Save the Children Mozambique Field Office. Child Survival 12 Detailed Implementation Plan

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1 1... \ Save the Children Mozambique Field Office Child Survival 12 Detailed Implementation Plan Nacala-a-Velha District Nampula Province, Mozambique Cooperative Agreement No. FAO-0500-A September 30, September 30, 2000 Written by: Karen Waltensperger, MPH, SC Mozambique Health Program Director David Marsh, MD, MPH, Child Survival SpecialistJEpidemiologist Sunny Wijesinghe, MPH, Child Survival Coordinator Aurelio Macie, Monitoring and Evaluation Coordinator, Maputo Submitted by: David Marsh, MO, MPH Child Survival Specialist/Epidemiologist Save the Children 54 Wilton Road Westport, CT (203) March 31,1997

2 .. Glossary APE ARI BCC CBR COD CBP CS DIP EPI FP GH-NP HIS HIV/STD HPN IEC IMR KPC MCH MMR MOH MTE NGO ORT P/ID PHC PVO QOC SC STD/AIDS TBA TH TOT U5MR UNICEF VAC VHC VHP WCI WFP WHO WRA Agente Polivalente Elementare Acute Respiratory Infection Behavior Change Communication Crude Birth Rate Control of Diarrheal Diseases Community-Based Provider Child Survival Detailed Implementation Plan Expanded Programme for Immunizations Family Planning General Hospital-Nacala Porto Health Information Systems Human Immunodeficiency Virus/Sexually Transmitted Disease Health/Population/Nutrition Information, Education, Communication Infant Mortality Rate Knowledge, Practices and Coverage Maternal and Child Health Maternal Mortality Rate Ministry of Health Mid-Term Evaluation Non-Governmental Organization Oral Rehydration Therapy Partneringll nstitutional Development Primary Health Care Private Voluntary Organization Quality of Care Save the Children Sexually Transmitted Disease/Acquired Immunodeficiency Syndrome Traditional Birth Attendant Traditional Healer Training of Trainers Under Five Mortality Rate United Nations Children's Fund Vitamin A Capsules Village Health Committee Volunteer Health Promoter Women and Child Impact World Food Programme World Health Organization Women of Reproductive Age

3 Table of Contents Section A. Section B. Table A: Field Program Summary Table B: Program Goals and Objectives Section C. Program Location 1 C.1 Location Maps 1 C.2 Location Description 1 Section D. Program Design 4 D.1 Summary of Overall Program Design 4 D.2 Collaboration and Formal Agreements 6 D.3 Technical Assistance 9 DA Detailed Plans by Intervention 10 a. Maternal and Newborn Care 10 b. Immunization 18 c. Diarrhea Case Management 23 d. Vitamin A 29 D.5 Innovations which may be Scaled Up 33 D.6 Schedule of Field Program Activities 33 Section E. Human Resources 34 E.1 Organizational Chart 34 E.2 Health Workers 34 E.3 Supervision Plan 37 EA Community Committees and Groups 38 E.5 Role of Country Nationals 39 E.6 Role of Headquarters Staff 39 Section F. Program Monitoring/HIS 39 F.1 HIS Plan 39 F.2 Data Variables 40 F.3 Data Analysis and Use 41 FA Other HIS Issues 42

4 Section G. Sustainability Strategy 42 G.1 Sustainability Goals, Objectives 43 and Activities G.2 Community Involvement 44 G.3 Phase-over Plans 45 GA Cost Recovery 46 Section H. Budget 46 ATTACHMENTS 1. Responses to Proposal Review Comments 2. Baseline Survey Report (under separate cover) 3. Not applicable 4. Not applicable 5. Appendices

5 DIP TABLE A. FIELD PROGRAM SUMMARY PVO/Country: Cooperative Agreement No.: Program Duration: Save the ChildrenlMozambique FAO-0500-A /1/96-9/30/00 1. Program Effort and USAID Funding by Intervention Intervention % of Total Effort % USAID Funds Maternal and Newborn Care Immunizations Diarrhea Vitamin A Total Beneficiary Population per Year Population Age Group Infants (0-11 months) month old children month old children month old children Total 0-71 month old children Women (15-49 years) Total Beneficiaries Estimated Number of Beneficiaries 4400* 3850** 11,880*** 3520** ** "assumes: total population=110,000. and 4% of TP=infants 0-11 months of age (Manual 515,1991, p 25) ""estimate ***<5=18.3% TP (SOWC) **22.7% oftp (CIHI, 1995)

6 DIP Table B: Project Goals & Objectives PROJECT GOAL: Sustainable reduction in infant, under 5, and maternal mortality Maternal and Newborn Care: Program Objectives Measurement Major Inputs Major Outputs Measurement Method Methods for for Outputs Objectives 50% of births attended by TBA non-literate refresher training for MOH 5 MOH MCH nurses pre/post training trained personnel tallies and HC MCH nurses refreshed in maternity care evaluations delivery log 40% of gravidae receive at compared to TOT training for MOH staff 6 MOH MCH nurses and quarterly supervision and least one prenatal contact expected number technicos trained as trainers support of TBAs, VHPs of births intervention training for TBAs, and THs 40% of women of VHPs, VHCs, and THs 50 TBAs trained in safe reproductive age will know mid-term and end- delivery quarterly support to at least 4 pregnancy-related line KPC survey SC MCH Nurse to collaborate VHCs by SC Community danger signs with MOH for outreach ANC 400 VHPs trained in danger Relations specialist SC Community clinics signs and promoting birth plan 50% of regu/ados will have Relations Activity a transport plan Register 35 bicycles 104 VHC committee members trained in danger signs, ANC, community data 2 two-way radios and birth plan, and PPC boards in telephone rehabilitation participating 75 THs trained in PPC communities functional literacy training for TBAs, VHPs, and VHCs 8000 households trained in danger signs, ANC, birth plan, BCC by NGO partners and PPC

7 ! Immunization: Program Objectives 50% of children will be fully immunized by age 12 months 30% of women of reproductive age will have received at least 2 doses of tetanus toxoid Measurement Methods for Objectives mid-term and endline KPC survey EPI activity reports from HC and outreach EPI (and ANC) clinics community data boards in participating communities Major Inputs refresher training for MOH MCH and EPI nurses TOT training for MOH staff training for TBAs, VHPs, VHCs and THs SC MCH Nurse to collaborate with MOH for outreach ANC clinics 3 refrigerators, 4 cool boxes, and 35 bicycles Major Outputs 7 MOH MCH nurses and EPI personnel refreshed in EPI methods and planning for increased coverage 50 TBAs trained in promoting EPI 400 VHPs trained in promoting EPI and site preparation 104 VHC committee members trained promoting EPI Measurement Method for Outputs pre/post training evaluations EPI outreach calendar quarterly supervision and support of TBAs, VHPs and THs by MCH and SC nurses quarterly support to VHCs by SC Community Relations Specialist functional literacy training for TBAs, VHPs, and VHCs 75 THs trained in promoting EPI BCC by NGO partners households trained in importance of EPI

8 Diarrhea Case Management: Program Objectives 60% of mothers continue to practice ORT (same or increased fluids including breast milk and/or ORS packets and/or HAF, including CBORT) 40% of mothers know that hand-washing before food handling prevents diarrhea 20% of mothers practice exclusive breast feeding through age one month Measurement Methods for Objectives mid-term and endline KPC survey community data boards in participating communities Major Inputs refresher training for MOH MCH nurses TOT training for MOH staff training for TBAs, VHPs, VHCs, and THs functional literacy training for TBAs, VHPs, and VHCs BCC by NGO partners Major Outputs 7 MOH MCH nurses refreshed in diarrhea case management and prevention 50 TBAs trained in diarrhea case management and prevention.400 VHPs trained in diarrhea case management and prevention 104 VHC committee members trained diarrhea case management and prevention Measurement Method for Outputs pre/post training evaluations quarterly supervision and support of TBAs, VHPs and THs by MCH and SC nurses quarterly support to VHCs by SC Community Relations specialist 75 THs trained in diarrhea case management and prevention households trained in diarrhea case management and prevention

9 Vitamin A: Program Objectives.70% of children 6-71 months of age will have received one Vitamin A capsule (200,000 IU) in the last 6 months by year 4 Measurement Methods for Objectives mid-term and endline KPC survey VAC activity records Major Inputs refresher training for MOH MCH nurses TOT training for MOH staff training for TBAs, VHPs, VHCs, and THs Major Outputs 7 MOH MCH nurses and technicos refreshed in Vitamin A treatment and prevention 50 TBAs trained in Vitamin A prophylaxis for postpartum mothers Measurement Method for Outputs pre/post training evaluations quarterly supervision and support of TBAs, VHPs and THs by MCH and SC nurses functional literacy training for TBAs, VHPs, and VHCs seeds and tools horticulture training by ADPP.400 VHPs, 104 VHC members, and 75 THs trained in promoting Vitamin A prevention, dietary change and home gardening households trained in Vitamin A prevention, dietary change, and home gardening TBAs' tally sheets quarterly support to VHCs by SC Community Relations specialist

10 Sustainability: Goal Produce outputs and outcomes of sufficient value and generate local resources adequate to continue their benefits beyond the life of the project Objectives Trained individuals: 90% MOH staff and 80% trained TBAsfTHs know 5+ pregnancyrelated "danger signs" aoc: 90% MOH EPI staff know 5+ elements of cold chain quality Maternal Referral: 50% of communities (regu/ados) have developed emergency referral systems Functional Health Committees: 50% health committees make quarterly decisions based on health data Literacy: 50% volunteer health promoters and TBAs independently complete periodic health reports and accurate tallies Activities Train MOH personnel, THs, TBAs, VHPs, VHCs Develop viable partnerships Promote aoe and supporting structures Communities develop emergency transport plans and plans to support/sustain community-based providers Promote literacy and data-for-decisionmaking Promote democratic principles in VHCs, peer review structures, partners, and associations,

11 CS-12: Mozambique Detailed Implementation Plan SECTION A: FIELD PROJECT SUMMARY See Table A for a summary of the field project. SECTION B: PROJECT GOALS AND OBJECTIVES See Table B for a summary of the project's goals and objectives. SECTION C: PROGRAM LOCATION C1 Location Maps See Appendix 1-A for maps of Mozambique, Nampula Province, and Nacala-a Velha District, the project impact area. (All appendices are in Annex 5.) C2 Location Description Mozambique: Mozambique is the world's fourth poorest country with a per capita GNP of $90. 1 The most recent (1995) IMR (158/1000) and U5MR (275/1000) are the fourth highest. 2 The latter exceeds the 1980 figure (269/1000).3 In 1993 more than 400 Mozambican children died each day.4 The recorded maternal mortality rate (MMR) based on mothers dying in health facilities is 203 deaths per 100,000 live births.5 As 70% of births 6 nationally occur at home without trained assistance, the actual MMR is believed to be much higher. Data from the UNICEF-funded Sentinel Community Surveillance System indicates an MMR as high as 1,100 per 100,000 live births in some areas. 7 The total fertility rate is 6.3,8 virtually unchanged since Seventy per cent of rural Mozambican households live in destitution or absolute poverty. During the 16 year civil war, 60-80% of the country's rural health infrastructure was destroyed. Today, only 17% of the rural population has access to potable water and 11 % to adequate sanitation, and only 30% have access to health facilities. 10 Ninety per cent of Mozambican women are engaged in agricultural activities for household food production, and only 20% are in the labor market. The rural female literacy rate only 11 %.11 Few village women are able to speak Portuguese, the country's official language used universally in commerce and education. The Informacao Estatistica Sumaria of the first nine months of 1996 provides the most recent official estimates of national and provincial health parameters (Appendix 2-A). Nacala-a-Velha District, Nampula Province: Nampula is one of the most heavily populated of Mozambique's ten provinces, with 3.3 million people, almost a quarter of the country's population, estimated at 16 million.12 the single impact Save the Children/USA

12 CS-12: Mozambique Detailed Implementation Plan area of the CS-12 project is comprised of the northeastern coastal district of Nacala-a-Velha (Old Nacala), located on the west side of the bay, across from the port city of Nacala Porto (Nacala Porto). Nacala-a-Velha is a rural district of approximately 110,000 emakhwa speaking people (Macua), settled in 13 regu/ados. These traditional units of social organization, under the authority of a traditional chief (regulo), do not correspond to the Frelimo government's administrative structure (e.g., celula, bairro, circulo, localidade, posto, etc.). However, a majority of the Nacala-a-Velha communities were in the Renamo sphere of influence during the civil war and continue to identify themselves on the basis of their regulos. Although there is no open hostility, these former Renamo communities still view the current Frelimo-dominated government, its local administration, and the district MOH with varying degress of suspicion. During the sixteen years of war, Nacala-a-Velha and neighboring districts were areas of intense partisan contention and armed conflict, resulting in severe social disruption and internal dislocation of the population. Since the peace accords in October 1992, a majority of families, once separated, have reunited and now returned to their communities of origin. Three years ago, in March 1994, the district was one of four hardest hit by Hurricane Nadia. Virtually every family in the district suffered severe losses to living quarters, crops, fields, food reserves, and material possessions. Traditionally, Macua families are matrilineal and matrilocal. Polygyny, though not as common as in the south of the country, does occur, especially among Muslims. A majority of the population is nominally Muslim, although there are a large Catholic minority, some Protestant denominations, and traditional animists. Few opportunities for wage labor exist in the area, and most families engage in subsistence farming, outside of, or on the very edge of, the cash economy. Some men in the coastal settlements fish. Almost all women in the district are engaged in agricultural activities in addition to their domestic chores. Few women sell agricultural products or anything else in the market, as this is the domain of men. Although need exists throughout Mozambique, Nampula Province, and Nacalaa-Velha District in particular, demonstrate clear need, the feasibility of interventions given existing infrastructure and likely partners, and synergy with other SC programming. Consistent with the need are the many constraints, including those suggested above: weak transportation and communication infrastructure; illiteracy; severe poverty; lack of women participating fully in society; political mistrust; unpredictable district administrative staffing patterns; and geographic remoteness from Maputo (virtually unreachable except by air) and Nampula City. Save the Children/USA 2

13 CS-12: Mozambique Detailed Implementation Plan Mortality and Morbidity Specific mortality data are not available for Nacala-a Velha. Maternal complications at delivery are cited as one of the major causes of death and disability, both by community members and MOH officials. Five of the six maternal deaths in 1996 at General Hospital-Nacala Porto (GH-NP), the first referral facility in the neighboring district, were due to uterine rupture and obstructed delivery. Most emergency surgery is for Caesarean delivery for ectopic pregnancy, and most of these come from Nacala-a-Velha, Memba and neighboring Districts, according to the surgeon. Among children, the most commonly diagnosed diseases in the district health center are diarrhea, pneumonia, and malaria. Pediatric admissions at GH-NP include these conditions plus malnutrition. Health Infrastructure The health infrastructure of Nacala-a-Velha is explicitly detailed since the project seeks to strengthen the community-district health system link as well as the district-first referral link. Nacala-a-Velha District's facilities include: two government health centers, two health posts staffed by district MOH personnel, and five small posts attended by agentes polivalentes elementares (APEs). The principal health center, located in the Sede (district seat), was seriously damaged in the 1994 hurricane and partially rehabilitated in 1995 by the French PVO, Hopitaux sans Frontieres (HSF). The district health director (a tecnico de medicina preventiva) works out of this facility which has an inpatient capacity of 16 general medical beds and eight maternity beds. The maternity is attended by one basic MCH nurse and one elementary midwife. The maternity delivers babies monthly. Maternity staff express the need for a casa de espera (waiting house) of ten beds to accommodate pregnant women at high risk who need to arrive at the health center early. Till eighteen months ago, the health center was visited one day a week by a doctor from the first referral hospital in Nacala Porto; but this arrangement could not continue because of lack of transport. Provincial MOH would assign a doctor to the district if the doctor's house in Nacala-a-Velha could be rehabilitated. Twenty km. west from the Sede, about 40 minutes by road, there is a second government health center in Mueria, operating on the grounds of a Roman Catholic mission. This center has 16 general medical beds and six maternity beds. Currently, Mueria has no MCH nurse nor trained midwife. Births are currently assisted by a servente with no formal training. However, it is planned for a qualified MCH nurse to be transferred from Nacala Porto within the next few months. In addition, the health center at Mueria benefits from the services of a Brazilian nursing sister trained in community health nursing. The Roman Catholic church formerly supplied drugs to Mueria, making it very popular with the local community, but it no longer does so. However, Mueria continues to be heavily utilized and delivers more than 20 babies per month. The new health post in Barragem is served by an elementary nurse; the post at Salina, by a servente. APEs, who are supervised by district MOH but do not Save the Children/USA 3

14 CS-12: Mozambique Detailed Implementation Plan receive a salary or other compensation, attend the five small posts in Covo, Ger Ger, Namalala, Muentaze, and Micolene. The APEs dispense drugs from UNICEF Kit C (Appendix 2-B). Some attend between 30 to 40 clients per day. The district's transport capacity theoretically consists of one vehicle and two motorcycles, all of which are out of service. The telephone in the Sede health center is also out of service, but could be restored for under $200 US. Public transport between the Sede and Nacala Porto is limited but does exist. All roads in the district are unsurfaced, some impassable during the rainy season (January through March); and many bridges have been washed away or not rebuilt since the war. The district's first referral facility (the second largest in the province) is the General Hospital in Nacala Porto in the adjacent district, 30 minutes east by road. Its maternity ward (3000 deliveries/year), newly constructed by Finnida in 1991, is in good condition, with 24 beds and the availability of trained personnel, including doctors and a general surgeon, four elementary midwives, eight MCH nurses, and a nurse midwife. The hospital also has ongoing in-service training for health workers, including a 6 week TBA training course piloted once in The hospital has two telephones and one all-purpose vehicle which serves as its ambulance. When available and functional, it can be dispatched to neighboring districts to transport patients, petrol permitting (rationed at 10 liters daily). The District MOH in Nacala Porto and medical personnel at the hospital recognize the importance of extending services to the districts and are willing to work with SC and district MOH in Nacala-a-Velha District. The second referral-level facility is the provincial hospital in Nampula City, the provincial capital, three hours inland by a tarred road in poor condition. SECTION D: PROGRAM DESIGN D1 Summary of Overall Design Interventions and Rationale Epidemiological context, feasibility constraints, and proposal guidelines converge on the four selected interventions. Maternal and Newborn Care (MNC) are essential because of the absolute lack of trained MCH personnel outside one health center, the corresponding low coverage, enthusiastic MOH staff, the likelihood of creating a functional maternal health system given favorable government policies, and the proximity of a first-referral facility. Although the project emphasizes the maternal aspect of the package, the interventions should save many perinates given that they are vulnerable to many of the same conditions as their mothers. COO and EPI are also justified on epidemiological grounds. Measles, diarrhea, and tetanus are the 2nd, 3rd, and 5th leading causes of death among Mozambican children under age five years.13 Save the Children/USA 4

15 CS-12: Mozambique Detailed Implementation Plan MOH does provide EPI services but not beyond the health centers, as the low district coverage figures attest. Nutrition is poor in Nacala-a-Velha, so much so, that standard growth monitoring is not appropriate. Indeed, larger-scale inputs are planned through a concomitant SC Title II and PV02 programs for Nacala-a Velha and Memba Districts (see below). The CS-12 project proposes a modest, but likely life-saving, intervention, mass targeted distribution of vitamin A capsules (VAC) after a more detailed dietary assessment. We chose not to intervene now against ARI nor malaria (although they are reported as the first and fourth leading killers of children, respectively) because both interventions are required together by PVC, and the required level of effort would preclude other critical interventions. Follow-on or additional funding would allow a broader array of interventions against these and other health threats. Mozambique is moving towards Integrated Management of Childhood Iliness,A and SC will take advantage of opportunities to integrate programming at both community and service provider levels. Priority follow-on interventions include family planning, and HIV/STDs, both of which could capitalize on a successful Maternal Care intervention. Of note, our selected interventions are consistent with the priorities of a recent MCH/FP review for USAID/Mozambique. B Overall strategy The three key strategies are: (1) public-private provider alliance, (2) quality of care (OOC), and (3) data for decision making. These will act through human resources and health systems to improve the district's health. Key human resources are: traditional healers, trained birth attendants and Volunteer Health Promoters (VHP). Key health systems components include: traditional healers and community birth attendants linked to MOH (public-private mix); maternal health (a health services paradigm from household to referral facility); Village Health Committees (sustainable partners for decentralized health and development); and Health Information Systems (an accountable district.) The project seeks to ally communities, MOH, and NGOs for a healthier district. Save the Children will facilitate the partnerships, support MOH services, share supervision of community-based services with MOH, provide logistical support to NGOs and MOH, mobilize communities, and monitor the project's implementation and effects. SC will refresh district MOH staff and train them as trainers of community-based providers (TBAs, VHPs, and THs). SC will provide funds to strengthen MOH's cold chain and bicycles for each facility and regu/ado and coordinate transport to assist MOH needs. MOH will provide facility-based A Dr. Felix, Medical Chief of Nampula Province, advised the DIP team, that IMCI manuals were in ~reparation (2/97). LaRosa J. MCH/FP Activities in Mozambique, REDSO/ESAlPH, February 15, In LaRosa's review of USAID Mission programs, she prioritzes: maternal health, home/health-seeking behavior change, COD, EPI, and FP. She recommends that nutritional interventions be guided by research and that ARI and malaria interventions be deferred. Save the Children/USA 5

16 CS-12: Mozambique Detailed Implementation Plan services adding outreach clinics for EPI and ANC, the latter assisted by a SC nurse. Communities will nominate individuals for training, strengthen VHCs, address emergency transportation, and experiment with databoards. NGOs will provide essential BCC skills, literacy training, gardening expertise, and community mobilization. SC aims to cement partner links such that sustainable working relationships will remain after project end. Target groups The program targets women years for MNC and EPI; children 0-11 months for EPI, children 0-24 months for COD, and children 6-71 months for VAC. The high risk population for the interventions are the complete relevant demographic groups given the present low coverage of all health services. Eligible women, children and newborns will enter the program though community mobilization for health, community-based providers' and NGO partners' behavior change communication (BCC), MOH outreach services, and birth into a participating family. In selected communities, "social pressure" through community databoards may further motivate participation. Non-BHRlPVC complementary interventions CS-12 interventions in Nacalaa-Velha will be complemented by USAID Mission-funded PV02 health interventions in nutritional improvement (breast-feeding, complementary feeding, weaning foods; STD/HIV/AIDS prevention) and nutritional rehabilitation education, using a "positive deviance approach,,14.15 with home-based nutritional rehabilitation foyers. The five year PL 480 Title II Food for Peace initiative, to be mounted by SC in the districts of Nacala-a-Velha and Memba in mid-1997, will focus on long-term food security through agricultural and infrastructural development. 02 Collaboration and Formal Agreements Partnerships When SC CS-12 project personnel arrived in Nacala-a-Velha District during the first quarter of FY97 for start-up, circumstances with regard to potential partners had changed during the intervening year since proposal submission. Management and financial irregularities made it impossible for the Nampula-based NGO, KARIBU, to fulfill its role as a project partner. The Associacao de Mulheres Rurais (AMR), also based in Napula City, was also not in a position to enter into immediate partnership, although its officers remain interested in moving slowly toward collaboration. Discussions will continue in the area of literacy training. AMETRAMO, the professional association of traditional healers, is in the process of extending its reach into the districts and is just beginning to register members in Nacala-a-Velha. A partnership with traditional healers, both AMETRAMO and non-ametramo members, will proceed as planned, focusing on training, aoc, and BCC. During the first two years, the project will work with traditional healers Save the Children/USA 6

17 CS-12: Mozambique Detailed Implementation Plan at the level of the regu/ado, allowing time for AMETRAMO to organize and build membership in the district. AMETRAMO, though an autonomous professional membership body, is associated in the minds of some with the Frelimo party. Thus, SC will proceed to collaborate with individual healers, seeking the formal partnership with AMETRAMO more slowly. A new natural partner, well situated in neighboring Nacala Porto, emerged early in project implementation. ADPP, Development Assistance People-to-People, (brochure, Appendix 3-A; excerpts from 1995 Annual Report, Appendix 3-B, "Child Aid Project" summary, Appendix 3-C) is a Mozambican national NGO (registered in 1993) and federation member of the international organization known as UFF/Humana People-to-People. Funds raised by UFF/Humana in Scandinavia and Europe fund ADPP projects in Mozambique. These include a wide-range of community mobilization, education and training, and child and family welfare activities. In Nacala Porto, ADPP operates a primary school for 300 "street" children; a vocational school for 60 young adults that offers training in agriculture, business, and construction; literacy classes (in Portuguese) for 300 rural women; partial support of an MOH health post for the surrounding community; and a project called Ajuda as Criancas (Assistance to Children) that works with 2,200 families and 11 primary schools in the rural bairros surrounding Nacala Porto. ADPP's proximity to Nacala-a-Velha, institutional capacity, willingness to collaborate, and common interests make it an ideal partner for the CS-12. Since January 1997, SC and ADPP have cooperated in the following areas: KPC Survey. ADPP seconded five full-time community mobilizers and helped recruit 15 graduates of its teacher's training and vocational schools to be trained as KPC interviewers. Training Exchanges: SC offers periodic training workshops to ADPP personnel to upgrade knowledge and skills in topics related to health and child survival. In January and February 1997, SC staff organized and ran workshops for ADPP community mobilizers in Child Spacing/Family Planning and STD/HIV/AIDS prevention. ADPP personnel and trainees will participate in SC gender training offered as part of the WCI initiative. Planned future activities with ADPP include: Training: ADPP's 16 community mobilizers will participate in training of trainers and community-based providers in Nacala-a-Velha. Through this participation, ADPP mobilizers will increase their knowledge and capacity to carry out child survival-related BCC activities in their target communities. In turn, ADPP mobilizers will contribute to the training of trainers and providers Save the Children/USA 7

18 CS-12: Mozambique Detailed Implementation Plan by sharing their knowledge and skills in the areas of participatory approaches and community mobilization techniques Experiential Exchange Visits: During years 1 and 2 of the CS-12 project, SC staff (especially the Community Mobilizers) will visit ADPP's Ajuda as Criancas project sites in Nacala Porto to obtain experiential training in community mobilizing and promotion of appropriate health- and hygienerelated technology (e.g., elevated drying racks for cooking utensils, improved latrine construction, simple wood-sparing stoves, and appropriate trash pits and composting). Horticultural Gardens: ADPP will assign agriculture students from its vocational training school to work in Nacala-a-Velha communities during their practical attachments of 2-6 weeks. SC will provide seeds and tools from private funds, and ADPP students, living and working in Nacala-a-Velha communities, will teach horticultural gardening to families, with a focus on increasing dietary sources of vitamin A and enriching weaning foods. Technical Assistance: Through an informal agreement, SC will provide technical assistance to ADPP in school health, community-based BCC, maternal-child health at the community-level, and monitoring and evaluation. ADPP will provide technical assistance to SC in the areas of appropriate technology, community mobilization, horticultural gardening, and literacy training. Bee Through Theatre - SC will provide technical assistance to ADPP's existing theatre group to develop effective comedy-dramas to communicate effective child survival messages focusing on aspects of maternal care, immunization, diarrhea case management, and dietary prevention of vitamin A deficiency. SC will provide transport and lunch for theatre group members to visit Nacala-a-Velha communities to perform. When possible, these performances will be scheduled to coincide with outreach vaccination sessions, community campaigns, health fairs, and other events in order to insure maximal participation. SC is holding discussions with ADPP in Maputo with regard to additional future collaborative efforts. Persons and organizations consulted during and participating in preparation of the DIP: Provincial Health Directorate Jose Maue Felix, Chief Provincial Medical Officer Alberto Sumalgy, Provincial Supervisor of APE program Felisberto Mueca, Provincial Supervisor of EPI Fernando Massaca, Provincial Supervisor of Nutrition Save the Children/USA 8

19 CS-12: Mozambique Detailed Implementation Plan -.. Nacala-a-Velha District Health Directorate Pedro Muehua, Director Joaquim Fanito, Supervisor of APEs and for Tuberculosis and Leprosy Jamal Fonseca, EPI Supervisor Arminda Masuca, MCH Nurse (Basic) Mario Amisse Rachide, APE, Muentaze Health Post Nacala-a-Velha District Administration District Administrator Administrator of Ger-Ger Administrative Post Nacala Porto District Administration Luis Jose, District Director Nacala Porto General Hospital Staff Dr. Yahaia, General Surgeon and Representative, African-Muslim Agency Dr. Agostinho, Medical Officer Traditional Authorities - Regulos Nacala-a-Velha, Murrimone, Murroto, Catava, M'phira, Motia, Rojolo, Meua, Vanhtia, Nautar, Mezope, and Canira. Traditional Healers - Groups (8 men and women) in Mezope. ADPP Maria Koves, Director, Assistance to Children, Nacala-a-Velha Arlindo Joao, Director, Vocational School, Nacala-a-Velha Soren Fransen, Dir., Primary School "Formigas do Futuro", Nacala Abdala Celestino, Program Officer Birgit Holm, Director, ADPP Mocambique, Maputo Dr. Julie Cliff, Dept. Comm. Health, Fac. of Medicine, E. Mondlane U., Maputo Dr. Herve Guillouzic, Technical Advisor in Health, USAID Mission, Maputo MaryAnn Abeyta-Behnke, COP, USAID/URC PHC Support Project, Maputo Other PVOs: World Vision in Nampula, CARE International in Nampula. 03 Technical Assistance Technical assistance from SC Headquarters in Westport, Connecticut, includes annual visits for days by members of the HPN Unit for such critical events Save the Children/USA 9

20 CS-12: Mozambique Detailed Implementation Plan as: 1) DIP preparation; 2) annual field TA consultation; and 3) mid-term and final evaluations...- SC is collaborating with Helen Keller International to carry out a dietary micronutrient assessment focusing on vitamin A and iron in Nacala-a-Velha and Memba Districts. This study has the support of provincial MOH which desires more information on micronutrient deficiencies. The assessment is planned for spring, 1997 and may benefit from OMNI support. Consultants: To compensate for loss of the CS-12-funded ethnographic consultant for EPI attitudes, beliefs, and behaviors cut during budget negotiations, the project will be a co-beneficiary of consultations anticipated for the PV02 health project funded by the USAID/Mission. These include consultants in HIS, ethnography (especially cultural beliefs, knowledge, and practices related to child survival and maternal care), participatory rural appraisal, and materials development. Details, including names and dates, will be finalized once PV02 funds are released and pending a needs assessment, most likely in mid Finally, the project hopes to use the BASICS verbal and social autopsy methods to review selected deaths through the optic of the "pathway to survival" to strengthen both BCe and health system response. Negotiations are under way with Dr. Henry Kalter, of JHU and BASICS. D4 Detailed Plans by Intervention D4-a Maternal and Newborn Care 1. Intervention Objectives Each MNC objective indirectly seeks to decrease maternal and neonatal mortality: (1) 50% of births will be attended by trained personnel; (2) 40% of pregnant women will receive at least one prenatal contact; (3) 40% of women of reproductive age will know at least 4 pregnancy-related "danger signs"; and (4) 50% of regu/ados will have established a referral system for obstetric emergencies. All objectives serve a hygienic delivery with the prompt recognition and effective response to signs of potential calamity for the mother and/or her unborn child. 2. Baseline Information Maternal mortality in Mozambique is due to obstructed labor, eclampsia, malaria, anemia, blood loss and infection, compounded by inadequate referral and surgical support for complications of pregnancy and delivery.16 In Nacala-a-Velha District, there are only 15 trained TBAs. This cadre of women (most are members of the Frelimo party-linked Organisation of Mozambican Women) was trained in 1989, but few are practicity due to lack of political acceptability at the community level and because they have received no materials nor supervisory support from MOH. Save the Children/USA 10

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