Maternal and Child Survival Program Guatemala

FY 2018 Q3 Quarterly Report April1- June 30, 2018

Submitted: July 31, 2018

Submitted to: United States Agency for International Development Cooperative Agreement No. AID-OAA-A-14-00028

Submitted by: Jhpiego in collaboration with Save the Children PATH Population Services International John Snow, Inc. Results for Development (R4D)

Program Overview

Program Name Maternal Child Survival Program (MCSP) Program Start and July 1, 2017 – December 31, 2018 End Date Prime Implementing Save the Children Partner Partner Jhpiego, PATH, PASMO/PSI, JSI, R4D Organizations Ministry of Public Health and Social Welfare (MOH) and Key Partners: Secretariat of Food and Nutrition Security (SESAN) Reporting Period April 1 – June 30, 2018 30 prioritized municipalities of the Western Highlands of Geographical Guatemala (Huehuetenango, Quiché, Quetzaltenango, San Coverage Marcos and Totonicapán)

Table of Contents Program Overview ...... 1 Acronyms ...... 1 Introduction ...... 2 Summary of Activities ...... 4 OBJECTIVE 1: Provide TA and collaborate with the MOH to improve the provision of services related to RMNCAH/N within the context of the primary health care model...... 4 Result 1: Primary health care model revised, adjusted and implemented in MCSP’s 30 prioritized municipalities ...... 4 Result 2: Quality RMNCAH/N health services provided by the network of health facilities and workers6 Result 3: Strengthened linkages between the municipality and the community to improve community engagement in the co-management and monitoring of health and nutrition services and to create demand...... 14 Result 4: Improved knowledge, competencies, and skills of health workers in the areas of RMNCH/N 19 OBJECTIVE 2: Increase visibility, collaboration and multi-sector efforts in the prevention of chronic malnutrition in the Western Highlands...... 25 Result 1: The National Strategy for Prevention of Stunting is implemented at the national level and in 13 prioritized municipalities ...... 25 Monitoring and Evaluation ...... 30 Collaboration and Coordination ...... 34 Implementation Challenges ...... 35 Upcoming Activities in the Next Quarter ...... 35 International Travel - Quarter 3 ...... 38 Annexes ...... i

1 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Acronyms CAIMI Centro de Atención Integral Materno Infantil (Maternal Child Integrated Care Center) CAP Centro de Atención Permanente (Permanent Care Center) CCA Clean Clinic Approach CDC Centers for Disease Control Comisión Departamental de Seguridad Alimentaria Nutricional (Food and Nutritional Security CODESAN Departmental Commission) Comisión Municipal de Seguridad Alimentaria Nutricional (Food and Nutritional Security COMUSAN Municipal Commission) Consejo Nacional de Seguridad Alimentaria y Nutricional (Food and Nutritional Security CONASAN National Council) CNAA Comisión Nacional de Aseguramiento de Anticonceptivos Dirección de Asistencia Administrativa Financiera Municipal (Municipal Administrative DAAFIM Financial Assistance Directorate) DAS Dirección de Area de Salud (Health Area Directorate) DECAP Departamento de Capacitación (Training Department) DMS Distrito Municipal de Salud (Municipal Health District Office) Estrategia para la Prevención de la Malnutrition Crónica (National Strategy for the Prevention ENPDC of Chronic Malnutrition) ENSMI Encuesta Nacional de Salud Materno Infantil (National Maternal Child Health Survey) FP Family Planning GSK GlaxoSmithKline HBB Helping Babies Breathe HEP+ Health and Education Policy Plus Project IFPRI International Food Policy Research Institute Instituto de Nutrición de Centroamérica y Panamá (Central America and Panama Nutrition INCAP Institute) IP Implementing Partner JMP Joint Monitoring Programme on Water Supply and Sanitation LOP Life of Project MCSP Maternal and Child Survival Program MIDES Ministerio de Desarrollo Social (Ministry of Social Development) MOH / MSPAS Ministerio de Salud Pública y Asistencia Social (Ministry of Health) PAHO Pan American Health Organization PDQ Partnership Defined Quality PROSAN Food and Nutritional Security Program PHC Primary Health Care RMNCH/N Reproductive, maternal, neonatal, child health and nutrition SBCC Social and Behavior Change Communication SESAN Secretaría de Seguridad Alimentaria y Nutricional (Food and Nutritional Security Secretariat) SIAS Sistema Integral de Atención en Salud (Integrated Health Care System) SIGSA Sistema de Información Gerencial en Salud (Health Management Information System) Sistema de Vigilancia Epidemiológica de Salud y Nutrición (Health and Nutrition SIVESNU Epidemiological Surveillance System) TA Technical Assistance UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHIP Western Highlands Integrated Program WHO World Health Organization

1 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Introduction This PY2Q3 report covers activities, achievements, and challenges between April 1-June 30, 2018. During most of the quarter, MCSP temporarily suspended activities and was at risk of closing the program due to the delay of the program’s remaining obligation of funds. Funding delays were the result of delays in the USG’s certification process. In the May-June period, MCSP focused on tasks that did not require incurred costs aside from staff salaries. Additionally, MCSP ensured that relations with the Ministry of Health (MOH), Food and Nutritional Security Secretariat (SESAN), municipalities, and partners at central and local levels remained active until the program could resume activities. The Q3 report summarizes activities implemented in April as well as the modified activities conducted by program staff between May-June.

MCSP continued to provide technical assistance (TA) to the MOH in the review and adaptation of the management manuals, Health Care Model Pre-testing Guide, which are currently under review by the Primary Health Care Vice-Minister, before implementation rollout. The MOH’s Training Department (Departamento de Capacitación/DECAP) has approved the online course to strengthen the management skills of municipal health district directors. Over the last quarter, MCSP collaborated with the Integrated Health Care System (Sistema Integral de Atención en Salud/SIAS) to define the course content and training plans; prepare the workshop guide; identify participants; and develop presentations, support documents, and exercises. The course is expected to begin in August 2018.

For activities under Result 2, which aims to strengthen the quality of the continuum of care across different maternal child areas, the second round of measurements of quality indicators in ambulatory sites was completed in 15 health services. MCSP continued to support the development of plans to close the gaps in family planning (FP) services and worked with the national commission for provision of FP methods (CNAA) to ensure voluntarism and informed choice. Gaps in maternal and neonatal health care were identified and performance issues were discussed with the MOH Supervision teams. New critical pathways were identified in Huehuetenango in response to MOH’s priority to address the increase in maternal deaths. In nutrition, the mentoring approach strengthened health providers’ capacity in specific interventions such as the skin-to-skin technique and early breastfeeding. MCSP also held several meetings with United Nations (UN) entities to define the route to support the MOH in strengthening all activities related with maternal mortality and RIS (Integrated Network of Health Services).

Under the WASH in health care facilities (HCFs) component, MCSP entered into Step 5 out of 10 of the Clean Clinic Approach (CCA). This step consists of presenting the CCA standards and criteria to the MOH staff and target HCFs. MCSP participated in a workshop to present the CCA; share results from the baseline assessment conducted in 11 target HCFs; and show how the CCA would support improving conditions in labor, delivery, and newborn spaces and contribute to reductions in maternal and newborn mortality rates. MCSP also hosted the National Workshop “Presenting the Clean Clinic Approach and Planning Actions to Strengthen Processes for Improvement of WASH at Health Facilities with Childbirth and Newborn Care,” that led to the harmonization of standards, indicators and criteria for continuous quality improvement.

MCSP continued to support the implementation of the Partnership Defined Quality (PDQ) methodology in 17 communities. To date, nine communities in Quiche, Totonicapán and Huehuetenango reached Phase 4 and identified interventions to address gaps to strengthen linkages between communities and health services. The remaining communities continue to work on Phase 1 (creating support), Phase 2 (exploring quality) and Phase 3 (closing the gaps). MCSP’s effort with the PDQ has already motivated different health areas and districts to initiate the PDQ process on their own after receiving TA in the approach. MCSP trained 87 health staff and educators in the Ixil Area, Quiche, to initiate PDQ in 14 communities and the San Marcos DAS is planning to pilot the PDQ in 30 communities after health promoters from that area were trained by MCSP.

2 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 During Q3, MCSP completed the preparatory phases of the mentorship approach, in which MCSP staff strengthened their competencies and were certified to support the health care providers in mentoring principles and clinical competencies. MCSP has now progressed into Step 3 – training and certification of clinical mentors.

In April, MCSP held a workshop for 18 teachers from the Da Vinci and PanAmerican Universities to train them in the teaching methodology, curriculum, and practice under the Midwifery Technical Career (MTC).

In support of increasing the visibility and collaboration efforts in the prevention of chronic malnutrition, MCSP continued to coordinate with the MOH, SESAN, municipalities and INCAP. The design of the distance-learning course was finalized, with the first facilitator workshop taking place in Quetzaltenango, during May 14-16, 2018, training a total of 55 participants. Those trained will be in charge of organizing, implementing and monitoring the circle studies. Among the topics addressed in this workshop: situational analysis of health and nutrition in the Western Highlands, considerations for anthropometric evaluation, demonstration of anthropometric measurement techniques, effective counselling and essential messages for pregnant women, review of the didactic plan related to the first three circle studies including promotion of breastfeeding. Furthermore, during this quarter three circle studies by municipality were initiated, targeting approximately 352 auxiliary nurses of the health posts. A total of six circle studies in 30 municipalities will be carried out over a period of four to five months. TA to eight municipalities was also continued, as well as the design of an online course focused on increasing municipal investments in nutrition, in coordination with the DAAFIM/MINFIN.

MCSP supported the USG-Mexico-Guatemala collaboration by hosting Drs. Juan Rivera and Anabelle Bonvecchio from the National Institute of Public Health of Mexico for a two-day meeting between representatives from these three countries. The goal of this collaboration was to share Mexico’s experiences and best practices in reducing stunting over the last 20 years. Participants included representatives from SESAN, civil society actors (INCOPAS, ALIANMISAR and FUNDESA/Nutrition Alliance), the National Council of Food and Nutrition Security (CONASAN), the Food Security and Health Commissions from Congress, academia and donors.

The data collection and data analysis for the Health and Nutrition Epidemiological Surveillance System (Sistema de Vigilancia Epidemiológica de Salud y Nutrición/SIVESNU) in Huehuetenango was also completed in Q3.

3 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Summary of Activities OBJECTIVE 1: Provide TA and collaborate with the MOH to improve the provision of services related to RMNCAH/N within the context of the primary health care model.

Result 1: Primary health care model revised, adjusted and implemented in MCSP’s 30 prioritized municipalities

Activity 1: Working with the MOH, develop management skills at the national level to support implementation of the new health care model 1.1.1.1. Development of effective coordination mechanisms with the MOH to review progress in the implementation and management of the PHC model at the national, regional and district levels. MCSP remained engaged with the Directorate of the Integrated Health Care System (Sistema Integral de Atención en Salud/SIAS), Health Area Directorate (Dirección Area de Salud/DAS), Municipal Health Districts (Distritos Municipales de Salud/DMS), and National and District Hospitals, to share results and activity plans for when MCSP could reinitiate its normal implementation.

1.1.1.2. Technical assistance and support to the MOH in the review and adaptation of MOH management manuals MCSP Coordination meeting with the In April, MCSP provided TA to review the Health Care Model Pretesting Quiche DAS. Photo: Walfred Garcia, MCSP Monitoring and Evaluation Guide, jointly with the MOH. The PHC manuals are currently being reviewed by the Primary Health Care Vice Minister, Dr. Julio García Colindres, who took office on April 24, 2018. The process to document the analysis of strengths and weaknesses of the Health Management and Care Model has started and will be completed in Q4.

1.1.1.3. Strengthen the management skills at the regional and district level as required by the MOH MCSP developed the “Proposal to Strengthen Health Management Capacities”, referencing the course developed under the USAID/Nutri-Salud Project to strengthen the managerial skills to support the prevention of chronic malnutrition strategy. MCSP reviewed the guide contents and identified sections that were applicable to the proposed course. In May, the DECAP approved this course to strengthen the management skills of the municipal district directors. Over the last quarter, MCSP collaborated with the SIAS to define the course content; prepare the workshop guide; and develop presentations, support documents, and exercises. The Health Area Directors have identified course participants from the DMS and Health Areas and shared this list of names with the SIAS, which will then be shared with DECAP by July. The anticipated start date for the course is August 2018.

Please refer to Annex 1: Programa general - Curso para el fortalecimiento de capacidades de Gestión en Salud en el altiplano occidental de Guatemala.

Emergency Technical Support to the MOH – Vaccinations Through SCUK - GSK Project entitled ¨Strengthening capacities in maternal child health and nutrition in the Western Highlands of Guatemala, which are matching funds, MCSP supported primary and second level services in delivering health promotion materials related to immunizations and the HPV vaccine, which included vinyl banners, coverage monitoring tables, cold chain calendar, flyers and posters for all 30 municipalities. Support was also provided with the distribution of childbirth plans and family emergency plans

4 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 for health posts, CAP, CAIMI and hospitals of the 30 municipalities of the six Health Areas. MCSP also continued providing TA on the follow-up of implementation of the National Immunization Program Guidelines and analysis of coverage in Delivery of immunizations materials in the Delivery of vaccination coverage monitoring tables the 10 municipalities Quiché Health Area Office. Photo: Salvador in San Antonio Huista, Huehuetenango. Photo: prioritized in Avilés, Rural Health Technician of MSPAS Mishelle Sum, MNCH Specialist, MCSP Huehuetenango.

MCSP provided TA during the AIEPI Reproductive Health Strengthening Workshop attended by 166 health providers in Barillas, Huehuetenango, which addressed the following themes: prenatal care, use of the RH programs, handling obstetric complications, how to complete cards correctly, postpartum period control, emergency plan, health commission, and FP methods. The Facilitator’s and Participant Guides of the Neonatal AIEPI, Clinical AIEPI, and Post-partum Comprehensive Care and for children younger than 5 years of age were also delivered to staff from the 30 Immunization and Reproductive Health priority municipalities. Workshop in Santa Cruz Barillas. Photo: Licda. Karla Contreras, DMS nurse Activity 2: Provide TA to the DAS to support facilitation of the model of care implementation at the regional level 1.1.2.1 Adaptation and validation of a manual for the management and operation of the model of care for the DAS of Western Highland areas. Due to changes during this quarter and new guidelines provided by the Minister’s Office, the MOH is reviewing the Internal Rules and Regulations to enable a functional reorganization of the General Directorate of the SIAS, DAS and DMS. Once this process is completed, the operations manuals will be prepared.

Activity 3: Provide support to the MOH at the national, regional and local levels to develop dashboards to monitor the implementation of services 1.1.3.1 Develop a dashboard to support the management and monitoring of health services in prioritized health areas and health municipal districts The design of the Dashboard (tableros de mando) was developed using Tableau software and includes indicators that track interventions supporting the first 1,000 days window, considered the most important time to meet the nutritional needs of a child from pregnancy to two years of age. Since 2011, the MOH has promoted certain interventions supporting the 1,000 day window to prevent chronic malnutrition and include the following: maternal nutrition, micronutrient supplementation in pregnant women; promotion of breastfeeding; supplementary feeding after 6 months; hygiene practices and hand washing; supplementation of children with vitamin A and sprinkled micronutrients; use of zinc in the treatment of diarrhea and pneumonia; vaccination, deworming and consumption of fortified foods.

In the month of June, the concept note and workplan, prepared last quarter, were endorsed by SIGSA, and will be implemented from July-October. Further details are provided in the Monitoring & Evaluation section of this report.

5 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Activity 4: Development of a non-monetary incentive program to encourage improved staff performance 1.1.4.1 Develop an incentives strategy to motivate and strengthen performance of staff in relation to their operational, technical and management functions. No progress during Q3. MCSP will assess if it can be conducted in Q4.

Result 2: Quality RMNCAH/N health services provided by the network of health facilities and workers Activity 5: Establish and test a national WASH program in HCF using its CCA tested in 11 priority facilities in four departments 1.2.5.1. Develop a national WASH in HCF program, that includes standards, monitoring indicators, training modules, monitoring systems and implementation tools) based on the CCA. During Q3, MCSP completed the first three steps out of 10 of the Clean Clinic Approach (CCA) and is currently implementing Steps 4- 5. Step 5 consists of presenting the CCA standards and criteria to central level MOH staff (Integrated System of Attention in Health –SIAS-, Viceministry of Hospitals – VMH-, Direction of Regulation, Certification and Vigilance of Health –DRCVS-, Direction of Regulation, Accreditation of Health Establishments –DRACES-) and to target HFs.

On April 17, MCSP participated in a workshop to orient attendees on the CCA, present the results of the baseline assessment conducted in the target 11 HFs, and show how the CCA would be implemented to improve prevention and control in labor, delivery, and newborn spaces and contribute to reducing maternal and newborn mortality rates in these facilities. The workshop was attended by USAID partners implementing WASH activities, such as Mancuerna de San Marcos, Nexos Locales, and others, who shared their experiences and approaches to improve WASH conditions in HFs. The event also included participation from the MOH, directors of Health Areas and prioritized hospitals in the Western Highlands as well as USAID/Guatemala’s HEO, Economic Growth and Governance Offices and USAID/Washington.

On April 25-26, MCSP hosted the National Workshop “Presenting the Clean Clinic Approach (CCA) and Planning Actions to Strengthen Processes for Improvement of WASH at Health Facilities with Childbirth and Newborn Care.” Opening remarks were given by the Technical Vice-Minister and participants included the SIAS Directorate, Regulations Department, Regulations Directorate, Vice-Ministry of Hospitals, Strategic Planning Unit, Supervision and Monitoring Unit, Health Promotion and the Education Department, SESAN, USAID and WASH partner organizations. The main outcome was the harmonization of standards, indicators and criteria for continuous quality improvement (Mejoramiento Continuo de la Calidad – MCC) of Steps 7 and 8 of the CCA, which consist of implementation, supervision, monitoring and verification of the reach of the clean clinic status. Quality standards, indicators and criteria were defined for prioritized health facilities in the Western Highlands with childbirth services (see Table 2). Each criterion had a value of 1 to 100 points and addressed three areas: General Facility, Delivery Room and Newborn Room. According to the continuous quality improvement plans, facilities can be certified based on their classification as presented in Table 3.

6 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018

Table 1. Quality Standards, Indicators and Criteria. Table 2. Clean Clinic Certificate Classification STANDARD CRITERIA Water 11 91-100 Toilets 7 Diamond Washbasins and showers 16 81-90 Sterilization 11 Gold Solid residues 10 Cleanliness 11 70-80 Administration 4 Silver Hot, residual and rain water 10

MCSP WASH-CCA advisors, on June 13-16 of 2018, participated in the “Ibero-American Rural Sanitation and Safe Water Congress” organized by the Guatemalan Association of Sanitation and Environmental Engineering, to learn about the progress made to comply with water and sanitation millennium development goals. MCSP presented on the CCA approach, the baseline assessment results from the target 11 HFs for the CCA, and the eight standards developed as part of the continuous quality improvement process to achieve the CCA certificate. This meeting led to MCSP’s coordination with PAHO to implement similar assessments and the CCA in facilities outside of MCSP’s geographic scope.

In Q4, MCSP will continue with the CCA implementation through training of health providers on the approach; orienting them on the use of the Intra-hospital Infection Prevention Guide; development, implementation and monitoring of HFs action plans; verification of HFs Clean Clinic status; and application of a non-monetary incentive recognition for staff in target facilities who have advanced the implementation of the continuous improvement plans.

Activity 6: Identify and prioritize gaps and barriers in the service delivery network in selected municipalities In Q3, MCSP supported the MOH to measure indicators in 14 of the 15 sites that provide delivery care services and that MCSP provides technical support to (See Table 1. Only the Barillas/Huehuetenango District Hospital is pending). Indicators measured included: 1) Triage Danger Signs, 2) Partogram, including differentiated care for adolescent females; 3) AMSTL 4) Immediate Postpartum Family Planning; 5) Essential Newborn Care, and 6) Routine Newborn Care (see Chart 1 for an overview of results). Measurements at the hospital level was carried out in coordination with the Vice-ministry of Hospitals and in coordination with hospital supervisors. For services at the second level of care, MCSP coordinated with SIAS and the DAS.

Table 3: Coverage of health services on the Day of birth in prioritized municipalities No. DEPARTMENT NAME OF THE SERVICE HOSPITALS 1 Quetzaltenango Western Regional Hospital 2 Huehuetenango Departmental Hospital 3 Huehuetenango District Hospital Barillas 4 San Marcos Departmental Hospital 5 Quiché San Elena Departmental Hospital 6 Quiché Uspantán District Hospital 7 Quiché Nebaj, Ixil District Hospital 8 Totonicapán Departmental Hospital HOSPITAL SECOND LEVEL SERVICES 9 Totonicapán Momostenango CAIMI 10 San Marcos Tajumulco, CAP 11 San Marcos Nuevo Progreso, CAP 12 Quiché Chichicastenango, CAP

7 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 13 Quiché Sacapulas, CAP 14 Huehuetenango San Sebastian H., CAP 15 Huehuetenango Cuilco, CAIMI *Source: Unidad de Monitoreo y Evaluación Proyecto MCSP. Mediciones Servicios Enero-Junio 2018

Chart 1: Summary of quality of care from 14 facilities providing Day of Birth Services

Results from this activity will be used to support a participatory analysis, identify root causes and to prepare intervention plans by site. The DAS Health Care Services Management Team (medical director, financial manager & human resources manager) participated in the preparation of the results as well as clinical staff (obstetrician, pediatrician, nutritionist, psychologist, nursing staff, social worker and technical lab and pharmacy staff). In the sites where mentors were already trained, mentorship teams were included as part of the analysis teams in order to identify where clinical competencies need to be strengthened for the key DOB indicators selected for the continuous service delivery Meeting with the coordination team of the Health improvement model proof of concept. For additional details, District, doctors from the Cuilco CAIMI, and USAID to please see Annex 2: Detalle de mediciones de los 6 identify and analyze gaps in maternal-neonatal care. indicadores del día del parto. After the meeting, an intervention plan for improvement in health care services was prepared. Photo: Glendy de In addition, MCSP is providing technical support to Health León, MCSP Regional Manager Area Directorates (DAS) and municipal health districts to analyze the gaps in the health care system, as follows:

Table 4: Strengthening Family Planning Capacities based on gaps defined THEME Doctor EP AE Other Total Contraceptive Methodology Ixil DAS and 3 Ixil Districts 22 1 23 PFPP Ixil DAS and Nebaj Hospital 1 7 1 1 10 PFPP Hospital in Santa Cruz and DAS Quiche (Training Center) 0 7 3 0 10 Counseling about FP-LACR postpartum to providers involved in prenatal control/DAS 4 6 17 27 Quetzaltenango, San Juan Ostuncalco and Concepción Chiquirichapa Counseling about FP-LACR postpartum to providers of the National Hospital in San 3 5 4 12 Marcos

8 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Refreshment training to providers of the Health Center in Santa Cruz Barillas 0 6 1 7 Huehuetenango related to the long term methods Refreshment training related to MRLP to provider of the FP clinic from the Health Posts of San Ramón, and Barillas Health Center and District Hospital in 1 10 4 15 Huehuetenango, including staff responsible for FP of the DASH PSR Training related to Family Planning; long term reversible methods, balanced counseling, use of oral contraceptives, IUD insertion technique. Health Post of Salquil 1 1 Grande, Nebaj Critical Pathway TOTAL 105

The permanent methods consultancy supported the development of health providers’ competencies related to male and female VSC in the following hospitals: Barillas District, Quiché Regional, San Marcos Regional and Western Regional Quetzaltenango. Four providers received training about male VSC and four about female VSC.

Male VSC certification, Regional Hospital of Anatomical model practice, VSC Female. Santa Cruz Quetzaltenango. Photo: Ruby Miranda, MCSP Hospital, El Quiché. Photo: Ana Uz, MCSP FP and FP and Youth Specialist Youth Specialist

LARC postpartum workshop, Regional Hospital Santa MRLP Refresher Workshop for priority districts, Cruz, Quiché. Photo: Ludy Rodas, MCSP FP Advisor Huehuetenango. Photo: Glendy de León, MCSP Regional Manager

1.2.6.2 Facilitate a formative assessment in two districts (Nebaj and Uspantan) to explore and understand the perspectives at the community and health care levels on respectful care. Data collection for the respectful care formative assessment has been completed. Quantitative and qualitative data were collected from Nebaj, Santa Cruz and Uspantan, to understand women’s experience of childbirth care, including disrespect and abuse, during facility-based deliveries in Guatemala and within these communities. More specifically, in-depth interviews and focus group discussions were held with women of reproductive age who gave birth to their babies in health facilities and who delivered at home; with maternity care providers and comadronas (midwives); and with local health officials, including the hospital directors. Surveys were conducted with women who delivered in the district hospitals in Nebaj, Santa Cruz and Uspantan and with selected health providers in those hospitals. The data are being analyzed and findings will be shared

9 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 with local stakeholders. The data will also be used to develop a localized theory of change, which will form the foundation for the Respectful Care plan (Activity 1.2.7.3).

Activity 7: Design the model for improving the quality of service delivery 1.2.7.1.b: Orient and advocate for MOH buy-in for the QI model at the national, DAS and Health District levels and; c: Support the national level to invigorate a QI mechanism in which they can collaborate/ involve the health districts/DAS. MCSP continues to work closely with the MOH to support coordination, planning and implementation of their Continuous Quality Improvement methodology, which has 4 phases:  Phase 1: Planning desired performance: based on compliance with day of birth (DOB) and child health indicators and the country’s standards according to MBE guidelines and WHO recommendations. This phase defines the measurement structure, appoints external and internal quality committees, and defines timing and tools.  Phase 2: Execution of interventions based on guidelines: The MOH care and attention guide is aligned with the indicators and standards ensuring correct compliance with maternal-neonatal care processes – those processes are ensured through mentorship actions.  Phase 3: Verification: This phase allows measurement of current performance, identifying the degree of compliance with indicators and standards. It also identifies gaps (i.e. non-compliance with criteria) through which interventions are generated. The verification means is a review of maternal and neonatal files. The process is complemented with observation processes regarding care performance for each of the indicators being verified. Verification is carried out by previously trained teams that have been standardized in quality methodologies. LQAS is used with 95% reliability in observations and consistency of data obtained. This phase includes analysis and decision-making based on data through easy to use methodologies (Iceberg, Why-Why, strength fields, Pareto, fish bone).  Phase 4: Control of processes: In this phase, an intervention plan is developed, which defines mentorship interventions for management of supplies and resources to ensure compliance with indicators and standards. Those interventions ensure in short cycles (PEVA) quality improvement assurance and closing of gaps previously identified. The degree of compliance with the plan is led by upper management of health care services (hospital directors, health district directors and health area directorate heads), with support from the owners of such processes (gynecologists, pediatricians, nurses, lab technicians, pharmaceutics, anesthesiologists, nutritionists and psychologists, among others).

Each one of these phases is described in the Maternal and Neonatal Care Quality Monitoring and Evaluation Manual that will be launched soon by the MOH and the interventions are aligned to the model launched in 2016 by WHO. In phase 4, MCSP will support documentation of good practices as well as innovative actions applied by health care services’ teams. These interventions will then be systematized and adopted and expanded by MOH with the purpose of achieving continuous quality improvement in maternal-neonatal care.

1.2.7.2. Sharing of results of the pilot phase of the Critical Pathway (Ruta Critica) approach with the MOH/DAS, identifying key elements for adaptation and/or scale-up as well as deployment of an action plan. MCSP continues to provide technical support for the maternal and neonatal mortality surveillance and participates in the analysis commissions at the central level and health area directorates, including providing technical support to the critical pathway that allow community structures to link with the health services network in geographical areas prioritized by the MOH.

MCSP currently supports critical pathways in the following areas: 1. Huehuetenango: This critical pathway is in the community of San Mateo Ixtatán. The Permanent Care Center (CAP) covers 44,944 inhabitants in 86 communities. The critical pathway includes three health posts, each covering eight communities where maternal and neonatal health indicators are poor.

10 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 o During this period, six maternal deaths occurred in these communities. o While the San Mateo Health District has trained 27 midwives, the communities do not have community organizations or health committees to support families or referral actions. To address this, the DAS is coordinating with local leaders (Mayors, COCODES, religious leaders and NGOs) to establish Community Health Committees. However, recent internal conflicts between the communities and health care services have hindered articulation of the critical pathway interventions.

2. San Marcos: This critical pathway includes communities of Pueblo Nuevo in the Municipality of Tajumulco and is supported by the Mayor’s Office, Curamericas, the DAS and MCSP. Sixteen communities with a total population of 7,390 take part in this critical pathway. The nearest health care service is the Pueblo Nuevo Health Center, which has nursing staff to provide referral services. o During this period, 36 simple normal deliveries have been attended, of which 11 patients with danger signs were identified and referred to the network referral hospital for immediate attention. During this period, no maternal or neonatal deaths have occurred in this region. o MCSP continues to coordinate with health care authorities to train service provider staff on key competencies for child health care, MATEP, newborn care and actions about basic and essential obstetrics and neonatal care (Basic CONE) and for general maternal and neonatal complications. MCSP is also strengthening the five steps of community organization as part of the efforts to reduce maternal and newborn mortality.

3. Quiche: This critical pathway is in the community of Salquil Grande. Three health care services and three health posts participate in the pathway (Health Post of Salquil Grande, Palop and Vicalama) which provide services to 25 communities, covering a total population of 14,247. There are currently 23 organized health commissions. o Results during this period include 15 pregnant women identified with danger signs, who were stabilized and referred to Nebaj Hospital. There was one maternal death during Q3.

Health care staff at these locations have been trained in obstetric and neonatal complications. With district participation, management of supplies and care for emergencies equipment was also provided (obstetric and neonatal emergency kit) this quarter.

2.7.3 Prepare a Respectful Care Plan and strategies that include adaptation of services and care to address cultural norms in order to increase equitable access to respectful care, cultural relevance and voluntary decision-making by the population within a human rights framework in two municipalities (Nebaj and Uspantan) Activities will begin once the respectful care assessment is finalized in Quarter 4.

1.2.7.4. Strengthen Youth Friendly Spaces based on the MOH strategy in order for adolescents to have access to family planning and reproductive health information and services At the central level, MCSP supported the drafting and review of the Training Guide for Comprehensive Adolescent Care and Pregnancy Prevention, which is currently being validated by the National Reproductive/Adolescent Health Program. Educational materials were designed for use during trainings to address contraception for adolescents and to promote services offered at the Youth Friendly Spaces.

In May, MCSP updated USAID on the project’s progress in improving adolescent reproductive health services. See Annex 9: Avances Adolescentes for full details. Some of the results included the following:  Pregnancy Prevention Workshops: trained 9 MOH health providers in Huehuetenango and 4 OSAR (Reproductive Health Observatory) and Municipality Young Office facilitators in Quiche;  Adolescent Comprehensive Care: trained 92 health care service providers differentiated care in “Friendly Spaces” in Quetzaltenango and El Quiche.

11 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018  MCSP’s coordination and technical support to partners: - Participation in a presentation of social audit results hosted by youth OSAR and Youth Peace in Huehuetenango; as audience and technical support. - Coordination and TA with bi-ministerial working groups (MOH and MINEDUC) to support prevention of adolescent pregnancies in the three intervention regions: San Marcos, Quetzaltenango and Quiche. - The Adolescent Fair in Quiche in the community of Xeabaj I, Chichicastenango, which was attended by 86 students from 4th, 5th, and 6th grades and teachers, that aimed at informing adolescents ways of preventing pregnancies and tips on decision-making; - Meeting with the Municipal Child and Youth Office in the municipality of Chichicastenango with participation of Children’s Refuge, students of the Juan de León Institute, MINEDUC, and the National Civil Police. As an outcome of this meeting, a 15 km race was organized to race against child labor and exploitation, which was attended by the municipal fire department, municipal Mayor and Presidential Commission for Child Rights (Comision presidencial de derechos de la infancia/COPREDI). MCSP supported the activity’s logistics including preparation of the agenda, and organization of support committees. - Participation in an information fair on “Learning to Care for Myself and Plan my Information Fair about “Learning to Care for Myself Future” with messages raising awareness on and Plan my Future”. Photo: Quiché MCSP Team adolescent reproductive health issues hosted by youth. OSAR and the Municipal Child and Adolescent Office.

Departmental Training Workshops / Photos: MCSP Team

Activity 8: Coordinate with partners to facilitate the processes to close gaps in logistics/ supply 1.2.8.1 Coordination with other USAID projects to improve procurement processes, logistics and supply of medicines and inputs. MCSP was convened by the Comisión Nacional de Aseguramiento de Anticonceptivos (CNAA) sub-committee of the Ixil DAS to provide technical support and training to analyze the situation of supplies and develop improvement plans to address identified gaps. The meeting included participation of HEP+, Alas and civil society representatives.

MCSP also accompanied the Regional CNAA Sub-committees and participated in a meeting convened by the central level commission. Participants included sub-committees from Quetzaltenango, Quiché, Huehuetenango and Ixil. During the meeting, a DAS representative presented the FP situation room, including strengths and weaknesses. Collaboration lines with the central CNAA were identified as well as with other collaborating

12 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 organizations and projects. MCSP also participated in meetings with the Huehuetenango CNAA sub- committee to support preparations for their 2018-2019 work plan.

In April and May, MCSP participated in meetings organized by the national CNAA that were held in Quetzaltenango. The following agreements were reached: provide follow-up to dissemination of the Internal CNAA Bulletin by institution members that are part of the working group and provide follow-up to agreements of the meeting in the Hospital Regional de Occidente de Quetzaltenango (HROQ) to strengthen female and male VSC. Additionally, it was recommended that IGSS (Guatemalan Social Security Institute) be integrated into the sub-committee.

In upcoming quarters, MCSP will support training on the new Contraceptive Supplies Logistics Manual to strengthen managerial mentors’ capacities, as well as training and certification of new providers from the first level of attention on the use of contraceptive methods, including long-acting reversible contraceptives (LARCs) and postpartum LARCs.

Activity 9: Support and monitor compliance with USG family planning (FP) and abortion- related legislative and policy requirements. 1.2.9.1. Conduct orientation of staff working with MCSP and monitor compliance with USG FP and abortion-related legislative and policy requirements In Q3, MCSP staff at central and regional offices completed the following online courses: Protecting Life in Global Health Assistance and Statutory Abortion Restrictions– 018 and United States Requirements about Abortion and Family Planning (FP) 2017. Completion certificates for all MCSP staff are available upon request.

MCSP oriented 44 health staff on the legislative requirements and national and international regulations related to abortion and family planning. In Ixil DAS, 22 Auxiliary Nurses, 6 Primary Nurses, and the secretary’s legal framework team were trained. In San Ramón and Barillas Health Centers, Compliance check, Uspantán Hospital, Huehuetenango, participation included one doctor, four ANs, Quiché. Photo: MCSP Maternal Specialist and 10 PNs.

Table 5: Consolidated visits and interviews in primary and second level health care services, including hospitals

Type of service No. of visits Provider interviews User interviews First level 25 17 23 Second level 29 22 45

Hospital 8 6 10 TOTAL 62 45 78

A summary of findings from these routine FP compliance-monitoring visits includes:  No violations identified.  During visits to second level services and hospitals, MCSP reviewed clinical records to verify voluntary informed consent for permanent methods and found that all files had the document duly completed and signed.

13 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018  At the Reinforced Health Center in San Antonio Huista, MCSP verified that the female nurse carried out improvement changes to strengthen the clinic’s privacy as recommended during the previous visit and she was congratulated for her enthusiasm and commitment to making improvements.  The five DAS faced challenges regarding condom supplies since the National Reproductive Health Program (PNSR) recalled all condoms due to technical problems. This issue lasted a couple of weeks and the replacement supplies have already been delivered to all affected DAS.  During visits to health services, MCSP checked and confirmed the availability of Family Planning Guides. While those were readily available, not many facilities had family planning method brochures available. These visits were also used to deliver medical eligibility criteria wheels to providers.

Activity 10: Design and support the use of dashboards to monitor and follow-up quality improvement process that address performance gaps and barriers to access to care. This is the same dashboard reported under Result 1 and Result 4.

Result 3: Strengthened linkages between the municipality and the community to improve community engagement in the co-management and monitoring of health and nutrition services and to create demand.

Activity 11: Support the MOH to develop linkages between health services and communities to create demand for quality services and carry out social auditing processes based on information, taking into account the operational tactics of the PHC model. 1.3.11.1 Increase participation and coordination with civil society and community leaders to collaborate with the MOH in implementation of the PHC model.

As reported in previous quarters, MCSP is supporting MOH in the implementation of the Partnership Defined Quality (PDQ) methodology PLAN AND DESIGN in 17 pilot communities. Due to MCSP’s financial challenges this quarter, activities were slowed BUILD SUPPORT down in May and suspended in June, with expected re-start in July. The start-up process will take at least three weeks, as new dates will be negotiated with the community according to EXPLORE QUALITY leaders’ availability and to ensure participant’s commitment to the meetings. The following summarizes activities and progress achieved at the BRIDGING THE GAP beginning of Q3.  Phase 4 (Working Together) started with preparation of four health quality improvement plans in four communities in the Department of Quiche, two in Totonicapán, and three in Huehuetenango, in

Phase 4, a total of 9/17.  Quiché Department: four communities; members of the community committees for quality improvement have begun to meet to prepare the action plan and support closing PDQ Approach gaps in action plans in the coming months;

14 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 o Ixil Area Health Districts: MCSP provided TA to promote community participation with civil society leaders and workshops replicating the PDQ process were held to share the methodology with DMS staff. Active participation by members of the Social Work/Ixil Area Educators’ Department was key since they replicated three workshops on the PDQ process in the Ixil Area, training 87 individuals in charge of the territory (auxiliary nurses) and Health Area educators. Ixil Area staff have taken the initiative to implement the PDQ in 14 communities on their own. This process will be reported in the following quarterly report. Twenty-seven civil society network leaders (members of the Redmisar, Alianmisar and Men’s Network, including four community leaders from the COCODES) accompany the process promoting links and contact with the community to encourage their participation and improvements in the monitoring and social audit processes in a pro-positive and participatory manner.  Totonicapán Department: two communities in Phase 2 (exploring quality)  Huehuetenango Department: three communities, where there had already defined action plans; one community is in Phase 3 (closing gaps), where the community assembly is pending;  San Marcos Department: MCSP restarted work on Phase 1 (creating support) and advanced to Phase 2 in the five communities.  In May, there were celebrations commemorating Women’s Health month and Mothers’ Day in six priority municipalities in Quiche, Totonicapán and Huehuetenango. A total of 529 participants benefitted in the

Mothers’ Day Panel- Forum in Mothers’ Day celebration in Nebaj. Photo: Mothers’ Day Celebration in Huehuetenango. Photo: Efren Gutiérrez, Bayron Palacios, MCSP SBCC Specialist Momostenango. Photo: Alejandra Morales, MCSP SBCC Specialist MCSP SBCC Specialist

six municipalities (229 in the Ixil Area, 200 female community leaders from Huehuetenango and 100 from Totonicapán). Health Fairs and forums with female community leaders to raise awareness about the importance of health and nutrition for mothers were also held in several other municipalities. These activities were supported through MCSP’s cost-share funds from GlaxoSmithKline/SCUK-GSK. The month of responsible parenthood and Fathers’ Day celebrations were commemorated in June in three priority municipalities in the Department of Quiché (Cotzal, Chajul and Nebaj) and one municipality in Huehuetenango (Chiantla) with support from GSK cost-share funds.

Fathers and male community leaders of the health districts were invited to present participatory workshops about the active role of fathers in child rearing and their engagement in benefitting women’s health and nutrition, pregnant women and children under 5 years. A total of 379 community members, district and community leaders participated (184 from the Ixil Area, 100 from Huehuetenango and 95 from Totonicapán).

Through support with MCSP cost-share funds, MCSP hosted an award ceremony for the “Photography in the Mother’s Health Framework” competition. The event was organized jointly with the Young Artists for Social Justice Network and several other organizations. MCSP supported selecting winning photos and presented on teenagers health and nutrition Award ceremony for the Photography situation during the forum. Competition, Mother’s Health theme. Photo: Haydée Lemus, MCSP SBCC Advisor

15 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 1.3.11.2 Improve knowledge of MOH personnel responsible of selected territories about processes for community health situation analyses implemented by community groups. As follow-up to commitments acquired during Q2 with PROEDUSA/central level to strengthen capacities and knowledge of MOH staff in charge of executing community processes and analyze community health, Q3 trainings were conducted on the PDQ methodology with the 3 Health Districts of the Ixil Area and 30 districts of San Marcos. In the Ixil Area, the training took place by municipality on April 17, 18 and 24, 2018 in coordination with staff in charge of health promotion and MOH technical teams to transfer the PDQ process Celebrating Responsible Parenthood Month. methodology. In total, 87 participants were trained, including professional Cotzal. Photo: Pedro Sajic nurses, educators, rural health technicians, sanitation inspectors and auxiliary nurses. During the workshop, district staff prioritized 14 communities in which they will conduct a pilot project to expand the community mobilization strategy through the PDQ methodology. These 14 communities include two communities in Nebaj (Rio Azul and Vicalama), five in Chajul (Chel, Xolcuay, Amajchel, Pal and Santa Rosa Morelia) and seven in Cotzal (San Felipe Chenla, Vichivala, Chichel, Villa Hortencia 1, Villa Hortencia 2, Villa Hortencia Antigua and Buenos Aires).

Replication workshops directed to DAS Ixil territories’ staff. Photos Byron Palacios, MCSP SBCC Specialist

In May, MCSP conducted a training for San Marcos staff from 30 health districts. The DAS’ approach to train health staff responsible for promotion is intended to achieve 100% implementation in these districts. These Health Districts plan to start the PDQ process on their own in one community per district, totaling 30 pilot communities in that DAS. MCSP will provide accompaniment for the DAS and the Health Districts of San Marcos once the pilot project starts.

Workshop for health promotion coordinators of the San Marcos Health Districts. Photo Sandra López/Alejandra Morales.

1.3.11.3. Strengthen the capacity for analysis of the health situation at the community level and prioritization of problems and risks related to the community and health /nutrition services provision (PDQ process).

16 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 In April, MCSP stopped working in the communities of the Aldea and Cantón Checambá in the Sibinal municipality due to difficulties in access caused by a landslide and road closure. Activities were re-directed to the communities of Rio Hondo and Nueva Esperanza in the municipality of San Lorenzo, in agreement with the Health District. Table 6 summarizes PDQ’s progress to date.

Table 6: Communities prioritized and level of progress by PDQ Implementation Phase

INDICATOR Rate of target communities (n=17) with quality improvement committees or groups trained. Achievements and progress outcomes of Phase 1: Establish support – summarized below: 1. Discussion with community leaders (facilitators, health care providers, 17 / 17 communities with process completed religious leaders, community leaders, youth, midwives, others mapped) 2. Obtain support and commitment from community leaders. Identify 17 / 17 communities with process completed vulnerable groups. 3. Train civil society members as volunteers to implement the PDQ process at 17 / 17 communities with process completed community level, trained about the PDQ methodology and basic principles of 27 / 27 Civil society facilitators trained about gender roles. PDQ Achievements and progress outcomes of Phase 2: Exploring quality – summarized following: Meeting with vulnerable groups (mothers, pregnant women) 14 / 17 communities with process completed Meeting with male and religious community leaders 17 / 17 communities with process completed Meeting with influencer group of midwives, grandmothers (elders) 15 / 17 communities with process completed Meeting with health care services providers in the community (P/S) 15 / 17 communities with process completed Achievements and progress outcomes of Phase 3: Closing the gap - summarized following: Community assembly to identify and prioritize problems identified by the community and health service (previously discussed during separate 9 / 17 communities with process completed meetings) Establish the Quality Improvement Committee (with community members 9 / 17 communities with process completed and health care provider) 4 / 4 communities in Quiché with process completed 2 / 4 communities in Totonicapán with process completed

3 / 4 communities in Huehuetenango with process completed Pending: 5 communities in San Marcos and 2 in Totonicapán Achievements and progress outcomes of Phase 4: Working together - summarized following: Develop the community action plan that approaches problems identified 9 / 17 communities with process completed. during Phase 3: tree of problems, tree of solutions, and community action Action plans defined plan Implement activities according to community work plan (progress according to dates stated in the action plan) 7 / 17 communities with at least 1 activity  PHASE IN PROCESS. NO COMMUNITY SESSION TOOK PLACE IN implemented out of 5 activities included in each JUNE DUE TO MCSP FIELD TRIP LIMITATIONS. action plan  IN QUICHÉ: the project managed to coordinate with PAHO/Inter-

Agency Group for the Nebaj Area delivery of supplies for midwives THIS PHASE WILL BE RETAKEN DURING THE in four communities. Quality committee members received FOLLOWING SIX MONTHS (Q4 FY2018 and training about the use of Wheel of practices to live Q1FY2019) better/nutrition.

Mentoring and Support for Quality Improvement Community Committees established who are in charge of implementing the Action Plan and closing During Q4 FY2018 to Q1 FY2019 gaps Source: MCSP Partnership Defined Quality –PDQ data sheets. Phase 1-Creation of Support, Phase 2-Exploring Quality, Phase 3- Bridging the Gap, Phase 4-Working Together. 17 communities of nine prioritized municipalities. Preliminary Data

See Annex 3: PDQ Participants Table for tables with data about the PDQ process as follows:  Table 1 – Number of participants in the PDQ process by gender and by phase, disaggregated by vulnerable and influence areas for each Department

17 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018  Table 2 – Quality improvement community’s /community committees with action plans, training and key gender and health promotion activities (Phase 4 – Working together)  Table 3 – Institutional staff trained about PDQ: civil society facilitators, DAS, health districts. The following pictures show the community works

Community session as part of Phase 3- Closing the Gap. Ilom community. Photo by Byron Palacios, SBCC Specialist

Training meeting about Wheel of Practices to live better; Santa Avelina and Xix communities. Photo by Byron Palacios, SBCC Specialist

Pamaría: Influencer Group: grandmothers, mothers-in-law and midwives. Photo: Alejandra Pamaría and Pacorral Influencer Group: Leaders, husbands Morales, SBCC Specialist and religious leaders. Photo: Alejandra Morales

Quality Improvement committee in Chexap. Quality Improvement committees’ selection, Aldea Photo: MCSP Team Huehuetenango Paquix, Chiantla. Photo: MCSP Team Huehuetenango

18 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Activity 12: Actions to promote and support governance of civil society and the community. 1.3.12.1 Facilitate tools for social auditing and plans to provide follow-up within the framework of Development Councils. The monitoring tools to conduct social audits were developed within the framework of the 1000 Days Window. The digital app was developed and validated with civil society leaders over the past months. Progress in Q3 is reported under the Monitoring and Evaluation section of this report.

Activity 13: Strengthen response capacity and community resilience to disasters and health and nutrition emergencies. MCSP participated in meetings held by the emergency cluster for child protection led by Save the Children/Guatemala and the nutrition cluster led by UNICEF, providing input and technical guidance on infant feeding practices including promotion of breastfeeding, safe handling of water and foods, and review of SBCC materials related to nutrition in emergencies.

1.3.13.1 Development of community emergency plans and implementation of new critical pathways for reduction of maternal and neonatal deaths. See Sub-activity 1.2.7.2 for an update on the progress of expansion into new critical pathways.

Activity 14: Develop strategy for respectful care in RMNACH/N See Sub-activity 1.2.6.2 for an update on the progress towards the respectful care strategy.

Result 4: Improved knowledge, competencies, and skills of health workers in the areas of RMNCH/N

Activity 15: Design a strategy for continuous in-service learning and capacity building for health providers. 1.4.15.1 Preparation, review and approval of the program proposal Implementation of the proof of concept for Continuous Service Delivery Improvement via 16 identified clinical skills is shown in illustration 1, which shows the steps and key actors for integrating clinical capacity building, mentoring and quality measurement processes in the prioritized health services. Currently, MCSP is in Step 3: Training and certification of clinical mentors. During this quarter, MCSP also defined, established and validated checklists to certify providers in mentorship and Clinical Packages for the DOB and Postpartum FP. MCSP has also secured anatomical models to support the training of clinical competencies.

Tools to systematize DAS and Hospital information were also developed during meetings held to review progress in the proof of concept. MCSP also developed a list of MOH personnel participating in the Mentorship approach that will be used to track their progress in mentorship and clinical skills certification.

Dr. Karem Morales, coordinator of the PNSR family planning component, convened institutions that provide FP capacity strengthening to present the Strategic FP Plan for 2018 and to promote collaboration across each intuitions’ activities. MCSP was asked by Dr. Gustavo Batres, coordinator of the maternal mortality ministerial technical committee, to present this proof of concept to enable the National Reproductive Health Program to engage in the strategy and provide follow-up to at the DAS level.

In Q4, MCSP will hold coordination meetings with the DAS, teacher’s committees and district directors to present progress and achievements in mentorship. A regional meeting will be organized with participation from reproductive health facilitators of the National Reproductive Health Program to update the Mentorship Pathway and present lists of mentor teachers, managerial and clinical providers for each health care service included in the proof of concept since they will be responsible for institutional follow-up. MCSP will also provide follow-up on the postpartum LARC strategy at the central level.

19 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 RUTA DE CAPACITACIÓN A. CAPACITACIÓN B. MENTORIA

QUE CON QUIEN

1 Asesor Tecnico Capacitación ------Consejería ------Especialista ------DIU ------REALIZADO PEDIENTE A ------con - IH clientes ------A

Mentoria Asegurar Asesor Tecnico 2 la competencia de ------

INTERNO mentoria/certificación ------Especialista ------EN CURSO B ------proveedor ------clientes ------B

Linea basal Paso 1

A Capacitación Asesor Técnico + Especialista Mentores ------3 Menetoria/Capacitación ------Asegurando las ------Maestros Clinicos (DAS) ------competencias de mentores y A+B ------B Mentoría las competencias clinicas de Proveedores ------paso 1 --- -B------Clientes ----Clientes A

C Calidad

Mentoría/Capacitación Especialistas + MM Clinicos 4 Asegurando las ------competencias de mentores y ------MM clinicos (en servicio) ------las técnicas clínicas de paso 2 A+B ------Proveedores ------B---- Clinentes Clientes A

Mentoria Especialistas + MM mentores 5 para fortalecer las ------+ Mentores clinicos ------SERVICIOS competencias clínicas de los B -Proveedores --- proveedores ------Clientes B

Capacitar en Especialistas + 6 CALIDAD ------MM clínicos (entran pasos de calidad) ------C ------Mentores clínicos ------se forman equipos de calidad

Especialistas + MM clínicos Calidad 7 + Seguimiento C Mentores clínicos + equipos de calidad

Illustration 1

Activity 16: Organize and provide technical assistance to training centers in Quetzaltenango, San Marcos and Quiche and local mentor teams, on clinical capacities, continuous quality improvement and mentorship in at least six DAS and six DMS 1.4.16.1 Use the three Regional Training Centers implemented under PSI/PlanFam, establish local mentoring teams to build capacity of DAS.

20 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 MCSP has worked closely with the regional training centers (located in Quiche, San Marcos and Quetzaltenango) in order for them to become the central training sites for all clinical competencies. As training in Permanent Methods (Quiche), Long Acting Reversible contraceptive (Quetzaltenango)

1.4.16.2. Develop mentor profiles by technical area and train mentoring staff to implement the peer- to-peer capacity-building strategy, either in person, in distance learning sessions, or in combination of both During this quarter, MCSP helps virtual monitoring meetings to identify support needs for general managers (management mentors) and clinical specialists (clinical mentors) in regards to RMNCHA+N programming. MCSP created a tool in Excel to identify gaps in compliance with the “Mentorship Critical route” using the six steps designed for compliance and improvement of mentorship implementation in the RMNCHA+N programs package, required for mentors’ certification.

During Q3, MCSP completed phase 1 of the proof of concept for continuous services delivery improvement (these were preparatory phases in which MCSP staff capacity was strengthened in both mentoring and clinical competencies). At the time of this report all MCSP specialists were certified in mentorship, and step-down of mentor training and certification began, including site visits for direct observation of providers trained in mentorship (using the mentor verification tool).

In Q3, MCSP also started phase 3 of the mentorship proof of concept (see Illustration 1), including certification of mentors on mentorship principles and training on clinical competencies. See Table 7 for results to date.

Table 7 : Advances in Mentorship Proof of Concept (Total per DAS) Clinical Mentors Trained on Certified on Certification in Health Area Trained in Clinical Mentorship Mentorship Clinical Packages Directorate (DAS) Packages (16 *MT **MM Principles Principles (16 competencies) competencies) San Marcos 27 14 15 in process 5 5 Totonicapán 6 1 *0 (training 1 1 programmed for July) Quetzaltenango 7 3 7 in process 1 3 Huehuetenango 21 12 9 in process 0 2 3 Quiche 29 5 7 in process 9 5 Ixil 11 2 4 in process 3 4 TOTAL 101 37 42 21 21 *Mentor Teacher; **Managerial Mentor

Left to right: Mentorship visit-certification for provider in Huehuetenango. Photo: Michel Sum, MCSP Specialist; Training clinical mentor, PPPF CAIMI from Cuilco Nebaj Hospital, Photo by Ana Maria Us, MCSP FP/Youth Specialist

21 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 In Q4, mentor and clinical competency certification will be ongoing in all sites and MCSP will continue to present progress to the DAS and jointly plan next steps. On average, there are 2-3 providers per prioritized facility, which is approximately a total of 30 providers.

On the road to a sustainable mentorship approach… The Quiché DAS is committed to improvement processes and has seen the advantages of the mentorship approach through their initial experience with it. They have already taken the initiative to plan to expand the mentorship principles’ training to a larger number of health providers than planned under MCSP (including nursing staff in the Quiché Regional Hospital; Chichicastenango CAP; Sacapulas CAP; and Uspantán District Hospital). The purpose of this expansion is to raise awareness and capacity for the mentorship approach in order to contribute to a change in attitudes of health providers to improve communication and (top) Mentorship Principles Training in CAP of quality of their work. Chichicastenango. Photo by Sandra Mendez, MCSP Maternal Specialist (bottom) Clinical Mentors Training at the San Marcos Hospital. Photo: Vilma Velasquez, MCSP Maternal Specialist Activity 17: Support clinical, mentoring and peer- to-peer capacity building, including the use of dashboards and quality improvement approaches by mentor teams in the regional hospital of Quetzaltenango and in departmental hospitals, DAS, DMS and CS –10, CAP and CAIMI. See results reported under activity 1.4.16.2. No additional activities to report during this quarter. Activity 18: Ensure continuous quality improvement of competency-based performance for RMNCAH/N providers in training centers, hospitals, DAS, DMS, CAP and CAIMI. During this quarter, MCSP held meetings with UNPFA, PAHO and UNICEF to coordinate quality improvement activities supporting the MOH, particularly in regards to the National Reproductive Health Care Program and around strengthening of a quality management system for child health services. The document “Guia del Monitoreo y Evaluación de la Mejora Continua de la Calidad en Atención Maternal y Neonatal” is under development will include quality indicators, standards, criteria and guidelines to establish internal quality teams at health care services.

Strategies that MCSP is supporting the MOH to implement aim to strengthen the four pillars1 for the reduction of maternal mortality. This past quarter, MCSP’s related efforts in Huehuetenango included:  In the Maternity Unit in San Sebastián, MCSP provided technical support to the internal quality teams to review and update sample stamps used to facilitate documentation processes on compliance with care standards and criteria previously documented (for example, surveillance of vital maternal signs during the immediate postpartum period).

1 1. Proveedor calificado, 2. Red de servicios de calidad y entorno habilitante. 3) Planificación familiar y 4) Vigilancia de la muerte materna y neonatal

22 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018  In Cuilco CAIMI, MCSP provided posters on Treating Pregnancy Complications. The childcare head nurse, a member of the internal quality committee and clinical mentor, received the materials (Photo B).  In San Sebastián CAP MCSP provided Guides on Essential Care of Newborns and Small Babies. These training materials are supporting capacity building in MNH care (Photo A).  Materials on the immediate care of the newborn were delivered to the Head of the Pediatrics Units at the Huehuetenango Regional Hospital (Photo C).  In the Huehuetenango Hospital, participation of a spouse/partner in the care of the newborn is encouraged to strengthen actions in services and providers’ competencies of providers about comprehensive mother-newborn care (Photo D).

Photo A: Michelle Sum, MCSP MNC Specialist Photo B: Michelle Sum

Photo C: Ericka López/ MCSP Maternal- Neonatal Specialist. Photo D: Michelle Sum

Activity 19: Technical assistance to the MOH to implement Helping Babies Breathe (HBB) Strategy to health care providers in WHIP area (Selected Health Services) No activities to report during this quarter

Activity 20: Support the initiation of the Guatemalan Midwifery Career Path, contributing to the development of new cadres of skilled health providers 1.4.20.3 Support the implementation process of the first cohort of the Midwifery Technical Career (MTC). In April, MCSP held a 5-day workshop facilitated by professors from the San Martín de Porres University in Peru for 18 teachers from the Da Vinci and Pan-American Universities to train them in teaching methodology, the curriculum, and practice under the MTC. Topics addressed included self-evaluation, checklist, digital portfolio, objective tests, use of seminars, discussion based on cases of study, inverted classroom, simulation, case studies and critical thinking. MCSP also supported the establishment of the MOH midwifery technical working group that includes a Ministerial Agreement, which incorporates cooperation agencies, including MCSP. Financial availability to provide 50 midwifery scholarships for two years for the first cohort of midwifery students, as per agreement UPDA-167-2018 allocated to budget heading 416, “Scholarships for local studies”.

23 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018

Training workshop targeted to teachers of Da Vinci and Pan-American Universities. Photo: MCSP/Guatemala

Midwifery workshop teaching team. Photo: MCSP/Guatemala

24 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 OBJECTIVE 2: Increase visibility, collaboration and multi-sector efforts in the prevention of chronic malnutrition in the Western Highlands.

Result 1: The National Strategy for Prevention of Stunting is implemented at the national level and in 13 prioritized municipalities Activity 1: Inter-sectoral coordination (national and local) with municipalities, SESAN, and CONASAN 2.1.1.1: Participation and inter-sectoral coordination with national and local government groups, USAID, and partners linked to the implementation of the National Strategy for Prevention of Chronic Malnutrition MCSP participated in several inter-sectoral coordination meetings across different municipalities in the Western Highlands and included the following:

Municipality Purpose and MCSP’s participation

Quiché, Food and  Analysis and discussion of malnutrition as part of the situation room implemented by the three Nutritional Security Health Areas. Departmental  Exchange with other projects, including FUNCAFE (organization that will work the Seguridad Commission(Comisión Alimentaria Nutricional (SAN) policy in Cunén and Sacapulas) and FUDI, which will promote Departmental de SAN in the two aforementioned municipalities, supported by USAID. Seguridad Alimentaria  The CODESAN included representatives from the MOH, MINEDUC, DMM, DMP, SESAN, SOSEP, Nutricional/CODESAN) MCSP and other NGOs

April 16, 2018 June 18, 2018 Sacapulas, Food and  Technical support for selection of food distributed to families with acute malnutrition (8 cases), Nutritional Security which were collected with funds obtained from a fundraiser organized by the Mayor’s Office. Municipal Commission  The Wheel of Practice was promoted in the COMUSAN, sharing the counselling cards that can (Comisión Municipal de be used to guide the actions for the prevention of stunting. As a result of this presentation, Seguridad Alimentaria the COMUSAN will use the wheel practice counselling cards and the wheel of practice as part Nutricional of their home visits /COMUSAN)  The importance of nutritional foods and diet diversity was promoted in the meeting of June  An instrument was developed to support the household visits. May 8, 2018 June 12, 2018 Nebaj, COMUSAN  Socialize the banner of the Wheel of Practices to Live Better to members of the Municipal Food and Nutrition Council of Nebaj who represent MIDES (Ministry of Development), MAGA May 17, 2018 (Ministry of Agriculture), MOH, SOSEP (Secretaría de Obras Sociales de la Esposa del Chichicastenango, Presidente/ Secretariat of Social Welfare of the Wife of the President), Coordinator of the COMUSAN Municipal Council, local NGOs/projects (Paisano, Verde y Azul)  A presentation of the wheel of practice was made in one of the meetings of the COMUSAN, May 9, 2018 focused on the actions for the prevention of stunting, using the counselling cards June 13, 2018 Chiantla, COMUSAN  MCSP presented the results of the mapping of actors in favor of food and nutrition security in the municipality. April 5, 2018  A brief presentation was also made on the National Strategy for the Prevention of Chronic Malnutrition. Chiantla and San  Continuing education sessions were held with members of the COMUSANES. Sebastian  Case studies and actions carried out at institutional level regarding the First 1000 Days, as well Huehuetenango, as actions carried out in favor of the National Strategy for the Prevention of Chronic COMUSANES Malnutrition were reviewed. Chiantla: April 26, 2018

25 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 San Sebastian: April  Based on the analysis made, it was evident that more emphasis is being placed to address 17, 2018 acute malnutrition instead of stunting, emphasizing the importance to prioritize stunting and implement the nutrition specific and sensitive interventions. Expo SAN  An educational expo was planned with the CODESAN to share with 600 students from diverse education centers in the Department of Huehuetenango about good health and nutrition June 5-6, 2018 practices for pregnant women and children younger than 2 years of age, as well as identify actions that each participating institution is executing to prevent chronic malnutrition.  Themes promoted included the following: correct way to wash hands; Wheel of Practices to Live Better focused on the 1000 Days Window; condom use; using agricultural resources to increase availability and consumption of nutritious foods (protein and micronutrients; and food and nutritional security.  Representatives from the following institutions participated: MOH, SESAN, MIDES, DIACO, MAGA, MARN, CONRED, INAB, MINTRAB, DIDEDUC, SEPREM, Departmental Governor’s Office, CONAP, FONTIERRAS, INFON, and SEGEPLAN. Acute malnutrition  The first workshop took place in Santa Lucía Reforma, Totonicapán with participation of 23 protocol workshop and individuals and 3 facilitators Types of Malnutrition  The second group included 29 participants (physicians, professional nurses and auxiliary (Group 1 and Group 2) nurses) and 3 facilitators from the health posts, providing information related to the different types of malnutrition (undernutrition: stunting, acute and micronutrients) and over nutrition. May 2: Group 1  The second group May 9, Group 2  The acute malnutrition protocol of MOH was shared with the participants

Left to right: Sacapula’s COMUSAN (Photo: Gladys Miranda, MCSP Nutrition Specialist); Expo SAN participants in Huehuetenango; Expo SAN demonstration of handwashing practices (Photo: Ericka López, Nutrition Specialist).

2.1.1.3: Facilitation of the municipality process to prioritize nutrition interventions, i.e., baby-friendly communities MCSP is preparing to facilitate the incorporation of nutrition interventions in municipal plans of eight municipalities: 1) San Lorenzo, 2) San Miguel Ixtaguacán, 3) Tajumulco – San Marcos; 4) Concepción Chiquirichapa – Quetzaltenango; 5) Nebaj, 6) Chichicastenango – Quiché; and 7) Chiantla, 8) San Sebastián Huehuetango – Huehuetenango. The work will lead to a proposal of the 2019 Annual Operation Plan (AOP) presented to and approved by the Municipal Development Council (COMUDE).

MCSP is also developing and implementing the online course “Increase in municipal investment to prevent chronic malnutrition”, aimed at staff of the Municipal Planning Directorate and the Financial Administrative Directorate of the Mayor’s Offices in the 30 prioritized municipalities. The 5-week course will be implemented on the virtual platform of the Administrative Financial Assistance Municipal Directorate (DAAFIM/MINFIN). This activity is being designed in close collaboration with the DAAFIM.

There have been some delays in the implementation of the online course due to a change in Director of DAAFIM. However, MCSP has already held coordination meetings with the new director to ensure that the course will be implemented through MINFIN’s online platform. The course is now expected to begin in October 2018.

26 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 2.1.1.4: Conduct Micronutrient Malnutrition Technical Consultation meeting with MOH and Western Highlands partners to identify key priorities for addressing micronutrient deficiencies in Guatemala, building on key outcomes of the February 2016 Micronutrient Malnutrition Technical Consultation meeting and the MCSP follow-on in May/June 2017 As reported in the last quarterly report, MCSP held a technical consultation on the “Review of the Status of Micronutrients and Intervention Performance: Progress and Next Steps in Guatemala.” The objectives were to a) present the current situation of micronutrients in Guatemala, b) share experiences related to prevention, control and reduction of micronutrient deficiencies, c) identify possible toxicity risks with specific micronutrients in Guatemala; and d) analyze gaps, barriers and facilitators for the prevention, control and reduction of micronutrient deficiencies. International and national experts from the central and local levels of the MOH, the MOA, INCAP, Center for Disease Control (CDC), the Harvest Plus program/International Food Policy Research Institute (IFPRI), and USAID participated in the consultation.

The final report developed in Q3 included recommendations to the MOH to review and adjust the guidelines regarding Vitamin A supplementation, which will be included in the New Healthcare Norms in process of being published, the recommended change / adjustment has been accepted by the MOH. See Annex 4: text of recommendation/Modificación de la Norma de Suplementación con Vitamina A for full report details.

Activity 2: Strengthening the service network in promotion, incorporation and achievement of specific, critical actions to reduce malnutrition. 2.1.2.1: Provide technical assistance for the preparation of an operational guide for the prevention of stunting for health services in first and second level of attention. This is planned for Q4.

2.1.2.2: Identification of gaps in competencies for application of specific nutrition interventions, including growth monitoring The training related to the nutritional evaluation of children < 5 years of age took place in the health post of El Porvenir, with participation of the Nutritionist from the Health Area Directorate of Huehuetenango. The training addressed key concepts related to anthropometric measurement technique and counseling for mothers or caregivers.

Left to right: Training for health post staff at El Porvenir; counseling mothers about feeding children under 5 years in Aldea el Porvenir. Photo: Ericka López, MCSP Nutrition Specialist

27 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 2.1.2.3: Strengthening capacities and competencies of health care providers to address specific, critical nutrition actions, taking into account recommendations of the Maternal/Child Nutrition Diploma Program The first workshop to train facilitators of the “Mother Child Nutritional Strengthening at the First Care Level of the Ministry of Health and Social Assistance Program” took place in May in Quetzaltenango and included health staff from the 30 prioritized municipalities. The program was presented during that session and materials were provided to participants. See Annex 5: Manual de Bolsillo for additional details. Start-up session of study circles lead by 2.1.2.4: Secondary analysis of information using ENSMI auxiliary nurses and facilitators in 2014/2015 at national level and in prioritized departments. Huehuetenango. Photo: Ericka López, The draft report with preliminary results has been shared by INCAP MCSP Nutrition Specialist and is currently being reviewed by MCSP.

2.1.2.5: Strengthen technical capacities of MOH for monitoring and surveillance of GMP and nutritional evaluation of pregnant women MCSP and INCAP are collaborating with the MOH’s Monitoring and Evaluation Unit to prepare a guide to support supervision processes in nutrition. The supervision guide will be implemented in September – October 2018 in health posts with auxiliary nurses who are participating in the Maternal Child Nutrition Diploma Program.

Activity 3: Strengthen participation of community through civil society engagement for nutrition service demand and monitoring 2.1.3.1: Technical assistance to SESAN to pilot the implementation of the growth mat and counselling messages This activity has been completed and the report has been shared with SESAN.

2.1.3.2: Collaboration and coordination with USAID partners (HEP+) to strengthen civil society capacities in demand creation and monitoring of nutrition services This activity is reported in Result 3 regarding civil society.

Additional Activity: Exchange of experiences between Mexico-Guatemala-United States in their efforts to reduce stunting In May, MCSP supported hosting of Drs. Juan Rivera, Director of the National Institute of Public Health of Mexico (INSP) and Anabelle Bonvecchio, Nutrition Polices and Programs Research Director at INSP, to share experiences, lessons learned and best practices of Mexico’s experience in the reduction and prevention of chronic malnutrition over the last 20 years. During the two-day visit, six sessions took place with participants from SESAN, civil society (INCOPAS, ALIANMISAR and FUNDESA/Nutrition Alliance), CONASAN, the Food Security and Health Commissions from Congress, academia and donors.

28 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 The representatives from INSP shared successful experiences in the following: 1) use of an effective multisector approach, implementing nutrition specific and sensitive actions; 2) evidence-based interventions; 3) focused interventions, such as the first 1000-Days aimed at at-risk groups; 4) effective coverage rates (scale-up, inclusion of all children under 2 years of age in focus areas); 5) ensuring the delivery of quality products and services; 6) demand and adequate utilization of services by target groups; 7) strengthening staff competencies and facilitated supervision; and 8) a strong monitoring and evaluation system. Mexico’s experience in reducing stunting is relevant to Guatemala’s situation and potential in reaching similar results given the existing policies, legislation, and a national strategy for the prevention of stunting. SESAN is committed to identifying ways to strengthen the effectiveness of multisectoral efforts, defining a pathway to implement nutrition sensitive and specific interventions, strengthening monitoring and evaluation efforts of the strategy, and identifying ways to increase the allocation of resources to vulnerable groups. See Annex 6: Report of Meeting for additional details.

Left to right: Panel session with participation of Armando Barreno-INCOPAS), Sandra Batz-ALIANMISAR), Adonai Cajas- FUNDESA/Nutrition Alliance and Juan Rivera-INSP; Opening remarks from CONASAN, Tanya Urquieta Deputy USAID; Opening remarks from CONASAN session by Vice President, Dr. Jafeth Cabrera; Vicky Stein, USAID/Guatemala Health and Education Office Director, participating in sessions. Photos: Haydee Lemus, MCSP SBCC Advisor

29 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Monitoring and Evaluation Please refer to Annex 8 for a full report on the results on PMP indicators.

Secondary Analysis of ENSMI data During this quarter, INCAP shared a second draft of the report of profile of indigenous women of five Mayan groups of Guatemala, derived from the secondary data analysis of ENSMI 2002 and 2014-2015. Feedback was provided by MCSP and the results of the bivariate analyses will be presented next quarter.

Health and Nutrition Surveillance System (SIVESNU) in Huehuetenango, Guatemala Table 13 has been updated to illustrate the progress between April and June 2018:

Table 13: Progress of activities during April – June, 2018 Activity programmed Status 1. Prepare technical document, adjustments to protocol, instruments and Completed first week of February Informed Consent 2. Approval by Ethics Committee of MOH and Save the Children Completed: Second week of February 3. Tablet configuration and testing Completed: First week of March 4. Selection of 50 cartographic sectors Completed: Last week of March 5. Cartographic update of 50 sectors Completed: Last week of June 6. Prepare field operations plan Completed: Second week of March 7. Staff refreshment and re-standardization Completed: First week of April 8. Purchase of lab supplies and office materials Completed: First week of April 9. Administrative paperwork: contracts, vehicle rental, per diem, petty cash In progress 10. Development of socialization activities about implementation of Completed: First week of May departmental SIVESNU with officers from SESAN, National Police, Municipal Mayors and Governors 11. Data collection in cartographic sectors In progress 12. Synchronization, cleaning and preparation of the data base In progress

The sample design proposed by the TA teams of the Center for Disease Control and Prevention (CDC) and INCAP includes visiting a sample of 1516 homes, equal to 50 cartographic sectors. The National Statistics Institute (INE) carried out the random selection of 50 representative sectors for Huehuetenango.

Training of field staff, including standardizing anthropometric measurements, took place in April. Anthropometrics were standardized and re-standardized on usual anthropometric measurements: length/height, weight in children; height, weight and waist/hips in women, taking into consideration pilot testing using “body imaging” methodology (taking body measurements) for children younger than five years of age. There was also a session to refresh staff knowledge about taking water samples in homes and their analysis to verify presence of coliforms and fecal coliforms.

The field phase started in April; to cover sampled sectors, four micro-regions were defined to group those sectors closer to one another. They are presented in table 14:

Table 14: Municipalities participating in SIVESNU Huehuetenango Group Municipalities in the Group Southeast Huehuetenango, Chiantla, Aguacatán, Malacatancito, Santa Bárbara Northeast Barillas, San Miguel Acatán, Santa Eulalia, Soloma, San Juan Ixcoy, San Rafael la Independencia Nentón, Santa Ana Huista, San Antonio Huista, Jacaltenango, Concepción Huista, Todos Santos Northwest Cuchumatán La Democracia, La Libertad, San Pedro Necta, Santiago Chimaltenango, Colotenango, San Sebastián Southwest Huehuetenango, Ixtahuacán, Cuilco

30 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Initial communication with department and municipal authorities in Huehuetenango took place in May, including leaders and representatives from communities and hamlets of the cartographic sectors to visit. During each of the visits to the Governor’s Office, SESAN Departmental Delegation, Mayor’s Offices and Police, official letters were handed and providing a brief explanation about the process. As a result, contacts were established with members of the community councils to be able to enter communities without problems.

Throughout the field phase, security copies of the different synchronization files have been made. Additionally, each of the synchronization files has been exported to integrate all of them into a centralized database. Validation checks are periodically made to find any inconsistency in records with each database; inconsistencies are addressed as they are discovered.

As of 5 July 2018, SIVESNU data collection teams had visited a total of 1290 urban and rural households over 43 mapped sectors, covering 950 women of reproductive age and 540 children under the age of five years. Data collection has also included, in households accepting to participate, samples of food and water from households, along with biometrics and biological samples.

Development and implementation of e-health tools During Q3, there has been progress in the indicator dashboards to be used by Municipal Health Districts. In June, SIGSA approved the concept note and workplan, which has a duration of fourth months, beginning in July 2018. Work phases are presented in Table 15.

Table 15 Summary of activities related to district level indicator dashboard development Work Phase Description Dates Phase 1: Conceptual Review existing indicators July 6 and 12 Technical meeting with SIAS, SIGSA, PNI and Epidemiology Department. July 20 Technical meeting with SIAS, SIGSA, PROSAN and Epidemiology July 24 Department Technical meeting with SIAS, SIGSA, IRAS, ETAS and Epidemiology July 25 Department Technical meeting with SIAS, SIGSA, PNSR and Epidemiology Department July 26 Adjust indicators’ technical and operational cards July Update SIGSA staff about use of the Tableau® tool August 3 to 10 Phase II: Computer Define criteria to extract information Development Create data repositories (central DB) August Develop ETL projects Validate data September Validate dashboards Phase III: Configure Web-service connection Implementation Install data repository September-October Install and configure tools to execute ETL´s (PENTAHO) Socialize the situation room with central level authorities October Phase IV: Implementation at Train staff from districts and DAS prioritized October local level

Indicators’ mobile app and dashboards to support monitoring interventions of the 1,000 Days Window by civil society During March and April, MCSP worked on automating monitoring forms used by civil society by designing a customized mobile app on the Android system. The monitoring activities are conducted at primary and secondary level MOH facilities.

31 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Nine forms were enabled to monitor the following:  Health facility service conditions,  Availability of micronutrients and other essential supplies,  Good storage practices,  Knowledge of service staff on nutrition supplementation norms,  Review of children’s cards,  Review of pregnant and postpartum women’s card,  Adherence of micronutrients in children, pregnant and postpartum women,  Vaccine availability.

The app allows to store the forms in the mobile device and check if the information is correct, allowing the user to work offline as well. In April, MCSP carried out a workshop with ALIANMISAR and youth volunteers to validate the approach and train them on the use of the mobile app. Field tests took place in five APROFAM office clinics in Guatemala City. Training for the end users took place on April 24 to 26, which included practical experience with data collection in four health posts and two health centers in San Juan Ostuncalco and Concepción Chiquirichapa.

Civil society carried out monitoring visits to randomly selected health services in May and June. In those facilities, interviews were conducted with mothers with children under 5 years of age, pregnant women and female adolescents. The activity included participants from the National Alliance of Indigenous Women’s Organizations for Reproductive Health, Nutrition and Education (Alianza Nacional de Organizaciones de Mujeres Indígenas por la Salud Reproductiva, la Nutrición y la Educación - ALIANMISAR); National Men’s Network; FESIRGUA Association; the Instance for Consultation and Social Participation (INCOPAS); the Young Artists for Social Justice Network; ASOGEN; and accompaniment from the Ombudsman’s Office.

During this period, MCSP provided TA by enabling a WhatsApp chat group in each Department. In June, MCSP began designing the indicators dashboards to be launched on the web by the end of July 2018.

32 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018

Development of the app to monitor care processes From April to June, MCSP worked on adjusting the app presented by NutriSalud, enabled in Microsoft Access, to monitor clinical care processes using a continuous quality improvement approach. The new version includes the following improvements: - Follow-up of outpatient and day-of-birth care processes promoted by MCSP; - Information disaggregated by general and critical; - A graph related to indicator compliance trends and their criteria; - An option to prepare an improvement plan where poor performance is noted so that interventions can be monitored by continuous quality improvement teams (EMCC) at each service.

The app has been designed to allow updating of criteria for indicators already enabled and to include new processes to monitor, as prioritized by the MOH.

Upcoming activities: During Q4, MCSP will be presenting progress in the following:  Work with programs and start designing district level situation rooms;  Meetings to disseminate results of civil society’s monitoring of the 1,000 Days Window of opportunity, including six departmental meetings and one at national level;  Implementation of the continuous quality improvement app in prioritized health districts;  Development of the app to capture mentorship processes.

33 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Collaboration and Coordination Some of MCSP’s key coordination efforts, in addition to those mentioned previously in the report, include the following (additional updates are included in Annex 7: Integrated Weekly News)

GlaxoSmithKline (GSK): MCSP received cost-share funds from GSK for activities aimed at strengthening links between health, nutrition, municipalities and communities. Specifically, activities included improvement of health and nutrition service delivery, creating demand for services and conducting social audits in 10 prioritized municipalities in the Western Highlands, and development of mobile applications used by youth networks. During Q3, GSK supported community health fairs for Mother’s Day and Father’s Day celebrations to promote the importance of MNCH topics to parents.

USAID/HEP+: With support from GSK cost-share funds, continued development of a mobile application to strengthen the capacity of youth networks, supported by HEP+, to monitor the quality and availability of health and nutrition services in first and second level health services. Design and pre-testing of the mobile application is complete and the team has moved onto data collection. The first part of this process contributes to improving data collection for social audit actions. In the second phase, MCSP will develop dashboards to improve use of information for decision-making oriented at improving health and nutrition services: - MCSP collaborates with HEP+ to coordinate participation of civil society leaders and volunteer networks to carry out quality management processes, ensuring adequate and reflective community engagement. - MCSP coordinated with HEP+ on nutrition activities to organize participation of youth leaders in community health fairs organized with the CODESAN and COMUSAN to promote food and nutritional security.

PAHO, UNFPA, UNICEF: MCSP coordinated activities with PAHO in 11 communities of the Ixil Area related to Result 3 (PDQ implementation). The joint PAHO program was developed in this region, promoting preparation and implementation of community development plans. Both projects (MSCP and the Joint Program) agreed to include in the community plan and negotiate actions to reduce coverage and health care quality gaps identified with the PDQ methodology during community assemblies with leaders and facilitators. To support the MOH, the MCSP coordinated with the UN to standardize and launch the childbirth care quality- monitoring manual.

Pies De Occidente: MCSP continued coordinating activities with this NGO in Totonicapán to strengthen the critical pathway of Pologuá in Momostenango, to prevent maternal-neonatal mortality. This is a sustained collaboration to improve effectiveness of the “Critical Pathway” of Pologuá to prevent mother-neonatal mortality. MCSP also provided support to train health care staff to improve their competencies in preventive nutrition services. Both institutions support the MOH in the implementation of the Program to Strengthen Nutritional Skills in the First Care Level.

Mancommunity Mancuerna MANCUERNA (San Marcos-Totonicapán-Quetzaltenango)/Proyecto Nexos Locales-USAID: MCSP coordinated activities with the Mancuerna mancommunity and the Nexos Locales project to strengthen water and sanitation activities in priority municipalities.

Save the Children International, Volcano Fuego Eruption Emergency: In response to Volcano Fuego eruption-related emergencies, MCSP participated in cluster meetings for child protection and nutrition. MCSP provided input and guidance for the development of a proposal as well as technical guidance on health and nutrition issues that are part of the management of the shelters to protect the children and women.

34 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Implementation Challenges During most of the quarter, MCSP temporarily suspended activities and was at risk of closing the program due to the delay of the program’s remaining obligation of funds. Funding delays were the result of delays in the USG’s certification process. In the May-June period, MCSP focused on tasks that did not require incurred costs aside from staff salaries. Additionally, MCSP ensured that relations with the MOH, SESAN, municipalities, and partners at central and local levels remained active until the program could resume activities. Some of MCSP’s activities and processes that were delayed due to the funding challenges included the following (not an exhaustive list):  Technical support in the development of the midwifery program;  Implementation of the online course to increase municipal investment in health and nutrition;  Completion of the training cycle for the mentorship approach;  The PDQ process in targeted communities Another challenge often encountered by MCSP is coordinating timelines with counterparts such as the MOH, SESAN, and municipalities. MCSP has tried to identify ways of integrating its program activities and initiatives within the priorities and workplans of these entities to ensure the most cohesive alignment and technical support. MCSP has also tried to engage new implementing partners and donors such as the IDB, European Union, and the World Bank, whose projects also align with MCSP’s priorities in support of the MOH’s efforts to improve maternal and child health outcomes in the Western Highlands.

Upcoming Activities in the Next Quarter Activities planned for Q4 of FY18 (July 1 – September 30, 2018) include the following:

OBJECTIVE 1 RESULT 1 a) Continued support and TA to the MOH to improve (restore) coverage in RMNCAH/N programs such as vaccination, micronutrient supplementation, de-worming, pre-natal care and growth monitoring of children under 5 years of age; b) Provide TA to consolidate the model of attention in the first level and preparation of operation manuals to support model implementation; c) Strengthen managerial competencies of DAS and DMS through implementation of a semi face-to-face training course for DAS managers and DMS coordinators; d) Provide TA to DAS and hospitals to improve data use and analysis by strengthening the situational rooms through the use of dashboards; e) Development of dashboards for CSOs to monitor indicators of the 1000 Days Window.

RESULT 2 a) WASH  Under the WASH component that promotes the CCA, there will be two workshops: one with MOH central level staff and another with DAS, with the objective of: 1) standardizing and validating the guide to prevent intra-hospital infections; and 2) management of WASH standards according to the CCA;  Preparing improvement plans at the 11 target facilities to close gaps according to assessment results. MCSP expects to start these activities by September 2018. b) Neonatal Care:  As a follow-up to the process of implementing a quality improvement system for MNCH, MCSP will execute the neonatal component through training workshops to develop HBB competencies directed

35 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 to MCSP Specialists to form a team of trainers that will later train clinical health care service providers at six hospitals and 10 services that provide childbirth care (CAP and CAIMI);  MCSP will work with health care facilities’ staff to reorganize and strengthen quality teams for the aforementioned services. Monthly TA visits will be conducted as well as analysis of indicators and implementation of improvement plans. c) Maternal Care:  MCSP will support MOH in establishment of the “Technical Working Group for Analysis of Mother Mortality” whose purpose is to promote and support actions for surveillance, prevention and care of obstetric complications that will contribute to prevent maternal-neonatal mortality. MCSP supports the central level’s MOH team and coordinates its actions with Cooperation Institutions. At the six DAS, MCSP will promote compliance with the maternal mortality surveillance protocol and the neonatal mortality protocol;  MCSP will also provide TA (at central and DAS levels) to optimize spaces for analysis of maternal deaths with a longitudinal approach and identification of critical links;  Along the same maternal mortality prevention line, MCSP will hire three local consultants to strengthen the critical pathways such as local integrated health services and community networks to prevent mother and neonatal mortality. The existing pathways will be supported in Pologuá, Totonicapán; Nebaj in Quiché and San Ramón in Huehuetenango. It will also support establishment of two new pathways: one in Tajumulco, San Marcos and another in municipalities of the northern region of Huehuetenango (Santa Eulalia, Soloma and San Mateo Ixtatán). d) Quality Improvement  MCSP will meet with the UN to standardize and launch the childbirth care quality-monitoring manual.  MCSP will continue advocacy to the Technical Vice-ministry for the approval of the norms and guidance of maternal and neonatal health care for first and second level of attention as well as monitoring and evaluation of quality;  Regional workshop regional to transfer the childbirth care quality services methodology;  Measurement of quality indicators at hospital level for childbirth care;  Second measurement of quality prenatal care, postpartum, newborn and breastfeeding child care in first and second level health care services. e) Youth and Adolescent Care:  Training workshops on systematic offering of contraceptive methods for adolescents (according to legal framework) directed to health care services providers and DAS;  Finalize the training and supervision guide for comprehensive and differentiated care for adolescents;  Finalize the training phase about comprehensive and differentiated care, promoting friendly services, directed to health care providers and DAS;  Workshops with partners (HEP+, Leer Aprender, Puentes, CARE, Pies de Occidente, Nuevos Horizontes and others). Training about differentiated recreational methodologies for ages 10 to 14 and 15 to 19 years of age. f) Assessment of Respectful Care  Finalize the field stage (data collection) and continue to clean and analyze data and prepare reports.

RESULT 3 a) Complete PDQ Phase 2 “Exploring Quality”, and Phase 3 “Reducing Gaps,” based on the progress of the communities prioritized for PDQ implementation. These phases include group discussions with vulnerable community members and members of health services;

36 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 b) Facilitate discussions to promote interaction between clinical and non-clinical health personnel, community health workers, volunteers, and trained midwives.

RESULT 4 This component integrates into the mentorship approach and development of competencies for care of the seven cross-cutting RMNCAH/N themes. The specific themes to be supported include:  Continue training clinical mentors about HBB with official certificates.  MCSP will continue with Active Management of the Third Childbirth Period (Manejo Activo del Tercer Período del Parto -MATEP) and classification and selection of patients according to danger signs (Triage);  For ASRH, strengthening knowledge about differentiated care for childbirth in adolescents younger than 14 years of age in prioritized municipalities, focused on preventing a second pregnancy;  Continue to support the implementation of the midwifery program with the Pan-American University and Leonardo Da Vinci University.

OBJECTIVE 2 Result 1  Specialized TA to selected municipalities to promote municipal investment in health and nutrition projects and coordinate inclusion of these priorities into municipal plans;  In coordination with DAAFIM/MINFIN, design and implement the online curse for municipal management of the operational guide for municipal planning in food and nutritional security;  Implement the Maternal Child Nutrition Diploma Program for auxiliary nurses working at the first level of care, as well as training of facilitators;  Completion of SIVESNU data collection, review data and prepare reports;  Continuous education sessions in Quiché and Huehuetenango to support prevention of chronic malnutrition, SAN, and complementary foods;  Train MOH staff about monitoring and supervision of prenatal care actions and promotion and monitoring of growth.

M&E  The monitoring component will support the MOH (Program to Regulate Care for Individuals) in the process of validating indicators of the situation room. MCSP will work with SIGSA-MOH on the design of dashboards and support training on the Tableau program;  Support socialization of monitoring results through meetings at Department and central levels;  Continue to develop and implement a tool in Microsoft Access for continuous quality improvement. This is meant to support health service staff in documenting outpatient care (prenatal, neonatal, postpartum, breastfeeding mothers and children, family planning), as well as labor and delivery care (detection of danger signs, use of partogram, active management of third stage of labor, immediate postpartum period, immediate care of the newborn, routine care of the newborn);  Conduct the second measurement of enabling environment conditions (as a follow-up to the first carried out in 2017), which will take place in health posts at communities where PDQ is implemented; and at second level services that were monitored during the first measurement. Aspects to monitor include equipment, infrastructure, H.H.R.R., access to technology, documentation and production.

37 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 International Travel - Quarter 3 Name(s) of traveler Scope of Work Dates  Propose of visit: WASH – Clean Clinic Approach Advisory Visit  Dates/location of travel: April 15-28, 2018, Guatemala City with site visits to select departments  Trip report submitted: May 08, 2018  Overview: Stephen Sara, WASH Advisor, visited Guatemala (Guatemala City, Quetzaltenango, Totonicapán) to provide technical guidance and support to WASH country team staff in preparation and facilitation of a national-level WASH in health care facilities (HCF) workshop. Additionally, Mr. Sara worked in close collaboration with the team to begin implementation of the program’s Clean Clinic work.  Results of the visit: Stephen Sara, 1. Reviewed recently collected WASH in HCF assessment data and determined the priority April 15-28, 2018 WASH Advisor improvements for Clean Clinic work. 2. Conducted field visits to share experiences and discuss program priorities/improvements 3. Supported the MCSP/Guatemala WASH team with preparations to host the national WASH in HCFs workshop with USAID, Departmental Ministry of Health offices and other relevant government stakeholders. 4. Co-facilitated national workshop to determine parameters, indicators, roles and responsibilities for relevant stakeholders for Clean Clinic Approach implementation 5. Established the first draft of WASH/IPC indicators and monitoring forms for facilities, delivery rooms and inpatient newborn care spaces along with procurement lists and Clean Clinic implementation guidelines.

Dr. Juan Rivera,  Identify possible areas of collaboration and key actions between the United States and Mexico Director of the to collaborate and support Guatemala in its efforts to reduce rates of chronic malnutrition; National Institute for  Present an analysis on the current nutrition situation in Guatemala, including opportunities to Public Health improve nutrition outcomes;

 Foster the exchange of experiences, best practices, lessons learned, and actions to prevent and May 2-4, 2018 Dr. Anabelle reduce malnutrition. Bonvecchio, Research Director See activity summary on pg. 28-29 and meeting report in Annex 6: Intercambio de Experiencias Entre for Nutrition Policies Guatemala Y México Para Reducir La Desnutrición Crónica, May 2018 and Programs

38 USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018 Annexes

Annex 1: Programa general - Curso para el fortalecimiento de capacidades de Gestión en Salud en el altiplano occidental de Guatemala. Annex 2: Detalle de mediciones de los 6 indicadores del día del parto Annex 3: PDQ Participants table Annex 4: Modificación de la Norma de Suplementación con Vitamina A, para niños de 1 a 5 años de edad Annex 5: Manual de Bolsillo en Apoyo al Diplomado de Nutrición Materno Infantil Annex 6: Informe - Intercambio de Experiencias Entre Guatemala Y México Para Reducir La Desnutrición Crónica, Mayo 2018 Annex 7: Q3 Weekly News Annex 8: Performance Indicators Annex 9: Avances Adolescentes

i USAID | MCSP Guatemala Quarterly Report Q3 FY18, April 1 – June 30, 2018