USAID’s MCH Program Component 5: Health Systems Strengthening
QUARTERLY REPORT OCTOBER-DECEMBER 2014
USAID Cooperative Agreement: No. AID-391-A-13-00002
Submitted: January 30, 2015
USAID’s MCH Program Component 5: Health Systems Strengthening
Quarterly Report October-December 2014
USAID Cooperative Agreement: No. AID-391-A-13-00002
JSI Research & Training Institute, Inc. HSS Component 44 Farnsworth Street House #6, Street No. 5, F-8/3 Boston, MA 02210 Islamabad, Pakistan 44000 +1 617-482-9485 +92 051-111-000-025 www.jsi.com
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
Acronyms ...... 3 I. Executive Summary ...... 4 II. Health Systems Strengthening Component’s Vision of Success ...... 5 III. Activities and Results ...... 7 IR 3.1 Increased Accountability and Transparency of Health System ...... 7 IR 3.2 Improved Management Capacity at Provincial and District Levels of DOH and PWD ...... 24 IR 3.3 Strengthened Health System Through Public Private Partnerships ...... 41 IV. Monitoring, Evaluation, and Reporting ...... 49 V. Project Management ...... 52 VI. Issues and Challenges ...... 54 VII. Activities Planned for Next Quarter ...... 55 VIII. Annexes ...... 56 Annex 1:International Travel Status Report ...... 56
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 2 Acronyms
BHU Basic Health Unit CMW Community Midwife DAP District Action Plan DHIS District Health Information System DHO District Health Officer DHPC District Health Planning Committee DHPMT District Health & Population Management Team DOH Department of Health DPWO District Population Welfare Officer EPI Expanded Programme on Immunization GOS Government of Sindh HCF Health Care Financing HHF Heartfile Health Financing HSS Health Systems Strengthening IR Intermediate Result JSI JSI Research & Training Institute, Inc. JPMC Jinnah Post-graduate Medical Center LHW Lady Health Worker LSO Local Support Organization LUH Liaquat University Hospital MCH Maternal and Child Health MCHIP Maternal and Child Health Integrated Program M&E Monitoring & Evaluation MIS Management Information System MNCH Maternal, Newborn, and Child Health MSS Marie Stopes Society MTBF Medium Term Budgetary Framework NCD Non-Communicable Disease NICH National Institute of Child Health NICVD National Institute of Cardiovascular Diseases PIMS Pakistan Institute of Medical Sciences PPHI People’s Primary Healthcare Initiative PWD Population Welfare Department RFP Request for Procurement RGH Rawalpindi General Hospital RHC Rural Health Center RMNCH Reproductive, Maternal, Newborn, and Child Health RSPN Rural Support Programmes Network UAT User Acceptance Testing USAID United States Agency for International Development
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 3 I. Executive Summary
During the quarter, the Health Systems Strengthening (HSS) Component scaled up its support to strengthen M&E of routine immunization in Jacobabad, Kashmore, Thatta, and Tharparkar districts to cover all 151 Union Councils of these four districts. As a result, a total of 22,497 children under the age of two years and 6,445 pregnant women were vaccinated in these Union Councils during the reporting quarter. The project also provided technical support to these low performing districts to develop Union Council micro-plans which will enable them to provide immunization services effectively to children under the age of two years and pregnant women. Keeping in mind the fact that most of the vaccinators lacked transport to cover all the Union Councils, HSS Component provided 550 motorcycles to the Department of Health (DOH) to improve coverage of Expanded Programme of Immunization (EPI) in 11 districts of Sindh.
HSS Component successfully supported 23 District Health Departments, including Karachi, to prepare District Action Plans and Medium Term Budgetary Framework (MTBF) estimation for 2015-16 fiscal year of Government of Sindh on prescribed forms of the Finance Department. Prior to this, HSS Component, in close collaboration with the Finance Department, built capacity of all cost centers in the DOH on MTBF and supported them to finalize key performance indicators for service and management components of the DOH. In addition, HSS Component provided technical support to 22 District Health and Population Management Teams (DHPMTs) to hold their quarterly performance review meetings.
HSS Component finalized an assessment report on the capacities of the DOH, Population Welfare Department (PWD), and People’s Primary Healthcare Initiative (PPHI) and reviewed them with relevant stakeholders in a workshop held in November. Based on World Health Organization’s six health system building blocks, the assessment will serve as the foundation for the capacity building strategy that HSS Component is developing for the DOH, PWD, and PPHI to improve individual skills and practices and organizational systems and procedures for sustainable delivery of health services in Sindh. The assessment will also inform the work of all partners of USAID’s Maternal and Child Health (MCH) Program.
During the reporting quarter, HSS Component finalized a report which tracks health related manifesto commitments of Pakistan’s main political parties before the 2013 general elections. The report, which is the first study of its kind in Pakistan, found that even though manifesto formulation had become more professionalized over the years, it remained centralized and donor-oriented and the manifestos were still not central to electoral success of political parties.
Under the Heartfile Health Financing (HHF) program, HSS Component made commitments for 113 underserved patients worth Rs.5,912,799 (approximately $57,968). To date, this figure represents the highest number of patients supported through HHF program in one quarter since the start of the project. Of these 113 patients, 82 were children below the age of 15 and 31 were women.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 4 II. Health Systems Strengthening Component’s Vision of Success
By the end of the project, the Government of Sindh’s Department of Health (GOS/DOH) will have the management capacity and systems necessary to move towards universal coverage and address equity issues with a particular focus on the poor and vulnerable. The GOS will have tested and scaled proven public private partnerships (PPPs) and have the capacity to manage and sustain these partnerships and to identify and develop new ones over time. Additionally, the capacity of civil society to effectively engage in policy dialogue will have been built, and there will be a sustained increase in financial risk protection to move towards universal health coverage.
Goal
The goal of HSS Component is to develop and support innovative, cost effective, integrated, and quality programs and services to strengthen systems around reproductive, maternal, newborn and child health (RMNCH) services for improved outcomes. The primary focus of the program proposed under HSS Component is:
1. Strengthening systems that will foster improved RMNCH service delivery and outcomes, including accountability and transparency; 2. Strengthening management capacity at the provincial and district levels; 3. Developing innovative approaches to catalyze community outreach services and access to health services for marginalized populations (including financing schemes); and 4. Strengthening private sector delivery for the urban and rural poor populations.
HSS Component will also engage in the coordination, alignment, and calibration of RMNCH activities undertaken by technical partners of USAID’s MCH Program to ensure there is no duplication of effort and that all critical elements for achieving results reinforce each other and are laid out to achieve synergy and the desired results of USAID’s MCH Program objectives.
Health Systems Strengthening Component’s Intermediate Results
The results of HSS Component will follow USAID’s Results Framework. Most of the project’s activities will fall under IR 3.
IR 3: Strengthened Health System IR 3.1: Increased Accountability and Transparency of Health System IR 3.2: Improved Management Capacity at Provincial and District Levels within the Health Department IR 3.3: Strengthened Public Private Partnerships
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 5 Overall Approach and Strategic Principles
JSI and its sub-partners Rural Support Programmes Network (RSPN), Contech International, and Heartfile implement HSS Component to improve the capacity of the Government of Pakistan (GOP), and particularly the GOS, to develop and implement innovative, cost-effective, integrated, and quality programs and services to strengthen systems around RMNCH services. Throughout the project, HSS Component will strictly adhere to and promote the following strategic principles: Using a customized approach to capacity building that will be crafted to each specific entity. This is reflective of the project’s overall commitment to flexibility and adaptability in implementation; Strengthening strategic partnerships and coordination to effectively manage an integrated health system; Promoting a culture and practice of a results-oriented approach; Strengthening local expertise and focusing on local innovation to promote sustainability and ownership; Focusing on demand and supply side financing schemes to strengthen the health system; Promoting community actions for accountability and transparency of the health system; and Prioritizing gender mainstreaming within the Health Systems Strengthening Component’s implementation approach.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 6 III. Activities and Results
IR 3.1 Increased Accountability and Transparency of Health System
3.1.1 Policy Advocacy through RMNCH Steering Committee
The second meeting of the RMNCH Steering Committee was tentatively scheduled to be held in December, but was postponed due to the transfer of the Secretary Health. The post of Chief Health Sector Reforms Unit, who is a Member/Secretary of the Steering Committee, remains vacant.
A request has been made to the Additional Chief Secretary, who chairs the Steering Committee, to give a date and time for the RMNCH Steering Committee to meet in the next quarter.
3.1.2 Advocate with Policy-makers and Parliamentarians to Improve Governance and Accountability
Given the unexpectedly low turn-out of parliamentarians at the first advocacy meeting on September 30, HSS Component modified its strategy of engaging parliamentarians. Instead of aiming to invite a large number of parliamentarians to a seminar on a particular theme (e.g., the theme of the September 30 meeting was “Challenges of Population and Family Planning”), HSS Component will aim to meet with a smaller group of parliamentarians (10-15), such as those who are members of the Standing Committees on Health, Finance, and Public Accounts, at the district level within their constituency.
HSS Component has planned a meeting with Sindh Provincial Assembly’s Standing Committees on Health and Public Accounts for January 2015.
Manifesto Study
HSS Component made revisions to the draft of the manifesto study based on USAID’s feedback, and the finalized report is scheduled to be disseminated during the January- March 2015 quarter. Before sharing the report with a wider audience, HSS Component plans to share the findings of the report at MCH Program partners meeting in March 2015. This would be followed by sharing the report at forums such as The Planning Commission of Pakistan, Donor’s (Development Partner’s) Forum, Pakistan Institute of Legislative Development and Transparency. Members of the Parliament, especially from the five political parties whose election manifestos were studied, would be invited to these forums so that the findings of the study can be shared with them and a dialogue can be initiated on the way forward.
The first of its kind in Pakistan, the report tracks the health-related commitments made by Pakistan’s major political parties in their 2013 election manifestos. The report includes the Pakistan Muslim League (Nawaz), Pakistan People’s Party, Muttahida Qaumi Movement, and Pakistan Tehreek-e-Insaf. The choice of political parties for inclusion in the study was based on their Parliamentary representation, their presence
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 7 in the national or provincial governments, and the inclusion of health related topics in their 2013 general election manifestos.
The main findings of the study included: A political party’s manifesto is central to the electoral success but yet does not play a significant role in guiding the political party’s strategic direction. While manifesto formulation has become more professionalized, the process remains centralized and donor-oriented. The nature of political competition impacts and possibly biases policy choices. Coalition governments and fragmented political systems inhibit fulfillment of promises in manifesto. Absence of local government remains a pressing limitation. Divergence persists within the same party between those who draft manifestos and those who implement them, reflecting a weakness in the manifesto development process.
Following the release of the report in early 2015, a short manuscript will be submitted for a peer review publication. This will enable the international community, academics, policy-makers, and other stakeholders to learn from this experience. The following excerpt from the report summarizes its significance:
As the nature of the changes required to improve Pakistan’s health system is systemic, the opinion of those at the helm of health policy and governance, i.e., political parties and politicians, is of critical importance. If structural issues, including concerns about public financing, risk protection, equity of health outcomes, and responsiveness of the health system are to be resolved, Pakistan will require political will and vision on the part of governing political parties.
Manifestos are an important tool in this respect, as they contain the commitments made by political parties prior to the election and thus, theoretically, form the basis of the policy compact between politicians and voters. Manifestos can serve as the benchmark to gauge progress at policy, fiscal, and programmatic levels.
3.1.3 Provide Technical Support to GOS to Strengthen Supportive Supervision and Monitoring and Evaluation Functions
On November 12, the DOH and USAID inaugurated the M&E Cell, established within the office of Director General Health Services, with technical and financial support from HSS Component and the USAID│DELIVER Project. The objectives of the M&E Cell include the development of a monitoring,
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 8 evaluation, and supervisory framework linked with the Sindh Health Sector Strategy, development of key M&E framework features, and defining the M&E-related roles and responsibilities of the office of Director General Health Services and district health offices. HSS Component has been providing technical support to the DOH in this regard.
The next step will be to implement the M&E framework and to develop monitoring and supervision tools. HSS Component reviewed the existing tools used for monitoring and supervision to help supervisors organize their work and focus on critical inputs and processes required to provide basic information about the delivery of essential RMNCH services allowing for the objective review of all the required elements. During field visits, tools and checklists will be used by the DOH staff to monitor the presence and use of the most important resources and activities.
On December 5, HSS Component organized a one-day workshop in Karachi with representatives of vertical programs and USAID’s MCH Program to review the existing monitoring and supervisory tools. The aim of the workshop was to prepare a manual on monitoring and supervision for the DOH that integrated the most useful tools of the representative organizations with those used by the office of the Director General Health Services and district offices for their monitoring and supervisory visits. After reviewing each tool/checklist, the following information was collected: 1. Purpose of information gathered through the tool/checklist 2. Designation of the respondent at the health facility 3. Designation of the supervisor 4. Frequency/schedules of visits according to the person responsible 5. Whether the tool is currently in use 6. Additional questions to add to the tools/checklist 7. Questions to delete from tools/checklist (e.g., questions which are redundant) 8. Questions that need to be rephrased
After this review, key performance indicators were reviewed and aligned with the monitoring and supervisory checklists for each vertical program/DOH. The manual will be finalized during the January-March 2015 quarter. HSS Component will organize a stakeholder meeting in March to incorporate feedback from the DOH, USAID, and other key stakeholders/partners. It will be used to improve planning for supervision, monitoring, and restructuring, including identifying appropriate supervisory staff at the provincial and district levels. The staff at all levels will prepare monthly monitoring and supervision plans for their managers to review. Managers will supervise their respective staff by conducting spot checks based on submitted plans and reviewing monthly and quarterly performance reports at all levels.
3.1.4 Provide Technical Assistance to Strengthen District Health System District Health & Population Management Teams (DHPMTs)
All 22 DHPMTs held their fifth quarterly meetings during the October-December quarter. Contech International, a sub-partner in the Health Systems Strengthening Component, provided support throughout the quarter at district and provincial levels to improve the performance of DHPMTs.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 9
Contech facilitated the scheduling and organizing of all 22 DHPMT meetings and provided assistance with developing meeting agendas, compiling data from District Health Information System (DHIS) and other management information systems (MISs), and preparing presentations on district specific health issues.
To improve the performance of DHPMTs and ensure regular participation of designated members in quarterly meetings, Contech held coordination meetings with important DHPMT members, including DHOs, District Population Welfare Officers (DPWOs), District Managers of People’s Primary Healthcare Initiative (PPHI), District Education Officers, and local community members, as a part of pre-DHPMT meeting support. These coordination meetings aimed to garner support from government officials and to strengthen these fora by ensuring full participation and cooperation of the notified members.
Contech staff also participated in all DHPMT meetings to generate discussion on various issues, review District Action Plans, and follow-up decisions made in the previous quarterly meetings. Moreover, Contech staff maintained continuous communication with the secretaries of the DHPMTs to facilitate the DHPMT meeting process and ensure timely dissemination of meeting minutes.
Following are some of the important decisions taken during the fifth DHPMT quarterly meetings: 1. Minutes of meeting, invitation letters, and agenda will be provided to every member of DHPMTs on time. 2. DHO Kamber Shahdadkot will submit a request to the Secretary Health to upgrade Taluka Headquarters Hospital, Shahdadkot, to a District Headquarters Hospital. 3. DPWO district Kamber Shahdadkot will write a letter to the relevant authority requesting that the five vacant posts of doctors in District Population Welfare Office be filled. 4. DHO and DPWO of district Larkana will conduct joint health education sessions in schools and colleges with support from the Department of Education. 5. DHO Larkana will conduct monthly meetings of health facility in-charges after the 5th of every month during which the district DHIS Coordinator will present DHIS reports to resolve issues related to accuracy and quality of data. 6. Medical Superintendent will write a letter to higher authorities to bring attention to the issue of not having a gynecologist at Civil Hospital Tando Muhammad Khan. 7. Six new Family Welfare Centers will be opened in district Tando Muhammad Khan. PPHI may provide space in the health facilities managed by it. 8. District Badin’s Department of Education will share a list of its educational institutions and will prepare a plan for health education sessions to be conducted in these institutions. 9. DHO will write a letter to higher authorities asking to fill vacant positions of doctors in district Umerkot; presently, only 125 doctors are working against 406 sanctioned posts. 10. DHO district Umerkot will ask Taluka Municipal Administrations to share plan for malaria fumigation and will conduct monitoring in this regard.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 10 11. DHO district Umerkot will write a letter to IT/Communication Department, Government of Sindh, for dissemination of health messages on electronic and print media. 12. DHO and his team will monitor the shortage of essential medicines in district Naushehro Feroze. 13. Shortage of human resource in district Tando Allah Yar, e.g., of the lack of Women Medical Officers and vaccinators at District Headquarters Hospital and Taluka Headquarters Hospital Chamber, will be brought again to the notice of higher authorities. 14. Any organization conducting a family planning campaign will share its schedule of events and service provision data with DHO office, district Tando Allah Yar. 15. Focal persons DHIS and vertical programs will give a joint presentation on all MISs in the next DHPMT meeting of Mirpurkhas. 16. PPHI will provide support to TB DOTS Coordinator for establishing a Basic Management Unit at the Basic Health Unit (BHU) Makhan Samoo, Mirpurkhas district. 17. DHO Mirpurkhas will write a letter to Program Director of the Expanded Program on Immunization (EPI) to request repair of cold chain and supply of new vehicles. 18. DHO Tharparkar will conduct follow up of 100 KV generators required for Civil Hospital Mithi. 19. MCHIP/Jhpiego will arrange refresher training for Community Midwives (CMWs) for three months in district Tharparkar. 20. Population Welfare Department (PWD) will arrange a vasectomy camp every month in district Shikarpur. 21. MNCH focal person in district Shikarpur will be directed to conduct verbal autopsy to improve accuracy of Maternal Mortality Ratio and Infant Mortality Ratio. 22. Focal person of TB Control Program in district Shikarpur will send SMS messages to all health facility in-charges to remind them about the referral of suspected TB cases. 23. Meeting of District Technical Committee will be held in district Thatta in the last week of every month. All NGOs working in the health sector will be asked to attend the meeting and share their monthly activity plans. 24. DOH district Thatta will support PWD in organizing family planning camps in government’s health facilities to ensure maximum number of clients. 25. With support from development partners, the Rural Health Center (RHC) Drigh Bala, Dadu, will be upgraded so that it is equipped to provide comprehensive EmONC services, thus resolving the issue of non-availability of MCH services at this particular RHC. 26. The DHPMT-directed focal person for the LHWs Program will investigate the reason behind the failure of LHWs to ensure TT vaccination to pregnant mothers in district Dadu.
Performance Analysis of DHPMTs
Performance assessments of quarterly DHPMT meetings in all project districts are conducted quarterly and reported in the subsequent quarter. Performance assessment of DHPMT meetings held during the July-September quarter against DOH’s designed nine-points scoring criteria is presented in Table 1 on the next page.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 11
A look at Table 1 shows that DHPMT Jamshoro and DHPMT Badin scored the maximum of nine points whereas DHPMTs in Jacobabad, Sanghar, Tando Allah Yar, Thatta, Ghotki, and Dadu scored eight points. In addition, 11 districts got scores between six and seven, highlighting their good performance. Districts Kashmore, Mirpurkhas, and Naushehro Feroze showed satisfactory performance by scoring the minimum of five points.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 12
Table 1: Performance Score for 4th DHPMT (July-September 2014) Nine Point Scoring Criteria Performance 1 2 3 4 5 6 7 8 9 Score Data from Number of Progress on Meeting Meeting various decisions Performance District Meeting DAP discussed held chaired by Agenda Participation MIS implemented shared with minutes and reviewed Total Achieved within 100 designated circulated 80% including out of Provincial circulated (Tasks and days chairman DHIS previous Authority responsibilities) presented meetings
Badin 1 1 1 1 1 1 1 1 1 9 9 Dadu 1 1 1 1 0 1 1 1 1 9 8 Ghotki 1 1 1 1 0 1 1 1 1 9 8 Hyderabad 1 1 1 1 0 1 1 0 1 9 7 Jacobabad 1 1 1 1 1 1 1 0 1 9 8 Jamshoro 1 1 1 1 1 1 1 1 1 9 9 Kamber 1 1 1 1 0 0 1 0 1 9 6 Shahdadkot Kashmore 0 1 1 1 0 0 1 0 1 9 5 Khairpur 1 1 1 1 0 1 1 0 1 9 7 Larkana 1 1 1 1 0 1 1 0 1 9 7 Matiari 1 1 1 1 1 0 1 0 1 9 7 Mirpurkhas 1 0 1 1 0 1 0 0 1 9 5 Naushehro Feroze 0 1 1 1 0 0 1 0 1 9 5 Shaheed 1 1 1 1 0 1 1 0 1 9 7 Benazirabad Sanghar 1 1 1 1 0 1 1 1 1 9 8 Shikarpur 0 1 1 1 1 0 1 0 1 9 6 Sukkur 1 1 1 1 0 0 1 0 1 9 6 Tando Allah Yar 1 1 1 1 0 1 1 1 1 9 8 Tando M. Khan 1 1 1 1 0 0 1 1 1 9 7 Tharparkar 1 1 1 1 0 1 1 0 1 9 7 Thatta 1 1 1 1 0 1 1 1 1 9 8 Umerkot 1 1 1 1 0 0 1 0 1 9 6
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 13 The overall scoring matrix of the 22 DHPMT meetings held during Project Year 2, from Quarter 1 (October-December 2013) to Quarter 4 (July-September 2014) in project districts against the scoring criteria is illustrated in the Figure 1.
Figure 1: Performance of DHPMTs During Project Year 2 (Quarters 1-4)
22 22 Performance shared with provincial authority 19 22
8 Reviewed the implementation of the previous 12 meetings decisions 12
14 13 Progress on DAP discussed and reviewed 15 21
19 19 Meeting held within 100 days 21
21 20 Meeting chaired by designated chairman 20 22
22 22 Nine PointCriteria Scoring Agenda circulated 21 18
21 22 Data from various MIS Including DHIS presented 21 14
22 22 Meeting minutes circulated 21 22
5 2 Participation 80% 4 9
0 5 10 15 20 25 Number of DHPMT meetings
Q-4 (Jul-Sep' 14) Q-3 (Apr-Jun' 14) Q-2 (Jan-Mar' 14) Q-1 (Oct-Dec' 13)
As can be seen from Figure 1, the performance and functioning of DHPMTs has gradually improved from quarter one to quarter four during Project Year 2. For example, it is very
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 14 encouraging to see that during quarters three and four, all of the 22 DHPMTs circulated the agenda and minutes of meetings and also shared their performance with provincial authorities. Likewise, the performance of DHPMTs with regards to discussions and presentations on various MIS data, including DHIS, and the participation of designated chairperson in meetings was also encouraging. However, scheduling meetings within 100 days, reaching participation of 80% of the notified members, and reviewing of the implementation status of the previous meetings’ decisions still remain challenges and need the attention of higher authorities of the DOH.
Contech team supported the office of Director General Health Services Sindh in analyzing the decisions made during the current reporting quarter. A detailed matrix was prepared by consulting the DHPMT meeting minutes. DHPMT meetings were categorized by the number of decisions made, their level of responsibility/jurisdiction, if action was taken, and if the decision was implemented.
The analysis showed during the fourth quarterly (July-September 2014) DHPMT meetings, a total of 284 decisions at provincial, district and Taluka levels were made, as illustrated in Figure 2. These decisions were the primary responsibilities of Director General Health Services, Director General Population Welfare, DHOs, District Education Officers, PPHI, focal persons for vertical programs (i.e., EPI, MNCH, DHIS, Malaria, LHWs), and DPWOs, Medical Superintendent District/Taluka Headquarters Hospitals, etc., where necessary actions were required to ensure implementations of decisions.
Figure 2: Summary Status of Decision Taken vs. Implemented- Fourth DHPMT Quarterly Meeting 250 201 200 183
150 120
80 Number 100 38 50 24 3 3 - 0 Provincial District Taluka Level of Responsibility/Jurisdiction
Decisions Taken Action Taken Decision Implemented
(‘Decisions Taken’ refers to consensus to move toward taking action on an issue. ‘Action Taken’ refers to issuing letters/minutes and organizing meetings where actions are discussed, whereas ‘Decision Implementation’ refers to execution actions articulated in meetings, such as repair and maintenance of buildings and equipment, filling of vacant positions, distribution of drugs and supplies.)
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 15
Table 2: Status of District Level Decisions Number of Number of District Decisions Decisions Implemented Badin 5 5 Dadu 9 9 Ghotki 6 6 Hyderabad 3 2 Jacobabad 10 8 Jamshoro 5 5 Kamber Shahdadkot 3 0 Kashmore 3 2 Khairpur 4 3 Larkana 8 6 Matiari 9 2 Mirpurkhas 5 4 Naushehro Feroze 1 0 Sanghar 5 5 Shaheed Benazirabad 2 1 Shikarpur 4 2 Sukkur 5 1 Tando Allah Yar 6 6 Tando Muhammad Khan 11 11 Tharparkar 13 8 Thatta 9 9 Umerkot 4 1
Out of the 284 decisions taken during 22 meetings of DHPMTs, 224 actions, or 79%, were reportedly taken and 144 decisions (51%) were reportedly implemented at the provincial and district levels. However, no decision was implemented at Taluka level despite taking necessary actions, such as writing letters to authorities/decision makers to address an issue. The policy level decisions at Taluka/district level are not within the purview of the Medical Superintendent of Tehsil Headquarters Hospitals or DHO. All such requests are forwarded to Director General Health Services to be discussed with Secretary Health who is the relevant authority. For example, approval of up-gradation of a RHC to Tehsil Headquarters Hospitals, provision of a Phaco-machine for eye surgery, or establishment of a reproductive health center by PWD.
Figure 3 illustrates the status of the fourth quarterly DHPMT meetings, highlighting the number of actions/decisions taken and implemented. A total of 284 decisions were taken in the fourth round of DHPMT meetings. Of these, 80 (28.2%) decisions were provincial level decisions, 201 (70.8%) were district level decisions, and three (1.05%) were Taluka level decisions. Out of the provincial level decisions, action was taken on 36 (45%) decisions, while action was taken on 185 (92%) district level decisions. Action was taken on all the three Taluka level decisions.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 16 Figure 3: Fourth DHPMT Meetings Decisions and Actions Taken 250
201 200
150 Decisions Taken Actions Taken 100 80 185
50
36 3 0 Provincial District Taulka
Working Retreat on DHPMTs
On December 3, JSI organized a working retreat on DHPMTs as a follow up to the discussion during the meeting of Chiefs of Party of MCH Program on October 17 in JSI’s office in Islamabad. Representatives of DOH, USAID, JSI, Contech, and MCH Program partners participated in the working retreat which was held in Karachi. HSS Component discussed DHPMTs approach with the partners to share operational challenges faced by other MCH Program partners during implementation of their respective program activities. A representative of Contech gave a presentation on DHPMTs, detailing their concept and revitalization process, as well as the importance of inter-sectoral collaboration, strategic linkages for coordination with stakeholders, and the technical support being provided by HSS Component.
Table 3 summarizes actions points, strategy and assigned responsibility discussed during the meeting: Table 3: DHPMT Working Retreat Action Points Action Strategy Responsibility Health Communication Districts to share required DHOs, Component will support support for planned health supported by HSS health awareness related awareness activities Component activities included in District Collective review to finalize (Cluster Action Plans, including events future actions Coordinators) for engaging communities Health Communication Sharing information on health Districts supported Component will issue a awareness and other activities by Health newsletter Communication Component and HSS Component MCHIP/Jhpiego and Health Share coordination mechanism Health Communication Component Review/agreement with DHPMT Communication
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 17 Action Strategy Responsibility are drafting “district Component and coordination mechanism” MCHIP/Jhpiego USAID’s MCH Program DHPMT meeting schedule to be MCHIP/Jhpiego partners will participate in shared with MCH Program and HSS DHPMT meetings partners Component MCHIP/Jhpiego will lead coordination between MCH Program partners and DHPMTs Focal person from MCHIP/Jhpiego and Cluster Coordinators will represent MCH Program partners in DHPMT meetings MCHIP/Jhpiego will share inputs available with respective DHPMTs MCHIP/Jhpiego will raise identified issues in DHPMT meetings Provincial level officers Pursue DOH for nominating officers Director General should attend DHPMT and issue letters in this regard Health Services meetings supported by HSS Component Review performance scoring Propose revised performance Director General matrix of DHPMT scoring points (especially output Health Services related, MCH Program partners’ participation), and share with DOH for agreement Ensure participation of Focus engaging district level elected DHPMTs elected representatives in representative DHPMT meetings Co-opt Secretary Union Approach Deputy Commissioner’s DHPMTs Council as community office for assigning Secretary Union representative in DHPMT Council to participate in meetings Participate in district level Approach respective departments HSS Component meetings like District Technical Committee conducted by PWD and monthly review meeting by PPHI as preparation for DHPMT meeting Improve DHPMTs agenda DHPMTs will also review: DHOs Reporting rate of contraceptive supported by HSS and vaccine Logistic Component Management Information Systems M&E visit reports Supportive supervisory activities
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 18 Provincial Quarterly DHPMT Performance Review Meeting
Contech provided technical assistance to DOH to organize a quarterly provincial review of DHPMTs held at the office of Director General Health Services in Hyderabad on December 31. The meeting was chaired by Director General Health Services, Dr. Hassan Murad Shah, and attended by more than 60 participants, including stakeholders from PWD, PPHI, Department of Education, DHOs from 22 districts, representatives from vertical programs, and USAID’s MCH Program partners. The meeting focused on the following agenda: DHPMT performance review and improving effectiveness of meetings. Common issues and gaps that need improvement. Feedback such as listing benefits, bottlenecks, and suggestions for improvement. Views on performance assessment criteria. Status of decisions taken by districts during last quarter’s DHPMT meetings.
The meeting broadly discussed issues related to irregular participation of notified members, especially of District Education Officers, DPWOs and District Managers PPHI, dates for DHPMT meetings, quality of meeting minutes, and their follow- up reporting. It was pointed out in the meeting that some of the districts had not revised their notifications in line with the one issued by the Government of Sindh in December 9, 2013.
The Director General Health Services stressed that the decisions taken in DHPMT meetings should be categorized by type, level, and jurisdiction/responsibility, e.g., decision types include: • Administrative decisions entailing staff detailment (staff positioning at a place other than the posted place from where she/he draws salary), repair of buildings and
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 19 equipment, staff absenteeism, routine reporting, frequency of demand submission for drugs and supplies. • Local level troubleshooting decisions encompassing provision of DHIS tools and distribution of drugs and supplies. • Demands and resources-related decisions such as human resources (LHWs, CMWs, doctors, paramedics) and requirements for new equipment. • Coordination decisions entailing engagement of other institutions and communities.
To implement these decisions, full support and involvement is required of decision makers at all levels, including: provincial level Secretaries, Director Generals, Provincial Directors/Managers of vertical programs, Chief Executive Officer of PPHI, DHOs, District Managers PPHI, DPWO, District Education Officers, private sector, NGO representatives, focal persons of vertical programs, Medical Superintendents and facility in-charges at the district level. Timely support and coordination at all levels will ensure effective linkages between district and provincial authorities, allowing for implementation of decisions.
The DHPMT performance review meeting proved an effective channel to bring together all districts and provincial authorities to enhance coordination and achieve collective decision- making for optimal utilization of resources for improved health care services.
District Action Plans (DAPs)
HSS Component provided hands-on support to respective District Health Planning Committees (DHPCs) and all cost centers in 22 districts for the preparation of DAPs and Medium Term Budgetary Framework (MTBF) budget estimations for 2015-16. HSS Component supported districts to strengthen the capacity of DHPC members by providing hands-on support on district action planning. It also strengthened the capacity of cost centers on MTBF budgeting. The following activities took place this quarter: 1. Shared DAP 2015-16 with revised outlines, contents, updated district profile and detailed activity matrix, including Essential Package of Health Services interventions, targets, and validation of funding sources other than the DHO. 2. Set targets for key performance indicators based upon criteria by using S-2 Forms coupled with finalization of list, and baseline targets. The e-copy and printed copy of S-1 and S-2 Forms were signed by each cost center in-charge along and their annexes were also obtained. 3. Assessed Essential Package of Health Services resources of each facility in the district, including staff positions, equipment quantities, and medicine.
Contech team maintained continuous coordination with all districts and other stakeholders regarding DAP 2015-16 development and completion of S-1, S-2, and S-3 Forms.
Capacity Building Workshop on DAPs for Karachi District
Initially, the Government of Sindh had not included the district of Karachi as an intervention district for district action planning under HSS Component. However, on the request of the Government of Sindh for technical assistance to DOH for MTBF budgeting, HSS Component strengthened the capacity of nominated DHPC members and provided hands- on support for preparation of DAP and MTBF budget at all cost centers. Contech organized a two-day capacity building workshop on DAP for the district of Karachi on December 5-6.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 20 Town Health Officers and other members of DHPC attended this workshop. DHO also attended the first day of workshop, but had to leave for monitoring of the polio campaign.
The workshop aimed to build capacity in health planning by training senior management and members of DHPC on the identification and prioritization of problems, intervention design, and the costing of activities.
DHPC members also reviewed and agreed upon the outline of the DAP for Karachi district for 2015-16, and are in the process of compiling the information related to district profile and action plan. DHPC endorsed the key performance indicators and agreed that its members, in coordination with DHIS Coordinator, will set targets for year 2015-16. HSS Component is providing technical assistance to DHPC in the preparation of the district profile and action plan for the year 2015-16 and MTBF budget of each cost center.
Review of DAPs for 2015-16
On December 26 HSS Component organized a review meeting for DAPs 2015-16 at the office of Director General Health Services, Hyderabad. The meeting was chaired by the Director General Health Services, Dr. Hassan Murad Shah, and attended by DHOs of Naushehro Feroze and Tando Mohammad Khan, the Head of PPP Node and Special Initiatives, Program Director Provincial Health Development Center, and other officials of the DOH. A representative of the Economic Reforms Unit of the Finance Department also attended the meeting. During the meeting, participants discussed the DAP preparation process, MTBF budgeting process, and model DAP components. DAP 2015-16 of district Naushehro Feroze was also reviewed and changes were proposed. It was decided that after incorporating changes, the final DAP of Naushehro Feroze will be submitted to the Director General Health Services and the remaining districts will finalize their DAP accordingly. Moreover, the Director General Health Services will submit the revised District Action Plans to Secretary Health for formal approval.
3.1.5 Provide Technical Support to Strengthen and Improve Coordination of Health Functions at Federal Level and Between Federal and Provincial Governments
During the reporting quarter, HSS Component participated in the following meetings:
1. The Ministry of National Health Services, Regulations, and Coordination, in collaboration with the WHO and the Aga Khan University, held a provincial consultative meeting on “Integration of Non Communicable Diseases into Primary Health Care” in
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 21 Islamabad on December 19-20. The meeting brought together all stakeholders to discuss the present status and way forward regarding screening, prevention, and control of non-communicable diseases (NCDs).
The NCDs framework prepared by the WHO and the Government of Pakistan identified strategic interventions that are required in following four areas: Governance Prevention and reduction of risk factors Surveillance, monitoring and evaluation Health care
The framework is to be followed at country level in developing provincial and national action plans on NCDs from 2015-2018. Each province has established NCD Units and nominated focal persons who will develop provincial action plans in consultation with stakeholders.
2. The Chief of Party of HSS Component was invited by the Ministry of National Health Services, Regulations, and Coordination to attend a meeting on social health insurance at the Health Services Academy in December. It is an initiative of the Federal Government called “Prime Minister’s Social Health Insurance Program.” As 74% of the population (mostly poor and rural) pay out-of-pocket for health expenditures and more than 25% of the population is living below the poverty line, many are pushed into the “medical poverty trap,” or worst, do not receive any care.
The financial risk protection for healthcare is, therefore, a priority of the present Government. The federal and provincial governments are embarking on national health insurance schemes for the poor with joint responsibilities. Prime Minister’s Office is leading the process with a vision of covering 100 million people in a phased manner.
The meeting was of particular interest to HSS Component as the Sindh Health Minister had requested HSS Component to provide support to the DOH to implement social health insurance in four selected districts of Sindh. Sindh DOH has estimated this will cost Rs.1.9 billion for phase one and is still in discussions regarding the social health insurance scheme with the Federal Government. Dr. Nawab Mangrio is the Provincial Coordinator of Program Management Unit.
3. HSS Component was invited for a meeting at the Ministry of National Health Services, Regulations, and Coordination on November 18 to discuss the situation in Tharparkar district. The Federal Minister chaired the meeting. HSS Component’s Chief of Party gave a brief presentation on what USAID’s MCH Program was doing in Tharparkar district.
A meeting with USAID and the Ministry of National Health Services, Regulations, and Coordination is scheduled for January 2015. The objective of this meeting is to come up with a roadmap regarding the Federal support extended by HSS Component.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 22 3.1.6 Advocate on Issues Related to Accountability and Transparency
Documentary on Choked Pipes
On October 9 Rockhopper TV was chosen as the shortlisted bidder in a joint meeting of the procurement related Technical and Finance Committees, formed by Heartfile for this purpose. Heartfile is in the process of discussing technical, financial, and contractual matters to move the project forward according to plan.
Since the payment to the successful bidder is to be made in US dollars, HSS Component explored options for payment modalities with JSI’s Home Office. HSS Component has requested a geographical waiver from USAID as Rockhopper TV is a UK based company. Relevant documents such as details of the procurement process, comparative analysis of the shortlisted bids, and details of Rockhopper TV’s personnel were shared with USAID. Once the waiver is granted, Heartfile will outline the next steps with Rockhopper TV, initiating the pre-production phase of the project.
Heartfile also notified the eight unsuccessful bidders of the status of their bid outlining the procurement process that was followed. All expressed satisfaction on the decision, which testifies to the transparency of the procurement process that was followed.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 23 IR 3.2 Improved Management Capacity at Provincial and District Levels of DOH and PWD
3.2.1 Provide Technical Support to Design and Develop Capacity Building Strategy
The Sindh Health Capacity Assessment Report was a very important component of this quarter as it was the first part of the process in developing a capacity building strategy for the DOH, PWD, and PPHI. The PPHI is contracted by the DOH to manage various first level care facilities, including 71% of BHUs, dispensaries, MCH Centers, and RHCs, while PWD is responsible for the policy, strategy, and technical approaches, pre-service and in- service training of family planning service providers, and the planning and management of service delivery. A comprehensive capacity building strategy to improve the health indicators of the population requires the involvement of all three entities at the headquarters and district levels. The purpose of this assessment was to build a foundation of the strategic plan that includes an M&E framework along with an operational plan for the first year, i.e., 2015. A summary of the qualitative findings of the assessment is given below.
Building Individual Level Organizational Level Systems Level Block Leadership Management and Strategies in place Political influence and leadership skills and though not shared affects ability to make Governance experience needed at throughout the appropriate technical provincial, district and system and managerial facility levels Internal decisions; reduces local Specific skills: communication ownership advocacy, change mechanisms within Strategic, operational management; provincial HQs, planning system does delegation of authority districts, and between not routinely involve and responsibility; levels is ad hoc and districts communication not documented Routine communication protocols are lacking both within DOH, PPHI, PWD and between them Health Lack of performance Districts unable to HR system from Workforce management system retain female staff planning to retention, and requisite skills Limited workforce performance Staff motivation low; planning management and staff little incentive to work Training institutions development is in remote areas, need improved fragmented and where especially female staff infrastructure and systems exist, not Staff not aware of the operational support uniformly implemented specific job District roles and or enforced descriptions and authorities for all Policies needed for respective tasks aspects of HR not recruitment and uniformly retention of female staff implemented Health District Staff need more Timely data Data quality Information support in data quality submission rates are assessment processes Systems assessment and high not fully implemented feedback to facilities; Data analysis and Little planned use of
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 24 facilities need more utilization is low routine information for skills in record keeping Low and /or no decision-making feedback from District and /or Provincial offices Access to Lack appropriate Supply based on Logistics Management Essential procurement skills availability of drugs Information System is Medicine PWD, DOH and funds, not on not fully rolled out and is procurement staff utilization rates and fragmented by type of lacks quantification stock on hand program and or skills including commodity forecasting SCMP’s in place but not followed Health Inadequate skills in Lack of routine Budgeting centralized at Systems budget development monitoring of budget provincial level: Finance Financing and execution against results. No Department defines performance based ceilings budgeting practices Province receives block allocation Little additional resource mobilization Budget preparation processes are not transparent Political influence Delivering Health workers not Standards exist for Lack of interaction with Essential aware of health family planning and districts on prioritization Health protocols and service vertical programs, of services during Services standards; monitoring not all services; planning cycle and supervision often articulated by Service delivery mechanisms donors, partners standards and protocol Performance is not Mapping Exercise not available for all recognized and needed to better services; Essential rewarded by plan service delivery Package of Health supervisors outlets Services not yet rolled out to districts and facilities
On November 18-19, HSS Component organized a strategic workshop to review and discuss the findings of the assessment. Managers and technical staff of the provincial and district offices of DOH, including vertical programs, PWD, and PPHI, and representatives of WHO, UNICEF, and MCH Program partners attended the workshop.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 25 The workshop participants agreed on the major findings generated through the self- assessment process, established strategic priorities, and recommended possible interventions at the individual, organizational, and systems levels. They also developed a set of principles, listed below, to guide the development and implementation of this strategy. Recognize that it is a continuous process that goes beyond training to include key management and leadership functions such as mentoring and coaching; performance management; changes in policies and procedures. It also requires honest review, assessment, and re-planning. Capacity building is based on the needs of systems, work groups, facilities, and individuals to achieve better health outcomes. Coordination and collaboration (DOH, PWD, PPHI): This is an organizational and systems capacity as well as a key strategy for capacity development. Provide capacity building opportunities for all levels of system and all cadres of staff. Institutionalize the process by using and strengthening local institutions. Maximize use of available resources. Participation of all relevant stakeholders and staff is necessary. Innovation Empowerment Merit based Accountability for producing results based on increased capacity.
Individual Level
The DOH’s Capacity Building Oversight Committee met on December 5 to discuss short courses offered by the Aga Khan University, Karachi. In addition to the notified members, JSI and a representative of the Aga Khan University (from its Department of Community Health Sciences) also attended the meeting. The Committee decided that a total of 15 provincial managers from the DOH, five from PWD, and five from PPHI will be enrolled, over a period of two years, starting 2015. Managers will take the following short courses offered by the Aga Khan University: organizational management, strategic planning, human resources for health, quality management in health services, program monitoring and evaluation, and health sector reforms. (All courses are two credit courses, except for organizational management which has three credits.) In addition, a total of 60 district level managers of the DOH, from 22 districts, will attend short-term courses in the fields of organizational management (three credits), strategic planning (two credits), and human resources for health (two credits). A maximum of 10 candidates from the provincial health managers will enroll in a two year master’s of public health program at the Aga Khan University, subject to the clearance of the entry test of the university. Aga Khan University has a long standing experience of working with the DOH and the selected courses meet the requirements of the DOH. JSI’s Home Office is in the process of reviewing and finalizing JSI’s contract with the Aga Khan University. As soon as the contract is signed, training at the Aga Khan University will start.
On October 13, 30 candidates from the DOH and PWD started a Master’s of Science in Public Health degree program at the Health Services Academy. The process of selection of
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 26 the second batch of 30 candidates for Master’s of Science in Public Health at the Health Services Academy will start in March 2015.
Table 4 provides a summary of district and provincial managers from the DOH, PWD, and PPHI who will benefit from capacity building opportunities through HSS Component.
Table 4: Capacity Building of Managers at a Glance Department Master’s of Science Master’s of Public Short Courses in Public Health Health (Aga Khan (Aga Khan (Health Services University University) Academy) DOH (district 50* 0 60 managers) DOH (provincial 0 10 15 managers) PWD 10** 0 5 PPHI 0 0 5 Total 60 10 85 * 25 district managers from DOH started classes in October 2014; 25 will enroll in 2015. ** Five districts managers from PWD started classes in October 2014; five will enroll in 2015.
3.2.2 Provide Technical Support to Improve the Quality of DHIS/LMIS for Evidence- based Decision-making
District Health Information System (DHIS)
Contech provided hands-on support to districts to promote the use of data for decision- making by improving DHIS data quality in Dadu, Khairpur, Tando Muhammad Khan, Jamshoro, and Sanghar districts. Follow-up visits were made in Dadu and Khairpur to monitor changes or improvements resulting from hands-on support provided during last the quarter. Overall support was provided to the DHIS Cell at DHO offices, and data collection and compiling points at health facilities levels for improving data quality. (HSS Component will provide hands-on support to all the districts during Project Year 3.) During the reporting quarter, technical assistance was provided in Dadu district’s different health facilities, including Taluka Headquarters Hospital Khairpur Nathan Shah, RHC Drig Bala, RHC Radhan, BHU Mithobabar, BHU Chowkhand, BHU Bali Shah, BHU Khera, and the office of DHO where the following activities were carried out: - Reviewed and discussed availability of tools, their correct filling, and definition of indicators with HF staff. - Coached health facility focal person on DHIS data quality checks, preparation of DHIS monthly reports, and use of information. - Discussed with health facility in-charge data quality, data accuracy, report completeness, timely reporting, and the use of information for decision-making. - Applied Lot Quality Assurance Sampling technique to check DHIS data accuracy. - Assisted health facility in-charge in conducting monthly performance review meeting. - Supported follow up of decisions of previous meeting.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 27 Contech also visited various facilities and offices of DHOs in districts Khairpur, Tando Muhammad Khan, Kamber Shahdadkot, Jamshoro, and Sanghar to provide hands-on support to the facility staff on DHIS data recording, performance reporting, calculations, displaying indicators, and using information for decision-making. Contech staff also briefed them on online DHIS, integrated M&E and dashboard, weightage and data sources of key performance indicators, and application of Lot Quality Assurance Sampling technique for improving data quality. Step-by-step guidelines were adopted to provide support for improving data quality in DHO offices and health facilities.
HSS Component tracked the following indicators for DHIS related performance of health facilities: - Availability of DHIS tools - Regularity in reporting - Timely submission of monthly reports - Display of data - Maintenance of record - Preparation of feedback report - Monthly DHIS meeting - Summary of issues - Integration of other MIS with DHIS, including LMIS.
Performance of health facilities improved with hands-on support. Figures 4 and 5 illustrate comparison of DHIS performance for two districts after two rounds of support. The first round was conducted during July-Sept 2014 quarter and the second during October- December 2014 quarter.
Figure 4: Health Facilities DHIS Performance - Tando Allah Yar 9 8 7 7 7 7 7 7 6 5 4 4 3 3 3 3 3 2 2 1 0 0 DHIS* Cell at DHQ* Hospital THQH* RHC* RHC Misan BHU* Piyaro DHO* office Chambar Nasarpur Wadi Lund
Performance Score after 1st Round Performance Score after 2nd Round
*DHQ: District Headquarters; TQHQ: Taluka Headquarters Hospital
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 28 Figure 5: Health Facilities DHIS Performance - Tharparkar 9 8 8 8 8
7 6 6 6 6
5 4 4 4 4 3 3 3 3
2
1
0 DHIS Cell at DHQ Hospital THQH Diplo THQH Nangar THQH Chachro RHC Islamkot DHO office Parkar Performance Score after 1st Round Performance Score after 2nd Round
3.2.3 Provide Technical Support to Institutionalize Medium Term Budgetary Framework (MTBF)
Medium Term Budgetary Framework (MTBF)
HSS Component provided technical assistance to the Government of Sindh in the preparation of MTBF-based regular budget estimates for the fiscal year 2015-16 for all cost centers in all districts of Sindh, including Karachi.
As a first step, Contech formulated five district teams comprising of public health, planning, and finance experts. These teams and the eight Cluster Coordinators, which Contech hired in November, were briefed in a “Teaming up and Orientation Meeting,” held on November 12, on preparation of DAPs and MTBF budgeting process. All the planned activities to be carried out during district visits were discussed in detail, along with schedule of visits. The coordination mechanisms between district team members and Cluster Coordinators were also settled.
HSS Component conducted a total of 11 MTBF training workshops, organized in collaboration with the Economic Reforms Unit of Finance Department, for the staff of
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 29 the DOH that prepares budgets. Members of district teams and Cluster Coordinators also participated in the MTBF training workshops. These one-day training workshops were conducted in various batches combining districts, and consisted of the following sessions: Session 1: Participants were introduced to MTBF budgeting framework, its basis, objectives, process, and overall benefits. Participants were also informed about the contents and use of the Budget Call Circular, Chart of Accounts, and key performance indicators. Session 2: Participants were given orientation on “Health Reforms and District Action Planning” and costing of activities planned in district action plans. Session 3: Participants were trained in how to use the MTBF S-1, S-2, and S-3 Forms for budget preparation. All the supporting documents/annexes of the budget were also introduced and a sample budget was shared. Participants were given time to practice using the MTBF Forms with various hands-on learning exercises.
Following these workshops, Contech teams, comprising one public health/planning expert and two finance experts from GOS, carried out field visits to all districts to provide hands-on support. A total of five such teams were formulated, including a separate team for the district of Karachi, to carry out the following activities: 1. Provided orientation training to in-charges of cost centers on MTBF 2. Shared MTBF S-1 Forms with cost centers 3. Prepared contents of S-1 Form, including vacancy position, actual expenditures, and projected budget estimates, for the next three years 4. Shared DAP budget with cost centers and validated its allocation to cost centers 5. Updated existing list of cost centers in the district 6. Collected information about facilities allotted to each cost center and their functions in the district 7. Confirmed all new initiatives and prepared list of all scheduled new expenditure schemes in consultation with DHO 8. Collected revised budget estimates for districts from the last five years
Contech successfully supported 23 districts, including Karachi, in the preparation of MTBF budgets of all cost centers. All budget estimates for fiscal year 2015-16, including supporting forms and documentation (S-1, S-2, S-3 Forms, etc.,) were submitted on December 23 to the Section Officer (Budget), DOH, for further processing. E-copies of S-1 Forms were also submitted to the Finance Department, Government of Sindh, for updating their budgeting data, as per their request. A notable outcome of this round was that separate allocations were made for activities under health awareness campaigns, capacity building, and monitoring and supervision.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 30 Table 5: DAP Activities Specific Budget Estimates – All Districts (All Costs are in Pak Rupees) DAP Object Object Classification Activities Code Cost Coordination Meetings* 2,657,050 A03902 Printing and Publication 70,405,500 Health Awareness Campaign** 58,495,800 A03903 Conference/seminars/workshops/symposia 1,362,680 (Community level) A03927 Purchase of Drug and Medicines-including 56,569,700 supplies (DHO) A03906 Uniform and Protective Clothing 1,039,500 POL (Fogging machines)** 4,043,600 A09601 Purchase of Plant and Machinery 6,557,100 Monitoring and Supervision** 1 P.O.L Charges Staff Car, Motorcycles 7,920,000 2 Travelling Allowance 17,160,000 3 Transport Repair and Maintenance 2,200,000 A03927 Purchase of Drug and Medicines-including 307,063,956 supplies (health facilities) A03801 Trainings (Govt. Servants) 88,831,455 A03821 Trainings (Other than Govt. servants) 3,630,440 Total activity costs 627,936,781 *The Finance Department to assign an “Object Code”. **The Finance Department will assign “Object Codes” to them as they are new.
3.2.4 Provide Support to Enhance the Capacity of DOH to Implement Human Resource for Health Plan
This activity is dependent upon the formal approval of the Human Resource Strategy which is being reviewed by the DOH. The report on the separation of management cadre from the general cadre within the DOH is being finalized and will be disseminated during the January-March 2015 quarter.
3.2.5 Strengthen M&E of Routine EPI in Sindh
On October 30, USAID, JSI, and RSPN met at JSI’s Islamabad office and decided that RSPN, through sub-awards with its partner Rural Support Programs, namely National Rural Support Programme, Thardeep Rural Development Programme, and Sindh Rural Support Organization, will continue to work under HSS Component on strengthening M&E of routine immunization. It was agreed that RSPN will scale up activities in the four low performing EPI districts of Sindh--Jacobabad, Kashmore, Thatta, and Tharparkar--to cover all Union Councils (155 in total) of these districts. Prior to this decision, RSPN was working in selected Union Councils in each district which were not covered by Lady Health Workers (LHWs).
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 31 In LHW covered areas, RSPN’s field teams coordinate with LHWs to register children under the age of two years months and pregnant women. RSPN teams collect data on children under the age of two years and pregnant women that have been registered by LHWs and then verify the information. In cases where an LHW appointed to cover a village does not have the relevant data or is not working in the village, RSPN field teams, with support from communities, register children under the age of two years and pregnant women and share the data with the DOH and vaccinators. For vaccination, RSPN teams coordinate with vaccinators; LHWs are not involved in routine vaccination as it is done by EPI vaccinators.
In light of the decisions of October 30, RSPN carried out activities related to the strengthening of M&E of routine immunization in areas covered and not covered by LHWs in 93 Union Councils. RSPN extended its EPI work to 58 Union Councils during the October-December quarter, bringing the total number of Union Councils to 151 in four districts. (District-wise breakdown of the newly added 58 Union Councils is as follows: 10 from Tharparkar district, 15 from Kashmore district, 17 from Thatta district, and 16 from Jacobabad district). Table 6 gives district-wise total number of Union Councils as well as population figures. In LHW covered areas, homes of LHWs are used by the DOH as EPI vaccination centers during polio campaigns, measles campaign, and, in some cases, for routine immunization. In addition, LHWs also engage in social mobilization for vaccination activities of the DOH within their catchment areas.
Table 6: Number of Union Councils and Population by District
No. of Population No. of No. of Total Population Union not District Talukas in Vaccinators Population Covered by Councils Covered by District in District of District LHWs in District LHWs
Tharparkar 4 44 101 1,250,404 569,773 680,631 Jacobabad 3 40 80 878,412 480,000 398,412 Kashmore 3 37 89 823,060 330,704 492,356 Thatta 5 30 149 862,088 415,012 447,076 Total 15 151 419 3,813,964 1,795,489 2,018,475
For details on registration and vaccination of children aged 0-23 months and pregnant women, see pp.32-34 below.
Hiring and Orientation of Project Staff
In light of the decision taken to cover all Union Councils of the four target districts, RSPN, in consultation with JSI, decided they would need district-wide field staff. RSPN hired additional staff in the third week of November 2014 and organized a two-day district level orientation of project staff in the four districts from November 24-December 2. During the orientation, RSPN provided comprehensive training to staff on the EPI program. Topics included: the importance of EPI, the role of HSS Component in strengthening M&E of routine EPI in Sindh, the burden of vaccine-preventable diseases, program priorities, key targets, priority groups for immunization (i.e., children aged 0-23 months and pregnant women), vaccination schedules, EPI service delivery, possible adverse reactions following
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 32 immunization, and their role in registration JSI’s EPI Specialist also participated in the orientation.
Staff also learned about how to coordinate with EPI staff at the facility level and DHOs and share issues faced by field teams in coordinating with vaccinators for routine immunization. DHOs and District Superintendents of Vaccination from target districts also attended the orientation and appreciated the support being provided by HSS Component.
Development of Micro-plans for EPI
During the reporting quarter, HSS Component provided technical support to Jacobabad, Kashmore, Thatta, and Tharparkar districts to develop Union Council micro-plans for routine immunization. Micro-plans are work plans used by EPI for vaccination activities and include names of locations, total number of households in the area, the number of target children and women, and the name of the person responsible for coverage. These tools were developed in coordination with the DOH and relevant stakeholders. A well-formulated micro-plan helps districts reach all target populations with immunization services, includes actions to improve the quality of services, including use of EPI data, and reduces high drop- out and missed opportunity rates. Micro-plans also guide immunization teams to use a problem-solving approach that focuses attention on past achievements, current barriers to increasing the coverage and quality of services, and available resources (time, human, material, and financial).
HSS Component also developed monthly reporting forms to be used for resident and non- resident children and pregnant women by antigen with status of vaccines and syringes received that are used to monitor vaccination performance by Union Council. Similarly, the project prepared tally sheets for resident and non-resident children and pregnant women to summarize vaccination data. The appropriate implementation of these forms by the districts will bring accuracy in the vaccination data.
JSI’s EPI Specialist visited the four districts from December 21-28 to review the routine immunization progress, status of planning and coordination meetings at facility and district levels, completion and implementation of micro-plans, issues and challenges encountered, and the way forward for further improvement. The EPI Specialist and RSPN held joint meetings with DHOs, EPI Coordinators, District Superintendent Vaccinations, and Taluka Superintendent Vaccinations and decided the following: 1. Districts will fix dates for monthly meetings to be held at health facility, Taluka, and district levels. Meetings will be attended by Taluka Superintendent Vaccinations, vaccinators, RSPN staff, and representatives of Local Support Organizations. 2. Districts will fix dates for completion of micro-plans for outreach activities and field supervision. 3. Districts will ensure sharing of tally sheets on daily basis with RSPN field team. 4. Districts will ensure development and implementation of supervision plans at every level. 5. Districts will ensure use of one permanent register for permanent resident of union council and start referral system for non-residents to avoid duplication in records.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 33 6. The province will ensure district requirement of vaccines, syringes, safety boxes, daily and permanent registers and vaccination cards for fixed sites, and field level vaccination activities. 7. The province will ensure the timely release of funds required for the operational activities and repair and maintenance of operational vehicles and cold chain equipment. The releases will be in accordance with district micro-plans. The districts will submit their actual requirements for operational funds for vaccination, mobility of supervisors, repair and maintenance of vehicles, and cold chain equipment to provinces within the agreed timelines. 8. The province may arrange 4x4 vehicles; one each for Taluka for mobile activities in Tharparkar district. 9. RSPN team will share registration data of due and defaulter children, 0-23 months, and pregnant women with vaccinators, TSVs, DSV and District EPI Coordinator on regular basis. 10. RSPN will provide name and contact details of community activist or resource person to the district for coordination with vaccinator. 11. RSPN field team will assist vaccinators in organization of vaccination sessions, mobilize community for vaccination and ensure 100 % retention of vaccination cards within the community. 12. JSI’s EPI Specialist will share supervisory checklist with district government and RSPN staff. Findings of the checklist will be discussed during monthly district level review meeting.
Registration of Children and Pregnant Women
During the reporting quarter, RSPN’s field staff continued door-to-door registration of children, age 0-23 months, pregnant women, and new births. RSPN’s field team ensured the authenticity of data by spot checking the registration process and verifying registration data. District-wide details of registration of target groups during the reporting quarter are given in Table 7.
Table 7: Status of Registration of Target Groups by District Actual Registration done Over all registration Expected Target During October- Completed as of December 2014 December 2014 Total 0-23 Months Pregnant District Population Children Women 0-23 0-23 of District Pregnant Pregnant (6.9% of (4.1% of Months Months Women Women Total Total Children Children Population) Population) Tharparkar 1,250,404 86278 51267 27,436 8,665 46,292 13,131 Jacobabad 878,412 60610 36015 19,064 3,598 35,110 9,850 Kashmore 823,060 56791 33745 24,913 5,700 38,837 10,812 Thatta 862,088 59484 35346 21,069 5,351 31,653 7,201 Total 3,813,964 263164 156373 92,482 23,314 151,892 40,994
During the reporting quarter, 92,482 children, age 0-23 months, and 23,314 pregnant women were registered. The process of registration will be completed in January 2015.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 34 RSPN started the registration of target groups in April 2014 and so far a total of 151,892 children and 40,994 pregnant women have been registered.
An analysis of the registration data for children showed that 49% of the registered children are boys and 51% are girls. Only 14% (20,832) of children were found to be following the regular immunization schedule; 55% (83, 744) were defaulters/partially immunized and 31% (47,316) had received no vaccinations. Children are considered fully immunized when they are vaccinated according to the following schedule.
1. Immediately after birth for Oral Polio Vaccine (OPV) Zero dose and BCG 2. At age of six weeks for OPV1, Pentavalent 1, PCV-1 3. At age of 10 weeks for OPV2, Pentavalent 2, PCV-2 4. At age of 14 weeks for OPV3, Pentavalent 3, PCV-3 5. At the age of 9 months for Measles
However, to increase the immunity against measles, a second dose of measles is given to a child at the age of 15 months.
Vaccination of Children and Women
RSPN’s field teams actively coordinated with District Superintendent Vaccinations and Taluka Superintendent Vaccinations for the implementation of micro-plans, but, due to insufficient funds for transportation and involvement of vaccinators in polio campaigns, these plans could not be implemented properly. Keeping in mind the mobility issues of the vaccinators, JSI and RSPN agreed that RSPN will provide transport support to vaccinators to cover three rounds of vaccination in one Union Council of Thatta district and 16 Union Councils of Tharparkar district. The remaining Union Councils will make their own transport arrangements to complete vaccination of registered children and women.
RSPN provided transport support in the agreed Union Councils for three rounds of vaccination and have been continuously advocating with the DHOs and District Superintendent Vaccinations of all target districts for vaccination of all registered children. However, they were unable to complete the vaccination as per registration due to insufficient funds for transport and involvement of vaccinators in polio campaigns. Table 8 shows district-wide number of children and pregnant women vaccinated during the October-December quarter. Table 8: District-wise Details of Vaccination Vaccination Done Over-all Vaccination of Target Groups for Percentage of During October- Target Groups as of Vaccination Vaccination December 2014 December 2014 District 0-23 0-23 0-23 Months Pregnant Pregnant 0-23 Months Pregnant Pregnant Months Months Children Women Women Children Women Women Children Children Tharparkar 46,292 13,131 8,944 2,604 13,733 4,736 30% 36% Jacobabad 35,110 9,850 2,725 533 4,672 1,315 13% 13% Kashmore 38,837 10,812 5,276 2,015 8,653 2,897 22% 27% Thatta 31,653 7,201 5,552 1,293 6,462 1,480 20% 21% Total 151,892 40,994 22,497 6,445 33,520 10,428 22% 25%
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 35 Meetings of Local Support Organizations (LSOs)
During the reporting quarter, RSPN’s field team had meetings with 110 LSOs of all target Union Councils. During these meetings they discussed the role of community to improve routine vaccination coverage. The project staff helped the LSO members to understand the process of registration and provided them the formats for the registration of target groups (0-23 months’ children and pregnant women). With the help of the LSOs, RSPN’s field staff also identified one community volunteer from each target village to provide support to vaccinators at the time of vaccination. These community volunteers will help vaccinators to select a suitable place for vaccination and will also bring all registered children and women to the vaccination point.
Immunization Cards
It is very important that parents retain their children’s immunization records so parents must demand the immunization cards from vaccinators and keep them in their homes. An analysis of registration data showed that out of the 151,892 registered children, the parents of only 13,481 (9%) were able to show the immunization cards at the time of registration. Parents of children eligible for immunization often fail to produce immunization cards at the time of immunization; the cards are often lost or misplaced. An important responsibility of RSPN is to increase awareness on retaining immunization cards at community level. RSPN is advocating with communities to keep immunization cards with one person (i.e., a school teacher or a community activist could become the custodian of immunization records of a community). This will also help to ensure the availability of immunization cards during the visit of vaccinators.
In this regard, the field teams of RSPN through LSOs have started to provide information to communities to demand the immunization card and retain it safely at home. The community volunteer from target villages will also ensure that immunization cards are retained at the community level for validation purposes. Starting next quarter, RSPN will also report the data on immunization card retention in the quarterly report.
Distribution of 550 Motorcycles in 11 Districts to Strengthen Immunization Activities
Lack of sufficient means for transportation is a major hindrance to the efforts of EPI, particularly to those hard-to-reach rural villages where coverage is less than 14%. For example, district Thatta had a mere nine motorcycles for 149 vaccinators, district Kashmore had only 29 motorcycles for its 99 vaccinators, district Tharparkar had only two motorcycles for its 101 vaccinators, and district Jacobabad had 20 motorcycles for 80 vaccinators.
Keeping this in mind, HSS Component provided 550 Honda motorcycles (70cc) to EPI field staff and supervisors to improve health coverage across the province. The 11 districts which received motorcycles included Jacobabad, Kashmore, Thatta, Tharparkar, Dadu, Khairpur, Tando Allah Yar, Umerkot, Naushehro Feroze, Sukkur and Sanghar. HSS Component has developed a strong relationship with EPI and DHOs for vaccination activities. This coordination and follow up by HSS Component will help increase vaccination.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 36 JSI organized a ceremony on November 21 in Karachi to formally hand over the motorcycles to the DOH. Mr. Leon S. Waskin, USAID’s Regional Director for Sindh and Balochistan (on the left in the photo below), and Dr. Jam Mehtab Dahar, Provincial Minister for Health (on the right), gave away keys of motorcycles to DHOs of the aforementioned 11 districts.
The breakdown of distribution of the 465 motorcycles is given below, and the event was highlighted in the media. (The piece from the Business Recorder, Karachi, is given on the next page.)
Table 9: Motorcycle Distribution by District District Number of Motorcycles Received Khairpur 68 Thatta 64 Dadu 51 Sukkur 50 Tharparkar 50 Kashmore 50 Umerkot 32 Jacobabad 25 Naushehro Feroze 28 Tando Allah Yar 27 Sanghar 20
The remaining 85 motorcycles will be distributed in the remaining five MCH Program districts when Jhpiego start their program activities in these districts.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 37
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 38 3.2.6 Provide Technical Support to the Sindh Health Care Commission
HSS Component will provide technical support to the Sindh Health Care Commission to develop and strengthen its role in the delivery of its mandated functions. The DOH has mentioned the possibility of technical assistance request to Sindh Health Care Commission.
3.2.7 Capacity Development for Consortium Partners and JSI Staff
On November 20, staff from JSI, Contech, and Heartfile attended “Fraud Awareness and Prevention Workshop” which was organized by USAID in Islamabad. In addition, JSI’s two staff members from its Islamabad office attended “Participant Training ADS 252 & 253” organized by USAID.
Three staff members from JSI, one from Contech, and one from Heartfile attended a week long manuscript writing workshop in Colombo, Sri Lanka in December. The workshop was organized by Jhpiego and facilitated by its US-based staff. It was part of the efforts to showcase the technical excellence and research findings of USAID’s MCH Program and to ensure that the results of the MCH Program are accessible and contribute to the global learning agenda on MCH. This activity brought together technical staff from all the five components of MCH Program with the aim of accomplishing the following objectives: Build capacity of key stakeholders to develop and draft high quality academic papers. Publish results from MCH Program surveys in peer-reviewed journals. Engage Pakistani policy-makers with empirical evidence to advocate for improved maternal and child health outcomes.
The five participants from HSS Component were made part of five different groups by the M&E Working Group of MCH Program. Their names, designations, and the title (tentative) of the manuscripts their groups worked on are given below.
Name Title Organization Title of the Manuscript
Dr. Arshad Deputy Chief of JSI What are the opportunities Mahmood Party available to programs to reach non-users of family planning in Pakistan? Dr. Anis Kazi Senior Heartfile The role of quality health Manager, Policy services and discussion about Advocacy and birth spacing in postpartum Research contraceptive use in Sindh, Pakistan: A multilevel analysis’
Dr. Muhammad Manager for Contech Reaching Every Newborn: Adeel Alvi Health Policy, International Attributes of Missed Advocacy, and Health Opportunities in Sindh, Communication Consultants Pakistan Ms. Jamila Program JSI Effects of Social Mobilization Soomro Manager M&E Campaign on Breastfeeding Practices
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 39 Name Title Organization Title of the Manuscript
Dr. Dileep Program JSI Determinants of immunization Kumar Manager HSS and how they differ among provinces?
The programmatic and financial reviews that JSI holds with its consortium partners are also aimed at building the capacity of these organizations. JSI is planning a retreat for HSS Component staff which will be held in February 2015.
3.2.8 Health Facility Assessment
HSS Component met with the DOH to discuss health facility assessment in all districts of Sindh. It was agreed that the DOH will submit a technical assistance request to JSI, after which JSI will develop Terms of Reference and seek USAID’s approval.
3.2.9 Expansion of Community Health Workers
Expansion of community workers (such as Community Resource Persons or MARVI workers) requires a planning strategy that should consider many aspects such as recruitment, training, supervision, and community relations. Furthermore, incorporating these workers into the existing LHWs Program is a difficult undertaking which requires arrangements with multiple stakeholders from the provincial to the village levels. The design and implementation of this plan needs to be coordinated with decision-makers and other stakeholders to determine timelines, objectives, engagement with communities, reporting mechanisms, and to establish regular planning that successfully trains, supervises, and retains these workers in the LHWs Program. More than six years have passed since the last external evaluation of the LHWs Program. Major changes have occurred in the structure of the LHWs Program during this time, the most important of which has been transition of the program from central to provincial management.
During the reporting quarter, HSS Component developed Terms of Reference to conduct an assessment of the LHWs Program with the following objectives: Assess programmatic, managerial, and operational issues inhibiting more effective implementation of the program, with a view to identifying how barriers to better performance may be removed. Determine government’s (including DOH, PWD, and Planning & Development) vision for the program, including plans for increasing operational efficiencies of the program and plans for coordination or expansion of work in geographic areas currently not covered by the program. Determine the space for further strengthening functional integration/coordination with other MCH programs (MNCH Program, Nutrition Program, and EPI).
JSI incorporated USAID’s feedback in the Terms of Reference which were approved by USAID. JSI will advertise the consultancy in newspapers in the first week of January.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 40 IR 3.3 Strengthened Health System through Public Private Partnerships
3.3.1 Strengthen the Capacity of DOH in Improving Public Financial Management and Exploring Options to Bring Equity and Coverage Challenges
HSS Component, in collaboration with the Economic Reforms Unit of the Finance Department, conducted training for the relevant staff of all the 580 cost centers within the DOH on preparing budgets which are aligned with MTBF, an output based budgeting process and a major financial reform underway in the DOH. For details, see IR 3.1 above.
3.3.2 Scale up Supply Side Health Equity Model in Sindh
During the reporting quarter, the Heartfile Health Financing (HHF) program made a total of 113 commitments worth Rs.5,912,799 for poor patients in the hospital departments/units of the six hospitals1 enrolled in HHF under the HSS Component. This is the highest enrollment of patients both in numbers and quantum of allocation so far in any quarter. Amongst the 113 financing commitments made during the reporting quarter, 82 beneficiaries (73%) were minors below the age of 15, and 31 (27%) were adult females of reproductive age. A total of 45 patients (40%) were males and 68 (60%) females.
Figure 6: Number of Cases Committed for Support in Respective Wards During October-December 2014 through HHF
Breakdown by Speciality
LUH Neurosurgery, 25 LUH Cardiac Surgery, 5 National Institute of Child Health, 15
PIMS Bone Marrow PIMS Cardiac surgery, 1 Transplant, 13
PIMS Orthopedics, 2
PIMS Gynaecology, 7 JPMC Orthopedics, 2
National Istitute of Cardiovascular Diseases, 28 LUH Gynaecology, 15
1 The six hospitals are: Liaquat University Hospital (LUH), Hyderabad; Jinnah Postgraduate Medical Center (JPMC), Karachi; National Institute of Cardiovascular Diseases (NICVD), Karachi; National Institute of Child Health (NICH), Karachi; Pakistan Institute of Medical Sciences (PIMS), Islamabad; and Benazir Bhutto Hospital, Rawalpindi.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 41 Figures 7 and 8: Age and Gender-wise Breakdown: Number of Cases Committed for Support in Respective Wards during October-December 2014 through HHF Breakdown of Commitments by Breakdown of Commitments by Age Gender
Female, 68
Minor, 82 Adult Male, 45 Female, 31
Figure 9: Breakdown of Assistance Amount by Specialty Committed for Support in Respective Wards during October-December 2014
Assisstance Amount Committed (in PKR) by Speciality
LUH Cardiac Surgery, 421,384 PIMS Bone Marrow Transplant, 707,707 LUH Neurosurgery, 654,190
PIMS Gynaecology, 49,970
National Institute of Child Health, 566,300 LUH Gynaecology, 71,250
PIMS Cardiac surgery, 230,000
PIMS Orthopedics, 42,300
National Istitute of Cardiovascular Diseases, 2,455,000 JPMC Orthopedics, 714,697
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 42 Supplier Capacity Building Workshop
On December 11, Heartfile organized a day long capacity building workshop in Islamabad for HHF program suppliers from Hyderabad, Karachi, Islamabad, Rawalpindi, and Peshawar. (HHF’s activities in Peshawar are covered by a different donor.) The workshop was attended by 23 suppliers; all except one supplier working with HHF program under the HSS Component attended the workshop.
The objectives of the workshop included the following:
1. Showcasing the Humanitarian Side of HHF Program: Suppliers tend to have a bottom line denominator of “profit” in all their ventures. During the workshop, HHF showcased not only the objectives, scale of operations, and entire working of its departments, but also the humanitarian aspect of the program. This let the suppliers know that their supplies are not only saving lives, but also making a positive contribution to the society, preventing the poorest of the poor from spending catastrophically on healthcare and ending up more impoverished. The humanitarian aspect of the project was well appreciated by the suppliers, who indicated that this had catalyzed their intent to continue partnering with the program. 2. Training and Refresher: Heartfile re-oriented the suppliers on the whole HHF program and its workings. The entire start to end process of the financial assistance was shown and explained to the suppliers. The workshop also served as a refresher training session for the suppliers wherein HHF staff provided the training and necessary guidance on their queries. HHF’s policies, procedures, and protocols were reiterated to them and their questions were answered there on the spot. 3. Knowing the Supplier Perspective: The suppliers were provided an opportunity to present their views/issues and challenges faced. The suppliers appreciated the program’s humanitarian aspect and transparency, alongside an acknowledgement of speedy payment turnarounds during the July–September 2014 period. Open discussions encouraged them to voice their opinions and find solutions to the problems they are facing. A very interesting moment arrived during the workshop when the HHF presenter claimed that all invoices at HHF are processed purely on merit and totally without any under the table payments. A supplier seconded the claim in a loud voice addressing the entire gathering to say that “this claim is hundred percent true”. 4. Process Innovations: During the April-June 2014 quarter, HHF had conducted an extensive internal workshop and reviewed its processing, controls, and efficiency in the process of invoicing. Important procedural improvements were designed and put into effect. The suppliers appreciated, in particular, that queries management and
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 43 invoice processing have been the focus of process level changes. During their feedback, the suppliers acknowledged that HHF’s payments turnaround time had improved over July-September quarter, a time when HHF implemented the process innovations.
Technology Upgrades
Version 2 of HHF technology, which is in part paid for by USAID under HSS Component, had been programmed by Heartfile’s technology partner during the July-September 2014 quarter. It was made available to Heartfile module-wise for User Acceptance Testing (UAT), a software development activity whereby pre-release beta versions are test run by the clients to ensure that all their required functionality is being provided in their soon to be deployed software.
The software module meant for UAT was delivered to Heartfile by its Pakistan-based technology development partner Healthcare Technologies (Smc-Pvt) Ltd., during October- December quarter. The UAT was a major activity during the quarter and continued for over seven weeks. Heartfile thoroughly examined the functionality of version 2 of HHF technology and cross-matched it with the requirements originally laid out by Heartfile. After synthesizing and documenting inputs of different departments within Heartfile, the HHF operational staff discussed each point with the program manager. These inputs were compiled together and a focus group discussion was held to present different aspects and generate consensus. A final consolidated feedback report was put together by the program manager. The report identified gaps between the ordered vs provided functionality. Heartfile shared the report with its technology development partner and handled queries through skype sessions.
Heartfile conducted a series of meetings in the first week of November to analyze and review HHF technology hosting charges demanded by the technology development partner. After conducting comparative assessments, HHF was able to reduce the hosting charges from Rs.4.4 million to Rs.1.8 million.
Some of the salient features of version 2 are shown below.
Version 2 of the technology provides greater visibility and transparency into the supply chain management. Suppliers receive full detailed specifications of each individual item ordered. This also assures the patient that both the doctors and suppliers know exactly what is needed and ordered for a surgical procedure. Version 1 had limited capability in this regard (Figure 10).
Figure 10 : Supply Items in Version 1
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 44 To increase oversight over supply chain, version 2 of HHF technology will be able to generate and communicate ‘smart’ purchase orders to suppliers (Figure 11).
Figure 11: Smart Purchase Orders
Another feature of version 2 is that it will be able to report on the success/failure status of system generated communication in real time on a system dashboard, a critical feature lacked by version A (Figure 12).
Figure 12: Enhanced Dashboard and Gadgets for Version 2
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 45 The patient workflow in version 1 did not have intelligence to cater for the various real-world scenarios of a workflow task (Figure 13).
Figure 13: Limited Features to Set a Tasks Completion Scenario in Version 2
However, in version 2, the process/workflow of a financing request is capable of catering to different scenarios of process steps and adjusting itself accordingly. An interesting example would be when assessment teams arrive at the hospital only to find that the intended patient has been discharged from the hospital. This process step, though technically complete, does not show the true outcome (Figure 14). The process must readjust to the scenario and so would the technology in version 2.
Figure 14: Process Workflow Can Reconfigure itself based on User Inputs in Version 2
HHF Technology Version 3 Scope Understanding Meetings
On November 13, Heartfile held the first of a series meetings on HHF Version 3 with the technology developer to conduct a broad conceptualization of the basic functionality and key features of the HHF version 3, which is a smartphone/tablet based App version. Heartfile invited three external technology and banking experts to attend the meeting at Heartfile as peer reviewers. At the closure, Heartfile asked the technology developer to draw up a draft contract for review.
3.3.3 Provide Technical Support to Improve Stakeholder Coordination to Strengthen Health Systems
Coordination with the DOH and the Finance Department
During the reporting quarter, HSS Component held regular coordination meetings with Director General Health Services, Provincial DHIS Coordinator, and other relevant staff at the office of Director General Health Services on DHPMTs, DHIS, and MTBF. JSI also met Secretary Health to discuss and provide updates on HSS Component’s program activities. In addition, the project team maintained continuous communication and conducted coordination meetings/visits with district health officials.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 46
HSS Component also held meetings with the Finance Department and the Planning Department for the preparation of DAPs on MTBF. This cross sector collaboration proved very fruitful in preparing DAPs on MTBF. Contech coordinated with all districts and provincial DOH for preparation of DAPs and budget estimates for fiscal year 2015-16.
During the reporting quarter, HSS Component provided technical assistance to DHOs to organize meetings of 22 DHPMTs and to strengthen coordination between the DOH, PWD, Department of Education, and PPHI. The project supported the office of Director General Health Services to organize quarterly DHPMT performance review held on December 31. DHOs of 22 DHPMTs attended the meeting which was chaired by the Director General Health Services.
Keeping in mind the increasing need for technical assistance at the district level, Contech hired eight Cluster Coordinators who are public health experts and are based in districts and will provide hands-on support to 22 districts.
For strengthening M&E of routine immunization, HSS Component held coordination meetings with DHOs, District Superintendent Vaccinations and Taluka Superintendent Vaccinations of Jacobabad, Kashmore, Thatta, and Tharparkar. These meetings facilitated the preparation of micro-plans, by DOH vaccinators and HSS Component jointly, and allowed for a review of the performance of these four districts in terms of vaccination coverage against the registration of children under the age of two years and pregnant women.
Coordination with USAID’s MCH Program Partners
On October 17, USAID organized a meeting of Chiefs of Party of the five components of USAID’s MCH Program. The meeting made a number of key decisions to avoid duplication of work by all components of the MCH Program. To streamline MCH Program’s community platform, the meeting decided RSPN, as part of the HSS Component, will stop implementing activities with community organizations (Village Health Committees and Union Council Health Committees) to improve health services and advocacy in Thatta, Tando Allah Yar, Dadu, Tharparkar, and Umerkot districts. Instead, it was decided in the meeting, Jhpiego will use its Partnership Defined Quality teams to ensure that issues that come up during meetings are raised in DHPMT meetings.
By December 15, RSPN had stopped implementing this activity and its teams informed Village Health Committees and Union Council Health Committees about the end of their activities and linked them with Jhpiego’s teams. In addition, RSPN’s teams held meetings with stakeholders through District Health Networks in five districts to inform them about the end of this activity under HSS Component and that, in the future, Jhpiego will coordinate with them about the issues to be raised in DHMPT meetings.
During the reporting quarter, HSS Component also organized a working retreat on DHPMTs for MCH Program partners. For details, see the section on DHPMTs above.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 47 3.3.4 Provide Technical Support to Jacobabad Institute of Medical Sciences (JIMS) to Ensure Successful Operations Start-Up
During the reporting quarter, HSS Component provided technical assistance to develop a business plan for JIMS. JSI shared a draft of the business plan with USAID and is now revising it in light of USAID’s feedback. The five year business plan outlines JIMS mission statement and goals, establishes key performance indicators, and determines financial projections for JIMS. The business plan aims to make JIMS a viable entity by optimizing services, improving their financial sustainability, and providing quality health care services to people. The revised draft of the business plan will be finalized during the January-March quarter and then presented to the DOH and JIMS Board of Governors for approval.
HSS Component also provided technical assistance to the DOH in the recruitment of staff for JIMS. HSS Component hired consultants to provide support in preparing human resource inventory of existing District Headquarters Hospital staff who had opted for JIMS and to create selection criteria, job descriptions, advertisements for newspapers, interviews, list of selected candidates, and contract documents. The DOH identified 28 different categories of staff to be hired for JIMS on an immediate basis which were advertised on November 26. A total of 742 candidates appeared for the walk-in interviews. The DOH is in a process of short listing and seeking approval of the selected candidates.
On a request for technical assistance from the DOH, HSS Component initiated the process of preparing an Operational Manual for JIMS. HSS Component drafted Terms of Reference for the assignment which were reviewed and approved by USAID. HSS Component invited applications from qualified individuals through a newspaper advertisement. The successful applicants, shortlisted in consultation with USAID, will start work in January 2015.
3.3.5 Health Care Financing Working Group
On December 23, JSI organized the sixth meeting of Health Care Financing Working Group of USAID’s MCH Program. Representatives of the DOH, Marie Stopes Society, USAID │DELIVER, and Heartfile attended the meeting. The Working Group discussed Heartfile Health Financing program and public-private partnership initiatives taken by the DOH. The meeting participants agreed that the DOH may be assisted in the following areas: development of a comprehensive health financing plan; capacity development of relevant staff on contract development and management, and performance monitoring; development of a regulatory/implementation framework with the requisite structures to be put in place for the Sindh Health Care Commission Bill 2014; costing of Essential Package of Health Services for secondary level hospitals in Sindh; and assessment of functionality of Health facilities financed and governed by the public sector across the province. The DOH representative said that his department will submit a formal request to HSS Component to provide technical assistance in these areas.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 48 IV. Monitoring, Evaluation, and Reporting
Details of M&E activities related to DHPMTs, DHIS, and strengthening M&E of routine EPI are provided in the relevant sections in the preceding pages. During the reporting quarter, JSI submitted 12 weekly activity reports and a quarterly report to USAID. JSI also held regular review meetings with its three consortium partners Contech, RSPN, and Heartfile.
On November 14, a two member team of USAID visited JSI’s Islamabad office to conduct a Data Quality Assessment. Data Quality Assessment is USAID/Pakistan’s tool to assist in assessing the five aspects of data quality: validity, integrity, precision, reliability, and timeliness. The USAID team reviewed data collection procedures and documentation and HSS Component’s files, and interviewed Deputy Chief of Party of HSS Component. It also reviewed the following indicators.
IR-5.3; Sub IR 5.3.1: Percent of DHPMTs using district health information system (DHIS) data for decision making IR-5.3.1a: Number of village health committee (VHC) meetings IR-5.3; Sub-IR 5.3.2: Number of trained health and population managers posted IR-5.3; Sub IR 5.3.1: Number of districts with improved institutional capacity scores in management and oversight of FP/MNCH
HSS Component has completed the actions suggested by the USAID team, including keeping files secure with a password and ensuring staff know their roles and responsibilities.
Success Stories
1. Promoting Routine Immunization
When HSS Component introduced EPI work in the village of Suleman Mari and discussed the essential role of communities to strengthen routine immunization, Mohammad Luqman was the first person to volunteer to support the team in the process of registration of children and women. The village of Suleman Mari is located in Union Council Choubandi, of Thatta district.
Mohammad Luqman is now 20 years old; when he was two years old, he got polio. He says: “I would have been saved from lifetime disability if I had been given polio vaccination. I feel the pain. I don’t want to see other children of my village and district in this miserable condition because most of the families in my area can barely afford the travel cost to their nearest health facility. Moreover, the cost of vaccine at private clinics is expensive; so this is
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 49 a good opportunity for us to get every child vaccinated in collaboration with RSPN.”
Luqman provided his full support in data collection, not only in his own village but in other villages as well, resulting in the vaccination of 716 children (349 boys and 367 girls) in Union Council Choubandi. He is also providing support to vaccinators by organizing immunization camps in his village and has a strong commitment to reaching 100% routine immunization of all registered children and women.
2. Rasheeda’s Determination
Rasheeda is a wife and mother of five who lives in a remote village of Union Council Gehlpur, in the District of Kashmore; a community where, until recently, women and children rarely got immunized. Until RSPN’s EPI related activities started, she and her community had a limited understanding as to why routine immunization is important. The RSPN team, in partnership with a Local Support Organization, met with village organizations on a monthly basis to discuss the necessity of routine vaccinations and their schedule and mobilized them to get their women and children vaccinated. Members of the LSO met with influential people of the village and asked for their support, and through their endeavors, many more children and women got vaccinated.
Rasheeda, who is a member of one of the village organizations that RSPN worked with, showed a willingness to get her children vaccinated, inspiring others to do the same. At the time of the registration process, Rasheeda was eight months pregnant with her fifth child. Not only did she get her children vaccinated, but Rasheeda also got herself vaccinated and is now following her TT vaccination schedule. Her newborn was immunized at the time of his birth and she says she is fully committed to complete the routine immunization of her baby boy.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 50
3. Saving Abdullah
Three years old Abdullah Hakeem, of village Seherish Nanger in Hyderabad district, was born with Hydrocephalus, a condition in which large volumes of cerebrospinal fluid gets accumulated in the cranial cavity. The implications of this condition are severe; an increase of pressure within the cranial cavity can cause painful headaches, vomiting, convulsions, vision loss and permanent deformities. Since brain tissue can be severely damaged because of this condition, Abdullah Hakim was at the risk of memory loss and delayed learning abilities.
Six months after Abdullah’s birth, his parents, unable to get help, borrowed money from their relatives to pay for the treatment, a Ventriculo-Peritoneal (VP) Shunt. The shunt which drains the excessive fluid in the brain and channels it to the gut, where it can be re-absorbed, was purchased and the operation was conducted.
What followed was nothing less than a nightmare for the family and more misery for little Abdullah. The shunt used was of inferior quality, and health service provider was not trained to undertake the procedure which requires skill and qualification. His cerebrospinal fluid drained rapidly, and as a result, his headaches increased and so did his bouts of vomiting. Abdullah started losing power in his limbs and gradually lost his vision.
When his parents took Abdullah to the neurosurgery department at Liaquat University Hospital in Hyderabad on November 11, they were told that their son would require an operation to replace the faulty VP shunt. Abdullah’s father supports his family off his daily wages, which total to a meager Rs.8,000 (about $80) a month. He could not afford to pay for the procedure. He had migrated with his family from Matiari to Hyderabad for better economic opportunities and had no social network to lean on to pay for the Rs.27000 (about $270) needed for the procedure. He had still not been able to return the money he borrowed 18 months ago for the earlier procedure. The life of his son was at risk but he did not have the money for treatment because of high costs.
The service requesting doctors sent Heartfile Health Financing program, which operates in Liaquat University Hospital as part of HSS Component, a request for the patient, and after completing the procedures required for assistance through HHF, assistance was provided to Abdullah. Though he is recovering with decreased headaches and increased mobility in his limbs, Abdullah, unfortunately, has lost his vision forever.
Abdullah’s story is an example of the inequality of health care in Pakistan. A program like Heartfile Health Financing helps impoverished families to have access to lifesaving treatments.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 51 V. Project Management
Financial Management
The financial management activities during the quarter mainly included review and processing of disbursements to vendors/consultants and maintaining close liaison and extensive coordination with JSI’s Home Office in Boston. This included reporting of monthly project expenses, budget tracking, obligation tracking, and cash flow requests for funds management. The tracking sheets are updated on monthly basis to track expenditures against the approved budget and authorized obligation.
HSS Component responded to USAID/Pakistan’s queries regarding submission of financial data for accruals and other project related information during the reporting period.
Project Spending
HSS Component reviewed, processed, and approved expenditures and accruals of around $1,964,674 from both the field office and JSI Home Office during the October-December quarter. The cumulative project expenses reported and accruals as of December 31, 2014, were $6,704,774.09. The average quarterly burn rate for the last two quarter expenditures is approximately $1,548,847.9. The following table shows quarterly expenditure trends.
Figure 15: Quarterly Expenditure Trend as of December 31, 2014
2,000,000.00 Expenses in US $ 1,964,674.00
1,800,000.00
1,600,000.00
1,400,000.00 1,133,021.80 1,200,000.00 1,082,615.93 884,540.36 1,000,000.00 633,414.00 800,000.00 544,553.00 600,000.00 461,955.00
400,000.00
200,000.00
- 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 5th Qtr 6th Qtr 7th Qtr
Source: Standard Form 425
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 52 Administrative Management
Recruitment and Human Resource Management
During the reporting period, Dr. Nasir Idrees, Director Health Systems/Governance resigned due to personal reasons and the position was advertised in newspapers in November. JSI completed the selection process and made an offer of employment to Dr. Yousaf Hayat, in December, who accepted the offer and will join JSI on February 2, 2015. His hiring was approved by USAID Agreement Officer as this is one of the key positions of the project. JSI also hired Mr. Pervaiz Ali as Office Attendant for Karachi Office in December 2014.
Heartfile had hired and trained a Field Officer for Karachi operations during July 2014; unfortunately, he could not continue his engagement with HHF due to poor health after November 2014. The candidate next in line during the July recruitment was offered the said position. He was invited to Heartfile Islamabad for project orientation and training by HHF, which started on November 8 and lasted for two weeks.
International Travel
There were six international trips during the reporting period. These included five trips between Pakistan and Sri Lanka and one visit to Liberia from Pakistan. Out of the total 26 approved international travel trips, a total of six international travel trips were utilized by the end of the reporting period. Details of international travel are given in Annex 1.
Contracts/Purchase Orders
A total of 14 contracts and purchase orders for supply of goods and services amounting to $828,941.59 were issued during the reporting period.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 53 VI. Issues and Challenges
During the reporting quarter, Secretary Health, with whom HSS Component had developed a good professional relationship, was transferred. In addition, Director General Health Services retired from service and the Government appointed an Acting Director General who was replaced when the new Director General Health Services took office in December.
Some of the major challenges faced during the operationalization of DHPMT meetings included irregular participation of the notified members, untimely circulation of agenda and minutes, lack of interest of other departments (e.g., Department of Education), other engagements of DHOs leading to rescheduling, and follow-up of decision implementation at provincial level, especially with reference to staff recruitment, etc.
During the preparation of DAPs, the availability of data remained a key challenge as information on most of the key performance indicators was scarce, especially in Karachi. Moreover, reconciled budget statements were missing and there were capacity issues of the officials, especially in using computers.
As regards to DHIS implementation, challenges included capacities of healthcare providers, non-availability of regular trainings, lack of monitoring and supervision, non-availability of DHIS tools at certain places, and lack of quality checks to improve data quality.
Due to seasonal migration from many parts of Tharparkar and from one Union Council of Thatta, registration of children and pregnant women remained low. The security situation in three target Union Councils of Kashmore, located near the border of Sindh and Balochistan provinces, remained quite unstable, effecting registration process in those Union Councils. Mobility support for vaccinators from the office of DHO and their involvement in polio campaign remained a big challenge and the planned outreach activities could not be implemented. An important challenge is unjustified allocation of vaccinators as some Union Councils have no vaccinators at all, while others do not have any EPI Center or health facility. Union Council Karampur in Thatta district is an example.
As reported in the last quarterly report, Heartfile’s interface with NADRA database through secure VPN tunnel is still dysfunctional and the response from NADRA has not been encouraging. This is understandable given the internal governance situation in NADRA and the government’s changed priorities in wake of the political and security landscape in the country. However, it does not pose a serious threat to HHF’s poverty assessment process, as it does not solely rely on NADRA poverty assessment results, and has multiple tools whose triangulation decides a patient’s eligibility to get assistance from the program.
HHF program initially faced tracking issues with a particular surgical item (Anti-D Injection) in Liaquat University Hospital’s Departments of Obstetrics and Gynecology. The issue was thoroughly examined and reasons were identified. The reduced transparency level at the facility was addressed via enhanced delivery protocols especially designed for this particular clinical item.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 54 VII. Activities Planned for Next Quarter
Registration of children and women for vaccination from the remaining villages of the four target districts. Meetings with LSOs for community level awareness and retention of cards. Development of micro-plans for four districts (Jacobabad, Kashmore, Thatta, and Tharparkar) and start of vaccination activities in the remaining Union Councils of these districts. Review and coordination meetings at Union Council, Taluka, and district levels. Pre-production phase of documentary on Choked Pipes. Launch and dissemination of manifesto study and preparation of a manuscript for peer review publication. Technical assistance for quarterly meetings of DHPMTs. Technical support to finalize DAPs 2015-16. Technical support for monitoring and supervision. Scale up DHIS hands-on practice in 10 selected districts. Meeting with Parliamentarians (January). Assessment of LHWs Program in Sindh. Technical assistance to develop a regulatory/implementation framework with identification of requisite structures to be put in place for Sindh Health Care Commission. Technical assistance for capacity development of relevant staff in the DOH on contract development and management, performance monitoring, etc. Technical assistance to develop Essential Package of Health Services for secondary level health facilities. Technical assistance for comprehensive assessment of health care facilities. HSS Component staff retreat. The process of selection of the second batch for Master’s of Science in Public Health at the Health Services Academy and short courses at the Aga Khan University.
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 55 VIII. Annexes Annex 1: International Travel Status Report (As of December 31, 2014) No. of Reference Name of Arrival Departure Sector Travel Bala Sr.# Organization Designation Travel Type CA Traveler Date Date Traveled Complete nce (Sr.#/Tr#) d
Dr. Theo USA-PAK- Senior Technical 1 5-May-13 10-May-13 JSI-Boston Team Planning Travel 5/1 1 25 Lippeveld USA Advisor
PAK-USA- 2 Dr. Nabeela Ali 11-May-13 1-Jun-13 JSI-Boston Chief of Party COP/Field Office Travel 4/1 1 24 PAK
USA-PAK- 3 John Abbott 10-Jun-13 19-Jun-13 JSI-Boston Finance Manager Team Planning Travel 5/2 1 23 USA
USA-PAK- Project Home Office Support 4 Andrew Dallos 6-Sep-13 22-Sep-13 JSI-Boston 3/1 1 22 USA Coordinator Travel
USA-PAK- International International 5 Ms. Judith Oki 21-Jun-14 6-Jul-14 JSI-Boston 2/1 1 21 USA Consultant Consultant Travel To attend a USAID Dr. Sagheer PAK-USA- Government Minister for 6 24-Jun-14 29-Jun-14 meeting in NA 1 21 Ahmed PAK of Sindh Health - Sindh Washington, D.C. PAK-USA- 7 Dr. Nabeela Ali 8-Jul-14 28-Jul-14 JSI-Boston Chief of Party COP/Field Office Travel 4/1 1 20 PAK Public Health USA-PAK- Home Office Support 8 Nancy Brady 2-Aug-14 21-Aug-14 JSI-Boston Technical 3/2 1 19 USA Travel Advisor USA-PAK- Project Home Office Support 9 Andrew Dallos 2-Aug-14 21-Aug-14 JSI-Boston 3/3 1 18 USA Coordinator Travel
Liberia-Pak- Home Office Home Office Support 10 Ms. Judith Oki 7-Nov-14 21-Nov-14 JSI-Boston NA 1 17 Liberia Support Travel Travel To attend writing Dr. Arshad Pak-Sri Deputy Chief of 11 6-Dec-14 13-Dec-14 JSI-Boston workshop organized NA 1 16 Mahmood Lanka-Pak Party by Jhpiego To attend writing Dr. Dileep Pak-Sri Program 12 6-Dec-14 13-Dec-14 JSI-Boston workshop organized NA 1 15 Kumar Lanka-Pak Manager HSS by Jhpiego To attend writing Pak-Sri Program 13 Jamila Soomro 6-Dec-14 13-Dec-14 JSI-Boston workshop organized NA 1 14 Lanka-Pak Manager M&E by Jhpiego
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 56 No. of Reference Name of Arrival Departure Sector Travel Bala Sr.# Organization Designation Travel Type CA Traveler Date Date Traveled Complete nce (Sr.#/Tr#) d Manager Health To attend writing Pak-Sri Contech Policy, Advocacy workshop organized 14 Dr. M. Adeel Alvi 14-Dec-14 20-Dec-14 NA 1 13 Lanka-Pak International and by Jhpiego Communication Senior Manager To attend writing Pak-Sri 15 Dr. Anis Kazi 14-Dec-14 20-Dec-14 Heartfile Policy Advocacy workshop organized NA 1 12 Lanka-Pak and Research by Jhpiego
Component 5: Health Systems Strengthening Quarterly Report October-December 2014 57