ACCESS End of Project Report

Transcription

1 ACCESS End of Project Report October 1, 2004 March 31, 2010 Submitted to: United States Agency for International Development under Cooperative Agreement # GHS-A Submitted: March 2010 Submitted by: Jhpiego in collaboration with Save the Children, Constella Futures, Academy for Educational Development, American College of Nurse-Midwives, IMA World Health

2 Table of Contents Acronyms... iii Executive Summary... 1 Project Achievements by HIDN Pathways... 5 Global Leadership... 5 Antenatal Care Results Pathway... 7 Postpartum Hemorrhage Results Pathway... 9 Skilled Birth Attendance Results Pathway Newborn Results Pathway Achievements in Other Technical and Crosscutting Areas Addressing Malaria in Pregnancy: A Comprehensive Approach to Maternal and Newborn Health Outcomes Strengthening the Integration of PMTCT within MNCH Services Community Mobilization: An Effective Strategy to Improve MNH Quality Improvement of Maternal and Newborn Health Services: Introducing Standards and Recognizing Achievements Recommendations for Future Programming Country Briefs Bangladesh Ethiopia India Kenya Malawi Nepal Nigeria Rwanda Tanzania Annex A: Program Coverage Matrix Annex B: ACCESS Global M&E Framework with Targets for Year 5 Annex C: Individual M&E Frameworks: Bangladesh, Ethiopia, Kenya, Malawi, Nepal and Tanzania Annex D: Table of In-Country Materials and Presentations Annex E: ACCESS Country/Regional Activities-Funding Levels and Summary of Key Activities Annex F: Associate Awards Annex G: Country Specific Survey Results: India, Nigeria and Rwanda Annex H: Final Evaluations: Nigeria, Pre-Service and Tanzania

3 Acronyms ACCESS AC ACT AMTSL ANC ANM ANMTC APHIA ART BASICS BEmONC BP/CR CAC CAG CBO CCG CEmONC CHEW CHW CMT CRP CSSC DHMT DHS DRH EARN EMNC EmONC ENMA ESOG FANC FBO FCHV FHD FIGO Access to Clinical and Community Maternal, Neonatal and Women s Health Services ACCESS Counselors Artemisinin-based Combination Therapy Active Management of the Third Stage of Labor Antenatal Care Auxiliary Nurse-Midwife Auxiliary Nurse-Midwife Training Center AIDS, Population, Health Integrated Assistance Program Antiretroviral Treatment Basic Support for Institutionalizing Child Survival Basic Emergency Obstetric and Newborn Care Birth Preparedness/Complications Readiness Community Action Cycle Community Action Group Community-Based Organization Community Core Group Comprehensive Emergency Obstetric and Newborn Care Community Health Extension Worker Community Health Worker Community Mobilization Teams Community Resource Person Christian Social Services Commission District Health Management Team Demographic and Health Survey Department of Reproductive Health East Africa Roll Back Malaria Network Essential Maternal and Newborn Care Emergency Obstetric and Newborn Care Ethiopia Nurse Midwife Association Ethiopia Society of Obstetricians and Gynecologists Focused Antenatal Care Faith-Based Organization Female Community Health Volunteer Family Health Division International Federation of Gynecologists and Obstetricians ACCESS End of Project, October 1, 2004 March 31, 2010 iii

4 FMOH FP GoI GoN HEP HEV HEW HHCC HIDN HIV HMIS HO HSA HSDP HTC ICM IEC IPTp IMAI IMCI INC IPC ITN KMC LAPM LBW LGA LHV MAISHA MIP MIPESA MNCH-CM MNH MOH MOHFW MOHP MOHSW MTUHA Federal Ministry of Health Family Planning Government of India Government of Nepal Health Extension Program Evangelical Hospital C.B.CO Vanga Health Extension Worker Household-to-Hospital Continuum of Care Health, Infectious Diseases and Nutrition Human Immunodeficiency Virus Health Management Information System Health Officer Health Surveillance Assistants Health Sector Development Plan HIV Testing and Counseling International Confederation of Midwives Information, Education and Communication Intermittent Preventive Treatment during Pregnancy Integrated Management of Adolescent and Adult Illness Integrated Management of Child Illness Indian Nursing Council Infection Prevention and Control Insecticide-Treated Nets Kangaroo Mother Care Long-Acting and Permanent Methods Low Birth Weight Local Government Authority Lady Health Visitor Mothers and Infants, Safe, Healthy, Alive Malaria in Pregnancy Malaria in Pregnancy East and Southern Africa Coalition Maternal, Newborn and Child Health-Community Mobilization Maternal and Newborn Health Ministry of Health Ministry of Health and Family Welfare Ministry of Health and Population Ministry of Health and Social Welfare Tanzania s Health Management Information System iv ACCESS End of Project, October 1, 2004 March 31, 2010

5 NASCOP NESOG NFHP NGO NHTC NMCM NMCP PAC PAHO PE/P PEPFAR PGH PHC PLWHA PMI PMTCT POPPHI PPH PPLAPM PQI PSI PwP RAOPAG RBM RH RHU SBA SBM-R SNL SP SSMP STI TB TBA USAID VCHW VCT WARN National AIDS and STI Control Program Nepal Society of Obstetricians and Gynecologists Nepal Family Health Program Nongovernmental Organization National Health Training Centre Nurses and Midwives Council of Malawi National Malaria Control Program Postabortion Care Pan American Health Organization Pre-Eclampsia/Eclampsia President s Emergency Plan for AIDS Relief Provincial General Hospital Primary Health Center People Living With HIV/AIDS President s Malaria Initiative Prevention of Mother-to-Child Transmissions Prevention of Postpartum Hemorrhage Initiative Postpartum Hemorrhage Postpartum Long-Acting and Permanent Methods Performance and Quality Improvement Population Services International Prevention with Positives West African Regional Coalition for Malaria in Pregnancy Roll Back Malaria Reproductive Health Reproductive Health Unit Skilled Birth Attendant Standards-Based Management and Recognition Saving Newborn Lives Sulfadoxine-Pyrimethamine Support to Safe Motherhood Program Sexually Transmitted Infections Tuberculosis Traditional Birth Attendant United States Agency for International Development Voluntary Community Health Worker Voluntary Counseling and Testing West Africa Roll Back Malaria Network ACCESS End of Project, October 1, 2004 March 31, 2010 v

6 WHO WHO/AFRO WHO/SEARO WRA WRATZ UNFPA UNICEF UPMB USG World Health Organization World Health Organization Africa Regional Office World Health Organization South-East Asia Regional Office White Ribbon Alliance White Ribbon Alliance/Tanzania United Nations Population Fund United Nations Children's Fund Uganda Protestant Medical Bureau United States Government vi ACCESS End of Project, October 1, 2004 March 31, 2010

7 Executive Summary The Access to Clinical and Community Maternal, Neonatal and Women s Health Services (ACCESS) Program a five-year, $75 million Leader with Associates Award aimed to improve the health and survival of mothers and their newborns through expansion of coverage, access and use of maternal and newborn health (MNH) services, and through improving household health behaviors and practices. The Program was implemented by Jhpiego in collaboration with Save the Children, Futures Group, Academy for Educational Development, American College of Nurse-Midwives and IMA World Health. This report presents Program achievements over the period of 1 October 2004 to 31 December During these five years, ACCESS worked in 26 countries, reaching millions of women, newborns and families. The Program s largest country programs were in Bangladesh, Ethiopia, Kenya, Malawi, Nigeria, Rwanda, South Africa and Tanzania. ACCESS also received five associate awards: ACCESS-FP, Afghanistan Health Services Support Program (HSSP), Cambodia, Kenya UZIMA, and Tanzania MAISHA. ACCESS produced wide-ranging, global results in international leadership, capacity building, demand generation and service delivery in MNH. Working with its partners, the Program also developed or updated documents of global significance 1 including key international training materials recognized as the standard in maternal and newborn care and disseminated these resources to stakeholders worldwide to advance knowledge of programming in MNH. In addition, nearly 8,000 people completed the seven ACCESS-developed United States Agency for International Development (USAID) Global Health elearning courses. Countries supported by the Program increased their coverage of evidence-based, high-impact interventions for women and newborns. Overall, ACCESS realized its vision of improved health for mothers and newborns by: Developing strategies and programs that integrated evidence-based maternal and newborn care with existing health delivery systems; ACCESS addressed the serious challenges required in meeting MDGs 4 and 5 in regions that contribute the most to worldwide maternal and neonatal deaths. Specifically, the Program: Reached over 30 million women of reproductive age in 26 countries with Program interventions Trained more than 20,000 health workers over the life of the project Introduced and/or expanded antenatal care services in 15 countries Increased the pool and improved the skills of birth attendants in 15 countries Scaled up PPH prevention efforts in 14 countries Worked in 16 countries to improve the health outcomes for newborns, including establishing or expanding KMC services in 5 key countries Strengthened the capacity to mobilize communities in 9 countries Disseminated key training and reference materials globally, and developed seven e-learning courses for the Global Health website (from which nearly 8,000 users have received certificates) Assisting in the development and implementation of policies that influenced the global agenda to improve MNH; 1 These documents include: Best Practices in Maternal and Newborn Care: A Learning Resource Package for Essential and Basic Emergency Obstetric and Newborn Care; an online animated demonstration of active management of the third stage of labor; Malaria in Pregnancy Resource Package; Christian and Islamic sermon guides; and Demystifying Community Mobilization: an Effective Strategy to Improve Maternal and Newborn Health. For a full listing of ACCESS references, visit: ACCESS End of Project, October 1, 2004 March 31,

8 Bringing MNH services closer to households and communities; and Addressing operational barriers that prevent families from seeking care. This report presents key Program results and activities over the life of the Program. Results are presented by the four results pathways of the USAID Office of Health, Infectious Diseases and Nutrition (HIDN): skilled birth attendance, antenatal care (ANC), postpartum hemorrhage (PPH), and newborn care as well as by other technical and cross cutting topics. Important lessons learned and results by country have also been included. To be successful, ACCESS recognized that any approach to improve essential maternal and newborn care services must address the issues of the community and the health system together, systematically, and in close collaboration among all stakeholders. Therefore, a key Program approach was based on the Household-to- Hospital Continuum of Care (HHCC) model, which aims to improve health delivery by strengthening the facility, connecting the household to the facility, and mobilizing family and community members to make the links necessary to care for mothers and newborns. Projects in Asia and Africa expanded life-saving interventions along the HHCC to overcome the complex obstacles that prevent pregnant women and newborns from receiving appropriate and timely care preferably as close to home as possible. In northern Nigeria, for example, an environment of poor service utilization for maternal care, the HHCC approach allowed staff to work at the policy level to improve the service delivery environment to eventually increase the availability of skilled providers, while at the same time improving the quality of services by renovating dilapidated primary health centers and mobilizing communities to increase demand for and utilization of life saving services. Similarly in Malawi, ACCESS worked across the continuum, from strengthening midwifery pre-service education, to supporting the Ministry of Health to finalize national standards for EmONC and community MNH counseling, to improving the quality of services in hospitals and health centers, to mobilizing communities to better prepare for birth and access services. At the facility level, the HHCC strengthened the capacity of health service providers in peripheral health facilities and referral hospitals to improve the access to and quality of MNH care. At the community level notably in Afghanistan, Bangladesh and Nepal ACCESS promoted healthy pregnancy and birth practices, better self care, recognition of complications, and timely health service seeking. 2 While many countries and ministries of health have a vision to provide services across a continuum of care that reaches from the household to the hospital, it is a difficult vision to achieve. The HHCC model provided a useful framework for ACCESS to work with host country governments to assess gaps and provide strategic inputs so that their vision could become reality. To further improve health outcomes for women and their babies, ACCESS helped to expand the pool and improve the skills of birth attendants in 15 countries 3. As part of this effort, the Program strengthened clinical training sites and labs, revised midwifery curricula, and updated the knowledge and practices of midwives in basic emergency obstetric and newborn care (BEmONC). For instance, in Rwanda, ACCESS trained more than 150 health care providers and community health workers in BEmONC, leading to 100% of births in ACCESS-targeted facilities occurring with a skilled attendant using a partograph and active management of the third stage of labor (AMTSL). These efforts, coupled with work to improve the skills of midwifery tutors and preceptors in 126 pre-service education institutions (schools and training centers) in seven countries (Ethiopia, Ghana, Malawi, Tanzania, Nigeria, Afghanistan and India), helped to improve the quality of 2 Otchere, S. and Ransom, E Bringing Care Closer to Mothers and Newborns: Using the Gap Analysis Tool to Develop a Household to Hospital Continuum of Care. Save the Chidren. Washington, DC: Afghanistan, Cameroon, Ethiopia, Ghana, Guinea, Haiti, India, Malawi, Mauritania, Nepal, Niger, Nigeria, Rwanda, Tanzania and Togo 2 ACCESS End of Project, October 1, 2004 March 31, 2010

9 skilled attendance at birth, and will lead to more skilled midwives graduating in the future. In Nepal, ACCESS also strengthened the skilled birth attendant content of the national pre-service and in-service training curriculum. In 15 countries 4, ACCESS introduced and/or expanded antenatal care (ANC) services, facilitated Road Map development and, where appropriate, used ANC as a platform to strengthen services to prevent malaria in pregnancy (MIP). More than 28,000 women at targeted facilities in Haiti were provided with prevention of mother-to-child transmission of HIV services and, in Burkina Faso alone, more than 3.8 million people were covered by focused ANC and MIP services. ACCESS was also a committed partner to the Roll Back Malaria (RBM) Initiative and promoted the World Health Organization s (WHO) three-pronged strategy to address MIP prevention and control in areas of stable transmission. Program support and active participation in regional coalitions in Africa contributed to improved coordination and implementation support in 29 countries. Through its membership in the MIP working group, ACCESS contributed to the development of the RBM Global Malaria Action Plan, which is considered the global road map for malaria control and elimination around which all stakeholders can coordinate their actions. The Program, in close collaboration with WHO, also revised and updated the Malaria in Pregnancy Resource Package, which outlines seven essential programming components necessary for putting MIP policy into practice at the health facility level, and draws on existing country experiences, best practices and lessons learned for practical implementation. To combat the primary cause of maternal death, ACCESS introduced and/or expanded efforts in 14 countries 5 to prevent and treat PPH. The Program trained thousands of health care providers to correctly practice AMTSL to prevent PPH. These trained providers in turn employed this life-saving practice at tens of thousands of births. As a frontline intervention to prevent PPH, ACCESS piloted community-focused birth preparedness programs emphasizing obstetric care by a skilled birth attendant during and immediately after childbirth. Program experience showed that community-based education and distribution of misoprostol is a safe, acceptable, feasible and programmatically effective tool for preventing PPH in low-resource settings where access to skilled attendance is limited. As a result, in areas like Afghanistan, ACCESS achieved nearuniversal coverage of a method to prevent PPH in the intervention area, and the MOPH will expand the intervention to areas of the country where access to emergency obstetric care remains a challenge. And in Nepal, the proportion of deliveries protected by a uterotonic increased from 10.4% to 72.5% during the Program, with the largest increases being among the poor, illiterate and those living in remote areas. ACCESS also worked in 16 countries 6 to improve the health outcomes of newborns. Essential newborn care practices (warming and drying of the infant, resuscitation if needed, early and exclusive breastfeeding and clean cord care) were promoted in all ACCESS SBA training and facility-based quality improvement efforts. Interventions also led to increased knowledge of essential newborn care such as in Bangladesh and India where 100% of targeted workers are now equipped with such knowledge. The Program significantly expanded coverage of Kangaroo Mother Care (KMC), a life-saving, low-tech, low-cost intervention to protect vulnerable preterm/low birth weight newborns, especially from hypothermia. In Nigeria, Rwanda and Nepal, ACCESS established the foundation for future expansion of KMC services by establishing KMC learning centers and supporting the provision of KMC services in a number of hospitals. In Malawi and Ethiopia, the Program built on the foundation of already established programs to expand KMC services to additional hospitals. 4 Afghanistan, Burkina Faso, Cameroon, Ethiopia, Haiti, India, Kenya, Madagascar, Malawi, Nigeria, Rwanda, South Africa, Tanzania, Uganda and Zambia 5 Afghanistan, Cameroon, DRC, Ghana, Haiti, India, Kenya, Malawi, Mauritania, Nepal, Niger, Nigeria, Tanzania and Togo 6 Afghanistan, Bangladesh, Cambodia, Cameroon, Ethiopia, Ghana, India, Kenya, Malawi, Mauritania, Nepal, Niger, Nigeria, Rwanda (KMC), Tanzania and Togo ACCESS End of Project, October 1, 2004 March 31,

10 ACCESS recognized that partnerships among faith-based organizations (FBOs) and other stakeholders are critical in promoting and delivering improved MNH services, and the Program s collaboration with FBOs and their facilities enhanced opportunities for scale-up of MNH interventions. ACCESS led efforts to highlight the value of FBO contributions and partnerships on a global scale through presentations at key international meetings the 2008 Women Deliver Conference; 2009 Global Health Council s Faith and Global Health Caucus Meeting; and Christian Connections for International Health conference and established partnerships with the World Health Organization s Partnerships Office and the World Council of Churches. Staff also developed a technical brief, Faith-Based Models for Improving Maternal and Newborn Health, which was widely shared with audiences in the US, Africa and Asia. And on a local level, ACCESS helped FBOs become connected to wider networks, for instance by helping The Protestant Church of Congo and the Uganda Protestant Medical Bureau gain visibility by sponsoring their participation in a panel presentation at the 2008 Women Deliver conference. To train religious leaders to successfully advocate for women s health, ACCESS worked with Christian and Islamic leaders in three countries and developed two sermon guides 7 to help them change attitudes and behavior toward maternal and newborn health among their constituents with appropriate Safe Motherhood messages. In addition, ACCESS hosted a regional workshop in Tanzania on high-quality focused ANC for, among others, 40 faith-based healthcare service providers and FBOs from five East African countries. As a result, country teams developed action plans, some of which received ACCESS support, to train providers and community health workers in focused ANC and MIP. ACCESS technical assistance also helped a number of FBOs improve their funding prospects by linking faith-based health service delivery networks in Africa with the United Nations Population Fund (UNFPA), WHO and other stakeholders. ACCESS achieved lasting impact for women and children through its support of evidence-based program expansion, improved policies and tools, and strengthening of individual and institutional capacity within governments, in health training centers, facilities and communities. The processes and results described throughout this report are evidence of the important progress the Program made toward meeting the critical needs of women and newborns in developing countries for life-saving services and information. ACCESS staff have been proud to contribute to these achievements, working alongside thousands of dedicated public servants, policymakers, health professionals, community health workers, volunteers, women and their families. 7 Muslim Khutbah Guide to Save the Lives of Mothers and Newborns: A Toolkit for Religious Leaders; and Christian Sermon Guide to Save the Lives of Mothers and Newborns: A Toolkit for Religious Leaders 4 ACCESS End of Project, October 1, 2004 March 31, 2010

11 Project Achievements by HIDN Pathways Over the past five years, ACCESS and its Associate Awards have worked globally, regionally and in 26 countries often with difficult-to-reach populations to expand services and increase awareness of maternal, newborn and women s health needs. The Program received $74,990,000 against a ceiling of $75,000,000. Five Associate Awards were granted under ACCESS, one for family planning (FP) at the global level and four at the country level: Afghanistan, Cambodia, Kenya and Tanzania. All Associate Awards, with the exception of Cambodia, will extend beyond the end date of ACCESS. Afghanistan Gaining International Recognition through Midwives Association With ACCESS support, the Afghan Midwives Association (AMA) has celebrated significant progress since its establishment in In the short time since the association was formed, it has established itself as a credible professional association and gained international recognition as a member of the International Confederation of Midwives (ICM). It now boasts more than 1,000 members, a number that continues to grow as new midwives graduate and awareness of the association spreads. To meet the enormous need for skilled birth attendants in Afghanistan, the AMA receives considerable technical assistance from the ACCESS Program and the ACCESS Associate Award Health Services Support Project (HSSP). The AMA has worked tirelessly with the Government of Afghanistan and its ministries to promote the use of midwives as the primary provider for pregnant women, and has facilitated the involvement of midwives in the policy development process. The association is now taking a role in providing continuing professional education courses for trained midwives. Partograph teaching, Afghanistan The results have been tangible: coverage of evidence-based, high-impact interventions has increased for women and newborns in countries where ACCESS has worked; national maternal and newborn health (MNH) policies have changed; and midwives and doctors across Africa are better prepared to deliver life-saving care. The Program has laid the groundwork for continued improvement in health for mothers and infants, and schooled thousands of providers and community health workers (CHWs) to care and advocate for them. This section of the report presents ACCESS Program achievements in global leadership and results over the life of the program, organized by the four results pathways of the United States Agency for International Development s (USAID) Office of Health, Infectious Diseases and Nutrition (HIDN): skilled birth attendance, antenatal care (ANC), postpartum hemorrhage (PPH) and newborn care. Additional results by country and additional technical areas are presented later in the report and in the annexes. GLOBAL LEADERSHIP Through its global and local alliances, ACCESS global leadership has increased international and national attention and commitment to improve MNH across the continuum of maternal and newborn care. Partners with which the Program has allied in these efforts include: the World Health Organization (WHO), including Roll Back Malaria s (RBM) Malaria in Pregnancy Working Group (MIP WG); the United Nations Children's Fund (UNICEF); the United Nations Population Fund (UNFPA); the Partnership for Maternal, Newborn and Child Health; the Healthy Newborn Partnership; the White Ribbon Alliance (WRA); the International Confederation of Midwives (ICM); the International Federation of Gynecologists and Obstetricians (FIGO); and local organizations, including many faith-based organizations (FBOs). ACCESS End of Project, October 1, 2004 March 31,

12 In 2006, ACCESS supported the U.S. launch of the Lancet Maternal Survival Series, and the seminar was webcast worldwide. ACCESS also supported the Partnership for Maternal, Newborn and Child Health by providing a technical advisor to help the Partnership implement their global activities, strategic planning and fundraising. Through collaboration with partners such as Saving Newborn Lives (SNL), the Program improved access to knowledge of newborn health with the development and dissemination of tools and materials. It worked with global partners to launch the Lancet Neonatal Survival Series in Nepal and Indonesia, and the Lancet Child Survival Series in Washington, D.C. With partners, ACCESS staff co-authored several chapters in Opportunities for Newborns in Africa, a regional review of newborn health in Africa, and supported the dissemination of the report. The Program is also providing technical input to revise the resource manual Managing Newborn Complications in collaboration with WHO. In 2008, ACCESS increased awareness of USAID s contributions to MNH through its presentations at a Congressional briefing on MNH accomplishments in Nigeria and Afghanistan. In addition, Global Health TV developed a five-minute, widely-broadcast film on the Program s community midwifery work in Afghanistan. ACCESS facilitated Road Map development in 15 countries in Africa. Between 2005 and 2006, the Program collaborated with the World Health Organization Regional Office for Africa (WHO/AFRO) to assist the Africa Road Map Initiative by supporting Anglophone, Francophone and Lusophone regional workshops on development and use of the Road Map. ACCESS also translated the original WHO/AFRO Road Map guidelines from French to English, and revised the draft guidelines with WHO/AFRO and partners at a meeting in Addis Ababa, Ethiopia. During the same meeting, the Program along with WHO/AFRO and other partners also reviewed the framework for the integration of FP, MIP, nutrition and prevention of mother-to-child transmission of HIV (PMTCT) with MNH care. In 2009, ACCESS co-organized and co-facilitated with WHO/AFRO and the key U.N. Road Map partners the Entebbe regional workshop for the operationalization of the Road Map. The country teams from Malawi, Zambia, Uganda, Kenya, Namibia and Ethiopia participated in the workshop and each team identified bottlenecks and developed responses. In addition, concrete guidance was provided for the operationalization of the Road Maps at district level. The Program established itself as a global leader in the prevention and control of MIP throughout Africa. In its work with RBM, MIP WG including as Secretariat for the WG from 2003 to 2006 ACCESS supported the development of a number of important consensus statements, including: sulfadoxinepyrimethamine (SP) for intermittent preventive treatment in pregnancy (IPTp) in areas with SP resistance, interactions between HIV and malaria and implications for service delivery, insecticide-treated net (ITN) delivery though ANC, and a global monitoring and evaluation guidance document for MIP. The Program collaborated with and supported WRA and ICM to influence policies and programs. In Year 3, it also helped support WRA s capacity-building workshop, which focused on skilled birth attendants (SBAs), in India for national secretariat representatives from 14 countries. During this conference, a how to guide entitled Building, Maintaining, and Sustaining National White Ribbon Alliances was developed. This guide documented approaches and lessons learned from existing alliances to provide guidance to new groups. Using the guide as a model, a new Alliance was formed in Yemen and in Pakistan. 6 ACCESS End of Project, October 1, 2004 March 31, 2010

13 After a regional WRA conference in Malawi, members of country-level WRAs from Tanzania, Zambia, Malawi and South Africa developed a plan for a concerted regional effort on the human resources crisis and its effect on MNH. In Tanzania, more than 10,000 people marched to raise awareness about the need for home-based, life-saving skills in the Morogoro District through WRA/Tanzania. ACCESS provided technical assistance to the Mali Midwives Association, an ICM affiliate, to work with SBAs at the community level to prevent PPH. ICM reported on their work in a panel presentation on PPH prevention with SBAs, and at the community level at the ICM conference in Scotland in Some of the results presented included: integration of active management of the third stage of labor (AMTSL) with Mali s national curriculum for obstetric nurses and midwives; national recognition for AMTSL after its inclusion in the National Day of the Midwife; and a joint statement between the Malian midwifery and obstetrics/gynecology associations for the prevention of PPH. The Program also participated in the 2005 ICM conference in Brisbane by presenting on AMTSL. ACCESS helped to shape the Women Deliver Conference in London in 2007, and Program staff made presentations and facilitated panel discussions on PPH, SBA, postpartum family planning (PPFP), FBOs and MIP. ACCESS also sponsored more than 20 participants and panelists from several developing countries, and provided leadership for the MNH sessions at the Scaling up High Impact FP/MNCH Best Practices in the ANE Region conference in 2007 in Bangkok. ANTENATAL CARE RESULTS PATHWAY The provision of high-quality, basic ANC safe, simple, cost-effective interventions that all ACCESS introduced and/or expanded antenatal women should receive helps maintain normal care services in 15 countries. 8 pregnancies, prevent complications, and facilitate early detection and treatment of complications. Focused antenatal care (FANC) services include: Health Promotion and Disease Prevention: Tetanus immunization, iron/folate supplementation and, where appropriate, malaria prevention, HIV prevention, presumptive treatment for hookworm, and protection against vitamin A and/or iodine deficiency. Early Detection and Treatment of Complications and Existing Diseases: As part of focused assessment, the skilled provider talks with and examines the woman for problems that may harm her health or that of her newborn. Birth Preparedness and Complication Readiness (BP/CR): Counseling on danger signs and key preparations for birth, including the importance of delivering with a skilled attendant, saving emergency funds, and identifying emergency transport. Because so many women, globally, visit an ANC provider at least once during their pregnancy, ACCESS worked to strengthen ANC as an opportunity to prevent and screen for pre-eclampsia, to increase testing and referrals for HIV, as a venue to screen and refer for TB, and as a platform for preventing malaria in pregnancy (MIP). In Tanzania, ACCESS worked with the Ministry of Health and Social Welfare (MoHSW) to nationally scale up FANC as part of routine maternal and child health services. Through the program, 76% of ANC providers nationally (4,536) had their knowledge and skills updated in FANC, 880 in-service trainers were trained, and 2,633 facilities had at least one provider trained in FANC. In addition, pre-service curriculum 8 Afghanistan, Burkina Faso, Cameroon, Ethiopia, Haiti, India, Kenya, Madagascar, Malawi, Nigeria, Rwanda, South Africa, Tanzania, Uganda and Zambia ACCESS End of Project, October 1, 2004 March 31,

14 were revised to reflect up-to-date FANC content and performance standards were created to ensure that facilities could monitor their own performance in providing high-quality FANC services. Through training, introduction of facility standards, and advocacy, ACCESS contributed to a reduction in stockouts of SP for the treatment of MIP. (See Figure 1.) Figure 1: Days of Stock-outs of SP Per Quarter (Data from 37 sentinel Surveillance sites in Tanzania) In Malawi, ACCESS worked with the MoH s Reproductive Health and the HIV/AIDS units to strengthen the integration of mother to child transmission of HIV (PMTCT) into ANC. After finding that not all ANC providers had been trained in HIV testing and counseling (HTC)/PMTCT and that patient flow and high ANC volumes resulted in many clients not getting tested, ACCESS revised training packages and introduced facility performance standards to prevent these missed opportunities. ACCESS also revised community MNH training for health surveillance assistants (HSAs) to include more information on the importance of counseling and testing in order to prevent PMTCT. Figure 2 shows data from Nkhotakota District Hospital from January 2008-February Beginning in June 2008, Nkhotakota had a surge in the number of ANC clients being both counseled and tested for HIV and receiving their results. The original community MNH package included some content on PMTCT with HSAs primarily referring pregnant women for HTC. Because the implementation of the original community MNH package occurred in early 2008 (at the start of ACCESS), it is possible that the surge in clients was a direct result of the increased community interventions implemented by the Program. Since that time, the majority of ANC clients in Nkhotakota have received HTC and their results. (See Figure 2.) Figure 2: PMTCT services in ANC, Nkhotakota District, (Source: HMIS) 8 ACCESS End of Project, October 1, 2004 March 31, 2010

15 In Kenya, in collaboration with the Department of Reproductive Health and the Division of Leprosy, TB and Lung Disease, ACCESS strengthened and integrated TB screening, referral, diagnosis and treatment for pregnant women with FANC. ACCESS developed an orientation package for FANC that includes MIP, PMTCT and TB, and trained 50 service providers and 30 supervisors from four pilot sties. During the intervention period, ACCESS saw an increase in TB screenings of new ANC clients increase from 0.4% to 91%. The Program also focused on the antenatal period by providing community-based services to pregnant women. In Afghanistan and Nepal, ACCESS introduced community-based distribution of misoprostol to women in late pregnancy for the prevention of postpartum hemorrhage. In Nepal, ACCESS initiated the testing of community-based distribution of calcium for prevention of pre-eclampsia and eclampsia. (This work is continuing under MCHIP. See the PPH pathway section for more information on misoprostol in Afghanistan and Nepal.) Most of the ACCESS work along the ANC pathway supported efforts to prevent and control MIP. Because more than 70% of pregnant women attend ANC at least once during pregnancy, ANC services provide an important platform to address MIP prevention and control. As part of its work in FANC, ACCESS was a committed partner to the RBM Initiative and promoted WHO s three-pronged strategy to address MIP prevention and control in areas of stable transmission. The Program also supported and actively participated in regional coalitions in Africa that contributed to improved coordination and implementation support in 29 countries. 9 At the country level, ACCESS supported the introduction or scale-up of FANC/MIP services in several countries, including Burkina Faso, Madagascar, Malawi, Nigeria, Rwanda, Tanzania and Uganda. These countries with the exception of Rwanda, where IPTp is not provided exhibited substantial increases in IPTp uptake. On a global level, ACCESS helped to develop and disseminate evidence-based materials, resources and tools. POSTPARTUM HEMORRHAGE RESULTS PATHWAY ACCESS introduced and/or expanded PPH prevention programs in 14 countries. 10 Most cases of PPH whether mothers give birth with a skilled provider at home or in a facility can be prevented using safe, low-cost, evidencebased practices. Knowing how to prevent PPH, however, is not enough. The ACCESS Program worked to translate this knowledge into action when implementing essential maternal and newborn care (EMNC) and BEmONC interventions. ACCESS established itself as a global resource and leader in the dissemination of evidence-based practices to prevent and treat PPH. These include well-known but underutilized procedures such as AMTSL (which is comprises injection of an uterotonic drug, controlled cord traction and uterine massage) as well as cuttingedge interventions such as use of misoprostol at the community level when an SBA is not available. Dissemination of this knowledge facilitates advocacy for commitment to improve maternal health at national levels, as well as to improve the capacity of the health systems and providers in facilities and communities to offer these programs and services at all levels. In several countries, the Program promoted prevention of PPH at scale by developing and rolling out national-level guidelines (Kenya) and performance-based standards 9 MIPESA, RAOPAG, EARN and WARN countries are: Bénin, Burkina Faso, Burundi, Cape-Verde, Comoros, Côte d'ivoire, Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Malawi, Mali, Mauritania, Niger, Nigeria, Rwanda, Somalia, Sudan North, Sudan South, Sénégal, Sierra Leone, Tanzania, Togo, Uganda and Zambia. 10 Afghanistan, Cameroon, DRC, Ghana, Haiti, India, Kenya, Malawi, Mauritania, Nepal, Niger, Nigeria, Tanzania and Togo ACCESS End of Project, October 1, 2004 March 31,

16 (Nigeria, Rwanda and Afghanistan). In India and Ghana, it implemented district-level programs to test program feasibility of selected interventions that will inform scale-up. In collaboration with other partners such as ICM, FIGO, USAID, WHO and others, ACCESS set the global agenda for prevention and treatment of PPH. Building on the work of the MNH Program that resulted in the development of a CD-ROM on AMTSL for use as an advocacy and teaching tool, ACCESS collaborated with the Prevention of Postpartum Hemorrhage Initiative (POPPHI) Project to translate the CD-ROM into Spanish and French and distribute it globally, along with the PPH Toolkit, outlining the evidence base for use of AMTSL. It also provided support for community-based prevention of PPH using community-based delivery of misoprostol in Nepal and Afghanistan as part of its goal to introduce and scale up this successful approach in multiple countries. ACCESS chaired two of the POPPHI Project working groups one on community-based PPH and another on training. In October 2006, ACCESS participated in WHO s expert panel review to examine the evidence for the prevention of PPH. Moreover, it helped to bring these recommendations to the country level by influencing a number of African and Asian countries to revise their national policies. In Asia, ACCESS held technical discussions and advocacy workshops in Afghanistan, which resulted in the approval from the Ministry of Health and Population (MOHP) for a PPH demonstration project. In Nepal, it worked with the Nepal Family Health Program (NFHP) to prepare for scale-up of the use of misoprostol for prevention of PPH. Along with UNICEF/SNL, ACCESS supported the development of a high-level Joint Statement on community-based care for the newborn. Program staff co-authored chapters in Opportunities for Newborns in Africa, a regional review of newborn health in Africa, and supported the publication and dissemination of the report. This review was launched at the African Health Ministers Meeting and at several other events to garner support for addressing neonatal mortality in Africa. The ACCESS Program piloted community-focused birth preparedness programs as the frontline intervention to prevent PPH, emphasizing obstetric care by an SBA during and immediately after childbirth. In instances when women were unable to access skilled care, use of misoprostol immediately postpartum was advised. Experiences from these programs showed that, in low-resource settings with limited access to skilled attendance, community-based education and distribution of misoprostol is an appropriate strategy for preventing PPH at home births. Preventing Postpartum Hemorrhage in Afghanistan and Nepal ACCESS projects in Afghanistan and Nepal expanded life-saving interventions along the Household-to- Hospital Continuum of Care (HHCC), and assessed the safety, acceptability, feasibility and programmatic effectiveness of community-focused birth preparedness programs involving education and distribution of misoprostol to prevent PPH at home births. This included: Educating women and their families on BP/CR at the community level; Strengthening provider performance through performance improvement strategies to increase quality of care during childbirth at the facility level; and Increasing awareness on the urgency of addressing PPH and advocating for policy changes to support an enabling environment for MNH at the national level. In Afghanistan and Nepal, a convergence of factors created a dismal environment for MNH, including high maternal mortality ratios (1,600 per 100,000 live births in Afghanistan and 281 per 100,000 live births in 10 ACCESS End of Project, October 1, 2004 March 31, 2010

17 Nepal), 11 evidence of hemorrhage as the most common cause of maternal mortality (30% of maternal deaths are related to PPH in Afghanistan 12 and 46% in Nepal 13 ), and low rates of skilled attendance at birth (19% in Afghanistan 14 and 18.7% in Nepal). The MOHs in both countries are committed to reducing maternal mortality ratios by 2015 as part of the Millennium Development Goals and had begun interventions aimed to increase and strengthen institutional delivery services. In these scenarios, community-based birth preparedness education and distribution of misoprostol projects were implemented to prevent PPH at home births and complement larger, national efforts to reduce the burden of PPH. The intervention was adapted to fit the context in both countries; however, there were several key features in each project: Educating pregnant women and their support persons through existing networks of CHWs: In both intervention and comparison areas, trained CHWs provided education with the assistance of culturally appropriate pictorial messages to women and their support persons (such as husbands and mothers-in law) during home visits on: BP/CR; Recognition of danger signs, particularly PPH, during pregnancy, childbirth and the postpartum period; The importance of a skilled provider at birth, where AMTSL can be offered to prevent PPH; and What to do in case of a complication and where and from whom to seek care. Women in the intervention area also received education on the purpose and correct timing and use of misoprostol to prevent PPH, the risks of taking misoprostol before birth of the baby and common side effects of misoprostol. Use of misoprostol was advised only if a skilled provider was not present at birth. Distributing misoprostol to women for use at home births when facility-based services and skilled attendance was unavailable. After the educational session, women and their support persons were asked to describe the purpose and correct use of misoprostol, and the risks associated with use and misuse of the drug. Education was repeated until women could correctly describe the messages. The CHWs gave the women in the intervention area three 200-mcg tablets of misoprostol in their eighth month of pregnancy. CHWs visited all women postpartum to collect Educating women, Nepal 11 Ministry of Health and Population, NewERA and MACRO Inc. Nepal Demographic and Health Survey Kathmandu, Nepal Bartlett L, Mawji S, Whitehead S, Crouse C, Dalil S, Ionete D, Salama P, and the Afghanistan Maternal Mortality Study Team Where giving birth is a forecast of death: Maternal mortality in four districts of Afghanistan, Lancet 365: Pathak LR, Maternal Mortality and Morbidity Study, Family Health Division, DoHS, Ministry of Health and Population, Kathmandu: Government of Nepal Ministry of Public Health, Afghanistan Health Survey, ACCESS End of Project, October 1, 2004 March 31,

18 information about exposure to and comprehension of messages, delivery information, reported PPH, experience with side effects, use and timing of misoprostol and other key information. Use of misoprostol was rigorously monitored through stock cards and records to ensure correct use and to prevent use outside the intervention area. Holding advocacy and sensitization meetings with stakeholders at various levels to mobilize groups on BP/CR and explain the intervention. At the community level, meetings were held where the community health supervisors and CHWs shared information about the intervention. This included provision of education around the purpose of the intervention, mobilization around transport to facilities and how to support the CHW. At the national level, meetings were held with stakeholders to inform on project progress, guide decision making, and ensure that the intervention was complementary within national strategies and policies. Promoting institutional delivery and strengthening capacity of providers at the referral health facility. Woman just delivered, India In Afghanistan, a national government effort is under way to increase the number of skilled providers, and pre-service midwifery education employs use of standards to guide provider performance. ACCESS partnered with projects involved in increasing capacity of skilled providers in emergency obstetric services to ensure that providers were equipped to manage the occurrence of lifethreatening complications, including PPH. Afghanistan results 15 Achieved near-universal coverage of a method to prevent PPH: 96% of women in the intervention area received a uterotonic agent compared with 26% in the comparison area. Completed identification of pregnant women and the first education messages for 94% of the expected population by the end of the recruitment period. Distribution of misoprostol paralleled the recruitment of women, in that almost every woman identified as pregnant accepted misoprostol from the CHW (96%). 1,970 (96%) of the women who took misoprostol used the drug correctly. No women took the drug at the wrong time, or took the drug prior to the birth of the baby. Found trained, non-literate CHWs to be an acceptable source of educational messages and misoprostol distribution. Contrary to expectations, rates of all reported symptoms (e.g., shivering, nausea, cramping, transient fever) were higher in the comparison areas than the intervention areas: 60% of women in the intervention area who received misoprostol reported experiencing no unpleasant symptoms, compared with only 19% of women in the comparison area. In the comparison areas, women were more likely to use traditional remedies to stop bleeding. After review of the promising results achieved under the pilot project, the MOPH has approved gradual expansion of the intervention to additional geographic areas of the country where access to emergency 15 Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan. Sanghvi H., Ansari N., Prata N., Gibson H., Ihsan A., Smith J. International Journal of Gynecology and Obstetrics. 2010; 108(3): ACCESS End of Project, October 1, 2004 March 31, 2010

19 obstetric care remains a challenge. This expansion will be implemented under the ACCESS Health Services Support Project (HSSP) in 2010 and 2011 and is projected to protect 20,000 women against PPH. Nepal results Dispensed misoprostol to 18,761 pregnant women by the female community health volunteers with no significant adverse events or incorrect use. The proportion of deliveries protected by a uterotonic increased from 10.4% to 72.5%; the largest increases were among the disadvantaged: the poor, the illiterate and those living in remote areas. Institutional deliveries increased from 9.9% to 16.0%. Maternal mortality ratio among 13,969 misoprostol users was 72 per 100,000 live births, which was significantly lower than among non-users (304 per 100,000 live births) and the national level (281 per 100,000 live births). Misoprostol can effectively be used without deterring women from seeking care by a skilled attendant at birth. A higher percentage of women in the intervention area received facility-based deliveries than women in the control area in Afghanistan (21.4% versus 18.1% respectively). In Nepal, the intervention area experienced an institutional delivery coverage increase from 11% pre-intervention to 20.4% post-intervention compared to a national increase of 11.3% to 15.3%. Use of AMTSL by a skilled provider remains the most effective method to prevent PPH, and the importance of its provision was emphasized throughout these projects. These results show that the intervention was, in fact, complementary toward efforts to increase rates of facility-based deliveries. Small Grants to Reduce Postpartum Hemorrhage In April 2006, ACCESS sponsored a regional PPH conference in Uganda where 22 countries from Africa were represented with more than 250 participants. From this conference, ACCESS awarded small grants to seven local organizations in six countries in Africa in support of their expansion of country-level PPH activities (Burkina Faso, the Democratic Republic of Congo, Ethiopia, Kenya, Madagascar and Mali). In addition to training health workers, the ACCESS PPH small grant recipients conducted numerous Management of PPH course, Congo activities, including: work with communities to increase PPH awareness and BP/CR; policy and managerial support for the prevention of PPH; promotion of networking among groups with AMTSL programs; work with pre-service programs to incorporate curricula on AMTSL with midwifery and nursing schools; provision of equipment and basic supplies to target centers for the prevention and management of PPH; and development of support and monitoring systems to track progress. For example, the Evangelical Hospital of the Baptist Community of Congo in Vanga, or HEV, is a missionary Baptist community organization in the Democratic Republic of Congo and serves as the referral hospital for the rural Vanga Health District. HEV is also a training and internship center for doctors and nurses in Bandundu Province. HEV developed a five-day training course on prevention and management of PPH, and a community-awareness program using communication channels such as radio, health care providers, community leaders, pastors and leaders of mothers associations. They also purchased, stored and distributed equipment and supplies. ACCESS End of Project, October 1, 2004 March 31,

20 With an average grant of USD$12,000 to seven organizations, 16 recipients of ACCESS PPH small grants achieved significant successes. For instance, over the 11-month project period, HEV used Program funds to improve Safe Motherhood at both the health center and community level. Specific results include: Introduced AMTSL to 38 health centers and 50 maternities the first facilities in the Democratic Republic of Congo to use the intervention covering more than 50,000 women of reproductive age. Trained 50 health agents (100%) and 28 clinicians (85%) in target centers in AMTSL. A reported 4,318 (85%) births in these facilities included AMTSL during the project period. Educated community members to correctly identify signs of danger during pregnancy, labor and postpartum; several communities put an emergency plan or financing scheme in place for deliveries. SKILLED BIRTH ATTENDANCE RESULTS PATHWAY Most common maternal complications can be prevented, or appropriately managed, by an SBA conducting the delivery at a facility or at home. The ACCESS Program supported government policies in Africa and Asia to increase the availability of SBAs, provided training to improve the skills of SBAs, and mobilized communities to increase demand for delivering with an SBA in most of the countries in which it worked. ACCESS worked with pre-service institutions to update their curricula, to strengthen their tutors and clinical preceptors and to upgrade their training sites. The Program produced a new comprehensive learning resource package, Best Practices in Essential and Basic Emergency Maternal and Newborn Care, which provides updates on best practices needed to teach faculty and students the most current evidence-based care. The Program worked with in-service partners to train well over 1,000 providers in essential and basic emergency obstetric care and to improve the quality of obstetric services in hospitals and clinics. Hundreds of communities were mobilized to appreciate the need and prepare for delivery with an SBA. ACCESS helped the Government of Ethiopia reach new targets for training health officers (HOs) on clinical skills in maternal and newborn care to improve maternal and newborn survival. In Nepal, ACCESS supported the government to roll out its National Skilled Birth Attendants Policy by developing pre- and in-service training materials and strengthening the quality of SBA training sites. In Bangladesh, families were counseled and communities mobilized to create birth plans to increase attendance with a skilled provider. In Malawi, the Program upgraded the skills From Zulaihat Aminu, Mother of Twin Babies from Dawanau Community, Nigeria I am grateful to ACCESS for bringing this program to my village. Before, all women in my village including myself do not go to hospital either for antenatal care, delivery or postpartum visits. But as soon as ACCESS-trained female household counselors began to visit me in my house, telling me what to do when pregnant, I and other women in the village started going to hospital. I want to say that I really feel very happy with what the volunteer nurse-midwives are doing to save lives of women in my village. Another area that touched my life and that of my twin babies positively, is the Tallafin Mata Masu Dubara (TMMD) savings club initiated by ACCESS. When my babies were seriously sick, the TMMD in my village loaned me some money to take them to hospital to seek treatment. That single assistance has saved my children and they are now looking healthy. 16 Association du Personnel du Service de Gynécologie Obstétrique Befelatanana (Madagascar); Midwife Association of Mali (Mali); Society of Obstetrics and Gynecology (Ethiopia); HEV (Democratic Republic of Congo); Organization for Health, Education and Research Services, and Community Capacity Building Initiative (Kenya); Regional Prevention of Maternal Mortality (Burkina Faso); Family Care International (Burkina Faso). 14 ACCESS End of Project, October 1, 2004 March 31, 2010

21 Nepal Standards Help New Training Sites to Improve Performance After their selection by the National Health Training Centre as an SBA training site, staff at Baglung District Hospital participated in an ACCESS-led quality improvement (QI) process. An initial assessment using the QI tools yielded a total score of 70% on nine clinical tools, after which staff participated in a workshop to develop action plans to address gaps. Medical Superintendant Dr. Tarun found the QI tools useful in preparing him and his staff for SBA in-service training. In particular, he cited the verification criteria as helpful in identifying the exact cause of not meeting a standard and in developing action plans to eliminate or reduce the cause. He carried the prepared action plan in his pocket at work and reviewed it regularly with staff to assess progress. A later assessment using the QI tools showed significant improvements, and the site had reached 91% on the nine clinical tools. In addition, staff had started working on the clinical training tools for a total score of 77%. Staff presented their accomplishments during the November progress sharing workshop, noting they had been able to implement the majority of their action plan. of midwifery faculty in every pre-service school in the country, and in Nigeria, the Program developed nationally endorsed performance standards for emergency obstetric and newborn care (EmONC) for the hospital and primary health center levels. In Rwanda, ACCESS improved skilled birth attendance by training more than 150 health care providers and CHWs in EmONC. Results of this training demonstrated that 92% of hospital providers in the sample practice all three steps of AMSTL as opposed to 17% at baseline. ACCESS introduced and/or expanded skilled birth attendance programs in 15 countries. 17 Most ACCESS achievements along the SBA pathway are presented in the country briefs found later in this report. This section highlights a regional effort in Africa to improve pre-service education and a pilot project in India to demonstrate that delivery of life-saving skills by auxiliary nurse-midwives (ANMs) combined with community mobilization improves access to and use of key MNH services. A Regional Approach to Strengthening Pre-service Education in Africa Starting in 2006, ACCESS in collaboration with WHO/AFRO implemented a multi-country pre-service midwifery strengthening activity to support efforts to accelerate the reduction of maternal and neonatal mortality and morbidity. Over the lifetime of the project, tutors and preceptors from four countries (Ethiopia, Ghana, Malawi and Tanzania) participated in technical updates and clinical skills standardization courses in BEmONC to improve their knowledge and practices, and in Effective Teaching Skills courses to improve their clinical training skills. In addition, the Program strengthened clinical training sites and supported use of clinical training skills labs. Tutors also participated in curriculum design workshops so they could participate in reviewing and revising curricula in their own countries. Through these efforts, a pool of resources has been built within each country that will strengthen pre-service midwifery education leading to more prepared and qualified midwives graduating from each country s midwifery schools. 17 Afghanistan, Cameroon, Ethiopia, Ghana, Guinea, Haiti, India, Malawi, Mauritania, Nepal, Niger, Nigeria,, Rwanda, Tanzania and Togo ACCESS End of Project, October 1, 2004 March 31,

22 Specific achievements include: 132 pre-service tutors/preceptors from four participating countries updated in BEmONC (22 in Malawi, 38 in Tanzania, 36 in Ethiopia and 36 in Ghana). Each received a follow-up visit to reinforce use of their newly acquired knowledge and skills. 34 tutors and preceptors trained in Effective Teaching Skills, approximately eight in each country. Five clinical training sites strengthened, one each in Tanzania, Malawi and Ethiopia, and two in Ghana. Strengthening includes supporting facility with basic supplies but also provision of supportive supervision visits and quality improvement using the Standards- Based Management and Recognition (SBM-R) approach. 209 hospital providers/staff received BEmONC updates as a part of site strengthening activities. From Susan Wright, Senior Advisor, HPN, USAID/Ghana The midwives [in Ghana] were effusive about the importance of the training they had received, and I noted that they put as much attention on interpersonal communications as on clinical procedures. Infection prevention was also clearly a priority for them. A total of 14 stakeholder meetings were held in Ethiopia, Ghana, Malawi and Tanzania. These meetings brought together key midwifery stakeholders, including representatives from respective MOHs, Nurses and Midwives Councils, WHO, UNFPA and ICM. Midwifery curriculum revisions undertaken in all four countries. Dedication of field funds in Tanzania and Malawi to scale up the initiative in each country. Learning resource package, Best Practices in Essential and Basic Emergency Maternal and Newborn Care, completed and disseminated to country programs and at stakeholder meetings in Ethiopia, Ghana, Malawi and Tanzania. This package can be adapted for use in pre-service and in-service programs for skilled providers and addresses the continuum of care from ANC through postpartum and postnatal care, including PPFP, MIP and PMTCT. An evaluation of the regional approach identified challenges in reaching sufficient numbers of tutors/preceptors and in providing supportive supervision; however the following benefits were noted: There was opportunity for sharing of experiences, so that participants could acquire information about approaches or strategies being implemented in countries other than their own. A platform for cross-country collaboration was established, creating the potential for further crossfertilization of educational and clinical ideas, and the development and mentorship of midwifery leaders. Regional training activities focused on standardization of practice, which is intended to flow over into country-based approaches to clinical service delivery. Increasing Skilled Birth Attendance in Underserved Communities in India In Jaharkhand, India, where skilled attendance at birth is among the lowest in the country, ACCESS worked with the state government and its implementing partners to operationalize new Government of India (GoI) guidelines to expand the skills of ANMs and reposition them as community midwives. ACCESS developed and field-tested competency-based training materials for a 12-week course on the GoI-mandated skills set for ANMs. ANM training centers were strengthened and equipped along with two hospitals and three PHCs as clinical training sites. A total of 58 ANMs were trained in the 12-week curriculum. In parallel, 223 communities and 2,600 community members were mobilized to take action to increase access to skilled care at birth. An evaluation of this approach demonstrated the following results: 16 ACCESS End of Project, October 1, 2004 March 31, 2010

23 The 12-week training course produced competent SBAs in the experimental group, specifically related to partograph use, AMTSL practice and newborn resuscitation. A significant improvement in knowledge and practice of BP/CR for pregnant women and recent mothers including clean cord care, drying and wrapping, and delayed bathing. A significant increase in the proportion of births attended by ANMs from 5% to 13%. As a result of ACCESS work, the Indian Nursing Council developed a national strategic plan to establish national- and state-level resource centers to support improved capacity of ANM training centers at the district level. NEWBORN RESULTS PATHWAY To address the nearly 40% of global child deaths that occur each year during the first month of life, the ACCESS Program worked to expand interventions that prevent and manage the major causes of newborn death: infection, pre-term birth and asphyxia. Resources and Partnerships ACCESS laid the groundwork for strengthening newborn health partnerships and future relations through its involvement with MotherNewBorNet and collaboration with the WHO South-East Asia Regional Office (WHO/SEARO). In 2005, the Program collaborated with WHO/SEARO to conduct a Continuum of Care for Maternal and Newborn Health workshop in Bangkok, Thailand. The workshop focused on country- and regional-level interventions for MNH, and gave particular attention to newborn health, skilled birth attendance, and the human resource issues and other constraints affecting MNH programming. In attendance were 50 participants from 11 countries, including Cambodia (from the Regional Office for the Western Pacific) and Afghanistan (from the Regional Office for the Eastern Mediterranean). Subsequently, in collaboration with WHO/SEARO and the WHO Regional Office in Bangladesh, ACCESS provided support to develop and help facilitate a five-day training course to strengthen the capacities of trainers so that they can replicate the training. Attendees developed follow-up action plans, including national-level training in Bangladesh and Nepal. Nepal Kangaroo Mother Care Saves Low Birth Weight Twins At a maternity home in Kathmandu, Mrs. Rai gave birth to low birth weight fraternal twins the boy weighed just 1.68 kg and the girl 1.98 kg. At four days old, Mrs. Rai and her husband brought the twins to Kathmandu Medical College, where ACCESS-trained staff taught both parents KMC. After 17 days of this care, both babies had gained weight, the boy up to almost 2 kg and the girl to 2.2 kg. When the Rai family returned home, they continued to receive support and advice from hospital staff. Now, at six months old, the Rai boy has reached 7 kg and the girl 6.5 kg, and both are up-to-date on their immunizations (with the exception of the measles vaccination). ACCESS introduced and/or expanded newborn care programs in 16 countries. 18 In 2005 and 2006, the Program participated in the Asia Region USAID MotherNewBorNet meeting in New Delhi, India. Participants learned about state-of-the-art interventions and research, and shared innovative 18 Afghanistan, Bangladesh, Cambodia, Cameroon, Ethiopia, Ghana, India, Kenya, Malawi, Mauritania, Nepal, Niger, Nigeria, Rwanda (KMC), Tanzania and Togo ACCESS End of Project, October 1, 2004 March 31,

24 SAVING NEWBORN LIVES BY INCREASING USE OF SKILLED CARE IN RURAL INDIA For women like 35-year-old Mercila Hembrom in rural Jharkhand state in India, the value of skilled midwifery care is evident both she and her son are alive and well. For her previous five pregnancies, Mercila sought ANC from the local ANM named Sangita Kumari, but had the local Dai, or traditional birth attendant (TBA), deliver her at home. Sadly, she lost her last child soon after childbirth. In this pregnancy, Mercila learned that Sangita had received a recent training on pregnancy, childbirth and newborn care. Sangita was one of the 37 ANMs trained by the ACCESS Program in Dumka on maternal and newborn care. During Mercila s sixth pregnancy, she met a community worker Ms. Mary Mina Hembrom who gave her friendly advice whenever they would meet. In this way, Mercila and her family learned about the importance of having a trained, skilled provider during birth, and the danger signs for mother and baby. When Mercila went into labor, her husband called Sangita. Within an hour, she arrived with her equipment and drugs and assessed Mercila s progress. After a long delivery, a baby boy was born; however, he was blue and not breathing. Sangita quickly cleared the mucus from his mouth and nose, and dried and covered him. She then separated the baby by clamping and cutting the cord, and began resuscitating him with a bag and mask. After 20 minutes, the baby was breathing normally and stable. During this time, Sangita had also cared for Mercila, ensuring she took misoprostol and performing active management of the third stage of labor. Sangita stayed with the mother and baby to provide immediate postpartum care, initiate breastfeeding, and explain the postnatal and newborn danger signs. During the next week, she came back to check on Mercila and her son three times. Mary Mina, the community worker, also visited the mother at home and counseled her on exclusive breastfeeding and family planning. Today, Mercila is very happy with her seven-month-old son and is thankful for the services provided by Mary Mina and Sangita. Her story highlights ACCESS s work in Dumka and illuminates the numerous opportunities to save lives with SBAs and community mobilization. ANMs, once trained, have been able to provide community-based maternal and newborn care competently and increase access to and use of these services. Moreover, women, families and communities in Dumka have quickly learned about maternal and newborn care, and have been willing and able to seek services, plan for childbirth, and be prepared for complications. approaches to MNH. Participants also discussed challenges for scaling up evidence-based interventions to address maternal and newborn deaths in the community, and identified gaps in Program work and ways to overcome them. Technical experts joined together to address the issue of prevention and management of low birth weight (LBW) babies in the community, including overviews on global and regional LBW issues, the role of KMC, and findings from a community-based research program in Bangladesh. To follow up on the meeting, ACCESS worked with USAID programs in Asia to accelerate uptake and scale-up of programs for PPH and community-based maternal and newborn care, particularly to address infections. In Phnom Penh in 2005, the Cambodia MOH joined ACCESS and other partners (USAID, WHO, UNFPA, UNICEF, PATH, Reproductive and Child Health Alliance, Partners for Development, University Research Corporation, Reproductive Health Association of Cambodia, CARE, MEDiCAM and BASICS) to hold a national workshop on MNH for approximately 150 participants. The workshop served as a technical update in evidence-based MNH, and relevant experiences and programs from the region were also highlighted. Participants included policymakers, clinicians and administrators from throughout Cambodia, as well as representatives from the partners cited above. The Program contributed to the Latin America and the Caribbean Regional Strategy and Action Plan on Neonatal Health within the continuum of maternal, newborn and child care through its collaboration with the Pan American Health Organization (PAHO), 18 ACCESS End of Project, October 1, 2004 March 31, 2010

25 USAID, BASICS, the CORE Group and MOHs. ACCESS also served as a member of the Latin American and Caribbean Newborn Health Alliance, an interagency group that promotes newborn health within a reproductive, maternal and child health continuum, with a specific focus on the most vulnerable and marginalized population groups. In 2007, ACCESS contributed an influential article to MotherNewborNews which described the state of the art in facility- and community-based KMC, and also reviewed common concerns and challenges. This widely disseminated article outlined a road map for scaling up a comprehensive KMC program. The Program worked with host governments in selected developing countries to implement and scale up facility-based KMC in hospitals and health centers, with the overall goal of reducing neonatal mortality through improving care for LBW newborns using KMC. ACCESS either introduced and laid the foundation for expansion of KMC, or built upon existing pilot/demonstration sites to further expand KMC services. This section describes the KMC program approach, results and lessons learned from experience in five countries (Ethiopia, Malawi, Nepal, Nigeria and Rwanda). KMC Program Approach While there was some variation from country to country, the general approach, as well as a number of specific inputs, was common to all five programs, namely to: Create awareness and local ownership through dialogue with key stakeholders (MOH, professional associations and donors) Work in partnership with the MOH and other NGOs to develop an introduction or expansion strategy Establish a national KMC technical advisory or working group Identify a local pediatrician or neonatologist to serve as KMC champion Support development of a national KMC policy and/or service guidelines Support adaptation of ACCESS global KMC Muhima Hospital, Rwanda training manual and associated job aids for in-service training, either as a stand alone training or integrated with the existing national MNH manuals Support establishment of a core group of national KMC trainers Support establishment of KMC units at selected hospitals by training service providers and providing basic newborn care equipment such as beds, nasogastric tubes, caps and weighing scales KMC Results Table 1 below summarizes the Program s key achievements in its effort to introduce and/or expand KMC services in the five target countries. Table 2 shows ACCESS scale-up across the HIDN results pathways. ACCESS End of Project, October 1, 2004 March 31,

26 Table 1: ACCESS Key Achievements COUNTRY Malawi 19 Nepal Nigeria Rwanda Ethiopia 20 RESULTS Expanded KMC from three to seven hospitals Introduced KMC services to five health centers 414 newborns received KMC Nearly all central, district and mission hospitals have initiated KMC Incorporated KMC with MOH national LBW care guidelines Introduced KMC to five hospitals with direct ACCESS funding Introduced KMC to two central hospitals due to ACCESS awareness creation Certified seven national KMC trainers Trained 112 service providers Established KMC sites in four hospitals Developed 15 trainers Trained 62 service providers Currently, KMC expansion is continuing by other development actors using materials developed by ACCESS Introduced KMC services to eight hospitals Developed 15 trainers Trained 37 service providers 477 newborns received KMC services Average daily weight increased from nine to 28 grams Length of hospital stay decreased from 26 to 19 days KMC expanded from one to eight hospitals Developed 13 trainers Currently expanding KMC services to 22 health centers and two hospitals in 2010 through Save the Children s SNL Program 19 KMC service guidelines and training materials were already developed in Malawi prior to the ACCESS Program. 20 KMC was already a national policy in Ethiopia prior to the ACCESS Program. 20 ACCESS End of Project, October 1, 2004 March 31, 2010

27 Table 2: ACCESS Scale-up across HIDN Pathways ACTIVITY TITLE PY 1 & 2 FY05 AND FY06 PY 3 FY07 (FY06 $) PY 4 & 5 FY08 AND FY09 TOTAL NUMBER OF COUNTRIES INVOLVED Introduction and/or expansion of focused ANC within EMNC 6- Burkina Faso Cameroon Haiti Madagascar Rwanda Tanzania 8- Haiti India Kenya Madagascar Nigeria Tanzania Uganda Zambia 10- Afghanistan Ethiopia India Kenya Madagascar Malawi Nigeria RSA Rwanda Tanzania 15 Total: Afghanistan Burkina Faso Cameroon Ethiopia Haiti India Kenya Madagascar Malawi Nigeria Rwanda South Africa Tanzania Uganda Zambia Introduction and/or expansion of PPH prevention programs into countries 3- Cameroon Haiti Nepal 10- Afghanistan Cameroon Democratic Republic of the Congo Mauritania Haiti India Nepal Niger Nigeria Togo 14- Afghanistan Cameroon DRC Ethiopia Ghana India Kenya Malawi Mauritania Niger Nigeria Rwanda Tanzania Togo 14 Total: Afghanistan Cameroon DRC Ghana Haiti India Kenya Malawi Mauritania Nepal Niger Nigeria Tanzania Togo ACCESS End of Project, October 1, 2004 March 31,

28 ACTIVITY TITLE PY 1 & 2 FY05 AND FY06 PY 3 FY07 (FY06 $) PY 4 & 5 FY08 AND FY09 TOTAL NUMBER OF COUNTRIES INVOLVED Introduction and/or expansion of SBA programs into countries 2 Cameroon Haiti 12- Afghanistan Cameroon Ghana Haiti India Mauritania Malawi Nepal Niger Nigeria Togo Rwanda (Safe Birth Africa) 15- Afghanistan Cameroon Ethiopia Ghana Guinea Haiti India Malawi Mauritania Nepal Niger Nigeria Rwanda Tanzania Togo 15 Total: Afghanistan Cameroon Ethiopia Ghana Guinea Haiti India Malawi Mauritania Nepal Niger Nigeria Rwanda Tanzania Togo Introduction and/or expansion of newborn care into countries 3 new countries with FY 05 core funds and Mission funds 11- Afghanistan Bangladesh Cameroon India Kenya21 Mauritania Nepal Niger Nigeria Rwanda (KMC) Togo 16- Afghanistan Bangladesh Cambodia Cameroon Ethiopia Ghana India Kenya Malawi Mauritania Nepal Niger Nigeria Rwanda Tanzania Togo 16 Total: Afghanistan Bangladesh Cambodia Cameroon Ethiopia Ghana India Kenya1 Malawi Mauritania Nepal Niger Nigeria Rwanda (KMC) Tanzania Togo 21 Kenya was covered through work under the ACCESS-FP associate award. 22 ACCESS End of Project, October 1, 2004 March 31, 2010

29 Achievements in Other Technical and Crosscutting Areas Beyond the results pathways, ACCESS activities led to improved care for women and newborns by preventing and treating malaria in pregnancy, integrating PMTCT within MNCH services, engaging communities at the community level, and improving quality. ACCESS End of Project, October 1, 2004 March 31,

30 24 ACCESS End of Project, October 1, 2004 March 31, 2010

31 Addressing Malaria in Pregnancy: A Comprehensive Approach to Maternal and Newborn Health Outcomes Malaria is a major public health crisis, especially in sub-saharan Africa, where 90% of all malaria-related deaths occur. The most vulnerable populations are pregnant women, their unborn babies, and children under five years of age. Approximately 25 million women become pregnant in high (stable) transmission areas of Africa each year and are at risk for malaria illness primarily through the Plasmodium falciparum parasite. This translates into an estimated 400,000 cases of severe maternal anemia, a potentially fatal condition, and from 75,000 to 200,000 infant deaths annually. 22 Women in stable transmission areas have the greatest risk of developing these complications during their first and second pregnancies. 23 The prevalence and intensity of malaria illness in pregnancy is higher among HIV-infected women and the risk to the woman and her newborn exists regardless of the number of times a woman has given birth. 24 HIV infection in pregnancy is also associated with reduced efficacy of malaria prophylaxis and treatment. ACCESS APPROACH ACCESS was a committed partner to the Roll Back Malaria (RBM) Initiative and promoted the World Health Organization s (WHO) three-pronged strategy to address malaria in pregnancy (MIP) prevention and control in areas of stable transmission. The strategy addresses prevention of MIP through a platform of focused antenatal care (FANC) services. (See text box). To address MIP, FANC services include intermittent preventive treatment in pregnancy (IPTp) with an appropriate antimalarial (currently sulfadoxinepyrimethamine, or SP), and insecticide treated bed-nets (ITNs). In addition, case management of MIP is addressed through prompt and effective treatment for pregnant women with a trained healthcare provider. Malaria in Pregnancy: Continuum of Care The ACCESS Program aimed to strengthen health systems across the continuum of care, reaching pregnant women at both the community and facility levels, and fostering the synergistic link between communities and facilities to improve health systems for women and their families. Since more than 70% of pregnant women attend ANC at least once during pregnancy, ANC services provide an important platform to address MIP prevention and control. (See Figure 3.) 22 Steketee RW et al The burden of malaria in pregnancy in malaria-endemic areas. Am J Trop Med Hyg 64 (Suppl 1-2): Brabin 1983; Jelliffe 1968; McGregor, Wilson and Billewicz 1983; Steketee et al Verhoeff F et al Increased prevalence of malaria in HIV-infected pregnant women and its implications for malaria control. Trop Med Int Health 4(1): ACCESS End of Project, October 1, 2004 March 31,

32 Figure 3: Focused Antenatal Care/Malaria in Pregnancy Global Leader in Advocacy and Global Learning ACCESS established itself as a global leader in the prevention and control of MIP throughout Africa. In its work with the RBM MIP Working Group (MIP WG) including as Secretariat for the Working Group from 2003 to 2006 ACCESS supported the development of a number of important consensus statements, including: SP for IPTp in areas with SP resistance, interactions between HIV and malaria and implications for service delivery, ITN delivery through ANC, and a global monitoring and evaluation guidance document for MIP. ACCESS helped to develop and disseminate global, evidence-based materials, resources and tools. These materials include Prevention and Control of Malaria in Pregnancy in the Africa Region: A Program Implementation Guide, 25 which outlines seven essential programming components that are needed to put MIP policy into practice at the health facility level and draws on existing country experiences, best practices and lessons learned for practical implementation. ACCESS also updated the 25 Developed in collaboration with WHO, the Centers for Disease Control and Prevention (CDC) and Rational Pharmaceutical Management Plus, through the Malaria Action Coalition. 26 ACCESS End of Project, October 1, 2004 March 31, 2010

33 global Malaria in Pregnancy Resource Package, available on CD-ROM and on the Jhpiego website. This package is a compilation of tools and resources for countries to adapt to their context as they work toward the prevention and control of MIP, including: the WHO Strategic Framework for MIP, Jhpiego s MIP Learning Resource Package, an MIP Implementation Guide, job aids and MIP key articles. ACCESS support and active participation in regional coalitions in Africa contributed to improved coordination and implementation support in 29 countries. 26 For instance, through the Malaria in Pregnancy East and Southern Africa Coalition (MIPESA) and the West African Regional Coalition for MIP (RAOPAG), ACCESS ACCESS support to regional coalitions in Africa contributed to MIP activities in 29 countries. support led to improved regional capacity among national-level trainers, as well as the documentation and dissemination of best practices and lessons learned. ACCESS assisted MIPESA and RAOPAG in the development of regional global fund proposals, which yielded improved capacity i n grant writing and regional planning among MIPESA and RAOPAG representatives. ACCESS also helped document MIPESA countries experiences through the report, Assessment of MIPESA Country Experiences in the Adoption and Implementation of Malaria in Pregnancy Policies including Best Practices and Lessons Learned. The Program also provided continued support to the RBM East Africa Roll Back Malaria Network (EARN) and the West Africa Roll Back Malaria Network (WARN). RESULTS ACCESS contributed to the acceleration and scale-up of MIP prevention and control in a number of countries, including: Burkina Faso, Kenya, Madagascar, Tanzania, Uganda, Nigeria, Rwanda, Mali, Ghana and Malawi. Summarized below are the major results from the first five of these countries. Burkina Faso ( ): ACCESS supported the Ministry of Health (MOH) in Burkina Faso to expand implementation of FANC/MIP services by building on achievements of an MIP pilot study implemented through USAID s flagship Maternal and Neonatal Health (MNH) Program and the CDC. The pilot In Burkina Faso, more than 3.5 million people were covered by these services. study in Koupéla District resulted in notable improvements in maternal and newborn health indicators and IPTp uptake, which increased dramatically to over 90% during the study intervention. Influenced by evidence from this study and two similar studies conducted in Mali and Benin, Burkina Faso adopted a new MIP policy in 2004 promoting the WHO three-pronged approach. With the new policy in place, ACCESS went on to train 114 service providers from 49 facilities in five districts of one health region in FANC and MIP. An estimated population of 3,849,335 was covered by these services. Kenya ( ): The ACCESS Program in Kenya built upon previous work by Jhpiego and the MOH, which involved the introduction of FANC/ MIP services to 16 malaria endemic districts. ACCESS supported the MOH to expand these efforts further by: Strengthening clinical services in an additional seven endemic districts, reaching approximately 3,000 healthcare providers through training and supervision; Disseminating comprehensive reproductive health messages, including MIP, to communities in three districts through community leaders; and 26 MIPESA, RAOPAG, EARN and WARN countries are: Bénin, Burkina Faso, Burundi, Cape-Verde, Comoros, Côte d'ivoire, Eritrea, Ethiopia, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Malawi, Mali, Mauritania, Niger, Nigeria, Rwanda, Somalia, Sudan North, Sudan South, Sénégal, Sierra Leone, Tanzania, Togo, Uganda and Zambia. ACCESS End of Project, October 1, 2004 March 31,

34 Supporting rollout in Coast Province of Kenya s new malaria treatment policy, including guidance for MIP. In four of the original 16 districts, IPTp1 uptake increased to 77%, providers who reported they were giving SP increased to 93%, and colleagues updated on MIP increased from 27.5% to 52.5%. 27 In 2005, CDC conducted an evaluation for MIP based on the training of service providers and sensitization of communities by Jhpiego in Asembo, and the results showed increased use of SP in the intervention area. 28 In Coast Province, 9 28 healthcare providers were sensitized to the national treatment policy. Figure 4: IPTp Coverage among Recent Mothers Who Attended ANC in Intervention and Control Districts in Kenya; Baseline (2002) and Follow-up (2005) Percent of Women Receiving IPTp Data Source: Ouma et al, TMIH; Asembo 02 Gem 02 Asembo 05 Gem 05 District and Year: Asembo = Intervention and Gem = Control Madagascar ( ): Following Madagascar s adoption of an MIP policy in 2005, ACCESS worked with the MOH/Family Planning Unit to facilitate the development of the national policy and service delivery guidelines for MIP and all aspects of malaria. In addition, ACCESS identified five health sites in a highly endemic province covering a population of 103,609 with 4,700 pregnant women in which to initiate MIP prevention and control. ACCESS interventions included: developing learning materials, training health providers, and introducing a performance and quality improvement (PQI) process at five model sites. The training, supervision and PQI approach used in the five model health facilities led to notable improvements in IPTp coverage. Second dose IPTp coverage increased from 0% to 65% in the five sites compared to 35% nationally. 29 Facilities improved their average performance score from 20% of standards achieved at baseline, to 65% at 6 months and 76% at 25 months follow-up. 27 MOH, Ouma PO et al The effect of health care worker training on the use of intermittent preventive treatment for malaria in pregnancy in rural Kenya. Trop Med Int Health 12(8): National Malaria Control Program, Photo credit: Rene Salgado/PMI Tanzania IPTp1 IPTp2 28 ACCESS End of Project, October 1, 2004 March 31, 2010

35 Tanzania ( ): Building on efforts begun under the MNH Program, ACCESS supported the MOH to standardize FANC/MIP in-service training and is supporting comprehensive scale-up of this training FANC/MIP nationally. ACCESS also supported integration of FANC, MIP and screening and treatment of syphilis in pregnancy into the nursing/midwifery pre-service education schools, revising the ANC curricular component and training tutors and clinical preceptors from all certificate, diploma and higher-level nursing/midwifery schools in the country. 30 To ensure that learning is transferred to practice, ACCESS supported both pre-service and in-service health care providers to implement a standards-based quality improvement approach for ANC. Additionally, while improving the quality of ANC services at the facility, ACCESS also worked to create demand for such services within the target population through collaboration with local nongovernmental organizations (NGOs), advocacy with religious leaders, and the development of radio messages in collaboration with a local project called T-MARC. The Tanzania approach led to improved MIP results: in the program s FANC/MIP sentinel surveillance sites where HMIS data were reported, IPTp2 doubled over baseline DHS IPT2 coverage in 2004, and the program has moved towards a model of scale-up quite rapidly. A total of 4,536 (76%) of ANC providers in Tanzania have had their knowledge and skills updated in FANC/MIP with ACCESS support. To date, 2,633 ANC facilities (or 55%) have at least one provider trained in FANC, and 880 in-service clinical trainers have been trained since the start of the program in Moreover, due to national-level advocacy efforts, stockout days for SP at sentinel site surveillance facilities decreased by 50%. Uganda ( ): ACCESS supported the MOH in the implementation of a 10-month pilot project that targeted the faith-based sector, drew on best practices and lessons learned from the Kenya program approach, and built upon existing structures and systems. Despite the short duration of the intervention, significant improvements were made. The program brought together stakeholders from the MOH and the faith-based sector and other national partners (including WHO) to adapt training materials to the Ugandan context. With materials in place, providers were trained using national trainers. Following implementation, supportive supervision visits were incorporated, which offered reinforcement for the trained providers and assisted them in recognizing and correcting service delivery gaps. Orientation of community leaders empowered them to take key messages about FANC and MIP to the community. Challenges and Lessons Learned Implementation efforts across countries have demonstrated a number of challenges and yielded important lessons learned, summarized below, that should be considered as MIP programs move toward wide-scale implementation. 30 This is a total of 53 schools, with more than 3,200 graduates updated/trained in FANC/MIP/SIP to date. ACCESS End of Project, October 1, 2004 March 31,

36 CHALLENGES No attendance or late attendance at ANC The forgotten prongs: ITNs and case management Lack of MOH policy and program coordination Human resource shortages Stock-outs at ANC clinics Weak monitoring and recordkeeping Little support for pre-service education Inconsistent involvement of the private sector LESSONS LEARNED/RECOMMENDATIONS Involve communities early to engage women and their families and mobilize demand for services. Address the three prongs comprehensively in MIP programs, including IPTp, ITNs and case management. Advocate for stronger MOH relationships, especially between reproductive health and malaria control programs, as well as HIV, Tuberculosis, diagnostics and lab. Collaborate with Ministries to address the use of unskilled providers, including developing a plan for their training and supervision. Advocate for continuation of SP supplies for prevention at the ANC facility, especially as countries transition to artemisinin combination therapies for treatment. Integrate monitoring and recordkeeping into programs as a routine component to explain program trends and inform the direction of the program. Incorporate MIP programs into pre-service education for medical, nursing and midwifery schools for ultimate sustainability and costeffectiveness. Target public and private sectors together throughout program implementation. WAY FORWARD Moving toward scale-up is a process that will lead to increasing the program s impact while maintaining its quality. Policy dissemination and program implementation need to move forward at the same time, complementing one another for wide-scale impact. A platform of ANC, coupled with community mobilization efforts, leads to improvements in MIP intervention coverage. However, to achieve national coverage, programs should consider additional proven approaches such as quality improvement, pre-service education and engagement with the faith-based sector to augment existing strategies. 30 ACCESS End of Project, October 1, 2004 March 31, 2010

37 Strengthening the Integration of PMTCT within MNCH Services ACCESS APPROACH While not planned as a major focus of the ACCESS Program, the prevention of mother-to-child transmission of HIV/AIDS (PMTCT) was addressed in several ACCESS countries using PEPFAR funding. HIV is the leading cause of mortality among women of reproductive age worldwide and is a major contributor to maternal, infant and child morbidity and mortality (WHO 2009; UNAIDS 2009). Without treatment, one-third of children living with HIV will die before they reach their first birthday and more than 50% will die by their second year of life (Newell 2004). In 2008, an estimated 1.4 million pregnant women living with HIV in low- and middle-income countries gave birth, 91% of whom reside in sub-saharan Africa (UNAIDS, 2009). For pregnant women, access to comprehensive HIV care that is integrated with maternal health services leads to healthier outcomes for both mothers and newborns. However, despite the introduction and scale up of PMTCT services globally, the number of women accessing these services has not come close to the estimated need. Policies have been updated, space has been created and supplied with medicine, supplies and equipment, providers have been trained, and yet the number of women accessing high-quality PMTCT services remains low. To make services more accessible to women, both quality and convenience of services must improve. Ideally and intuitively, any effort to prevent the transmission of HIV from mother to child should be based on a compressive and integrated four pronged approach which includes: Prong 1 Prevention of HIV infection among women of childbearing age Prong 2 Prevention of unintended pregnancies among women living with HIV Prong 3 Prevention of transmission of HIV from mothers living with HIV to their infants Prong 4 Treatment, care and support for mothers living with HIV and their children and families For the individual woman, a comprehensive, coordinated, cascading continuum of services must be provided beginning with increased access to counseling, testing and primary prevention services, as well as reproductive health choices enabling either the prevention of unintended pregnancies or appropriate planning for intended future pregnancies. There must be no missed opportunities during ANC, delivery and postnatal care to provide appropriate PMTCT services. In areas where there is limited access to facility care, outreach services are needed to ensure that women and their infants receive the care they need. While many governments have policies supporting a comprehensive/integrated approach and guidelines identifying the multiple opportunities to integrate PMTCT into routine MNH services, different funding streams, divisions within ministries, resource constraints, and the involvement of multiple implementing partners all present challenges to making comprehensive PMTCT services a reality. And, as a result, women and infants drop out of services at multiple points along the continuum. ACCESS End of Project, October 1, 2004 March 31,

38 RESULTS Ethiopia: Integrating PMTCT into the Care Provided by Community Health Workers PMTCT Environment Even though PMTCT services are offered at nearly 719 sites (includes health centers and hospitals 31 ) in Ethiopia, service delivery statistics reveal poor utilization 32. National PMTCT service delivery guidelines were released in 2007 by Ethiopia s HIV/AIDS Prevention and Control unit (HAPCO), which include an opt-out approach integrated into routine MCH services at all service points along the health care continuum, including the health post. Services are available and the enabling policy environment is strong. However, with only 28% of women accessing ANC services and less than 6% 33 of women delivering in a facility, many women simply never have the opportunity to benefit from these supportive services and policies. To help bring healthcare closer to the community and rural populations, a new cadre of community health worker was created called the Health Extension Worker (HEW), whose responsibilities include provision of communitybased ANC and safe, clean deliveries. Gap Identified Despite government policies that promote an integrated approach to PMTCT, many women do not access the health system and therefore can not take advantage of the services available. Approach to Integration To bring PMTCT services closer to the household level, ACCESS proposed using the new cadre of HEWs to provide PMTCT services at the household level. ACCESS adapted existing national PMTCT and HIV counseling and testing training materials for health care providers to create a learning resource package for HEWs. A one-week, competency based training was conducted for 40 such workers on a pilot basis to explore if this cadre which was already focusing on MNCH services could help expand PMTCT services to women and their children. The project also utilizes the HEWs and voluntary community health workers (VCHWs) to improve community awareness and demand for PMTCT services, and to strengthen community and health center referral linkages to improve access to care and support for women and infants found to be HIV-positive. HEWs are encouraged to train the VCHWs in their communities to ensure that they talk with pregnant women about the new PMTCT services and the importance of delivering with the HEW. Key Achievements Forty HEWs were trained in comprehensive PMTCT and use of rapid HIV test kits. These HEWs then counseled more than 875 pregnant women on PMTCT; tested 771 pregnant women for HIV; and identified 7 HIV positive pregnant women and referred them to health centers for continual care. Although the pilot is too small to draw conclusions about coverage, this experience demonstrates that HEWs performing ANC and deliveries at the community level represent a viable opportunity to expand the availability of and thus increase the uptake of PMTCT services. If these cadres are supported with training, follow-up supervision, and the necessary supplies and materials, they have the capacity to deliver community-based PMTCT 31 National data as of June Ethiopia DHS ACCESS End of Project, October 1, 2004 March 31, 2010

39 services. Tentatively, the MOH in Ethiopia has indicated interest in scaling up this approach to rural areas of high HIV prevalence. Kenya: Introducing an integrated supervision tool and standards-based quality improvement approach to improve the quality of integrated service PMTCT Environment Prior to 2004, PMTCT was not integrated into FANC services in Kenya. In 2004, PMTCT was integrated into ANC and scaled up to over half of Kenya s facilities by While widely available, the quality of services was never assessed. By 2007, integrated ANC-PMTCT services were available in more than 3,000 facilities, but the quality of these services was unknown and supervision continued to occur separately through distinct HIV and reproductive health (RH) teams. Gap Identified There is no integration of HIV/RH supervision and an absence of information about the quality of PMTCT services. Approach to Integration ACCESS worked with the MOH to develop an integrated supervision tool and fostered the use of this tool by both HIV and RH providers. With the Division of Reproductive Health (DRH) and the National AIDS Control Program (NASCOP), ACCESS developed the performance standards and an assessment tool for PMTCT in The standards were pretested, piloted and implemented in the 8 provincial hospitals. In 2009, the standards and quality improvement process were scaled up to19 district hospitals in three provinces, 1 sub-district hospital, 9 mission hospitals, and 3 mission health centers. Key Achievements The integrated supervision tool has been adopted nationally by the MOH and is now being used throughout the country to support integrated care. Baseline assessments in four provincial hospitals revealed fairly low levels of adherence to high-quality PMTCT standards, demonstrating that the availability of services does not mean that they are standards based. A follow up survey (see Figure 5) showed steady increases in quality, but still significant gaps between actual and desired performance. Managers at the facilities where the quality improvement process was introduced were able to use the standards to identify gaps in performance and mobilize resources both from within the facilities and the partners on the ground to make improvements. Figure 5. Kenya PMTCT National Standards Performance of Selected PGHs A B C D Malawi: Integrating PMTCT across the MNCH Continuum of Care Toward the end of FY 2008, USAID engaged the ACCESS Program in testing a model for PMTCT integration with MNCH services. In the FY 08 HOP, $300,000 was provided to ACCESS to field test an integrated approach that expanded care through community-based approaches and strengthened and standardized referral linkages between the community and health facilities. USAID also provided limited 48.1 Baseline 1st Internal Assessment ACCESS End of Project, October 1, 2004 March 31,

40 funding to BASICS and requested that the two programs combine efforts to reach the target population of pregnant and postpartum women, newborns and children under five years of age. It was determined that Malawi where both ACCESS and BASICS were already working would be the country for field testing to strengthen MNCH. PMTCT Environment Malawi s PMTCT The full PMTCT package as presented in Malawi s 2007 draft national PMTCT guidelines, includes the following services: Provider initiated testing and counseling (PITC) in ANC and labor and delivery; Antiretroviral (ARV) prophylaxis or antiretroviral therapy (ART) according to guidelines; Cotrimoxazole preventive treatment (CPT) prophylaxis to HIV pregnant women following delivery given to HIV exposed infants and young children according to guidelines; Infant feeding counseling and support, and Counseling and follow-up. The MOH intent is to integrate PMTCT-specific services with existing services of trained counselors, nurse/midwives and clinicians at MCH clinics. Gaps Identified Program observations of PMTCT sites concluded that each PMTCT site operates differently due to the lack of formalized national PMTCT guidelines. As a result, some sites used the most recent information for provision of multi-regimen ART, while other sites continued to use only the single regimen of Nevirapine. Another major area of concern observed in all PMTCT sites included the lack of follow up for the few mothers and infants that access the services (mother-infant pair follow-up). Part of the challenge is that postnatal check-ups are recommended within 2 weeks following delivery; however, most mothers who deliver in a facility will only return for a postnatal check up at 6 weeks to enroll their infant in the immunization program (EPI). For those who do return for postnatal care in the MCH clinic, there is no cohort register that is able to track patients and enable follow-up. Other major gaps observed include: Not all ANC providers have been trained in HIV testing and counseling (HTC)/PMTCT; therefore, MNCH and PMTCT services are not truly integrated. Some providers are only trained as counselors and therefore they refer clients to another provider for testing. The inefficiency in patient flow and the high volume of clients in ANC results in many clients not getting tested. Where PMTCT has not been integrated into ANC, clients who test positive on the rapid test require two lab visits, contributing to clients not receiving the full set of services. No standardized register exists to document HIV tests done in the maternity ward. New registers for ANC and maternity that will have PMTCT-specific data were disseminated countrywide in December 2009, approximately one year behind schedule, after receiving funding from BASICS. Similarly, no standard PNC register exists to capture visits at one to two weeks follow-up. No standard system is in place for mother-infant pair follow-up. Evidence from a study in the Central Region suggests high lost-to-follow up rates nationally. Most infants are determined to be HIV exposed or positive only once they present at a hospital due to sickness. There is a missed opportunity for early diagnosis through PMTCT. 34 ACCESS End of Project, October 1, 2004 March 31, 2010

41 There is an inadequate mechanism to link clinical assessment, treatment and care of mother-infant pair to specific PMTCT services for HIV exposed infants at various entry points in the system. There is very weak follow-up of HIV infected mothers and linkages to FP. The availability of ARV prophylaxis is perceived to provide total PMTCT protection through breastfeeding, which results in poor monitoring of breastfeeding practices and timely introduction of complementary feeding methods. Approach to Integration Based on the situational analysis, ACCESS/Malawi in collaboration with BASICS, PSI, and the MoH s Reproductive Health and HIV/AIDS units designed an approach to integrate PMTCT content into existing MNCH packages across the antenatal to postpartum continuum of care. The first step was to integrate PMTCT content into current MNCH training and service delivery packages before piloting them in two districts (Nkhotakota and Phalombe). As the approach was implemented, the following significant actions were taken: Facility-based performance and quality improvement (PQI) standards were updated to include specific PMTCT standards; Malawi s national BEmONC training package for Maternal and Newborn Care was updated to include PMTCT; National community MNCH training materials were revised to include more PMTCT content; Facility providers and community health workers (HSAs) were trained in the content of the new integrated training packages; Facilities were oriented to the new performance standards and monitored through supportive supervision; and Through PSI, hygiene kits refills (of soap, oral rehydration salts and Zinc )were given during ANC visits, at delivery, and in the postpartum period for HIV positive mothers (up to 4 visits) as an incentive to accessing care. Key Achievements When the project began in January 2009, there were indications that new maternity registers intended to capture PMTCT-specific data would be in use at health facilities in early to mid 2009, but national level delays resulted in the registers not being in use at health facilities until January Consequently, ACCESS struggled to collect PMTCT-related data over the course of implementation as PMTCT documentation was not standardized across health facilities. With the introduction of the new ANC and maternity registers in December 2009, PMTCT data collection by health facilities is expected to be stronger and analysis of the data will be more robust, reliable and valid. ACCESS and BASICS made concerted efforts in January and February 2010 to collect available HMIS indicators on coverage of HIV testing among pregnant women since 2008 for inclusion in this report, but the data should be interpreted with caution as the registers have only been in use for two months. Figure 6 shows 2008 data for mothers who were counseled and tested for HIV and given their result, and the percentage who were given Nevirapine, CPT and/or ART (if needed). Nkhotakota District is well behind the national average in terms of percentage of HIV-positive mothers provided with Nevirapine and CPT, while Phalombe District seems consistent with the national average. This suggests further support is needed in Nkhotakota. ACCESS End of Project, October 1, 2004 March 31,

42 Figure 6: Pregnant Mothers Receiving PMTCT Services, 2008 Data (Source: HMIS) Figure 7 shows the data from Nkhotakota District Hospital from January 2008-February Beginning June 2008, Nkhotakota had a surge in the number of ANC clients being both counseled and tested for HIV and receiving their results. The original community MNH package included some content on PMTCT, with HSAs primarily referring pregnant women for HTC. Since the implementation of the original community MNH package occurred in early 2008 (at the start of ACCESS), it is possible that the surge in clients was a direct result of the increased community interventions implemented by the Program. Since that time, the majority of ANC clients in Nkhotakota have received HTC and their results. Figure 7: PMTCT Services in ANC, Nkhotakota District, (Source: HMIS) Unlike Nkhotakota District, the data for Phalombe (see Figure 8) indicates there is a significant gap between the number of ANC clients and those who receive HTC. One reason may be the lack of HIV test kits considering the high volume of ANC visits. It was noted that in May 2008 there was a stock out of test kits. However, 100% of clients who receive HTC also receive their results. 36 ACCESS End of Project, October 1, 2004 March 31, 2010

43 Figure 8: PMTCT Services in ANC, Phalombe District, (Source: HMIS) An analysis of two indicators show improvements in coverage from 2008 (pre-intervention) to March 2010 (post-intervention) in the target sites in both districts. While the validity of the data may be interpreted with caution, Figure 9 clearly indicates significant coverage improvement in HIV testing among pregnant women at the target sites as well as provision of antiretrovirals to reduce mother-to-child transmission. Prior to 2009, these facilities were primarily using single dose Nevirapine as the chosen prophylactic drug. In 2009, facilities were introduced in a phased manner to a combination prophylactic regimen using two antiretroviral drugs. Figure 9: Improvement in PMTCT Coverage, (Source: HMIS) * Facilities include: Benga, Malowa (2009 only) and Ntosa ** Facilities include: Mpasa and Holy Family Mission Hospital Another important result is the improvement in administering antiretrovirals as a prophylactic according to current guidelines. The guidelines no longer recommend sdnvp as a first option. Prior to the full roll-out of the draft guidelines in 2008, all pregnant women received sdnvp. As of March 2010, the registers allow facilities to track patients according to regimen. In Phalombe, 68.9% of pregnant women now receive the recommended combination ARVs (see Table 3 below). ACCESS End of Project, October 1, 2004 March 31,

44 Table 3: PMTCT coverage 2008 vs in Phalombe (Source: HMIS) Percent pregnant women receiving antiretrovirals to reduce MTCT by prophylactic regimen (Jan-Mar) 2 ARVs 0% 68.9% (n=84) HAART 0% 0% SD NVP only 100% (n=545) 31.1% (n=38) Percent of pregnant women newly counseled and tested for HIV and received results in Maternity 0% 35.1% (n=26) Community Intervention Results and Coverage Emerging data also supports improvements in PMTCT counseling through HSAs during antenatal home visits. In Phalombe, after the introduction of an integrated PMTCT-community MNH package, 87.6% identified pregnant women in the catchment areas of the target health facilities received PMTCT counseling. HSAs visited pregnant women at home to deliver counseling on the importance of testing for HIV, couples counseling, and counseling on skilled delivery and safe infant feeding. One hundred percent of the women to receive PMTCT counseling by HSAs in Phalombe were tested and received results at a health facility. Nkhotakota s coverage and follow-up rates were lower. Figure 10: Community-level PMTCT Coverage (counseling and referral) Post Intervention (Source: Community MNH Register) Importantly, the integration activity served as a catalytic strategy by motivating partners to understand the benefits of integration and employ similar approaches, for example: The Clinton HIV/AIDS Initiative incorporated the use of the hygiene kits as incentives to increase ANC attendance, male involvement, skilled birth attendance and mother-infant followup in their focus district Machinga; Two districts (Balaka and Chiradzulu) receiving funding from the Partnership of Maternal, Newborn, and Child Health (PMNCH) introduced the integrated community MNH package in selected health center catchment areas; BASICS is introducing a mother-infant pair followup register in Chikwawa district; 38 ACCESS End of Project, October 1, 2004 March 31, 2010

45 MCHIP is scaling up integrated PQI standards to 12 hospitals and 12 health centers, integrated BEmONC training to 60 tutors, and integrated community MNH to 8 health center catchment areas; and Save the Children is scaling up the integrated community MNH package in 3 districts (Chitipa, Dowa, Thyolo), saturating the entire district. WAY FORWARD The examples presented here demonstrate various approaches used to address different gaps along the ideal continuum of PMTCT services. Most countries support integrated PMTCT services along an integrated continuum of care, but are unable to provide such services seamlessly for many different reasons. Lessons learned and recommendations drawn from the examples presented here include: More examples of PMTCT-HIV integration are needed to address Prong 2: prevention of unintended pregnancies amongst women living with HIV. Under the ACQUIRE project, an interesting effort was undertaken by the Ugandan Organization, TASO to integrate FP into ART clinics. 34 This project had promising results and at the same time revealed some biases amongst ART providers about FP use by people living with HIV/AIDS. This suggests that much remains to be done to ensure that women living with HIV have access to a broad range of FP methods to prevent unintended pregnancies. A project currently underway by ACCESS-FP to integrate PMTCT and FP in Tanzania, focusing on the postpartum period, should provide additional contributions for addressing this often neglected prong. To achieve an integrated, comprehensive PMTCT program funding should be provided for an integrated comprehensive program. Aligning vertical programs that are already underway is cumbersome and time consuming. In Malawi, multiple partners were involved, each with separate funding streams. The time it takes to coordinate among partners with different mandates and different operating structures reduces the time and resources available for program implementation. Malawi expended significant effort on developing an appropriate set of monitoring tools. To some extent, tools are specific to the country context; however, a standardized set of tools to monitor and evaluate the impact of integration activities that could be adapted to the country context would be helpful to move programs forward. Any intervention to strengthen the PMTCT continuum of care should be based on a careful analysis of prevailing gaps in existing services. Programs should strengthen the weakest link in the continuum and optimize resources based on where the greatest coverage could be achieved. In countries where only 10% of women deliver in a facility, using community health workers or other peer-to-peer approaches become essential. 34 The Acquire Project, Research International Kenya/Uganda. Evaluation of a Family Planning and Antiretroviral Therapy Integration Pilot in Mbale, Uganda E & R Study #13, September 2008 ACCESS End of Project, October 1, 2004 March 31,

46 40 ACCESS End of Project, October 1, 2004 March 31, 2010

47 Community Mobilization: An Effective Strategy to Improve MNH ACCESS APPROACH The HHCC approach formed the foundation of ACCESS efforts to reduce maternal and newborn deaths that result annually from pregnancy and childbirth complications. At the facility level, the HHCC strengthens the capacity of health service providers in peripheral health facilities and referral hospitals to improve the access to and quality of MNH care. At the household and community level where women, their families and community members are the focus the HHCC approach promotes healthy pregnancy and birth practices, better self care, recognition of complications, and timely health service seeking.35 Because communities play a critical role in the process of achieving an effective continuum of care, ACCESS sought to systematically engage communities to improve MNH outcomes through the tested and documented approach of community mobilization. ACCESS advocated for community engagement as an important complementary strategy within comprehensive MNH programs, and developed two important resources to guide community mobilization programs. The first, Demystifying Community Mobilization: An Effective Strategy to Improve Maternal and Newborn Health, presents evidence of the effect of community mobilization in reducing newborn mortality. A complementary manual, How to Mobilize Communities for Improved Maternal and Newborn Health, provides the organizing framework and guidance for implementing MNH-focused community mobilization initiatives. In addition to these global contributions to advance community mobilization, the Program supported three large, multi-year country programs in Bangladesh, Malawi and Nigeria that included significant community mobilization components. WHAT IS COMMUNITY MOBILIZATION? ACCESS adopted the following definition of community mobilization in its programs: a capacity-building process through which community members, groups or organizations plan, carry out and evaluate activities on a participatory and sustained basis, either on their own initiative or stimulated by others. Key Components of Effective Community Mobilization Initiatives Community mobilization can raise awareness of MNH issues and motivate people to participate in activities that have been prioritized and planned from within the community. It is an empowering strategy that includes the following activities: Carrying out careful, formative research in order to design a locally-appropriate, context specific community mobilization strategy; Selecting and training individuals who will facilitate the community mobilization process within communities; Raising community awareness about the local MNH situation; 35 Otchere, S. and Ransom, E Bringing Care Closer to Mothers and Newborns: Using the Gap Analysis Tool to Develop a Household to Hospital Continuum of Care. Save the Chidren. Washington, DC: ACCESS End of Project, October 1, 2004 March 31,

48 Working with community leaders and others to invite and organize participation of those most affected by and interested in MNH; Exploring with community members the local practices, beliefs and attitudes that affect MNH; Supporting communities to set local priorities for action; Helping community members develop and implement their own community action plans; and Working with communities to build their capacity to independently monitor and evaluate their progress towards achieving improved health outcomes for mothers and newborns. These activities are summarized in the phases of what is known as the Community Action Cycle (CAC) (see Figure 11). The CAC is the common framework that ACCESS used in all programming contexts. Figure 11: Community Action Cycle Figure 2. Community Action Cycle Explore MNH Situation and Set Priorities Plan Together Prepare to mobilize Organize The Community For Action Act Together Prepare to scale-up Evaluate Together The Program s primary role in supporting From Dr. Sani Musa, Kano State, Nigeria community mobilization for MNH included: Since the commencement of the ACCESS community Facilitating the integration of mobilization program in my village a year and a half ago, community mobilization into the particularly with the introduction of the Community Core broader national, regional or district Groups, no single woman has died of pregnancy related health plan; problems. We have also experienced a significant reduction in neonatal deaths over the same period. The program has raised Supporting implementing community awareness organizations (MOHs, local about maternal and government or NGOs) to develop newborn health, and community mobilization technical gained participatory skills and expertise through training, involvement of religious targeted technical assistance and joint and traditional leaders in development of guidelines, manuals the roll out of the and supportive communication community mobilization materials; and process. Monitoring progress of community mobilization efforts to refine strategies, energize stakeholders and contribute to community mobilization expansion/scale-up planning. 42 ACCESS End of Project, October 1, 2004 March 31, 2010

49 RESULTS The tables below highlight community mobilization interventions ACCESS implemented in Bangladesh, Malawi and Nigeria, respectively. Each intervention was uniquely designed to respond to the specific context in which the MNH program operated. As such, the Bangladesh program represents an NGO-led model, the Malawi program an MOH-led program, and the Nigeria program a model led jointly by MOH and civil society. The CAC framework was common to each intervention whether facilitated by MOH staff (as in the case of Malawi) or by NGO staff (as in case of Bangladesh) and the development of skilled community mobilization facilitators was essential in all three programs. None of the programs provided monetary incentives to community members to organize, analyze and address the local barriers to MNH in their communities. Those community members with heightened awareness of the problems faced by families acted collectively out of a desire to make a difference. Table 4: Bangladesh: NGO-led Model CONTEXT INPUTS RESULTS Population covered by the intervention: approximately 795,000 Most CHWs inactive and many vacant posts Severely limited access to public, facility-based MNH services No funding to strengthen public service delivery Active NGO environment Neonatal mortality rate: 37/1,000 Skilled attendance at birth: 11% Total fertility rate: 3.7 Modern contraceptive prevalence rate: 32% Community mobilization training manual, tools and communication materials developed 125 NGO staff trained and supported to facilitate community mobilization Over 2,500 local leaders instructed on how to lead community mobilization efforts 1,904 Community Action Groups (CAGs) received monthly facilitation support. CAGs were composed of 21,875 men and women who participated to track pregnancies in their communities, and create and implement plans to encourage healthy home practices and remove barriers to use of services 56% of CAGs included MOH health and FP staff 61% of CAGs generated community emergency funds (to date used by 619 families for transportation or doctors fees, drug purchase or food). 83% of CAGs organized emergency transport systems (to date used by 436 mothers and 247 newborns) for cases of obstructed labor, retained placenta, convulsions and (in the newborn) pneumonia, convulsions and jaundice, among others. CAGs re-opened 69 inactive clinics and Expanded Program on Immunization Centers, and opened 12 new satellite clinics and 2 Expanded Program on Immunization Centers, working closely with local government and NGO representatives. ACCESS End of Project, October 1, 2004 March 31,

50 Table 5: Malawi: MOH-led Model CONTEXT INPUTS RESULTS Population covered by the intervention: 178,000 in communities linked to nine targeted health centers in three focus districts Program support to strengthen public health services along the full HHCC Health Surveillance Assistants (HSAs) have a mandate to engage community members in addressing local health challenges Neonatal mortality rate: 33/1,000 Infant mortality rate: 72/1,000 Skilled attendance at birth: 54% Contraceptive prevalence rate: 41% Facilitated national stakeholder review of community mobilization experiences to agree on a common framework and process National Community Mobilization Training Manual and tools developed in partnership with MOH/Reproductive Health Unit (RHU) 10 MOH staff trained as national (master) trainers 30 district MOH staff trained as trainers 120 HSAs and 18 Supervisors trained HSAs are supporting 675 villages to develop MNH CAGs that are linked with existing village development committees MOH/RHU owns community mobilization guidelines and training materials and plans to use them in training HSAs to facilitate community mobilization. Levels of community participation are high, especially among men. Deliveries by a skilled birth attendant increased to 71.7%, based on data collected by HSAs during their home visits between January and September USAID will continue catalytic support to MOH for expansion of community mobilization coverage under MCHIP. Community Meeting 44 ACCESS End of Project, October 1, 2004 March 31, 2010

51 Table 6: Nigeria: Jointly Led MOH and Civil Society Model CONTEXT INPUTS RESULTS Community mobilization inputs provided in 17 Local Government Authorities (LGAs) in Kano, Katsina and Zamfara states in North West Zone HHCC framework; inputs at all levels National recognition of community engagement s importance (policies and structures in place, but not operational) Many civil society actors at all levels, including NGOs, associations, CBOs and unions) Neonatal mortality rate: 55/1,000 Modern contraceptive prevalence rate: 3.3% 17 Community Mobilization Teams (CMTs) at the LGA level formed and trained 37 CMTs at the Primary Health Centers (PHC) level formed and trained PHC CMTs supported formation and training of community core groups composed of 338 volunteer representatives from existing civil society groups in PHC catchment areas Transportation agreements negotiated with transport unions in all 17 LGAs to allow emergency transport to health facilities at a fixed low cost (to date, 6,500 women have used the transport system). Advocacy efforts resulted in new resources, such as an ambulance purchased to transport patients from PHC to hospital; ANC drugs and long-lasting insecticideimpregnated nets; a doctor and midwife posted to facility and paid shift-duty allowances so the facility is now open 24 hours a day, seven days a week. Increased ANC visits and facility deliveries based on program monitoring data. 36 WAY FORWARD Challenge 1: MOH staff who are closest to the community (i.e., the CHWs) are already overworked. Lessons Learned: Simplify and shorten community mobilization training curricula and processes as much as possible. Examine whether CHWs should lead or only support community mobilization efforts. There may be other options for community mobilization facilitation such as existing community leaders, volunteers or members of civil society organizations, who can engage and feed input from communities to the health system. Challenge 2: Community mobilization competes with many other priorities (clinical training, infrastructure development) within a resource limited environment. Lessons Learned: Community meeting, India Technical experts need to make every effort to integrate community mobilization into broader national health strategies, especially when existing MOH policy calls for strong community engagement. When communities, CHWs and program managers experience results, the relative value of community mobilization is compelling and support is more likely. 36 Improvements in service utilization are likely due to a combination of community mobilization inputs, as well as improved quality of care at the facility and volunteer female counselors in the community. ACCESS End of Project, October 1, 2004 March 31,

52 Challenge 3: Ensuring stakeholder ownership of community mobilization is a timeconsuming process. Lessons Learned: Recognize this reality and plan accordingly. Stakeholder engagement cannot be over-emphasized. Develop solid partnerships with existing organizations at all levels. Community mobilization efforts have limited potential to expand and receive continued support without MOH buy-in. Seek greater flexibility in donor timelines. Challenge 4: Community mobilization takes time. Lessons Learned: Simplify the processes as much as possible before you start, and refine further as you rollout. As staff becomes more confident and skilled, community mobilization processes speed up. Good training is essential. Community mobilization successes build momentum and can lead to organic expansion. Communities and groups with prior experience organizing to solve problems can move more quickly. Men s group, Afghanistan Challenge 5: There is generally inadequate supportive supervision and mentoring available for community groups. Lessons Learned: Factor supervision needs into human resource planning and program timelines. More supervision is needed in the beginning. Link communities so they learn from each other. Develop and provide communities with easy-to-use tools and learning materials. Consider working with existing groups in the community that are interested in supporting MNH, such as women s groups or agriculture groups. Existing groups need less support than newly-formed groups because they already have experience working together. Recommendations for Future Community Mobilization Programming 1. Advocate with donors and program managers to include a community mobilization component in all comprehensive MNH programs. Community mobilization is an essential component of the HHCC approach, and is effective in increasing demand for and use of services. 2. Analyze the programming context carefully to identify existing systems, resources, policies, community structures and cultural factors. A community mobilization initiative that fits with and builds on local resources is more likely to be sustained and scaled up. 3. Continue to simplify community mobilization processes and tools without losing the empowering, capacity building foundation. 4. Disseminate guidance on community mobilization indicators and monitoring systems so that program managers will be confident in tracking and reporting community mobilization outputs. 46 ACCESS End of Project, October 1, 2004 March 31, 2010

53 5. Budget sufficient resources to document and share community mobilization results especially in peer review journals, because these are powerful advocacy tools. 6. Conduct cost-effectiveness studies to quantify the added-value of community mobilization. 7. Test variations of the community mobilization model for peri-urban and urban contexts. ACCESS End of Project, October 1, 2004 March 31,

54 48 ACCESS End of Project, October 1, 2004 March 31, 2010

55 Quality Improvement of Maternal and Newborn Health Services: Introducing Standards and Recognizing Achievements THE APPROACH The ACCESS Program used a quality improvement approach in 11 countries (see Table 5) to improve maternal, newborn and reproductive health services. The process Jhpiego s Standards-Based Management and Recognition Approach (SBM-R) was used in a fairly consistent manner across all countries. SBM-R, which focuses on standardization around clearly defined service delivery processes or a specific content area, is an internal quality improvement process that involves providers, health workers and managers, and emphasizes internal learning and continuous improvement. Through recognition, improvements achieved are formally or informally recognized, providing motivation to maintain progress and institutionalizing a culture of quality at the facility. The approach is less focused on problem analysis and more aimed at generating solutions to close gaps between expected (standardized) and actual performance. The SBM-R process strengthens health systems by linking national clinical standards, preservice education, in-service training and supervision to the service delivery point. It puts standards into the hands of providers and facility-based quality improvement teams, providing a concrete set of expectations for performance. The SBM-R process is based on the model presented below. In the first step, standards are set by a broad group of national-level stakeholders, drawing from national and international guidelines. Based on the level of facility targeted (hospital or health center) and the clinical areas covered, the standards vary in complexity and scope. In the second step, the standards are introduced to service delivery points by training facility-based quality improvement teams (QIT), which typically include service providers, administrators and support staff. As this stage, the QIT conducts a baseline assessment to determine how the facility measures against the standards and prepares an action plan to make improvements. In the third step, progress is periodically measured against the baseline, usually by the internal QIT. At this stage it is important to involve district-level stakeholders in the process as some gaps are beyond the control of the facility to address and external support may be needed (i.e., in resolving stockouts or human resource shortages). Finally, when a predetermined threshold is reached and verified by an external assessment team, achievements are rewarded or recognized. This recognition can range from informal mechanisms such as community celebrations to formal recognition involving certification through governmental or professional bodies. ACHIEVEMENTS The application of SBM-R varied in technical and geographic scope across the 11 ACCESS countries. (See Table 7 below.) While most standards covered a broad range of services, in some settings the quality improvement process was more focused. In Kenya, the SBM-R process was used to strengthen PMTCT, for instance, and in Tanzania the process focused on ANC and malaria in pregnancy. In all cases, standards were set through a collaborative process at the national level and were endorsed by ministries of health and/or professional associations. ACCESS End of Project, October 1, 2004 March 31,

56 Table 7. Where and How SBM-R was Applied by the ACCESS Program ACCESS APPLICATION OF SBM-R Country Technical Area Purpose Scope of Intervention Afghanistan Ethiopia Ghana 1) Pre-service education 2) Comprehensive maternal/ newborn/ reproductive health services Comprehensive maternal/ newborn/reproductive health services Comprehensive maternal/newborn/ reproductive health services 1) To strengthen community and hospital midwifery schools 2) To strengthen service delivery To assess and strengthen clinical training sites for Health Officer Training Program To strengthen service delivery Haiti Postabortion care To strengthen service delivery Kenya PMTCT To strengthen service delivery Madagascar Malaria in pregnancy To strengthen service delivery Malawi Nepal Comprehensive maternal/newborn/ reproductive health services Comprehensive maternal/newborn/ reproductive health services and training standards To strengthen service delivery To assess and strengthen SBA clinical training sites Nigeria EmONC and FP To strengthen service delivery Rwanda BEmONC To strengthen service delivery Tanzania 1) Pre-service education 2) ANC 1) To strengthen preservice education 2) To strengthen service delivery 1) All midwifery programs in the country use the SBM-R process as basis for accreditation 37 2) 319 facilities hospitals, basic and comprehensive health centers and health posts (expansion continues) 4 hospitals 11 facilities in Birim North District including 2 district hospitals 6 hospitals 8 provincial and general hospitals 5 model facilities 16 district hospitals All 4 central hospitals 12 health centers (expansion continues) 10 hospitals/clinical training sites (expanded to 25 after ACCESS assistance ended) 15 hospitals 15 primary health care centers (expansion continues) Six hospitals 1) 24 Nurse Midwifery schools 2) 2, facilities (55% of all facilities) 37 At the time of writing there are 34 hospital and/or Community Midwifery education programs in Afghanistan; the number continues to grow. 38 Tanzania was able to reach so many facilities through a modified abbreviated SBM-R approach that provided an orientation to SBM-R combined with provider ANC raining. 50 ACCESS End of Project, October 1, 2004 March 31, 2010

57 In all cases, ACCESS saw increases in achievement of standards, regardless of the technical area or level of facility. In many cases, the baseline assessment provided facility-based staff with their first opportunity to actually see what they were supposed to be doing and how close or how far they were from performing to standard. In some cases, notably Northern Nigeria, the baseline performance was shockingly low with no facility achieving greater than 20% of EmONC standards. However, even in those cases, improvements were seen over time. (See Figures 12 and 13 below.) Figure 12. Baseline and Follow-up Scores for EmONC Performance Standards at 13 ACCESS-supported Hospitals in Kano and Zamfara States Dawanaun Babawa Shagari Dr. Karima WCWC Kurya PHC Baseline 1st Follow up 2nd Follow up Figure 13. Baseline and Follow-up Scores for EmONC Performance Standards at 13 ACCESSsupported PHCs in Kano and Zamfara States Baseline 1st Follow-up 2nd Follow-up MMSH Gezawa GH Dawakin Tofa GH Kaura Namoda GH Zurmi GH KFGH In most countries, SBM-R standards were adopted by the central ministries of health (or other central bodies) for application beyond the ACCESS intervention areas. In Nigeria, although ACCESS worked in a limited number of Local Government Authorities (LGAs) in three states, the first stage of setting the standards resulted in the Federal Ministry of Health directing that the performance standards be institutionalized in all tertiary health facilities in the country. ACCESS End of Project, October 1, 2004 March 31,

58 In Nepal, ACCESS supported the National Health Training Center (NHTC) to develop training site quality improvement tools for the training of skilled birth attendants. ACCESS introduced the process to 10 sites; however, it continued beyond the project period and was institutionalized within the NHTC, which continued to expand the process to a total of 25 sites without ACCESS assistance. Similarly, in Malawi, the SBM-R process had a national scope. Prior to ACCESS, Jhpiego had worked with the Reproductive Health Unit (RHU) in Malawi s Ministry of Health to introduce performance standards for infection prevention in all hospitals in the country. Based on a positive experience, the RHU requested that PQI (as SBM-R is called in Malawi) for a broad range of maternal, newborn and reproductive health services (PQI-RH) be part of the ACCESS program design. Figure 14 below shows the broad range of services covered by this national quality improvement program and the steady improvements made over time in one of the district hospitals. Figure 14. Percentage of selected RH areas achieved by Mchinji District Hospital Pre- and Post-PQI Baseline Feb 08 1st Assess. Apr 08 2nd Assess. Aug 08 Ext. Verification 0 Antenatal Care Labor & Delivery (Normal) Labor & Delivery (Abnormal) Postnatal care Family Planning (follow up) Post Abortion Care Management Malawi is also looking to document how achievement of standards affects health outcomes. The effect of SBM-R on improved maternal and newborn health outcomes is beginning to emerge based on routine service statistics gathered at the facility level. Preliminary analysis from a 2009 evaluation of PQI showed a dramatic difference in the rate of cesarean sections at RH sites compared to the control, with cesarean sections increasing rapidly after the introduction of PQI RH across all intervention facilities. (See Figure 15). The increasing trend indicates that providers are able to readily identify emergency obstetric complications, refer, and conduct timely cesarean sections to avoid obstetric complications. Figure 15. Service Statistics from Malawi SBM-R Evaluation: Cesarean Sections Increased More in Intervention Group January- March April-June July- September October- December January- March April-June July- September October- December January- March April-June July- September October- December January- March April-June July- September October- December January- March April-June July- September October- December Number of c-sections RH PQI intervention began Control Sites Intervention Sites ACCESS End of Project, October 1, 2004 March 31, 2010

59 Note: The country briefs presented later in this report provide additional information on SBM-R achievements in other countries. Lessons Learned SBM-R strengthens the health system by serving as a bridge from pre-service education and inservice training to the service delivery point. Putting performance standards into the hands of service providers allows for continuous learning at the service delivery point. One aspect that service providers like most about SBM-R is that the standards can be used as job aids to help remind them of how to do their job correctly. In Nepal, the MNH standards were actually made into a pocket guide so that providers could keep them with them for easy reference. SBM-R strengthens the health system by making supervision more relevant and focused. In many countries, supervision is cursory, unfocused and ad hoc. In countries where SBM-R has been linked to the supervision system (Kenya and Malawi) it has provided supervisors with a meaningful tool to assess performance. SBM-R can successfully be applied in the pre-service setting. Pre-service education lends itself to standardization. ACCESS supported the application of SBM-R to the pre-service system in Afghanistan and Tanzania. The process now forms the foundation for Afghanistan s National Midwifery Education Accreditation Board and is used to accredit all midwifery schools across the country. By starting at the national level, SBM-R can be sustained over time. Setting standards with nationallevel stakeholders allows quality improvements to be expanded beyond a project intervention area because there is ownership at the country level. In Afghanistan, for example, all donors working in midwifery education use the same educational standards because they are now institutionalized in the National Midwifery Education Accreditation Board. Recommendations for Future Programming Linking facility improvements to community mobilization will likely increase the impact. In some ACCESS countries such as Nigeria, Malawi and Rwanda the quality improvement process was loosely linked to community mobilization work. Given that communities have a stake in facility performance and have the power to mobilize resources, closer ties between these approaches should be promoted as they are expanded within MCHIP and elsewhere. Selected outcome indicators should be tracked alongside of improvement in standards. Although most standards promoted through SBM-R are evidence based, it is important to demonstrate that achievement of standards is directly linked to improved practices and health outcomes. The work started by Malawi to track health outcomes should be expanded and replicated in other countries. Build on what is in place: promote quality improvement principles, not a branded approach. ACCESS did not insist on calling the quality improvement process SBM-R if a country already had a quality strategy in place. The term SBM-R is not used at all in Tanzania or Malawi, for instance. And, in Afghanistan, the ACCESS Associate Award and the HCI project are collaborating on improving quality of health services with the MoPH, and the term used for the process is quality assurance. Ensure involvement of district level stakeholders to avoid plateau-ing. A typical pattern for achieving standards is quick initial gains followed by a slowing down and possible stalling when some of the barriers are out of the control of hospital management (e.g., supply chain issues). The SBM-R process is designed to tackle the quickw wins first and then engage a broader group of stakeholders to tackle the more systemic problems. Broad and representative stakeholder involvement from the beginning can help facilities resolve the more difficult problems. ACCESS End of Project, October 1, 2004 March 31,

60 Recognition is a critical component of the process, and linking incentives with quality improvements should be vigorously pursued. Recognition increases motivation; it can promote healthy competition and help increase utilization of services. While formal accreditation based on provision of quality services is the ultimate goal of this process, incremental and informal recognition can motivate providers and advertise high-quality services to surrounding communities. Linking quality improvements to tangible incentives should be expanded where governments are seeking to base financing on performance. 54 ACCESS End of Project, October 1, 2004 March 31, 2010

61 Recommendations for Future Programming In almost all cases, work begun under ACCESS continues to be supported and expanded by host country governments, other in-country partners, USAID and/or other donors. This section presents a number of important lessons learned in targeted areas that should be considered as work initiated by ACCESS is expanded upon by other partners and programs. ANTENATAL CARE AND MALARIA IN PREGNANCY To adequately address MIP, policy dissemination and program implementation need to move forward at the same time, complementing one another for wide-scale impact. A platform of ANC, coupled with community mobilization efforts, leads to improvements in MIP intervention coverage. However, to achieve national coverage, programs should consider additional proven approaches such as quality improvement, pre-service education and engagement with the faith-based sector to augment existing strategies. Specific suggestions for moving forward with FANC/MIP include: The ANC platform should promote all three prongs for preventing and treating malaria in pregnancy: IPTp, use of ITNs and case management. Advocacy for stronger relationships within MOHs especially between RH and malaria control programs, as well as HIV, tuberculosis (TB), diagnostics and lab can increase program effectiveness. Advocacy for continuation of SP supplies for prevention at the ANC facility, especially as countries transition to artemisinin combination therapies for treatment, is essential to avoid stock-outs at ANC clinics. Incorporating MIP into pre-service education for medical, nursing and midwifery schools will ultimately support sustainability and cost-effectiveness. Integrating monitoring and recordkeeping into programs as a routine component will explain program trends and inform the direction of the program. Involving communities early on and engaging women and their families to mobilize demand for services can increase timely attendance at ANC clinics. PREVENTING POSTPARTUM HEMORRHAGE IN HOME BIRTHS Every woman, regardless of location, should have the basic right to a healthy and safe delivery. However, many women die from largely preventable causes because they do not have access to simple, life-saving interventions. The ACCESS experience showed that community-based education and distribution of misoprostol is a safe, acceptable, feasible and programmatically effective tool for preventing PPH in lowresource settings where access to skilled attendance is limited. Other innovative technologies have also become available, including oxytocin in Uniject for prevention of PPH and the uterine tamponade and the anti-shock garment for treatment of PPH. As complementary components of a comprehensive strategy to address PPH, these innovative interventions show promise for the many women in the world who live in remote settings, without access to facility-based skilled care, to prevent unnecessary maternal deaths that occur from PPH. Specific suggestions for moving forward to prevent PPH at home births include: Distribution of misoprostol is not a stand-alone, single approach to address the burden of PPH. Education and distribution of misoprostol are appropriate in settings where there are a large proportion of home births and an existing cadre of CHWs who can reach pregnant women in the community. The intervention should be a component of a comprehensive PPH prevention package, including efforts to ACCESS End of Project Report: Recommendations for Future Programming 55

62 increase the availability and accessibility of skilled attendance at birth and facility-based emergency obstetric services. The intervention can be integrated within the existing government health service delivery framework. In Afghanistan and Nepal, existing CHWs were widespread, accepted in the communities, and supervision and logistics systems were in place to oversee performance and provide supplies. Both projects delivered interventions as part of a basic package of care. Moreover, skilled attendants were present in facilities to manage referred cases of PPH and other complications. The community should be an active partner in any strategy to improve maternal health. The community used innovative and non-monetary methods for motivating and supporting CHWs. In Afghanistan, many CHWs stated that community recognition was a primary impetus that motivated them to fulfill their responsibilities related to the project. Community support is important and leads to increased knowledge about MNH, danger signs, the need for skilled attendance at birth and transport to emergency care. Delivering a PPH prevention measure directly into the hands of women makes good sense. Sadly, there are many women in the world that give birth alone. This intervention provides a protective method to the one person who will unequivocally be present at the moment of birth: the woman. Trained and supervised CHWs were successful sources of education to women on the risks of PPH and the safe and correct use of misoprostol. INCREASING THE SUPPLY AND ACCESS TO SKILLED BIRTH ATTENDANTS ACCESS worked in 14 countries to increase the availability and competence of SBAs. Efforts included support to roll out government SBA policies, development of training materials and training packages tailored to the needs of the country, support for in-service training, strengthening of pre-service institutions and mobilizing communities to increase demand for delivery with a skilled provider. Ultimately, a strong, standardized, competency-based, pre-service education system will have the most far-reaching impact on expanding the cadre of SBAs. Below are specific suggestions for future investments in pre-service education as an upstream method for increasing the supply and competence of skilled providers: BEmONC skills are basic skills that need to be in the repertoire of midwives at the time they enter the workforce and need to be incorporated into midwifery pre-service curriculum of studies. MOHs and the respective regulatory authorities for both medicine and nursing/midwifery must be engaged in the planning of programs that will enhance or expand the scope of practice of midwives, so that these skills can be acknowledged, valued, supported and facilitated at both policy and practice levels. Recruitment and admissions policies for midwifery students should encourage enrollment of the more qualified and better educated candidates, preferably at post-secondary level, and with the option of a direct-entry pathway to midwifery. Regional training can be effective for content that can be transported across country borders without the need for translation (e.g., adult learning principles, teaching skills); however, country-based training is preferable for teaching of clinical skills that must be tailored to the country context. Teaching and learning BEmONC skills require the investment of substantial time for acquisition of the fundamental anatomic and physiological principles and the hands-on skills of the various maneuvers. A standardized, competency-based, teaching/learning package cannot be short-cut without compromise to quality. Investments in the clinical training environment must be made if BEmONC training is to have any impact. The enabling environment includes basic equipment and supplies, and, as importantly, requires 56 ACCESS End of Project Report: Recommendations for Future Programming

63 that peer practitioners, supervisor and other medical practitioners are also updated in these evidence-based practices. USING KANGAROO MOTHER CARE TO SAVE NEWBORN LIVES In Nigeria, Rwanda and Nepal, ACCESS established the foundation for future expansion of KMC services by establishing KMC learning centers and supporting the provision of KMC services in a number of hospitals. In Malawi and Ethiopia, ACCESS built on the foundation of an already-established program to expand KMC services to additional hospitals. The Program experience introducing and expanding KMC services highlights the importance of engaging appropriate stakeholders the MOH in particular and professional bodies to ensure local acceptance and ownership of KMC for preterm babies. Engagement of these stakeholders facilitated the development and acceptance of national KMC guidelines and associated training materials. The establishment of learning centers served as an advocacy tool in facilitating the adoption of the method by other in-country development programs, thus assisting in the expansion of KMC services. To further expand KMC services, programs need to assist nursing and medical institutions to incorporate this method into their pre-service curricula. Specific suggestions for moving forward with KMC include: Scale-up of KMC services requires the technical and financial collaboration of multiple partners including the MOHs and national professional associations and cannot be supported by one organization alone. Introduction and expansion of KMC services requires local ownership from program start-up. Having national KMC policies, guidelines and a training manual with associated job aids facilitates introduction and expansion. Following up with mothers after discharge from the KMC unit is the single biggest challenge and will require extending KMC training/services beyond the facility level. KMC training should be integrated into ongoing MNH training. A two- to three-day training in KMC is sufficient when integrated into other MNH in-service training. However, a stand-alone KMC training program for persons not competent in identification of danger signs and newborn feeding techniques (including breastfeeding and cup feeding) requires four to five days of training to ensure appropriate skills are acquired. KMC training should include a hands-on practicum to ensure trainees acquire the necessary competencies. A general orientation of all facility staff on KMC, not just the immediate care providers of LBW babies, has proven beneficial. A system for ensuring training or mentoring for new staff posted to KMC units is essential to guarantee the continuation of service whenever trained staff is reassigned out of the unit. INTEGRATING HIV AND MATERNAL AND NEWBORN HEALTH SERVICES TO INCREASE PREVENTION OF MOTHER-TO-CHILD TRANSMISSION COVERAGE Although there are ample opportunities to integrate PMTCT into routine MNH services, different funding streams, divisions within ministries, and the involvement of multiple implementing partners all present challenges. However, with persistence and a commitment to consider all possible opportunities, ACCESS strengthened integrated PMTCT-MNH service delivery in Ethiopia, Kenya, Malawi and South Africa, thereby increasing the numbers of women and children receiving critical, life-saving services. ACCESS End of Project Report: Recommendations for Future Programming 57

64 Specific suggestions for moving forward with MNH-HIV integration for expanding PMTCT coverage include: Experience from Ethiopia demonstrated that community-based Health Extension Workers (HEWs) represent a viable opportunity to expand the availability of and thus increase the uptake of PMTCT services. In order to sustain their effectiveness, they need training, follow-up supervision and the necessary supplies and materials. Experience from Kenya showed that use of an integrated (RH and HIV) supervision tool, along with introduction of a facility-based quality improvement process, helps supervisors and motivates providers to improve the quality of care. Integration activities must be flexible to accommodate all contingencies. An example from Malawi showed that community-based collection of specimens was more effective than sending community members for HIV antigen testing. It is critical to have appropriate tools for monitoring services and progress ensuring these are in place can take time. Integrated services include integrated registers, which need to be tackled from the outset if results are to be accurately captured. Ideally, instead of developing project-specific registers, MOH registers will be enhanced. Linking Mother Infant Pair follow-up to household counseling and or community MNH mobilization efforts is an excellent way to ensure that HIV exposed infants return for follow-up care until a definitive diagnosis is reached. MOBILIZING COMMUNITIES TO IMPROVE MATERNAL AND NEWBORN HEALTH ACCESS s work in community mobilization identified several challenges and lessons learned. The Program found that CHWs are often overworked and community mobilization work competes with many other priorities. Although ensuring stakeholder ownership is critical, it takes time as does the community mobilization process. Ensuring supportive supervision and mentoring for community groups can be challenging. Specific suggestions to overcome these challenges and move forward with community mobilization for MNH include: Advocate with donors and program managers to include a community mobilization component in all comprehensive MNH programs. Community mobilization is an essential component of the HHCC approach, and is effective in increasing demand for and use of services. Analyze the programming context carefully to identify existing systems, resources, policies, community structures and cultural factors. A community mobilization initiative that fits with and builds on local resources is more likely to be sustained and scaled up. Continue to simplify community mobilization processes and tools without losing the empowering, capacity building foundation. Disseminate guidance on community mobilization indicators and monitoring systems so that program managers will be confident in tracking and reporting community mobilization outputs. Budget sufficient resources to document and share community mobilization results especially in peer review journals, because these are powerful advocacy tools. Conduct cost-effectiveness studies to quantify the added-value of community mobilization. Test variations of the community mobilization model for peri-urban and urban contexts. 58 ACCESS End of Project Report: Recommendations for Future Programming

65 INTRODUCING STANDARDS AND RECOGNIZING ACHIEVEMENTS The ACCESS Program used a quality improvement approach in 11 countries to improve maternal, newborn and reproductive health services. Jhpiego s SBM-R approach was used in a fairly consistent manner across all countries. The approach, which focuses on standardization around clearly defined service delivery processes or a specific content area, is an internal quality improvement process that involves providers, health workers and managers, and emphasizes internal learning and continuous improvement. Specific suggestions for moving forward with quality improvement approaches include: Linking facility improvements to community mobilization will likely increase the impact. In some ACCESS countries such as Nigeria, Malawi and Rwanda the quality improvement process was loosely linked to community mobilization work. Given that communities have a stake in facility performance and have the power to mobilize resources, closer ties between these approaches should be promoted as they are expanded within MCHIP and elsewhere. Selected outcome indicators should be tracked alongside of improvement in standards. Although most standards promoted through SBM-R are evidence based, it is important to demonstrate that achievement of standards is directly linked to improved practices and health outcomes. The work started by Malawi to track health outcomes should be expanded and replicated in other countries. Build on what is in place: promote quality improvement principles, not a branded approach. ACCESS did not insist on calling the quality improvement process SBM-R if a country already had a quality strategy in place. The term SBM-R is not used at all in Tanzania or Malawi, for instance. And, in Afghanistan, the ACCESS Associate Award and the HCI project are collaborating on improving quality of health services with the MoPH, and the term used for the process is quality assurance. Ensure involvement of district level stakeholders to avoid plateau-ing. A typical pattern for achieving standards is quick initial gains followed by a slowing down and possible stalling when some of the barriers are out of the control of hospital management (e.g., supply chain issues). The SBM-R process is designed to tackle the quickw wins first and then engage a broader group of stakeholders to tackle the more systemic problems. Broad and representative stakeholder involvement from the beginning can help facilities resolve the more difficult problems. Recognition is a critical component of the process, and linking incentives with quality improvements should be vigorously pursued. Recognition increases motivation; it can promote healthy competition and help increase utilization of services. While formal accreditation based on provision of quality services is the ultimate goal of this process, incremental and informal recognition can motivate providers and advertise high-quality services to surrounding communities. Linking quality improvements to tangible incentives should be expanded where governments are seeking to base financing on performance. USING SMALL GRANTS TO SCALE UP EVIDENCE-BASED MNH INTERVENTIONS With less than USD$200,000, ACCESS helped to build the capacity of 14 FBO, community-based organization (CBO) and professional organizations throughout sub-saharan Africa. Due to their presence in the community and intent to stay regardless of the funding or political atmosphere investment in these types of grassroots organizations has an enormous ability to make sustainable changes to MNH. These organizations are familiar with the local culture and therefore adept at transmitting messages and influencing behavior change, and have a significant outreach capacity as well as the trust of the communities in which they work. Moreover, professional associations have the capacity to set the standards for their respective professions. ACCESS End of Project Report: Recommendations for Future Programming 59

66 However, in program planning, the need to build in adequate time and resources cannot be overemphasized. Recipients of small grants often lack either the financial, technical or managerial skills to implement larger programs. It is therefore imperative to concentrate on improving these skills of small grantees, especially since these grants are small investments for often large returns. Specific suggestions for future MNH investments through small grants include: Build in adequate monitoring and evaluation and financial management technical assistance for small grant funding. Link the monitoring and evaluation plan to the results required for the sponsor. Issue fewer grants and set aside more resources for technical assistance for the entire process from proposal writing, baseline data collection, implementation, endline assessment, report-writing and supervision activities. The time frame to use the funds must be realistic. The capacity to use money efficiently and in a short period of time can be overwhelming for small organization. 60 ACCESS End of Project Report: Recommendations for Future Programming

67 Country Briefs ACCESS End of Project Report, October 1, 2004 March 31,

68 62 ACCESS End of Project Report, October 1, 2004 March 31, 2010

69 BANGLADESH Strengthened Maternal and Newborn Care Services INTRODUCTION Almost two-thirds of infant and child deaths in Bangladesh occur in the neonatal period, and more than 90% of all births occur at home, generally attended by a traditional birth attendant. 36 With 36% of newborns estimated to be low birth weight (LBW), Bangladesh has some of the most elevated LBW levels in the world. At the request of USAID Bangladesh, ACCESS and its partners 37 successfully implemented a program based on community mobilization and household counseling to improve MNH practices. ACCESS modeled its program in Bangladesh on Projahnmo I, 38 which demonstrated that early postnatal care can significantly lower neonatal mortality and that home-based management of newborn sepsis is feasible and effective. Working in seven upazillas of Sylhet District, ACCESS demonstrated like Projahnmo I that a phased implementation of home- or community-based management can offer an effective alternative to facility-based care in settings where the health system is weak and care-seeking is low. 39 Sylhet District, with administrative areas covering a population of 1.5 million, was chosen due to its particularly high maternal mortality ratio, estimated at 320 to 400 per 100,000 live births, as well as its high neonatal mortality rate. PROGRAM STRATEGIES AND INTERVENTIONS Strengthening Home Practices, Counseling and Utilization of Services More than 280 local women, called ACCESS counselors (ACs), visited the home of each pregnant woman identified in the program area four times twice during KEY INDICATORS Neonatal mortality rate (per 1,000): 37 Skilled attendance at birth: 11% (Sylhet), 18% (National) Modern contraceptive prevalence rate: 32% (Sylhet), 56% (National) Unmet need for family planning: 26% (Sylhet), 18% (National) Total fertility rate: 3.7 (Sylhet), 2.7 (National) Antenatal care attendance with trained provider: 47% (Sylhet), 52% (National) DHS Bangladesh Demographic and Health Survey Calverton, Maryland; National Institute for Population Research and Training (NIPORT) and Measure DHS Macro International, Inc. 37 The intervention was implemented by two national NGOs: Friends in Village Development, Bangladesh (FIVDB) and Shimantik. International Centre for Diarrhoeal Diseases Research Bangladesh (ICDDR,B) provided technical support in monitoring and evaluation. ACCESS also worked with the government at the national and district levels to promote improvement of referral services. 38 Funded by USAID and Save the Children s Saving Newborn Lives Initiative, the Projahnmo I Program was implemented by Johns Hopkins University through national partners ICDDR,B and Shimantik from October 2003 to January Baqui AH, Arifeen SE, Darmstadt GL et al. for the Projahnmo Study Group. Impact of a package of communitybased newborn care interventions implemented through two service delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet 2008; 371 (9628): ACCESS End of Project Report: Country Brief, Bangladesh 63

70 pregnancy, once within 24 hours after delivery, and once from five to seven days post-delivery to counsel her, the newborn care person (usually a family member) and the birth attendant on newborn health and hygiene. The majority of these women were young and resided in the area, serving approximately 800 1,200 households and covering a population of 5,000 7,000. Some of the ACs worked in remote areas with limited access to roads and transportation, and thus could cover a smaller population. ACs received a 10-day training course on basic MNH, including essential newborn care, clean delivery practices, basic counseling and negotiation skills, and recordkeeping/reporting. ACCESS also introduced community-based kangaroo mother care (KMC), the practice of constant skin-toskin contact between a caretaker and newborn, to Sylhet to ensure thermal care for LBW babies. Before this intervention, most LBW babies were referred to the only tertiary level health facility in Sylhet District, MAG Osmani Medical College, where they were managed using incubators. ACs coached mothers and other members of the household who care for newborns to use the KMC method, frequently breastfeed and refer any baby with a danger sign to the nearest health facility. Mobilizing Communities A community mobilization initiative further supported and facilitated the work of the ACs by working with women s and men s groups and locally identified formal and informal leaders (referred to as Community Resource Persons or CRPs) to identify and address specific barriers to improved MNH in their communities. Typically, after analyzing and prioritizing the key barriers influencing MNH household and care-seeking practices, community groups developed plans that encouraged appropriate care-seeking. This included preparing birth and newborn care plans, establishing emergency transport, securing financial resources for treatment or transportation and facilitating reactivation of MNH services. This approach, called the Community Action Cycle (CAC), aimed to develop sustainable, community-led solutions to improve the health of mothers and babies, and to strengthen the capacity of community members to act collectively to address future community needs that may arise. Engaging Traditional Birth Attendants and Village Doctors Basic emergency obstetric and newborn care (BEmONC) remains out of reach for the majority of women and their families in Sylhet. ACCESS worked with traditional birth attendants (TBAs) and village doctors to improve home birth practices by providing focused training to reduce harmful practices, ensure clean delivery, better identify maternal and newborn danger signs, and provide timely and appropriate referrals to facilities to obtain EmONC. ACCESS counselor, Bangladesh Strengthening Linkages with Health Services ACCESS worked with district health centers to improve knowledge and skills on essential obstetric and newborn care and BEmONC. The program also provided clinical updates on safe birth services and newborn care to medical doctors, nurses and paramedics of the Upazilla Health Complex. Using a variety of data sources to monitor and evaluate program work, a population-based survey was conducted at the start of the program, and the preliminary results were disseminated. Qualitative data, including mapping of community health resources, was used to assess the current capacity of community groups, service provision and utilization. Routine monitoring data were used to inform program progress. 64 ACCESS End of Project Report: Country Brief, Bangladesh

71 RESULTS Routine program data shows that ACCESS succeeded in reaching thousands of women with antenatal care, delivery care, postpartum care and family planning services. (See Table 8 below, organized by selected USAID Operational Plan Indicators.) Table 8: Results for Selected USAID Operational Plan Indicators in Maternal and Newborn Health INDICATOR FY07 FY08 FY09 TARGET ACHIEVE- MENT TARGET ACHIEVE- MENT TARGET ACHIEVE- MENT** Newborns receiving essential newborn care through USGsupported programs Postpartum/newborn visits within three days of birth in USGassisted programs Counseling visits for FP/RH as a result of USG assistance People who have seen or heard a specific USG-supported FP/RH message People trained in maternal/newborn health through USGsupported programs n/a* 2,098 11,695 21,391 26,804 22,834 5,845 4,120 25,989 26,294 31,579 31,597 11,500 7,099 25,989 29,993 29,381 32,431 11,500 7,099 31,095 32,711 35,119 36, ,849 3,767 4,022 7,778 2,456 Number of women 769 1,790 2,776 3,927 6,248 2,343 Number of men , People trained in FP/RH with USG funds 426 1,849 3,767 4,022 7,078 2,456 Number of women 369 1,790 2,776 3,927 5,748 1,330 Number of men , Institutions with improved management information systems, as a result of USG assistance * No baseline available for this indicator. ** Results represent partial year achievements due to transition to MCHIP Program. During the life of the project, 128,978 pregnant women were identified and registered, 95,696 pregnant women received a counseling visit at three to five months of pregnancy, 93,653 pregnant women received a counseling visit at seven to eight months of pregnancy, and 73,704 births were notified. Moreover, ACs reached 38,500 (52%) of these births within 24 hours and 59,205 (80%) within five to seven days. (See Figure 16.) ACCESS End of Project Report: Country Brief, Bangladesh 65

72 Figure 16: Counseling Coverage 50,000 40,000 30,000 20,000 10,000-40,841 48,905 39,232 Pregnancy Identified 17,246 42,896 35,554 10,322 34,092 30,110 P1 vis it P2 visit MNC1 visit MNC2 visit FY07 FY08 FY09 Of the 59,596 women who gave birth and received postnatal visits during the project, routine data revealed increasing trends in healthy maternal and neonatal behaviors. (See Figure 17.) 3,624 19,347 15,918 5,382 29,993 24,521 Figure 17: Levels of Selected Maternal and Newborn Health Behavior Birth Plan Clean Cord Cut Breastfeeding within 1 hour of birth Baseline06 FY07 FY08 FY09 Delay bathing for 3 days ACCESS established 1,174 CAGs in 614 villages through 73 trained community supervisor mobilizers and 40 community mobilizers who helped promote health practices and care-seeking behavior. MAJOR PROJECT OUTPUTS Trained 286 ACs to identify pregnant women and conduct home counseling visits. Used ACCESS-established pregnancy surveillance system to register 245,982 married women of reproductive age and 128,978 pregnant women as of May Trained 73 community supervisor mobilizers and 40 community mobilizers, who are working with 1,904 CAC committees in 614 villages. Over half of the villages in the ACCESS intervention area have a functional CAG. Completed village mapping in 1,789 villages and seven upazillas in Sylhet. Conducted 237,446 home counseling visits and distributed 79,953 clean delivery kits. Developed training manual on community-based KMC, and conducted training of trainers. Trained 691 TBAs and oriented an additional 3,000 TBAs and 2,000 CRPs. Trained 32 village doctors and conducted training of trainers for paramedics. 66 ACCESS End of Project Report: Country Brief, Bangladesh

73 LESSONS LEARNED AND SUSTAINABILITY Community Mobilization Impacts Behavior Change Health service facilities in some communities were often either very limited or entirely absent, creating frustration in the community. To address this situation, CAGs used their local capacity to advocate for health services. Some of these groups succeeded in reactivating community-based satellite clinics and immunization centers. One example of this is Majanpur, a disadvantaged village in the Deokalash Union of the Bishwanath Upazilla where there were no satellite health or immunization centers for pregnant women and babies seeking antenatal care and immunizations. To remedy this situation, the CAG contacted local representatives and government health officials to formally apply to the Ministry of Health and Family Welfare (MOHFW), which has the authority to set up satellite centers. In February 2008, the MOHFW s local representative established an immunization center in Majanpur. The local newspaper reported on the establishment of the center and concluded, If people in disadvantaged communities take initiative, most problems can be easily solved by community members and will remain a part of the community forever. Working with All Members of the Household Influences Family Decision-Making ACs worked to change perceptions of family decision-makers despite initial resistance. Nazma Begum delivered her baby at home with assistance from an untrained family birth attendant. Her husband, Masuk Mia, informed the 20-year-old AC, Hafsa, after the birth took place. Hafsa visited the mother and newborn immediately and discovered that the mother was continuing to bleed heavily postpartum. The AC, who had discussed danger signs with Nazma and her husband during the pregnancy preparedness visit, stressed to Masuk Mia that his wife needed emergency care. He was initially reluctant to take her to the health center because he believed that bleeding is a common birth phenomenon. However, the AC succeeded in persuading Masuk Mia to take his wife to the nearest health center, where she received emergency care for postpartum hemorrhage. Nazma s husband and the attending service provider at the facility both recognized the timeliness of the AC s referral. Woman, her husband and their baby, Bangladesh WAY FORWARD: FROM ACCESS TO MAMONI Based on ACCESS results and learning, USAID has funded a follow-on project, MaMoni, which will continue until early With an estimated 26% unmet need in FP, FP was added as a major component of MaMoni. Similarly, the follow-on project added sick newborn management and newborn infection prevention through handwashing, as these interventions are critical to ensuring the survival of newborns. The use of project-paid ACs, although successful, will be discontinued and instead the existing government infrastructure will be mobilized and strengthened in the expansion district, Habiganj. ACCESS End of Project Report: Country Brief, Bangladesh 67

74 68 ACCESS End of Project Report: Country Brief, Bangladesh

75 ETHIOPIA Improved Capacity of Training Institutions for Health Workers INTRODUCTION KEY INDICATORS Maternal mortality rate (per 100,000): 720 Neonatal mortality rate (per 1,000): 39 Infant mortality rate (per 1,000): 77 Skilled attendance at birth: 5.7% Current use of contraception (modern methods): 9.7% Total fertility rate: 5.4 Antenatal care attendance with trained provider: 27.6% Source: Ethiopia DHS 2005 ACCESS-supported facilities and operational woredas Ethiopia has one of the highest maternal mortality ratios in the world, with nearly 720 maternal deaths per 100,000 live births. 40 Moreover, an overwhelming majority of births (94%) occur at home, and there are large disparities among the regions in access to antenatal care (ANC) 88% of mothers in Addis Ababa received ANC from a health professional compared with less than 10% of mothers in the Somali Region. Requested by USAID Ethiopia to address this dire situation for mothers and their newborns, ACCESS worked to improve the quality of essential maternal and newborn care (EMNC) services by building the capacity of training institutions for health workers. In partnership with the Federal Ministry of Health (FMOH) and local institutions such as the Ethiopian Nurses Mother and baby, Ethiopia and Midwives Association (ENMA) and the Ethiopian Society of Obstetricians and Gynecologists (ESOG), ACCESS trained health officers (HOs) and health extension workers (HEWs) in EMNC, including infection prevention practices in service delivery and linkages with HIV prevention, care and support services at the community level. By program end, their capacity to develop learning materials and conduct competency-based training and supportive supervision was greatly improved. 40 DHS, 2005 ACCESS End of Project Report: Country Brief, Ethiopia 69

76 PROGRAM STRATEGIES, INTERVENTIONS AND RESULTS Accelerated Health Officer Program Pre-service education of health officers strengthened with a focus on clinical skills in maternal and newborn care to improve maternal and newborn survival The government of Ethiopia set new targets for training HOs under a program called the Accelerated Health Officer Training Program (AHOTP), with a goal of 5,000 HOs trained by 2010 using the approved, three-year degree program currently offered in five national universities. With intakes of 1,000 nurses per year, 41 the existing clinical facilities could not accommodate all interested students. As a result, 21 hospitals were designated as affiliated hospitals to support the AHOTP. The Carter Center provided financial and material support to these hospitals, and invited selected staff to participate in MAJOR RESULTS Eight hospitals strengthened as clinical training sites for HOs 500 HOs trained in improved clinical training sites 47 trainers developed to train HEWs in maternal and newborn care 335 HEWs trained in maternal and newborn care 3,208 women attended at birth by trained HEWs HIV tests provided to 625 women in the community by HEWs KMC services expanded from one to five hospitals across the country workshops on clinical training skills and learning methodology. Building on these efforts, ACCESS worked in eight of the hospitals to create enabling environments for the HO trainees to acquire knowledge and skills in the clinical care of mothers and newborns. Based on gaps identified during an initial site assessment, action plans were developed and clinical sites were strengthened to ensure adequate resources to support teaching and learning activities. A three-week basic EmONC 42 (BEmONC) training course was conducted in three sites for 52 participants from the eight selected hospitals. Among the participants, 18 were selected to attend a six-day clinical training skills course to enhance their capacity to transfer knowledge and skills. In total, more than 500 HOs have benefited from the improved clinical learning environments. Focused antenatal care (FANC) is now the standard of care in seven of the eight hospitals, and all eight have markedly improved their infection prevention practices and women-friendly care. Active management of the third stage of labor (AMTSL) and essential newborn care are routinely carried out in all eight hospitals. Care and follow-up in the immediate postpartum has also improved, and many women remain in the facilities for at least six hours before discharge. To address remaining gaps in performance, ACCESS selected four of the hospitals and oriented them to the Standards-Based Management and Recognition (SBM-R) approach, which uses agreed-upon performance standards as the basis for measuring performance and identifying gaps in quality of care, as well as rewarding compliance with standards through recognition mechanisms. A number of challenges remain, including inconsistency in practices and non-availability of magnesium sulphate for treatment of pre-eclampsia and eclampsia. As the program ends, ACCESS will support ongoing efforts by the eight hospitals to improve the 41 HO training is often seen as a career path for nursing and midwifery for those who only have the qualifications to enter the diploma (rather than the degree) program. 42 Basic EmONC services should include the following: parenteral antibiotics, parenteral uterotonics, parenteral anticonvulsants, manual removal of placenta, manual removal of retained products (preferably by manual vacuum aspiration), assisted delivery by vacuum and newborn resuscitation. Comprehensive EmONC services at the district hospital level should include: all the above plus surgical capability (caesarean section), anaesthesia and blood transfusion. 70 ACCESS End of Project Report: Country Brief, Ethiopia

77 quality of care and to focus on standardizing the use of partographs in labor and the administration of magnesium sulphate for eclampsia. 43 Health Extension Worker Program Designed and implemented an in-service training program to update HEWs in evidence-based maternal and newborn care The Ethiopian Ministry of Health (MOH) developed a Health Sector Development Plan (HSDP-III), which includes the goal of accelerating the expansion of primary health coverage and increasing the number of health care workers. At the core of the HSDP-III is the Health Extension Program (HEP), introduced in , which trained and deployed nearly 30,000 female HEWs, two per kebele (village) or approximately two per 5,000 people. These tenth-grade graduates undergo an additional year of training and perform a variety of community-based services in rural areas, operating from a health post. 44 As the government s main vehicle for bringing key maternal, neonatal and child health interventions to the community, HEWs conduct household visits and work with community volunteers and kebele administration to carry out 16 different health interventions. ACCESS was tasked to build the capacity of the HEWs to provide EMNC using the following approaches: Training of HEWs ACCESS worked through the ENMA to train HEWs in EMNC at the community level. Twelve health centers in the Oromia Region were selected as target training sites, and materials and supplies were procured and distributed to each to fill identified gaps and create an enabling environment for trainees. Working closely with the FMOH s Family Health Division, UNICEF, Save the Children USA, the ENMA and others, ACCESS formulated a learning resource package comprising a reference manual, trainer s guide, participant s manual and a monitoring logbook. The reference manual is based on the Hesperian Foundation s A Book for Midwives, and is targeted to the knowledge and skills that HEWs need to provide safe and clean births and newborn care. Trained HEWs have attended 3,208 births, given misoprostol to 2,596 women during delivery, provided immediate essential care for 3,112 newborns, and conducted 3,347 postpartum visits within of three days of birth. Standardization courses were conducted for 47 trainers, including midwives, nurses and HOs, from the selected sites. The trainers were provided with updates on EMNC, oriented to the HEW learning materials for safe and clean birth, and prepared to teach effectively through participation in a modified clinical training skills course. 43 In 2010, UNICEF is arranging a large procurement of Mag SO4 to address this major gap in provision of EmOC. 44 HEP document, 2006 ACCESS End of Project Report: Country Brief, Ethiopia 71

78 Between March and October 2008, these 47 trainers in turn trained 358 HEWs from 265 health posts, and during each round of training, ENMA and ACCESS staff provided supportive supervision in collaboration with the regional health bureau. In total, trained HEWs in 153 of these health posts attended 3,208 births, gave misoprostol to 2,596 women during delivery to prevent postpartum hemorrhage (PPH) (a new approach in Ethiopia), provided 3,112 newborns with immediate essential care, 45 and conducted 3,347 postpartum visits within three days of birth. Moreover, these HEWs attended 11% (or 3,208) of all expected births for these 153 health posts. 46 Linkages between HEWs and referral health centers were also strengthened through ongoing monthly meetings at the district level. Table 9 highlights the improvements in MNH services at all 12 health centers in which training was conducted. Table 9: Performance of ACCESS-supported Health Centers and Hospitals in Terms of Deliveries with Skilled Birth Attendants (SBAs), use of AMTSL and Use of Partograph INDICATOR OROMIA (JANUARY OCTOBER 2008) WEST HARARGHE (APRIL JULY 2009)* TARGET % ACHIEVED HEALTH CENTER (N=11) HEALTH CENTER (N=4) HOSPITALS (N=6) Number of deliveries with a SBA at USG-assisted programs Number of women receiving AMTSL through USG-supported programs Number of births in ACCESStargeted facilities that occurred with a skilled attendant using a partograph 2, ,968 7,500 75% 1, ,774 1, % 47 1, ,740 94% *Note: The West Hararghe program began in the spring of 2009, with data collection initiated in April Mobilizing Communities ACCESS assisted the HEWs in the Oromia Region to conduct community mobilization activities to increase demand for their MNH services and to extend the reach of these services in their communities. This included support in adapting and distributing information, education, communication (IEC)/behavior change communication (BCC) materials to educate families about maternal and neonatal health issues. In West Hararghe, ACCESS distributed 1,090 such materials, including flip charts, misoprostol cue cards, and birth preparedness and complication readiness cue cards. ACCESS met quarterly with the HEWs to review implementation of activities. At project end, ACCESS is rolling out utilization of the Community Action Cycle (CAC) to volunteer community health promoters. The CAC is a community mobilization process in which the capacity of the community to address their health needs is enhanced by planning, carrying out and evaluating activities on a 45 Immediate essential care includes drying and wrapping, clean cord care and immediate breastfeeding. 46 Based on the DHS 2005 rural crude birth rate of 37.3% and the catchment population of a health post being 5,000 individuals. 47 ACCESS had set this target very low, as AMTSL was not institutionalized and not being reported, a situation which continues despite a full review of national HMIS logbooks. However, AMSTL is now the norm. 72 ACCESS End of Project Report: Country Brief, Ethiopia

79 participatory and sustained basis. Thus far, 96 HEWs have participated in a two-day training course on the CAC. Extending Prevention of Mother-to-Child Transmission of HIV (PMTCT) Services through HEWs The greatest challenges to comprehensive HIV/AIDS services in Ethiopia are low ANC coverage and institutional delivery rates, as well as poor uptake of PMTCT services in public facilities. Efforts to increase the uptake of PMTCT and HIV counseling and testing (HCT) services should be directed closer to the community to improve utilization of these services. HEWs, situated at the community level and performing ANC and delivery services, represent a viable opportunity to increase the availability and uptake of PMTCT services. In response to this need, ACCESS piloted a project supporting 40 HEWs in 31 selected health posts in the Oromia Region to: 1) target women accessing ANC and labor and delivery services in the home and at the Mother and father with new daughter in Robe Health Center, Ethiopia health post; and 2) deliver comprehensive PMTCT services, including HIV rapid testing and referral to health centers for antiretroviral therapy (ART). The project utilized HEWs and voluntary community health workers (VCHWs) to improve community awareness and demand for PMTCT services and to strengthen community and health center referral linkages to improve access to care and support for women and infants found to be HIV-positive. HEWs are encouraged to train the VCHWs in their communities to ensure that they talk with pregnant women about new PMTCT services and the importance of delivering with a HEW. To date, HEWs in 21 of the 31 pilot PMTCT health posts have provided PMTCT counseling to 725 women and provided HIV testing to 625 of these women, seven of whom were HIV-positive. HIV-positive women were referred to health centers and in some cases were accompanied by the HEW for their first visit. ACCESS CORE-FUNDED INITIATIVES Africa Regional Pre-service Midwifery Education Initiative In partnership with the WHO Regional Office for Africa, ACCESS worked for five years to implement the Africa Regional Pre-Service Midwifery Education Initiative. To address the Initiative s goal of reducing maternal and newborn morbidity and mortality, ACCESS trained a total of 36 midwife teachers and preceptors from approximately half of the 24 midwifery schools on best practices in BEmONC and the Maternity Section at Yekatit 12 Hospital was strengthened to be a clinical training site, and this site continues to be used. ACCESS also advised on revisions to curricula for midwives to include the latest evidence-based standards of maternal and newborn health care with a focus on BEmONC. This included work with UNFPA and other stakeholders on a competency-based job description on which to base a revised curriculum, and support to the Ministry of Education to strengthen degree-level programs through review of curricula. ACCESS was also instrumental in sharing resources such as the Best Practices in Essential and Basic Emergency Obstetric and Newborn Care Learning Resource Package with all training institutions. ACCESS improved the knowledge and skills of midwifery tutors and clinical preceptors in BEmONC to enable them to effectively teach their students to care for women and newborns at all levels of the health care system. These tutors and clinical preceptors, now armed with updated BEmONC knowledge and skills as well as enhanced teaching capacity, will form a core of local experts who can conduct training activities and act as mentors for other trainers. ACCESS End of Project Report: Country Brief, Ethiopia 73

80 Increased Use of Targeted Interventions by Skilled Providers ACCESS and the ESOG worked together to increase the use of targeted interventions such as AMTSL, essential newborn care and newborn resuscitation by skilled providers to enhance maternal and newborn survival. As the selected clinical training site, Ambo Hospital in the Oromia Region was strengthened through the capacity building of hospital staff and provision of essential equipment. The hospital is staffed with an obstetrician and can now provide comprehensive emergency obstetric care. In addition, the ESOG strengthened the capacity of providers from health centers attached to Ambo Hospital to allow BEmOC to be performed at peripheral levels so as to decrease the delays in care and promote faster management of obstetric and newborn complications. Kangaroo Mother Care (KMC) With its partners, 48 ACCESS adapted its global KMC training manual for use in Ethiopia, and provided financial and technical assistance to develop related BCC materials to support KMC training and implementation. ACCESS also strengthened the KMC component of the national integrated management of childhood illness (IMCI) training by developing a supplementary KMC module to be used in conjunction with the current IMCI training manual. The complementary manual is currently under review. Prior to ACCESS interventions, KMC services were limited to a single health facility Black Lion Hospital. ACCESS supported the upgrade of the KMC ward in this hospital and used it as a training center, which enabled the expansion of KMC services to five additional hospitals in other regions. These five hospitals were strategically selected (one per region) to serve as learning centers for further expansion through ongoing IMCI training. LESSONS LEARNED AND SUSTAINABILITY Engaging with the community is essential in increasing utilization of HEWs and SBAs in Ethiopia, and the ACCESS Program was able to demonstrate that there are effective ways to mobilize and engage the community, often by tapping into existing groups. These groups can be used as a mechanism to address health concerns for example, to establish funds for pregnant women who need to travel to deliver in a health facility. To measure the impact such groups can have requires appropriate monitoring tools that sufficiently capture the personal stories of how women and their families were able to use such funding Woman and baby, Ethiopia mechanisms. Strengthening supervision systems needs to be an integral part of any continuum-of-care intervention. In a number of ACCESS Program areas, woreda-level supervision systems and a general lack of understanding of the importance of supervision led to delays in achieving targets in some kebeles. Woreda health officials must be involved in all community-linked health programs from the beginning to ensure that they are a part of and engaged in the program implementation process. Additionally, incorporating supervision skills and motivational strategies for supervisors needs to be considered. Scaling up HEW training in safe and clean birth requires standardizing and strengthening health centers that serve as training sites, building capacity of trainers, strengthening linkages with referral facilities, ensuring availability of supplies and providing supportive supervision. Under the ACCESS 48 Partners included the FMOH, UNICEF, WHO, USAID's Essential Services for Health Project, Ethiopian Pediatric Association and other stakeholders. 74 ACCESS End of Project Report: Country Brief, Ethiopia

81 Program, the ideal model was used; however, as the FMOH approaches national scale up, many of the elements that will ensure competency of HEWs in safe and clean birth are missing. Working within MOH data collection systems is challenging when the existing tools are not able to capture critical MNH interventions and cannot effectively monitor program impact. Development of the program monitoring plan needs to be realistic to the extent that the existing data collection system can support it. Focused coaching and support with those involved in data collection from the HEW to woreda offices needs to be included in program planning. In designing an effective training initiative, performance gaps in service provision which include resources, knowledge and skills should be assessed in advance and, where possible, coaching of trainees should continue after the training program ends to ensure the effective transfer of learning and to promote sustainability of knowledge and skills gained. Regional referral hospitals must be strengthened and included in training activities, as they can serve as training and clinical practicum sites for HOs and midwives. The midwifery PSE activities were implemented at a time when the MOH were focused on the Health Extension Program. However, toward the end of the ACCESS program (and linked to the HR strategy for the next 10 years) there was greater interest in investing in midwives and their education. ACCESS End of Project Report: Country Brief, Ethiopia 75

82 76 ACCESS End of Project Report: Country Brief, Ethiopia

83 INDIA Program Years 2006 to 2009 Increased Skilled Birth Attendance in Underserved Rural Communities in Jharkhand State INTRODUCTION With a high maternal mortality ratio and a population of more than one billion people, India leads the world in the number of women dying in pregnancy and childbirth every year. When ACCESS began working in India in 2006, only 29.1% of births were attended by skilled providers in Jharkhand state; 49 the majority of women also give birth at home. This lack of skilled birth attendants (SBAs) meant no life-saving emergency obstetric services for the many women who experience life-threatening complications, putting them and their newborns at great risk. In 2005, the Government of India (GoI) addressed the need for SBAs by expanding the range of skills for auxiliary nurse-midwives (ANMs) and lady health visitors (LHVs) to enable them to provide life-saving skilled care at birth. With USAID support, ACCESS worked with the Government of Jharkhand, CEDPA and implementing partners 50 to operationalize these guidelines and improve health outcomes for mothers and newborns. ACCESS designed a pilot project and evaluation to demonstrate that increasing the availability of skilled delivery care offered by ANMs combined with community mobilization activities improves access to and use of key MNC services, ultimately contributing to improved health outcomes and reducing maternal and newborn morbidity and mortality. ACCESS implemented this project in Jharkhand, where skilled attendance at birth, ANC attendance and the contraceptive prevalence rate are among the lowest in the country (see text box above right). Dumka District was KEY INDICATORS FOR JHARKHAND Total fertility rate: 3.3 Contraceptive prevalence: 31.1% (modern methods) Births with skilled attendant: 29.1% Antenatal attendance (3+ visits): 36.1% Source: National Family Health Survey-3, WHO Statistical Information System Women s group, India 49 National Family Health Survey-3, GoI, Government of Jharkhand, Government of Dumka, Mohulpahari Christian Hospital, Sadar Hospital Dumka and ANM Training Center, Chetna Vikas, CEDPA, Jhpiego (ACCESS), Save the Children (ACCESS), Social and Rural Research Institute/IMRB International. ACCESS End of Project Report: Country Brief, India 77

84 selected due to its challenging MNH situation, and the project was implemented in three of Dumka s ten blocks: Jarmundi, Shikaripara and Saraiyahat. PROGRAM STRATEGIES AND INTERVENTIONS The project s formative assessment in June 2006 found that the majority of women and their families in Jharkhand seek care from traditional birth attendants (TBAs) and that basic emergency obstetric and newborn care (EmONC) remained out of reach for most women. Within the formal health care system, ANMs are intended to provide midwifery care, but they infrequently attended deliveries. To make skilled care by ANMs available in communities in Jharkhand, ACCESS focused on three areas: 1. creating demand in the communities for skilled care; 2. training ANMs to ensure that they are competent SBAs; and 3. supporting ANMs to provide care in the communities, either at home or from peripheral health care centers (sub-centers and primary health care centers). ACCESS and its partners worked at the national, state and district levels to achieve the program objectives. ACCESS conducted a number of key, coordinated activities that were essential to the project s success, including: Trained ANMs as community-based midwives for 12 weeks using competency-based training materials in Hindi. Strengthened clinical training sites and built/strengthened capacity of faculty, clinical providers and supervisors. Deployed and supervised ANMs in communities and developed ongoing support systems within the government health care system. Introduced community mobilization activities and materials to increase awareness of birth preparedness/complications readiness (BP/CR). Established/strengthened mahila mandals in communities to generate support for BP/CR and ANMs placed in communities. ACCESS monitored and evaluated its model to inform the ongoing national discussion of strategies to increase skilled birth attendance. The project conducted a pre/post quasi-experimental evaluation that included a household survey of pregnant women and recently delivered mothers, and interviews with ANMs in intervention and comparison areas. ACCESS also strengthened systems for collecting service statistics from ANMs and project-supported CHWs. In early 2009, ACCESS shared findings with stakeholders at the state and national levels and then continued to work with national policymakers such as the Indian Nursing Council (INC) to integrate key findings with ongoing programs. RESULTS Increased ANM Training Capacity Strengthened the ANM training centers (including a teaching skills laboratory) and training skills for ANM tutors and improved the teaching quality. These sites offer in-service and pre-service ANM education. Strengthened two hospitals and three primary health centers, improving evidence-based practices consistent with GoI guidelines. The hospitals were used as clinical practice sites for ANMs during training. Developed and tested a 12-week competency-based training course on GoI guidelines. Trained 58 ANMs to competency as SBAs in evidence-based care in ANC, normal delivery, postnatal/postpartum care and management of complications. 78 ACCESS End of Project Report: Country Brief, India

85 MAJOR PROJECT RESULTS Demonstrated that the 12-week ANM training course produced competent and skilled SBAs in the intervention group who practiced the life-saving skills they were taught, such as partograph use, AMTSL practice and newborn resuscitation. Significantly improved the practice of BP/CR for pregnant women and recent mothers and the practice of essential newborn care among recent mothers including clean cord care, drying and wrapping, and delayed bathing. Significantly increased the proportion of births attended by ANMs in the intervention group of recent mothers from 5% to 13%. With the INC, developed a national strategic plan to scale up project findings aimed at supporting improved capacity of ANM training centers (ANMTCs) at the district level. Increased Access to Skilled Maternal and Newborn Care Supported two groups of ANMs (37 total) for a year of training as they worked in communities to provide MNC at home and/or in facilities. Local project staff provided regular monitoring, supervision and data collection. Introduced and supported the trained ANMs as skilled providers to communities and linked community workers, communities and trained ANMs to create awareness and accountability. Increased Knowledge and Action on Maternal and Newborn Care Community Mobilization and Outreach Mobilized 223 communities in 180 locations of three blocks. Trained more than 2,600 community members, including 434 safe motherhood volunteers, 231 safe motherhood advocates and over 1,400 mahila mandal members. Mobilized more than 220 villages to take action to increase access to skilled care, resulting in 100% of villages having a functional emergency transport system. Significantly increased knowledge of postpartum/postnatal care, including essential newborn care, among pregnant women and recent mothers in the intervention group. Increased Use of Maternal and Newborn Care Services and Home-based Practices Significantly increased (from 5% to 13%) the proportion of births attended by an ANM among recent mothers in the intervention group. Increased the average number of deliveries per ANM based on service statistics they reported, conducting a mean of 4.6 deliveries per month over the last eight months of the project. At baseline, most ANMs in the study area did not conduct any deliveries. Increased numbers of institutional deliveries by encouraging ACCESS-trained ANMs to conduct deliveries at health subcenters so mothers could access Mukhya Mantri Janani Sishu Swasthya Aviyan 51 benefits. Significantly improved the practice of BP/CR during pregnancy, and the practice of essential newborn care among pregnant women and recent mothers: Fewer pregnant women decided to deliver at home (94% to 76% at endline) and significantly more had set aside funds for delivery (17% to 32% at endline) among the intervention group. No significant changes were seen in the comparison group for BP/CR practices. 51 This is a state-sponsored National Rural Health Mission maternity incentive scheme similar to the national Janani Suraksha Yojana that pays women who deliver in facilities. ACCESS End of Project Report: Country Brief, India 79

86 Statistically significant difference in the practice of clean cord care (such as using a new razor blade or blade in the delivery kit, and not applying anything to the stump) among the intervention (69%) and comparison (31%) groups of recent mothers surveyed. (See Figure 18.) Statistically significant difference in the proportion of the recent mothers in the intervention group (77%) who reported that the newborn was dried and wrapped but not bathed compared with the comparison group (50%). (See Figure 19.) From project monitoring data, 99% of newborns delivered by ANMs in the experimental group received the three key newborn care components (i.e., immediate drying and wrapping, clean cord care, breastfeeding within one hour). Figure 18: Births with Clean Cord Care Figure 19: Newborns Who Were Dried and Wrapped But not Bathed after Birth % of Births Baseline Endline % Newborns Baseline Endline Intervention Group Comparison Group Intervention Group Comparison Group Increased Quality of Maternal and Newborn Care Services Introduced and increased partograph use by ANMs in the intervention group over three-quarters (in a nine-month period) up to 25%. Increased AMTSL practice among ANMs in the intervention group. (See Figure 20.) Service statistics showed that AMTSL was provided by these ANMs for 97% of deliveries they attended in the same nine-month period (July 2007 through March 2008). Prior to training, AMTSL was not practiced by ANMs in the study area. Significantly higher reported practice of newborn resuscitation among ANMs in the intervention group as opposed to the comparison group. (See Figure 21.) Woman and baby, India 80 ACCESS End of Project Report: Country Brief, India

87 Figure 20: AMTSL and Partograph Use among Women who Gave Birth and Were Attended by Trained ANMs Figure 21: Reported Practice of Newborn Resuscitation % of Women st Qtr 2nd Qtr 3rd Qtr % of ANMs st Qtr 2nd Qtr 3rd Qtr AMTSL Partograph Intervention Group Comparison Group Increased Capacity of the Indian Nursing Council and National Auxiliary Nurse-Midwives Educational System to Produce SBAs Expanded perspective on the role of INC and selected nodal centers of education to lead a process of reform of the ANM education system. Developed a strategic plan with INC to establish national- and state-level resource centers to support improved capacity of ANM training centers at the district level. Supported INC to develop a network of nursing/midwifery education institutions across India. LESSONS LEARNED AND SUSTAINABILITY There were important lessons learned that are relevant to national SBA policies and programs: Because ANMs are generally not positioned as midwives and are not very skilled in delivery care, they required substantial refresher training to develop all the necessary skills to provide normal MNC including recognition, management and referral of complications. All project-trained ANMs achieved competency, but the full 12 weeks was required to master all skills. The overall health care system needs to be strengthened to ensure that providers have the infrastructure, equipment, supplies and supervision they need to provide high-quality MNC services particularly referral to comprehensive EmONC services. The project demonstrated that ANMs can provide community midwifery care with proper training, support, a well-equipped environment and connections to the communities they serve. Informed and mobilized communities seek and use MNC services. Community mobilization activities were essential to help women, families and communities understand the importance of skilled care and know where to seek services. Villages mobilized to organize emergency transport systems, save funds for emergencies through the mahila mandals, and sought MNC from trained ANMs and/or facilities. Once communities were aware and wanted MNC services, accessibility to skilled care was important. Communities need MNC advocates to connect them to available services. ACCESS supported those who worked closely with the communities, trained ANMs and health facilities. With training, sahiyaas and anganwadi workers could play this role. ACCESS, in its work with the INC, planned for long-term sustainability and impact on ANM education through the development of a pre-service education regulatory and quality improvement system. Built on the experiences and lessons learned from Dumka, this system incorporated the resources and the long-term goals of the INC, and has the potential to be catalytic in producing fundamental change in the approach to nursing ACCESS End of Project Report: Country Brief, India 81

88 and midwifery education across the country. It is anticipated that the resources from USAID used strategically to guide INC will leverage INC and other donor funds and create a new pathway for excellence in pre-service education. 82 ACCESS End of Project Report: Country Brief, India

89 KENYA Improved Maternal, Newborn and Women s Health through Increased Access to Evidence-based Interventions INTRODUCTION Although Kenya is seen as an example among African countries of rapid progress in health, increases in total fertility and maternal and infant mortality as well as the HIV/AIDS burden and weak health systems are complicating the situation. At the request of USAID, ACCESS worked with the Kenyan Ministry of Health (MOH) to adopt and adapt cutting edge technical innovations to address health promotion and disease prevention and treatment. In addition, the Program prepared state-of-theart, standardized learning materials; developed national- and provincial-level resource persons; and provided technical assistance to implement these innovations through the AIDS, Population, Health Integrated Assistance Program 52 (APHIA II) structure. PROGRAM OBJECTIVES In 2005, ACCESS began targeting several priority technical areas in Kenya with the following objectives: 1. HIV/AIDS: a. Provide technical support to the National AIDS and STI Control Program (NASCOP) at the central level, and technical assistance for HIV testing and counseling (HTC) for 30 district hospitals across all eight provinces. b. Strengthen the Department of Reproductive Health (DRH) s leadership, supervision, coordination and oversight role for the Kenya PMTCT program. KEY INDICATORS Maternal mortality: 414 Infant mortality: 77 Contraceptive prevalence rate: 33% Antenatal care attendance: 88% KEY HIV INDICATORS (KAIS 2008): Number of people (15 64 years) living with HIV: 1.4 million Adult HIV prevalence: 7% Women ( 15 years) living with HIV: 8% compared to Men 5% Deaths due to AIDS (per year): 150,000 Source:DHS APHIA II a five-year program funded by USAID with support of the U.S. President s Emergency Plan for AIDS Relief (PEPFAR) and Population funds helps communities in Kenya s Eastern Province address health concerns by strengthening linkages between health care providers and community groups. ACCESS End of Project Report: Country Brief, Kenya 83

90 c. Help equip antiretroviral therapy (ART) service providers with knowledge and skills on family planning (FP), sexually transmitted infections (STIs) and prevention with positives (PwP). d. Introduce prevention of mother-to-child transmission of HIV-plus (PMTCT-plus) in selected hospitals. 2. Injection Safety: a. Strengthen and improve safe injection and medical waste disposal practices through training and dissemination of national injection safety and management guidelines to health workers in Nyanza and Rift Valley Provinces. 3. Maternal and Newborn Health: a. Improve knowledge and skills of service providers to prevent and manage postpartum hemorrhage (PPH). b. Improve capacity of service providers to address postpartum needs of women and their babies with an emphasis on FP. c. Integrate tuberculosis (TB) screening during antenatal care (ANC). 4. Malaria: a. Support the DRH to integrate prevention of malaria in pregnancy (MIP) services with focused antenatal care (ANC) services at two facilities and, as part of outreach efforts by community health workers (CHWs), in three malaria-endemic districts. INTERVENTIONS AND RESULTS In addition to supporting APHIA II (mandated to improve health care by scaling up evidence-based interventions at the district and community levels), ACCESS worked with the MOH to strengthen central and provincial capacity to roll out priority interventions in HIV/AIDS, reproductive health (RH), and maternal and newborn health (MNH). Key interventions and results are described below. MAJOR RESULTS Developed national guidelines for: HTC, HIV clinical mentorship, prevention of PPH, reproductive tract cancers and PMTCT standards. Trained 3,057 service providers in integrated management of adult illnesses (IMAI), PMTCT, HTC, postpartum FP and injection safety. Developed 595 trainers in clinical training skills. Trained 1,102 CHWs in infection prevention and focused ANC/MIP. Implemented PMTCT standards in eight provincial general hospitals for improved quality of PMTCT services. Developed and disseminated an FP/STI/HIV integration package. Increased Access to HTC Kenya introduced HTC services in 2001 to provide Kenyans with access to confidential services. To date, more than 900 HTC sites have been established nationwide. Since 2005, the Program provided critical support to NASCOP to introduce high-quality HTC to meet the Government of Kenya s priority of expanding access to these services through the health system. 84 ACCESS End of Project Report: Country Brief, Kenya

91 Results include: Developed 95 HTC core trainers at national and provincial levels to roll out training through APHIA II. Trained 627 providers from 73 health facilities on provider-initiated HTC who have cascaded their skills to 679 providers and oriented 409 providers. Initiated 63 new HTC sites in 15 districts. Enabled 73% of trained providers to offer HTC in nine national referral and teaching hospitals, with more than 100,000 patients tested in these facilities. Worked with NASCOP to implement activities for HTC Campaign Week, including: workplace testing, door-to-door campaigns, testing at the health facilities, Moonlight HTC (which takes place at night to reach high-risk populations such as commercial sex workers) and other outreach initiatives. Developed HTC learning resource package and a simplified and comprehensive job aid. Developed national guidelines for HTC. Expanded High-quality PMTCT Services The Program supported the DRH to strengthen its leadership, supervisory, coordination and oversight role for the Kenya PMTCT program. In particular, ACCESS supported the development of supervisors assessment tools and training packages, which include all components of maternal and child health with an emphasis on PMTCT and introduction to the quality improvement process for strengthened PMTCT services. Results include: Developed 284 PMTCT trainers. Mother and child health booklets distributed through Jhpiego s PMTCT program Trained 624 service providers in PMTCT at the provincial level. Trained 29 national- and provincial-based PMTCT managers in supportive supervision. Developed national integrated RH and HIV supportive supervision tool. Supported DRH to conduct quarterly supportive supervision visits to the provinces. Developed and implemented national PMTCT service standards in eight provincial general hospitals using the Standards-Based Management and Recognition (SBM-R) approach to quality improvement. Printed and distributed 150,000 mother and child health booklets 53 to the APHIA II programs. Improved Antiretroviral Therapy Skills In 2006, ACCESS supported the Kenyan MOH to roll out WHO s IMAI training approach to build the capacity of nurses and clinical officers to provide HIV prevention, care and treatment in first-level health facilities. During these training courses, people living with HIV/AIDS (PLWHA) are trained and used as expert patient trainers. The Program also assisted the MOH in creating training materials and developed trainers at the national and provincial levels. In Group session during IMAI training, Eldoret, Kenya 53 The mother and child health booklet is a tool developed by the MOH to track key health data during pregnancy and childhood. ACCESS End of Project Report: Country Brief, Kenya 85

92 collaboration with the APHIA II projects, these trainers have trained providers at the district level. In addition, ACCESS strived to ensure high-quality implementation and supervision of ART services, prevention with positives (PwP), and FP and STI/HIV integration, among other services. Results include: Developed and disseminated pediatric ART orientation package. Developed HIV clinical mentorship guidelines and an orientation package. Developed national FP/STI/HIV integration training package. Developing (in process) community PwP orientation package. Conducted ART training of service providers in 64 districts (38% of all districts in the country), covering a total population of 32,084,400 of which 8,609,171 are women of reproductive age (15 49). Trained 1,338 service providers in IMAI (347 trainers and 991 providers). Developed 123 PLWHAs as expert patient trainers. Developed 26 providers as HIV mentors. Trained 56 HIV managers in supportive supervision. Trained 200 providers in FP/STI/HIV integration and 570 providers in PwP. Initiated ART services at 162 sites, 70 of which included pediatric ART services. Strengthened Infection Prevention Practices in Rift Valley and Nyanza Provinces The Injection Safety/Infection Prevention Program strengthened and improved safe injection and medical waste disposal practices in 12 health facilities in Rift Valley and Nyanza Provinces, and oriented community health workers (CHWs) on infection prevention. All 12 target hospitals saw improvements in waste management, with New Nyanza Provincial General Hospital in particular demonstrating exceptional results. Some facilities bought protective gear for their waste handlers, trained them on care of accidental injuries, and fenced off the waste disposal areas. Notable in these health facility units was the formation of functional Infection Prevention Control Committees, and the availability of infection prevention IEC materials, national guidelines and injection safety procedures. The CHWs continued educating their communities on infection prevention, some positively influencing those communities without tapped water to improvise with running handwashing buckets that hang from trees. In Baringo District, communities were mobilized to construct toilets. Increased Capacity of the Department of Reproductive Health The Program supported the DRH to strengthen its in-house capacity and address the MOH s priority RH issues. Key areas of support included: 1) improved FP through the Implementing Best Practices program; 2) expanded knowledge base through RH technical updates; 3) improved quality of RH services through the development of trainers and supervisors; 4) strengthened capacity to deliver high-quality services targeting reproductive tract cancers; and 5) improved capacity to provide post-rape care services. Results include: Developed national reproductive tract cancer (including breast and prostate cancers) guidelines and training materials. Developed training package for community-based distribution of Depo-Provera. Procured and disseminated three cryotherapy machines to selected referral hospitals. Procured 25 sets of anatomic models to strengthen RH training capacity for selected national training sites. 86 ACCESS End of Project Report: Country Brief, Kenya

93 Oriented 19 DRH staff and provincial RH coordinators on care and use of anatomical models. Oriented 19 DRH managers and officers to the concepts of post-rape trauma counseling. Provided three technical updates on MIP, PMTCT and prevention of postpartum hemorrhage (PPH). Trained 62 providers in cervical cancer screening and pre-eclampsia. Trained 37 providers on comprehensive management for survivors of sexual violence. Supported DRH meetings for technical working groups in RH, FP and adolescent RH. Strengthened Prevention of PPH Skills Prevention of PPH efforts aimed to institutionalize active management of the third stage of labor (AMTSL) throughout the country. Results include: Developed 16 national trainers in AMTSL. Oriented 41 providers from APHIA II Eastern and Western districts on AMTSL. Strengthened AMTSL skills of 14 providers. Mother and baby, Kenya Developed reference manual for prevention of PPH. Established Kenyatta National Hospital as a center of excellence for AMTSL. Integrated Tuberculosis Screening During Antenatal Care In collaboration with the DRH and the Division of Leprosy TB and Lung Disease, the ACCESS strengthened and integrated TB screening, referral, diagnosis and treatment for pregnant women with focused ANC (FANC) services the only ACCESS country to do so. Building on prior DRH efforts to scale up FANC service delivery, this project aimed to: 1) improve service delivery for ANC clients; 2) improve service provider knowledge and skills to effectively screen, refer, diagnose and treat TB and ANC patients; and 3) strengthen linkages between the national TB Division and the DRH. Results include: Developed an orientation package for FANC, including MIP, PMTCT and TB. Trained 50 service providers and 30 supervisors from four pilot sites. Increased screening of new ANC attended from 0.4% to 91% during the intervention period. Improved Prevention and Control of Malaria in Pregnancy ACCESS supported the DRH in integrating the prevention of MIP with FANC services and provision of outreach services by CHWs in three malaria-endemic districts. CHWs promoted community awareness on MIP and the link with comprehensive RH services. Results include: Developed RH community orientation package for service providers and CHWs. Trained 497 CHWs and 135 service providers in three malaria-endemic districts. Based on the service providers trained and communities sensitized by ACCESS in Asembo, the CDC conducted an evaluation of MIP. Results showed increased uptake of intermittent preventive treatment ACCESS End of Project Report: Country Brief, Kenya 87

94 during pregnancy (IPTp) in the intervention district (Asembo) compared with the control district (Gem). 54 In 2004, Kenya changed its case management policy from sulfadoxine-pyrimethamine (SP) to the current first-line treatment with artemisinin-based combination therapy (ACT). ACCESS worked with the MOH Division of Malaria Control to roll out the policy change in Coast Province. Results include: Developed orientation package for service providers on ACT and received MOH endorsement. Oriented 965 providers and supervisors from Coast Province on ACT, quinine, laboratory diagnosis and MIP/IPTp. Strengthened Postnatal Care and Family Planning Services ACCESS took advantage of the skills and resources available through the global ACCESS-FP program to improve postpartum FP services. Working with the DRH, the Program strengthened existing postnatal programs by increasing the number, timing and context of the postnatal consultations that women and their newborns receive. Results include: Purchased and distributed postpartum intrauterine contraceptive device (IUCD) instruments to one provincial hospital, one subdistrict hospital and six health centers. Trained 106 providers in postpartum FP and postpartum IUCD use. Inserted 402 postpartum IUCDs in target facilities in a one-year period. Printed 300 copies of the training manual and 100 copies of MOH postnatal care register. Distributed FP handbook and charts to 20 sites in Embu District Mother and baby, Kenya in Eastern Province. Developed postnatal care learning resource packages (trainer, participant and reference manual) and a brochure. Conducted needs assessment of postpartum, long-acting and permanent methods (PPLAPM) at Embu Provincial General Hospital. Held advocacy meeting on PPLAPM with 18 members of the Embu Provincial General Hospital Management Team to establish a PPLAPM Center of Excellence at the facility. Formed a RH team at Embu Provincial General Hospital to address RH issues. Pre-tested postpartum IUCD standards. LESSONS LEARNED AND SUSTAINABILITY Through advocacy, development of guidelines and training materials, and provision of financial and technical support, ACCESS demonstrated that working at the central level is vital for the introduction and scale-up of high-impact interventions at the peripheral levels. Policies, standards and guidelines were essential for coverage and standardization, as was MOH approval. These factors and its advocacy efforts enabled 54 Ouma et al. TMIH ACCESS End of Project Report: Country Brief, Kenya

95 ACCESS to successfully support MOH efforts to create a strong human resources base and develop tools to support expansion of high-quality health care services. The development of a critical pool of trainers, supervisors and champions at national and provincial levels supports continued scale-up of high-quality implementation of key interventions for RH/HIV services throughout the country. ACCESS End of Project Report: Country Brief, Kenya 89

96 90 ACCESS End of Project Report: Country Brief, Kenya

97 MALAWI Increased Access to High-quality Maternal and Newborn Health Care Services in Facilities and Communities INTRODUCTION With funding from USAID Malawi, ACCESS improved the availability of and access to MNH services by supporting MOH and USAID efforts to increase utilization of these services and the practice of Coverage of ACCESS programs in Malawi healthy behaviors. Working in collaboration with its partners 55 at the community level and with facilities in all 28 districts, the Program worked on a national scale to improve the quality of RH services including infection prevention and control (IPC) practices, basic emergency obstetric and newborn care (BEmONC) and malaria in pregnancy (MIP) services. ACCESS also worked in three focus districts Machinga, Nkhotakota and Rumphi to increase the utilization and quality of MNH services by: Implementing services along the householdto-hospital continuum of care (HHCC); Introducing KMC at referral hospitals and selected health centers; Supporting quality improvement at the hospital and health center level; Championing community-based MNH services; Facilitating community mobilization; and Raising demand for high-quality, facilitybased MNH services. PROGRAM STRATEGIES AND INTERVENTIONS Creating Enabling Environment In collaboration with the Reproductive Health Unit (RHU) of the MOH, ACCESS supported the development of national standards integrating IPC and RH, including PMTCT, for application at both hospital and health center levels. With the RHU and the Nurses and Midwives Council of Malawi (NMCM), the Program improved the national capacity to train skilled providers in MIP, PQI/IP was implemented in all districts KEY INDICATORS Maternal mortality ratio: 807/100,000 live births Infant mortality rate: 72/1,000 live births Neonatal mortality rate: 33/1,000 live births Contraceptive prevalence rate: 41% Delivery with skilled attendant: 54% Tested for HIV during ANC visit: 27% Source: MICS The MOH s Reproductive Health Unit and National Malaria Control Program, the Nursing Directorate of the MOH, the Nurses and Midwives Council of Malawi, and all 13 of Malawi s nurse-midwife technician training institutions. ACCESS End of Project Report: Country Brief, Malawi 91

98 BEmONC by revising the midwifery syllabus and core curriculum, updating tutors and preceptors in BEmONC and clinical training skills, and strengthening clinical training sites. The Program collaborated with UNICEF and Saving Newborn Lives to develop the national community MNH package and community mobilization training manual. Working with the NMCM and PMI, the Program revised and printed gestational wheels and other job aids to support prevention of MIP. At the district level, ACCESS liaised with district health management teams (DHMTs) to advocate for the support of essential MNH, Infection prevention recognition ceremony, Malawi both through regular supervision of MNH activities and inclusion in the District Implementation Plan. Finally, through its work with the White Ribbon Alliance (WRA), the Program continued advocating for improved MNH services at the national level. Improving Quality of MNH Services Using PQI ACCESS worked with health facilities in all 28 districts in Malawi to increase the availability and quality of MNH services. In collaboration with the RHU, the National Quality Assurance Technical Working Group and health facility staff, the Program provided support to 16 of 28 district hospitals and all four central hospitals in implementing quality improvement for RH. Additionally, the Program provided support to 25 of 28 district hospitals, all four central hospitals and seven Christian Health Association of Malawi hospitals in supporting a previously introduced quality improvement for IPC initiative. Moreover, the Program has worked with all 28 district hospitals to improve uptake of IPTp to prevent MIP. At the request of the MOH, ACCESS targeted a total of 12 health centers in the three focus districts approximately 33% of the MOH health centers in each district to implement a quality improvement process that integrates RH with IP. To increase the evidence-based services available to pregnant women and newborns, the Program also trained providers in the targeted facilities in BEmONC, and introduced KMC to 10 targeted health facilities including each of the referral hospitals in the three districts. Mobilizing Community to Improve MNH ACCESS trained all health surveillance assistants (HSAs) linked to the nine target health centers in three focus districts. They were trained in the complete Maternal, Newborn and Child Health-Community Mobilization (MNCH-CM) model to deliver essential MNH messages and enhance preventive care before, during and after childbirth, and to promote the use of health care when necessary. The same HSAs also received community mobilization training to enable them to better engage community members in defining and addressing local MNH challenges in partnership with the health system. The Program s community interventions brought basic MNH services closer to families and raised awareness and demand for highquality, facility-based MNH services. Integrated PMTCT-MNCH Pilot Based on the initial success of the HHCC model in the three focus districts, ACCESS in collaboration with BASICS and PSI, designed a pilot initiative to strengthen and integrate PMTCT services within a specific package of activities. This integrated package which included PQI, IPC/RH, BEmONC and MNCH was introduced in Phalombe in 2008, targeting three additional health facilities. As the PQI intervention was 92 ACCESS End of Project Report: Country Brief, Malawi

99 introduced, ACCESS updated providers from those facilities on BEmONC to ensure that staff had the necessary skills to meet the PQI standards. Building on the PMTCT component, partners were able to show the importance of identifying and linking HIV-positive pregnant women to care and treatment during ANC and managing them throughout their pregnancy, delivery and postpartum care in order to successfully link the mother and newborn to care and treatment. RESULTS Pre-service Training In addition to the Program s major results (see box above), ACCESS trained 31 midwifery tutors and 27 preceptors in BEmONC, representing all 13 midwifery training schools. Twenty tutors and two preceptors subsequently attended a clinical training skills course to improve their capacity to transfer knowledge and National MAJOR RESULTS PQI process adopted by the MOH with a functioning recognition system and performance standards for use at hospital and health centers. Implementation of the PQI/RH process at 100% of the central hospitals and 61% of the district hospitals. Community MNH and community mobilization guidelines and training materials adopted by the MOH/RHU to use in training HSAs to deliver basic MNH services in the community and to facilitate community mobilization. MOH/RHU adopted ACCESS s three-week, competency-based BEmONC and postabortion care (PAC) training model as Malawi s pre-service and in-service training approach. NMCM-revised syllabus for BEmONC pre-service and in-service training used to inform a standard core curriculum for BEmONC training courses and also being used by 100% of Malawi s midwifery training schools. PAC training materials adapted, printed and used by MOH for ongoing PAC training courses. Gestational wheels and other MIP prevention job aids were adapted, printed and disseminated to all 28 districts. Three Focus Districts Functioning HHCC established that includes: PQI/RH and IPC in the district hospital and 33% of MOH health centers in each district that provide services to 81,000 women of reproductive age in those districts. KMC services established in 33% of MOH health facilities in each district. Service providers in target facilities trained in BEmONC and the provision of high-quality services. HSAs delivering community-based MNH services. One Focus District: PMTCT-MNCH Integration Pilot. Integration of PMTCT along HHCC in Phalombe in collaboration with BASICS and PSI practice. The MOH/RHU recognized ACCESS continued leadership in BEmONC training by requesting ACCESS to facilitate two non-usaid-funded BEmONC training courses that included an additional 20 tutors and 19 preceptors. At the facility level, ACCESS supported BEmONC training courses for the 12 target health centers and hospitals in the focus districts, training 76 service providers, representing 96% of providers in the target facilities. ACCESS End of Project Report: Country Brief, Malawi 93

100 Malaria in Pregnancy Supported by PMI, ACCESS collaborated with NMCP to strengthen MIP prevention services in health facilities providing ANC services in all 28 districts. Working through the DHMTs, the Program trained 680 service providers in FANC and MIP, provided necessary supplies for facilities to implement directly observed therapy for taking IPTp, and developed job aids to improve IPTp uptake. Through collaboration with key stakeholders, the Program revised gestational wheels for use in ANC to include key MNH messages for pregnant women, and printed and disseminated the gestational wheels to all health facilities countrywide. Performance and Quality Improvement Figure 22: Percentage of RH Standards Achieved by Facilities Pre- and Post-PQI Interventions Percentage (%) Machinga Mchinji Rumphi Mwanza Karonga Chiradzulu ACCESS supported 16 of 28 district hospitals and all four central hospitals in implementing PQI in RH. Six facilities were introduced to the process in January 2008 and have made marked improvements, with three hospitals achieving nearly 80% of performance standards in August In July 2009, following the third internal assessment that showed significant improvements, Mchinji District Hospital was the first hospital to receive recognition in RH by scoring 89% on the external verification assessment. Figure 23: Percentage of selected RH areas achieved by Mchinji District Hospital Pre- and Post-PQI Baseline Jan 08 1st Assess. April 08 2nd Assess. Aug Baseline Feb 08 1st Assess. Apr 08 2nd Assess. Aug 08 Ext. Verification 0 Antenatal Care Labor & Delivery (Normal) Labor & Delivery (Abnormal) Postnatal care Family Planning (follow up) Post Abortion Care Management Impact on RH service provision and outcomes on improved MNH are beginning to emerge based on routine service statistics gathered at the facility level. Preliminary analysis from a 2009 evaluation on PQI showed a dramatic difference in the rate of cesarean sections at RH sites compared to the control, with cesarean sections increasing rapidly since the introduction of PQI RH across all intervention facilities (Figure 24). The 94 ACCESS End of Project Report: Country Brief, Malawi

101 increasing trend indicates that providers are able to readily identify emergency obstetric complications, refer, and conduct timely the cesarean sections to avoid obstetric complications. Figure 24: Service Statistics from Malawi SBM-R Evaluation: Cesarean Sections Increased More in Intervention Group Cesarean Sections in Malawi January- March April-June July- September October- December January- March April-June July- September October- December January- March April-June July- September October- December January- March April-June July- September October- December January- March Number of c-sections April-June July- September October- December RH PQI intervention began Control Sites Intervention Sites Kangaroo Mother Care The MOH adopted the Ambulatory and Community KMC protocols for Malawi for national use. ACCESS also established KMC services at 33% of the MOH facilities in three focus districts, and trained 47 providers in KMC to date. Additional Results ACCESS trained 161 HSAs and 25 HSA supervisors from three focus districts in community MNH, and 121 HSAs and 17 supervisors in community mobilization. These HSAs are delivering home-based services to approximately 81,000 women of reproductive age in their coverage area of approximately 221,308 women of reproductive age, and have mobilized 60 community groups consisting of men and women to address local MNH issues. Based on cumulative data from the Program ( ), approximately 65% of pregnant women were identified in the HSA catchment area and, of the home visits conducted, 6.9% were conducted during the first trimester, and 42.1% and 19.1% during the second and third trimester, respectively. During their pregnancies, 63% of women were counseled on FP, and 76.7% prepared a birth plan. Postnatally, 71.7% delivered with a SBA and 77.1% of mothers and newborns were visited within 72 hours of delivery (regardless of place of delivery). During these visits, the HSAs screened for danger signs using job aids; provided health education to the mother, spouse and significant others; encouraged the mother to attend health facility services; and referred to a health facility if any danger signs were identified. Identified danger signs for mothers included body pain (32.0%), fever (9.2%), stomach pains (4.8%), dizziness (3.9%) and vaginal bleeding (3.5%). Approximately 9.5% newborns had danger signs, including 2.9% with LBW. All babies with danger signs were referred. During the postpartum visits, 85.6% of women were counseled on FP. LESSONS LEARNED Host country government ownership of PQI promotes sustained improvements in quality of services. The MOH/RHU and National Quality Assurance Technical Working Group showed ACCESS End of Project Report: Country Brief, Malawi 95

102 incredible support for the PQI process and continue to advocate for quality improvement at facilities. To realize meaningful change at the facility level, district health officers and nursing officers must support the PQI initiative in their facilities. Ownership and support of the process, demonstrated by functional, districtlevel recognition systems, is vital to achieving and sustaining quality improvements. Co-workers attitudes can impede providers from applying newly acquired skills. ACCESStrained providers in a few facilities reported that peers who had not yet received training had negative attitudes toward them, which impeded their full implementation of newly gained concepts and skills. The Program will continue dialogue with the DHMTs to facilitate support to these providers. Facility efforts to achieve RH/IPC standards can be hampered by high turnover and inadequate supervision. Many facilities had not been recognized as achieving excellence in IPC and RH standards through the PQI initiative. A common challenge these facilities faced is frequent turnover of district health officers, who create the enabling environment for the PQI process to take hold. Without consistent DHMT support and supervision, members of the Quality Improvement Support Teams cannot ensure adherence to the performance standards in daily work, and facilities must spend valuable time training new staff, instead of working to implement standards. To address this challenge, ACCESS made frequent visits to district hospitals to ensure that the process has not been adversely affected by changes in senior management. Inadequate supplies and lack of essential RH drugs at Central Medical Stores also negatively affect adherence to RH standards. The next generation of health professionals, Malawi Involving husbands and fathers in MNH produces positive results. Pregnancy and childbirth are often considered women s issues in communities. However, recent experience involving men in problemsolving related to these issues showed that they can make a positive difference quickly. HSAs reported that men who had been involved in MNH-focused community groups and/or household counseling were very supportive, welcoming the opportunity to learn how to help their wives. MNH-trained HSAs are highly valued in the community. HSAs received a 10-day training to prepare them to make home visits to pregnant women during the antenatal period and during the first week postpartum. Families appreciated the HSAs home counseling efforts, and HSAs welcomed the new skills and knowledge as it makes a visible difference in MNH service use and outcomes. WAY FORWARD The Maternal and Child Health Integration Program (MCHIP) started in Malawi in October 2009 and continues to support these interventions. MCHIP will use the lessons learned under ACCESS to improve and streamline the HHCC interventions and make them appropriate to scale up at a national level. MCHIP is actively engaged with other MNCH stakeholders in Malawi to bring these important interventions to scale. 96 ACCESS End of Project Report: Country Brief, Malawi

103 NEPAL Improving Maternal and Newborn Health in Partnership with the Government of Nepal INTRODUCTION Nepal is making considerable progress toward achieving its Millennium Development Goals (MDGs) for child and maternal health. Between 1996 and 2006, the maternal mortality ratio dropped from 539 to 281 deaths per 100,000 live births, the infant mortality rate declined from 64 to 48 deaths per 1,000 live births, and neonatal mortality decreased from 39 to 33 per 1,000 live births. 56 To further improve MNH, Nepal is now focused on increasing skilled attendance at birth. With 80% of Nepal s population living in rural areas amid challenging topography, most women still deliver at home and without the care of a skilled health care provider. When the ACCESS Program began, just 10.9% of women in Nepal had been delivered with a health professional (doctor or nurse-midwife) and only 9% in a health facility. 57 And while remarkable reductions in child mortality rates have occurred in the country over the last decade, an estimated 32,000 children still die each year during their first month of life with more than two-thirds not surviving their first week. PROGRAM STRATEGIES AND INTERVENTIONS At the request of USAID, ACCESS worked in partnership with the Government of Nepal (GoN) to contribute to MNH initiatives that focused on: Increasing skilled attendance at birth; Identifying and piloting new interventions to address leading causes of mortality with simple, low-cost approaches aimed at public health impact; and Exploring key programmatic and policy issues to inform national MNH strategies. The Program rolled out planned interventions in collaboration with the Family Health Division (FHD), Child Health Division (CHD), the National Health Training Center (NHTC), the Nepal Family Health Program II (NFHP II), Support to Safe Motherhood Program (SSMP), Plan International, Nepal Society of Obstetricians and Gynecologists (NESOG) and other stakeholders. KEY INDICATORS Maternal mortality ratio: 281/100,000 live births Infant mortality rate: 48/1,000 live births Under-five mortality rate: 61/1,000 Births with skilled provider: <20% ANC: 44% receive ANC from SBA Total fertility rate: 3.1 Contraceptive prevalence: 44% (modern methods), 48% (all methods Source: DHS Demographic and Health Surveys from 1996 and Nepal Demographic and Health Survey ACCESS End of Project Report: Country Brief, Nepal 97

104 RESULTS Increasing Skilled Attendance at Birth Increased Provider Capacity to Provide Skilled Attendance at Birth In support of the National Skilled Birth Attendants Policy (2006), ACCESS in collaboration with FHD developed the Maternal and Newborn Care (MNC) Learning Resource Package (LRP) with active participation from clinical trainers and key stakeholders. After field-testing and endorsement by the GoN in 2007, the MNC LRP became the national standard for all SBA training. NHTC received 400 copies from ACCESS in 2007 and reproduced hundreds more with other donor funding. To date, more than 1,000 health care providers have been trained in skilled birth attendance using the MNC LRP. Assessed, Improved and Maintained the Quality of SBA In-service Training Sites To assess, strengthen and monitor the quality of training sites, ACCESS, with participation from a variety of stakeholders, supported the NHTC to develop SBA in-service training site quality improvement tools. These tools include 201 standards and cover nine clinical areas and three training-related areas. After an orientation to the tools and process, participants at 10 sites assessed their performance, identified gaps and worked to make improvements. NHTC continues to use the quality improvement tools which are now available in Nepal in 15 sites. As of September 2009, 12 sites had achieved 80% (or more) of standards. Identifying and Piloting New Interventions to Address Leading Causes of Mortality with Simple, Low-cost Approaches Aimed at Public Health Impact Developed and Tested a Community Strategy to Prevent PPH Using Misoprostol Because postpartum hemorrhage (PPH) is the leading cause of maternal mortality, ACCESS, FHD, NFHP II and development partners piloted a community-based intervention to prevent PPH among women who do not seek skilled birth attendance during delivery. Female community health volunteers (FCHVs) provided women with misoprostol to be taken immediately after delivery as well as the necessary counseling and instructions on appropriate use and potential side effects. The pilot demonstrated that pregnant women can safely and effectively take misoprostol and be protected from PPH (see Table 10). In total, 73% of women who received misoprostol took it, and an additional 21% did not take it but received protection from PPH through other means. 58 Moreover, neonatal mortality was significantly reduced, and the evidence suggested that maternal mortality also decreased. In , FHD is planning to scale up PPH prevention using misoprostol as part of its remote areas strategy, targeting women who still have limited access to skilled care. Table 10: Women s Use of Misoprostol and Their Protection Status from PPH, among Misoprostol Recipients NOT PROTECTED FROM PPH PROTECTED FROM PPH TOTAL Received misoprostol and took it 0 (0%) 447(73%) 447(73%) Received misoprostol and did not take it 36 (6%) 132 (21%) 168(27%) Total 36 (6%) 579 (94%) 615 (100%) 58 In this project, a woman was considered to be protected from PPH if she meet one or more of the following criteria: 1) took misoprostol correctly; 2) delivered in the presence of a SBA; 3) received an injection in the thigh or buttocks immediately after delivery (presumed to be oxytocin); and/or 4) delivered in a health facility (hospital, primary health care center or health post). 98 ACCESS End of Project Report: Country Brief, Nepal

105 Demonstrated the Feasibility of Community-based Management of Low Birth Weight (LBW) Infants ACCESS with FHD, NFHP II and the District Public Health Office trained 220 female community health volunteers (FCHVs) to identify LBW babies using weighing scales, manage their care and educate their mothers on how to practice KMC at home in Kanchanpur District. Key findings from the pilot include: FCHVs are capable of identifying LBW and very LBW infants, and providing homebased counseling about exclusive breastfeeding, prevention from infection and KMC. They identified 980 infants as LBW or very LBW (17% of 5,865 live births registered in the FCHV registers). FCHVs provided early postnatal care (PNC) to mothers and their infants, reaching % of mothers and newborns each quarter with an average of more than four PNC visits. More than 70% of mothers with LBW newborns practiced KMC by the end of the project period. Figure 25. Percentage of LBW Neonates Who Received PNC Visits from FBW/FCHVs by Quarter FCHVs were able to identify danger signs among LBW infants: 14% of the 980 LBW neonates were identified as experiencing a danger sign and referred to a health facility. FCHVs were effective in performing the five essential newborn care skills: counseling, weighing, temperature taking, recordkeeping and KMC. By the project s end, FCHVs correctly performed each of the five skills at the desired competency level of 85%. Based upon the findings of this community intervention, ACCESS provided technical assistance to the CHD to develop National LBW Neonate Management and Implementation Guidelines in line with the National Neonatal Health Strategy of Improved Management of LBW Newborns at Facilities Using KMC To support LBW referrals, ACCESS introduced facility-based KMC services at two zonal hospitals and three primary health care centers, 59 and supported the integration of KMC with newborn care services. As a result, 53 LBW newborns (including several sets of twins) among 610 deliveries were managed with KMC from June to November 2007 at Mahakali Zonal Hospital. At Seti Zonal Hospital, 56 LBW newborns (including twins) received KMC from a total of 1,173 deliveries from July to November And at the three primary health care centers, KMC services were provided for six of seven LBW newborns from a total of 114 deliveries in two months. Father doing Kangaroo Mother Care, Nepal 59 The health facilities included Seti Zonal Hospital Kailali, Mahakali Zonal Hospital Kanchanpur, and three primary health care centers in Kanchanpur District. ACCESS End of Project Report: Country Brief, Nepal 99

106 Designed and Initiated a Community-level Intervention to Prevent Pre-eclampsia/Eclampsia (PE/E) Based on the WHO recommendation that calcium intake during pregnancy reduces the risk of PE/E by 67%, 60 ACCESS worked in collaboration with FHD and NFHP II to develop a PE/E prevention pilot of calcium supplementation to pregnant women. FCHVs distribute a three-month supply of calcium and educate pregnant women and their families (see Figure 14) about the dangers of PE/E, a leading cause of maternal mortality. A small-scale acceptability study comparing tablet and powder forms of calcium was started and will be continued under MCHIP. Plan International donated calcium tablets, and Jhpiego provided calcium powder in sachets. The study findings will inform a larger, district-wide pilot to assess the feasibility, acceptability and programmatic effort required to achieve high-level coverage with calcium supplementation during pregnancy. Improved Management of PE/E at the Facility Level ACCESS with the Nepal Society of Obstetricians and Gynecologists (NESOG) promoted and strengthened the use of magnesium sulphate and institutionalized this best practice in 22 health facilities. ACCESS worked with a NESOG team to develop standards, an inservice orientation package and job aids. The NESOG team then provided on-site orientations, support and coaching to service providers during several visits to each facility. Results showed that facilities can manage PE/E appropriately with support with average scores increasing from 26% at baseline to 60%. By the end, 11 of the 22 facilities (50%) were performing at 80% or higher. Figure 26: Information for Women and their Families on the Importance of Calcium during Pregnancy Exploring Key Programmatic and Policy Issues to Inform National MNH strategies Reviewed and Recommended Options for Increasing Skilled Attendance at the Community Level At USAID s request in 2005, ACCESS reviewed how best to operationalize the National Policy on Skilled Birth Attendants to increase skilled birth attendance at the community level in Nepal. ACCESS primarily recommended strengthening auxiliary nursemidwife (ANM) training and adding a supplementary training package to ensure that graduate ANMs assigned to community posts have the requisite skills. Only those ANMs who were prepared to work at the community level could enter this post-graduate training to obtain the SBA skills that are not included in the ANM curriculum. The report was shared with GoN and development partners to help inform national nursing training and education discussions. Identified Key Factors that Support Use of Skilled Birth Attendance in Nepal ACCESS and FHD conducted a study identifying the key factors that contribute to successful utilization of SBA services. The study found that most women preferred and planned a home delivery, and sought care at the facility only for complications. Facilities associated with a high volume of delivery services include: 24/7 services and availability of BEmONC; easy geographic access; three or more trained staff available in primary health care centers; a referral system and/or ambulance on site; dynamic leadership of the facility; energetic community collaboration; and employment of local personnel. GoN shared availability of maternal and 60 Hofmeyr GJ, Atallah AN, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems (Cochrane Review). In: The Cochrane Library, Issue 4, Chichester, UK: John Wiley & Sons, Ltd. 100 ACCESS End of Project Report: Country Brief, Nepal

107 neonatal 24/7 services from this study at the Scaling-up FP/MNCH Best Practices in Asia and the Near East Technical Meeting in Identified Reasons for Maternal Mortality and Morbidity Reduction In , USAID and SSMP supported FHD to design and conduct a Maternal Mortality and Morbidity Study in eight districts to prioritize interventions and approaches to address the leading causes of maternal mortality with a strong focus on community deaths. ACCESS supported the Technical Advisory Group and a number of implementation activities for the study. The study found a decreasing trend in MMR that is on track to meet the MDGs, as well as a decrease in death due to maternal causes among women of reproductive age. While the percentage of maternal deaths caused by eclampsia, abortion-related complications, gastroenteritis and anemia have increased, maternal deaths from obstructed labor and puerperal sepsis have more than halved since a similar study was conducted in LESSONS LEARNED AND SUSTAINABILITY ACCESS in its work with GoN found the partnership effective in identifying and conducting a number of pilot interventions and studies that contributed directly to national policies, programs and guidelines. For example, based upon the LBW and KMC project results, GoN developed and approved the Implementation Guidelines for the Low Birth Weight Neonate Care. GoN leadership fostered and demonstrated innovation such as piloting misoprostol for PPH prevention for home deliveries. High levels of government commitment also led to scaling up of proven interventions, as illustrated by LBW neonate care and management now being provided by FCHVs in 10 districts. Based on a number of these successful community-based pilots, GoN has the opportunity to combine them into an integrated community-based maternal and neonatal care package. ACCESS also found its technical assistance was most effective when collaboration with GoN and external development partners worked well to support a national strategy or priority. For example, the MNC LRP and quality improvement tools developed through a participatory process with government and stakeholders have been institutionalized by government systems that will continue to train thousands of health care providers as SBAs. As a result of ACCESS-supported activities, quality improvement in MNH services was measurable and evident at SBA training sites and other health facilities. ACCESS End of Project Report: Country Brief, Nepal 101

108 102 ACCESS End of Project Report: Country Brief, Nepal

109 NIGERIA Increased Use of High-quality Emergency Obstetric, Newborn and Family Planning Services INTRODUCTION In the northwest zone of Nigeria an area with alarmingly high maternal mortality and very low levels of skilled attendance at birth, antenatal care (ANC) attendance and contraceptive prevalence ACCESS worked with USAID funding to address some of the most dire health indicators in the country. ACCESS implemented a three-year program to increase the use and quality of emergency obstetric and newborn care (EmONC) and family planning (FP) services. To achieve these aims, ACCESS collaborated with all levels of government, initially focusing its interventions in four Local Government Authorities (LGAs) in Kano and Zamfara States. Literacy levels are low in both states, especially among women, and the region is predominantly rural and poor. KEY INDICATORS Neonatal mortality rate (10-year period): 55 (NW), 53 (all) Skilled attendance at birth: 12.3% (NW), 35.2% (all) Modern contraceptive prevalence rate: 3.3% (NW), 8.2% (all) Total fertility rate: 6.7 (NW), 5.7 (all) The program in Nigeria was designed to help reduce the high burden of maternal and neonatal mortality in Kano and Zamfara States, contributing to USAID Nigeria s Strategic Objective 17: Increased Use of Child Survival and Reproductive Health Services. In , ACCESS expanded its program to Katsina State, also in the northwest zone. At the end of the program, ACCESS was working in 22 LGAs across the three states, covering an estimated population of 4,979,149 people. PROGRAM STRATEGIES AND INTERVENTIONS The Program implemented both community- and facility-based interventions focused on ANC, safe delivery care, EmONC, postpartum care and FP including healthy timing and spacing of pregnancies. This approach, which also involved working at the policy level to improve the service delivery environment, is called the household-to-hospital continuum of care (HHCC) approach, and encourages communities and health care providers to work together and use simple, cost-effective interventions. These interventions were intended to increase the availability of skilled providers, and improve the quality, availability and demand for services. ACCESS End of Project Report: Country Brief, Nigeria 103

110 KEY PROGRAM INTERVENTIONS Develop national policies, guidelines and operational performance standards. Strengthen health systems to deliver improved services: Conduct in-service training of health care providers in EmONC, ANC and FP. Advocate for improved deployment of medical and paramedical staff to increase availability of skilled providers. Orient facility-based providers to a quality improvement approach, and apply the approach to program facilities. Rehabilitate facilities by supporting improvements in their infrastructure, supplies and equipment. Strengthen pre-service education for EmONC at two midwifery schools. Train community volunteers and community health extension workers (CHEWs) to provide counseling services during home visits to promote behavior change. RESULTS MAJOR RESULTS Developed national performance standards for EmONC for the hospital and primary health center levels and received government endorsement. Upgraded 48 health facilities in Kano and Zamfara States to provide EmONC and FP, and renovated 17 facilities. Trained/oriented more than 497 providers in EmONC and FP. Skilled providers at ACCESS-supported facilities provided antenatal services to pregnant women during 367,308 clinic visits. Skilled birth attendants/anc providers delivered 76,576 women, 95.6% of whom received active management of the third stage of labor (AMTSL). Established two functioning kangaroo mother care (KMC) centers to address low birth weight babies in Kano and Zamfara States. ACCESS succeeded in reaching thousands of women in northern Nigeria with improved ANC, delivery care, postpartum care and FP services, with increasing numbers over time, as demonstrated in Table 11 on the following page. Recordkeeping to capture this information was also improved. Group discussion session with older women, Nigeriaw 104 ACCESS End of Project Report: Country Brief, Nigeria

111 Table 11: Results for Selected USAID Operational Plan Indicators from 28 Hospitals in 22 LGAs SERVICE/ PRACTICE OUTCOME INDICATOR Q1 (Baseline) FY07 FY08 FY09 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Number of ANC visits by skilled providers in USG-assisted facilities 4,887 6,598 9,278 12, , , , , , , , ,54 3 Number of deliveries with a skilled birth attendant in USG-assisted programs ,517 3,969 3,590 5,746 6,498 6,258 7,873 10, , ,29 7 Number of women receiving AMTSL through USGsupported programs Couple years of protection in USGsupported programs N/A 37 2,240 3,950 3,590 5,268 6,137 6,258 7,305 7,474 7,478 8, ,713 2,516 2,199 2,468 3,213 3,635 3,901 4,472 3,763 3,839 It has been estimated that about 2% of expected births in the supported LGAs was by cesarean section, while 43% of labors where monitored by the use of a partograph. The ongoing endline survey will provide more information about the proportion of PE/E cases managed according to set standards. More detailed achievements are presented below by major expected program results. Improved Enabling Environment for Scale-up of EmONC Best Practices ACCESS supported the Federal Ministry of Health (FMOH) to develop national operational performance standards for EmONC in hospitals and primary health care centers and, at project end, was applying the standards in all program-supported facilities. The FMOH has directed that the performance standards be institutionalized in all tertiary health facilities in the country. The Program also developed a KMC training manual, and collaborated with the FMOH to produce the Situation Analysis and Action Plan for Newborn Health in Nigeria. Save the Children-UK (SCUK) in Nigeria is currently using the KMC training manual in its programs. Increased Availability and Capacity of EmONC and FP Health Care Workers ACCESS strengthened two EmONC facilities in Kano and Zamfara States to serve as in-service training sites. In addition to training or orienting 1,317 health care workers on EmONC and 1,250 on FP, 61 the Program also upgraded 17 facilities and developed, printed and distributed a variety of related job aids. In addition, to 61 These numbers exclude volunteers trained. See Table 14 for information on community volunteers. ACCESS End of Project Report: Country Brief, Nigeria 105

112 meet the UN standards for EmONC services, 62 ACCESS consistently advocated for rational deployment of trained skilled birth attendants to program-supported facilities in order to ensure 24-hour coverage, seven days a week. Service statistics from the ACCESS-supported sites show significant increases in the number of women receiving ANC and delivery services from skilled birth attendants. What impressed me in delivering in the hospital is the neatness and even the way they handle the baby s cord you just go home, enter your room with your baby without concerning yourself with the cleaning of all the mess that comes with delivery. Patient at ACCESS-supported facility ACCESS strengthened providers capacity in EmONC, KMC and postpartum FP. Table 12 provides an overview of all training conducted. Table 12: Health Care Providers Trained to Date TRAINEES TRAINING TOPIC TOTAL # TRAINED In-service training of physicians, nursemidwives and CHEWs Physicians and nurse/midwives Clinical training in EmONC and orientation to SBM-R Training of trainers and step-down training in KMC Nigeria Youth Service Corps, medical and paramedical staff and sociology graduates in Kano and Zamfara States Orientation to EmONC 377 Nurse-midwives and CHEWs Postpartum FP training 140 Nurse-midwives IUD and Jadelle 37 Health care providers at ACCESS-supported facilities Recordkeeping/Health Management Information System (HMIS) 144 Community volunteers: Community Core Group (CCG) members, community mobilization team members, household counselors and male motivators Maternal and newborn health and FP 524 TOTAL 1,414 Improved Quality of EmONC Services ACCESS introduced the Standards-Based Management and Recognition (SBM-R) approach for quality improvement in EmONC at 30 facilities, training providers at 15 hospitals and 15 primary health centers in its use. Follow-up assessments using the SBM-R operational standards assessment tool at 26 of these facilities revealed impressive improvements in achievement of the EmONC standards from 20% or lower at baseline to 70 90% at the second follow-up assessment (see Figures 27 and 28 below). The Program worked with facility quality improvement teams to find solutions to identified gaps in performance. 62 For a population of 500,000 inhabitants, UN standards require providers be available at a minimum of four facilities to provide 24-hour/seven-day coverage of basic EmONC services, and one facility for comprehensive EmONC. 106 ACCESS End of Project Report: Country Brief, Nigeria

113 Figure 27: Baseline and Follow-up Scores for EmONC Performance Standards at 13 ACCESSsupported Hospitals in Kano and Zamfara States Baseline 1st Follow-up 2nd Follow-up MMSH Gezawa GH Dawakin Tofa GH Kaura Namoda GH Zurmi GH KFGH Figure 28: Baseline and Follow-up Scores for EmONC Performance Standards at 13 ACCESSsupported PHCs in Kano and Zamfara States Dawanaun Babawa Shagari Dr. Karima WCWC Kurya PHC Baseline 1st Follow up 2nd Follow up Increased Demand for Maternal and Newborn Services ACCESS implemented community counseling and community mobilization activities for FP and maternal and newborn health. In the initial four program LGAs, the Program trained 38 community mobilizers as trainers in the Community Action Cycle (CAC) process. Community mobilization supervisory teams which consist of members of community development associations and religious groups, and community core groups (community volunteers) were trained by ACCESS and implemented maternal and newborn health action plans tailored to their communities needs. The activities of these teams and core groups led to the donation of ITNs, ANC drugs, water tanks, benches, mini-pharmacy shelves, bore holes and generators among other items to the facilities around which they operate. The CCG around a particular PHC identified that the issue of lack of skilled birth attendants at the PHC was the root cause of high delivery rates at home. They mobilized the services of three nurse-midwives as volunteers from within and outside the community to assist in conducting deliveries at the PHC and deliveries have been conducted there ever since. ACCESS End of Project Report: Country Brief, Nigeria 107

114 ACCESS increased the capacity of 85 women as household counselor trainers, and created and pre-tested (with women of reproductive age, husbands, older women and religious leaders) materials for use in homebased counseling. These 85 women comprise junior CHEWs and volunteers and part of their work is to refer to the KMC centers when they identify low birth weight babies in the community. The Program also initiated the Mothers Savings and Loans Clubs, which were very successful in providing alternative channels for paying for transport and health services for labor or during emergencies. In the past we refused to allow our wives to go to health facility for delivery, but this phenomenon has changed with the coming of ACCESS CCGs. Mallam Umaru Isah, Kano Improved Management of Maternal and Newborn Services ACCESS introduced KMC for care of low birth weight babies in Nigeria to great enthusiasm and interest, especially among health care workers and clients due to it being natural and practical for home use. Two KMC demonstration centers were established in Kano and Gusau, and local and national media repeatedly aired a documentary featuring the training of trainers workshop held by the Program. Results from Murtala Mohammed Specialist Hospital revealed that 157 low birth weight babies were admitted and seven died, representing a 95.5% survival and 4.5% case fatality rate. ACCESS further improved recordkeeping at target Community mobilization officer, Nigeria facilities, revising the national HMIS to track key quality indicators, including the new USAID operational plan indicators. The Program revised and distributed registers and maternity and newborn charts, and gave job aids to those providers trained in their usage. LESSONS LEARNED AND SUSTAINABILITY Stakeholder Involvement Helps Promote Scale-Up and Dissemination of Tools and Standards. ACCESS materials and approaches including the national performance standards for EmONC and a training manual for KMC were developed with multiple stakeholders and received approval at the national level. These products now have the potential for expansion beyond the Program areas. In fact, the FMOH has committed to disseminating the EmONC performance standards to all tertiary facilities in Nigeria. Similarly, through the National Primary Health Care Development Agency, the FMOH adopted most ACCESS training materials and job aids for its new Midwives Service Scheme. Political will and commitment at multiple levels is necessary in a decentralized environment. Nigeria has a strongly decentralized political structure. Within this context, the Program worked with multiple stakeholders (including community and traditional leaders) at the national, state and LGA levels to create buy-in and promote the success and sustainability of program interventions. This was a challenging effort and required a strong staff presence in the target states. ACCESS was more successful gaining political commitment at the national and state levels than at the LGA level. Many primary heath centers, which are managed by LGAs, are still not open 24 hours a day, seven days a week due to staff shortages and lack of resources to pay incentives (such as shift duty allowances to CHEWs and midwives). Community mobilization, where implemented, greatly supported primary health center-level advocacy efforts to find local resources. 108 ACCESS End of Project Report: Country Brief, Nigeria

115 Using a Systems Approach Increases ACCESS to Care. ACCESS applied the household-tohospital continuum of care (HHCC) approach in full in Nigeria, recognizing the importance of systematically addressing maternal and newborn issues of the community and facility together using evidence-based interventions. In an environment of poor service utilization for maternal care, this approach allowed the Program to address all three delays known to affect the provision and utilization of skilled care to prevent maternal deaths: delay in deciding to seek care if a complication occurs, delay in reaching care and delay in receiving care. Behavior change communication and community engagement are crucial in increasing awareness of problems and finding local solutions. The community mobilization and behavior change communication (BCC) strategy included frequent group discussions led by trained volunteers, education by household counselors and male FP motivators, and the development and distribution of information, education and communication (IEC) materials in the local Hausa language. These combined efforts and the introduction of the innovative Mothers Savings and Loans Clubs led to increased utilization of health services for antenatal and delivery care, and helped to empower women and improve their health-seeking behaviors. WAY FORWARD By making these services free, the State Ministries of Health (SMOH) have shown some commitment to maternal and newborn health. The SMOH also currently orders key emergency obstetric care drugs (such as oxytocin, misoprostol and magnesium sulphate) for use in its facilities. ACCESS-supported states have a core team of trained EmONC and FP service providers who are able to provide services wherever they are posted; and the nationally approved EmONC performance standards are now regarded as the benchmark for EmONC in the country. In total, 30 health facilities were introduced to the SBM-R process as ACCESS staff speaking at a CCG meeting, Nigeria a quality improvement approach, and SMOH staff were trained to take ownership of this process. Moreover, the fact that demand for contraceptives in the country has outstripped supply, leading to stock-outs in the FMOH Central Medical Stores, is an indication of increased use of the commodities nationwide. The 2008 Nigeria Demographic and Health Survey showed marginal increases in the use of contraceptives, fueling the hope that these efforts may be sustained beyond the tipping point for an accelerated uptake. ACCESS End of Project Report: Country Brief, Nigeria 109

116 110 ACCESS End of Project Report: Country Brief, Nigeria

117 RWANDA Improving Maternal and Newborn Health Outcomes INTRODUCTION Rwanda has some of the highest levels of maternal and newborn mortality in Africa, and a high level of fertility among households of limited resources. According to the most recent DHS (2008), the fertility of Rwandan women remains high; each woman giving birth on average to 5.5 children by the end of her reproductive life. The level of fertility is much higher among rural women (5.7) than among those in urban areas (4.7), regardless of the age group. Unmet need for FP is also high at 58%. i According to the DHS (2008), 49% of the births in the five years preceding the survey took place at home and 45% gave ACCESS Geographic and Technical Areas in Rwanda birth at a health facility, mainly a public sector facility. The incidence of home births was found to be highest among women who received no ANC (88%) and among women in households in the three lowest-wealth (poorest) quintiles (more than 52%). 63 At the request of USAID Rwanda, ACCESS introduced targeted interventions designed to bring drastic improvements within a short time frame. In 2004, ACCESS began working with Rwanda s MOH and its implementing partners to promote the adoption of best practices in FANC (including MIP) and EmONC. ACCESS initially focused its efforts in four districts, but ultimately expanded its FANC/MIP interventions to 10 additional districts. 64 In 2006, USAID requested that ACCESS carry out the Safe Birth Africa Initiative (SBAI) in Rwanda in collaboration with the major maternal and newborn health bilateral Twubekane, led by IntraHealth. The purpose of the SBAI was to achieve rapid improvement in maternal and newborn health by targeting the time when the majority of deaths occur: labor, birth and the immediate postpartum/postnatal period. PROGRAM STRATEGIES AND INTERVENTIONS ACCESS supported the scale-up of FANC/MIP and EmONC programs in Rwanda at the national/policy level KEY INDICATORS Maternal mortality: 750/100,000 live births Infant mortality: 62 deaths per 1,000 live births ANC attendance: 96% (at least one visit) Skilled attendance at birth: 52% Total fertility rate: 5.5 children per woman Proportion of households with at least one ITN: 57% Proportion of children under five years old who slept under an ITN the previous night: 58% Proportion of pregnant women who slept under an ITN the previous night: 62% 63 Rwanda Interim DHS MIP activities were field-funded; all other activities were supported by core funds. ACCESS End of Project Report: Country Brief, Rwanda 111

118 and through implementation of both facility- and community-based activities. The Program s efforts included: Increasing collaboration among key stakeholders, especially the multiple divisions of Rwanda s MOH. 65 Strengthening the clinical skills of health care providers by developing clinical training materials and providing knowledge and skills updates. Improving knowledge in communities through the development of CHW training materials and tools and provision of training. Improving the quality of MNH services by instituting supportive supervision and quality improvement systems in health care facilities. ACCESS provided technical assistance to the MOH to ensure that evidence-based information and approaches were incorporated with national policies. In close collaboration with multiple divisions of Rwanda s MOH, ACCESS provided technical assistance, both nationally and at the district level, to assist the MOH to roll out key MNH interventions. ACCESS assisted Rwanda s MOH to improve and expand the use of the partograph and AMTSL with the aim of achieving significantly increased coverage of skilled birth attendance and postpartum/postnatal care. ACCESS introduced KMC to Rwanda, provided technical and material assistance to establish a KMC Center of Excellence in Kigali, and expanded KMC to an additional five hospitals throughout the country. Photos: John Healey/jhph.com At the community level, ACCESS developed a BCC strategy that targeted providers, CHWs and community members. An ACCESSdeveloped training package for CHWs was also being used to improve their capacity to counsel women to give birth at the health facility and to practice essential household behaviors (e.g., identification of danger signs, clean cord care, immediate and exclusive breastfeeding, and thermal care/warming and drying). Work with religious leaders helped to further spread Safe Motherhood messages into the community through use of the Sermon Guide for Religious Leaders, developed with ACCESS support. ACCESS also improved demand for and quality of FANC/MIP services with PMI funding. ACCESS collaborated with the MOH s National Program to Fight against Malaria and the MOH s Maternal Health Desk to formulate clinical ANC/MIP training materials adapted to Rwanda s revised MIP policy. The new policy discontinues the use of IPTp using SP and places increased emphasis on: four ANC visits, Woman practicing KMC, Rwanda beginning in the first trimester of pregnancy; use of ITNs; distribution of iron, folate and mebendazole; and prompt case management of malaria. FANC/MIP messages have also been incorporated with the tools and materials for CHWs to address the importance of using ITNs throughout pregnancy and attending ANC early in pregnancy, in accordance with the new policy. 65 This includes the Maternal Health Desk, National Program to Fight against Malaria, Community Health Desk, Child Health Desk, Communication Center for Health, and Quality Improvement Division. 112 ACCESS End of Project Report: Country Brief, Rwanda

119 RESULTS Improved Enabling Environment for Scale-up of FANC/MIP and EmONC Best Practices KEY RESULTS 92% of hospital providers observed (n=12), practice all three steps of AMTSL as opposed to 17% at baseline (n=6). 80% of health center providers observed (n=10), correctly practiced AMTSL, compared with 21% at baseline (n=19). Providers were given 12 questions to reflect their knowledge about newborn resuscitation; at baseline, the mean score among 7 providers was 55% and at endline, the mean score among 12 providers was 89%. 100% of all providers observed (n=22) practiced clean cord care, compared with 68% at baseline (n=25). In the baseline survey, four out of six hospital providers observed used the WHO-revised partograph or other partograph and slightly over half of health center staff did as well. In the endline survey, all hospital providers and 90% of health center staff observed used a partograph to monitor labor. Through the provision of key technical support to Rwanda s MOH to update its national policy for MIP, ACCESS set the stage for large-scale MIP programming in Rwanda. With the MIP policy in place, ACCESS assisted with the adaptation of global FANC/MIP clinical training materials and used these adapted materials to train supervisors and trainers from 25 of Rwanda s 30 districts. These trainers are now training providers at the district level in accordance with Rwanda s MIP action plan. ACCESS was a major contributor to the revision of National Maternal Newborn Health Guidelines, and supported the MOH to develop a national-level EmONC scale-up strategy, adding 20 national-level EmONC trainers to the national training pool. (There were 15 such trainers previously.) ACCESS supported the adaptation of the EmONC training package for use in health centers, and supported the integration of FANC/MIP, EmONC and KMC with one learning resource package for use throughout the country. Increased Demand for Maternal and Newborn Services At the community level, ACCESS conducted formative research to identify key characteristics that contribute to successful utilization of services. ACCESS used this study to develop, with key stakeholders, nationally approved BCC messages in ANC and EmONC, as well as CHW training materials and tools. With these materials, ACCESS trained CHWs and service providers to help improve pregnancy outcomes by encouraging pregnant women to access services. ACCESS mobilized Community Health Worker training, Rwanda religious leaders to advocate for Safe Motherhood, by including faith-based organizations that are involved in community-level activities to foster behavior change among religious congregations. ACCESS End of Project Report: Country Brief, Rwanda 113

120 Improved Management of MNH Services Currently, KMC is being practiced in eight sites around Rwanda. ACCESS led the establishment of a KMC Center of Excellence at Muhima Hospital, trained a core group of 25 national-level trainers for KMC, and equipped five district hospitals with materials for supporting the KMC units. (ACCESS also trained the providers at three UNICEF- and Twubakane-supported health facilities.) In addition, ACCESS provided these facilities with all of the materials necessary to begin providing KMC services. Fostered Enabling Environment for Maternal and Newborn Services ACCESS collaborated with IMA World Health to ship $175,000 in donated medical supplies and equipment, including several hundred kits to assist with safe delivery, to health facilities in Rwanda. Improved Quality of FANC/MIP and EmONC Services ACCESS increased the capacity of clinicians and health workers to provide MNH services through the application of the SBM-R approach to service quality improvement. Using SBM-R, ACCESS strengthened providers capacity in EmONC, KMC and FANC/MIP. (See Table 13 below for an overview of all training conducted.) Table 13: ACCESS Rwanda Program Health Care Providers Trained, 2008 to Date TRAINING FANC/ MIP EmONC/ MNH KMC SBM-R NUMBER TRAINED Training of trainers from the national level as well as 14 districts Clinical training in EmONC for providers in the four focus districts Training of trainers for providers from four focus districts and Muhima Hospital in Kigali SBM-R training for providers from four focus districts CHW national training of trainers for providers and district supervisors from four focus districts X 244 X 101 X 40 X 93 X X 51 Training religious leaders in Safe Motherhood X X 61 TOTAL 590 To reinforce training, ACCESS introduced the SBM-R approach for quality improvement in FANC, EmONC and KMC, and trained providers at six district hospitals. These providers have now begun implementing the necessary changes within their respective facilities to provide high-quality services. Only one year after introduction, general performance improvement scores changed impressively, from 10% to more than 60%. (See Figure 29 on the following page.) 114 ACCESS End of Project Report: Country Brief, Rwanda

121 Figure 29: Quality Improvement Scores at Six ACCESS-supported District Hospitals for SBM-R Quality Improvement Scores After One Year of Implementation Baseline Endline 100% 80% 60% 40% 20% 0% Kibagabaga Kanombe Kigeme Kaduha Nyanza Muhima LESSONS LEARNED AND SUSTAINABILITY In a decentralized system, involvement of the DHMT from the start is critical to a program s success. Rwanda s MOH requires partners to participate in a joint work planning process that is vetted at all levels. Advocating for activities at the district level and building consensus among district-level stakeholders is key to gaining program support. And partnering with organizations that champion the same goals and approaches to achieve them can lead to scale-up and sustainability. Piloting new services and demonstrating their success can lead to policy change. For example, ACCESS developed a KMC Center of Excellence and then piloted KMC in select sites, which gained visibility and approval of stakeholders. ACCESS was then involved in drafting the first national KMC policy to promote national scale-up of this life-saving practice. Linking facilities with the communities they serve increases utilization of services. The Program s activities emphasized reaching women and their families through CHWs to increase knowledge of and demand for services, while continuing to support the training of providers and supervisors in high-quality services consistent with Rwanda s policies. Collaborating with the MOH and building on their strategies is crucial to program success and scalability. ACCESS End of Project Report: Country Brief, Rwanda 115

122 116 ACCESS End of Project Report: Country Brief, Rwanda

123 TANZANIA Strengthened Services and Institutions to Expand Focused Antenatal Care and Address Maternal and Newborn Health and HIV/AIDS INTRODUCTION With funding from USAID, ACCESS led efforts to develop and expand focused antenatal care (FANC) as a platform for maternal and child health interventions in Tanzania. Using clinical training, community interventions and advocacy, the Program worked to build the capacity of health providers and facilities, expand community knowledge and use of health services, and increase support at all levels for improving the quality and availability of care for mothers and newborns. ACCESS worked with the Ministry of Health and Social Welfare (MOHSW) to nationally scale up FANC as part of routine maternal and child health services, strengthening preservice education of health care professionals, as well as in-service training and quality improvement interventions. The Program also worked with the White Ribbon Alliance to advocate for change at a policy level, and supported the Alliance in efforts to bring national awareness to issues such as MIP. ACCESS continues to support the MOHSW by strengthening FANC services, pre-service training institutions, infection prevention practices, and basic EmONC throughout Tanzania under its associate award, the MAISHA Project. KEY INDICATORS Infant mortality rate: 58/1,000 (NBS 2007) Maternal mortality ratio: 578/100,000 (DHS 2005) Malaria cases annually: >14 18 million (Tanzania PMI MOP 2008) Percentage who received any SP during an ANC visit: 60% (THMIS ) Percentage who received 2+ doses of SP, at least one during ANC visit: 21.7% (DHS 2005) Percentage of pregnant women who make at least one visit to an ANC provider during pregnancy: 96.6% DHS 2005 ACCESS End of Project Report: Country Brief, Tanzania Because many women visit an ANC provider at least once during their pregnancy, the antenatal period is an ideal time to promote key MNH interventions in a platform of complete, integrated services, including: MIP prevention and treatment Infection prevention Provision of tetanus toxoid (TT) Iron/folate supplementation and de-worming with mebendazole to reduce maternal anemia 117

124 Urine testing and taking of blood pressure to identify pre-eclampsia Screening and treatment of STIs such as syphilis and HIV ACCESS also uses these visits to link pregnant women who test positive for HIV with PMTCT services, including referrals for care and treatment. PROGRAM STRATEGIES AND INTERVENTIONS ACCESS worked to increase uptake of intermittent preventive treatment (IPTp) with sulfadoxinepyrimethamine (SP) by improving the quality of ANC services in more than 4,800 government-owned and faith-based health facilities throughout Mainland Tanzania and Zanzibar. Specifically, the Program: Strengthened the technical content and overall quality of pre-service nurse-midwifery education by integrating FANC with the curriculum, implementing a quality improvement approach in pre-service institutions and providing state-of-the-art teaching tools. Developed training systems for in-service training. Improved performance of facility-based ANC providers by introducing an ANC quality improvement approach and strengthening skills of supervisors. Increased awareness of and demand for MNH services through advocacy campaigns. Strengthened the technical content and overall quality of pre-service medical education in HIV/AIDS. MAJOR RESULTS Contributed to a 50% reduction in stock-out days at sentinel facilities due to national level advocacy efforts. Incorporated FANC into the curriculum of all 53 nursing and midwifery training institutions. Provided assistance to the MOHSW to develop, produce and disseminate national infection prevention and control guidelines, standards, and an orientation guide to quality improvement of infection prevention and control. Introduced a quality improvement process for pre-service education at 24 nursemidwifery schools. Trained 880 in-service clinical trainers in FANC, who are now training other clinicians at their own facilities. Trained 4,536 ANC providers (76% nationally) in FANC and quality improvement at 2,633 (55%) facilities. Improved capacity of all nursing educational institutions through distribution of and training on teaching tools such as projectors and laptop computers. RESULTS Increased Capacity to Provide Prevention and Referral for Care of Malaria during Pregnancy Using the FANC Platform Through the Program, a total of 4,536 (76%) 66 ANC providers had their knowledge and skills updated in FANC through training. In total, 880 in-service clinical trainers were trained, 67 and 2,633 ANC facilities now have at least one provider trained in FANC. ACCESS held advocacy meetings with high-level district and regional health officials in each region to encourage stakeholder and policymaker support for FANC interventions, and to ensure that funds for ANC interventions are allocated. The Program found that a total of 37 districts (out of 133 nationwide) conducted FANC training with outside sources of funds 68 primarily by including the training as part of their Comprehensive Council Health Plans. As a result, an additional 845 providers from 559 facilities 66 Out of an estimated 6,000 reproductive and child health care providers in Tanzania are providers from health facilities in all 21 regions plus Zanzibar; 104 are zonal and regional reproductive and child health coordinators from all eight zones in Tanzania. 68 Donors included UNICEF, UNDP and the Christian Social Services Commission. 118 ACCESS End of Project Report: Country Brief, Tanzania

125 received FANC training. In combination with those trained by ACCESS, more than 5,300 providers from 2,942 facilities received FANC updates, representing 61% coverage of all health facilities in Tanzania. Increased Coverage of FANC Interventions Nationally Through training health providers in FANC service provision, ACCESS reached thousands of women with improved malaria prevention interventions. The Program collected data on key FANC indicators on a quarterly basis at 37 health facilities 69 serving as sentinel surveillance sites between January 2007 and October Regarding MIP, the Program tracked uptake of IPTp1 and IPTp2. Because of the need for repeated visits to achieve IPTp, coverage is best reviewed over a period of time. Over two years, trends in IPTp uptake at the sentinel facilities have increased to an average of 59% for IPTp1 but decreased to an average of 38% for IPTp2 at the end of the reporting period. Antenatal care counseling poster. ACCESS conducted additional data analysis and a root cause analysis to identify reasons for this decline. (See Lessons Learned section for more information.) Providers trained in FANC also provide a number of other interventions to antenatal clients. Reduction of Stock-outs Working closely with the National Malaria Control Program (NMCP) and other partners, ACCESS helped to minimize SP stock-outs in ANC clinics by reporting them and following up with the Medical Stores Department and other stakeholders to address availability. In 2009, 32% of ACCESS sentinel sites experienced stock-outs. ACCESS advocated from the national to the district level for timely ordering of SP as well as for the continuing need for SP for IPTp in light of the switch from SP tow artemisinin-based combination therapies (ACTs) for treatment. As a result, the average number of stock-out days per quarter that a facility experienced decreased by 60% between October through December 2008 and July through September (See Figure 30 below.) Although the MOHSW enacted some positive changes, such as the provision of SP free of charge to facilities, challenges still remain in the system. At the start of the program period, facilities were required to purchase SP from Central and Zonal Medical Stores, while facilities can now order SP supplies at no charge. Nevertheless, 26% of ACCESS sentinel site facilities noted that there was at least one occasion during the last year in which they received less SP than they had ordered. Reduction of stock-outs results in increased IPTp uptake as noted in the graphs below. Despite the positive trends displayed below, poor recording and client overload continue to compromise accurate reporting of IPTp uptake. In a survey at the sentinel site facilities, 16% of ANC providers said they only sometimes record IPTp2 and 3% said that they rarely or never record IPTp2. When disaggregating by client load, ACCESS found that sites serving fewer clients had much higher rates of IPTp uptake. For example, in facilities serving less than 100 clients per month, overall uptake was 85%, but in facilities serving 2,000 or more clients per month, the uptake was 37%. 69 ACCESS sentinel sites began with 30 sites in January 2007; an additional seven sites were added in October ACCESS End of Project Report: Country Brief, Tanzania 119

126 Figure 30: Trend of SP Stock-out during the Period of October 2008 September 2009: Number of days of stock-outs of SP per Quarter, Data from 37 Sentinel Surveillance Sites Increased National Awareness of FANC Through its collaboration with T-MARC Company Ltd., ACCESS integrated FANC messages with the Mama Ushauri radio serial drama, reaching 12 million people annually with accurate FANC information through the storylines. The Program also supported the development of a number of information, education, communication (IEC) materials including fliers for pregnant woman and the community about the importance of ANC and timing of visits, the need for syphilis testing, prevention of malaria and anemia in pregnancy, birth preparedness planning, and promotion of facility delivery. (Currently, 5,000 copies of each flier are being disseminated through the MAISHA Project.) Posters were also developed to promote facility delivery, and ACCESS supported Zanzibar in creating an ANC job aid. In addition, ACCESS supported 26 meetings to sensitize 677 religious leaders on the importance of preventing and treating MIP and on practices that help make motherhood safer. Celebrating at the 2008 WRATZ White Ribbon Day ceremony, Tanzania Improved Enabling Environment to Address Safe Motherhood Issues ACCESS worked with the White Ribbon Alliance Tanzania (WRATZ) to advocate for change at a policy level and to bring national awareness to issues such as MIP. With Program support, WRATZ established a successful annual White Ribbon Day that has been attended by more than 1,000 people each year including the President of the Republic of Tanzania in March WRATZ prepared an advocacy package with key, theme-related messages for policymakers, service providers and the community, and disseminated the package to several districts throughout Tanzania. One such package focused on increasing human resources for health at the district level. As a result of this advocacy, during a one-year period from 2006 to 2007, seven dispensaries in Monduli District and 17 dispensaries in Sumbawanga District experienced a 33% increase in health workers. There was also a 50% increase in facility deliveries at these 24 dispensaries. Working in close collaboration with the MOHSW, ACCESS developed or supported a number of national guidelines, performance standards and learning resource packages, including: the national training package and performance standards; the national infection prevention and control guidelines and accompanying 120 ACCESS End of Project Report: Country Brief, Tanzania

127 pocket guide; an orientation guide for quality improvement of infection prevention and control; the One Plan for Maternal, Newborn and Child Health; and the National Road Map Strategic Plan to Accelerate the Reduction of Maternal and Newborn Deaths in Tanzania Mainland and Zanzibar. ACCESS and the MOHSW also established the Safe Motherhood Working Group to address policy and operational aspects of MNH. Strengthened Pre-service Nurse-Midwifery and Medical Institutions The Program assisted the MOHSW to revise the two-year certificate and three-year diploma program in nursing and midwifery, and integrated FANC with the curricula. Additionally, ACCESS supported the training of two tutors and two preceptors at each of the country s 53 pre-service nurse-midwifery schools representing 100% coverage from which approximately 6,000 students have graduated since ACCESS also developed and introduced a quality improvement tool for pre-service education to assess the quality of teaching in nurse-midwifery schools. At baseline, 24 schools reported reaching an average of 58.9% of standards for quality teaching. The Program worked with Tanzania s five medical schools to strengthen technical content, teaching methods and clinical practice related to HIV/AIDS. Fourteen faculty members representing all five schools were updated on HIV/AIDS and core competencies for HIV/AIDS education. At both the nursing and medical schools, ACCESS supported the procurement and placement of state-of-the-art teaching tools. All schools received projectors and laptop computers following training of a representative from each school on their use. The Program purchased equipment including anatomical models, reference manuals and medical supplies for demonstration skills labs to be set up at 15 nursing schools and five medical schools. LESSONS LEARNED AND SUSTAINABILITY Support to the MOH and creation of sentinel In one year, seven dispensaries in surveillance sites can help ensure accurate Monduli District and 17 dispensaries in data reporting. The Tanzania Health Management Sumbawanga District experienced a Information System (known as MTUHA) is significantly 33% increase in health workers, and 24 outdated and does not adequately meet current data dispensaries had a 50% increase in needs in areas of FANC, such as IPTp. To address this facility deliveries. issue, ACCESS selected 37 sentinel surveillance sites from across the country for quarterly collection of key FANC service statistics. In addition to data collection, ACCESS provided feedback on analysis of data for use in decision-making. At the national level, the Program provided input to the MOHSW in the revision of the MTUHA registers for ANC, as well as labor and delivery and postnatal care. These registers are currently being pre-tested in Dodoma Region for eventual national distribution. Supportive supervision can help boost low motivation of overburdened health providers. The shortage of health providers in Tanzania remains a barrier to the implementation of high-quality ANC services. In many locations where ACCESS conducted training, there were limited numbers of health workers available to provide FANC services. For health workers trained to remain motivated and continue practicing, it is essential that the Program continue to work with facilities to assess and ensure that supportive supervisory structures are in place. Use of data and sustained advocacy can help reduce stock-outs. Stock-outs of SP continue to present an obstacle in reaching IPTp targets and improving FANC service provision. ACCESS conducted an analysis of possible underlying causes of such stock-outs and compiled its findings into a report brought to the attention of policymakers and donors. Highlights include: ACCESS End of Project Report: Country Brief, Tanzania 121

128 Inaccurate SP forecasts: The national Medical Stores Division had not accurately forecasted SP needs given the switch to ACTswsww for malaria treatment. This correction was made and additional supplies of SP for the nation were procured. Furthermore, SP was integrated with the essential drug list and a policy was established to allow facilities to receive SP free of charge. Finally, ACCESS integrated aspects of the Integrated Logistics System for ordering essential drugs with its FANC training to ensure that facilities are ordering SP accurately and in a timely manner. Poor recording: In a separate survey at the sentinel site facilities, 16% of ANC providers said they only sometimes record IPTp2 and 3% said that they rarely or never record IPTp2. Providers cited the following barriers to good recording: client overload/shortage of staff, no specified space in MTUHA, 6 registers for IPTp, forgetfulness/carelessness, and the burden of having to find return client s name in a separate register. Client overload: When disaggregating by client load, ACCESS found that sites serving fewer clients had much higher rates of IPTp uptake, skewing results. Under the MAISHA Project, ACCESS will support facilities to overcome identified challenges and improve provision of IPTp. 122 ACCESS End of Project Report: Country Brief, Tanzania

129 Annex A: Program Coverage Matrix ACCESS clinical (e.g., capacity building and service delivery) and community-based (e.g., demand generation) interventions over the past year have reached women and families in Afghanistan, Bangladesh, Ethiopia, Ghana, India, Kenya, Malawi, Nigeria, South Africa and Tanzania. The Program Coverage Matrix below presents information on the types of interventions being implemented in each country and the associated potential population coverage (those living in the intervention target communities and/or facility catchment areas). It is important to note that this matrix does not always capture national-level policy work. In addition, ACCESS country programs are at different stages of implementation some began in 2004 while others began in 2007 thus, coverage may be vastly different. Finally, ACCESS is a global, core-funded program that uses its core funds primarily for technical leadership and global learning. Core-funded country-level interventions tend to be relatively small in geographic scope and serve to demonstrate transfer of research to practice of evidence-based approaches in MNH. These results are then used to inform national and global policy and programming. Field support-funded programs, on the other hand, tend to have larger geographic scope and funding for scale-up.

130 ACCESS PROGRAM COVERAGE MATRIX COUNTRY INTERVENTION # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) # OF DISTRICTS/ DEPARTMENTS % OF DISTRICTS/ DEPARTMENTS # OF REGIONS/ PROVINCES TOTAL POP. (in target communities or facility catchment areas/districts) # OF WOMEN OF REPRODUCTIVE AGE (15 49) AFGHANISTAN Community-based PPH study: Counseling + misoprostol Community-based PPH study: counseling alone N/A 6 3 out of 329 1% 2 out of 34 79,500 18,285 N/A 3 3 1% 2 out of 34 35,840 8,244 PPG skilled birth attendant intervention N/A 427 out of 514 (83%) 181 out of % 13 out of 34 9,204,100 1,840,820 BANGLADESH Prenatal/postnatal community outreach visits and referral BURKINA FASO 7 sub-districts (upazillas) N/A 1 out of % N/A 1,460, ,685 FANC/MIP service delivery scale-up N/A 49 5 out of 53 9% 1 out of 11 3,849, ,737 (estimate)

131 COUNTRY INTERVENTION # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) # OF DISTRICTS/ DEPARTMENTS % OF DISTRICTS/ DEPARTMENTS # OF REGIONS/ PROVINCES TOTAL POP. (in target communities or facility catchment areas/districts) # OF WOMEN OF REPRODUCTIVE AGE (15 49) CAMEROON EMNC (SBA) training and service delivery Social mobilization for quality maternal and newborn care ETHIOPIA N/A 26 3 out of 58 departments* (Ngaoundere, Tignere and Tibati) Communities in 18 facility catchment areas/health zones N/A 1 out of 58 departments (Ngaoundere) 5% 1 out of ,667 68,274 (estimate) 2% 1 out of ,009 58,318 (estimate) Technical updates and clinical skills standardization for midwifery educators N/A out of 80 zones 15% 6 out of 11 regions N/A N/A Training of HEWs in comprehensive PMTCT 29 Kebeles 29 out of 71 health posts (41%) 8 woredas/4 zones 4 zones out of 17 zones in Oromia region (24%) 1 out of 11 regions 145,000 N/A SBM-R process in MNH implemented in 6 hospitals N/A 6 hospitals out of 21 AHOTP sites (21%) N/A N/A 2 out of 12 regions N/A N/A

132 COUNTRY INTERVENTION # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) # OF DISTRICTS/ DEPARTMENTS % OF DISTRICTS/ DEPARTMENTS # OF REGIONS/ PROVINCES TOTAL POP. (in target communities or facility catchment areas/districts) # OF WOMEN OF REPRODUCTIVE AGE (15 49) GHANA Technical updates and clinical skills standardization for midwifery educators N/A 2 1 out of 138 districts (Accra City) 1% 1 out of 10 regions 2,029, ,402 (estimate) SBM-R Process and MNH Technical Updates and Clinical Skills Standardization for maternity providers N/A 13 PSE institutions 4 clinical sites covered under Africa SD project All because PSE institutions cover all districts All but do not know the number of districts attached to each of the 4 major facilities and to all pre-service institutions 10 regions 151,401 (based on 4 clinical sites) 73,884 (based on 4 clinical sites) HAITI PMTCT service delivery (ANC clinic and maternity) Long-term family planning service delivery N/A 23 7 out of 10 70% N/A 2,797, ,531 N/A 21 8 out of 10 80% N/A N/A N/A

133 COUNTRY INTERVENTION # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) # OF DISTRICTS/ DEPARTMENTS % OF DISTRICTS/ DEPARTMENTS # OF REGIONS/ PROVINCES TOTAL POP. (in target communities or facility catchment areas/districts) # OF WOMEN OF REPRODUCTIVE AGE (15 49) INDIA Skilled birth attendance (community- and facility-based midwives plus community mobilization) 223 villages 3 out of 10 PHCs (30%) 1 district 4.1 % (1 district out of 24 districts in the state of Jarkhand) N/A 118,878 20,208 KENYA HTC/PITC N/A 44 out of 77 H/F (57%) 9 dstricts (Igembe, Embu, Moyale, Marsabit, Meru, Tigania, Isiolo, Nyeri and Nyandarua) 6% 2 out of 8 (Central and Eastern) 3,198, ,460 DRH support N/A 52 out of 212 H/F (24%) 17 districts (Nairobi, Rachuonyo, Nyamira, Kisumu, Kisii, Homabay, Gucha, Siaya, Migori, Bondo, Mombasa, Tana, Kwale, Taita Tavata, Kilifi, Lamu, Malindi) 10% 3 out of 8 (Nyanza, Coast and Nairobi) 7,361,189 1,942,037

134 COUNTRY INTERVENTION Injection safety (supportive supervision) # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) N/A 12 out of 166 H/F (7%) ART N/A 564 out of 729 H/F (77%) PMTCT N/A 423 out of 598 H/F (71%) Postpartum family planning (ACCESS-FP) N/A 4 facilities 1 district (Embu) # OF DISTRICTS/ DEPARTMENTS 12 districts (Kisumu, Bondo, Homabay, Suba, Nyamira, Kisii, Nakuru, Baringo, Trans Nzoia, Kericho, Nandi North and Nanyuki) % OF DISTRICTS/ DEPARTMENTS # OF REGIONS/ PROVINCES 7% 2 out of 8 (Nyanza and Rift Valley) 64 Districts 38% 8 out of 8 (Nyanza, Central, Eastern, Western, Coast, Rift Valley, Nairobi and North Eastern) 53 31% 7 out of 8 (Nyanza, Eastern, Rift Valley Coast, Nairobi and Central) TOTAL POP. (in target communities or facility catchment areas/districts) # OF WOMEN OF REPRODUCTIVE AGE (15 49) 5,950,502 1,692,092 32,084,400 8,609,171 26,781,884 7,172, % 1 out of 7 318,724 78,087 Orientation to malaria case management guidelines N/A out of 76 Kilifi, Kwale, Malindi, Mombasa, Lamu, Tana River, Taita Taveta 9.2% 1 out of 8 (Coast) 3,031, ,067

135 COUNTRY INTERVENTION TB/ANC training package pilot and provincial and district training # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) N/A 3 (Pilot in one district Mbeere) # OF DISTRICTS/ DEPARTMENTS 9 out of 76 Embu, Kitui, Machokas, Mbeere, Meru Central, Meru North, Meru South, Tharaka ART 70 N/A out of 76 All seven districts in Central Province, all 13 districts in Eastern Province and all 8 districts in Nairobi Province HIV/AIDS counseling and testing N/A 11 (9 Provincial Level Hospitals and 2 National Referral/ Teaching Hospitals) 10 out of 76 (Embu, Garissa, Kakamega, Kiambu, Kisumu, Machakos, Mombasa, Nairobi, Nakuru, Uasin Gishu) % OF DISTRICTS/ DEPARTMENTS # OF REGIONS/ PROVINCES 11.8% 1 out of 8 (Eastern) 36.8% 3 out of 8 (Central, Eastern, Nairobi) TOTAL POP. (in target communities or facility catchment areas/districts) # OF WOMEN OF REPRODUCTIVE AGE (15 49) 4,709,58 1,201,609 12,224,133 (GOK Province projections 2007: Central- 4,076,631 Eastern- 5,206,592 Nairobi- 2,940,910) 3,358,814 (GOK Province projections 2007: Central- 1,176,872 Eastern- 1,286,460 Nairobi- 895,482) 11.8% 8 out of 8 10,110,947 2,683, The focus of the ART and CT projects in Kenya are on training of national and provincial trainers. However, through support supervision or through echo training, trainings are rolled down to reach the health facility level.

136 COUNTRY INTERVENTION # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) # OF DISTRICTS/ DEPARTMENTS % OF DISTRICTS/ DEPARTMENTS # OF REGIONS/ PROVINCES TOTAL POP. (in target communities or facility catchment areas/districts) # OF WOMEN OF REPRODUCTIVE AGE (15 49) MADAGASCAR FANC/MIP service delivery scale-up N/A 76 4 out of 22 18% 2 out of 6 710, ,197 (estimate) MALAWI Technical updates and clinical skills standardization for midwifery educators N/A 1 1 out of 27 (Kasungu) 0.4% 3 480, ,706 (estimate) Basic emergency obstetric and neonatal care (BEmONC) in preservice education 13 training institutions 13 training institutions (100%) 8 districts 100% 3 out of 3 regions 3,799, ,687 (approximate) BEmONC for service providers Community maternal and newborn health Community mobilization Establish KMC sites for management of LBW babies Women and newborns receiving AMTSL and ENC health centers; 4 hospitals 746 villages 12 health centers 675 villages 9 health centers 4 districts out of % (4 out of 28 districts) 3 out of 3 regions 3 districts 10.7% 3 out of 3 regions 221,308 53,109 (approximate) 3 districts 10.7% 3 out of 3 regions 144,512 34,682 (approximate) 11 facilities 3 districts 10.7% 3 out of 3 regions 221,308 53,109 (approximate) 20 hospitals; 12 health centers 28 districts 100% 3 out of 3 regions 13,100,000 3,143,749 (approximate)

137 COUNTRY INTERVENTION # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) # OF DISTRICTS/ DEPARTMENTS % OF DISTRICTS/ DEPARTMENTS # OF REGIONS/ PROVINCES TOTAL POP. (in target communities or facility catchment areas/districts) # OF WOMEN OF REPRODUCTIVE AGE (15 49) FANC/MIP Nationally 100% 28 districts 100% 3 out of 3 regions 13,100,000 3,143,749 (approximate) PQI in RH district hospitals PQI in RH health center N/A N/A (RH) 16 out of 16 district hospitals (100%) (RH) 10 out of 10 health centers (100%) PQI in IP N/A (IP) 23 out of 24 hospitals (100%) FANC/MIP N/A 730 out 730 health facilities (100%) Pre-service and in-service N/A 13 out of 13 RN/M training institutions (100%) KMC N/A 13 out of 13 health facilities (100%) Integrated PQI IP- RH at health centers 746 villages 12 health centers 16 districts 61% (16 out of 26 district hospitals) 100% (4 out or 4 central hospitals) 3 districts 11% (3 out of 28 districts) 23 districts 82% (21 out of 28 districts) 3 out of 3 regions 10,014,245 2,403,226 3 out of 3 regions 341,000 81,833 3 out of 3 regions 10, ,403,266 (approximate) 28 districts 100% 3 out of 3 regions 13,100,000 3,143,749 8 districts 29% (8 out of 28 districts) 3 districts 11% (3 out of 28 districts) 3 out of 3 regions 3,799, ,687 3 out of 3 regions 341,000 81,833 4 districts 14.3% 3 out of 3 regions 221,308 53,109 (approximate)

138 COUNTRY INTERVENTION # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) # OF DISTRICTS/ DEPARTMENTS % OF DISTRICTS/ DEPARTMENTS # OF REGIONS/ PROVINCES TOTAL POP. (in target communities or facility catchment areas/districts) # OF WOMEN OF REPRODUCTIVE AGE (15 49) MAURITANIA EmONC (SBA) service delivery N/A 13 7 out of 44* 16% 6 out of 13 1,063, ,727 (estimate) NEPAL SBA LRP pretest N/A 3: 2 hospital s and 1 nursing campus SBA LRP developed SBA training site upgrade Mgmt. of LBW infants at community level N/A SBA LRP used to train SBAs from 246 facilities Pretesting: 2 out of 75 districts (Chitwam, Morang) Trained 900 SBAs from 75 districts N/A 8 facilities 8 out of 75 districts 19 Village Development committees (60,158 households) 22: 10 SHP, 8 HP, 3 PHCC, 1 zonal hospital SBA study 90 groups 1 HP, 1 clinic, 4 PHCC 2.6% 2 out of 5 1,143, , % of district 5 out of 5 regions 26,239,521 (total national population 2006/2007) 11% 4 out of 5 5,304, ,442 1 out of 75 2% 1 out of 5 380,461 74,518 6 out of 75 districts (Morang, Panchthar, Kavre, Nawalparasi, Kapilvastu, Baitadi) 8% 4 out of 5 2,952, ,182 6,467,379 (total national population for women of reproductive age)

139 COUNTRY INTERVENTION # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) # OF DISTRICTS/ DEPARTMENTS % OF DISTRICTS/ DEPARTMENTS # OF REGIONS/ PROVINCES TOTAL POP. (in target communities or facility catchment areas/districts) # OF WOMEN OF REPRODUCTIVE AGE (15 49) Facility-based KMC 61 Village Development Committees, 3 municipalities 5: 2 zonal hospitals and 3 primary health care centers 2 out of 75 districts 3% 1 out of 5 1,016, ,103 Management of PEE at facility level using MgSO4 N/A 9 hospitals: 3 primary health centers; 10 private hospitals 12 out of 75 districts 16% 5 out of 5 regions 8,081,421 (total population for 12 districts) 1,815,785 (total population for 12 districts for women of reproductive age) Community based distribution of misoprostol for the prevention of PPH N/A 1 hospital; 3 primary health care centers; 9 health posts; 35 subhealth posts 1 out of 75 districts 2% 1 out of 5 regions 3,413,799 (total population for 1 district) 838,038 (total population for 1 district for women of reproductive age) NIGER EmONC (SBA) service delivery NIGERIA N/A 11 2 (Maradi and Zinder) out of 7 departments 29% 2 out of 7 617, ,921 Emergency obstetric and newborn care as an entry point to postpartum family planning and community mobilization : 19 general hospitals out of 21 (90%) 6 CHCs and 30 PHCs out of 65 PHCs (45%) 24 out of 774 LGAs (6 in Zamfara, 8 in Kano, and 8 in Katsina) 3% 1 out of 6 4,979,149 1,145,204 (estimate) 71 Population data for Niger from

140 COUNTRY INTERVENTION # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) # OF DISTRICTS/ DEPARTMENTS % OF DISTRICTS/ DEPARTMENTS # OF REGIONS/ PROVINCES TOTAL POP. (in target communities or facility catchment areas/districts) # OF WOMEN OF REPRODUCTIVE AGE (15 49) RWANDA SBAI Program : 5 General Hospitals out of 40 (13%) 41 health centers out of 417 (10%) PMI Program : 18 general hospitals out of 40 (45%) SOUTH AFRICA 213 health centers out of 417 (51%) 4 out of 30 districts (Gasabo, Kicukiro, Nyaruguru, and Nyamagabe) 14 out of 30 districts (Gasabo, Kicukiro, Nyaruguru, Nyamagabe, Rulindo, Gakenke, Musanze, Nyabihu, Gicumbi, Rubavu, Gatsibo, Rutsiro, Huye, Nyamasheke) 13% 2 out of 5 1,247, ,999 46% 5 out of 5 4, 775, 308 1, 117, 422 Cervical cancer prevention and training support N/A 32 out of 82 (39%) Note: total includes mobile and satellite clinics 2 out of 53 9% 2 out of 9 1,068, ,878

141 COUNTRY INTERVENTION Implementation of Antiretroviral Service Standardbased Management TANZANIA # OF COMMUNITIES # AND % OF FACILITIES (% of facilites covered across target districts) # OF DISTRICTS/ DEPARTMENTS % OF DISTRICTS/ DEPARTMENTS N/A 5 2 9% of the 53 districts country-wide # OF REGIONS/ PROVINCES TOTAL POP. (in target communities or facility catchment areas/districts) 2 out of 9 1,068, ,878 # OF WOMEN OF REPRODUCTIVE AGE (15 49) FANC/MIP service delivery scale-up N/A 2,633 out of 4,795 facilities (55%) 143 out of 143 Mainland and Zanzibar 100% 22 out of 22 (100%) 42,519,420 8,503,884 Technical updates and clinical skills standardization for midwifery educators N/A 53 out of 53 facilities (100%) at least 1 facility per each school 40 out of 133 (Mainland) 30% 19 out of 21 16,118,294(esti mate) 3,223,659 (estimate) TOGO EmONC (SBA) service delivery N/A 13 6 out of 31 prefectures (Sotouba, Tchaoudjo,Blitta, Tchamba, Est- Mono, Lomé) 19% 3 out of 5 divisions 1,189, ,470 Note: Data sources for population figures include national census data; US Census Bureau, International Database, World Gazetteer at (Cameroon); (Nepal, Mauritania, Burkina,);; (Mauritania, Madagascar); (Burkina); Kenya 1999 Population and Housing Census Volume VII: Analytical Report on Population Projections, 2002 (Kenya) *Districts in Mauritania include: Nouakchott, Kaedi, Bababe, Aleg, Aioun, Kiffa and Neima; Regions: Nouakchott, Gorgol, Brakna, Hodh El Gharbi, Assaba and Hodh Ech Chargui **Cameroon s 58 departments are divided into 269 arrondissements and 53 districts. Data source: rights.org. * Population projections from National Census 2002 for Year 2008.

142 Annex B: ACCESS Global M&E Framework with Results INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY ACCESS Program Result: Increased use and coverage of maternal/neonatal and women's health and nutrition interventions A. Number of ACCESS countries demonstrating improvement in ACCESS target areas in the past year in indicators appropriate to areas of program activity as determined by country-specific M&E plan and budget agreed by USAID Mission (collection is fielddependent) Indicators to track, appropriate to areas of program activity, will be determined from the final country M&E plans and budget agreed by USAID Mission, but potentially include:%/# of births attended by skilled attendants; %/# of mothers who report immediate and exclusive breastfeeding for last live birth; %/# of mothers who receive antenatal iron folate, IPT, ITN use rates, etc. Program records and country reports, populationbased surveys by ACCESS, HMIS Number of countries: 3 (Bangladesh, Nigeria and India) Bangladesh: The project s baseline survey showed 73.4% of newborns were breastfed within one hour of birth, while end of project data from the project s health management information system (HMIS) indicate that 87.2% of mothers reported immediate breastfeeding for last live birth in program coverage areas At baseline, 5.3% of mothers reported newborn s first bath was delayed three days, compare with 81.1% at the end of the project (HMIS) At baseline, 32% of newborns had nothing applied on to their umbilical stump after birth compared with 82% at the end of the project At baseline, 1.3% of newborns delivered at home were dried and wrapped immediately after birth, compared with 54% at the end of the project (HMIS) Nigeria ACCESS/MCHIP baseline and endline household survey: At baseline, 48% of women had received antenatal care during their last pregnancy, while at endline the proportion of women who attended antenatal care increased significantly, to 73% of respondents At baseline only 1.2% of women reported using a family planning method, while at endline this increased significantly to 15.1% of respondents India ACCESS baseline and endline household survey: At baseline, the percentage of births assisted by auxiliary nurse midwives (ANMs) was 6%. This increased significantly to 13% at endline. At endline, significantly higher proportions of recent mothers reported delayed bathing of the newborn and immediate drying and wrapping Note: ACCESS only did endline and/or baseline surveys in these

143 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY countries. Please see Annex G, Country M&E Frameworks, for more details. B. Number of ACCESS countries demonstrating improvement since the last survey in appropriate impact/outcome indicators collected by other mechanisms (e.g., DHS, MICS, RAMOS, SPA, and others) (collection is fielddependent) Indicators to track will be determined in conjunction with the country's USAID Mission considering planned data collection activities relevant to maternal, neonatal, and women's health and nutrition status and potentially include: :%/# of births attended by skilled attendants; %/# of mothers who report immediate and exclusive breastfeeding for last live birth; %/# of mothers who receive antenatal iron folate, IPT, ITN use rates, etc. National or other populationbased surveys data (e.g., DHS, MICS, etc.) Number of countries: 2 (Nigeria and Tanzania) Nigeria: DHS 2008: 49.8% of women age who had a live birth in the five years preceding the survey received antenatal care from a skilled provider for the most recent birth in Kano State and 13.1 % in Zamfara state, compared with 73% in the ACCESS intervention areas in Kano and Zamfara at endline in 2009 Tanzania In 2004 (DHS), 46 % of households owned a mosquito net of any type compared with 56% of households in 2007/8 (Tanzania HIV/AIDS and Malaria Indicator Survey THMIS) In 2004/5 (DHS), 16% of pregnant women slept under an ITN the night before the survey, while in 2007/8, 27% of pregnant women slept under an ITN the night before the survey In 2004/5 (DHS), only 22% of pregnant women received IPTp 2 during an ANC visit, but this increased to 30% in 2007/8 (THMIS)

144 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY C. (Country-level) Estimated population of women of reproductive age living in communities or catchment areas of facilities targeted by ACCESS interventions The number of reproductive age women is the female population estimated to be between the ages of Communities or catchment areas Targeted by ACCESS will be determined at the country level. The number will be calculated as country totals where appropriate and available and a global total for all of the countries meeting the definition. National census data, DHS data or other national sources as available Please see Annex 4, the Program Coverage Matrix, for population details for 18 ACCESS program countries. ACCESS Program Intermediate Result 1: Global leadership for maternal, neonatal, and women's health and nutrition program and policies strengthened 1a. Number of technical approaches and/or products being promoted for international use through ACCESS leadership roles 72 Technical approaches and products include those advocated by USAID. Some may be strengthened by ACCESS prior to promotion while other approaches that are already proven will simply be promoted by ACCESS. Promotion for use occurs through many venues: meetings, collaboration, alliances and partnership implementation. Program reports and activity tracking 26+ These include resources developed by the ACCESS Program as well as resources developed by other projects, such as POPPHI and Saving Newborn Lives. Examples include: the Malaria Resource Package, Prevention of Postpartum Hemorrhage: Implementing AMTSL (2007), Best Practices in Maternal and Newborn Care: A Learning Resource Package for Essential and Basic Emergency Obstetric and Newborn Care (2008), E-Learning Courses developed by ACCESS for the USAID Global Health elearning Center, etc. 72 A full listing of ACCESS Program resources is available on the Program website:

145 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY 1b. Number of countries that implement and promote national policies, including service delivery guidelines, to increase access to high-quality maternal and neonatal health services Policies, including clinical care and service delivery guidelines, are national instructions meeting international evidence-based quality criteria related to ACCESS goals. Countries increasing access to high-quality EMNC services are those whose national leadership, MOH and/or others ensure dissemination of such standards in strategies that reach the point of service delivery and service providers. Program reports and activity tracking Number of countries: 9 Bangladesh: CKMC training manual Haiti: National PMTCT Guidelines and evidence-based service delivery guidelines for infection prevention (IP) India: Skilled Birth Attendance Guidelines Kenya: MOH reference manual for the prevention and management of PPH was completed with ACCESS support; Developed National Reproductive Tract Cancer Guidelines, which include breast and prostate cancers, in Kenya (PY 2-5); PMTCT standards and national guidelines; Community infection prevention package; Standards and guidelines for injection safety and medical waste management orientation package; National guidelines for HIV testing and counseling in Kenya (PY 2-5); National HIV mentorship guidelines Madagascar: revised and updated the malaria norms and protocols document, Normes et Procedures en matières de Lutte contre le Paludisme, at the request of USAID/President s Malaria Initiative (PMI). Malawi: Developed BEmONC syllabus and curriculum for NMTs at all training institutions (n=13) in the country and developed Community Mobilization Guidelines Nepal: Skilled Birth Attendance Policy South Africa: National PMTCT Training Guidelines Tanzania: National Infection Prevention Guidelines

146 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY 1c. Number of international and/or national policies, including service delivery guidelines, revised and/or strengthened to promote access to and coverage of integrated EMNC services Policies and guidelines are international or national instructions to health system decision-makers (e.g., clinical service delivery points, managers, and service providers) meeting international evidence-based quality criteria related to ACCESS goals. Policies and guidelines promoting access to integrated EMNC services are those whose focus includes expanding availability or coverage of service delivery covering the ACCESS-recommended package of EMNC and other services. Revised or strengthened policies and guidelines are those where ACCESS review and improvement activities targeting EMNC service integration are reported to have been successfully completed. Program reports and activity tracking Number of policies/guidelines: 14 Afghanistan (1): National 5-year MNH Strategy Burkina Faso (1): policy for intermittent preventive treatment (IPT) for prevention of MIP Cameroon (1): Social Mobilization Strategy and Action Plan Kenya (1): Prevention of PPH Guidelines for Health Care Workers Madagascar (1): Norms & protocols for malaria control in adults and children and MIP Malawi (2): Comprehensive reproductive health standards for hospitals; Integrated RH-IPC standards for health centers Nepal (2) : National Skilled Birth Attendant Policy; KMC Guidelines Nigeria (1): National performance standards for maternal and newborn health Rwanda (4): Guidelines for FANC, EmONC, KMC, CMNH ACCESS Program Intermediate Result 2: Preparation for childbirth improved

147 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY 2a. Number of ACCESStargeted communities with social mobilization approaches leading to achievement of improved birth planning (applicability is fielddependent) ACCESS-targeted communities are those identified social and geographic areas where program activities and alliances aim to enhance shared responsibility and collective action in birth preparedness/ complication readiness. Program reports and activity tracking Bangladesh: 990 communities Burkina Faso: 2 districts Cameroon: 2 departments India: 40 communities in 3 blocks of 1 district in Jharkhand Kenya: PPFP in 1 district and 6 divisions Achievement of improved birth planning is defined as having fulfilled birth preparedness goals of the community's selfdeveloped action plan. Malawi: 844 communities in 4 districts received MNH messages through community mobilization Nigeria: 50 communities Rwanda: 134 communities 2b. Percent/number of women who delivered in past 6 months in ACCESS-targeted facilities/communities who received 2 tetanus toxoid (TT) injections (applicability is fielddependent) [Note: Tanzania (PY 1-5) definition: Number of ANC clients with 2 doses of TT/Number of 1 st visit ANC clients] Percent of women delivering in facilities is according to facility records showing 2 TT injections having been given to the mother: Number of women's records that show a delivery in the past 6 months and 2 TT injections prior to that delivery (numerator)/ number of women's records that show a delivery in the past 6 months (denominator). Number delivering in communities will be calculated from home records if available (e.g., if the country uses cards the client keeps) or program records. HMIS and/or home records Tanzania: 57 % of ANC clients (18182/28368) at sentinel sites from April- September 2009 (in 37 facilities) Note: Data only reported on this indicator in Tanzania.

148 INDICATOR 2c. Percent/number of women who delivered in past 6 months in ACCESS-targeted facilities/communities who received iron/folate supplementation (applicability is fielddependent) [Note: Tanzania (PY 1-5) definition: Number of ANC clients who received iron (alone)/total number ANC visits] 2d. Percent/number of women who gave birth in the past 6 months who received counseling/information/ materials for ITN use during pregnancy and with newborn (applicability is fielddependent) 2e. Percent/number of pregnant women who attended antenatal care services at ACCESStargeted facilities who DEFINITIONS AND CALCULATION Percent of women delivering in facilities will be calculated from facility records that show iron/folate supplementation having been given to the mother: Number of women's records that show a delivery in the past 6 months and iron/folate supplementation prior to that delivery / number of women's records that show a delivery in the past 6 months (numerator/denominator). Number of women delivering in communities will be calculated from home records if available (e.g., if the health system uses cards that the client keeps) or program records. Women delivering in communities in the past 6 months will be identified through program records or if appropriate facility-based records. Delivery/receipt of counseling, information and/or materials (including vouchers) for ITN use will be determined from program records or if appropriate facilitybased records. Calculation: Number of pregnant women who receive IPT1 under observation/ Number of 1 st ANC visits DATA SOURCE END OF PROJECT RESULTS BY COUNTRY HMIS and/or home records Tanzania: 59% of ANC clients (16653/28368) at sentinel sites from April September 2009 HMIS and/or home records HMIS Note: Data only reported on this indicator in Tanzania. Tanzania: proxy indicator in 57% of ANC clients at sentinel sites received ITN vouchers ) (16046/28368) from April September 2009 Uganda-baseline 0% to 27% in Y3 Madagascar: 48% in Y2 Tanzania: 64% of women (18246/28368) at sentinel sites from April to September 2009

149 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY received 1 st does of intermittent preventive treatment (IPT1) under direct observation Receipt of IPT with SP will be determined from facility records. These indicators will be measured in malaria- endemic countries only. Uganda: 76% in Y3 2f. Percent/number of pregnant women who attended antenatal care services at ACCESStargeted facilities who received 2 nd dose of intermittent preventive treatment (IPT2) under direct observation (applicability is fielddependent) Calculation: Number of pregnant women who receive IPT2 under observation/ Number of 1 st ANC visits Receipt of IPT with SP will be determined from facility records. This indicator will be measured in malaria-endemic countries only. HMIS Madagascar: 40% in Y2 Tanzania: 41% of women (11508/28368) at sentinel sites from April September 2009 and 38% (81316/213305) Uganda: 76% in Y3 2g. Number of antenatal care providers trained through ACCESSsupported curricula or events in focused antenatal care and/or prevention of maternal to child transmission (applicability is fielddependent) ACCESS-supported curricula and training events are those developed and managed by ACCESS staff or ACCESSapproved training staff. Training that targets focused ANC and/or PMTCT is a preservice or in-service course or other learning experience that includes competency-based knowledge and skills to provide evidence-based ANC and PMTCT (CT for HIV). Training records Total number: 9263 Bangladesh: 399 providers Burkina Faso: 114 providers Cambodia: led a coalition of 7 partners to train 335 midwives and 23 trainers in a national postpartum/postnatal care in-service training package Cameroon: a total of 94 providers were trained in EmONC (five were developed as trainers). Haiti: 482 providers India: 58 ANMs Kenya: 732 trainees (261 in clinical training skills and 471 service providers for PMTCT; 111 providers trained in FANC/MIP)

150 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY Madagascar: 14 trainers & 96 FANC/MIP providers Malawi: -680 providers trained in FANC Nepal: 87 nurses & doctors Nigeria: 108 providers Rwanda: 327 providers South Africa: 1178 providers trained in PMTCT clinical package Tanzania: 4,536 providers 2h. Total number of pregnant women provided with PMTCT services at target facilities, including counseling and testing 73 (applicability is fielddependent) Pregnant women include those attending ANC services and/or those delivering in the maternity at the PMTCT target facilities, as applicable to the country program. HMIS, Centers for Disease Control and Prevention (CDC) Global AIDS program database Total number: 39,321 Haiti: 28,819 pregnant women South Africa: 1256 women (in 8 facilities) Malawi: 9246 pregnant women received HIV counseling, testing and their results ACCESS Program Intermediate Result 3: Safe delivery, postpartum care, and newborn health improved 3a. Number of ACCESStargeted facilities with PQI initiatives contributing to compliance with international standards ACCESS-targeted facilities are those identified service delivery points where program activities and alliances aim to enhance quality of care through PQI approaches. Program PQI records PQI database Total number: 471 Afghanistan: 319 facilities, including hospitals, health centers and health posts (comprehensive MNH/RH) Ethiopia: 4 hospitals (comprehensive MNH/RH) Ghana: 11 facilities (comprehensive MNH/RH) Haiti: 6 facilities (PAC) Kenya: 8 provincial and general hospitals (PMTCT) 73 PEPFAR indicator

151 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY Madagascar: 11 facilities (FANC/MIP) Nepal: 10 hospitals (comprehensive MNH/RH services and training) Nigeria: 30 facilities, including 15 hospitals and 15 primary health centers (EmONC and FP) Malawi: 32 facilities, including 16 district hospitals, 4 central hospitals, and 12 health centers (comprehensive reproductive health) Rwanda: 6 hospitals (BEmONC) Tanzania: 10 facilities have had external assessments showing improvement over baseline in FANC/MIP. All facilities with trained FANC providers (2,633) have had PQI initiatives introduced. Plus 24 nurse/midwifery schools have implemented PQI for preservice. 3b. Percent/number of births in ACCESStargeted facilities in the past 6 months that occurred with a skilled attendant using a partograph (applicability is fielddependent) Women delivering in the past 6 months will be identified through facility records. Correct use of a partograph will be determined from facility records. Skilled attendants are those employed in skilled service provider categories according to the standards of the country. The percentage will be calculated by dividing the number of births recorded in the past 6 months that occur with a skilled attendant using a partograph (numerator) by the number of births recorded in the past 6 months (denominator). Facility records, completed partographs Ethiopia - 30% of births (1,725 out of 5,713 deliveries) Nigeria % of births (32,752/76,576) Rwanda - 100% of births in ACCESS-targeted facilities (8857/8857)

152 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY 3c. Percent/number of births in the past 6 months in ACCESStargeted facilities/communities with active management of third stage of labor (applicability is fielddependent) Births in the 6 months prior to data collection will be identified through facility records and/or program records at the community level. AMTSL is determined by information available in the records. For facility births, the percentage is calculated by dividing the number of births recorded in the past 6 months where AMTSL is recorded (numerator) by the number of births recorded in the past 6 months (denominator). For community or home births, the number is an annual count of the births in the 6 months prior to data collection meeting the definition criteria. HMIS and/or program records where data are available Ethiopia - 83% (4,753/5,713 deliveries) India - AMTSL provided for an average of 96% of vaginal deliveries attended by ACCESS-trained ANMs Malawi - 100% of vaginal births in targeted facilities (102,955/102,955) Nigeria % of vaginal births in targeted facilities Rwanda - 100% of vaginal births in targeted facilities (7621/7621) 3d. Percent/number of newborns in the past 6 months in ACCESStargeted facilities or communities dried and warmed immediately after birth (applicability is fielddependent) Newborns in the past 6 months are those whose births are recorded in the 6 months prior to data collection. Being dried and warmed immediately after birth is determined by information available in the records. Facility and/or program records if data are available Bangladesh- 54% of newborns in targeted facilities over LOP Ethiopia - 91% of newborns delivered by HEWs in targeted facilities (3,149/3,749) Malawi -100% of newborns in targeted facilities (102,955/102,955) Nigeria -61.4% of newborns in targeted facilities (47,070/76661) over LOP Rwanda-100% of newborns in targeted facilities (8964/8964) India 99% of newborns delivered by ANMs were immediately dried and wrapped

153 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY 3e. Percent/number of newborns in ACCESStargeted facilities or communities that are breastfed within one hour of birth (applicability is fielddependent) Breastfeeding within 1 hour of birth is determined by information available in the records or through exit interviews with new mothers at facilities or interviews with recent mothers in the community. Facility and/or program records if data are available Client exit interviews Community survey Bangladesh % over LOP Ethiopia - 55% of newborns delivered by HEWs in targeted facilities (3,149/3,749) Nigeria % of newborns in targeted facilities (47,070/76661) over LOP 3f. Percent/number of providers with adequate knowledge of essential newborn care Adequate knowledge will be determined. Provider knowledge survey Bangladesh - 100% of targeted providers over LOP India -100% of targeted ANMs at completion of training Malawi Mauritania - 12/13 or 92% of targeted providers over LOP Nepal - 80% of targeted providers over LOP

154 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY 3g. Percent/number of women in ACCESStargeted facilities or communities who accept a contraceptive method by 6 weeks postpartum 74 (applicability is fielddependent) Women who accept a contraceptive method are those recorded in facility or community outreach records as receiving the contraceptives or a prescription for a method (if appropriate in context). The number is a semi-annual count of women recorded at ACCESS-Targeted facilities or through community outreach as meeting the definition criteria. Facility and/or program records Kenya - 6,970 LAM; 1103 POP; 1724 DMPA; 588 PPIUCD; 267 Interval IUCD; 247 OCP; 247 condoms; 284 BTL; 103 implants in 22 health facilities for PPFP. Note: These data were only collected in one country (Kenya) by ACCESS- FP. 3h. Percent/number of women who delivered in past 6 months in ACCESS-targeted facilities/communities who received a postpartum visit within 3 days after childbirth Percent of women delivering in facilities will be calculated from facility records that show the mother receiving postpartum care. Number of women's records that show a delivery in the past 6 months and postpartum care within 3 days/number of women's records that show a delivery in the past 6 months (numerator/denominator). Number of women delivering in communities will be calculated from home records if available (e.g., if the health system uses cards that the client keeps) or program records. HMIS and/or home records or community survey Bangladesh % of women in target facilities over LOP Ethiopia - 91% (3,422/3,749 deliveries in target facilities Kenya - 27% of women in target facilities (5,105/18852) (Dec 2006-Dec 2009) Malawi (or 85.5% of 539) received PNC with skilled providers at ACCESS facilities in Malawi (PY 3-5). This data is based only on projectcollected data since the HMIS does not collect this information. Nigeria % (66,861/78588) of women in targeted facilities 74 This indicator will be collected through ACCESS-FP.

155 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY ACCESS Program Intermediate Result 4: Management of obstetric complications and sick newborns improved 4a. Percent/number of women attending ACCESS-targeted facilities with eclampsia who appropriately receive magnesium sulfate (applicability is fielddependent) Women with eclampsia attending Targeted facilities are those recorded as presenting at the facility with clinical symptoms. Appropriate treatment with magnesium sulfate is determined according to the clinical record or aggregated records. The percentage is calculated by dividing the numerator (women recorded at ACCESS-Targeted facilities with eclampsia and receiving magnesium sulfate) by the denominator (all women recorded at ACCESS-Targeted facilities with eclampsia). Facility records Nepal - 22 health facilities with 106 HW assessed on use of MgSO4 for management of PE/E trained and knowledge updated using SBM-R approach over LOP Nigeria - 100% of cases managed with magnesium in ACCESS supported facilities (3073/3073) over LOP 4b. Number of maternal/neonatal providers trained through ACCESS-supported curricula or events in infant resuscitation (applicability is fielddependent) ACCESS-supported curricula and training events are those developed and managed by ACCESS staff or ACCESSapproved training staff. Training that Targets infant resuscitation is a pre-service or in-service course or other learning experience that includes competency-based knowledge and skills to treat infant asphyxia. Maternal/neonatal providers are service delivery staff whose core competencies and employment duties include pregnancy and birth-related health issues. Training records Total number: 4,609 Cameroon - 24 providers Ethiopia - 2,328 providers (32 preceptors; 1,827 graduates trained in preservice; 111 providers in BEMONC; 358 HEWs in safe and clean birth and newborn care) Ghana - 11 providers Malawi Mauritania -17 providers Nepal -900 SBAs trained using MNC LRP and course outline Niger- 4 providers Nigeria providers

156 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY Trained providers are those who complete a training course satisfactorily according to the course criteria. Rwanda Tanzania: 143 (38 through AFR/SD efforts and105 through MAISHA) Togo - 4 4c. Number of maternal/neonatal providers trained through ACCESS-supported curricula or events in management of LBW newborns/kmc (applicability is fielddependent) ACCESS-supported curricula and training events are those developed and managed by ACCESS staff or ACCESSapproved training staff. Training that targets KMC is a pre-service or in-service course or other learning experience that includes competency-based knowledge and skills related to management of LBW babies. Training records Total number: 2251 Malawi Nepal providers in KMC Nigeria - 34 providers Rwanda - 43 providers Tanzania - 15 through MAISHA Maternal/neonatal providers are service delivery staff whose core competencies and employment duties include pregnancy and birth-related health issues. Trained providers are those who complete a training course satisfactorily according to the course criteria. 4d. Number of ACCESStargeted communities with social mobilization approaches leading to achievement of improved complication readiness (applicability is fielddependent) ACCESS-targeted communities are those identified social and geographic areas where program activities and alliances aim to enhance shared responsibility and collective action in birth preparedness/ complication readiness. Program reports and activity tracking Bangladesh Burkina Faso-1 district Cameroon - 2 departments India - 40 communities in 3 blocks of 1 district of Jharkhand state Kenya - 1 district (Embu) with 6 divisions covering 78,087 women of reproductive age

157 INDICATOR DEFINITIONS AND CALCULATION DATA SOURCE END OF PROJECT RESULTS BY COUNTRY Achievement of improved complication readiness is defined as having fulfilled complication readiness goals of the community's self-developed action plan. The number will be calculated as an annual count of Targeted communities meeting the definition criteria. Malawi communities in Malawi receiving MNH messages through community mobilization Nigeria - 50 communities Rwanda communities ACCESS Program Intermediate Result 5: Prevention and treatment of priority health problems of non-pregnant women of reproductive age improved (Targets of Opportunity) 5a. Number of linkages with international obstetric fistula networks initiated and technical assistance provided International obstetric fistula networks are those organizations or groups of organizations who identify obstetric fistula as a key area of international concern and needed activism. Linkages are working relationships on identified tasks toward specified goals agreed between a network and ACCESS. Program records 1 Note: This version of the ACCESS Global M&E framework reflects the modifications mutually agreed upon by ACCESS and USAID in January 2006.

158 Annex C: Individual M&E Frameworks: Bangladesh, Ethiopia, Kenya, Malawi, Nepal and Tanzania BANGLADESH ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS Goal: To improve maternal and neonatal health outcomes Neonatal mortality rate in ACCESS intervention area Number of deaths of newborn 0-28 days in last year in ACCESS intervention area x 1000 Total number live births in last year PBS report PBS survey Baseline and endline surveys SO: To increase the practice of healthy maternal and neonatal behaviors in antenatal, childbirth, and postnatal periods in a sustainable and potentially scalable manner *Percent of recent mothers who had a birth plan during their last pregnancy Number of recent mothers who reported having a birth plan during their last pregnancy x 100 Total number of recent mothers interviewed Recent mother is defined as having given birth within the last year (12 months) MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys 0.3% 57.5% A recent mother is considered having a birth plan if she had: selected birth place, birth attendant, newborn care person and arranged money and transport during her last pregnancy

159 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS *Percent of recent mothers whose birth was attended by a skilled provider, by type of provider, by place of delivery Number of recent mothers attended at their last childbirth by a skilled provider, by type of provider, by place of delivery x 100 Total number of recent mothers interviewed Skilled provider refers to doctor (specialist or nonspecialist), nurse, midwife or their equivalent who can manage normal deliveries and diagnose or refer obstetric complications. Both trained and untrained traditional birth attendants are excluded. MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys Delivery place: Home: 88.2% Facility: 11.8% Birth attendant at home delivery: Skilled provider: 1.6% TBA: 76.8% Relative: 20.9% Others: 2.5% Delivery place: Home: 86.6% Facility: 13.4% Birth attendant at home delivery: Skilled provider: 2.6% TBA: 85.7% Relative: 11.0% Others: 0.7% *Percent of recent mothers who gave birth at home whose newborns were attended by a Newborn Care Person at birth Number of recent mothers who gave birth at home had a Newborn Care Person (counseled by ACCESS Counselor) at birth x 100 Total number of recent mothers who gave birth at home interviewed MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys 22.6% 73.4% *Percent of recent mothers who gave birth at home whose newborns cord were cut with clean/new instrument or that clean birth kit were used at their last childbirth Number of recent mothers who gave birth at home whose newborns cord were cut with clean/new instrument or that clean birth kit were used at their last childbirth x 100 Number of recent mothers who gave birth at home interviewed MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys 92.2% 95.9% *Percent of newborns who were breastfed or cup fed with breast milk within the first hour after childbirth Number of recent mothers who reported initiating breastfeeding or cup feeding breast milk their babies within 1 hour of birth x 100 Total number of recent mothers interviewed MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys %

160 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS *Percent of newborns who were exclusively breastfed or cup fed breast milk in the last 24 hours Number of recent mothers whose babies are less than 6 months old who reported exclusively breastfeeding or cup feeding their newborns in the last 24 hrs prior to the survey x 100 Total number of recent mothers whose babies are less than 6 months old at time of interview (disaggregated by age/month of baby) MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys % *Percent of newborns whose first bath was delayed for 3 days Number of recent mothers who reported delaying bathing their newborn for the first time until 3 day after birth x 100 Total number of recent mothers interviewed MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys 5.3% 81.1% *Percent of newborns who were delivered at home who were dried and wrapped immediately after birth Number of recent mothers who delivered at home who reported that their newborns were dried and wrapped before the delivery of the placenta x 100 Total number of recent mothers who delivered at home interviewed MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys 1.3% 54.0% *Percent of newborns who had nothing applied on to their umbilical stump after birth Number of recent mothers who reported that their newborns had nothing applied to their umbilical cord after birth x 100 Total number of recent mothers interviewed MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys 32.3% 82.4% Percent of recent mothers who reported receiving two TT immunizations during their last pregnancy Number of recent mothers who reported receiving two TT immunizations during their last pregnancy x 100 Total number of recent mothers interviewed PBS report PBS survey Baseline and endline surveys 40.6% - Percent of recent mothers who consumed iron/folate tablets during their last pregnancy Number of recent mothers who reported consuming iron/folate tablet during their last pregnancy x 100 Total number of recent mothers interviewed PBS report PBS survey Baseline and endline surveys 38.8% -

161 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS Percent of recent mothers who want to delay their next pregnancy for at least 2 years Number of recent mothers who want to delay their next pregnancy for at least 2 years x 100 Total number of recent mothers interviewed PBS report PBS survey Baseline and endline surveys 29.5% - Percent of recent mothers whose recent pregnancy were delayed for at least 2 years Number of recent mothers whose recent pregnancy were delayed for at least 2 years x 100 Total number of recent mothers interviewed PBS report PBS survey Baseline and endline surveys Percent of recent mothers who accepted a modern contraceptive method by 6 week postpartum Number of recent mothers who accepted a contraceptive method by 6 weeks postpartum x 100 Total number of recent mothers interviewed PBS report PBS survey Baseline and endline surveys 1.4% - Percent of recent mothers who reported using KMC or skin-to-skin with their newborn for their most recent birth Number of recent mothers who reported using KMC or Skin-to-skin with their newborns for their most recent birth x 100 Total number of recent mothers interviewed PBS report PBS survey Baseline and endline surveys 0.6% - Percent of recent mothers who reported practicing LAM as a method of contraception for their most recent birth Number of recent mothers who reported practicing LAM as a method of contraception for their most recent birth x 100 Total number of recent mothers interviewed PBS report PBS survey Baseline and endline surveys *Percent of recent mothers who reported putting her baby skin-toskin contact immediately after delivery Number of recent mothers (mothers who delivered 0-28 days prior to visit) who reported putting her baby skin-to-skin contact (skin-to-skin refers putting the baby on the mother s abdomen/chest immediately after delivery, after drying the baby) immediately after delivery x 100 Total number of live births MIS Report AC visit record review Quarterly 0.6% 13.7%

162 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS *Percent of recent mothers who reported practicing KMC with their newborn Number of recent mothers who reported practicing KMC (disaggregated by daytime and nighttime and by person) with their newborns, by duration in average number of hours per day and number of days x 100 Total number of live births KMC refers to prolonged skin-to-skin beyond the immediate skin-to-skin period. In KMC, the baby is placed skin-to-skin against the mother s chest, wearing only a nappy and a cap. The baby is then kept upright between the mother s breasts, inside her clothes and held in place by a cloth (sari) wrapped around the mother and baby. The baby is kept in this position constantly except for short periods for bathing, diaper changing, or when the mother is attending to personal needs. MIS Report AC visit record review Quarterly - Newborn kept in KMC position: 28.7% Kept for 1 day: 68.0% Kept for 2 days: 19.5% Kept for 3 days: 7.6% Kept for >3 days: 4.9% *Percent of recent mothers who were observed practicing KMC with their newborn Number of recent mothers who were observed practicing KMC with their newborns at the time of AC visit x 100 Total number of very tiny and smaller than average live births MIS Report AC visit record review Quarterly - Observed practicing KMC in MNC1 visit: 7.2% Observed practicing KMC in MNC2 visit: 5.5% IR1: To increase knowledge, skills, and practices of healthy maternal and neonatal behaviors in the home ACCESS/Bangladesh did not track indicators under IR 1 through routine MIS. However, these indicators were tracked through a baseline PBS survey and will be tracked again through an endline survey, which was not yet complete at the time of this report's publication.

163 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS Percent of recent mothers who can cite the key components of birth plans Number of recent mothers who listed preparation of birth materials and environment, maternal/newborn attendant arrangements, emergency transport plan, and arrangements for funds as part of a birth plan x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys Deciding where to deliver: 10.5% Deciding who will assist birth: 16.5% Ensuring a newborn care person: 7.4% Ensuring emergency transport: 6.0% Savings for emergency: 11.2% - Percent of recent mothers who know to seek at least 4 ANC from a skilled provider during pregnancy Number of recent mothers who reported knowing to seek at least 4 ANC during pregnancy x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 14.2% - Percent of recent mothers who know to consume iron/folate tablets during pregnancy Number of recent mothers who reported knowing to consume iron/folate tablets during pregnancy x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 13.5% - Percent of recent mothers who know to use a skilled provider during childbirth Number of recent mothers who reported knowing to use a skilled provider during childbirth x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 47.6% -

164 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS Percent of recent mothers who gave birth at home who know to use a Newborn Care Person at birth Number of recent mothers who gave birth at home who reported knowing to use a Newborn Care Person at birth x 100 Total number of recent mothers who gave birth at home interviewed PBS report PBS Survey Baseline and endline surveys 0.2% - Percent of recent mothers who gave birth at home who know using clean/new instrument or clean birth kit to cut newborns cord Number of recent mothers who gave birth at home who reported knowing using clean/new instrument or clean birth kit to cut newborns cord x 100 Total number of recent mothers who gave birth at home interviewed PBS report PBS Survey Baseline and endline surveys 78.0% - Percent of recent mothers who know to breastfeed their babies immediately after childbirth Number of recent mothers who reported knowing to breastfeed their babies within 1 hour of birth x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 98.8% - Percent of recent mothers who know to exclusively breastfeed their babies for the first 6 months Number of recent mothers who reported knowing to exclusively breastfeed babies for the first six months of life x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 74.4% - Percent of recent mothers who know to delay first bathing of their newborns for 3 days Number of recent mothers who know to delay first bathing of their newborns for 3 days x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 5.8% - Percent of recent mothers who know to dry newborns immediately after childbirth Number of recent mothers who reported knowing drying newborns before the placenta is delivered x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 14.9% - Percent of recent mothers who know to wrap newborns immediately after childbirth Number of recent mothers who reported knowing wrapping newborns before the placenta is delivered x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 19.4% - Percent of recent mothers who know that nothing should be applied on to the umbilical stump of the newborn Number of recent mothers who reported knowing that nothing should be applied on to the umbilical stump of the newborn x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 20.8% -

165 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS Percent of recent mothers who can cite at least three danger signs of pregnancy Number of recent mothers who cited 3 danger signs of pregnancy x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 58.0% - Percent of recent mothers who can cite at least three danger signs of childbirth Number of recent mothers who cited 3 danger signs of childbirth x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 29.4% - Percent of recent mothers who can cite at least three danger signs postpartum Number of recent mothers who cited 3 danger signs postpartum x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 46.7% - Percent of recent mothers who can cite at least three danger signs in newborn babies Number of recent mothers who cited 3 danger signs in newborn babies x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 94.6% - Percent of recent mothers who know to seek at least 2 PNC visits after delivery from a skilled provider Number of recent mothers who reported knowing to seek PNC after delivery from a skilled provider x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 13.2% - Percent of recent mothers who know how to use KMC or skin-toskin care Number of recent mothers who know how to use KMC or skin-to-skin care x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 1.7% -

166 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS Percent of recent mothers who know LAM as a method of contraception Number of recent mothers who know LAM as a method of contraception (disaggregated by source of information) x 100 Total number of recent mothers interviewed PBS report PBS Survey Baseline and endline surveys 0.97% Source- Doctor: 21.0% Nurse/midwi fe: 2.6% Paramedic: 5.8% FWV: 13.2% TBA: 1.1% Village doctor: 1.1% Relative: 8.4% Neighbor/fri end: 1.1 Other: 12.1% - IR2: Increased appropriate and timely utilization of home and facility-based essential maternal and neonatal health services *Percent of recent mothers who received at least four ANC visits from a skilled provider during their last pregnancy, by type of provider Number of recent mothers who received at least four ANC from a skilled provider during their last pregnancy, by type of provider x 100 Total number of recent mothers interviewed MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys 10.0% Doctor: 85.8% Nurse/midwi fe: 2.5% Paramedic: 4.8% FWV: 11.0% MA/SACMO : 0.7% 23.3%

167 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS *Percent of recent mothers who reported having developed a danger sign during pregnancy and sought care from a skilled provider, by type of provider Number of recent mothers who reported developing a danger sign during pregnancy and sought care from a skilled provider, by type of provider x 100 Total number of recent mothers who reported having developed a danger sign during their last pregnancy MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys 59.3% Doctor: 71.6% Nurse/midwi fe: 1.2% Paramedic: 0.9% FWV: 2.1% MA/SACMO : 0.6% 71.8% *Percent of recent mothers who reported having developed a danger sign during childbirth and sought care from a skilled provider, by type of provider Number of recent mothers who reported developing a danger sign during childbirth and sought care from a skilled provider, by type of provider x 100 Total number of recent mothers who reported having developed a danger sign during their last childbirth MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys 36.3% Doctor: 50.4% Nurse/midwi fe: 7.6% Paramedic: 0.7% FWV: 1.4% MA/SACMO : 0.6% 65.5% *Percent of recent mothers who received a PNC visit within 3 days after childbirth Number of recent mothers who received a PNC visit within 3 days after childbirth x 100 Total number of recent mothers interviewed MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys 13.2% 24.0% Percent of recent mothers who received at least two PNC visits for themselves from a skilled provider after childbirth, by type of provider Number of recent mothers who received at least two PNC for themselves from a skilled provider after childbirth by type of provider x 100 Total number of recent mothers interviewed PBS report PBS survey Baseline and endline surveys 4.8% - Percent of recent mothers who received at least two PNC visits for their newborns from a skilled provider after childbirth, by type of provider Number of recent mothers who received at least two PNC for their newborns from a skilled provider after childbirth by type of provider x 100 Total number of recent mothers interviewed PBS report PBS survey Baseline and endline surveys 6.5% -

168 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS Percent of recent mothers who reported having developed a postpartum danger sign and sought care from a skilled provider, by type of provider Number of recent mothers who reported developing a postpartum danger sign and sought care from a skilled provider, by type of provider x 100 Total number of recent mothers who reported having developed a danger sign after their last childbirth PBS report PBS survey Baseline and endline surveys 35.9% Doctor: 34.6% Nurse/midwi fe: 0.6% Paramedic: 0.2% FWV: 0.6% MA/SACMO : 0.4% - *Percent of recent mothers who reported that their newborns developed a danger sign at birth or within 1 month after birth and sought care from a skilled provider, by type of provider Number of recent mothers who reported that their newborns developed a danger sign at birth or within 1 month after birth and sought care from a skilled provider, by type of provider x 100 Total number of recent mothers who reported their newborns developed a danger sign at birth or within 1 month after birth MIS Report; PBS report AC visit record review; PBS survey Quarterly; baseline and endline surveys 43.7% Doctor: 41.5% Nurse/midwi fe: 0.5% Paramedic: 1.6% FWV: 2.1% MA/SACMO : 1.0% 52.5% IR3: Improved key NGO systems for effective intervention delivery *Number of married women of reproductive age (MWRA) living in ACCESS intervention areas The number of married women of reproductive age (MWRA) is the married female population between the ages of MIS report Census Quarterly - 245,982 *Number of pregnant women identified and registered in ACCESS intervention areas The number of pregnant women identified from all sources and registered by ACCESS Counselor in ACCESS intervention areas MIS report Pregnanc y Register Review Quarterly - 128,978 *Percent of recent mothers whose pregnancy was identified and registered at least 3 months before delivery Number of recent mothers whose pregnancy was identified and registered at least 3 months before delivery x 100 Total number of recent mothers interviewed MIS report Pregnanc y Register review Quarterly %

169 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS *Percent of recent mothers who reported having received at least two home visits by an ACCESS Counselor during their last pregnancy Number of recent mothers who reported receiving at least two home visits by an ACCESS Counselor during their last pregnancy x 100 Total number of recent mothers interviewed MIS report; PBS report Pregnanc y Register review; PBS survey Quarterly; endline survey 0.5% 70.9% Percent of recent mothers who reported receiving counseling from an ACCESS Counselor on the importance of 4 ANC visits Number of recent mothers who reported receiving counseling from an ACCESS Counselor on the importance of 4 ANC visits by a skilled provider x 100 Total number of recent mothers interviewed PBS report PBS survey Endline survey - - Percent of recent mothers with a danger sign during pregnancy who were referred by an ACCESS Counselor Number of recent mothers with a danger sign during pregnancy who were referred by an ACCESS Counselor x 100 Total number of recent mothers with a danger sign during their last pregnancy PBS report PBS survey Endline survey - - Percent of recent mothers who reported receiving counseling from an ACCESS Counselor on the importance of 2 PNC visits Number of recent mothers who reported receiving counseling from an ACCESS Counselor on the importance of 2 PNC visits by a skilled provider x 100 Total number of recent mothers interviewed PBS report PBS survey Endline survey - - *Number of pregnant mothers who received birth kits from ACCESS Counselor Birth kits consist of a square metre of plastic sheet, bar of soap, a razor blade, a length of string, and a pictorial instruction sheet. MIS report Pregnanc y Register Review Quarterly - 79,953 *Percent of recent mothers who reported receiving home visit by an ACCESS Counselor within 24 hours after childbirth Number of recent mothers who reported receiving home visits by an ACCESS Counselor within 24 hours after childbirth x 100 Total number of recent mothers interviewed MIS report; PBS report Pregnanc y Register Review; PBS survey Quarterly; endline survey 0.01% 52.2% *Percent of recent mothers who reported receiving home visit by an ACCESS Counselor within 5-7 days after childbirth Number of recent mothers who reported receiving one home visit by an ACCESS counselor within 5-7 days after childbirth x 100 Total number of recent mothers interviewed MIS report; PBS report Pregnanc y Register Review; PBS survey Quarterly; endline survey 0.02% 80.4%

170 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS *Percent of recent mothers who needed follow-up visits Number of recent mothers who needed follow-up visits (Follow-up visit includes additional visits to AC s current two postnatal visits, MNC1 & MNC2, that the AC may conduct for reasons such as mother needs more KMC/breastfeeding support (disaggregated by number, timing and reasons for visits) x 100 Total number of live births MIS report AC visit record review Quarterly - 3.1% Timing- Before 10 th day: 7.4% On 10 th day:72.4% After 10 th day:20.2% Reason- Positioning & attachment: 42.5% Expressed breastfeedin g: 18.8% KMC positioning: 65.0% Others:4.5% Percent of recent mothers with a postpartum danger sign who were referred by an ACCESS Counselor Number of recent mothers with a postpartum danger sign who were referred by an ACCESS Counselor x 100 Total number of recent mothers with a postpartum danger sign after their last childbirth PBS report PBS survey Endline survey - - Percent of newborns with a danger sign who were referred by an ACCESS Counselor Number of newborns with a danger sign who were referred by an ACCESS Counselor x 100 Total number of newborns with a danger sign PBS report PBS survey Endline surveys - - *Percent of recent mothers whose newborns had a danger sign reported complying with referral by an AC Number of recent mothers whose newborns had a danger sign reported complying with referral by an AC x 100 Total number of recent mothers whose newborns had a danger sign and were referred by AC PBS report PBS survey Endline surveys - -

171 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS Percent of recent mothers satisfied with specified services by an ACCESS Counselor by type of service Number of recent mothers satisfied with specified services (negotiation, counseling & referral) by an ACCESS Counselor by type of service x 100 Total number of recent mothers interviewed PBS report In-depth interview Endline survey - - *Percent of ACCESS Counselors who received two supervisory visits in the last month by Community Supervisor Mobilizer (CSM) Number of ACCESS Counselors who received two supervisory visits in the last month by Community Supervisor Mobilizer x 100 Total number of ACCESS Counselors MIS report CSM visit record review Quarterly % IR4: To mobilize community action, support and demand for the practice of healthy maternal and neonatal behaviors *Percent of villages in ACCESS intervention areas that have a Community Action Group (CAG) Number of villages that have a CAG by intervention union x 100 Total number of villages in that union MIS report CM/CSM Register Review Quarterly % Percent of recent mothers who are aware of the existence of a Community Action Group (CAG) in their villages Number of recent mothers who are aware of the existence of a Community Action Group (CAG) in their villages (if there are CAGs in the villages) x 100 Total number of recent mothers interviewed (in CAG villages) PBS report PBS Survey Endline survey - - Percent of recent mothers who are members of Community Action Group (CAG) Number of recent mothers who are members of Community Action Group (CAG) (if there are CAGs in the villages) x 100 Total number of recent mothers interviewed in CAG village PBS report PBS Survey Endline survey - - *Percent of Community Action Groups (CAG) that met at least once in the last 2 months Number of CAG that met at least once in the last 2 months x 100 Total number of CAG MIS report CAG Register review Quarterly % *Percent of Community Action Groups (CAG) with action plans to advocate for improved EMNC services Number of CAG with action plans x 100 Total number of CAG MIS report CAG Register review Semi- annually %

172 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS *Percent of Community Action Groups (CAG) that implemented at least 2 of their action plans within six months following the development of action plans Number of CAG that implemented at least 2 of their action plans within six months following the development of action plans x 100 Total number of CAG with action plans MIS report CAG Register review Semi- annually % *Percent of Community Action Groups (CAG) with an emergency transport system Number of CAG with an emergency transport system x 100 Total number of CAG MIS report CAG Register review Semi- annually % Percent of recent mothers who are aware of the existence of an emergency transport system Number of recent mothers in CAG village with emergency transport system who are aware of the existence of an emergency transport system x 100 Total number of recent mothers interviewed in CAG village with emergency transport system PBS report PBS Survey Endline survey - - Percent of recent mothers who experienced a pregnancy-related complication, or whose newborns experienced a complication, who used the emergency transport Number of recent mothers in CAG village with emergency transport system who experienced a pregnancy-related complication, or whose newborn experienced a complication, who used (during their last pregnancy/child birth/postpartum period) the emergency transport x 100 Total number of recent mothers who experienced a pregnancy-related complication, or whose newborns experienced a complication, in CAG village with emergency transport system interviewed PBS report PBS Survey Endline survey - - *Percent of Community Action Groups (CAG) with an emergency financing system Number of CAG with an emergency financing system x 100 Total number of CAG MIS report CAG Register review Semi- annually % Percent of recent mothers who are aware of the existence of an emergency financing system Number of recent mothers in CAG village with emergency financing system who are aware of the existence of an emergency financing system x 100 Total number of recent mothers interviewed in CAG village with emergency financing system PBS report PBS Survey Endline survey - -

173 ILLUSTRATIVE INDICATOR DEFINITION DATA SOURCE DATA COLLEC- TION METHOD FREQUENCY OF DATA COLLECTION PROGRESS UPDATE Baseline EOP MIS Percent of recent mothers who experienced a pregnancy-related complication, or whose newborns had a complication, who were benefited from the emergency financing system Number of all recent mothers or those who experienced a pregnancy-related complication, or whose newborns had a complication, in CAG village with emergency financing system who were benefited (during their last pregnancy/child birth/postpartum period) from the emergency financing system x 100 Total number of all recent mothers or those who experienced a pregnancy-related complication, or whose newborns had a complication, interviewed in CAG village with emergency financing system PBS report PBS Survey Endline survey - - *Percent of Community Action Groups (CAG) that have representation from the nearest health facility Number of CAG with at least one representative from the nearest health facility x 100 Total number of CAG MIS report CAG Register review Semi-annually % IR5: To increase stakeholder leadership, commitment, and action for these maternal and neonatal health approaches An integrated advocacy strategy developed. Yes/no measure. Activities will be identified and scoring will be done on the basis of the accomplishments. Program report Review of program report Annually Number of non-access supported organizations/programs that take action to expand home behavior messages or practices related to EMNC Program report Review of program report Annually Conferences, professional meetings, and formal presentations in which ACCESS Bangladesh staff contribute in Bangladesh Program report (qualitativ e list) Review of program report Semi-annually Number of government and/or donor policies, strategies and/or programs modified to incorporate maternal and neonatal health approaches promoted by ACCESS Program report (including qualitative list) Review of program report Annually

174 ETHIOPIA: UPDATE AS OF OCTOBER 23, 2009 RESULT INDICATORS (IN OUTCOME, OUTPUT, ACTIVITY SEQUENCE ) OPERATIONAL DEFINITION DATA SOURCE MEANS & FREQUENCY OF REPORTING RESPONS- IBILITY TARGET STATUS AS OF SEPTEMBER 9, 2009 Number of people trained in maternal/newborn health through USG supported programs (ACCESS)* This indicator will be disaggregated by type of course and sex of participant. Types of training courses include: clinical training skills for MNH for nurse-midwives community mobilization for MNH, BP/CR, and counseling and distribution of misoprostol, infection prevention and clean and safe delivery, postpartum/postnatal care for HEWs BEmONC training for HC staff TIMS reports Quarterly Jhpiego Target= * HEW=76 *TOT participant = 12 *BEmONC=16 Operational Indicator HEW: 71 of 76 trained TOT: 12 of 12 BEmONC: 17 Currently 12 participants are being trained in BEmONC at Assela hospital Number of community health promoters trained in community maternal and newborn health care Community mobilization for MNH, BP/CR, and counseling and distribution of misoprostol, postpartum/postnatal care for CHWs HP registers Access data collection form used at 38 kebeles /Semiannual SC/US Target = CHW 416 Custom Indicator 425 trained Number of deliveries with a skilled birth attendant (SBA) at USG-assisted programs* This indicator will be tracked at ACCESSsupported health centers and hospitals and includes deliveries by doctors, health officers, nurse/midwives. HMIS (18 HC and 6 Hospitals) Semi-annual ENMA Target =7500 Custom Indicator 5,627 Number of deliveries with a health extension worker in USG assisted programs This indicator will be collected from the health posts where the HEWs were trained in i.e deliveries attended by the 358 HEWs. HEWs are not considered skilled birth attendants; however USAID is interested in tracking the performance of this front-line cadre. HMIS HP in Oromia w/358 HEWs/Semiannual SC/US Target =2,250 Operational Indicator Roll over from prior Year: 3,749

175 RESULT INDICATORS (IN OUTCOME, OUTPUT, ACTIVITY SEQUENCE ) OPERATIONAL DEFINITION DATA SOURCE MEANS & FREQUENCY OF REPORTING RESPONS- IBILITY TARGET STATUS AS OF SEPTEMBER 9, 2009 Number/% of women receiving active management of the third stage of labor (AMTSL) through USG-supported programs* AMTSL is defined as the following three elements: 1) Use of uterotonic drug within one minute of birth (oxytocin is the drug of choice, preferred 10 IU/IM); 2) Performance of controlled cord traction; and 3) Performance of uterine massage after the delivery of the placenta. Number of women who received AMTSL in the specified time period at target facilities/total number of women with vaginal deliveries recorded in the specified time period at target facilities HMIS at 7 Health Centers and 6 Hospitals Semi-annual SC/US Yr 1: 300 Yr 2 =1200 Program Target: 1500 Operational Indicator 4,734 Percent/number of births in ACCESS-targeted facilities that occurred with a skilled attendant using a partograph Correct use of a partograph will be determined from facility records. Skilled attendants are those employed in skilled service provider categories according to the standards of the country. The percentage will be calculated by dividing the number of births recorded in the specified time period that occur with a skilled attendant using a partograph (numerator) by the number of births recorded in the specified time period (denominator). HMIS at 7 Health Centers and 6 Hospitals Take 20% of the completed partograph randomly and check whether they are used correctly Semi-annual SC/US Yr 1: 300 Yr 2 =1440 Program Target: 1740 Custom Indicator 1,631

176 RESULT INDICATORS (IN OUTCOME, OUTPUT, ACTIVITY SEQUENCE ) OPERATIONAL DEFINITION DATA SOURCE MEANS & FREQUENCY OF REPORTING RESPONS- IBILITY TARGET STATUS AS OF SEPTEMBER 9, 2009 Percent/Number of pregnant women who received misoprostol who took it correctly Number of pregnant women who received misoprostol and counseling from a trained HEW who took it according to standard/number of pregnant women who received misoprostol from a trained HEW HMIS (or in some cases, HEW/health post registers) Semi-annual SC/US Yr 1: 0 Yr 2: 740 Program Target=740 Custom Indicator 79 from West Harerge in 2009 Data from Y1 of program Is 3039 Number of MNH job aids printed and distributed to HEWs and CHWs Job aids are defined as community education pamphlets, cue cards, household action cards pertaining to maternal and newborn health developed and shared with trained HEWs and CHWs Save the Children/US records Semi-annual SC/US Target=1704 Custom Indicator 1,090 IEC materials (flip charts, Misoprostol cue cards, and BP/CR cue cards) were distributed Number of community groups who have generated funds (via different mechanisms) to contribute to maternal and neonatal complications and/or emergencies Number of community groups in program kebeles who report having generated funds (via different mechanisms) specifically to contribute to maternal and neonatal complications and/or emergencies Save the Children/US field visits and program records Semi-annual SC/US Target=208 Custom Indicator 220

177 RESULT INDICATORS (IN OUTCOME, OUTPUT, ACTIVITY SEQUENCE ) OPERATIONAL DEFINITION DATA SOURCE MEANS & FREQUENCY OF REPORTING RESPONS- IBILITY TARGET STATUS AS OF SEPTEMBER 9, 2009 Percent of USG supported health facilities compliance with clinical standards In addition to calculating a percentage of facilities which meet a minimum threshold for SBM-R (which is expected to remain low even at the end of the project period as typically months are needed to get significant gains in such an indicator), ACCESS will measure changes in percentages of standards achieved and thus measure progress toward this indicator. SBM-R records/fiel d visits and program records from 6 Hospitals SBM-R records/semiannual Jhpiego Operational Indicator 50% On the first internal assessment three of the six hospitals showed an improvement of more than 20 % Number of referrals for maternal and/or newborn complications by HEWs and other health cadres This indicator is referring to referrals from the health post to the health center or hospital. It will be disaggregated by referrals for maternal versus newborn complications disaggregated by facility HMIS (HEW/health post registers) From Oromia and West Hararge health posts Semi-annual SC/US Target=400 (Please note that referrals on the HMIS registrar do not differentiate between referrals for PMTCT, HIV testing and others) Custom Indicator 353

178 RESULT INDICATORS (IN OUTCOME, OUTPUT, ACTIVITY SEQUENCE ) OPERATIONAL DEFINITION DATA SOURCE MEANS & FREQUENCY OF REPORTING RESPONS- IBILITY TARGET STATUS AS OF SEPTEMBER 9, 2009 Number of occurrences where HEW (and/or HC staff) received feedback from a referral for a maternal or newborn complication This indicator represents the number of times that after a referral to a health center or hospital was made, the number of those times that feedback information about the patient was received at the health post. HMIS (HEW/health post registers) From Oromia and West Hararge health posts Semi-annual SC/US Target=360 Custom Indicator 8 Number of postpartum/newborn visits within 3 days of birth in USG assisted programs* This includes all skilled attendant deliveries plus facility or outreach postpartum/newborn visits for mothers/newborns that did not have SBA delivery. This includes all visits by HEWs Note, however, that there are limitations with the HMIS in Ethiopia. For example, the Ethiopia HMIS document only tracks the six hour, six days and six week postpartum visits. Therefore, it may be difficult to use the HMIS to track this indicator even though it specifies the date of visit in each postpartum visit. HMIS from 38 kebeles in West Harargie and 358 Oromia HEWs Health Post HMIS/Semiannual SC/US Y1: 2500 Y2: =1272 Program target = 3772 Operational Indicator 3882

179 RESULT INDICATORS (IN OUTCOME, OUTPUT, ACTIVITY SEQUENCE ) OPERATIONAL DEFINITION DATA SOURCE MEANS & FREQUENCY OF REPORTING RESPONS- IBILITY TARGET STATUS AS OF SEPTEMBER 9, 2009 Number of newborns receiving essential newborn care by HEWS through USG assisted programs This indictor captures infants who receive ENC (including clean cord care, drying and wrapping, immediate breastfeeding) from HEWs - The indicator will be tracked from the previously trained HEWs HMIS HP records (In Oromia only) Semi-annual SC/US Y1: 2500 Y2: =630 Program target = 3130 Operational Indicator 3654 Number pregnant women who are provided PMTCT counseling by HEWs Total number of pregnant women counseled for PMTCT counseling out of total number of pregnant women who received ANC Register/HM IS HMIS - Quarterly SC/US Target = 1500 Custom Indicator Roll over from prior 875 Number of pregnant women who receive HIV testing by HEWs Total number of pregnant women who were tested for HIV out of total number of pregnant women who were counseled for HIV Register HMIS HMIS - Quarterly SC/US Target = 1350 Custom Indicator Roll over from prior 771 Number of pregnant women who tested positive who were referred to health centers by HEWs Number of pregnant women who tested positive and were referred for combination therapy to a health center out of the total number of pregnant women who tested positive Register HMIS HMIS - Quarterly SC/US Target = 100% Custom Indicator Roll over from prior 7 NOTE: All women Referred to HC with ART; some women Accompanied by HEW

180 RESULT INDICATORS (IN OUTCOME, OUTPUT, ACTIVITY SEQUENCE ) Number of pregnant women who are not able/willing to go to health center to delivery and received Nevirapine at the time of delivery attended by HEWs OPERATIONAL DEFINITION Number of pregnant women who tested positive for HIV and were not able/willing to go to health center to delivery and received Nevirapine at the time of delivery by HEWs out of the total number of women who tested positive and did not go to the health center for delivery. DATA SOURCE Register HMIS MEANS & FREQUENCY OF REPORTING HMIS Quarterly Data Collection Sites HC = West Hararge Health Centers (6 new sites) + Oromia (12 sites from 2008) 2. 7 HC = West Hararge Health Centers (6 new sites) + Oromia (1) 3. HP (Health Post) register provided by Access with additional indicators added Kebeles in West Hararge Zone SC/US Save the Children Federation / USA ENMA- Ethiopian Nurse Midwives Association RESPONS- IBILITY SC/US TARGET Custom Indicator STATUS AS OF SEPTEMBER 9, 2009 Per policy decision by MOH,HEWs were not To be supplied with Nevirapine, so Indicator Is not Applicable

181 KENYA: 2007 SEPTEMBER 2009 INDICATOR / DELIVERABLE DEFINITION/CLARIFICATION DATA SOURCE FREQUENCY TARGET VALUES 2007 Jan- Jun 08 Jul- Sep 08 Oct- Dec 08 Jan- Mar 09 Apri- Jun 09 Jul- Sept 09 Program Performance ART Program Number of service providers trained in IMAI Number of trainers trained in IMAI Number of trainers trained in FP/STI/CCC Number of providers trained in FP/STI/CCC Number of trainers trained in PwP clinical skills training (CTS) Number of providers trained in PwP Providers are all qualified and practicing health workers, trained/re-trained using national curricula. These are clinical trainers trained using Jhpiego approach. Only those completing training satisfactorily are counted. Clinical trainers trained using Jhpiego approach. Only those completing training satisfactorily are counted. Providers are all qualified and practicing health workers, trained/re-trained using national curricula Clinical trainers trained using Jhpiego approach. Only those completing training satisfactorily are counted. Providers are all qualified and practicing health workers, trained/re-trained using national curricula TIMS Monthly TIMS Monthly TIMS Monthly TIMS Monthly TIMS Monthly TIMS Monthly

182 INDICATOR / DELIVERABLE DEFINITION/CLARIFICATION DATA SOURCE FREQUENCY TARGET VALUES Number of trainer trained in National Mentorship and Planning Clinical Skills Training (CTS) Clinical trainers trained using Jhpiego standardization approach. Only those completing training satisfactorily are counted Jan- Jun 08 Jul- Sep 08 Oct- Dec 08 Jan- Mar 09 Apri- Jun 09 Jul- Sept 09 Program Performance TIMS Monthly HIV/AIDS Testing and Counseling (HTC) Number of health facilities with service providers trained in PITC Number of health workers trained in PITC using the national approach and orientation package Number of health workers orientated on-site (Cascadees) by colleagues (cascaders) Facilities include district and sub-district hospital (service outlets) providing PITC services. Qualified and practicing health providers trained using the national curricula. Only those completing training satisfactorily are counted. Qualified and practicing health providers trained using the national curricula by colleagues. Only those completing training satisfactorily are counted. TIMS Monthly TIMS Monthly TIMS Monthly Prevention of Mother to Child Transmission of HIV (PMTCT) Number of health workers trained in SBM-R Module 1 for PMTCT plus Qualified and practicing health providers trained on SBM-R. Only those completing training satisfactorily are counted. TIMS Monthly

183 INDICATOR / DELIVERABLE DEFINITION/CLARIFICATION DATA SOURCE FREQUENCY TARGET VALUES Number of health workers trained in SBM-R Module 2 for PMTCT plus Qualified and practicing health providers trained on SBM-R Only those completing training satisfactorily are counted Jan- Jun 08 Jul- Sep 08 Oct- Dec 08 Jan- Mar 09 Apri- Jun 09 Jul- Sept 09 Program Performance TIMS Monthly Number of health workers trained in SBM-R Module 3 for PMTCT Plus Number of trainers trained in SBM-R CTS for PMTCT plus Number of health workers trained in PMTCT plus IMAI CTS Number of health workers trained in PMTCT plus IMAI Qualified and practicing health providers trained on SBM-R Only those completing training satisfactorily are counted. Qualified and practicing health providers trained on SBM-R. Only those completing training satisfactorily are counted. Clinical trainers trained using Jhpiego approach. Only those completing training satisfactorily are counted. Qualified and practicing health providers trained on PMTCT Plus IMAI are trained/re-trained using national curricula. Only those completing training satisfactorily are counted. TIMS Monthly TIMS Monthly TIMS Monthly TIMS Monthly Postpartum Hemorrhage (PPH)

184 INDICATOR / DELIVERABLE DEFINITION/CLARIFICATION DATA SOURCE FREQUENCY TARGET VALUES Number of trainers trained in AMTSL CTS to serve as a national resource Number of trainers mentored in first training Number of health workers receiving AMTSL skills strengthening Number of service providers receiving technical support on AMTSL in Western and Eastern provinces Clinical trainers trained using Jhpiego approach. Only those completing training satisfactorily are counted. Clinical trainers mentored using Jhpiego approach. Only those completing training satisfactorily are counted. Providers are qualified and practicing health providers trained using the national curricula. Only those completing training satisfactorily are counted. Providers are qualified and practicing health providers trained using the national curricula. Only those completing training satisfactorily are counted Jan- Jun 08 Jul- Sep 08 Oct- Dec 08 Jan- Mar 09 Apri- Jun 09 Jul- Sept 09 Program Performance TIMS Monthly TIMS Monthly TIMS Monthly TIMS Monthly The Division of Reproductive Health (DRH) Number of DRH trainers and officials oriented to the concepts of post rape care Managers will be selected from the central and provincial levels. Using an orientation package developed by JHPIEGO will be oriented RT Ca Management TIMS Monthly

185 INDICATOR / DELIVERABLE DEFINITION/CLARIFICATION DATA SOURCE FREQUENCY TARGET VALUES Number of providers trained in comprehensive management for survivors of sexual violence Number of trainers trained on clinical training skills (CTS) Number of providers oriented in knowledge on the diagnosis, management, treatment and referral of reproductive tract cancers Number of DRH staff and provincial RH coordinators oriented on care and use of anatomical models Providers are qualified and practicing health providers trained using the national curricula. Only those completing training satisfactorily are counted. Clinical trainers mentored using Jhpiego standardization. Only those completing training satisfactorily are counted. After the TOTs and service providers orientation, health workers at the facility will be disseminated with knowledge on RT Ca management using JHPIEGO OP. Providers are qualified and practicing health providers trained using the national curricula. Only those completing orientation satisfactorily are counted Jan- Jun 08 Jul- Sep 08 Oct- Dec 08 Jan- Mar 09 Apri- Jun 09 Jul- Sept 09 Program Performance TIMS Monthly TIMS Monthly TIMS Monthly TIMS Monthly

186 INDICATOR / DELIVERABLE DEFINITION/CLARIFICATION DATA SOURCE FREQUENCY TARGET VALUES 2007 Jan- Jun 08 Jul- Sep 08 Oct- Dec 08 Jan- Mar 09 Apri- Jun 09 Jul- Sept 09 Program Performance Injection Safety Number of health providers trained on injection safety Number of community health workers trained on infection prevention Number of health workers orientated on-site (cascadees) by colleagues (cascaders) Providers are qualified and practicing health providers trained using the national curricula. Only those completing training satisfactorily are counted. Community health workers trained using the national Infection Prevention Standards and Guidelines and Community Orientation package. Only those completing training satisfactorily are counted. Providers are qualified and practicing health providers trained using the national curricula. Only those completing training satisfactorily are counted. TIMS Monthly TIMS Monthly Program reports Cascadee data collection tool Monthly - 1,50 0 1, ,000 Integration of TB/FANC/MIP Number of providers and supervisors trained from four pilot sites Number of FANC/MIP trainers trained Providers are qualified and practicing health providers trained using the national curricula. Only those completing training satisfactorily are counted. Clinical trainers trained using Jhpiego approach. Only those completing training satisfactorily are TIMS Monthly TIMS Monthly

187 INDICATOR / DELIVERABLE DEFINITION/CLARIFICATION DATA SOURCE FREQUENCY TARGET VALUES Number of community health workers from the 3-malaria endemic districts trained Number of health workers from the 3-malaria endemic districts trained counted. Community health workers trained using the Community Orientation package. Only those completing training satisfactorily are counted. Providers are qualified and practicing health providers trained using the national curricula. Only those completing training satisfactorily are counted Jan- Jun 08 Jul- Sep 08 Oct- Dec 08 Jan- Mar 09 Apri- Jun 09 Jul- Sept 09 Program Performance TIMS Monthly TIMS Monthly Postnatal Care and Family Planning Number of service providers trained in PP- FP Number of trainers trained in PP-FP Number of health facility supervisors trained in PP- FP PQI Providers are qualified and practicing health providers trained using the national curricula. Only those completing training satisfactorily are counted. Clinical trainers trained using Jhpiego approach. Only those completing training satisfactorily are counted. These are the health facility in-charges. TIMS Monthly TIMS Monthly TIMS Monthly

188 INDICATOR / DELIVERABLE DEFINITION/CLARIFICATION DATA SOURCE FREQUENCY TARGET VALUES Number of PP-FP IUCD insertions These are clients receiving PPIUCD method after FP counseling as a method of choice. Program reports PP-FP monthly report form *Note: Materials/presentations developed and reproduced are reported on materials section 2007 Jan- Jun 08 Jul- Sep 08 Oct- Dec 08 Jan- Mar 09 Apri- Jun 09 Jul- Sept 09 Program Performance Monthly

189 MALAWI PERFORMANCE INDICATOR INDICATOR DEFINITION AND UNIT OF MEASURE SOURCE OF DATA METHOD OF DATA COLLECTION REPORTING Schedule Responsible PY1 Target PY1 TARGET AND RESULTS PY1 Results PY2 TARGET AND PROGRESS PY2 Target PY2 Results Goal: Accelerate the reduction of maternal and neonatal morbidity and mortality towards the achievements of the Millennium Development Goals (MDGs) ACCESS Program Objective: Increased utilization of MNH services and practice of healthy maternal and neonatal behaviors Result 1: Increased access to and availability of quality essential maternal and newborn care services Number of postpartum / newborn visits within 3 days of birth by trained workers from USG-assisted facilities Number of home visits conducted to newborns born at an ACCESS-supported health facility, within 3 days of their birth HSA Activity Log, Medical records HSAs to record dates/times of visit as they occur; Monthly feedback reporting to ACCESS office. Year 2 and EOP M&E Specialist 14,000 5,087 14,000 14,987 Number of women giving birth receiving AMTSL through USG supported programs Number of women who received AMTSL at sampled facilities/total number of women with vaginal deliveries at sampled facilities AMTSL is defined as the following three elements: Use of uterotonic drug within one minute of birth controlled cord traction uterine massage after the delivery of the placenta Maternity Register or patient charts; Observatio nal study Data collection as AMTSL occurs; Monthly feedback reporting to ACCESS for data review; ACCESS will conduct a formal mixed methods study on AMTSL provision. Year 2 and EOP M&E Specialist, Chief of Party 41,910 37,419 45,000 65,536

190 PERFORMANCE INDICATOR INDICATOR DEFINITION AND UNIT OF MEASURE SOURCE OF DATA METHOD OF DATA COLLECTION REPORTING Schedule Responsible PY1 Target PY1 TARGET AND RESULTS PY1 Results PY2 TARGET AND PROGRESS PY2 Target PY2 Results Number of newborns receiving essential newborn care through USG supported programs # of newborns born in selected ACCESSsupported health facilities who receive essential newborn care/ total number of newborns born in selected ACCESSsupported health facilities Essential newborn care consists of: Partograph review, KMC (LBW) register, Observatio nal study Copies of partograph and KMC register will be submitted to ACCESS monthly. Additionally, a formal mixed methods observational study will be conducted Year 2 and EOP M&E Specialist 41,910 37,419 45,000 65,536 Clean cord care Thermal care (immediate drying and wrapping or KMC) Immediate breastfeeding within 1 hour of birth

191 PERFORMANCE INDICATOR INDICATOR DEFINITION AND UNIT OF MEASURE SOURCE OF DATA METHOD OF DATA COLLECTION REPORTING Schedule Responsible PY1 Target PY1 TARGET AND RESULTS PY1 Results PY2 TARGET AND PROGRESS PY2 Target PY2 Results Number of ANC visits by skilled providers from USG-assisted facilities Number of antenatal care (ANC) visits by skilled providers from USG-assisted facilities. Skilled providers includes: medically trained doctor, nurse, or midwife. It does NOT include traditional birth attendants (TBA). ANC supplement al log Skilled providers conducting ANC visits will complete a log indicating the communities and pregnant women visited Semiannually M&E Specialist 330, , , ,100 Number of people trained in maternal and/or newborn health and nutrition through USGsupported programs Number of people (health professionals, primary health care workers, community health workers, nonhealth personnel, volunteers) trained in maternal and/or newborn health and nutrition care through USG-supported programs TIMS MNH trainings (including KMC, BEmONC, HSA for CM, PAC, etc. trainings) as they occur Semiannually M&E Specialist trained in PAC refresher; 91 new PAC providers Number of pregnant women referred by HSAs to ANC services Number of pregnant women referred by HSAs for ANC services HSA Activity Log HSAs record referrals as they occur; submit copies of logbook to ACCESS on monthly basis Semiannually M&E Specialist TBD Activities started in August ,700 2, Does not include PAC trainings. 77 Even though ACCESS exceeded this target, data from all implementing sites continues to be consolidated and entered into the database. In this case, ACCESS underestimated the number of ANC referral HSAs would be able to provide via home visits when setting the target.

192 PERFORMANCE INDICATOR INDICATOR DEFINITION AND UNIT OF MEASURE SOURCE OF DATA METHOD OF DATA COLLECTION REPORTING Schedule Responsible PY1 Target PY1 TARGET AND RESULTS PY1 Results PY2 TARGET AND PROGRESS PY2 Target PY2 Results Number of ACCESSsupported facilities where KMC services are in use Number of ACCESSsupported facilities which have established KMC room / all ACCESSsupported facilities KMC (Lowbirth weight) Register Review of KMC register to ascertain that clients are being admitted Year 2 and EOP M&E Specialist % of ACCESSsupported health facilities reporting a supervision visit in the last quarter Number of ACCESSsupported facilities which received at least one supervisory visit in the previous quarter / total number of ACCESSsupported facilities Program follow up visits, provider interview Provider and District Health Authority interviews will be conducted and reviewed alongside program reports. Semi- Annually M&E Specialist 100% (PY1 target) 100% (PY1 target) 100% 100% total (27 sites visited of 44 in current quarter) # of people at ACCESS-supported facilities who have been trained in safe injection practices Number of health care providers who have been trained in safe injection TIMS Data collection as training occurs Semiannually M&E Specialist (provided funds for onsite trainings in focus districts)

193 PERFORMANCE INDICATOR INDICATOR DEFINITION AND UNIT OF MEASURE SOURCE OF DATA METHOD OF DATA COLLECTION REPORTING Schedule Responsible PY1 Target PY1 TARGET AND RESULTS PY1 Results PY2 TARGET AND PROGRESS PY2 Target PY2 Results Number/% of facilities in target districts achieving 80% of standards in RH, PAC, and IP Number of ACCESSsupported facilities which were able to achieve a total score of 80% or higher, across all standards, on national performance standards / all ACCESS-supported facilities implementing PQI PQI database Data collection as assessments occur using a standardized PQI checklist Semiannually M&E Specialist IP:4 RH: 3 IP: 1 RH: 0 RH: 3 RH: 1 Number/% of facilities which are actively implementing PQI standards in RH, PAC and/or IP Number health centers and district hospitals completing at least 1 assessment in the past 6 month period / total number of health centers and district hospitals implementing PQI standards in target districts PQI database Data collection as health facility assessments occur Semiannually M&E Specialist 100% 100% 100% 100%

194 PERFORMANCE INDICATOR INDICATOR DEFINITION AND UNIT OF MEASURE SOURCE OF DATA METHOD OF DATA COLLECTION REPORTING Schedule Responsible PY1 Target PY1 TARGET AND RESULTS PY1 Results PY2 TARGET AND PROGRESS PY2 Target PY2 Results Number of people trained in FP/RH Number of people (health professionals, primary health care workers, community health workers, volunteers, non-health personnel) trained in FP/RH (including training in service delivery, communication, policy systems, research, etc.) TIMS Data collection as trainings occur Semiannually M&E Specialist Number of USGassisted service delivery points providing FP counseling or services Number of service delivery points (excluding door-todoor CBD) providing FP counseling or services, disaggregated, as appropriate, by type of service: vertical FP/RH; HIV including PMTCT; prenatal/post-natal or other MCH; sites offering long-acting or permanent methods (IUD, implants, voluntary sterilization). TIMS, Program Reports As trainings occur providers indicate the facility they represent. Semiannually M&E Specialist

195 PERFORMANCE INDICATOR INDICATOR DEFINITION AND UNIT OF MEASURE SOURCE OF DATA METHOD OF DATA COLLECTION REPORTING Schedule Responsible PY1 Target PY1 TARGET AND RESULTS PY1 Results PY2 TARGET AND PROGRESS PY2 Target PY2 Results Number of counseling visits for FP/RH as a result of USG assistance Number of visits that include counseling on FP/RH. Can include clinic visits as well as contact with CBD agents. HSA logbook As counseling visits occur Quarterly M&E Specialist 25,000 37,738 40, ,203 Number of policies or guidelines developed or changed with USG-assistance to improve access to and use of FP/RH services Number of policies or guidelines developed or changed to improve access to and use of FP/RH services. Program Reports Program officer will detail developments in FP/RH policies or guidelines Annually M&E Specialist (BEmONC in midwifery curriculum) Result 2: Strong MNH policies, planning and management in place at the national, zonal, and district level. Preservice nursing and midwifery BEmOC curricular component based on international evidence-based standards developed Preservice curricular component created and endorsed by national educational body for nurses and midwives Program reports Review of quarterly reports submitted by Program Officer and approved updated curriculum Annually M&E Specialist Number of students graduating from target nursing and midwifery preservice schools Number of students graduating from target nursing and midwifery preservice schools School records Aggregate number of graduating students reported to ACCESS by target schools Annually M&E Specialist TBD Students still in training TBD in May when students sit college exams 270 Result 3: Increased adoption of household behaviors that positively impact the health of mothers and newborns Number of target communities with Communities include Village Executive Program Records, Review of program reports Year 2 and EOP M&E Specialist 1 Community Mobilization 3 6

196 PERFORMANCE INDICATOR INDICATOR DEFINITION AND UNIT OF MEASURE SOURCE OF DATA METHOD OF DATA COLLECTION REPORTING Schedule Responsible PY1 Target PY1 TARGET AND RESULTS PY1 Results PY2 TARGET AND PROGRESS PY2 Target PY2 Results mechanisms for supporting birth preparedness/ complication readiness Committees which have developed mechanisms for supporting birth preparedness and complication readiness for community members key informant interview s supplemented by informant interviews during field visits activities to start in PY2 Examples include community financial schemes, emergency transport systems or community education schemes

197 USAID/NEPAL INTERMEDIATE RESULT 2.2: INCREASED USE OF SELECTED MATERNAL AND CHILD HEALTH SERVICES Number of Generic Maternal Newborn Care (MNC) Learning Resource Package (LRP) developed, tested and provided to HMG and key partners to be adapted and incorporated to the curricula of various cadre of SBA. This generic SBA Learning Resource Package accommodates the competencies and skills of Skilled Birth Attendants as defined by SBA policy of Nepal. Program records SBA Learning Package Record review ACCESS Nepal Program Manager and Program Officer Baseline: 0 Target: 1 Achieved: 1 Number and type (by cadre) of curricula adapted using MNC LRP. Existing in-service training curricula for various cadres adapted to ensure, the coverage of all SBA competencies to produce competent, skilled SBAs. Program records New curricula Record review ACCESS Nepal Program Manager and Program Officer Baseline: 0 Target:: 2 Achieved:3 Number of SBAs trained using MNC LRP The MNC LRP has been used to train Skilled birth attendants. Record from Nepal Health Training Center (NHTC) Record Review ACCESS Nepal Program Manager and Program Officer Baseline: 0 Target::5,113 Government of Nepal target for trained SBA by Achieved: 900 Number of SBA In-service Training (IST) Site Standards developed for use by NHTC and/or national accreditation systems A set of performance-based standards developed / adapted from Afghanistan midwifery school standards for Nepal SBA IST sites. Program records Standards Records review ACCESS Nepal Program Manager and Program Officer Baseline: 0 Target: 1 Achieved:1

198 Number of SBA In-Service Training (IST) sites assessed according to standards and working towards meeting them Current IST sites conducting BEOC (Basic emergency Obstetric care) and/or Midwifery Refresher training (MRT) training were selected for upgrading to SBA IST sites, according to the newly-defined standards. Program records Site assessment reports Record review ACCESS Nepal Program Manager and Program Officer Baseline: 0 Target:: 25 Achieved: 25 Number of QI (quality improvement ) tools with standards for site assessment printed and disseminated to Nepal Health Training Center (NHTC) The standards for site assessment were developed into a QI tool booklet that was distributed by NHTC to SBA training sites. Program Records Record Review ACCESS Nepal Program Manager and Program Officer Baseline: 0 Target: 500 Achieved : 500 Number of SBA training site meeting 80% of the QI tools (standards) by Nepal Health Training Center (NHTC) Selected training sites were assessed using the QI tools, Sites that score 80% and above are certified as SBA training sites. Program Records Record Review ACCESS Nepal Program Manager and Program Officer Baseline:0 Target: 25 Achieved: 15 Number of Community Strategies to identify and manage Low Birth Weight (LBW) Infants developed, tested and provided to Government of Nepal (GON) a for incorporation into the national protocols The community model will identify Low Birth Weights (LBWs) for targeted care at the home level by families and community workers and assist in referral if necessary. LBW Community Strategy Records review, Annual ACCESS Nepal Program Manager and Program Officer (LBW) Baseline: 0 Target: 1 Achieved: 1 Number of LBW infants identified and managed at the community as per the protocol Newborn infants who are less than 2.5 Kg identified in all VDCs in Kanchanpur. Cared for at home and community health facilities as per the protocol developed. CB MNC (Community based maternal and newborn care) forms and data collection system CB MNC reporting systems, Monthly CB MNC Kanchanpur team Baseline: 0 Target: TBD based on expected pregnancy and percentage of LBW Achieved: 980

199 Number of LBW infants managed at the facilities as per the protocol Newborn infants who are less than 2.5 kg referred in two zonal hospitals and one primary health care center. Managed at the facilities as per the protocol developed. Facility based forms and data collection system. Facility Reporting systems, Monthly ACCESS Nepal Program Manger and Program Officer (LBW) Baseline:0 Target:: TBD based upon case load at the facilities Achieved: 109 Number of guidelines developed for LBW infants to be included in the National Maternal and Neonatal standards and protocols Number of studies conducted to assess factors affecting skilled birth attendance and provide recommendations to HMG and other stakeholders Number of ITAG(International Technical Group) meetings for the Maternal Mortality and Morbidity Study conducted Number of Health Facilities assessed using standards for management of preeclampsia/eclampsia (PE/E) using Magnesium sulphate as evidence-based practice. Based on recommendations and information gained from relevant studies a National Guideline/ Protocol for LWB will be developed for the used at all service delivery levels and these guideline will be incorporated into national standards and protocols Study conducted thorough review of successes and failures of projects and investigates the perceptions and needs of community and the service provides, explore public private partnership and other factors affecting skilled birth attendance. NMMMS study conducted through SSMP, ACCESS provided the technical input through involvement of international technical advisory group. ACCESS worked in close collaboration with the professional association of Ob/ gyns using the SBMR approach LBW Guidelines Program records Study report Records review, Annual Records review, Annual ACCESS Nepal Program Manager and Program Officer (LBW) ACCESS Nepal Program Manager and Program Officer (LBW) Baseline: 0 Target: 1 Achieved:1 Baseline: 0 Target: 1 Achieved: 1 Study report Semi-annual National Baseline: 0 Project report Annual Regional, District Target :4 Achieved: 4 Baseline: 0 Target :22 Achieved:22

200 Number of Health Facilities meeting 80% of standards for management of pre-eclampsia/eclampsia (PE/E) using magnesium sulphate as evidencebased practice ACCESS worked professional association of Ob/gyns using SBM-R approach. Project Report Quarterly District Baseline: 2 Target: 22 Achieved: 11 Number of Health Facilities staff including FCHVs oriented to the importance of calcium during pregnancy for the Banke pilot, including distribution and IEC materials ACCESS oriented health facilities staff including FCHVs for calcium distribution at the community level to prevent pre-eclampsia/ eclampsia (PE/E) Project Report Annual District Baseline:0 Target: 40 Achieved: 66

201 ACCESS TANZANIA: REPORTED INDICATORS FY09, JULY SEPTEMBER 2009 INDICATOR BASELINE OCT DEC 2008 Percent/number of people trained in malaria treatment or prevention with USG funds Percent/number of facilities meeting clinical performance standards for FANC Percent/number of ANC clients who received a syphilis test at USGassisted health facilities Percent/number of ANC clients testing positive for syphilis who have received appropriate treatment at MAISHA-supported health facilities 2,988/50% (mainland, as of 30 Sept 08) 274 mainland; 24 Zanzibar JAN MAR mainland APR JUN mainland; 75 Zanzibar JUL SEPT mainland; 24 Zanzibar ANNUAL 1,449 mainland; 123 Zanzibar ANNUAL TARGET 875 (cumulative of 3,863/64%) mainland; 100 Zanzibar COMMENTS Using denominator of 6,000 ANC providers (for mainland) until further clarification provided by RCHS; no denominator yet available for ZNZ; in addition, 37 districts supported training of 845 providers with funds allocated to FANC in their CCHP N/A 1 or 10% 30% 10 facilities were assessed; one (Mnazi Mmoja) reached 85%, another (Kagera Regional Hospital) was at 65% and the others averaged around 45%) 66% (Oct-Dec08 sentinel site data) 100% (Oct-Dec08 sentinel site data) 66% 75% 68% 73% 71% 70% From sentinel site data 100% 87% 84% 83% 87% 100% From sentinel site data

202 INDICATOR BASELINE OCT DEC 2008 Percent/number of ANC clients at MAISHA-supported health facilities who received at least 90 tablets of iron over course of ANC visits Percent/number of ANC clients at MAISHA-supported health facilities who received one dose of mebendazole or albendazole Percent/number of ANC clients at MAISHA-supported health facilities who received 2 nd dose of IPT under DOT Percent/number of ANC clients at MAISHA-supported health facilities who received at least 2 injections of tetanus toxoid Percent/number of USG-assisted health facilities experiencing stockouts of specific tracer drugs (FANC) JAN MAR 2009 APR JUN 2009 JUL SEPT 2009 ANNUAL ANNUAL TARGET COMMENTS N/A N/A 30% 51% 65% 49% 50% From sentinel site data (denominator is 1st ANC visit clients, not all ANC clients) 63% (Oct-Dec08 sentinel site data) 54% (Oct 07-Sept 08 sentinel site data) 69% (Oct-Dec08 sentinel site data) 32% for SP ; 22% for RPR kits; no data for mebendazole/albe ndazole (Oct- Dec08 sentinel site data) 63% 53% 57% 83% 65% 65% From sentinel site data 37% 32% 36% 44% 38% 60% From sentinel site data; each quarter, MAISHA will report quarterly data as well as compiled data for the previous 4 quarters 69% 54% 58% 56% 62% 70% From sentinel site data SP=32%; RPR=22%; Meb/alb=N/ A ; Iron=N/A SP=32%; RPR=22%; Meb/alb=19 % ; Iron=41% SP=24%; RPR=27%; Meb/alb=16 % ; Iron=30% SP=31%; RPR=39%; Meb/alb=6% ; Iron=33% SP=49%; RPR=49%; Meb/alb=27 % ; Iron=59% 30% From sentinel site data (this number represents facilities which have had any stock out, even 1 day)

203 Annex D: Table of In-Country Materials and Presentations All materials for a global audience are available on the ACCESS website, and country materials are available through info@accesstohealth.org. BANGLADESH DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR MNH Reference Manual for ACs training ACCESS counselors/front line behavior change agents 2006 MNH Facilitators Guide training/counseling ACCESS core staff 2006 CM Manual training/supervision community mobilizers 2006 CKMC Manual training/supervision ACCESS counselors and all supervisory staff 2008 TBA Manual training traditional birth attendants 2007 Village Doctor s Orientation Guide Paramedic Training Manual training village doctors 2008 training Paramedics 2008 Flip chart training/resource tool pregnant mothers and family members 2007 Pictorial on dangers signs job aid pregnant mothers 2007 Birth and Newborn Care Preparedness card job aid pregnant mothers and family members 2007 Pictorial on KMC job aid pregnant mothers and family members 2008 Pictorial on dangers signs job aid traditional Birth attendants 2008 Demonstration doll training/resource tool pregnant mothers and family members 2007

204 ETHIOPIA DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Adapted community action cycle manual training material health extension workers 2008 Assessment of community capacity in 12 districts and linkage with health system survey report donor and partners including Oromia regional health bureau 2008 Birth preparedness and complication readiness tool job aids health extension workers, volunteers and community 2009 Maternal and newborn care tool job aids health extension workers, volunteers and community 2009 Misoprostol BCC tool job aids health extension workers, volunteers and community 2009 M&E activity report activity report donor, Oromia Regional/zonal/ woreda health offices and partners 2009 ACCESS community mobilization report activity report donor, Oromia regional/zonal/ woreda health offices and partners 2009 Program brief activity report donor, Oromia regional/zonal/ woreda health offices and partners 2009

205 HSSP DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Quality Assurance Nutrition Standards (English) Quality Assurance Mental Health Standards (English/draft) standards healthcare providers 2009 standards healthcare providers 2009 PPG newsletter newsletter PPG NGOs, MoPH, Partners, and MoWA AMA quarterly newsletter newsletter all AMA members, BPHS Implementers, and Midwifery Education Programs 2009 Basic & Advanced Newborn Care LRP LRP midwifes, doctors and nurses who are providing care for newborn baby and program people 2008 Condom Use Pictorial Job Aid Family Planning Myths Realities Correction Factsheet (draft) job aid healthcare providers 2009 factsheet healthcare providers 2009 National Health & Nutrition Communication Strategy (English, Dari) national strategy program managers, MoPH, and NGOs 2008 Neonatal Resuscitation job aid health workers at BPHS levels and program people 2009 Immediate Care of Newborn after Birth job aid health workers at BPHS levels and program people 2009 Tuberculoses (English, Dari) Action plan for HSSP activities to address gender job aid health care providers 2009 action plan HSSP employees 2008 Gender Training Curriculum (English, Dari, Pashto) LRP healthcare providers, NGOs, and health Shuras

206 KENYA DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR PPH and DRH Support Program Documents PPH Reference Manual reference manual service providers 2008 National RT Cancer Guidelines guideline policy makers, managers, and service providers 2009 RT Cancer Prevention and Management Orientation Package orientation package policy makers and managers 2009 RT Cancer Prevention and Management Learning Resource Package ART Program Documents learning resource package service providers 2009 Mentorship (clinical, pharmacy, laboratory and M&E) tools tools clinicians, pharmacists, lab technicians etc 2008 HIV mentorship orientation package service providers (doctors, clinical officers, nurses, lab techs, pharmacist, M&E ) already doing mentorship at their levels 2008 National HIV mentorship guidelines guidelines HIV service providers 2008 STI- CCC Integration orientation package HIV service providers working at the CCC 2008 FP-CCC Integration orientation package HIV service providers working at the CCC 2008 PMTCT Program Documents Draft PMTCT National Standards tool service providers and supervisors 2008 FANC/MIP Program documents Focused Antenatal Care/Malaria in Pregnancy orientation package service providers

207 DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR HIV Counseling and Testing (CT) Program Documents National Guidelines for HIV Testing and Counseling in Kenya, National AIDS & STI Control Programme guidelines healthcare workers 2008 Postnatal Care Family Planning Program Documents PPIUCD Learning Resource (trainers, participants and reference manual) Package learning resource package service providers 2009 PPIUCD Brochure IEC service providers 2009 PPIUCD Job Aid IEC service provider 2009 Injection Safety Community Infection Prevention Package orientation package community health workers and community health education workers 2008 Standards and Guidelines for Injection Safety and Medical Waste Management Orientation Package WHO/Jhpiego IP Standards Universal Precaution Job Aid orientation package health workers 2008 job aid health workers 2008

208 MALAWI DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR PQI RH Standards for Health Facilities training material Government, RH stakeholders, Service providers 2006 PAC Training Package 1. Teaching Notes 2. Participants Handbook 3. Facilitators Handbook training material Service providers 2009 Community Mobilization Manual training material HSAs and service providers 2008 KMC Module of Integration RH Training Manual (MOH) training material Service Providers 2008 BEmONC Curriculum/Syllabus curriculum/syllabus Midwifery tutors, preceptors and students 2009 CMNH IEC materials: 1. Care of the newborn 2. Nutrition 3. FANC 4. Dangers of traditional herbs Gestational wheels and MIP job aides IEC materials General population 2009 job aids ANC providers 2009 Ambulatory KMC training material training material HSAs and service providers 2009

209 NEPAL DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Nepal Maternal Mortality and Morbidity study strategy document national and international stakeholder 2009 IEC materials for Calcium supplementation for the prevention of PE/E at the community level packing material, sticker, BPP page, orientation leaflet pregnant women pregnant women Healthcare workers FCHVs 2009 Job Aids for MgSO4 intervention flyer A4 Size Flex Diary healthcare providers 2009 Maternal and Newborn Learning Resource Package (MNC LRP) trainer notebook, user s guide, participant handbook, CD-ROM (Nepali, English), clinical experience logbook skilled birth attendants trainers, teachers and students, participants 2007 Maternal and Newborn Care Quality Improvement Tools for Service Delivery and SBA In- service training (English, Nepali, and CD format) twelve individual tools consistent with MNC LRP, nine tools related to MNC services, three tools related to competency based- SBA training healthcare providers, skilled birth Attendants 2007 SBA In-service Training Course outline for Staff Nurses (for BEOCtrained participants) training course outline BEOC trained nurses 2007 SBA In-service Training Course for ANMs and staff nurses ( for MRTtrained participants) SBA In-service Training Course Outline for ANMs and Staff Nurses training course outline MRT trained nurses 2007 training course outline staff nurses and ANMs 2007

210 DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Utilization of Rural Maternity Delivery Services in Six Districts: A Qualitative Study qualitative Study Policy makers, healthcare professional associations, healthcare providers, donors 2007 Introduction of Kangaroo Mother Care (KMC) Services in Nepal program brief program managers, donors, healthcare providers 2007 Creating a Maternal and Newborn Care Learning Resource package in Nepal program brief program managers, donors 2008 Improving Skilled attendance at the community level in Nepal program brief program managers, stakeholders 2007 Strengthening Inservice training sites for Skilled Birth Attendants Using Standards in Nepal program brief program managers, stakeholders 2007 Providing Care For Low Birth Weight Infants: A community Level Approach in Kanchanpur District, Nepal program brief program managers, technical personnel, healthcare providers, donors 2007 National Implementation Guidelines for the Low Birth Weight Neonate Care and Management Kangaroo Mother Care (KMC) for Low Birth Weight Babies (LBW) guidelines policy makers 2007 training guide healthcare workers 2007 Care of LBW infants training manual female community health volunteers 2007

211 NIGERIA DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Factors enabling and constraining the use of maternal and newborn health services in northern Nigeria: Formative research findings and implications presentation American Public Health Association (APHA) 2007 Setting performance standards for emergency obstetric and newborn care in Nigeria presentation Society of Gynaecologists and Obstetricians of Nigeria (SOGON) 2007 Strengthening emergency obstetric and newborn care in Nigeria: results from a baseline survey presentation Society of Gynaecologists and Obstetricians of Nigeria (SOGON) 2007 Competency-based training for the prevention and management of postpartum haemorrhage presentation Society of Gynaecologists and Obstetricians of Nigeria (SOGON) 2007 Prevention of PPH: role of uterotonics presentation Society of Gynaecologists and Obstetricians of Nigeria (SOGON) 2007 Criteria based audit for the management of PPH presentation Society of Gynaecologists and Obstetricians of Nigeria (SOGON) 2007 Malaria in pregnancy presentation Society of Gynaecologists and Obstetricians of Nigeria (SOGON) 2007 Community mobilization for emergency obstetric and newborn care in Northern Nigeria: Successes and challenges presentation Public Health Physicians of Nigeria 2008 Using the Standards based management and Recognition Approach to improve the quality of emergency obstetric and newborn care in Nigeria presentation Public Health Physicians of Nigeria 2008

212 DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Strengthening monitoring and evaluation systems for emergency obstetric and newborn care in Nigeria presentation Public Health Physicians of Nigeria 2008 Strengthening Emergency Obstetric and Newborn Care in Northern Nigeria Through the Household- Hospital Continuum of Care presentation US Congress June-07 Healthcare standards in Nigeria presentation Society for Quality in Healthcare in Nigeria 2009 Training community-based providers in maternal and newborn health presentation Mini-university: Jhpiego Country Directors'retreat 2009 Kangaroo Mother Care: ACCESS Nigeria Experience presentation Paediatric Association of Nigeria (PAN) Conference 2009 Community Empowerment for improved Maternal and Newborn Health Care in Northern Nigeria presentation International Conference on Urban Health 2009 Pre-eclampsia and eclampsia presentation Mini-university: Jhpiego Country Directors'retreat 2009 Skilled birth attendance: the Nigerian reality presentation Nigerian Academy of Science 2009 Mobilizing for Community- Based Maternal and Newborn Care in Nigeria presentation Nigerian Society for Neonatal Medicine 2009 The role of coordination for effective collaboration in promoting reproductive health presentation MacArthur subgrantees in Nigeria 2008 Evolution of reproductive health programs in Jhpiego presentation GHC

213 DOCUMENT TITLE Mobilizing Communities for Maternal and Newborn Health: A Training Guide for Community Mobilization Teams TYPE OF RESOURCE TARGET AUDIENCE YEAR training material community trainers 2007 Mother and Newborn Health Reference Manual for Household Counsellors training material household counselors 2007 Training Curriculum for Household Counsellors - Trainer's Guide training material community trainers 2007 Birth Spacing through Male Motivators: A participant's Manual training material male healthcare providers 2008 Kangaroo Mother Care Training Manual Emergency Obstetric and New Born Care Counseling Flip Chart Counselling Flip Chart for Post Partum Family Planning training materials clinical trainers 2008 job aid healthcare providers 2008 job aid healthcare providers 2009 ACCESS 2 Health Poster job aid healthcare providers? Postpartum Family Planning Active Management of the Third Stage of Labor The ABCCCD of Eclampsia Management Job Aid for Management of Eclampsia Focused Antenatal Care Guide Prevention and management of postpartum haemorrhage Prevention and management of eclampsia job aid healthcare providers 2007 job aid healthcare providers? job aid healthcare providers 2007 job aid healthcare providers 2007 training materials healthcare providers 2008 training materials healthcare providers 2008 training materials healthcare providers 2008

214 DOCUMENT TITLE Skills Checklist Antenatal History, Physical Examination and Basic Care Lactational Amenorrhea Method (LAM): A Family Planning Method for Breastfeeding Women TYPE OF RESOURCE training materials/job aids training materials/job aids TARGET AUDIENCE YEAR healthcare providers 2008 healthcare providers, clients 2009 Malaria During Pregnancy Poster Algorithm for Management of Post-Partum Haemorrhage Required Skills for Management of Post- Partum Haemorrhage Are you pregnant? Promotion of Antenatal Care Poster Help Yourself to Survive Pregnancy and Childbirth Poster job aid healthcare providers 2008 job aid healthcare providers 2007 training materials healthcare providers 2007 behavior change clients 2009 training materials clients 2009 Performance Standards for Emergency Obstetric and Newborn Care in Nigerian Hospitals guidelines policy makers, healthcare providers 2007 Performance Standards for Emergency Obstetric and Newborn Care in Nigerian Primary Health Care Centers guidelines policy makers, healthcare providers 2007 Hand hygiene job aid healthcare providers 2008 Birth plan card Reducing maternal and Newborn Mirtality in Nigeria: A Quick Reference Guide for Frontline Health Workers behavior change clients 2007 training materials healthcare providers 2009

215 RWANDA DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Behave model document policy makers, program managers, healthcare providers Adaptation of EmOnC manual manual policy makers, program managers, healthcare providers 2008 Adaptation of FANC manual manual policy makers, program managers, healthcare providers Adaptation of KMC training manual manual policy makers, program managers, healthcare providers 2008 Rwanda national KMC guidelines guidelines policy makers, program managers, healthcare providers 2009 Postpartum counseling cards cards community health workers 2009 CHWs training manual manual community health workers 2009 CHWs register register community health workers 2009 Follow up card for pregnant women cards community health workers 2009 Referral sheet for pregnant women sheet community Health Workers 2009 Referral sheet for newborns sheet community health workers 2009 Christian and Muslim Sermon Guide to Promote Maternal and Infant Health FANC job aid for providers manual religious leaders 2009 poster healthcare providers 2009

216 SOUTH AFRICA DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Training Information Monitoring System (TIMS) A tool for bridging training GAPS workshop presentation KZN HIV AIDS Comprehensive Care, Management & Treatment summit 2009 TB Screening monthly staff presentation Jhpiego Program managers, Jhpiego staff members 2009 VIA / Cryotherapy in N W Province, South Africa training presentation Dr. Kenneth Kaunda district policy makers and facility/subdistrict/district health managers 2009 Cervical cancer screening using the Single Visit Approach through Visual Inspection with Acetic Acid (VIA) and treatment with Cryotherapy in the North West Province workshop briefing presentation US embassy staff, MCHIM affiliates and other PEPFAR funded organizations 2009 Jhpiego COP Indicators FY 2008 M & E Reportable indicators dashboard monthly internal reporting tool Jhpiego program managers, Jhpiego staff members 2009 Biomedical prevention of HIV: Male circumcision in South Africa workshop briefing presentation US embassy staff, MCHIM affiliates and other PEPFAR funded organizations 2009 MCHIP Programmes briefer Jhpiego staff and Jhpiego-SA Program managers 2009 Reducing maternal and child mortality through strengthening the PMTCT programme workshop briefing presentation US embassy staff, MCHIM affiliates and other PEPFAR funded organizations 2009

217 DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Prevention of Motherto-Child Transmission (PMTCT) Situational Analysis in Ventersdorp and Maquassi Hills Subdistricts training workshop District management TEAM of Kenneth Kaunda district (policy implementers and program managers) 2009 Jhpiego-Siyazi HIV counselling and Testing Project poster presentation US embassy staff, MCHIM affiliates and other PEPFAR funded organizations 2009 Improved Program Design, Implementation & Reporting Tools: Logical Framework Analysis - LFA briefer Jhpiego Program managers, Jhpiego staff members 2009 TIMS briefer Jhpiego program managers, Jhpiego staff members 2009

218 TANZANIA DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Anaemia Supplement report policy makers 2009 Assessment of MIPESA Country Experiences in the Adoption and Implementation of Malaria in Pregnancy Policies report stakeholders 2006 Core Competencies for Medical Officers for Comprehensive HIV/AIDS services in Tanzania guide medical Schools, stakeholders 2009 Delivering Malaria in Pregnancy Services in Tanzanian Communities presentation GHC Annual Conference 2008 Facilitator s Guide for Training Focused Antenatal Care Malaria and Syphilis in Pregnancy training guide trainers 2008 Focused antenatal care Malaria and Syphilis in Pregnancy National Advocacy Guide policy document policy makers, program managers, healthcare providers 2007 Focused Antenatal Care Malaria and Syphilis in Pregnancy: Antenatal Care Quality Improvement Tool tool HCWs 2008 Focused Antenatal Care: Malaria and Syphilis in Pregnancy- Learner s Guide for ANC Service Providers and Supervisors training guide service providers, supervisors 2007 For Good Health - Test For Syphilis brochure clients 2008 From Policy to Practice: A Quality Improvement Approach Improves Antenatal Care Services in Tanzania presentation APHA conference 2007 Improving quality of ANC services at health facilities in Tanzania presentation Arusha conference 2007 Increasing Uptake of IPTp Through Scaling Up FANC brief website visitors 2007 National Infection Prevent Control Guidelines printed guidelines healthcare providers 2007 National Infection Prevention and Control Guidelines for Healthcare Services in Tanzania: Pocket Guide For Health Care Workers reference guide healthcare providers 2007 National Road Map Strategic Plan to Accelerate the Reduction of Maternal and Newborn Deaths in Tanzania Mainland and Zanzibar policy document policy makers 2008

219 DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Nutritional counseling for Pregnant Women in Tanzania presentation providers 2008 Pre Service Education Quality Improvement tool for Nursing and Midwifery Programmes in Tanzania tool nursing school administrators 2007 Pre Service Learning Resource Package for FANC training guide nursing and medical school administrato rs and students 2008 PSE Medical School Needs Assessment Report report medical schools 2009 Results of applying an antenatal care quality improvement approach to IPT in Tanzania from 2004 through 2006 presentation AMANET Conference 2007 Save Lives: Go for ANC Services as soon as you recognize you are pregnant brochure clients 2008 Save Lives: Prevent Anaemia in Pregnancy brochure clients 2008 Save Lives: Prevent Malaria in Pregnancy brochure clients 2008 Scaling Up IPTp Using the Platform of Focused ANC: ACCESS Program in Tanzania: June 2004 to May 2007 presentation malaria and IMCI conference 2007 Status of Tanzania Mainland Malaria in Pregnancy Program presentation MIPESA conference 2008 Stockouts of SP for IPTp in Tanzania: Results from Mini-Audit report policy makers, MCP 2008 Supporting the Tanzania MoHSW to Scale Up Focused Antenatal Care Nationwide presentation press club 2008 Tanzania ACCESS Country Brief brief general 2009 The One Plan for Maternal, Newborn and Child Health policy document policy makers 2008 Training Module on Nutritional Counseling for Pregnant Women in Tanzania training guide providers 2008 Training Needs Assessment in Nutrition and Care During Pregnancy for Antenatal Care Providers report policy makers 2007 Using Sentinel Site Surveillance to Monitor Prevention of Malaria in Pregnancy Services in Tanzania presentation GHC Annual Conference 2009

220 DOCUMENT TITLE TYPE OF RESOURCE TARGET AUDIENCE YEAR Where did they go? Following nursing and midwifery graduates in Tanzania presentation World Bank HRH Conference 2008 Whole-site Infection Prevention and Control Orientation Guide training guide healthcare providers 2009

221 Annex E: ACCESS Country/Regional Activities- Funding Levels and Summary of Key Activities ACCESS COUNTRIES: AFRICA ACCESS COUNTRY PROGRAM YEAR FUNDING OBLIGATED KEY ACTIVITIES Ethiopia 1 $0 2 $0 3 $120,000 Core Build capacity of skilled providers in EMNC through Ethiopian Society of Obstetricians and Gynecologists Training Health officers Training Community Health Extension Workers Collaboration with AFR/SD preservice initiative 4 $1,792,476 Field Training Health officers in BEmONC Training Community Health Extension Workers $105,000 Core Build capacity of skilled providers in EMNC through Ethiopian Society of Obstetricians and Gynecologists Collaboration with AFR/SD preservice initiative ($174,991, core, for 3 countries) 5 $764,000 Field Training Health officers in BEmONC Training Community Health Extension Workers Ghana 1 $0 2 $0 $6,182 Core Build capacity of skilled providers in EMNC through Ethiopian Society of Obstetricians and Gynecologists Collaboration with AFR/SD preservice initiative ($171,753, core, for 2 countries) 3 $180,000 Core Expand EmONC Training Collaboration with AFR/SD preservice initiative 4 $100,000 Core Collaboration with AFR/SD preservice initiative ($174,991, core, for 3 countries) 5 $250,000 Field Strengthen MIP prevention and treatment

222 ACCESS COUNTRY PROGRAM YEAR FUNDING OBLIGATED KEY ACTIVITIES Guinea 1 $0 $114,989 Core Collaboration with AFR/SD preservice initiative ($171,753, core, for 2 countries) 2 $100,000 Field Expansion of PAC 3 $0 (field carry forward) Expansion of PAC and FP 4 $100,000 - Field Revise preservice module for school of medicine Train medical faculty and update in clinical skills and instructional design 5 $0 Kenya 1 $0 Institutionalizing best practices for FP [activities began in PY 1 and will be reported in 1st annual report even though we never got an approved workplan] 2 $1,120,000 Field Institutionalizing best practices for FP 3 $2,299,592 Field $125,000 Core Training for voluntary counseling and testing (VCT) counselors and Anti retroviral therapy (ART) within PMTCT programs Strengthen counseling and testing services for HIV in clinical setting 4 $3,132,740 Field Strengthen counseling and testing services for HIV in clinical setting Scaling up ART services $64,000 Core Expanding AMTSL service delivery 5 $0 76 Madagascar 1 $0 2 $0 3 $50,000 Field Quality and sustainability of focused antenatal care (FANC), intermittent preventive therapy (IPT) services 4 $300,000-Field Scale up FANC and quality improvements Strengthen MIP services through increasing uptake of IPTp Malawi 1 $0 76 ACCESS activities continued through Associate Awards and the MCHIP Program.

223 ACCESS COUNTRY PROGRAM YEAR FUNDING OBLIGATED KEY ACTIVITIES 2 $0 3 $ 215,000 Core Expand EmONC Training Collaboration with AFR/SD preservice initiative 4 $2,690,000 - Field Expansion of PAC, FP and Emergency Obstetric and Newborn Care (EmONC) in six districts hospitals FANC/IPT Community-based maternal and newborn care Kangaroo Mother Care (KMC) 5 $2,055,000 - Field Expansion of PAC, FP and Emergency Obstetric and Newborn Care (EmONC) in four central hospitals Community-based maternal and newborn care Kangaroo Mother Care (KMC) $300,000 Core OHA $300,000 Field OHA Integrate PMTCT and MNCH and implement as part of ACCESS model in two districts Nigeria 1 $0 2 $1,000,000 Field (multi-year) Emergency obstetric care and obstetric fistula 3 $2,750,000 Field Improvement of EmONC services Community mobilization regarding access to skilled providers Policy work on deployment of skilled providers $125,000 - Core Conduct study on local financing mechanisms to increase equity of health services in Nigeria 4 $2,323,000 Field Improvement of EmONC services Community mobilization regarding access to skilled providers Policy work on deployment of skilled providers $130,000 Core Apply lessons learned on local financing mechanisms to increase equity of health services in Nigeria

224 ACCESS COUNTRY PROGRAM YEAR FUNDING OBLIGATED KEY ACTIVITIES 5 $0 using carryforward Rwanda 1 $0 Apply lessons learned on local financing mechanisms to increase equity of health services in Nigeria 2 $20,000 Field 3 $650,000 Core Implementation of Safe Birth Africa Initiative $330,000 Field 4 $782,000 Core Implementation of Safe Birth Africa Initiative $650,000 Field/PMI 5 $601,299 Core (Includes carryforward) Expand FANC/MIP Implementation of Safe Birth Africa Initiative South Africa 1 $0 2 $0 3 $600,000 Field Dissemination of clinical guidelines around HIV/AIDS prevention and treatment 4 $1,245,000 Field Dissemination of clinical guidelines around HIV/AIDS prevention and treatment 5 $0 using carryforward Dissemination of clinical guidelines around HIV/AIDS prevention and treatment Tanzania 1 $950,000 Field Integrated ANC and PMTCT Preservice training in focused ANC Dissemination of IP guidelines Support to WRA 2 $2,320,000 Field Integrated ANC and PMTCT Preservice training in focused ANC Dissemination of IP guidelines Support to WRA Support to CEEMI (Malaria Center) 3 $1,962,000 Field Scale up FANC and MIP Strengthen nutrition in in-service and preservice training

225 ACCESS COUNTRY PROGRAM YEAR FUNDING OBLIGATED KEY ACTIVITIES $80,000 Core Collaboration with AFR/SD preservice initiative ($250,000, core, for 3 countries) 4 $4,053,000 Field Scale up FANC and MIP Core Collaboration with AFR/SD preservice initiative ($174,991, core, for 3 countries) 5 $743,016 Field 76 Scale up FANC and MIP Zambia 1 $0 2 $0 3 $50,000 - Field (pay back) 4 $0 Enhance the Social Mobilization effort to fight HIV/AIDS 5 $0 Malaria Action Coalition 1 $920,000 MAC Core $770,000 MAC Field 2 $900,000 MAC Core $685,000 MAC Field 3 $440,000 MAC Core ($200,000 new + $240,000 estimated carry forward) Field support from Kenya, Madagascar, REDSO ESA, Rwanda and WARP Coordination with MAC core funding Field support from Kenya, Madagascar, REDSO and Mali Personnel support in field and HQ to consolidate lessons learned PMI 4 $100,000 Personnel support in field and HQ to consolidate lessons learned 5 $100,000 Personnel support in field and HQ to consolidate lessons learned

226 ACCESS COUNTRIES: ASIA ACCESS COUNTRY PROGRAM YEAR FUNDING OBLIGATED KEY ACTIVITIES Afghanistan 1 $0 2 $3,000,000 - Field Support to the Afghan Midwives Association (AMA) Assist in the development of a new maternal and newborn health strategy Establish demonstration project for the prevention of postpartum hemorrhage (PPH) for home births Feasibility study for a maternity waiting home in Badakhshan Province 3 Carry forward Field $8,500,000 Associate Award/HSSP (multiyear) 4 $10,641,074 Associate Award/HSSP 5 $15,469,888 Associate Award/HSSP Support to AMA Continuation of PPH study Activities to support new program on improving quality of care in 13 provinces and training community midwives Expansion and scale up of PPH prevention Activities to support new program on improving quality of care in 13 provinces and training community midwives Expansion and scale up of PPH prevention Activities to support new program on improving quality of care in 13 provinces and training community midwives Bangladesh 1 $0 2 $1,600,000 - Field Support a community based initiative in Sylhet to improve access to evidencebased maternal and newborn health interventions 3 $2,445,146 - Field Community mobilization and behavior change for maternal and newborn health Policy work and advocacy for strengthening services 4 $1,916,006 - Field Community mobilization and behavior change for maternal and newborn health Policy work and advocacy for strengthening services TBA training

227 ACCESS COUNTRY PROGRAM YEAR FUNDING OBLIGATED KEY ACTIVITIES 5 $0 using carryforward Community mobilization and behavior change for maternal and newborn health Policy work and advocacy for strengthening services TBA training Cambodia 1 $0 2 $95,000 Core/ANE Policy support for maternal and newborn health Strengthen midwifery skills and increasing access to skilled providers 3 $600,000 Associate Award (1.8 million multi-year funding) Policy support for maternal and newborn health Strengthen midwifery skills and increasing access to skilled providers Expansion of evidence-based maternal and new born interventions $200,000 Core PPH prevention 4 $1,100,000 Policy support for maternal and newborn health Strengthen midwifery skills and increasing access to skilled providers Expansion of evidence-based maternal and new born interventions $0 Core (carry forward) 5 $0 Field ( carry forward) $0 Core (carry forward) PPH prevention Policy support for maternal and newborn health Strengthen midwifery skills and increasing access to skilled providers Expansion of evidence-based maternal and new born interventions PPH prevention India 1 $0 2 Core Improving Auxiliary Nurse midwives (ANMs) skills to provide services and increasing demand in the community 3 $500,000 Core $50,000 Field Improving ANM skills to provide services and increasing demand in the community 4 $496,000 Core Improving ANM skills to provide services and increasing demand in the community

228 ACCESS COUNTRY PROGRAM YEAR FUNDING OBLIGATED KEY ACTIVITIES 5 $75,000 Core Improving ANM skills to provide services and increasing demand in the community Nepal 1 $200,000 Field Development of human resource strategy for skilled birth attendants (SBA) and community-based maternal and newborn care 2 $2,450,000 Field (multi-year) 3 $0 ($1,000,000 field carry forward) Develop SBA learning resource package Develop and test a community strategy for the identification and management of low birth weight (LBW) infants Assist with national guidelines for LBW in the National Neonatal Health strategy Policy work on the enabling environment of SBAs in rural communities. CEDPA (Adolescent health Curriculum development and training for skilled providers Guidelines development for LBW infants Community management of LBW infants $160,000 Core KMC 4 Carry forward Core Continue expansion of KMC 5 $500,000 Field Strengthening national in-service training systems Community management of LBW infants

229 ACCESS COUNTRIES: LATIN AMERICA AND CARIBBEAN ACCESS COUNTRY PROGRAM YEAR FUNDING OBLIGATED KEY ACTIVITIES Haiti 1 $1,500,000 Field Increased accessibility and use of PMTCT Strengthened reproductive health postabortion care (PAC), infection prevention and family planning (FP) Assess Cervical Cancer Prevention 2 $695,000 Field Increase accessibility and use of PMTCT services Strengthen RH PAC, FP, IP Assess Cervical Cancer Prevention activities 3 $450,000 Field Strengthen PMTCT training and services Strengthen RH PAC, FP, IP 4 $130,000- Core FP/RH Field test PAC module Revise curriculum 5 $0 pw ACCESS COUNTRIES: USAID REGIONAL BUREAU ACTIVITIES ACCESS BUREAU PROGRAM YEAR FUNDING OBLIGATED COUNTRIES KEY ACTIVITIES USAID/ East Africa 1 $0 2 $0 3 $127,000 Kenya 4 $0 (carry forward) Strengthen and integrate TB screening and referral, diagnosis for pregnant women into FANC services Wrap up activities 5 AFR/SD Bureau 1 $200,000 Angola, Ethiopia, Ghana, Mozambique, Nigeria, Mali, Senegal, Tanzania Training of technical experts/facilitators for the implementation of the Africa Road Map Preservice midwifery education

230 ACCESS BUREAU PROGRAM YEAR FUNDING OBLIGATED COUNTRIES KEY ACTIVITIES 2 $400,000 Zambia, Niger, Senegal, Burkina Faso, Mauritania, Ghana, Malawi, Tanzania, Ethiopia 3 $400,000 Ghana, Tanzania, Ethiopia, Malawi 4 $400,000 Ghana, Tanzania, Ethiopia Implementation of Africa Road Map in 5 countries Preservice midwifery education in 4 countries Lusophone conference Improve pre-service midwifery education Support WHO s Road Map for Safe Motherhood in Africa Improve pre-service midwifery education Support WHO s Road Map for Safe Motherhood in Africa 5 $100,000 Ghana, Ethiopia Improve pre-service midwifery education Support WHO s Road Map for Safe Motherhood in Africa ANE Bureau 1 $430,000 Nepal, Bangladesh, Cambodia, Afghanistan, India, Indonesia, Philippines, Pakistan, West Timor Support to WHO/SEARO Country level advocacy for Lancet series on neonatal health Technical support to scaling up prevention of PPH Development and integration of community-based postpartum care MotherNewBorNet in Asia 2 $0 ($373,150 carry forward) 3 $0 ($208,932 carry forward) 4 $0 ($34,722 carry forward) 5 $0 Nepal, Bangladesh, Cambodia, Afghanistan, India, Indonesia, Philippines, Pakistan, West Timor Support MotherNewBorNet Support to WHO/SEARO for a regional meeting Support to USAID and MOH/Cambodia Support panelists and participants to ANE Best Practices meeting LAC Bureau 1 $50,000 Guatemala, Peru,, Bolivia, DR, Paraguay Research and preparation of strategic document for newborn health with multiple stakeholders

231 ACCESS BUREAU PROGRAM YEAR FUNDING OBLIGATED COUNTRIES KEY ACTIVITIES 2 $75,000 (received as GH/HIDN core) 3 $0 ($17,271 carry forward) 4 $0 5 $0 Bolivia, DR, Guatemala, Peru Completion of regional newborn strategy on EMNC Printing and dissemination of Newborn Policy USAID/ West Africa 1 $300,000 Mauritania, Cameroon Development of EMNC providers in Cameroon Training of community social mobilizers 2 $300,000 Cameroon Development of EMNC providers in Cameroon and Mauritania Training for social mobilization trainers 3 $300,000 Cameroon, Mauritania, Togo, Niger Development of EMNC providers Training for social mobilization 4 $0 (carry forward) 5 $0 Cameroon, Mauritania, Togo, Niger Wrap up activities

232 Annex F: Associate Awards ACCESS/CAMBODIA ACCESS/Cambodia is a $1.8 million project (December 15, December 30, 2009) that aims to improve the availability of and access to high-quality, sustainable maternal and newborn health services. ACCESS/Cambodia works with the Cambodia Ministry of Health, USAID and their local partners, and key stakeholders to: strengthen maternal and newborn health policies and programs to reduce maternal and neonatal mortality; improve the capacity of the Cambodian government to increase access to skilled providers; and expand essential maternal and newborn care interventions through existing health services. The project is primarily focused at the national level; however, through strong collaboration with seven local partners, the integrated postpartum/postnatal care package pilot was field tested in 80 health facilities in 12 operational districts in seven provinces. Major results include: Conducted a national survey to determine how AMTSL and management of eclampsia are practiced in Cambodia and identify key areas for improvement. In the 30 health facilities selected, 141 vaginal deliveries were observed and structured interviews were conducted with facility staff and new mothers. Results indicated the nationally representative percentage for AMTSL use among public facilities with 400 or more annual deliveries is 17.1%. No facility adhered to correct eclampsia practice according to international standards. Results led to an agreement by the MOH to revise the national safe motherhood polices for prevention of PPH and management of eclampsia to align with WHO recommendations and international standards. Led a coalition of seven partners to develop, field test, and finalize a national integrated postpartum/postanatal care in-service training package. Through this pilot, 335 midwives and 23 trainers were trained, including members from the NRHP training unit and provincial level trainers. Results from the field test indicated an overall trend toward improvement in PNC visits for mothers and babies, particularly within the first 24 hours of delivery. Target behaviors by pregnant women, mothers and newborns increased, such as coverage of Vitamin A (58% to 77%) and iron (57% to 75%) for mothers and immunizations (38% to 59% for Hepatitis B vaccination) and skin-to-skin care (32% to 42%) for babies. Contents of the package have been reflected in the recently revised national safe motherhood protocols. Reviewed all current midwifery in-service training packages in Cambodia and provided the MOH with a detailed assessment and an evidence-based plan to develop a single, cohesive, modular package that adheres to the national safe motherhood protocols. ACCESS-FP Initiated September 25, 2005, ACCESS-FP is an associate to the ACCESS Leader Program. It is a five year award with a total of $17,217,000 obligated $8,252,000 core and $8,965,000 field for eight countries as of September The goal of ACCESS-FP is to reduce unmet need for family planning (FP) among postpartum women by strengthening FP in maternal, neonatal, and child health service delivery programs. Specifically, the program aims to: 1. Test alternative service delivery approaches to expand contraceptive options and increase the use of modern FP methods among postpartum women; 2. Improve use of the lactational amenorrhea method (LAM) and the transition to longer-term modern contraceptive methods; 78 ACCESS activities continued through Associate Awards and MCHIP.

233 3. Promote healthy timing and spacing of pregnancy; and 4. Identify targets of opportunity to strengthen FP in maternal, neonatal, and child health programs. Major Results Include: Created the term "PPFP" and crafted a working definition and strategy for addressing this significant gap at country level. Innovated application of DHS data for women in first year postpartum. Developed PPFP profiles for 17 countries (including 13 PRH priority countries) as well as synthesis of findings. Operationalized and tested integrated models of PPFP including postnatal care and FP in Kenya and community-based newborn care and FP in Bangladesh with research partners. Revitalized LAM with an emphasis on transition; pushed the field forward in thinking about transition from LAM to other methods through barrier analysis in three countries; harmonized integration strategies by promoting exclusive breastfeeding linked to LAM promotion. Complementary training package for LAM transition developed and disseminated. Revitalized PPIUCDs, leading integration with delivery care including AMSTL and midwives role in providing services; created country-level champions in India and Kenya in PPIUCD; In Kenya, 355 postpartum women received PPIUCD since October 2008 and ACCESS-FP is currently carrying out a follow-up survey of 49 providers and client satisfaction among 120 PPIUCD clients post-insertion and at six months. Established and led on-line PPFP community of practice through the IBP website. The PPFP community of practice has over 700 members and on line discussions with experts from a variety of organizations and projects are hosted three-times a year. Led and hosted three global PPFP technical meetings to facilitate learning and exchange in PPFP advocacy and programming. The last meeting in May 2009 convened 76 experts and learners in FP and MNCH from 22 organizations. Prepared global tools for PPFP including provider learning resource package, PPFP message guide, and community health worker learning training package for low literacy workers. Developed e-learning course for PPFP and PPFP toolkit website. Led and evaluated an application of systematic screening for breastfeeding and amenorrheic women in two hospital sites in Northern Nigeria. Introduced PPFP concepts and operationalized programs in ten countries, Afghanistan, Albania, Bangladesh, Burkina Faso, Guinea, Haiti, India, Kenya, Nigeria and Tanzania. Introduced PPFP concepts in Rwanda, Ghana and Mali for program application by other partners. Trained 1,116 service providers in Albania, Bangladesh, Burkina Faso, Guinea, Haiti Kenya and Uganda in areas of LAM, PPFP, PNC, EmONC/FP, PAFP or PPIUCD. In addition, 51 service providers were trained in Nigeria (also reported under ACCESS). Trained 937 community health workers Bangladesh, Burkina Faso, Guinea, Haiti Kenya and Uganda in PPFP; and 384 in Nigeria (also reported under ACCESS). Counseled 199,262 clients attending essential MNCH services for integrated family planning services in Albania, Bangladesh, Kenya and Nigeria.

234 HSSP INFO FOR ACCESS REPORT The Health Services Support Project (HSSP) which runs July 2006 to November 2011 is a $57 million project that focuses on improving the delivery of high-quality health care services in health facilities across 13 (soon to be 17) provinces in Afghanistan. The HSSP strategic framework aims to develop stronger health systems, increase access to high-quality services at the primary and secondary health facility levels, increase capacity of the MoPH to design and implement effective and research-based behavior change communication programs, and increase community involvement in the protection and promotion of health. The cornerstone of HSSP is strong partnerships with the MoPH and NGOs implementing the BPHS. Gender is a key area that cuts across all activities, such as quality improvement, behavior change, and capacity building. HSSP has achieved significant results to date. Specifically, HSSP has Developed national quality assurance standards for 14 priority areas of the BPHS to improve health service delivery. Awarded 11 midwifery education grants to support the training of midwives. To date, 462 midwives have graduated from HSSP-supported hospital midwifery and community midwifery education programs. Supported the National Midwifery Education Accreditation Board to accredit 21 of the 27 midwifery education programs. This represents 78% of the total number of midwifery programs in the country. Trained 5,267 participants from NGOs, health facilities and the MoPH on subjects including basic emergency obstetric care, rational use of drugs, effective teaching skills, and behavior change and communication. Trainings target specific needs identified by the MoPH and the NGOs. TANZANIA-MAISHA The MAISHA (Mothers and Infants Safe, Healthy and Alive) program, which runs from October 2008 until September 2013, is a $40 million project focusing delivering critical, evidence-based health interventions on a national scale to reduce maternal and newborn morbidity and mortality. As such, the MAISHA program is building local and national human and material capacity to address the following objectives: Reduction of maternal mortality due to major direct causes of mortality; Reduction of newborn mortality due to infection, hypothermia and asphyxia through immediate newborn care; Reduction of low birth weight, stillbirth and newborn mortality due to malaria and congenital syphilis; and Reduction of transmission of HIV infection from mother to child and increase of HIV free survival. MAISHA has Achieved the Following Results to Date: Trained 1,425 additional providers in FANC/MIP/SIP on mainland and 123 on Zanzibar equaling, on mainland, a cumulative total of 4,536 providers trained out of an estimated 6,000 reproductive health providers in FANC/MIP/SIP, and 123 on Zanzibar. In addition, through advocacy under ACCESS and MAISHA, an additional 845 providers were trained on mainland with district support between July 2008 and June 2009, for a cumulative total of 5,381 providers trained on mainland. Covered an additional 1,102 FANC facilities with a trained provider, equaling a cumulative total of 2,633 FANC facilities (54% coverage of all FANC facilities). In addition, 845 providers trained with district support represent an additional 309 facilities, for a total of 2,942 facilities with a FANC trained provider (60% coverage). On Zanzibar, 83 facilities have been covered to date through MAISHAsupported FANC training. Trained 30 service providers in BEmONC.

235 Prepared 15 national KMC trainers to conduct KMC training. Trained 20 providers in KMC through transfer training. Established KMC services at regional hospital in Mtwara. Trained 19 regional RCH coordinators in facilitative supervision and use of FANC performance standards. Provided 15 facilities with initial supplies for strengthening BEmONC service delivery. Noted decreases in stockouts of SP, mebendazole and oxytocin. KENYA-UZIMA ACCESS-Uzima, a $9,000,000 associate cooperative agreement of the ACCESS Program, ran from March 2009 to March 08, The program coverage is national and provincial mandated to improve maternal, newborn, reproductive health and HIV outcomes. The program aimed to: provide direct support to the ministries of health at central level, mainly the Division of Reproductive Health and NASCOP; strengthen central and provincial MOH capacity to rollout priority interventions; introduce key technical areas to enhance existing programs that directly impact services throughout the country; and collaborate with APHIA II partners and other stakeholders to enhance and expand implementation efforts. Major Results Include: Trained 1,224 participants (service providers and supervisors) from the Ministry of Health and others, such as Community Health Workers (CHWs), to scale up high-impact interventions and increase utilization of family planning, reproductive health and HIV services in various program areas: PMTCT (74); ART and Clinical PwP (1,012); PITC (60); and PNC-FP/PPIUCD (78). Printed several documents: The RCO curriculum (20); FANC/MIP training packages (3,000); FP/HIV Orientation Packages (700); STI/HIV Orientation Packages (700); clinical mentorship guidelines (200); and the PPIUCD Learning Resource Package (300). The PNC-FP Orientation Package was also updated and printed. ACCESS-Uzima supported the revision of the Clinical Officers pre-service curriculum to strengthen Prevention and Treatment of Malaria in Pregnancy and the Performance Standards and Assessment Tool for PMTCT in Kenya. Supported the Division of Reproductive Health to conduct quarterly supportive supervision visits to all provinces. ACCESS-Uzima also supported four provincial general hospitals to provide HIV treatment to eligible pregnant women at the MCH clinic and to improve the quality of PMTCT care at eight provincial general hospitals through implementation of service standards using the SBM-R approach. ACCESS-Uzima supported several stakeholder, advocacy and mobilization meetings in all program areas in order to build consensus and get stakeholders buy-in.

236 Annex G: Country Specific Survey Results: India, Nigeria and Rwanda 79 Specific Survey Results: India EXECUTIVE SUMMARY The importance of Maternal and Neonatal health interventions is reinforced by the high incidence of the maternal and neonatal deaths which occur mainly due to infection and complications relating the pregnancy. Majority of these deaths can be prevented though access to skilled attendants and emergency obstetric care facilities and supplies. The high rates of maternal death, coupled with inadequate health services and poor nutrition, also contribute to high numbers of infant and child mortality. ACCESS, USAID s global program to improve access to clinical and community maternal and neonatal care tested a model for maternal and newborn care that will improve access to skilled birth attendance during pregnancy, delivery and the postnatal period. ACCESS worked in partnership with Government of India (GoI), Government of Jharkhand (GoJ), CEDPA and a number of local organizations in India to implement and evaluate this project. This study to assess the effect of the maternal and neonatal health interventions was conducted by Social and Rural Research Initiative of IMRB International (SRI-IMRB). This report presents the findings from the endline survey carried out in the Dumka District of Jharkhand. The study was conducted to provide technical assistance to the Maternal and Child Health Division, Ministry of Health and Family Welfare, Government of India to test the new Guidelines on skilled attendance at birth, and early postnatal care and test a training model to increase access and quality of services for women and newborns during pregnancy, labor and postpartum period through the skilled attendance at birth initiative of its Reproductive and Child Health (RCH) II program under the National Rural Health Mission (NRHM) in the Dumka District of Jharkhand. RESEARCH OBJECTIVES The assessment of the effect that a maternal and new born care (MNC) training program for ANMs on, a. Increasing the number of women using their services and b. The quality of the MNC services they provide at the community level. An assessment of the effect of a Behavior Change and Communication (BCC) intervention on Birth Preparedness and Complication Readiness (BP/CR) and postpartum care for mother and newborn implemented through the community mobilization of self help groups like Anganwadi Workers (AWWs) Sahiyakas, Community Health Volunteers (CHVs) and Mahila Mandal, on a. pregnant women s BP/CR knowledge and practice, b. immediate postpartum care for the mother and newborn, and c. the use of SBAs by women who have recently (in the past three months) given birth. An assessment of the effect that a training program for supervisors (LHVs) has upon their ability to provide appropriate performance support and supervision to newly trained ANMs. 79 All documents are available through the MCHIP Program: Endline Survey Report: Increasing Skilled Attendance at Birth in Dumka District, Jharkhand, India 1

237 METHODOLOGY A quasi-experimental posttest only control group design was utilized for Objective 1. The design consists of an experimental group comprised of ANMs (N=28) who received the training intervention of three months on the GoI guidelines for skilled attendance, and a control group of ANMs (N=18) who did not receive any training, but are located in the same three blocks, where GoI guidelines have been disseminated. Upon completion of their training, nine months was given for the ANMs in the experimental group to conduct their maternal and newborn care activities. Hypotheses were tested using data collected from the two groups at the end of the period (posttest) on the use and quality of services they have provided. A quasi-experimental pre-test-post-test control group design was utilized for Objective 2. This design contains an experimental and control group, each comprised of systematic random samples of pregnant women, and women who have recently given birth (within the past six months). The design is characterized by a baseline household survey of the experimental and control groups; a BCC intervention of 12 months on BP/CR conducted in the experimental group; and a follow-up household survey in the experimental and control groups that can be compared with the baseline to test hypotheses on the effects of the intervention. Data were collected for Objective 3 from ANMs in the experimental and control groups on the monitoring and supervision provided by LHVs and Medical Officers. FINDINGS The project interventions produced statistically significant but modest increases in the numbers of women who delivered with an ANM. The project demonstrated improvements in the quality of services provided by the trained ANMs in the experimental group. The project demonstrated statistically significant increases in client satisfaction among recent mothers in the experimental group. The project interventions did not produce a significant effect upon the knowledge of BP/CR among pregnant women or among recent mothers. The changes in level of knowledge over the program period in the control group of women essentially kept pace with the changes in levels found in the experimental group. Further analysis is required to identify the reasons for this outcome, including the possible contamination of the control group from the BCC intervention and/or other BCC activities implemented in the area. The project interventions showed significant effects on the knowledge of postpartum/postnatal care including essential newborn care, among pregnant women and recent mothers in the experimental group. The project interventions had a significant effect on the practice of BP/CR for both pregnant women and recent mothers, and on the practice of essential newborn care among recent mothers.

238 SUMMARY AND CONCLUSIONS Maternal and neonatal health has been much discussed in various studies and the importance of the same cannot be ignored in any respect. Similar studies have been conducted in Jharkhand after its formulation as a separate state in the year It has been observed that the health status in Jharkhand especially the maternal and neonatal health is a matter of concern. Being a predominantly tribal state there are many factors contributing to the poor health status including poverty, poor infrastructure, lack of adequate management of services, high morbidity etc. The health statistics show that maternal mortality and morbidity comprise a major portion of the disease burden of the state. Infant mortality rate is as high as 70 per 1,000 live births. Sixty percent of the infant deaths are neonatal deaths. Maternal mortality is very high at 504 per 100,000 live births. According to state government figures among all pregnant women antenatal care was received by only 40 percent, 33 percent received Iron Folic Acid supplement, 50 percent received tetanus toxoid injection. Nearly 90 percent deliveries take place at home and only 25 percent of all couples use modern methods of family planning. Female sterilization dominates (88 percent) and 20 percent married women need of unmet FP needs. 2 The facts relating to the maternity deaths point out towards the need of health interventions in the sector of maternal and neonatal deaths. It can be said that training birth attendants who are responsible for these deliveries on grounds of major aspects of antenatal care, delivery care and postnatal care can be a probable solution to equip them with better skills so that the related deaths can be avoided. This model of training of ANM was floated for test by CEDPA in Dumka district of Jharkhand. The study was conducted by SRI to assess the effect of the Maternal and Neonatal Health Interventions in Jharkhand. From the study, it was found that about 13.2 percent deliveries are attended by the ANMs in the experiment group (trained ANMs) and 6.8 percent by the ANMs in the control group (untrained ANMs). It was also found that the majority of deliveries conducted at home were not attended by an SBA. There was a significant increase in recent mothers satisfaction with ANMs in the experimental group (compared to control group) in their: ability to explain various aspects of pregnancy and childbirth (z=3.65), advice on diet and nutrition (z=3.47), advice on care during pregnancy (z=4.21), advice on preparations for delivery (z=3.94), ability to answer all queries (z=4.63) and advice on importance of checkups (z=5.79). Use of a partograph and active management of third stage labour were not practiced at all in Dumka district before this project. By the end of the three quarters, ANM in the experimental group improved AMTSL. There was a significant increase in the counseling pertaining to mother and newborn. This includes counseling on exclusive breastfeeding, healthy timing and spacing of pregnancies, care of the newborn, child immunizations. Data were also collected on the level of satisfaction that the beneficiaries get from the services provided by ANMs. Respondents of the experimental group were found to be significantly more satisfied on certain parameters like approachability and relevance of information on advice provided than the respondents of the control group at the same time duration. Majority of the respondents in both baseline and endline are satisfied with the various parameters related to ANC. By endline, the satisfaction level decreased in both groups regarding the ANMs ability to handle complications during pregnancy. On all other areas of ANC surveyed respondents with experimental group were more satisfied on ANM services than those with the control group. A significantly higher percentage of respondents of the experimental group were satisfied regarding all parameters related to delivery care and postnatal care such as explaining importance of postnatal, conducting postnatal check-ups and advice on immunization than control group. The assessed the knowledge levels of both pregnant women and recent mothers on various aspects of birth preparedness, complications readiness, care of new born, and actions to be performed immediately after birth. Pregnant women identified SBA, saving money for delivery, arranging for transport and identifying a blood donor. 2 Endline Survey Report: Increasing Skilled Attendance at Birth in Dumka District, Jharkhand, India 3

239 The respondents were also asked about serious health problems that could occur during the first seven days after birth. The major health problems mentioned by the respondents were difficult or fast breathing, pneumonia, yellow skin/eye color and cough. The knowledge levels regarding the danger signs in the newborn baby seem to be quite low among the respondents. Ascertaining about the correct knowledge on initiation of breastfeeding after delivery, the responses of those who had mentioned that the child should be breastfeed immediately before delivery of placenta, within half an hour of delivery and within one hour of delivery were combined to obtain one clear indicator. It emerged that 74 percent of mothers in the experimental group who had given birth recently reported that the child should be breastfeed within an hour of birth. The practices relating to birth preparedness and complications readiness and the actions taken immediately after the delivery were analyzed in the study. Fewer recent mothers in the experimental group planned for a home birth by endline (70% to 57% vs. 73% to 77.8% in the control group). Also more recent mothers in the experimental group set aside funds: 26% to 57.5% vs. 31% to 38.9% in the control group. Similar changes were found among currently pregnant women surveyed. The effectiveness of any program depends on the level of monitoring and supervision and hence it is expected that adequate monitoring and supervision over the health service providers will ensure maximum reach of the services related to maternal and neonatal health to the beneficiaries. However, from the study it was found that the visit of Lady Health visitor (LHVs) and medical officers were not very frequent as reported by ANMs. The results presented above support the following conclusions: The project interventions produced statistically significant but modest increases in the numbers of women who delivered with an ANM. The project demonstrated improvements in the quality of services provided by the trained ANMs in the experimental group. The project demonstrated statistically significant increases in client satisfaction among recent mothers in the experimental group. The project interventions did not produce a significant effect upon the knowledge of BP/CR among pregnant women or among recent mothers. The changes in level of knowledge over the program period in the control group of women essentially kept pace with the changes in levels found in the experimental group. Further analysis is required to identify the reasons for this outcome, including the possible contamination of the control group from the BCC intervention and/or other BCC activities implemented in the area. The project interventions showed significant effects on the knowledge of postpartum/postnatal care including essential newborn care, among pregnant women and recent mothers in the experimental group. The project interventions had a significant effect on the practice of BP/CR for both pregnant women and recent mothers, and on the practice of essential newborn care among recent mothers.

240 Specific Survey Results: Nigeria SAFE MOTHERHOOD IN NORTHERN NIGERIA RESULTS FROM AN EVAULATION OF THE ACCESS PROGRAM IN KANO AND ZAMFARA STATES

241

242 EXECUTIVE SUMMARY INTRODUCTION In November and December 2006 the ACCESS Nigerian Program conducted a household survey of women who had given birth in the past year (recent mothers) in Kano and Zamfara states, located in the North West Zone of the country. This survey examined recent mothers reported utilization of maternal and newborn health services, knowledge of target behaviors and danger signs, and reported barriers to accessing care to establish baseline measures and provide information for program design. This household survey was part of a larger ACCESS Program evaluation study carried out in four Local Government Authorities (LGAs) in Kano and Zamfara, which also included a facility survey. In November 2009, after three years of program intervention in the four LGAs, another study was conducted, using the same instrument, but with some modifications, to provide endline measures of changes that have occurred in knowledge of emergency obstetric, newborn and family planning services as well as target behaviours among recent mothers. This report presents the findings of this endline evaluation, and comprises findings from the household survey and qualitative data derived for focus group discussions (FGDs). Nigeria s health and development indicators are among the worst in the world, especially in the northern states. The national maternal mortality ratio (MMR) is estimated at 545 per 100,000 live births and the neonatal mortality rate (NMR) is estimated at 46 per 1,000 live births (NPC and ICF Macro 2009). With a total fertility rate of 7.3 in the North West zone, higher than the 5.7 for the entire country, women are repeatedly exposed to the risks associated with childbearing. The high levels of maternal and newborn deaths in Nigeria are reflections of low utilization of maternal and newborn services due to inadequate availability and accessibility of these services. Skilled attendance at birth in the North West is the lowest of all six geopolitical zones in the country: only 9.8% of women delivered with a skilled attendant relative to 38.9% nationally (NPC and ICF Macro 2009). Only 31% of pregnant women in the North West Zone received antenatal care (ANC) from a trained health provider (nationally 57.7%). The contraceptive prevalence rate in the North West is only 2.8%, with 2.5% of married women using a modern method of family planning (FP). The corresponding figures for Nigeria are: 14.6% and 9.7%. Educational levels of females in Nigeria are low, with only about 64% having at least some primary school education (only 25.8% in the North West Zone), a variable known to be associated with use of health services. The United States Agency for International Development (USAID)/Nigeria awarded the ACCESS Program funds to design and implement a three-year program to increase the use and quality of emergency obstetric and newborn care (EmONC) and FP services beginning with two northern states: Zamfara and Kano. The program initially targeted two LGAs in each state, but has now been expand to Katsina States. Although the Project initially commenced implementation in four LGAs in Kano and Zamfara States, the total coverage as at the time of the endline evaluation was 22 LGAs in three States including Katsina. The ultimate health goal of the ACCESS Nigeria Program is to reduce maternal and neonatal mortality in Nigeria. To achieve this objective, the ACCESS Nigeria Program is implementing community- and facility-based interventions focusing on comprehensive and basic EmONC, FP, ANC and postpartum care. The present report is an evaluation of three years of project implementation in two original states: Kano and Zamfara. ACCESS Nigeria Baseline Household Survey in Kano and Zamfara States 1

243 METHODOLOGY The evaluation study consists of a cross-sectional pre-/post-intervention design. The two major components of the study are: 1) a survey at the household level to ascertain knowledge, practices and coverage associated with evidence-based maternal and newborn health care behaviors and services; and 2) a facility survey to ascertain the quality of delivery, especially EmONC, postpartum and FP services. The surveys were conducted in the four start-up LGAs in the two states, which were selected with stakeholder input: Dawakin Tofa and Gezewa in Kano and Gusau and Kaura Namoda in Zamfara. A multi-stage sampling procedure was used in the selection of eligible women, starting with a random selection of five enumeration areas (EAs) from each of the four target LGAs in the two states. Fieldwork was carried out during November Verbal informed consent was obtained for all study participants and confidentiality was ensured by protecting both the respondent and the data collected. At the individual level, confidentiality was protected by: private interviews, appropriate training for interviewers and adequate field supervision. Once the data were collected, confidentiality was protected by limited access to completed data collection forms, and lack of individual identifiers in the electronic data sets. The completed data collection forms were stored in a secured cabinet and only staff involved in this study have access to the data. KEY FINDINGS This report presents the findings from the endline household survey of women who delivered in the past year. A total of 444 women were included in the final analysis. Socio-Demographic Characteristics of Respondents: Mean age of respondents was about 27 years Mean parity was 4 children Respondents had 444 live births A total of 19 women were pregnant at the time of the survey. Respondents were predominantly rural, poor, uneducated and illiterate, and of Hausa ethnicity. About half of the women lived in Kano and half in Zamfara. Knowledge of Danger Signs and Essential Newborn Care: Knowledge of danger signs and essential newborn care was significantly higher at the endline than the baseline. The percentage of women could identify at least four danger signs across the four periods of analysis (pregnancy, labor and delivery, postpartum and newborn) was significantly higher at endline (from 53% at baseline to 79.5% at endline). Urban women, women with six or more births, those who were educated/literate, and those lived in Kano State were more knowledgeable than others. For elements of essential newborn care, 91% of respondents knew to dry and wrap the baby immediately, 65% knew to practice clean cord care and 41% knew to breastfeed within one hour of birth. The corresponding figures at baseline were 72.5%, 62.6% and 26.5% respectively. Knowledge and Practice of Birth Preparedness 2 ACCESS Program Evaluation in Kano and Zamfara States

244 More than eight out of ten women (83.6%) at endline had heard about birth preparedness relative to only 46.5% at baseline. As at the baseline women identified purchasing clothes for the baby and purchasing clean delivery kits/items as the top two birth planning steps (both at 84.4%). Women with formal education or literate, and those living in Kano were more familiar with the concept of birth preparedness than others at endline. About 68% of the women reported making any birth preparedness arrangements at endline; only 31.8% of respondents did so at baseline. The most common arrangement was saving money for birth at a facility or at emergency (92.9%), identification of a skilled provider (45%) and identification of a means of transportation (40.3%). This is a very significant improvement in knowledge from the situation at the baseline. Perceptions of Local Health Facilities Overall, 76.2% of respondents were able to mention at least one public or private facility where a woman could give birth with a skilled attendant, up from 62.9% at baseline. Among these women about 79% ranked the services as excellent or good (compared with 62.7% at baseline). There was a more positive perception of facility at endline in Kano than Zamfara, among illiterate than literate women, among rural than urban women and among those with no formal schooling than those who has a formal education. The three most important reasons for positive rating of facility include facility always open, doctor always there, and staff treat women with respect. Experience and Care during Last Pregnancy At baseline about 42% women received at least one ANC visit during their last pregnancy. This increased to 74% at endline. Among those who had at least one ANC visit, the mean number of visits was 5.8 at baseline and 4.5 at endline. The mean number of months pregnant at first visit was 4.7 at baseline and 4.8 months at endline. About 53% of the women received 4 or more ANC visits at endline; only 34.3% of women did so at baseline. Women who did not receive ANC said the main reasons health facility too far (21.1% of the women, down from 31.4% at baseline), too expensive (15.5% at endline and 9.6% at baseline) and do not know where to go (9.9% at endline and 8.1% at baseline). Government hospitals were the most important source of ANC for study respondents who received ANC at the endline (78.4%), followed by PHCs (14.4%). The corresponding figures at baseline were 72.4% and 26.3% respectively. A higher percentage of women received each of the six key components of ANC services at the endline than the baseline period, but the greatest change was observed for anti-malaria drugs and FP, especially in Kano. The proportion of respondents who received advice for each of the birth preparedness issues doubled between the baseline and endline periods, with where to give birth, where to go if there are danger signs, and danger signs of serious health problems as the most discussed. Only 43 women (10.9%) reported that they experienced a serious health problem during their last pregnancy at baseline compared with 32.9% at endline. The four top health problems experienced by the women at endline were: severe headache, high fever, severe abdominal pain and severe weakness. ACCESS Program Evaluation in Kano and Zamfara States 3

245 Experience and Care during Labor and Delivery Of the respondents, 25.3% reported having a skilled attendant (doctor, nurse/midwife or clinical officer) at endline. Among those assisted by others or who did not respond, 14.3% said they would have preferred that someone else assisted with the birth instead of the person who actually did it. Most women delivered their last child at home, about 80% at both baseline and endline. This is very high, but lower than 90% found by 2008 NDHS for North West zone where the two states are located. Only two women delivered by cesarean section at baseline, and only seven women said they experienced severe health problems, such as severe bleeding and prolonged labor. At endline there were six cesarean sections, and 54 women reported severe health problems. Among women who reported at baseline that a final decision about where to deliver was made by someone, it was either made by jointly by her and her husband or by the woman herself in most cases. At endline the final decisions were made jointly by the woman and her husband or by the husband alone. Nearly 30% of the women at baseline said that no one made any decision, only 15% of women said so at endline. Experience and Care during the Postpartum Period About 51% of women at endline reported that someone checked on their health after they gave birth, up from 22% at baseline. Nearly 80% of those whose health was checked on by someone were seen within minutes or hours after delivery (67.8% at baseline). Significantly higher percentages of women at endline than baseline were given Vitamin A and iron supplements during their postpartum visit. Forty-eight women or about 23% of those who received postpartum care selected an FP method during their postpartum visit at endline. Only five did so at baseline. Most reasons for not choosing a method were husband-related. Only 21.1% of women with live births (80 women out of 379 women with live births) reported that someone checked their babies within the first six weeks after birth. A total of 63.0% of those were checked minutes or hours after giving birth. Urban women, Zamfara women, women with some education, literate women and women with parity two or higher were more likely to have their babies checked within six weeks after birth. A total of 27 women at baseline (6.8%) said they experienced a serious health problem during the two days after birth, including bleeding, headache, blurred vision, swollen hands/face and difficulty breathing. At endline 55 women or 13.2% experienced a serious health problem. About 78% of these women sought medical assistance (68% at baseline). Those who did not seek assistance thought it was not necessary or used home-made remedies. There is a significant increase in the proportion of women whose children were examined by someone within the first six weeks after birth. Only nine women at baseline and 35 women at endline said their baby experienced a serious health problem within seven days of birth. Virtually all the women at baseline and endline said they breastfed their most recent baby; 88% of the women fed their babies with the first liquid that came from the breasts, up from 66% at baseline. Fertility Preferences and Knowledge, Use and Perceptions of Family Planning 4 ACCESS Program Evaluation in Kano and Zamfara States

246 Only 11 women (2.8%) at baseline and 43 women (9.8%) at endline did not want any more children. About 80% of women at baseline and endline would like to have a/another child. A sizable proportion of women (15.1% at baseline and 10% at endline) were undecided as to whether or not they would have another child. Knowledge of FP methods was generally low at baseline, except for pills and injectables. There is a significant increase in knowledge of most of the FP methods at the endline. Current use of FP among non-pregnant women was extremely low, with only five women reporting they were using a method at baseline; 67 women reported current use of FP at endline. The three most common methods were LAM, injectables and pills. Almost 30% of respondents at baseline thought their husbands should decide about whether or not to use FP and 19.4% supported a joint decision between the husband and wife. The corresponding figures at endline were 47% and 37% respectively. While 32.6% of the women said they don t know who should make decisions about FP, only 2% said so at endline. Exposure to community action groups and household counselors About 58% of respondents (60% in Kano and 55.6% in Zamfara) knew about a committee or group in the community working towards improving the health of pregnant women and their babies. Those who had such knowledge stated that the group had been working in the communities for an average of 15.8 months. Only about 15% of the respondents said they or a family member were members of the community groups. The three main issues the committees or groups addressed were identified as : mother s health (95.2%), baby s health (92.4%), and family planning (63.2%). Among women who knew about the community committees or groups, 24.4% said they received some help from them, and most of them (62.2%) received health talk; 22% received transport support and 12.2% received financial support. About one-half of the women reported that a community health worker visited them in their home during their last pregnancy; 46% of the women were not visited by any community health worker. About 47% of women reported that a community health worker visited their home after delivery to check on the baby, 49% in Kano and 46% of Zamfara. Most of health workers who came to their homes to visit their babies were ACCESS trained household counselors (86%). The majority of the women (86%) reported that the health workers who visited their homes carried the blue bag designed for ACCESS trained health workers. About 16% of the women were visited once by ACCESS trained workers before the birth of their baby, 22.3% were visited twice and 9.3% were visited three or more times; 45.6% were never visited by ACCESS trained workers. ACCESS trained health worker (with grey bag) visited about 15% percent of the women once within the first week of delivery, 21.4% were visited twice and 6% more than twice; About 52% of the women were not visited by the health workers. About 71% of the women stated that ACCESS Counsellors discussed birth preparedness during their visit. Most of them (79%) were able to give examples of messages related to birth preparedness which they learnt through the counsellors. About 73% of women in Kano and 84% of those in Zamfara discussed what they learnt about birth preparedness someone, mostly their husbands. About 84% of the women said they took action related to birth preparedness after learning about it from ACCESS counsellors. The action mostly taken included: arranged money (90.6%), arranged skilled provider (25%), and arranged transportation (16.4%). ACCESS Program Evaluation in Kano and Zamfara States 5

247 The most prevalent things the health workers did when they visited were to ask about the health of the mother (84.5%), the newborn (83.6%), and to counsel on danger signs for the baby (42%). DISCUSSION Results of the endline household survey in four LGAs in Kano and Zamfara States provide measures of changes that have occurred in knowledge and practice of emergency obstetric, newborn and family planning services after three years of program intervention in the selected locations. The endline survey shows a general improvement in knowledge of danger signs or risk factors associated with pregnancy, labor and delivery, two-day postpartum, and care for newborns in the first seven days after birth over the results of the baseline survey. There was also a significant improvement in knowledge about birth preparedness which can be attributed to the program intervention. The percentage of women who made any arrangement before the birth of their last child more than doubled at the endline. The tremendous improvement both in knowledge and action with respect to birth preparedness is expected to have positive pregnancy outcome in the predominantly rural setting covered by the survey. The endline survey found that about 74% of the women received at least one ANC visit during their last pregnancy, up from 42% at baseline, indicative of a substantial increase in accessing ante-natal care between the two periods. The component of care received during ANC visits showed a more superior outcome at the endline period, with anti-malaria drug receiving the highest improvement. Rather worrisome is that a vast majority of deliveries in the two states still took place at home (about 80%), virtually the same rate with the baseline, and only slightly higher than 90% found by 2009 NDHS for North West Zone, where the two states are located. Given that about 73% of women visited a health facility for a least one ANC service, it seems that even though women have realized the importance of ante-natal care, they still preferred to have their babies at home. This is perhaps supported by the large percentage of women (78.5%) who claimed to have planned to give birth where they did; only 20.4% did not plan to have their babies where they eventually had them. Important barriers to seeking care during pregnancy and birth documented by the survey are financial, socio-cultural and logistical in nature. While some women reported that lack of funds is the primary constraint, socio-cultural factors and norms, such as gender roles and conservative religious beliefs, obstruct other women s ability to seek the health care services they desire. Strikingly, husband s disapproval of facility-based care did not seem to be the driving force behind the decision to give birth at home (in fact, 76% of those who delivered at a facility were accompanied by their husbands), and most women reported making the decision about where to give birth with their husbands or on their own, while about one-third of the women said that no one ever made a decision in this regard. This is likely a reflection of a cultural norm of giving birth at home. There is a significant improvement in knowledge and use of family planning at the endline. However, apart from the pill and injectables, the level of knowledge of other family planning methods remains low. Only five women were using a family planning method at the baseline in the four LGAs, but the number of current users of FP increased to 67 at the endline. The three methods mostly used are LAM, injectables and pills. Despite the fact that most women did want another child but did not want to become pregnant again soon, the vast majority were not using any 6 ACCESS Program Evaluation in Kano and Zamfara States

248 method of contraception. The primary barrier to use of FP appeared to be a culturally fatalistic approach to fertility with a belief that God will decide on the number of children. An evaluation of the level of program presence in the community indicates that 58% of the respondents knew about a committee or group set up by the ACCESS program, slightly more in Kano. Those who knew about the community groups identified mother s health, baby s health and FP as the main issues they deal with, with only about one-fifth actually receiving some help from them. The data suggest that ACCESS health workers provided to the communities the requisite services they were trained to provide, but it seems they have not covered all the communities or their membership or available resources are inadequate to do so. Given the low level of facility use in the areas as well as the relatively low level of knowledge of birth preparedness, danger signs and family planning, the activities of ACCESS trained health workers and counsellors should be supported by the local and state governments. This will greatly improve awareness of danger signs and utilization of maternal and newborn services, and reduce the high levels of maternal and newborn deaths being experienced in the area. RECOMMENDATIONS The substantial improvement in knowledge, attitude and behavior with respect to maternal and newborn health situation in the four LGAs where the ACCESS/Nigeria Program was implemented is an indication the project has been a success, and should therefore continue for a longer duration in the initial project areas, as also be scaled up. Already the project is being implemented in Katsina State; more states in the North could benefit from this laudable project. The Community Action Groups and Household Counsellors have been greatly instrumental for the positive changes observed in the communities. They are acceptable in the communities and pose little threat to the people. They have free access to the women and are able to discuss freely with them, also being responsive to their concerns and needs. This is a great positive reinforcement which should continue to be encouraged. Because the ACCESS Program is a short-term intervention, the community should strongly identify with it and show ownership so that the gains from the project will continue after its termination. To sustain the gains of this project, therefore, LGAs and community-based organizations should be encouraged to see reduction of maternal and neonatal mortality through increased utilization of quality EmONC services by pregnant women, mothers and their newborns as a priority which more than compensates for any investment put into it. To achieve this there is need for continuous information dissemination to all segments of the population, especially among men whom the studies have revealed to be the main decision makers in the home. ACCESS Program Evaluation in Kano and Zamfara States 7

249 ACCESS Nigeria Baseline Household Survey in Kano and Zamfara States 9

250 Specific Survey Results: Rwanda Safe Birth Africa Initiative in Rwanda Endline Assessment of Maternal and Newborn Health Services at Facilities in Four Districts in Rwanda: Gasabo, Kicukiro, Nyamagabe and Nyaruguru November 2009

251 Executive Summary Introduction Rwanda has some of the highest levels of maternal and newborn mortality in Africa, and a high level of fertility compared to the limited resources of households. According to the most recent interim DHS, the fertility of Rwandan women remains high since each woman gives birth on average to 5.5 children at the end of her reproductive life. Adolescents aged contribute to only 4% in the total fertility while women of years contribute to 25%. The level of fertility is much higher among rural women (5.7) than among those areas urban (4.7). This is true regardless of the age group. i In the most recent interim Rwanda DHS, 49% of the births in the five years preceding the survey took place at home and 45% were delivered at a health facility, mainly a public sector facility. The incidence of home births was also found to be highest among women who received no antenatal care (88%) and among women in households in the three lowest (poorest) wealth quintiles (more than 52%). The ACCESS Program conducted an endline survey of health facilities in three districts in Rwanda in September-October 2009 to examine the availability, quality, and utilization of delivery and maternal and newborn care services, including emergency obstetric and newborn care (EmONC) services. This report presents findings from the endline survey and changes in availability and quality of services from baseline in 2007 to endline in Methodology The data from the endline facility survey described in this report is part of a pre/post evaluation study design targeting SBAI program districts in Rwanda. The major components of this study were the same as in the baseline study: 1.) structured clinical observation with clients and/or anatomic models; 2.) facility audits of infrastructure, supplies and equipment; 3.) record review; and 4.) structured interview with providers in the maternity who assist deliveries. Results Antenatal Care: As in the baseline survey, the staff still prepare the examination area, equipment and documents but have now addressed deficiencies in the quality of greeting clients and encouraging clients to ask questions about what will take place during their visit. Unlike in the baseline, vital signs are now regularly taken by health center staff, clients are informed about the results of their visit, and potential danger signs were discussed with clients. 2

252 Maternity Care: The active management of the third stage of labor was carried out by 92% of hospital providers and 80% of health center providers. This differs from the baseline survey in which 17% of hospital providers and 21% of health center providers performed all three steps of AMTSL. Also, in the baseline survey, encouraging the mother to breastfeed after delivery was virtually nonexistent but in the endline survey, all hospital providers encouraged the mother to breastfeed during the first hour after birth. Conclusion This study showed that quality and availability of many aspects of clinical ANC and labor and delivery services has improved from baseline to endline in many of the facilities surveyed. i Rwanda Interim DHS

253 Annex H: Final Evaluations: Nigeria, Pre-Service and Tanzania 79

254 USAID/NIGERIA MATERNAL, CHILD, AND REPRODUCTIVE HEALTH PROGRAM MID-TERM EVALUATION This report has been abridged to include ACCESS Program information only. Information about other programs included in the full USAID/Nigeria report have been removed. November 2009 This publication was produced for review by the United States Agency for International Development. It was prepared by Dr. Dan Blumhagen, Dr. Carol Barker, Dr. Muyiwa Oladosu, Dr. Olubunmi Olufunke Asa, and Dr. Jack Reynolds through the Global Health Technical Assistance Project.

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256 USAID/NIGERIA MATERNAL, CHILD, AND REPRODUCTIVE HEALTH PROGRAM MID-TERM EVALUATION DISCLAIMER The authors views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

257 This document (Report No ) is available in print or online. Online documents can be located in the GH Tech web site library at Documents are also made available through the Development Experience Clearing House ( Additional information can be obtained from The Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC Tel: (202) Fax: (202) This document was submitted by The QED Group, LLC, with CAMRIS International and Social & Scientific Systems, Inc., to the United States Agency for International Development under USAID Contract No. GHS-I

258 CONTENTS CONTENTS...i Tables... iii Figure2... iii AcknowledgementS... iv Abbreviations... vi Executive Summary... viii Program Description... viii Programmatic Issues... viii Future USAID Programming... ix Conclusions:... ix Recommendations... xi General Recommendations... xi ACCESS... xi 1. Introduction Objective Reproductive Health Situation in Nigeria Government and Donor Commitment USAID Strategic Plan Mid-Term Evaluation Scope of Work Methodology Team Composition Project Components Overview ACCESS Cross-Cutting Issues:...20 Annex A: Scope of Work...24 I. Purpose...24 II. Background...24 III. Scope of work...24 IV. Methodology...26 V. Team Composition...27 VI. Logistic Support...29 VII. Oversight and Management...29 VIII. Level of Effort and Timing...29 IX. Cost...31 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION i

259 ii USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

260 TABLES Table 1: Facilities currently covered by ACCESS...10 Table 2: Proportions of population currently covered by ACCESS...10 Table 3: Progress on ACCESS Project Objective Indicators...12 Table 4: ACCESS Supported Health Facilities as a proportion of Health Facilities in the State..15 Table 5: Total Unit Sales and CYP by Type OF Contraceptive, FY Table 6: CYP Achievement FY 2006 FY Table 7: CYP Targets, FY 2006 FY Table 8: CYP Targets vs. Achievements, FY 2006 FY Table 9: SO Data Table...39 Table 10: Quality Data Indicators...40 Table 11: Enabling Environment Data Table...40 Table 12: Demand Data Table...41 Table 13 A: Access Data Table...42 Table 17 B: Additional Access DATA Indicator Table...43 Table 14: Mystery Client Results...44 Table 15: Client Satisfaction with FP service...44 FIGURE2 Figure 2: ACCESS Program Results Framework...11 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION iii

261 ACKNOWLEDGEMENTS The evaluation team wishes to express its gratitude to the management and staff of the Society for Family Health. Its cooperation, openness, and logistical support were very much appreciated. The team also wishes to thank our two research/logistics assistants, Mr. Charles Asa and Ms. Ezedwueme Chinene of Mira Monitor, who accompanied us throughout the evaluation. All of the implementing partners, ACCESS, ACQUIRE, Pathfinder, and the Society for Family Health, graciously made themselves available to support the team in its understanding of their projects. Without this support, the team would not have been able to complete the study. iv USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

262 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION v

263 ABBREVIATIONS ACCESS ACQUIRE ADS AGMPN AIDS ANC BCC BEmONC CBD CBO CHC CHEW CPR CSO CYP DHS ECWA EH EmONC ENHANSE FMOH FOMWAN FP GHAIN GH Tech GON HIV HMO HPN IEC IHRIN IMNCH IIP IP IPC IR IUD LAM Access to Clinical and Community Maternal, Neonatal and Women s Health Services Access, Quality, and Use in Reproductive Health Project Automated Directives System Association of General Medical Practitioners of Nigeria Acquired immune deficiency syndrome Antenatal care Behavior Change Communications Basic Emergency Obstetric and Newborn Care Community-based distribution program Community-based organization Comprehensive health center Community Health Extension Worker Contraceptive prevalence rate Civil society organization Couple-years of protection Demographic and Health Survey Evangelical Church of West Africa EngenderHealth Emergency Obstetric and Newborn Care Enabling HIV/AIDS, TB, and Social Sector Environment Federal Ministry of Health Federation of Muslim Women s Associations in Nigeria Family planning Global HIV/AIDS Initiative Nigeria Global Health Technical Assistance Project Government of Nigeria Human immunodeficiency virus Health maintenance organization Health, Population, and Nutrition Information, education, and communication Improved Reproductive Health in Nigeria project Integrated Maternal, Newborn, and Child Health Investing in people Implementing partner Interpersonal communicator Intermediate result Intrauterine device Lactational amenorrhea method vi USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

264 LGA LOE LQAS MAP MAQ MAWCH MCFWP MCH MCHIP MDG MDS M&E MNCH MOH NACA NARHS NDHS NMA NGO OC PCN PE PEPFAR PHC PMP PO PPMV PSI RH SBM-R SFH SMO SO THT TFR TSHIP USAID USG WHO WRA Local Government Area Level of effort Lot quality assurance sampling Measuring Access and Performance survey Maximizing Access and Quality Maryam Abacha Women and Children's Hospital Managed Care and Family Wellness Programs Maternal and child health Maternal and Child Health Integrated Program Millennium Development Goal Manufacturers Delivery Service Monitoring and evaluation Maternal, Newborn, and Child Health Ministry of Health National Action Committee on AIDS National HIV/AIDS and Reproductive Health Survey Nigerian Demographic and Health Survey Nigerian Medical Association Nongovernmental organization Oral contraceptive Pharmacists Council of Nigeria Peer educator President s Emergency Plan for AIDS Relief Primary health center Performance Monitoring Plan Program objective Proprietary Patent Medicine Vendor Population Services International Reproductive health Standards-Based Management and Recognition Society for Family Health State Ministry of Health Strategic objective Total Health Trust Total fertility rate Targeted States High Impact Project United States Agency for International Development United States Government World Health Organization Women of Reproductive Age USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION vii

265 EXECUTIVE SUMMARY The United States Agency for International Development (USAID) Mission to Nigeria contracted with the Global Health Technical Assistance Project (GH Tech) to provide a team of five experts to examine three of the family planning/reproductive health (FP/RH) projects that they have been supporting in Nigeria. This is one of a series of evaluations that is being conducted to provide guidance to the Mission as it implements new projects and develops its strategy. This summary does not focus on assessments of the individual projects although the full evaluation contains many comments and recommendations on these but rather on the major issues that must be addressed in the next five years. The team was charged with doing a late mid-term evaluation of: Access to Clinical and Community Maternal, Neonatal, and Women s Health Services (ACCESS)/Maternal and Child Health Integrated Program (MCHIP), ACQUIRE/Fistula Care (ACQUIRE), and Improving Reproductive Health in Nigeria (IRHIN). The evaluation outlines opportunities, challenges, and critical areas for the Mission to address, and makes recommendations on the most effective and efficient path forward. Health statistics, and particularly the maternal mortality rates, in the northern states of Nigeria, are among the worst in the world. Infant and child mortality rates are also extremely high. The team does not believe there is any possibility that Nigeria will attain the Millennium Development Goals (MDGs) without massive donor and government commitment. PROGRAM DESCRIPTION The ACCESS Nigeria Program has the following goal: To accelerate the reduction of maternal and newborn mortality and the attainment of the MDGs in Nigeria. This three-year program has been running since January 2006, and was due to end in September It has been extended to 2010 under the Maternal and Child Health Integrated Program (MCHIP) project. It now operates in 18 Local Government Areas (LGAs) in Kano, Katsina, and Zamfara states. Overall, the ACCESS program shows healthy progress. The number of deliveries assisted by a skilled birth attendant rose steadily over as did the number of antenatal care (ANC) visits and postpartum visits, all of which surpassed their targets with a roughly three-fold annual increase. Coupleyears of protection (CYP) increased more slowly, but this was partly related to stock-outs of contraceptive supplies in some facilities, a matter out of the hands of the project. PROGRAMMATIC ISSUES The evaluation team found that the following major issues affected nearly all of the projects, and will need to be addressed in the next phase of USAID assistance: Geographic Distribution: The project activities were spread so thinly across Nigeria that there was little synergy between even different project sites of the same agency. If, for example, there are 350 km between different project sites in the same state, the project team will spend more time on the road than in providing support and mentoring to the project site staff. Health Impact: The impact of FP/RH on CPR and CYP has been limited. That is because activities are spread over large areas and there are few intervention sites. The IRHIN Social Marketing program is the one exception to this, but even this project barely distributes sufficient commodities to have a measurable nationwide impact. viii USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

266 Synergy: There is very little coordination among the projects, which, in part, is a function of project design. Projects generally take place in sites that do not overlap with one another. Gender Equality: The team was pleased at the way women and men had been incorporated into all aspects of the project: 30% of pharmaceutical vendors are women, and, in the north, the number of male community outreach workers is nearly as large as the number of female outreach workers. Inadequate resources: USAID and the implementing partners (IPs) do not have enough funds or staff to manage the large number of activities in the various sites. Joyce Holfeld, who conducted an evaluation of the USAID-financed ENHANSE and COMPASS projects, recommended six USAID staff. 1 The evaluation team agrees. Poor data quality: Some of the service statistics presented by the partners are suspect. ACQUIRE is the exception. IRHIN does a better job because it has a number of national and sub-national surveys, but the team was not able to track service statistics from the provider to Abuja where reports were written. In addition, since clients seek contraceptives from multiple sources, three of the activities (ACQUIRE, ACCESS, and Pathfinder) do not have enough data that enables them to link project activities with contraceptive use. Logistics: Every project had significant problems with stock-outs, which frequently caused activities and contraceptive sales to drop. Staff mobility: In almost any location, staff is extremely transient. After workers get trained, they tend to leave for greener pastures. Both of the most senior trainers in the ACQUIRE project have been promoted to higher government posts. Others look for more secure jobs, since some positions only receive support for 12 months. This is also true in the private sector, as staff come and go nearly as quickly as in public facilities. Lack of basic facilities: In most places visited, there was a lack of electricity, drugs, water, transport, and/or adequate facilities. USAID and its partners need to find ways to address these issues. FUTURE USAID PROGRAMMING The projects under review will continue under one or more programs. Thus, it will be important to address the most critical issues right away. Here are the most important suggestions: Focus and concentrate program efforts to achieve program results. Logistics should be the principal focus of new efforts. If there are no supplies, there is no program. Establish ways of working with all three levels of government to build commitment. Consider ways of reaching out to where people are, rather than requiring them to come to a fixed facility. CONCLUSIONS: USAID and its IPs have done a very good job given the constraints of the environment, staffing, and funding. The ground may be softening, but there is a lot of work ahead that requires dynamite and pick-axes. 1 Holfeld, et al. An Evaluation of the USAID/Nigeria Social Sector Projects: ENHANSE and COMPASS, USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION ix

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268 RECOMMENDATIONS GENERAL RECOMMENDATIONS 1. Funding should be increased as currently planned, and the USAID Health Office should be increased to six direct hire equivalents. In future work in this area, efforts should be made to work with communities to advocate use of family planning/birth spacing. 2. SFH, civil society organizations (CSOs), and government agencies need to identify ways to reduce turnover of key personnel, especially providers. 3. Retention indicators should be developed and used in recruiting for these positions, for example, tracking candidate ties to his/her home state or town. 4. An awards system needs to be developed to encourage key staff and providers to continue working for the program. ACCESS 5. ACCESS should review its lactational amenorrhea method (LAM)-only contraceptive policy for postpartum family planning, and consider whether it makes more sense to start women on a contraceptive regimen immediately. 6. USAID should discuss the future of work begun in Katsina State with all stakeholders and consider redirecting resources, possibly including staff, to the other two states. 7. ACCESS should continue in Kano and Zamfara until the end of the MCHIP period, and then consider whether to continue them or to arrange for transfer to another donor. 8. Work should be undertaken in the future on a state-wide basis, rather than only in selected LGAs. 9. The Mission should explore the possibility of the new midwifery school in Zamfara to train a new cadre of community midwives. 10. ACCESS should immediately add secondary fistula prevention to its Nigeria outreach and clinical Emergency Obstetrics and Newborn Care (EmONC) services. 11. ACCESS should develop more robust measures to link family planning motivation and support to government clinics with actual contraceptive use. USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION xi

269 xii USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

270 1. INTRODUCTION 1.1. OBJECTIVE USAID/Nigeria requested that the Global Health Technical Assistance Project (GH Tech) assemble a team of five internationally recognized family planning and reproductive health (FP/RH) experts prepare a mid-term evaluation of three of USAID s FP/RH programs: ACCESS/MCHIP, ACQUIRE/Fistula Care, and Improving Reproductive Health in Nigeria (IRHIN). The review is intended to show how the program could be improved over its remaining year, and, more importantly, to make recommendations that use the lessons learned to improve the design and execution of the USAID Health Strategy. The purpose of this mid-term evaluation is to provide the USAID/Nigeria Investing in People (IIP)/Health, Population, and Nutrition (HPN) Team with sufficient information to make programmatic and budgetary decisions in the future. The evaluation outlines opportunities, challenges and critical areas to address and makes recommendations on the most effective and efficient path forward. The evaluation reviews the performance of each project through June REPRODUCTIVE HEALTH SITUATION IN NIGERIA Each year about one million Nigerian children die before their fifth birthday. These infant and child mortality rates are extremely high, even when compared to other sub-saharan countries. Maternal mortality rates are among the highest in the world, particularly in the northern states, where completed fertility remains over seven, childbearing starts very early and births are very closely spaced. This document does not need to repeat the grim statistics, which can be found in almost every other recent report on FP/RH in Nigeria. 234 Given that the Millennium Development Goals (MDGs) require a 75% reduction in the maternal mortality ratio and universal access to reproductive health services including antenatal care, peri-partum care, and family planning, 5 the team does not believe that Nigeria has any possibility of attaining the goals without massive donor and government commitment GOVERNMENT AND DONOR COMMITMENT The Nigerian federal government and its partners have recently developed an Integrated Maternal, Newborn, and Child Health (IMNCH) Strategy. It lays out a collaborative approach to accelerating progress in reducing child and maternal mortality through targeted interventions, including family planning. The IMNCH strategy has been approved by the National Council for Health, and plans are underway to implement it through advocacy and analytical support, initially in 12 states. Donors have worked closely with the government in all stages of this process. There are, however, several areas of concern: In the first place, government interventions happen on three levels: national, state, and local. The federal level is responsible for setting policies, providing overall guidance, managing and funding tertiary facilities and key research and development programs. The state level funds and manages state hospitals and maternities, teaching colleges, and provides higher technical staff for the State Ministry of Health (SMOH). The local government authorities (LGAs), with little technical expertise and insufficient funds, are responsible for basic staffing, managing and financing 2 Holfeld & MacDonald: The Ground is Softening, Holfeld et.al.: An Evaluation Of The USAID/Nigeria Social Sector Projects: ENHANSE and COMPASS, Maternal Child Health, Family Planning and Reproductive Health Strategic Approach, USAID/Nigeria, December USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 1

271 of primary health clinics within their jurisdiction. 6 One of the biggest problems encountered during this evaluation was that local governments, for cost reasons, want to hire the lowest paid staff, the Community Health Extension Workers (CHEWs), to perform many clinical functions in hospitals and clinics under their purview. It was also troubling that the officials at the state and local levels 7 seemed relatively unconcerned about the need for family planning, even when presented as birth spacing. While in 2002 there was an entire booklet covering the federal strategy on family planning, by 2007 family planning had been reduced to a half page in the overall strategy on reproductive health. Secondly, there are multiple levels of multilateral, bilateral, and private donors supporting a variety of activities, sometimes scattered broadly. While it is possible for the major players to participate in planning and overall implementation, on the ground it is much more difficult. As will be described below, even different USAID supported programs operating in the same states rarely collaborate. Finally, partly because the public sector has proven so unreliable, a host of private sector providers from traditional healers and birth attendants to pharmaceutical vendors to tertiary hospitals have emerged. While the team support and applaud the work done by the private sector, the fact that an individual often can choose between multiple facilities means that it is difficult to measure service impact. A woman, for example, may be motivated to seek family planning 8 by a private sector community-based distribution agent and then by or a radio drama, and may ultimately get commodities from a local vendor. This means that data cannot be easily captured by service statistics, leading to marked over- and under-reporting USAID STRATEGIC PLAN The work done by USAID over the past several years has been guided by two strategic plans: the January 2006 Country Strategy Statement, and the December 2008 Maternal Child Health, Family Planning, and Reproductive Health Strategic Approach. The earlier strategy outlined activities in nine states and the Federal Capital Territory (Abuja), and was directed at: (1) preventing and controlling infectious diseases, (2) improving child survival, health, and nutrition, (3) improving maternal health and nutrition, and (4) supporting family planning. Given the Nigerian population size and the relatively low level of USAID funding, the targets for this were ambitious, including projecting increase of the CPR from 9% to 11%, and providing quality RH/FP services to 4.2 million women. The 2008 revised strategic framework directed the USAID Mission to concentrate on two states, Sokoto and Bauchi, both of them in Hausa-speaking areas in the north. The health statistics and levels of health care in northern Nigeria are among the worst in the country. One telling statistic is that in Kano State, available health facilities operating at capacity, could only handle 20% of births in their catchment areas. The strategic framework proposed a full package of RH and Emergency Obstetrical and Newborn Care (EmONC), including antenatal care, immunizations of mothers and children and presumptive malaria treatment. The team was concerned, however, that the mission believes that All of the interventions can be delivered at the community level by a range of community-based and facility-based public and private sector workers with relatively low levels of training. Given the very low level of basic education observed discussed below, under ACCESS this approach is overly optimistic. USAID correctly identified the need to intervene at both state and local government levels to improve capacity to plan and manage health care. While unlikely to yield results in the short or even medium term, this is an investment that is crucial to developing a sustainable public health sector in Nigeria. 6 Holfeld et al Because of scheduling problems, the team was unable to meet with any federal-level officials. 8 This, of course, applies to all social service delivery and not solely to family planning. 2 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

272 Responses to a request for applications are currently being reviewed by the mission and are expected to be awarded before this report is finalized. The report will then become the operational plan for intervention in the public sector. Since it is still in the procurement process, the GH Tech team could not make any comments on the strategies being proposed by the applicants. It is troublesome that the 2008 USAID strategy does not include partnerships with private providers as a source for FP/RH as well as EmONC services in selected facilities. The only possibilities suggested include expanding the social marketing program with SFH (itself an NGO, and nearly totally supported by donor funds) and developing a single public-private partnership with a major employer MID-TERM EVALUATION SCOPE OF WORK The USAID Mission to Nigeria asked GH Tech to address the current situation of each of the three projects (ACCESS, ACQUIRE, and IRHIN) with a focus on the implications of the team s findings for the further development of the Mission s health strategy for Program Questions The Mission posed a number of questions to the evaluation team. These were organized by topic: program, geographic coverage, local capacity and ownership, compatibility, synergy and sustainability, and future USAID health programming. Are the projects on the right track and are benchmarks/results being met? What changes, if any, need to be made? What are the gaps? Are the interventions adequate for a significant health impact on RH/MCH? Are the interventions adequate for improving access to quality services? Discuss how the interventions are implemented. What were trends? Results achieved? Successes? What were the major obstacles/difficulties confronting RH/maternal health? How are these issues being addressed by the project? What were the results/achievements towards Strategic Objective (SO) 13 objectives? Discuss missed opportunities, if any, for linkages with PEPFAR-funded HIV/AIDS activities. Recommend strategies for addressing and improving linkages in the future. Recommend future strategic areas that need to be addressed Geographic Coverage Are the current project geographic areas rational? If new areas are selected in the future, what geographic coverage would make sense, considering the Mission s and health team s strategic priorities, other United States Government (USG) programs, and the Federal Ministry of Health s (FMOH) plan for strengthening the health sector? Local Capacity Building and Local ownership USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 3

273 To what extent have government institutions at the state and LGA levels bought into and participated in the projects? What approaches were used and what challenges did the projects face in obtaining buy-in and participation? Discuss project efforts at capacity building (institutional, management, programmatic and technical) among grantees (NGOs including local), central government, state government, local health department, community, and private sectors. Is the project strengthening county (state/lga) capacity to deliver health services? What are the major obstacles? How are they addressed at the various levels? What were the major breakthroughs and accomplishments? Give evidence and cite examples Compatibility, Synergy, Sustainability Do the current projects respond to the FMOH s desired directions for Nigeria? How do projects coordinate, collaborate, and seek synergy with the FMOH/State/LGA? How can this relationship be strengthened further? How does the program complement other RH/MCH services in the country? To what extent have projects sought to coordinate activities and seek synergies with USAID/Nigeria s other health projects, SOs, donors, and local partners (NGOs, private sector)? Describe approaches used. To what extent have the projects improved the enabling environment for MCH/RH? Are the projects working towards sustainability? How and what else could be done? To what extent have the projects achieved gender equity, and what approaches where used to do so? Any challenges and gaps? Future USAID/Nigeria Health Programming What are the lessons learned that should be expanded in the remaining life of the project, or follow-on project? What else could/should be done? What activities would have the greatest impact? What should be the balance between service and health capacity/systems work? What are recommendations for future strategic directions in strengthening Federal, state, LGA, NGO/private sector? What are the strengths and innovative activities being undertaken that should be continued, scaled-up, and emphasized? 1.6. METHODOLOGY The evaluation was conducted using a combination of document review, key informant interviews, and site visits. USAID divided it into a public component (ACCESS and ACQUIRE) and a private component (IRHIN). One team was assigned to evaluate the public components and a second team assessed the private components. 4 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

274 The first week, beginning June 29, 2009, was spent on team formation, document reviews, and meetings with the USAID Mission staff and representatives from the Abuja offices of the partners being evaluated. These activities provided a wide array of documents to add to our understanding of the project. The next two weeks were spent in site visits. The Public Sector team (ACCESS, ACQUIRE) visited sites in Kano, Katsina, Zamfora, and Sokoto States before returning to Abuja. The private sector team (IRHIN) visited Kaduna, Kano, Lagos, and the Cross River States. The team leader divided his time between the two teams. The final 10 days were spent in meetings with the Abuja offices to get further clarifications and as many statistics and monitoring and evaluation reports as were readily available. After extensive discussions, the team arrived at conclusions that spread across all three projects and into the future programming needs of USAID. On July 27 a briefing on the evaluation was held for USAID and its implementing partners (IPs). A draft report was distributed on July 28. USAID/Nigeria submitted its comments to the team on August 20. A final report was sent back to USAID for approval and to GH Tech for editing and production TEAM COMPOSITION Dr. Dan Blumhagen (Team Leader): Consultant in Public Health and strategic planning, monitoring and evaluation, with 25 years of international experience, including 20 years as a USAID Population, Health and Nutrition specialist and Program Officer Team A: Public sector Dr. Olubunmi Olufunke Asa: Public Health Physician with 12 years of experience as a specialist in promotion of maternal and child health at national and community levels. Dr. Carol Barker: Specialist in health planning and policy in the context of international health, with 35 years of experience full-time in this field. In recent years, she has worked extensively in the area of maternal and neonatal health and in northern Nigeria in the field of strategic health planning Team B: Private sector Dr. Muyiwa Oladosu: International expert in research, monitoring, and evaluation of development projects around the world. He has over 23 years of experience conducting evidence-based monitoring and evaluating development projects in Asia, Africa, Europe, North America, and South America. Dr. Jack Reynolds: Specialist in health planning and policy in the context of international health. For over 40 years, he worked to improve the delivery of health services in domestic and international programs. USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 5

275 6 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

276 2. PROJECT COMPONENTS 2.1. OVERVIEW As noted above, there are three projects being evaluated. Each project has the same SO: increased use of child survival and RH services. The three have similar project objectives: to increase utilization of health services. They also have similar intermediate results (IRs). For example, all have improving access and quality as an IR. Two have strengthening of the enabling environment and increasing demand as IRs. However, they are not identical. ACCESS is focused on EmONC, ACQUIRE on fistula services, and IRHIN on the improving child spacing and RH. See Figure 1 for a graphic display of each project s program objectives (POs) and IRs. The projects also work in various states. Pathfinder (a subcontractor to SFH) works exclusively in three states: Kaduna, Cross River, and Abia. SFH s community program is in 18 states and its social marketing program is nationwide. ACCESS works in three states: Kano, Katsina, and Zamfara. ACQUIRE works in seven states: Sokoto, Zamfara, Kano, Kebbi, Katsina, Bauchi and Ebonyi. USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 7

277 Figure 1: SO 13: Increased use of child survival and RH services (63 IR indicators overall) ACCESS: PO: Increased utilization of EmONC services (23 indicators) Acquire: PO: Increased use of fistula services in 4 states (19 indicators) IRHIN PO: Increased use of CS and RH services (21 indicators) IR 13.1: Improved quality of social sector services: Sub-IR 1: Improve FP quality Sub-IR 2: Improve EmONC quality (8 indicators) IR 1: Increased access to quality fistula repair services (9 indicators) IR 15.1: Improved quality of CS and RH health services (6 indicators) IR 13.2: Strengthened enabling environment Sub-IR 3: Scale-up EmONC Sub-IR 4: Maternal/newborn best practices (5 indicators) IR 13.3: Expanded demand for improved social (maternal & newborn) services (4 indicators) IR 13.4: Increased access to (EmONC and FP) services, commodities and materials (6 indicators) IR 2: Increased fistula prevention activities (3 indicators) IR 3: Increased reintegration for repaired fistula clients (4 indicators) IR 4: Increased access to quality FP services and commodities (3 indicators) IR 15.2: Strengthened enabling environment (2 indicators) IR 15.3: Expanded demand for improved CS and RH services (10 indicators) IR 15.4: Increased access to CS and RH services (3 indicators) 8 USAID/NIGERIA MCH/REPRODUCTIVE HEALTH PROGRAM MID-TERM EVALUATION

278 2.2. ACCESS Introduction The ultimate health goal of the ACCESS Nigeria Program is: To accelerate the reduction of maternal and newborn mortality and the attainment of the MDGs in Nigeria. This is similar to FMOH s National Reproductive Health Policy, which is to reduce maternal and neonatal mortality in Nigeria, as well as FMOH s goal to accelerate the reduction of maternal and newborn mortality and the attainment of the MDGs in Nigeria. The need to increase use and access to emergency obstetric care services is crucial in Nigeria, especially in the northern states. In the North West Zone, infant mortality overall is 114 per 1,000 births, of which 55 are neonatal. 9 Maternal mortality is also known to be high. The Federal Ministry of Health quotes a figure of 800 per 100,000 live births for Nigeria as a whole, but it is well known that rates are much higher in the north. ACCESS uses a figure of 1,025 for the North West Zone. 10 Some authors however put this even higher. A 2003 estimate was 2,420 deaths per 100,000 live births. 11 Furthermore, as many as 17,000 per 100,000 women are left after childbirth with serious disabilities such as fistula, uterine prolapse, damage to bladder or urethra, pelvic or urinary tract infections, anemia, and infertility. Maternal mortality has complex causality. Mortality is reduced when births are spaced so that the mother remains healthy and her baby well fed. The priorities in achieving safe childbirth for mother and baby are to ensure that skilled birth attendants are available to deliver babies, and that emergency obstetric care is available and can be reached quickly within a few hours if things start to go wrong. In this situation, the challenge is to encourage women to avail themselves of services provided. The baseline survey for ACCESS found that in Kano and Zamfara, 80% of women surveyed had delivered their last child at home, and out of the total sample surveyed, only 8.3% said they would have preferred that someone else assist with the birth instead of the person who actually did. There are other reports that women consider three days to be a normal labor. The three-year ACCESS program has been running since January 2006, and, while originally scheduled to end in September 2009, it has been extended to 2010 under the MCHIP project. It was initiated in four selected LGAs in two northern states (Kano and Zamfara). It is now in 18 LGAs in three states (Kano, Katsina and Zamfara). The key program approach is the implementation of an integrated program along the Household-to- Hospital Continuum of Care. This includes community and facility-based essential maternal and newborn care interventions focusing on ANC, emergency obstetric and newborn care, and postpartum care including FP. The program is being implemented in a range of facilities as set out below. The program in Katsina, launched in March 2008, has been implemented for only one year. As the number of facilities being covered in each state has expanded, it is difficult to review progress against targets that may have been set earlier, when less capacity was available. In the follow-on project, targets should be revised when there is a significant change in program capacity. This is permitted by the USAID Automated Directives System (ADS), as long as the changes in indicators are documented in the annual report. In addition, the mission and project should develop project and possibly site-specific indicators that will help 10 ACCESS Nigeria Country Program Brief, June 2009, quoting FMOH and UNICEF. 11 Adamu Y.M. et al., Maternal Mortality in Northern Nigeria: a Population-based Study European Journal of Obstetrics & Gynaecology, Volume 109, no. 2, 15 August USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 9

279 clarify project developments, even if these are not the overall USAID project indicators. Situationspecific indicators are also permitted by the ADS. TABLE 1: FACILITIES CURRENTLY COVERED BY ACCESS Specialist hospital General Hospital CHC 12 WCWC 13 PHC 14 Zamfara 6 (of which 1 for women & children) 2 9 Kano Katsina It should be noted that this is only partial coverage of the facilities in each state. Zamfara has 17 general hospitals and around 502 primary health centers (PHC) facilities, for instance. TABLE 2: PROPORTIONS OF POPULATION CURRENTLY COVERED BY ACCESS Total Population of State (millions) Population of LGAs where ACCESS is working (millions) Percentage of State Population in ACCESS supported LGAs Zamfara % Kano % Katsina % However, this may over-represent the proportion of the state populations covered as one would need to look at figures ward by ward within the selected ACCESS LGAs Life of Project Objective Overall, the program shows healthy progress. The number of deliveries with a skilled birth attendant in rose steadily over as did the number of ANC and postpartum visits. Targets were exceeded for all of these indicators. It is unfortunate that the indicators could not be expressed as a percentage of all deliveries or pregnancies. One area where performance is below target is that of increasing couple-years of protection (CYP). Part of this may be due to the fact that it is very difficult to link women receiving prenatal and perinatal care to contraceptive use, and even more difficult to link motivational efforts in the community to women s use of birth spacing techniques. This is complicated by frequent stock-outs, which have the effect of requiring women to seek contraceptives in other outlets. 12 Comprehensive Health Center 13 Women and Children Welfare Clinic 14 Primary Health Center 10 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

280 Figure 2: ACCESS Program Results Framework SO15: Increased use of child survival and reproductive health services Program Objective: Increased utilization of EmONC services by pregnant women, mothers, and newborns at selected LGAs in two states Key Indicators: % of births attended by skilled health personnel [C 33.1] % of caretakers seeking care from skilled care providers for sick newborns % of pregnant women who received at least 4 antenatal care visits [C 33.2] Couple-years of protection (CYP) [C 34.1] # /% of postpartum women using contraception (including LAM) 6 weeks postpartum ACCESS Result #4 Sub-IR.1 Improved quality of family planning services in selected LGAs Indicators # / % of women delivering in ACCESS-supported facilities receiving postpartum FP counseling % of providers trained in FP who are performing according to standards ACCESS Result #3 Sub-IR.2 Improved quality of EmONC services in selected LGAs Indicators: # of buildings (clinics) rehabilitated/built [C 20.9] % of health facilities using SBM-R approach for performance improvement % of births at ACCESSsupported facilities with active management of the third stage of labor % of women with supported facilities for which the partograph was used ACCESS Result #1 Sub-IR.3 Improved enabling environment for scale-up of EmONC best practices at national and state levels Indicators Training curricula and strategy for pre-service midwifery education revised and implemented in Kano and Zamfara states Operational performance standards for EmONC developed and distributed National KMC policy and guidelines developed and distributed in ACCESSsupported facilities ACCESS Result #6 Sub-IR.4 Improved management of maternal and newborn services in selected LGAs Indicators % of EmONC facilities experiencing no stock-outs of essential EmONC drugs in the last 3 months ACCESS Result #5 Sub-IR.5 Increased demand for maternal and newborn services in selected LGAs Indicators # of beneficiaries of community activities [C 20.10] # of community committees that have work plans that include activities to reduce maternal and newborn deaths, including promoting birth spacing # of communities with plans that include emergency funds and/or a transport system for maternal and newborn complications ACCESS Result #2 Sub-IR.6 Increased availability of EmONC and FP health care workers in selected LGAs Indicators % of births in target LGAs delivered by Cesarean section # of health facilities per 500,000 population in ACCESSsupported LGAs providing essential obstetric and newborn care % of births with complications treated at EmONC facilities # of persons trained in maternal and newborn care [C 33.5] # of ACCESS-supported health facilities providing postpartum FP counseling and services # of women reached through postpartum FP counseling and services USAID/NIGERIA MCH/REPRODUCTIVE HEALTH PROGRAM MID-TERM EVALUATION 11

281 TABLE 3: PROGRESS ON ACCESS PROJECT OBJECTIVE INDICATORS Indicators FY07 FY08 # Deliveries with a skilled birth attendant 7,685 22,092 # Antenatal care visits by skilled providers from USG-assisted facilities 33, ,678 # Postpartum/newborn visits within 3 days of birth in USG-assisted program 7,534 26,842 Couple-years of protection in USG-assisted programs 6,492 11, IR 13.1: Improved Quality of Social Sector Services There are two aspects to quality of care: FP and EmONC services. Family planning services Family planning (FP) progress overall is good. The provision of USG-assisted service delivery points providing FP counseling or services is on target with CHEWs providing services at PHCs. The number of staff trained in FP/RH is, if anything, slightly ahead of target. The reports do not contain training statistics disaggregated by gender. Many respondents among facility staff clearly rated family planning activities as a major area of success. This is due in part to the extra training provided, in part to the efforts to raise demand for contraceptives in local communities (see below). In the current performance monitoring plan (PMP), no indicator is used to reflect the volume of contraceptive devices actually distributed. In Zamfara and Katsina there was no shortage of contraceptive supplies, but in Kano there was a mysterious shortage at Murtala Mohammed Specialist Hospital, which was made family planning services almost nonexistent. The number of counseling sessions being held was significantly below target. The explanation offered was that health workers are not entering records for non-acceptors. The most likely explanation is that the target for this indicator was set bearing in mind the introduction of household counselors program in Katsina state. This activity is yet to take place because of the long process of involving stakeholders in the selection of household counselors. (Quarterly report April 2009). In addition to the extension work that is done by the community mobilization teams, ACCESS works with the local family planning providers to upgrade their skills. For example, in FY 2008, ACCESS reports: ACCESS Nigeria recognizes family planning (FP) as a key component in the efforts to reduce maternal and newborn mortality in the country. ACCESS Nigeria has, therefore, been actively involved in FP activities in its program states of Kano, Katsina and Zamfara. Activities carried out by ACCESS in these states include training of providers and their supervisors, development of FP performance standards, development of supervisory checklists, establishment of FP services and supervision of these services. During the past year, ACCESS trained 14 Community Health Extension Workers (CHEWs) and 18 midwives on postpartum FP (PPFP). Trainees were provided with technical assistance to commence or improve PPFP services at their various facilities. This has contributed to the increased access to FP services during the postpartum period. ACCESS also trained 17 midwives to provide long-acting contraceptives, specifically IUD and Jadelle, in order to increase the method mix at their various facilities. In order to increase demand for, and uptake of FP services, ACCESS trained 22 male motivator trainers who will be training other men to raise awareness of FP and reproductive health issues and services among men in their communities. Twenty-eight supervisors from State Ministries 12 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

282 of Health (SMOH) and Local Government Areas (LGAs) were also trained on supportive supervision to ensure that FP services including patient and service records are of high quality. ACCESS Nigeria also coordinated the development of FP performance standards for Nigeria in collaboration with the Federal Ministry of Health (FMOH). The process of developing these standards involved relevant stakeholders from the FMOH, National Primary Health Care Development Agency, Teaching Hospitals, Society of Gynaecology and Obstetrics of Nigeria, Nursing and Midwifery Council of Nigeria, and developments partners working in the field of FP. The FP performance standards will help to improve the quality of FP services in the country. (The standards are currently ready for production.) Similarly, ACCESS has also developed a supervision manual for use by FP services supervisors that will help to ensure that FP services meet the required standards. (emphasis in original) Because of the extensive support that ACCESS provides to Government of Nigeria (GON) facilities, the team believes that all contraceptives provided by their FP clinics can be used to assess ACCESS project impact, as measured by CYP. If there are two or more programs supporting the same GON facility, the Mission and IPs should develop a methodology to allocate CYP to each partner. Clearly, this will be somewhat artificial, but is more likely to be useful without the expenses of developing a complicated monitoring scheme that will be difficult to implement. Health workers rated acceptance rates among those counseled as generally very high, and felt that there was no under-reporting. While high acceptance rates are to be welcomed, it must be remembered that these are the acceptance rates for the (still small) proportion of the female population now seeking services for ANC and delivery, and do not mirror an equally high potential rate for the population at large. Family planning statistics continue to show the magnitude of the problem facing ACCESS as it attempts to encourage use of birth spacing methods in northern Nigeria. For example, in 2008, ACCESS reported some 22,000 deliveries, 116,000 antenatal visits, and 26,800 postpartum visits to program facilities. 15 There were nearly 31,000 FP/birth spacing counseling visits. Despite this activity, ACCESS was only able to provide 11,500 CYP during that year. As discussed elsewhere, ACCESS, ACQUIRE and Pathfinder all have difficulty in linking services and counseling with actual contraceptive use, partly because clients have many options for purchasing contraceptives that are not under the purview of the project. In light of this, the team believes that there is significant under-reporting. The work continues to be very difficult, but ACCESS is aware of the problem and is seeking solutions. When ACCESS began its activities in Nigeria, an important area of focus was postpartum birth spacing activity. As the PMP developed, there was no indicator to measure the number of acceptors of FP methods among postpartum women counseled. One of the main reasons for this is that all women are being counseled to use the lactational amenorrhea method (LAM) of birth control whereby breastfeeding for the first six months of the baby s life offers protection against conception. Women are therefore counseled to use LAM for the first six months postpartum, and then advised to come back for FP/birth spacing methods. The team considered this to be of concern. While exclusive breastfeeding for the first six months is good practice for the baby, a delay in starting contraception for the following six months seems to be a lost opportunity. After the six-month gap, mothers may have forgotten the advice they received, may simply be too busy or too far distant from care providers, or may have become pregnant. If mothers are not counseled to begin contraception immediately, the successor project may wish to build a six-month outreach modality to recruit birth spacing acceptors among former patients. Recommendation: ACCESS should review its LAM only contraceptive policy for postpartum FP, and consider whether it makes more sense to start women on a contraceptive regimen immediately. 15 ACCESS: USAID/Nigeria FY08 Quarter 4 and Annual Report, November 19, USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 13

283 Emergency Obstetric and Neonatal Care Improving the quality of EmONC services has been more problematic. This is partly because there have been delays in infrastructural improvements, which is exacerbated by the lengthy process of getting construction approvals and release of funds. This results in slow releases of needed equipment, which procedurally follow only after rehabilitation is completed. This in turn has impeded teaching staff how to how to use equipment. In the case of Katsina State, the delays are particularly damaging, as it seems likely that the rehabilitation work will only be complete shortly before the presently foreseen date for project closure. The review team was reassured that, following discussion around this point, equipment would be issued ahead of the usual schedule. Concerns remain, however, that it is now late to retrieve this situation. Training for performance improvement in delivery services using the Standards-Based Management and Recognition (SBM-R) Approach has been widely undertaken and is generally on track, although the Katsina facilities need to catch up. Training on basic BEmONC) and the posting of the National Youth Service Corps doctors to ACCESS supported PHCs are leading to an increase in the number of women receiving active management of the third stage of labor. The performance in this area is overall, up to target. Progress on improving management of pre-eclampsia and eclampsia has been somewhat slower, though reporting is incomplete in this area. One cause of delay is that there have been major shortages of magnesium sulfate. This is now being manufactured in Nigeria, so the problems should be reduced. However, it may also be that training has not yet covered eclampsia treatment adequately. Another consideration is that staff may not be able to give enough time (or consider it enough of a priority) to keep the patient under as regular observation as would be desirable. Incorporation of the partograph into standard delivery practice has been particularly slow. One reason is that if women turn up too late into labor, there is little point in starting a partograph. Other reasons are that proper training in use of partographs has yet to take place (at least for CHEWs, who are being offered a simplified modular form of the BEmONC training); and that production of the actual stationary was delayed and getting partographs into circulation has taken time. Furthermore, staff claim they do not have time to use this instrument IR Strengthened Enabling Environment ACCESS does not operate in an enabling environment. In many cases external factors have posed problems. One example is with contraceptive stock-outs (see below). Other problems largely stem from staff being transferred to other parts of the state, and also from delays in production of materials and standards where these must be approved by an outside body. The development of performance standards for EmONC for use in hospitals and PHCs has been significantly delayed. Though these are now approved, the performance standards for FP services continue to be delayed. The national guidelines being developed by ACCESS for Kangaroo Mother Care await approval by external reviewers. One wonders if the contribution would be taken more seriously if ACCESS had a presence state-wide rather than solely in selected facilities. In some instances, senior SMOH officials seemed unaware of ACCESS and its current and potential contribution. Other environmental problems arise from the fact that working with LGAs is not always easy and the LGAs themselves have scant resources and lack technical support. 14 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

284 In terms of donor support, the review team concurred with the earlier findings of Holfeld and MacDonald 16 that the work of USAID in this sector receives relatively small amounts of funding compared with the problems to be addressed, and that the USAID office lacks both funding and staff to support the ACCESS program adequately. It is also important to mention the physical environment in which services must be offered. All facilities visited have major problems with electricity supply and spend a large proportion of their meager recurrent budget on diesel for generators. Furthermore, because the sterilizing equipment provided by USAID cannot be operated without a power supply, in all three states, sterilization was being done with chemicals an unsatisfactory and unreliable method. Water is also a problem. The most frequent single request made for extra support was, time after time, for a bore hole. However, a bore hole requires a pump, so it is useless unless electricity can be made available. The IMNCH Strategy of the Federal Ministry of Health (2007) specifies that each state should invest in ensuring a power supply for all its secondary level facilities, while providing at primary level standby generators, solar lanterns, and kerosene or gas fridges for blood storage (p60). That services are being provided in these inauspicious circumstances is a tribute to determination. The impact of the dispersion of the project is shown in the table below: TABLE 4: ACCESS SUPPORTED HEALTH FACILITIES AS A PROPORTION OF HEALTH FACILITIES IN THE STATE State Number of general hospitals in the state* Number of ACCESSsupported hospitals Percent of hospitals supported by ACCESS Program Number of PHCs in the state** Number of ACCESS supported PHCs % PHCs supported Kano Katsina Zamfara *Source: Ministries of Health (verbal information), June 2009 **Source: WHO (2002) RH Resources and Services Survey This table shows how thinly ACCESS services were spread over northern Nigeria. Only about a quarter of the hospitals within each state have received ACCESS support. More importantly, it only provided support to about 6% of the PHCs in each of the three states. It is extremely difficult to have an impact on a population basis with as few facilities as were available. As a counter-example, ACCESS could have focused the same amount of services to all the hospitals in Zamfara and could have been more effective in that state. In this example, it would still have only provided about one third of the ZAMFARA PHCs. This concentration of effort could have had synergistic effects between hospitals and PHCs, and could have built a stronger public outreach effort, reducing problems with staff training, material logistics, and project staff movement IR EXPANDED DEMAND FOR IMPROVED SOCIAL SERVICES 16 Holfeld, Joyce M. and Patricia MacDonald. The Ground Is Softening, for the USAID/Nigeria Health Portfolio: Considerations for the Present and the Future. Submitted To Akua Kwateng-Addo and the USAID/Nigeria Health Team, January USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 15

285 The communities visited by the team showed a great deal of energy and enthusiasm. Mobilizers are typically men, though in some communities a few women had also been selected. It is more difficult for women to obtain permission to travel than it is for men, and also women are generally less educated. Men are probably better at persuading other men to take a more liberal view on issues such as birth spacing and use of maternity services than has been the case in the past. The baseline survey for ACCESS indicated a high level of male control over decision-making about the conduct of pregnancy and birth, so this is probably an important aspect of the work. The work of mobilizers is now going beyond advocacy, and schemes such as ones for emergency transport are being developed. Despite this, although the reported numbers of beneficiaries recruited by community activities is not as high as hoped, they have probably been under-reporting because women are free to choose which provider to use. One particularly impressive community level activity is that of the volunteer saving clubs for women Tallafis (self-help in Hausa). These clubs are similar to Gramin banks, and enable women to have access to credit and resources they can access. The team saw a gathering of women from several clubs in Mada, Zamfara State, which was an impressive sight, bringing together perhaps 200 women who are participating in this activity. There are now 13 savings clubs in five communities. Across the clubs in this local area alone, it was said that women have raised around N1 500,000 in funds that can be called upon by members, both for entrepreneurial activity or for emergencies in childbirth IR Increased Access to Services, Commodities and Materials The main indicators for this result are measures of drug stock-outs for BEmONC. This seems to be an unreliable measure of management capacity in the selected LGAs, because the project has no control over drug supplies. There are frequent stock-outs of the designated tracer drugs and efforts to reduce this have been unsuccessful. In 2008, every EmONC facility had a stock-out of some essential drug. ACCESS is doing all it can to advocate for improvements in the drug supply. This is another area where, if ACCESS had a presence in state-wide activity, it could be more influential in bringing about improvements. The other indicator for improved access to services measures the provision of newborn essential care: this information has not been consistently collected and reported over the project lifetime, and therefore cannot be assessed. The more directly relevant indicators for this result are related to actual provision of services and trained staff. Cesarean section rates are one indicator that is important here, though the reporting on this indicator shows discrepancies in various documents. However, taking the data from the report for Quarter 2, 2009, the rate is estimated at 5%, well below the 15% target. The reasons given are infrastructural challenges, staff shortages, and the continuing high prevalence of home deliveries. The other indicator of availability of services and staff is the number of people trained in maternal/newborn health through USG-supported programs. The project has generally kept pace with its targets in this area, though it would be useful if reporting were more consistently disaggregated to show numbers of female and male workers trained. However, there are two problems in looking only at volume of training. First, achievements in training are undermined by the high rate of staff transfers, which leads to a lack of trained staff at the various sites. Second, simple training does not necessarily result in changed behavior in a clinical setting. A further problem is that the CHEWs who form the backbone of maternity care capacity for PHCs are inadequately prepared in terms of basic education (possibly even literacy) and improving their professional skills is difficult. An example of this problem is seen in weighing of babies: often, CHEWs were not recording birth weight, or recording it inaccurately. The project has recognized the lack of education by creating a training program based on short, simple modules of 2 3 days each, offered at intervals in the hope that the new learning can be digested before moving on. The review team feels that a 16 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

286 better approach would be on-the-job, highly practical training in which an experienced instructor works alongside the CHEWs in a health facility for perhaps one month, helping them to incorporate good practices into their daily work learning by doing. The evaluators doubt whether the CHEWs can ever form the basis for a para-midwifery cadre. It would seem more promising to explore the possibility of the new midwifery school in Zamfara training a new cadre of community midwives. This would work if standards can be established such that the trainees become skilled birth attendants in line with the World Health Organization (WHO) definition and professional specifications Project Management Project activities began in Kano and Zamfara states in The Katsina activities were started in early 2008, and thus have had far less time to mature. There is a central office in Abuja to manage coordination and policy dialogue with the central government and other stakeholders, including USAID. There is a regional office in each state, which supports the project sites. At least once a month each site receives a supervisory visit and more often as needed to support the hospitals and PHCs. There is no specific project management indicator. It might be useful for the follow-on project to track frequency of supervisory, training, and monitoring visits and compare them to how quickly sites reach their goals. Based on interviews and document reviews, there do not appear to be significant management issues other than those discussed above, which are principally due to the challenging environment. Because of this, the project team works extremely hard to achieve results, displaying considerable energy and commitment. The only concerns were around monitoring and record-keeping. These are mentioned below Monitoring and Evaluation Although data collection is taken seriously in the project, there are a number of flaws that were noticed in the course of the field visits. Some data appeared to be seriously suspect. One example, noted in Daura General Hospital, involved 156 entries for June which included records of only two low birth weight babies and three complicated deliveries an observation that seems incredible. Also, actions taken were often recorded with a just a check-mark, with no detailed information provided as to treatment given. One explanation is that staff are struggling with the difficult situation that they must record data in at least three places: the government records system, the project recording system, and the individual patient notes. This is tough for anyone, but especially so for staff that are sometimes only barely literate, and often overworked. For example, in one busy little maternity ward, the lack of basic recording was noted. The explanation offered was that at any one time, there was only one nurse-midwife to cover that ward. How, then, can good record-keeping be expected? USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 17

287 Other related issues are: Lack of ownership of the project record feeling that keeping a system is an unwarranted intrusion on the time available for patient care, Lack of appreciation of the importance of the information to be recorded and used to improve quality of care, and Need for more training in record-keeping. The focus on service facilities and on the numbers of users of these facilities does not show the level of impact that the ACCESS program could have. At some point in the project cycle of the follow-on activity, the Mission and IPs should make some estimates of the number of deliveries, and their expected impact. In the original PMP, population-based surveys were projected, but these have not been done. An alternative is to use relatively simple calculations of the annual incidence of pregnancy among women of reproductive age (WRA). When combined with population figures, this can lead to a rough estimate of the impact of any particular program. However, at this point it is more important for ACCESS to ensure that the service statistics are accurate, and that records are collected in one place instead of being spread across a variety of patient records and clinic/hospital logs. It is also important to understand that higherlevel indicators such as an increasing proportion of the population using services will not be useful in the first few years of small projects Links to other USAID programs USAID requested information on the collaboration between the three programs that are the subject of this evaluation. During visits to ACCESS and its facilities, respondents were questioned about their contact or collaboration, if any, with ACQUIRE and IRHIN. The answer was consistently that there was little interchange, although the lead project officers said they all knew each other and meet in certain situations. There was even some suggestion that the programs compete with each other. This was specifically mentioned in the case of ACCESS and ACQUIRE. The issue seems to be that these two projects have some similar performance indicators and data sources, This leads to the possibility of double counting and distrust about who should claim credit for positive results. It may be possible to review the indicators and reorganize them to eliminate this problem. However, if more active collaboration is viewed as important, USAID may need to take the lead in convening meetings of senior staff from the programs. Another option to consider would be creating a formal organizational link that effectively brings the present projects under one umbrella Analysis and Conclusions Immediate considerations (to December 2010): The whole ACCESS team is to be congratulated at doing a good job in difficult circumstances and in the absence of an enabling environment. Health workers in the facilities visited are grateful for what ACCESS has done. However, the late start and the delays described above have prejudiced the work in Katsina. In the view of the review team, it is unlikely to be able to bear fruit within the program time available, and will, at best, become a turn-key activity with little chance of success unless it is picked up by another donor, presumably the Department for International Development (DFID). The team understands the political desires of both of the state government and the National Planning Commission to spread benefits of donor activity widely across the region. Nonetheless, the team feels that USAID and ACCESS/MCHIP should be in a position to negotiate the location of service sites to ensure their greatest effectiveness. While in no 18 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

288 way wishing to denigrate the efforts that have been made to further the work of ACCESS and to extend it to three states, the review team urges USAID to immediately discuss the future of the work already begun in Katsina State with stakeholders and consider redirecting resources (including possibly staff) to the other two states. It is noteworthy that Katsina is one of the states selected for support in the field of MNCH work under the new DFID-Norwegian program in the northern states. The work that ACCESS has initiated should be discussed with DFID managers so that some degree of continuity might be achieved. Long term: As ACCESS is winding down, and the Targeted States High Impact Project (TSHIP) is starting, USAID should reconsider how it does MNCH/RH work in the public sector. As long as work is focused on only a few facilities in selected LGAs, it is difficult for a SMOH to give much attention to the important and evidence-based work being supported by USAID. It is also difficult for the Ministry of Local Government to appreciate the importance of this work or to relate to it. Rather than spreading work thinly over several states, it may be preferable to work in one (or if funding permitted, more than one) entire state, rather than at individual facility/lga levels. The same point was made by Holfeld and MacDonald. 17 This approach would make it possible to work with the State Ministry to support the development of a human resources strategy, to tackle the problems of logistics management, to improve quality assurance, and to open up the possibility of creating a unified and simplified approach to data collection and monitoring. Alternatively, a more practical approach might be to start with a few contiguous LGAs and expand services to the whole state over a two to three-year period. Working state-wide would allow an ACCESS-type project to really make a difference in a way that work in selected LGAs simply cannot. It would also provide a show-case for USAID s work so that methods could be adopted on a national basis. ACCESS has much to offer. Already, it has developed the operational performance standards for EmONC in hospitals and PHCs, in collaboration with the FMOH, WHO, UNICEF, and Partnership for Transforming Health Systems. The training manual for Kangaroo Mother Care is also available for all states. ACCESS and FMOH have jointly produced a Situation Analysis and Action Plan for Newborn Health in Nigeria. However, there remains a good deal of learning that is not being fully utilized in development of national standards and guidelines, and, if ACCESS were better positioned, more opportunities would be available. USAID has decided to focus its work on just two states, Bauchi and Sokoto. This implies the end of ACCESS work in Zamfara, Kano, and Katsina. In the course of field visits, the team repeatedly asked health workers how they would feel if ACCESS work came to an end. On the whole, the responses were that ACCESS had done a good job and that they would appreciate continued support. However, if ACCESS did end, they said that they would continue within the framework and approaches developed with ACCESS. DFID and the European Union are both active in these states and may be willing to take up the projects that USAID has started. Bauchi has 4.7 million people; Sokoto has 3.7 million people. The current resources of ACCESS are financing work that is claimed to reach 5 million people. These resources would be adequate to finance work in one state, including a greater emphasis on improving state systems. Increased resources would make it possible to operate in both states. Recommendations 17 Holfeld, Joyce M. and Patricia MacDonald. The Ground Is Softening, for the USAID/Nigeria Health Portfolio: Considerations for the Present and the Future. Submitted To Akua Kwateng-Addo and the USAID/Nigeria Health Team, January USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 19

289 1. USAID should discuss the future of work begun in Katsina State with all stakeholders and consider redirecting resources (including possibly staff) to the other two states. 2. ACCESS should continue in Kano and Zamfara until the end of the MCHIP period. 3. Future work should be undertaken on a state-wide basis, rather than in selected LGAs only. 4. USAID should consider how to improve links between the work of ACCESS and ACQUIRE to develop the synergies that are possible in the programs efforts to improve maternal and neonatal health. 5. The Mission should explore the possibility of using the new midwifery school in Zamfara to train a new cadre of community midwives. 6. ACCESS should immediately add secondary fistula prevention to its Nigeria outreach and clinical EmONC services. 7. ACCESS should develop more robust measures to link family planning motivation and support to government clinics to actual contraceptive use Increased fistula prevention activities Fistula prevention has both a primary and a secondary aspect. Primary prevention requires training women and traditional birth attendants to recognize prolonged labor and arrange immediate transfer to a facility that can intervene before damage is done. There are enormous roadblocks to prevention, given the state of roads, transport, and CHC and secondary hospital deficiencies. Secondary prevention requires early recognition that a fistula is starting to form if the woman is leaking two days after delivery. It then requires treatment with a catheter into the bladder for two weeks. Nearly all women who start treatment within four weeks of delivery will be prevented from developing a permanent fistula. It is striking that the ACCESS EmONC package does not include secondary fistula prevention. ( While ACCESS standard procedures call for catheter use following difficult deliveries, it is not clear that this is carried out. ACCESS s successful outreach program should also be used to mobilize women who are leaking after home delivery. Recommendation: ACCESS should ensure that secondary fistula prevention is actually provided through the Nigeria EmONC and outreach services CROSS-CUTTING ISSUES: A number of issues apply to all three projects. There are several questions that the team was asked to address directly that have not been dealt with in the document so far: Are the interventions adequate for a significant health impact on RH/MCH? This is a difficult question. The answer is clearly yes if one only looks at the individuals whose lives have been saved or changed by the intervention. However, when measured on a population basis, the project s success is minimal. ACCESS: A relatively small percent of deliveries in their local catchment areas come to hospital for complicated deliveries. This is the case because of cultural practices, lack of transport in an emergency, and because most women s experience with government hospitals has not been helpful. In addition, few traditional birth attendants bring their patients to even project hospitals for fear of losing their fee or of being berated by the hospital staff. There is not sufficiently fine data to pick up changes at the LGA level in maternal and neonatal mortality and morbidity. 20 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

290 Are the current project geographic areas rational? ACCESS: Distribution across widely separated LGAs means that it is difficult to provide proper support. It is difficult for the small staff to do effective monitoring and on-site training if it must spend hours on the road to reach scattered clinics. This is most notable in Katsina. While ACCESS is doing better in Kano and Zamfara, either clustering LGAs or operating at the state level providing services to all LGAs will be more geographically realistic Compatibility, Synergy, Sustainability Do the current projects respond to the FMOH s desired directions for Nigeria? How do projects work (coordinate, collaborate, and seek synergy) with the FMOH/State/LGA? How can this relationship be further strengthened? How does the program complement other RH/MCH services in the country? Compatibility: The team has reviewed FGON policy documents, and has spoken with a few northern state health officials, but, for scheduling reasons, it was unable to meet with any officials at the federal level. ACCESS, to take one example, was reportedly very effective working at that level to help design policies and curricula regarding EmONC. Synergy: The team spoke with many people in the projects about synergy. Unfortunately, it found little coordination at best, and outright competition at worst. To take a single example, the IRHIN s PPMVs and private practitioners were competitors for clients in Cross River State, and both competed with the local government health centers. Other situations were worse. According to ACQUIRE, when it asked ACCESS to help with training of outreach workers, ACCESS reportedly refused unless it could count all the CYP generated by ACQUIRE s staff against ACCESS s targets. This is absurd. In some ways, the team faults the Mission for allowing the number counting to get ahead of project implementation. Coordination: There was very little coordination with the DFID. This was confirmed by meetings with this organization, even though both donors had similar activities in the north. There was more coordination with state government, and efforts to reach out to local governments. Sustainability: This was discussed with staff from each of the projects. The team believes that, at this point, none of these three activities are sustainable without continued donor support. The one most likely to continue would be the fistula hospitals, but they have no succession plans, and their current master trainer is in his 70s. They are only sustainable because they represent a feel good project, and other private and public sector donors are likely to step in and fill the gap. To be realistic, three years of effort is not sufficient for almost any activity to become self-supporting. At this point, it will take major donor and government commitment to continue for at least years. Gender equality: One of the most striking things about Nigeria s work is that all projects have made good progress in incorporating men and community/religious leaders in their outreach efforts Other Significant Issues Poor data quality: This is a problem that the Mission needs to address immediately. The team did not see PMPs either for the health office of the Mission, or for any IP except IRHIN and even that did not include targets for the Pathfinder program. The team found the following problems: ACCESS registers are not filled in sufficiently to know whether EmONC procedures are actually being carried out. CHEWs do not understand or are not able to follow the need for documentation. The Partograph not being used, registers suggest that the CHEWs do not know how to use the scales to weigh newborns, and that they grossly underestimate the number of complicated deliveries. Bluntly put, the team does USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 21

291 not believe any of the service statistics presented by ACCESS. However, there is no reason to doubt their non-service statistics, trainings, equipment furnished, buildings rehabilitated, etc. The team also does not believe their CYP estimates, since in many sites FP services are actually provided by a government facility instead of ACCESS. Inadequate funding: The team believes that, for the projects to date, USAID has not had sufficient resources to begin to meet needs: it is absurd to try to do social marketing across the country with $13.5 million. Indeed, the only reason why USAID has succeeded so well is that some management and logistical activities have been costed under other USAID projects. In addition, the USAID staff numbers are grossly inadequate to monitor and manage the projects: Joyce Holfeld recommends at least six staff headed by two direct hires, and the team agrees with that assessment. While the team has not costed out a new private sector project, it feels that it should be as large as the TSHIP award. Recommendation: Funding should be increased as currently planned, and the USAID Health Office should be increased to six direct hire equivalent positions. Project staff mobility: This has been adequately discussed under each of the projects, but it is worth repeating. As soon as public sector staff begin to be trained, they are transferred elsewhere, leaving a vacuum behind. This is even true of the two most experienced trainers in the fistula project. Unfortunately, the private sector has same problems with staff leaving to seek better employment elsewhere Recommendations: SFH, CSOs, and government agencies need to identify ways to reduce turnover of key personnel, especially providers. Retention indicators should be developed and used in recruiting for positions. An awards system needs to be developed to encourage key staff and providers to continue working for the program. Lack of basic facilities: These issues have also been discussed in depth: lack of electricity, lack of water, lack of the resources to sterilize instruments, lack of transport, and run-down hospitals and clinics Future USAID/Nigeria Health Programming The Mission requested that the team look at specific issues concerning future health work in Nigeria. Greatest impact: The team agrees with the Mission s decision to focus on two states for most public and private sector efforts. There is an enormous unmet need for FP across Nigeria. This means that the Mission should increase CSM efforts with an emphasis on increased supply and logistics and frequent mass/multi media campaigns. Fistula training should be incorporated into core and specialist medical training. There should be an effort to offer a full range of services away from fixed clinical facilities. The PPMVs are one good effort, but they need to be markedly expanded. The team feels that there should 22 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

292 be FP outreach, with skilled providers in all methods at places where people congregate regularly, such as market days. Balance between Service and System Strengthening: At this point, the project should focus on service supervision with enough system strengthening to address immediate obstacles, i.e., frequent staff transfers, preference of LGAs for cheaper and poorly skilled CHEWs at health facilities. As has been learned over the past 40 years, there is no upper limit to the demand for system strengthening, and there is almost no lower limit to the impact that most efforts have. It will take years of relatively low-level efforts to bring most LGAs and even states to the point where they can manage all parts of their local programs. Future Directions in supporting the Three Levels: The work to date has been good, but it has depended more on the interests of the individuals in top positions than any structural improvements. Extremist attacks, such as those seen on the last day the team was in country, can easily wipe out a decade of careful work. That they occurred in one of USAID s intended focus states, Bauchi, is ominous. The team believes that USAID and its implementation partners need to work at all levels to increase the recognition that family planning/birth spacing is critical to achieving any health objectives. Strengths: SFM is an extremely experienced CSM organization. It has the capacity to move to scale under the new private sector/social marketing program. Innovative programs: Innovative fistula repair program Innovative outreach to men, community, and religious leaders Innovative approaches to women s credit for support for perinatal care Little innovation in other programs: they seem to be replicating work done elsewhere without considering Nigeria s unique needs. Conclusion: Each member of the team believes that the USAID/Nigeria Mission and its IPs did a very good job given the constraints of the environment, staffing, and funding. To paraphrase Joyce Holfeld: The ground may be softening, but there s a lot of work ahead that requires dynamite and pick-axes. USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 23

293 ANNEX A: SCOPE OF WORK USAID/Nigeria MCH/Reproductive Health Program Mid-term Evaluation (Revised: ) I. PURPOSE The purpose of this mid-term evaluation is to provide USAID/Nigeria Investing in People (IIP)/Health, Population, and Nutrition (HPN) Team with sufficient information to make programmatic and budgetary decisions regarding future directions. The evaluation will focus on USAID/Nigeria s public sector projects, ACCESS/MCHIP and ACQUIRE/Fistula Care, both implemented through field support mechanisms, and the bilateral private sector project Improving Reproductive Health in Nigeria (IRHIN) implemented by the Society for Family Health (SFH). The evaluation will outline opportunities, challenges and critical areas to address and make recommendations on the most effective and efficient (i.e., operating within the implementation cost) path forward under the follow-on period. The evaluation will look at the performance of each project through June II. BACKGROUND Nigeria has among the worst health indicators in the world. Maternal and under five mortality is estimated at 1,100/100,000 and 201/1,000 deaths respectively. Total fertility is 5.7 births per woman with only 3% of women using a modern contraceptive. USAID has a long history of activities in the health sector, including MCH, family planning, and reproductive health implemented both in the public and private sector. Under the Mission s current ( ) strategic plan, USAID aims to increase use of social sector services under its Strategic Objective (SO) 13 and meet its four intermediate results: (1) IR 13:1 Improved quality of social sector services; (2) IR 13:2 Strengthened enabling environment; (3) IR13:3 Expanded demand for improved social sector services and (4) IR 13:4 Increased access to services, commodities and materials to assist the Government of Nigeria to improve the quality, access, and use of social sector services. USAID has various mechanisms in place to attain its health SO, including bilateral programs and field support/central mechanisms. The focus of this midterm evaluation will be on the following three projects: ACCESS/MCHIP: (1/06 to 12/09): ACCESS/MCHIP supports the utilization of quality Emergency Obstetric and Newborn Care services (EmONC) including birth spacing, reproductive health, and family planning by pregnant women, mothers, and their newborns in three states: Kano, Katsina, and Zamfara. The project is implemented in Nigeria by Jhpiego. These three projects have similar goals but different activities; therefore they are being evaluated as a program package. III. SCOPE OF WORK The following illustrative questions should be used as a guideline for the evaluation team: Program Questions Are the projects on the right track and are benchmarks/results being met? What changes, if any, need to be made? What are the gaps? Are the interventions adequate for a significant health impact on RH/MCH? 24 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

294 Discuss how the interventions are implemented. What were trends? Results achieved? Successes? What were the major obstacles/difficulties confronting RH/maternal health? How are these issues being addressed by the project? What were the results/achievements towards SO 13 objectives? Discuss missed opportunities, if any, for linkages with HIV/AIDS PEPFAR funded activities. Recommend strategies for addressing and improving linkages in the future. Recommend future strategic areas that need to be addressed. Geographic Coverage Are the current project geographic areas rational? If new areas are selected in the future, what geographic coverage would make sense, considering the Mission s/health team strategic priorities, other USG programs, and the FMOH s plan for strengthening the health sector? Local Capacity Building and Local ownership To what extent have the projects succeeded in gaining the buy-in and participation of government institutions at state and LGA levels? What approaches were used and what challenges did the projects face in obtaining buy-in and participation, if any? Discuss projects efforts at capacity building (institutional, management, programmatic, and technical) among grantees (NGOs including local), central government, state government, local health department, community and private sectors and where relevant. Is the project strengthening county (state/lga) capacity to deliver health services? What are the major obstacles? How are they addressed at the various levels? What were the major break-through and accomplishments? Give evidence and cite examples. Compatibility, Synergy, Sustainability Do the current projects respond to the FMOH s desired directions for Nigeria? How do projects work (coordinate, collaborate, and seek synergy) with the FMOH/State/LGA? How can this relationship be further strengthened? How does the program complement other RH/MCH services in the country? To what extent have projects sought to coordinate activities and seek synergies with USAID/Nigeria s other health projects, SOs, donors and local partners (NGOs, private sector)? Describe approaches used. To what extent have projects improved the enabling environment for MCH/RH? Are the projects working towards sustainability? How and what else could be done? To what extent have the projects achieved gender equity and what approaches where used? Any challenges and gaps? Future USAID/Nigeria Health Programming What are the lessons learned that should be expanded in the remaining life of the project, or follow-on project? What else could/should be done? What activities would have the greatest impact? USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 25

295 What should be the balance between service and health capacity/systems work? What are recommendations for future strategic directions in strengthening federal, state, LGA, NGO/private sector? What are the strengths and innovative activities being undertaken that should be continued, scaled-up and emphasized? IV. METHODOLOGY The evaluation team will be divided into two sub-teams. One sub-team will examine the public sector projects (ACCESS, ACQUIRE), and the other will focus on the private sector project (IRHIN). The subteams will travel separately to their respective geographical locations, and then, upon return will work together to produce a single evaluation report that discusses not only the specifics of the individual projects but also analyzes how the projects are collaborating and what are the synergies. In order to address the comparability issues due to use of two separate teams for project review, a common questionnaire/interview guide will be developed and used to collect information and guide the analysis. The evaluators should consider a range of possible methods and approaches for collecting and analyzing the information required to assess the evaluation questions. The methodology will be discussed and finalized with the USAID/Nigeria HPN Team once the evaluation team has arrived in Nigeria. The methodology will include, but not limited to: document review, team planning meeting, key informant interviews, site visits, and observation. Team Planning Meeting The full team will have a two-day team planning meeting upon arrival in Nigeria. The team planning meeting is an essential step in organizing the team s efforts. During this meeting, the team will produce a workplan, timeline, interview instruments, and preliminary draft outline of the report. Roles and responsibilities will be agreed upon, and the team will have an initial briefing from USAID. This meeting will allow USAID (and the partners) to present the team with the purpose, expectations, and agenda of the assignment. In addition, the team will: clarify team members roles and responsibilities review and develop final assessment questions review and finalize the assignment timeline and share with USAID develop data collection methods, instruments, tools, guidelines, and analysis review and clarify any logistical and administrative procedures for the assignment establish a team atmosphere, share individual working styles, and agree on procedures for resolving differences of opinion develop a preliminary draft outline of the team s report assign drafting responsibilities for the final report Document Review 26 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

296 USAID/Nigeria will provide the evaluation team with key documents prior to the start of in-country work for their review (many of these are located on the USAID/Nigeria web site). These will include, but are not limited to: USAID/Nigeria Health Strategic Objective SO13 ( ) USAID/Nigeria health result framework and standard indicators Draft new health strategy ( ) IRHIN Cooperative Agreement Projects workplan and monitoring plans Projects quarterly/annual reports Baselines surveys Trip reports Government health strategies, policies, guidelines, and protocols Interviews Key informant interviews will include but not limited to: USAID/Nigeria HPN Team GON staff at federal, state, LGA level Projects (ACCESS/MCHIP, ACQUIRE/Fistula Care and IRHIN) staff in Nigeria and in Washington, D.C. Health facilities staff and beneficiaries at targeted sites Targeted Community groups and NGOs Other implementers, international donors, private sector group working in partnership with each projects Site Visits and observations The evaluation team is expected to conduct site visits of targeted states. It should be noted that the IRHIN social marketing project is implemented nationwide, with limited service delivery aspect in select states, while the public sector projects (ACCESS/MCHIP and ACQUIRE/Fistula care) are implemented in selected states. The evaluation team is expected to travel to sites in Kano and Sokoto. Note about Security: The in-country and actual site visit travel plan will be reviewed and cleared by the Regional Security Office (RSO) prior to any team in country travel. V. TEAM COMPOSITION USAID is looking to conduct one comprehensive evaluation of the three projects covering all the geographic zones with some geographic overlaps. The evaluation team will consist of: International USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 27

297 The five international consultants will possess the following qualifications: Team leader (responsibility for overall evaluation coordination and final report, will travel with sub-team A: public sector focus): a senior level consultant with extensive experience designing, managing and evaluating large and comprehensive health programs. He/She will have strong skills in assessment and analysis of USAID population and health projects and extensive experience working in Africa. The team leader will have expertise in FP/RH, excellent leadership and management skills, strong writing skills, and demonstrated ability to manage a team of professionals. MCH/evaluation expert (will travel with sub-team A): a senior consultant with extensive knowledge and experience in evaluating public health programs with a particular focus on maternal, newborn and child health care. FP/RH expert (will travel with sub-team A): a senior consultant with extensive knowledge and experience in public health programs with a particular focus on public sector FP/RH programs. Private sector/evaluation expert (will travel with sub-team B: private sector focus): a senior level consultant with extensive knowledge and experience in evaluating public health programs with a particular focus on the private sector. He/She must have experience in evaluation and MCH programming. FP/RH expert (will travel with sub-team B): a senior consultant with extensive knowledge and experience in public health programs with a particular focus on private sector FP/RH programs. The team leader will: Finalize and negotiate with USAID/Nigeria the evaluation work plan; Establish evaluation teams, roles, responsibilities and tasks; Coordinate different teams; Lead the discussion on site visit selection; Ensure the logistics arrangements in the field are complete; Coordinate the process of assembling input/findings for the evaluation report and finalizing the evaluation report; Coordinate schedules to ensure timely production of deliverables; Lead the oral and written preparation and presentation of key evaluation findings and recommendations to USAID/Nigeria, government counterpart, and other audiences as appropriate. The Team Leader will be responsible for the overall planning, design and implementation of the evaluation and work coordination among team members. It will be the Team Leader s responsibility to submit a satisfactory report to USAID within the agreed timelines. The Team Leader is responsible for report writing and the organization of the debriefing presentations. Program schedules for field visits shall be discussed and prepared prior to the team s arrival in Nigeria. This plan will be finalized during the TPM. The team members duties will be determined in consultation with the Team Leader and may include the following: Assist the team with instrument development and data collection; 28 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

298 Participate in data analysis and report writing; Assisting the Team Leader as directed in all aspects of completing evaluation deliverables. Domestic Research/Logistics Assistants (2): The team will be supported by two local Research/ Logistics Assistants who will provide logistical and administrative support during the team work in country. The logistics assistant will work directly with, and report to, the team leader. Responsibilities will include: Arrange for copying/compiling reading materials, field visits, local travel reservations, hotel reservations, appointments with stakeholders, arranging for vehicles for appointments and on site visits, and other tasks as requested by the team; Participate in the development of interviews and FGD guides/training in their use; Conduct interviews and FGDs where needed; Serve as note takers and organizers during interviews and FGD; Participate in daily field debriefing; Write, revise and submit hard and electronic copies of interviews field notes to the team leader. USAID/Washington GH office (2). (To be confirmed by the Mission) USAID/Nigeria health team USAID/Nigeria staff will not accompany the consultant team to the field visits or interviews; rather they will provide program support and guidance if they happen to be at the same site/state the team is visiting. The government (at state and LGA level) It is anticipated that government officials such as Ministry of Health and National Planning Commission personnel will accompany the consultant team on field visits. This will be an opportunity for government officials to learn about progress made in USG-supported RH/FP interventions. VI. LOGISTIC SUPPORT GH Tech will be responsible for providing logistics support for this assignment. Two Research Assistants/Logistics Coordinators will be hired to assist the team (refer to section V. above for details). USAID/Nigeria guidance on hotels and methods of in-country travel is essential and appreciated. VII. OVERSIGHT AND MANAGEMENT The evaluation team will report to USAID/Nigeria HPN Team Leader. VIII. LEVEL OF EFFORT AND TIMING The evaluation will begin o/a late June and will require a total of eight weeks of effort on a six-day work week. One/two week(s) for preparation, document review and drafting interview and FGD guidelines/questions, four week(s) of data collection and two week(s) of analysis and writing. USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 29

299 Task/Deliverable Review of background documents & offshore preparation work Phone interviews and meetings with ACCESS/MCHIP & ACQUIRE staff Duration/LOE Team Leader FP/RH (Team A) FP/RH (Team B) MCH Eval Expert Private Sector Eval Expert Research/ Logistics Assistants (Team A) Research/ Logistics Assistants (Team B) MOH/ GON Officials Travel to Nigeria Team Planning Meeting and meeting with USAID/Nigeria Meetings and interviews with key informants (stakeholders, USAID staff) in Abuja Information and data collection Kano, and Sokoto (maybe another site) Discussion, analysis and draft evaluation report preparation in country Debrief meetings with USAID and key stakeholders (preliminary draft report due to USAID) Depart Nigeria /Travel to US USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

300 Task/Deliverable Duration/LOE Team Leader FP/RH (Team A) FP/RH (Team B) MCH Eval Expert Private Sector Eval Expert Research/ Logistics Assistants (Team A) Research/ Logistics Assistants (Team B) MOH/ GON Officials USAID & partners provide comments on draft report (out of country) 10 working days Team revises draft report and submits in final to USAID (out of country) USAID completes final review GH Tech edits/formats report (one month) Total Estimated LOE A six-day work week is approved when team is working in country. IX. COST The cost will be determined once the team composition is finalized VIII. DELIVERABLES The following deliverables will be submitted to USAID/Nigeria HPN Team Leader. The timeline for submission of deliverables will be finalized and agreed upon during the team planning meeting: A work plan specifying the deliverables, draft interview and focus group instruments, and a timeline upon the completion of the team planning meeting. In and out briefings with key mission personnel, including the Mission Director, and a PowerPoint presentation of findings and recommendations to USAID. The team will consider USAID comments and revise the draft report accordingly, as appropriate. Draft report in both hard and electronic formats. A draft report of the findings and recommendations should be submitted to USAID/Nigeria prior to the Team Leader s departure from Nigeria. The written report should clearly describe findings, conclusions, and recommendations. USAID will provide comments on the draft report within two weeks of submission. Final report in both hard copy and electronic format. GH Tech will be responsible for editing and formatting the final report, which takes approximately 30 days after the final unedited content is approved by USAID. GH Tech makes its evaluation reports USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 31

301 publicly available on its website and through the Development Experience Clearinghouse unless there is a compelling reason to keep the report internal (such as procurement-sensitive information). Note: USAID is looking for one consolidated report containing findings on the three projects. 32 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

302 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 33

303 ANNEX B: CIVIL SOCIETY ORGANIZATIONS SFH developed partnerships with 18 CSOs to set up community outreach/referral projects in 18 states with high unmet need. The following is a listing of these CSOs and the states where they are working. S/N State Civil Society Organization 1. Rivers Support for Mankind Development Initiative 2. Cross River Centre for Health Works, Development and Research 3. Bayelsa Center for Development Support initiatives 4. Plateau FOMWAN 5. Gombe Community Oriented Health Providers Association 6. Abia Eziukwu 1 Community Partners for Health 7. Delta Hope Health Organization 8. Ebonyi Safe Motherhood Ladies Association 9. Bauchi Rahama 10. Borno Community Development and Reproductive Health Initiative 11. Zamfara Future Hope 12. Katsina Association for Reproductive Family Health and Youth Development 13. Kaduna Women Development Organization 14. Lagos Human Development Initiative 15. Ogun Positive Outreach Foundation 16. Kwara Royal Covenant Heritage Foundation 17. Edo Centre for Research and Preventive Health Care 18. Ondo Knowledge and Care Organization 34 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

304 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 35

305 ANNEX C. TABLES CONTRACEPTIVE TARGETS AND ACHIEVEMENTS SFH and USAID plot monthly, quarterly and annual sales of contraceptives. It is important to report and analyze CYP as well as unit sales. It is also important to look at the contributions of each method. In the text CYP sales are summarized by method and fiscal year in table 10. This annex provides more detail on CYP sales. For example, Table 9 shows that almost three million Depo Provera injections were sold during the FY period, and close to 15 million packets of Duofem were sold. However, that does not necessarily mean that Duofem outsold Depo Provera, since one is an injectable that is good for three months and the other only lasts one month. To standardize sales the project computes Couple Years of Protection, known as CYP. The table shows the conversion factors that are used to calculate CYP for each method. For example, four injections equal one CYP and 15 packets of Duofem equal one CYP. These factors take into account such behavioral issues as missing an injection or pill. The table shows that condoms are by far the most common contraceptives sold. In terms of CYP, condom sales account for almost two-thirds of all contraceptives sold. Three brands of contraceptives (Gold Circle, Depo Provera, and Duofem) dominate the market, accounting for almost 90% of all sales. Almost two-thirds of CYP are attributable to condoms, which is generally of limited effectiveness. The most effective and cost-effective method listed in the chart is IUD, which accounts for less than 4% of all CYP. Clearly, the emphasis on methods is the reverse of what it should be. Long-term methods should be dominant. Condoms and CycleBeads should be at the bottom of the list of effective methods. TABLE 5: TOTAL UNIT SALES AND CYP BY TYPE OF CONTRACEPTIVE, FY CYP Product Type factor Total Sales Total CYP Per-cent Depo Provera Injectable N / 4 2,908, , % Duofem Oral N / 15 14,947, , % IUD IUD N * , , % Condoms* Condom N / ,633,686 4,321, % Noristerat Injectable N / 6 2,623, , % Postinor 2 Emergency oral N / ,800 51, % CycleBeads Standard days N * 2 15,270 30, % Norigynon Monthly injectable N / 12 44,760 3, % Jadelle 2-rod implant N * , % Pregnon Emergency oral N / 15 49,850 3, % Total 6,826, % *Gold Circle. Another brand (Lifestyle) has just been introduced. 36 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

306 If enough short-term methods were sold, then the program would not need to concentrate on long-term methods. These data show that this is not the case. The relative distribution of CYP by method shows little change year by year. IUDs, for example, increased in 2007 but declined in Almost all other methods showed modest increases each year. But overall, total CYP gained 12.6% between and 15.7% between 2007 and Again, most of that increase was in condom sales. The program needs to put more effort into the promotion of long-term methods if it is going to have any effect on CPR and total fertility rate (TFR). TABLE 6: CYP ACHIEVEMENT FY 2006 FY 2008 Product FY06 Actual CYP FY07 Actual CYP FY08 Actual CYP Total Actual CYP Percent Depo Provera 179, , , , % Duofem 302, , , , % IUD 139, , , , % Condoms 1,342,339 1,414,735 1,564,841 4,321, % Noristerat 104, , , , % Postinor2 51,920 51, % CycleBeads 1,740 10,000 18,800 30, % Norigynon 3,730 3, % Jadelle 1,785 1, % Pregnon 3,323 3, % Total CYP 2,069,788 2,331,593 2,697,831 7,099, % Table 11 shows the CYP targets by year. What stands out is a significant increase in targets for Depo Provera and condoms. Targets for IUDs remain low and flat at less than 1% increase over the three years. Condom targets, on the other hand, more than doubled in Postinor 2 had an unattainable target of 480,000 CYP in That dropped to 53 58,000 CYP in 2007 and It appears that the project set unrealistic targets for some key methods and put its emphasis on condoms, one of the least effective contraceptives. USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 37

307 TABLE 7: CYP TARGETS, FY 2006 FY 2008 Product FY 06 CYP Target FY 07 Target CYP FY 08 Target CYP Total Target CYP Percent Depo Provera 3,000,000 3,300,000 3,630,000 9,930, % Duofem 308, , ,500 1,116, % IUD 31,250 32,035 32,832 96, % Condoms 700,000 1,648,333 1,771,958 4,120, % Noristerat 100, , , , % Postinor2 480,000 52,800 58, , % CycleBeads 20,000 30,000 50, , % Total CYP 4,639,250 5,558,168 6,087,370 16,284, % Excludes new contraceptives (Norigynon, Jadelle and Pregnon), for which targets had not been set. Table 4 shows that by the end of 2008 the project had significantly overestimated sales of Depo Provera (9 million CYP) and Postinor 2 (close to 540,000 CYP). Although condom sales did well, this is still the dominant market method. TABLE 8: CYP TARGETS VS. ACHIEVEMENTS, FY 2006 FY 2008 Product FY 06 Actual - Target CYP FY 07 Actual - Target CYP FY 08 Actual - Target Total Actual - Target CYP Percent Depo Provera -2,820,625-3,060,125-3,322,075-9,202, % Duofem -5,690-63,280-51, , % IUD 107, , , , % Condoms 642, , , , % Noristerat 4,867 39,333 62, , % Postinor2-480,000-52,800-6, , % CycleBeads -18,260-20,000-31,200-69, % Total CYP -2,569,462-3,226,575-3,398,378-9,194, % Excludes new contraceptives (Norigynon, Jadelle, and Pregnon), for which targets had not been set. The main conclusion from this analysis is that the program is relying too much on condoms and will have a very difficult time increasing CPR and decreasing TFR through this strategy. Much more emphasis will be needed on longer-term methods (IUDs, implants, voluntary surgical contraception) and mid-range methods (orals and injections). 38 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

308 PROJECT MONITORING INDICATORS It is especially important that all of the key stakeholders (SFH, Pathfinder, USAID, government agencies, et al.) have access to all of the project monitoring indicators. This includes baseline, mid-term, and final performance data. These data are crucial for determining how well the projects are doing in carrying out their planned activities. Mid-term data are especially important for USAID/HPN s planning process. After all, HPN will continue IRHIN through mid-2010 and thereafter in new projects in social marketing and private sector. It will be important for the current Performance Monitoring Plan (PMP) to be examined and decisions made as to what changes, if any, will be made for the next phase of support. The following table summarizes the status of all of the 32 PMP indicators selected for the IRHIN project. The evaluation team did not have the time needed to do the same for ACCESS and ACQUIRE. USAID should make sure that those PMPs are completed, analyzed and revised as needed. The IRHIN PMP is organized by IR. The number of indicators selected for the SO and IRs is summarized below: SO 15: Increased use of CS & RH services IR 15.1: Improved quality of CS & RH services IR 15.2: Strengthened enabling environment IR 15.3: Expanded demand for improved CS & RH services IR 15.4: Increased access to CS & RH services, commodities and materials Other indicators 2 indicators 6 indicators 2 indicators 12 indicators 5 indicators 4 indicators There are two SO indicators. As noted already, the project has not done well with respect to the most significant indicator use of modern contraceptive methods. In the future much more emphasis and support will be needed to go well beyond the miniscule CPR target. Data on the second indicator have not been collected, much less analyzed. This is a key behavioral indicator that should be activated so that program managers can identify interventions that lead to increased use of services. TABLE 9: SO DATA TABLE Indicator Source Baseline Target Mid-term Difference Mid - Target SO 15: Increased Use of Child Survival & Reproductive Health Services 1. CPR (modern methods) NARHS 9% 11% 9.7% Increased percentage of women seeking FP counseling and information in targeted areas TRAC Nigerbus survey Kaduna 26% Abia 29% Cross River 44% The six quality indicators are not especially enlightening because the first two, which are positive, are very limited. If Pathfinder developed and administered a quality score the team could not find it. The indicator on clinics rehabilitators is a simple count that does not indicate much about quality. The last two indicators are also broad estimates, which may not even be accurate. USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 39

309 Overall, quality of care is an important contributor to program success and deserves to be carefully monitored. USAID should make sure that better indicators are selected and data on quality are collected, analyzed, and acted upon. TABLE 10: QUALITY DATA INDICATORS Indicator Source Baseline Target Mid-term Difference Mid - Target IR 15.1 Improved Quality of Child Survival & Reproductive Health Services 1.1 Provision of correct information on FP 1.2 Score on client satisfaction 1.3 Quality score of clinic providers 20.9 Clinics Rehabilitated /built (homes, schools, clinics, markets) Beneficiaries of Clinic Activities 33.5 Number of people trained in FP/RH with USG funds Mystery See Table 18 Client Survey Exit surveys See Table 19 Pathfinder Quality Assurance system Program reports Program reports Program reports million ,474 +1,411 The indicators for enabling environment do not reflect the very significant contributions that FSH has made in gaining support for new contraceptives and licensing of PPMV. Both indicators should be dropped and replaced by more qualitative measures. TABLE 11: ENABLING ENVIRONMENT DATA TABLE Indicator Source Baseline Target IR 15.2 Strengthened Enabling Environment Midterm Difference Mid -Target 2.1 Belief that parents, community leaders or religious leaders support the use of FP by couples 2.2 Accurate and timely RH research disseminated to GON/MIH to make appropriate policy decisions NARHS M: 30% F: 29% IRHIN reports Not available M: 35% F: 34% Religious leaders only Kaduna 52.2% Abia 17.8% Cross River 34.4% The 12 demand indicators are, in general, much more informative and useful. The first seven of these indicators are from the NARHS and reflect national and state performance. The data are broken down by gender, which is very important for planners. They also show that mid-term performance is below target 40 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

310 for all but one of these indicators (intention to use FP in next 12 months). These figures should encourage USAID, the government, and partners to put more emphasis on specific demand creation activities. Our assumption is that the NARHS indicators reflect local conditions and values: for example, belief in the effectiveness of FP. If not, the indicators should be revised to do so. In addition, some consideration should be given to adding key service indicators to the NARHS, such as women seeking FP counseling and information. Some indicators need to be standardized. For example, the NARHS asks women if they know at least two FP methods. The PMP asks if they know at least one FP method. Thus the NARHS data cannot be used for the PMP on this indicator. The indicators on contraceptive distribution are collected regularly and are essential to the social marketing part of the program. These data on unit sales and CYP were examined in the tables below. TABLE 12: DEMAND DATA TABLE Indicator Source Baseline Target Mid-term Difference Mid - Target IR 15.3 Expanded demand for improved Child Survival & RH Services 3.1 Belief that FP/CS methods are effective 3.2 Intention to use FP in the next 12 months 3.3 Belief that use of FP can lead to infertility 3.4 Discussion of FP with a partner (at least once) in the last 12 months 3.5 Belief in the efficacy of condoms 3.7 Belief that contraceptives are easy to obtain (daily pill) 3.8 Knowledge of (at least 2) FP methods (PMP is at least 1) Distribution of Condoms Distribution of contraceptives (OCs) (Duofem and Postinor2) NARHS M: 63% F: 55% NARHS M: 8% F: 8% NARHS M: 36% F: 33% NARHS M: 34% F: 30% M: 67% F: 60% M: 12% F: 12% M: 31% F: 28% M: 38% F: 34% M: 51.5 F: 47.2 M: 19.8 F: 13.4 M: 22.5 F: 21.8 M: 16.8 F: 14.5 NARHS F: 42% F: 52% M: 54.0 F: 44.9 NARHS Oral pills: M: 30 F:33 Injectable M: 26 F: 31 IUD M: 12 F: 16 Oral pills M: 36 F:39 Injectable M: 32 F: 38 IUD M: 15 F: 20 NARHS M:30 F:37 M: 35 F:42 NA MIS monthly report MIS monthly report 150 million 1,025 million M: 20.9 F: 25.5 M: 20.6 F: 22.4 M: 6.4 F: 10.2 M: F: M: F: M: 8.5 F: 6.2 M: 21.2 F: 19.5 M F: -7.1 M: 15.1 F: 13.5 M: 11.4 F: 15.6 M: 8.6 F: ,780, ,780,896 4 million 29 million 6,365,400-23,365,400 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 41

311 TABLE 12: DEMAND DATA TABLE Indicator Source Baseline Target Mid-term Difference Mid - Target IR 15.3 Expanded demand for improved Child Survival & RH Services Distribution of contraceptives (injectables) Distribution of contraceptives (IUD) 34.1 Couple years of Protection MIS monthly report MIS monthly report MIS reports Noristerat 490,700 Depo Provera 571,500 Noristerat 3,464 million Depo 4,329 million 1,098,100 1,231,700-2,365, ,115,300 25, ,982 54, ,682 1,984,413 13,391,649 2,697,831-10,693,818 The five access indicators focus on distribution and coverage of contraceptives. There are no indicators of access to services. The commodity data come from annual MAP surveys that provide detailed information about the presence of each type of contraceptive. This is valuable information that is used to adjust social marketing strategies. One indicator (number trained in RH) was not reported and should probably be put in an activity category rather than a performance category. USAID should consider including access to services in its revised PMP. TABLE 13 A: ACCESS DATA TABLE Indicator Source Baseline Target Mid-term Difference Mid - Target IR 15.4 Increased Access to Child Survival & RH Services, Commodities and Materials 4.1 Distribution of OCs by PPMA & CBD (outlets with OCs in stock) Coverage standard met for condoms Coverage standard met for OCs Coverage standard met for Injectables 33.5 Maternal Capacity Building Number trained in RH Distribution survey or MAP survey 65% 75% 68% - 7 MAP survey 85% 90% Gold = 68% Life =18% MAP survey 65% 75% 68% - 7 MAP survey 45% 60% Program reports 0 20,000 Noris = 41% Depo = 49% Norig = 7% USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

312 *Annual sales A new set of seven indicators was added in FY No data were collected on three of the indicators. This is unfortunate as the indicators identify specific behaviors that are crucial to program performance: counseling visits, provision of counseling and services, and stock-outs. The fourth indicator is important to determine if mass media messages are being heard. This indicator fell some five million listeners below its target. TABLE 17 B: ADDITIONAL ACCESS DATA INDICATOR TABLE Indicator Source Baseline Target Mid-term New Number of counseling visits for FP/RH as a result of USG assistance New: Number of people who have seen or heard a specific USG-supported FP/RH message (Radio Drama) New Number of USGassisted service delivery points providing FP counseling or services New Number of service delivery points reporting stock-outs of any contraceptive commodity offered by the SDP Project reports NA Difference Mid - Target Nigerbus 25 Million 19,956,288-5 Million The overall conclusion is that an enormous amount of time and effort went into setting up a comprehensive PMP that is not being fully carried out as planned. The principal result is that some important PMP data are being collected and used (contraception distribution and NARHS data, in particular). However, much or the remaining PMP data are either being collected and not used or not even collected. USAID will need to review its PMP for IHRIN to make sure that key indicator data are routinely collected, tabulated, analyzed, and acted upon. This recommendation applies to ACCESS and ACQUIRE, as well. Mystery Client Survey Results The data on the PMP indicator for Provision of Correct Information on Family Planning was to be collected through a Mystery Client Survey. That survey was conducted in early However, the survey does not include a specific, single question on provision of correct information. The following findings list a number of relevant questions that give a broad picture of provision of correct information. There are no baseline or target data USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 43

313 TABLE 14: MYSTERY CLIENT RESULTS Information was clear and simple 95 % Provider took concerns seriously 91 % Had private talk with provider 88 % Satisfied with the service 88 % Obtained resupply of pill 84 % Counseling time spent with provider was adequate 77 % Good facility environment 77 % Dissatisfied with pills and referred to hospital 51 % First time users referred to clinic or MD 45 % Informed of different FP methods 39 % First time users prescribed daily pill 39 % Information was not clear about how to take the pill 37 % Told what to do if missed taking a pill 22 % First time users sold pills 17 % Stock-out 15 % Informed about side effect of pill 14 % Asked method preferred 8 % This information and the qualitative section of the report conclude that the vendor was aware of situations requiring referral to a clinic, hospital or physician. However, many vendors did not refer new clients to health facility, largely because they were afraid of losing a customer. Exit Interview Results One of the PMP indicators is Score on client satisfaction. However, there are no data on that specific score. There are some data on client satisfaction, however. Exit interviews were conducted with 126 women in Abia, Cross River, and Kaduna states as part of Nigerbus. The data were analyzed in May 2009 and are summarized here. There are no baseline or target figures. TABLE 15: CLIENT SATISFACTION WITH FP SERVICE Satisfied with FP service 97 % Cost is expensive 7 % Cost is affordable 82 % Cost is cheap 11 % Spent too much time in the clinic 25 % Satisfied with services provided and will recommend to friends 99 % The data show that clients are very satisfied, believe prices are affordable, and would recommend the service to their friends. 44 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

314 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 45

315 46 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

316 ANNEX D: PERSONS CONTACTED ACCESS, ABUJA Professor Emmanuel Otolorin Dr. Tunde Segun Dr. Gbenga Ishola Ms. Awele Ekpubeni Deji Adeyi ACCESS, KANO Hannatu Abdullahi Samaila Yusuf Aminu Idris Country Director Senior Program Manager Senior M&E Officer Senior Finance and Administrative Officer Senior Program Assistant MCH/RH Coordinator Community Mobilization Officer Finance and Administrative Assistant KANO STATE & HOSPITAL OFFICIALS Hajiya Aisha Isyaku Kiru Commissioner for Health Hajiya Sa adatu Nataalah National Coordinator FP Hajiya Asmau Ahmed Safe Motherhood Coordinator Dr. Garba Tella Medical Officer I/C, Gezawa General Hospital Bashir Magaji Community Health Officer in Charge, Babawa PHC Yahaya Jogana Babawa Community Mobilization Team Leader Pat Okonkwo Nurse/Midwife Haladu Mohammed Ward Focal Person ACCESS, KATSINA Amina Sule Sogiji Ibrahim ACCESS, ZAMFARA Dr. Shittu Abdu-Aguye Zaynab Nyako Salamatu Bako Aliyu Adamu Tsafe MCH/RH Coordinator Community Mobilization Officer Program Officer Community Mobilization Officer Clinical Officer Strategic Information Officer ZAMFARA STATE & HOSPITAL OFFICIALS Hajiya Zainab Haliu Anka Commissioner for Women and Children s Affairs Dr. Muhammed Bello Buzu Executive Chairman, Hospital Services Management Board Mohammed Mustapha Secretary, Hospital Services Management Board Ibrahim Nahushe Director, Nursing Service Mr. Zurumi Deputy Director, Finance USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 47

317 Engr. Haliru Garba Dr. Ibrahim Hajiya Ladi Dawa Sanni Mada Hajiya Ladi Gusua Dr. T.M. Moriki Ramatu Usman Ajuji M. Rector Director, Services Medical Director, King Fahd Women & Children Hospital Matron, King Fahd Women and Children s Hospital Deputy Director Health, Mada PHC/Community Mobilization Officer CHEW, Mada PHC Principal Medical Officer, Zurmi General Hospital Matron, Zurmi General Hospital FP Clinic, Zurmi General Hospital 48 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

318 ANNEX E: DOCUMENTS REVIEWED 1. ABSNON and CAPA in Abia State. A Report on Behavioral Change Communication Training for CBD Agents. 2. ACCESS Nigeria, Emergency Obstetric and Newborn Care FY09 Work plan Jhpiego Corporation. 3. ACCESS Nigeria. Performance Management Plan (August 2008). 4. ACCESS Nigeria Performance Management Plan (Draft of July 12, 2006). 5. ACCESS Nigeria Performance Management Plan (Draft of July 2007). 6. ACCESS Nigeria year one January September 2006 and year two October 06 September 2007 Workplan. 7. ACCESS-FP. An Assessment of Integration of Family Planning and Maternal New Born and Child Health Care in Kano, Nigeria (2009). 8. Adekunle, Adeyemi O. Assessment of the Implementation of the National Reproductive Health Policy and Strategic Framework and plan. ENHANSE Project (2007). 9. Analysis of Family Planning Omnibus Survey Based on Implementing Partner s Performance Table (2007). 10. Assessment of Private Organizations Involved in Reproductive Health and Child Survival Services in Nigeria Report. ENHANSE/USAID Nigeria. 11. C. Ujuju, S. B. Adebayo, R. Fakolade, J.Mohammed-Jantabo, and J. Anyanti. Increasing Access to and Use of Modern Contraceptive Methods among Women of Reproductive Age in Nigeria: an Integrated Approach to Reproductive Health. 12. Evaluation of Quality of Family Planning Services among Private Patent Medicine Vendors in Nigeria: Mystery Clients Survey. November Exposure by Campaign and Numbers of Persons Exposed. NARHS 2003, NARHS Exposure to FP Campaign and Numbers of Persons Exposed. Nigerbus February Fatusi, Adesegun O. and Kayode Ijadunola. National Study on Essential Obstetric Care Facilities in Nigeria. UNFPA and FGN, Federal Ministry of Health Abuja (2002). National Reproductive Health Strategic Framework and Plan Federal Ministry of Health, Abuja (2007). Integrated Maternal, Newborn and Child Health Strategy. 18. Federal Ministry of Health, Nigeria (2007). National Policy on the Health and Development of Adolescents and Young People in Nigeria. 19. Holfield, Joyce M. and Patricia Macdonald (2007). The Ground is Softening for the USAID/Nigeria Health Portfolio for the Present and the Future. 20. Implementing Partner s Performance Table (2007). USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 49

319 21. IRHIN Nigeria. Project Report from October 1, 2005 to September 30, SFH, PSI, and Pathfinder International. October IRHIN (2005) Report on the Monitoring Access and Performance (MAP) Study on Gold Circle, Oral and Injectables Contraceptives, Kid Care, Permanent, and Waterguard. 23. IRHIN Project List of Partner NGOs, Officials, and State Family Planning Coordinators as of June January March Quarterly Progress Report: Improved Reproductive Health In Nigeria (IRHIN). Project Report from January March SFH, PSI, and Pathfinder International, April July-September Quarterly Progress Report: IRHIN. Project Report from July 1to September 30, SFH, PSI, and Pathfinder International. October Keating, Joseph and MEASURE Evaluation. Nigeria Reproductive Health, Child Health and Education Baseline Household Survey, USAID, MEASURE Evaluation, October List of PPMVs Training (2006) Lagos State, Nigeria. 28. List of PPMVs Training (2007) Cross River State, Nigeria. 29. List of PPMVs Training (2007) Lagos State, Nigeria. 30. List of PPMVs Training (2008) Abia State, Nigeria. 31. List of PPMVs Training (2008) Cross River State, Nigeria. 32. List of PPMVs Training (2008) Kano State, Nigeria. 33. List of PPMVs Training (2008) Lagos State, Nigeria. 34. List of PPMVs Training (2009) Imo State, Nigeria. 35. List of PPMVs Training (2009) Kaduna State, Nigeria. 36. List of PPMVs Training (2009) Lagos State, Nigeria. 37. National HIV/AIDS And Reproductive Health Survey. NARHS Nigeria, Nigeria (2007): MAP Study on the Availability of Social Marketing Products in Nigeria Phase 2. March Nigeria Demographic and Health Survey Nigeria Demographic and Health Survey Nigeria Demographic and Health Survey Nigeria Demographic and Health Survey 2008 Preliminary Report. National Population Commission, Nigeria. MEASURE DHS, ICF Macro Calverton, Maryland, USA. 43. Pathfinder International. Report on a Six-Day Update Family Planning Training for Nurses/Midwives from IRHIN Project States of Abia, Cross River and Kaduna. 44. Performance Monitoring Plan, Strategic Objective. May 13, Quarter 1 FY 2007 Quarterly Progress Report: Improved Reproductive Health in Nigeria (IRHIN). Project Report, October December SFH PSI), and Pathfinder International. January USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

320 46. Report on the 2008 MAP Study on the Availability of Social Marketing Products in Nigeria, Phase Report on the MAP Survey. October Reproductive Health and Gender Indicators. Baseline Survey of UNFPA Assisted States in Nigeria, Reproductive Health Knowledge and Practices in Northern Nigeria: Challenging Misconception. Pathfinder International. 50. Road Map for Accelerating the Attainment of the MDGs Related to Maternal and Newborn Health in Nigeria. WHO, FGN. 51. Saving Newborn Lives in Nigeria: Situation Analysis and Action Plan for New Health in the Context of Integrated Maternal New Child Health Strategy. 52. SFH Nigeria. Introduction of the Standard Days Method of Planning in Two States of Nigeria: Experience with Use. March Society for Family Health, Abuja (2008) Evaluation of Family Planning Services Among Private Patent Medicine Vendors in Nigeria. 54. Socio-Cultural Context of Reproductive Health and Gender Issues. A Qualitative Research Report, Sokoto State. 55. Summary Report on Exit Interviews Conducted for IRHIN Project Partner Health Facilities in Abia, Cross River, and Kaduna States and Analyzed in May The ACQUIRE-Fistula Care Project. Nigeria Prevention, Repair, and Reintegration of Fistula Project. Year II Work plan. Strategic Objective 15. April The ACQUIRE-Fistula Care Project. Nigeria Prevention, Repair, and Reintegration of Fistula Project. Strategic Objective 13. July The ACQUIRE-Fistula Care Project. Nigeria Prevention, Repair, and Reintegration of Fistula Project. Year II Work plan. Strategic Objective 15. Revised Copy with Additions on Female Genital Cutting and Expansion to Ebonyi and Bauchi States. February The ENHANSE Project. June (2005) Reproductive Health in Nigeria: Situation, Response and Prospects. 60. The Factors affecting the Use of Modern Contraceptive Methods in Nigeria: A Segmentation Dashboard Analysis. Nigeria. February The Impact of Family Planning Mass Media Intervention in Nigeria: An Evaluation Dashboard Analysis. The PSI Dashboard. Nigeria. March The Nigeria Network of NGOs/CSOs for Population and Reproductive Health (NINPREH) Strategic Plan USAID, the David and Lucile Packard Foundation. 63. The Socio-Cultural Context of Reproductive Health and Gender Issues in Bauchi State, Nigeria: A Qualitative Research Report. UNFPA, FGN. 64. Umanah A. L. Report of a Two-Day BCC Training for CBD Agents from WE-Women Network in Ikom/Ugep Communities, Cross River State. 65. Umanah, A. L. Report of a Two-day Retraining on Family Planning for CBD Agents in Ugep/Ikom Communities in Cross River State. USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 51

321 66. USAID/ACQUIRE. Nigeria. Prevention, Repair, and Reintegration of Fistula Project Quarterly Report. January March USAID/ACQUIRE. Nigeria. Prevention, Repair, and Reintegration of Fistula Project Annual Report October 2006 September USAID/ACQUIRE. Nigeria. Prevention, Repair, and Reintegration of Fistula Project. 69. USAID/ACQUIRE. Nigeria. Prevention, Repair, and Reintegration of Fistula Project Annual Report, October 2007 September USAID/ACQUIRE. Nigeria. Prevention, Repair, and Reintegration of Fistula Project. Quarterly Report April June USAID/ACQUIRE. Nigeria Prevention, Repair, and Reintegration of Fistula Project. Quarterly Report. Second quarter FY 2009, January March USAID/ACQUIRE. Nigeria Prevention, Repair, and Reintegration of Fistula Project. Quarterly Report October December USAID/ACQUIRE. Nigeria Prevention, Repair, and Reintegration of Fistula Project Work plan. Final November USAID/ACQUIRE. Nigeria Prevention, Repair, and Reintegration of Fistula Project. Quarterly Report. First quarter FY 2009 FY October December USAID/Nigeria (2008) Maternal, Child Reproductive Health and Family Planning Strategic Approach. 76. USAID/Nigeria Country Strategic Plan USAID/Nigeria Quarterly Report Format, January March 2006 Quarterly Progress Report. 78. USAID/Nigeria Quarterly Report Format October December 2006 Quarterly Progress Report. 79. Wolf, Merrill and Aisha Abubakar (2006), Child Spacing Attitudes in Northern Nigeria. 52 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

322 ANNEX F: RECOMMENDATIONS MATRIX The following table summarizes the key findings and their related recommendations. The recommendations are organized by project (ACCESS, ACQUIRE, IRHIN) and topic. Findings General The EmONC sector receives relatively small amounts of funding when viewed in relation to the problems to be addressed, and that the USAID office lacks both funding and staff to support the ACCESS program adequately. (p. 14) Officials met at the state and local levels seemed relatively unconcerned about the need for family planning. (p. 2) The PMP targets were: million units for condoms; 29 million for OCs; 3.5 million for Noristerat; 4 million for Depo; 271,000 for IUDs; and 13.4 million CYP. Most of these targets are so high that they must be in error. (p. 43) Staff and Training Multiple places in document: all activities are hampered by staff turn-over. (e.g. p. 45) Recommendations Funding should be increased as currently planned, and the USAID health office should be increased to six direct-hire equivalents. In future work in this area, efforts should be made to work with communities to advocate use of family planning/birth spacing. Revise the project targets to be more reasonable and attainable. SFH, CSOs and government agencies need to identify ways to reduce turnover of key personnel, especially providers. Retention indicators should be developed and used in recruiting for these positions. Examples are: the candidate has ties to his/her home state or town. CHEWs may not have adequate basic education to serve as trained birth attendants. (p. 16) There has been little, if any, update training. (p. 35) A total of 16 detailers have been trained to cover all of Nigeria. (p. 37) Only 100 of 900 trained providers have received updates. (p. 36) An award system needs to be developed to encourage key staff and providers to continue working for the program. The Mission should explore the possibility of the new midwifery school in Zamfara training a new cadre of community midwives. Refresher or upgrade training should be introduced to keep PPMV current as to advances in FP and contraceptive technology. More detailers should be hired and trained if the program is to expand. Periodic upgrade/refresher training is needed for staff and providers. USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 53

323 Findings Commodities and Logistics Stock-outs have a significant effect on PPMV sales and customer confidence in the reliability of supplies. (p. 35) There is frequent borrowing between the private and public sectors, despite USAID prohibitions. (p. 39) Frequent staff transfers have made training facilities maternity staff difficult. (p. 18) Communication and Media Mass media campaigns are limited, and community IPC initiatives are limited to a year s support. (p. 41) IEC materials were difficult to find in most sites that were visited by the team. (p. 41) The radio drama, One Thing at a Time has been an effective mode to reach selected markets. (p. 39) IEC materials were difficult to find in most community outreach sites that were visited by the team. (p. 40) One Catholic diocese has been open to a program called Contraception for Catholics, which teaches all methods, while focusing attention on the methods approved by church hierarchy. Recommendations Linkages between wholesalers/detailers and retailers (such as PPMVs and CSOs/CBOs) should be strengthened to ensure that adequate stocks are readily available in rural as well as urban areas. SFH should examine ways to reduce or eliminate stock-outs. For example, it could establish buffer stocks or emergency supplies at warehouses that can be tapped to fill unexpected gaps. USAID should relax its distribution policy so that public and private stocks can be loaned to each other in cases of emergency. Work should be undertaken in the future on a statewide basis, rather than only in selected LGAs. More effort is needed in both mass media and interpersonal communication, since they are complementary. Both will be needed in the two states that are going to be the focus of the follow-on project. In addition, more IEC materials are needed to complement key messages conveyed by mass media and IPC. Materials are especially needed for PPMV and the intensive community outreach sites. IEC and point-of-sale materials should be more readily available at the retail level. These materials are critical to outreach workers (such as PEs, IPCs, and providers) so that they can reinforce messages about the benefits of FP as well as the range of contraceptives available. Develop 26 or more Radio Drama segments and other mass media series on health issues. Produce and distribute new and standard IEC and point of service material. Expand the existing Contraceptives for Catholics campaign. 54 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

324 Findings ACCESS Exclusive use of LAM for postpartum FP may be a missed opportunity for women to use longerterm methods. (p. 12) Only a few months remain in the ACCESS project in Katsina State. Very little has been accomplished because of staff turnover and construction procurement delays. (p. 13) Future support for MNCH/FP is unclear in strategy statements. There is little or no synergy between the three projects evaluated. (p. 17) There are poor relations between the ACQUIRE fistula repair project and the professional training at basic medical and specialty levels. (p. 21) The ACCESS EmONC package does not include secondary fistula prevention. (p. 23) 80% of women in the north deliver at home. (p. 8) It is very difficult to link women receiving pre- and perinatal care to contraceptive use, and even more difficult to link motivational efforts in the community to women s use of birth spacing techniques. This is complicated by frequent stock-outs, which have the effect of requiring women to seek contraceptives in other outlets. (p. 9) ACQUIRE does not provide contraceptive goods or services directly, but refers patients to another center, often co-located with ACQUIRE. (p. 24) The Mission has not adequately negotiated the reason for data collection and reporting with ACCESS and ACQUIRE. (p. 24) Other programs do not have specific secondary fistula prevention programs. (p. 23) Recommendations ACCESS should review its LAM-only contraceptive policy for postpartum FP, and consider whether it makes more sense to start women on a contraceptive regimen immediately. USAID should discuss the future of work begun in Katsina State with all stakeholders and consider redirecting resources (including possibly staff) to the other two states. ACCESS should continue in Kano and Zamfara until the end of the MCHIP period. ACCESS should relocate its work under TSHIP to one or both of the selected priority states. USAID should link ACCESS and ACQUIRE interventions in the future to ensure that maternal and neonatal services are provided. USAID should work with specialist obstetricians and gynecologists to introduce appropriate fistula repair technology into medical school and specialist training. ACCESS should immediately add secondary fistula prevention to its Nigeria outreach and clinical EmONC services. ACCESS should develop more robust measures to link family planning motivation and support to government clinics to actual contraceptive use. The ACQUIRE project does not provide contraceptive services directly, so it needs to develop effective ways of measuring contraceptive use that are directly related to clinical and outreach services. The mission s monitoring system that places a premium on numbers should be discouraged. In the words of one program staff: We don t ask why these targets are set; we ask how we can meet them. The integration of fistula prevention/care into ongoing country programs and initiatives should be promoted. It should be integrated into the maternal newborn and child health strategy. ACQUIRE should develop a compact guide on effective approaches to involving fistula survivors at the facility and community levels. USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION 55

325 56 USAID/NIGERIA MCH/RH PROGRAM MID-TERM EVALUATION

326 For more information, please visit

327 Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC Tel: (202) Fax: (202)

328 ASSESSMENT OF MIDWIFERY PRE-SERVICE TRAINING ACTIVITIES OF THE ACCESS PROJECT Limited Internal Distribution March 2010 This publication was produced for review by the United States Agency for International Development. It was prepared by Judith T. Fullerton, Ph.D., CNM and Sebalda Leshabari, Ph.D., RM through the Global Health Technical Assistance Project.

329

330 ASSESSMENT OF THE PRE-SERVICE TRAINING ACTIVITIES OF THE ACCESS PROJECT DISCLAIMER The authors views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

331 (If this is an internal or limited report, note it on the cover page, title pages, and this page, and elsewhere if so requested by USAID) This document (Report No ) is available in printed or online versions. Online documents can be located in the GH Tech web site library at Documents are also made available through the Development Experience Clearing House ( Additional information can be obtained from The Global Health Technical Assistance Project 1250 Eye St., NW, Suite 1100 Washington, DC Tel: (202) Fax: (202) This document was submitted by The QED Group, LLC, with CAMRIS International and Social & Scientific Systems, Inc., to the United States Agency for International Development under USAID Contract No. GHS-I

332 EXECUTIVE SUMMARY The United States Agency for International Development (USAID) maternal and newborn health program is dedicated to the reduction of maternal mortality. The program is designed to focus attention on the delivery of high impact interventions to address the major direct causes of maternal and newborn mortality, while strengthening health systems by addressing human resource issues. USAID supports policies, strategies and programs that promote awareness, prevention, and intervention across the childbearing cycle. USAID s Global Health (GH) program supports in-service and pre-service education (PSE)/training of skilled birth attendants to improve Essential/Emergency Obstetric and Newborn Care (EONC/EmONC) skills to manage maternal and newborn complications and is introducing quality improvement tools to enhance and monitor performance. USAID/GH also supports quality of care and health system strengthening to promote an enabling environment that contributes to maternal survival. THE ACCESS GLOBAL HEALTH PROJECT Access to clinical, community maternity, neonatal and women s health services (ACCESS) was a 5-year USAID/GH Leader with Associate award ( ) focused on reproductive health. ACCESS was implemented by Jhpiego, in collaboration with Save the Children, Constella Futures, the Academy for Educational Development, the American College of Nurse Midwives, and IMA World Health. ACCESS promoted the continuum of care approach, linking individual community members to appropriate levels of health services. This approach includes building capacity to deliver evidence-based practices and interventions at every level of care. ACCESS pre-service activities were initiated at the Africa regional level in collaboration with The World Health Organization s Regional Office for Africa (WHO/AFRO). ACCESS implementing partners worked in Ethiopia, Ghana, Malawi and Tanzania in partnership with the Ministries of Health, USAID missions, and other collaborating agencies/funders in activities designed to strengthen the capacity of midwives and other SBAs. The program included a specific focus on pre-service midwifery education and training, and on the provision of technical assistance to midwifery schools in Africa. Enhancing skills for the provision of competency-based EmONC was a specific clinical agenda. The purpose of this assessment was to learn about the impact of the ACCESS project on pre-service midwifery training to guide future programming in this area and to make recommendations for any change in approach or strategic direction. This report addresses the midwifery pre-service activities conducted in the three countries of Ethiopia, Ghana and Malawi. The assessment of ACCESS pre-service activities in Tanzania was part of the evaluation commissioned by the USAID/Tanzania Mission for all ACCESS activities in the past four years. METHODS AND STRATEGIES A multi-method evaluation matrix was designed. Assessment methods and strategies included the following: Preliminary planning for this forward-looking assessment was conducted in collaboration with USAID-GH/HIDN/MCH and AFR/SD offices, ACCESS AOTR, and ACCESS personnel. Participants achieved consensus on the intended outcomes of the assessment, Assessment of pre-service training: ACCESS 5

333 and deliberated the various approaches that could be taken to generate the information that would be required to guide future programming in this area. Key documents were reviewed to acquire a depth of understanding of the ACCESS project, and the context of its programmatic activities in each of the three countries included in the assessment. A mixed quantitative and qualitative survey that addressed key BEmONC skills and the the impact of personal participation in training activities conducted under the ACCESS project was developed and implemented in advance of the assessment activities. A set of interview guides was crafted and used to guide discussions conducted in-person or by teleconference with national key informants, Jhpiego/ACCESS key personnel, country-specific stakeholders, country-level collaborating and/or supporting agencies and a broad sample of individual stakeholders (tutors, preceptors, midwifery program graduates and current students). Site visits were conducted in the training institutions and clinical teaching facilities in each country in which educational or clinical site strengthening activities had been conducted and where training activities were implemented. FINDINGS Overall achievements ACCESS conducted country-level assessments and stakeholder meetings in each of the countries prior to the initiation of training activities. The intended outcome of these meetings was to generate commitment for educational and health system strengthening that would promote an enabling environment for midwifery education and practice. ACCESS offered support, as requested, to promote revisions to midwifery curricula, with the objective of including BEmONC best practices within the national curriculum guidelines, or, as was the case in Ethiopia, within the individual school curricula, because the midwifery curriculum has not yet been standardized across educational levels (baccalaureate and technical schools). ACCESS strengthened the clinical learning environment for in-service and pre-service learners. A clinical training center or classroom was enhanced in Ethiopia and in Ghana. Clinical site strengthening was conducted in the hospitals that were affiliated with the training centers/sites used by ACCESS (one each in Malawi and Tanzania, two in Ethiopia, three in Ghana). A small contribution was made to enhancement of the learning skills laboratories (simulation labs) in selected educational institutions in each country. Effective Teaching Skills courses were provided to improve the classroom and clinical training skills to tutors in the academic institutions. The Learning Resource Package included manuals that addressed content such as effective teaching strategies, guidelines for development of lesson plans, and information concerning best practices for student assessment in clinical and classroom settings. Trainers and preceptors at selected pre-service institutions participated in technical updates (TU) and clinical skills standardizations (CSS) to improve their knowledge, practices and competencies to perform the signal functions of BEmONC. The Malawi Mission also requested that PAC and FP content be added to the midwifery BEmONC training. Pre-service education of midwives Ethiopia

334 There are a total of 24 public and private midwifery education programs in Ethiopia. Five are at the university level (4 public and 1 private) and 19 are diploma-granting institutions (18 public, 1 private). Jhpiego/Ethiopia used ACCESS core funds to conduct BEmONC training for a minimum of two (2) tutors from each of 11 (61%) PSE diploma schools and 2 universities (46%), thus interacting with one half of the midwifery training institutions in the country overall. A total of 36 individuals were trained using ACCESS core funds over the life of the project. Four Master Trainers (including one preceptor) were trained in Fifteen (15) 15 tutors and 2 preceptors were trained in 2007, and 15 tutors were trained in Ghana A new 3-year, post-secondary, diploma course of direct entry midwifery studies was initiated in 2007, replacing all previous pathways to midwifery education. There are presently a total of thirteen (13) pre-service midwifery programs in the country. These schools produce approximately 350 graduates annually. The ACCESS project in Ghana focused initially on the training of trainers, then on training of tutors and preceptors from the population of schools in the country. An aggregate total of (36 ) tutors/ preceptors/midwifery regulatory authority supervisors were included in either teaching or clinical skills updates. Each of Ghana s 13 schools (100%) were covered (at least two tutors were trained) by the ACCESS project. Ten of the 13 schools were included in BEmONC training. Tutors from the remaining three schools participated in the clinical training skills instruction. Malawi There are 17 training institutions and two active pathways to nursing and midwifery in the country. Three schools offer Level 1 education to post-secondary students, who complete four years of University study leading to the designation State Registered Nurses. Graduates obtain work experience, and then return for a 1-year intensive course in midwifery. Level 2 education is offered through a 3-year post-secondary integrated nursing/midwifery curriculum for the Nursing/Midwifery Technician (NMT). This curriculum was inaugurated in The first cohort of students to complete the integrated course of nursing/midwifery studies has just recently graduated. A total of 51 tutors and 46 preceptors were trained, including those trained by ACCESS with funds obtained from other donors. A 2 week BEmONC course was augmented by a 1-week PAC course, given that abortion is the third cause of maternal death in the country. However, the number trained represented only 32% of target (all tutors in all schools; N = 160). Follow-on trainings for service providers in five selected districts extended the benefits of BEmONC training to an additional 121 individuals. LESSONS LEARNED The relevant Ministries of Health and the respective regulatory authorities for both medicine and nursing/midwifery must be engaged in the planning of programs that will enhance or expand the scope of practice of midwives, so that these skills can be acknowledged, valued, supported and facilitated at both policy and practice levels. (Also noted in Afghanistan.) The development and advancement of the midwifery workforce within a country is advantaged by the active engagement of a professional association, which can serve as advocate for the policies that would strengthen the education and clinical practice Assessment of pre-service training: ACCESS 7

335 environments of the midwifery workforce. Technical assistance should be provided to establish, where necessary, or to strengthen existing midwifery professional associations. Training is expensive, both of time and money. A standardized, competency-based, teaching/learning package cannot be short-cut without some compromise to quality. This investment must be understood and appreciated and agreed in advance of any commitment to engage in programming. Particular benefit was derived when BEmONC skills were able to be incorporated into the midwifery pre-service curriculum of studies. These are basic skills that need to be in the repertoire of midwives at the time they enter the workforce. Teaching these skills in pre-service will, over time, reduce the burden of in-service training that focuses on enhancement of basic skills. (Also noted in Afghanistan.) The training burden must be a priority consideration when planning the scope of a training intervention. Planning for CSS/TU courses (e.g., BEmONC and related content) should include consideration of the time that will be required for participants to acquire and to demonstrate competence in learning outcomes (e.g., minimum number, and range of hands-on clinical experiences required by lesser and more experienced learners), the potential for access to clients with relevant clinical concerns (i.e., clinical incidence in the affiliated teaching hospital; learning needs of other cadres in the same clinical setting); and the tutor/learner ratio that is appropriate for the mix of learners. This information may perhaps be available from literature or NGO resources. However, further inquiry and/or basic research may be needed. This same lesson learned applies to midwifery pre-service education. Standardization of midwifery curricula, including clear statements of the expected outcomes of competency-based midwifery education, is an internationally recommended best educational practice. Country-based program accreditation mechanisms may offer a strategy for strategic thinking about appropriate limit-setting for the number of schools established, the qualifications of teachers/tutors assigned to teach the midwifery course of studies, and the student enrollment that can be accommodated, in order to offer opportunity for each student to acquire and demonstrate competency. Regulatory authorities should be developed, where necessary, and in those countries where they are already established, should be provided with technical assistance to explore program accreditation as a next step for the advancement of the professional midwifery workforce. Recruitment and admissions policies for midwifery students should encourage enrollment of the more qualified and better educated candidate, preferably at postsecondary level, and with the option of a direct-entry pathway to midwifery. There is little advantage to engaging in BEmONC programming or midwifery PSE if the learning (simulation labs) and clinical (maternity ward) environments do not support the acquisition of skills in the short-term or the practice of these skills over time. Those in charge of the educational institutions and of the health facilities must make the investment in the enabling environment for learning and practice. This enabling environment includes basic equipment and supplies, but, as importantly, requires that peer practitioners, supervisors and other medical practitioners are also updated in these evidence-based practices. (Also noted in Tanzania and Afghanistan.) All participants and stakeholders must contribute to the documentation of data for decision-making. It will take a period of time to demonstrate the effect (or impact) of incorporating BEmONC skills into a midwifery pre-service curriculum but unless there

336 is a culture of documenting the practice of these skills (e.g., client records, maternity care logbooks) there will never be the opportunity to measure this impact (and specifically, any progress toward MDG 4 and 5). RECOMMENDATIONS 1. USAID, the country mission and collaborating partners should continue to invest in midwifery pre-service education in its global programming, incorporating the policy and program enhancements that are addressed in these recommendations, in order to maximize the strategic investment already made in certain countries and to create a multiplier effect that is greatly needed to expand the cadre of skilled birth attendants. 2. USAID should link its PSE programming with country-based policy advocacy, capacity building, human resource retention and system strengthening initiatives and strategies that promote an enabling environment for the delivery of quality health services. Ministries/Authorities must take the leadership responsibility for ensuring that clinical teaching and practice sites are fully and reliably supplied and equipped. 3. USAID and Country Ministries should make a substantial investment into strengthening the teaching institutions. Ensuring the quality of the teaching/learning environment (simulation labs, internet and library resources) is fundamental. The preparation of a sufficient cohort of well-qualified teachers and preceptors is also critical in order to reduce the teacher to student ratio to match international standards. A review of student admissions policies and practices should be encouraged, to promote selection of students who are highly motivated and best qualified for the profession to which they aspire. 4. USAID-supported PSE programming should include assistance to educational institutions to enhance and to broaden the scope of the teaching and learning environments. Tutors and preceptors should be encouraged to engage with one another in both classroom and clinical settings, and share responsibilities for academic and clinical teaching. The link between classroom and communities must be strengthened so that students can engage in helping to address health problems of the community, and have opportunity to acquire clinical skills in community settings in addition to the academicaffiliated health facilities and referral hospital(s). This strategy might also address regional teaching aggregates/groups through which sharing of resources can be facilitated. 5. USAID should encourage a continued investment into programming that strengthens the midwifery pre-service curriculum to ensure the standardization of curricula, ensure the inclusion of evidence-based best practices as core content, promote a competency-based approach to teaching and learning, and clearly state the expected outcomes of learning (core competencies). Country ministries must be collaborative partners in this programming, make similar commitments to quality education (standardization of curricula and program accreditation) and develop budget plans and strategies to assume the costs of midwifery pre-service education. 6. USAID should support pre-service and/or in-service training in BEmONC and similar evidence-based practices and life-saving skills for midwives and for their health service delivery partners (e.g., doctors, clinical officers). Country Ministries/Authorities should be participant stakeholders in planning for these training activities. This includes the dissemination of reproductive health guidelines that Assessment of pre-service training: ACCESS 9

337 clearly indicate roles, responsibilities and standards of practice for all cadres trained in BEmONC. 7. USAID should expand the content of its trainings to go beyond BEmONC to include the MCH content areas most relevant to the health needs (burden of disease) of the country, using the same approaches to competency-based teaching and learning that have already been well developed and well-modeled under ACCESS. Examples of this content include, but are not limited to, PMTCT and PAC. Collaborative programming should be planned with partner agencies whose scope of expertise extends across the continuum of care (e.g., child health, adolescent reproductive health). 8. USAID should require its cooperating partners to incorporate specific plans for monitoring and evaluating the longer-term outcomes and impact of its PSE and in-service programming. These plans should address both the degree to which learners sustain or continue to improve their professional performance, and the effect that improved performance may have on health service delivery outcomes. 9. USAID should support (independently or in partnership with other donor agencies and professional organizations, such as ICM) the strengthening of midwifery professional associations, to enhance the capacity of midwifery leaders, and to promote the professional development of midwives as a preferred cadre of skilled birth attendant, including a career pathway to higher academic and policy-making levels. CONCLUSIONS AND LESSONS LEARNED The overall finding of the assessment of ACCESS programming in the three countries included in this assessment is that there was clear benefit to stakeholders at all levels. Individual midwives acquired competence and competence to perform life-saving skills. Teachers enhanced their classroom and bedside clinical teaching skills. Preceptors acquired new clinical teaching and clinical practice skills that they could impart to both students and colleagues in the clinical teaching and practice environments. Education programs benefited by strengthening of capacity of teachers/tutors in performance of their role, and by some (limited) enrichment of the clinical simulation laboratories in the various institutions, or by enrichment of dedicated teaching/learning sites established at the affiliated hospitals. Health facilities benefited when providers skilled in BEmONC returned to their work sites and began to practice their own learned skills, and to model those skills for others (both peers and other cadres of health practitioners). Women and families were better served. For example, there is at least anecdotal evidence that the incidence of postpartum hemorrhage has declined following the introduction of AMTSL as a clinical best practice. Midwives can offer examples of saving the lives of some women and newborns when BEmONC skills were practiced in a timely manner. The countries were better served when the professional associations could advocate for and/or contribute to the shaping of educational and practice policies, as they are best

338 positioned to describe the appropriate scope of professional practice, according to international standards. Ministries of Health benefited by the BEmONC training model and materials, and the cadre of highly trained master tutors that were available for future use by the Ministries in other trainings they might plan to conduct in the country. Still, there were barriers that limited the effectiveness of ACCESS programming. There were also lessons learned in these three countries and in other countries in which ACCESS conducted similar midwifery pre-service education activities (specifically Tanzania and Afghanistan) that can guide the design of future programming. The relevant Ministries of Health and the respective regulatory authorities for both medicine and nursing/midwifery must be engaged in the planning of programs that will enhance or expand the scope of practice of midwives, so that these skills can be acknowledged, valued, supported and facilitated at both policy and practice levels. (Also noted in Afghanistan.) The development and advancement of the midwifery workforce within a country is advantaged by the active engagement of a professional association, which can serve as advocate for the policies that would strengthen the education and clinical practice environments of the midwifery workforce. Technical assistance should be provided to establish, where necessary, or to strengthen existing midwifery professional associations. Training is expensive, both of time and money. A standardized, competency-based, teaching/learning package cannot be short-cut without some compromise to quality. This investment must be understood and appreciated and agreed in advance of any commitment to engage in programming. Particular benefit was derived when BEmONC skills were able to be incorporated into the midwifery pre-service curriculum of studies. These are basic skills that need to be in the repertoire of midwives at the time they enter the workforce. Teaching these skills in pre-service will, over time, reduce the burden of in-service training that focuses on enhancement of basic skills. (Also noted in Afghanistan.) The training burden must be a priority consideration when planning the scope of a training intervention. Planning for CSS/TU courses (e.g., BEmONC and related content) should include consideration of the time that will be required for participants to acquire and to demonstrate competence in learning outcomes (e.g., minimum number, and range of hands-on clinical experiences required by lesser and more experienced learners), the potential for access to clients with relevant clinical concerns (i.e., clinical incidence in the affiliated teaching hospital; learning needs of other cadres in the same clinical setting); and the tutor/learner ratio that is appropriate for the mix of learners. This information may perhaps be available from literature or NGO resources. However, further inquiry and/or basic research may be needed. This same lesson learned applies to midwifery pre-service education. Standardization of midwifery curricula, including clear statements of the expected outcomes of competency-based midwifery education, is an internationally recommended best educational practice. Country-based program accreditation mechanisms may offer a strategy for strategic thinking about appropriate limit-setting for the number of schools established, the qualifications of teachers/tutors assigned to teach the midwifery course of studies, and the student enrollment that can be accommodated, in order to offer opportunity for each student to acquire and demonstrate competency. Regulatory Assessment of pre-service training: ACCESS 11

339 authorities should be developed, where necessary, and in those countries where they are already established, should be provided with technical assistance to explore program accreditation as a next step for the advancement of the professional midwifery workforce. Recruitment and admissions policies for midwifery students should encourage enrollment of the more qualified and better educated candidate, preferably at postsecondary level, and with the option of a direct-entry pathway to midwifery. There is little advantage to engaging in BEmONC programming or midwifery PSE if the learning (simulation labs) and clinical (maternity ward) environments do not support the acquisition of skills in the short-term or the practice of these skills over time. Those in charge of the educational institutions and of the health facilities must make the investment in the enabling environment for learning and practice. This enabling environment includes basic equipment and supplies, but, as importantly, requires that peer practitioners, supervisors and other medical practitioners are also updated in these evidence-based practices. (Also noted in Tanzania and Afghanistan.) All participants and stakeholders must contribute to the documentation of data for decision-making. It will take a period of time to demonstrate the effect (or impact) of incorporating BEmONC skills into a midwifery pre-service curriculum but unless there is a culture of documenting the practice of these skills (e.g., client records, maternity care logbooks) there will never be the opportunity to measure this impact (and specifically, any progress toward MDG 4 and 5). RECOMMENDATIONS 1. USAID, the country mission and collaborating partners should continue to invest in midwifery pre-service education in its global programming, incorporating the policy and program enhancements that are addressed in these recommendations, in order to maximize the strategic investment already made in certain countries and to create a multiplier effect that is greatly needed to expand the cadre of skilled birth attendants. 2. USAID should link its PSE programming with country-based policy advocacy, capacity building, human resource retention and system strengthening initiatives and strategies that promote an enabling environment for the delivery of quality health services. Ministries/Authorities must take the leadership responsibility for ensuring that clinical teaching and practice sites are fully and reliably supplied and equipped. 3. USAID and Country Ministries should make a substantial investment into strengthening the teaching institutions. Ensuring the quality of the teaching/learning environment (simulation labs, internet and library resources) is fundamental. The preparation of a sufficient cohort of well-qualified teachers and preceptors is also critical in order to reduce the teacher to student ratio to match international standards. A review of student admissions policies and practices should be encouraged, to promote selection of students who are highly motivated and best qualified for the profession to which they aspire. 4. USAID-supported PSE programming should include assistance to educational institutions to enhance and to broaden the scope of the teaching and learning environments. Tutors and preceptors should be encouraged to engage with one another in both classroom and clinical settings, and share responsibilities for academic and clinical

340 teaching. The link between classroom and communities must be strengthened so that students can engage in helping to address health problems of the community, and have opportunity to acquire clinical skills in community settings in addition to the academicaffiliated health facilities and referral hospital(s). This strategy might also address regional teaching aggregates/groups through which sharing of resources can be facilitated. 5. USAID should encourage a continued investment into programming that strengthens the midwifery pre-service curriculum to ensure the standardization of curricula, ensure the inclusion of evidence-based best practices as core content, promote a competency-based approach to teaching and learning, and clearly state the expected outcomes of learning (core competencies). Country ministries must be collaborative partners in this programming, make similar commitments to quality education (standardization of curricula and program accreditation) and develop budget plans and strategies to assume the costs of midwifery pre-service education. 6. USAID should support pre-service and/or in-service training in BEmONC and similar evidence-based practices and life-saving skills for midwives and for their health service delivery partners (e.g., doctors, clinical officers). Country Ministries/Authorities should be participant stakeholders in planning for these training activities. This includes the dissemination of reproductive health guidelines that clearly indicate roles, responsibilities and standards of practice for all cadres trained in BEmONC. 7. USAID should expand the content of its trainings to go beyond BEmONC to include the MCH content areas most relevant to the health needs (burden of disease) of the country, using the same approaches to competency-based teaching and learning that have already been well developed and well-modeled under ACCESS. Examples of this content include, but are not limited to, PMTCT and PAC. Collaborative programming should be planned with partner agencies whose scope of expertise extends across the continuum of care (e.g., child health, adolescent reproductive health). 8. USAID should require its cooperating partners to incorporate specific plans for monitoring and evaluating the longer-term outcomes and impact of its PSE and in-service programming. These plans should address both the degree to which learners sustain or continue to improve their professional performance, and the effect that improved performance may have on health service delivery outcomes. 9. USAID should support (independently or in partnership with other donor agencies and professional organizations, such as ICM) the strengthening of midwifery professional associations, to enhance the capacity of midwifery leaders, and to promote the professional development of midwives as a preferred cadre of skilled birth attendant, including a career pathway to higher academic and policy-making levels. Assessment of pre-service training: ACCESS 13

341

342 ACCESS-MAISHA Program Tanzania Empowering Midwives to Provide Quality Services December 2009 Dr. Elizabeth C. U. Hizza, Consultant Pamela J. Putney, CNM, Consultant

343 Executive Summary Background Although under five and infant mortality have declined in Tanzania over the past 10 years, the maternal and neonatal mortality and morbidity rates remain high. Tanzania is one of USAID s priority countries for Africa, a focus country for the Presidential Malaria Initiative, and receives significant funding from PEPFAR (President s Emergency Plan for AIDS Relief). In 2004, at the request of the USAID Mission and the Tanzanian Ministry of Health, Jhpiego began working in Tanzania under HPO Maternal and Child Health funds to improve Focused Antenatal Care (FANC), Malaria in Pregnancy (MIP) and Syphilis in Pregnancy (SIP) through in-service and pre-service training programs, targeting providers previously trained in PMTCT. Focused Antenatal Care (FANC) and improvements in Tanzania s 53 nurse-midwifery pre-service training programs and in-service training, QI and supervision, along with advocacy was used as a strategy to catalyze and sustain improvements in maternal, neonatal health care and outcomes through Jhpiego s ACCESS (2005-March2010) and follow-on MAISHA programs, USAID now plans to focus on Basic Emergency Obstetric and Newborn Care (BEmONC). Purpose of the Evaluation The purpose of the evaluation was to assess how the investments in the ACCESS program have influenced the quality of service provision in antenatal care and what the opportunities and constraints are to successfully achieving the objectives of the MAISHA program. Evaluation Team and Methodology The evaluation team included Pamela Putney, a nursemidwife and MNH/International Public Health consultant, Dr. Elizabeth C. U. Hizza, Ob/Gyn and Quality Assurance Advisor, Dr. Ruth Johnathan, RCHS/MOHSW, and Dr. Muthoni Kariuki, Program Manager, Jhpiego. After reviewing key documents 1, training materials, standards and protocols, and IEC/BCC materials produced and used by the programs, the team developed an evaluation tool in collaboration with USAID. 2 Following the site visits and interviews the team compiled, synthesized and analyzed the findings, followed by the development of recommendations. A draft summary of the findings and recommendations 3 was presented to USAID and Jhpiego along with a presentation 4 on December 17, Findings and Observations Quantitative data is not collected consistently at government facilities and no baseline was conducted prior to implementation of the project. Therefore, actual service statistics regarding the impact of FANC were not available to the evaluation team. 1 See Annex 6 for List of Documents Reviewed 2 See Annex 3 for Evaluation Tool 3 See Annex 4 for Handout 4 See Annex 5 for Presentation 2