SSDI-Services Best Practices and Lessons Learnt

Transcription

1 SSDI-Services Best Practices and Lessons Learnt 1 P a g e

2 FOREWORD This Best Practices Handbook is a product of a rigorous process of documenting techniques, methods, and innovative ways used to achieve the SSDI-Services Project goals. It is an interesting handbook in which we share with different stakeholders the experience of SSDI-Services regarding what works in achieving results across a broad array of health technical areas Family Planning and Reproductive Health, Maternal, New Born and Child Health, Malaria, HIV/TB, Nutrition, Performance Based Incentives (PBI), Performance Quality Improvement (PQI), Community Based Services, Community Mobilisation; and Monitoring and Evaluation as a cross cutting area. The methodology used in producing this work borrowed greatly from the OECD DAC criteria for program evaluations. This process evaluated practices on the scale of and based on their relevance, efficiency, effectiveness, impact, sustainability, possibility of duplication, partnerships achieved and community involvement. There were five phases that were designed in order to thoroughly capture a practice, subject it to an intense examination, and document it. In the first phase, meetings were held with Senior project Management Team of the SSDI-Services Project, comprising the Chief and Deputy Chief of Party, and Directors of Monitoring and Evaluation (M&E), and of Reproductive, Maternal, New Born and Child Health (RMNCH). This team tightened the approach, set the scope of the work and deadlines. Again, in this phase, discussions were held with respective Senior Technical Advisors (STAs). The thrust of the discussion was to appreciate what STAs considered best practices, from the design, implementation and monitoring of the SSDI-Services project. The second phase was desk study. This phase involved reading quarterly and annual reports. The purpose was to read the practices outlined by the STAs side by side with the reports to build them into compelling cases or drop them wherever there was insufficient or no data to substantiate the claim in them. The third phase involved visits to selected SSDI-Services districts to further evaluate whether some of the practices were indeed such, and not mere claims. These visits targeted Zonal Managers, District Team Leaders, Clinical, M&E and Community Coordinators; HSAs, CAGs, Care Groups, Community leaders and MoH Facility staff. The fourth phase involved comprehensive writing of the practices and evaluation of the practices by Senior project Management Team. This phase made what this booklet is. The practices presented in the booklet are a result of thorough analyses and vetting that happened at this phase. The fifth and last phase was the publication of this handbook. This phase involved editing and designing the handbook in conformity with demands and standards for publication of work of this nature. We hope this handbook makes a contribution to the vast body of knowledge being created everyday everywhere as we keep implementing different projects in the health sector and will help stakeholders not to re-invent the wheel. 2 P a g e

3 Table of Contents ACRONYMNS... 5 A. BEST PRACTICES PROJECT MANAGEMENT... 6 a. Performance review meetings for implementation teams are imperative for successful multi-level project planning and implementation... 6 b. Integration... 6 c. Designating a Project Coordinator at Ministry of Health (MOH) helps to guarantee successful program implementation MATERNAL NEWBORN AND CHILD HEALTH... 8 Coaching, mentorship and supervision: are best done jointly with the Ministry of Health FAMILY PLANNING & REPRODUCTIVE HEALTH (FP/RH)... 8 Family planning (FP) campaigns significantly increase access and uptake of family planning services MALARIA... 9 Directorate synergy is key in delivering on Malaria in Pregnancy (MiP) HIV/TB... 9 a. Expert Clients: pathway to achievement of the HIV/TB targets... 9 b. Employment of HIV Diagnostic Assistants (HDAs) in an HIV/TB care and treatment project is an effective strategy towards the achievement of the 90:90:90 global targets NUTRITION Care groups: Care groups effective in improving the adoption of health behaviors COMMUNITY ENGAGEMENT AND COMMUNITY-BASED SERVICES Community and facility staff interface (community score card (CSC)), process is fundamental in improving health service delivery at local level Model family s helps to dispel misconceptions and myths associated with sleeping under mosquito nets PERFORMANCE BASED INCENTIVES (PBI) Health Advisory Committees (HACs) are central in linking communities and health facilities PERFORMANCE QUALITY IMPROVEMENT (PQI) Institutionalizing quality, a contributing factor to PQI achievement MONITORING AND EVALUATION (M&E) Monitoring and evaluation technical review meetings are important in strengthening M&E systems B. LESSONS LEARNT P a g e

4 1. Mobile outreach clinics for HTC: more resources less yield Capacity building and equipment distribution Thorough preparation of trainings Instric motivation Staff Turnover Technical updates Changes in Ministry of Health guideline District Leadership Appliction of internal controls Empowering communities P a g e

5 ACRONYMNS AEHO ART CBCC CMAM CoP CSC DHIS DHMT DHO EHO EHP FP/RH HAC HDA HSA HIV HMIS HTC IFHOC M&E MUAC PBI MCH MiP MoH NMCP PQI RHD SSDI SUN TB Assistant Environmental Health Officer Anti-retroviral Treatment Community Based Care Centre Community Management of Acute Malnutrition Chief of Party Community Score Card District Health Information System District Health Management Team District Health Office/District Health Officer Environmental Health Officer Essential Health Package Family Planning/Reproductive Health Health Advisory Committee HIV Diagnostic Assistants Health Surveillance Assistant Human-Immunodeficiency Virus Health Management Information System HIV Testing and Counselling Integrated Family Health Outreach Clinics Monitoring and Evaluation Middle Upper Arm Circumference Performance Based Incentives Maternal and Child Health Malaria in Pregnancy Ministry of Health National Malaria Control Programme Performance Quality Improvement Reproductive Health Directorate Support for Service Delivery Integration Scaling up Nutrition Tuberculosis 5 P a g e

6 A. BEST PRACTICES 1. PROJECT MANAGEMENT a. Performance review meetings for implementation teams are imperative for successful multi-level project planning and implementation The SSDI-Services project intensively invested time and guidance in performance review meetings. These meetings were conducted monthly with project central level staff, and semiannually with all project staff (including zone and district teams). These meetings were highly beneficial in enabling all project staff to understand and internalize the project, review progress, refocus project implementation plans, and utilizing data for re-strategizing and ongoing programming. These meetings resulted in standardization of project implementation modalities and strategies; prioritization of high impact interventions; strengthened capacity of district and zonal project staff to perform critical analyses of project activities through a result-oriented lens; and strategic monitoring of program achievements. b. Integration Provision of health services in an integrated way proved effective and efficient in the SSDI- Services project. The project collaborated with district hospitals in the 15 districts where it was being implemented, to conduct Integrated Family Health Outreach Clinics (IFHOCs) once every month in hard to reach areas. In Malawi, about 80% of the total population live in rural areas 1 and cannot access health services easily and expeditiously. Most rural populations are in hardto-reach areas and travel 8 to 10 kilometres to the access health services. In the absence of IFHOCs these communities would have no health services at all or they would have to walk long distances to access the services. Through the SSDI-Services monthly IFHOCs, multiple health services were provided to the people in hard-to-reach areas at one location, during one single visit. This strategy brought a full package of preventive and treatment services where women and their families got treated for several conditions. The integrated services offered at these clinics included focused antenatal care (FANC), postnatal checkups, immunization, Vitamin A supplementation, deworming services (Albendazole), growth monitoring and nutritional screening, family planning, HIV testing and counselling, malaria treatment and ITN distribution and HIV Early Infant Diagnosis (EID)., child health services and HIV prevention services were integrated through these IFHOCs. District Health Management Teams (DHMTs) members also conduct supervision and 1 Rural Poverty Portal, Statistics, Social Indicators, Malawi Overview-Source World Bank Indicators 6 P a g e

7 mentorship for service providers at these outreach clinics. These integrated clinics reached out to large populations of people accessing all vital health services from one place at one time. 2 c. Designating a Project Coordinator at Ministry of Health (MOH) helps to guarantee successful program implementation The Ministry of Health designated a program coordinator who was responsible for all the three SSDI projects. The coordinator facilitated coordination between the three projects. In terms of planning, all quarterly activities were shared and vetted by the coordinator, implying that the MoH was aware of all the activities being implemented at each stage in all the three SSDI projects. Again, in terms of progress of the project, the Chief(s) of Party (CoPs) appraised the coordinator of the progress on all the activities planned and implemented. This sort of program coordination helped in fast-tracking implementation of planned activities, as the process expedited decision-making. It also provided a platform for dialogue, where, for example, SSDI, District Health Officers (DHOs), Zonal Managers and Ministry of Health officials planned activities together (DIP), shared progress reports and allowed the DHMTs to raise any challenges that they were facing while implementing the project. Further to this, there was another good coordination at the district level. SSDI-Services project staff worked closely with the DHMT. They were sharing monthly plans and activity progress updates. Focus of the updates was on indicators in order to assess and appreciate how the district was doing on the key program indicators. For example, they would share feedback on how a district was performing on malaria, family planning and reproductive health or maternal and newborn or child health indicator. These updates helped the DHMTs to keep abreast of program progress and areas needing improvement. Due to this increased coordination at district level SSDI-Services district staff were part of the extended DHMT which consists of the district program coordinators and the generic DHMT. This planning was crucial in allowing MOH coordinators to jointly plan and conduct supervision, mentoring, and coaching sessions at health facilities and communities together with SSDI- Services staff. This was advantageous in that it cut down on resources, which were otherwise not always available at the districts (for supervision, mentoring and coaching by MOH coordinators). Of interest, is the fact that in some districts, like Lilongwe, district leadership designated an SSDI-Services focal person, an arrangement that triggered joint planning of the day-to-day operations with SSDI-Services staff and increased project ownership. 2 Reached 74,358 people through 147 IFHOC conducted in hard-to-reach areas with the following services antenatal, under-five clinic, family planning, INT distribution and OPD-Support from Service Delivery Integration SSDI-Services, FY 2015, Quarter 3 Progress Report (Apirl1, 2015-June 30, 2015) 7 P a g e

8 This project design is unique. It tremendously improved coordination between the MoH, SSDI and the donor USAID. It was interesting to note that whenever the donor wanted to contact the Ministry of Health, they simply contacted the designated Ministry of Health coordinator, who was as well versed with the project as much as the project staff themselves. It also increased the Ministry of Health s ownership of the project at national and district levels. 1. MATERNAL, NEWBORN AND CHILD HEALTH (MNCH) Coaching, mentorship and supervision: are best done jointly with the Ministry of Health Coaching and mentorship are two strong strategies that were employed across the whole broad array of technical areas within the SSDI-Services project. The use of joint coaching and mentorship came out clearly in maternal, newborn and child health areas. The technical teams from SSDI-Services and MOH officials conducted joint coaching, mentorship and supervision exercises to the different health facilities. This helped to ensure compliance with MOH standards and seriousness on the part of those being supervised. Health facilities attached a lot of significance to these joint supervision visits because of the presence of their superiors from the different technical areas in the Ministry of Health (district, zone or headquarters). The joint supervision and coaching was done according to specialty, and therefore beneficial to the facilities. It also proved to be helpful to the directors because it helped in real-time solving of identified gaps and joint decision making with DHMTs. Due to joint coaching, mentorships and supervisions multiple improvements were registered in the health facilities across all the 15 SSDI-Services districts. Of significant note are the improvements in BEmONC functionality following on site coaching and mentorship in two signal functions which have been lagging behind vacuum extraction and manual removal of placenta. Providers, especially in health centers, have overtime improved their competence and self-confidence in doing these procedures. 2. FAMILY PLANNING & REPRODUCTIVE HEALTH (FP/RH) Family planning campaigns significantly increase access and uptake of family planning services Family planning campaigns and open day events have proved to be reliable and critical strategies for expanding access to family planning services and thereby meeting the family planning needs of women. In the SSDI-Services project, family planning campaigns and open days were organized as a means to provide information on family planning services, create demand and increase access by providing an expanded method mix using community outreach clinics and community-based health workers 3. The family planning campaigns and open day events 3 Abstracts from SSDI-Services Project Overcoming Service Barriers and Expanding Access to Family Planning in a Predominantly Catholic District of Rural Malawi 8 P a g e

9 registered outstanding results across the SSDI-Services project districts. For example, in the weeklong family planning campaigns that were conducted in Balaka, Chikwawa, Mangochi and Nsanje districts, there was significant increase in the access to family planning products and subsequently increased Couple Years of Protection (CYP) in these districts. 3. MALARIA Directorate synergy is key in delivering on Malaria in Pregnancy (MiP) In Malaria prevention, treatment and care among pregnant mothers, two directorates are involved the Reproductive Health Directorate (RHD) and National Malaria Control Program (NMCP). From the experiences of malaria prevention, treatment and care within the SSDI- Services project, coordination, collaboration and team work between the two directorates has proven to be an effective means to implement malaria in pregnancy interventions. In the SSDI- Services project, RHD and NMCP jointly developed the malaria in pregnancy guidelines, training manuals, and job aides which were used to orient the district safe motherhood, maternal and child health (MCH) coordinators, malaria coordinators, and facility in-charges in all the 15 districts. Furthermore, the two directorates planned and conducted joint supportive supervision visits to monitor progress in implementation, assess provider adherence to the guidelines, identify gaps and work with DHMT s to develop strategies to resolve the gaps. 4. HIV/TB a. Expert Clients: pathway to achievement of the HIV/TB targets Expert clients were enrolled in the implementation of the HIV/TB expansion of the SSDI- Services project. Expert clients are essentially persons who have been on Anti-Retroviral Treatment (ART) for a long time. They are recruited based on their experience in the ART drug, its prescription and care required for persons living with HIV. Expert clients work as volunteers. They obtain minimal support from the project, in the form of phones, bicycles and gumboots. They provide care and support to clients on ART, but also, trace and bring back to care, clients who have missed counselling sessions for one or more times. This strategy has proved effective and efficient it produces tremendous results while employing less resources. In Salima, for example, the expert clients who were enrolled in October 2015, were able to identify 130 clients who had stopped treatment in the SSDIsupported facilities. 107 of these 130 (i.e. 82%) were brought back to care and it was discovered that 19 had transferred to other facilities while 9 had died. In addition, in the quarter of April June 2016, Expert Clients bought back to care 1,441 clients. 9 P a g e

10 b. Employment of HIV Diagnostic Assistants (HDAs) in an HIV/TB care and treatment project is an effective strategy towards the achievement of the 90:90:90 global targets In the HIV/TB expansion component of the SSDI-Services project, which focused on treatment and care, HIV diagnostic assistants were recruited as a strategy aimed at achieving the first of the HIV global targets. The HIV diagnostic assistants were engaged to conduct testing for viral load, collect dry blood samples and testing, and testing exposed infants. SSDI-Services project recruited 106 HIV testing and counselling (HTC) HDAs in April 2015, and deployed them to its four focus districts following an intensive training in HTC and dry blood sample (DBS) collection technique. Depending on number of service delivery points and client volume, one to four HDAs were deployed to each of 52 facilities to deliver uninterrupted daily HTC services and actively conducting provider-initiated counseling and testing. It has been observed that by engaging HDAs, the number of tests conducted increased, with about 60% of the total tests being attributed to the HDAs. A total of 208,067 clients were tested in the one year period exceeding the annual target (183,172) by 27%. Monthly HTC uptake continuously increased as more HDAs were recruited. Furthermore, the positive yield in the four districts also increased substantially by 24% in the HDA period compared to the period before the HDAs were deployed. 5. NUTRITION Care groups: Care groups effective in improving the adoption of health behaviors SSDI adopted the care group model to mobilise and empower communities as agents of their own change in 11 of the 15 SSDI-Services supported districts (Chikwawa, Chitipa, Kasungu, Karonga, Lilongwe, Machinga, Mangochi, Nkhotakota, Nsanje, Phalombe and Salima). A care group comprises of 10 to 15 community-based health educators (volunteers) who are selected by the community and local leaders. The care group members are selected from a cluster of household which they end up serving. Each cluster appoints a cluster leader who represents the cluster in the care group. The project trained 694 care groups that were used as behavior change agents within their communities to facilitate targeted and contextualized nutrition education and counseling. Led by the local leaders and frontline workers, the 694 care groups reached 144,105 households where they created community awareness and reinforced caregivers and household knowledge and skills on optimal nutrition behaviors related to improving maternal nutrition during pregnancy and lactation, infant and young child feeding, micronutrient promotion, early seeking of care, early antenatal care, compliance to 4 antenatal visits, malaria and HIV prevention, family planning and food and dietary diversification and WASH. They did this through door-to-door focused and nutrition education and counselling open day activities, community level cooking demonstrations, talking walls carrying messages on nutrition and through local campaigns. Working with the Community Leaders Action Group on 10 P a g e

11 Nutrition (CLANs), they mobilized different population groups such as the grandmothers, the youth, men and teachers to disseminate nutrition messages and promote health behaviors with a purpose of using all to reach all. They generated evidence for selected behaviors through role modelling and testimonies to motivate others. They were also instrumental in active case finding of children through door to door nutrition assessment of children with 6-59 months for early case detection and referral of those with acute malnutrition for treatment. Through the use of the care groups, there has been improved dietary diversification using local foods, increased number of home gardens, improved health seeking behavior, early case identification and referral of children with acute malnutrition through MUAC assessment at household level with a total of children screened in 2016, increased number of sanitary facilities in the communities (pit latrines, bathrooms, rubbish pits, hand washing facilities and kitchens) and improved clean surroundings. In 2016, a total of children were screened Story II Chikwawa is one of the districts the care group model is being implemented. Within two years of establishing care groups, there was a significant increase in backyard gardens and sanitary facilities. There was movement from 4,320 toilets before the project to 21,538 after project interventions; from zero hand-washing facilities to 9,184 hand washing facilities after project interventions; and from 1,145 protected rubbish pits before the start of the project to 9,754 protected rubbish pits after project interventions. In 2016, 274,915 children were screened and 187 were referred for further assessment. Similarly 45,115 pregnant and lactating women were screened and 3813 were referred for further assessment. This helped in early case identification and treatment and increased probability of recovery. Story II At the beginning of the project, care groups mainly focused on promotion of nutrition interventions, however, within the course of the project they embraced the role of promoting key messages on all the essential health package to facilitate integrated approach. One particular area of focus was promoting early antenatal care and completion of the recommended antenatal visits by pregnant women. This was integrated in the care group s functions after realizing that, despite several maternal health interventions, initiation of first antenatal (ANC) visit and completion of four recommended ANC visits for pregnant women, remained low in a number of health facilities supported by SSDI-Services. For instance in Lilongwe, the service uptake remained as low as between 7% - 20%. Interestingly, after training care groups and intensively supervising them on focused antenatal care (FANC) messages, the groups created awareness in the communities and followed up pregnant women through the door to door visits. This resulted in noticeable change in ANC services uptake adherence to four ANC visits and initiation of first antenatal visit. By analyzing routine facility service data, for Chadza Health Centre in Lilongwe, it was discovered that there was a 13 percentage-point increase (39% to 52%) in uptake of ANC services. Again, first trimester ANC initiation increased from 6 to 15% and, furthermore, completion of 4+ ANC visits increased by 8% in at the facility. What is important, again, is that at the beginning of the project, care groups mainly focused on promotion of nutrition interventions, however, within the course of the project they embraced the role of promoting key messages on all the essential health package. 11 P a g e

12 6. COMMUNITY ENGAGEMENT AND COMMUNITY-BASED SERVICES Community and facility staff interface (community score card process) is fundamental in improving health service delivery at health center level Community Score Card, a two-way and ongoing participatory tool for assessment, planning, monitoring and evaluation of health services, was at the centre of community empowerment during the implementation of the SSDI-Services project. Community score card approach brings together demand side ("service user") and supply side ("service provider") of a required service or program, to jointly analyze underlying service delivery problems and find a common and shared way of addressing them. This method increases participation, accountability and transparency between service users, providers and decision-makers. This process that promotes this interface has proven to be an effective way of demanding services that transform the general health service delivery system at health center level. It positively influences the quality, and efficiency of services provided at facility and community levels. Seventy-six of the 304 SSDI-supported health facilities are effectively using this community score card approach to influence positive change in their facilities. The changes have cut across all the Essential Health Package (EHP) areas, and registered enormous impact on the communities. Below are some examples that illustrate how successfully this has transformed delivery of health services at the community level: Story I After noting that the ambulance assigned to their health center was taken away to the district health office, community members of Malembo in Balaka, through the community score card interface meeting, enquired from the district health office why that was the case. They questioned why each time an ambulance was assigned to their health center, it was taken away within a few month. The DHO responded by reassigning the ambulance to the health centre. The same is true for Mbingwa community in Dowa and Chilipa in Mangochi, where communities, through the community score card interface meetings, demanded for ambulances, and their DHOs assigned them accordingly. For Mbingwa community, when the DHO indicated that their health center had no ambulance because of lack of resources to cover fuel costs, the community, in response, offered to pay for the cost of fueling the ambulance. Since then, the community has been fueling the ambulance for their facilities. Model families help to dispel misconceptions and myths associated with sleeping under mosquito nets There is a popular myth that sleeping under a mosquito net causes impotence in men. This myth is very prominent in rural areas and it prevents a lot of families from using mosquito nets there by exposing them to malaria. SSDI-Services used model families to disseminate messages 12 P a g e

13 on malaria prevention and promote the use of long lasting insecticides treated mosquito nets. SSDI-Services community mobilization district teams, through community action groups, identified families that had reported to be using mosquito nets after attending SSDI-Services organized community meetings on malaria. The families were visited to verify the use of the mosquito nets. Once use was confirmed the families, became model families and were encouraged to share their experiences on use of mosquito nets during community meetings. During these meetings, the model families reported of pregnancies that were conceived while sleeping under insecticide treated mosquito nets. They also talked about the reduced incidence of Malaria in their homes as a major benefit of consistent use of the misquote nets. They attracted many questions from the audience and they responded accordingly. In Salima, where the model family concept was mostly used, the number of households using mosquito nets increased from 13,037 in 2013 to 34,585 in March Apart from the impotence myth, mosquito nets are also rumored to cause suffocation while other people associate sleeping under a mosquito net to be similar to being in a coffin (geneza). All these work against people using mosquito nets for Malaria prevention. Through the model families, SSDI-Services was able to dispel these myths and promote the use of insecticidetreated mosquito nets for malaria prevention. Co-location of SSDI-Services and SSDI-Communication at district and zonal level led to the successful implementation of community mobilization activities. Project staff for SSDI-Services and SSDI-Communication were co-located in the same building and offices at zonal level, where SSDI-Services had a Zonal Manager, Zonal Technical Specialist and a Zonal Monitoring & Evaluation staff while SSDI Communication had a Zonal Communications Coordinator and Zonal Community Mobilization Coordinator. At district level, community mobilization was implemented by local NGO sub-grantees that were hired and monitored by SSDI-Services. Although community mobilization sub-grantee staff were hired to implement community mobilization, there was no SSDI-Communication staff at district level to supervise them. The project was designed to utilize SSDI-Services district-level staff to provide the day-to-day oversight to the sub-grantee. This arrangement allowed SSDI-Services to provide consistent and comprehensive support to the sub-grantees and led to the successful implementation of community mobilization activities. Co-location allowed for joint planning and implementation of activities. In the South East Zone, for example, to improve utilization and access to health services, SSDI-Services organized service providers from district health office to provide HIV testing and family planning services in the community and they used the SSDI-Communications community action groups to mobilize clients for the services. This collaboration helped the SSDI-Services to reach many 4 Community Mobilization 2015 annual review meeting report). 13 P a g e

14 people with HIV testing and family planning services thereby improving achievement of some of the SSDI-Services indicators in the South East Zone, e.g. in family planning, CYP improved from 96,741 in 2012 to 559,763 in Co-location also led to cost sharing of activities. SSDI-Services provided funds for conducting zonal community mobilization review meetings in the South East, Central West and Central East zones. This enabled the sub-grantees to share experiences and encourage districts that were lagging behind to improve their community mobilization skills. The review meetings also helped to improve uniformity in the implementation of community mobilization activities. Cost sharing was also done through carrying out joint supervision and equipment distribution exercises. 7. PERFORMANCE BASED INCENTIVES (PBI) Health Advisory Committees (HACs) are central in linking communities and health facilities PBI has effectively linked communities with their facilities through the health advisory committee (HAC) structure. Through the HACs, communities surrounding PBI facilities now know what is going on in their health facilities and actively participate in the planning of facility activities. This has led to communities cooperating and supporting the implementation of facility based activities. In health facilities where HACs were not functional, PBI has collaborated with facility and district health management teams to revamp them (including training and reorienting them on their roles) so that they can link communities and facilities. A case in point is the Nthalire story in Chitipa where part the roof at the health centre was blown off due to heavy rains. The community through their HAC contributed money to fix the roof. Similarly, at Nkhunga health centre in Nkhotakota, the community through their HAC has become involved in the planning of development activities at the facility to an extent that they cover all facility electricity bills. In order to ensure that HACs were active and remain vibrant, PBI introduced and supported monthly HAC and DHMT meetings. Again, community score-card worked in the background to add vigor and further strengthen the collaboration between the communities and health facility staff. This led to outstanding improvement in the management and delivery of health services in the facilities. 5 South East Zone end of project report P a g e

15 8. PERFORMANCE QUALITY IMPROVEMENT (PQI) Institutionalizing quality, a contributing factor to PQI achievement Institutionalizing quality at health facility level has proved to be a contributing factor towards achievement of PQI. Three key elements have come out as necessary for building of the culture of quality at facilities leadership, championship and internal rewards. Strong, inspiring and dedicated leadership is paramount in cultivating a culture of quality. Whenever DHOs or Health Centre in-charge are committed to improving quality of service in their facilities, and are able to motivate and support staff, tremendous progress is registered and maintained. Secondly, internal rewards are another important element that motivate staff to stick to quality service provision. What happens is that DHMTs conduct quarterly internal assessments at health facilities where outstanding departments within the facilities are rewarded. This initiative entrenches a culture of healthy competition, where in their quest to outsmart each other, departments enforce quality standards. Thus, a culture of quality reigns and is sustained at health facilities and hospitals. Thirdly, intensive coaching and mentorship on skills, especially the use of the performance standards, is another element that has proved to work. In Lilongwe district, SSDI-Services collaborated with the MOH staff worked on series of intensive day and night shifts conducting coaching and mentorship on the use of the performance standards. Normally, supervision is mostly done during the day but in Lilongwe, they did it even at night. Within one quarter of adopting this approach, three facilities in the district were recognized as centers of excellence in infection prevention practices Nkhoma, St Gabriel and Mlare Mission hospitals. Lastly, the award of the status of a champion also contributes towards quality institutionalization. Facilities that have been awarded the status of a champion in PQI strive to maintain this status. Such facilities are not willing to let one department in their facility underperform and lead to the loss of the prestigious status. This helps service providers to encourage each other to maintain quality service provision. What is critical, however, is that many health facilities have not achieved the status of centers of excellence in PQI because they don t have these elements. Thus, it entails that these are not known factors. This far, only 17 out of 175 health facilities implementing PQI in the 15 districts have been recognized. 15 P a g e

16 9. MONITORING AND EVALUATION (M&E) Monitoring and evaluation technical review meetings are important in strengthening M&E systems In supporting the Ministry of Health, the M&E directorate conducted quarterly technical review meetings, drawing M&E participants from all the SSDI-Services districts. The purpose of the technical review meetings was to share experiences and standardize practices in M&E. These forums provided opportunities where facility-tailored support, dependent on situations on the ground, were provided to ensure that the project maintained connection to the national Ministry of Health s Health Management Information System (HMIS) and standards that were set up. These meetings also provided opportunities where M&E systems were standardized across all the 15 SSDI-Services districts. Additionally, the technical review meetings brought about accountability, on the part of district and zonal M&E coordinators. Since district M&E coordinators were aware of their responsibility to present district M&E progress at subsequent meetings, they remained alert to the M&E developments in their districts, and ensured that they were delivering on key milestones set and agreed upon. As a result of these meetings, the M&E directorate was able to effectively contribute towards establishment of DHIS2 in all the 15 SSDI-Services districts, the national database hub, established data quality assessment systems, and that the M&E functionality at health centers were strengthened. The meetings also enabled district staff to learn from and adopt colleagues strategies and encouraged them to engage and coordinate with DHMTs on a continuous basis. Additionally, these meetings improved adherence to M&E plans, strengthened collaboration with Ministry of Health and ultimately significant improvement in District Health Information System 2(DHIS2) reporting rate for all program reports, from 7% in April, 2012 to 70% in January, 2015, in all the 15 SSDI-Services project districts with over 5 districts having % reporting rates 6. B. LESSONS LEARNT 1. Mobile outreach clinics for HTC: more resources less yield The global campaign aims at testing 90 percent of people living with HIV, put 90 percent of those with HIV on treatment, and achieve viral load suppression in 90 percent of 6 The statistics used are from SSDI-Services Past Performance Report and from Abstracts from SSDI-Services Project in Malawi Strengthening Malawi s National Health Management Information System (HMIS) through DHIS2 Institutionalization 16 P a g e

17 those on treatment. Mobile outreach clinics that were designed to get 90% of those with HIV onto treatment were not effective nor efficient in achieving this goal. Mobile outreach clinics used a lot of resources compared to the low results that they yield. By low yield, it is meant that the number of HIV-positive persons identified compared to the number of people that turn up for the test is low (even lower than the HIV prevalence), and therefore cannot lead to realization of the global targets. On the contrary, targeting high risk groups like armed personnel, fishermen, sex workers etc. is what registers results. 2. Capacity building and equipment distribution alone do not directly translate into improved service delivery Capacity building of health facility staff (training, orientation) and provision of health facility equipment and supplies alone does not directly translate into improved service delivery especially in the absence of system to hold service providers accountable for the services that they are required to provide. It s essential that district level managers, through follow up supervision and coaching, ensure that trained providers put skills to practice. Future projects should consider mechanisms that will facilitate service providers being held accountable by their immediate supervisors. Providers, who upon training, have ably demonstrated effective utilization of the knowledge and skills gained, could be sent for further training, as a way to institute positive reinforcement and motivation system. 3. Advanced preparation and procurement Prerequisite for competence-based trainings Competence-based trainings, such as BEmONC, HBB and CBMNH trainings, require advance planning for the training, as well as advance procurement of materials to be used for the training and subsequent service provision. Ideally, the planning and procurement of materials should be done a year prior to conducting the trainings. This ensures that the trainees are wellequipped with the materials that they need to put their skills in use once they go back to their duty stations. During the first 2 years of the project, procurements were done at the same time trainings were being planned and this resulted in preventable gaps in service provision despite skill acquisition. For example, HSAs going to the field without the requisite CBMNH materials such as weighing scales, timers, back packs and counseling cards. 4. Changes in DSA policies can affect project implementation Changes in the daily subsistence allowances (DSA) negatively affected participants attendance in trainings, coaching, mentorship and supervision exercises. Low attendance at these crucial activities affected service provision (at facility and community levels). Ultimately, this negatively affected program implementation and achievement of results. 17 P a g e

18 SSDI-Services managed the situation by ensuring that all partner organizations in the consortium applied a uniform DSA policy to avoid confusion and minimize resentment among participants. 5. Frequent Staff Turnover negatively affects project implementation and investments in capacity building activities a. Uncertainties/changes in end of project dates contributed to staff turnover. In SSDI- Services from the third year of the project, end of project dates were changed several times which caused a lot of staff attrition due to perception of uncertainties. b. Staff turnover and staff transfers in health facilities negatively affected program implementation especially where staff transfer happened after SSDI s investment in capacity building in different technical areas. We recommend that DHMTs should minimize such staff movements for continuity of service provision and provision of quality services. 6. Technical update sessions should be recurrent and not one-time activity Technical update sessions, which were conducted for both project and MoH staff only at the beginning of the project, should be repeated periodically throughout the life of the project. This would help to cater for project and MoH staff who join in the course of project implementation and maintain technical integrity and excellence, as well as standardization of practices.. 7. You Snooze you lose changing and implementing new guidelines When projects support the ministry to develop or change guidelines that guide service delivery, the projects should print and distribute to service delivery points without delays. Significant delays may result in the project being compelled to discard the previous production (waste of invested resources) and reprint new guidelines as the dynamic nature of health programs sometimes necessitates frequent changes in guidelines. 8. Investment in DHMT leadership enhances facility-level service delivery Investing in building capacity of district level leaders like the DHOs, DNOs, DEHOs and MOH program coordinators, facilitates smooth implementation of project activities at facility level. In districts where DHMT leadership was optimal, facility service delivery was also enhanced. 9. There is need for balanced application of internal controls There has to be a clear understanding and balance in the application of existing administrative and financial internal control systems in order to make sure that they work to support program activity implementation and not impede it. This is more critical for finance and procurement systems which are critical in facilitating program implementation. 18 P a g e

19 10. Empowering communities improves accountability in health facilities Empowering communities with skills and knowledge increases their ability to identify health issues within their communities and resolve them on their own. Empowered communities are also more confident to demand better services at their catchment facilities and hold service providers accountable for optimal care. This was exemplified through the Community Action Groups (CAGs) and Community Score Card process under SSDI-Services. For more information contact: The Country Director Jhpiego Malawi Country Office, P.O. Box, 1091, Lilongwe, Malawi. Tel; P a g e