The Maternal and Child Health Integrated Project (M-CHIP) is a global program whose vision is to accelerate the reduction of maternal, newborn, and child mortality in 20 priority countries by increasing the use of a focused set of high impact maternal, newborn and child health (MNCH) interventions that address the major causes of death among mothers, newborns and children under five. Delivery strategies will address barriers to access and use of these interventions along a MNCH continuum of care that links households, communities, first-level facilities, and hospitals. One of the overarching goals of the MCHIP Program is to contribute to the reduction of both the under 5 mortality rate and maternal mortality ratio (MMR) by 25 percent in the 20 high mortality-burden countries.

In Malawi, MCHIP is implementing a household to hospital continuum of care model in maternal and newborn health in four focus districts: Rumphi, Nkhotakota, Machinga and Phalombe. The HHCC comprises of a set of proven, evidence-based interventions focused on facility and community activities and include improving providers' skills to deliver Basic Emergency Obstetric and Newborn Care (BEmONC), improving the quality of care in facilities, and establishing Kangaroo Mother-Care (KMC), community maternal and newborn health (CMNH) and community mobilization (CM). Nationally, MCHIP is scaling up the quality improvement initiative in reproductive health to cover all district and central hospitals.

Traditionally, in Malawi PMTCT has been implemented using a vertical approach to current reproductive health (RH) initiatives resulting in a missed opportunity to strengthen the continuum of care for women and children. Being one of the main RH partners in Malawi, and through PEPFAR support, MCHIP's goal will be to strengthen and improve the quality of PMTCT integration into reproductive health (RH) and family planning with a key focus on improving HIV care and treatment, and mother-infant pair follow-up. M-CHIP will focus on the 8 interrelated activities which are described in more detail under the PMTCT budget code narrative below.

• Supportive mentorship in the Central East Zone and selected districts • Introduce the Standards Based Management and Recognition approach for performance and quality improvement (PQI) throughout the PMTCT continuum of care. • Results-based financing for PMTCT and maternal and neonatal health • Training of HSAs in Central East and Northern Zones in PMTCT-follow-up • Strengthen integration of PMTCT and Family Planning • Procurement of the Hygiene Package for HIV+ pregnant and lactating women • Conduct retrospective analysis of maternal deaths linked to HIV. • Capacity building of the central eastern zonal health office and select district health offices to improve data utilization and reporting for PMTCT.

PMTCT Budget 1,710,087.00) Activity 1: Supportive mentorship in the Central East Zone and selected districts

MCHIP mentorship activities will focus on supporting the Central East Zonal Health Office. M-CHIP will mentor and support ZHOs and DHOs to build their capacity to supervise, plan, and to help PMTCT sites develop and implement systems for better managing patient care and data flow. Sites will be supported to provide a comprehensive package of PMTCT services for mothers and children, including strengthening linkages and referrals between HIV care and treatment services and PMTCT. These efforts are part of a broader zonal quality improvement initiative, in which, under MOH leadership, M-CHIP will collaborate with 4 other USG partners who are supporting the other 4 zones and share best practices to improve the quality of PMTCT services with one another. MCHIP will also provide more intensive support to specific districts of Nkhota-Khota and Rumphi where MCHIP is already working on reproductive health and child survival activities, as well as to two new districts, Ntchisi and Likoma Island, which currently lack partner support for PMTCT.

Activity 2: Introduce the Standards Based Management and Recognition approach for performance and quality improvement (PQI) throughout the PMTCT continuum of care.

MCHIP will build on existing MoH-adopted standards on RH that include areas of PMTCT to support the MoH to develop specific PMTCT standards covering the continuum of care from antenatal, delivery and through to the postpartum period. The SBM-R methodology utilizes operational, observable performance standards that are linked to a scoring system which will enable partners and the Ministry of Health to numerically measure quality of care at every PMTCT site. At Nkhotakota and Rumphi where the program is already working, MCHIP will introduce and refine SBM-R through on-site training and coaching of the PMTCT providers in the spring of FY10. M-CHIP will then share the refined SBM-R approach for PMTCT with the other zonal mentoring partners and provide them with TA so that they can support the MOH to implement a standardized PQI process nationally.

Activity 3: Results-based financing for PMTCT and maternal and neonatal health

MCHIP will work closely with the MoH and German and Norwegian government currently developing a holistic system for implementing results based financing (RBF) in the health sector of Malawi. RBF consultants recently identified the PQI interventions used by Jhpiego/MCHIP as a platform for introducing RBF at the facility level. With PEPFAR funding, MCHIP will leverage this new partnership to also develop a system for recognizing and awarding PMTCT sites that reach accreditation and meet pre- determined targets for increasing the number of eligible pregnant women initiated on ART and the

number of skilled birth attended deliveries. Support may also be provided to incentivize staff such as nurses who work on weekends to initiate more pregnant and lactating women on ART. This support complements other USG MCH funding being provided to MCHIP for RBF. M-CHIP's subpartner Broad Branch with expertise in RBF will be engaged in this activity. Specific approaches will be worked out in the spring of 2010 in consultation with the MOH and other donors.

Activity 4: Training of HSAs in Central East and Northern Zones in PMTCT-follow-up

USG partners have worked with the MOH to develop a model for the implementation of MIP follow up at three sites in Phalombe District. This model, which had its origin through the PEPFAR HQ PMTCT/peds TWG initiated integration program, is based on the identification of a PMTCT coordinator at facility level, typically a Health Surveillance Assistant (HSA), who is responsible for tracking mother-infant pairs over time, the use of a register which facilitates tracking of MIP's, the implementation of a screening process to ensure that MIP's are assessed clinically during each visit, and the implementation of IYCF counseling every time a MIP visits the facility. M-CHIP will provide training and the in-service orientation of HSAs and other staff to this model at PMTCT sites in Rumphi, Nkhotakota, Ntchisi and Likoma Island. The emphasis will be on on-site training to reduce costs.

Activity 5: Strengthen integration of PMTCT and Family Planning

In order to build on the theme of increasing capacity for quality PMTCT services in reproductive health, MCHIP proposes to strengthen the family planning (FP) component of all PMTCT and HIV Testing and Counselling (HTC) service delivery points. As per Activity 1, FP will be a strong component of the PMTCT standards that will be developed and therefore FP will need to be well integrated into PMTCT clinical practice in order for a site to receive PMTCT accreditation. As part of the Malawi integration strategy, MCHIP will review and update the STI and Cervical Cancer Prevention (CECAP) components of the current Reproductive Health Standards to integrate HTC and FP into STI and CECAP service provision. Inclusive in the trainings will be an emphasis on HTC for couples and FP counselling which will provide increased prevention benefit for the couple rather than just the individual client. MCHIP will provide follow-up support in the form of supervision and quality assurance assessments using the integrated reproductive health standards assessment tool. MCHIP will share these tools and best practices with the other 4 zonal mentoring partners, and provide technical assistance to help them support their respective ZHOs and DHOs to include family planning integration as part of the PMTCT PQI process. M-CHIP will also collaborate with the Safeguard the Household in these efforts, the other USG-funded partner with strong expertise in family planning and HIV integration.

Activity 6: Procurement of the Hygiene Package for HIV+ pregnant and lactating women USG-supported program evaluation in Malawi has shown that the free provision of water purification materials (PuR) and a bucket, along with IEC materials, significantly increases health service utilization by women attending maternal health clinics, and also decreases incidence of diarrheal disease. M- CHIP's partner PSI will procure the hygiene package and work with the USG partners in each district and zone to ensure that it is provided to sites and utilized correctly. The intent is to scale up this hygiene package nationally serving all HIV+ women identified in ANC settings. At a cost of ~$5 per household, M-CHIP will procure adequate supplies for one year for the households of all HIV+ women identified in PMTCT settings in Malawi outside of the Central West Zone. (Note that because Proctor and Gamble is donating these packages for the Central West Zone as part of the Safeguard the Household Project, M- CHIP will only provide these hygiene packages for sites in the other four zones.) This will also promote male involvement, increase antenatal attendance beyond the first visit and promote couple counseling and testing. Refills of soap, ORS and Zinc will be given to the couple for every subsequent ANC visit, delivery at the health facility, and postnatal visit.

Activity 7: Conduct retrospective analysis of maternal deaths linked to HIV.

Although maternal death audits are supposed to occur at the community level as well as the facility level, no standardized community-based maternal death audit form exists. MCHIP will lead in the development of a community maternal death audit form and orient HSAs to conduct the death audits using the developed tool. MCHIP, in cooperation with other partners, will then conduct a retrospective review of all maternal deaths in at least 3 districts from 2010-2011 at both the facility and community levels highlighting the proportion of maternal deaths occurring for HIV-positive women and HIV-negative women, and the causes of maternal death in each subgroup. These finding will be utilized to better inform programming aimed at reducing maternal mortality in Malawi.

ACTIVITY 8: CAPACITY BUILDING TO IMPROVE DATA UTILIZATION AND REPORTING M-CHIP staff will work side by side with central east zonal staff and district health staff to build their capacity to interpret and use data to improve programs and enable them to be able to better report to the MOH on the national level what they have accomplished. M-CHIP will then report to PEPFAR how its efforts have helped the CE zone and the districts of Rumphi, Nkhota-Khota, Ntchisi, and Likoma Island to contribute to national PMTCT targets. A select number of high volume sites in these districts will receive intensive support from M-CHIP and in these cases their targets will be categorized as directly supported by PEPFAR.