An Integrated facility – Community Intervention for Improving Maternal, Newborn and Child Health (MNCH) Services in Tanzania

Program Goal To link Pregnant and Postpartum Women as well as their infants to the continuum of comprehensive MNCH services through and integrated Facility - Community Approach. The community component aims at promoting health seeking behaviours among pregnant women, postpartum mothers and community members while strengthening linkages and improve rapport between facilities and communities, so as increase demand and utilisation of MNCH services especially Postpartum care (PPC) services inclusive of follow up of HIV +ve mothers and exposed infants and PPFP

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

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 Facility & Community Linkage There was three aspects : 1. Facility: Supported Development of the PPC guideline and LRP which also includes PPFP and HIV / PMTCT Supported training of National Facilitators on PPC Supported training of the facility providers on PPC HIV testing for postpartum mothers and follow up of HIV + mothers and exposed infant as well as Post partum Family Planning (PPFP) was the point of integration. 2. Community: Supported Development of the integrated MNCH Guideline and LRP which is in Swahili Supported training of National Facilitators Supported training of the CHWs 5

3. Innovation: Development of Mobile phone protocols for ANC and PPC for facility providers and CHWs Providers at the facility use mobile phone to report and generate the report as well as for linking the clients to the community for continuum of care and follow up by the CHWs  To strengthen technical capacity or providers routine supportive supervision conducted on a quarterly basis Implementation of the Facility & Community Linkage (2)

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 PPC 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

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) 9

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 due to improved counselling 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 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

Integrated cMNCH Component

Integrated Community MNCH approach Development of standardized CHW program to promote cMNCH including PMTCT and PPFP in the community by home visits Focuses on 4 thematic 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 ** Other cross-cutting issues also addressed (such as M&E, IEC/BCC) CHWs conduct health education, mobilization, and referrals rather than direct service provision

Key Areas Trained CHW to provide health education on: o FANC including IBP o Prevention of malaria, o Infant feeding o Importance of hospital delivery, o PPC for mothers, newborns and child o PPFP o PMTCT/CTC services o Networking with other stakeholders o Gender and male involvement Infection prevention 16 1st Supervisor XY Facility CHW V1 CHW V1 CHW V1 CHW V1 2nd Supervisor XY Facility CHW V2 CHW v2 CHW V2 CHW V2

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

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

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

Achievements at national level: English version National Guidelines on Integrated Community MNCH Swahili version Community MNCH Training guide CHW Reference Guide Supervisor Guide Job Aids ( 26)+ IEC Materials Data collection materials Referral forms Reporting forms

M&E Tools and Equipment for CHWs Recording and Reporting Client register Monthly report forms Referral forms Form for births and deaths from the community Counter book Census summary form Reference Materials and Equipment Job aids CHW reference Guide Bags Bicycles Manila Sheets

Training of Community MNCH 25 National trainers 132 target (134 trained) CHW supervisors 528 target( 535 trained) MNCH CHWs in 132 villages from 6 districts

Achievements on the community program March-December 2013 GairoKilosaMorogoro DC Morogoro MC MvomeroUlangaTOTAL No. of household visited ,835 No. of health education meetings held No. of people attending health education meetings ,692

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

Referrals made by CHW from March-Dec 2013

Innovation – Use of mHealth (A phone based Tool for Maternal Health

Benefits of Technology Two main benefits a)capacity for immediate feedback given to the health worker (and standardization of health care delivery); and b)the ability to store the information that is collected (potential for tracking HIV+ mothers and infants over the course of pregnancy and beyond, minimizing loss to follow-up). Upon further development, this cell phone technology can also allow for SMS reminders to pregnant/postnatal women (attending ANC, follow-up visit at CTC, postnatal care schedule, etc.).

Challenges and Lessons Learned Retention of trained providers in their areas of work High 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 (RCH and Postnatal ward) Some providers feel PNC services not important Gap in PNC register (need of review) Limited number of providers trained - poor knowledge sharing between providers Drop out of CHWs – Calling for Proper retention mechanism Sustainability of the program in terms of Coverage ( need a lot of effort to reach all villages) Lessons Learned: CHW as a strategy foster utilization of MNCHS and contributes in reduction of MNCH mortalities

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