Health Systems Strengthening Component USAID's Maternal And

Health Systems Strengthening Component

USAID’s Maternal and Child Health Program

Final Report

Cooperative Agreement No. AID-91-A-13-00002

All photographs in this final report are credited to Veronique de Viguerie, The Verbatim Agency for JSI, unless otherwise noted.

Cover photo: Pregnant women in Sindh province line up to receive the tetanus toxoid vaccination. A JSI- implemented pilot increased tetanus toxoid coverage among pregnant women from 25 to 95 percent in four districts.

Disclaimer

This document 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. and do not necessarily reflect the views of USAID or the United States Government.

Table of Contents LIST OF ABBREVIATIONS ...... 5 EXECUTIVE SUMMARY ...... 7 CHAPTER I: BACKGROUND ...... 9 Introduction ...... 9 Key Areas of Focus & Intermediate Results ...... 10 Approach and Strategic Principles ...... 11 Major Opportunities and Constraints ...... 11 CHAPTER II: INCREASED ACCOUNTABILITY & TRANSPARENCY OF HEALTH SYSTEMS ...... 13 Strengthening Oversight Mechanisms and Advocacy for Health Reform ...... 13 Technical Backstopping ...... 13 Use of Information for Improved Accountability ...... 13 Oversight at the District Level through District Health & Population Management Teams ...... 15 Accountability at the Grassroots Level ...... 16 CHAPTER III: IMPROVED HEALTH MANAGEMENT CAPACITY ...... 18 Fostering a Paradigm Shift in the District Planning Culture in Sindh ...... 18 Human Resource Capacity Building for Saving Lives ...... 19 Strengthening District Health Information Systems ...... 22 Health Facility Assessment ...... 24 Pilot for Improving Coverage of Routine Immunization ...... 26 Sindh Health Care Commission ...... 28 CHAPTER IV: STRENGTHENED PUBLIC PRIVATE PARTNERSHIPS ...... 29 Overview ...... 29 Health Financing Model ...... 29 Key Elements of the Model ...... 30 CHAPTER V: HEALTH SYSTEMS STRENGTHENING AT THE FEDERAL LEVEL ...... 32 Overview ...... 32 National Health Vision ...... 33 Health Planning, Systems Strengthening, and Information Analysis Unit at the MoNHSR&C ...... 34 ISO Certification ...... 34 Anti-microbial Resistance ...... 34 System Strengthening for Securing Essential Medicines: The Case of Chlorhexidine ...... 35

CHAPTER VI: KEY PERFORMANCE INDICATORS ...... 37 Performance Metrics ...... 37 CHAPTER VII: Lessons Learned and Way Forward ...... 42 Lessons Learned ...... 42 Way Forward ...... 43

LIST OF ABBREVIATIONS

ANC Antenatal Care AOP Annual Operational Plan BCG Bacille Calmette-Guerin vaccine (for tuberculosis) CBOC Capacity Building Oversight Committee CHX Chlorhexidine DAP District Action Plan DDO Drawing and Disbursing Officer DGHS Director General Health Services DHIS District Health Information System DHN District Health Network DHO District Health Officer DHPMT District Health and Population Management Team DOH Department of Health DPT3 The Third Diphtheria, Pertussis, and Tetanus Vaccine DPWO District Population Welfare Officer ENAP Every Newborn Action Plan EPI Expanded Program on Immunization FM Field Manager FP/MNCH Family Planning/Maternal, Newborn, and Child Health HFA Health Facility Assessment HHF Heartfile Health Financing HR Human Resources HSS Component Health Systems Strengthening Component ICT Islamabad Capital Territory IMR Infant Mortality Rate IHS Integrated Health Services IR Intermediate Result JSI JSI Research & Training Institute, Inc. LHW Lady Health Worker MMR Maternal Mortality Ratio MSPH Master of Science In Public Health MTBF Medium-Term Budgetary Framework M&E Monitoring and Evaluation M&S Monitoring and Supervision MCH Maternal and Child Health MNCH Maternal, Newborn, and Child Health MNHSR&C Ministry of National Health Services, Regulations & Coordination NMR Newborn Mortality Rate OPV Oral Polio Virus Vaccine PDHS Pakistan Demographic and Health Survey PCV Pneumococcal Conjugate Vaccine Penta Pentavalent Vaccine (Diphtheria, Pertussis, Tetanus, Hepatitis B & Hib) PHC Primary Health Care

PHDC Provincial Health Development Centre PHCC Punjab Health Care Commission PIMS Pakistan Institute of Medical Sciences PNC Postnatal Care PPHI People’s Primary Healthcare Initiative PRISM Performance Review of Information System PWD Population Welfare Department RMNCH Reproductive, Maternal, Newborn, and Child Health RSPN Rural Support Program Network SHCC Sindh Health Care Commission SHIS Sindh Health Information System UCHC Union Council Health Committee UNICEF United Nations Children’s Fund USAID United States Agency for International Development

EXECUTIVE SUMMARY

The Health Systems Strengthening Component of USAID’s Maternal and Child Health Program (the HSS Component) was a five-year project (2013-2018) implemented by JSI Research & Training Institute, Inc. (JSI) with partners CONTECH International, the Rural Support Program Network (RSPN), and Heartfile Health Financing.

USAID’s MCH Program consisted of five interrelated and mutually supportive components: 1) family planning and reproductive health; 2) maternal, newborn and child health services; 3) health communications and behavior change communication; 4) commodity procurement and logistics management; and 5) health systems strengthening. The HSS Component was designed to complement the other four components.

In 2010, Pakistan’s 18th constitutional amendment decentralized the country’s health system, giving provinces a much greater role in setting health sector strategies, policies, and financing. Decentralization was a major paradigm shift for Pakistan and required provincial health systems to make substantial structural and fiscal adjustments to be in line with the new legislation.

USAID’s Maternal and Child Health Program was developed to support the Pakistani government and Sindh province, in particular, through the initial process of decentralization. The HSS Component worked at all levels of government to make critical human and financial resources available at federal, provincial, and district levels. In Sindh, the HSS Component worked with the Department of Health to improve its ability to manage how RMNCH services are provided to citizens.

Only with the help and collaboration of numerous stakeholders was it possible for the HSS Component to put in place health systems strengthening measures that are truly sustainable. A key approach was to ensure that USAID’s assistance dovetailed with short- and long-term government plans, at both the federal and provincial levels, in support of strengthening Pakistan’s health system in a continuous and sustainable manner.

By contributing and mobilizing significant resources across key components of the health system, the HSS Component was able to leverage synergies of the various interventions. For example, making sure that government policies support expanding access to actionable data, while giving health managers the training needed to generate and use that data, enabled districts to make sound financial and programmatic decisions to improve care.

With simultaneous improvements in policies, infrastructure, training, and community engagement; USAID, in partnership with the Ministry of National Health Services, Regulation, and Coordination (MNHSR&C), the Sindh Department of Health (DOH), and other stakeholders, has built a foundation that enables better quality health services and sets national and provincial standards in the wake of decentralization. To complete such a comprehensive program, the HSS Component worked with stakeholders from all levels of the country’s health system, including government agencies, faith-based and nongovernmental organizations, international donors and implementers, local communities, and the private sector.

The HSS Component helped foster positive change at the federal level and in Sindh. Result highlights include improving the “culture of data use” in Sindh Province: Data accuracy rose from 64 to 78 percent

in just two years (2014 to 2016)1 and District Health and Population Management Teams (DHPMTs) voluntarily hold quarterly meetings on their own, where they meet to review health data and use it for planning, budgeting, and problem solving.

Moreover, Sindh districts are able to address most (80 percent) of their health-sector challenges on their own, thanks to DHPMTs using data to identify and solve problems. And in response to DHPMTs engaging in district action planning and using the medium-term budgetary framework to substantiate budget requests, Sindh health budgets grew a remarkable 187 percent in the budget for 2017-18 as compared to 28.1 percent in 2014-15 budget. An online, integrated data dashboard the HSS Component helped create has been handed over to the Sindh government and is now fully funded by the province.

At the federal level, among many other accomplishments, chlorhexidine (CHX) is poised to be scaled up nationwide, thanks to a new national protocol, a standardized health provider curriculum, local production of CHX, and other systems-level interventions facilitated by the HSS Component. This is potentially a game-changer for improving newborn mortality.

The key lesson learned from implementing the HSS Component is that a system strengthening approach for developing long-term institutional capacity is far more effective and sustainable than approaches that focus on short-term gains or service delivery alone. Health system strengthening requires a multipronged approach that improves various tiers of the health system in unison, building partnerships and developing strong coordination mechanisms. Such an approach also gives new insight into how changing some of the supporting systems and using credible data results in the allocation of adequate resources based on need, an appetite for reform, and commitment at the highest levels to institute the institutional and policy measures required. Fundamental to system strengthening is adopting an approach in which recommendations are rooted in evidence and proper assessments first to understand where the problems exist and then used to forge a strategy to best deal with them.

While the HSS Component has laid the groundwork for systems strengthening and instituted many strong mechanisms that are likely to be sustainable, experience has shown that old habits die hard. It is important to ensure that incentives within the system are strong enough to continue to implement the measures proposed and that some of the interventions which need further support are continued by the health management system on its own at both the provincial and district level. While there is strong evidence that, in most cases, the government is committed to continuing the work, there is also frequent turnover of senior leadership and a need to re-ensure commitment. The HSS Component has demonstrated many useful interventions in key areas of the health sector, and this will need support at the highest levels to continue the challenging task of improving the health outcomes of the people of Sindh.

In 2017 USAID supported an external evaluation of the HSS Component,2 which concluded the project left lasting changes in the way health systems function in Sindh and created a strong foundation for sustainability.

1 Assessment Report of the District Health Information System (DHIS) PRISM Framework, December 2016. Health Systems Strengthening Component of USAID’s MCH Program 2 Health Systems Strengthening. Final Evaluation Report. Contracted under Order No. AID-391-C-15-00004 Performance Management Support Contract. Management Systems International. January 2018. USAID.

CHAPTER I: BACKGROUND

Introduction The Health Systems Strengthening Component of USAID’s Maternal and Child Health Program (the HSS Component) was a five-year project (2013-2018) implemented by JSI Research & Training Institute, Inc. (JSI) with partners CONTECH International, the Rural Support Program Network (RSPN), and Heartfile Health Financing.

USAID’s Maternal and Child Health (MCH) program was designed to improve women and children’s health status through increased delivery of quality services and strengthened health systems. Under this program, USAID supported innovative approaches to enhance the capacity of Pakistan’s public and private sectors to deliver high-impact interventions to address reproductive health needs and reduce maternal, newborn and child morbidity and mortality. The program mobilized communities to adopt positive health practices and reinforce the social contract to support the devolution process.

Table 1. USAID’s Maternal and Child Health Program Implementing Partners

MCH Program Component Implementing Partner Organization

Family Planning and Reproductive Health Marie Stopes Society

Maternal, Newborn, and Child Health Services Jhpiego

Health Communications and Behavior Change Johns Hopkins University Center for Communication Communications Programs

Commodity Procurement and Logistics John Snow, Inc./Chemonics Management/ Procurement and Supply Management

Health Systems Strengthening JSI Research & Training Institute, Inc.

The HSS Component coordinated with other MCH program partners to ensure coordination and collaboration in the development of annual work plans and other key aspects of the health systems.

This final report focuses on the HSS Component’s intermediate outcomes, institutional and policy impact, impact on service delivery, prospect for sustainability, lessons learned, and recommendations for the future. While it may be too early to assess the impact of the HSS Component on key maternal

and child health (MCH) indicators in Sindh, the ongoing multi-cluster indicator survey (MICS) and the demographic and health survey (DHS) are expected to reflect the impact of HSS interventions on the MCH indicators in Sindh. This report discusses implementation of the HSS Component at the federal level and in Sindh.

Key Areas of Focus & Intermediate Results The goal of the HSS Component was to develop and support innovative, cost-effective, integrated, and systems-based interventions to strengthen reproductive, maternal, newborn, and child health (RMNCH) services for improved health outcomes.

The goal of the HSS Component was to improve health outcomes in communities across Sindh Province.

The HSS Component project initially worked at the provincial level in Sindh and at the district level in all districts of Sindh, except for Karachi. In Sindh, the HSS Component worked with the Sindh Department of Health to improve its ability to manage how RMNCH services are provided to citizens. At USAID’s request, the project expanded activities to the federal level in its third year. At all three levels (federal, provincial and district), the project provided technical assistance to the health and population sector to reform and improve service delivery. The program had the following key areas of focus:

● Strengthening systems to foster improved RMNCH service delivery and outcomes, including accountability and transparency; ● Strengthening management capacity at the provincial and district levels; ● Developing innovative approaches to catalyse community outreach services and access to health services for marginalized populations (including financing schemes); ● Strengthening private sector delivery for the urban and rural poor populations.

The HSS Component was designed to engage in the coordination, alignment, and calibration of USAID’s RMNCH activities undertaken by MCH Program partners to ensure there was no duplication of efforts and that all critical elements for achieving results reinforced each other. The HSS Component worked to achieve the following intermediate results (IRs) from the USAID Results Framework for IR 3: Strengthened Health Systems.

● IR 3.1: Increased Accountability and Transparency of Health Systems ● IR 3.2: Improved Management Capacity at Provincial and District Levels within the Health Department ● IR 3.3: Strengthened Public Private Partnerships ● IR 3.4: Improved Health Outreach Services

The HSS Component initially pursued all IRs. However, in October 2014 USAID decided, after the commencement of the Health Communication (HC) Component activities, the mobilization work in communities would be undertaken by the HC Component and not the HSS Component. Thus, the community mobilization activities that had been initiated by RSPN were transferred to the HC Component.

Approach and Strategic Principles The HSS Component adhered to the following strategic principles:

● Flexibility and adaptability in implementation using a customized approach for each entity. ● Strengthening strategic partnerships and coordination to effectively manage an integrated health system. ● Promoting a results-oriented culture. ● Strengthening local expertise and focusing on local innovation to promote sustainability and ownership. ● Promoting community actions for accountability and transparency of the health system. ● Ensuring gender is integrated in the HSS Component’s implementation approach.

Major Opportunities and Constraints When the HSS Component began, several opportunities existed to improve maternal and newborn health in Pakistan. The most significant was the 18th constitutional amendment in 2010, which decentralized many of the sectors in the country, including the health system, to the provincial level. The responsibility for health and population matters was taken away from the federal government and transferred to the provincial level, giving provinces authority and stewardship over policies and service delivery, including priority setting, strategy development, and management of vertical programs. Devolution brought with it a major paradigm shift and required provincial health systems to make substantial structural and fiscal adjustments in line with the new legislation. USAID’s MCH Program came at the right time to support the Pakistani government and Sindh province, in particular, in steering through the initial process of devolution.

The USAID MCH Program was initiated during Pakistan’s commitment to decreasing the infant mortality rate (IMR) by two thirds and the maternal mortality rate (MMR) by three quarters by 2015. In 2016, the country committed to achieve the Sustainable Development Goals (SDGs). The government also adopted the National Maternal and Child Health Policy and Strategic Framework (2005-2015), to be

implemented through the national maternal and child health program. Pakistan’s ambitious health sector reform agenda focused on building devolved district health systems and developing community- centred solutions to health problems. The HSS Component was designed to assist with this transition and build capacity at various institutional tiers.

Along with these opportunities came a set of challenges that needed to be negotiated and addressed to ensure that investments being made through the HSS Component would have a sustainable and scalable impact on the delivery of health services and the improvement of health outcomes in Sindh. These constraints included the socio-economic profile of the target population, the nature of the health system, and administrative and bureaucratic constraints, among others. Pakistan’s health system is a complex mix of public and private service delivery systems, suffering from inefficiencies and the lack of a regulatory framework for the private sector.

The public health sector is underfinanced and funds are released in piecemeal. A high proportion of sanctioned posts are vacant especially in the more remote parts of Sindh; there is a high degree of staff absenteeism and staff turn-over; staff salaries are low; and there is no incentive system to motivate existing staff. There are also frequent transfers of civil servants, a lack of accountability, and inefficiencies in staff deployment, which add to the poor performance and perception of the public health system.

Devolution brought with it a new set of challenges such as the insufficient definition of roles and responsibilities and low priority of the health sector in accessing resources from the district budgets. Devolution occurred without a strategic dialogue between federal and provincial entities about how authority and responsibility would be transferred effectively. There was no national-level vision for how a post-devolution environment should operate, or a unified planning apparatus. This was exacerbated by a lack of information about what was happening at the federal level, which hampered the ability of provinces, including Sindh, to assume management of key federal programs, such as health and population programs. In addition, there was no clarity about important and successful programs that affect maternal and child health and achievement of the MDGs, such as the expanded program of immunization (EPI) and the lady health worker (LHW) program.

Among the social issues, the most significant was the fact that health-seeking behaviour is deeply influenced by socio-cultural attitudes and religious views, which are often misinterpreted and contribute to a high degree of risk, especially for mothers and children. This is compounded by the fact that literacy rates are extremely low, especially among women, and were reported to be 49 percent in 2015.3 The lack of recognition of danger signs during pregnancy by families and communities and the lack of timely referral to health facilities was a major factor in contributing to high maternal and neonatal mortality rates. The combined effect of these factors led to delays in decision making which often threatened the lives of pregnant women and newborns. The poor availability of transport, financial constraints, and the unavailability of chaperones were important barriers to seeking health care. In addition, private facilities were often preferred due to the perceived superior quality of services.4 These social factors were often found to be even more critical than the institutional factors that impeded the performance of the public health sector.

3 Pakistan Social and Living Standards Measurement Survey (2014-2015). Pakistan Bureau of Statistics. Government of Pakistan. March 2016. 4 Qureshi et al. Health Care Seeking Behaviors in Pregnancy in Rural Sindh, Pakistan: a Qualitative Study. Reproductive Health 201613 (Suppl 1):34. June 2016.

CHAPTER II: INCREASED ACCOUNTABILITY & TRANSPARENCY OF HEALTH SYSTEMS

Strengthening Oversight Mechanisms and Advocacy for Health Reform The HSS Component adopted a multipronged approach to enhance accountability and transparency of the health system in Sindh. It strengthened the oversight and steering mechanisms at the highest level by assisting the Government of Sindh (GOS) to establish the reproductive, maternal, newborn, and child health (RMNCH) steering committee, a multi-sector coordination body mandated to provide strategic direction and oversight to improve RMNCH services. After a few meetings, oversight was provided directly by the Secretary Health office. The HSS Component also engaged parliamentarians in the Sindh Assembly to enhance their awareness about RMNCH issues and capitalize on their capacity to influence key reforms in the health sector. With this in mind it also actively engaged the Standing Committee on Health in the Sindh parliament. The focus of these efforts was on urging change through (i) an urgent review of the human resources (HR) situation at the district headquarter hospitals; (ii) lifting a ban on staff hiring in the province; (iii) filling vacant positions for sanctioned posts; and (iv) devising stop-gap arrangements where permanent appointments were not immediately possible. The HSS Component helped draft HR legislation, which the Secretary Health Sindh shared with the law department, however, it has not been finalized. The HSS Component also advocated for establishing the Sindh Health Care Commission and for strengthening the lady health worker (LHW) program. In addition, HSS Component supported the re-structuring of the DOH in partnership with the World Bank.

Technical Backstopping In 2012, the Health Sector Reforms Unit (HSRU) was established to assist the DOH to undertake several strategic functions that included policy, regulation, technical backstopping, HR and organizational restructuring, and evaluation and research. However, the HSRU did not become part of the regular budget of DOH after the completion of the PC-I in part because the DOH realizes the Secretariat does not have the right technical staff to carry out some of the functions. The DOH asked the HSS component to provide technical assistance to establish a technical unit at the Secretariat for evidence-based decision making, planning, budgeting, improved accountability, and governance. Although initially delayed due to lack of space, a space was recently identified and is now being renovated. The HSS Component provided technical assistance to define the functions of the technical unit staff and to orient the staff on various management information systems (MIS) and other monitoring indicators. The technical unit was expected to use information made available through the newly created online dashboard (see below) to advocate for rational budget allocations and prioritized interventions.

Use of Information for Improved Accountability A well-functioning health information system is a central building block of health system strengthening. It can increase transparency, track health system performance, support health policies and health- related decisions, and ultimately improve the quality of care. However, monitoring the delivery of health care services and ensuring accountability of performance has remained one of the most challenging areas in the health sector, where responsibility for developing policies, plans, monitoring, and accountability is at the provincial level. The Sindh Health Sector Strategy 2012–2020 noted that provincial health MIS were inadequate, and even when they did exist, were under used.

The Sindh DOH requested the HSS Component to provide technical assistance to develop an integrated,

online, interactive MIS dashboard. This dashboard was designed to link data from all vertical service delivery programs, including national, provincial, and district level health and social sector surveys such as the Pakistan Social and Living Standards Measurement Survey (PSLM), the Multi-Cluster Indicator Survey (MCIS), the Pakistan Demographic and Health Survey (PDHS), the National Nutrition Survey (NNS), and more. The vision was to develop a “one-stop shop” where routinely updated information on service delivery, HR for health, and district level efforts to supervise and improve service delivery could be monitored and assessed at the district and provincial levels for evidence-based decision making.

The integrated dashboard was developed into the Sindh Health Information System (SHIS), currently serves as the provincial dashboard, and incorporates district health information system (DHIS), LHW- MIS, MNCH-MIS, a monitoring and supervisory system, and an integrated family planning dashboard. In addition to the routine HIS, it includes the national, provincial, and district level health and social sector surveys (e.g., PSLM, PDHS, MICS, NNS). The Sindh dashboard allows desk-based, routinely updated data monitoring, and visual data display. Currently, data for all public health facilities and individual LHW and CMW data are online for all districts across Sindh province. This system also allows a ranking of districts based on their performance on a selected set of indicators. The system has generated healthy competition among district managers.

HSS Component and DGHS staff members officially inaugurated M&E cell in Sindh Province.

The HSS Component helped rehabilitate monitoring and evaluation (M&E) cells in all districts and trained more than 200 health managers accordingly. Over the life of the project, data quality improved significantly: data accuracy rose from 64 to 79 percent between 2014 and 2016 and data is more often used for advocacy and evidence-based decision making, monitoring, and supervision. Prior to HSS

Component interventions, data did not influence district-level budgeting or planning; now data from the integrated dashboard is used to develop district action plans and district-level medium-term budgetary frameworks in all districts. Before the end of the program, the HSS Component handed over the cloud- based hosting control panel and MIS administration panels to relevant Sindh DOH staff. Financial support for the dashboard is now included in the annual health budget of the GOS. The integrated dashboard system is a model that is being scaled–up to other provinces in Pakistan.

The final evaluation5 report confirmed the integrated, online SHIS dashboard improved the use of information at the district level through improved access to data. The online dashboard made data available through mobile apps and desktop computers in the M&E cells, and by storing MISs in one place. Better access to data strengthened planning processes and contributed to shared accountability and transparency as data sets from various programs and departments are now visible to all stakeholders. All of this has enabled district- and provincial-level managers to provide appropriate oversight and make evidence-based decisions.

Oversight at the District Level through District Health & Population Management Teams The HSS Component assisted the DOH to form District Health & Population Management Teams (DHPMTs) where they did not exist, and to revitalize them where they did. The HSS Component supported the DHPMTs to strengthen their oversight role by improving planning, management, and coordination. The HSS Component held consultations with the DOH and the Population Welfare Department (PWD) and reviewed the status of DHPMTs in selected districts. The HSS Component provided technical assistance to strengthen the role of DHPMTs to improve coordination and accountability. DHPMT meetings focused on improving planning, monitoring progress, and improving coordination among DOH, PWD, and People’s Primary Healthcare Initiative (PPHI). Standard operating procedures (SOPs) for step-by-step implementation of DHPMT meetings were prepared jointly and approved by the Director General Health Services (DGHS) to be displayed in the districts.

The HSS Component demonstrated how DHMPT platforms could be used to advocate for corrective measures to improve MCH outcomes. The HSS Component shared findings from the health facility assessment with the DHPMTs to help them identify and fill gaps to improve health service delivery outcomes. Over the project lifespan, DHMPTs became an important mechanism for improving the performance of the system. The DHMPT meetings improved coordination between DOH and line departments; collective evidence-based decision-making; performance reviews of administrative and service delivery areas; and identification and resolution of local issues, problems, and concerns related to health care service delivery. For example, in response LHWs not being in compliance with reporting requirements in some districts, DGHS Sindh instructed the respective DHOs to improve LHW reporting compliance.

To improve sustainability, the DOH institutionalized the DHPMTs and took ownership of them. The HSS Component initially played an active role in convening DHPMT meetings but encouraged the DOH to gradually assume primary responsibility for convening them. The HSS Component provided technical support for this transition by developing SOPs, standardizing tools, and updating DHPMT performance assessment criteria.

5 Final Evaluation Report. HSS Component. Management Systems International. USAID. January 2018.

At the provincial level, the HSS Component helped the DGHS analyze DHPMT performance and provide feedback to the districts. During these meetings, policy-level decisions are made to support district managers to make decisions and take action for improving health care delivery. DHPMT performance data shows gradual but continued improvement, with 21 districts demonstrating excellent progress toward targets on priority actions outlined in district action plans. More than 80 percent of challenges identified at quarterly DHPMT meetings are resolved at the district level. Policy-level issues were brought to the RMNCH steering committee for deliberations. If steering committee deliberations were ineffective, the matters were brought directly to the Secretary Health office. Revitalizing DHPMTs also brought community input to the process of prioritizing health issues and decision-making. Provincial roles and communication between the provincial and district levels were also strengthened through joint provincial quarterly review meetings of activities at the district level, which allowed problems beyond the scope of the districts to be communicated and delegated to the provincial level.

Accountability at the Grassroots Level At the grassroots level, the HSS Component established village health committees and union council health committees (UCHCs) to improve health services and accountability. Some of the existing community organizations formed by Rural Support Programs (RSPs) were revitalized. However, in October 2014 the task of strengthening these community organizations was handed over to the USAID MCH Program HC Component. The HSS Component implemented this work for only the first two years.

The initial experience of the HSS Component with these grass-roots organizations was very positive. At the time when they were being monitored by HSS Component, their membership was very diverse. The VHCs included representation from women, poor, and socially marginalized groups to advocate for better delivery of health services as part of their scope of work. VHCs and UCHCs served as forums for community members to receive information about functional facilities in their areas and services that were available in these facilities. The main purpose was to empower them to demand quality services from the public sector. The HSS Component also mapped private health facilities to provide information to rural communities if public sector facilities did not exist in their areas.

As of September 2014, the HSS Component had formed or revitalized 1,238 VHCs in 35 union councils in Dadu, Tando Allah Yar, Tharparkar, Thatta, and Umerkot districts. The main focus during the second year was to support VHCs to hold quarterly meetings. A review of the performance showed that while 30 percent of the VHCs held the requisite number of meetings, the others did not successfully hold quarterly meetings. More than 17,000 VHC members (6,381 men and 10,866 women) attended these quarterly meetings. Participation of women stood at over 60 percent. VHCs spread the word about health services in their respective villages and collected feedback from community members about the availability of health services and supplies, improving accountability of public health staff and awareness of the role that they could play in strengthening health services.

At the union council level, VHCs were aggregated into UCHCs, which were further consolidated into district health networks (DHNs), coalitions of all UCHCs in a district. DHN membership consisted of representatives from UCHCs and health sector NGOs, including USAID MCH Program implementing partners Marie Stopes Society and Jhpiego. The HSS Component formed five DHNs during its second year, one in each of the five target districts, which interfaced with DHPMTs in their districts to advocate for improved health services. The work of VHCs, UCHCs, and DHNs showed that communities are capable of working together to maintain their own system of accountability whereby problems faced at the grassroots level can be brought to the attention of district level health officials. These grassroots mechanisms played active roles in sharing feedback regarding problems in the availability and quality of

16 healthcare services in their areas and have also lobbied and taken steps to rectify those issues. Some examples of the gains that were made by these communities are listed in Table 2 below:

Table 2. Improving Performance by Building Local Accountability

● In district Tando Allah Yar, UCHC Tando Soomro received feedback from one of its VHCs about a family planning client whose case was mishandled and who was treated poorly at a clinic. The UCHC approached the district in-charge and reported the case and the lack of a follow-up visit. The district in-charge apologized and sent a health care provider to provide services to the client. ● UCHC Kharoro Syed (in Umerkot district), upon learning about the absence of a vaccinator, approached the in-charge of the basic health unit (BHU) in the area and the district health officer apprised them of the situation. The vacancy was addressed, and as a result, 40 eligible children received BCG vaccinations and an additional 202 children received measles vaccinations. ● In Dadu district, one UCHC, upon receiving a complaint from a VHC about the unprofessional treatment by a clinician at a PPHI- managed MCH center, had a meeting with the PPHI district support manager. As a result, the clinician was disciplined for her actions. In addition, PPHI recognized the lack of supplies at the MCH center and immediately provided financial support to address the shortages. ● As a response to community feedback shared during the UCHC quarterly meeting, PPHI, which manages BHUs in Sindh, appointed a lady health visitor at the local BHU.

CHAPTER III: IMPROVED HEALTH MANAGEMENT CAPACITY

Fostering a Paradigm Shift in the District Planning Culture in Sindh The HSS Component approach was designed to support the paradigm shift in the health sector in Pakistan which transferred the stewardship, policy-making, and strategic decision-making responsibility from the central to the provincial levels and the role of translating strategy into action to the district level. What was once a more passive role for districts as implementers of actions became a proactive one as they now must determine their own actions. The HSS Component played a key role helping districts adapt to the changes in their organizational and fiscal planning culture. A key instrument to undertake some of the planning functions at the district level was revitalizing the DHPMTs. The Health System Strengthening Component revitalized DHPMTs in all 23 intervention districts in Sindh Province. The revitalization facilitated district-level coordination and decision-making and strengthened fiscal and operational planning to improve health service delivery. As part of the revitalization process, the HSS Component built DHPMT capacity to conduct participatory decision-making, evidenced-based planning, and performance-based budgeting.

DGHS Office team regularly meet and use high-quality data, generated at the district level, to make program- and budget-related decisions affecting Sindh’s health sector. (Photo credit: JSI)

The process of capacity building was based on an “inside-out” philosophy, which built upon existing structures and processes from within by supporting key stakeholders to lead and steer the process forward. This was foundational to the capacity-building approach and ensured the acceptability, sustainability, and accountability within this new planning culture. While the HSS Component provided intensive technical assistance during the first year, this was gradually reduced as the skills and capacity of district-level players was strengthened. District health planning committees (DHPCs) were instituted comprising of key representatives, including senior health managers, Department of Education representatives, district health officers, district managers of PPHI, and district population welfare officers. The HSS Component facilitated a series of workshops to enhance the planning skills of DHPC members. Technical assistance to build financial skills and ensure financial integration in planning was provided to rationalize the financial support needed to operationalize the plans.

The HSS Component also assisted in conducting a situational analysis of each district and created district analytic profiles. The analysis identified health issues and system-level challenges specific to each district to ensure that planning would address the specific needs of each district. In addition, Multiple Indicator Cluster Survey (MICS) and Pakistan Social and Living Standard Measurement (PSLM) data were used to identify district challenges. The HSS Component engaged the Economic Reforms Unit of the Sindh Department of Finance to train district teams on the medium-term budgetary framework (MTBF). As a result, all districts, for the first time, have independently developed district action plans (DAPs) covering fiscal years 2015–18 which outline key health challenges, identify specific interventions to address root causes, and identify gaps in resources and requirements. Provincial annual operational plans based on the information from the DAPs were created for fiscal years 2015–16, 2016–17, and 2017–18.

To help ensure sustainability of the DAP process, the HSS Component built the capacity of critical personnel to sustain the systems beyond U.S. government support by training 580 cost-center staff in planning, performance-based decision making, and related skills. It also trained 81 master trainers and 405 staff involved in budget preparations in the MTBF process. Using the results of DHPMT review meetings, the HSS Component worked with stakeholders to advocate with politicians, policy entrepreneurs, and other key decision makers and planners in the Sindh Departments of Health, Finance, and Planning and Development. As a result, the government of Sindh allocated an additional budget of PKR 330.8 million for fiscal year 2016–17 for staff training, monitoring and supervisory visits, and conducting health care awareness community events. SOPs were developed to guide budget preparation at the district level.

Human Resource Capacity Building for Saving Lives With the increased responsibility of provincial and district staff following decentralization, capacity building became an integral part of strengthening the health system. The HSS Component developed a capacity building strategy to support Sindh’s plans to manage the provision of health services through a combination of technical support, training, and tools for management strengthening. The HSS Component conducted a capacity assessment that involve representatives from the three organizations responsible for delivering health and population services in Sindh: DOH, PWD, and PPHI. The representatives self-assessed their skills and abilities related to the WHO health system building blocks. Based on the assessment, the HSS Component’s approach integrated building capacity at the individual, organizational, and systems levels to improve the health system in a sustainable manner.

Training at the individual level elevated knowledge and skills; development of internal processes and resources such as supervision tools, data collection, and review procedures help develop organizational capacity; and effective HR policies provide the systems framework for deployment, retention, and

promotion of newly trained managers. The HSS Component supported a two-year master’s degree training program for public health professionals for ensuring a significant and sustainable increase in capacity. The HSS Component worked with Sindh’s Capacity Building Oversight Committee (CBOC), which was created to identify and select training institutes, develop eligibility and selection criteria for candidates, and identify candidates for training opportunities. Health managers were selected from all districts of Sindh. Graduates gained skills to improve district and institutional performance through accredited training institutes. The HSS Component worked with DOH to develop a deployment plan to ensure that graduates were placed in appropriate jobs upon completion.

At the individual level, 163 health managers completed long-term and short-term training programs as described in the box below. Graduates returned to management posts at district or provincial levels with improved leadership and management skills. The HSS Component made a deployment plan that nominated each graduate for an appropriate position. At the institutional level, the HSS Component assessed the Provincial Health Development Center’s (PHDC)—the only capacity-development institution in the province— potential as a center for in-service training programs in 2014. The assessment identified areas for improvement and the need to develop linkages with other institutions in the province and the Health Services Academy in Islamabad. On a request from the DOH, the HSS Component developed a costed operational plan in 2016. In 2017, the DOH submitted a PC-16 to upgrade the PHDC to the Provincial Health Services Academy with technical assistance from the HSS Component. Policy decisions on next steps are pending.

Box 1. Human Resources Trained under the HSS Component

● 77 managers (25 PPHI, 47 health, and five population department managers) completed two-year master’s degrees in public health

● 86 health managers completed short-term training programs (strategic planning, human resources for health, organizational management)

● 200 health managers trained to use the online monitoring and supervisory system

● 580 health staff trained to develop a medium-term budgetary framework

● 105 health staff trained to develop district action plans

● More than 2,300 health facility staff trained to use the online DHIS

At the systems level, the HSS Component helped each district in Sindh Province develop a district action plan in line with the medium-term budgetary framework (MTBF) that prioritized issues according to its respective health and service delivery system. One-hundred-and-five health managers (nearly 40%) were trained to develop district action plans and 580 staff were trained to use the MTBF. As a result, Sindh Province received an 18 percent budget allocation increase over the previous year. For the first time, the budget included funding for in-service trainings, which were identified as a need during district action planning.

6 A PC-1 is a planning tool used by governmental departments in Pakistan for the development and execution of projects.

The HSS Component revitalized DHPMTs to translate policy into action by building capacity for planning and budget preparation, coordination, and decision-making. Ninety-five percent of DHPMTs now use health data to make district-level health-sector decisions when they meet. The HSS Component built the capacity of managers and policymakers to use Sindh’s new, web-based, integrated dashboard, which provides real-time health information to anyone with a log-in and an internet connection. 2,300 public- sector staff in 226 health facilities managed by DOH were trained in recording accurate data and reporting complete data.

The HSS Component also emphasized building the capacity of individuals and teams engaged in monitoring and supervision and of institutions to strengthen systems. Two-hundred health managers were trained to use the online monitoring and supervisory system, also part of the integrated dashboard. Training sessions were conducted in Hyderabad at the DGHS office Sindh and in Sukkur. A total of 138 district focal persons and 12 provincial representatives of MNCH, hepatitis, TB control, EPI, malaria, and the national program for primary health care (PHC) and FP were trained by their respective provincial technical teams on the use of online monitoring and supervisory checklists. These trainings helped supervisors observe the quality of services and validate the progress reported through their respective MISs. The HSS Component was mindful of the sustainability of the M&E system that it had put in place and began to develop an exit strategy in its final year. It gradually transferred the MISs and control panels to government counterparts and developed a capacity building plan for DOH technical staff.

When the HSS Component began in 2013, all districts received more or less the same increase in funding every year, regardless of their individual circumstances and needs. District-level health budgets were disbursed either on the basis of a flat annual increase or based on elements that were not very transparent. There were no mechanisms or standards to ensure that facilities were reporting quality data and providing the right health services. With the preparation of the DAPs, the districts now use their own data to plan the provision of health services. The DAPs are created in line with the Sindh DOH’s budgetary framework, and this has enabled districts to develop realistic budgets and thus implement their plans successfully. DAPs and MTBFs are tracked online via the integrated dashboard, which has increased district transparency and accountability. The Sindh DOH now allocates district health funding based on the DAP and MTBF process. DAPs also provide a way to measure progress towards achieving district-specific RMNCH priorities.

The HSS Component provided technical support to all 580 cost centers of Sindh to prepare the MTBF budget for fiscal year 2016-17 based on service provision data. Technical support was provided to the Finance Department to link DAPs with the MTBF. Districts reported on their progress against annual operational plans (i.e., achievement of targets and expenditures incurred) using the new online M&E dashboard. This online system is helping the Finance Department monitor the use of funds released against proposed activities. The districts are now in a position to effectively advocate their own case for larger budget allocations and timely release of funds. The strategy has been very effective as is evidenced by the real increase in annual budgetary allocations over the program period. For the first time in 2016, budgets in three areas: M&E, health communication, and training were allocated, and activities were initiated by the DOH. The efforts of the USAID were acknowledged in the 2016 budget speech by the Finance Minister of Sindh.

There was sufficient confidence in the HSS Component so that in 2017 when the Sindh DOH felt that there was a need to make structural adjustments in the system, it requested the HSS Component to provide technical assistance. The HSS Component’s team reviewed the organograms of the DOH secretariat, DGHS, and district health offices. Based on this review the HSS Component suggested

revisions to DOH job descriptions and structures to accommodate projections for DOH responsibilities over the next ten years. Among the identified weaknesses were the integrated disease surveillance and response system, the Drug Regulation Authority of Pakistan, outsourcing contract management, procurement, financing, service delivery, nongovernmental organization management, in-service trainings, and planning development and research.

Strengthening District Health Information Systems Among the essential requisites for strengthening health systems is the implementation of a rigorous M&E system, which can ultimately improve coverage and equity of services. The goal of the DHIS cell at the DOH is to implement DHIS in all districts of Sindh. When the HSS Component began in 2013, all 23 districts were submitting DHIS reports regularly. However, an assessment of the quality of data, completeness, timeliness, and use of information had not been conducted. Thus, before designing any interventions to strengthen the DHIS, the HSS Component conducted an assessment using the Performance of Routine Information System Management (PRISM) framework to identify the gaps and weaknesses in the implementation of DHIS. The PRISM framework acknowledges the broader context in which routine health information systems operate and looks into the knowledge and skills of the staff responsible to collect and use data. It also observes information culture, resources, and responsibilities of the health system at each level.

The findings of the assessment, which became available in the first year of the project, showed poor data quality, submission of incomplete reports by health facilities, delayed report submission at both the facility and district levels, decision-making without the use of data, and limited staff competency for data analysis and report writing at the district and provincial levels. The HSS Component provided hands-on support to health facilities in the five selected districts where the DHIS assessment was conducted. The support focused orienting medical superintendents and facility in-charges and training facility staff to use tools correctly, understand key indicators, prepare DHIS monthly reports, check for data quality and accuracy, submit complete reports, and use information for decision-making. Lot quality assurance sampling techniques were used to validate DHIS data accuracy. Master trainers from all 23 districts were trained on efficient use of the system, data entry, and accuracy.

The HSS Component assisted in the review and selection of new DHIS indicators suggested by vertical programs and development partners. Patient registers at health facilities, reporting formats, and the DHIS manual were revised. The revision of DHIS indicators is expected to create uniformity among different MIS indicators and allow public health managers to track the performance of vertical programs. The HSS Component provided technical assistance to improve analytical reports in the DHIS, LHW-MIS, FP-MIS, and the monitoring and supervision (M&S) system. The HSS Component also developed an online implementation system to monitor DAP-related spending. After finalizing interfaces for planning and reporting, new system functions were created including budget release and estimation, activity targeting, expenditure-incurred interfaces, and reporting modules. Reporting modules document details of activities and compares actual versus planned activities. Each district uploads activity reports with code-based cost estimates. Each of the cost centers monitor the implementation progress and expenditures incurred on a quarterly basis. The HSS Component team conducted training sessions for DAP focal persons, accountants, and M&E cell staff of all districts including DGHS Sindh team at the provincial and district levels to enhance their capacity to enter data and monitor activities.

To improve data visualization, access to information through different databases maintained by vertical programs, DOH, PPHI, etc. was synchronized. DHIS data of PPHI-administered health facilities was brought online. As a result, DOH did not have to enter the PPHI data manually because the dashboard

included the PPHI data set as well. PPHI staff were briefed on DOH Sindh DHIS indicators and the availability of indicator-based reports in the newly developed online DHIS. PPHI staff were also informed how to access the variety of analytical reports, generate custom reports using advance report options, and use the dashboard to track specific health facilities through drill down mechanisms. The HSS Component also supported the DOH and vertical programs to integrate the LHW-MIS with DHIS Sindh. The system was introduced for the first time in Pakistan in Sindh province, and contributes to data reliability and identification of bottlenecks impeding performance. A third-party evaluation was conducted to assess the effectiveness of this intervention using PRISM technique. The findings show a significant improvement in all indicators as compared with the December 2013 baseline conducted in the five districts. The data quality improvements are due to the mentoring approach adopted by HSS Component for DOH managed health facilities.

The online integrated dashboard allows provincial health managers to view and compare data across facilities and districts.

To address the data gap, the HSS Component assessed Sindh’s District Health Information System (DHIS) during the first year of the project and used the findings to propose interventions to improve Pakistan’s routine health information system. One of the most important interventions was an integrated, online, interactive health information dashboard. The HSS Component worked with federal, provincial, and district stakeholders to create the dashboard, which is online at www.shis.sindhealth.pk. The integrated dashboard allows health managers to monitor how Sindh is performing across three critical area of its health system. Each area is measured through 17 key performance indicators (KPIs). On the homepage of the integrated dashboard, users have one-click access to the Sindh DHIS, which currently houses data on all public health facilities in Sindh province; the MIS for all vertical health programs, including immunization, community midwives, and LHWs. Health managers working in Sindh at the provincial and

district levels can now review the performance of each health facility, LHW, and community midwife in the province and use this information to make evidence-based financial and programmatic decisions. The HSS Component not only played a critical role in creating the integrated dashboard, but also in developing user guidelines and training health managers and others. These efforts improved data quality and use, which positively impacted transparency and accountability in Sindh.

The HSS Component also worked with the Sindh DOH and other implementing partners to standardize and bring online the provincial M&S system. Before this innovation was introduced, there was no systematic way to oversee and evaluate M&S efforts, which are a critical part of a well-functioning health system. The HSS Component provided technical assistance to the DOH to design the online M&S system (which is integrated into the www.shis.sindhealth.pk dashboard). Vertical program staff worked with the HSS Component to develop standardized tools and checklists, which are available online to download before M&S visits. The HSS Component also convened stakeholders to develop SOPs for M&S visits. The SOPs are available online and displayed in all district health offices and facilities. The M&S system supports supervisors and program and health facility managers to monitor and supervise how health services are delivered. Where capacity was weak, the HSS Component provided technical assistance.

The HSS Component provided training for more than 200 health managers, including district health officers, DHIS coordinators, and vertical program district focal persons, on how to plan for M&S field visits and upload the resulting reports online. All supervision checklists are now completed electronically, and the system has built-in data quality checks. Similar to other components of the integrated dashboard, M&S data can be drilled down to the individual level. Supervisors and supervisees can verify whether supervisory visits are indeed occurring. For example, at each M&S visit, the supervisor must take a picture of him/herself at the supervisory site, which is geo-referenced. When supervisory visits are tied to remuneration, good supervisors are rewarded based on merit, which creates effective supervision.

This use of information has resulted in improved medical stock and performance of vertical programs. The capacity of provincial health authorities has been improved to ensure regular follow up and review of the performance of district health office teams on M&S field visits. Over the time the HSS Component also supported establishment of M&E cells in all districts for evidence-based decision making and to enable health managers and policy makers to have access to reliable and timely data. The M&E cells are collecting, compiling, and disseminating updated progress of all the programs, especially on the KPIs linked to the DAPs through the M&E dashboard. The system has provided structure for facilities and districts to follow submission timelines and ensure accuracy, consistency, and relevance for reporting on progress.

Health Facility Assessment Health facility assessments (HFAs) are increasingly used to measure facilities’ functionality and readiness. In Sindh, the health system faces multiple challenges, including aging infrastructure, deficient human resources, and insufficient quantities of essential medicines, supplies, and equipment. While the Government of Sindh is committed to implementing a reforms agenda through the Sindh Health Sector Strategy 2012–2020, comprehensive facility-level data was required to establish a baseline to measure future health investments. In 2015, the Sindh DOH asked the HSS Component to assess all existing government health facilities in the province. HFA findings were used by the Sindh secretary of health for the annual procurement of medicines and supplies and for BHUs, rural health centers (RHCs), and tehsil and district headquarter (THQ, DHQ) hospitals.

In partnership with the DOH and PPHI, the HSS Component designed an HFA to generate evidence for informed planning and improved transparency among key stakeholders. The HSS Component built consensus among key stakeholders from the initial design stage and followed a standardized methodology throughout the process. All government health facilities (i.e., district headquarter hospitals [DHQHs], taluka headquarter hospitals [THQHs], RHCs, and BHUs) were assessed to ascertain general readiness for their mandated service packages including basic amenities, human resources, facility management, infrastructure, equipment, diagnostics, and medicines and supplies. 928 health facilities (15 DHQHs, 58 THQHs, 121 RHCs, 734 BHUs) in 23 districts, excluding Karachi, were assessed. Data collection medical teams used tools adapted from the service provision assessment of USAID’s MEASURE Evaluation project and the WHO service availability and readiness assessment methodology. Robust monitoring and quality assurance activities were conducted throughout the data collection exercise to validate findings. The HSS Component employed quantitative techniques including interviews of facility in-charges and other staff members, along with physical validation and observation of facility records.

A health worker examines a child at a health facility in Sindh Province. The health facility assessment conducted by the HSS Component laid the groundwork for improving HR, equipment, and medicines in facilities across Sindh.

While the HFA demonstrated critical gaps in functionality and site readiness at all levels of the health system, it gave the Government of Sindh an evidence-based snapshot of HR gaps, infrastructure deficiencies, and inefficient supply chain systems to inform future planning. The HSS Component followed up with specific recommendations for each level of care. By January 2016, the HSS Component completed assessments of 928 health facilities and the findings have been used to inform planning and

decision-making about HR and to serve as a baseline for contracting out health facilities to implementing partners. The DOH is recruiting and placing staff to fill HR gaps. Dissemination of findings was critical and the HSS Component produced 928 health facility-level reports (DHQH, THQH, RHC, and BHU), 23 district- level reports, and a provincial-level report and disseminated them to the provincial government of Sindh, all district health offices, and other stakeholders.

The HSS Component also held a joint meeting with the Sindh secretary of health and his team in Karachi to develop a dissemination strategy for the HFA findings, with the goal of helping inform health planners. The HSS Component held an HFA dissemination workshop at DGHS Sindh to share the findings with stakeholders including PPHI, vertical programs, and USAID MCH Program partners and discuss the way forward. At the district level, DHPMTs were used to inform key stakeholders about the state of health services and the readiness of health facilities in their districts. The DHMPTs were expected to address the gaps highlighted in the assessment. The findings of the HFA helped prioritize key management issues such as HR, equipment, and medicine to improve the quality of health services. The Planning and Development Department in Sindh is using the HFA reports for development schemes and preparation of approval formats (e.g., PC-17) for further action. The Public Private Partnership Node is using the reports for contracted out facilities. PPHI has used the findings to prepare its future plans.

Pilot for Improving Coverage of Routine Immunization Pakistan’s expanded program on immunization (EPI) was launched nationwide in 1978 with the objective of protecting children by immunizing them against childhood tuberculosis, poliomyelitis, diphtheria, pertussis, and measles and protecting pregnant women and their newborns against tetanus. However, the 2013 Pakistan Demographic and Health Survey (PDHS) found low vaccination coverage and implementation gaps in all four provinces in Pakistan. After Baluchistan, the lowest provincial coverage was found in Sindh, where coverage of children 12–23 months with all basic vaccines was reported at 29 percent and 9 percent had no vaccinations at all. Sindh also had the highest urban-rural disparities in the percentage of children who had vaccination cards and in coverage of all basic vaccines relative to other provinces: 52 percent of urban children were vaccinated compared to 14 percent of rural children. Maternal tetanus toxoid coverage in Sindh was also low: 47 percent of pregnant women in Sindh did not receive tetanus toxoid injections before giving birth in the three years preceding the 2012-13 PDHS.

Recognizing the challenges to improving EPI performance in the province, the Sindh DOH requested technical support from the HSS Component to conduct an EPI pilot in the four lowest performing districts: Jacobabad, Kashmore, Tharparkar, and Thatta. These districts were targeted because they had the lowest levels of immunization coverage in Sindh. This technical assistance was aligned with the DOH goals of attaining 90 percent immunization coverage (all basic vaccines) at the provincial level and eradicating polio, measles, and tetanus through supplemental immunization activities. The HSS Component focused on the root causes of low levels of childhood immunizations and mitigating health system barriers to routine immunization coverage. As a preliminary action, the HSS Component needed to understand the target population. Using both population estimates and a complete census of the population in the four target districts, the HSS Component established a target of vaccinating nearly 330,000 children under 2 years of age with EPI and training an existing cadre of 327 vaccinators.

7 A PC-1 is a planning tool used by governmental departments in Pakistan for the development and execution of projects.

The HSS Component developed mechanisms to improve recording, reporting, monitoring, and supervision to ensure transparency and accountability. The HSS Component oriented vaccinators and their supervisors, supported logistics to improve EPI service delivery, and registered all pregnant women and children under the age of two. Central to this systems-based approach was the development of micro-plans and a supervisory system to ensure successful implementation. The HSS Component improved the quality of EPI service delivery by training vaccinators and supervisors in the proper handling of vaccines and methods for maintaining cold chain systems for vaccine storage. In parallel, community outreach was conducted to create awareness of and dispel myths about vaccinating children.

A father holds his son during a routine immunization visit by a Sindh province vaccinator. The percentage of children under one year of age who received the DPT3 vaccine increased from 13 to 87 percent under the HSS Component pilot.

Over the life of the pilot, all vaccinators and 52 supervisors underwent refresher trainings. Five-hundred- and-fifty motorcycles were distributed throughout Sindh to help vaccinators reach their catchment communities. 329,174 children under two years and 119,800 pregnant women were registered and 87 percent of immunized children retained routine immunization cards. Coverage of the first oral polio virus (OPV1) vaccine, the first pentavalent (Penta, which includes diphtheria, pertussis, tetanus, hepatitis B and hib) vaccine, and the first pneumococcal conjugate (PCV1) vaccine increased from 24 to 97 percent between December 2014 and June 2016; similar increases were found with subsequent doses. The percentage of children under the age of two who received the first measles vaccine increased from 12 to 67 percent; the second measles vaccine coverage increased from six to 40 percent. Bacille Calmette-Guerin (BCG, for tuberculosis) and OPV coverage more than doubled over the project period.

The percentage of pregnant women receiving tetanus toxoid immunizations increased from 25 to 95 percent and full coverage was attained in Thatta District. An external evaluation of the pilot found it to be extremely cost-effective.

Sindh Health Care Commission In Sindh province, as in many areas of the developing world, the quality of health services in both the public and private sector is highly uneven. Many services are of poor quality, many health facilities are dilapidated, some health providers perform unnecessary interventions, and quackery is on the rise. When the HSS Component initiated its activities, the health care regulatory functions performed by the government of Sindh were at a nascent stage. Even basic regulatory instruments, such as licensing and registration of facilities and providers, were poorly enforced or lacking. There were many reasons for this, including a lack of institutional technical skills to design, implement, and monitor an effective regulatory framework for health services. The need for a regulatory mechanism for both public and private sector providers was identified in the Sindh Health Sector Strategy (2012–2020) as a key strategy. The Sindh Assembly passed the Sindh Health Care Commission Act in 2014. In the subsequent year, the government of Sindh asked the HSS Component to help establish a Sindh Health Care Commission (SHCC) by strengthening staff capacity and technical skills to design and implement an effective regulatory framework.

The HSS Component started by conducting a situational analysis and developing a strategy for creating the SHCC. The HSS Component convened a multidisciplinary team to provide technical assistance and arranged two study tours for the Sindh Department of Health to Punjab province, which had previously set up its own health care commission. Participants learned about the functional status of the Punjab commission, factors that led to its successful implementation and the process of developing minimum service delivery standards for secondary and private sector facilities. The study tours were instrumental to Sindh’s decision to run the SHCC as a “body corporate,” meaning it has an independent governance structure and autonomy. The HSS Component helped the government of Sindh:

● Codify the SHCC governance structure ● Formulate SHCC rules and regulations ● Develop a SHCC business plan ● Prepare annual budget estimates ● Develop job descriptions and criteria for selection ● Recruit executive SHCC staff ● Develop Sindh service delivery standards ● Transform the service delivery standards into a survey guide for health facilities to perform self and external assessments.

CHAPTER IV: STRENGTHENED PUBLIC PRIVATE PARTNERSHIPS

Overview The model used to strengthen public-private partnership under the HSS Component was the participation of local communities in the health sector, the contracting out of health facilities to selected partners, and the development of a health financing facility. The major focus of the HSS Component was on developing and piloting the Heartfile Health Financing model. The urgency of developing a health financing model was based on the recognition that out-of-pocket payments force millions—especially the poor—to spend significant amounts on the health sector, which leads to either high levels of indebtedness during times of crisis or going without health care. More than 78 percent of people in Pakistan pay out-of-pocket for health care. Health care costs are, therefore, the most common cause of household economic shocks.8

Health Financing Model The HSS Component partner Heartfile Health Financing (HHF) has a model, which is a new and third type of a health financing model, a fund-based health care purchasing system.9 Most developing countries have mixed health systems,10 in which elements of both the Bismark (health insurance) and Beveridge (revenue-funded) models operate. These models have limited financial risk protection for high-cost illnesses, especially for people in the informal sector. The objective of HHF was to supplement the Beveridge and Bismarck models in mixed health systems to achieve universal health coverage.

Before HHF began working with the HSS Component, the first version of HHF’s technology platform provided assistance in 20 hospital wards in three cities and had provided 1,700 very poor patients with free care. With HSS Component support, four additional Sindh hospital wards enrolled in the program and its scope in existing approved hospitals expanded. In terms of numbers, 1,231 additional women and children were helped during the project period. Versions two and three of the HHF technology platform were developed and deployed with help from the HSS Component, which has made the program more robust and efficient. Upgrades have enhanced transparency features and made the platform more partnership-conducive and scalable. Again with assistance from the HSS Component, a sustainability plan was developed and is helping to expand the program in two phases.

HHF has four components—a technology platform, a system of validating poverty and prioritizing patients, a health fund, and partnerships with public hospitals. HHF’s web-based technology platform is mHealth-enabled, which connects health workers, health seekers, suppliers, and health financiers with the central hub. The technology platform serves five functions: (i) donation and inventory management; (ii) configuring and enforcing “rules” such as contracts with hospitals and suppliers and criteria for eligibility; (iii) patient-centric workflows and user action archives; (iv) two-way SMS messaging with stakeholders during workflow; and (v) interface with Pakistan’s National Database Registration Authority (NADRA), which enables eligibility based on a set of poverty proxy indicators developed by the Government of Pakistan. HHF’s eligibility system can configure multiple questionnaires based on donor

8 Planning Commission of Pakistan, 2005. 9 Nishtar S. Fusion Funds for Health. In: To Save Humanity: what matters most for a healthy future. Frenk J, and Hoffman SJ. Oxford Press, 2015. 10 Nishtar S. Mixed Health Systems Syndrome. Bulletin of the World Health Organization 2010; 88: 74-75.

preference. Doctors in pre-registered hospitals send requests for assistance on behalf of patients. Eligibility is ascertained by triangulating information from the doctor and the Heartfile verifier’s assessment, NADRA’s validation, and patient stratification based on preconfigured rules. A donor is then matched with a patient and payment made on behalf of the patient to the supplier or hospital from which services or medicines and supplies are being purchased.

A happy mother hugs her son, who received life-saving open heart surgery thanks to Heartfile Health Financing. In version three of the technology platform, HHF was able to demonstrate an example of a four-way multi-stakeholder partnership involving the public sector, NGOs, businesses, and individuals. HHF illustrates how these entities can work together to achieve the sustainable development agenda. At present, many Pakistani NGOs refer patients and several trusts donate to HHF. Public hospitals owned by federal and provincial government partner with Heartfile and share costs (e.g., hospitals cover bed and doctors’ fees; Heartfile pays for medicines, disposables, and implants). The public-private character of the program is also manifested in partnerships with the Pakistan Poverty Alleviation Fund and NADRA. HHF’s division of responsibilities prevents the introduction of “ghost patients” in the system, which is one of the main risks in such a purchasing system, and one that has plagued Pakistan’s existing social protection channels. A number of private industry partners participate in the program through their corporate social responsibility portfolios.

Key Elements of the Model The model’s technology infrastructure was developed with scale-up as a main consideration at inception and the HSS Component support has strengthened that aspect of the model. A two-stage plan for scale up is being implemented. The first is underway and the HHF technology platform is tapping philanthropy

30 by allowing the private sector to channel, target, and track donations. The second stage will allow the government to use the platform. HHF plans to offer this option to provincial and federal governments when election manifestos are being prepared. The HHF model was able to demonstrate a model with the following key aspects:

● A system with enhanced partnerships. Version three of the HHF technology platform offers enhanced features that facilitate partnerships through better contract handling, relationship management, and dedicated partner portals.

● A more transparent and robust system. The use of technology guards against corruption through pre-configured workflow rules, time stamping, and tracking of user activities. Stakeholder communication and HSS Component support has reinforced these safeguards.

● A more efficient system. The HSS Component supported a switch from paper-based to automated tools and HHF is now a paperless system. HSS Component financing of the technology upgrade has enabled a redesigned process workflow, stakeholder integration, enhanced supply chain and inventory management, integration between the management and financial information systems, a leaner field-data gathering model (on tabs with instant data relay), and hardware independence.

● A scalable system. The telemedicine-for-assessments and mHealth features allow scale up with lean operational costs and without extensive field operations. This system can be deployed wherever there is global system for mobile communications (GSM) service and can thus be widely scaled.

● A sustainable system. With HSS Component support, Ernst & Young prepared a sustainability plan that mathematically modelled how a small service charge levied on grants and/or revenues from a traditional endowment and social impact investing can finance the operations of HHF. Over a certain level of volume, the operations become totally sustainable with a service charge, as is evidenced by the numbers in the sustainability plan.

CHAPTER V: HEALTH SYSTEMS STRENGTHENING AT THE FEDERAL LEVEL

Overview The HSS Component started working with the newly formed Ministry of National Health Services, Regulation, and Coordination (MNHSR&C) in early 2015 on a special request to assist with specific elements of health services at the national level. Although devolution began in 2011, federal functions that had been distributed under several ministries were consolidated under the MNHSR&C in 2012. The MNHSR&C needed time to consolidate its role and take ownership for these responsibilities, especially regarding regulation, enforcement of drug laws and regulation, coordination of preventive programs funded by GAVI, the Vaccine Alliance and The Global Fund to Fight AIDS, Tuberculosis, and Malaria, reporting on international commitments including attainment of MDGs/SDGs, and services for the areas and regions still run and managed by the ministry, such as the federally administered Azad Jammu and Kashmir and Gilgit-Baltistan.

Dr. Mohammad Aslam, CEO of Drug Regulatory Authority of Pakistan, attends a meeting at the Ministry of National Health Services, Regulation, and Coordination.

The technical assistance extended to the MNHSR&C by the HSS Component contributed to Pakistan’s Global Health Security Agenda. The HSS Component provided a wide array of technical support at the federal level focused on improving its governance and management in a systematic fashion. The HSS Component worked with the MoNHSR&C to assist in developing the country’s first National Health Vision document, which was mandated by the 18th constitutional amendment. The HSS Component also provided technical assistance to develop the documentation for approval of the financing for the MNHSR&C’s international health regulation responsibilities. This entailed the preparation of a PC-111 and managing a dialogue with all the provinces to develop a five-year roadmap for implementation at different levels across the country.

11 A PC-1 is a planning tool used by governmental departments in Pakistan for the development and execution of projects.

The HSS Component helped the ministry establish a Health Policy Systems Strengthening Information Analysis Unit (HPSIU) to provide technical support for the MNHSR&C’s federal mandate. The HSS Component worked with the MNHSR&C to scale up the use of chlorhexidine (CHX) for newborn umbilical cord care, which is an evidence-based best practice for reducing newborn mortality and morbidity. The HSS Component also helped develop national guidelines for anti-microbial resistance (AMR) in line with global guidelines and best practices. These initiatives, which are discussed in detail below, all helped the MNHSR&C adopt a participatory and planning-based approach to its work, resulting in both systems strengthening and improving the ministry’s credibility as a federal institute that respects the provincial mandate. In December 2016, with assistance from the HSS Component, the MNHSR&C became the first federal ministry in Pakistan to receive the ISO 9001 certification for quality management.

National Health Vision After devolution, Pakistan lacked national consensus on a vision for how to achieve better health outcomes for all citizens. The country needed a National Health Vision document aligned with the country’s Vision 2025 and international health priorities and based on provincial realities. Developing the National Health Vision document was the responsibility of the MNHSR&C according to its post-18th Amendment constitutional roles and responsibilities. The delivery of high-quality health care services was now a provincial responsibility but the federal government was mandated to support and facilitate the provinces in developing and implementing their health sector strategies. The federal government was responsible for providing a vision and facilitating and advocating for the financial and technical resources to ensure that essential health services are accessible to all citizens. It was within this mandate that the HSS Component provided technical assistance to the MNHSR&C to develop the National Health Vision.

The final version of the National Health Vision 2016-2025 provides a direction for the health sector and harmonizes provincial and federal efforts to achieve optimal health outcomes for citizens. The National Health Vision is aligned with provincial and federal health policy frameworks, post devolution health sector strategies, and international commitments to which Pakistan is a signatory. Beyond the health sector, the document is aligned with important national programs and policies such as the Pakistan Vision 2025, the country’s Poverty Reduction Strategy, and pro-poor social protection initiatives.

Box 2. The National Health Vision

The National Health Vision (2016–2025)

● Provide a unified vision to improve health while ensuring provincial autonomy and diversity; ● Build coherence between federal and provincial efforts by consolidating progress, learning from experience, and moving towards universal health coverage; ● Facilitate synchronization across international reporting and treaties; ● Ensure coordination for regulation, information collection, surveillance, and research on improved health systems; ● Create a foundational basis for charting and implementing SDGs in partnership with other sectors.

Health Planning, Systems Strengthening, and Information Analysis Unit at the MoNHSR&C With assistance from the HSS Component, the MoNHSR&C established a Health Planning, Systems Strengthening, and Information Analysis Unit (HPSIU) in July 2015 after multiple rounds of consultations with provincial health departments, international donor agencies, and development partners. The unit provides national-level stewardship for health policy and planning, aligning health systems strengthening activities uniformly across the country, knowledge management and health information analysis, and building an integrated health information system, which will enable a sound monitoring and evaluation system and use of data for decision-making.

ISO Certification ISO 9001 certification is a well-recognized global instrument verifying institutional quality management systems. The HSS Component provided technical assistance to the MONHSR&C to develop and implement a quality management system for the ministry. The HSS Component helped improve MONHSR&C staff understanding of how to develop and implement a quality management system. The implementation process was divided into five phases. First, the HSS Component conducted a gap analysis, which included meetings with ministry stakeholders to identify current practices and documentation. After recommending areas for improvement, the HSS Component worked with MONHSR&C staff to develop a diagnostic and planning report as a roadmap for institutionalizing the quality management system. The HSS Component facilitated a series of trainings to raise awareness about the certification followed by trainings on procedure development, operational and technical document development, system implementation, and internal and external audits. The HSS Component trained 38 officers as assurance coordinators who will continue to act as resources for maintaining quality standards in their respective departments. With the support of the HSS Component, the MONHSR&C established a management review committee to provide strategic direction and approve resources for implementing the quality management system. In December 2016, MONHSR&C received its ISO 9001certification testifying that their system had become more efficient and productive.

Anti-microbial Resistance Antibiotic resistance has risen alarmingly and emerged as a major health threat not only in the developed world, but also in resource poor countries. This increasing trend has been documented over the last two decades in all health care settings, particularly in high-risk areas such as intensive care units, surgical units, and neonatal intensive care units. Realizing the global threat of drug resistance, WHO in 2001 developed “The WHO Global Strategy for Containment of Antimicrobial Resistance,” which provided key interventions to slow the emergence and reduce the spread of antimicrobial-resistant microorganisms. Pakistan, like other countries, faces the challenge of antibiotic resistance. Antibiotic misuse and overuse has contributed tremendously to this challenge.

The factors responsible for antimicrobial resistance (AMR) in Pakistan include a lack of knowledge about AMR; inappropriate use of antibiotics; lack of information and awareness about proper use; absence of a policy on antimicrobial use; spurious, substandard, falsified, fake and counterfeit antimicrobials on the market; and unregulated access and availability without prescription. Other factors include use of antibiotics in agriculture as growth promoters; lack of infection, prevention, and control programs in health facilities; poor environmental sanitation; and inadequate surveillance on antimicrobials use. Tackling antibiotic misuse in Pakistan requires a coordinated and sustained effort. Keeping these factors in mind, the HSS Component worked with the Government of Pakistan to develop a “National Strategic Framework for the Containment of Antimicrobial Resistance” in line with WHO recommendations.

Specifically, the HSS Component supported a newly-formed Inter-Sector Core Committee (ICC), comprised of experts and stakeholders from various ministries, the health sector, and provincial authorities, to oversee the consultative process. The HSS Component supported the ICC to conduct a literature review of available AMR studies in Pakistan, conduct a gap analysis, and conduct two consultative workshops to formulate the AMR framework. The consultative process ensured national ownership and stakeholder commitment. The National Framework for the Containment of Antimicrobial Resistance was launched in December 2016 and established a coordinated, collaborative, and sustainable AMR containment system with measurable outcomes and involved all relevant stakeholders and sectors. The intent is to ensure antimicrobials remain effective as long as possible and costs associated with their indiscriminate use are minimized. The Framework has been recognized as an important milestone for Pakistan in implementing the global health security agenda.

System Strengthening for Securing Essential Medicines: The Case of Chlorhexidine The HSS Component demonstrated how a strong health system could support efforts to standardize chlorhexidine (CHX) protocols and training guidelines for widespread distribution of CHX. The HSS Component worked with the MNHSR&C to standardize and scale up the use of CHX in the first 48 hours after birth to save newborn lives. In 2014, WHO recommended the use of CHX for cord care in areas where the NMR was above 30/1,000 live births and included CHX in its list of essential medicines for children. CHX reduces the risk of both umbilical cord infections and newborn mortality. In Pakistan, at- scale delivery of CHX was assessed to have the potential to reduce the risk of umbilical cord infection by 42 percent and the risk of newborn death by 38 percent. CHX use, at-scale, would greatly reduce newborn umbilical infection and death, and would be a cost-effective way to reduce the stubbornly high NMR in Pakistan. In light of these findings, CHX advocacy and service delivery programs had been working to increase awareness and CHX service delivery across Pakistan. In 2014, provincial health departments and public and private stakeholders successfully advocated for the inclusion of CHX in the Pakistan essential drug list for all provinces and regions. Despite these efforts, there was a lack of coordination and standard guidelines and protocols did not yet exist, which resulted in fragmented CHX service delivery. The CHX supply was also inadequate and there was little community-based demand for the drug.

USAID recognized the need for a coordinating mechanism to enable a national scale-up initiative, and in 2015 tasked the HSS Component with streamlining efforts between the MNHSR&C, provincial health departments, and other development partners. The HSS Component embarked on a collaborative systems-based approach to develop national scale-up policies and guidelines and ensure availability and use of a standardized CHX regimen. The HSS Component worked with partners to advocate for a seven- day regimen of CHX to be included in national guidelines. The 2015 MONHSR&C national guidelines for umbilical cord infection prevention now call for applying 7.1% chlorhexidine gluconate gel to the newborn umbilical stump for seven days.

The HSS Component worked with leadership and governance at national, provincial, and district levels to use evidence to standardize CHX protocol and ensure its inclusion in essential drug listings. In parallel, the HSS Component and partners developed messages and information to increase the acceptability and use of CHX, and to increase the health care workforce trained in its application. Local production of CHX began in October 2017, and four local pharmaceutical companies registered with DRAP for manufacturing. Until local production of CHX was available, USAID ensured its continuous availability by donating 2.1 million tubes of CHX to the MNHSR&C for distribution across all provincial health departments, and an additional 650,000 CHX tubes for distribution in the Sindh Province.

A health worker at a Sindh province health facility shows a mother how to apply CHX to her newborn’s umbilical stump.

CHAPTER VI: KEY PERFORMANCE INDICATORS

Performance Metrics The HSS Component developed a performance monitoring plan (PMP) to demonstrate how the HSS Component contributed towards achieving the goal and objectives of the program. The PMP contains a monitoring and evaluation (M&E) plan, to define how the project will document inputs, processes, outputs, outcomes, and impact of the project during its lifetime. The plan uses the WHO six “building blocks” of a health system: (i) service delivery; (ii) health workforce; (iii) health information systems; (iv) access to essential medicines; (v) financing and (vi) leadership and governance.

The planning and implementation of the M&E plan was undertaken in close collaboration with other USAID-funded health projects and the public health sector in Sindh. The list of indicators was agreed as well as the data collection system, including the schedule of measurements and responsibilities. The conceptual framework of the M&E plan envisions building the capacity of public sector stakeholders for participation in planning, management, and M&E of RMNCH activities. The use of participatory approaches to track HSS Component progress helped the partners understand how HSS Component activities were improving their own competencies and work. This in turn increased the motivation of project implementers to perform M&E tasks on a regular basis and improve demand and use of evidence for decision-making, learning, and accountability.

Table 3. Performance Indicators, Targets, and Results for the HSS Component

PY2 PY3 PY4 EOP

# Indicator

Target Accomplishment Target Accomplishment Target Accomplishment Target Accomplishment

Number of children who Indicator received DPT3 by 12 Nil 92,000 228,000 87% 228,000 198,360 5.1d: months of age in USG-

assisted programs Quarterly Percent of USG-supported facilities that are Indicator submitting timely, 25% 25% 45% 45% 60% 68% 60% 68%

5.3b complete and accurate district health information

system (DHIS) reports Annual

Indicator Number of trained health 65 0 64 65 26 94 155 159 – 5.3.2a: and population managers posted Quarterly Number of districts with Indicator improved institutional 8 8 15 15 20 23 20 23 – 5.3.2b: capacity scores in management and oversight

of FP/MNCH Annual

Percent of USG-supported facilities that are submitting timely, complete, and accurate district health information system (DHIS) reports

The project met the target of “60 percent of USG-supported facilities submitting timely, complete and accurate district health information system (DHIS) reports in December 2017.” The graph below illustrates the gradual improvement in this indicator and the quantum jump in performance from the start to the project completion.

Graph 1. Submission of Reports by Districts

Number of trained health and population managers posted

Table 4. Details of Training

Long and short term courses Graduates 1. Masters of Science in Public Health – HSA 45 2. Masters of Science in Health Policy & Management - AKU 7 3. Masters’ Program in Public Health – APPNA (out of 25, 5 could not pass) 20 Short term courses: Graduates Short Courses: Provincial Managers – AKU 56 1. Quality Management in Health Services 33 2. Strategic Planning 30 3. Health Sector Reforms 27 4. Organizational Management 19 5. Human Recourse for Health 19 6. Program Monitoring and Evaluation 7 Short Courses: District Managers - AKU 30 1. Human Recourse for Health 30 2. Strategic Planning 25 3. Organizational Management 20

Number of districts with improved institutional capacity scores in management and oversight of FP/MNCH

Box 3. The Composite Institutional Capacity Score

● Increased budget allocation in primary health care by at least 5% per year; (No=0, Yes=1) ● District Action Plan is synchronized with Essential Package of Health Services (not included=0, included=1) ● Four quarterly review meetings held and performance discussed (DHPMTs quarterly meetings score achieved); (score less than 8=0, score equal to (9 or more=1) ● Percent of health facilities reporting on DHIS; (if less than 100%=0, 100% reporting=1) ● Districts receiving feedback on DHIS reports from the provincial M&E cell/vertical programs (No=0, Yes=1)

This performance target was achieved. At the end of the project period, 21 districts scored above 80 percent on the composite score for improved institutional capacity in management and oversight of FP/MNCH services. The remaining two districts scored 80 percent. All the districts were reporting on DHIS and all health facilities submitted the DHIS reports by the due date for the reporting period. The DAP was synchronized with the essential package of health services in all 23 target districts. There was increased budget allocation in primary health care by at least 5 percent per year and all 23 districts experienced this increase. Four quarterly review meetings were held and DHPMT quarterly meeting performance was discussed. Twenty-one of the 23 districts scored nine or more in the DHPMT quarterly meetings. Also, the M&E cell provided feedback to all 23 districts on monthly performance on different aspects of reports generated using DHIS.

Table 5. Key Performance Aspects of the HSS Component

Health budgets rose in response to DHPMTs engaging in district action planning and creating medium-term budgetary frameworks. This allowed managers to effectively advocate for larger budgets by demonstrating 1 the need through evidence by providing data to substantiate their requests. As a result, the PHC budget increased 137% since 2014. DHPMTs have proven to be an effective mechanism for local problem resolution. Eighty percent of 2 problems identified at the local level can be addressed at the local level. Health managers can use the integrated online dashboard for Sindh to make evidence-based financial and 3 programmatic decisions. This has positively impacted transparency and accountability in the Sindh health system. The HSS Component has demonstrated that the culture of data use can be influenced; when people begin 4 to use data and collect it in a manner that inspires confidence it further adds to the regularity and reliability of data. Data accuracy improved from 64% to 79% percent in just two years (2014 to 2016). The online, integrated dashboard has been handed over to the government of Sindh and is now fully 5 funded and managed by the province. Increased budget allocation in primary health care by at least 5 percent per year

Graph 2. Increase in Sindh health sector budget allocations

District action plans synchronized with the essential package of health services

A primary level essential package of health services (EPHS) was developed for Sindh and is currently being implemented in the province. Without proper DAPs, there were no mechanisms to ensure that financial and human resources required to implement the EPHS were available. District-level planning provides an opportunity to address district-specific health challenges. The DAP SOPs ensure available resources are reviewed and inventories updated. To facilitate the process, the DOH has costing sheets that can be adapted according to the expected facility load. The synchronization of the EPHS has been integrated as a key element in the DAP SOPs. DHOs and DHPMTs have used their DAPs as advocacy tools to secure additional resources to ensure that they address EPHS standards.

Four quarterly review meetings held and performance discussed (DHPMTs quarterly meetings score achieved)

Feedback on DHPMT performance was provided through a structured scoring system. By the end of the project, nineteen districts scored more than 80 percent on the DHPMT scoring index, which means that 83 percent of districts (19 out of 23) scored nine or above points out of the eleven-point criteria. Eleven districts (Dadu, Hyderabad, Sujawal, Thatta, Matiari, Tando Muhammad Khan, Kashmore, Naushero Feroze, Sukkur, Shikarpur, and Ghotki) maintained their high scoring index. Three districts (Sanghar, Shaheed Benazirabad, and Badin) improved their scores over the previous quarter. However, the performance of seven districts (Jamshoro, Tando Allah Yar, Larkana, Khairpur, Tharparkar, Kamber, and Umerkot) decreased but remained above the target. Jacobabad was unable to conduct the meeting within the specific time period due to the retirement of the DHO.

Percent of health facilities reporting on DHIS

The HSS Component provided technical assistance to improve DHIS implementation at all DOH facilities according to the DHIS manual. The HSS Component provided hands-on support to improve the quality of monthly reports by health facilities. The project conducted a baseline assessment in five districts in Sindh to assess the quality and use of DHIS and MIS data and reporting compliance at the health facility, district, and provincial levels. The findings revealed that only 15 percent of health facilities submitted timely, accurate, and complete reports. As a result, the HSS Component was able to make a case to bring the DHIS online. In December 2017 more than 68 percent of health facilities submitted accurate, timely, and complete reports.

Districts receiving feedback on DHIS reports from the provincial M&E cell and vertical programs

Findings from the 2013 PRISM assessment showed little provincial feedback or any type of report providing guidelines or recommendations based on DHIS information. In response, the HSS Component helped establish an M&E system with a built-in feedback process. Information collected from all sources is now being assessed, used, and the progress disseminated in monthly reports. These progress reports include monthly achievements, shortfalls, and reasons thereof. The reports are shared with all stakeholders and districts, allowing comparison, and healthy competition, with other districts. The feedback system assures field staff that information collected from them is being used and decisions made for the improvement of the program. As timeliness, reliability, content, and quality of feedback affect the M&E process, the importance of these elements is fully recognized in the monitoring and evaluating exercises. Depending on the facilities’ performance, positive feedback or routine constructive feedback is provided on a monthly basis.

The 2016 Performance Routine Information System Management (PRISM) assessment findings show that 78 percent of DHOs sent feedback reports to facilities using DHIS information. The 2016 assessment also showed that 96 percent of district health offices reported receiving provincial feedback. Routine correspondence of the provincial M&E cell showed feedback on performance and error reports. All districts received feedback on DHIS reports from the provincial M&E cell and vertical programs by June 2017.

Number of children who received DPT3 by 12 months of age in USG-assisted programs

The target for the number of children immunized with the third diphtheria, pertussis, and tetanus toxoid (DPT3) vaccination was 228,000, which is estimated to be 80 percent of the number of children under one year registered by June 2016. The public health services in selected pilot districts achieved the target. The proportion of children vaccinated with DPT 3 improved from 13 to 87 percent. The Sindh DOH has since implemented the systems-based methodology used in the pilot districts to increase routine immunization (RI) coverage in 15 additional districts.

This target was selected in recognition of challenges to improving the performance of the immunization program in the province. The DOH’s goal was to attain 90 percent immunization coverage (all basic vaccines) at the provincial level and eradicate polio, measles, and tetanus through supplemental immunization activities. The HSS Component provided technical support for immunization activities in four districts selected for their low levels of immunization coverage. Although, the pilot immunized children under two years old, the required reporting indicator to USAID was more stringent: children under one year.

CHAPTER VII: Lessons Learned and Way Forward

Lessons Learned

1. Projects that work to develop systems and strengthen long-term institutional capacity can be more effective and sustainable than those that focus on exclusively on service delivery and short- term gains. The HSS Component structured its investment in building the capacity of individuals within Pakistani institutions so that those individuals are able to improve service delivery over the long run. The HSS Component also assisted the DOH to adopt a “systems approach,” which addressed the interrelated and mutually reinforcing processes of data collection and review; planning, budgeting, leadership and management; coordination mechanisms; human resource management and development; and more.

2. Systems development requires an appetite for reform and ownership at the highest level to ensure sustainability. The HSS Component experience illustrated very clearly the need for commitment at the highest level of government, as often reform initiatives require changes in key processes and protocols on an ongoing basis. This also requires developing partnerships with key stakeholders such as those managing the resources (finance) and those that implement the various components of the health system. Health reform would not have been possible without a commitment to data collection and analysis, development and deployment of human resources, moving from incremental budgeting to performance-based budgeting and regulatory reform within the health sector. All these measures required the public sector at the highest level to be committed to these reform initiatives.

3. Donor-funded initiatives can build credibility with government counterparts by putting forward recommendations based on evidence. The HSS Component adopted a three-phased approach for implementing an evidence-based package of interventions to ensure continuity and sustainability. The HSS Component conducted a series of assessments to understand where the problems and gaps existed within the health system and then developed reports recommending evidence-based interventions. The HSS Component advocated with DOH counterparts to implement the interventions at the provincial and district levels. The approach was successful because it allowed the HSS Component to work alongside the Sindh DOH to identify the roots of specific challenges. Sindh DOH managers were willing to work on solutions because they were involved with both the problem and solution identification. In other words, the Sindh DOH was part of the entire process and not excluded from decision-making, which empowered them in their governance role.

4. Investment in technology-based options that increase transparency and data reliability can improve management and decision-making. Technology and digital platforms can be used to deliver health services, increase health service demands, and hold governments and providers accountable for the delivery of high-quality services. In the context of Sindh, the development of an online integrated dashboard was critical to addressing the lack of transparency, accountability, and evidence-based resource allocation. A major challenge was inaccuracy of data in manual reports, which were cumbersome to fill and often delayed. Over time the reports were not used regularly and the incentive to submit or use them dwindled. The online integrated dashboard allowed for these reports to become digitized, which reduced errors and timeliness problems. Over time, their usefulness grew and the reports became a source of credible information and performance review.

5. A strong M&S system improves performance and service quality A good M&S system is the backbone of a functioning and efficient health system in which managers take interest in employee performance and can hold them accountable based on KPIs. The HSS Component worked with the Sindh DOH and other implementing partners to standardize and bring online the provincial M&S system. Before this innovation was introduced, there was no systematic way to oversee and evaluate M&S efforts. The M&S system supports supervisors and program and health facility managers to monitor and supervise how health services are delivered and the quality of data submitted through monthly reports.

6. A management continuum instituted at different tiers within the health system can improve coordination, supervision, accountability, and performance. The HSS Component revitalized DHPMTs, a governance platform which consists of a diverse set of professional stakeholders who develop plans, share information, experiences, and resources to improve the health system at the district level. By strengthening capacity at the district level, districts were empowered to make local decisions and could be held accountable for their performance. The districts were provided with quality data, and then used this information to plan, develop budgets, and improve overall systems at the local level. By establishing a management and coordination continuum between districts and the province, Sindh has strengthened institutional capacity, improved the use of information for decision-making, and improved coordination among district-level stakeholders.

7. Sustainable, nation-wide scale up of CHX required a multi-stakeholder approach rooted in partnership. To scale-up the standardized use of CHX across Pakistan, the HSS Component adopted a coordinated approach that brought all partners together. Pakistan’s MNHSR&C was required to play a leadership role in the process. The HSS Component worked with leadership and governance at all levels to use evidence to standardize the national CHX protocol and ensure CHX is the drug of choice for preventing umbilical cord infection. The HSS Component and ministry partners worked together to develop messaging and information to increase the acceptability and use of CHX and expand the health care workforce trained in CHX application. The partnership extended to the private sector and included pharmaceutical companies to encourage the local production of CHX.

Way Forward Increased accountability and transparency of health systems

1. Strengthening oversight mechanisms and advocacy for health reform. There is a clear need for the Government of Sindh to revive the role of the RMNCH Steering Committee, continue engaging parliamentarians to support the reform measures initiated under the HSS Component, and identify new measures to enhance accountability and transparency within the health sector.

2. Technical backstopping. The Secretariat of the DOH is not sufficiently backed up by technical staff to undertake some of the technical functions for effective evidence-based decision making, planning and budgeting, and improved accountability and governance. The Government of Sindh needs to provide adequate human and financial resources for technical backstopping.

3. Use of information for improved accountability. There are several steps the Sindh DOH must take to ensure that efforts to create improved data quality and use are sustained. First, the DOH must ensure that all districts comply with SOPs for improving data quality and use and that provincial health managers have the capacity to maintain and improve data quality in the system. Data must

be validated at health facilities; LHW and CMW data quality must be assessed as part of supervisory visits. Bi-directional communication and feedback loops must be institutionalized to ensure that M&E cells at the provincial and district levels ensure timely, quality data each month. Regular review meetings must be conducted to ensure evidence-based decision-making and continued quality improvement for good governance.

4. Oversight at the district level through DHPMTs. Previous experience has shown that these district forums can become defunct without a proper M&S system, or a system of accountability. As such it is extremely important for DHPMTs to be properly supervised on a regular basis. It is also important to continue to oversee the effectiveness of each DHPMT through a transparent ranking system (i.e., scoring system) based on performance and data.

Improved management capacity at provincial and district levels within the health department

● Strengthening health management systems. Sindh Province has taken significant steps toward a sustainable health system by integrating a systems approach to planning with a performance-based financing framework. Despite these achievements, efforts to ensure a supportive environment to institutionalize the approach are still needed. Administrative structures, policies, and procedures must continue to be supported at all levels so that staff responsible for implementation and oversight can conduct their functions effectively and responsively. Strengthening the skills of the monitoring unit and technical wing of the Health Secretariat to review performance and support implementation of decisions at the provincial level is essential.

● Strengthening health sector planning and financing. Using performance-based financing and district action planning, Sindh Province has taken significant steps toward strengthening the provincial health system. Despite the achievements, efforts to further institutionalize the approach are still needed. Administrative structures, policies, and procedures must continue to be supported at all levels so that staff responsible for implementation and oversight can conduct their functions effectively and responsively. Strengthening the skills of the monitoring unit and technical wing of the Health Secretariat to review performance and support implementation of decisions at the provincial level is essential. Strengthening the budget section of the Health Secretariat will help ensure appropriate oversight of budget preparation and reporting. Online mechanisms to help streamline budget preparation and expenditure reporting and tracking how funds are used will increase transparency, efficiency, and accountability.

● HR gaps and deployment plan. The DOH should consider closing immediate HR gaps by filling vacant posts. This is a crucial step to improve the current health landscape. There is also need to deploy HSS Component-trained managers in positions and locations which would enable the system to derive the maximum use of their strengthened capacity.

● HR capacity building. The Government of Sindh has made several advances in developing the capacity of its health workforce, but much work remains. To continue capacity-development efforts, the DOH should consider (i) developing a comprehensive HR policy that includes a clear career path for health workers; (ii) Continuing to support and institutionalize the CBOC, which helped implement the Sindh capacity development strategy; (iii) deploying master’s degree graduates in open management positions at provincial and district levels and institutions; (iv) developing a comprehensive in-service training strategy that responds to the needs of the workforce, including

non-clinical staff, and (v) continuing to foster a culture of using data for informed decision-making.

● Health facility assessment. The HFA-generated data provides many insights into how Sindh’s health system can be further strengthened to improve service delivery and, ultimately, health outcomes for the people of Sindh. The DOH should consider continuing advocacy efforts with the Government of Sindh and maintain a dialogue on critical provincial health indicators and required government health spending. The roadmap approach of selecting priority programs for improvement and tracking their performance is highly recommended. The DOH should consider conducting HFAs on a periodic basis to assess the status of health service delivery in Sindh Province.

● Capacity development at tehsil headquarter hospitals. The DOH should focus on strengthening THQHs because they are more numerous than DHQHs so more patients will benefit if investments are spent on THQHs. In addition, staff who generate health information used for evidence-based decision-making need regular capacity building. There is a need to support the automation of data for continually updating and assessing stocks. Automation will help health managers forecast accurate stock procurements to avoid shortages.

● Sindh Health Care Commission. Regulating health services is an important step to providing the people of Sindh with access to quality health care. The HSS Component laid the foundation for a SHCC, which now is equipped to initiate and expand the process of registration, licensing, and standardization of both public and private health facilities. A capable executive management is in place. However, more is required to sustain these efforts. To achieve the SHCC business plan, for example, the executive team will need to advocate continually with political leaders and decision- makers in Sindh. Technical assistance, either through internal funding or donor support, should be sustained beyond the life of the HSS Component. Ongoing areas of need include standards implementation and assessment, establishing a complaint-management system, conducting anti- quackery campaigns, completing a private health care provider census, and accrediting health care services.

● Expanded programme of immunization. The EPI pilot showed that reaching the DOH goal of 90 percent coverage for all vaccinations is achievable, but several considerations must be addressed to ensure the pilot’s impact is sustained and scaled. Based on HSS Component experience, continued support to ensure that managers are able to monitor, supervise, and train vaccinators on developing and implementing micro-plans is needed. Vaccinators with the best performance should be acknowledged and rewarded. Financial resources to support EPI programs must be allocated to districts. Aging cold chain equipment must be upgraded; supplies of vaccines, syringes, safety boxes vaccination cards, and registers guaranteed; human resource gaps and deployment issues remedied; and the potential of community-based organizations must be maximized and regulated.

Strengthened Public Private Partnerships

● Expanding the scope of review of the PPP. The mandate given to the HSS Component in terms of PPPs was fairly limited and focused primarily on developing a model for health care financing. While the HSS Component was able to pilot test a sustainable model, much more needs to be done to explore other models of PPPs, for example examining the performance of public health facilities contracted out to civil society organizations and studying the role communities play in improving health system performance through participating in VHCs, UCHCs, and DHNs. Such issues were not within the scope of the HSS Component but should be considered for future programs.

● Sustaining scale-up of the CHX initiative. Federal-level collaboration with DRAP and advocacy to manufacture CHX locally is recommended as is collaboration with private sector pharmaceutical retailers to expand CHX access to clients. The public sector should consider ensuring financial resources are adequate for procuring CHX. Additionally, CHX should become a standard medicine in LHW and CMW delivery kits. Information, education, and communication efforts should continue to build community support for CHX and service provision records to capture use of CHX in communities should be kept. Continued support for strong coordination between these groups will uphold the Pakistani government’s efforts to end preventable newborn deaths from umbilical cord infect

Annex 1.

Annex 2.

Heartfile in Action: A Life-saving Bone Marrow Transplant

Twelve-year-old Muhammad Aleem lives in a remote, mountainous village about 150 kilometers northeast of Pakistan’s capital, Islamabad. In June 2014, when Aleem was eleven, he started experiencing high fevers. The local physician was unable to diagnose the problem and so his family took Aleem to the district headquarters hospital. There, a blood test diagnosed Aleem with aplastic anaemia, a condition when the bone marrow stops producing blood cells.

Since the district hospital was not equipped to treat aplastic anemia, Aleem’s family brought him to the Pakistan Institute of Medical Sciences (PIMS) in Islamabad in August 2014. By their second visit to PIMS, where doctors were performing preliminary tests, Aleems’s family had exhausted their entire savings of PKR 150,000 (USD 1,500). Yet Aleem still needed a costly bone marrow transplant (BMT) to save his life. The time-consuming and costly BMT was beyond the financial means of Aleem’s father, who is a primary school teacher, and earns only PKR 18,000 (USD $180 a month).

Aleem was fortunate to be taken to a hospital that is a registered site for Heartfile Health Financing (HHF). Aleem’s doctor, Dr. Sadaf Khalid, sent an SMS requesting initial financial assistance to perform a diagnostics search (required for finding an appropriate bone marrow match). Heartfile responded by conducting a financial needs assessment and approved the request within 24 hours.

Fortunately, one of Aleem’s siblings was a match. Again, Dr. Sadaf requested financial assistance from Heartfile Health Financing, this time to perform the transplant and provide post-transplant medication. Heartfile approved the financing once more.

Over a period of 12 months, the complex bone marrow transplant was completed. As of September 2015, Aleem is well and his parents are grateful to the people and organizations that helped them. The partnership among PIMS, Heartfile, and the HSS Component saved a young boy’s life.

Annex 3

Sustainability Plan Summary in Pak Rupees

Sustainability Plan in USD

Annex 4.

National Health Vision 2016-2025

The National Health Vision 2016-2025 was developed as a sequel to a series of meetings with provincial stakeholders, NGOs, development partners, academia, researchers, and civil society representatives.

The Vision presents a health systems strengthening approach using WHO’s building blocks: (i) Governance, (ii) Information systems, (iii) Human resources, (iv) Service delivery, (v) Medical Technologies & Supplies, and (vi) Health financing. An additional block (vii) Inter-sectoral collaboration has been added to define the role of other ministries and line departments in health sector development.

Each chapter has three sections: 1) challenges, 2) government’s response, 3) priority actions.

The Vision is a guiding document and provides a road map to improve the health of all Pakistanis, particularly women and children, through universal access to quality essential health services, with a particular focus on vulnerable groups, and delivered through resilient and responsive health systems.

The word ‘national’ depicts common political aspirations of the provincial and the federal governments. It is a unified vision to improve the health of the people across the provinces while ensuring provincial autonomy and diversity.

The Vision will help build coherence between federal and provincial efforts to consolidate progress, learn from experiences, and move towards universal health coverage. It has consonance with provincial and federal health policy frameworks, post devolution health sector strategies, and international health treaties, commitments (e.g., SDGs), and regulations (e.g., IHR) to which Pakistan is a signatory.

Moving beyond the health sector, the Vision builds convergence with important national programs and policy setting documents such as the Pakistan Vision 2025, Poverty Reduction Strategy, and the two pro- poor social protection initiatives: Benazir Income Support Programme and Prime Minister Health Insurance Programme.

The final draft was circulated to the provinces and other stakeholders. The final meeting has been proposed for the first week of August 2018, to be chaired by the honorable minister.

Annex 5