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

Quarterly Report January 1 – March 31, 2016

Ms. Shikha Banik, Family Welfare Visitor, looking up previous medical records by scanning the health ID card of Mosammat Khairunnesa of Noapara Union. MaMoni has introduced health ID cards in Madhabpur of as part of the Routine Health Information System (RHIS) initiative.

Submitted May 6, 2016

Cover Photo Story: Ms. Shikha Banik, Family Welfare Visitor (FWV) is one of three FWVs in Madhabpur upazila who are testing an automated Maternal, Newborn, and Child service module at UH&FWC level. Here client service history can be accessed from a centralized server through a bar-code enabled health ID card, eliminating the need for paper based registers or reporting forms. This is part of USAID’s multi-partner Routine Health Information System (RHIS) initiative where MaMoni HSS, as a partner, is implementing different components of an automated health information system in Madhabpur and Lakhai of Habiganj district.

Photo Credit: Imrul Hasan, Shimantik/MaMoni HSS Project

This document is made possible by the generous support of the American people through the support of the Office of Population, Health, Nutrition and Education, United States Agency for International Development (USAID), (USAID/Bangladesh), under the terms of Associate Cooperative Agreement No. AID-388-LA-13-00004 through Maternal and Child Health Integrated Program (MCHIP). The contents of this document are the responsibility of the MCHIP Project and do not necessarily reflect the views of USAID or the United States government. Table of Contents MaMoni Health Systems Strengthening Activity ...... 1 Table of Contents...... i Abbreviations ...... ii Executive Summary ...... 1 Introduction ...... 3 Program Results for the Quarter ...... 3 IR 1. Improve Service Readiness through Critical Gap Management ...... 3 IR 2: Strengthened Health Systems at District Level and Below ...... 13 2.9 Monitoring Quality of Care Indicators ...... 23 IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems 25 IR 4. Identify and Reduce Barriers to Accessing Health Services ...... 26 Challenges, Solutions, and Action Taken ...... 27 Challenges ...... 27 Opportunities ...... 27 Appendix 1: Scope and Geographical coverage of Mamoni HSS project ...... 28 Appendix 2: Case Studies ...... 30 Appendix 3: Program Performance Indicators (October–December 2015) ...... 33 Appendix 4: MNCH Essential Drugs Monitoring Report ...... 46 Appendix 5: Documentation and Dissemination of MaMoni Program Learning ...... 57 Appendix 6: Environmental Compliance Report ...... 58 Appendix 7: Links to Media Stories Published ...... 60 Appendix 8: Update on USAID Abortion and FP Requirement 2016 Training ...... 61 Appendix 9: Status of Health Facility Renovations ...... 62

MaMoni Health Systems Strengthening Activity: FY’16 Q2 Quarterly Report i ABBREVIATIONS AHI Assistant Health Inspector AMTSL Active management of third stage of labor BCC Behavior Change Communication BEmONC Basic emergency obstetric and newborn care BNF Bangladesh Neonatology Forum BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CB Community-based CEmONC Comprehensive emergency obstetric and newborn care CHW Community Health Worker CHX Chlorhexidine CIPRB Center for Injury Prevention and Research, Bangladesh CMAM Community-based management of acute malnutrition cMPM Community microplanning meeting CNCP Comprehensive newborn care package CSBA Community Skilled Birth Attendants CV Community Volunteer CVRS Civil registration and vital statistical system CYP Couple years of protection DDFP Deputy Director Family Planning DGFP Directorate General Family Planning DGHS Directorate General Health Services DRS District Reserve Store EPCMD Ending Preventable Child and Maternal Deaths FPI Family Planning Inspector FWA Family Welfare Assistant FWV Female Welfare Visitor GOB Government of Bangladesh HA Health Assistant HBB Helping Babies Breathe HPNSDP Health, Population, and Nutrition Sector Development Program HS Health systems HSS Health systems strengthening IFA Iron plus Folic Acid

ii MaMoni Health Systems Strengthening Activity: FY’16 Q2 Quarterly Report IMCI Integrated Management of Childhood Illness IPHN Institute of public health nutrition IR Intermediate result JSV Joint supervisory visit LAPM Long-acting and permanent method LMIS Logistics management information system MAMA Mobile Alliance for Maternal Action mCPR Modern contraceptive prevalence rate MCWC Maternal and Child Welfare Center MNCH/FP/N Maternal, newborn and child health, family planning, and nutrition MNH Maternal and newborn health MOH&FW Ministry of Health and Family Welfare MOLGRD&C Ministry of Local Government Rural Development & Cooperatives MOU Memorandum of understanding MPDR Maternal and perinatal death review NIPORT National Institute of Population Research and Training NNS National nutrition services OGSB Obstetrics and Gynecology Society of Bangladesh PPIUCD Postpartum intra-uterine contraceptive device QA Quality assurance QI Quality improvement QPRM Quarterly performance review meeting RHIS Routine health information system RRQIT Regional roaming quality improvement team SACMO Sub-assistant Community Medical Officer SAM Severe Acute Malnutrition SBA Skilled Birth Attendant SBM-R Standards-Based Management and Recognition SC Save the Children SCANU Special care newborn unit SDP Service delivery point SIAPS Systems for improved access to pharmaceuticals and services SSN Senior Staff Nurse STG Strategic thematic group TBA Traditional Birth Attendant

MaMoni Health Systems Strengthening Activity: FY’16 Q2 Quarterly Report iii TOT Training of trainers UEHFPSC Union Education Health and Family Planning Standing Committee UFPO Upazila Family Planning Officer UHC Upazila health complex UH&FPO Upazila Health and Family Planning Officer UH&FWC Union Health and Family Welfare Centers UP Union parishad USAID United States Agency for International Development

iv MaMoni Health Systems Strengthening Activity: FY’16 Q2 Quarterly Report EXECUTIVE SUMMARY Key Accomplishments of the MaMoni Health Systems Strengthening Project (MaMoni HSS) In the second quarter of year three, the key accomplishments of the project include the following: • MaMoni HSS has been supporting the Directorate General Family Planning (DGFP) in assessing all Union Health and Family Welfare Centers (UH&FWCs) in Bangladesh for readiness to provide 24/7 delivery services. During this quarter, all remaining facilities of , , and Rajshahi divisions have been completed, bringing the total assessment to 4,463 out of an initially projected 4,000+ health facilities nationwide. MaMoni also organized three divisional advocacy meetings in , Rangpur, and Khulna divisions. MaMoni validated some of the key indicators of the data through an independent team of 6 who visited 7 divisions, and through its periodic service delivery point (SDP) assessment in district. • MaMoni HSS has been supporting the routine health information system (RHIS) initiative of the Directorate General Health Services (DGHS) MOH&FW to pilot the automated population registry system (PRS) in Madhabpur and Lakhai upazilas of Habiganj district. As of March 31, 2016, 3,323 household members in 621 households of Lakhai upazila of Habiganj district have been registered. In Madhabpur upazila, where PRS has been completed, 1,823 health ID cards were distributed in two unions in late March 2016. MaMoni also introduced offline capability so that the data can be entered offline at the SDP level. In three unions of Madhabpur, Family Welfare Visitors (FWVs) recorded service data of 1,994 ANC, delivery, and PNC in the maternal, newborn, and child health (MNCH) e-register. MaMoni HSS also developed FP modules to record service data of pill, condom, injectables and IUD through laptop and tablets, and are in the process of deploying the software. • National scale-up of Chlorhexidine support included training of 28,469 service providers in 39 districts in this quarter. Cumulatively, 34,904 providers from 59 districts have been trained so far. In January 2016, the Chlorhexidine procurement from DGHS was transferred to Central Medical Store Depot (CMSD), and by March 31, 53 districts received chlorhexidine supply for use in district hospitals, UHCs and DGHS managed UH&FWCs. DGFP has received 110,000 dose of CHX from the Global CHX working group, but has not distributed the doses through their system yet. • Newborn sepsis management at UH&FWCs have been introduced in 10 upazilas. 816 newborn cases were seen by Sub-assistant Community Medical Officers, out of which 63 cases were treated for clinically severe infection, and 11 cases were referred to higher level facilities.

Challenges and Mitigation Strategies • Drug shortage: The Drugs and Dietary Supplements (DDS) kits of UH&FWCs and the drug supply of the community clinics have been interrupted since September 2015 due to procurement issues at DGHS and DGFP. This has severely affected the coverage and quality of essential services at the community level. MaMoni HSS has been closely monitoring the situation, and where appropriate, has been liaising with the Union Parishads, and Ministry of Social Welfare to leverage temporary support to meet the

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 1 shortfall for drugs and supplements such as oxytocin, iron plus folic acid (IFA) and misoprostol. • The online DHIS2 MIS system of DGHS, or DGFP MIS does not include reporting for Chlorhexidine (CHX) yet. Thus, even though chlorhexidine has been made available in 59 districts, and the new EmOC registers rolled out by UNICEF has space for recording CHX use, utilization reports are not available. MaMoni has been following up with Integrated Management of Childhood Illnesses (IMCI) section of DGHS to organize a joint meeting with the Director of MIS, DGHS to speed up the revision process.

Way Forward • In the upcoming quarter, the focus of the project will be on consolidating implementation components as per the recommendation of the MaMoni Mid Term Evaluation. • MaMoni HSS will organize a national dissemination meeting on the assessment findings of UH&FWC strengthening at divisional levels. • MaMoni will engage in an assessment of workload of all levels of workers in one district, in partnership with WHO and the Human Resource for Health unit of MOH&FW. • MaMoni will provide technical assistance to the Quality Improvement secretariat. • MaMoni will introduce unified LMIS in all high intensity upazilas.

2 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Introduction The MaMoni Health Systems Strengthening (HSS) project, a four-year USAID-funded award,1 has the goal of improving utilization of integrated maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) services delivered through a health systems strengthening lens. The project supports the Ministry of Health and Family Welfare (MOH&FW) to introduce and leverage support for the scale-up of evidence-based practices that have been applied and tested in Bangladesh. To support this scale-up, MaMoni HSS is actively engaging with local government structures and nongovernmental organizations (NGO) to improve delivery of health services, and strategically partner at the national level to build consensus on policies and standards that positively drive evidence- based interventions at all levels. The scope and geographical coverage of the MaMoni HSS Project has been included in Appendix 1 of the report.

PROGRAM RESULTS FOR THE QUARTER

IR 1. Improve Service Readiness through Critical Gap Management

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

1.1.1 Maternal Health MaMoni HSS, in collaboration with Obstetrical and Gynaecological Society of Bangladesh (OGSB) is introducing pre-eclampsia and eclampsia management at the union level where loading dose magnesium sulfate will be administered at the union level by Family Welfare Visitors (FWVs). In the previous quarter, MaMoni HSS conducted a PE/E management orientation session for Jhalokathi and Habiganj districts with the district and upazila level managers. In this quarter, Noakhali and Lakshmipur managers were oriented. The project will roll out PE/E management interventions in 44 unions in five upazilas of the Photo 1: In an OGSB facilitated training, high intensity districts: Nabiganj (Habiganj), participants practice administration of injectable Companyganj (Noakhali), Kamalnagar and magnesium sulfate on a dummy model. Ramganj (Lakshmipur), and Rajapur (Jhalokathi). National and district level TOTs were completed in this quarter, and 21 master trainers

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

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 3 were developed from the four districts, who will train FWVs in the subsequent quarters. The project will also continue to work with OGSB to strengthen the referral facilities in those districts, where providers are already trained on intravenous administration of magnesium sulfate.

MaMoni HSS is supporting service providers (mostly FWVs) from high intensity districts to distribute misoprostol to mothers during third trimester ANC visits to prevent postpartum hemorrhage in home deliveries. Around 27,955 mothers received misoprostol through union and community level providers in this quarter. Field level misoprostol distribution was interrupted as a large number of doses were set to expire in the coming months. The consumption of misoprostol among mothers delivering at home, ranged from 33 percent in Habiganj (42 percent in Baniachang upazila) to 8 percent in (6 percent in ). Appendix 3 program performance section has district-wide estimates for all high intensity districts. MaMoni HSS has emphasized ANC in the third trimester in all community level activities to ensure misoprostol distribution.

1.1.1a. Increasing SBA at the District Level In the six MaMoni HSS districts, the project is supporting MOH&FW to strengthen the UH&FWCs to provide the comprehensive package of MNCH/FP/N services, including normal delivery care through a combination of leveraging existing resources of MOH&FW; mobilizing local resources; and providing direct inputs to meet facility needs (i.e. training, infrastructure improvement). As of March 2015, a total of 58 out of 193 UH&FWCs in the high-intensity upazilas are providing 24/7 delivery services. Overall, as depicted in Figure 1 below, institutional deliveries at the facility level are increasing.

Figure 1. Trend of SBA deliveries in MaMoni HSS high intensity districts

20000 18,838 17,325 16820 14,433 15,252 15000 13,507 16,100 13039

10000

5000 3,578 3637 3,476 1,520 240 144 147 110 0 Facility Delivery CSBA PCSBA Total SBA

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

1.1.1b Private CSBAs (pCSBA) Introduced Private community SBAs (pCSBA), are non-salaried workers, who only earn income by charging for different services (ANC, deliveries, PNC) and selling essential commodities. 39 new pCSBAs from Noakhali and Lakshmipur completed their six month training in the previous quarter. Bangladesh Nursing Council certified them in March 2016. These pCSBAs participated in 21 days of residential clinical attachment at the OB/GYN wards of

4 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 the District Hospital and MCWC at their respective districts. It is expected that this orientation will increase both knowledge and skills for improved performance at the community level. MaMoni also continued to support the 54 private CSBAs in Habiganj.

1.1.1c Participation in the HOPE Maternal Health and Fistula Conference MaMoni HSS Project participated in the national conference on “Joining Hands with Global Providers in Improving Care of Local Mothers Need” held on March 19-20 in Cox’s Bazar. The conference discussed obstetric fistula as a significant cause of maternal morbidity, management of SPE/E, family planning, adolescent health, and midwifery programs. MaMoni HSS is a partner in the National Maternal Morbidity Validation Study 2016 where mothers from Baniachang and Nabiganj upazilas of Habiganj district will be enrolled in a screening program for identification and management of obstetric fistula and third and fourth degree uterine prolapse. The screening activity will commence in the fourth quarter, and EngenderHealth’s Fistula Care Plus (FC+) project will organize repair operations in the following year. 1.1.1d Supported Health Facility Preparedness for MNCH/FP/N Services In Year Two of MaMoni HSS, the MOH&FW requested the project to provide technical assistance to the DGFP to strengthen UH&FWCs across the entire country by training providers, strengthening commodity management, and establishing quality improvement mechanisms. As a starting point, the program has initiated a nationwide assessment, which includes a facility readiness assessment that covers over 4,000 health facilities and assesses Photo 2: UH&FWC Divisional Advocacy meeting infrastructure, FWV residence, human resources, in Chittagong training, furniture, equipment and supplies. Three Divisional Advocacy Meetings (Chittagong, Rangpur and Khulna) were completed where DDFPs, representatives from DGHS from central level, CSs Divisional Commissioners, representatives from local government, NGO representatives and other stakeholders participated. The Director of MCH-FP of DGFP and other directors of DGFP co-hosted the meetings. Additional secretaries (Kulsum Begum in Rangpur and Mr. Harun- ur-Rashid Khan at Khulna) made themselves available to participate in these meetings. They showed their encouragement and interest in these meetings and committed to take future direction. The Honorable State Minister participated in the Chittagong divisional meeting as chief guest. The Minister was especially interested in the information and showed keen interest in the data and resource allocation. Other participants also showed huge interest. MaMoni HSS Chief of party (COP) shared assessment information in the Donors consortium. Donors showed vast interest in prioritizing this in the new sector program. Six supervisors visited all seven divisions to validate selected variables of the previously collected UH&FWC data. Monitoring continued at Kushtia, Chittagong, Rangpur, and Rajshahi districts visited by the MaMoni HSS team. In total 4,463 UH&FWCs have been assessed. Of which about 75% of the facilities were found to belong to DGFP. A key finding was the skill gap: a good number of FWVs need additional six month midwifery training to properly conduct delivery at these UH&FWCs.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 5

1.1.2 Newborn Health 1.1.2a. National scale up of 7.1% Chlorhexidine to prevent newborn infection DGHS has procured 600,000 units of 7.1% chlorhexidine (CHX) aqueous solution to be distributed nationally. This has been added to the Central Medical Store Depot (CMSD) in January 2016. 53 districts have received 7.1% Chlorhexidine supply during February and March. Chlorhexidine is also available in the private sector through the supply chain of ACI Pharmaceuticals, and in the Smiling Sun clinics. Even though DGFP received 110,000 units of CHX from the Global Chlorhexidine Working Group, these have not been distributed, as training for all 64 upazilas are not yet complete. As part of the national roll out of chlorhexidine intervention, MaMoni HSS conducted 2 batches of national level TOTs for master trainers, Divisional Advocacy and Planning Meeting in Chittagong and Dhaka divisions, District Advocacy and Planning Meeting in 39 districts, 39 TOT in 39 districts and 1162 batches orientation in 56 districts (including total 28,469 participants). To date, 34,904 health workers of 59 districts have been oriented on chlorhexidine. Job Aids and IEC materials have also been provided. 39 Independent Monitors (IMs) have monitored 532 training sessions among batches in 39 districts. They also filled in a standardized check list and shared their observation and recommendations. They have monitored around 66% of batches among total batches held in this quarter. The percentage of IM status has calculated with only the batch number of the new phase [39 district]. Photo 2: TOT participants practicing In addition, to supervise the training session the chlorhexidine application independent monitors also visited the IMCI-N corners of the concerned upazila health complex to determine the exact scenarios of the facility to ensure/ improve the quality of services.

1.1.2b. Newborn Sepsis Management MaMoni HSS introduced newborn sepsis management at the union level facilities in 10 upazilas2 through Sub-assistant Community Medical Officers (SACMOs) for newborns in situations where referral was not possible or acceptable. 39 GoB master trainers trained 266 SACMOs to prepare for this intervention. In this quarter, 816 cases of newborn sepsis were identified by the SACMOs (460 in Habiganj, 139 in Noakhali, and 217 in Lakshmipur). Figure 3, below, shows the total number of cases disaggregated by types of infection.

Figure 2: Category of 816 sick newborn/infants (0-59 days) treated at UH&FWCs during this quarter

2 All eight upazilas of Habiganj, of Lakshmipur and Companyganj upazila of

6 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Critical Infection, 11 Clinically Severe Infection, 63

Other, 254

Isolated Fast breathing, 259

Local Bacterial Infection, 229

In the case of 11 critical infection cases, first doses of antibiotics were provided and the sick infants were referred to higher level facilities. MaMoni followed up with each of the infants and found that treatment completion was high. However, MaMoni facilitation was critical to ensure this.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 7 Case Study: Sepsis Management at Union Level saved the life of Abdur Rahman Abdur Rahman, a baby boy of Hannan & Suborna of Teori Bhuian Bari village, Volakat union, Ramgonj upazila, Lakshmipur district was born at home by a traditional birth attendant (TBA) on February 16, 2016. He is the second child of his parents. Suborna obtained two ANC consultations from Family Welfare Visitor (FWV) during her pregnancy. During ANC consultation she was informed about essential newborn care and newborn danger signs. She also got the information of newborn danger signs from Community Action Group (CAG) meeting organized by MaMoni HSS Community Volunteer (CV).

On March 28, Suborna noticed that her child was breathing with difficulty. With the help of the CV, she took the child to Volakot Union Health & Family Welfare Center (UH&FWC). Mr Hossain Bhuian, Sub Assistant Community Medical Officer (SACMO) of Volakot UH&FWC examined the baby and diagnosed him as a case of Clinically Severe Infection (CSI). He advised the parent to take the baby to Upazila Health Complex (UHC). Since they were not able to take the baby to UHC, Mr Bhuiyan treated the case following protocol of referral failure CSI cases. SACMOs received training on management of infection of young infants (<2 month). He took weight of the baby and gave 1st dose of Injection Gentamycin and oral Amoxicillin. He counseled the family to come the following day for 2nd dose of medicine. Next day he examined the baby and gave 2nd dose of Injection Gentamycin. He advised them to continue with oral Amoxicillin for a total of 7 days and report back if the baby’s condition deteriorated. Mr Bhuian followed up with the parents on 4th day over telephone. Since the baby was improving, he advised them to complete the oral amoxicillin dose for seven days. The baby was cured.

Bangladesh has approved management of sick infants (<2month) from UH&FWC in case of referral failure. SACMO is the designated provider for initiation of this management at that level.The MaMoni HSS project is supporting MoHFW to roll out this intervention in the project area. Project support includes provider training, logistic and medicine arrangement, improved supervision and monitoring. Mr Bhuiyan received necessary training, UH&FWC Volakot was ensured with necessary medicine and logistics, service availability at UH&FWC was communicated through CAG. All these have contributed to the survival of Abdur Rahman and will be continuing in coming days as a lifesaving effort for sick newborns of the union.

1.1.2c. Kangaroo Mother Care MaMoni HSS introduced a KMC corner at Noakhali District Hospital within the Paediatric department in December, 2015 and is going to introduce KMC in the district hospitals and two high volume UHCs from each district. Under this initiative MaMoni provided support for capacity building of doctors and nurses with necessary logistics and printed recording tools. As part of this, one doctor and 2 nurses were trained from Noakhali district hospital and 6 doctors from high volume (delivery) UHCs of Noakhali and Habiganj district were trained on KMC. During January and February, two newborns (one every month) were admitted to the KMC unit

8 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 in Noakhali District Hospital. MaMoni HSS is assessing the reason for slow uptake of KMC care despite high number of deliveries at the district hospital. According to Round 3 MaMoni HSS tracer survey, in , 27.2 percent of mothers delivered at private facilities, compared to 12.2 in the public sector.

1.1.2d. Special Care Newborn Units (SCANUs) MoHFW is establishing Special Care Newborn Unit (SCANU) and Newborn Stabilization Unit (NSU) from SAARC Development Fund (SDF) in 10 districts in Bangladesh. Four of them i.e., Noakhali, Habiganj, Pirojpur and are in MaMoni HSS project area. MoHFW have completed renovation, procured equipment but they require equipment installation support. Project supported installation and maintenance support for the SCANU equipment (radiant warmers, phototherapy machines, pulse oximeters, etc.), on job orientation of operation of Photo 5: Director, Primary Health Care of DGHS visiting equipment in 4 districts of the project area during the new SCANU at Habiganj Adhunik Sadar hospital the period. Necessary training of providers will be provided by MoHFW. This effort will ensure availability of services for advanced care of sick newborns in the district.

1.1.2e Comprehensive Newborn Care Package Training 839 Community Health Workers (CHWs) were trained on CNCP package. Outreach workers (HA, FWA, CHCP) and their supervisors (AHI, FPI, HI) participated in 34 batches. Although the outreach workers are not expected to perform deliveries or provide immediate newborn care, they are expected to conduct PNC visit (at home or at community clinics), promote chlorhexidine use, identify preterm/low birth weight and sick newborns and refer them to appropriate facilities. They have received appropriate job aids, including IEC materials. MaMoni HSS plans to conduct post-training follow up in subsequent quarters.

1.1.2f. Helping Babies Breathe follow-on Field Officers have observed 95 participants in 9 sessions of refresher training in and . Field officers have visited 105 out of 214 facilities in these two districts. They have replaced HBB equipment from district Civil Surgeon office & distributed 57 training DVDs in those districts. Two district review meetings on HBB were held in Comilla and Jamalpur districts as well. A total of 79 district and upazila level managers of health and family planning, consultants from pediatrics and OBGYN departments and district level officials attended the meetings. HBB training was provided to 169 SBAs and private facility providers in 8 batches in Comilla & Jamalpur districts and BSMMU. A buffer stock has been created in all the 64 districts under the custody of the respective Civil Surgeons for replacement when required. 1,856 sets of HBB equipment were also distributed.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 9 The Smiling Sun Clinics of NHSDP project have requested replacement of 125 HBB equipment sets. MaMoni HSS is facilitating the discussion with the IMCI section of DGHS.

1.1.3 Child Health The National Newborn & Child Health Cell within the IMCI section of DGHS supported IMCI section to organize a workshop on “Capacity Development, Coordination & Performance Appraisal for Health Managers & Statisticians” for quality improvement of Child Health Services. During the quarter, 9 workshops were held. Health Managers & Statisticians of fifteen districts (Barisal, Bhola,

Chapai Nababganj, Chuadanga, Gaibandha, Photo 6: Workshop for health managers Habiganj, Jamalpur, Madaripur, Magura, Narail, and statisticians at IMCI section of DGHS Rangpur, Shariatpur, Sherpur, Panchagarh & Jhenidah) were invited to those 9 workshops. Respective UH&FPOs, UFPOs & Statisticians of concerned districts were present. Analysis of online IMCI reporting and feedback was given. Subsequently, this analysis report was sent to the Civil Surgeon, Deputy Director Family Planning, Divisional Director-Health, Director-PHC and Director- MIS. The National Newborn & Child Health Cell also initiated a process of updating IMCI reporting site and assessment of training status for MaMoni HSS project districts.

1.1.3a Community Case Management (CCM) MaMoni HSS supported introduction of CCM from community clinics (CCs) in Jhalokathi district. A total of 85 Community Health Care Providers (CHCP) were trained. The Project conducted post-training follow up and supplied chart booklets, Salter scales, MUAC tape, and GMP cards for all the CCs. 85 CHCPs from 82 existing Community Clinics (CC) are now treating ARI, pneumonia, and diarrheal cases along with nutritional counseling following the CCM protocol. CHCPs provide daily reports online from the CC. The project, in collaboration with UNICEF, is facilitating performance monitoring through monthly meetings of CHCPs at upazila and district level. However, performance data was not available at the time of writing of the report.

1.1.4 Family Planning At the district level, MaMoni undertook several initiatives to strengthen the family planning interventions. Following the training of 15 service providers on PPIUCD in Lakshmipur in Year 2, MaMoni HSS continues to provide operational support to increase their performance. Figure 4, below, shows the increasing trend in PPIUCD insertions as a result of improved provider confidence and client acceptance within the district. During winter, IUCD insertion dropped a bit, but the year to year trend is encouraging.

10 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Figure 3: Number of Postpartum IUCD insertions in Lakshmipur3, January 2015- February 2016

100 87 90 90 83 80 72 70 54 60 53 53 43 50 39

Number 40 28 23 30 19 20 11 10 2 0 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

Case Study: How leadership of MO-Clinic rapidly improved PPIUCD in Lakshmipur MCWC Dr. Ashfaqur Rahman, MO-Clinic of Lakshmipur took positive steps to encourage his providers to promote postpartum IUCD in MCWC. This has had a tremendous impact on utilization. On average 100 deliveries take place there, but before March 2015, Dr. Rahman was the only provider trained on insertion of IUCD during postpartum period, and only 2-3 clients would accept the method each month. In March 2015, with support from MaMoni HSS, Dr. Rahman sent all the FWVs to the Mohammadpur Fertility Services and Training Center (MFSTC) to be trained on postpartum IUCD insertion. He subsequently oversaw the counseling and motivation by the providers, and ensured appropriate equipment. Because of improved provider confidence, quality of counseling and better removal management, between October 2015 and March 2016, average PPIUCD acceptance rate was 38, a significant increase.

• MaMoni HSS is supporting integration of FP services in all Figure 4: FP Method Mix from MaMoni districts service delivery points of Feb 2016 MOH&FW, particularly in the 100 upgraded UH&FWCs. During the 80 quarter, the CYP for the high 60 intensity upazilas was 116,634 40 20

(lower than previous quarter), and Percentage 0 in the health systems capacity building upazilas was 99,964 (slightly lower as well). Figure 5 shows the current method mix as of February 2016. The majority of Pill Condom Injectable IUD Implant NSV Tubectomy

3 Facilities represented include: MCWC, Uttor Joypur, Dattopara, Chandraganj, Kerowa, and Char Falcon UH&FWCs

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 11 clients chose oral contraceptives followed by injectables, across all districts.

• During the quarter, 23% of new LAPM acceptors were referred by community volunteers of MaMoni HSS. Figure 6 shows current progress in LAPM uptake in project districts.

Figure 5: Number of LAPM Acceptors and CV contribution in four high intensity districts

8000 6,896 7000 5,631 6000 5,350 4,989 5000 4000 3000 Number 1,426 2000 1,078 970 1,268 1000 0 Total CV Total CV Total CV Total CV FY15 Q3 FY15 Q4 FY16 Q1 FY16 Q2

1.1.5 Nutrition At the district level, MaMoni HSS focuses on screening, identifying, and referring children with Severe Acute Malnutrition (SAM) to Upazila Health Complexes (UHC). MaMoni also conducted a TOT on basic nutrition for establishment of Nutrition Units in four upazilas, namely Madhabpur (Habiganj, Companyganj (Noakhali), Ramganj (Lakshmipur) and Rajapur (Jhalokathi). 21 master trainers were developed in this quarter who will, in turn, train frontline health workers to implement nutrition activities. Photo 7: IPHN review meeting

1.2 Management of Critical Human Resource Gaps of GOB Service Providers MaMoni HSS was invited to be a member of the Strategic Technical Group on Human Resources for Health, constituted to draft the recommendations for the fourth HPN Sector Development program. The project’s contributions to these forums were informed by the experiences and data from the MaMoni HSS implementation. In the six districts where implementation is in progress, the project is currently supporting 58 paramedics, one EmOC-trained Medical Officer, and 19 nurses to fill critical human resource gaps. There have been changes from quarter to quarter in the number of paramedics deployed in Habiganj, Noakhali, and Jhalokathi—largely a result of frequent

12 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 staff turn-over. The status of vacancies and MaMoni HSS gap management will be expected to undergo changes in December when new FWVs are deployed (refer to Table 1). Table 1. Summary of critical health workforce gap management provided by MaMoni Health Systems Strengthening (HSS) in high-intensity districts, as of March 31, 2016.

FWV Nurses

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

Habiganj 13 1** 29 28 1** 14

Noakhali 05 0 16 33 0 3

Lakshmipur 0 0 8 29 0 3

Jhalokathi 7 1** 4 2 1** 0

Total 27 2 57 92* 2 20

* 92 vacant nurse posts reported by DGHS and DGFP, but project assessment findings suggest that this number was significantly underreported. Project assessment estimates nurse vacancies to be around 197 (47 in Habiganj, 46 in Noakhali, 29 in Lakshmipur, 2 in Jhalokathi) ** New FWVs were deployed in Nurpur Union of Habiganj Sadar, and Ponabalia Union of Jhalokathi Sadar. New nurses deployed in Madhabpur UHC and Kathalia (Amua) UHC

One additional anesthetist was deployed in Habiganj in this quarter. A gap of 20 surgeon/anesthetists is a big barrier in the high intensity upazilas to ensure proper comprehensive emergency obstetric and neonatal care.

IR 2: Strengthened Health Systems at District Level and Below

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

2.2 Strengthened Quality Improvement Initiatives 2.2.1 National Level Contributions • The project continued to collaborate with the MoHFW QI Secretariat in coordinating the design and implementation of QI interventions. Dr. Shayema Khorshid, National QI Advisor, QI Secretariat participated in the National Program Review Meeting held at DGHS MIS Conference on February 25, 2016. She contributed to presenting and

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 13 discussing the Project’s QI interventions in line with the national QI strategy, particularly the project’s effort to strengthen the ownership and leadership of the QI process through the establishment of QI committees at district, upazila, and health facility levels. • On February 4, the project held a meeting with the national QI Secretariat to coordinate the design and implementation of operations research, conducted in collaboration with ICDDRB, to assess the effectiveness of a QI Committee in Habiganj District in improving a predetermined set of QI indicators. • Workplan sharing and coordination meeting on QI with Director Hospital Services: on March 7th, 2016, the meeting took place at NIPSOM with participation of Prof. Dr. Shamiul , Director, Hospital and Clinics Line Director and several Assistant and Deputy Directors of the Hospitals and Clinics, DGHS. The meeting included presentations of MaMoni HSS Project’s QI strategy, interventions, and progress. Participants discussed the coordination in implementing QI activities, particularly in forming QI committees at the district hospital level and strengthening their capacity and ownership to lead QI activities in their respective hospitals. • On March 24, the project participated in an inauguration event for SSK (Shasto Shurakha Kormoshuchi) (Health Protection Program) in , organized by the QI Secretariat and chaired by the honorable Minister of Health, Mohammad Nasim, MP. SSK is an initiative supported by the MoHFW to provide health services to families below the poverty line through an insurance scheme that ensures basic services for common ailments without cost to the families. The initiative is expected to relieve poor families from incurring out-of-pocket expenses commonly paid while getting health services. SSK has a component of improving access and quality of care provided by Upazila Health Complexes. SSK will be piloted in three UHCs in Tangail District. • Contributing to developing national guidelines for Every Mother and Every Newborn (EMEN) Standards: on March 26 and 27, 2016, the project participated in a national workshop organized by the National QI Secretariat at UNICEF, in participation with WHO and members of professional associations (OGSB, BPA, BNF). Participants developed draft guidelines and assessment tools for testing the implementation of EMEN standards in as part of the Mother and Baby Friendly Facility (MBFF) initiative. • The project participated in a QI partners meeting, hosted by the QI Secretariat, on March 31 to discuss the development and testing of a package of QI interventions with the participation of international partners including JICA, UNICEF, and WHO.

2.2.1a. Implementation of a new QI paradigm The project organized a workshop on February 3-4, 2016, including all QI staff at Dhaka and district (QI managers, QI focal persons, and district managers) to review QI strategy and implementation status and present and discuss progress and challenges. The meeting entitled “Where is the improvement?” focused on reviewing and documenting the status of each health facility supported by the project in Habiganj, Noakhali, Lakshmipur, and Jhalokathi districts in relationship to the stage of QI as described in the project’s guidelines. The challenges to accelerating the improvement in achieving stage 1 QI (improved basic cleanliness, infection prevention measures, and medical waste management) were discussed in particular detail.

14 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2

The graph below summarizes the status of health facilities by QI Stage.

Figure 6: Status of Health Facilities by QI stage (Feb 2016) 180 165 160 140 132 120 100 80 69 48 48 60 43 42 36 34 40 28 3333 2119

Number of Health Facilities 20 7 6 9 6 1 0 2 0 5 5 0 0 0 0 0 District Upazila Union Habiganj Noakhali Lakshmipur Jhalokathi

Total Number of Facilities Stage 1 Stage 2 Stage 3

The graph above demonstrates that while some facilities (36 in Habiganj, 9 in Noakhali, and 6 in Lakshmipur) were able to move from Stage 1 to Stage 2 QI (improved organization of services, crowd management, infection prevention, application of minimum clinical standards), the majority of facilities, including all facilities in are still at stage 1, indicating that they have not yet met the basic standards for cleanliness, infection prevention, and medical waste management. Increasing ownership of local health managers and involving local government and community will be needed to accelerate QI in all health facilities. To accelerate the application of QI interventions, the project completed the translation of the “Guidelines for implementing QI interventions at district and sub-district level”. In addition, the project developed a poster on hand-washing that will be posted in all health facilities supported by the project as a job aid to improve compliance with handwashing standards.

CASE STUDY: Analysis of Mohammadpur UH&FWC, Noakhali The following table summarizes the situation at different times at the aforementioned clinic Situation Before Improvement Situation After Improvement Interventions

• Facility not clean. Waste is • Facility is clean, waiting area is • JSVs identified gaps and dumped outside the facility. clean and organized. action plan. Project supported • Waiting area is disorganized. • Dumping pits constructed the follow up on the • No waste management within facility premises. implementation of action plan. dumping pits. • Color coded waste bins in • Local government involved in • Poor infection prevention place. the construction of waste measures. • Infection prevention measures management pits. • No functioning autoclave in established including hand • Autoclave provided by the use. washing, decontamination of upazila. • Partograph is not in-use used instruments with chlorine • Staff reminded of the use of solution and a functioning partograph as part of labor.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 15 autoclave. • Partograph is used during labor.

2.3 Increase Local Ownership of Quality Improvement through establishing (QI) Committees The project continued to support the national QI strategy to establish QI committees at district, upazila, and health facility level. The project played an important role in facilitating the establishment of QI committees in Habiganj, Noakhali, Lakshmipur, and Jhalokati districts as per the guidelines provided by the national QI Secretariat. In addition, the project is facilitating the activation of the QI committees through holding meetings, summarizing action points for improvement, and following up on the their implementation. The graph below summarizes the status of the formation and activation of QI committees by district. While several QI committees have been formed, their activation is lagging behind.

Figure 7: Status of QI Committees in four High Intensity districts

100 86 80 73

60 54 43 40 35 40 28 Number Number 25 16 20 2 2 0 0 Habiganj Noakhali Lakshmipur Jhalokathi

Expected number of QI Committees QI Committees Formed Active QI Committees

2.4 Strengthening routine supervision system and promoting supportive supervision: The project continued to support Habiganj, Noakhali, Lakshmipur, and Jhalokati, in planning and conducting supervisory visits for first line and second line supervisors. The project puts emphasis on utilizing each supervisory visit as an opportunity to conduct an effective assessment of infection prevention measures, medical waste management, and compliance with clinical standards through the use of structured checklists. In addition, the project promotes the concepts of supportive supervision through strengthening the capacity of supervisors in providing on-job training and problem solving as well as developing an action plan for improvement for each facility and following up on its implementation.

Table 3 below summarizes the status of supervisory visits conducted in four districts in January and February, 2016.

16 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Districts 1st Line (Union) 2nd Line (Upazila/District) Planned Accomplished Planned Accomplished Habiganj 68 44 49 36 Jhalokathi 16 16 08 02 Lakshmipur 20 13 10 05 Noakhali 22 21 10 22 Total 58 50 28 29

2.5 Maternal Perinatal Death Review (MPDR): The project continues to assist the national plan for implementing MPDR in all districts. The project had started by implementing MPDR in Bebumganj upazila in Nk district. To date, the project scaled up MPDR implementation in 3 more upazilas in Nk district (Senbagh, Companiganj, and Hatiya), one upazila in LK district (Raipur), one upazila in Hg district (Nabiganj) and one upazila in Jk district (Rajapur).

Table 4: MPDR introduction in three districts. Districts Upazila of Intervention Participants Total (One Upazila/District) Male Female

Noakhali Rest 03 Upazilas 136 126 262 Lakshmipur Raipur 98 74 172 Jhalakathi Rajapur 40 61 101 Total 233 256 489

During the reporting quarter, the project organized orientation/sensitization meetings at the district level (Lk, Jk & Hg) under the leadership of the district’s Civil Surgeon and district and upazila Health Managers. The sensitization meeting was followed by training of trainers (TOT) on death notification (DN), verbal autopsy (VA), social autopsy (SA), and facility death review (FDR). Trainers were chosen from the selected upazilas in Lk, Jk, and Hg. The TOT was followed by service provider training. In total, 489 participants were trained including service providers, NGO staff, and MaMoni HSS project staff (see below).

An example of the maternal death findings and the death notification (DN), verbal autopsy (VA), and social autopsy (SA) conducted in Begumganj upazila, Noakhali district is presented below.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 17 Figure 8: Number of Maternal Death (MD), Death Notification (DN), Verbal Autopsy (VA), and Social Autopsy (SA), Begumganj, Noakhali 6

5 5 4 4

4 3 3 3 3 3 3 2 2 In Number 2

1 1

0 0 Apr-Jun'15 Jul-Sep'15 Oct-Dec'15 Jan-Feb'16 Axis Title

MD DN VA SA

2.6 Standards-based Management and Recognition (SBM-R): During the reporting quarter, health facilities in Habiganj, Noakhali, Lakshmipur, and Jhalokathi continued implementing the improvement action plan based on the internal assessment conducted using the structured assessment tools. Specifically, the table below summarizes progress by district during the reporting quarter:

District Number of Activity facilities

Habiganj 7 Implementing action plan based on 2nd internal assessment

Noakhali 7 Implementing action plan based on 2nd internal assessment

Lakshmipur 8 Implementing action plan based on 2nd internal assessment

Jhalokati 8 Implementing action plan based on 1st internal assessment

Common action plan items addressed by health facilities for improvement include:

• Improving health facility management including basic cleanliness, infection prevention and medical waste management. • Improving compliance with ANC standards. • Improving compliance with normal vaginal delivery standards. • Improving compliance with postnatal care standards. • Improving compliance with newborn and child care. • Improving compliance with family planning standards.

18 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 The following table summarizes the overall implementation of SBM-R and the expected time frame for completing all SBM-R steps in 35 facilities in four districts.

Cumulative number of facilities completing SBM-R steps and time frame for completing process

District SBM-R Implementation Steps

Baseline 1st Internal 2nd Internal External Recognition Assessment Assessment Assessment

Habiganj 12 12 12 5 Yr3 Q3

Noakhali 7 7 7 Yr3 Q3 Yr3 Q4

Lakshmipur 8 8 8 Yr3 Q3 Yr3 Q4

Jhalokati 8 8 Yr3 Q3 Yr4 Q1 Yr4 Q3

2.7 Establishing and supporting Regional Roaming Quality Improvement Team (RRQIT) to strengthen comprehensive emergency obstetric and newborn care The project continues to utilize the technical capacities available at the regional level, such as medical colleges and professional associations, to provide specialized technical support for improving CEmONC services. The project had developed RRQIT, in line with the national strategy for developing divisional quality improvement teams, in Sylhet and Barisal. Both teams had visited respective districts (Hg, Jk) and developed action plans for improvement of CEmONC services as well as general Photo 10: RRQIT Planning in management of district hospitals and MCWCs.

In this reporting period, the project facilitated the formation of RRQIT in Chittagong Division. Activities included preparation meetings that took place in Chittagong on February first and second to plan the formation and activation of the RRQIT. The meeting included divisional director FP, deputy divisional director DGHS, and OGSB members in Chittagong Medical College. As a result, another meeting was held on February 28, 2016 in Noakhali for the formation of the RRQIT. Members of the team include staff of Comilla and Noakhali medical college, instead of Chittagong medical college, to ensure regular support of MaMoni HSS districts (Nk and Lp). The meeting included RRQIT members and the Chittagong divisional and Noakhali, Lakshmipur, and representatives of

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 19 DGHS and DGFP as well as members of professional associations such as OGSB and the Bangladesh Pediatric Association (BPA).

In addition, the project followed up on the implementation of the findings and action plan developed based on the visit conducted by the Sylhet RRQIT to Habiganj district and the Barishal RRQIT to Jhalokati district. The following table summarized the action taken for improvement based on the RRQIT findings.

Table 7: Actions taken after RRQIT visits in Habiganj and Jhalokathi districts

Habiganj DH action taken based on RRQIT findings: New consultant has been posted & joined Color coded medical waste management bins have been introduced in some places including Obs. & pediatric ward, OT & labor room. All 5 GA machines are functioning. OT lights has been repaired. X-ray machine is functioning. Ultrasonogram machine sent to Dhaka for repair. Broken delivery tables has been removed & replaced. Cleanliness has been improved. Three dumping pits have been arranged, Pourshabha collecting general waste every day from DH. Visitors are controlled at least during consultant visit. Small traders in front of hospital have been restricted. Habiganj MCWC action taken: New autoclave machine has been available & functioning. Three dumping pits have been arranged. Cleanliness has been improved Construction for OT is under process. Jhalokathi DH action taken: Posting of an Anestheologist in process. Opening of digital ultrasonography service in process. Use of paper-based partograph is activated. Use 7,1% CHX and record started. Introduced comment box.

2.7 Strengthening Logistics MIS National level activities Coordination with SIAPS at the national level: The project continued to collaborate activities with SIAPS. A meeting was held with SIAPS on 2nd March, 2016 to share progress in implementing the Uniform LMIS at Lakshmipur district and the UMIS system for family planning and maternal health. As a result of the meeting, SIAPS will provide technical support by facilitating training on LMIS Uniform system in MaMoni HSS districts (Noakhali, Habigonj and Jhalokathi).

20 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Monitoring and improving availability of essential drugs at district level: The project continued supporting the district and sub-district managers in monitoring the availability of 25 drugs essential for MNCH programs as well as essential FP commodities. Data are shared with local counterparts in simple color coded dashboard with red indicating stock- outs and green indicating item availability (see examples below):

MNCH Essential Drugs' Monitoring

MNCH Essential Drugs' Monitoring

Civil Surgeon Store, Lakshmipur District

Jan, Feb. March. April. May. June. July. Aug. Sep. Oct. Nov. Dec. Name Items 15 15 15 15 15 15 15 15 15 15 15 15 SL#

1 Inj. Mag. Sulphate 2 Inj Oxytocin 3 Tab. Misoprostol 4 Tab. Iron Folate 5 Amoxicillin DT 6 Inj Gentamycin NA NA NA NA NA NA NA NA NA NA 7 7.1% Chlorhexidine 8 ORS MNCH drug: Inj.Oxytocin, District : Lakshmipur Jan. Feb. Mar. April May June July Aug. Sep. Oct. Nov. Dec. Store site SL# 15 15 15 15 15 15 15 15 15 15 15 15 1 CS Store 2 Dist. Hospital 3 Sadar Upz. 4 Ramgati 5 Kamal Nagar 6 Raipur 7 Ramganj

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 21 Number of district and upazila stores having Inj.Oxytocin in four districts of MaMoni HSS in January 2016 12

10

8 5 6 3 4 4 5 5 2 3 2 1 0 Noakhali Laksmipur Habigonj Jhalokathi

Number of stores available Number of stores not available

See Annex 4 for more results.

Utilization of data, case study: Jhalokathi district re-distributing IFA tablets for efficient utilization In February, 2016, a large quantity of IFA tablets at Jhalokathi district hospital store will expire in May 2016. As a result, the estimated amount needed for the hospital until May 2016 was calculated and the additional stock (100,000 tablets) was re-distributed to Upazilla Health Complex stores within the district of Jhalokathi where IFA tablets were in short supply.

2.8 Collaboration with Private Hospitals for Quality Improvement of Maternal and Newborn Services: In response to the increasing role of the private sector in providing health services, including maternal and newborn care, MaMoni HSS Project has started an initiative in Jhalokati district to strengthen collaboration between private hospitals and the district QI committee. The overall purpose of the collaboration is to monitor and improve maternal and newborn care services, particularly comprehensive emergency obstetrics and newborn care. During the reporting quarter, the project organized a meeting, on March 27, 2016, with representatives from 9 private hospitals in Jhalokati District. The meeting was chaired by Civil Surgeon, Jhalokati District and included several members of the district’s QI committee and a representative of OGSB professional association. The meeting emphasized the importance of establishing ongoing collaboration and information sharing between the QI committee and the private hospitals. Presentations included a summary of the maternal and newborn situation in Bangladesh and main interventions to reduce maternal and newborn mortality. In addition, a summary of main infection prevention standards and actions needed to monitor quality of emergency obstetrics and newborn care was presented. Discussion included the need for collecting and sharing basic data reflecting coverage and quality of cesarean section and ensuring basic measures in blood transfusion. The meeting was concluded with identification of next steps including the need for establishing continuous collaboration between the office of the civil surgeon and quality improvement committee and the private hospitals.

22 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2

Public-Private Collaboration on QI of Maternal & Newborn Services, Jk district, March 27, 2016 Case study: delivery situation and outcomes in private clinics of Noakhali MaMoni continued to collect information from Noakhali private clinics (refer to Table 10, below). In January and February, 14 clinics reported their data based on the supplementary form introduced by the previous Civil Surgeon. Sixty-four percent of all deliveries were performed through C-section, which reflects the national trend.

Table 10: Select data from private clinic reports (Jan-Feb 2016)

Month Admission Normal C- Total Live Still Neonat Matern Referral delivery Section birth birth al death al out Deaths

Jan 16 786 363 723 1,119 1,104 11 4 0 10

Feb 16 802 239 469 741 730 10 5 1 0

2.9 Monitoring Quality of Care Indicators Preliminary results from the first round The project conducted preliminary analysis of the first round of the quality of care (QoC) survey conducted in 4 districts (Habiganj, Noakhali, Lakshmipur, Jhalokhati). The survey included 10 sentinel sites in each district (1 DH, 1 UHC, 4 UH&FWC, and 4 Satellite Clinics). Data collection was performed through direct observation by trained surveyors. Preliminary results of assessing quality of ANC services show that, data from a total of 27 facilities in the 4 districts, iron and folic acid tablets were available in 25 facilities (93%). Running water was available in 24 out of 27 facilities, soap for hand-washing was available in 23 facilities, and latex gloves were available in 25 facilities. Available results from Jhalokati and Noakhali show that out of 14 facilities surveyed conducting normal vaginal deliveries, 10 (71% had newborn resuscitation bag and mask, 12 (86 %) had resuscitation mask, and 11 (79%) had penguin sucker.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 23 Out of a total of 26 facilities conducting normal vaginal deliveries surveyed in the four districts, 18 (69%) had partograph paper and wallboard (pre-drawn partograph on a fixed board on the wall, 11 (42%) had oxytocin injection, and 4 (15%) had magnesium sulfate 5 ml ampule. Out of 122 deliveries observed in Lk district all of them (100%) had oxytocin injection administered within 1 minute of delivery. Out of 172 deliveries observed in Jk district, due to shortage in stock, only 18% received oxytocin injection within 1 minute of delivery. Family planning data from Habiganj district shows that out of 272 clients, privacy was ensured in 13 cases (3%), client concerns were discussed with 56 clients (27%), job aid was used with 142 clients (47%), and next date of visit was mentioned to 40 clients (8%). Based on the survey findings, MaMoni HSS took immediate steps to ensure uterotonic availability and ensure replaced HBB equipment in all health facilities.

Preparation for the second round The project has advanced in the preparation for the second round of the QoC indicator survey. Data collection tools have been revised, measures to ensure quality of data collection have been reviewed and strengthened, and the method of data collection and data entry has been transformed from paper-based to digital through tablets. 2.10 Local Government engagement to improve quality of service MaMoni HSS has engaged Union Parishads to allocate budget to improve quality of service. This included investments in facility cleanliness, supplies for infection prevention and waste management.

Table 11: Union Parishad budget allocated in FY’15-16 to improve coverage and quality of service District Total UP allocated UP allocated UP utilized Investment areas UP budget for budget for budget for MNCHFPN MNCHFPN MNCHFPN (BDT.) (Oct.-March) (BDT.) Habiganj* 77 76 7,320,159 538,060* Medicine, solar panels, Noakhali 44 44 5,497,455 1,173,629 minor facility repair, chair for EPI centre, Lakhsmipur 58 58 4,832,940 183, 050 water pump for Jhalokathi* 32 32 2,729,169 88,070* UH&FWC, EPI center renovation, FWC Total 211 210 20,379,729 1,799,759 construction, temp. staff cost, referral cost etc

Most of the Union Parishads of Jhalokathi and Habiganj were dissolved because of a new round of nationwide UP elections. The Chairmen did not have signatory authority to funds to prevent the funds to be used for campaign financing. Thus spending was much lower in the January-March quarter. This will continue in April-June quarter as well.

24 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 2.11 Support MOH&FW to roll out paper-based RHIS MaMoni HSS continued to support DGFP MIS unit to roll out the “Training on FWA Register (8th edition) and MIS Forms” in the project districts. All the FWAs, FPIs, FWVs, SACMOs (DGFP) and concerned project staff received the training. The trainings were organized at respective upazilas in batches. DGFP Dhaka and upazila level resource persons (UFPO & MO-MCH) along with the project staff facilitated the training. The field workers have been using these new MIS tools since January 2016.

IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems 3.1 Journalist Engagement In this quarter, MaMoni HSS organized a number of journalist visits in different locations of its project area with a special focus to ensure optimum media coverage on MNCH/FP/N. As a result of broader MaMoni HSS media advocacy, 22 news stories have been published by different media outlets (Appendix 9). The news/stories included: issue-specific current situation, case studies, and technical information with calls of actions for required health system improvement. Following the journalist orientation on newborn health, a long-term follow up activity has been established to ensure that the oriented journalists put into practice what they have learned through this training. The reporters are well connected with local project office personnel who always help them to improve reporting and brainstorm ideas. The media engagement and capacity building program has been delivering a significant increase in media coverage on MNCH/FP/N issues and increased engagement of involved stakeholders. Representatives from multiple government ministries/directorates, and non- governmental partners have been deeply involved in the program. This contributes to facilitating closer collaborations across organizations and has resulted in both increased dialogue and news coverage. 3.2 Program learning initiatives undertaken and disseminated MaMoni HSS participated in two TRAction dissemination meetings where lessons from MaMoni I and MaMoni HSS implementation were shared on “Improvement of staff presence and quality of care at the district level facilities in Habiganj”, and “Assessing effectiveness of targeted approach for neonatal health and family planning services in Bangladesh” was disseminated on January 18, 2016. In Year Two, a total of five operations research (OR) efforts were approved for program learning purposes on: the use of partograph as a decision-making tool for identifying and referring complicated pregnancies; viability of private CSBAs; assessment of the quality of ANC at satellites and identification of the challenges; assessment of quality of permanent methods for family planning services provided at public health facilities; and experience of CHX pilot implementation. MaMoni HSS shared findings on quality of LAPM services with the Mayer Hashi project of EngenderHealth and Marie Stopes in early April 2016, to obtain their buy-in for joint advocacy with DGFP. A meeting with the CCSDP unit of DGFP has been scheduled for early May 2016.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 25

IR 4. Identify and Reduce Barriers to Accessing Health Services 4.1 Community mobilization and BCC activities to remove barriers MaMoni HSS facilitated the monthly cMPM meetings involving community volunteers (CVs), frontline health workers (Health Assistants, FWAs, CHCP), and their supervisors (FPIs; AHIs), to update the information on eligible couples, mothers, and children, and to follow up on drop-outs. During January-March 2016, 98% of the cMPMs were held in 23 high-intensity upazilas. The project supported BCC teams to conduct targeted BCC campaigns on prioritized MNCH/FP/N messages, reaching 33,056 people. These campaigns delivered a number of BCC messages, which were prioritized at the upazila level. MaMoni HSS trained 19,982 CVs on FP counseling and compliance. These volunteers were unpaid, and worked as an extension of the FWVs and FWAs in reaching the mothers with critical information.

4.2 Reaching mothers through Aponjon services Average monthly registration has gone up by 6% with the introduction of Aponjon’s own sales force in this quarter. Aponjon registered 11,657 new clients. Its cumulative client total as of March 31, 2016 stands at 1,539,475. Major contributors of registration in this quarter have been MCC, Aponjon Salesforce, and IMS in descending order.

Table 12: Customer acquisition by source: Jan-Mar 2016 Month Aponjon BP Icddr,b IMS MCC January 8220 0 2 68 February 753 16 0 3 March 2684 0 1 3

Aponjon call center The quality and effectiveness of Aponjon service is ensured through rigorous monitoring and maintenance. Operations teams monitor call center & counselling lines. Aponjon outsources the call center & counselling line with Synesis It ltd. Number of subscriber calls is summarized below.

Call from Month Incoming call Outgoing call DOB update Data Entry subscriber Jan 2247 5219 7341 28 N/A Feb 1378 2844 3492 25 N/A Mar 1239 2318 2019 32 N/A

Aponjon counselling Line

26 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Aponjon introduced a counselling line for clients to access appropriate counsellors during the pregnancy and postnatal period. The following table shows the incoming and outgoing call patterns.

Month Incoming call Outgoing call

Jan 2977 60 Feb 2663 43 Mar 2549 34 Total 8,189 137

CHALLENGES, SOLUTIONS, AND ACTION TAKEN

Challenges • Drug shortage: The DDS kits of UH&FWCs and the drug supply of the Community Clinics have been interrupted since September 2015 due to procurement issues at DGHS and DGFP. This has severely affected the coverage and quality of essential services at the community level. MaMoni HSS has been closely monitoring the situation, and where appropriate, has been liaising with the Union Parishads, Ministry of Social Welfare funds to leverage temporary support to meet the shortfall for drugs and supplements such as oxytocin, IFA, and misoprostol. • While the DGHS-procured Chlorohexidine has been distributed to 53 districts for use in district hospitals, UHCs and DGHS managed UH&FWCs, the DGFP has yet to distribute110,000 doses of CHX received from the Global CHX working group through their system. • Union Parishad election: Several rounds of UP elections were held this quarter. Local government funds were not available

Opportunities • In the upcoming quarter, the focus of the project will be on consolidating implementation components as per the recommendation of the MaMoni midterm evaluation. • MaMoni HSS will expand RHIS to entire Habiganj district, and commence readiness assessment in three other high intensity districts • MaMoni HSS will organize a national dissemination meeting on the assessment findings of UH&FWC strengthening at divisional levels. • MaMoni will engage in an assessment of workload at all levels of workers in one district, in partnership with WHO and the Human Resource for Health unit of MOH&FW. • MaMoni will provide technical assistance to the Quality Improvement Secretariat. • MaMoni will support development of program implementation plan (PIP) of the 4th sector program • MaMoni will introduce unified LMIS in all high intensity upazilas.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 27 APPENDIX 1: SCOPE AND GEOGRAPHICAL COVERAGE OF MAMONI HSS PROJECT

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

MaMoni HSS designed a two-pronged approach in which districts and upazilas (sub-district) were categorized into one of two groups—high-intensity intervention areas and health system capacity strengthening areas. The aim of the high-intensity areas is to demonstrate best-practice models of MNCH/FP/N health care delivery through intensive support to the Government of Bangladesh (GoB), and if needed, direct implementation to maximize learning and advocacy for scale-up nationally. Based on an analysis of gaps in coverage and equity of access to high-impact MNCH/FP/N services, the project identified a total of 23 upazilas across five districts to serve as the project’s high-intensity areas. Of the 23 upazilas, district saturation was achieved in Habiganj, Lakshmipur, and Jhalokathi Figure 13: MaMoni geographical scope districts, while in the Noakhali and Pirozpur districts, four and two upazilas were supported, respectively. The health systems (HS) capacity strengthening areas cover a total of 17 upazilas—all seven upazilas of Bhola, five upazilas of Noakhali, and five upazilas of Pirozepur (refer to Figure 1 and Table 1). Whereas the high-intensity areas focus on support for a complete package of MNCH/FP/N interventions, the HS capacity strengthening areas receive less intensive technical assistance on a selected set of interventions. Minimal support was provided to GoB health systems to scale up interventions such as 24/7 Union Health and Family Welfare Centers (UH&FWCs), chlorhexidine for cord care, and Helping Babies Breathe (HBB); instead, the focus was on supporting the strengthening of existing MNCH/FP/N services. MaMoni HSS has four intermediate results (IR): IR 1. Improve service readiness through critical gap management. IR 2. Strengthen health systems at district level and below. IR 3. Promote an enabling environment to strengthen health systems at the district level. IR 4. Identify and reduce barriers to accessing health services.

28 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Table 1. Summary of MaMoni HSS geographic scope

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

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

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

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

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

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 29 APPENDIX 2: CASE STUDIES

A.1.1. Marjiya Begum used Aponjon messages to prepare for motherhood Marjiya Begum, a mother of two and housewife from Bagerhat Sadar, has been receiving Aponjon service since the early weeks of her last pregnancy. She signed up for the service using her husband’s mobile and preferred receiving the IVR messages at night when her husband is back home from work. Following her baby’s birth, Marjiya graduated into the new mother service of Aponjon. Messages from Aponjon are currently addressing ways of taking better care of Photo: Marjiya Begum and her baby her four month old. She remembers how messages from Aponjon not only made her realize the importance of ANC but also reminded her of visits at the right time. Over time she grew so fond of “Doctor Apa” (a fictional character in some Aponjon messages) that she called the Aponjon registration number to report date of birth as soon as her baby was born. Although she is aware of the Aponjon counseling line, she chose not to use it because of the price of the service. She thought such a counseling line could be immensely helpful for others like her but a little lower price would improve uptake. Marjiya said wistfully, “Now I see how little women in my neighborhood know about proper maternal and newborn care. Aponjon messages opened my eyes to many danger signs I didn’t know existed!” Marjiya said she became an advocate for Aponjon among friends and family after using the service. She fondly remembers how Aponjon has helped her through her latest pregnancy and newborn period, and helped her husband prepare better for the delivery as well. For instance, she felt taken care of when messages addressed the importance of blood group matching and tetanus vaccination a week before her delivery. “I’m definitely signing up for it too!” is how Marjiya Begum reacted when asked about the new Aponjon Shoishob service for children 1-5 years of age.

A.1.2 Social autopsy at the community level to understand preventable deaths in Noakhali

January 12, 2016, was supposed to be a happy day with the delivery of for the first baby born to Morshida Aktar Monzu, a 20-year old housewife from Chotki Bari village of Durgapur Union. However, instead of the joy of hearing her newborn’s cry, Morshida and her family were mourning the delivery of a dead baby. Morshida never went for any antenatal care. She experienced jaundice, apparently caused by severe anemia. When she started feeling labor pain in the morning, she also noticed that the fetus’s movement was less than usual. She is illiterate, and her husband, a 26 year old day

30 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 laborer who only completed class 5, did not seek medical help. 12 hours later when the labor pain was severe, at that time Morshida did not feel any fetal movement, a traditional birth attendant (Dai) performed the delivery at home.

The death notification was completed on the same day of death, followed by verbal autopsy on January 26. A social autopsy was conducted on January 27 in front of the deceased person’s house. It was facilitated by the Family Planning Inspector (FPI) of Durgapur Union. Over 40 persons attended including the family of the stillbirth, men and women from the community including pregnant women, elite members of the community such as the Chairman Durgapur Union Purishad. MaMoni HSS Project’s staff also participated in the social autopsy.

After discussion of the case, the community members identified the following main causes of death:

1. No ANC checkup. 2. No care for mother’s anemia and jaundice by qualified service provider. 3. Lack of education and awareness by mother and family members about pregnancy and possible complications such as un-noticed absence of fetal movement for several hours. 4. Delivery by un-skilled birth attendant. Actions identified to avoid future stillbirths:

1. Every pregnant woman should get ANC from qualified staff. 2. Every pregnant woman should have a plan for delivery ahead of time (where, how to go there, arrange transportation, arrange needed cash ahead of time). 1. All deliveries should be conducted at the health facility instead of the local dai.

A.1.3. Malnourished baby Ruhul Amin on his way to recovery because of MaMoni’s Community Case Management intervention Ruhul Amin, the second child of Badsha Howlader, 30, and Saleha Howlader, 22, was born September 10, 2015 by an untrained Traditional Birth Attendant at home. They live in Alokdia village, Binoykathi upazila of Jhalokathi district. The nearest community clinic is 2 km away, and the UH&FWC is 3 km away. On February 18, 2016, Saleha visited the community clinic with her son. Abdus Salam, the CHCP screened the baby for malnutrition by weighing him and measuring his mid-upper arm circumference (MUAC) using the tape received during a MaMoni HSS CCM training. The baby, with a weight of 4.5kg and a 10 cm MUAC measurement, was diagnosed as severely malnourished.

The CHCP advised the mother to go to the SAM corner at Photo: Saleha and baby Ruhul Jhalokathi District Hospital. When the mother refused, the Amin CHCP contacted MaMoni Field Support Officer (FSO) to provide additional counseling for referral. The CHCP and FSO visited their house the next day, and discussed the urgency of referral and treatment options with the family. Once the baby was admitted to the SAM corner, Dr. Golam Mostafa, the Resident Medical Officer (RMO) initiated therapeutic treatment according to the SAM protocol. As of March 31, his weight increased to 5.6kgs and MUAC increased to 11.8cm. Saleha is very happy.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 31 She said, “when the baby was sick, I was very worried. Day by day, my baby is getting better. When the baby is healthy, I am also happy.” They believe Ruhul will completely recover after receiving care and treatment from the district hospital.

32 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 APPENDIX 3: PROGRAM PERFORMANCE INDICATORS (OCTOBER–MARCH 2016) Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Project Goal: Improve utilization of integrated maternal, newborn, child health, family planning and nutrition services Source: Population based Survey: Percent of women received at least one antenatal care visit from a medically Round III: Tracer indicators (Nov trained provider 2015 - Mar 2016) High intensity areas

Lakshmipur 67 NA 71 Noakhali* 61 NA 66

Habiganj 66 NA 81

Jhalokathi 69 NA 74 Pirozepur* 67 NA 75 HSCS areas

Pirozepur 63 NA NA MaMoni will conduct the next Bhola 51 NA NA round of population based survey

for the HSCS areas in FY'17 Noakhali 60 NA NA

Source: Population based Survey: Percent of births receiving at least four antenatal care (ANC) visits during Round III: Tracer indicators (Nov pregnancy 2015 - Mar 2016) High intensity areas

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

Pirozepur 43 NA NA MaMoni will conduct the next Bhola 22.5 NA NA round of population based survey

for the HSCS areas in FY'17 Noakhali 20 NA NA

Source: Population based Survey: Percent of Births Attended by a Skilled Doctor, Nurse or Midwife Round III: Tracer indicators (Nov 2015 - Mar 2016) High intensity area

42.0 NA Lakshmipur 37 Next round of data from Noakhali* 36 NA 35 Population based Survey: Round III: Tracer indicators will be Habiganj 37.0 NA 32 available in Q2 report

Jhalokathi 50.0 NA 51

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 33 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Pirozepur* 48 NA 51 HSCS areas

Pirozepur 48.5 NA NA MaMoni will conduct the next Bhola 29 NA NA round of population based survey

for the HSCS areas in FY'17 Noakhali 37 NA NA

Source: Population based Survey: Percent of women with home births who consumed misoprostol to prevent Round III: Tracer indicators (Nov postpartum hemorrhage 2015 - Mar 2016) High intensity areas

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

Pirozepur 30.5 NA NA MaMoni will conduct the next Bhola 23 NA NA round of population based survey

for the HSCS areas in FY'17 Noakhali 18 NA NA

Source: Population based Survey: Percent of newborns initiated breastfeeding within one hour after birth Round III: Tracer indicators (Nov 2015 - Mar 2016) High intensity areas

Lakshmipur 73 NA 48 Noakhali* 70 NA 64 Habiganj 85 NA 79

Jhalokathi 65 NA 42 Pirozepur* 60 NA 41 HSCS areas

Pirozepur 56 NA NA MaMoni HSS will conduct the next Bhola 68 NA NA round of population based survey

for the HSCS areas in FY'17 Noakhali 75 NA NA

Source: Population based Survey: Percent of newborns received chlorhexidine application on their umbilical cord Round III: Tracer indicators (Nov immediately following birth 2015 - Mar 2016) High intensity areas

Lakshmipur 40 NA 1 Noakhali* 40 NA 1

Habiganj 40 NA 4

34 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Jhalokathi 40 NA 1 Pirozepur* 40 NA 2 HSCS areas

Pirozepur NA NA NA - MaMoni will conduct the next Bhola NA NA NA - round of population based survey Noakhali NA NA NA - for the HSCS areas in FY'17 Source: Population based Survey: Percent of newborns receiving postnatal health check within two days of birth Round III: Tracer indicators (Nov 2015 - Mar 2016) High intensity areas

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

Pirozepur: 9 NA NA MaMoni will conduct the next Bhola: 9 NA NA round of population based survey

Noakhali: 19 NA NA for the HSCS areas in FY'17

Source: Population based Survey: Modern contraceptive method prevalence rate Round III: Tracer indicators (Nov 2015 - Mar 2016) High intensity areas

Lakshmipur 53 NA 54

Noakhali* 51.5 NA 55

Habiganj 47 NA 45

NA Jhalokathi 57 56 Pirozepur* 57 NA 53 HSCS areas

Pirozepur 54.5 NA NA MaMoni will conduct the next Bhola 57.5 NA NA round of population based survey

for the HSCS areas in FY'17 Noakhali 50 NA NA

Couple years of protection (CYP) Source: DGFP MIS Form 4 in USG-supported programs (accessed online) High intensity areas 748,496 133,134 116,634 Lakshmipur 229,858 38,062 35,890 Noakhali* 138,470 30,814 23,389 Habiganj 221,972 39,607 35,799

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 35 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Jhalokathi 107,178 15,728 13,669 Pirozepur* 51,018 8,924 7,887 HSCS areas 106,936 99,964

Pirozepur 20,744 18,326 Bhola 59,242 57,164 Noakhali 26,950 24,474

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

Lakshmipur 35 NA 44 Noakhali* 35 NA 35 Habiganj 85 NA 78 Jhalokathi 35 NA 59 Pirozepur* 35 NA 19 HSCS areas

Pirozepur 35 NA NA Source: SDP assessment and Bhola 35 NA NA training data (HI Upazilas only) Noakhali 40 NA NA Percentage of public health facilities with functional bags and masks (two neonatal size mask) in the delivery room High intensity areas

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

Jhalokathi 35 NA 61 Pirozepur* 35 NA 63 HSCS areas

Pirozepur NA NA NA

Bhola 35 NA NA

Noakhali NA NA NA

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

Lakshmipur 85 NA 87

Noakhali* 85 NA 81 Habiganj 99 NA 88 * Jhalokathi 85 NA 74 *

36 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Pirozepur* 85 NA 100 HSCS areas

Pirozepur 10 NA

Bhola NA NA

Noakhali 15 NA

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

Lakshmipur 25 NA 31 Noakhali* 16 NA 18

Habiganj 35 NA 36

Jhalokathi 17 NA 16 Pirozepur* 2 NA 5 HSCS areas

Pirozepur 7 NA Bhola 30 NA

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

Lakshmipur 13 11 0 Noakhali* 17 20 0 Reason for Variation: MaMoni Habiganj 43 54 42 plans to reduce temporary health workers in phases in FY'16. Jhalokathi 16 4 0 In addition to the temporary gap Pirozepur* NA NA NA against vacant positions, the project has deployed 39 HSCS areas temporary staff to complement Pirozepur NA NA GOB staff in ensuring round the close. Bhola NA NA Noakhali NA NA

Sub-IR 1.2: Strengthen capacity of service providers to provide quality services Number of people trained in maternal/newborn health 82090 Source: Project MIS through USG-supported programs High intensity areas 1906 349 Note: This is appropriate Lakshmipur NA 404 according to Annual Workplan

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 37 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Women 215

Men 189

Noakhali* NA 483 Women 285

Men 198

Habiganj NA 135 334 Women 51 186

Men 84 148

Jhalokathi NA 164 Women 68

Men 96

Pirozepur* NA 720 15 Women 441 7

Men 279 8

National level NA 17070 22073 trained on CHX, CNCP, HBB HSCS areas 665 616

Pirozepur 255

Women 158 Men 97 Bhola NA 665 361 NA Women 320 199

Men 345 162

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

Men 0

Noakhali* 0 115 Women 104

Men 11

Habiganj 0 107 Women 107

Men 0

Jhalokathi 0 Women

Men

38 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Pirozepur*

Women

Men

National level NA 8

HSCS areas NA NA 0 Pirozepur NA

Bhola NA

Women

Men

Noakhali NA

Number of people trained in child health and nutrition Source: Project MIS through USG-supported programs High intensity areas 760 0 356

Lakshmipur 120

Women 66

Men 54

Noakhali* 137

Women 78

Men 59

Habiganj 52

Women 27

Men 25

Jhalokathi 47

Women 29

Men 18

Pirozepur*

Women

Men

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

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

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 39 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Lakshmipur 26 16 16 intensity upazilas

Noakhali* 14 11 11 Habiganj 28 26 26 Jhalokathi 10 16 16 Pirozepur* 4 6 6 HSCS areas 0 0

Pirozepur 0 0 Bhola 0 0

Noakhali 0 0 Intermediate Result 2: Strengthen health systems at district level and below Number of district level quarterly performance review meeting held for data-driven Source: QPRM meeting minutes performance review and planning High intensity areas 24 5 6 Lakshmipur 4 1 1

Noakhali* 4 1 1

Habiganj 4 1 1

Jhalokathi 4 1 1

Pirozepur* 4 1 1 Bhola NA 0 1 Data expected from QI sentinel monitoring. The system is being established. However we have Intra partum still birth rate in project assisted facilities collected it from DGFP MIS and DHIS2 according to our suggested sentinel sites <7/1,00 High intensity areas NA 0 <7/1,00 Lakshmipur NA 10.4 0 <7/1,00 Noakhali* NA 4.6 0 <7/1,00 Habiganj NA 7.1 0 <7/1,00 Jhalokathi NA 2.7 0 <7/1,00 Pirozepur* NA NA 0 Sub-IR 2.1: Improve leadership and management at district level and below Number of GOB managers supported for leadership and management capacity development Lakshmipur NA NA 5 Source: Project MIS & District Noakhali NA NA 3 team

40 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Habiganj NA NA 8

Jhalokathi NA NA 5

Pirozepur NA NA 5 Bhola NA NA 3 Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs Number of upazilas with updated comprehensive annual Source: Project MIS

MNCH/FP/N plan High intensity areas 23 36 Lakshmipur 5 0 5 Noakhali* 4 0 5 Habiganj 8 0 8 Jhalokathi 4 0 4 Pirozepur* 2 0 7 Bhola NA 0 7 Sub-IR 2.3: Strengthen local management information systems Percentage of community micro planning units conducting monthly meeting Source: Project MIS High intensity area

Lakshmipur 95 99 99

Noakhali* 95 99 99

Habiganj 100 100 100

Jhalokathi 95 99 96

Pirozepur* 95 81 83 Sub-IR 2.4: Establish quality assurance system at district level and below Percent of planned supervision visit conducted where a supervision tool was used and findings shared with providers High intensity areas 90 122 67 Lakshmipur 90 47 60 Noakhali* 90 108 179 Habiganj 90 183 59 Jhalokathi 90 108 25 Pirozepur* 90 0 0 Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 41 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Percent of USG-assisted service delivery points (SDPs) that experience a stock out at any time during the reporting period of a contraceptive method that the SDP is expected to provide High intensity areas <3 7 3 1.7 Lakshmipur <3 Noakhali* <3 6 6.1 * Please refer to Appendix for explanation Habiganj <3 10 9.8 *

Jhalokathi <3 1 3.4 Pirozepur* <3 2 2.7 Sub-IR 2.6: Strengthen local government planning and engagement in health service provision The data was not available. Because of a server crash of CRVS Percentage of unions that had online data. Government online at least 50 percent of the system is not functioning and estimated births registered MaMoni HSS did not have access within 45 days of birth to the information. Therefor we are using EPI data. High intensity areas 40 NA Lakshmipur 40 NA 75 Noakhali* 40 NA 96 Begumganj upazila only Habiganj 40 NA 161 Jhalokathi 40 NA 28 Pirozepur* 40 NA 58 Nazirpur upazila only Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N Number of union parishads (UP) that spent funds to support Source: Project MIS

MNCH/FP/N activities High intensity areas 226 67 100 Lakshmipur 58 4 11 Noakhali* 44 17 30 Reason for variation: Some of the UP were dissolved in Habiganj and Habiganj 77 33 46 Jhalokathi ahead of elections Jhalokathi 32 13 13 Pirozepur* 15 0 0 Intermediate Result 3: Promote enabling environment to strengthen district level health system Number of critical vacancies filled by GOB recruitment or Source: Project MIS redeployment in project areas High intensity areas 25 Lakshmipur 5

42 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Noakhali* 5 Habiganj 5 3 3 FWV, Nurse, doctor Jhalokathi 5 2 FWV, Nurse Pirozepur* 5 2

Sub-IR 3.1: Policy reforms in place to promote local planning and need-based human resource deployment in the public sector 1. Guideline on "Prevention of Pre- Number of policies/ eclampsia and Eclampsia and its strategies/guidelines on MNH primary management in the 4 0 2 developed/revised with MaMoni community” HSS support 2. Guideline on CSBA counselling on FP methods and services Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program Number of program learning TRAction Targeted approach, initiatives completed and 10 3 2 TRAction Referrral Study disseminated Intermediate Result 4: Identify and reduce barriers to accessing health services Number of deliveries with a SBA DGFP MIS, DHIS2, pCSBA in USG-assisted programs High intensity areas 61,440 10,985 12,894 Lakshmipur 17,332 3,940 3,121 Noakhali* 11,622 1,991 3212 Habiganj 23,580 4,082 5263 Jhalokathi 6,362 607 634 Pirozepur* 2,544 365 664 HSCS areas 45,579 5,115 5,337 Pirozepur 10,796 1,595 1,531 Bhola 1,755 2,229 3,235 Noakhali* 33,028 1,291 571 Number of antenatal care (ANC) visits by skilled providers from 486,499 150,691 155,192 DGFP MIS, DHIS2, pCSBA USG-assisted facilities High intensity areas 303,839 106,244 110,895 Lakshmipur 48,846 26,655 20,697 Noakhali* 39,468 23,012 30,034 Habiganj 191,464 45,969 48,405 Jhalokathi 15,048 7,974 7,331 Pirozepur* 9,013 2,634 4,428 HSCS areas 182,660 44,447 44,297

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 43 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Pirozepur 31,544 7,528 7,519 Bhola 62,314 16,311 15,634 Noakhali 88,802 20,608 21,144 Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches Number of people reached through project supported BCC Source: Project MIS activities High intensity areas 650,000 223,488 16,528 Lakshmipur 175,000 54,111 5,636 Women 28348 4047 Men 25763 1589 Noakhali* 135,556 160,584 4,331 Women 71927 3505 Men 88657 826 Habiganj 195,000 5,855 4,217 Women 4983 3678 Men 872 539 Jhalokathi 113,587 2,938 2,344 Women 2139 1946 Men 799 398 Pirozepur* 30,857 0 0 Women 0 0

Men 0 0

Bhola Women Men Sub-IR 4.2: Enhance community engagement in addressing health needs Number of trained community volunteers promoting MNCHFPN Source: Project MIS through project support High intensity areas 24,925 23,168 23,181 Lakshmipur 6,710 6,409 6,485 Noakhali* 5,900 5,664 5,693 Habiganj 8,379 8,265 8,345 Jhalokathi 2,731 2,300 2,304 Pirozepur* 1,205 530 354

44 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Achieve Achievemen Target ment Variation t (Oct–Dec Remarks 2016 (Jan-Mar (%) 2015) 2016) Number of Community Action Groups with an emergency transport system for maternal and newborn health care through USG-supported Source: Project MIS programs High intensity areas 20,001 18,999 20,081 Lakshmipur 6,461 6,056 6,102 Noakhali 3,876 3,586 3,871 Habiganj 4,369 8,136 8,060 Jhalokathi 3,746 1,221 1,694 Pirozepur* 1,549 0 354

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 45 APPENDIX 4: MNCH ESSENTIAL DRUGS MONITORING REPORT

The LMIS activity in this quarter included different type of activity and had the common sharing of information related to LMIS in different activity of the program among different stakeholders. The basis for LMIS related activity is the collection of data from the DGHS and DGFP at the store level on the availability, Non availability of MNCH essential drugs and relationship of availability with the services provided.

Table 1: MNCH essential drugs monitoring throughout the year at Civil Surgeon store, Lakshmipur district using color code.

MNCH Essential Drugs' Monitoring Civil Surgeon Store, Lakshmipur District S Mar June Name Jan, Feb. April. May. July. Aug. Sep. Oct. Nov. Dec. L ch. . Items 15 15 15 15 15 15 15 15 15 15 # 15 15 Inj. Magnesi um Sulphat 1 e Inj 2 Oxytocin Tab. Misopro 3 stol Tab. Iron 4 Folate Amoxicil 5 lin DT Inj Gentam 6 ycin 7.1% NA NA NA NA NA NA NA NA NA NA Chlorhe 7 xidine

ORS 8

Table 2: Availability of MNCH tracer drugs ,Inj Oxytocin at all the stores of Lakshmipur district.

MNCH Essential Drugs' Monitoring MNCH drug:Inj.Oxytocin, District : Lakshmipur

SL Name Jan. Feb. Mar. April. May. June. July. Aug. Sep. Oct. Nov. Dec. # Items 15 15 15 15 15 15 15 15 15 15 15 15 CS

1 Store Dist. Hospit 2 al

46 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Sadar

3 Upz. Ramg

4 ati Kamal

5 Nagar Raipu

6 r Ramg

7 anj Each month the status of MNCH essential medicine at different store level were collected and information were extracted to prepare the color coded report. This report is used for sharing of information at different level with different stakeholders. Table 3: Availability of Inj. Gentamycin at different stores of Jhalokathi

Monitoring MNCH Essential Drugs MNCH Drug:Inj.Gentamycin, District: Jhalokathi Name of the store Nov.15 Dec.15 Jan.16 Feb.16

1 CS Store 2 District Hospital 3 Sadar 4 Nalchiti 5 Kathalia 6 Rajapur

Table 4: Availability of Inj. Oxytocin at different stores of Jhalokathi

Monitoring MNCH Essential Drugs

MNCH Drug: Inj. Oxytocin, District: Jhalokathi Name of the store Nov.15 Dec.15 Jan.16 Feb.16

CS Store 1 District Hospital 2 Sadar 3 Nalchiti 4 Kathalia 5 Rajapur 6 Table for availability of Tablet Misoprostol at different stores of Jhalokathi and availability of Inj. Magnesium Sulphate at different stores of Jhalokathi are given in the Annex. Table 5: Availability of Tab. Iron Folate at different stores of Jhalokathi

Monitoring MNCH Essential Drugs

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 47 MNCH Drug: Tab. Iron folate, District: Jhalokathi Name of the store Nov.15 Dec.15 Jan.16 Feb.16

1 CS Store 2 District Hospital 3 Sadar 4 Nalchiti 5 Kathalia 6 Rajapur

Table 6: Availability of Inj. Oxytocin at different stores of Noakhali

Monitoring MNCH Essential Drugs

MNCH Drug: Inj.Oxytocin, District: Noakhali Name of the store Nov.15 Dec.15 Jan.16 Feb.16

1 CS Store Sebbag 2 Begum ganj 3 Companigonj 4 Subornachar 5 6 Hatiya

Table 7: Availability of Tab. Misoprostol at different stores of Noakhali

Monitoring MNCH Essential Drugs

MNCH Drug: Tab. Misoprostol, District: Noakhali Name of the store Nov.15 Dec.15 Jan.16 Feb.16

CS Store 1 Sebbag 2 Begum ganj 3 Companigonj 4 Subornachar 5 Hatiya 6

Table 8: Availability of Tab. Iron Folate at different stores of Noakhali

Monitoring MNCH Essential Drugs MNCH Drug: Tab. Iron Folate, District: Noakhali Name of the store Nov.15 Dec.15 Jan.16 Feb.16

48 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 1 CS Store 2 Sebbag 3 Begum ganj 4 Companigonj 5 Subornachar 6 Hatiya Sharing of LMIS data with local level GoB official: Collected data, including the color coded report, were shared in the Quarterly Partners Review Meetings in Noakhali, Lakshmipur, and Habigonj districts to inform local level Managers about the Essential MNCH drug status at the store level and help them plan on LMIS to prevent potential stock outs. The planning included ensuring availability of essential MNCH drugs at the store and Service Delivery Point (SDP) level. The CS, DDFP, UFPO were all present in those meetings and relationships with the availability of essential MNCH drug with services were analyzed e.g. cross checking the distribution of tablet Misoprostol with the number of ANC visits.

Meeting with the Civil Surgeons (CS) from Noakhali, Lakshmipur and Jhalokathi districts on LMIS reporting:

Meetings were arranged at the CS offices with the CSs of Noakhali, Lakshmipur and Jhalokathi districts during field visits to those districts. The stock status of the 25 essential drugs at all the upazila stores were shared with the CS. Lakshmipur district suggested including the different strengths of a drug in the list to express the actual status of MNCH drug availability at the store level of DGHS. They also suggested collecting more information from SDPs, which has already been started as a part of the Quality Improvement (QI) visits like Joint Supervisory Visit (JSV), and Regional Roaming Quality Improvement Team (RRQIT).

Utilization of LMIS data for improving MNCH services: Transfer of iron plus folic acid tablets from District Hospital to DDFP office.

During a visit to the Jhalokathi District Hospital on 24th February, it was identified that there were about 3,00,000 doses of iron plus folic acid at the district hospital (DH) set to expire in May 2016. The utilization rate is much slower than the expiration date, so a meeting was arranged with Dr. Abdur Rahim, Civil Surgeon, Jhalokathi and Ferdousi Begum, DDFP and UFPO Sadar upazilla, Jhalokathi to facilitate the transfer of iron plus folic acid tablets from the DH to DGFP sites (MCWC,UH & FWC) of different upazilas. The transfer of 1,00,000 doses was done after having proper Government Order dated 1/3/2016 to four upazilas. These tablets would be utilized before the expiration date. The amount of tablets were 30,000 in Jhalokathi Sadar, 30,000 in Nalchiti upazila, 20,000 in Razapur upazila and 20,000 in Kathalia upazila.

Some examples of availability of MNCH essential drugs in January, 2016:

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 49 NUMBER OF STORES HAVING AMOXICILLIN IN FOUR DISTRICTS OF MAMONI HSS PROJECT IN JANUARY 2016

Number of stores available Number of stores not available

3

3 4 5 7

3 2 1 NOAKHALI LAKSMIPUR HABIGONJ JHALOKATHI

Fig 1: Number of stores (DGHS store) having availability of Amoxicillin DT at four different districts of MaMoni HSS

Amoxicillin DT: Amoxicillin DT was available (FIG.3) at the 2 stores of Noakhali district out of 6 stores, namely CS store and Begamgonj store. In Lakshmipur the drug was available only in the , which means it was available only in one out of 6 upazila. In Habigomj, the Amoxicillin DT was available in 7 out of 10 stores. The drug was not available in three stores, namely CS store, district hospital store, and sadar upazila.

Number of stores having Inj.Oxytocin in four districts of MaMoni HSS in January 2016 12

10

8 5 6 3 4 4 5 2 5 3 2 0 1 Noakhali Laksmipur Habigonj Jhalokathi

Number of stores available Number of stores not available .

Fig 2: Number of stores (DGHS store) having the availability of Inj. Oxytocin at four different of MaMoni HSS

Inj.Oxytocin: Inj. Oxytocin is necessary for AMTSL for facility deliveries. In January, among the DGHS stores Inj.Oxtocin was available at 3 stores and not available at 3

50 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 stores at Noakhali district. At Lakshmipur district, it was available in 2 stores and not available at 4 stores. At Habigonj district it was available in 5 stores and not available in 5 stores, and in Jhalokathi it was available at 1 store and not available at 5 stores. The GoB circular, responsible for maintaining stock status at the UH & FWC where 24/7 delivery service is available was reenforced to be maintained by the providers. A few of the UH&FWC are being supported for maintaince of the minimum stock at the SDP level by the support from the upazila chairman.

Number of stores having Tab.misoprostol in four districts of MaMoni HSS in January 2016 12

10

8 5 6 3 4 4 5 2 5 3 2 0 1 Noakhali Laksmipur Habigonj Jhalokathi

Number of stores available Number of stores not available

Fig 3: Availability of tablet Misoprostol at different stores of DGHS in January

Misoprostol: Misoprostol was available in 3 out of 6 stores at Noakhali district, 2 out of 6 stores in Lakshmipur, 5 of 10 stores in Habigonj and in Jhalokathi, it was available in 1 among 6 stores. Proper communication was done and procurement of misoprostol was done in January and will be distributed in the field very soon. At the SDP level, misoprostol is available, which was identified during field visit to different districts.

Number of stores having Inj.Magnesium Sulphate in four districts of MaMoni HSS in January 2016 12

10

8

6 10 3 4 4 6 2 3 2 0 Noakhali Laksmipur Habigonj Jhalokathi

Number of stores available Number of stores not available

Fig 4 : Availability of Inj. Magnesium sulphate at different store.

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 51 Inj. magnesium sulfate was available in 3 out of 6 stores at Noakhali, 2 out of 6 stores at Lakshmipur. It was not available at any store in Habigonj or Jhalokathi districts.

Visit to upazila stores: The upazilla store of Roypur upazila, Lakshmipur was visited to review the LMIS related documentation process and the physical condition of the store. The Inventory Control Register was maintained with the monthly report using the new form of SIAPS, including the different strengths of the 25 Essential MNCH drugs. Many of the MNCH essential drugs were not available in the store.

Follow up action: To continue reporting on MNCH essential drugs, it will be shared with the local level GoB official to prevent potential stock-out by local level procurement and redistribution of drugs between centers according to the utilization rate. The CS also needs to be informed by the local level management to prevent stock-outs. It would also help for the calculation of the next procurement at the national level.

Picture 1 & 2: Discussion with the storekeeper at Raypur upazila store (DGHS part) of Lakshmipur district

Utilization of LMIS data for program implementation

Interventions for monitoring the availability of FP commodities:

The project staff also monitored family planning commodities distributed at all service delivery points through UIMS2 V.7. MaMoni HSS staff at the district level assisted the district level staff in downloading and summarizing data on availability of FP commodities and use of results to take action to avoid stock out.

SDP Stock Status of Family Planning Commodities of Habiganj district in February 2016

52 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Upazila Contraceptives Overstock Satisfactory Under Potential Stock stock Stock out (0 (3 + MOs) (1.7 – 3.0 out (0.1 – MOs) MOs) (0.7 – 0.6 MOs) 1.6 MOs)

Sadar Condom 12 52 06 00 00

# of SDP- Pill 05 57 08 00 00

GoB-66 IUD 10 01 01 00 00

NGO-04 Injectable 04 52 13 01 00

Implant 00 01 00 00 00

Madhabpur Condom 13 41 10 01 01

# of SDP- Pill 06 59 04 00 00 GoB-60 IUD 05 04 02 00 00

Injectable 02 49 11 01 01

Implant 00 00 01 00 01

Bahubal Condom 04 10 15 06 03

# SDP- Pill 21 07 08 02 00

GoB-43 IUD 06 00 00 00 00

Injectable 18 07 09 02 00

Implant 00 00 00 01 00

Lakhai Condom 04 31 02 02 00

# of SDP- Pill 04 00 00 00 00 GoB-40 IUD 05 24 11 00 00

Injectable 01 23 12 03 00

Implant 00 00 03 00 00

Condom 00 00 00 00 00

Chunarughat Pill 00 00 00 00 00

# of SDP- IUD 00 00 00 00 00 GoB-68 Injectable 00 00 00 00 00

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 53

Implant 00 00 00 00 00

Nabiganj Condom 20 32 11 07 06

# of SDP- Pill 16 38 17 06 02 GoB-No Data IUD 10 03 00 00 00

Injectable 10 02 02 01 01

Implant 00 00 00 01 01

Baniachang Condom 12 46 22 02 00

# of SDP-88 Pill 09 43 23 06 01

IUD 10 00 00 00 00

Injectable 07 52 19 03 01

Implant 01 00 00 00 00

Ajmeriganj Condom 07 17 02 02 00

# of SDP-29 Pill 01 22 03 02 00

IUD 04 00 00 00 00

Injectable 02 19 06 01 00

Implant 01 00 00 00 00

Collaboration with SIAPS in LMIS activity at the national level:

A meeting was held with SIAPS on 2nd March, 2016 for the collaboration with SIAPS in LMIS activity at the MaMoni districts as well as with the LMIS activity at the national level.

The agenda of the meeting was:

• To share the updates of LMIS activity at Lakshmipur district where uniform logistic system has already been established with digitalization of LMIS system. • To share the updates on the UMIS system for family planning and maternal health The subnational procurement assessment needs to be improved, which dependS on the digitalized LMIS system which has been started at Lakshmipur district. UMIS has information about all SDPs in Bangladesh where upgrades have been completed by including information on inj. oxytocin, inj. magnesium sulfate , iron plus folic acid, tab.misoprostol and 7.1% chlorhexidine in , which will be also done for other districts in the future.

54 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 Follow up activity: SIAPS will provide technical support by facilitating sessions in the training on the LMIS documentation process which will be arranged in Noakhali, Habigonj, and Jhalokathi districts in the next quarter.

Sharing of role of LMIS in overall project activity:

• Workplan Sharing and Coordination Meeting –director PHC • Workplan Sharing and Coordination Meeting –director hospital

Investigation of SDPs that reported stock-out on online LMIS

MaMoni investigated stock-outs reported by online LMIS to verify the online reports. The results are as follows:

Name of SDP Month Particulars Causes of stock out 14. Jesmin Akter, FWV Jan-16 Pill As per MIS-3 on Jan- 16 available stock (Inch), Hazipur was Sukhi-153+ Apon-26, 14. Jesmin Akter, FWV Jan-16 Condoms As per MIS-3 on Jan- 16 available stock (Inch), Hazipur is 384, 14. Jesmin Akter, FWV Jan-16 IUD As per MIS-3 on Jan- 16 available stock (Inch), Hazipur is 18, 14. Jesmin Akter, FWV Jan-16 Injection As per MIS-3 on Jan- 16 available stock (Inch), Hazipur is 124, 16. Aleya Begum, FWV, Jan-16 Pill As per MIS-3 on Jan- 16 available stock (Inch) Kadirpur was Sukhi-138+ Apon-28, 16. Aleya Begum, FWV, Jan-16 Condoms As per MIS-3 on Jan- 16 available stock (Inch) Kadirpur was 453, 16. Aleya Begum, FWV, Jan-16 IUD As per MIS-3 on Jan- 16 available stock (Inch) Kadirpur was 15, 16. Aleya Begum, FWV, Jan-16 Injection As per MIS-3 on Jan- 16 available stock (Inch) Kadirpur was 80, 1/ Kha, Rowshan Ara, FWA, Feb-16 Pill As per MIS-2 on Feb- 16 available stock Jirtoli was 451,

1/ Kha, Rowshan Ara, FWA, Feb-16 Condoms As per MIS-3 on Feb- 16 available stock Jirtoli was 856,

1/ Kha, Nurun Nahar Mar-16 Injection As per MIS-3 on Mar- 16 available stock Begum, FWA (Inch), Jirtoli. was 66, 06. Hosne Ara Begum, FWV, Jan-16 Condom As per MIS-3 on Jan-16 Stock out Code-Ka Rampur, RD (Supply not gotten) 07. Ruma Rani Mojumdar, Jan-16 Condom Supply not collected, due to mentioned FWV, Musapur, FWC FWV was in training 3/ kha, Sobita Rani Jan-16 Inject able As per MIS-2 on Feb- 16 available stock Mozumdar, FWA(in ch.), was nil. ( Supplies not collected due to Nabipur additional unit)

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 55 3/ Ka, Sobita Rani Feb-16 Condom As per MIS-2 on Feb- 16 available stock Mozumdar, FWA, Nabipur was 532, 1/ Ka, Ferdaus Ara Begum, Jan-16 Inject able As per MIS-2 on Feb- 16 available stock FWA (in ch.), Nabipur was 50 01.Sedratul Muntaha, Feb-16 Pill As per MIS-3 on Feb- 16 available stock FWV(Add), Char Jabbar was Sukhi-209+ Apon-30, (Sedratul Muntaha, FWV was not in charge in mentioned period) 01.Sedratul Muntaha, Feb-16 Condom As per MIS-3 on Jan- 16 available stock FWV(Add), Char Jabbar was 176, (Sedratul Muntaha, FWV was not in charge in mentioned period) 01.Sedratul Muntaha, Feb-16 IUD As per MIS-3 on Jan- 16 available stock FWV(Add), Char Jabbar was 14, (Sedratul Muntaha, FWV was not in charge in mentioned period) 01.Sedratul Muntaha, Feb-16 Injection As per MIS-3 on Jan- 16 available stock FWV(Add), Char Jabbar was 104, (Sedratul Muntaha, FWV was not in charge in mentioned period) 04. Sedratul Muntaha, FWV, Jan-16 Injection As per MIS-3 on Jan- 16 available stock Char Wapda was 10, (Sedratul Muntaha, FWV was not in charge in mentioned period) 1/Ga, Seuly Akter, Feb-16 Injection After supplied to Volunteer then returned Volunteer, Char Wapda to FWA in another unit Union.

56 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 APPENDIX 5: DOCUMENTATION AND DISSEMINATION OF MAMONI PROGRAM LEARNING

MaMoni HSS lessons were disseminated in the following forum

Title Forum Month Type of Dissemination TRAction Targeted newborn and family planning Jan 2016 Oral Presentation Dissemination TRAction 24/7 service availability at TRAction Feb 2016 Oral Presentation District Hospital and MCWC Dissemination Empowering Community Volunteers to International increase utilization of FP Conference on Family Jan 2016 Poster Presentation services in a remote district of Planning, Nusa Dua, Bangladesh Indonesia

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

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 57 APPENDIX 6: ENVIRONMENTAL COMPLIANCE REPORT During the reporting quarter, January 1 to March 31, 2016, MaMoni HSS Project supported renovation in 11 health facilities. The list of health facilities, their location, and the type of renovation conducted are summarized in the table below.

Sr. Name of Facility Location Type of Renovation No. District Upazilla

1 Alyarpur UH&FWC Noakhali Begumgonj Tiles setting, painting, sanitary, electric wiring & fan, light, door and window repair, medical waste pits construction, door shutter replacement. 2 Gopalpur UH & FWC, Begumgonj Medical waste pits construction, plastering & coating. 3 Sonadia UH & FWC Hatiya Plastering, GF casting, sharp disposal tank casting. 4 Charking UH & FWC Hatiya Tiles setting, painting, sanitary, electric wiring, medical waste pits construction.

5 Dalal Bazar UH&FWC Lakshmipur Sadar Water barrier on roof top, tiles setting. Sanitary work, pit construction. 6 Dorbespur UH&FWC Ramgonj Tiles setting, painting. Sanitary electric wiring, fan installation, door and window repairing, pits construction. 7 Lakshmipur Sadar Sadar Door and window repair replacement Hospital window shutter repair, tiles setting, painting, sanitary electric wiring, fan setting, pit construction. 8 Chechrirampur UH&FWC Jhalokathi Kathalia Roof water barrier, tiles setting, plastering, sanitary fitting, electric wiring, pit construction. 9 Saturia UH&FWC Rajpur Roof top repairs, tiles setting, electric wiring, pit construction. 10 Binoykathi UH&FWC Sadar Roof water barrier, tiles setting, sanitary repairs, electric wiring, door and window repair, pit construction. 11 Shiddhokathi UH&FWC Nalchity Roof water barrier, tiles setting, sanitary repair, electric wiring, door and window repair, pit construction.

Potential impact and mitigation measures have been outlines below.

Project Activities List each Mitigation Status of Mitigation List any outstanding Remarks with potential Measure in the EM Measures issues relating to environmental required conditions impact (NDC) Dismantling of By using mask, Mitigation Debris to be dumped Staff following damaged plaster is helmet and measures properly. up on proper creating dust spraying water implemented dumping before starting the stripping works Surface By using mask, Mitigation Debris to be dumped

58 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 preparation for gloves and water in measures properly. painting the area implemented

In case of fire or Fire extinguisher Mitigation Provide training on any other and first aid box is measures use of fire incidental case available in the site implemented extinguisher & first for primary aid box during any protection incident.

Sound pollution for Tiles cut in a sealed Mitigation None tiles work room for sound measures minimizing implemented

Using paint on wall Paint is lead free Mitigation None and ceiling measures implemented Using other All materials are Mitigation None materials likes asbestos free measures sand , cement and implemented reinforcement

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 59 APPENDIX 7: LINKS TO MEDIA STORIES PUBLISHED Media Date Article Title and Link

’ﶟKaler March �সূিতেসবা-হাওর-কন뷍ারা এখন ‘ডা�ার েব Kantho 08, http://www.kalerkantho.com/print-edition/last- 2016 page/2016/03/08/333488#sthash.yNmK2F2m.dpuf Independent January Ashar Bangladesh: Durgapur UH&FWC TV 23, 2016 https://www.youtube.com/watch?v=x_Y1dX-Qktg

কানাﶠ Prothom Alo February শিনবােরর িবেশষ �িতেবদন; �সূিতেদর আপন 05, 2016 http://www.prothom-alo.com/bangladesh/article/761524/%E0%A6% BDNews24. January Breastfeeding is a smart investment in people and economies com 30, http://bdnews24.com/health/2016/01/30/breastfeeding-is-a-smart-investment-in-people- 2016 and-economies-the-lancet

BDNews24. March Bend the health curve with efficiency and quality, says Save the Children director com 23, http://bdnews24.com/health/2016/03/23/bend-the-health-curve-with-efficiency-and-quality- 2016 says-save-the-children-director

Daily March মাধবপুের �া�뷍 ক া ড쇍 িবতরণ Khowai 17, http://www.dailykhowai.com/news/2016/03/17/53903 2016

Madhabpur March �া�뷍 ক া ড쇍 িবতরণ News 16, http://www.madhabpurnews24.com/?p=15303 24.com 2016

Daily Feb 14, মাধবপুের ইউিনয়ন �া�뷍 ও পিরবার কল뷍াণ েকে� ৫মােস ৪শ িনরাপদ �সব Probhakar 2016 http://dailyprobhakar.com/%E0%A6%AE%E0%A6%BE%E0%A6%A7%E0%A6%AC%E0%A6%AA% E0%A7%81%E0%A6%B0%E0%A7%87- %E0%A6%87%E0%A6%89%E0%A6%A8%E0%A6%BF%E0%A7%9F%E0%A6%A8- %E0%A6%B8%E0%A7%8D%E0%A6%AC%E0%A6%BE%E0%A6%B8%E0%A7%8D%E0%A6%A5% E0%A7%8D Kaler েদেশ �িতিদন ২২৭ মৃত স�ান �সব Kantho http://www.kalerkantho.com/print-edition/last-page/2016/01/20/315427

Prothom Alo Jan 20, মৃত স�ান �সেবর তািলকায় বাংলােদশ স�ম 2016 http://www.prothom-alo.com/bangladesh/article/745285 The Daily Jan 22, STILLBIRTH IN BANGLADESH: Rate halved in 15 years Star 2016 http://www.thedailystar.net/frontpage/rate-halved-15-years-205471 Dainandin Feb 12, Workshop and training on Chlorhexidine use completed (Cox’s 2016 Bazar) Online link not available

60 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 APPENDIX 8: UPDATE ON USAID ABORTION AND FP REQUIREMENT 2016 TRAINING

The project continues to ensure compliance with US abortion and FP legislative and policy requirement that guide U.S. assistance. USAID/Bangladesh requires that all staff involved in family planning and reproductive health activities should annually complete the online course on “US Abortion and FP Requirement”. To fulfil this obligation, all 190 MaMoni HSS Project relevant staff, including partners, have successfully completed the online course and received certificates. The table below includes the number of staff needed to complete the course and the completion status.

Sl Name of District Total person Completion to complete Status 1 Dhaka 43 43 SCI 37 37 Jhpiego 3 3 JSI 1 1 ICDDRB 2 2 2 Habiganj 68 68 SCI 6 6 FIVDB 26 26 Shimantik 36 36 3 Jhalakathi 20 20 SCI 08 08 PHD 12 12 4 Noakhali 42 42 SCI 10 10 BEES 20 20 RIC 12 12 5 Lakshmipur - DSK 19 19 TOTAL 192 192 (100%)

MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2 61 APPENDIX 9: STATUS OF HEALTH FACILITY RENOVATIONS

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

62 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q2