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LANDSCAPE ANALYSIS To Provide Insight on Barriers and Facilitators to Policy Translation and Commodity Access in the Public and Private Sector for Child Survival in Pakistan Analytical Report & Accountability Framework Copyright © UNICEF Pakistan Photo credits: UNICEF Pakistan Design: Human Design Studios ACKNOWLEDGEMENT “Landscape Analysis to provide Insight on Barriers and Facilitators to Policy Translation and Commodity Access in the Public and Private Sector” is a project funded by Bill and Melinda Gates Foundation (BMGF) and UNICEF to contribute to increased child survival in Pakistan and is implemented by Contech International. Contech International highly values the support extended by MNHSR&C, DRAP, Provincial Health Departments, MNCH programs, members of provincial Child Survival Groups (CSG), Sindh Child Survival Programme, paediatricians, Pakistan Paediatric Association, WHO and other development partners in enhancing the quality and scientific rigor of the study as well as the report. We are also grateful to the pharmaceutical manufacturers who provided us with their invaluable insights about the industry and to the all those who were involved in and facilitated the data collection: Federal, Provincial and District Health Managers; data collection teams including field teams and the support staff. We would also like to extent our gratitude to facility and pharmacy in-charges, community health workers, GPs and parents/ care-givers whose participation and freedom of expression allowed us to gather relevant and reliable information for this report. Last but not the least, we would like to express our gratitude to UNICEF’s national and provincial project implementation teams and UNICEF Project Monitoring, Evaluation and Research (PMER) Unit for their unstinted support and invaluable feedback during the process of this landscape analysis. We hope that the study findings and the frameworks hence developed will make a valuable contribution in improving child survival in Pakistan. v LIST OF ACRONYMS AND ABBREVIATIONS Amoxicillin DT Amoxicillin Dispersible Tablets ARI Acute Respiratory Infection BHUs Basic Health Units CEO Chief Executive Officer CPSP College of Physicians and Surgeons Pakistan DFID Department for International Development DHIS District Health Information System DOC Driver of Change EDO Executive District Officer EML Essential Medicine List EPI Expanded Program On Immunization FGDs Focus Group Discussions FLCF First Level Care Facility FPAP Family Planning Association of Pakistan GAPPD Global Action Plan for Pneumonia & Diarrhoea GPs General Practitioners ICCM Integrated Community Case Management IMNCI Integrated Management of Neonatal and Childhood Illnesses IYCF Infant and Young Child Feeding JAF Joint Accountability Framework KII Key Informant Interviews LHW Lady Health Worker M&E Monitoring & Evaluation MNCH Maternal Neonatal Child Health NIH National Institution of Health ORS Oral Rehydration Solution PATS Pakistan’s Approach to Total Sanitation PIEA Political Institutional Economy Analysis PMDC Pakistan Medical and Dental council PMER Planning Monitoring Reporting and Evaluation PMRC Pakistan Health (Medical) Research Council PPA Pakistan Paediatric Association RHCs Rural Health Centres RMNCH Reproductive Maternal Neonatal Child Health SOPs Standard Operating Procedures TOC Theory of Change U5 Under-five UNICEF United Nations International Children’s Emergency Fund USAID United States Agency for International Development WHO World Health Organization Zinc-DT Zinc Dispersible tablets vi Acknowledgement v List of acronyms and abbreviations vi Contents vii Executive summary ix 1. Introduction 1 1.1. Child health services in Pakistan 2 1.2. Research framework 4 1.3. Aims and objectives 5 2. Literature review 7 2.1. Global scenario 8 2.2. Global action plan for Pneumonia and Diarrhea (GAPPD) 11 2.3. National and provincial policies for childhood illnesses 12 2.4. Management practices for Pneumonia and Diarrhea 15 2.5. Zinc dispersible tablets 16 2.6. Amoxicillin dispersible tablets 18 2.7. Pulse oximetry 19 2.8. ARI timers 19 2.9. Oxygen therapy 20 3. Design & methodology 23 3.1. Research purpose 24 3.2. Research design 24 3.3. Main research questions 24 3.4. Research toolkit 25 3.5. Geographic focus 25 3.6. Sample composition 25 3.7. The inception phase 27 3.8. Research team 27 3.9. Preparing for fieldwork 27 3.10. Data collection 28 3.11. Content analysis 28 3.12. Quality assurance 28 3.13. Ethical considerations 29 3.14. Study limitations 30 vii 4. Results & findings 33 4.1. Policy environment 34 4.2. Management of Pneumonia & Diarrhea 42 5. Feasibility analysis 65 5.1. Introduction 66 5.2. Pharmaceutical market and regulation 66 5.3. Current market trends 70 5.4. Factors influencing supply 79 5.5. Factors influencing demand 80 5.6. Demand and supply gap analysis 81 5.7. PEST analysis 82 5.8. Conclusion 83 6. Theory of change & accountability framework 87 6.1. Pathway of change and strategic areas 88 6.2. Desired policy change 88 6.3. Accountability framework 91 6.4. Assumptions informing theory of change 101 7. Policy analysis 105 8. Lessons learned & conclusions drawn 113 8.1. Policy environment 114 8.2. Clinical management practices 115 8.3. Pharmaceutical feasibility 115 9. References 119 10. Bibliography 125 11. Annex 1 130 12. Annex 2 169 13. Annex 3 170 viii EXECUTIVE SUMMARY This report presents the findings of a landscape analysis on Pneumonia and Diarrhea among children of Pakistan, which have long been regarded as diseases of poverty, closely related to living conditions with poor hygiene and sanitation, malnutrition as well as limited access to other basic necessities. Hence there is a dire need to move beyond obvious medical concerns at micro level, to a more complex macro level strategy focusing on economic, social and political issues. The Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea (GAPPD) has ranked Pakistan as third highest with the score of 46 (UN Inter-agency Group for Child Mortality Estimation, 2015). UNICEF and Bill and Melinda Gates Foundation (BMGF) established a partnership to contribute to increased child survival in Pakistan, through improving prevention, diagnosis and treatment of Pneumonia and diarrhoea in children under-five years of age. The Project “Accelerating Policy Change, Translation and Implementation for Pneumonia and Diarrhoea Commodities in Pakistan”, is being implemented in close coordination with the Government of Pakistan and relevant stakeholders to ensure sustainable changes. The overarching project objective is to improve management of childhood diarrhoea and Pneumonia and increase child survival by the end of 2019. This has to be done through ensuring that the relevant national policies are revised, understood and adhered to in order to guarantee quality treatment and availability of essential commodities. These commodities include Amoxicillin DT, Zinc DT, Low osmolarity ORS (LoORS), ARI timers, Pulse Oximeters and Oxygen. The goal of this baseline Landscape Analysis study was to provide insight on barriers and facilitators to policy translation and commodity access in the public and private sectors at national and provincial level. Specific objectives were to: • Identify gaps in existing policies relevant to Child Survival Strategies in the context of GAPPD • Assess the prescribing behaviours and treatment approaches among public and private sector service providers and the LHW program • Recommend steps for inclusion of Pneumonia and Diarrhea commodities into essential medicine lists, procurement lists based on evidence-based briefing papers and policy notes including GAPPD on the benefits of Amoxicillin-DT, Zinc-DT, co-packaged ORS and Zinc, Pulse Oximeters, and Oxygen • Map key stakeholders and activists at all levels; and • Draft a framework to define the roles and responsibilities of key implementing stakeholders for child survival groups (CSGs). It was a cross-sectional study that primarily involved desk reviews and qualitative research. Research was conducted at Federal level and also in provinces of Punjab and Sindh. Provincial capitals along with two districts of Punjab (Pakpattan and Bahawalnagar) and three districts of Sindh (Tharparkar, Shikarpur, and Tando Muhammad Khan) were covered. Primary data was collected through in-depth interviews as well as focus group discussions conducted with officials at policy and strategy development level (representatives from MNHSR&C, DRAP, provincial health departments; health sector reform units; IRMNCH/MNCH and LHW programmes; donors and development partners); district managers (CEO/DHO, DHIS Coordinator); health-service providers (health providers at both public and private facilities, outreach field staff, in-charges of medical stores); service- users (parents/guardians of children receiving services for Pneumonia and Diarrhea at both public and private health facilities). In total 112 in-depth interviews and 5 focus group discussions were conducted. The research findings have been arranged into policy environment, clinical management, pharmaceutical feasibility and accountability framework. ix Findings revealed that for facilitating commodity access, a robust policy change is required, which would lay the necessary foundations for translating policy into operational processes. After the eighteenth amendment, the provincial health departments developed their own health sector strategies, which are on the verge of completing the terms for which they were drafted and

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