ACCESS Program by G2ED1p


                                 Mozambique Trip Report

MCHIP STAFF: Koki Agarwal

SITE VISITED: Maputo, Mozambique

DATES OF VISIT: November 30 – December 11, 2009

DATE SUBMITTED: December 17, 2009

TRIP PURPOSE: Participate in USAID assessment visit; Observe the current MCHIP
program and make recommendations for future MCHIP work

  1. Participate in the assessment: understand the current maternal and newborn health
     situation in Mozambique, visit program sites, review the current MCHIP program
     focus and the partner roles
  2. Present MCHIP to the USAID Mission
  3. Develop plans with the MCHIP team to address recommendations from the
     Assessment team


Objective 1: Participate in the assessment: understand the current maternal and newborn
health situation in Mozambique, visit program sites, review the current MCHIP program
focus and the partner roles

Assessment visit: Agarwal accompanied the USAID/W team (Mary Ellen Stanton and
Nahed Matta), USAID/Mozambique (Ana Bodipo-Membo) and MCHIP/Mozambique
(Veronica Reis) to all the meetings with the Ministry, UN partners and filed visits to
different facilities. The itinerary of the visit and the list of individuals that the team met
during the visit is attached (Attachment 1). The team visited hospitals and health centers
in Maputo Province and in Nampula and the training institute in Nampula.

MCHIP is currently supporting the Ministry of Health (MoH) in implementing the
Model Maternity Program in 34 facilities; training and setting up facilities to address
cervical cancer preventions and treatment. This program is relatively new and only a few
providers have received training since MCHIP began the program in August. The team
observed several changes in some of the high-volume facilities visited but some of the
critical life saving interventions were not being carried out routinely. Few key
observations are listed below.


   1.   High volume maternities, few staff. Maternity with 20-50 deliveries per day had only one
        MCH nurse. Third delay can be a real problem.

   2.   Staff are not practicing high-impact interventions like Active Management of Third Stage of
        Labor (AMTSL) and recording on the partogram. Women left alone after delivery. They are
        not monitored for signs of postpartum hemorrhage (PPH) or blood pressure after delivery

   3.   AMTSL is not practiced because ( a) staff do not know it as a best practice and (b) staff want
        to conserve oxytocin since they only have sufficient quantities for administration of 5 IU post
        delivery. Currently staff practice spontaneous delivery of placenta.

   4.   Nurses do not record the progress of labor on the Partogram because the perceived norm is that
        only doctors can record on the Partogram. The doctors do not have the time to record.

   5.   LAM is underutilized. Post partum family planning (PPFP) can be much stronger since
        women do stay for 24 hours.

   6.   Practice of skin to skin care for newborns is increasing immediately after birth. However, none
        of the facilities had rooms for Kangaroo mothercare (KMC) where mothers can stay longer
        term for KMC . It is unclear about what messages are given to women when they leave with
        low birth weight (LBW) babies

   7.   Not all maternities have bed nets

   8.   Most facilities had adequate supplies of oxytocin, Magnesium sulfate, antibiotics and staff did
        not report stockouts.

   9.   Non functioning essential equipment. Blood pressure instrument, only one across 3 ANC
        rooms in a very busy maternity.

   10. More effort needed in humanizing approach. Respect for privacy is minimal

Partner roles

In Mozambique, WHO, UNFPA, UNICEF and UNFPA subscribe to joint planning and
are members of the SWAP- RH and MCH Safe Motherhood Technical Working Group.
WHO plays a technical role in assisting the Ministry of Health (MOH) in developing,
reviewing and updating policies, standards and guidelines. UNFPA supports the MOH
financially and technically through training and provision of equipment, ambulances,
supplies such as RAPID syphilis tests, HIV test kits and contraceptives as a major donor
in addition to USAID. Mozambique is a designated Partnership for Maternal and Child
Health (PMNCH) Country with funding from Bill and Melinda Gates Foundation. The
PMNCH funding is channeled through UNFPA for two districts each in 6 focus
provinces including Niassa, Zambezia, Maputo Province, Cabo Delgado, Nampula, and
Soafaola, to scale up few high impact interventions for maternal and child health.
PMNCH funding is also supporting an accelerated plan for training 330 MCH nurses.

UNICEF is the lead for the Catalytic Initiative. Primarily focusing on child health,
UNICEF supports scaling up of IMNCI; child health days (Vit A, de-worming and
Immunization); and youth friendly activities. UNICEF will support the baby-friendly
hospital initiative to promote early and exclusive breast feeding and plans to collaborate
with MCHIP for its implementation within the model maternity facilities. From 2003, in
the area of maternal health, UNICEF has worked in Cabo DelGado in emergency
obstetric care training and strengthening of some maternities. The Catalytic Initiative
Intervention package for Mozambique includes five components:
    (1) Reaching Every District ( RED) Approach
    (2) Integrated Management of Newborn and Childhood Infections (IMNCI)
    (3) Vitamin A Supplementation
    (4) Distribution of Long lasting Insecticide Treated Bed Nets (LLINs)
    (5) Promotion of Breast Feeding

Next steps:
   1. Agarwal and the USAID team will share recommendations with the
       MCHIP/Mozambique team

Objective 2: Present MCHIP to the USAID Mission

Findings: Agarwal made a presentation on the global MCHIP award to the extended
USAID team. Mary Ellen Stanton made a presentation on the USAID priorities and the
latest development on the Global Health Initiative. The members of the health, PMI and
PEPFAR team attended the briefing. There was strong interest in the team for looking
into issues of introducing Pay for Performance (P4P). Additionally USAID/Mozambique
mentioned that they are interested in developing an Associate Award under MCHIP.

Next steps:
   1. Agarwal will wait to hear from USAID/Mozambique regarding their decision on
       MCHIP Associate Award

Objective 3: Develop plans with the MCHIP team to address recommendations from the
Assessment team

Findings: Partial analysis of the facility assessment funded by UNFPA revealed several
shortfalls in the health infrastructure in the country. Several modules of the data still
remain to be analyzed including observational data on the quality practices relating to
high impact interventions. See attached Summary of maternal and newborn health
situation in Mozambique prepared by MCHIP Mozambique staff (Attachment 2).

Based on the observations from the team, review of the existing data would eliminate the
need to do a Quality of Care Survey and would inform the expansion of the model
maternity program.


 Next steps:
    1. Evaluate the current pipeline to see if the analysis of the data can be undertaken in
        the current year.
    2. MCHIP Mozambique tem will ensure the engagement of community
        representation in the SBM-R assessment team and in the maternal mortality
        committees being set up under the Model Maternity approach.
    3. The MCHIP team will place a greater emphasis on key high impact interventions
        as they expand the SBM-R approach
    4. MCHIP Mozambique will also bring together the teams of trained providers from
        each province region for a sharing meeting so they can address bottlenecks by
        learning from each other.

            Annexe 1: List of contacts (this list should not be from Moz??)

Date of        Organization              Name                      Title
February       USAID/India               Kerry Pelzman             Chief, HPN
                                         Kendra Phillips           Deputy Chief, PHN
                                         Dr. Rajeev Tandon         Division Chief, Maternal,
                                                                   Child Health, Nutrition and
                                                                   Urban Health
                                         Anchita Patil             MCH Division
                                         Sanjiv Upadhyaya          MCH Division
                                         Monique Mosolf            Division Chief,
                                                                   Reproductive Health
                                         Loveleen Johri            Sr. Reproductie Health

                               Sheena Chhabra      Division Chief, Health
February   Jhpiego             Dr. Bulbul Sood     Country Director, Jhpiego
           Save the Children   Dr. Anil Misra      Technical Advisor
                               Mr. Thomas Chandi   Country Director

           John Snow Inc.      Dr. Karan Sagar     Country Representative,


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