Mali Country Report FY16

USAID ASSIST Project Mali Country Report FY16 Cooperative Agreement Number: AID-OAA-A-12-00101 Performance Period: October 1, 2015 September 30, 2016 DECEMBER 2016 This annual country report was prepared by University Research Co., LLC for review by the United States Agency for International Development (USAID). The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project is made possible by the generous support of the American people through USAID.

USAID ASSIST Project Applying Science to Strengthen and Improve Systems Mali Country Report FY16 Cooperative Agreement Number AID-OAA-A-12-00101 Performance Period: October 1, 2015 - September 30, 2016 DECEMBER 2016 DISCLAIMER This country report was authored by University Research Co., LLC (URC). The views expressed do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Acknowledgements This annual country report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID) under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, which is funded by the American people through USAID s Bureau for Global Health, Office of Health Systems. The project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC's global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard T. H. Chan School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communication Programs; and WI-HER, LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write assist-info@urc-chs.com. Recommended citation USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. 2016. Mali Country Report FY16. Published by the USAID ASSIST Project. Bethesda, MD: University Research Co., LLC (URC).

Table of Contents List of Figures and Tables... i Abbreviations... ii 1 INTRODUCTION... 1 2 PROGRAM OVERVIEW... 2 3 KEY ACTIVITIES, ACCOMPLISHMENTS, AND RESULTS... 2 Activity 1: Improve delivery of high-impact evidence based maternal and newborn care and post-partum family planning services at facility... 2 Activity 2: Improve Delivery of Evidence-based Interventions to Reduce Anemia among Pregnant Women and Infants at Facility and Community Levels in Target Districts in Sikasso Region... 7 Activity 3: Application of WHO s Framework for Integrated People-Centered Health Services... 8 4 SUSTAINABILITY AND INSTITUTIONALIZATION... 10 5 KNOWLEDGE MANAGEMENT PRODUCTS AND ACTIVITIES... 11 6 GENDER INTEGRATION ACTIVITIES... 11 7 DIRECTIONS FOR FY17... 12 APPENDIX... 13 Activities Summary Table: Report on Progress against the Work Plan (October 2015-September 2016... 13 Annual Indicators Table Reflecting Cumulative Numbers for the Progress Achieved in FY16... 30 List of Figures and Tables Figure 1: Percentage of adhesion compliance to norms for newborn resuscitation, 148 sites, Kayes Region (Apr-Sep 2016)... 5 Figure 2: Percentage of Safe Childbirth Checklist use by health providers according to standard norms and compliance to norms and standards for PE/E, 47 sites, 2 districts, Kayes Region (Apr-Sep 2016)... 6 Figure 3: Percentage of women who received immediate PPFP counseling before discharge, 284 sites, Kayes and Sikasso regions (Jan Jun 2016)... 7 Table 1: Key actions related to WHO Integrated People-Centered Health Services for delivery and postpartum care, Diéma Health District... 9 USAID ASSIST Mali Country Report FY16 i

Abbreviations AMTSL Active management of the third stage of labor ANC Antenatal care ASACO Association de santé communautaire (Community Health Association) ASC Agent de santé communautaire ASSIST USAID Applying Science to Strengthen and Improve Systems Project BCC Behavior change communication BF Breastfeeding CSCom Centre de santé communautaire (Community health center) CSRef Centre de sante au niveau référence (Referral level health center) DHIS2 District Health Information System 2 DNS Direction Nationale de la Santé (National Health Directorate) DRS Direction Régionale de la Santé (Regional Health Directorate) DSR Division de Santé Reproductive (Division of Reproductive Health) ENC Essential newborn care EONC Essential obstetric and neonatal care FP Family planning HIS Health information system HBB Helping Babies Breathe HMIS Health Management Information System HSS Health systems strengthening IP Implementing partner IPC Interpersonal communication IPT Intermittent preventive therapy KM Knowledge management LAPM Long-acting methods and permanent methods MDG Millennium Development Goal M&E Monitoring and evaluation MIYCN Mother, infant, and young child nutrition MNCH Maternal, newborn, and child health MNH Maternal and newborn health MOH Ministry of Health NGO Non-governmental organization NR Newborn resuscitation PCIHS People-centered integrated health services PE/E Pre-eclampsia and eclampsia PPFP Postpartum family planning PPH Prevention of postpartum hemorrhage QI Quality improvement QIT Quality improvement team RC Relais communautaire (Community health worker) RH Reproductive health SCC Safe Childbirth Checklist SIAPS Systems for Improved Access to Pharmaceuticals and Services TOT Training of trainers URC University Research Co., LLC USAID United States Agency for International Development UNICEF United Nations Children's Fund WASH Nutrition/water, sanitation, and hygiene WHO World Health Organization ii USAID ASSIST Mali Country Report FY16

1 Introduction During the last several years, the Government of Mali and its partners have made serious investments in the health care sector and have developed multiple integrated strategies to improve the access, demand, and quality of maternal, newborn, and child health (MNCH), family planning (FP), and nutrition services at both facility and community levels. Despite these efforts, the country has not yet seen an improvement in key health indicators. The maternal mortality rate remains at 368 per 100,000 live births. The causes of maternal death are postpartum hemorrhage, hypertensive disorders, sepsis, unsafe abortion, and prolonged or obstructed labor. The neonatal mortality rate is 34 per 1000 due to preterm births, asphyxia, and sepsis, and the child mortality rate is 95 per 1000. Skilled birth attendance, reported at only 59% of births, could if expanded, significantly reduce maternal mortality due to hemorrhage. Antenatal care visits are reported at 41% overall but only 2% for four visits (DHS 2012-2013). Mali has a high total fertility rate of 6.1 and a low contraceptive prevalence rate of 10% for modern methods. The unmet need for FP in Mali is 26% among all women of reproductive age (DHS 2012-2013). While postpartum family planning (PPFP) with healthy timing and spacing of pregnancies, lactational amenorrhea, and transition to modern FP methods are included in Mali s policies, greater emphasis on longer-acting FP methods is needed to help women to achieve appropriate pregnancy spacing. In Mali, the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project is contributing to the reduction of maternal, newborn, and child mortality by working to improve health care and essential functions of the health system at facility and community levels. To achieve these goals, the project is continuing to work with the government and USAID implementing partners (IPs) to strengthen high-impact evidence-based MNCH/FP and nutrition/water, sanitation, and hygiene (WASH) intervention packages at the community and facility levels. ASSIST is working hand-in-hand with regional and national Ministry of Health (MOH) representatives to reinforce and expand ongoing efforts to achieve country maternal newborn and child health targets. Since 2013, ASSIST has successfully worked in 244 community health centers and referral health centers in Kayes and Sikasso regions to improve the provision of MNCH/FP and nutrition services by applying quality improvement. More than 7,000 skilled providers and 8,000 community health workers have been involved in capacity and competency building at different levels of the health care system. In FY16, USAID ASSIST in Mali strengthened and expanded activities undertaken in FY15 to deepen and broaden the technical content and coverage of ASSIST-supported work. ASSIST has scaled up the WHO Safe Childbirth Checklist (SCC), including best practices for active management of the third stage of labor (AMTSL), essential newborn care (ENC), pre-eclampsia and eclampsia (PE/E), Helping Babies Breathe (HBB), PPFP, and antenatal care (ANC) to all 10 districts in the Kayes Region and four districts of the Sikasso Region, covering all 338 facilities in the two regions. Anemia prevention and control work has been scaled up in the 10 districts of Kayes and three new districts of Sikasso Scale of USAID ASSIST s Work in Country MOH (National Directorate of Health and 2 Regional Directorates) 2 out of 9 regions 14 out of 20 districts 338 facilities 235 communities in Sikasso 338 QI teams 3,717,861 out of 5,686,908 USAID ASSIST Mali Country Report FY16 1

2 Program Overview What are we trying to accomplish? At what scale? 1. Improve delivery of high-impact evidence based maternal and newborn care and postpartum family planning services at facility and community levels Improve delivery of high-impact Regions: 2 out of 9 (Kayes and Sikasso) evidence based maternal and Districts: 14 out of 20 in 2 regions newborn care and post-partum family o Target districts in Kayes Region: Bafoulabé, planning (PPFP) services at facility Oussoubidiagna, Diema, Kayes, Nioro, Kenieba, and community levels Kita, Sefeto, Sagabari and Yelimané Build capacity of district, regional, and o Target Districts in Sikasso Region: Bougouni, national managers and stakeholders Kolondieba, Yanfolila, Kadiolo to support quality improvement processes Facilities in selected districts: 338 out of 462 (233 out of 233 in Kayes and 109 out of 229 in Sikasso), 14 district hospitals and 1 regional hospital Communities: 10 out of 28 health areas in 1 district Catchment population in facilities served: 2,375,000 out of 2,375,000 in Kayes and 1,272,954 out of 3,242,001 in Sikasso Region 2. Improve delivery of evidence based interventions to reduce anemia among pregnant women and infants at facility and community levels Improve delivery of evidence-based Regions: 1 out of 9 (Sikasso) interventions to reduce anemia Districts: 4 out of 10 (Bougouni, Kolondieba, Yanfolila, among pregnant and postpartum Kadiolo) women and infants at facility and community levels Build capacity of district, regional, and national managers and stakeholders to support quality improvement processes Facilities in target region: 100% (109 out of 109) Facilities in selected districts: 100% (105 out of 105 health centers) and 4 district hospitals Communities: 56 out of 506 Catchment population facilities served: 1,272,954 out of 3,242,001 3. Application of WHO s Framework for Integrated Person-Centered Health Services (IPCHS) (Cofunded by the Office of Health Systems as a Cross-Bureau activity) Apply people-centered care framework in partnership with WHO Improvement Activity 5 facilities in two districts (Diema and Yelimane) in Kayes Region 3 Key Activities, Accomplishments, and Results Activity 1: Improve delivery of high-impact evidence based maternal and newborn care and post-partum family planning services at facility BACKGROUND The project is focusing on evidence-based MNCH/FP high-impact, cost-effective best practices including but not limited to: AMTSL, ENC, HBB, and PE/E early detection and management interventions. These interventions are integrated with the WHO Safe Birth Checklist (SCC) and are being scaled up from nine districts and 266 community health centers (CSCOMs) to 14 districts and 338 CSCOMs in two regions. Separately from the integrated package through the SCC, the project is applying QI to PPFP in all 10 districts of Kayes and scaling up PPFP to four districts of Sikasso Region where anemia improvement work has been scaled up from one to four districts. 2 USAID ASSIST Mali Country Report FY16

ACCOMPLISHMENTS AND RESULTS Integration of quality improvement indicators into national Health Management Information System (HMIS). USAID ASSIST has worked with the MEASURE Evaluation Project under the leadership of the Ministry of Health HMIS Department to introduce the District Health Information System 2 (DHIS2) in Mali. The project is a member of the Monitoring and Evaluation (M&E) working group set up by USAID Mali and its implementing partners. Through this working group, the project M&E team has contributed to the review process of the national HMIS by providing technical assistance and including five quality improvement indicators to sustain the quality improvement process within the national HMIS. The indicators are related to AMTSL, PE/E, and ENC. They have been tested in at least 225 sites in Kayes Region from 2014 to 2016. Through the demonstration and the testing within sites, the indicators have been validated each quarter by QI teams at regional and district levels. In addition, the same indicators have been checked during USAID Mali annual data quality assessment and validated for national use. The five indicators are: 1. Number of deliveries in health facilities using AMTSL 2. Number of postpartum hemorrhage cases after using AMTSL 3. Number of newborns who received vitamin K1 4. Number of newborns who received tetracycline 1% 5. Number of newborns who received immediate breastfeeding (with 30 minutes of delivery) Appropriation of quality improvement approach as national orientation for quality applied to service delivery at the health center level. ASSIST has worked to implement quality improvement in MNCH and FP in all 10 districts of the Kayes Region and four districts of the Sikasso Region. As a result, the project was able to influence national technical norms and standards related to postpartum family planning and the WHO SCC, including HBB, PE/E, AMTSL, and essential newborn care. Two dissemination meetings for the PPFP and WHO SCC results were organized at the regional level to ensure national uptake of this process for service delivery at the health center level. Recommendations made after the meetings include the scale-up of these activities at the national level to cover more districts and regions. As of the writing of this report, quality improvement is included in the National Directorate for Health priorities to achieve more results to decrease maternal and child mortality. Authorization at regional level in Kayes for the use of MgSO4 by trained providers to facilitate the transfer of women with pre-eclampsia to higher levels of referral care. One of the major causes of maternal death in the Kayes Region is linked to PE/E. The project prioritized working to improve PE/E diagnosis and case management within the region through QI methods. For the past year, the project invested in training skilled providers and non-skilled providers to increase the screening and case management of PE/E in all sites of all ten districts of Kayes. Regular monthly and quarterly coaching visits were organized by QI teams and health managers to support the implementation of activities at each level. As a result, 95% of providers complied with the norms and standards for PE/E screening and management. Previously, non-skilled providers and even trained providers at the primary care level were not allowed to provide the first dose of MgSO4 to a woman with PE/E before she was transferred to a higher level of referral care (i.e., the referral care health center or CSREF). The project has tested and demonstrated that trained and coached providers can easily prepare the women for transfer by providing the first dose of MgSO4. Actually MgSO4 is available in the delivery room as well as within the Caesarian-section kits in all sites of the region. As this was not included in the National Reproductive Health Norms and Standards, the project has conducted advocacy with regional health managers and authorities to obtain an official letter allowing trained providers to proceed with this procedure in order to help reduce mortality due to PE/E. To facilitate the implementation of this recommendation, the project has worked with USAID SIAPS to ensure the availability of MgSO4 in the health centers through its inclusion in the National Essential Drugs list by the MOH Drugs Management Department. Increasing human resource capacity to implement quality improvement at national, regional, and district levels. USAID ASSIST has been working on quality improvement since 2013 in Mali, and one of the key strategies has been capacity building of health managers and providers at national, regional, and district levels to ensure sustainability and uptake of quality improvement within the country. During FY16, the project trained more than 7,000 health providers and 15,000 USAID ASSIST Mali Country Report FY16 3

community members to facilitate the implementation of QI applied to MNCH and FP in the impact regions. Forty (40) regional coaches and 110 districts coaches are now available to continue with capacity building and scale-up of QI in other regions of the country. In addition, more than 100 health decision makers have been oriented and informed about the quality improvement process and are helping advocate for scale-up of the project s activities. In addition, the project has oriented other USAID-funded project teams on improvement approaches, tools, and training materials. The staff of these projects have been exposed to quality improvement process and implementation on the ground. Development of national strategy for quality improvement for service provision and care. To WHO checklist training session, Sikasso, respond to sustainability and institutionalization issues August 2016. Photo Credit: Ibrahima Kamaté regarding quality improvement applied to MNCH and FP, the project initiated the development of the National Strategy for Quality Improvement with the National Directorate for Health, as well as other projects and partners working on quality improvement for health. For this process, a national working group for quality improvement was set up, which is composed of 27 representatives of each technical division involved in working on quality improvement. The committee has developed, with the technical assistance of the project team, the terms of reference for the national process to develop the national strategy. As of the reporting period, this strategy has been validated by all partners working on quality in the country, and the workshop to present the strategy to MOH decision makers for official launch is set for early in FY17. Increasing compliance to norms for Helping Babies Breathe (HBB) in Kayes Region. Figure 1 shows the percentage of compliance to norms for newborn resuscitation in 148 sites in the Kayes Region. The district of Bafoulabe is used as a model to illustrate how well it is performing. Bafoulabe is one of the largest districts in Kayes, and access to the community health center is challenging during the raining season. However, the district team is very dynamic and has taken a lot of initiative for building the capacity of the community health centers and staff recognition. They have initiated refresher trainings for their staff working at the maternity, especially nurses and midwives who are in charge of delivery at the referral health center and matrons who are at the community health center level. They also intensified formative supervision visits in addition to project coaching visits. The six coaches of Bafoulabe are all trainers on HBB. They have put in place a follow-up system for the use of job aids during resuscitation, checking, and daily maintenance of resuscitation materials and procurement of new complementary materials for the center. 4 USAID ASSIST Mali Country Report FY16

Figure 1: Percentage of adhesion compliance to norms for newborn resuscitation, 148 sites, Kayes Region (Apr-Sep 2016) 148 sites of KAYES District of BAFOULABE 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 500 400 300 200 100 0 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Number of criteria to be respected 26 21 21 11 26 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Ideas of change - Use of job aids during resuscitation - Checking and Maintenance daily of resuscitation materials - Systematic on site practical training for of all nurses and midwifes of the maternity Strengthening quality improvement results by introducing the WHO Safe Childbirth Checklist for delivery and post-partum care in Kayes Region. Four coaching visits on the Safe Childbirth Checklist were conducted in 97 sites of five districts of Kayes (Kayes, Diéma, Oussoubidiagna, Yelimané, and Nioro) with 22 districts and regional coaches. One hundred eighty-two (182) providers were assessed (116 women, 66 men), and 95% were found to comply with standards for the use of the checklist. Within the sites where mother and child transmission services are provided, it was found that there was a stock-out of HIV tests and medicines during this period. The use of the Safe Childbirth Checklist has highlighted the issue of availability of HIV prevention and treatment services. Figure 2 illustrates the trends of services provided during delivery at maternities in the two demonstration districts of Kita and Kenieba in 47 sites. USAID ASSIST Mali Country Report FY16 5

Figure 2: Percentage of Safe Childbirth Checklist use by health providers according to standard norms and compliance to norms and standards for PE/E, 47 sites, 2 districts, Kayes Region (Apr- Sep 2016) 100% 90% Improvement in delivery care quality through use of the SCC % of Check-list which documented that provider gave ENC care according to the norms 80% 70% 60% 50% 40% 30% 20% 10% 0% Insufficiency of systematic counseling during ANC visits Stock-out of HIV test and medicine Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 % of Check-list which documented that provider has managed successfuly bleeding for mothers by applying AMSTL % of compliance to the norms and standards for PE E management % of Checklist which documented that provider complied with the documentation of mother HIV status and treatment 250 200 150 100 50 0 180 184 190 184 188 197 196 179 164 126128 145 148 159 122 125 136 117 128 135 106 108 119 113 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Number of checklist monitored Number of standards norms for PE E Number of checklist monitored Number of checklist monitored Provided technical support to strengthen and scale up ANC and PPFP best practices. As postpartum family planning activities were extended in Sikasso, the best practices from Kayes were used to improve the quality of these services within health centers in 105 sites of four districts of Sikasso. In the meantime, the achievements from the 179 sites in seven districts of Kayes were consolidated during coaching visits during this reporting period. Coaching visits on PPFP were conducted in all the targeted sites. Eighty-four percent (84%) of providers were found to comply with the norms on PFPP services provision. District coaches and project technical staff worked with non-performing sites to provide refresher trainings. One of the key areas that was strengthened during these coaching visits was the inventory of FP supplies within sites, especially for long-acting methods. This was done with the support of the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program, also funded by USAID. The increase in the percentage of women who received PPFP counseling in immediate post-partum period, especially in the Sikasso Region, is illustrated in Figure 3. 6 USAID ASSIST Mali Country Report FY16

Figure 3: Percentage of women who received immediate PPFP counseling before discharge, 284 sites, Kayes and Sikasso regions (Jan Jun 2016) Activity 2: Improve Delivery of Evidence-based Interventions to Reduce Anemia among Pregnant Women and Infants at Facility and Community Levels in Target Districts in Sikasso Region BACKGROUND With the increase of anemia awareness among community partners (i.e., CSCom staff, community health associations or ASACO, local leaders, and other community groups such as women s groups), ASSIST is building on the results of previous efforts to scale up and spread best practices to the other 38 health areas of Bougouni and three new districts of Sikasso (Kadiolo, Yanfolila, and Kolondieba). At the facility level, ASSIST is focusing its technical support on the MOH and partners to improve screening and case management of anemia among children six to 59 months of age and pregnant women; increase the number of children six to 59 months of age and pregnant women who receive services and information on anemia prevention; and increase the number of children six to 59 months of age and pregnant women who know and adopt adequate attitudes on anemia prevention. Collaboration with partners implementing WASH interventions is being cultivated to address parasitic causes of anemia in women and children. ACCOMPLISHMENTS AND RESULTS Systematic application of anemia screening and management for children under age five and pregnant women by providers and community members within project impact areas. During FY16, USAID ASSIST has contributed to the improvement of anemia prevention and case management for pregnant women and children under age five in four districts of Sikasso Region, covering 105 sites in total. The project increased the number of providers and community health workers who complied with anemia systematic screening and case management at the health center USAID ASSIST Mali Country Report FY16 7

level and within communities. The project has strengthened the capacity of 325 providers to provide quality services during antenatal care and post-partum periods. As a result, 96% of coached and trained providers from the 105 sites are complying with norms and standards for anemia management. In each health center, anemia screening became a systematic process during antenatal care and preventive surveillance of children. In addition, volunteers and community health workers worked together to identify, sensitize and refer pregnant women for early antenatal care services in 528 villages (first three months of pregnancy). In total, 2378 pregnant women have benefited from these services due to the effort of community committees trained by the project. Sustaining use of antenatal care services and prevention actions with community committees in 528 villages of four districts of Sikasso Region. USAID ASSIST has developed a community mobilization approach based on existing community networks led by women leaders and decision makers in the demonstration district of Bougouni. The best practices from this demonstration have been scaled up in three new districts in Sikasso to increase the number of women who go for early antenatal care, which includes anemia prevention with iron folate tablet use. To sustain the understanding of anemia disease as a major cause of complications during pregnancy, the project has trained and coached community committees. With the skills gained through the training and orientation done by the project, the committees have initiated local improvement changes to support project activities such as: providing financial support to pregnant women who accepted early antenatal care (transportation and antenatal care fees); sensitizing neighboring villages not included in the project impact area to spread best practices; mobilizing other community leaders through theater performances and local songs/poems; organizing exchange learning visits between committees for better performance; and involving local authorities in community coaching visits to sustain them without project resources. SPREAD OF IMPROVEMENT In FY16, USAID ASSIST scaled up the WHO Safe Childbirth Checklist (including best practices for AMTSL, ENC, PE/E, HBB, PPFP, and ANC) to all 10 districts in Kayes Region and four districts of Sikasso Region, covering 338 out of 338 facilities in the two regions. Anemia prevention and control work has been scaled up in the 10 districts of Kayes and three new districts of Sikasso, with a coverage of 338 facilities in total. Activity 3: Application of WHO s Framework for Integrated People-Centered Health Services BACKGROUND In 2015, ASSIST Mali in collaboration with its partners decided to implement the WHO Framework on Integrated People-Centered Health Services (IPCHS) in areas where they had a long history of promotion and coordination of interventions to improve quality of essential obstetric and newborn care and nutrition at health care centers and in the community. The objective of this activity, which is co-funded by the Office of Health Systems with Cross-Bureau funds, is to contribute to reducing maternal, neonatal, and child mortality and morbidity in Kayes and Sikasso regions by improving the quality and patientcenteredness of essential health services that are provided at health facilities and at the community level. ACCOMPLISHMENTS AND RESULTS Strengthening quality improvement results by applying the WHO Integrated People-Centered Health Services Framework for the delivery and post-partum care in two districts of Kayes Region. In collaboration with the National Department of Health, the Regional Departments of Health, the Social Development Department, the Department of Economy and Solidarity, the Department of the Promotion of the Child, Women and Family of Kayes, the SLDSES, and the CSRef of Diéma, the project has initiated and is now implementing the approach as a pilot in five health areas of Diéma District (Farabougou, Lambidou, Torodo, Fassoudébé, and Diéoura). Key actions taken or underway are summarized in Table 1 below. 8 USAID ASSIST Mali Country Report FY16

Table 1: Key actions related to WHO Integrated People-Centered Health Services for delivery and post-partum care, Diéma Health District Sites Plans activities Status of implementation Lambidou Farabougou Diéoura Fassoudébé Torodo Build water source for the health center Build new rooms to extend the maternity to provide privacy for women during labor and delivery Procure beds for the maternity to extend the capacity of the site Finalize the building of antenatal care room at the maternity and equipped it for service provision Mobilize women groups to support sensitization activities for pregnant women to get the first ANC visit in the first three months of pregnancy Increase the capacity of the health center by recruiting additional staffs for the maternity Procurement of additional materials for the maternity Procurement of infection prevention materials and new delivery table Achieved In progress Achieved In progress Achieved Achieved Comments This has been done with the support of the water management team and the ASACO ($634) The ASACO is currently working to mobilize the complementary funding for the building of the rooms with local private donor This has been done by the ASACO The mayor is working with the ASACO to mobilize resources through the decentralization system of health financing The mayor office has committed one person per village to mobilize and sensitize women groups for the delivery of messages regarding ANC in the first three months of pregnancy 1 matron was recruited to strengthen the services at the maternity and facilitate the implementation of 24-hour delivery services Achieved 3 beds, 3 waste boxes, and 2 delivery boxes were procured by ASACO for the center Achieved A set of infection prevention materials and one delivery table were procured; 1 additional cleaner was recruited for the maternity USAID ASSIST Mali Country Report FY16 9

IMPROVEMENT IN KEY INDICATORS Activity Indicator Baseline Improve EONC intervention at the facility level in Kayes Region Improve anemia prevention and control in Bougouni District (Sikasso Region) Increase access to antenatal care for pregnant women by involving community members Compliance to 3 key AMTSL norms Postpartum hemorrhage rate Compliance to ENC norms Compliance to PE/E diagnostic standards Compliance to PE/E treatment standards Newborn with successful resuscitation Compliance to ANC standards % of pregnant women for whom pallor and/or hemoglobin are checked at ANC visits % of pregnant women who received good counseling on how to prevent anemia during ANC visits Immediate breast feeding Provision of iron # of pregnant women identified by committee members # of pregnant women receiving ANC visit during the 1st quarter of their pregnancy 0% (Nov. 09) 17 sites 1.2% (Nov. 09) 17 sites 39% (Nov. 09) 17 sites 25% (Nov. 09) 17 sites 0% (Nov. 09) 17 sites 25% (Jun. 13) 47 sites 40% (Jun. 14) 17 sites 0% (Jan.13) 13 sites 0% (Jan.13) 13 sites 27% (Jan.13) 13 sites 68% (Jan.13) 13 sites 4 Sustainability and Institutionalization March 2016 99%, 179 sites 1%, 179 sites 98%, 179 sites 89%, 116 sites 88%, 116 sites 98%, 179 sites 95%, 200 sites 97%, 43 sites 95%, 43 sites 100%, 43 sites 98%, 43 sites June 2016 98% 182 sites 0,5% 182 sites 97% 182 sites 92% 150 sites 88% 150 sites 89% 182 sites 88% 283 sites 96% 105 sites 88% 105 sites 94% 105 sites 82% 105 sites Last Value Sept 2016 99% 176 sites 0,6% 176 sites 99% 176 sites 88% 229 sites 86% 229 sites 90% 182 sites 87% 276 sites 98% 105 sites 100% 105 sites 99% 105 sites 100% 105 sites 0 (Oct.13) 275 682 3,421 0 (Oct.13) 229 580 2,378 ASSIST Mali works at the country level in partnership with the MOH and other USAID implementing partners on the implementation and scale-up of integrated MNCH and nutrition intervention packages. By building the capacity of MOH managers, decisions makers, and technical staff as well as other USAIDfunded implementing partners, the project is facilitating the roll-out of quality improvement processes within their respective programs for greater sustainability. Stakeholders from national, regional, and district levels and technical teams from other USAID-funded projects are involved in scaling up the improvement strategy and institutionalizing it at different levels of the health system. 10 USAID ASSIST Mali Country Report FY16

In FY16 the project initiated the development of the National Quality Improvement Strategy in collaboration with the National Health Directorate and all divisions. Currently, the national technical QI committee (technical and advisory) has finalized the terms of reference for the workshop for the development of the national QI strategy. The terms of reference have been validated with all partners involved in quality work in Mali. UNICEF Mali has volunteered to work in collaboration with ASSIST to support this process at the national level. Two national facilitators were identified in addition to the project staff to conduct the workshop, and the draft strategy developed will be shared with the regional quality team for feedback before final validation. It was also decided that after the strategy is developed, the policy development will follow in early FY17; a consultant will be added to the current facilitator group to conduct this second process. In addition, due to the results achieved in the past three years and the dissemination of results at the regional level, districts have prioritized QI activities in their work plans and have started to mobilize additional resources from other projects and or donors to support implementation. Best practices and lessons learned are gathered into technical materials that are disseminated among partners through the training-of-trainers and training of providers for more leadership and ownership of capacities. One of the key achievements for sustainability is the integration of quality indicators on MNCH and anemia into the new DHIS2. The project has also advocated for trained providers to administer the first dose of MgSO4 to women with PE/E before transferring them to the referral level in Kayes Region which brings an important change to the national EONC norms and protocols. 5 Knowledge Management Products and Activities Finalized an anemia case study paper in English and French titled Gender integration in quality improvement: Increasing access to health services for women in rural Mali available in English at https://www.usaidassist.org/sites/assist/files/mali_gender_case_study_english_final.pdf and in French at https://www.usaidassist.org/sites/assist/files/mali_case_study_french.pdf. Published a Post-Partum Family Planning best practices package synthesis available at https://www.usaidassist.org/sites/assist/files/mali_synthese_pfpp_combined-final.pdf. Drafted Anemia best practices package synthesis and Eclampsia and Pre-Eclampsia implementation package. Filmed a short video documentary on prevention and management of anemia in Bougouni. Developed draft video testimony on sustainability and institutionalization by government partners. Developed draft video testimony on the use of the Safe Childbirth Checklist by providers. 6 Gender Integration Activities All project data continue to be sex-disaggregated for training, coaching visits, learning sessions, and service provision at facility and community levels. During the family planning campaign, the project initiated age-disaggregated data collection for FP services for women in 105 sites of four districts of Sikasso from April to June 2016. Data entry and analysis were conducted in July and August. The data collection was focused on the factors influencing gender-based violence related to FP use by women in these districts. The FP campaign was an opportunity to interview each woman accessing services who consented to be part of the process. Of the 197 women who were interviewed, 133 sought FP services. Among those seeking FP services, 33% said they were pressured not to do so by their husbands and families, 22% by mothers-in-law, 11% by elder women from the villages, and 33% by brothers-in-law and friends. The project is planning to disseminate these results and work with partners to increase behavior change and communication activities on FP services and uptake in the region. Regarding ANC visits during the first quarter of pregnancy, as of today 528 community committees from the four districts of Sikasso (Kadiolo, Bougouni, Kolondièba, Yanfolila) have identified and referred 2,378 pregnant women to the CSCOM for the ANC visit during the first trimester of pregnancy. The training sessions on gender have been integrated into the PPFP training of providers in the eight districts of Kayes and four districts of Sikasso, resulting in 458 providers and 18 coaches having been trained on gender. Based on the gender improvement plan, the project has developed a community strategy to engage mothers-in-law and heads of families to support pregnant women for ANC during the USAID ASSIST Mali Country Report FY16 11

first trimester of pregnancy. Community committees in the district of Bougouni have significantly improved the use of antenatal services at the community center level by identifying pregnant women, sensitizing them to declare and recognize their pregnancy, and referring them to the health center for services, including anemia screening and case management. As a result, the number of women getting antenatal services increased from 580 women to 2378 in 43 sites of Bougouni. The gender activities have been extended to the three new districts of Sikasso. 7 Directions for FY17 In FY17, based on the project achievement, USAID Mali requested that key technical content be scaled up from 14 districts to 38 districts covering a total of 791 facilities in five regions. Knowledge gathered from FY16 implementation and results will be packaged and used in the new regions to contribute to the reduction of maternal, newborn, and child deaths. Existing MOH coaches will be used for training, capacity building, follow-up, data collection, and data validation at all levels to sustain project approaches and results. Scale-up strategies will be shared and implemented with project resources, and additional funding will be leveraged from others partners working on quality improvement in each region. At the community level, best practices from the anemia work will be expanded in FY17 to 752 peripheral facilities where community health workers are functional. This implementation will be facilitated by representatives of social development and women welfare technical staff at the regional level. 12 USAID ASSIST Mali Country Report FY16

APPENDIX Activities Summary Table: Report on Progress against the Work Plan (October 2015- September 2016) Summary plan of activities Status of Implementation Comments Objective 1: Reduce maternal and newborn mortality through implementation of high impact interventions at facility and community levels in target districts of Kayes and Sikasso Regions Technical content 1: People-Centered Integrated Health Care 1.Enhance the PCIHS concept with Ministry of Health partners at national and regional level (orientation of MOH on the concept) 2.Finalize the design of the PCIHS pilot with partners at regional level with HQ and Regional office technical assistance support 3.Organize a launch meeting at regional level in Kayes for the PCIHS work with the participation of districts teams 4.Develop and/or adapt PCIHS tools (baseline questionnaire, training module, monitoring and evaluation tools etc.) to country local context The project team has conducted four meetings and workshops in Kayes and Bamako (two per zone) to inform and introduce PCIHS concept with implementing partners at regional level in Kayes and national level in Bamako. As a result, 25 managers of health and social development programs were exposed to PCIHS concept, principles, objectives and expected results to strengthen people centered activities within the existing maternal health program. The meetings and orientation workshops were facilitated by the project team. The project team has worked with the MOH regional technical health team of Kayes to complete the design of the pilot for the two districts. The draft plan developed with support from HQ and Regional office has been shared and improved during this review and finalization with regional team in order to have a consensus on the work plan for the period. After the review and finalization of the work plan and the pilot design, the project team, in collaboration with regional health managers, has organized a launch meeting with Diema and Yelimane districts representatives. As a result, PCHIS activities have been integrated into districts work plans for FY16 and districts representatives have declared their commitment to participate into this pilot with the project technical assistance. With the commitment of the regional and districts teams to support the pilot in Kayes, the project team has organized two workshops to identify existing tools and adapt them into local context with technical support from a WHO consultant, HQ and Regional team. As a result, a training module with key elements on PCHIS program integration, indicators and monitoring plan were developed and validated with all partners from different level. In the meantime, during the development of tools, the project team with technical support form research team of HQ has also worked on a protocol of study linked to this improvement activity for the global learning agenda. The draft protocol was completed, submission to the ethic committee of Mali and HQ is in process. USAID ASSIST Mali Country Report FY16 13

Summary plan of activities 5.Organize a training of providers and community actors (community health centers management teams) on PCIHS concept and tools 6.Conduct a baseline survey in the targeted districts (interviews, observations) 7.Organize 4 learning sessions at community health centers on PCIHS 8. Implement PCIHS activities in targeted health peripheral facilities Status of Implementation Comments With the technical support from WHO consultant and regional team, the project team has organized the training of trainers in Kayes. Participants were from Diema, Yelimané and Kayes and the session was facilitated by a WHO consultant and the project team from Bamako. As a result, 21 trainers were trained from different backgrounds to facilitate the integration of PCIHS within current activities at maternities in the two districts. During the training the participants have developed their plans for PCIHS implementation in their respective district. The training of community actors has been organized in Diema with the facilitation of district trainers on PCIHS. Participants from multiple sectors were involved into the training. As a result, 28 (11 women and 17 men) participants were trained with a level of performance from 58% at the pretest to 74% at the post test. In addition, 26 providers (17 women and 9 men) also have been trained with a level of performance at the end of the training at 86 %. These participants will help the project with the implementation of district plans and data collection facilitation per site. The project team has worked with a WHO consultant and HQ/Regional team to develop the baseline questionnaire and design for the targeted sites in the two districts. The field data collection, analysis was completed. The baseline report is available and has been disseminated during the training of providers and actors to ensure gaps identified are align with the plans contents Because of non-availability of partners on the field, the project encountered a two-month delay in conducting the training sessions of participants. the project was able to conduct only two learning sessions. 24 health providers and community actors participated into these learning sessions to gather best practices implemented and validated them for further use in new sites. A list of change tested per site is available as well as the list of 7 practices validated for scale up. Trained providers and participants have started with their improvement plans implementation and data collection initiated in early Q. They are continuing through coaching visits. Process documentation is ongoing with the support of a WHO consultant and Knowledge Management Advisor to elaborate a global report for PCIHS implementation and develop an article for publication at the national and international level. 14 USAID ASSIST Mali Country Report FY16

Summary plan of activities Status of Implementation Comments 9. Supervise and collect data per sites 10. Conduct an end line survey in the targeted health peripheral facilities (interviews, observations) 11. Document results per site and lessons learned from communities and providers 12. Develop article on the results and or lessons learned and publish 13.Support research and evaluation activities for PCIHS implementation in Kayes 1.Organize the training session of district coaches on quality improvement applied to antenatal care in 4 districts of Kayes (Kenieba, Kita, Sefeto and Sagabari) In progress In progress In progress 4 coaching visits were conducted in 5 targeted sites in Diéma district. The purpose of these coaching visits were to observe maternities providers during services provision to patient and interview the patient after services. As a result, 21 providers (17 women and 4 men) were observed and 55 ASACO members were interviewed. 63 patients were interviewed about the services received from providers, the health center environment and welcome and orientation service. The level of patient satisfaction after care is 91% at Farabougou, 93% at Diéoura, 95% at Fassoudébé, and 100% at Lambidou and Tordo. Each site has developed an improvement plan during the initial training. The implementation of this plan was checked during coaching visits. 60% achieved the action plan at Farabougou, 80% at Diéoura, 100% at Fassoudébé, and 83% at Lambidou and 67% at Torodo. The end line survey will be conducted in FY17 for the demonstration sites through the cycle of quality improvement Documentation is ongoing along with training of providers and actors, coaching visits, learning sessions and best practices sessions. The implementation report is available and the list of tested practices also. The final report will be elaborated in FY17 and disseminated at the national level with WHO Mali and Geneva and ASSIST HQ and regional office. This activity is ongoing and will be accomplished in FY17. The first draft of implementation report is available and the presentation of results is ongoing with regional partners. The research protocol for PCIHS assessment was finalized and data will be collected after the pilot phase of PCIHS implementation. Technical content 2: Improved Antenatal Care The training for two districts (Sefeto and Sagabari) was completed with the participation of regional trainers and project team. 49 coaches have been trained (Sefeto 25, Sagabari 24) for the two districts. The level of performance during the pretest was 51% and 74% for the post test. The training sessions for the others districts followed with the participation of a total of 22 providers. The level of performance during the pretest was 66% and 86% at the post test. The trainings were facilitated by regional coaches and project staff. USAID ASSIST Mali Country Report FY16 15

Summary plan of activities 2. Organize the training session of district coaches on quality improvement applied to antenatal care in 3 districts of Sikasso (Kolondieba, Kadiolo and Yanfolila) 3. Organize the training sessions of providers from Referral health centers and community health centers on quality improvement applied to antenatal care in 3 districts of Sikasso (Kolondieba, Kadiolo and Yanfolila) 4.Conduct monthly coaching visits on improved ANC in 3 districts of Sikasso (Kolondieba, Kadiolo and Yanfolila) 5. Continue conduct coaching visits on improved ANC every two month in the 6 old districts of Kayes (Kayes, Diema, Bafoulabe, Nioro, Oussoubidiagna, Yelimane) 6. Conduct monthly coaching visits on improved ANC in 4 new districts of Kayes (Kenieba, Kita, Sefeto, Sagabari) 7. Organize a regional workshop of best practices on improved antenatal care in Kayes Status of Implementation Comments 18 coaches, 11 women and 7 men from the 3 districts have been trained on QI applied to antenatal care in Sikasso. As a result, the level of performance during the pretest was 53% and 85% for the post test. The follow plan for the trained coaches was developed with the project team and implement during the next quarter. The training for non-skilled providers was completed for Kolondieba district. As a result, 23 matrons were trained on QI applied to antenatal care. The level of performance during the pretest was 75% and 91% at the post test. The follow up plan was developed and implemented to test providers competences after the training. The training for the others districts for non-skilled and skilled providers was also organized. 112 skilled providers (35 women and 77 men) were trained on PPFP, PEE and Improved ANC. The level of performance after the training increased from 46% in the pretest to 95% in the post test. The training of non-skilled and skilled providers from Yanfolila and Kadiolo were done. As a result, 121 non skilled were trained (90 women and 31 men). The level of performance after the training increased from 64% in the pretest to 83% in the post test. 15 coaching visits were conducted in the 3 new districts of Sikasso, 352 providers (195 women, 157 men) were assessed and 81% found performing regarding the norms compliance for ANC. The non performing providers were given a refresher on ANC norms during the training on ANC organized by the regional health team in collaboration with UNICEF. 13 coaching visits were conducted in Yelimane, Nioro, Kayes, 227 providers (139 women, 88 men) were assessed and 78% found performing regarding the norms compliance for ANC. The non performing providers were refreshed on site with the facilitation of district coaches and project technical field staff. Coaching visits were conducted in the targeted districts on monthly basis with 118 providers (83 women, 35 men) were assessed and 87% found performing regarding the norms compliance for ANC. The non performing providers were refreshed on site with the facilitation of district coaches and project technical field staff. Best practices on improved ANC have been documented with the collaboration of districts and regional coaches in Kayes and Sikasso. The regional workshop organized with Kayes team allowed the validation of the PPFP guide and best practices which have been shared with Sikasso teams. 16 USAID ASSIST Mali Country Report FY16