DISCLAIMER This report is made possible by the support of the American People through the US Agency for International Development (USAID). The contents of this report are the sole responsibility of Organized Network of Services for Everyone’s (ONSE) Health Activity and do not necessarily reflect the views of USAID or the United States Government.

ONSE HEALTH ACTIVITY MALAWI MONTHLY UPDATE PY3 Quarter 1: December 2018Submission Date: December 21, 2018 Contract Number: AID-612-C-17-00001 COR Name: Evelyn Zimba

Submitted by: Rudi Thetard, Chief of Party Management Sciences for Health (MSH) Mercantile Office Building Area 13/138 P Bag 398 Lilongwe, Malawi

PHOTO CREDIT: SAMY RAKOTONIAINA FOR ONSE

ONSE HEALTH ACTIVITY OVERVIEW

Program Name Organized Network of Services for Everyone’s (ONSE) Health Activity

Activity Start and End Date November 15, 2016 – November 15, 2021

Name of Prime Implementing Partner

Management Sciences for Health (MSH)

Contract/Agreement Number AID-612-C-17-00001

Names of Subawardees Banja La Mtsogolo (BLM)

Dimagi

Overseas Strategic Consulting, Ltd. (OSC)

VillageReach

Major Counterpart Organization Malawi Ministry of Health and Population

Geographic Coverage Sixteen districts in the country of Malawi:

Balaka, Chikwawa, Chitipa, Dowa, Karonga, Kasungu, Lilongwe, Machinga, Mangochi, Mchinji, Mulanje, Nkhatabay, Nkhotakota, Ntcheu, Salima, Zomba

Reporting Period Project Year 3, Quarter 1: December 2018

CONTENTS

ONSE HEALTH ACTIVITY OVERVIEW 1

ACRONYMS AND ABBREVIATIONS 3

I. MAJOR ACTIVITIES AND ACCOMPLISHMENTS 5 CLINICAL SERVICES 5 HEALTH SYSTEMS STRENGTHENING 17 COMMUNITY MOBILIZATION AND ENGAGEMENT 22 KEY COLLABORATION MEETINGS 25

II. PROJECT MANAGEMENT 26 GRANTS UNDER CONTRACT 26

III. KEY CHALLENGES 26

IV. LESSONS LEARNED AND BEST PRACTICES 27

V. SHORT-TERM TECHNICAL ASSISTANCE 27 COMPLETED STTA 27 UPCOMING STTA 27

ACRONYMS AND ABBREVIATIONS

AMTSL Active Management of the Third Stage of Labor BFHI Baby Friendly Hospital Initiative BTL Bilateral Tubal Ligation CAC Community Action Cycle CCPF Chipatala Cha Pa Foni (Health Center by Phone) CBMNC Community-Based Maternal and Newborn Care CHAG Community Health Action Group CMAM Community Management of Acute Malnutrition CMT Community Mobilization Team CSC Community Scorecard CYP Couple Years of Protection DHMT District Health Management Team DHO District Health Office DMO District Medical Officer DMPA Depo Provera DTC Drug and Therapeutic Committee DQA Data Quality Assessment EmONC Emergency Obstetric and Newborn Care EPI Expanded Programme on Immunization ETAT Emergency Triage Assessment and Treatment FHP Family Health Package FP Family Planning GVH Group Village Head HBB Helping Babies Breathe HC4L Health Communication for Life HCMC Health Center Management Committee HMIS Health Management Information System HMS Helping Mothers Survive HtRA Hard-to-reach Area HSA Health Surveillance Assistant iCCM Integrated Community Case Management IUCD Intrauterine Contraceptive Device IFHOC Integrated Family Health Outreach Clinic IPC Infection Prevention Control IPTp Intermittent Preventive Treatment in Pregnancy ISS Integrated Supportive Supervision KMC Kangaroo Mother Care LARC Long-acting and Reversible Contraceptives LMIS Logistics Management Information System WASH Water, Sanitation, and Hygiene MDSR Maternal Death Surveillance and Response M&E Monitoring and Evaluation MIP Malaria in Pregnancy MNH Maternal and Newborn Health MoHP Ministry of Health and Population mRDT Malaria Rapid Diagnostic Test MVTK Mobile Village Toolkit NASG Non-Pneumatic Anti-shock Garment

NRU Nutrition Rehabilitation Unit ODF Open Defecation Free ONSE Organized Network of Services for Everyone’s Health OPD Outpatient Department OTSS Outreach Training and Supportive Supervision PA Pharmacy Assistant PBF Performance-Based Financing PDSA Plan, Do, Study, Act PPH Postpartum Hemorrhage PY Project Year RHD Reproductive Health Directorate QI Quality Improvement QMD Quality Management Directorate QoC Quality of Care SBC Social and Behavior Change SLA Service Level Agreement SRH Sexual and Reproductive Health SSDI Support for Service Delivery Integration TA Traditional Authority TB Tuberculosis UNICEF United Nations International Children’s Emergency Fund USAID US Agency for International Development USG United States Government WASH Water, Sanitation, and Hygiene VHC Village Health Committee YFHS Youth Friendly Health Services

I. MAJOR ACTIVITIES AND ACCOMPLISHMENTS

CLINICAL SERVICES

RENOVATION OF HEALTH FACILITIES AND EQUIPMENT PROVISION

In Chikwawa, the renovation and construction works at Chapananga Health Center postnatal and maternity blocks, as well as waste disposal facilities, were completed on December 14th. Final activities included: Drilling of a new borehole and installation of a water reticulation system to improve

water supply to the health center. Completing a water test report with support from the Ministry of Health and

Population (MoHP) and Population’s Central Water Laboratory. In Zomba, ONSE procured and delivered electrical materials for maintenance of equipment at

Matawale maternity ward and outpatient department. The work will be completed by the MoHP Physical Asset Management Unit.

INTEGRATED FAMILY HEALTH OUTREACH CLINICS (IFHOC)

Through December 14, ONSE supported 167 integrated family health outreach clinics (IFHOCs) in all 16 ONSE districts, reaching a total of 41,908 beneficiaries (Table 1), 68% of those planned for the month of December. The most commonly cited reasons for cancellations included lack of fuel or reliable transport, impassable roads, and funerals within communities. ONSE works closely with MoHP counterparts to support fuel and transport to ensure IFHOCs occur regularly.

TABLE 1. INTEGRATED FAMILY HEALTH OUTREACH CLINICS –DECEMBER 2018

DISTRICT # OF IFHOCS PLANNED

# OF IFHOCS SUPPORTED

TOTAL # OF BENEFICIARIES

BREAKDOWN BY GENDER

Balaka 11 4 2,541 625 M, 1,916 F Chikwawa 5 2 268 64 M, 204 F Chitipa 13 12 2,079 776 M, 1,303 F Dowa 29 18 2,555 818 M, 1,737 F Karonga 27 25 2,071 N/A* Kasungu 31 13 4,961 1,689 M, 3,272 F Lilongwe 29 29 11,204 4,336 M, 6,868 F Machinga 16 5 1,023 320 M, 703 F Mangochi 4 6 775 261 M, 514 F Mchinji 9 4 630 57 M, 573 F Mulanje 10 7 1,483 549 M, 934 F Nkhatabay 11 5 1,082 455M, 627 F Nkhotakota 12 6 1,217 493 M, 724 F Ntcheu 9 8 3,912 1,504 M, 2,408 F Salima 11 3 674 N/A* Zomba 20 20 5,433 N/A* Total 247 167 41,908

*Gender disaggregation not available for all districts at time of report compilation

MATERNAL AND NEWBORN HEALTH

INTRAPARTUM CARE

In Karonga, Kasungu, and Nkhotakota, ONSE supported emergency obstetric and newborn care (EmONC) supportive supervision for 32 (13 M, 19 F) providers from 11 facilities to assess performance on EmONC functionality and to support capacity building for performing all signal

functions. Most of the facilities supervised showed performance improvements from Project Year (PY) 2 and felt confident that they could perform all signal functions for as long as the cases were available at the facilities. Many of the improvements can be attributed to the deployment of registered Nurse

Midwives in facilities who are able to perform all signal functions, the provision of KIWI vacuum extractors that are easy to use, and ongoing mentorship on signal function performance across all facilities.

Some facilities were found to be dirty and monitoring of women and neonates in the postpartum period was inadequate. Led by the Matron, facilities helped to identify a day for general cleaning each week. Facilities will be followed up on in January to assess progress towards addressing action points.

Retained placenta and provision of parenteral anticonvulsants were the scarcest cases across all facilities.

In Zomba, ONSE supported the MoHP to conduct MNH mentorship at the cluster level for 10 health facilities and 22 (9 M, 13 F) providers. The activity aimed to improve providers’ skills, knowledge, and attitude in the management of life-threatening obstetric conditions. Participants were mentored on adherence to partograph when monitoring patients, Helping Babies Breathe (HBB), Kangaroo Mother Care (KMC) using the Family Led Care Model, management of postpartum hemorrhage (PPH), pre-eclampsia and eclampsia, and methods for improving data capture in various registers. ONSE will conduct follow up supervision in Q2 to assess performance improvement.

In Chitipa and Salima, ONSE supported MoHP district health offices to conduct facility-based mentorship on Non-Pneumatic Anti-shock Garment (NASG), Helping Mothers Survive (HMS), and active management of the third stage of labor (AMTSL) through drills and return demonstrations for 27 (13 M, 14 F) midwives and clinicians from 9 facilities. This mentorship aimed to impart lifesaving skills for managing obstetric emergencies, thereby preventing maternal deaths. At the end of the mentorship, all participants were proficient on using the NASG for managing bleeding complications and improved their skills in providing general management for patients with hemorrhage.

In Lilongwe, ONSE supported neonatal case reviews with a focus on partograph adherence. The case reviews were based on the neonatal death audit report for October 2018, which revealed that 55% of the neonatal deaths that occurred at Bwaila Hospital from August to October 2018 were attributed to health worker competency factors. A total of 47 (10M, 37F) health providers at Bwaila’s labor ward received hands-on mentorship on partograph scoring using scoring sheet, standard monitoring of women in labor, and partograph documentation. They were also provided with skills for developing Plan, Do, Study, Act (PDSA) cycles and plotting progress on graph papers (run charts). Challenges observed included: Partograph scoring revealed poor fetal heart monitoring (fetal heart rate was checked

every two hours on average, as opposed to the recommended every 30 minutes) and delayed decision making when labor is prolonged. Team leaders for shifts were actioned to be conducting spot checks on monitoring of women in labour and hold accountable those not complying.

Poor monitoring of maternal condition due to shortage of resources (only one functional blood pressure machine and two thermometers were available in the unit). ONSE has since supported the facility with ten thermometers but the District Health Management Team (DHMT) was tasked to source blood pressure machines.

POSTPARTUM CARE

In December, ONSE supported onsite orientation of 35 (8 M, 27 F) health workers from 15 facilities to the Family Led Care model of KMC in Nkhotakota and Mulanje districts. The activity

was conducted to orient health providers on KMC and the new component of the Family Led Care Model, in which the mother and her family become highly involved in the care of low birth weight or premature babies. At the end of the orientation, Family Led Care in KMC was rolled out to 8 facilities in Nkhotakota and 9 facilities in Mulanje. Orientation included sessions on Essential Care for Every Baby and Essential Care for

Small Babies, which gives the foundation of comprehensive care for early and small babies before proceeding to Family Led Care in KMC units or corners.

Sessions also covered calculation of feedings for premature babies, monitoring weight gain, and the importance of maintaining warmth.

In addition, participants also learned how the family and other caregivers can be involved in the care of their fragile babies in the facility as well as in the home.

Evaluation of the orientation in Nkhotakota showed knowledge gain with an average pretest score of 59.2% and post-test score of 72.5% with several participants scoring 100% in post-test. The KMC focal person and KMC Family Led Care trainers will conduct quarterly supportive supervisions to all health facilities and data on Family Led Care in KMC will be reviewed during bi-annual MNH review meetings.

In Zomba and Mulanje, ONSE supported community-based maternal and newborn care (CBMNC) mentorship of 43 (23M, 20F) providers serving the catchment areas of 12 health facilities. The activity aimed to improve providers' skills and competencies during service provision at the community level. During the exercise, participants were mentored on how to conduct antenatal and postnatal home visits using counselling cards, documentation in the revised registers and reporting forms among others. The participants also received some CBMNC materials like counselling cards, thermometers and mother baby cards.

In Machinga, ONSE supported the MoHP with the provision and distribution of CBMNC items to 133 (99M, 34F) HSAs from 12 facilities. Distribution is ongoing, with three facilities and 31 Health Surveillance Assistants (HSA) to be reached by the end of the month. CBMNC reporting tools were also distributed and providers were mentored on how to use them. It is expected that, with these items, HSAs will improve in their monthly reporting and also improve on the quality of home visits at community level.

MATERNAL DEATH SURVEILLANCE AND RESPONSE (MDSR)

In December, ONSE supported a Maternal Death Surveillance and Response (MDSR) meeting in Machinga and Nkhotakota, where 20 (8 M, 12 F) participants reviewed five maternal deaths. In Machinga, three maternal deaths were reviewed, with the main causes of deaths

including, hypovolemic shock as a result of a ruptured uterus, hypovolemic shock due to placenta abruption, and shock following cesarean section. Contributing causes included a lack of essential equipment (monitors and ventilators), lack of blood transfusion, delay in reporting to the facility, and inadequate monitoring at the health center.

In Nkhotakota, two maternal deaths were reviewed which occurred due to PPH and anemia. Contributing causes included a lack of blood transfusion, delay in reporting to the facility, and inadequate monitoring at the health center.

In Machinga, following an increase in the number of maternal deaths resulting from hemorrhage and shortage of blood and blood products, ONSE collaborated with the Malawi Blood Transfusion Services Team to assist the District Health Office (DHO) with mobilization of donor, donor assessments, and collection. A total of 107 pints were collected from 107 (87 M, 20 F) donors, which will be screened and sent to the Machinga District Health Office for distribution.

CHILD HEALTH

EMERGENCY TRIAGE ASSESSMENT AND TREATMENT (ETAT)

In Nkhotakota, ONSE supported the MoHP to conduct supervision of seven (4 M, 3 F) providers from three health facilities to strengthen triage systems, enforce segregation between adults and under-fives for outpatient department (OPD) clinics. The activity revealed that, due to staff rotations and turnover, very few providers across the facilities had been trained in Emergency Triage Assessment and Treatment (ETAT). ONSE will facilitate ETAT orientations for Nkhotakota in Q2.

In Lilongwe, ONSE conducted an ETAT supervision for 31 (6 M, 25 F) clinicians and nurses from three facilities working in under-five departments to improve provider skills and attitudes towards triaging all sick children and management of children with emergency conditions. Challenges included unavailability of staff trained in ETAT, poor teamwork at the OPD clinic, unavailability of ETAT stabilization rooms, and shortage of basic essential drugs. ONSE will support the district in reallocation of trained personnel in under-five OPD clinics, orientations on ETAT roles and responsibilities, and identifying rooms for use as ETAT corners.

In Mulanje, ONSE facilitated the establishment of seven ETAT corners at Mulanje Mission Hospital and Mulanje District Hospital. It is anticipated that the ETAT stabilization corners will facilitate triaging of sick under-five children, provision of emergency drugs, promote short stay observation, and facilitate directly observed therapy of oral rehydration solution for children with mild diarrhea. Additionally, a brief on-site mentorship session was provided to facility staff on ETAT and how to run the corners as well as how to monitor functionality of the corners.

INTEGRATED COMMUNITY CASE MANAGEMENT (iCCM)

In Chitipa, Dowa, Lilongwe, Machinga, Ntcheu, and Salima, ONSE supported the MoHP to conduct integrated community case management (iCCM) supportive supervision of 201 (125 M, 76 F) iCCM providers from 195 village clinics in an effort to strengthen the quality of service delivery by Health Surveillance Assistants in village clinics. The supervisory team identified gaps in service provision and provided on-site coaching following the standard iCCM protocols. The team also observed documentation practices and interacted with the village health committees to assess their involvement in the implementation of the interventions. Following the supervision exercise, ONSE distributed iCCM supplies to the supervised HSAs including pails, basins, a laminated sick child recording form, 5 ml spoons, cups, clear medicine cups, referral booklets, and respiratory timers.

CHILD HEALTH DAYS

In December, ONSE supported the implementation of Child Health Days in Balaka and Zomba. The activity distributed Vitamin A & Albendazole and all under-five children were also screened for malnutrition. Children that were due for immunization were also been immunized at the various sites which were set for the activity. Detailed activity reports are yet to be shared by the respective DHOs.

NEONATAL DEATH AUDITS

In December, ONSE supported neonatal death audits for 4 deaths in Nkhotakota to establish causes of death and initiate methods of mitigating neonatal death at the facilities. Severe prematurity, respiratory distress syndrome, and sepsis were the direct causes of

death. Secondary causes of death include inadequate monitoring of women during labor and

delivery, lack of provider supervision visits, and late facility reporting of parents or guardians with sick neonates.

The District Medical Officer (DMO) supported the audits and plans to locate specific clinicians to review sick neonates in the neonate care unit, additionally nurses will be placed within the unit and the Hospital Matron will take up direct supervision.

PEDIATRIC DEATH AUDITS

In December, ONSE supported a pediatric death audit for 12 deaths in Machinga. Malaria, anemia, and sepsis remain the major leading causes of pediatric deaths. Secondary causes of death include incomplete initial assessments upon admission,

incorrect management of children with danger signs (i.e., shock and convulsion), inadequate patient monitoring, and failure to provide emergency treatment.

A clinical presentation on the management of shock and convulsion was provided to pediatric clinicians and ONSE will support ETAT orientation and coaching sessions in Q2. Additionally, ONSE will continue to support ETAT Quality Improvement (QI) audits and mentorship sessions, as well as continuous professional development sessions to facilitate knowledge and skills for providers.

EXPANDED PROGRAMME ON IMMUNIZATION (EPI)

In December, ONSE supported the collection and distribution of Expanded Programme on Immunization (EPI) supplies from the Central Vaccine stores to 86 health facilities in Chitipa (11), Dowa (26), Lilongwe (26), and Mulanje (23) such as vaccines and gas cylinders for refrigerators. This activity was conducted jointly with the distribution of other commodities such as family planning methods, drugs and supplies, and registers and reporting booklets.

FAMILY PLANNING

Community-Level Family Planning IFHOCs Through support to MoHP IFHOCs in the 11 family health package (FHP) districts, ONSE

reached a total of 5,907 clients with a full method mix, generating 2,831 Couple Years of Protection (CYP) through mid-December.

In December, 40% (665 clients, new and revisit) of the CYP generated through IFHOCs was through implants (Jadelle and Implanon), compared to 26% (2,929 clients) from Depo Provera (DMPA), suggesting a shift from shorter term methods to long-acting and reversible contraceptives.

ONSE Nested Providers assisted with IFHOC clinics in Machinga and Zomba in an effort to increase availability and uptake of voluntary long-term and permanent methods of family planning. In the coming months, this practice will be expanded to the other FHP districts and planned so that hospital FP clinics are not left unstaffed.

TABLE 2. IFHOC FP SERVICES – DECEMBER 2018

METHOD NEW VISIT REVISIT CYP DMPA 463 2,466 732 Oral Contraceptives 216 761 65 Implanon 248 204 1,130 Jadelle 90 123 809 Male Condoms 315 364 6 Female Condoms 588 60 5 IUCD 0 0 0 BTL 0 N/A 0 Vasectomy 9 N/A 84 Total 1,929 3,978 2,831

Mobile Youth Outreach Teams Nine ONSE mobile youth outreach teams are active and covering the 11 family health package

districts. In the month of November, teams reached a total of 6,830 (down from 8,007 in October) clients, generating 9,267 CYP (down from 11,650 in October), with 19% of clients between 15-19 years of age and 34% of clients between 20-24 years of age. The drop in clients and CYP can be attributed to a reduction in travel to distant sites due to budget constraints and clinic cancellations due to meetings. Numbers are expected to increase again in January.

TABLE 3. YOUTH OUTREACH CLINIC CLIENTS AND CYP – NOVEMBER 2018

DISTRICT CONDOMS (M)

CONDOMS (F)

PILLS EC

DMPA

IMPLANTS IUCD

BTL

CLIENTS

CYP

Pie Cl Pie Cl Cyc Cl 3y 4y 5y Balaka 10,545 275 0 0 276 92 1 148 74 2 161 0 7 733 1,017 Chitipa 0 0 0 0 16 6 0 18 0 5 13 1 5 48 126 Dowa 2,150 64 55 5 132 52 7 194 104 0 118 3 3 528 828 Karonga 3,508 103 0 0 99 43 0 106 10 47 72 1 19 401 706 Kasungu 6,202 202 20 2 98 36 0 269 47 19 58 10 12 651 960 Lilongwe 10,686 254 120 6 351 152 13 520 147 137 45 0 35 1,223 1,571 Machinga 30,206 647 110 6 120 61 6 276 17 15 47 1 2 887 624 Mulanje 13,052 360 100 2 179 69 4 369 37 95 113 16 13 887 1,113 Salima / Nkhotakota

10,809 284 320 15 166 64 2 219 17 66 153 10 19 771 1,040

Zomba 3,384 48 0 0 390 138 5 155 129 47 146 9 12 701 1,282 TOTAL 90,542 2,237 725 36 1,827 713 38 2,274 582 433 926 51 127 6,830 9,267

Family Planning Campaigns In Mulanje, ONSE supported the MoHP to conduct community sensitization and service

provision of FP methods in TA Chikumbu in an effort to increase access to a full method mix and demystify misconceptions on LARC and permanent FP methods. During the campaign, a total of 196 clients accessed a full range of methods, generating 132 CYP; 63% of CYP generated came from implants and 21% permanent methods.

Community-Level Supervision In Chitipa and Karonga, ONSE supported MoHP to conduct integrated DMPA, YFHS, iCCM,

and Nutrition community supervision in the catchment areas of five facilities to assess the provision of quality integrated services through HSAs and village clinics. Key observations include: There is a lack of essential drugs and FP commodities at most village clinics, which has

been reported back to district pharmacy personnel for redistribution planning. HSAs were not routinely using C-Stock, contributing to poor documentation of stock

levels at village clinics. Mentorship in Q2 will include refreshers and hands-on practice of C-Stock mobile software.

Facility-Level Family Planning Nested Providers November saw a 2% increase in clients (5,166 in October to 5,265 in November) and 2.8%

increase in CYP (7,193 in October to 7,395 in November). Short term methods (68%) were the most popular, followed by LARC (29%), and permanent

methods (3%). Lilongwe gave out six times more male condoms than in any previous month, due to having

better access to stocks and ensuring clients received back-up supply. Also, there were a number

of clients who could not take hormonal methods and opted for condoms. Balaka gave out no condoms or pills in November due to stock outs.

TABLE 4. NESTED PROVIDER CLIENTS AND CYP – NOVEMBER 20181

DISTRICT CONDOMS (M)

CONDOMS (F)

PILLS EC DMPA IMPLANTS IUCD BTL CLIENTS CYP

Pie CL Pie Cl Cy Cl 3y 4y 5y Balaka 0 0 0 0 0 0 0 156 127 0 103 9 11 414 899 Dowa 112 5 0 0 24 8 0 373 32 0 37 2 17 477 496 Karonga 1,880 86 0 0 57 19 0 361 52 0 42 4 6 516 478 Kasungu 90 3 0 0 45 15 2 223 109 0 106 2 4 450 784 Lilongwe 2,870 136 0 0 41 27 2 70 94 0 166 14 26 424 1,234 Machinga 350 12 40 2 40 16 4 352 102 0 76 16 29 636 1,002 Mulanje 1,137 37 0 0 3 1 0 403 50 0 47 8 11 582 561 Nkhotakota 1,068 42 25 2 27 15 15 273 99 0 54 6 9 501 649 Salima 75 2 0 0 30 10 0 626 71 0 60 7 16 794 757 Zomba 520 22 0 0 48 24 0 338 45 0 31 5 19 471 535 TOTAL 8,102 345 65 4 315 135 23 3,175 781 0 722 73 148 5,265 7,395

Facility-Based Outreach Teams In November, the four facility-based outreach teams in Balaka, Karonga, Machinga, and

Nkhotakota reached a total of 3,187 clients with a variety of methods, generating 7,411 CYP (comparable with October data). Details of the facility-based outreach teams are provided in the table below. Of the 3,187 clients seen, the majority were between the ages of 20-24 years (32%), followed by 25-29 years (23%).

TABLE 5. FACLITY-BASED FAMILY PLANNING OUTREACH – NOVEMBER 2018

DISTRICT CONDOMS (M)

CONDOMS (F)

PILLS EC DMPA IMPLANTS IUCD BTL CLIENTS CYP

pie Cl Pie Cl Pie Cl 3y 4y 5y Balaka 3,580 123 0 0 8 3 14 305 151 11 211 24 79 862 2,222 Karonga 2,315 82 0 0 111 37 0 137 169 0 162 26 27 897 1,489 Machinga 1,653 40 0 0 83 31 0 292 108 42 136 18 55 699 1,646 Nkhotakota 1,200 60 0 0 83 31 0 292 108 42 136 18 55 699 1,646 Total 8,748 305 0 0 281 104 19 990 587 54 649 77 261 3,185 7,411

BTL Clinics ONSE supported the MoHP at Karonga District Hospital to conduct a bilateral tubal ligation

(BTL) clinic to clients within the hospital catchment area. A total of 11 women accessed BTL services, generating 102 CYP. ONSE will continue to support weekly BTL clinics at the district hospital to increase access to permanent FP.

DMPA-SC / SAYANA PRESS

ONSE participated in a DMPA-SC task force meeting at the Reproductive Health Directorate (RHD) to forecast and cost the second phase of roll out in the next 10 districts (Balaka, Chikwawa, Dedza, Karonga, Lilongwe, Mwanza, Neno, Nkhatabay, Nsanje, and Ntcheu). Of these districts, ONSE was requested to support roll out in Balaka, Lilongwe (in coordination

1 Figures in table reflect CYP generated through direct service delivery provided by the Nested Providers. Service delivery figures are also captured in DHIS2 and factored into ONSE's overall CYP achievements.

with PSI), and Karonga. It is expected that costing of the roll out in these districts will be covered by funds from the Bill and Melinda Gates Foundation and the Clinton Health Access Initiative (CHAI), with ONSE providing technical oversight.

ONSE is on course to finalize the rollout of DMPA-SC in the first phase of roll out in Machinga, Nkhotakota, and Salima.

BREAKTHROUGH ACTION COLLABORATION

ONSE collaborated with Ideas42 to share key findings from the user testing exercise conducted within health facilities in Lilongwe and Machinga in October. The update zeroed in on a key behavior gap, which is that providers are not counseling clients on appropriate contraceptive methods. The team presented behavioral bottlenecks identified during user testing that may be contributing to the problem and methods to address them, including: Establishing a counseling table “tent” job aid to promote balanced counseling of all

methods. A two-sided card with a “promise side” illustrating a provider-client pledge and a

“methods side” facilitating comprehensive counseling. Development of a provider self-assessment exercise.

The final report of the user testing exercise will be shared with USAID through Breakthrough ACTION in quarter 2, which will inform the next steps looking at an impact evaluation of the designs.

MALARIA

MALARIA CASE MANAGEMENT

In December ONSE supported malaria case management supervision and mentorship for 112 (74 M, 38 F) health workers from 51 (41 public and 10 private) facilities in Chikwawa, Machinga, Mangochi, Salima, and Nkhatabay to strengthen and enhance health workers’ competencies, knowledge, skills, and attitudes. The mentorship addressed gaps and challenges observed during the third round of Outreach Training and Supportive Supervision (OTSS) conducted in August 2018. Participants were mentored on patient assessment and history taking, use of malaria rapid diagnostic tests (mRDT), documentation, and severe case management in order to ensure delivery of quality and standardized malaria case management services at facility level.

MALARIA IN PREGNANCY

In Chikwawa, Balaka, Mangochi, Nkhatabay, Nkhotakota, and Salima, ONSE supported MIP supervision for 17 health facilities for 164 (99 M, 65 F) health workers. The supervision and mentorship was in line with the malaria in pregnancy (MIP) guidelines, intermittent preventive treatment of malaria in pregnancy (IPTp) and focused antenatal care standard protocols. The notable challenge observed during this round of supervision is that most ANC providers are not oriented to the new MIP guidelines and are providing services using the outdated guidelines. This adversely affects the quality of MIP services provided to pregnant women and IPTp initiation is delayed until 16 weeks of pregnancy, as opposed to the recommended 13 weeks.

NUTRITION

IFHOCS

In December, Balaka, Chitipa, Mulanje, Nkhotakota, Chikwawa, Mangochi, Machinga, Mulanje, Ntcheu, Mchinji, Lilongwe, Dowa, Kasungu, and Nkhatabay provided data on nutrition services provided through support to MoHP IFHOCs. In these districts, a total of 13,544 (6,335 M, 7,209 F) children attended growth monitoring sessions.

A total of 4,011 caregivers with children 6-59 months received nutrition counseling.

Of the 1,911 pregnant women who attended the IFHOCs in these then districts, 1,105 (80%) received iron tablets and 345 (25%) received Albendazole. ONSE district teams will coordinate with DHMTs to ensure that there are adequate stock levels available at IFHOCs and provide follow-up mentorship to providers.

A total of 2,720 pregnant and lactating women received nutrition counseling and 265 received support to initiate breastfeeding.

TABLE 6. NUTRITION SERVICES PROVIDED TO PREGNANT WOMEN AT IFHOCS – DECEMBER 2018

Age Pregnant Women

Attending ANC

# Pregnant Women Receiving Iron Tablets

# Pregnant Women Receiving Albendazol

n % n % 10-14 Years 7 7 100% 3 43% 15-19 Years 451 364 81% 110 24% 20-24 Years 652 560 86% 191 29% 25+ 801 648 81% 154 19%

COMMUNITY MANAGEMENT OF ACUTE MALNUTRITION (CMAM)

In Mulanje, ONSE and the United Nations International Children’s Emergency Fund (UNICEF) conducted joint mentorship at 18 health facilities for 39 health workers on improving documentation on stock cards, triaging of clients in the OPD clinic, appetite test administration, and provision of sugar water to prevent hypoglycemia.

In Machinga, ONSE supported three Nutrition Rehabilitation Unit (NRU) death audits, with participation from 16 (5 M, 11 F) facility staff. Of the three deaths, two were referrals from Balaka. The audit revealed that the main causes of death were severe pneumonia, secondary to HIV immunosuppression and hypoglycemia. Contributing causes identified included delay in referral, delay in seeking care by guardian, and inadequate initial nutrition assessment by NRU staff members. Agreed action points to improve future care included follow up on client cases in Balaka by the District Nutrition Officer, targeted mentorship and coaching on initial clinical assessments, orientation on revised Community Management of Acute Malnutrition (CMAM) guidelines, and community sensitization campaigns to improve earlier care seeking.

BABY FRIENDLY HOSPITAL INITIATIVE (BFHI)

ONSE supported the MoHP to disseminate feedback of the Baby Friendly Hospital Initiative (BFHI) external assessments for Atupele Community Hospital in Karonga and Chitipa District Hospital.

Atupele passed the assessment and will soon be recognized as a Baby Friendly Hospital, with the MoHP taking the lead on accreditation.

Chitipa District Hospital passed 7 out of the 10 steps (a minimum pass score is 8 steps). The three failed steps included: training of all healthcare staff in skills necessary to implement the BFHI policy, informing all pregnant women about the benefits and management of breastfeeding, and helping mothers initiate breastfeeding within an hour of birth. The facility was given three months to work on the failed steps, after which it will be reassessed. In the interim, ONSE will support the facility to conduct an internal self-assessment and supportive supervision.

QUALITY OF CARE

At the national level, ONSE participated in pre-testing for the Quality Management Directorate (QMD) Quality Improvement Training Manual in Lilongwe. The activity was funded by the German cooperation, the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) and co-facilitated by ONSE. Following the testing, QMD is incorporating suggestions made including:

The need to create a more comprehensive QI module prior to sharing with the Quality of Care (QoC) Technical Working Group in January by bringing in all of the relevant pieces on QI that appears in other modules so that it may act as a standalone module.

In Blantyre, ONSE participated in the development of the QoC Monitoring and Evaluation (M&E) framework, organized by QMD with funding from the World Health Organization (WHO), drawing participation from implementing partners including Kuunika, MaiKhanda, the Parent and Child Health Initiative Trust organization (PACHI), and MoPH officials. This workshop was an important activity for ONSE’s support to the QMD for implementation of the Quality Road Map and led to the prioritization of global indicators for inclusion in the final document. The final set of indicators is expected to be selected in January. Two sets of indicators were considered for inclusion including the global indicators used

by all countries in the Quality, Equity, and Dignity (QED) network for reporting and local indicators selected by Malawi for tracking.

TUBERCULOSIS

In Machinga, ONSE supported facility-based review meetings at three facilities, with participation from 30 (18 M, 12) health care workers. The activity will continue through the end of December, reaching all supported facilities in the district. Observations included: Facilities are still reporting low case detection due to inadequate TB screening of clients

in all departments of the facility, as well as a lack of TB community awareness meetings coordinated by TB volunteers. ONSE will support facilities to assign a health care worker to conduct systematic TB screening to all antiretroviral clinic clients during clinic days, as well as ensuring that all supplies and source documents (presumptive TB register, sputum bottles, and laboratory request forms) are available.

Poor TB sensitization and awareness at the community and village clinic level. HSAs should provide health education about TB to mothers during village clinics and all under-five children should be screened for TB during under-five clinics. ONSE will support HSAs to conduct frequent supportive supervisions to community TB volunteers.

No microscopy services offered at Namandanje Health Center, despite the facility being a microscopy center. The microscopist was trained two years ago, but has never practiced his skills, referring patients to Ntaja Health Center (10km away) for sputum examination. ONSE will follow up with on-the-job mentorship in January.

WASH

MCSP VISIT ON INFECTION PREVENTION CONTROL

In December, the ONSE WASH team hosted Stephen Sara, from USAID’s Maternal Child Survival Project (MCSP) from Dec 4 – 13, 2018. During this technical visit, a number of meetings and health facility assessments were conducted with different stakeholders to understand the level at which each stakeholder was implementing WASH/Infection Prevention Control (IPC) in the health facilities. Meetings were held with the Preventive Health (Environmental Health) Directorate, Nurses and Midwifery Directorate, QMD, RHD, WHO Malawi Country Office, UNICEF (WASH) country office, WaterAid Malawi, and USAID. Following the consultative meetings, field visits were made in Lilongwe and Dowa to

assess WASH IPC in health facilities using a checklist developed for MCSP in Nigeria. The checklist was used to assess the level at which health facilities in Malawi are implementing WASH IPC in health facilities.

It was observed that health facilities were at different levels in the implementation of the WASH IPC. A number of gaps were identified in the implementation of WASH IPC including water supply, sanitation, hygiene practices, cleaning supplies, waste

management, and personal behaviors towards general WASH. Action plans were developed to assist facilities in fulfilling WASH IPC.

FACILITY-LEVEL WASH

In Lilongwe, ONSE conducted a WASH inspection tour at Bwaila Hospital to assess the condition of plumbing following reports that there were sewerage and waste water blockages, malfunctioning toilets, and surface water run-off from open drainages. Challenges observed included: During the visit, it was observed that some women practice open defecation at nearby

open spaces (including the area where the Cholera Treatment Unit was erected), while others use available pit latrines to relieve themselves. Women noted that they were more comfortable with pit latrines and open defecation, as these are practices used in their respective villages.

Soapy water from the washing troughs was being directed into the storm water drainages, which are not covered by cross-over slabs in some areas, posing health risks.

The labor ward, which has 10 delivery rooms, had only two functional toilets and showers, with the other eight broken down due to non-functional cisterns, flexible connectors, and shower blockages.

The postnatal ward has a major blockage of waste water pipes. Sinks are nonfunctional, as plumbers are unable to clear blockages due to the system design; inspection bends were cast in the walls making them difficult to access.

ONSE proposed solutions to improve WASH at Bwaila, which would significantly improve the situation including: The Physical Asset Management Unit developed a list of materials required for the

maintenance of the facilities, which is currently under review for purchase by ONSE. ONSE support to conduct civic education on the use of WASH facilities, especially

toilets and showers within facilities. Identified the need to erect a new waste water system in the postnatal ward, with

support from ONSE for the design and procurement of materials. Procurement of cross-over slabs to cover the open storm water drainage.

ONSE completed a list of health facilities that will receive support to improve sanitary facilities to reduce structural barriers limiting the access to healthcare services. A total of 32 health facilities from 9 districts were assessed, from which 6 health facilities have been selected to be supported with ventilated improved pit (VIP) latrines by ONSE in PY3. The criteria for selection were based on need using WHO Standards which require that, at a minimum, public health care facilities should have four sanitation facilities (latrines)--1 for male clients, 1 for female clients, 1 for male staff and 1 for female staff.

TABLE 7. HEALTH CARE FACILITIES TO BE SUPPORTED WITH VIP LATRINES

DISTRICT HEALTH FACILITY SUPPORT TO BE PROVIDED

Mulanje Muloza 2 double blocks of VIP latrine Mlomba 2 double blocks of VIP latrine

Machinga Nyambi 2 double blocks of VIP latrine

Lilongwe Mbang`ombe 2 double blocks of VIP latrine Chimbalanga 2 double blocks of VIP latrine

Karonga Wiliro 2 double blocks of VIP latrine In an effort to promote infection prevention in health facilities, ONSE WASH Officers

conducted follow-up supervision on health facility WASH action plans that were developed in 10 facilities in Balaka, Machinga, Mulanje, and Lilongwe. Some of the issues that have been addressed include lack of hand washing stations in key care points such as the postnatal care

section, lack of soap in hand washing stations, lack of privacy in latrines due to broken doors, and lack of latrine drop hole covers to prevent disease vector like flies from accessing excreta. The health facility staff and the community through health center management committees (HCMC) implement/address the issues through developed WASH action plans. Table 8 highlights the WASH issues and what has been done to address them.

TABLE 8. SAMPLE HEALTH FACILITY WASH ACTION PLANS IN BALAKA, LILONGWE, MACHINGA, AND MULANJE

DISTRICT FACILITY ISSUES FOUND WHAT HAS BEEN IMPLEMENTED/ CHANGE/ IMPROVED

Balaka

Balaka District Hospital

Lack of handwashing station in key care points (labor ward, postnatal ward, pediatrics, male and female ward) to support handwashing by health care providers.

Balaka DHMT has released and distributed 8 tap buckets to provide ward with soap and water to support hand washing by health care providers.

Lack of personal protective equipment for hospital attendants such gumboots to protect them from infections.

Balaka DHO`s WASH IPC team has distributed 1 pair of gumboots to one hospital attendant.

Inappropriate/unsafe waste disposal making the disposal site filthy.

Meeting held with all hospital attendants about unsafe disposal of refuse/rubbish. In December, all the filthy sites (guardians shelter, outside post-natal ward) were cleaned.

Machinga Kawinga Inadequate pit latrines-- only one latrine was available for male and female clients.

HCMC has started constructing two additional pit latrines which are at the pit excavation stage.

Karonga Fulirwa No handwashing station in outpatient department (OPD) latrine.

Health facility team led by HSAs constructed a tippy tap on the latrine to promote handwashing after using latrine.

Lilongwe

Kabudula

Open urination by guardians around OPD and administration block during night.

HCMC summoned local leaders and facilitated by-laws to punish anyone found urinating around the facilities. Hygiene messages on proper disposal of human excreta was shared.

Chikowa OPD latrine has a broken door, compromising privacy of users.

A door was made and installed by HCMC.

Katchele No drop-hole cover on latrine for clients and no clear demarcation/ allocation of latrines to male and female clients.

Drop-hole cover was made and installed by DHO & HCMC. Signage was placed to indicate male and female latrine.

Mitundu

Dirty walls and floor in the EPI vaccine administration room. Overgrown bushes around mortuary area which can harbor vectors for disease.

The walls and floor were mopped and a cleaning schedule was developed and followed. The overgrown grasses have been cut short by DHO.

Mulanje Mbenje

Dirty general surrounding, blocked rainwater drainages making rain water to flood around the facility. No clear structure or responsible person to lead on general sanitation and hygiene at the facility.

HCMC mobilized community members to clean the facility surrounding and clear the blocked rainwater drainage channels. WASH/IPC focal person has been selected by health facility management.

COMMUNITY-LEVEL WASH

In Salima, ONSE supported the assessment of three water points (Chadzanje, Chadza and Kalimba) to identify needs for rehabilitation. Once rehabilitated, these boreholes will increase access to basic drinking water to 750 people and avert the risk of diarrheal diseases. The checklist on the non- functional boreholes was used to identify spares parts needed for the rehabilitation and a bill of quantities for borehole spare parts was developed.

In December, ONSE continued to roll out its sanitation marketing strategy, with 6 (6M) local masons from Lilongwe oriented on the low cost of basic/improved pit latrine construction. As a result of this approach, 87 (38 M; 59 F) community members have been oriented on improved sanitation focusing on cement sand screed technology, hand washing with soap stations, and the importance of improved latrines. To-date, these orientations have contributed to the improvement of 453 latrines and a total of 2,039 people in the 11 WASH districts are accessing basic latrines that safely separate excreta from human contact.

In December, ONSE engaged the services of WASH grantees to support the implementation of community-led total sanitation in Lilongwe (Canadian Physicians for Aid & Relief) . Table 9 below outlines progress to-date in achieving open defecation free (ODF) status in Lilongwe:

TABLE 9. GROUP VILLAGE HEADS THAT HAVE ATTAINED ODF STATUS THROUGH WASH GRANTEES – DECEMBER 2018

DISTRICT TRADITIONAL AUTHORITY (TA)

GROUP VILLAGE HEAD (GVH)

# OF VILLAGES

ODF STATUS2

Lilongwe Kabudula

Chinyama 20 95% Chisinga 11 95%

Nkhongoni Mkhuwiro 7 95%

PRIVATE SECTOR

PRIVATE SECTOR ASSESSMENT

In December, data collection for the private sector health assessment was completed. After analysis of data on the private health sector assessment is completed, findings will be disseminated and tailored interventions will be planned at the district level to strengthen access to quality services from private health facilities, pharmacies, and drug shops. Initial findings will be included in the PY3 quarterly activity report for Q1.

HEALTH SYSTEMS STRENGTHENING

LEADERSHIP AND MANAGEMENT

INTEGRATED SUPPORTIVE SUPERVISION

In December, at ONSE held a senior-level meeting with QMD on DHMT Integrated Supportive Supervision (ISS), drawing participation from the Director for Quality Management to discuss action items for moving forward with the ISS tool including: ONSE should distribute tablets to all supported districts for the ISS tool. All districts should use CommCare to conduct DHMT ISS. QMD will sponsor a retreat in January 2019 engaging MoHP Senior Management and

DHMTs to emphasize the importance of conducting DHMT ISS, as it is one of their core responsibilities.

As a result of this national level meeting, ONSE distributed 50 Tablets to Karonga, Nkhotakota, Nkhatabay, Karonga, Northern Zone, Dowa, Salima, Balaka, Machinga, Zomba and South East Zone Office. In January, ONSE will distribute the final 25 tablets to Central East Zone Office, Mangochi and Chikwawa.

2 Footnote: Level 1 ODF: Every household uses a latrine with privacy (100% latrine coverage, sharing is acceptable). This accepts a latrine coverage of at least 95%; Level 2 - ODF++: Every household has a latrine with cover and hand washing facility (100% coverage); all religious institutions, market centers, and health centers int he catchment area have latrines with covers and hand washing facilities (100% coverage)

At the zonal level, ONSE supported the Central West Chief Quality Management Officer conducted mentorship for DHMTs facing issues using the ISS tool in Mchinji. The need for this mentorship arose from a supervision exercise in November that revealed DHMT members were continuing to use paper-based checklists despite having been oriented on the tool and provided with tablets. Following mentorship, DHMT members demonstrated competency in using the ISS tool on the provided tablets.

In December, 120 staff from 20 health facilities received ISS in eight ONSE districts. A further analysis on the implementation of action items in response to ISS, a critical indicator, will be available in the PY3Q1 report.

SERVICE LEVEL AGREEMENTS

In Machinga, ONSE supported service level agreement (SLA) supervision visits at three facilities to ensure targeted people are accessing services through CHAM facilities. Challenges observed included that registers in some facilities had incomplete documentation and that some facilities were using old protocols in the management of MIP. The focal persons at each facility were notified and are in the process of developing action plans for improvement.

In Mulanje, ONE supported SLA verification exercises at three facilities. At the time of reporting, the exercise was still underway and takeaways will be included in the PY3 quarterly activity report for Q1.

PERFORMANCE BASED FINANCING

In December, ONSE’s Performance Based Financing (PBF) Technical Advisor was introduced to USAID. USAID was informed about the technical assistance provided by ONSE to the MoHP in reviewing the National PBF Framework. The meeting also discussed the support to policy dialogue and stakeholders coordination including initiating a stakeholder consultative meeting, to be conducted in January, tentatively. Key stakeholders will have an opportunity to discuss a national PBF design outlining partner’s roles and responsibilities, funds flow mechanisms specifically and other ways forward in order to kick start implementation.

A meeting between the ONSE PBF team and RHD was organized to further discuss the technical assistance to be provided by ONSE including a suggestion and consideration for the PBF Technical Advisor to split time between ONSE and the MoHP. This will ensure ONSE visibility at the MoHP and efficiency in stakeholder coordination to support discussions and coordination activities and ultimately drive the policy dialogue for a successful Health Sector Joint Fund.

ONSE conducted a meeting with GHSC-PSM to discuss the design of a study that will indicate the impact of PBF on supply chain performance. The meeting emphasized that the PBF design will consider the processes underlying the systems that they seek to influence with specific focus on the key drivers for commodity availability. Indicators will depend on the capabilities of the different subsystems within the supply chain, particularly those that are the bottlenecks or critical drivers of commodity availability and overall responsiveness of the supply chain system. It was agreed that although the purpose is to improve commodity availability at the facility level and to hold the facility accountable for meeting those standards, considerations will be made not to penalize or hold a facility accountable in cases where availability of a given commodity are ascertained to be out of the facility’s control.

HUMAN RESOURCES FOR HEALTH

SUPPORT TO RELIEF ALLOWANCES

In December, ONSE continued to support relief placement of 23 frontline healthcare workers in 17 facilities in hard-to-reach areas (HtRAs) in Chitipa, Karonga, Lilongwe, Mulanje, Ntcheu, and Zomba to strengthen quality of health service provision.

TABLE 10. STAFF SUPPORT IN HTRAS – NOVEMBER 2018

DISTRICT FACILITY SUPPORTED

NUMBER SUPPORTED

CADRE SUPPORTED

Chitipa Msumbe 1 Clinician Mahowe 1 Nurse

Karonga Ngana

1 Nurse 2 Clinician

Fulirwa 3 Medical Assistant (1), Community Nurse Midwife (2) Katili 1 Medical Assistant

Lilongwe

Lemwe 1 Medical Assistant Maluwa 1 Nurse

Katchale 1 Nurse 1 Medical Assistant

Mulanje Namphungo 1 Nurse

Chambe 1 Nurse Kambenje 1 Clinician

Ntcheu

Nsiyaludzu 1 Clinician Dzunje 1 Clinician

Chikande 1 Nurse Kapeni 1 Nurse

Zomba Maela 2 Nurse (2) Chisi 1 Nurse

TOTAL SUPPORTED 23

SUPPLY CHAIN

DRUG AND THERAPEUTIC COMMITTEES AND ACTIVITIES

In December, ONSE supported Drug and Therapeutic Committee (DTC) meetings in five districts, with key issues discussed outlined in the table below:

TABLE 11. ONSE DTC MEETINGS – DECEMBER 2018

DISTRICT PARTICIPATION HIGHLIGHTS

Karonga 11 DTC members, (10M, 1F)

Ordered drugs for the district hospital and the health centers in the district.

Dowa 9 DTC members (9M) Discussed how to address documentation challenges currently being experienced in most facilities.

Ordered drugs for DHO and health centers. Nkhatabay 7 DTC members (7M) Ordered drugs for DHO and health centers.

Discussed areas of focus during the planned DTC supervision, selecting: LMIS data quality assessment and on-the-job orientation, check of stock levels for proper redistribution planning, and check of storage conditions for medicines and medical supplies.

Mchinji 15 DTC members (8M, 7F)

Ordered medicines and medical supplies for the district from Central Medical Stores.

Continued discussions on how to orient health workers on rational use of medicines.

Ntcheu 12 DTC members (9M, 3F)

Ordered drugs for DHO and health centers (including supplies for cholera preparedness).

Agreed to intensify DTC supervisions.

DRUG AND MEDICAL SUPPLY REDISTRIBUTION

ONSE supported district pharmacy teams to conduct redistribution of commodities as highlighted in the table below. Some of the redistribution efforts are currently underway.

Redistributions enhance equity in service provision by leveraging the commodity quantities available within the district at any point in time. This is also pivotal to reducing out-of-pocket payments which clients would be subjected to in cases where there are prolonged stockouts.

A success identified from the redistribution exercise in November is that the commodity redistribution ensured facilities that were in short supply or stocked out of specific commodities received additional stock to better facilitate patients’ access to medicines. A challenge identified is that the lack of pharmacy personnel has led to a delay or postponement of redistribution exercises in some districts, such as Chikwawa.

TABLE 12. ONSE SUPPLY REDISTRIBUTION – NOVEMBER 2018

HEALTH COMMODITY

QUANTITY REDISTRIBUTED

DISTRICT FACILITIES

LA 1 103,320 Ntcheu From 8 to 21 facilities 2,700 Kasungu From 2 to 1 facility

LA 2 113,040 Ntcheu From 11 to 15 facilities LA 3 28,620 Ntcheu From 9 to 15 facilities LA 4 106880 Ntcheu From 9 to 18 facilities

mRDTs 200 Ntcheu From 1 to 1 facility 2,700 Nkhotakota From 1 to 1 facility

Female condoms 70 Chitipa From 2 to 1 facility

Microlut 535 Kasungu From 3 to 1 facility 45 Chitipa From 1 to 2 facilities

Jadelle 700 Nkhotakota From 4 to 1 facility 10 Chitipa From 1 to 1 facility

Implanon 170 Nkhotakota From 3 to 1 facility

Microgynon 1200 Nkhotakota From 1 to 1 facility 170 Kasungu From 1 to 2 facilities

Oxytocin 2,000 Kasungu From 1 to 2 facilities Magnesium Sulphate

364 Kasungu From 2 to 3 facilities 10 Chitipa From 1 to 1 facility

PHARMACY SUPERVISION

During this reporting period, ONSE supported pharmacy supervisions in Balaka, Karonga, and Machinga districts. The activities are still in progress. This is a crucial activity in that it is an opportunity for the district pharmacy personnel to provide supply chain support and interface with health center personnel. This has a positive impact on the smooth operation of drug stores in health facilities, enabling continued commodity availability, which consequently increases access to priority health services. Updates from these activities will be provided in the next reporting period.

PHARMACY ASSISTANT MENTORSHIP

In December, ONSE supported Pharmacy Assistant (PA) mentor visits to drug store clerks (mentees) at facilities in Nkhotakota and Nkhatabay. In Nkhatabay, ONSE supported a Pharmacy Assistant (1M) to mentor 4 mentees (3M,

1F) in 4 health facilities. The activity was conducted between 13th and 27th November 2018. The focus of the mentorship was on documentation and proper storage of health products. Proper documentation is essential for providing the necessary LMIS data that is used for decision-making, for example resupply and redistributions.

In Nkhotakota, the PA mentorship activity is still in progress and updates on this activity will be provided in the next reporting period.

REPORTING ON HEALTH COMMODITIES (OpenLMIS)

ONSE provided internet bundles for OpenLMIS data entry to all districts. OpenLMIS data is crucial for reordering of medicines, for checking stock imbalances to plan for redistribution. These efforts are instrumental in ensuring that there is continued and uninterrupted supply of medicines and medical supplies. This in turn contributes to increased access to priority health services.

OpenLMIS reporting for November is still in progress in December and updates will be provided in the next reporting period.

HEALTH MANAGEMENT INFORMATION SYSTEMS

DATA REVIEWS AND DATA QUALITY ASSESSMENTS

In Chikwawa, ONSE supported biannual malaria data review meetings and feedback for previous supervisions at cluster level, including 18 private clinics and drawing participation from 85 (64 M, 21 F) participants.

In Balaka, ONSE supported district Health Management Information System (HMIS) officers to conduct malaria data verification in 11 health facilities and two private clinics. The objective was to assess the quality of national malaria surveillance reports, which are collected on a monthly basis from health facilities where malaria case management is being done. Challenges noted included: variations in data captured from HMIS and malaria monthly reports and missing data for clients accessing services over the weekend. At both private clinics, laboratory registers, page and monthly summaries are missing, and there are no monthly reporting forms for the private sector. ONSE agreed to continue quarterly Data Quality Assessments (DQA) and on-site mentorship to data clerks and supervisions.

In Mchinji, ONSE conducted a DQA in six health facilities, including the district HMIS Officer and M&E Mentor. The aim was to mentor the new data clerks in the facilities on register filing, reporting, and graphing data for reports and will assist in improving reporting rates, fata quality, and data use at the facility level for decision making.

In Nkhotakota, ONSE supported follow up supervision of 19 (17M, 2 F) staff from 6 facilities on poorly performing health facilities in malaria data management including to establish and discuss ways of managing discrepancies between malaria cases and treatments dispersed. Most facilities reported more treatments than cases, with some not including page and monthly summaries in malaria registers. As a way forward, the facility managers called for a meeting with all staff involved in data management to develop a performance action plan and ONSE will conduct follow up supervision in Q2.

In Karonga, ONSE supported a DQA in four facilities to assess the quality and management of data collected and entered into registers and HMIS. Four indicators were selected for follow up in PY3Q4 including HBB, oxytocin, 48 hour postnatal checks, and ARI.

In Balaka, ONSE conducted quarterly mentorship of 23 (10 M, 13 F) from three facilities on the new postnatal and FP registers and reporting tools. Identified issues included small fonts in the postnatal register, making it difficult for providers to use and feedback will be fed back to MoHP.

MOBILE VILLAGE TOOL KIT (MVTK)

In December, ONSE continued finalizing refinements to Mobile Village Toolkit (MVTK) version 2 including: Final steps to complete the Community Health Indicator dashboard, including writing up

the report on the different indicators illustrated in the dashboard as examples. Review of the current HSA user list and their performance, which is expected to be

completed by end of December 2018. This included reviewing duplicate HSA users and listing those that were registered by mistake with the same location within CommCare for cleanup.

Clarification of definitions of iCCM performance indicators to effectively report on the newly endorsed community health indicators in collaboration with M&E officers from the IMCI unit of the MoHP.

In coordination with MoHP (CHSS), ONSE worked with the Community Health Services Section (CHSS) to finalize planning for Karonga’s MVTK deployment, which is scheduled for January 2019.

COMMUNITY MOBILIZATION AND ENGAGEMENT

COMMUNITY ACTION CYCLE

In December, ONSE supported the MoHP to conduct supportive supervision of 193 Community Health Action Groups (CHAG) in the 16 ONSE districts as they plan and implement their respective community interventions. District Community Mobilization Teams (DCMT) in several districts provided necessary support and mentorship to both CHAGs and Community Mobilization Team (CMT) members, with the main issues being addressed including clarification of roles and responsibilities of CHAGs, use of monitoring and reporting tools by CHAGs and CHVs, and progress of interventions against developed plans. The general observation of the supportive supervision teams was that there is a

realization and acceptance of the new roles by the CHAGs, with CMTs in some areas working with CHAGs and HSAs to revamp Village Health Committees (VHC) and linking to care groups.

To further improve supportive supervision, the ONSE central team developed an standard operating procedure to assist district teams to provide facility-focused supportive supervision. This is expected to strengthen HSA and CHAG relationships as they support VHC functionality, as well as to link community efforts with facility data in the process of improving documentation of community interventions.

COMMUNITY SCORECARD

In December, ONSE supported Community Scorecard (CSC) follow up meetings in Nkhatabay, reaching 211 (129 M, 82 F) people to track progress based on the joint action plan developed during CSC sessions in November 2017. The follow-up session drew participants including service providers and service users (youth, women, and men), in addition to HCMC members and community leaders. Key indicators assessed included: availability of supplies and commodities, punctuality of

health staff, availability of equipment and other materials at the health center, attitude of providers towards clients, and community participation on health related issues. It was noted that all indicators have improved in the past year. For example, punctuality of health workers at Chikwina health facility improved from 40% to 90% and at Mzenga health facility from 30% to 100%.

Outstanding issues to be addressed in upcoming action plans included inadequate availability of paracetamol and the ambulance is not stationed at Mzenga, as it still operates from the district. Some action points were made to ensure that the identified issues are addressed.

In Zomba, ONSE supported a CSC at TA Chikowi in the Lambulira Health Center catchment area and drawing participation from 416 (169 M, 247 F) community members, including the local leaders and a ward counsellor. It is expected that the scorecard sessions will help improve accountability both by service users and service providers. Further details will be reported in the upcoming quarterly activity report.

CHAMPION COMMUNITIES

In December, ONSE provided technical support to six Champion Communities and 219 (97 M, 132 F) members in Nkhatabay, Karonga, and Balaka. At Chakupompha Champion Community in Nkhatabay, members are mobilizing

resources for an under-five clinic which is currently under construction. At Mphinga Champion Community in Karonga, members reported that they have led

several charity and sanitation activities in the community including building latrines for people with disabilities and distributing soap to households for hand washing after latrine use.

At Atusaye Champion Community in Karonga, members reported that they supported the building of six improved drop hole cover latrines and are now sand screeding latrines in the community.

At Chikutu Champion Community in Karonga, members grew their income generation activity (IGA) funds to 393,990 MWK and are currently rearing five goats and 28 chickens. The GVH has offered the volunteers a piece of land for the next planting season.

In Balaka, the two Champion Communities in TA Sawali and TA Amidu are conducting small group sessions and door-to-door activities to reinforce the use of pit latrines, insecticide treated nets, emergency transport, and the construction of an outreach shelter.

ONSE accompanied staff from the MoHP Community Health Section on a learning visit to seven Champion Communities in Dowa, Nkhatabay, Nkhotakota, Karonga, Machinga, and Zomba to provide MoHP staff with insight on the overall approach and to identify synergies with the National Community Health Strategy. Key observations include: The Champion Community approach has strong linkages with existing structures such as

VHCs and community health volunteers. Champion Communities are strong in using data for decision making, a quality to be

reinforced with other community structures. HSAs are key in ensuring community interventions are systematically carried out, as

evidenced by the role they play in supporting communities to implement the interventions under the Champion Community Approach.

The Champion Community approach enhances CHAG functionality as it creates a conducive environment for CHAGs to provide oversight to community health volunteers.

CHIPATALA CHA PA FONI (CCPF)

TECHNOLOGY UPGRADES

After an initial internal release of the new Chipatala Cha Pa Foni (CCPF) software produced by Viamo and user testing, five key users (‘early adopters’) were trained and provided more feedback to Viamo with remaining staff to be trained by the end of the month. The new Viamo software system is live as of the first week of December, and the hotline is working on perfecting the new system’s performance and call quality.

No Airtel blasts were sent out in quarter 1, as there are ongoing negotiations for a new annual Memorandum of Understanding between Airtel, VillageReach, and Viamo.

HOTLINE ACTIVITIES

The hotline has continued to provide services 24/7 since mid-August. The two shifts have stabilized and calls during the night shift continue coming in steadily. The hotline receives around

50 – 60 calls with no downtime during each night shift. The night shift starts from 5pm to 8am with the day shift running from 8am to 5pm.

The hotline workers attended a First-Aid training in November. A National Trainer from MoPH facilitated a two-day training of all 21 hotline workers. The internal quality assurance team noted that the knowledge levels of the hotline staff in the area were rather low and hence affected the quality of information given to clients in an attempt to address any emergency queries.

MOHP TRANSITION

Dr. Fosiko, the CCPF transition lead at the MoHP with guidance from the Planning department, is leading the CCPF budget review within the MoHP and the development of the HR plan. The team has created a full transition implementation plan.

Dr. Fosiko is currently working with a team of clinical doctors at MoHP to review all existing CCPF reference materials on various clinical topics.

MOH and VillageReach are still working on a Memorandum of Understanding with Airtel and Viamo for the upcoming fiscal year. The key directors at Airtel have been doing extensive travelling for the last three months and Airtel has assured us that they are still pushing for each of the directors’ approvals to ensure the Memorandum of Understanding goes through, which is anticipated to occur by the end of December.

MONITORING AND EVALUATION

After a record month in August 2018 following a mega Airtel SMS blast promoting CCPF in 9 districts, call volumes declined as expected in the subsequent months. Over the past 3 months (September to November 2018), total national call volumes stayed steady just under 4,000 calls per month. In addition, despite no Airtel blasts over the past 3 months, the call volumes are higher than in July 2018. (Airtel will resume the blasts once the annual MOU is finalized). In November 2018, nationally there were 3,891 total calls answered from all districts, of

which 3,437 were ‘new relevant calls’ (these exclude follow-up calls from clients who had been referred to a health facility; short dropped calls; and irrelevant calls that were not about health or nutrition).

Specifically for ONSE, there were 3,283 total calls answered from the 16 districts, of which 2,823 were ‘new relevant calls’ (see graph below). 25% were calls about SRH, 10% about MCH, 3% about Nutrition, 6% about Tips and Reminders, while about half of the calls were about hundreds of other health topics.

Machinga and Zomba continued to have the highest call volumes (as for most of the past 1.5 years), followed by Mchinji, Lilongwe, Ntcheu, Nkhotakota, Mangochi, Salima, Karonga, Balaka, Dowa, Mulanje, Kasungu, Chikwawa, Chitipa, and Nkhatabay. Please note that Lilongwe and Mangochi are two of the newer CCPF districts that never received an Airtel blast and were not the focus of other projects/donors, but that now have fairly high call volumes; this means the rise in demand can be attributed primarily to ONSE community mobilization efforts.

SOCIAL AND BEHAVIOR CHANGE

ONSE continues to collaborate closely with Health Communication for Life (HC4L) to ensure that low literacy materials are available in all ONSE districts. Currently, the materials under distribution are reprints from the predecessor project, Support for Service Delivery Integration. In PY3, HC4L is engaging ONSE to support the development and design of new messages and materials to enhance behavior change. As this process is underway, the normal level of Social and Behavior Change (SBC) material distribution was much lower during the month of December.

In December, ONSE distributed CCPF SBC materials to seven health facilities and 38 CHAGs in Dowa and Lilongwe. Materials included posters (23), brochures (126), and business cards (96). Distribution of CCPF materials is expected to promote the use of CCPF services by both health workers and community members.

YOUTH AND GENDER

In Balaka and Kasungu, ONSE supported MoHP to conduct a Youth Friendly Health Services (YFHS) assessments of 15 facilities (14 in Balaka, 1 in Kasungu) in preparation for a national assessment Findings in Balaka showed that all facilities had the minimum number of providers

trained in YFHS and that the minimum package of YFHS is being provided to youth. In Kasungu, Linyangwa health center scored less than half on the assessment: the facility

has no providers trained in YFHS and no guidelines and standards for service provision for the youth. In Q2, ONSE will lobby with other stakeholders in the district to support capacity building for YFHS providers.

Across both districts, the main challenges observed included: lack of meeting minutes with communities and a lack of recreational materials in all facilities.

In December, ONSE captured data on the number of youth reached with sessions from the sexual and reproductive health (SRH) manual by youth life skills facilitators from Balaka, Karonga, Lilongwe, Nkhotakota, and Salima. SRH facilitators are reaching more very young adolescents with SRH information than older adolescents. As this is the age period when peer sharing of accurate information is particularly critical, these sessions could have a powerful impact on preventing teenage pregnancies in the communities.

TABLE 13. ONSE LIFE SKILLS SESSIONS – DECEMBER 2018

Session - Topic 10-14 Adolescent Girls

15-19 Adolescent Girls

10-14 Adolescent Boys

15-19 Adolescent Boys

Total

Knowing me and my dreams 300 300 289 400 1,289

Understanding my body 250 321 400 530 1,501

Communication with people 395 400 350 400 1,545

KEY COLLABORATION MEETINGS

USAID MEETINGS

LISA BALDWIN, HEAD OF USAID AFRICA BUREAU, MALAWI VISIT

In December, ONSE was privileged to host the Head of the USAID Africa Bureau, Lisa Baldwin. Ms. Baldwin was taken on a visit of Bwaila Hospital in Lilongwe, as well as a field visit to Salima, in an effort to demonstrate the support the USG has provided to health delivery in Malawi through the implementation of the ONSE Health Activity.

Ms. Baldwin appreciated the efforts ONSE and the MoHP are collaborating on to reduce maternal and neonatal morbidity and mortality in Malawi, particularly in the efforts of smart capacity building and improving provider performance and motivation.

OTHER KEY PARTNER COLLABORATIVE MEETINGS

ONSE AND CCPF DONOR MEETING

In December, VillageReach had visitors from the Skoll Foundation, a former and potential future donor for CCPF. ONSE provided an overview of the transition process of CCPF to the MoPH in an effort to share program learning experiences.

ONSE AND MATERNITY WORLDWIDE MEETING

Maternity Worldwide is an organization based in Zomba, focusing on MNH activities. ONSE and Maternity Worldwide met in December to discuss areas of potential collaboration, as both organizations are implementing in the same facilities in Zomba. The discussion will be ongoing and will allow for the organizations to organize programming in a way of maximizing reach to beneficiaries.

II. PROJECT MANAGEMENT

GRANTS UNDER CONTRACT

In December, grantees continued to implement activities in their assigned districts. These included the demand creation and social accountability grants in Karonga, Machina, and Salima and the WASH interventions in the 11 FHP districts.

USAID provided concurrence to extend at cost the malaria SBC grants so that they can continue carrying out their activities in the 10 malaria districts in PY3.

ONSE issued a request for applications for sanitation marketing in Zomba and Machinga. It is expected that three NGOs will compete for the opportunity.

FAMILY PLANNING COMPLIANCE

In December, ONSE supported FP compliance monitoring visits at 20 facilities in Karonga, Lilongwe, Nkhotakota, and Zomba to assess how facilities and providers are adhering to compliance requirements in line with USG support. Hard copies of compliance monitoring forms are stored securely in ONSE district offices. All facilities visit were found to be compliant.

A total of 50 ONSE staff completed the U.S. Abortion and Family Planning e-learning course during the month of December and certificate copies were filed at district and central offices. All ONSE staff are required to complete the course by end of January.

III. KEY CHALLENGES

In communities where there are no VHCs, CHAGs continue to undertake the roles of implementing activities and not overseeing the implementation as their new roles spell out in the National Community Health Strategy. This is seen especially where CHAGs have been reactivated from Community Action Groups of the previous SSDI project, where they were implementers. ONSE will continue to reinforce the new roles of CHAGs and work with HSAs and DCMTs to reactivate the passive VHCs in specific communities where these problems have been identified. Further, in remote areas, the Champion Community approach will be initiated where VHCs are part of this approach.

Poor collaboration between CMTs and HSAs in the catchment areas where CHAGs have slowed down implementation of community activities. ONSE has designed a new strategy on supportive supervision focusing on facility-based supportive supervision involving facility staff and community structures such as CHAGs and other volunteers. This will fully involve the HSAs of

the catchment area. The launch of the new Viamo software for CCPF has led to a reduced audio quality of the calls and some calls dropping on pick-up. The team continues to identify bugs in the new system and the Viamo team is working to rectify the technology glitches.

IV. LESSONS LEARNED AND BEST PRACTICES

Continued collaboration with other supply chain partners such as PSM is important to ensure synergies and complementary efforts in implementation. For instance, both PSM and ONSE supply chain teams have committed to jointly ensuring use of supervision log books at district and facility level. This is a key approach as it will enhance proper follow-up of action plans on supply chain challenges developed at the facilities but also give visibility and ownership to the district pharmacy teams, which is pivotal for sustainability of initiatives to improve stock availability.

A key lesson learned during the technology upgrade process for CCPF is that one way to ensure quality of data collection during the transition to the new Viamo software is to continue using paper forms to record call data. With the glitches in the system, relying on the automated data entry in the early adoption stages might affect the quality of data collected. Once the new system is fully stable and no anomalies in data are noted, the hotline will cease using the paper forms.

V. SHORT-TERM TECHNICAL ASSISTANCE

COMPLETED STTA

UPCOMING STTA

Name of Traveler Purpose of trip Dates (LOE)

N/A No STTA was conducted in the month of December N/A

Name of Traveler Purpose of trip Expected Dates (LOE)

Atanas Stoilov, MSH Senior Procurement Officer

Procurement training and capacity building January 28 - February 15, 2019 - pending approval

Gordon Kihuguru, MSH Regional Director of Finance and Operations

Procurement training and capacity building January 21- February 1, 2019 - pending approval