7.1.3. UHI Annual Report 2022.pdf

USAID.GOV UHI FY3 ANNUAL REPORT - OCTOBER 2022-SEPTEMBER 2023 | 1

Urban Health Initiative

Project Year 03 Annual Report – October 01, 2022, to September 30, 2023

Cover Photo

Pule-Khusk clinic, District 13, Kabul.

Disclaimer

Urban Health Initiative is a five-year U.S. Agency for International Development (USAID) project in Afghanistan, implemented by a consortium led by Jhpiego Corporation, in partnership with Management Sciences for Health, CARE, Intellecap, Agency for Assistance and Development of Afghanistan, Afghan Midwives Association, Afghan Social Marketing Organization, BAO Systems, Internews, Project ECHO, Terre des Hommes, and Viamo. This document is made possible by the support of the American people through USAID under the cooperative agreement number 72030620CA00007. The contents of this document are the sole responsibility of Jhpiego Corporation and do not necessarily reflect the views of USAID or the U.S. Government.

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TABLE OF CONTENT

List of Tables iv

List of Figures v

Abbreviations vi

Project Overview viii

Executive Summary 9

Objective 1: Strengthen the health service delivery ecosystem in urban areas to deliver high-quality services to the most vulnerable 9 Objective 2: To improve access for vulnerable populations to critical primary and lifesaving secondary and referral care health services in urban areas through the public and private sectors 9 Objective 3: To improve the quality of public and private critical primary and lifesaving secondary and referral health services in urban areas 13 Objective 4: improve awareness, demand, and care-seeking for key services and referral 15

Summary of Achievements in Year 3, Annual Report (October 01, 2022–September 30, 2023) 16

Introduction 19

Work Environment in FY3: 19

Activity Implementation Progress 20

Objective 1: Strengthen the health service delivery ecosystem in urban areas to deliver high-quality services to the most vulnerable 20 Objective 2: To improve access for vulnerable populations to critical primary and lifesaving secondary and referral care health services in urban areas through the public and private sectors 22 Objective 3: To improve the quality of public and private critical primary and lifesaving secondary and referral health services in urban areas 42 Objective 4: To improve awareness, demand, and care-seeking for key services and referral 59

Cross-Cutting Issues 62

C.1 Restriction on female staff working with NGOs 62 C.2 Personnel 62 C.3 Coordination with UHI partners 62 C.4 Coordination with USAID and the stakeholders 62 C.5 Coordination with AFIAT, LHSS, and THIRD-PARTY Monitoring 62 C.6 Monitoring and evaluation 63 C.7 Gender 68

Challenges and Operating environment 70

Annexes 72

Annex 1: Geographic Coverage of UHI Project 72 Annex 2: Progress on Pre-Installation of Oxygen Plants 73

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Annex 3: UHI Consortium Partner Focus Areas 74 Annex 4: Topics Covered in Learning Sessions 75

LIST OF TABLES

Table 1: Summary of Project Scope and Financial Update viii

Table 2: Performance on UHI Annual* Performance Plan and Report Indicators for Y3, Annual Report (October 01, 2022–September 30, 2023) 16

Table 3: TB Performance Indicators, UHI Target Provinces, in FY3 (October 01, 2022–September 30, 2023) 24

Table 4: TB Performance by Type of HF, FY3, (October 01, 2022–September 30, 2023) 24

Table 5: Services Provided by MLMCC FY3 (October 01, 2022–September 30, 2023) 27

Table 6: Percent of Women with a Normal or Assisted Birth Accepting PPFP (IUCD and Implants only), by FY3, (October 01, 2022–September 30, 2023) 28

Table 7: Group ANC Meeting Participants FY3, Annual Report (October 01, 2022–September 30, 2023) 29

Table 8: COVAX Mobile Teams, Y3, Annual Report (October 01, 2022–September 30, 2023) 30

Table 9: Equipment Fixed by the Biomedical Engineers’ Team in FY3, (October 01, 2022–September 30, 2023) 31

Table 10: COVID-19 Service Delivery in 14 Inpatient HFs in FY3 (October 01, 2022–September 30, 2023), Disaggregated by Sex 34

Table 11a: Number of Clients Referred by uCHWs by City in FY3 37

Table 11b: Number of Clients Referral Per CHWs in FY3 37

Table 12: Number of Beneficiaries and Services Provided in 149 HP in Jalalabad, Mazar, Herat, and Kabul in FY3 37

Table 13: Fixed Centers Provide Psychosocial Support to Pregnant Women 39

Table 14: FHHs Achievements in FY3, (October 01, 2022–September 30, 2023) 40

Table 15: Comparison of Services Provided by FHH and Community Midwives (CM) in FY3, (October 01, 2022–September 30, 2023) 41

Table 16: Contraceptives Leveraged by UHI in FY3, (October 01, 2022–September 30, 2023) 42

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Table 17: ECHO Sessions Conducted by UHI and their Participation in FY3 (October 01, 2022–September 30, 2023) 42

Table 18: Number of Health Care Providers Who Participated in Learning Sessions and Assessed as Competent in UHI-Targeted, HFs, FY3 (October 01, 2022–September 30, 2023) 47

Table 19: Training and Orientation Conducted in UHI-Targeted Provinces, FY3 (October 01, 2022–September 30, 2023) 49

Table 20: Summery finding of client exit interview FY3 by quarter (Q2, Q3 and Q4) 53

Table 21: Number of Death Cases Reported and Reviewed in UHI-Targeted HFs in FY3 (Oct 01, 2022–Sept 30, 2023), by Facility 56

Table 22. Details of Calls, FY3, (October 01, 2022–September 30, 2023) 59

Table 23: Awareness-Raising Sessions Y3, Annual Report (October 01, 2022–September 30, 2023) 62

Table 24: Data Management System in Health Facility in Y3 by Quarter 66

Table 25: Comparison of source documents and reported data …………………………….. 67

Table 26: Comparison of source documents and reported data……………………………... 67

LIST OF FIGURES

Figure 1: TB Performance by Type of HF, FY3, (October 01, 2022–September 30, 2023) 25

Figure 2: TB Performance by Type of HF FY3, (October 01, 2022–September 30, 2023) 25

Figure 3: COVID-19 Service Delivery in 14 Inpatient HFs in FY3 (October 01, 2022–September 30, 2023) 33

Figure 4: COVID-19 Service Delivery in 14 Inpatient HFs in FY3, (October 01, 2022–September 30, 2023) disaggregated by sex 33

Figure 5: Service Delivery by Community Midwives, FY3, (October 01, 2022–September 30, 2023) 36

Figure 6: Service Delivery by uCHWs at 149 HPs FY3 38

Figure 7: Average Number of Participants in TB ECHO Sessions, by Quarter and gender, FY3, (October 01, 2022–September 30, 2023) 43

Figure 8: Participants in MNH Learning Sessions Who Completed vs Who Is Competent in UHI-Targeted HFs, FY3 (October 01, 2022–September 30, 2023) 44

Figure 9: Participants in FP, PAC Learning Sessions Who Completed vs Who Is Competent in UHI-Targeted HFs, FY3 (October 01, 2022–September 30, 2023) 44

Figure 10: Participants in Child Health and Nutrition Learning Sessions Who Completed vs Who Is Competent in UHI-Targeted HFs, FY3 (October 01, 2022–September 30, 2023) 45

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Figure 11: Participants in Data, Pharmacy, and TB Learning Sessions in UHI-Targeted HFs, FY3 (October 01, 2022–September 30, 2023) 45

Figure 12: Participation of Providers in COVID-19 Learning Sessions in UHI-Targeted HFs, FY3 (October 01, 2022–September 30, 2023) 46

Figure 13: Percent of Cesareans in which the Safe Surgery Checklist Was Used, by Hospital, FY3 (October 01, 2022–September 30, 2023) 51

Figure 14: Trends in Maternal and Neonatal Death and Institutional Deliveries, FY3 (October 01, 2022–September 30, 2023) 57

Figure 15: Percentage of Births that Received Key High Impact Interventions 57

Figure 16: MNH Cascade by Facility Category FY3 58

Figure 18. Participant responses to survey of self-care infoline 61

Figure 19. Improvement in Growth monitoring and IYCF counselling Y2 to 1,932 in Y3 63

Figure 20. Improvement in coverage gap of ANC1 and ANC4 Q2 to Q4, Y3 64

Figure 21: Spread of ECHO sessions’ effect on providers’ treatment skills 65

Figure 22: Distribution of feeling more professional after attending ECHO sessions 66

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ABBREVIATIONS

AFIAT Assistance for Families and Indigent Afghans to Thrive

AMA Afghan Midwives Association

ANC antenatal care

ANV antenatal visit

ARI acute respiratory infection

DMPA depot medroxyprogesterone acetate

DQA data quality assessment

DR-TB drug-resistant TB

DS-TB drug-susceptible TB

ECHO Extension for Community Healthcare Outcomes

ENRS electronic nominal registration system

EPI Expanded Program on Immunization

FHH family health house

FP family planning

HF health facility

HP health post

ICU intensive care unit

IEA Islamic Emirate of Afghanistan

IEC information, education, communication

IUCD intrauterine contraceptive device

MAM moderate acute malnutrition

MEL monitoring, evaluation, and learning

MLMCC midwifery-led maternity care center

MNDSR maternal and newborn death surveillance and response

MNH maternal and newborn health

MoPH Ministry of Public Health

MoU memorandum of understanding

MSF Médecins Sans Frontières

MSH Management Sciences for Health

MUAC middle upper-arm circumference

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NTP National TB Control Program

OPD outpatient department

PE/E pre-eclampsia/eclampsia

PMDT programmatic management of drug-resistant TB

PNC postnatal care

PNV postnatal visit

PPFP postpartum family planning

PPH postpartum hemorrhage

PPHD Provincial Public Health Directorate

PPIUCD postpartum IUCD

QI quality improvement

RMNCAH reproductive, maternal, newborn, child, and adolescent health

SAM severe acute malnutrition

TB tuberculosis

TT tetanus toxoid uCHW urban community health worker

UHI Urban Health Initiative

UNFPA United Nations Population Fund

USAID United States Agency for International Development

USG United States Government

WHO World Health Organization

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PROJECT OVERVIEW

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EXECUTIVE SUMMARY

The Urban Health Initiative (UHI) is a five-year cooperative agreement (October 14, 2020–October 13, 2025) funded by the United States Agency for International Development (USAID) and implemented by a consortium led by Jhpiego, with Management Sciences for Health (MSH), CARE, Intellecap, Agency for Assistance and Development of Afghanistan, Afghan Social Marketing Association, Afghan Midwives Association (AMA), Terre des Hommes, Internews, BAO Systems, Project ECHO, and Viamo.

OBJECTIVE 1: STRENGTHEN THE HEALTH SERVICE DELIVERY ECOSYSTEM IN URBAN AREAS TO

DELIVER HIGH-QUALITY SERVICES TO THE MOST VULNERABLE

During the reporting period, the UHI project continued coordinating activities with the United Nations (UN) agencies (UNICEF, World Health Organization [WHO], UN Population Fund [UNFPA], UN Office for the Coordination of Humanitarian Affairs [UN-OCHA]). In addition, UHI worked with the professional associations (AMA, Afghanistan Society of Obstetricians and Gynecologists), Afghanistan Nurses and Midwives Council, and private sector stakeholders, as well as with the technical departments of the Ministry of Public Health (MoPH). UHI also ensured regular participation in the national health cluster and provincial public health coordination committee (PPHCC), which are good platforms to collaborate with various partners, including UN agencies, to avoid duplication of efforts, complement support, look for local solutions, and coordinate with provincial public health officers. In addition, PPHCC assisted UHI with provision of support letters for female staff, short-term solutions for the community midwifery program, and better access to target nahias/health facilities. Furthermore, UHI was able to complement the efforts in the areas of TB (drug-resistant TB [DR-TB] cases, sample and patients’ transportation, supporting the lab test for DR-TB patients and food baskets), COVID (outreach vaccination including transportation of the teams), family planning (FP) (provision of timely commodities through UNFPA support), nutrition and child health (growth monitoring, referrals, counselling).

OBJECTIVE 2: TO IMPROVE ACCESS FOR VULNERABLE POPULATIONS TO CRITICAL PRIMARY AND

LIFESAVING SECONDARY AND REFERRAL CARE HEALTH SERVICES IN URBAN AREAS THROUGH THE

PUBLIC AND PRIVATE SECTORS

2.1 IMPROVE ACCESS TO BASIC PUBLIC AND PRIVATE HEALTH CARE SERVICES FOR VULNERABLE POPULATIONS

IN FIVE CITIES

● Improve service delivery readiness in 76 health facilities: UHI supported different service levels (e.g., regional hospitals, specialist hospitals, district hospitals, private hospitals, and other health centers) to strengthen the delivery of integrated services across reproductive, maternal, newborn, child, and adolescent health (RMNCAH) including FP, nutrition, Expanded Program on Immunization, COVID-19, and TB through in-person structured mentoring, and tele-mentoring. In FY3, UHI activities continued at 50 targeted public health facilities (HFs) and 26 private HFs. UHI support to these HFs has enabled significant readiness of essential services and built the potential to increase adaptive service delivery system capacity in the future. Service delivery data has been collected from all 76 HFs (please see Annex 5, Performance Indicator Summary). Mentors/clinical specialists were deployed to the 76 private and public HFs to support the service providers for improving service delivery readiness (including information on all priority areas) as well as quality of services in a resource-constrained setting.

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Through the 76 HFs (public and private) a total of 198,090 first antenatal care visits (ANC1) and 237,246 first postnatal care visits (PNC1) were conducted this year, and 582,147 women were counselled on FP (interval, postpartum, and post abortion care) of these 346,722 (59.5%) accepted FP methods (condoms 127,976, oral pills 142,543, DMPA 40,438, emergency 5,873, tubal ligation 3,276, IUD 13,343, implant 13,273). In addition, UHI-trained midwives and delivery-care providers at these HFs supported 230,059 births. Moreover, 650,431 children 2–5 years old were screened for malnutrition using middle upper-arm circumference (MUAC) by the UHI-trained nutrition service providers. The providers identified 70,173 children with moderate acute malnutrition (MAM) and an additional 31,649 children with severe acute malnutrition (SAM). During the reporting period, 10 new nutrition corners were established in 10 HFs and in total, 55 nutrition corners remained functional in 55 UHI-targeted HFs in five cities.

During the reporting period EPI fix centers remained functional and provided EPI services in 63 UHI-targeted HF. A total of 97,042 children less than 12 months of age received the third dose of the pentavalent (PENTA3) vaccine and 90,311 children received their first dose of the measles-containing vaccine (MCV1) by 12 months of age. Immunization services are provided by UHI-mentored vaccinators in the targeted facilities. UHI conducted mentorship sessions for 684 Health care providers on cold chain management (157), vaccine sessions planning and data registration(158), vaccine wastage and opened vial policy (161), and monitoring chart & drop out calculation (208). Overall, EPI services statistics indicate a positive trend towards improved immunization rates over the past year. 306,073 children under one year received PENTA vaccines, representing a 43.5% increase; 170,613 children received Measles 1 and 2, representing a 42.6% increase; 93,775 pregnant women received TT vaccines, representing a 54.1% increase; and 238,550 newborns received BCG, OPV0, and HB0 vaccines, representing a 34.5% increase in comparison to Y2.

● TB: UHI supported the implementation of TB activities in targeted HFs. In total, 70,311 presumptive TB patients were identified, of these, 9,656 (14%) were diagnosed as TB cases; 2,638 of the identified cases were among children under the age of 15 years.

● COVID-19 support: In FY3, the project continued with 50 COVAX mobile teams—10 teams/city, each with five members per team. During the reporting period, a total of 348,918 doses were administered (177,961 J&J first and last recommended dose, 140,350 J&J booster, 28,762 Sinopharm first, 1793 Sinopharm second, and 52 Sinopharm booster).

The project also continued to support COVID-19 services in the five cities through mentorship and providing oxygen supply to COVID-19 hospitals. In FY3, UHI supplied 7,512 cylinders of oxygen (each cylinder contains 42 liters of oxygen) to the targeted hospitals (6,543 cylinders of oxygen to Kabul city, 50 cylinders to Herat, 180 cylinders to Jalalabad, 40 cylinders to Kandahar, and 699 to Mazar-e-Sharif COVID-19 HFs).

In FY3, UHI biomedical engineers conducted training for Kabul hospital staff on proper use of medical equipment. They also repaired and maintained 505 different pieces of biomedical equipment.

UHI received the two oxygen plants via the Pakistan border and transported them safely to prepared sites in Jalalabad and Kandahar regional hospitals in Q3. The installation work was completed in Q4.

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Each oxygen plant has the capacity to produce 12 oxygen cylinder/24 hours and provide oxygen to 50 patient beds through an oxygen pipeline system. Moreover, UHI also received some shipments of COVID equipment, devices, consumables, and supplies that were transported to UHI-targeted cities.

2.2 IMPROVE PATHWAYS TO PRIMARY AND SECONDARY CARE FOR MOTHERS, CHILDREN, AND VULNERABLE

POPULATIONS

● Community midwives: In FY3, through 36 community midwives in Kabul (24) and Herat (12), a total of 16,427 ANC1 and 11,741 PNC1 were conducted; 28,769 women were counselled on FP, of whom 12,946 (45%) accepted a FP method, in addition, community midwives supported 162 home births. During the reporting period, these UHI-trained community midwives screened 9,320 children 2–5 years old in Kabul with MUAC to assess their nutritional status; 1,149 children under 5 were referred to the hospital for SAM or MAM. Overall, in FY3, 14,638 beneficiaries were referred for services, including 7,344 pregnant women for tetanus toxoid (TT) vaccination. The Kandahar community midwifery program is still suspended. The UHI team is working on a modality where midwives would work in a semi-fixed midwifery center, this modality has been proposed to have five to 10 small midwifery houses, using the same urban community midwives and helping the mothers who cannot go to the facilities. However, while this modality has been discussed with Kandahar PPHD, it has not yet been approved. Further discussion and agreement are still required.

Currently, midwives are providing services through the nearest HFs. UHI is coordinating with Kandahar PPHD to obtain approval.

● Family health houses (FHHs): UHI continued its support to urban FHHs in rented houses in Jalalabad city. Per the UHI Y3 approved workplan, four FHHs located in underserved areas are functional, with two midwives in each FHH. The services include ANC, skilled care at birth, PNC, FP, newborn care, immunization, and health education. During FY3, these FHHs provided a total of 4,514 ANC1 and 2,393 PNC1 visits to service seeking women of reproductive age; 4,679 women were counselled on FP (interval, postpartum, and post abortion), of whom 2795 accepted a FP method (condom 907, DMPA 621, emergency contraceptives 93, IUCD 120, pills 1,054). FHH midwives conducted 1,946 deliveries, 1,226 children <1 year received PENTA3 vaccine, 979 children <1 year received MCV1, and 1,780 pregnant women received TT vaccination.

● Mobile outreach services: During FY3, UHI established four mobile health teams, three in Kabul and one in Jalalabad. These four mobile health units started their activities in Q4, offering integrated health services. Mobile health teams (MHTs) located in underserved areas are functional, with one pediatrist male, one obstetrics and gynecologist, one sonologist, one midwife, one male nurse, and one lab technician in each MHT. The services include ANC, skilled care at birth, PNC, FP, newborn care, immunization, and health education.

● Midwifery-led maternity care center (MLMCC): This innovative service delivery approach continued at Ahmad Shah Baba district hospital with full presence of UHI clinical and support staff.

UHI provided technical and logistical support and supplies to the MLMCC to maintain services.

During FY3, of the 28,694 women screened by the MLMCC midwives, 8,713 gave birth in the MLMCC. All of these women received PNC1 and 8,691(99.7%) received FP counselling before discharge; of these 1,760 accepted postpartum FP methods (80 postpartum IUCDs [PPIUCD], 283 implants, and 1,397 lactational amenorrhea methods). A total of 5,523 (63%) had a companion at birth, 3,305 (38%) had a companion at labor, and 3,860 (44%) gave birth in a non-supine position. A

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new MLMCC was established in Herat in coordination with the PPHD, UHI selected the location, processed the recruitment of staff, and completed the orientation of staff and procurement of needed equipment and supplies. The MLMCC is fully functional and will start the service delivery from October 2023.

● Urban health posts (HP) and urban community health workers (uCHWs): During FY3, through 149 urban HPs in Kabul (75), Jalalabad (24), Mazar (20), and Herat (30), a total of 218,859 families were visited, with 19,016 antenatal visits (ANV) and 9,435 postnatal visits (PNV) conducted.

● During FY3, 72,885 children 2–5 years old were screened using MUAC to assess their nutritional status. Overall, in the reporting period, 77,465 beneficiaries were referred for services.

● Psychosocial call center (PSC): During FY3, UHI established a call center at Najmul Jehad comprehensive health center in Jalalabad to provide psychosocial support to pregnant women who need support. As part of group ANC (G-ANC) in three HFs in Jalalabad and Kabul, women are screened for prenatal mental health concerns and are then referred to the PSC if needed.

Counsellors are present in these three facilities and can see clients directly when they are referred, or women receive a number that they can call so that counsellors can call them back. The two counsellors provide virtual counselling services via a dedicated number using cloud contact services.

They work from their homes and use tablets with sim cards to call clients. Clients initiate the first contact and counsellors call them back immediately (or at a time that is convenient for the client), ensuring that the call is free for the client. UHI activated the PSC in May 2023 to add additional services to the current counsellors at the HFs. Since then, 83 clients have received counselling.

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2.3 IMPROVE AVAILABILITY OF ESSENTIAL MEDICAL AND NON-MEDICAL SUPPLIES IN PUBLIC AND PRIVATE

URBAN HFS

● UHI leveraged contraceptives through cost share and provided them to the targeted HFs and community programs, which contributed to increased uptake and couple years of protection from all methods.

OBJECTIVE 3: TO IMPROVE THE QUALITY OF PUBLIC AND PRIVATE CRITICAL PRIMARY AND

LIFESAVING SECONDARY AND REFERRAL HEALTH SERVICES IN URBAN AREAS

3.1 CENTERS OF EXCELLENCE PROVIDE SUPPORT TO HFS

Virtual communities of practice: During FY3, six additional ECHO sites were established, at the Rabia-e-Balkhi Hospital, Khairkhana hospital, and Balkh, Nangarhar, Herat, and Kandahar regional hospitals resulting in a total of 26 ECHO sites. In FY3, 58 ECHO sessions were conducted; 21 on TB, 19 on child health,16 on mother and newborn health, and two on general topics. A total of 8,965 providers participated (4,330 females and 4,635 males). The sessions were moderated by UHI to ensure structured discussion of case management and peer review on holistic case treatment.

In FY3, a total of 52 maternal and newborn death surveillance and response (MNDSR) committees in public and private targeted HFs were functional (27 public HFs and 25 private HFs). The committees review most of maternal and some newborn deaths that occur in HFs to identify the cause, review and identify the gaps, and develop action plans with hospital staff. During FY3, 117 maternal and 1,473 newborn deaths were reported and the committees reviewed109 maternal deaths and 215 of the newborn deaths. In addition, the teams reviewed the progress on the implementation of action plans developed by the assigned committees.

3.2 AND 3.3 IMPROVED CAPACITY OF STAFF AT PUBLIC AND PRIVATE FACILITIES

Improving the quality of services through mentorship program implementation: Mentorship is the overarching approach of direct/virtual support that UHI uses to support service delivery strengthening. The clinical specialist/mentorship teams are assigned to facilities to work with health care providers over time to identify and address gaps and to improve services. The process supports health care providers in terms of the knowledge, skills, competence, and confidence needed to provide quality health services. UHI is coordinating with the Capacity Development Unit/MoPH on a certification and accreditation process.

In addition to mentorship, UHI undertook the following activities to strengthen staff capacity:

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● Training of health care workers: In addition to the onsite mentorship, in FY3, UHI provided 33 different group trainings to a total of 2,221 participants (1,607 female and 614 male). For more details, please refer to Table 20.

● Waste management: During FY3, 30 health care providers (24 female and 6 male) were trained and 66 health care providers (26 female and 40 male) oriented on health care waste management. In addition, the HFs were supported with the supplies and consumables and additional job aids were distributed.

● Safe obstetric surgery: To ensure that cesarean sections are being performed with due diligence, UHI is using the WHO Surgical Safety Checklist under the safe surgery program in 20 public and private hospital to ensure quality of cesarean birth, improve the safety of operations, and reduce complication and deaths. During the FY3, the Safe Surgery Checklist was applied in 36,030 out of 39,496 cases, which is 91% of all cesarean births in 20 targeted hospitals where cesarean sections are performed.

3.3 E-MENTORING AND SUPPORT SYSTEMS FOR SERVICE PROVIDERS

UHI has increasingly been using ECHO as a way to bridge the knowledge gaps of professionals in supported HFs, sharing critical, timely (as they occur) lifesaving information and data with health workers at different sites and geographical locations.

As of FY3-Q4, UHI is supporting one ECHO site in each targeted hospital that has agreed to participate in this initiative. However, due to increasing pressure to segregate women and men, some hospitals have requested establishing a second ECHO site, which is under UHI’s consideration. That said, given its success in the current context, UHI will further expand ECHO sites to ensure more participation of health workers and enable them to use this technology.

Through the ECHO platform, UHI will continue streamlining the ECHO session processes, support the current sites, and expand to potential new ECHO program areas: MNH (including maternal and neonatal death reviews), TB, safe surgery, COVID-19, and emergency medicine/trauma. The project provides Dari and Pashto interpretation for scheduled virtual ECHO partner training (formerly known as “immersion”) for UHI staff and/or partners to prepare for the application of the ECHO model to new programs.

A few virtual sessions will be planned by Project ECHO with India support to fulfill two objectives: 1) better interaction between the ECHO/Afghanistan and ECHO/New Mexico teams to discuss progress to date, experiences, and way forward; and 2) benefit from the well-established India TB program to learn from their experiences.

3.4 COMPREHENSIVE INTEGRATED QUALITY ASSURANCE/QUALITY IMPROVEMENT I MODEL AND STRATEGIES

DEVELOPED AND IMPLEMENTED

In FY3, quality improvement (QI) committees were functional in 66 HFs and conducted meetings. They also followed up with the relevant focal persons of different committees (MNDSR, infection prevention, Health Care Waste Management (HCWM) to ensure the implementation of corrective actions. UHI staff followed up with the committees and focal person to support implementation of corrective actions.

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3.5 INCREASED PATIENT SATISFACTION AND PUBLIC CONFIDENCE WITH PUBLIC AND PRIVATE HEALTH CARE

Three rounds of client exit interviews were launched during year three to assess the client experience of health services at UHI-supported HFs. The interviews asked about whether or not key components of quality services were addressed during care and about client satisfaction with the care they received. Key components assessed included waiting time less than 30 minutes, friendly and professional treatment from providers, understandable explanations from providers, receipt of prescribed medications, and instructions were easy to understand. Satisfaction was measured using a net promoter score.

In Q4, in 10/23 (43.5%) HFs, more than 80% of clients report all UHI-expected components of quality of care during their visit. Moreover, in 20/23(87%) of HFs, 80% or more of clients reported satisfaction with the care they received.

OBJECTIVE 4: IMPROVE AWARENESS, DEMAND, AND CARE-SEEKING FOR KEY SERVICES AND REFERRAL

4.1 INCREASED AWARENESS OF POSITIVE HEALTH-SEEKING BEHAVIOR AND HOME-BASED PRACTICES

INCLUDING:

● 234: Viamo Platform (234 service) is an on-demand, 24/7 and public service that allows Afghan citizens to access a wide variety of beneficial and actionable information on themes including health, FP, COVID-19, financial literacy, and more Viamo and Jhpiego developed and launched an FP bundle in FY2022 and extending it to FY2023 to allow 24,665 users dialing in and listening to the family planning messages in FY2023 alone. Viamo and Jhpiego are planning to launch three more health bundles in FY2024 under the “Improving client health literacy” sub-objective.

In FY3, the team began developing content on several topics (FP counselling, the benefits of birth spacing, FP methods, misconceptions about DMPA) and sought MoPH approval for the dissemination of this free, automated call line on which people can access pre-recorded health messages in the language they speak and on the mobile phone they own, no matter how basic. UHI will promote existing and future content on 234 using multiple promotion channels, such as below-the-line and above-the-line marking approach. During FY3, 24665 individuals listened to the FP messages developed last year.

● Self-care Infoline: This innovative solution aims to support women who are either pregnant or postpartum to access and engage with content (e.g., interactive voice recordings) that promote self-care behaviors. Women can register for this free service and the platform will automatically call them each week and they can select the content that they are most interested in. At the start of FY3, this was only targeting women in the postnatal period who had given birth at the five large hospitals in Kabul. However, over the course of the year, this infoline was expanded to include the antenatal period and expanded to all 32 UHI-supported HFs in Kabul. By the end of FY3, the self-care infoline has reached 30,521 (15,129 women during pregnancy and 15,392 during the postpartum period).

4.2 INCREASED COMMUNITY ENGAGEMENT AND AWARENESS

● Community mobilization: In FY3, the community mobilizers conducted 2,779 awareness-raising sessions (1,486 with women and 1,293 with men) with a total of 42,082 community members (23,108 female and 18,974 male) in Kabul, Herat, Mazar, and Jalalabad on health topics, including

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acute respiratory infections, FP, immunization, ANC, PNC, delivery, and COVID-19, personal hygiene and HIV, diarrhea, women/child danger signs, and polio.

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SUMMARY OF ACHIEVEMENTS IN YEAR 3, ANNUAL REPORT (OCTOBER 01,

2022–SEPTEMBER 30, 2023)

Table 2: Performance on UHI Annual* Performance Plan and Report Indicators for Y3, Annual Report (October 01, 2022–September 30, 2023)

Indicators Achievements Deviation +/- 10% Explanation

OP 2.2.1: HL.7.1-2 – Percent of USG-assisted service delivery sites providing family planning (FP) counselling and/or services

100% No 10%+-deviation

OP 2.2.2: HL 7.1-1 – Number of couple years protection in USG-supported programs

186,913 Over achieved (Target 155,090)

1. Focus on providing quality FP counselling through bedside coaching, on-the-job training and learning sessions

2. Availability of FP commodities in the targeted HFs and decrease in stockout rate of FP commodities

3. Potentially increased demand. We see substantial increases in all cities; in facilities (150% increase in quarterly average), through community health workers (CHWs) (200% increase in quarterly average), and FHH (just under 200%);

and we see increases in all methods (ranging from a 27% increase in emergency contraception to a 177% increase in condoms)

OP 2.2.11: HL 6.4-62 –

Number of children who received their first dose of MCV1 by 12 months of age in USG-assisted programs

91,290 No 10%+-deviation

OP 2.2.17: HL.2.1-7 –

Childhood TB notifications

2,638 No 10%+-deviation

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Indicators Achievements Deviation +/- 10% Explanation

OP 2.2.20: HL.2.1-9 - Contact investigation coverage rate

44% Over achieved (Target 36%)

1. Strengthening the active contact tracing at HFs by provision of transportation to health care providers

2. Through supportive supervision and mentorship visits the HF staff were encouraged to visit the households of TB index cases

3. Additional staff hired by UHI in the HFs

OP 2.2.18: HL 2.4-1 –

Drug-resistant TB notifications

174 Under Achieved (Target 233)

1. Lengthy international procurement process led to a delay in the supply of 5 new GeneXpert machines in UHI-supported HFs; a delay in the installation of 5 GeneXpert machines was because there was no memorandum of understanding in place with MoPH

2. Shortage of GeneXpert cartridges at national and project level

3. In addition, the small target results in a greater likelihood of a +/-10% difference

OP 2.2.19: Number of TB notifications: HL.2.1-8 – private sector TB notifications

9,656 No 10%+-deviation

OP 2.2.21: HL.2.1-10 – TB

preventive treatment (TPT) enrollment

2,395 Over achieved (Target 1,681)

1. Strengthening the active contact tracing at HFs by provision of transportation to health care providers

2. Through supportive supervision and mentorship visits, the HF staff were encouraged to visit the households of TB index cases

3. Ensure availability of INH (isoniazid) in UHI-supported HFs

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OC 3.1.7: HL.2.5-1 – TB

treatment success rate

91.5% (5,833/6,374)

Over achieved (Target 80%)

1. Regular follow-up of TB registered patients by UHI and HF staff

2. Provide top-up card for regular follow-up of TB patients to receive the treatment regularly

3. Focus on the regularity of TB treatment during TB mentorship learning sessions

OC 3.1.8: HL.2.4-4 –

Drug-resistant TB treatment success rate

66% (176/266) No 10%+-deviation

OP 2.2.23 (NEW): HL 2.9-1

Bacteriological diagnosis coverage rate - pulmonary TB

59.4% No 10%+-deviation

OP 3.2.3: HL 6.2-1 – Number of women giving birth who received uterotonics in the third stage of labor (or immediately after birth) through USG-supported programs

230,168 No 10%+-deviation

OP 3.2.5: HL 6.3-1 – Number of newborns not breathing at birth who were resuscitated in USG-supported programs

12,417 No 10%+-deviation

OP 3.2.6: HL 6.6-1 –

Number of cases of child diarrhea treated in USG-assisted programs

161,972 No 10%+-deviation

OP 3.2.7: HL.6.6-64 –

Number of cases of childhood pneumonia treated in USG-assisted programs

82,409 No 10%+-deviation

OP 2.2.3: HL.7.2-2 - Number of USG-assisted CHWs providing FP information, referrals, and/or services during the year

149 No 10%+-deviation

Average stockout rate of contraceptives at service

3% Over achieved (Target 25%)

1. Close coordination with the RMNCH department to receive

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delivery points by family planning method regular supplies of FP commodities from AFGA

2. Timely supply of FP commodities to the targeted HFs based on request and consumption report from HFs

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INTRODUCTION

The goal of UHI is to improve health outcomes for people living in urban areas in Afghanistan, particularly women, children, and other vulnerable populations. The UHI consortium aims to achieve this goal by improving public and private health service delivery in the five major urban cities (Kabul, Mazar-e-Sharif, Herat, Kandahar, and Jalalabad) through strengthening the health service delivery ecosystem in urban areas to deliver high-quality services to the most vulnerable (Objective 1); improving access for vulnerable populations to critical primary and lifesaving secondary and referral care health services in urban areas through the public and private sectors (Objective 2); improving the quality of public and private critical primary and lifesaving secondary and referral health services in urban areas (Objective 3); and improving awareness, demand, and care-seeking for key services and referral (Objective 4).

WORK ENVIRONMENT IN FY3:

In FY3, UHI faced several issues including a ban on women working with non-governmental organizations (NGOs), short-term suspension of some activities due to lack of a memorandum of understanding (MoU) and limited access of women to UHI offices.

UHI had different strategies to respond to the situation and address the key challenges and mitigate the associated risks, UHI continued its coordination and communication with the respective PPHDs and targeted HFs, developed standard operating procedures (SOPs) for specific scenarios.

The following sections describe the progress in Year 3, Annual Report (October 01, 2022–September 30, 2023)

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ACTIVITY IMPLEMENTATION PROGRESS

OBJECTIVE 1: STRENGTHEN THE HEALTH SERVICE DELIVERY ECOSYSTEM IN URBAN AREAS TO

DELIVER HIGH-QUALITY SERVICES TO THE MOST VULNERABLE

1.1 EFFECTIVE COORDINATION MECHANISM FOR IMPLEMENTATION OF URBAN HEALTH ACTIVITIES

STRENGTHENED

During the reporting period, the UHI project continued coordinating activities with the United Nations (UN) agencies (UNICEF, World Health Organization [WHO], UN Population Fund [UNFPA], UN Office for the Coordination of Humanitarian Affairs [UN-OCHA]). In addition, UHI worked with the professional associations (Afghan Midwives Association [AMA], Afghanistan Society of Obstetricians and Gynecologists), Afghanistan Nurses and Midwives Council, and private sector stakeholders, as well as with the Ministry of Public Health (MoPH) technical units and Provincial Public Health Directorates (PPHDs). UHI also worked with the technical department of MoPH to support them in the development, revision, and updating of guidelines, standard operating procedures (SOPs), and strategies (e.g., preconception care training follow-up tools, self-care monitoring and follow-up after the training checklist, WHO Labor Care Guide, national operational plan for comprehensive newborn care 2023–2027, national reproductive, maternal, newborn, child, and adolescent health [RMNCAH] strategy revision, national immunization strategy revision, adolescent reproductive health package, newborn action plan, maternal, infant and young child nutrition guidelines, and national quality and patient safety guideline and implementation plan).

UHI ensured regular participation in the PPHCC, which is a good platform to collaborate activities with various partners including UN agencies (WHO, UNICEF, UNFPA, and UN Development Programme) to avoid duplication of efforts, complement support, look for local solutions, and coordinate with provincial public health officers. In addition, this platform assisted UHI with provision of support letters to female staff, short-term solutions for the community midwifery program, and better access to target nahias/HFs.

Furthermore, UHI was able to complement the efforts in the areas of TB (drug-resistant TB [DR-TB] cases, sample and patients’ transportation, supporting the lab test for DR-TB patients and food basket), COVID (outreach vaccination including transportation of the teams), family planning (FP) (provision of timely commodities through UNFPA support), nutrition, and child health (growth monitoring, referrals, counselling).

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UHI coordinated with MoPH and other partners supporting the National TB Program and started providing food basket support to patients with DR-TB in four regions (Herat, Kabul, Mazar, and Jalalabad). Patients in Kandahar are receiving this support from Médecins Sans Frontières (MSF). The coordination helped UHI to ensure continued implementation of interventions in all five cities and avoid duplication of efforts. The coordination with MoPH resulted with provision of support letters to process the customs clearance of oxygen plants and other shipments that arrived in the country through the borders and Kabul airport. UHI was the consignee for the mentioned shipments. In addition, PPHDs and national Expanded Program on Immunization (EPI) supported the project to support COVID outreach vaccination with active engagement of female vaccinators in five cities and establishment of mobile health units in Kabul and Jalalabad cities.

Please see Annex 3 for details on UHI consortium partner focus areas.

1.2 URBAN-SPECIFIC APPROACHES RELATED TO ACCESS, QUALITY, AND BEHAVIOR CHANGE ARE DEVELOPED

AND IMPLEMENTED

The activities under sub-objective 1.2 are cross-cutting approaches that are described throughout the report (see for example 2.1 for a description of UHI’s implementation of the urban community health workers [uCHW] and the family health house [FHH] models).

1.3 IMPROVED SUPERVISION AND PERFORMANCE MONITORING OF HEALTH SERVICES IN FIVE TARGET CITIES

UHI central and field teams continued supportive supervision visits to health workers in communities and at health facilities (HFs). The team also supervised and monitored the performance of health services at various levels, identified areas that would benefit from coaching and mentoring, conferred with HF staff, and enabled the HFs to come up with the corrective actions. In FY3, overall, 76 HFs were supervised by UHI team; the main findings include: assessment of HFs for GeneXpert installation, training need assessment and conducting trainings of emergency triage and treatment, rational use of drugs, health care waste management, plus orientation of newly developed Learning Sessions (LSs) (e.g., neonatal hypothermia and hypoglycemia). In addition, issues in TB case findings, use/distribution of new National TB Control Program (NTP) registers, referrals to ensure the referred patients are enrolled for TB treatment at the next facility and avoid initial loss to follow-up, triage system at the HFs, using personal protective equipment, COVID corners, patient screening, disposing health care waste, capacity building and couching of vaccinators on EPI related topics, data discrepancy between/with registers, tally sheets and monthly reports, height/length measurement and reporting of the malnourished children, recording of anthropometric measurements of children under two in growth monitoring and screening registers (double reporting), not considering the decimal points in the measurements in most visited HFs, no medical treatment for worms in outpatient department (OPD) moderate acute malnutrition (MAM), unavailability of charts, no functionality of COVID-19 screening corners in some HFs, no use of

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Maternal and Child Health Handbook, weak sputum transportation, COVID case management, BCS plus cards and medical eligibility criteria (MEC) wheel availability in the postnatal care (PNC) wards, patient overcrowding in OPDs and triage system were found and addressed through provision of direct technical support, discussing/ problems solving/sharing the health providers concerns with the city management for follow-up. They also followed up with the quality improvement (QI) committees and relevant focal persons to ensure the implementation of corrective actions. Moreover, the UHI team conducted joint supportive supervision visits with the partners (CARE, Terre des Hommes, and AMA) to ensure quality of community and midwifery services.

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OBJECTIVE 2: TO IMPROVE ACCESS FOR VULNERABLE POPULATIONS TO CRITICAL PRIMARY AND

LIFESAVING SECONDARY AND REFERRAL CARE HEALTH SERVICES IN URBAN AREAS THROUGH THE

PUBLIC AND PRIVATE SECTORS

2.1 IMPROVE ACCESS TO BASIC PUBLIC AND PRIVATE HEALTH CARE SERVICES FOR VULNERABLE POPULATIONS

IN FIVE CITIES

UHI is working across different service levels to rapidly strengthen the delivery of integrated services in the areas of RMNCAH, FP, nutrition, EPI, COVID-19, and TB. Despite severe disruptions to the health sector and the challenges in FY3, UHI was able to ensure continuity of services.

Strengthen existing public and private HFs and improve integrated service delivery

Based on the HF mapping conducted of new HFs in early FY3, UHI provided the following support:

● Technical and financial support for transportation of samples from patients with signs and symptoms for TB to the diagnostic centers and from diagnostic centers to GeneXpert sites to find out their drug resistance status. During FY3, the UHI project supported public and private HFs in five targeted cities to strengthen the referral mechanism between 75 diagnostic facilities and GeneXpert sites via the sample transportation mechanism. In FY3, 5,428 samples were collected from public and private HFs and transported in a cool box to diagnostic and GeneXpert sites.

● Technical support for referral to programmatic management of drug-resistant TB (PMDT) sites and follow-up of patients identified as being drug resistant was provided in FY3 of the project. A total of 211 health care providers received training in SOPs and 65 lab technicians received sputum smear microscopy training.

● Food basket for DR-TB patients. During FY3, 4,007 DR-TB patients received local transportation costs, 3,951 received food baskets, and 325 were referred for initial lab examinations in four PMDT sites in Kabul, Herat, Mazar, and Jalalabad cities.

● COVID-19 services including some consumables/supplies and establishment of COVID corners.

COVID consumable supply were provided to the targeted HFs. And 18 new COVID corners were established in FY3.

Mentorship support continued in FY3 in all 76 UHI-supported HFs, project mentors/clinical specialists and clinical coordinators (i.e., senior staff) at the HFs conducted 4,770 onsite learning sessions for 2,334 service providers (participation of 14,200 service providers); 882 mentees were assessed as competent in at least one topic (4,422 assessment resulted in a competent outcome in different topics). UHI has been using structured follow-up of the mentee by the mentors and supportive supervision by the technical advisors.

● Minor renovations were carried out based on the need’s assessment and essential needs in terms of critical supplies provided to the targeted HFs during FY3 of the project. During the reporting period (Y3), minor repair was done in a total of 23 targeted HFs in five cities.

● The referral system at community and HFs was maintained and continued in FY3. (Please refer to Figure 5 and Table 11 for more details).

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UHI continued the support to adolescent health care and implemented the following initiatives in FY3:

o Developed mentorship learning sessions based on the WHO adolescent health package and Learning sessions for healthcare providers.

o Conducted orientation session on adolescent, sexual and reproductive health to all UHI clinical specialists, o Meetings were held with UNFPA and the MOPH adolescent health unit to coordinate adolescent health programs.

o Service delivery data was collected with age-segregation in UHI targeted sites (FHH, Community midwives, and MLMCC) to track and analyze adolescent clients who received care.

o Case presentation on adolescent responsive care in child health ECHO session to all sites o Take part in the review of RMNCAH national strategy and provided feedback / comments on the adolescent health component.

Expansion of services: In FY3, one more site (Aria Apollo private hospital) began offering antenatal care (ANC), PNC, child health, and immunization services. This site was added to replace Hakim Farabi private hospital in Q3.

Infrastructure: UHI continued with provision of support for minor renovation and critical needs of targeted HFs during the quarter.

Referrals: During FY3, UHI continued with the support to the referral systems.

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Early diagnosis and treatment of TB

UHI supported the implementation of TB activities in targeted HFs. In total, 70,311 presumptive TB patients were identified and 9,656 (14%) of them were diagnosed as TB cases (Table 3). Over the year, 104% of the annual target of 9,312 TB notifications was achieved. Of the cases identified, 2,638 were in children under 15 years of age, 97% of the annual target.

Table 3: TB Performance Indicators, UHI Target…