Integrated MNCH facility and community intervention

Rationale Improve maternal health: 60% of maternal deaths occur during first week postpartum, yet only 31% of women who deliver at home are seen within the first week after delivery Improve neonatal and infant health: 75% of neonatal deaths occur during first week Prevent unintended pregnancies: Total fertility rate: 5.4; Contraceptive Prevalence rate is 27% for modern methods Ensure ongoing care of HIV+ mother and her exposed infant: by 2011 only 64% of HIV infected pregnant women and 56% exposed babies receive ARV for PMTCT

Program goal To provide a continuum of comprehensive and integrated MNCH care especially postpartum care (PPC) services, inclusive of follow up of HIV + mothers and exposed infants and postpartum family planning (PPFP) 3

Intervention Community Raising awareness in the community on the importance of antenatal, delivery, and postpartum visits & key MNCH behaviours for mothers and infants with support from CHW Ensuring ALL women are tested for HIV postnatally and all HIV+ women and their exposed infants are linked to a continuum of care Facility

Implementation of the PPC package Pre-discharge counseling for newly delivered women, Routine check up of post partum care women, encouraging them to attend PPC within: 48 hours, 3-7 days, 8-28 days and days after delivery Medical check up: checking for sepsis, fistula, post partum depression, breastfeeding, cord care etc HIV testing for mothers and follow up of HIV + mothers and exposed infant Post partum Family Planning (PPFP)  To strengthen technical capacity or providers routine supportive supervision conducted on a quarterly basis 5

Iringa Morogoro Lindi Mtwara Coverage Nov 2010-Feb 2014: 22 districts in 4 regions Program active in 62 facilities, of which: 16 Hospitals 35 Health Centers, 11 Dispensaries Regional coverage of the facility component of the program Program started in 2009 with Guidelines Development

facilities 14 facilities 25 facilities 37 facilities 62 facilities MOROGORO IRINGALINDI MTWARA PHASED APPROACH METHOD OF IMPLEMENTATION

Program Achievements 1. PPC Materials developed in collaboration with the MoHSW: National Post Partum Care Guidelines Learning resources package: including Facilitators Guide, Participants guide, PowerPoint slides, pre and mid course knowledge assessments, M&E tools Performance tools of PPC Standards Based Management at facility level 2. Training of health care providers in PPC: Training of trainers in PPC for trainers in Morogoro and Iringa Training of providers in PPC in all 4 regions (Morogoro, Iringa, Lindi and Mtwara) 8

Trainings PPC facility component People trained TOT Postpartum Care Facility Based Training49 Post partum Care Facility Based Training229

Service delivery achievements Increase in proportion of postpartum visits overall Increase in proportion of 3 rd and 4 th visits More women are receiving the message that they should come back for PPC check-ups More women are counselled on PPFP Women not tested during ANC or L&D have the option of testing at PPC HIV+ clients are reminded to follow up care at CTC for both themselves and their new born

PPC visits by visit type 1 st, 2 nd, 3 rd, 4 th visit

HIV/FP Specific Indicators FY 2010 (Nov Sept 2011) FY 2011 (Oct Sept 2012) FY 2012 (Oct Sept 2013) FY 2013 (Oct Feb 2014) TOTAL Women tested for HIV at PPC ,1981,1563,194 Women identified HIV+ after testing at PPC 22 (8%) 25 (4%) 54 (5%) 28 (2%) 129 (4%) HIV infected women receiving PPC services , ,612 % of PPC clients counselled on FP at least once during their PPC visit -97%95%96%

Challenges on PPC Retention of trained providers in their areas of work Work load/shortage of staff High client load especially for first visit Reporting and recording difficult for high delivery sites PPC services provided in multiple locations Some providers feel PNC services not important New PPC register Gap in PNC register (need of review) Limited number of providers trained - poor knowledge sharing between providers

Integrated Community MNCH Component

Community MNCH (cMNCH) approach Development of standardized CHW program to promote cMNCH including PMTCT and PPFP in the community by home visits Focuses on 4 areas: 1) Women during pregnancy and after delivery 2) Newborns and under 5 children 3) Follow-up of HIV+ mothers and exposed infants 4) Postpartum family planning CHWs conduct health education, mobilization, and referrals rather than direct service provision

Achievements at national level: English version National Guidelines on Integrated Community MNCH The package is officially endorsed and recognized by MOHSW Swahili version Community MNCH Training guide CHW Reference Guide Supervisor Guide Job Aids ( 26)+ IEC Materials Data collection materials Referral forms Reporting forms

Other materials and resources M&E - Recording and Reporting Client register – for birth and deaths registration and service delivery CHW monthly summary report Referral forms Supervisor summary form Census summary form Reference Materials and Equipment Job aids CHW reference Guide Bags Bicycles Manila Sheets Counter book

Selection Criteria of CHWs Selected by the community through the village government in collaboration with the back up health facility supervisor. To be accepted by the community Should be residing in the community To have shown a heart of voluntarism Above 18 years of age Preferable form 4 Male or female A good example in RCH issues

Coverage 19 Dispensary 1 CHW supervisor Village 4-8 CHW Village 4-8 CHW Village 4-8 CHW Village 4-8 CHW Village 4-8 CHW Village 4-8 CHW Village 4-8 CHW Village 4-8 CHW Village 4-8 CHW Village 4-8 CHW Dispensary 1 CHW supervisor Dispensary 1 CHW supervisor Dispensary 1 CHW supervisor Dispensary 1 CHW supervisor Health Centre 1 CHW supervisor In each district, two health centres will oversee 10 dispensaries (5 dispensaries each), and each dispensary will serve 2 villages with up to 4-8 CHWs each.

Roles of Community Health Workers Planning activities in his/her catchment area To provide health education and basic counselling on MNCH To provide referrals to clients to the back up health facility To participate in village health meetings and to collaborate with other stakeholders in the community Data collection and reporting

Health education messages FANC including - Individual Birth Plan Prevention of malaria, Infant feeding Importance of hospital delivery PPC for mothers, newborns and child PPFP PMTCT/CTC services Networking with other stakeholders Gender and male involvement Infection prevention

Roles of CHW Supervisors and Village Leaders CHW Supervisors Selecting CHWs Monitoring and supervision of CHWS as needed Conducting monthly meetings with CHWs Attending clients referred by CHWs Compiling monthly reports from CHWS Sending CHW reports to district level through DRCHCo Village leaders Selecting CHWs Assisting in identification of CHW catchment areas Follow up of CHW performance/ Provide support Engaging CHWs in village meetings Use of data from CHWs in planning

Training Duration of Training for CHWs: 3 weeks, residential, two weeks in class and one week field work o Training conducted by, district, regional, and national trainers Supervisors of CHW: facility providers who supervise CHWs Training takes two week, includes supervision skills Trainers: training 3 weeks; 2 weeks cMNCH based training. One week training methodology

Training Community MNCH 25 National trainers 134 CHW supervisors 535 trained MNCH CHWs (132 villages from 6 districts)

25 Home Visits by CHWs Antenatal home visit As early the CHW identify a pregnant woman About 6 months of pregnant About 8 months of pregnant Postnatal home visit Day 1 after discharge from health facility/after delivery Day 3, 8 after delivery End of third week End of fifth week End of third month End of fifth months

Community Health workers visits March 2013 – February 2014 FY 2012 (March-Sept 2013) FY 2013 (Oct Feb 2014) TOTAL No. of household visited 15,98520,43036,415 No. of health education meetings held No. of people attending health education meetings 16,24518,98935,234

Type of clients visited by CHW’s from March-December 2013

Referrals made by CHW from March-Dec 2013

Challenges and Lessons Learned Drop out Proper retention mechanism Sustainability Coverage (need a lot of effort to reach all villages and not enough CHW per village) Lessons Learned CHW as a strategy foster utilization of MNCHS and contributes in reduction of MNCH mortalities

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