MaMoni Health Systems Strengthening Activity (USAID Cooperative Agreement AID-338-LA-13-00004)
Quarterly Report October 1 – December 31, 2015
The newly formed Regional Roaming Quality Improvement Team for Barisal region examining the Operation Theatre of Jhalokathi Maternal Child Welfare Center
Submitted February 5, 2016
Cover Photo Story:
Mr. Md. Taiabur Rahman, DDFP (in charge), Barisal District, and Regional Consultant, FP-CST/QAT for Barisal region visited Jhalokathi Maternal Child Welfare Centre to assess quality gaps. MaMoni HSS Project is supporting the Quality Improvement Unit of MOH&FW, and developed a regional roaming quality improvement team in Barisal division.
Photo Credit: Partners in Health and Development/Save the Children
This document is made possible by the generous support of the American people through the support of the Office of Population, Health, Nutrition and Education, United States Agency for International Development (USAID), Bangladesh (USAID/Bangladesh), under the terms of Associate Cooperative Agreement No. AID-338-LA-13-00004 through Maternal and Child Health Integrated Program (MCHIP). The contents of this document are the responsibility of the MCHIP Project and do not necessarily reflect the views of USAID or the United States government. Table of Contents MaMoni Health Systems Strengthening Activity ...... 1 Table of Contents ...... i Abbreviations ...... ii Executive Summary ...... 1 Introduction ...... 3 Program Results for the Quarter ...... 5 IR 1. Improve Service Readiness through Critical Gap Management ...... 5 IR 2: Strengthened Health Systems at District Level and Below ...... 15 IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems...... 27 IR 4. Identify and Reduce Barriers to Accessing Health Services ...... 29 Challenges, Solutions, and Action Taken ...... 31 Challenges ...... 32 Opportunities ...... 32 Appendix 1: Case Studies and Success Stories ...... 33 A.1.1 Crash program at char abdullah, Ramgoti, Lakshmipur brings much needed services to a remote island ...... 33 Appendix 2: Program Performance Indicators (October–December 2015) ...... 37 Appendix 3: MNCH Essential Drugs Monitoring Report ...... 49 Appendix 4: Dissemination of MaMoni Program Learning ...... 55 Appendix 5: Environmental Compliance Report ...... 56 Appendix 6: Links to Media Stories Published ...... 58
MaMoni Health Systems Strengthening Activity: FY’16 Q1Quarterly Report i ABBREVIATIONS AHI Assistant Health Inspector AMTSL Active management of third stage labor BCC Behavior Change Communication BEmONC Basic emergency obstetric and newborn care BNF Bangladesh Neonatology Forum BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community action group CB Community-based CEmONC Comprehensive emergency obstetric and newborn care CHW Community Health Worker CHX Chlorhexidine CIPRB Center for Injury Prevention and Research, Bangladesh CMAM Community-based management of acute malnutrition cMPM Community microplanning meeting CNCP Comprehensive newborn care package CSBA Community Skilled Birth Attendants CV Community Volunteer CVRS Civil registration and vital statistical system CYP Couple years of protection DDFP Deputy Director Family Planning DGFP Directorate General Family Planning DGHS Directorate General Health Services DRS District Reserve Store EPCMD Ending Preventable Child and Maternal Deaths FPI Family Planning Inspector FWA Family Welfare Assistant FWV Female Welfare Visitor GOB Government of Bangladesh HA Health Assistant HBB Helping Babies Breathe HPNSDP Health, Population, and Nutrition Sector Development Program HS Health systems HSS Health systems strengthening IFA Iron plus Folic Acid
ii MaMoni Health Systems Strengthening Activity: Annual Report IPHN Institute of public health nutrition IR Intermediate result JSV Joint supervisory visit LAPM Long-acting and permanent method LMIS Logistics management information system MAMA Mobile Alliance for Maternal Action mCPR Modern contraceptive prevalence rate MCWC Maternal and Child Welfare Center MNCH/FP/N Maternal, newborn and child health, family planning, and nutrition MNH Maternal and newborn health MOH&FW Ministry of Health and Family Welfare MOLGRD&C Ministry of Local Government Rural Development & Cooperatives MOU Memorandum of understanding MPDR Maternal and perinatal death review NIPORT National Institute of Population Research and Training NNS National nutrition services OGSB Obstetrics and Gynecology Society of Bangladesh PPIUCD Postpartum intra-uterine contraceptive device QA Quality assurance QI Quality improvement QPRM Quarterly performance review meeting RHIS Routine health information system RRQIT Regional roaming quality improvement team SACMO Sub-assistant Community Medical Officer SAM Severe Acute Malnutrition SBA Skilled Birth Attendant SBM-R Standards-Based Management and Recognition SC Save the Children SCANU Special care newborn unit SDP Service delivery point SIAPS Systems for improved access to pharmaceuticals and services SSN Senior Staff Nurse STG Strategic thematic group TBA Traditional Birth Attendant TOT Training of trainers
MaMoni Health Systems Strengthening Activity: FY’16 Q1Quarterly Report iii UEHFPSC Union Education Health and Family Planning Standing Committee UFPO Upazila family planning officer UHC Upazila health complex UH&FPO Upazila Health and Family Planning Officer UH&FWC Union Health and Family Welfare Centers UP Union parishad USAID United States Agency for International Development
iv MaMoni Health Systems Strengthening Activity: Annual Report EXECUTIVE SUMMARY Key Accomplishments of the MaMoni Health Systems Strengthening Project (MaMoni HSS) In the first quarter of year three, the key accomplishments of the project include the following: • MaMoni HSS has been supporting the Directorate General Family Planning (DGFP) in assessing all Union Health and Family Welfare Centers (UH&FWCs) in Bangladesh for readiness to provide 24/7 delivery services. During this quarter, assessment of 1,703 UH&FWCs in all of Rangpur division and parts of Dhaka, Khulna and Rajshahi divisions have been completed, bringing the total assessment to 3,052 out of a projected 4,000 health facilities nationwide. MaMoni also organized the first meeting of the technical assistance cell (TAC) at DGFP where the preliminary findings from the assessments were reported. • MaMoni HSS has been supporting the routine health information system (RHIS) initiative of the Directorate General Health Services (DGHS) MOH&FW to pilot the automated population registry system (PRS). As of December 31, 2015: 342,200 household members in 47,802 households of Madhabpur upazila of Habiganj district have been registered, and preparations were completed to introduce PRS in Lakhai upazila in January 2016. In three unions of Madhabpur, Family Welfare Visitors (FWVs) were trained to record service data in maternal, newborn, and child health (MNCH) e-register, which includes antenatal care (ANC), delivery, newborn, and post-natal care (PNC) modules of the UH&FWC register. The FWVs shared that, after a learning curve, it has been very helpful for them to use the automated system, both in laptop and tablet PCs. • MaMoni HSS successfully advocated with DGHS to place four gynecology consultants, and two anesthesia consultants in CEmOC designated centers. These staff were posted in Habiganj and Jhalokathi district hospitals, Hatiya Upazila Health Complex (UHC) in Noakhali district, Ajmiriganj and Baniachang UHC in Habiganj district. MaMoni is working with the district administration to ensure that these consultants stay at their work place and contribute to improve CEmONC service delivery. • National Scale-up up of Chlorhexidine support has included training of 17,077 service providers in 20 districts. In January 2016, the Chlorhexidine procurement has been transferred to Central Medical Store Depot (CMSD), and distribution is expected to commence soon after that. • Newborn sepsis management at UH&FWCs have been introduced in 10 upazilas. 558 newborn cases were seen by Sub-assistant Community Medical Officers, out of which 59 cases were treated for clinically severe infection.
Challenges and Mitigation Strategies • Staff transitions: In this quarter, the Director General of Family Planning, Director, MIS, DGFP, Civil Surgeon of Noakhali and UH&FPO of Hatiya were transferred, creating a continuity challenge for the advocacy and sensitization work of the project. MaMoni has developed plans to sensitize the new officials and obtain their support for the project. • Drug shortage: The Drugs and Dietary Supplements (DDS) kits of UH&FWCs and the drug supply of the community clinics have been interrupted since September 2015 due to procurement issues at DGHS and DGFP. This has severely affected the coverage and
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 1 quality of essential services at the community level. MaMoni HSS has been closely monitoring the situation, and where appropriate, has been liaising with the Union Parishads, and Ministry of Social Welfare to leverage temporary support to meet the shortfall for drugs and supplements such as oxytocin, iron plus folic acid (IFA) and misoprostol. • DGHS procurement of chlorhexidine for national scale-up has been delayed. Beyond high intensity districts, MaMoni HSS prepared the service delivery mechanisms, but wasn’t able to roll out the intervention as planned. Chlorhexidine is expected to be available in late January.
Way Forward • In the upcoming quarter, the focus of the project will be on post-training follow up of priority of Ending Preventable Child and Maternal Deaths (EPCMD)/FP interventions through quality improvement initiatives: Regional Roaming Quality Assurance Teams (RRQAT), quality improvement (QI), including Standards-Based Management and Recognition (SBM-R), joint supervisory visits (JSV), sentinel site surveillance and maternal and perinatal death review (MPDR). • MaMoni HSS will also continue to organize advocacy meetings on UH&FWC strengthening at divisional levels. • MaMoni is closely monitoring the drug shortage in the field. In four MaMoni high intensity districts, where appropriate, Union Parishads have been engaged to provide temporary support. • An automated routine health information system (RHIS) will be introduced in Lakhai upazila and the Madhabpur experience of introducing MNH e-register will be shared with key stakeholders to ensure broad support. • Lessons from introduction of newborn sepsis management will be analyzed and shared.
2 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 Introduction The MaMoni Health Systems Strengthening (HSS) project, a four-year USAID-funded award,1 has the goal of improving utilization of integrated maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) services delivered through a health systems strengthening lens. The project supports the Ministry of Health and Family Welfare (MOH&FW) to introduce and leverage support for the scale-up of evidence-based practices that have been applied and tested in Bangladesh. To support this scale-up, MaMoni HSS is actively engaging with local government structures and nongovernmental organizations (NGO) to improve delivery of health services, and strategically partner at the national level to build consensus on policies and standards that positively drive evidence- based interventions at all levels. The project objective is well aligned with the GoB’s Health, Population, and Nutrition Sector Development Program (HPNSDP) for 2011–2016; and also directly supports the USAID/Bangladesh Development Objective 3 (DO 3: “Health Status Improved”), which is under the “Investing in People” objective of the Country Development Cooperation Strategy (CDCS) framework of USAID in Bangladesh.
MaMoni HSS designed a two-pronged approach in which districts and upazilas (sub-district) were categorized into one of two groups—high-intensity intervention areas and health system capacity strengthening areas.
The aim of the high-intensity areas is to demonstrate best-practice models of MNCH/FP/N health care delivery through intensive support to the Government of Bangladesh (GoB), and if needed, direct implementation to maximize learning and advocacy for scale-up nationally. Based on an analysis of gaps in coverage and equity of access to high-impact MNCH/FP/N services, the project identified a total of 23 upazilas across five districts to serve as the project’s high-intensity areas. Of the 23 upazilas, district saturation was achieved Figure 1. MaMoni health systems strengthening in Habiganj, Lakshmipur, and Jhalokathi project area districts, while in the Noakhali and Pirozpur districts, four and two upazilas were supported , respectively. The health systems (HS) capacity strengthening areas cover a total of 17 upazilas—all seven upazilas of Bhola,
1 MaMoni HHS is the result of an Associate Award under the Maternal and Child Health Integrated Program, with a period of performance from September 24, 2013 to September 23, 2017. MaMoni HSS is supported by Jhpiego—in partnership with Save the Children, John Snow, Inc., and The Johns Hopkins University Institute for International Programs—with national partners: International Centre for Diarrhoeal Disease Research, Bangladesh; Dnet; and Bangabandhu Sheikh Mujib Medical University (BSMMU). Save the Children serves as the lead operational partner for the Award in Bangladesh.
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 3 five upazilas of Noakhali, and five upazilas of Pirozepur (refer to Figure 1 and Table 1). Whereas the high-intensity areas focus on support for a complete package of MNCH/FP/N interventions, the HS capacity strengthening areas receive less intensive technical assistance on a selected set of interventions. Minimal support was provided to GoB health systems to scale up interventions such as 24/7 Union Health and Family Welfare Centers (UH&FWCs), chlorhexidine for cord care, and Helping Babies Breathe (HBB); instead, the focus was on supporting the strengthening of existing MNCH/FP/N services. MaMoni HSS has four intermediate results (IR): IR 1. Improve service readiness through critical gap management. IR 2. Strengthen health systems at district level and below. IR 3. Promote an enabling environment to strengthen health systems at the district level. IR 4. Identify and reduce barriers to accessing health services.
Table 1. Summary of MaMoni HSS geographic scope
No. of Health Facilities Population No. of No. of Area (2015 Upazilas Unions District projection) Upazila Union Community (MCWC)
High- Intensity 23 26 7,355,822 5 20 208 619 Areas
Health Systems CB 17 151 4,870,933 5 13 121 488 Area
Total 40 377 12,226,755 10 33 329 1,107
Notes: (Community-Based), (Maternal and Child Welfare Center)
4 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 PROGRAM RESULTS FOR THE QUARTER
IR 1. Improve Service Readiness through Critical Gap Management
1.1 Introduction and Scale-up of MNCH/FP/N interventions
1.1.1 Maternal Health At the national level, MaMoni HSS partnered with the Obstetrical and Gynaecological Society of Bangladesh (OGSB), Population Council, and icddr,b to disseminate results from an intervention to identify and manage pre-eclampsia/eclampsia (PE/E) using a loading dose of injectable magnesium sulfate at the community level in Habiganj district, and guide the Ministry of Health and Family Welfare (MOH&FW) to scale up this intervention. MaMoni HSS support includes providing technical assistance to review and update the national PE/E protocol in light of new global evidence, and participate in the landscape analysis conducted by Population Council’s Ending Eclampsia project. The PE/E results dissemination was well-received by MOH&FW stakeholders with the Director of MCH committing to scale-up of FWVs to provide loading dose of injectable magnesium sulfate followed by referral to a higher-level facility.
At the district level, MaMoni HSS conducted a PE/E management orientation session for Jhalokathi and Habiganj districts with the district and upazila level managers. In the subsequent quarters, the project will roll out PE/E management interventions in five upazilas of the high intensity districts: Nabiganj (Habiganj), Companyganj (Noakhali), Kamalnagar and Ramganj (Lakshmipur), and Rajapur (Jhalokathi). The project will also work with OGSB to strengthen the referral facilities in those districts.
MaMoni HSS is supporting the district level providers of high intensity districts to distribute misoprostol to mothers to prevent postpartum hemorrhage. Around 52,179 mothers received misoprostol through union and community level providers. Field level misoprostol distribution was interrupted as a large number of doses were set to expire in the coming months, and because of delays in overall drug procurement at DGFP, new supplies were not on hand. MaMoni HSS has been in discussion with DGFP and DGHS to ensure that this challenge is addressed systematically in order to prevent future stock-outs.
1.1.1.a. Increasing SBA at the District Level In the six MaMoni HSS districts, the project is supporting MOH&FW to strengthen the UH&FWCs to provide the comprehensive package of MNCH/FP/N services, including normal delivery care through a combination of: leveraging existing resources of MOH&FW; mobilizing local resources; and providing direct input to meet facility needs (i.e. training, infrastructure improvement). As of December 2015, a total of 58 out of 193 UH&FWCs in the high-intensity upazilas are providing 24/7 delivery services. Overall, as depicted in Figure 1 below, institutional deliveries at the facility level are increasing; however the total trend in skilled attendance at birth has declined over the last 3 quarters. This is likely due
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 5 to some private CSBA dropout, Eid holidays, and CSBAs being away from the field to attend various orientations, including the new FWA register, CNCP and CHX training, etc.
Figure 1. Trend of SBA deliveries in MaMoni HSS high intensity districts
20000 1732516820 15608 14099 15000 1350713039
10000 Number 5000 3578 3637 1357 240 144 152 0 Facility Delivery CSBA PCSBA Total SBA
FY 15 Q3 FY 15 Q4 FY 15 Q1
1.1.1.b Private CSBAs (pCSBA) Introduced Private community SBAs (pCSBA) were approved by the GOB in 2008 to increase availability of skilled birth attendants at non-facility level deliveries. pCSBAs have the same skills as government CSBAs (trained FWA/HA), but do not have other responsibilities. As non-salaried workers, pCSBAs only earn income by charging for different services (ANC, deliveries, PNC) and selling essential commodities. MaMoni HSS trained 52 pCSBAs in Habiganj in the first two years. In this quarter, 38 new pCSBAs from Noakhali and Lakshmipur completed their six month training. These pCSBAs were trained in Noakhali and Chandpur nursing institutes, and will receive certification from Bangladesh Nursing Council to conduct delivery as an SBA. In this quarter, 152 deliveries were conducted by pCSBAs of Habiganj.
Photo 1: pCSBA in Chandpur being 1.1.1.c Supported Health Facility provided delivery set after completion of Preparedness for MNCH/FP/N Services course In Year Two of MaMoni HSS, the MOH&FW requested the project to provide technical assistance to the DGFP to strengthen UH&FWCs across the entire country by training providers, strengthening commodity management, and establishing quality improvement mechanisms. As a starting point, the program has initiated a nationwide assessment, which includes a facility readiness assessment that covers over 4,000 health facilities and assesses infrastructure, FWV residence, human resources, training, furniture, equipment and supplies. In Year Two, 1,348 UH&FWCs were assessed in Sylhet, Barisal, and Chittagong divisions.
6 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 In this quarter, another 1,703 UH&FWCs were assessed, bringing the cumulative total to 3,052 UH&FWCs. Rangpur division has been completed, and assessment of Dhaka, Khulna and Rajshahi are expected to be completed by January 2016. MaMoni also organized the first meeting of the technical assistance cell (TAC) at DGFP in November
Photo 2: TAC meeting on UH&FWCs at 2015, where the preliminary findings from the DGFP assessments were reported.
1.1.2 Newborn Health
1.1.2.a. National scale up of 7.1% Chlorhexidine to prevent newborn infection DGHS has procured 600,000 units of 7.1% chlorhexidine (CHX) aqueous solution to be distributed nationally. This has been added to the Central Medical Store Depot (CMSD) in January 2016. MaMoni HSS, through five partner NGOs, supported orientation of 1,091 district and upazila level MOH&FW staff and 15,893 outreach workers in 27 districts. This included 21 independent monitors assessing 354 orientation sessions to ensure completeness and accuracy of the orientation. Some of the findings have been described in Table 2. As Photo 3: Khulna divisional advocacy meeting on 7.1% Chlorhexidine CHX was not available at the time of the assessment, it was not included in observation.
Table 2: Findings from independent monitoring of CHX orientation Challenges faced by independent monitors and corrective action Some government facilities do not have specific and functional training rooms. The monitors had to check the training venue and ensure the facilities before training. Field staff came from remote areas, so there were problems to start the program on time. To overcome this situation, the independent monitor had to talk with field officers and local coordinators to readjust the time schedule keeping in mind distance from the venue, if it is a remote area. Sometimes there was overlapping of sector specific programs at the upazila level. As the independent monitors have vast experience working in the health and family planning sector, and they had played a key role, so there is a need to have strong coordination between health and family planning sector regarding training date issue. In some specific cases the trainer was not available due to various reasons [transfer/ sick/ other reason]. In this case the independent monitors had the very vital role to continue the training as well as ensure the quality of the training.
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 7 MaMoni also supported the Program Manager, IMCI of DGHS to organize a scale-up mapping of CHX implementation in October 2015, inviting NGO partners to agree to a common reporting mechanism on CHX rollout. NHSDP, Care-BD, Plan Int’l, MSH/SIAPS, SMC, and 3 MaMoni partners participated. In this quarter, NHSDP reported procuring 13,304 units of Chlorhexidine from ACI to be used in Smiling Sun clinics, and orienting 222 doctors, 1,172 paramedics, and 4,739 community service providers. NHSDP has requested government supplies to serve poor clients free of charge. At the district level, MaMoni HSS procured Chlorhexidine through leveraged funds for distribution and use. In the first two months of the quarter, 2,528 newborns of Habiganj and 815 newborns of Noakhali received Chlorhexidine.
1.1.2.b. Newborn Sepsis Management MaMoni HSS introduced newborn sepsis management at the union level facilities in 10 upazilas2 through Sub-assistant Community Medical Officers (SACMOs) for newborns in situations where referral was not possible or acceptable. 39 GoB master trainers trained 266 SACMOs to prepare for this intervention. In this quarter, 558 cases of newborn sepsis were identified by the SACMOs (375 in Habiganj, 85 in Noakhali, and 98 in Lakshmipur). Figure 3, below, shows the total number of cases disaggregated by type of infection.
Figure 3: Sick infants (0-59 day) treated at UH&FWC of intervention upazila during the period October-December 2015
Anecdotal feedback from SACMOs revealed that more support and visual job aids are needed for them to identify and manage sick newborns using proper dosage. The national protocol of newborn sepsis management assigns Family Planning Inspectors (FPIs) the responsibility to conduct follow up on day 2 and day 8 to ensure treatment
2 All eight upazilas of Habiganj, Ramganj upazila of Lakshmipur and Companyganj upazila of Noakhali district
8 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 completion, but this recommendation may also need to be revisited, as FPIs do not have household visit mandate other than for supervisory purpose. MaMoni HSS has provided baby weighing scales, 1mL syringes and introduced a supplementary service register (jointly developed with MOH&FW and SNL) and reporting form to facilitate this intervention. Operations research has been designed in Ramgonj upazila of Lakshmipur district to evaluate sepsis management activities. This is a collaborative effort of MaMoni HSS with Johns Hopkins University (JHU), Saving Newborn Lives (SNL) program of Save the Children, and icddr,b. The SNL Program is implementing a similar intervention using the same newborn sepsis management protocol in Kushtia district, and JHU has been implementing one in two upazilas of Sylhet district. A coordination meeting with sepsis OR partners was held in December. A review meeting of sepsis OR will be held in January 2016 to review findings from different baseline data and field findings.
1.1.2.c. Kangaroo Mother Care At the national level, MaMoni HSS is collaborating with SNL and other partners to finalize KMC implementation guidelines for facility introduction and community follow-up. In MaMoni districts, 2 nurses from Noakhali and 1 nurse from Habiganj participated in national level KMC training. MaMoni also initiated facility assessments at 3 district hospitals, 2 MCWCs and 4 UHCs to assess support needed to introduce KMC. An observation and learning visit for pediatricians (Asst. Prof. Dr. Lutfunnesa and Dr. Main Uddin) from Noakhali and Photo 4: First newborn receiving KMC at Noakhali Sadar Hospital Lakshmipur Sadar Hospitals was organized at SCANU and KMC Unit of BSMMU in November. The first newborn was admitted in the newly set up KMC unit of Noakhali Sadar Hospital in December. However, follow up discussions revealed that more support is needed to regularly run the KMC unit.
1.1.2.d. Antenatal Corticosteroids for threatened preterm labor According to national protocol and guidelines, the clinical conditions for which antenatal corticosteroid will be administered (ACS) has been investigated as those associated with threatened or inevitable preterm delivery between 24-34 weeks of gestational age and that the guidelines stipulate that it be given by a skilled provider; it should promptly initiate administration of ACS- Inj Dexamethasone 6 mg IM every 12 hours for a total of 4 doses, or 12 mg IM every 24 hours for a total of two doses. Facilities with ability to accurately assess gestational age and determine risk of imminent preterm birth, should ensure that they have capacity to adequately care for preterm newborns through resuscitation, KMC, provide adequate feeding support, treatment of infection, and reliable, timely and appropriate identification and treatment of maternal infection. Taking this guidance into consideration, the project has initiated the process of introduction of ACS at district hospitals in four high-intensity districts (Habiganj, Noakhali, Lakshmipur and Jhalokathi).
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 9 During the reporting period, 4 cases who received ACS were reported from Habiganj district hospital.
1.1.2.e. Special Care Newborn Units (SCANUs) DGHS has been trying to establish SCANU from SAARC Development Fund (SDF) in 10 districts of Bangladesh. In that regard, equipment was procured last year for ten districts, four of which (Habiganj, Noakhali, Bhola, Pirozpur) are MaMoni districts. In response to a request from DGHS for SCANU equipment installation support in those districts, the project commissioned a local firm to support DGHS for SCANU establishment in the project area. The activity will be carried out next quarter. Project is also supporting establishment of a SCANU in Lakshmipur district hospital. Support includes necessary renovation and key equipment supply. In addition to that, the Project will be facilitating trainings on technical competency, reporting, and limited human resource assistance.
1.1.2.f. Helping Babies Breathe Follow up HBB training was provided to 39 private facility providers in 2 separate batches in 2 districts. 24 nurses attended the training in Narshingdi district, and 5 doctors and 10 nurses attended in Narayanganj district. 77 district and upazila level managers of health and family planning, consultants from pediatrics and OBGYN departments, and district level officials attended district review meetings in these two districts. Field Officers of BSMMU observed 95 participants in 9 sessions of refresher training. They also visited 59 of the 118 facilities there, and replaced 6 pieces of equipment in 6 of them, and provided 34 training DVDs. Beyond revisit schedules, 4 neonatal resuscitation models were provided to Rajshahi Medical College Hospital, and icddr,b. 167 bag and mask/sucker sets were provided to OGSB, and C-SBAs of Plan International.
1.1.3 Child Health At the national level, the newborn and child health cell is supporting the IMCI section. Review of IMCI reporting site, review of IMCI report and feedback process from the central level have started because of this additional support. Routine online IMCI reports were monitored regularly and feedback was provided to the respective health manager. The Cell also worked with the MIS unit regarding correction of the facilities name in DHIS2. As a result, online reporting now and MIS reports are more accurately reflected in the DHIS2. The Cell is also working to prepare and maintain a huge HR database, containing the list of all field level health workers in Bangladesh.
1.1.3.a Community Case Management (CCM) MaMoni HSS supported introduction of CCM from Community Clinics (CCs) in Jhalokathi district. A total of 85 Community Health Care Providers (CHCP) were trained. The Project conducted post-training follow up and supplied Chart booklets, Salter scales, MUAC tape, and GMP cards for all the CCs. 85 CHCPs from 82 existing Community Clinics (CC) are now treating ARI, pneumonia, and diarrheal cases along with nutritional counseling following the CCM protocol. CHCPs provide daily reports online from the CC. The project, in collaboration with UNICEF, is facilitating performance monitoring through monthly
10 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 meeting of CHCPs at Upazila and district level. However, performance data was not available at the time of writing of the report.
1.1.4 Family Planning At the district level, MaMoni undertook several initiatives to strengthen the family planning interventions. • In Jhalokathi, 115 FWAs were deputed for 5 days secondment with FWV at UH&FWC in November 2015 to ensure their competency to provide 5 unassisted second dose injectable contraceptives under observation of FWVs. All attachments were completed successfully, and it is expected to increase injection safety at the community level. • In the previous year, 181 CHCPs of Lakshmipur district received FP counseling training. MaMoni HSS followed up with them and found them counseling male and female clients and referring new clients for LARC and LAPM services. MaMoni HSS community microplanning has documented some of these referrals by CHCP. CHCPs currently do not have a register or reporting format to document the counseling and referrals. MaMoni is exploring the options to address this challenge. • Following the training of 15 service providers on PPIUCD in Lakshmipur in Year 2, MaMoni HSS continues to provide operational support to increase their performance. Figure 4, below, shows the increasing trend in PPIUCD insertions as a result of improved provider confidence and client acceptance within the district.
Figure 4: Postpartum IUCD insertions in Lakshmipur3, July-December 2015
80 70 72 60 50 46 40 30
Total Number Total 20 10 11 13 12 0 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15
• MaMoni HSS is supporting integration of FP services in all service delivery points of MOH&FW, particularly in the upgraded UH&FWCs. During the quarter, the CYP for the high intensity upazilas was 266,269, and in the health systems capacity building upazilas was 106,936. Figure 5 shows the current method mix as of November 2015. The majority of clients choose oral contraceptives followed by injectables, across all districts.
3 Facilities represented include: MCWC, Uttor Joypur, Dattopara, Chandraganj, Kerowa, and Char Falcon UH&FWCs
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 11
• During the quarter, 20% of LAPM Figure 5: FP Method Mix from MaMoni services were contributed by districts Nov'15 community volunteers of MaMoni 90 HSS. Figure 6 shows current 80 progress in LAPM uptake in project 70 districts. 60 50 40
30 20 42 43.3 39.0 34.3 36.4 35.3 30.9 10 0 Projection Habiganj Lakshmipur Noakhali Jhalokati Pirojpur Bhola Pill Condom Injectable IUD Implant NSV Tubectomy
Figure 6: Trend of LAPM and CV contribution in four high intensity districts
9000 8453 8000 7000 6000 5350 4989 5000 4000 Number 3000 1706 2000 1078 970 1000 0 Total CV Total CV Total CV FY15 Q3 FY15 Q4 FY16 Q1
1.1.5 Nutrition At the national level, MaMoni HSS aims to mainstream nutrition service delivery through different levels of the existing health system (community to district) through filling up the capacity and quality gaps by providing monitoring and supportive supervision.. In November 2015, MaMoni HSS participated in a learning-sharing meeting with the ‘Tackling Childhood Malnutrition (TCM)’ project to learn about the challenges faced by the TCM project to mainstream nutrition service delivery through the existing health system and the strategies to overcome them. TCM project worked closely with NNS and the Community Clinic project to improve nutrition service delivery through the Govt. health Photo 5: Child examined at SAM corner in Ramgoti UHC, Lakshmipur 12 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 system. Some of these learnings have helped MaMoni HSS project in refining its nutrition activities. At the district level, the nutrition activities were more focused on screening, identifying, and referring children with Severe Acute Malnutrition (SAM) to Upazila Health Complexes (UHC). A total of 37 SAM cases were admitted in 8 SAM corners located in UHCs of Habiganj, Lakshmipur, and Noakhali districts and received treatment. Implementing SAM management has been challenging for several reasons. The following challenges were encountered: Table 3: Challenges of SAM management and MaMoni response Issues MaMoni HSS response SAM children stay only one or two days at Hospital. The MaMoni HSS is strengthening counseling at hospitals are overloaded, and families are hesitant to stay household level to sensitize families, and the duration necessary (in some cases 14 days) to ensure exploring options for obtaining IEC materials for complete recovery. The treatment compliance is a continuing families. challenge; as household level follow-up is not possible by hospital staff. Only one MO and only one nurse per facility received training on SAM management. So 24 hours trained manpower is not available at UHC. MaMoni HSS is in discussion with NNS to address provider vacancy and ensure sufficient In the absence of an MO or nurse it becomes difficult to number of trained providers. provide uninterrupted services. Transfer of trained personnel.
1.2 Management of Critical Human Resource Gaps of GOB Service Providers MaMoni HSS has been closely engaged at the national level in developing the National Health Workforce (HWF) Strategy, which has now been forwarded by the Human Resources for Health Task Group for approval by MOH&FW. MaMoni HSS has now been included in the HR Task Group of MOH&FW. In consultation with the USAID mission, the project held several consultation meetings with other key DPs who are supporting the MOH&FW in the area of HRH. These discussions, involving WHO, CIDA, UNFPA and DFID, helped to identify potential areas for the project to support as the MOH&FW prepares to implement the national HWF Strategy. MaMoni HSS was also invited to be a member of the Strategic Technical Group on Human Resources for Health, constituted to draft the recommendations for the fourth HPN Sector Development program. The project’s contributions to these forums were informed by the experiences and data from the MaMoni HSS implementation. The recommendations of the STG have been incorporated in the Sector Investment Plan drafted by MOH&FW for the next sector program.
At the district level, MaMoni HSS continued to provide temporary staff to address the vacancies in nurses and FWV positions in selected facilities in Habiganj, Noakhali, and Lakshmipur districts, while continuing to advocate with local leaders (UP Chairman and Members of Parliament) for long-term solutions by filling the vacancies through GOB recruitment. Simultaneously, the project continually advocated for prioritization of posting newly recruited staff in underserved areas with major human resource shortages. As a
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 13 result of the project’s advocacy efforts, in this quarter, 4 gynecology consultants and 2 anesthesiology consultants were deployed in the project areas by the GOB.
Table 4: Consultants placed to support CEmOC due to MaMoni advocacy
• Consultant, Gynaecology in Hatiya UHC, Noakhali • Anesthetist in Hatiya UHC, Noakhali • Consultant, Gynaecology in Habiganj district hospital • Consultant, Gynaecology in Ajmiriganj, Habiganj • Consultant, Gynaecology in Baniachong, Habiganj • Anesthetist in Jhalokathi district hospital
In the six districts where implementation is in progress, the project is currently supporting 58 paramedics, one EmOC-trained medical officer, and 19 nurses to fill critical human resource gaps. There have been changes from quarter to quarter in the number of paramedics deployed in Habiganj, Noakhali, and Jhalokathi—largely a result of frequent staff turn-over. The status of vacancies and MaMoni gap management will be expected to undergo changes in December when new FWVs are deployed (refer to Table 5).
Table 5. Summary of critical health workforce gap management provided by MaMoni Health Systems Strengthening (HSS) in high-intensity districts, as of December 31, 2015.
FWV Nurses
District Vacant Paramedics Vacant Vacant Nurses Vacant Posts Posts Sep deployed by Posts Sep Posts Dec deployed by Dec 2015 2014 MaMoni HSS 2014 2015 MaMoni HSS
Habiganj 11 13 32 28 42 14
Noakhali 7 11 16 33 30 3
Lakshmipur 0 2 8 29 24 3
Jhalokathi 9 7 4 0 3 0
Total 27 33 60 90* 99 20
* 90 vacant posts reported but HRH assessment findings suggest that this number was significantly underreported.
From the previous quarter, MaMoni HSS has increased one nurse support in Noakhali district, and two paramedics in Lakshmipur district to support 24/7 delivery centers. One of the limitations of the human resource assessment is that FWVs deputed to the MCWC are still shown as part of their respective union. In Jhalokathi Sadar, four FWVs from the unions have been posted at the MCWC, leading to zero ANC coverage of the entire Sadar upazila. MaMoni HSS hasn’t been able to address this structural problem.
1.2.1 Advocacy to deploy Midwives in MaMoni districts
14 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 MaMoni HSS met with the President and two members of the Bangladesh Midwifery Society in December to explore deployment of midwives at MaMoni HSS districts. Further consultation will take plan in the coming quarter.
IR 2: Strengthened Health Systems at District Level and Below
2.1 Strengthen District Planning and Performance Management In Year Two, the project supported the development of decentralized MNCH/FP/N action plans at district and upazila levels, using local level data and analysis. The data from tracer indicator surveys on priority MNH/FP indicators, along with health systems bottlenecks analysis, helped prioritize interventions as well as geographic areas. Quarterly performance review meetings (QPRM), held jointly by DGFP and DGHS staff with project facilitators, were held regularly in four districts. A total of 14 QPRMS were held, leading to management decision-making and actions plans for program improvement.
2.2 Strengthened Quality Improvement Initiatives
2.2.1 National Level Contributions • The project continued its collaboration with the MoH&FW QI Secretariat. This included several meetings organized by the National QI Secretariat, involving MoH&FW officials from DGFP and DGHS as well as representatives from several implementing partners such as UNICEF, WHO, and JICA. Discussions included the development of a national strategy for QI and the review of the national workplan, developed by the QI Secretariat. • MaMoni HSS Project contributed, through an effort led by the National QI Secretariat, to developing national guidelines for Maternal and Perinatal Death Review (MPDR). The guidelines will provide a basis for scaling up MPDR to all 64 districts of Bangladesh with the aim to improve notification for maternal death, newborn death, and stillbirth as well mapping the incidence of death to highlight unions where most of deaths occur and hence require special attention. MPDR scale up includes verbal autopsy of all cases of maternal mortality and a sample of newborn mortality to identify main social, logistical, and service delivery factors contributing to mortality and using information to take measures to avoid future mortality. • The project finalized the development of a document on “MaMoni HSS Project Quality Improvement Framework and Strategy: Contributing to improving the quality of MNCH/FP/N Services in Bangladesh”. The document articulates the overall strategy adopted by the project to contribute to improving the utilization and effectiveness of MNCH/FP/N services through the following objectives: i. Improve the effectiveness of the critical MNCH/FP/N services provided at health facilities and community levels in MaMoni HSS Project areas. ii. Advocate for the importance of QI for MNCH/FP/N programs at all levels. iii. Strengthen the capacity of national counterparts at all levels in QI and institutionalize effective QI approaches.
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 15
The document will facilitate articulating MaMoni HSS Project’s QI strategy and approaches to MoHFW and international counterparts. 2.2.1.a Implementation of a new QI paradigm
• The project continues to implement the new QI paradigm that is based on recognizing the challenges to delivering quality clinical care including inadequate human and financial resources, over-centralized decision making and management system, and lengthy and complicated bureaucratic regulations. As a response, the project adopted the new QI paradigm that aims to improve quality of clinical services incrementally in stages:
Table 6: The New Quality Improvement Paradigm
Stage Improvement Aim Stage 1 Improve basic cleanliness, waste management, minimum infection prevention
Stage 2 Improve organization of services, crowd management, infection prevention Basic antenatal care, delivery care, newborn care standards Stage 3 Improve compliance with clinical standards for maternal, newborn, child care, family planning, and nutrition services
Hence, the initial focus for QI is on improving the basic cleanliness, waste management, and basic infection prevention. Each district is developing a table summarizing the existing status of each health facility regarding whether the facility is at stage 1, 2, or 3. The table will serve as a monitor on status of improvement for each facility as it is implementing its action plan for improvement. The action plan is developed based on Joint Supervisory Visits’ checklists, QI committee’s assessment, and QI members of the health facilities. For example, supervisory visit at MCWC in Lakshmipur district identifies the need to improve overall cleanliness of the facility. As a result, the staff allocated time to clean their own facility starting with the backyard.
16 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1
Photo 5 : Staff at MCWC, Lakshmipur District, cleaning the backyard of their clinic
The project developed “Guidelines for implementing QI interventions at district and sub- district level”. The purpose of the guidelines is to explain to district level staff the overall quality improvement (QI) strategy of the project and the main interventions adopted by the project to contribute to improving the quality of MNCH/FP/N services. The guidelines also provide instructions for district level staff on how to implement different QI interventions in their respective districts. It includes necessary checklists and tools. The objectives of the guidelines are to: 1. Articulate the overall project strategy for contributing to improving the quality of MNCH/FP/N services in the districts covered by the project. 2. Explain the methods of building the capacity of MoHFW managers and service providers at the district and sub-district levels in using available data and information to analyze causes of poor quality of services and take corrective action in response. 3. Explain the mechanisms for increasing the ownership of implementing the QI process to the project’s counterparts at the district, upazilla, and health facility levels. 4. Explain the various QI interventions adopted by the project and the steps and the tools to implement them in the project covered districts. 5. Articulate the methods for evaluating the impact of the project interventions in improving the quality of MNCH/FP/N services.
The project developed “guidelines for applying basic infection prevention and waste management measures for primary health care”. The guidelines are meant to provide basic information and practical instructions to MaMoni HSS Project staff at the district level to enable them to support their counterparts at the MoHFW in applying basic infection prevention and waste management measures in health facilities. The overall objectives of the guidelines are to:
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 17 1. Prevent infection of patients/clients utilizing the health facilities. 2. Protect staff working in the health facilities from infection. 3. Protect the community from infection and from harmful effects of medical waste. 4. Provide quality of care in general and gain confidence of the community in the effectiveness of provided clinical services.
2.3 Increase Local Ownership of Quality Improvement through establishing (QI) Committees During the reporting quarter, the project facilitated the issuing and dissemination of the Government Order for the establishment of QI Committees as per directives of the MoHFW. The table below includes the number of QI Committees established by level. Table 7: Quality Improvement Committees Formed District Organizational Level Committees Facility Level Committees
District Level Upazila Level DH UHC Noakhali 01 02 (Begumganj & - 03 (Hatiya, Companiganj & Hatiya) Begumganj) Lakshmipur - - 01 - Jhalakathi 01 - - 03 (Rajapur, Nalchity & Kanthalia)
QI committees were established as per Government Order (GO). The Government Order was shared and discussed with the district’s Civil Surgeon and DDFP and under their leadership the district and upazilla managers were invited to a meeting to share the composition and scope of work of the QI committees in each level.
2.4 Strengthening routine supervision system and promoting supportive supervision: The project built on the existing routine supervision system and structures established by the MoHFW at the district and sub-district levels. The project contributed to ensuring the conduction of regular supervisory visits covering all facilities at the district and sub district levels through joint supervisory visits (JSV) involving project staff and MoHFW district and Upazilla level supervisors. In addition, the project promoted the concepts of supportive supervision for quality improvement and problem solving and the use of structured supervisory checklists to ensure the completeness and the objectivity of the supervisory visits and to document status of service coverage and quality. The project put emphasis on assisting the MoHFW officials in summarizing and using the results of supervisory visits and taking action for improvement and recognition of improved services. The specific activities supported by the project to strengthen routine supervision included: • Conducting Joint Supervisory Visits (JSV): MaMoni HSS Project supported the district level health managers in establishing and implementing a schedule for supervision. The table below includes a summary of the JSVs planned and accomplished during the reporting period.
18 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1
Table 8: Joint Supervision Visits conducted in high intensity districts
1st Line (Union) 2nd Line (Upazila and District) Districts Planned Accomplished Planned Accomplished
Habiganj 61 54 68 43
Jhalakathi 16 16 08 09 • Lakshmipur 20 19 10 05 • Noakhali 18 13 08 04 • Total 115 102 94 61 Promo ting Supportive Supervision and using structured supervision checklists: The main purpose of supportive supervision is to utilize the routine supervision system for capacity building of service providers, quality improvement, and problem solving. To ensure the objectivity of the supervisory visits and to guide the supervisors in conducting comprehensive assessment of services, the project developed checklists for first line supervisors at the union level, such as Family Planning Inspectors and Health Inspectors, and second line supervisors at the district and upazila levels, such as Civil Surgeon, Deputy Director Family Planning, and Medical Officers. The checklists cover the following topics: Facility management, infection prevention, waste management, antenatal care, normal vaginal delivery, postnatal care, and family planning services. Checklists prompt supervisors to obtain information by direct observation of services, interview of services providers, review registers, and interview of clients.
Table 9: Summary and Action Points at 2nd Line JSV; Jhalokathi district Summary of Recommendations
• BP Machine, weight measuring tape is not available at satellite clinic • Hb & Albumin strip is not available at UH&FWC • BP & Weight not measured at UH&FWC in case of Ante-Natal Care (ANC) • DDS Kit supply is not available at UH&FWCs • UH&FWC Performance board was not updated.
Summary of Actions taken: • Shared with district level managers since most of these are out of order • Discussed with MO-MCHFPs for ensuring the supply (Hb & Albumin strip) • Discussed with FPI & UFPO for ensuring the supply (BP & weight machine) • Communicated from the DDFP office to the DRS for ensuring supply of DDS kits • Shared with FPI for updating performance board
The project puts emphasis on the utilization of the results of the supervision for QI. Hence, the project facilitates the development of summary findings and action plan for improvement for each JSV. The following are examples of findings and action plan developed in Jhalokathi and Lakshmipur districts.
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 19
2nd line JSV by Civil Surgeon at Mohammadpur FWC, 1st Line Supervisor Visit (JSV) at Satellite at Kanthalia, Subarnachar, Nokhali Jhalakathi
Table 10: Common Findings and Action Plan of JSV, first line supervisor, Lakshmipur Findings Action Plans DDS Kit supply not available Being monitored, not yet available at District Regional Store Family Health Cards were not distributed by FWA and FPI provided orientation on the spot, and shared at FP FWV but supply was available to them monthly meeting FWA was not present in CMPM meeting Discussed with FPI and UFPO in Union Follow Up meeting and monthly coordination meeting FWA was absent at last two cMPM meetings Shared with FPI and UFPO. Update to be provided at Union Follow Up meeting FWV did not use daily activity report sheet of satellite On the spot orientation clinic in the MNC register UH&FWC performance board was not updated FPI committed to update performance board FWA register not found during home visit, satellite UFPO emphasized this at the monthly coordination clinic and cMPM meeting meeting
2.5 Maternal Perinatal Death Review (MPDR): After early implementation phase of MPDR in Begumganj upazila of Noakhali district, MaMoni HSS took the initiative to scale up the initiative in the three high intensity upazilas of Noakhali district with the technical assistance from CIPRB. For scaling up MPDR in rest three upazillas (Companiganj, Senbagh & Hatiya) of Noakhali, MaMoni-HSS intended for capacity building of GOB & project staff. As per implementation plan, sensitization/orientation on MPDR has been completed followed by TOT and training at field level in a cascade manner.
20 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 Orientation/Sensitization Meeting: This orientation/sensitization meeting was conducted in the presence of upazila level managers from health and family planning wings at district level. The meeting was chaired by Civil Surgeon (CS). A total of 27 personnel were oriented/sensitized on MPDR. Among the personnel 21 were men and 6 were women.
Capacity Building: the capacity building process was designed in two layers: 1. Training of the Trainers (TOT): TOT on Death Notification (DN) and Verbal Autopsy (VA) 2. Training of GOB staff: The master trainers developed during TOT act as facilitators for next stage field level training on Death Notification (DN) and Verbal Autopsy (VA) During these two layers of training, 23 (19 men & 4 women) master trainers were developed from district and the rest from three upazilas (Senbagh, Companiganj, Hatiya). Those master trainers trained 162 GOB, Project & Other NGO staff on Death Notification and Verbal Autopsy by phase.
Table 11: MOH&FW staff trained on MPDR in this quarter
Batch # Training Name Duration Venue Category of participants Participants Total (Days) M F
01 TOT on Death Notification 01 CS Office UH&FPO, UFPO, MOCS, MODC, 19 04 23 & Verbal Autopsy under Consultant Gynae, Consultant MPDR Paedi, FCQA, M&E Officer and Project Staff
08 Training on Death 01 Upz Health UFPA, Statistician, HA, FWA, 64 78 142 Notification (DN) under Complex CHCP, NGO worker, FSO MPDR hall room (Compani- 01 Training on Verbal 02 ganj & HA, AHI, FPI, TO, UFPA, 18 02 20 Autopsy (VA) under Senbagh) Statistician, NGO worker, SI, MT- MPDR EPI
Performance at Begumganj upazila: After necessary training, MPDR activities started from 3rd quarter of Year Two. As of October –November 2015 the summarized MPDR activities are as follows:
Table 12: Status of Death Notification (Oct – November 2015): Activities Maternal Death Neonatal Stillbirth Death Number of deaths 03 38 08 Death Notification at community level 03 36 07 Death Notification at Facility Level Upazila Health Complex; Begumganj upazila 00 00 00 MCWC; Begumganj upazila 00 00 00
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 21 District Hospital; Noakhali 04 56 46
Table 13: Status of Death Reviewed at Community and Facility Level (Oct – Nov 2015): Activities Maternal Death Neonatal Stillbirth Death Verbal Autopsy (VA) 01 09 04 Social Autopsy (SA) 00 00 00 Facility Death Review (FDR) 04 04 04
Upazila and District Level Review & Sharing of MPDR Findings: After collection of data on MPDR, the analyzed findings (after death review) were shared and discussed with upazila level managers. The 2nd sharing meeting was accomplished as per plan.
Table 14: MPDR Review Meetings this quarter Activity Male Female Total
Upazila MPDR Review Meeting 07 04 11
District MPDR Review Meeting - - -
Grand Total 07 04 11
2.6 Establishing and supporting Regional Roaming Quality Improvement Team (RRQIT) to strengthen comprehensive emergency obstetrics and newborn care The project utilizes the technical capacities available at the regional level, such as medical colleges and professional bodies, to provide technical support to the service provision of MNCH/FP/N programs at the district level. During the reporting quarter, RRQIT was established in the Barisal division. A meeting was organized on Barisal Regional Roaming Quality Improvement Team (RRQIT) Orientation and Planning at the Divisional Health Training Center, Brown Compound, Barisal on 16th November 2015. The purpose of the meeting was to share the RRQIT concept and supervision checklists on 11th December 2014 at national level. As per the decision from that meeting, one sharing meeting was conducted in Sylhet Division and then in Barisal Division – a strategic approach to improve quality of care (QoC) through supportive supervisory visits by an integrated technical team consisting of DGHS, DGFP, professional organizations, and active NGOs in MaMoni HSS project areas. In addition, the project continues to work closely with MoH&FW in 6 districts (Habiganj, Noakhali, Lakshmipur, Jhalokathi, Pirozpur and Bhola). This RRQIT meeting was conducted with the following objectives: • Share the Integrated Quality improvement approach of MaMoni HSS Project • Share RRQIT concept and its modality • To agree on a mechanism of coordination among the stakeholders at the regional level • Formation of RRQI team in Barisal division
22 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 • Sharing the checklist and feedback • Finalize date for 1st Barisal RRQIT visit at district level and below
The meeting was chaired by Dr. Binoy Krisno Biswas, Divisional Director- Health, Barisal Division. Dr. Basudev Kumer, Das, Asst. Director-Admin, Director Health office, Barisal, and Dr. Najmul Haque from the National QI Secretariat were present as the special guests.
In addition, during the reporting period, the Table 15: Gaps Identified by RRQIT at first RRQIT visit of Jhalokathi was Jhalokathi DH th conducted on 30 of December 2015. Four • DH was upgraded as 100 bed hospital 5 years RRQIT members were present at the visit. back, patient load remains at 140 but the The team identified the main gaps in manpower & supplies are for 50 beds. DH&MCWC. • Even though the post are not filled like out of 14 MO only 9 medical officers are posted. No Because of poor infection prevention and Emergency Medical Officer, no outdoor medical control practices, overall quality of care is officer. not maintained. • Nurses are 35 out of 40. No Statistician, gate keeper, night guard, ward boy, or aya. In Jhalokathi MCWC, infrastructure and • Only 4 cleaners post are there for the huge task. maintenance is satisfactory. Only staff is • Only one autoclave for the whole DH; 3 sterilizers clinic MO and 3 FWVs. There is no regular are out of order among 4; 3 GA machines are out of anesthetist there, so EmOC services are order among 4; OT lights are out of order; sucker highly restricted. They are managing only machine are not working. daytime C/S by anesthetist from DH and the • No emergency fund is available for small repair. • total number of C/S is only 10. CMSD’s role is not satisfactory.
Neonatologist is reviewing records in visit Representative from OGSB filling the checklist in OT
2.7 Strengthening Logistics MIS National level activities • A meeting with Director of Primary Health Care (PHC) was arranged for proper coordination with DGHS for planning, procurement and supply system of essential 25 tracer drugs. The Director shared that DGHS is going to procure the medicines as much possible according to the availability of budget.
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 23 • A meeting with SIAPS was arranged to track and monitor 25 essential drugs using the supply chain management portal. SIAPS is going to complete the training on LMIS in the remaining 10 districts by December 2015 and complete accordingly. The training included the proper maintenance of drugs in the store with proper documentation.
District Level Activities The project implements a basic system to assist local authorities at the district level to use local data to track the availability of essential MNCH drugs and family planning commodities. The project collects data on the availability of 25 drugs that were deemed by the MOHFW as essential for MNCH programs. The project conducts simple analysis and uses a visual color-coded dashboard to share results with relevant decision makers at the district level to stimulate discussion and identify actions to be taken to avoid stock-outs. In addition, the project uses the information available online regarding family planning commodities to track and ensure their availability. Among the QI interventions, utilization of logistics data to monitor and improve availability of essential drugs is included. Until last quarter (September 2015), data on the 25 tracer drugs were being collected only from Lakshmipur and Noakhali Districts as trainings on LMIS were done by SIAPS in these two districts a few months back. Logistics related reporting in Noakhali and Lakshmipur included Monthly Medicine Supplies and Commodities Report, in addition to Inventory Control Registers, which are usually maintained in other districts. Data has been further summarized in Appendix 3.
2.8 Strengthening Medical Waste Management A team composed of MaMoni HSS staff and PRISM conducted an initial assessment of waste management of Lakshmipur hospital. The current waste management procedures of the hospital are unacceptable with major gaps. However, some improvement was noticed as the hospital is establishing waste dumping pits (with support of the project). The Municipality is taking part in transporting some of the Lakshmipur waste to a landfill outside the city. On visiting the landfill, we found the situation unacceptable as the waste is basically dumped on the side of a road (this visit was conducted with the Mayor of Lakshmipur Municipality). After discussion, the Mayor of Lakshmipur municipality dedicated land owned by the municipality for the purpose of establishing a medical waste management plant. The team visited the site, which was adequate and suitable. A partnership development meeting was held at the office of the Deputy Commissioner, Lakshmipur District. Participants included Deputy Commissioner, Civil Surgeon, Deputy Director Local Government, Secretary District Council, and other officials. The meeting included a couple of presentations by MaMoni HSS and PRISM followed by discussion. The conclusion of the meeting is that the situation of medical waste management needs attention and requires a partnership of MoHFW (CS), Municipality, community, private sector, and facilitation of MaMoni HSS. The leadership of Lakshmipur is committed to improving the situation as demonstrated by allocating land for the purpose of establishing a medical waste management plant. Next steps: PRISM will develop a draft concept note including what is needed to establish a waste management plant (land, which had already been allocated by the Mayor, construction, equipment, supplies, staff, training, and preliminary cost estimates). MaMoni
24 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 HSS will discuss the concept note with PRISM and USAID to determine feasibility and roles and responsibilities. A follow up meeting to discuss roles and responsibilities, developing a Memorandum of Understanding with municipality, and develop a plan of action with Lakshmipur officials.
Dumping pits being built at Lakshmipur Meeting on building partnership for MWM, District Hospital Lakshmipur District
2.9 Monitoring Quality of Care Indicators
In an effort to track progress in improvement of quality of services, MaMoni HSS has developed a system for monitoring Quality of Care (QoC) indicators that provides regular and efficient data collection and management mechanisms to track the quality of essential MNCH/FP/N services according to national standards.
Data are collected from a sample of randomly selected health facilities and satellite clinics from four MaMoni HSS project covered districts (Habiganj, Noakhali, Lakshmipur, and Jhalokati). The sample includes health facilities at different levels (district, Upazilla, Union, and satellite clinics). The table below summarizes the sentinel heath facility sampling pattern per district.
Table 16: Number and Category of Health Facility Sentinel Sites and Satellite Clinics per District Category of Health Facility No. of Facilities District Level (DH/MCWC) 1 UHC 1 UH&FWC 4 Satellite Clinic 4 Total sites / district 10
The QoC indicators are measured through data collected mainly by the QI team in each district including QI Manager, Field Coordinator QI (FC-QI), Logistics Officer, and Technical Officer (TO). Additional qualified data collectors, with medical background (such as paramedics), have been recruited by partner NGOs to assist with data collection.
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 25
Data collectors have been trained by the MaMoni HSS project on the use of data collection tools, developed by the project. Data collection is performed by direct observation, record review, interview of health facility staff, or simulation and exit interview of clients. MaMoni HSS staff will monitor the process of data collection to ensure quality. The project is planning to conduct this QoC survey twice a year. The first round of data collection started in September 2015. Analysis of the first round data is underway,
2.10 Local Government engagement to improve quality of service MaMoni HSS has engaged Union Parishads to allocate budget to improve quality of service. This included investments in facility cleanliness, supplies for infection prevention and waste management.
Table 17: Union Parishad budget allocated in FY’15-16 to improve coverage and quality of service District Total UP allocated UP allocated UP utilized Investment areas UP budget for budget for budget for MNCHFPN MNCHFPN MNCHFPN (BDT.) (Oct.-Dec) (BDT.) Habiganj 77 76 7,320,159 538,060 Medicine, Solar Panel, Newborn dress, facility Minor Noakhali 44 44 5,497,455 595,641 repairing, cord clamp, chair for Lakhsmipur 58 58 4,832,940 49,800 EPI centre, Water Pump for UH&FWC, EPI center Jhalokathi 32 32 2,729,169 13,000 renovation, FWC Construction, Total Temp. staff cost, Referral cost 211 210 20,379,729 1,196,501 etc
2.11 Support MOH&FW to roll out paper-based RHIS
MaMoni HSS supported DGFP MIS unit to roll out the “Training on FWA Register (8th edition) and MIS Forms” in the project districts. All the FWAs, FPIs, FWVs, SACMOs (DGFP) and concerned project staff received the training. The trainings were organized at respective upazilas in batches. DGFP Dhaka and upazila level resource persons (UFPO & MO-MCH) along with the project staff facilitated the training. The field workers will be using these new MIS tools from January 2016.
26 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1
IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems
3.1 Journalist Engagement Since October 2015, MaMoni HSS organized a numbers of journalist visits in different locations of its project area with a special focus to ensure optimum earned media coverage on MNCH/FP/N. As a result of broader MaMoni HSS media advocacy, 25 news stories have been published by different media outlets (Appendix 9). The news /stories includes: issue- specific current situation, case studies, and technical information with calls of actions for required health system improvement. Following the initial journalist trainings, a long-term follow up activity has been established to ensure that the trained journalists puts into practice what they have learned through this training. The reporters are well connected with local project office personnel who always help them to improve reporting and troubleshoot ideas. The media engagement and capacity building program has been delivering a significant increase in media coverage on MNCH/FP/N issues and increased engagement of involved stakeholders. Representatives from the multiple government ministries/directorates, and non-governmental partners have been deeply involved in the program. This contributes to immensely facilitating closer collaborations across organizations and resulted in both increased dialogue and news coverage.
3.2 Observation of World Prematurity Day In Bangladesh, each year 450,000 thousand babies are born premature and over 31,000 thousand of them die, contributing 45% of the total newborn deaths. World Prematurity Day this year was observed with much attention and importance as Bangladesh is passing through a critical juncture when it comes to newborn survival. MaMoni HSS Project and Saving Newborn Lives (SNL) program of Save the Children is closely working with DGHS of MoH&FW to introduce KMC in a number of Upazila Health Complexes and District Hospitals in its project areas. As an activity to observe World Prematurity Day, MaMoni HSS, DGHS and SNL jointly organized a national level round table discussion and a seminar to mark the day on November 16 and 17, 2015. This round table discussion and the seminar highlighted the burden of prematurity and advocates for KMC as a key intervention. Participants from different backgrounds attended both the seminar and the round table discussion and created a scope of mutual sharing and understanding. Everyone also stressed the need that we can change the scenario of newborn death through our sincere effort and determination. The participant profile of both the events included health and family planning officials, medical professionals, professional bodies, Ministry of Planning, NGOs, journalists, etc.
3.3. Engagement of the Parliament
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 27 The yearly review meeting of the Parliamentary Caucus on Child Rights (PCCR) was held on 7-8 December, 2015 with the participation of PCCR members. The honorable Deputy Speaker of the Bangladesh National Parliament, Advocate Fazle Rabbi Miah, MP, chaired the meeting while Mr. Mir Sowkat Ali Badsha, MP moderated the meeting session as the PCCR chair. In order to address the goal of ending the preventable maternal child and child maternal deaths, the meeting had a very interactive discussion and produced future directions and actions. The health related discussion was mostly focused on “Ending preventable maternal and child and maternal deaths: Parliamentarians role and responsibilities”. The meeting asked the parliamentarians to be a champions for children and mothers, allocation of human resources and facilities for universal health coverage, and strengthening primary health care, and also stressed that allocation and efficient budget is essential for quality health services and well as strengthening the governance factor of program implementation. The meeting also emphasized on the inequity in health indicators across the country and requests to focus on a process that could address the high inequity in Bangladesh.
3.4 Program learning initiatives undertaken and disseminated MaMoni HSS participated in two TRAction dissemination meetings where lessons from MaMoni I and MaMoni HSS implementation were shared on identification and management of pre-eclampsia/eclampsia in remote areas of Bangladesh, and assessment of referral mechanisms in a remote district of Bangladesh. A third TRAction collaboration, “Assessing effectiveness of targeted approach for neonatal health and family planning services in Bangladesh” was disseminated on January 18, 2016. In Year Two, a total of five operation research (OR) efforts were approved for program learning purposes on: the use of partograph as a decision-making tool for identifying and referring complicated pregnancies; viability of private CSBAs; assessment of the quality of ANC at satellites and identification of the challenges; assessment of quality of permanent methods for family planning services provided at public health facilities; and experience of CHX pilot implementation. The results from the partograph study and the private C-SBAs were shared in the International Federation of Gynecology and Obstetrics (FIGO) conference in Vancouver, Canada in October 2015 (refer to the posters in the figure 7 below).
MaMoni HSS also collaborated with TRAction to conduct baseline data analysis on 24/7 delivery and EmONC services in public facilities by health systems strengthening in Bangladesh. Areas covered in the analysis included availability of infrastructure, essential drugs and equipment for MNH services, availability of human resources based on sanctioned post, utilization of care, and availability of different service providers for MNH care. Findings were shared with the project’s national team in August 2014. The study will continue until to June 2016.
Figure 7: Posters presented at the International Federation of Gynecology and Obstetrics (FIGO) annual conference in Vancouver, Canada on October 6, 2015
28 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1
IR 4. Identify and Reduce Barriers to Accessing Health Services
4.1 Community mobilization and BCC activities to remove barriers MaMoni HSS facilitated the monthly cMPM meetings involving CVs, frontline health workers (HAs, FWAs, CHCP), and their supervisors (FPIs; AHIs), to update the information on eligible couples, mothers, and children, and to follow up on drop-outs. During October–December 2015, 96% of the cMPM were held in 23 high-intensity upazilas. The project supported BCC teams to conduct targeted BCC campaigns on prioritized MNCH/FP/N messages, reaching 397,818 people. These campaigns delivered a number of BCC messages, which were prioritized at the upazila level. MaMoni HSS trained 19,982 CVs on FP counseling and compliance. These volunteers were unpaid, and worked as an extension of the FWVs and FWAs in reaching the mothers with critical information.
4.2 Reaching mothers through Aponjon services Average monthly registration has gone up by 6% with the introduction of Aponjon’s own sales force in this quarter. Aponjon registered its 1,501,656 clients on December 31, 2015. Table 18: Registrations during October-December 2015 (as of 19th December) Subscriber Type October November December Total
Primary Subscribers
Expecting Mothers 7,485 9,616 9,815 26,916
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 29 New Mothers 19,305 19,006 23,856 62,167
Secondary Subscribers (Gatekeepers)
Husbands 1048 908 779 2,735
Mother In-Laws 18 17 4 39
Mothers 48 65 18 131
Other Relatives 208 202 230 640
Total 28,112 29,814 34,702 92,628
The proportion of Interactive Voice Response (IVR) and SMS recipients this quarter hasn’t changed much since the last quarter. Previously, 10% of new subscribers were IVR recipients as opposed to 12% in this quarter. This upsurge of SMS recipients in new acquisition could be possibly attributed to the expansion of our acquisition activity in urban areas over the last 6 months. Moreover, the proportion of secondary subscribers (gatekeepers) in quarterly acquisition has crept up to 4% from 2% in the last quarter.
Major contributors of registration in this quarter have been MCC, Aponjon Salesforce, and BRAC in descending order.
Figure 5: Sources of Acquisition in this quarter
Acquisition between Oct-Dec 2015
BRAC 14872
SMC 107
Smiling Sun 540 Outreach TothyoKollyani 1456 IMS 2 MCC 54218
Agency RELATION 2
Self Registered 116
Aponjon salesforce 19050 Other Call Center 1584
Figure 6. Activity of call center at a glance
30 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 Call Center Activities 14000 11769 12000 10968 9564 10000 8377 7384 8000 6903 6000
4000 2116 2151 2536 2000 149 0 154 0 139 0 0 October November December
Call from subscriber Incoming call Outgoing call DOB update Data Entry
Note: Date of birth (Dob); Short message service (SMS)
4.3 Birth registration conducted through HA/FWA and Union Parishads MaMoni HSS is implementing an improved system for coordination between frontline health workers and the LG. In this quarter, births registered through health assistants via EPI sessions was 34.8% in Begumganj and Kamalnagar upazilas, as recorded in the online civil registration and vital statistics (CRVS) data of the government. Currently, the HAs send birth notifications after EPI sessions, usually 45 days after a birth. Thus newborn deaths are not recorded in the CRVS system. MaMoni has been providing input to ensure that the birth notifications occur during the newborn period.
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 31 CHALLENGES, SOLUTIONS, AND ACTION TAKEN
Challenges • Staff transition: In this quarter, the Director General of Family Planning, the Director of, MIS, DGFP, the Civil Surgeon of Noakhali and Habiganj, and UH&FPO of Hatiya were transferred, creating a continuity challenge for the advocacy and sensitization work of the project. MaMoni has developed plans to sensitize the new officials and obtain their support for the project. • Drug shortage: The DDS kits of UH&FWCs and the drug supply of the community clinics have been interrupted since September 2015 due to procurement issues at DGHS and DGFP. This has severely affected the coverage and quality of essential services at the community level. MaMoni HSS has been closely monitoring the situation, and where appropriate, has been liaising with the Union Parishads, Ministry of Social Welfare funds to leverage temporary support to meet the shortfall for drugs and supplements such as oxytocin, IFA, and misoprostol. • DGHS procurement of Chlorhexidine for national scale up has been delayed. Beyond high intensity districts, MaMoni prepared the service delivery mechanisms, but wasn’t able to roll out the intervention as planned. The drug was finally delivered to CMSD in January 2016.
Opportunities • The Directorate of Nursing Services (DNS), with support from UNFPA, is training registered nurses on a six month, post-basic certified midwifery training as well as a direct entry midwifery track. A total of 1,476 nurses will receive the ICM standard midwifery training. To date, 600 have already been posted to UHCs and UH&FWCs and another 600 will be posted in 2016. This presents an excellent opportunity for MaMoni HSS to advocate for placing the midwives to UHCs and UH&FWCs. The project has initiated discussions with UNFPA and DNS to prioritize Category A and B UH&FWCs for the posting of these midwives. • The Director General of Health Services is prioritizing the posting of anesthesiologists and gynecologists to UHCs that are designated as CEmOC facilities. Based on the project’s advocacy, DGHS has now posted consultants to seven of the UHCs in project areas. This presents an opportunity to strengthen CEmOC services at these UHCs. The MOH&FW has also made a decision to increase the number of seats for anesthesiologist training to meet the future needs.
32 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 APPENDIX 1: CASE STUDIES AND SUCCESS STORIES A.1.1 Crash program at char abdullah, Ramgoti, Lakshmipur brings much needed services to a remote island
Char Abdullah, a remote island off Lakshmipur mainland has a population of 9,000. It doesn’t have any middle school, therefore, the education level is quite low. The island also does not have any formal health facility with staff in residence. There’s one community clinic, Char Gazaria, but the CHCP do not reside as it is not very safe for providers to stay at night. MaMoni supported UH&FPO and UFPO to undertake a crash program to bring services to this EPI being provided by Mahmudul Hasan, island. Two separate satellite clinics were held Health Assistant simultaneously. A total of 37 mothers came for ANC service in just one day. Among the pregnant women was Rokeya Begum, 32, and pregnant for the seventh time. Two of her children died right after birth. A woman in her neighborhood died last month during labor. This is the first time she actually received any health service in her life. She was happy to receive iron tablets, and received advice that she needs to gain weight for her baby. 500 people came to see the video show. Since they don’t have electricity, for many, this is the first time they have seen a health related video. The community members, and union parishad chair requested the government providers to come back once a month, so that people, particularly children in their area, could receive services and not die from preventable causes.
A.1.2. Delivery reports from Private clinics of Noakhali
Noakhali Sadar has 62 private clinics. It has been difficult to get a reasonable estimate of deliveries conducted at a facility because the public sectors share is quite low. During the quarterly performance review meetings, it was decided that the Civil Surgeon will invite private clinics to submit reports on essential MNH information. In a meeting supported by MaMoni HSS in October 2015, 18 private clinics participated and committed to submit the report. In the month of November 2015, 14 clinics submitted a report using a reporting tool developed by Sample report from private clinic MaMoni. The highlights of their report is as below:
Table 19: Performance Report from 14 clinics, Nov 2015
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 33 Upazila Number Complication Delivery Outcome Deaths admitted Normal C -Sctn Total Live Still Maternal Newborn Birth Birth deaths deaths Sadar 810 16 170 633 803 791 19 0 2
A quick calculation shows 79% of all deliveries were conducted via C-section. This is an important information for program decision making, and community referral.
A.1.3 Collaboration with BRAC to support community micro-planning in Pirozpur
In Pirozpur district, Brac, the Bangladeshi NGO, has been implementing an integrated maternal, newborn, child survival (IMNCS) program since Jan 2013. However, the program was not aligned with the government program. MaMoni HSS project entered into an MOU with Brac so that in Nazirpur and Bhandaria sub-districts, Brac will carry out the community engagement activities through Shastha Shebikas (SS), or volunteers, following MaMoni HSS model. Here, Brac Shastha Shebikas have maintained surveillance of their catchment areas of 750 people, and have been participating in community micro-planning (cMPM) meetings to support government outreach workers (FWA, HA and CHCPs) update their information system.
100 88 80 81 78 81 100 80 79 80 81 81 71 75 73 74 75 72 77 76 75 68 68 66 71 67 50 50
0 0 Bhandaria Nazirpur Bhandaria Nazirpur
June'15 July'15 August'15 June'15 July'15 August'15 Sept'15 Oct'15 Nov'15 Sept'15 Oct'15 Nov'15
Figure 20.a: Percentage of cMPM meetings held in Figure 20.b Percentage of cMPM meetings where BRAC areas Shastha Shebikas were present
Figure 20 shows that the model is working, as over three fourths of cMPM meetings are being held as planned, and SS presence has been steady over a period of six months, as government and Brac workers are finding the activities to be mutually beneficial. In this quarter, Brac is scaling up this model to cover the entire Pirozpur district using their own funds, with only minimal technical support from MaMoni HSS.
34 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1
Figure 21.a A Shastha Kormi, Brac supervisor Figure 21.b Community microplanning meeting with reviewing the action plan of a SS Brac SS
A.1.4. how JSV visits led to concrete actions: two case studies
JSV Case I: Md Abdul Hamid, UFPO (in charge) of Bahubal Upazila, conducted a Joint Supervision Visit (JSV) on October 04, 2015 at Satellite Clinic of Lamatashi Union. Nurunnahar, FWV, was conducting the satellite clinic as per plan. Using the JSV checklist Md Abdul Hamid observed the services provided from the satellite. FWV was providing ANC services without examining urine and without estimating hemoglobin, and wasn’t maintaining records in the MNC register properly. On the basis of these findings Md Abdul Hamid provided feedback to use all ANC logistics in every ANC checkup and to keep the records properly in the MNC register. Subsequently, a Technical Officer of MaMoni HSS Project conducted a follow-up visit to the FWV and found her using ANC logistics in satellite clinics and maintaining the MNC register.
JSV Case II: Md. Samsul Haque, FPI of Kakailseo union under Ajmiriganj upazila conducted a Joint Supervision visit on 18th November 2015 at a satellite clinic of his working area. Israt Jahan, Paramedic, was conducting the satellite clinic as per plan. Using JSV checklist Md. Samsul Haque observed the service provider form satellite clinic. This satellite clinic was attached with the EPI session. Md Samsul Haque discussed with the clients regarding services. Pregnant women were coming for the ANC services but they were not comfortable because there was no privacy. As toilet facility was not available in the place of satellite clinic, urine test was not done in this satellite clinic. In this regards, Md. Samsul Haque, FPI, shared this issue with the UFPO to shift the satellite clinic in a suitable place adjacent to the EPI center. Md. Samsul Haque shared this issue with the community people and managed a suitable household with toilet facility adjacent to EPI center. Now the Satellite clinic has been shifted to the selected house.
A.1.5 An Upazila Health and Family Planning Officer (UH&FPO) in Kathalia Upazila, Jhalokathi making a difference
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 35 Dr. Zafor Ali Khan took charge of Kathalia Upazila Health Complex as UH&FPO three years ago, and turned the health facility around through his leadership and support from MaMoni HSS. He received leadership and management training from HRCI project. Kathalia UHC, a 50 bed hospital, has several disadvantages in terms of location and was thus underutilized. It is not located in Kathalia Sadar union, but rather in Amua union, further away from the central part of the upazila. For most
Photo: Dr. Zafor Ali Khan at Amua UHC of the unions of this upazila, going to this UHC is a burden, as the referral facilities, Jhalokathi district hospital, and Barisal Medical College are located in the opposite direction. The UHC was also short staffed, lacked proper staff quarters, essential supplies, water supply and necessary medicine. Dr. Khan has taken several steps to improve quality of service. The only tube well inside the hospital premises was broken. He installed one tube well from LGSP funds, and two more through local fundraising. From the open budget process of the local government, he raised 500,000 for the UHC, which he is using to set up proper pits. With the support of the Upazila Chairman Faruk Shikder, he has also repaired one of the two ambulances placed at the UHC, used in November to transport 3 women to Barisal. He is in the process of raising 65,000 for repairing the newer ambulance, which requires a control box. Dr. Khan also obtained 80,000 ccs of saline solution from the social welfare fund of the Ministry of Social Welfare, as this was a persistent shortage in his facility. Dr. Khan is taking active steps to ensure delivery services, and retain staff. He worked with the local authorities to repair the nurses’ dormitory, and construct a mosque inside the premises for hospital staff. Kathalia UHC is a designated EmOC facility, and five deliveries by Cesarean section occurred in the one month in FY’15, but the service has stopped as the gynecological consultant was transferred, and a replacement is not present at the moment. Dr. Khan recognizes that, for the agricultural dependent community of Amua, it is not often possible for mothers and children with complications to reach Barisal medical college (75 minutes away) on time. Dr. Khan is working tirelessly to ensure that no one leaves the facility without receiving proper care, and is confident that the partnership with local government and MaMoni can go a long way to achieve that.
36 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 Appendix 2: Program Performance Indicators (October–December 2015)
Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) Project Goal: Improve utilization of integrated maternal, newborn, child health, family planning and nutrition services Percent of women received at least one antenatal care visit from a medically trained provider High intensity areas
Lakshmipur 69 NA Next round of data from Noakhali* 64 NA Population based Survey: Round III: Tracer indicators will be Habiganj 75 NA available in Q2 report in April Jhalokathi 71 NA 2016
NA Pirozepur* 69
HSCS areas
Pirozepur NA NA MaMoni will conduct the next Bhola NA NA round of population based survey for the HSCS areas in FY'17 Noakhali NA NA
Percent of births receiving at least four antenatal care (ANC)
visits during pregnancy High intensity areas
Lakshmipur 24 NA Next round of data from Noakhali* 24 NA Population based Survey: Round Habiganj 30 NA III: Tracer indicators will be Jhalokathi 46 NA available in Q2 report
Pirozepur* 33 NA HSCS areas
Pirozepur 42 NA MaMoni will conduct the next Bhola 21.5 NA round of population based survey
Noakhali 19 NA for the HSCS areas in FY'17
Percent of Births Attended by a Skilled Doctor, Nurse or Midwife High intensity area
Lakshmipur 39 NA Next round of data from Noakhali* 32 NA Population based Survey: Round Habiganj 34 NA III: Tracer indicators will be Jhalokathi 47 NA available in Q2 report
Pirozepur* 45 NA
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 37 Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) HSCS areas
Pirozepur 46 NA MaMoni will conduct the next Bhola 27 NA round of population based survey
Noakhali 35.5 NA for the HSCS areas in FY'17
Percent of women with home Source: Population based Survey: births who consumed Round III: Tracer indicators (Nov misoprostol to prevent 2015 - Mar 2016) postpartum hemorrhage High intensity areas
Lakshmipur 20 NA Next round of data from Noakhali* 20 NA Population based Survey: Round Habiganj 40 NA III: Tracer indicators will be Jhalokathi 47 NA available in Q2 report
Pirozepur* 37 NA HSCS areas
Pirozepur 28.5 NA MaMoni will conduct the next Bhola 20 NA round of population based survey
Noakhali 15 NA for the HSCS areas in FY'17
Percent of newborns initiated breastfeeding within one hour
after birth High intensity areas
Lakshmipur 71 NA Next round of data from Noakhali* 67 NA Population based Survey: Round Habiganj 85 NA III: Tracer indicators will be Jhalokathi 62 NA available in Q2 report
Pirozepur* 57 NA HSCS areas
Pirozepur 53 NA MaMoni HSS will conduct the next Bhola 65 NA round of population based survey
Noakhali 73 NA for the HSCS areas in FY'17
Percent of newborns received chlorhexidine application on their umbilical cord immediately following birth High intensity areas
Lakshmipur 25 NA Noakhali* 25 NA Next round of data from Population based Survey: Round Habiganj 25 NA III: Tracer report Jhalokathi 25 NA Pirozepur* 25 NA HSCS areas
Pirozepur - NA - MaMoni will conduct the next
38 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) Bhola - NA - round of population based survey Noakhali - NA - for the HSCS areas in FY'17 Percent of newborns receiving postnatal health check within
two days of birth High intensity areas
Lakshmipur: 17 NA Next round of data from Noakhali:* 18 NA Population based Survey: Round Habiganj: 29 NA III: Tracer indicators will be Jhalokathi: 30 NA available in Q2 report
Pirozepur:* 10 NA HSCS areas
Pirozepur: 7 NA MaMoni will conduct the next Bhola: 7 NA round of population based survey
Noakhali: 17.5 NA for the HSCS areas in FY'17
Modern contraceptive method prevalence rate High intensity areas
Lakshmipur 51 NA Next round of data from Noakhali* 50 NA Population based Survey: Round III: Tracer indicators will be Habiganj 45 NA available in Q2 report Jhalokathi 55 NA
NA
Pirozepur* 55
HSCS areas
Pirozepur 54 NA MaMoni will conduct the next Bhola 56.5 NA round of population based survey
Noakhali 58 NA for the HSCS areas in FY'17
Couple years of protection (CYP)
in USG-supported programs High intensity areas 748,496 133,134 Lakshmipur 229,858 38,062 Noakhali* 138,470 30,814 Habiganj 221,972 39,607 Jhalokathi 107,178 15,728 Pirozepur* 51,018 8,924 HSCS areas 106,936
Pirozepur 82,734 20,744 Bhola 213,393 59,242 Noakhali 102,721 26,950 Intermediate Result 1: Improve service readiness through critical gap management
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 39 Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) Percent of targeted facilities that are ready to provide
essential newborn care High intensity areas 45 NA Lakshmipur 35 NA Noakhali* 35 NA Source: SDP assessment and training data will be available in Habiganj 85 NA Q2 report. Jhalokathi 35 NA Pirozepur* 35 NA HSCS areas
Pirozepur 10 NA Bhola 10 NA Noakhali 10 NA Percentage of public health facilities with functional bags
and masks (two neonatal size mask) in the delivery room High intensity areas 60 NA
Lakshmipur 60 NA
Noakhali* 60 NA Source: SDP assessment and Habiganj 60 NA training data will be available in Jhalokathi 60 NA Q2 report. Pirozepur* 60 NA HSCS areas
Pirozepur NA NA MaMoni will conduct the next Bhola NA NA round of population based survey
Noakhali NA NA for the HSCS areas in FY'17
Percent of USG-assisted service delivery sites providing family 439 NA planning (FP) counselling and/or services High intensity areas
Lakshmipur 70 NA Source: SDP assessment and Noakhali* 70 NA training data will be available in Q2 report. Habiganj 99 NA
Jhalokathi 70 NA Pirozepur* 70 NA HSCS areas
Pirozepur NA NA
Bhola NA NA
Noakhali NA NA
40 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) Number of targeted facilities ready to provide delivery services 24 hours a day, seven days a week High intensity areas 95 NA Lakshmipur 25 NA Source: SDP assessment and Noakhali* 16 NA training data will be available in Q2 report. Habiganj 35 NA
Jhalokathi 17 NA Pirozepur* 95 NA HSCS areas
Pirozepur NA NA SDP assessment data not Bhola NA NA available for HSCS areas Noakhali NA NA Sub-IR 1.1: Increase availability of health service providers Number of vacant positions filled by temporary non-GOB Paramedic, nurses and doctors health workers High intensity areas 34 40 Lakshmipur 5 11 Noakhali* 7 20 Reason for Variation: MaMoni Habiganj 20 54 plans to reduce temporary health workers in phases in FY'16. Jhalokathi 2 4 In addition to the temporary gap Pirozepur* NA NA against vacant positions, the HSCS areas project has deployed 39 temporary staff to complement Pirozepur NA NA GOB staff in ensuring round the Bhola NA NA close. Noakhali NA NA
Sub-IR 1.2: Strengthen capacity of service providers to provide quality services Number of people trained in maternal/newborn health
through USG-supported programs High intensity areas 6521 1,906 Lakshmipur NA 404 Women 215
Men 189
Noakhali* NA 483 Note: This is appropriate Women 285 according to Annual Workplan
Men 198
Habiganj NA 135 Women 51
Men 84
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 41 Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) Jhalokathi NA 164 Women 68
Men 96
Pirozepur* NA 720 Women 441
Men 279
National level 75,569 17,070 trained on CHX, CNCP, HBB HSCS areas 56
Pirozepur 0 0 NA Bhola NA 665 NA Women 320
Men 345
Noakhali 0 0 NA Number of people trained in
FP/RH with USG funds High intensity areas 5,589 Lakshmipur 0 Women
Men
Noakhali* 0 Women
Men
Habiganj 0 Women
Men
Jhalokathi 0 Women
Men
Pirozepur*
Women
Men
National level
HSCS areas NA
Pirozepur NA
Bhola NA
Women
Men
Noakhali NA
42 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) Number of people trained in child health and nutrition Note: Not planned for this through USG-supported quarter programs High intensity areas 760 0
Lakshmipur
Women
Men
Noakhali*
Women
Men
Habiganj
Women
Men
Jhalokathi
Women
Men
Pirozepur*
Women
Men
National level 25 0 HSCS areas NA 0 Pirozepur NA Bhola NA Noakhali 0
Sub-IR 1.3: Strengthen infrastructure preparedness to improve MNCH service utilization Number of union level public health facilities that are ready to
provide normal delivery services High intensity areas 53 69 Lakshmipur 12 16 Source: Monthly report from high Noakhali* 12 11 intensity upazilas Habiganj 27 26
Jhalokathi 2 16 Pirozepur* 4 6 HSCS areas 4 0
Pirozepur 2 0 Bhola 2 0
Noakhali NA NA
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 43 Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) Intermediate Result 2: Strengthen health systems at district level and below Number of district level quarterly performance review meeting held for data-driven
performance review and planning High intensity areas 24 5 Lakshmipur 4 1
Noakhali* 4 1 Habiganj 4 1 Jhalokathi 4 1
Pirozepur* 4 1 Data expected from QI sentinel Intra partum still birth rate in monitoring. The system is being project assisted facilities established. No data is available for this quarter. <7/1,00 High intensity areas NA 0 <7/1,00 Lakshmipur NA 0 <7/1,00 Noakhali* NA 0 <7/1,00 Habiganj NA 0 <7/1,00 Jhalokathi NA 0 <7/1,00 Pirozepur* NA 0 Sub-IR 2.1: Improve leadership and management at district level and below Number of GOB managers supported for leadership and 40 management capacity development Lakshmipur 10 Noakhali 22 Data not available Habiganj 8 Jhalokathi NA
Pirozepur NA Bhola NA Sub-IR 2.2: Improve district-level comprehensive planning (including human resources) to meet local needs Number of upazilas with updated comprehensive annual Note: Planned in January
MNCH/FP/N plan High intensity areas 23 0 Lakshmipur 5 0
44 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) Noakhali* 4 0 Habiganj 8 0 Jhalokathi 4 0 Pirozepur* 2 0 Sub-IR 2.3: Strengthen local management information systems Percentage of community micro planning units conducting
monthly meeting High intensity area 96 98 Lakshmipur 95 99 Source: Project MIS Noakhali* 95 99 Habiganj 100 100 Jhalokathi 95 99
Pirozepur* 95 81 Sub-IR 2.4: Establish quality assurance system at district level and below Percent of planned supervision visit conducted where a
supervision tool was used and findings shared with providers High intensity areas 90 122 Lakshmipur 90 47 Noakhali* 90 108 Habiganj 90 183 Jhalokathi 90 108 Pirozepur* 90 0 Sub-IR 2.5: Develop comprehensive logistic management systems at district level and below Percent of USG-assisted service delivery points (SDPs) that experience a stock out at any
time during the reporting period of a contraceptive method that the SDP is expected to provide High intensity areas <3 7 Lakshmipur <3 3
Noakhali* <3 6 Habiganj <3 10 Jhalokathi <3 1
Pirozepur* <3 2 Sub-IR 2.6: Strengthen local government planning and engagement in health service provision
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 45 Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) The data was not available. Percentage of unions that had Because of a server crash of CRVS at least 50 percent of the online data. Government online estimated births registered system is not functioning and within 45 days of birth MaMoni HSS did not have access to the information High intensity areas 40 NA Lakshmipur 40 NA Noakhali* 40 NA Habiganj 40 NA Jhalokathi 40 NA Pirozepur* 40 NA Sub-IR 2.7: Improve local governance and oversight for MNCH/FP/N Number of union parishads (UP) that spent funds to support
MNCH/FP/N activities High intensity areas 226 67 Lakshmipur 58 4 Noakhali* 44 17 Reason for variation: LGSP funds were disbursed late, around Habiganj 77 33 September Jhalokathi 32 13 Pirozepur* 15 0 Intermediate Result 3: Promote enabling environment to strengthen district level health system Number of critical vacancies filled by GOB recruitment or
redeployment in project areas High intensity areas 25 Lakshmipur 5 Noakhali* 5 Habiganj 5 3 Doctors deployed Jhalokathi 5 Pirozepur* 5 2 Doctors deployed Sub-IR 3.1: Policy reforms in place to promote local planning and need-based human resource deployment in the public sector Number of policies/ strategies/guidelines on MNH 4 0 Note: None planned in this quarter developed/revised with MaMoni HSS support Sub-IR 3.2: Strengthen advocacy and coordination for adoption of evidenced-based learning in national policy and program Number of program learning Collaboration with TRAction, initiatives completed and 10 3 Ending Eclampsia landscape
disseminated analysis Intermediate Result 4: Identify and reduce barriers to accessing health services
46 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) Number of deliveries with a SBA
in USG-assisted programs High intensity areas 61,440 10,985 Lakshmipur 17,332 3,940 Noakhali* 11,622 1,991 Habiganj 23,580 4,082 Jhalokathi 6,362 607 Pirozepur* 2,544 365 HSCS areas 45,579 5,115 Pirozepur 10,796 1,595 Bhola 1,755 2,229 Noakhali* 33,028 1,291 Number of antenatal care (ANC) visits by skilled providers from 486,499 140,691 USG-assisted facilities High intensity areas 303,839 106,244 Lakshmipur 48,846 26,655 Noakhali* 39,468 23,012 Habiganj 191,464 45,969 Jhalokathi 15,048 7,974 Pirozepur* 9,013 2,634 HSCS areas 182,660 44,447 Pirozepur 31,544 7,528 Bhola 62,314 16,311 Noakhali 88,802 20,608 Sub-IR 4.1: Promote awareness of MNCH through innovative BCC approaches Number of people reached through project supported BCC
activities High intensity areas 650,000 223,488 Lakshmipur 175,000 54,111 Women 28,348
Men 25,763
Noakhali* 135,556 160,574 Women 71,927
Men 88,657
Habiganj 195,000 5,855 Women 4,983
Men 872
Jhalokathi 113,587 2,938 Women 2,139
Men 799
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 47 Achievemen Target Variation t (Oct–Dec Remarks 2016 (%) 2015) Pirozepur* 30,857 0 Women 0
Men 0
Bhola Women Men Sub-IR 4.2: Enhance community engagement in addressing health needs Number of trained community volunteers promoting MNCHFPN
through project support High intensity areas 24,925 23,168 Lakshmipur 6,710 6,409 Noakhali* 5,900 5,664 Habiganj 8,379 8,265 Jhalokathi 2,731 2,300 Pirozepur* 1,205 530
Number of Community Action Groups with an emergency transport system for maternal
and newborn health care through USG-supported programs High intensity areas 20,001 18,999 Lakshmipur 6,461 6,056 Noakhali 3,876 3,586 Habiganj 4,369 8,136 Jhalokathi 3,746 1,221 Pirozepur* 1,549 0
48 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 APPENDIX 3: MNCH ESSENTIAL DRUGS MONITORING REPORT
Logistics related reporting in Noakhali and Lakshmipur included Monthly Medicine Supplies/Commodities report in addition to Inventory Control Register, which are usually maintained in other districts. Data has been further summarized for an individual store over time, e.g. Civil Surgeon Store (Fig 1 below) or by an individual drug item over time, e.g. Misoprostol (Fig 2 below), Inj. Oxytocin (Fig 3 below), Inj. Magnesium Sulphate (Fig 4 below).
Fig 22: Color coded presentation of Civil Surgeon (CS) store for 10 among 25 essential MNCH drugs for Monitoring availability at Lakshmipur district. Red = stock-out Green = available
Monitor Availability of MNCH Tracer Drugs District: LaKshmipur, Example : Tablet Misoprostol Store Location Sep, Oct, Nov, Dec, Jan, Feb, Mar, Apr, May, June, July, Aug, Sep, Oct, 14 14 14 14 15 15 15 15 15 15 15 15 15 15 CS Store District Hospital Sadar Upazila Ramgati Kamal Nagar Raipur Ramganj Fig 23: Color coded presentation on the availability of Misoprostol tablets at different stores of Lakshmipur district.
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 49 Monitor Availability of MNCH Tracer Drugs District: LaKshmipur, Example –Inj. Oxytocin Store Location Sep, Oct, Nov, Dec, Jan, Feb, Mar, Apr, May, June, July, Aug, Sep, Oct, 14 14 14 14 15 15 15 15 15 15 15 15 15 15 CS Store District Hospital Sadar Upazila Ramgati Kamal Nagar Raipur Ramganj Fig 24: Color coded presentation on the availability of Inj. Oxytocin at different stores of Lakshmipur district.
Monitor Availability of MNCH Tracer Drugs District: Lakshmipur, Example –Inj. Magnesium Sulfate
Store Location Sep, Oct, Nov, Dec, Jan, Feb, Mar, Apr, May, June, July, Aug, Sep, Oct, 14 14 14 14 15 15 15 15 15 15 15 15 15 15 CS Store District Hospital Sadar Upazila Ramgati Kamal Nagar Raipur Ramganj Fig 25: Color coded presentation on the availability of Inj. Magnesium Sulfate at different stores of Lakshmipur district.
The project staff presented and discussed the color coded dashboard with district and upazila level health managers during different occasions such as QI Committee meetings, monthly & quarterly review meetings. Based on the presented data, action to avoid stock out of essential drugs should be identified. Such actions would include sending an indent of drug requirement to the central store, mobilize resources for local procurement of essential drugs or transfer drug items for one store to another.
The maintenance status has improved after the training which was observed during the field visit to upazila store at Kamal Nagar sub-district. The store keeper is maintaining temperature monitoring chart (picture 1 & 2 below) and Bin card (picture 3 below) in addition to maintenance of Inventory Control Register (including the Mfg. date/Exp. Date, Balance Usable) and Monthly Medicine Supplies/Commodities report.
50 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1
Picture 1, 2, 3: Maintenance of Temperature monitoring chart (degree Celsius-picture 1 & 2) and BIN card (picture 3) at upazila store at Kamal Nagar
Decision has been made to collect Monthly Medicine Supplies/Commodities report from different stores of DGFP & DGHS in Habigonj and Jhalokathi districts in addition to maintaining Inventory Control Register (ICR) in each store as training on ‘Scaling up of MNCH Medicines (Tracer Drugs) Monthly Reporting system’ and supply of reporting format has been completed in September 2015. Mamoni HSS concerned Managers will prepare LMIS report by 10th of next month after receiving them from all stores within 5th of every month. The Project staff also started preparing report from November, 2015 by including yellow color for item which is available but will expire within 6 months.
The below color coded figure shows that among the 25 Essential MNCH drugs, only ORS is available in all stores of Noakhali, Lakshmipur and Habigonj districts. Inj. ampicillin, Resuscitation (HBB kit), Inj. Pethidine, Inj. Frusemide, tab. Frusemide, Inj. Plasmosol were out of stock. Fig.5
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 51 MNCH Essential Drugs' Monitoiring Month:November 2015 District : Noakhali District : Lakshmipur District : Habigonj SL# Name Items CS Seb Begu Compa Subor Hati CS Gen. Sadar Ram Kamal Rai Ram CS Dist Sadar Madh Chuna Bah Bania Nabi Ajmeri lakhai Store bag mganj niganj nachar ya Store Hosp Upz. gati Nagar pur ganj Store .Hosp abpur rughat ubol chong gonj gonj UHC i 1 Inj. Ampicillin 2 Amoxicillin DT 3 Inj. Gentamycin 4 Inj. Cephradine 5 Inj. Metronidazole 6 Tab. Metronidazole 7 Inj. Antenatal Corticosteroids 8 7.1% Chlorhexidine 9 Resuscitation (HBB kit) 10 ORS 11 Zinc 12 Inj Oxytocin 13 Tab. Misoprostol 14 Inj. Magnesium Sulphate 15 Salbutamol Respirator (Solns) 16 Iron Folate 17 Inj. 5% DNS 18 Inj. Hartman’s Solutions 19 Inj. Bupivacaine 20 Inj. Ephedrine 21 Inj. Pethidine 22 Inj. Furosemide 23 Tab. Furosemide 24 Inj. Ergometrine 25 Inj. Plasmasol Fig 26: Color coded monitoring report of 25 Essential MNCH drug for the month of November, 2015 at Noakhali, Lakhsmipur and Habiganj district
Percentage of stores in Noakhali, Lakhsmipur and Habigonj district (n=23 stores) where MNCH drugs are available
120.00% 100.00% 80.00% 60.00% 40.00% 20.00%
0.00% …
Inj.… Zinc ORS Tab.… 7.1%…
Iron Folate Salbutamol… Inj. 5% DNS Inj. Inj Oxytocin Inj
Inj. Pethidine Resuscitation… Inj. Antenatal… Inj. Inj. Ampicillin Inj. Hartman’s Hartman’s Inj. Inj. Plasmasol Inj. Inj. Ephedrine Amoxicillin DT Inj. Furosemide Inj. Inj. Cephradine Inj. Inj. Magnesium… Inj. Inj. Ergometrine Inj. Inj. Gentamycin Inj. Inj. Bupivacaine Inj. Tab. Furosemide Tab. Tab. Misoprostol
52 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 Fig 27: Percentage of availability of 25 Essential MNCH drugs in the 23 stores of Noakhali, Lakhsmipur, and Habigonj districts
Availability of Family Planning (FP) commodity is monitored through the DGFP UMIS data from the website. These data are well maintained in the website which helps to prevent stock out at the Service Delivery Point(SDP)s .Data of all the FP commodity at Lakshmipur district in November 2015 were downloaded and summarized as below table number 1:
Name of Type of Number of Overstock Satisfactory Understock Potential Stock out Upazilla Contra SDP stock out distributing (3+ stock) (1.7=3.0 (0.7-1.6 (0 MOs) ceptives method MOs) MOs) (0.1-0.6 MOs) Kamal Nagar: Condom 34 16.6% 60.2% 15.1% 2.8% 0.9% Total SDP: 34 Pill 34 5.9% 85.3% 8.8% 0% 0% IUD 06 50.0% 33.3% 0% 0% 16.7% Injectable 34 2.9% 38.2% 41.2% 17.6% 0% Implant 01 100% 0% 0% 0% 0% Lakshmipur Sadar: Condom 143 28.7% 55.9% 7.7% 2.8% 0.7% Total SDP: 144 Pill 143 2.1% 53.8% 39.9% 3.5% 0% IUD 23 8.7% 34.8% 52.2% 4.3% 0% Injectable 143 13.3% 46.2% 36.4% 2.8% 0% Implant 03 33.3% 0% 33.3% 33.3% 0% Ramganj: Condom 70 28.6% 35.7% 22.9% 4.3% 0% Total SDP:71 Pill 70 5.7% 70% 15.7% 1.4% 0% IUD 12 0% 33.3% 50.0% 16.7% 0% Injectable 70 7.1% 67.1% 24.3% 0% 0% Implant 02 0% 0% 0% 50.0% 50% Ramgoti: Condom 45 11.1% 82.2% 4.4% 0% 0% Total SDP:45 Pill 45 0% 88.9% 8.9% 2.2% 0% IUD 09 33.3% 22.2% 44.4% 0% 0% Injectable 45 0% 53.3% 40.0% 4.4% 2.2% Implant 02 100% 0% 0% 0% 0% Roypur: Condom 58 32.8% 46.6% 5.2% 1.7% 0% Total SDP:58 Pill 58 3.4% 74.1% 13.8% 0% 0% IUD 11 % 27.3% 54.5% 9.1% 0% Injectable 56 % 66.1% 16.1% 1.8% 0% Implant 01 % 0% 100% 0% 0% SDP = Service Delivery Point
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 53 National level coordination: Meeting with DGHS: Meeting with Director Primary Health Care (PHC) were arranged for proper coordination with DGHS for planning, procurement and supply system of essential 25 tracer drugs. Director shared that DGHS is going to procure the medicines as much possible according to the availability of budget.
Meeting with SIAPS: Meeting with SIAPS was arranged to track and monitor 25 essential drugs using the supply chain management portal. SIAPS is going to complete the training on LMIS in the remaining 10 districts within December 2015 and completed accordingly. The training included the proper maintenance of drugs in the store with proper documentation.
54 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 APPENDIX 4: DISSEMINATION OF MAMONI PROGRAM LEARNING Title Forum Month Type of Dissemination Providers Performance in Antenatal and Delivery Care at Community-Level FIGO, Vancouver, Oct 2015 Oral Presentation Government Health Services in Canada Bangladesh Bringing Health Services Closer to Home: Community Skilled Birth FIGO, Vancouver, Oct 2015 Poster Presentation Attendants in the MaMoni Project, Canada Bangladesh Use of Partograph to Identify Complications and Facilitate Referral FIGO, Vancouver, Oct 2015 Poster Presentation Decisions by health providers at Canada peripheral level Newborn care surveillance: Bangladesh Global MNH Experience with sentinel surveillance, conference, Auxiliary Oct 2015 Oral Presentation data capture and use Session Mexico Community based prevention and TRAction treatment of Severe pre- dissemination, icddr,b, Oct 2015 Oral Presentation eclampsia/eclampsia Dhaka Community based prevention and Pop Council treatment of Severe pre- Landscape Analysis, Nov 2015 Oral Presentation eclampsia/eclampsia Dhaka TRAction MaMoni Referral network dissemination, icddr,b, Nov 2015 Oral Presentation Dhaka MaMoni lesson on UH&FWC PMMU Unit, MOH&FW, Dec 2015 Oral Presentation strengthening Dhaka International Empowering Community Volunteers to Conference on Family Poster Presentation increase utilization of FP Nov 2015* Planning, Nussa Dua, (moved to January) services in a remote district Bangladesh Indonesia
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 55 APPENDIX 5: ENVIRONMENTAL COMPLIANCE REPORT Progress of the Environmental Compliance activities will be reported on a six-monthly basis using the format below. Project Activities List each Mitigation Status of Mitigation List any Remarks with potential Measure in the EM Measures outstanding environmental issues relating impact (NDC) to required conditions Inappropriate Develop guidelines for Developed Translation of disposal of medical waste management “Guidelines for guidelines to waste materials applying basic Bangla. generated by infection prevention Orientation of providing maternal, Raise include and waste staff and follow child, newborn appropriate medical management up on health, family waste management measures for implementation. planning and as part of ongoing primary health care”. nutrition services project quality supported by the improvement project. activities. Included medical waste management
as part of the overall all quality improvement Utilize routine strategy of the supervisory visits to project. Improving monitor and improve overall cleanliness, medical waste infection prevention, management and waste management is the first stage of quality improvement.
Included checklists for medical waste management in the routine supervision visits conducted by project staff and GoB staff to health facilities at all levels. District Hospitals Develop a partnership Conducted Developing plan *There is generate large for medical waste assessment of with cost interest and quantities of management in one Lakshmipur district estimates for willingness of medical waste district hospital waste improving Lakshmipur management management medical waste distict leaders
process. management to cooperate for Lakshmipur (e.g. allocating
district. land for Supporting the establishing
construction of medical waste dumping pits within Developing management Lakshmipur hospital MOU with unit). premises. Lakshmipur district leaders
for defining Engaged in a roles,
56 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 dialogue with responsibility, Lakshmipur district and leaders to develop a contribution of partnership for each partner. improving medical
waste management.
Dismantling of By using mask, good damage plaster is helmet and watered creating dust of this area
Surface preparation By using mask and good for painting watered of this area
In case of fire or any Fire extinguisher and Good other incidental fast aid box is (at this stage did not case available in the site face any type of for primary protection incident) Sound pollution for Tiles cutting in a good tiles work sealed room for sound minimizing
Using paint on wall Paint is lead free Good and ceiling Using other All materials are Good materials likes sand asbestos free , cement and reinforcement
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 57 APPENDIX 6: LINKS TO MEDIA STORIES PUBLISHED Media Date Article Title and Link Daily Naya Oct 17, http://www.dailynayadiganta.com/detail/news/62438 Diganta 2015 Daily Naya Nov 07, http://www.dailynayadiganta.com/detail/news/67530 Diganta 2015 Daily Nov 17, http://www.prothomalo.com/bangladesh/article/685852 Prothom Alo 2015 Daily Nov 22, http://www.prothom-alo.com/bangladesh/article/690841/ Prothom Alo 2015 Daily Nov 17, http://www.prothom-alo.com/we-are/article/685621/ Prothom Alo 2015 Daily Nov 20, http://www.prothom-alo.com/bangladesh/article/688642/ Prothom Alo 2015 Daily Nov 23, http://www.prothom-alo.com/bangladesh/article/691855/ Prothom Alo 2015 Daily Nov 12, http://www.prothom-alo.com/bangladesh/article/681493/ Prothom Alo 2015 Daily Nov 22, http://www.prothom-alo.com/bangladesh/article/690742 Prothom Alo 2015 Daily Nov 22, http://www.prothom-alo.com/bangladesh/article/690799/ Prothom Alo 2015 Daily Star Nov 17, Roundtable on World Prematurity Day 2015 2015 http://www.thedailystar.net/round-tables/world-prematurity-day/world-prematurity-day-2015- 173440 BDnews24 Nov 16, Bangladesh to introduce Kangaroo Care to save premature babies .com 2015 http://bdnews24.com/health/2015/11/16/bangladesh-to-introduce-kangaroo-care-to-save- premature-babies BSS Nov 16, Bangladesh witnesses 4,39,000 preterm births every year 2015 http://www.bssnews.net/newsDetails.php?cat=0&id=532698&date=2015-11-16 Daily Sun Nov 17, Preterm Birth poses threat to child survival 2015 http://daily-sun.com/printversion/details/91659/Preterm-birth-poses-threat-to-child-survival News Today Nov 17, 4,39,000 preterm births a year in country 2015 http://www.newstoday.com.bd/index.php?option=details&news_id=2427467&date=2015-11- 17 Asian Age Nov 17, Preterm birth high in Bangladesh 2015 http://dailyasianage.com/news/2588/preterm-birth-high-in-bangladesh
Naya Nov 17, http://www.dailynayadiganta.com/detail/news/70257 Diganta 2015 Bdnews24.c Nov 17, Campaigners encourage Bangladesh government to invest more in women newborn care for om 2015 triple return. http://bdnews24.com/health/2015/11/18/campaigners-encourage-bangladesh-government- to-invest-more-in-women-newborn-care-for-triple-return Kaler Nov 18, http://www.kalerkantho.com/print-edition/news/2015/11/18/291741 Kantho 2015 Prothom Alo Nov 18, http://www.prothom-alo.com/bangladesh/article/686695/ 2015
58 MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 Bdnews24.c Dec 19, Usage of tabs revolutionises health services in Bangladesh om 2015 http://bdnews24.com/health/2015/12/19/usage-of-tabs-revolutionises-health-services-in- bangladesh
Naya Dec 20, http://www.dailynayadiganta.com/detail/news/78752 Diganta 2015
MaMoni Health Systems Strengthening Activity: Quarterly Report FY’16 Q1 59