MaMoni Health Systems Strengthening Activity - pdf.usaid.gov

MaMoni HSS FY16 Q3 Quarterly Report(USAID Cooperative Agreement AID-388-LA-13-00004)
Submitted
Joint Efforts to Restore Confidence in Health Care Delivery System
Char Folcon Union Health & Family Welfare Center (UH&FWC) – the image of transformation
This document is made possible by the generous support of the American people through the support of the Office of Population, Health, Nutrition and Education, United States Agency for International Development (USAID), Bangladesh (USAID/Bangladesh), under the terms of Associate Cooperative Agreement No. AID-388-LA-13-00004 through Maternal and Child Health Integrated Program (MCHIP). The contents of this document are the responsibility of the MCHIP Project and do not necessarily reflect the views of USAID or the United States government.
Cover Story:
Char Folcon Union is a rural community in Komolnagar Upazila of Lakshmipur district. The Union Health and Family Welfare Center (UH&FWC) was established in 1982 by DGFP of MoH&FW. Since the UH&FWC is the closest access point for health services for the community, its functionality is critical for saving lives and serving the community, particularly women and children who are under privileged and the most vulnerable. Previously, services at the facility were very poor due to scarce resources, limited availability of health workers, and poor quality of care. It was not unusual to find the facility locked and ill-equipped to provide services for maternal emergencies, including stock-outs of key consumables that are life-saving during such emergencies. To compound the situation, the center had very poor infrastructure, including a leaky roof, broken windows, and cracked walls and ceiling; there was also no access road, power, or water supply. This unsanitary situation in the clinic was worsened by the lack of a functional residence and toilet facility for service providers, making it difficult to ensure staff were available to attend maternal and newborn emergencies.
The MaMoni HSS program set out to transform this facility into a functional facility where the community could expect to receive quality care and services. As a first step and to ensure the initiative was locally driven and supported, the program conducted an assessment of the facility in collaboration with local government. Identified needs included facility upgrading, staff capacity development, and community engagement. MaMoni HSS has worked hard with local government, facility leadership and the community to address these needs, with the following achievements:
• Facility & Infrastructure Upgrades - The approach road and the infrastructure were reconstructed, and power and water supplies were ensured by installing solar panels. In support of this effort, the Char Folcon Union Parishad allocated a budget of 202,000 BDT (do you want to include approximate value in USD?) for the approach road, facility renovation, delivery bed and kits during the 2014-15 fiscal year; a budget of 122,000 BDT for the solar panel in the 2015-16 fiscal year; and 30,000 BDT for furniture in the 2016-17 fiscal year. Additional investments came from MaMoni HSS, with 2,700,000 BDT for dumping pits, a residence for service providers, and a deep tube well in year three of the program.
• Effectively Engaging Existing Institutions – Sufficient quantities of relevant drugs and supplies were made available by bridging DGFP and LG, and MaMoni HSS helped to reinforce the UH&FWC Management Committee to engage with the community so that needs and quality issues can be raised and addressed. Under the leadership of UP Chairman, the committee meets bi-monthly at the facility to address high priority issues. As a result, significant improvements have been made in the ability of the facility to apply basic infection prevention practices and maternal, newborn, child health, and family planning (MNCH/FP) standards of care.
“Before the renovation of the facility, patients expressed their disgruntlement over the poor state of the facility infrastructure and the environment and the poor quality and absence of services arises from its condition,” she said. “But now, our clients are happy and there is up-trend in the demand of services” - Shumi Majumder, Sub-Assistant Community Medical Officer (SACMO), Char Folcon UH&FWC
The program’s initiatives and efforts towards the improvement of the UH&FWC have converged to manifest outcomes that are consistent with the initial goal of providing high quality services that are well-utilized. Prior to 2013, the services provided at the Char Folcon UH&FWC were very poor with low utilization levels. But since the improvement initiatives began, service utilization has increased dramatically from 1120 in 2013 to 2926 in 2017. Furthermore, when 24/7 services began at the facility in 2013, there were no normal deliveries recorded at the center, but usage since then has increased dramatically, with 251 normal deliveries in the first half of 2017 alone.
“We the people are happy because of 24-hours service, improved facility, and well trained & well-behaved smiling doctor apa are available for us,” says Mr. Abdul Khaleque, husband of Mosammat Selina Akhter, a mother who received delivery care and services from the facility.
“I really appreciate the cleanliness of the facility which is much far better from private clinics. I thank Allah and pray that they will do more.” - Mother-in-Law of Marium Begum (a mother who received services from the facility), Village Zazira, Char Folcon Union.
MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report 3
TABLE OF CONTENTS
TABLE OF CONTENTS .................................................................................................................... 3
Way Forward: ..................................................................................................................................... 9 Introduction ....................................................................................................................................... 9
DATA SOURCES ................................................................................................................................ 9
Program Results for the Quarter ................................................................................................ 10
IR 1. Improve Service Readiness through Critical Gap Management ........................... 10 IR 2: Strengthened Health Systems at District Level and Below .................................... 29 IR 3. Promote an Enabling Environment to Strengthen District Level Health
Systems .................................................................................................................................. 39 IR4. Identify and Reduce Barriers to Accessing Health Services ................................... 39 Challenges, Solutions, and Actions Taken ....................................................................................... 45
Appendix 1: Scope and Geographical coverage of the Mamoni HSS program ............... 48
Appendix 2: DATA SOURCES ...................................................................................................... 49
Appendix 3: Program Performance Indicators (April 2017–June 2017) ........................................ 50
Appendix 4: Additional Indicators .................................................................................................... 66
Appendix 5: QIS ACTIVITIES ...................................................................................................... 70
Appendix 6: News Clips Published During ……………………………………………………… 75 Appendix 7: Documentation and Dissemination of MaMoni Program Learning ... Error! Bookmark not defined.
4 MaMoni Health Systems Strengthening Activity: FY’17 Q3 Quarterly Report
ABBREVIATIONS
ACS Antenatal Corticosteroid ADCC Assistant Director, Clinical Contraceptive AUFPO Assistant Upazila Family Planning Officer AHI Assistant Health Inspector AMTSL Active Management of Third Stage of Labor ANC Antenatal Care APK Android package kit BCC Behaviour Change Communication BEmONC Basic Emergency Obstetric and Newborn Care BSMMU Bangabandhu Sheikh Mujib Medical University CAG Community Action Group CBT Competency Based Training CC Community Clinic CCSDP Clinical Contraceptive Service Delivery Program CDCS Country Development Cooperation Strategy CEmONC Comprehensive Emergency Obstetric and Newborn Care CHW Community Health Worker CHX Chlorhexidine CIPRB Centre for Injury Prevention and Research, Bangladesh CMPM Community Micro Planning Meeting CS Civil Surgeon CSBA Community Skilled Birth Attendants CSI Clinical Severe Infection CV Community Volunteer DDFP Deputy Director Family Planning DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DH District Hospital DHIS2 District Health Information System-2 DN Death Notification DP Development Partner EH Engender Health ENC Essential Newborn Care EoP End of Project ETAT Emergency Triage and Treatment e-LMIS electronic-Logistics Management Information System e-MIS electronic- Management Information System FDR Facility Death Review FP Family Planning FPCS-QIT Family Planning Clinical Services – Quality Improvement Team FPI Family Planning Inspector FWA Family Welfare Assistant FWV Family Welfare Visitor GOB Government of Bangladesh HA Health Assistant HBB Helping Babies Breathe HEU Health Economics Unit Hg Habiganj HI Health Inspector HPNSP Health, Population and Nutrition Sector Program HR Human Resource HRIS Human Resource Information System HRM Human Resource Management HS Health Systems HSCS Health Systems Capacity Strengthening
HSS Health Systems Strengthening IDD Iodine Deficiency Diseases IEM Information, Education and Motivation IFB Isolated Fast Breathing IFA Iron Folic Acid IMCI Integrated Management of Childhood Illness IP Infection Prevension IPHN Institute of Public Health Nutrition IR Intermediate Result ISQUA International Society for Quality in Health Care IUCD Intra Uterine Contraceptive Device IUD Intra Uterine Death Jk Jhalokathi JSV Joint Supervisory Visit KMC Kangaroo Mother Care LAPM Long-acting and Permanent Method LARC Long-acting Reversible Contraceptive LG Local Government LMIS Logistics Management Information System LOC Letter of Collaboration Lp Lakshmipur MAM Moderate Acute Malnutrition MCWC Maternal and Child Welfare Center MEC Medical Eligibility Criteria MFSTC Mohammadpur Fertility Services and Training Centre MNCH/FP/N Maternal, Newborn and Child Health, Family Planning, and Nutrition MNH Maternal and Newborn Health MO Medical Officer MOCS Medical Officer – Civil Surgeon MOH&FW Ministry of Health and Family Welfare MOLGRD&C Ministry of Local Government Rural Development & Cooperatives MOMCH&FP Medical Officer-Maternal and Child Health & Family Planning MPDSR Maternal and Perinatal Death Surveillance and Response MSCS Marie Stopes Clinic Society MSH Management Sciences in Health MUAC Mid Upper Arm Circumference NGO Non-government Organization Nk Noakhali NNS National Nutrition Services NVD Normal Vaginal Delivery OBGYN Obstetrics and Gynecology OGSB Obstetrical and Gynecological Society of Bangladesh OP Operational Plan pCSBA Private Community Skilled Birth Attendants PDCA Plan-Do-Check-Act PE/E Pre-eclampsia/Eclampsia PHC Primary Health Care PHD Partners in Health and Development PIP Program Implementation Plan Pj Pirojpur PM Program Manager PMMU Planning, Monitoring and Management Unit PNC Post Natal Care PPFP Post-partum Family Planning PPH Postpartum Hemorrhage PPIUCD Post-partum Intra-uterine Contraceptive Device PRS Population Registration System PW Planning Wing
QI Quality Improvement QIS Quality Improvement Secretariat QoC Quality of Care RMO Residential Medical Officer RMNCH Reproductive, Maternal, Neonatal and Child Health RRQIT Regional Roaming Quality Improvement Team SACMO Sub-assistant Community Medical Officer SAM Severe Acute Malnutrition SBA Skilled Birth Attendant SBCC Social & Behavioral Change Communication SBM-R Standards-Based Management and Recognition SCI Save the Children International SCANU Special Care Newborn Unit SCMP Supply Chain Management Portal SDP Service Delivery Point SIAPS Systems for Improved Access to Pharmaceuticals and Services SOP Standard Operating Procedure SSN Senior Staff Nurse TAB Tablet Computer TAG Technical Advisory Group TB Tuberculosis UFPO Upazila Family Planning Officer UHC Upazila Health Complex UH&FPO Upazila Health and Family Planning Officer UH&FWC Union Health and Family Welfare Centers UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UP Union Parishad USAID United States Agency for International Development USC Union Sub-centers WISN Workload Indictors of Staffing Need WHO World Health Organization
EXECUTIVE SUMMARY During the third quarter of its fourth year, the MaMoni HSS program continued with ongoing activities for health systems strengthening at the national and district level, with some activities expanding at the national level and others under consolidation at the district level. In addition, there has been a renewed focus on SBCC activities in specific areas to improve health behavior and practices of those communities.
Key accomplishments in this quarter include: SBA delivery: Deliveries by skilled birth attendants has slightly increased than last
quarter, total 28,568 deliveries were conducted by SBAs during the reporting period, of them, 12 percent are in upgraded 24/7 UH&FWCs. The number of deliveries by pCSBAs has also increased in this quarter (309 deliveries) than that of previous quarters.
Specific newborn intervention revisits - In this quarter, phase two of the specific newborn intervention (essential newborn care including HBB and 7.1% CHX) revisits have been completed in 16 districts of Khulna, Chittagong and Dhaka Divisions. Phase 3 of the revisits were initiated in 16 districts of Rajshahi, Chittagong, Sylhet and Dhaka divisions. Data collectors from partner organizations PHD and BSMMU conducted revisits in 868 facilities and gathered data using the standard checklist.
7.1% Chlorhexidine for newborn cord care - Five divisional dissemination meetings to share results of the post training follow-ups on application of 7.1% Chlorhexidine were organized in Chittagong, Barisal, Dhaka, Rajshahi and Rangpur divisions. The post training follow-ups were conducted by independent monitors in 64 districts during August and September 2016.
Family planning orientations for health providers - Orientation of DGHS managers and providers from district hospitals and the upazila health complexes was held in all four MaMoni HSS districts on FP and PPFP service delivery. The objective of these orientations was to strengthen FP services at upazila and district level facilities and to intensify coordination between health & family planning departments.
Initiation of Plan-Do-Check-Act cycle for quality improvement - A residential training on Plan-Do-Act-Check (PDCA) was held in Rajendrapur targeting 4 district hospitals (Hg, Nk, Lp, Jk). National level facilitators from the Quality Improvement Secretariat (QIS) and MaMoni HSS staff at national and district level who will facilitate the application of PDCA in their respective districts participated in the training. Participants were supported to develop a specific Quality Improvement (QI) project to work on in their respective facilities. This included the identification of specific improvement objectives, a root-cause analysis of the selected performance gaps, identification of counter measures, selection of indicators to measure progress, and the development of a workplan. Moving forward, divisional and district QI staff will monitor the progress of the PDCA process in the four facilities.
Implementation of Human Resource Information System - MaMoni HSS is supporting the implementation of the central HRIS at Habiganj and Noakhali districts. A two-day training of trainers (ToT) on central HRIS was provided to 64 participants in collaboration with the MIS department of DGHS. One batch was organized at Habiganj and another at Noakhali. After the ToT, statisticians and HIS coordinators provided
training to 207 Community Health Care Providers (CHCPs) and Sub-assistant Community Medical Officers (SACMOs) from all eight upazilas of Habiganj.
Introduction of e-LMIS in additional districts - In coordination with SIAPS, the project is supporting the MOHFW to introduce electronic logistics management information system (e-LMIS) in three additional districts (Hg, Nk, Jk) to improve recording, monitoring, and availability of essential drugs, particularly MNCH items. During the reporting quarter, the project conducted an orientation of district level stakeholders in Habiganj, Noakhali, and Jhalokathi districts on e-LMIS. Because the e- LMIS will be linked to the national DHIS2 data, the project hired a consultant to input health facility specific data into DHIS2 as an initial step for implementing e-LMIS.
E-registers rolled out in Habiganj - In this quarter, maternal, newborn, and child health (MNCH), family planning (FP), and general patient and community e-registers were rolled out in all union facilities of Habiganj. Supervisors/managers of Madhabpur upazila have started using the e-MIS monitoring tool. The facility module of the e-Register has been launched in Lakshmipur and Jhalokathi.
Challenges and Mitigation Strategies:
As the project is approaching its end, the HR gaps filled by MaMoni HSS need to be absorbed within the MOHFW cadres, or replaced by MOHFW staff. For ensuring continuation of service the project has initiated dialogue with local health managers and local government for resolving this issue.
Every year, a good number of trainings are being conducted by different programs but there is no formal system of follow up after training and supportive supervision. MaMoni HSS strongly feels the need and hence conducted follow-up after ENC training. The project has now initiated dialogue with DGHS and DGFP for institutionalization of training follow-up and supportive supervision after critical technical trainings such as PPIUCD, EOC etc.
MaMoni HSS has been in continuous dialogue with DGHS, DGFP, QIS and other development partners for improving the quality of clinical care at a large scale. Innovative approaches need to be tested to encourage local ownership and leadership for quality improvement as well as expanding the involvement of the local government in problem solving and quality improvement.
Poor case admission and post discharge follow up of KMC as well as poor day-8 follow up of PSBI cases remain as key challenges for newborn health. In consultation with national and district health managers, the project has plans to orient and engage union level supervisors of public sector providers for the follow up of KMC and PSBI cases at community level.
In order to reap the benefit of Mobile Camps in boosting LARC& PM uptake, MaMoni HSS has initiated coordination with Mayer Hashi II project and DGFP in order to ensure skilled human resource, supplies, client referral etc. Moreover, In this quarter pace of work was slow because of Ramadan and Eid festival in late May and entire June. Also GOB managers were busy with closing of financial year in June.
Way Forward:
Orient and engage union level supervisors in follow-up of KMC and day-8 follow-up of PSBI.
Support coordination between health and family planning directorates to ensure FP service provision by DGHS staff.
Coordinate with Mayer Hashi II project for effective utilization of mobile camps. Monitor and document PDCA in 4 district hospitals. Implement eMIS facility and community modules in Lakshmipur and Noakhali and only
facility module in Jhalokathi. Linking eLMIS to DHIS2.
INTRODUCTION The MaMoni Health Systems Strengthening (HSS) project is a five-year USAID-funded award1 aimed at improving utilization of integrated maternal, newborn and child health, family planning, and nutrition (MNCH/FP/N) services through a health systems strengthening approach. In quarter 2 of the fourth year, MaMoni HSS has continued to support the MOH&FW to strengthen health systems at the national level as well as at district level. During the reporting period, the program’s technical assistance at the national level has expanded, at the same time that implementation at the district level is under consolidation. However, during this quarter low performance have been observed for many indicators, most likely as a result of Ramadan and Eid festival in late May and through June. The project supports 40 upazilas in 6 districts, 23 of them are designated as high intensity (HI) areas and the remaining 17 as health systems capacity strengthening (HSCS) areas. The scope and geographical coverage of the MaMoni HSS Project has been summarized below. Program coverage is described in more detail in Appendix 1.
Table 1. Summary of MaMoni HSS geographic scope
Area No. of Upazilas No. of Unions
Population (2015
17 (Bhola-7, Noakhali-5, Pirojpur-5)
Total 40 377 12,226,755 10 33 329 1,107
1The MaMoni HSS program is an Associate Award under the Maternal and Child Health Integrated Program, with a period of performance from September 24, 2013 to September 23, 2018. MaMoni HSS is supported by Jhpiego—in partnership with Save the Children, John Snow, Inc., and The Johns Hopkins University Institute for International Programs. National partners include: International Centre for Diarrhoeal Disease Research, Bangladesh; Dnet; and Bangabandhu Sheikh Mujib Medical University (BSMMU). Save the Children serves as the lead operational partner for the Award in Bangladesh.
DATA SOURCES Program monitoring data for this report comes from different sources, including a population based tracer survey (in high intensity areas), a sentinel survey (selected facilities in MaMoni areas), service delivery point (SDP) assessments (select facilities in MaMoni areas), a revisit of specific newborn interventions (14 districts nation-wide), and routine MIS of DGHS. A list and detail on the scope of the surveys is attached as Appendix 2.
PROGRAM RESULTS FOR THE QUARTER
IR 1. Improve Service Readiness through Critical Gap Management 1.1 Introduction and Scale-up of MNCH/FP/N interventions
1.1.1 Maternal Health The program’s major interventions in maternal health are pregnancy identification & registration through front line health workers, the provision of at least four antenatal care (ANC) contacts with Quality of Care (QoC), birth planning, promotion of, and increase availability and accessibility to quality skilled birth attendance including active management of the third stage of labor (AMTSL), distribution of misoprostol for home delivery, and ensuring four postnatal visits, including the promotion of post-partum family planning. There are also special interventions in selected areas, such as the management of severe pre- eclampsia & eclampsia through the administration of MgSO4.
1.1.1. a. Pre-eclampsia/Eclampsia (PE/E) management at union level facility: MaMoni HSS, in collaboration with the Obstetrical and Gynecological Society of Bangladesh (OGSB), has introduced severe pre-eclampsia and eclampsia management at the union level where a loading dose of injectable Magnesium Sulfate (MgSO4) is administered at the union level by Family Welfare Visitors (FWVs). This intervention has been rolled out at 140 union level facilities in 16 upazilas (5 upazilas in year 3 and rest in year 4) of 4 districts. In this quarter, need-based refresher trainings were organized for union level service providers (FWV, Paramedics) of Nabiganj, Companiganj, Ramganj, Raipur & Rajapur upazilas. The purpose of the training was to refresh the knowledge of the service providers on the identification and management of PE/E as per the algorithm.
A total of 65 cases of severe PE/E patients (fig 1) were identified and managed in this quarter. Senior OBGYN professionals from OGSB continued their monitoring visits to provide on the job support to the service providers in case identification and management. Additionally, a
Practical session of refresher training on PE/E at UHC
meeting was organized with Population Council who is implementing a similar study in other locations. It has been decided that MaMoni HSS, Population Council and icddr,b will organize regular meetings to share experiences and identify areas for performance improvement.
Figure 1: No. of Severe PE/E cases identified and received pre referral loading dose of MgSO4 in 16 upazila of 4 districts (Aug 16 –June,17)
Source: MIS-3, DGFP
1.1.1b. Misoprostol to prevent postpartum hemorrhage (PPH) at home births
MaMoni HSS is facilitating the distribution of misoprostol tablets to prevent PPH following home deliveries to pregnant women in their third trimester via FWAs and FWVs. A total of 27,914 tablets were distributed in this quarter (fig 2). The project also tracks consumption of the tablets by the mothers immediately after birth through tracer surveys every six months.
Figure 2: Trends in Misoprostol distribution in MaMoni HSS districts
1 2
17
0
5
10
15
20
25
30
Aug'16 Sep'16 Oct'16 Nov'16 Dec'16 Jan'17 Feb'17 Mar'17 Apr'17 May'17 Jun'17
No. of SPE/Eclemsia identified by Service Provider No. of cases (SPE/E) received loading dose of MgSO4
Monitoring field visit by Prof. Sabera Khatun from OGSB at Bamni & Sonapur
UH&FWCs of Raipur Upazila
Source: MIS-4, DGFP
1.1.1. c. Increasing Skilled Birth Attendance (SBA) at the District Level
A total of 28,568 deliveries were conducted by skilled birth attendants (fig 3) during the reporting period. Of them 3,420 (12%) were in upgraded 24/7 UH&FWCs (fig 4). Figure 3: Trends in SBA deliveries in MaMoni HSS districts
Source: DGFP MIS 2 and 4, EmOC and CSBA report in DHIS-2, Project pCSBA report.
11609
16191
14882 18386
N um
be r
SBA delivery in HI area SBA delivery in HSCS area
Figure 4: No of deliveries in 24/7 UH&FWCs in MaMoni HSS districts
Source: MIS-3, DGFP
1.1.1. d. Private CSBAs (pCSBA) assisted deliveries The number of deliveries by pCSBAs has slightly increased in this quarter (309 deliveries) than that of previous quarters (fig 5).
65 65
Q-2(FY-3) Q-3 (FY-3) Q-4 (Y-3) Q-1(FY-4) Q-2(FY-4) Q-3(FY-4)
No. of 24/7 UH&FWC No. of delivery
FWV of Jhalokathi MCWC is filling partograph during a delivery in the facility
A happy mother with her baby just immediate after delivery at 24/7 delivery centre, Harni of Hatiya Upazila
Figure 5: Trends in deliveries by pCSBAs in MaMoni HSS districts
Source: Project MIS.
In order to improve the quality of services and reporting, the project organized the following trainings during the reporting quarter: 1. Refresher training on reporting: To strengthen reporting mechanisms and to increase
coordination of pCSBAs with GOB providers, MaMoni HSS organized a refresher training for 11 pCSBAs.
2. Refresher training on ANC, PNC and Infection Prevention: MaMoni HSS organized a refresher training on ANC, PNC and infection prevention for FWVs and nurses in Noakhali and Jhalokhati districts in May, 2017.
1.1.2 Newborn Health National Scale Up Activities: National scale-up activities for newborn health are being supported by MaMoni HSS implementing partners - Bangabandhu Sheikh Mujib Medical University (BSMMU) and
95 93
Refresher Training on Reporting Mechanism and refresher Refresher Training on ANC, PNC and
Infection Prevention
Partners in Health and Development (PHD) under the leadership of the IMCI section of DGHS.
To follow up on support provided by MaMoni HSS for the national scale up of Helping Babies Breathe (HBB) and 7.1% Chx for newborn cord care, the program is supporting the MOHFW to conduct a revisit of these two interventions. This activity includes:
- Identification and training of two medical officers (MO’s) from each upazila as a newborn focal person
- Divisional and district level advocacy and planning meetings to sensitize district/upazila managers about the importance of the program, explain activities and make upazila wise plans as per their directions.
- Refresher training of skilled birth attendants (SBAs) on Essential Newborn Care including HBB and application of 7.1% Chlorhexidine for cord care
- A revisit in all facilities in the district: this includes a quick assessment of preparedness for newborn interventions with respect to human resources, skills retention, facility readiness, medicine and supply stocks (including 7.1% Chlorhexidine)and replacement or provision of supplies for newborn resuscitation equipment (bag, mask and sucker) in the facilities. The team also records the number of live births, still births, total delivery, C Sections, use of 7.1% CHX, number of preterm deliveries, number of LBW babies, number of AMTSL, use of oxytocin and number of newborns required resuscitation.
The national newborn and child health cell is providing management support for this activity and it will be completed in phases. The revisit in 16 districts (2nd phase) was initiated in February 2017 and completed by May 2017. Later in May, the revisit started in another 16 districts (3rd phase). Gradually, all 64 districts will be covered by this intervention with this phased approach.
1.1.2.a. Revisit of priority newborn interventions:
In this quarter, phase two of the specific newborn intervention revisits were completed in 16 districts of Khulna, Chittagong and Dhaka divisions (phase two districts include: Khulna, Bagerhat, Jessore, Narail, Magura, Kustia, Chuadanga, Meherpur, Jhenaidah, Satkhira, Rangamati, Bandarban, Khagrachari, Sherpur, Narsingdi, Narayanganj). Activities under phase three of the revisit have been initiated in 16 districts of Rajshahi, Chittagong, Sylhet and Dhaka division (phase three districts include: Rajshahi, Bogra, Sirajganj, Naogaon, Natore, Chapai Nawabganj, Joypurhat, Habiganj, Noakhali, Lakshmipur, Jhalakathi, Faridpur, Shariatpur, Gopalganj, Rajbari, Madaripur).
Data collectors from partner organizations PHD and BSMMU conducted revisits in 868 facilities in this quarter and gathered data using a standard checklist. Three district level advocacy meetings and 123 upazila level refresher trainings on a package of HBB & ENC interventions (including application of 7.1% Chlorhexidine) were organized for SBAs and CSBAs; a total of 2,427 providers received the refresher training.
Table 2: Percentage of service and logistics available by types of facility
Facility types Offer delivery HBB kit 7.1% CHX Gentamycin Amoxycillin MgSO4 N
DH 100 78 89 67 33 28 18 MCWC 100 76 67 14 90 10 21 UHC 89 79 82 50 34 7 96 UH&FWC-FP 91 89 66 6 86 2 638
UH&FWC-H 94 97 57 31 91 3 35 USC 55 45 36 27 36 0 11 RD 74 77 45 0 42 0 31 Others 50 50 50 17 50 6 18
Total 89 86 66 14 77 3 868
Training Types n n % 7.1% CHX trained 5304 3966 75 HBB trained 4604 2258 49 Source: Revisit Survey, February to May 2017
1.1.2.b.Divisional Dissemination of post training follow-up of application of 7.1% Chlorhexidine in newborn umbilical cord Five divisional dissemination meetings on post training follow up of 7.1% Chlorhexidine for cord care were organized in Chittagong, Barisal, Dhaka, Rajshahi and Rangpur divisions. The results of the post-training follow up, conducted by 32 independent monitors in 64 districts during Aug-Sept 2016, were presented in these divisional dissemination meetings. The presentations included the status of human resources, skills and knowledge retention from trainings, availability and use of 7.1% Chlorhexidine in all level of facilities and pharmacies, and the availability, use, and cleanliness of HBB equipment in all tiers of facilities. Divisional and district level managers of health and family planning division attended the meetings.
The post-training follow-up revealed that 86% of the respondents (N=3400) who participated in the post-training follow-up received orientation on ENC including application of 7.1% CHX in the umbilical cord. At the time of the visit, 7.1% Chlorhexidine was available in 53% facilities. Eighty-four percent providers could demonstrate CHX use in right way and 47% of them reported applying 7.1% CHX in the newborn umbilical cord during the last week preceding the revisit. Eighty-six percent providers advocated pregnant mothers to use of CHX. It was also found that 7.1% CHX was available in 54% private pharmacies. Independent Monitors also found that bag- mask and sucker were available in 84% OT/ delivery rooms. Bag-mask and sucker was found to be clean in 86% facilities.
1.1.2.c. Mentoring workshop for Newborn Focal Persons in 21 Upazilas of MaMoni districts
Newborn focal persons were nominated by respective Civil Surgeons in 21 high intensity upazilas of 4 MaMoni districts (Habiganj, Noakhali, Lakshmipur, Jhalokathi). They were designated by the Program Manager-IMCI section on behalf of the Director, PHC. Doctors from DGHS who are interested to work on newborn and child health and have some newborn related training were selected as newborn focal persons. They were further oriented on new newborn interventions and will be mentored by DGHS and BSMMU. MCH/FP Medical Officers from DGFP in respective upazilas were also oriented so that they can work in
Prof. Mohammod Shahidullah is delivering his speech in Dhaka divisional meeting
coordination with the newborn focal persons. A total of 32 doctors attended, 7 of them had attended the previous workshop last year.
Participants were trained on Essential Newborn Care including HBB and 7.1% Chlorhexidine for cord care, quality improvement, program monitoring and record keeping & reporting. The newborn focal persons will support their managers in rolling out newborn health interventions in respective districts and upazilas including monitoring the quality of training sessions. They will also facilitate district and lower level training sessions as and when needed, visit facilities to monitor the supply and performance of health care providers, and provide on the job support for improving quality of service. They will highlight relevant issues in different meetings and forums and help support national level policy and advocacy. 1.1.2.d. Other national activities through National Newborn and Child Health Cell
MaMoni HSS provides regular and continuous technical support to the national newborn and child health cell in the MOH&FW to carry out its priority initiatives. During this quarter, the newborn and child health cell has supported the Line Director for MNC&AH to prepare the operational plan (January 2017- June 2022). As a part of its routine activity, the newborn and child health cell continuously supported the IMCI program manager (PM) to implement IMCI as well as the revisit activity for specific newborn interventions throughout the country. The national cell also supported the scale-up of kangaroo mother care (KMC), emergency triage and treatment (ETAT), sick newborn care and newborn sepsis management.
The cell plays a leading role in the technical sub-committee that reviews and updates the IMCI-N case recording form and online reporting form. Along with the Challenge TB program of MSH, the newborn and child health cell plays a vital role in fostering inter-sectoral collaboration on childhood TB. The newborn and child health cell also worked with the ‘National Coordination Cell’ to arrange a consultative workshop on cervical cancer, fistula, and the national newborn health program.
The newborn and child health cell has analyzed and circulated Upazila specific ‘IMCI services and online reporting of 2016’ (IMCI service related performance analysis) to all the concerned Upazila Health and Family Planning managers. 1.1.2.e. Support for the development of the Child Health Strategy:
The IMCI section of DGHS has initiated the development of a national child health strategy. MaMoni HSS is participating in the development process through contributions in the technical sub-committees.
District Level Newborn Interventions:
1.1.2.f. Use of 7.1% Chlorhexidine for cord care to prevent newborn infection As a part of the essential newborn care package, 7.1% chlorhexidine application for cord care of every newborn has been implemented as part of the national scale-up. MaMoni HSS has provided targeted support in project districts for the national roll-out. During the period of Apr-May 2017, a total of 15641 babies received 7.1% Chlorhexidine for newborn cord care. Of this number, a total of 4913 were from Habiganj, 5852 from Noakhali, 4245 from Lakshmipur, 1684 from Jhalokathi, 3627 from Bhola and 2350 from Pirojpur.
Figure 6: Use of 7.1% CHX in DGFP facilities or by DGFP providers by place of CHX application in MaMoni 4 districts (Oct'16 to Jun'17)
Source: DGFP MIS Snapshots from DHIS2 (Fig 7 and 8) also show increased use of CHX both in community and facility delivery. The map of Bangladesh presented in Figure 9 shows use of CHX is comparatively higher in 5 MaMoni HSS districts (46-68%), except in Noakhali where it is between 29-45%. Figure 7: Percentage of newborns delivered by SBA in the community who received 7.1% chlorohexidine to the cord after birth
97 99 100 102 97 98
103 103 103
Pe rc
en t
CHX 7.1 used at facility delivery CHX 7.1 used at home delivery
Figure 8: Percentage of newborns delivered by SBA at facility who received 7.1% chlorohexidine to the cord after birth
Fig 9: Map of Bangladesh showing rates of 7.1% CHX application
1.1.2.g. Management of sick children Sick young infant (<2 month of age) management following the national guidelines has been implemented out of 148 Union Health & Family Welfare Centers (UH&FWC) in 4 MaMoni HSS districts. The Sub-assistant Community Medical Officers (SACMOs) are the designated providers of this intervention, with the Family Welfare Visitors (FWV) enabled and authorized to provide a second dose of injectable Gentamycin for the management of Clinical Severe Infection (CSI) cases where referral has failed. MaMoni HSS has facilitated the training of all the SACMOs and FWVs in the facilities that provide this service.
To improve the 8-day follow up of PSBI cases by union level supervisors such as the Family Planning Inspectors (FPIs), MaMoni HSS supported the orientation of FPIs to conduct follow up visits at the household level. A training of trainers (TOT) for twenty master trainers (MTs) was completed in Lakshmipur and Jhalokathi districts. These MTs will conduct the orientations of supervisors at upazila level. During the period from Apr-June 2017, a total of 1351 sick children were managed from UH&FWCs in Habiganj (614), Noakhali (236), Lakshmipur (268), Jhalokati (233) districts, the categories of illness were Critical Illness (CI)-3%, Clinical Severe Infection (CSI)- 6%, Isolated Fast Breathing (IFB)- 28%, Local Bacterial Infection (LBI)-26%, Other- 38%.
Figure 10: Number of sick infants (<2 month) managed at the union level in 21 upazilas of 5 districts during the Jan'16 - Jun'17 period.
Source: Project MIS
Figure 11: Classification of sick infants (<2 months) presented at the union level facilities in 21 upazilas of 4 districts during the Jan'16-Jun'17 period.
474 396
719 640
376
CI CSI IFB LBI Other Total
Source: Project MIS
1.1.2.h. Kangaroo Mother Care (KMC) Kangaroo Mother Care (KMC) units were established at 15 facilities (4 district hospitals, 2 maternal and child welfare centers (MCWCss), and 9 upazila health complexes (UHC) of four MaMoni HSS implementation districts (Habiganj, Noakhali, Lakshmipur and Jhalokati).
During the period from April-Jun 2017 a total of 46 cases received KMC services in Hg(10), Nk(15), Lk(15),) from the KMC units. Short duration of hospital stays and poor post discharge follow up are the key challenges of this intervention. To address these challenges, the MaMoni HSS program organized sensitization and program review meetings with concerned personnel at 4 facilities. To improve post discharge follow up of cases, the project is supporting an orientation of union level supervisors (Assistant Health Inspectors) of respective upazilas who will conduct the follow up visits at the household level. A TOT of 22 master trainers (MT) was completed in Lakshmipur and Jhalokathi districts. These MTs will conduct orientation of supervisors at the upazila level.
1.1.2.i. Antenatal Corticosteroids (ACS) for threatened preterm labor MaMoni HSS has been supporting the use of Antenatal Corticosteroids (ACS) in threatened preterm deliveries following national guideline in 3 District Hospitals (Habiganj, Noakhali and Lakshmipur). During the Q3 period of Apr-Jun 2017, a total of 114 eligible pregnant women received ACS from these hospitals (Habiganj 42, Noakhali 51 and Lakshmipur 21).
1.1.2.j. Facility based care for sick children Special Care Newborn Units (SCANU) in five MaMoni HSS supported district hospitals (Habiganj, Noakhali, Lakshmipur, Bhola & Pirojpur) have been providing services to the community. The availability of dedicated GOB manpower is the main challenge for service delivery in the SCANUs. MaMoni HSS is supporting the capacity building of GOB staff and has deployed trained staff nurses in Habiganj, Noakhali and Lakshmipur district hospitals. During the April-June ’17 period, a total of 15 doctors and 48 nurses received ETAT training in 3 batches. The project also supported training of 17 nurses in two batches of on-the-job training for standard operating
233, 3% 536, 6%
Online Reporting Training
procedures (SOPs), sick newborn management at the SCANUs, online reporting into DHIS- 2 and hands-on practice for use of equipment. The trainings were conducted at BSMMU.
During the period April-June 2017 a total of 845 cases were managed at 5 SCANUs, of them 145 at Noakhali, 113 at Lakshmipur, 465 at Bhola, 102 at Habiganj and 20 at Pirojpur. Fig 12: Number of cases managed at SCANU by district
During the period, the project also supported maintenance services for SCANU equipment of in all project-supported SCANUs by a technical expert. It may be noted here that the MNCAH Operational Plan of MOHFW has kept a budget earmark for the maintenance of the SCANU, but that will not be functional before 2018.
1.1.3 Family Planning 1.1.3.a. Use of modern methods of family planning The utilization of various methods of family planning remained almost the same since last year in all intervention districts (Figure 13).
0 0 0
34 43 25
28 0
28 7 6 6 2 4 6 7 70 0 0 0 0
87
123
0
50
100
150
200
Sep' 16 Oct' 16 Nov' 16 Dec' 16 Jan' 17 Feb' 17 Mar' 17 Apr' 17 May' 17 Jun' 17
Noakhali Habiganj Laksmipur Pirojpur Bhola
Preventive maintenance and on the job coaching at Bhola SCANU
Figure 13: FP method mix from June 2016 to June 2017
Source: MIS-4, DGFP In this year MaMoni HSS focused on increased coordination of DGHS and DGFP to intensify FP interventions, especially long acting and reversible contraceptives (LARCs), permanent methods (PMs), and post-partum family planning (PPFP) at all service facilities. Health managers are not oriented on FP or PPFP, and providers working under DGHS also don’t have adequate skills to provide FP methods to clients despite an estimated 44% unmet need for PPFP. MaMoni HSS is contributing to the scaling up of FP services in general and PPFP in particular. The project is putting a special emphasis on strengthening the capacity of providers at health facilities managed by DGHS to ensure service readiness and provision of care. In addition to strengthening DGFP activities, a number of activities & interventions in this quarter have been completed which are exclusive to DGHS. These are as follows: A. Coordination meeting organized by the Clinical Contraceptive Service Delivery
Program (CCSDP), DGFP, Dhaka: This is a regular meeting to develop action plans and prioritize areas to reduce gaps identified in the assessment findings for facility readiness on LARC & PM services. An action plan was developed and a team has been formed to work on the action plan.
B. Family Planning Counseling module: A national working group was formed during the quarter, and includes members from DGHS & DGFP, including representatives from MCH, CCSDP, Field Service Delivery, the IEM of DGFP and PHC, and Hospital Services of DGHS, as well as NGOs like Save the Children International, Marie Stopes Clinic Society (MSCS) and EngenderHealth (EH) Bangladesh.
42 43 44 32 32 39 40 36 36 36 36 34 34
6 7 7
4 4 5 5 6 6 8 8 5 5
17 12 12 32 32 15 15 16 16 18 18 23 23
4 3 3 2 3
5 5 5 5 3 3 3 3 4
2 3 4 5
4 4 3 3
7 7 8 3 3 5
5 7 7
0 10 20 30 40 50 60 70 80 90
Jun-16 Jun-17 Jun-16 Jun-17 Jun-16 Jun-17 Jun-16 Jun-17 Jun-16 Jun-17 Jun-16 Jun-17
Standard Habiganj Bhola Pirojpur Jhalokati Noakhali Lakshmipur
Pe rc
en t
Oral pill Condom Injectable IUD Implant NSV Tubectomy
C. Orientation of DGHS providers (DH & UHC) on FP service delivery including PPFP: An orientation of DGHS managers and providers from the district hospitals (DH) and upazila health complexes (UHCs) was held in all four MaMoni HSS districts on FP and PPFP service delivery. The objective of these meetings was to strengthen FP services at upazila and district level facilities and to intensify coordination between health and family planning departments, including the provision of basic information on FP services to the participants. The event was jointly organized by MaMoni HSS and DGFP. Participants included the Upazila Health and Family Planning Officer (UH&FPO),
Medical Officer – Civil Surgeons (MOCS), OBGYN Consultants, the Residential Medical Officers/UHC’s, Senior Staff Nurses (SSN’s) and were facilitated by the Medical Officers (MO) -Clinic, and the MOs MCH-FP of DGFP.
Feedback from one health manager following the training included the statement that, “This orientation will change the perception, knowledge, and attitude of DGHS managers, as well as provider’s roles and responsibilities on FP & PPFP”. The managers will subsequently inform and build the capacity of other health service providers in their monthly meetings for effective counseling and skills building of providers to offer clients easy access to a wide range of affordable, reliable, and good quality FP & PPFP contraceptive services with a special focus on promotion of methods like PPIUCD. A follow up meeting will be organized in each quarter for intense liaison and communication between DGHS and DGFP providers.
D. Training on FP policy changes & MEC wheel for Health & FP Managers: Training on FP Policy changes and medical eligibility criteria (MEC) wheels were organized in all four MaMoni HSS implementation districts with the objective of informing health and FP managers on recent updates of FP policy changes and Government Orders (from 2010 to 2017) and their implementation status. These updates aim to: - ensure that clients are able to make informed decisions on FP - fulfill the huge unmet need of PPFP - promote FP method acceptance - popularize LARCs & PMs - clarify the 2016 MEC wheel - refresh knowledge and skills on bottom up projection of FP
The Deputy Director of Family Planning (DDFP) was the Chairperson and the Civil Surgeon (CS) was the Chief Guest in these events. Quality Assurance staff from CCSDP, DGFP, and the District Manager of the QIS of HEU were the key resource people. Partners from Engender Health facilitated the session on bottom-up projection of family planning.
CS speaking on FP & PPFP counselling in Jhalokathi
Orientation of DGHS providers on FP and PPFP
Participants included the CS, MOCS, the Assistant Director Clinical Contraceptives (ADCC), UH&FPO from Health department and Upazila Family Planning Officer (UFPO), MO Clinic, Assistant UFPO (AUFPO), and the MO-MCH in charge from the Family Planning department. The training ended with the formulation of an action plan for follow up and monitoring.
E. Interventions for increasing the coverage of LARC & PM in MaMoni HSS districts:
• Competency based training of newly appointed MO MCH-FP: Three batches of training on LARCs and PMs have been completed for the newly appointed MOs (MCH- FP) of DGFP in Sylhet, Barisal and Chittagong divisions under the direct supervision of CCSDP and with coordination from the FPCS QIT and MaMoni HSS. The 18 day training included lectures, dummy practice, and field camps designed to make the participants competent and skilled on placing implants and IUD’s, as well as tubal ligation and vasectomy. The training was organized outside of Dhaka where more cases are available for practice to further develop the participants confidence and skills. Supportive supervision to the trainees will be provided by CCSDP and the MaMoni HSS program and performance reviewed intermittently.
• Facility readiness of DH, MCWC & UHC: A facility readiness assessment of 4 DHs,
6 MCWCs and 22 UHCs was conducted to understand the current status and areas for improvement to address low utilization of LARC and PM services in MaMoni HSS areas. A structured checklist was used and the findings were shared with CCSDP, DGFP during this quarter to engage their support for infrastructure improvements, human resource strengthening, logistics and supply management, capacity development, infection prevention and improved QoC to increase utilization and patient satisfaction. An action plan has been developed for monitoring progress. CCSDP and MaMoni are jointly trying to improve the facility for quality service delivery of LARCs and PMs.
1.1.3.b. PPIUD performance
Two batches of basic training on IUCD and PPIUCD for Senior Staff Nurses have been completed at the Mohammadpur Fertility Services and Training Center (MFSTC), Dhaka during this quarter. All participants were provided with a training manual and other resources related to IUDs and PPIUCDs. Identifed challenges include the lack of strong coordination between the Health and FP departments regarding supply, reporting mechanisms, and fund mobilization. To mitigate these barriers, the project is coordinating between DGFP and DGHS at the national and district level to ensure the availability of essential FP supplies and funds needed to support services. MaMoni HSS also organized a two-day refresher training on FP that included PPFP and PPIUCD for FWVs, Female SACMOs, and Paramedics, with the objective to increase the performances of FP and PPFP, and particularly PPIUCD in the UH&FWCs. They received the initial training earlier through the MaMoni HSS project with technical support from Engender Health, Bangladesh. Fig 14 shows an increasing trend in PPIUCD performance in Habiganj, Jhalokathi and Pirojpur districts.
Figure 14: Trends in PPIUD performance in MaMoni HSS districts
Source: MIS-4, DGFP
1.1.3.c. Contribution of CSBAs and CVs in family planning The numbers for PPFP counselling have slightly decreased both in high intensity areas and health system strengthening areas (Fig 14) in this quarter. Also the total number of LAPMs recipients has decreased in this quarter, possibly because of Ramadan and the Eid festival in late May and through June.
Figure 14: No. of women counseled on PPFP by CSBAs (Oct ’16 to Jun ’17)
92
188
32
N um
be r
1311 1198 1294 1542 1590 1672 1622 1466 1413
466 451 274
No. of PPFP counselling (HI) No. of PPFP counselling (HSCS)
Source: MIS-4, DGFP Though the total number of LAPM recipients has decreased in this quarter, the contribution of Community Volunteers (CV) has increased from 21 percent to 25 percent in this quarter. (Fig 15).
Figure 15: CV contribution in LAPM performance Jan'16-Jun'17 by quarter
Source: Project MIS
1.1.4 Nutrition Malnutrition is one of the most serious health problems affecting infants, children and women of reproductive age in Bangladesh, among others. Despite progress made, millions of children and women still suffer from different forms of under-nutrition, including low birth weight, stunting, underweight, wasting, vitamin A deficiency, iodine deficiency disorders, and anemia. The nutritional status of children is a proxy indicator of the state of health of a community or population. With this status in consideration, MaMoni HSS has been working in four districts (Noakhali, Lakshmipur, Jhalokathi and Habiganj) under the directive of the Institute of Public Health Nutrition (IPHN) and with the district and upazila level health and family planning authorities. MaMoni HSS has taken the initiative to develop skilled front line health workers on primary nutrition screening and counseling at household and outreach centers, which will help the program expand coverage through active case identification and lower the burden of malnutrition during the project life to strengthen the nutritional landscape and support related objectives in the HPNSDP (2011-2016). 1.1.4.a. Logistic for Nutrition Screening:
MaMoni HSS facilitated the distribution of basic equipment and supplies (50 Spring Scales, 50 Height/Length Boards, 500 MUAC Tapes) for screening nutrition at Service Delivery Points (SDPs) from IPHN.
1.1.4.b Service Statistics:
Data from DGFP MIS, DHIS-2 and Project MIS show the following outcomes in MaMoni supported districts during this quarter:
5969 6066
1195
500
1500
2500
3500
4500
5500
6500
7500
Total LAPM CV contribution
151,910 children and mothers (31,607 mothers & 120,303 children) were reached with nutrition interventions from different types of service delivery points (Community Clinics, UH&FWCs, UHCs and DHs from where IMCI services are being provided)
37,490 caretakers received BCC interventions on essential infant and young feeding practices, hand washing, IDD, Vit-A etc.
31,607 pregnant mothers were reached with Iron Folic Acid (IFA) supplementation during ANC visits
1,726 children were identified who have been suffering from MAM
314 children were identified as SAM patients and referred Among the reached children about 14,670 (12.19%) children were identified as
malnourished. Among them 4,943 were stunted (4.12%), 3,596 were wasted (2.99%) and 6,131 were under weight (4.77%).
1.1.4.c. Management of acute malnutrition:
As per the national protocol, acute malnutrition is categorized as Moderate Acute Malnutrition (MAM) where cases are traditionally treated in the home and Severe Acute Malnutrition where cases are referred for facility based management (SAM Unit/Corner at Upazila Health Complexes and District Hospitals). These children get therapeutic treatment as well as treatment for other co-morbidities (complicated SAM). In therapeutic treatment the F-75 is used for initial or ‘Stabilizing Phase’ and F-100 is used for ‘Catch-up’ phase. During the reporting period (Apr – Jun 2017), a total of 36 SAM patients were admitted into 10 SAM units of MaMoni HSS supported project areas. At the end of the quarter 28 SAM patients were discharged. Among them 10 were cured (27.77%), 11 were discharged after stabilizing (30.55%), 7 (19.44%) left the facility without completing the treatment and the rest 8 (22.22%) remained in the facility for completion of treatment. 1.1.4.d. Monitoring visits and performance review meeting: Two monitoring visits and performance review meetings were organized and attended by the Line Director of NNS and the Director of IPHN at Noakhali and Lakshmipur districts. The visits were held in the Upazila Health Complexes, Union Health & Family Welfare Centers and Community Clinics. After the visits the Deputy Program Managers (DPMs) met with District and Upazila level managers and reviewed the district performance. During the visits and performance review meetings the DPMs discussed the nutrition activities in the respective districst and way forward for mitigating current bottle necks.
28%
31%
19%
22%
Representatives from IPHN visiting Nutrition activities at UHC, Ramganj, Lakhsmipur
1.2 Management of critical human resource gaps of GOB service providers:
Table 3: Critical human resource gaps filled-in by MaMoni HSS
D is
tr ic
ac an
O B
V ac
an cy
fi lle
d up
b y
M aM
on i
Noakhali 165 0 0 18 0 2 67 0 0 6 0 0
Lakshmipur 71 0 0 10 0 0 48 0 0 4 0 0
Habiganj 92 0 12 27 2 24 54 0 13 5 0 0
Jhalokathi 74 0 0 7 0 2 0 0 0 0 1 0
Total 402 0 12 62 2 28 169 0 13 15 1 0
MaMoni HSS is currently supporting 12 FWAs, 28 FWVs, and 13 nurses to fill in the critical human resource gaps of GOB service providers. The decisions for filling such vacancies are made through local level discussions with district/upazila managers.
IR 2: Strengthened Health Systems at District Level and Below The MaMoni HSS program is implementing a comprehensive quality improvement strategy to support the MOHFW at the national and district levels to improve the quality of clinical care for MNCH/FP/N services. The project’s QI strategy comprises of three main components:
• National level support to QI efforts; • Improving service delivery of MNCH/FP/N services; and • Measurement of QI indicators and recognition of achievements for QI.
The progress in improving the quality of clinical care during Year 4, Quarter 3 of the project is summarized below:
2.1.1. Supporting the national Quality Improvement Secretariat (QIS):
During the reporting quarter, MaMoni HSS continued its support to the QIS in implementing the national QI strategy and aligning it with WHO MN QI Framework. The project’s seconded staff at the national and division level continue to provide vital assistance to the QIS in implementing the QI interventions nationwide. In addition, MaMoni HSS has provided assistance to the QIS in the following areas:
• Curriculum development and training on Plan-Do-Check-Act (PDCA): The residential training, held in Rajendrapur on May 7-9, 2017, targeted 4 district hospitals (Hg, Nk, Lp, Jk). National level facilitators from QIS and MaMoni HSS staff at national and district level that will facilitate the application of PDCA in their respective districts participated in the training. The outcome of the training was the development of a DH specific QI project to be implemented by DH members of the QIC in their respective hospitals. The performance gaps selected for participating district hospitals to address ranged from increasing service utilization for deliveries and KMC, to improving crowd management and sterilization of used instruments. Specific QI projects were developed including identification of the specific “aim” for the improvement, root cause analysis of
the selected performance gap, identifying counter measures, indicators to measure progress, and developing a workplan.
• Developing National RMNCH QI indicators: The project contributed to the national effort led by the QIS and with participation of several international partners to develop RMNCH QI indicators based on the standards included in WHO MN QI Framework.
• Developing National Patient Safety Guidelines: Based on QIS request, the project has recruited a consultant to develop national patient safety guidelines. The guidelines include several domains such as: infection prevention, medication safety, patient identification and procedure matching, clinical handover, blood and blood product handling, and preventing pressure injuries.
• Developing QIS Communication Plan: the project is in the process of recruiting a consultant to work with the QIS to develop a communication plan to help advocate for QI at the national level, increase ownership and interest in quality of care by service providers, and engage community and other governmental and private entities in QI.
Please see Annex 5 for a detailed description of MaMoni HSS QIS supported activities.
2.1.2. Improving the quality of clinical care in stages:
The project continues to provide support to the district health managers to improve the quality of clinical care provided by health facilities in stages as follows:
• Stage 1: to improve the cleanliness, infection prevention, and medical waste management;
• Stage 2: to improve sterilization measures and compliance with antenatal care and newborn care services, and
• Stage 3: to improve compliance with all range of MNCH/FP/N standards.
The following graph summarizes the progress in the number of facilities succeeded in passing the first stage of QI.
Figure 16: Number of Health Facilities in 4 Districts Meeting *Basic Infection Prevention Standards
Total Habiganj Noakhali Lakshmipur Jhalokathi
Total number of facilities 230 79 57 59 35
% with acceptable IP 33 42 21 37 26
*Basic Infection Prevention Standards=Cleanliness; Hand Washing; Use of Gloves; Decontamination by 0.5% Chlorine Solution; Basic Medical Waste Management.
2.1.3 Increasing local ownership of QI through establishing and supporting QI committees:
MaMoni HSS continues to support the establishment and facilitation of QIC at district, upazila, and health facility levels. Project facilitation includes supporting QIC meetings, summarizing action points, and following up on implementation for improvement with the involvement of local government.
The table below includes an update on the status of the formation and activation of QI Committees by district.
Table 4: Status of Quality Improvement Committee Formation and Activation by District, May 2017
Number of QI Committees District
Habiganj Noakhali Lakshmipur Jhalokathi
Actually formed 86 42 54 35
Active (had at least 1 meeting in the last 3 months)
86 41 49 25
The project supports districts in developing monthly visit plans and conducting joint supervisory visits (JSV) with district and upazila supervisors. Supervisory visits take place using structured supervisory checklists in the areas including: infection prevention measures, service delivery management, ANC, nutrition, FP, newborn and child health, IMCI, normal vaginal delivery, and postnatal care. MaMoni HSS facilitation ensures that each supervisory visit identifies gaps, action plan for improvement, and follow up on results.
Table 5: Planned and Conducted Second JSVs by District (April - June, 2017)
District
Habiganj Noakhali Lakshmipur Jhalokathi
Number of JSV Planned
49 62 06 24
Number of JSV Conducted
50 43 04 17
Table 6: Example of Joint Supervisory Visit (JSV) Observations and Follow-Up Action Taken :
SL# Observations during visits Recommendations/ Action Taken Facility
Date of Observat
ion Noakhali
01 a. Facility is not net and clean,0.5% chlorine solution and autoclave are available
b. Performance board is not updated.
a. Ensure regular preparation of chlorine solution..
b. Ensure Performance board update regularly.
Kadirpur UH&FWC, Begumganj
02 a. Weight scale and b. IFA was not available
To ensure Weight scale and IFA regular Satellite Clinic.
Aleyarpur UH&FWC, Begumganj
03 a. No use of height scale, b. Inadequate hand
washing facility and c. Not maintaining privacy
for patients.
FWV noticed to use a. Height scale for ANC mother & children
under 5 b. Arrange hand washing facility for interim
period and the concerned persons will take care to solve the problem permanently and
c. Maintain the patient privacy as per guideline.
Arjuntola UH&FWC, Senbagh
3rd May’17
04 Delivery room is not eligible for conducting delivery due to lack of power supply, spot light and electric ceiling fan.
Ensure supply of power, spot light and ceiling fan(s).
Dumuria UH&FWC, Senbagh
Suggested to take some steps for maintaining basic infection prevention including hand washing. Follow up will be continued
Char Clark UH&FWC; Subarnoch ar
7th Jun’17
for primary collection of waste
b. No waste management provision within the premise of the facility
c. Performance board is not up-to-date
a. The other two color coded waste bins (yellow & black) need to be provided
b. UFPO will sit with Union Parishad to address the issue to create a permanent solution by constructing dumping pits.
c. The concerned FWV, SACMO & FPI have been instructed toupdate it immediately and to continue doing so.
Bhadur UH&FWC; Ramganj
07 a. Pregnancy and EDD list were not updated
a. The responsible FWV was instructed by the UFPO to update the list by getting information from FWA at Union Follow up meeting
Char Mohona UH&FWC; Roypur
7th May’17
08 a. Color Coded bin was not available (yellow and black)
b. No dumping pit. c. Display board was not
updated.
a. The UHC store will be explored to see if bins can be provided from there.
b. UFPO will sit with Union Parishad to address the issue to have permanent solution by constructing dumping pits.
c. The concerned FWV, SACMO & FPI have been instructed to update it immediately and to continue doing so.
Ichhapur UH&FWC, Ramganj
2.1.5 Supporting the implementation of Maternal and Perinatal Death Surveillance and Response (MPDSR):
During the reporting period, MaMoni HSS continued to support the QIS in scaling up of facility level MPDSR in Hg, Nk, Lp, Jk districts. The capacity building initiative of Death Notification (DN) and Facility Death Review (FDR) has been designed in two steps. In the first step a TOT on DN and FDR were conducted with the technical assistance of CIPRB
followed by cascading training of service providers at District Hospital, Upazila Health Complex and MCWC. During the reporting quarter, the following TOTs and trainings have been completed:
TOT on DN and FDR :
District Category of trainees Number trained
Noakhali MOCS, OBGYN & Pediatric Consultant, Sr. Staff Nurse, Sr. FWV, MO-Clinic, RMO/MO
36
2.1.6 Supporting CEmONC through Regional Roaming QI Teams (RRQIT):
The project has been supporting the RRQIT as an additional supervisory and mentoring team focused on monitoring and improving the quality of CEmONC provided at the district level in Hg, Nk, Lp, Jk. RRQIT includes OBGYN and neonatologist from medical colleges close to the project districts as well as district level supervisors. RRQIT visits are conducted using structured checklists to assess general CEmONC infection prevention measures, delivery services, readiness to provide CEmONC, and neonatal care including SCANU. During the reporting quarter, the 4th RRQIT visit has been conducted in Jk district hospital and MCWC. Based on the findings, an action plan has been developed in coordination with the district hospital service providers and quality improvement committee. The RRQIT’s 4th visit included follow up on progress of implementation of action points identified during previous visits. Table 6 below summarizes results: Table 6: Progress in implementing RRQIT action plan – Jhalokathi district:
Major findings from previous visits Improvement Dirty environment & hospital floor in DH Basic Cleanliness of DH improved Only one labor table was available in DH Two more labor tables supplied in DH OT lights with fused bulbs OT light arranged Autoclave of labor room was not functional Autoclave for labor room at DH arranged
RRQIT visits to Jahlokathi DH delivery room RRQIT debriefing MCWC staff
Major findings from previous visits Improvement Inactive QI Committee at DH & MCWC Functional QI Committee at DH & MCWC Poor medical waste management at MCWC Dumping pit at MCWC is under process Only one MO-MCHFP in the district Posting of 4 new MO-MCHFP in the district Post for nurse was vacant in DH Posting of 35 SSN at DH, so a new maternal
complex has been designed No use of partograph & practice of AMTSL for NVD at DH & MCWC
Use of partograph & practice of AMTSL for NVD at DH & MCWC has been started
Nonfunctioning digital X-Ray & USG machine at DH
Functional digital X-Ray & USG machine at DH
Cesarean section at MCWC could be performed only on Sundays with support from DH
Regular caesarian section in MCWC because of new MOMCH has anesthesia training in sadar upazila
2.2 Support human resource for health
2.2.1 Workload and staffing needs assessment study The study on “Workload and Staffing Needs Assessment at Public Sector Healthcare Facilities” is in the final stage. The objective of the study is to understand the existing workload of different cadres of health workers at health facilities and at the community level. The study has adapted WHO’s “Workload Indicators of Staffing Need” (WISN) methodology to the Bangladesh context. The study includes one medical college hospital (Rajshahi Medical College Hospital), two district hospitals (Kushtia and Brahmanbaria), two MCWCs (Kushtia Sadar and Brahmanbaria Sadar), four selected Upazila Health Complexes (Daulatpur, Kumarkhali Nabinagar, Sarail), eight union level facilities, and four Community Clinics and corresponding community level workers of selected unions at Kushtia and Brahmanbaria districts. A Technical Advisory Group (TAG) formed by the MOHFW with representatives’ key departments of the ministry, professionals and key stakeholders provided guidance and advice on technical issues, methodology, and tools to expedite the study. During the second phase of the study the workload components and activity standards obtained from analysis of the first phase data was shared with key persons at each facility for reconfirmation. These were further fine-tuned by matching with findings from direct observation of actual delivery of services. Relevant annual service data were also collected from respective facilities. Data analysis was done using WISN method. A draft report has been preparedand a summary of findings will be shared with the TAG in the next meeting and the report will be finalized incorporating comments from the TAG. 2.2.2 Support implementation of the HRIS The central Human Resource Information System (HRIS) is a web-based software developed by the MOHFW for capturing human resources information of all directorates/ agencies under the ministry at various levels across the country. MaMoni HSS is supporting implementation of the central HRIS at Habiganj and Noakhali districts. A two-day ToT on central HRIS was provided to 64 participants in collaboration with MIS department of DGHS. One batch was organized at Habigonj and another at Noakhali. Participants were UHFPOs, Statisticians, HIS coordinators and M&E Officers of MaMoni HSS project. Following the ToT, statisticians and HIS Coordinators provided training to 207 CHCPs and SACMOs from all eight upazilas of Habiganj.
2.2 Monitoring and improving the availability of essential MNCH/FP drugs:
2.2.1 Scaling up the implementation of electronic logistics management information system (eLMIS), in coordination with SIAPS:
In coordination with SIAPS, the project is supporting the MOHFW in introducing electronic logistics management information system (e-LMIS) in three additional districts (Hg, Nk, Jk) to improve recording, monitoring, and availability of essential drugs, particularly MNCH items. During the reporting quarter, the project conducted an orientation for district level stakeholders in Hg, Nk, and JK districts about the e-LMIS. Because the e-LMIS will be linked to the national DHIS2 data system, the project hired a consultant to input health facility specific data of the these districts into DHIS2 as an initial step for implementing e-LMIS. The project conducted district level orientation on e-LMIS for health managers in Jhalokathi, Noakhali and Habigonj districts. The purpose of this orientation was to refresh the district level GOB manager’s knowledge on basic logistics management system, their roles and responsibilities in improving LMIS status, the supply chain management portal (SCMP) of MOHFW and the LMIS activity done so far at each district. The MOCS facilitated the sessions and MaMoni staff shared the overall concept on the scale up of e-LMIS activity. The new e-LMIS is expected to improve essential drugs stock monitoring, procurement processes, and to reduce stock outs.
2.2.2 Supporting Sylhet Regional Warehouse, DGFP: The project LMIS advisor provided technical assistance to the Sylhet Regional Warehouse, of DGFP to review storage conditions, documentation processes, and the condemnation process of expired drugs. The QIS Sylhet team participated in the visit.
Jhalokathi district eLMIS orientation, Jhalokathi Civil Surgeon Conference Room
Reviewing temperature maintanence and storage conditions, Regional Warehouse, DGFP, Sylhet
2.2.3. Use of a color-coded system to monitor the availability of essential drugs:
The project continued to provide support to Hg, Nk, Lp, Jk districts to monitor availability of essential MNCH drugs and engage district managers in using stock information to take action to avoid stock-outs. This stock data monitoring is conducted by a color-coded chart to simplify data interpretation and use. The following is an example of the color-coded chart for tracking misoprostol stock in DGFP store in Noakhali district from October 2016 to May 2017.
Noakhali district from October 2016 to May 2017:
Color-coded chart showing availability of Tab.Misoprostol 200 MCG at DFGP stores, Noakhali district.
Green= stock available; Yellow = stock avaible, yet expiring within 6 months; Red = stock-out 2.2.4. Monitoring availability of MNCH essential drugs at service delivery points:
As part of the joint supervisor visits, the stock of essential MNCH drugs is checked and action is identified to avoid stock out. The following box summarizes some of the action taken during the reporting period to improve availability of essential drugs.
Examples of action taken to improve the availability of essential MNCH drugs:
• MaMoni HSS facilitated moving Inj. Oxytocin from CS Store to Rajapur and Kathalia UHC where NVD services are available.
• Facilitated the process of redistribution of 750 bottles of 7.1% Chlorhexidine from Jk Health store to Barisal Medical College. The expiration date was on 30 May’17. But as a result of redistribution, the supplied amount of 7.1% Chlorhexidine were used up.
• The food supplement (F-75 and F-100) was inadequate at SAM corners of district hospital and Rajapur UHC of Jhalokathi district early in the month of April, 17. After discussion with CS- Jhalokathi, it was revealed that Pirojpur district had sufficient stock. Through coordination with Pirojpur CS office, Zianagar UHC, the DNSOs of unicef, 1 carton (90 sachet F-100) and 1 carton (120 sachet F-75) were distributed to the SAM corners of Jhalokathi DH and Rajapur UHC.
• MaMoni facilitated the supply of 304 bottles of 7.1%Chlorhexidine and 304 packs of Tab. Misoprostol (2 tab. in a pack, total 608 Tab. Misoprostol) from DGFP to all Community Clinics of Sadar Upazila, Lakshmipur in April and May, 2017 as there were no supply of 7.1%Chlorhexidine and Tab. Misoprostol from DGHS. These were given to the mothers who did not receive those from the FWAs.
TAB. MISOPROSTOL 200 MCG (2 tab. = 1 dose) Sl No.
Name of the store
2 Companiganj 3 Hatiya 4 Senbag 5 Subarnochar
• Facilitated the replacement of nonfunctional HBB kits from DGHS stores to different UH&FWC of Sadar upazila, Kamalnagar upazila and Roypur upazila of Lakshmipur district in April and May,2017. In Sadar upazila it was Khusakhali UH&FWC, Digholi UH&FWC, Dalal Bazar UH&FWC and Dattapara UH&FWC. In Kamalnagar upazila it was in Char Kadira UH&FWC, and Hajirhat UH&FWC. In Roypur upazila it was in Sonapur UH&FWC, Charpata UH&FWC and MCH-unit of Upazila Health Complex.
• Mamoni facilitated the supply of ARI Timer from DGHS to DGFP UH&FWC level to roll out sepsis intervention after receiving the training of DGFP SACMOs in Lakshmipur district and also there were no supply from DGFP source. Total 28 pieces of ARI timer were supplied, at Sadar upazila14 pieces, at Kamalnagar upazila1 piece, at Roypur upazila6 pieces, at Ramgoti upazila 5 pieces and at Ramgang upazila 2 pieces in May 2017.
• Facilitated the supply of IUD from DGFP to DGHS at district hospital & Upazila Health Complex for PPIUD performance of nurses in May 2017 after the training. (District Hospital 13, Kamalnagar UHC 09, Roypur UHC 05, Ramgoti UHC 01, Ramgang UHC 02 total 30 pcs of IUD for PPIUD service)
• Facilitated the supply of Implant from DGFP Roypur upazila store to DGFP Ramganj upazila store: 25 pcs in May, 2017 as there was stock out in Ramganj.
• Facilitated the supply of one delivery table from DGFP Roypur upazila store to DGHS Ramgonj Upazila Health Complex as there was no delivery table available through DGHS supply.
• Facilitated the supply of 1000 bottles of 7.1%CHX from DGHS store to cSBA (FP) and all UH&FWC, Chatkhil Upazila, Noakhali in April 2017 to overcome insufficient supply from DGFP.
• Supplied HBB Kit from DGHS store to Harni UH&FWC of Hatiya Upazila in April’2017 after establishment of new DGFP facility.
• Facilitated the supply of around 500 unit of Inj. Oxytocin to UH&FWC (24/7 Delivery Centers) from union parishad e.g. to Durgapur UH&FWC (24/7 Delivery Centers) under Begumangonj Upazila, Char Kakra UH&FWC under Companiganj Upazila, Jahajmara UH&FWC and Char King UH&FWC under Hatiya Upazila, Mohammadpur UH&FWC under Senbag Upazila. It was done in April& May 2017 and will continue in future.
2.3. Monitoring quality of care (QoC) indicators in sentinel sites:
During the reporting quarter, the project completed preparation for conducting the third round of the QoC sentinel survey. This included updating data entry tools, preparation of data entry platforms, and training of data collectors and project district staff. Four data collectors and 8 participants (Manager QA and FCQA) were trained on new tools and the web based data entry platform. Data collection started in Hg, Nk, Lp, Jk districts. In this round of data collection a new tool for exit interviews with a sample of postpartum women who delivered in the health facility will be conducted to assess the client’s experience of childbirth services. Data collection is ongoing in Noakhali, Lakshmipur, Habiganj and Jhalokathi.
2.4 Routine Health Information Systems (RHIS)/eMIS Initiative
This quarter activities focused on the integration between FWV and FWA modules of the e- register, enhancement of the monitoring tools, and addressing feedback from the field level GoB supervisors. Initiating the expansion of e-MIS to new districts is one of the major milestone achieved this quarter.
2.4.1 Implementation and Support
A ToT on the facility module e-register has been completed for Tangail and Lakshmipur districts. Following the ToT, the facility module e-register training has been completed for Tangail district. The reference document and manual for the e-register were re-developed as per of icddr,b and MEASURE Evaluation’s requirement. The developed hypothetical scenarios are embedded in the manual are practiced during the training session.
The e-MIS design team is also helping to resolve implementation issues of the FWA e-register throughout Habiganj and Tangail. Team members are testing APK in TAB before releasing to the field and are continuously monitoring e-MIS reports from unions using the monitoring tool.
In this quarter, the MNCH, FP, General Patient, and Community e-registers were rolled out in all union facilities of Habiganj. Supervisors/managers of Madhabpur upazila have already started using e-MIS monitoring tool and it will be replicated in the rest of the upazila by next quarter.
A total number of 37 FWAs were trained on the FWAs e-Register. A ToT on facility module e-register has been completed for Lakshmipur district, and the UFPO and MO (MCH-FP) from Lakshmipur, HIS Coordinators, IT Officers and M&E personnel from Lakshmipur and Noakhali were trained on the module. All the Health ID cards are printed for Madhabpur and almost 92% of the registered population has received Health ID cards. In Lakhai upazila 60% of the Health ID cards were printed and 40% of the registered population has received HID cards. The GOB field workers are distributing the HID cards during their HH visits and also counseling the community to bring the HID cards during facility visits.
2.4.2. Development Activities:
In this quarter, more MNH and FP indicators have been added into the monitoring tools. The team also incorporated GIS plotting for all of the Habiganj facilities and started work on facility plotting on the other five districts. A lot of feedback from the field and other stake holders have been incorporated. Some of the major changes include the ability to associate a single provider with multiple facilities as they fill gaps, , enhanced search facilities for faster performance and implant e-register. Facility Registry table with Geo-Location has been developed. The newly developed login tracking system with new screen allows tracking of health providers with geospatial coordinates.
The team has completed the development of the implant e-register and the permanent method register for family planning is near completion. A lot of feedback from GoB officials have been incorporated for the smooth flow of the system. Also lists of pregnant women collected by the CHWs are now automatically being reflected on the facility system.
2.4.3 Inauguration of e-MIS:
A district sensitization meeting on e-MIS has been completed in Lakshmipur and Jhalokathi districts in this quarter. In Lakshmipur, the Director General of DGFP graced the meeting as Chief Guest; the Director of MCH Services, the Line Director of MC-RAH, the Line Director of CCSDP, and DGFP were present at the meeting as special guests. Participants from MaMoni HSS, district and upazila level managers from DGHS and DGFP, local
government members and officials, different NGO officials, and journalists were also present in the meeting. The DG highly appreciated the system and expressed his interest in seeing it in practice where the system is already being implemented (Habiganj District). 2.4.4. Visit of Government officials
Following his interest from the Lakshmipur Inauguration, the Director General of DGFP, an officer of DGFP, and the MaMoni HSS Chief of Party visited the Madhabpur upazila of Habiganj district to observe the e-MIS field level activities during this quarter. During his visit, the FWV demonstrated the various advantages and features of the e-register as compared to the paper based register, such as continuum of care and embedded medical intelligence for risky categories. 2.4.5 Other activities:
1. The e-MIS team participated in the D4D Session in Hotel La Meridian. 2. The eMIS team is also extending support to other MaMoni activities. In conjunction
with a consultant, the team supported the development of the Sentinel Survey forms during this quarter.
3. More indicators and improvements have been done for the eMIS monitoring tool and it has been demonstrated to the MaMoni HSS team and GoB officials. Their feedback is being incorporated for further enhancement.
IR 3. Promote an Enabling Environment to Strengthen District Level Health Systems 3.1 National level technical Assistance The Program Management and Monitoring Unit of the Ministry of Health and Family Welfare (MOHFW) has been playing a significant role in providing technical support in management, monitoring and evaluation functions of the HPN Sector Program, which is being implemented by the MOHFW. The Program Management and Monitoring Unit (PMMU), Planning Wing (PW), of the MOHFW consists of GOB officials, TAST and an administrative support team consisting of 19 staff in different positions, who are working for the PMMU/PW of MOHFW. As an important partner to the Health, Population and Nutrition Sector in Bangladesh, the MaMoni HSS program is associated with supporting the MOHFW in matters related to policy formulation, health systems strengthening, and program implementation through an LOC signed between the MOHFW and MaMoni HSS to ensure the continued availability of administrative and operational support.
MaMoni HSS has provided regular sa

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