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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. 2 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 3 CHAPTER VI: KEY PERFORMANCE INDICATORS .......................................................................................... 37 Performance Metrics .............................................................................................................................. 37 CHAPTER VII: Lessons Learned and Way Forward ...................................................................................... 42 Lessons Learned ...................................................................................................................................... 42 Way Forward ........................................................................................................................................... 43 4 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 5 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 6 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
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