PPP ECD Programming

PPP ECD programming

CA AID-656-A-16-00002 (GDA ECD Programming)

Fiscal Year 2018 Year 3: April 2018–March 2019

Quarterly Report: Q1 April–June 2018

Submitted on: July 31, 2018 Submitted to: United States Agency for International Development Cooperative Agreement No. AID-656-A-16-00002

Submitted by: PATH Street address: 2201 Westlake Avenue, Suite 200 Seattle, WA 98121, USA Mailing address: PO Box 900922, Seattle, WA 98109, USA Tel: 206.285.3500; Fax: 206.285.6619 www.path.org

This work is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents of this document are the sole responsibility of PATH and do not necessarily reflect the views of USAID or the United States Government

Contents

Abbreviations...... 2 1. Overview of the reporting period ...... 3 2. Project objectives ...... 4 3. Results framework/logical framework ...... 5 4. Indicators ...... 6 Indicator 1 ...... 6 Progress and issues ...... 6 Indicator 2 ...... 7 Progress and issues ...... 8 Indicator 3 ...... 8 Progress and issues ...... 8 Indicator 4 ...... 11 Progress and issues ...... 11 Indicator 5 ...... 12 Progress and issues ...... 13 Indicator 6 ...... 15 Indicator 7 ...... 17 Indicator 8 ...... 17 Progress and issues ...... 17 Indicator 9 ...... 21 Progress and issues ...... 21 Indicator 10 ...... 22 Progress and issues ...... 22 Indicator 12 ...... 25 Progress and issues ...... 25 Indicator 13 ...... 26 Progress and issues ...... 26 Indicator 14 ...... 27 Progress and issues ...... 27 Indicator 15 ...... 27 Indicator 16 ...... 28 Progress and issues ...... 29 5. Upcoming plans ...... 33 6. Administrative update ...... 34 7. Financial information ...... 34 8. Appendices ...... 34

Abbreviations

ANC antenatal care APE agente polivalente elementar (community health worker) ART antiretroviral therapy CBO community-based organization CCD Consulta da Criança Doente (sick-child consultation) CCR Consulta da Criança em Risco (child-at-risk consultation) CCS Consulta de Criança Sadia (child well-being consultation) CDC Centers for Disease Control and Prevention CHC child health committee CHW community health worker CPC child protection committee DPGCAS Provincial Directorate of Gender, Children and Social Welfare DPS Provincial Health Directorate ECD early childhood development FANTA Food and Nutrition Technical Assistance GDA Global Development Alliance HF health facility IEC information, education, and communication IMCI Integrated Management of Childhood Illness IR intermediate result LOP life of project MCH maternal and child health MCSP Maternal and Child Survival Program MGCAS Ministry of Gender, Children and Social Action MOH Ministry of Health NGO non-governmental organization OVC Orphans and Vulnerable Children PEPFAR US President's Emergency Plan for AIDS Relief PES Plano Económico e Social (Social and Economic Plan) PMTCT prevention of mother to child transmission PNC postnatal care PPP public-private partnership PRN Programa de Reabilitação Nutricional (Nutrition Rehabilitation Program) S-ECD Scaling Up Early Childhood Development SDSMAS District Directorate of Health, Women and Social Welfare TDI Tratamento da Desnutrição em Internamento (in-patient treatment of malnutrition [TDI]) TOT training of trainers UNICEF United Nations Children's Fund USAID United States Agency for International Development WEI World Education International WHO World Health Organization

1. Overview of the reporting period

The Integrating Early Childhood Development (ECD) Global Development Alliance (GDA) Programming is a public-private partnership (PPP) between the United States Agency for International Development (USAID), the Conrad N. Hilton Foundation, and PATH, which works to integrate early childhood development programming in Mozambique. This PPP focuses on improving child development outcomes for vulnerable children 0–3 years in targeted areas of Mozambique, through an integrated health, nutrition, sensitive care, and stimulation intervention for health and social services provided by government and partners. This PPP is a three-year cooperative agreement that started on April 6, 2016. This progress report summarizes the accomplishments of the project during the first quarter (April–June 2018) of the third year of project implementation. PATH in collaboration with Ministry of Health (MOH) and Ministry of Gender and Social Action (MGCAS) has developed several activities in health facilities and communities with the objective of integrating ECD and improving the life of children ages 0–3 years. To achieve these results, PATH combines innovation and provision of technical assistance for strengthening ECD service delivery through health facilities (HFs) and community-based organization (CBOs).

During this quarter, the PPP team continued to work with the Child Health, Nutrition, and Health Promotion departments of the MOH to review relevant documents to integrate ECD, including the guideline for consultations for child at-risk clinic (Consulta da Criança em Risco, [CCR]), child well-being clinic (Consulta da Criança Sadia [CCS]). Additionally, PATH continued to follow up on the relevant ECD information, education, and communication (IEC) materials under review by the health promotion department to ensure their approval and green light for replication and use at HF and community levels. During this period, the report from the National ECD workshop that took place in March 2018 was approved and relevant ECD materials— specifically developmental milestones and nutrition counseling posters—were distributed to all provinces, prioritizing high-volume HFs.

Although PATH was not involved in the clinical treatment of malnutrition, nutritional counseling to caregivers of children from 0–5 years old was carried out in all HFs supported by the project as part of the ECD integration strategy. A total of 14,300 children were reached with nutrition interventions by agentes polivalentes elementares (community health workers [APEs]).

During this reporting period, PATH also continued engaged in the review of the MCH nurse pre- service curriculum to ensure that ECD content is included.

At the HF level, data collected across all 49 target HFs of the six target districts supported by the project indicated a total of 31,655 beneficiaries (caregivers or children under five) who received ECD and nutrition counseling. This figure implies an achievement of 177 percent of the quarterly target.

A total of 98 playbox sessions were conducted in the ten target HFs, with 11,094 caregivers of children under five years participating in these sessions. During the reporting period, a total of 158 video sessions were conducted in HFs across the six intervention districts and were attended by a total of 6,658 caregivers. The playbox sessions and the video sessions are part of IEC activities facilitated by trained HF service auxiliary staff and HIV counselors and supported by maternal and child health (MCH) nurses. Playbox and video sessions are held in the early morning hours in HF waiting areas, while caregivers and their children wait to receive different

MCH services—e.g., antenatal care (ANC), postnatal care (PNC),CCR, CCS, and pediatric antiretroviral therapy (ART).

The PPP team in collaboration with the District Directorates of Health, Women and Social Welfare (Serviço Distrital de Saúde, Mulher e Acção Social [SDSMAS]) continues to provide direct mentoring and supervision to APEs in the districts. During this quarter, all districts conducted a refresher trainings and a total of 150 APEs participated in the sessions. The training contents included: the MOH package of services for families of orphans and vulnerable children [OVC] (case finding of “lost to follow-up” cases related to HIV, tuberculosis, and malnutrition) and APEs’ practical skills in identifying risk signs of developmental delays and providing referrals.

A total of 55 APEs were mentored during the period, 13 of whom reached the threshold score of 60 percent using the PATH mentoring tool.

A total of 222 monitored children across CCS, CCR, Consulta da Criança Doente (sick child consultation [CCD]), pediatric ART, PNC, and maternity consultations were suspected to have developmental delays. Of those, 181 were suspected during the first consultation and 41 during the follow-up consultations.

2. Project objectives

The goal of the Global Development Alliance PPP for integrating ECD programming is to improve development outcomes for children 0–3 years in targeted areas of Mozambique through an integrated health, nutrition, sensitive care, and stimulation project. The project has three objectives/result areas:  Result 1: Create an enabling environment at the national level for the integration of ECD interventions, which target the youngest vulnerable children, into social action and health systems and services.  Result 2: Improve care and stimulation behaviors of caregivers of vulnerable children aged 0–3 years through social action and health-sector partnerships with government and civil society that expand integrated ECD programs in the country.  Result 3: Expand the knowledge and evidence base on integrated ECD.

3. Results framework/Logical framework

The results framework included in Figure 1 represents the PPP project’s vision for achieving its objectives.

Figure 1. Results framework for the Integrating Early Childhood Development Global Development Alliance Programming

4. Indicators

In line with our performance monitoring plan, below we discuss project progress and achievements toward results and intermediate results (IRs) indicators. For a better understanding of the indicators and their figures, the following concepts are defined:

LOP: Life of Project. While the PPP lifetime is from April 2016 to March 2019, for indicator reporting purposes, LOP also includes the lifetime of the Scaling Up Early Childhood Development (S-ECD) project funded by the Conrad N. Hilton Foundation.

S-ECD project only: Refers to results obtained under S-ECD project between July 2015 and March 2016—i.e., immediately before the start of the PPP. These results are mentioned as “baseline” in the terminology utilized in the PPP performance monitoring plan and are included in the LOP target column.

PPP Year 1 achievements refer to results obtained in project Year 1 (between April 2016 and March 2017).

Result 1: Create an enabling environment at the national level for the integration of ECD interventions, which target the youngest vulnerable children, into social action and health systems and services.

IR 1.1: Improved adoption of orphans and vulnerable children (OVC), MCH, and community health worker (CHW) materials with integrated ECD content.

Indicator 1

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Achievements Percent target only Achieve Achieve Y3 achieved of Indicator -ments -ments Annual Y3 annual target Q1 Q2 Q3 Q4 target

Number of PATH IEC materials approved 7 2 4 3 1 0 0% by provincial or national government

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year; IEC: information, education, and communication.

Progress and issues During this quarter, progress was made toward revising and integrating ECD content in a number of relevant documents and guidelines in collaboration with MOH—including guidelines on CCS and CCR, which were reviewed and subsequently submitted to the technical working group on June 11, 2018. PATH also reviewed relevant chapters of the HIV handbook and submitted revisions to the HIV Department of the MOH. In addition, PATH in collaboration with the Food and Nutrition Technical Assistance (FANTA) Project reviewed the documents of the Programa de Reabilitação Nutricional (Nutrition Rehabilitation Program [PRN]) to incorporate ECD content.

In this reporting quarter, the PPP team submitted the final report and operational plan developed at the National ECD Workshop. This event took place on March 16 and brought together over 70 participants—including provincial chief medical officers and child health focal points from all 11 provinces, as well as MOH, UNICEF, World Health Organization (WHO), Association of Mozambican Nurses, USAID, Centers for Disease Control (CDC), and health partners. As the report was approved by the MOH, PATH initiated the distribution of posters on child development milestones and nutrition counseling, as well as videos on ECD, to all provinces. 595 posters each on stimulation and developmental milestones were distributed to high-volume HFs in accordance with the distribution plan established by the MOH.

No new PATH IEC materials were developed and/or submitted for approval in this quarter, as the project currently has a full set of tools for implementation; however, several tools submitted for approval in previous quarters, such as final versions of Community Integrated Management of Childhood Illness (IMCI), are still under review in the Health Promotion Department. Other tools planned for future development include adapted Thinking Healthy Cards for Mental Health for technicians to counsel on maternal depression (in partnership with MOH) and a Parenting Education program (in partnership with MGCAS).

We are currently in conversation with partners regarding sharing the cost of printing registers for Maputo Province. We will also support printing of a select number of registers in Nampula Province, albeit solely with Conrad N. Hilton Foundation funding. In addition, we will look into sharing the cost of training sessions with partners. One training session costs approximately Mt. 500,000, for which we do not have the budget and will need to be cost-shared with other partners.

Also in this reporting period, PATH supported participation of MOH staff in the Aga Khan University’s Science of ECD course, held in Mozambique. The Science of ECD course is offered annually and provides participants with a strong foundation on the scientific literature and programmatic evidence underlying the delivery of ECD services for children 0–3 years through the health sector.

IR 1.2: Increased ECD content in district and provincial social action and health plans.

Indicator 2

LOP S- PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target ECD Achieve- Achieve- Annual achieved of Indicator only ments ments target Y3 annual Q1 Q2 Q3 Q4 target

Number of targeted health and social action plans that 20 3 5 7 8* NA NA include ECD content and goals for ECD integration.

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. *Including Matola and Boane

Progress and issues

Planning of 2018 (PES, Plano Económico e Social) During the reporting period, the PPP ECD team in collaboration with the Provincial Health Directorate (DPS) and SDSMAS from the six implementation districts continued implementing the activities planned for the current year. Additionally, PATH established regular meetings with the purpose of involving the PPP team in PES planning sessions, which are currently scheduled for July and August 2018 in all eight of the project districts, including the two recently added districts of Boane and Matola. The outcomes of the planning sessions will be reported in the next quarter. On May 3 and May 14, 2018, we attended a meeting at DPS regarding Coordination Council. On May 30, we attended another meeting at DPGCAS (planning and preparation for Coordination Council which took place on July 2–4, 2018. In addition to technical support, PATH provided financial support to Coordination Council the in the amount of $1,800.

IR 1.3: Improved ECD content in existing health and social action curricula, guidelines, and data tools.

Indicator 3

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Percent Y3 Achievements target only Achieve- Achieve Annual achieved of Indicator ments -ments target Y3 annual target Q1 Q2 Q3 Q4

Number of government curricula, guidelines, and data tools revised by 4 1 1 2 1 5* 500% PATH to include ECD content and adopted by government

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

*Materials already revised but still under review by MOH. These include CCS and CCR norms; PRN chapter; community PRN chapter; treatment of acute malnutrition pocketbook; and PMTCT chapter in the HIV pocketbook.

Progress and issues

A. MCH nurses’ pre-service curricula review On April 3–5, the PPP team in collaboration with UNICEF, United Nations Population Fund (UNFPA), WHO, and Instituto Superior de Ciências de Saúde (ISCISA) provided technical

support to the MOH Training Department to finalize the revision of the MCH nurse pre-service curriculum with integrated ECD content. The review focused on the technical competencies of MCH nurses in areas such as ANC, labor and delivery, PNC, CCS, CCR, sexual reproductive health, family planning, pediatrics, and community health, and nutrition. The review sought to ensure that ECD content is integrated in the entire MCH nurse pre-service profile.

The specialists who will develop the modules will soon be hired. This hiring will be funded by UNFPA and after that PATH will fund an orientation meeting for specialists who will develop the modules. In addition to its activities with the MCH curriculum, PATH has agreed with ISCISA to include an addendum on ECD to its maternal and child health courses. As noted in previous reports, this review process will continue to take place through 2018.

B. Other technical assistance provided through participation in MOH/MGCAS technical working group Through participation in the MCH technical working group, the PPP team was able to contribute to the review of the CCS and CCR consultation norms. Specifically, PATH has designed a protocol for developmental monitoring and counseling for CCS norms, and has proposed that the CCR protocol be aligned with IMCI, since IMCI is used in that consultation. The revised norms are currently under review.

In the context of PATH’s collaboration with MOH and UNICEF on PRN, the PPP team conducted a three-day national training of trainers (TOT) on April 25–27, 2018 on stimulation in pediatric wards. The training saw participation from the MCH, Nutrition, and Mental Health departments of the MOH, as well as partners such as World Bank and FANTA. The training was financed by UNICEF and involved two practice sessions in Mavalane General Hospital’s Pediatric Ward. It prepared the trainers to train pediatric ward teams to carry out the following activities: (1) monitor developmental status of children at admission and discharge using IMCI guidelines; (2) carry out regular demonstrations in stimulation and engage caregivers in practice and toy-making; (3) ensure child-friendly physical spaces, adequate maintenance of play materials, and recording of stimulation activities.

Although the training has been developed in the context of PRN, it is designed in such a way that all children and caregivers in the pediatric ward, from prematurely born infants to children with malaria and others, can participate in and benefit from stimulation activities. PATH has supported the MOH to revise some of the training materials following the training, as well as to prepare for provincial replication trainings. Two of these trainings were carried out in June in Nampula and Inhambane provinces with UNICEF support, with other provinces to be targeted in the next quarter. Provincial trainings target the six largest HFs in each province that have already received trainings on treatment of malnutrition in pediatric wards.

As a result of this work, there is now a team of national (MOH) trainers on stimulation (albeit specifically in pediatric wards) representing relevant departments as follows.

PRN  Stimulation activities in pediatric wards are now verified as a part of routine supervision in PRN/TDI by MOH.  UNICEF plans to support trainings in stimulation in pediatric wards in all other provinces in the next year.

 Developmental monitoring and counseling is likely to be integrated into the community nutritional monitoring project supported by the World Bank.  The priority now is to also reinforce stimulation in CCR consultations. This has not yet happened yet, although relevant content has already been integrated into PRN manual

MCH  The MCH supervision guide with integrated ECD content used at the provincial level has now been submitted for consideration to the national- level MCH team, to advocate for ECD integration into this tool nationwide.  The upcoming trainings in CCD/CCS registers will reinforce ECD activities nationwide due to presence of ECD indicator in these registers.  Neonatal IMCI, although approved and containing ECD content, has not yet been printed or rolled out, so it is too early to comment on its impact

HIV ECD monitoring and counseling has been added as a requirement into the HIV pocketbook for pediatric HIV, although it is still not clear how this will affect practice.

APE ECD topic has been added to preservice APE training program, although its implementation still depends on provincial/district interest/attention to this area.

In addition to the work conducted on the standalone stimulation training described above, three other MOH materials on PRN have now been revised to include ECD content. Specifically, the Mozambican Association of Paediatricians revised the Pocketbook on Treatment of Acute Malnutrition, integrating the content on stimulation that PATH provided. Secondly, at the request of FANTA, PATH has concluded the revision of the chapter on stimulation in the national PRN manual. New content includes: scientific rationale for joining nutritional and stimulation interventions, guidance on responsive care in the pediatric ward setting, a tool to monitor child developmental status while in the pediatric ward, revised stimulation activities for children 0–36 months, and strategies for integrating stimulation into daily routines of the ward. A similar revision was done on the community PRN materials, where PATH provided overall comments on the proposed model of community PRN, as well as suggested content on basic developmental monitoring and counseling. Furthermore, PATH has been approached by World Bank and the MOH Nutrition Department to contribute to the design of the IEC and training materials for the new World Bank–supported five-year community nutrition project.

PATH has also now joined the Prevention of Mother to Child Transmission (PMTCT) technical working group, where it has been advocating for integration of ECD content into relevant technical guidelines. As mentioned previously, content on ECD monitoring and counseling has been integrated into the PMTCT chapter in the HIV pocketbook.

Finally, PATH has resumed discussions with the Mental Health Department of the MOH on training MCH nurses working in PNC consultations in Maputo Province on the new MOH- adapted tool for screening maternal depression. The MOH has pretested the tool in several HFs and is now eager to roll it out at larger scale. PATH is currently exploring possible models and costs for this work with MOH, including training not just nurses but also mental health

technicians who would be receiving mothers with depressive symptoms using an adaptation of the WHO Thinking Healthy package.

The PPP team has continued supporting MGCAS priorities, such as the completion of the national Manual of Community Preschools, the commemoration of Children’s Day, and testing of the parenting education program that PATH has developed—with the intent to inform MGCAS decision-making in regards to a national parenting education package.

Result 2: Improve care and stimulation behaviors of caregivers of vulnerable children aged 0 to 3 years through social action and health-sector partnerships with government and civil society that expand integrated ECD programs in the country.

IR. 2.1: Improved ECD knowledge and skills of service providers at HFs.

Indicator 4

LOP S-ECD PPP Y1 PPP Y2 PPP Percent achieved Y3 Achievements target only Achieve Achieve Y3 of Y3 annual target Indicator -ments -ments Annual target Q1 Q2 Q3 Q4

Number of health providers 255 135 85 35 230* 127 55.2% trained on ECD by PPP project

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. * Health providers from Matola, excluding counselors

Table 1. Training of staff during the quarter Achieved during the Quarter

# of providers trained District (Y 1&2) Total TDI IMCI ECD TOT

Namaacha 45 16 13 3 0 0 Marracuene 43 3 0 3 0 0 Matutuine 42 16 14 2 0 0 Moamba 46 17 14 3 0 0 Magude 36 3 0 3 0 0 Manhiça 43 23 20 3 0 0 Matola NA 46 0 11 22 13 Boane NA 3 0 3 0 0

Total 255 127 61 31 22 13

The number of providers trained in Matola and Boane districts is zero for years 1 and 2, since the project had not yet engaged with these districts under the PPP mechanism. Engagement with these districts commenced in the present quarter, with trainings scheduled to take place in the next reporting quarter.

Progress and issues A. Trainings  Provide financial and technical support to TDI training (including stimulation in pediatric wards) Continuing from the last quarter, PATH provided technical support to MOH on PRN/tratamento da desnutrição em internamento (in-patient treatment of malnutrition [TDI]). During the current reporting quarter, the PATH team in partnership with SDSMAS of Manhiça, Matutuine, Moamba, and Namaacha districts trained 61 health providers on the treatment of child malnutrition in pediatric wards, which included both clinical and stimulation topics. As a result, the integration of stimulation has helped the health providers to understand and conduct practical activities with children and caregivers in pediatric wards.

 Provide technical and financial support to simplified IMCI training integrating ECD During the reporting quarter, PATH provided technical and financial support on IMCI training to 31 health providers from eight districts of Maputo Province. The training had five different objectives: 1) reduce the mortality in children under five years; 2) improve the quality of effectiveness, efficiency, and care in health services; 3) promote accurate identification of diseases; 4) strengthen caregiver orientation; and 5) identify needs and accelerate referrals for critically sick children. In addition, PATH ensured integration of the stimulation component as part of its efforts to “top up” standard government packages with ECD content. During the next quarter, the DPS and PPP-ECD teams will focus on follow-up supervision activities.

 TOT and ECD replication trainings As part of its expansion to Matola District, the PPP team conducted a TOT orientation for 13 participants, including district supervisors and the heads of four HFs. The training provided content on how to integrate ECD in CCS, CCR, nutrition, ANC, PNC, MCH, and IMCI service delivery touch points. Recognizing the importance of practice, the second day of the TOT was focused on a practical session while the PATH and DPS teams supervised the integration of ECD during the daily work at each of the services.

After the training, the participants conducted a planning session to replicate the lessons to health providers allocated in each of the targeted HFs. In this reporting period, the PATH team trained a total of 22 health providers from Machava II and Matola I.

B. Coordination with DPS and DPGCAS During the reporting period, the PPP team attended several routine meetings at DPS and DPGCAS In addition, the PPP team coordinated with the DPS focal point to establish a date and agenda for the bi-annual PPP-ECD project evaluation, which will also involve DPS and district teams.

C. Meeting with Matola and Boane SDSMAS to present the Conrad N. Hilton Foundation Phase III ECD Project and work plan

During the previous quarter, USAID approved the inclusion of two districts (Boane and Matola) on the PPP-ECD project using funds from the Conrad N. Hilton Foundation. In this quarter, the PATH team conducted a meeting with leadership of the two districts to present the project and plan activities for coming months—including TOTs, replication trainings, and APE refresher trainings in Boane District.

Additionally, in Matola District, PATH attended a bi-annual meeting with SDSMAS to review the progress of the work plan for the district. The PATH team also presented the PPP-ECD project for other district health providers and the District Director, who showed great interest in project activities.

Indicator 5

Y3 Achievements Total Percent project PPP Y1 PPP Y3 Q1 Q2 Q3 Q4 LOP S-ECD PPP Y2 achieved accumula Indicator Achieve- Annual target only Achieve of annual -tive ments target -ments target Y3 achievement Percentage of health facility clinical providers reaching the 191 24 91 32 46** NA*** NA 77% threshold score of 80% for ECD services (*) Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. According to the new strategy, mentoring sessions will take place only in Matola district and will start only in 3 HFs with total staff of 86 health providers that will be trained by the project. Using this rationale, the annual target is 86 (staff from Matola II 32; MachavaII 27 and Ndlavela 27). The target may increase if new HFs are incorporated.

(*) See Chapter 5, Monitoring and Evaluation, Monitoring and Evaluation Plan (**)This is the health providers who are eligible for receiving mentoring sessions. (***) For this quarter the target Is not applicable as the trainings currently taking place and mentoring data will be reported in the next quarter.

Progress and issues

Support SDSMAS teams to produce, implement and evaluate quarterly specific action plans for priority health facilities to address challenges identified during supervision

A. At district level: Manhiça and Moamba

As mentioned in the previous quarterly report, the LOP target for this indicator has already been achieved. Therefore, during this quarter, the PPP team engaged in implementing quality improvement measures, including supervision aligned with the model already in use in the national health system. This makes the whole approach more sustainable and compatible with an exit strategy.

During this reporting period quarter, the PPP team jointly with the SDSMAS team from two districts (Manhiça and Moamba) followed up on the gaps in supervision identified in each district, as well as the previous agreed-upon action plans. The actions plans focused on the following areas: MCH, nutrition, data collection, and integrating developmental monitoring and stimulation counseling during routine health service delivery. Gaps being addressed include the following:  Improving quality of consultations and ensuring that consultations conform to the standard of services that must be provided to clients.  Ensuring that developmental monitoring is carried out on children who receive services at the health facility according to norms.  Confirmation of cases of suspected developmental delays by a medical doctor/pediatric nurse.  Filling in registers and arranging of the materials necessary for conducting proper developmental monitoring and counseling.

In general, the PPP and district teams noted several improvements compared with the previous quarters. The PPP and district teams observed health providers registering and compiling monthly ECD summary data, noting nutrition surveillance and vitamin A supplementation data, and using the IMCI mapping notebook to correctly use the developmental monitoring tool.

B. Supervision—Namaacha

During the reporting period, the PPP team and the Namaacha SDSMAS team conducted supervision visits to health providers in all the district HFs. The supervision focused on MCH, IMCI, nutrition, data collection, stimulation, and integration of stimulation counseling. During the supervision activity, the team observed service delivery to identify both positive aspects and gaps, analyzed the data collection tools used in each of the service delivery touch points, provided technical support, and shared strategies for improvement. The teams also provided in- service refresher trainings for health providers on IMCI and ECD and noted substantial progress compared with the previous reporting period because for the health providers supervised during the previous quarter and achieved also during this quarter, most of them showed best practices on ECD integration using the IMCI, nutrition packages and also best practices on counselling the caregivers on care and stimulation. This bodes well for the sustainability of the project. Because most of the districts received supervision on IMCI and followed the last quarter actions plans, the PPP team prioritized the community component—such as APE supervision and mentoring and APE refreshers—during this reporting period, as there is still a need for more PPP-ECD team support in these areas.

C. Provide technical and financial support to DPS supervision in child health

During the reporting period, the PPP team, in coordination with the DPS team and the district IMCI focal points, provided technical and financial support to the district health providers who were trained on IMCI with integrated ECD content. Supervisory visits were conducted to understand how effective the IMCI training was for district technicians—if, for example, the technicians made decisions and inquiries based on the knowledge gained in the training, or if they used the materials distributed during training. In addition, it was noted that all trained health providers were at work, using the materials provided, and the IMCI emergency kits and rehydration corners in the waiting rooms present at the HFs visited. Finally, during the reporting period, the PPP team followed up with DPS on the progress made in attaining the targets

regarding the number of children who will be monitored for developmental delays in each district and HF.

D. Provide technical and financial support to district mobile brigades ensuring integration of ECD activities

During this reporting period, due the measles and rubella vaccination campaign which covered all communities and schools in the districts of Maputo Province and a deworming campaign in the districts of Namaacha and Matutuíne, it was not necessary to conduct mobile brigades. Therefore, in coordination with DPS, PATH provided support for transport, fuel, and drivers in Matola District, as it was in need of more support compared to the other districts of the province.

E. Implementation of playboxes in target health facilities

During the reporting period, 91 playbox sessions were conducted in the ten target HFs, reaching a total of 10,446 caregivers of children under five. The caregivers learned how to stimulate their children and how to check for signs of developmental delays. Playbox sessions were held in early morning hours in the HF waiting areas, while caregivers and their children waited to receive health services (e.g., ANC, PNC, CCR, CCS, CCD, and pediatric ART).

Compared to the previous quarter, the number of beneficiaries for this quarter is low because facilitators in Magude and Marracuene Districts were on leave and playbox activities were not conducted. The PPP team has already met with the facilitators to strategize on ways to increase the number of beneficiaries for the next quarter, including a bi-annual refresher meeting.

Table 2. Number of playbox sessions and participants.

District Nr of Sessions Nr of participants

Namaacha 24 875 Marracuene 7 648 Matutuine 9 1,530 Moamba 25 1,849 Magude 0 0 Manhiça 33 6,192 Total 98 11,094

IR. 2.2: Improved ECD knowledge and skills of community-based health and social action providers.

Indicator 6

LOP S-ECD PPP PPP PPP Year 3 Achievements Percent target only Year 1 Year 2 Year 3 achieved Indicator Achieve Achieve Annual of Y3 -ments -ments target Q1 Q2 Q3 Q4

annual target

Number of beneficiaries (caregivers or children under 5) 202,186 NA 62,211 90,130 71,543 34,125 48% receiving ECD and nutrition counseling in HFs

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; HF: health facility; PPP: public-private partnership; Q: quarter; Y: year. Target per quarter = 17,886

During the reporting quarter, a total of 34,125 beneficiaries received ECD and nutrition counseling at all 49 HFs of the six PPP project implementation districts. This figure translates to an achievement of 191 percent of the quarterly target. In general, this data has shown an increasing trend throughout Year 2 and the figures for this reporting quarter are higher than the previous quarter. This can be explained as a result of overall improvement in ECD service delivery and better reporting using the registers in HFs.

Table 3 below provides more detailed information.

Table 3. Number of beneficiaries (caregivers of children under five) receiving ECD and nutrition counseling in health facilities (targets and achievements by district during the quarter).

District

CCS

CCR

CCD

CCS(*)

PED ART

PN CPN

TOTAL

achieved

MATERNITY

Target

% Age 0-11M 1-4 y 0-18M 0-4Y 0-14Y RN

Namaacha 422 146 82 1,101 16 299 336 432 2,834 2,507 113 Marracuene 1,288 0 220 31 0 1,036 773 1,275 4,623 6,526 71 Matutuine 107 18 45 1,154 0 151 164 202 1,841 1,346 137

Moamba 740 40 226 7,907 29 662 722 883 11,209 2,303 487 Magude 523 26 141 2,131 8 497 485 636 4,447 1,079 412 Manhica 1,080 128 306 3,342 91 1,194 1,455 1,575 9,171 4,124 222

TOTAL 4,160 358 1,020 15,666 144 3,839 3,935 5,003 34,125 17,886 1,442

Indicator 7

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target only Achieve- Achieve Annual achieved of ments -ments target Y3 annual Indicator target

Q1 Q2 Q3 Q4

Number of CHWs trained 166 58 108 NA 0 NA NA on ECD by PPP project

Abbreviations: CHW: community health worker: LOP, Life of Project: ECD, early childhood development; PPP: public-private partnership; Q: quarter; Y: year.

No ECD-specific training for APEs was planned for this quarter, as all existing APEs in the province have been trained in ECD. But in partnership with DPS, the PPP team will conduct a provincial APEs training next quarter, which will take place in Moamba District. This trainng will support ECD integration by utilizing the revised APEs facilitator manual.

Indicator 8

Percent PPP Y1 PPP Y2 PPP Y3 Total project LOP S-ECD Y3 Achievements achieved of Indicator Achieve Achieve Annual accumulative target only Y3 annual -ments -ments target achievement target Q1 Q2 Q3 Q4 Percentage of CHWs reaching the threshold 125 7 55 69 NA 13 115.2% score of 60% for ECD services (*) Abbreviations: CHW: community health worker; LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. (*) See Chapter 5, Monitoring and Evaluation, Monitoring and Evaluation Plan

Progress and issues As community interventions still require robust project support, the PPP team continued to provide direct mentoring and supervision to APEs in the districts. The following section will provide more detailed information regarding ways in which the PPP team supported APEs.

A. Supervision and mentoring of APEs The PPP team provided financial and technical support to APE supervisors in Magude, Marracuene, and Namaacha districts to support their APEs around previously identified gaps in service provision. Gaps at the level of APE supervisors include: inconsistency in APE monthly summaries in some health units; lack of reports in some instances; and lack of oversight plans

and provision of adequate support for APEs. Gaps at the level of APEs include: APEs spending more time on curative activities rather than disease prevention and health promotion; weaknesses in identifying OVC, difficulties in interpreting the child health card and woman’s book; and challenges with monitoring child development and making appropriate referrals.

During this quarter, the PPP team and SDSMAS officers from all target districts jointly conducted mentoring visits to the APEs from districts of Marracuene, Matutuíne, Manhiça and Moamba. The mentoring visits consisted of observation of two or three home visits to families with children under three years of age, verification of register books, confirmation of availability and conservation of drugs, and provision of feedback to the APEs at end of the visit. During this reporting quarter, the mentoring activities focused mainly on APEs who did not achieve the 60 percent threshold score and who did not receive a visit during the previous three months. Furthermore, the PPP team and APE district coordinators have worked to provide enhanced support to the local APE supervisors who usually conduct day-to-day oversight the APEs in their areas of operation.

There continue to be some difficulties related to the use of the OVC package by APEs. Moreover, from the review of the record books, it is well known that APEs spend more time in delivering curative services rather than disease prevention and health promotion activities. However, the APEs have also demonstrated their capacity in using the correct technique to measure and use mid-upper arm circumference for evaluation of nutritional status and also to provide good counselling to the caregivers on care and stimulation. During this reporting quarter, the PPP team jointly with district APE coordinators sensitized APEs to spend more time on preventive activities, provide home-based care and support to facilities, and continue using correctly use the mid-upper arm circumference technique. The PPP team also sensitized local and district APE coordinators on how they can better support APEs through direct support for their daily work and through refresher meetings, which happened during the reporting period quarter in all targeted districts.

During this quarter, a total of 55 APEs were mentored, 13 of whom reached the threshold score of 60 percent on PATH’s mentoring tool for ECD for the first time. The annual target for Year 3 was already achieved (125 APEs), as currently 131 APEs already achieved the desired score of 60 percent threshold on mentoring sessions. Target redefinition may therefore be necessary. Currently, APEs not meeting the 60 percent threshold are from Manhiça and Marracuene districts, due to not receiving adequate support from their local supervisors.

Finally, all of the project districts have received overall financial and technical support from PATH to support the APE network.

Table 4 shows the mentoring distribution across target districts, disaggregated by sex.

Table 4. Number of APEs mentored, disaggregated by sex per district. # CHW # CHW mentoring #CHW mentoring # CHW Trained mentoring visits visits in the visits in the Total # CHW that received in the quarter quarter that quarter that trained to date mentoring visit that meets the meets the 60% meets below the in the quarter 1st 60% in the (not 1st time) District 60% threshold quarterly threshold

Total Male Total Male Total Male Total Male Total Male

Female Female Female Female Female Namaacha 16 11 5 9 8 1 3 2 1 6 6 0 0 0 0 Marracuene 41 32 9 15 14 1 4 3 1 6 6 0 5 5 0 Matutuine 16 12 4 4 4 0 0 0 0 4 4 0 0 0 0 Moamba 27 18 9 5 1 4 3 1 2 2 0 2 0 0 0 Magude 25 16 9 8 5 3 1 1 0 7 4 3 0 0 0 Manhica 41 24 17 14 8 6 2 1 1 7 3 4 5 4 1 Total 166 113 53 55 40 15 13 8 5 32 23 9 10 9 1

B. Refresher training for APEs During this quarter, all districts conducted a refresher training for the APEs. A total of 150 APEs participated in the sessions: 17 in Namaacha, 27 Marracuene, 14 Matutuíne, 23 Magude, 35 Manhiça, 13 Boane, and 21 in Moamba District. The refreshers were facilitated by the PPP team and officers from DPS and SDSMAS.

Contents of the refresher training included the following:  Orientation and recommendations to APEs regarding the MOH package of services for OVC families.  Case-finding of ‘lost to follow-up’ cases related to HIV, tuberculosis, and malnutrition.  APEs’ practical skills in identifying risk signs of developmental delays and providing referrals.  Registration process for OVC families.  Use of OVC-related record data in the daily work of APEs.  Understanding linkages with the social action sector around community referrals at different levels.

There continue to be gaps on OVC identified and recorded by APEs and some APE supervisors have difficulties identifying critical milestones and explaining the developmental milestones poster. To solve these issues, the PPP team and district APE supervisors, during mentoring and supervision visits, will reinforce the need for OVC registration and provide in-service training to APE supervisors.

Table 5 below summarizes the number of APEs who received refresher training in each district, disaggregated by sex.

Table 5. APEs receiving refresher training during the quarter, disaggregated by sex. APEs

District Trained APEs Total number of refreshed Female Male trained APEs during the quarter Namaacha 16 17 13 4 Marracuene 41 27 23 4 Matutuine 16 14 9 5 Moamba 27 21 10 11 Magude 25 23 12 11 Manhiça 41 35 22 13 Boane 15 13 11 2 Total 181 150 100 50

Previously, PATH had defined criteria for APE supervisors and APEs to receive an additional allowance of 1,200 Mt as an incentive for optimal service delivery. For APE supervisors, the criteria include preparing the monthly report correctly, making corrections after receiving feedback from district APE supervisors, submitting reports on time, maintaining an archive of the APE program in the HF, conducting monthly meetings, submitting reports on time, conducting monthly supervision visits to APEs, and using and filling in supervision forms correctly. For APEs, the criteria include filling out registers correctly, preparing monthly reports, making corrections after receiving feedback from district APE supervisors, submitting reports in a timely manner, attending monthly meetings in the HFs, availability to receive supervision visits, and having a bag with toys and playthings to demonstrate games and other stimulating activities to caregivers and also identified and conduct more OVC registration. This quarterly incentive appears to have contributed to the increased number of the children identified and registered by APEs in communities.

Using the above criteria, during this reporting quarter, 36 APEs and 1 local APE supervisor from the six districts received these vouchers.  Magude: 6 APEs  Marracuene: 5 APEs and 1 supervisor  Moamba: 6 APEs  Matutuíne: 3 APEs  Namaacha: 6 APEs  Manhiça: 10 APEs

Indicator 9

Indicator LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target only Achieve- Achieve Annual achieved of Y3 ments -ments target annual target Q1 Q2 Q3 Q4

Number of nongovernmental partners receiving 7 2 2 3 0 NA NA technical assistance from PATH

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Progress and issues

A. Other community partners—home visits, parenting education, and awareness building/sensitization activities

During this quarter, the PPP team has continued collaborating with the nongovernmental organization (NGO) VIDA and its partner CESAL in Matutuíne District, with whom it had earlier launched a parenting education pilot, by training facilitators from 22 agricultural associations. Specifically, the project supported two consultants to conduct an assessment of the parenting education pilot. The data collection has been completed and the final report is currently being revised and prepared for dissemination. Preliminary results indicate positive changes in knowledge and practices among both facilitators and participants of parenting sessions in three main areas: nutritional practices, father’s participation in the family, and early stimulation and positive discipline. Agricultural associations appear to be an effective medium for integrating parenting education sessions, and facilitators have also extended the sessions to other community gatherings. At the same time, results show that creative solutions are needed to improve data collection on the sessions in low literacy context, as well as to reinforce technical support to the facilitators who operate in remote rural communities. The dissemination of pilot assessment results to government, partners, and donors is planned for August.

PATH had planned to conduct an ECD field visit to support the World Education International (WEI) team. However, due to the demand of a competing planning session at WEI, they have requested to postpone the activity for next quarter. It is noted that PATH will only be able to provide long-distance technical support rather than hands-on support as originally planned.

IR. 2.3: Increased developmental screening and referrals of developmental delays.

Indicator 10

LOP S-ECD PPP Y1 PPP Y2 PPP Percent Y3 Achievements target only Achieve Achieve Y3 achieved Indicator -ments -ments Annual of Y3 target Q1 Q2 Q3 Q4 annual target

Number of children monitored for 29,095 N/A 9,726 13,652 10,018 4,160 42% developmental delays

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Developmental monitoring data collected prior to PPP project had duplication problems; and a new monthly data tool was introduced to eliminate this issue.

Quarterly targets = 2,504

Progress and issues

A. ECD counseling and child development monitoring at health facilities

This indicator is collected during the first CCS visits to avoid double counting, which may occur if collecting data from additional services as well. It serves to assess the degree of compliance in conducting developmental monitoring in all children during their first year of life.

During this reporting quarter, data collected across the 49 target HFs in the six project districts indicate that 4,160 children ages 0–11 months attended CCS for the first time, which corresponds to 166 percent compared to the target for this quarter (2,504). The total achievement thus far corresponds to 42 percent of the Year 3 target. Compared to the last quarter of Year 2, the number of children monitored has increased and appears to correlate with the improvement of work in the HFs and the reporting of data in the registers. The new facilities in Boane and Matola will be included in the next quarterly report, as the PPP team was mostly engaged in planning and mapping for these districts during the current reporting period.

A total of 222 monitored children across CCS, CCR, CCD, pediatric ART, PNC, and maternity consultations were suspected to have developmental delays. Of those, 181 were suspected during the first consultation and 41 during the follow-up consultations. Table 6 below summarizes this information disaggregated by district and by service.

This number is lower than the estimated target of detecting 343 children with suspected developmental delays per quarter. However, it must be noted that this is only an estimate and there is no literature on the actual prevalence of developmental delays in Maputo Province. The PPP team continues to work and discuss internally and with DPS and SDSMAS about the best ways to increase identification of developmental delays in a sustainable manner. The PPP team has supported IMCI training, communicated with DPS the targets for developmental problems

for each district and HF, reinforced the capacities of health providers to conduct developmental monitoring, and supported physiotherapist outreach visits. During the following reporting quarter, the team will conduct an analysis of children referred for suspected developmental delays. The PPP team foresees challenges because: 1) often nurses refer directly to the specialist, without referring to medical consultation/pediatric consultation first, in order to speed up the process; 2) the children are sometimes referred out of province, to Central Hospital, José Macamo Hospital etc., in case of complicated cases or because certain specialists such as speech therapists do not exist in the province, or because hospitals in Maputo City are closer for some districts than Provincial Hospital.

Table 6. Number of child’s suspected of developmental delays per service (first and following consultation).

CCS

CCR District CCD PN

TOTAL

PED ART

MATERNITY first following first following first first following NB NB Following first following Namaacha 0 0 3 0 1 0 0 1 1 0 6 0 Marracuene 1 3 0 0 1 0 0 17 0 0 19 3 Matutuine 0 6 0 0 7 0 0 8 2 1 17 7 Moamba 0 15 3 7 15 0 0 13 0 0 31 22 Magude 0 1 1 0 10 0 0 4 1 0 16 1 Manhica 2 5 9 0 38 0 0 34 9 3 92 8 TOTAL 3 30 16 7 72 0 0 77 13 4 181 41

B. Physiotherapists outreach visits During the reporting quarter, the project provided financial and transport support for the DPS and Matola Provincial Hospital physiotherapists to conduct consultations in Matutuíne and Namaacha districts, which do not have physiotherapist services. Technicians conducted consultations for both ambulatory and hospitalized patients. In these districts, the physiotherapists attended 144 first-time external consultations and 22 internal consultations for children 0–5 years. The table below provides detailed information disaggregated by district, pathology, and sex. Table 7. Total number of children 0–5 attending physiotherapy consultations during the quarter.

HGMachava Xinavane HR Moamba Boane Marracuene Manhica Matola HP Magude Matutuine Namaacha TOTAL Pathology/ age 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 New cases Ext Int Ext Int Ext Int Ext Int Ext Int Ext Int Ext Int Ext Int Ext Int Ext Int Ext Int Neurology 16 0 2 0 2 0 8 0 9 0 28 2 20 5 1 1 2 0 1 0 89 8 Rheumatology 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Traumatology 0 0 0 0 2 0 0 0 4 0 5 0 7 0 0 0 0 0 0 0 18 0 Orthopedic 0 0 0 0 0 0 8 0 4 0 0 0 14 5 0 0 0 0 0 0 26 5 Cirurgic 2 0 0 0 0 0 0 0 0 0 0 0 0 9 0 0 0 0 0 0 2 9 Respiratory 2 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 Cardiovascular 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Other Pathologies 0 0 0 0 0 0 1 0 3 0 1 0 0 0 0 0 0 0 0 0 5 0 TOTAL 20 0 2 0 4 0 19 0 20 0 34 2 41 19 1 1 2 0 1 0 144 22 Male 11 0 1 0 0 0 11 0 11 0 19 2 23 5 1 1 1 0 0 0 78 8 Female 9 0 1 0 4 0 8 0 9 0 15 0 18 14 0 0 1 0 1 66 14 TOTAL 20 0 2 0 4 0 19 0 20 0 34 2 41 19 1 1 2 0 1 0 144 22

C. Other activities performed to ensure data capture and quality

During the reporting quarter, the monitoring and evaluation team and SDSMAS (district statistics staff and ECD focal point) conducted joint data collection and technical assistance visits to all six target districts to guarantee quality of the data received from each district. This activity had a special focus on ECD but included other aspects of MCH as well, and consisted of review of HF data, register books, monthly and daily summaries, and patient observation checklists and referral booklets across all MCH services (ANC, PNC, CCR, CCS, CCD, maternity, and medical consultation). One of the key results was the verification of an improvement in recording of ECD counseling and monitoring data across all target HFs. Due the Health Government System, called SISMA which it are not provide data disaggregation by age, sex it contribute to PATH not provide a gender as requested by USAID only PATH can disaggregate by age and gender in Projecting health and OVC’s reported by APE’s indicators. During the refresher trainings to the APEs, the PPP team also incorporated content on using data collection tools—including the parallel tools introduced by PATH to collect OVC data.

Result 3: Expand knowledge and evidence base on integrated ECD

IR. 3.1: Increased demand for ECD materials and services among implementers and policymakers.

Indicator 11

Indicator LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target only Achieve- Achieve- Annual achieved ments ments target of Y3 Q1 Q2 Q3 Q4 annual target

Number of children 5,376 referred by 25,716 NA NA 8,980 1,847 20.6% CHWs to health facility

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Quarterly targets = 2,245

During the reporting period, APEs made 1,847 referrals to the HFs. Out of those, 32 were due to malnutrition and 41 due to suspected developmental delays. This translates to an achievement of 82.3 percent of the planned target for the period and 20.6 percent of the annual target. Nevertheless, it is important to note that establishing targets in number of referrals is an estimative exercise.

Unfortunately, none of the APE-level data cannot be disaggregated by sex because the APEs’ monthly summary tool does not have a way to disaggregate data in this manner.

Table 8. ECD counseling and early detection of signs of development delays at the community level.

5 5

– –

28 days28

–

5 years old old 5 years

District –

to HF

or DAG)

old surveilled for surveilled for old

and nutrition by APEs the

management)

community case

Healtheducation

old) surveilledforold)

postpartum period

Childrenmonth 1 Childrenmonth 1

Newborn (0

years by attended old

referred to due HFs

development APEs by development APEs by

Children 0

APEs (home visitsAPEs and (home with malnutrition (DAM

Childrento HF referred

years

sessions, in ECD which

Women pregnant and in Women in and pregnant in counseled stimulation

Total of children referredTotal of problems developmental wasprovided integrated, Namaacha 1,912 71 1,680 199 2 10 269 301 Marracuene 3,790 367 1,864 736 18 9 566 439 Matutuine 575 24 293 15 0 1 192 192 Moamba 2,512 148 1,551 114 2 1 245 614 Magude 1,902 97 1,318 194 5 3 71 337 Manhiça 3,609 454 944 589 5 17 695 970 TOTAL 14,300 1,161 7,650 1,847 32 41 2,038 2,853 Abbreviations: APE, Agente Polivalente Elementar (community health worker); ECD, early childhood development; HF: health facility.

Indicator 12

LOP S-ECD PPP Y1 PPP Y2 PPP Y3 Y3 Achievements Percent target only Achieve- Achieve- Annual achieved ments ments target of Y3 Indicator annual target

Q1 Q2 Q3 Q4

Number of partners using 7 2 4 6 1 0 0% PATH materials for programming

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Progress and issues Several partners have expressed interest in using PATH’s nutrition and ECD materials in the past quarter. The response to these requests will be conditional on agreements done with each partner. Outside Mozambique, the MCH Department of the MOH in Zambia has adopted some PATH-developed materials in its Kangaroo Mother Care and Pregnancy, Childbirth, Postpartum and Newborn Care Guidelines, as a result of a technical exchange between two countries. In addition, PATH is the process of transferring three posters to Elizabeth Glaser Pediatric AIDS Foundation in Tanzania for use in ECD service delivery in MCH and PMTCT settings. Moreover, a large USAID-funded OVC service provider in Zambia asked for PATH IEC materials on ECD for use in the community.

IR 3.2. Increased evidence base on high-quality ECD service provision and the impact of ECD services on care and stimulation behaviors in target communities.

Indicator 13

LOP S-ECD PPP Y1 PPP Y2 Y3 Y3 Achievements Percent target only Achieve Achieve Annual achieved of Indicator -ments -ments target annual Q1 Q2 Q3 Q4 target for Y3

Number of dissemination 24 6 11 8 6 5* 83% instances

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. (*) Zambia & Ethiopia learning visit; ICAP, WHO, M2M field visit; Children’s day; VIDA event in Matutuíne; Community of Practice Workshop in Cote d’Ivoire

Progress and issues PATH has continued to disseminate its work through different events. It hosted two learning visits: one for a delegation comprising the Zambia and Ethiopia MOH, UNICEF, and nongovernmental partners; and another for HIV-focused partners ICAP and mother2mothers, as well as WHO. During the Zambia and Ethiopia learning visit, the participants met with several MOH departments and their provincial counterparts, UNICEF, and WHO and conducted field visits in Maputo Province to see ECD integration in clinical and community settings at PATH- supported sites. Staff from the Mozambique MOH Nutrition and APE departments took part in the visit as well.

Several HIV partners (ICAP, mother2mothers) were invited to observe how ECD services are integrated into HIV-related CCR and pediatric HIV consultations, as well as in CBO work under the PEPFAR-funded COVida, with the objective to encourage HIV partners to think about how to effect such integration in their own projects.

Additional fora for dissemination were public events such as the national Children’s Day celebration in Maputo on June 1, where PATH was invited by MGCAS to demonstrate toy- making and stimulation activities for young children and a local commemoration of agricultural associations in Matutuíne, where PATH presented the preliminary results of the parenting education pilot assessment.

The PPP team has also disseminated PATH’s work outside of Mozambique, specifically, at the World Health Assembly annual meeting in Geneva in May, and in the ECD Community of Practice meeting with partners and government stakeholder in Côte d’Ivoire in June.

Indicator 14

Y2 Achievements Percent S- PPP Y1 PPP Y2 Y3 achieved LOP Indicator ECD Achieve- Achieve- Annual of annual target only ments ments target Q1 Q2 Q3 Q4 target for Y3

Number of publications 40 10 10 9 10 2 0 0 0 20% (newsflashes)

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year.

Progress and issues During the reporting quarter, the PPP team continued to produce electronic newsflashes, where success stories and key project achievements were highlighted. In this quarter, the newsflashes focused on the national TOT on stimulation in the pediatric wards and on support to MGCAS with the new Manual for Community Preschools under COVida.

The produced newsflashes are distributed to a total of over 100 institutions and 250 persons every month. PATH’s distribution list includes institutions such as USAID/PEPFAR, UNICEF, WHO, World Bank, MOH, MGCAS, Ministry of Education, and Human Development, Eduardo Mondlane University, Provincial Health Directorate, district services, Elizabeth Glaser Pediatric AIDS Foundation, ICAP, FHI 360, World Vision, Save the Children, among others.

IR 3.3 Improved caregiver knowledge, attitudes, and practices on ECD.

Indicator 15

LOP S- PPP Y1 PPP Y2 Y3 Y2 Achievements Percent target ECD Achieve Achieve- Annual achieved Indicator only -ments ments target of annual Q1 Q2 Q3 Q4 target for Y3

Number of caregivers receiving IEC messages 901,072 NA 281,585 207,517 323,823 59,088 18.2% through CHW- led community talks

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; IEC: information, education, communication; CHW: community health worker; PPP: public-private partnership; Q: quarter; Y: year; N/A, not applicable

Quarterly targets = 80,956

During the reporting period, APEs reached a total of 59,088 caregivers in their community educational talk activities—which covered a range of different topics such as ECD, nutrition, family planning, hygiene, water and sanitation, prevent diseases, etc. This figure converts to 73 percent of the planned target for this quarter and 18.2 percent of the annual target. Table 9 below provides more detailed information.

Table 9. Number of caregivers receiving CHW IEC messages through community talks (targets and achievements by district during the quarter). Indicator 3.3.1: Number of caregivers receiving IEC messages through APE-led community talks. Total of Percent District caregivers Target achieved covered Namaacha 7,314 7,513 97 Marracuene 13,383 19,881 67 Matutuíne 2,984 3,545 84 Moamba 11,554 18,374 63 Magude 7,341 7,711 95 Manhiça 16,512 23,932 69 Total 59,088 80,956 73

During this quarter, the number of caregivers receiving IEC messages through community talks delivered by APEs was slightly higher than the corresponding number from the previous quarter. However, whereas last quarter’s figures represented a 79 percent achievement of the quarterly target, the corresponding achievement for this quarter is 73 percent. This may be explained by APEs focusing more on curative activities rather than disease prevention and health promotion activities. The PPP team will consider the use of increased technical assistance to increase the number of community talks; or may also consider reviewing targets to factor in the realities of working with a weak health system.

Indicator 16

LOP S-ECD PPP Y1 PPP Y2 Y3 Y2 Achievements Percent target only Achieve Achieve Annual achieved Indicator -ments -ments target of annual Q1 Q2 Q3 Q4 target for Y3

Number of beneficiaries attending Projecting Heath 23,976 NA NA 25,423 8,484 6,658* 78% sessions at health facilities

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year; N/A, not applicable * 5,445 female; 1,213 male ; Quarterly targets = 2,121

Progress and issues

A. Projecting Health, facilitation of educational video sessions at health facilities

Projecting Health video sessions are held during early morning hours in the waiting areas of 17 HFs of six districts, including the Matola Provincial Hospital, while caregivers and their children wait for different mother and child services (e.g., ANC, PNC, CCR, CCS, and pediatric ART). A total of 12 different videos are currently in use in HFs.

During the reporting period, a total of 158 video sessions were conducted in HFs across the six intervention districts and were attended by a total of 6,658 caregivers (1,213 male and 5,445 female), largely exceeding the quarter target. As the target was based on available data when video projection activities initially started, it should be reviewed again now that the activity is more mature. Table 10 below details number of projections and attendants per sex and per district.

Table 10. Number of Projecting Health sessions and participants, by sex per district. Number of beneficiaries attending to Projecting Heath sessions at health facilities

District Male Female Total Target % Coverage # of sessions Namaacha 379 1,532 1,911 338 565 45 Marracuene 200 1,611 1,811 484 374 42 Matutuíne 56 270 326 66 495 14 Moamba 280 632 912 631 145 12 Magude 142 473 615 172 357 16 Manhiça 156 927 1,083 429 252 29 Total 1,213 5,445 6,658 2,121 314 158

With technical support from the PPP team, health providers trained on Projecting Health also showed general improvement in the quality of facilitation during sessions.

B. Projecting Health, expanding educational video sessions at community level During the reporting period, the PPP team—in collaboration with Magude, Moamba, and Manhiça SDSMAS—conducted a technical support visit on the utilization of videos to the two district child protection committees (CPCs) and child health committees (CHCs) trained on projecting health video sessions. In general, the CPCs and CHCs felt that the video sessions helped caregivers enhance their knowledge levels in the areas of care and stimulation and nutrition. A more systematic assessment of the acceptability and feasibility of Projecting Health as a tool for influencing behavior change in the Mozambican context is currently ongoing.

C. Monitoring and evaluation plan

During the reporting period, the PPP M&E team and project management team conducted the quarterly review meeting to assess the progress of each indicator according to the planned targets. An internal exercise was also conducted to adjust the value of certain indicators to avoid double-counting. As a result, Indicator 5 (Percentage of HF clinical providers reaching the

threshold score of 80% for ECD services) and Indicator 8 (Percentage of CHWs reaching the threshold score of 60% for ECD services) were revised and are reflected in this report.

D. Collaboration with WEI

As mentioned in the last quarterly report, WEI is currently using the same data collection tools as the COVida Project. These tools were developed by PATH, therefore capturing ECD data and allowing for comparison with districts where the COVida Project is being implemented.

E. Operations research and other assessments

During this reporting period, the operations research protocol was reviewed by the Bioethics Committee. Two rounds of feedback were addressed in the revised protocol, which was resubmitted by the PPP team. Currently we are waiting approval, following which, the consultant will commence with the next steps of study implementation.

Additionally, during this quarter, multiple assessments (also considered project activities) were initiated—specifically the baseline assessment in Matola District, the Boane District assessment, as well as assessments of Projecting Health, playboxes, and the parenting education pilot.

 Matola District baseline assessment The activity occurred as part of the expansion of integrated ECD services in Matola District. It was necessary to carry out a baseline assessment on ECD integration in three Matola District HFs, specifically Ndlavela, Machava II, and Matola II, which took place in April. As result of this assessment, it was discovered that the majority of Matola staff were not conducting children developmental monitoring or counselling on stimulation. It was also noted that improvements are needed on nutritional screening and counseling. Training for Matola staff was designed based on results obtained from this assessment.

 Boane District assessment The main objective of this assessment was to determine the status of ECD integration in MCH and APE services in Boane District, which had been supported up to 2016 by PATH through the BHP Billiton Sustainable Communities–funded Window of Opportunity Project. Five HFs and five APEs were visited for the assessment—specifically Boane, Campoane, Beleluane, Picoco and Massaca HFs and the APEs of the communities of Tchonissa, Estevele, Mariem-Nguabi, Jossias Tongogara, and Mahanhane. A rapid assessment of services (CCS, ANC, PNC, CCR, maternity, and pediatric ART) took place at each HF, as well as key informant interviews

The initial findings indicate that while some of the staff are still integrating ECD in their services, improvements are needed to achieve the desired level of implementation, as the quality of services and registries has decreased due to a lack of technical and financial support from partners. The next steps to support Boane District with integrated ECD service delivery will be based on the results and recommendations from this assessment.

 Projecting Health assessment The Projecting Health assessment began in May in Matutuíne, Namaacha, Moamba, Manhiça, Marracuene, and Magude districts. As part of this assessment, qualitative data was collected from six HFs (one from each district) and from three CHCs. The assessment sought to investigate perceived impact of the intervention and key challenges, as well as understand ways in which caregivers are using content from the video sessions. Additional data was collected

regarding the availability of Projecting Health equipment and their condition, as well as the availability of data registers for capturing number of caregivers attending sessions.

Assessment results confirm the value-add of video sessions, as evident by the self-reported gain in knowledge levels of participants. The participants indicated that they share the lessons learned from the Projecting Health sessions with others in the community. They also proposed additional topics for future sessions. On the other hand, some equipment was reported as being missing.

 Playbox assessment The playbox assessment was conducted in Magude, Marracuene, Namaacha, Moamba, Ressano Garcia, Matutuíne, Manhiça and Xinavane HFs and at the provincial hospitals of Matola and Geral da Machava. The assessment sought to investigate the operation of playboxes in each HF, identify key challenges regarding their operation, and define strategies to ensure continuity of the intervention. As part of the assessment, qualitative data was collected using interviews with facilitators and caregivers from all ten HFs implementing playboxes.

Results suggest that there is a need to improve playbox activity coordination and clearly identify responsible staff. It became clear that medical staff and district authorities were not entirely aware of playboxes being implemented in their district. The caregiver responses, however, indicated the importance of the playbox sessions, as they reported learning new information and recognized the importance of play for their children. Recommendations from this assessment will be used to further improve the implementation of playboxes across Maputo Province.

 Parenting education assessment The purpose of this assessment was to assess whether the parenting education program, implemented in the agricultural associations supported by VIDA and CESAL in Matutuíne District stimulated the development of the expected parental educational competences in the members of the associations and in their communities in general. In this regard, two key questions were pursued: (1) Has the parenting education program been implemented with sufficient fidelity to the model, regarding the number of sessions given and the adherence of the participants? (2) Will there be changes in the knowledge and practices reported in participants in the parental education program?

In the data collection process, six focus group discussion sessions were conducted: one with six facilitators and the remaining five with participants. The focus group was adequate to capture perceptions, opinions, and feelings regarding the idea of training in parental education. Individual interviews were also held with the facilitators in order to obtain their perceptions about the feasibility of parenting education and the impact they are perceiving in their families and community.

The results indicate that caregivers are adhering to the key messages and that the visual materials have been used in the desired manner. Evidence gathered in the four communities suggests that the project stimulated a change in behavior and attitudes that not only favor the improvement of conditions facilitating child growth and development, but also resulted in an improvement of the quality of relationship in the families. Given the brief duration of the project (less than a year) and based on the results of the pilot evaluation of the selected communities, it can be stated that the parenting education pilot was a success.

F. PEPFAR OVC indicators The PATH team is working in coordination with SDMAS and DPS to support APEs to improve registration and data collection from OVC in all six districts. During this quarter, refresher trainings of APEs took place in all six districts and included issues of data collection and registration of OVC using the APEs record book, the exercise had the objective to improve registry on the record book fields that allow the registry of children exposed on HIV and TB illness. Difficulties in obtaining data still persist, as the APEs are responding slowly to the provided support. However, the team will continue providing support.

HL. 9-1 INDICATOR While the PPP project is not supporting clinical nutrition interventions or treatment of nutrition conditions, it has a strong component on nutritional counseling to caregivers to improve nutritional knowledge and practices for their children as part of the approach of integrating ECD into clinical and community services. Table 14 reflects children benefiting from nutrition counseling provided by APEs during the period April to June 2018. A total of 14,300 children were reached by the APEs in all six districts (6,864 male and 7,436 female). Out of this figure, 2,973 children were under one year old (1,441 males and 1,532 female), and 11,326 children between 1–4 years old (5,423 males and 5,903 female).

Table 11. HL. 9-1: Number of children under five (0–59 months) reached with nutrition-specific interventions through United States Government-supported programs (April–June 2018). Code Indicator name HL. 9-1: Number of children under 5 (0-59 months) reached with nutrition-specific interventions HL. 9-1 through United States Government-supported programs Male TOTAL Female TOTAL Total District <1 ano 1-4 anos <1 ano 1-4 anos

Magude 192 721 913 204 785 989 1902 Manhica 364 1369 1732 387 1490 1877 3609 Marracuene 382 1437 1819 406 1565 1971 3790 Matutuine 58 218 276 62 237 299 575 Moamba 253 953 1206 269 1037 1306 2512 Namaacha 193 725 918 205 789 994 1912 TOTAL 1441 5423 6864 1532 5903 7436 14300

Progress in implementation of environmental mitigation actions and gender analysis issues As proposed in the approved Gender Action Plan and Environmental Mitigation Plan, the PPP team has continued promoting the use of recycled materials for toy production in every training. In this quarter, pediatric wards in Maputo, Inhambane, and Nampula provinces have been trained to adopt recycling and toy-making practices through PRN trainings on stimulation. With regard to promoting gender equality, the PPP team has continued to develop leadership skills among its technical staff, which is largely female, by delegating to them greater responsibility for specific tasks with MOH, DPS, and district services. Additionally, the parenting education package has a separate module on the role of the father in the family, and the father is featured prominently in other modules as well. The recently conducted evaluation of parenting education pilot suggests that positive change in gender dynamics was one of the strongest results of participating in parenting education sessions.

5. Upcoming plans

The following are some major activities planned for the upcoming quarter: 1. Actively participate in all district PES meetings ensuring integration of key ECD activities. 2. Support national distribution of developmental posters and guidelines. 3. Participate in technical working group sessions and meetings to approve pre-service MCH curriculum profile and initiate development of curriculum modules. 4. Provide technical and financial support to DPS supervision in child health: Magude: July 2 and 3, 2018; Marracuene: July 4 and 5, 2018; Matola: July 6 and 9, 2018; Boane: July 10 and 11, 2018; Namaacha: July 11 and 12, 2018; Manhiça: July 17 and 18, 2018; Matutuíne: July 19 and 20, 2018 and Moamba: July 23 and 24, 2018

5. Actively participate in all district PES meetings ensuring integration of key ECD activities: Namaacha and Moamba (July 9–13, 2018), Magude and Matutuíne (July 16–20, 2018), Boane and Matola (July 23–27, 2018), Marracuene and Manhiça (July 30–August 3, 2018). 6. Implement new quality improvement approaches and support district supervision and facility-specific action plans. 7. Conduct training for MCH nurses and mental health technicians on screening and counseling for maternal depression. 8. Conduct semi-annual reflection meetings with DPS/DPGCAS and SDSMAS, including ECD screening and referral data. 9. Provide technical support to training of 30 new APEs on ECD component (new APEs trained by MOH in the province). 10. Conduct refresher training of APEs. 11. Support mobile physiotherapy brigades in Matutuíne and Namaacha districts. 12. Support health workers of selected HFs on utilization of videos in morning educational activities. 13. Provide technical and financial support to SDSMAS to conduct follow-up visits to CHCs and CPCs that have been trained in screening Projecting Health videos. 14. Provide long-distance support and technical field follow-up visits to WEI in Sofala and Zambézia provinces. 15. Support semi-annual refresher for the facilitators of playboxes. 16. Receive approval from National Bioethics Committee and launch operations research study.

For detailed activities of the upcoming quarter, refer to Appendix B, which is attached with this report submission.

6. Administrative update

During the reporting period, Traifina Domingos, Child Health & Development Associate/Mentor announced her resignation from PATH. Her duties will be taken over by Elino Fumo, who is currently a Regional ECD Specialist on the COVida Project. Also during the current quarter, Jordi Fernandez, Mozambique Country Program Manager, commenced an extended leave of absence. During this absence from the office, Debjeet Sen, Regional Specialist for ECD & Nutrition, has served as Project Director of the PPP Project.

7. Financial information

A total of $124,107.82 USD were expended during the quarter April–June 2018. The table below shows the expenses for the quarter by categories and projected expenses for April–June 2018.

Cumulative Projected Expenditures for Total budget Expenditures for expenses Total approved budget current period project to date remaining (7/1/18–9/30/18)

(4/1/18-6/30/18) (4/6/16–6/30/18) Direct labor 514,215.00 52,612.13 424,009.60 90,205.40 51,783.93 Fringe benefits 166,605.00 16,570.86 130,627.70 35,977.30 16,777.99 Travel 66,200.00 4,056.97 69,655.33 (3,455.33) 4,500.00 Supplies 4,156.00 - 4,364.09 (208.09) - Sub-awards 91,761.00 - 25,673.68 66,087.32 13,448.28 Other direct costs 233,214.00 22,967.65 219,214.60 13,999.40 15,000.00 Indirect costs 423,296.00 27,900.21 243,770.95 179,525.05 29,437.96

Total project 1,499,447.00 124,107.82 1,117,315.92 382,131.05 130,948.15 costs

PATH will be submitting a budget re-alignment for the remaining period in the coming weeks.

8. Appendices

Appendix A. Success stories and photos From client to service provider: How a caregiver became a volunteer facilitator of playbox sessions in a health center

"My name is Cândida Ângelo Machel, I use the services of Manhiça Health Center as a client.”

Adds Cândida with a twinkle in her eye, “I am also a playbox facilitator.”

It all started about seven months ago when 28-year-old Candida took her son for a well-baby consultation at the Manhiça Health Center. In the past, she would have arrived for the consultation, sat in the waiting area for some time, attended the consultation, and then left for home.

During this particular visit, things were different. “I came to the consultation with my son and I found the nurses facilitating a playbox session, talking of the importance of playing with a child. I really liked the things they said, the toys, my son having something to play with while we waited to be attended. I liked it so much that I decided to participate,” says Cândida.

Playbox sessions at the Manhiça Health Center are held three times a week, with an average of 200 caregivers participating per session. During these sessions, facilitators give a short talk on a topic relevant to child health and development. Following that, caregivers waiting to receive services are invited to pick toys from a box full of play materials made with locally-available materials. Children play with these toys, while facilitators check for any signs of developmental delays and counsel caregivers that seem to have challenges bonding with their children.

“Always during the playbox sessions, we ask the caregivers to talk a little bit about what they have learned during the sessions. Cândida was a very active participant, answering questions, explaining to other caregivers, and practically doing a second facilitation of the activity,” recalls playbox supervisor and Preventive Medicine Technician, Levane Mucare.

Cândida loved attending playbox sessions every time she came to the health facility, until one day, she requested the nurses if she could facilitate the activity. “I got there early and went to the nurse and asked if I could help her with the sessions. She agreed and that's how I became a playbox facilitator.”

For Technician Levane, Cândida’s enthusiasm and request to become a facilitator was a confirmation that the playbox sessions and associated talks were having the desired effect. Levane also realized that having a mother as a facilitator would encourage other mothers to adopt the ECD and nutrition messages and behaviors promoted during playbox sessions and in clinical consultations. Moreover, having such enthusiastic volunteers facilitate these sessions is helpful for long-term sustainability. Nurses and technicians may not always have time to facility sessions and relying on nongovernmental partners to pay facilitators is not always feasible.

In the past four months, Cândida has made it a point to reserve two days every week to go the health center to conduct playbox sessions. She comes to the health center even on days when her children do not have scheduled consultations. According to her, “facilitating the playbox is not complicated because what I counsel other mothers are same things that I learned myself and do at home.”

Cândida has received support from everyone: other mothers and caregivers coming to the health center, the nurses at the health center, and her own husband. When other mothers realize that she does not work at the health center, they admire her, congratulate her, and encourage her to continue. For Cândida, being a facilitator has also changed the way in which she interacts with her own children. She plays more with them and is more aware of the role of play and communication in facilitating optimal ECD.

Levane summarizes perfectly: “She is our mother model, an example to us all.”

Cândida Machel, a caregiver who facilitates playbox sessions in Manhiça Health Center