Healthy Mother/Healthy Child Project Completion Report

Transcription

1 Healthy Mother/Healthy Child Project Completion Report John Snow, Inc. (Contract No. 263-C ) Arabic Software Engineering (ArabSoft) Clark Atlanta University The Manoff Group Inc. TransCentury Associates In collaboration with The Ministry of Health and Population Cairo, Egypt and USAID/Egypt

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3 Table of Contents LIST OF TABLES...IV LIST OF FIGURES...V ACRONYMS...VII I. EXECUTIVE SUMMARY... 1 Essential Package of Maternal, Neonatal (Perinatal) and Child Health Standards and Services Established...2 Improved and Strengthened Role and Competency of all Health Personnel through Competency-based Training...3 Improving household behaviors and preventive actions...4 Increased district capacity in planning, managing and monitoring MCH services...6 Pilot interventions to adapt the implementation of the HM/HC Package of Services...7 II. BACKGROUND... 9 USAID Strategic Framework...10 Healthy Mother/ Healthy Child Basic Benefits Package of Essential Services...10 Scope and Scale of the JSI Contract (Option Period)...11 MOHP Counterparts and Partners...11 Subcontractor Involvement...12 JSI Task Statement of Work and Milestones...12 Task One: Basic Package of Essential Services Established and Standards Defined...12 Task Two: Pre/In-Service Training System Designed to Disseminate Standards to Public and Private Providers...12 Task Three: Public and Private Provider Partnerships with Communities to Develop and Manage District Plans...13 Task Four: Monitoring System in place to Track Utilization and Impact and Provide Feedback...13 Task Five: Research Activities...14 Task Seven: Better Social Community Services...14 Task Ten: Small Grant Program...15 Task Eleven: Commodity Procurement Program...15 Task Twelve: Coordination Activities...16 III. IMPLEMENTATION STRATEGY AND INTERVENTIONS Strategic Development for Implementation...19 Pathway to Care and Survival...20 Life Threatening Illness Complications during pregnancy and the perinatal period...21 The Pathway to Care and Survival - A Shared Responsibility...26 Decentralization and Capacity Building...26 Community Participation and Responsibility...27 Sustainability...27 Strategy for Increasing Access to Quality Services in Disadvantaged Communities...28 Phasing of Interventions...29 IV. TASK ACCOMPLISHMENTS TASK ONE: Basic Package of Essential Services and Standards Defined...35 i

4 Table of Contents I. MCH Component of the Basic Benefits Package Revised II. Service standards and clinical protocols upgraded, produced and disseminated III. Implementation of the MCH component of BBP in 75 cumulative districts TASK TWO: Pre/In-Service Training System Designed to Disseminate Standards to Public and Private Providers I. Assist in the coordinated implementation of IMCI training in at least one additional target governorate II. Monitor QA scores of Neonatal Centers in Target Governorates Improved Quality of Neonatal Care III. Complete implementation of MCH-FP integrated package of services, including Health Sector Reform, in one pilot district IV. Assist the MOHP/Urban Health Department to pilot test adapted HM/HC interventions in 1-2 urban slum areas First stage: Development of a situation analysis Second stage: Design of an intervention model Third stage: Implementation of the intervention activities Fourth stage: Post intervention evaluation TASK THREE: Public and Private Providers in Partnership with Communities to Develop and Manage District Plans Safe Motherhood Committees Health Committees Building the capacity of SMCs and HCs District Health Plans Monitoring system and tools Continuous Quality Improvement System Facility Self-Improvement Plans Coordination with General Directorate of Quality on the Accreditation Program TASK FOUR: Monitoring System in Place to Track Utilization and Impact and Provide Feedback Personnel Training Development and installation of Software Application Provision of Equipment Upgrading the Physical Infrastructure MHIS Supervision and Data Collection Planning and Monitoring System to Utilize Information TASK FIVE: Research Activities The completed 12 operations research studies Develop, pilot test and monitor the implementation of a national maternal mortality surveillance system in target governorates of Upper Egypt TASK SEVEN: Better Social Community Services district Community Action Plans developed and implemented Integrating HM/HC messages in the literacy curriculum of the General Authority for Literacy and Adult Education (GALAE) Student Health Insurance Program {SHIP} Information, Education and Communication Program TASK TEN: Small Grant Program... 98

5 Table of Contents A cumulative total of 170 small grants awarded to NGOs in target districts...98 TASK ELEVEN: Commodity Procurement Commodity Procurement Renovations Publications TASK TWELVE: Coordination Activities MOHP/USAID/JSI monthly coordination meetings MOHP intra-ministerial coordination TAHSEEN Project NGO Service Center Partnership in Health Reform (PHR) Environmental Health Project (EHP) NAMRU World Education General Authority for Literacy and Adult Education (GALAE) WHO/UNICEF Institution of International Education, Development Training 2 Project IIE- DT Regional Center for Training (RCT) Healthy Egyptians Initiative Private Sector (Abbott) The National Population Council Population Council Egyptian Society for Population Studies and Reproductive Health Communication for Healthy Living (CHL) Human Workforce Development (HWD) Save the Children Plan International Student Health Insurance Program (SHIP)/Adolescent Anemia Prevention Program (AAPP) General Directorate of Quality/Accreditation Program V. CONTRACT MILESTONES AND COMPLETION INDICATORS Contract Milestones Completion Indicators VI. LESSONS LEARNED ANNEXES iii

6 Table of Contents List of Tables Table 1. Trends in Maternal Health Indicators in Egypt, 1992 to Table 2. Trends in Child Health Indicators in Egypt, 1992 to Table 3. Percentage of births in which the mothers received antenatal care by content of care, Upper Egypt, Table 4. Number of Health Professionals Trained in Target Governorates, Table 5: Number of Staff Trained in Various Aspects of Management... 7 Table 6. Application of Pathway to Care and Survival based on ENMMS 2000 Findings and Recommendations Table 7. Pathway to Care and Survival: A Shared Responsibility Table 8a. Phasing of Major Results in the Target Governorates and Districts of the Base Period Table 8b. Phasing of Major Results in the Target Governorates and Districts of the Option Period Table 9. Phase Out Workshop Dates Table 10. The 10 Elements of the MCH Component of the BBP and the Partner s Responsibilities Table 11. Summary of the Basic MCH Package Implementation in Nine Governorates and 75 Cumulative Districts Table 12. The 10 Steps of Implementing the MCH Component of the BBP Table 13. Status of BEOC, CEOC, and NC Hospital Improvements by Governorate Table 14: Training of EOC Physicians and Nurses and Midwifery Skills for Nurses Table 15. Cumulative Number of NC Health Providers Trained in the Target Governorates Table 16: Training of Emergency Services for Physicians and Nurses Table 17: Blood Bank Services for Physicians Table 18: Anesthesia Training for Physicians Table 19: OR and CSSD Trainings for Nurses Table 20: Laboratory Training for Physicians Table 21: BEOC Training for Physicians Table 22. Teleconference Workshops for Clinical Supervisors/Lead Trainers Table 23. Governorates and districts implementing IMCI activities under the Memorandum of Cooperation Table 24. Data Related to the Achievements in the Training and Follow-up in Target Districts Table 25. Utilization of 55 Neonatal Care Units in the Target Governorates,

7 Table of Contents Table 26: Comparison of Survival Rates in All Units in the Target Region...59 Table 27. Number of Trained Safe Motherhood Committee and Health Committee Members...71 Table 28. Classification of District Health Plans...73 Table 29: Training Courses Conducted During the Establishment of MHIS Centers...79 Table 30: Training Courses Conducted During the Implementation of the MHIS Application...80 Table 31: Training Courses Conducted During the Pilot Implementation of the MHIS Application...80 Table 32. CHCs and CHC Members Selected and Oriented...87 Table 33. Results of First and Second CNI-DMT in Beni Suef, Fayoum and Qena Governorates...89 Table 34: Distribution of Grants in the Target Governorates of the Option Period...99 Table 35. Types of Commodities for Specific Recipients Table 36. Procurement Expenditures Table 37. Renovation Activities List of Figures Figure 1. Selected maternal and health indicators, Upper Egypt, Figure 2. Pathway to Care and Survival: A Conceptual Framework...21 Figure 3. The Decentralization Process...27 Figure 4. The Continuum of Sustainability...28 Figure 5. An Overview of Factors Related to Sustainability...28 Figure 6. Domains of Care: Proportion of Neonatal Care Unit Cases Managed According to Clinical Protocol...57 Figure 7. Proper Management of Specific Diseases/Conditions: Proportion of Neonatal Care Unit Cases Managed According to Clinical Protocol...57 Figure 8. NCU Admissions and Mortality Rates Compared to Governorate Births and Neonatal Deaths, Figure 9: Slum Areas Intervention Model...66 Figure 10: Slum Areas Intervention Model (stage 2)...68 Figure 11a. Example of Compliance with Input Standards at Imbaba General Hospital - Comparison between Q4, 2003 (baseline) and Q3, Figure 11b. Example of Compliance with Input Standards at Imbaba General Hospital - Comparison between Q4, 2003 (baseline) and Q3, v

8 Table of Contents Figure 12a. Example of compliance with Clinical Performance Monitoring Indicators at Hawamdeya General Hospital - Comparison between Q4, 2003 (baseline) and Q3, Figure 12b. Example of compliance with Clinical Performance Monitoring Indicators at Hawamdeya General Hospital - comparison between Q4, 2003 (baseline) and Q3, Figure 13: Distribution of Topics in the Target Governorates of the Option Period... 98

9 Acronyms AAPP Adolescent Anemia Prevention Program ALOS Average Length of Stay ANC Antenatal Care APHA American Public Health Association ARI Acute Respiratory Illness AWP Annual Work Plan BBP Basic Benefits Package BEOC Basic Essential Obstetric Care CAP Community Action Plan CAU Clark Atlanta University CBT Competency Based Training CDC Centers for Disease Control CDD Control of Diarrheal Diseases CEDPA Center for Development and Population Activities CEOC Comprehensive Essential Obstetric Care CGC Credit Guarantee Company CHC Community Health Committee CHL Communication for Healthy Living CNI DMT Community needs Identification Decision Making Tool COP Chief of Party CQI Continuous Quality Improvement CQIS Continuous Quality Improvement System CS Child Survival CSSD Central Supply and Sterilization Department DH District Hospital DHC District Health Committee DHIC District Health Information Center DNF Death Notification Team DSMC District Safe Motherhood Committee DT2 Development Training Two EDHS Egypt Demographic and Health Survey EHP Environmental Health Project EMS Emergency Medical Services ENMMS 2000 Egypt National Maternal Mortality Survey 2000 EOC Essential Obstetric Care vii

10 Acronyms EPI ER EU FETP FFH FGM FP FSIP FSMC GALAE GDQ GH GHC GHO GOE GP GSMC GWU HC HC HIO HIS HM/HC HP HSMS HU HWD IC ICA IDSR IEC IH IHC IHU IIE-DT2 IMCI Expanded Program of Immunization Emergency Room European Union Field Epidemiology Training Program Focus on Family Health Female Genital Mutilation Family Planning Facility Self-Improvement Plan Facility Safe Motherhood Committee General Authority for Literacy and Adult Education General Directorate of Quality Governorate Hospital Governorate Health Committee Governorate Health Office Government of Egypt General Practitioner Governorate Safe Motherhood Committee George Washington University Health Center Health Committee Health Insurance Organization Health Information System Healthy Mother/Healthy Child Health Practitioner Hospital Safe Motherhood Committee Health Unit Health Workforce Development Infection Control Institution for Cultural Affairs Infection Disease Surveillance and Response Information, Education and Communication Integrated Hospital Integrated Health Center Integrated Health Unit Institute of International Education-Development Training Two Integrated Management of Childhood Illnesses

11 Table of Contents IPC JSI LBW LR MC MCH MCH BBP MHIS MMR MMSS MMSSQ MOC MOE MOHP MP&C NAMRU NC NCU NGO NICHP NICU NID NMMS NMR NPC NTI OJT OR PAC PES PHC PHR PPC PRA QA QPMR Interpersonal Communication John Snow, Inc. Low Birth Weight Laundry Room Maternity Center Maternal Child Health Maternal and Child Health part of the Basic Benefits Package Management Health Information System Maternal Mortality Rate Maternal Mortality Surveillance System Maternal Mortality Surveillance System Questionnaire Memorandum of Cooperation Ministry of Education Ministry of Health and Population Maternal, Perinatal and Child US Naval Medical Research Unit Neonatal Care Neonatal Care Unit Non Governmental Organization National Information Center for Health and Population Neonatal Intensive Care Unit National Immunization Days National Maternal Mortality Study Neonatal Mortality Rate National Population Council National Training Institute On-the-Job Training Operating Room Post Abortion Care Package of Essential Services Primary Health Care Partnership in Health Reform Postpartum Care Participatory Rapid Appraisal Quality Assurance Quarterly Performance Monitoring Report ix

12 Acronyms RCT RDBMS RFP RH RHG RHU RTI SDP SFD SHIP SIF SIP SIS SMC SO STD TH TOT TSA TT UE UHC UNFPA UNICEF USAID UTI WHC WHO WHO-EMRO WRA WRH Regional Center for Training Relational Database Management Systems Request for Proposal Reproductive Health Rural Health Group Rural Health Unit Reproductive Tract Infection Systems Development Project Social Fund for Development Student Health Insurance Program Service Improvement Fund Self-Improvement Plan State Information Services Safe Motherhood Committee Strategic Objective Sexually Transmitted Disease Teaching Hospital Training of Trainers TransCentury Association Tetanus Toxoid Upper Egypt Urban Health Center United Nations Population Fund United Nations Children s Fund United States Agency for International Development Urinary Tract Infection Women s Health Center World Health Organization World Health Organization Eastern Mediterranean Regional Office Women of Reproductive Age Women s Reproductive Health

13 I. Executive Summary Egypt s Ministry of Health and Population (MOHP) prioritized the reduction of maternal mortality in response to the first National Maternal Mortality Study (NMMS ). The emphasis was on regions with the highest rates of maternal mortality, particularly Upper Egypt. The Healthy Mother/Healthy Child (HM/HC) Project, funded by USAID with the technical leadership of John Snow, Inc. (JSI), undertook the task of reducing the risk factors for maternal and neonatal mortality and significantly improved outcomes in nine governorates of Upper Egypt; a region that traditionally has been associated with the worst health statistics. A set of interventions aimed at reducing maternal mortality was designed and implemented using an integrated approach involving policy, technical, management and community-based components 1. This integrated approach, with a special emphasis on the population with the highest risk, proved to be a successful strategy. Between and 2000 there was a 52 percent reduction in Egypt s maternal mortality ratio (MMR) and the magnitude of change was significantly greater in Upper Egypt (59%), than in Lower Egypt (30%). A study of factors that could have contributed to the dramatic decrease in the MMR, especially in Upper Egypt, concluded that the decline appears to be associated with the focused efforts of the MOHP through the MotherCare and HM/HC Projects 2. These factors include a combination of: improved access to, and quality of maternal and reproductive health services, reduced fertility rates, antenatal care utilization and skilled attendance at delivery. Rates of improvement for several maternal health indicators were greater in Upper Egypt than Lower Egypt during the period between the two National Maternal Mortality Studies although many of the maternal health indicators in Upper Egypt still lag behind the Lower Egypt levels (see Table 1). Table 1. Trends in Maternal Health Indicators in Egypt, 1992 to 2000 National maternal mortality ratios (1) per 100,000 Receipt of antenatal care (2) Assisted by medical providers during delivery (2) Contraceptive prevalence rates (2) Upper Egypt % 44% 30% 48% 31% 45% Lower Egypt % 54% 40% 65% 54% 62% Total % 53% 41% 61% 47% 56% Source: (1) MOHP, Egypt National Maternal Mortality Study (2) MOHP, EDHS. 1 USAID assistance and support to the MOHP was provided through the Family Planning Systems Development Project (SDP), the Child Survival Project, and the MotherCare Project ( ). 2 Campbell, Gipson etc. WHO article. 1

14 Maternal health improvements also have a direct positive impact on neonatal and child morbidity and mortality. Efforts to improve neonatal health services and preventive health practices have also contributed to improvements in neonatal and infant mortality between 1992 and 2000 in Upper Egypt. Table 2. Trends in Child Health Indicators in Egypt, 1992 to 2000 Neonatal Mortality per 1,000 Infant Mortality per 1, Upper Egypt Lower Egypt Total A summary of the key achievements made in the target region and at the national level towards meeting the HM/HC Project s overall objective of Increased Use of Maternal and Child Health Services in Target Populations is presented in the following sections. Essential Package of Maternal, Neonatal (Perinatal) and Child Health Standards and Services Established The MOHP and HM/HC worked together to define and refine the essential package of maternal child health (MCH) services and standards for antenatal and postnatal care, delivery, essential obstetric care, neonatal care, and preventive child health services. The package of services combines best practices with the promotion of behaviors and interventions that are essential for saving lives and reducing morbidity among women and children. The service standards cover all key areas: essential equipment, supplies, drugs, staffing, physical condition of structures, infection control, record keeping and administration. In 2004, the MOHP officially approved the essential obstetric care (EOC) and neonatal care (NC) service standards as national standards for all public sector health facilities, paving the way for sustainable change nationwide in the quality of care. A total of 253 facilities in the 75 target districts received a package of essential inputs to upgrade obstetric and neonatal care to meet the service standards for each level of care. Inputs included essential equipment, drugs and supplies and renovations where needed. The upgraded facilities included: 1 teaching hospital 11 general hospitals (comprehensive essential obstetric care [CEOC] and neonatal care units [NCU] level III) 59 district hospitals (CEOC and NCU levels III and II) 182 rural/urban hospitals and centers (basic essential obstetric care [BEOC]) Special initiatives were also carried out that resulted in improved standards in emergency medical services (EMS), anesthesiology, infection control, blood banks, and laboratory services. As a result of these inputs, an estimated 22,934,908 million people in nine Upper Egypt governorates and two slum areas now have improved access to essential obstetric and neonatal care due to HM/HC. This includes an estimated 2,611,400 females of

15 reproductive age and the approximately 661,593 infants born each year in the region. Project and population-based data show that utilization and the quality of maternal and child services have increased substantially. The MOHP goal for 2010, of having 80 percent of women delivered by a trained health provider, is being approached in Upper Egypt. In 2003, population-based data showed that 77 percent of urban births and 50 percent of rural births were attended by a trained health provider (EDHS 2003). The former increased by 45 percent since 1998 and the proportion of rural births delivered in a health facility increased by 100 percent. The quality of antenatal care improved between 2000 and 2003 as more women received a wider range of antenatal services and the gap lessened between what urban and rural women receive during antenatal care (ANC) visits. The table below shows rates of improvement for four selected elements of care from the eight measured in the survey. Fifteen percent more Upper Egyptian women had their blood pressure measured (22% rural increase), 23% more had an urine sample taken/analyzed (45% rural increase), 24% had a blood sample taken/analyzed (44% rural increase) and 35% more were told about possible complications (57% rural increase). Table 3. Percentage of births in which the mothers received antenatal care by content of care, Upper Egypt, 2003 Upper Egypt Blood pressure measured Urine sample taken/analyzed Blood sample taken/analyzed Told about complications region Rural Urban Total Source: EDHS, 2003 Neonatal care unit admissions in the nine target governorates increased by 150 percent between 1999 and 2003, from 6,149 to 15,355 cases in a total of 55 NCUs. The utilization rate tripled from 11.6/1000 live births in the year 1999 to 27.9/1000 live births in the year This increase reflects the integrated approach including both community and facility-based components as well as increased access through newly constructed NCUs and the larger number of cribs/incubators as a result of the upgrading of existing facilities. Improved and Strengthened Role and Competency of all Health Personnel through Competency-based Training Thousands of physicians, nurses and support staff in upgraded facilities received HM/HC competency-based training (CBT) courses (see Table 4). The courses, based on clinical protocols, covered obstetric and neonatal (perinatal) care, including EMS, postpartum care, central supply and sterilization, anesthesia, operating room (OR), blood blank and laboratory services. A total of 12,133 days of on-the-job clinical supervision of EOC, NC, EMS and management personnel to certify mastery of skills among trainees was provided by 993 Master Trainers/Clinical Supervisors. The time and resource investment for clinical competency was considerable: individuals required an average of 4-6 months of supervision and on-the job training (OJT) to reach the mastery level in management of obstetric complications. The investment is invaluable in that these individuals are 3

16 influential role models and can provide skilled hands-on training to the many new (and old) health professionals that pass through the hospitals each year. Table 4. Number of Health Professionals Trained in Target Governorates, Classroom workshop completed Basic Competency Achieved EOC physicians and nurses NC physicians and nurses EMS physicians and nurses Anesthesia physicians and nurses Midwifery skills for nurses OR/CSSD nurses Blood bank physicians and nurses Laboratory service physicians and technicians Total health providers trained Mastery Competency Achieved In addition, JSI, in collaboration with the MOHP/IMCI Program, assisted in the implementation of an expansion plan to introduce a variety of IMCI activities in a cumulative total of 17 districts. The application of the program improved health care provider skills required for the effective management of childhood illnesses and the family and community practices to promote children s healthy growth and development. Improving household behaviors and preventive actions One of the key objectives was to increase knowledge and improve health behaviors in households to enable them to better protect and maintain their health. Creating community demand for accessible, quality services and creating structures where these demands can be voiced and effectively acted upon was an essential component of the health service improvements. Involving Community Leaders Over 3,071 local community leaders were involved through 182 community health committees (CHCs) in identifying needs, and planning and implementing health promotion activities in collaboration with local health authorities and providers. As part of this process, 4,317 trained outreach workers conducted two rounds of knowledge, attitude and practice surveys in more than 9,650 households with mothers registered in MCH clinics as having delivered in the last 12 months. The surveys were used to

17 measure and inform local community leaders of changes in knowledge and practice and showed notable improvement in all indicators. Small grants were received by 170 non-governmental organizations (NGOs) to carry out household visits and hold community meetings to spread standardized HM/HC messages specifically on prenatal, delivery and postnatal care. The focus was on rural and urban settlements with little access to care and high poverty levels. Over 629,500 households were reached through these activities. The degree and rate of improvement in health care practices in Upper Egypt between 2000 and 2003, at the height of Project implementation, are a direct reflection of HM/HC efforts spent both at the community and facility levels. The continued improvements suggest that further reductions in maternal and infant mortality can be expected. % receiving care Receipt of antenatal care Deliveries assisted by trained HP TT immunization Postnatal exam in first 2 days Source: MOHP, EDHS 2000 and 2003 Figure 1. Selected maternal and health indicators, Upper Egypt, Figure 1 shows the percentage of women receiving any antenatal care increased 30 percent in Upper Egypt; deliveries assisted by trained health providers increased 15 percent; 10 percent more births had at least one tetanus toxoid immunization; and 8 percent of newborns delivered at home received a postnatal exam within the critical two days after delivery, up from only 1 percent in The national IEC television campaign on safe motherhood conducted in contributed to increasing knowledge about safe pregnancy. The 2003 EDHS showed that more than half of the surveyed women in Upper Egypt reported hearing about pregnancy danger signs, the great majority (80%) from TV. 5

18 Increased district capacity in planning, managing and monitoring MCH services Improvements in service standards and quality of care are sustained by the 75 district and 9 governorate Safe Motherhood Committees (SMC) and the 71 facility level SMCs that were established. The SMCs are supported by the management health information system (MHIS) centers that were established and/or upgraded in the 9 governorates and 75 districts and where new tools were introduced to streamline monitoring and evaluation functions. These SMCs and MHIS centers are actively developing annual implementation plans; monitoring facility service standards and solving identified problems; and tracking progress towards achieving MCH service targets. A comprehensive continuous quality improvement system (CQIS) was introduced and applied to work in harmony with the existing health care system in Egypt. Two CQIS manuals have been produced and implemented by HM/HC. These manuals deal with primary health care (PHC) units providing MCH and BEOC services. They are also used in district/general hospitals to provide tools to assist in the overseeing of quality patient care and to address the continuous monitoring and improvement of both managerial and clinical processes. A national Maternal Mortality Surveillance System (MMSS) was designed and implemented in the 9 governorates. The purpose of the MMSS is to provide MMR data within these governorates; identify the causes and avoidable factors of the maternal deaths; and develop and implementg actions to prevent the occurrence of future maternal deaths. As part of these efforts, a total of 3,485 management and technical personnel were trained in multiple areas including: Planning and monitoring Continuous improvement of HM/HC services Management of general/district hospitals Training of trainers (TOT) for Management Data use and interpretation MMSS

19 Table 5: Number of Staff Trained in Various Aspects of Management Governorate Planning and Monitoring Number of Staff Attending Training Courses CQI Data Use and Interpretation MMSS TOT Total Number of Attendances Aswan Luxor Qena Fayoum Beni Suef El Menya Assiut Sohag Giza Total Pilot interventions to adapt the implementation of the HM/HC Package of Services JSI chose two slum areas, Basateen Sharq and Gharb El-Matar, to pilot the adapted HM/HC Project Package of Essential Services (PES). The intervention model consisted of a four stage process including: development of a situation analysis, designing of an intervention model, implementation of the intervention activities and post-intervention evaluation. Another pilot intervention involved having a Memorandum of Cooperation (MOC) signed to capitalize on current and previous investments in the MCH area which could be integrated with family planning (FP) activities. Both JSI and TAHSEEN coordinated and integrated FP and MCH systems and then developed and implemented a strategy to integrate MCH/FP activities in Mallawi and Mattay in the El Menya governorate. 7

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21 II. Background The government of Egypt has demonstrated continued political commitment to improving maternal and child health. Egypt was one of six countries that supported the 1990 Summit Conference for the Protection and Development of Children, which strongly endorsed safe motherhood programs and strategies. In 1994, as host nation of the International Conference on Population and Development, the government of Egypt endorsed a comprehensive approach to women s health, with a focus on reducing maternal mortality. Reducing maternal mortality was also a key goal of the successive national five-year plans of the MOHP with the latest being the Five-Year Plan ( ). The current goals for 2007 are to reduce maternal mortality to no more than 50 per 100,000 live births, infant mortality to 12 per 1000 live births and neonatal mortality to 7 per 1000 live births. Specific projects and interventions have been implemented through the MOHP/MCH Department with support from USAID, UNICEF, UNFPA, WHO, EU, the Population Council and other international donors. The MOHP National Child Survival Project( ), funded by USAID, implemented interventions that contributed to improved quality and use of child health services as well as antenatal, delivery and postpartum health services throughout Egypt. Two national maternal mortality studies were performed in 1992/93 and 2000 in Egypt. Both studies indicated that gains in improving health status were significant. According to these surveys, the MMR in Egypt has dropped from 174/100,000 live births in 1992/93 to 84/100,000 live births in the year Maternal Death per 100,000 life births However, high fertility, low literacy, poverty, and inadequate access to National Maternal Mortality quality health care continued to contribute to excess maternal and child mortality rates in areas such as Upper Egypt and rural populations. Based on this information, the HM/HC Project bilateral agreement was signed by USAID and GOE. As part of this agreement, the MOHP, with USAID assistance, implemented targeted interventions to improve obstetric services through the MotherCare Project ( ). This Project focused on Luxor and Aswan in UE, and was followed by the HM/HC Project (March 1998 March 2005) to strengthen, integrate and decentralize health services in order to consolidate, improve and sustain improvements in maternal and child health in the rest of the UE governorates including; Fayoum, Beni Suef, Qena, Sohag, Assiut, El Menya and Giza in addition to two slum areas in Giza and Cairo. Note: Annex 1 presents a coverage profile for each district which includes the total population, the estimated female population, the number of females of reproductive age, pregnant females and live births. JSI, as the USAID Prime Contractor for the Healthy Mother/Healthy Child Basic Benefits Package (HM/HC BBP), submitted the First Completion Report in November 2001 to document all the accomplishments that were implemented during the Base /

22 Period from March 15, 1998 to November 30, 2001 in five target governorates in Upper Egypt (Aswan, Luxor, Qena, Beni Suef and Fayoum), and covering 25 administrative districts with over eight million inhabitants. This second report summarizes the achievements of JSI from September 16, 2001 to March 14, The activities were implemented in four target governorates in Upper Egypt (El Menya, Assiut, Sohag and Giza) and two slum areas in Cairo and Giza; an area covering 50 administrative districts with over 14 million inhabitants. In this document, however, cumulative numbers for interventions have been presented to reflect JSI s wholistic approach to achievements. Note: Maps for the nine governorates are attached in Annex 2. USAID Strategic Framework The HM/HC Project is designed to meet USAID/Egypt s health sector Strategic Objective No. Five (SO5), Achieving Sustainable Improvements in the Health of Women and Children, (which was replaced by Strategic Objective No. Twenty [SO20], Healthier Planned Families), (Annexes 3 and 4) through improving the quality and increasing the utilization of maternal, perinatal and child health services. The specific focus of JSI within the HM/HC Project is to assist the MOHP in developing the package of essential maternal and child health care services, service standards, health provider training, links to ongoing family planning services, community education and community mobilization for health, and district level planning and monitoring systems in high-risk districts of Upper Egypt. Healthy Mother/ Healthy Child Basic Benefits Package of Essential Services As stated in the contract, there are six major process outcomes, to which JSI technical assistance efforts will contribute, along with other partners: 1. All 75 HM/HC Project supported districts (25 during the Base Period and 50 during the Option Period) will become capable of planning, monitoring, budgeting, organizing, delivering, and partially financing their own integrated, quality maternal and child health services. Public and private health facilities in these districts will be providing the essential HM/HC Project and community health education programs. 2. Household members, particularly women, in the 75 districts will have an increased ability to provide and seek appropriate health care for themselves and their children through social mobilization. 3. The MOHP will have enhanced capacity nationally to set standards, policy, and management systems for cost-effective maternal and child health services. It will consolidate its MHIS so that all data essential for monitoring and management are collected, while reporting burdens on service delivery facilities are minimized. Planning, budgeting, supervision, and support to districts at the governorate level will also be strengthened. 4. Medical and nursing school graduates will have improved skills and knowledge for delivering the HM/HC Project interventions through the strengthening of curricula and in-service training programs at all undergraduate health professional schools and the programs of the national breast-feeding training

23 center. (The pre-service education activity covering 13 medical schools and selected nursing schools in the target governorates was for Base Period only). 5. National mass media campaigns will have increased popular awareness of, and demand for, essential reproductive and child health services and avoidable health risk behaviors (Base Period only). 6. Established national child survival programs shall be sustained: EPI, acute respiratory infection (ARI), control of diarrheal diseases (CDD), neonatal care, and daya training (Base Period only for EPI, ARI and CDD). Scope and Scale of the JSI Contract (Option Period) John Snow, Inc. through its contract with USAID/Egypt has primary responsibility for providing technical assistance on national level activities and implementation of program activities in 75 districts of nine Upper Egypt governorates. In the Base Period, (March 15, 1998-November 30, 2001) activities were implemented in 25 districts in five target governorates: Beni Suef, Fayoum, Aswan, Luxor, and Qena. In the Option Period, (September 16, 2001-March 15, 2005) activities were implemented in an additional 50 districts. These districts include the six remaining districts in three of the original Base Period target governorates (Qena, Beni Suef and Fayoum), plus 13 districts in Assiut, 11 districts in Sohag, 9 districts in El Menya and 11 districts in the Giza governorate. In addition, the Urban Health Department was approached to assist MOHP in pilot testing the adapted HM/HC interventions in two slum areas in Cairo and Giza governorates. The contract also includes the implementation of a MCH/FP integrated package of services in one pilot district including Health Sector Reform. (See Annex 5: Governorates, Districts and Facilities covered by the HM/HC Project). MOHP Counterparts and Partners The HM/HC Project activities are implemented in large part through the MOHP at the central, governorate and district levels. The main counterpart within the MOHP is the MCH General Department of the Primary and Preventive Health Care Division. In the governorates, JSI worked with MOHP governorate and district SMCs and Community Health Committees and Departments. JSI was also responsible for coordinating its activities with the activities of the other contractors supported by USAID in implementing SO20 activities: 1. Population: TAHSEEN CATALYST 2. Infection Disease Surveillance and Response (IDSR) NAMRU, CDC 3. Focus on Family Health (FFH) PHR 4. Communication for Healthy Living (CHL) Johns Hopkins University 5. Health Workforce Development (HWD) JPHIEGO JSI also worked closely with other partners in the area of MCH. The list of partners includes: UNICEF, Credit Guarantee Company, NGO Service Center, Institute of International Education-Development Training Two (IIE-DT2) and the Field Epidemiology Training Program (FETP). 11

24 A listing of USAID partners, MOHP counterparts and collaborating partners is attached in Annex 6. Annex 7 contains a list of all JSI internal partners represented in full and part time staff. Subcontractor Involvement JSI works with the following subcontractors to implement the following task activities: Clark Atlanta University (CAU): Tasks One and Two Arabic Software Engineering Co. (ARABSOFT): Task Four The Manoff Group: Task Seven TransCentury Ass. (TCA): Task Eleven JSI Task Statement of Work and Milestones The Scope of Work and Option Period Milestones for each Task are presented below. (See Annex 8 contains the JSI Contract Performance Milestones). Task One: Basic Package of Essential Services Established and Standards Defined Task One was responsible for phasing-in new districts/governorates through coordinating all task efforts from conducting a baseline survey to assessing facility compliance with service standards of physical infrastructure, equipment, and supplies based on the results of the assessment. The task also assisted the facility management in developing a plan of action for upgrading the facility and overseeing its implementation. Task One was also responsible for coordinating the phasing-out from target governorates and districts, developing sustainability plans, and monitoring their implementation. In addition to this, the task was responsible for training the board of directors in two urban health facilities in the Giza and Cairo slum areas on planning and management including commodity management and better utilization of Service Improvement Funds (SIF). Milestone # 02 (15/09/2002): Implementation of basic package in 12 additional districts for a cumulative total of 37 districts. Milestone # 11 (15/09/2003): Implementation of basic package in 16 additional districts for a cumulative total of 53 districts. Milestone # 20 (15/09/2004): Implementation of basic package in 17 additional districts for a cumulative total of 70 districts. Milestone # 28 (15/03/2005): Implementation of basic package in 5 additional districts for a cumulative total of 75 districts. Task Two: Pre/In-Service Training System Designed to Disseminate Standards to Public and Private Providers Task Two continued to provide support to institutionalize the training curricula developed and implemented in the Base Period in the target districts/governorate. This Task also assisted the local lead trainers in taking over the responsibility of training local health teams to cover the training of staff who have not received training.

25 Competency-based training was provided for clinical/hospital teams in the target districts to upgrade their skills and meet service standards. Training of staff took place in CEOC and BEOC facilities. Task members worked with the MOHP and professional syndicates to establish continuing education training programs for private and public providers and integrate clinical protocols and service standards in national level programs. Moreover, this Task worked closely with the MOHP and partners to integrate the MCH/FP package of services in two pilot districts in cooperation with the TAHSEEN Project and to assist the MOHP/Urban Health Department to pilot test adapted HM/HC Project interventions in two Urban Slum Areas. Milestone # 03 (15/09/2002): Assist in the coordinated implementation of IMCI training in at least one additional target governorate. Milestone # 12 (15/09/2003): Monitor QA scores of neonatal centers in target governorates. Milestone # 21 (15/09/2004): Complete implementation of MCH/FP integrated package of services in one pilot district including Health Sector Reform. Milestone # 29 (15/03/2005): Assist the MOHP/Urban Health Department to pilot test adapted HM/HC interventions in 1-2 urban slum areas. Task Three: Public and Private Provider Partnerships with Communities to Develop and Manage District Plans Task Three supported the implementation of the HM/HC Project at all levels by strengthening the management capabilities of governorate and district health teams and strengthening existing links with communities to ensure that planning and monitoring of health services was more effectively responsive to local needs. In collaboration with other Tasks, Task Three led a process to involve private sector professional health organizations and practitioners as well as NGOs in efforts to improve the access to and quality of maternal and child health services. Policy guidance, supervision, and technical support from the national MOHP and governorate health directorates were also secured. Milestone # 04 (15/09/2002): 12 Additional District Health Plans and Monitoring Systems developed and implemented for a cumulative total of 37 districts. Milestone # 13 (15/09/2003): 16 Additional District Health Plans and Monitoring Systems developed and implemented for a cumulative total of 53 districts. Milestone # 22 (15/09/2004): 17 Additional District Health Plans and Monitoring Systems developed and implemented for a cumulative total of 70 districts. Milestone # 30(15/03/2005): 5 Additional District Health Plans and Monitoring Systems developed and implemented for a cumulative total of 75 districts. Task Four: Monitoring System in place to Track Utilization and Impact and Provide Feedback The Task Team installed an improved MHIS in 81 Upper Egypt districts to enable district-wide monitoring of process and outcome indicators. The MHIS was upgraded from DOS-FoxPro based System to Windows-RDBMS based system. The MHIS monitors the implementation of the HM/HC district strategy and provides data on 13

26 indicators and strengthened vital statistics registration in target districts. The MHIS gathers, analyzes, and evaluates data, which is used for decision-making at all levels of service delivery and management. Activities are accomplished in coordination with the National Information Center for Health and Population (NICHP). Milestone # 05 (15/09/2002): Assist MOHP to establish 70 district MHIS centers. Milestone # 14 (15/09/2003): Assist MOHP to establish 75 district MHIS centers. Milestone # 23 (15/09/2004): Assist MOHP to establish 80 district MHIS centers. Milestone # 31 (15/03/2005): Assist MOHP to establish 85 district MHIS centers. Task Five: Research Activities This task was two fold: Identify and conduct a total of 12 operational research studies to address operational issues and reveal opportunities for improving the efficiency, efficacy and sustainability of maternal and child health services provided. Design and assist the MOHP in implementing the MMSS to provide information to policy makers regarding the MMR at the governorate level and identify avoidable factors contributing to maternal deaths and help to develop interventions to save the lives of pregnant mothers. Milestone # 06 (15/09/2002): Comprehensive research plan developed. Milestone # 15 (15/09/2003): 5 operational research studies completed. Milestone # 24 (15/09/2004): Assist MOHP in the development and pilot test of a national maternal mortality surveillance system. Milestone # 32 (15/03/2005): 12 operational research studies completed. Milestone # 33 (15/03/2005): Monitor implementation of surveillance system in target governorates of Upper Egypt. Task Seven: Better Social Community Services Task seven assesses and selects community organizations to: Partner with health providers and form community health committees (also part of Task Three) Provide training in needs assessment, problem solving and community mobilization Develop and test partnership schemes Conduct sensitization training of health providers Provide support to schools to implement/sustain anemia prevention and antismoking programs Train district health educators in behavior change skills Develop IEC activities and materials for providers and households/patients Milestone # 07 (15/09/2002): Community Action Plans developed and implemented in 12 additional districts for a cumulative total of 37 districts.

27 Milestone # 16 (15/09/2003): Assist the MOHP and HIO to maintain the Adolescent Anemia Prevention Program in the five original Upper Egyptian governorates and phase into the new target governorates. Milestone # 17 (15/09/2003): Community Action Plans developed and implemented in 16 additional districts for a cumulative total of 53 districts. Milestone # 25 (15/09/2004): Community Action Plans developed and implemented in 17 additional districts for a cumulative total of 70 districts. Milestone # 34 (15/03/2005): Community Action Plans developed and implemented in 5 additional districts for a cumulative total of 75 districts. Task Ten: Small Grant Program The Small Grants Program aimed to encourage mobilization of community resources to assess their own needs and develop local solutions to address local health problems. The program also assisted in providing health awareness and improving services to the most underprivileged communities in Upper Egypt. These goals were achieved through providing grants and technical assistance to small NGOs that have potential for working in areas of interest to the HM/HC Package of Essential Services. All NGOs seeking grants were required to complete an application in which a proposal and a budget were presented. Applications reflected the results of a careful planning process. Priority for grant funding was given to NGOs that provided clearly defined details regarding proposed activities which achieve clear and measurable results. Each application provided details of the proposed activities and the costs of these activities. The application also provided sufficient information about the organization applying for the grant to enable JSI to assess the organization s experience and capabilities. The program supports and strengthens the capacity of these NGOs by developing their institutional and management capabilities through a package of training that included: Training on development and the writing of proposals so they were able to successfully apply for funds. Technical training on community outreach and communication skills. Financial management training on how to manage and report on grant funds. Milestone # 08 (15/09/2002): A cumulative total of 120 small grants awarded to NGOs in target districts. Milestone # 18 (15/09/2003): A cumulative total of 140 small grants awarded to NGOs in target districts. Milestone # 26 (15/09/2004): A cumulative total of 160 small grants awarded to NGOs in target districts. Milestone # 35 (15/03/2005): A cumulative total of 170 small grants awarded to NGOs in target districts. Task Eleven: Commodity Procurement Program Task Eleven was responsible for procuring commodities and assisting in the renovation activities that will continue to support HM/HC Project activities at the central, governorate, district, facility and community levels. 15

28 By the end of the Option Period, project commodities will equal $8,464,363; necessary to achieve the results of the contract. The commodities procured will include, but are not limited to, utility vehicles, medical commodities, audio-visual equipment, computing equipment, office equipment, and office furniture. Most of the procurement took place in the US. Under Task Eleven, and in cooperation with Task One, special emphasis was also made to train the staff members who are the intended users of the equipment on the proper purpose, operation, and maintenance. In-house systems to monitor and track the entire procurement process including the completion of government inventory forms were also maintained in coordination with the MOHP. L.E. 2,762,288 was reserved for renovation activities. These funds are for supplemental physical improvements to various MOHP district health facilities and Health Information Centers in HM/HC Project target governorates of Upper Egypt that cannot be covered by the MOHP contractor in a timely manner. JSI also will provide technical assistance in the form of architectural and engineering services (developing plans and bills of quantities and monitoring activities of the MOHP architectural and engineering services) to expedite the renovation of MOHP district health facilities in Upper Egypt target governorates. L.E. 15,537,868 was allocated for the printing and distribution of IEC materials. The publications were distributed to MOHP counterparts in the target governorates. IEC documents will also be used for community and NGO activities. Milestone # 01 (15/03/2002): Development of an HM/HC Project Procurement Plan Milestone # 09 (15/09/2002): Procurement of $1.5 Million of Project commodities Milestone # 10 (15/03/2003): Procurement of $3 Million of Project commodities. Milestone # 19 (15/09/2003): Procurement of $5.5 Million of Project commodities. Milestone # 27 (15/09/2004): Procurement of $7.5 Million of Project commodities. Milestone # 36 (15/03/2005): Procurement of $9 Million of Project commodities. Comment [S1]: Ask Hazem Task Twelve: Coordination Activities The purpose of this task was to coordinate with active partners in order to profit from convergent or paralleled support, and avoid duplication. Coordination and collaboration among HM/HC Project partners in the planning and implementation of USAID-funded activities is of vital importance as it is expected to increase efficiency and effectiveness of Project inputs and resources and to promote sustainability by building upon and linking mutually supportive activities at the various levels of implementation from central policy making to local field implementation. There are several functional levels of coordination: The first level of coordination concerns integration between activities, where the partners collaborate and work closely together to jointly develop and implement activities. The second level of coordination concerns dependency relationships between activities. Dependency relationships indicate that one activity cannot begin until another activity is accomplished. This level of coordination is significant since it implies critical path arrangements.

29 The third level of coordination involves the prevention of scheduling conflicts. Such conflicts occur when two or more activities are planned to be conducted at the same time and/or in the same place and/or potentially utilize the same resources. The fourth level of coordination is the need to share information so that all partners work from the same base of knowledge concerning the plans and progress of the tasks in the Project. These functional levels of coordination, mentioned above, will continue to be carried out with USAID-funded projects working in areas related to improving maternal and child health as well as their agencies activities. In particular, the contract specifies coordination with current and future contractors working with the Population/Family Planning Sector (TAHSEEN/Catalyst), Infectious Disease and Surveillance (Centers for Disease/FETP), Partnership in Health Reform (PHR), Communication for Healthy Living (CHL), and support of non-governmental organizations (NGO Service Center). 17

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31 III. Implementation Strategy and Interventions John Snow, Inc. s original strategy for implementation required innovative approaches and methodologies, which can be summarized as: Process oriented with a focus on results, and yet flexible to respond to evolving circumstances. Development of effective teams at each level that are well trained, supported and motivated with common goals and objectives. Involving women in defining their needs and participating in the design of services to meet their needs. Ensuring that adequate, appropriate and timely information is available to districts to make effective decisions. Taking decision making closer to the people to improve accountability to people. Encouraging broader ownership thus improving accountability and governance at the local level by establishing Governance Committees that are separate from Management or Executive functions. This also provides a means for coordination, cooperation and linkages between public, private and NGOs. Taking an institutional development approach to strengthening delivery of services, i.e., taking a longer term view of capacity and capability development that looks beyond the Project. Focusing on competence rather than knowledge and emphasizing the longer term investment in developing mastery of skills. Strategic Development for Implementation Many elements of JSI s original strategy were adapted and further developed to suit the socio-cultural conditions in Upper Egypt. The majority of these elements have been effective in the achievement of planned objectives. Participatory development and implementation proved to be challenging in the prevailing context and within the governmental, institutional cultural framework. JSI provided technical assistance to develop tools and methodologies to be implemented within these principles. Significant technologies and methodologies that JSI has introduced, refined and/or developed in response to the HM/HC contract requirement include: Pathway to Care and Survival adapted to the Egyptian context as the guiding implementation tool Essential Obstetric Care model to reduce obstetric complications from becoming obstetric emergencies adapted and refined Competency-based methodology to focus on skill development versus conventional teaching and training methodologies Trainers/supervisors to develop on-the-job mastery of competencies Context-specific tactical interventions focusing on sub-standard clinical practices linked to most frequent and most serious clinical outcomes Integrated training of different health providers 19

32 Self-assessment process for implementing institutional management change Community assessment by local women (primary stake holders) to develop responsive local plans Consensus building to encourage ownership and cooperation Operations research to refine implementation strategies Behavior change to influence and improve provider behavior Communication for behavior change approach to communication strategy development and implementation Developing and strengthening local networks to respond to local needs including linking community leadership with facility-based personnel Pathway to Care and Survival The continuum of care represented in the MCH part of the Basic Benefits Package is based upon a conceptual framework, The Pathway to Care and Survival, which follows the steps necessary to increase the likelihood of survival of a mother and her infant in the event of complications or illness. The Pathway begins with: (Step 1) Recognition of the problem by the woman, her family and/or traditional birth attendant, or health provider. If the woman is at home or a site where the problem cannot be managed, the decision to seek care must be made). (Step 2) A health-seeking decision is generally based on consideration of the perceived benefits versus the perceived barriers to action or inaction. Once a decision is made to seek care, any barriers to reaching quality care must be overcome. (Step 3) Cost, transportation, availability of doctors, and the perceived poor quality of services and negative attitude of providers are often cited as barriers to access. Once services are reached, quality care must be available. (Step 4) The availability of essential drugs and equipment and the technical competence, efficiency and interpersonal communication skills of the provider are critical to increase mother/child survival, as are appropriate, timely care for emergency cases and correct diagnosis.

33 Life Threatening Illness Complications during pregnancy and the perinatal period Step 1: Recognition of Problem Knowledge/awareness of severity/effect/vulnerability Step 2: Decision to Seek Care Perception of benefits of behavior Perception of barriers Step 3: Logistics to Reach Quality Care Transportation Stabilization Referral Cost Step 4: Quality Care Technical competence of health provider Effectiveness of treatment Efficiency Safety Continuity of care Interpersonal communication skills Amenities Survival Figure 2. Pathway to Care and Survival: A Conceptual Framework Based on the ENMMS 2000 findings and recommendations for HM/HC interventions, Table 6 is an application of the pathway to care and survival tool that summaries problems, steps, HM/HC objectives, activities and interventions as well as the coordination with other partners. 21

34 Table 6. Application of Pathway to Care and Survival based on ENMMS 2000 Findings and Recommendations Household and Community Problems Problems: 2000 MMR in UE 89/100,000 81% of deaths avoidable 30% of deaths due to delay 93% sought care Major causes of death: 38% Hemorrhage 22% Hypertensive disease 8% Sepsis 8% Ruptured uterus 13% Cardiovascular disease Problems: Neonatal NMR in UE 28.8 Urban; 35.4 Rural 70% died at home in first week 52.5% received care Major causes of death: Sepsis Asphyxia Birth trauma ARI and diarrhea Pathway to Care and Survival Steps Step 1. Recognition of Problem Knowledge/ awareness Severity/effec t/vulnerability Step 2. Decision to Seek Care Behavior Motivation to seek care Barriers HM/HC Objectives Increase knowledge of households/ communities Improve health behavior in households/ communities HM/HC Activities and Interventions by Task(s) Support better antenatal care especially for high risk pregnancies (1,2) Support early postpartum home visits (1) Educate community on danger signs (7) Train dayas on danger signs (1,2) NGO activities (10) Research on health knowledge (5) Research on nutrition knowledge (9) Improve Daya and health provider links (1,2) Research on care seeking and barriers (5,7) Reduce local barriers through community groups and NGO activities (7,10) Sensitize health providers to community needs (7) Coordination with MOHP and other HM/HC partners MCH Dept. Training Unit IEC Unit Daya program Social Services Research Unit MCH Dept. Training Unit IEC Unit Daya program Social Services Research Unit UNICEF NGO Service Center SHIP UNICEF NGO Service Center FETP

35 Problems Pathway to Care and Survival Steps HM/HC Objectives HM/HC Activities and Interventions by Task(s) Coordination with MOHP and other HM/HC partners Problems: Child (<5 yrs) Mortality 54/1000 Diarrhea ARI Nutritional deficiencies Immunizable diseases Problems: Providers and Facilities 43% of maternal deaths due to substandard care by obstetrician 11% due to GPs and 8% to dayas 16% to lack of blood, 4% to transport, 2% drugs/supplie s 25% NCU mortality Limited services available in MOHP facilities No referral system Lack of management systems to maintain quality of service Low demand for services Step 3. Access to Care (Logistics to reach) Transportatio n Cost Remove barriers to access quality care Mobilize community resources for transport and other support (7,10) Assist in implementation of IMCI (1,2) Social Services MOHP IMCI Unit NGO Service Center WHO/ UNICEF Step 4. Quality Care Knowledge, skills, attitudes, behaviors Technical competency: training and experience, effectiveness, safety Ability to provide supplies, equipment, drugs Continuity of care Improve quality of essential maternal, perinatal and child (MPC) health services Strengthen district capability to provide essential MPC health services Sustain established child survival programs Upgrade selected anchor facilities (1,3) Establish national service standards for obstetric and neonatal care (1) Improve planning and management systems to ensure staff and resources available and in compliance to standards (3) Provide competencybased training for clinical trainers, doctors, nurses, midwives (1,2) Revise medical and nursing school curricula and improve training skills to include CBT methods and service standards (1,2) Administration Engineering Dept. QA unit MCH unit ARI, CDD, EPI IMCI NPC Training Unit Medical education Research unit HIS/NICHP TAH- SEEN FETP SHIP PHR CGC DT2 23

36 Problems Pathway to Care and Survival Steps HM/HC Objectives HM/HC Activities and Interventions by Task(s) Develop and test maternal and neonatal referral system (1,3) Assist MOHP to improve ANC, PPC, ARI, CDD, EPI services in target governorates (1) Train private providers in EOC and NC topics (1,2) Conduct research on mortality patterns to improve service effectiveness (5) Improve nutrition education curricula and health educator skills (7) Upgrade selected anchor facilities (1,3) Establish national service standards for obstetric and neonatal care (1) Improve planning and management systems to ensure staff and resources available and in compliance to standards (3) Coordination with MOHP and other HM/HC partners Health Facility and Provider Improve quality of essential maternal, perinatal and child (MPC) Administration Engineering dept. QA unit MCH unit ARI, CDD, EPI IMCI NPC Training unit Medical education research unit HIS/NICHP TAH- SEEN, FETP, SHIP, PHR, CGC, DT2

37 Problems Pathway to Care and Survival Steps HM/HC Objectives HM/HC Activities and Interventions by Task(s) Provide competencybased training for clinical trainers, doctors, nurses, midwives (1,2) Revise medical and nursing school curricula and improve training skills to include CBT methods and service standards (1,2) Develop and test maternal and neonatal referral system (1,3) Assist MOHP to improve ANC, PPC, ARI, CDD, EPI services in target governorates (1) Train private providers in essential obstetric and neonatal care topics (1,2) Conduct research on mortality patterns to improve service effectiveness (5) Improve nutrition education curricula and health educator skills (7) Coordination with MOHP and other HM/HC partners Problems: Providers and Facilities 43% of maternal deaths due to substandard care by obstetrician 11% due to GPs and 8% to dayas 16% to lack of blood, 4% to transport, 2% drugs/supplie s 25% NCU mortality Limited services available in MOHP facilities No referral system Lack of management systems to maintain quality of service Low demand for services Step 4. Quality Care Knowledge, skills, attitudes, behaviors Technical competency: training and experience, effectiveness, safety Ability to provide supplies, equipment, drugs Continuity of care health services Strengthen district capability to provide essential MPC health services Sustain established child survival programs Administration Engineering dept. QA unit MCH unit ARI, CDD, EPI IMCI NPC Training unit Medical education research unit HIS/NICHP TAH- SEEN, FETP, SHIP, PHR, CGC, DT2 25

38 The Pathway to Care and Survival - A Shared Responsibility The Pathway to Care and Survival is a shared responsibility throughout all levels of the system. Table 7. Pathway to Care and Survival: A Shared Responsibility A policy maker creates an environment that supports the survival of Policy maker the pregnant woman and the newborn. Facility Provider Community Family Woman The facility must be adequately equipped, staffed, and managed in accordance with the QA service standards to assure that skilled care is provided for the pregnant woman and the newborn. The provider is responsible for providing skilled care during normal and complicated pregnancies, birth, and the postpartum period in accordance with the standards specified in the protocols. The community advocates and facilitates preparedness and readiness to carry out the required actions to assure access to services. The family supports the pregnant woman s plans during pregnancy and birth and during the postpartum period. The woman prepares for birth and values and seeks skilled care during pregnancy, childbirth and during the postpartum period. Decentralization and Capacity Building Decentralization is a theme which permeates through many aspects of HM/HC. Tasks Three, Seven, and Ten took the lead in this area, with the establishment of facility, district and governorate SMCs, as management teams, as well as CHCs as represented by the Health Committees of Elected Councils at community, district and governorate levels. District health planning and systems provided a good opportunity to make decisions more responsive to local needs and promote citizen participation. Each district was supported/enabled to tailor a strategy to meet its own unique set of needs and challenges. Capacity Building of the MOHP to institutionalize the protocols and systems developed was the center piece of JSI technical assistance. Decentralization and capacity building were two driving forces behind achieving better utilization of available resources and contributed to sustainability. With the establishment of SMCs at a multitude of levels, the focus was on activating and promoting vertical and horizontal work relationships between MOHP departments as well as between MOHP and other government agencies and community based organizations.

39 Top-Down Central SMC Governorate (GSMC/GHC) Planning Supervision Feedback District (DSMC/DHC) Hospital (HSMC) Communties (CHC) Implementation Households MHIS Data Monitoring & Evaluation Bottom-Up Figure 3. The Decentralization Process Community Participation and Responsibility Community participation and responsibility was a major determinant of the use of health services and also sustainability. HM/HC aimed at changing behavior at household/community levels and engendered a sense of community ownership of health services. Increasing demand of quality upgraded services was one of the main strategies for implementing the MCH BBP. Increased use of quality antenatal care contributed to improved pregnancy outcomes through health education and promotion of appropriate delivery care, especially for high-risk pregnancies, recognition of danger signs and making the decision to access care immediately. Sustainability Sustainability, community participation and responsibility, and decentralization were three key aspects of implementing the HM/HC Project. They were inter-related. An overriding objective for work planning and implementation was to strengthen sustainability of interventions. JSI has developed an initial sustainability strategy entitled Continuum of Sustainability as depicted (See Figure 4 below). Within this strategy, the utilization of services was considered a primary focus influenced by both the sustainability of quality care delivery systems and the sustainability of demand dependent on client satisfaction. 27

40 Quality of Care Sustainability of Care Delivery Systems Sustainability of Demand Client Satisfaction Figure 4. The Continuum of Sustainability In implementing the proposed strategy, JSI and MOHP counterparts focused on the specific factors related to sustainability at the national, governorate/district, and community/household levels as described below. Figure 5. An Overview of Factors Related to Sustainability Strategy for Increasing Access to Quality Services in Disadvantaged Communities Improving access to the package of MCH services among disadvantaged high risk and vulnerable communities and households was a key goal. With the highest maternal and child mortality rates in the country, all governorates in Upper Egypt, including the nine target governorates, were disadvantaged from a health perspective. This was particularly so in the rural areas, which have child mortality rates twice as high as the national average. Most women in the communities in the target governorates are uneducated, have high parity, and a third of households have a low standard of living. Half to twothirds of the population in the districts live in rural areas. All of these factors were associated with the poor health status of the most vulnerable at-risk segment of the population, women and children.

41 The MOHP strategy is to provide sufficient service capacity to meet the needs of all pregnant women in the target districts, thereby ensuring that 100% of women have access to safe, affordable services and adequate access to essential obstetric care and neonatal care services for woman and children with complications. The WHO model was adapted to calculate the needed supply of obstetric services. For every 100,000 people, JSI, in collaboration with the MOHP, established/upgraded at least one health center to provide basic obstetric services, and in every district, the district/general hospital was upgraded to provide care for complicated cases. With respect to neonatal services, there are a fixed number of neonatal care units in the target governorates and the focus, therefore, was on expanding their service capability to manage cases by upgrading skills, physical space and equipment. Increasing the supply of both essential obstetric services and neonatal care in the underserved districts was achieved by upgrading and expanding the service capability of district/general hospitals. The district hospitals serve up to 500,000 people and are often the only source of care available in the entire district for complicated maternal and neonatal cases. General hospitals serve as the referral facility for the entire governorate. Baseline assessments indicated that while most district hospitals have sufficient staff, equipment, and supplies for basic care, their capability to manage complicated cases is curtailed by a number of inadequacies. These facilities are a vital source of care, especially for those who cannot afford private health care. The rural facilities that were chosen to be anchor facilities were selected specifically to serve communities that currently have very limited access to services. Basic obstetric services in rural areas of the target governorates are seriously limited, as the majority of the rural hospitals do not have delivery services at all. Those that do have some capability were providing very limited services because of the lack of equipment and/or drugs and supplies, or inadequate provider skills. The factors considered in the selection process included population size and distribution, distance to the district hospital and capital city, facility condition, staff availability, number of other public health facilities serving the area, and geography (e.g., barriers such as the Nile River). Once selected, the anchor facilities became part of a referral system that further increased access to care for those people living in under-served areas. Phasing of Interventions The overall strategy of implementation was similar for each target governorate. Variations between governorates were mainly due to the phasing in of activities and some differences due to the overall size of the respective governorates. Tables 8a and 8b show the phasing of major results in the target governorates and districts during the Base and Option Period contracts. There was some staggering of the timing of the phases for various results due to the timing of their respective Performance Milestones. It should be pointed out that there are a total of 75 districts within the nine target governorates in addition to two slum areas in Cairo and Giza. Nine phase out workshops were conducted to review the achievements of the HM/HC Project. Table 9 includes the dates of the phase out workshops. The strategies and Assiut phase out 29

42 plans of the MCH and Curative Care Central Departments and the Aswan, Luxor, Beni Suef, Fayoum, Qena, Sohag, Assiut, El Menya and Giza MOHP Directorates to sustain HM/HC Project achievements were discussed. The phase out for each governorate included a phase out completion report detailing the achievements/accomplishments of that governorate. In addition, service standards, protocols, CBT curricula, the QA system and management tools were reviewed, and plans to sustain them were developed. In support of the phase out process, the HM/HC Executive Director issued a letter to the director generals and undersecretary of the nine MOHP departments advising them that JSI is in the process of phasing out its technical assistance from the nine governorates. The nine departments were directed to hand over JSI field offices, with all furniture and equipment, to the MCH section as the HM/HC Project is on-going and will continue its activities in their governorates, without external technical assistance, until September 15, Table 8a. Phasing of Major Results in the Target Governorates and Districts of the Base Period Contract One Two Three Four Year: Quarter: Task Ending: 6/15/98 9/15/98 12/15/98 3/15/99 6/15/99 9/15/99 12/15/99 3/15/00 6/15/00 9/15/00 12/15/00 3/15/01 6/15/01 11/30/01 7 Districts 3 Districts 10 Districts 5 Districts 25 1 Districts delivering the Maternal & Child Health Care part of the Basic Benefits Package Luxor phase out El Menya phase out Aswan (A) Daraw (A) Esna (Q) Armant (Q) Fayoum Urban (F) Wasta (BS) Qena (Q) Beba (BS) El Fashn (BS) Kom Ombo (A) Qous (Q) Fayoum Rural Deshna (Q) Naga Hamadi Edfu (A) Nasr (A) Luxor (L) Bayadeya (L) (F) Etsa (F) Ibshway (F) Beni Suef (BS) Ehnasia (BS) Nekada (Q) (Q) Abu Tesht (Q) Farshout (Q) 10 Districts 10 Districts 5 Districts 25 3 District Aswan (A) Bayadeya (L) Fayoum Urban Wasta (BS) Beba (BS) Health Plans Daraw (A) & Monitoring Kom Ombo (A) Esna (Q) Armant (Q) (F) Fayoum Rural Qena (Q Deshna (Q) El Fashn (BS) Naga Hamadi (Q) Systems Edfu (A) Qous (Q) (F) Nekada (Q)) Abu Tesht (Q) Developed & Nasr (A) Implemented Luxor (L) Etsa (F) Ibshway (F) Beni Suef (BS) Ehnasia (BS) Farshout (Q) 20 Districts 5 Districts 25 Total

43 Contract One Two Three Four Year: Quarter: Task Ending: 6/15/98 9/15/98 12/15/98 3/15/99 6/15/99 9/15/99 12/15/99 3/15/00 6/15/00 9/15/00 12/15/00 3/15/01 6/15/01 11/30/01 7 Districts Offering Social Community Services 4 District MHIS Centers Established Aswan (A) Daraw (A) Kom Ombo (A) Edfu (A) Nasr (A) Luxor (L) Bayadeya (L) Esna (Q) Armant (Q) Qous (Q) Fayoum Urban (F) Fayoum Rural (F) Etsa (F) Ibshway (F) Beni Suef (BS) Ehnasia (BS) Wasta (BS) Qena (Q) Deshna (Q) Nekada (Q) Beba (BS) El Fashn (BS) Naga Hamadi (Q) Abu Tesht (Q) Farshout (Q) 10 Districts 20 Districts 35 Districts 65 Aswan Luxor Beni Suef Qena Assiut Fayoum El Menya Sohag 18 Districts 6 Districts 24 Total 10 Small Grants Awarded 74 Awards 18 Districts Armant (Q) Qous (Q) Esna (Q) El Wasta (BS) Beni Suef (BS) Beba (BS) Fashn (F) Fayoum (F) Fayoum City (F) Ebshway (F) Etsa (F) Luxor City (L) Luxor (L) Nasr (L) Aswan (A) Kom Ombo (A) Daraw (A) Edfu (A) 28 Awards 6 Districts Nekada (Q) Qena (Q) Deshna (Q) Abou Tesht (Q) Farshout (Q) Nagaa Hamadi (Q) 102 Awards Table 8b. Phasing of Major Results in the Target Governorates and Districts of the Option Period Contract Five Six Seven Year: Quarter: Task Ending: 12/31/01 3/31/02 6/30/02 9/30/02 12/31/02 3/31/03 6/30/03 9/30/03 12/31/03 3/31/04 6/30/04 9/30/04 12/31/04 3/15/05 1 Districts delivering the Maternal & Child Health Care part of the Basic Benefits Package 12 Districts 16 Districts 17 Districts 5 Districts Qift (Q) El Wakf (Q) Sennoures (F) Tamia (F) Nasser (BS) Somosta (BS) El Menya (M) El Fakreya (M) Tema (S) Samalout (M) Beni Mazar (M) El Balyana (S) Gharb Assiut (A) Shark Assiut (A) Deir Mowas (M) El Fath (A) El Kouseyah Dar El Salam (S) Saqolta (S) Geheina (S) Markaz Assiut (A) El Maragha (S) (A) Sohag (S) El Ghanayem (A) Tahta (S) Gerga (S) Akhmeim (S) El Mounshaa (S) Mallawy (M) Mattay (M) Maghagha (M) El Edwa (M) Badary (A) Sahel Selim (A) Sedfa (A) Abu Teeg (A) Manfalout (A) Dayrout (A) Abnoub (A) Ayaat (G) El Badrasheen (G) Osseem (G) Saff (G) Etfieh (G) North Giza (G) Hawamdeya (G) Mansheit El Qanater (G) Aqouza (G) Waraq (G) Wahat Bahareya (G) 12 Districts 16 Districts 17 Districts 5 Districts 50 Total 31

44 Contract Five Six Seven Year: Quarter: Task Ending: 12/31/01 3/31/02 6/30/02 9/30/02 12/31/02 3/31/03 6/30/03 9/30/03 12/31/03 3/31/04 6/30/04 9/30/04 12/31/04 3/15/05 3 District Qift (Q) Health Plans & Monitoring El Wakf (Q) Systems Sennoures (F) Developed & Tamia (F) Implemented Nasser (BS) Somosta (BS) 7 Districts Offering Social Community Services El Menya (M) El Fakreya (M) Tema (S) Samalout (M) Beni Mazar (M) El Balyana (S) Gharb Assiut (A) Shark Assiut (A) Deir Mowas (M) El Fath (A) El Kouseyah Dar El Salam (S) Saqolta (S) Geheina (S) Markaz Assiut (A) El Maragha (S) (A) Sohag (S) El Ghanayem (A) Tahta (S) Gerga (S) Akhmeim (S) El Mounshaa (S) Mallawy (M) Mattay (M) Maghagha (M) El Edwa (M) Badary (A) Sahel Selim (A) Sedfa (A) Abu Teeg (A) Manfalout (A) Dayrout (A) Abnoub (A) Ayaat (G) El Badrasheen (G) Osseem (G) Saff (G) Etfieh (G) North Giza (G) Hawamdeya (G) Mansheit El Qanater (G) Aqouza (G) Waraq (G) Wahat Bahareya (G) 12 Districts 16 Districts 17 Districts 5 Districts 50 Qift (Q) El Wakf (Q) Sennoures (F) Tamia (F) Nasser (BS) Somosta (BS) 4 District MHIS North Giza (G) Centers Established El Omrania (G) South Giza (G) El Haram (G) Markaz Giza (G) El Menya (M) El Fakreya (M) Tema (S) Samalout (M) Beni Mazar (M) El Balyana (S) Gharb Assiut (A) Shark Assiut (A) Deir Mowas (M) El Fath (A) El Kouseyah Dar El Salam (S) Saqolta (S) Geheina (S) Markaz Assiut (A) El Maragha (S) (A) Sohag (S) El Ghanayem (A) Tahta (S) Gerga (S) Akhmeim (S) El Mounshaa (S) Mallawy (M) Mattay (M) Maghagha (M) El Edwa (M) Badary (A) Sahel Selim (A) Sedfa (A) Abu Teeg (A) Manfalout (A) Dayrout (A) Abnoub (A) Ayaat (G) El Badrasheen (G) Osseem (G) Saff (G) Etfieh (G) North Giza (G) Hawamdeya (G) Mansheit El Qanater (G) Aqouza (G) Waraq (G) Wahat Bahareya (G) 10 Districts 7 Districts 17 El Warrak (G) El Agouza (G) El Badrashein Osseim (G) (G) El Hawamdeya El Ayat (G) (G) El Dokki (G) El Saff (G) Etfeih (G) Boulaq El Dakrour (G) El Wahat El Bahareya (G) Menshaat El Qanater (G) 7 Districts 15 Districts 7 Districts 29 Total

45 Contract Five Six Seven Year: Quarter: Task Ending: 12/31/01 3/31/02 6/30/02 9/30/02 12/31/02 3/31/03 6/30/03 9/30/03 12/31/03 3/31/04 6/30/04 9/30/04 12/31/04 3/15/05 10 Small Grants Awarded 17 Awards 7 Districts Wakf (Q) 33 Awards Qift (Q) 15 Districts Fayoum (F) Senoures (F) Tamia (F) Nasser (BS) Somosta (BS) Maragha (S) 18 Awards Moushaa (S) 7 Districts Sakolta (S) Tahta (S) Dar El Salam (S) Sohag city (S) Gerga (S) Assiut City (A) Fath (A) Koussia (A) Samalout (M) El Menya City (M) Beni Mazar (M) Deir Moas (M) Fekria (M) Bassateen Slum (C) Warrak (G) Ossim (G) Badrashein (G) Ayat (G) Giza (G) North Giza (G) Total 68 Awards Table 9. Phase Out Workshop Dates Governorate Phase Out Workshop Date Luxor June 23-24, 2002 Aswan July 17-18, 2002 Beni Suef February 23, 2003 Fayoum April 21, 2003 Qena May 7-8, 2003 Sohag March 15, 2004 Assiut September 1-2, 2004 El Menya September 28-29, 2004 Giza November 29-30,

46

47 IV. Task Accomplishments TASK ONE: Basic Package of Essential Services and Standards Defined I. MCH Component of the Basic Benefits Package Revised The MCH component of the BBP is an evidence-based package of services that combines best practices with the promotion of behaviors and interventions that are essential for saving lives and reducing morbidity among women and children (for the MCH BBP see Annex 9). The strategy of the HM/HC Project in implementing the MCH component of the BBP was to improve quality of care and increase access to and utilization of these services among those most in need, such as communities in rural areas and Upper Egypt. The MOHP is working together with its partners to ensure that: Health personnel receive the necessary training to improve their competency to the level of mastery against the criteria of the clinical performance monitoring indicators (concurrent assessment) and the resultant clinical Self-Improvement Plans (SIPs). Facilities are renovated and up to standard to provide quality services. Essential equipment and supplies are available. Management and supervisory systems are in place to support the provision of quality services. Communication and counseling materials are available to influence household practice. Health personnel are required to ensure that: Services are delivered and Facility Self-Improvement Plans (FSIP) developed according to standards of care as defined by the MOHP. Services are available to communities according to required schedules. Health personnel is available at the required times and provide care that respects the dignity of women and families. Efforts are made to encourage timely care-seeking by households. Communities are involved in improving household practices. Table 10. The 10 Elements of the MCH Component of the BBP and the Partner s Responsibilities MCH Components Responsibility of the Basic Benefits Package GOE Technical Assistance 1. Premarital examination and Family Planning Div., MOHP TAHSEEN counseling 35

48 MCH Components Responsibility of the Basic Benefits Package GOE Technical Assistance 2. Prenatal, delivery and postnatal care (essential obstetric care - basic and comprehensive) HM/HC Project, MCH Div., MOHP (screening and referral of STDs/RTIs) Curative Care Division, MOHP Family Planning Div., MOHP (diagnosis and treatment of STDs/RTIs) 3. Peri/neonatal care HM/HC Project, MCH Div., MOHP Curative Care Division, MOHP 4. Promotion of immediate and exclusive breastfeeding 5. Fortieth day postpartum check-up integrated visit for mother and infant 6. Children s preventive health services 7. Sick child case management 8. Reproductive health services HM/HC Project, MCH Div., MOHP HM/HC Project, MCH Div., MOHP Family Planning Div., MOHP HM/HC Project, MCH/IMCI Div., MOHP HM/HC Project, MCH Div., MOHP Family Planning Div., MOHP MCH Div. 9. Nutrition services HM/HC Project, MCH Div., MOHP HIO/SHIP 10. Counseling and health education on all of the above As indicated above JSI for EOC JSI to facilitate materials development JSI to facilitate coordination of implementation of MCH/PHC activities in target areas TAHSEEN for screening, referral, diagnosis and treatment for STDs/RTIs JSI JSI TAHSEEN for development and implementation of materials for FP services/counseling JSI to facilitate development of EOC postpartum care materials development JSI to facilitate coordination of implementation of MCH/PHC JSI collaborates and facilitates JSI collaborates and facilitates TAHSEEN JSI with SHIP and IEC Materials JSI TAHSEEN During the Option and Base periods a total of 75 districts with 253 facilities (attached in Annexes 10 and 11) received the package of essential inputs to improve obstetric and NC services. All facilities were assessed for their baseline compliance with the EOC and NC service standards, and SIPs were developed to upgrade services in each facility. Needed renovations were made and essential equipment and supplies were provided to meet standards. These facilities consist of 71 CEOC facilities (1 Teaching, 11 general and 59 district hospitals) of which 55 have NCUs in addition to 182 selected BEOC facilities.

49 263 facility managers were trained in hospital management systems skills. 782 physicians and 873 nurses received CBT on obstetric protocols; 1064 physicians (basic and advanced) and 386 nurses on NC protocols; and 682 lead trainers received training in clinical supervision skills using CBT methodology in TOT workshops. Table 11 summarizes the Basic MCH Package implementation in nine governorates and 75 cumulative districts. Table 11. Summary of the Basic MCH Package Implementation in Nine Governorates and 75 Cumulative Districts Facilities Training Governorate No. Selected No. of Renovations Completed/ Under Renovation No. of Commodities Completed No. of Clinical Lead Trainers (Attending Workshops) Management* (No. of Attendances) Managerial Lead Trainers No. of Service Providers (Attending Workshops) Aswan Luxor Qena Fayoum Beni Suef El Menya ,071 Assiut ,152 Sohag Giza ,026 Total , ,878 *Management training includes planning and monitoring, CQI, data use and interpretation and MMSS training workshops only. II. Service standards and clinical protocols upgraded, produced and disseminated During the Child Survival Project, a series of CBT modules and resources were initiated and then developed and refined by the HM/HC Project. Mother Care Project protocols and CBT modules for BEOC level, CEOC level, neonatal and support services, including nursing, were developed, field-tested, and continue to be revised and updated based on lessons learned, identification of harmful practices and substandard care, and strategies for minimizing these practices and improving the quality of care. Standardized publication templates are now used. Supporting materials such as data shows and CD presentations are now more user-friendly. Based on observable and measurable clinical indicators, Clinical Performance Monitoring Indicators (concurrent assessments) were streamlined and converted to a computerized format, so as to facilitate the clinical/nursing self-improvement planning process addressed in the nine-part teleconference series. Retrospective Assessment Indicators were expanded to include high-demand conditions such as presumptive normal labor, cesarean section and bleeding before twenty weeks. Perinatal Medical Records were distributed and field-tested with feedback from the service providers. Currently, this feedback is being integrated and incorporated into the records. A final draft of the Perinatal Medical Records was submitted to the Curative Sector at the MOHP. Upon approval of the MOHP, they will be printed in the MOHP print shop and distributed countrywide. A list of all HM/HC Publications is attached in Annex

50 III. Implementation of the MCH component of BBP in 75 cumulative districts A standardized implementation process was initiated in the Base Period (March15, 1998 November 30, 2001) and continued through the subsequent project years (September 16, 2001 March 14, 2005). Implementation Steps The MotherCare Pathway to Care and Survival model was used as the initial framework for the technical analysis, and the basis for the design of interventions. The overall concept of the Pathway to Care and Survival focuses on the fact that approximately 15% of pregnant women in Egypt will have a complication and/or life-threatening emergency, which cannot be prevented or predicted. The requirements to ensure the survival of mother or child are given in 10 steps. The objectives of the Project were analyzed in reference to these 10 steps and are summarized in Table 12. The steps address problems that can lead to maternal, neonatal, and child mortality, as well as adolescent morbidity. Table 12. The 10 Steps of Implementing the MCH Component of the BBP No. Steps Quality Activities Tools Responsibilities 1 Prepare a district profile to serve as baseline data and create a framework for planning and implementing activities 2 Conduct assessment of district hospital CEOC/BEOC facilities for clinical services and management system services Baseline assessment Identification of catchment areas PHC units/beocs selection Utilization District Indicators Task 1 Task 3 HM/HC, QA unit JSI field office management specialists Baseline assessment District hospitals: Obstetric Departments, Neonatal Units, Support Services (blood bank, lab, OR, CSSD, EMS, anesthesiology, IC) PHC units/beocs Clinical performance monitoring indicators ( retrospective assessment ) Managerial performance assessment tools Inputs checklists for CEOCs, NCUs, PHC units/beocs Task 1 Task 3 HM/HC, QA unit JSI field office management specialists

51 No. Steps Quality Activities Tools Responsibilities 3 Develop a Facility Self- Improvement Plan 4 Initiate the clinical service improvement activities and implement a full competencybased training program for hospital personnel 5 Procure needed equipment and supplies, and carry out renovations 6 Train district and governorate level management/ supervisory teams (GSMCs/DSMCs) Initial activity based on baseline assessment District hospitals: Obstetric Departments, NCUs, Support Services (blood bank, lab, OR, CSSD, EMS, anesthesiology, IC) PHC units/beocs Concurrent assessment Retrospective assessment Case records CBT methodology Assessment using QA Service Standards: District hospitals: Obstetric Departments, NCUs, Support Services (blood bank, lab, OR, CSSD, EMS, anesthesiology, infection control) QA Planning and management Service Improvement Fund Self- Improvement formats for Inputs Clinical performance Managerial performance QA clinical checklist Clinical/Facility Self- Improvement Plans CBT modules, protocols, flow charts, resources Clinical performance monitoring indicators ( concurrent assessment ) Retrospective assessment indicators Teleconference resources Equipment Equipment operation and maintenance training Supplies Renovations Equipment Supplies Renovations Task 1 Task 3 Task 2 coordinators, specialist, master trainers/clinical supervisors Facility lead trainers/supervisors Facility SMC HM/HC MOHP counterparts Task 1 Task 2 Task 11 Task 1 Task 3 GSMCs DSMCs 39

52 No. Steps Quality Activities Tools Responsibilities 7 Mobilize community health committees to identify health needs 8 Train FSMC team in practical ways to improve facility system 9 District SMCs develop, implement and review Annual Work Plans 10 Support local NGOs with small grants Community Needs Assessment Training Workshop: QA Commodity management Planning and management Service Improvement Fund Quarterly monitoring reports HM/HC package PHC/BEOC units: PHC programs District hospitals: Obstetric departments NCU Support Services (blood bank, lab, OR, CSSD, EMS, anesthesiology, infection control) Pre-award assessment for NGOs (institutional and financial assessment) Effective home visits Indicators assessed skills, knowledge, behavior and impact of HM/HC interventions on the community Quality and Management Training Manual: Inputs Clinical performance Managerial performance Utilization General health status (maternal and neonatal mortality statistics) Inputs, process, outcomes Clinical process Pre-award checklist Task 7 Community Health Committees Outreach workers Task 1 Task 3 Task 2 Task 3 DSMCs HM/HC Project JSI field office management specialists Task 10 JSI field office community development specialists Selecting and upgrading BEOC, CEOC and NC facilities 1. District profile development Preparation of the district profile started with collecting data on the population size, distribution, local administrative units, district map, and existing health facilities for each administrative unit. The selection method for health facilities is based on requirements defined by the World Health Organization (WHO). WHO states that for every 500,000 people, there should be at least one comprehensive obstetric care unit (CEOC) (DH/GH hospital) responsible for delivery and pregnancy cases that require anesthesia, blood transfusions or surgical interventions and at least four other facilities (BEOC) that provide basic services for normal delivery and pregnancy.

53 2. Selecting BEOC Facilities In 2002, it was decided that the first priority would be to select BEOC facilities which had already been renovated and had delivery rooms. The HM/HC Project would not be involved in any major renovation because all facilities would be upgraded by the MOHP in the next two to three years. Minimum interim renovations would be implemented in units which had yet to be renovated. Four selection criteria for BEOC facilities were used based on lessons learned in the Base Period: Catchment population size Service utilization and access Deprived/underserved area Training needs A total of 182 health care facilities were upgraded to provide MCH and BEOC services (primarily normal delivery care and referral). This included rural health units, integrated hospitals, maternity centers and urban health centers. The size of the catchment area populations ranged from 11,000 to 116,000 inhabitants with an average size of 60,000. Emphasis was given to the more remote areas of each governorate to ensure that populations living in isolated areas would be served. Of these, 43 facilities had existing delivery rooms. The remaining 139 facilities did not have formal delivery rooms, but space was available to establish a delivery room. Facilities were assessed using two checklists: Essential Obstetric Care Protocols and Maternity Hospital QA Service Standards. Substantial inputs in renovation and commodities were needed to establish an adequate level of compliance with service standards. The necessary commodities were provided based on the HM/HC Project Commodity Checklist. Training of the staff was the same in all facilities with or without formal delivery rooms. 3. Selecting CEOC and NC Facilities District hospitals are mandated to provide comprehensive EOC and specialized NC to their district populations. General hospitals serve as the referral hospital for the entire governorate. A team consisting of JSI staff under the HM/HC Project and district health office staff carried out assessments in 75 districts of the nine target governorates, including 71 CEOC facilities and 55 NCUs. The JSI assessment team with representatives from the Curative Care Department of the MOHP met with the undersecretary of each governorate who assigned counterparts to accompany the team during their assessment visits. These assessments used the HM/HC Project s Comprehensive Essential Obstetric Care and Neonatal Care Service Standards and Monitoring Checklists. The assessments covered: staffing; planning; maintenance and repair; management of pharmaceuticals and clinical supplies; forms and records; referral systems; availability of reference materials and self-monitoring and evaluation procedures. The outcome was the development of a FSIP by representatives of the newly established FSMC. The proposed FSIP was discussed in detail with team members responsible for corrective actions (detailed individual strategies, including staff training are developed for upgrading standards of care in addition to some essential renovations and 41

54 procurement of basic equipment, furniture and supplies,). Follow-up of the implementation of the FSIP was completed by the FSMCs with assistance from the HM/HC-JSI team and other representatives of the MOHP. The FSMCs are responsible for implementing, monitoring and updating their plan to reflect improvements or, in some instances, new problems encountered. 4. Upgrading of Facilities The upgrading of the BEOC, CEOC and NC facilities started with essential renovations and the procurement of basic equipment, furniture and supplies in addition to developing detailed individual strategies, including staff training for upgrading the standards of care in each facility (CEOC facilities often included several departments, including the obstetric/gynecology and neonatal departments, operating room, central supply and sterilization, and laundry room). Annex 13 lists the facilities renovated by USAID/JSI, USAID funds and by the MOHP/GOE. Table 13 shows the status of health facility improvements by governorate. Maabda IH before renovation Maabda IH after renovation Table 13. Status of BEOC, CEOC, and NC Hospital Improvements by Governorate No. of Facilities Having Completed/Undergoing Physical Governorate Upgrading Renovations Commodities BEOC CEOC NC BEOC CEOC NC Aswan Luxor Qena Fayoum Beni Suef El Menya Assiut Sohag Giza Total * Note: The following CEOC facilities are under renovation by the HM/HC Project, MOHP: Assiut governorate: Sahel Selim DH, Abu Teeg DH, Manfalout DH, Dayrout DH, Abnoub DH El Menya governorate: Mattay DH Giza governorate: Ayaat DH, Badrasheen DH, Etfieh DH, Tahrir GH, Osseem DH, Imbaba GH, Hawamdeya DH and Wahat Bahareya DH *CEOCs do not total 75 as Fayoum governorate has hospitals in only five of six districts and El Fath District in Assiut, and Manshet El Qanater and Waraq in Giza have no district hospitals.

55 Medical commodities were provided for all 71 CEOC facilities in addition to the BEOC and NC facilities. Commodity assessments were completed by facility staff, JSI field office staff and/or clinical supervisors using the approved commodity requirement forms for each of the facilities being upgraded. Based on the commodity assessment results, required commodities were delivered to the facilities by the JSI subcontractor TransCentury Associates (TCA). Delivery of commodities was made in two or more batches. The first delivery included missing life-saving equipment, furniture and supplies that were to be used in the interim areas. Final shipments included all remaining commodity requirements after completion of renovation activities. JSI field office staff and clinical supervisors worked with the facilities to ensure that all items were set up in the clinical departments per the protocols and standards. Training in the operation and maintenance of equipment was provided. Improving obstetric, neonatal and support services 1. Training of Lead Trainers Top performers of the EOC and NC training program who worked in general or district hospitals were selected and trained as clinical supervisors/lead trainers for the district. Selected clinical supervisors/lead trainers first completed a TOT workshop in CBT methodology, supervisory skills and in the use of QA clinical concurrent assessments. Both the EOC and NC physician and nurse lead trainers were supervised by master trainers and clinical supervisors in clinical and supervisory skills during the period of OJT, allowing them to reach the level of basic or mastery competency. EOC classroom training This strategy has proven successful in maintaining a high level of care with improved skills. 2. Obstetric Care A cumulative total of 782 physicians, including 441 in the Option Period, have completed the 9- day EOC classroom course. This didactic training was followed by supervised OJT, during which obstetricians were able to practice the knowledge acquired during th9-day workshop in a hospital setting with patients under the supervision of their trainers (JSI clinical supervisors/lead trainers). EOC on-the-job training During the Option Period, the OJT focus was on the development of competency in the skills needed to manage women with problems during pregnancy, labor and puerperium. Concurrent assessments were used to monitor 43

56 the progress made by the trainees towards attaining competency of the clinical skills needed to reduce maternal morbidity and mortality. EOC training was also provided for 873 nurses who further received OJT in obstetric care skills. A total of 3,306 supervisory days for physicians and 2,499 days for nurses were conducted. During the Option Period, the training of 133 EOC lead trainers was completed. Table 14: Training of EOC Physicians and Nurses and Midwifery Skills for Nurses Governorate Workshop Participants EOC Nurses EOC Physicians Midwifery Skills for Nurses OJT - Basic Competency OJT - Mastery Workshop Participants OJT - Basic Competency OJT - Mastery Workshop Participants OJT - Basic Competency Aswan Luxor Qena Beni Suef Fayoum El Menya Assiut Sohag Giza Total Neonatal Care OJT - Mastery During the Option Period, 717 NC physicians received basic and advanced courses. A cumulative total of 1,064 attendants, including 532 physicians, have completed the CBT basic training and 532 completed the advanced courses. 386 NC nurses attended NC training. During the Option Period, master trainers spent three days/month in level II units and four to six days/month in level III units to ensure through OJT that the health providers could effectively implement the skills acquired during the training courses. Neonatal on-the-job training Supervisory visits emphasized competent implementation of all protocol items. A total of 1,735 supervisory days for physicians and 1,184 days for nurses were conducted. During the Option Period, the training of 119 NC lead trainers was completed. OJT was monitored on a quarterly basis through a series of checklists that evaluated managerial and clinical aspects of care (input and clinical performance checklists). Clinical concurrent assessments were used to monitor individual health provider s performance within the CBT methodology.

57 Table 15. Cumulative Number of NC Health Providers Trained in the Target Governorates NC Nurses NC Physicians Governorate Workshop Participants OJT - Basic Competency OJT - Mastery Workshop Participants OJT - Basic Competency OJT - Mastery Aswan Luxor Qena Beni Suef Fayoum El Menya Assiut Sohag Giza Total Training for Neonatal Intensive Care Unit IV Fluid Preparation and Mixing Training for intravenous fluid therapy and mixing was conducted for the staff of 63 NCUs. Staff from 11 NCUs received IV training during Phases III and IV of the Option Period. In 22 units, teams received their training through a conjoint program of the MOHP and the US Naval Medical Research Unit (NAMRU) during Phase I Option Period. For the remaining 41 units, the interventions were carried out as a part of the OJT. A total of 1,501 health providers received this training. 4. Emergency The initial management of emergency obstetric and neonatal cases provided in the majority of emergency departments in Upper Egyptian hospitals is substantially substandard. In many instances such service does not even exist. This fact has resulted in the delay of timely resuscitation with a subsequent impact on maternal and neonatal mortality. The success of the initial pilot model encouraged the MOHP to expand this activity to other facilities. Encouraging results were obtained as evidenced by steady improvements in QA service standards and concurrent assessment scores within each facility. Emergency training has been provided for 379 physicians and 322 nurses. Approximately 170 supervisory days for physicians and 140 days for nurses were conducted. Table 16: Training of Emergency Services for Physicians and Nurses Emergency Services Nurses Emergency Services Physicians Governorate Workshop Participants OJT - Basic Competency OJT - Mastery Workshop Participants OJT - Basic Competency OJT - Mastery Aswan Luxor Qena Beni Suef Fayoum El Menya

58 Governorate Emergency Services Nurses Workshop Participants OJT - Basic Competency OJT - Mastery Emergency Services Physicians Workshop Participants OJT - Basic Competency OJT - Mastery Assiut Sohag Giza Total Blood Bank The package of HM/HC services has been refined and expanded to include blood bank services. This activity aims at facilitating the availability of blood and blood components and promotes the timely and competent use of blood volume expanders. Blood bank services training has been provided for 164 physicians. Approximately 300 supervisory days for physicians were conducted. Table 17: Blood Bank Services for Physicians Governorate Workshop Participants Blood Bank Services for Physicians OJT - Basic Competency OJT - Mastery Aswan Luxor Qena Beni Suef Fayoum El Menya Assiut Sohag Giza Total Anesthesia Inappropriate use of anesthesia (e.g., general anesthesia for obstetric cases) is an avoidable factor of maternal mortality according to the ENMMS The training focused primarily been on competencies related to setting up an appropriate mechanism for operating and maintaining modern anesthesia machines, ventilators and monitors to provide safe obstetric anesthesia and managing complications related to hemorrhage and anesthesia. Anesthesia training has been provided for 243 physicians. A total of 679 supervisory days for physicians were conducted. Anesthesia workshop

59 Table 18: Anesthesia Training for Physicians Governorate Workshop Participants Anesthesia for Physicians OJT - Basic Competency OJT - Mastery Aswan Luxor Qena Beni Suef Fayoum El Menya Assiut Sohag Giza Total Infection Control Lack of infection control (IC) remains a significant challenge to quality of care, with genital sepsis ranked third among the major direct causes of maternal death as noted in the ENMMS Initial assessments of IC in target facilities revealed extremely poor IC practices, poorly managed hospital waste and inadequate sterilization procedures. Kouseyah Hospital OR scrub area before renovation The main objective of the HM/HC Project s IC strategy is to reduce the probability of infection to both mother and child with a consequent reduction in maternal and child mortality rates. During the Option Period, central MOHP IC representatives became actively involved in interventions. OR and CSSD training has been provided for 1,213 nurses. Approximately 2,000 supervisory days for nurses were conducted. Table 19: OR and CSSD Trainings for Nurses Kouseyah Hospital OR scrub area after renovation OR and CSSD Nurses Governorate Workshop OJT - Basic Participants Competency OJT - Mastery Aswan Luxor

60 Governorate Workshop Participants OR and CSSD Nurses OJT - Basic Competency OJT - Mastery Qena Beni Suef Fayoum El Menya Assiut Sohag Giza Total Laboratory The package of HM/HC services has been expanded to strengthen the laboratory services, which undoubtedly play an important role in supporting all EOC, NCU and other clinical services. The emphasis of the interventions was on improving the laboratory back-up in the management of major causes of maternal and neonatal mortalities. This activity has been done in collaboration with the MOHP Central Department of Laboratory Services. Laboratory training has been provided for 279 physicians. Approximately 120 supervisory days for physicians were conducted. Table 20: Laboratory Training for Physicians Governorate Workshop Participants Laboratory for Physicians OJT - Basic OJT - Mastery Competency Aswan Luxor Qena Beni Suef Fayoum El Menya Assiut Sohag Giza Total BEOC Training for Physicians The training interventions at BEOC facilities started with a six-day BEOC CBT workshop. This classroom training provided the primary health care physicians with knowledge needed to carry out practical skills with special emphasis on antenatal care, postpartum care, normal delivery skills, first aid and referral of complicated cases during pregnancy, labor and puerperium. These workshops for primary health care physicians were enriched with support materials such as the BEOC protocols and guidelines, handouts and flowcharts.

61 These materials also helped in teaching skills necessary for rapid diagnosis and appropriate clinical case management. Table 21: BEOC Training for Physicians Governorate No. of Trainees from BEOC Facilities Fayoum 9 Sohag 36 El Menya 35 Assiut 53 Giza 40 Total Training in Midwifery Skills for Nurses The HM/HC Project implemented an assessment of the midwifery training course. The following recommendations were made: Bring the midwives back for follow-up training Add counseling as part of the training as well as an introduction to the HM/HC counseling materials Include midwives in the Interpersonal Communications and Counseling training Develop a monitoring system to assess their performance Add the taxonomy of terms to the various training courses for health providers HM/HC-JSI has conducted 2 courses for training nurses in midwifery skills for 25 nurses in El Menya and 23 nurses in Assiut governorates. 11. MCH Training for Physicians and Nurses During the Option Period, a 4-day course on maternal and child care was conducted for PHC physicians and nurses working in the selected BEOC facilities. Each course covered maternal and child health problems, including antenatal, delivery and postnatal services; training on proper filling of the mothers health cards; and proper feeding of both the mother and the child (including breast-feeding and micronutrients). Training on child care included growth and development of the child at different ages; detection and management of handicaps; and training on filling out the child health card. MCH training covered 23 districts in El Menya, Assiut and Giza and was attended by 153 physicians and 202 nurses. Nursing on-the-job training 49

62 12. Training for Dayas During Phase I of the Option Period several refresher training courses for dayas were conducted in the Fayoum, Beni Suef, and Qena governorates. Each 5-day training course covered the various topics related to antenatal, perinatal, and postnatal care including proper maternal nutrition during pregnancy, care of the newborn, breast-feeding, and lactation. Health messages about the hygienic practices in the households included infection control steps and precautions to be followed when conducting home deliveries to guard against maternal and neonatal sepsis. Daya training There was a great emphasis on the role of dayas as a member of the health team to provide a positive collaborative environment from which the woman and her infant would benefit the most. During these courses daya license renewal was discussed and the necessary logistic arrangements were planned for. 147 dayas were trained in Fayoum, Qena and Beni Suef. Improving the utilization of obstetric and neonatal center services The HM/HC Project s inputs into each facility are intended to improve treatment and outcomes, and increase utilization of the services as the center s reputation improves. These interventions should lead to a reduction in maternal and neonatal mortality. The major emphasis of the HM/HC Project in the maternity centers was on training and supervisory OJT. The specific focus was to set up and encourage an increase in the utilization of normal, safe, clean delivery services in BEOC facilities in order to take this load off district hospitals. The interventions also included a community component. Communities were encouraged to utilize the maternity centers for normal antenatal, delivery and postnatal services so as to reduce the demand for these services on district hospital staff. After upgrading takes place, there is a certain lag time before the improved facilities and services are recognized by the population. The utilization numbers are not expected to increase significantly within the first few months. The full impact of Phase III and IV upgrades should be reflected in the utilization data of Special quality of care improving activities 1. Private Sector Research has shown that both physicians and patients need to be made more aware of the risks associated with the obstetric and NC services provided at private clinics where both equipment and staffing are often inadequate (JSI Base Period Operational Research Report No. 4 Standards of Care in the Private Sector). The private sector activity was created to support and enhance private sector maternal and neonatal health services in During the Option Periods, 2-day EOC courses were conducted for the private sector; a total of 159 physicians were trained. One-day courses were conducted for pharmacists from the private sector. QA standards and self-assessment checklists have been developed for use in the private clinics. A cumulative total of 734 physicians and 1,127

63 pharmacists, all from the private sector, were trained. The HM/HC Project also produced information, education and communication material on EOC and NC for distribution to the private sector. The material was also distributed to 628 pharmacists who were trained during the Base Period. 2. Obstetric Referral System The implementation of the referral system is a fundamental element of the Health Policy Reform Project. Although this Project has established a comprehensive referral system, the system is not currently operational in all areas. The HM/HC Project is now introducing three basic referral forms in those areas that have not yet been reached. In this way, all areas will have at least basic referral coverage providing greater assurance that complicated obstetric cases will be transferred to higher level facilities where they can receive the necessary care. 3. Teleconference Eight teleconference sessions were developed and implemented during the Option Period to improve clinical performance and case management by Egyptian physicians based on cases presented by physicians from target MOHP facilities. The sessions were implemented in collaboration with the USAID through the Institute of International Education/Development Training 2 Project (IIE/DT2) and the technical medical assistance provided by the George Washington University Medical School s Technical Advisory Team in Maternal/Fetal Medicine and with logistical assistance from the Neonatal Department of Cairo University Medical School. The sessions aimed at assisting Egyptian physicians in accurately identifying and reducing avoidable factors contributing to maternal and perinatal/neonatal mortality and acted as an educational and training tool for medical house officers, residents and junior specialists. The sessions were put on CD and disseminated throughout MOHP training centers as well as the faculties of medicine in Egyptian universities. The sessions also introduced and emphasized the concept of perinatal care by involving the neonatologists and obstetricians as one team in discussing case management and outcome. A total of eight medical teleconferences were conducted and shot as live events. An RFP was developed and sent out to production houses. One production house was selected and contracted to work on the production of the teleconference video tapes. Teleconference video tape covers were designed and the tapes were distributed according to a distribution plan. A total of 1500 teleconference CDs were printed and distributed. An agreement was reached with the Horus channel to air the series of medical teleconferences in 30 minute episodes during the telemedicine program. Perinatal Medical Teleconference Session Plan and Topics During Phase III of the Option Period, dissemination/utilization workshops for local clinical supervisors/lead trainers were conducted on how to utilize the Perinatal Medical Teleconference videotapes according to the CBT Facilitator Module. The purpose of the Facilitator Module is to disseminate the teleconferencing activity to service providers all over Egypt. This module was revised and finalized during the dissemination/utilization workshops, based on field testing results. A series of workshops were conducted to train clinical supervisors/lead trainers in how to utilize 51

64 the teleconference package effectively as well as the Facilitator Module that outlines how to use the teleconference videotapes to supplement existing training resources. Table 22 shows the number of clinical supervisors/lead trainers trained in these workshops. Table 22. Teleconference Workshops for Clinical Supervisors/Lead Trainers Governorate From To No. of Participants Assiut (1st group) June 20, 2004 June 22, El Menya (1st group) June 28, 2004 June 30, Assiut (2nd group) July 20, 2004 July 22, El Menya (2nd group) July 26, 2004 July 28, Giza (1st group) August 24, 2004 August 26, Giza (2nd group) August 29, 2004 August 31, Total 97 TASK TWO: Pre/In-Service Training System Designed to Disseminate Standards to Public and Private Providers I. Assist in the coordinated implementation of IMCI training in at least one additional target governorate Implementation Process John Snow, Inc., in collaboration with the MOHP/IMCI Program, assisted in the implementation of an expansion plan to introduce a variety of IMCI activities in an additional 11 districts during the period of September 15, 2001 to September 14, 2002.This resulted in a total of 17 districts with IMCI activities. Six of the 11 districts were located in the Fayoum, Beni Suef, and Qena governorates and the remaining five districts were located in the El Menya and Sohag governorates. The following table presents a list of the 17 districts in which the IMCI Program was implemented. Table 23. Governorates and districts implementing IMCI activities under the Memorandum of Cooperation Governorate Beni Suef El Menya* Fayoum Sohag* Qena Total = 5 Governorates * Additional governorates District Beba, El Fashn, Ehnasia**, Somosta** Mattay, Maghagha, Beni Mazar Ebshway, Etsa, Sennoures**, Tamia** Akmeim, El-Maragha Armant, Qous, Quft**, El Wakf** Total = 17 Districts ** Additional districts

65 JSI assisted the IMCI Program in implementing the following activities in the 17 targeted districts Selection of districts Selection criteria were used to select the governorates and districts in order to start implementing the IMCI program. These criteria included the commitment of health directorate and district leaders to implement IMCI activities, the availability of manpower to work as trainers and supervisors, the presence of low health indicators for children under five years old and the pre-existing cooperation among various health care projects in the governorates. Completion of situation analysis for health facilities Following the selection process, situation analyses were conducted in all the new districts to collect data and build a database including demographic data, and implemented systems including supervisory, follow-up, health information and drug distribution. Also, the data collected included information about the resources in each health care facility concerning manpower, physical structure, availability of equipment, supplies, and essential drugs. Local teams from the selected districts were trained in data collection, form completion, consistency of collected and submitted data, and submission procedures. The central IMCI Program staff held meetings with governorate and district staff to analyze the collected data and ensure its consistency. Orientation of governorate and district key personnel about the IMCI Program Orientation workshops were held for governorate and district key personnel. The objective of the orientation was to introduce the IMCI Program including its concept, objectives, components, and implementation steps in addition to preparing for IMCI district planning workshops. Implementation of district level planning workshops Needs assessments were developed for each district based on the results of the situation analyses and used as a foundation for planning IMCI activities in each district. The workshop objectives included preparing practical and feasible operational IMCI Program implementation plans in the selected health care facilities with the participation of districts and governorate representatives and ensuring ownership at the district and governorate levels by using a participatory planning approach and building district level planning capacity. IMCI skills training for physicians and nurses One of the key elements of the IMCI strategy is the integrated case management training course for first-level health care physicians. The case management training course combines classroom and hands-on clinical practice, training physicians in effective management practices for sick children from birth to five years of age. IMCI physicians: on-the-job training 53

66 Physicians were trained in updated routine immunization schedules and skills, micronutrient supplementation, breast-feeding promotion, and counseling to resolve feeding problems. A four-day course provided training for outpatient nurses who care for sick children in the IMCI Program. The course combined classroom sessions with hands-on clinical practice to teach nurses effective nursing management skills for sick children from birth to five years of age. Implementation of follow-up sessions to reinforce IMCI skills and identify and resolve problems faced by the health care staff The second component of the IMCI training course is post-training follow-up visits. Follow-up visits were conducted by an IMCI team trained in IMCI techniques, facilitation, and follow-up visits. The follow-up visits are generally scheduled to take place within four to six weeks of the initial training. The objectives of the follow-up are to gather information on health care provider performance and conditions that influence performance to improve IMCI implementation, reinforce IMCI skills and help health care providers utilize these skills in their clinical work to solve the case management problems they face. Achievements in training and follow-up Table 24 presents data related to the achievements in the training and follow-up in target districts. Table 24. Data Related to the Achievements in the Training and Follow-up in Target Districts Activities Governorate District Numbers Attended Sohag Maragha and Akmeim 9 Training for Mattay, Beni Mazar and El Menya Data Maghagha 14 Collection Fayoum Tamia and Sennoures 9 Beni Suef Ehnasia and Somousta 9 TOTAL 41 Sohag Maragha and Akmeim 27 Mattay, Beni Mazar and IMCI El Menya 49 Maghagha Orientation Workshops Fayoum Tamia, and Sennoures 22 Beni Suef Ehnasia and Somousta 22 Qena Keft, and El Wakf 19 TOTAL 139 Sohag Maragha and Akmeim 14 District Planning Workshops El Menya Mattay, Beni Mazar and Maghagha Fayoum Tamia, and Sennoures 13 Beni Suef Ehnasia and Somousta 13 Qena Keft and El Wakf 12 TOTAL 69 IMCI Case Sohag Maragha and Akmeim 44 17

67 Activities Governorate District Numbers Attended Management for Physicians El Menya Mattay, Beni Mazar, Maghagha and Samalout Fayoum Etsa and Ebshway 45 Qena Quos, Armant, Keft, and El Wakf 45 TOTAL 209 Sohag Maragha and Akmeim 48 IMCI Case Mattay, Beni Mazar, Maghagha El Menya Management and Samalout 75 for Nurses Fayoum Etsa and Ebshway 45 Qena Quos, Armant, Keft, and El Wakf 45 TOTAL 213 IMCI Follow- Up after Training for Physicians and Nurses Sohag El Menya Qena Maragha and Akmeim Mattay, Beni Mazar, Maghagha and Samalout Quos, Armant, Keft, and El Wakf 75 The follow-up for Sohag governorate covered 36 facilities; 41 physicians and 45 nurses were interviewed. The follow-up for El Menya governorate covered 62 facilities; 67 physicians and 66 nurses were interviewed. The follow-up for Qena governorate covered 32 facilities; 25 physicians and 32 nurses were interviewed. Fayoum Etsa and Ebshway The follow-up for Fayoum governorate covered 40 units; 40 physicians and 42 nurses were interviewed. II. Monitor QA scores of Neonatal Centers in Target Governorates Improved Quality of Neonatal Care The HM/HC quality assurance monitoring system is based on the premise that a facility cannot improve what it is not able to measure. Changes to improve quality cannot be made in total ignorance of the causes of poor performance and with a limited understanding of the process of care. The development of a full package of evidencebased guidelines for care processes and standards that describe related inputs and expected outcomes is a good entry point for objectively measuring the quality of care. The monitoring function consists of a process of regular collection and analysis of quantifiable data. The system provides valid and reliable data that enhances fact-based decision-making by facility leaders, which is a fundamental requirement for quality Health provider training 55

68 improvement and service design/redesign. The monitoring system is intended to support an information system that plays a key role in each stage of a management process at both the departmental and facility level. Monitoring activities cover both managerial and clinical processes, together with practitioner and facility performance and utilization. Important clinical and managerial processes are under continuous review and provide feedback about performance for further improvement, an activity that is integrated into daily tasks. Monitoring activities follow the same logic as the standards. They are divided into hospital managerial performance and departmental performance, which is further subdivided into departmental managerial performance and departmental clinical performance. Clinical performance is monitored concurrently for all departments. In addition, clinical performance is monitored retrospectively through record review in neonatal and obstetric departments, which are the main focus of the HM/HC Project. The methodology for improving the quality of neonatal and maternal health care has evolved rapidly during the life of the HM/HC Project in response to a growing demand for proven quality. From its inception in 1998, the Project set standards for the minimal required resources or inputs for care provision and focused on improving the competency of health care providers. The quality assurance activities were limited to inspecting the availability of these inputs on a quarterly basis and to solving problems of non-compliance. These activities began in obstetric departments and were expanded shortly thereafter to neonatal units. By 2000, efforts were made to focus on the process of care as the main priority, while ensuring that compliance with standard and individual performance was maintained. This shift in emphasis grew out of the realization that the provision of different resources does not necessarily ensure their effective, efficient use and consequently may not lead to quality improvement in patient care. By the end of 2001, records were audited (retrospective assessment) for data collection related to aspects of care provision that significantly affected neonatal and maternal mortality. Starting in 2002, the system was fully established in neonatal and obstetric departments. During the same year, other tools were developed to describe and measure performance in different departments, and to measure hospital managerial performance. Thus, the program expanded to include improvement in non-clinical care management, as well as clinical care. Implementation of the QA program started by establishing a supervisory system that includes clinical on-the-job training. The clinical supervisors were selected from different universities and the team was gradually expanded to involve MOHP neonatal unit staff. The clinical supervisors currently Neonatal classroom training include 31 physicians and 15 nurses. All members of the clinical supervisory system received a six-day Training of Trainers (TOT) course for competency-based training methodology and were orientated to the input and clinical performance QA checklists. The MOHP staff both at the central and governorate levels now plays a major role in the QA process. They are expected to maintain the same supervisory system after the

69 Project s end. The supervisory system covers each hospital; three days a month for district hospitals and six days a month for general hospitals, for a minimum of 12 months. Phase-out is directly related to individual facility needs. In addition to providing technical assistance in the implementation of protocols, clinical supervisors demonstrate neonatal clinical procedures and train health providers on using the performance checklists. Checklists are used as a self-assessment tool to calculate compliance scores and assist in designing performance-based improvement plans. At the end of each visit, clinical supervisors submit a trip report summarizing the achievements, constraints and actions that need to be taken. The supervisor attaches a facility improvement plan that is updated monthly by the facility management team and higher authorities as needed. The implementation of the QA program resulted in measurable improvements in quality of care provided in neonatal care units. Overall facility compliance with NC service standards increased from 65 percent in 2000 to 89 percent in These improvements in service standards regarding 96% administration, clinical 100% Base Line 2004 Q2 environment and equipment 90% 78% and supplies are reflected in 75% 80% the higher quality of care 67% 58% 70% provided in all NCU patients. Figures 6 and 7 compare the 60% 50% 45% baseline and end-of-project 50% 37% average compliance with 40% 30% clinical protocols scores for 30% the 55 NCUs. The scores are based on patient record 20% reviews of all admissions by 10% HM/HC clinical supervisors. 0% History taking Examination Investigations Monitoring during stay Treatment Figure 6. Domains of Care: Proportion of Neonatal Care Unit Cases Managed According to Clinical Protocol 80% Formatted: Font: 7.5 pt, Bold Formatted: Font: 7.5 pt 2004 Q2 Base Line 80% 76% 73% 72% 74% 70% 63% 60% 47% 49% 50% 39% 40% 30% 21% 20% 12% 10% 8% 5% 0% Asphyxia Sepsis Prematurity Hyperbilirubinemia Respiratory Distress Figure 7. Proper Management of Specific Diseases/Conditions: Proportion of Neonatal Care Unit Cases Managed According to Clinical Protocol IDM 57

70 Increased Coverage and Utilization of Essential Neonatal Care The success of the QA program resulted in increased coverage and utilization of essential neonatal care units. Table 25 shows the admission and mortality data of neonatal units in the nine target governorates. Neonatal center admissions in the nine target governorates increased by 150 percent between 1999 and 2003, representing a total numerical increase from 6,149 to 15,355 cases in the total 55 NCUs. The utilization rate in the nine Upper Egyptian governorates tripled from 11.6/1000 live births in the year 1999 to 25.7/1000 live births in the year Table 25. Utilization of 55 Neonatal Care Units in the Target Governorates, Total Registered Births Number of NCU Admissions Utilization rate (NCU admissions/1000 live births) Estimated Governorate Neonatal Deaths (34/1000) Number of NCU Deaths (% of admissions) NCU mortality % of total neonatal mortality Number of Preterm Admissions (% of admissions) , , , , ,403 6,149 8,844 10,700 11,584 14, ,986 19,754 20,072 20,502 18,700 1,306 (21%) 1833 (21%) 1878 (17.5%) 1894 (16%) 2,402 (15.6%) 7.26% 9.28% 9.35% 9.24% 12.84% 2,896 ( 47%) 4,138 (47%) 4986 (46.5% 5,482 (47%) 6,778 (47.8%) The increased utilization rate reflects the integrated intervention approach including community and facility based components. Not only has community awareness improved regarding signs of newborn illnesses, supply and access have increased through newly constructed neonatal units and the larger number of available cribs/incubators as a result of the upgrading of existing facilities and the improved nurse/patient ratio in NCUs. The CBT of health providers, supported by a supervisory system, also had a direct effect on the quality of service provision in the units and was associated with a steady improvement in survival rates. These improvements encouraged neonatal and Ob/Gyn providers to increase referral of cases to the units. The adoption of an integrated perinatal approach by the hospitals Ob/Gyn and neonatal departments further fostered the involvement of pediatricians in high-risk deliveries and increased direct referrals to neonatal units. Thirty-six percent of NCU admissions in

71 2003 were born in the same facility, up from 31 percent in 1999 (not shown in table). The increase in inborn admissions also indicates that more high risk pregnancies and complicated deliveries are being referred to the hospitals for care. The rate of survival increased over time as did the proportion of facility-based neonatal mortality when compared to the total neonatal mortality for the same time period. In the figure below the increase in rate of admission/1000 live births is associated with a consistent decline in mortality of neonates admitted to the 55 units. There is another encouraging utilization indicator presented graphically in the figure: A notable increase in the proportion of neonatal deaths occurring in the facilities demonstrates an increase in the access of high acuity cases to the neonatal units. Ideally all neonatal deaths should be occurring in hospitals and not in homes, but the current percentage of 12.8% in 2003 represents a 77% increase over the baseline rate of 7.26% in 1999, undoubtedly an encouraging trend over a short time interval. Figure 8. NCU Admissions and Mortality Rates Compared to Governorate Births and Neonatal Deaths, The final outcome of the QA program of neonatal units is the survival rate of infants admitted to those units. Survival rates are affected by all components of the existing system for service delivery, including physical facility, equipment, personnel and skills. The survival rate for all admissions increased from 79% in the year 1999 to 84% in the year The survival rate for full term infants increased from 87% to 90% while that for LBW infants increased from 68% to 75% in the year Table 26: Comparison of Survival Rates in All Units in the Target Region Total Number of Admissions Survival Rate for All Admissions 79% 79% 84% Survival Rate for Full Term Infants 87% 89% 90% Survival Rate for Preterm Infants 68% 68% 75% 59

72 III. Complete implementation of MCH-FP integrated package of services, including Health Sector Reform, in one pilot district These HM/HC and TAHSEEN/FP Projects are being implemented by the MOHP with technical assistance and funding by USAID. According to Ministerial Decree 29/1998 dated January 1, 1998, there shall be integration between projects to avoid duplication of efforts and resources. Since the activities implemented by the two said Projects support the same Ministry, often the same clinics, mostly the same clients and strengthen similar and often identical support systems, coordination and cooperation is needed to maximize efficiency and to prevent the unwanted efforts of vertical programs. After a series of meetings, a Memorandum of Cooperation (MOC) was finalized and signed in July 2003 by USAID, HM/HC s and TAHSEEN s Population Team Leaders, JSI s Chief of Party (COP), TAHSEEN/Catalyst s Country Representative, the MOHP Undersecretary for Integrated Health Care, and the Family Planning Undersecretary. See Annex 14 for the Memorandum of Cooperation between JSI and TAHSEEN. The MOC included two types of activities; the first type is the coordination and integration of the FP and MCH systems and the second is the development of a strategy and a plan for the implementation of the integrated MCH/FP activities in two districts in El Menya governorate. Coordination and Integration of FP and MCH Systems A. Memorandum of Cooperation between MCH and FP The first orientation/coordination meeting between TAHSEEN and JSI took place on February Its aim was to give a brief orientation presentation on the TAHSEEN and HM/HC Projects, to introduce key personnel and initiate discussions on areas of coordination and possible mechanisms for collaboration. HM/HC provided TAHSEEN with all their publications and information and expressed their readiness to share their field experiences. On March 23, 2003 and after attending the briefing on TAHSEEN s work plan 2003, JSI s Chief of Party sent a letter including a number of recommendations, that are timelinked opportunities which could help TAHSEEN/MOHP/FP to capitalize on current and previous investments in the MCH area and which could be integrated with FP activities. A series of joint meetings, that followed the March 2003 letter and recommendations, paved the way to the development, finalization and signing of the MOC in July B. Integration of a Basic Package of Essential MCH/FP Services Using the HM/HC Package of Essential Services, TAHSEEN worked on identifying a draft FP/RH portion of the Basic Benefits Package. The draft included areas such as: reproductive health services, contraceptive methods, adolescent health, the premarital package, management of infertility, post-abortion care, menopause, hormone replacement therapy, early detection of genital malignancy, and reproductive tract infections and sexually transmitted diseases. HM/HC and TAHSEEN worked collaboratively to develop an integrated MCH/FP Package of Essential Services. This package is a tool for the provision of family planning, reproductive health and maternal and child health services. The package highlights the integration between the two Projects so that resources are utilized efficiently, efforts are not duplicated and areas of opportunity are not missed.

73 C. Development of Integrated Service Standards and Guidelines for Clinical Practice JSI developed a complete set of protocols, training materials, modules and teaching curriculum for the MCH/PES. Upon TAHSEEN s request, a complete set of the MCH services materials has been handed over to them to be used as a guiding outline to formulate the standards of practice for family planning and reproductive health. In June 2004, TAHSEEN completed a draft document FP/RH standards of practice and invited JSI, Ob/Gyn professors from Egyptian universities and MOHP family planning officials at the central, governorate and district levels, in addition to other members of health related projects such as the Health Sector Reform and Family Medicine, to give their feedback on the draft copy. With JSI assistance, TAHSEEN completed the FP/RH standards of practice and obtained consensus on topics to be included in the integrated MCH/FP standards of practice. D. Development and Implementation of Post Abortion Care Guidelines A working group consisting of representatives from JSI in addition to the MOHP, Egyptian Fertility Care Foundation, USAID, Population Councils, Regional Center for Training and Alexandria University, developed an outline for a comprehensive PAC package. The MOHP approved the comprehensive PAC package which is currently in the finalization process. Consequently, TAHSEEN invited the Ob/Gyn physicians and nurses of Samalout and Mattay districts and El Menya General Hospital to a workshop in El Shatbi Hospital in Alexandria to establish a team of PAC trainers to start large scale implementation of the package in El Menya governorate. E. Development and Implementation of Postpartum Care Guidelines In April 2004, JSI provided TAHSEEN with the latest version of the postpartum care guidelines which is an integral part of the BEOC Protocols as published by HM/HC-JSI. TAHSEEN agreed to use the module as it is, and suggested meeting representatives from the FP, MCH and Curative sectors, as well as USAID, RCT and other stake holders to discuss the implementation of a separate publication: Postpartum Care Guidelines. F. Development of Integrated Quality Improvement/Supervisory/Incentive Systems Since the FP and MCH Quality Improvement Systems are two parallel systems, each has its own indicators, data collection tools and the outcomes of both systems are used differently. MCH uses its Quality Improvement System only to monitor and improve performance, whereas the FP has included an incentive scheme in its system. These parallel systems lead to competition and fragmentation of efforts between the FP and MCH rather than mutual support. Therefore, in order to achieve maximum effectiveness and efficiency of the proposed Integrated Supervision System, the MOHP/MCH/FP and TAHSEEN Project organized a three day workshop from 8-10 October, 2003 to present and review the current systems of monitoring/incentives implemented by MCH and FP Departments of the MOHP. 61

74 Meetings resulted in the development of a comprehensive integrated supervision system in which the outcome will be used for the purposes of performance monitoring, evaluation, improvement and rewarding. The new system has the following features: 1. Applies a rating scale that distinguishes between different indicators based on their relative impact on the quality of the service offered 2. Adds a new element in addition to the traditional types of indicators (input, process and output), namely client satisfaction interviews 3. Can be expressed as a single score that summarizes the facility s performance in all aspects 4. Avoids the waste of resources and duplication of efforts by the district supervisory teams After the newly developed system is piloted and finalized, a comprehensive coordination meeting will be scheduled to discuss how to use the outcomes to incorporate incentives to motivate the staff and enhance their performance. G. Integration of MOHP and FP Information Systems to Ensure Compatibility Collaboration between the HM/HC-MCH Project and Family Planning sector took place as early as 2001 to support the development of the District Health Information Centers (DHIC). To further enhance and strengthen the integration of the FP and MCH information systems, the MOC signed in July 2003, stipulated the revision of a common system of codes for both sectors. Consequently, two coordination meetings were conducted on February 8 and June 6, Discussions revealed that the MCH HIS system uses the coding system of the NICHP and is compatible and consistent with the MOHP National Information Standards. Therefore, it was proposed to conduct a joint assessment to determine if the system of codes used by the FP HIS could be changed to that used by NICHP. H. Revision and Upgrading of the Woman s Health Card JSI suggested some modifications that would increase the card s effectiveness in disseminating some important health messages such as: adding the birth preparedness guide at the end of the card, refining some technical issues, re-designing antenatal care pictures and reformatting the card itself. The card was pre-tested to make sure that in the new version each picture reflected the related messages. The Undersecretary for Integrated Health Care and HM/HC Executive Director encouraged JSI to propose to TAHSEEN to review the FP section of the card and use it to track the family planning services provided to women. After modifying the FP section of the card, it was reviewed and approved by the MOHP and USAID. The final design has been printed and distributed by the MOHP and is currently in use. I. Revision of the Secondary Technical Nursing School Curriculum In February 2003, JSI established a committee, composed of a number of professors from Egyptian universities and members of the MOHP Central Departments of State Sector of Development and Research, to incorporate the modifications of the MCH section into the curriculum. After approval by the MOHP, all parties agreed to implement the newly revised curriculum in all nursing schools (228 schools), starting in school year TAHSEEN followed the same pattern adopted by JSI to revise, upgrade and update the family planning section of the MCH component of the curriculum. Special emphasis was given to the adoption of the competency-based training approach in the development and delivery of these teaching materials. The TAHSEEN Project finalized

75 the FP component of the Secondary Technical Nursing School Curriculum and distributed it among all concerned parties including JSI. J. Coordination of IEC Messages and Strategies The Communication for Healthy Living (CHL) Project has been contracted by USAID to coordinate, develop and disseminate all IEC messages and strategies for all health related issues. Implementation of the integrated MCH/FP activities in two pilot districts A. Management Structure and Management Training To be able to achieve and implement the planned integrated activities between FP and MCH, the composition of the Safe Motherhood Committees of Mallawi and Mattay were adjusted to accommodate more representation from the Family Planning Sector in addition to the ten regular members. To start implementing the integrated MCH/FP activities in the pilot districts, JSI and TAHSEEN organized a one-day orientation workshop for DHCs and DSMCs in both districts in January The workshop was attended by 48 participants from Mallawi and Mattay Districts and paved the way for the new integration. The planned outline for the integrated MCH/FP activities was presented, highlighting the modifications introduced to the standard planning procedure to accommodate for the integration process. In order to start the planning process for the integrated activities, the JSI and TAHSEEN Projects in coordination with the MCH and FP departments in the MOHP prepared a 4-day workshop on Management and Planning in El Menya from January 26-29, It was attended by 21 participants from the Mallawi and Mattay districts. The workshop was modified to suit the new needs of the planned integrated MCH/FP activities. Participants were asked to share their experiences and brainstorm ways of forwarding the integration of services. Participants from the two pilot districts were also encouraged to a put together draft plans on integrated RH/FP and HM/HC activities. B. The Planning/Management Process Applying the WHO model for selecting the required EOC facilities, two CEOC facilities, (Mallawi General Hospital and Mattay District Hospital), five BEOCs in Mallawi and one BEOC in Mattay were selected to implement the MCH/FP integrated activities. The selected facilities were assessed and all required commodities and renovations were done to start the implementation of the integrated activities. As in other districts, HM/HC started to institutionalize and capitalize on the role of Community Health Committees (CHCs) and a decision was made to work with existing entities instead of forming new ones. Data needed to develop community profiles were collected from the local administration units and health facilities to identify significant differences and properties among sub-communities in order to be able to tailor specific messages and appropriate communication channels. The Community Needs Identification Decision Making Tool (CNI-DMT) process was implemented in all six communities of Mallawi and Mattay. Community Action Plans (CAPs) were developed based on the Community Needs Identification and rapid household surveys. Finally, the districts incorporated the previously prepared community needs and facility improvement action plans into the master district health plan ( ). The plans 63

76 were then discussed and refined during the monthly SMC meeting until they reached the final copy which was approved by the GSMC. Members from the SMCs were introduced to different monitoring and evaluation systems to follow-up and evaluate the achievements of the planned targets against the district annual work plan. Implementation of the Integrated MCH/FP Package of Essential Services A. Training on the Integrated Management of Childhood Illness (IMCI) Program The HM/HC Project implemented the IMCI Program in El Menya governorate in all health units including target BEOCs selected by JSI during During the workshop, participants were divided into working groups by district to complete the action plans according to the IMCI guidelines and tables. The district level planning workshop resulted in the following outcomes: Data was recorded to reflect the current status and needs were completed for each district health care facility. District plans of action to improve health care services and health care providers skills were completed. This was done through remodeling of facilities in compliance with IMCI activity requirements and making estimates for the purchase of furniture, equipment and supplies in accordance with IMCI standards taking into account the timeframe required for purchasing the items. B. Training in Basic Essential Obstetric Care In March 2004, JSI conducted a 6-day workshop on Basic Essential Obstetric Care. The workshop was attended by 13 participants from the target BEOCs of Mallawi and Mattay. The aim of the workshop was to train participants in the identification of the causes of maternal death, highlighting the avoidable factors and recognizing substandard care and harmful practices that are contributing to maternal deaths. C. MCH Training A 4-day MCH training workshop was conducted by JSI s Implementation Specialist for PHC physicians and nurses working in the selected BEOCs of Mattay and Mallawi districts. The purpose of the training was to familiarize the BEOC physicians and nurses with all MCH activities.

77 D. Clinical Training on Common MCH/FP Topics JSI, in collaboration with TAHSEEN, conducted a 2-day workshop for PHC/BEOC physicians to review the common services that would be provided collectively to the same client during the same visit. The workshop was attended by 15 BEOC physicians from the six BEOC facilities of Mallawi and Mattay. The agenda included a quick revision of the list of integrated services with special emphasis on postpartum care, post abortion care and cross-referral. During the cross-referral session, the participants brainstormed to identify the possible opportunities for MCH and FP services that can be concurrently delivered to the client. A 2-hour session was conducted to introduce the MOHP accreditation system. The purpose of this session was to help BEOC staff members coordinate activities to provide quality services and prepare their facilities for accreditation. E. Training in FGM and IPC Twenty five health workers at the district and BEOC levels were trained through workshops in health education, FGM for medical staff, FGM for non-medical staff and interpersonal communication. F. Workshop on the Implementation of the Integrated MCH/FP Package of Services JSI conducted a 2-day workshop on the implementation of the Integrated MCH/FP Package of Services in Mallawi and Mattay. The aim of the workshop was to review the Integrated Package of Services and determine actions needed for appropriate implementation. The workshop was attended by 27 participants representing members of the integrated DSMCs in addition to managers of BEOC facilities in both districts. As a workshop pre-requirement, JSI requested participants to conduct a BEOC selfassessment to collect quality data using separate HM/HC and FP quality checklists and to bring the results to the classroom for discussion and further usage. During the workshop, the data collection outcome was jointly employed to define performance gaps and problems and to recommend solutions through formulating selfimprovement plans for every BEOC facility. Participants informed the trainers that they were eager to proceed with the mechanisms of monitoring the implementation of the self-improvement plans. The workshop also highlighted the fact that TAHSEEN s management skills and behavior change approach, complement JSI s management approach. IV. Assist the MOHP/Urban Health Department to pilot test adapted HM/HC interventions in 1-2 urban slum areas Nowadays, Egypt faces the problem of the spread of slum areas as a result of migration from rural areas to urban areas in a continuous and rapid way without planning. As a result of this, slum areas have begun to appear in and around cities. Slums are urban areas characterized by poor environmental conditions which pose a significant burden on the health of their inhabitants. This has led to many problems such as poverty, illiteracy, unemployment, and a lack of suitable services. Nearly 800 slum areas are registered in Cairo and Alexandria with over two million inhabitants. JSI chose two slum areas, Basateen Sharq (Basateen Sharq Health Center and El-Khalifa General Hospital to which the health center refers) and Gharb El-Matar (Gharb El Matar Health Center and El-Tahrir General Hospital to which the health center refers), to implement a 65

78 pilot of MCH package of services, which can be extended successfully to other slum areas in the future. JSI developed a multidisciplinary model for intervention based on identified needs and the adapted HM/HC Project PES. The intervention model followed a process of four stages: Development of a situation analysis Design of an intervention model Implementation of the intervention activities Post intervention evaluation Figure 9: Slum Areas Intervention Model First stage: Development of a situation analysis The first stage for implementing the MCH Package of Services in the slum areas involved developing a situation analysis. A slum profile for each area was developed separately to study the social, demographic and environmental status as well as to understand how problems are perceived and prioritized by the existing inhabitants. Compilation of data was gathered from two secondary resources (MOHP and the Local City Council), primary data from actual assessment of the area and health facilities/health services available as well as a community needs assessment through the Participatory Rapid Appraisal (PRA) approach.

79 The district profile included characteristics which describe the location of the slum area, the population, the average family monthly income, the main jobs for the people who live in the area, the educational standards, the literacy level, the government health services provided within the slums, the primary health care and hospital locations, the number of staff available for each health facility, the available health services with specific attention to maternity services as well as the vital rates (mortality rate, birth rate, rate of natural increase and death rate), infrastructure, commodity status and with specific consideration for the current nonfunctioning referral system. In addition to the district profile a MCH-focused community needs assessment (PRA) was applied to diagnose potential local community partners and to identify, as well as prioritize, the local community social and environmental problems that exist and/or are perceived. Following the previous activities, it was important to conduct a study that highlights the concerns and problems related to some specific social characteristics, behavior, beliefs, practices, attitudes and related maternal/child health issues. This study was conducted through the Survey Methodological Approach using a structured questionnaire directed at women in the reproductive age group living in the slum areas of Basateen Sharq and Gharb El-Matar. The collected data was analyzed and considered as baseline data (pre-intervention data) that helped and assisted in designing the appropriate and suitable intervention model to fit the identified slum needs. Second stage: Design of an intervention model The second stage of implementing the MCH Package of Services in the slum areas was to create an intervention model that adapted the HM/HC MCH Package of Services to match slum characteristics enforced by adopting the Pathway to Care and Survival (The Delay Model). The intervention program activities were designed to answer the slum areas needs assessment findings. The following graph describes the model of intervention that was designed. 67

80 HM/HC Package of Essential Services Situation Analysis Identified Needs & Problems Community Diagnosis Health Facility Assessment Formatted: Font: 9 pt HM/HC Maternal PES Antenatal L&D Postnatal WRH HM/HC Child PES Neonate Infant School Modified PES for Slum Area Pathway to Care and Survival Formatted: Font: 9 pt Formatted: Left Formatted: Font: 9 pt Formatted: Font: 9 pt Formatted: Font: 9 pt Formatted: Font: 9 pt Formatted: Font: 9 pt Formatted: Left Formatted: Font: 9 pt Formatted: Font: 9 pt Formatted: Font: 9 pt Implementation Monitoring and Evaluation PES for Slums Figure 10: Slum Areas Intervention Model (stage 2) Third stage: Implementation of the intervention activities The third stage for implementing the MCH Package of Services in the slum areas was to implement the intervention model that was previously designed. This stage targeted two main areas: the community and the local health facility. For the community, a health education program was designed for the slum areas to be implemented through the Non Governmental Sectors represented by local active NGOs. Three NGOs were chosen to receive grants and technical assistance in order to encourage the mobilization of community resources. Slum area training The outreach workers affiliated with the selected NGOs were trained on how to collect data using JSI slum area data collection questionnaires and how to communicate specific health messages to target beneficiaries. Additionally, the outreach workers were trained in communication skills and health education. The main activities of the outreach workers were to carryout home visits and to conduct seminars. As a result, a series of home visits were conducted (5 visits per

81 women) using the health education guidelines specifically developed by the JSI team to assist the outreach workers while communicating health messages. The guideline included categorization of women according to their reproductive age, then selection of the messages to pass on during the home visit. Furthermore, JSI conducted a total number of 36 seminars on a weekly basis in collaboration with the NGOs. The main objective of these seminars was to introduce the health messages to a broader domain in order to increase community awareness and to motivate the customers to raise their demands. Another guideline developed by the JSI team was to be prepared before the seminars with the topics to be discussed, the trainer assigned, as well as the date and place for each seminar. All IEC materials used for the health education program were produced previously by JSI in different forms: flyers, counseling cards, posters and video tapes. JSI planned a new community approach; community integrated meetings. These meetings were attended by local city council representatives, NGO members and MOHP representatives (PHC, district, and directorate levels). Regular meetings were conducted under the coordination of the JSI team on a monthly basis in each area. The aim of these meetings was to discuss the proper management of the current community health problems and related constraints. Community integrated meetings were considered an executive outlet for community needs improvement. After each meeting, the JSI team developed an action plan to assign problem solving tasks to each sector s representatives and follow-up meetings were planned to discus their achievements. Community conference in a slum area For the health facility, the major activities were upgrading and monitoring services. The physical structure assessment using project service standards was followed by renovations and provision of the required commodities. A delivery unit in each PHC facility was established to offer normal delivery services 24 hours per day. All staff members working at the PHC facility received training in the field of their specialties. Local registered dayas were considered to be members of the health team. The CBT methodology was used to improve staff performance and ensure individual competency. Activating the existing nonfunctioning referral system between PHCs and area referral district hospitals was achieved after reaching a consensus on applying the referral procedures and using the referral forms. Furthermore, a list of health indicators was selected to reflect the influence of the different intervention program activities. A total number of 36 program relevant heath indicators were highlighted to cover the utilization rates, coverage rates, general health status, quality improvement, and referral status. Fourth stage: Post intervention evaluation The fourth stage of implementing the MCH Package of Services involved conducting the post intervention evaluation to assess the influence of the various intervention model activities on the quality of heath care provided, coverage of health services as well as community knowledge and practices. Lessons learned from the experience in slum 69

82 areas, what proved to be successful and appealing to this community, delineated the future processes to be followed and those to be abandoned. This stage was also divided into two main areas: the community and the local health facility. For the community, a post intervention survey was conducted to evaluate the upgrade of health education activities implemented in the area by the NGOs in community awareness, mobilization and behavior changes. Data gathered from the target community using the same pre-intervention questionnaire, were analyzed to assess and evaluate the differences between pre and post intervention activities. Furthermore, evaluating community achievements through the collaborative work of the governmental and non governmental sectors involved in the integrated community meeting was also part of the post intervention evaluation stage. For the health facility, the main tasks were to evaluate the current implemented referral system by monitoring the processing of the referral forms between the PHC and the hospital to which it refers and to evaluate the utilization and coverage rates by comparing the pre and post list of the 36 relevant program indicators. Finally, after evaluating the post intervention activities, JSI established a Sustainability System for each of the slum areas. In this system community awareness is the driving force for creating the demand for quality health care, which obligates the health provider to maintain quality services through their outlet (PHC/Hospital). This is reinforced and strengthened at the district, directorate and central health levels. TASK THREE: Public and Private Providers in Partnership with Communities to Develop and Manage District Plans Safe Motherhood Committees Changes to the Project structure have been carried out to increase sustainability. These changes have focused on making the Project design consistent with the existing structure within the MOHP and health facilities. In 1999, JSI formed the Informal Task Forces (management teams) and paved the way for the birth of district SMCs. By June 2001, the HM/HC Executive Director and Undersecretary of Integrated Health Care issued a letter to all health directorates formalizing and authorizing the Task Force s list of members and their assigned responsibilities, and the frequency of meetings of the governorate and district level SMCs. Accordingly, SMCs were established in 50 target districts in Upper Egypt governorates. The old Governorate/District Management Teams that were established in 25 districts during the base period were transformed into multidisciplinary SMCs. Safe Motherhood Committee activities are taking place in all target districts (75 districts in UE Governorates). Ministerial Decree 197/2002. It established the National SMC chaired by the Minister of Health and Population at the central level, and confirms the SMCs at all other levels (governorate, district and facility). During the project period, JSI, in collaboration with the MOHP, provided the 75 SMCs with the basic skills and tools necessary to fulfill their new responsibilities. Classroom training was given in planning, monitoring, and supervision as well as on-the-job practical training in developing annual plans, writing quarterly progress reports, holding monthly meetings, and facility assessments using QA checklists.

83 Health Committees To further broaden the base for service planning and improvement, community mobilization has been assigned to the health committees of the Local elected councils, the DHC and its parallel at the governorate level, the GHC (functioning under law 43/1979 of the local administration) The SMCs and the HCs at all levels work together as a network and were set up in keeping with the HM/HC Project goals to provide technical support, strengthen district level institutional capacity, build linkages between stake holders, mobilize local resources and create a sustainable management system. Building the capacity of SMCs and HCs All GSMC and DSMC members have been trained in management and planning, and quality improvement, but only selected members have been trained in data interpretation to help them prepare work-plans and monitor progress. GHC and DHC members were oriented to the HM/HC program and how health committees can further those objectives (See Table 27). Progress has been faster in some areas than in others, but in all districts, examples of success have been seen. Meetings between teams and committees are now used for brainstorming and resolution by a larger group of stake holders who can share in taking credit for advancing service to their own community. JSI, in collaboration with the MOHP, conducted TOT courses for selected members of GSMCs and DSMCs in the target governorates so that there would be a reservoir of trainers to ensure that all new personnel can be trained on the Management/Planning and Quality Improvement. Table 27. Number of Trained Safe Motherhood Committee and Health Committee Members Number of Staff Attending Training Courses Governorate Planning and Monitoring GHC Orientation DHC Orientation Data Interpretation Aswan Luxor Qena Fayoum Beni Suef Giza management training CQI for DSMC El Menya Assiut TOT 84 71

84 Governorate Planning and Monitoring Number of Staff Attending Training Courses GHC Orientation DHC Orientation Data Interpretation CQI for DSMC Sohag Giza Total District Health Plans The adopted planning approach allows for significant flexibility at the local level, while guiding efforts towards common goals. The Healthy Egyptian Initiative 2010 and the MOHP/MCH Five-Year Plan ( ) provide the main guiding principals for this decentralized planning. Each DHP consists of three sections in addition to the introduction and annexes. DHPs vary somewhat from one district to another and are not completely uniform in terms of order and level of detail. 1. Introduction: The introduction shows the magnitude of the problem on a national level and explains the unacceptably high figures for maternal, child and neonatal mortality. It also emphasizes the differences observed between Upper and Lower Egypt and urban and rural areas. 2. Section I: General description of the district - Section I explains the geographical configuration, the population and the available health facilities. It also includes, for the old districts, a summary of the previous year s MCH report produced by the upgraded District Information Center. This section also describes how the entire geographical service area has been divided into catchment areas, where each catchment area corresponds to one of the selected anchor facilities. 3. Section II: District objectives - Section II describes the annual objectives of the district based on the data obtained from the Health Information Center. Objectives are determined based on the previous year s value of the indicator as well as the national objectives as per the MCH five-year plan and Healthy Egyptians Initiative Details concerning the calculation of the district objectives are available in the Maternal and Child Health Planning and Management Manual. 4. Section III: District Activities and Implementation Schedule - Section III describes the different activities that should be implemented to achieve the annual objectives. In most of the old district plans of the Base Period governorates, this section includes the Community Action Plans. The activities are presented in a Gantt chart describing the activities, completion date and responsible person. 5. Annexes: The National MCH Five-year Plan The MCH objectives of Healthy Egyptians Initiative 2010 Selection process of anchor facilities District map Family planning and IMCI plans. Community needs assessment and action plans Reporting forms TOT

85 MCH and EOC available human resources in the district With technical assistance from JSI, DSMCs completed the development of 75 district plans. Table 28 shows how long these districts have been with the Project. Table 28. Classification of District Health Plans Time Period Number of Districts Six years 10 Five years 10 Four years 5 Three years 12 Two years 16 One year 22 Total 75 Monitoring system and tools Monitoring systems measure work progress, staff performance and service achievements. Monitoring information is also used to redirect activities that are not producing their intended results. This redirection function is the responsibility of the facility, district and governorate SMCs. This process emphasizes the importance of a regular flow of monitoring data within and between the three levels. Information obtained from the monitoring system is used to identify day-to-day problems. It is also used as a yearly planning tool. Members from the SMCs were introduced to different monitoring and evaluation systems to follow-up and evaluate the achievements of the planned targets against the district annual work plan. Seven tools have been developed (or improved) and used in order to create an effective monitoring and evaluation system within the HM/HC interventions. These tools include: 1. Monitoring Indicators 2. Management Health Information System (HIS) 3. Quality Assurance System 4. Quarterly Progress Reports 5. District and Governorate Supervisory Field Visits 6. Facility, District and Governorate Safe Motherhood Committee Meetings 7. Maternal Mortality Surveillance System Giza management training 73

86 The SMCs monthly review meetings started after the management and planning workshop. As usual, the meetings are conducted every month to discuss achievements/constraints in the annual work plan, current status of the HM/HC indicators, the maternal mortality surveillance system and quality checklists, in addition to any subject that has a direct/indirect impact on the MCH indicators. During the monthly meetings, challenges to reaching the work plan s goals are addressed immediately and recommendations and corrective actions are set to be implemented. In addition, the MCH supervisory plans are discussed and approved. Minutes of the meetings are documented, signed by all members and the chairman, and sent to the GSMC and HM/HC Project for analysis and follow-up. The progress report is another tool that the SMCs use to monitor quality and utilization of MCH services in their districts on a quarterly basis. This is done using facility statistics reported monthly to each DHIC. Further, QA checklists are used to assess compliance with standards from the package of MCH services. A comprehensive set of MCH indicators is used by the MOHP to enable managers to monitor service coverage while trying to reach the objective of the integrated MCH activities. The MCH indicators are divided into seven categories: 1. General health status 2. Service coverage and utilization 3. Basic and comprehensive essential obstetric services 4. Neonatal services 5. Service quality 6. Community awareness and behavior 7. Family planning and reproductive health services In addition to the monthly review meetings and the quarterly progress reports, the DSMC and the Health Committees hold quarterly joint meetings to discuss and analyze the MCH indicators and collect feedback from community representatives. During the meetings, problems are addressed, and recommendations and corrective actions are documented and approved for implementation. The following tools, QA checklists, HIS indicators and the MMSS, will be further highlighted and discussed in the second part of Task 3 and in Tasks 4 and 5 successively. Continuous Quality Improvement System The goal of the Continuous Quality Improvement System (CQIS) is to ensure the continuous improvement of the outcomes of maternal and neonatal services for the community. Considering the complexity of the health system and of the medical field itself, it is unlikely that optimal quality care will be achieved and continually improved without a systematic, ongoing, and organization-wide intervention. Therefore, the CQIS intends to describe the minimal continuous quality improvement activities necessary to provide quality care. The CQIS model was designed to be in harmony with the existing health care system in Egypt. Two CQIS manuals have been produced and implemented by HM/HC to deal with the PHC units providing MCH and BEOC services and in district/general hospitals. The purpose of these two manuals is to introduce the CQIS for

87 activities concerned with maternal and neonatal health care in BEOC and CEOC facilities. Both manuals provide tools that assist in overseeing the quality of patient care and address the continuous monitoring and improvement of both managerial and clinical processes. CQIS in BEOC Facilities The different aspects of basic MCH services in BEOC facilities are the focus of continuous monitoring and improvement. National service standards covering PHC services have been developed to ensure that the care provided is of a high quality. These standards are assessed by facility staff (self-assessment) once a month to make sure that their facility complies as closely as possible with the service standards. Following selfassessment, facility staff make an action plan to solve non-compliance problems. Each quarter the DSMCs assess all facilities providing MCH services in their districts and produce quarterly reports to ensure proper compliance with standards, and help facility staff to solve problems beyond their control. The GSMC verify the DSMCs assessments to ensure that they are complete, accurate and a true representation of a facility s compliance to the service standards. CQIS System in CEOC Facilities The CQIS includes different departments in general/district hospitals such as the obstetric department, neonatal units, emergency services, anesthesiology, infection control, operating room, central supply and sterilization department, blood bank services, laboratory services and nursing services. However, there are more details specific to the obstetric department and neonatal units due to their importance in reducing maternal and neonatal morbidity and mortality. I. Hospital managerial performance standards and monitoring This section describes the hospital managerial performance standards together with a monitoring checklist, and is intended to ensure effective hospital management systems in allocating the resources required to provide quality care. These standards are categorized into facility board of directors, FSMC, Infection Control Committee, organizational structure, planning, medical equipment, Supplies, medications, and a Service Improvement Fund. II. Department performance standards and monitoring This section covers obstetric and neonatal units in addition to related support services, and is subdivided into two parts: A. Managerial performance standards and monitoring This section is intended to guide the administrative activities of each department leader. The standards are described and monitored through two sub-sections. The first focuses on the inputs (resources) required for the provision of quality care, while the second is concerned with the different managerial competencies that enable the head of a department to carry out his managerial responsibilities. 75

88 Imbaba District Hospital Compliance with Managerial Standards Comparison between Q4, 2003 (baseline) and Q3, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Physical Structure Furniture Equipment Supplies Medication Registers Baseline Q3, 2004 Figure 11a. Example of Compliance with Input Standards at Imbaba General Hospital - Comparison between Q4, 2003 (baseline) and Q3, 2004 Imbaba District Hospital Compliance with Managerial Standards / Service Area Comparison between Q4, 2003 (baseline) and Q3, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Delivery Rate Pre-Post Labor Rate Pre-Eclampsia Rate Admission Rate Nurse Office Rate Baseline Q3, 2004 Figure 11b. Example of Compliance with Input Standards at Imbaba General Hospital - Comparison between Q4, 2003 (baseline) and Q3, 2004 B. Department clinical performance standards and monitoring Clinical performance standards are described in separate protocols, one for each department. Monitoring of clinical performance focuses on those diseases that are highrisk to the patients, occur in high volume or are problem-prone. The assessments are done using sets of clinical performance monitoring indicators that focus on the vital processes of care for each particular disease (medical history, physical examination, investigations, monitoring during stay, first aid management and active management). Clinical performance is monitored both concurrently and retrospectively.

89 Hawamdeya General Hospital Compliance with Clinical Performance Indicators Comparison between Q4, 2003 (baseline) and Q3, % 90% 80% 92% 74% 94% 76% 97% 84% 89% 88% 70% 60% 50% 55% 49% 46% 52% 40% 30% 20% 10% 0% PPH PIH APH Normal Labor Cesarean Section Abortion Baseline Q3,2004 Figure 12a. Example of compliance with Clinical Performance Monitoring Indicators at Hawamdeya General Hospital - Comparison between Q4, 2003 (baseline) and Q3, Hawamdeya General Hospital Compliance with Clinical Performance Indicators Comparison between Q4, 2003 (baseline) and Q3, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% History Taking Examination Investigation Monitoring 1st Aid Management Baseline Q3,2004 Active Management Figure 12b. Example of compliance with Clinical Performance Monitoring Indicators at Hawamdeya General Hospital - comparison between Q4, 2003 (baseline) and Q3, Facility Self-Improvement Plans The managerial performance monitoring is used in tandem with the clinical performance monitoring in order to produce quality reports for each department. The reports that emerge from these tools identify the problem areas, opportunities for improvement and trigger the development of Facility Self-Improvement Plans which, when implemented and routinely monitored, contribute to the ultimate goal of reducing maternal and neonatal morbidity and mortality in Egypt. 77

90 GSMCs verify quarterly reports, together with the self-improvement plans, and provide needed support to solve any problem requiring a level of authority that exceeds the ability of the FSMC. Coordination with General Directorate of Quality on the Accreditation Program The CQIS has been developed in close coordination with the General Directorate of Quality (GDQ), the MOHP, and in coordination with the central department of curative care and MCH. The CQIS is designed to be in harmony with the existing health care system in Egypt and in accordance with the MOHP accreditation program, one of the cornerstones of the health sector reform program. The CQIS is a tool to be used alongside accreditation standards, particularly in the area of clinical performance measurement. In an effort to maximize the efficiency and effectiveness of JSI interventions, the accreditation program has been pilot tested in two facilities, El Tahrir General Hospital and Gharb El Matar Health Unit (a primary health care facility and its referral hospital where JSI provides technical assistance) and in collaboration with the GDQ. Efforts are going on to continually upgrade the two facilities toward acceptable compliance with accreditation standards. Based on JSI s experience in quality management, particularly in the area of clinical performance measurement, the General Director of the GDQ formally requested that JSI actively participates with other stake holders to organize a national conference addressing the following points: Provide a method to measure the quality of care in hospitals Help decision-makers to identify potential quality problems Agree upon 2-3 performance quality indicators to be used at the national level. TASK FOUR: Monitoring System in Place to Track Utilization and Impact and Provide Feedback In order to avoid duplication of activities among HM/HC and Family Planning POP IV, a Memorandum of Cooperation was drafted and discussed with USAID, POP and HM/HC teams in The aim of this agreement was to clarify the roles and responsibilities of each project. This helped to ensure that a district information center would be established in each health district as appropriate and to support information activities for both projects and other activities related to the health district. The Memorandum of Cooperation also called for coordination on training district staff on managing HM/HC and POP/FP data. During the Base Period of the contract, JSI submitted documentation describing the establishment of the first 64 District MHIS centers in the target governorates of Aswan, Luxor, Beni Suef, Fayoum, Qena, Assiut, Sohag, and El Menya. During the Option Period of the contract, and in coordination with Family Planning and NICHP, JSI completed the establishment of 17 district MHIS centers in Giza for a cumulative total of 81 MHIS centers all through the life of the Project. Currently, all 81 district MHIS centers in Upper Egypt are established, collecting monthly data, performing data entry, producing reports, and transferring electronic data to governorate MHIS centers and the NICHP.

91 Personnel Training In parallel with the establishment of MHIS centers in the nine target UE districts, JSI conducted 9 types of workshops on the different components of the use of the MHIS application. Table 29: Training Courses Conducted During the Establishment of MHIS Centers Course ID Name of Course Type of Participants No. of Days No. of Participants in 2002 Total MHIS 1 Basic Computer Training & Arabic Keyboard Statistical Technicians MHIS 1.1 Basic Computer Training District Managers/ Deputies MHIS 2 TOT: MHIS Application End User Training Governorate-Level Statistical Technicians and NICHP technicians MHIS 3 TOT: MHIS Application Management User Training Governorate-Level Managers and Deputy Managers MHIS 4 MHIS Application End User Training Statistical Technicians who completed MHIS including Family Planning Application 241 MHIS 6 MHIS Application Management User Training District Managers/ Deputies MHIS 7 PC Support Technician Training Governorate Statistical Technicians and Deputy District Managers (23 days) 67 MHIS 8 TOT: Providing On the Job Support to MHIS Application End Users and Management Users Statistical Technicians and Managers who completed MHIS 2 or MHIS MHIS 9 TOT: Follow-up Visit and Testing of MHIS Application End Users Statistical Technicians who completed MHIS During the implementation of the upgraded version of the MHIS application, a training program was designed to address the following target groups in the Upper Egyptian MHIS centers. JSI and the NICHP agreed to establish new cadres within the NICHP 79

92 capable of implementing the application, not only in Upper Egypt governorates, but also in Lower Egypt. This began by establishing one central implementation team responsible for the basic training of MHIS technical staff in Lower Egypt governorates. The team includes staff members of the NICHP (central level) and selected staff members of governorate MHIS centers. Tables 30 and 31 list these workshops sorted by the year of implementation. Table 30: Training Courses Conducted During the Implementation of the MHIS Application Course Participants Governorate From To MHIS Application for Technical Personnel MHIS Manager at the Governorate Level Governorate MHIS Center Staff Members District MHIS Center Staff Members MHIS Center Managers Aswan, Luxor Qena, Beni Suef and Fayoum No. of Participants 14/12/03 18/12/ /12/03 24/12/03 21 Giza 15/2/04 19/2/04 44 El Menya 22/2/04 26/2/04 22 Assiut 18/1/04 22/1/04 30 Sohag 22/2/04 26/2/04 22 Aswan 11/1/04 15/1/04 12 Luxor and Qena 3/1/04 6/1/04 26 Beni Suef 8/2/04 12/2/04 18 Fayoum 14/2/04 18/2/04 14 All Governorate MHIS Center Mangers in Upper 13/10/03 16/10/03 12 Egypt MHIS Managers at the Central Level Central Level Implementation Team NICHP 21/9/03 25/9/ /9/03 2/10/03 15 MHIS Programmer NICHP Programmer NICHP 21/9/03 24/9/03 6 Total 277 Table 31: Training Courses Conducted During the Pilot Implementation of the MHIS Application Course Participants Governorate From To MHIS Application for Technical Person Central Level Implementation Team Governorate MHIS Center Staff Members Cairo No. of Participants 16/2/ /2/ /2/ /2/ Alexandria 15/3/ /3/ El Menya 22/3/ /3/ Assiut 3/5/2003 7/5/

93 No. of Participants Sohag 31/5/2003 6/6/ Cairo 21/6/ /6/ El Menya 7/7/ /7/ Assiut 3/8/2003 6/8/ Sohag 14/7/ /7/ Course Participants Governorate From To MHIS Application Administrator MHIS Technical Specialist Central Level Implementation Team NICHP Staff Members District MHIS Center Staff Cairo 17/7/ /7/ El Menya 7/9/ /7/ Development and installation of Software Application Total 144 In coordination with the NICHP, the MHIS application has been upgraded from a DOS- FoxPro environment into a Windows/Access/SQL Server environment. The design of the application includes a health statistics information system, a planning and monitoring system, and a quality assurance system. It also respects the current standards of the coding system, data dictionary, data flow channels, procedures and methods of data management and it enhances the implementation of these standards by inserting add-ons that are in most cases transparent to the end users. Also, JSI developed and released the final version of the MHIS application working under Windows operating systems, client/server networks, Relational Database Management Systems (RDBMS) such as Access and SQL Server, and Microsoft Office; and provided technical assistance to the NICHP to install the MHIS application and the planning and monitoring system in 81district MHIS centers and nine governorate MHIS centers in Upper Egypt. Provision of Equipment JSI provided the 17 district MHIS Centers of the Option Period with air conditioning, fax machines, photocopying machines, and office furniture. Family Planning distributed computers and printers. Upgrading the Physical Infrastructure Sites identified by District Health Managers for the district MHIS centers usually require renovation. Such renovations are often required in order to upgrade electrical systems, ensure there is no water leakage, upgrade doors and windows to improve security, provide electricity cables required for air conditioning, and generally improve the quality of the physical environment of the room. According to the Memorandum of Cooperation signed by Dr. Esmat Mansour and Dr. Yehia El Hadidi, Family Planning and JSI coordinated the renovations activities of 17 district MHIS centers in Giza governorate. JSI took the responsibility for renovating the districts of Markaz Giza, El Badrashein, El Ayat, El Wahat El Bahareya, Dokki and Boulaq El Dakrour. 81

94 Giza HIS on-the-job training Nasser district office HIS department On the other hand, HM/HC established a dial-up telephone communication system between the Giza governorate MHIS center and district MHIS centers in Giza. This allowed the governorate MHIS center staff members to have on-line access to the district MHIS databases through a dial-up connection. Moreover, the new service allows electronic digital data transfer from district to governorate and from governorate to the central level. MHIS Supervision and Data Collection A three-level system of supervision has been established within the MOHP: At the Central level: the NICHP and HM/HC Project supervise and provide support (with technical assistance from JSI) to governorate MHIS center personnel. At the governorate level: the MHIS center personnel (with technical assistance from JSI field offices) supervise and provide support to district health managers and staff of the district MHIS centers. At the District level: MHIS center personnel assess and provide on-the-job support in record-keeping and reporting in health facilities. With the introduction of the district MHIS, the responsibilities of governorate MHIS center personnel began to take on more of a supervisory and support role, rather than an operational/implementation role. They no longer function primarily as data entry personnel, which is now the responsibility of district MHIS center staff. Improving the quality of data produced by the health facilities is a top priority of the NICHP and HM/HC Project. The MCH supervisors at district and governorate levels are responsible for assuring the accuracy of data recorded at the facility level, and that data reported monthly from the health facility to the district level is consistent with the facility registers. Data entry at the district level takes place with the approval of the District Health Manager and district level technical staff. On the other hand, JSI assisted the NICHP to establish a MHIS help desk. The help desk is located on NICHP premises at the central level, and receives queries from district and governorate MHIS centers by telephone, fax or e mail. The help desk staff provides problem-solving technical assistance to the callers. For complicated problems, a specialist can be sent to the relevant MHIS center. Help desk staff are trained on issues relating to the MHIS application and Windows operating system.

95 Two workshops were held in Cairo during February and April 2004 for governorate MHIS and MCH managers from the nine Upper Egypt governorates. The workshops focused on assessing the current data flow procedures to identify problems related to differences that exist between manual reports and electronic data reports. Emphasis was also placed on data feedback to district level and facility level centers. The upgraded MHIS application includes a data quality monitoring module, producing three types of reports. The purpose of these reports is to provide a monitoring tool for MHIS center managers at all levels to identify problems related to data completeness, accuracy and timeliness. Planning and Monitoring System to Utilize Information Once data are collected and entered into the district MHIS database, the planning and monitoring sub-system of the upgraded MHIS application produces several reports, and automatically calculates all health indicators (e.g. birth rates, infant mortality rates etc.). The indicators are then used by district health managers to analyze facility services and overall district performance in achieving HM/HC Project objectives and targets. A. Tracking Service Utilization Against District Targets Objectives are determined based on the previous year s value of the indicator as well as the national objectives as per the MCH five year plan and Healthy Egyptians Initiative Data reflecting the performance of each facility is collected on a monthly basis. The application is then used to combine this data at the district level. The application allows the comparison of these data with the target indicators to track performance evaluation. B. Monitoring Quality and Utilization of Services SMCs monitor progress of the quality and utilization of MCH services in their districts. This is done using facility statistics reported monthly to each district MHIS center on service utilization. QA checklists are used to assess compliance with standards for the package of MCH services. A comprehensive set of HM/HC indicators is used by the MOHP to enable managers to measure service coverage of the catchment population, as well as to assess the quality of facility MHIS data. C. Workshops on MHIS Use in Planning During 2002 and 2003, HM/HC conducted several Data Use workshops at the district level. The objective of these workshops was to improve the skills of district managers and deputies for MCH in data analysis and use. In 2002, 42 individuals participated in 6 Data Use workshops. In 2003, 4 Data Use workshops were conducted to cover 20 districts and 55 participants. In 2004, using the lessons learned from the previous workshops and in coordination between JSI and the HM/HC Project, JSI developed MHIS Use in Planning workshops, which focused on improving the skills of targeted members of SMCs in the effective use of data for planning and monitoring. The objective of the workshops was to allow all district health managers and assistant managers to share information with their counterparts in other districts within the same governorate, and with the governorate MCH manager. At the completion of the workshop, each district had a list of recommendations that had a direct impact on its annual activities, and hence, on the annual district plan for MCH. 83

96 Workshops were conducted in all nine governorates of Upper Egypt, covering over 75 districts. A total of 302 participants attended these workshops. TASK FIVE: Research Activities The completed 12 operations research studies Operations research was used to evaluate the effectiveness of interventions, identify ways to increase effectiveness, and to provide feedback on the implementation process. Research priorities and partners were identified according to implementation needs and questions. Below is the list of studies completed during the Option Period. Further details on the studies, objectives and findings can be found in Annex 15. The following are the 13 Study Titles completed in the Option Period: 1. Premixed Intravenous Fluid Formulae for Neonates for the Prevention Of Nosocomial Infections (1A). 2. Premixed Intravenous Fluid Formulae for Neonates for the Prevention Of Nosocomial Infections Cost Effectiveness (1B) 3. Cost Analysis and Efficiency Indicators of Three Neonatal Care Units in Upper Egypt 4. Defining Indicators and Developing Tools for Monitoring Client Satisfaction with Maternal and Child Health Services from an Egyptian Woman s Perspective 5. Pilot Study: Reasons For Poor Availability of Blood for Emergency Obstetric Care in Upper Egypt 6. Comparative Study of Maternal And Child Health Terms 7. Impact of the Use of CPAP on Neonates with Respiratory Distress 8. Collaborative Patterns between Specialists During and Immediately Following Deliveries 9. Hospital Practices for Normal Delivery in Upper Egypt Governorates 10. The Role of the Non-Pneumatic Anti-Shock Garment in the First-Aid Management of Obstetric Hemorrhage 11. The Use of Uterotonics for the Management of the Third Stage of Labor 12. Nutritional Survey in El Basra Village 13. Assessment of Case Fatality Rate in NICUs

97 Develop, pilot test and monitor the implementation of a national maternal mortality surveillance system in target governorates of Upper Egypt The ENNMS 2000 was organized on February 18, 2002 under the auspices of the Minister of Health and Population bringing together over 400 representatives from local and international organizations, NGOs, Universities and MOHP counterparts. This conference issued a series of recommendations including the further reduction in maternal mortality through strengthening and improving the capacity of health systems and improving the knowledge and capacity of women to maintain their health. The study makes a range of recommendations for improving antenatal care, referral linkages, hospital management, pre-service and in-service training of health provides, and management of obstetric emergencies. It also recommends actions to ensure that women and their families are better informed about the importance of family planning and antenatal care, and to ensure that they recognize and act on complications during pregnancy and delivery. Although the ENNMS 2000 provided extremely valuable maternal mortality information, limitations were revealed in terms of data collection and problems were encountered relating to the complexity of the survey s questionnaires. The MOHP recognized the importance of collecting maternal mortality data on a regular basis as a tool for policy makers and in 1998 decided to plan and implement a Nationwide Maternal Mortality Surveillance System. The main advantage of a MMSS compared to the survey is that it could include an analytical component allowing health providers to target specific problematic areas as detected on a monthly basis. The MMSS is a surveillance system aimed at tracking the ratio of maternal deaths in the target governorates. Data is being collected from the health offices using the Female Death Notification Form (DNF). Female deaths are then further investigated and categorized through the Maternal Mortality Surveillance System Questionnaire (MMSSQ) finally submitted to the SMCs at the governorate level for planning health interventions programs. During the Option Period, JSI assisted the MOHP in the development and revision of policy and procedures guidelines, questionnaires, and reporting formats for the MMSS and its implementation plan. JSI developed a tailored CBT module for the MMSS and its related materials. Documents were revised and approved in the early stage of the Option Period. JSI identified, designed and implemented 5 different types of workshops aimed at training appropriate staff (obstetricians including health office and SMC staff) on how to collect and process data on maternal deaths. Training workshops were defined as follows: Workshops for the MMSS subcommittee of the SMCs at the governorate and district levels. The MMSS subcommittee of the SMC includes the El Menya Conference-MMSS discussion 85

98 Undersecretary for health director, the MCH Director, Preventive Health Director, Curative Health Care Directors, PHC Director, HIS Director and District Assistant Directors for MCH. A total of 14 workshops were conducted in this area. Workshops on the introduction of the MMSS to Ob/Gyn physicians and anesthesiologists at districts/general governorates and private sector hospitals. A total of 22 workshops were carried out. Supervisory visits with OJT for health offices, health districts and health directorates were conducted to monitor and check the performance scores and provide corrective actions to the weak ones. A total of 294 days in 218 districts were needed to carry out this task. Refresher Lead Trainer Workshops were done to assist the health officers and clerks in all health districts in the nine target governorates. A total of 9 workshops were done. Defaulters at all levels were trained on MMSS. The implementation of the MMSS took place in the nine target governorates of Upper Egypt. The implementation went through different stages as follows: The MMSS was introduced into 1,486 health offices which considered the primary death registration points. MHIS centers were established, the upgraded software installed and target staff trained. Assistance was provided to the MOHP in monitoring data in Giza, Fayoum, Beni Suef, El Menya, Assiut, Sohag, Qena, Luxor and Aswan governorates. The MMSSQ was automated and installed at the MHIS center at the governorate level. This form is linked to the DNF, which was already automated through the MHIS. Data has been supervised and validated on a regular basis in 9 Upper Egypt governorates since A MMSS Performance Monitoring Checklist was developed and tested to assess the performance before and after OJT for the health offices, health districts and health directorates. The monitoring checklist assessed the use and completeness of the DNF, the use and completeness of the death registration log book, if the DNF was forwarded weekly, if the cause of death was correctly completed, if the investigation of maternal death was done properly, if the number of female and maternal deaths corresponded with all administrators, and if all incomplete forms were returned back for correction. All barriers and weaknesses were discussed during the MMSS subcommittee of the SMC meetings at the governorate level and corrective actions were applied. A self assessment format of the MMSS performance for the health offices, health districts and health directorates has been in use on a monthly basis since 2004 and was validated in August and November, All findings have been reported to the MOHP Undersecretary for Integrated Health Care and the HM/HC Executive Director. The external evaluation of the current, revised MMSS in use in 9 UE governorates was done in February, 2004 by Dr. Hani Atrash, a CDC Consultant. He recommended that the current revised MMSS should be extended to the remaining 18 governorates of Egypt.

99 The governorate MMSS subcommittee of the GSMCs reviews all maternal deaths on a monthly basis and takes corrective actions for avoidable maternal deaths. These actions are monitored by the central MOHP. MMSS result findings for 2002 and 2003 are being disseminated to other governorates through regional conferences held in the Ismailia, El Menya and Luxor governorates. At these conferences the attendees were able to review and discuss the causes and avoidable factors contributing to maternal deaths and develop an improvement plan to reduce the avoidable maternal deaths for TASK SEVEN: Better Social Community Services 75 district Community Action Plans developed and implemented During Phase I of the Option Period, HM/HC started to institutionalize and capitalize on the role of Community Health Committees (CHCs). A decision was made to work with existing entities instead of forming new ones as was done during the Base Period. In other words, work began with the CHC that belonged to the elected local council in each village. These entities were already formed and functioning as required under administrative law 43/1979. To revitalize the role of the CHC, new members were added, including the head of the executive council in each selected village, as well as the manager of the health facility. Community coalitions, as organized through CHCs, represented a mix of members from the executive and elected councils in addition to the manager of the health facility. One of the advantages of working with existing CHCs is that they already held regular monthly meetings. This meant that HM/HC no longer needed to pay honoraria for additional meetings. Thus, sustainability of the process is ensured, as CHCs are institutionalized and legally mandated to continue meeting, even after the phase out of the HM/HC Project. CHCs were selected and oriented in 182 communities in 75 districts (one CHC for each catchment area of an anchor facility). Table 32 summarizes the number of CHCs and the number of CHC members involved in this process. Table 32. CHCs and CHC Members Selected and Oriented Number of Governorate Number of CHCs Districts Number of CHC Members Luxor Aswan Beni Suef Fayoum Qena Sohag Assiut El Menya Giza Total

100 CHCs within districts maintain continuous communication through the DHC, who in turn receive consultative support from the GHC. Both DHCs and GHCs coordinate with DSMCs and GSMCs. Health provider sensitization The purpose of health provider sensitization is to heighten the awareness of health providers and officials at different levels to local conditions. Sensitization training emphasizes the benefits of community involvement and seeks to introduce health providers to community perceptions and attitudes about MCH issues, enabling them to use this information to treat their patients more effectively. By the end of the sensitization process, health providers and officials recognize the knowledge and experience of both providers and health care beneficiaries and are better able to combine the two to encourage more successful health care programs. Sensitization training encourages health providers to view beneficiaries and community groups as active partners in a joint process of program development and implementation. Following sensitization training, providers are more aware of the importance of acquiring and developing the appropriate skills to communicate with and motivate the beneficiaries to better health practices. Health care sensitization targeted decision-makers, planners and managers of health facilities at the governorate and district levels, as well as health care providers in health facilities at the community level. By now, sensitization orientation sessions have been held for 1,121 health providers including; chief nurses, physicians and MOHP health educators, as well as health planners and managers from the 75 districts. In preparing the sessions and session material, the results of qualitative and quantitative research were used to provide a better understanding of community perceptions and practices. Community Needs Identified To help CHCs identify the maternal and child health care needs in their communities, HM/HC developed the Community Needs Identification and Decision Making Tool (CNI-DMT). The tool guides CHCs through a structured process combining the use of rapid household surveys, local health facility data, and community meetings. Communication training for outreach workers The process informs community leaders about the health needs of women and children and whether they are receiving appropriate and effective health care. It also provides a means for the community to become part of the decision-making process about MCH services in their area. Rapid household surveys by 182 CHCs were carried out in order to identify priority areas and needed actions. The survey questionnaire included key DHS questions as well as others that had been identified as a problem area or where more information was desired. More than 9,650 households were surveyed (50 households in each community) by local outreach workers who received a five-day training course. Households were selected if they had a woman with a birth registered at the local health bureau in the 12 months prior to the survey.

101 As the HM/HC Project was phasing out, a sample research was conducted to measure the impact of the Project inputs on the households related to MCH knowledge and practices and more specifically to measure progress in improving knowledge and practices in target households. HM/HC conducted a second rapid household survey in some communities. Table 33 illustrates in cumulative percentages the results of the first and second rounds of rapid household surveys in the three governorates of Beni Suef, Qena and Fayoum. Table 33. Results of First and Second CNI-DMT in Beni Suef, Fayoum and Qena Governorates Indicator First CNI-DMT (2000) For all pregnant women, seek antenatal care at least 4 times during the last pregnancy. 28% 41% For the first pregnancy, get tetanus immunization as least twice. 77% 87% For second or more pregnancy, get tetanus immunization at least once. 78% 90% Take iron syrup and/or tablets daily. 28% 45% For all pregnant women deliver by a trained health provider. 58% 60% Start breast-feeding baby within 1 hour of giving birth. 43% 56% Every mother has a Maternal Health Card. 49% 69% Knowledge of 4-6 danger signs related to complications during pregnancy. 18% 36% Knowledge of 3-5 danger signs related to labor and delivery. 29% 55% Knowledge of 4-7 danger signs among children. 12% 42% Second CNI-DMT (2002) The most significant changes between the first and second CNI-DMT were associated with improvements in knowledge. Of these, knowledge of four danger signs in neonates increased from 12% to 42%, while knowledge of three danger signs related to labor and delivery jumped from 29% to 55%. Another important change was in the number of women holding maternal health cards, which increased from 49% to 69%. These improvements are largely due to the efforts of outreach workers and local NGOs to raise community awareness about MCH care, often in conjunction with local authorities and health care providers. Indeed, better cooperation and increased coordination among all community actors was essential to the success of these efforts. This illustrates that outreach workers, supported by a competent and trusted health care provider, are an important element in behavior change interventions. Field observations also suggest that enhanced educational levels among Home visit by outreach workers 89

102 recently married women translate into increased knowledge of and receptivity to proper MCH care. Although changes in behavior were detected, the degree of change is less than that related to knowledge indicators. This is a significant finding in that it indicates that community members are not lone actors in accessing quality MCH care. Even with increased knowledge individuals are not necessarily following appropriate health behaviors. Although reasons for the persistence of negative behaviors vary from community to community, field observations indicate recurring patterns. Health provider behavior may be a barrier that hinders improvements in health practices at the community level. Specifically, better communication between health providers and women would facilitate trust building. In turn, this would enable health providers to encourage positive behavior and address entrenched negative behaviors and beliefs more effectively. Indeed, in those communities in which health providers were an integral part of awareness and trustbuilding campaigns, striking improvements in behavior were witnessed. Other factors, such as the availability of health care providers, the availability of drugs such as iron tablets, or the availability of maternal health cards, could also affect these rates of change. Community Action Plans (CAPs) The purpose and design of the surveys were not intended for research purposes but to generate useful information for CHCs on local knowledge, behaviors and service utilization so they could take action. The survey findings were presented and discussed at CHC meetings by the outreach workers and supervisors. Problem areas were prioritized and action plans drawn up. Where possible, CHCs used local resources to address problems. Perhaps the most important achievement of the CHC, however, was the ongoing communication that took place through formal mechanisms (e.g., regular meetings) and informal ties that linked CHCs to local leaders and health committees at the district and governorate levels. Although the path is somewhat hierarchical, evidence collected from the field indicates that the model is working successfully. Community meeting Implementation of CAPs began by reaching consensus amongst members of the CHCs at two levels: first, initiation of activities to be carried out at the community level and second, presentation of the CAP to the DHC for incorporation into the District Health Action Plan. In a quarterly joint meeting of the DHC, the district s plans incorporating CAPs were discussed, responsibilities were assigned and plans were approved. In subsequent quarterly meetings, progress, constraints and corrective actions were discussed. The joint meetings were attended by the chairpersons of CHCs and managers of anchor

103 facilities within the district. During this meeting, there was an opportunity to oversee the problems addressed in District Health Plans. At the community level, CAP implementation involved two types of activities: Problem solving of issues outlined in the CAP Awareness raising and health education Problem solving is the responsibility of the CHC unless it is an issue that must be resolved at the district or governorate level. Both the CHC and outreach workers are responsible for awareness raising and health education. Examples from the field of the implementation of CAPs The following are a few examples of the implementation of CAPs. Partnership with the State Information Services (SIS) to provide health education to community residents. In the governorates of Assiut and El Menya, an agreement was reached between the HM/HC and the SIS offices in these governorates to exchange work plans and schedules with a view to coordinating field activities in a way that would allow staff from both organizations to contribute to community health communications events. It was agreed to nominate CHC members to attend events organized by the SIS on reproductive health. In return, CHCs would mobilize and gather women of reproductive age in their areas and set a date for the SIS mobile team to conduct mini-campaigns. Partnership with the Health Education Department in the MOHP. In Assiut, an agreement was reached between the HM/HC and the Health Education Department under which HM/HC staff would show CAPs in their catchment areas to the Health Education Department staff to facilitate the delivery of health messages in these communities. In addition, HM/HC provided MOHP staff with the necessary IEC materials. Implementation of this partnership model has already started in some communities in Assiut. CHCs provide non-cash incentives to mothers to encourage them to seek antenatal care in the health facility. In the El-Magabra community, (Gerga district, Sohag governorate), the CHC realized that the number of women seeking antenatal care was very low. The head of the CHC suggested the provision of non-cash incentives such as soap, cotton, or other cleaning supplies for mothers who seek antenatal services, and he implemented this initiative from a fund in the local unit. In a couple of months, the number of women seeking antenatal care had doubled. CHCs solve problematic issues: In El-Galaweya community (Saqolta district, Sohag governorate), a Community Needs Assessment was conducted with residents of the community. One of the problems identified was the lack of transportation for women to the health facility during delivery, particularly at night. Long discussions with community leaders and the CHC were conducted in an attempt to reach a solution for this problem. The local unit leader suggested solving the problem locally. He concluded an agreement with local taxi drivers, who would be on call 24 hours in the local unit building; any woman who needed to go to the health facility for delivery or an emergency could call the local unit, who would send the taxi driver on duty for free. After monitoring the system, we found it was functioning, and the rate of women who suffered from lack of transport decreased tremendously. We can conclude from this experience that the local community is willing to donate and mobilize local resources if they find credible reason for doing so. 91

104 Training outreach workers to provide health education: In El-Wahat El-Baharia, five three-day workshops were held for outreach workers who conducted the Community Needs Assessment. Fifteen outreach workers from each community with a total of 90 outreach workers attended the workshops. The purpose of these workshops was to train outreach workers on communication for health education and how to conduct home visits for the households to increase women s health knowledge and improve their health practices related to MCH issues. The training included sessions on how to use the HM/HC IEC materials during home visits. As a result of the five workshops, each outreach worker was assigned 30 households in which to conduct health education. The CHC members and health providers in these communities were involved in this process. The outreach workers started the home visit activities, documented the findings of each visit and reported back to the CHCs and health providers. The CHCs were facilitating the logistics of the home visits for the outreach workers. The total number of households visited was 2,700 in the six communities of El-Wahat. Integrating HM/HC messages in the literacy curriculum of the General Authority for Literacy and Adult Education (GALAE) HM/HC, in collaboration with World Education, GALAE, the MOHP and local NGOs, worked with female literacy students, and literacy facilitators and supervisors in Luxor to develop and test 5 integrated health and literacy lessons, in addition to teaching and supervisory materials. A memorandum of cooperation (see Appendix 16) was signed with GALAE in September 2002 to introduce the integrated health and literacy approach and materials to central GALAE literacy supervisors and trainers. They were to function as lead trainers at the national level and to develop and implement new lessons in El Menya governorate. The signatories included the GALAE chairman, the undersecretary of the MOHP and representatives from USAID, the Ford Foundation, JSI and World Education. The integrated health and literacy materials were compiled in a book to supplement the literacy books. They provided an innovative and practical method for delivering essential health messages while reinforcing women s basic literacy skills. Work continued and the experiment phase was expanded to include all the literacy classes in Luxor and 200 literacy classes in Cairo and Giza with a focus on the slum areas and eventually expanded to include El Menya governorate. As a result of these activities, 9,520 female students in literacy classes in Luxor, Cairo and Giza have benefited from new health information. In some cases this information led to improved health practices. For example, some pregnant women started using trained health providers for delivery rather than dayas. In addition, a total of 25 literacy supervisors and 560 literacy facilitators were trained in teaching health messages in their literacy classes, and they subsequently became trainers for their colleagues. Examples from the field The following comments represent feedback received by literacy facilitators and students on the integration of health messages in the literacy curricula. Prior to this book, I used to think that the best age for marriage was from I always wanted to get married as quickly as possible, like my mother and many of my friends, who all got married at that age. Now I m convinced that marriage at my age is premature.

105 The health and literacy books open the window on new ideas and behavioral change. Even though I m old, I think the information in the new book is valuable and worthwhile to share with others. The new health and literacy book has encouraged my illiterate daughter, who didn t go to school, to attend literacy classes. Thanks to you, I am now cognizant of health knowledge that I had no idea about. These new ideas will be passed on to my literacy students. It is a unique book, especially because we teach in slums and underprivileged areas, and deal with vulnerable women against whom society discriminates. However, we need more health topics. This is the kind of training material we need here in Imbaba, and we need even more. Let me recommend the following topics: nutrition, childhood, adolescence, pre-marriage checkups, iron deficiency and anemia, discrimination against women, sexism, female circumcision and FGM. I am married and have children. However, this is my first time to be introduced to danger signs and to the relation between breast-feeding and the protection it provides. I fed my first baby sugar water instead of my first breast milk. Now, I regret that. I am pregnant and I have an idea about the schedule of tetanus shots and the number of medical check-ups I need. My students are now encouraged to get out of their houses and come to the class. They feel that this is something interesting and different: they play, interact and learn. They feel the change. This book should be expanded to the national level. It is useful for the educated and uneducated, for rural and urban citizens, and for women and men. Student Health Insurance Program {SHIP} The primary goal of SHIP is to assist the MOHP and HIO to maintain the Adolescent Anemia Prevention Program in the five original UE governorates and phase in the new target governorates: Sohag, Assiut, and el Menya as required through the JSI Option Period contract. The Adolescent Anemia Prevention Program/SHIP was developed using research conducted in Egypt and is consistent with worldwide recommendations from international organizations. The purpose of this program is to reduce the high levels of anemia among adolescents (46.6% nationwide according to a 1997 national survey of Egyptian adolescents) and to introduce improved eating habits that will help to sustain reductions in anemia. School Health Insurance Program (SHIP) The potential short-term results of this reduction include improved scholastic performance, improved growth rates and improved performance in physical work and 93

106 sports. The potential long-term benefits include lower maternal and infant mortality and morbidity, as well as fewer birth defects from folic acid deficiency. The program is implemented in two key ways: Distribution of weekly iron tablets and health education. During the Base Period, the program was implemented in five governorates; Aswan, Luxor, Qena, Beni Suef and Fayoum. Over one million students enrolled in 1,641 preparatory and secondary schools in the five targeted governorates received weekly iron tablets. In addition, to promote healthy dietary behaviors, IEC materials were developed and disseminated in all the schools. School-based health education activities were conducted through a new cadre of nutrition and health educators who were trained and hired by SHIP. A Nutrition and Health Educator s Guide was developed and serves as the curriculum for the health educators. The IEC materials distributed included booklets for preparatory and secondary students and their parents and classroom posters. A TV spot was also produced and aired on local channels throughout the school year (the spot won first prize in an international advertising and marketing competition). Iron Supplementation During the Option Period, JSI maintained the Adolescent Anemia Prevention Program at the central and local level in Aswan, Luxor, Qena, Beni Suef and Fayoum through meetings with SHIP coordinators in HIO and MOHP. The meetings followed-up the purchase of iron tablets and cups, printing of program registers and forms, printing of IEC materials, updating of the school data base, reviewing the governorates schools statistics, and organizing monitoring visits for the central SHIP coordinators. Iron tablet distribution The Adolescent Anemia Prevention Program was launched in the Sohag governorate during the school year and in Assiut (eight districts) and El Menya (six districts) during the school year. Implementation was sustained in all eight governorates at the beginning of the second semester of the school year. Weekly iron tablets were distributed to more than 1.9 million students in the eight governorates. Health Education During the Option Period, in addition to four Base Period governorates (Qena, Fayoum, Luxor and Aswan), health education activities were sustained in El Menya, Assiut and Sohag. Based on the results of the Gerga pilot, a new protocol of introducing health education through science teachers was implemented in the three Option Period governorates at the beginning of the second semester of the school year. Health Education Program (SHIP)

107 A health education guide was developed to be used by the science/biology teachers. It includes activities covering smoking and anemia prevention. Activities are conducted though new informal techniques with an emphasis on more physical and mental exercises. It is an approach different than the traditional way of teaching. Each science/biology teacher conducted two sessions for each of his/her classes: one for anemia and the other for smoking. Target students were the same as in the Base Period governorates: second year preparatory and first year secondary. Also, based on the Gerga pilot, antismoking activities were added as well to the curricula of the Base Period governorates. Training For iron tablets distribution, the MOE and Al Azhar identified two master trainers within each district of Sohag, Assiut and El Menya As with the five Base Period governorates the master trainers then trained one vice principal from each of the target schools in their districts. At the school level vice principals trained all the class teachers who would become tablet distributors. As for health education, pre-implementation training of science teachers supervisors took place to enable them to conduct a similar training course for science teachers. Science teachers were trained to relate to adolescents and conduct health education sessions annually for the targeted classes. In addition to all training courses related to iron supplementation and health education in schools, HIO and MOHP central staff expressed the need to develop their managerial skills in order to cope with program demands. A fourteen-day workshop was organized by the IIE-DT2; designed and conducted by Gebril for Training and Consultancy (GETRAC). Thirteen HIO, MOHP, MOE and Al Azhar senior managers at central and governorate levels (Base and Option Period governorates) participated in this workshop. Going National with the Program An overview of the SHIP program was given to the Minister of Health and Population in January 2003, through a memo prepared by the Undersecretary of Integrated Health Care (HM/HC Project Executive Director), and the Chairman of the Health Insurance Organization, with the assistance of JSI. The memo included information on the prevalence of iron deficiency anemia among adolescents in Egypt, the impact of the SHIP program in raising the iron levels of students in Upper Egypt, and a proposed national plan with an estimated budget. The memo got the Minister s consent and a plan was prepared to extend the SHIP program to cover all governorates of Egypt during a period of four years ( ). Since the program extends to all the governorates of Egypt the budget was significantly increased and will run beyond the financial capacity of the HIO. It was agreed therefore that MOHP will cover about 50% of the entire program cost. HIO and MOHP officials signed an agreement (Annex 17) outlining their financial responsibilities; HIO will cover the expenses of the cups, registers, IEC materials, training courses, and regular meetings, as well as the salaries of the health educators of the five Base Period governorates; MOHP will cover the expenses of the iron tablets and the monitoring visits. 95

108 Information, Education and Communication Program Female Genital Mutilation A. Non-medical FGM activities Ninety-seven percent of ever-married women in Egypt have undergone female genital mutilation (EDHS 2000). Although support of the practice is decreasing in women (75 % in 2000 vs. 82% in 1995), the practice is still virtually universal. There is also a growing danger of "medicalization" of the practice as increasing numbers of physicians perform the procedure. During the Base Period, JSI produced three FGM prevention materials for individuals with low literacy skills. These materials included a booklet, a flyer, and a series of matching cards. Materials were developed in a material development workshop that included key players in FGM. During the Option Period, an FGM material dissemination workshop was conducted; fifty-six participants attended the workshop representing USAID, UNFPA, UNICEF, and NGOs from various governorates. The materials have proven to be very useful and were re-printed by Caritas and the Center for Development and Population Activities (CEDPA). A FGM TOT manual along with a trainer s guide was developed to train health educators, social workers and NGO personnel on becoming future FGM trainers. Furthermore, an FGM TOT workshop was conducted in El Menya governorate. Twenty-nine participants attended the workshop representing the social workers Departments, Health Education Departments and NGOs from El Menya, Sohag, Assiut, Aswan, Luxor, Qena, Fayoum, and Beni Suef. These trained health educators and social workers tutored some sessions Workshops- FGM prevention materials during the FGM workshops. A FGM curriculum was developed to train health educators, social workers and NGO personnel in advocating against FGM and using the existing JSI FGM materials in advocacy efforts. The curriculum was printed and distributed through a series of FGM workshops in the target governorates. A total number of 451 participants attended the workshops including social workers, health educators, and NGO personnel. Additionally refresher FGM workshops were conducted. The aim of the refresher workshop FGM session in El Menya governorate was to foresee outcomes and plans as well as to provide a refresher course for FGM trainees and to develop an improvement plan for the FGM activities.

109 B. Medical FGM Activities An FGM protocol for physicians was developed highlighting the origin, prevalence, classification and anatomy of FGM. The protocol is an excellent reference for Ob/Gyns in the management of FGM complications in general, as well as during pregnancy, delivery, and the postpartum period. Additionally, a CBT module was also developed. It is an educational tool covering the classification, types and percentages of FGM, the management of FGM complications, and counseling of circumcised women. The protocol and module were used together in a series of successful one-day training workshops for Ob/Gyns in Giza, Assiut, Sohag and El Menya, in which 334 physicians received theoretical and practical Anti FGM training. C. Health Education IEC activities aim to promote healthy behavior and empower communities and families through MCH messages. Health educators serve as change agents at the district level, and therefore require effective communication skills in order to improve the health status of women of reproductive age and their families within the community. As a result, during the Base Period, a TOT training curriculum for the health educators together with a Health Education Manual were developed with the MOHP Health Education Department and used in improving communication skills of governorate and district level health educators and outreach workers. The curriculum covers the following topics: HM/HC priorities, health behavior, communication skills in health education, effective management of health education programs, and practical application of skills. During the Option Period, the Health Education Manual was revised and new topics were included linking with NGOs and CHCs. Additionally, a six-day TOT workshop for health educators was conducted in El Menya, with 24 participants from El Menya and Assiut governorates. These trained health educators tutored some sessions during the health education workshops. Additionally, a series of health education workshops took place to strengthen the health educators capacity to plan, implement and evaluate IEC activities. The health education workshops were designed to improve the ability of health educators to conduct community outreach work and IEC programs. A total number of 283 participants attended these workshops representing health educators and NGO personnel from Giza, El Menya, Sohag, and Assiut. D. Interpersonal Communication During the Base Period, two CBT modules were developed to train providers in the important skills of interpersonal communication (IPC) and counseling. Adapted versions of these modules were also produced for use by medical and nursing school faculty to train medical residents, house officers (interns), and nursing students. During the Option Period, the modules were pre-tested and some modifications were added. As a result, a final Arabic module incorporating recommendations and lessons learned was produced to be used in training in a way that facilitates efficient diagnosis and treatment, encourages utilization of health services, achieves client satisfaction, and respects clients humanity and dignity. 97

110 A series of IPC training workshops for the health providers was conducted in the targeted governorates. A total number of 28 IPC workshops were conducted for physicians and 25 workshops were conducted for nurses. A total number of 480 physicians and 510 nurses were trained. TASK TEN: Small Grant Program A cumulative total of 170 small grants awarded to NGOs in target districts JSI awarded 170 small grants (L.E. 5,071,129) to local NGOs working in the target districts of Upper Egypt, Cairo and Giza governorates to assist in raising health awareness and mobilizing their resources to develop local solutions to maternal and child health problems in areas complementary to the goals and objectives of the HM/HC Project. In the Base Period, 102 small grants (L.E. 3,106,373) were awarded to NGOs working in the five target governorates of Upper Egypt (Luxor, Aswan, Qena, Beni Suef, and Fayoum). In the Option Period, an additional 68 small grants (L.E. 1,964,756) were awarded to capable NGOs working in the target districts of Upper Egypt (Qena, Beni Suef, Fayoum, el Menya, Sohag and Assiut), Cairo and Giza governorates. NGOs were asked to define and assess their own community needs and address their local health problems through predefined categories of outreach activities ranging from household visits to public seminars (community meetings) and support groups. NGOs specialized in one or more topic areas as shown in Figure 13. Children s' diseases (10 ) Early and relative marriage (10 ) Supplementary feeding (2) FGM (13) Repetitive pregnancies (8 ) Danger signs (1 ) Breast-feeding (9 ) Antenatal care (67) Pre /postnatal care (28 ) Nutrition (2) Inconsistencies noted between the number of NGOs and the number of projects implemented is due to the fact that one NGO can implement one or more projects. Figure 13: Distribution of Topics in the Target Governorates of the Option Period

111 The home visiting program reached 114,389 women of reproductive age (WRA), including 51,654 pregnant and postpartum women. A total of 773 outreach workers were active in promoting healthy practices in 100 households each. 629,500 home visits were conducted in the Option Period. Households were selected if a WRA was present and households with pregnant, postpartum or newly married women were particularly targeted. Parallel to the household visits, 1,514 seminars were conducted by the 68 NGOs and were attended by 43,634 male and female participants. Seminars tackled 10 different MCH-related issues as shown in the previous chart. Support group meeting in Assiut The first series of workshops were intended for the recruited outreach workers. They were instructed by physicians and social/religious leaders who provided them with the necessary medical and non-medical information and answered their questions. The second series of public seminars were conducted to introduce the Project, outreach workers and physicians working in the nearby local health unit to their community and deliver HM/HC messages. To further enhance the dissemination of these messages, The 773 outreach workers formed 1,831 support groups with a total number of 13,255 female participants. All outreach workers received JSI training on interpersonal communication and how to use related IEC materials. They were also trained on how to assess the quality of their activities using developed quality checklists. Outreach workers were also given health education training on related medical issues. During their home visits, outreach workers used specially developed materials such as discussion cards with pictorial illustrations of messages to ensure standardization of health messages. The average grant size for each NGO was L.E. 29,000. The distribution of grants between governorates of the Option Period and the total amount of grants per governorate is detailed in Table 34. See Annex 18 for additional details, including the 170 NGOs that have been awarded Small Grants through JSI on behalf of USAID. Table 34: Distribution of Grants in the Target Governorates of the Option Period Governorates Number of Grants Total Value of Grants (L.E.) Qena 6 264,630 Beni Suef 6 355,245 99

112 Governorates Number of Grants Total Value of Grants (L.E.) Fayoum 5 246,260 El Menya ,775 Sohag ,280 Assiut 6 114,700 Giza ,128 Cairo 1 32,738 8 Governorates 68 Grants L.E. 1,964,756 TASK ELEVEN: Commodity Procurement JSI's commodity procurement program was implemented according to the Life of Contract Procurement Plan developed by JSI and approved by USAID. In the Base Period, the commodity procurement plan was estimated at $9,362,000. Included in this contract amendment was also an approval for JSI to expend a maximum of $300,000 for minor renovation activities in the target facilities in order to expedite the upgrading process. Commodity examination During the Option Period, the commodity procurement plan was estimated at $9,000,787. Included in this contract, was an approval for JSI to expend a maximum of $600,000 for minor renovation activities in the target facilities in order to expedite the upgrading process. Commodity Procurement Specific commodities were purchased for the selected recipients. The recipients were primarily MOHP administrative offices and clinical facilities in the target governorates of Upper Egypt. A detailed summary of the commodities procured for specific recipients is listed below in Table 35. Table 35. Types of Commodities for Specific Recipients Recipients District Hospitals and Basic Centers (100) Governorate(5) and District Health Offices (25) Types of Commodities Medical Commodities (Equipment, Furniture, and Supplies) for Ob/Gyn wards, Operating Rooms, Emergency Rooms, Sterilization Rooms, and Neonatal Centers; Resource Room Furniture for the District Hospitals; Furniture for GH Residence Quarters Vehicles, Office Furniture, Office Equipment, Computing Equipment (GHO only)

113 Recipients Governorate (7) and District Information Centers (65) HIO (6) Medical (13) and Nursing Schools (13) Ob/Gyn and Neonatal Departments Types of Commodities Office Furniture, Office Equipment, Computing Equipment Office Furniture, Computing Equipment, Survey Equipment and Supplies Training Room Furniture, A/V Equipment, Computing Equipment, Training Models A computerized tracking system was established to monitor commodity procurements and distribution. The system was used to monitor the status of procurements through the different stages of procurement and to track delivery including the final receipt of the GOE required Forms 111/112. In addition, the system produced reports which subtotaled procurements by type of recipient, category, and source of procurement (i.e. local vs. offshore). This information can be found in the relevant Performance Milestone Reports. The total value of commodities equaled approximately $8,464,363. A detailed summary of the estimated expenditures versus the actual expenditures by commodity category generated by the computerized tracking system is included (See Table 36). Table 36. Procurement Expenditures Commodity Category Total Estimated Expenditures per Approved Procurement Plan Actual Expenditures* Difference Audio-Visual $39, $19, $20, Computing $50, $118, $68, Medical $5,387, $5,539, $151, Office Equipment $413, $424, $10, Office Furniture $102, $75, $27, Vehicles $1,188, $815, $372, Renovations $600, $491, $108, Publications $500, $233, $266, Other $718, $747, $29, Total $9,000, $8,464, $536, * Actual expenditures are approximate values due to exchange rate differences. Renovations In addition, minor facility renovations have been completed under the Commodity Procurement Program. Specific locations of the renovations and total value of the renovations by governorate are listed below in Table 37. Comment [mga2]: Cherine is it possible to add some renovation photos around this very long table? Marty 101

114 Table 37. Renovation Activities Facility Total (L.E.) Fayoum Fayoum GH Tamia DH Sersena IH Total 53, Beni Suef Naser DH Ashmant IH El-Shantour IH Dashtout IH Total 14, Qena Waqf DH Qift DH Total 308, Giza Abul Nomros MHIS Badrashein MHIS Ayyat MHIS Boulaq MHIS Wahat MHIS South Giza MHIS Menshat EL Qanater MHIS EL Dokki MHIS El Warak MHIS JSI Giza office Gharb EL Matar UHC EL Saff DH Soal H. Group (Atfeeh District) Arab Abo Sa'ed WHU (El Saff) EL Hayy RHU EL Saff Maternity MCH Center (Maternity) Nasria IHU (Ayyat) Matania IHU Barnasht UHC Badrashein Maternity Menshat Dahshour RHU

115 Facility Total (L.E.) Abo Ragwan WHU Gezerat Mohammed HU Bashteel IH EL Motemideya Saquil IH Kerdassa IH Barageil IH Basharmos HC Atrees WHU Om Dinar RHU Madinet EL Ommal MC Aziz Ezzat MC EL Bouhy UHC Imbaba UHC EL Harah RHU (EL Wahat) El Zabwa HU Mandisha RHU Qabala RHU Total 610, Cairo EL Basateen Sharq UHC Total 46, El Menya El Menya GH Damsheer Tala Tahna El-Gabal Tahnasha Beni-Mazar DH Sandafa Shk Fadl Abu-Garg Samalout DH Biahio Qalosna Menshat El-Sheraiee Al-Saleeba Fikriya DH Asmant 103

116 Facility Total (L.E.) Der Mowas MC Nazlet Badraman Bani Haram Malwi DH (High Risk Pregnancy) Mallawi DH, ER Mallawi MC Dayrout Om Nakhla RHU Kalandoul IH Beni - Khaled WHU Al Barsha WHU Manshiet Menbal WHU Dahamro WHU Bartabat IH Dahrout RHU Atf Heder IH JSI El Menya office Total 464, Assiut Eman Gedida GH Arbe'een UHC Assuit GH Ob/Gyn Spec. Moteaa Naga Saba Ghanayem DH Naghamish RHU Al Fath UHC AL Ghanayem DH and NICU AL Atawla IH Ghanayem DH (Post labor and Pre Eclampsia Rooms) Othmania (Tadamon) WHC Sahel Selim MC Sedfa MC EL Dowina IH Hawatka IH Arab Beni Shokir WHC Kodiet Mubarak IHU Dashlut IH EL Maabda IH

117 Facility Total (L.E.) Faraza IH Kouseya MC Beni Kora WHC Total 424, Sohag Sohag GH Geziret Shandaweel Balsfoura Tema DH Tahta DH Gehina DH Enaibes Maragha DH Menshaa DH Shatoura IHU EL Sawama IH Tema UHC Om Doma IH Al Rayana IH Saqolta MC Galawiya IH Nida IH Kola IH Gerga DH Magarba Sheikh Baraka WHU Sheikh Marzouk IHU Menshaa Maternity Center El Zouk EL Sharqia IH Awlad Hamza IH Eneibis IH Shandaweel IH Gherizat IH Maragha DH (Laundry Room) Maragha DH (Ob/Gyn and NICU) JSI Sohag field office Total 751, Grand Total 2,675,

118 Publications During the Base Period, JSI developed IEC materials for the Birth Preparedness Campaign, the Caring for Mother and Baby Campaign, Iodine Deficiency Disorder, Neonatal Screening, and Female Genital Mutilation. During the Option Period all previously produced IEC materials were reprinted and copies of HM/HC TV spots were condensed onto one videotape and duplicated to be used by NGOs Publication booth conducting community activities. Additionally, Nefertity TV channel was given the Beta-Cam tapes of the HMHC Campaign TV spots for re-airing. JSI developed and printed new IEC materials including: The MOHP Woman s Health Card with an integrated birth preparedness guide and a set of 33 counseling cards. All IEC materials either produced or reprinted during the Option Period were distributed among NGOs, district/general hospitals, and primary health care units in order to assist in conducting outreach visits and in conveying information during the community health education meetings. Publications and IEC materials were printed locally and in accordance with USAID rules and regulations. A list of all HM/HC publications is attached in Annex 12. The materials were also used to help standardize and present the information effectively. In addition to this, during the Option Period seven posters were produced to display JSI activities at various conferences. The produced posters were as follow: Intervention model for slum areas for the Second International Conference on Urban Health in New York. The Adolescent Anemia Prevention Program for the Second Conference for School Health in Beirut. The ENMMS 2000 for the APHA 2003 meeting in San Francisco HMHC activities for the conference on Averting Postpartum Hemorrhage from Research to Practice held in Bangkok Ways of averting maternal deaths due to postpartum hemorrhage for the conference on Averting Postpartum Hemorrhage from Research to Practice held in Bangkok Anti-FGM activities for the APHA 2004 conference in Washington DC The importance of IPC to health service providers for the APHA conference in Washington DC. JSI also developed IEC materials for other communication needs in order to highlight HM/HC activities and emphasize HM/HC success stories. The following materials were produced: English and Arabic brochures of HM/HC activities. A brief summary describing all HM/HC publications.

119 HM/HC success stories. Three stories titled A day in the life of JSI employees with one of them selected to be published in the JSI Anniversary Book. Approximately 20,250 admission sheets for Essential Obstetric Care Departments. TASK TWELVE: Coordination Activities MOHP/USAID/JSI monthly coordination meetings Monthly coordination meetings were held on a regular basis and involved the Undersecretary for Integrated Health Care, HM/HC Executive Director, USAID/ HM/HC Team Leader and JSI Chief of Party. The primary purpose of these meetings was to review the Monthly Work plan, coordinate activities and secure the involvement of HM/HC Project staff in joint missions with JSI staff. The meetings also discussed areas of intra-ministerial coordination and integration, as well as coordination with other ministries and government and non-government organizations. MOHP intra-ministerial coordination Following the first meeting of the High Committee for Safe Motherhood chaired by H.E. Minister of Health and Population and to respond to the call of H.E. for more integration and cooperation between the concerned departments/sectors of MOHP, a series of follow-up meetings were held in the following departments: Curative Care Department Infection Control Department Private Sector Department Urban Health Department Nursing Department Human Resources Development Department Central Laboratory Department Safe motherhood committee meeting Family Planning Department National Information Center for Health and Population (NICHP) Blood Bank Affairs Department Project Development and Technical Support Department MCH General Department 107

120 General Department for Quality Primary Health Care General Department Health Sector Reform (HSR) Integrated Management of Childhood Illness (IMCI) Expanded Program of Immunization (EPI)/Maternal and Neonatal Tetanus TAHSEEN Project The TAHSEEN Project demonstrates its commitment to using an inclusive and participatory approach to solidify MOHP s investment in FP/RH activities and establish a sustainable program that addresses behavior change, quality improvement, linkages to other sectors and community involvement to promote usage of FP/RH services by those in need. Both TAHSEEN and HM/HC Projects are being implemented by the MOHP with technical assistance and funding by USAID. According to Ministerial Decree 29/1998, there shall be integration between Projects to avoid duplication of efforts and resources. Since the activities implemented by the two said Projects support the same ministry, often the same clinics, mostly the same clients and strengthen similar and often identical support systems, coordination and cooperation was needed to maximize efficiency and to prevent the unnecessary efforts of vertical programs. After a series of meetings, a MOC was finalized and signed by FP, MCH, USAID, JSI and Catalyst. Through this MOC TAHSEEN and HM/HC Projects intend to deepen, enhance and continue this cooperation for the furtherance of the goals of both Projects and the Government of Egypt. The MOC included two types of activities; the first type was the coordination and integration of the FP and MCH systems and the second was the development of a strategy and a plan for the implementation of the integrated MCH/FP activities in two districts in El Menya Governorate; Mallawi and Mattay. For more details on the activities conducted in this area, please refer to Task Two in the Accomplishments Section of this Report (Section 3). NGO Service Center During the Option Period, JSI assisted the NGO Service Center in reviewing their training materials. These training materials mainly address 5 topics; gender, advocacy, networking, capacity building and management and are used in training NGO staff. Also, JSI provided the NGO Service Center with a copy of its technical materials. These materials included protocols, training modules and IEC materials. JSI also provided a list of the NGOs working in the Upper Egyptian governorates in fields related to the health issues. JSI and the NGO Service Center reviewed together the criteria for the selection of the umbrella NGOs. JSI shared in a round table meeting with the NGO Service Center, Swiss Fund, Institution for Cultural Affairs (ICA), Social Fund for Development (SFD) and the Businessmen Association. The aim of the meeting was to discuss and share the experiences of these different organizations in regard to the constraints of the implemented credit programs in Egypt.

121 The Population and Health Advisory Committee was established to provide technical assistance and to support NGO Service Center activities. The committee includes relevant staff from the NGO Service Center, JSI, Pathfinder and USAID. This committee advises on NGO grant selection criteria, ensures the application of the FP- HM/HC quality management systems in the target grantees clinics, guides the integration of community health awareness in NGO Service Center programs and advises on the procurement process for medical commodities. JSI reviewed the eligibility criteria of NGOs that were submitting their concept papers to the NGO Service Center. A list of consultants was recommended to help potential NGOs in preparing their proposal prior to the final submission and grants agreement. The areas of action of these organizations include clinical and non-clinical services in the areas of MCH and RH. Partnership in Health Reform (PHR) A series of coordination and information sharing meetings took place tackling HM/HCrelated topics such as Basic Benefit Package standards, referral system guidelines, quality assurance, accreditation and certification processes. Meetings dealing with the means and ways of coordination and implementation of a monitoring system to track utilization and impact took place in the Sohag, Assiut and El Menya governorates. Environmental Health Project (EHP) The EHP is a centrally funded USAID Project focused on the prevention of diarrhea disease and infant mortality. Although its primary focus is on environmental health in Indian slums, EHP also aims to identify reliable approaches that could be applied to urban health programs in general. EHP s involvement in Ezbet El Nawar in Egypt is relatively minor and serves to explore a community approach to improved urban health. A regional USAID meeting was held in India in February 2004 where EHP presented its findings on urban health frameworks. JSI participated with two presentations addressing the following topics: HM/HC strategies, objectives and activities Urban health problems in Egypt The HM/HC intervention model in two slum areas in Egypt Community multi-disciplinary interventions in the HM/HC Project with a focus on the slum areas The common search for an urban health approach creates a great complementarity between the activities of EHP and HM/HC in the slum areas. (HM/HC could provide technical assistance on the behavior and education components of EHP s hygiene improvement framework). The development of new urban health specific literacy modules carried out by World Education in partnership with GALAE and HM/HC was identified as an ideal area for integrating the urban health efforts of EHP and HM/HC. NAMRU-3 A coordination meeting was held with NAMRU-3 to determine topical areas for the experimental program on infection control in neonatal units in the MOHP and Egyptian Medical Schools. The program included the development of a protocol of cooperation, 109

122 the development of assessment tools, sharing training packages and attending assessment visits. Another meeting was held between the National Program for Infection Control and Safe Injection and the JSI Community Health Team to share information and exchange experiences. The focus of the discussion was on how to build on the community work that has been established to reach households and community committees with messages on safe injection. The NAMRU-3 team shared with JSI the Qualitative Baseline Assessment of the Neonatal Program for the promotion of Infection Control and Safe Injection in Egypt. This assessment was conducted in 2001 targeting the general population and health care workers. The NAMRU-3 team also shared efforts in the promotion of infection control and safe injection. Activities included research, development of a strategy for the infection control program, and the implementation of this program in pilot governorates (Qena and Sharkia). They also shared their achievements in the IEC field as well as infection control activities implemented in 22 NICUs in MOHP hospitals. World Education General Authority for Literacy and Adult Education (GALAE) A concept paper for the replication of the pilot phase for integrating the HM/HC critical messages to the literacy curriculum of GALAE was developed to start the activity in the rest of the Luxor governorate as well as the Cairo and Giza governorates. JSI attended a number of meetings between the Ford Foundation in Cairo and World Education which were organized in response to the Ford Foundation s interest in supporting and expand the cooperation between HM/HC and GALAE in integrating health messages into the GALAE curriculum for low literacy classes. The meetings yielded an agreement between the Ford Foundation and World Education to add ten new lessons to the five lessons that have been developed, tested and taught in Luxor. A MOC between HM/HC-MOHP-GALAE, World Education and JSI was prepared and signed by the concerned parties. The purpose of this memo was to identify roles and responsibilities in building the capacity of GALAE to train governorate facilitators and teachers to integrate health messages in the literacy program. Accordingly, the training of 10 national trainers took place in Cairo and Giza. JSI, in cooperation with World Education, organized and facilitated a meeting to share the results of the community needs assessment conducted in Mallawi, El Menya in areas pertaining to the following topics: maternal and child nutrition, reproductive health and personal and domestic hygiene. In the framework of a MOC signed in September 2002, World Education began the implementation of the Ford Foundation-funded Expanded Women s Integrated Health and Literacy Activity (in January 2003). For more details, please refer to Task Seven in the Accomplishment Section of this Report (Section 3). WHO/UNICEF JSI participated in a two day workshop organized by the IMCI National Program and WHO-EMRO to review an IMCI Supervisory Package and discuss the ways and means of incorporating this package into the MOHP Supervisory System. IT officials from concerned departments of MOHP participated in this workshop.

123 JSI participated in the health facility survey activities conducted by the IMCI National Program and WHO, from December 2001 through April 6, The activities included, planning, testing of the survey forms, training of surveyors, field work and data collection and finally review of the survey results. National Polio Campaign: Responding to USAID s request, JSI mobilized highly qualified staff to help in the national polio campaign on Dr. Mahmoud Fatthalla, WHO Consultant, during a safe motherhood committee meeting September 28-30, 2002, a function which was beyond JSI contract requirements. The main role of JSI staff was to assist the 11 international polio experts in observing polio activity in more than 15 governorates. JSI provided four consultants to serve as observers during the National Immunization Days (NID) October, After a briefing with WHO/MOHP officials, the consultants were assigned the responsibility of monitoring the NID activities in high risk districts and randomly selected health centers. A meeting was held between JSI and UNICEF to discuss the social mobilization activities planned to be implemented as part of the national Polio Immunization Campaign. A meeting was held to coordinate the integration of the daya training curriculum with UNICEF and to conduct field visits to review UNICEF s Healthy Woman, Healthy Child Project in the El Menya and Assiut governorates. UNICEF, based on a recommendation by the HM/HC Executive Director, sought the support of JSI in two related areas: The planning of a routine TT campaign as well as clean and safe delivery. JSI provided IEC materials that would support such efforts and expressed its willingness to join any future planned efforts in Upper Egypt target governorates. The JSI/SHIP specialist together with the SHIP coordinator in HM/HC participated in the Roundtable Dissemination Meeting on the study of Adolescents Media Habits in Egypt: What We Know and What We Need to Know. The meeting was organized by UNICEF. It was held on October 19, 2003 in the UNICEF Cairo office. Another meeting was held to discuss collaboration in the area of micronutrients in general and the prevention of anemia in particular. UNICEF was briefed on the objectives and components of the Adolescent Anemia Prevention Program and provided with materials produced under the umbrella of this program 111

124 Institution of International Education, Development Training 2 Project IIE-DT2 A coordination meeting was held with USAID and IIE-DT2 to finalize the training plan that would be implemented through DT2. Additional meetings were held to review the approved plan and agree on pre-training logistical requirements. The HIO and MOHP central staff expressed the need to develop their managerial skills in order to cope with the demands of the Adolescent Anemia Prevention Program. Accordingly, a fourteen-day workshop was organized by IIE-DT2, and designed and conducted by Gebril for Training and Consultancy, GETRAC. Thirteen HIO, MOHP, MOE and Al Azhar senior managers at central and governorate levels (Base and Option Period governorates) participated in this workshop. In cooperation with JSI, DT2/RCT conducted a series of training workshops for the MOE and Al Azhar master trainers in Assiut and El Menya governorates. The main purpose of these workshops was to enable the participants to train school vice principals on the procedure of iron tablet distribution in schools. In addition to the above several meeting took place as follows: 1. Meetings relevant to the selection of participants for the GWU Advanced Neonatal Care Course for physicians and nurses. 2. Meeting with IIE-DT2 concerning the MHIS training for statistical technicians and district managers in five governorates. A training plan was submitted to IIE-DT2. 3. Meeting with IIE-DT2 and the training provider in regards to the TOT workshops on planning and management and the training schedule. 4. A one-day meeting in Cairo with the HM/HC Project and IIE-DT2 for the participants of the Offshore Training Course on Leadership and Total Quality Management that ended on February 11, Each participant presented an action plan to solve a priority problem in his/her location using the methodologies and experience gained during the course. Follow up on the process of selecting candidates and training occurred along with regular monitoring of training quality. 5. A meeting at USAID with IIE/DT2 representatives was held to discuss the possibility of utilizing savings from the allocated budget for eight teleconference sessions to hire a production house to assist in the development of self instruction videotapes for the teleconferences. It was agreed that this activity was of vital importance and a useful endeavor. JSI helped IIE/DT2 in developing the Scope of Work, issuing the request for quotation and selecting the production house. Regarding the HM/HC Medical Teleconference activities, JSI reached an agreement with IIE-DT2 to produce a series of videotapes related to the Perinatal Medical Teleconferencing activities. Eight teleconference activities have been shot and finalized. Regional Center for Training (RCT) JSI participated in the workshop organized by the RCT on the Quality of Reproductive Health Care. The main topics included the introduction and approaches to quality of reproductive health care and the latest advances in managing obstetric hemorrhage presented by two JSI consultants from the University of California. JSI provided the RCT, based on their request, with CDs and hard copies of the protocols and modules developed and used by HM/HC. They also provided CDs of the eight perinatal teleconference videos. RCT used these materials in producing a Reproductive

125 Health Curriculum as well as in the training of MOHP physicians through the National Training Institute (NTI). Healthy Egyptians Initiative 2010 JSI requested a copy of the MCH objectives of the Healthy Egyptians Initiative These objectives were included in the planning/management training materials which were introduced to the district health officials, to be considered in setting district level annual targets for the district health plans. Private Sector (Abbott) Abbott Laboratories showed interest in collaborating and verbally approved the donation of 2500 solusets, with a promise that in the company s coming planning cycle, they would include more solusets to be donated to continue the pilot study of infection control prevention in NICUs. The National Population Council JSI attended the seminar organized by the NPC on November 4, 2002 to present the findings of the research project The Potential for NGOs FP/RH Clinics for Providing Sustainable Quality Services. His Excellency the Minister of Health and Population inaugurated the meeting which was attended by concerned parties of the MOHP, NGOs, donors and research centers and institutes. The research issued the following recommendations: Family planning clinics run by NGOs should include more RH services in an integrated way to be more attractive to beneficiaries, and to create demand and increase utilization. Reschedule the service times and working hours with a clear focus on having evening shifts to suit more clients needs. Design and conduct training for providers working with NGO clinics in order to provide correct and suitable information and messages to clients on contraceptive methods; in particularly, on how to use them and their side effects. Coordinate between the MOHP and NGO clinics to create more integration and efficiency in providing FP/RH services. Population Council JSI participated in a seminar organized by the Population Council/Frontiers in Reproductive Health Program on October 3, The key findings and the summary of interventions of the operation research was presented. The aim of the research was to demonstrate how improving the quality of client-provider interaction could be achieved in large health care systems and how these improvements could be translated into positive client outcomes of family planning knowledge, method continuation rates and method satisfaction. Egypt s study is one of the global operations research projects that have been conducted in two other countries. The major outcome is that a client-centered interaction will have a positive impact on clients, providers and the entire clinic. JSI participated in the Dissemination Meeting on December 19, 2002 for the Facility Practices Normal Labor: An Observation Study. It is the first comprehensive study of normal labor, where the process rather than the outcome was the main point of emphasis. The tool was pre-tested for 3 days (24 hours of observation every day) and 113

126 changes were made after pre-testing. 188 women were included in the study. Twelve of the observations were discontinued due to complications (thus not considered normal labor anymore). Twelve observers participated in the study and covered 672 hours of continuous observation (28 continuous days). The meeting was concluded with remarks on the relevance of the findings, challenges to policy implementation and future plans. Egyptian Society for Population Studies and Reproductive Health JSI participated in a workshop on January 9, 2002 to disseminate the results of interventions made to integrate a reproductive health framework at the PHC level. The intervention was based on a study, which was conducted in Giza governorate to determine the prevalence of reproductive morbidity. The study was implemented in 18 health centers in Giza, two health centers in Qaliubiya and one slum area in Cairo. The interventions include the following four components: Upgrade the basic level of infrastructure of health care centers at low cost Expand and integrate reproductive health services at the PHC level, which involves the training and re-training of medical and non-medical personnel Expand health education to women in the community Develop indicators to monitor and evaluate the progress and cost of the intervention A separate evaluation of the intervention was done by Dr. Jack Reynolds, who presented its key achievements, shortcomings, challenges, recommendations and overall conclusions. Communication for Healthy Living (CHL) The CHL Project has been contracted by USAID to coordinate, develop and disseminate all the IEC messages and strategies for all health related issues. The Project took the lead in coordinating with other partner projects the development of a bank of messages, called the Family Health Handbook, for use in the family health campaigns. During May 2004, CHL conducted a two-day workshop to update JSI and other key program partners on the implementation of the Family Health Campaigns and to collaborate on the creation of the Family Health Handbook. This workshop provided an opportunity for program partners to update each other on their role in the campaign, to reach a consensus on the objectives, target audience, messages and uses of the handbook. CHL will enhance collaboration, information exchange and knowledge sharing among program partners and hence support the integration between MCH and FP activities. Human Workforce Development (HWD) In a joint agreement between HM/HC, USAID, and JSI, complete sets of HM/HC publications were delivered to JHPIEGO, the technical assistance contractor of HWD/USAID Project, to be distributed to all Medical and Nursing Schools of the universities in accordance with their plan. Save the Children On October 29, 2003, JSI met with the Save the Children team who conducted research in El Menya governorate on Improving Pregnancy Outcomes through Positive

127 Deviance. They presented the major results of the research which was a joint effort between TUFTS University, Save the Children and the MOHP. The presentation of the results of the research, which was conducted in two villages in El Menya with a third village as a control area indicates that reasons for Low Birth Weight (LBW) include: pregnancy intake, day-time rest, household assistance, exposure to second hand smoke and urinary tract infections (UTI). The Project succeeded in reducing the prevalence of LBW in the two villages through the following interventions: Quality antenatal care Micronutrient supplementation treatment of urine tract infections Counseling/social mobilization Plan International A meeting was held on March 11, 2004 with Dr. Raed Azab, Health Advisor, Plan International to join efforts in the slum area of El Basateen Shark where Plan International is working. It was agreed at the end of the meeting to coordinate activities in the area of reproductive health in a complementary way. Student Health Insurance Program (SHIP)/Adolescent Anemia Prevention Program (AAPP) During the Option Period, increasing participation of the Ministry of Education (MOE) and Al Azhar in the SHIP was taking place. Class teachers took the responsibility of distributing iron tablets to the students in all governorates. During the Base Period tablet distribution was included in the health visitors and nurses' responsibilities. Science teachers attained the role of implementing the health education component of the program in the Option Period governorates. Accordingly, many coordination meetings were held at all levels to emphasize the new roles and responsibilities of the education and health staffs. An overview of the SHIP program was given to the Minister of Health and Population in January 2003, through a memo prepared by the HIO and HM/HC officials, with the assistance of JSI. The memo included information on the prevalence of iron deficiency anemia among adolescents in Egypt, the impact of the SHIP program in raising the iron levels among students in Upper Egypt, and a proposed national plan with an estimated budget. The memo received the Minister s consent and the SHIP program is being gradually expanded to all governorates of Egypt during a period of four years ( ). Since the program is extending to all the governorates of Egypt the budget significantly increased and will run beyond the financial capacity of the HIO. It was agreed therefore that MOHP will cover about 50% of the entire program cost. HIO and MOHP officials signed an agreement outlining their financial responsibilities; HIO will cover the expenses of the cups, registers, IEC materials, training courses, regular meetings, as well as the salaries of the health educators of the five Base Period governorates; MOHP will cover the expense of the iron tablets and the monitoring visits. Since SHIP is being sustained through collaborating governmental parties; MOHP, HIO, MOE and Al Azhar, key stake holders have gathered representatives from these parties to form The High Committee for Adolescent Anemia Prevention Program. The purpose of this committee is to provide leadership throughout the national 115

128 implementation phase of the program. The committee began meeting bi-weekly in 2003 and continues to meet monthly. General Directorate of Quality/Accreditation Program The CQIS has been developed in close coordination with the General Directorate of Quality (GDQ), the MOHP, and in coordination with the central department of curative care and MCH. The CQIS is designed to be in harmony with the existing health care system in Egypt and in accordance with the MOHP accreditation program, one of the cornerstones of the health sector reform program. In an effort to maximize the efficiency and effectiveness of JSI interventions, the accreditation program has been pilot tested in two facilities, El Tahrir General Hospital and Gharb El Matar Health Unit (a primary health care facility and its referral hospital where JSI provides technical assistance). The overall goals of these activities were to: Use the nationally recognized accreditation standards for initial facility assessment in the future, and later to measure facility performance over time Establish a framework for a comprehensive, ongoing and systematic procedure of assessment and hence improvement Motivate facility staff to take responsibility for self assessment and improvement Observe the impact of implementing the accreditation standards within JSI interventions Significantly contribute to the provision of quality care in health facilities by improving the way hospitals function, while maintaining the focus on practitioners performance Develop staff managerial capacity and engage them in a comprehensive improvement process (i.e. development, implementation and monitoring of the facility plans) Preparatory meetings were held to discuss and identify areas of cooperation and collaboration to achieve the above mentioned goals. As a result of the discussions El Tahrir GH and Gharb El Matar HU were chosen to be assessed for accreditation. Training workshops for the facilities' staff were conducted. These workshops were followed by a field visit to El Amriya District Hospital in Alexandria, which achieved a provisional accreditation score of 63%. The main purpose of the workshops and the field visit was to provide technical support to the staff of the two facilities enabling them to develop an improvement plan in order to meet accreditation standards. The visit provided exposure for JSI staff to the accreditation program, which may affect future JSI strategies, assuming that accreditation and accountability remain a priority in health reform. It also allowed JSI staff to observe first hand the impact the program has made towards improving the El Amriya DH.

129 V. Contract Milestones and Completion Indicators Contract Milestones The JSI contract is a Cost-Plus-Fixed-Fee Contract. Payment of fees was based upon the completion of performance milestones established for the contract. These performance milestones were developed by JSI during the proposal process and approved by USAID. The milestones define and specify the scope, implementation, and timing of HM/HCdeveloped products and systems that will directly further the achievement of each subresults package. Under the JSI contract, there are 36 performance milestones. All the milestone documents have been submitted to USAID for validation and approved as documented in Annex 19 Milestone Status Report. Completion Indicators The contract specifies the indicators for contractually required inputs, processes and outputs to be achieved by JSI. These indicators which include milestones and completion indicators have been compiled into a single internal tracking tool called the Contract Indicator Matrix. The status of achievement is shown in Annex