Questions/Answers

Whereas reducing maternal newborn and child mortality has been top priority for global health agenda over the last 20 years, 7.7 million children five children die each year while nearly 1000 women die each day from complications related to childbirth, (Mbizvo and Say, 2012). In Uganda, 1 in 44 women face death during pregnancy or childbirth, and a third of young child deaths occur during the neonatal period (Countdown 2015). In low income countries such as Uganda, rural women have limited access to care as a result of inadequate comprehensive maternal healthcare leading to pregnancy and childbirth related complications, (Lawn, Blencowe et al, 2016). This situation can be improved through innovative community-level interventions such as Village Health Team (CHW) Strategy. The ‘MamaToto initiative, a district-led CHW programming and facility-based MNCH strengthening was developed from experiences and lessons learned in Bushenyi and other districts supported by Healthy Child Uganda. MamaToto is a seven step process; SCAN ORIENT, PLAN, EQUIP TRAIN, ACT and REFLECT (SOPETAR), where leaders developed, implemented and monitored their own MNCH priorities; MNCH clinical skills short courses, In-charges and Health Unit Management Committee workshops, training in health management information systems and CHWs and their leaders. Training, mentorship and support supervision encouraged strong networks of CHWs to conduct home visits, assess and refer patients, provide health education, and mobilize communities to participate in health activities. SOPETR encourages continuous participation of local leadership, ownership, local resource mobilization and reflection through active stakeholder engagement. Local capacity is built through developed repeated processes which introduce, practice and develop skills to foster local involvement and leadership once the project has ended. During orientation, Bushenyi identified a district core team of individuals from within the community

The MamaToto initiative builds upon the Healthy Child Uganda comprehensive, community-based MNCH experience that was developed, implemented and evaluated since 2003 by a partnership; Mbarara University of Science and Technology, Canadian Paediatric Society, University of Calgary and Bushenyi District. The overall objective of MamaToto initiative is to improve the health and survival of pregnant women, newborns, and young children living in southwest Uganda. There are three specific objectives at each of the engagement levels: 1. DISTRICT HEALTH SYSTEM STRENGTHENING: To improve existing MNCH health systems in Bushenyi District by creating a MNCH strategic plan, strengthening MNCH health information systems and inter-facility referral systems. 2. HEALTH CENTRE MNCH SERVICE DELIVERY: To enhance staff, facility and program MNCH capacity and infrastructure at health centres/hospitals, enabling safe deliveries, acute treatment for sick and malnourished children, and primary health services including vaccination/vitamin A, newborn care, antenatal care, family planning, and growth monitoring 3. COMMUNITY MNCH PROGRAMS: To enhance community-based MNCH care and promotion through a network of volunteer community health workers (CHW). 4. MODEL EVALUATION: To develop, describe, and evaluate the Bushenyi District comprehensive MNCH delivery experience with subsequent testing of scale up in

Through community engagement by CHWs and strengthening capacity of health facilities, MamaToto initiative has been able to reach the poorest and most vulnerable. CHW open selection created strong respect and utilization of their services including implementing practical improvements and consultations on ill health for both children and mothers. The evaluation documented that CHWs were playing an effective role both in promoting healthy behaviors within households and in motivating individuals to visit health facilities for improved MNCH outcomes. It was also noted by the external evaluation team that clinical staff felt that clients were more open to seeking care at the facility because of advice from the CHWs. Vulnerable women are encouraged to come to the health facility since CHWs have a roster whereby one CHW is present at the health facility, helping with behavior change communication, supporting health workers and helping non-clinical staff. This kind of CHW integration into the health system creates positive relationships between community and clinical staff thus making facilities more friendly to all. It is evident that CHWs promoted hygiene at household level, increased use of bed nets, which has contributed to reduction in cases of suspected malaria being seen by health centres.

Through MamaToto initiative, HCU has enhanced MNCH programming capacity at Mbarara University and in local government districts, health centers and communities. MamaToto initiative activities have yielded dramatic reductions in rates of common childhood illnesses, malnutrition, under-five mortality and capacity to prioritize plan, budget and management skills. At district level, the initiative built capacity of district health managers through developing, implementation, monitoring and evaluation of district MNCH needs. The initiative improved understanding of MNCH data, its importance was documented and motivated providers at all levels. Provision of basic equipment, clinical training and quality improvement initiatives led to increased MNCH-service capacity at health centres. Health Unit Management Committees were re-invigorated and management training resulted in increased local participation in MNCH-related service planning. CHWs conducted home visits for women and children, assessed and referred those with danger signs as well as providing MNCH focused health education, improved home health and care-seeking practices and mobilized communities for National Child Health Days and other community initiatives. Evidence from a detailed household, health centre and operational data and stakeholder periodic input informed planning, modification of the initiative thus attending to

Health Center Management benefited from leadership training by creating a much more collaborative, practical, and engaging relationship with clinic staff through shared responsibility to improve MNCH outcomes. Quality of care was affected by improvements in cleanliness and sanitation at health facilities. During evaluation, staff noted that health promotion messages on the walls contributed positively to client-friendliness and positive work environment for clinical staff, “the pictures and paintings on the facility have acted as educational materials both to patients and health workers.” The Ministry of Health has often used our sites to develop or modify CHW policy and guidelines and creates a favorable learning environment for medical students during field placement. Strong linkage and partnership between CHWs and health centers, CHWs and local leaders strengthened the relationship between community and health facility, benefiting vulnerable populations to seek timely health care. “Now because CHWs reach the real people in communities, people no longer stay there with a sickness… when she finds a sick person, she sends them to the hospital in time, death reduced.” -Health worker. “For her when she sees you pregnant, she comes and tell you the danger of not going for ANC.” -Community Member, Focus Group Participant.

“About three years ago, we lost many children between 0 to 5 years of age…… I am telling you that in last one year, I have not got any report about miscarriage or death of a child between 0 and 5 years.” – CHW “Yeah, because when we look at our indicators, at least the data we get from health facilities, we are seeing improvement; our indicators have at least improved especially mortality and morbidity.”- Leadership • 1669 CHWs trained in 64 parishes, all 563 villages represented • 97% CHW retention after one year; 96% after two years • Analysis of post-intervention focus groups revealed the following three key positive outcome themes supported by household survey findings (absolute changes shown, all statistically significant): • Theme 1: Decreased morbidity ➝ presumed pneumonia (-4%), diarrhea (-7%), underweight status (-3%) • Theme 2: Improved household health practices ➝ Vitamin A (+12%), deworming (+20%), measles vaccine (+10%) • Theme 3: Improved care-seeking practices/access ➝ Antibiotics for pneumonia (+17%); ANC 4+ (+13%), postnatal care <48 hours (+43%), met need for contraception (+15%) • Bushenyi District leaders have been active and advocates in the MamaToto process and continue to plan, implement and monitor MNCH activities

Mbarara University of Science and Technology, University of Calgary and other partners have worked together for over a decade to reduce maternal and child mortality through community and facility based maternal newborn and child health (MNCH) programming, Healthy Child Uganda (HCU). On pilot basis, since 2003, HCU has developed, implemented and evaluated a series of programs in southwest Uganda with emphasis on operationalization of CHWs and related health centre strengthening to improve MNCH services. The MamaToto initiative, a district-led CHW programming and facility-based MNCH strengthening was developed from experiences and lessons learned by HCU at scale in Bushenyi district and later transferred to Mbarara, Ntungamo, Rubirizi and Buhweju districts. MamaToto is a seven step process; SCAN, ORIENT, PLAN, EQUIP, TRAIN, ACT and REFLECT (SOPETAR), where leaders developed implemented and monitored their own MNCH priorities. Whereas in this case the MamaToto processes were used to improve MNCH indicators, the same process can apply to any other area of interest such as environment and climate change. The initiative emphases active engagement of all stakeholders in planning, implementation monitoring and evaluation and builds in a mentorship and coaching element for continuity which is required for advancement with any of the SDGs.

The MamaToto initiative was developed based on experiences and lessons learned by Mbarara University of Science and Technology, University of Calgary and Districts in South Western Uganda through MNCH programming, implementation and evaluation. Through a series of SOPETAR processes, leaders from three levels (district, health facility and community) implemented various activities resulting in an operational CHW program and strengthened health facilities. Districts developed and monitored their own MNCH priorities through short clinical, management and leadership as well as monitoring and evaluation activities. An implementation guide and related materials and packages are on the Healthy Child Uganda website: www.healthychilduganda.org. The initiative is original and Dr. Edward Mwesigye, DHO Bushenyi district is a champion and an advocate for the innovation as a pioneer district to scale it up and has helped to orient Rubirizi, Mbarara, Ntungamo and Buhweju districts in Southwestern Uganda as well as supporting the Regional scale up of the initiative to Mwanza in Tanzania where its referred to as Mama naMtoto.

The MamaToto interventions can be integrated into the district plans and budgets, most of the activities could easily fit into the schedules of the already existing district staff such as selection and training of CHWs is majorly the role of health center staff, including training and support supervision. The District Health Team is responsible for monitoring and mentorship of lower facilities. In Bushenyi, the DHT was in the driver’s seat, these spearheaded all the SOPETAR process at all levels and are still using the same approach to engage, plan, implement, monitor and supervise district health performance. Health facilities link up with CHWs to encourage communities to utilize services at facilities. We calculated the cost of the initiative and its summarized here below: Costing the initiative Cost of Training: $ 6.75 pp/day CHW training $45.00 pp/day HW training $45.00 pp/day District training $ 350,000 medium district (250,000 population) Cost of Model: $ 6.63 cost/person/year $ 9.95 cost/person/18 months $38.70 cost/pregnant woman/year

Yes

In Uganda, the approach has been scaled up to the whole of Rubirizi district, with limited adjustments, the MamaToto approach has been adapted to promote bio-fortified Orange Sweet Potato and High Iron Beans Project in Mbarara and Buhweju districts, and partial implementation in Ntungamo district in Southwestern Uganda. As a result of successes using simulation cases and equipment during health worker training in Bushenyi and Rubirizi during this project, a new partnership between experts in simulation from UofC and a highly faculty of medicine at MUST has been born; SIM for Life 2015-2018. Sim for Life is a research and educational partnership for simulation-based teaching to enhance maternal and newborn emergency care, with funding sought from American, Norwegian and Canadian agencies. Catholic University of Health and Allied Sciences – Bugando Medical School together with Mwanza Region, UofC, and MUST have been awarded a research grant by IDRC to study replication of the MamaToto model to Tanzania, 2015-2020. As well, an implementation project using MT approach is running in TZ in two districts in Mwanza.

The initial cost of MamaToto Approach through SOPETAR processes is substantial. However most of the activities can be integrated into the district workplan, therefore sustainability becomes manageable. MamaToto encourages ownership, input, and reflection by engaging stakeholder throughout the project cycle. Local leadership involvement is enhanced through skills developed, repeated processes and practices which help to maintain ownership once the project funding has ended. Engagement is critical to create real and longstanding impact, even for vertical, top down projects. The MamaToto intervention for instance in Bushenyi had was integrated into the district plans and budgets, most of the activities could easily fit into the schedules of the already existing district staff such as selection and training of CHWs is majorly the role of health center staff, including training and support supervision. The District Health Team is responsible for monitoring and mentorship of lower facilities. The MamaToto intervention operationalises government policy on district planning, health facility management and community engagement using MNCH as an entry point. “I think one is planning was inclusive, we were involved as the district leadership, we moved together. It is like we saw where we were and we decided where we want to go as a unit, because to us that was key.” -Bushenyi DHT member, Endline “The involvement, the health workers and linking them with the community and health workers knowing that the community has a say in whatever service they get. It really helped…” -District Health Team Focus Group Discussion, Endline Cost of Model: $ 6.63 cost/person/year, $ 9.95 cost/person/18 months and $38.70 cost/pregnant woman/year. Intervention in Bushenyi with external funding ended in 2014, but MamaToto is still alive up to now!

In 2003, the Healthy Child Uganda Program was established under Faculty of Medicine, Mbarara University of Science and Technology to reduce maternal and child mortality through community and facility-based integrated maternal newborn child (MNCH) programming. In 2014, Healthy Child Uganda transitioned into the MUST Maternal, Newborn, Child Health Institute (MNCHI). The institute partnered with the districts to document the experiences of HCU thus the birth of MamaToto. Therefore, in terms of MamaToto sustainability, MNCHI will provide a long-term oversight, follow up and technical support as needed to communities involved in MamaToto interventions. MNCHI will provide a platform for training, research and implementation to MamaToto package including mentorship, supportive supervision and modestly-priced refresher training. The MamaToto interventions require funds which could be raised by government or through grants to set up a strong foundation especially capacity building at health facility and community. Training and equipping health facilities as well as establishing CHW structure require funds. However, once the foundation is in place, the sustainability costs are minimal and can be managed by districts. For instance, CHW retention four years post MamaToto intervention is still more than 96%. Another sustainability pillar is high engagement and enthusiasm of district health team members under strong leadership of the District Health Officer for supportive supervision and peer training visits at health centres. Mentorship by these individuals is now occurring incorporated as a part of DHT routine quarterly visits at no additional cost which should be sustained over time. District ownership has been very positive in all districts as evidenced by districts own presentations to national and to other district counterparts. MNCH Action Planning is a core part of Districts plans and budgeting. The district engagement processes (SOPETAR) particularly worked well in Rub

Yes

The MamaToto Initiative was had external evaluation by a team composed of Canadian and Ugandan consultants who had not been involved with the development of the proposal neither were they in any way involved in the implementation. The evaluation took place in the first half of December 2014, shortly after the completion of most project activities. External evaluation included a review of relevant documents, collection of qualitative information through site visits, focus group discussions and key informant interviews to generate stakeholders’ views on the strengths and weaknesses of the initiative and recommendations for improvement. Additionally, a team of University of Calgary, Mbarara University and District representatives conducted comprehensive base-line and end-line survey in both Bushenyi and Rubirizi Districts, a process which included a household survey, collection of anthropometric data from children, health centre audits, and collection of data from service providers at the community, clinic and district levels.

Evaluation of the initiative noted that involved partners were found to have a strong, mutually respectful, cooperative relationship, strong spirit of voluntarism, and a well-established style of collaborative which significantly contributed to the success of the innovation. The evaluation also appreciated MNCH strategic planning at the district level, with a focus on actionable plan that is easily monitored and updated. The team noted effective partnership relationships at all levels that promoted local leadership and ownership and on integrated partnerships across all levels within the district, integrated partnerships were seen as one of the most critical aspects behind the success of the Mama Toto initiative. The initiative was able to strengthen management structures and processes at the facility level, through management training for clinic in-charges and training for Health Unit Management Committees, technical staff were trained in clinical skills, provided basic equipment and facility upgrades to encourage and sustain improved practices in clinical care and better client-focus in their work. Strengthened connections between communities and health workers at the community and clinic level were recognized by stakeholders as a significant achievement. This linkage has motivated CHWs to conduct health education in their community which has positively impacted health.

In the baseline and endline the key evaluation indicators were decreased morbidity for children under five improved household health practices and improved care-seeking/access. Under morbidity, illnesses such as fever, diarrhea, presumed pneumonia, under five underweight (Moderate & Severe), stunting (Moderate & Severe) and wasting (Moderate & Severe) were investigated. Improved health practices looked at improved water source, improved latrine/sanitation, under five bednet use, vitamin A supplementation in last 6 months (6-23 months), deworming in last six months (12-59 months), DPT3 (12-23 months), measles (12-23 months) and exclusive breastfeeding (0-5 months). Regarding access to improved care, the baseline and underline household surveys looked at fever considering use of antimalarial treatment, Diarrhea using ORS treatment, presumed pneumonia using antibiotics, four or More ANC Visits, skilled attendant present at delivery, delivery at health facility, postnatal visit, postnatal Visit, contraceptive prevalence rate and unmet need for contraception. The external evaluation was mainly qualitative in nature and looked at key achievements and key areas for improvement, identify strong elements of the Mama Toto approach and suggest recommendations on weak elements of the Mama Toto approach.

The SOPETR process used by the MamaToto initiative emphases community-based health planning and health systems strengthening through specific steps to ensure local priorities, planning and goal setting, integration within existing health system structures, maximized use of existing and potential partner resources. During implementation it was key to align with current and changing policy, ongoing monitoring based on relevant and local targets and broad stakeholder engagement with regular planned dissemination and reflection throughout. Core team of individuals from within the community, health sector or otherwise was involved in the careful review of the overall project concepts, assessment of willingness to participate and assurance alignment of the project with local priorities which was important prior to any undertaking. A one week course helped to develop skills in participatory engagement amongst decision-makers and potential ‘champions’ which sparked energy to a positive start. Annual NGO coordination meeting was established in Bushenyi, led by the district to foster linkages in Health and other sectors as well as resource sharing to avoid duplication. In Mbarara and Buweju Districts the initiative was adapted to the Agricultural sector to promote bio-fortified crops and this has had high adoption and utilization successes. In Tanzania, Mama naMtoto is incorporated into the Regional and district health sector with evident collaboration. Various stakeholders added value to the Mama Toto including district political and technical teams for political well, policy and resource allocation, health facility management and clinical staff played key role in providing services as well and linkage to the community, community CHWs and leaders, ministry of health in Uganda for policy guidance, a team from University of Calgary provided technical guidance of the implementation process, Canada Pediatric Society - these provided technical and in-kind support and Mbarara Un

• Alignment with government systems, policies and priorities at different levels improve sustainability of project initiatives. • Strengthening of health facility services in conjunction with CHW scale up is critical to meet increasing demand created by CHWs. Health centre staff, leaders and Management should receive initial orientation about their role in CHWs supervision to engage fully. CHW supervisors should become a recognized position with documented incentives, job description and training. • Provide the same support for all CHWs in a group and consistent messaging around incentives. CHWs incentives should be carefully planned for fairness, maintenance, and distribution. Benefits (including bicycles, phones, training and specialized roles) given to some but not all CHWs should be very carefully considered for potential impact on community perception and morale. The volunteer role of CHWs should be clearly and regularly emphasized to communities. • The careful documentation and scientific surveys of the MamaToto initiative provided a strong base for the promotion of the MamaToto approach as a model and has been an integral part of generating interest and engagement from the highest levels. • To improve the initiative a clearer implementation guide should be readily available and accessible with all the required tools.