Plan Malawi Maternal and Child Health Project Mid Term Review

Background

The maternal and child health project is implemented by Plan Malawi with support from Plan Norway using NORAD funding. The project has been running from 2003 and is expected to be concluded in 2007. This review therefore comes mid way to draw useful lessons for making the rest of the project more effective. The project goal is to promote children's right to survival, health and development. It focuses on building capacities of families, communities, local Government and other duty bearers to ensure fulfilment of women and children's right to improved health associated with reduced morbidity and mortality. The project contributes towards strengthening Primary Health Care (PHC) in targeted program areas by controlling outbreak of preventable diseases through immunization and adoption of health seeking behaviours, increasing access to modern family planning and adoption of good hygiene practices as well as improving the nutritional status of under-five children and pregnant women. Integrated management of childhood illnesses, safe motherhood and are the basic strategies used to strengthen duty bearer capacity to ensure survival, growth and development of children under five.

Purpose/objective

The review of the Plan Malawi Maternal and Child Health Project therefore was meant to assess the effectiveness of strategies used in implementing the project, timeliness and progress made against the set objectives and thereby draws necessary recommendations to ensure the achievement of the expected results for this project.

Methodology

The assessment methodology was aimed at collection of both quantitative and qualitative data which involved conducting focused group discussions, interviews and data collection from a study population consisting of women with under-five children, care takers, community based distribution agents, traditional birth assistants, community health workers and extension workers. Observations were also carried out at health facilities. Enumerators were oriented in data collection. All of these complemented the literature review that was done prior to conducting the field visits and interviews.

Key findings

Integrated Management of Childhood Illnesses (IMCI) as key strategy for child survival: On the whole the project has been most effective in strengthening Community IMCI as the basic strategy for control and management of childhood illnesses. Particularly the project has built community capacity and practices in the 17 Key Care Practices. The result has been the community being actively involved in conducting participatory planning and monitoring. Progress made using this approach in each specific area of common childhood illnesses are discussed in 1 below:
1. Reducing Incidence of preventable and communicable diseases
Incidence of both kwashiorkor and marasmas amongst under - five children was found to be very low i.e. less than 4% even though of the few cases that were observed, kwashiorkor was more prevalent. On the other hand lack of supervision and support for mothers to conduct supplementary feeding negatively affected feeding practices and nutritional status of infants and children under five.
There has also been improved knowledge and practices in areas of management of diarrhea and immunization coverage has also increased. More women (81%) are able to manage diarrhea with ORT a success which the review attributes to training of extension workers and mothers as well as logistical support through drug supplies. Immunization campaigns and health weeks coupled with increased community participation contributed to increased mobilization and vaccine coverage rate of 72%.
Efforts to increase ITN (Insecticide Treated Nets) coverage for families with under - five children, as a means to reduce incidence of malaria, had limited success as only 49% of the families were found to be using bed nets and the majority (80%) of whom were using untreated nets. While some families have been able to access nets through Drug Revolving Schemes / Community Pharmacies, there remains limited number of families who have bed nets and insecticide treated nets in particular, awareness and utilization of the community pharmacies in the communities remains low.
Area of hygiene and sanitation using PHAST (Participatory Hygiene and Sanitation Transformation) approach still needs further re-enforcement. Reportedly, there are still few households who use latrines (32%), only 32% and use of waste disposal pits at household level is also limited (39%). The adoption of hand washing facilities and concrete sanitation platforms for the pit latrines has been rather slow and ineffective. Poor participatory processes applied are believed to have contributed to the poor reception of the sanitation practices amongst households.
2. Safe Motherhood: Adoption of modern family planning practices has been effective. However, other components of the safe motherhood strategy were not successfully implemented i.e. refresher training for community based family planning distribution agents and traditional birth attendants; again there is limited equipment/logistical support for emergency obstetric care and low utilization of postnatal care. Promotion of PMTC to ensure survival of children born to HIV infected mothers is yet to be done. On the other hand there is still limited support for men's participation in sexual and reproductive health.
3. School health Promotion: While most schools have active youth clubs, out of school youths are usually left out. Majority of schools organize school health competitions and have child to child (peer) health education. However, support to school health e.g. in terms of IEC material and First Aid training and equipment has been limited.

Recommendations

General Recommendations
1. Safe mother hood and promotion of school health strategies require more emphasis.
2. To effectively use these strategies and achieve the set targets the strategies require a proper strategic planning with clearly defined planned activities and approaches and persons responsible to carry out those activities at all levels.
3. Plan should contract the Community Health nurses and Home craft workers who would work with mothers in the communities as originally planned. This is needed for the successful implementation and supervision of the project at community level, especially in trying to reduce malnutrition in the children and to foster effective implementation of other family key care practices in community IMCI which are moving at a very slow pace.
Specific Recommendations
4. Community dialogue and conventional IEC must be strengthened in the use of ITNs. Communities must be guided in their priorities since the nets are already subsidized. Frequent dipping of nets in insecticides should be done at every 6 months. Committees at village level e.g. the village health/ITN committee should be empowered to conduct such campaign.
5. Plan should make a deliberate effort to build the capacity of HSA s in PHAST and these should train and supervise village health committees in carrying out PHAST activities.
6. Communities must be properly oriented to the Drug Revolving Fund and efforts by Plan must be made to maintain a constant supply. Committees dealing with DRF issues must undergo initial training and refresher courses.
7. There must be proper orientation and engage a more representative community committee to oversee use of ambulances and bicycles provided to support emergency obstetric care.
8. Traditional Birth Attendants and community Based Distribution contraceptive agents must have refresher courses annually. There should be good coordination and collaboration with the District Health Team which will assist in monitoring and supervision of the TBAs and CBDs.
9. Plan must support capacity building for health workers working in health facilities within the Project units so that PMTCT messages can reach the communities in order to sensitize them.
10. Plan should consider integrating PMTCT within the existing VCT services and support capacity building of health workers in health facilities to engage in PMTCT activities.
11. Men's participation in sexual reproductive health, as indicated in the project proposal, should be encouraged. There is need to conduct campaigns, civic education at village level on SRH issues.
12. Another way of encouraging men's participation in SRH issues is formation of men's clubs where men educate fellow men. Extension workers at community level can facilitate this process.
13. While the study shows that there is good access to youth friendly health services there is need to educate the youths about the different activities offered by these services.
14. All health workers in the targeted areas should be trained in provision of youth friendly services.
15. There is need to intensify training of parents and teachers in sexual and reproductive health. The training should be complemented by support to schools with different IEC materials and first aid kits.
Comments from the organisation, if any:
The report failed to acknowledge the countrywide challenge in subsidized ITN supply as another contributing factor for low ITN coverage.
While the review assessed the progress towards the set targets, there was no clear reference to the baseline situation and how that situation influenced the set targets. Limitations in the ToR for this review might have contributed to this shortcoming.

IEC - Information, Education and Communication
HAS - Health Surveillance Assistant
PMTCT- Prevention of Mother to Child Transmission
VCT- Voluntary Counseling and Testing