USAID’s MCH Program Component 5: Health Systems Strengthening
Quarterly Report April-June 2014
Cooperative Agreement No. AID-391-A-13-00002
This Report has been submitted to the United States Agency for International Development for consideration and approval.
It was submitted by JSI Research & Training Institute, Inc. and prepared by JSI Research & Training Institute, Inc. in collaboration with Contech, Rural Support Programmes Network, and Heartfile.
USAID’s MCH Program Component 5: Health Systems Strengthening
Quarterly Report April-June 2014
Cooperative Agreement No. AID-391-A-13-00002
Disclaimer: “This study/report is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of JSI Research & Training Institute, Inc. and do not necessarily reflect the views of USAID or the United States Government.”
Component 5: Health Systems Strengthening Quarterly Report April-June 2014 2
Table of Contents
Acronyms ...... 4 I. Executive Summary ...... 5 II. Health Systems Strengthening Component’s Vision of Success ...... 5 Health Systems Strengthening Component’s Intermediate Results ...... 6 III. Activities and Results ...... 8 IR 3.1 Increased Accountability and Transparency of Health System ...... 8 IR 3.2 Improved Management Capacity at Provincial and District levels within the Health Department ...... 22 IR 3.3 Strengthened Public Private Partnerships ...... 25 IV. Coordination ...... 31 V. Monitoring, Evaluation, and Reporting ...... 31 VI. Project Management ...... 36 VII. Issues and Challenges ...... 37 VIII. Activities Planned for Next Quarter ...... 38 IX. Annexes ...... 40
Component 5: Health Systems Strengthening Quarterly Report April-June 2014 3
Acronyms
BHU Basic Health Unit DAP District Action Plan DHIS District Health Information System DHN District Health Network DHO District Health Officer DHPMT District Health & Population Management Team DOH Department of Health EPI Expanded Programme on Immunization GOS Government of Sindh HCF Health Care Financing HHF Heartfile Health Financing HSRU Health Sector Reforms Unit IR Intermediate Result JSI JSI Research & Training Institute, Inc. 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 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 RMNCH Reproductive, Maternal, Newborn, and Child Health RSPN Rural Support Programmes Network UCHC Union Council Health Committee USAID United States Agency for International Development VHC Village Health Committee
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I. Executive Summary
During the April-June 2014 quarter, Government of Sindh’s Department of Health (DOH) created an M&E Cell to improve monitoring, supervision, and accountability within the DOH. Established with technical support from the Health Systems Strengthening Component, the formation of M&E Cell is a crucial step in the direction of integrating District Health Information System (DHIS) and Management Information Systems (MIS) of vertical programs as well as monitoring and improving the performance of District Health & Population Management Teams (DHPMTs). The Health Systems Strengthening Component and DELIVER are jointly providing support for renovation and office equipment for the M&E Cell which will be formally inaugurated in the next quarter.
All 22 DHPMTs held their quarterly review meetings with technical support from the Health Systems Strengthening Component. This intervention is proving extremely helpful in monitoring key performance indicators, using information and generating evidence for decision-making as well as improving coordination among district level stakeholders.
During the April-June quarter, the Health Systems Strengthening Component supported District Health Departments in linking activity costs of District Action Plans (DAPs) with district budgets and preparation of budgets on Medium Term Budgetary Framework, enabling districts to develop realistic budgets to implement DAPs.
The Health Systems Strengthening Component continued to support Village Health Committees (VHCs). Out of the 1,021 VHCs formed so far, 1,016 VHCs held meetings during April-June quarter. Since October 2013, when VHCs started to meet, 302 VHCs have held three quarterly meetings, 431 have held two quarterly meetings, and 283 have met once. 67% of VHC members who participated in these meetings were women.
Under Heartfile Health Financing (HHF) scheme, the Health Systems Strengthening Component supported 80 patients for medical treatment. Of these patients, 37 were women and 43 children (24 boys and 19 girls). The total number of patients supported by the project to date is 184. One more hospital was enrolled in the scheme during the quarter, bringing the total number of enrolled hospitals to six.
The Health Systems Strengthening Component provided technical support to develop “Rules and Regulations” and “Human Resource Strategy” for Jacobabad Institute of Medical Sciences (JIMS); both were approved by the Board of Governors of JIMS so that the hospital can provide state of the art services by adopting the best management practices from private sector hospitals as well as improve the quality of care by attracting skilled human resources.
In June, 50 applicants from DOH and Population Welfare Department (PWD) appeared for testing and interviews to enroll in a Masters of Science in Public Health program at the Health Services Academy. This is part of the long-term management capacity building options that the Health Systems Strengthening Component is providing to health managers in Sindh. Thirty successful candidates will start this program in August.
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II. Health Systems Strengthening Component’s Vision of Success
At 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 the Health Systems Strengthening Component is to develop and support innovative, cost effective, integrated, and quality programs and services to strengthen systems around reproductive, maternal, newborn, and child health (RMNCH) services for improved outcomes.
The Health Systems Strengthening Component will also engage in the coordination, alignment, and calibration of RMNCH activities undertaken by technical partners of USAID’s Maternal and Child Health (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 Health Systems Strengthening Component will follow USAID’s Results Framework. Most of the project’s activities will fall under IR 3.
IR 3: Strengthened Health System IR 3.1: Increased Accountability and Transparency of Health System IR 3.2: Improved Management Capacity at Provincial and District Levels within the Health Department IR 3.3: Strengthened Public Private Partnerships
Overall Approach and Strategic Principles
JSI and its sub-partners RSPN, Contech International, and Heartfile implement the Health Systems Strengthening Component to improve the capacity of the Government of Pakistan (GOP), and particularly the GOS, to develop and implement innovative, cost-effective, integrated, and quality programs and services to strengthen systems around RMNCH services. Throughout the project, the Health Systems Strengthening Component will strictly adhere to and promote the following strategic principles: Using a customized approach to capacity building that will be fit to each specific entity. This is reflective of the project’s overall commitment to flexibility and adaptability in implementation; Strengthening strategic partnerships and coordination to effectively manage an integrated health system;
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Promoting a culture and practice of results-oriented approach; Strengthening local expertise and focusing on local innovation to promote sustainability and ownership; Focusing on demand and supply side financing schemes to strengthen the health system; Promoting community actions for accountability and transparency of the health system; and Special consideration to gender will be made to ensure that it is mainstreamed within the Health Systems Strengthening Component’s implementation approach.
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III. Activities and Results
IR 3.1 Increased Accountability and Transparency of Health System
3.1.1 Foster the Development of RMNCH Steering Committee
JSI attended the first meeting of the RMNCH Steering Committee held on April 21 in Karachi. The meeting was chaired by the Additional Chief Secretary and attended by all the members including Secretary Health, Secretary Population Welfare Department, and USAID. The Steering Committee discussed the RMNCH situation in Sindh, District Heath & Population Management Teams, District Action Plans, health sector challenges, including resource allocations, out of pocket expenses, efficient resource utilization, integration of vertical programs, completion of essential services delivery packages for primary and secondary care services, coordination between GOS departments, donors, and the private sector. The Steering Committee formed two Technical Committees: one on the integration of vertical programs and rolling out of Essential Package of Health Services and the other on innovations and institutional reforms, including human resources. The meeting also decided that DOH will review and prepare a report to revamp Lady Health Workers (LHWs) Program in Sindh.
3.1.2 Advocate with Policy-makers and Parliamentarians to Improve Governance and Accountability
With feedback from USAID, the Health Systems Strengthening Component finalized Terms of Reference of a set of comprehensive advocacy activities aimed at engaging parliamentarians both in Sindh and at the national level to improve the poor health indicators and fix the broken health care system. After the approval of the Terms of Reference by USAID, JSI began to finalize the agreement and budget with the company which will organize and facilitate two national level and four provincial level, Sindh- focused, meetings during 2014-2015. The first meeting with the parliamentarians is planned for late August this year in Karachi.
The Health Systems Strengthening Component is also tracking commitment of those political parties which are either part of the national or provincial governments currently or were in the government in the recent past. The literature review, which the project completed in June, found that though some studies were done on political party manifestos around the world, there was a paucity of data with respect to Pakistan. This also informed the overall scope of the study and the construct of the study questionnaire. The latter was peer reviewed and modified in light of the input received. The Health Systems Strengthening Component conducted and completed a scan of the 2013, 2008, and 2002 manifestos of political parties for commitments on RMNCH as well as budget analysis of fiscal allocations towards RMNCH. The political parties included the Pakistan Muslim League (Nawaz), Pakistan People’s Party, Pakistan Tehrik-e-Insaf, Muttahida Quami Movement, Awami National Party, Pakistan Muslim League (Quaid-i-Azam), and Jamiat-e-Ulema-e-Islam (Fazal).The parties chosen for the study have had at least 3% representation in the parliament in the last three general elections and had declared commitment to health in their elections manifestos. Additionally, the project completed stakeholder mapping which comprised identifying
Component 5: Health Systems Strengthening Quarterly Report April-June 2014 8 individuals within the political parties who were directly involved in drafting the manifesto of their political party. Primary data collection has commenced which includes interviews with the stakeholders and will be completed by the end of July. Two out of the nine planned interviews were conducted in this quarter.
3.1.3 Provide Technical Support to Strengthen Supportive Supervision and Monitoring and Evaluation Function
As a result of technical support provided by the Health Systems Strengthening Component, the Director General Health Services notified an M&E Cell as part of his office in Hyderabad. The M&E Cell will act as a coordination hub in the Office of Director General Health Services to strengthen integration between District Health Information System (DHIS) and other MIS of vertical programs, along with functional coordination between various stakeholders. The Director General also appointed a DHPMT focal person who will review the proceedings of DHPMTs and prepare feedback with the aim of improving the performance of DHPMTs. Specifically, the M&E Cell will perform the following functions: 1. Act as the relay point for consolidation of district based data and its compilation, on monthly and quarterly basis, for DHIS, LMIS and program-based MIS. 2. Monitor implementation of Sindh Health Sector Strategy by collecting, compiling, and producing reports in coordination with relevant stakeholders. 3. Report to Director General Health Services and provide feedback to districts, facilities, and vertical programs. 4. Review performance of DHPMTs, provide feedback and guidance, and enhance their capacity to improve their performance by solving the operational issues to strengthen health systems. 5. Support districts in identifying problems, making decisions and implementing them at the district level, following up with the Director General Health Services, and putting forward issues to provincial authorities for decisions and implementation. 6. Monitor overall progress on District Action Plans (DAPs) and service delivery by various stakeholders. 7. Build capacity of district managers on monitoring and evaluation.
The Health Systems Strengthening Component and DELIVER are jointly providing support for the renovation of M&E Cell which will be formally inaugurated in August 2014.
The Health Systems Strengthening Component also finalized a concept paper on monitoring and evaluation framework for DOH and shared it with the Director General Health Services who approved it. The framework was developed under the parameters of the Sindh Health Sector Strategy with the aim to improve the health situation in Sindh by strengthening the management capacity at the institutional level, i.e., the Health Secretariat, provincial DOH, and District Health Departments.
During the quarter, the Health Systems Strengthening Component developed two concept papers: one on development of web-based DHIS and dashboard, the other on hands-on practice of facility staff and district managers on improving the quality of DHIS
Component 5: Health Systems Strengthening Quarterly Report April-June 2014 9 data and use of information. Both papers were approved by the Director General Health Services.
3.1.4 Provide Technical Support to Strengthen District Health System
District Health & Population Management Teams (DHPMTs)
All 22 DHPMTS held their third quarterly meetings during the April-June quarter. Contech International, a sub-partner in the Health Systems Strengthening Component, attended all DHPMT meetings and provided technical support in the preparation of meetings and their minutes.
District Project Officers of RSPN (another sub-partner in the project) in Dadu, Tando Allah Yar, Tharparkar, Thatta, and Umerkot districts attended DHPMT meetings and briefed the members about the process of documentation of community feedback. They also facilitated community representatives to attend DHPMT meetings in Thatta and Dadu and shared consolidated feedback of community about health services in their areas. Following is a summary of key issues presented in DHPMT meetings: Non-availability of medicines at Basic Health Units (BHUs) and Tehsil Headquarters and District Headquarters Hospitals. Unprofessional attitude of staff at BHUs and Maternal and Child Health Centers. Lack of facilities for medical tests such as urine, blood, and Hepatitis, at the Tehsil Headquarters and District Headquarters Hospitals. Non-functional dispensary. Lady Health Workers (LHWs) lack supplies, e.g., contraceptives and medicines which they are mandated to carry with her during household visits. Non-availability of Lady Doctor/Lady Health Visitor at BHU Ahori Farm in district Umerkot. Lack of facility for normal delivery at BHU Atta Mohd Pali in Umerkot district.
As a result of community feedback, People’s Primary Healthcare Initiative (PPHI), which manages BHUs in Sindh, appointed a Lady Health Visitor at the BHU in Ahori Farm.
In the DHPMT meeting held in Tando Muhammad Khan, a community representative expressed the concern that posters and other health education material for MCH Week in the district were yet to be distributed in his area. The community representative said that volunteers from his community will post and distribute such material in their area when they have it and will also conduct health education sessions. Another community representative, a medical doctor, who attended DHPMT meeting in Badin requested the Population Welfare Department (PWD), PPHI, and the District Health Officer (DHO) to work together to increase awareness about Thalassemia which is, he said, was on the rise in Badin.
Using data from 21 DHPMT meetings held during January-March quarter1 as well as the information from performance analysis tools specifically developed for DHPMTs, the Health Systems Strengthening Component conducted an analysis of meetings of 21
1 DHPMT Tharparkar did not meet due to famine emergency in the district.
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DHPMTs. Information collection included attendance of participants, meeting notices, meeting minutes, as well as decisions taken during the meeting using the following scoring criteria: DHPMT meeting held within 100 days of the last meeting. Meeting chaired by the designated chair. Meeting agenda circulated. Meeting minutes circulated. 80% participation of members. Progress on DAP discussed and reviewed (tasks and responsibilities). Data from various management information systems, including DHIS presented. Number of decisions implemented (decisions made in the previous meeting). Performance shared with provincial authorities.
Table 1 on the next page shows the performance score of DHPMT meetings held in last quarter. In all districts, meetings were held within the required time period since the last meeting and the designated official chaired the meetings. However, DHPMT meetings in Badin, Jacobabad, Kashmore, Sukkur, and Umerkot achieved 80% attendance. Meeting minutes were shared with all team members. All districts presented DHIS and other MIS data. This allowed the districts, with technical support of the Health Systems Strengthening Component, to follow up on improving the quality of reporting. Seven districts (Jamshoro, Khairpur, Larkana, Mirpurkhas, Naushahro Feroze, Shaheed Benazirabad and Sanghar) could not implement decisions taken in their last meetings. Challenges/problems identified during the analyses included the following:
1. Attendance of notified members remained a major challenge as not a single district could achieve 100% attendance of notified members. Regular participation of District Population Welfare Officers and District Education Officers is also essential for sectoral representation. 2. Minutes of DHPMT meetings were not issued on time; in some cases, the delay was of more than one month, resulting in delayed actions on decisions. 3. Identification of community representatives as DHPMT members in all districts had not been done.
Performance assessment of quarterly meetings of DHPMTs in all districts is carried out on quarterly basis and reported in the subsequent quarter. Performance assessment of DHPMT meetings held during January-March is being reported in this quarterly report.
The Health Systems Strengthening Component shared performance analyses reports of first and second DHPMT meetings with the Director General Health Services who appointed a DHPMT focal person as part of the M&E Cell. The Director General Health Services also issued a letter to all DHOs containing feedback on DHPMT meetings of the previous quarter and a schedule of DHPMT meetings for July-September quarter. The Director General and the Health Systems Strengthening Component will work together to organize a provincial review meeting of 22 DHPMTs with DHOs on July 9. Details of the meeting will be reported in the next quarterly report.
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Table 1: Performance Scores for 2nd DHPMT Nine Point Scoring Criteria Performance 1 2 3 4 5 6 7 8 9 Score
Date
Sr District Quarter
# Names
variousMIS
Total
meetings
chairman
Achieved
responsibilities)
Participation 80%
Agendacirculated
Provincial Authority
Number of Number decisions
Data from Data
and reviewed and (Tasks and
Performanceshared with
includingDHIS presented
Meeting minutescirculated
Progresson DAPdiscussed
implemented ofout previous
Meeting heldMeeting within 100 days
Meeting chairedby designated PY2 Badin 24.3.2014 1 1 1 1 1 1 1 1 1 9 9 1 Qtr-2 PY2 2 Dadu 19.12.2013 1 1 1 1 0 1 1 1 1 9 8 Qtr-2 PY2 3 Ghotki 20.2.2014 1 1 1 1 0 1 1 1 1 9 8 Qtr-2 PY2 4 Hyderabad 31.3.2014 1 1 1 1 0 1 1 1 1 9 8 Qtr-2 PY2 5 Jacobabad 11.2.2014 1 1 1 1 1 1 1 1 1 9 9 Qtr-2 PY2 6 Jamshoro 20.2.2014 1 1 1 1 0 0 1 0 1 9 6 Qtr-2 Kamber PY2 7 02.03.2014 1 0 1 1 0 1 1 1 1 9 7 Shahdadkot Qtr-2 PY2 8 Kashmore 06.03.2014 1 1 1 1 1 1 1 1 1 9 9 Qtr-2 PY2 9 Khairpur 13.02.2014 1 1 1 1 0 1 1 0 1 9 7 Qtr-2 PY2 10 Larkana 13.03.2014 1 1 1 1 0 1 1 0 1 9 7 Qtr-2 PY2 11 Matiari 13.02.2014 1 1 1 1 0 1 1 1 1 9 8 Qtr-2 PY2 12 Mirpurkhas 18.02.2014 1 1 1 1 0 0 1 0 1 9 6 Qtr-2 Naushahro PY2 13 06.02.2014 1 1 1 1 0 0 1 0 1 9 6 Feroze Qtr-2 Shaheed PY2 14 14.02.2014 1 1 1 1 0 0 1 0 1 9 6 Benazirabad Qtr-2 PY2 15 Sanghar 20.02.2014 1 1 1 1 0 1 1 0 1 9 7 Qtr-2 PY2 16 Shikarpur 14.02.2014 1 1 1 1 0 1 1 1 1 9 8 Qtr-2 PY2 17 Sukkur 17.02.2014 1 1 1 1 1 1 1 1 1 9 9 Qtr-2 Tando Allah PY2 18 29.01.2014 1 1 1 1 0 1 1 1 1 9 8 Yar Qtr-2 Tando M. PY2 19 06.02.2014 1 1 1 1 0 1 1 1 1 9 8 Khan Qtr-2 PY2 Meeting not 20 Tharparkar 9 0 Qtr-2 held PY2 21 Thatta 13.03.2014 Qtr-2 1 1 1 1 0 1 1 1 1 9 8 PY2 22 Umerkot 30.01.2014 Qtr-2 1 1 1 1 1 0 1 1 1 9 8
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Below are a few examples of DHPMT decisions which show the use of data and request for support from DOH at the provincial level: 1. All health facilities in district Dadu, including experimental dispensaries, must submit DHIS reports in future. 2. The quality of DHIS data will be improved in district Umerkot. 3. PPHI’s District Manager in Umerkot will share schedule of monthly review meetings with the office of DHO for the participation of his representative. 4. DHIS Coordinator and Statistical Assistant in office of DHO Sanghar will review and mark the errors in DHIS monthly reports and provide feedback to in-charges of facilities and ensure proper utilization of DHIS instruments at facility level. 5. Office of DHO Jacobabad will submit a request to Secretary Health for hiring staff to fill the vacant positions in health facilities of the district. 6. MCH related indicators needing immediate attention will be presented in the next DHPMT meeting in Jacobabad. 7. Office of DHO and PPHI will conduct mass awareness campaign on health in district Tando Mohammad Khan through public announcements. A team will visit selected parts of the district each month and PPHI will provide vehicle and POL. 8. Taluka Municipal Officers will be invited in the next DHPMT meeting in Tando Muhammad Khan to sensitize them on the alarming situation of dog bite cases. 9. Presence of District Education Officer in district Tando Mohammad Khan will be ensured in the next DHPMT meeting to seek help in starting an awareness campaign in schools about hepatitis. 10. DHO Sukkur will instruct District Coordinator of LHW Program to involve LHWs in counselling and referral of patients with over two weeks old cough for tests of Tuberculosis. 11. DOH, Department of Education, PPHI, and PWD will improve their coordination for conducting school awareness sessions on health in district Sukkur. 12. PPHI will instruct doctors in district Badin to create awareness about malaria, and Taluka Health Officers will be directed to conduct two awareness sessions on malaria each month in their respective areas and submit reports to DHO. 13. PWD will share monthly schedule of camps with DHO and PPHI offices in Badin district. 14. Duplication of data will be checked during monitoring and supervision visits in district Matiari. 15. DOH will improve coordination with PWD to strengthen family planning services in district Hyderabad. 16. Taluka Health Officer and District Manager PPHI will discuss with Deputy Commissioner improving EPI coverage in district Jamshoro. 17. Taluka Health Officer in Jamshoro will ensure correct and timely submission of MNCH reports. 18. Request will be forwarded to higher authorities for deployment of Community Midwives at MCH Centers in district Ghotki. 19. DHO Qamber Shahdadkot assured that there would be no transfers of government staff under PPHI-managed facilities without prior consent.
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20. Nutrition status of children below three years will be recorded and presented in the next DHPMT meeting in district Larkana.
The Director General Health Services will share provincial level issues with Secretary Health and the RMNCH Steering Committee. As far as the impact of DHPMT meetings is concerned, they are proving to be useful in the use of information, and generating evidence for decision-making and are helping to improve coordination among district level stakeholders and strengthen the district health systems.
Table 2 below presents the status of decisions taken in the second DHPMT, and minutes of third DHPMT meetings received during this quarter. Column four shows the number of decisions implemented out of those taken during last DHPMT meeting (column 3). It shows that out of 22 districts, 10 issued minutes of meeting.
Table 2: Status of Decisions Taken in DHPMT Meetings # of Decisions Taken in # of Decisions Implemented # of Decisions Taken in S. No District 2nd DHPMT Meeting (Reported in 3rd DHPMT Meeting) 3rd DHPMT Meeting
1 Hyderabad 1 Minutes Not Received Minutes Not Received
2 Jamshoro 5 4 7
3 Matiari 5 3 9 Tando Allah Not mentioned in minutes of the 4 4 8 Yar meeting Tando 5 Mohammad 3 3 5 Khan 6 Thatta 5 Minutes Not Received Minutes Not Received
7 Badin 13 Minutes Not Received Minutes Not Received
8 Dadu 9 9 8
9 Sanghar 4 Minutes Not Received Minutes Not Received Not mentioned in minutes of the 10 Mirpurkhas 3 4 meeting Shaheed Not mentioned in minutes of the 11 1 3 Benazirabad meeting 12 Sukkur 8 Minutes Not Received Minutes Not Received Naushehro 13 4 Minutes Not Received Minutes Not Received Feroze 14 Khairpur 7 Minutes Not Received Minutes Not Received
15 Ghotki 7 5 5
16 Larkana 2 Minutes Not Received Minutes Not Received Kambar 17 1 Minutes Not Received Minutes Not Received Shahdadkot 18 Shikarpur 10 Minutes Not Received Minutes Not Received
19 Jacobabad 5 Minutes Not Received Minutes Not Received
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# of Decisions Taken in # of Decisions Implemented # of Decisions Taken in S. No District 2nd DHPMT Meeting (Reported in 3rd DHPMT Meeting) 3rd DHPMT Meeting
20 Kashmore 7 Minutes Not Received Minutes Not Received
21 Umerkot 3 3 5
22 Tharparkar 2 2 10
District Action Plans (DAPs)
During the reporting quarter, the Health Systems Strengthening Component formed four teams comprising public health and finance experts which visited all 22 districts and provided technical support to DHOs on formatting their district budgets according to MTBF S-1 budgeting format, preparing budget of nine districts (Tando Muhammad Khan, Larkana, Kashmore Kandhkot, Badin, Sukkur, Hyderabad, Tharparkar, Jamshoro, and Thatta) which could not submit their annual budget demands on time, and linking cost of activities of respective DAPs with the ‘cost center’ budget as recommended by the DHOs. (A cost center is budgeting unit under MTBF framework.) DHOs, their Accounts Officers, and in-charges of relevant cost centers participated in this activity. MTBF S1 and S2 forms (the prescribed budgeting format under MTBF) of all 22 districts were finalized and submitted along with DAPs by DHOs to the office of Director General Health Services for onward submission to provincial DOH and the Finance Department for approval.
However, these forms are under process for DHOs’ signatures, as per demand of Finance Department and the office of Director General Health Services is providing support in this regard. In addition to obtaining signatures of DHOs on MTBF S1 and S2 forms, the Finance Department made some observations, through a letter it issued on May 26, regarding inherent deficiencies in S1 forms and shortage of time. The main challenge faced during the process of preparation of MTBF forms was lack of knowledge of district officials of DOH about MTBF and their limited capacity. Due to time constraints, the above mentioned teams of experts supported districts in preparation of MTBF forms.
3.1.5 Utilize Existing Community Organizations of RSPN to Improve Health Services and Advocacy
Village Health Committees (VHCs)
During the April-June quarter, the Health Systems Strengthening Component formed 38 new VHCs; 16 in Union Council Gujjo of Thatta district and 22 in Union Council Tando Soomro in Tando Allah Yar district, bringing the total number of VHCs in five target districts to 1,021. No community organizations existed in two Union Councils when the Health Systems Strengthening Component began working with the communities to form VHCs. Out of these 38 VHCs, three have male members only, three have female members only, and 32 are mixed. Poor and socially marginalized groups are also represented in these VHCs which elected their presidents and secretary general through a majority vote.
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Of the 1,021 VHCs formed so far in 23 Unions Councils of Dadu, Tando Allah Yar, Tharparkar, Thatta, and Umerkot districts, 1,016 VHCs (99%) met this quarter. Since October 2013, when VHCs started to hold meetings, 302 VHCs have held three quarterly meetings, 431 have held two quarterly meetings, and 283 have met once. 67% of VHC members who participated in these meetings were women. District-wise and Union Council-wise details of VHC meetings and formation of VHCs during the current reporting quarter are provided in Annex 1.
The Health Systems Strengthening Component used the printed copies of information package and charts, printed by PSI/Greenstar in May 2014, to provide information about the public sector delivery points and MNCH Centers (established by MCHIP/Jhpiego) and services available there. The project disseminated Sindhi language information package to 327 VHCs during their quarterly meetings in June. The remaining VHCs will get the copies of the information package during their quarterly meetings in July- September quarter.
The feedback received from individual VHCs of a Union Council is discussed and consolidated by Union Council Health Committees (see the section on UCHCs below) and shared with DHPMTs. (See the section on DHPMTs above for the main issues identified by VHCs.)
The Health Systems Strengthening Component collected feedback from VHCs on MNCH Centers established by MHCIP/Jhpiego in Dadu, Tharparkar, Thatta, and Tando Allah Yar districts. (In VHC meetings, the Health Systems Strengthening Component provides information about these MNCH Centers and encourages community members to seek health care services there, and share their feedback about services.)
Six VHCs from Dadu and Tando Allah Yar shared positive feedback about MNCH Centers in their area, saying the communities were satisfied with the services being offered at these Centers. VHCs from Tharparkar (VHC Marvi in Union Council Diplo, VHC Maleer in Union Council Manjthi, and VHC Marvi Chawanhar in Union Council Bhakuo) reported that MCHIP/Jhpiego no longer worked in those three Union Councils and MNCH Centers there had been closed since April 2014. VHC Faqeer Suleman Chandio (Union Council Morano of Tharparkar) reported that the MNCH Center reopened in May after remaining closed during February-April and was providing services 24/7. VHC Hashim Khaskheli (Union Council Gharo of Thatta district) reported that the MNCH Center (managed by DKT) in their village had been closed since April 15 and a Community Midwife (CMW) was providing services from her home. RSPN field teams shared the community feedback with the district level staff of MCHIP/Jhpiego.
Union Council Health Committees (UCHCs)
During the quarter, the Health Systems Strengthening Component established two new UCHCs, one in Union Council Gujjo (Thatta district) and one in Union Council Tando Soomro (Tando Allah Yar district), bringing the total number of UCHCs to 23. The new UCHCs selected their office bearers (president and general secretary) who were briefed by RSPN’s district staff on their roles and responsibilities.
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During the reporting quarter, the Health Systems Strengthening Component organized orientation for five UCHCs. (Orientation for 18 UCHCs was organized in the last quarter.) The orientation focused on the role of UCHCs in improving health services, specifically, collecting, compiling, and analyzing community feedback, and then appropriately using this feedback as an advocacy tool in forums, such as District Health Networks (DHNs) and DHPMTs. (On DHNs, see below.) During orientation, the Health Systems Strengthening Component also provided information on the overall situation of maternal and child health, reproductive health rights, the role of community organizations in improving EPI coverage, and USAID’s MCH Program.
All 23 UCHCs met this quarter: five each in Dadu, Tando Allah Yar, Tharparkar, and Thatta districts and three in Umerkot. A total of 511 members (321 men and 190 women) participated in these meetings and after discussing the feedback of VHCs consolidated it for presentation in relevant DHN and DHPMT meetings. Medical Officers working on BHUs (managed by PPHI) from the following Union Councils also attended UCHC meetings: Atta Mohammad Pali and Kharoro Syed (Umerkot), Gharo (Thatta), Beggan Jarwar, Missan, and Shaikh Musa (Tando Allah Yar), and Khuda Abad (Dadu). The Medical Officers appreciated the constructive feedback about the BHUs and promised to address the issues raised by them. They encouraged UCHCs to provide regular feedback about the performance of BHUs so that they can rectify the situation.
UCHCs have started to interact with health sector stakeholders to address issues faced by the communities. For example, UCHC Kharoro Syed (Umerkot district) on learning about the absence of vaccinator approached the in-charge of BHU in the area and DHO Umerkot and apprised them of the situation. The issue was addressed and, as a result, 40 eligible children received BCG vaccination and 202 children measles vaccination.
As part its support to MCHIP/Jhpiego, RSPN used the platform of UCHCs to select individuals for focus group discussions on partnership defined quality. For this purpose, during the reporting quarter, RSPN formed two Quality Improvement Teams, one in Tando Allah Yar and one in Tharparkar.
District Health Network
During the quarter, the Health Systems Strengthening Component formed a District Health Network (DHN) in Thatta. (In Dadu, Tharparkar, Umerkot and Tando Allah Yar districts, DHNs were formed in the last quarter.)
A District Health Network (DHN) consists of representatives of UCHCs, NGOs working in the health sector in the district, Marie Stopes Society (MSS), MCHIP/Jhpiego, and designated representatives from DOH. DHNs meet quarterly where the UCHC representatives of each Union Council in the district share the consolidated community feedback of VHCs in their Union Councils about services and seek support from NGOs, MCH Program partners, and DOH to address community issues related to services. The DHNs are also responsible for advocating with DHPMTs to improve the quality of services.
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The Health Systems Strengthening Component organized orientation for all five DHNs on advocating for improving health services, underlying causes of poor RMNCH situations and the role of various stakeholders, including the community and the government. The participants also learned about USAID’s MCH Program and its components. DHNs in Thatta, Tharparkar, Tando Allah Yar, and Umerkot elected, through majority vote, one representative each to present feedback of communities in DHPMT meetings.
DHN Dadu held its second quarterly meeting which was attended by representatives of UCHCs and health sector NGOs in the district, DHO Dadu, Coordinator National Program for LHW, and Coordinator EPI. After discussion, DHN Dadu decided to present the following issues in the next DHPMT meeting. Non-availability of routine medicines at BHUs. Re-opening of government dispensary in village Charo (Union Council Kamal Khan) which has been closed for the last three years. Some BHUs, managed by PPHI, charge fees for sugar and malaria tests (which they are not supposed to). LHWs do not work in the assigned population.
Community Events in Five Districts
In collaboration with MCHIP/Jhpiego, the Health Systems Strengthening Component organized “Health Melas” in five Union Councils of Dadu, Tando Allah Yar, Tharparkar, Thatta, and Umerkot districts. The purpose was to highlight the work USAID’s MCH Program in these districts and provide a wider platform for interaction between the communities, health sector stakeholders, and local political activists on issues related to health services. A total of 873 persons (383 male and 490 female) attended these events, including representatives of VHCs, UCHCs, DOH, PPHI, MCH Program partners, local NGOs, Social Welfare Department, and local political activists.
Health mela participants in Tharparkar district
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USAID’s MCH Program partners and different NGOs set up display stalls and disseminated messages about services they are providing to communities. The health melas featured puppet shows, trivia on RMNCH, and interactive sessions which allowed members of VHCs and UCHCs to share with health sector stakeholders and political activists issues being faced by them in accessing quality services. In the health mela held in Union Council Kharoro Syed, DHO Umerkot DHO facilitated a session on health and hygiene, whereas in Union Council Missan (in Tando Allah Yar district), District President of Pakistan People’s Party appreciated the efforts to organize the health mela.
A view of the health mela held in Thatta district
3.1.6 Provide Technical Support to Strengthen and Improve Coordination of Health Functions at Federal Level and Between Federal and Provincial Governments
The Health Systems Strengthening Component discussed with the Ministry of National Health Services, Regulations, and Coordination revitalizing the National Health Information System, managed by the National Health Information Resource Center, at the federal level to collate routine data from all provinces to show provincial trends against agreed upon key performance indicators.
The Health Systems Strengthening Component also provided technical support to The World Bank to prepare PC-1 for Sindh EPI.
3.1.7 Provide Technical Support to Monitoring and Supervision System and Management Information System of Population Welfare Department (PWD)
During the quarter, JSI held several meetings with Secretary PWD to discuss the technical assistance needs of PWD. As a result of the meetings, PWD requested JSI to provide technical assistance in the following six areas.
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1. Monitoring system for PWD, including e-monitoring and dashboard. 2. Research and development (PWD will submit a concept paper to JSI highlighting areas to be addressed). 3. MTBF for PWD. 4. Pre-marriage counselling. 5. Capacity building strategy for PWD. 6. Review of existing training modules of PWD.
However, as only the first three areas relate to the work of the Health Systems Strengthening Component, JSI requested PWD to submit a formal letter to JSI to provide technical assistance in those areas. JSI will formally commence the work once it has received the request from PWD.
3.1.8 Advocate on Issues Related to Accountability and Transparency in Pakistan’s Mixed System
A documentary on Choked Pipes is part of the work plan of the Health Systems Strengthening Component and a Request for Procurement (RFP) was floated in the last quarter. At the close of bids on March 31, five applications were received, which were reviewed in the first meeting of the Technical Committee for the documentary on April 15, 2014. The Technical Committee unanimously agreed to re-launch the bid as the proposals received were not of high quality. The Technical Committee also decided to include in the RFP information about the budget ceiling to attract high quality and well- known players.
The revised RFP was launched on May 15 on the websites of Heartfile and JSI and a number of follow up steps were taken to advertise and disseminate the RFP. In particular, an advisement was placed on a specialized website http://www.nofilmschool.com to draw the attention of high end filmmakers to this opportunity. This website serves as a platform for professional film and documentary makers to find out about opportunities, gain technical expertise, and make connections for business development. The RFP was also disseminated through the help of several international agencies. Posted below (see Figure 1 on the next page) is an image from a tweet the GAVI Alliance sent from their official account in June. Health Systems Global and the Rockefeller Foundation also retweeted about the announcement (see Figure 2 below on the next page).
During the quarter, Heartfile held conference calls with three potential bidders to provide clarifications to their queries. It also started the process of hiring an investigative journalist to work with it during the development of the documentary. The journalist will collect evidence of filmable financial collusion in health, identify whistleblowers, arrange and conduct interviews, and act as a bridge between Heartfile and the successful bidder/production house assigned with the task.
Component 5: Health Systems Strengthening Quarterly Report April-June 2014 20
Figure 1: Tweet from GAVI Alliance about the RFP
Figure 2: Retweets from Health Systems Global and Robert Marten (Rockefeller Foundation)
Component 5: Health Systems Strengthening Quarterly Report April-June 2014 21
IR 3.2 Improved Management Capacity at Provincial and District levels within the Health Department
3.2.1 Provide Technical Support to Design and Develop Capacity Building Strategy
Systems Level
As part of developing capacity building strategy for DOH and PWD, the Health Systems Strengthening Component’s consultants developed a capacity assessment tool, based on WHO Health Systems Framework, to help DOH and PWD to determine priority areas for capacity building to help strengthen health system. The team of three national and international consultants held meetings with DOH, PWD, PPHI, MCH Program partners, and other stakeholders to review existing capacity issues within the two departments, explore the potential areas for capacity building, and how capacity building will help improve RMNCH situation in Sindh. During the reporting period, the consultants also conducted literature review which is being finalized. In addition, they started capacity assessment of DOH, PWD, and PPHI at the provincial level; the assessment will be completed during the July-September quarter along with district level assessment.
Individual Level
After meeting a number of times, JSI, World Learning (which manages USAID Training for Pakistan Project), and the Health Services Academy signed in June a Letter of Understanding which describes the roles and responsibilities of the three parties and coordination among them in supporting mid-level managers of DOH and PWD to build their long-term capacity through enrolment in the Masters of Science in Public Health program offered by the Health Services Academy.
By the end of the deadline for applications, the Health Services Academy had received 50 applications; 45 from DOH and five from PWD. On June 25-26, the Health Services Academy conducted written tests and interviews of the applicants in Karachi; the interview panel comprised two representatives from the Health Services Academy. The Chief of Party of USAID Training for Pakistan Project and Director M&E/DHIS of the Health Systems Strengthening Component participated in the process as observers. The selection process will be completed in July; the course will commence on August 18, 2014.
3.2.2 Provide Technical Support to Improve the Quality of District Health Information System (DHIS) for Evidence-based Decision-making
As part of improving DHIS implementation, the Health Systems Strengthening Component held a meeting in the Office of Director General Health Services in June to explain the standard operating procedures for the hands-on support it will provide to DOH in improving the quality and use of DHIS data. DHIS Coordinators from Tharparkar, Tando Allahyar, Thatta, Dadu and Khairpur districts and officials from the office of Director General Health Services participated in the meeting which was
Component 5: Health Systems Strengthening Quarterly Report April-June 2014 22 conducted by JSI and Contech staff. They presented the M&E framework and the guide to hands-on practice developed for this purpose by the project.
It was decided in the meeting that Director General Health Services will inform DHOs in writing the technical support the Health Systems Strengthening Component will provide to improve DHIS at the health facility through hands-on support activity on recoding the profile of clients, consolidating and reporting the monthly performance reports, LMIS reporting, and displaying the indicators data and use of information for decision making. In addition to the facility staff, DHIS experts will also provide technical support to district level staff in consolidation of monthly reports, calculations of indicators, preparation of data for presentation in DHPMT meetings and support them to use the data for evidence-based decision-making. Development of a web-based version of DHIS software and development of a dashboard for DHIS and key performance indicators system, with support from the Technical Resource Facility will be initiated in the next quarter.
3.2.3 Provide Technical Support to Strengthen Knowledge Management of the DOH
JSI worked closely with the Health Sector Reforms Unit to finalize the text and layout of the first issue of the e-bulletin which was published in April. The e-bulletin was distributed among all the stakeholders, including the provincial Secretaries of the Government of Sindh. The content of the e- bulletin included updates from USAID’s MCH Program partners DELIVER and MCHIP/Jhpiego. Work on the second issue of e-bulletin has been started.
3.2.4 Provide Technical Support to Institutionalize Medium Term Budgetary Framework (MTBF)
In a meeting of DOH with Economic Reform Unit of the Finance Department, it was agreed that the budgets of all districts on MTBF forms will be submitted to the Finance Department by April 30. The Health Systems Strengthening Component provided technical support to districts enabling them to prepare and submit district budget on MTBF format by the due date; however, Thatta, Larkana, Hyderabad, Kashmore Kandhkot, and Sukkur district could not meet the timeline and subsequently submitted their budget by May 5, with the concurrence of Finance Department.
MTBF-based budgeting is a fairly extensive process, pre-arranged on cost centers (depending upon its size, each district has 18-25 cost centers) and involves identification of functions of each cost center, assessment of all resources required to perform the specific functions, identification of new initiatives (resources), key outputs, input indicators, costing, etc. The Health Systems Strengthening Component could not start capacity building on MTBF during the reporting quarter as the work of supporting
Component 5: Health Systems Strengthening Quarterly Report April-June 2014 23 districts in linking DAP activity costs with district budgets took longer than expected due to the clarifications asked for by the Finance Department (such as the number of cost centers to be considered for capacity building and provincial level trainings). After finalizing the capacity building strategy on MTBF with the Finance Department, the Health Systems Strengthening Component will start building capacity of districts teams on MTBF during July-September.
The Health Systems Strengthening Component will start budget analysis using district level allocations in the 2014-2015 fiscal year and using district level 'Object Code' which were linked with DAP activity cost (as per recommendations of respective DHOs). This analysis will help in comparing budget allocations for 2013-14 with current year 2014-15 (with and without DAP activities cost demands) showing variance in amount and percentage. Analysis using district level allocations and cost center based analysis will be completed in the next quarter. This allocation comparison will help in determining the extent of realigning DAP targets accordingly. In addition, DAPs for all towns of Karachi will be prepared so that DOH can provide required MTBF budgets for whole of the province.
3.2.5 Provide Support to Enhance the Capacity of the DOH to Implement HRH Plan
This activity is dependent on the HRH Plan to be developed and formally approved/announced by DOH, which is still pending. Hence, the activities under this were not done during April-June quarter.
3.2.6 Strengthen M&E of Routine EPI in Sindh
During the quarter, the Health Systems Strengthening Component initiated activities related to strengthening routine immunization in areas not covered by Lady Health Workers (LHWs) in Jacobabad, Kashmore, Tharparkar, and Thatta districts. The number of target Union Councils in these districts is 89. (This includes 24 Union Councils in Jacobabad, 22 in Kashmore, 30 in Tharparkar, and 13 in Thatta. Of these, only 10 Union Councils in Tharparkar and Thatta have VHCs and UCHCs.) The Health Systems Strengthening Component is working with Local Support Organizations (LSOs) in these 89 Union Councils.
RSPN hired staff for EPI activities in April and conducted orientation for them. JSI’s EPI Consultant attended the orientation and explained the process of mapping areas not covered by LHWs, registering children aged 0-23 months, pregnant women, and new births, tracing defaulter and drop-out cases, planning and coordination with EPI teams at district and facility levels, linking vaccinators with LSOs, and advocating with communities for routine immunization.
After obtaining lists from the National Program for Family Planning and Primary Health Care of LHWs for areas both covered and not covered by LHWs (the lists were incomplete), a revised list was prepared after verification through LSOs. From areas not covered by LHWs, LSOs and UCHCs will register the eligible children (0-23 months)
Component 5: Health Systems Strengthening Quarterly Report April-June 2014 24 and pregnant women and will provide all this data to EPI vaccinators to ensure their vaccination. Details are provided in Table 3 below.
Table 3: District-wise Detail of Population Not Covered by LHWs in Target Union Councils No. of Name of Union Population Population Non- LHW Covered Total Total the Councils Covered Not Covered Villages/Basties/ in Population LHWs District with by LHWs by LHWs Union Councils LSOs
Tharparkar 30 775,143 415 375,184 399,959 1,005 Jacobabad 24 644,423 246 199,781 453,264 1,380 Kashmore 22 415,678 267 204,649 211,029 9,10 Thatta 13 374,570 405 142,450 232,120 1,086 Total 89 2,2098,14 1,333 922,064 1,296,372 4,381
RSPNs’s project staff organized joint meetings of 10 UCHCs and 79 LSOs to discuss with them the status of EPI coverage, importance of the Vaccination and discussed at length the role of community in providing the support to EPI to improve the routine vaccination coverage. During these meetings, the project staff helped the UCHCs and LSOs 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).
The door-to-door registration of children (0-23 months), pregnant women, and new birth was stared in target Union Councils this quarter and will be completed during the July- September quarter. The collected data will help identify children and women who need to be vaccinated. Relevant LSOs/UCHCs will share the data with DOH’s EPI for routine vaccination of registered groups. The registration of 0-23 months children in one time activity; however, LSOs and UCHCs will keep on registering the new births and pregnancies on monthly basis and will share the data EPI teams. District-wise details of registration of target groups are given in Table 4 below.
Table 4: District-wise Details of Registration of Target Groups Actual Target Group Expected Target Group Total Registered Non LHWs- Districts 0-23 Months Pregnant Covered children @5% Women @8% 0-23 Months Pregnant Population of Total of total MWRA Children Women Population (15-49 Years) Tharparkar 399,959 19,998 5,119 17989 5626 Jacobabad 453,264 22,663 5,802 13,374 4,876 Kashmore 211,029 10,551 2,701 12,948 4,789 Thatta 232,120 11,606 2,971 3,787 582 Total 1,296,372 64,819 16,594 48,098 15,873
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RSPN’s project team had meetings with EPI staff at the district level in the four target districts and updated them about the registration process. JSI’s EPI consultant provided technical support to project teams and facilitated coordination meetings with EPI staff in Jacobabad and Kashmore.
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IR 3.3 Strengthened Public Private Partnerships
3.3.1 Provide Technical Support to Explore Options and Health Care Financing Mechanisms to Address Equity and Coverage of Health Services
As reported in the January-March Quarterly Report, the Health Systems Strengthening Component had provided short-term technical assistance to DOH to prepare an analysis of health financing experiences at International level and in Pakistan and make recommendation to DOH as to how to adapt these experiences to the Sindh health system. During this quarter, DOH accepted all the five recommendations for implementation. (See January-March Quarterly Report for the recommendations.) The Health Systems Strengthening Component will provide technical assistance when requested, to build capacity of DOH to provide oversight roles.
3.3.2 Provide Technical Support to Scale up Supply Side Health Equity Model in Sindh
Support to Patients
During the reporting quarter, the Health Systems Strengthening Component made commitments for 80 patients under the Heartfile Health Financing (HHF) program, bringing the total number of patients supported so far under the project to 184. Of the 80 patients supported during April-June, 37 were women and 43 children (24 boys and 19 girls). For break up by specialty and amount of money spent of assistance, see Figures 3 and 4 below.
Figure 3: Number of Cases Committed for Support, April-June 2014 Break up by Speciality
5 8 24 21 5 9
2 12 1 2 LUH Cardiology RGH Orthopedics LUH Neurosurgery Others PIMS Pediatric Surgery LUH Gynecology NICVD PIMS Cardiology PIMS Gynecology PIMS Gastroenterology PIMS Orthopedics
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(*Others in the above figure refers to cash assistance provided to patients to fulfil their pressing health care needs such as purchase of post-op medicines for patients so poor that they cannot afford pre-op medicines in case the surgery gets delayed due to deteriorating clinical indicators or even to offset travel cost to far flung areas. These cash assistances are made via “mobile money” platform.)
Figure 4: Assistance Amount Committed for Support in Five Hospitals During April-June 2014 Assistance Amount in Rupees by Speciality
36,881.0
900,100.0
724,160.0 550,400.0
61,440.0 45,253.0 254,885.9 245,000.0 56,700.0 5,183.0 31,150.0
LUH Cardiology RGH Orthopedics LUH Neurosurgery Others PIMS Pediatric Surgery LUH Gynecology NICVD PIMS Cardiology PIMS Gynecology
Enrollment of New Units
During April-June quarter, the Health Systems Strengthening Component enrolled National Institute of Child Health (NICH), Karachi, bringing the total number of enrolled hospitals under HHF to six. Additional treatment packages of bone marrow transplant and hemophilia were enrolled in the already registered unit of Bone Marrow Transplant Unit of Children’s Hospital, Pakistan Institute of Medical Sciences (PIMS), Islamabad. In National Institute of Cardiovascular Diseases (NICVD), Karachi, assistance to patients started during the reporting quarter. (NICVD was enrolled in the last quarter.)
In the already registered Oncology Unit of Children’s Hospital, PIMS, the project initiated support for chemotherapy and registered suppliers for supplying medical supplies in corresponding wards. After the four-step registration process (register units, nominate doctors, select packages for support, and select vendors), Heartfile conducted training on how to initiate a request and follow service delivery and consumption along with the documentation required by HHF. The training also focused on the responsibilities of doctors in handling USAID-financed supplies under HHF and their inputs in invoice processing as and when required. These steps are necessary to ensure that the accountability and transparency features of HHF are well understood by
Component 5: Health Systems Strengthening Quarterly Report April-June 2014 28 partnering hospitals/doctors and that in the running of the patients’ assistance operations, partnering hospitals remain transparent in their dealings.
HHF Process Refinement
Heartfile conducted an internal workshop to review the payment and billing system and processing of invoices as this space is very collusion-prone. The review found the existing level of checks and balances to be adequate in terms of hedging against any potential collusive practices. However, the review found the system to be slow and inefficient with frequent communication lapses between suppliers and the billing department. This was also highlighted during the preliminary results of a qualitative process evaluation study, which is underway and is close to completion. (The study is funded by IDRC, Canada). Findings from the study and the review process guided modifications to the invoice processing format, which will enable greater efficiency in terms of processing payments and better communications with suppliers. However, it was extremely encouraging that not even one of the suppliers reported lack of confidence in the Heartfile transparency system. Findings of the study will be made public in the last quarter of 2014.
Based on the recommendation of the doctors in enrolled units and meetings with suppliers, Heartfile reviewed prices of suppliers and updated HHF system of managing “packages”. It should be noted that HHF financed supplies are grouped/packaged into identifiable sets of medical supplies called packages. In addition, Heartfile held meetings with its technology partner for the development of version 2 of HHF technology. It also conducted training/refreshers in PIMS, NICVD, NICH, and Jinnah Post-graduate Medical Center to help hospital staff develop initial/new treatment packages and emphasize the roles and responsibilities of doctors in handling supplies and their inputs in invoice processing as and when required.
Recognizing the window of opportunity due to the availability of 3G and 4G mobile telecommunications technology, Heartfile started exploring internally the potential benefits of the new technology for HHF. Introduction of 3G and 4G will enable wider use of this capability and allow deeper integration of the HHF platform with social networks. It will, additionally, leverage people’s existing devices and allow mobilization of resources from donors that are willing to give small donations ($100 or less) as well. (Under the current version, small donors are not part of the system.) Thus it will help mobilize resources from philanthropy and help in making this project sustainable.
3.3.3 Provide Technical Support to Improve Stakeholder Coordination to Strengthen Health System
Quarterly meetings of 22 DHPMTs provide a district level forum for collective planning, review, and decision-making. RMNCH Steering Committee sets policies, prioritizes strategies, etc., at the provincial level. The M&E Cell will coordinate MIS of vertical programs. The Health Systems Strengthening Component provides technical support to both forums.
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3.3.4 Provide Technical Support to Build an Urban Primary Health Care (UPHC) System through Public-Private Partnerships for Addressing Needs of Low-income Urban Settlements
In light of the discussions held with USAID and the recent notification by DOH to separate primary health care and secondary health care, this activity will not be carried out.
3.3.5 Provide Technical Support to Jacobabad Institute of Medical Sciences (JIMS) to Maximize Effectiveness and Efficiency of its Board of Governors
The Health Systems Strengthening Component has been providing technical support DOH to: (i) develop and document comprehensive rules and regulations which will enable it to develop strong and sustainable systems in JIMS; and (ii) develop a human resource strategy and human resource management plan for JIMS. “Rules and Regulations” and “Human Resource Strategy” were approved by the Board of Governors of JIMS which met under the chairmanship of GOS Health Minister on May 22. The Health Systems Strengthening Component also assisted DOH in drafting the job description of Director JIMS. DOH plans to hire the Director during July-September quarter.
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IV. Coordination
Coordination with DOH and PWD
The Health Systems Strengthening Component met DOH officials, especially the Director General Health Services and his staff and Chief Health Sector Reforms Unit on a regular basis. These meetings proved vital in moving forward the ongoing initiatives of the Health Systems Strengthening Component such as improving DHIS, establishing M&E Cell, strengthening M&E of EPI, etc. It also held meetings with PWD to explore PWD’s needs for technical assistance. JSI also attended meetings of Capacity Building Oversight Committee.
Coordination with USAID’s MCH Program Partners
On June 5, JSI attended the seventh quarterly meeting of USAID’s MCH Program implementing partners. JSI also participated in the brainstorming meeting of Chiefs of Party on the possible legacy of USAID’s MCH Program. JSI’s and staff of its consortium partners participated in meetings of the M&E and Behavior Change Communication (BCC) Working Groups. JSI organized fourth meeting of the Health Care Financing Working Group, which it chairs. In May, JSI participated in USAID’s mission-wide Communications Working Group meeting organized by the Office of Development, Outreach, and Communications.
V. Monitoring, Evaluation, and Reporting
JSI submitted 12 weekly activity reports and a quarterly report to USAID during the reporting quarter. JSI also held review meetings with its three consortium partners, Contech International, RSPN, and Heartfile. In addition, JSI and RSPN’s Karachi and Islamabad based staff attended meetings of VHCs, UCHCs, and DHN to monitor activities and verify records. RSPN’s Islamabad based Chief Executive Officer attended a VHC meeting in Thatta.
A review meeting between JSI and RSPN decided to restructure large VHCs (with more than 40 members) to ensure participation of all members and proper documentation of their feedback. The restructuring process will be completed during July-September quarter and the restructuring of VHCs is being done with the consent of VHC members. Based on the discussions in the review meeting, RSPN, in consultation with JSI, developed tools for monitoring and validations of meetings of VHCs.
During the reporting quarter Heartfile developed a Risk Based Monitoring Plan. The risk based approach identifies threats to HHF program (such as enrollment of ghost patients, missing requests sent from the field, corruption in operations, delays in payment, quality compromise in delivery of supplies) and places emphasis on monitoring explicitly to mitigate these risks, rather than conducting monitoring as a ritual. It will be refined on a continuous basis.
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A few field insights from a visit to Liaquat University Hospital (LUH), Hyderabad, are given below.
1. During a visit to the Neurosurgical Unit of LUH, the project staff saw firsthand the value that the project brings for children with Hydrocephalus. Since the launch of HHF in the Unit, all the poor children brought to the hospital with the condition now have access to high quality Ventriculoperitoneal shunts. “Previously they used to be taken back home and [were] left to die,” said Dr. Sohail of the Unit, “or else we would put Chinese shunts which have a high infection rate associated with them.”
Two children from impoverished families with advanced hydrocephalus requiring VP-Shunts. Funding requests for both were approved. May 12, 4 pm, Neurosurgery Department, Liaquat University Hospital.
2. Another highlight was from the Cardiac Surgery Unit of LUH where the project staff saw three patients in line for assistance: two women with Mitral valve disease and a young boy with pericardial disease. The Unit head, Dr. Raheel regards the program as “vital to the ability of the new unit to cater to the needs of the poor”.
A boy with pericardial constriction, whose funding application had just been submitted. Liaquat University Hospital, Department of Cardiology, Hyderabad. May 12, 12:00 noon.
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Success Stories
A Story on Kanwal
Kanwal Bibi’s world is quite different from most women her age. Now 20, her childhood dreams faded away when her family married her off at an early age to a low income husband. Now she now finds her health slipping away as well.
Five years ago, Kanwal gave birth to a baby girl. The baby’s arrival, however, was marked by the beginning of persistent health problems for Kanwal. Chest pain and a general malaise, or overall feeling of weakness, made her life miserable, eventually forcing her to leave her remote village in Tando Allah Yar district to travel to Hyderabad for treatment. There she was diagnosed with two blocked heart valves, treatment of which stood at Rs. 150,000. Barely being able to afford the travel costs to the city, there was little hope her family could muster such resources.
Left with few tangible options, Kanwal did what anyone in her situation would do; she chose to wait and see what would happen. Yet, her condition only continued to worsen. To make one last ditch effort, her family took her to Karachi’s Jinnah Hospital with hopes of finding a cheaper surgery, or any alternative that might address this life threatening condition.
To their disappointment, they were met with similar options in Karachi. Still unable to afford the procedure, the family returned disappointed and disheartened to Tando Allah Yar.
Having already sold off livestock and other assets to cope with the expense of palliative care, the family found itself indebted and able to borrow further within their social circle. Medical impoverishment was drawing the family further into a vicious poverty cycle. Pakistan’s health system had failed them. The procedure required to save Kanwal was readily available, yet remained inaccessible. While public sector financing agencies, such as Bait ul mal, exist in Pakistan, they are dogged by inefficiencies, patronage, and an inability to respond to time- sensitive situations.
As her condition worsened, and all hope was seemingly lost, the family struggled to cope. Not knowing what else to do, and not expecting a real solution, they decided to try Hyderabad’s Liaquat University Hospital when Kanwals’s condition took a particularly bad turn. And yet, this trip was not the same as the previous one. The family received word that an NGO working in the cardiac surgery ward was providing support to patients like Kanwal, and with that news a flicker of hope was rekindled.
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After checking in and beginning the process of waiting, an unexpected SMS arrived on their mobile. Someone was coming to discuss their financial needs for the surgery. Imagine their surprise; they had not even filed any paperwork or made any request. After so many years of searching, it was as if help was finding them. Surprised, and not knowing what to expect, they eagerly waited.
Shortly thereafter a man arrived with a laptop. He introduced himself as being from a project funded from United States Agency for International Development (USAID), asked a few questions, used the laptop to connect with a colleague, and left. By midday the next day they received another SMS, notifying the family that Kanwal’s surgery qualified for 100% financing.
Not sure whether to believe what the SMS said, they searched for the attending doctor and, upon finding him, hurriedly tried to explain the SMS, the financing, the man with the laptop. The doctor explained that he also had received a similar SMS from the USAID funded project which implements Heartfile Health Financing program which provides financial access to health care for the poorest of the poor. The doctor informed the family that Kanwal Bibi would be operated as soon as she was healthy enough for surgery.
Kanwal Bibi underwent the operation at the public sector facility of LUH Cardiac Surgery in May. She is currently (June 2014) recovering and doing quite well, surrounded by loved ones. Though nothing can change the years of struggle, the family can now begin the process of putting their lives back together, thanks to funding through USAID’s Health Systems Strengthening Component.
Advocating for Child Immunization: A Success Story from Umerkot
Mir Mohammad is a resident of village Salik Bajeer in Umerkot district and president of his VHC. He is also the general secretary of the newly formed UCHC in Union Council Kharoro Sayed. A keen community activist, Mir Mohammad takes great interest in health issues, and helps raise awareness for the importance of institutional healthcare in his village.
When Mohammad’s son was born in February 2014 at a private clinic in Umerkot, the first thing Mohammad wanted to do was have him immunized. However, there were no immunization facilities at the clinic. Mohammad’s village is located in a remote area of Umerkot, difficult for immunization workers to reach and is not covered by the LHWs. Immunization statistics in his village have also traditionally been low; only about 40% children have been vaccinated.
As the president of VHC, Mohammad knew that he had to set an example for his community to motivate other parents to get their children vaccinated. With his VHC members, he called on his area’s vaccinator and asked him to come to the village to vaccinate his son and other children of the village. The immunization worker, who was the relative of an influential community member and, therefore, did not have much regard for his duties, refused; Mohammad’s village was too far from the BHU, he said.
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Determined to get the children in the village vaccinated, the VHC contacted the Medical Officer of the BHU, but still had no luck. The UCHC also joined in and after lobbying with the DHO of Umerkot, Mohammad was finally able to get the immunization worker come to his village and give polio and the first dose of BCG vaccinations to his baby boy and to 40 other children in the village. It took the VHC and UCHC 40 days of lobbying with the DHO, but when the immunization worker finally arrived, he spent five hours there administering vaccines. Later on, when the government began its measles vaccination campaign in Umerkot, the VHC got the EPI team to visit the village once again and 202 children were vaccinated. Mohammad has been widely appreciated by his fellow community members for all the hard work he does with his VHC and UCHC to ensure basic health care for his village.
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VI. Project Management
Financial Management
The financial management activities 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 expense, 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.
The Health Systems Strengthening Component responded to USAID/Pakistan’s queries regarding submission of financial data for accruals and other project related information during the reporting period.
Project Spending
The Health Systems Strengthening Component reviewed, processed, and approved expenditures of around $1,082,615.93 from both the field office and JSI Home Office during the April-June quarter. The cumulative project expenses reported as of June 30, 2014, were $3,607,077.56. The average quarterly burn rate for the last two quarter expenditures is approximately $772,285.47. The following table shows quarterly expenditure trends:
Quarterly Expenditure Trend as of June 30, 2014
900,000 884,540 Expenses in US $ 1,082,616 800,000
700,000 633,414 600,000 544,553
500,000 461,955 Expenses 400,000
300,000
200,000
100,000 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter 5th Quarter
Source: Standard Form 425
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Administrative Management
Recruitment and Human Resource Management
During the April-June quarter, JSI hired Program Manager M&E and Program Manager HSS, both based in Karachi. Heartfile hired two full-time staff: a pharmacist to support operations in Islamabad and a field officer based in Karachi. Deputy Chief of Party of the project resigned during the reporting quarter.
International Travel
There was no international travel during the reporting period. Out of the total 20 approved international travel trips, a total of four international travel trips were utilized by the end of the reporting period. Details of international travel are given in Annex 2.
Contracts/Purchase Orders
A total of 15 contracts and purchase orders for supply of goods and services amounting to $109,190.98 were issued during the reporting period.
VII. Issues and Challenges
Despite the technical assistance of the Health Systems Strengthening Component, preparation and submission of DHPMT meeting minutes and use of information and evidence-based decision-making is still poor. Hands-on support activity on DHIS during July-September quarter should help in improving the use of information. DHPMT performance review, to be held on July 9 and organized by the office of Director General Health Services, will help in sensitizing DHOs’ and improving DHPMT performance. Lack of capacity at the district level of DOH in MTBF was a significant challenge in linking DAP activities to MTBF.
Due to seasonal migration2 of people living in rural areas of Tharparkar and Umerkot, the participation of maximum number of VHCs members remained challenging. Due to seasonal migration, meetings of five VHCs could not be organized during the reporting quarter. Participation of BHU in-charges in UCHC meetings remained low as they were not allowed by their District Support Managers to attend meetings. According to them, they cannot attend UCHC meetings without permission from PPHI’s head of program at the provincial level.
Law and order situation in three target Union Councils of Kashmore district remained unstable. Therefore, EPI-related field activities were not started in these Union Councils.
2 Seasonal migration is very common during agricultural cycles in Tharparkar and Umerkot. It includes moving sheep or cattle to higher elevations during summer to escape heat and find more forage. Human labor often moves during wheat harvesting season to other cities in search of labor. This year’s drought in Tharparkar also caused temporary migration of large population to other areas.
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Heartfile’s online system with the National Database and Registration Authority (NADRA, which is charged by the Government of Pakistan with running the registration system for the entire population of Pakistan) has been non-functional for the past two months and NADRA has not been responsive in restoring the connection due to internal governance issues at NADRA. However, this is not posing a risk for ascertaining patient’s eligibility due to the robust assessment questionnaire and overall process.
At the LUH, Hyderabad, the conditionality imposed by USAID to restrict funding to women and children is becoming a reputational risk since there is constant demand to provide support for men. The highest need is in the areas that are outside of MNCH. President Heartfile, Sania Nishtar, who provides time pro bono to oversee and steer Heartfile operations under the Health Systems Strengthening Component is planning fund raisers to raise additional resources to serve these needs in Hyderabad. This is a significant time drain for her already very crowded schedule.
In addition, there seems to be a disconnect between the administration of LUH and its obstetricians. The administration insists that ample money and resources are available for procurement and that hospital stocks amply provide for all the medicines and equipment (including supplies for emergency surgeries). However, the obstetricians were not aware of this and there seemed to be a visible disconnect. On the insistence of the obstetricians, Heartfile started providing assistance for high value antibiotics but stopped immediately thereafter for two reasons: one, the hospital administration insisted that these could be provided by the hospital; two, monitoring by Heartfile revealed that the tracking of antibiotics could not be done properly through the one-time assistance model of Heartfile.
Heartfile has received repeated requests from the administration and clinicians at LUH that the assistance being provided by USAID through the Health Systems Strengthening Component should be maximized in neurosurgery and cardiac surgery as opposed to gynecology and obstetrics as supplies are available in the latter but the hospital administration cannot secure them for the former two categories. In particular, requests to register the orthopedic wards are persistent. It should be noted that gynecologists in LUH want an age relaxation for females so that they can help older women who have surgical needs. NICVD has also requested for age relaxation for the pediatric category up to 18 years.
VIII. Activities Planned for Next Quarter
DHPMT performance review meeting at the provincial level. DHIS hands-on practice in five selected districts. Preparation of DAP implementation strategy. Meetings with the Economics Reform Unit and Finance Department on MTBF. Development of management standard operating procedures, tools, and guidelines. Technical support in operationalizing M&E Cell and its renovation. Advocacy meetings with parliamentarians at the national and provincial level.
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Finalization of manifesto study. Selection of two new Union Councils in each of the five project districts for formation of VHCs and UCHCs. Selection of media partner for documentary on Pakistan’s health and governance issues, meetings with media partner, consultative meetings with stakeholders to build consensus on script. Launch of HHF operations in National Institute of Child Health, Karachi. Development, deployment, and testing of new mHealth modules.
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IX. Annexes Annex 1: VHCs Formed, Meetings Held, Households organized, and Participation of Women
No. of VHCs by number of meetings held No. of VHC during reporting quarter VHCs meetings Total No formed Total Total HH conducte VHCs VHCs VHCs of VHCs during VHCs organized d during No. of members which held which held which held % of women as of April- formed as as of April- who attended 1st 2nd 3rd who March, June 20 of June June, June meetings during quarterly quarterly quarterly attended April-June Union Council 2014 14 2014 2014 2014 April-June 2014 meeting meeting meeting meetings Chatto Chand 82 0 82 1,580 82 1,580 0 21 61 42 Makli 30 0 30 753 30 539 1 2 27 92 Gujjo 17 16 33 936 33 939 33 0 0 91 Gharo 39 0 39 1,216 39 1,047 39 0 0 91 Thatta Sakro 34 0 34 919 34 872 34 0 0 88
0 72 0 Atta Muhammad Pali 72 0 72 1,320 72 1,378 60 Kharoro Sayed 54 0 54 865 54 1,058 0 48 6 67 Mir Wali Muhammad 0 53 12 Umerkot Talpur 65 0 65 1,313 65 1,168 59 Began Jarwar 69 0 69 1,204 69 1,087 0 53 16 58 Missan 47 0 47 852 47 822 0 41 6 58 Pak Singhar 28 0 28 1,003 28 895 28 0 0 80 Tando Allah Shaikh Moosa 39 0 39 1,116 39 955 39 0 0 53 Yar Tando Soomro 0 22 22 481 22 414 22 0 0 54 Khudaabad 64 0 64 2,036 64 1,140 0 34 30 37 Kamal Khan 52 0 52 1,279 52 912 0 18 34 46 Yar Muhammad 0 23 26 Kalhoro 49 0 49 1829 49 879 46 Kakar 19 0 19 455 19 337 19 0 0 26 Dadu Phulji Station 19 0 19 584 19 330 19 0 0 45 Malanhore Vena 42 0 42 1838 41 1,122 0 0 41 82 Bhakuo 39 0 39 2345 39 728 0 10 29 96 Mohrano 74 0 74 2445 70 1,401 0 56 14 92 Manjthi 35 0 35 859 35 848 35 0 0 94 Tharparkar Diplo 14 0 14 315 14 334 14 0 0 95 Total 983 38 1,021 27,543 1016 20,785 283 431 302 67 Component 5: Health Systems Strengthening Quarterly Report April-June 2014 40
Annex 2: International Travel Status Report (April 15, 2013- June 30, 2014)
Name of Arrival Departure Sector Travel Reference CA No. of Travel Sr.# Organization Designation Balance Traveler Date Date Traveled Type (Sr.#/Tr#) Completed
Senior Team Dr. Theo 5-May- USA-PAK- 1 10-May-13 JSI-Boston Technical Planning 5/1 1 19 Lippeveld 13 USA Advisor Travel Dr. COP/Field 11-May- PAK-USA- 2 Nabeela 1-Jun-13 JSI-Boston Chief of Party Office 4/1 1 18 13 PAK Ali Travel Team Mr. John 10-Jun- USA-PAK- Finance 3 19-Jun-13 JSI-Boston Planning 5/2 1 17 Abbott 13 USA Manager Travel Home Mr. 6-Sep- USA-PAK- Project Office 4 Andrew 22-Sep-13 JSI-Boston 3/1 1 16 13 USA Coordinator Support Dallos Travel
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