PPP ECD Programming

PPP ECD programming

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

Fiscal Year 2017 Year 2: April 2017- March 2018

Quarterly Report: Q 3- October -December 2017

Submitted on: April 30th, 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 ...... 9 Progress and issues ...... 9 Indicator 5 ...... 10 Progress and issues ...... 11 Indicator 6 ...... 13 Indicator 7 ...... 14 Indicator 8 ...... 15 Progress and issues ...... 15 Indicator 9 ...... 18 Progress and issues ...... 18 Indicator 10 ...... 19 Progress and issues ...... 20 Indicator 12 ...... 23 Progress and issues ...... 23 Indicator 13 ...... 23 Progress and issues ...... 24 Indicator 14 ...... 24 Progress and issues ...... 24 Indicator 15 ...... 25 Indicator 16 ...... 26 Progress and issues ...... 26 5. Upcoming plans ...... 31 6. Administrative update ...... 32 7. Financial information ...... 32 8. Appendices ...... 33

Abbreviations

ANC antenatal care APE Agente Polivalente Elementar (community health worker) ARV antiretroviral CCD Consulta da Criança Doente (sick child clinic) CCR Consulta da Criança em Risco (child at risk clinic) CCS Consulta de Criança Sadia (child well-being clinic) 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 ENMP Environmental Mitigation Plan HF health facility GAP Gender Analysis Plan GDA Global Development Alliance 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) PPC postpartum care PPP public-private partnership PRN Nutrition Rehabilitation Program S-ECD Scaling Up Early Childhood Development SDSMAS District Directorate of Health, Women and Social Welfare TOR terms of reference TOT training of trainers TWG technical working group 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 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 fourth quarter (January to March 2018) of the second year of project implementation.

This report presents details and results of the activities performed by PATH in collaboration with the Ministry of Health (MOH) and Ministry of Gender, Children and Social Action (MGCAS) between January and March 2018. To achieve the below 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 Health Promotion Department of the MOH to review information, education, and communication (IEC) materials and obtain formal approval of pending PPP- developed IEC materials submitted earlier in the year. The project also contributed both financially and technically to a national ECD workshop held in Maputo on March 16. This workshop brought over 70 participants, including provincial chief medical officers and child health focal points from all 11 provinces and representatives from Maternal and Child Health (MCH), Nutrition, Mental Health and Health promotion departments of the MOH. Also in attendance were UNICEF, the World Health Organization (WHO), Association of Mozambican Nurses, USAID, Centers for Disease Control and Prevention (CDC), and health partners.

Although PATH was not involved in the clinical treatment of malnutrition, nutritional counseling to caregivers of children from 0–5 year olds was carried out in all HFs supported by the project as part of the ECD integration strategy. A total of 13,773 children were reached with nutrition interventions by community health workers (or Agentes Polivalentes Elementares [APEs]).

During this reporting period, PATH also engaged in the review of the MCH nurse preservice 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 29,665 beneficiaries (caregivers or children under five) who received ECD and nutrition counseling. This figure implies an achievement of 173 percent of this quarter target.

A total of 149 playbox sessions were conducted in the ten target HFs where playboxes are being implemented, with 11,546 caregivers of children under five years participating in these sessions. Caregivers learned how to stimulate their children and how to check for signs of developmental delays. 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 MCH nurses. Playbox and video sessions are held in the early morning hours in the waiting areas of HFs, while caregivers and their children wait to receive different MCH services—e.g., antenatal care (ANC), postpartum care (PPC), consultation for child at-risk clinic (Consulta da Criança em

Risco, [CCR]), child well-being clinic (Consulta da Criança Sadia [CCS]), and pediatric ARV treatment.

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 139 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 62 APEs were mentored during the period, 31 of whom reached the threshold score of 60 percent using the PATH mentoring tool.

During this reporting quarter, data collected across the 49 target HFs in the six districts in analysis indicate that 3,853 children 0–11 months attended CCS for the first time, which corresponds to 159 percent in relation to the planned figure (2,429) for this quarter.

A total of 231 monitored children across CCS, CCR, CCD, pediatric ARV, postpartum, and maternity consultations were suspected to have developmental delays. Of those, 155 were suspected during the first consultation and 76 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 Achievements Percent target only Achieve- Y2 achieved of Indicator ments Annual Y2 annual target Q1 Q2 Q3 Q4 target

Number of PATH IEC materials approved 7 2 4 2 0 2 1 0 150% 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 In this reporting quarter, the PPP team finalized the terms of reference (TOR) and supported the MOH (jointly with UNICEF and WHO) to carry out a high-level National ECD Workshop. The workshop, which took place on March 16, brought together over 70 participants including provincial chief medical officers and child health focal points from all 11 provinces, as well as MCH, Nutrition, Mental Health and Health Promotion departments from the MOH. Also participating were UNICEF, WHO, Association of Mozambican Nurses, USAID, CDC, and health partners. This was the first time that an ECD event targeted key health stakeholders and

ECD interventions in health, as previous national ECD events focused on ministries, partners and interventions in child protection and education.

During the workshop, participants were sensitized on the health sector’s role in delivering ECD services for the youngest children and updated on progress in integrating ECD into key guidelines and tools. Participants also learned more about experiences from Maputo Province, where PATH has been supporting DPS and SDSMAS to systematically integrate ECD into facility- and community-level health services, as well as introduce a parenting education package and a video-based behavior change communication innovation.

The playbox activity as a strategy to potentially increase retention in HIV and other child services by making them more child and caregiver friendly has generated considerable interest, with all provinces asking for the playbox video that was shared at the workshop. At the end of the workshop, the participants worked to develop sector-based work plans to operationalize ECD in maternal, newborn and child health work streams. Participants came up with activities such as the revision of MCH supervision tools to integrate ECD component, distribution of IEC materials on ECD to the HFs, and conducting trainings and refreshers on ECD. The combined work plan has been shared with all workshop participants and the PPP team will work with Child Health Technical Working Group (TWG), UNICEF and WHO to validate and carry out the planned activities in the coming months.

To continue the momentum generated at the workshop, the PPP team has started working with the MOH to distribute over 600 posters on developmental milestones and ways to promote responsive caregiving and early learning. These posters were printed at MOH’s request last year. The posters will be distributed to the CCS consultation rooms in the highest volume HFs nationally. CCS has been chosen due to the interest of the MOH to revitalize this consultation and also because this is the service delivery touch-point that does not have any visual monitoring/counseling tools such as the IMCI flipchart, which is in use in other child consultations. PATH has designed a simple visual protocol for developmental monitoring in CCS, which is currently being reviewed by the Child Health TWG and which will be distributed to the provinces together with the posters.

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

Indicator 2

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

Number of targeted health and social action plans that include ECD 20 3 5 7 7 NA NA NA 100% 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.

Progress and issues

Planning of 2018 (PES, Plano Económico e Social) During the reporting period, the PPP ECD team in collaboration with DPS and SDMAS from the six implementation districts continuing implementing the activities planned for the current year. We expect the annual planning exercise (PES) led by government to happen in next quarter.

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 Percent Y2 Achievements target only Achieve- Annual achieved of Indicator ments target Y2 annual target Q1 Q2 Q3 Q4

Number of government curricula, guidelines, and data tools revised by 4 1 100% 1 0 2* 0 0 200% 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.

*IMCI Neonatal package (participant manual, facilitator manual, caderno de mapas); APEs participants manual (Module III)

Progress and issues

A. MCH nurses’ pre-service curricula review During the reporting period, the PPP team in collaboration with other partners provided technical support to the MOH Training Department to finalize the revision of the MCH nurse pre-service curriculum to integrate ECD content. The review focused on the technical competencies of MCH nurses in areas such as ANC, labor and delivery, PPC, 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. However, as noted in previous reports, this process will continue to take place through 2018. The PPP project will continue to provide technical support and make limited financial contributions into the common resource pool.

B. Other technical assistance provided through participation in MOH/MGCAS technical working group The PPP team continued participating in the Nutrition Rehabilitation Program (PRN) TWG to prepare a three-day training on stimulation in pediatric wards. The training manual and

accompanying tools designed by PATH for this purpose have been reviewed by the Child Health, Mental Health, and Nutrition departments of the MOH and the Mozambican Pediatric Association and are being finalized for the training of trainers, which will take place at the end of April and will include the above mentioned MOH departments and clinical partners working on nutrition. As part of this work, PATH has designed a developmental monitoring form which can be added to a child’s clinical processes and will permit tracking child’s developmental status at admission and discharge from PRN program. This tool is currently under discussion.

Additionally, following initial conversations in the last quarter, the Food and Nutrition Technical Assistance Project has reached to PATH with a request to revise a chapter on stimulation in the national PRN manual. The revision work has begun and will be concluded by PATH in the next reporting quarter.

At the level of MGCAS, the PPP team has continued working with FHI360/COVida to advocate with MGCAS to include ECD as well as reporting on children with disabilities in the Child Status Index tool (Matriz da Crianca). The most recent version of the Child Status Index tool with ECD component integrated into it has been reviewed at the OVC TWG meeting and MGCAS will be submitting the finalized version to its Technical Council shortly. In addition, PATH has continued supporting other MGCAS priorities, such as the completion of the National Manual of Community Preschools through its work on the COVida project.

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 Percent achieved Y2 Achievements target only Achieve- Y2 of annual target Indicator ments Annual target Q1 Q2 Q3 Q4

Number of health providers 255 135 85 35 35 0 0 0 100% 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.

Progress and issues No ECD-specific training for health providers was planned for this quarter. However, continuing the advocacy work done to include ECD component into relevant MOH training packages, the PPP team has moved ahead with the strategy of integrating ECD into relevant DPS-planned trainings. Specifically, in this quarter, the PPP team provided financial and technical support to the six-day provincial training on IMCI in February 2018. Beyond support to overall training

quality and logistics, the PPP team ensured the integration of developmental monitoring and early stimulation content. Twenty-eight health workers from all the districts of Maputo Province benefited from the training. Table 1 lists the numbers of the health providers who attended the IMCI training disaggregated by cadre of health providers.

Table 1. Number of health workers trained in IMCI during the quarter. Category Number District Enf achieved Basic General MCH Enf Medical AMG TMG Sup Nurse Nurse Nurse Sup doctors Pedi Namaacha 3 0 1 1 0 0 0 0 1

Marracuene 5 1 1 1 1 0 1 0 0

Matutuíne 3 0 0 0 1 2 0 0 0

Moamba 3 0 1 0 1 1 0 0 0

Magude 3 0 0 0 3 0 0 0 0

Manhiça 3 2 1 0 0 0 0 0 0

Matola 6 0 0 0 3 1 1 1 0

Boane 2 0 0 1 0 0 0 0 1

Total 28 3 4 3 9 4 2 1 2

Indicator 5

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

Percentage of health facility clinical providers 77% reaching the 191 24 91 124 13 19 NA NA 26%

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.

Quarterly target=36 (*) See Chapter 5, Monitoring and Evaluation, Monitoring and Evaluation Plan

Progress and issues

A. At district level: Magude, Marracuene, Moamba, Matutuíne, and Namaacha

As mentioned in the report for the last reporting period quarter, 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 of five districts (i.e., all project districts except Manhiça) 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. With regard to Manhiça, it was not possible to follow up on their action plan, due to the competing schedules of the district team. This activity will take place in the next quarter.

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. Nonetheless, some challenges persist—mainly linked to the need to increase the number of children monitored for developmental delays and improving the process of developmental monitoring.

B. Supervision—Magude

During the reporting period, the PPP team and the Magude SDSMAS team conducted supervision to health providers in the all 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.

C. DPS

During the reporting period, the PPP team did not carry out any activities linked to direct support of DPS to facilitate ECD integration. No joint supervision took place, but the PPP and DPS teams conducted meetings with the purpose of coordinating trainings, visits, and planning activities and strategies to increase the number of children monitored for developmental milestones and counselled by health providers in each HF. The PPP team also prepared and shared with DPS its anticipated targets regarding the number of children who will be monitored for developmental delays in each district and HF.

D. DPGCAS

In February 2018, the PPP team supported DPGCAS by providing transport and per diem allowance to conduct household visits to the families of children living in difficult situations, as identified by the community child protection committees using the Matriz da Crianca

(Mozambican adapted version of the Child Status Index). The activity sought to determine eligibility for further support in social protection programs and took place in Boane, Manhiça, Namaacha, Magude, and Moamba districts. Of the 44 families visited, 32 were found to be eligible for social support and two families—because of their critical situation—immediately received emergency products. The families that were visited are headed by women, the elderly, or by minors and living in very poor conditions. The visit also identified children who had dropped out of school, some children on ART, and some children without birth registration. As OVC are part of the DPGCAS mandate, the PPP team also conducted a collaboration meeting with the aim of jointly discussing the best way to identify vulnerable children.

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

During this reporting period, to respond to requests from districts, the PPP team provided technical and financial support to conduct mobile brigade outreaches to Magude, Namaacha and Moamba districts. The mobile brigades—which include ECD content—are a means to reach communities that are located far away from HFs and will also help achieve project targets. The PPP team will continue funding this activity in the following quarter, depending on district needs.

F. Implementation of playboxes in target health facilities

During the reporting period, 149 playbox sessions were conducted in the ten target HFs, reaching a total of 11,546 caregivers of children under five. The caregivers learned how to stimulate their children facilitating their development and how to check for signs of developmental delays. Playbox sessions are held in early morning hours in the HF waiting areas, while caregivers and their children wait to receive health services (e.g., ANC, PPC, CCR, CCS, CCD, and pediatric ARV treatment).

Compared to the last quarter, the number of beneficiaries for this quarter has been low, since some of the facilitators were on vacation in January and February, as is usual in government settings. The PPP team has already met with the facilitators to strategize ways to increase the number of beneficiaries for the next quarter.

Table 2. Number of playbox sessions and participants. District # of Sessions # of Participants Namaacha 32 2485 Marracuene 33 1331 Matutuíne 9 1534 Moamba 52 2471 Magude 13 764 Manhiça 10 2961 Total 149 11546

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

Indicator 6

LOP S-ECD PPP PPP Year 2 Achievements Percent target only Year 1 Year 2 achieved Indicator Achieve- Annual of Y2 ments target Q1 Q2 Q3 Q4 annual target

Number of beneficiaries (caregivers or children under 5) 202,186 NA 62,211 68,432 16,465 25,489 18.511 29,665 132% 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. Quarterly targets=17,108.

During the reporting quarter, a total of 29,665 beneficiaries received ECD and nutrition counseling at all 49 HFs of the six PPP project implementation districts. This figure implies achievement of 173 percent of the quarter target.

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 CPN

CCR CCD

CCS(*)

TOTAL

PED ARV

MATERNITY

Target

Age 0-11M 1-4Y 0-18M 0-4Y 0-14Y RN Percent achieved

Namaacha 335 0 85 1603 11 220 307 405 2966 2398 124

Marracuene 898 0 239 1076 2 1041 508 1451 5215 6243 84

Matutuíne 166 47 35 1409 2 154 157 264 2234 1287 174

Moamba 773 0 192 6966 36 635 684 891 10177 2203 462

Magude 538 1 155 1117 6 456 454 624 3354 1032 325

Manhica 1143 0 178 1937 11 177 830 1443 5719 3944 145

TOTAL 3853 48 884 14108 68 2683 2940 5078 29665 17108 173

Indicator 7

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

Number of CHWs trained 166 58 108 0 NA NA NA 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.

Indicator 8

Percent S- PPP Y1 PPP Y2 LOP Y2 Achievements achieved of Indicator ECD Achieve- Annual target Y2 annual Total project only ments target target accumulative Q1 Q2 Q3 Q4 achievement Percentage of CHWs reaching the threshold 166 7 55 108 19 17 5 18 64 % 73% 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.

Quarterly target=27 (*) See Chapter 5, Monitoring and Evaluation, Monitoring and Evaluation Plan

Progress and issues The numbers for this indicator from previous quarters have been reviewed to avoid double counting of providers trained (see Chapter 5, Monitoring and Evaluation Plan). Double counting was not considered when Year 2 targets were established.

When this adjustment has been completed, the project has already been found to achieve 97 percent of the LOP target during this quarter.

As community interventions still require robust project support, the PPP team continued to provide direct mentoring and supervision to APEs in the districts and 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 Matutuíne, Marracuene and Namaacha districts to support their APEs around previously identified gaps in service provision.

During this quarter, the PPP team and SDSMAS officers from all target districts jointly conducted mentoring visits to the APEs. 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. 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. APEs have also demonstrated difficulties in using the correct technique to measure and use brachial perimeter for evaluation of nutritional status. 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 correctly use the brachial perimeter 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.

During this quarter, a total of 62 APEs were mentored, 18 of whom reached the threshold score of 60 percent on PATH’s mentoring tool for ECD for the first time. This figure represents 64 percent achievement of the annual target for year 2. To improve APE performance in next quarter, the project will prioritize mentoring of APEs who did not achieved 60 percent threshold yet.

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 Trained # CHW mentoring #CHW mentoring visits in the quarter Total # CHW that received visits in the quarter visits in the quarter that meets the 60% trained to date mentoring visit in that meets 60% 1st that meets below threshold (not 1st the quarter time in the quarter the 60% threshold time) District

Male Male Male Male Male

Total Total Total Total Total

Female Female Female Female Female

Namaacha 16 11 5 9 7 2 4 1 3 4 4 0 1 1 0 Marracuene 41 32 9 14 11 3 8 6 2 2 2 0 4 3 1 Matutuíne 16 12 4 12 7 5 8 6 2 4 1 3 0 0 0

Moamba 27 18 9 5 4 1 1 1 0 2 2 0 2 1 1 Magude 25 16 9 18 12 6 8 6 2 4 1 3 6 4 2 Manhica 41 24 17 4 3 1 2 2 0 2 1 1 0 0 0

Total 166 113 53 62 44 18 31 22 9 18 11 7 13 9 4

B. Refresher training for APES During this quarter, all districts conducted a refresher training to the APEs. A total of 139 APEs participated in the sessions: 17 in Namaacha, 30 Marracuene, 12 Matutuíne, 20 Magude, 38 Manhiça and 22 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.

The refresher trainings also provided an opportunity for the collection, analysis, and discussion of OVC data recorded by the APEs.

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.

During this reporting quarter, 25 APEs and 11 local APE supervisors from the six districts received these vouchers.  Magude: 4 APEs and 3 Supervisors  Marracuene: 4 APEs and 2 Supervisors  Moamba: 4 APEs and 2 Supervisors  Matutuíne: 5 APEs and 1 Supervisor  Namaacha: 4 APEs and 2 Supervisors  Manhiça: 4 APEs and 2 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 receiving Total number of refresher training during Female Male trained APEs the quarter Namaacha 16 17 13 4 Marracuene 41 30 25 5 Matutuíne 16 12 9 3 Moamba 27 22 15 7 Magude 25 20 11 9 Manhiça 41 38 22 16 Total 166 139 95 44

Indicator 9

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

Number of nongovernmental partners receiving 7 2 2 3 0 2 1* 0 100% technical assistance from PATH

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public- private partnership; Q: quarter; Y: year. (*) 22 IREX-supported community radios in northern Mozambique

Progress and issues

A. Other community partners—home visits, parenting education, and awareness building/sensitization activities During July and August 2017, the PPP team had provided ECD training for the World Education International (WEI) team and its partners. During this quarter, the PPP team in collaboration with WEI provided field support in Sofala and Zambézia Provinces to verify the level of ECD integration by WEI partners, identify gaps and areas of weakness requiring further support, and suggest ways in which partners can work with each other. This activity took place on March 12– 16 and March 19–23, 2018.

The PPP team noted when observing home-based care provision by WEI partners that most of them were able to integrate ECD content into their daily work by counselling caregivers on ECD and using toys to demonstrate play activities. However, the PPP team also noted gaps in partners not being able to seamlessly integrate ECD into other service delivery areas, use of the child development posters, and ability to describe age-appropriate stimulation and nutrition practices. The team supported WEI on these identified gaps and will continue with physical support during the following quarter, after which support will be long-distance.

During this quarter, the PPP team has continued collaborating with nongovernmental organization (NGO) VIDA in Matutuíne District, with whom it had earlier launched a parenting education pilot. As part of its support, the PPP team provided refresher training to new staff and assisted with preparations for the assessment of the parenting education pilot. VIDA’s work has formally come to an end in Matutuíne on March 31, but the PPP team will work another partner (CESAL) to conduct the parenting education pilot post-test and final assessment. The assessment protocol has been designed and a consultant contracted to lead the assessment. The lessons learned from the assessment will be used for programmatic decisions regarding parenting education package as well as for advocacy for parenting education with MGCAS. Several partners such as CESAL (supporting agricultural associations in Matutuíne) and ASSORE (supporting an adolescents’ project in Moamba) have expressed interest in being trained by the PPP team in the parenting package.

While not using PPP funds, in this quarter PATH used core ECD funding from the Conrad N. Hilton Foundation to partner with h2n (IREX subsidiary) to pretest the Xipalapala platform for posting radio spots. As a result, two radio spots, one on nutrition and one on stimulation, have been translated into Macua and successfully broadcasted during the most popular radio program on the Monapo community radio in Nampula (a district that is going to be a site for a Nurturing Care pilot funded by the Conrad N. Hilton Foundation). The use of radio spots for facilitating ECD behavior change that makes use of complementary USG-funded platforms can contain potentially useful learnings for other USG partners who are currently contemplating the use of community radios as a behavior change communication strategy.

B. Sensitization of child protection committees (CPCs) and child health committees (CHCs) During this reporting period, the PPP team—in partnership with SDSMAS of Marracuene District—conducted a one-day ECD sensitization for up to 23 mixed members of CPCs and CHCs in a number of locations of Matalane (12 members) and Ngalunde (11 members). The topics of the sensitization included revitalization of the committees and discussion of their responsibilities, the importance of care and stimulation, how to identify OVC in communities, and the role of CPCs and CHCs in referring these cases.

In addition, during this quarter, one CHC from Matutuíne and one from Manhiça have received support from the PPP team and district supervisors to guide them on carrying out their daily activities and also how they can identify, register, and refer vulnerable children.

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

Indicator 10

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

Number of children screened for 29,095 N/A 9,726 9,717 2,543 4,082 3,175 3,853 141% 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=2,429.

Progress and issues

A. ECD counselling and child development monitoring at health facilities

This indicator is collected during the first well-being clinic 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 districts in analysis indicate that 3,853 children ages 0–11 months attended CCS for the first time, which corresponds to 159 percent in relation to the planned figure (2,429) for this quarter. The total annual target has already been achieved with one quarter still remaining in the year.

A total of 231 monitored children across CCS, CCR, CCD, pediatric ARV, post-partum, and maternity consultations were suspected to have developmental delays. Of those, 155 were suspected during the first consultation and 76 during the follow-up consultations.

Table 6 below summarizes this information disaggregated by district and by service. 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. In this regard, the PPP team has supported IMCI training, sent to DPS the targets for developmental problems for each district and HFs, reinforced the capacities of health providers to conduct developmental monitoring, and supported physiotherapist outreach visits.

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

Total

PPC

CCS

CCR CCD

District PED ARV

MATERNITY

first following first following first first following NB NB following first following

Namaacha 1 5 4 0 1 0 0 9 0 0 15 5

Marracuene 0 16 5 0 0 0 0 28 0 0 33 16

Matutuíne 2 3 0 4 0 0 0 5 3 0 10 7

Moamba 0 16 1 0 4 0 0 7 2 0 14 16

Magude 1 15 4 0 3 0 0 10 1 0 19 15

Manhica 2 15 9 2 21 0 0 14 18 0 64 17

TOTAL 6 70 23 6 29 0 0 73 24 0 155 76

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 135 first-time external consultations and 38 internal consultations for children 0-5 years. The table below provides detailed information disaggregated by district, age 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 10 0 5 0 8 0 7 3 9 0 20 0 9 4 3 0 3 0 5 0 79 7 Rheumatology 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 1 0 3 0 Traumatic 0 0 0 0 9 0 1 0 7 0 2 0 4 0 0 2 1 0 0 0 24 2 Ortopedic 0 0 3 0 0 0 2 0 3 0 1 0 6 1 1 1 1 0 0 0 17 2 Cirurgic 0 0 0 0 0 0 0 0 0 0 0 0 2 20 0 0 0 0 0 0 2 20 Respiratory 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Cardiovascular 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 Other Pathologies 4 0 0 0 1 0 0 0 3 1 1 0 0 0 0 0 0 0 1 0 10 1 TOTAL 14 5 8 0 18 0 10 3 22 1 24 0 23 26 4 3 5 0 7 0 135 38 Male 6 3 5 0 7 0 6 2 13 1 12 0 14 13 2 3 3 0 2 0 70 22 Female 8 2 3 0 11 0 4 1 9 0 12 0 9 13 2 0 2 0 5 0 65 16 TOTAL 14 5 8 0 18 0 10 3 22 1 24 0 23 26 4 3 5 0 7 0 135 38

C. Other activities performed to ensure data capture and quality

During this quarter, the PPP project team attended and provided technical support to monthly statistics meeting on MCH data compilation—including ECD.

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 six target districts with the purpose 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, PPC, 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.

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

Number of children referred by 25,716 NA NA 8,572 1,376 1,418 964 1618 60.4% CHW 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=2,143.

During the reporting period, APEs made 1,618 referrals to the HFs; out of those, 14 were due to malnutrition and 21 due to suspected developmental delays. This translates to an achievement of 76 percent of the planned target for the period and 60.4 percent of the annual target. Nevertheless, it is important to note that establishing targets in number of referrals is an estimative exercise.

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

for

5 5

– –

for

28 days28

–

5 years old old 5 years

District –

monitored

to HF

or DAG)

monitored

old old

and nutrition by APEs the

management)

community case

Healtheducation

old)

postpartum period

Childrenmon 1 Childrenmonth 1

Newborn (0

years by attended old

referred to to due HFs

development APEs by development APEs by

Children 0

APEs (home visitsAPEs and (home with malnutrition (DAM

Childrento HF referred

sessions, in ECD which

years

Women pregnant and in Women in and pregnant in counseled stimulation

Total of children referredTotal of problems developmental wasprovided integrated, Namaacha 1212 47 1165 178 1 0 1088 278 Marracuene 4760 293 4467 648 8 13 623 462 Matutuíne 492 40 452 9 1 1 65 148 Moamba 2304 141 2163 116 1 4 238 692 Magude 1715 66 1649 183 2 2 143 293 Manhiça 3290 317 2973 484 1 1 559 955 TOTAL 13773 904 12869 1618 14 21 2716 2828 Abbreviations: APE, Agente Polivalente Elementar (community health worker); ECD, early childhood development; HF: health facility.

Indicator 12

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

Q1 Q2 Q3 Q4

Number of partners using 7 2 4 2 0 4* 2** 0 200% PATH materials for programming

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

(**) Complementary feeding poster in use by MCSP project; radio spots, messages, parenting sessions in use by community radios supported by IREX.

Progress and issues Several partners have expressed interest in using PATH’s nutrition and ECD materials in the past quarter, among them CARE, CESAL (agricultural NGO), and EGPAF. The response to these requests will be conditional on agreements done with each partner. Outside Mozambique, the MOH Nutrition Department in Côte d’Ivoire has adopted PATH-developed material as an integral part of its nutrition flipchart, as a result of a technical exchange between two countries.

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 Y2 Y2 Achievements Percent target only Achieve- Annual achieved Indicator ments target of annual target for Q1 Q2 Q3 Q4 Y2

Number of dissemination 24 6 11 8 1 4 1 2* 100% instances

Abbreviations: LOP: Life of Project; S-ECD: Scaling Up Early Childhood Development; PPP: public-private partnership; Q: quarter; Y: year. (*) ECD Workshop & Côte d’Ivore Visit

Progress and issues PATH has continued to disseminate its work through different events. The most important examples were a learning visit from a Côte d’Ivoire nutritional delegation and the national ECD workshop. The learning visit featured nine participants from Côte d’Ivoire, including the SUN representative from the Prime Minister’s office, Director of Nutrition at MOH, a donor agency and several implementing partners. During their time in Mozambique, they discussed ECD in Mozambique and Côte d’Ivoire with the National Director of Public Health, Nutrition and Child Health Department, representatives of UNICEF, SETSAN and WHO, as well as 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 Department took part in the visit as well. The learning visit has been critical in influencing greater uptake of ECD among the MOH and donors in Côte d’Ivoire. The national ECD workshop, attended by approximately 70 health stakeholders, has been another important dissemination event, as previously described.

The PPP team has already initiated the preparation of the second learning visit for May 2018, which will include MOH, WHO, and UNICEF staff from Zambia and Ethiopia, illustrating how Mozambique is emerging as a learning center for the region and is excelling in this new area of programming.

PATH has also been invited to prepare a case study on creating an enabling environment for ECD integration into health for the upcoming World Health Assembly in May 2018.

Additionally, PATH has for the first time presented its work to several potential partners such as clinical (EGPAF and ICAP) and community (ASSORE, Handicap) partners, which resulted in expressed interest to collaborate.

Indicator 14

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

Number of publications 40 10 10 10 2 2 3 2 90% (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 learning visit of the Côte d’Ivoire delegation to Mozambique, and on the national ECD workshop hosted by MOH. In March, PATH collected data on women successfully facilitating parenting education sessions in their agricultural associations in Matutuíne, and is

currently preparing a success story to be published in April—a month that celebrates Mozambican women.

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 Y2 Y2 Achievements Percent target ECD Achieve Annual achieved Indicator only -ments target of annual Q1 Q2 Q3 Q4 target for Y2

Number of caregivers receiving IEC messages 901,072 NA 281,585 295,664 55,854 57,296 36,340 58,027 70.1% 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 =73,916.

During the reporting period, APEs reached a total of 58,027 caregivers in their community educational talk activities—which include a range of different topics such as ECD, nutrition, family planning, hygiene, water and sanitation, prevent diseases, etc. This figure corresponds to 79 percent of the planned target for this quarter and 70.1 percent of the annual target. Table 9 below provides more detailed information.

Table 9. Number of caregivers attending to 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 8242 6860 120 Marracuene 13891 18152 77 Matutuíne 2304 3237 71 Moamba 11749 16776 70 Magude 5875 7040 83 Manhiça 15966 21851 73 Total 58027 73916 79

During this quarter, the number of community-based activities increased in relation to the past quarter and achieved 79 percent of coverage, against 40 percent in the previous quarter. Namaacha and Magude performed better than other districts during the quarter and achieved 120 and 83 percent coverage respectively.

Indicator 16

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

Number of beneficiaries attending Projecting Heath 23,976 NA NA 8,115 6,667 3,543 8,648 6,565 232% 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

Quarterly targets=2,029.

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, postpartum care, CCR, CCS, and pediatric ARV treatment). During the reporting period, six additional videos in ECD and nutrition topics and facilitation guidelines were distributed and a total figure of 12 different videos are currently in use in HFs.

During the reporting period, a total of 174 video sessions were conducted in HFs across the six intervention districts, and were attended by a total of 6,565 caregivers (1,268 male and 5,297 female), largely exceeding the quarter target. As this target is based on available data when video projection activities 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 303 905 1208 324 373 38 Marracuene 135 701 836 463 180 35 Matutuíne 103 389 492 63 781 21 Moamba 275 1344 1619 603 268 25 Magude 37 90 127 165 77 8 Manhiça 415 1868 2283 411 556 47 Total 1268 5297 6565 2029 324 174

In general terms, with PPP team technical support, health providers trained on video utilization showed improvement in the quality of facilitation of video projection 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 CPCs and 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 conducted an internal exercise to adjust the value of some indicators to avoid double counting. This exercise affected indicators 5 (Percentage of HF clinical providers reaching the threshold score of 80% for ECD services) and 8 (Percentage of CHWs reaching the threshold score of 60% for ECD services). The revised values for these indicators have been included in the respective tables 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

During the reporting quarter, the operational research protocol was translated and submitted to the National Bioethics Committee. Currently we are waiting approval, following which, the consultant will commence with the next steps of study implementation.

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 new parallel tools introduced for the APEs by PATH. Difficulties in obtaining data still persist, as the APEs are responding slowly to the provided support. However, the team will continue providing support.

OVC SERV INDICATOR

Tables 11–13 show figures related to the OVC_SERV indicator.

Table 11. Total number of orphans and vulnerable children served by CHWs during the last semester (October 17–March 18). Codigo Indicator name C.CCC.02.05-S Number of orphans and Vulnerable children served (6 months) Male TOTAL Female TOTAL Total Geral District <1 year 1-4 years <1 year 1-4 years Target % Achieved Magude 21 78 99 22 85 107 206 365 56 Manhica 138 520 658 150 563 713 1371 1213 113 Marracuene 72 271 343 78 293 371 714 605 118 Matutuine 9 35 44 10 38 48 92 185 50 Moamba 53 199 252 57 216 273 525 263 200 Namaacha 33 123 156 35 133 168 324 246 132 TOTAL 326 1226 1551 353 1327 1681 3232 2876 112

Table 12 includes information related to the total number of OVC served. This data refers to the total number children from 0–4 years attended by APEs during the semester that corresponds to total of 3,232 children (1,551 male and 1,681 female).

Table 12. Number of active beneficiaries served by PEPFAR OVC programs for children and families affected by HIV, by program. Codigo Indicator name Number of active beneficiaries served by PEPFAR OVC C.CCC.02.05.03 Programs for children and families affected by HIV Parenting caregiver Parenting caregiver Type of Service program program TOTAL Male Total Female Total (Female District <1 year 1-4 years Male <1 year 1-4 years Female +Male) Magude 21 78 99 22 85 107 206 Manhica 138 520 658 150 563 713 1371 Marracuene 72 271 343 78 293 371 714 Matutuine 9 35 44 10 38 48 92 Moamba 53 199 252 57 216 273 525 Namaacha 33 123 156 35 133 168 324 TOTAL 326 1226 1551 353 1327 1681 3232

Table 13 includes information related to the total number of new OVC served. This data refers to the total number children attended by APEs for the first time during the semester and includes a total of 242 children (116 male and 126 Female)

Table 13. Number of new OVC children served. Codigo Indicator name

C.CCC.02.05.08 Number of new orphans & vulnerable children served (6 months) Male Female District <1 year 1-4 years TOTAL <1 year 1-4 years TOTAL TOTAL Magude 4 0 4 4 0 4 8 Manhica 74 0 74 81 0 81 155 Marracuene 13 0 13 15 0 15 28 Matutuine 4 0 4 4 0 4 8 Moamba 14 0 14 16 0 16 30 Namaacha 6 0 6 7 0 7 13 TOTAL 116 0 116 126 0 126 242

OVC HIV Status

Tables referring to the data of HIV status of OVC reported during the semester are presented in Appendix B. In general, a total of 3,232 OVC were reported during the semester. Of those, 3,219 were of unknown status and 13 were of known status.

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 October to December 2017. A total of 13,773 children were reached by the APEs in all six districts (6,611 male and 7,162 female). Out of this figure, 2,863 children were under one year old (1,388 males and 1,475 female), and 10,909 children between 1–4 years old (5,223 males and 5,686 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 (January–March 2018). 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 Year 1-4 Years <1 Year 1-4 Years Magude 122 460 582 130 500 630 1212 Manhica 480 1805 2285 510 1965 2475 4760 Marracuene 50 187 236 53 203 256 492 Matutuíne 232 874 1106 247 951 1198 2304 Moamba 173 650 823 184 708 892 1715 Namaacha 332 1248 1579 352 1358 1711 3290 TOTAL 1388 5223 6611 1475 5686 7162 13773

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 continued promoting the use of recycled materials for toy production in every training. For example, collecting recyclables and making toys with recycled materials has been integrated in the recently completed training manual and supervision guide on stimulation in pediatric wards, which incentivizes hospitals to adopt recycling and toy making practices.

PATH has also been regularly inviting visitors to its toy-making space in its new office in Maputo, which demonstrates a variety of toys that can be made with recycled materials. The use of local and recycled materials in also promoted in PATH’s parenting education package, where families are encourage to work together to construct simple community playgrounds and produce toys at home.

With regard to promoting gender equality, during trainings and mentoring visits, the PPP team has continued to develop leadership skills with its technical staff, which is largely female, by delegating to them greater responsibility for specific tasks with MOH, DPS, and district services. Additionally, parenting education package has a separate module on the role of the father in the family, and father is featured prominently in other modules as well.

5. Upcoming plans

The following are some major activities planned for the upcoming quarter: 1. Support national distribution of developmental posters and guidelines. 2. Meet with Matola and Boane SDSMAS to present the Conrad N. Hilton Foundation– funded Phase III scope of activities and work plan. 3. Participate in TWG sessions and meetings to approve pre-service MCH curriculum profile and initiate development of curriculum modules. 4. Provide financial and technical support to training to integrate stimulation into inpatient treatment of malnutrition (Tratamento Da Desnutrição No Internamento). 5. Provide technical and financial support to simplified IMCI training integrating ECD. 6. Provide technical and financial support to DPS supervision in child health. 7. Implement new quality improvement approach and support district supervision and facility-specific action plans. 8. Conduct refresher training of APEs. 9. Support mobile physiotherapy brigades in Matutuíne and Namaacha districts. 10. Support health workers of selected HFs on utilization of videos in morning educational activities. 11. 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. 12. Provide long-distance support and technical field follow-up visits to WEI in Sofala and Zambezia provinces. 13. Conduct technical support visits on parenting education to community partners and their supported associations in Matutuíne District. 14. Receive approval from National Bioethics Committee and commence operations research study. 15. In coordination with MOH and DPS, receive a high-level delegation for a learning visit to project implementation sites of government, donors and partners from Ethiopia and Zambia.

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

6. Administrative update

Following the PPP ECD project manager’s resignation in August, PATH hired a new incumbent, Dr. Joaquim Rebelo Brandão, who started on March 1, 2018. Dr. Brandão will lead PPP activities under IR 1, but will broadly provide overall technical support to PPP activities.

PATH received a four-year award from the Conrad N. Hilton Foundation for Phase III of the ECD project that began in July 2017. This award brings additional resources that will be partially deployed in Maputo Province and will allow PATH to expand the ECD intervention to two additional districts of Maputo Province (Matola and Boane), thus covering the whole province. This expansion responded to different criteria including provincial demand to include all Maputo Province districts and positive progress of project indicators in already covered districts. Following a previous meeting with USAID in December, PATH submitted to USAID a formal request for review of the Cooperative Agreement to integrate the expansion of the Global Development Assistance ECD Programming to the two new districts. Activities in these new districts are covered by additional Conrad N. Hilton Foundation funding.

A contract with the operations research consultant firm was signed by both parties in the reported quarter.

7. Financial information

A total of 130,091.48 USD were expended during the quarter January–March 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 (4/1/18–6/30/18)

(1/1/18-3/31/18) (4/6/16–3/31/18) Direct labor 514 215.00 52,474. 22 371,397.47 142,817.53 49 500.00 Fringe benefits 166 605.00 14,765.75 114,056.84 52,548.16 16 038.00 Travel 66 200.00 11,953.81 65,598.36 601.64 4 500.00 Supplies 4 156.00 (704.22) 4 364.09 (208.09) - Sub-awards 91 761.00 3134.26 25 673.68 66 087.32 13 000.00 Other direct costs 233 214.00 19,222.29 196,246.95 36,967.05 15 000.00 Indirect costs 423 296.00 29,245.37 215,870.74 207,425.26 31 331.00

Total project 1,499,447.00 130,091.48 993,208.13 506,238.87 129 369.00 costs

8. Appendices

Appendix A. Success stories and photos

Community health worker applies her skills to support a child with acute malnutrition

Lidia Paulo Chauque is 33 years old and lives in Marracuene District of Maputo Province. Lidia is HIV positive and has a physical disability due to a childhood illness, which has left her without movement in her legs and with limited movement in her left arm. To move around, Lidia has to drag her body on the floor, using her right arm for support.

Lidia is the mother of 9-month-old Zertina Jaime Cossa. When Lidia got pregnant, she was abandoned by the child’s father. With no job or source of income, Lidia depended on goodwill of her neighbors and often travelled 30 kilometers to beg on the streets of Maputo.

Due to lack of funds, Lidia ate poorly during pregnancy, sometimes having just one meal per day. Her daughter Zertina was born low-weight. “When she was born she was very small and weak,” tells Lidia.

Today Zertina still suffers from low weight, weighing only 5.6 kilos, while the optimal weight for her age is 8 kilos. Zertina has been diagnosed with acute malnutrition at the health facility. While she receives supplements, Zertina rarely accepts to eat them.

Zertina and her mother have been receiving home visits from Laura Zefania, a community health worker (or Agente Polivalente Elementar [APE]). As her first action, Laura referred the family to Social Welfare services to ensure that the family receives basic support. Confronted with a response that Social Welfare currently has no funds to support Zertina’s family, Laura decided on another course of action. Trained in child feeding and development by PATH, in partnership with district health services, Laura started regular counseling of the family on home- based feeding and care for Zertina.

“... I have been visiting the family... talking to [Lidia] how to take care of the child, how to play, feed and make porridges... When she makes porridge, if she has potatoes or banana, she can mix it into the porridge. She can add oil… whatever they have at home,” tells Laura. Besides the APE, Lidia relies on the help of her neighbor and childhood friend, Virginia Tembe. According to Virginia, the advice given by the APE has helped Zertina to gain weight and strength.

“I have been helping [Lidia] to take care of Zertina since pregnancy. When Zertina was born she was very small. When we started talking with grandma Laura [APE], she explained to us what we should do to help Zertina improve. We see signs of change, she is already sitting, becoming bigger, is very active unlike before, and shows that she has strength,” tells Virginia.

Similarly to Virginia, Lidia has noticed signs of improvement in her daughter, which makes her happy in spite of all the challenges. “Before she would not hold her head up but now she is able to do it. And when we put some toy in front of her she tries to grab it, even though earlier she would not even move,” tells Lidia.

Although Zertina’s weight is still too low for her age, Lidia believes she will see her daughter much improved one day. “We will continue following the recommendations of grandma Laura, for Zertina to become strong and have a good weight,” promised Lidia.

APE Laura sums it up: “I feel happy to see Zertina as she is now, to know that the advice I gave has been helpful.”

To see Zertina become stronger and see her engage in Laura Zefania, APE, with Lidia and Zertina. play and exploration has been a source of joy for Lidia.

Appendix B. OVC HIV status

OVC HIV status—Manhiça District

District Year 1 Year 2 Year 3 Percent Manhiça LOP FY 2017 FY 2017–2018 FY 2018–2019 achieved of target (April 2017–March (April 2018–March LOP target (2016–20 (October 2016–March 2017) 2018) 2019) 19) Annual Actual Annual Indicator Description Baseline Annual target Actual Actual Target (Q4) Target comments Positive TBC TBC 0 TBC Negative TBC TBC 0 TBC On ART TBC 0 TBC <1 yr TBC No ART TBC 0 TBC

Unknown status TBC 150 TBC

TOTAL 150 Female Positive TBC 3 TBC Negative TBC 0 TBC On ART TBC 3 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown status TBC 560 TBC Percentage of orphans and TOTAL 563 vulnerable Positive TBC 1 TBC children (<18 years old) with Negative TBC 0 TBC HIV STAT HIV status On ART TBC 1 TBC reported to <1 yr. TBC implementing No ART TBC 0 TBC partner Unknown status TBC 137 TBC (including status TOTAL 138 not reported) Male Positive TBC 1 TBC Negative TBC 0 TBC On ART TBC 1 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown stat TBC 519 TBC TOTAL 520 Positive TBC 5 TBC Negative TBC 0 TBC Total 0–4 yrs TBC On ART TBC 5 TBC No ART TBC 0 TBC Unknown stat TBC 1366 TBC TOTAL 1371

OVC HIV status—Magude District

District Year 1 Year 2 Year 3 Percent LOP FY 2017–2018 FY 2018–2019 Magude FY 2017 achieved of target (April 2017–March (April 2018–March LOP target (2016–20 (October 2016–March 2017) 19) Annual Actual Annual Indicator Description Baseline Annual target Actual Actual Target (Q1) Target comments Positive TBC TBC 0 TBC Negative TBC TBC 0 TBC On ART TBC 0 TBC <1 yr TBC No ART TBC 0 TBC Unknown status TBC 22 TBC TOTAL 22 Female Positive TBC 0 TBC Negative TBC 0 TBC On ART TBC 0 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown status TBC 85 TBC Percentage of orphans and TOTAL 85 vulnerable Positive TBC 0 TBC children (<18 Negative TBC 0 TBC years old) with HIV STAT HIV status On ART TBC 0 TBC reported to <1 yr. TBC No ART TBC 0 TBC implementing partner Unknown status TBC 21 TBC (including status TOTAL 21 not reported) Male Positive TBC 0 TBC Negative TBC 0 TBC On ART TBC 0 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown stat TBC 78 TBC TOTAL 78 Positive TBC 0 TBC Negative TBC 0 TBC Total 0–4 yrs TBC On ART TBC 0 TBC No ART TBC 0 TBC Unknown stat TBC 206 TBC TOTAL 206

OVC HIV status—Moamba District

District Year 1 Year 2 Year 3 Moamba FY 2017 Percent LOP FY 2017–2018 FY 2018–2019 achieved of target (April 2017–March (April 2018–March LOP target (2016–20 (October 2016–March 2017) 2018) 2019) 19) Annual Actual Annual Indicator Description Baseline Annual target Actual Actual Target (Q1) Target comments Positive TBC TBC 0 TBC Negative TBC TBC 0 TBC On ART TBC 0 TBC <1 yr TBC No ART TBC 0 TBC Unknown status TBC 57 TBC TOTAL 57 Female Positive TBC 1 TBC Negative TBC 0 TBC On ART TBC 0 TBC 1–4 yrs. TBC No ART TBC 1 TBC Unknown status TBC 215 TBC Percentage of orphans and TOTAL 216 vulnerable Positive TBC 0 TBC children (<18 Negative TBC 0 TBC years old) with HIV STAT HIV status On ART TBC 0 TBC reported to <1 yr. TBC No ART TBC 0 TBC implementing partner Unknown status TBC 53 TBC (including status TOTAL not reported) Male Positive TBC 0 TBC Negative TBC 0 TBC On ART TBC 0 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown stat TBC 199 TBC TOTAL Positive TBC 1 TBC Negative TBC 0 TBC Total 0–4 yrs TBC On ART TBC 0 TBC No ART TBC 1 TBC Unknown stat TBC 524 TBC TOTAL 525

OVC HIV status—Namaacha District

District Year 1 Year 2 Year 3 Percent Namaacha LOP FY 2017 FY 2017–2018 FY 2018–2019 achieved of target (April 2017–March (April 2018–March LOP target (2016–20 (October 2016–March 2017) 2018) 2019) 19) Annual Actual Annual Indicator Description Baseline Annual target Actual Actual Target (Q1) Target comments Positive TBC TBC 0 TBC Negative TBC TBC 0 TBC On ART TBC 0 TBC <1 yr TBC No ART TBC 0 TBC Unknown status TBC 35 TBC TOTAL 35 Female Positive TBC 0 TBC Negative TBC 0 TBC On ART TBC 0 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown status TBC 133 TBC Percentage of orphans and TOTAL 133 vulnerable Positive TBC 0 TBC children (<18 Negative TBC 0 TBC years old) with HIV STAT HIV status On ART TBC 0 TBC reported to <1 yr. TBC No ART TBC 0 TBC implementing partner Unknown status TBC 33 TBC (including status TOTAL 33 not reported) Male Positive TBC 0 TBC Negative TBC 0 TBC On ART TBC 0 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown stat TBC 123 TBC TOTAL 123 Positive TBC 0 TBC Negative TBC 0 TBC Total 0–4 yrs TBC On ART TBC 0 TBC No ART TBC 0 TBC Unknown stat TBC 324 TBC TOTAL 324

OVC HIV status—Marracuene District

District Year 1 Year 2 Year 3 Percent LOP Marracuene FY 2017 FY 2017–2018 FY 2018–2019 achieved of target (April 2017–March (April 2018–March LOP target (2016–20 (October 2016–March 2017) 2018) 2019) 19) Annual Actual Annual Indicator Description Baseline Annual target Actual Actual Target (Q1) Target comments Positive TBC TBC 0 TBC Negative TBC TBC 0 TBC On ART TBC 0 TBC <1 yr TBC No ART TBC 0 TBC Unknown status TBC 78 TBC 78 Female Positive TBC 1 TBC Negative TBC 0 TBC On ART TBC 1 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown status TBC 292 TBC Percentage of orphans and 293 vulnerable Positive TBC 0 TBC children (<18 Negative TBC 0 TBC years old) with HIV STAT HIV status On ART TBC 0 TBC reported to <1 yr. TBC No ART TBC 0 TBC implementing partner Unknown status TBC 72 TBC (including status 72 not reported) Male Positive TBC 6 TBC Negative TBC 0 TBC On ART TBC 6 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown stat TBC 265 TBC 271 Positive TBC 7 TBC Negative TBC 0 TBC Total 0–4 yrs TBC On ART TBC 7 TBC No ART TBC 0 TBC Unknown stat TBC 707 TBC TOTAL 714

OVC HIV status—Matutuíne District

District Year 1 Year 2 Year 3 FY 2017–2018 FY 2018–2019 Percent LOP Matutuine FY 2017 (April 2017–March (April 2018–March achieved of target 2018) 2019) LOP target (2016–20 (October 2016–March 2017) 19) Annual Actual Annual Indicator Description Baseline Annual target Actual Actual Target (Q1) Target comments Positive TBC TBC 0 TBC Negative TBC TBC 0 TBC On ART TBC 0 TBC <1 yr TBC No ART TBC 0 TBC Unknown status TBC 10 TBC TOTAL 10 Female Positive TBC 0 TBC Negative TBC 0 TBC On ART TBC 0 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown status TBC 38 TBC Percentage of orphans and TOTAL 38 vulnerable Positive TBC 0 TBC children (<18 Negative TBC 0 TBC years old) with HIV STAT HIV status On ART TBC 0 TBC reported to <1 yr. TBC No ART TBC 0 TBC implementing partner Unknown status TBC 9 TBC (including status TOTAL 9 not reported) Male Positive TBC 0 TBC Negative TBC 0 TBC On ART TBC 0 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown stat TBC 35 TBC TOTAL 35 Positive TBC 0 TBC Negative TBC 0 TBC Total 0–4 yrs TBC On ART TBC 0 TBC No ART TBC 0 TBC Unknown stat TBC 92 TBC TOTAL 92

OVC HIV status—sum of all districts

District Year 1 Year 2 Year 3 TOTAL FY 2017 Percent FY 2017–2018 FY 2018–2019 LOP achieved of (April 2017–March (April 2018–March LOP target target (October 2016–March 2017) 2018) 2019) (2016–20 19) Annual Actual Annual Indicator Description Baseline Annual target Actual Actual Target (Q1) Target comments Positive TBC TBC 0 TBC

Negative TBC TBC 0 TBC On ART TBC 0 TBC <1 yr TBC No ART TBC 0 TBC

Unknown status TBC 352 TBC TOTAL 352 Female Positive TBC 5 TBC

Negative TBC 0 TBC

On ART TBC 5 TBC 1–4 yrs. TBC No ART TBC 1 TBC

Percentage of Unknown status TBC 1323 TBC orphans and TOTAL 1328 vulnerable children (<18 Positive TBC 1 TBC years old) with Negative TBC 0 TBC HIV STAT HIV status reported to On ART TBC 1 TBC <1 yr. TBC implementing No ART TBC 0 TBC partner (including status Unknown status TBC 325 TBC not reported) TOTAL 326 Male Positive TBC 7 TBC Negative TBC 0 TBC On ART TBC 7 TBC 1–4 yrs. TBC No ART TBC 0 TBC Unknown stat TBC 1219 TBC TOTAL 1226 Positive TBC 13 TBC Negative TBC 0 TBC Total 0–4 yrs TBC On ART TBC 12 TBC No ART TBC 1 TBC Unknown stat TBC 3219 TBC TOTAL 3232