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: Q2 July–September 2018

Submitted on: October 30, 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 ...... 8 Progress and issues ...... 8 Indicator 3 ...... 8 Progress and issues ...... 9 Indicator 4 ...... 10 B. Semi-annual reflection meetings with DPS/DPGCAS and SDSMAS...... 11 Indicator 5 ...... 12 Progress and issues ...... 12 Indicator 6 ...... 15 Indicator 8 ...... 16 Indicator 9 ...... 19 Progress and issues ...... 19 Indicator 10 ...... 20 Progress and issues ...... 20 Indicator 12 ...... 24 Progress and issues ...... 25 Indicator 13 ...... 25 Progress and issues ...... 25 Indicator 14 ...... 26 Progress and issues ...... 26 Indicator 16 ...... 27 Progress and issues ...... 27 5. Monitoring and evaluation ...... 28 6. Upcoming plans ...... 33 7. Administrative update ...... 34 8. Financial information ...... 34 9. Appendices ...... 35

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 EGPAF Elizabeth Glaser Pediatric AIDS Foundation 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 second quarter (July to September 2018) of the third year of project implementation. PATH has continued to support the Ministry of Health and Ministry of Gender and Social Action (MGCAS) in developing activities to reinforce the integration of ECD in health facilities (HFs) and communities with the objective to improve 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 HFs and community-based organization (CBOs).

During this quarter, the PPP team continued working with the Child Health, Nutrition, and Health Promotion departments and technical working groups of the Ministry of Health (MOH) to review and follow up relevant documents for integrating ECD—such as stimulation posters for the maternity ward and child health supervision tools. Also during the quarter, the final report of the national ECD workshop held in late March was approved by the MOH. The report includes a draft of a national action plan for the integration of ECD into health services. This report was disseminated to all 11 provinces in Mozambique. The distribution process for posters on developmental milestones and nutrition counseling to all provinces with logistic support of several PEPFAR implementing partners was concluded during this quarter.

PATH was invited by MOH to participate in two national neonatal and child supervision exercises in Maputo Province. These supervision exercises included oversight of Integrated Management of Childhood Illness (IMCI), at-risk child consultation (Consulta da Criança em Risco [CCR]), child well-being consultation (Consulta de Criança Sadia [CCS]), and postnatal care (PNC) with the objective of monitoring the quality of implementation and post-training follow up of providers.

Although PATH is not directly 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 10,391 children were reached with nutrition interventions by community health workers (agentes polivalentes elementares [APEs]).

Following the expansion of the PPP-ECD project to Matola and Boane districts, the PPP team conducted a training of trainers (TOT) orientation for nine participants from these districts. Subsequently, the PPP team provided support for two-day replication trainings in high-volume HFs of these two districts, benefiting 29 providers in Boane and 23 in Matola. Additionally, the project trained another 23 providers of Marracune District who were not previously trained.

At the HF level, data collected across all 55 target HFs of the eight target districts supported by the project indicated a total of 55,945 beneficiaries (caregivers or children under five) who received ECD and nutrition counseling. This figure reflected a significant increase following starting project activities in six new HFs from Matola and Boane.

The playbox activity was extended to three additional HFs from Boane District during the quarter. Now the activity is being implemented in 13 HFs, and a total of 221 playbox sessions were conducted during the period with 16,761 caregivers of children under five years participating in these sessions.

During the reporting period, a total of 147 video sessions were conducted in HFs across the six intervention districts.A total of 6,642 caregivers attended these sessions. The playbox and the video sessions are part of the information, education, communication (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), 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 support, mentoring, and supervision to APEs in the districts. During this quarter, the PPP team supported DPS on the initial training—conducted in Moamba—of 30 new APEs, who serve several districts in the province. Through these mentoring and supervision visits, The PPP team is reinforcing specific ECD topics that have been integrated into the APEs training package. Additionally, all districts conducted refresher trainings with a total of 151 APEs participating in the sessions, with the exception of Matola, since they have no APEs. Training contents were defined by each district, but all districts agreed to address the following common priority issues included in the MOH package of services for families of orphans and vulnerable children [OVCs]: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 34 APEs were mentored during the period, 2 of whom reached the threshold score of 60 percent using the PATH mentoring tool.

During this reporting quarter, data collected across the 55 target HFs in the eight project districts indicate that 6,406 children ages 0–11 months attended CCS for the first time, which translates to 177 percent in relation to the quarter target (3,624)

A total of 461 monitored children across CCS, CCR, sick child consultation (Consulta da Criança Doente [CCD]), pediatric ART, PNC, and maternity consultations were suspected to have developmental delays. Of those, 347 were suspected during the first consultation and 114 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 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

PATH-developed IEC materials for maternity wards (a set of 12 poster-cards on mother and child nutrition, health, and stimulation), previously approved by Maputo Province DPS, have been revised at the national level by MOH and authorized for use in Nampula Province, where PATH is launching work with a coalition of government health partners.. The PPP team is working to obtain MOH formal approval of these materials.

Working in collaboration with the World Bank Health and ECD staff , specific content on early stimulation and responsive feeding was integrated into the implementation guide for community- based counseling on child feeding, to be used under Disbursement Linked Indicators 4 ( DLI 4), which is part of the new health sector funding package to Mozambique under the Global Financing Facility (GFF) in eight provinces starting next year. PPP materials and illustrations were used to developing these sections. Following negotiation with the MOH Nutrition team, the PPP team was allowed to further revise and enrich the section on stimulation and to recommend the IEC materials to be used by the APEs and health community agents in the communities. These proposed revisions are currently under review by the MOH Nutrition team.

The PPP team worked jointly with MOH Mental Health and Maternal Health departments to produce the first version of the terms of reference for piloting screening and counseling on maternal depression as a part of postnatal consultations in selected HFs of Maputo Province. While the terms of reference are being finalized by the MOH and United Nations Development Program, the PATH team has designed and initiated formative data collection on the experiences of mothers during the postnatal period, to inform the adaptation of the World Health Organization’s (WHO’s) Thinking Healthy counseling cards on maternal depression to the context of Mozambique. The formative data and the first drafts of adapted counseling cards are expected to be available by end of November; additional discussions are underway with United Nations Development Program to fund the evaluation of this pilot.

In September, the MOH Nutrition and MCH departments, the PPP team, and the UNICEF and WHO focal points worked together to take stock of what has been achieved in Nurturing Care nationally to date and to prepare for the regional stakeholder meeting on Nurturing Care Framework in the health sector, which took place in Kenya in October 2018. As a result of the analysis done, the team has discovered, for example, that there is currently no single policy or strategy document at the MOH level that makes reference to ECD explicitly. This realization has encouraged the PPP team and MOH to initiate work to integrate relevant ECD content into the national Child Feeding Strategy about to be finalized; specific content has been proposed and is now being revised by the Nutrition Department. The assessment also pointed to the gap in current neonatal IMCI flipchart, which does not include any content on responsive care and stimulation, limiting itself to developmental monitoring of the newborn. As a result, UNICEF is currently supporting this integration at PPP team’s request, since it is the agency that will be funding the reproduction of the IMCI flipcharts.

The PPP team is also working with MOH and its technical partners to follow up on the recommendations from March’s national ECD workshop, to move towards a national MOH-led ECD action plan to be integrated into the annual Social and Economic Plan (Plano Económico e Social [PES]).

Several tools submitted for approval in previous quarters—such as final versions of the Community IMCI, a national supervision guide, and maternity posters—are waiting for approval at national level.

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 22 3 5 7 8* NA 8 100% 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

A. Planning of 2019 (PES, Plano Económico e Social).

The district and provincial annual planning exercises for elaborating the 2019 PES took place in July and August. The PPP team participated in these exercises and worked together with the eight districts to ensure ECD integration in final versions of 2019 PES, enhancing district appropriation and integration of ECD into routine activities as a strategy to enhance project sustainability.

B. Support to DPGCAS to conduct the 2018 Provincial Coordinating Council meeting and to improve intersectoral collaboration. The PPP team provided technical, organizational, and limited financial support to the 2018 DPGCAS Provincial Coordination Council, which occurred in September with 68 participants from government institutions and NGO partners. The DPGCAS praised the support provided to the event by the PPP team.

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 Q1 Q2 Q3 Q4 target

Number of government curricula, guidelines, and data tools revised by 4 1 1 2 1 5 1 600% 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.

Progress and issues

A. MCH nurses’ pre-service curricula review. The MOH continues to lead the process of review of the MCH nurses’ pre-service curriculum. In this regard, the MOH has mobilized additional funding from UNFDP to hire the consultants who will develop training modules. It is planned that next quarter the PPP project will fund an orientation meeting to start the process. The PPP team will work with the consultants, MOH, and partners along the process and provide technical support for ECD integration in different areas of the modules such as ANC, labor, PNC, CCS, CCR, sexual reproductive health, family planning, pediatrics, community health, and nutrition.

B. Other technical assistance provided through participation in MOH/MGCAS technical working groups. MCH  During the quarter, MOH-approved posters on developmental monitoring and counseling were distributed to all provinces and are to be used during CCS consultations with support from other PEPFAR partners (ICAP, CHASS, FHI360, CCS, EGPAF, M2M). To ensure adequate utilization of posters, the PPP team has also distributed provider guidelines that accompany each poster along with specific indications to provincial medical officers.  The PPP team participated in the national TOT on new CCS and CCD registers with integrated ECD, and has been invited to support these trainings at the provincial level in Maputo Province.  The PPP team is working with the MOH prevention of mother-to-child transmission (PMTCT) technical working group in the technical review of a PMTCT supervision guide and Mother to Mother training material to ensure ECD integration. The process is still ongoing.

Nutrition During this quarter, the team continued to work with MOH and partners on the revision and integration of ECD content into several national level relevant documents and guidelines. As a result, the second edition of the Nutrition Rehabilitation Program (Programa de Reabilitação Nutricional [PRN]) Manual (Vol. I) was published in September 2018, and now includes new content on developmental monitoring and updated content on stimulation in both inpatient and outpatient treatment of acute malnutrition (namely, in pediatric wards and CCR).

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 23 providers 370 135 85 35 115* 93 101% ** 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. * 63 Health providers from Matola , 29 from Baone and 23 new Health providers from Marracuene . ** In Q1 127 providers received ECD training in different components such as IMCI, nutrition in-patient treatment, etc. but only 23 of these providers were trained for first time

Progress and issues

A. Trainings TOT and ECD replication trainings Following the expansion of the PPP-ECD project to Matola and Boane districts, in August the PPP team conducted a TOT orientation for nine participants from these districts, including district supervisors and the heads of several high-volume HFs. The training focused on how to integrate ECD in CCS, CCR, nutrition, ANC, PNC, MCH, and IMCI service delivery touch-points, and included a practical session in which PPP and DPS teams supervised training participants on the integration of ECD during the daily work at each of the services.

Subsequently, the PPP team provided support for two-day training replications in high-volume HFs of these two districts, benefiting 29 providers in Boane and 41 in Matola. Additionally, the project trained another 23 providers of Marracuene District who were not previously trained. A total of 93 providers of different categories were trained during the reporting period as shown in Table 1.

Table 1. Number of staff trained during the quarter.

Category

District

Achieved

TMP

TSSP

TMG AMP

Male AMG

TMSP

Other

Female Enf Bas

Enf Ger

Enf Sup

Medico

Enf SMI

Tec Nutr

EnfSup Ped EnfSup

Enf Sup SMI Enf Sup

Tec Sup Nutr Tec Sup

Total Total

Namaacha 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Marracuene 23 6 17 3 1 6 0 1 1 3 7 0 0 1 0 0 0 0 0

Matutuine 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Moamba 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Magude 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Manhica 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Boane 29 2 27 1 2 1 0 1 1 1 8 0 0 0 1 4 2 2 5

Matola 41 4 37 3 3 3 0 0 0 2 10 1 1 3 0 8 1 1 5

Total 93 12 81 7 6 10 0 2 2 6 25 1 1 4 1 12 3 3 10

B. Semi-annual reflection meetings with DPS/DPGCAS and SDSMAS. With support from the PPP team, the DPS led a PPP semi-annual reflection meeting in August chaired by the provincial medical chief with the participation of DPGCAS and the SDSMAS of all the eight project working districts. The meeting had several objectives: discussion of project achievements during the period January–June 2018; sharing the early experiences of Matola District in project implementation; discussion of project activities until end of the project; dissemination of the results from the assessment of ECD integration in Boane District after the Window of Opportunity Project ended; and dissemination of the playbox assessment conducted in six districts. The meeting was attended by 45 participants from the all institutions previously mentioned.

Overall, the meeting showed strong engagement and leadership from DPS, which we consider an extremely important outcome considering we are in the final year of the project. Regarding project implementation, the districts showed improved capacities on ECD integration in the all areas including MCH services, APEs, and early morning educational activities in HFs. The review also highlighted significant improvement in the achievement of the project’s annual targets when compared with the previous period. As an indicator of the appropriation of the project, for the first time the DPS took the lead, with PPP team support, to produce and distribute the meeting report , including recommendations agreed on during the meeting, to each district. It was agreed that a follow-up meeting will happen in February 2019 with the purpose to evaluate the accomplishment of each recommendation by SDSMAS and DPS.

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 75% reaching the 265 24 91 32 NA*** NA*** 0 56% (74)** 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. (*) See Chapter 5, Monitoring and Evaluation, Monitoring and Evaluation Plan (**)This is 75% of the number of health providers who are eligible for receiving mentoring sessions according to the new strategy: 99 providers of Matola (46), Boane (31) and Marracuene (22), additional to the 191 accumulated until Y2. (***) For these quarters the target Is not applicable as training took place recently and providers have not yet been fully mentored. It is expected that some data will be available already in 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. Action plans.

During this reporting period quarter, the PPP team has prioritized the follow-up of action plan activities identified during the previous supervision at the priority HFs of Motaze, Panjane, and Moíne (Magude District) and Ilha Josina, 3 de Fevereiro, and Chibucutso (Manhiça District). The PPP team is working towards building SDSMAS ownership of these activities and jointly following up on gaps identified in supervision conducted in different services (MCH, nutrition, data collection, and integrating developmental monitoring and stimulation counseling during routine health service delivery). Gaps addressed through mentoring and on-the-job training include the following:  Completion of the child's health card and conducting CCS consultations according to the norms.  Data collection and preparation of monthly activity ECD, MCH, and nutrition summaries at the HFs.  Correct ECD and IMCI implementation.  Ensuring developmental monitoring is carried out with children who receive services at the HF, according to norms.

In general terms, the PPP and district teams noted several improvements compared with the previous quarters. These improved observations include health providers registering and compiling monthly ECD summary data using the new forms allocated in each HF; increased integration of child monitoring and caregiver counselling on care and stimulation in consultations; improved CCS consultations including all services recommended by national

guidelines; improved IMCI according to the norms with better practices regarding child development monitoring.

B. Supervision—Matutuine and Namaacha.

During the reporting period, the PPP team and the SDSMAS teams from Matutuine and Namaacha conducted supervision visits to health providers in all the district HFs. The supervision focused on MCH, IMCI, nutrition, data collection, development monitoring, stimulation, and counseling. During the supervision activity, the team observed provision of services to identify both positive aspects and gaps. In general terms, the results denoted much improvement by providers in areas such as monitoring psychomotor development; correct assessment of nutritional status and treatment of malnutrition in children and pregnant women according to PRN standards; health providers with good counseling knowledge and skills in care and stimulation and nutrition; compliance with MOH standards and protocols with completed ECD registration; and promotion for the participation of men and partners in the MCH services for pregnant women. In general terms, this improvement showed how the project-designed supervision approach contributed towards improvement on quality of health services offered by providers.

Overall, the PPP team has noticed that supporting government-led supervision activities has created greater ownership of nutrition and ECD-related interventions by SDSMAS and HFs. The frequent participation of district chief medical officers has been especially recognized as valuable and contributing to the uptake of the recommendations given to the health providers.

The monitoring and evaluation team is currently developing a simple system to quantify the information collected during supervision visits, focusing on nutrition and ECD-related activities in particular. This system will allow the team to attribute a score to an entire HF for each supervisory visit and to track whether that score improves over time. The long-term objective is to have a growing number of HFs that can be seen as providing quality of care on activities related to developmental and nutritional monitoring and counseling.

C. Mentoring activities to the new health providers in Matola, Boane, and Marracuene.

Following with the ECD training of 84 providers from Matola, Boane, and Marracuene districts described in the previous section, the PPP team worked jointly with the SDSMAS to initiate the mentoring process as recommended by MOH. This entails that each health provider must be monitored three times after a training, and then the health provider must be integrated into a regular supervision. During the reporting period, 47 health providers (14 from Marracuene and 33 from Matola) benefited from joint mentoring between SDSMAS and the PPP team.

The monitoring activities were conducted with the purpose of ensuring that training content has been assimilated and that health providers are able to integrate ECD into their routine daily activities; to identify possible gaps that may require intervention and further coaching; and to monitor the improvements made after each visit. It is still premature to assess the achievements of these newly trained providers.

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

During the reporting period, the project provided technical and financial support for provincial supervision to district health providers who were trained on IMCI with integrated ECD content.

The supervision team, led by DPS and district IMCI focal points with support from the PPP team, visited a number of HFs and spent two days in each of the eight districts.

The supervision team verified implementation of newly ECD-enriched IMCI , in all facilities visited, and provided accreditations to the ones that achieved recommended standards. As a result, three new HFs were accredited as good IMCI performers: Mahubo in Boane District, Mumemo in Marracuene, and Mahulane in Moamba. Some other HFs that had been previously accredited maintained their status, such as Boane HF, Manhiça HF, and Magude HF. In addition, it was noted that when HFs were visited, all trained health providers were at work using the materials provided, and IMCI emergency kits and rehydration corners were present in the waiting rooms.

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

During this reporting period, the PPP project provided limited support to Matutuine District to carry out one mobile brigades exercise- with ECD integrated. Mobile brigades are composed by several technicians and are a MOH strategy to provide different services such as vaccination, MCH and medical consultations, etc to remote communities with limited acces to health facilities.

F. Implementation of playboxes in target health facilities.

The playbox activity was extended to three additional HFs from Boane District during the quarter.

During the reporting period, 221 playbox sessions were conducted in the 13 target HFs, reaching a total of 16,761 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).

There was an increase in the activity when compared with last reporting period (98 sessions and 11,094 participants) due to the PPP team’s efforts to mobilize the activity, as well as the improvement of data collection. Table 2 below summarizes the activities for the quarter.

Table 2. Number of playbox sessions and participants. District # of sessions # of participants

Namaacha 28 2,304 Marracuene 12 1,046 Matutuíne 13 141 Moamba 35 1,739 Magude 19 393 Manhiça 53 7,450 Boane 47 3,404 Matola 14 284 Total 221 16,761

Refresher training on playboxes

During this reporting period, the PPP team conducted a semi-annual refresher meeting on playboxes with participation of playbox facilitators and supervisors from all districts except Matutuine and Matola, which were not represented due to an agenda conflict. The objectives of the refresher were to reinforce conducting playbox sessions based on the plans prepared together; produce toys to replenish the playbox and continue sessions; verify playbox toy inventory; promote the use of toys adequate for the age of the children; improve data collection; and explain project modalities of support to this activity such as conducting semi-annual refreshments, quarterly district support to each playbox and continue with monthly mentoring visits to each playbox as needed. The refresher meeting was attended by 45 participants. As a result of this meeting playboxes facilitators improved their knowledge about how to dynamize playboxes and how to increase production of toys. They were instructed as well about how to engage caregivers in the use of playboxes’ toys.

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

Indicator 6

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

Number of beneficiaries (caregivers or children under 5) receiving 254,916 NA 62,211 90,130 124,273 34,125 55,945 72% 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 = 31068

During the reporting period, a total of 55,945 beneficiaries received ECD and nutrition counseling in all 55 HFs of the eight PPP project implementation districts.

This figure represents an increase when compared with previous quarter, which can be attributed to the expansion of project activities to six new HFs (three in Matola and three in Boane). In general, this increasing trend remains positive throughout the whole project lifespan. This can be explained by the 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

PPC

CCS CCS CPN

CCR CCD

TOTAL

PED ARV

Target

MATERNITY

Age 0-11M 1-4Y 0-18M 0-4Y 0-14Y RN Percent achieved Namaacha 364 780 62 1,443 28 277 316 436 3,706 2,507 148

Marracuene 1,136 327 159 3,514 6 837 860 1,086 7,925 6,526 121

Matutuíne 184 161 36 1,987 16 215 213 221 3,033 1,346 225 Moamba 652 111 244 5,895 40 621 685 827 9,075 2,303 394 Magude 603 640 145 2,081 11 350 418 703 4,951 1,079 459 Manhica 1,655 1,472 270 3,218 92 1,154 1,295 1,621 10,777 4,124 261 Boane 472 0 63 1,697 12 233 287 294 3,058 3,262 93 Matola 1,340 667 342 7,130 55 1,097 1,531 1,258 13,420 14,315 93 TOTAL 6,406 4,158 1,321 26,965 260 4,784 5,605 6,446 55,945 67,462 82

Indicator 7

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

Number of

CHWs trained 196 58 108 NA 30 NA 30 100% 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.

In this quarter, the PPP team supported DPS with the initial training of 30 new APEs in Moamba who will serve several districts in the province. The PPP team also supported specific ECD topics that were integrated into the APEs’ training package at national level.

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 Q1 Q2 Q3 Q4 target

Percentage of CHWs reaching the threshold 75%* 133 7 55 69 13 2 110% score of (135) 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. (* )This is 75% of all APEs of all districts including Boane and newly trained APEs (166+14=180) 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. During the reporting period, the PPP team provided financial and technical support to APE supervisors in Magude, Marracuene, Moamba, Manhiça, and Namaacha districts to support their APEs in service provision to the communities. The supervision activity achieved a total of 34 APEs in all referred districts. Most of the APEs showed improvements when compared to findings from previous visits, in relation to data collection, screening for malnutrition cases, using brachial perimeter tape, care and stimulation integration into their home visits, and use of the counseling cards and album.

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. As in previous quarters, 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. Furthermore, the PPP team and APE district coordinators worked to provide enhanced support to the local APE supervisors who usually conduct day-to-day oversight to the APEs in their areas of operation.

During this period, 34 APEs benefited from project-supported mentoring visits. Among them, 22 had already reached the threshold score of 60 percent in previous occasions. Only 2 among the remaining 12 APEs mentored reached 60 percent for the first time in the quarter. More efforts will be made to support the remaining APEs to improve their performance.

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

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

Male Male Male Male Male

Total Total Total Total Total

Female Female Female Female Female

Namaacha 16 11 5 7 5 2 7 5 2 1 1 0 0 0 0 Marracuene 41 32 9 6 4 2 4 2 2 0 0 0 2 2 0 Matutuíne 16 12 4 0 0 0 0 0 0 0 0 0 0 0 0 Moamba 27 18 9 4 3 1 2 1 1 0 0 0 2 2 0 Magude 25 16 9 7 5 2 3 2 1 0 0 0 4 3 1 Manhica 41 24 17 10 3 7 6 4 2 1 0 1 2 1 1 Boane 14 11 3 0 0 0 0 0 0 0 0 0 0 0 0 Total 180 124 56 34 20 14 22 14 8 2 1 1 10 8 2

B. Refresher training for APEs.

During this quarter, all districts conducted a refresher training for the APEs. The refreshers were facilitated by officers from DPS and SDSMAS with support from the PPP team. The district coordinators of APEs and SDSMAS technicians presented several topics, with a focus on recording OVC data, filling the data book correctly, integrating ECD in home visits, and assessing nutritional status. At the end of the refreshers, it was noted that APEs understood the refresher content and that it will help to improve the APEs provision services to the communities. A total of 151 APEs participated in the sessions: 14 in Namaacha, 26 in Marracuene, 12 in Matutuíne, 25 in Magude, 38 in Manhiça, 13 in Boane, and 23 in Moamba District. Table 5 below summarizes the participants. Table 5. Number of APEs who attended a refresher training during the quarter, disaggregated by sex.

APEs

District Trained APEs receiving Total number of trained refreshment training during Female Male APEs the quarter Namaacha 16 14 11 3 Marracuene 41 26 24 2 Matutuíne 16 12 9 3 Moamba 27 23 13 10 Magude 25 25 14 11 Manhiça 41 38 23 15 Boane 14 13 11 2 Total 180 151 105 46

Previously, the PPP team in coordination with SDSMAS 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 included 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 included 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 identify 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, 42 APEs from six districts received these 1,200 Mtn equivalent vouchers.  Magude: 6 APEs  Marracuene: 6 APEs  Moamba: 6 APEs  Namaacha: 6 APEs  Manhiça: 12 APEs  Boane: 6 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 non- governmental partners receiving 7 2 2 3 0 NA 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 completed the report on the formative evaluation of the parenting education pilot in Matutuine, and shared it with selected partners and MGCAS. A

dissemination event is being planned jointly with MGCAS but has not yet been carried out due to the full agenda of the Ministry. Additionally, CESAL (an NGO in Matutuine that supported the piloting of parenting education) has conducted a meeting with PATH to evaluate the first year of implementation and to identify next steps. It is agreed that the partnership in Matutuine District will continue, and a new team of parenting education facilitators (including men this time) will be trained at each agricultural association. Some gaps identified from last year’s pilot implementation included: 1) the need for participant pre- and post-test to be done by an external data collector and not by the facilitators; 2) the need for rigorous hands-on training of supervisors to adequately use the mentoring tool and to provide support to the facilitators; 3) the need for simpler data registers and data collection mechanisms for the facilitators; and 4) the need for occasional but regular facilitator meetings and some type of occasional incentives. These lessons from pilot implementation will be used during this quarter to design follow-on to the pilot and to explore potential package use beyond Matutuine.

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

Indicator 10

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

Number of children monitored for 34,893 N/A 9,726 13,652 15,816 4,160 6,406 67% 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. Target revised as result of Boane Inclusion. Quarterly targets = 3,954

Progress and issues

A. ECD counseling and child development monitoring at health facilities.

This indicator is collected during the first CCS visit 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 all 55 project target HFs in the eight project districts indicate that 6,406 children ages 0–11 months were monitored for developmental delays for first time in the CCS consultation, which corresponds to 174 percent compared to the

target for this quarter (3,624). The total achievement thus far corresponds to 67 percent of the Year 3 target.

A total of 461 children monitored across CCS, CCR, CCD, pediatric ART, PNC, and maternity consultations were suspected to have developmental delays. When compared with the last quarter number of identified children with suspected delay (222), this figure shows a significant increase of 239 children, equivalent to 108 percent. This increase is partially due to the inclusion of data from Matola and Boane districts this quarter, as 111 cases came from these two recently added districts. Excluding Matola and Boane data, there is still a significant increase of 128 cases from last quarter, which converts to 58 percent. The team attributes this improvement to the implementation of the measures discussed and agreed with DPS to increase number of children suspect of developmental delays: a service letter issued by DPS to districts establishing annual and monthly targets for this indicator; a data analysis meeting carried out with all districts in this trimester, in which the provincial chief medical officer urged all districts to work on improving their developmental monitoring services; and ongoing mentoring and supervision efforts undertaken by the districts in partnership with PATH.

Of the 461 children with suspected delays, 347 were suspected during the first consultation and 114 during the follow-up consultations. Table 6 below summarizes this information, disaggregated by district and by service.

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

Total

PPC

CCS District CCR CCD

PED ARV

MATERNITY

first following first following first first following NB NB following first following Namaacha 4 0 3 9 68 0 0 8 0 7 83 16 Marracuene 6 5 2 3 1 0 0 16 0 0 25 8 Matutuíne 3 14 3 3 14 1 0 14 1 0 36 17 Moamba 0 26 11 4 13 1 6 10 2 1 37 37 Magude 3 15 7 2 12 0 0 1 1 0 24 17 Manhica 2 1 0 2 10 34 0 0 1 0 47 3 Boane 0 0 0 0 0 0 0 0 0 0 0 0 Matola 8 3 1 4 30 0 0 50 6 9 95 16 TOTAL 26 64 27 27 148 36 6 99 11 17 347 114

B. Follow-up of referrals of children identified with developmental delays by health providers.

During this quarter, the PPP team completed a small-scale data collection exercise of children suspected of developmental delays who were referred to specialists and who received these services. Only physiotherapy and mental health specialties data were collected, as these are the two most commonly used specialists for referrals of children with developmental delays. The objective of this exercise was to track the difference between numbers of children with suspected delays referred and the number of children entering specialist services. The follow-up

activity was carried out in September at selected HFs in six districts (Magude, Manhiça, Marracuene, Moamba, Namaacha, and Matutuine). The activity consisted of reviewing the daily registers in CCD and maternity wards to count children identified with developmental delays and referred for follow-up. As the next step, the register books of physiotherapists and mental health providers were reviewed. The exercise verified that despite the referrals that were happening amongst peripheral HFs to district level and to reference hospitals, they are difficult to track because in many cases referrals are not registered at origin, even though they are in the specialist consultations. As a result, there are big differences between the two points. As part of follow-up to these findings, the PPP team will work in coordination with DPS and SDSMAS to improve records of children referred in HFs. The introduction of new CCD registers, which provides more detail on referrals, should help improve the quality of referral data.

The team will also invest some time consulting with Mozambican Association of Pediatrics (AMOPE) and PATH in-house specialists to understand whether it is useful and feasible to compare numbers of children with identified developmental delays and numbers of children referred, as a group, due to diverse referral touchpoints and possible referral decisions. For example, a CCD provider may decide to refer the child first to the pediatrician at the provincial hospital instead of referring him/her directly to the specialist. Also, according to IMCI protocol, not all children with developmental delays need to be immediately referred—only those who do not reach milestones for the previous age group need to be referred. While that decision is being made, the team will continue tracking individual trajectories of at least three “indicative cases” in every quarter, following up on a child that has been referred to a specialist, checking whether the child has started the treatment; the wait time before seeking the treatment, if any; and whether treatment regime has been maintained, along with associated barriers and facilitators. This in-depth look should help DPS and PATH gradually build knowledge of how the referral process can be improved for children with identified developmental delays.

B. Physiotherapist outreach visits and other supportive activities.

During the reporting quarter, the project provided financial and transport support for the DPS and Matola Provincial Hospital physiotherapists to conduct consultations in Namaacha District, which has no physiotherapist services. Technicians conducted consultations for both ambulatory and hospitalized patients and attended 50 first-time external consultations—four patients were transferred to Matola Provincial Health.

In August, the DPS with support from the PPP team led a formative supervision at nine HFs (Magude, Xinavane, Manhiça, Marracuene, Moamba, Boane, Matutuíne, Hospital Geral da Machava and Hospital Provincial da Matola) in the area of physical medicine and rehabilitation. The supervision was led by DPS.. The objectives of the exercise were to assess and improve strategies for effective referral of children with developmental delays and disabilities; to provide technical support to physiotherapy technicians in order to improve patient diagnosis and care; to strengthen the referral flow with all programs that serve children from 0–5 years of age; to evaluate the condition of existing rehabilitation equipment; to assess sector needs; and to raise the awareness of the directors of SDSMAS in Matutuíne and Namaacha for the expansion of services. During the supervision process, it was noted that all HFs with the exception of HG Machava and HP Matola have ECD focal points that help facilitate referrals; the sectors of physical medicine and rehabilitation are well organized, and at Manhiça HF the referral flow of patients with development delays is functioning as recommended. Some challenges identified include a lack of physiotherapy technicians in Namaacha and Matutuine districts, and a low number of referral cases of patients in general but of children with developmental delays in particular. To address these challenges, a meeting with the director of SDSMAS was conducted

in each district. In Matutuine and Namaacha, the mission unsuccessfully advocated for including the salaries of physiotherapy technicians in the annual plan (PES). To address the issue of low referrals, health providers were sensitized on the importance of regular developmental monitoring and early referrals.

C. Other activities performed to ensure data capture and quality.

During the reporting quarter, the PPP monitoring and evaluation team and SDSMAS (district statistics staff and ECD focal point) conducted joint data collection and technical assistance visits to all eight project target districts to guarantee the 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 reviewing 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. The fact that government health information system (SISMA) does not allow for disaggregation of data by age and sex contributes to the PPP team not being able to provide gender- disaggregated data as requested by USAID. The PPP team can only disaggregate by age and gender for Projecting Health video screenings and when are OVCs reported via APE’s indicators.

During the refresher trainings for the APEs, the PPP team also incorporated content on using data collection tools—including the parallel tools introduced by PATH to collect OVC data.

In preparation for PPP close-out, the team has agreed during this term that the project needs to start moving from parallel data collection tools and indicators in Maputo Province and increasingly work with government tool and indicators; the team is currently collaborating with DPS towards this end.

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

Number of children referred by 27,847 NA NA 5,376 11,111 1,847 1,836 33% CHWs to health facility

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. Target revised as result of Boane Inclusion. Quarterly targets = 2,778

During the reporting period, APEs made 1,836 referrals to the HFs. Out of those, 19 were due to malnutrition and 39 due to suspected developmental delays. This translates to an achievement of 66 percent of the planned target for the period and 33 percent of the annual target.

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 7 below provides detaild information about ECD counseling and early detection of signs of development delays at the community level.

Table 7. ECD counseling and early detection of signs of development delays at the community level.

old

5 years old years 5 years 5

– –

28 days28 old)

District –

by theby APEs

ferred to HF with ferred

APEs APEs

5 years old referred referred old 5 years

problems

–

management)

and communityand case

provided

stimulation nutrition and

Women pregnant and in Women in and pregnant

Newborn (0

malnutrition or DAG) (DAM

which ECD was integrated, which integrated, ECD was

Children re

todue HFs developmental to

Health education sessions, sessions, inHealtheducation

Childrenmonth 0 Childrenmonth 1

monitored for development monitoredby for development monitoredby for

attended by APEs (home visits visits attended (home APEs by HF children referredTotal to of

Children 0

postpartum period counseled in in postpartum counseled period Namaacha 1,241 67 1,174 222 0 13 2,195 423

Marracuene 3,023 307 2,716 594 4 12 362 432

Matutuíne 816 30 786 24 2 3 58 266 Moamba 1,345 129 1,216 86 0 0 149 514 Magude 1,435 119 1,316 217 1 1 38 374 Manhiça 2,397 503 1,894 508 10 9 325 925 Boane 134 91 43 185 2 1 1 209 Matola 0 0 0 0 0 0 0 0 TOTAL 10,391 1,246 9,145 1,836 19 39 3,128 3,143 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 Indicator ments ments target of Y3 Q1 Q2 Q3 Q4 annual target

Number of partners using 7 2 4 6 1 0 2 200% 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. Following an agreement with PATH, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) in Tanzania has adapted PATH posters on developmental monitoring and stimulation to be translated to Swahili and used in ECD service delivery in MCH and PMTCT settings in 80 EGPAF-supported HFs. In addition, PATH materials approved by MOH have been introduced for the first time in the HFs of Monapo District in Nampula Province as a result of a Conrad N. Hilton Foundation-supported TOT conducted in September.

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 4* 150% instances

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. (*) Nampula partners meeting; World Breastfeeding Day celebration; ECD teacher’s event at UEM; NAIMA NGO Fair.

Progress and issues PATH continued to disseminate its work through different events, which included the Nampula Nurturing Care project partners meeting in July—where PATH, UNICEF, COvida, CCS, MCSP, and ICAP came together to discuss planned joint action to reinforce developmental monitoring, responsive care and early stimulation at the level of Monapo district. Furthermore, PATH team supported World Breastfeeding Day celebration in Maputo Province, and also created a breastfeeding room in its office as a way to assume institutional responsibility to promote breastfeeding among PATH staff who are mothers with young children. Finally, PATH was invited to speak about its work to approximately 150 undergraduate students in early childhood education course at University Eduardo Mondlane in commemoration of ECD teacher’s day, and also take part in annual Naima NGO Fair.

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 2 0 0 40% (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 World Breastfeeding Day and the first provincial TOT on ECD in clinical services carried out in September in Nampula.

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 925,663 NA 281,585 207,517 348,414 59,088 58,725 34% 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 Revised as result of inclusion of Boane Quarterly targets = 87,104

During the reporting period, APEs reached a total of 58,725 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 67 percent of the planned target for this quarter and 34 percent of the annual target. In responding to the PPP-ECD project expansion, during this reporting period we have added information from Boane District. Of note, this intervention only occurred in seven districts, as Matola District has no APEs. Table 8 below provides more detailed information.

Table 8. 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.

District Total of caregivers covered Target Percent achieved

Namaacha 6,055 7,513 81 Marracuene 14,320 19,881 72 Matutuíne 5,627 3,545 159 Moamba 9,987 18,374 54 Magude 6,396 7,711 83 Manhiça 12,025 23,932 50 Boane 4,315 6,148 70 Total 58,725 87,104 67

Indicator 16

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 beneficiaries attending 27196 NA NA 11,704 6,658 6,642* 113%% Projecting Heath 25,423 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 *1,050 male and 5,592 female Quarterly targets = 2926

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 addressing nutrition, children stimulation, and promotion of utilization of health services topics are currently in use in HFs.

During the reporting period, a total of 147 video sessions were conducted in HFs across all intervention districts, with the exception of Boane and Matola, and were attended by a total of 6,642 caregivers (1,050 male and 5,592 female). As result of this adjustment, the Year 3 annual target achievement is 113 percent and quarter achievement is 208 percent, which means that Projecting Health activities are well attended by the clients coming to the HFs. Table 9 below provides more detailed information about projecting health sessions conducted and participants.

Table 9. Number of Projecting Health sessions and participants, by sex per district. Quarterly % # of District Male Female Total Target Coverage sessions Namaacha 209 1062 1271 338 376 35 Marracuene 213 2008 2221 484 459 43 Matutuíne 89 328 417 66 632 24 Moamba 334 1140 1474 631 234 25 Magude 106 562 668 172 388 15 Manhiça 99 492 591 429 138 5 Boane 0 0 0 1074 0 0 Total 1050 5592 6642 3194 208 147

Additionally, the PPP team has been providing technical support to health providers trained on Projecting Health to improve 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 three 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.

5. Monitoring and evaluation

A. Monitoring and evaluation plan.

During the reporting period an internal exercise was conducted to revise Year 3 annual targets of several indicators to respond to the inclusion of Matola and Boane districts in the project. The indicators affected by this review are:

 (4) Number of health providers trained on ECD by PPP project.  (5) Percentage of HF clinical providers reaching the threshold score of 80 percent for ECD services.  (6) Number of beneficiaries (caregivers or children under 5) receiving ECD and nutrition counseling in HFs.  (7) Number of CHWs trained on ECD by PPP project.  (8) Percentage of CHWs reaching the threshold score of 60 percent for ECD services.  (10) Number of children monitored for developmental delays.  (11) Number of children referred by CHWs to HF.  (15) Number of caregivers receiving IEC messages through CHW-led community talks.  (16) Number of beneficiaries attending Projecting Heath sessions at HFs,

For calculation of the new proposed Year 3 annual targets for these indicators, the PPP team has utilized the methodology recommended by USAID for calculation of Year 1, Year 2 and Year 3 on the last approved version of the project Performance Monitoring Plan. More detailed information may be found in appendix C. The new proposed targets for Year 3 have already been used on the elaboration of this report. Whenever appropriate, LOP targets have been updated as well.

Also during this quarter, the parallel APEs data collection tools introduced by the PPP team were simplified as a result of DPS suggestions, and the field reporting of HIV status was simplified to “known” and “unknown” status. In this sense, the results of HIV status of OVCs served will be referring only to known or unknown status and not if they are positive or negative.

B. Collaboration with World Education International.

During the reporting period, the PPP-ECD team has provided support to World Education International (WEI) Girl’s Education project teams in Sofala and Zambézia provinces. The PPP team travelled for one week to each of these provinces and conducted home-based visits to local implementing partners, jointly with WEI team, to verify ECD integration as well as the referral and follow-up of children identified with malnutrition or developmental delays. In addition, since PATH has technical expertise on community preschools and WEI are implementing this component, the PPP team provided technical support in community mobilization, preschool committee members responsibilities, and also supported on best ways to reinforce delivery of services to the beneficiaries. Due to the expected end of the PPP Project on April 5, 2019, PATH has informed WEI that it will no longer be available to provide direct technical support to their project in the provinces. In response, WEI recognizing the added value that PATH brings to their intervention have requested a discussion with PATH team to extend collaboration and also provide support to two other Girl’s Education project provinces, Manica and Gaza. These conversations will continue along next quarter and any potential future collaboration will be supported by WEI’s project budget .

C. Operations research and other assessments.

Following with the approval of the operational research protocol by MOH Bioethics Committee last quarter, the implementation phase of the research started during this reporting period. First steps included the training of research staff and data collection in the HFs. By the end of the quarter, data collection in all six research districts has already concluded and the data entry process is ongoing. As per approved workplan the consultant is preparing the second stage of

data collection. Activities are happening according to the approved schedule and it is expected that the final report will be completed by the end of next quarter.

D. PEPFAR OVC indicators.

The PPP team continues working in coordination with SDMAS and DPS to support APEs to improve registration and data collection from OVCs in all seven districts with APEs. Difficulties in APEs filling registration forms and obtaining data still persist, as the APEs are responding slowly to the provided support. To address this issue, refresher trainings of APEs took place during this quarter in all districts with APEs, including Boane. The objective was to improve registry on the record book fields that collect data of children exposed on HIV and TB illness. The exercise included topics of data collection and registration of OVC using the APEs record book.

OVC SERV indicator

Table 10 below provides information about total number of OVCs served. These data refer to the total number of children 0–4 years attended by APEs during the semester April to September, with a total figure of 2,994 children (1,436 male and 1,558 female). In general, when compared to the previous semester, there is a reduction of OVCs served from 3,232 to 2,994. This could be due to low motivation of APEs (subsidy delays, etc.) that affect their performance. However, when considering the defined target for the period, results are very satisfactory as 139 percent was achieved, excluding Boane District (whose target has not been defined yet). Table 10. Total number of new orphans and vulnerable children served by community health workers during the last semester (April–September 2018).

Code Indicator name C.CCC.02.05-S Number of orphans and vulnerable children served Male Female % District <1 year 1-4 years TOTAL <1 year 1-4 years TOTAL Total Target achieved Magude 29 110 139 32 119 151 290 274 106 Manhica 76 286 362 82 310 392 754 909 83 Marracuene 77 290 367 84 314 398 765 454 169 Matutuine 19 70 89 20 76 96 185 138 134 Moamba 81 306 387 88 332 420 807 197 410 Namaacha 11 42 53 12 46 58 111 184 60 Boane 8 31 39 9 34 43 82 * * TOTAL 301 1,135 1,436 327 1,231 1,558 2,994 2,156 139 * Target for Boane not yet defined.

Table 11 shows information related to the total number of OVC served by the parenting caregiver program 2,994 children (1,436 male and 1,558 female).

Table 11.Total number of active beneficiaries served by PEPFAR OVC Programs for children and families affected by HIV (April–September 2018).

Code Indicator name Number of active beneficiaries served by PEPFAR OVC Programs for C.CCC.02.05.03 children and families affected by HIV Type of Service Parenting caregiver program Parenting caregiver program Male Total Female Total District <1 year 1-4 years Male <1 year 1-4 years Female TOTAL Magude 29 110 139 32 119 151 290 Manhica 76 286 362 82 310 392 754 Marracuene 77 290 367 84 314 398 765 Matutuine 19 70 89 20 76 96 185 Moamba 81 306 387 88 332 420 807 Namaacha 11 42 53 12 46 58 111 Boane 8 31 39 9 34 43 82 TOTAL 301 1,135 1,436 327 1,231 1,558 2,994

During the reporting period, a total of 361 new OVCs received assistance from CHWs—these children belong to the <1 year age group (172 male and 189 female). When compared to the previous quarter, this increase is a result of new births (i.e., children ages 0–2 months).

Table 12 below provides detailed information about new OVCs served by community health workers. A total figure of 361 new OVCs (189 female and 172 male) benefited of APEs intervention during the reporting period.

Table 12. Total number of new orphans and vulnerable children served by community health workers during the last semester (April–September 2018).

Code Indicator Name C.CCC.02.05.08 Number of new orphans & vulnerable children served Male Female Total District <1 year 1-4 years TOTAL <1 year 1-4 years TOTAL

Magude 1 0 1 2 0 2 3 Manhica 107 0 107 116 0 116 223 Marracuene 4 0 4 4 0 4 8 Matutuine 19 0 19 21 0 21 40 Moamba 1 0 1 2 0 2 3 Namaacha 39 0 39 43 0 43 82 Boane 1 0 1 1 0 1 2 TOTAL 172 0 172 189 0 189 361

OVC HIV status

During the last quarter, the APEs data collection tools were simplified as a result of DPS suggestions and the fields reporting the HIV status were simplified to “known” and “unknown” status. Table 13 illustrates the information related to this indicator based on the data collection tool used. A total figure of 2,994 OVCs were reported during the semester. Of those, 69 were of known status and 2,923 were of unknown status.

Table 13. Percentage of orphans and vulnerable children (<18 years old) with HIV status reported to implementing partner (April–June 2018).

OVCs served HIV Status HIV Status District Female Male Total Known Unknown TOTAL % Known % Unknown Magude 151 139 290 0 290 290 0.00 100 Manhica 392 362 754 53 701 754 7.03 93 Marracuene 398 367 765 0 765 765 0.00 100 Matutuine 96 87 183 13 170 183 7.10 93 Moamba 420 387 807 0 807 807 0.00 100 Namaacha 58 53 111 3 108 111 2.70 97 Boane 43 39 82 0 82 82 0.00 100 TOTAL 1,558 1,434 2,992 69 2,923 2,992 2 98

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 the number of children benefiting from nutrition counseling provided by APEs during the period April to June 2018. A total of 10,391 children were reached by APEs in all seven districts with APEs (4,989 male and 5,402 female). Out of this figure, 2,162 children were under one year old (1,049 males and 1,113 female), and 8,229 children were between 1–4 years old (3,940 males and 4,289 female).

Table 14. 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 GRAND TOTAL District <1 year 1-4 years <1 year 1-4 years Magude 125 471 596 133 512 645 1,241 Manhica 305 1146 1,451 324 1,248 1,572 3,023 Marracuene 82 309 391 87 337 424 815 Matutuine 136 510 646 144 555 699 1,345 Moamba 145 544 689 154 592 746 1,435 Namaacha 242 909 1,151 257 990 1,247 2,398

Boane 14 51 65 14 55 69 134 TOTAL 1,049 3,940 4,989 1,113 4,289 5,402 10,391

Progress in implementation of environmental mitigation and monitoring plan (EMMP) As proposed in the approved Environmental Mitigation Monitoring Plan, the PPP team has continued promoting the use of recycled materials for toy production in every training.

Following with the TOT for inpatient treatment of malnutrition, in this quarter training replicas have been conducted for the pediatric wards of Maputo, Inhambane and Nampula provinces. As one of the topics of the training participants have been trained to adopt recycling and toy- making practices.

Progress of gender analysis issues

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.

6. Upcoming plans

The following are some major activities planned for the upcoming quarter: 1. Financial support to an MOH-led orientation meeting and technical support to integrate ECD into MCH curriculum modules. 2. Financial and technical support for participation of MOH staff in ECD stakeholder’s meeting on Nurturing Care Framework to be held in Kenya, and support follow-up activities leading to integration of priority actions. 3. Work with MOH and UNICEF to ensure integration of ECD/nutrition content in APE training materials, job aids, and supervision tools. 4. In collaboration with MOH, continue support to the development of job aids, data collection mechanisms and training materials for MCH nurses and mental health technicians on screening and counseling for maternal depression. 5. Provide technical support to DPS PES 2019 final review. 6. Participate in national TOT about new CCS and CCD registers. 7. Provide technical and financial support for training on development monitoring in the new register books for CCS and CCD in Maputo Province. 8. Provide technical and financial support for the training of mental health providers in Maputo Province. 9. Provide financial and technical support to training on partograph and asphyxia to providers of Maputo province.

10. Conduct monthly mentoring visits for new health care workers trained on ECD in Matola, Marracuene, and Boane Districts. 11. Implement project quality improvement approach, and support district supervision and facility-specific action plans around MCH, nutrition, and ECD. 12. Provide financial support to conduct monthly outreach physiotherapy consultations in Matutuine and Namaacha districts. 13. Provide technical support on ECD and nutrition contents in the ongoing pre-service training of 30 new APEs to serve several districts of Maputo Province. 14. Support quarterly refresher trainings for already existing APEs. 15. Support district APE coordinators to conduct quarterly APE supervision visits with integrated ECD content. 16. Discuss with DPS and SDSMAS the integration of supervision of Projecting Health video sessions and playboxes into district supervision visits and guides. Support health workers of selected HFs in conducting video sessions and playboxes in morning educational activities. 17. Advocate the importance of Nurturing Care for Child Development through upcoming commemorative events such as Mental Health Day, Prematurity Day, and Global HIV/AIDS Day. 18. Submission and approval of project closeout plan. For detailed activities of the upcoming quarter, refer to Appendix B, which is attached with this report submission.

7. Administrative update

In mid-September Jordi Fernandez, Mozambique Country Program Manager and PPP project director, returned from his leave of absence and taken in charge his normal duties.

In compliance with the collaborative agreement signed, the PPP team is working on the preparation of the project closeout plan, to be submitted by October 5th.

8. Financial information

A total of $102,728.55 USD were expended during the quarter July–September 2018. Table 15 below shows the expenses for the quarter by categories and projected expenses for October– December 2018.

Table 15. Projected expenses for October–December, 2018. Total approved Expenditures for Cumulative Total budget Projected budget current period expenditures for remaining expenses (7/1/18–9/30/18) project to date (10/1/18– (4/6/16–9/30/18) 12/31/18) Direct labor 514,215.00 34,764.99 458774.59 55440.41 35,000.00 Fringe benefits 166,605.00 10,832.80 141,460.50 25,144.50 11,200.00 Travel 66,200.00 3,927.82 73,583.15 -7,383.15 7,000.00 Supplies 4,156.00 - 4,364.09 -208.09 0 Sub-awards 91,761.00 13,156.64 38,830.32 52,930.68 15,310.00 Other direct costs 233,214.00 17,237.49 236,452.09 -3,238.09 25,000.00 Indirect costs 423,296.00 22,808.81 266,579.76 156716.24 27,118.00 Total project costs 1,499,447.00 102,728.55 863,116.65 279,402.50 122,428.00

9. Appendices

Appendix A. Success stories and photos

Appendix B. October–December 2018 workplan

Appendix C. Proposed reviewed Year 3 targets, including Boane and Matola districts