The Clean Clinic Approach: All Guatemalan Health Facilities In Project Achieve ‘Clean Clinic’ Status Within One Year

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by Dr. Sergio Tumax Sierra, Water, Sanitation and Hygiene Manager, Guatemala

As the water, sanitation and hygiene (WASH) manager for Save the Children’s Clean Clinic program in Guatemala, I saw firsthand how this novel, low-cost strategy delivered very encouraging results over a short period of time in 2018-19.

Clean Clinic – one of the three pillars of the BASICS initiative – is our proven process that empowers healthcare staff to make infection prevention improvements through easy-to-use monitoring, accountability and rewards systems.

In Guatemala, we implemented Clean Clinic at 11 Ministry of Public Health and Social Assistance health facilities, including district and department hospitals. It enabled and motivated the facilities to set WASH goals and make incremental improvements towards the ultimate goal of obtaining “Clean Clinic” status.

Within the year, after our close work with the Ministry to develop a weighted evaluation for conducting standardized ward evaluations in each health facility, all 11 had achieved one of three “Clean Clinic” certification levels. Facility staff, from cleaners and nurses to doctors and management personnel, were motivated to make actions sustainable.

We found that even small improvements made a difference in providing patients with better quality services. For example, facilities enrolled in Clean Clinic:

  • Improved the management of water quality for consumption
  • Improved solid and liquid waste management processes
  • Ensured that hand-washing stations were identified and functional and had the necessary supplies
  • Assigned operation and maintenance roles and responsibilities

Clean Clinic’s 10-step improvement process and monthly action plans made it easier for facilities to make WASH improvements despite limited external financing. These activities contributed to quality of care improvements and very likely the reduction of puerperal and neonatal sepsis infections.

The innovativeness of the strategy was also seen in the establishment or revitalizing of infection prevention and control committees at each facility. They monitored bi-monthly evaluations and made plans for timely improvements to achieve Clean Clinic standards in the least time possible.

Evaluations were conducted by personnel outside the healthcare facility, including regional Ministry of Health staff, after which committees made their improvement plans and assigned responsibilities for their management and monitoring. Likewise, a monitoring team was established at the Ministry’s head office to help manage resources and for sensitizing staff on the topic of infection prevention.

 

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.

 

 

 

 

 

 

BASICS: Helping the Fight Against Antimicrobial Resistance

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

 

Written by the BASICS Team

Every use of an antibiotic, whether appropriate or inappropriate, gives resistant bacteria an advantage and accelerates the development of resistance. Drug-resistant infections are associated with higher morbidity, mortality and health expenditures, and resistant infections are becoming a significant cause of death, particularly for children.

An estimated 700,000 lives are lost to these antimicrobial resistant (AMR) infections every year. Around 200,000 newborns die annually because they catch infections that simply do not respond to drugs. According to the World Health Organization, around 40% of infections contracted by newborn babies resist available treatments[1]

The burden of resistance falls heavily on low- and middle-income countries (LMICs). Here, some population groups suffer from frequent and rapid spread of infectious disease and poor nutrition. Healthcare systems in these countries are often less able to manage this burden, and the situation is exacerbated by increasing rates of antibiotic consumption in humans and animals and by limited standards and regulations that govern access, use and quality of antibiotics[2].

Many infections, both drug-resistant and drug-susceptible, are acquired in hospitals. Healthcare-acquired infections (HAIs), particularly sepsis, are a danger for both neonates and their mothers, who are increasingly being encouraged to seek birth and delivery care at hospitals. Increasing rates of drug resistance render many such infections untreatable.

Professor Clare Chandler, Co-Director of the London School of Hygiene and Tropical Medicine’s Antimicrobial Resistance Centre, and Dr. Laurie Denyer Willis, Assistant Professor at the School, have conducted extensive research in East Africa on the roles that antibiotics play in LMICs beyond their immediate curative effects. Their findings suggest that antibiotics have become a “quick fix” for care available through fractured health systems and, among others, for the lack of hygiene in settings of limited resources.

Although there is no single silver bullet, the most obvious solutions – improved infection prevention and control practices – remain among the most effective interventions[3]. All health care facilities, at a minimum, must have clean running water and sanitation services, and healthcare professionals must follow good hygienic practices such as handwashing[4].  Many LMICs face significant challenges in setting up effective systems that can achieve these basic objectives.

This is the core of what BASICS aims to achieve: supporting the institutionalization of simple, inexpensive hygiene measures in healthcare facilities through effective training platforms, monitoring and accountability systems, reliable supply chains and upgraded water, sanitation and hygiene infrastructure. This will create a clear roadmap for national healthcare systems to take comprehensive action to improve infection prevention and control and dramatically lessen the burdens that HAIs place on under-resourced systems and impoverished families.

BASICS projects a 50% reduction in HAIs in participating facilities based on robust evidence linking improvements in hygiene and cleanliness in healthcare facilities with improved patient outcomes.[1-4] These improvements will significantly reduce the usage of antibiotics – and, in turn, dramatically curb the development of new AMR pathogens.

BASICS is where it can start and it should start now.

To learn more about AMR and how to fight back, watch this roundtable discussion with Professor Chandler – one of our BASICS team members at the London School of Health and Tropical Medicine.

 

Acknowledgements: Professor Wendy Graham and Professor Clare Chandler from LSHTM – a BASICS partner – provided comments and review.

 To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.

 

References:

[1]        P.C. Carling et al., “Improving environmental hygiene in 27…,” Crit. Care Med., vol. 38, no. 4, Apr. 2010. https://www.ncbi.nlm.nih.gov/pubmed/20081531

[2]        R. Orenstein et al, “A targeted strategy to wipe out Clostridium…,” Infect. Control Hosp. Epidemiol., vol. 32, no. 11, Nov. 2011. https://www.ncbi.nlm.nih.gov/pubmed/22011546

[3]        S. J. Dancer et al., “Measuring the effect of enhanced cleaning…” BMC Med., vol. 7, p. 28, Jun. 2009. https://www.ncbi.nlm.nih.gov/pubmed/19505316

[4]        B. Allegranzi et al., “A multimodal infection control and patient safety…,” Lancet Infect. Dis., vol. 18, no. 5, May 2018. https://www.ncbi.nlm.nih.gov/pubmed/29519766

 

[1] https://www.who.int/mediacentre/commentaries/antibiotic-resistant-bacteria/en/

[2] https://www.ncbi.nlm.nih.gov/books/NBK525181/

[3] https://www.infectioncontroltoday.com/antibiotics-antimicrobials/antimicrobial-resistance-stewardship-and-strategies-conquering-global

[4] https://www.who.int/mediacentre/commentaries/antibiotic-resistant-bacteria/en/

Morsal’s Bright Future

By:  Farida Holkar, Sponsorship MEAL Officer

Morsal is a five-year-old resident of Shahchinar village in Sar-i-pul province, Afghanistan, where she lives in a small house made of mud with her mother and siblings.  Since the death of her father due to cancer, Morsal’s family relies solely on her mother Khalida’s monthly teacher salary of $95, leaving little extra money to spend on toys to play with or access to educational materials at home. “My daughter was not smiling much and not interacting with others,” explains Khalida.  “I was busy working and doing home chores, and I knew I was not spending enough time with Morsal and that she wasn’t learning like she should be.”

Fortunately, in 2017, Save the Children established a sponsorship-funded school-based Early Learners program in the village to serve marginalized groups of children between the ages of three and six.  A one-room building, including wash facilities, was constructed and two teachers were hired and trained to provide early education in such areas as language and communication and knowledge with letters and numbers.  So far, this program has served almost 6,694 pre-school age children and 6,286 adults in home-based Early Learning groups, school-based centers and various parent groups within the community.

Morsal (far right) playing and having fun at her school

The positive impact sponsorship made on the village’s youngest residents was felt right away.  “One prominent change is that our community children like Morsal became more and more courageous in speaking,” explained classroom teacher Zahra.  “Before, the children in this age group just walked around the village, and did not do much when their parents were busy with work.”

For Morsal and other children like her, the program opened up a whole new world – a safe space to learn as well as take part in interesting activities, including storytelling, games, singing, dancing, drawing and sport. Morsal now joyfully takes the lead on games and activities and she is not shy to be the first to answer any question asked by her teacher and classmates. “I feel excited to go to ECCD center because there are so many toys, good friends and games. Now I can read and write my name.”

Morsal (center) playing dolls with her friends at the center

With tears welling up in her eyes, an appreciative Khalida explains just how impactful Save the Children’s Sponsorship has been to her family, “We had never heard and seen this kind of early childhood care and development program in our village. Now every morning Morsal always asks me to take her to the center because she wants to learn more and play with her friends.  We see a positive difference.”

Save the Children Bangladesh

Dreaming to be a Teacher

By: Md. Hasan Iqbal, Deputy Manager–Sponsorship Communications and Data Quality

Delwar dreams of becoming a teacher one day in his village in the Meherpur district, Bangladesh. The 14-year-old ninth grader loves reading books and spending time with friends, his two brothers and his mother, Momotaz, who takes care of the family. Up until just a few short years ago, Delwar’s dream would be considered far-fetched at best.  His early years were full of hardship. His father worked very hard in the village selling kitchen utensils, but as the only earning member of the family, that was not enough to meet basic needs. So he moved abroad to work as a construction worker where he could earn more. 

“I have passed my childhood with misery.  I did not have a joyful time when I was small,” recalls Delwar.  Due to malnutrition, he could not walk or talk properly. The family found it difficult to eat well three times daily, could not find adequate medical care and his physical growth was slow. His future looked very bleak.

However, thanks to sponsorship, in 2013 Delwar was able to enroll in school through the early learners program, which played a vital role in improving his circumstances.  It was through this program that he learned many crucial skills, including proper hygiene like hand washing before and after meals, and visits to the lavatory. He learned reading, counting and writing through sponsorship, and his speech improved where he could talk easily to his friends, family members, teachers and neighbors.

Delwar with his pet goat

Delwar soon moved up to primary school and was selected as a Sponsorship Child Leader to a group of schoolchildren from his neighborhood. He received training to help Save the Children’s Field Workers learn more about other families in the community, sharing important updates regarding sicknesses and accidents with Save the Children staff who could provide necessary assistance. Nominated as a “Little Doctor,” Delwar learned how to use first aid kits — knowledge that he shared with his classmates, increasing awareness of correct health and hygiene habits.

In addition, he plays another important role in his community – regularly making home visits to students who irregularly attend school and encouraging their families to send them. “It has become a regular task or habit of mine to take the irregular students with me to school,” he proudly boasts.

Delwar discussing schoolwork with his classmates

Delwar is now on track to become the teacher he dreamed about and now that Save the Children’s work in Meherpur is winding down, he’s grateful for all sponsorship has done for him.  “Although Save the Children will leave us, our learnings, good practices, manners, awareness on education, health and hygiene will remain with us for long time. Many thanks to my friend Kim Moonjeong for her support for many children in our community.”

#GenerationEquality Starts in Childhood!

Photo credit: Save the Children

The year 2020 is a crucial opportunity to look back at international commitments to achieve girls’ rights, assess our progress and take concrete, forward-looking action. For girls, this has never been so urgent.

All over the world, too many girls remain in danger of being left behind on global progress, risking their futures, as well as the prospects of sustainable development, global peace and the achievement of girls’ universal human rights. However, today, girls risk falling through the gaps of a new global process intended to accelerate progress for gender equality over the critical next five years.

With this letter – 37 leading child rights and women’s rights organizations, including Save the Children, call for the Generation Equality Leads to ensure that girls’ rights are addressed through the Beijing +25 process with a standalone action coalition.

#GenerationEquality starts in childhood!

Integrating Water, Sanitation and Hygiene (WASH) and Health for Improved Universal Health Outcomes: What Governments Must Do to Deliver Quality Care

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

Written by Blessing Sani, WaterAid Communications Officer, Nigeria

 

As the world accelerates progress toward quality healthcare, governments must prioritize increased access to inclusive and sustainable water, sanitation and hygiene (WASH) services in healthcare facilities.

Clean water, decent toilets and good hygiene help to control and prevent diseases and their spread. They protect health workers and patients and allow the delivery of quality health care services. Sadly, these normal things are the forgotten foundations for good health. The impact on women and children is alarming – estimates are that one in five births globally takes place in least-developed countries and, each year, 17 million women in these countries give birth in health centers with inadequate water, sanitation and hygiene.1

In Nigeria – one of the four countries that BASICS initially targets – half of healthcare facilities lack clean water, 88% are without basic sanitation and 57% lack handwashing facilities with soap. In a corroborative assessment by WaterAid in 2016 in six Nigerian states (Bauchi, Benue, Ekiti, Enugu, Plateau and Jigawa), primary healthcare centers assessed in urban, semi-urban and rural areas generally had low access to piped water within the facility; more than 20% lacked toilets. In addition, our assessment found there were no structured systems for the operation and maintenance of water and sanitation facilities.

For health workers like Gloria Samuel, the lack of water makes it difficult for her to carry out her duties as a cleaner at the Bwari Town Clinic in Abuja.

“We don’t have water so we buy it from the vendor or practice rain harvesting during the rainy season,” Gloria says. “The rain-harvested water is used to clean the toilets and water bought is used for cleaning more sensitive instruments and for patients who need clean water to wash up, but we still do not know how clean the water is.

“With the water situation, I only wash the toilets once a day and that is not good enough, but if we have constant water flow, we will be happy. When we work without water, it is difficult because this is a hospital. A hospital can’t stay without water because the work will not move forward.”

Globally, an estimated 896 million people use healthcare facilities with no water service, and one in five facilities has no sanitation service, impacting 1.5 billion people.2  Diseases like Ebola, Lassa Fever and cholera spread fastest when these services are lacking. This cycle ensures improvements in health are not sustainable. Often times, the dire consequences are manifested in ill health, deaths, economic losses and a lifetime legacy of disease and poverty.

When clean water, decent toilets and good hygiene services are available, the ripple effect is transforming. Risks of infection for patients and their families, staff and surrounding communities are greatly reduced; people are kept safe from deadly diarrhoeal diseases and are better able to break free from poverty.

 

Accelerating Quality Healthcare
In 2017, Nigeria launched a scheme to revitalize 10,000 primary healthcare centers across the country to make quality and affordable healthcare accessible to the poor and vulnerable. This commitment presented a window to integrate inclusive and sustainable WASH services into the program plans and design. However, despite this and other efforts around improving maternal and child health and nutrition, achieving the goal of Universal Health Coverage requires increased political commitment, practical policies, strong coordination and partnerships, financing and preventive interventions.

There’s need for better coordination, collaboration and integration between WASH and health actors based on the recognition that WASH underpins quality health outcomes. Furthermore, improving healthcare requires a multi-sector approach that incorporates investments in WASH alongside other sub-sectors like nutrition, maternal and child health, menstrual hygiene management and gender. WASH is an essential building block for patient safety, quality of care, for tackling undernutrition and threats like antimicrobial resistant infections, and for realising Sustainable Development Goal 3 – ensuring healthy lives and promoting well-being for all.

United Nations Secretary-General António Guterres says “Water, sanitation and hygiene services in health facilities are the most basic requirements of infection prevention and control, and of quality care. They are fundamental to respecting the dignity and human rights of every person who seeks health care and of health workers themselves.”

We couldn’t agree more! Only by making clean water, decent toilets and good hygiene available for everyone, everywhere, can we prevent diseases from spreading, transform lives and livelihoods and deliver quality health services that keep people well and unlock their potential.

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.

 

1,2. World Health Organization and the United Nations Children’s Fund, WASH in health care facilities: Global Baseline Report 2019

Year-long Hospital Pilot Documents Highlight®’s Role in Reducing Failure Rate of Cleaning Sampling to Zero

This post is part of a series authored by the BASICS (Bold Action to Stop Infections in Clinical Settings) team. BASICS is a new initiative that will transform healthcare and reduce healthcare-associated infections (HAIs) by at least 50%.

 

Written by Jason Kang, Co-founder and CEO, Kinnos

 

The World Health Organization estimates that 10 out of every 100 hospitalized patients in developing countries will acquire at least one healthcare-associated infection (HAI). Studies have shown that less than 50% of surfaces in healthcare settings are effectively cleaned, but that better cleaning technique could prevent 40-80% of HAIs.

Highlight® addresses this gap in cleaning by providing real-time visual feedback to empower health workers to disinfect surfaces correctly every single time they use a disinfectant. It does this by colorizing existing disinfectants so that workers can easily see exactly what has and has not been covered, so no spots are ever missed. The color then fades after several minutes to provide an approximation of when disinfection is complete.

In 2018, Highlight® was piloted in a 500-bed academic hospital based in Boston, Massachusetts, in 11 medical and ICU inpatient wards.[1] In the U.S., a common method of determining cleaning efficacy is ATP bioluminescence. After a surface has been cleaned, a sample of the surface is taken using a swab, which is then placed in a device that generates a number in relative light units (RLUs). The higher the number, the “dirtier” the surface. The sample is recorded as a pass or a fail depending on a certain RLU threshold.

Across a period of 55 weeks at the hospital, ATP bioluminescence was used to quantify thoroughness of cleaning on over 1,000 high-touch surfaces, such as bedside tables and door knobs, comparing disinfectant alone vs. disinfectant with Highlight®. The study found that introducing Highlight® completely eliminated the failure rate – from 5.7% to 0%.

The breakthrough that Highlight® represents – the ability to overcome training and language barriers to empower health workers and those who clean facilities with a feeling of confidence through disinfection they can see – can have a profound impact in reducing HAIs globally as part of the BASICS solution.

 

To learn more about BASICS (Bold Action to Stop Infections in Clinical Settings), visit savethechildren.org.

[1] Tyan et al. Infect Control Hosp Epidemiol. 2019;40(2):256-258.

The International Community Must Ensure That No Girl Is Left Behind

Written by Carolyn Miles, Advisor, Gender Equality and Girls’ Empowerment at Save the Children

The world’s girls deserve an action coalition that is focused holistically on their lives and includes their participation. #GenerationEquality starts in childhood. Let’s work together with girls to ensure that no girl is left behind!

The year 2020 is a crucial opportunity to look back at international commitments to achieve girls’ rights, assess our progress and take concrete, forward-looking action. For girls, this has never been so urgent. All over the world, too many girls remain in danger of being left behind on global progress, risking their futures, as well as the prospects of sustainable development, global peace and the achievement of girls’ universal human rights. However, today, girls risk falling through the gaps of a new global process intended to accelerate progress for gender equality over the critical next five years.

Today, UN Women released its plans to rally the international community to accelerate progress for gender equality over the next five years by creating a set of “action coalitions” to drive concrete progress on gender equality.

Despite the fact that a 16-year-old girl was named Time magazine’s person of the year, the world’s girls continue to face rights violations. An estimated 12 million girls continue to be married each year,[ii] contributing to the leading cause of death for adolescent girls between the ages of 15 and 19: pregnancy and childbirth-related complications. The second most common cause is suicide.[iii] In countries where female genital mutilation is most concentrated, the majority of girls are cut by the time they are 14.[iv] If there was a time to bring about a step change in girls’ rights, then 2020 is the year. 

Twenty-five years ago, the international community came together and adopted what is considered to be the most progressive blueprint written on women’s and girls’ rights. The Beijing Declaration and Platform for Action, adopted in 1995 at the Fourth World Conference for Women, was endorsed by 189 countries and later adopted unanimously by the United Nations General Assembly.

Crucially, the Beijing Declaration and Platform for Action was the first global document that recognized girls as a distinct group, facing specific rights violations and needs due to the intersection of age and gender. It dedicated a standalone section to addressing the specific rights violations that girls experience – affirming their rights not only to health and education, but also to have a voice in shaping the decisions that impact their lives.

Yet despite comprehensive commitments to girls, 25 years later, girls continue to fall through programmatic and policy gap, and girls’ voices – their hopes and dreams for the futures – too often go unheard.

A failure to systematically and consistently include girls’ voices and perspectives in policy making and accountability processes compounds the issue. As governments, UN agencies, civil society and other actors come together on the 25th anniversary of the Beijing Declaration and Platform for Action, we must seize this opportunity. This is a watershed moment for girls, and the international community must not fail them.

I recently met a girl named Khadra while visiting a Somali refugee camp. After her husband, to whom she was married at age 13, left her behind to marry another girl in the village, Khadra was struggling to support her two small children on her own. Though Khadra told me she had done well in her studies and was ready to go on to secondary school, the decision to get married at age 13 and to stop her education was not her own.

Tackling issues such as child marriage are complex. They often reflect compounding forms of discrimination and require holistic investment – in education, health care as well as in voice and agency. At the national level, many countries are developing integrated costed national action plans to accelerate progress for girls; a global system that mirrors and supports that ambition is critical.

Photo credit: Save the Children
Anxhela, Cecelia and Keren hold signs supporting girls’ rights during Save the Children’s Bridge the Gap for Girls event in Brooklyn, New York on International Day of the Girl. “That day, I felt more energetic, optimistic and motivated to continue my fight for girls’ rights, said 16-year old Anxhela, “and empowerment that can lead them to a better life and future.”Photo credit: Save the Children, 2019.

All over the world, when given the slightest opportunity or encouragement, we see girls demanding their own seat at the table. Just this past October, three girls, Anxhela from North-East Albania, Cecelia from Malawi and Keren from Peru, joined me in leading Save the Children’s Bridge the Gap for Girls walk across the Brooklyn Bridge. They also participated in a panel discussion at the U.S. Senate, where they spoke about the importance of girls’ voices and the meaningful participation of girls in policy spaces. Anxhela, Cecelia and Keren, along with so many other girl champions, are making their voices heard and their communities stronger and healthier, taking on some of the toughest challenges of their societies.

As the international community, we must stand with girls like these across the globe and ensure that they have a strong platform to use to shape their future – and that we are accountable to them. The best opportunity for this to happen is for there to be an action coalition focused on adolescent girls that looks holistically at their lives and that includes their participation throughout the process.

We know from experience that girls face distinct rights violations, and they need a concrete action plan tailored to address their specific gender- and age-driven needs.

#GenerationEquality starts in childhood. Let’s work together with girls to ensure that they are not left behind!

 

[i] UNESCO UNESCO; UNICEF, Save the Children, Many Faces of Exclusion

[ii] Girls Not Brides

[iii] WHO

[iv] UNICEF

 

 

 

 

Photo credit: CJ Clarke / Save the Children, 2015

Scaling-up first-time and young parent access to postpartum family planning: Could small shifts change the game?

In many contexts, the youngest mothers (ages 15-24) are less likely than older mothers to use health services, including postpartum family planning (PPFP), for themselves and their children, increasing their vulnerability to rapid repeat pregnancy and poor health outcomes. At this life stage, a period of rapid change and vulnerability, it is vital young mothers get the support they need, and it is increasingly seen as a window of opportunity to shape life-long practices. A growing body of program experiences have shed light on first-time parents’ (FTPs) needs and related programming considerations. Evidence shows that comprehensive approaches addressing individual, family, community, and health system factors can increase FTPs’ use of PPFP and other essential health services. While showing promising impact, these comprehensive approaches have proven challenging to scale.

In Save the Children’s large-scale projects, we have long seen that the mothers bringing young children to immunization services, participating in community nutrition groups, or receiving household visits from community health workers are often young themselves. FTPs are often being reached, but not necessarily targeted with interventions addressing their family planning needs—despite evidence that improving birth spacing through PPFP contributes to diverse project goals.

This gives rise to two sets of sticky questions:

  1. Could a large-scale project be enhanced to leverage its reach and connect FTPs to PPFP?

Could we add an activity, or rework an existing activity, to take advantage of a large-scale initiative’s reach of FTPs? For example, a community group for pregnant women or mothers could strengthen referral systems to connect the youngest members to health facilities. Alternatively, for FTPs delivering in facilities, we might augment counseling to address their unique needs, facilitating PPFP uptake before discharge. Such a “program enhancement” could maximize impact with limited resources, reducing missed opportunities to target a vulnerable population.

We need to understand whether such an enhancement could be effective in increasing PPFP use. But to be truly instructive, we also need to understand how the enhancement interacts with and is shaped by the “host project” and the broader health system—and how it can be sustained through existing platforms at scale.

Which brings us to the second, stickier question, one that is often ignored in evaluations of this kind.

2. What factors would shape implementation and impact of an enhancement to a large-scale project?

We know that context matters: country- and host project-specific factors—goals, strategies, supervision mechanisms, health worker workloads, even intrinsic and extrinsic motivators—will make or break design, implementation, and scale of even a simple tweak to planned activities. We also know that over time, approaches adapt to context and implementation learning—so that what started as Plan A evolves to become Plan D or H or even Plan M by the time we evaluate and scale up.

In other words, to sustainably embed an enhancement into the health system—and to inform similar endeavors—we’d need to unpack the “black box” between implementation and impact. What unique elements of the host project and health system influence an enhancement—and what questions would others need to raise to layer an enhancement in a different setting? How do the enhancement and its implementation evolve over time and in scale-up, and why? What unintended effects emerge from the interplay between the enhancement, the host project, and the broader health system?

Introducing Connect

Connect, with support from the Bill & Melinda Gates Foundation, is poised to grapple with these questions. Over 4 years, Connect will build on two Save the Children-led projects and design, scale, and evaluate an incremental enhancement to reach FTPs at scale.

In Bangladesh, Connect will partner with the USAID-funded MaMoni-Maternal and Newborn Care Strengthening Project (MaMoni MNCSP), which supports the Ministry of Health and Family Welfare to improve maternal and newborn health in ten focus districts. In Tanzania, Connect leverages the USAID-funded Lishe Endelevu project, which aims to reduce stunting in children under five and improve the diet of 1.5 million women of reproductive age.

Connect will rigorously evaluate the impact on FP use and, drawing from realist evaluation principles, dig into that “black box” between implementation and results. Connect will yield practical how-to guidance, informing other efforts to more efficiently and effectively target FTPs with PPFP.

Connect’s partnership

Save the Children, the project lead, leverages our FTP and health system strengthening expertise and multisectoral operating presence to spearhead the design and implementation of program enhancements with MaMoni MNCSP and Lishe Endelevu and country stakeholders.

The George Washington University Milken School of Public Health (GWU) evaluates the impact of the program enhancements through rigorous quantitative methods and contributes to a qualitative realist-inspired evaluation exploring factors shaping implementation, scale, and sustainability.

We’re excited to dive into these complex questions and look forward to sharing Connect’s results and lessons. For more information, check out Connect’s fact sheet or contact myahner@savechildren.org