USAID’s MCH Program Component 5: Health Systems Strengthening
Quarterly Report October-December 2013
Cooperative Agreement No. AID-391-A-13-00002
This Report has been submitted to the United States Agency for International Development for consideration and approval.
It was submitted by JSI Research & Training Institute, Inc. and prepared by JSI Research & Training Institute, Inc. in collaboration with Contech, Rural Support Programmes Network, and Heartfile.
USAID’s MCH Program Component 5: Health Systems Strengthening
Quarterly Report October-December 2013
Cooperative Agreement No. AID-391-A-13-00002
Disclaimer: “This study/report is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of JSI Research & Training Institute, Inc.Component and do not 5: necessarily Health Systems reflect the Strengthening views of USAID Quarterly or the United Report States October Government.”-December 2013 2
Contents
Acronyms ...... 4 I. Executive Summary ...... 5 II. Health Systems Strengthening Component’s Vision of Success ...... 6 III. Activities and Results ...... 8 IR 3.1 Increased Accountability and Transparency of Health System ...... 8 IR 3.2 Improved Management Capacity at Provincial and District levels within the Health Department ...... 15 IR 3.3 Strengthened Public Private Partnerships ...... 17 IV. Coordination ...... 18 V. Monitoring, Evaluation, and Reporting ...... 19 VI. Project Management ...... 21 Financial Management ...... 21 Administrative Management ...... 22 VII. Issues and Challenges...... 23 VIII. Activities Planned for Next Quarter ...... 23 IX. Annexes ...... 24 Annex 1: International Travel Status Report (April 3-December 31, 2013) ...... 24
Component 5: Health Systems Strengthening Quarterly Report October-December 2013 3
Acronyms
CMWs Community Midwives DAP District Action Plan DHIS District Health Information System DHN District Health Network DHO District Health Officer DHMT District Health Management Team DHPC District Health Planning Committee DHPMT District Health & Population Management Team DHQ District Headquarter DOH Department of Health EPI Expanded Programme on Immunization HCF Health Care Financing HHF Heartfile Health Financing HSS Health Systems Strengthening HSRU Health Sector Reforms Unit IR Intermediate Result IT Information Technology JSI JSI Research & Training Institute, Inc. LHV Lady Health Visitor LHW Lady Health Worker MCH Maternal and Child Health MCHIP Maternal and Child Health Integrated Program M&E Monitoring and Evaluation MIS Management Information System MNCH Maternal, Newborn and Child Health MSS Marie Stopes Society PPHI People’s Primary Healthcare Initiative PWD Population Welfare Department RFP Request for Procurement RHC Rural Health Center RMNCH Reproductive, Maternal, Newborn and Child Health RSP Rural Support Program RSPN Rural Support Programmes Network UCHCs Union Council Health Committees USAID United States Agency for International Development VHCs Village Health Committees
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I. Executive Summary
During the October-December 2013 quarter, the Health Systems Strengthening Component supported rural communities in Thatta, Tando Allah Yar, Umerkot, Dadu, and Tharparkar districts to organize quarterly meetings of 478 VHCs (out of a total of 738 VHCs), meaning that 67% of all VHCs held a meeting. Additionally, nine Union Councils in the above mentioned districts were selected for the formation of additional VHCs. The Union Councils were selected after consultation with the Maternal and Child Health Integrated Program (MCHIP), led by Jhpiego. The Health Systems Strengthening Component also formed new Union Council Health Committees (UCHCs) in Thatta and Umerkot districts.
During the reporting period, 21 District Health & Population Management Teams (DHPMTs) held their first quarterly meetings, and DHMPT Dadu held its second meeting. The project supported preparation of drafts of District Action Plans (DAPs) for Dadu, Jacobabad, and Sukkur, which were presented by their respective District Health Officers in DHPMT meetings in those districts. This was preceded by workshops conducted by the project to build the capacity of District Health Planning Committees (DHPCs) for district action planning.
Following a comprehensive District Health Information System (DHIS) assessment in the proceeding reporting period, the Health Systems Strengthening Component proposed an intervention package for the Department of Health (DOH) to design priority interventions to improve performance, quality, and use of routine health data.
Under its supply side health financing, the Health Systems Strengthening Component initiated operations in Liaquat University Hospital, Jinnah Post-graduate Medical Center, and Benazir Bhutto Hospital.
During the reporting quarter, coordination with other Maternal and Child Health (MCH) Program partners, particularly MCHIP/Jhpiego and Marie Stopes Society (MSS) increased, and the scope of work of Health Systems Strengthening Component sub- partner Rural Support Programmes Network (RSPN) was revised to facilitate the work of MCHIP/Jhpiego and MSS in areas not covered by Lady Health Workers (LHWs).
JSI did encounter a few noteworthy challenges during the reporting period, including frequent transfers and postings of senior officials (Secretary Health, Additional Secretaries, and Chief Health Sector Reforms Unit [HSRU]), which led to delays for project activities such as RMNCH Steering Committee meetings. Additionally, while there have been challenges establishing coordination linkages with the Population Welfare Department (PWD), JSI is optimistic that the anticipated Memorandum of Understanding between USAID and PWD will significantly improve this situation.
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II. Health Systems Strengthening Component’s Vision of Success
At the end of the project, the Government of Sindh’s (GOS) Department of Health (DOH) will have the management capacity and systems necessary to move towards universal coverage and address equity issues with a particular focus on the poor and vulnerable. The GOS will have tested and scaled proven public private partnerships (PPPs) and have the capacity to manage and sustain these partnerships and to identify and develop new ones over time. Additionally, the capacity of civil society to effectively engage in policy dialogue will have been built, and there will be a sustained increase in financial risk protection to move towards universal health coverage.
Goal
The goal of the Health Systems Strengthening Component is to develop and support innovative, cost effective, integrated, and quality programs and services to strengthen systems around reproductive, maternal, newborn and child health (RMNCH) services for improved outcomes. The primary focus of the program proposed under the Health Systems Strengthening Component is:
(1) Strengthening systems that will foster improved RMNCH service delivery and outcomes, including accountability and transparency;
(2) Strengthening management capacity at the provincial and district levels;
(3) Developing innovative approaches to catalyze community outreach services and access to health services for marginalized populations (including financing schemes); and
(4) Strengthening private sector delivery for the urban and rural poor populations.
The Health Systems Strengthening Component will also engage in the coordination, alignment, and calibration of RMNCH activities undertaken by technical partners of USAID’s MCH Program to ensure there is no duplication of effort and that all critical elements for achieving results reinforce each other and are laid out to achieve synergy and the desired results of USAID’s Maternal and Child Health (MCH) Program objectives.
Health Systems Strengthening Component’s Intermediate Results
The results of Health Systems Strengthening Component will follow USAID’s Results Framework. Most of the project’s activities will fall under IR 3.
IR 3: Strengthened Health System IR 3.1: Increased Accountability and Transparency of Health System
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IR 3.2: Improved Management Capacity at Provincial and District Levels within the Health Department IR 3.3: Strengthened Public Private Partnerships
Overall Approach and Strategic Principles
JSI and its sub-partners RSPN, Contech International, and Heartfile will implement the Health Systems Strengthening Component to improve the capacity of the Government of Pakistan (GOP), and particularly the GOS, to develop and implement innovative, cost-effective, integrated, and quality programs and services to strengthen systems around RMNCH services. Throughout the project, the Health Systems Strengthening Component will strictly adhere to and promote the following strategic principles:
Using a customized approach to capacity building that will be fit to each specific entity. This is reflective of the project’s overall commitment to flexibility and adaptability in implementation; Strengthening strategic partnerships and coordination to effectively manage an integrated health system; Promoting a culture and practice of results-oriented approach; Strengthening local expertise and focusing on local innovation to promote sustainability and ownership; Focusing on demand and supply side financing schemes to strengthen the health system; Promoting community actions for accountability and transparency of the health system; and Special consideration to gender will be made to ensure that it is mainstreamed within the Health Systems Strengthening Component’s implementation approach.
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III. Activities and Results
IR 3.1 Increased Accountability and Transparency of Health System
Village Health Committees
After the formation of Village Health Committees (VHCs) in the July-September 2013 reporting quarter, the Health Systems Strengthening Component’s focus for the October-December 2013 quarter shifted to supporting quarterly meetings of VHCs. During this quarter, the Health Systems Strengthening Component supported rural communities in Thatta, Tando Allah Yar, Umerkot, Dadu, and Tharparkar districts to organize quarterly meetings of 478 VHCs (out of a total of 738 VHCs), meaning that 67% of all VHCs held a meeting. (All the VHCs could not hold the meetings because of the turnover of RSPN’s project staff in Tando Allah Yar and Thatta.) In these meetings, Social Mobilizers highlighted the role VHCs can play in strengthening health services, increasing the outreach of public sector health facilities, and improving accountability mechanism for public health staff.
In addition to supporting communities to hold VHC meetings, the Health Systems Strengthening Component also worked with VHCs to increase their respective memberships. Indeed, as new households become members of VHCs, coverage of activities of VHCs subsequently increases. During the reporting period, 480 women and 264 men became new members of the 478 VHCs. District-wise and Union Council-wise details of VHCs in terms of numbers and membership are provided in Table 1 on the next page.
In consultation with MCHIP/Jhpiego, the Health Systems Strengthening Component selected nine additional Union Councils in MCH Program target districts, in which to support the formation of VHCs during the next quarter. The names of additional Union Councils and districts where they are located are as follows:
Sakro, Gujjo, and Gharo in Thatta district Pak Singhar and Sheikh Moosa in Tando Allah Yar district Diplo and Manjthi in Tharparkar district Kakar and Phulji station in Dadu district
Some of these Union Councils includes areas where there are currently no community organizations, and so the Health Systems Strengthening Component will also work with to revitalize dormant community organization. This will include providing support to incorporate health in their scopes of work, increase their membership to include poor and disadvantaged groups, and reconfigure them as VHCs.
In light of the feedback received from MCH Program partners, the Health Systems Strengthening Component revised its VHC information package by simplifying the list of medicines available at the health facilities and translating the information package into Sindhi. Moreover, the Health Systems Strengthening Component also incorporated input from the DOH, including its desire
Component 5: Health Systems Strengthening Quarterly Report October-December 2013 8 for pre-testing. Based on the information package, RSPN and JSI developed charts containing information about the service delivery points/health facilities, including those of Marie Stopes Society and MCHIP/Jhpiego, for sharing with the communities.
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Table 1: District-wise and Union-Council-wise Information about VHCs
New Membership added Total No. of VHC meetings Total No of members attended Total No. of VHCs households conducted during October- households Union organized the meetings organized District December 2013 Council as of New as of September Male Female Total households December 2013 organized 2013 Male Female Mixed Total Male Female Mixed Total Male Female Total
Chatto 47 12 23 82 1,504 20 7 34 61 585 606 1,191 0 0 0 0 1,504 Thatta Chand Makli 5 14 10 29 493 1 19 7 27 49 482 531 17 47 64 47 5,40
Atta Muhammad 23 26 23 72 1,273 0 2 26 28 305 374 679 21 18 39 34 1,307 Pali
Umerkot Kharoro 6 45 3 54 843 0 2 22 24 196 331 527 0 0 0 0 843 Sayed
Mir wali Muhammad 22 25 18 65 1,195 0 2 36 38 362 577 939 41 0 41 27 1,222 Talpur
Began 41 9 19 69 1,184 10 12 40 62 463 539 1002 4 13 17 17 1,201 Tando Jarwar Allah Yar 24 8 15 47 810 9 10 28 47 326 480 806 5 17 22 22 832 Messen Khudaabad 34 1 29 64 1,984 4 1 33 38 377 360 737 57 80 137 40 2,024 Kamal Khan 2 1 49 52 1,163 0 0 34 34 311 309 620 50 75 125 104 1,267 Dadu Yar Muhammad 13 4 32 49 1,677 0 0 30 30 328 335 663 47 96 143 115 1,792 Kalhoro
Malanhore - - 42 42 1,833 0 12 18 30 257 559 816 0 25 25 0 1833 Vena Tharparkar Bhakuo - - 39 39 2,299 0 9 7 16 158 473 631 4 4 8 0 2299 Mohrano - - 74 74 2,449 0 16 27 43 219 991 1,210 18 105 123 0 2445 Total 217 145 376 738 18,707 44 92 342 478 3,936 6,416 10,352 264 480 744 406 19,109
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Union Council Health Committees
The Health Systems Strengthening Component worked with rural communities in Union Council Chatto Chad in Thatta district to form a Union Council Health Committee (UCHC). The newly formed UCHC has 22 members (16 men and 6 women). Similarly, Health Systems Strengthening Component worked with rural communities in Union Council Atta Mohammed Pali in Umerkot district to form a UCHC, which now has 32 members (23 women and nine men). The formation of UCHCs in Union Councils Makli in Thatta district, and Missan and Began Jarwar in Tando Allah Yar district started during the reporting period.
During the reporting period, the representatives of UCHC did not participate in DHPMT meetings as the first meetings of UCHCs had to be held first. All UCHCs formed so far are expected to participate in District Health Network meetings in their respective districts in January-March 2014 quarter. The following nine UCHCs held their first meetings during the reporting quarter.
Chatto Chad in Thatta district Kharoro Syed, Atta Mohammad Pali, and Mir Wali Mohammad in Umerkot district Bhakuo and Mohrano in Tharparkar district Khudabad, Yar Mohammad Kalharo, and Kamal Khan in Dadu district
In these meetings, Social Mobilizers and District Project Officers shared objectives of the Health Systems Strengthening Component, highlighted what role communities can play in improving health systems in rural areas, and discussed the role and responsibility of UCHCs.
Expanded Role of RSPN to Provide a Platform to USAID MCH Program Partners to Improve Community Outreach
The scope of work of RSPN was revised during the reporting quarter to support MNCH activities of USAID’s MCH Program partners. The Health Systems Strengthening Component will provide lists of VHCs, UCHCs, and District Health Networks, being formed by RSPN in 10 MCH Program districts, with MCHIP/Jhpiego and MSS. MCHIP/Jhpiego and MSS will participate in community level advocacy events whenever RSPN organizes them. In addition, the three MCH Program partners agreed on the following: MSS’s Field Health Educators will become members of VHCs for interpersonal communication and dissemination of key health messages. Field Health supervisors will join UCHCs. Information about MSS’s Suraj clinics and services offered by its service delivery partners will be shared with VHC members. RSPN will collect feedback from communities on their experiences with Suraj clinics and service delivery partners and share with MSS on quarterly basis. MSS will develop a flyer on key messages which will be shared by Field Health Educators during meetings of VHCs.
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Identification of Traditional Birth Attendants and Non-active Community Midwives in Areas not Covered by Lady Health Workers
This activity has been added to the Health Systems Strengthening Component’s Year 2 Work Plan at the request of MCHIP/Jhpiego. During the October-December quarter, the Health Systems Strengthening Component developed tools to be used for collecting data on Traditional Birth Attendants and Community Midwives (CMWs) in Union Councils, which are not covered by Lady Health Workers (LHWs). These tools were finalized in consultation with MCHIP/Jhpiego and are being translated into Sindhi. The Health Systems Strengthening Component will begin collection of data on Traditional Birth Attendants and CMWs during the January-March quarter and will seek assistance of VHCs and UCHCs in this task.
RMNCH Steering Committee
The first meeting of the Reproductive, Maternal, Newborn, and Child Health (RMNCH) Steering Committee, planned for December, had to be postponed because of the transfer of Secretary Health and other senior staff of the GOS. The Secretary (Dev.) of P&D Department verbally advised DOH that someone relevant from DOH, preferably Chief HSRU, may be notified as the member/secretary of the RMNCH Steering Committee (missing in original Notification issued by GOS).
As a procedure, a proposal for this was required to be moved to the Chief Secretary, Sindh for issuance of a modification/addition to the original Notification,
JSI supported DOH to draft the proposed agenda for the meeting. The agenda is with Secretary Development. JSI is following up with the DOH to initiate the proposal for soliciting requisite approval from the Chief Secretary Sindh and issuance of the modified Notification. The Secretary Health plans to convene the meeting in March 2014.
Documentary on Pakistan’s Health and General Governance Issues
JSI drafted a Request for Procurement (RFP) for a documentary on Choked Pipes, a book written by Heartfile Founder and President Dr. Sania Nishtar. Choked Pipes was published in 2010 and focuses on Pakistan’s health systems issues and offers reform solutions. Once the draft has been finalized with feedback from JSI’s Home Office, JSI will officially submit the RFP for USAID’s approval.
District Health & Population Management Teams
The Health Systems Strengthening Component has been supporting the DOH to strengthen district health systems through the establishment of DHPMTs and revitalization of DHPMTs where they already exist as District Health Management Teams. The Health Systems Strengthening Component reviewed District Health Management Teams and found that, with a few exceptions, most of the District Health
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Management Teams had not met for business in the past three years and those that did meet were due to the efforts of relevant District Health Officers.
During the reporting period, 21 DHPMTs in the following districts held their first meetings: Hyderabad, Tando Allah Yar, Sukkur, Shikarpur, Jacobabad, Kashmore, Ghotki, Khairpur, Naushero Feroze, Shaheed Benazirabad, Larkana, Kamber Shadadkot, Matiari, Sanghar, Jamshoro, Tando Muhammad Khan, Thatta, Mirpur Khas, Umerkot, Badin, and Tharparkar.
The District Health Departments in 22 districts issued notifications for their respective DHPMTs following a notification issued by the GOS in September 2013. Meetings of notified 21 DHPMTs were held after the issuance of meeting notice and agenda. The agenda items included DHPMT orientation, review of DHIS performance, progress on District Action Plans, and coordination and information exchange between districts stakeholders. Participants of the meetings included representatives of the DOH, PWD, PPHI, and community representatives. The following decisions were taken in these meetings: Requesting DOH to fill vacant posts Discussion around improving coordination between stakeholders and information sharing Reviewing DHIS reports Requesting Director General Health Services to set targets for vertical programs
District Action Plans (DAPs)
Health Systems Strengthening Component conducted workshops to build the capacity of District Health Planning Committees (DHPCs) in district action planning in the following 18 districts after District Health Officers notified them in their respective districts: Hyderabad, Jamshoro, Matiari, Tando Allah Yar, Tando Muhammad Khan, Thatta, Badin, Sanghar, Mirpur Khas, Shaheed Benazirabad, Sukkur, Naushero Feroze, Khairpur, Ghotki, Shikarpur, Jacobabad, Umerkot, and Tharparkar. (District Health Officer in Dadu had notified Dadu’s DHPC in September.) The focus of these workshops was on preparation of DAPs, which address local health problems and inter- sectoral coordination.
The Health Systems Strengthening Component followed up these workshops by providing hands-on support to DHPCs in the above-mentioned districts wherein DHPCs reviewed proposed interventions for health and health systems problems. This provided an opportunity to recommend targets for the proposed activities for the next year based on district stakeholder consensus.
The Health Systems Strengthening Component followed up these capacity building workshops by providing hands-on support for district action planning to DHPCs in 12 districts: Hyderabad, Thatta, Badin, Shaheed Benazirabad, Sukkur, Naushero Feroze, Khairpur, Ghotki, Shikarpur, Jacobabad, Umerkot, and Tharparkar. Draft District Action
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Plans for Dadu, Jacobabad, and Sukkur were prepared and presented by District Health Officers in DHPMT meetings in their respective districts.
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IR 3.2 Improved Management Capacity at Provincial and District levels within the Health Department
Strengthening M&E of Routine EPI in Sindh
The Health Systems Strengthening Component prepared Terms of Reference for technical assistance requested by DOH for strengthening M&E of routine immunization in Sindh. The Terms of Reference were prepared in consultation with EPI Sindh and the office of Director General Health Services.
After approval of the Terms of Reference by USAID, JSI signed a contract with a selected consultant in December 2013. Thereafter, the consultant began a literature review and will submit a report to the project in January 2014.
District Health Information System (DHIS): Assessment and Proposed Areas of Improvements
The Health Systems Strengthening Component finalized its DHIS assessment report in five districts (Dadu, Khairpur, Thatta, Tando Allah Yar, and Tharparkar) and presented the findings to the relevant officials of DOH, including the DHIS Coordinator, Deputy Director Health Education, Director Public Health, and Chief/Coordinators of Health Sector Reforms Unit (HSRU). The assessment examined the district and provincial levels’ analyses and use of information related to DHIS. As reported earlier, the quality of data was weak; health facilities submitted incomplete reports and often submitted them late both at the facility and district levels, decision-making was not based on data, and the staff at the district and provincial levels did not have the required technical competencies for data analysis and report writing.
Based on the assessment, the Health Systems Strengthening Component proposed an intervention package to DOH to design priority interventions to improve performance, quality, and use of routine health data. The project made the following recommendations to DOH to improve DHIS implementation.
1. Policy and Planning Ensure compliance to policy guidelines to improve data quality and use of information. Constitute a provincial technical committee to review MIS.
2. Coordination and Communication Ensure quarterly review meetings are held between provincial and district managers. Ensure monthly meetings of district and facility staff, as well as meetings of facility staff, are held regularly. Regularize feedback mechanism at both the provincial and district levels. Develop quarterly analytical reports on different parameters and submit to Director General Health Services.
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3. Supportive Supervision Mechanism Ensure an effective supportive supervision system to improve DHIS data quality, completeness, and timeliness. Conduct Lot Quality Assurance Sampling exercise periodically, as mentioned in the DHIS manual, to improve data quality.
4. Health Information Systems Resources Ensure availability of funds through regular budgeting. These funds should also cover costs for printing, trainings, and supervision and monitoring. Create additional staff positions needed at the provincial and district levels, exclusively for DHIS (for example, data analyst/manager, data entry [software] operator). Explore support to fill the gaps in terms of equipment, instruments printing, transportation of DHIS tools, and mobility. Strengthen IT infrastructure and software to improve DHIS.
5. Training Arrange trainings/refresher trainings on data collection and reporting for managers, medics, and paramedic staff. Health managers, medics, and para medic staff should receive trainings/refresher trainings on data collection and reporting. Provide trainings on data analysis and use of information and supportive supervision to provincial and district level managers. Provincial level and district level managers should be trained in data analysis, information use, and supportive supervision. Train computer operators at the district and provincial level.
6. Incorporation of Health Information Systems Establish a knowledge management hub at the provincial level under the Director General Health Services. Establish a data storage bank at the district level. Develop web-based DHIS, as well as a Dashboard.
The recommendations have been approved by Director General Health Services, and the Health Systems Strengthening Component will support DOH to implement them.
Strengthening Knowledge Management Hub at the Provincial Level
During the reporting quarter, JSI held several meetings with HSRU about strengthening the Data Management, Evaluation, and Research Unit (HSRU) by establishing a knowledge management hub as part of the Unit. However, Director General Health Services decided, in a meeting held in December 2013, that the knowledge management hub would be established as part of the M&E Unit in the office of Director General Health Services in Hyderabad.
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IR 3.3 Strengthened Public Private Partnerships
Initiation of Program Operations in Jinnah Post-graduate Medical Center, Liaquat University Hospital, and Benazir Bhutto Hospital
During the reporting quarter, Heartfile hired two Coordinators, one based in Karachi and another in Hyderabad, and trained them on Heartfile Health Financing’s (HHF) socio- economic assessment mechanism. These Coordinators will work with the hospital units that were enrolled in HHF in Jinnah Post-graduate Medical Center, Karachi, and Liaquat University Hospital, Hyderabad, during the July-September 2013 reporting quarter. (Four units of Liaquat University Hospital and one unit of Jinnah Post-graduate Medical Center were enrolled in light of the eligibility ascertainment methodology as reported in the project’s July-September 2013 Quarterly Report.) The Coordinators will ascertain the eligibility of patients, verify requests, and authorize cash transfers to underwrite the cost of health care.
A customized workflow for the MNCH needs of patients, which included request initiation, eligibility ascertainment, service delivery, invoicing and payments modules, was deployed in the enrolled units of Liaquat University Hospital and Jinnah Post- graduate Medical Center.
A tele-medicine assessment module, an innovative feature of HHF platform, was successfully tested and deployed in the enrolled units in Liaquat University Hospital and Jinnah Post-graduate Medical Center. This module has been operational for the past year and a half and has facilitated HHF in reaching out to patients through previous HHF. Detailed socioeconomic assessments have been carried out at patients’ bedsides by connecting them with seasoned socioeconomic verifiers at Heartfile’s central office; all ethical protocols pertaining to patients’ confidentiality and informed consent are followed. This feature is enabling operations teams to not only process requests in an expedient manner, but also holistically map subjective and objective observations, seek cross verifications, and validate information from multiple sources. Unlike state supported social protection channels, patients do not have to physically visit multiple offices during the entire request seeking process and are able to manage their cases from within the hospital. Therefore, there are no ancillary costs (traveling and food expenditures) borne by the patient and/or the family.
Request processing and decision-making are done through an authority matrix. Strict supply chain, financial, and IT controls have been built in requisitioning, ordering, receiving, and inspection of supplies. Invoice verification and payment processing are undertaken by segregating duties. With this, delegation of responsibility and staff accountability make the process transparent.
Setting up Organizational Platform for Mobile Money (mMoney) Transfers
To support poor women and children to meet their emergency needs whilst being in hospital, HHF is in discussion with leading telecom operators in Pakistan, such as Ufone and Telenor, for developing its organizational capacity to send instant
Component 5: Health Systems Strengthening Quarterly Report October-December 2013 17 money.transfers (Ufone has upaisa scheme and Telenor has epaisa scheme for mobile phone users.) Leveraging onto this already established branchless banking feature in Pakistan, HHF is expecting to bring financial inclusion, security, and convenience in money transfers to the underprivileged.
Upgrade of mHealth Enabled Technology Platform for MNCH
Heartfile discussed requirements for the following modules with its technology partner who organization selected three years ago. The purpose of the discussion was to rationalize the need, inputs, and envisaged outputs of the planned up-gradation and to avoid over-automation, thus ensuring that needs drive technology instead of the other way around. Some of the identified issues included: Advanced request outcome scenarios handling. Advanced adaptive poverty questionnaire selection. Enhancements in reporting, invoicing, and payment modules. Improved/enhanced system generated communications. Functional enhancements to the website. Advanced task management. Security enhancements for user privileges, architecture, and configuration.
Short-Term Technical Assistance on Health Care Financing
As part of providing short-term technical assistance to DOH on health care financing, the Health System Strengthening Component engaged two consultants to review available health care financing models and provide recommendations for a sustainable health care financing model for Sindh. Before their arrival in Pakistan in January 2014 (their visit was delayed because of difficulties in obtaining visas), the consultants conducted a literature review on health care financing in Pakistan and produced a “Results-based Financing for Health in Sindh: A Desk-based Feasibility Review” which was shared with USAID and relevant stakeholders. Based on the findings of the literature review, the consultants will explore results-based financing options for Sindh.
IV. Coordination
Coordination with USAID’s MCH Program Partners
On December 4th, JSI hosted, in its Islamabad office, a quarterly meeting of USAID MCH Program implementing partners.
The Health Systems Strengthening Component’s staff regularly participated in meetings of M&E and Behavior Change Communication (BCC) Working Groups. In addition, JSI organized meetings for the Health Care Financing Working Group, which it chairs. The Health Systems Strengthening Component also participated in USAID’s Communications Working Group meetings organized by the office of Documentation, Outreach, and Communication. .
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During the reporting period, the Health Systems Strengthening Component held meetings with the Maternal Newborn Child health Component, led by MCHIP/Jhpiego, and the Family Planning and Reproductive Health Component, led by Marie Stopes Society, to coordinate and support one another’s field activities. RSPN’s scope of work was revised to cater to the needs of MCH Program partners.
In December, JSI’s Vice President and Director of International Division, Mr. Ken Olivola, and Senior Technical Advisor, Ms. Nancy Brady, visited Pakistan and met with representatives of USAID, Health Systems Strengthening Component’s consortium partners, Federal Minister for Health Services, Regulations and Coordination, officials of DOH, and MCH Program implementing partners. Mr. Randy Hatfield Deputy Regional Director USAID, Dr. Ashfaque Memon, Director General Health Sindh and Mr. Ken Olivola inaugurated the Health Systems Strengthening Component’s Karachi Office.
Coordination Meetings with DOH and PWD
During the reporting quarter, the Health Systems Strengthening Component regularly met with HSRU staff and staff from the Office of Director General Health Services to discuss technical assistance for the DHIS assessment, knowledge management, and e- bulletins, and received request to provide technical assistance for the following: assess the Provincial Health Development Center; design and develop a capacity building strategy; develop a management cadre; and strengthen M&E of routine EPI. The project also held meetings with the Secretary Health and other senior officials of DOH, PWD, EPI, and PPHI.
V. Monitoring, Evaluation, and Reporting
Project Year 2 Work Plan
The Health Systems Strengthening Component submitted the revised version of its Project Year 2 Work Plan to USAID, which was approved in December. The approved Project Year 2 Work Plan was subsequently posted on the USAID MCH Program’s web portal.
Weekly Reports
During the quarter, Health Systems Strengthening Component submitted 13 weekly activity reports to USAID.
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Success Story
Inayat Anwar’s medical history is an untold story of gender inequity, malnutrition, needless suffering, and even abuse. But her story is also one of survival, selflessness, cultural pressure, and of a person whose unwavering effort to save her marriage brought her to Liaquat University Hospital in Hyderabad where the Health Systems Strengthening Component of USAID’s Maternal and Child Health Program helped her and her newborn child survive.
Inayat Anwar hails from a far-flung area of Kotri, near Jamshoro, in Pakistan’s Sindh Province. The depth in her eyes speaks volumes about the distress and the agony of the journey to Hyderabad she made for her baby during the ninth month of her pregnancy. Inayat is only 35 years old, and this is her 12th pregnancy with a child whose chances of survival are as grim as of those in earlier pregnancies. Inayat’s previous 11 pregnancies had been a series of miscarriages and stillbirths, due to a congenital disease.
A miscarriage is undoubtedly one of the most painful experiences a woman can endure. Without access to suitable health and family planning clinics centers in her village, Inayat’s family supported her to seek health expertise in the nearest city, Hyderabad, and she came to Liaquat University Hospital.
When Inayat and her family arrived at the hospital, they did not have enough money to pay for her Caesarean section; the cost was only Rs. 5,000 ($45).
Seeing Inayat’s condition and her family’s impoverished circumstances, a doctor at the enrolled gynecology unit at the hospital sent an SMS on Heartfile’s server mentioning the urgency of Inayat’s condition. The unit had been enrolled and the staff there trained in Heartfile health financing (HHF) during the July-September quarter.
Upon receiving the SMS, Heartfile initiated socio-economic verification which confirmed Inayat’s socio-poor and impoverished status. Within 72 hours, a registered vendor, who had also been trained on invoicing and payment modules of HHF provided the medical supplies required for Caesarean section. With HHF intervention, Inayat got the chance to give birth to her child. She said it changed everything for her.
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VI. Project Management
Financial Management
The financial management activities mainly included the review and processing of disbursements to vendors/consultant and maintaining close liaison and extensive coordination with the JSI Home Office in Boston regarding financial and administrative management. This included discussing monthly project expense reporting, budget tracking, and cash flow requests for funds management and updating several tools/reports designed for financial management to track expenditures against the approved budget and the authorized obligation to the budget ceiling.
The Health Systems Strengthening Component responded to USAID/Pakistan’s queries regarding submission of financial data for accruals and other project related information during the reporting period.
Project Spending
The Health Systems Strengthening Component reviewed, processed, and approved expenditures of around $730,127.00 for disbursement from both the field office and JSI Home Office during the October-December quarter, including a total of 156 vouchers. As per the latest Standard Form 425 report, total project expenses, as of December 31, 2013, were $2,062,506.90. The average quarterly burn rate for the last two quarter expenditures is approximately $637,340.00 and the following table shows quarterly expenditure trends:
Quarterly Expenditure Trend as of December 31, 2013
Expenses in US $
1,000,000 884,540 800,000 730,127 1st Quarter 600,000 544,553 2nd Quarter
400,000 3rd Quarter 200,000
- 1st Quarter 2nd Quarter 3rd Quarter
Source: Standard Form 425
Component 5: Health Systems Strengthening Quarterly Report October-December 2013 21
Administrative Management
Recruitment and Human Resource Management
JSI hired the following staff during the reporting period; both are based in JSI’s Karachi office.
Sr. Date of Name Designation # Joining Mr. Shaheryar Manager Finance & October 07, 1 Akhter Administration 2013 Ms. Ruqayya October 02, 2 Receptionist Quettawala 2013
International Travel
In this quarter, there was no international travel. Out of the total 20 approved international travel trips, a total of four international travel trips have been utilized as of December 31, 2013. Details are given in Annex 1.
Contracts/Purchase Orders
A total of 12 contracts and purchase orders for the supply of goods and services, amounting to $68,608.44, were issued during the reporting period.
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VII. Issues and Challenges
The July-September 2013 Quarterly Report mentioned frequent transfers and postings of senior DOH officials as one of project’s main challenges. This remained true during the current reporting quarter as a new Secretary of Health, two additional secretaries, and a Chief HSRU were appointed by GOS.
Additionally, establishing better coordination linkages with PWD was a significant challenge during the reporting period. However, we are optimistic that the anticipated Memorandum of Understanding between USAID and PWD will significantly improve this situation.
Some other challenges include: 1. The limited availability of government officials and the fact that their presence at meetings is not assured until the last minute. 2. The hiring of qualified field staff in Tando Allah Yar and Thatta district, which, in turn, delayed the implementation of project activities. 3. A delay in the selection of new Union Councils for the formation of VHCs and UCHCs due to delays in the provision of information by MCHIP about the MCH Centers it plans to establish. 4. Coordination issues between the office of Director General Health Services and other provincial offices, including HSRU.
VIII. Activities Planned for Next Quarter
Meeting of RMNCH Steering Committee. Implementing DHIS recommendations. Publishing an e-bulletin. Assessing the Provincial Health Development Center. Providing technical assistance to explore HCF options, develop a management cadre, design and develop a capacity building strategy, strengthen the DHIS and disseminate it through an e-bulletin, and strengthen M&E of routine EPI. Working to produce a documentary on Pakistan’s health and general governance issues. Scaling up HHF operations in Jinnah Post-graduate Hospital Center, Karachi, Liaquat University Hospital, Hyderabad, Pakistan Institute of Medical Sciences, Islamabad, and Benazir Bhutto Hospital. Finalizing an orientation module for field staff and VHCs. Conduct orientation of project staff on community engagement and interface with the health system. Forming and orienting VHCs and UCHCs in the newly selected districts and Union Councils. Collecting data on Traditional Birth Attendants and CMWs for MCHIP. Supporting EPI to strengthen routine immunization in areas not covered by lady Health Workers in Thatta, Tharparkar, Kashmore, and Jacobabad districts.
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IX. Annexes
Annex 1: International Travel Status Report (April 3-December 31, 2013)
Name of Arrival Departure Sector Travel Reference CA No. of Travel Sr.# Organization Designation Balance Traveler Date Date Traveled Type (Sr.#/Tr#) Completed
Senior Team Dr. Theo 5-May- USA-PAK- 1 10-May-13 JSI-Boston Technical Planning 5/1 1 19 Lippeveld 13 USA Advisor Travel Dr. COP/Field 11-May- PAK-USA- 2 Nabeela 1-Jun-13 JSI-Boston Chief of Party Office 4/1 1 18 13 PAK Ali Travel Team Mr. John 10-Jun- USA-PAK- Finance 3 19-Jun-13 JSI-Boston Planning 5/2 1 17 Abbott 13 USA Manager Travel Home Mr. 6-Sep- USA-PAK- Project Office 4 Andrew 22-Sep-13 JSI-Boston 3/1 1 16 13 USA Coordinator Support Dallos Travel
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