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SEXUAL AND REPRODUCTIVE HEALTH FOR ALL INITIATIVE (SARAI) AID-611-A-15-00001

APRIL TO JUNE 2019 QUARTERLY REPORT

SOCIETY FOR FAMILY HEALTH

In partnership with Population Services International Development Aid from People to People ChildFund International

Activity Summary

Implementing Party Society for Family Health

Sub Awardees Development of Aid from People to People (DAPP) Population Services International (PSI) ChildFund International Activity Name Sexual and Reproductive Health for All Initiative (SARAI) AID-611- A- 15-00001

Project Period 20th April 2015 to 19th April 2020

Total estimated Amount $15,250,000

Objective To provi de support for a program in In t e g r a t e d F a m i l y Planning and Reproductive Health Project Sites P r o v i n c e : , , Kalulushi, , , : Mpika, Mafinga, Shiwang’andu, Nakonde, Lavushi Manda, Kanchibiya : Mansa, Chienge, Lunga, Nchelenge, Kawambwa Gina M. Smith, Acting Country Representative/Chief of Party-SARAI Society for Family Health Plot 549 Ituna Road, Ridgeway Report Submitted by: P O Box 50770, Tel: +260 21 125 7407 Email: [email protected]

August 2019 This report was produced for review to the United States Agency for International Development It was prepared by SFH for the Sexual and Reproductive Health for All Initiative Project. Table of Contents

ACRONYMS ...... 5

1. INTRODUCTION ...... 7

2. OPERATIONAL ACTIVITIES ...... 7

3. FAMILY PLANNING SERVICE DELIVERY IMPROVED ...... 9 3.1. Improved Method Mix through Enhanced Community Based and Facility Service Delivery Models for Family Planning ...... 10 3.2. Enhanced FP/HIV Integrated ...... 20

4. USE OF HEALTHY FAMILY PLANNING AND REPRODUCTIVE HEALTH PRACTICES INCREASED ..... 21 4.1. Revise FP messaging with a focus on youth engagement...... 21

5. FAMILY PLANNING SERVICE DELIVERY SYSTEMS AND ACCOUNTABILITY STRENGTHENED...... 25 5.1. Strengthen Quality of FP Service Delivery ...... 25 5.2. Strengthened use of data for decision making ...... 29

6. PROJECT INDICATOR TRACKING ...... 30

7. CHALLENGES / MITIGATION ...... 31

8. CONCLUSION ...... 32

LIST OF TABLES Table 1: Off-Duty services provided by province ...... 12 Table 2: FP Contribution of SARAI Supported vs. Non-Supported Health Facilities ...... 13 Table 3: Number of clients who received FP services from CBDs by age and type of method ...... 16 Table 4: Number of clients switching FP method by Province ...... 17 Table 5: Number of referrals by FP method and by province ...... 18 Table 6: Number of clients referred for FP services by age group and by method ...... 19 Table 7: FP integration indicators ...... 21 Table 8: Indicator Tracking Table ...... 30

LIST OF FIGURES Figure 1: District DHIS2 reporting rates by month and by quarter ...... 9 Figure 2: Distribution of new FP acceptors ...... 10 Figure 3: Distribution of FP commodities by quarter ...... 11 Figure 4: Distribution of FP commodities by Province ...... 11 Figure 6: CBD FP distribution by method and by province ...... 15 Figure 7: Total condoms distributed by province ...... 17 Figure 8: Comparison of CBDs reporting stock-Outs by method and province ...... 17

3 Figure 9: Comparison of complete referrals by Province for Qt1 and 2 of 2019 ...... 19 Figure 10: Clients reached with SRH messages by FP Champions ...... 24 Figure 11: Number of facilities adhering to quality standards ...... 25 Figure 12: Number of Facilities Reporting Stock out by Commodity ...... 27 Figure 13: Total Number of Days Facilities Reporting Stock Out by FP Commodity ...... 27 Figure 14: Number of facilities conforming to waste management standards by province ...... 28 Figure 15: Number of facilities adhering to providing quality community FP services by province ...... 29

4 ACRONYMS AE Adverse Event CBD Community Based Distributor CSE Comprehensive Sexuality Education DAPP Development Aid from People to People DMPA SC Depo Provera Subcutaneous DHO District Health Office DQA Data Quality Assessment eMTCT Elimination of Mother to Child Transmission FP Family Planning FY Financial year HIA2 Health Information Aggregation 2 HCW Health Care Worker HCD Human Centered Design HMIS Health Management Information System HIV Human Immunodeficiency Virus HTS HIV Testing Services IGA Income Generating Activity IPC Interpersonal Communication IUCD Intra Uterine Contraceptive Device LARC Long Acting Reversible Contraceptives mCPR Modern Contraceptive Prevalence Rate M&E Monitoring and Evaluation MOGE Ministry of General Education MOH Ministry of Health OVC Orphans and Vulnerable Children PNO Principal Nursing Officer PPE Personal Protective Equipment PSI Population Services International QA Quality Assurance RH Reproductive Health SARAI Sexual and Reproductive Health for All Initiative SBC Social Behavior Change SIMS Site Improvement through Monitoring Systems SFH Society for Family Health 5 SRH&R Sexual, Reproductive Health and Rights USAID United States Agency for International Development VMMC Voluntary Medical Male Circumcision YFHS Youth Friendly Health Services

DISCLAIMER: The author’s views expressed in this report do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government.

6 1. INTRODUCTION The Sexual and Reproductive Health for All Initiative (SARAI) is a 5-year USAID funded project running for the period 2015-2020 with a project budget of USD 15,250,000. It is working with the Ministry of Health (MOH), Development Aid from People to People (DAPP), ChildFund and Population Services International (PSI). SARAI operates in 17 districts with a total of 173 health facilities across Copperbelt, Muchinga and Luapula Provinces. The main objective of the project is to increase the modern Contraceptive Prevalence Rate (mCPR) by 2% annually through increased access to and improved quality of FP/RH services. This is envisioned to be achieved through: (i) improving Family Planning (FP) service delivery (ii) strengthening accountability of FP service delivery systems (iii) increasing healthy FP and Reproductive Health (RH) practices Additional emphasis is being placed on strengthening FP/RH services for adolescents and other vulnerable populations, including young mothers and orphans and vulnerable children (OVC).

The 2019 quarter two report gives an account of the SARAI project activities conducted from 1st April to 30th June, 2019 by SFH and its sub awardees across all project areas. As per award agreement, this report focusses on the seven quarterly indicators as specified in the SARAI monitoring and evaluation plan related to facility-based FP service provision, community-based service provision, Family Planning (FP) and Human Immunodeficiency Virus (HIV) integration and quality assurance.

2. OPERATIONAL ACTIVITIES

During second quarter of 2019 SFH head office through the Internal Audit Manager and Grants and Contract Accountant conducted a sub-awardee compliance visit to DAPP in Ndola in April 2019 for the period January to March 2019. Amongst the findings were falsification of travel expenses and excess per diem and meal allowances claimed. SFH is yet to conclude the full investigation, however, USAID has been informed and will be continually updated. Following DAPP’s disciplinary process, some project staff have been suspended pending further investigation into the misconduct. The final report will be submitted in the third quarter of 2019.

The Technical Services Manager, Senior Quality Control Officer and Senior Monitoring and Evaluation Officer conducted a Data Quality Assessment (DQA) and Technical Supportive Supervision (TSS) to Copperbelt region in May 2019. This exercise was implemented both at SFH and Sub-awardee (DAPP) 7 region offices. Also, field visits to 5 facilities randomly selected were made. The specific objectives of the visit included assessment of the project compliance level at district and facility level, monitoring of infection prevention and control, verification of the availability of family planning protocols and assessment of data quality by Community Based Distributors (CBDs). Findings included incomplete updating of facility registers with CBD data, non-display of FP protocols, performance graphs and IEC materials due to renovations at the facilities; integrated family planning registers were available in all facilities, missing CBD reports at DAPP region office, incomplete compliance courses by partners, and stock out of Jadelle. The Copperbelt Province team committed to rectify anomalies by the next submission of monthly report.

The USAID Agreement Officer Representative/Family Planning Advisor conducted an FP compliance visit to Luapula Province in June 2019. She was accompanied by the USAID Senior Technical Advisor for Luapula and the SARAI Technical Services Manager. The main objective of the visit was to monitor project implementation and assess compliance with USAID requirements. The team paid courtesy calls to the provincial and district health offices for Mansa, Kawambwa and Nchelenge. During courtesy calls the FP Advisor emphasised the compliance requirement that USAID does not allow setting of provider FP targets. She also mentioned that the team was interested in understanding how the Result Based Financing (RBF) was being implemented in the districts especially the SARAI supported facilities where it was mentioned targets were potentially being used. The team assessed seven facilities in the three districts. At PHO the Public Health Specialist clarified on the issue of target setting that the province does not give targets to either providers or facilities as he had been misunderstood when previously explaining the low performance of family planning uptake in the province. The three District Health Directors explained in detail how the RBF project was being implemented. They said the RBF project awarded facilities according to their performance in different thematic areas based on seven (7) specific indicators (institutional deliveries by skilled birth attendants, antenatal visits within 14weeks, postnatal visits within 48hrs, fully immunized children below 1year, new family planning acceptors, HIV positive women initiated on ART, and growth monitoring of the under five children). The FP indicator is based on catchment population of women of child bearing age.

During the quarter under review and in line with the National Implementation Plan for depot medroxyprogesterone acetate (DMPA) which calls for the piloting of self-injection as a service delivery channel SFH requested the Zambian MOH to consider moving forward with a progressive roll-out of self- injection of DMPA-SC within a broad range of voluntary FP methods. Through the proposed activities as agreed by the FP TWG in April 2019, SFH Zambia would contribute to the national scale-up plan by

8 leveraging existing programmatic infrastructure through SARAI. Review of training materials and planning is scheduled to take place in July.

The SARAI team continued to participate in the National and Provincial FP TWGs in order to share and learn best practices and influence policy for FP services.

It is important to note the period coincided with SFH staff changes including the end of employment of the Executive Director, Dr. Namwinga Chintu who will be in turn temporarily by Gina Smith as the Acting Country Representative. The Senior Research, Monitoring and Evaluation Officer and Muchinga Integration Officer positions are vacant and will be replaced using a competitive recruitment process.

3. FAMILY PLANNING SERVICE DELIVERY IMPROVED SARAI directly provides support to 173 out of 414 facilities in 17 supported districts across Copperbelt (6), Luapula (5) and Muchinga (6) Provinces. The increase in facilities is as a result of SARAI having scaled up to 30 more facilities towards the end of second quarter and opening up of new health facilities and posts. SARAI uses project and MoH DHIS2 district wide data to measure progress towards achievement of set targets in the M&E Plan. During the reporting period, MoH DHIS2 facility service delivery reporting rate was on average at 99% in all SARAI supported districts. The figure below shows DHIS2 reporting rates:

Figure 1: District DHIS2 reporting rates by month and by quarter

100% 100% 100% 99% 99% 99% 99% 99% 99% 98% 98% 98%

Copperbelt Muchinga Luapula Average

Apr May Jun Overall Jan - Mar 2019 Apr -Jun 2019

Source: MOH DHIS2 district data

Comparing to the previous quarter, the reporting rate increased by 1%. This translates into a margin of 4% higher than the project target of 95%. The reporting rates have remained above target as a result of an

9 effective collaboration between project M&E staff and MoH officers in ensuring that data from facilities is compiled and reported timely despite the National HMIS being suspending during the quarter for upgrades. .

3.1. Improved Method Mix through Enhanced Community Based and Facility Service Delivery Models for Family Planning Progress towards the Number of Women of Reproductive Age Who Receive FP Methods: According to data obtained from DHIS2, 161,638 FP related visits were made by clients during the reporting period. Among the those seeking FP service, 40,607 were new acceptors while 117,334 were repeat visitors. Compared to the previous quarter, there was a 9% increase of new FP acceptors during this quarter. This was due to enhanced coordination for client mobilization between facility outreach teams and CBDs. Figure 2 below shows the distribution of new FP acceptors by quarter.

Figure 2: Distribution of new FP acceptors

Q2 2019 44,304 Q1 2019 40,607

Source: MOH DHIS2 district data, mCPR calculator

Distribution of FP commodities by quarter: Various FP commodities were distributed both at facility and community level in SARAI implementing districts. The figure below shows the distribution of FP commodities in comparison to last quarter.

10 Figure 3: Distribution of FP commodities by quarter

Jan - Mar 2019 Apr - Jun 2019

Sterilisation - male 7 7

Male condoms distributed 961,375 1,743,738

Sterilisation female 78 205

Oral pill cycle 37,318 34,558

Progesterone only pill 18,783 17,070

Norethisterone enanthate injection 13,698 10,289

Medroxyprogesterone injection 83,077 82,986

IUCD inserted 1,078 2,981

Implant 10,911 14,719

Female condoms distributed 27,900 22,399

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Source: MoH DHIS2

Comparing to the previous quarter performance the following trends were observed: • There was a noticeable positive increase in female sterilization and LARCs, this mostly resulted from enhanced utilization of CBDs to mobilize FP clients prior to outreach sessions in Luapula and Copperbelt provinces. The project also collaborated with Marie Stopes International (MSI) in provision of female sterilization services. • Significant increase (81%) in male condoms distributed due to SARAI’s participation in the International Trade Fair and Agricultural and Commercial Show in Copperbelt and Muchinga Provinces respectively. The chart below shows distribution of FP methods in SARAI supported provinces.

Figure 4: Distribution of FP commodities by Province

11 Copperbelt Luapula Muchinga

Sterilisation - male 5 2 Male condoms distributed 1,281,119 263,650 198,969 Sterilisation female 25 166 14 Oral pill cycle 23,266 4,879 6,413 Progesterone only pill 10,161 3,056 3,853 Norethisterone enanthate injection 5,702 2,830 1,757 Medroxyprogesterone injection 46,873 26,426 9,687 IUCD inserted 802 2,003 176 Implant 7,290 5,040 2,389 Female condoms distributed 10,919 8,203 3,277

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Source: MoH DHIS2

The strengthened referral system for FP clients and availability of commodities in Luapula Province produced a positive impact as can be noticed from their large contribution to IUCD insertions and female sterilisation. Copperbelt and Muchinga Provinces recorded a drop in LARCs because of stock out of these methods. Efforts were made by project staff to continue building capacity in supply chain management at district and facility level.

3.1.1. Dedicated and Off-Duty Provider Model Implemented Besides the use of Community Based Distributors and routine facility-based FP service provision, SARAI also uses the off-duty provider model to provide, where possible, additional support to minimize intermissions in provision of FP services as well as support the provision of LARCs. The off-duty model was used in 86 high volume facilities. The table below shows the performance of the off-duty model.

Table 1: Off-Duty services provided by province

Off-duty FP provision Copperbelt Luapula Muchinga Total Number of Facilities 53 14 19 86 Number of off-duty providers 100 58 28 186 Number of off-duty shifts 517 431 133 1,081 Number of clients seen 10,561 4,270 1,643 16,474 Source: Project data (Client intake forms)

12 During the reporting period, 16,474 clients were seen by off-duty Providers representing an increase of 24% from last quarter. The increase was largely attributed to the increased number of outreach sessions in most facilities as well increased number dedicated Off-duty Providers who worked on high turn-out days. Compared to other provinces, Copperbelt had a higher increase following the continued engagement of seasoned Off-duty Providers to conduct peer to peer mentorship in targeted high-volume facilities. Muchinga and Luapula provinces also recorded some increase attributed to more outreach sessions conducted during the same period.

3.1.2. Contribution of SARAI supported facilities to district wide FP methods distribution During this reporting period, the project directly supported 173 facilities out of 414 facilities across 17 implementing districts. SARAI supported facilities have a total catchment area population of 575,309 WRA representing 76% WRA of SARAI implementing districts. The table below shows the proportional contribution of directly supported facilities to overall performance.

Table 2: FP Contribution of SARAI Supported vs. Non-Supported Health Facilities

SARAI SARAI & % SARAI FP Method Supported Non-SARAI Contribution Female condoms distributed 17,929 22,399 80% Implant 11,099 14,719 75% IUCD inserted 2,481 2,981 83% Medroxyprogesterone injection 61,496 82,986 74% Norethisterone enanthate injection 6,865 10,289 67% Progesterone only pill 12,760 17,070 75% Oral pill cycle 26,257 34,558 76% Sterilisation - female 170 205 83% Male condoms distributed 1,486,628 1,743,738 85% Sterilisation - male 7 7 100% Source: MOH DHIS2 district data

Generally, SARAI supported facilities contributed significantly 76% or more in 6 out of 10 FP methods including LARCs, female condoms and permanent methods. This was attributed to improved FP messaging, referral of more clients to facilities by CBDs, engagement of off-duty providers and participation in national and traditional events.

13

3.1.3. Community Based FP Service Provision

Monitoring and Supervision of CBDs: The project actively worked with 820 of the 855 trained CBDs in 143 facilities as those in the 30 scale up facilities are gradually being deployed in the community as and when they gain competency, therefore, their data will be included in the next reporting period. These CBDs provided FP services with emphasis on the importance of FP accessibility and improved quality of service. Mentorship and monitoring of CBDs was done to ensure that CBDs submitted timely reports on monthly basis and that the data was also recorded correctly in the health facility integrated FP registers. Luapula province replaced 10 CBDs who were trained in this reporting period while the other two provinces will be replacing those who dropped in quarter three of 2019. The proportion of trained CBDs actively reporting has remained at 96% from last quarter.

Table 3: Total trained and active CBDs by province

Copperbelt Luapula Muchinga Total Trained CBDs 386 264 205 855 Active CBDs 368 255 197 820 Retention rate 95% 97% 96% 96%

Figure 5: Total active CBD by province

197; 24%

368; 45%

255; 31%

Copperbelt Luapula Muchinga

The project is in the process of replacing a portion of CBDs specifically those that have been inactive for a long time and the deceased.

Monitoring and supervising of CBDs in communities has continued in order to assess the quality of services

14 offered and their competence in FP service delivery. In order to adhere to MoH guidelines and standard operating procedures and requirements, CBDs were supervised in all SARAI supported health facilities and supervisor check list tools were used to ensure that all steps followed in counseling were followed and that CBDs were competent to deliver quality health services.

During supervision sessions, it was observed that CBDs continued to provide FP services in accordance with MoH guidelines and procedures. CBDs were using FP messaging tools, FP counselling tools and FP counselling flow charts correctly during service delivery.

CBD supervisors continued ensuring that CBD monthly meetings were held in all 143 health facilities to ensure CBDs submit their monthly reports, that data is transferred in the integrated FP registers at health facilities as well as consolidating and filing reports. Major challenges identified were stock-outs of condoms, DMPA-IM, pills, and waste disposal bags. The other challenge was frequent transfer of trained CBD supervisors. In order to mitigate these challenges, the project worked with Ministry of Health structures and facilitated for redistribution of stocked out commodities.

Figure 5: CBD FP distribution by method and by province

Injectable Injectable Female Pill Male Condom Totals DMPA-IM DMPA-SC Condom Copperbelt 18,110 1,404 5,261 11,677 619 37,071 Luapula 8,183 676 1,507 12,010 820 23,196 Muchinga 4,193 710 1,902 5,382 224 12,411 Totals 30,486 2,790 8,670 29,069 1,663 72,678

Copperbelt reached a total of 37,077 clients compared to 35,383 reached in the previous quarter showing an increase of 5% while Luapula and Muchinga provinces recorded a slight reduction in terms of the number of clients who accessed services from CBDs owing to frequent stock out of FP commodities.

15 Table 3: Number of clients who received FP services from CBDs by age and type of method

Age Group Total Type of contraceptive 10-14yrs 15-19yrs 20-24yrs 25-49yrs 49

In comparison to the last quarter, DMPA IM remains the most distributed method and female condoms the least.

Client Switching Behavior: The project continued monitoring clients’ switching behavior by tracking the number of clients that switched from one contraceptive to another. During this reporting period, 495 clients switched compared to 1,155 reported last quarter. A total of 317 clients switched from Injectable DMPA IM to DMPA SC compared to 796 clients in quarter one, 85 clients switched from Injectable DMPA SC to Injectable DMPA IM compared to 185 clients who made a similar switch during the last quarter;71 clients switched from pill to Injectable DMPA SC while during quarter one, 161 clients were reported to have made a similar switch. Other clients who switched methods included those who opted to receive injectable DMPA SC after having IUD removals. It is likely that Muchinga experienced higher than expected switching likely due to FP commodity stockouts.

16 Table 4: Number of clients switching FP method by Province

Switching from Switching to Copperbelt Luapula Muchinga Total Injectable DMPA IM Injectable DMPA SC 9 50 258 317 Injectable DMPA SC Injectable DMPA IM 5 0 80 85 Pill Injectable DMPA SC 5 19 47 71 IUD Injectable DMPA SC 0 0 6 6 Male Condom Injectable DMPA SC 0 0 2 2 Female Condom Injectable DMPA SC 0 0 0 0

Condom distribution by province: In order to encourage the dual protection, the project distributed a total of 486,939 condoms (473,754 male condoms and 13,185 female condoms). Comparing the distribution for quarter one and quarter two of 2019, there is an increase of 3% due to consistent availability of the product.

Figure 6: Total condoms distributed by province 173,007 182,891 117,856

3,319 8,190 1,676

Copperbelt Luapula Muchinga Male Condoms Female Condoms

CBD family planning commodity supply at supported health facilities: During this reporting period, the project-supported facilities continued to experience stock outs of different FP commodities. Out of the 820 active CBDs, 62% reported stock outs in female condoms, 40% in male condoms, 35% in pill, 12% in injectable Depo and 19% in Syringes. The stock out was mainly attributed to some lapses in the commodity supply chain such as late delivery by Medical Stores Limited (MSL). In order to address stock out of the commodities, the project worked with Global Health Supply Chain Procurement and Supply Management (PSM) and provincial and district pharmacists to build capacity the supply system.

Figure 7:CBDs reporting stockouts by method and province

17 250 236

200 145 134 142 150 124 106 94 100 90 61 70 49 45 50 25 28 23

0 Female Condoms Male Condoms Pills Injectable Depo- Syringes Provera Copperbelt Luapula Muchinga

Referral system established for CBDs to link clients for LARC and other services: There was an increase in the number of clients referred by CBDs to health facilities. Referrals for Implants increased by 10%, IUDs by 54%, sterilization by 250% and referrals for other services by 19%. Luapula province recorded more referrals (2,606) compared to Copperbelt province (1,748) and Muchinga province (913). This was attributed to increased involvement of CBDs to mobilize clients prior to outreach activities. The table below shows referrals made by province and by FP type in comparison with quarter one of 2019:

Table 5: Number of referrals by FP method and by province

Referred for Province Injectable Implant IUCD Sterilization Sub-Totals Other Copperbelt 658 373 50 7 250 1,338 Luapula 1,751 484 16 5 131 2,387 Quarter 1 (2019) Muchinga 645 291 8 0 258 1,202 Totals 3,054 1,148 74 12 639 4,927 Referred for Province Injectable Implant IUD Sterilization Sub-Totals Other Copperbelt 940 360 31 14 403 1,748 Luapula 1,597 785 76 26 122 2,606 Quarter 2 (2019) Muchinga 518 122 7 2 264 913 Totals 3,055 1,267 114 42 789 5,267 Total % change from Q1 2019 0.03% 10% 54% 250% 23% 7%

Clients referred by age and by method: From the table below, the highest number of clients (2,315) referred were aged between 25 and 49 years with the lowest (20 clients) being between 10 and 14years.

18

Table 6: Number of clients referred for FP services by age group and by method

10-14yrs 15-19yrs 20-24yrs 25-49yrs >49yrs Injectable Depo 7 535 1,121 1,274 118 Implant 0 192 461 562 52 IUDs 0 7 37 66 4 Sterilization 0 0 0 41 1 Referred for others 13 113 228 372 63 Totals 20 847 1,847 2,315 238

Proportion of completed referrals: The referral system linked clients to facilities in order to be assessed for eligibility and administration of LARC. During this reporting period, the project recorded 5,267 referrals of which 3,937 were completed with feedback. This represented a total of 75% of referred clients who confirmed having accessed health services. In comparison to quarter one of 2019, this represented an increase of 1% of the total feedback forms completed. This was mainly due to consistent follow up on health facility staff by CBDs in Luapula and Muchinga. Copperbelt province had a reduction of 3% on this score due to transfer of staff who were conversant with the referral system. The project team has since began to orient all staff who were recently transferred to SARAI supported facilities.

Table 7: Referrals and Feedbacks by Province

Project Copperbelt Luapula Muchinga Overall Total Referred 1748 2,606 913 5,267 Number of Referral Feedbacks Received 983 2,278 676 3,937

Percentage of complete referrals 56% 87% 74% 75%

Figure 8: Comparison of complete referrals by Province for Qt1 and 2 of 2019

19 85% 87% 75% 69% 74% 74% 59% 56%

2% 5% 1% -3% Copperbelt Luapula Muchinga Project Overall

% of complete referrals Qt1 % of complete referrals Qt2 % Change Qt1 to Qt 2

3.2.Enhanced FP/HIV Integrated

3.2.1. Adolescents reached with age appropriate sexual education and linked to FP/RH Services Review meetings for guidance and counselling teachers in the SARAI project-supported schools: Implementation of Comprehensive Sexual Education (CSE) curriculum through in-school clubs was carried out in 505 schools. The guidance and counselling teachers and Peer Educators disseminated information on SRH&R to pupils. The in-school club reached out to 532 pupils. Below are pictures showing activities with in school youth clubs.

School health clubs and out-of-school youth clubs were supported to conduct FP/SRH awareness activities: SARAI worked with 165 out-of-school youth clubs in providing SRH&R key messaging on HIV/AIDS, early marriages and prevention of unwanted pregnancies among youths. A total of 10,386 adolescents were reached after conducting 438 sessions and distributed 61, 756 condoms to 4,156 clients.

Condom and IEC materials distributed by trained shop owners: The project worked with 472 shop owners who distributed 38,638 condoms to 2,954 people after conducting 237 education sessions.

Strengthening of Anti-AIDS clubs: Through the Anti-AIDS clubs, the project worked with trained guidance

20 and counselling teachers and matrons to reach out to 532 pupils with SRH&R information.

3.2.2. FP Integration Facilitated

During this reporting period, all 173 supported facilities offered integrated services. According to project data, the project facilitated testing of 18,160 women for HIV during static and outreach family planning services. Compared with the previous quarter, this reporting period recorded a 4% increase in number of women being tested for HIV. This slight positive gain is attributed to increase in the number of facilities which were assessed. Out of the total number tested, 64 tested positive (0.4%) and were linked to ART services. The underperformance of Luapula and Muchinga on clients receiving FP from ART is mainly due to unavailability of FP registers in ART service delivery points, however, referral of FP clients to MCH department were made appropriately.

The table below shows family planning integration indicators the project is tracking and performance recorded during period under review.

Table 7: FP integration indicators

Indicator Muchinga Luapula Copperbelt Total Number of integrated sites 39 49 85 173 Number of women receiving FP from ART 0 0 661 661 Number of women counselled for FP at VCT 1 385 9,177 9,563 Number of women counselled for HIV at FP 18,057 9,377 12,428 39,862 Number of women tested for HIV at FP 5,442 6,543 6,175 18,160 Number of women tested positive for HIV at FP 0 15 49 64

4. USE OF HEALTHY FAMILY PLANNING AND REPRODUCTIVE HEALTH PRACTICES INCREASED 4.1. Revise FP messaging with a focus on youth engagement

Community and individual awareness of FP developed: Family planning key messaging activities promotes the use of modern family planning methods in order to help clients make informed choices as well as creating demand for FP/SRH. During this reporting period, the project conducted 9,592 IEC sessions reaching 249, 474 people. Of those reached, 36% were males and 66% were below the age of 25. Comparing the current reporting period to the previous one, the project recorded a 2% reduction. This was attributed to less IEC

21 sessions due to crop harvesting activities which were taking place in most of the rural communities.

• International Trade Fair: During this reporting period, SARAI project in Copperbelt participated at the International Trade Fair where the project team gave out sexual and reproductive health information to people using CBDs. A total of 556 clients were reached and 15,000 condoms were distributed.

• Agriculture and Commercial Show: In Muchinga province, the project participated in the show in . A total number of 1,500 people were reached and 1,000 condoms were distributed and 145 FP clients..

The Luapula team participated in one traditional ceremony in where 1,107 FP clients received FP services.

Male Involvement in FP: The project continued involving males in FP/SRH awareness creation in the communities. During this reporting period, 525 males were reached during football matches, pool table games and church gatherings in Muchinga Province. Using similar channels, Copperbelt Province reached 71 males.

Adolescents engaged in FP service delivery: SARAI continued working with adolescents using the youth friendly spaces in public health facilities where sexual reproductive health services are provided. These spaces have enabled youths to share information, distribute condoms and refer their peers to CBDs and health facilities for other RH services.

The SARAI team conducted two adolescent wellness days and confidentiality pledge which were held at Twapia and Buchi Health Facilities in the Copperbelt reaching 268 adolescents. These were developed as a result of a user centred approach that used an interactive process to design solutions for adolescent boys and girls aged 15-19 in order to encourage adolescents’ participation in preventative health services. The design packages were designed by SFH and the Breakthrough Action project in collaboration with Ministry of Health (MOH) health promotion team. The health centres provided clinicians, nurses and counsellors to

22 offer services such as malaria screening, family planning, HIV testing, GBV counselling and nutrition. SFH integrated HIV self-testing into the adolescent wellness day. The provincial health promotions department and MCH district level staff were also present to show support as well as Breakthrough Action representatives. Below are details for each wellness day:

Buchi Clinic

Total Number HIV Self- Nutrition S/N IEC Attended the HTC F/P GBV Condoms Others Test Kits Assessment Event

1 153 153 26 12 2 7 153 100 6

F M F M F M F F M F M F M F M 153 75 78 14 12 7 5 2 1 6 75 78 39 61 4 2

Twapia Clinic

Total OPD/ Number Screening HIV Self- F/P F/P Nutrition Condoms S/N IEC Attended the i.e. Malaria, Test Kits IEC Provision Assessment Distributed Event STIs, BP

1 115 115 45 27 34 7 115 89

F M F M F M F M F M F M 115 34 58 57 27 18 19 8 7 0 58 57 10 79

In addition, PSI provided technical assistance for youth programing activities. It was planned that SFH SARAI team would conduct an insight gathering activities to be completed by August 2019. The design workshop would be organized in September 2019.

Adolescents reached with FP counselling using youth champions: Adult and youth family planning

23 champions conducted SRH messaging sessions and condom distribution. The project worked with 1,455 champions (439 youths and 1,016 adults) who conducted 1,520 sessions reaching to 24,616 adolescents and youths. The champions also distributed 62,241 condoms to 4,602 adolescents and youths. Below is the figure showing adolescents and youths reached by champions by province.

Figure 9: Clients reached with SRH messages by FP Champions

191 1,323 1,698 2,105 2,189

963 Muchinga 3,001 3,161 2,405 2,058 Luapula Copperbelt 2,313 1,632 2,145 366 586 10-14Yrs 15-19Yrs 20-24yrs >24 Sessions

Awareness of FP/HIV developed among OVCs (OVC_SERV PEPFAR Indicator): This indicator is captured in Copperbelt Province. The project provides information on SRH&R to the Orphans and Vulnerable Children (OVCs) through in and out of School Youth Clubs, door-to-door campaigns, peer to peer interaction, community meetings, youth friendly spaces and road shows. In addition, SARAI trained CBDs to enroll and screen OVCs in Non-ZAMFAM catchment areas. During this reporting period, the project reached 7,387 OVCs representing 108% progress made against an annual target of 6,829.

OVC HIV status and services: The target population are OVCs aged between 10 and 18 years. The indicator tracks self-reporting of HIV status of OVCs including reports of no status. During this reporting period, SARAI CBDs reached a total of 2,169 adolescent girls. Out of a total of the OVCs reached, 63 (0.03%) were HIV positive OVCs. Of the 63 who tested positive, 58 (92%) reported being on care and treatment. However, 17 did not disclose their HIV status for various reasons.

Priority Population Prevention (PP_Prev): A total of 40,481 Adolescent Girls and Young Women (AGYW) were reached against an annual target of 5,637. Activities conducted included community meetings, one-on- one sessions and drama performances targeting AGYW aged 10-24 through use of CBDs, youth champions, peer educators and in out of school clubs. AGYW received IEC on HIV and AIDS prevention services?, decision making, personal hygiene, alcohol abuse and SRH&R. Guiding protocols for these sessions 24 included MoH Standard Peer Educators’ Manual and Ministry of Community Development and Social Services National Peer Education manual.

5. FAMILY PLANNING SERVICE DELIVERY SYSTEMS AND ACCOUNTABILITY STRENGTHENED

5.1. Strengthen Quality of FP Service Delivery

Adherence to Quality Standards: Measuring quality in FP important as it helps the project understand how much has been achieved and identify the gaps that need to be rectified. The quarterly facility quality assessments are conducted in order that the services ensure client’s rights are respected and a method mix of FP is offered. The services need to be offered in a safe and confidential environment by trained and competent staff. Clients were offered appropriate counseling that fosters informed choice on the contraceptive method they need. In addition, continuity of services is assessed, in order to ensure that clients receive the comprehensive integrated FP services. The project conducted an assessment in 173 supported facilities to determine whether the facilities had available wide choices for contraceptive methods, integration of FP in other clinical areas, trained staff, adolescent friendly health services and availability of FP data management tools. Out of 173 facilities 163 scored above 80% which is a benchmark for quality assessments. This showed that 94% of the SARAI supported facilities adhere to the set quality standards.

Figure 10: Number of facilities adhering to quality standards

173 163

79 85

46 49 38 39

Copperbelt Luapula Muchinga Total Facilities Adhering to Quality Standards Total Number of Facilities

The facilities appreciate the QA systems created by the project and are adherent and when the reports are 25 shared, facilities ensure that they act on the recommendations. During this quarter the facilities performed well in the following aspects; availability of method-mix of contraceptives, counselling offered was age appropriate, the facilities have QA committees where FP QA issues are discussed. The gaps identified included the lack of color-coded bin liners, lack of fencing around the refuse pit and the incinerators. The project staff conducted the assessments in collaboration with the MCH coordinators in order to ensure that the gaps that need the MOH intervention are communicated immediately. Most of the gaps identified lack financial resources and rely on the MOH to rectify.

Family planning commodity stock out rate: The project monitors the availability of FP commodity to ensure that clients are offered a variety of FP methods including dual protection. The assessment are conducted monthly and solutions are sought immediately by liaising with the MOH staff. Informed choice is one of the quality standards and cannot be fully achieved when there is persistently long shortage of FP commodities. The project aims at ensuring that FP commodities are available at facilities through continuous periodic assessment, identification of gaps, lobbying and advocating to the MoH in order that remedial actions are affected timely. During the quarter under review all the 173 facilities were assessed to monitor FP commodity availability. A total of 89 facilities (Copperbelt 43, Luapula 29 and Muchinga 17) experienced commodity stock of out of one or more commodities, giving an average of 51%. The percentage has increased in comparison to last quarter’s percentage which was at 40%. This can be attributed to the general stock out at national level, the number of facilities that the project has scaled up to also has influenced the increase. The number of facilities that experienced a stock out per commodity and the length of days that the commodity was stocked out for has also increased. The project staff worked closely with the district pharmacists and MCH coordinator in identifying the root cause of the stock out, in some instances they assisted in the redistribution of commodity from overstocked facility to those that had a stock out. As indicated in the graphs below.

26 Figure 11: Number of Facilities Reporting Stock out by Commodity

60 51 Sum of Implant 50 Sum of Progesterone only pill

40 Sum of IUCD

30 Sum of Medroxyprogesterone injection 19 19 20 17 18 Sum of Combined Oral contraceptives 14 13 9 Sum of Male Condom 10 Sum of Female Condom 0 Total

Figure 12: Total Number of Days Facilities Reporting Stock Out by FP Commodity

1600 1518

1400 Sum of Implant

1200 Sum of Progesterone only pill 1000 Sum of IUCD 800 544 Sum of Medroxyprogesterone 600 510 492 432 injection 359 400 293 Sum of Combined Oral 203 contraceptives 200 Sum of Male Condom 0 Total

Environmental Monitoring and Management: Environmental Mitigation and Monitoring Plan (EMMP) is important in the implementation of health services as it provides protection of the environment and personnel from adverse health and environmental impacts. This is mainly attributed to unintended release of hazardous chemicals or biological hazards, including drug-resistant microorganisms, into the environment. To measure EMMP the project focused on how waste is handled and disposed of at facility and community levels. Further,

27 the project reviewed policies and practices on waste aggregation, waste handling, interim storage, and the final disposal.

Figure 13: Number of facilities conforming to waste management standards by province

173 151

85 71 49 49 31 39

Copperbelt Luapula Muchinga Total Number of Faciltities Adherent Total no. of facilities

From the data above 87% were adherent to the minimum acceptable standards for the waste management. The percentage has reduced by 10% from the previous quarter because of the facilities that the project has scaled up to. Lack of colour-coded bin liners still remains a challenge across all the project supported facilities, and lack of fencing on most of the pits and incinerators in the clinics. The fencing of pits is a work in progress as it is dependent on the facilities having the needed funds, otherwise the gap has been communicated and the facilities have put it in their work plans. There is need for local pharmacies to stock yellow (biohazard) coloured bin liners because the facilities buy the bin liners from the local supermarkets. This has been communicated with the national TWG as an issue that needs to be advocacy.

Community Family Planning Assessment (CBD): One of the strategies of SARAI is engagement of CBDs to offer FP information and services closer to the communities. The CBDs offer information and services to clients in the community at their convenience without them having to cover long distances and wait on long queues at the clinic. The project appreciates the essence of this and ensures that FP services by the CBDs are functional, and that YFHS counselling was offered with age appropriate messaging. The other areas assessed includes adherence to quality practices, mentorship and supervision, supply chain, and data management. The project therefore conducted schedules assessments on how the CBD are monitored and managed by the health facility staff to ensure safety and quality of services. During the quarter under review of 89% of the supported facilities adhered to offering quality community family planning services as shown in the table below. 28 .

Figure 14: Number of facilities adhering to providing quality community FP services by province

160 143 140 132 120 100 80 60 65 60 44 44 40 28 34 20 0 Copperbelt Luapula Muchinga Total Facilities Adhering to minimum Community FP standard Total no. of facilities

Amongst other achievements CBDs submitted correct and complete FP data to the facilities and held monthly meetings with facility in-charges. Commodity stock out was the biggest challenge that was faced in the quarter under review, there was a national stock out on DMPA IM. This led to CBDs that are not trained in provision of DMPA SC not being able to administer the DMPA in the community. The project is scheduled to train all the CBDs in DMPA SC by end of July 2019, this will ensure the continuity of services despite which DMPA is available should the facilities experience a stock out in future.

5.2. Strengthened use of data for decision making

During the quarter, several activities were conducted aimed at strengthening MoH M&E systems. Among the key activities were;

Data Quality Assessment (DQA): During this reporting period, SARAI M&E team conducted DQA using a rotational mechanism thereby providing equal chance of visiting select project sites across the three supported provinces. The selection criteria involved facilities which had outstanding data inconsistencies. The team sampled 5 facilities representing 10% of the total SARAI supported facilities in the province. The exercise aimed at data verification, auditing capacity of M&E systems and providing technical support on data management. The team focused on checking for completeness, correctness and consistency of reproductive health facility data that was reported by all sub-reporting levels for the reporting period.

29 Based on DQA findings, the province documented evidence on monitoring visits, technical support and data review meeting. Further, all project staff were well informed on both project and MoH reporting timelines and procedures. In addition, the Province had a feedback mechanism in place which was mostly via phone. Also, data filed at the Province matched 100% with data reported at HQ. At facility level, data captured on the aggregation form (HIA2) matched 100% with data reported onto DHIS2 database. However, minor disparities were found between data recorded on the service delivery form (HIA2) and data captured FP registers. The cause of this variation was due to failure by some facilities to adhere to the HMIS procedure which requires that commodities, and not clients, should be recorded under FP methods distribution of the HIA2 report. As an action point, it was recommended that Provincial M&E teams should be checking facility reports for compliance with the HMIS procedures manual on a monthly basis. All facilities sampled during the DQA had updated FP registers with data generated by CBDs before compilation of HIA2 reports.

Data Review Meetings: To promote HMIS data use among healthcare providers, the project conducted three (3) data review meetings in the three SARAI supported provinces. Key MoH staff (i.e., District Health Directors, District Health Information Officers, District MCH coordinators, District Pharmacists and select health facility staff in-charge attended the data review meetings.

The meetings focused on discussing data management, stock forecasting and quantification, FP service provision at both facility and community level. Further, the providers were oriented on MoH data flow requirements and feedback mechanism using the MoH HMIS procedures manual.

SFH has requested USAID to assist with coordinating the National M&E TWG meetings that have not taken place regularly.

6. PROJECT INDICATOR TRACKING

Table 8: Indicator Tracking Table

PERIOD PROJECT LIFE INDICATOR % Oct 18 –Sep 19 Jan – Mar 19 Apr – Jun 19 Target Achieved Target Achieved Achieved Achieved 1. # of additional SARAI trained CBDs providing FP information and/or services 180 0 93 1135 948 84% during the year 2. # of women requiring other services that 54,480 4,927 5,267 134,120 52,232 39% are referred by CBDs

30 3. Proportion of women referred for other FP methods who access the services (age, 95% 74% 75% 90% 75% 75% method) 4. % of CBDs providing FP services after 97% 96% 96% 97% 96% 96% one-year post-training 5. Percentage of SARAI supported health facilities stocked out, by family planning 10% 64% 51% 10% 51% 51% product or method, on the day of the assessment during the reporting period. 6. % of FP access points adhering to quality 70% 99% 92% 70% 92% 92% standards for service provision 7. Completeness of reporting by facility 95% 98% 99% 95% 99% 99% 8. Data Quality Assessments conducted 12 2 2 48 40 83% 9. SARAI supported quarterly data review 12 3 3 48 40 83% meetings held

From the table above, the project successfully trained 93 CBDs from the 30 scale up facilities as the remaining 87 will be trained in the next quarter. The project has continued to maintain a fairly well retention rate of trained CBDs. During the reporting period, the project successfully supported the holding of data review meetings in 3 implementing districts according to the target.

7. CHALLENGES / MITIGATION CHALLENGES PROPOSED SOLUTION Inability of MoH partners to complete the online SARAI to provide data bundles to project staff USAID compliance courses due to competing and in select facilities, hard copies of course demands and limited internet services. material to be used as alternative. Inability for select facilities to graduate due failure of Project to continue engaging MOH to rectify the meeting the graduation criteria. Among the gaps identified gaps. The data collection tool was identified are inadequate IEC materials, inadequate IP revised to take into account some of the aspects materials, stock out, no rooms designated for which do not apply to some facilities. provision of FP services.

Frequent stock-outs of FP commodities (i.e COC, SARAI staff to conduct joint TSS visits with Noristerate, IUDs, condoms and DMPA etc) and MOH PHO and DHO staff, liaising with disconnect with stock levels at MSL vs facility level. DHOs pharmacists. Gaps noted during national Especially in Mpika since January 2019. TWG meetings to identify potential solutions. Further collaboration with GHSCM-PSM project and USAID.

31 Continued transfer of LARC trained providers to non- Continued engagement with DHO and PHO to SARAI supported sites ensure trained staff are maintained. Seek additional resources/partner trainings to train providers. Poor management of waste in the facilities across SARAI staff to liaise with DHO on the the program in areas such as fencing of pit latrines for importance of including waste management waste disposal, mixing of waste, lack of bin liners. expenses on DHO budgets through use of grants and funding from RBF. Inadequate supply of HMIS tools such as Integrated Principal Health Information Officers are being FP registers and HIA2 report booklets. proactively engaged on a regular basis so as to ensure that health facilities have adequate stock of HMIS tools.

8. CONCLUSION

It can be concluded from the details presented in this report that the SARAI continues to make great strides towards meeting the goal of increasing the modern contraceptive prevalence rate by 2% annually. Both facility based providers and CBDs continue to increasingly reach more woman and youth with FP services.

Uptake of long-term methods continues to rise. The CBD model continues to flourish and there are more women using DMPA-SC, bringing services closer to the community. In general high quality services are being offered, however persistent commodity stockouts continue to be a major problem that must addressed, especially in Muchinga province. The project is on track with expenditure of $12,528,741 spent through end of June 2019, representing 82% of the total budget and 94% of the obligated amount of $13,320,326. A request for increase in obligation was submitted to USAID recently.

In the next quarter, the project will complete trainings of CBDs, implement new youth interventions, submit abstracts for ICASA, self-injection of DMPA-SC, and plan for closeout. The project plans to coordinate more with other partners and projects on the ground such as Population Media, creating synergies and lessening duplication of resources. The project has high expectations in the last full year of the project, therefore a strong effort will be made to maximize the impact and sustainability even beyond SARAI sites.

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