World Bank ‐ Third Party Monitoring Service Progress Report Contract Number: 8006033 Dates Covered: 01 to 30 November 2018 Program Title: Third Party Monitoring Date 8 December 2018 Service Submitted: Report Type Monthly Progress Report Author: Philippa Morgan, Monitoring and Evaluation Officer 1. Administration IOM completed the induction of the new Field Monitors. The Field Monitors have already been given orientation on the TPM project and also completed all the required IOM and UN related security trainings to enable them to go to the field. The recruitment of the Program Officer is completed. She is expected to join the TPM team early January 2019. The recruitment of the Information Management Officer is pending interviews. 2. Key Achievements IOM conducted a Third Party Monitoring (TPM) verification mission to former Upper Nile State on 5 to 14 November 2018 to conduct physical verification of implementation progress of Health Facilities (HFs) currently supported under the World Bank’s Rapid Results Health Project (RRHP) portfolio. Eight HFs were visited in former Upper Nile State. See annex 1 for a breakdown of the HFs visited by location, type of HF and Implementing Partner (IP). The objective of the project is to improve the delivery of High Impact Primary Health Care (PHC) Services in former Upper Nile and Jonglei States. The findings are structured around the key areas for verification and quality assurance under the RRHP provided by the Bank and represent a consolidated summary of findings from the verification mission. A more substantive analysis of the findings will be presented to the Bank in comprehensive report due in February 2019. 3. Findings Service Delivery (i) Implementation of routine curative diseases Out of eight HFs assessed, only two of the HFs assessed (Assosa PHCC and Malakal Teaching Hospital PHCU) offer a full range of basic curative services including treatment of malaria, acute respiratory infections, diarrhea, tuberculosis and HIV. Lul PHCU in Fashoda County offers limited basic curative services – currently it provides malaria testing only‐ and no maternal health services. Based on findings from the verification tool, which included a checklist of available equipment in the HFs, all HFs lack basic medical equipment. Statistics relating to available equipment in the HFs will be provided in the full report. In many cases, infrastructure was compromised with large structural cracks in the buildings evidenced and bat infestations in the roof and wall structures. (ii) Implementation of outreach activities Outreach activities are currently being conducted at half of the HFs visited (4 out of 8). Those HFs that undertake outreach activities include Assosa PHCC, Bam PHCC and Malakal Teaching Hospital PHCU in Malakal County; and Akoka PHCU in Akoka County. Typical outreach activities include health education messaging on ANC, family planning and safe delivery and availability of services at the clinics. IOM did not see any evidence of extension services on offer in the community. (iii) Supporting of advocacy activities at community level There are currently no ongoing advocacy activities supported by any of the health facilities at the community level. (iv) Implementation of immunization activities as part of outreach programs All HFs, with the exception of Baliet PHCC and Anakadiar PHCU, Baliet County, are implementing immunization activities as part of outreach programs. Cold chain was evidenced through either vaccine carriers or the presence of a fridge in all six of the HFs, however, only two of the six HFs had antigens available (Akoka PHCU, Akoka County and Bam PHCC, Malakal County) and only one (Akoka PHCU) had vaccine order forms. (v) Presence of IPs on the ground Health Link currently has a limited presence on the ground and lacks transportation to ensure regular oversight takes place at the 13 Health Facilities under Health Link’s management. International Medical Corps (IMC) has a well established presence in Malakal and conducts regular visits to each of the three health facilities. Regular supervision of Kodok Town is taking place by CORDAID staff, however, support to rural HFs is limited to phone calls or the occasional visit to those HFs located close to the river. CORDAID put this down to lack of transportation, both land and water, and lack of human resources to physically travel to HFs in Fashoda which are often in hard to reach locations. (vi) Documentation of coordination activities between IPs and Project Implementation Unit (PIU) At the time of the assessment, no individual meetings had taken place between UNICEF and IPs, however, during the IOM mission, a Juba based UNICEF team had arrived in Malakal to conduct partner meetings and undertake further HF assessments. UNICEF held an Inception Workshop on 25 August 2018 for all partners in Malakal. IPs reported that they are required to report to UNICEF on a monthly and quarterly basis using a pre‐designed template. (vii) Review of Health Management Information System (HMIS) and data management at facility level Six health facilities included in the sample are producing HMIS reports. All health facilities are complying with the Ministry of Health’s Strengthened Integrated Disease Surveillance Response requirements by producing weekly Integrated Disease Surveillance Reports (IDSR). All of HFs but one (Assosa PHCC, Malakal County) are producing monthly reports. (viii) Documentation of information keeping and management Clinic information is documented through patient cards, registers, daily tally sheets, weekly IDSR and monthly reports. At the time of the verification visit, five of the health facilities did not have >5 patient cards, while two lacked <5 patient cards on site, however, all HFs have > 5 and < 5 patient registers, which were duly completed and appeared to be up to date. Pharmaceuticals (i) Availability of medicines at facilities IMC has received and distributed one shipment of drugs from UNICEF in October 2018 that included individual named cartons for each of the three health facilities assessed. Health Link received and distributed drugs for Akoka health facility in early November and mid‐November for health facilities in Baliet County. CORDAID received a shipment of drugs on the 7 November 2018, however at the time of the verification mission in Kodok Town on the 13 November 2018; only two of the 14 health facilities had received their drug quotas. IOM will provide statistics related to the availability of tracer drugs in the HFs in the full report. (ii) Record delivery of pharmaceuticals IPs verified that all drugs received from UNICEF were accompanied by a weigh bill, however, IOM was able to verify that only two of the health facilities (Kodok Town PHCC and Malakal Teaching Hospital PHCU) keep receipts for delivery of pharmaceuticals. (iii) Documentation of stock outs at facilities Only two health facilities (Kodok Town PHCC, Fashoda County and Baliet PHCC, Baliet County) kept records of expired drugs. Malakal Teaching Hospital PHCU, Malakal County; Asssosa PHCU, Malakal County; and Kodok Town PHCC, Fashoda County document stock outs while only the maternity department of Assosa is documenting stock outs. (iv) General documentation of medicine stocks While all health facilities conducted a monthly inventory recorded on stock cards, only three (Kodok Town PHCC, Lul PHCU and Malakal Teaching Hospital PHCU) were correctly filling in the stock cards. Stock cards were being distributed and completed during IOM’s verification mission to Lul PHCU, Fashoda County and IOM was unable to find any evidence that stock cards had previously been used in Lul PHCU. Citizen Engagement (i) Pharmaceutical supplies and health services reach intended beneficiaries IOM conducted focus group discussions with community members in Anakdiar, Baliet County and Akoka, Akoka County. Health facilities are easily accessible for community members who are generally satisfied with the services they receive. Focus group respondents were not actively engaged in health service provision in their community and did not attend meetings or individual consultations relating to health services. All respondents complained of the lack of availability of drugs between July and October 2018, which required them to walk to Malakal Town or utilize private pharmacies in order to fulfill prescriptions. In order to compliment the findings from the verification mission, IOM plans to conduct a Knowledge Attitude and Practice (KAP) survey in Upper Nile and Jonglei State. The KAP survey will help us better understand community health practices to inform more targeted recommendations. 4. Challenges Many of the HFs IOM visited ceased operations during the 2013 and 2016 eruptions of violence, resuming operations in 2017, as such, service delivery was either severely restricted or absent altogether during those periods. The assessment was not designed to assess Quality of Care (QoC), therefore, determining whether a HF was offering basic curative services was in line with the terms of reference, assessing how well those services were being implemented was not. 5. Planned Activities Next Month Field visit to the Wulu County in the former Lakes State and Gogriel in the former Warrap State for the verification of the institutional strengthening component of the LOGOSEED project at the respective county levels. The team will also finalize the data collection tools for the LOGOSEED project. IOM will develop a Terms of Reference for a consultant to undertake a KAP survey for the RRHP in former Upper Nile and Jonglei States to be shared with the Bank for approval and review. If approved, roll‐out is tentatively scheduled for February‐March 2019. 6. Annexes Annex 1 – List of Health Facility Demographics Annex 2 – RRHP data collection tools Annex 3 – LOGOSEED civil work specification checklist sample (classroom) Annex 4 – TPM in Pictures .