onse health activity malawi monthly update

DISCLAIMER This report is made possible by the support of the American People through the US Agency for International Development (USAID). The contents of this report are the sole responsibility of Organized Network of Services for Everyone’s (ONSE) Health Activity and

do not necessarily reflect the views of USAID or the United States Government.

ONSE HEALTH ACTIVITY MALAWI

MONTHLY UPDATE PY5 Quarter 1: December 2020Submission Date: December 21, 2020

Contract Number: AID-612-C-17-00001

COR Name: Reuben Ligowe

Submitted by: Rudi Thetard, Chief of Party Management Sciences for Health (MSH)

Mercantile Office Building

Area 13/138

P Bag 398

Lilongwe, Malawi

PHOTO CREDIT: REJOICE PHIRI FOR ONSE

USAID.GOV AID-612-C-17-00001 MONTHLY UPDATE PY5 Q1: DECEMBER 2020 2

ONSE HEALTH ACTIVITY OVERVIEW

Program Name Organized Network of Services for Everyone’s (ONSE) Health Activity

Activity Start and End Date November 15, 2016 – November 15, 2021

Name of Prime Implementing Partner

Management Sciences for Health (MSH)

Contract/Agreement Number AID-612-C-17-00001

Names of Subawardees Banja La Mtsogolo (BLM)

Dimagi

VillageReach

Major Counterpart Organization Malawi Ministry of Health and Population

Geographic Coverage Sixteen districts in the country of Malawi:

Balaka, Chikwawa, Chitipa, Dowa, Karonga, Kasungu, Lilongwe, Machinga, Mangochi, Mchinji, Mulanje, Nkhatabay, Nkhotakota, Ntcheu, Salima, Zomba

Reporting Period Project Year 5, Quarter 1: December 2020


CONTENTS

ONSE HEALTH ACTIVITY OVERVIEW 2

ACRONYMS AND ABBREVIATIONS 4

I. MAJOR ACTIVITIES AND ACCOMPLISHMENTS 6 COVID-19 RESPONSE ACTIVITIES 6 CLINICAL SERVICES 9 HEALTH SYSTEMS STRENGTHENING 40 COMMUNITY MOBILIZATION AND ENGAGEMENT 44

II. PROJECT MANAGEMENT 48 GRANTS UNDER CONTRACT 48

III. KEY CHALLENGES 49

IV. LESSONS LEARNED AND BEST PRACTICES 49

V. COMPLETED STTA 50

VI. UPCOMING STTA 50


ACRONYMS AND ABBREVIATIONS

ADC Area Development Committee

AEHO Assistant Environmental Health Officer

AM Area Mechanic

ANC Antenatal Care

BEmONC Basic Emergency Obstetric and Neonatal Care

BTL Bilateral Tubal Ligation

CAC Community Action Cycle

CBDA Community-Based Distribution Agent

CC Champion Community

CHAG Community Health Action Group

CHAM Christian Health Association Malawi

CHV Community Health Volunteer

c-IPTP Community-Based Delivery of IPTp

CLTS Community Led Total Sanitation

CMAM Community Management of Acute Malnutrition

CMT Community Mobilization Team

CPD Continuous Professional Development

CSC Community Scorecard

CYP Couple Years of Protection

DCSA Disease Control and Surveillance Assistants

DCT District Coordination Team

DHIS2 District Health Information System 2

DHMT District Health Management Team

DHO District Health Office

DHSS Director of Health and Social Services

DMPA Depo Provera

DMPA-IM Depo Provera intramuscular

DMPA-SC Depo Provera Sub-Cutaneous Injection (Sayana Press)

DTC Drug and Therapeutic Committee

DWO District Water Office

EPI Expanded Programme on Immunization

ETAT Emergency Triage, Assessment, and Treatment

FHP Family Health Package

FP Family Planning

GBV Gender Based Violence

GVH Group Village Head

HB Hemoglobin

HBB Helping Babies Breathe

HCMC Health Center Management Committee

HMIS Health Management Information System

HSA Health Surveillance Assistant

iCCM Integrated Community Case Management

IEC Information, Education, and Communication

IFHOC Integrated Family Health Outreach Clinic

IMCI Integrated Management of Childhood Illnesses

IPC Infection Prevention and Control

IPTp Intermittent Preventive Treatment in Pregnancy

ISS Integrated Supportive Supervision


ITN Insecticide Treated Net

IYCF Infant and Young Child Feeding

IUCD Intrauterine Contraceptive Device

KMC Kangaroo Mother Care

LA Lumefantrine Artemether

LARC Long-acting and Reversible Contraceptives

MDSR Maternal Death Surveillance and Response

MIP Malaria in Pregnancy

MNCH Maternal, Newborn, and Child Health

MNH Maternal and Newborn Health

MoH Ministry of Health

mRDT Malaria Rapid Diagnostic Test

MR Measles Rubella Vaccine

NCST Nutrition Care, Support and Treatment

NMCP National Malaria Control Program

ODF Open Defecation Free

ONSE Organized Network of Services for Everyone’s Health

OPD Outpatient Department

OTP Outpatient Therapeutic Program

PA Pharmacy Assistant

PAM Physical Asset Management

PENTA Pentavalent Vaccine

POE Point of Entry

PPE Personal Protective Equipment

PPH Postpartum Hemorrhage

PY Project Year

Q Quarter

QI Quality Improvement

QIST Quality Improvement Support Teams

QoC Quality of Care

RH Reproductive Health

RHD Reproductive Health Department

SAM Severe Acute Malnutrition

SBC Social and Behavior Change

SBCC Social and Behavior Change Communication

SP Sulfadoxine-pyrimethamine

SRH Sexual and Reproductive Health

TA Traditional Authority

TB Tuberculosis

TWG Technical Working Group

USAID US Agency for International Development

USG United States Government

VDC Village Development Committee

VHC Village Health Committee

VIP Ventilated Improved Pit

WASH Water, Sanitation, and Hygiene

WMA Water Management Authority

WPC Water Point Committee

WHO World Health Organization

YFHS Youth Friendly Health Services


I. MAJOR ACTIVITIES AND ACCOMPLISHMENTS

COVID-19 RESPONSE ACTIVITIES

COORDINATION, PLANNING, & MONITORING

Screening of passengers at Point of Entries (POEs) was supported in five districts with a total of

5,047 (3,406M; 1,641F) people screened at various land, water, and airport entry points. In Mwami

border in Mchinji, a total of 3,168 (2,208M; 960F) people were screened while in Muloza border in

Mulanje, a total of 202 (184M, 18F) people were screened. At Biriwiri border in Ntcheu, a total of

13 (13M, 0F) people were screened, while at Nkhatabay jetty in Nkhatabay, a total of 1,010 (620M,

390F) people were screened. Lilongwe supported screening of incoming passengers at Kamuzu

International Airport, KIA, with a total of 654 (381M, 273F) people screened.

District surveillance was strengthened by the Organized Network of Services for Everyone’s Health

(ONSE) Health Activity supporting a sample collection in 8 districts as highlighted in the table below.

A total of 135 (117M, 18F) samples were collected. The drop in samples collected in the districts is

due to the country running low on test kits hence the Ministry of Health (MoH) gave guidance that

sample collection be done for those presenting with symptoms only. The other reason for the drop

in samples collected is that Malawi now has a reduced COVID-19 caseload, indicating less people

are presenting with COVID-19 symptoms.

TABLE 1. SUMMARY OF COVID-19 SAMPLE COLLECTION

DISTRICT MALE FEMALE TOTAL

Machinga 0 1 1

Lilongwe 10 4 14

Zomba 22 0 22

Dowa 12 11 23

Nkhatabay 6 2 8

Mulanje 1 0 1

Karonga 65 0 65

Ntcheu 1 0 1

Total 117 18 135

District COVID-19 planning and coordination through the Public Health Emergency Management

Committee (PHEMC) forum was supported by ONSE in 4 districts. The Karonga and Salima PHEMC

meetings were held on December 4, drawing 30 (25M, 5F) and 47 (30M, 17F) participants

respectively. Nkhatabay and Dowa conducted their meetings on 25 November 25, drawing 15 (8M,

7F) and 24 (15M, 9F) participants respectively.

COVID-19 monitoring was enhanced by ONSE supporting various supervisions in 3 districts.

Karonga District Health Management Team (DHMT) conducted COVID-19 service delivery

supervision at Songwe border on November 20, supervising a total of 7 (5M, 2F) health workers.

Salima supported e-surveillance supervision of Health Surveillance Assistants (HSAs) from

Chinguluwe, Khombedza, and Chitala health facilities from November 23-24, supervising a total of 3

(3, 0F) workers. Dowa supported COVID-19 surveillance supportive supervision of five health

facilities of Mponela, Mvera Army, Mvera Mission, Dzaleka, and Kasese to ensure systematic data

collection and analysis from November 23-27, supervising a total of 22 (10, 12F) health workers.

Lastly, in the reporting period, ONSE supported COVID-19 orientation of peer educators and

facility youth friendly focal persons in Zomba from November 24-25, orienting a total of 20 (13M,

7F) participants.


RISK COMMUNICATION & COMMUNITY ENGAGEMENT

In Lilongwe, ONSE partnered with International Training and Education Center for Health to

support a community sensitization review on COVID-19 in traditional authorities (TAs) Mazengera,

Chiseka, Kabudua, Kalolo, Masumbankhunda, Chimutu, and Kauma; drawing participation from 133

(107M, 26F) people.

In Mangochi and Nkhatabay, ONSE collaborated with HC4L to jointly sponsor the district health

promotion technical working group (TWG) meeting to focus on improving coordination among all

health promotion stakeholders, particularly the role of the district council. A total of 28 members

(20M, 8F) attended the meeting, bringing together various government departments such as

environmental, nursing, clinical, District Information Office, police, social; and non-governmental

organizations (NGOs) like CPAR, Pakachere, YONECO, and community radio.

In an effort to increase knowledge of COVID-19, the District Health Office (DHO) engaged

partners to support awareness programs under the risk communication and community engagement

programs. In the reporting period, ONSE supported the MoH in Salima to conduct awareness

campaigns using a mobile van in under-five health facility catchment areas. The catchment areas

serve a population of 72,759 people (32,165M; 40,594F)

ONSE supported dissemination of COVID-19 messages including posters at Kabudula health area

and Information, Education, and Communication (IEC) materials to schools around Lilongwe.

In Chitipa, 67 people (45M; 22F) were oriented on COVID-19 during community structures review

meetings for Mwandisi, Kanjeri, and Mwalabira Community Health Action Groups (CHAGs) of TA

Mwenemisuku on November 17-18. Participants also drew COVID-19 problem trees during the

review meeting and are expected to help their communities’ prevention response.

In Karonga and Nhakatabay, community sensitization through health talks at Integrated Family

Health Outreach Clinics (IFHOCs) were supported at eight facilities with the objective to reach

people in hard-to-reach areas with priority health services. In total, 755 people (171M; 584F) were

reached with COVID-19 messages through health talks, looking at several myths about COVID-19

which the facilitators cleared.

In Nkhotakota, CHAGs are working with community structure to bring about mindset change in

their communities by targeting primary schools going children with COVID-19 prevention and

control measures.

SURVEILLANCE, RAPID RESPONSE TEAMS, AND CASE INVESTIGATION

As of December 10, Malawi had a cumulative total number of 6,051 confirmed cases and a total of

30 active cases. About 4,868 of these cases were spread through local transmission while 1,183

were imported cases mainly from returnees. In terms of gender, 68.3% of these cases were male

while 31.7% were female. In terms of mortality, the pandemic has claimed 185 lives with 1 new

death. According to the data, the pandemic is mostly killing male adults (76.1%) especially among

those with a median age of 56 years. During the reporting period, Malawi has reported a cumulative

total of 5,487 recoveries. Malawi has 29 districts and all districts are affected by the pandemic.

In response to the pandemic, a number of intervention measures are in place including contact

tracing. ONSE, with support from the United States Government (USG), is at the forefront

supporting contact tracing activities at the district level. During the reporting month, ONSE

supported contact tracing in its supported districts tracing a total of 40 (24M;16F) contacts. This

has dropped from 905 in August, due to logistical issues that were there such as lack of reagents

that prompted tests to be conducted only on symptomatic cases. But according to a Press Release

by the Government of Malawi dated December 16, 2020, Malawi has now resumed testing of

contacts to all confirmed cases regardless of being asymptomatic or not. This change has been made

following identification of cases from asymptomatic people tested for travel reasons. Contact tracing

is an essential public health measure and a critical component of comprehensive strategies to


control the spread of COVID-19. Contact tracing breaks the chains of human-to-human

transmission by identifying people exposed to confirmed cases, quarantining them, following up to

ensure rapid isolation, and testing and treatment in case symptoms develop. When implemented

systematically and effectively, these actions can ensure the number of new cases generated by each

confirmed case is maintained below one. Additionally, during the reporting period, 77 (61M; 16F)

samples were collected; and 19 were confirmed positive from Lilongwe, Mchinji, Balaka, and Ntcheu.

Further, a total of 164 (113M; 51F) cases were followed up during the reporting period. ONSE also

supported training of HSAs on contact tracing using new guidelines in Chitipa and Zomba districts

training a total of 65 (33M; 32F) HSAs.

INFECTION PREVENTION, CONTROL, (IPC) AND CASE MANAGEMENT

General IPC Water, Sanitation, and Hygiene (WASH) and COVID-19 IPC are being implemented in

an integrated manner. In Kasungu, ONSE supported IPC-WASH supportive supervision to 14 health

facilities from November 12-14 with the objective aimed at preventing the spread of health facility

infections that come due to poor water, sanitation, hygiene, and environmental conditions and

practices. A team of 12 facilitators (two teams of six members each) conducted the supervision to

the selected health facilities comprising the following cadres: two nurses, five environmental health

workers, two medical/clinical officers, four nurses and lab technicians (8M, 4F). Each area of focus

had a number of items/indicators that were assessed, and the following recommendations were

made to address the identified gaps:

Ground Laborers and Hospital Attendants need to be deployed at Kapyanga Health Center

to replace the community volunteers who are currently executing their works which is not

part of their job descriptions

Facility in-charges should make sure that support staff, especially ground laborers and

hospital attendants, attend to their duties they were employed for before they are assigned

other tasks.

With the introduction of new IPC/WASH guidelines, support staff need to be oriented to

update their knowledge.

Collaboration should be improved between facility in-charges and IPC/WASH coordinators

in addressing the challenges.

In Mangochi, ONSE supported IPC/WASH supervision in 3 facilities on November 26, supervising a

total of 10 service providers (6M, 4F). Following the supervision, the following recommendations

were made:

In-charges to ensure the staff members are practicing waste segregation.

Senior disease control and surveillance assistants (DCSAs) and HSAs were tasked to ensure

placement of hand washing facilities at toilet places.

Pharmacy staff to make sure stock of important items like oxytocin and sterile gloves is

consistent unless otherwise.

IPC Coordinator to see that facilities have IPC guidelines and protocols in strategic areas of

the hospital by January 2021.

In-charges solicit heavy duty gloves and gumboots for maids and ground workers.

Patient placement must always be checked, and entertaining a mixture of sick babies and

postnatal mothers are to stop.

In Chitipa, ONSE supported IPC WASH assessments in 6 health facilities from November 30-

December 4 consisting of three Quality Improvement Support Teams (QIST) members (2M; 1F).

The team noted strengths and weaknesses for each of the visited facilities, and recommended the

need to orient newly employed staff members on IPC protocols, personal protective equipment

(PPE) to be procured and distributed, and sterilizers to be distributed to some facilities by the

DHMT.


In Lilongwe, ONSE supported orientation of 462 (188M; 274F) support staff on IPC-WASH from 18

health facilities.

In Balaka, ONSE supervision and mentorship on IPC WASH in four health facilities focused on labor

ward, postnatal, and newborn care units. Three health facilities were assessed on IPC WASH, and

the average score was 60% for labor and postnatal wards and 72% for newborn care units.

CLINICAL SERVICES

RENOVATION OF HEALTH FACILITIES AND EQUIPMENT PROVISION

In December 2020, the ONSE Health Activity continued implementation of construction and

renovation activities of a number of targeted projects at health facilities in supported districts,

including:

Construction of 10 Double Pit Latrines: Completion of the remaining latrine at Mponela

Health Center.

Family Planning (FP) Units: Procurement of furniture and equipment for the completed FP

clinics has commenced. These are new prefabricated clinics at Bwaila; conversion of ONSE

District Offices at Kasungu, Chitipa, Nkhotakota, Zomba, and Chikwawa; and conversion of

bathrooms at Mulanje.

Construction of Waste Disposal Facilities: The construction of waste disposal facilities has

been completed for sites in the central region in Ntcheu, Dowa, Lilongwe, and Mchinji.

Emergency Treatment Centers, Holding Shelters, and Quarantine Centers for COVID-19:

ONSE has supported selected health facilities in prevention of COVID-19 by supporting

plumbing works at Chancellor College hostel in Zomba which is in progress, isolation center

of Nkhatabay Old Hospital at 80% progress, and the holding shelter at Chitipa District

Hospital which has finished.

Renovation of One Stop Center: Conversion of old cholera facility in Balaka has been

completed. The physical asset management (PAM) team is correcting defects that were

identified.

Sluice Units at Kamuzu Central Hospital (KCH): Installation of seven sluice units at KCH is

in progress and is expected to be completed by December 18, 2020.

Renovation of Maternity and Postnatal Wards: In Dowa District Hospital, the postnatal

ward is completed, and the labor ward is at an advanced stage, with an extension to create

washing rooms remaining.

Construction of 4 Ventilated Improved Pit (VIP) Latrines and Placenta Pit at Bwaila; ONSE

has commenced procurement of construction materials of the pit latrines and placenta pit,

with work expected to commence in December.

QUALITY OF CARE

In December 2020, ONSE continued to support MoH with various QoC activities at the national

and facility level.

NATIONAL LEVEL ACTIVITIES

ONSE participated in the collaborative meeting by stakeholders in Lilongwe to share their

implementation experiences. The following partners participated: ONSE, GIZ, Maikhanda, NEST,

PACHI, UNICEF, and EGPAF. The following issues were identified: The QoC assessments to health

facilities had revealed that some Maternal, Newborn, and Child Health (MNCH) registers were out

of stock; there was ambiguity in the roles and responsibilities of QIST and WITS; some QISTs and

WITS have not been oriented to the revised IPC guidelines; and there was unavailability of IPC

protocols. Some of the action points identified included that the QMD is to lobby with partners to


address the concerns and issues raised such as orientation of the WIT and QISTs on the revised IPC

guidelines. It was also noted that there is a need for the QMD to have a clear road map with regard

to the annual plans and coordination plan for the implementing partners to avoid duplication of

efforts. QMD committed itself to share the road map and coordination plan to all partners by the

end of January 2021.

DISTRICT/FACILITY LEVEL ACTIVITIES

Several QoC activities have been conducted in most districts including activities such as Maternal

Death Surveillance and Response (MDSR), pediatric death audits, neonatal death audits, and clinical

supervision and mentorship in MNCH. This report captures quality improvement (QI) project and

IPC WASH in health facilities.

QI PROJECTS

QoC Assessment ONSE supported an Maternal and Newborn Health (MNH) QoC assessment in Machinga and Dowa

district hospitals from November 16-17 and November 24-27, respectively, with the aim to

appreciate QoC provided for MNH and identify quality gaps from and develop QI projects.

Assessors consisted of two officials from QMD, one from Reproductive Health Department (RHD),

one QoC Advisor from ONSE, and certain hospital QIST members were involved as a way of

capacity building and ownership of the process. The activity started with orientation on the tools

for assessment in antenatal, labor ward, postnatal ward, and nursery. A total of 15 QIST members

(7M, 8F) for Machinga and 14 QIST members (6M; 8F) for Dowa participated in the assessment. The

process is still ongoing, as the exercise of developing actual QI projects is taking place from

December 9-11, supported by external QI mentors.

QI Orientation ONSE supported the orientation of 17 (3M; 14F) new members of staff at Matawale Health Center

in Zomba on QI approaches covering such topics as the definition of QI, initiating QI projects,

developing change ideas, plan-do-study-act cycle, and how to spread QI improvements.

PRIVATE SECTOR

INTEGRATED SUPPORTIVE SUPERVISION

In the reporting period, ONSE supported DHMT integrated supportive supervision in Chikwawa

and Mulanje to provide leadership and governance support to the facilities. A total of five private

clinics were targeted and drew participation from 24 (16M; 8F) health workers that were

supervised.

Key notable findings were incomplete documentation in registers and completeness of reports, late

initiation of first trimester antenatal care (ANC), stock outs of emergency drugs, blocked septic

tank, cold chain procedures not followed due to frequent blackouts, and the facility did not have a

backup power supply. The supervision teams advised the facilities to rework on the registers and

reports and in-charges to intensify supervision on the correct recording in the registers and

checking for completeness before submitting to the DHO. Lack of integration of ANC services was

the root cause for late initiation in the first trimester, hence facilities were encouraged to attend to

all women with a positive pregnancy result immediately and not been given a later date for ANC.


INTEGRATED FAMILY HEALTH OUTREACH CLINICS (IFHOCS)

In December, ONSE supported 165 IFHOCs in all 16 ONSE districts, reaching an estimated total of

32,305 clients (Table 2); 66% of those planned for the month of December were supported. During

the typical month, between 80-85% of scheduled IFHOCs take place.

TABLE 2. INTEGRATED FAMILY HEALTH OUTREACH CLINICS – DECEMBER 20201

DISTRICT #IFHOCS

PLANNED

# (%) IFHOCS

SUPPORTED*

TOTAL # OF

CLIENTS

AVERAGE #

CLIENTS PER

IFHOC

Balaka 10 7 (64%) 975 520

Chikwawa 5 4 (44%) 999 500

Chitipa 12 10 (83%) 1,429 576

Dowa 30 19 (106%) 3,302 794

Karonga 29 15 (48%) 2,236 488

Kasungu 31 18 (86%) 3,672 822

Lilongwe 29 20 (69%) 6,180 1,231

Machinga 16 18 (113%) 3,575 796

Mangochi 5 7 (78%) 1,256 350

Mchinji** 9 4 (40%) 441 276

Mulanje** 9 0 (0%) 0 0

Nkhatabay 13 1 (13%) 143 143

Nkhotakota 12 9 (82%) 2,869 956

Ntcheu 9 3 (27%) 319 222

Salima 11 13 (118%) 1,173 346

Zomba 20 17 (85%) 3,736 879

Total 250 165 (66%) 32,305 556 *Total IFHOCS supported was calculated using the Actual Reports data set function on MSH’s enterprise DHIS2 instance.

MATERNAL AND NEWBORN HEALTH (MNH)

In December, ONSE continued to support the MoH and other partners to improve access to

quality, high-impact, cost-effective MNH interventions at both the community and facility levels.

ONSE strengthened service provision through smart capacity building of both community and

facility-based health workers using mentorship, supportive supervision, and coaching. ONSE also

supported low dose orientation for Family Led Care in Karonga.

ANTENATAL CARE (ANC)

In December, ONSE supported ANC supportive supervision and coaching at Phalula, Comfort,

Kalembo, Ulongwe, Utale 2, Nandumbo, Mbera, and Kankao health facilities in Balaka to assess the

quality of ANC services that the facilities provide and to coach health workers on the gaps

identified. A total of 34 (17M, 17F) health workers (nurses & community midwife assistants) were

supervised and coached. Below is the summary of strengths, challenges and recommendations.

1 IFHOC data covers November 15-December 12 (calendar year week 47-50)


TABLE 3. SUMMARY OF ANC SUPPORTIVE SUPERVISION, BALAKA

STENGTHS CHALLENGES RECOMMENDATIONS

ANC services are

provided four times a

week at Comfort,

Kalembo, & Kankao, and

three times a week at

Mbera

All facilities had

insecticide treated net

(ITNs)

Utale 2 & Comfort

hospital had almost all the

essential drugs & supplies

(functional weighing scale,

Sphygmomanometer,

Ferous Sulphate,

Sulfadoxine-

pyrimethamine (SP), and

antiretrovirals)

Stock outs of pregnancy

test kits at all facilities

except at Comfort

No Hemacue at

Nandumbo, Mbera and

Kalembo

No Syphilis test kits at

Ulongwe and Comfort

Nonfunctional adult

weighing scales for

Nandumbo, Ulongwe,

Phalula

Stockouts of Ferrous

Sulphate at Ulongwe,

Kalembo, Phalula, Mbera,

and Kankao

DHO should include pregnancy test kits

in the drug procurement list by

December 31, 2020

DHO to procure Hemacue machines

for Nandumbo, Mbera & Kalembo by

February 28, 2021

Administrators for Ulongwe and

Comfort should order Syphilis test kits

from DHO pharmacy

DHO should procure weighing scales

for Nandumbo, Ulongwe, Phalula, and

Nandumbo

Facility in-charges for Ulongwe,

Kalembo, Phalula, Mbera, Kankao to

order Ferrous Sulphate from the

District pharmacy by December 30,

2020

INTRAPARTUM CARE

ONSE supported Basic Emergency Obstetric and Neonatal Care (BEmONC) mentorship in Chitipa,

Mulanje, and Balaka districts in December, reaching a total of 57 (18M, 19F) health providers from

12 BEmONC and non BEmONC facilities. This mentorship aimed at improving provider skills in

managing various obstetric complications, performance of signal functions, improving monitoring of

women in labor, and improving documentation in relevant MNH registers. Mentorship involved both

theory and practical components of learning; and content was delivered through power point

presentations, classroom assimilations on anatomical models, return demonstrations, and practical

documentation in the maternity and Helping Babies Breathe (HBB) registers as well as partographs.

Health providers were encouraged to always document all stillbirths and asphyxiated babies

including their outcomes in the HBB registers as per protocol. During mentorship in Balaka, it was

discovered that the sterilizing machine was not working at Kalembo, cord clamps and sutures were

not available at Nandumbo, there was a faulty vacuum extractor at Utale 2, and non-functional MVA

syringes were present at Utale 2 and Comfort hospital. Furthermore, Comfort hospital did not have

a HBB action plan. ONSE pledged to provide the HBB action plan and KIWI vacuum extractors by

December 31, and encouraged the SMI Coordinator to source for the other supplies and provide to

the facility by January 15, 2021. It is expected that continued MNH mentorship and coaching

sessions coupled with systems support will help improve management of obstetric cases and

complications at facility levels. Below is a summarizing BEmoNC mentorship in these three districts.


TABLE 4. SUMMARY OF BEMONC MENTORSHIP - DECEMBER 2020

DISTRICT # OF SITES # OF

PARTICIPANTS TOPICS COVERED

Mulanje 1 29 (12M, 17F)

HBB, manual removal of placenta, documentation in HBB,

maternity registers, and partographs.

Balaka

8 21 (5M, 16F)

Use of partograph and HBB registers, manual removal of

placenta, postpartum hemorrhage (PPH) management,

vacuum extraction, and management of hypertensive

disorders during pregnancy.

Chitipa

3 7 (1M, 6F)

HBB, administration of Magnesium Sulphate, and

document on partograph for women who deliver in

transit to facility.

INTEGRATED MNH SUPERVISION

In Zomba, Machinga, Chitipa, and Nkhotakota, ONSE supported integrated MNH supervision and

coaching for 35 (18 M, 22 F) providers from 13 health facilities with the aim of providing technical

support by assessing current clinical practice and strengthening MNCH service provision.

TABLE 5. SUMMARY OF SUPPORTIVE SUPERVISION IN INTEGRATED MNH CONDUCTED WITH ONSE SUPPORT

DISTRICT

(FACILITIES)

#

SUPERVISED STRENGTHS CHALLENGES RECOMMENDATIONS

Zomba (9) 27 (13M,

14F)

Availability of

MNCH registers in

all the supervised

health facilities.

Clean environment

in 80% of the

supervised health

facilities

Improved MNCH

service provision at

Lambulira health

center e.g. vital signs

checked twice a day

and emergency tray

well updated.

Pre-referral

treatment being

given to all patients

at Mmambo and H.

parker health

centers.

Updated emergency

trays in 80% of the

supervised health

facilities.

Monitoring of

fetal heart and

vital signs not

routinely done.

Pre referral

treatment not

given at Chingale

and Chilipa health

centers.

Non adherence

to follow up of

preterm babies at

Chipini health

center

Poor filling of

partograph only in

40% of the

supervised health

facilities

The supervisory team

encouraged the nurses in

all the supervised health

facilities to always adhere

to obstetric protocols

Coaching on guidelines

on follow up care for

newborns on Kangaroo

Mother Care (KMC)

done on day of visit

Coaching on use of

partograph and its

documentation was done

on the day of visit.

Machinga

3

3 (3F) Clean environment

at all facilities

All registers and

reports were

present and well

stored.

Oxygen

concentrator not

in use due to

cable

incompatibility

No angle-poised

lamp for MVAs

SMI to follow up with

maintenance supervisor

on O2 concentrator

power cable by

December 23


DISTRICT

(FACILITIES)

#

SUPERVISED STRENGTHS CHALLENGES RECOMMENDATIONS

Some registers

were well

documented and

summaries done as

per standards

Documentation

challenges where

normal deliveries

were recorded as

obstructed labor

Check with stores for an

angle-poised by

December 23

Mentored the staff on

proper documentation

and reporting.

Chitipa

3

5 (1M, 4F) The facilities have a

KMC room with

KMC beds

Improvement in

partograph

completeness

All essential MNH

drugs and supplies

were available such

as F/S, Oxytocin, SP,

BP machine, suction

machine, O2

concentrator

Decontamination

buckets were

available and dates

labeled at Kaseye

Wastes were not

segregated, only

one bin was found

in delivery room

at Msumbe

There is no

functional

sterilizer at

Msumbe

Bins had no bin

liners at all

facilities

Maternity in charge was

advised to do a thorough

search in their facility

store for buckets that

were received during

COVID-19 supplies and

get at least 3 buckets for

labor ward waste

disposal.

Maternity in charge to

follow up with

maintenance supervisor

on repairing the sterilizer

and check with

administrator on

provision of bin liners

Nkhotakota

1

7 (5M, 2F) Generally clean

facilities

Health providers on

duty were

committed to

improve the current

status.

Lack of essential

drugs and test kits

e.g. albendazole,

urine dipsticks,

pregnancy test

kits

Inadequate

monitoring of

women in the

postnatal ward.

Vital signs are

checked only

once a day

Discussed to inform Drug

and Therapeutic

Committee (DTC) to

include these drugs and

supplies on the

December drug

procurement list

SMI Coordinator advised

to collect and share with

postnatal ward the HSAs

list and their catchment

areas for quick referral of

KMC babies on discharge

Coaching on

comprehensive

monitoring of women in

labor was done by

supervisors.

KMC AND FAMILY LED CARE

In Balaka, ONSE Supported KMC supervision and coaching at nine facilities in the district with the

aim of assessing the quality of KMC services that the facilities provide and coaching the health

workers on the gaps identified. A total of 34 (17M, 17F) health workers were supervised and

coached. Some of the strengths of the supervision included that all facilities had KMC corners, six of

the eight facilities supervised had registers (latest version), hand washing facilities were available at

all facilities, and babies initiated on KMC were documented in the KMC register. The challenges

include that Kalembo was using an old version of KMC register, and the register for Utale 2 was


missing. It was agreed that ONSE will source and provide KMC registers to Kalembo and Utale 2 by

December 30, 2020

In Karonga, ONSE supported an orientation of KMC family led care in order to orient staff at

Karonga District Hospital on KMC family led care concept in which the mother and her family

become part and highly involved in the care of the low birth weight or premature babies. The

session covered feeding of the babies and calculation of feeds, the importance of maintaining

warmth, and how they can effectively involve the families as caregivers. A total of 11 (2M, 9F)

providers were oriented.

MATERNAL DEATH SURVEILLANCE AND RESPONSE (MDSR)

In December, ONSE supported MDSR for four maternal deaths in Zomba (1), Machinga (2), and

Balaka (1); of which, three were due to PPH (two following home delivery and one following

abortion). In Machinga, ONSE supported a maternal death verbal autopsy to a death that occurred

at home. A 26 year-old Para 2 woman delivered at home on November 27. Two hours after

delivery, she started complaining of heart palpitations, and when the relatives checked, they saw that

she was bleeding. Due to delays in accessing transport, she died before reaching the facility. The

verbal autopsy that took place in the deceased village aimed also to raise awareness on the

importance of facility deliveries and the identification of emergency transport systems as part of

birth preparedness. ONSE, through its subgrantees, is helping communities to identify emergency

transport systems.

In Nkhotakota, ONSE supported a MDSR meeting at NKhotakota DHO aimed at reviewing action

points for the July to September 2020 quarter attended by 10 (5 M, 5 F) health workers. Between

July and September, the team conducted MDSR for four maternal deaths and developed nine action

points, of which, seven action points were completed. The leads for the remaining action points

were encouraged to hasten implementation of the action plans for the district to reap fruits of

MDSR.

The team also reviewed maternity data to identify areas of improvement. Among others, the

following were the findings and recommendations:

High incidence of fresh stillbirths (31). Labor ward in-charge was tasked to review all fresh

stillbirth cases and report to MDSR in the January 2021 meeting on the factors contributing

to the high occurrence of cases.

PPH (44). ONSE is to support mentorship on active management of third stage of labor and

other PPH prevention measures including reminding women to empty the bladder regularly

while in labor and management of those still develop PPH even with application of

preventive measures.

Five ruptured uterus and one sepsis case. The team noted that there was under-reporting

for both conditions. Providers were reminded of the importance of documentation of

complications and proper reporting. The District Nursing Officer has also introduced a

notebook at labor ward and postnatal to capture cases of puerperal sepsis which will be

used to triangulate data in the registers.

CHILD HEALTH

CARE OF THE INFANT AND NEWBORN (COIN)

Neonatal Death Audit COIN is an advanced skill concept that was designed to enable clinical staff and nurses to provide

important, best-practice, and evidence-based care for every newborn and young infant less than two

months old who is sick and admitted to the special care neonatal unit. In the reporting month of

December, ONSE supported neonatal death audits for four Zomba health facilities of Nkasala,

Mmambo, Chingale, and Chipini with the aim of reducing neonatal morbidity and mortality through

identification of preventable factors contributing to neonatal deaths and to find strategies and


develop actions that would lead to improvement in the QoC provided at unit level. A total number

of four neonatal death cases were audited by 42 (16M; 26F) health care workers with birth asphyxia

(100%) being the major causes of death for all four cases.

TABLE 6. SUMMARY OF NEONATAL DEATH AUDIT - ZOMBA

STENGTHS CHALLENGES RECOMMENDATIONS

Availability of 24/7 nurses

in the in labor ward to

provide basic neonatal

care when complications

arise

Availability of neonatal

care forms e.g.

standardized partographs

with newborn care

section.

Availability of basic

equipment ambu-bag and

mask and penguin suckers

Availability of neonatal

care spaces for

resuscitation and

provision of essential

care.

Poor monitoring of

women in labor

Poor documentation of the

labor graph

Inadequate resuscitation

skills by the health care

workers

Delay in making decisions

by the health care

workers.

Late arrival of the patients

at the hospital

The safe motherhood coordinator will

organize onsite mentorship sessions

with focus on HBB, management and

monitoring of women in labor, and

documentation and interpretation of the

labor graph in January 2021

The nurse-midwife facility in charge will

plan for Continuous Professional

Development (CPD) sessions in

documentation of partographs in

January 2021

The safe motherhood coordinator in

liaison with ONSE Zomba clinical

coordinator plan to schedule a MNH

community awareness campaign on the

importance of early health seeking

behavior for expectant women and

newborns.

EMERGENCY TRIAGE, ASSESSMENT, AND TREATMENT (ETAT)

ETAT activities complement Integrated Management of Childhood Illnesses (IMCI) and Integrated

Community Case Management (iCCM) services as a point for emergency care of the under-five

conditions. It is an essential process of saving the lives of very sick under-five children by identifying

children with immediately life-threatening conditions. It involves triaging of sick under-five children

and categorizing children according to levels of illness, which include a child having emergency signs,

priority signs, and non-urgent signs. In the reporting month of December, the two ONSE ETAT

activities were pediatric case review for Balaka and pediatric death case audit for Mulanje.

Pediatric Case Review ONSE supported a pediatric case review in Balaka and utilized the criterion based audit tool for 25

pediatric cases to identify preventable factors contributing to pediatric morbidity and strategize and

develop action points that would lead to improvement in the QoC provided at unit level. The

pediatric case audit methodology involved randomized sampling of 10-malaria, 10-pneumonia, and 5-

severe dehydration cases that were admitted at the pediatric unit at Balaka District hospital from

September to November 2020. A total of 18 (10M; 8F) nurses and clinicians were involved in the

exercise. According to the criterion–based audit tool, the quality of patient care is within acceptable

limits when the total score of per case is above 80% as minimum score. The average scores were as

per table below.

TABLE 7. SUMMARY OF PEDIATRIC CASE REVIEW SCORES

CONDITION # OF CASES AUDITED SCORE

Malaria 10 78%

Pneumonia 10 68%

Severe Dehydration 5 45%


Findings from the Case Review Audit Monitoring was seriously inadequate for patients with pneumonia, as oxygen saturation monitoring

was at 0% and respiratory rate monitoring at 40%. There are no pulse oximeters at the pediatric

unit because the pulse oximeter went missing following the fire that gutted down part of Balaka

District Hospital. Oxygen was administered incorrectly and monitored on 70% of the patients with

pneumonia. Only 10% of malaria cases were checked for blood glucose in the entire period,

antimalarial medication was not prescribed correctly on 40% of the malaria cases, three of the five-

cases had correct classification of dehydration, and two of the five-cases of dehydration had correct

administration of fluids. Zinc tablets were only administered to three of the five cases with diarrhea,

and management of dehydration is still a challenge with a score of 45%.

Moving forward, ONSE in collaboration with the ETAT Coordinator, pediatric unit in-charge, and

clinician in charge for the pediatric unit will organize CPD sessions on monitoring of sick children

with malaria, pneumonia, and severe diarrhea in January 2021. The ETAT Coordinator will also

organize orientation sessions for technical staff and support staff on triaging of sick children as well

as strengthen the function of the ETAT stabilization rooms by ensuring that the required

medications and supplies as well as steps in treating a child with an emergency condition are put in

place.

Pediatric Death Audit In Mulanje, ONSE supported a pediatric death audit for 6 pediatric cases including severe malaria,

severe anaemia, severe dehydration, meningitis and hypoglycemia at Mulanje District Hospital. Four

of the pediatric deaths occurred within 24 hours which may indicate the probability of failure of

health care providers to administer emergency treatment and care, and the remaining two pediatric

deaths occurred within 48 hours. Findings of the pediatric death auditing included a lack of triaging

techniques at the Outpatient Department (OPD) under-five consultation area; lack of either

technical skill to determine the correct diagnosis and initiate emergency treatment; incomplete use

or no use of the standardized pediatric admission and critical care pathway forms during the period

of admission, as well as period of care after admission; and lack of basic equipment in the ETAT

stabilization rooms such as pulse oximeters, glucometers as well as oxygen concentrators.

Moving forward, the ETAT Coordinator and the OPD in-charge worked towards improving the

setup of the ETAT stabilization rooms by sourcing for a pulse oximeter and glucometer, assigned

health care providers in OPD to ensure that basic medication and supplies like intravenous fluids

and its accessories are available, ensuring a functional ORT corner, availability of pediatric admission

sheets and daily updating of the emergency trays. The ETAT Coordinators have requested the

District Medical Officer to consider deployment of clinicians and nurses to under-five OPD units to

increase staffing levels. ONSE will continue to support the ETAT coordinator and OPD in-charge to

continue working with health care providers in the unit to ensure emergency treatment is provided

as per sick child’s condition. ONSE will support the unit with ETAT orientations and mentorship

sessions to strengthen the aspect of emergency treatment and care for sick children.

INTEGRATED COMMUNITY CASE MANAGEMENT (ICCM)

iCCM Supportive Supervision The iCCM program is one of the essential community health programs that is reducing under-five

morbidity and mortality and focuses on hard to reach areas to complement fixed or scheduled

facility-based services and iCCM compliments facility-based IMCI services. In December, ONSE

supported district-level iCCM supportive supervision for 46 iCCM (33M; 13F) providers from 47

village clinics and 7 health facilities in Chikwawa (28) and Nkhotakota (19). The aim of the activity

was to build capacity of iCCM providers in the assessment, classification, and treatment processes as

they assist sick under-five children, assess the status of iCCM commodities, and to enhance quality


care in the management of under-five children at community level in order to avert unnecessary

deaths.

TABLE 8. ICCM SUPPORTIVE SUPERVISION – PROJECT YEAR (PY)5 DECEMBER 2020

STRENGTHS CHALLENGES RECOMMENDATIONS

Most clinics in

Nkhotakota have

adequate antimalarial

medicine and

commodities e.g.

Tetracycline eye

ointment, Oral

Rehydration Therapy

(ORS), zinc tablets,

examination gloves,

Documentation is good in

most village clinics in

Nkhotakota

During the supervision,

distribution of buckets,

basins and soap

supported by ONSE was

done for most village

clinics.

Drug shortages due to

inadequate drug supplies

and stock-outs in

Chikwawa

No drug boxes in most

village clinics in Chikwawa.

Poor data documentation

in some of the visited

village clinics number of

suspected cases in the

registers not tallying with

the number of cases tested

for Malaria Rapid

Diagnostic Test (MRDT)

and treated for malaria.

Inadequate supervision and

review meetings

iCCM Providers were advised to order

Amoxicillin, ORS, and other stock out

supplies from the DHO – Chikwawa

and Nkhotakota.

The iCCM providers were supervised

and mentored in different areas

according to identified gaps some of

which included: identifying problems and

the correct treatments, data

documentation, and advice to be given

care takers during health education

counselling.

The iCCM providers were provided

with the assistance of Village Health

Committees (VHCs) and community

leaders in the community need to

source, lobby, and advocate for funds

for the procurement of drug boxes and

village clinic structure.

EXPANDED PROGRAMME ON IMMUNIZATION (EPI)

VACCINE COLLECTION AND DISTRIBUTION

During the reporting period, ONSE supported the collection and distribution of EPI supplies from

the Central Vaccine Stores to the districts and to the health facilities. Some of the EPI supplies that

were transported included: vaccines, gas cylinders for gas refrigerators, safety boxes, and injection

materials (5ml, 2ml, 0.5ml, and 0.05ml syringes). The distribution was based on monthly

consumption and current stock status per commodity. This contributed to the availability of

vaccines and other supplies at the health facility and also assisted in improving immunization

coverage in the districts. A total of 311 health facilities from 10 districts of Balaka, Chitipa, Dowa,

Kasungu, Karonga, Lilongwe, Machinga, Mulanje, Salima and Zomba) benefited from the activity while

Nkhotakota district had not yet started the distribution.

INTEGRATED FAMILY HEALTH OUTREACH CLINICS (IFHOCS)

During the reporting period, the EPI immunization activities continued to be supported through the

IFHOCs and the immunizations given were as follows:

Pentavalent Vaccine (Penta 1): 824 (356M; 468F),

Penta 3: 790 (384M; 406F),

Measles Rubella Vaccine (MR1): 634 (318M; 316F),

MR2: 594 (247M; 347F)

According to the immunizations provided during the reporting period, immunization coverage for all

antigens had dropped in December as compared to other months as the activity was still in

progress.


FIGURE 1. COMPARISON OF THE NUMBER OF CHILDREN IMMUNIZED IN JUNE, JULY, AUGUST, SEPTEMBER, OCTOBER, NOVEMBER, AND DECEMBER 2020

EPI SUPERVISION

During the reporting period, ONSE with USG funds supported supportive supervision in four

districts of Balaka, Dowa Lilongwe, and Salima to assess how vaccines are handled, stored, managed,

and delivered at all service delivery points. The supervisory visits conducted benefited 71 health

facilities and 257 (163M; 94F) immunization providers as follows:

Balaka: 8 health facilities and 18 (12M, 6F) immunization service providers,

Lilongwe: 32 health facilities and 52 (20F, 32M) immunization service providers,

Salima: 18 health facilities and 108 (64M, 44F) immunization service providers,

Dowa: 13 health facilities and 79 (55M, 24F) immunization service providers.

During the supervisory visits, it was pleasing to note that some health facilities were adherent to EPI

standards such as zero clinic cancellations, immunization schedules were displayed, and having

functional refrigerators with acceptable temperature recordings of a range between +2oC and 8oC

for the ideal storage of vaccines. Below are some of the major issues and actions taken during the

supervisory visits made to the districts.

TABLE 9. SUMMARY OF EPI SUPERVISION - LILONGWE, SALIMA, AND DOWA

DISTRICT ISSUES ACTIONS TAKEN

Lilongwe Few health facilities 28% had micro

plans

Health facility staff were advised to develop

microplans for their health facilities

EPI monitoring charts were not

updated in 83% of the health

facilities visited

Health facility staff were advised to update EPI

monitoring charts in order to monitor EPI

performance.

Lack of EPI refresher courses for

immunization in practice for EPI

focal persons (some trained 2 years

ago while others are not trained at

all)

District staff were advised to lobby funds from

other partners for immunization in practice

training from other partners working in the

district

Vaccine stock books and under-two

registers were not updated

Health facility staff were advised to be updating

vaccine stock books and under-two registers


DISTRICT ISSUES ACTIONS TAKEN

IEC materials are available in all

facilities but not adequate

The district was advised to order more IEC

materials on immunization and distribute them to

health facilities.

Salima Lack of transport for outreach

clinics operations like ADMARC,

Baptist, Chagunda, MAFCO, etc.

The district was advised to prioritize outreach

clinics in transport allocation

Breakdown of motorcycle at

Makioni for clinic operations

The district was advised to service the motorcycle

for the facility

Some health facilities did not have

adequate waste disposal facilities

for disposing vaccination wastes

The district was advised to construct incinerators

and ash pits for proper disposal vaccine wastes

Dowa Inconsistent temperature

monitoring in some health facilities

Health workers were advised to record

refrigerator temperatures twice daily in the

morning and in the afternoon including the

weekends to ensure the vaccines are kept with

the recommended temperature range of 2o-8oC

Nonuse of vaccine and injection

material stock books in nine

facilities visited

Health facility staff were advised to be consistently

using the vaccine and injection materials stock

books

In 12 health facilities visited, opened

vaccine vials were not labeled (the

date opened) according to the multi

dose vial policy

Health workers were advised on the need for

adherence to the multi dose vial policy which

states that all opened vials should be labeled with

a date when they are opened

Inadequate supplies like 2mls

syringes, safety boxes, and Vitamin

A

Health facilities were advised to order supplies

when minimum stock levels (25%) have been

reached to ensure there are no stock outs of

supplies

Lack of motorbike and push bicycle

maintenance

The district was advised to support health

facilities with motorcycle and bicycle maintenance

Lack of EPI refresher courses for

Immunization in Practice (IIP) for

EPI

District staff were advised to lobby funds from

other partners for immunization in practice

training from other partners working in the

district

FAMILY PLANNING

COMMUNITY-LEVEL FAMILY PLANNING

IFHOCs Through support to MoH IFHOCs in the 11 Family Health Package (FHP) districts, ONSE reached a

total of 5,846 (815 new, 5,031 revisit) clients with a full method mix, generating 3,181 Couple Years

of Protection (CYP). It is worth noting that the services reported are only for three weeks support

due the upcoming Christmas closure. IFHOCs are aimed at reducing barriers in access to priority

health services at the community level. The services provided include ANC, FP, malaria screening

and treatment for under-five children, postnatal care, growth monitoring, and immunizations.


TABLE 10. IFHOC FP SERVICES - DECEMBER 20202

METHOD NEW VISIT REVISIT TOTAL

CLIENTS CYP

Male Condoms 194 566 760 6.3

Female Condoms 80 0 80 0.7

Oral Contraceptives 37 661 698 47

Depo Provera intramuscular (DMPA-IM) 345 3,272 3,617 904

Implanon 37 161 198 495

Jadelle 67 239 306 1,163

Levoplant 42 132 174 435

Intrauterine Contraceptive Device (IUCD) 0 0 0 0

Bilateral Tubal Ligation (BTL) 13 0 13 130

TOTAL 815 5,031 5,846 3,181

EMERGENCY CONTRACEPTION ORIENTATION

During the reporting period, ONSE supported emergency contraception briefing sessions in

Machinga, Balaka, Salima, and Nkhotakota districts. The activity was aimed at disseminating the

emergency contraception strategy and new World Health Organization (WHO) guidance to

2 IFHOC data covers November 15-December 12 (calendar year week 47-50)

HEALTH TALK ON FP BY HSAS DURING IFHOC IN MACHINGA. PHOTO CREDIT: GEORGE MARUWO FOR ONSE


DHMTs, FP, Youth Friendly Health Services (YFHS), District Youth Officer, safe motherhood

coordinators and key FP stakeholders on the updated emergency contraception guideline and to

orient FP providers (nurses, clinicians, HSAs, Community-Based Distribution Agents (CBDAs),

pharmacists, and data clerks) on provision of emergency contraception at the facility and community

level. The agenda items for the briefing session included:

WHO guidance and medical eligibility criteria for emergency contraceptives counselling and

how to provide emergency contraceptives

Supply chain management for FP commodities including emergency contraceptives

Policy change and new guidelines on provision of emergency contraception in Malawi and

way forward.

At the end of the sessions, a total number of 189 (79M, 110F) members were briefed and oriented

on emergency contraception changes and provision. In addition to this, participants developed work

plans for the emergency contraception roll out which included:

FP and YFHS Coordinators to take lead in orienting more Youth CBDAs and peer

educators on the new guidelines

Utilize the CBDAs that ONSE supported to orient

Director of Health and Social Services (DHSS) and/or Health Promotion Officer to sensitize

the community and other significant leaders including District Executive Committees and

Area Development Committees (ADCs) on availability and usage of emergency

contraception.

The FP coordinators and the hospital matron to conduct on job trainings to service

providers on emergency contraception in their departments

Health Promotion Officer to facilitate health education to communities on the availability

and usage of emergency contraception from month end November 2020 on going

In the coming months, ONSE will continue supporting the MoH to orient additional

providers on the emergency contraception strategy to ensure smooth roll out of the

commodity especially for the HSAs and CBDAs who were not providing this contraception

previously.

EMERGENCY CONTRACEPTION ORIENTATION IN PROGRESS IN SALIMA. PHOTO CREDIT: CHRISTABEL KOMAKOMA


DEPO PROVERA SUB-CUTANEOUS INJECTION (DMPA-SC) SUPERVISION

In Balaka, ONSE supported DMPA-SC mentorship for 56 (37M, 26F) health workers (HSAs,

community midwife assistance, data clerks, and medical assistants) from 5 facilities (Chiendausiku,

Kalembo, Balaka, Phimbi, and Namanolo). The activity aimed at improving provider skills in service

provision at the community level. The participants were mentored on administration of DMPA-SC,

documentation in the FP registers, and the reporting booklets. It is expected that the mentorship

sessions will assist in standardizing provision of DMPA-SC especially counselling for self-injection.

TABLE 11. SUMMARY OF DMPA-SC SUPPORTIVE SUPERVISION - BALAKA

STRENGTHS CHALLENGES RECOMMENDATIONS

Availability of FP

commodities in most

facilities

Most of the providers at

Kalembo, Chendausiku,

and Phimbi had FP

registers

Nine Providers at

Namanolo and four

providers at Balaka did not

have FP registers.

HSAs at Balaka OPD

complained that they are

given inadequate supply of

FP commodities.

13 FP registers were distributed during

the mentorship session

FP coordinator to order commodities

for Balaka OPD

BTL OUTREACH CLINICS

In Mulanje, ONSE supported BTL outreach clinics targeting three facilities of Namasalima, Chikonde,

Mpala, Chambe, and Chinyama. The aim of the outreach clinics was to improve access to permanent

and long-term methods for people in health facilities where such methods are not readily available.

The activity was conducted in collaboration with ONSE-BLM nested clinicians and nurses including

MoH FP providers. At the end of the BTL clinics, a total of 57 clients accessed FP services, and it is

expected that access to long term and permanent FP methods will continue to increase in the

district with continued support towards targeted FP outreach clinics.

TABLE 12. SUMMARY OF BTL CLINIC - MULANJE

METHOD TOTAL CLIENTS CYP

Implanon 3 7.5

Levoplant 6 9.6

Jadelle 21 73.5

IUD 3 13.8

BTL 24 223.2

Total 57 328


Mobile Youth Outreach Teams The 9 Youth teams saw 5,539 client visits which generated 10,749 CYPs which represents an

increase from October of 1% and 5% for client visits and CYPs respectively. The most productive

team in November was Lilongwe 1,026 client visits and generated 1,351 CYPs. The Dowa team was

the next most productive, serving fewer client visits at 682 but generating more CYPs with 1,373.

Machinga also generated a greater number of CYPs (1,731) from fewer client visits which is

attributed to a greater proportion of clients seeking BTLs from the team. Teams continue to report

that clients have expressed a preference for services at an outreach rather than a busy public facility

where there are fears about COVID-19 being present.

Of the 5,539 client visits, 89% were female and 58% were under the age of 25, which is in line with

previous months. Of those under 25 years, 20% were under 19 years.

The method mix for Youth Outreach teams in November was 60% short term methods, 36% Long-

acting and Reversible Contraceptives (LARCs), and 4% permanent methods. Over the preceding

months the method mix has shifted back towards short term methods after several months of

increasing LARC and permanent method uptake. In November, short term methods decreased by

3% as those clients elected to take a LARC method instead. There has been an observed increased

interest in LARC methods during COVID-19 which is attributed to a desire to reduce visits to

facilities.

The Youth Outreach teams continued to offer choice to clients seeking voluntary FP methods, with

11 methods available across the 9 teams as well as emergency contraception. There were shortages

of IUCD across all districts and shortages of Implanon, Levoplant and Jadelle and emergency

contraception experienced in many districts.

NESTED PROVIDER CONDUCTS GROUP COUNSELLING ON THE LEFT PHOTO AND PERFORMS IMPLANT INSERTION ON THE RIGHT DURING THE BTL CLINIC AT HEALTH CENTER IN MULANJE: PHOTO CREDIT ZIMA NINDI


TABLE 13. MOBILE YOUTH OUTREACH CLINICS - NOVEMBER 2020

DISTRICT CONDOMS (M) PILLS

EC DMPA IMPLANTS IUC

D BTL

CLIEN

TS CYP

Pie Cl Cyc Cl IM SC 3y 4y 5y

Balaka 7,168 184 150 50 0 39 168 47 15 157 7 0 637 916

Chitipa 60 1 13 5 0 0 57 0 89 37 8 0 206 478

Dowa 9,269 170 70 33 0 74 106 0 129 124 7 33 682 1,373

Karonga 420 7 15 6 0 29 1 2 55 91 6 0 201 566

Kasungu 8,665 122 131 49 0 0 2 1 86 88 3 19 338 897

Lilongwe 6,324 168 422 177 0 0 440 0 0 237 0 26 1,026 1,351

Machinga 2,739 66 15 5 0 0 193 12 29 169 14 83 566 1,731

Mulanje 8,020 184 114 42 0 0 250 0 72 124 13 67 640 1,568

Nkhotakota 6,340 165 24 8 0 0 48 0 51 34 4 1 307 387

Salima 1,794 59 12 4 0 0 79 23 40 87 1 9 365 646

Zomba 6,646 152 85 34 0 150 84 0 105 54 12 12 571 836

TOTAL 57,445 1,278 1,051 413 0 292

1,42

8 85 671 1,202 75 250 5,539 10,751

FACILITY-LEVEL FP

Nested Providers Nested providers saw 1,425 client visits in November which generated 3,113 CYPs. Client visits

were 24% lower than October. The reduction in Nested productivity is an anticipated part of the

strategy to move the focus from direct service provision to mentorship – nested providers are

prioritizing the public providers and working with them to improve confidence and quality rather

than providing services themselves.

Public facilities are seeing fluctuations in their client flow which is attributed to the MoH COVID-19

response plan which directs people to their nearest medical facility, to ease the burden at the

district hospitals which is where the nested teams are located. Clients also continue to report

concerns about attending big public facilities as they will be seeing and treating COVID-19 patients,

and therefore it is perceived as more likely to spread there.

In August, Nested providers started to collect data on DMPA-SC self-injection: the providers

document on the client record forms the dose was given by the provider or whether the client had

injected herself. The self-injection numbers include the number of doses given to the client to self-

inject at home. The total number of DMPA-SC doses provided for self-injection in November was

565 of 824 DMPA-SC services. The method mix for November was: 50% short term methods, 46%

LARCs and 4% permanent methods.

TABLE 14. NESTED PROVIDER CLIENTS AND CYP – NOVEMBER 2020

DISTRICT CONDOMS

(M)

PILLS EC DMPA

IMPLANTS IUCD BTL CLIENT

S

CYP

PIE CL CY CL IM SC SI 3Y 5Y

Balaka 0 0 3 1 0 0 5 0 25 29 5 1 65 207

Dowa 0 0 18 6 1 0 56 2 21 11 0 0 95 110

Karonga 420 21 18 4 0 0 39 3 15 41 7 8 128 371

Kasungu 174 2 120 40 4 0 40 0 41 50 7 5 189 398

Lilongwe 1,084 40 20 12 6 0 6 1 2 65 18 12 162 592

Machinga 362 14 57 20 7 9 492 477 4 37 11 10 395 542

Mulanje 130 6 0 0 0 0 32 6 0 31 4 10 91 303

Nkhotakota 750 20 42 5 0 0 81 75 1 60 2 0 141 269

Salima 0 0 16 6 0 2 70 1 22 34 1 4 146 270

Zomba 0 0 0 0 0 0 3 0 0 6 1 2 13 51

Total 2,920 103 294 94 18 11 824 565 131 364 56 52 1,425 3,113


Facility-Based Outreach Teams The facility-based outreach teams saw 2,774 client visits in November which generated 7,295 CYPs.

Client visits decreased by 6% from October and CYPs declined by 9%. The decrease in client visits is

attributed to the intensification of farming activities in some of the districts which means women are

less available for services. The continued high CYP numbers are attributed to the method mix being

more focused towards LARC and permanent methods, as more clients elect to receive these

services.

The method mix was 53% short term methods, 40% LARCs and 7% permanent methods,

representing a slight shift away from permanent methods which is expected as farming activities

increase. This is due to that many women tend to opt away from LARC and permanent methods

during the farming season due to soreness of the arms/abdomens making it more difficult for them

to contribute to household/farming activities. 19% of the client visits were those under 20 while 30%

were aged 20-24 years.

TABLE 15. FACILITY-BASED FP OUTREACH – NOVEMBER 2020

DISTRICT CONDOMS

(M)

PILLS EC DMPA

IMPLANTS IUCD BTL CLIENT

S

CYP

PIE CL PIE CL IM SC 3Y 4Y 5Y

Balaka 2,992 102 160 59 0 167 110 102 52 222 22 101 941 2,481

Karonga 15,520 512 102 34 0 31 298 0 156 234 19 17 782 1,864

Machinga 4,344 131 29 13 5 84 175 0 157 73 16 38 581 1,337

Nkhotakota 720 36 44 30 0 0 104 0 119 116 10 71 470 1,613

Total 23,576 781 335 136 5 282 687 102 484 645 67 227 2,774 7,295

YOUTH

YOUTH-FRIENDLY HEALTH SERVICES (YFHS)

In the reporting month, ONSE supported Lilongwe, Karonga, and Nkhotakota to conduct a YFHS

internal assessment in which a total of 44 facilities were assessed: 25 facilities in Lilongwe, 12

facilities in Karonga, and 7 facilities in Nkhotakota; reaching 60 (37M, 23F) YFHS focal point persons.

District Youth Officers, District Friendly Health Providers, and YFHS trainers facilitated the activity

with the aim of assessing the quality of services that youth are accessing in the facilities and provide

mentorship and coaching to health service providers according to identified gaps. The MoH checklist

which measures five standards was utilized, and a summary of findings can be found in the table

below.

TABLE 16. SUMMARY OF YOUTH FRIENDLY HEALTH ASSESSMENT FINDINGS - LILONGWE, KARONGA AND NKHOTAKOTA

STANDARD FINDINGS ACTION POINTS

Service

provider’s

knowledge,

skills and

positive attitude

in the provision

of YFHS

Of the 25 facilities visited in Lilongwe, 23 of

them had providers oriented in YFHS with

exception of Dickson, Chileka, and

Ming’ongo.

88% of the facilities visited in Lilongwe had

their support staff oriented in YFHS.

In Karonga, of the 12 facilities visited, only

42% had providers trained/oriented in YFHS.

For Nkhotakota, of the 7 facilities, 88% have

trained providers and support staff that are

oriented in YFHS

For Lilongwe facilities it was noted that 96%

of the facilities visited accord the youth

necessary privacy required and 84% of

The YFHS Coordinator in

collaboration with the DYO are to

lobby with other partners to support

orientation of providers in the

facilities where there are no trained

providers.

During this orientation, support staff

are included in the facilities where

they are not oriented.


STANDARD FINDINGS ACTION POINTS

providers provide services to the youth with

respect.

In Nkhotakota, all facilities visited do

provide required privacy and only a few

facilities in Karonga as most of them do not

have special rooms for youth.

Health facilities

are providing a

minimum

package of

services to the

youths

according to

the needs of

the youths.

All visited facilities in all districts are able to

provide a minimum package of services

according to the needs of the youth.

19 out of 25 facilities in Lilongwe had

adequate supplies, drugs, and equipment for

YFHS provision while for Nkhotakota, all

the facilities have adequate supplies. In

Karonga, few facilities have necessary

supplies and drugs

Quarterly supervision to continue in

all facilities just to maintain quality of

services being provided to the youth.

ONSE will continue supporting

mentorship of providers in YFHS

data tools so that all supplies and

drugs utilized during service

provision can be accurately recorded

to aid proper supply chain

Service

provision is

done according

to existing

policies and

procedures.

At least 96% of service providers that were

visited were oriented in the relevant YFHS

standards in Lilongwe and Nkhotakota and

almost all facilities visited have reproductive

health (RH) and youth policies.

In Karonga, most facilities visited there are

no guidelines for service provision

The National YFHS Strategy has

become outdated and the current

review process has begun and will

take into consideration the relevant

supporting documents. Once

printing of these revised guidelines is

completed all providers will be

oriented.

Youths

obtaining health

information

(including

Sexual and

Reproductive

Health [SRH]

and HIV)

relevant to

their needs

For facilities that were visited in Lilongwe,

88% had posters depicting YFHS while 60%

of facilities had leaflets that youth could take

and use at home. While for facilities in

Karonga, there were no leaflets that youth

could take but had posters with information

on YFHS.

In Nkhotakota, all facilities visited had

posters with information on YFHS and few

had IEC materials that youth could pick and

use as reference at home.

Most facilities that were visited for all

districts have established relationship with

other partners and organizations

Once the review of the YFHS

strategy and relevant documentation

is done, issues of IEC materials and

posters will be issued from the past

as all facilities will be furnished.

Availability of

data including

its analysis and

utilization.

For facilities in Lilongwe, 75% of them are

able to report to the district every month. A

challenge is on the analysis of data and its

utilization, in which only 32% of the 25

facilities visited in Lilongwe are able to

analyze and use the information collected.

Similarly in Karonga, facilities are collecting

and submitting monthly reports to the

district but data is not analyzed and utilized

for decision making.

In Nkhotakota, 100% of facilities visited are

submitting monthly reports to the district.

And Nkhotakota as a district is the one of

the few districts that is utilizing data for

decision making. In 2020 so far, more than

two activities have been supported in

response to poor indicators.

ONSE to continue mentoring YFHS

Coordinators and DYOs on the

importance of data analysis to

reduce teenage pregnancies in the

districts and provide relevant

activities to meet needs of the youth

that ONSE is trying to serve.

District Youth Officer and District

Youth friendly Coordinator together

with ONSE team in the district have

been commended for the good work

they are doing.


During the supervision, the following materials were distributed in the facilities visited, monthly

reporting forms, client exit forms and YFHS accreditation forms.

Key Implications for ONSE ONSE will continue to support supervision and mentorship sessions for providers in YFHS in order

to maintain quality of services for the youth. Mentorship sessions of providers on data collection

tools has yielded results as more facilities are reporting now, but as we continue ONSE will focus

more on data use for decision making both at district and facility level. This will help YFHS focal

point persons to plan activities based on the evidence that is being provided by data. On this,

Nkhotakota will be taken as a district where other districts can learn from. At the national level,

ONSE will continue to lobby other partners to support training of providers in YFHS as this is an

ongoing activity with transfer in and out of staff in the facilities

In the reporting month, ONSE in Zomba supported orientation of peer educators and YFHS focal

point persons in COVID-19 targeting 7 health facilities of Zilindo, Matiya, Sadzi, Chamba, Bimbi,

Nkasala, and Naisi. The orientation was aimed at equipping peer educators and YFHS focal point

persons with correct information on COVID-19 as the need to continue observing precaution

measures are still necessary. It is expected that participants oriented will share similar information

to other fellow youth. The activity reached out to 24 (14M; 10F) participants covering topics

including an overview of COVID-19, signs and symptoms, prevention of COVID-19, infection

prevention during COVID-19, management of COVID-19 patients in the communities, and

challenges faced by young people during COVID-19 pandemic and the role of young people in the

fight against COVID-19 pandemic. It is expected that the youth will be instrumental in disseminating

COVID-19 messages upon undergoing the orientation and this will promote message assimilation by

the community at large.

GENDER

Sixteen Days of Activism In this reporting month, ONSE participated and supported in the launch of 16 days of Activism for

Gender Based Violence (GBV) in Balaka on December 4. The theme of the activity was “Unite to

end Gender based violence; Prevent, Report, Respond, Fund.’’ The guest of honor at the function

was STA Kachenga, chosen because of her passion in the fight against GBV. In her remarks, the

guest of honor appreciated all partners that supported the activity and pledged her commitment to

support all efforts targeted at bringing an end of GBV acts in her area and district at large. She also

called on her fellow chiefs to hold hands with the government and partners so that perpetrators for

GBV are reported to help bring justice to the victims.

A GROUP PHOTO OF PARTICIPANTS UPON ORIENTATION OF PEER EDUCATORS AND FOCAL PERSONS IN COVID-19 ON NOVEMBER 25, 2020. (PICTURE TAKEN BY GLORIA CHING’ANI-YOUTH FRIENDLY HEALTH TRAINER).


ONE STOP CENTER MEETING – NKHOTAKOTA

In the reporting period, ONSE in Nkhotakota supported a One Stop Center steering committee

meeting attended by 9 (7M, 2F) members to review cases that the center is receiving and identify

those that have been completed. The Youth and Gender Advisor participated in this meeting and

presented 13 plastic chairs purchased by ONSE in a bid to promote quality service delivery at the

center. Chairs are part of the items that ONSE committed to support the center in response to the

District Medical Officer request on basic furniture the center is lacking.

TABLE 17. OVERVIEW OF ONE STOP CENTER MEETING - NKHOTAKOTA

STRENGTHS WEAKNESSES

During the meeting members were informed

that sensitization meetings the committee

has been conducting announced the

presence of the GBV prevention and

management services has yielded results as

more people are utilizing the services.

Culture of silence on issues of GBV is

reducing; currently the center is receiving

cases where wives are reporting their

spouses or reporting a relative who has

misbehaved.

There is good collaboration between service

providers in handling of the cases which has

resulted in victims waiting for less time for

services

Members were informed that NOID, an

organization which was implementing its

activities in the districts but ceased to

operate donated plastic chairs to the center.

Members were informed that the request for basic

furniture is critical now, especially a lockable filing cabinet

as files for victims are not well secured. He cited an issue

where evidence of the defilement case was almost altered

because someone managed to open the room as keys are

kept at the reception and accessible to everyone.

Responding to this issue, members were informed that

ONSE will source a lockable cabinet where files can be

kept.

Changes at the police have disrupted services at the

center. Members were informed that the police officer

who was assigned to the One Stop Center was transferred

to another district and the one which replaced him is not

following the terms the committee agreed. Members

agreed that senior officers from different sectors are to go

and present the issue to the police officer in-charge so that

the new officer can be adequately oriented to the agreed

terms of the center.

Nkhotakota One Stop Center has a register, but

documentation is a challenge. The register was designed in

such a manner that all the service providers were

documenting their findings in the same register.

Unfortunately, so far only health service providers are the

ones completing their part unlike the other sectors like

police, judiciary, and social welfare. Members complained

that since three quarters of the current members were

those that did not receive the initial training, they have

limited capacity in filling the register. Members agreed to

select one day to do a mentorship session on filling of the

GROUP VILLAGE HEAD (GVH) CHULU IN BLUE JACKET AND YOUNG MUSICIAN ELI NJUCHI IN THE SOLIDARITY WALK FROM KACHENGA MARKET TO MPIRISI PRIMARY SCHOOL. PHOTO CREDIT: JACK MABVUKA


STRENGTHS WEAKNESSES

register and those that participated in the actual training

will facilitate this session.

Health service providers are not willing to go and witness

in court for fear for interrogating officers who at times

intimidate the providers. Members agreed that during the

mentorship sessions, they should invite a magistrate in the

district to drill the providers on how to write medical

reports and respond to questions in court.

Lastly, members also were informed that the center is

receiving cases from Dwangwa which is over 70km away.

Members felt that those that come may be a small fraction

of the cases looking at the distance, meaning that many are

not seen and don’t receive appropriate treatment. The

Gender Officer informed the members that he will make a

special request to the partners to expand One Stop

Center services to Nkhunga Health Center so that more

people could be served.

MALARIA

MALARIA DIAGNOSTICS AND CASE MANAGEMENT

Malaria case management supervision continues to be a core activity supported by ONSE. In the

month under reporting, ONSE supported malaria case management supervisions in Balaka, Ntcheu,

and Nkhotakota. Twenty-eight facilities were supervised with intensive coaching and mentorship in

areas of diagnosis and treatment. In health centers, the focus of coaching and mentorship was on use

of mRDTs, adherence to test results, and pre-referral management of severe cases; while in facilities

providing in-patient services, mentorship extended to management of severe cases of malaria. The

emphasis of severe case management was on patient monitoring which has been a consistently low

performing area in OTSS findings. These supervisions managed to provide coaching and mentorship

to 74 health workers (51M, 23F).

In order to broaden the reach of case management supervisions, ONSE also supported group

mentorships on case management in Nkhatabay to mentor and support health care workers in their

delivery of quality malaria care and treatment services. Mentees were equipped with skills,

knowledge, and attitude necessary to provide high quality care and treatment in the context of a

facility work environment. For efficiency and effective achievement of the group mentorship

objectives, mentors used OTSS checklists and identified specific gaps and developed specific

mentorship plans to correct shortfalls. The mentorship reached 44 (31M, 13F) health workers.

In Machinga, ONSE supported mRDT QI supportive supervisions centered around malaria

diagnostic supportive supervision and mentorship to follow up on the impact orientations and OTSS

conducted in the districts. The objectives of the activity were to assess availability of human

resources and the capacity to provide malaria diagnosis services, availability of mRDTs, and assess

adherence to standards as recommended by the National Malaria Control Program (NMCP) and

WHO. The supervision was conducted in nine facilities resulting in mentorship and coaching of 16

(11M, 5F) workers. ONSE will continue to provide support to the district laboratory team to

continue to build the necessary capacity for all facilities in the districts. Below is a summary of the

findings.


TABLE 18. SUMMARY OF MRDT QI SUPPORTIVE SUPERVISIONS

CHALLENGES AGREED ACTION POINTS

Incomplete documentation in laboratory

registers

Mentorship and coaching provided on how to appropriately fill

registers

Some facilities were not following mRDT

standards like checking results after 15-20

minutes

Staff were mentored the minimum standards expected to be

accomplished during testing using mRDTs

Some facilities had more Lumefantrine

Artemether (LA) dispensed than confirmed cases

Advised staff to ensure they adhere to positive and negative

results

In addition to routine case management supervisions, coaching, and mentorships; ONSE supported

pediatric malaria case reviews in Mchinji in 10 facilities across the district. The main objective of the

exercise was to build the capacity of health workers in diagnostics, case management, and data and

supply chain management to strengthen transparency and accountability of malaria commodities.

Intense discussions and review of relevant records were some of the methods used during the case

reviews whilst being guided by a checklist. While there has been improvement in case management

especially on diagnostics, challenges exist in some facilities testing using RDT and microscopy. RDT

and microscopy performance has been quite good except at Kapiri where there are still reports

using the plus systems instead of parasite density. Lack of weighing scales, thermometers, and stock

out of glucostics are some of the challenges facilities face and do hinder provision of quality care to

patients.

MALARIA IN PREGNANCY (MIP)

In the reporting month, ONSE supported Ntcheu, Nkhotakota, Nkhatabay, and Machinga to provide

MIP supervisions to 34 health facilities building capacity of ANC providers in areas of understanding

MIP guidelines, Intermittent Preventive Treatment in Pregnancy (IPTp), and ANC standard

protocols. The sessions also continue to focus on the newly introduced ANC registers. A total of

105 (41M, 64F) health workers were reached and mentored.

TABLE 19. SUMMARY OF FINDINGS IN THE SUPERVISED FACILITIES

CHALLENGES ACTIONS DONE AND RECOMMENDATIONS

As other facilities are improving on documentation, the

majority are finding challenges especially high volume

facilities.

COVID-19 has affected ANC attendance in facilities, only

few mothers report for ANC services.

COVID-19 preventive measures are not exercised in

most facilities, many health has relaxed, not exercising

proper preventive measures.

Stock-out of essential commodities such as ferrous

sulphate, NVP, and albendazole in some facilities

Despite that mothers are given ITN and iPTp, the

majority report the facility with malaria infection.

Facilities are facing challenges on 8 contact approach, as

many mothers are unable to report facilities because of

distance to the facilities

Waste segregation is not properly conducted, mixing of

wastes in one bin in many facilities.

Lack of proper skills and techniques on abdominal

palpation of a pregnant mother

Done mentorship on proper documentation

in the revised ANC register and tasked

facility in-charge to make monthly spot

checks on documentation

Pharmacy team to conduct relocation of

commodities in facilities to stock those

stocked out.

In-charges were advised to conduct meetings

with community leaders regarding mothers’

inability to use ITNs to prevent malaria, and

act accordingly to mitigate the challenge.

Conducted bedside mentorship on proper

abdominal assessment of pregnant mothers to

impart midwives with best skills and

techniques.


COMMUNITY-BASED DELIVERY OF IPTP (CIPTP)

Study Data Filing and Archiving The implementation of c-IPTp study ended in July 2020. In the month of December, the ONSE study

team transferred all data forms and copies of HSA registers to Blantyre Malaria Alert Centre

(MAC). All study documents including investigator site file filed together with all the data forms at

MAC.

Final Study Close out Meetings The study team visited all the study facilities in Nkhatabay and conducted the close out study

meetings. There were no study outstanding issues in all facilities in Nkhatabay. All HSAs including

facility in-charges and ANC providers were informed that the study is now officially closed. The

ONSE study team further advised the HSAs that study results are not yet out and that they will be

able to get the results through the MoH. The ONSE study team thanked all the facility staff for their

efforts during the study implementation and encouraged all HSAs to continue referring pregnant

women to ANC. Final study close out meetings in Ntcheu to be done the week beginning

December 14, 2020.

NUTRITION

COMMUNITY MANAGEMENT OF ACUTE MALNUTRITION (CMAM)

ONSE supported CMAM supportive supervision at Kwitanda, Kankao, Phimbi, and Mbera Health

Centers from November 10-13, 2020 in Balaka to improve the quality of CMAM service provision in

the targeted facilities. The team managed to reach 19 (12M, 7F) health workers and the supervision

was conducted by 2 (1M, 1F) officers from Balaka DHO. Similar support was also provided to

Chididi, Kapiri, Malowa, Mwansambo, Mpamantha, Benga, Alinafe, and Mtosa Health Centers in

Nkhotakota from November 23-25. The following table summarizes the findings.

TABLE 20. SUMMARY OF CMAM SUPERVISION – BALAKA AND NKHOTAKOTA

DISTRICT STRENGTHS CHALLENGES ACTION POINTS

Balaka Proper documentation

in the registers at

Kwitanda

Data consistency in

registers & reporting

forms at Kwitanda and

Kankao

Admission and

discharge criteria for

both Outpatient

Therapeutic Program

(OTP) & SFP was

followed at all facilities

Stocks were properly

managed and stock

cards were properly

filled at Kankao

There was clinical

involvement in OTP at

Phimbi & Mbera

Incomplete client

information on monitoring

charts for OTP at all the 4

facilities

Incomplete documentation

on SFP monitoring charts at

Phimbi

Incomplete information in

the OTP & SFP registers at

Kankao & Mbera

Routine medications were

not given at Kwitanda &

Kankao

Clinicians at Mbera health

center had knowledge gap

on CMAM

HSAs at all facilities to

properly document in the

monitoring charts for

OTP

HSAs at Phimbi to

properly document in the

SFP register

HSAs at Kankao & Mbera

to completely fill the SFP

& OTP registers

Health workers at

Kankao & Kwitanda to

administer routine

medications to children in

OTP

Mentor clinicians at

Mbera health center on

CMAM

Nkhotakota HSAs were working

hand in hand with care

group volunteers in

At Malowa, out of eleven

children in OTP none were

given routine drugs, while at

There is need to mentor

health workers on the

importance of giving


DISTRICT STRENGTHS CHALLENGES ACTION POINTS

making follow ups of

children under CMAM

program

All health centers

submitted reports to

District Hospital in

time

Clinicians and Nurses

always available during

OTP clinic

Kapiri only 2 of 6 were

given routine drugs

At Malowa and Benga there

was inconsistency in testing

of HIV and malaria where

about half of the patients

were not tested for HIV and

malaria. While at Kapiri

none was tested for both

HIV and Malaria

No child was given the

routine Albendazole at

Alinafe and Mtosa

At Alinafe, children on SFP

program were not

registered but appeared in

reports only

Alinafe, Benga and Mtosa

not admitting children

discharged from OTP to

SFP

At Benga Albendazole was

given to a child of less than

12 months against the

standards of giving it to

children above 12 months

routine drugs to children

in OTP program

Need to sensitize health

workers on importance

of HIV and malaria test to

children in OTP program

Need to orient health

workers in management

of acute malnutrition

guidelines

Need for readily

availability of transport

from DHO to supply

amoxicillin and RUTF for

OTP

ONSE supported an orientation for health workers on the management of NRU children in context

of COVID-19 at Karonga District Hospital from November 16-17 for a first session and November

19-20 for a second session. A total of 24 (11M, 13F) nurses and clinicians were oriented with the

objective of coaching health workers on the management of patients (NRU, OTP and SFP) in

context of COVID-19 pandemic and orient people on the key messages of Infant and Young Child

Feeding (IYCF) in the context of COVID-19 pandemic. Also included in the training was a discussion

on nutrition care, support and treatment (NCST) for adolescents. Participants raised interesting

issues during the training including that breastfeeding while putting on face masks disrupts the bond

between the mother and the child, lack of nutrition supplies in NCST program demotivates clients

to come for follow ups, and incomplete documentation in NRU management forms are largely due

to knowledge gaps. It was advised that breastfeeding mothers are to adhere to control measures by

putting on face masks and observing water and sanitation hygiene principles; nurses, clinicians, and all

other staff are to properly document in NRU management forms; and all key IYCF messages to be

put under practice.

During the reporting period, ONSE supported data quality supervision in Zomba to strengthen data

quality in the registers and reporting forms to make sure that the data entered into the DHIS2 is of

good quality. Data was checked for the period of July 2020 to September 2020, and a total of 5 (1M,

4F) health workers were supervised by one female nutrition officer from ONSE. The activity took

place at Domasi NRU on November 26, 2020.


TABLE 21. SUMMARY OF DATA QUALITY SUPERVISION - ZOMBA

OUTCOMES OTP RESULTS ACTION POINTS

There was proper documentation in

both the registers and reporting

forms following the mentorships that

ONSE has supported in the facility

All Severe Acute Malnutrition (SAM)

children admitted in the NRU were

tested for HIV, hemoglobin (HB),

MRDT and documentation of results

was available

In July, August, and September 2020

the data that was entered into the

register was the same as the data

that was in the reporting form for

NRU and entered into the DHIS2

In July 2020, the facility over

reported by 3 for SFP program

It was noticed that in the

month of July 2020, the facility

had 14 admissions and

discharged four as cured in the

register, however in the

reporting form, the number of

clients cured were seven for

the same month

Page summaries on the

reporting forms were not done

for 80% samples reports. The

nutrition officer mentored and

encouraged the team to be

writing the summaries on the

reporting forms so that they

are able to make decisions

based on their data

The nurse in charge to

facilitate a meeting and

mentor Home Craft Worker

on proper reporting of data by

November 30

Summaries on the reporting

forms to be completed by the

NRU QI team by November

30. The nurse in charge to

lead the meeting

NRU QOC

NRU Case Reviews in Nkhotakota In the reporting month, ONSE supported 16 (10 M, 6F) health workers to conduct NRU case

reviews at Nkhotakota DHO on November 24 with the aim of auditing QoC provided to children

with SAM. A total of 10 files were randomly selected and audited using a criterion based audit tool.

The overall score for the audit was 72%.

TABLE 22. SUMMARY OF NRU CASE REVIEWS - NKHOTAKOTA

WEAKNESSES WAY FORWARD

Incorrect frequency of administration of

routine drugs (antibiotics) to NRU patients

i.e. providing benzyl penicillin less than four

times a day

Routine tests were not done on some NRU

cases e.g. HB checking, HIV testing, and

blood glucose level

Poor documentation and record keeping.

Some files were missing admission numbers

and lab results are not attached to the case

files

Nurses in the NRU ward to work with home care

workers to ensure all patients are receiving routine drugs

and tests and ward in-charge to review case notes weekly

Ward in-charge to source a stapler machine and assign one

home care worker on a daily basis to ensure they are

pinning lab results to the case notes

Ward clinicians to conduct ward round at the NRU ward

daily

Data clerk to check case files for the admission number

and ward in charge to check for completeness of all

technical documentation

NRU Death Audit In the reporting month, ONSE supported NRU death audit at Mulanje District Hospital Pediatric

ward on November 30 to review the QoC for children in NRU and take action for shortfalls to

prevent future recurrences. A total of 9 (1M, 8F) MoH staff conducted the audit. A total of five

deaths were audited using a standardized NRU death checklist, and it was observed that four of the

deaths occurred in the stabilization phase and one occurred in the transition phase.


TABLE 23. SUMMARY OF NRU DEATH AUDIT - MULANJE

WEAKNESSES WAY FORWARD

Poor monitoring of feeds

Late health care seeking by family members

(child had diarrhea for seven days and came

two days after referral)

Poor nutrition assessment of child

Poor documentation

Nurses and clinician need to improve on documentation

There is need for conducting proper assessment during

admission by all health workers

Staff to improve on monitoring of feeds for NRU children

NRU QI team to monitor action points and review care in

February 2021

Salima District Hospital with support from ONSE conducted a death audit on November 19 in a

pediatric ward by 15 (8M, 7F) health workers. The main causes of death were cardiac failure, severe

pneumonia, meningitis, severe malaria, and hypoglycemia. Action points were discussed and agreed

upon as follows.

TABLE 24. SUMMARY OF DEATH AUDIT FINDINGS - SALIMA

FACTORS CONTRIBUTING TO DEATH ACTION POINTS TO IMPROVE IN FUTURE

Delay in seeking health care by caregivers Strengthen active case finding

Rolling out of family mid-upper arm circumference and edema

assessment

Inadequate clinical assessment and management Improve clinical assessment and management

Inadequate optimal IYCF practices Intensify counselling on IYCF practices

Inadequate monitoring of vital signs Improve monitoring of vital signs

BFHI

Monthly BFHI Meeting in Dowa In Dowa, ONSE supported a BFHI meeting at Mponela Rural Hospital on November 13, in which 20

(7M, 13F) care providers participated. District BFHI coordinator facilitated the meeting, and the

following cadres participated: four community health nurses, five nurse midwife technicians, two

medical assistants, two DCSAs, two nursing officers, one Assistant Environmental Health Officer

(AEHO), and one data clerk. The objectives of the meeting were to review progress of BFHI at

Mponela Rural Hospital, brief participants on breastfeeding activities to be implemented for the pilot

study, orient participants on BFHI data tools (registers and reporting forms) to be used for the pilot

study, and discuss measures to strengthen linkage/referral systems between facility and community

during the time of discharge from postnatal ward.

TABLE 25. SUMMARY OF BFHI MEETING - MPONELA RURAL HOSPITAL

ACHIEVEMENTS CHALLENGES ACTION POINTS

Copies of breastfeeding policies

were available, skin to skin contact

and early breastfeeding initiation is

done, currently health talks are done

in antenatal clinic, and postnatal

ward and slightly in labor ward

Participants acquired knowledge on

what topics to include on

breastfeeding health talks/education

at all service delivery points i.e.

antenatal clinic, waiting home, labor

ward, postnatal ward, and under-five

clinic

Involvement of public health

personnel i.e. AEHO and DCSAs, in

the meeting helped in mapping way

Some providers are not taking

part in promoting breastfeeding

because of inadequate

knowledge

There are no IEC materials at

the facility e.g. brochures,

leaflets, and available wall

posters are faint (they have

overstayed and need

replacement)

There are no routine or

monthly facility level meetings

to discuss BFHI issues

Lack of monthly supportive

supervision at the facility

BFHI coordinator to forward

concerns on antenatal register

to the nutrition department in

MoH by November 17

There is a need to mentor or

train providers that have

inadequate knowledge. BFHI

coordinator to lobby for

support from DHO and

partners by February 2021

There is a need to provide

IEC materials. This was

reported and nutrition

department promised to

support by end November

2020


ACHIEVEMENTS CHALLENGES ACTION POINTS

forward on linking hospital and

community groups on breastfeeding

issues

The AEHO and DCSAs to provide

the list of available care groups in

their catchment areas to postnatal

ward for linkage during discharge.

The discharging midwife will link the

mothers to their care groups at the

time of discharge

Participants agreed to strengthen

and conduct health talks/education

on breastfeeding on a daily basis in

the following departments: antenatal

clinic and waiting home so that

mothers have adequate knowledge

by delivery. Health education do be

done on daily basis before and

during discharge from the hospital

During the meeting, participants

identified shortfalls in the new BFHI

registers that need to be revised, e.g.

breastfeeding antenatal register

needs to have a column to indicate

subsequent visits.

The hospital does not have a

fence as a result it is difficult to

control traffic/visitors,

frequently interrupting mother-

infant bonding during rooming

Labor and delivery room have

four delivery beds only against

average of 10 deliveries per

day, leading to inadequate time

of skin-to-skin for the first 2

hours after delivery

Lack of supervision to care

groups and updates on

breastfeeding issues

BFHI coordinator to lobby for

support from DHO and

partners to re-paint wall

messages

Ward in-charges to start

producing monthly health

education talk schedule that

include breastfeeding

Discharging midwives to link

mothers to community care

groups and DCSAs during

discharge by communicating

the name of catchment DCSA

and the name of the care

group in their communities.

TUBERCULOSIS (TB)

In the reporting period, ONSE supported TB contact investigation community follow ups from

November 13-14 at four health centers of Ntaja, Nthorowa, Ngokwe, and Mkwepere. A total of 41

(25M, 16F) household contacts were followed up, and among the contacts, 5 (4M, 1F) were under-

five children who missed their IPT appointment dates, and resupply of IPT drugs was completed.

The activity was integrated with a follow up of two male TB patients at Ntaja health center on

November 14 and 16 who missed their sputum examination follow up appointments at 6 months.

Samples were collected for smear examination and they all came out negative.

WATER, SANITATION, AND HYGIENE (WASH)

WASH FACILITY ACTION PLANS

In an effort to promote IPC/WASH, the ONSE WASH team in Mulanje conducted follow up visits

to WASH action plans that were developed in the previous months. The visit found that two health

care facilities Mimosa and Lijeru have implemented their WASH action plans. The table below

highlights the WASH issues that were found and what was done to resolve them.


TABLE 26. WASH ISSUES THAT HAVE BEEN IMPLEMENTED IN DECEMBER 2020

DISTRICT WATER

POINT

MEMBERS TRAINING STATUS LINKAGE

TO AREA MECHANIC

OPERATION AND MAINTENANCE

COSTS

Mulanje Lijure 19/11/2020 The facility refuse pit was

full and the surrounding

area was dirty. Yes

On 01/12/2020: a new refuse pit

was dug by Health Center

Management Committees (HCMCs)

and the facility environment was

clean

Mimosa 20/11/2020 The facility borehole had

dirty foul smelling stagnant

water without a proper

drainage system.

Yes

On 01/12/2020 the HCMC

organized itself and cleaned the

facility borehole area, dug a soak

away pit at the end of the drainage

channel, and filled it with stones

The facility had no refuse

pit as the previous one was

completely full.

Facility ground had

overgrown grasses making

the area look untidy

Yes

On 01/12/2020 the facility ground

staff dug a refuse pit and cut short

the overgrown grasses

COMMUNITY WATER SUPPLY

In the reporting month of December 2020, ONSE continued to track the status of water supply to

the communities. In order to ensure the safety water supply, ONSE engaged one of the prequalified

laboratory services providers, Malawi Bureau of Standards (MBS). A total of 316 water points in 11

WASH targeted districts of Chitipa, Karonga, Kasungu, Dowa, Nkhotakota, Salima, Balaka, Lilongwe,

Machinga, Zomba, and Mulanje were tested for water quality. The eight key drinking water quality

parameters recommended by US Agency for International Development (USAID) for the general

assessment of water quality were investigated. The parameters, divided into two groups of health-

related parameters: arsenic, fecal coliform, fluoride and nitrate (as NO3); and operational-related

parameters: electrical conductivity, total dissolved solids, pH, and turbidity. The results of the water

quality testing will inform the decision to take into consideration the remedial actions to address the

situation.

TABLE 27. WATER POINTS DISTRIBUTION PER DISTRICT

DISTRICT NUMBER OF WATER POINTS

Chikwawa 1

Chitipa 8

Karonga 6

Kasungu 7

Dowa 9

Nkhotakota 10

Salima 8

Lilongwe 13

Balaka 11

Machinga 9

Zomba 7

Mulanje 227

In the reporting period, ONSE continued to support the District Water Office (DWO) and District

Environmental Health Office (DEHO) to conduct community water point supportive supervision for

sustainability. During this reporting period, the supportive supervision targeted water point


committees (WPC) and Area Mechanics (AM) in Kachenga, Phalula. and Magomelo areas in Balaka

facilitated by four district WASH supervisors (3M, 1F) on November 11-27, drawing participation

from 46 (18M, 28F) community members. The objectives were to assess the functionality of WPCs

and provide technical/mentorship support to the AMs.

Observations on AMs During the supervision, the following observations were made and corrected:

Community contribution towards Borehole maintenance funds. The water management

authorities (WMAs) explained to the community members on the need to develop

sustainable strategies of maintaining a borehole fund since its beneficiaries responsibility to

maintain a borehole

Linking up the committee and AM. The WMA explained the need for each WPC to know

the responsible AM for the area so that they can seek technical support in case of borehole

breakdown

Collection of data and reports from AMs. AMs were encouraged to be providing monthly

reports to the DWO on their activities

Challenges AMs encountered:

Transport is a major challenge for the program, as some water points are very far.

Involvement of untrained AMs. This has led to more complications as they fail to repair

complicated breakdowns consequently they cause further damages to the pump

Unwillingness of some WPCs to involve AMs whenever their boreholes are broken.

OBSERVATIONS ON WPCS

TABLE 28. OBSERVATIONS ON THE WPCS, BALAKA

DISTRICT WATER POINT DATE OF SUPERVISION

OBSERVATION ACTION POINT MAINTENANCE FUND

Balaka Chikombola Nov 16,

2020

The water point

surroundings are

poor.

The WPC is inactive.

They fail to mobilize

enough money for a

borehole maintenance

fund.

The pump is hard to

pump a sign that it

need technical

The WPC to come up with a

cleaning schedule.

WMAs observe the current

committee for 2 months,

then can be reshuffled if not

improving.

Engage the AM to check on

the pump

MK24,000

Mthengomwacha Nov 17,

2020

Inactive WPCs. WMAs is observe the

current committee for 2

months, then can be

reshuffled if not improving

MK13,000

Struggling to maintain

a borehole fund.

Water point

surrounding the area

is not clean.

Hard to pump, need

technical checkup

because it is hard to

pump




improving.

The WPC to come up with

cleaning schedule.


the pump

Pofera Nov 17,

2020

Inactive WPC.

Struggling to maintain

a borehole fund.




MK10,000


DISTRICT WATER POINT DATE OF

SUPERVISION

OBSERVATION ACTION POINT MAINTENANCE

FUND

Water point

surrounding the area

is not clean.

Hard to pump, need a

technical checkup

because it is hard to

pump

improving

The WPC to come up with a

cleaning schedule.


the pump

In Mulanje, ONSE believes in collaboration in its implementation of activities at district level to

increase synergies. ONSE is an active member of District Coordination team (DCT), a coordinating

body of WASH activities in the district. In Mulanje during this reporting period, ONSE WASH

Officer participated in the DCT field visit at Musakha village, TA Tombondiya in Mulanje district on

November 20, organized by Tikonze Mijigo and Maintenance System (TIMMS), a local NGO that is

promoting and training AMs in the Southern Region of Malawi. The aim of the field visit was to

accord the DCT members an opportunity to appreciate the role of the AMs in ensuring water

points sustainability. TIMMS is promoting the linking of AMs with WPCs in which a service

agreement involving the AM and the WPCs is signed. The agreement empowers the AM to carry

out preventive maintenance of the boreholes at an agreed annual fee with the individual WPC. The

WPC takes stock and monitors the servicing of the water point by the AM. Mulanje district council

is promoting and implementing this strategy.

All AMs who have been linked to 316 water points ONSE have rehabilitated in the 11 WASH

targeted districts were initially trained by TIMMS/BASEDA, and ONSE conducted the refresher-

training course after seeing lack of activeness of the program.

HEALTH FACILITY WATER SUPPLY

During the reporting period, ONSE conducted a verification and monitoring of all 40 health care

facilities including a learning institution, Machinga Teachers Training College (TTC) in Machinga, in

the WASH Targeted districts of Chitipa, Karonga, Nkhotakota, Dowa, Kasungu, Salima, Lilongwe,

Balaka, Machinga, Zomba, and Mulanje. The aim of this exercise was to ensure that all rehabilitated

points are up and running properly as well as ONSE to hand over all the plumbing works to the

DHO officially by signing off on the supervisory checklist.

COMMUNITY-LEVEL SANITATION

ONSE continues with the implementation of the sanitation marketing strategy in the 11 WASH

districts of Dowa, Zomba, Machinga, Balaka, Salima, Nkhotakota, Karonga, Chitipa, and Mulanje. In

the reporting period, ONSE worked with masons who were capacitated in PY2, PY3, PY4, and PY5

in promotion of low cost improved sanitation. In December 2020, ONSE facilitated the construction

of 3,092 latrines reaching out to 13,914 additional people gaining access to basic sanitation services.

The figure below shows the number of latrines constructed per district in December 2020.


FIGURE 2. NUMBER OF IMPROVED LATRINES CONSTRUCTED PER DISTRICT - FEBRUARY 2020

Through social marketing and behavior change and communication (SBCC), ONSE continues to

promote adoption of improved sanitation products such as sato pans and flappers. In December, a

total of 127 flappers were installed on household latrines. Besides making the latrine look tidy, a

flapper bars flies and other insects from coming into contact with human extra, and this alone helps

to reduce transmission of poor sanitation and hygiene related diseases such diarrhea.

ONSE through the sanitation grantee, PDI in Karonga, is implementing community led total

sanitation (CLTS) which is aimed at ensuring every household processes and uses latrines. In

November, ONSE through PDI triggered and followed up three GVHs in TA Mwerang`ombe for the

construction of latrines. Following satisfactory results of the follow up, ONSE and PDI invited

Karonga DCT to come and assess/verify the three GVHs. On December 10, Karonga DCT declared

the three GHVs open defecation free (ODF) meaning that every household in the three GVHs

(Mjalibana, Mwakashunguti, and Kaswera) has a latrine and there is no visibly seen faeces in the

surrounding environment. The three GVHs have a total of 25 villages.

HEALTH SYSTEMS STRENGTHENING

LEADERSHIP AND MANAGEMENT

INTEGRATED SUPPORTIVE SUPERVISION (ISS)

ONSE has continued its collaboration with KUUNIKA to achieve CommCare-DHIS2 integration. In

the month of December 2020, ONSE has provided a demo to ONSE HSS team of the changes in ISS

community and environmental health module on how (with integration) the supervision questions

now flow; provided preliminary questions and feedback, which is being included in further adaptation

of the work; completed DHIS2 integration document to act as reference document on best

practices in setting up integration with DHIS2; and completed DHIS2 app building to facilitate

integration work. This included making changes to all ISS checklist forms that DHIS2 will integrate

with, and writing out a quality assurance (QA) plan to test integration that it is working as expected.

The support engineer has conducted re-orientation sessions with dashboard users from Mulanje and

Salima to help improve their usage of the dashboard as one step of strengthening data use for


decision making. In addition, the technical team has continued to update the ISS dashboard v2 and its

documentation to reflect recent changes. Furthermore, the team has set up software quality

assurance support for the ISS to assure quality of the data from the tool and undertaken weekly

updates to keep it up to date in terms of the data and indicators it provides.

DHMT ISS ONSE supported DHMT ISS in 7 districts of Karonga, Mulanje, Salima, Lilongwe, Mchinji, Ntcheu,

and Chikwawa, in which 30 health facilities, 95 (67M, 28F) health workers were supervised. A total

of 34 action points were developed and seven action points from the previous visits were resolved.

The table below depicts some of the revolved actions.

TABLE 29. SUMMARY OF ISSUES AND ACTIONS TAKEN AT LILONGWE, DECEMBER 2020

DISTRICT HEALTH FACILITY ISSUES AND ACTIONS TAKEN

Lilongwe Ming’ongo LA registers now being documented properly

BCG and Measles are now above 74% coverage

Facility monthly meetings now being conducted where action points

are discussed

There is an increase in the uptake of FP methods

DISTRICT IMPLEMENTATION PLAN (DIP)

ONSE participated in the leadership and governance TWG meeting at national level during the

month. The main agenda of this meeting was to respond to consultation questions as part of

midterm review for the Health Sector Strategic plan II (2017-2022) particularly on leadership and

governance thematic areas in the health sector, specifically at the district level. ONSE contributed a

lot on issues of DHMT leadership roles which include planning and supervision as well as on health

sector governance in terms of its support on Health and Environmental Committee (HEC) and

Health Centre Management Committees (HCMCs). Finally, the consultant made separate

arrangements to meet ONSE and also requested some DIP reports.

HEALTH CENTER MANAGEMENT COMMITTEES (HCMCS)

In the reporting month, ONSE supported the HCMCs supportive supervision in Balaka district in

which two health centers where 19 (9M, 4F) members were supervised. The objectives of the

supportive supervision meeting were to confirm if HCMC monthly meetings are held and minutes

are taken during such meetings, determine if action points are implemented, check the general

cleanliness of the facility including if the facility has rubbish pits and toilets, and to reinforce COVID-

19 preventive measures.

Issues identified included that members were unable to meet due to COVID-19, shortage of drugs,

theft of staff property, construction of maternity block at Chimatiro, construction of toilets,

construction of incinerator, and connection of electricity.

ONSE supported MoH with fuel, refreshments, and lunch allowances to conduct HCMC orientation

in 22 facilities (10 in Salima, 8 in Nkhotakota, and 4 in Nkhatabay) with a total of 392 (262M, 130F)

members oriented.

Facilitators from the DHO delivered the following modules: HCMC overview, community

engagement and mobilization, leadership, essential health package, health service users and provider

rights and responsibilities, conflict resolution, drug monitoring, local resource mobilization,

improving health center functionality, monitoring health center functionality, improving availability of

essential drugs at health center, and effective advocacy. It was encouraging to note that members

were very active, always available in time, and very eager to learn new things as they were asking

questions to know extra information regarding their mandate.


Grantees also continued to finalize orienting and supervising targeted HCMCs in Dowa, Lilongwe,

Mchinji, Ntcheu, Mangochi, Machinga, Zomba, Mulanje, and Chikwawa.

SUPPLY CHAIN

DTC MEETINGS AND ACTIVITIES

ONSE supported some districts to conduct monthly DTC meetings. The table below summarizes

the deliberations during these meetings.

TABLE 30. ONSE DTC MEETINGS - DECEMBER 2020

DISTRICT PARTICIPATION KEY DELIBERATIONS

Zomba 14 (10M, 4F) District Medical Officer (DMO) to discuss with USAID Procurement and

Supply Management Project (PSM) on the issue of delayed LMIS data

bundles.

The pharmacist to press an emergency order for the dental,

rehabilitation and ophthalmology supplies currently stocked out.

Ordered medicines and medical supplies for the DHO and health

centers.

Ntcheu 10 (5M, 5F) DTC agreed to revise upwards the amount planned for special orders in

the current fiscal year.

Ordered medicines and medical supplies for the DHO and health centers

Mangochi 18 (16M, 2F) DTC to reach out to the district council and partners for medicine

procurement support as the district’s annual medicine budget has been

cut by the government by almost 10%.

To consider a special order request for Monkey Bay community hospital

for the following items: oxygen concentrators, suction machines,

nebulizers, ultrasound machines, autoclave and anesthesia machines.

Furthermore, ONSE supported Nkhatabay district to conduct DTC spot checks completed by 7

(7M, 0F) DTC members. Inadequate supplies, limited storage space as well as prevalence of expired

medicines were some of the key challenges that were revealed in the visited facilities. The DTC will

continue to work with the facilities to improve on these grey areas. However, on a positive note, it

was also observed that there is increasing involvement of HCMCs in medicine receipt exercises as

well as satisfactory adherence to general recommended medicine storage procedures.

DRUG AND MEDICAL SUPPLY REDISTRIBUTION

Dowa was supported by ONSE to conduct redistribution of priority health commodities during the

period under review as per the following table:

TABLE 31. ONSE SUPPLY REDISTRIBUTION - DECEMBER 2020

COMMODITY

NAME QUANTITY

REDISTRIBUTED FROM HOW

MANY

FACILITIES

TO HOW

MANY

FACILITIES

LA 1X6 6,000 2 2

LA 2X6 7,200 1 2

mRDTs 3,375 3 4

LLINs 100 1 1

Oxytocin 1,050 5 15

Magnesium Sulphate 1,580 2 5

ORS 800 5 8

RUTF 3,900 2 5


PHARMACY SUPERVISION

ONSE supported pharmacy supervision in Mulanje, from November 23-29. The activity was

conducted at Mulanje Mission, Thembe, Chambe, Kambenje, Chisitu, Mbiza, Chonde, Thuchila,

Namasalima, and Muloza health facilities by 8 MoH staff (7M, 1F), who in turn supervised 11 health

workers (6M, 5F). Among the strengths observed during the exercise included that all LMIS reports

were available in all the health facilities supervised, storage guidelines are being adhered to in all

facilities, and two or three lock systems are observed in all facilities to enhance security of medicines

and medical supplies.

The challenges that were noted include inadequate storage area for Namasalima; stock outs of some

essential medicines like Benzathine, Erythromycin, Doxycycline, Ciprofloxacin and antihypertensives;

temperature monitoring charts not displayed or recorded in all facilities; poor documentation in

malaria register in all facilities; understock of mRDT and LA at Namasalima health center; and non-

functional air conditioners in some facilities. As remedial solutions, on the job training on storage of

items was done at Namasalima, health facility staff were implored to order the stocked out items

from the district pharmacy, and the district pharmacy in-charge to report to DHMT and

maintenance supervisor on the prefabricated storage unit for medicines maintenance needs.

In Mchinji, a total of 3 (2M, 1F) district pharmacy personnel were supported to conduct pharmacy

supportive supervision to two health facilities. The desirable practices that these facilities currently

have were in areas of good documentation of delivery notes as well as corresponding of LMIS

records to the stock card medicine captured quantities. The major challenge that was unearthed

was that of inconsistencies in use of requisition and issue vouchers for ordering medicines and

medical supplies. Mentorship and on the job training was offered to the facility staff on this

shortcoming.

PHARMACY ASSISTANT (PA) PROGRAM

ONSE supported 2 (2M, 0F) PAs in Nkhatabay to conduct mentorship to 6 (4M, 2F) drug store

clerks in 6 health facilities. The major focus of these mentorship visits were on creation of

dispensing charts, review of proper documentation procedures, expired medicines management, and

adherence to first to expire first out.

HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS)

MONTHLY DATA COLLECTION AND UPLOAD IN DHIS2

ONSE collaborates closely with central-level HSS partners and other stakeholders to reduce

fragmentation and improve holistic use of data across information systems. During the reporting

period, only Nkhatabay and Mulanje had started supporting HMIS data collection from public,

private, and Christian Health Association Malawi (CHAM) health facilities in order to increase the

reporting rates on time of HMIS reports. The 14 districts will start this activity on December 7,

2020. ONSE provided the districts with operational support for internet connectivity in order to

upload the data in the DHIS2. During the data collection exercise, ONSE collected supplementary

data for reporting of data which is available in registers but not in the reporting tools. Specifically:

In Nkhatabay, the support was provided to 5 people (3M, 2F) on December 4 to collect

data from Nthungwa, Mpamba, and Maula health facilities

In Chikwawa, the activity was conducted from December 3-4 in 8 of the 28 facilities in the

district by 5 (4M, 1F) data clerks.

DATA QUALITY MANAGEMENT

HMIS Supportive Supervision In Dowa, ONSE supported monthly facility data management meetings from November 23-

December 2 as part of the routine HMIS supportive supervision to check whether data collection


tools are being used at the facility that ensures quality data is collected and reported; ensure that

health facilities are using the data collected for planning, monitoring and validation; and check how

data storage is done and displayed graphically. A team of two male HMIS staff and one ONSE

Monitoring Evaluation Performance Specialist supported this activity at Dzoole, Thonje, Grace

Alliance, Chizolowondo, and Mvera Mission. A total of 10 all male (1 data clerk and facility in-charge)

facility staff were involved in the exercise.

In Mchinji, HMIS office with support from ONSE conducted data mentorship at five health facilities

of Fanuel, Gumba, Kazyozyo, Kaigwazanga, and Chipumi. A total of 16 (10M; 6F) health facility staff

were mentored.

Data Verification The activity is aimed at ensuring that the facilities have and use quality data for decision-making. The

exercise assessed the completeness of data in reports; complete documentation of source registers;

triangulation of reported data, source document data, and verified data; and use of data at facility

level for decision-making. The data verification teams together with facility staff developed action

points and agreed on the timeline for action points’ implementation. During the reporting period, six

districts conducted the activity as follows:

In Lilongwe, 10 HMIS staff (4M, 6F) conducted data verification for January to March 2020

data from November 23-27, 2020 at 13 facilities (Nsalu, Mbwatalika, Mbang’ombe 2,

Kabudula, Chilobwe, ABC, Likuni, Nthondo, Lemwe, Chiwe, Chileka, Ukwe, and Nambuma).

In Nkhatabay, ONSE supported data verification from November 23-27, 2020 at five

facilities (Kachere, Liuzi, Tchesamu, Nthungwa, and Tukombo), in which a total of five (3M,

2F) statistical clerks supported were supported to conduct the activity.

In Salima, ONSE supported data verification from November 23-27, 2020 at five health

facilities (Ngozi, Chipoka, Mchoka, Chagunda, and MAFCO), and three (2M, 1F) statistical

clerks supported were supported to conduct the activity.

Chikwawa conducted data verification for July to September data from November 24-27,

2020 at Bureau, Nkombezi, Ndakwera, Lengwe, and Nkumaniza health facilities. A total of

four (1M, 2F) MoH staff from Chikwawa DHO participated in the activity.

In Mangochi, ONSE supported data verification exercise from November 23-27, 2020 at

Malembo, Phirilongwe, Namalaka, Malombe, and Namwera health facilities. A team of five

people (4M, 1F) conducted the exercise.

In Mulanje, ONSE supported four (3M, 1F) HMIS staff to conduct data verification for July to

September 2020 data from November 23-27, 2020 targeting five health facilities of Chambe,

Chisitu, Chonde, Namphungo, and Naphimba.

COMMUNITY MOBILIZATION AND ENGAGEMENT

COMMUNITY ACTION CYCLE (CAC)

In the reporting month, ONSE supported community activities in 12 districts of Lilongwe, Ntcheu,

Mchinji, Balaka, Zomba, Dowa, Mangochi, Salima, Nkhatabay, Karonga, Nkhotakota, and Chitipa.

Community activities included supportive supervision, review meetings, mentoring, and coaching of

community structures. Focus of the community engagement aimed at strengthening community

capacity in tracking progress of COVID-19 implemented activities, designing local solutions to

respond to pandemics/outbreaks such as anticipated diarrhea cases during the rainy season, as well

as timely reporting and completeness of reports. Groups of people involved in the various sessions

included TAs, GVHs, ward councilors, ADC members, Village Development Committee (VDC)

members, CHAG members, VHCs, champion communities (CCs), and other village community

health volunteers (CHVs). The interactions were facilitated by HSAs, Community Mobilization Team


(CMT) members, DCSA, and community nurses reaching a total of 214 CHAGs, 62 VHCs, and

3,188 (1,508M; 1,680F) community members.

Key Highlights

In Balaka and Salima, it was noted that CHAGs receiving support from the local leadership are

performing better when compared to those that do not have the support. One of the main roles of

the GVH in these districts is to verify CHAG reports against actual performance as observed by the

local leadership within their catchment areas.

The supportive supervision noted an improvement in CHAGs and VHCs collaboration. The two

structures are able to work together and are integrating COVID-19 messages in all the activities

being conducted. VHCs that are not working with CHAGs are mostly those that were not oriented

on COVID-19 prevention and control measures.

CHAGs in Mchinji have contributed to some health initiatives in their catchment areas, for example,

Sankhani CHAG under TA Mlonyeni has molded bricks for construction of dispensary after noting

how the 17km distance to the health facility was affecting community access to health services.

Manjomeka CHAG under TA Kazyozyo has advocated for bicycle ambulances in all its five villages.

The villages have devised ways of raising funds to acquire bicycles and ambulances.

In TA Mlonyeni, CHAGs are working with HSAs to revamp non-functional VHCs and establishment

of VHCs in villages that did not have these structures. Integrated supervision helped in creating a

good working relationship between CHAGs and VHCs.

The focus of some of the CHAG COVID-19 prevention and control interventions include

reinforcement of door-to-door sensitizations on COVID-19, orientation of COVID-19 preventive

measures at funerals, sensitizing communities on use of mobile platforms such as CCPF, and

encouraging small group meetings. Mask wearing, however, is proving to be challenging mainly due

to phobias as well as access to masks in the community.

In Balaka and Dowa, two CHAGs procured hand washing facilities to be used by community

members at funerals. However, Nthema CHAG collaborated with vendors to procure hand washing

facilities which are available at every POE of Nthema market. CHAGs in Mangochi and Mchinji are

working with health workers to report returning residents from high risk areas.

In Nkhotakota and Karonga, functional CHAGs were mentored on how to interpret indicators and

progress, problem tree analysis, and reporting on village community data. In Salima, CHAGs were

coached on how to aggregate data for monthly reporting.

COMMUNITY SCORECARD (CSC)

In the reporting month, ONSE continued to support districts with two-day CSC sessions focused on

emerging issues such as teen pregnancies, home deliveries, ANC initiation, and other similar related

poor performing indicators due to the impact of the COVID-19 pandemic. COVID-19 preventive

measures were followed by ensuring that the CSC sessions and interface were attended by less than

50 people, while also ensuring proper representation by selecting "key informants” to participate in

the sessions.

ONSE supported CSC sessions in Mulanje, Machinga, Karonga, and Nkhotakota districts in five

health facilities. A total of 254 key informants (151M, 103F) from 26 out of 37 GVHs participated in

the CSC sessions. Below is a summary of the scorecard sessions.


TABLE 32. SUMMARY OF CSC SESSIONS, DECEMBER 2020

DISTRICT HEALTH

FACILITY

POOR

INDICATOR

CONTRIBUTING FACTORIS

COMMUNITY FACILITY

Machinga Mpkwepere High

prevalence

teen

pregnancy

Traditional beliefs and

misconception on FP

methods,

Role of community,

family, guardians/parents

of adolescents on SRH &

FP

Proper use of FP methods

by adolescents

Health workers’ attitude

towards adolescents accessing

FP methods

Availability of qualified health

providers of FP

Availability of preferred FP

methods

Karonga Mlare Poor uptake

and delivery of

MNCH & FP

services

64 teenage pregnancies

registered between April

and October 2020

Late initiation of ANC

within first trimester

Lack of maternity wing at Mlare

Health Center

Nkhotakota Katimbira Poor uptake

and delivery of

YFHS

Youth attitude towards

YFHs

Community attitude on

YFHs

Poor participation of

youth in YFHS meetings

Inadequate messages on

YFHS

Abuse of items procured

by ONSE Youth playing

materials

Availability of YFHs at Katimbira

Availability of health workers

and relevant resources

Lack of YFHs room hence youth

meet outside the hospital.

Late opening of facility

Inactive trained YFHS facilitators

Mulanje Mbiza and

Kambeje

HC

High cases of

home delivery

and neonatal

deaths

Young pregnant girls

afraid of parents

Long distance to service

points

Late initiation of ANC in

the first trimester

Poor male involvement

Minimal role of

community leaders

Weak HCMC

Shortage of staff

Poor service provision

Inadequate information on

maternal health services

Health worker attitude

Poor referrals

Availability of medical supplies

and poor infrastructure

CHIPATALA CHA PA FONI (CCPF)

During December 2020, the hotline workers registered 1,813 total calls nationally, of which 1,207

calls (67%) were from the 16 ONSE districts. Some of the calls 177 had no district indicated possibly

because of call disruption before demographics were captured. Out of the 1,813 calls received this

month, 1,798 (99%) were ‘new relevant calls. The call volume has not been compared with previous

months due to different reporting periods as this report only covers up to December 10, 2020.

However, system challenges continued during the reporting period which contributed to some

dropped calls. These system challenges are being resolved.

According to the December 2020 data set, most of the new relevant calls were about COVID-19

(51%) followed by general health (28%) then SRH (11%), and MNCH (6%).


CHAMPION COMMUNITIES

In the reporting month, ONSE supported districts with the following CC activities: supportive

supervision/assessment of CCs, seed money presentation, CC roll out, and SBCC-education

through listening (ETL) orientations of CCs in Dowa, Kasungu, Karonga, Chitipa, and Nkhotakota. A

total of 139 (64M, 75F) CC members were reached.

Highlights on CC Activities Supportive supervision in Dowa and Kasungu was conducted to assess eligibility for certification of

three CCs including Salala Senti CC in Dowa and Mgwede and Chidelezi in Kasungu.

Salala Senti is an autonomous CC that was formed in February 2019 following their visit to

Chiwandira CC. Since then, the CC has registered tremendous achievements in their community

including successful drip irrigation, which they started after collaborating with the African Institute of

Corporate Citizenship (AICC). They have successfully developed a “model village” after learning the

concept from World Relief. IGAs include practicing piggery and formation of a CC village loan saving

scheme.

Chidelezi CC has 65 members (30M, 35F). After a self-sponsored benchmarking visit to Chiwandira

CC in Dowa 2019, and the members were encouraged to replicate the CC approach. They

currently have MWK50, 000 in their account, and resources will be used to address their

community health needs. IGAs practiced include piggery and goat rearing. Additionally, they have a

viable VSL scheme, rented gardens, and are planning to grow soya beans and maize in the rainy

season. During the peak of COVID-19 pandemic, the CC conducted sensitizations meetings

encouraging people to adhere to COVID-19 preventive and control measures specifically washing

hands, social distancing, and wearing of masks. They also reported that they managed to sew 20

cloth masks that were distributed to two schools targeting pupils who could not afford a mask.

Mgwede CC is very organized as they work together with the VHCs, care groups, and WPCs. In

their October to December 2020 work plan they included cholera awareness activities. The

community has a very committed HSA who provides necessary support to the CC. In their

catchment area, there is a clinic, which was built by Livingstonia Synod but has not been opened due

to lack of health workers. The CC and GVHs mobilized themselves to the DHO requesting urgent

allocation of a health worker at the facility. Mgwede CC is practicing piggery, rearing goats, they

have a village servings loan of which is currently at MWK150 000.

Supportive supervision conducted to Namakwati CC in Nkhotakota noted some achievements

made by the CC including the CC vision, linkage between community and health workers, as well as

their role on COVID-19 was appreciated. CC documentation was excellent as community data was

available, ability to present their work was noted, a detailed report on COVID-19 activities was

outlined, and their collaboration with VDC and ADCs was encouraged.

In Karonga, Katiri CC was given MWK200,000 as IGA seed money at Katiri TA Kyungu. The

occasion was graced by CC volunteers, chiefs, VDC chair, HSAs, ONSE district coordinator, DHSS,

District Nursing Officer, and CMT trainer. The CC qualified for the seed money after an assessment

in September that showed they had helped improve most of their nutrition, FP, and MNH home

delivery indicators. The CCs involvement in charitable projects at its Kazguli outreach clinic as well

as its coming generating activities were also commended. The guest of honor, the DHSS, also gave

the CC an additional MWK25,000 on the seed money and was impressed with their activities and

vision. The CC is expected to multiply their seed money through ground nut and honey bee farming

as well as livestock and other businesses. They also intend to buy a motorbike and contribute

towards addressing Katiri’s water problems and the construction of a maternity wing.


SOCIAL AND BEHAVIOR CHANGE (SBC)

In the reporting period, USAID ONSE supported distribution of SBC materials on various thematic

areas including COVID-19 to health facilities and community health structures Dowa, Kasungu,

Salima, Nkhatabay, Chitipa, Chikwawa, Machinga, and Nkhotakota. This exercise is aimed at

increasing awareness on various health prevention and curative interventions at both the facility and

community levels. A total of 8,534 assorted SBCC materials, 835 posters, and 2,323 leaflets on

COVID-19 were distributed reaching 18 health facilities and 23 CHAGs.

TABLE 33. FP COMPLIANCE MONITORING VISITS - FEBRUARY 2020

THEMATIC AREA TYPE OF SBC MATERIAL DISTRIBUTED # OF MATERIALS MNCH Early ANC posters 425

KMC posters 154

MALARIA Wheel of good practices 210

Malaria case management posters 50

EPI Immunization posters 2,485

FP AND RH TIART Chart 240

FP/RH girls posters

2,150 FP/RH boys seated posters

FP/RH boys football posters

NUTRITION Complementary feeding posters 660

Other IPC cards 2,160

COVID-19 leaflets 2,323

COVID-19 posters 834

ONSE in Dowa discussed sustainability plans with the community health coordinator and

determined that strengthening district community health TWG district work plans can be shared

and supported by other donors. The district further agreed to borrow leaflets from Kasungu, where

integrated community health services are present. The approach is being funded by UNICEF which

aims at strengthening integration of the delivery of community health services including community

engagement and leadership. The importance of liaising with partners such as UNICEF, WVI, and Plan

International that have shown interest to support community health structures in areas of

supervision, training, and meetings was discussed. It was also discussed to include CHAG activities in

the DIP, print report forms, and decentralize supportive supervision and review meetings to health

center teams.

II. PROJECT MANAGEMENT

GRANTS UNDER CONTRACT

During December, grantees finalized the implementation of their PY5 Quarter (Q)1 planned

activities.

SANITATION

The grantees wrapped up this quarter’s activities in the seven targeted districts of Dowa, Zomba,

Salima, Lilongwe, Karonga, Machinga, and Nkhotakota. The grantees oversaw the finalization of the

construction of improved latrines for the households that had been planning to fulfill this need as

well as worked with health center facilities in the implementation of interventions identified in

WASH plans developed by health center facilities through HCMCs and facility staff at the beginning

of the quarter. Further, the grantees supported WPC and realized plans they had made in

addressing poor hygiene and sanitation conditions identified in their boreholes. In addition to the


above-mentioned interventions; in Salima, Zomba, Karonga, and Machinga districts, the grantees

covered more villages with CLTS interventions thereby accelerating the attainment of ODF.

HCMC, EPI; AND EMERGENCY TRANSPORT SYSTEMS

In the nine districts of Chikwawa, Mangochi, Zomba, Machinga, Mulanje, Dowa, Lilongwe, Ntcheu,

and Mchinji, the grantees wrapped up the formation and training of HCMC and supported the newly

instituted HCMC to attain full functionality. Additionally, they ensured that the HCMC led the

process of establishing emergency transport systems for pregnant women in their respective health

center facility catchment communities. In selected districts of Zomba, Machinga, Mulanje, Dowa,

and Lilongwe, grantees supported targeted health center facilities in the development of Reach Every

Child (REC) micro plans aimed at enhancing EPI.

MALARIA

Grantees wrapped up planned work on malaria awareness activities in all targeted communities in

the eight districts of Mchinji, Lilongwe, Nkhatabay, Nkhotakota, Salima, Mangochi, Machinga, and

Chikwawa. As this was the last month of performance, the grantees ensured that all communities

that had been earmarked for malaria awareness activities were categorically reached to attain

saturation of geographical coverage for the targeted districts.

COMMUNITY-BASED MANAGEMENT FOR RURAL WATER SUPPLY

For the period of August to December 2020, one grantee has been facilitating the formation and

training of WPC in Mulanje district from the previously identified 218 borehole sites that ONSE has

rehabilitated and/or drilled. In December, the grantee wrapped up the training for the last lot of the

targeted WPC.

Looking forward to the next month, the grants program shall scale down with the majority of

grants-supported activities closed in the month of December. Sanitation grants shall continue to

implement activities in PY5Q2, building on gains achieved in the past six months of performance.

III. KEY CHALLENGES

In some facilities, KMC babies are not linked to community health workers once they are

discharged. This is affecting follow- up of clients at home.

Due to the rainy season in Malawi, most clinics have no shelter and are operating under a tree and

with no latrines.

Health passports in some districts have been a challenge for a long time. Some health facilities have

no health passport books for recording immunizations leading to loss of data. The districts have

been advised to lobby other partners for support as the current ONSE budget does not have the

line item for purchase of health passport books.

IV. LESSONS LEARNED AND BEST PRACTICES

Inconsistent refrigerator temperature monitoring in some health facilities is becoming a problem.

Therefore, health workers were advised to record refrigerator temperatures twice daily in the

morning and in the afternoon including the weekends to ensure the vaccines are kept with the

recommended temperature range of 2o-8oC.

A number of facilities are lacking recommended drugs at one stop centers like PEP, STI drugs,

pregnancy test kits, and other relevant supplies, particularly for cases coming in at night and during

weekends as some of these areas are closed. This has been attributed to lack of lockable cabinets in

the room. It was therefore agreed that there is a need to purchase filing cabinets or partners like


ONSE would donate to ensure that once drugs are delivered, they will be safely kept within the

room.

V. COMPLETED STTA

No STTA took place in December 2020.

VI. UPCOMING STTA

No STTAs are planned for the month of January 2021.

onse health activity malawi monthly update

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