

CNCP Training teaches newborn examination skills Char Falcon UH&FWC of Lakshmipur introduced NVD services

MaMoni HSS – Year Two Third Quarterly Report July 2015 34 Annex 2: Performance Indicators (October 2014-June 2015) The data presented is based on final PMP approved by USAID

Indicator Data Disaggregat Basel Baseli Remarks Source ion ine ne 2015 Oct-Dec Jan-Mar Apr-June Year Value Target 2014 2015 2015

Project Goal: Improve utilization of integrated maternal, Coverage will be reported on newborn, child health, family planning and nutrition services annual basis Percent of women received at least one antenatal care visit Tracer District, from a medically trained provider indicat High or Intensity survey areas and report Health Systems Strengtheni ng areas High intensity areas Lakhsmipur 2013 60.1 67 64.3 ̶ Noakhali* 2013 50.7 61 ̶ Habiganj 2012 37.1 66 72.5 Jhalokathi 2014 65.7 69 65.7 Pirozepur* 2014 64.9 67 HSCS areas Pirozepur 2014 61.3 63 61.3 Bhola 2013 44.3 51 48.8 Noakhali 2013 52.8 60 57.8 Percent of births receiving at least four antenatal care (ANC) Tracer District, visits during pregnancy indicat High

or Intensity survey areas and report Health Systems Strengtheni

MaMoni HSS – Year Two Third Quarterly Report July 2015 35 Indicator Data Disaggregat Basel Baseli Remarks S ngi areas i

High intensity areas Lakhsmipur 2013 13.6 22 18.4 Noakhali* 2013 11.81 22 Habiganj 2012 8.6 23 34.3 Jhalokathi 2014 43.8 46 43.8 Pirozepur* 2014 30.4 33 HSCS areas Pirozepur 2014 10.2 42 40.2 Bhola 2013 13.8 21.5 19.9 Noakhali 2013 11.5 19 17.6 Percent of Births Attended by a Skilled Doctor, Nurse or Tracer District, Midwife indicat High or Intensity survey areas and report Health Systems Strengtheni ng areas High intensity area Lakhsmipur 2013 34 39 35.1 Noakhali* 2013 27.9 32 Habiganj 2012 19.4 34 28.9 Jhalokathi 2014 44.2 47 44.2 Pirozepur* 2014 42.7 45 HSCS areas Pirozepur 2014 44.7 46 44.7 Bhola 2013 21.7 27 24.6 Noakhali 2013 33.4 35.5 32.9

MaMoni HSS – Year Two Third Quarterly Report July 2015 36 Indicator Data Disaggregat Basel Baseli Remarks Percent of women with home births who consumed TracerS District,i HI i misoprostol to prevent post-partum haemorrhage indicat areas and or HSS areas survey report High intensity areas Lakhsmipur 2014 10.6 20 7.9 Noakhali* 2014 7.7 20 Habiganj 2014 34.8 40 37 Jhalokathi 2014 41 47 25 Pirozepur* 2014 31.5 37 HSCS areas Pirozepur 2014 25.9 28.5 15.6 Bhola 2014 16 20 13.2 Noakhali 2014 9.2 15 7.2 Percent of newborns initiated breastfeeding within one hour Tracer District, HI after birth indicat areas and or HSS areas survey report High intensity areas Lakhsmipur 2013 52.6 71 66.4 Noakhali* 2013 48 67 Habiganj 2012 64.7 85 76.9 Jhalokathi 2014 57.5 62 57.5 Pirozepur* 2014 51.8 57 HSCS areas Pirozepur 2014 49.9 53 49.9 Bhola 2013 70.7 65 62.3 Noakhali 2013 53.1 73 70.8

MaMoni HSS – Year Two Third Quarterly Report July 2015 37 Indicator Data Disaggregat Basel Baseli Remarks Percent of newborns received chlorhexidine application on TracerS Districti i In 2014. 7.1% chlorhexidine is not their umbilical cord immediately following birth indicat introduced in the country, except or in small scale research settings. survey The baseline is assumed to be zero report in all program areas High intensity areas Yet to start Lakhsmipur 2014 25 Noakhali* 2014 25 Habiganj 2014 25 Jhalokathi 2014 25 Pirozepur* 2014 25 HSCS areas Pirozepur 2014 - Bhola 2014 - Noakhali 2014 - Percent of newborns receiving postnatal health check within Tracer District, HI two days of birth indicat areas and or HSS areas survey report High intensity areas Lakhsmipur: 2013 12.1 17 15.1 Noakhali:* 2013 11.1 18 Habiganj: 2014 26.8 29 3.9 Jhalokathi: 2014 26.6 30 26.6 Pirozepur:* 2014 3.5 10 HSCS areas Pirozepur: 2014 3.5 7 3.5 Bhola: 2014 3.2 7 3.2 Noakhali: 2013 10.5 17.5 15.8

MaMoni HSS – Year Two Third Quarterly Report July 2015 38 Indicator Data Disaggregat Basel Baseli Remarks Modern contraceptive method prevalence rate TracerS District,i HI i indicat areas and or HSS areas, survey method report High intensity areas Lakhsmipur 2013 48.2 51 N/A Noakhali* 2013 47 50 Habiganj 2012 40.6 45 42.1 Jhalokathi 2014 52.6 55 52.6 Pirozepur* 2014 52 55 HSCS areas Pirozepur 2014 52.7 54 52.7 Bhola 2013 54.4 56.5 N/A Noakhali 2014 44.4 58 57.1 Couple years of protection (CYP) in USG-supported programs DGFP District, HI MIS areas and Form- HSS areas, 4 Long acting and short term method Overall 953,3 986,38 181,369 211,858 225,563 53 5 High intensity areas 521,3 538,99 02 0 Lakhsmipur 2013 149,7 151,47 34,784 84 2 Noakhali* 2013 99,21 102,15 25,615 5 4 Habiganj 2013 166,7 177,39 38,898 64 4 Jhalokathi 2013 71,99 71,557 16,333 Jhalokati : method distribution was 1 projected for the month of June 15

MaMoni HSS – Year Two Third Quarterly Report July 2015 39 Indicator Data Disaggregat Basel Baseli Remarks Pirozepur* S i 2013i 33,54 36,413 8,431 8 HSCS areas 432,0 447,39 51 5 Pirozepur 2013 86,99 90,420 20,487 0 Bhola 2013 229,7 243,91 56,271 05 6 Noakhali 2013 115,3 113,05 24,745 56 9

Intermediate Result 1: Improve service readiness through critical gap management Percent of targeted facilities that are ready to provide Service District, NA NA 24 Baseline and targets to be revised essential newborn care deliver type of after first SDP assessment y point facility assess ment form High intensity areas Lakhsmipur 2013 NA 20 21 Excluding DH & MCWC Noakhali* 2013 NA 20 13 Habiganj 2013 NA 80 32 Jhalokathi 2013 NA 20 26 Pirozepur* 2013 NA 20 HSCS areas Pirozepur 2013 NA 10 Bhola 2013 NA 10 Noakhali 2013 NA 10 Percentage of public health facilities with functional bags and Project District, NA NA 55 Baseline and targets to be revised masks (two neonatal size mask) in the delivery room SDP type of after first SDP assessment assess facility ment

MaMoni HSS – Year Two Third Quarterly Report July 2015 40 Indicator Data Disaggregat Basel Baseli Remarks formS i i

High intensity areas Lakhsmipur 2015 N/A 5 49 Excluding DH & MCWC Noakhali* 2015 N/A 5 62 Habiganj 2015 N/A 5 60 Jhalokathi 2015 N/A 5 44 Pirozepur* 2015 N/A 5 HSCS areas Pirozepur 2015 N/A Bhola 2015 N/A 1 Noakhali 2015 N/A Percent of USG-assisted service delivery sites providing family Project District, NA NA Baseline and targets to be revised planning (FP) counselling and/or services SDP sites after first assessment assess offering ment long acting form and permanent method High intensity areas FWA level survey not yet finished Lakhsmipur 2013 NA 70 Noakhali* 2013 NA 70 Habiganj 2013 NA 99 Jhalokathi 2013 NA 70 Pirozepur* 2013 NA 70 HSCS areas Pirozepur 2013 NA 7 Bhola 2013 NA NA Noakhali 2013 NA 10

MaMoni HSS – Year Two Third Quarterly Report July 2015 41 Indicator Data Disaggregat Basel Baseli Remarks Number of targeted facilities ready to provide delivery ProjectS District,i i 8 Baseline and targets to be revised services 24 hours a day, seven days a week SDP facility type after first assessment assess ment form High intensity areas Lakhsmipur 2013 NA 22 Excluding DH & MCWC Noakhali* 2013 NA 13 Habiganj 2013 NA 34 Jhalokathi 2013 NA 10 Pirozepur* 2013 NA 2 HSCS areas Pirozepur 2013 NA 7 Bhola 2013 NA 30 Noakhali 2013 NA 7 Sub-IR 1.1: Increase availability of health service providers Number of vacant positions filled by temporary non-GOB MaMo District, 172 78 78 health workers ni HSS type of Report provider, type of facility High intensity areas Lakhsmipur 13 11 Paramedic and Nurse Noakhali* 17 14 Paramedic and Nurse Habiganj 2013 81 43 48 Paramedic and Nurse Jhalokathi 14 5 Paramedic Pirozepur* NA HSCS areas Pirozepur NA Bhola NA

MaMoni HSS – Year Two Third Quarterly Report July 2015 42 Indicator Data Disaggregat Basel Baseli Remarks Noakhali S i i NA

Sub-IR 1.2: Strengthen capacity of service providers to provide All training targets will be set quality services during annual workplans Number of people trained in maternal/newborn health Project District, 5500 1760 1637 1833 through USG-supported programs trainin Gender g report Overall 8630 High intensity areas Lakhsmipur 641 Women 100 Men 82 Noakhali* 0 Women 186 Men 51 Habiganj 3478 Women 1095 Men 146 Jhalokathi 538 Women 42 Men 21 Pirozepur* 0 Women 26 Men 28 National level 3019 To be determined through annual workplans HSCS areas Pirozepur 0 Bhola NA

MaMoni HSS – Year Two Third Quarterly Report July 2015 43 Indicator Data Disaggregat Basel Baseli Remarks Women S i i 41

Men 15 Noakhali 0 Number of people trained in FP/RH with USG funds Project District, All training targets will be set trainin Gender during annual workplans 19 21449 g report High intensity areas 1500 42 Lakhsmipur Women Men Noakhali* Women 25 Men 17 Habiganj Women Men Jhalokathi Women Men Pirozepur* Women Men HSCS areas Pirozepur NA Bhola NA Women Men

MaMoni HSS – Year Two Third Quarterly Report July 2015 44 Indicator Data Disaggregat Basel Baseli Remarks Noakhali S i i NA

Number of people trained in child health and nutrition Project Gender, 1200 0 540 through USG-supported programs trainin District g report High intensity areas Lakhsmipur 0 Women Men Noakhali* 0 Women Men Habiganj Women Men Jhalokathi Women Men Pirozepur* 0 Women Men National level 25 Pirozepur 0 Bhola NA Women Men Noakhali 0 Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization

MaMoni HSS – Year Two Third Quarterly Report July 2015 45 Indicator Data Disaggregat Basel Baseli Remarks Number of union level public health facilities that are ready to MaMoS District,i i 43 NA NA 13 provide normal delivery services ni HSS Type of Report facility High intensity areas Lakhsmipur N/A 11 Noakhali* N/A 2 Habiganj 2013 7 N/A 0 Jhalokathi N/A 0 Pirozepur* N/A HSCS areas Pirozepur NA Bhola NA Noakhali NA Intermediate Result 2: Strengthen health systems at district level and below Number of district level quarterly performance review MaMo District 2014 Nil 24 NA meeting held for data-driven performance review and ni HSS planning Report High intensity areas Lakhsmipur 2014 4 1 1 Noakhali* 2014 4 1 1 Habiganj 2014 4 1 1 Jhalokathi 2014 4 1 Pirozepur* 2014 4 Intra partum still birth rate in project assisted facilities Sentin District NA NA The baseline and targets will be set el site after an assessment of the sentinel report site records s High intensity areas <10/10 Sites and tool not finalized 00 Lakhsmipur 2014 <10/10 00

MaMoni HSS – Year Two Third Quarterly Report July 2015 46 Indicator Data Disaggregat Basel Baseli Remarks Noakhali* S i 2014i <10/10 00 Habiganj 2014 <10/10 00 Jhalokathi 2014 <10/10 00 Pirozepur* 2014 <10/10 00 Sub-IR 2.1: Improve leadership and management at district level and below Number of GOB managers supported for leadership and Project District NA management capacity development trainin g report Lakhsmipur 2014 NA 2 Noakhali 2014 NA 6 Habiganj 2014 NA 8 Jhalokathi 2014 NA 2 Pirozepur 2014 NA Bhola 2014 NA Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs Number of upazilas with updated comprehensive annual Project District 2013 Nil 6 0 4 MNCH/FP/N plan report High intensity areas Lakhsmipur 2014 5 Noakhali* 2014 4 Habiganj 2014 8 Jhalokathi 2014 4 Pirozepur* 2014 2 Sub-IR 2.3: Strengthen local management information systems Percentage of community micro planning units conducting MaMo District NA NA monthly meeting ni HSS

MaMoni HSS – Year Two Third Quarterly Report July 2015 47 Indicator Data Disaggregat Basel Baseli Remarks ReportS i i

High intensity area Lakhsmipur 2014 90 95 Noakhali* 2014 90 97 Habiganj 2014 90 100 Habiganj: as of May 2015 Jhalokathi 2014 90 94 Pirozepur* 2014 90 Sub-IR 2.4: Establish quality assurance system at district level and below Percent of planned supervision visit conducted where a Project District N/A 56 supervision tool was used and findings shared with providers JSV report High intensity areas Lakhsmipur 2014 90 68 Noakhali* 2014 90 26 Habiganj 2014 90 128 Habiganj: June,2015 Data projected Jhalokathi 2014 90 94 Pirozepur* 2014 90 Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below Percent of USG-assisted service delivery points (SDPs) that LMIS District 5.1 12 10 experience a stock out at any time during the reporting period report of a contraceptive method that the SDP is expected to provide High intensity areas Lakhsmipur 2014 <5 4 Noakhali* 2014 <5 5 Habiganj 2014 <5 25 Jhalokathi 2014 <5 1 Pirozepur* 2014 <5 5

MaMoni HSS – Year Two Third Quarterly Report July 2015 48 Indicator Data Disaggregat Basel Baseli Remarks Sub-IR 2.6: Strengthen local government planning and S i i engagement in health service provision Percentage of unions that had at least 50 percent of the BRIS/L District NA NA collected from EPI report estimated births registered within 45 days of birth DG online report High intensity areas Lakhsmipur 2014 20 11883 Noakhali* 2014 20 1205 Habiganj 2014 10 9738 Habiganj: June,2015 Data projected Jhalokathi 2014 10 1280 Pirozepur* 2014 15 Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N Number of Union Parishads (UP) that spent funds to support Meeti District NA NA MNCH/FP/N activities ng minute s of UEHFP SC High intensity areas Lakhsmipur 58 30 Noakhali* 44 19 Habiganj 77 62 Habiganj: as of May,2015 Jhalokathi 32 7 Pirozepur* 15 Intermediate Result 3: Promote enabling environment to strengthen district level health system Number of critical vacancies filled by GoB recruitment or Project District 19 - The targets will be revised on redeployment in project areas report annual basis, based on HR data throug h MOH&

MaMoni HSS – Year Two Third Quarterly Report July 2015 49 Indicator Data Disaggregat Basel Baseli Remarks FWS HR i i report

High intensity areas Lakhsmipur 5 Noakhali* 5 Habiganj 5 Jhalokathi 5 Pirozepur* 5 Sub-IR 3.1: Policy reforms in place to promote local planning and need-based human resource deployment in the public sector Number of policies/ strategies/guidelines on MNH Project Stages of 4 2 - developed/revised with MaMoni HSS support report developme on nt (i) advoca Agenda cy setting, (ii) Formulation , (iii) Adoption, (iv) Implementa tion Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program Number of program learning initiatives completed and Project None 5 2 - disseminated report Intermediate Result 4: Identify and reduce barriers to accessing health services Number of deliveries with a SBA in USG-assisted programs MOH& District 18102 14759 14953 FW MIS report High intensity areas Lakhsmipur 2013 12,81 14,215 4,070

MaMoni HSS – Year Two Third Quarterly Report July 2015 50 Indicator Data Disaggregat Basel Baseli Remarks S i i 2

Noakhali* 2013 23,20 11,756 1,653 4 Habiganj 2013 18,42 21,663 3,657 Habiganj: PCSBA report June '2015 8 projected Jhalokathi 2014 5,750 273 Jhalokati: matenal care report,DGFP, projected for June 2015 Pirozepur* 2014 2,470 581 Pirojpur: CSBA report projected for June 2015 HSCS areas Pirozepur 2014 9,445 1,398 Bhola 2014 1,529 2,037 Noakhali 2013 23,20 25,940 1,285 Noakhali:No EOC report from DH 4 Number of antenatal care (ANC) visits by skilled providers MOH& District 149655 148343 144437 from USG-assisted facilities FW MIS report High intensity areas Lakhsmipur 2013 38,44 44,405 24,200 6 Noakhali* 2013 69,89 35,880 21,405 5 Habiganj 2013 150,7 174,05 55,721 Habiganj: PCSBA report June '2015 00 9 projected Jhalokathi 2014 13,680 3,444 Jhalokati: matenal care report,DGFP, projected for June 2015 Pirozepur* 2014 8,193 2,672 Pirojpur: CSBA report projected for June 2015 HSCS areas Pirozepur 2014 28,676 7,218 Bhola 2014 56,649 14,114 Noakhali 2013 69,89 80,729 15,664 Noakhali:No EOC report from DH, 5 Senbag ANC data need to add in

MaMoni HSS – Year Two Third Quarterly Report July 2015 51 Indicator Data Disaggregat Basel Baseli Remarks S i i EOC report, June 2015

Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches Number of people reached through project supported BCC Project District, 64167 130230 activities MIS Gender, report Topic (MNH, FP/RH, Nutrition/C H) High intensity areas Lakhsmipur 115,00 0 Women 21690 Men 18626 Noakhali* 35,556 Women 2867 Men 846 Habiganj 150,00 0 Women 4079 Habiganj: June,2015 Data projected Men 890 Jhalokathi 80,000 Women 2115 Men 545 Pirozepur* 19,444 Women Men Sub-IR 4.2: Enhance community engagement in addressing health needs Number of trained community volunteers promoting Project District 27,971 33,961 22,929 MNCHFPN through project support MIS

MaMoni HSS – Year Two Third Quarterly Report July 2015 52 Indicator Data Disaggregat Basel Baseli Remarks reportS i i

High intensity areas Lakhsmipur 2014 6,710 6,635 Noakhali* 2014 5,900 5,457 Habiganj 2013 14,00 8,379 8,364 Habiganj: as of May,2015 0 Jhalokathi 2014 2,731 2,305 Pirozepur* 2014 1,205 Number of Community Action Groups with an emergency Project District 2013 2,126 24,355 14,726 15,953 transport system for maternal and newborn health care MIS through USG-supported programs report High intensity areas Lakhsmipur: 2014 6,461 6,604 Noakhali: 2014 3,876 2,608 Habiganj: 2013 2,126 4,369 8,043 Habiganj: as of May 2015 Jhalokathi: 2014 3,746 319 Pirozepur* 2014 1,549

MaMoni HSS – Year Two Third Quarterly Report July 2015 53 Annex 3: Success Stories

A. Chlorhexidine application prevents a repetition of traumatic experience for Sahena Khatun and family.

When Sahena Khatun’s fifth child Ariful Islam was born in March 2012, the family went through a traumatic experience. Sahena Khatun lives in Olua village, Shatkapon union of Bahubal sub-district, Habiganj district. Eleven days after he was born, the area around his naval became red and swollen with pus emanating from the area, and the baby would cry uncontrollably. Sahena Khatun, and husband Angraz Mia brought the newborn to the Bahubal Upazila Health Complex, and only after six days of hospital stay and expensive antibiotics, the infection was brought under control. The mustard oil and ash that was applied at the time of birth was blamed for the infection.

Shatkapon, a populous union of 35,000 is underdeveloped and deprived in many ways. Seventy-seven percent of the population are illiterate, 91 percent earn their living from agriculture. The union level facility does not offer delivery services, so home delivery by traditional birth attendants is the norm. In 2014, the contraceptive prevalence rate was only 24%, and skilled attendance at birth was 27%. In 2014, one mother and 19 newborns died as a result of delivery related complications.

Kulsuma Begum, a traditional birth attendant, received orientation on 7.1% chlorhexidine in 2014 from a MaMoni HSS pilot initiative. When Sahena’s sixth child, Ahmad Ullah was born on 31st March this year, Kulsuma applied chlorhexidine at the umbilical cord just after delivery, and instructed the family not to apply anything else. After five days, the stump dried and fell off without any incident. The baby has been healthy since then. Angraz Mia said, “If we had this medicine two years ago, we wouldn’t have to spend so much money on medicine and treatment.” Kulsuma Begum is also convinced. She said, “I conducted Arif’s delivery, and I felt pain at the misery of the child. Now I apply chlorhexidine on every newborn, and so far no one has had any problems.”

MaMoni HSS has supported the introduction of 7.1% chlorhexidine, including training of providers, communication, follow up, and also ensured distribution of chlorhexidine through different channels including DGHS and DGFP upazila stores to entire Bahubal sub-district at the beginning of 2015. This initiative will be scaled up to cover entire Habiganj district in the next three months.

B. Application of Standards Based Management approach to improve antenatal care consistency at Chunarughat Upazila Health Complex

The challenges of providing quality care at Chunarughat Upazila Health Complex of Habiganj district is typical of all newly upgraded 50-bed hospitals. Even though the newly added structure with additional space is there, additional manpower (nurses, support staff) was not provided to them. This results in uneven quality of service when it comes to antenatal care. MaMoni HSS applied standards-based management and recognition approach to improve quality of care at Chunarughat UHC in early 2014. At the baseline assessment, the hospital met none of the standards for antenatal care, receiving a score of zero. During a problem tree analysis, it was found that there was a coordination problem between DGHS and DGFP staff. The medical officers in the outdoor wing attended pregnant women, but they did not have the necessary logistics support, as the lab service was non-functional. They did not have access to the iron supplementation recommended nationally. On the

MaMoni HSS – Year Two Third Quarterly Report July 2015 54 same premises, a Senior FWV/UFPA also sits at the back, and provides ANC and FP services. She has plenty of iron tablets, and urine strips for use, but she does not get many clients as her room is at the back of the facility, and not very visible. The recordkeeping was also a mess, as many women who received ANC services were not recorded at all. After a limited facilitation from MaMoni HSS, the two units agreed to work together. Since, the lab service was not functional, the doctors would write prescription chits for women. The women would go to the back, get their urine tests done with the UFPA, and collect iron supplementation, and bring the results back to the doctor. In the process, their records were noted in the FWV register. The former UH&FPO, Nishith Nandi Mojumdar, (currently Civil Surgeon of Sunamganj) said, “Without quality ANC, we couldn’t identify pre-eclampsia/eclampsia cases before. We can make arrangements to refer the cases to the district hospital without much delay… [because of MaMoni HSS intervention].”

C. Joint Supervision Visits motivate Deputy Director Family Planning to take steps to ensure services at Char Kakra UH&FWC

Char Kakra UH&FWC was established in 2010, but for a long time, it has been largely underutilized, depriving service to a large population in Companyganj Upazila of Noakhali district. Because of its strategic location, Char Kakra UH&FWC was selected to introduce 24/7 delivery services and its first delivery occurred on March 23, 2015. Deputy Director, Family Planning (DDFP) and Jr. Consultant of UHC visited the site on several occasions as part of joint Junior Consultant, Gynae from Companiganj UHC visiting Char Kakra supervision visit (JSV) organized through MaMoni HSS. They UH&FWC as part of a JSV found that services were not up to the mark because of the attitude of the FWV present at that point. Satellite clinics did not take place regularly, and clients complained about unsatisfactory behavior from the provider. After JSV and follow up, these issues were resolved, increasing ANC, delivery and PNC services for this union. Eventually, through mutual discussion, a new FWV was deployed to this facility, and the previous FWV Durlata Bala Das was transferred to another facility. The Union Parishad and Upazila Parishad Chairmen have both expressed satisfaction at this decision, and confirmed that by ensuring services, women from the community would no longer need to travel great distances to receive basic services.

D. Immediate CNCP care save a newborn life

“After providing CNCP care when the baby started crying, I could not stop my tears.” Selina Parveen became emotional when she was sharing. She is the FWV of the Family planning department’s sadar clinic in Daulutpur Upazila Health Complex of Bhola district.

MaMoni HSS – Year Two Third Quarterly Report July 2015 55 Selina has been providing delivery care since she received six months midwifery training from Barisal Family Welfare Visitor (FWV) Training Institute in 2007. However, she often referred the complicated patients to other facilities. In 2012, she was trained to manage birth asphyxia offered by BSMMU in collaboration with the Helping Babies Breathe Project, supported by MaMoni HSS and USAID. She also received some necessary equipment for newborn care (bag-mask and penguin sucker) along with the training. Recently, she again received a five-day comprehensive newborn care package (CNCP) training from MaMoni HSS in May 2015. She has conducted 47 normal deliveries over the last six months. Before receiving CNCP training she was afraid to handle the complicated newborn cases. Now she is not scared and has become very confident to deal with newborn complications.

Mafizul Islam (23) took her eight-month pregnant wife Shahnaz begum (18) with severe labor pain to Selina Parveen. Shahnaz’s membrane had already ruptured on the way to facility and the baby’s legs and body came out first and the head became stuck. Before coming to the facility at the first sign of complications, they tried to deliver at home instead of seeking facility care. Selina Parveen initiated immediate action to remove the baby’s head immediately after observing the child’s critical condition. However, the baby was not breathing or moving after birth. The skin color became blackish. Observing the situation, Selina Parveen provided artificial breathing very swiftly following the HBB protocol. After eight minutes of breathing, the baby started moving slightly and cried out. At the same time the baby passed stool and urine. When the breathing became normal, she kept the baby on mother’s chest and cut the cord and measure the weight; it was only 1800 g. Then she helped the mother to provide the baby skin-to-skin care on her chest to keep the baby warm and encouraged breastfeeding. She demonstrated how to feed expressed breast milk to the low birth weight baby if the baby could not suck breast milk. She also shared the importance of kangaroo mother care (KMC) for low birth weight babies with Mafizul, the baby’s father, and provided a KMC binder made up by a local tailor as they could not afford one. After the delivery, Selina visited their home to check the baby and found that baby’s hands and legs became cold. Then she collected a cap, shocks and warm clothes from their neighbor to cover the baby. Additionally she bought diapers from the medicine shop for the baby. Again she taught the new mother on using the KMC binder. After the second week, Shanaz came to visit Selina for her checkup. The baby’s weight had increased to 2250 g; mother and the baby both were well.

During the birth, the baby was near to death. However, the ‘dying baby’ turned into a healthy baby because of the appropriate and effective newborn care delivered by Selina after receiving training through MaMoni HSS. So Shahnaz’s family is very happy and they are very pleased with Selina’s effort and care.

E. UH&FWC Management Committee leverages drugs from Morakuri Union Parishad

Morakuri UH&FWC of Lakhai has been a highly Utilized health facility because of MaMoni input to introduce delivery services. Because of that, the facility wasn’t able to provide sufficient iron and calcium supplementation to all mothers, they would frequently run out of these

MaMoni HSS – Year Two Third Quarterly Report July 2015 56 Figure X: UP Chair, Alhaj Md. Liakat Ali distributing IFA and Calcium to FWV and others supplements. As MaMoni has initiated phase out of Habiganj and scaling down the inputs, FWV Rokeya Akhtar was worried that she won’t be able to provide quality service. Through, FPI Baidyanath Das and AHI Ratan Chandra Roy, she placed an appeal to the UH&FWC management committee to discuss the solution. The committee members discussed this issue, and convinced the UP Chairman Alhaj Md. Liakat Ali to procure them.

On April 19, at the presence of Medical Officer, MCH-FP Dr. Nasima Khanam Eva, the UP Chairman donated 70,000 IFA and 3,500 calcium tablets to the health facility. The UH&FWC management committee also has other plans to sustain the level of performance of the facility after MaMoni withdraws the paramedics and support staff from the facility in the next year. MaMoni is also working with DGFP to reform the DDS kit procurement, which was repackaged this year, and will be able to address these kinds of shortage after 18-24 months.

MaMoni HSS – Year Two Third Quarterly Report July 2015 57 Annex 4: Key Achievements of Aponjon/MAMA initiative

The local initiative of the Mobile Alliance for Maternal Action (MAMA), branded as Aponjon in Bangladesh, was fully integrated with MaMoni HSS on July 1, 2014. The mHealth initiative targets expectant mothers, new mothers, and their family members in Bangladesh, and has the following five objectives:

• Objective 1: Achieving improvements in health knowledge and practice as well as health seeking behavior of targeted women and gatekeepers o Sub Objective 1.1: Reaching at least 2,000,000 pregnant and new mothers with gatekeepers by December, 2015 o Sub Objective 1.2: Achieving Improvement in health knowledge and practice as well as health seeking behavior of targeted women and Gatekeeper • Objective 2: Ensuring quality and effectiveness of service • Objective 3: Build and manage partnerships • Objective 4: Test financing /Business Model for sustainability • Objective 5: Share learning from the project

This annex presents a summary of key accomplishments of Aponjon during the period of April 2015 – June 2015.

Objective 1: Achieving improvements in health knowledge and practice as well as health seeking behavior of targeted women and gatekeepers

Sub Objective 1.1: Reaching at least 2,000,000 pregnant and new mothers with gatekeepers by December, 2015

Training workshops Aponjon organized a number of trainings and workshops during the previous quarter:

• Two BP selection workshops were held with approximately 40 participants. Among those, eight Aponjon BPs were selected, who are now in training. • Five Aponjon orientation training sessions (four at Jessore regional office and one in Dhaka) were completed in April with a total of approximately 50 participants. • Fifteen Aponjon orientation training sessions of CA & SA were conducted with a total of 460 Shasthya Kormi (SK), 24 Program organizers, and 25 District managers. Aponjon arranged trainings for the SKs of BRAC from April 19-28, 2015 in different areas of Comilla and Brahmanbaria districts to orient the CHWs on the benefits of ‘Aponjon’ services, client registration process and reporting mechanisms. • New Aponjon BPs of Jessore organized 67 yard meetings in April, with more than 1,000 beneficiaries in attendance. • A total of 8,995 subscribers were enrolled this quarter by outreach partners. As seen in Figure below, 6,850 of these were registered with BRAC health workers, 2,115 with MaMoni HSS and NHSDP and the remaining 30 were enrolled by TothyoKollyani and Local NGOs. • Aponjon BPs collected data from approximately 30,364 subscribers, largely from Maternal Hospitals and other locations with high densities of pregnant women and new mothers.

MaMoni HSS – Year Two Third Quarterly Report July 2015 58 Table 1: Acquisition by subscriber types

Subscriber Type April May June Total for Q3 Primary Subscribers 5045 27436 16480 48961 Expecting Mothers 2512 5940 5960 14412 New Mothers 2533 21496 10520 34549 Secondary Subscribers (Gatekeepers) 213 75 72 360 Husbands 197 56 55 308 Mother In-Laws 1 1 1 3 Mothers 3 4 2 9 Other Relatives 12 14 14 40 Total Subscribers (Primary and Secondary) 5258 27511 16552 49321

Approximately 68% are receiving voice messages, and 32% are receiving text messages.

Bus Branding As a way of reaching out to potential customers and strengthening the brand footprints, Aponjon branded eight buses covering four routes. Approximately 348 calls have been attributed to this campaign resulting in 168 subscriptions to date.

Figure 14: Aponjon-branded bus

Sub Objective 1.2: Achieving Improvement in health knowledge and practice as well as health seeking behavior of targeted women and Gatekeeper

Inclusion of Family Planning content into existing Aponjon content scripts As part of Aponjon’s continuous improvement, the content is continually modified based on content surveys and suggestions made by the Technical Committee on Content. During the past quarter, a workshop was held during which the FP content in the Aponjon messages was updated under guidance from USAID.

Objective 2: Ensuring quality and effectiveness of service

Call center & Counseling Line Management During the past quarter, a total of 3,464 registration calls, 8,525 incoming calls, and 36,542 outgoing calls were placed through the Aponjon call center, with 166 DOB updates. A total of 3,936 calls were made to the Aponjon counseling line. See Figure 3 below for more details.

MaMoni HSS – Year Two Third Quarterly Report July 2015 59 Figure 14: Call center status

18000 15532 16000 14000 11997 12000 10000 9013 8000 6000 3225 4000 2914 2386 2000 1065 1334 1065 0 April May June

Call for Registration Incoming call Outgoing call DOB update SMS Request regiatration Data Entry

Quality Control of Aponjon Registration In the past quarter, the Quality Control management Team was involved in various assignments, mainly those pertaining to subscriber acquisition through LNGOs and Outreach Partners. The team of 20 QA members who make up the team ensure registration authentication over phone; the subscribers are registered only after proper verification of credentials and explicit consent for subscription.

During the quarter, 18,436 phone calls have been made by the QA members from Outreach Partners (BRAC, Smiling Sun and Infolady), from which, a total of 10,393 subscribers were enrolled. While making calls from the LNGO list, QA members approved 1,242 subscribers out of total calls 2,354.

Annual outcome progress evaluation study The biannual phone survey was completed with 120 respondents surveyed by trained call center agents. The survey data has been cleaned and analyzed, and will be summarized in a report in the next quarter.

Objective 3: Build and manage partnerships

Continuation of Partnerships Agreements with Beximco Pharma Ltd. and Lal Teer Seed Ltd. regarding in-kind contributions were renewed, while a new agreement was signed between Aponjon and icddr,b regarding a pilot research project involving 350 new mothers. In the pilot study, the project beneficiaries will receive Aponjon messages for a one-year duration, during which time the icddr,b research team will be tracking the women’s nutritional status for a total of six months. The study includes an incentive mechanism for enrollees to be mediated by Payable, Aponjon’s own m-cash disbursement platform.

Objective 4: Test financing /Business Model for sustainability

Partnership and Business Development

MaMoni HSS – Year Two Third Quarterly Report July 2015 60 On June 15, 2015, a launch event for Dnet Global was held at the Mozilla Foundation headquarters, funded by external sources. During the event, both Aponjon and Infolady were showcased as flagship initiatives of Dnet, which hopes to play a catalytic role in ensuring sustainable partnerships and/or funds for Aponjon in the future.

Objective 5: Share learning from the project

Participation in various workshops and seminars Aponjon’s Impact & Research team have participated in the maiden international conference on health coverage and public health in Bangladesh, “Realizing UHC Goals,” which took place April 9-11, 2015 in Dhaka. An abstract submitted by Atik Ahsan, Tahsin Ifnoor Sayeed, and Kazi Farzana was selected among the top 12 entries of 120 submissions for the poster session. The abstract was titled "Making a Case for Localized mHealth Content: Triangulations from Verbal Autopsy and Ethnographic Study" and received significant attention for the uniqueness of its research method and the intervention discussed.

Figure 15: Atik Ahsan presenting at the Realizing UHC Goals conference in April 2015

Annex 5: An Update on Routine Health Information System

USAID and its implementing partners, MEASURE Evaluation, icddr,b and MaMoni HSS have been working with the DGHS and DGFP to strengthen the routine health information system (RHIS) of the country. Particular focus was to support M&E functions of the HPNSDP and activities under MIS Operational Plans (OP) of the two directorates and limited to the six OPs that cover MNCH-FP and Nutrition services and the Community Clinics. In addition, MSH/SIAPS has been providing technical assistance to the DGFP and DGHS to design and use a supply chain management portal for efficient and effective logistics management of RMNCH commodities.

i. Specific objectives of this initiative are, to support the MOH&FW:To design and pilot test, a comprehensive but modular, electronic, interoperable routine health management information systems for MNCH-FP and Nutrition services, which is virtually integrated across both

MaMoni HSS – Year Two Third Quarterly Report July 2015 61 directorates ii. To support national roll-out of the automated electronic routine health management information system iii. To build capacity of workers, service providers and managers at all levels to use the systems to generate and use real-time data for management, monitoring, planning purposes.

Activities: Population registry training for GoB field staff: GOB field staffs from three unions of Madhabpur were trained on Population registry module RHIS initiatives. MaMoni-HSS supported DGFP and DGHS managers of Madhabpur Upazila to organize two batches of three-day trainings on Population registry. The participants were FWAs, HAs, FPIs, AHIs & HI from three Unions (Dharmagar, Chowmohoni, Jagadishpur). A total of 37 participants attended the training in two batches.

Data Collection: Figure 16: “Population Registry Training” conduction at Upazila 20 data collectors started data collection from Health Complex of Madhabpur upazila March 15, 2015 and HAs and FWAs started data collection from June 1-30, 2015. In that time, they have visited 20,755 Households and registered 108,096 members.

Post training follow-up activities: UHFPO, UFPO & MOMCH-FP of Madhabpur Upazila made a plan to monitor RHIS activities at the field level. The first line supervisors will closely monitor the registration activities in the field and will meet twice a month at the union level to know the progress and address challenges. They will also meet at Upazila level once in a month or as or when required for the successful completion of the RHIS activities.

Software Development Activity: Development of the RHIS system has many Photo: UH&FPO, UFPO and MO-MCHFP, are Madhabpur observing population data collection by TAB and interacting with dependencies and stakeholders. Since the Data collector and its respondent. government is also undergoing some changes to its health information system through DHIS2 and SHR initiative, the potential changes need to be factored into the total system design. There are technical challenges incorporating the existing and upcoming government initiatives. Some of the problems have layered dependencies and some are stand alone issues. In order to address one issue or one cluster at a time, the understanding of the existing system is crucially important and therefore, a number of

MaMoni HSS – Year Two Third Quarterly Report July 2015 62 meetings were organized between different stakeholders to share ideas. The developers attended meeting organized by DGHS and Thoughtworks walking through the technical details and the documentation of the SHR in order to understand the interoperability with RHIS system.

The RHIS software development is distributed among two teams from Save the Children and icddr, b. The development team from Save the Children is primarily focusing on the facility-based service and the icddr, b team is focused on the community-based service. However, as RHIS is an integrated system, updates and modification of data is reflected on both systems. In order to achieve this, a common database is designed for ANC, Delivery, Newborn and PNC register for the FWC and the corresponding parts in the FWA register. The technical challenges of interfacing the system developed by the broader RHIS team is resolved through negotiation and consultation and is part of a continual process of review.

ANC Newborn Delivery PNC Background Architecture

FWC Done Done Done In Progress In Progress

FWV Scheduled Scheduled Scheduled Scheduled In Progress

FWA Demo - - - In Progress

The DGHS follows a development philosophy that all the software should use open source material. Following that, all the FWC modules are prepared and tested in an open source environment. The application server ‘Tomcat’, the database ‘PostgreSQL’, the ‘Linux’ host are all open source. The development is also done primarily with Java Script and Java Servlets which do not have any dependency on proprietary licenses. The team also initiated migration of the existing population registry database from a proprietary SQL Server database to a PostgreSQL database. The schedule for migration of the monitoring tools associated and administrative tools is also underway.

In order to incorporate field learning and other associated logistics issue, we have identified and prioritized the mother and the newborn care registers to be developed and prototyped first. While developing the modules feedback and input from the domain-level experts have been incorporated to make it more intuitive and user friendly. Automation and built in Decision Support System is introduced. For instance, automatic calculation of EDD from LMP is now facilitated. One of the primary design goal behind designing the system is to facilitate automation and reduce the work load of the existing field staff.

Development of FWC Module: ANC, PNC, Delivery, Newborn and PNC registers of the FWC module are now being converted into e- registers. For the legacy reasons, a browser-based application is selected for the purpose. In the frontend part java script with jquery is used along JSON for data storage and later incorporated to the database initialization. Java servlet is used with JDBC for the backend database connectivity. While developing the modules feedback and input from the domain level experts have been incorporated to make it more intuitive and user friendly. Automation and built in Decision Support System is introduced. While developing the module special measure was taken to keep the patient history and present in a format that is readily accessible and understandable. The challenge was to provide the maximum flexibility possible for the end user as they currently enjoy in the paper p-based system. In pen and

MaMoni HSS – Year Two Third Quarterly Report July 2015 63 paper, a lot of information currently collected in structured. Therefore, the developers involved worked to convert this unstructured information into a universally presentable format. For instance, automatic calculation of EDD from LMP is now facilitated. The module is already connected to a remote database and application server which ensures its field deployment.

The following is a summary of technology used: • Front end development: HTML: Static web page, CSS: Styling the web page, Java script: To make the static web page dynamic and also to connect with the back end class • Back end development: • Java Servlet: developing servlet as the communication middleware between front end and back end • Java Class: developing java classes as the middleware between servlet and database • Database: Prepare the tables and populate test data in automated way that can be later replicated.

Platform Unification: One of the primary responsibilities of the Senior Manager HISD is to unify the development platform and provide leadership for the development effort. Since development process is distributed between iccdr, b and Save the Children, it is a continuous challenge to reach consensus for every decision that impacts both the development team. We have finally managed to take the first step towards establishing the unified platform. After it was highlighted during a broader RHIS meeting that current population registries and other development activities are done in proprietary platforms, the decision was made that the FWV modules and the rest that will follow are all being developed in open source platforms.

Guide and Facilitate Software Development: The Senior Manager set up the host and configured the application servers and the database to host the FWC application. In this mode, we are already testing remote deployment. The role also require providing continuous advice and architectural guidance to both the SCI team and broader RHIS team in plenty of technically challenging issues. The changes in the architectural design and in development philosophy will have a positive long-term impact.

Data Ownership: Another lingering issue for the project was ownership of the data collected at the field level. This is the first time the organization was able to receive live data being updated on the field. In order to do so, the Senior Manager had to work with the ICT team to facilitate the environment for data hosting and resolve numerous connectivity issues. The management of the data also comes with the ownership of the data. The Senior Manager is involved with a number of database management related issues.

Platform Evaluation: Recently the team needed to analyze the feasibility of migrating to Open SRP platform for the community modules. In the process, the existing framework and each technology (Enceto, couchdb etc.) used by the Open SRP platform needed comprehensive analysis for feasibility study.

MaMoni HSS – Year Two Third Quarterly Report July 2015 64 Visits: Dr. Umme Salma Jahan Meena, Team Leader, Health Systems Strengthening, Office of Health, Nutrition & Education, USAID, had visited “Population Registry training” on May 12, 2015. The training was attended by HAs, FWAs, FPIs, AHIs & HI from Dharmagar, Chowmohoni & Jagadishpur unions of Madhabpur. Dr. Meena also visited the field to observe the data collection process by data collectors and one HA, and expressed satisfaction with the overall progress of RHIS activities.

Meeting: Photo: The visitor is observing “Population Registry” at field A series of meeting in different issues on RHIS held by GoB staff (HA) at Vill: Alboxpur, Madhabpur within this quarter. Among them software development, issues related to RHIS ID, Community module development, FWC Module development, Supervisory module development, etc. are mentionable.

MaMoni HSS – Year Two Third Quarterly Report July 2015 65 Annex 6: An update on national UH&FWC strengthening initiative

In order to achieve the Millennium Development Goals 5 and 4 on maternal health and child health, the Ministry of Health and Family Welfare (MOHFW) has adopted several strategies in its Health Population and Nutrition Sector Development Program (HPNSDP). A major sector specific strategy is to streamline, expand the access and quality of MNCH (Maternal Newborn and Child Health) services, in particular attended deliveries. One of the priority interventions adopted in HPNSDP is to expand skilled birth attendance at institutional level by initiating basic obstetric and newborn care services at the Union Health and Family Welfare Centers (UH&FWC) and at home through continued Community Skilled Birth Attendant (CSBA) training program with strengthened management and clinical supervision in facilities. MaMoni HSS is designed with the goal to improve utilization of integrated maternal, newborn, and child health, family planning, and nutrition (MNCH/FP/N) services in Bangladesh. The project's objective is to increase availability and quality of high-impact interventions through strengthening district level management and health systems.

MaMoni HSS has recently disseminated its experience of achieving high coverage of skilled attendance and antenatal care in several unions through ensuring provision of 24/7 delivery care services from the UH&FWCs. This experience has stimulated the MOH&FW and other key stakeholders to adopt MaMoni HSS experience as an effective approach to attain HPNSDP priority goals of delivery by skilled care providers.

The objective of this collaborative effort is to provide technical assistance to develop and implement an Accelerated Scale Up Plan to rapidly increase the coverage of skilled attendance at birth by strengthening the union level facilities of DGFP to achieve and exceed the HPNSDP target of 50% skilled birth attendance coverage by 2016, and thus significantly reduce maternal and newborn mortality

Based on this agreement MaMoni HSS has taken up the UH&FWC strengthening initiative to accelerate the activities to improve the skilled attendance at birth. In this regards following activities have been accomplished in the period of April to June 2015. UH&FWCs assessment data collection has been started from April 2015. 2 Divisions (Barisal and Sylhet) have been completed and Chittagong Divisional assessment is going on.

Below table shows the district wise assessment and re-interview by supervisors of UH&FWCs

MaMoni HSS – Year Two Third Quarterly Report July 2015 66 Table 12: Number of assessments and re-interviews completed by supervisors of UH&FWCs, by district

No of Assessment No of Re-interview Sl Division District Remarks Completed Completed 1 Jhalokati 30 1 2 Bhola 45 4 3 Patuakhali 63 4 Assessment done by Barisal 4 Barisal 80 8 PHD 5 Pirojpur 49 5 6 Barguna 32 3 7 Habiganj 68 3 8 Moulavibazar 53 3 Sylhet Assessment done by 9 Sunamganj 43 5 SHIMANTIK 10 Sylhet 84 8 11 Lakshmipur 43 3 12 B.Baria 92 9 PHD Chittagong Ongoing, 13 Noakhali 53 3 SHIMANTIK Total 735 59

In Barisal Division, a total of 299 UH&FWC assessments have been completed In Sylhet Division, a total of 248 UH&FWC assessments have been completed In Chittagong Division, a total of 188 UH&FWC assessments have been completed

During this quarter for monitoring of the assessment process Jhalokati, Bhola, Habiganj, Moulavibazar and Sylhet districts visited from Dhaka MaMoni HSS team.

Photo: Data collector interviewing FWV at Bishwanath Photo: Data collector interviewing one SACMO, Jhalokati UH&FWC, Sylhet

MaMoni HSS – Year Two Third Quarterly Report July 2015 67 Stakeholders meeting for strengthening UH&FWCs to increase SBA Coverage held on 13 May 2015 at Spectra Convention Center, Gulshan,Dhaka.

Mr. Syed Monjurul Islam, Hon’ble Secretary, Ministry of Health and Family welfare, Government of the People’s Republic of Bangladesh was the chief guest and Md. Nur Hossain Talukder, Director General, DGFP, MOHFW chaired the program. Dr. Ishtiaq Mannan, Director, Health, Nutrition & HIV/AIDS, Save the Children, Allyson P. Bear Deputy Director, OPHNE, USAID, Joby George, Chief of Party, MaMoni HSS, Save the Children attended the program as special guest.

Twenty Data Collectors and two Supervisors from PHD and SHIMANTIK were attended the training. Mr. Mostafa Kamal, DDFP, Noakhali, was the Chief Guest. Mr. Salauddin, Sr. Manager, MaMoni HSS, Noakhali, Dr. Jebun Nessa Rahman, Program Director, Maternal Health, FP & Nutrition MaMoni HSS, Dhaka. Dr. Afsana Karim, Program Director, District Implementation, MaMoni HSS, Dhaka. Dr. Mahibubul Abrar, Advisor, HMIS, MaMoni HSS, Photo: DDFP, Noakhali delivering his speech Dhaka attended the program as special guest.

Photo: Special Guest and facilitators are presented the Refresher Training

Md. Zahangir Hossain, UH&FWC Coordinator, Dhaka and Md.Mamun-ur-Rashid, DM-HSS, MaMoni HSS, Dhaka facilitated the training session.

MaMoni HSS – Year Two Third Quarterly Report July 2015 68

The following activities were also accomplished and some initiative have been taken during this quarter:

Table 17: Additional activities conducted during Quarter 3

Sl.No Activity Descriptions Remarks Data analysis and District wise District wise categorization done and it is seen in 1 categorization the wave. Sharing with MaMoni team Categorization share with MaMoni team on 16 2 regarding categorization June 15. Sharing DGFP team regarding Sharing DGFP team regarding categorization will be 3 categorization very soon. The list of the Next small stakeholders meeting will be held on 4 Next small stakeholders meeting stakeholders are July 22, 15 at MCH unit conference room of DGFP already been updated Divisional workshop will be held at Sylhet in end of 5 Divisional workshop August 15. 6 Setup Dash Board at DGFP Dash Board at DGFP will be set up in July 2015 . 7 Assign Focal Person of DGFP It will be finalized by July 2015. TOR for National co-ordination TOR for National co-ordination committee & 8 committee & Technical Technical Assistance cell already been submitted to Assistance cell the DGFP for review and finalization Work plan for FWVs training/ 9 It is in the process refresher on Midwifery skilled Division wise Directory for 10 It is in the process. UH&FWCs More 20 (twenty) Data Collectors and 2 (two) Recruiting of more new Data 11 Supervisors will be recruited for the next year Collectors and Supervisors immediately

MaMoni HSS – Year Two Third Quarterly Report July 2015 69 Annex 7: Media Stories Published this Quarter

This quarter, MaMoni HSS published numerous news stories, facilitated discussion on six television programs, and produced five videos on safe motherhood day on social media. In addition, several stories were published in the local newspapers in MaMoni HSS districts.

BDNews24.com ‘Helping Babies Survive’, new survival package for Asian countries launched in Bangladesh Senior Correspondent, bdnews24.com Published: April 9, 2015 Link: http://bdnews24.com/health/2015/04/09/helping-babies-survive-new-survival-package- for-asian-countries-launched-in-bangladesh

Daily Observer Published Date: April 9, 2015 Regional workshop on helping babies survive begins in city http://www.observerbd.com/2015/04/09/82740.php

Prothom Alo Publish Date: May 28, 2015 Link: http://www.prothom- alo.com/bangladesh/article/538810/%E0%A6%B9%E0%A6%BE%E0%A6%93%E0%A6%B0%E0% A7%87-%E0%A6%AE%E0%A6%BE%E0%A7%9F%E0%A7%87%E0%A6%B0- %E0%A6%B9%E0%A6%BE%E0%A6%B8%E0%A6%BF

The Daily Bangladesh Observer Publish date: May 28, 2015 Antenatal check-up makes difference in reducing maternal mortality Link: http://www.bdnews21.com/browse.php?link=observerbd.com

Prothom Alo Publish Date: May 29, 2015 Link: http://www.prothom-alo.com/opinion/article/539791/

Prothom Alo Published Date: June 12, 2015 Link: http://www.prothom-alo.com/bangladesh/article/551536/

Daily Shamakal Publish Date: May 28, 2015 Link: http://www.samakal.net/2015/05/28/139915

Publish Date: May 28, 2015 Link: http://www.dailynayadiganta.com/detail/news/26090

MaMoni HSS – Year Two Third Quarterly Report July 2015 70

Daily Naya Digonto Publish Date: May 4, 2015 http://dev.dailynayadiganta.com/detail/news/19996

The Daily Naya Digonto Publish Date: May 19, 2015 Link: http://www.dailynayadiganta.com/detail/news/23693

The Daily Observer Newborn deaths still a pain in the neck Publish Date: May 20, 2015 Link: http://www.observerbd.com/2015/05/20/89773.php

Prothom Alo Publish Date: May 28, 2015 Link: http://www.prothom-alo.com/bangladesh/article/539569/

Prothom Alo Govt to employ 3,000 midwives Publish Date: May 16, 2015 Link: http://en.prothom-alo.com/bangladesh/news/66555/Govt-to-employ-3-000- midwives

Prothom Alo Publish Date: May 16, 2015 Link: http://www.prothom-alo.com/bangladesh/article/530005/

Prothom Alo ১৩০ তম Link: http://www.prothom-alo.com/bangladesh/article/520492/

Prothom Alo Publish Date: May 6, 2015 Link: http://www.prothom-alo.com/we-are/article/512065/

Daliy Kaler Kantho Link: http://www.kalerkantho.com/online/national/2015/05/28/227061

Kaler Kantha Publish Date: May 28, 2015 Link: http://www.kalerkantho.com/print-edition/news/2015/05/28/226957

Kaler Kantha

MaMoni HSS – Year Two Third Quarterly Report July 2015 71 Publish Date: May 29, 2015 Link: http://www.kalerkantho.com/print-edition/news/2015/05/29/227377/print

Prothom Alo Published date: May 26, 2015 Link: http://www.prothom-alo.com/opinion/article/537184/

The Daily Star Maternity and poverty: Fistula in Bangladesh Published date: May 24, 2015 http://www.thedailystar.net/health/maternity-and-poverty-fistula-bangladesh-86236

The Daily Star Improving Urban Poor’s Health Status; Public health experts call for more investments Published date: May 17, 2015 Link: http://www.thedailystar.net/city/public-health-experts-call-more-investments- 82825

The Daily SUN Coordination between health, local govt ministry stressed Published Date: May 17, 2015 Link: http://www.daily-sun.com/print/metropolis/2015/05/17/503576

VOA Bangla Publish date: June 16, 2015 Link: http://www.voabangla.com/content/health-workshop-3/2819360.html

Table 2: Television Programs Aired during Quarter 3 through MaMoni HSS Facilitation

Station Program Date Guest Topic BTV Shastha Jiggasha April 24 Prof Laila Arjumand Delivery Care Banu BTV Tanumon June 19 Dr. Iffat Ara Safe Motherhood Bangla Vision Sushastho May 1 Prof. Saleha Khatun Delivery Care Bangla Vision Green Life Bhalo June 26 Prof. Shahla Khatun Prenatal Care Thakun Prof. Farhana Dewan Channel 71 71 Shakal May 13 OGSB Representative Delivery Care

MaMoni HSS – Year Two Third Quarterly Report July 2015 72 Annex 8: National Newborn Scale-Up Initiatives

Major accomplishments during this quarter included the introduction of two different packages of Comprehensive Newborn Care Package (CNCP) training in six MaMoni HSS Project districts, HBB training under district revisit program, TOT for TBA orientation on application of 7.1% Chlorhexidine, and HBB & Surveillance data sharing with BSMMU senior faculties. 100 doctors were developed as trainers and 790 health provider at different levels and categories received training on CNCP, 11 doctors received TOT for TBA orientation on 7.1% Chlorhexidine and 20 providers received HBB training.

A. Comprehensive Newborn Care Package (CNCP)

CNCP CNCP is a comprehensive newborn care training package comprises of HBB, most of the chapters of Essential Care for Every Baby (ECEB) those are in alignment with the national guideline and four new newborn interventions (Chlorhexidine, ACS, Sepsis management at union level facility and KMC) endorsed by MOH&FW, Bangladesh.

CNCP is being implemented at three different levels of facilities with three different training modules: upazila and above level providers, union level facility providers, and community level health workers. In this quarter, the project rolled out two packages of CNCP.

1. TOT on CNCP

Trainers from district and upazila health and family planning.

a. TOT for CNCP for upazila and above providers

We organized the remaining five-day long TOT on CNCP for upazila and above level providers (doctors and nurses) for Jhalakathi district. Fourteen doctors attended the training.

b. TOT for union providers

Four batches of five-day long TOTs were organized for Figure 1: Comprehensive Newborn implementing training of union-level providers (FWV Care Package materials and SACMO) on CNCP.

Eighty-six doctors from Noakhali, Habiganj, Lakshmipur, Bhola, Pirojpur and Jhalakathi district received TOT in 4 batches.

MaMoni HSS – Year Two Third Quarterly Report July 2015 73

Photos: TOT session on CNCP for upazila and above

Photo: TOT session on CNCP for union providers

2. CNCP Training

The project completed CNCP trainings for upazila and above providers in all upazilas of Habiganj, Noakhali and Lakshmipur districts. Union provider trainings in Habiganj and Lakshmipur were also completed. The remaining participants of Noakhali will be covered in next quarter.

a. CNCP training for upazila and above level providers

A total of 345 upazila and above level providers from three districts received five-day long CNCP training in 18 batches.

Table 3: Number of health care providers who received CNCP training, by district

Participants Information District Training Total Category Category Name Name Batch Doctor Nurse MaMoni Total Male Female Total

MaMoni HSS – Year Two Third Quarterly Report July 2015 74 Noakhali CNCP 10 63 136 1 200 44 156 200 Laksmipur Provider 3 22 28 3 53 19 34 53 Habiganj Training 5 38 45 9 92 23 69 92 Total 18 123 209 13 345 85 260 345

b. CNCP training for union providers

A total of 445 union providers of six districts received five-day long training on CNCP in 24 batches.

Photo: Union providers receiving CNCP training in Lakshmipur (left) and Bhola (right)

Table 4: Number of participants who received CNCP training, by district

Total Participants Information District Training Batche Category Category Name Name s SACMO FWV MaMoni Total Male Female Total Noakhali 02 18 19 0 37 7 30 37 Laksmipur CNCP 07 74 49 6 129 63 66 129 Habiganj Union 06 36 45 14 95 27 68 95 Jhalokathi Level 03 39 24 0 63 21 42 63 Pirojpur Training 03 45 19 0 64 28 36 64 Bhola 03 19 37 0 56 15 41 56 Total 24 231 193 20 444 161 283 444

B. TOT on TBA orientation on 7.1% Chlorhexidine application to umbilical cord

A day-long TOT was organized in Habiganj on TBA orientation on 7.1% Chlorhexidine application to umbilical cord. Participants will train the FWVs for rolling out the training among TBA in Habiganj.

MaMoni HSS – Year Two Third Quarterly Report July 2015 75

Photo: Civil Surgeon of Habiganj is delivering a speech in the inaugural session of TBA Orientation on 7.1% Chlorhexidine Application for Newborn Cord Care and Essential Newborn Care.

Table 5: Participant information for training on 7.1% Chlorhexidine application to umbilical cord

District Batch Participant Information Name Category RMO MO MO (MCH-FP) Total Habiganj 1 06 03 02 11

C. Helping Babies Breathe (HBB)

HBB Training During this quarter, 20 SBAs were trained in on the HBB curriculum. The cumulative number of HBB trainings that have occurred since project inception is 28,151.

Table 6: Participant information for HBB trainings

Venue Batch Participant Doctor Nurse Total Male Female Total Conference Room, Shaheed Ziaur 1 5 15 20 1 19 20 Rahman Medical College Hospital, Bogra

District Revisit During this quarter, 109 of the 115 facilities in Bogra district were visited.

MaMoni HSS – Year Two Third Quarterly Report July 2015 76 The four components of the district revisit program are 1. District review meeting, 2. SBA training for private facility providers, 3. Re-strengthening of refresher training, and 4. Monitoring of logistics and logistics gap management.

Distribution of Resuscitation Devices During the quarter, 148 NeoNatalie Complete, 740 Resuscitators, 748 Penguin Suckers and 226 training DVDs were distributed throughout the project districts.

Data sharing meeting

The Program Director of the BSMMU component of MaMoni HSS, Professor Mohammod Shahidullah, presented on the HBB national scale-up, newborn care surveillance and CNCP update in the CME meeting of BSMMU attended by VC, Pro-VC, BSMMU management and doctors from the Neonatology and Ob-Gyn department, along with members of BPS including Professor MR Khan.

Way Forward

BSMMU will complete roll out of all the three packages of CNCP including CNCP training for CHWs in selected MaMoni HSS districts. The project is also looking forward to introducing the CNCP in non–project districts as a commitment to national scale-up efforts.

Signing of MoU on National Scale Up of 7.1% Chlorhexidine application for newborn cord care between IMCI section, DGHS, MoH&FW and MaMoni HSS, Save the Children

Background:

In 2013, Bangladesh declared its commitment for “Ending Preventable Child Deaths by 2035” and incorporated four priority interventions to prevent neonatal death. Application of 7.1% Chlorhexidine for newborn cord care was one of the priority interventions for newborn survival which the Ministry of Health and Family Welfare (MOH&FW) decided to scale up nation-wide. In response to a request from DGHS for supporting the national scaling up of 7.1% Chlorhexidine application for newborn cord care, USAID agreed to support this initiative to achieve the Ending Preventable Child and Maternal Death goals as agreed by USAID and the Government of Bangladesh. National Scale up of 7.1% Chlorhexidine for newborn cord care will be another milestone of USAID assistance for newborn survival initiative in Bangladesh. USAID has entrusted MaMoni HSS to support the MOH&FW to scale up this intervention. MaMoni HSS signed a memorandum of understanding with the IMCI Section of DGHS, which will be leading the scale-up initiative. The proposed national launch will be a major milestone in the history of newborn health program in Bangladesh, and a major step towards realizing the goal of Ending Preventable Maternal and Child Deaths in Bangladesh.

Modality As noted above, the IMCI section of DGHS will lead implementation in coordination with the MCH unit of DGFP, and in collaboration with the National Technical Working Committee for

MaMoni HSS – Year Two Third Quarterly Report July 2015 77 Newborn Health (NTWC-NBH), Saving Newborn Lives (SNL)/Save the Children, professional organizations and other key stakeholder with financial assistance from USAID through MaMoni HSS. As the implementing agency for MaMoni HSS in Bangladesh, Save the Children and its partners will support the IMCI Unit of DGHS to roll out the intervention. This support will include orientation of different categories of public sector providers in proper application of 7.1% Chlorhexidine digluconate for newborn cord care; the design and implementation of a multi- level, multi-channel communication campaign to raise awareness among the population; and planning and coordinating the logistics management for the distribution of 7.1% Chlorhexidine digluconate procured by DGHS.

Partner NGOs will be acting as local partners of MaMoni HSS, implementing the activities outlined in the workplan in specific geographical areas.

Major Activities • Provide orientation on Chlorhexidine use for all health facility providers and field level health workers of all the districts, phase by phase • Advocacy on Chlorhexidine use at national, divisional and district level • Development and implementation of communication campaign including TV, Radio and Billboard components • Logistics management for 7.1% Chlorhexidine solution distribution • Establishment of a national newborn and child health cell (support unit) for the Chlorhexidine national scale-up housed within the IMCI section of DGHS, MOH&FW.

Table 7: Working areas for the next quarter

Division District No. of upazilas Implementing partner Sylhet Sylhet 30 FIVDB Moulovibazar, Sunamganj Barisal Barisal, Bhola, Barguna, Prirojpur, Patuakhali 38 PHD Dhaka Dhaka, Narayanganj, Munshiganj, Gazipur, 34 Shimantik Manikganj,Narsingdi, Mymensingh, Jamalpur, Tangail, 66 PHD Kishoreganj, Netrokaona, Sherpur

D. Newborn Sepsis Management:

As noted above, as part of the Government of Bangladesh’s commitment to Ending Preventable Child Deaths by 2035, management of newborn infection at lower level facilities were identified as one of the major interventions to achieve the target, and the MOH&FW decided to scale-up this intervention nationally. The national Core Committee on Neonatal Health adopted a policy in July 2013 to strengthen union level facilities to ensure newborn infection management in case of referral failure. MaMoni HSS project was actively involved during the entire process of developing the Bangladesh Call for Action and planned to prioritize introduction of key, related interventions within the project area, which will be undertaken in collaboration with the MOH&FW and other stakeholders.

MaMoni HSS – Year Two Third Quarterly Report July 2015 78 Based on this, MaMoni HSS is contributing to the implementation of a new initiative for strengthening newborn sepsis prevention and management by injectable antibiotic from union level facilities in three districts (Habigonj, Noakhali and Lakhsmipur) with the objective of effectively introducing newborn sepsis management within the existing GoB health care delivery system and documenting and disseminating lessons learned. Under this program the sick newborn and infants (aged 0-59 days) will be assessed and categorized at the union level health facilities (Union Health and Family Welfare Centers) or similar facilities by Sub-Assistant Community Medical Officers (SACMO), paramedics as per standardized national guidelines.

This initiative will be intensively implemented in 10 Upazilas – eight in Habiganj, one in Noakhali (Companigonj), and one in Lakshmipur (Komalnagor). The workplan for the initiative includes consulting with the IMCI Unit of DGHS, and MCH Unit of DGFP, competency-based trainings for union level service providers, and orientations for supervisors, village doctors, and pharmacy owners. Orientations will include identification, referral, and follow-up of newborn sepsis cases. In addition, MaMoni HSS is providing logistics support for this initiative including injection of Gentamycin, Amoxicillin drops, and insulin syringes. The field level implementation is planned to start next quarter. MaMoni HSS Project’s Partner NGOs have been selected and new staff have been recruited.

In addition, an operations research study is planned, in partnership with Johns Hopkins University, to assess the feasibility of the implementation of the newborn sepsis management in one upazilla of Lakshmipur district.

MaMoni HSS – Year Two Third Quarterly Report July 2015 79 Annex 9: Summary of Behavior Change Communication materials produced during the quarter

Audience Total # of District BCC activities Audiences Messages Channel size/ materials name(s) coverage

Mothers, Distributed Poster for Safe Importance of Families, through civil All service All 64 Motherhood Safe 30,000 Community surgeon at all recipients districts Day 2015 Motherhood members districts

Preventing PPH by using misoprostol Pregnant Pregnant Flip chart on covering basics Display & women & 2,200 mothers & All districts misoprostol of use and Counseling Community community management after use, if needed Booklet and Pregnant Delivery Pregnant Flipsheet on Display and 65,000 Women and preparedness mothers & All districts newborn Counseling each Families and ENC community messages Habiganj, Roman Banner FP options All Noakhali, Community Display 600 on FP Messages (Tiahrt) community Lakshmipur, Jhalokathi

MaMoni HSS – Year Two Third Quarterly Report July 2015 80

Annex 10: Stakeholder consultation meeting on strengthening Union Health & Family Planning Centers - UH&FWCs to increase SBA Coverage

The MCH Services Unit, Director General of Family Planning organized stakeholders meeting on strengthening UH&FWCs to increase SBA coverage, with support from USAID funded MaMoni Health Systems Strengthening project. The meeting was held on May 13, 2015 at Spectra Convention Center, Gulshan, Dhaka.

Mr. Syed Monjurul Islam, Hon’ble Secretary, Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh was the Chief Guest and Md. Nur Hossain Talukder, Director General, DGFP, MOHFW chaired the program.

Dr. Mohammed Sharif Director, MCH Services and Line Director (MCR-AH), DGFP, MOHFW welcome the participants and describe the objectives of the meeting and the program of Strengthening UH&FWCs to increase SBA Coverage in his presentation.

Joby George, Chief of Party, MaMoni HSS, Save the Children presented on overview and background to increase coverage of Skilled Attendance at Birth through strengthening UH&FWCs and also share the experiences of MaMoni in Habiganj district. The USAID funded MaMoni Health Systems Strengthening project prioritized the strengthening of the government owned UH&FWCs in four under-served unions of Habiganj in Sylhet Division to provide normal delivery care services 24 hours a day, seven days a week. Since 2012, the project supported physical renovation of the facility, including residence for the staff; deployed midwifery-trained paramedics on temporary basis; expanded the outreach of antenatal care services through well planned satellite clinics; established community-managed referral networks; applied clinical standards-based quality improvement initiatives; mobilized the support and oversight of local government institutions; and mobilized community groups and volunteers to generate awareness and increase demand for the services provided at the UH&FWCs. In the 2014, utilization data from these areas showed very rapid increase in the utilization of maternal and newborn care services. Antenatal care by medically trained providers is 84% and 4+ ANC from any medically trained provider is 55%. As per the routine MIS data reported, 85% of deliveries in these unions were conducted by skilled birth attendants. The UH&FWCs alone conducted 58% of the total deliveries in these unions. Based on this experience, MaMoni HSS has further expanded this intervention more underserved areas in

MaMoni HSS – Year Two Third Quarterly Report July 2015 81 Noakhali, Lakhsmipur and Jhalokathi districts. In these districts, MaMoni HSS now supports 41 UH&FWCs to provide round-the-clock delivery care services.

Dr. Ishtiaq Mannan, Director, Health, Nutrition & HIV/AID, Save the Children highlighted the efforts of the MaMoni HSS to strengthen the health systems of the government. Achieving 85% coverage for skilled birth attendants in rural areas of Bangladesh is not an impossible dream, as demonstrated by the experience of MaMoni. If Bangladesh has the will to improve the survival of mothers and newborns, we can achieve the goal of 50 percent SBA deliveries by 2016. Alyson P. Bear, Deputy Director, OPHNE, USAID mentioned that USAID is proud to be part of this initiative will be pleased to continue its support in scaling up this experience throughout the country with the Ministry of Health and family Welfare.

Mr. Syed Monjurul Islam, Hon’ble Secretary, Ministry of Health and Family welfare, Government of the People’s Republic of Bangladesh in his speech expressed that there are lots of achievement in the health sector of Bangladesh. Bangladesh is on course to become a middle income country by 2020. As a middle income country, we cannot see that 63% deliveries are taking place at home. Availability of SBAs is a single factor that can contribute immensely to reduce maternal and neonatal mortality and morbidity. Md. Nur Hossain Talukder, Director General, DGFP chaired the program. He reinforced the need to strengthen the all the UH&FWCs in the country to rapidly increase the coverage of SBA. He also invited other partners to come forward and support the initiative taken by DGFP.

Mr. A K M Zafar Ullah Khan, Sr. Policy Advisor, Population Council and Dr. Ikhtiaruddin Khandaker , Health Advisor, Plan International, Bangladesh also presented their experiences of strengthening the UH&FWCs. Several recommendations were made by the participants on the way forward.

MaMoni HSS – Year Two Third Quarterly Report July 2015 82 MaMoni HSS – Year Two Third Quarterly Report July 2015 83 Annex 11: Summary of pending activities of Year 2 workplan (Quarter 4)

IR/Sub- Major activities and Current status and reasons Plan for completion Responsibility IR deliverables pending as per for delay Workplan 1.2 Involvement of NGOs, private The initial focus of the A national scale up planning Joby sector, social marketing national roll-out plan has meeting scheduled for programs in national scale up been on the public sector so September. This will be of 7.1% chlorhexidine far. Informal discussions with organized by MOHFW with other partners initiated. support from MaMoni HSS and SNL. Another meeting of USAID implementing partners on CHX implementation scheduled for September. 1.2 Support the establishment of KMC has been introduced as Plan to start with two KMC Sabbir Ahmed six KMC units in Habiganj and part of the CNCP training for units at Lakhsmipur DH and Lakhsmipur districts. district and upazila level Habiganj MCWC in September, service providers in four with support from BSMMU. districts. However, Draft training materials will be preparation of facility and used for training. RRQIT to further follow up needed to monitor quality of start KMC services. implementation. Additional training will also be required. The NTWC has As per national consensus KMC not finalized the national will not be introduced at training manual and UH&FWCs in the first phase. materials yet. 1.2 Pilot implementation of the After consultations with Newborn sepsis management Sanjida Alam newly recommended NTWC, it was agreed to by SACMOs at union level, as simplified antibiotic regimen introduce this intervention in per the revised guidelines, will in two upazilas of Habiganj, 10 upazilas – all of Habiganj start in 10 upazilas in

MaMoni HSS – Year Two Third Quarterly Report July 2015 84 which will be followed by and one upazila each in September. The providers will scale up in the whole district. Noakhali and Lakhsmipur. be oriented on record keeping The CNCP training has been and the supply of drugs will be completed. All preparatory ensured. activities completed. 1.2 Use of antenatal The national training BSMMU will complete the Mostaque corticosteroids to be manuals have not been training of district level Ahmed institutionalized in district finalized yet. But, the district providers on ACS. Record- level facilities, in line with the level providers (consultants) keeping and reporting systems recommendations of NTWC, in are already providing ACS. to be established to monitor Habiganj, Lakhsmipur, and the implementation. RRQIT to Jhalokathi districts review the quality of implementation. 1.2 Establish SCANU in Renovation work for SCANU The renovation work for Sabbir Ahmed Lakhsmipur and support the in Lp delayed. MOH&FW, SCANU in Lp will start in SCANU functioning in with SDF support, in the September. Contract already Noakhali and Habiganj. process of establishing finalized. Training of staff for SCANU in Hg and Nk. SCANU in Nk and Hg completed. Project will follow up with DGHS to start the SCANU in Hg and Nk. 1.2 Establish a SAM/MAM The training of upazila level The project will follow up with Mamun demonstration model in one providers on SAM/MAM IPHN to ensure the supply of F- Bhuiyan upazila of Habiganj, including completed in Madhabpur. 75/F-100 and to improve the a district level referral facility Unicef is supporting SAM at GMP and referral from CC and for the management of SAM DH. Case management at UHC UH&FWCs. Follow to improve at and functioning of IMCI record keeping and reporting and Nutrition corners not on nutrition interventions. The started yet. model will be functional by September. 3.1 UH&FWC strengthening plan The assessment has been Divisional level consultation Selina Amin to be developed for all 4,000 completed in three divisions. and planning to be completed UH&FWCs Development of national in Sylhet and Barisal divisions.

MaMoni HSS – Year Two Third Quarterly Report July 2015 85 master plan requires Analysis and categorization of divisional and national level Chittagong will also be consultations and planning. completed. The assessment in the remaining four divisions and planning and consultations will have to be moved to year 3. 1.2 Eclampsia and Pre-eclampsia The NTC has recommended The TRAction study findings Jebunnesa management: National level implementation of PE/E will be disseminated in first Rahman. sharing of the results from management at union level week of October. ORs conducted by MaMoni facilities and not at In year 2, the PE/E with TRAction and by community levels. The management in all district level Population Council to inform guidelines and training facilities will be ensured. the policy guidelines; materials need to be modified The implementation at union community based PE/E before starting level will start in one upazila of prevention and management implementation. Jhalokathi by September. protocol scaled up in 1 district 1.3 Facility renovations: USAID approval for the Finalize the contract for 12 Afsana Karim renovation of 13 UH&FWCs UH&FWCs and DH by early and Lakhsmipur DH, September. The renovation including SCANU, obtained. work will continue into year 3. The competitive selection All minor renovation work are process for contractors expected to be completed by initiated. December. The renovation plan for of one of the UH&FWCs (Char Falcon, LP) withheld as HED is currently undertaking some renovation work. 1.3 Upgrade a cumulative total of As of August 55 UH&FWCs Additional 17 facilities will Afsana Karim 69 UH&FWCs to provide 24/7 are providing 24/7 services start providing 24/7 services delivery care services in the 23 HI upazilas. In by the end of September. The addition, 6 UH&FWCs are total by the end of Year 2 will

MaMoni HSS – Year Two Third Quarterly Report July 2015 86 conducting 24/7 deliveries in be 72 the HSCS areas, making the total to 55 3.1 Support MOH&FW in Human Continuous dialogue with The project will coordinate Joby Resources for Health: (i)- MOH&FW and other with WHO and other DPs to support to MOH&FW with development partners to finalize the areas for providing national level HRIS identify the areas for project TA in Year 3. Also, participate development, (ii) national support. As per the advice in Strategic Thematic Group for master plan for recruitment from the mission, the HRH to inform the fourth and deployment of doctors, project’s involvement in sector plan priorities in HRH. nurses and midwives; (iii) these areas has been delayed. Revised national HRH strategic plan. 2.4 Comprehensive quality JSV roll out completed. Start RRQIT in Barisal. Finalize Youssef Tawfik improvement initiatives: (i) RRQIT has been established the tools and checklists for roll out JSV in all HI areas, (ii) in Sylhet, visits scheduled for RRQIT. It has been agreed that establish and support RRQIT September. Preparatory the project will switch over to a in three divisions, (iii) Scale work for RRQIT in Chittagong comprehensive QI approach up SBM-R to 16 new facilities, and Barisal divisions that involves all facilities, in addition to supporting the completed. following a step-by-step 34 existing, (iv) introduce The QI approach has been approach. SBM-R will not be MPDR in Noakhali and revised to include a more further scaled-up, rather the Lakhsmipur comprehensive and step-by new QI model will be initiated step approach. in all facilities by September.

MPDR implementation started in Noakhali. Further expansion will be done in Y3, along with the new QI model. 1.4 Finalize Maternal Health The MH strategy and SOPs Facilitate final review and Jebunnesa Strategy and MNH-SOPs and have been finalized with the approval process with DGHS Rehman support dissemination at involvement of all and MOHFW. Final approval national and divisional levels. stakeholders. The documents expected in September.

MaMoni HSS – Year Two Third Quarterly Report July 2015 87 are pending approval of Preparations for MOH&FW. Currently with dissemination, such as DGHS. printing, will be completed in September. 2.3 Roll out the pilot Pilot implementation started PRS will be completed in all Selina Amin implementation of the new with the population unions of Madhabpur by mid- automated RHIS in one registration system in October. The printing and upazila, including a pilot on Madhabpur. The automated distribution of Health IDs will the use of digital registers for modules for community and begin in September. The first of FWA and FWV; national level union level providers and the community and union level support to plan for rolling out supervisors being developed modules will be deployed by the automated RHIS by MaMoni HSS and icddr,b. end of September. The The RHIS development is a remaining modules will be joint effort and the design/ completed and deployed by Q2 development of the in Year 3 automated modules is a very time-taking process. 2.3 Roll out the revised MNH The new MNH registers Obtain approval from DGFP to Abrar registers and reporting tools rolled out in all MaMoni HSS introduce the revised reporting for DGFP in MaMoni HSS districts. forms. Initiate the roll out of districts The revised reporting forms new reporting tools in all are pending approval of MaMoni districts in September. DGFP. 2.1 Initiate a mentorship program Guidelines for mentoring A district level follow up Afsana Karim for district and upazila developed. Mentors meeting with managers managers on Leadership and identified and SOW scheduled in Noakhali to Management developed. Mentees introduce the mentorship identified in one district. program. The first interaction and planning discussions between mentor-mentee to be completed in September. 4.1 Operations research and Two of the proposed OR Three OR reports will be ready Imteaz Mannan program learning studies have been completed for dissemination by end of (with JHU)

MaMoni HSS – Year Two Third Quarterly Report July 2015 88 – use of partograph, viability September. of private CSBAs. The data collection for quality of LAPM A two-year process services is underway. documentation and program IRB approval process is un learning plan to be developed progress for the following with support from JHU in studies: September.

New Operations Research on A prospective country case management of NN sepsis at study on CHX national scale up union level, in collaboration to start in September. with JHU/IIP, started in Lakhsmipur 4.1 Implementation of automated, All MIS modules deployed Full implementation of the Imteaz Mannan online project MIS and data entry completed. automated MIS and switch- Analysis interface under over from the Excel-based development. Data entry to reporting to the new system clear the backlog from Y1 and from October y2 in progress.

MaMoni HSS – Year Two Third Quarterly Report July 2015 89