QUARTERLY PERFORMANCE MONITORING REPORT JANUARY 01, 2017 - MARCH 31, 2017
May 2017 This publication was produced for review by the United States Agency for International Development. It was prepared by the Health Finance and Governance Project. The Health Finance and Governance Project USAID’s Health Finance and Governance (HFG) project helps to improve health in developing countries by expanding people’s access to health care. Led by Abt Associates, the project team works with partner countries to increase their domestic resources for health, manage those precious resources more effectively, and make wise purchasing decisions. As a result, this six-year, $209 million global project increases the use of both primary and priority health services, including HIV/AIDS, tuberculosis, malaria, and reproductive health services. Designed to fundamentally strengthen health systems, HFG supports countries as they navigate the economic transitions needed to achieve universal health care. May 2017 Cooperative Agreement No: AID-OAA-A-12-00080 Submitted to: Scott Stewart, AOR Office of Health Systems Bureau for Global Health United States Agency for International Development Recommended Citation: Health Finance and Governance project. May 2017. Quarterly Performance Monitoring Report January 01, 2017 - March 31, 2017. Bethesda, MD: Health Finance and Governance project, Abt Associates Inc.
Abt Associates Inc. | 4550 Montgomery Avenue, Suite 800 North | Bethesda, Maryland 20814 T: 301.347.5000 | F: 301.652.3916 | www.abtassociates.com
Avenir Health | Broad Branch Associates | Development Alternatives, Inc. (DAI) | Johns Hopkins Bloomberg School of Public Health (JHSPH) | Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)
HEALTH FINANCE AND GOVERNANCE PROJECT QUARTERLY PERFORMANCE MONITORING REPORT JANUARY 01, 2017 - MARCH 31, 2017
DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government.
CONTENTS
Acronyms ...... vii 1. Introduction ...... 1 2. Highlights ...... 5 3. Cross-bureau Activities ...... 11 4. Directed Core Activities ...... 39 4.1 Global Health Security ...... 39 4.2 HIV and AIDS ...... 43 4.3 Malaria ...... 50 4.4 Maternal and Child Health ...... 53 4.5 Population and Reproductive Health ...... 56 4.6 Tuberculosis ...... 58 5. Field Support Activities ...... 63 5.1 Africa ...... 64 5.1.1 Africa Bureau ...... 64 5.1.2 Angola ...... 67 5.1.3 Benin ...... 70 5.1.4 Botswana ...... 72 5.1.5 Côte d’Ivoire ...... 75 5.1.6 Democratic Republic of the Congo ...... 82 5.1.7 Ethiopia ...... 92 5.1.8 Ghana ...... 117 5.1.9 Guinea ...... 126 5.1.10 Mali ...... 139 5.1.11 Namibia ...... 143 5.1.12 Nigeria ...... 147 5.1.13 South Africa ...... 159 5.1.14 Tanzania ...... 164 5.1.15 West Africa Regional ...... 166 5.2 Asia ...... 171 5.2.1 Asia Bureau ...... 171 5.2.2 Bangladesh ...... 175 5.2.3 Cambodia ...... 181 5.2.4 India ...... 186 5.2.5 Indonesia ...... 192 5.2.6 Vietnam ...... 197
CONTENTS- III 5.3 Eastern Europe and Eurasia ...... 210 5.3.1 Eastern Europe and Eurasia Bureau ...... 210 5.3.2 Ukraine ...... 211 5.4 Latin America and Caribbean ...... 219 5.4.1 Dominican Republic ...... 219 5.4.2 Eastern and Southern Caribbean ...... 222 5.4.3 Haiti ...... 227 5.5 Middle East ...... 239 5.5.1 Middle East Bureau ...... 239 6. Financial Update ...... 241 7. Knowledge Management/ Communications Update ...... 243 8. Gender Update ...... 249 9. M&E Update ...... 251 10. Management Update ...... 253
List of Tables Table 1. Cross-bureau Activity 1 Detail ...... 12 Table 2. Cross-bureau Activity 2 Detail ...... 13 Table 3. Cross-bureau Activity 3 Detail ...... 14 Table 4. Cross-bureau Activity 4 Detail ...... 15 Table 5. Cross-bureau Activity 5 Detail ...... 16 Table 6. Cross-bureau Activity 6 Detail ...... 17 Table 7. Cross-bureau Activity 7 Detail ...... 19 Table 8. Cross-Bureau Activity 8 Detail ...... 20 Table 9. Cross-bureau Activity 10 Detail ...... 23 Table 10. Cross-bureau Activity 11 Detail ...... 25 Table 11. Cross-bureau Activity 12 Detail ...... 27 Table 12. Cross-bureau Activity 13 Detail ...... 27 Table 13. Cross-bureau Activity 14 Detail ...... 29 Table 14. Cross-bureau Activity 15 Detail ...... 31 Table 15. Cross-bureau Activity 16 Detail ...... 33 Table 16. Cross-bureau Activity 17 Detail ...... 34 Table 17. Cross-bureau Activity 18 Detail ...... 36 Table 18. Cross-bureau Activity 20 Detail ...... 37 Table 19. Global Health Security Activity Detail ...... 42 Table 20. HIV and AIDS Activity Detail ...... 47 Table 21. Malaria Activity Detail ...... 51 Table 22. Maternal and Child Health Activity Detail ...... 54 Table 23. Population and Reproductive Health Activity Detail ...... 57 Table 24. TB Activity Detail ...... 60
IV - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Table 25. Africa Bureau Activity Detail ...... 66 Table 26. Angola Activity Detail ...... 69 Table 27. Benin Activity Detail ...... 71 Table 28. Botswana Activity Detail ...... 73 Table 29. Côte d'Ivoire Activity Detail ...... 78 Table 30. Democratic Republic of Congo Activity Detail ...... 87 Table 31. Ethiopia Activity Detail ...... 95 Table 32. Ghana Activity Detail ...... 121 Table 33. Guinea Activity Detail ...... 133 Table 34. Mali Activity Detail ...... 140 Table 35. Namibia Activity Detail ...... 145 Table 36. Nigeria Activity Detail ...... 154 Table 37. South Africa Activity Detail ...... 161 Table 38. Tanzania Activity Detail ...... 165 Table 39. West Africa Regional Activity Detail ...... 169 Table 40. Asia Bureau Activity Detail...... 173 Table 41. Bangladesh Activity Detail ...... 179 Table 42. Cambodia Activity Detail ...... 183 Table 43. India Activity Detail ...... 189 Table 44. Indonesia Activity Detail ...... 195 Table 45. Vietnam Activity Detail ...... 202 Table 46. Ukraine Activity Detail ...... 214 Table 47. Dominican Republic Activity Detail ...... 220 Table 48. Eastern and Southern Caribbean Activity Detail ...... 224 Table 49. Haiti Activity Detail ...... 229 Table 50. Middle East Regional Activity Detail ...... 239 Table 51. Financial Overview ...... 241
CONTENTS - V
ACRONYMS
AFD Agence Française de Développement (French Development Agency) AfHEA African Health Economics Association AFR/SD Africa Bureau Office of Sustainable Development AIDS Acquired Immune Deficiency Syndrome ANAM Agence National d’Assurance Maladie (National Agency for Health Insurance) ANCRE Advancing Newborn, Child and Reproductive Health ANHSS Asia Network for Capacity Building in Health Systems Strengthening AO Agreement Officer AoA Articles of Association AOR Agreement Officer Representative APATS AIDS Prevention and Treatment Software APPF Asia Public Policy Forum APTS Auditable Pharmacy Transaction and Services ARC Advocating Reproductive Health Choices ARC African Health Profession Regulatory Collaborative ART Antiretroviral Therapy ARV Antiretroviral ASH African Strategies for Health ASHA Accredited Social Health Activist ASSIST Applying Science to Strengthen and Improve Systems ASTMH American Society of Tropical Medicine and Hygiene AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy BAS Basic Accounting System BHRF Bangladesh Health Reporters Forum BHSP Basic Health Services Package BNHA Bangladesh National Health Account BoFED Bureau of Finance and Economic Development BPJS National Health Insurance Agency (Indonesia) BPR Business Process Reengineering BSC Balanced Score Card BSC Business Support Center, LLC CAR Capability, Accountability, and Responsiveness CARICOM Caribbean Community CARPHA Caribbean Public Health Agency CASH Clean and Safe Hospitals CASN Canadian Association of Schools of Nursing CBHI Community-based Health Insurance CCSS Comité de coordination du secteur santé (Health Sector Coordination Committee) CCT-SS Technical Coordination Committee for the Health Sector CDC Centers for Disease Control and Prevention
ACRONYMS - VII CDC-CRED Competencies Development Centers for Children’s Growth and Development Control CDD Center for Democratic Development CFC Child-Friendly Court CGAT Country GeneXpert Advisory Team CGD Center for Global Development CHAG Christian Health Association of Ghana CHAI Clinton Health Access Initiative CHF Community Health Fund CHP Country Health Partnership CHPM Center for Health Policy and Management CHPS Community-based Health Planning and Services Initiative CHR Centres Hospitaliers Regionaux CHU Centres Hospitaliers Universitaires CHW Community Health Worker CIDRZ Centre for Infectious Disease Research in Zambia CIH Commission on Investing in Health CII Center for Accelerating Innovation and Impact CMAM Central de Medicamentos e Artigos Médicos (Central Medical Store, Mozambique) CNP-SS National Steering Committee for the Health Sector CONSAMUS Le Conseil National des Structures d’Appui aux Mutuelles de Santé COP Chief of Party COP Community of Practice COP Country Operational Plan CPC Claims Processing Center CPD Continuing Professional Development CPHL Central Public Health Laboratory CPP Provincial Steering Committee CPR Contraceptive Prevalence Rate CPS Cellule de la Planification et des Statistiques (Planning and Statistics Unit) CPU Central Procurement Unit CPWA Child Protection and Welfare Act CSI-FBP Interdepartmental Scientific Committee for the Implementation of the National Performance-Based Financing Strategy CSO Civil Society Organization CWFD Concerned Women for Family Development DAB Direction de l’Administration et du Budget (Department of Administration and Budget) DAF Direction des Affaires Financieres (Directorate of Financial Affairs) DAI Development Alternatives, Inc. DALY Disability-Adjusted Life Year DCA Development Credit Authority DCE Discrete Choice Experiment DEP Directorate of Economy and Planning DEP Direction des Etudes et Planification (Studies and Planning Directorate)
VIII - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
DFID Department for International Development DFPSS Direction de la Formation et de Perfectionnement en Sciences de la Santé DG Directeur Generale (Director General) DGFP Directorate General of Family Planning DGHS Directorate General Health Services DGS Directeur Générale de la Santé DHI Department of Health Insurance DHO District Health Office DHMT District Health Management Team DHS Demographic and Health Survey DJSN Dewan Jaminan Sosial Nasional (National Social Security Council) DOGSS Direction de l’Organisation et de Gestion des Services des Soins de Santé (Directorate of the Organization and Management of Health Services) DOH Department of Health DOSS Direction d'Organization des Services de Santé (Directorate of the Organization of Health Services) DPF Department of Planning and Finance DPHI Department of Planning and Health Information DPM/MT Direction de la Pharmacie et du Médicament et de la Médecine Traditionnelle (Directorate of Pharmacy, Medication, and Traditional Medicine) DPS Division Provinciale de la Santé (Provincial Health Division) DPPEIS Direction de la Prospective, de la Planification et des Stratégies (Department of Planning and Statistics) DQA Data Quality Assessment DR-TB Drug-Resistant Tuberculosis DRC Democratic Republic of Congo DRG Center of Excellence on Democracy, Rights and Governance DRG Diagnosis-Related Group DRH Direction des Ressources Humaines (Department of Human Resources) DRM Domestic Resource Mobilization DSC Direction de la Santé Communautaire (Department of Community Health) DSCMP Direction de la Santé Communautaire et de la Médecine de Proximité DSD Department of Social Development DSGRH Direction des Ressources Humaines (Directorate of General Services and Human Resources) DSIM Direction des Soins Infirmiers et Maternels DSNE North-East Geographical Department DSO Department de Santé de l’Ouest DSW Department of Social Welfare E&E Eastern Europe and Eurasia E2Pi Evidence to Policy Initiative EADS Economic Analysis and Data Services EAHF East Africa Health Federation ECEA Extended Cost-Effectiveness Analysis
ACRONYMS - IX eCMS Electronic Case Management System EFY Ethiopian Fiscal Year EGPAF Elisabeth Glaser Pediatric AIDS Foundation EHAC Ethiopian Hospital Alliance for Quality EHIA Ethiopian Health Insurance Agency EHRIG Ethiopian Hospital Reform Implementation Guideline EHSP Essential Health Services Package EID Early Infant Diagnosis eMTCT Elimination of Mother-to-Child Transmission ENAP Every Newborn Action Plan EOI Expression of Interest EPCMD Ending Preventable Child and Maternal Deaths EPHS Essential Package of Health Services EPM Entry Point Mapping EQUIST EQUitable Impact Sensitive Tool ERP Expert Review Panel ESP Essential Services Package EVD Ebola Viral Disease F&A Finance and Administration FARA Fixed Amount Reimbursement Agreement FENAMUS Federation National des Mutuelles de Santé National Federation of Health Mutuelles FMOF Federal Ministry of Finance FMOH Federal Ministry of Health FP2020 Family Planning 2020 FP/RH Family Planning/Reproductive Health FSU Former Soviet Union G-DRG Ghana Diagnosis-Related Group GAR Results-Focused Management GCBS Government Capacity Building Support GDP Gross Domestic Product GEPE Gabinete de Estudios, Planeamiento e Estatística Department of Research, Planning and Statistics GFF Global Financing Facility GHB Global Health Bureau GHI Global Health Initiative GHS Ghana Health Service GHSA Global Health Security Agenda GHSC/PSM Global Health Supply Chain/Procurement and Supply Management Project GIS Geographic Information System GODR Government of the Dominican Republic GoDRC Government of DRC GOP Government of Peru GRN Government of the Republic of Namibia GTT Groupe Technique de Travail (Technical Working Group) GVN Government of Vietnam HA Health Accounts HAAT Health Accounts Analysis Tool
X - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
HAPT Health Accounts Production Tool HBP Health Benefit Plans HC Health Center HCF Health Care Financing HCFRTF Health Care Financing Resource Task Force HCFS Health Care Financing Strategy HCM-II Healthy Communities and Municipalities II HCMC Ho Chi Minh City HEU Health Economics Unit HF Health Facility HFA Health Financing Assessment HFG Health Finance and Governance HFS Health Financing Strategy HFS-IP Health Financing Strategy Implementation Plan HFTWG Health Financing Technical Working Group HHA Harmonizing Health in Africa HIDN Office of Health, Infectious Diseases, and Nutrition HIS Health Information Systems HIV Human Immunodeficiency Syndrome HIWG Health Insurance Working Group HMIS Health Management Information Systems HNP Health, Nutrition and Population HNPSIP Health, Nutrition and Population Strategic Investment Plan HP Health Policy Reform HP+ Health Policy Plus HPMI Hospital Performance Monitoring and Improvement HPNSDP Health, Population, and Nutrition Sector Development Program HPP Health Policy Project HRAA Human Resources Alliance for Africa HRH Human Resources for Health HRHMC Human Resources Management Committee HRHTWG Human Resources for Health Technical Working Group HRIS Human Resources Information System HRU Human Resources Unit HSA Health Services Assessment HSAA Health Systems Assessment Approach HSB Health Systems Benchmarking HSCM Sacré Coeur Hospital of Milot HSDA Health Services Delivery and Administration HSDP Health Sector Development Program HSFR Health Sector Finance Reform HSG Health Systems Global HSHRC Haryana State Health Resource Center HSPI Health Strategy and Policy Institute HSR Health System Research HSS Health Systems Strengthening HSSP Health Sector Strategic Plan HTC HIV testing and counseling HUEH Hôpital d l'Universite d'Etat d'Haiti
ACRONYMS - XI HUM Hôpital Universitaire de Mirebalais IASP Indian Association for the Study of Population ICAP International Center for AIDS Care and Treatment ICB Institutional Capacity Building ICT Information and Communication Technology IDI Infectious Disease Institute IDU Injecting Drug Users IG Inspector General IGSLS Inspector General for Health and the Fight Against AIDS iHEA International Health Economics Association IHME Institute of Health Metrics and Evaluation IHP Institute for Health Policy IHR International Health Regulations IMCI Integrated Management of Childhood Illness INE National Institute of Statistics INFAS Institute National de Formation des Agents de Santé (National Institute of Health Worker Training) INFS Institut National de Formation Sociale I(National Institute of Social Worker Training) IP Implementing Partner IPPF International Planned Parenthood Federation IPS Provincial Health Inspectorate IR Intermediate Result IR Implementation Research IRB Institutional Review Board IRS Indoor Residual Spraying ISDRHS Interim Plan for the Development of Human Resources for Health ISS Integrated Supportive Supervision IT Information Technology JEE Joint External Evaluation (tool) JHPN Journal of Health, Population and Nutrition JHSPH Johns Hopkins School of Public Health JICA Japan International Cooperation Agency JKN Jaminan Kesehatan Nasional JLN Joint Learning Network JPGSPH James P Grant School of Public Health, BRAC University JSI John Snow, Inc. JUH Hôpital Universitaire Justinien (Justinien University Hospital) KEMRI Kenya Medical Research Institute KII Key Informant Interview KPI Key Performance Indicator KSPH Kinshasa School of Public Health L&M Leadership and Management L3M Level 3 Monitoring LAC Latin America and the Caribbean LCMS Living Conditions Monitoring Survey LGA Local Government Authority LLIN Long-Lasting Insecticide-Treated Net
XII - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
LMD License, Master, Doctorate LMG Leadership, Management and Governance Project LMIC Low‐and Middle‐Income Countries LOA Letter of Agreement LOE Level of Effort LSHS Lagos State Health Scheme LSMS Living Standards Measurement Survey M&E Monitoring and Evaluation MA Management Assessment MaHTAS Malaysian Health Technology Assessment Section MARP Most At-Risk Population MCCO Mutuals, Cooperatives, and Community-based Organizations MCDMCH Ministry of Community Development, Maternal and Child Health MCH Maternal and Child Health MCPR Modern Contraceptive Prevalence Rate MCSP Maternal and Child Survival Program MCTS Mother and Child Tracking System MDA Ministries, Departments, and Strategies MDG Millennium Development Goal MDR Multidrug Resistant MDSR Maternal Death Surveillance and Response MDTF Multi-Donor Trust Fund MEF Ministère de l’économie et des Finances (Ministry of Economics and Finance) MeLSAT Medical Laboratory Scientists Association of Tanzania MER Malaria Economic Research MHE Ministry of Higher Education MHIF Mandatory Health Insurance Fund MINSA Ministerio da Saûde (Ministry of Health) MIS Malaria Indicator Survey MIS Management Information Systems MMT Methadone Maintenance Treatment MNCH Maternal, Neonatal, and Child Health MOE Ministry of Education MOEF Ministry of Economy and Finance MOF Ministry of Finance MOFED Ministry of Finance and Economic Development MOH Ministry of Health MOHCDGEC Ministry of Health, Community Development, Gender, Elderly and Children MOHFW Ministry of Health and Family Welfare MOHS Ministry of Health and Sports MOHSS Ministry of Health and Social Services MOHSW Ministry of Health and Social Welfare MOHW Ministry of Health and Wellness MOJ Ministry of Justice MOPS Ministry of Public Service MOU Memorandum of Understanding MoWCA Ministry of Women’s and Children’s Affairs
ACRONYMS - XIII MPCE Ministry of Planning and Donor Coordination MPH Masters in Public Health MRO Membership and Regional Operations MSA Medical Services Administration MSD Medical Services Directorate MSF Médecins Sans Frontières (Doctors Without Borders) MSH Management Sciences for Health MSHP Ministère de la Santé et de l'Hygiene Publique (Ministry of Health and Public Hygiene) MSLS Ministère de la Santé et de la Lutte contre le SIDA (Ministry of Health and Fight Against AIDS) MSM Men Who Have Sex with Men MSP Ministère de la Santé Publique (Ministry of Public Health) MSPLS Ministry of Health and Fight Against HIV/AIDS MSPP Ministère de la Santé Publique et de la Population (Ministry of Public Health and Population) MTR Mid-Term Review NAA National AIDS Authority NACA National Agency for the Control of AIDS NACO National AIDS Control Organisation NCHADS National Center for HIV/AIDS, Dermatology and STD NDOH National Department of Health NGO Nongovernmental Organization NHA National Health Accounts NHIA National Health Insurance Authority NHIA National Health Insurance Administration NHIS National Health Insurance Scheme NHM National Health Mission (formerly National Rural Health Mission (NRHM)) NHSDP NGO Health Services Delivery Project NHSSPII National Health Sector Strategic Plan II NICE National Institute for Health and Clinical Excellence NITI National Institution for Transforming India NMCC National Malaria Control Centre NMCP National Malaria Control Program NRM National Health Mission NURM National Urban Health Mission NT National Treasury NTBLCP National Tuberculosis and Leprosy Control Program OCA Organization Capacity Assessment OECD Organization for Economic Co-operation and Development OECS Organization of Eastern Caribbean States OGAC Office of the Global AIDS Coordinator OGEI Office of Statistics and Informatics OHA Office of HIV/AIDS OHS Office of Health Systems OHT OneHealth Tool
XIV - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
OMRH Office de Management et des Ressources Humaines (Office of Management and Human Resources) OOP Out-of-Pocket OP Operational Plan OPC Outpatient Clinics OR Operations Research ORAS Organismo Regional Andino de Salud (Andean Health Agency) ORT Other Recurrent Transactions OSM Office of Strategic Management OVC Orphans and Vulnerable Children P4H Providing for Health PAC Provincial AIDS Center PAHAL Partnerships for Affordable Healthcare Access and Longevity PAHO Pan American Health Organization PANCAP Pan Caribbean Partnership Against HIV-AIDS PAO Annual Operational Plan PATHS2 Partnership for Transforming Health Systems, Phase Two PBF Performance-Based Financing PBI Performance-Based Incentives PCRP President’s 2013 Comprehensive Response Plan PDS Plan Directeur de Santé PE Personnel Emoluments PEA Political Economy Analysis PEPFAR President’s Emergency Plan for AIDS Relief PER Public Expenditure Review PES Package of Essential Services PF Partnership Framework PFIP Partnership Framework Implementation Plan PFM Public Financial Management PFPA Procurement, Finance, and Property Administration PGI Post Graduate Institute of Medical Education and Research PHC Primary Health Care PHC CTT Primary Health Care Costing Task Team PHER Public Health Expenditure Review PHFI Public Health Foundation of India PHR Partners for Health Reform PIO Public International Organization PIPPSE HIV/AIDS Partnership: Impact through Prevention, Private Sector and Evidence-based Programming PLHIV People Living with HIV PMC Preventive Medical Center PMI President’s Malaria Initiative PMP Performance Monitoring Plan PMTCT Prevention of Mother-to-Child Transmission PNDS Plan National de Développement Sanitaire (National Plan for Health Development) PNDS Plano Nacional de Desenvolvimento Sanitário (National Health Development Plan)
ACRONYMS - XV PNLS Programme National de Lutte contre le SIDA (National Program for the Fight Against AIDS) PNS Politique Nationale de Sante (National Health Policy) PNSR National Reproductive Health Program POC Point-of-care PPJK Center for Health Financing and Insurance PPP Public-Private Partnership PPPN Preferred Primary Care Provider Network PPRC Power and Participation Research Centre PRB Population Reference Bureau PRH Population and Reproductive Health PRODESS Procedures Manual for the Health Sector Development Plan PS Permanent Secretary PSA Private (Health) Sector Assessment PSDRHS Strategic Plan for the Development of Human Resources for Health PSEC Private Sector Engagement Collaborative PSI Population Services International PSS Provincial Social Security PSSP Plateforme du Secteur Sanitaire Privé (Private Health Sector Platform) QA Quality Advisor QA Quality Assurance QHC Quality Healthcare R4D Results for Development RAMU Régime d’Assurance Maladie Universelle (Universal Health Insurance Scheme) RBF Results-based Financing RBM Results-Based Management RCM Regional Coordinating Mechanism RDQA Routine Data Quality Audit RFA Request for Applications RGA Request for Application RHB Regional Health Bureau RHSA Rapid Health Systems Assessment RMD Resource Mobilization Department RMG Ready-made Garment RMNCH+A Reproductive, Maternal, Newborn, Child, and Adolescent Health RMS Resource Mobilization Strategy RPME Research, Policy, Monitoring, and Evaluation RRU Revenue Retention and Utilization S4H Systems for Health SACA State Agency for the Control of AIDS SADC Southern African Development Community SAMBA Simple Amplification-based Assay SASCP State AIDS and STD Control Program SCMS Supply Chain Management System SCTF Single Donor Trust Fund SDG Sustainable Development Goal
XVI - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
SEARO South East Asia Regional Office SEGAL Secretary General’s Office SFI Sustainable Financing Initiative SGBP State Guaranteed Benefit Package SHA System of Health Accounts SHI Social Health Insurance SHOPS Strengthening Health Outcomes through the Private Sector SHP Strategic Health Purchasing SIAPS Systems for Improving Access to Pharmaceuticals and Services SID Sustainability Index Dashboard SIFPO Support for International Family Planning Organizations SIGRH Systeme d’Information et de Gestion des Ressources Humaines (Human Resource Information Management System) SIHFW State Institute of Health and Family Welfare SIMPA Swaziland Institute of Management and Public Administration SIS Sistema Integral de Salud (Integrated Health System) SLA Service-Level Agreement SLHA State-Level Health Accounts SME Small and Medium Enterprises SMC Seasonal Malaria Chemoprevention SMT Senior Management Team SMT-RHD Regional Health Directorate in San Martin SNC Swaziland Nursing Council SNNP Southern Nations, Nationalities, and Peoples Region SOP Standard Operating Procedures SOTA State of the Art SOW Scope of Work SPWG Social Protection Working Group SQA Service Quality Assessment SRI Sustainable Financing Initiative SRM Sustainability Road Map SSA Sub-Saharan Africa SSC Social Security Commission SSHIS State-supported Health Insurance Scheme SSNIT Social Security and National Insurance Trust SVG St. Vincent and the Grenadines SW Social Welfare SYSEP Systeme d’Evaluation de la Performance (Performance Management System) TA Technical Assistance TACAIDS Tanzania Commission for AIDS TAG Technical Advisory Group TASC Technical Assistance and Support Contract TB Tuberculosis TBSS Tuberculosis Supportive Supervision TDY Temporary Duty Yonder TFR Total Fertility Rate TMS Tibetan Medicare Scheme TOR Terms of Reference
ACRONYMS - XVII TOT Training of Trainers TWG Technical Working Group TWG Thematic Working Group UADS Unité d’Appui à la Décentralization Sanitaire (Decentralization Unit) UEMOA Union Economique de Monitaire Ouest Africaine (West African Economic and Monetary Union) UEP Unité d’Evaluation et de Programmation (Evaluation and Planning Unit) UFR-SM Unité de Formation et de Recherches des Sciences Médicales (Training and Research Unit/School of Medicine) UHC Universal Health Coverage UHCAN Universal Health Care Advisory Committee for Namibia UHSP Universal Health Services Package UI University of Indonesia UN United Nations UNAG United Nations Association of Georgia UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Program UNFPA United Nations Population Fund UNICEF United Nations International Children’s Fund UNMSM University of San Marcos UoPH Yangon University of Public Health UPE Unité de Programmation et d’Evaluation (Planning and Evaluation Unit) US Under Secretary USAID United States Agency for International Development USG United States Government UWI University of the West Indies VAAC Vietnam Administration of HIV/AIDS Control VCT Voluntary Counseling and Testing VL Viral Load VSS Vietnam Social Security WAHO West Africa Health Organization WA/RHO USAID West African Regional Health Office WB World Bank WBI World Bank Institute WHO World Health Organization WoFED Woreda Office of Finance and Economic Development WorHO Woreda Health Office WRAI White Ribbon Alliance ZHD Zone Health Department ZISSP Zambia Integrated Systems Strengthening Project ZPCT-II Zambia Prevention, Care, and Treatment Project
XVIII - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
1. INTRODUCTION
Countries need strong health systems that are well managed and country financed if they are to increase the use of life-saving health services, especially by women and children, or by poor and/or rural populations. USAID's Global Health Bureau (GHB) launched the Health Finance and Governance (HFG) project to support countries in their quest for stronger health systems that deliver the life-saving services their citizens need, when and where they can access them, and at affordable prices. To achieve this goal, domestic financing for health will need to increase in many countries. At the same time, and as policymakers and donors know, strong governance at all levels of the health system is necessary to ensure that the resources indeed go to the health sector and achieve their intended results. HFG integrates governance into country programs to improve government stewardship, civil society voice, transparency, and accountability. HFG's strategy is to deliver country-responsive technical assistance and interventions that reduce system bottlenecks in order to increase the use of priority health services, including for tuberculosis (TB), HIV/AIDS, malaria, maternal and child health (MCH), and reproductive health. HFG collaborates with other USAID projects and other donors to ensure harmonized and efficient progress. HFG partners with local institutions and builds their capacity to sustain the impact of project interventions. HFG's four Intermediate Results (IRs) (Figure 1) work in concert to move countries toward self- sufficient health system financing and governance, and to advance global learning and consensus: IR1: Improved financing by mobilizing domestic resources, reducing financial barriers, expanding health insurance, and implementing provider payment systems IR2: Strengthened governance for better health system management and greater accountability and transparency IR3: Improved country-owned health management and operations systems to improve the delivery and effectiveness of health care, for example, through mobile money and public financial management IR4: Improved techniques to measure progress in health systems performance, especially around universal health coverage (UHC) The project's monitoring and evaluation (M&E) framework (Figure 2) maps the causal pathway from project inputs to outcomes. This report summarizes the inputs, processes, outputs, and outcomes of more than 200 activities implemented across all project programs: 24 countries, four regional bureaus, five health offices (directed core), and the cross-bureau program of the Office of Health Systems (OHS).
1. INTRODUCTION - 1 FIGURE 1: HFG RESULTS FRAMEWORK
2 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
FIGURE 2: HFG M&E FRAMEWORK
1. INTRODUCTION - 3
2. HIGHLIGHTS
Side Meeting at 2017 Prince Mahidol Award Conference on Extending Health Coverage to Marginalized Groups In partnership with the SHOPS Plus and HP+ Projects, HFG coordinated a USAID side meeting at the Prince Mahidol Award Conference 2017 in Bangkok, on January 29, 2017. Jennifer Adams, Acting Assistant Administrator in the GHB, welcomed 70 people to the session. The all-day session drew on country experiences and global evidence to explore strategies to expand financial protection to those who are often excluded ‒ the informal sector and the poor ‒ and how initiatives targeting the most vulnerable can be scaled up. Speakers included Jodi Charles, USAID’s Senior Health Systems Advisor, OHS; Asha George, School of Public Health, University of the Western Cape; Davidson Gwatkin of the Results for Development Institute; and Prastuti Soewondo, Government of Indonesia. HFG’s Asha George, Bob Fryatt, Adam Koon, and Jeanna Holtz presented various sessions during the day. OHS Director Kelly Saldana closed the session.
Supporting Guinea’s Post-Ebola Recovery: Health Sector Oversight by Parliament HFG Guinea has seen the impacts of a series of workshops for members and staff of the Health Commission of the National Assembly in November 2016; the workshops helped them to better understand the national health budget and its implications for the health system. The Honorable Dr. Ben Youssouf Keita, a member of the Commission noted: “Members of Parliament are not fully equipped in budget analysis – I am a medical doctor. This training initiated by USAID will […] enable us to better fulfill our mission of controlling government actions and passing laws in defense of the interests of the people.” Using the skills gained in these workshops, the Health Commission held budget hearings in January 2017, during which the Minister of Health and his senior staff discussed the health component of the national budget with the commission members. As a result of these deliberations, the final budget contained a 2.4 percent increase in health funding over the Government’s original submission.
Landscape Study of Health Financing and UHC across West Africa To reach UHC, governments are looking to pursue more and better spending for health care and to promote financial protection for households. HFG’s report, Financing of Universal Health Coverage and Family Planning: A Multi-Regional Landscape Study and Analysis of Select West African Countries, released in January 2017, observed trends and lessons learned from a health financing landscape study of 15 countries. The report contains detailed analyses of eight “core” countries in West Africa (Benin, Burkina Faso, Cameroon, Guinea, Mali, Niger, Senegal, and Togo), and seven “reference” countries (Ethiopia, Ghana, Indonesia, Kenya, Malaysia, Nigeria, and South Africa) at various stages of achieving UHC to draw lessons learned and inform potential strategies.
PEPFAR 2017 Report to Congress HFG’s work in Vietnam under the Sustainable Financing Initiative (SFI) to support long-term sustainability of HIV and AIDS programming was featured in PEPFAR’s 2017 Annual Report to Congress. The work is highlighted on page 77 of the report.
2. HIGHLIGHTS - 5 Health Care Financing Training Workshop for Nigeria’s Sokoto and Bauchi States HFG organized a five-day Health Care Financing Training workshop in Abuja, for Sokoto and Bauchi states, in collaboration with the Federal Ministry of Health, the National Health Insurance Scheme, and the National Primary Health Care Development Agency, as part of an effort to strengthen health care financing reform processes at the state level in Nigeria. The workshop was designed for state health sector actors with state ministries of health, policy drivers in the finance, planning, and legislative sectors. Participants from relevant state institutions and civil society came together to build state teams that will make contributions toward health care financing reforms in the HFG-supported states.
New Study: Expanding Coverage of Health Services to Informal Workers In January, HFG produced a report on how health reforms can improve the welfare of informal workers. Focusing on the 25 USAID Ending Preventable Child and Maternal Deaths (EPCMD) countries, Expanding Coverage to Informal Workers: A Study of EPCMD Countries’ Efforts to Date complements existing literature on how health reforms can improve the welfare of informal workers. Given the strong interest in expanding coverage to informal workers among EPCMD countries, HFG conducted this research to provide recommendations relevant to UHC policy discussions in the countries.
Studies on Strategic Purchasing to Improve the Quality of Maternal Health Services To help illustrate how provider payment is linked to the quality of maternal health services, HFG developed a conceptual framework and analyzed provider payment systems in 16 countries where payment is linked with quality measurement. The Link between Provider Payment and Quality of Maternal Health Services: A Framework and Literature Review and its accompanying case study report highlight design features and context-specific implementation requirements of such systems, and draw lessons that may be applied to the design and implementation of these systems elsewhere. Lead author Jenna Wright presented the studies at a technical briefing at USAID on March 9.
HFG Study on Association between Malaria Control Scale-Up and Micro-Economic Outcomes in Zambia Featured in Malaria Journal Country-level evidence on the impact of malaria control on micro-economic outcomes is vital for mobilizing domestic and donor resources for malaria control. Using routinely available survey data could facilitate this investigation in a cost-efficient way. HFG researchers explored this and compiled findings in an article, “Exploring the use of routinely-available, retrospective data to study the association between malaria control scale-up and micro-economic outcomes in Zambia,” published in the January 2017 issue of Malaria Journal.
Bangladesh Flagship Course on Health System Strengthening and Universal Health Coverage A Success In January, HFG co-organized a Bangladesh-focused flagship course on Health System Strengthening (HSS) and UHC in Savar, Bangladesh, to enhance the capacity of stakeholders to analyze health policy and health system performance issues, in the context of UHC. The project partnered with the Health Economics Unit of the Ministry of Health and Family Welfare (MOHFW), the World Health Organization (WHO), and the World Bank to offer the course. HFG’s regional partner, James P. Grant School of Public Health at BRAC University supported the Bangladesh focus for the course as secretariat. Over 40 participants from multiple government agencies, WHO, USAID implementing partners, educational institutes, and national NGOs attended. Secretary of Bangladesh’s MOHFW, Mr. Md. Sirazul Islam, said: “I believe that not only government can provide health care coverage for all; relevant agencies, government, non-government, as well as our developments partners, should get together and come up with a plan to achieve the UHC goal.”
6 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Nigeria's President Commits to Revitalizing 10,000 Primary Health Care Centers On January 10, the Federal Government of Nigeria kicked off a scheme to revitalize over 10,000 primary health care (PHC) centers across the country. The Federal Ministry of Health has made a provision for the revitalization of more than 10,000 centers in the 2017 budget. At the launch, President Buhari formally launched the Basic Health Care Provision Fund guidelines and inaugurated the National Health Act steering committee. HFG is supporting these initiatives through several activities. HFG supported the drafting, reviewing, and finalization of the fund’s guidelines and served on the NHAct steering committee. The project’s Service Availability Readiness Assessments in five states provide an evidence base for determining current infrastructural, training, and commodity availability gaps.
Workshop to Explore Opportunities to Improve Efficiency of Dominican Republic’s HIV and AIDS Response On March 1, HFG and UNAIDS facilitated a workshop to explore opportunities for improving the efficiency of the Dominican Republic’s HIV/AIDS response. The workshop was attended by public and private health sector stakeholders. HFG and UNAIDS also held individual meetings with the head of the National HIV/AIDS Council, the Social Insurance Superintendent, and other important decision makers to share the outcomes of the workshop. This exercise will feed into the Dominican Republic’s strategy for ensuring the financial sustainability of the HIV/AIDS response as donors decrease their investments. The strategy will include a financial gap analysis, a plan for improving efficiency, and options for new sources of financing for HIV/AIDS.
Indonesia: Implementation Research Unpacks Universal Health Coverage Reforms HFG conducted a “deep-dive” workshop to disseminate the results of the first cycle of implementation research on Indonesia’s new national health insurance program. The workshop was convened in collaboration with Indonesia’s Ministry of Health and Gadjah Mada University’s Center for Health Policy and Management. At the workshop, government participants from around the country discussed three key issues revealed in the research. The workshop served to deepen stakeholder understanding of and commitment to the implementation research process seeking to strengthen UHC in Indonesia.
In Nigeria’s Cross River and Rivers States: Working to Bridge the Gap between Evidence, Policy, and Practice In January, HFG organized evidence synthesis workshops for Nigeria’s Cross River and Rivers states. The workshops were intended to pull together the findings from several health financing core diagnostic analyses conducted to assess the health financing landscape. The meetings provided a space for state actors and policymakers at the national and state levels to question and dialogue on the findings, before forging a consensus on feasible recommendations for action.
Presenting the Results of TB Financing Analysis in Ukraine In late January, HFG presented the results of a comprehensive analysis of TB hospitals performance conducted for all TB hospitals in Kyiv city and Poltava and Odessa regions. In collaboration with the health departments of Kyiv city and the Odessa region, HFG conducted two workshops to present and discuss results with TB providers and regional health authorities. The results of the analysis are being considered by the health departments for TB hospitals’ optimization and improvements in the TB
2. HIGHLIGHTS - 7 Review of Government-Funded and Community-Based Health Insurance Schemes in India In March, HFG completed a review of government-funded and community-based health insurance (CBHI) schemes in India, part of the groundwork to inform scale-up of health mutuals in India. The review was aimed at critically analyzing the evolving scenario of government-funded and CBHI schemes in India, their design and implementation experiences, challenges, and possible growth trajectories. The review provided vital insights on the health financing imperatives to accelerate India’s progress toward UHC, and made a compelling case for a CBHI scheme to explore linkages and areas of complementarity with government-schemes.
Nigeria Health Financing Advocacy Network: Making the Case for a Political Economy Approach The Federal Ministry of Health invited the HFG project Nigeria to lead a discussion on political economy at the inauguration of the National Network of Advocacy Champions for Adequate Health Financing in Abuja, Nigeria, in late February. The invitation was extended in recognition of the increasingly relevant role that HFG plays in health financing reforms in the country. At the session, Dr. Gafar Alawode highlighted the importance of engaging various stakeholders in discussions and activities regarding increasing funding for health and public financial management.
Ghana: National Health Insurance Authority Operations Research Training of Trainers Workshop In early February, HFG and the Research, Policy, Monitoring and Evaluation (RPME) Directorate of Ghana’s National Health Insurance Authority (NHIA) hosted a three-day Operations Research Training of Trainers workshop for 17 participants from the regional and head offices of the NHIA. The main objective of the workshop was to develop the capacity of NHIA staff to train their peers on operations research (OR) methods and processes. HFG has been working with the RPME Directorate since April 2015 to develop and systematize a process for conducting OR, and in Year 5 is working to institutionalize this process at all levels of the NHIA. The workshop follows HFG-supported trainings in September 2016 to introduce OR methods and processes to 50 regional staff.
Institutionalizing Community Health Conference HFG participated in the USAID-sponsored Institutionalizing Community Health conference held in Johannesburg, South Africa, at the end of March. HFG’s Hailu Zelelew was invited to present at a panel on community health financing. On March 28, Hailu presented on HFG’s work in CBHI, alongside a representative from Ethiopia’s Federal Ministry of Health.
International Women’s Day and World TB Day For International Women’s Day (March 8), HFG highlighted the project’s work in maternal health and quality of care, including studies that found that provider payment systems can improve quality of maternal health services at the point of care. On World TB Day (March 24), HFG highlighted its work to improve the effectiveness and efficiency of TB service provision by identifying and recommending small improvements in TB purchasing/provider payment and related public financial management to better target country health budgets toward priority TB services for the poor in several countries.
8 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Training Journalists on Health Financing in Nigeria’s Cross River State In February, HFG Nigeria organized a one-day training on health care financing and the role of the media for Cross River State journalists and media professionals. The training was organized to deepen their understanding of the basics of health financing, improve their knowledge of the State-Supported Health Insurance Scheme (SSHIS), and enable them to communicate and educate the population via newspaper and radio. Mrs. Rosemary Archibong, Cross River State Hon. Commissioner of Information and Communication, said that by the end the training, “Cross River’s media and communication practitioners should be able to effectively communicate the benefits of the SSHIS to citizens, ensuring a “multi-sectorial” approach to the launch of the state’s SSHIS.”
2. HIGHLIGHTS - 9
3. CROSS-BUREAU ACTIVITIES
Moving toward Universal Health Coverage: ACTIVITY 1 State of the Art and Lessons Learned
Activity Objectives - In Year 5, HFG will synthesize lessons learned from its multiple engagements with the UHC agenda across the world to produce a series of briefs on key lessons learned. The precise topics for these briefs will be agreed on in discussion with the AOR team after an initial review but they could include issues such as: strategies for extending health insurance coverage to the poor and informal sector; institutional requirements to support UHC; or managing stakeholder relationships through the development of strategies to achieve UHC. Year 5 Progress - Drawing primarily upon MandE and the HFG website, the HFG team identified all completed and ongoing learning- and knowledge-related activities across the project. The team compiled this information into a database, analyzed the content of the database, and together with Technical Management Team and Country Management Team, decided on three priority knowledge themes for the UHC synthesis technical briefs:
Developing and reforming health financing strategies for UHC: HFG has supported Haiti, Bangladesh, Botswana, Nigeria, and Tanzania to draft health financing strategies. The brief will explore lessons learned in the strategy development process, including an overview of typical financing indicators chosen by countries, and highlight the role of Health Accounts in producing these indicators.
Extending health insurance coverage: This brief will showcase HFG's lessons learned in supporting diverse countries (Ethiopia, Ghana, India, Nigeria, and Senegal) to expand coverage of financial protection schemes, including health insurance.
Building understanding for UHC: This brief will include lessons around effective strategic communications for UHC as well as more didactic knowledge-sharing workshops. The HFG team conducted an initial rapid review of existing documentation for these activities and extracted information on key messages and likely audiences. Technical writing teams were formed, and oriented to the process, available resources, template, and calendar for producing the learning briefs. The final products (of approximately 4-8 pages) will have a standard format that comprises: 1. A short summary of key messages 2. An introduction that elaborates the problem or challenge that the brief addresses, and situates the brief in the context of the broader evidence 3. A description of HFG's approach to addressing the problem 4. Key learnings from HFG work and their relevance to different audiences (policymakers, USAID, etc.) 5. Recommendations or next steps, for example, identifying required changes in policy or practice at country, regional, or global level (depending on the nature of the work done by the project), and/or remaining gaps in our knowledge, etc.
3. CROSS-BUREAU ACTIVITIES - 11 Table 1 provides additional activity-specific updates. TABLE 1. CROSS-BUREAU ACTIVITY 1 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Conduct review of past and ongoing The review of past experiences was The teams will revise their outlines UHC-related activities and products; completed for brief 1 and initiated for and develop full narratives during Q3. select focus topics in consultation brief 2. with AOR team Conduct key informant interviews Not yet started. and additional desk research as needed to inform state-of-the-art briefs Draft series of briefs and disseminate Not yet started. through webinar and other fora
A Country Guide for Assessing ACTIVITY 2 System-level Technical Efficiency
Activity Objectives - In response to a direct request from WHO’s Health Systems Governance and Finance Division (April 2016), and building on the HFG project’s MOH-MOF toolkit: Indicators of technical efficiency, HFG will develop a country self-diagnostic guide for prioritizing potential improvements in technical efficiency at the system level. HFG will collaborate with WHO to develop a user-friendly and clear self-assessment protocol. The goal is to produce a guide that country stakeholders can apply independently, with minimal external support. HFG will then pilot-test the guide with HFG program staff in one or more countries where HFG works to ensure that the guide is clear and relevant. Input and feedback will be solicited from country counterparts in one or more HFG countries to revise and refine the guide. The guide will be produced in an electronic format that can be available publicly for downloading and use, possibly on WHO’s website. The target audience for this guide is ministries of health in low- and middle-income countries that are interested in improving the efficiency of their health systems as a way to free up scarce resources. Year 5 Progress - In Y5Q1, HFG initiated work on this activity by conducting a review of existing frameworks on the concept of technical efficiency. HFG then held an internal meeting to discuss the activity and how to adapt frameworks identified to serve as the foundation for the activity. HFG also compiled a set of technical efficiency indicators, including inputs, outputs and outcomes, and modifying factors affecting how inputs are converted into outputs. Additionally, HFG liaised with WHO counterparts to discuss the activity and move the collaboration forward. In Q2, HFG held a series of internal consultations and reviewed existing literature with a focus on key sources of inefficiency, measurement and definitions, and potential mechanisms to realize efficiency gains. Based on these inputs, HFG organized and held the first external consultation with USAID’s OHS and OHS partners. A total of 18 participants drawn from USAID, HRH2030, USP, SIAPS, Measure Evaluation, and HFG participated in the half-day consultation. The meeting enabled HFG to describe the purpose and status of the work, gather information on OHS projects’ work on measuring and improving technical efficiency, and discuss and gather inputs around the common sources of health system-level technical inefficiency. As a next step, HFG will incorporate the feedback received and develop modules for the guide, aiming for technical review over the summer
12 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Table 2 provides additional activity-specific updates. TABLE 2. CROSS-BUREAU ACTIVITY 2 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Conduct landscape analysis of Completed, reviewed, and synthesized existing work around technical the literature for common areas of efficiency technical inefficiencies and how they are organized/categorized, also compiled indicators used to measure technical inefficiencies in the health sector. Conduct meetings with key Completed, held a consultative meeting • Drafting the guide stakeholders to present findings with USAID’s OHS and OHS partners in • Identifying a country to pilot the from the landscape analysis as well March 2017. guide as gather inputs for refining the conceptual framework
Cost-effectiveness and Equity Analysis of Sin Taxes ACTIVITY 3 for Domestic Resource Mobilization
Activity Objectives - The objective of this activity is to undertake an extended cost-effectiveness analysis (ECEA) of a proposed sugar-sweetened beverage tax in the Philippines to better understand the potential for generating revenue in support of health promotion and prevention efforts and the equity implications of such a tax. This work will enable HFG to make evidence-informed policy recommendations for using sin taxes as a means of financing UHC in low- and middle-income countries. To the best of our knowledge, this will be the first ECEA conducted on sugar-sweetened beverage taxation and will thus contribute substantially to global knowledge. Furthermore, in countries with available household and consumer data, this approach could potentially be replicated to aid ministries of finance and of health in making decisions about how to allocate resources more effectively. Year 5 Progress - In Q1, HFG refined the scope of the activity. The team interviewed and hired two consultants (a Philippines-based Senior Research Advisor, and a US-based Disease Modelling Specialist); received permission to begin data collection from the AOR team, the USAID Mission in the Philippines, and the Philippines Department of Health; and began defining the cost-effectiveness and disease modelling parameters. In Q2, HFG defined the cost-effectiveness and disease modelling parameters, and began collecting secondary data. The Senior Research Advisor began liaising with responsible government authorities in- the Philippines to obtain the needed government data sets. Census and Demographic and Health Survey (DHS) datasets were obtained. Partial data have been received from the National Nutrition Survey and PhilHealth. Access has been granted to the Family Income and Expenditure Survey.
3. CROSS-BUREAU ACTIVITIES -13 Table 3 provides additional activity-specific updates. TABLE 3. CROSS-BUREAU ACTIVITY 3 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps
Obtain datasets Complete Census and DHS Data compilation will be completed datasets have been obtained. Partial in Q3. data has been received from the National Nutrition Survey and PhilHealth. Access has been granted, but payment is pending for the Family Income and Expenditure Survey
Design protocol Completed.
Analyze data Not yet started. Will begin in Q3.
Developing Guidance for Strategic Communications ACTIVITY 4 and Stakeholder Engagement to Achieve Strong UHC Using a Joint Learning Approach
Activity Objectives - Strategic communications that effectively engage health systems stakeholders are essential for UHC implementation plans to meet their stated objectives. Practitioners and policymakers participating in the Joint Learning Network for Universal Health Coverage (JLN), for example, have repeatedly identified strategic communications as a key challenge for the implementation of major health systems reforms: Ghanaian policymakers have cited the importance of strategic communications in the roll-out and scale-up of a new provider payment model, and the Philippines recently invested significantly in an engagement strategy to roll-out their expanded primary care benefit. As several countries embark upon a path to attain UHC and related health financing reforms, a practical understanding of how to communicate effectively to engage stakeholders has become increasingly necessary. With the help of systematic, inclusive communications and feedback loops to share change management strategies with relevant stakeholders (i.e., providers, consumers, funders, suppliers, community groups, political leaders, and the media) all actors will be better positioned to understand their rights, responsibilities, and opportunities to maximize the benefits of these reforms. In this activity, HFG will support country participants from government agencies to develop and co- produce a practical guide on lessons learned in countries that have developed and implemented strategic communications plans in support of health reforms. The guide will enable countries to understand how to identify and analyze stakeholders, determine strategic communication objectives, and choose forms of engagement such as messaging, consultative processes, champions, and change management.
14 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Year 5 Progress - In Y5Q1, HFG mobilized the activity team and developed a detailed scope of the activity. In Y5Q2, HFG identified country participants by circulating a Call for Expressions of Interest through the JLN’s Member Portal and conducting targeted outreach to select countries. The team contacted all country participants for preliminary outreach, and will conduct key informant interviews with all participants prior to the first virtual engagement session, scheduled for Q3. HFG has also begun a comprehensive literature review to disseminate to countries prior to the first virtual engagement session. During Q3, HFG plans to begin developing the first draft of the practical guide for strategic communications and planning for the in-person joint learning workshop to be held in July 2017. Q2 Challenges - HFG received considerable interest in the activity through the JLN and targeted outreach, resulting in 10 applications for country participation. Several applicants are not HFG priority countries; in order to include as many countries as possible, HFG has worked to secure necessary approvals and identify alternative funding streams to support all interested parties. While the initial project activities have not followed the initial timeline laid out in Q1, HFG is on track to complete the project's work within the initial timeframe. Q2 Additional Information - The in-person peer-learning workshop is tentatively scheduled for mid- to late July 2017 Table 4 provides additional activity-specific updates. TABLE 4. CROSS-BUREAU ACTIVITY 4 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Plan logistics and agenda for first Coordinated interpretation, Logistical details and distribution of virtual engagement session technology, and agenda for virtual relevant materials (e.g., country engagement session. preparation packets) will be finalized in early Q3 prior to engagement session. Conduct literature review Conducted desk review and compiled Literature review to be finalized comprehensive literature review. following the Q3 virtual engagement session. HFG team will use feedback from that event to inform additional research. Post Call for Expressions of Interest Posted Call for Expressions of Followed-up with country applicants and conduct targeted outreach to Interest on JLN Member Portal and to schedule key informant interviews solicit country participation in activity conducted targeted outreach to and next steps of activity Cambodia and Senegal. participation. Hold key informant interviews with Conducted outreach to schedule key Interviews with remaining country selected participants to further informant interviews with all country participants to be held in Q3, prior to inform HFG team on country participants. Held interviews with first virtual engagement session. progress toward UHC and related Malaysian and Sudanese teams. experiences, tools, and challenges pertaining to strategic communications
3. CROSS-BUREAU ACTIVITIES -15 Understanding the Operational Factors behind ACTIVITY 5 Sustainable Health Systems Strengthening
Activity Objectives - While the USAID-supported health system reforms in Central Asia are widely acclaimed by development practitioners who are familiar with the region, the process and the reasons behind the success have not been fully documented for a development practitioner audience, and therefore the lessons learned from the experience may not be applied to other development contexts. The 2015 report Anatomy of Health Care Transformation: USAID's 20-Year Legacy of Health Systems Strengthening in Central Asia synthesizes the results of 20 years of USAID investment in health systems strengthening (HSS) in Central Asia for a general audience. Building on the themes addressed in this document, HFG will further investigate and draw from existing statistics and research on HSS and service delivery outcomes in the region. The result will be an article on lessons learned from long-term investment in HSS in Central Asia. Year 5 Progress - In Q1, HFG carried out discussions with HFG HSS and research experts to determine the best approach to this activity. Additionally, HFG met with potential writers and researchers for this work. In Q2, with a writer identified for this work, HFG reviewed relevant literature and created an annotated outline for the article. The article will look at the impact of our Central Asia HSS work over a 20-year period, using the USAID HSS Vision framework with a focus on progress toward UHC outcomes Table 5 provides additional activity-specific updates. TABLE 5. CROSS-BUREAU ACTIVITY 5 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Conduct desk review of program Informal desk review conducted. documentation and previous research reports from World Bank and other partners on the health reforms in Central Asia Conduct stakeholder interviews with Informal interviews to shape key partners structuring of the outline took place in Q2. Formal interviews are planned for Q3. Produce /submit final article to Planned for Q4. journal
16 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Domestic Resource Mobilization for Health: ACTIVITY 6 Getting Health's Slice of the Pie
Activity Objectives - Many countries are seeing improvements in domestic resource mobilization (DRM) for health due to tax administration reforms, substantial economic growth, and low energy prices. However, the work performed by HFG on tax administration reform and allocations to health shows that greater allocations to health are not automatic and cannot be assumed when general government resources increase. To ensure that adequate domestic resources are allocated to the health sector, dedicated analytic, policy, and advocacy efforts are required. The objective of this activity is to assist selected countries in developing strategies for mobilizing additional domestic resources for health, through a joint learning approach. The activity aims to engage countries that are benefitting from either strong economic growth, falling energy prices, or both, and where government resources devoted to health are relatively low compared with their peers. In Year 4, HFG held the first of two DRM for health workshops, in Abidjan on September 1–2, 2016. The workshop convened 25 health and finance experts from Bangladesh, Côte d’Ivoire, Ghana, Peru, Tanzania, and the United States. Over the course of the workshop, participants from ministries of health and of finance discovered common priorities, including poverty reduction, reduced costs, efficient and effective use of resources, investing in healthy, productive workers and students, and eliminating corruption. In addition, participants actively engaged in joint learning across country teams. Each country team presented a thorough and ambitious plan that they are committed to implementing, incorporating one or more of the practical resources presented at the workshop. Year 5 Progress - In Y5Q1, HFG hosted a webinar to sustain momentum from its Y4Q4 DRM for Health workshop in Côte d’Ivoire. During the webinar, representatives from all four participant countries (Bangladesh, Côte d’Ivoire, Ghana, Tanzania) shared progress and challenges implementing their DRM for Health action plans developed in Côte d’Ivoire. For example, several countries have validated their draft action plans with a wider group of stakeholders, and several have continued to develop their discussion dossiers. The webinar also yielded a list of priority topics that will inform the agenda for the second workshop. In Q2, planning began for the second workshop, which will be held in Accra, Ghana, on May 11-12, 2017. Table 6 provides additional activity-specific updates. TABLE 6. CROSS-BUREAU ACTIVITY 6 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Organize and hold second workshop HFG began logistical planning for the In Y5Q3, HFG will hold the second second of two DRM for Health workshop in Accra, Ghana (May 11- workshops, to be held in Accra, 12). Ghana on May 11-12 (Y5Q3). Organizers also developed a draft agenda, which incorporates suggestions from participants of the first workshop in Abidjan (Y4Q4) and follow-up webinar (Y5Q1).
3. CROSS-BUREAU ACTIVITIES -17 ACTIVITY 7 Understanding the Dynamics of Successful HSS Reforms: Case Studies and Cross-Case Analysis
Activity Objectives - The goal of this activity is to implement a set of comparative case studies of global HSS interventions to bring into better balance our focus on “what works” in HSS with “how and why HSS works,” to improve the performance of future HSS efforts. Case studies will be based on a sample of six HSS initiatives perceived as successful, and analysis will focus on teasing out some of the policy setting, adoption, and implementation factors and processes that drove the initiative. To ensure a wide global dimension to the analysis, the set of cases examined will be diverse, drawing from HSS initiatives that were implemented in different places under different conditions and with different features. Here “successful” is defined as an initiative that has done at least one of the following: achieved process objectives (initiative was implemented as planned); generated expected outputs; or positively impacted service use, and (in some cases) health outcomes. In Year 4, HFG designed and began implementing the study. HFG drafted the study design and instruments, selected projects to investigate for the case studies, and vetted the design and case selection with a Technical Advisory Group (TAG) of 14 USAID staff recruited from across the GHB. Then, for each case, we completed document review, conducted interviews, coded the data using a common codebook we developed, and analyzed the data. We were unable to complete the case study for one project due to insufficient response rates from previous project staff. We drafted case study narratives for each completed case study and presented the results to the TAG at USAID. We initiated review of the case study narratives by the Chief of Party (COP) of each project studied and a member of the TAG. Year 5 Progress - In Y5Q1, the drafting of the case study narratives using interview and document review data collected in Y4 was completed. The case study narratives were submitted to the respective projects’ COPs and to TAG members for review and comment. Final revisions of the narratives based on the COP and TAG members’ feedback commenced. The outline for the cross-case report was drafted and the analysis plan for the cross-case analysis was completed. In addition, the data from each case in NVivo to enable cross-case analysis was merged and initial text analysis of the data across cases was begun. In Y5Q2, the cross-case analysis was conducted. To do this, data across cases in NVivo were analyzed along each factor of the guiding implementation framework and matrices were used to look for patterns. Based on the analysis, the cross-case analysis report was drafted. The report included results organized by the implementation framework, reflections on the implications of the findings for HSS projects, and recommendations for donors and future HSS projects. The third and final meeting was held with the TAG at USAID to share findings, solicit feedback, and discuss next steps for the dissemination of the study. An abstract was submitted to the American Public Health Association annual meeting to disseminate the findings.
18 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Table 7 provides additional activity-specific updates. TABLE 7. CROSS-BUREAU ACTIVITY 7 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Compose, validate, and revise A final set of comments were received from These will be finalized and posted draft case study narratives USAID in Q2 and used to revise the along with the cross-case analysis reports. The reports need final editing and report. It was decided these would formatting. be best disseminated as part of the broader package of study findings rather than as individual case reports. Do a cross-case analysis of Analysis was completed in NVivo in the primary and secondary data merged NVivo project. The data were reviewed by factors and domains in the implementation framework across cases. Matrices in NVivo were used to look for patterns across cases. Convene a panel of experts This is in progress. Recommendations based The panel of experts was the TAG. A and develop a 2-page policy on the cross-case findings were developed. proposal for dissemination activities brief with recommendations The TAG reviewed the recommendations (to include a short policy brief) that and provided feedback, which will be can be completed within the budget incorporated into the final will be developed and submitted to recommendations. The TAG will review USAID. and approval the final recommendations. Prepare journal article for Planning has started, but this activity is publication planned for Q3. Submit journal article This activity is planned for Q3. manuscript to a relevant peer- reviewed journal
ACTIVITY 8 Revision of USAID’s Health Systems Assessment Approach
Activity Objectives - USAID's Health Systems Assessment Approach (HSAA) will be revised through a collaborative effort among USAID health system projects (HFG, ASSIST, SIAPS, PQM, and other Global Health implementing partners (IPs)) to address the following:
Promote UHC and systems thinking, a holistic perspective, and interactions among the health systems functions.
Identify ways to conduct the health systems assessment (HSA) with fewer resources.
Incorporate new knowledge and new global and country priorities.
Better inform policy and program decision making at the country level. By the end of 2016, a draft version of the HSAA manual will be produced. In 2017, the revised HSAA manual will be pilot-tested in one or two countries and finalized. OHS proposes that HFG coordinate and facilitate this collaborative effort.
3. CROSS-BUREAU ACTIVITIES -19 Further, USAID/OHS has asked HFG to explore possibilities for engagement with WHO and the World Bank, two global entities also in the midst of addressing the need for comprehensive, current, and feasible approaches to HSAs. HFG developed potential scopes of work and budgets for USAID's consideration and laid the groundwork for a mid-April in-person discussion with key stakeholders from USAID, WHO, and the World Bank to discuss ways to collaborate on HSAs. Following this, WHO conducted a light-touch review of the HSAA modules in Year 4, in addition to revisions done by USAID's IPs. Year 5 Progress - In Q1, HFG reviewed edits to the technical modules of the HSAA manual by IPs (ASSIST, SIAPS, PQM, HRH2030, MEASURE Evaluation) as well as comments from WHO with the goal of addressing, harmonizing, and cross-referencing inputs across the manual. Furthermore, HFG included a low-budget assessment option, for clients that would like the option of conducting a rapid assessment focusing on select components of a health system. HFG also conducted an overall technical review of both the technical and non-technical modules to integrate a UHC and holistic systems-thinking lens into the overall approach of the assessment. Following this, a completed draft of the manual was posted for public comment to obtain feedback on the revised content from a wider array of development partners, including the United Kingdom's Department for International Development (DFID). After two weeks of public posting, HFG consolidated submitted comments and held a briefing session with USAID to discuss the comments and identify next steps. HFG is currently incorporating this feedback into the final version of HSAA Manual Version 3.0 During Q2, the HSAA Manual Version 3.0 was edited further based on comments from the public posting period. HFG communicated with IPs about comments specific to their technical modules and facilitated additional revisions. Furthermore, HFG held multiple calls with USAID to discuss final technical revisions to the manual as well as strategies to increase buy-in and uptake of the manual by country partners and make its contents more suitable for non-HSS audiences. As a result of these conversations, HFG expanded the systems-thinking dimension of the manual in an effort to make to make it a more prominent structure of the manual. Professional copyediting is also underway in preparation for the posting of the final HSAA Manual Versions 3.0. Q2 Additional Information - In an effort to make the final product more accessible, tangible, and user-friendly, and pending Year 6 funds, HFG is planning on posting the manual as an interactive e- resource on the HSAA website. Table 8 provides additional activity-specific updates. TABLE 8. CROSS-BUREAU ACTIVITY 8 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Coordinate and facilitate activity Ongoing: HFG collaborated closely with HFG and IPS will be finalizing implementation, including IPs and USAID to address public additional technical edits. HFG will convening meetings, collaborative comments and finalize technical revisions. also be managing communications and sessions, and process holding regular update calls with management USAID during the final revision. Finalize draft of revised HSAA Copyediting and final technical revisions HFG will work with USAID to Manual Version 3 are currently ongoing. determine final format and posting of the final product, including branding and style.
20 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
EQUIST: Modeling the Link Between Health Systems ACTIVITY 9 Strengthening and Lives Saved
Activity Objectives - OHS sought a tool that could be used to build evidence linking HSS and impact on lives saved. In Year 3, using evidence from a literature review and feedback from a virtual advisory group, HFG produced an Excel-based tool that converts HSS intervention/strategy data into an impact matrix. HFG also participated in meetings with USAID and the United Nations Children’s Fund (UNICEF) about the relationship between this draft tool and UNICEF’s EQUitable Impact Sensitivity Tool (EQUIST). Through these meetings, participants realized that both EQUIST and the HSS Impact Tool had incorporated elements of the “Marginal Budgeting for Bottlenecks” methodology and the Lives Saved Tool. Given these similarities, USAID and UNICEF agreed to merge the separate modeling efforts into one work stream, using EQUIST as a platform. The limitations of the existing HSS research base (including weak evidence, lack of evidence, variations in interventions and observed effects, context dependence, and unmeasured interaction effects) are well known. In order for EQUIST to generate robust, defensible impact projections associated with different health system investments, researchers at both HFG and UNICEF agree that the model’s underlying effect measures and assumptions should be vetted by experts. USAID thus tasked HFG to collaborate with UNICEF to convene a Health Systems Strengthening Expert Review Panel (ERP) of health system academics and expert practitioners. In Year 4, HFG conducted a literature review, and compiled evidence on the effects of identified HSS strategies on reducing health systems performance and coverage bottlenecks. The ERP was convened in Y4Q4 at UNICEF headquarters in New York City to review and vet these effect size estimates. The consensus impact estimates will be incorporated into EQUIST, and will also be useful to other HSS practitioners. In Year 5, HFG sought to collaborate with UNICEF to finalize the HSS impact matrix that incorporates effect size estimates vetted by the ERP. HFG and UNICEF planned to meet to determine a protocol for incorporating the consensus values from the ERP meeting and finalize the structure of the impact matrix. The teams would collaborate on the development of this impact matrix to calculate the impact of investing in HSS activities. The matrix wpuld then be incorporated into the EQUIST platform to inform health system planning, priority-setting, and resource allocation. Year 5 Progress - In Q1, HFG organized a two-day meeting with UNICEF and USAID to review outputs of the HSS ERP that took place late in Year 4. The goal of this meeting was to determine the format of the impact matrix. Based on the technical decisions and next steps identified during this meeting, HFG converted the expert-vetted impact estimates into a format that could be incorporated into EQUIST. The impact matrix captured range of effect sizes of HSS strategies on coverage outcomes in form of relative risks (RR) and included pertinent context and credibility information. HFG finalized this matrix and submitted it to USAID as the final deliverable of the activity on November 30, 2016. Based on this, UNICEF is currently modifying EQUIST and incorporating the data from the impact matrix. The revised modeling tool will have evidence metrics for HSS strategies and will be able to estimate potential lives saved through investments in HSS strategies. Furthermore, HFG shared with USAID and UNICEF the notes and results worksheets for each of the 22 HSS strategies that were reviewed during the meeting. These reflect consensus values, additional relevant studies, and other expert feedback. These working documents were also shared with experts that attended the HSSERP.
3. CROSS-BUREAU ACTIVITIES -21 ACTIVITY 10 Marshalling Evidence for Governance Contributions to Health Outcomes
Activity Objectives - In Year 4, HFG launched a major initiative focused on generating evidence of governance contribution to health system performance. Thematic working groups (TWGs) were formed to compile evidence, both scientific research and tacit knowledge. HFG participated in a WHO technical consultation meeting on health systems governance for UHC. This meeting led to detailed discussions on HFG collaboration with WHO on Year 5 HFG events to support marshalling the evidence agenda. The marshalling the evidence activity will unfold over three phases: Phase 1 was the launch event at the end of Year 4, with HFG supporting the USAID OHS and WHO to launch this major initiative. This event established TWGs and set next steps. Subsequent phases will be implemented in Year 5 with the existing pipeline. In Phase 2, the TWGs will produce synthesis papers. The working groups will be responsible for consolidating the inputs to the high-level meeting. Each group will have an assigned lead responsible for guiding the group to organize and package the research and field practice on their theme. HFG will provide substantial analytic and secretarial support to the groups. The following are proposed TWGs:
Public Financial Management: Planning, budget allocations and execution, internal controls and audit, and DRM all play a role, from facility to national level, in the quantity of resources available to the health sector and the efficiency and effectiveness with which those resources are spent.
Policy and Regulation: The process of developing, implementing, and overseeing policies in accreditation, quality control, equity, and access to services all guide efforts to achieve UHC and access to priority services.
Uses of Knowledge in Health Systems: Strategies for achieving improvements in health system performance including those that allow for timely feedback about service quality, the transparent generation and use of data and evidence, quick and accurate responsiveness to the needs of beneficiaries, and aligning incentives with improved performance.
Health System Accountability: Accountability mechanisms for health system performance help to ensure the delivery of priority services and the efficient use of health resources. A range of systems, structures, and procedures can promote vertical and horizontal, and internal and external accountability, including the role for citizen voice in promoting greater accountability. Phase 3 will be the planning and conducting of a one- or two-day high-profile event to highlight USAID's leadership in the area of health governance. The event will include plenary sessions, panel discussions, and breakout sessions around the four TWGs. These working groups will represent a broad spectrum of ongoing health governance activities, both field based and research. The event might also include a marketplace of governance interventions, including tools, approaches, and methodologies, that have had a demonstrated impact on strengthening health programming. Year 5 Progress - In Q1, following the HFG workshop at the end of Year 4, each group drafted a conceptual framework document. The Marshalling the Evidence Secretariat, composed of USAID, HFG, and WHO representatives, coordinated on the design of a final event to disseminate findings. A call with all TWG co-chairs was conducted on December 1, 2016. In Q2, the four TWGs including Public Financial Management, Accountability, Policy and Regulations, and Uses of Knowledge in Health Systems are working on the literature reviews guided by their respective frameworks and conceptual frameworks developed in Q1. The groups have identified potential key informants for each area and planning for the key informant interviews. The Secretariat conducted a brief
22 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
review of the scopes of work for the four TWGs with the aim to look for areas of synergy across the four groups, and to clarify if there are any major gaps in the work. The review summary highlights recommendations for the TWGs moving forward. A second quarterly call with the co-chairs was held on March 16, 2017 to discuss the progress on the literature reviews and the key informant interviews. Communication materials were developed to support the key informant interviews process. In Q3, the TWGs will be conducting key informant interviews and developing the first drafts of the TWGs reports. The Secretariat will also be conducting a second analysis on cross-cutting themes, including gaps not covered by the TWGs that will be incorporated into the final report. Table 9 provides additional activity-specific updates. TABLE 9. CROSS-BUREAU ACTIVITY 10 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Lead planning for large Fall 2017 The four TWGs have been working Next step: event on health governance on the literature reviews guided by Finalize the questions their respective frameworks and Start reaching out to key informants conceptual frameworks. for interviews. The TWGs identified potential key informants and completed drafts of the interview questions. The Secretariat prepared communication materials to facilitate the key informant process interviews that will be starting soon.
Governance and Quality— Institutional Roles and ACTIVITY 11 Relationships to Ensure Service Delivery
Activity Objectives - In Years 3 and 4, HFG teamed up with the ASSIST Project (University Research Co., WHO, and the Institute for Healthcare Improvement) to identify different ways that countries promote quality of care through governance structures and functions such as: institutional roles and relationships; provider payments; and policy, regulatory, and other levers. In Year 4, HFG is bringing this learning to the field so countries can learn from each other's experiences in improving the quality of health care through more effective institutional arrangements and policy instruments. HFG and ASSIST hosted a roundtable workshop with "learn-from" countries including select EPCMD/JLN member countries to present and use the research from the literature review and country tacit knowledge to explore strengthening the governance of quality. HFG is also providing technical assistance to one EPCMD country to identify country bottlenecks and ways to improve the governance of quality through enhancements to the roles and responsibilities of institutions governing quality.
3. CROSS-BUREAU ACTIVITIES -23 In Year 5, HFG will continue the learning exchange among "learn from" and EPCMD and JLN nations, and implement the activities proposed by the countries themselves at the Tanzania Product Development Meeting in March 2016. HFG will build on the findings of challenges, successful experiences, and the landscape of what countries are doing now (literature review and country case studies). To this end, HFG will:
Contribute to a consensus statement on institutional roles for governing quality in context of UHC. Consensus statement will be co-authored with participating countries and endorsed by USAID, WHO, and the member countries of the COP (and ideally by the JLN if possible.)
Support a Governance of Quality Community of Practice (COP). This COP will be led by the ASSIST project and will be a repository for resources, and a platform for virtual meetings and webinars. HFG will provide technical inputs in the form of several webinars on topics chosen by members. The COP will eventually be transitioned to the WHO Learning Lab.
Establish and pilot a "check-list" and/or a decision tree/process guide to tackle the governance challenges of linking finance to quality, e.g., the institutional implications of where to house the quality functions and whether and how to incentivize quality. This will build on the Year 4 work of documenting current global experiences around the world.
Develop a Joint Research Agenda on institutional roles and relationships for governing quality in context of UHC. Prioritize based on JLN/EPCMD country interest. Issues that seemed to generate a great deal of interest are 1) governing to develop a culture of quality; 2) using accreditation and other regulatory techniques to improve quality; 3) linking quality to finance; 4) garnering political will for quality improvement; and 5) how governments can determine and monitor whether a population is receiving quality services. The COP above will be a vehicle through which communications on this agenda will be launched and gathered. Year 5 Progress - In Y5Q1, HFG finalized the Governance of Quality literature review of the experiences of 25 countries in governing quality. Along with the ASSIST project, HFG finalized and disseminated the final report of the Governance of Quality research and in-person product development meeting co-chaired by ASSIST. HFG participated in one COP meeting and introduced a series of activities that will benefit community members. All activities will be member-driven and participatory in nature including webinars on demand-driven topics, a consensus statement, and a guide for institutional roles and relationships in governing quality. HFG solicited interest from COP members on participation and leadership of the above-listed products, and formed a team to implement the activities. In Q2, HFG established the teams that will be working on each of the products, e.g., research agenda, checklist, and consensus statement. Working with these teams, brainstorming began on how to produce a tool that would be useful to countries, based on their experiences and lessons learned. Therefore, teams have begun developing one-day working sessions that will generate the content for each product, including pre-meeting semi-structured interviews with country stakeholders. These sessions will form the basis of the second Governing for Quality Stakeholder meeting. HFG began the process of planning for this second annual meeting. We plan to make it more interactive and dynamic than the first roundtable. Our objective for the meeting will be to come together to develop a consensus statement, finalize a research agenda to be advocated for in each country, and develop the framework for the checklist to ensure health financing mechanisms incorporate quality considerations. NB: The checklist will also be informed by qualitative research that a parallel Asia Bureau Activity is collecting looking at how the Philippines, Indonesia, and Thailand are linking health financing mechanisms with quality. We will also use the meeting as an opportunity to discuss the full integration of the COP into the Global Learning Lab with WHO. We believe the members of the COP and those stakeholders invested in improving quality service delivery in their countries have valuable tacit knowledge to enrich each of the
24 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
HFG products for Year 5. We are committed to developing demand driven tools and products that are produced by and for our country stakeholders. The COP continues to meet quarterly, led by ASSIST. The January meeting brought together many members who remain engaged. We reached out to 75 percent of members this quarter to discuss the products and ideas of most interest to the members, and encouraged them to join the COP. This successful tactic was unfortunately stymied by poor telecommunications that morning, and we lost many participants. The COP will transition to WHO's Global Learning Lab in Q3. Finally, in Q2 we began developing a new webinar to present either through the COP or the Global Learning Lab. We will facilitate this webinar in Q3. Q2 Additional Information - Leizel Lagrada joined our team from R4D. She will support the 2nd Product Development Round Table. Teams were selected with country stakeholders from Kenya, the Philippines, and Malaysia accepting lead coordinator roles working with HFG counterparts to move the product development forward at the workshop. Table 10 provides additional activity-specific updates. TABLE 10. CROSS-BUREAU ACTIVITY 11 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Support a Governance of Hosted January COP meeting. Generated Telecommunications created Quality COP demand for meeting participation, and many connection problems for many people joined. participants. Develop checklist linking Organized the team that will work on the financing mechanisms to checklist. Developed the questionnaire for quality the qualitative interview for stakeholders in the Philippines and Indonesia. These data will be used for case studies and to inform the checklist. The team is also beginning to work on a session for the Q3 meeting to facilitate country-driven inputs and suggestions to design the tool and make it most useful. Technical assistance to one Given that the checklist will be developed EPCMD country (TBD) to with inputs from the 2nd Product implement lessons from the Development Stakeholder meeting in Q3 and guide to improve quality from inputs from qualitative research in the through changes Philippines, Indonesia, and Thailand, we /enhancements to the roles believe technical assistance to one country and responsibilities of will likely take place in Q4, and may or may institutions governing quality not be provided through the Asia Bureau activity. Facilitate Governance of We developed the team to work on the Quality Consensus Statement consensus statement. Team in process of drafting outline for consensus statement to share with group for comments.
3. CROSS-BUREAU ACTIVITIES -25 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Develop Research Agenda on Team identified to lead this product Governing Quality development. HFG lead developing an outline and framework for capturing priority research questions, building from gaps identified in the literature review study from Year 4. Will seek input and refinement of framework early in Quarter 4. Team began preparing one-day session for next stakeholder meeting and workshop.
Promoting Effective Oversight of EPCMD through ACTIVITY 12 Standing Committees on Health
Activity Objectives – HFG’s work to develop an entry point mapping tool to help civil society focus its advocacy on the right audience at the right time identified parliamentary standing committees as a key stakeholder. In many EPCMD priority countries, standing committees for health play a significant role in reviewing health budgets and overseeing implementation of health priorities. More effective civil society engagement with the committees can lead to more evidence-based decision making and targeted oversight. However, civil society organizations (CSOs) often lack the understanding of how standing committees operate including monitoring committee performance and contributing to their review of budgets and policy. In Year 4, HFG developed a set of guidelines for how standing committees can better oversee programs for EPCMD, with their ability to review budgets, oversee program priorities and implementation, and network with CSOs. In Year 5, with the Year 4 pipeline, HFG will 1) complete the Year 4 step of piloting the guidelines in one of the EPCMD priority countries. HFG will introduce and expand use of the guidelines by several more standing committees in EPCMD countries by partnering with existing multi-country health governance platforms. Potential partner platforms include the Southern and Eastern African Parliamentary Alliance of Committees of Health annual conference, and the International Parliamentary Union planned regional meeting on MCH; and 2) HFG will finalize a parallel guide for CSOs to hold their parliamentary standing committees accountable for EPCMD funding. Year 5 Progress – In Q1, HFG received helpful feedback on the guidelines from USAID's Center for Democracy, Rights and Governance. HFG incorporated the feedback into the guidelines and is now working to identify an appropriate country for piloting. In Q2, HFG met with the AOR team to review the draft guidelines and potential countries for piloting. AOR suggested that HFG refine the guidelines to serve as a "User's Guide" and create two additional products: a condensed version for Members of Parliament; and a PowerPoint presentation to guide a workshop. Also in Q2, the Standing Committee oversight plan framework was used in the HFG Guinea activity to guide the Standing Commission on Health's development of an annual oversight plan.
26 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Table 11 provides additional activity-specific updates. TABLE 11. CROSS-BUREAU ACTIVITY 12 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Conduct one multi-country event co- The multi-country event will follow hosted with an existing health the in-country pilot of the guidelines. governance organization focused on actions by parliamentary bodies
Stimulate USAID Field Research into Advancing Universal ACTIVITY 13 Health Coverage and Results-Based Financing
Activity Objectives - USAID Missions and country counterparts will gain a deeper understanding of the value of research to advance UHC and results-based financing (RBF) and of how to integrate research in this context. This will be done by producing a series of technical briefs to share lessons from specific implementation research for UHC initiatives in Myanmar and Indonesia that is being funded by the Asia Regional Bureau. The briefs will document the experiences in these two countries to test implementation research methodologies. HFG will disseminate lessons globally through publication on the HFG website and other channels. Year 5 Progress - In Year 4, the first of three technical briefs, Implementation Research for UHC in Practice: A Series of Technical Briefs Based on Lessons Learned from the Field in Myanmar and Indonesia, was finalized; it is currently featured on the HFG website. In consultation with USAID’s OHS and Asia Bureau it was decided to pursue a wider dissemination strategy upon completion of all three briefs. The second brief in the series will be on Defining and Designing the IR. In Y5Q1, while the design phase of implementation research for UHC was completed in Indonesia, it was still underway in Myanmar. We anticipate being able to complete the second brief in Q2 and our aim is to invite local partners to participate as reviewers or co-authors. In Q2, the second brief was completed and is currently undergoing a quality review. After revisions, it will be disseminated in Q3. Table 12 provides additional activity-specific updates. TABLE 12. CROSS-BUREAU ACTIVITY 13 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Produce second brief The second brief was drafted. After undergoing a quality review, it will be ready for dissemination.
3. CROSS-BUREAU ACTIVITIES -27 ACTIVITY 14 Use of Mobile Money for Health
Activity Objectives - Cash payments in the health system are susceptible to security risks, fraud, and leakage. Processes for paying health worker salaries, and paying out incentives in a timely and safe manner, are cumbersome, and can carry expensive administrative burdens. Moreover, those without access to bank accounts (75 percent of the world’s poor) are burdened by the inability to securely save money, access credit, or pay for health insurance. Mobile money services are emerging throughout the developing world as a banking alternative, and offer promising benefits for health systems. Mobile money can strengthen health financial systems with improved efficiency, accountability, and transparency, but there is limited information about its potential benefits, barriers, and opportunities within health programs. In Year 4, HFG’s mobile money team promoted knowledge and learning through publication and dissemination of 1) a landscape report analyzing mobile money options to strengthen RBF program in Senegal; 2) a compendium of case studies featuring 14 use cases highlighting benefits and challenges implementing mobile money in health programs; and 3) e-newsletters highlighting applications trends, and events relevant to mobile money in health. Efforts were also undertaken to plan, convene, and execute a global meeting of digital finance experts, which ultimately did not take place due to shifting USAID priorities. Year 5 Progress - With limited carryover funds in Year 5 for mobile money activities, HFG is consolidating lessons learned in years 1-4 with a Brief in mid-year as well as additional knowledge dissemination activities. To support those deliverables, in Q1, Pam Riley represented HFG at the second annual Financial Inclusion Forum on December 1-2 sponsored by USAID and the US Department of Treasury. This invitation-only event brought together donors, governments, and implementing and corporate partners to share growing evidence of benefits attributed to uptake of digital financial services by the “unbanked” including access to savings, credit, insurance, payments, and money transfers. The Forum contributed to the HFG objective to advance understanding of mobile money in health through opportunities to discuss common (e.g., salary payments) and unique (e.g., risk protection) needs of the health sector, which lags other sectors including energy, agriculture, and education in use of digital financial services. A side meeting with USAID’s Center for Digital Development’s new lead on digital finance, Brian Duzsa, was an opportunity to highlight HFG’s lessons learned and success factors for achieving broader agency objectives for digital financial inclusion. Digital financial services in health were also a topic at the 8th annual Global Digital Health Forum (previously called the mHealth Summit). Pam Riley moderated a panel on digital financial services that highlighted two promising use cases: a digital savings card in Uganda that helps women cover the costs of facility-based deliveries, and expedited health worker payments during the Ebola crisis in Liberia. Findings from use cases such as these suggest that digital financial services can contribute to USAID goals by lowering program management costs, expanding the reach of health services, and improved health worker productivity. In Q2, HFG is continuing to network with digital financial services stakeholders to inform drafting of a brief on lesson learned integrating mobile money in health. On March 8, Pamela Riley representing HFG was the featured speaker at an internal USAID brown bag on digital financial services in health. At the request of GHB Center for Accelerating Innovation and Impact (CII) and the Global Development Lab, Ms. Riley helped to shape the agenda, and identify key themes and speakers from the field. More than 50 participants from Missions, GHB offices, and Lab colleagues attended the event in person or on line. HFG’s presentation highlighted the ways in which digital finance intersects with each of the six pillars of strong health systems and provides benefits to both supply- and demand-side initiatives. The feedback
28 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
was very positive, with appreciation for the breadth of the detailed case studies presented, culled from the HFG Mobile Money for Health Compendium. There is more Mission interest in learning how mobile money can provide programmatic benefits, with increased awareness of Procurement Executive Bulletin 2014-06 requiring all contract and agreement officers to make e-payments the default payment mechanism for all organizations receiving funds from USAID. CII and the Lab have expressed interest in HFG continuing its involvement, such as contributing to training tools and helping to raise awareness through conferences, webinars, and workshops. Currently HFG is collaborating with the Lab in planning a mobile money for health workshop in May under the sponsorship of the Global Digital Health Network Table 13 provides additional activity-specific updates. TABLE 13. CROSS-BUREAU ACTIVITY 14 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Knowledge dissemination to HFG is continuing to network with digital advance understanding of mobile financial services stakeholders to inform money in health drafting of a brief on lesson learned integrating mobile money in health. On March 8, Pamela Riley representing HFG was the featured speaker at an internal USAID brown bag on digital financial services in health. At the request of the GHB’s CII, and the Global Development Lab, Ms. Riley helped to shape the agenda, and identify key themes and speakers from the field.
Following the Money: Resource Tracking for ACTIVITY 15 Improved Resource Allocation to Priority Services
Activity Objectives - A standardized methodology for tracking health expenditures is key to keeping countries and donors accountable for their financial commitments. USAID has been a leader in health resource tracking in collaboration with the WHO, World Bank, and Organization for Economic Cooperation and Development (OECD). This mutual accountability is a key element of USAID's initiatives, including both the EPCMD and AIDS-Free Generation initiatives. The Year 5 objectives of the Resource Tracking portfolio are as follows:
Continue to share the lessons learned (through field-supported countries) about rolling out the System of Health Accounts (SHA) 2011, to support WHO's further refinement of guidance materials and tools, such as the Health Accounts Production Tool (HAPT), thus enabling countries to better track spending on EPCMD services.
Support routine country-led resource tracking, including continued updates to the HAPT and development of in-country capacity to conduct SHA exercises.
Track global progress toward routine annual Health Accounts production and identify gaps for institutionalizing Health Accounts by expanding and applying the WHO’s key indicators to monitor progress.
Increase use of health expenditure data through an enhanced Health Accounts Analysis Tool (HAAT) dashboard that responds to countries' data needs.
3. CROSS-BUREAU ACTIVITIES -29 Raise awareness about the value of resource tracking, including the role of different resource tracking methodologies for different policy questions, by preparing a brief comparing different resource tracking options.
Enhance in-country technical capacity for resource tracking by creating an online training course on the SHA 2011 methodology.
Institutionalize mechanisms for tracking pharmaceutical expenditures using the SHA 2011 framework through collaboration with the SIAPS Project. Year 5 Progress - In Y5Q1 (October), HFG participated in a WHO-organized workshop, Strategic Direction for Resource Tracking to Inform Health Financing: Priorities for the Next Five Years. The workshop was attended by key global stakeholders in the health resource tracking sphere including USAID, the Bill and Melinda Gates Foundation (BMGF), Global Fund, and OECD. Country participants came from Zambia, Hungary, Mongolia, and Thailand. The workshop aimed at: i) exploring mechanisms to put country policy needs at the forefront for undertaking resource tracking exercises, ii) gathering inputs for revamping the Global Health Expenditure Database as a global public good availing quality resource tracking data, and iii) reviewing mechanisms to promote collaboration among the different stakeholders in the area of health resource tracking. In addition to contributing to the discussions throughout the meeting, the HFG team presented on the SHA framework, the relevance of resource tracking to decision making, potential for institutionalization, and overall reflections on lessons learned from experience. Also in Q1 (November 28-December 1), HFG hosted a Peer-Learning Workshop with WHO in Geneva. At the workshop, participants, approximately 70 in-country practitioners, shared their lessons learned and best practices on implementing Health Accounts. The country feedback obtained from the workshop will be useful in informing the other resource tracking activities for the quarter, which include the e- learning course, WHO key indicators development, and the Resource Tracking brief. The e-learning course and the WHO key indicators are in the research and planning stage. The Resource Tracking brief is in the research stage and includes work with the WHO, providing feedback on its resource tracking strategy, to which the brief will ultimately contribute. HFG has drafted a guidance document that will help countries use the data they produce by instructing them on how to compile indicators in the HAAT. Q2: HFG is in discussion with WHO and the Pan American Health Organization (PAHO) about how best to contribute to an SHA e-learning course already developed by PAHO. The Resource Tracking comparison brief is in the advanced research stage - a summary of the key methodologies and an outline of the guidance was shared with WHO for feedback. HFG supported WHO to review country feedback on the HAPT to inform how the tool can be improved to streamline both the production. HFG also contributed to a workshop in Geneva in March that discussed how to improve the quality of data on disease spending. Q2 Challenges - Given the recent bankruptcy of WHO’s HAPT software developer (Prognoz), WHO is taking this opportunity to review its resource tracking tools (such as the HAPT, HAAT, and Global Health Expenditure Database), take stock of lessons learned, and identify how these tools should evolve. WHO has requested HFG’s assistance with this review and potential revision of these tools, particularly the HAPT. Responding to this request will require additional resources beyond our ongoing ad hoc support. As such, we would like to propose repurposing funding for an existing HFG activity ("Build on the Health Accounts Analysis Tool (HAAT) to create a dashboard for country use") in order to support the HAPT development. HFG looks forward to discussing this further with the AOR team.
30 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Q2 Additional Information - The disease-specific resource tracking workshop held in Geneva in March sparked discussions about potential improvements to the SHA's disease classification and the role that the SHA framework should play to serve the reporting needs of global partners, such as UNAIDS Global AIDS Monitoring and GAVI's Joint Reporting Form. Countries and donors agreed on some high- level principles and activities for the future, and WHO should be sharing these with stakeholders soon. Table 14 provides additional activity-specific updates. TABLE 14. CROSS-BUREAU ACTIVITY 15 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Resource Tracking Brief The resource tracking team developed an Upon receiving feedback from outline of the brief that will help in-country colleagues at WHO, HFG will decision makers decide which resource incorporate comments and compose tracking methodology to use and for what a draft of the brief. purpose. The brief includes a summary of the distinctive features of several popular methodologies (e.g., SHA 2011, PER, NASA), and compares the various approaches. The annotated outline of the brief has been shared with WHO for comment before HFG prepares a more detailed draft. Collaboration with SIAPS to Development of guidance on tracking produce guidance for tracking pharmaceutical spending has been postponed pharmaceutical expenditures until experience from one or two countries with SHA 2011 has been compiled. The content and format for the guidance will be based on country feedback. WHO Key Indicators HFG solicited insights from country Health Accounts practitioners to inform indicators on how Health Accounts institutionalization can be measured more effectively. Online Learning Course HFG recently met with PAHO to review the HFG will continue to communicate SHA 2011 e-learning course it has developed with PAHO, WHO, and USAID to in Spanish through its online platform. PAHO determine mutually beneficial value- has developed a comprehensive course and added contributions to PAHO’s at this stage it would be duplicative for HFG eLearning course. Contributions to also develop an online course. PAHO and may include adding course content HFG are discussing the possibility of HFG about the practical implementation contributing to some modules, e.g., case of the SHA methodology and/or studies to the online course to highlight how case studies on countries’ Health Accounts results have been used for experiences using Health Accounts policy use. data for policy use.
3. CROSS-BUREAU ACTIVITIES -31 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Production Tool support to WHO Improve the HAPT software WHO provided final feedback and approval The video will be disseminated in on the HAPT promotional video script. We Q3. are finalizing incorporation of visual images and animations to the video. HAAT dashboard WHO is currently assessing all of its HFG will follow up to confirm this resource tracking tools (including the HAPT reallocation with the AOR team. and HAAT) to determine the way forward. As such, HFG proposes to reallocate the funding for this activity so that we can support the WHO in assessing its current tools and providing recommendations for future versions of the tools. Improve the HAAT software The draft health accounts analysis tool (HAAT) user guide was prepared and is undergoing final internal team review.
Pathways to UHC: Cross-country Analysis of ACTIVITY 16 Strategies for Covering the Informal Sector
Activity Objectives - This activity aims to provide EPCMD countries with recommendations on strategies for targeting poor workers in informal employment, based on country experiences documented in the literature and interviews with key informants. The activity will contribute to efforts toward expanding health coverage to informal workers in limited-resource settings. In Year 4, the HFG team refined the scope of this activity, proposing to synthesize the experiences of EPCMD countries in expanding coverage of an essential package of health services to informal workers. The team compiled statistics on informal employment in all 24 EPCMD countries, including a brief descriptive analysis of these data. They conducted key informant interviews with respondents in Bangladesh, Ethiopia, Ghana, India, Indonesia, Mozambique, Nigeria, Senegal, Tanzania, and Uganda. Interviews were transcribed, coded, and analyzed using NVivo software. An outline for the report and initial sections were drafted. Year 5 Progress - In Y5 Q1, HFG drafted the full report, synthesizing findings from the qualitative study of 10 EPCMD countries, the quantitative compilation of data on the labor force for all EPCMD countries, and the review of seminal documents in the literature on expanding coverage to informal workers into a draft report. This report was circulated internally for review and comments were addressed. In Y5Q2, HFG finalized the report and disseminated it through multiple online channels. In addition, HFG presented key findings and policy implications of the study at the Prince Mahidol Award Conference 2017, which focused on assessing the health of vulnerable populations for an inclusive society. HFG also planned a webinar for April 4 on expanding coverage for informal workers, with panelists including one of the report’s authors as well as external speakers from the International Labor Organization and Oxfam. Finally, HFG drafted a manuscript for peer review publication, a final version of which will be submitted early in Q3.
32 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Table 15 provides additional activity-specific updates. TABLE 15. CROSS-BUREAU ACTIVITY 16 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Prepare and finalize a product and Final product finalized and Webinar will be delivered April 4 and online material that summarize the disseminated online and at the Prince manuscript will be submitted for peer information gathered along with the Mahidol Award Conference. review to further disseminate report analysis and recommendations. findings. Disseminate results
Support for Essential Packages of Health Services for ACTIVITY 17 UHC
Activity Objectives - Priority setting is critical for governments that seek to promote equitable access to health care. An essential package of health services (EPHS) is a policy mechanism for a government to legally prioritize certain health services. An EPHS comprises those health care services that a government is providing or is aspiring to provide to its citizens in an equitable manner (Wright and Holtz 2016). Another way that governments prioritize certain health services is through a health benefit plan (HBP). A health benefit plan is financed, at least partially, with public resources and provides financial protection to the covered population for an explicit list of services. In Year 3, HFG completed a series of country snapshots and a cross-country analysis on the extent to which the EPHS in EPCMD countries includes priority reproductive, maternal, neonatal, and child health (RMNCH) services. In Year 4, HFG built on this work by 1) mapping EPHSs to HBPs, such as those found in a government-sponsored health insurance scheme, and 2) conducting in-depth qualitative research in Ethiopia and Tanzania on how an EPHS is used to develop and update a health benefit plan. The Year 4 analysis shows that while some governments appear to align certain HBPs with the EPHS, this is not true all the time. There may be other ways the government is working to strengthen implementation of the EPHS aside from aligning it with HBPs. In Year 5, HFG proposed to select up to three EPCMD countries that have defined UHC roadmaps and assist their ministries of health in these countries to map health systems initiatives to the country’s stated EPHS. HFG planned to help these ministries assess the extent to which services listed in their EPHS are covered (population-wise, service-wise, and financially) by existing and any known future public health initiatives (including initiatives in the UHC roadmap). This mapping and assessment was intended to generate lessons for other governments to use for a similar exercise as they prepare and update UHC strategies. HFG planned to produce a synthesis report of the mapping exercise from the three countries, with a section on lessons learned for a global audience. This did not occur for the reasons listed below, and HFG has proposed to use Year 5 to disseminate the above materials from years 3 and 4. We note that in addition to this activity, HFG has proposed an activity to map HIV and AIDS services in EPCMD and AIDS Free Generation countries. If approved, this funding would come through PEPFAR. This PEPFAR activity and the current one would have different focuses and would complement each other.
3. CROSS-BUREAU ACTIVITIES -33 Year 5 Progress - In Q1, HFG continues to finalize the suite of outputs from this large activity. We have finalized 17 country briefs that compare EPHS and HBPs in each country. Two of the 17 have been submitted to the AOR team before we have them copyedited. In addition, HFG has completed a cross- country synthesis report that summarizes our findings across EPCMD countries. Finally, the Ethiopian Country Case Study Report has undergone extensive revision and has been sent for copyediting. In addition to refining Year 4 deliverables, we continue to develop the scope of our Year 5 activity. In Q2, we finalized all country briefs, the cross-county synthesis report, and the Ethiopian Case Study. They are awaiting feedback from the AOR team. We consulted our colleagues in Bangladesh, Democratic Republic of Congo (DRC), and Haiti about conducting the EPHS mapping activity in their countries. DRC's work does not align with HFG's portfolio of work there; it remains unclear if this assistance would add value, and it was seen to be logistically complicated to execute. In Bangladesh, this work is being conducted by an entrenched stakeholder in country. Haiti initially seemed interested in conducting this work, but then determined that it would be complicated to execute in Year 5 given pressures surrounding the HFG team's existing work there. For this reason, we have proposed to use Year 5 to further disseminate our large portfolio of outputs from the previous years. Q2 Challenges - We have been unable to generate buy-in for our Year 5 mapping activity in any of the proposed countries. This is not for lack of interest, but rather is due to unforeseen circumstances or overlap with existing activities being conducted by partners. Table 16 provides additional activity-specific updates. TABLE 16. CROSS-BUREAU ACTIVITY 17 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Technical consultation for EPHS HFG has proposed to disseminate the We have been unable to get buy-in years 3 and 4 suite of outputs in Year 5 from proposed countries for the Year to generate further discussion around 5 activity. We have proposed to use the alignment of HBPs and EPHSs. the remaining funds to disseminate the large package of products developed in years 3 and 4 for this activity.
Support Universal Health Coverage Measurement ACTIVITY 18 at Country Level
Activity Objectives - UHC as a goal of health policy has gained wide acceptance at country and global levels since the publication of the World Health Report 2010, and it has been included in the Sustainable Development Goals as a part of the post-2015 development agenda. For this to be feasible, however, policymakers must first be able to define, measure, and monitor UHC. This activity flexibly supports strategic steps in building and testing affordable data collection processes, guidance, and tools for UHC measurement. The project will continue efforts to find feasible indicators that EPCMD and AIDS Free Generation priority countries can adapt and use for country-led UHC progress measurement. Technical assistance will be provided to Ghana and Ethiopia Ministries of Health in the area of UHC measurement, including the measurement of service coverage, financial protection, and equity.
34 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
In Year 4, HFG prepared a UHC kit designed to assist OHS in engaging and educating USAID Mission staff on the topic of UHC and its measurement. The project also initiated discussions with country stakeholders in Ethiopia and Ghana for technical assistance in the area of UHC measurement and developed a scope of work for each country. In Ethiopia, the assistance would focus on developing a roadmap to enhance measurement of financial protection. In Ghana, the assistance would include a baseline assessment of UHC measurement that identifies gaps that can be prioritized and addressed in the future. Year 5 Progress - In Y5Q1, in Ethiopia, the HFG consultant met with the Resource Mobilization Director at the Ministry of Health (MOH) to validate the scope of work for this technical assistance on UHC measurement. The MOH requested that the scope be broadened to include assessment of health service and population coverage indicators to complement the initial focus on proxy indicators for financial protection. A literature review of international and Ethiopian indicators to measure progress toward UHC was then conducted after which a draft report was prepared. The report aims to identify indicators, establish data sources, define the roles and responsibilities of the responsible organizations, and recommend a road map for measurement of progress toward UHC in Ethiopia. The draft report is ready to be vetted with 20 relevant stakeholders at a workshop to be held in Addis Ababa. Initially planned for late 2016, and the workshop was deferred until February 2017, at the request of the MOH. After inputs from the stakeholders, the report will be finalized and disseminated. In Ghana, HFG’s local consultant held key informant interviews with directors of the National Health Insurance Authority, the Ghana Health Service, and the MOH as well as other development partners. Meetings with the Technical Working Group were held in September and November to discuss potential indicators for measurement of progress toward UHC and to confirm the groups responsible for data compilation and reporting. The consultant has prepared a draft report outlining an action plan detailing steps and persons responsible to advance national efforts to achieve UHC. The report is currently under quality review and will be finalized and disseminated in Q2. In Q2, the consultant in Ethiopia finalized his report after presentation to 15 stakeholders at a two-day workshop in Bishoftu, Ethiopia, on February 16-17, 2017. Stakeholders from the MOH, USAID, Clinton Health Access Initiative, WHO, and the Ethiopian Health Insurance Agency provided input on the indicators that Ethiopia could use to track progress toward UHC. During the workshop, after discussions by the stakeholders, a set of 15 proxy indicators was proposed to measure health service coverage and nine proxy indicators to measure financial protection. They designated the Monitoring and Evaluation case team located at the MOH Policy and Planning Directorate to be responsible for overall monitoring of UHC. A roadmap for the implementation of UHC measurement was more specifically outlined by the consultant in the report. Ghana’s report was finalized in Q2 by the consultant. Forty to fifty sector-wide indicators were identified to measure progress toward UHC, most of which are routinely available in Ghana, minimizing the burden required to collect them. The consultant proposed that the Directorate of Policy, Planning, Monitoring and Evaluation at the MOH along with the Ghana Health Service harmonize the indicators and identify 20 tracer indicators to follow. The majority of the indicators that were identified in the report and validated at the workshop are reported through health facility data collection; they are already disaggregated by age, sex, and district/region, allowing measurement of equity. A short-term and longer-term action plan to advance UHC measurement in Ghana was presented in the report. Both reports are ready for dissemination to country stakeholders. This activity is now complete.
3. CROSS-BUREAU ACTIVITIES -35 Table 17 provides additional activity-specific updates. TABLE 17. CROSS-BUREAU ACTIVITY 18 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Hold workshops with relevant HFG hosted a stakeholder workshop Input from the stakeholders was used stakeholders on February 16-17, 2017, with to finalize the Ethiopia report. relevant stakeholders to identify the indicators needed for UHC measurement. Prepare report on UHC The reports for both Ethiopia and The reports are ready to be measurement and disseminate results Ghana have been finalized. disseminated.
ACTIVITY 19 Co-Sponsor Health Systems Global
Activity Objectives - Health Systems Global is a professional society established in 2012 to strengthen the field of health systems research and thereby contribute to improving the evidence base needed for health system strengthening. Since 2014, HFG has been participating in the Evidence Translation Thematic Working Group. HFG's objective in Year 5 is to continue to support the overall coordination of the Evidence Translation TWG and finalize the inventory of the evidence to policy and knowledge translation initiatives worldwide. Year 5 Progress - HFG’s assistance to the Translating Evidence into Action TWG is in its final stages. On October 26, 2016, the Translating Evidence into Action TWG hosted a webinar to introduce the completed Inventory of Knowledge Translation Resources to the TWG members. Over 50 participants joined the discussion. The TWG formally launched the inventory during a panel session at the Fourth Global Symposium on Health Systems Research where the global inventory of knowledge translation initiatives was shared and discussed by a panel of research producers and users. The inventory and a form allowing individuals to continue to contribute initiatives to the inventory are now available online on the HSG website. The TWG hosted a leadership election and successfully transitioned it's leadership from HFG to a newly elected Chair, two Vice-chairs, and Secretary. All TWG members had the opportunity to participate in the election by nominating and voting for candidates. There was strong participation in the election, with nine candidates nominated and strong voting participation. The election results were announced leading up to the HSR Symposium so that the new leadership could actively participate in and run the TWG's business meeting at the Symposium. The leadership of the TWG has been formally transitioned to the new team.
36 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
ACTIVITY 20 Dissemination of Health Systems Strengthening Impact Report
Activity Objectives - In July 2015, the OHS released a major new report prepared by HFG – Impact of Health Systems Strengthening on Health – which, for the first time, presents a significant body of evidence linking health systems strengthening interventions to measurable impacts on health outcomes. The report identifies 13 types of HSS interventions with quantifiable effects. The goal of this activity is to reach a wider audience – preferably in EPCMD and OHS priority countries – who can use the report’s findings to improve health outcomes in their countries. OHS and HFG prepared several dissemination activities during Year 4 and in Year 5 will prepare a manuscript and submit it to a peer-reviewed journal. Year 5 Progress - In Y5Q1, the report was presented at the Health Systems Research symposium held in November in Vancouver. The manuscript was submitted to the Journal of Health Systems & Reform. In Q2, HFG submitted the manuscript to the journal Globalization and Health. Table 18 provides additional activity-specific updates. TABLE 18. CROSS-BUREAU ACTIVITY 20 DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Manuscript for publication The manuscript has been submitted to the journal Globalization and Health and is under peer review.
3. CROSS-BUREAU ACTIVITIES -37
4. DIRECTED CORE ACTIVITIES
This section presents a summary of progress made in the five directed core areas – Global Health Security, HIV and AIDS, Malaria, MCH, Population and Reproductive Health (PRH) and TB. 4.1 Global Health Security Program Objectives - On February 13, 2014, the White House launched the Global Health Security Agenda (GHSA) with partners around the world to support a multisectoral approach to strengthen both global and nations' capacity to prevent, detect, and respond to infectious disease threats whether naturally occurring, deliberate, or accidental and achieve the core capacities required by the International Health Regulations (IHR). The United States has committed to work with more than 31 countries and one region to complete a self-assessment of GHSA capabilities using the WHO's Joint External Evaluation tool (JEE) and develop a five-year roadmap based on the assessment to achieve each of the GHSA targets. Most countries in the Caribbean region are small and have limited resources to implement the IHRs. Significant economies of scale could be realized through a regional effort to integrate GHSA/IHR capacities across the region and thereby support economic growth and tourism. The Caribbean Community (CARICOM) serves as the political framework for the Caribbean and focuses on four pillars: economic integration, human and social development, foreign policy coordination, and security. The Caribbean Public Health Agency (CARPHA) is the regional public health agency for the Caribbean region and supports 26 countries. The Agency rationalizes public health arrangements in the region by combining the functions of the previously existing five Caribbean Regional Health Institutes (RHIs) into a single agency to address regional responses. The Pan American Health Organization (PAHO) also serves a vital role in supporting CARICOM and CARPHA in the implementation of the IHRs. HFG's objectives under the Global Health Security directed core focus on supporting and facilitating USAID/Barbados Office and the USAID GHSA headquarters staff to convene GHSA stakeholders from the Caribbean region to conduct a Caribbean regional GHSA self-assessment, led by CARICOM and CARPHA, and develop a regional GHSA Five-Year Roadmap to strengthen capacity across 29 technical areas. Year 5 Activities - The one activity of this directed core program is supporting the Caribbean region to engage in an internal self-assessment using an instrument based on the JEE tool, and to develop a five- year roadmap to be approved by regional policymakers to advance GHSA objectives in the Caribbean region. HFG successfully took a collaborative and facilitative approach in executing the GHSA internal self- assessment, ensuring it was completed in an interactive and consensus-driven manner. HFG completed a draft roadmap by the end of the workshop, and is currently soliciting its second round of inputs from workshop participants. A final version should be ready in time for the CARICOM Heads of State meeting in 2017, where the roadmap is expected to be endorsed. The multi-country, multisectoral nature of the GHSA in the Caribbean is a unique feature of this exercise and the HFG team received overwhelmingly positive feedback from both USAID and from Caribbean stakeholders on these fronts.
4. DIRECTED CORE ACTIVITIES: GLOBAL HEALTH SECURITY - 39 HFG planned and facilitated a five-day regional GHSA Roadmap Development Workshop held November 14-18 in Miami, Florida. Participants included:
Representatives of regional bodies, including CARICOM, CARPHA, Secretariat of the Organization of Eastern Caribbean States (OECS), the Caribbean Disaster Management Agency, trade and tourism agencies, regional representatives of the private sector, and others.
Development partners such as the Caribbean Development Bank, World Bank, PAHO, and others.
Country representatives including representatives from ministries of health, finance, and agriculture.
Other regional and national stakeholders such as civil society groups and trade associations. In all, over 70 participants from 13 Caribbean nations collaborated on two main processes throughout the week: reviewing and finalizing the internal assessment, and creating the regional roadmap. They reached consensus on the region's current capacities in preventing, detecting, and responding to global health security threats, and completed the first draft of the GHSA regional roadmap. This is the first regional-level GHSA roadmap and was lauded by several stakeholders as extremely successful. To ensure that valuable, informed discussions would take place during the November workshop, HFG worked beforehand to gather relevant data from countries and regional bodies, and conducted a desk review that was used as reference material during the conference. HFG also hosted a one-day preparatory meeting with U.S. Government (USG) agency representatives to provide facilitation training, and to gather information on technical and other support planned for the region. Other development partners completed a rapid assessment survey during the first days of the conference, which HFG used to build a comprehensive mapping of donor activity in the Caribbean region. This mapping has been incorporated into the draft roadmap. The first two days of the workshop were spent introducing the participants to the concept of the GHSA and dialoguing to reach consensus on the Caribbean region's internal self-assessment. Speakers included Ambassador Bonnie Jenkins and Rear Admiral Jordan Tappero. The last three days were spent drafting the roadmap itself. For this, participants were grouped by technical expertise to encourage in-depth evaluation of key milestones and activities. Each group focused on writing sections of the roadmap that encompassed areas of their expertise, but rotated briefly through all technical areas to encourage cross- sector participation. Outcomes at the end of the conference were a completed internal self-assessment, a completed first draft of the regional GHSA roadmap, a stronger understanding of global health security by Caribbean stakeholders, and stronger cross-sector ties among Caribbean stakeholders (e.g., strengthened relationship between CaribVET, CDEMA, and CARPHA). Year 5 Progress Against Objectives - In Y5Q1, the HFG team successfully executed the GHSA Roadmap Development Workshop and all major deliverables expected in that quarter. Within the first weeks of the activity, HFG developed an implementation plan and timeline, stakeholder mapping, and a stakeholder engagement strategy. The activity team hosted weekly meetings with regional stakeholders and USG representatives. HFG conducted an extensive literature review of relevant strategies and plans in the region, and organized the findings along the 19 capacities of the GHSA. The team conducted one- on-one interviews both remotely and in person during a field visit with key stakeholders. We used the literature review and these interviews as inputs and supporting evidence for the baseline internal self- assessment based on the JEE tool. HFG developed an online platform to implement a regional internal self-assessment based on the JEE tool, with one portal for the regional assessment and a second portal for individual countries to complete the tool. This tool was successfully completed by the key stakeholders in the region and three countries.
40 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
We conducted a survey of key development partners in the region in order to have data on ongoing initiatives and planned support for the 19 capacities of the GHSA. This information was later incorporated into the draft GHSA roadmap. Lastly, the team customized the roadmap template for ease of use on a regional basis. The template was completed at the GHSA Roadmap Development Workshop using the baseline information gathered via the above activities, and with inputs and validation of workshop participants. Workshop invitations were sent to more than 155 participants. HFG also set up an event website that detailed logistics such as venue location, workshop objectives, background information on the GHSA, example roadmaps, and additional reading material that could be used to prepare before the workshop. During the workshop, HFG facilitated each session from 9AM to 5PM, took notes on roadmap template discussions and decisions, updated the internal self-assessment and roadmap technical area information after each discussion, and assisted with participants' logistical needs. Three days after the workshop ended, HFG distributed the initial draft of the roadmap for rapid participant feedback focused on accuracy. A second draft was distributed two weeks later, which gave participants time to provide more substantial comments that drew from a wider group of stakeholders. In Q2, HFG reviewed key stakeholders' comments and edits on the draft roadmap, and facilitated several remote meetings to discuss feedback, including an essential conversation on prioritization of activities over the next five years. After these comments were incorporated into a third draft, several USG agencies did a final review. They are expected to sign off on the final version by the end of April. Also in Q2, HFG developed at the request of CARICOM and CARPHA, and with USAID approval, a briefing document that can be shared at these high level meetings to summarize the roadmap. The final version will be submitted in ample time for a spring meeting of ministers of finance and development finance organizations to discuss financing the plan, an April regional meeting of Chief Medical Officers, and a May Regional Health Security Mechanism meeting - all of which are in preparation for a July endorsement at the CARICOM Heads of State meeting. Q2 Challenges - The process of gathering and responding to feedback from conference participants and government stakeholders went smoothly overall, but delays in receiving feedback from certain stakeholders delayed finalization of the roadmap. Fortuitously, the CARICOM Heads of State meeting was also postponed, so the roadmap will still be ready to be presented and discussed at the meeting as planned. Q2 Additional Information - HFG will provide limited support to a May 2017 Regional Health Security Mechanism meeting by presenting the roadmap process and content with the funds remaining from the activity budget. Meeting participants will discuss and validate the roadmap and agree on how it will be used to guide activities over the coming years.
4. DIRECTED CORE ACTIVITIES: GLOBAL HEALTH SECURITY - 41 Table 19 provides additional activity-specific updates. TABLE 19. GLOBAL HEALTH SECURITY ACTIVITY DETAIL
Critical Assumptions/ Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/ Follow-up Steps Activity 1: Developing five-year Global Health Security Roadmap for Caribbean Region Implement Stakeholder Engagement Completed Strategy Draft five-year Caribbean GHSA The latest draft of the roadmap was The report will be shared at the Roadmap just completed. It included three CARICOM Heads of State meeting in rounds of feedback from workshop summer 2017 with the goal of being participants, Caribbean stakeholders, endorsed. and several USG agencies.
42 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
4.2 HIV and AIDS Program Objectives – Activity 1: Assessing Resource Allocation of HIV Services and Improving Efficiency of Antiretroviral Therapy (ART) Provision at the District Level in Botswana. HFG is conducting an analysis to determine the efficiency of HIV treatment programs in Botswana, by comparing actual health expenditure data with normative data (as defined in national guidelines/protocols). The objective is to identify opportunities to improve efficiency in ART provision. The final report will do that and will also address cost variation, data envelopment analysis, lessons learned, and challenges.
Activity 2: Costing and Planning Tools to Support Rational Strategies to Scale Up Viral Load (VL) Monitoring Within ART Programs. This activity contributes directly to the current President's Emergency Plan for AIDS Relief (PEPFAR) 3.0 mandate, as described under the Impact Action Agenda, on ensuring effective monitoring of treatment though VL testing. The study explores costing, budgeting, and planning for the scale-up of point of care (POC) VL monitoring to sustain ART programs. The objective is to determine the characteristics of POC VL technologies and factors that influence the feasibility of adoption of these technologies in low-income or middle- income settings on a sustainable basis.
Activity 3: Evaluating Efficiency of Integrated HIV and AIDS and Family Planning (FP) Services. PEPFAR supports the integration of HIV/AIDS and FP services to improve the efficiencies and maximize impact of programs in meeting the comprehensive needs of women living with HIV. This activity aims to measure the efficiency gains in integrated FP-HIV service delivery, exploring factors at both the system and facility level. Expected results include 1) improved understanding of potential efficiency gains in integrated FP-HIV programs as well as documentation of missed opportunities; and 2) key recommendations for FP-HIV service integration on production processes, including where efficiency gains are fully realized, and improvements that could be implemented in order to maximize those gains
Activity 4: Financial Management and Costing Support to Global Fund Applicants and Recipients. Grant applications to the Global Fund under the new funding model will require a different level of capacity from country coordination mechanisms and principal recipients. HFG has been asked to assist with costing, development of transition plans, and expenditure analyses. Expected results include increased availability of quality financial data to guide decision making for Ministry of Health (MOH) leaders in selected countries, improved HIV/AIDS resources alignment with the strategic objectives of the national strategic plan, strategies for transition from donor dependence to domestically generated resources, and applications for Global Fund grants.
Activity 5: Lessons learned from Partnership Frameworks (PF) and Related Implementation Plans (PFIP) for HIV Sustainability Planning. The purpose of this activity is to understand the lessons learned from the PFs and PFIPs and to show their implications for country ownership and program sustainability.
Activity 6: Sustainable Financing Initiative. Quarterly report for the Sustainable Financing Activity can be found under the Nigeria and Vietnam programs.
Activity 7: Hormonal Contraception (HC) and HIV Modeling in sub-Saharan Africa. Recent studies have linked the use of DMPA (progestin-only, injectable method of contraception) with higher risk levels of spreading HIV. This activity furthers modeling work to refine existing mathematical models of the HIV epidemic and contraceptive method mix in South Africa, through modeling analysis conducted for South Africa, Kenya, and Malawi. The objective of the modeling is to use the most up-to-date estimates to model the potential association with HIV acquisition for
4. DIRECTED CORE ACTIVITIES: HIV AND AIDS - 43 women using DMPA, to ultimately assist countries in determining how best to maximize health, and reduce the risk of new HIV infection among women who use DMPA.
Activity 8: Sustainable Financing Initiative (SFI) in Uganda. Within the broader objective of the SFI to deliver an AIDS-free generation with shared financial responsibility with host-country governments, the SFI in Uganda will work to increase service coverage, strengthen financial protection, and improve access to vulnerable populations. The objectives of SFI support in this area are the following:
• To produce technical analysis that will provide a relevant evidence base for the MOH and UAC to use during budget negotiation and policy dialogue with the Ministry of Finance (MOF), Parliament, and other stakeholders for increased financing of health and HIV/AIDS programs;
• To produce targeted policy advocacy briefs that appropriately articulate evidence and analyses and promote and assist the MOH in using the briefs effectively to advocate for more effective investments in health and HIV/AIDS during budget negotiation and policy dialogue with the MOF, Parliament, and other stakeholders ;
• To ensure the institutionalization of health and HIV/AIDS resource tracking methods such as Health Accounts and the National AIDS Spending Assessment (NASA) by supporting their application and harmonization between the two during data collection, analysis, and use to address efficiency concerns preventing increased health sector financing and issues within HIV/AIDS programs using efficiency analyses.
• To support the development of a roadmap to guide pursuit of the universal health coverage (UHC) agenda that recognizes the importance of the HIV burden and service needs. Year 5 Activities - Activity 1: A majority of this activity was completed in Year 4. A technical brief that addressed the costing analysis was developed and disseminated at the Health Financing Technical Working Group (TWG) in October 2016. The report, Measuring Technical Efficiency of the Provision of Antiretroviral Therapy Among Public Facilities in Botswana, was finalized. HFG disseminated the report at a meeting with PEPFAR and the Ministry of Health and Wellness in December 2016.
Activity 2: This activity encompasses three main sub-activities:
• Costing: This activity seeks to determine the characteristics of POC VL technologies and factors that influence the feasibility of adoption of these technologies in low-income or middle- income settings on a sustainable basis.
• Cost-effectiveness analysis: Through examination of inappropriate antiretroviral (ARV) drug switches, development of resistance, and different monitoring protocols, the cost-effectiveness model will assess the price at which the POC VL technology would save money. The model compares (1) current monitoring methods (given values for other parameters) and (2) specific thresholds (e.g., gross domestic product per life-year). Data from Kenya will be used to complete modeling for the work that was initiated for Uganda.
• Planning and budgeting: HFG will develop an Excel-based forecasting tool to support pilot country teams in planning the transition toward virologic monitoring so they can implement the monitoring in a deliberate and phased manner over the next several years. It is anticipated that the forecasting tool will be able to be shared across countries to further catalyze VL transition even after the conclusion of this activity.
44 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Activity 3: Through this activity, HFG will measure the efficiency gains in integrated FP-HIV service delivery, exploring factors at both the system and facility level. In years 2 and 3, Tanzania and Zambia were selected as the two countries for the Integration Efficiencies study. The Zambia study was completed in Year 4. In Tanzania, HFG is working with EngenderHealth, a recipient of PEPFAR FP/HIV Acceleration Funds, to conduct an operations research activity. The main objective is to compare different models of integration (service-based integration vs. unit-based integration) and describe strengths and weaknesses of each approach in the delivery of quality integrated services within typical health center settings in Tanzania.
Activity 4: HFG is working with USAID to confirm new countries for its technical assistance including Ghana, Vietnam, and potentially Botswana or Zambia. HFG introduced the activity to a few stakeholders in Ghana and they were very receptive. Additional meeting are planned for April during the Ghana Health Forum.
Activity 5: No Year 5 tasks are planned as this activity has already been completed. Activity 6: Quarterly report for the SFI can be found under the Nigeria program and Vietnam program.
Activity 7: This activity furthers modeling work to refine existing mathematical models of the HIV epidemic and contraceptive method mix in South Africa, through modeling analysis conducted for South Africa, Kenya, and Malawi. The objective of the modeling is to use the most up-to-date estimates to model the potential association with HIV acquisition for women using DMPA, to ultimately assist countries in determining how best to maximize health, and mitigate any potential impact of DMPA on HIV acquisition in those countries most affected by HIV. Key outputs will be estimated for 2018-2030 and will include the following: HIV infections, HIV- related deaths, unintended pregnancies, unsafe abortions, maternal deaths, and DALYs.
Activity 8: HFG submitted a work plan to USAID’s SFI team who decided not to proceed with the scope of activities proposed. No further activity is anticipated. Year 5 Progress Against Objectives - Activity 1: In Y5Q1, the report, Measuring Technical Efficiency of the Provision of Antiretroviral Therapy Among Public Facilities in Botswana, was finalized. HFG disseminated the report at a meeting with PEPFAR and the Ministry of Health and Wellness in December 2016. Q2: This activity is completed.
Activity 2: In Y5Q1, working in consultation with KEMRI, critical costing data gaps were mostly filled and resolved. The cost per sample using conventional diagnostics is being calculated. HFG is still filling data gaps to calculate the cost per sample using POC diagnostics. HFG has begun drafting the Cost Analysis Report. Available literature was reviewed and secondary data were collected to inform inputs for the model. Parameter inputs for the cost-effectiveness are being finalized but the model has been run preliminarily. Final costs from the costing analysis will be used for the model. The Excel-based forecasting tool is being finalized. In Y5Q2, HFG completed a draft of the Cost Analysis Report. For the cost-effectiveness analysis, parameter inputs for the model were revised based on more recent data and reports. The model was run preliminarily and reviewers provided feedback. HFG is working on updating figures and ensuring that the model aligns realistically with policy guidelines. Final costs from the costing analysis were used in the model. HFG reviewed the Excel-based forecasting tool with Avenir and provided additional pieces of information. The tool is being finalized and gaps will be filled with information provided or with publicly available costs. A short accompanying manual is also being prepared.
4. DIRECTED CORE ACTIVITIES: HIV AND AIDS - 45 Activity 3: In Y5Q1, HFG presented the baseline findings of the integration study at USAID's FP/HIV Integration Taskforce meeting. The study is being jointly conducted by EngenderHealth's RTP program in Tanzania, the Population Council, and HFG. HFG began endline data collection at the 12 sites in Q1, and finished in early Q2. Data analysis is ongoing; preliminary analysis suggests high uptake of HIV counselling and testing services in FP clinics and of FP services in the HIV care and treatment centers; results are still pending for outpatient and RMNCH service delivery points. Analysis and report writing will be completed in Q3.
Activity 4: In Y5Q2, HFG neared completion in clarifying scope and preparatory work, and began work obtaining data and developing crosswalks for Vietnam.
• Vietnam: The scope of work (SOW) has four components. The third, an assessment of poor/non-poor, and fourth, assisting in the application for Catalytic Funds, will begin Q3.
• Ethiopia: The MOH continues to request that the spending analysis await the conclusion of their Health Accounts exercise. The Health Accounts report has been drafted and is currently undergoing review by the Health Care Financing TWG. HFG is communicating with the Health Accounts Team on the timeline for finalization and will update once the Ministry informs HFG of the timeline.
• Ghana (new country): Government of Ghana and Mission support achieved. A draft SOW will be reviewed with the MOH at their Health Summit in April and develop detailed timeline.
• Botswana (possible new country): UNAIDS and HFG met and discussed potential areas for USAID/Global Fund technical assistance work in Botswana. Activities will need to be strategic to ensure they align with the unique status of Botswana being so far along in its transition from donor support to country funding and ownership.
Activity 5: No Year 5 tasks are planned as this activity has already been completed. Activity 6: Quarterly report for the SFI can be found under the Nigeria program and Vietnam program.
Activity 7: In Y5Q1, based on the SOW that it received from the client, the findings and recommendation of the scoping mission, and subsequent consultation with USAID Washington and Uganda, HFG identified priority activities and submitted them for client approval. In Y5Q2, HFG has worked with the subawardee (Imperial College) to finalize the subaward, corresponding budget, and SOW.
Activity 8: No further activity is anticipated. Q2 Challenges - Activity 4: Progress continues to be slow due to the non-availability of the SHA data as well as continued hesitation on the part of the Federal MOH to proceed; this latter is due to concerns that the proposed HFG analysis may duplicate other analyses the Ministry intends to undertake.
Activity 7: The slow response of Imperial in sending documents required to finalize the subaward delayed HFG’s progress on the analysis – this prevented HFG from being able to finance Imperial’s participation in the WHO and partners Stakeholders Meeting on Hormonal Contraception and HIV in Johannesburg, South Africa. To facilitate completion of the subaward, HFG has recently had multiple phone calls with Imperial to explain the subaward requirements.
46 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Table 20 provides additional activity-specific updates. TABLE 20. HIV AND AIDS ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 2: Costing and planning tools to support rational strategies to scale up VL monitoring within ART programs Input data into cost- HFG revised parameters for the cost- Some structural/ policy challenges were effectiveness model and revise effectiveness model and ran the model. uncovered in the model (length of model as needed New results were reviewed and cycle/delay) during a preliminary review; feedback was received. model parameters are being revised accordingly for more feedback. Create costing reports to HFG has completed a draft of the Cost The Cost Analysis report will be disseminate results Analysis Report. completed in Y5Q3. Develop a planning tool HFG reviewed the tool with Avenir and HFG and Avenir will finalize a working provided additional pieces of tool and produce a short accompanying information. The forecasting tool is manual by the end of April. being finalized. Publish a policy brief/ scaling-up The policy background piece has been Once the results from the cost- VL monitoring in ART started; results from the cost- effectiveness analysis and costing report resource limited settings effectiveness analysis and costing report are complete, the brief can be are still pending. completed. Perform analysis and modeling One-way sensitivity analyses have been There has been a delay in the scenarios conducted with model parameters. probabilistic sensitivity analysis because HFG would like to make sure the base case is validated first. Write up cost-effectiveness HFG drafted the cost-effectiveness HFG is revising parameters and will run report report and made an internal formal sensitivity analyses again before finalizing presentation to receive feedback on the results and completing the report. report methods and results. Activity 3: Evaluating efficiency of integrated HIV/AIDS and FP services Dissemination Tanzania Study Dissemination Not relevant for this report. Not relevant for this report. Tanzania Prepare for and conduct Endline data collection was completed in The team has cleaned and verified data endline data collection early Q2. received. This task is complete. Complete data analysis and Data analysis is ongoing; a draft report is Will be completed in Q3. produce endline evaluation expected by mid-Q3. report
4. DIRECTED CORE ACTIVITIES: HIV AND AIDS - 47 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 4: Public financial management support to Global Fund/PEPFAR collaboration Identify countries requiring Vietnam and Ghana were added as new Ghana: Health Summit will be support for Global Fund countries to receive technical assistance supportive of the SOW and will not proposals and develop SOWs from HFG. Work plans for both propose changes that would hold up the countries have been approved and both work. country activities are under way. HFG is Botswana: Discussions with key also beginning to plan for a potential stakeholders and USAID Mission will be SOW in Botswana. held to determine the best focus for In Vietnam, HFG worked with the MOH HFG SOW there. to cost the HIV/AIDS strategy through 2020. This was needed to articulate the MOH’s funding needs, and provide some costing information to its funding application to the Global Fund. HFG also received USAID’s approval to assist Vietnam in writing a proposal for funding under the Global Fund’s Catalytic Fund mechanism. In Ghana, HFG shared planned activities with the MOH, the Global Fund Portfolio Manager, DFID, and the USAID Mission. The SOW for Ghana was enthusiastically received by the MOH and HFG has been asked to make a presentation to the Ghana Health Summit regarding the proposed activities by way of gaining broad stakeholder buy- in, in April 2017. Public Financial Management HFG continued to communicate with Progress continues to be slow due to Support to Global the Director of the Federal MOH's the non-availability of the SHA data as Fund/PEPFAR Collaboration in Resource Mobilization Directorate to well as continued hesitation on the part Ethiopia track the timing of SHA data availability of the Federal MOH to proceed due to and to reach agreement on the way concerns that the proposed HFG forward. The Director asked HFG to analysis may duplicate other analyses delay activity implementation until the the Ministry intends to undertake. Health Accounts exercise was complete. The Global Fund and USAID were kept updated on the status and the Global Fund assisted in engaging with the MOH. Provide support to countries in Will begin in Q3. public financial management of Global Fund grants Activity 6: Sustainable Financing Initiative Develop baseline report See country plans in Nigeria and See country plans in Nigeria and Vietnam. Vietnam.
48 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 7: Hormonal contraception and HIV modeling in sub-Saharan Africa Refine existing model of the HFG has worked with Imperial and The slow response of Imperial in contraceptive method mix in USAID to finalize the SOW and refine sending documents required to finalize South Africa the activities and deliverables which are the subaward has stalled HFG’s necessary. progress on the analysis. To facilitate completion, HFG has had multiple phone calls with Imperial to explain the subaward requirements. Recalibrate South Africa model This is expected to start in Q3. to represent Kenya and Malawi
4. DIRECTED CORE ACTIVITIES: HIV AND AIDS - 49
4.3 Malaria Program Objectives - The USAID/President's Malaria Initiative (PMI) recognizes the critical importance of operations research and other types of studies to respond to the changing epidemiology of malaria. These studies help identify cost-efficient ways to improve uptake and scale-up of interventions, measure the impact of interventions on reducing malaria, and improve the broader health system. In Year 5, HFG is working with PMI on three continuing activities, including two studies. Through these activities, HFG expects to generate evidence and improve collaboration, which will in turn:
Help garner increased domestic and international resources for malaria prevention and treatment and;
Support the more effective and efficient use of existing resources. Expected results:
More effective, evidence-based advocacy for domestic and international funding of malaria control based on HFG's impact study from Zambia, cost-effectiveness study from Senegal, and field research guide for malaria programmers.
Greater coordination and collaboration among researchers, implementing partners, and donors interested in economic research through a Community of Practice (COP) that will organize and review recent malaria economic research (MER), identify gaps, and contribute to the evidence base on the economic impact of malaria control and elimination. Year 5 Activities - The following three activities support the above objectives: Evaluation of the microeconomic impact of malaria prevention, diagnosis, and treatment interventions at the household level (ongoing; wrapping up in Year 5).
Assessment of the cost-effectiveness of different malaria prevention, diagnosis, and treatment strategies implemented in areas with seasonal malaria transmission (ongoing). The analysis examines which packages of malaria control strategies have the highest value for money, in order to determine whether the current allocation of funding for malaria is efficient given the distribution of strategies. The results of the analysis will help inform policymakers and malaria program officials on how the level and allocation of resources should be adjusted to maximize impact. The results of this analysis will also supplement the literature: currently no formal concurrent empirical evaluation of "packages of interventions" exist.
Facilitation of a COP around the economics of malaria interventions, and continued dissemination of MER (ongoing). Year 5 Progress Against Objectives - In Y5Q1, HFG received word that the manuscript developed on the Zambia microeconomic study assessing the association between malaria control and microeconomic outcomes had been accepted for publication in Malaria Journal. The study aims to place malaria control strategies within the broader context of poverty alleviation, serving to inform decision making for donors and policymakers. The study was published online on January 5, 2017, and the link was shared with USAID/PMI and posted to the HFG website. In Q1, HFG successfully facilitated a symposium on MER at the ASTMH Annual Meeting, held in Atlanta in November 2016. The panel brought together different stakeholders in a debate-style discussion on how to prioritize different approaches to MER required for financing malaria program scale-up. Prior to the meeting, HFG invited members of the MER COP to join a dry-run of the panel presentation. HFG used input from that session to finalize the panel presentation. One of the feature presentations showcased preliminary results from the cost-effectiveness analysis of targeted malaria prevention,
50 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
diagnosis, and treatment intervention packages in Senegal, where, in certain parts of the country, the opportunity to attain elimination or pre-elimination exists. The panel was well attended and received. Following the panel, HFG focused on drafting the two key deliverables for the cost-effectiveness analysis: an analytical report and journal manuscript. As Year 5 progresses, HFG will continue to increase the engagement of the COP through the continued development of the three key deliverables: 1. A framework for codifying MER, 2. A literature review to support the creation of an "evidence gap map" or similar framework, and 3. A guidance document to support the production and/or use of available data for context-specific research. Table 21 provides additional activity-specific updates. TABLE 21. MALARIA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 4: Cost-Effectiveness of Seasonal Malaria Interventions Draft manuscript The manuscript is currently undergoing The manuscript will be shared with an internal quality assurance review. PMI for comment following completion of internal quality assurance. Activity 5: Community of Practice for Malaria Economics Research Produce guidance document for This task is ongoing. A draft outline for Once the literature review is malaria programmers, the guidance document has been finished, the team will revise the policymakers, and funders on the completed. outline and flesh out more detailed production and use of available sections of the guidance document. data for context-specific MER Create COP including participants In Q2, HFG collaborated with COP The team expects to hear about the from academic institutions, members on a symposium submission to status of the symposium submission national research organizations, the ASTMH meeting in November 2017. in May. HFG will continue regular PMI, National Malaria Control The panel will highlight the increasing communication with the ARMPC Programs, and MOH to share need to collaborate effectively across co-chairs to share progress and knowledge and expertise and stakeholder groups in the MER ensure effective collaboration. support the creation of technical community in the context of pre- resources elimination/elimination. The panel is diverse, consisting of four COP members representing different organizations (Global Fund, the Mahidol Oxford Tropical Medicine Research Unit (MORU), PATH's Malaria Control and Elimination Partnership in Africa (MACEPA), and Kumasi Centre for Collaborative Research in Tropical Medicine) and perspectives (donor, researcher, implementer/user of MER). HFG also attended the first meeting held by the Roll Back Malaria Advocacy and Resource Mobilization Partnership Committee (ARMPC) to learn more about the group and how the COP could collaborate.
4. DIRECTED CORE ACTIVITIES: MALARIA - 51 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Malaria Economics Framework Based on internal discussions, the The framework will be revised framework developed and shared with based on key findings from the MER COP members has been acknowledged lit review. as a useful tool, but it will need to be reworked in order to display areas of concentration/ duplication/ gaps in MER in an aesthetically-pleasing way. Literature review for MER This task is ongoing. After finalizing the The team expects the lit review will list of keywords, the team generated the be completed in Q3. list of relevant articles and finalized the data abstraction spreadsheet. Information abstracted will be used to 1) categorize the literature (according to the MER Framework) and 2) inform the development of the guidance document on the production and use of data for MER.
52 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
4.4 Maternal and Child Health Program Objectives - Across its priority countries, USAID focuses on key evidence-based interventions to address the primary causes of newborn and child mortality (oral rehydration treatment and zinc supplementation, immunization, micronutrient supplementation, malaria prevention and treatment) as well as to increase uptake of safe motherhood interventions (birth spacing, antenatal care, skilled birth attendance, clean deliveries, and postpartum counseling). The HFG project links its technical assistance and analytic activities directly to these key initiatives and projects, identifying opportunities to leverage health financing and governance strategies to enhance demand for, quality and effectiveness of, and access to priority maternal and child health (MCH) interventions. HFG's Year 5 MCH portfolio supports the following specific objectives:
Generate stronger evidence on the full costs of saving a woman's and newborn's life
Increase the capacity of country decision-makers to use costing and planning tools to increase coverage of MCH services;
Generate stronger evidence on the role of provider payment systems in improving MCH service quality; and
Generate evidence on the impact of HSS interventions on health outcomes. Year 5 Activities - HFG's work plan for Year 5 comprises the following five activities: 1. Costing packages of interventions to mitigate the "three delays" in accessing maternal and newborn health care: Improving maternal health outcomes has focused on reducing the three delays: (1) delays in deciding to seek care, (2) delays in reaching needed maternal care at a facility, and (3) delays in receiving high-quality, respectful, and timely maternal health care. The objectives of this activity are to 1) retrospectively estimate the unit costs of selected interventions designed to mitigate the three delays; and 2) estimate the cost per death averted (maternal deaths and newborn deaths within first two days) using secondary data. The results of this study are expected to inform global partners, ministries of health, and other stakeholders' planning and budgeting processes for maternal and newborn health interventions that address the three delays and avert maternal and newborn deaths. 2. Building capacity for OneHealth Tool (OHT) to Support Cost Analysis in an EPCMD Country: The OHT for costing and strategic planning can be used to analyze health systems investments needed to achieve maternal, newborn, and child health (MNCH) goals in countries that are working to bring priority interventions to scale. In Bangladesh, the Ministry of Health and Family Welfare (MOHFW) requested assistance with costing the newly revised Essential Service Package (ESP), an integrated package of services including MNCH services. This activity aims to improve the capacity of country officials in Bangladesh to adequately cost the ESP and use the estimates for policy and planning. This activity is co-funded with Bangladesh field support. For more details, see section 5.2.2. 3. Using provider payment to improve quality of maternal health services: Countries are increasingly recognizing the importance of good quality care for achieving health targets, and several are exploring ways in which financial payments and incentives to health care providers can not only improve access to services, but also improve the quality of those services. Under this activity, HFG will review and document country examples of privately or publicly sponsored arrangements that link financial payments to providers with the quality of maternal health care, and analyze the mechanisms through which these incentives influence provider behavior. The aim is to derive practical lessons that would guide other countries to design and implement similar schemes.
4. DIRECTED CORE ACTIVITIES: MATERNAL AND CHILD HEALTH - 53 4. Marshalling the evidence: Documenting the HSS expert review panel for EQUIST: In the past few years, USAID's "Marshalling the Evidence for HSS" initiative has aimed to compile and synthesize available evidence on the effects of HSS strategies on coverage of priority health interventions and on health status. Relatedly, UNICEF has developed "EQUIST," a health system modeling tool designed for planning, priority setting, and resource allocation in low- and middle-income countries. EQUIST helps planners and policymakers select strategies to reduce mortality and morbidity and links automatically with the Lives Saved Tool (LiST) to calculate the effects of various strategies on maternal and child deaths averted. In 2015 and 2016, the HFG project collaborated with UNICEF to convene an expert panel, aiming to review and incorporate the available HSS evidence into the EQUIST tool (see activity 10 under Cross Bureau for more information). The expert review process, and the preparations for the expert meeting, generated a wealth of supporting information. Under this activity, HFG will prepare the supporting documentation for circulation and use by the global HSS community, including country practitioners. The information will also greatly facilitate any future efforts to update and refine the consensus estimates around HSS. 5. Resource tracking for MCH: Accurately tracking resources for MCH is critical to ensure sufficient and effective allocation of health resources. With the roll-out of WHO's updated System of Health Accounts (SHA) 2011 framework, countries conducting Health Accounts estimations are seeking guidance on tracking health sector resources - particularly within a specific priority health area, such as MCH - using this new framework. In collaboration with the WHO, HFG is (a) developing practical guidance materials on MCH resource tracking for countries applying the SHA 2011 methodology, and (b) piloting the MCH guidance in a USAID-identified priority country that is conducting a SHA 2011 estimation. Year 5 Progress Against Objectives - In Q1, HFG continued to make progress on all activities, and received approval to begin work on the new "Three Delays" costing analysis and the EQUIST documentation activities described above. At the end of Q1, HFG submitted a revised Year 5 work plan for review and approval. Upon approval, all funds for MCH will be successfully programmed. HFG is finalizing two reports that document country examples of mechanisms that link financial payments to providers with the quality of maternal health care, and analyze the mechanisms through which these incentives influence provider behavior. The reports will be disseminated in Q2. HFG also finalized a brief on maternal health spending in Zambia, which will be disseminated in Q2. Table 22 provides additional activity-specific updates. TABLE 22. MATERNAL AND CHILD HEALTH ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Costing Packages of Interventions to Mitigate the “Three Delays” in Accessing Maternal and Newborn Health Care Develop concept note with The concept note has been completed and The concept note may need further dummy results tables adapted for Zambia. adaptation for Uganda. Develop study protocol, data The study protocol for Zambia has been Study protocols likely will need collection instruments written and circulated. Feedback from adaptation to Uganda. USAID has been received. Data collection tools are pending the scoping visit to Zambia.
54 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Scoping visit to 1 or 2 countries Scoping visit to Zambia has been scheduled for the first week of April. Hire of local consultant to lead Request for expressions of interest have data collection activities been advertised and CVs received in Zambia. Likely interviewing will take place during the scoping visit.
4. DIRECTED CORE ACTIVITIES: MATERNAL AND CHILD HEALTH - 55
4.5 Population and Reproductive Health Program Objectives - HFG supports USAID's contribution to meet the global goal of 120 million additional family planning users by 2020 that was established during the London Summit on Promise Renewed, and resulted in the global initiative Family Planning 2020. HFG focuses on strengthening health systems, with a particular focus on resource tracking for policy and programmatic decisions and strengthening USAID partner international nongovernmental organizations (NGOs) to deliver family planning services through implementation of performance-based incentives. The Global Financing Facility (GFF) presents a potentially strategic opportunity to embed reproductive health priorities into the strategies that countries and development partners will jointly commit to achieving and HFG will provide assistance to help countries incorporate family planning into GFF investment cases. Year 5 Activities - HFG will achieve the program objectives by:
Assessing the performance-based financing (PBF) initiative of the International Planned Parenthood Federation (IPPF) and recommendations for how to strengthen it. For PBF to achieve its full potential, leadership, guidance, and vision for PBF needs to emanate from the IPPF Senior Management Team; be owned by IPPF regional management teams; and be effectively communicated as a federation-wide strategy. This activity will provide evidence of the performance impact of its payment system on its Member Associations (MAs) and provide recommendations on how to revise and strengthen its impact on the performance of its MAs.
Developing and testing a methodology to help countries develop the investment case for including family planning in their GFF initiatives
Continuing to provide technical assistance in applying the SHA 2011 framework to track family planning and use these results to improve family planning programming. Year 5 Progress Against Objectives - In Q1, the final assessment and recommendation report, Strengthening Performance with the IPPF Performance Based funding Model: Evidence and Recommendations, was completed and shared with the IPPF senior management team and with USAID. HFG presented the findings and recommendations to the IPPF Senior Management Team through the SIFPO project titled "Sustainable Networks," and to USAID in November 2016. Evidence from this assessment indicates that PBF is having an impact. IPPF is considering the recommendations and may appreciate further support from HFG. Efforts to begin designing a GFF priority setting methodology began in Year 4. Continued uncertainty about whether USAID Missions would like support on integrating family planning into the GFF platforms in their countries imposed a delay in programming these funds. The PRH office is now considering changing the scope for this activity to focus on incentives for quality when including family planning in RBF initiatives. HFG is exploring participation in a community of practice that will focus on this issue and on determining a product and or process that will contribute to global impact. HFG continued to support Burkina Faso with analyzing its family planning spending to facilitate decision making for family planning policymakers
56 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Table 23 provides activity-specific updates. TABLE 23. POPULATION AND REPRODUCTIVE HEALTH ACTIVITY DETAIL
Critical Assumptions/ Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/ Follow-up Steps Activity 1: Technical assistance to FP2020 Working Groups on Expenditure Tracking Provide technical assistance to In Q2, HFG developed a policy brief with understand expenditure tracking the Burkina Faso MOH using family of international financial planning data collected through the Health commitments Accounts. The brief highlights key policy implications of the findings and will help family planning decision makers identify resource mobilization or make needed resource allocation decisions. We are currently awaiting the ministry's communications team to approve the final brief before it is disseminated. Activity 2: Methodology for prioritizing family planning services for GFF funding Develop draft methodology to Postponed. The PRH office is now help countries establish considering changing the scope for this priorities for investments in activity to focus on incentives for quality family planning/ reproductive when including family planning in RBF health supported through the initiatives. HFG is exploring participation GFF platform in a community of practice that will focus on this issue and on determining a product and or process that will contribute to global impact.
3. DIRECTED CORE ACTIVITIES: POPULATION AND REPRODUCTIVE HEALTH - 57
4.6 Tuberculosis Program Objectives - The objective of HFG's Core TB activity is to improve the relationship between health financing and TB service delivery through strategic health purchasing - better targeting of general revenue health budget funds to priority TB services and populations. Scale-up and sustainability will be increased by ensuring that service delivery interventions are designed, developed, and implemented directly linked to and consistent with health financing and governance improvements. Year 5 Activities - Activity 1: Country-level interventions: In Year 5, country implementation support will focus on regional workshops and in-country technical assistance to selected USAID TB priority countries, to (a) increase understanding of the importance of TB strategic purchasing among decision-makers in USAID TB priority countries; (b) foster implementation of small changes in provider payment or public financial management (PFM) to improve efficiency and effectiveness of TB services building on the purchasing continuum and lessons learned to date including improving TB provider payment systems in Kyrgyzstan and better matching TB plans and budgets in Malawi (including introduction of the planning and budgeting approach or tool developed by HFG, as applicable).
Activity 2: Global Indictor Activity: By definition, all USAID TB priority countries are included in the TB global indicator activity. During Year 4, HFG collected data on 27 indicators for all 23 USAID TB priority countries and developed a user interface to allow for easy comparison of indicator data across countries. During Year 5, HFG will undertake a quality assurance (QA) process to verify country indicator data and will finalize data presentation through a report and continued work on the user interface. HFG will also disseminate country indicator data (see Activity 3, below).
Activity 3: Dissemination: In Year 5, HFG will disseminate information aimed at fostering understanding of the link between provider payment and TB service provision. Year 5 Progress Against Objectives - To ensure high-quality implementation of the Year 5 activities, in Q1 HFG's TB strategic purchasing team established an advisory group to support indicator analysis and regional workshop development. This team includes Laurel Hatt (Abt), Rena Eichler (Broadbranch), Chelsea Taylor (R4D), Sheila O'Dougherty (Abt/Activity Quality Advisor), and Barton Smith (practicing MD / independent consultant with extensive service delivery and health systems experience connected to TB). Additionally, health insurance expert Jeanna Holtz (Abt HFG and SHOPS Plus projects) is being consulted on relevant issues. During Q1, HFG moved the Global Indicator activity forward, through submission of a formal draft of indicators to USAID including not only data on 27 indicators for 23 high burden TB countries, but also data sources, functions, definitions, and measurements (methodology) for each indicator. HFG engaged in discussions with USAID on the indicators and how to use the data collected; initiated a quality assessment of the data collected; and engaged in discussions on indicators and analysis with the advisory group, as well as with WHO's TB M&E team in Geneva. Toward development of the regional workshop model, HFG developed initial country selection criteria and agreed with USAID on workshop objectives, namely, to help national TB programs be heard in country's provider payment reforms, and ensure that strategic purchasing mechanisms developed for the country address TB in a way that makes sense. HFG's strategic purchasing team has been discussing the workshop approach with the team of advisors and toward presentation of a detailed concept to USAID for comment later in the year.
58 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
In Q2, HFG disseminated the cost accounting and discharged patient database approach developed for Kyrgyzstan and Ukraine. Through leading a session and co-facilitation of the six-day WHO/Euro-TB REP Project TB and HSS course in Barcelona in October, HFG was able to gain interest and understanding of the model and of shifting TB hospitals in the former Soviet Union (FSU) to output-based financing. The course was attended by 44 participants representing 12 former Soviet and East European countries. Based on the technical quality of the work presented by HFG, the Global Fund, WHO/Euro, and the TB- REP project leadership have expressed interest in further collaboration and are eager to leverage HFG technical capacity for future collaboration in the FSU region. HFG chaired a satellite session on strategic purchasing at the Union Conference of Lung Health (Liverpool, UK) in October. This satellite session was one of the few times strategic purchasing has even been mentioned at the world's largest meeting of the TB community in 2016. The talk show-style session focused on presentation of the Kyrgyzstan and Ukraine TB hospital payment reform models as a case study, while also addressing broader issues of provider payment for a TB audience. Additionally, at the Health Systems Research conference in Vancouver in November, HFG presented a poster on the cost accounting and discharged patient database analysis conducted in Kyrgyzstan. During Q2, HFG presented USAID with specific concept notes for the Asia and FSU workshops. Based on discussion with USAID, it was decided to hold a single, shorter Asia-Africa combined workshop in June 2017. An FSU workshop is tentatively planned for September 2017. HFG has been working on agenda and approach for the Asia-Africa workshop. HFG finalized the strategic purchasing indicator database data, conducted QA, presented the product to USAID, and made the updated online interactive interface/database available to USAID for further review. HFG also developed and refined a country-focused indicator dashboard, and presented it to the USAID TB team for discussion. Q2 Challenges - After an interesting discussion session with USAID, HFG developed and submitted a concept note to USAID for a new piece of work under the HFG TB strategic purchasing activity. Entitled "High Level TB Briefers: Addressing the Cost of Inaction," HFG proposes to conduct analysis using secondary data toward high-level advocacy of increased domestic resource mobilization for TB. Targeting leaders and decision-makers in high-burden TB countries, this new area of work proposes three key areas, as outlined below. HFG will prepare analysis and provide a set of country-specific recommendations for each of these three areas, for a sub-set of high-burden TB countries.
Documenting and quantifying the rationale for investing in TB: This part of the work will detail the drivers of the disease in different parts of the world and link the drivers to the standard justification for public actions (public finance and welfare economics - the language of ministries of finance). This would include strong arguments for a robust role of government in addressing TB, including links to poverty and social vulnerability, and issues around the public good nature of communicable diseases, the quantification of social externalities related to TB, the need to work across sectors and with the private sector, and the need to address behavior change for both patients and providers.
From rationale to action: This part of the work will identify the most effective tools in the fight against TB to highlight the multisectoral best-buys against TB. Simply justifying a role for the public sector does not automatically identify the nature of that role. Governments possess a set of tools that can be used to advance public welfare, including financing, provision, mandating, taxation, guidance, laws, regulations, and research.
4. DIRECTED CORE ACTIVITIES: TB - 59 Health systems and TB: TB is an excellent candidate by which to measure the success or failure of the health system in responding to population needs. This part of the work will help point the way for using the different policy instruments in health such as financing, provider payment, organization, public-private partnerships, regulation, and behavior change, to address this important public health issue. Through highlighting effective use of these policy instruments, HFG will provide suggestions on ways that health systems can effectively adapt to address TB, in light of the risks of development of drug resistance. Q2 Additional Information - Carrying out multi-country activities that require both USAID/Mission and country partner linkages has proved challenging with Core TB funding. At times, getting agreement on which countries to involve, or establishing the initial linkages and contacts with the Missions/country partners/global counterparts creates bottlenecks in HFG moving forward with Core TB activities. For this reason, in-country assessments were removed from the work plan after only three were conducted in earlier years. However, the same types of bottlenecks were also encountered in Q2 related to the regional workshops, and if not resolved, they threaten HFG's ability to conduct the Asia-Africa regional workshop planned for Year 3. Table 24 provides activity-specific updates. TABLE 24. TB ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Country Interventions/ Workshops and Follow-up Technical Assistance on Provider Payment for Improved TB Services Identify countries In Y5Q2, HFG met with USAID to finalize the HFG is waiting for USAID to clarify list of countries best suited for workshops. protocol on reaching out to USAID HFG and USAID have agreed that a mix of Missions and national country countries can benefit from a joint-Asia Africa partners (national TB programs, workshop. Target countries for the Asia- MOHs, MOFs, health insurance Africa workshop include four Asian countries funds) in order to move forward (Cambodia, Indonesia, Philippines, and with engaging countries in Myanmar) and up to five African countries preparation for the workshop. (Kenya, Nigeria, South Africa, Tanzania, and Uganda). While this country list is very diverse, and includes countries with varying levels of strategic purchasing experience, all of the countries have interest in the topic and some level of provider payment reform happening (or in the planning stages) in the country. After discussion, it was agreed with USAID not to expand the country list for the FSU workshop beyond the USAID TB priority countries in the FSU, which include Ukraine, Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan. Design workshops HFG has drafted an overarching agenda for a now two-day workshop and is working on presentations and approach for the Africa- Asia workshop. Design for the FSU workshop will begin in Q3.
60 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Three regional workshops Planned for Q3 and Q4: conducted • Based on meetings with USAID this quarter, HFG is planning a single two-day Africa-Asia workshop to be held in Geneva following the WHO STAG-TB meeting in June 2017. • The FSU workshop will remain separate and is planned for September. Provide in-country technical Planned for Q4 and Year 6. As part of the assistance to support workshop, participants from each country will implementation of specific devise an action plan for follow up steps. HFG provider payment or PFM will provide monitoring and mentoring and interventions, to allow for technical technical assistance as needed to improved resource allocation support countries in achieving their action and improved TB outcomes plans. Activity 2: Global Indictor Presentation and Analysis Update country indicator data Indicator data have been collected for based on new information 24 countries and HFG has carried out a made available from in- QA process for the data. country assessments (carried out previously) Finalize user-friendly HFG has developed on online interactive user presentation format interface for the data. Additionally, HFG has developed a one-page country dashboard with indicator information and explanations. This format was presented to USAID’s TB team for discussion at a USAID TB staff meeting in March. Conduct QA on data QA and data validation were carried out in Q1 and Q2. All sources are cited and linked in the indicator table. Conduct data analysis as HFG will discuss with USAID whether any Bivariate analyses conducted in Q2 requested by USAID further analysis is desired and will continue to revealed inconclusive results. Even discuss final deliverables and uses for these before this analysis was conducted, data. HFG and USAID had discussed the difficulty of this type of analysis across countries. Activity 3: Dissemination of TB Strategic Purchasing Work Disseminate indicator data During Q2, HFG drafted the country During Q3, HFG agree with USAID dashboards and presented them to USAID for on desired final deliverables and discussion and review. This is the second completion of the indicator activity. deliverable, along with the online indicator Potential deliverables are interface/ database presented to USAID contribution to the WHO TB earlier. HFG will incorporate feedback into annual report and contribution to these before starting its next deliverables (see the USAID justification to right). Congress.
4. DIRECTED CORE ACTIVITIES: TB - 61 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Document and disseminate Now that in-country assessments methodological approach to have been discontinued, need to in-country assessments revisit with USAID whether indeed there is a demand from national partners/other donors for this methodology.
62 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5. FIELD SUPPORT ACTIVITIES
The section provides a summary of progress made on activities in the 24 countries and with the three regional USAID bureaus (Africa, Asia, and Eastern Europe and Eurasia) with which HFG works.
5. FIELD SUPPORT ACTIVITIES – 63 5.1 Africa 5.1.1 Africa Bureau Program Objectives – Overall Objective: Overall objective: Improve capacity and country commitment to implement health financing reforms within the African region. Specific Year 5 objectives: Increased capacity for health financing reforms in the African region
Greater understanding of the funding of the social sectors from domestic sources and opportunities for more efficient resource utilization at different administrative levels to improve value for money.
Increased availability of demographic and family planning information, leading to improved strategic planning in those areas.
Greater use of digital health applications to improve country health systems. Year 5 Activities - Continued work on improving efficiency in allocation and utilization of resources in selected countries in order to generate policy and program options for USAID to implement, and to improve efficiency of resource allocation and utilization at different administrative levels in order to improve value for money
Analytical support to Africa Bureau Office of Sustainable Development (AFR/SD) for assessment and strategic project planning
New: World Bank Flagship course partnership
Proposed support to the 2017 African Digital Health Summit Year 5 Progress Against Objectives - Domestic Allocation Study: In early September 2016, USAID and HFG agreed that HFG would continue to work with the Ghana Center for Democratic Development (CDD) to build the capacity of its staff in political economy analysis (PEA) so that they could complete the final report on the PEA of social sector resource allocation. A new sub-award was approved that will allow CDD to revise the final report to include a section on comprehensive PEA and to make any necessary edits to the overall resource allocation report backstopped by HFG. In October 2016, HFG held a three-day training course to build CDD capacity; it transferred basic knowledge and skills needed to do a PEA and in particular on how to structure the analytical process to lay the groundwork for revising the current draft. HFG also conducted a second round of key informant interviews to inform report revision. As of March 2017, the macro/political economy section of the report has been thoroughly revised. However, it had become evident that the CDD does not have capacity to complete the final section revisions and editing. As a result, USAID and HFG will finalize the report. Both the Africa Bureau and HFG are making extensive revisions to the health, education, and comparative sections.
64 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
The preliminary results include:
Democratic competition and the fight for swing voters create strong pressure to improve and extend programs. Consolidation into a de facto two-party system and programmatic efforts by the New Patriotic Party to distinguish itself from the National Democratic Congress in the 2000 election set in motion a positive dynamic. Although the fiscal planning for health insurance was poor, no one is considering retreating to cash and carry. Understanding how this two-party dynamic unfolds has wider relevance to USAID work in other countries.
The national health insurance grew from this pressure but voters do not have the information to influence or know what to do technically to fix it. Experts say the National Health Insurance Scheme (NHIS) is a fiscal emergency. But the new government announced a cabinet with 110 ministers, casting doubt on whether it grasps the extent of the fiscal crunch, which the IMF says predicts will take 10-15 years to resolve.
Raising VAT and diverting a fraction of oil revenue to fund the NHIS have been suggested but these are short-term solutions and inadequate if Ghana reaches its goal of enrolling 60 percent of the population in the NHIS. Aside from the fact that oil revenue is less than expected because production targets are not being met, that revenue was to have funded large long-term infrastructure. Instead, leaders have been using it for many small projects and recurrent costs. It is unclear how politically feasible it would be to shift spending to health or education.
The new government has vowed to offer universal secondary education but it is unclear how they can pay for this amid austerity and still unresolved energy production/electricity problems. Analytical support to AFR/SD: Avenir Health started work on a new round of analysis and projections of quintile age-structure differentials for five new sub-Saharan Africa countries selected by the Africa Bureau (Ghana, Senegal, Malawi, Madagascar, and Ethiopia). The first country analysis is for Ghana, with quintile projections using DemProj and FamPlan expected to be available for review in early January 2017, followed by application of the Lives Saved Tool (LiST) model to compare the poorest and the richest quintiles, to develop the argument that investing in family planning helps reduce maternal and child health (MCH) costs to the health sector. In addition, Avenir Health updated the paper on Inequity and Fertility by expanding the literature review, preparing new projections using newly available DHS data, and focusing the analysis on a comparison of the four focus countries (Kenya, Nigeria, Rwanda, and Uganda) instead of having separate sections analyzing each country's results. In March 2017, Avenir Health completed draft policy briefs for Kenya, Rwanda, and Tanzania. The briefs showed how investing in family planning reduces MCH costs, as do potential education-work participation linkages with age at marriage, fertility and family planning linkages. Avenir also completed family planning and fertility projections for six new sub-Saharan Africa countries selected by the Bureau (Ethiopia, Ghana, Madagascar, Malawi, Senegal, and Tanzania) for a new round of analysis and projections of quintile age-structure differentials. World Bank Flagship Course Partnership: In Y5Q2 the World Bank and USAID Africa Bureau agreed to support the initial implementation of an Africa Flagship Training Program. The proposed Flagship Program will help establish a long-term partnership within the African region for capacity building and policy dialogue. It is expected that the Flagship Program will help build a consensus among stakeholders on how to proceed with design of health system reforms and implementation. For this purpose, both USAID and the Bank, together with WHO and other partners, aim to support in-country policy dialogue, contribute to building capacity for policy making and implementation, and strengthen partnerships through selected tailor-made Flagship courses.
5. FIELD SUPPORT ACTIVITIES: AFRICA BUREAU - 65 Q2 Challenges - Ghana CDD does not have capacity to lead the revision and editing of the final report on Resource Allocation and Utilization in the Health and Education Sectors of Ghana. As a result, the HFG and USAID will do this in consultation with Ghana CDD. This, along with the presidential election cycle, delayed the completion of this work. Table 25 provides activity-specific updates. TABLE 25. AFRICA BUREAU ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Study on Allocation and Utilization of Domestic Financial Resources Across Sectors in Selected Countries Prepare first country draft As of March 2017, the macro/ political Ghana CDD has not been able to assessment report economy section of the report has been finalize the second draft report due thoroughly revised. The health, education, to capacity constraints and and comparative sections are going through presidential election-related delays. extensive revisions by both USAID Africa HFG with the support of USAID’s Bureau and HFG. Africa Bureau has taken on the task The most useful preliminary conclusions of producing the report from the report are noted above. incorporating comments of both USAID and HFG-HQ. Activity 2: Analytical support to the AFR/SD for assessment and strategic planning Provide analytical support to In March 2017, Avenir Health completed Avenir explored the possibility of the AFR/SD for assessment and draft policy briefs for Kenya,Rwanda, and submitting the final Inequity and project planning (funding for Tanzania, along with an exploratory analysis Fertility paper for publication. Avenir) of Ghana data to prepare age at marriage, However, due to strict journal health, education, and employment rules, papers that have been tabulations by quintiles. Avenir also previously printed and disseminated completed family planning and fertility (2016 ICFP in Bali) are not eligible projections for 6 new sub-Saharan African for publication. countries selected by the Bureau (Ethiopia, Ghana, Madagascar, Malawi, Senegal, and Tanzania) for a new round of analysis and projections of quintile age-structure differentials. Activity 3: World Bank Flagship Course Partnership Planning and Scoping The World Bank and USAID Africa Bureau Preliminary discussions are to have agreed to support the initial support West Africa with one implementation of an Africa Flagship Training English and one French subregional Program. Flagship course. Discussions are currently underway to determine the regional focus, scope, and timing of the courses. Activity 4: Support to Africa Digital Health Summit Define HFG Scope of Work HFG is working with USAID AFR/SD to Planning for this summit by USAID define areas of support. East Africa is scheduled to begin in April 2017.
66 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.1.2 Angola Program Objectives - Activity 1: National Plan for Health Development (PNDS) Monitoring and Evaluation (M&E) Plan: The MOH (Ministerio de Saúde, MINSA) must be able to demonstrate the effectiveness of the PNDS to a variety of stakeholders, many of whom are outside the health sector, in order to secure government financing for the PNDS. A strong operational plan for M&E of both the programmatic and financial implementation of the plan is critical to ensuring that MINSA can manage PNDS implementation and make the case for continued public investments in the health sector. Expected Results: The output of this technical assistance is a plan to monitor and evaluate the PNDS, both programmatically and financially. The plan will be practical, with clearly outlined steps for how it can be operationalized. The M&E plan will strengthen accountability for program performance and budget execution for PNDS at the central, provincial, and district levels.
Activity 2: Support Implementation of Health Accounts: There is an urgent need to increase MINSA's capacity to monitor government financing of the PNDS and make informed decisions based on reliable information on the quantity of financial resources used for health, their sources, and the way they are used. Health expenditure tracking is internationally recognized as critical information for developing countries such as Angola to improve efficiency, equity, and financial sustainability in the health sector as well as understanding resource allocation across priority health programs. Angola has so far undertaken resource tracking exercises such as: a public expenditure review (2007), assessing the magnitude and flow of public spending, and household surveys to provide insight into household health seeking behavior and spending on health (living conditions and household survey, 1995; survey of households’ income and expenditure, 2000/01; and multiple indicators and cluster sampling surveys, 2000–01). While these resource tracking exercises provided policymakers with critical information about the respective resource flows, they have not provided a full understanding of the magnitude and flow of resources in the health sector. Additionally, the available data are not current and do not serve as a baseline for the country's strategic plan, the PNDS 2012–2025. Year 5 Activities - Activity 1: PNDS M&E Plan: By the end of Year 4, HFG had produced a full draft of the M&E plan, including a list of Key Performance Indicators (KPIs) to measure the progress achieved through the PNDS. In addition, HFG conducted a rapid assessment of public financial management (PFM) processes and systems affecting financial monitoring of the PNDS. In Year 5, HFG will finalize the PNDS M&E plan and build capacity of MINSA staff to implement the plan. Further, HFG will provide targeted institutional reform support to either a new MINSA department created to conduct M&E or to an existing MINSA unit expanded to take responsibility for M&E requirements. Throughout the process, HFG will continue to collaborate closely with the PNDS M&E Working Group, which includes representatives from across MINSA, especially GEPE and Finance Departments. Specific Year 5 Activities:
• Finalize M&E plan: based on feedback from the PNDS M&E Working Group on the current draft, HFG will review and finalize the M&E plan. The plan will include clear recommendations and next steps to enable effective implementation of the plan.
• Build MINSA capacity to implement the M&E plan: based on the final recommendations and next steps from the M&E plan and MINSA capacity-building needs, and in consultation with USAID, HFG may provide targeted training to MINSA staff to build their M&E skills.
5. FIELD SUPPORT ACTIVITIES: ANGOLA - 67 • M&E institutional reform: The PNDS M&E plan will outline the MINSA institutional structures necessary to manage the PNDS M&E plan. HFG will provide targeted institutional reform support to either a new MINSA department created to conduct M&E or to an existing MINSA unit expanded to take responsibility for M&E requirements.
Activity 2: Support Implementation of Health Accounts: HFG will continue to provide technical assistance and guidance to the MINSA Health Accounts team to undertake its first Health Accounts exercise using the SHA 2011. The exercise will be adapted to the Angolan context (through the classifications and the distribution keys) and use the (existing) Portuguese version of the Health Accounts Production Tool (HAPT) and the Health Accounts Analysis Tool (HAAT). In Year 3, HFG provided strategic support to start laying the groundwork for Angola’s first Health Accounts exercise. HFG supported the MINSA to develop and update the Health Accounts work plan and the data collection work plan, as well as to develop and validate a list of Health Accounts indicators. In addition, HFG held policy discussions with stakeholders including the minister of health, to advocate for the use of the latest Health Accounts framework (SHA 2011) in doing the Health Accounts exercise. In preparation for data collection, HFG developed a household expenditure questionnaire to be included in the upcoming DHS led by Angola's National Institute of Statistics (INE). However, in July 2015, the process for preparing for the Health Accounts stalled, due to competing priorities at MINSA and the uncertainty that the household expenditure survey would take place. In July 2016, USAID attended a meeting of the new Health Finance Working Group responsible for developing a national health financing strategy and for conducting Health Accounts. HFG will liaise with WHO, which will also provide technical assistance for Health Accounts, and with the new MINSA point-of-contact in the Health Financing Working Group in order to resume this activity. Through this activity, the HFG technical assistance will help develop the capacity of the Health Accounts team to gradually institutionalize the exercise and use the data to monitor the progress of the PNDS. The project will work on building the Health Accounts technical team capacity on the updated framework and the use of the HAPT, a software application developed by WHO and HFG to streamline the Health Accounts data collection and analysis. HFG will also provide technical guidance and backstopping to the country Health Accounts team during the key stages of the exercise, specifically during the analysis and generation of key expenditure tables. Finally, the project will backstop the team in interpreting the results, developing a brief report to inform the country’s policy and plan and disseminate the key results to stakeholders. To facilitate the institutionalization of Health Accounts, the project will work with the Health Accounts team to identify and, where relevant, recommend implementation mechanisms to enable routine (regular) data collection from the different data sources for health spending data (i.e., government, donors, NGOs, private and public insurance). Year 5 Progress Against Objectives - Activity 1: PNDS M&E Plan: During this quarter, HFG finalized the third draft of the PNDS M&E plan based on the feedback and discussions held during the October-November 2016 visit to Angola. Based on the next steps outlined in the plan, HFG will travel to Angola in Q3 to provide technical assistance to GEPE and MINSA to continue to lay the foundations for implementing the plan.
68 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Activity 2: Support Implementation of Health Accounts: In March 2017, the HFG consultant providing technical assistance to MINSA on Health Accounts traveled to Angola to launch the Health Accounts exercise. During the trip, the consultant led a three-day workshop for the MINSA Health Accounts team on the Health Accounts process, and worked with MINSA to begin data collection. In Q3, HFG will collaborate with the WHO to carry out the second portion of the workshop, which covers the HAPT, continue the data collection process, and begin data analysis. Table 26 provides activity-specific updates. TABLE 26. ANGOLA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: PNDS monitoring and evaluation plan Investigate financial execution data Completed in Year 4. availability at national, provincial, and district level and budget procedures Draft plan for monitoring and evaluating Completed in Year 4. PNDS Revise draft M&E plan based on MINSA Completed in Q2 Year 5. feedback Activity 2: Support implementation of Health Accounts (HA) Stakeholders briefing meeting / short Completed in Q1 Year 5. training (outline all the HA process) Establish steering committee for HA and Committee already exists. HA technical team (if not available) Train HA team on the updated SHA Part of this training completed Originally, the March 2017 workshop 2011 framework and use of the HAPT, during March 2017 trip. was planned to cover the whole HA use this opportunity to develop a process; a WHO consultant was to lead detailed work plan, data collection plan, the HAPT training sessions. and customize the production tool Unfortunately, WHO told HFG at the last minute that they were not able to execute their consultant's contract by the workshop dates. Therefore HFG had to adjust its plans for the trip, carry out only part of the training, and begin as much data collection as possible without the HAPT training. The WHO consultant has since been hired and is now scheduled to travel to Angola in May to deliver the HAPT training. HFG will plan a trip to coincide with the WHO consultant's to continue the work in collaboration.
5. FIELD SUPPORT ACTIVITIES: ANGOLA - 69
5.1.3 Benin Program Objectives - HFG seeks to support the government of Benin to appropriately and effectively plan and finance their health strategy in order to achieve universal access to health coverage. Year 5 Activities - HFG Benin provided strategic support to the completion of the 2012 National Health Accounts (NHA) exercise, using the SHA 2011 methodology. In Year 2, the HFG team supported the collection of expenditure data, provided technical assistance for appropriate data mapping, and assisted the Beninese Ministry of Health (MOH) in disseminating the results of the 2012 NHA exercise at the annual Journée de la Santé on April 29, 2014. Last year, HFG supported the MOH in the second round of Health Accounts, for 2013 and 2011. A new tool (Health Accounts Analysis Tool, HAAT) was introduced to the MOH. This tool will assist the Health Accounts team to do a time series analysis and data analysis to support the use of evidence for policymaking within the Beninese health system. While the MOH NHA team's capacity has improved, a series of actions to further enhance sustainability and country ownership were documented and shared with USAID/Benin. HFG Benin will continue to work with the MOH to provide targeted support including exploring mechanisms for routine health expenditure data collection to improve the development of allocation formulas for target and non- targeted spending and the mapping of all activities. To support this, HFG is proposing to develop a monitoring and evaluation (M&E) classification tool that the MOH can use to institutionalize the Health Accounts mechanism and facilitate the annual review of the National Health Strategic Plan (PNDS). HFG supported Benin in developing the health system activities classification (PNDS classification) based on the previous PNDS. The classifications will be updated when the new version of the PNDS is released. As a next step for the M&E tool, an operational plan will be collected from each unit in the health system and coded following the PNDS classifications to build a database. Thus, at the end of each year, the database will be used to track the activities implemented and spending, in order to update the database. The Health Accounts team will then use the spending database and import it in the Health Accounts Production Tool (HAPT). During Year 3, HFG also supported the MOH team to introduce the OneHealth tool (OHT). The OHT is a costing tool. It is used for supporting planning processes at country level, specifically to strengthen aspects of costing, budgeting, financing, and strategy development of the health sector in developing countries. As a first step, HFG conducted a training to build capacity in the use of the tool for the new PNDS development. During Year 5, HFG will continue assisting the MOH to develop the PNDS M&E tool and use the OHT in preparation for costing of Benin's next PNDS. As the new PNDS is being completed, HFG aims to cost it using the OHT in Q2. Activities:
PNDS costing with the OHT when the final draft of the PNDS becomes available.
PNDS M&E tool development (PNDS classification and database development). Four essential steps are required to build the M&E tool:
• Use new PNDS and new operational plans for coding using the PNDS classification and build a database for planned activities;
• Develop a database and classification system for all the PNDS activities;
• Assign a tracking code to planned activities;
• Populate the database with data throughout the year, and use the data to monitor and evaluate the PNDS implementation.
70 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Year 5 Progress Against Objectives - During Y5Q1, the new PNDS became available, and has been going through the validation process within the Beninese government. The HFG team has been preparing to undertake the planned activities that were contingent on the finalization of the PNDS.
PNDS costing: will proceed in Y5Q3.
PNDS M&E classification tool: is ready to be revised and updated in accordance to the finalized PNDS in Y5Q3. Q2 Challenges - Although a final draft of the PNDS was available in Q1, the validation and dissemination event did not take place in Q2 as expected. As mentioned above, the PNDS needs to be validated to be costed. Full effectiveness of the PNDS M&E classification tool depends on the use of the database to track PNDS activities. The MOH will need to fully support the use of the database and track all PNDS activities. Table 27 provides activity-specific updates. TABLE 27. BENIN ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity: Resource tracking Provide technical assistance to NHA Specialist Andre Zida has been in The PNDS is validated and the Beninese MOH team communication with the team at the MOH disseminated. as they finalize the new PNDS and prepare to undertake additional activities. Do training on and application The 2017-2021 PNDS draft is available and The PNDS Draft Validation of OHT currently under review by the MOH's workshop on November 2-5, 2016, directions departmental de santé and the recommended that the PNDS draft zones sanitaires. be shared with the health department before the costing. This will take place in April 2017, and costing will begin immediately after. Develop PNDS M&E Tool The first draft of the M&E classification Benin plans to use the M&E tool, to which HFG contributed in Y3Q3, is classification tool to guide new PNDS available but will be revised based on the development without HFG support. new PNDS. Developing and using an M&E tool is a long process and requires high-level commitment. The M&E classification tool will be presented to stakeholders with the PNDS costing results. The next steps for the tool will be limited by budget constraints. Support NHA production for The 2014 and 2015 NHA Report is The Beninise team finalizes and years 2014 and 2015 completed but not available yet. shares the report.
5. FIELD SUPPORT ACTIVITIES: BENIN - 71
5.1.4 Botswana Program Objectives - HFG’s field program in Botswana is contributing to the Government of Botswana’s goal to strengthen health systems and increase the efficiency of national health programs to address the health needs of the population, in particular, to protect and sustain gains made in HIV care and treatment. The Government of Botswana and Botswana U.S. Government (USG) team are working together to achieve a broad set of intermediate results to improve the efficiency of national health programs through activities including revising the Universal Health Services Package (UHSP), conducting an actuarial analysis, and developing a blueprint and implementation plan for public health insurance. HFG support of the Ministry of Health and Wellness (MoHW) will have two components. The first will be technical assistance in the development of Botswana’s health financing activities. The second, and perhaps more important, will be facilitating the process of developing health financing products, including consensus building and establishing local ownership in order to ensure uptake, full ownership, and long- term sustainability of the results. Year 5 Activities - The Government of Botswana and Botswana USG team are working together to achieve a broad set of intermediate results to improve the efficiency of national health programs. HFG is continuing work from Year 4 and introducing two new activities in Year 5.
Activity 5: Support the development of a comprehensive health financing strategy. USAID asked HFG to provide technical assistance to analyze and develop plausible scenarios and the most equitable, affordable, and sustainable mechanisms to finance health insurance based on an efficient public-private mix of financing, management, and provision of health services. The health financing strategy will make the case for efficiency gains and their potential to increase value for money and reduce waste. This activity not only will provide focused technical assistance and strategic analysis, but also will build full ownership and an accompanying process to build consensus and incorporate input from stakeholders at every step.
Activity 6: Support implementation and institutionalization of Health Accounts using the updated SHA 2011 framework. HFG will provide technical assistance to the Botswana Health Accounts team to build capacity for regular production and use of the SHA 2011 framework in the future including all the HIV expenditure categories.
Activity 7: Support the development of an actuarial model to effectively finance the essential health services package that is sustainable. HFG will provide technical assistance to the MoHW to develop the capacity to analyze health financing information including the development of an actuarial model to effectively finance a UHSP making sure that it is affordable as well as sustainable. The sustainability analysis will explore health financing in Botswana including accumulation of resources to cover the health needs of the population, especially costs of treating chronic conditions like HIV.
Activity 8: Facilitate an iterative process for prioritizing a revised UHSP including HIV services (UHSP+HIV). HFG will provide technical assistance to the MoHW to facilitate an iterative process to develop a framework for selecting a narrower set of cost-effective interventions, including HIV services. HFG will support the MoHW to link the package of services to a per capita/premium and to the level of government subsidies needed to provide these services based on an expansion of the ongoing actuarial analysis exercise. This revised UHSP will include HIV services (UHSP+HIV) and be developed in a way that ensures it is affordable as well as sustainable.
72 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Activity 9: Develop a blueprint and implementation plan for National Health Insurance. HFG will provide technical assistance to the MoHW and the Health Financing Technical Working Group (HFTWG) to develop a blueprint for a health insurance financial platform including insured HIV services. The main objective is to provide comprehensive information and a base to determine the key design parameters such as target population, benefit package, risk mitigation measures, financing options, institutional arrangements, options of provider payment mechanism, and contributions from different segments of the population. Year 5 Progress Against Objectives - In October, HFG presented the Health Financing Strategy document to the HFTWG, which provided comments and suggestions. After incorporation of their comments, the document was presented to the MoHW Senior Management Team and the Minister of Health at a meeting in December. HFG will prepare additional briefs to support the minister as she plans to present the strategy to Parliament. Future meetings of the HFTWG will focus on the Botswana Health Insurance blueprint. A preliminary meeting held in December focused on health insurance operations, and this information will be used to prepare an outline for the blueprint. To support a revised UHSP, HFG held a two-day workshop in December with MoHW, medical aid schemes, and private sector clinicians to develop a framework for selecting a narrower set of cost- effective interventions in the Essential Health Services Package (EHSP) by using multi-criteria decision analysis. There was also an opportunity to apply the framework developed to a modified list of EHSP interventions. Discussions with stakeholders about establishing a process for routinely updating the package of services is ongoing. Also, in December, the Botswana 2013/14 Health Accounts report was disseminated to 40 key stakeholders. A separate statistical note was finalized for Health Accounts practitioners and researchers who desire additional detailed results and a brief was developed providing a high-level summary of the Health Accounts results. During Q2, a governance chapter for the health insurance blueprint was drafted. It describes governance and accountability systems and outlines a proposed institutional architecture required to govern the health insurance system in Botswana. The draft report was presented to HFTWG members during a workshop held on March 22, 2017 and discussions were held to develop and reach consensus on the governance arrangements for the health insurance. Member feedback will be incorporated and the chapter will be finalized in Q3. Also during the quarter, an actuarial model was built to cost a draft UHSP. The methodology and the model were presented to members of the HFTWG on March 23, 2017. After input assumptions for the model are received from the MoHW, the costing analysis will be finalized. Q2 Challenges - Members of the senior management are questioning the need of a health system overhaul and reforms implementation. Table 28 provides activity-specific updates. TABLE 28. BOTSWANA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 7: Develop an actuarial model to assess the sustainability of two packages of health services: the EHSP and the UHSP+HIV Guide the development of a Features of the package and its design There is progress in design issues but detailed actuarial model of were specified and shared and an actuarial other issues (e.g., vaccines) have not UHSP (including HIV) model was built to cost a draft UHSP yet been finalized. We are awaiting input from the MoHW on input assumptions for the model.
5. FIELD SUPPORT ACTIVITIES: BOTSWANA - 73 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Present the results of the The actuarial costing methodology and The costing analysis will be finalized actuarial analysis of UHSP to draft results were presented to the after design issues are settled and the HFTWG HFTWG on March 23, 2017. operating system input assumptions are collated. Provide technical assistance to HFG presented the principles of actuarial If required, further direct technical develop and interpret the models for health insurance to the assistance with MoHW could happen principles of actuarial models HFTWG. One-on-one technical on site if there is another mission for for health insurance discussions were held with the MoHW the actuarial consultant. team on site, post workshop. Prepare the actuarial analysis The actuarial report and policy brief are report and a policy brief and being drafted and will be ready for review hold a dissemination event in Q3. Activity 8: Prioritizing a revised Universal Health Services Package including HIV services (UHSP+HIV) Develop a framework for This is complete. selecting a narrower set of cost-effective interventions Guide the development of a A UHSP benefits package was selected detailed universal health and costed. services package Present the revised package to The UHSP benefits package was The UHSP benefits package will be the HFTWG presented to the HFTWG at a meeting finalized based on HFTWG feedback. on March 23, 2017. The Department of Clinical Services will provide a comprehensive review including the inclusion of IDC-10 codes. Activity 9: Develop a blueprint for a health insurance financial platform Guide the development of a HFG developed a draft of the governance health insurance blueprint chapter for discussion at the March HFTWG meeting. Facilitate quarterly meetings On March 22, the HFTWG convened to The next HFTWG meeting will be held with the HFTWG and present develop and reach consensus on the in June 2017. MoHW counterparts will progress governance arrangements for the health liaise with senior leadership to ensure insurance. engagement from high-level officials in MoHW and Ministry of Finance and Economic Development. Produce intermediate reports HFG presented the draft governance HFG will incorporate feedback from on financing, governance, chapter at the March HFTWG meeting. the HFTWG and send a revised draft operations and beneficiaries in April. HFG will develop the draft financing chapter in preparation for the June HFTWG meeting. Prepare final report and a A policy brief and frequently asked policy brief and hold a questions document that distill the main dissemination event elements of the health insurance proposal and the health financing strategy were prepared.
74 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.1.5 Côte d’Ivoire Program Objectives - USAID/Côte d'Ivoire asked HFG to address two major areas in FY 2016: (1) human resources for health (HRH), including an assessment of the pre-service training institutions for health personnel and (2) health financing. Côte d'Ivoire activities are entirely funded by PEPFAR; as such they contribute to achieving AIDS-Free Generation goals, and are in line with the PEPFAR Blueprint, which includes health systems strengthening under the pillar "Smart Investment." In Year 5 (FY17), HFG will continue to support the implementation of the performance-based financing (PBF) strategy in Côte d'Ivoire in collaboration with several cooperating agencies, including the World Bank, the Global Fund, various U.N. agencies, and PEPFAR implementing partners. HFG will focus on improving the capacity of the Ministry of Health and Public Hygiene (Ministère de la Santé et de l'Hygiène Publique, MSHP) to advocate for increased domestic financial resources for HIV/AIDS. Additionally, through the assistance provided to the MSHP in the development of tools through the activities related to HRH performance management, HFG will collaborate with the Leadership, Management and Governance (LMG) project to deploy tools throughout the country. Other agencies with which HFG collaborates on HRH are the following: Elizabeth Glaser Pediatric AIDS Foundation, Agency for Preventive Medicine (Agence de Médecine Préventive/AMP), Japan International Cooperation Agency (JICA), JHPIEGO, International Center for AIDS Care and Treatment Programs (ICAP), WHO, UNICEF, and Conseil Santé (a French company). Year 5 Activities - 1. Support MSHP Department of Human Resources (Direction des Ressources Humaines, DRH) in the development of the national of 2016-2020 HRH Strategic Plan 2. Support MSHP by advocating for an increase in the number of adequately trained HIV services providers at clinical and community levels. 3. Support the national PBF model implementation 4. Improve MSHP capacity to advocate for increasing domestic financial resources for HIV/AIDS 5. Provide assistance to MSHP to conduct the System of Health Accounts (SHA) 2015 exercise (with a focus on the HIV subaccount) Year 5 Progress Against Objectives - Support MSHP/DRH in the development of the 2016-2020 HRH Strategic Plan. In Q1, the recruitment of a consultant to support the MSHP/ DRH in the development of the 2016-2020 HRH Strategic Plan was finalized. In Q2, a consultant was hired for the HRH 2014-2015 interim assessment and completed the following tasks: (i) developed the methodology of the evaluation, (ii) conducted a literature review, (iii) developed tools for data collection, and (iv) completed the first field mission to collect data in preservice schools (INFAS) in Korhogo, Bouaké, and Daloa. During the field mission, 20 people (15 men and 5 women) from the INFAS site management team, Health Districts, and Regional Health Department were interviewed as were 11 students (5 men and 6 women). The consultant then carried out a data analysis and drafted a progress report. In addition, HFG participated in a workshop related to the presentation of the Côte d'Ivoire Health Workers Labor Market Study. This workshop was held at the WHO office. In Q3, the consultant will complete the following tasks: (i) propose a draft of the evaluation report of the Interim Human Resources Development Plan for Health (PIDRHS) covering 2014-2015, (ii) conduct a literature review of all initiatives related to HRH, (iii) recommend focus areas and effective strategies for mobilizing resources for the next Strategic Plan for the Development of Human Resources for
5. FIELD SUPPORT ACTIVITIES: CÔTE D'IVOIRE - 75 Health (PSDRHS) 2016-2020, (iv) participate in the validation workshop of the Evaluation Report of the PIDRHS, (v) prepare the PIDRHS covering 2014-2015 and provide recommendations for areas of intervention of the PSDRHS 2016-2020, and (vi) finalize the evaluation report of the PIDRHS 2014-2015 and recommendations for the PSDRHS 2016- 2020. Support MSHP by advocating for increasing the number of adequately trained HIV service providers at clinical and community levels. In Q1, HFG participated in the development of the National Strategic Plan for the implementation of community-based interventions for community health workers (CHWs) through a workshop held November 2-5, 2016. The draft plan seeks to address the country's lack of progress in maternal and child health outcomes and improve access to primary health care, HIV/AIDS care and treatment, and other priority services. Key objectives include strengthening the national framework for community health, improving coverage and quality of community health services, increasing community participation in health issues and governance, and ensuring the sustainability of community health activities. In Q2, from January 30 to February 3, 2017, HFG supported a workshop related to the validation of the National Community Health Policy in Yamoussoukro. This policy will contribute significantly to organizing and extending access to HIV/AIDS services to the community level. Forty-five participants (15 women and 30 men) from AMP, UNICEF, CARITAS-CI, ACF, ASAPSU, HKI, ICAP, ANADER attended the workshop. In addition, on February 28, 2017, HFG took part in a workshop related to the dissemination of the final results of ICAP Project on CHW approach, at Hotel NOVOTEL Abidjan. In Q3, HFG will support the Department of Community Health (Direction de la Santé Communautaire, DSC) of the MSHP to finalize and validate the National Community Health Workers Strategic Plan. HFG will also support DSC/MSHP to harmonize and consolidate CHW's referral and counter-referral tools for HIV/AIDS care and treatment by (i) elaborating a study protocol to evaluate the use of existing CHW referral and counter-referral tools regarding the HIV/AIDS activities, and the link between CHWs and nurses and midwives; and (ii) organizing a field mission to collect data. HFG will also support the TWG to develop, harmonize, and consolidate new CHW referral and counter-referral tools related to HIV/AIDS activities. Supporting the national PBF model implementation. In Q2, HFG participated in three work sessions on the PBF model implementation with the following:
World Bank Principal Economist on February 14, 2017;
USAID Mission and the World Bank on February 29;
PEPFAR team (including USAID) and Ariel Glaser Pediatric Aids Foundation on March 21 to discuss the partners' roles and responsibilities in the PBF implementation. The purpose of this work session was to define how each partner will contribute to the PBF implementation. As a result, it was agreed that the Ariel Foundation will provide technical assistance to three health districts (Grand- Bassam, San Pedro, Soubré) to implement PBF, and the HFG project will continue to assist the MSHP to address PBF's institutional framework development, particularly in the field of health facilities' governance and financial management. In addition, HFG participated in two workshops, on PBF tools revision January 3-6, 2017 and on PBF indicators pricing revision Jan.24-27, 2017. The workshop on pricing is an important step in PBF implementation and in establishing the indicator values for purchasing agreements.
76 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Improve the capacity of MSHP to advocate for increased domestic financial resources for HIV/AIDS. In Q1, HFG supported the Domestic Resources Mobilization (DRM) Technical Working Group (TWG) by organizing a workshop to finalize the country plan for DRM. In preparation for this workshop, held on October 19-21, 2016, HFG worked with the TWG to provide to the plan inputs related to the optimization of the use of financial resources allocated to health. HFG also participated in the Health Sector-Based Committee meeting on November 30, 2016. At the request of the USAID mission, at the meeting HFG presented achievements of the supported DRM activities such as: (i) technical assistance to the cross-ministerial TWG on DRM, (ii) organization of the DRM international workshop on September 1-2, 2016, and (iii) support to the TWG for the development of a 2017-2018 work plan for the optimization of the use of the financial resources allocated to health. In addition, HFG presented DRM activities planned for 2017 such as (i) the organization of a second DRM international workshop (through HFG USAID/W cross-bureau funding) and (ii) assistance to implement the country plan for optimizing the use of financial resources for the health sector. In Q2, HFG provided support to national counterparts through technical and financial assistance for two additional workshops. The first, held January 22-28 in Yamoussoukro, was to develop the aforementioned 2017-2018 work plan for DRM; 37 participants attended this workshop including nine women from the MSHP, Ministry of Finance (Cabinet), Ministry of Planning (Cabinet), Reseau des Parlementaires pour la Santé, and the Community of Practice/HUB Côte d’Ivoire. The second workshop, to finalize the work plan, was held February 21-25, 2017 with 14 participants, including four women. The work plan aims to: (i) set up an integrated planning and budgeting system within the MSHP, (ii) link the budget to the Ministry operational plan, and (iii) improve the financial management of public health facilities. In Q3, HFG will provide assistance to the plan implementation. HFG was asked to develop a scope of work (SOW) for the provision of technical assistance, as requested by the MSHP, on financial issues including DRM through an embedded advisor within the Finance Division (DAF). This advisor will assist the MSHP in the development and implementation of a strategic plan to increase domestic resources for health including HIV/AIDS. HFG developed the SOW, which the USAID mission transmitted to the MSHP in January for review and feedback. In addition, HFG assisted the MSHP One Health team in the development and costing of the next HIV National Strategy costing through the OneHealth Tool. The final report was approved by the MSHP. Provide assistance to MSHP to develop a system of health accounts (with a focus on HIV subaccount). In Q2, HFG project provided support to MSHP's Financial Division for a workshop on National Accounts 2015 and 2016 and brief notes development. The workshop took place March 8-10, 2017, with 21 participants (two of whom were women) from the MSHP, Ministry of Budget, and the Social Security Department in charge of medical insurance (Caisse Nationale d'Assurance Maladie). In Q3, HFG will assist the MSHP in the collection of data for the 2016 Health Accounts. Q2 Additional Information - HFG participated in several activities including: USAID/PEPFAR workshop for COP 17 indicators (January 30-February 1, 2017)
TWG meeting on quality assurance (February 8, 2017)
National Council of HIV/AIDS (February 13, 2017)
USG Health Partners and MSHP Meeting (February 25, 2017)
Validation workshop of the National Strategic Plan on Quality Improvement, Hygiene and Security (March 23, 2017)
5. FIELD SUPPORT ACTIVITIES: CÔTE D’IVOIRE - 77 Table 29 provides activity-specific updates. TABLE 29. CÔTE D'IVOIRE ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Support MSHP DRH in the development of the 2016-2020 HRH Strategic Plan Evaluate HRH 2014-2015 • On February 22-24, 2017, the Next Steps: consultant developed the evaluation PIDRHS • Propose a draft of the PIDRHS methodology. 2014-2015 evaluation report. • On February 28-March 3, 2017, the • Conduct a documentary review consultant did a literature review and of all initiatives related to HRH elaboration of the tools for data and issues. information collection • Make recommendations for focus • On March 1418, 2017, a field mission areas and effective strategies for collected data in preservice schools mobilizing resources for the next (INFAS) in Korhogo, Bouaké, and PSDRHS 2016-2020. Daloa. • Participate in the Validation • On March 20-21 2017, the consultant Workshop of the PIDRHS 2014- analysed the data collected and 2015 Evaluation Report. produced a progress report. • Support the PIDRHS report and • On February 21-23 of 2017, HFG its recommendations for areas of participated in the workshop on the intervention of the PSDRHS restitution of the Côte d’Ivoire Health 2016-2020. Workers Labor Market Study, held in • the WHO office. Finalize the PIDRHS evaluation report and its recommendations for the PSDRHS 2016-2020. Support MSHP DRH to cost Activity planned to be completed in Q3. the strategic plan and develop a M&E plan Prepare for the development Activity planned to be completed in Q3. of an annual operational plan for implementation and costing Activity 2: Support MSHP to improve and increase the number of adequately trained HIV services at clinical and community levels Support the DSCMP/DRH to From January 30 to February 3, 2017, HFG Next Step: develop and validate the supported the organization of a workshop Support DSC/MSHP to finalize and Strategic Plan for the related to the validation of the Community validate the Strategic Plan. implementation of community- Health Policy in Yamoussoukro at Hotel les based interventions Parlementaires. 45 participants (15 women and 30 men) from AMP, UNICEF, CARITAS-CI, ACF, ASAPSU, HKI, ICAP, ANADER attended the workshop. On February 28, 2017, HFG took part in the workshop held to disseminate final results of ICAP Project on CHW approach at Hotel NOVOTEL Abidjan.
78 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Support DSC/MSHP DRH to Activity planned to be completed in Q3. Next Step: review and consolidate CHW Organize a workshop to validate the training materials and modules new CHW training materials and including HIV/AIDS care and modules, which include HIV/AIDS treatment aspects care and treatment aspects Support DSC/MSHP DRH to Activity planned to be completed in Q3. edit, duplicate, and disseminate CHW training tools including HIV/AIDS care and treatment aspects Support DSC/MSHP DRH to Activity planned to be completed in Q3. institutionalize CHW training system including HIV/AIDS care and treatment aspects Support DSC/MSHP to test Activity planned to be completed in Q3. CHW certification system in the scale-up to saturation district in the health region of Nawa San Pedro Support DSC/MSHP to Next steps: harmonize and consolidate • Develop a study protocol to CHWs’ reference and counter- evaluate the use of existing CHW reference tools in respect to referral and counter-referral HIV/AIDS activities tools related to HIV/AIDS activities, and the link between CHWs and nurses and midwives. • Organize a field mission to collect data and information according to study protocol. • Support TWG to develop, harmonize, and consolidate new CHW referral and counter- referral tools related to HIV/AIDS activities. Support DSC/MSHP to test if Next step: CHWs’ reference and counter- Organize a field mission to test the reference tools are revised referral and counter-referral harmonized and consolidated tools related to HIV/AIDS activities related to HIV/AIDS activities in the four health districts. in the 4 health districts prioritized by USAID/PEPFAR (Daloa, Issia, Bouake Nord-Est, and Bouake Nord-Ouest)
5. FIELD SUPPORT ACTIVITIES: CÔTE D’IVOIRE - 79 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Support DSC/MSHP to Activity planned to be completed in Q3 organize a workshop to share results of the test of CHW’s reference and counter- reference tools as they relate to HIV/AIDS activities Participate in meetings, Depends on needs and demand exchanges, and fora related to HRH issues, and collaborate closely with MSHP and other donors around HRH Activity 3: Promote the integration of HIV/AIDS services in PBF implementation to improve the effectiveness of HIV care and treatment Support PBF National HFG participated in two workshops on PBF Next step: Committee in PBF tools revision (January 3-6, 2017) and on HFG will continue to assist the implementation PBF indicators pricing revision (January 24- MSHP in regard to PBF institutional 27, 2017) framework development, particularly in the field of health facilities governance and financial management. Develop tools and standards of Neither implementing partners nor national Next step: practice (SOPs) for PBF counterpart asked HFG to develop tools or Tools and SOPs will be developed implementation SOPs. when requested. Assist PEPFAR implementing HFG team had a work session with USAID Next step: partners to implement the Mission and Ariel Glaser Foundation on HFG will continue to assist the national PBF scheme PBF implementation strategy. MSHP with PBF’s institutional USAID assigned roles to both HFG and framework development, particularly Ariel Glaser Foundation for PBF in the field of health facilities implementation in 3 health districts. governance and financial management. Activity 4: Improve the capacity of MSHP to advocate for increasing domestic financial resources for HIV/AIDS Support PNLS in costing the HFG provided the final report on HIV This task is completed. HIV/AIDS strategy using the National Strategy costing under the OneHealth Tool OneHealth Tool approved by the MSPH. Assist MSHP in the creation 2 workshops for 2017-2018 DRM were Next step: and functioning of the HIV held, on January 22-28 and February 21-25, In Q3, HFG will provide technical financing TWG related to HIV 2017, during which the DRM Action Plan assistance to MSHP to implement the domestic financing increase was developed. DRM Action Plan. Conduct a modeling study to The RFA is being finalized. Next step: assess health and economic Recruitment of the university or benefits (including future research institute to conduct the savings) expected from study. increased government HIV funding (in collaboration with university or research institute)
80 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Support MSHP to develop an HFG drafted a SOW that the USAID Next step: advocacy Plan related to DRM mission has sent to the MSHP. Depending on the MSHP feedback, for HIV/AIDS HFG will provide it technical assistance on financial issues, including DRM, through an advisor embedded in the Finance Division (DAF). Activity 5: System of Health Account (with a focus on HIV sub account) Collect and analyze Activity planned for Q3. institutional and household data Write SHA 2015 report Brief note on mother and child health developed. Activity 6: Ebola Preparedness Activities Finalize HRH Motivation survey HFG held a work session with the DRH Next Step: report team to establish a technical working group The HFG HRH specialist will to further develop strategies recommended complete a report on the by the consultant and incentive mechanisms consultation francophone countries' for HRH motivation. The TWG is consultation on Health Workers developing a ToR and timeline for this National Account and then share it work. with TWG team members. On February 16 and 17, the DRH Management Team had two work sessions with the TWG key actors (from IGLS, DEPS and union representatives) to discuss the HRH motivation survey report. Seventy percent of those interviewed were mostly satisfied with their quality of work, wellbeing at work and the quality their social relationships. The report has been reviewed and the TWG is at present analyzing the motivation mechanisms implemented in Guinea, Sierra Leone and DRC during the Ebola crisis to determine what might work best in Côte d’Ivoire. In addition, the HFG HRH Specialist attended the francophone countries' consultation on Health Workers National Account organized by the WHO in Dakar, Senegal, from March 14-16.
5. FIELD SUPPORT ACTIVITIES: CÔTE D’IVOIRE - 81
5.1.6 Democratic Republic of the Congo Program Objectives – In Year 5, the HFG project works on six distinct activities. The first is assisting the Ministry of Public Health (Ministère de la Santé Publique, or MSP) to implement the reform process. HFG assistance to MSP is divided into three broad streams of work: support to the Secretary General's (SG's) office in the overall reform process, institutional strengthening of two key central directorates, and establishment of two new provincial health divisions (Divisions Provinciales de la Santé, DPS). The second activity is to conduct a second training (similar to the one conducted in Year 4) for MSP staff on the basic concepts and principles underlying decentralization. The third activity is to prepare the Kinshasa School of Public Health (KSPH) to qualify for direct USAID funding. The fourth activity is to support the 30th anniversary of KSPH. The fifth and sixth activities provide limited institutional strengthening to the Faculty of Medicine in the University of Kinshasa and the National Reproductive Health Program. These activities are expected to have the following results.
Constituency built within MSP that supports and facilitates the MSP reform process; this will facilitate MSP efforts to improve coordination of stakeholders within the ministry
Key central MSP Directorates with improved capacity to function under the decentralized system
Two DPS assume new roles under the reform process
KSPH with a financial management system that qualifies for direct USAID funding
30 MPH and 3 doctoral students funded for one academic program
Increased understanding of core concepts and principles of decentralization by senior MSP and other Government of DRC (GoDRC) officials Year 5 Activities - The summaries of these activities are as follows: Support to MSP Reform. The SG is responsible for overall coordination of the reform process within the health sector including the development of regulations and norms, development of roadmaps and action plans, building of support for the reform process, and implementation of new organizational structures at all levels. The SG coordinates and monitors the implementation of the overall reform process with technical support from the Directorate of Studies and Planning (DEP). HFG provides targeted support to the SG's office in carrying out these key functions. This consists of support to the Technical Secretariat of the MSP Steering Committee, production of two issues of a newsletter, training of a second group of 14 national DPS coaches, and coaching assistance to the central MSP.
Institutional Strengthening of Central Directorates. USAID initially identified three key central directorates to support in the reform process and proposed that technical assistance be provided to establish and operationalize these offices. The three directorates are the Directorate of General Services and Human Resources (Direction des Services Generaux et des Ressources Humaines, DSGRH), Directorate of Financial Affairs (Direction Administratives et Financiere, DAF), and the Directorate of the Organization and Management of Health Services (Direction de l'Organisation et de Gestion des Services des Soins de Santé, DOGSS). Although the basic attributes of these offices were established in the "Cadre Organique," the operationalization of these offices (as well as others within the MSP) and the details of their interactions with the provincial structures have not yet been fully defined. However, as reported in Y4Q4, due to the DAF's legal framework not being in place (planned for FY17), it was decided that HFG will not provide technical assistance to the directorate due to lack of time.
82 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Establishing Provincial Health Divisions. HFG has been providing assistance to two DPS, in Haut- Katanga and Lualaba, at USAID's request. The focus of HFG's assistance is to ensure effective and efficient functioning of the DPS with the development of operational plans, a roadmap for the integration of specialized programs and capacity strengthening (using the PICAL tool as the basis for the capacity-strengthening plans) for both DPS. HFG has led the delivery of trainings in team- building, leadership and management, and financial management, thus strengthening accountability and management capacities. It also installed IT equipment and office furniture in both DPS. In Year 5, HFG will continue providing assistance to (1) strengthen the DPS through additional training in coaching, supervision, and performance management, to name a few, (2) establish the provincial health inspectorates (IPS) and (3) revive the provincial steering committee, the CPP-SS.
Decentralization Training for MSP Officials. In FY16, at the request of USAID, HFG helped support the development and delivery of a decentralization course for senior leadership at the MSP and DPS. The objective of the course was to train the MSP on basic concepts and the application of decentralization principles (following the MSP reform). Led by KSPH, with the guidance of Dr. Thomas Bossert (Harvard School of Public Health), the course successfully trained over 80 participants from the MSP and DPS and other key stakeholders involved in the reform. In Year 5, USAID requested that HFG support the replication of the course directed at the provincial level and the specialized programs. This will ensure increased understanding of decentralization of senior leadership for improved decision-making at the central and provincial levels.
Strengthening KSPH's Financial Management. KSPH is the premier institution in the DRC for training of public health professionals, many of whom become managers at different levels of the health system and some of whom become the public health leaders in the country. The core of the school is its master's-level programs in public health. A wide range of donors and implementing partners seek to work with KSPH in their activities, often engaging KSPH as a sub-awardee on specific projects. In addition, for many years, USAID has provided funding for scholarships to KSPH through a variety of contractual mechanisms including Health Systems 20/20, the predecessor project to HFG, and African Strategies for Health (ASH). Consistent with the objectives of USAID Forward, USAID/DRC would like to strengthen KSPH financial management capacity so that USAID can provide direct funding for scholarships to KSPH and potentially for other activities in the future. This will require strengthening KSPH's grants and financial management systems so that it meets generally accepted accounting standards and ensuring the organizational commitment by the Management Committee to strengthen its financial management systems. Health Systems 20/20 provided assistance in the area of financial management, but concluded at the end of its activity that more remained to be done in this area for KSPH to become a direct recipient of USAID funding.
KSPH 30th Anniversary. KSPH was founded in 1986 with US government help as the very first school of public health in the country. Since its inception, KSPH has provided graduate-level training in public health, health economics, bioethics, and nutritional epidemiology. To date, over 1,000 students have graduated from KSPH. To celebrate their achievements over the last 30 years, KSPH is planning a commemorative event, for which, at USAID's request, HFG will provide financial and planning support. During this event, KSPH will present their work and their impact on public health in DRC.
5. FIELD SUPPORT ACTIVITIES: DEMOCRATIC REPUBLIC OF THE CONGO - 83 Institutional Strengthening of Faculty of Medicine and National Reproductive Health Program. The Faculty of Medicine, located in Kinshasa, is one of a kind in the country, providing medical training and social services to communities in DRC. It includes KSPH, University Clinics, and the Center of Neuro Psycho Pathology. However, in the last couple of years, the Faculty of Medicine has seen its performance decrease (compared with medical schools in neighboring countries) and its relationship with its three institutions suffer. In order to rebuild these relationships and improve its performance, HFG will conduct an institutional assessment and assist in developing a strategic plan. Maternal and child health (MCH) in the DRC has proven to be extremely challenging with some of the highest maternal mortality ratio in sub-Saharan Africa. The mandate of the National Reproductive Health Program (PNSR) is to advance the MCH agenda. To begin the process of strengthening PNSR, USAID asked HFG to provide it limited organizational strengthening, by conducting an assessment and helping them develop a strategic plan. Year 5 Progress Against Objectives - Central Level. In Q1, HFG participated in the National Steering Committee for the Health Sector (CNP-SS) on September 29-30 and in the Health Sector Coordination Committee (CCT) on October 12 in a workshop to validate the implementation plan for CNP-SS Solutions and Recommendations. HFG helped plan and implement one of the recommendations, the CPP-SS meeting in Haut-Katanga on December 13-14. HFG also disseminated the first edition of the Magazine, which provides information about the reform process. Coaching support is on hold while funding from other partners materializes and the second group of coaches is recruited. In Q2, HFG participated in two meetings with the Governance Commission. The meetings, on January 27 and February 24, focused on the operational planning guidelines, the CPP-SS organizational guidelines, and the reform implementation roadmap. HFG also provided logistical support and actively participated in a meeting held on February 27 with the Human Resources Commission for the validation (please see below under DSGRH) of the draft Human Resources Management Procedures Manual before transmitting it to the Health Sector Technical Coordination Committee for approval. Central Directorates
DSGRH: During Q1, HFG participated in and co-financed with JICA and WHO a workshop led by the CNP-SS Human Resources Commission to develop the Human Resources for Health National Development Plan. HFG's organization development consultant was an integral part of this workshop. In Q2, HFG organized a restitution workshop, which aimed to review all DSGRH activities implemented in 2015 and 2016 to ensure that set targets were achieved and expected results were met. The workshop had 64 participants (51 men and 13 women) with 57 from MOH directorates, 4 from the Ministry of Public Service, and 2 from USAID/DRC and the HFG project. During the quarter, HFG also provided support for the development of the Human Resources Management Procedures Manual. This manual will serve as a job aid for all human resources managers at all levels of the health pyramid. The manual, validated by the CCT-SS, is currently in the course of adoption by the Committee.
DOGSS: In Q1, HFG worked on finalizing the DOGSS "referentiel des emplois" (employment reference document) by incorporating the Medical Imagery and Radiotherapy Division. A workshop on the results of HFG's interventions in the establishment of the DOGSS was also organized on November 1 with the participation of the MOH Secretary General and the Director of Cabinet of the Minister of Health. Forty-two people from the various MSP directorates and three public service experts also participated in this restitution.
84 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
In Q2, a restitution workshop for the restructuring activities and the development of the DOGSS employment benchmarks was held on February 13, presided over by the Minister of Health. The aim of the workshop was also to facilitate the decision-making process leading to the establishment of the directorate. The USAID Deputy Director, the Director of the Health Team, and the HFG team participated in the restitution workshop, which resulted in recommendations for the political endorsement of the process of establishing the DOGSS and a formal decision by the Minister of Health. Provincial Level. In Q1, HFG continued to implement the capacity-building strengthening plans in the two DPS by conducting training on the fundamentals of coaching and on institutional systems and performance monitoring (supervision) of the health zones. The goal of these two trainings was to build the capacity of DPS staff to better support the health zones. In Q2, HFG provided support to the Lualaba DPS from February 26 to March 8, 2017, for the development of the Annual Operational Plan (PAO). The report is being finalized and will be disseminated in Q3. The development of the PAO for the DPS Haut-Katanga will take place March 27- April 7. At the initiative of USAID, from February 28 to March 8, a joint USAID (Dr. Mayala)/ World Bank (Dr. Michel Muvudi)/ UNICEF (Dr. Dominique Baabo) mission visited the two DPS, Haut Katanga and Lualaba. The goal of the mission was to present the platform and synergies between the different donors (presentation of the different projects for the support to the MSP reform) and to follow up on the operational planning for 2017. The challenges encountered were a lack of leadership and management capacities of the zonal Chief Medical Officers and the need for support to the DPS district management teams accompanying the health zones.
Decentralization Training for GoDRC Officials. USAID/DRC requested that HFG organize a second training course in the basic concepts and principles underlying decentralization for MSP and DPS officials. HFG has drafted the terms of references and has prepared the documentation necessary for the subaward for KSPH to plan and conduct the training.
KSPH Financial Management. In Y5 Q1, HFG worked with KSPH to:
• Procure software licenses for the following: Director of School, Deputy Director, Server 1, Internal Auditor 1, and Chargé des finances. The delivery of the seven software licenses is in process (although the delay has been raised several times with the vendor).
• Capacity building of KSPH's financial staff: 16 staff members including the HFG Financial Management Advisor attended a refresher training in QuickBooks. The training took place November 28-December 2.
• Monthly reports: Monthly reports are produced regularly, albeit delayed and not without numerous reminders from the HFG Financial Management Advisor. The issue lies within the management committee, which must remind the financial team to comply with the procedures manual.
• Production of the 2015 and 2016 consolidated reports: The 2015 report is available. For 2016, a similar process has been followed. The report is 89 percent complete; projects such as the One Health Central and Eastern Africa (OHCEA) and PMI only provided their reports for 2015 at the end of August 2016. However, despite many reminders, the project accountants have not yet provided the remaining information needed to finalize the consolidated report for 2016.
5. FIELD SUPPORT ACTIVITIES: DEMOCRATIC REPUBLIC OF THE CONGO - 85 • 2017 budget development: The committee for the 2017 budget has been formed. According to memorandum 005/ESP/2016, the committee is composed of the following members: the coordinator, finance manager, KSPH accountant, and internal auditor. The team is planning to finalize this work by the end of December. In Q2, HFG provided support for the following activities in financial management:
• Monthly reports: HFG observed a notable improvement in the QuickBooks financial reporting. However, the reports are still being submitted late.
• Calculating the Indirect Cost Rate: the data to calculate the indirect cost required is available. However, Alioune Wade, who provides the technical expertise for these calculations, has not been granted a visa. Mr. Wade is now looking to provide remote support to the local team.
• Financial review of KSPH project: A financial review of the school's projects and studies took place March 28-31.
• KSPH institutional analysis: An institutional analysis was conducted January 23-February 14 and the restitution workshop took place on February 16. USAID's Health team and the CDCS Objective 1 (institutions effectively implementing their mandates) Team Lead were among the workshop participants.
KSPH Scholarship program. HFG completed two grants with KSPH in Y4Q1: one to fund scholarships for 30 MPH students and the other to support three PhD students for one academic year. These grants cover the academic year that began in December 2015 and ended in February 2017. Both payments have been made for the MPH program and the PhD program.
Faculty of Medicine. Upon USAID's request, in Year 4, HFG supported the University of Kinshasa School of Medicine at the in the design process of its strategic plan. One of HFG's consultants held meetings with faculty members and participated in a two-day workshop on strategic planning. The school had asked one of the professors to develop a strategic plan, but without adequate involvement of other faculty members. Thus, HFG suggested that an institutional assessment using the PICAL tool be conducted for the School of Medicine and its other components, namely KSPH, University Clinics, and the National Center of Psycho-Pathology, and that the results be used to develop an institutional strengthening plan. HFG would then provide assistance in developing a strategic plan and in providing training in team-building and leadership and management. In Q2, HFG carried out the institutional analysis for the Faculty of Medicine, on January 9- 20, using the PICAL tool. The restitution of the analysis results and the capacity-building plan resulting from this exercise took place in two phases (with 35 participants in Phase 1 and 67 Phase II) emphasizing broad internal and external accountability to the entire Faculty Council.
National Program for Reproductive Health. This institutional analysis is scheduled to take place in April. The terms of reference are being finalized. This activity will help identify synergies with the Directorate of Family Health (DSF).
86 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Q2 Challenges - The challenges encountered during this quarter are as follows: At the SG level: The cabinet of the new Minister is having challenges owning/adopting the 'Health and Reform' bulletin. An article from the cabinet is still pending in order to finalize it. Similar challenges are expected to finalize the magazine, which will require the Minister's signature.
At the central management level:
• Lack of strong political endorsement for the two directorates that HFG supports. This hinders the implementation of HFG's capacity-building activities.
• A culture of per diem continues. This is mainly due to low wages in the public sector and lack of motivation of government employees.
At the provincial level:
• Similar to the central management challenge, the same culture of per diem creates issues in the implementation of HFG's activities.
• Although 80 percent of the capacity-building activities in the DPS have been implemented, the DPS do not have adequate funding to accompany the Health Zones.
Administrative: Mr. Alioune Wade, who provides technical support for the KSPH financial management activities, has not received his visa after a second (failed) attempt. HFG's team is seeking an explanation of the reasons for his application denial. Q2 Additional Information - HFG hired two full-time staff this quarter, a full-time DPS coordinator based in Katanga, and an organizational development specialist to replace Chirume Mendo. Table 30 provides activity-specific updates. TABLE 30. DEMOCRATIC REPUBLIC OF CONGO ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Support MSP reform 1: Support to Secretary General's Office Train national coaches in This activity is on hold due to lack of coaching skills funding (previously provided by WHO). Participate in three technical HFG provided support and participated The Human Resources Management commissions operating under in the February 23 meeting for the Procedures Manual is in the process of the CNP-SS validation of the Human Resources being adopted by the CCT-SS. Management Procedures Manual. Strengthen communication The ‘Health and Reform’ bulletin is being The bulletin will be released on about the reform process finalized. March 31.
5. FIELD SUPPORT ACTIVITIES: DEMOCRATIC REPUBLIC OF THE CONGO - 87 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Support the national workshop The MSP, with GAVI-RSS financial Draft circulars will be submitted for to validate the draft guidelines support, organized a workshop on the the SG’s signature to ensure for IPS harmonization of the IPS operational understanding of the different guidelines of the Provincial Health modalities for the implementation of Inspectorates (IPS). The workshop was certain directives (which are currently an opportunity to clarify any ambiguity at the center of some controversy). between the DPS and the IPS. HFG will now be able to follow up on next steps (consensus-building workshop to establish the IPS in Lualaba and Haut Katanga). Produce magazine on the The magazine will be released a month reform after the newsletter (April 30). 2: Institutional capacity building of DSGRH Develop plans to strengthen the Completed institutional capacity of DSGRH Develop DSGRH strategic Completed operational plan Conduct training of trainers The TOT Terms of Reference were Planned for Q3. (TOT) to build a core group of drafted in collaboration with the DSGRH trainers Directorate for in-service training. Provide ICT training CVs for the three trainers A candidate was selected and the (programmers by trade) were reviewed training will take place in the third on March 21. week of April. Support the development of Waiting on the National Human administrative procedures and Resources Development Plan to develop tools for performance the administrative procedures and evaluation performance evaluation tools. Assist DSGRH in The Human Resources Management The following two activities remain: implementation of selected Procedures Manual was developed and 1. Development of the Human activities in its Strategic Plan finalized in the week of February 8. Resources Development Provincial Plan in Lualaba (JICA financed the plan for Haut- Katanga). 2. Implementation of the Human Resources database in Lualaba. 3. Institutional capacity building of DOGSS Conduct organizational Completed assessment (DOGSS) Develop institutional Completed strengthening plan (DOGSS) Implement institutional Waiting on formal decision for the strengthening plan (DOGSS) establishment of the DOGSS. Support implementation of new Waiting on formal decision for the DOGSS organizational structure establishment of the DOGSS.
88 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Conduct Leadership and Waiting on formal decision for the Management training establishment of the DOGSS. Develop strategic plan Waiting on formal decision for the establishment of the DOGSS. Conduct workshop on lessons Waiting on formal decision for the learned to take first step to establishment of the DOGSS. becoming a learning organization Conduct training in results- Waiting on formal decision for the based management establishment of the DOGSS. Activity 2: Establish Provincial Health Divisions Implement roadmap to integrate Planned for Q3. Opportunity for collaboration with specialized programs experts from the DLM (however, they are currently in training in the US). Conduct workshop on Planned for Q3 Prof. Kwilu’s contract and the training management of primary health material are being finalized. care Support training of DPS staff in Completed in Q1 This training was combined with the supervision of health zones performance management training for health zones. Provide training in performance Completed in Q1 This training was combined with the management performance management training for health zones. Validate the financial Planned for Q4 This activity depends on the management procedures manual completion of the MOH Financial being developed by MSP Procedures Manual (still with the DEP). Develop 2017 Annual The PAO for Lualaba was developed The Haut-Katanga PAO will be Operational Plans for both DPS February 26-March 8. The report is developed March 27-April 7. almost finished. Hold consensus-building Planned for Q3 This can only be done after the SG has workshop on reorganization of approved the guidelines and selected IPS the final list of health agents. Organize meeting to validate In progress. The PAO for Lualaba has The PAO was developed for Lualaba PAO been developed but not yet validated. and is awaiting validation at the next The development of the PAO for Haut CPP-SS meeting. The meeting’s Terms Katanga is scheduled for April. of Reference and budget have been drafted and are being reviewed by HFG for finalization and approval.
5. FIELD SUPPORT ACTIVITIES: DEMOCRATIC REPUBLIC OF THE CONGO - 89 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 3: Strengthen Kinshasa School of Public Health (KSPH) financial management Strengthen capacity of KSPH Refresher training in QuickBooks took financial management team place in Q1. Initiate regular monthly financial While the use of Quick Books has reporting improved noticeably, monthly reports are still late. Meet monthly with Management No monthly meetings took place in Q2. Monthly meetings will resume in April. Committee Do quarterly financial review A financial review of KSPH projects was conducted March 28-31. Complete 2016 consolidated The 2016 report is still awaiting data financial report from two projects, which is delaying the consolidated report. Procure 7 QuickBooks licenses Completed and install a network to improve information sharing Develop 2017 annual budget A budget committee has been formed. Carry out indirect cost This has been rescheduled to Q3 due to The assistance will be via distance to determination and tracking the expert (Mr. Wade) not being able to avoid any further delay. get a visa to travel to Kinshasa. The assistance will be via distance. Conduct institutional analysis The analysis of the institutional using PICAL assessment took place January 23- February 6 and the restitution workshop was held on February 16. Activity 5: Train MSP staff on decentralization of health sector Enter into subaward with KSPH The subcontract with KSPH is near There have been issues receiving the completion. required documentation from KSPH, which delays subaward completion. Engage contractually external Tom Bossert has been contracted. expert on decentralization Determine lessons learned from Completed the first course Identify faculty Completed KSPH already identified the main participants. The remaining participants to be identified will come from MOH. Revise course materials Planned for Q3 KSPH has identified the focal point for the course, Prof. NBgo Bebe. Thus, the review of the course material with Prof Bossert will start in early April. Deliver the training Confirmed for the week of May 15-19.
90 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 6: KSPH 30th anniversary celebration Develop action plan and budget Completed Activity 7: Institutional strengthening of the Faculty of Medicine Conduct institutional Completed assessment Present results and capacity Completed strengthening plan Draft assessment report Completed Assist the Faculty in revising and Three days were required to finalize the finalizing the strategic plan costed strategic plan and PAO 2017 with a small team of 5 people from the Faculty of Medicine. The strategic plan and PAO were finalized on March 28 and are awaiting HFG validation. Activity 8: Institutional strengthening of the National Program for Reproductive Health Conduct institutional Planned for Q3 assessment Present results and capacity Planned for Q3 strengthening plan Write assessment report Planned for Q3 Assist in developing a strategic Planned for Q3 plan for PNSR
5. FIELD SUPPORT ACTIVITIES: DEMOCRATIC REPUBLIC OF THE CONGO - 91
5.1.7 Ethiopia Program Objectives - The overall goal of HSFR/HFG support in Ethiopia is "increased utilization of health services". Program objectives are to:
Improve quality health services;
Improve access to health services;
Improve governance of health insurance and health services; and
Improve program learning. Year 5 Activities - HSFR/HFG Ethiopia’s scope of work focuses on supporting the government of Ethiopia to increase utilization of health services through technical assistance to health care financing (HCF) interventions and reforms that improve the governance and quality of health services. In the current project year, HSFR/HFG will continue strengthening supply-side interventions to improve access to health care services at all levels, while also enhancing utilization through demand-side interventions such as community-based health insurance (CBHI) and social health insurance (SHI), the fee waiver system, and exemption of selected services from fees. In Year 5, technical support for HCF reforms in all regions of Ethiopia will continue, with a greater focus on the two late starter regions (Afar and Somali), new health facilities in all other regions, and weak performing facilities. HSFR/HFG will continue readying for “graduation” those health facilities that have been implementing HCF reforms for a reforms longer period of time and are better able to continue doing so with minimal or no support. The project will also strengthen regional, zonal, and woreda capacity so that health facilities will have the required technical support from governmental bodies. Greater responsibility and cost sharing will be transitioned to RHBs and Ethiopian Health Insurance Agency (EHIA) in particular as part of the project’s capacity building and sustainability strategies. HSFR/HFG will also work with health facilities and government health authorities at all levels to enhance use of additional resources for interventions that would contribute to EPCMD and AFG efforts. Technical support to health insurance, protection mechanisms for the poor through the fee-waiver system and targeted subsidy in CBHI implementing woredas, as well as strengthening provision of selected public health services free of charge through the exemption system will continue. These interventions provide financial risk protection and enable increasing utilization of health services including services related to MNCH as well as to HIV prevention and treatment. HSFR/HFG will continue supporting the gradual scale-up of CBHI in all regions of the country and targets supporting the launch of an additional 176 CBHI schemes (in 176 woredas) in Year 5, for a total of 357 CBHI schemes/implementing woredas at different stages of development receiving HSFR/HFG support during the year.1 A concept note on an approach to implement CBHI in pastoralist areas will also be developed this year to explore expanding CBHI to these populations. HSFR/HFG will continue supporting EHIA with preparatory work for its anticipated launch and implementation of SHI.
1 The number of CBHI schemes/woredas that were functional (i.e., officially launched and providing services to beneficiaries) at the end of Year 4 totaled 181, disaggregated as follows: Amhara 76, Oromia 69, SNNP 30, and Tigray 6. In Year 5, HSFR/HFG will support the launch of 176 additional CBHI schemes as follows, by region: Amhara 24, Oromia 65, SNNP 44, Tigray 30, Addis Ababa 10, and Benishangul-Gumuz 3.
92 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Governance is critical to ensure the health system provides priority health services efficiently and as citizens need. It is also important for health insurance schemes to make strategic purchasing choices and to ensure the schemes’ benefit package covers priority health care services. HSFR/HFG will continue supporting the establishment of and capacity building for health facility governing boards, and improve networking and experience sharing among board members. Establishment and operationalization of effective health facility and health insurance governance systems is critical to enhance transparency, which in turn develops trust and confidence as well as efficiencies in these systems. In Year 5, HSFR/HFG targets providing technical assistance to establish governing boards in 15 hospitals and 17 health centers, and provide training in health facility governance to 721 hospital and health center governing board members. Program learning through routine project M&E, the conduct of Health Accounts (HA), and targeted studies including PLHIV surveys, have been important activities providing information to the project as well as Government of Ethiopia, USAID and development partners. In Year 5, HSFR/HFG will continue reporting on project performance. The project will also continue helping the Federal Ministry of Health (FMOH) to institutionalize the HA methodology within the Resource Mobilization Directorate for the conduct of future HA and related studies. The PLHIV survey started in Year 4 will be completed in Year 5, as will production and dissemination of the final HA report. HSFR/HFG will also continue generating evidence from CBHI schemes to articulate the lessons learned through design, implementation, and ongoing performance of the insurance schemes. In addition, regular supportive supervision of CBHI schemes and their units will be conducted jointly with EHIA and Regional Health Bureaus (RHBs). Supportive supervision has been an important tool allowing the project (and government counterparts) to identify valuable information on scheme performance, provide on-the-spot technical support to health facilities, CBHI schemes, and local authorities, and generate valuable data on progress and challenges related to different components of the reforms. The Government of Ethiopia will play an even greater role this year, as an increasing number of HSFR/HFG activities are transitioned to government. For example, kebele-level training for executive staff will be transitioned to EHIA and RHBs to conduct independently, cascading CBHI scale up directive orientation trainings will be conducted by EHIA branch offices for woreda and kebele cabinet members, and EHIA and RHBs will cover some CBHI training costs for health providers and the cost of broadcasting public service announcements (PSAs) and documentaries. HSFR/HFG will also work to further institutionalize HA within the FMOH. Year 5 Progress Against Objectives - Data collected from CBHI implementing regions indicates that:
Of 350 CBHI implementing woredas, 249 woredas have officially established CBHI schemes. Of these, 168 are providing health insurance coverage for beneficiaries and the remaining schemes are engaging in preparatory activities.
Of the 7,153,957 eligible households in the CBHI implementing woredas (in Amhara, Oromia, SNNP, and Tigray regions), 3,031,143 households (42.4 percent of eligible households; totaling 14.5 million beneficiaries) were enrolled in CBHI schemes as of March 2017.
In the CBHI implementing woredas, 247,179 visits by CBHI members were made to health facilities over the quarter.
CBHI schemes have generated 601,543,647 Birr (US$ 25.9 million) from member contributions July 2013 through March 2017 (excluding general and targeted subsidies). Of this, 212,802,419 Birr (US$ 9.1 million) were collected during the reporting quarter.
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 93 Q2 Additional Information - Activities Not Included in the Work Plan Developed draft CBHI legal frameworks (proclamation and regulation) documents: EHIA established a TWG comprising HSFR/HFG project staff and EHIA staff, to develop a draft CBHI proclamation. The TWG developed the document intended to serve as the legal backing for CBHI implementation nationwide. The proclamation was developed in two options: implement the CBHI program in a centralized structure, or implement the CBHI program with decentralized structures where the role of EHIA will be limited at the federal and regional levels. Prepared draft amendment bill on the SHI proclamation: The TWG established by EHIA produced a draft bill to amend certain articles of the SHI proclamation that led to serious grievances. The articles proposed for amendment mainly include the share of contribution between employees and employers, exclusion of police forces from membership, and waiving pensioners from insurance contributions.
Developed a concept note to examine pros and cons of expanding CBHI scheme to cover formal sector employees: The TWG established by EHIA also developed a concept note that examines the pros and cons of expanding the CBHI program to cover formal sector employees on a voluntary basis. The rationale for developing the concept note is to explore the possibility of expanding CBHI schemes nationwide and involving formal sector employees and their defendants in the insurance scheme, as the implementation of SHI has been delayed due to technical and policy challenges.
Held consultations with EHIA managerial and technical staff on the draft CBHI legal framework document: HSFR/HFG participated in a one-day, February 28, 2017, consultation with EHIA managerial and technical staff to discuss the draft CBHI legal framework document and concept note prepared to assess the pros and cons of including formal sector employees in the CBHI scheme. Participants forwarded some important feedback, and EHIA planned to undertake similar consultations with other groups of experts, stakeholders, and community members to further enrich and finalize the draft documents. A total of 6 people (13 men and 3 women) participated in the meeting—from USAID/Ethiopia, UNICEF, the Clinton Health Access Initiative, World Bank, EHIA, and HSFR/HFG. Participated in the regional review meeting in Amhara: The RHB organized a three-day biannual review meeting (February 15–17, 2017), in Bahir Dar town. The objective of the review meeting was to assess performances of the RHB. The RHB curative and rehabilitative process owner presented the performance report, which was followed by group discussions. HSFR/HFG facilitated the group discussion held on health insurance and presented the report to the audience. Facilitated CBHI woreda-level review meeting in Amhara: At the request of the North Gondar Chief Administrator, HSFR/HFG in collaboration with the EHIA branch office organized a CBHI woreda-level review meeting in two woredas, Alefa and Takusa, on February 18, 2017. The review meeting was aimed to improve weak performances of these woredas. A total of 145 people (109 men and 36 women) participated in the meeting.
Resource mapping: The FMOH requested that all implementing partners, including HSFR/HFG, submit data on annual expected expenditure for 2016/17 and an estimated budget for the upcoming year (2017/18)—an input to estimate required budget for the health system at all levels (federal, regional, zonal/sub-city, and woreda levels). The data will also be used for woreda-based planning. HSFR/HFG computed its expenditure for 2016/17 and estimated the 2017/18 budget by classifying expenditures to appropriate activities and categorizing the project budget into the HSTP strategic initiative.
94 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Table 31 provides activity-specific updates. TABLE 31. ETHIOPIA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Improve quality of health services Provide training on HCF reform Amhara: HSFR/HFG organized refresher training implementation on HCF reform implementation and financial management for select health facilities (with poor performance) on March 17–18, 2017 in Debre Tabor town. Presentations were made on: highlights of HCF reform and its progress to date in the country and in the Amhara region in particular; and the directives (RRU; organization, management, and duties of health center (HC) governing bodies; the new fee-waiver system; and government financial management). This was followed by a review of HC performance, and discussion of next steps. In total, 57 people (40 men and 17 women) drawn from 10 zones, 2 town administrations (Bahir Dar and Gondar), 27 woredas, and 29 HCs attended the training. SNNP: HSFR/HFG in collaboration with the RHB organized a two-day HCF training (February 25– 26, 2017) for health facility governing body members in Wolkitie town, Guraghie zone. The current status of HCF reform at national and regional levels, facility governance, RRU, fee waiver and exempted health services, user fee setting and revision, and monitoring and evaluation (M&E) of HCF reform were the primary training topics. Discussions enabled participants to reflect on the current status of reform implementation in their respective woredas and identify gaps requiring attention of governing bodies. A total of 35 governing board members (all men) drawn from 35 HCs, 5 zones, and 1 special woreda administration attended the training. Advocated and provided Benishangul-Gumuz: HSFR/HFG technical support for auditing of communicated with Bureau of Finance and health facilities Economic Development (BoFED) on the need to enforce financial auditing of health facilities. As a result, there is an encouraging movement in Woreda Finance and Economic Development (WoFED) offices to conduct financial audits of HCs. In addition, the two hospitals in the region (Assosa and Pawe) started financial audits using internal and external auditors. The latter are assigned by the Regional Audit Bureau. Gambella: HSFR/HFG continued to advocate on the need to undertake financial audits at health facilities. As a result, only two HCs (Pukedi and
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 95 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Basil) did not undertake a financial audit last fiscal year (2008 Ethiopian Fiscal Year). Currently, four facilities (two hospitals and two HCs) have assigned an internal auditor, while the remaining nine facilities have not yet recruited or assigned an internal auditor. SNNP: HSFR/HFG shared supportive supervision findings with the woreda administration, woreda health office (WorHO), and WoFED offices. The findings showed that 25 HCs had not conducted a financial audit. HSFR/HFG advocated to WoFED offices on the need to do financial audits in health facilities on an annual basis using external auditors. Though BoFED approved the structure for an internal auditor, 18 HCs have not yet recruited for and filled vacant positions. Provide financial management SNNP: HSFR/HFG held an eight-day financial and/or audit training management training in Butajira town on March 6–11, 2017. Forty key PFPA staff (35 men and 5 women) attended the training. They were from 8 HCs in Sidama; 5 HCs in Hadiya; 4 HCs each in Wolayta, Segen, and Gamo Goffa; and 3 HCs each in Gedeo, Silte, Guragie, Kembata Tembaro, and Butajira zones. The respective woredas covered the training costs; the project provided technical assistance, serving as trainers. Tigray: HSFR/HFG in collaboration with the RHB and BoFED organized and provided a seven-day financial management training on March 6–12, 2017, for health facility key finance staff in Adigrat town. The training was aimed at enhancing the knowledge and skills of key finance staff on theoretical and practical applications of a financial management system. The contents of the training included: basics of HCF reform implementation; source documents of the accounting cycle (transaction registration, legers, trial balance, and bank reconciliation); and types of reports (revenue, expenditure, transfer, receivables, payables, trial balance, and chart of accounts, etc.). The presentation was followed by thorough discussion. BoFED experts and HSFR/HFG staff served as trainers. Discussants reported high turnover of trained and experienced finance staff, due to disparities in the structure (job grade and salary scale) of finance staff and financial regulation of the region. BoFED experts promised to bring the high turnover rate issue to the attention of BoFED officials. A total of 42 finance personnel (26 men and 16 women) from 21 primary hospitals attended the training session.
96 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Advocate to government and Amhara: HSFR/HFG followed up with zones and new/existing HCs implementing woredas by phone to recruit key finance staff and HCF reforms to approve a facility place them at new HCs. Consequently, six newly structure that includes critical functioning HCs (three in Wag Himra and one finance staff and recruit for those each in North Shoa, North Gondar, and South positions Gondar zones) recruited key finance staff. Benishangul-Gumuz: HSFR/HFG provided technical support (by phone) to zones and woredas to recruit and place key finance staff at new HCs. Three of the five newly functioning HCs recruited and placed key finance staff (one in Kamashi and two in Assoza zones). The HSFR/HFG team has been facilitating the recruitment of substitute finance staff where there are reported turnovers. SNNP: HSFR/HFG provided evidence-based advocacy to the Bureau of Financing and Economic Development (BoFED), Woreda Finance and Economic Development (WoFED), and Woreda Health Office (WorHO), on the need to approve the structure (job grade and salary scale) of Procurement, Finance, and Property Administration (PFPA) staff for type A and B HCs. (Type A and B refers to the standard given by the Federal Ministry of Health (FMOH) based on facility infrastructure, number and composition of professionals, etc.) BoFED approved the structure, taking into account the volume of the work the staff have been performing. As per the findings of supportive supervision, 18 HCs situated in 7 zones and 12 woredas have 1 to 3 PFPA staff. Gambella: The number of PFPA staff recruited and placed in health facilities showed variation in the region. Some facilities are allowed to recruit six PFPA staff, others only four. HSFR/HFG advocated to the woreda administrations, WorHO, and WoFED office to approve the structure (job grade and salary scale) of PFPA staff, and facilitate recruitment.
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 97 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 2: Improve access to health services Provide training to CBHI Amhara: HSFR/HFG in collaboration with the implementing staff, cabinet RHB and EHIA Bahir Dar branch office organized members, executive organs, a one-day training session for woreda and kebele others cabinet members in 13 woredas (3 urban and 10 rural). The objective of the training was to enhance trainees’ knowledge and skill on the basics of the CBHI program and the Regional CBHI Directive. A total of 1,676 people (1,259 men and 417 women) attended the training. These were – woreda-level cabinet members and leaders, WorHO staff, heads of health facilities, kebele officials (chief administrator, manager, and one community representative), and two health extension workers. The RHB covered the training costs of 12 woredas, and the EHIA Bahir Dar branch office covered the training costs of one woreda (Merawi woreda). HSFR/HFG served as trainer and provided printed materials (directive, bylaws, and Financial and Administrative Management System (FAMS) manual). Oromia: HSFR/HFG in collaboration with Shashemene EHIA branch office provided training on CBHI financial management for CBHI executive staff from March 13 to15, 2017 at Arsi Negelle Town. The training focused on sources of revenue, financial source documents, the accounting cycle, chart of accounts, recording and posting of transactions, reimbursements to the health facilities, preparation of financial reports, bank reconciliation, and closing of scheme account at the end of the year. Trainers made PowerPoint presentations, which were followed by group exercises and plenary discussions. At the end of the training, participants visited the CBHI scheme in Arsi Negelle town. A total of 30 CBHI accountants attended the training—23 men and 7 women, drawn from 27 schemes (in Bale, Guji, West Guji, Borena, and West Arsi zones) and the Shashemene EHIA branch office (3 accountants). SNNP: HSFR/HFG provided orientation training on the CBHI directive to EHIA Hawassa and Hosanna branch office personnel to enable them cascade orientations to zonal, woreda, and kebele officials in Hawassa town and the Hulbareg woreda capital. A total of 108 people (73 men and 35 women) attended the orientation. Hawassa and Hosanna EHIA offices covered training costs (per diem and refreshments), while HSFR/HFG provided technical support, and served as trainers.
98 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps
Tigray: HSFR/HFG in collaboration with the EHIA branch office organized eight one-day orientation sessions (January 3–March 4, 2017) on the CBHI program to woreda and kebele cabinet members of eight woredas (Ofla, Saesie tsaeda Emba, Ganta Afeshum, Wukro town, Tsegedie, Dega Tembien, Wolkait and Alamata). The objective of the orientation was to enhance awareness of participants, accelerate CBHI information dissemination at the grassroots level, and facilitate the establishment of schemes. The orientation focused on basics of the CBHI program, the new regional directive, and responsibilities of different stakeholders. Major issues raised during discussion sessions included uneven implementation of the revised contribution amount of 240 Birr/year in the region, shortage of drugs in the market, and high workload of kebele managers. EHIA staff and woreda administrations addressed issues, and RHB representatives committed to addressing the observed problems. A total of 616 people (405 men and 211 women) participated in the orientation—woreda cabinet members, kebele administrators, kebele managers, kebele cashiers, heads of HCs, and health extension workers. HSFR/HFG provided technical support (served as co-trainer and trainer), and the RHB covered the training costs. Support adaptation of CBHI Addis Ababa: The TWG, comprising directive by regional government representatives from EHIA, the Addis Ababa Health Bureau, and HSFR/HFG, developed and finalized the Addis Ababa City Administration CBHI regulation in the first quarter of the year. The Addis Ababa City Cabinet endorsed it during the current reporting quarter. The regulation stipulates that the annual CBHI contribution is to be 350 Birr per household (HH), rather than the 500 Birr stated in the CBHI prototype scale-up directive issued by the FMOH. The city administration revised this contribution based on residents’ ability to pay for services. The TWG also revised other CBHI parameters such as membership renewal, the benefit package, and the reimbursement system. Provide technical and financial Amhara: HSFR/HFG provided technical support support for auditing of selected to all CBHI schemes to close their Ethiopian Fiscal CBHI schemes Year (EFY) 2008 (2015/16) accounts. Accordingly, 63 schemes closed their accounts during this year. Of these, 48 schemes closed their accounts during
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 99 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps the reporting quarter; 62 schemes were audited by respective WoFED auditors up to the end of this quarter. Audit findings indicate a loss of 3,969,913.16 Birr and that 664 cash receipt voucher pads were missing. The respective woreda administrations played a pivotal role in recovering some of the embezzled finances: 1,812,961.98 Birr, and 354 cash receipt voucher pads. Frequent staff turnover and poor commitment of WoFED auditors is a serious threat hindering accounts closing and financial audit of schemes. A significant amount of finances (nearly 2.2 million Birr) has not yet been paid back to the schemes due to uneven legal follow-up by the relevant officials. Support creation of CBHI SNNP: HSFR/HFG, in collaboration with EHIA implementation centers of Hawassa and Hosanna branch offices, provided excellence in regions technical assistance to the CBHI center of excellence woredas: Shebedino, Meskan and Mirab Azernet woredas. HSFR/HFG and the EHIA Hawasa branch office organized training (February 22, 2017) for community leaders and other influential stakeholders in Shebedino woreda, where 265 people (228 men and 37 women) attended. The training aimed to enhance trainees’ knowledge on the basics of health insurance (HI) and the CBHI directive. The team also participated in the Shebedino woreda cabinet meeting held on February 26, 2017 in Hawassa. The revised CBHI regional directive and performance of the scheme were the discussion agenda items. At the end of the meeting, all cabinet members promised to improve the current HHs enrollment rate using government structures at all levels. A total of 72 people (67 men and 5 women) participated in the meeting— woreda cabinet members, and representatives of WorHO and the zonal health department (ZHD). The team also made field visits in Meskan and Mirab Azernet woredas to review scheme performance, provide technical support, and provide feedback on the observed gaps to the respective woreda administrations. In the end, woreda officials promised to allocate operational budget and well-furnished office space to the schemes; and to take immediate action to solve some of the reported problems. Tigray: HSFR/HFG in collaboration with EHIA branch offices provided orientation on the CBHI center of excellence in a general assembly held in Tahitay Adiabo (February 15, 2017) and Kilte Awlaelo (February 23, 2017) woredas. The
100 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps orientation was followed by discussions, and participants forwarded their concerns on: unavailability of drugs in contracted health facilities—especially hospitals—and the highest increase on annual contribution (from 142 Birr to 240 Birr), absence of revised CBHI directive, and high workload of kebele managers. EHIA representatives and the HSFR/HFG team provided feedback on the issues raised. Representatives of health facilities and woreda administrations promised to resolve the problems as appropriate; and promised to bring some of the issues— unavailability of drugs and absence of revised CBHI directive—to the attention of regional decision-makers. In total, 402 people (307 men and 95 women) participated in the meeting — woreda cabinet members, kebele administrators, kebele managers, kebele cashiers, heads of HCs, health extension workers, and representatives of the CBHI membership. Follow-up with EHIA and EHIA Gambella: The region is divided into 3 branch offices on the allocation administration zones, 1 town administration, 1 and transfer of federal special woreda and 13 woredas. Of these, three government subsidy to CBHI woredas, Gog (Angna zone), Lare (Nuer zone) schemes and implementing and Godore (Mezang zone) were selected to woredas implement the CBHI program. The RHB in collaboration with woreda administrations selected these woredas based on population size, and availability of health facilities and skilled health professionals. The RHB endorsed the CBHI implementation directive and has been undertaking preparatory activities to start the program. SNNP: HSFR/HFG conducted continuous advocacy to woreda administrations, and facilitated the release of the targeted subsidy to the respective woredas. Six schemes (Alcho Wuriro, Lamfro, Getta, Butajira, Sheko, and Debub Benchi) received a total of 479,503 Birr as targeted subsidy from the respective woreda administration. Tigray: The regional government allocated and transferred 5,063,216 Birr, through BoFED, as targeted subsidy to 18 woredas implementing the CBHI program for EFY 2008. Advocate to and support woreda SNNP: HSFR/HFG held consultation meetings administrations and WoFED to with the RHB to discuss the need to undertake undertake financial audits of financial auditing of CBHI schemes. As a result, CBHI schemes and Provide TA the RHB wrote and issued an official letter for to CBHI schemes to close their each CBHI implementing woreda to undertake a annual accounts and prepare for financial audit as per the regional CBHI directive
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 101 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps being audited and bylaw (issued by respective woredas). The project team provided technical assistance to WoFED auditors on financial auditing, preparation of audit report, and how to facilitate corrective measures in areas where embezzlement of scheme funds is discovered. It also conducted continuous follow-up to assess the progress of this undertaking. Tigray: HSFR/HFG in collaboration with EHIA branch offices provided technical support to 13 CBHI schemes on pre-audit tasks, which included: cross-checking contribution, collection, and transfer to scheme; proper arrangement of financial documents and contract agreements; reconciliation of bank statements; cross-check of annual revenues and expenditure; and review of settlement of claims. Support was also provided in preparing the accounting cycle and financial reports. Five out of 13 schemes have not yet closed their financial accounts (for EFY 2008). This is variously due to turnover of scheme accountants, kebeles’ not having submitted their used receipt voucher pads to the schemes, and lack of attention by woreda administration and WoFED offices to the financial audit of schemes. Advocate to and follow-up with Benishangul-Gumuz: HSFR/HFG advocated for regional/zonal/woreda level indigent selection and budget allocation for officials regarding indigent and targeted subsidy in the three woredas (Bambasi, fee-waiver beneficiary selection, Dangur, and Kamashi) selected to implement the allocation and transfer of CBHI program. These woredas enrolled 69 targeted subsidy, renewal of percent, 44 percent, and 33 percent of eligible CBHI membership HHs. As per the CBHI regional directive, the regional government will cover 70 percent and woreda administration 30 percent of budget required for targeted subsidy. Accordingly, the regional government allocated 472,080 Birr (199, 640 Birr to Bambasi, 199,080 Birr to Dangur, and 73,360 Birr to Kamashi); and BoFED wrote a letter to the scheme to collect the funds. The respective woreda administrations allocated 85,520 Birr, 85,320 Birr, and 31,440 Birr as the targeted subsidy. However, only Dangur and Kamashi released funds: 66,000 Birr and 31,400 Birr to the respective schemes; they plan to release the remaining funds in the upcoming quarter. Amhara: HSFR/HFG followed up on implementation of the fee-waiver system in 20 non-CBHI woredas using regular supportive supervision visits. The visited woredas have been providing waived services as per the regional HCF directive. However, there is unevenness in
102 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps implementation of the fee-waiver system between existing and newly functioning HCs. The former provided services and received reimbursements on time, but the latter failed to do so. Benishangul-Gumuz: As in the Amhara region, HSFR/HFG followed up with 18 non-CBHI implementing woreda administrations (i.e., physically or by telephone) on the implementation of the new fee-waiver system. Major activities accomplished through the follow-up were revision of the list of waiver beneficiaries and renewal of fee-waiver beneficiaries’ ID cards. As a result, these woredas allocated budget for fee waiver beneficiaries, and have been reimbursing the cost of waived services regularly to health facilities. SNNP: HSFR/HFG advocated to 6 woreda administrations (where 13 HCs are situated), and to WorHO and WoFED offices, to select poor households and allocate budget for reimbursement to waived services. Support health facilities to apply a Amhara: HSFR/HFG has been continuously data capturing tool to collect advocating for institutionalizing CBHI data data on fee-waiver and exempted management in the RHB, during various review health services meetings, trainings, supportive supervisions, etc. A consensus was reached that schemes will directly send their CBHI data to their respective EHIA branch office and the RHB. Population figures obtained from woreda administration and WoFED differ; a consensus was reached to use projected population figures obtained from BoFED. Advocate to government on Amhara: The regional government allocated need to allocate budget for budget to cover costs health facilities (HCs and exempted health services and district hospitals) incurred to provide exempted follow-up on the implementation health services. All health facilities (811) have of exempted services in health been uniformly providing these services to facilities beneficiaries. Benishangul-Gumuz: HSFR/HFG advised 42 health facilities (2 hospitals and 40 HCs) to utilize retained revenue for the provision of exempted health services i.e., for procurement of essential drugs, laboratory reagents and basic medical equipment. It also communicated with 16 woreda administrations and heads WorHOs to allocate budget and reimburse health facilities for costs incurred in the provision of these services. Gambella: Findings of supportive supervision indicate that regional government did not allocate budget for exempted health services, and facilities are utilizing retained revenue and some donations allocated for the needy to cover costs of these services. This is because facilities (excluding
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 103 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Gambella Hospital) did not properly record the type of exempted health services provided, nor the costs they incurred to provide services and report to the concerned health office. HSFR/HFG advised facilities to record and report costs they incurred to provide services to the concerned health office; and the woreda administrations to advocate for the regional government to allocate budget for procurement of drugs and medical supplies at least to compensate the amount expended from the retained revenue.
SNNP: Findings from supportive supervision indicate that all visited woredas and town administrations did not allocate budget for exempted health services. HCs provided all exempted services free of charge for users, which drained facilities internal revenue. Some HCs charged women for antibiotic drugs required for delivery services, and many of facilities did not record or report the services provided or the amount they incurred in providing the services. Using this information, HSFR/HFG advocated to woreda and town administrations on the need to allocate budget for exempted health services. The team also advised HCs to abide by the Health Service Delivery and Administration (HSDA) legal framework, which states all exempted health services should be provided free of charge. Produce PSAs and/or Oromia: HSFR/HFG also facilitated the documentaries in Amharic, production and broadcasting of a CBHI television Tigrigna and Afan Oromo documentary program in Afan Oromo by the languages and conduct regional mass media agency. A team of experts broadcasting tasks drawn from the EHIA head office, RHB, and the regional communication affairs office visited the schemes in Gimbichu and Deder woredas to produce the documentary. The documentary is under review. The final version will be broadcast on regional TV. Tigray: HSFR/HFG in collaboration with Tigray RHB facilitated the production and dissemination of a television CBHI documentary program by the Tigray regional mass media agency on CBHI scheme performance, implementation challenges, and successes. The documentary includes interviews with beneficiaries, heads and professionals of health facilities, and local authorities in Kilte Awlaelo, Tahitay Adiabo, Tahitay Maichew, and Hawzen woredas on their views and perceptions of the operation of
104 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps schemes, benefit packages, etc. The documentary was finalized this quarter and is expected to be broadcast on regional TV in the upcoming quarter. Organize regional media visits to Amhara: HSFR/HFG facilitated (provided select CBHI schemes to facilitate vehicle)/participated in the second round media the production, broadcast and visit carried out by the Amhara Mass Media dissemination of programs on Agency (AMMA) this activity. (The first round health insurance activities media visit was held in the previous quarter). The through regional media team visited six woredas and documented best experiences on CBHI program implementation.
The AMMA has been broadcasting best experiences of CBHI schemes every Friday from 7:45 to 8:00 a.m., and has been documenting CBHI program implementation in woredas that were not covered during the first round. The EHIA Bahir Dar branch office covered the cost of airtime for disseminating CBHI messages. Oromia: HSFR/HFG in collaboration with EHIA branch offices in Oromia organized training for government affairs communication and media personnel. The training was aimed to impart knowledge on basic concepts of CBHI, principles, directives, and the role of media personnel in CBHI awareness creation activities. SNNP: HSFR/HFG organized a visit for regional media personnel from February 12 to 22, 2017 to Damboya, Mareko, Meskan, Lamfro, Mirab- Azernet, and Damot Gale woredas. The objective of the visit was to facilitate media personnel’s efforts to collect information that will be used as input to promote the CBHI program through South TV and FM 100.9 radio programs. The media personnel held interviews with woreda administrators on their governance and leadership capacities related to CBHI program implementation, and with community members in selected kebeles and health posts. The media personnel accompanied project staff in visiting health facilities to assess their readiness (in terms of human resource fulfillment, drugs and supplies adequacy, level of infrastructures, etc.) to provide services for beneficiaries. The project office followed up on the production and broadcasting of CBHI activities through TV and radio programs.
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 105 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Produce and print CBHI HSFR/HFG provided editorial support for the brochures and posters and EHIA branch offices to facilitate the production prepare and distribute CBHI and distribution of success stories and brochures. success stories in regions It also produced the success story of the Deder scheme (Oromia region) based on the life story of one CBHI member who improved his health status as a result of the CBHI program. The story tells how the CBHI program helped a household to protect its income from unexpected out-of- pocket payment for health care services and invest the money in income generating activities. HSFR/HFG also contributed an article on “the roles of the agency and health insurance practices in Ethiopia” to the EHIA sponsored Addis Zemen Newsletter. The article appeared as a special issue on the celebration of “Grand Renaissance Dam 6th year Anniversary.” HSFR/HFG contributed a written news story in English and Amharic for the EHIA quarterly newsletter. Support/provide training in CBHI SNNP: HSFR/HFG provided technical assistance directives, implementation to the RHB to undertake a two-day training for manual, data management woreda and kebele cabinet members in Tula sub- manual, clinical and financial city, Hawassa town; and three woredas in manuals Wolayta zone. The training was intended to strengthen CBHI preparatory activities in these sites. HSFR/HFG, the RHB, EHIA branch offices, ZHDs, and respective woreda administrations jointly provided the training. A total of 406 people attended the training (299 men and 107 women), drawn from Tulla Sub-city and Kindo Didaye, Damot Pulasa, and Duguna Fango woredas attended the training. Activity 3: Improve governance of health services and health insurance Conduct health facility governing HSFR/HFG provided two-day basic/refresher board or body training training for health facility governing board members. The objective of the training was to enable governing boards to comprehend their duties and responsibilities and properly oversee implementation of reform components, i.e., RRU, user fee setting and revision, fee waiver and exemption, outsourcing of non-clinical services, and establishing private wing/room in public health facilities. Trainers presented highlights of HCF reforms and progress to date; roles and responsibilities of health facilities governing boards/bodies; and HCF reform components.
106 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Support/organize experience- HSFR/HFG organized a thematic meeting in sharing, networking Adama town to review performance, draft a legal visits/meetings/workshops (in framework (a directive for higher-level pooling, a HCF reform implementation, directive for incentivizing kebele CBHI executives, health insurance, inter-regional, and for setting job grade and human resource thematic, etc.) sizes of CBHI schemes), and other operational documents. Furthermore, participants discussed the need to generate evidence on the performance of schemes as well as the impact of the CBHI program. Discussants agreed to use a standard checklist that will be issued by the central monitoring and evaluation (M&E) team, and data will be collected from selected schemes (10 in Amhara, 10 in Oromia, 6 in SNNP and 4 in Tigray) during the fourth quarter. A total of 21 staff participated in the meeting. Support CBHI performance Central: EHIA in collaboration with HSFR/HFG review meetings (including organized a biannual health insurance review federal, regional, zonal, steering meeting on March 9–10, 2017 in Bahir Dar town. committee) The review meeting aimed to assess progress, identify implementing challenges, and agree on the plan of action to be executed in the upcoming quarter. Prior to the meeting, invitees were divided into two subgroups and visited selected CBHI schemes in Amhara. The first group visited Kewot woreda (North Shoa), Kemise town and Dawa Chefa woreda (Oromo nationality zone), and Tehuledere woreda (South Wollo). The second group visited Dembecha and Aneded woreda, and Finoteselam town (in Western Amhara). In general, the overall achievement of the schemes was found to be promising, except for the scheme in Finoteselam town, where coverage was very low. Weak leadership, adverse selection, and inadequate health care service delivery were the observed implementation challenges that deter members from renewing membership. At a six-day EHIA biannual review meeting, Mr. Atakelti Abraha, Director of EHIA, made an opening speech stating that the agency is committed to fully supporting CBHI activities through its branches, and promised to allocate adequate budget for the remaining activities. EHIA presented a performance report, which was followed by thorough discussion. Dr. Amir Aman, Ministry of Health State Minister, moderated the discussion. He also reacted to issues related to drug supply, and equipping facilities to realize the Health Sector Transformation Plan (HSTP). He also promised to provide motor-bikes to strengthen the implementation of the CBHI
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 107 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps program in remote and hard-to-reach rural kebeles and to work to resolve the issue of staff benefits. A total of 139 participants (117 men and 22 women) attended the review meeting. HSFR/HFG provided technical support to EHIA on a daily basis through its seconded staff and project central health insurance staff. HSFR/HFG conducted joint meetings with EHIA to discuss: the preparation of CBHI legal framework, technical and logistics support for agency’s biannual review meeting, and joint review of the progress of CBHI program implementation in Addis Ababa with the city administration health bureau. Amhara: The RHB organized a one-day CBHI review meeting on February 25, 2017 in Bahir Dar town. The meeting was aimed at reviewing the status of CBHI program implementation, and sharing experiences between zones and woredas. HSFR/HFG and the RHB curative and rehabilitative process staff made a presentation on CBHI program performance. This was followed by thorough discussion, which was facilitated by the deputy head of the RHB and head of the president’ office. A total of 101 people participated in the meeting (91 men and 10 women)—mainly heads of zonal administration offices, EHIA branch managers, zonal CBHI coordinators, heads of selected woreda administration office, woreda CBHI coordinators, and health officers. HSFR/HFG and RHB jointly covered the cost of the review meeting. Amhara: HSFR/HFG in collaboration with the respective zonal administration offices organized one-day zonal-level CBHI review meetings (in 10 zones). The objective of the meeting was to review CBHI performance, assess implementation status and challenges, and share experiences among woredas. A total of 1,149 people participated in the review meetings (1,038 men and 111 women), from zonal offices and CBHI implementing woredas. Amhara: The RHB established a task force comprising RHB curative and rehabilitative officers, HSFR/HFG staff, and director of EHIA Bahir Dar branch office. The task force held regular weekly meetings. Deputy Head of the RHB chaired the meeting where participants discussed on implementation challenges, identified best experiences, and discuss the way forward. Discussants reviewed status of each zone and woreda on a weekly basis. At the end of the
108 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps meeting, minutes were endorsed and sent to each zone. Benishangul-Gumuz: HSFR/HFG participated in the RHB biannual review meeting held on January 11, 2017 in Assosa. Staff gave a presentation on the overall performance of the CBHI program; a total of 554 people (364 men and 190 women) drawn from the RHB, three ZHDs and 21 woredas, and selected health facilities participated. Benishangul-Gumuz: HSFR/HFG held periodic consultation meetings with CBHI coordinators assigned in the regional President’s Office, RHB, and EHIA branch office to review progress and discuss the way forward. Oromia: HSFR/HFG in collaboration with EHIA branch offices situated in Oromia region organized one-day zonal-level CBHI review meetings in seven zones. Meeting objectives were to review performances of schemes (enrollment of new members, membership renewal, and health care service provision to beneficiaries) and update those assembled on the new CBHI directive. About 400 zonal and woreda CBHI board members participated in the meetings. SNNP: HSFR/HFG in collaboration with zonal administrations, ZHDs, and Hosanna and Hawassa EHIA branch offices facilitated zonal-level CBHI biannual review meetings in Sidama, Gedeo, Silte, Hadia, and Kambata zones. Major discussion points included: review of the performance of each zone and woreda, CBHI implementation challenges, the revised CBHI directive, and planned activities for the upcoming quarter. A total of 414 people (299 men and 115 women) participated in the review meeting: 29 men and 4 women in Sidama, 13 men in Gedeo, 61 men and 10 women in Siltie, 46 men and 3 women in Hadiya, and 150 men and 98 women in Kembata Tembaro--participated in the review meeting. SNNP: HSFR/HFG held consultation meetings with Hossana and Arba-Minch EHIA branch offices’ technical and managerial staff. HSFR/HFG made presentations on major activities accomplished to realize health insurance in the region. This was followed by discussion on major implementation challenges, existing opportunities, and planned activities for the upcoming quarter. A total of 20 EHIA staff (3 from EHIA head office and 17 from branch offices) participated in the meeting. HSFR/HFG provided technical support and EHIA branch offices covered refreshment
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 109 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps costs. SNNP: HSFR/HFG gave a presentation to the CBHI Regional Steering Committee (RSC) members during a one-day (January 17, 2017) review meeting held in Hawassa town. The revised CBHI directive, performance of CBHI implementing woredas, and implementation challenges were addressed in the presentation. This was followed by thorough discussion on these issues. Participants decided that CBHI woredas need to enroll 50 percent eligible HHs before officially establishing schemes, and agreed to carry out contribution collection and financial audits of schemes on annual basis. A total of 20 people (all men) participated in the meeting. Tigray: HSFR/HFG participated in the EHIA branch offices biannual review meeting held on January 17, 2017 in Mekelle town. Progress of household enrollment and financial status of schemes, data management and CBHI orientation in the newly selected woredas, delays in the approval of revised directive and gaps in health service provision in contracted facilities, implementation of CBHI center of excellence, printing of receipt vouchers by BoFED, and impediment of new CBHI executive staff recruitment by the Civil Service Bureau were major discussion points. Discussants also reviewed the strengths and observed gaps in CBHI implementing woredas. In the end, they agreed to forward the issue to the decision makers i.e., RHB and BoFED. Provide technical support for the Amhara: HSFR/HFG advocated to the RHB, establishment of health facility ZHDs and woreda administrations on the need to governing boards/bodies establish health facilities governing boards. Accordingly 14 newly functioning facilities (7 hospitals and 7 HCs) established facility governing boards, and are waiting for the governance training. Support EHIA in conducting HSFR/HFG, through its seconded staff, supported supportive supervision of health EHIA in the preparation of EHIA’s three-year insurance programs, preparing program budget (2010-2012 EFY). The task program budget /workplan required the preparation of detailed budget for /reports, and conducting rapid 2010 and output-level targets for the remaining assessments on research topics two years. Currently, the overall process (budget preparation) is in progress and will be submitted to MoFEC for endorsement. HSFR/HFG also supported EHIA in revising its EFY 2009 annual work plan following the agency’s biannual review meeting, and drafting its EFY 2009 biannual performance report, which will be submitted by
110 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps EHIA to the Parliament through the FMOH. Activity 4: Improve program learning Conduct supportive supervision HSFR/HFG conducted regular quarterly at health facilities and select supportive supervision in 134 facilities and 41 CBHI schemes, and CBHI schemes. While conducting supervision, the kebeles/sections project team also provided technical support on CBHI advocacy and sensitization, enrollment of new CBHI members and renewal, ID card preparation and distribution, and contribution collection. They also held discussions with woreda administrators, CBHI scheme coordinators, kebele chairpersons, and heads of health facilities. The project also participated in FMOH/RHB routine integrated supportive supervision (ISS) held in health facilities and ZHDs and WorHOs, as follows. Participate in and support FMOH Central: During the reporting quarter, Afar RHB and EHCRIG ISS in select health in collaboration with the FMOH organized four facilities three-day training sessions (two sessions each in Awash and Logia). The objective of the training was to strengthen performance providers at Primary Health Care Units (PHCUs), and cascade the Ethiopian Health Centers Reform Implementation Guideline to the health providers. HFG received the TOT in Adama town, and served as a facilitator in all the trainings held in this region. Topics of the training included: Leadership and Governance, Linkage between HCs and HPs, Patient Flow in HCs, Medical Record Management, Pharmacy Service, Laboratory Service, implementing partners (IPs) and CASH, Facility Management and Medical Equipment, Human Resource Management, and Quality Management. Trainees were: RHB staff, Medical Directors, three health workers from 97 HCs, and heads and experts from 32 WorHOs. A total of 583 participants (189 in Awash and 394 in Logia) attended the training. Benishangul-Gumuz: HSFR/HFG participated in the task force established to conduct ISS on the implementation of EHCRIG in six HCs situated in Bambasi and Assosa woredas (Assosa zone), and Kamashi woreda (Kamashi zone). Oromia: HSFR/HFG participated in the two rounds of training of trainers (TOT) sessions (December 25-29, 2016, and January 15-18, 2017) organized by the RHB and Yale University in Jimma and Adama towns, respectively. The TOT was provided to 10 zonal primary health care unit (PHCU) teams and 16 town administrations in
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 111 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps that order. The TOT was aimed to enhance participant knowledge and skill on EHCRIG and woreda transformation. A total of 99 people attended the training (45 men and 8 women in Jimma, and 36 men and 10 women in Adama). Trainees made presentations on PHCU governance; woreda transformation; and other PHCU guidelines. Central: HFG participated in the ISS organized by the Medical Services Directorate of the FMOH, held in hospitals to validate the implementation of HSTP. Hospitals are expected to report their performances on HSTP using key performance indicators. Hospitals’ performance reports focused on four chosen reform components: Governance and Leadership, IP and Control, Facility Management, and Finance and Asset Management. When data were compared with the ISS first quarter performance report, improvements were observed only in facility management. IP and Control did not show any progress compared with the first quarter performance, while Governance and Leadership and Finance and Asset Management showed a relapse. SNNP: HSFR/HFG participated in the ISS organized by the RHB and held in 1 ZHD (Gedeo), 2 WorHOs (Gedeb and Dilla Zuria), and 4 health facilities (Gedeb primary hospital; Gotiti HC in Gedeb woreda; and Chichu and Mechile Sisota HCs in Dilla Zuria woreda) from February 13 through 23, 2017. Tigray: HSFR/HFG participated in the RHB biannual review meeting held from February 22 through 23, 2017 in Korem town. The meeting aimed to assess the progress of planned activities and discuss the observed implementation challenges. The RHB presented the findings of ISS to the participants, and provided feedback to the respective woreda and health facility where there were implementation gaps. HSFR/HFG participated in the review meeting, and the RHB covered the costs of the meeting. Produce and disseminate project HSFR/HFG produced and distributed 1,500 copies quarterly newsletter of HSFR/HFG's quarterly newsletter “Health Financing Newsletter” Volume 4, Number 1 to stakeholders.
112 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps For Health Accounts VI, finalize HSFR/HFG conducted several meetings with BDS, PLHIV health services utilization the consulting firm contracted to undertake the and spending survey (data PLHIV survey, to resolve unforeseen problems collection, data analysis, survey related with the delay of the report which was report) and produce and not submitted during the reporting quarter. To disseminate survey report and facilitate resolution and expedite completion of policy brief the study, HSFR/HFG held several meetings to resolve issues and the project is on track to complete the survey. Support and participate in CBHI Amhara: HSFR/HFG participated in the RHB review and hospital reform biannual review meeting held from February 15 review meetings (including through 17, 2017 in Bahir Dar town. The RHB federal, regional, zonal, other) planning and policy process owner presented data on six months of performance including in the areas of HCF reform and CBHI activities. Discussants raised unavailability of drugs in the market and the Pharmaceutical Fund and Supply Agency as major challenges, and the RHB promised to discuss the issue with the agency. Over 300 people participated in the meeting. Amhara: HSFR/HFG participated in the biannual ZHD review meeting organized in South Wollo zone from February 7 through 9, 2017 in Kombolcha town. The project made a presentation on major goals and rationales of HCF reform, proper utilization of retained revenue, performance of governing boards, and practical application of revised user fees, including the observed implementation challenges. Benishangul-Gumuz: HSFR/HFG participated in the RHB biannual health sector review meeting in Assosa town. The RHB planning and programing core process owner presented data on six months of performance, including health facilities’ performance on the implementation of HCF reform—with due emphasis on revenue retention and utilization. A total of 554 people (364 men and 190 women), drawn from the RHB, ZHDs, WorHOs, and health facilities, participated in the meeting. Discussants recommended building capacity of facility governing boards, which play a major role in the implementation of HCF reform as well as the governments’ woreda transformation agenda. SNNP: HSFR/HFG participated in the three-day (February 28 to March 2, 2017) RHB biannual review meeting held in Wolayta Sodo town. The meeting aimed to share knowledge and best experiences among zones/special woredas; it was organized by the RHB Medical Service Core Process (MSCP). Major topics of the discussion
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 113 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps included: HCF reform implementation, the status of the CBHI program, Emergency Case Services (Ambulance and Blood Bank), IPPS/CASH, Health Centers Reform, and Good Governance. Each zone/special woreda presented performance reports including specific implementation challenges encountered in the last two quarters. The RHB MSCP also presented the regional consolidated report, which was thoroughly evaluated. Two MSCP officers from each zone and special woredas participated in the review meeting. Provide support for and Amhara: HSFR/HFG held a review meeting on participate in FMOH, RHB, ZHD, March 9, 2017 in Babasi woreda. The objective of EHIA review meetings the meeting was to discuss selection of indigent HHs, CBHI implementation challenges and way forward. Woreda cadres and kebele leaders drawn from 12 kebeles, 6 each from Bambasi and Kamashi woredas, participated in the meeting. Discussants agreed to organize a CBHI community sensitization and awareness creation program on the government transformation agenda. HSFR/HFG shared the findings of ISS with head of the RHB and woreda officials to enable them to solve the implementation challenges. These challenges included lack of political commitment and technical support from concerned woreda officials; and that officials assigned respective vice woreda administrators to lead the CBHI program implementation. A total of 24 people (all men), drawn from 12 kebeles, attended the review meeting. Oromia: HSFR/HFG in collaboration with the RHB and EHIA branch offices conducted woreda- level CBHI review meetings in Ilu (January 15, 2017), Adea (February 14, 2017), Adami Tulu Jido Kombolcha (February 15, 2017), and Kuyu (February 25, 2017). The review meetings were aimed to assess schemes’ performance (enrollment of new households, membership renewal, and provision of health service to beneficiaries) and provide an update on the new CBHI directive. About 571 people (547 men and 24 women) including kebele leaders, woreda CBHI board members, heads of HCs, and representatives of ZHDs, participated in the review meetings. HSFR/HFG, RHB, and the respective EHIA branch offices covered the cost of the review meeting. Tigray: HSFR/HFG in collaboration with EHIA Mekelle branch offices supported 17 CBHI implementing woredas in conducting review
114 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps meetings in their respective woreda capitals. The forum enabled them to assess performance in terms of enrollment, preparation for renewal, ID distribution, provision of heath care services, and reimbursement to facilities. There were some reported delays in the reimbursement to health facilities. Discussants reviewed the revised directive and forwarded issues/concerns. The respective woreda administrators gave responses to the questions and direction to resolve implementation challenges, such as the busy schedules of government officials at the woreda and kebele levels. In total, 1,588 people (1,162 men and 426 women) participated in the review meetings. They included representatives of the – woreda administration office and WorHO, scheme executive staff, kebele administrators, and kebele managers. HSFR/HFG provided only technical support and woreda administration covered costs of review meeting. For Health Accounts VI, provide The HA TWG presented findings to the FMOH technical assistance to FMOH to higher officials, gathered comments and conduct data analysis and incorporated them as needed. The team also validation, report writing, and cross-checked double-counting, produced HA dissemination tables, and presented them to FMOH higher officials together with an outline of HA report and the schedule for the remaining activities. Discussants agreed to produce HA VI main report which incorporates statistical report with detailed methodology and HA tables, lessons from the current HA, and issues for/recommendations for future HA undertakings. A consensus was also reached to produce four, up to 5 pages policy briefs on selected disease burdens and priority areas: Reproductive Health, Malaria, Tuberculosis, Child Health, NCDs, and Immunization. The TWG and backstopping expert from Abt home office produced the main report and briefs which are currently undergoing review by the FMOH. Generate evidence on impact of HSFR/HFG conducted a quick assessment of the CBHI implementation towards CBHI program in Kilte Awlaelo woreda to learn EPCMD and AFG the contribution of the CBHI program to: financial protection of members (paying and non-paying), quality improvement in health facilities, and improvement on health services utilization. It also aimed to assess the contribution of the CBHI program towards EPCMD and creation of an AIDS free generation. The draft report is undergoing technical staff review.
5. FIELD SUPPORT ACTIVITIES: ETHIOPIA - 115 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Support CBHI data management SNNP: HSFR/HFG followed up on CBHI data at the scheme level management during the regular supportive supervision. The team provided technical support to schemes, kebeles, and health facilities on households’ enrollment, contribution collection, health care service provision, and reimbursement data management (encoding data into the computer), and properly documenting and maintain data in hard copies. A total of 19 woredas received technical support: Lemmu, Misha, Duna, and Soro (in Hadiya); Shebedino, Dale, and Yirgalem (Sidama); Dilla Zuryia and Yergachefe (Gedeo); Wolkite, Butajera, Sodo, Esha, Abeshege, Cheha, Gumer, Mehur Akilil, Geta, and Endagagn (Guragie). Tigray: HSFR/HFG provided on-the-job training on CBHI data management for CBHI executive staff drawn from Raya Azebo and Endamekoni woredas on February 13–14, 2017 in Mekelle town. The objective of the training was to impart knowledge and skills on the disaggregation of CBHI data and preparation of reports, using Microsoft Excel. In total, 21 people (12 men and 9 women), drawn from two CBHI schemes and the EHIA Mekelle branch office, attended CBHI data management training.
116 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.1.8 Ghana Program Objectives – In alignment with USAID's Global Health Initiative, HFG will continue to support a combination of activities aimed to improve the health behaviors of families and communities, the quality of health services, and the overall health system in Ghana. Focused technical assistance and implementation support will be provided to the National Health Insurance Authority (NHIA) in its efforts to ensure financial sustainability of the National Health Insurance Scheme (NHIS) while also increasing enrollment and improving effective coverage of health services.
Strategic Health Purchasing (SHP) Workstream: Strengthen implementation of capitation, improve claims processing, generate data for the early warning system, support dialogue between the NHIA and providers, and provide analytical support and sensitization to eventually move towards a budget neutral payment system with G-DRGs.
Evidence-based Workstream: Strengthen the NHIA's ability to detect (dashboard, M&E policy) and investigate (operations research, or OR) operational issues that have implications for SHP and the long-term sustainability of the NHIS, using evidence-based approaches. HFG's main priority in Year 5 is to institutionalize the evidence-based processes and tools that HFG developed and implemented with the NHIA in Years 2-4. In particular, HFG will work closely with the Research, Policy, Monitoring and Evaluation (RPME) Directorate to build its capacity to manage and take ownership over the dashboard, OR, and M&E policy activities, while also fostering collaborations between the RPME Directorate and other NHIA directorates to do these activities. HFG will also seek to make malaria a central focus of all these subactivities to help address the large financial and health burden that malaria poses in Ghana.
NHIS Review Follow-on Technical Support: Provide technical support to the NHIS and the health sector in general by supporting reforms aimed at defining norms or removing bottlenecks that impede the performance of the NHIS and the sector. The health system currently lacks a definition of what constitutes primary health care (PHC) and the work of the PHC Ministerial subcommittee will help set the parameters by which the NHIA will define its benefit package for PHC. Similarly, a lack of harmonization of data systems has led to duplication in facility-level data collection by the NHIA and the Ghana Health Service (GHS), while a lack of deployment of the NHIS' strategic purchasing potentially limits efficiency and raises NHIS costs. Year 5 Activities - 1. Strategic Health Purchasing: • Institutionalizing PHC capitation scale-up and formation of preferred PHC provider networks
• Ongoing analysis, development, and simulations to support process of refining G-DRGs
• Institutionalizing improvements in NHIS/NHIA claims management and information systems
• Ongoing strategy and policy dialogue and collaborations 2. NHIA as Evidence-Based Health Purchaser: • Replicating/scaling-up dashboards development and use
• Supporting the finalization and roll-out of an organization-wide M&E policy
• Systematizing and institutionalizing NHIA OR for strategic purchasing and improved service delivery 3. NHIS Review Follow-on Support
5. FIELD SUPPORT ACTIVITIES: GHANA - 117 Year 5 Progress Against Objectives - 1. Strategic Health Purchasing • Institutionalizing PHC capitation scale-up and formation of preferred PHC provider networks. By the end of Year 4, the SHP team left the capitation scale-up and enrollment in preferred primary care providers (PPPs) fully underway, with enrollment reaching 100 percent of NHIS members in Upper East, Upper West, and Volta regions. Capitation sensitization had also started in Brong-Ahafo, Central, Northern, and Western regions, meaning that with the pilot region and three scale-up regions, eight out of 10 regions are currently actively participating in capitation scale-up. In Y5Q1, HFG worked with the NHIA Provider Payment Directorate and finalized the Capitation Payment Implementation Resource binder, which includes materials for two modules of Capitation TOT training ("Overview of Capitation and How it Works in the NHIS" and "Communications Related to Capitation") as well as related reports and background literature on capitation. Thirty-four binders were printed and distributed to all regions of the country. Additionally, the SHP team supported the printing of the report Mapping of Health Service Providers: Ashanti Region, for distribution to regions in Q2. In Y5Q2, the HFG SHP team conducted a series of meetings with the NHIA Provider Payment, Claims, and Quality Assurance directorates and agreed on pillars of institutionalizing Health Service Provider Mapping. HFG and the NHIA reviewed the original data collection instrument and identified areas for further refinement including aligning capacity criteria with new PHC package, provider types with categories in the HMIS, and staff categories with GHS human resources policy. The NHIA also proposed to include minimum stocks of consumables and medicine, and diagnostic services offered as additional criteria for capitation capacity definition. Consensus was reached on the data virtual housing at the NHIA level in the interim period, so the NHIA will take responsibility for the Provider Mapping institutionalization until co-ownership is established with the GHS. The HFG SHP team continued working with the NHIA on the development of a Provider Payment Early Warning systems. Using the Excel-based claims data of 30, 000 records from 54 providers in Volta and Greater Accra regions, HFG prepared options for the data analysis, report structure, and operational dashboards to support the Provide Payment Early Warning system at different levels (NHIA, Regional-District, and Provider). The NHIA Provider Payment, Claims, and Quality Assurance directorates supported the proposed structure of routine provide payment system and capitation early warning monitoring reports.
• Ongoing analysis, development, and simulations to support process of refining G-DRGs. Policy dialogue at the NHIA has continued on general G-DRG refinement and transition to a formula-based financing model, and an agreement was reached to start DRG support capacity building and sensitization for NHIA district offices. In Year 4, the HFG team together with the NHIA Claims Directorate conducted an analysis of G-DRG system implementation based on an e-Claim database. The team analyzed more than 700,000 cases of treated patients in 12 hospitals during 2015. The analysis included overall hospitalization structure by G-DRG, the average length of stay, and cost of drivers. The NHIA e-Claim data from 55 health providers for 2014-15 was combined into one database with a standards structure and prepared for further analysis and updating DRG simulation model.
118 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
In Q1-Q2 of Year 5, the SHP team continued the technical discussion on G-DRG refinement and transition to formula-based financing. However, due to recent political changes in the country and management changes at NHIA, the analysis has stalled. We anticipate this subactivity will resume once the new NHIA CEO appoints key staff at the NHIA and presents NHIA work priorities.
• Institutionalizing improvements in NHIS/NHIA claims management and information systems. In Year 4, the HFG team provided extensive technical support to the NHIA in improving claims management in the transition to e-claims, helping to finalize the standardized claims summary form through a series of iterations on the form's structure and development of an automated data entry system for health providers. The final standardized claims summary form was tested at the provider level in Greater Accra region in May 2016. At the end of Year 4, the form was rolled out, and data collection started in Ashanti, Upper West, and Volta regions. In Y5Q1, with technical support from the HFG team, NHIA has implemented the standardized claim summary form across three districts of the Upper West region (approximately 72 facilities in Nadowli, Wa Central, and Wa West districts) and in the Greater Accra region (45 facilities in the Tema district). Monitoring visits were conducted by Claims Officers in Upper West. The monitoring team verified that the facilities have started using the new claims summary form and the facilities expressed their satisfaction with the form. The team also observed that some facilities lacked IT capacities needed to use the form (lack of computers or an old version of Office software) and insufficient knowledge of ICD-10 coding. Also, the HFG team continued working with the NHIA Claims Directorate to improve the Claims Collection program with a function to collect data when data entering in a hospital is done on several computers. The new version of the program allows data to be put on a flash drive in the form of the report, from which it can be merged with the data collected from the other computers. This permits the preparation of one file with data from all the computers of the hospital and its transfer to the data collection point. In Y5Q2, the HFG SHP team continued to support NHIA in the Excel-based standardized claims summary form roll-out and claims data aggregation at NHIA level. The team worked with the Management Information Systems (MIS) and Claims directorates and developed a technical solution to combine Excel-based claims summary data from individual providers at NHIA level and aggregate data across claims data sources including the E-Claims, Claim-IT, and Excel-based Claims forms. HFG tested the data aggregation tool, conducted a preliminary analysis of aggregated claims data, and presented results to the NHIA Claims, Auditing, and MIS directorates and regional claims processing centers (CPCs), and also trained technical staff of the NHIA and regional COC. The HFG SHP team started working with the Quality Assurance and Provider Payment directorates on the Excel-based claims form update, aligning the form with new G-DRG tariffs for 2017, the new credential list, and HPN for providers.
• Ongoing strategy and policy dialogue and collaborations. As opportunities arise, HFG Ghana engages in ongoing strategy and policy dialogue and development with the NHIA and other stakeholders. This dialogue can encompass any topic related to improving NHIS purchasing, efficiency gains, and sustainability. An example that continuously emerges is dialogue, planning, developing options, and analysis in preparation for refining drug payment with corresponding drug supply management improvements. In Year 4, the National Technical Review of the National Health Insurance Scheme was commissioned by the outgoing president and led by Chris Atim. The HFG SHP team was requested to provide rapid feedback on priority topic areas (governance, capitation, etc.), which was then collected and synthesized into a report with key challenges and recommendations that was presented to the NHIA and government. Following the review and in Y5Q1, the SHP team remains primed to accommodate requests for support
5. FIELD SUPPORT ACTIVITIES: GHANA - 119 to the NHIA as they begin to develop roadmaps to assist in the implementation of the recommendations identified through the review. The HFG SHP team contributed to national-level policy dialogue on malaria control. At the request of USAID/Ghana, the team participated in the Ghana Implementing Partners Meeting on the U.S. President's Malaria Initiative and presented HFG support to Ghana's NHIS in strengthening financial incentives and ensuring access to essential malaria services. . Capitation for PHC has been scaled up to four regions, 600+ NHIA staff trained, nearly 100 percent of active members enrolled with a preferred primary care provider. . Standard claims summary form implemented in four regions, analyzable claims data available for the first time, capitation early warning system with malaria indicators 2. NHIA as an Evidence-Based Health Purchaser Activity Workstream: • Replicate/scale-up dashboards development and use. The Membership and Regional Operations (MRO) directorate has routinely used the beta version of the membership dashboard since it was launched in April 2015. In Year 5, HFG will continue to support the refinement of the membership dashboard and its expanded use. HFG will also continue to collaborate with the NHIA to develop a second, claims-based dashboard, which will include high-level indicators monitoring the NHIA's financial liability and claims reimbursement process. The claims dashboard, like the membership dashboard, will provide clear pictorial evidence on the status of key performance indicators, and allow the NHIA to take timely action on problematic areas. Since January 2017, HFG has been working closely with the Claims Directorate to identify a scope for the claims-based dashboard and to establish a process for developing and vetting indicators. The NHIA and HFG are working to produce a visual mock-up of the dashboard in Y5Q3 and to complete a beta version of the dashboard by the end of Year 5.
• Support the development and roll-out of an organization-wide M&E policy. In 2015, the RPME Directorate developed a first draft of the M&E policy and accompanying roadmap for its dissemination. The M&E policy will guide the NHIA in managing initiatives related to provider payment systems, member identification tools, and claims processing that aim to improve access to health care and improve efficiency of the scheme. The M&E system will allow the NHIA to monitor and track progress of NHIA activities against its objectives and ensure that the intended outcomes are being achieved. The RPME Directorate will modify and finalize the policy based on the NHIS Technical Review Committee report, which is still awaiting endorsement from the new President of Ghana. In Year 5, HFG will continue to support the finalization and roll-out of the M&E policy.
• Systematize, improve, and augment NHIA operations research for strategic purchasing and improved service delivery. This activity saw the most intense focus and progress in Year 4, and HFG began to see results from many months of embedding and institutionalizing NHIA-staff-driven OR. In November 2016, HFG and NHIA completed the final study team draft report for the second of three initial OR studies. This second study examined Ghana's health sector regulatory landscape to understand how regulations are affecting NHIS operations (either positively or negatively), with a focus on identifying existing overlaps between NHIA's credentialing function and the accreditation function of the Health Facilities Regulatory Agency (HEFRA). Recommendations from this study are also intended to inform the NHIS Technical Review and will help the NHIA improve its coordination with other Ministry of Health (MOH) agencies on credentialing and accreditation matters. The study team submitted the final report to Dr. Chris Atim, Chair of the NHIS Technical Review, as well as the RPME directors for vetting and approval from the CEO and senior NHIA management.
120 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
HFG also continued its ongoing collaboration with the NHIA on the third OR study, which is examining the possible variation in providers' claims for malaria treatment. HFG is working with the NHIA to analyze a large sample of e-claims data from the Claims Directorate to quantify and describe the variation in providers' claims for the treatment of malaria. This will be conducted alongside an analysis of findings from key informant interviews to identify the root causes of the variability in anti-malarial drug costs (if any), and develop recommendations to address any identified problems. In addition to these OR studies, HFG collaborated with the RPME Directorate to conduct an OR training of trainers (ToT) course on Feb 7-9, 2017. These trainings followed the successful operations research methods training that HFG co-facilitated with the RPME Directorate in September 2016. The OR ToT course trained four Head Office staff, as well as 11 regional managers (from the 10 regions) to replicate the trainings in their respective regions. The RPME Directorate has worked to ensure that subnational trainings in OR are included in the NHIA's Annual Program of Work and 2017 budgets, which will allow OR to be further introduced and institutionalized within all levels of the NHIA. The NHIA expects to begin cascading the trainings in the second quarter of 2017, after a new NHIA CEO is appointed. 3. NHIS Review Follow-on Support Workstream: HFG is leading the organization of a forum on universal health care coverage (UHC) and health financing to discuss recommendations and proposals for strengthening the NHIS and the way forward for collaborative and coordinated action. Q2 Challenges - Mr. Otoo, the outgoing NHIA CEO, left the NHIA in early February following the transition in political power in Ghana. Several directors at the NHIA noted that ongoing work can continue, but that it may be more difficult to initiate new activities until a new CEO is appointed. A new CEO was appointed in mid-March. Table 32 provides activity-specific updates. TABLE 32. GHANA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Strategic health purchasing workstream Sub-Activity 1: PHC capitation scale-up and formation of preferred PHC provider networks Support institutionalization of In March 2017, HFG conducted a series of HFG together with NHIA will revise provider capacity mapping to meetings with NHIA Provider Payment, data collection instrument based on inform ongoing preferred PHC Claims, and Quality Assurance directorates discussion, develop a data entry, provider policy refinement and and agreed on pillars of institutionalizing analysis, and mapping program for network formation Health Service Provider Mapping. The automated reports, and test an agreed approach includes i) creation of one institutionalized system in one region. unified provider database with credentialing HFG will support NHIA in organizing information and capitation capacity a stakeholder workshop with MOH, information, and ii) co-housing the data GHS, etc. to present results of between NHIA and GHS with virtual Provider Mapping in Ashanti region housing, so everyone has access. and discuss a plan for Provider Mapping Institutionalization.
5. FIELD SUPPORT ACTIVITIES: GHANA - 121 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Support institutionalization of Using the Excel-based claims data of 30, HFG will program a prototype “one- the capitation early warning 000 records from 54 providers in Volta and button” report and test it with system Greater Accra regions, HFG prepared incoming Excel-based claims data. options for the data analysis, report NHIA will identify roles and structure, and operational dashboards to responsibilities to operate the early support the Provide Payment Early warning system at the Warning system at different levels (NHIA, national/regional/district levels and Regional/District, and Provider). On March test an institutionalized system in one 15, 2017, HFG presented results to NHIA region. and agreed on the structure of the early warning monitoring reports. Support institutionalization of The introduction of capitation supporting capitation and supporting systems in Upper West was postponed systems in Upper West until the appointment of a new NHIA CEO and key positions at NHIA directorates and regional CPCs. Sub-Activity 2: Refinement of G-DRGS with corresponding service delivery improvements Develop and implement G- HFG held a sensitization meeting on March HFG will reinforce policy dialogue on DRG sensitization workshops 16, 2017, with Dr. M. Tanko, Quality G-DRG and formula-based financing on capacity building for model Assurance Director, to discuss G-DRG with new NHIA team. and DRG payment system refinement and transition to formula-based financing. Continue to refine the Simulation module was populated with e- HFG will present DRG simulation exemplary DRG simulation claims data shared by Claims Directorate. analysis to the new NHIA model management team. Sub-Activity 3: Claims management and information systems Roll out final claims form in Continued roll-out of Excel-based standard HFG will update the Excel-based two regions claims summary form in four regions Claims Summary Form based on (Greater Accra, Volta, Ashanti, and Upper 2017 G-DRG tariffs, new credential West). list, and HPN for providers. HFG team together with core technical At the request of NHIA, HFG will team from Claims and MIS directorates develop an additional option of the visited and trained health providers to Excel-based claims form interface. install updated version of Excel-based Claims Summary Form in Greater Accra region. Series of meeting conducted with Provider Payments, Quality Assurance, Claims, and MIS directorates to update the Excel-based claims form aligning with new G-DRG tariffs for 2017, new credentials list, and HPN for providers.
122 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Generate the data in analyzable Completed programming for aggregating Continue support to MIS and Claims format and use for supporting and merging data files across claims data directorates to combine and systems sources (Excel, Claim-It, e-Claims) to aggregate claims data at regional CPC create data files for analysis. and NHIA level. Agreed on database format/ standard for Work with NHIA to combine claims combining data from E-Claims, Claim-IT, data for all health providers using the and Excel-based claims data. Excel-based claims (Q4 2016 and Q1 Tested data aggregation tool and process, 2017) for further analysis and combined claims data from 54 providers development of operational (more than 30,000 records). dashboards. Trained technical team from MIS and Claims directorates on data aggregation. Develop data quality Conducted an assessment and shared Continue to support Claims and MIS monitoring tools recommendations on data quality and directorates and regional CPCs in linkability of the Excel-based claims form, claims data quality management. Claim-It, e-Claims data. At the request of Dr. L. Selby, Claims Director, HFG conducted a technical workshop for 25 representatives of MIS and Auditing directorates and Greater Accra CPC to present data analytics and options for operational dashboards. Sub-Activity 4: Ongoing policy and strategy dialogue and collaborations Support ongoing policy At the request of USAID/Ghana, HFG SHP dialogue through workshops team participated in Ghana Implementing and other forums for policy Partners Meeting on the U.S. President’s dialogue and development Malaria Initiative and presented HFG including the NHIS technical support to Ghana’s NHIS in strengthening review financial incentives and ensuring access to essential malaria services. Activity 2: NHIA as an evidence-based health purchaser workstream Sub-Activity 1: Replicating/ scaling up dashboards development and use Improve and expand use of HFG followed up with the MRO director As discussed with the MRO director membership dashboard and deputy director in February to finalize and deputy director, HFG will meet the requested updates to the membership with the MIS Directorate to discuss dashboard and to discuss next steps. the IT required to make the requested updates to the membership dashboard. HFG will also work with the MRO Directorate to develop a work plan for introducing these changes to the membership dashboard.
5. FIELD SUPPORT ACTIVITIES: GHANA - 123 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Facilitate creation of a claims HFG has been working closely with a team Once a list of indicators is finalized dashboard from the Claims Directorate since January and approved, HFG will help the 2017 on this task. In early February, the Claims Directorate work with the Claims Directorate convened a multi- MIS Directorate to begin work on stakeholder meeting to solicit input for the the IT needed to build the scope of the claims dashboard. Following dashboard. this meeting, HFG helped the Claims Directorate organize the stakeholder feedback into three potential options for the scope of the dashboard, with some accompanying illustrative indicators. Dr. Selby, Claims Director, asked that the team move forward with developing a dashboard focused on capturing information on the NHIA’s financial liabilities, and tracking indicators related to the claims reimbursement process. HFG is now working with the Claims Directorate to develop and systematically vet indicators for the dashboard.
Institutionalize dashboard HFG has begun drafting a dashboard HFG will continue to focus largely on development and refinement development process guide for future the RPME, Claims, and MIS process reference at the NHIA, drawing on directorates as key actors in experience from supporting the institutionalizing dashboard development of both the membership and development processes. HFG will claims dashboards. plan to feed the dashboard development processes and lessons learned into new NHIA data integration strategies.
Sub-Activity 2: Support the development and roll-out of an organization-wide M&E strategy Support validation and Validation of this policy and indicators is HFG will follow up with Mr. Adjei to refinement of M&E policy ongoing; Mr. Adjei, Director of RPME, identify areas that HFG can support noted that he would like to move forward as the RPME Directorate finalizes the with finalizing this policy document in the M&E policy. coming months.
Sub-Activity 3: Systematize and institutionalize NHIA operations research for strategic purchasing and improved service delivery
Support identification and NHIA has completed the qualitative and Mr. Adjei stated that he would like to implementation of three OR quantitative analysis for the malaria OR disseminate the findings from the two projects study, and has shared a first draft of its completed OR reports during the findings with HFG. HFG reviewed these next NHIA senior management findings, and is now working with NHIA on retreat with the new CEO. He revisions to the analysis. anticipates this will take place in the spring. HFG anticipates that the malaria OR study report will be completed by Y5Q3.
124 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps HFG also encouraged NHIA to submit abstracts for the malaria claims and delay in claims reimbursement OR studies to the 2017 National Research Dissemination Symposium (organized by GHS R&D Division). Refine and institutionalize OR HFG conducted a three-day OR ToT NHIA regional offices have process course in February 2017 for 11 regional incorporated OR studies and NHIA officers and four NHIA Head Office regional- and district-level OR managers. The training covered trainings into their 2017 Programme fundamental training skills, a review of OR of Work and budget. However, the methods and processes, and opportunities RPME Directorate does not expect for participants to practice delivering the these activities to begin until after a OR training. Participants also drafted new CEO is appointed. training plans to cascade the OR trainings HFG and NHIA will also collaborate in their respective regions. on developing an OR process guide starting in Y5Q3. Support identification and N/A As requested by the RPME implementation of two Directorate, HFG will work with additional OR projects them to identify topics for the next set of OR studies in Y5Q3. Activity 3: Support to NHIS technical review and Follow-on technical support to NHIS and health sector Provide technical support to HFG is leading the organization of a forum The participation of the Minister of the NHIS and health sector on UHC and Health Financing to discuss Health and new NHIA CEO will key recommendations and proposals for to the forum having political buy-in strengthening the NHIS and the way and implementation value. forward for collaborative and coordinated action. Participants will be drawn from key Ministries, Departments and Agencies (MDAs) including the health and finance sectors; the health professional associations, service providers and interest groups; key civil society organizations, and NGOs. The end product of the forum will be a report on the deliberations from both the plenary and group sessions and a synthesis of proposals for the way forward for dissemination to key policymakers and stakeholders. It is also expected that participants will leave the forum better informed about the feasibility of various options and the position of the new government regarding the NHIS, and more committed to playing their roles in bringing about UHC through more efficient and effective health financing.
5. FIELD SUPPORT ACTIVITIES: GHANA - 125
5.1.9 Guinea Program Objectives - The Guinea program is an 18 month program. The program was officially launched at the end of Q3 FY16 and is currently planned to continue through December 2017. The 13 planned activities are as follows: 1. Conduct a functional audit of the Ministry of Health (MOH) 2. Strengthen MOH management capacity 3. Conduct a private health sector assessment 4. Strengthen health sector coordination capacity 5. Build MOH capacity to support research 6. Improve financial management capacity of the MOH 7. Improve coordination, collaboration and partnership between line ministries in charge of human resources for health (HRH) planning, training, and development 8. Support the ICT-based comprehensive management of human resources 9. Support pre-service education institutions to improve management and governance for better workforce development 10. Support the strengthening of continuing professional development programs for health 11. Strengthen the Inspector General function 12. Strengthen the legislative committee on health 13. Strengthen strategic communications for the health sector Year 5 Activities - Under the Ebola Recovery Strategy, the HFG activity is aimed at rebuilding the health system to better respond to crises such as the recent Ebola outbreak. It is at times of crises that health systems are most stressed. Health systems that are resilient and have public trust will be better equipped to respond to health emergencies. The HFG scope of work targets four areas of health systems strengthening - institutional strengthening, governance, financing, and HRH - all of which are building blocks of a well-functioning health system. The overall objective is to strengthen Guinea's health system to enhance the functioning of institutions and programs and improve their capacity to deliver better health services to the population of Guinea. The specific objectives are:
Objective 1: Improve institutional capacity and health governance across the health system
Objective 2: Enable the health financing environment and improve MOH capacity to efficiently mobilize and manage resources to foster greater coverage of quality health services.
Objective 3: Improve the institutional capacity of the MOH to effectively manage human resources Year 5 Progress Against Objectives - The Guinea program started in Q4 FY16 and is progressing according to plan.
Institutional Strengthening
• Functional Audit. This activity is to assess the functions of the central health units, regional- and district-level health management teams, and the MOH as a whole in terms of its capacity to carry out its core functions. Final deliverables include a functional audit report including an organizational framework (with analytical and conceptual components) and a roadmap for implementation. The audit is being carried out in collaboration with a six-person EU-funded team.
126 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
At the end of Q1, the team was finalizing the audit findings and recommendations. This quarter was mainly dedicated to the validation and dissemination of the audit findings. On October 12, 2016, HFG consultants met with the Minister of Health to discuss the findings. The Minister was very pleased with the results, and asked the consultants to develop a complementary presentation that he could share with the Council of Ministers. HFG completed this presentation and shared it with the minister in November. HFG also facilitated a two-day workshop October 19-20 to begin development of the roadmap to implement the audit recommendations. The workshop was well attended by MOH staff. Following the workshop, the HFG consultants drafted and shared the roadmap with ministry counterparts. In November, HFG worked with the Ministry to finalize the audit report and roadmap and prepare for a dissemination meeting in December. A successful dissemination meeting was held on December 21. His Excellency the Minister of Health chaired the meeting and in attendance were, among other persons, the Secretary General, all MOH central directors, regional directors, UNICEF representative, UNFPA representative, US ambassador, the Mission Director of USAID/Guinea, and representatives of civil society and other line ministries. Overall the audit report and roadmap were well received by all stakeholders, including the Minister and his colleagues, who stressed the alignment of the audit recommendations with the National Health Development Plan (PNDS). At the end of Y5Q2, HFG engaged the MOH to discuss follow-on support pending the actual restructuring of the ministry. Results of the audit and roadmap are being used to develop work plans for specific intervention areas supported by HFG such as health sector coordination and support for the Inspector General (IG) function. HFG plans to assist the MOH to prioritize and operationalize actions in the roadmap using a theory of change approach.
• Management Capacity Building. This activity has two distinct components: leadership and management, and project design and management. Both components were launched in Q4 FY16. In Q1 FY17, following the successful completion of the functional audit, the MOH agreed to January dates for the two senior leadership training courses and February dates for the training of trainers (TOT) for the management skills course that will be rolled out widely. The training materials for the leadership training were completed and the materials for the management skills course completed in early January. The plan for the management skills course was to train 20 MOH managers in the course content, and then train 10 of them as trainers. In the project design and management component, the procedures manual was drafted, then carefully reviewed in a workshop setting with MOH and partners, and then validated by the MOH. In Y5Q2, HFG conducted three leadership and management training workshops for senior MOH officials. The first two were aimed at central MOH officials including the Minister of Health, the Minister's Cabinet, the Secretary General, and directors of central directorates and programs. The third workshop targeted senior regional and district staff. In all, 65 senior officials were trained. MOH feedback on these workshops has been extremely positive, including from the Minister, who intends to build on the momentum created by these trainings to rally the cabinet and central and regional directors around the change dynamics initiated at the MOH for the improvement of the health sector performance.
5. FIELD SUPPORT ACTIVITIES: GUINEA - 127 In addition, HFG initiated a TOT program to develop a cadre of MOH staff capable of delivering the management skills course developed by HFG. The first part of the TOT was for the prospective trainers to learn the content by being participants in the training and the second part was on training methodology. Of the 12 MOH staff selected by the MOH only nine showed up and of those a maximum of six were seen as qualified to deliver the training. To expand the pool of qualified MOH trainers, HFG has proposed a second TOT in May for 12 participants, six of whom would be selected from the participants in the third leadership and management course discussed above. In the project design and management component, the comments on the draft procedures manual were consolidated and then validated by a technical working group established by the MOH. In addition, the MOH requested that HFG train two groups of 15 MOH staff or 30 total, 10 of whom will then be trained as trainers. HFG is discussing with the MOH dates for the training, to be conducted in Q3. • Health Sector Coordination. This activity aims at strengthening health sector coordination, especially the skills of the Coordination Committee of the Health Sector (Comité de coordination du secteur santé, CCSS). Following the Q1 planning visit to share activity terms of reference (TORs) and the assessment framework, later in the quarter HFG developed the assessment tools and conducted the assessment of the current various coordination mechanisms, and how they are functioning. The assessment was completed in November and a first draft of the assessment report was circulated for review. The next step will be drafting a plan for coordination improvement. During this quarter HFG also engaged the Groupe Thématique Santé / VIH, a coordination mechanism under the Prime Minister, in a discussion on its current role and the process of improving health sector coordination. HFG also met with the Global Fund to discuss how the Global Fund Country Coordination Mechanism will relate to the other health sector coordination mechanisms, namely the CCSS and the Groupe Thématique Santé/VIH. In Q2 (in late January), a workshop was held to validate the assessment report and draft the health sector coordination improvement roadmap. The assessment findings were presented to the development partners forum (PTFs) during their monthly meeting in February 2017. A harmonization workshop was held in March to discuss sector coordination architecture, and update the scope of work (SOW) of all thematic groups of the CCSS. The workshop proceedings are being processed by the CCSS secretariat (Secretariat Technique (S/T) in order to get the full endorsement/validation of senior MOH leadership. • Private Providers Survey. The goal of this activity is to assess the scope and scale of the private health sector in Conakry, its regulatory framework, and how to improve public-private dialogue. Responding to a request from the MOH, the HFG private sector activity changed focus from a private sector assessment to a survey mapping of private sector providers in Conakry. The proposed survey will update a 2006 mapping. It responds to the need for up-to- date data on the private sector, its composition, and its contribution to health provision. The survey will include modern private sector providers will be targeted including labs, imaging facilities (x-rays, scans), and pharmacies but will exclude traditional and Chinese medicine as well as informal drug sellers (markets and shops). Based on their experience with current and past private sector provider surveys in Benin and Senegal, the HFG team outlined the deliverables expected from the exercise. The MOH accepted this proposal in Q1. HFG then drafted the survey protocol and planned a search for an in-country data collection firm to conduct the survey.
128 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
In Q2, HFG advertised an RFA for an in-country or regional data collection firm to conduct the survey through a competitive procurement. It expects the procurement process will be completed by the end of May.
• Research Capacity. The purpose of this activity is to strengthen the capacity of the MOH to support the research process and to use research results to inform decision making. The activity was launched in the last month of Q4 FY16. In Q1 FY17, the consultant travelled to Guinea to do the situational analysis of the research capacities of the MOH and of health research of the country in general. The trip was successful and the consultant was able to meet many stakeholders in various levels of the MOH as well as implementing partners involved in research, research institutes, and university researchers. Following two weeks of data collection, the consultant was able to discuss some of the preliminary findings at a workshop attended by the above parties before leaving the country. He then drafted an assessment report that is currently being finalized after internal HFG reviews. The report findings and recommendations are scheduled to be validated in country in Q2 and will then be followed by the drafting of policy documents to advance research capacity of the MOH. In Q2, the HFG consultant travelled to Guinea for a validation workshop on the situational analysis. During this trip, the consultant also started discussions around priorities in terms of updating the current national policy for health research and drafting an M&E plan for the priority health research activities. To this end, HFG held a workshop to review the national health research policy in March. HFG also conducted interviews and engaged in discussions with the BSD focal point (Dr. Alpha Ahmadou Diallo) to organize the National Forum for Health Research.
• Strengthening Financial Management. With this activity, HFG aims to build on ongoing activities and work with the MOH to expand sustainable and effective financial management capacity. Building on the financial management recommendations of the roadmap of the institutional audit and on other assessments and evaluations of MOH capacity in financial management, HFG shared revised TORs for this activity with the MOH. Some of the specific activities proposed to the Chief of the Department of Administration and Finance (Direction de l'Administration et des Finances, DAF) and other development partners, are: . A functional assessment of the DAF that will identify gaps in skills, systems, and procedures. . An updating of the administrative and financial procedures manual, followed by the development of training material and a training/dissemination plan. . A diagnostic of the needs to computerize the DAF at the central level. The activities were validated by the DAF in Q1 and HFG is currently working to implement the functional assessment. HFG has discussed how to coordinate the work with other development partners interested in strengthening financial management in the MOH. Based on the financial management recommendations of the validated institutional audit roadmap and on other assessments and evaluations of MOH financial management capacity, HFG worked on the following activities in Q2: . The functional assessment of the DAF to identify gaps in skills, systems, and procedures. The preliminary report has been drafted and was shared for comments. . Updating of the administrative and financial procedures manual; HFG drafted the SOW for the local consultant who will work closely with the international consultant provided by the EU-funded Programme d'Appui à la Santé (PASA).
5. FIELD SUPPORT ACTIVITIES: GUINEA - 129 . Ongoing research and planning to identify computerization needs and potential support of the DAF. Both the functional assessment and updating of the administrative and financial procedures manual are being implemented in close collaboration with the EU project. In addition, following a partners meeting and in direct response to a request from the MOH's BSD, HFG drafted and facilitated the finalization of TORs for a consultancy to design an MOH financial management support unit. The consultancy will be financed by the Global Fund in collaboration with GAVI. This unit will support ongoing efforts to improve the financial management capacity of the DAF and MOH.
Human Resources for Health.
• HRH Coordination. In this activity, HFG supports the MOH to strengthen the HRH Multi- sectoral Committee so that it becomes an effective National HRH Platform that promotes better collaboration and intersectoral planning among all key stakeholders involved in health workforce training, planning, and management. In Q1, HFG supported the MOH in finalizing a ministerial decree to establish the platform and developed a draft action plan for the HRH committee. The project also developed and distributed to current committee members a questionnaire to assess its strengths and areas for improvement. The responses to the questionnaire were analyzed and used to inform a two-day retreat for the committee in January 2017. In Q2 (January 27-28), HFG supported a workshop to review the results of the HRH situational analysis, including findings from the survey of committee members to assess its strengths and areas for improvement. The workshop also produced a decree to reconstitute the Comité Intersectoriel Elargi des Ressources Humaines en Santé (CIERHS) and an organizational chart to establish the Division of Human Resources for Health within the MOH. Afterwards, the local consultant and HFG HRH Advisor finalized the workshop report and a technical note was developed that highlights the main recommendations and next steps for the committee. HFG is following up with the Office of the Minister of Health to validate the technical note and get approval of the decree and organizational chart.
• iHRIS. HFG supports the MOH to continue the roll out and institutionalization of the human resources information system (iHRIS) especially through data capture of health workers. In Q1, HFG assisted the MOH in a census and data collection of personnel at the central level, including MOH programs. Data collection for this phase was completed and data entry is underway. HFG will accompany the MOH in data collection at the hospital level and Conakry district level in the Q2. Training on iHRIS for statisticians and administrators at these institutions will take place in January 2017. In Q2, HFG assisted the MOH in completing data entry of personnel at the central level, including MOH programs. HFG is now accompanying the MOH in data collection at the national referral hospitals level and Conakry district level; HFG plans to complete this work in Q3. Additionally, training on iHRIS for statisticians and administrators at these institutions for 36 staff took place in February 2017.
• Management and Governance of Pre-service Education Institutions. For this activity, HFG will focus specifically on improving the governance and leadership capacity of three or four health training schools. Following the approval of this activity TORs in early Q1 FY17, HFG selected an international consultant to support the baseline assessment of the schools' organizational and governance capacity. Recruitment of a local consultant is also being finalized. The launch of the baseline assessment to identify management and governance challenges was planned for Q2.
130 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
To prepare for the baseline assessment to identify management and governance challenges of the schools in Q2, HFG developed an assessment tool and interview guides. The local consultant started in February, and accompanied the international consultant during a late February/early March trip to conduct assessments of the public Ecole Nationale de Santé de Kindia (ENSK) and private Ecole Superieure des Sages-Femmes (ESSF). Findings and recommendations were shared with the schools' leadership and the MOH. HFG is working with the schools and MOH to determine next steps for technical assistance. The assessment of two medical schools will be conducted in early May 2017.
• Continuing Professional Development. The goal of this activity is to support the MOH, in collaboration with the Ministry of Labor, to develop a national in-service training plan. In parallel, HFG also supports training institutions in charge of Continuing Professional Development (CPD) to build their capacity in coaching and mentorship. The HFG project finalized the TORs for this work, and selected an international consultant to train personnel in coaching and mentorship skills. The project also recruited a local consultant to document the coaching and mentorship program at the diabetes clinic of the Donka National hospital. The TORs and consultant recruitment for the national in-service training plan will be completed in early Q2 FY17. In Q2, HFG hired two national consultants to support the development of the national in- service training plan. The desk work, including meeting with key MOH stakeholders, was conducted. The consultants are currently drafting the conceptual framework and assessment tools. Field work will start with April and the revised in-service training policy and plans will be completed later in Q3. For the coaching and mentorship work, the international consultant travelled to Conakry in early February to assess the model coaching programs in diabetology and neonatology and collect information needed to plan the coaching training. The training, planned for 36 participants over three workshops, will be held in Q3. Meanwhile the draft documentation report of ongoing experiences in coaching was submitted to the MOH and the presentation of the results scheduled for early April 2017.
Governance and Democracy
• Strengthening the Parliamentary Health Committee. HFG provides targeted support to the Standing Committee on Health to improve oversight of health programming and build support for additional public investments in the health sector. During Q1, Health Commission staff were led through a series of orientation workshops relating to the national budget, enabling them to better understand the theory of budget analysis, coupled with practical deliberations on the 2017 national budget of Guinea. In particular, HFG supported the commission in preparing for a meeting with the MOH to discuss the health budget. Such a meeting between the commission and the health minister did not occur in the last two years and members of the commission were grateful for HFG budget analysis support in preparation for this meeting. In preparation for the post-budget period, the Health Commission was taken through an assessment of its current practices with respect to the following: 1) engagement with the MOH and other executive agencies; 2) interaction with civil society and the public; 3) research and other data collection processes; and 4) planning process on a sessional and annual basis. The assessment findings were used to design a three-day workshop in late January 2017 aimed at establishing an annual oversight plan for the Health Commission including priorities for Commission scrutiny, field visits, and media engagement. In support of this, the Conakry office has begun to seek an appropriate local consultant to assist the Governance Advisor and the Technical Lead over the course of the January-August 2017 timeframe.
5. FIELD SUPPORT ACTIVITIES: GUINEA - 131 In a Q2 (February) retreat, HFG supported the development of a coherent oversight plan for the Commission. The draft plan included: 1) priority areas of oversight focus; 2) research desk review plans; 3) field visits; 4) consolidation of findings and development of reporting practices; and 5) dissemination of reports and media engagement. HFG will support the Commission in its engagement with the National Assembly Secretariat to increase the resources available to the Commission so that it can implement the plan during the year.
• MOH Strategic Communications. To address the lack of public trust in the public health sector, HFG supports the MOH to develop and begin to implement a strategic communication plan. The plan will cover both internal and external communications, with particular emphasis on budget transparency and resource utilization. A communications gap analysis done in Q1 identified the deficiencies in the MOH's overall communications approach. In addition, results of a functional audit completed in late October 2016 were received and the recommendations relating to communications were incorporated into the activity plan for this component. The functional audit identified the audit itself as a key vehicle for greater transparency; thus, the communications consultant began work with the MOH to develop a communication launch of the audit results with the goal of having the main findings of the audit (and the roadmap to address these challenges) disseminated both internally and externally. This is a significant first in the health sector, and it publicly commits the Minister and his department to the reforms detailed in the audit. For this strategic communication activity, the Conakry office has also begun to seek out an appropriate local consultant to assist the Governance Advisor and the Technical Lead over the course of the January-August 2017 timeframe. Q2 featured the establishment of an MOH working group on communications. Building on the baseline assessment findings and the framework strategy drafted by the international consultant, the working group met in a series of technical workshops in March. With the support of the national consultant, they produced the zero draft of an external and internal communications strategy. The draft documents have been shared with stakeholders for their feedback and input. It is expected that the strategy documents will be finalized during Q3 after a broad consultation process and validation workshops by MOH leadership.
• Strengthening Inspector General Function. HFG support for the IG office aims at redefining the IG function and then strengthening its capacity to carry out its role. During the last quarter of 2016, the IG conducted a self-assessment, the results of which were fed into the planning of the strategic planning retreat scheduled for January 2017. In addition, the results of the functional audit, completed in late November 2016, were received and the recommendations for the future mission of the IG were incorporated into this planning. A three-day workshop was planned, which will aim to accomplish the following: 1) review and discuss the overall recommendations of the functional audit, specifically those relating to the role of the IG; 2) review and discuss the results of the self-assessment, and in particular those areas in which there is a large deviation from the results of the functional audit; 3) conduct a vision and mission defining exercise reflective of the main findings of 1) and 2); 4) conduct a series of strategic planning sessions to develop a revised Action Plan 2017; and 5) identify ways to communicate the new vision, mission, and strategic plan to the IG's partners and the wider group of stakeholders within the health sector.
132 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
The activities undertaken in Q2 included a strategic planning retreat for IG leadership and staff; during the retreat, the international consultant facilitated a variety of working groups that: 1) developed a revised vision / mission for the IG office; 2) discussed the recently completed functional audit and its implications for the IG office; and 3) developed a revised one-year and three-year strategic plan for the IG office. In addition, the international consultant worked with the IG to develop a plan for engaging MOH leadership on the revisions, to achieve buy-in from the Minister's office and to begin discussions with the MOH on appropriate resourcing of the revised work plan. The next steps include the validation of the strategic plan by MOH leadership. HFG will support the IGS to ensure that MOH adequately resources the IGS to carry out its new mandate. In addition, HFG Guinea will provide basic capacity building for the IGS staff in the areas of audit planning, execution, and report writing. Q2 Challenges - MOH absorptive capacity continues to be an ongoing issue. The planned workshop to assist the MOH in operationalizing the functional audit roadmap had to be rescheduled due to other demands on MOH time.
The overall activity would benefit from an additional six-month extension, until June 2018, now that HFG has been extended through FY 18. HFG has requested this extension and USAID is considering it. Table 33 provides activity-specific updates. TABLE 33. GUINEA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Conduct a functional audit of the Ministry of Health HFG consultants’ team travel to Completed: These activities were Guinea to begin work with MOH, completed in July. BSD, EU by agreeing on methods and beginning data collection Complete data collection, formulate Completed: Data collection was Aligning schedules for HFG and EU draft findings and recommendations, completed at the central and regional consultants for data collection and present drafts for validation levels. travel was challenging at times. Draft findings and recommendations were validated in October. Finalize functional audit report Completed: The report was finalized This work required considerable following comments from validation in mid-December following validation coordination between the MOH, presentation by the MOH in November. Guinea HFG, and the EU to integrate consultants incorporated all comments from all stakeholders. comments from the BSD into the report. The report was disseminated in late December. Establish steering committee Completed: The first steering committee (CoPil1) met in mid- August. Draft roadmap for implementation Completed: A draft roadmap was Since the roadmap was formally submitted to the MOH for presented, HFG has been following comments on November 4 and the up with the MOH to determine the
5. FIELD SUPPORT ACTIVITIES: GUINEA - 133 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps final roadmap was completed in mid- best ways to support proposed December. activities. Present draft roadmap for validation, Completed: The final roadmap was Since the roadmap was formally make revisions to make the roadmap presented at the dissemination presented, HFG has been following final meeting in late December. up with the MOH to determine the best ways to support proposed activities. Design change management process Potential assistance is still pending Assist in implementing change Pending management plan Activity 2: Strengthen Ministry of Health management capacity Make planning visit for leadership and Completed in Q4 FY16. management course Make planning visit for design and Completed in Q4 FY16. management course Develop training materials for design Underway. and management course Develop training materials for Completed. leadership and management course Train trainers for leadership and The TOT took place in mid- A follow up TOT is scheduled for Q3 management course February. to expand the pool of qualified trainers. Train trainers for design and The TOT will take place in Q3. First, management course two groups of 15 MOH staff will participate in the training, then 10-12 of them will be trained as trainers. Roll out training for the leadership The roll-out training will start in May and management course and be conducted by the national team of trainers under the supervision of the international consultant who will observe the two initial roll-out training sessions. Roll out of training for design and To be conducted after the ToT. management course Evaluation of impact for the Scheduled for Y6. leadership and management course Evaluation of impact of design and Scheduled for Y6. management course
134 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 3: Do Conakry private providers mapping survey Finalize SOW An RFA was drafted and published for an organization to survey private providers in Conakry. Responses are due and contractual agreement expected to be signed by the end of May. Adapt survey protocol and Will begin once local firm has been instruments selected in Q3. Collect data Data collection to start in Q4. Write and disseminate final report Scheduled for Y6 Q1 Activity 4: Strengthening health sector coordination capacity Assess coordination/ collaboration Completed Hold roadmap development Roadmap drafted. Workshop proceedings are being workshop processed by the Secretariat Technique (S/T) of the CCSS in order to get the full endorsement/ validation by senior MOH leadership. Implement roadmap Updated sector coordination Draft an overall sector architecture architecture has been discussed. proposal for consideration. HFG will determine which roadmap activities it can support. Activity 5: Build Ministry of Health capacity to support research Plan assessment Completed Develop assessment report Report completed and situational analysis validated. Develop policy guidelines Held workshop to review national health research policy. Policy being updated based on the workshop. Strengthen capacity of Cellule Planned for Q4. Recherche (research unit) Conduct training in use of guidelines Planned for Q4. for MOH staff Develop roadmap Planned for Y6.
5. FIELD SUPPORT ACTIVITIES: GUINEA - 135 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 6: Improve financial management capacity of the Ministry of Health Assess financial management Functional audit of the DAF Finalize functional audit, update completed and draft report roadmap based on feedback. circulated. Develop financial management TOR of local consultant for updating Start update of procedures manual. strengthening implementation plan financial procedures manual Propose recommendations to completed. improve computerized capacity of SOW of consultancy to design an DAF. administrative and financial management unit at MOH drafted and finalized. Plan implementation To be decided once roadmap is completed. Activity 7: Improve coordination, collaboration, and partnership between line ministries in charge of HRH planning, training, and development Support the strengthening of Situational analysis of the Decree and DRH organizational National HRH Platform multisectoral committee report chart awaiting signature from Office available. of Minister of Health. Organize quarterly meetings of the Last quarter a meeting was held with National HRH Platform stakeholders. Develop an action plan for National To be consolidated in Q3. HRH Platform Activity 8: Strengthen the ICT-based comprehensive management of human resources Support the meetings of the iHRIS Ongoing Technical Working Group Support the institutionalization of Training for statisticians, iHRIS administrators, and other technicians at tertiary hospitals and Conakry district level on iHRIS held. Support the roll-out of iHRIS and Data collection and entry at central Complete Phase 2 data collection and data capture of health workers in level completed. Began Phase 2 data entry. Conakry collection at tertiary hospitals and Conakry district facilities. Activity 9: Support pre-service education institutions to improve management and governance for better workforce development Conduct baseline organizational Assessments completed for two assessments in at least two schools schools: the public Ecole Nationale de Santé de Kindia (ENSK) and private Ecole Superieure des Sages- Femmes (ESSF). Assist schools with the Plan and begin technical assistance development/revision of strategic and implementation in Q3. operational plans
136 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Provide training in school Plan and begin technical assistance administration management implementation in Q3. (leadership, governance, management) Support quarterly networking Begin meetings once technical meetings assistance plans are in place. Activity 10: Support the strengthening of continuing professional development programs for health Do baseline assessment in a selected Local consultants recruited, literature Complete literature review and number of institutions in charge of review in progress. other analyses for baseline Continuing Professional assessment in Q3. Development Train two or three in-service Situational analysis report Coaching training planned for April institutions to conduct coaching and (documentation) of ongoing coaching and May 2017. mentorship in regional and district experiences available. hospitals Support the MOH to develop an in- Begin after baseline assessment service training policy completed. Activity 11: Strengthening the Inspector General function Conduct accountability self- Completed assessment Develop IG Function Mission Completed. Revised vision/ mission Next step / challenge: securing buy-in Statement and Operational Strategy and strategic and operational plans from MOH leadership. Securing drafted. appropriate resourcing for implementation of operational plans. Develop new and improved Development of new mechanisms New skills (audit, inspections) mechanisms for health sector will be part of Action Plan 2017 and required from present cadre of IGS. accountability will respond to a major recommendation of the functional audit. Activity 12: Strengthening of the legislative committee on health Conduct initial assessment of Initial needs assessment conducted. Standing Committee needs Provide support to Standing Budget analysis of 2017 national Lack of subject matter experts within Committee to strengthen health budget undertaken. Commission or Secretariat is a sector stewardship Planning for annual oversight is constraint. currently underway, including field Next steps: endorsement from visits, desk reviews, and other leadership of National Assembly. research. Provision of required resources to Annual oversight plan developed. carry out annual oversight plan.
5. FIELD SUPPORT ACTIVITIES: GUINEA - 137 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 13: Strategic communications for the health sector Do initial assessment of Completed communication capacities and needs Support external communications MOH working group on communications established. Draft of the zero draft external communication strategy in process. Support internal communications MOH working group on Challenge: securing broad agreement communications established. on communications strategy within Framework for internal working group. Adequately communications strategy developed. resourcing of new offices and Draft of the zero draft internal procedures arising out of strategy communication strategy in process. documents. Support budget transparency Expanded work in budget transparency a major part of the external and internal strategic communications plan for 2017.
138 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.1.10 Mali Program Objectives - In Year 5 (FY2017), the overall objectives of HFG's work in Mali are to (i) equip the Ministry of Health and Public Hygiene (Ministère de la Santé et de l'Hygiène Publique, MSPH) with the technical capacity to implement some of the recommendations of the 2015 Health Systems Assessment (HSA) (also supported by HFG) and (ii) equip the Secretary General's office (SEGAL) with the organizational capacity to better coordinate partners to design and implement reforms to achieve Universal Health Coverage (UHC). Year 5 Activities - 1. Private Sector Assessment. HFG will support the MSPH to conduct a Private Health Sector Assessment (PSA) in Mali. The PSA will provide a snapshot of private sector activity in health care and data to identify and mobilize untapped private sector resources. The PSA will assess the role of the private sector in financing, managing, and providing health services. It will include a mapping of private sector providers, public-private partnership initiatives, and challenges and successes encountered. 2. Operational research on the impact of mutuelles in Mali and the way forward to UHC. A study of mutuelles (community-based health insurance organizations) will be carried out to document the reasons for the slow pace of mutuelle expansion in the country and to measure mutuelles' impact in Mali to date. 3. Strengthening analysis and use of Health Accounts. HFG will support capacity building of a Health Accounts core group within the Planning and Statistics Unit (CPS) and other relevant MSHP entities and provide technical assistance to enhance the use of the System of Health Account (SHA) methodology to collect and analyze data on external financing. 4. Institutional capacity building of SEGAL's office. HFG will conduct discussions with the SEGAL and relevant staff to review the findings of the management assessment, develop a shared vision for the SEGAL's office, determine its strategic priorities, and identify ways its staff can work together more effectively. The strategic priorities will form the basis for an operational plan. 5. Support technical working groups (TWGs) to follow up on HSA recommendations. HFG will support the MSHP to reinforce the role and contributions of four TWGs (of 12 indicated in the interministerial arrêté N° 2011/MSP/MDSSPA/MPFEF-SG) to follow up on the implementation of PRODESS activities and HSA recommendations and become more functional, visible, and results oriented. Year 5 Progress Against Objectives - 1. Private Sector Assessment. In Q1, the draft concept note for the study and the terms of reference (TOR) for the PSA consultants were developed and are currently being finalized. In Q2, three international experts travelled to Bamako to conduct data collection and key informant interviews for the PSA. A local consultant also started collecting data to update the mapping of private health providers. 2. Operational research on the impact of mutuelles in Mali and the way forward to UHC. In Q1, the draft concept note for the study and the TOR for the operational research consultants were developed. In Q2, USAID and the MSHP provided feedback on these documents. HFG is revising the TORs to ensure that the study builds upon existing literature about the challenges of mutuelles and supports Mali to identify potential strategies to integrate mutuelles into the more sustainable financing mechanisms.
5. FIELD SUPPORT ACTIVITIES: MALI - 139 3. Strengthening analysis and use of Health Accounts. There have been some staff changes in the Health Accounts team. Our Chief of Party is coordinating with the CPS to identify potential travel dates for HFG's Health Accounts expert, Andre Zida. 4. Institutional capacity building of SEGAL's office. In Q1, a consultant made a second TDY to Mali on December 12-16, 2016, to share and discuss the findings of the Management Assessment report with the new Minister's cabinet and advisors; agree on key priorities to implement; and define an action plan for the implementation of the recommendations. During these meetings, the new cabinet's members shared their expectations regarding the capacity-building activity and an action plan for HFG in response to the request that is being finalized by the consultant. In Q2, HFG shared the findings from the December mission to discuss potential capacity-building activities for the SEGAL's office. Requests by the MSPH for embedded technical assistants were made to HFG but this falls outside the scope of our Y5 work plan; USAID has assigned this to HP+. HFG will discuss this with the Mission to identify the best way forward. 5. Support TWG to follow up on HSA recommendations. In Q2, HFG started recruiting for a local consultant to work with the SEGAL's Office and the CPS to make the TWGs functional again. Q2 Challenges - There is some concern that the research on mutuelles may not be a priority for the MSPH and may be duplicative. HFG is reviewing the scope of this activity in conjunction with the MSPH, and will finalize the TORs after incorporating the findings from the PSA. Q2 Additional Information - Coordination with other development partners continues to be a priority, particularly with USAID partners working in health, governance, and policy. The close relationship between HFG and the MSPH is an important factor for understanding the priorities of the MSPH and in transferring these priorities to the HSA and PSA analyses. Table 34 provides activity-specific updates. TABLE 34. MALI ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Health System Assessment Edit and disseminate the HSA report HFG received the final edited report The final report is awaited by most of in French in Q2. HFG will conduct the in-country partners. It is final quality checks before organizing expected to enhance understanding in-country dissemination in April/ of development programs and also May. help in updating strategies for health systems strengthening.
140 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 2: Management Assessment Write and disseminate report Following a TDY in Q1 to update new MSPH staff on the Management Assessment, HFG submitted its trip report with recommendations. Several requests made to HFG fall outside the project's scope and USAID has redirected them to the HP+ project, e.g., hiring 5 technical assistants who will be embedded advisors in the MSPH Health Services Directorate. HFG is due to speak with the Mission about potential ways forward and to identify capacity-building activities that the project will carry out. Activity 3: Institutional capacity building of SEGAL’s Office Develop and validate implementation HFG awaits USAID and MSHP final plan based on Management decision for this activity (see related Assessment recommendations activity above for Management Assessment) Activity 4: Operational research on the impact of mutuelles in Mali and the way forward in the path to universal health coverage Develop the concept note for the Several studies on mutuelles in Mali A decision was taken to suspend this mutuelles study have documented challenges to scale- activity until the results of the PSA up. There is also literature on are shared. challenges with sustaining small, independent mutuelle organizations. HFG will revise the TORs of this activity, including incorporating findings from the upcoming PSA report, to ensure that HFG's study adds value to Mali's discussion of the roll-out of the UHC scheme, e.g., reviewing strategies that other countries such as Ghana, Indonesia, and Rwanda have used to incorporate community-level health insurance into an integrated risk pool.
5. FIELD SUPPORT ACTIVITIES: MALI - 141 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 5: Private Sector Assessment Finalize PSA report with feedback Data collection and key informant The English version of the report is from USAID and other stakeholders, interviews in Bamako took place in expected to be submitted to USAID and disseminate February 2017. The PSA team is by mid-end of April. A workshop will drafting the report; a draft for the be organized to share the findings internal HFG report is due by the with a large in-country audience. No end of March. The update to the major impediments foreseen. private provider mapping is also underway and will be submitted with the PSA report. Activity 6: Strengthening analysis and use of Health Accounts Provide technical assistance to Following staff changes in the Health HFG is coordinating with WHO, MHPH to conduct analysis for policy Accounts team, a new focal person which is supporting the production of using Health Accounts data for CPS and a core technical team for Health Accounts. HFG's support is the training on health financing helping the MSPH use the Health analysis has been identified. HFG is Accounts data for policy decision- organizing a TDY for Andre Zida. making. Activity 7: Support Technical Working Group to follow up on Health System Assessment recommendations Hold Inception Workshop for TWGs Recruitment of the senior consultant is underway and participants for each TWG have been finalized. HFG's support will strengthen the functioning of these groups so that they can implement the recommendations from the HSA and PRODESS.
142 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.1.11 Namibia Program Objectives - The Government of the Republic of Namibia has reduced significantly its reliance on donor funding to finance health services, with approximately 8 percent of total health expenditure being funded by donors in 2012/13 compared with 21.7 percent in 2008/09. Most of this donor funding has been allocated to special programs, such as HIV and AIDS, TB, and malaria. With decreasing donor resources in the country, there is increasing pressure on the government to identify sustainable means of financing the HIV and AIDS multisectoral response to maintain the significant gains achieved under the PEPFAR program. According to the 2012/13 National Health Accounts (NHA) exercise, 51 percent of HIV and AIDS program expenditures were financed by donors; according to the 2014 draft National AIDS Spending Assessment (NASA), the percentage financed by donors has dropped to 36 percent. While Namibia has made progress in absorbing a portion of the HIV and AIDS expenditures, most notably in the areas of human resources and procurement of ARVs, there continues to be a high level of donor funding to support critical disease interventions According to the FY2014 PEPFAR Guidance for Sustainability Planning, Namibia is in the first wave of countries that have agreed to develop PEPFAR Country Health Partnerships (CHPs), which means it "eventually will be afforded a formalized joint decision making role in the allocation of PEPFAR financing and technical resources in their country [ies] through a small bilateral governance structure established under the PEPFAR CHP." As a result, the government is at a critical juncture in re-evaluating its health financing strategy, policies, and mechanisms and ensuring the long-term sustainability of gains made in the fight to eliminate the spread of HIV and AIDS; treatment of patients; and reducing the impact on families affected by the disease. Year 5 Activities - HFG's activities in Namibia in Year 5 include: 1. Institutionalization of NHA for resource tracking 2. Efficiency analysis of district hospitals in Namibia 3. Health facility unit costing study Year 5 Progress Against Objectives - Institutionalization of NHA for resource tracking: Providing technical support to the 2014/15 Health Accounts exercise: HFG has been supporting the Namibia Ministry of Health and Social Services (MoHSS) in its move toward institutionalizing Health Accounts. The support includes helping the Ministry conduct another Health Accounts study with emphasis on using mechanisms that simplify data collection, ensuring that the exercise is harmonized with other resource tracking exercises, such as NASA, thereby capturing information needs for HIV/AIDS programming as part of the exercise and avoiding parallel/duplicative efforts, and supporting development of follow-on policy products to help promote uptake of Health Accounts results to inform policy and planning. In Y4Q2, HFG and the WHO co-facilitated the MoHSS Health Accounts team's discussions with the Ministry's Directorate of Special Programs (DSP) and UNAIDS on lessons learned from the earlier, parallel (NASA) estimation of HIV spending. The aim was to inform the new round of Health Accounts, which will encompass HIV/AIDS programmatic spending. Based on the lessons learned from the previous Health Accounts estimate, HFG has helped the Health Accounts team review and revise the data collection instruments for the upcoming exercise. In Y4Q3 and Y4Q4, HFG provided the MoHSS technical support in conducting the 2014/15 Health Accounts' data review and analysis. In Y5Q1, the results of the 2014/15 exercise, which incorporate cross-analysis of the results to the NASA's AIDS spending categories, were being finalized. The preliminary results were sent to the Ministry team in November for their review and feedback.
5. FIELD SUPPORT ACTIVITIES: NAMIBIA - 143 In Q2, HFG received initial feedback from the MoHSS in February and additional feedback in March. The Health Accounts lead within the Ministry is satisfied with the preliminary results and these were presented to MoHSS management in March. The Health Accounts report will be finalized in April after the results have been validated by the MoHSS management.
Efficiency analysis of hospitals in Namibia: This activity started after the Economic efficiency and effectiveness analysis for sustainable HIV and AIDS financing study was cancelled after consultation with USAID/Namibia due to overlap with UNAIDS work on the investment case. HFG decided to focus instead on district hospital efficiency, which was a critical missing piece of information in the projection of resource needs for HIV funding. This quarter, the efficiency study's Scope of Work (SOW) and Protocol were finalized by the HFG team. HFG also completed a facility questionnaire. A study guidance manual was also prepared to aid facilities in filling out the questionnaires. Letters requesting the provision of data with specific data requirement descriptions were drafted for submission to central-level data sources, such as the National Institute of Pathology, Central Medical Stores, Response Monitoring & Evaluation, and the HMIS unit. HFG will include 35 hospitals, including four referral hospitals (three intermediate hospitals and one national referral hospital), in the study. Rundu Hospital was already covered in the unit cost study. Thus, only four referral hospitals need to be added. The Policy, Planning and Human Resource Development team will assist in following up with facilities where necessary. HFG submitted an application to the Abt Institutional Review Board (IRB) for an initial review. The study was exempted from IRB review as it does not include human subjects (the data being collected from facilities is at the aggregated patient level and no team member will have access to individual patient records). HFG also submitted an IRB application to the MOHSS research review board and is regularly following up on the approval with the Ministry.
Unit costing of health facilities: The objective of this study is to determine the cost per unit of service (per outpatient visit or inpatient day) in selected public and private health facilities based on actual expenditures incurred and the packages of services provided at different levels of health facilities in the 2014/15 financial year of the identified health facilities. Assessments were conducted to identify the key gaps in the quality of service provision at each health facility, and comprehensive quality improvement plans were drawn up to address those gaps. The results of the costing study and quality assessments will inform the Universal Health Coverage Advisory Committee of Namibia's (UHCAN) total financing requirement for UHC and other studies on the path towards UHC. The SOW/Protocol for this activity was approved by the MoHSS Research Committee in Y4Q3. Data collection was done in 13 public sector facilities between May and August 2016 for both the costing and quality assessment components of the study. Three private hospitals agreed to participate in the study and data collection was completed for two of them in Y4Q4. PharmAccess, our subcontractor, conducted the quality assessment component of the study. In Y5Q1, data collection was completed for all 13 facilities participating in the study. HFG faced challenges locating some of the data. Of the 13 facilities, four had gaps in data. One facility did not have facility-specific operational expenditure data, and three other facilities were missing pharmaceutical expenditure data. PharmAccess submitted all deliverables to HFG including the quality assessments of all facilities that agreed to participate, the SafeCare Assessment Reports showing gaps in the quality of health care services for each facility in the sample, the SafeCare Quality Improvement Plans, and the final Workshop Presentation. In Q2, HFG continued to work with MoHSS, with assistance from the Policy, Planning and Human Resource Development team, to fill facility-level gaps in pharmaceutical and operational expenditure data. Of the four facilities with remaining data gaps, data could be obtained from only one; therefore, HFG, in consultation with the MoHSS, decided to exclude the three facilities from the study. Data analysis is now in progress and the report should be available this quarter.
144 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Production of health financing review: In Y4Q1, HFG finished drafting the Health Financing Review report and submitted it to the UHCAN for review. The UHCAN suggested edits and made comments to strengthen the report, in particular to include additional local context and views regarding Namibia's vision for UHC. HFG addressed all edits and comments and in December 2015 re-submitted the report for approval by the technical committee of the UHCAN. The final report was delivered in Y4Q2. In Y5Q2, the MoHSS presented the results to a stakeholder meeting of the Public Service Employees Medical Aid Scheme (PSEMAS). Q2 Challenges - Health Accounts: The regular Ministerial management meeting at which HFG has presented the results (for the previous Health Accounts exercises) no longer take places, so HFG is looking for another venue at which to present results.
Unit costing of health facilities: Data collection at study facilities revealed many data gaps. Detailed or accurate information was not available on salaries, operational expenses, and pharmaceuticals for specific facilities. The regional budgets had detailed estimates for salaries per health facility including clinics and health centers. However, the regional and district budgets only use estimates for operational expenditures for the region as a whole using a historical budgeting approach. As a result, obtaining budget or actual expenditure information for operational expenses per facility was not possible. However, for most facilities, the cost of utilities per facility is tracked and these costs could be used as the proportion of the regional expenditure to estimate the other operational expenditure. PharmAccess faced many challenges in obtaining information, which delayed the completion of some deliverables. It was a challenge to obtain certain information from Nyangana Hospital, and this delayed the final Quality Assessment report. The SafeCare team also experienced technical system problems while completing data entry. Table 35 provides additional activity-specific updates. TABLE 35. NAMIBIA ACTIVITY DETAIL
Critical Assumptions/ Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/ Follow-up Steps Activity 1: Implementation and institutionalization of National Health Accounts using the updated framework Backstop the team in developing A draft maternal health policy brief policy briefs and communication based on the 2012/13 results was products that answer the key policy prepared in Y4. It is being updated questions identified at the outset of based on 2014/15 Health Accounts the exercise results. Provide technical assistance with HFG received feedback on the HFG plans to finalize the report by data analysis for the 2014/15 Health preliminary results in February and the end of April 2017. Accounts exercise March 2017. The MOHSS HA team presented preliminary results, which were prepared from data collected independently by the MOHSS HA team, to the MoHSS management in March 2017. HFG assisted the MoHSS HA team with data cleaning, importing, and mapping for the analysis.
5. FIELD SUPPORT ACTIVITIES: NAMIBIA - 145 Critical Assumptions/ Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/ Follow-up Steps Provide technical assistance with The MoHSS has collected the 2015/16 data analysis for the 2015/16 Health Health Accounts data. Accounts exercise Activity 2: Unit costing studies Conduct unit cost study of various HFG continued to seek missing data to HFG has begun drafting the report. health facilities fill outstanding data gaps for four facilities. HFG decided to exclude three of the four facilities from the study due to outstanding operational and pharmaceutical data. Do quality assessment study Data collection was completed at all Dissemination is being planned for facilities in Q1. Q3. Activity 3: Efficiency analysis of district hospitals in Namibia Request for IRB approval HFG submitted an application to the Once HFG has received a response Abt IRB for an initial review. The study from the MOHSS research review was exempted. HFG also submitted an board, HFG will begin data collection. IRB application to the MoHSS research review board. HFG is awaiting feedback from the board. Prepare SOW/Protocol The SOW/Protocol was finalized by The task is complete. the HFG team in early January. Prepare questionnaire for data A questionnaire for data collection was This task is complete. collection finalized. A guidance manual to aid facilities in completing the questionnaires was also prepared. Conduct data collection at health Letters requesting the provision of facilities data with specific data requirement descriptions were drafted for submission to central-level data sources. Complete final report including descriptive results showing the distribution of key efficiency indicators for public hospitals and efficiency measurements and recommendations to improve efficiency
146 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.1.12 Nigeria Program Objectives - In November 2016, HFG submitted two work plans to USAID for Year 5 activities that focused on 1) developing health care financing core analytics and capacity at the state level in Bauchi, Sokoto, and Cross Rivers states to improve the financing, management, and delivery of sustainable pro-poor reproductive, maternal, neonatal and child health (RMNCH) services and 2) implementing the Sustainable Financing Initiative (SFI) in Lagos and Rivers states to increase HIV service coverage, strengthen financial protection, and improve access for vulnerable populations. To achieve these objectives, HFG will implement a range of activities focused on increasing levels of domestic resource mobilization (DRM) and strengthening health financing functions including:
Building capacity in health financing strategy design and implementation
Strengthening and implementing targeted, evidence-based advocacy strategies and building support for increased government financing of HIV programs and the health sector in general, recognizing the broad range of stakeholder within and outside of state ministries of health (SMOHs)
Gathering data and conducting relevant analytics for health financing strategy design The overall objective of the activities is to develop and implement health financing and DRM strategies that increase the level of resources going to health and HIV programs with a focus on ensuring access and risk protection for vulnerable populations. Year 5 Activities - • RMNCH Health Financing. To ensure increased resources are available to improve access and financial risk protection for RMNCH, HFG will carry out the following across each of the three focal states: . Conduct a health financing situational analysis to clarify the state’s context for the project, other implementing partners, and the state ministries of health and finance; . Conduct a political economy/governance analysis to identify stakeholders, institutions, and capacities that are key to the development and implementation of a health financing strategy; . Conduct a fiscal space analysis to identify the level of resources available (state and federal) and resources required for state health financing mechanisms per state objectives and targets; . Support the implementation of state Health Accounts (to be conducted in Kogi and Ebonyi states in Year 5 as well as the three focal states); . Support the formation, capacity building and functioning of a technical working group (TWG) on health financing in each state. In addition, to forming this TWG, HFG will also establish a state peer-learning network among the three focal states, the SFI states, Kogi, and Ebonyi; . Carry out Service Availability and Readiness Assessments (SARAs) in Bauchi and Sokoto states; . Cost a defined (ward) minimum benefit package to support decision-making around the final definition of one by each state; . Finally, the state-level activities will be supported by HFG at the federal level where HFG will be using the Capability, Accountability, and Responsiveness (CAR) framework to assess the CAR of institutions involved in the Basic Health Care Provision Fund's
5. FIELD SUPPORT ACTIVITIES: NIGERIA - 147 implementation. This assessment is key to unlocking federal-level support (technical and financial) for state-level health financing initiatives. Following this assessment, an accountability framework will be developed to articulate the roles, responsibilities, and performance of each of the key institutions required for Basic Health Care Provision Fund implementation at the federal and state levels.
• Sustainable Financing Initiative. To ensure increased resources available to improve access and risk protection for those needing HIV services, HFG will carry out the following activities in Lagos and Rivers states: . Participate in the Core Implementation Team to support the finalizing of the state- supported health insurance scheme's benefit package while making the case for the inclusion of prevention of mother-to-child transmission (PMTCT) and HIV care and treatment services. To this end, HFG will also provide quantitative evidence and modeling such as actuarial analysis and gap analyses to strengthen advocacy and support for HIV service inclusion. . Work with the Core Implementation Teams, State Agencies for the Control of AIDS (SACAs)2 and State AIDS and STD Control Programs (SASCPs)3 to advocate for increased funding for HIV programs. In conjunction with this advocacy, HFG will work with the relevant government agencies to ensure that processes (e.g., procurement, financial management) are in place to ensure that all budget resources (existing and supplemental) are fully expended in an accountable manner. . One carryover TB activity from Year 4 will be finalized in Y5Q1. HFG will complete its work on connecting TB data streams for better planning of TB programs by creating an interactive dashboard that will track TB programs using data from various sources including DHIS2, eTB manager, TB Supportive Supervision, and GxAlert (which HFG supported the national scale-up of in Years 3 and 4). The final dashboard element due in Year 5 is the warranty and calibration tracking of GeneXpert machines through GxAlert. Year 5 Progress Against Objectives - The socio-economic and political landscape in the country was characterized by fiscal challenges, uncertainties, and insecurity during the period. In spite of this, HFG took key steps toward achieving the objectives of the SFI in Lagos and Rivers states and RMNCH Health Financing in Bauchi, Sokoto, and Cross River states:
Capacity building and roadmap development: The Q2 focus was to build the capacity of multisectoral stakeholders on basic health care financing concepts and acquaint them with institutional and legal frameworks of health financing reforms. The trainings for Bauchi and Sokoto states were organized in collaboration with the Federal Ministry of Health, National Primary Health Care Development Agency (NPHCDA), and the state offices of the National Health Insurance Scheme. HFG also collaborated with the Bill and Melinda Gates Foundation-funded Health Service Delivery Foundation to extend to Niger and Kaduna states. Participants from Abia and Bayelsa states also attended the training in Rivers state, through collaboration with the World Bank and NPHCDA. At the end of the training, participating states developed roadmaps that articulate immediate next steps, timeline, resources needed, and persons responsible.
2 SACAs focus on program coordination. 3 SASCPs are within state ministries of health and focus on care and treatment.
148 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Roadmap implementation: In line with the roadmaps they developed after the health care financing training, Bauchi and Sokoto states have set up multisectoral health care financing TWGs. The TWG is part of the institutional arrangement that ensures inputs of diverse institutions are leveraged, to improve funding for health and enhance accountability – in this way, the inputs achieve more money for health and more health for the money. In Cross River State (CRS), HFG has continued to support the Health Financing TWG’s implementation efforts by engaging with the highest Traditional Ruling Council, Labor Union, State House of Assembly, Office of the Governor, and state ministries of information, budget and economic planning, and finance. These advocacy efforts are yielding results as the sum of NGN26 billion has been set aside for the Cross River State Health Insurance Scheme (CRSHIS) and approved in the 2017 state budget. A Director General has also been appointed to oversee the CRS Health Insurance Agency. In Lagos and Rivers, HFG continued to strengthen advocacy efforts aimed at ensuring an adequate budgetary allocation to HIV/AIDS in the 2017/2018 budget as well as a satisfactory budget performance for fiscal year 2016. The SFI work plan was approved early in Y5Q2. A kick-off meeting on SFI was conducted for both Lagos and Rivers states to inform stakeholders of SFI targets and deliverables, obtain a better understanding of the states’ policy direction, and align goals and activities for better ownership and sustainability of the SFI initiative. HFG facilitated engagement of stakeholders for the USAID and State Government Memorandum of Understanding and the review of the document in both states before finalization and signing, which has reached an advanced stage in both states. Already, Rivers State has committed to a contribution of approximately $1.65 million for HIV/AIDS.
Progress toward increasing resources available to improve access and risk protection for RMNCH
• Bauchi State: Quarter 1: The kick-off meeting could not be held in the week of December 12 as planned and was postponed to early January. A technical training for the Health Financing TWG in Bauchi and Sokoto was planned for the week of February 6 and was expected to bring together a wide range of actors from the state ministries of health, finance, budget and economic planning; houses of assembly; organized labor; professional health bodies; and private health practitioners to deepen their understanding of the basic concepts of health financing and forge a consensus on the legal, policy, and organizational frameworks needed to achieve health financing reforms. Quarter 2: A kick-off meeting was held to introduce the Health Financing for RMNCH project to the state. In this meeting, the health financing direction for the state was discussed and project activities presented to the state actors. Areas of alignment were identified and priority activities agreed upon. A health financing capacity-building workshop also took place in the first week of February with participants drawn from a wide range of stakeholders. As an output, the state developed a roadmap for health financing reforms encompassing key activities, responsible persons, timelines, and resources needed under the following headings: Advocacy, policy reforms, legal reforms, institutional arrangements and health financing core diagnostics. HFG has continued to provide technical assistance in the implementation of this roadmap. To advance roadmap implementation, a stakeholder mapping and analysis was conducted to understand the actors in the Bauchi health financing space. Using this information, a multisectoral Health Financing TWG was constituted by the state and inaugurated by the Honorable Commissioner of Health. Terms of reference are being deliberated and a date for the inaugural meeting has been agreed upon. A Health Financing Unit also was established as
5. FIELD SUPPORT ACTIVITIES: NIGERIA - 149 part of the institutional arrangements and currently has a focal person in charge. This unit shall serve as the secretariat of the Health Financing TWG. To deepen understanding of the health financing situation analysis in the state and as identified in the state roadmap, a stakeholder’s engagement on health financing core diagnostics was held in the reporting quarter. This meeting provided an opportunity to introduce the fiscal space analysis, governance/political economy assessment, and resource tracking to the stakeholders for their buy-in. Additionally, the SARA, which is taking place in 68 facilities (primary health care centers and secondary and tertiary health facilities), has been concluded. Information from this assessment will provide the needed evidence for targeted investment in bridging the infrastructure, human resources for health (HRH), and commodity/equipment gaps and serve as an advocacy tool for resource mobilization.
• Cross River State: Quarter 1: HFG completed the household survey to estimate out-of-pocket expenditure on health as a share of household expenditure – a baseline needed to measure the achievement of financial risk protection following the launch of the CRSHIS and to contextualize proposed benefit package and premium/subsidization impact. An evidence synthesis workshop was also conducted to bring together all the findings from various health financing core diagnostics – fiscal space assessment, public sector financial management assessment, governance/political economy assessment – in order to understand their implications for the design and implementation of the CRSHIS and forge a consensus on feasible recommendations for action. Quarter 2: A capacity-building workshop was held for the Health Financing TWG members to deepen their understanding of health financing concepts, the CRSHIS law, and the reforms going on in CRS. An output of the workshop was the CRSHIS design implementation plan, which details the critical pathway for setting up the CRSHIS. As part of HFG’s efforts to rally support from other development partners, commitments have been extracted from WHO, UNFPA, and Salt & Einstein MTS to support the state primary health care (PHC) revitalization efforts, develop a health financing policy/strategy document, and deploy an ICT platform for the CRSHIS, respectively. Similarly, media practitioners were trained on health financing concepts and their role in propagating information on health financing reforms generally and the benefits of health insurance principally. HFG has continued to support the Health Financing TWG’s implementation efforts by engaging with the highest traditional ruling council, the labor union, state house of assembly, office of the Governor, and the state ministries of information, budget and planning, and finance. These advocacy efforts are yielding results as the sum of 26 billion has been approved in the 2017 state budget and set aside for the CRSHIS. A Director General has also been appointed to oversee the CRS Health Insurance Agency. Consultancies for short-term technical assistance to the CRS government to develop operational guidelines for the CRSHIS and business process manual/organizational development for the CRS health insurance agency are being finalized. Likewise, technical support to cost the infrastructural, HRH, and commodity/ equipment gap at state selected facilities for the PHC Revitalization Programme is being concluded and field work will commence shortly.
150 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
• Sokoto State: Quarter 1: A multisectoral Health Financing TWG was inaugurated by the honorable commissioner who considered the arrival of USAID/HFG as timely. HFG organized a kick-off meeting with all stakeholders to achieve a shared understanding of the project scope, activities, and deliverables. Discussions at the meeting helped align HFG work plan activities with the state’s needs and priorities. At the end, there was a joint sequencing of the activities and next steps needed to achieve mutual objectives. Quarter 2: A health financing training was conducted for relevant stakeholders from different sectors. The training gave the stakeholders a good understanding of key health financing concepts needed for health financing reform. Another outcome of the training was the development of a roadmap for the state’s health financing reforms, which comprised legal, policy, institutional, and diagnostic frameworks and activities that will be conducted in Q3. The roles and responsibilities of different actors were highlighted and timelines set. To ensure the effectiveness of the TWG, and as a result of improved knowledge from the health financing training, the Sokoto SMOH expanded the TWG’s membership to include representatives from all relevant and influential sectors in the state. The TWG was inaugurated and held a first meeting, during which the members defined their terms of reference and operating approaches and identified key issues to be addressed. A health financing unit was established to coordinate all health financing activities in the state; it also serves as secretariat to the activities of the TWG. To obtain adequate evidence to inform health financing reforms, an engagement meeting was held with relevant stakeholders to introduce the core health financing diagnostics (governance analysis, fiscal space analysis, resource tracking, and household surveys) to the key actors. The actors were identified and engaged, roles were defined, objectives set, and initial data collection begun. The diagnostics will generate context-specific information necessary for the design of the reforms and decision making. Furthermore, SARA studies were conducted and relevant information collected. Findings will inform appropriate decisions for strengthening the service delivery points to deliver quality health care services as a supply-side strategy for attaining UHC.
Progress toward increasing resources available to improve access and risk protection for HIV/AIDS (SFI). In Lagos and Rivers, HFG continues to provide technical support for advocacy efforts aimed at ensuring adequate budgetary allocation to HIV/AIDS in the 2017/2018 budget as well as satisfactory budget performance for fiscal 2016. SFI baseline activities commenced in year 4 and continued into Y5Q1. The SFI work plan (post-baseline) was approved early in Y5Q2.
• Lagos State: Quarter 1: Additional actuarial analysis was conducted to understand the financial implications of adding selected HIV/AIDS services to the Lagos State Health Scheme (LSHS) benefit package. Results will be used for continued advocacy for benefit package expansion to include HIV/AIDS services in a bid to secure a predictable and sustainable means of financing the state HIV/AIDS response domestically. Other evidence that will be leveraged for advocacy and the design of the health scheme include technical support provided by HFG; fiscal space analysis, a public financial management assessment, resource tracking, and development of provider payment guidelines. The process of finalizing the governance assessment began. In particular, the recent adoption of test and treat poses financial and advocacy challenges as promoting the inclusion of PMTCT, from an ethical standpoint, requires the state to also commit to placing HIV-positive pregnant women on antiretroviral therapy (ART) for life. The synthesis of HFG’s fiscal space analysis, and additional actuarial and gap analyses are necessary to
5. FIELD SUPPORT ACTIVITIES: NIGERIA - 151 demonstrate/provide reassurance that (given current PEPFAR commitments and the conservative targets for scheme enrollment) the inclusion PMTCT in the benefit package will not “bankrupt” the scheme as the number of women in need will be low and can be accommodated. Quarter 2: As stated above, HFG is supporting additional actuarial analysis of the LSHS benefit package, with HIV/AIDS included, to generate evidence of the financial implication of adding HIV/AIDS services to the premium cost and ultimately achieve benefit package expansion. HFG also continues to provide technical support to SACA/SASCP to enable the institutions to lead advocacy efforts for benefit package expansion. Key questions from the SMOH on improved coordination between the LSHS, government vertical programs, and donor programs has led HFG to consider supporting a short-term technical assistance on aligning the LSHS with stand- alone interventions generally and HIV/AIDS specifically. On budget advocacy for HIV/AIDS, the 2017 budget has been approved and implementation has begun. Budgetary trend analysis shows that SACA has an additional US$1.3 million in budget allocation from 2016 while SASCP achieved a US$312,500 increase from 2016. The efforts of the DRM TWG in escalating the need for improved funding for HIV/AIDS to the central budget MDAs and the Honorable Commissioner for Health has proved most beneficial. Additional support is ongoing to ensure adequate release of funds through the writing and submission of requisition memos. HFG’s technical support to the LSHS Core Implementation Team is ongoing. The provider payment guideline development and governance/political assessment have been concluded and the fiscal space analysis updated to reflect current realities. The management of the equity fund is being deliberated and HFG is providing technical assistance in public financial management to develop a guideline for the funds administration and disbursement. USAID/HFG is considering the SMOH request to support the alignment of vertical programs with the LSHS. This will help define a synergy between the different health financing mechanisms and bring about improved development cooperation. The resource tracking report is being written and incorporating input from stakeholders, which will help validate the report and enhance acceptance and ownership of the final report.
• Rivers State: Quarter 1: HFG conducted an evidence synthesis workshop, which aggregated all the findings from various health financing core diagnostics, fiscal space assessment, public sector financial management assessment, and the governance/political economy assessment. The implications for the Rivers state health contributory program was evaluated and feasible recommendations agreed upon for evidence-based decision making. Quarter 2: HFG supported Rivers State in ensuring an improved allocation – of 48 percent – to HIV/AIDS in the 2017 budget; further support is being given to ensure adequate release through the DRM TWG, SACA, and SASCP. HFG used findings of the household survey to generate state-specific evidence to support inclusion of HIV/AIDs in the design of the scheme’s benefit package. For example, over 95 percent of health expenditure in Rivers State comes from people’s out-of-pocket spending at point of service; households spend an average of 21,000 naira yearly on health care, far above current premium rates (10,000 naira for the Obio CBHIS). Relevant information was synthesized and used to develop the advocacy tools used in creating awareness and engaging stakeholders to buy into the state health insurance scheme. A health financing training was conducted for relevant multisectoral actors to educate them and build their capacity to develop and implement health financing reforms. This team comprised actors who can influence and impact health care financing from key MDAs and sectors, namely
152 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
the state’s ministries of Health, Budget and Economic Planning, Finance, Justice, and Information, State House of Assembly, civil society organizations, the private sector, SACA, State Primary Health Care Board, and the National Health Insurance Scheme. A key outcome of the training is the development of a roadmap for health financing reforms in the state, which clearly outlines the important advocacy, institutional framework, policy, diagnostics, and a legal framework that will need to be implemented for improved health financing. In the roadmap, advocacy will be done with key actors of interest to ensure increased budgetary allocation and release to health and the proposed Rivers State health insurance scheme. The TWG and Health Financing Unit to lead and drive the process will be established; a legal framework for the scheme will be passed and policies and guideline documents will be developed to guide the process and ensure effectiveness. Similarly, the media were trained on health financing concepts and benefits of health insurance, equipping them to effectively enlighten the public and enhance behavior change communication with respect to health insurance. A media plan was developed to guide the process. Furthermore, HFG supported advocacies to key groups on health financing reforms including key MDAs, trade groups, organizations, and ultimately to the Deputy Governor to ensure political will and commitment for maximum impact. The advocacy to the Deputy Governor was important as the SMOH had been functioning without a Commissioner; it was targeted to secure progress in the following areas: the establishment of the health financing unit; a constitution for the Health Financing TWG; revision of the legal framework of the River State Contributory Scheme technical committee (RIVCHPP) bill to incorporate the strategy to begin with the informal sector (HFG will provide support to the committee); and commitment to the MOU.
• The resource tracking report for Rivers State has been finished with input from the SMOH DPRS. The DPRS specifically asked to be on the report writing team to provide guidance and validation of the report before it was presented to a larger group of state actors. A second report on the state’s Public Sector Expenditure Review is also available. This was drafted as a stopgap while waiting for data from donors. The DPRS applauded this effort was applauded and requested that it be presented formally to the state alongside the resource tracking report. Q2 Challenges - The actuarial analysis consultancy in Lagos State is not progressing as expected. The engaged consultant is not able to commit the required attention at this time and all efforts to work around this have proved futile. Other options are being considered, including replacing the consultant. The absence of a substantive Honorable Commissioner for Health in Rivers State slowed the pace of activity implementation. However, the HFG team engaged the state’s Deputy Governor to ensure that the SMOH has the necessary political support to implement the agreed HFG work plan activities. HFG is finding it difficult to obtain data from the SARA that the World Bank conducted in Bauchi and Sokoto states. HFG needs the data to complete its SARA report; the facilities assessed earlier by the Bank were not included in HFG’s sample to avoid duplication. This issue has been escalated to USAID and is receiving necessary attention. Q2 Additional Information - HFG is fostering collaboration and exchange of ideas among legislators across the supported states. Considering that improved health financing is a core function of legislators, HFG intends to leverage these core functions, which include appropriation, legislation, accountability, oversight, and representation to improve appropriations for health and better release of appropriated funds with increased accountability. HFG will continue to support this initiative, which will soon culminate in the launch of the Legislative Network for UHC.
5. FIELD SUPPORT ACTIVITIES: NIGERIA - 153 HFG has been asked by the USAID to suspend the planned resource tracking activity in Kogi State due to security challenges. Table 36 provides activity-specific updates. TABLE 36. NIGERIA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity: Connecting tuberculosis (TB) data streams for better planning and establishing a secure and streamlined data network Finalize and deploy TB Dashboard modifications still in progress. SystemOne will finalize the supportive supervision (TBSS) development of the dashboard by dashboard March 31, 2017. Activity: Strengthen and expand case detection Find an in-country SMS Yet to find a suitable service provider in Global SMS gateway will be used provider country. Currently using the global SMS going forward. gateway. Activity: Strengthen state-level financing for health Do resource tracking for state Donor data received from the PEPFAR. Out-of-pocket spending for Akwa health expenditures Rivers State initial draft has been submitted Ibom State is not available because for review; Lagos State report is near a household survey was not completion; CRS report writing has begun. conducted there. Plan is in place to engage with the state’s stakeholders on extending findings from CRS to Akwa Ibom. Activity: Health financing support to RMNCH priority state: Bauchi Implement SARA survey Support the introduction of Stakeholder mapping and analysis conducted. state-supported health Roadmap on reforming the Bauchi State insurance scheme (SSHIS) health financing landscape has been developed. Implementation is ongoing. Draft SSHIS bill to be reviewed at the proposed inaugural TWG meeting. Establish/ support health Multisectoral HF TWG has been constituted financing TWGs and inaugurated by the Honorable Commissioner for Health. Inaugural meeting scheduled for March 21, 2017. Do political economy analysis/ Stakeholders’ engagement held. Data governance analysis collection to commence. Do fiscal space analysis Stakeholders’ engagement held. Data collection to commence. Establish state-level peer- To be discussed during the proposed learning network inaugural TWG meeting. Define minimum health benefit To be discussed during the proposed package inaugural TWG meeting.
154 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity: Health financing support to RMNCH priority state: Sokoto Implement SARA survey in Fieldwork begun and data collected from the In the next quarter, costing for the Sokoto selected facilities. Report drafted. gaps will commence. Establish/ support health Health Financing TWG expanded to Monthly meetings will be financing TWGs incorporate a multisectoral approach. The conducted next quarter. multisectoral TWG was inaugurated and its Subsequent meetings will be first meeting was held. quarterly. Emergency meetings will Terms of reference were reviewed and be called when necessary. adapted and key issues to be addressed in the next month identified. A Health Financing Unit established and a Health Financing Officer appointed; the unit will serve as secretariat to the TWG. Support the introduction of A Health Financing Training was conducted Further support will be given to SSHIS for relevant stakeholders; a roadmap for ensure the passage of the bill and to health financing reform developed develop an implementation guideline for the SSHIS. Define the minimum health To commence in Y5Q3. benefit package Do fiscal space analysis Stakeholder engagement held. Data collection will be completed in Tools validated. the next quarter, and then analyzed and disseminated for utilization in Data collection commenced. the design of reforms. Do political economy analysis/ Engagement meeting held. Data collection will be completed in governance analysis Tools validated. the next quarter, and then analyzed and disseminated for utilization in Data collection commenced. the design of appropriate targeted advocacies Establish state level peer- Concept notes developed. Stakeholders The network will fully commence learning network sensitized on benefit and mechanisms. activities in the next quarter. The Engagements for roll-out have commenced. legislative network will be scaled up and further supported. Legislative Network for health financing reforms established among states and linkages established.
5. FIELD SUPPORT ACTIVITIES: NIGERIA - 155 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity: Health financing support to RMNCH priority state: Cross River Establish/ support health Health financing capacity-building workshop financing TWGs held for TWG members. An output of the workshop was the CRSHIS design implementation plan. Technical support provided to Core Implementation Team in operationalizing the CRSHIS implementation plan: advocacy visits, engagement with labor union, engagement with media, etc. CRS household survey report finished. Findings are being used for continuous advocacy. Support the introduction of Advocacy for institutional organization of the HFG working with TWG to SSHIS CRS Health Insurance Agency; a Director coordinate support for the CRSHIS General has been appointed. implementation from other Technical support for the development of partners. the CRSHIS operational guidelines and ICT design and deployment (Salt & business process manual; a consultant has Einstein). been hired. Health Financing Strategy and Policy Technical support for organizational development (UNFPA). development for the CRS Health Insurance Health facility upgrade (WHO). Agency; a consultant has been hired. 2017 CRS budget approved with NGN 26 billion allocated for the implementation of the CRSHIS. Define the minimum health Scope of work for the consultancy is being benefit package developed. Activity will be expanded to include actuarial analysis, facility mapping, and facility selection. Activity to commence in Q3. Establish state level peer- Ongoing. The Chairman of the House learning network Committee on Health of the CRS House of Assembly has attended two workshops to share the CRS legal reforms experience with participants from Bauchi, Sokoto, Kaduna, Niger, Rivers, Bayelsa, and Abia states. Activity: RMNCH priority states resource tracking: State Health Accounts Execute NHAs in MNCH Stakeholder engagement concluded. The The Commissioner for Health in priority states process of engaging the data managers/ Bauchi State requested HFG’s collectors and supervisors has commenced. support for the analysis of facilities’ Data collection to commence in Y5Q3 internally generated revenue. This has been incorporated into the planned activities.
156 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity: Sustainable Financing Initiative for HIV in Lagos State Expand benefit package Provision of technical evidence for feasibility of benefit package expansion. Actuarial analysis to determine the financial implication of adding HIV/AIDS services to the benefit package on the premium cost. Technical support to align the LSHS with ongoing vertical programs including HIV/AIDS. Support the LSHS HIV/AIDS Technical support to mobilize additional core implementation team resources for the LSHS and HIV/AIDS by engaging the Local Government Authority actors. Development of the LSHS equity fund management guideline. Development of provider payment guidelines for the LSHS. Update the fiscal space analysis of the LSHS with current realities. Advocate for National Health Establish the legislative network for UHC, Act 2015 which will serve as a pressure group for health financing reforms in general and implementation of the Basic Health Care Provision Fund in particular. Do budget advocacy for HIV Lagos State 2017 budget has been approved and AIDS services and is being implemented. SACA: 616% budget allocation increase from 2016. SASCP: 200% budget allocation increase from 2016. Ongoing support to develop requisition memos to draw down funds for HIV/AIDS expenditure. Activity: Sustainable Financing Initiative for HIV in Rivers State Expand benefit package Stakeholders engaged in benefit package expansion. Benefit package expansion added to the roadmap for the state. Actual development to begin in Q3.
5. FIELD SUPPORT ACTIVITIES: NIGERIA - 157 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps HIV and AIDS core Advocacy tool used to advocate to key implementation team support stakeholders. Awareness creation for the for RSHS SSHIS conducted. Household survey finalized and information used for advocacies. Health financing training for key stakeholders conducted. A roadmap for health financing reforms developed. Media training on health financing and health insurance conducted and their capacity built to effectively communicate the benefits of health insurance and effect behavioral change. Media plans developed for awareness creation and BCC. Do budget advocacy for HIV Kick-off meeting conducted to enlighten The DRM TWG, SACA, and and AIDS services stakeholders on SFI goals and targets of SASCAP will be supported in Q3 to USAID/HFG and ensure that the state is ensure improvement in budgetary aligned to ensure ownership and releases. sustainability. Support provided to budgetary allocation to HIV with resultant 48% increase in allocation to HIV in the 2017 budget.
158 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.1.13 South Africa Program Objectives – The overall objective is to ensure the long-term sustainability of HIV/AIDS services as donor resources diminish by supporting South Africa Government efforts to:
Integrate HIV services into the benefits policy of the proposed NHI Fund;
Estimate ongoing resource requirements for doing so;
Identify options for pooling and strategic purchasing of HIV and other services through existing arrangements and the future NHI Fund; and
Target HIV resources to geographies where they will have the most impact on the epidemic. Year 5 Activities - In September 2016, USAID/ South Africa approved a work plan to continue three activities from Year 4 and begin a new activity. For Year 5, HFG's activities are: 1) sustaining HIV/AIDS financing through integration with National Health Insurance (NHI) Fund, 2) estimating HIV/AIDS- related revenue requirements for a future NHI; 3) developing options for strategic purchasing mechanisms between NHI and HIV/AIDS service providers; 4) providing analytical support for HIV expenditure mapping and analysis; and 5) providing technical support for the costing of services for orphans and vulnerable children (OVC). HFG's overall approach is based on strategic assumptions about the relationship and synergies between the project activities: 1) a balance of revenue increases and expenditure management improvements including efficiency gains is required to ensure sustainable financing of HIV services; 2) improving purchasing of HIV services requires a strong and direct relationship between specification of HIV benefits and payment to providers for those benefits or services; 3) work needs to encompass national, provincial, and district levels in order to improve financing and geographic targeting; 4) appropriate implementation sequencing and achievement of small victories is imperative to improving purchasing of HIV services and sustainability of HIV financing in the context of both domestic programs and declining donor funds. Year 5 Progress Against Objectives - The National Department of Health (NDOH) launched six workstream groups in Year 4 to support the roll-out of NHI. HFG consultant Tihomir Strizrep travelled to South Africa monthly in Y5Q1 to continue to provide technical assistance for the support of National Treasury's (NT) participation in the workstreams. In Q1, Tihomir's presentations to the various workstreams included the Croatian experience in organization and financing of the health care system as well as the country's path to universal health coverage (UHC). He presented "Purchasing Arrangement for the Primary Health Care" and prepared and presented a purchasing arrangement report. He also prepared a provider payment operational manual with a focus on HIV/AIDS services integrated into all levels of care and a report on NHI hospital financing. Tihomir contributed to NHI workstream meetings where discussion revolved around organization of primary health care (PHC), the Basic Benefit Encyclopedia, NHI costing, and the health technology assessment. HFG analyzed and summarized the public comments on the NHI White Paper and input into the Davis Tax Committee regarding financing of NHI. Finally, HFG delivered a briefing update on the status of NHI and HFG's program to officials from the USG Mission. HFG presented the PHC Costing Synthesis Report to the PHC Costing Task Team members at a meeting in Pretoria on December 14. Using the discussion themes, HFG will revise the report and present a final version to the NDOH and NT in early Q2. Two new activities were launched in December. HFG's Catherine Connor and Chaitkin met with the Government Capacity Building Support (GCBS) project to develop a scope of work for a new activity for the Department of Social Development (DSD) to improve its budget bids next fiscal year and ultimately develop a full investment case to increase funding for OVC services. They also met with the NDOH to review the scope of work and plan implementation for another new activity: HIV-TB budget
5. FIELD SUPPORT ACTIVITIES: SOUTH AFRICA - 159 and expenditure analysis. This analysis builds on similar analyses done for the past several years with support from PEPFAR and the Global Fund. The new HFG activity will benefit funding partners by consolidating estimates of government, PEPFAR, and Global Fund spending down to the district level for 2014/15 and 2015/16. It will benefit the NDOH by informing health budget estimates for upcoming financial years as a complementary input into planning, and will also inform business planning for the HIV-TB conditional grant. In Q2, Tihomir travelled to South Africa in January and March to continue to provide technical assistance on NHI to ensure that NT, NDOH, and other stakeholders benefit from international experience with establishing NHI, while sustaining the HIV/AIDS response. Tihomir provided comments on the NHI Implementation Plan which presents priorities for services to be covered and detailed sources of financing for NHI. He prepared a draft action plan for the implementation of NHI. Tihomir also synthesized comments on the NHI White Paper that were received from 156 different individual and institutional entities. NDOH indicated that the new version of the White paper is expected by Q3. He participated in the Workstream 6 meeting where he presented possible organizational arrangements for NHI to contract with public health care providers. In addition, he provided feedback on "Guidelines for the Establishment of District Health Management Office" and a draft report on the work of the WS-6 Technical Team. Tihomir participated in the Q2 and Q3 2016/2017 direct conditional grants review meetings at which the Health Facility Revitalization Grant, National Tertiary Services Grant, Health Professions Training and Development Grant, Comprehensive HIV and AIDS Grant, and National Health Insurance Grant were reviewed and where he made suggestions to improve data quality. On March 9, he contributed to a workshop on designing and adjusting health benefit plans for UHC by providing examples of instruments that can be used for negotiation with suppliers. Tihomir met with the director of Policy Coordination and Integrated Planning to discuss the current development of the patient registration system. He also met with the IT department about the health patient registration system to discuss adding new fields for ICD-10 diagnostic and CPT procedure codes. HFG met with NT to discuss possible support to prepare the NHI Fund to cover maternal health services. OVC activity: During a technical working group (TWG) session with GCBS and DSD on financing for DSD's drop-in centers, HFG shared its expertise on resource mapping and tracking, costing, and development of financing strategies that could be used to improve DSD's budget bids. HFG expects further guidance on how HFG can support the costing of the drop-in centers in Q3. HIV and TB expenditure analysis activity: HFG is collaborating with the NDOH, and the FIN-CAP project, implemented by the Centre for Economic Governance and AIDS in Africa, to undertake analysis of government and donor spending on HIV and TB at the national, provincial, and district level. HFG led a three-day in-depth training on budget and expenditure analysis with a focus on using government financial data reported in the Basic Accounting System (BAS). FIN-CAP is supporting the NDOH in their Q3 provincial review process by conducting orientations with provincial managers on budget and expenditure analysis using the BAS, and by working with provinces on their specific technical needs. HFG is supporting FIN-CAP in finalizing the government expenditure estimates and has started consolidating PEPFAR and Global Fund data for the joint analysis. The PHC Costing Synthesis Report continues to be disseminated, most recently to the National District Health Services Committee (NDHSC). Q2 Challenges - Delay in the release of the NHI White Paper.
160 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Table 37 provides additional activity-specific updates. TABLE 37. SOUTH AFRICA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Sustaining HIV/AIDS financing through integration of HIV services with NHI Support of NT's participation During January and March, Tihomir continued in NHI workstreams to provide technical assistance to the workstream groups on the implementation of NHI: • Technical review of NHI Implementation Plan, which presents priorities for services to be covered and detailed sources of financing for NHI; • Presentation of possible organizational arrangements for NHI to contract with public health care providers; • Feedback on “Guidelines for the Establishment of District Health Management Office”; • Suggestions to improve data quality of the conditional grant review reports for HIV/AIDS and other areas. The IT Department cited several areas of HFG technical assistance that they have applied: • Progress toward interoperability of vertical HIV and TB patient tracking systems and the NDOH health patient registration system • Defining specifications and licensing procedure for IT vendors to ensure future products will be interoperable with NDOH HIS; • Developed user-friendly system to coordinate school health services; • Patient records use bar codes for patient ID and have space for future coding of diagnosis and procedures.
5. FIELD SUPPORT ACTIVITIES: SOUTH AFRICA - 161 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 2: Costing and revenue requirements for HIV/AIDS under NHI Resource needs estimation for GCBS is partnering with the DSD on a costing HFG will wait for GCBS to discuss transition to output-based project for OVC services. The findings will be the activity with DSD and PACT purchasing of HIV and other used as an input to improve DSD’s budget bids, counterparts since it has not been services under NHI and will ultimately be used in an investment clarified who will undertake this case for OVC services. costing activity and how it will be In February, HFG participated in a day-long funded. HFG hopes to engage with TWG working session, chaired by Dr. Rose GCBS at the end of March to September (DSD), regarding financing for understand what our potential DSD’s vulnerable children services, especially capacity would be. those provided by drop-in centers or similar providers. HFG shared its expertise on resource mapping and tracking, costing, and development of financing strategies during discussions on how the TWG could contribute to a DSD discussion paper and subsequent resource mobilization efforts for its forthcoming ‘turnaround strategy.’ HFG provided input on the components and sequencing of financing-related analysis that can support the strategy in general and the budget bid in particular. HFG developed a rationale for costing, the process and timeline, and an estimated budget, which was submitted to GCBS in February. HIV resource tracking, As part of a new expenditure analysis activity To have the analysis ready by expenditure mapping, and tools on HIV and TB financing in South Africa, HFG July/August 2017 for validation by development is collaborating with the NDOH and the FIN- funders and inputting into the CAP project, implemented by the Centre for budget planning cycle for 2018/19, Economic Governance and AIDS in Africa, to HFG is supporting FIN-CAP to undertake analysis of government and donor finalize government expenditure spending on HIV and TB at the national, estimates, and consolidate donor provincial, and district level. In January, HFG data from PEPFAR and the Global and partners connected for a project kick-off Fund for the joint analysis. HFG will meeting where initial conversations on roles also provide technical support to and responsibilities, resources, and project partners as needed. planning were held. On February 14-16, HFG led a three-day in- depth training with the project team in Johannesburg. The training covered a range of topics on budget and expenditure analysis with a focus on using government financial data reported in the BAS. Detailed discussions on work planning and outputs also took place. As an immediate next step, FIN-CAP is supporting the NDOH in their Q3 provincial review process by conducting orientations with provincial managers on budget and expenditure analysis using the BAS, and by working with provinces on their specific technical needs.
162 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Costing Task Team - After dissemination of the PHC Costing HFG will continue to disseminate Coordination of PHC costing Synthesis Report in Q1 to representatives of the findings and resources from the partners, review of costing the NDOH, NT, DNA Economics, UKZN, study with approval from the models, application to 2-3 high- Insight Actuaries, Right to Care, and WHO, NT/NDOH leads and provide quality clinics, synthesis of HFG was asked to present the work to the follow-up as requested. The task is findings from various costing NDHSC. now complete. models HFG presented the PHC work to the NDHSC on February 17 and received positive feedback. Additionally, other organizations actively reached out to the HFG team (namely HE2RO) to inquire more about the work, process, and outcomes. Activity 3: Strategic purchasing of HIV/AIDS services under NHI Design, piloting, and evaluation On hold. of payment reform pilots in priority districts Comparing public and private HFG’s PHC Costing Synthesis Report (see HIV service costs and how to above) compares public and private HIV service level the playing field costs. Pricing of HIV/AIDS benefits HFG’s PHC Costing Synthesis Report (see under integrated NHI above) provides data for pricing HIV/AIDS benefits.
5. FIELD SUPPORT ACTIVITIES: SOUTH AFRICA - 163
5.1.14 Tanzania Program Objectives - Tanzania’s complex health system operates in an environment of constrained financial and human resources. While the Government of Tanzania is committed to strengthening the health system, it continues to face challenges in financing health care for its citizens. The government, through the Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC), is working with local stakeholders to address these challenges. Mobilization of financial resources for health from domestic sources is one of the key strategies envisioned. HFG Tanzania will collaborate with the MOHCDGEC and all key stakeholders to support the ministry’s efforts in health financing, with a focus on domestic resource mobilization (DRM). Through a core-funded activity, HFG will convene high-level policymakers from health and finance agencies in Bangladesh, Côte d’Ivoire, Ghana, and Tanzania to discuss the dimensions of DRM for the health sector. The workshop will use peer-learning approaches to promote knowledge exchange and the development of concrete DRM strategies and materials. To maintain momentum and ensure that strategies are implemented and resources mobilized, sustained technical guidance will be required. HFG/Tanzania will help build the capacity of Tanzanian counterparts in carrying out the strategies identified, with the ultimate objective of increasing domestic resources for health. The MOHCDGEC is also working in collaboration with other stakeholders to strengthen Tanzania’s health service delivery systems, including laboratory infrastructure, capacity, networks, and utilization, particularly as a key element for meeting HIV/AIDS national targets. Building on previous support from the Strengthening Health Outcomes through the Private Sector (SHOPS) project, which established an online directory of medical laboratory and radiology diagnostic services available in Tanzania for the Medical Laboratory Scientists Association of Tanzania (MeLSAT), HFG Tanzania is supporting MeLSAT to train providers to develop online profiles to increase provider participation, make select upgrades to the site to improve directory functionality, and train MeLSAT technical staff on site maintenance and quality assurance. As a result of this work, we anticipate increased public and private medical laboratory and radiology providers’ participation and data entry into the MeLSAT online directory database, which, in turn, will help provide up-to-date information on diagnostic and laboratory services available nationally, including HIV supportive services. Year 5 Activities - Activity 1: Sustain momentum of DRM for Health Workshop through continued technical assistance to participants. HFG will provide technical assistance to workshop participants as they continue to develop draft materials begun during the DRM for Health workshops in Abidjan and Accra. Materials include strategies, action plans, timelines, technical briefs, and other materials to support discussions among the ministries of health and finance. HFG will facilitate a series of two or three stakeholder meetings that convene workshop participants and a wider set of colleagues across relevant agencies, to validate the outcomes of the DRM for Health workshops and adapt and carry out the draft DRM for Health strategy. Through continued technical support, workshop participants from Tanzania will be able to adapt and apply their draft DRM for health strategy, resulting in higher allocations to the health sector.
Activity 2: Support MeLSAT to improve laboratory provider contribution of information to the MeLSAT online laboratory and diagnostic services directory. Because the MeLSAT website was offline at the end of the previous work plan year, this activity was carried over to Year 5. In Year 4, HFG supported MeLSAT in its efforts to increase provider participation in its online directory of medical laboratory diagnostic services while also helping to building MeLSAT’s site maintenance and quality assurance capabilities. HFG activities included technical assistance to improve provider/user functionality and knowledge issues, support MeLSAT in providing hands-on training and opportunities for providers to upload service profiles, and initial work to make
164 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
functional the supplier section of the site and to produce video tutorials on directory site maintenance and quality assurance. In Year 5, HFG activities will focus on completing work to make the supplier section functional and finalizing the video tutorials. Year 5 Progress Against Objectives - HFG supported MeLSAT in its efforts to increase provider participation in its online directory of medical laboratory diagnostic services while also helping to building MeLSAT’s site maintenance and quality assurance capabilities. The MeLSAT activity built upon previous USAID support through the SHOPS project to compile a comprehensive directory of medical laboratory diagnostic services available in Tanzania. HFG activities included technical assistance to improve provider/user functionality and knowledge issues, make functional the supplier section of the site that was built into the directory template under SHOPS, support MeLSAT in providing hands-on training and opportunities for providers to upload service profiles at MeLSAT meetings and workshops, and with support from Abt's Client Technology Center, produce video tutorials on maintenance and quality assurance of the site so that the information is readily available for MeLSAT reference and training of future staff. Table 38 provides additional activity-specific updates. TABLE 38. TANZANIA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Sustain momentum of DRM for Health Workshop through continued technical assistance to participants Help facilitate 2-3 stakeholder Conducted two phone calls with In Q3, HFG will hold a phone meetings focused on adapting the USAID Tanzania's Health Systems consultation with USAID’s Public draft DRM for Health strategy and Strengthening Advisor about how to Sector Systems Strengthening action plan coordinate implementation of Project (PS3) to: (1) ensure technical Tanzania's DRM for Health action plan alignment between the two projects, with other health financing activities. and (2) identify stakeholders to Stakeholder meetings will commence participate in meetings to adapt and after the final DRM for Health validate the DRM for Health action workshop in Accra, Ghana, in Q3. plan. Activity 2: Support MeLSAT to improve laboratory provider contribution of information to the MeLSAT online laboratory and diagnostic services directory Develop video tutorials on Completed the MeLSAT online Activity now complete. maintenance and quality assurance of directory site administration tutorial site video, which can be viewed here: https://youtu.be/lJx1UgajuZA. CDs of the tutorials were made and express mailed to MeLSAT to have on hand for local use. Captions were added to the tutorials to allow reading along with the audio.
5. FIELD SUPPORT ACTIVITIES: TANZANIA - 165
5.1.15 West Africa Regional Program Objectives - In Year 5, HFG will continue to support the USAID West African Regional Health Office (WA/RHO) in its overall objective of strengthening country commitment and capacity to achieving universal health coverage (UHC). Specifically, HFG will work with WA/RHO and West African government counterparts to facilitate learning and promote increased understanding of potential financing strategies to advance UHC. HFG will achieve this in the following two ways: (1) share findings from its landscape study and (2) provide technical assistance (TA) in priority areas identified by WA/RHO, government counterparts, and other key stakeholders in one or more of WA/RHO's focus countries. For Activity 3, HFG provides TA in support of a loan guarantee program so that it can play a catalyst role in facilitating business relations between the Cameroon branch of Ecobank and health sector small and medium enterprises (SMEs) in Cameroon. Access to finance has been found to be a challenge for small-scale health care providers to grow and improve services, given bank collateral requirements, SMEs' lack of knowledge of applying for and managing loans, and lack of awareness among banks of the private health care market. USAID's experience with guarantee programs has proven that for a successful loan guarantee program to play the expected role of facilitating access to credit by health sector SMEs, thereby allowing them to expand and improve the quality of essential health care services, these small health care providers may need support in developing bankable business plans and loan applications. The bank also needs a stronger awareness of the needs of the potential borrowers and how best to serve those needs with appropriately structured financial products that borrowers can realistically repay. The capacity-building effort will also build trust and confidence between borrowers and the lending institution. In Year 5, HFG continues to provide TA to borrowers on business planning, financial management, and business management, focusing on the peculiar nature of private health sector enterprises and their role in the health sector. Year 5 Activities - In Year 5, through Activities 1 and 2, HFG will continue to promote enhanced learning and capacity building around programs and approaches to achieve UHC. With Activity 1, HFG will attend the West African Health Organization (WAHO)'s regional workshop on health financing and UHC. HFG will also coordinate the logistics for a participant from Cameroon to attend the workshop. At the workshop, HFG will disseminate findings from the HFG Year 4 landscape study on health financing for UHC and family planning to regional stakeholders including WA/RHO, governments, and WAHO. Alongside this dissemination, HFG will collaborate with WA/RHO and WAHO to determine opportunities for targeted TA in one or more WA/RHO countries. With Activity 2, HFG will provide targeted TA to one or more West African countries to support them to advance toward UHC. HFG's TA will complement efforts by regional organizations to build learning and leadership around UHC. This TA may include designing and piloting health financing interventions that show potential to reach scale and sustainability. HFG's TA will be based on the findings of the landscape study conducted in Year 4, the outcomes of the workshop dissemination, consultations with WA/RHO and WAHO, key stakeholders in countries and regional organizations, and country interest, commitment, and potential. In Year 5, HFG also continues to provide technical support for implementation of the Development Credit Authority (DCA) program. Activity 3 is being implemented with HFG home office guidance and technical leadership as well as by a local consultant with on-the-ground practical experience in SME capacity-building, focusing on business plan development, financial management, and business management. The consultant provides capacity-building training for potential health sector SMEs, orients ECOBANK staff, and provides hands-on support for SMEs during their business plan preparation and application for credit.
166 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Year 5 Progress Against Objectives - In Q1, HFG sponsored the attendance of a key Cameroonian government official to WAHO's regional workshop on health financing initiatives that support UHC. At the workshop, which took place in Lome, Togo, on November 29-December 2, 2016, HFG disseminated findings of its landscape study on health financing for UHC and family planning to regional stakeholders from WA/RHO, WAHO, ECOWAS countries, and Cameroon and solicited feedback to finalize the study. HFG also assessed potential TA opportunities for select countries (Togo, Cameroon, Burkina Faso) identified by WA/RHO. During the course of WAHO's four-day regional workshop and at the advisement of WA/RHO, HFG conducted in-person consultations with stakeholders from Togo, Cameroon, Burkina Faso, WAHO, and WHO. During these consultations, HFG identified country-level priorities for TA for Togo, Cameroon, and Burkina Faso. In addition, given that the workshop took place in Togo, one of the countries of interest to WA/RHO, HFG consulted with key UHC stakeholders in the country. These stakeholders represented the social health insurance agency (INAM), the community-based health insurance scheme (mutuelles) coordinating body (CNCMUT), the Ministry of Health (MOH), and private sector (Ordre des Pharmaciens/FOASPS). HFG has synthesized findings from these consultations into a short-list of TA opportunities and is working with WA/RHO to select activities for subsequent TA. Activity 2, provision of TA, will begin in Q2. For Activity 3, trainings took place in Q3 in Douala and Yaounde, for 46 pharmacists. The president of the National Council of the Pharmaceutical Society of Cameroon (Dr. Hiag Prosper) attended both sessions and stressed the importance of this training for their profession. A range of topics was covered including: how to formulate a business strategy, how to prepare a budget, how to identify key performance indicators, and how to structure periodic reporting. After the trainings, one-on-one sessions were held with nine pharmacy managers who wanted to know more about the loan process and the documents necessary to apply for a loan. They also were provided help on how to structure their business plans. Three of them were seeking funds for manufacturing, which is disallowed by the DCA. However, the pharmacists expressed their gratitude to USAID "for offering them such a precious training that will directly be useful to them in their day-to-day activity and management." In the first year of this activity, HFG identified significant constraints preventing health sector SMEs from obtaining a loan from Ecobank:
Health SMEs are not able to show proven encounters dealing with banks, as they do not have business bank accounts that can readily show their experience. Most banks consider past banking history as part of credit analysis that impacts the loan decision.
Some clinics are not registered as businesses, which precludes them from entering into a loan agreement as a legal business entity with a bank
At some clinics, there is an absence of prior financial statements that can clearly show their costs, revenues, and profit margins. The absence of the data is a barrier to loan officers seeking to analyze their application, and it precludes health clinics from meeting basic loan application requirements.
Ecobank has a minimum loan amount of 20 million XAF (about $33,000), which is above the credit needs of most of the small private clinics and pharmacies that offer the priority health services that are important to USAID.
Ecobank had a 30 percent collateral requirement (later reduced to 15 percent per the technical advice of HFG)
5. FIELD SUPPORT ACTIVITIES: WEST AFRICA REGIONAL - 167 To make the clinics more ready for a bank loan, HFG recommends that they be assisted in their business practices and systems for a period of six months to a year. This will consist of applying for a bank account so that they can develop business relations with the bank, assist them in becoming a legally registered entity, help them to produce periodic reports, and organize their financial recordings so that financial statements can be easily produced. By doing these tasks and using the management training they received, the clinics will be considered more bankable, thus facilitating their access to financial institutions. To this effect, the project is discussing with WA/RHO the possibility of continuing project support for an additional period. Given Ecobank's relatively high minimum loan amount and collateral requirements, HFG recommends further exploration of other options such as involving microfinance institutions and the possibility of USAID signing additional DCA agreements with more flexible local banks. The consultant also had one-on-one sessions with three medical equipment suppliers, BIO HOSFRO, Camread, and Technologies Medicale, to determine how they can assist clinics and laboratories to obtain necessary medical equipment. Currently, the HFG consultant is supporting BIO HOSFRO to obtain a loan from Ecobank to finance its stock and enter into leasing-to-buy arrangements with clinics that are in need of specific equipment. The consultant facilitated the process between the clinics and BIO HOSFRO and thus far nine clinics have signed a contract with the supplier, eight of which are ProFam clinics (members of a clinic franchise operating in the private sector that offer family planning, maternal, and pediatric care). Equipment ordered by the clinics includes spectrophotometers, lab equipment, and equipment that will be used for provision of maternal and child health services such as an ultrasound machine and a delivery table. After providing a down payment, clinics will pay reasonable monthly amounts to BIO HOSFRO during lease periods ranging from 20 to 46 months. BIO HOSFRO has applied for a loan of nearly 100 million XAF (US$164,000) to order new equipment. The loan is in process at Ecobank and is expected to be finalized early in Q3. However, the supplier has already started to deliver ordered equipment to three clinics and will deliver the remaining requested equipment once they receive it from abroad. In Year 5, Quarter 2, HFG achieved the following progress:
In Q2, HFG began wider dissemination of its landscape study findings (Activity 1). In addition to making the report available in English and French on the HFG website, HFG disseminated the study to approximately 5,000 contacts representing USAID Washington and country missions, in-country partners across HFG's portfolio of countries, implementing partners, other donors and global agencies, academia, and the participants in WAHO's November 2016 regional UHC meeting, where HFG presented study findings. Additionally, HFG initiated planning to present the landscape study findings at the USAID West Africa Regional Partners Meeting in May 2017.
Under Activity 2, HFG built upon Q1 consultations with WA/RHO and government counterparts to propose and refine TA opportunities in support of achieving UHC in WA/RHO focus countries Togo and Cameroon. In Togo, HFG consulted stakeholders in Togo's MOH, in INAM, and in the private health sector alliance (PSPS-Togo) to determine high-priority TA needs. Based on these consultations, HFG's TA will focus on supporting Togo's aforementioned stakeholders as they establish their way forward for achieving UHC. In particular, HFG will be coordinating efforts by stakeholders and current technical and financial partners, and identifying approaches to cover the informal sector under social health insurance. HFG has begun reviewing five reports by technical and financial partners provided by Togo's MOH on health financing and UHC to inform further development of a TA plan for Togo.
168 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
In Cameroon, HFG consulted stakeholders in the MOH (Ministère de la Santé au Cameroun) and USAID Cameroon. The Government of Cameroon has established a multisectoral technical committee for UHC that intends to develop and finalize a national UHC strategy by July 2017. Concurrently, the MOH and USAID Cameroon identified the high-priority need for TA to develop and cost a benefit package that will be offered under a planned national health insurance scheme. Specifically, HFG will design and co-facilitate the workshop with the MOH and provide financial support to convene approximately 60 participants at the event.
In Q2, for Activity 3, the consultant provided TA to BIO HOSFRO, the equipment supplier, to respond to requests made by Ecobank for additional information needed for their loan application. There has been a delay for Ecobank to issue the loan due to approval they needed from their headquarters for extension of the repayment period requested by BIO HOSFRO. In the meantime, the consultant is currently working with five clinics that have entered into a leasing arrangement with BIO HOSFRO to produce financial statements. He has created simple dashboard tools to capture financial data and allow them to produce monthly reports. He is also collecting baseline data from the clinics and BIO HOSFRO on the types of services and products they offer and the number of patients/customers they serve. This will allow the impact of the loan to be measured. Q2 Challenges - In regard to Activity 3, there has been an extended delay for Ecobank to approve the loan for the equipment supplier due to the internal processes of the bank. The structural challenges encountered in Q1 continue to impede the utilization of the DCA guarantee in Cameroon. Table 39 provides additional activity-specific updates. TABLE 39. WEST AFRICA REGIONAL ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Dissemination of landscape study findings on financing strategies to achieve UHC and their applicability to West Africa Finalize landscape study report Complete Dissemination continues with a presentation at the USAID West Africa Regional Partners Meeting to occur in May 2017. Consult with stakeholders on key Complete: Early in Q2, HFG worked findings and priorities for technical with WA/RHO and government assistance counterparts to develop a high-level plan for TA to Togo and Cameroon. Activity 2: Provide technical assistance to WA/RHO focus countries in support of achieving health financing, family planning/reproductive health, and UHC goals Develop country-specific technical In progress: HFG has consulted HFG will develop country-specific TA assistance work plans with key diverse stakeholders to confirm and work plans with Togo and stakeholders in one or more selected refine its high-level TA plan. Cameroon, expected in early Q3. countries Provide country-specific TA, In progress: Country-specific TA is including stakeholder coordination, underway in Togo and Cameroon technical working meetings, and and is expected to continue evolving potential in-country stakeholder into Q3. meetings
5. FIELD SUPPORT ACTIVITIES: WEST AFRICA REGIONAL - 169 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 3: Technical assistance on initiation and implementation of Development Credit Authority (DCA) Conduct a quick market assessment The market assessment report was of health sector SMEs finalized and approved by the Mission during this quarter. Provide TA during business plan TA is being provided to 5 clinics to development of selected SMEs produce monthly financial statements. Monitor credit application of health This is ongoing with the current loan There has been an extended delay in SMEs and access to credit (approval application of BIO HOSFRO. Ecobank’s approval of the loan. of loan applications) A loan application tracker and post- loan impact trackers were created and updated.
170 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.2 Asia 5.2.1 Asia Bureau Program Objectives - HFG’s objectives under the Asia Bureau focus on supporting and facilitating countries’ progress toward universal health coverage (UHC) to end preventable maternal and child deaths in the Asia region. Asian nations are at various stages on the trajectory toward achieving UHC. In the context of limited time and resources, countries and USAID missions seek interventions that are most likely to succeed and benefit from global experience and evidence. The Asia Bureau's goal is to build local and regional institutional capacity to design and implement smart reforms to expand access to priority services and reduce out-of-pocket health expenditures. Year 5 Activities - HFG and the Bureau are working closely with regional and local partners on five activities that simultaneously advance reforms and build capacity, as described below. Year 5 Progress against Objectives - 1. Asia Pacific Network for Health Systems Strengthening (ANHSS) Capacity Building: HFG supported a strategic partnership with ANHSS to empower health policymakers to advance health care delivery through evidence, provide a platform for knowledge sharing, and further strengthen the alignment of the network with the USAID missions in Asia. The Institute for Health Policy (IHP) is a founding member of the ANHSS, and the current chairperson, Ravi Ranna-Eliya, serves as Executive Director. In Q2 of Year 4, following the discussion and endorsement of the Articles of Association (AoA) by ANHSS members at the general meeting held in Bangkok in December, and following the agreement to register ANHSS as a limited liability company in Hong Kong, ANHSS initiated formal engagement of a Board-approved secretarial services company in Hong Kong to complete legal incorporation. The ANHSS application for legal incorporation was finalized in Year 4 Q4 with the Hong Kong authorities, after the Secretariat received final clearance from all ANHSS Board members. ANHSS planned and coordinated the 2016 Asia Regional Flagship Course, held in Siem Reap, Cambodia in early Q1. In Q2, USAID and HFG began planning a 2017 Asia Flagship Course to be led by ANHSS. 2. Implementation Research (IR) Indonesia: In Q2, HFG’s local IR partner Center for Health Policy and Management (CHPM) at the University of Gadjah Mada held several consultative meetings with stakeholders at the national level and in the five target districts. The aim of these meetings was to 1) discuss the IR cycle 1 findings with stakeholders, including what specific measures might be taken to strengthen the implementation of Jaminan Kesehatan Nasional (JKN) at the primary care level; and 2) obtain stakeholders’ priorities for IR cycle 2. These consultative meetings revealed stakeholder interest in how to improve promotive- preventive services under JKN and strengthen the role of the District Health Office in JKN management. To link the stakeholders’ perspectives and findings from cycle 1, the research team proposed a focus on primary care staff incentives in cycle 2, since they are a critical element that determines performance and ultimately the effectiveness and sustainability of JKN. Cycle 2 will aim to provide an in-depth, contextual analysis of how various regulations on incentives and performance are being implemented in various settings within the same five districts targeted in cycle 1, and how these regulations may be revised to motivate and stimulate improved delivery of curative and promotive-preventive care. The next steps are to get feedback on the IR cycle 2 proposal from USAID and the Government of Indonesia counterpart Pusat Pembiayaan dan Jaminan Kesehatan, and, in the weeks ahead, proceed with questionnaire development, interviewer training, and piloting.
5. FIELD SUPPORT ACTIVITIES: ASIA BUREAU - 171 3. IR in Myanmar: All activities are currently on hold since August 2016 until USAID provides approval for HFG to conduct work in the country. 4. Reshaping the Agenda to Support Achieving UHC in Asia: Following the successful Asia Regional Flagship Courses on Health Systems Strengthening and Sustainable Financing in March 2014 and April 2015, HFG, USAID, and the World Bank agreed to hold a week-long curriculum development workshop in Year 4, at the Rockefeller Center in Bellagio, Italy. The workshop brought together course faculty and experts from the Asia Regional Course, as well as the Global Flagship Course, to discuss ways to improve the curriculum and content of the Asia course and to incorporate current data and evidence on UHC and health systems performance. Using findings from this meeting, the 2016 Asia Regional Flagship Course, on “Health System Strengthening and Health Financing: The Challenge of Universal Health Coverage,” was held in Siem Reap, Cambodia on October 3–8, 2016. The five-and-a-half-day course was attended by 58 participants from 10 countries in the region. ANHSS supported the logistics and planning for this event and submitted a completion report. In Q2, HFG began preparation and preliminary discussions for the 2017 Asia Flagship Course. 5. Public Stewardship of Private Health Providers: Country representatives discussed the need for public regulation of private providers during the Joint Learning Network (JLN) Private Sector Engagement Collaborative (PSEC) meeting held in July 2016. USAID and HFG concluded that few documented examples exist of effective, well-enforced regulatory frameworks in low- and middle- income countries, including JLN member countries. To help bridge this information gap, HFG developed a concept paper, for technical assistance to countries in the Asia region, on public stewardship of mixed health systems, including regulation of and contracting with private health care providers. On February 28–March 2, 2017, members of the PSEC of the JLN for Universal Health Coverage Primary Health Care (PHC) Initiative convened for a two-day workshop and international seminar in Yogyakarta, Indonesia. The workshop was co-organized by the JLN PHC Initiative and HFG with support from the Asia Bureau. Members of the PSEC are co-authoring a five-part practical guide titled Engaging the Private Sector in Primary Health Care to Achieve Universal Health Coverage: Advice from Implementers to Implementers. The first two modules of the guide have been completed and three additional modules are planned for development. The workshop participants accomplished the following: (1) launched a series of case studies about regulating the private health sector, which will inform the content and structure of Module 3 of a practical guide for engaging the private sector; (2) developed a plan for drafting Module 4 of the guide, focused on contracting with private sector providers; and (3) promoted joint learning and community-building among themselves. 6. Governance of Quality: A concept paper from HFG proposed to document lessons learned from experiences with the governance of quality in Malaysia and the Philippines, and subsequently Indonesia, and provide technical assistance to the Philippines and Cambodia based on the findings. In Q2, the work plan was revised based on discussions with the Asia Bureau, missions, and selected stakeholders working in the countries where the study will be conducted. HFG will now focus the activity on: (1) documenting and disseminating experiences and lessons learned, (2) linking quality to financing, given the interest expressed, and (3) replacing Malaysia—where linkages between quality and financing were less evident than in Thailand—with Thailand as the third case study country.
172 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
HFG will conduct key informant interviews in all three countries. In the Philippines and Indonesia, HFG will document the perspectives of national- and subnational-level actors in a decentralized health system context. In Thailand, a preliminary literature review on governance of quality highlighted that HFG could conduct key informant interviews to further understand the array of institutions that support the governance of quality at the national level. It is unclear the extent to which these arrangements are present at the subnational level in Thailand. Finally, given the interest in Indonesia, the Philippines, and other countries for cross-country learning on governance of quality, HFG included a regional dissemination workshop in the revised work plan. The workshop will convene stakeholders from the Philippines, Indonesia, and Thailand, as well as other countries in the region that have expressed an interest in this topic. The feedback obtained from stakeholders will inform the development of a process guide for linking quality to financing. HFG has finalized an interview tool, and a study protocol is currently being drafted. Desk reviews are under way on the governance arrangements that are in place linking financing to quality in each of the countries. Data collection in the countries will start upon receipt of final approval of the work plan by USAID. Q2 Additional Information - Susan Gigli left the HFG Activity, and Lisa LeRoy joined as the Technical Advisor for the Implementation Research for UHC activity in Indonesia. Table 40 provides additional activity-specific updates. TABLE 40. ASIA BUREAU ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Revision of ANHSS capacity-building ANHSS legal incorporation Completed. Completion report submitted. ANHSS board meeting and Completed. Completion report submitted. strategic business plan approval Delivery of UHC Flagship Completed. Completion report submitted. Planning for 2017 UHC Flagship Course Course has begun. Recruitment of an executive Cancelled. On March 24, USAID determined director that an executive director is not a
sustainable means to provide support for ANHSS and will be difficult to justify for Asia Bureau budgeting. Activity 2: Indonesia implementation research on UHC Stakeholder consultations at the The CHPM consultations at the national HFG and CHPM had to reconcile the district and national level to and district level included discussion of different priorities of national and inform priority questions priorities for IR cycle 2 based on the IR district stakeholders to develop a cycle 1 findings and the issues identified cohesive research design and strategy during the cycle 1 workshop. for IR cycle 2. Ongoing dissemination of IR CHPM engaged key stakeholders at the HFG and CHPM plan follow-up with cycle 1 results national level and district level through stakeholders to see how the IR tailored presentations on the results of IR results can catalyze concrete action. for UHC cycle 1.
5. FIELD SUPPORT ACTIVITIES: ASIA BUREAU - 173 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Develop cycle 2 research HFG collaborated with CHPM to draft a The schedule for IR cycle 2 will proposal detailed proposal for IR cycle 2 with depend on the timeliness of the research questions, methods, data feedback from key stakeholders and collection strategy, timeline, and draft the availability of district-level instruments. The draft proposal was sent participants (health workers and to USAID and the MOH Center for government and health officials). Health Financing and Health Security (PPJK) for review. Activity 4: Reshaping the agenda to support achieving UHC in Asia (Flagship Course) Implementation of an Asia After successful implementation of the The Asia Bureau and HFG will regional course on UHC 2016 Asia Regional Flagship Course, identify a transition approach for ANHSS and HFG have begun preliminary ANHSS to become more financially discussions for the 2017 Asia Regional sustainable; this will include including Flagship Course. charging fees to Flagship Course participants to offset course costs. Activity 5: Public stewardship of private health providers Private Sector Engagement The workshop convened 14 practitioners Moving forward, the JLN will support Collaborative workshop and and policymakers from seven JLN countries in developing case studies international seminar countries: Ghana, India, Indonesia, Kenya, related to regulation of private Malaysia, Mongolia, and Morocco. providers and managing contracting. Representatives from the Bill and Melinda Gates Foundation and USAID’s Asia Bureau, funders of the PSEC, also participated in the workshop. Activity 6: Governance of quality Create concept note on the Activity work plan was revised based on This activity was approved on March documentation and sharing of feedback from USAID and upon 27, 2017. lessons learned and targeted consultation with key contacts on technical assistance on the Indonesia and the Philippines. A governance of quality preliminary review of available literature on Thailand was also conducted to inform the revision of the work plan.
174 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.2.2 Bangladesh Program Objectives – The overarching goal of HFG work in Bangladesh is to help transform health care financing in Bangladesh towards the objective of achieving UHC. This is particularly important given Bangladesh’s commitment to achieving the Sustainable Development Goals (SDGs), with UHC a clear target for SDG 3. An additional goal of the HFG project in Bangladesh is to build on previous years’ investments and continue to support the implementation of the country’s Health Care Financing Strategy (HCFS). HFG’s Year 4 (fiscal 2016) and Year 5 (fiscal 2017) work plans also complement the development and implementation of the Health, Nutrition and Population (HNP) Sector Program in Bangladesh from 2016 to 2021. The HFG Year 5 work plan will directly support strategic objectives 1, 3, and 6 of the Health, Nutrition and Population Strategic Investment Plan (HNPSIP) 2016–2021. Strategic objective 1 is “To strengthen governance and stewardship of the public and private health sectors,” strategic objective 3 is “To provide sustainable financing for equitable access to health care for the population and accelerated progress towards universal health coverage,” and strategic objective 6 is “To improve health measurement and accountability mechanisms and build a robust evidence base for decision-making.”4 Furthermore, the Year 5 work plan follows priority focus areas highlighted in USAID’s recent Health Financing Assessment (HFA).5 Year 5 Activities – In Year 5, the HFG team in Bangladesh will work in the activity areas described below. We also highlight below the activities that are remaining from Year 4 and that will be completed in Year 5 with Year 4 funding. Successful implementation of this work plan will depend on the evolving security situation in Bangladesh enabling HFG staff, in country and globally, to execute the planned activities.
Activity 1: Raising national UHC awareness through communication. USAID’s Health Financing Assessment in October 2015 identified this as the first focus area for USAID support. In Year 4, HFG focused on raising awareness at the national level to develop a critical mass of professionals who can carry forward the UHC agenda in Bangladesh. In Year 5, the proposed activities continue to target supply-side professionals, expanding more to subnational levels. A decision was made not to target demand side clients at this stage—to do that we will need formative research on whom to target, how, and with what key messages. Also, targeting demand-side clients prematurely without having the supply side ready is premature.
Activity 2: Essential Service Package costing and dissemination, including policy briefs. This activity will be executed in collaboration with WHO. It began in Year 4 and will be completed in Year 5 with both Year 4 and 5 funding. USAID/Washington Core MCH co-funded this costing activity in Year 4 as part of a broader activity on OneHealth Tool (OHT) capacity building to support cost analysis in an EPCMD country.
4 References here to the investment plan are based on the final version: Planning Wing, Ministry of Health and Family Welfare. April 2016. Health, Nutrition and Population Strategic Investment Plan (HNPSIP) July 2016–June 2021, “Better Health for a Prosperous Society.” Dhaka, Bangladesh. 5 Karen Cavanaugh, Mursaleena Islam, Sweta Saxena, Muhammod Abdus Sabur, and Niaz Chowdhury. 2015. Universal Health Coverage and Health Financing in Bangladesh: Situational Assessment and Way Forward. Washington, DC. USAID.
5. FIELD SUPPORT ACTIVITIES: BANGLADESH - 175 Activity 3. Resource modeling and analysis for the Essential Services Package (ESP), including TB and immunization.6 Bangladesh recently revised its ESP and the HFG project, working with WHO and the Health Economics Unit (HEU), and is supporting costing of the ESP using the OneHealth Tool (Activity 2 above). USAID requested an analysis on resource modelling to identify resource gaps, needs, and trends to fund the ESP, particularly in light of increased domestic co- financing requirements by the Global Fund and GAVI. A recent fiscal space analysis completed by the World Bank found that there is sufficient fiscal space to increase the budget allocation for health; what is lacking is adequate advocacy for increasing the health budget. In competition with other sectors such as social security, power, and infrastructure, the health budget is a low priority. Further analysis is needed of the resource requirements for the health sector to fund the ESP.
Activity 4: Capacity building and support for establishment of a costing hub at HEU.7 This activity aims to improve the use of health costing results through the creation of a dedicated costing hub at HEU. It aims to create a culture of evidence-based decisions using costing data. HFG will work with HEU to build its capacity to analyze, draft, and present costing and health financing results so as to increase their use in the next sector program and beyond, from policy to planning, implementation, and monitoring. Activity 5: Research to support introduction of health insurance in Bangladesh. This activity is proposed in light of USAID interest in introducing health insurance in Bangladesh. HFG will support the groundwork in FY2017. Activity 5.1: Targeting the poor. USAID’s health financing assessment in 2015 identified an important need to define clear approaches for targeting the poor in any health insurance scheme. HFG will work with local partner Power and Participation Research Centre (PPRC) to build on PPRC’s earlier work on different approaches for targeting the poor. Based on previous experiences and future needs, HFG will develop and provide specific recommendations for practical pro-poor targeting approaches. Year 5 Progress against Objectives HFG made significant progress on its activities in Bangladesh over Y5Q2. Achievements of particular note are two high profile events organized to raise UHC awareness: Flagship course with the Secretary of Health as Chief Guest in January 2017 and UHC policy dialogue with the Minister of Health as Chief Guest in March 2017. The latter event was organized with a major Bangla daily newspaper, Prothom Alo, and included fourteen reputed panel speakers; the event was covered by television broadcast and print media. Additionally, HFG provided important technical assistance on costing of the ESP, with international OneHealth Tool experts who provided both remote and in-country support, including a customized version of the OneHealth Tool for Bangladesh.
Activity 1: Raising national UHC awareness through communication
• Activity 1.1: Action plan for UHC communication. Development of the action plan for UHC communication started in Y5Q2 and will be completed in Y5Q3. In discussion with the USAID Activity Manager, it was decided that the Action Plan will focus on HFG’s support to raise awareness on UHC. The action plan will draw on the experience and lessons learned from the UHC communication sessions, courses, and policy dialogues conducted over the past year.
• Activity 1.2: Divisional- and subdivisional-level UHC dialogue. The PPRC provided a proposal for conducting a series of seven divisional dialogue series, which will include multi-stakeholder
6 Sub-analysis on immunization financing will be coordinated with the World Bank, as Gavi has provided funds to the World Bank for some analysis (scope to be defined). 7 A short course with USAID staff and implementing partners will likely remain pending; HFG is waiting for USAID to provide a schedule for this.
176 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
policy dialogues and civic walks, followed by four national-level TV talk shows. HFG is processing the subaward for PPRC, and the activity is expected to start in May 2017.
• Activity 1.3: Flagship Course. HFG co-organized the second Bangladesh-focused Flagship Course on “Health System Strengthening and Universal Health Coverage,” with HEU, WHO, the World Bank, and James P Grant School of Public Health, BRAC University (JPGSPH). The course was held in Savar, Bangladesh on 22–26 January 2017, with 42 participants from multiple government agencies, USAID implementing partners, development partners, academia, and NGOs. The objective of the course was to enhance the capacity of stakeholders to analyze health policy and health system performance issues, in the context of UHC. In his opening remarks for the course as Chief Guest, Md. Sirazul Islam, Secretary, MOHFW, said: “I believe that not only government can provide health care coverage for all; relevant agencies, government and non- government, as well as our development partners, should get together and come up with a plan to achieve the UHC goal.” On February 14, 2017, JPGSPH organized a planning discussion with leaders of the Bangladesh Health Reporters Forum (BHRF) to explore effective approaches for expanding UHC awareness with journalists. Toufiq Maruf, President of BHRF and senior reporter for Kaler Kantho; Nurul Islam Hasib, Vice-president of BHRF and senior reporter for bdnews24.com; and Shishir Morol, special reporter joined the meeting. Journalists expressed interest in having more in-depth workshops and trainings covering topics such as health insurance, drug prices, and provider payment approaches; there is a clear gap to fill in equipping journalists with the right terminology and tools to cover health issues from a UHC perspective in Bangladesh. On March 5, 2017, the HFG project, with local partner JPGSPH, organized a high-profile roundtable policy discussion on universal health coverage, chaired by the Minister of Health, with the largest circulating Bangla newspaper, Prothom Alo. The session was conducted to facilitate the exchange of views, experiences, and learning towards achieving awareness on UHC among the audience (readership of Prothom Alo). The dialogue was chaired by Mohammed Nasim MP, the Honorable Health Minister, MOHFW, and panelists included: Dr. Hossain Zillur Rahman, Executive Director, PPRC; Prof. Dr. Abul Kalam Azad, Director General, Directorate General of Health Services (DGHS), MOHFW; Md. Shah Alamgir, Directorate General, Press Institute Bangladesh; Dr. Abdul Ehsan Md. Mohiuddin Osmani, Joint Chief, Planning Wing, MOHFW; Muslim Chowdhury, Additional Secretary, Ministry of Finance; Dr. Mahmud Hasan, Ex-President, BMA; Dr. Iqbal Arslan, Dean, Faculty of Basic Science and Para Clinical Science, BSMMU; Dr. Shakil Ahmed, Senior Health Economist, World Bank; Miranda Beckman, Deputy Director, Office of Population, Health, Nutrition, and Education, USAID; Hossain Ishrath Adib, Head of Education, JPGSPH, BRAC University; Dr. Rumana Huque, Professor, Department of Economics, University of Dhaka; and Md. Ruhul Amin, Director, DGDA. Matiur Rahman, Editor, Prothom Alo, also joined the session given its high profile. Health Minister Mohammad Nasim said, “UHC is important for the health care sector of the country, but it is difficult to achieve due to a shortage of resources,” and added, “We need more budgetary allocation in this sector for infrastructural development and recruiting more doctors, nurses and technicians.”The news was broadcast by several different TV channels, and several daily newspapers covered the event; a supplementary has been published on April 6, 2017 at popular Bangla Newspaper Prothom Alo.
5. FIELD SUPPORT ACTIVITIES: BANGLADESH - 177 Activity 2: Essential Service Package costing and dissemination, including policy briefs
• Activity 2.1: ESP costing and dissemination. In Y5Q2, HFG worked closely with the WHO- contracted icddr,b team on costing the ESP using the OHT. HFG reviewed and provided comments on the inception report and data collection tools developed by the icddr,b team, and provided technical input to the configuration of the OHT projection and mapping of ESP interventions to default OHT interventions. The HFG team participated in the weekly meeting of the National OHT Resource Pool for regular technical input in costing and OHT projection- related activities. HFG’s OHT international expert Nadia Carvalho provided remote technical support via phone calls and Skype to troubleshoot and answer questions related to the costing efforts. . HFG provided a customized Beta version of OHT for Bangladesh to address the problem of dissimilarities between OHT default interventions and ESP list of interventions for Bangladesh, and to avoid breaking down the connections between OHT interventions and Impact Modules. HFG is continuing discussion with WHO and HEU regarding inclusion of NGOs in ESP costing activity given time and scope for the icddr,b team. From March 26–30, Carvalho traveled to Dhaka to work with the icddr,b team to configure the OHT projection and continue to map ESP interventions to those in the OHT, as well as supporting the icddr,b team in using other features of the OHT, including: budget mapping, results generation, and the Impact Module. She also participated in a one-day workshop with the National OHT Resource Pool and the icddr,b team to review the configuration interventions and review data collected and entered thus far into the tool. Carvalho debriefed with the DG HEU on progress of work so far and provided him with an updated timeline for the ESP costing activity. Based on discussion with partners (HEU, WHO, and icddr,b), HFG anticipates preliminary results by mid-May 2017.
• Activity 2.2: Policy briefs and workshops on costing and use. The first policy brief, “Dissemination and Experience Sharing on Costing Studies in Health,” was completed and shared with the USAID mission.
Activity 3: Resource modeling and analysis for the ESP, including TB and immunization
• Activity 3.1: Resource modeling and analysis for the ESP. In Y5Q2, the concept note for this activity was developed with HFG partner Results for Development (R4D) and submitted to the local mission. Technical approach, data sources, and local consultants were identified as part of the concept note.
• Activity 3.2: TB and immunization financing. TB and immunization financing was covered as part of the concept note provided for Activity 3.1. It will be more efficient to do the analysis simultaneously, though separate analysis and Briefs will be produced for ESP, TB, and immunization financing.
Activity 4: Capacity building and support for establishment of a costing hub at HEU
• Activity 4.1: Organizational assessment for costing hub. In Y5Q2, HFG worked with partner TRG to develop the concept note for this activity. This concept note is planned to be shared with the mission in early April 2017, and the activity will resume soon thereafter and be completed in Y5Q3.
• Activity 4.2: Design of costing hub. This activity is planned for Y5Q3, as per the work plan.
Activity 5: Research to support introduction of health insurance in Bangladesh
• Activity 5.1: Targeting the poor. In Y5Q2, HFG started working with PPRC on the concept note on targeting the poor. The draft concept note is expected to be provided in late April 2017 and the activity will resume soon thereafter.
178 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Q2 Challenges - Activity 2: Essential Service Package costing and dissemination, including policy briefs. Due to delays in contracting the local team by WHO, the schedule is very tight, and costing of nonprofit (NGO) provision of the ESP is proposed to take place following the costing of public sector provision, at the request of HEU. Table 41 provides activity-specific updates. TABLE 41. BANGLADESH ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Raising national UHC awareness through communication Flagship Course The Flagship Course was offered on January Final report based on feedback from 22–26, 2016, in partnership with HEU, partners WHO, the World Bank, and JPGSPH. It involved a total of 42 participants from multiple government agencies, WHO, USAID implementing partners, educational institutes, and national NGOs. . Secretary of MOHFW joined as Chief Guest. A draft report was shared with partners and USAID/Bangladesh.
Policy Dialogue Round table policy dialogue conducted on March 5, 2017 at Prothom Alo. 14 policy experts participated in the dialogue with Honorable Minister of MOHFW, Mohammed Nasim MP as the Chief Guest. The news was broadcasted by several different TV channels, and several daily newspapers covered the event.
Action Plan for UHC Activities started in Y5Q2 and will be Brainstorming session planned for Communication finalized in Y5Q3. mid-April 2017 Divisional and sub divisional Preparation started in Y5Q2 and activities Subaward for PPRC in process level UHC dialogue will start in Y5Q3. Activity 2: Essential Service Package costing and dissemination, including policy briefs ESP costing and dissemination Feedback provided to icddr,b and WHO on Data collection to be completed in inception report and data collection tools. Y5Q3 HFG provided technical assistance on the Preliminary costing estimates of the OneHealth Tool and worked closely with public provision of the ESP in Y5Q3 the icddr,b team, WHO, and HEU. OneHealth Tool international expert Carvalho was in country to assist with this on March 26-30, 2017. Deliverable completed: Concept note on “Costing the Bangladesh Essential Service Package (ESP) Using the OneHealth Tool.”
5. FIELD SUPPORT ACTIVITIES: BANGLADESH - 179 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Policy briefs and workshop on Policy brief completed, titled: “Dissemination costing and use and Experience Sharing on Costing Studies in Health.” Reference: Yann Derriennic, Sohel Rana, Mursaleena Islam, Ben Johns. November 2016. Dissemination and Experience-Sharing on Costing Studies in Health. Bethesda, MD: Health Finance and Governance Project, Abt Associates. Activity 3: Resource modeling and analysis for the ESP, including TB and immunization Resource modeling and HFG established the partnership by Data collection and analysis analysis for the ESP identifying specific resource personnel from R4D to implement this activity. Deliverable completed: Concept note on “Resource Modeling for the Provision of Essential Service Package (ESP) with Special Focus on Immunization and Tuberculosis (TB) in Bangladesh.” TB and immunization financing Combined with Activity 3.1above. Activity 4: Capacity building and support for establishment of a costing hub at HEU Organizational assessment for Draft concept note for internal HFG review. Complete concept note; identify local costing hub consultant Conduct organizational assessment with international expert and local consultant Design of costing hub Planned for Y5Q3. Activity 5: Research to support introduction of health insurance in Bangladesh Targeting the poor Concept note being drafted. Finalize concept note and initiate research study
180 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.2.3 Cambodia Program Objectives - Achieving UHC is a primary objective of Cambodia's ongoing social protection reforms. The MOH, Ministry of Labor and Vocational Training, and Ministry of Social Affairs, Veterans and Youth Rehabilitation are independently working to develop social protection schemes to expand health insurance to different sectors of the population. All of these schemes aim to reduce out-of- pocket payments for medical care and reduce the risk of Cambodians being impoverished by health expenses. However, coordination between these ministries is limited, resulting in a duplication of efforts that creates complexities, and waste that could negatively impact health system performance. The Royal Government of Cambodia recognizes the potential issues with its social protection reforms, and has requested that a technical working group, led by the Ministry of Economy and Finance (MOEF), oversee and coordinate the reform efforts. However, the MOEF does not have expertise in health financing, and needs training and capacity building to successfully create an integrated strategy for achieving UHC. Lack of financial resources is Cambodia's other main barrier to implementing and scaling up social protection programs. The Royal Government of Cambodia currently dedicates only 1.4 percent of gross domestic product to health care, and international donor funding is declining rapidly. Responding to these challenges, the program objectives of the HFG team in Cambodia are to build the MOEF's capacity to carry out its functions of coordinating the social health protection reforms, and to support the MOH in its efforts to overcome barriers to increasing resources for health. HFG will specifically support the MOH in its efforts to: improve efficiency and change the MOEF's perception that the MOH does not manage its resources wisely; develop health financing and UHC indicators that would allow the MOH and MOEF to monitor the impact of health financing interventions; and develop high-quality, up-to-date HIV expenditure information to serve as a baseline for a strategy for mobilizing domestic resources for funding HIV programs. Year 5 Activities - Continued Year 4 Activities. In FY 2017 (HFG Year 5), the HFG Cambodia country program will finish implementing the following FY 2016 (Year 4) activities:
Following its efficiency report for the MOEF and MOH, HFG will conduct a multi-ministerial workshop on strategies for improving the efficiency of health care and disease spending. This workshop is intended to create a shared understanding of the resources needed for the health sector and mechanisms for improving efficiency.
HFG will finalize data analysis, write a report, and facilitate a dissemination workshop for Cambodia's National AIDS Spending Assessment (NASA) to provide the National AIDS Authority and National Center for HIV and AIDS, Dermatology, and STDs with up-to-date HIV expenditure information that it can use to redesign its HIV and AIDS policies to improve efficiency and access, and to advocate to the MOH and MOEF for additional funding. New Activities for Year 5 (FY 2017)
• Having strengthened the MOEF's technical capacity on UHC and health financing issues in fiscal 2016, the MOEF has asked that HFG and other development partners support the design of a health financing strategy that will lead to a sustainable health financing and social health protection system. HFG will develop policy option briefs on health financing, and facilitate workshops on these options.
• HFG will conduct an assessment to identify inefficiencies in Cambodia and design/implement strategies to address these. HFG will also strengthen the MOEF's capacity to: identify and target key areas of inefficiency, evaluate the progress of measures to improve efficiency, and understand and assess issues around fiscal space and funding flows.
5. FIELD SUPPORT ACTIVITIES: CAMBODIA - 181 • HFG will implement several activities focused on the sustainability of disease-specific financing, including: . Conducting a costing study, and actuarial modelling, of HIV/AIDS and TB services to inform the National Social Security Fund and Health Equity Fund provider payment rates . Carrying out a rapid assessment of the benefits, limitations, and trade-offs of different payment models and incentive structures for malaria community health workers within Cambodia, the region, and globally . Facilitating the development of an HIV/AIDS sustainability sub-technical working group among ministries and development partners . Rapidly assessing current implementation arrangements and funding flows within Global Fund grants to inform the next funding request Year 5 Progress against Objectives - HFG completed most of its remaining fiscal 2016 activities in the first quarter of fiscal 2017. To support MOEF and MOH collaboration and improve efficiency, HFG facilitated a multi-ministerial workshop in December 2016 on strategies for improving the efficiency of health and disease spending (Q1). This workshop created a shared understanding of the resources needed for the health sector and mechanisms for improving efficiency. HFG also finalized the data analysis and report of Cambodia's NASA 2014-2015. The report will provide the National AIDS Authority and National Center of HIV and AIDS, Dermatology and STDs with up-to-date HIV expenditure information that can be used to redesign HIV and AIDS policies to improve efficiency and access, and advocate to the MOH and MOEF for additional funding. A steering committee meeting was held in Y5Q2 to finalize the findings of the report. The NASA dissemination workshop is slated for Y5Q3. To support the MOEF in designing a health financing strategy, HFG conducted a capacity-building session with the Social Protection Working Group (SPWG), MOEF, and other ministries in Siem Reap during December 2016 (Q1). The session was designed to complement previous sessions and included specific sessions on governance, cross-subsidization, payment, and fiscal space for health. To assist the SPWG and MOEF to apply lessons learned and initiate decisions on the Social Health Protection strategy, HFG led the participants through a series of planning exercises on these topics. Participants demonstrated improved knowledge in health financing and UHC, and began to concretely consider how these lessons could be applied to the strategy. During the final capacity-building workshop, the SPWG/MOEF requested evidence to inform the design of Cambodia's Social Health Protection Framework and Policy in the areas of governance (specifically the role that ombudsmen play in governance) and re-insurance. HFG has submitted one brief to USAID and the MOEF and is currently developing two more. Guidance on a dissemination plan for these technical inputs will be sought from USAID. In Q2, HFG met with key stakeholders involved in Cambodia's SPWG (i.e., MOEF and USAID) to investigate recent progress made on the Social Health Protection strategy since the last capacity-building workshop. During this meeting, it was requested that HFG advise the SPWG/MOEF around the governance structure of Cambodia's Social Health Protection council and support the development of terms of reference for the secretariat that advises the council. HFG will present this evidence to USAID and later the MOEF/SPWG in Q3. Among subactivities focused on sustainable disease financing, HFG began work to conduct a rapid assessment of current implementation arrangements and funding flows within Global Fund grants. This included reviewing global literature, hiring a local consultant, conducting key informant interviews, and assessing current Global Fund funding bottlenecks and alternative options for Global Fund funding. The results were presented to the Country Coordinating Committee and other stakeholders who are discussing the different grant structure options.
182 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
The project also made notable progress in Y5Q2 in laying the groundwork for conducting an HIV/AIDS and TB costing study of public and private facilities. HFG developed a research protocol and tools, submitted them to Abt's IRB, and initiated their translation into Khmer for use in field collection. A research coordinator was also identified to lead fieldwork. In addition, an SOW was developed for a consultant to lead a landscape analysis of sustainability and incentive structures of village and mobile malaria workers. Work under this activity is expected to ramp up early in Q3. Q2 Challenges - The success of HFG activities and the pace at which they proceed is in large part dependent on the availability, interest, and willingness to engage of key ministerial staff in Cambodia. This engagement is essential to the design and implementation of HFG activities and ultimately the use of project-produced outputs. HFG works closely with relevant ministerial, development, and implementation partners to ensure that HFG activities remain of interest and move forward in an expeditious manner. But in some instances the level of engagement is not ideal. Identifying an individual with the requisite experience to lead the HFG country office and provide senior- level health financing support has proven challenging. However, in Q2, HFG identified Dr. Rajeev Ahuja, a former World Bank and Gates Foundation health economist, to assume the post of Lead Health Finance Advisor and Country Representative. Dr. Ahuja is expected to formally join the team and be based in Phnom Penh as of mid-April 2017. Table 42 provides activity-specific updates. TABLE 42. CAMBODIA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Support National AIDS Authority in the Development of 2014 and 2015 NASA Finalize data validation and The final 2014–2015 NASA report has The NASA dissemination is scheduled report writing to submit and been presented to the Steering Committee for early in Y5Q3. disseminate the 2014–2015 in Y5Q2. The Steering Committee NASA findings. recommended minor improvements, which have been completed. Activity 2: Support the Ministry of Economy and Finance in Designing a Social Health Protection (Health Financing) Strategy Conduct capacity-building HFG completed its final of four capacity- With the originally envisioned series of seminars on health financing building sessions with the MOEF and four capacity-building sessions now and UHC concepts, notably SPWG in Y5Q1. completed, the focus of the work has strategic purchasing and been to continue providing further benefit package design. evidence to the SPWG/MOEF at their request. HFG is planning a health financing capacity-building session for the SPWG to take place in Q3.
5. FIELD SUPPORT ACTIVITIES: CAMBODIA - 183 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 3: Strengthen Ministry of Economy and Finance's Capacity to Expand Fiscal Space and Improve the Efficiency of Health and Disease Spending Conduct a rapid efficiency No progress in Y5Q2. HFG’s Lead Health Financing Advisor assessment. for Cambodia, Dr. Rajeev Ahuja, will join the team in early Q3 and be based in Cambodia. He will focus on this activity. Provide technical support to No progress in Y5Q2. Same as above. the MOEF in the design and evaluation of a strategy for improving efficiency of health and disease spending. Activity 4: Costing Study and Actuarial Modeling of HIV/AIDS and TB Services at Public and Private Health Facilities Conducting an HIV/AIDS and Research protocol and study tools Next steps include IRB submission to TB costing study from public- developed and submitted to Abt’s IRB. National Ethics Committee in private facilities. Response expected shortly. Translation of Cambodia. After IRB approval is tools into Khmer under way. received, HFG will start with Identified a Research Coordinator to determination of study sites, training of support the work in country. Consulting in data collectors, and collection of data. process of finalization. Preparation of submission to National Ethics Committee is Cambodia under way. Will submit after response from Abt’s IRB. Build a cost financial No progress in Y5Q2. Progress on this task is dependent on projection model for data collected through the costing of HIV/AIDS and TB services. HIV/AIDS and TB services. Activity 5: Landscape Analysis of Sustainability and Incentive Structures of Village and Mobile Malaria Workers (VMWs/MMWs) Conduct literature review and SOW developed for consultant to lead this Work on this activity to begin in Q3. key informant interviews to work. Recruitment of consultant under identify options for way. incentivizing VMWs/MMWs and integrating community health programs. Facilitate the development of The working group did not meet in Y5Q2. Progress on this activity is dependent a HIV/AIDS sustainability sub- on the frequency with which the group technical working group meets. among development partners, ministries, and donors. Activity 6: Analysis and Support to HIV Sustainability Sub-Technical Working Group Facilitate the development of The working group did not meet in Y5Q2. Progress on this activity is dependent an HIV/AIDS sustainability on the group meeting. sub-technical working group among development partners, ministries, and donors.
184 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 7: Options Analysis to Inform the Next Funding Request to the Global Fund Conduct research and key HFG conducted Key Informant Interviews Finalization of this activity depends on informant interviews to assess and prepared options for the Global Fund how quickly the Country Coordinating current Global Fund funding grant architecture. The Country Committee and stakeholders can agree bottlenecks and alternative Coordinating Committee and other on the proposed structure for any new options for Global Fund stakeholders reviewed these options and grant. funding. narrowed down to three that are now undergoing a final selection process for the HIV and TB and malaria grant structures.
5. FIELD SUPPORT ACTIVITIES: CAMBODIA - 185
5.2.4 India Program Objectives - o improve health outcomes for the poor by: supporting the scale-up of health insurance; setting up a TA resource center for policy analysis, planning, and decisionmaking in priority health areas; strengthening civil society coalitions for improved advocacy, management, and sustainability; and establishing a challenge competition to test and scale up innovations. Year 5 Activities - Scaling up of selected health mutual scheme(s) and documenting best practices and evidence for a national roadmap for health mutuals in India; design of financing mechanisms for urban affordable PHC networks under the Partnerships for Affordable Healthcare Access and Longevity (PAHAL) project
Establishment of a well-functioning resource center to provide flexible, short-term TA for policy analysis, planning, and decisionmaking in priority health areas such as TB, FP, HIV, and adolescent health. This quarter, activities will include:
• Political economy analysis (PEA) of TB in India
• Research to support national family planning strategies, including: . Study of the relationship between key FP variables . Fund projection for the introduction of new contraceptives . Study to explore care-seeking behavior related to contraceptive use among adolescents • Technical assistance for strengthening adolescent health programme of Government of India
• Assistance/mentoring of 12 states regarding their efforts to complete the health and nutrition performance framework developed by the National Institution for Transforming India (NITI) Aayog
Strengthening the organizational and technical capacity of the civil society coalition White Ribbon Alliance India to improve quality and accountability of FP services Year 5 Progress against Objectives - HFG continued accelerated progress in the second quarter of Year 5. Substantive efforts were made to consolidate early gains, and the team successfully closed some assignment while laying a strong foundation for others. A summary and highlights on the project activities are presented below.
Scaling Up of Mutual Health Insurance: A key activity for Year 5 is supporting the scale-up of mutual health insurance and the design of financing mechanisms for urban primary health care networks through targeted desk research and TA. This work is expected to contribute to financial protection and access to affordable primary health care for the urban poor. This quarter, HFG successfully completed a review of government-funded community-based health insurance schemes in India and a case study on an established mutual, Annapurna Pariwar. The review has been succinctly summarized in a brief, Pathways to Universal Health Coverage: Lessons from Government-funded and Community-based Health Insurance Schemes in India. The brief was submitted to and well received by the USAID mission in India. HFG also conducted a study on Mutuals, Cooperatives, and Community-based Organizations (MCCOs) to inform the TA provided. The study provided vital insights on the evolving scenario of micro-insurance in India, MCCOs' experiences and challenges, and possible strategies that could spur MCCOs' growth. Based on the desk review of mutuals, a meeting with stakeholders and suggestions from the USAID mission, HFG has decided to provide TA and support in the scale-up of
186 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Uplift mutuals. HFG has visited Uplift sites and clinics for a better understanding of the existing systems, challenges, and processes, and is currently working on the detailed scope of TA. HFG also contracted a senior consultant to draft a report highlighting relevant innovations for scaling up health insurance in India. The consultant completed an advance draft of the report. The draft was submitted to the mission and is awaiting feedback.
Design of Financing Mechanisms for Urban Affordable Primary Health Care Networks under PAHAL Project: HFG had a detailed discussion with PAHAL on potential health insurance product design challenges and key questions to be considered while designing the product. Field visits are planned to Glocal and Merrygold networks to see the available preliminary data. HFG and the PAHAL team are also planning meetings with the Insurance Regulatory Development Authority of India and other commercial insurers to discuss collaboration opportunities. This quarter, the team brought on board Health Financing experts Arman Oza, Aloke Gupta, and Rahul Dutta, to support HFG's endeavor in providing low-cost primary health care solutions to the urban poor. They will support HFG in identifying partnerships and desired collaborations to provide affordable primary care solutions to prevent catastrophic health spending events and reduce the OOP burden on the urban poor. They will also introduce emerging and innovative approaches using data analytics to carry out these activities.
HFG India Resource Center: The HFG resource center will support the sustainability of USAID activities in India through flexible, short-term TA, research and analysis, and capacity building of USAID partner institutions. Under this activity, HFG is supporting four subactivities, the progress on which is briefly discussed below:
• Political economy analysis (PEA) of TB: HFG has contracted an agency (Amaltas) to conduct a PEA study, which will explore the social, economic, and political barriers and influencing factors to improved private sector engagement to control TB in India. The agency has completed and is submitting a final work plan with research questions, an analysis plan, and a theory of change, as well as a desk review and stakeholder analysis. The agency's field visits are ongoing in Patna, Mumbai, and Kolkata, and will be completed in April.
• Research to support national family planning strategies: This activity forms a major part of the HFG resource center work for Phase II. The Avenir team has completed proximate determinants analysis on NFHS1, 2, and 3 data. Data for NFHS 4 is awaited to complete the analysis. Avenir has completed the draft report for Fund projections for new contraceptives, and HFG will submit the financing report to the mission by early April and subsequently to the government. The adolescent care-seeking behavior study is approved by the government and the final study protocol and tools were approved by the Institutional Review Board. Preparations for data collection are in progress in the state of Madhya Pradesh and will begin in Odisha at the end of Y5Q2. In addition, the mission has asked for three new studies on family planning. The three studies include: 1) Study to assess factors responsible for high fertility in high priority districts in four states. 2) Study to analyze the trend in use of family planning methods by adolescent/young adults groups and early parity groups. 3) Study on the role of different communications and health workers' interaction in the use of family planning methods in India. HFG's partner, Avenir Health, will be conducting these studies.
• Technical assistance for strengthening adolescent health programme of Government of India. HFG is supporting the Government of India in developing a strategy document to operationalize multi- sectoral convergence mechanisms. A draft strategy document and guidelines were presented and submitted to USAID and the Government of India. The HFG team in India is also assisting the Government of India in designing a framework, methodology, and tools for vulnerability analysis and geographic mapping of the adolescent subgroup. A framework for vulnerability
5. FIELD SUPPORT ACTIVITIES: INDIA - 187 analysis, listing of determinants, and the broad methodology for developing the tool kit for vulnerability mapping was submitted to the Government and USAID.
• Mentor 12 states in completing the health performance framework developed by NITI Aayog: To improve health outcomes in 12 states, NITI Aayog has designed a framework to measure incremental improvements in states' performance in health. The HFG Resource Center acts as a mentoring agency and is assisting 12 states to understand the health index, indicator definitions, and data sources. HFG appointed six consultants to work as mentors within the identified states. Mentors have been introduced to eight states at four regional workshops. All mentors for eight states have successfully conducted the orientation of senior health officials and nodal officers on the Health Index framework.
Strengthening Civil Society Organization Coalitions in India for family planning promotion: HFG made favorable progress in strengthening CSOs for FP promotion. HFG hired two experts in CSO strengthening. As a notable achievement, 11 NGOs in Rajasthan and 15 NGOs in Jharkhand have been selected for the capacity-building activities. Preliminary meetings with NGOs were held to share objectives and plans for capacity building. HFG has completed in-depth organization capacity assessments (OCAs) for six NGOs in each state, and a short report has been prepared for each state. HFG has partnered with a training agency, a consortium led by Aaroh, to design the training curriculum informed by the OCAs. Q2 Challenges - Some activity timelines have been delayed by factors outside of HFG's control. The timeline to mentor states on the NITI Aayog Health Index was extended due to delays in regional orientation workshops, delayed appointment of state nodal persons, and delays in the design of the web portal. As a result, HFG mentors will require two more months to complete the activity. The NFHS study on key FP variables is not yet complete due to a delayed release of the NFHS 4 raw data, which is still awaited. The process of screening and selection of CSOs for capacity building was challenging and time-consuming. Detailed discussions were held with the White Ribbon Alliance to identify selection criteria in a fair and transparent manner. The preliminary orientation meetings and OCA process were delayed to ensure maximum participation of CSOs and not interfere with preexisting appointments and operations. Q2 Additional Information - As a part of the process of research and development, HFG India participated in the 2nd Asia Conference on Big Data and Analytics for Insurance from February 23 to 24 in Singapore. Big data technology is significantly useful in expanding insurance market reach, adding value to the products/services, and enhancing consumer satisfaction. The objective of participation in the workshop was to understand new trends in technology across the insurance industry and predictive modelling techniques for designing insurance products. The sessions offered insight on how using big data and analytics can enhance business value of insurance companies. In addition to learning about big data analytics and artificial intelligence, and web analytics and data modelling for insurance, the HFG team in India also initiated dialogue with various delegates and may consider procuring expert skills, through licensed software, to enhance HFG work on predictive modelling using machine learning and logistic regression techniques.
188 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Table 43 provides activity-specific updates. TABLE 43. INDIA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Support the scale-up of mutual health insurance to provide primary health care services to low-income households and vulnerable poor. Support to scale-up of one or HFG discussed TA requirements with the HFG is evaluating the request made by more health mutuals through CEO of Uplift. The HFG team has visited Uplift for TA and detailing the scope of TA and implementation Uplift’s office and OPD clinics in Mumbai each task item under TA. research and Pune to understand the systems and HFG will sign a nondisclosure processes of Uplift. agreement with Uplift to get access to Rahul Dutta, a predictive modelling its data and other documents required consultant, is looking at the available to start the work. HFG, the datasets that can be used to build the communication expert, and the predictive models, including propensity to predictive modeler will plan their next buy, claims, and the Upgrade model. visit to Uplift in April to understand Uplift’s data/MIS in detail and see the claims decision process and other activities including mobile OPD and simulation games in the field. Desk review on global A senior consultant was contracted to HFG is awaiting feedback from the innovations for scaling up draft the report. The consultant completed mission. health insurance an advance draft of the report. The draft was submitted to the mission for feedback. Review of government health A draft report was shared with the mission The findings of the review will be used insurance schemes and on February 14, for review and comments. as guidance for the TA provided to community based health scale up health mutuals and design insurance schemes in moving financing mechanisms for PAHAL health towards universal health networks. coverage in India Review of mutual-based health The paper was completed and submitted The findings will be used to provide insurance and its role in to the mission on March 15 for review and guidance for the TA plans to scale up strengthening the financial comments. health mutuals and design financing protection system in India mechanisms for PAHAL health networks. Activity 2: Design financing mechanisms for urban affordable primary health care networks under PAHAL project. Design of financing mechanisms The HFG team had a detailed discussion HFG will visit Glocal and Merrygold for urban affordable primary with the PAHAL team on health insurance health networks to review the available health care networks under product design. The attributes of the preliminary data in consultation with PAHAL project target insurance product and the IPE. HFG will also set up a working challenges encountered in designing the group with PAHAL with product, as well as the questions to be representatives from the Government considered, were discussed in detail. HFG of India, NITI Aayog, Commercial participated in a panel discussion in Action Insurance Providers, and others. HFG Meeting: Catalyzing Market Systems will share a concept note of the event Innovation for Health of India’s Urban with Mark White, the new USAID Poor, organized by IPE. HFG has prepared mission director. the scope for the consultation meeting for the Health Protection Reference Group.
5. FIELD SUPPORT ACTIVITIES: INDIA - 189 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 3: HFG Resource Center. Political Economy Analysis of The PEA study is ongoing. Amaltas has The field visit to Bangalore could not Tuberculosis in India submitted two deliverables: be organised due to THALI project Work plan, with research questions, staff scheduling issues. Instead, the analysis plan, and theory of change Kolkata THALI site was selected for a field visit. The planned stakeholder Desk review and stakeholder analysis workshops were rescheduled after the Field visits are ongoing in Patna, Mumbai, field visits. The mission recommended and Kolkata, and will be concluded by the that the need for stakeholder first week of April. workshop, in terms of timing and utility, will be reassessed in consultation with the Government of India. Research to support national Study of the relationship between key FP The next phase of the study is family planning strategies variables: Data analysis of NFHS2 and 3 is dependent on the release of under way. Proximate determinants NFHS4 raw data. analysis is complete for the NFHS1, 2 and The financing report will be shared with 3 data. NFHS data will be applied on the the mission in early April and same model to explore the relationship subsequently with the government. between TFR and CPR. The Odisha government has requested Study to assess the funds projection for the approval from their local Ethics introduction of new contraceptives: The draft committee. The government of Madhya report is ready to be shared with the Pradesh has requested that data mission. collection start in April. This may delay Study to explore the care-seeking behavior the study completion timeline to June related to contraceptive use among 2017. adolescents: The study was approved by the ministry. The final protocol and tools received IRB approval. Preparation for data collection in Madhya Pradesh is in progress and will start in Odisha in April. Technical assistance to the An SOW for two activities was agreed HFG will define the vulnerability government of India's upon with the mission. A draft note on the indicators and the methodology, and Adolescent Health Program multisectoral convergence mechanism for the template for vulnerability mapping adolescent health was shared with the will be completed. The toolkit will be ministry and revised as per the ministry’s field tested and finalized by June 2017. vision. A draft framework for a The SOW and timeline may be revised vulnerability mapping toolkit was shared to meet the MOHFW requirements. with the ministry and revised as per the ministry’s requirements. Assistance mentoring of 12 Mentors were introduced to eight states at Mentors of four states are waiting for states to complete the health four regional workshops conducted by the nomination of state nodal persons performance framework NITI Aayog. In eight states, mentors by NITI Aayog. The timeline for data developed by the NITI Aayog have conducted an orientation with senior collection has been extended to April health officials on the Health Index 30 by NITI Aayog due to a delay in the framework. NITI Aayog organized a launch of the Portal. training to train the mentors on the NITI Aayog online Portal.
190 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 4: Strengthen civil society organization coalitions in India for family planning promotion. Selection of HFG partner Eleven NGOs in Rajasthan and 15 NGOs NGOs have been selected. This task is coalition, finalizing Scope of in Jharkhand were selected for the capacity complete. Work and Memorandum of building in consultation with the White Understanding Ribbon Alliance. Selection took into consideration the NGOs’ capacity in terms of geographic scale, funding, population coverage, and demonstrated interest in the program. Preliminary meetings with selected NGOs were held, and objectives and plans for capacity building were shared. In-depth discussions on organization capacity assessment were conducted. Needs assessments HFG has completed in-depth The OCA reports will be used by the organizational capacity assessment for six training agency to design the NGOs in each state, and the other NGOs curriculum. are conducting self-assessments. A compiled assessment report was prepared. Design of training curriculum HFG has partnered with a training agency, The Aaroh team will conduct field visits a consortium led by Aaroh with the from April 1 to 15, to understand Center for Fund Raising, to design the training needs assessment and training curriculum. organizational capacity gaps. Aaroh will submit the training curriculum (final agenda, PowerPoint with notes, reading materials, templates, and checklists) on May 15, 2017.
5. FIELD SUPPORT ACTIVITIES: INDIA - 191
5.2.5 Indonesia Program Objectives - Given a backdrop of declining donor resources in the health sector, increasing domestic resources, and the continued roll-out of national health insurance coverage, in Year 5 HFG is continuing to support USAID/Indonesia in strategically investing in HSS. This includes assisting the Government of Indonesia to improve JKN implementation through implementation research, supporting strategic purchasing analysis and reforms, and supporting the MOH in its efforts to institutionalize the production of Health Accounts data. Year 5 Activities - HFG continues to implement the IR for UHC activity together with the University of Gadjah Mada CHPM and the PPJK, identifying potential recommendations to improve national health insurance (JKN) implementation. The activity supports policymakers and implementers in developing UHC- related research questions, undertaking rapid cycles of research that explore implementation gaps and bottlenecks, and offering improvements to implementation of JKN in Indonesia.
HFG is supporting PPJK in institutionalizing Health Accounts production, dissemination, and use in collaboration with the University of Indonesia. In the past, Health Accounts estimations were led by the University of Indonesia with funding from DFAT and some technical support from WHO. HFG is now helping to build Health Accounts capacity within PPJK, and is supporting PPJK in producing the estimates for fiscal 2015.
HFG is working with key health financing stakeholders, including the national health insurance agency (BPJS) and the Center for Health Financing, to assess the current institutional structures and regulatory functions for health care purchasing in Indonesia. The goal is to identify roadblocks to strategic health purchasing caused by misalignment between regulations and implementation, contradictory regulations, and other problems. This review will be used to develop a roadmap for step-by-step improvements. Year 5 Progress against Objectives - IR for UHC: HFG, in collaboration with the primary Indonesian government counterpart on the activity, PPJK, and HFG's local implementation research partner the Center for Health Policy and Management at the University of Gadjah Mada, conducted a deep-dive workshop in October 2016 on the results of the first cycle of IR for UHC. Carried out in Year 4, June-September 2016, the first cycle focused on the effects of JKN at the primary care level in five districts (Jember, South Tapanuli, Jayapura, Jayawijaya, and East Jakarta). The two-day workshop involved 76 participants including representatives from USAID, HFG, national-level ministries (MOH, Bappenas, BPJS), provincial and district-level organizations (district and provincial health offices, BPJS), development partners and NGOs (UNICEF, UNDP, UNFPA, Indonesia AIDS Coalition), and local university partners in the five selected districts. The objectives of the workshop were to disseminate the results of the IR; engage stakeholders in discussion of and learning from the findings; produce actionable recommendations for strengthening JKN policy and regulations on primary care and the conditions for their effective implementation; and provide input for the second cycle of IR for UHC.
192 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
The workshop presentations, plenary sessions, and group discussions focused on the gaps identified between "ideal" UHC policy and the reality of JKN policies and regulations for primary care, on the one hand; and between JKN policy and regulations for primary care and the reality of their implementation, on the other. The participants discussed three key issues revealed in the research:
• Capitation, as currently implemented, has little impact on improving performance.
• District health offices have relatively ambiguous authority to ensure that resources are spent to produce desired health outcomes.
• There is a misalignment between Indonesia's decentralized health service provision policies and the national regulations of BPJS as a centralized financial institution. After the "deep-dive" workshop in October, HFG's local partner CHPM held numerous consultative meetings with national-level stakeholders and stakeholders in our five target districts. The aim of these meetings was 1) to engage stakeholders in discussion of the IR cycle 1 findings and identify specific measures that might be taken to strengthen the implementation of JKN at the primary care level, and 2) to identify stakeholders' priorities for the focus of a second cycle of research. The consultations, held over the months of December and in Q2, January, February and March, revealed stakeholder interest in investigating how promotive and preventive services could be strengthened under JKN, and how the role of district health offices in local management of JKN could be improved. To link these interests and our findings from cycle 1, the research team proposed pursuing a deeper analysis of primary care staff incentives in cycle 2, as this is a critical element that determines performance and ultimately the effectiveness and sustainability of JKN. Cycle 2 will aim to provide in-depth, contextual analysis of how various regulations on incentives, capitation, and performance are being implemented in the five districts, and how the incentive environment might be modified to stimulate improved delivery of promotive and preventive care. In Q3, CHPM will proceed with instrument development, piloting, and interviewer training.
Support MOH in institutionalizing Health Accounts production, dissemination, and use: Early in Y5Q1, HFG worked with the University of Indonesia and PPJK to finalize the role of each in Health Accounts development. HFG finalized the scope of work for the University of Indonesia consultants, and attempted to onboard the consultants for rapid start-up of activities. Following extensive discussions in Q1 to agree on scopes of work for six Health Accounts consultants at the University of Indonesia (UI), USAID/Indonesia asked HFG to engage two Health Accounts consultants to be embedded at the Ministry of Health as well. In Q2, again after numerous extended discussions, HFG revised all eight scopes of work and collected necessary documentation to finalize the contracts. The Ministry of Health asked HFG to postpone the Health Accounts training from February until May 2017, due to scheduling difficulties. HFG started preparing the agenda and materials for the May trip and workshop on System of Health Accounts (SHA) 2011 process.
5. FIELD SUPPORT ACTIVITIES: INDONESIA - 193 Strategic health purchasing in Indonesia: In Y5Q1, HFG completed a scoping mission to support the development of a roadmap to improve strategic health purchasing within JKN and across all sources of health financing in Indonesia. During the scoping mission, the team conducted a landscaping and update of the current situation and key issues in strategic health purchasing in Indonesia, and established a working relationship with the National Social Security Council (Dewan Jaminan Sosial Nasional ; DJSN), MOH, BPJS-K, and other key stakeholders. Informational meetings were held with MOH directorates on the specific themes of HIV, immunization, malaria, MCH, nutrition, and TB. The team also supported DJSN in convening a stakeholder workshop to discuss the current situation and the challenges associated with the four aspects of strategic health purchasing: institutional structure, operational systems, capacity, and external factors. The objective was to frame future analysis of purchasing and provider payment in Indonesia, identify knowledge gaps that need to be filled, and inform a future process to develop a strategic health purchasing roadmap. A key message of the workshop from Y5Q1 was the need to harmonize and strengthen purchasing across all government health spending, including priority programs (HIV/AIDS, immunization, malaria, MCH, nutrition, and TB), and transition from donor support. More than 50 participants from the MOH, BPJS, MOF, and other stakeholder groups actively participated in the workshop. Following the Q1 scoping mission, the HFG team along with their government counterparts at the (DJSN, the MOH, and BPJS agreed upon three work streams for this activity:
• A review of current strategic purchasing functions and regulations, and desired realignment
• The establishment of a strategic purchasing Technical Working Group (TWG) convened by DJSN
• Capacity building for key stakeholders on strategic purchasing concepts, including local tailored trainings and international workshops In Q2, HFG engaged a local consultant from Gadjah Mada University to lead the review of health purchasing functions and regulations. The consultant began examining the institutional structure and regulatory foundations for health purchasing functions, comparing the existing regulations as described on paper, their actual implementation, and stakeholders' perception of more "ideal" purchasing arrangements. Based on priorities identified by the DJSN, the consultant's review is focusing on four key areas: Primary Health Care; medicines and pharmaceutical purchasing; the referral system; and remote areas. Findings will be used to identify roadblocks to strategic health purchasing in Indonesia (e.g., areas with misalignment between regulations, implementation, and/or the ideal situation), which will be the focus of the roadmap for improvement in health purchasing. Also in Q2, DJSN convened the strategic purchasing TWG for the first time, with support from HFG. The objectives of the TWG are to:
• Reach agreement on a strategic health purchasing concept and vision for Indonesia
• Identify the appropriate institutional roles and responsibilities to carry out strategic health purchasing functions across all sources of government health financing and at each level of government
• Develop a roadmap to make step-by-step changes to regulations, institutional roles and responsibilities, and operational processes, that will make health purchasing more strategic across all sources of government health financing and at each level of government
• Oversee a capacity-building plan for key stakeholder groups on fundamental concepts and processes of strategic health purchasing
194 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
The TWG met every two weeks, with each meeting focusing on one of the four key focus areas. Information obtained during the TWG meetings fed into the functional/regulatory review. Plans for the capacity-building work stream are under way. In Y5Q1, HFG also supported participants from the MOH Center for Health Financing in attending two strategic purchasing training workshops, one in Dublin and one in Cyprus. Participants gained a better understanding of basic concepts in strategic purchasing, and how to apply these concepts in the Indonesian context. HFG also supported DJSN in convening a meeting on primary health care. The project paid honoraria to 19 speakers and moderators, and provided meeting supplies. Q2 Challenges - Health Accounts: The process for engaging both the UI and the MOH consultants has been far more time consuming and laborious than expected. After six months of negotiations, helpfully supported by USAID/Jakarta, we are very pleased to have finally come to agreement and begun work.
Strategic purchasing: Local consultants from Gadjah Mada University, who are tasked with leading the regulatory review and the capacity-building efforts, have been underperforming. This may be due to communication challenges, being overcommitted, or having competing agendas. It has been difficult to ensure that they execute the originally agreed-upon scope. To mitigate this challenge, HFG has provided additional oversight and guidance to the local consultants, and will make monthly trips to Indonesia. Q2 Additional Information - HFG hired a new Technical Project Officer based in Jakarta. Zubaedah Kendar started work in Q2. Also, Susan Gigli (former lead of the IR for UHC activity) left the HFG project. Dr. Lisa LeRoy, an expert in qualitative research and rapid cycle learning, joined the HFG project to continue leading the activity. Table 44 provides activity-specific updates. TABLE 44. INDONESIA ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 2: Support Indonesian MOH in institutionalizing Health Accounts production, dissemination, and use. Provide technical assistance to Finalized roles and responsibilities This activity has been hampered by UI's PPJK for Health Accounts of HFG, University of Indonesia, reluctance to share their skills and knowledge production, dissemination, and and PPJK during Health Accounts of Health Accounts with the Ministry of use process. Health/PPJK, when UI would prefer to maintain Engaged in significant outreach its role as the sole producer of Health (multiple emails and phone calls) to Accounts. In addition, the UI consultants are University of Indonesia and PPJK very busy with several ongoing studies. HFG, consultants to negotiate scope and with the help of the USAID mission, has request documentation. engaged in numerous detailed discussions to come to an agreement on how UI, HFG, and Prepared agenda and draft PPJK will work together. We are hopeful that materials for SHA training in May. the Health Accounts activity will move faster, now that the consultants have signed their contracts. PPJK consultants have already started analyzing government data. HFG will conduct the SHA 2011 training in May and review the data collection and analysis completed thus far.
5. FIELD SUPPORT ACTIVITIES: INDONESIA - 195 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 3: Strategic purchasing TA in Indonesia. Review of institutional This work was begun by our Systematic assessment to be done. Goal is to structure and regulation for consultant. Misalignments between have key misalignments established, to be strategic purchasing regulation and implementation have addressed in April workshop. been identified. Goal is to have review completed and key roadblocks identified before April workshop. Facilitation of Strategic Health This group was convened and has Concentration on remote areas has not yet Purchasing Technical Working been meeting every other week begun, as relevant stakeholders (those from Group since January 2017. Each meeting remote areas) have not yet been able to has focused on a priority area attend meetings. identified by the DJSN (primary DJSN has had difficulty convening the right health care, participation in the TWG meetings. medications/pharmaceuticals, referrals, and remote areas). Develop capacity-building plan Concept note and plan being The Activity team with consultants is having developed. difficulty agreeing to a plan that both falls within scope of this project and matches desires of local stakeholders. Convene stakeholder Workshop to be held April 11 in Final concept note and invitation list to be workshop Jakarta. Objective is to review finalized. roadblocks to strategic purchasing found during functional/regulatory review, and to create a set of recommendations for policy changes to remove these roadblocks. Support MOH attendance at Supported participants in training in No problems encountered. international provider payment France. methods training
196 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.2.6 Vietnam Program Objectives - The overall strategic objective of HFG/Vietnam is to support the Government of Vietnam in ensuring the sustainability of HIV/AIDS programs with Social Health Insurance as the main financing agent. PEPFAR has begun the crucial stages of transitioning out of funding Vietnam's direct service delivery for HIV/AIDS in Vietnam. To guide stakeholders through the rapid transformations required for a successful transition, the USG/Vietnam team has identified critical "Game Changers": time-bound objectives whose fulfilment will allow the Government of Vietnam to effectively increase the mobilization of domestic resources for HIV and to take a leading role in the fight against the disease. Relevant to the mandate of the Sustainable Financing Initiative and PEPFAR's COP16, and in support of GVN's commitments, our programmatic objectives by end of September 2017 are:
Cover 23 percent of 2017 overall need (estimated at 133,000 first- and second-line patients) with Domestic Resources for HIV through Social Health Insurance (SHI) and other sources. External donors are planning to cover 77 percent of patients in 2017. The first ARV procurement with SHI funds will be completed by 2017, covering 15 percent of patients in treatment, while the remaining 8 percent of the total need in 2017 will be covered by State-funded procurement.
Continue integration of Outpatient Clinics (OPCs) into SHI, achieving completion of Phase 2 The majority of HFG-supported facilities are reimbursed for services provided to HIV patients in 2017. HFG supports 105 facilities (46 of which are PEPFAR sites) in nine provinces. By end of September 2017, we aim for the number of facilities providing HIV services reimbursed through SHI to be more than 70 percent of the total (75 out of 105). Current baseline is 13 percent (14 out of 105). Year 5 Activities - Activity 1. Provide support and technical assistance to the MOH and Vietnam Social Security in the integration of Outpatient Clinics for eligibility for reimbursement by the Health Insurance fund (COP16 Funding). HFG will continue the implementation of integration activities in the six assigned PEPFAR priority and maintenance provinces, and will also include three additional provinces to accelerate the overall integration process. In coordination with the Vietnam Administration of HIV/AIDS Control (VAAC), HFG proposes the consideration of three additional provinces currently not supported by PEPFAR: Dong Nai, Ninh Binh and Phu Tho. While the additional three provinces will make the integration activity more challenging, HFG expects to increase its impact on the transferring of HIV patients to SHI facilities by over 1,000 patients, and the potential for additional 760 PLHIV to access HIV treatment through SHI. At the central level, HFG will continue to provide technical and financial support to keep the integration of OPCs at the forefront of the MOH's agenda. At the provincial level, HFG will assume the role of leading coordination agency for the integration process and the migration of patients across all PEPFAR facilities in the nine assigned provinces. HFG will also strengthen technical assistance volume and frequency in each of the assigned provinces to assist DOHs to overcome the barriers preventing OPC integration. At the facility level, HFG will provide technical support for the transition of HIV patients to the hospitals and clinics in the SHI network. HFG will also provide capacity building to hospital and provincial staff to ensure proper SHI implementation, administration, and claim management. Finally, HFG will address the financing elements that might impact quality and availability of the HIV services as they are integrated within the SHI network.
5. FIELD SUPPORT ACTIVITIES: VIETNAM - 197 Activity 2. Enable the first centralized ARV procurement funded by SHI in coordination with Vietnam Social Security (VSS), VAAC, and Ministry of Finance (Sustainable Financing Initiative (SFI) Funding). HFG is already in advanced discussions with VAAC and VSS about issues that continue to emerge as the arrangements for the first procurement of ARVs paid by SHI become more developed. The objective for 2017 is to achieve complete preparation of documents, processes, and funding arrangements for the first ARV procurement paid by SHI by the end of the year. To that effect, HFG will:
• Provide information and guidance for transitioning procurement of ARVs from external/donor- funded programs to national systems, including the roles of institutions and agencies, accountability mechanisms, and market-shaping approaches
• Work with the VAAC/MOH and VSS/MOF to define the legal framework in the form of a circular to regulate the use of SHI funds for payment of suppliers
• Organize and train a unit for ARV centralized procurement at the Ministry of Health
• Support the VAAC/MOH and VSS, and guide them through the process of procuring ARVs by end of 2017
Activity 3. Provide evidence and technical assistance to the MOH and Vietnam Social Security in the ongoing Health Financing reform to ensure the advancement of the HIV agenda among other health priorities (SFI funded). Over the course of FY2015 and with support from the Sustainable Financing Initiative, HFG has been deeply involved with the design and approval of the roadmap for the basic health service package (BHSP) to be reimbursed by health insurance. However, both VSS and the MOH need continued technical support in their effort to better understand and estimate their revenue and expenditures, both past and future. HFG intends to respond to recent programmatic challenges through a combination of local and international technical support. The technical support team will comprise resources from R4D, Abt, and one international consultant in the field of insurance and actuarial science. In coordination with our local counterparts at Vietnam Social Security and Ministry of Health, and supported by our national experts, the HFG experts will:
• Address the lack of prevention in the SHI Benefit Package.
• Assist the Department of Planning and Finance at MOH to draft two SHI-related circulars.
• Provide technical support to the National Council for Health with regard to the approval of the Basic Health Services Package and related circulars.
• Continue the ongoing support to Vietnam Social Security to complete the drafting of the Projection Model for SHI, inclusive of HIV services.
• Continue and complete the National Health Account (NHA) and HIV subaccount expenditure tracking exercise for 2014 and for 2015 accounts.
Activity 4. Work with VSS, Provincial Social Security (PSS), and VAAC to ensure the Health Information System is strengthened and enabled to register, report, and follow up on HIV patients (SFI funded). Vietnam Social Security is in the process of updating its database systems to better capture and report on input data received from Provincial Social Security offices throughout the country. As a result of technical discussions with VSS, HFG proposes to support the agency in adapting and, if needed, modifying the Health Information System at the provincial level to ensure that the information related to HIV patients is properly recorded, stored, and shared. This includes the following activities:
198 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
• Define characteristics of a strong monitoring system of HIV patients accessing SHI facilities in the country.
• Provide Support to the VAAC, VSS, and PSS in modifying the design of VSS's Information System (IS) at the national level to integrate HIV patients' data and hospital reports.
• Build the capacity of Provincial Social Security to evaluate claims and process reimbursements related to HIV services.
Activity 5. Work with the VAAC, National Assembly, VSS, MOH, provincial authorities, and USAID partners to improve HIV patients' financial protection, in order to incentivize their transition to SHI-funded clinics (SFI funded). The main and most obvious barrier to the uptake of HIV services in an SHI context is the low level of PLHIV enrollment in Social Health Insurance. HFG proposes to work on the following tasks to contribute to the improvement of perceptions of PLHIV towards SHI, and improvement in their use of SHI:
• Provide evidence to BCC and promotion programs aimed at increasing PLHIV's enrollment in Social Health Insurance in provinces and major cities.
• Advocate for a fully subsidized status for PLHIV based on the infectious, debilitating, and costly nature of the condition.
• Support the drafting of legal language for the allocation of provincial funds in the nine provinces where HFG is currently working, to subsidize PLHIV's SHI premiums and copayments. Year 5 Progress against Objectives - In Y5Q2 (January-March 2017), most USAID/HFG Vietnam work focused on priority and transition provinces for the implementation of HIV services paid by the health insurance fund, including: (1) the resolution of accreditation issues with HIV/AIDS treatment facility currently unable to contract with Vietnam Social Security in nine HFG-supported provinces, including six currently supported provinces (Hanoi, Ho Chi Minh City, Hai Phong, Can Tho, Hoa Binh, Thai Binh) and three new provinces (Dong Nai, Ninh Binh, Phu Tho); (2) the needed increase of PLHIV's enrollment in health insurance; (3) the sustainable transfer of knowledge for tracking HIV resources from government and external sources, with the definition of the BHSP paid by the SHI fund including HIV/AIDS services; (4) proposed options for centralized procurement and reimbursement of ARV through the SHI Fund; (5) the development of the SHI projection model; (6) data collection for the NHA exercise 2014-2015 and Provincial Health Account with HIV subaccounts; and (7) Health Information System (HIS) strengthening. In Y5Q2, the USAID/HFG-Vietnam team achieved some key results as outlined below:
Integration of HIV/AIDS treatment facilities for health insurance reimbursement eligibility.
• Direct technical support to provinces: . In collaboration with key MOH departments including the Department of Planning and Finance (DPF), VAAC, Department of Health Insurance, and Medical Services Administration, along with VSS as the administrator of the SHI fund, HFG/Vietnam continued to provide technical assistance to six provinces (Hanoi, Ho Chi Minh City, Can Tho, Hai Phong, Hoa Binh and Thai Binh) with the standardized integration plans that were approved by DOHs, and to assist three additional provinces (Ninh Binh, Phu Tho, and Dong Nai) to develop an integration plan, with specific actions for each proposed option and criteria to fulfill SHI requirements for contracting, service provision, and reimbursement, based on the experiences from other provinces. In the three new provinces, after a situational analysis, the first integration workshop were organized by DOHs to kick off the integration activities for all HIV/AIDS treatment facilities in each province and speed up the integration process.
5. FIELD SUPPORT ACTIVITIES: VIETNAM - 199 . HFG and key MOH departments continued to conduct supportive supervision activities at the provincial and health facility level in the nine provinces to implement the integration plan; responded to policy and technical issues; and discussed solutions for speeding up the integration process.
• Technical support to MOH. . HFG continued to support the VAAC in the monitoring and tracking of the integration progress in 63 provinces, using the integration mapping tool. From this quarter onward, the tool will also monitor HIV/AIDS service provision and reimbursement by the SHI fund through the number of HIV patients receiving HIV/AIDS service paid by the SHI fund. . By the end of March 2017, compared with the set target of 62, 67 HIV/AIDS treatment facilities, with 19,234 patients receiving ART, had amended their SHI contract for HIV/AIDS. Health facilities reached phase 2 of integration, meaning they started to provide HIV/AIDS services through SHI and were reimbursed. To date, 41 sites out of a targeted 42 have already provided HIV services paid by the SHI fund; these included nine sites in Hai Phong, three in Hoa Binh, six in Thai Binh, 16 in Ho Chi Minh City, five in Can Tho, one in Ninh Binh, and one in Phu Tho. The achievement regarding service provision through SHI is about to meet the target (41 compared with the target of 42)
Proposed options for ARV centralized procurement and reimbursement from the SHI fund. USAID/HFG collaborated with the VAAC/MOH, VSS, and PSM in the development of models of centralized procurement and reimbursement of ARV through the SHI fund.
• After the Prime Minister's decision on ARV procurement and reimbursement of ARV from the SHI fund and support for ARV users (Decision 2188/TTg), the USAID/HFG team provided technical support to the VAAC/MOH in developing the draft of the circular, guiding them on the procurement and payment mechanism of ARV drugs from the SHI fund and the support for ARV users; collecting official comments from related ministries (MOF and VSS, MPI); and posting the draft circular on MOH's website for additional comments.
• Attended and provided technical support to the VAAC in the technical meeting with HCM City DOH, Provincial AIDS Center (PAC), PSS, and local hospitals to collect feedback for the draft circular. The comments from HCMC are extremely important, as the number of HIV/AIDS patients in HCMC accounts for one third of the total number of PLHIV in Vietnam, and the procurement and reimbursement mechanism of ARV from the SHI fund might bring about significant changes in HCMC.
• The technical team from HFG also worked closely with the VAAC/MOH to provide guidance for PAC and health facilities in the process of ARV drug quantification, liquidation, and the proposed financing mechanism for ARVs paid by the SHI fund.
National Health Account exercise/HIV account and provincial health accounts
• After collecting required data for the NHA exercise 2014-2015 from the MOF, MOH, VSS, and GSO, as well as the secondary data from the five provinces (Hanoi, Ho Chi Minh City (HCMC), Nghe An, Khanh Hoa, and Can Tho) to conduct the provincial health account exercise, the NHA team worked together to organize, validate, and input collected data in software, analyze data, and produce the initial basic indicators, as well as getting consensus on the distribution keys of NHA and HIV/AIDS for 2014 and 2015.
• Organized the technical workshop on the preliminary indicators of NHA and Provincial Health Account (for the five provinces) including HIV/AIDS subaccount analysis for the years 2014 and 2015.
200 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Definition of the BHSP paid by the SHI fund. Assisted the Department of Planning and Finance/MOH in the development and finalization of the BHSP circular, in which target at defining the BHSP paid by the SHI fund to be delivered at grassroots level. Supported DPF to have site visits to some Departments of Health and hospitals at the provincial level (Gia Lai, Can Tho and Dong Nai) to collect their feedback on the BHSP circular.
Development of the SHI financial projection model
• Collaborate with VSS to develop the data collection plan and templates for the data collection in 12 provinces, as part of efforts to develop the SHI financial projection model at national level.
• To expand the SHI fund financial projection model at national level, HFG has requested VSS and MOH to provide required data. The workable developed model will depend on having sufficient data provided by VSS and health facilities.
Health Information System strengthening
• To integrate the HIS of HIV into the hospital system for management of the HIV program and ARV quantification, USAID/HFG currently participate in the technical working team with the VAAC and other partners to get consensus on the standard output indicators for HIV management.
• Coordinated between MOH, VAAC, and VSS to get comments on the standard metrics to officially submit to MOH for HIV management based on the current HIS.
• Discussed with VSS the possibility of conducting a review of the current infrastructure of the health information system at health facilities for reimbursement by the SHI fund.
• Increasing PLHIVs' enrollment in SHI. HFG started collaborating with PATH through the Healthy Markets project to raise awareness of the advantages of enrollment, HIV services offered, and subsidies available to PLHIV. Q2 Additional Information -
As the DOHs in the assigned provinces go through the integration process outlined and started by HFG in 2016, the fact that PEPFAR and Global Fund commodity support still exists free of charge does not motivate health facilities to transit to SHI.
Due to the complexity of the OPC consolidation process, some provinces decided to transfer patients from OPCs located in a single function health center or preventive medicine center to a hospital-based OPC so there might be changes in the management of patients. This might lead to drop-out or loss to follow-up among ART patients.
There is still lack of attention for intervention for patients being treated at national-level hospitals as well as patients being treated at provincial-level hospitals of other provinces.
According to the Prime Minister Decision No 2188, People's Committees of the central cities/provinces will be responsible for allocating funding to provide SHI cards for all PLHIV. However, this provision may vary from province to province, and will depend on provincial action. There are only a few provinces allocating funding to buy SHI cards for PLHIV, and the long-term commitment of funding allocation is uncertain.
It is still a challenge to reach the target of 100 percent PLHIV enrolled in the SHI scheme, because some percentage of patients do not have identity papers, have an ID mismatch, or have no permanent residence in the provinces where they are living and receiving HIV/AIDS care and treatment.
5. FIELD SUPPORT ACTIVITIES: VIETNAM - 201 Table 45 provides additional activity-specific updates. TABLE 45. VIETNAM ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Year 5. Activity 1. Provide support and technical assistance to the MOH and Vietnam Social Security in the integration of Outpatient Clinics for eligibility for reimbursement by the Health Insurance fund. At the central level, HFG will At the national level: HFG continued to At national level: The integration at continue to provide technical assist the VAAC/MOH to monitor the most HFG supported provinces has and financial support to keep integration progress in 63 provinces using the passed phase 1, SHI contracting. the integration of OPCs at mapping tool. The indicator on number of Monitoring next steps requires the the forefront of the MOH’s HIV/AIDS patients receiving HIV/AIDS services VAAC’s attention to mainstream agenda. through SHI was included in the mapping tool reporting requirements from health to monitor service provision and facilities. Closer coordination with reimbursement. HFG also helped the VAAC VSS and PSS will also be needed to to refine the master table showing national measure financial impact of the integration progress for public viewing on the integration on the system. VAAC website. HFG continued to provide support to the VAAC in developing a set of Questions and Answers on the integration based on HFG’s technical experiences with provinces and health facilities. The Q&A is also expected to be published on the VAAC website. HFG, together with FHI 360, CDC, and PATH, also provided technical support to the VAAC in revising the circular 32/2013/TT-BYT on the Guideline for managing and monitoring HIV/AIDS treatment for PLWH and people exposed to the HIV virus. At the provincial level, HFG At provincial level: HFG provided technical At the provincial level: will assume the role of and financial supports on OPC integration • To continue follow-up leading coordination agency activities of DOHs and PACs in the six supportive supervision of for the integration process assigned PEPFAR priority and maintenance activities in all sites. New sites and the migration of patients provinces, as well as three additional Global in Ninh Binh, Phu Tho, and across all PEPFAR facilities in Fund-supported provinces (Ninh Binh, Phu Dong Nai province will receive the nine assigned provinces. Tho, and Dong Nai) to accelerate the overall similar support. integration process. The supports included: • To continue the provision of • Identifying appropriate and feasible steps for province-based technical the integration as well as actions to meet assistance to DOH, PAC, and the criteria for entering SHI contracts and health facilities. providing services through SHI scheme • Provincial understanding and • Implementation of the integration plans capacity for the integration in • Responding to policy and technical issues the new provinces (Ninh Binh, • Assisting the transfer of patients from Dong Nai) are of concern. district preventive medicine centers to These provinces need a much district hospitals where required higher volume of technical assistance.
202 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps In HCMC: USAID/HFG team had a meeting with DOH and PAC to discuss the current issues and the next steps of support and collaboration. HFG was requested to increase technical assistance to HCMC to respond to complex issues involved in the integration of district preventive medicine center-based OPCs. Then PAC HCMC issued the decision on the establishment of the TWG for the integration and HI coverage expansion among the HIV/AIDS treatment facilities in HCMC. This is an official proof of coordination among the development partners of whom USAID/HFG is one. On March 30, USAID/HFG supported HCMC DOH in organizing a workshop to review the integration of HIV/AIDS treatment facilities. The workshop aimed to discuss current achievements and challenges of the integration, SHI provision, and the reimbursement process, as well as action points/solutions for next steps. In Thai Binh: HFG supported Thai Binh PAC in designing the tool for need assessment of patient’s choice for HIV/AIDS treatment facilities through SHI. Over 600 patients are being treated at provincial-level hospitals, which are not their initial registered SHI health facilities, and they are not entitled to the full SHI benefit for general health care. The assessment will inform Thai Binh DOH of decisions on reallocating patients to suitable treatment facilities within Thai Binh Province, and provide essential inputs for the development of a provincial patient migration roadmap. In Ninh Binh, on March 14, 2017, with technical and financial support from USAID/HFG, Ninh Binh DOH and PAC successfully organized the workshop on the integration of HIV/AIDS treatment facilities into SHI scheme. After the situational analysis carried out in December 2016, this is the first integration workshop in Ninh Binh, to launch the integration activities for all HIV/AIDS treatment facilities. During the workshop, participants discussed the current situation, advantages and challenges of implementing integration, and HIV/AIDS services provision through the SHI scheme taking the lessons learnt and experiences from other provinces.
5. FIELD SUPPORT ACTIVITIES: VIETNAM - 203 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps
In Dong Nai, the first integration workshop to start the integration activities for all HIV/AIDS treatment facilities was also organized on March 23, 2017. Strengthen technical HFG, together with the VAAC, DPF, SHI, and • To continue the provision of assistance volume and DOH, completed follow-up supportive province-based technical frequency in each of the supervision activities in sites in the six assistance to DOH, PAC, and assigned provinces to assist provinces. There were 69 TA visits made health facilities. DOHs to overcome the during the quarter. For health facilities with • Less supportive supervision will barriers preventing OPC complex regulatory issues and concerns about be provided for the provinces, integration. service provision, additional visits were made where almost all sites have to ensure timely follow-up and actions. signed contracts with VSS, and As for HCMC, HFG recruited another local more-comprehensive TA will be consultant in responding to HCMC’s demand provided for the new for HFG technical assistance. provinces. At the facility level, HFG will During Q2, HFG has conducted the following • To continue follow-up provide technical support for activities in supporting sites within assigned supportive supervision of the transition of HIV patients provinces: activities in all sites in the nine assigned provinces. to the hospitals and clinics in • Can Tho: two TA visits to DOH and PAC the SHI network. • To continue the provision of • Hanoi: six TA visits to Hanoi DOH province-based technical • Hai Phong: 13 TA visits to DOH, PAC, and assistance to DOH, PAC, and health facilities health facilities. • HCMC: 28 TA visits to DOH, PAC, and • Health facilities’ understanding health facilities of the integration, as well as SHI • Thai Binh: 20 TA visits to DOH, PAC, and benefits for HIV patients in the health facilities new provinces (Ninh Binh, Dong Nai), are of concern. A much higher volume of technical assistance to facilities will be required.
Activity 2: Year 5.Activity 2. Enable the first centralized ARV procurement funded by SHI in coordination with VSS, the VAAC, and the Ministry of Finance. Provide information and Continuing with the current support to the HFG will mobilize experienced guidance for transitioning VAAC/MOH on ARV procurement from the consultants (both local and procurement of ARVs from SHI fund and financing mechanism for ARV, international) to collect external /donor funded HFG began analyzing how the system of international experience in this area programs to national procurement and distribution of ARVs links to and share it with the VAAC and systems. the facility level, in collaboration with the related partners to shape the VAAC, VSS and PSM. discussion based on practical Support the VAAC in developing the guideline experience and applicable in and official letter signed by Vice Minister of Vietnam context. health guiding the procedure of liquidation and reporting of ARV funded by the state budget and different sources. This is to improve ARV management, reporting and quantification of ARV from different sources.
204 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Organize and train a unit for The Decision 2188/Q-TTG on centralized HFG, in collaboration with PSM, ARV centralized procurement of ARVs from the SHI fund and will mobilize experienced procurement at the Ministry support to ARV users is in place, but the consultants on drugs quantification of Health. centralized procurement unit at the MOH has and procurement to provide direct just been set up and still in the preparation technical support to the stage. The VAAC proposed to the Minister of VAAC/MOH on the quantification Health to be responsible for the procurement and procurement of ARVs, as of ARV drugs but so HFG closely worked with adaptable within the Vietnam the VAAC/MOH ARV procurement unit in the context. development of the management, organizational structure, and financing arrangement to be ready for the bidding process of ARV. Support the VAAC/MOH USAID/HFG is currently collaborating with the • Follow up and support the and VSS and guide them VAAC/MOH, VSS, and PSM in the estimation VAAC in the process of through the process of of ARVs needed for the centralized quantification of ARV for the procuring ARVs by end of procurement from SHI to fill in the gaps for centralized procurement from 2017. 2017 and for the period of 2018–2020 when the SHI fund in 2017. donors transition out. HFG is focusing on the • Collaborate with the financial aspects of the estimation. VAAC/MOH, VSS, and PSM in The technical team from HFG also worked calculating the quantification closely with the VAAC/MOH and PSM to process, provision of guidelines provide guidance for PAC and health facilities for provinces in estimating the in the process of ARV drug quantification and need for ARV from the SHI proposed financing mechanism for ARVs paid fund, and the distribution and by the SHI fund. supply chain of ARV drugs. • Support the VAAC/MOH in development of the guideline on reporting and liquidation of ARV from the SHI fund. Work with the VAAC/MOH, • After the Prime Minister’s decision on ARV Continue to provide detailed VSS/MOF to define the legal procurement and reimbursement of ARV recommendations and technical framework in the form of a from the SHI fund and support for ARV support to the VAAC/MOH for circular to regulate the use users (Decision 2188/TTg), the finalizing the circular regulating the of SHI funds for payment of USAID/HFG team provided technical payment mechanism for centralized suppliers. support to the VAAC/MOH in developing procurement of ARV drugs using the draft of the circular, guiding them on the SHI fund and the support for the procurement and payment mechanism ARV users. of ARV drugs from the SHI fund and the support for ARV users; collecting official comments from related ministries (MOF and VSS, MPI); and posting the draft circular on MOH’s website for additional comments. • Also participated in the technical meeting with Ho Chi Minh City DOH, PAC, PSS, and local hospitals to collect feedback for the draft circular.
5. FIELD SUPPORT ACTIVITIES: VIETNAM - 205 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 3: Year 5. Activity 3. Provide evidence and technical assistance to the MOH and Vietnam Social Security in the ongoing Health Financing reform to ensure the advancement of the HIV agenda among other health priorities. Address the lack of The minister of health has decided to develop USAID/HFG was also proposed by prevention in the SHI Benefit the basic health service package that focuses on the vice-minister of health to Package equity and accessibility to health care services provide technical support for the at the district and commune level. The BHSP health financing reform for will be the commitment of the GVN to the preventive medicines in Vietnam. investment of infrastructure, capacity, and This is a good chance for the human resources to strengthen the service project to get involved in the delivery capacity at the grassroots level. The development of the HIV prevention BHSP will include services at commune health package and propose financing stations with the inclusion of primary health mechanisms for a preventive care services and the services for health medicine service package that promotion. includes HIV services. Since preventive services have not been reimbursed by the SHI fund as regulated by SHI law, with explicit reference to HIV, HFG has mobilized a local expert to work with the MOH and related partners to prepare the workable option to establish a path for the necessary regulatory and legal changes to include the relevant preventive and promotive services in the BHSP. Assist the Department of Based on the decision to develop the BHSP Support MOH in the finalization of Planning and Finance at first at the grassroots level, USAID/HFG the BHSP circular and annex to MOH to draft two SHI- worked with DPF and provided technical ensure the inclusion of HIV services related circulars. support to develop the BHSP circular and the in the package. annex with proposed services included in the BHSP. HFG also supported DPF to have site visits to some departments of health and hospitals at the provincial level (Gia Lai, Can Tho, and Dong Nai) to get their comments to the circular before it is completed. A final version of the circular has yet to be released. Provide technical support to Support MOH in the finalization of the BHSP the National Council for circular and annex to ensure the inclusion of Health with regard to the HIV services in the package. approval of the Basic Health Services Package and related circulars.
206 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Continue the ongoing Collaborated with VSS to develop the data Collaborate with VSS to conduct support to Vietnam Social collection plan and templates for the data the data collection in 12 provinces Security to complete the collection in 12 provinces to develop the SHI to develop the SHI financial drafting of the Projection financial projection model at national level. projection model at national level. Model for SHI, inclusive of To expand the SHI fund financial projection HIV services. model at national level, HFG has requested VSS and MOH to provide required data. The workable developed model will depend on the sufficient data provided by VSS and health facilities. Continue and complete the Regarding NHA exercise 2014–2015 and • By the end of May 2017: Finish NHA and HIV subaccount Provincial Health Account with HIV accounts, the preliminary data and expenditure tracking during the second quarter of the FY 2017, HFG organize a technical meeting to exercise for 2014 and for has done the following: get the agreement on the results. 2015 accounts. • After collecting required data for NHA exercise 2014–2015 from the MOF, MOH, • By the end of August 2017: VSS, and GSO, as well as the secondary Finalize the final results and data from the five provinces, the NHA report. team (HFG Vietnam team and Andre Zida, the international expert on health economics) worked together to organize, validate, and input collected data in software and analyze data. • Worked with HFG international expert and DPF to get the agreement on data used. • Produced the initial basic indicators and distribution keys of NHA and HIV/AIDs subaccounts for 2014 and 2015. • Prepared and organized the technical workshop on the preliminary indicators of National Health Accounts and Provincial Health Accounts (for five provinces) including HIV/AIDS sub-analysis for the year 2014–2015. The workshop was held to get agreement from stakeholders at the central and provincial levels on the health finance data and methodology used for NHA and Provincial Health Accounts, including HIV/AIDS sub-analysis for the year 2014– 2015.
5. FIELD SUPPORT ACTIVITIES: VIETNAM - 207 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 4: Year 5. Activity 4. Work with VSS, PSS, and VAAC to ensure the Health Information System is strengthened and enabled to register, report, and follow up on HIV patients. Define characteristics of a USAID/HFG currently participate in the Collaborate with VSS/PSS, the strong monitoring system of technical working team with the VAAC and VAAC, and DOH to conduct an HIV patients accessing SHI other partners to get consensus on the assessment of current HIS of OPCs facilities in the country. standard output indicators for HIV in selected provinces, to find the management that the VAAC will propose to solution for the reimbursement of the MOH and VSS for HIV program HIV services from the SHI fund management. based on the official standard Discussed with VSS how to conduct a review outputs from the VAAC. of the current infrastructure of health information system at health facilities for reimbursement by the SHI fund. Provide support to the To integrate the HIS of HIV into the hospital Discuss with VSS/PSS, VAAC, and VAAC, VSS, and PSS to system for management of the HIV program DOH how to conduct an modify the design of VSS’s IS and ARV quantification, USAID/HFG currently assessment of current HIS of OPCs at the national level to participate in the technical working team with in selected provinces, to find the integrate HIV patients’ data the VAAC and other partners to get consensus solution for the reimbursement of and hospital reports. on the standard output indicators for HIV HIV services from the SHI fund. management. Coordinate between MOH, VAAC, and VSS to get comments on the standard outputs to officially submit to MOH for HIV management based on the current HIS. Build the capacity of As of Q2, this activity has not been started yet. Provincial Social Security to This activity will be done based on the evaluate claims and process completion of Activity 1. reimbursements related to HIV services. Activity 5: Year 5. Activity 5. Work with the VAAC, National Assembly, VSS, MOH, Provincial authorities and USAID partners to improve HIV patients’ financial protection to incentivize their transition to SHI-funded clinics. Provide evidence to BCC Cooperate with PATH (Healthy Market • HFG will continue to cooperate and promotion programs Activity project) on some activities to increase and share cost with the Healthy aimed at increasing PLHIV the PLWH’s enrollment in SHI. Markets project (PATH) on finalizing the leaflet and the two enrollment in Social Health • Developing a leaflet providing information training courses. Insurance in provinces and on FAQs on HI for MSM and transgender major cities. women. • Collaborate with other partner projects such as the VAAC, • Providing contents or comments for posts with information regarding HI to post on U.S.CDC, and SHIFT to provide evidence, data, and other inputs Xomcauvong (Rainbow village) Facebook necessary to raise awareness page during March 2017. This platform already has more than 100,000 followers. and to encourage the enrollment to SHI. • Prepare for two training courses to provide information on HI for lead CBOs (who are lay testing providers and counselors), one in HCMC and one in Hanoi; tentatively organize in May or June 2017.
208 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Advocate for a fully The HFG team has had preliminary dialogue subsidized status for PLHIV with the Department of Health Insurance based on the infectious, (MOH), VAAC, VSS, and Ministry of Finance to debilitating, and costly nature outline possible benefit sand consequences of of the condition. granting a fully subsidized SHI status to PLHIV. Also, HFG has worked with the VAAC to revise Decree 105/2014/N-CP on regulating and guiding some specific articles of the HI Law and advocating for subsidies for PLWH. Support the drafting of legal There are alternative options that have opened language for the allocation of up, and HFG is exploring and providing provincial funds in the nine estimates for donors’ engagement in funding provinces where HFG is premiums and copayments in the future. currently working, to So far, some achievements regarding the subsidize PLHIVs’ SHI allocation of provincial funds, in the nine premiums and copayments. provinces where HFG is currently working to subsidize PLHIV’s SHI premiums and co- payments, include: • Hai Phong province: Hai Phong Provincial People’s Committee has decided to allocate 20 percent of the surplus of the SHI 2015 fund (VND 1,936,764,137) to buy HI cards for several groups, including 1,869 HIV patients currently not insured (Decision No 102/QÄ-UBND). • Hoa Binh province: Hoa Binh Provincial People Committee signed the decision No 3352/QÄ-UBND to allocate VND 244,372,000 from local funds to PSS to support 100 percent SHI coverage for PLHIV. • Can tho province: Provincial People Council’s Resolution committed to allocate local funds to support 100 percent SHI coverage for PLHIV with permanent residence in Can Tho. In addition, USAID/HFG also mobilized a national consultant to work with local authorities to advocate for the increased funding to support PLHIV and increase the coverage of SHI for PLHIV.
5. FIELD SUPPORT ACTIVITIES: VIETNAM - 209
5.3 Eastern Europe and Eurasia 5.3.1 Eastern Europe and Eurasia Bureau Program Objectives - The E&E Bureau activity will end in December 2016, at the end of Y5Q1. Thus, the Year 5 objectives focus on official launch and handover of the online NGO networking platform; final coaching for NGOs; and final monitoring and evaluation, including an endline capacity assessment of participating NGOs. Year 5 Activities - In the final quarter (Y5Q1) of implementation of this activity, HFG will continue to provide capacity development support and technical oversight to Business Support Center, LLC (BSC) and UNAG on provision of coaching to participating NGOs and on finalization of the online platform. Through subrecipient BSC, based in Armenia, and their lower-tier subrecipient UNAG in Georgia, local NGOs based in the three South Caucasus countries (Armenia, Azerbaijan, and Georgia) will continue to receive tailored coaching/mentoring from the subrecipients. This support will address funding mobilization and financial management: internal management and governance; advocacy and constituency building; and networking, partnerships, and external relations. Additionally, BSC will work with the local participating NGOs to finalize the online NGO networking platform launched in Year 4, to allow local NGOs to network and exchange information, and will hand the platform over to the local NGOs. Year 5 Progress against Objectives - During this final quarter of implementation of the E&E Bureau activity, HFG subrecipient BSC in Armenia and its subcontractor UNAG in Georgia completed the coaching sessions in the five component areas (Resource Mobilization; Financial Management; Internal Management & Governance; Advocacy and Constituency Building; Networking and Partnership) for the 15 NGOs across the three countries. Following the training and coaching sessions, the NGOs exhibited improvements in all of the training areas. A post-assessment of capacity of the NGOs demonstrated improvements as follows:
Average 30 percent increase across all 15 organizations in scores across the five component areas.
The resource mobilization and financial management components saw the greatest improvement, at 31 percent and 29 percent respectively.
The networking and partnership component saw the smallest improvement, at 14 percent across organizations.
Fourteen out of the 15 organizations reported improvements in at least four out of the five components. By way of context, it is worth noting that the overall scores for the NGOs remain relatively low, averaging 2.7 on a scale of 0 to 5. This is not surprising, given that the NGOs selected for participation in this program are not the strongest organizations in the region, but are organizations that are active in HIV-related areas, were identified as having a lot to learn from the training and coaching, and had enough capacity to learn from the training. Still, over the relatively short implementation period of this activity (10-month subaward implementation period), the improvements the NGOs saw in their own capacity is notable. Anecdotal reports from the NGOs demonstrate they feel they have gained significantly from the training and coaching, and they are appreciative of the tailored approach provided through this activity.
210 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.3.2 Ukraine Program Objectives – HFG Ukraine works to develop a new TB hospital payment system (Diagnosis- Related Group (DRGs)) for Ukraine based on data from HFG supported regions-Poltava Oblast, Odessa Oblast, Kyiv City, and Lviv Oblast-including TB case groups and relative payment weights. Objectives include:
Contribute to development of legal and Public Financial Management (PFM) changes required for implementation, including budget formation, operating systems, funds flow, and facility autonomy.
Establish linkages with broader national health financing reforms, and other USAID and development partner projects, to create synergies and an enabling environment for implementation of the new TB hospital payment system.
Create the required database for TB case group and relative weight analysis, combining TB clinical information and cost accounting information, and develop and institutionalize a simulation model for use in creating TB case groups and relative weights. The simulation model will allow comparison of payments to each TB hospital under the old and new TB hospital payment systems to assess impact, determine winners and losers, and contribute to the development of implementation and transition plans. It will also contribute to the development of plans for TB hospital restructuring required to create savings for reinvestment into TB outpatient services.
Establish a participatory process for new TB hospital payment system development, and preparation for implementation, to build capacity, institutionalize methodology, and link to national reforms. Year 5 Activities - To date, the HFG project has carried out subactivities 1-4 in Ukraine, with a focus on Poltava Oblast. Building on Year 4 work, including expansion of the Poltava pilot to three additional regions in Y4Q4-Odessa Oblast, Kyiv City, and Lviv Oblast-in Year 5, HFG will continue working in these pilot regions on the development of TB strategic purchasing instruments, and engage in policy dialogue at the national level on overall health reforms. Year 5 activities are organized as follows:
Improve and rationalize information system at oblast level, including creation of discharged patient database at each TB hospital, and generating analyzable data to monitor TB provider performance.
Build capacity of TB providers and regional health authorities in cost accounting and supporting facility-level cost accounting analysis in all TB hospitals of pilot regions.
Design and develop strategic purchasing instruments in TB, including TB DRGs module and the supporting systems to simulate and monitor provider responses to the new payment system.
Support policy dialogue and create linkages between improving purchasing of TB services and the broader national health financing reforms. Year 5 Progress against Objectives - Improving Hospital Information Systems-discharged patients' database. HFG continued working in pilot oblasts to support roll-out of the discharged patients' database in TB hospitals. By the end of December 2016, all 28 TB hospitals in HFG's four pilot regions had introduced, and were maintaining, the discharged patients' database. The discharged patient system has been fully introduced in all TB hospitals in Poltava Oblast and Kiev City; includes information on discharged patients for the 2014-2016 period; and is in the process of being rolled out in the additional two pilot areas. Odessa Oblast has continued rolling out the system, toward inclusion of all six TB hospitals in that oblast by January 2017. In October 2016, HFG conducted a practical training for TB hospitals in Lviv Oblast and installed the discharged patient entry system in nine TB hospitals to start the data collection process. HFG analyzed more than 25,000 cases of discharged patients from three pilot regions (Poltava, Kiev, Odessa) using a standard set of indicators, and presented results of the
5. FIELD SUPPORT ACTIVITIES: UKRAINE - 211 analysis to the regional health authorities and at the national DRG workshop in November 2016.
At the request of Kiev City Administration, HFG prepared a comprehensive analysis of TB hospital performance using the discharged patient and cost accounting data, and presented the results to the Kiev City Health Department in November. The data reveal a big difference among hospitals in both cost per case and average length of stay, both on average and for selected conditions; high level of avoidable and repeated hospitalization; low level of bed occupancy; and other inefficiencies. All these factors confirm the excess capacity of TB hospitals, the poor performance of current TB inpatient care, and a need for further optimization. Following the analysis, in late November, HFG and the Kiev City Health Department conducted a joint round table for the management teams from five TB hospitals to present the preliminary results of TB hospitals' performance analysis.
In Q2 Y5, HFG continued to support pilot regions in improving TB hospitals' information systems and their use of data for performance monitoring. Discharged patients' data collection is institutionalized and fully functioning in all TB hospitals in Poltava, Odessa, and Lviv Oblasts, and Kyiv City. The database includes detailed information on 37,000 discharged patients from 30 TB hospitals in pilot regions during the period 2014-2016 and the first quarter of 2017. Using these data, HFG conducted a comprehensive analysis of TB hospital admission for each pilot region and presented results of this analysis to the regional authorities and at the National End TB Conference on March 28-29, 2017.
Implementing facility-level cost accounting. During Y5Q1, HFG completed the roll-out of the cost accounting system in Lviv Oblast. By the end of December 2016, all new pilot regions including Kiev City, Odessa Oblast, and Lviv Oblast had introduced the cost accounting system in all TB hospitals, and had conducted a round of cost accounting analysis based on 2015 actual budget data. HFG presented the results of the cost accounting analysis and discussed them with the Kiev City Health Department and all TB hospitals in November. In December, HFG met with representatives from the Odessa Health Department to share initial analysis and discuss data quality issues in implementing a cost accounting study in Odessa Oblast. TB hospitals in Lviv Oblast completed data collection and started data analysis with support from the HFG team.
In Q2Y5, HFG conducted refresh training on cost accounting for economists and statisticians of all TB hospitals in four pilot regions and supported a second round of cost accounting analysis based on 2016 actual budget and statistical data. Thirty TB hospitals completed the data collection process, and, with HFG technical expertise, conducted an initial data analysis. Initial results were presented and discussed with TB hospitals and health authorities in each region.
Developing TB DRGs and supporting systems. To support the implementation of new payment systems and the planned introduction of a Health Purchaser in Ukraine, HFG continued working on the development of an analytical model to develop TB DRGs and simulate potential risks and monitor provider response to the new TB DRG system.
HFG worked closely with the Poltava Health Department to select key performance indicators (KPI) and define the process to monitor TB hospital performance. Based on the discussion, HFG developed an analytical module within the discharged patients' database that produces standard dashboards with KPI and quarterly performance reports for each TB hospital. HFG presented monitoring reports for three-quarters of the calendar year 2016 to the Poltava Health Department for further discussion with TB hospitals.
HFG worked on developing a simulation model for TB hospital optimization. The model allows simulation of a possible impact on bed needs and budget, using different scenarios, such as reduction in average length of stay for specific conditions, avoidable hospitalization, readmission, and other relevant factors. The model will help health authorities to estimate an appropriate level for TB admission and potential savings as a result of TB hospital restructuring.
212 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Additionally, the HFG team began discussion with the Global Fund, WHO/Euro, and the regional TB-REP Project on use of the HFG-developed simulation model in preparation of new TB admission criteria and TB bed norms to be developed by TB-REP and WHO. TB-REP is funded by the Global Fund and implemented by WHO/Euro in 11 countries of the former Soviet Union.
In Q2Y5, HFG worked closely with Poltava, Kyiv, and Odessa health authorities to introduce the TB hospital performance monitoring system; developed interactive dashboards on key performance indicators at the system level; and produced monitoring reports for individual TB hospitals based on 2016 data. The individual performance reports include information and trends in key performance indicators and provider benchmarking to help TB hospitals understand where their performance falls in comparison to others'.
HFG refined a simulation model for multivariate analysis of TB hospitals performance and TB hospital optimization, and presented the updated model for health authorities in pilot regions and at the National End TB Conference in March 2017.
Supporting policy dialogue. The HFG team continued to engage in dialogue with the MOH on both TB purchasing improvement and broader health financing reforms, and continued to collaborate with the World Bank, WHO, and other USAID-supported projects on health financing policies and development of improved health purchasing mechanisms including general DRGs. On November 28- 29, 2016, HFG together with the World Bank conducted a two-day national workshop for health authorities from all regions of the country, titled "What are DRGs and why implement them in Ukraine?" HFG shared international experience in implementing DRGs and lessons learned from the countries, and presented HFG work in developing the TB-DRG model for Ukraine.
Following the DRG workshop, Deputy Minister of Health Pavlo Kovtanyuk requested a separate meeting with HFG. At the meeting, HFG presented its current work on strengthening TB strategic purchasing in Ukraine and discussed general health financing reforms in Ukraine. Kovtanyuk expressed strong interest in HFG's health financing work and in further HFG support in replication of the technical instruments, such as cost accounting and discharged patient analysis, for general hospitals. Kovtanyuk asked the USAID mission in Ukraine for support in the implementation of general health financing reforms, particularly for the introduction of facility-level cost accounting systems and discharged patient analytical models developed by HFG to general hospitals around the country in the coming year.
In Q2Y5, HFG team followed up with the Deputy Minister of Health, Pavlo Kovtanuyk, and finalized an SOW for possible HFG support of broader health financing reforms and developing strategic purchasing instruments. HFG discussed a technical proposal with the USAID/Ukraine mission and received approval to extend the HFG program in Ukraine in strategic health purchasing.
At the request of National Public Health Center, HFG participated in the National END TB Conference and presented results of HFG support to improve strategic purchasing in TB. The conference took place on March 28-29, 2017 with participation of health authorities and TB specialists from all regions of the country.
USAID/Ukraine agreed to support the MOH in overall health financing reforms and strategic health purchasing, and allocated additional 1.7 minutes to extend HFG program in Ukraine. A new HFG - Ukraine Strategic Health Purchasing Activity will focus on:
Adaptation of an international-standard cost accounting system to Ukrainian conditions.
Supporting implementation of cost accounting and hospitals performance systems in the pilot region, and further national roll-out.
Development of the MOH and Agency's capacity to fulfill the functions of a strategic purchaser in the health system.
5. FIELD SUPPORT ACTIVITIES: UKRAINE - 213 Development of practical recommendations to adapt the DRG system to the conditions of Ukraine and to prepare the regional (oblast) health systems to use the new payment system. Table 46 provides additional activity-specific updates. TABLE 46. UKRAINE ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Design and develop DRG payment system for TB hospitals in four geographic regions of Ukraine. Poltava— Undertake facility-level cost accounting analysis and capacity building to support the development of TB DRGs. Calculate the facility level cost HFG worked with eight TB hospitals in HFG will complete cost accounting per case and other parameters Poltava to complete data collection for cost analysis and present results to agreed upon in the context of accounting analysis based on 2016 actual Poltava health authorities and TB clinical departments in budget and statistical data. The database hospitals next quarter. accordance with the step-down analysis is in process. cost accounting methodology. Poltava Oblast—Create a hospital discharge database from existing health information systems to support the development of TB DRGs and further strengthen health information systems for TB at the oblast level. Develop and keep up date Discharged patients’ data collection is HFG will continue to provide database at the level of the institutionalized in all TB hospitals in Poltava support in keeping the discharged Poltava Oblast Department of region. On March 20, 2017, the database patients database up to date at Health for TB hospital included detailed information on 10,864 oblast level. discharge data that includes treated patients in analyzable format. relevant clinical information. HFG conducted data analysis on main performance indicators based on 2016 data, updated operational dashboards for Poltava, and used data for a comprehensive analysis in four pilot regions. Using discharged patients HFG produced TB hospital performance HFG will support the Poltava health database, produce quarterly monitoring reports for four quarters of the department and produce a reports on TB hospitalization calendar year 2016, and presented it to monitoring report for the first structure for TB providers and Oblast health authorities in February 2017. quarter of the calendar year 2017. oblast health authorities. Odessa Oblast, Kyiv City, and Lviv Oblast Initiate policy dialogue at oblast Activity completed in Q1Y5. level to assess existing costing systems, adapt the systems to the cost accounting standards agreed for DRG development, and discuss findings of cost accounting analysis.
214 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Install cost accounting Cost accounting data collection was HFG will work with the MOH electronic tool and form cost conducted and the data analysis instrument Medical Statistic Center to accounting database .based on was installed in each TB hospital in the consolidate cost accounting data 2015 and 2016 data. previous period. from four pilot oblasts. On January 31, HFG team conducted a roundtable at the Kyiv City Health Department to present the results of an extended version of the cost accounting analysis including information on sources of TB drug funding (GF, MOH centralized procurement, city budget, current hospital budget). The results also were presented and discussed with TB hospitals on February 1, 2017. On February 2, HFG conducted a workshop for representatives of all TB hospitals in Odessa Oblast, and presented results for cost accounting analysis based on 2015 budget data. On February 23, 2017, HFG conducted a workshop for Lviv TB hospitals to present results of cost accounting study. New regions: calculate the In February 2017, HFG conducted refresher HFG will work with each oblast to facility- level cost per case and training on cost accounting for economists complete analysis and present other parameters agreed upon and statisticians from TB hospitals in Kyiv results of the second round of cost in the context of clinical City, Odessa, and Lviv Oblast. accounting analysis. departments in accordance All TB hospitals from four pilot regions with the step-down cost completed data collection for the second accounting methodology. round of cost accounting analysis based on 2016 budget and statistical data. Odessa Oblast, Kyiv City, and Lviv Oblast—Create a hospital discharge database from existing health information systems to support the development of TB DRGs and further strengthen health information systems for TB at the oblast level. Conduct policy dialogue at Ongoing: HFG continued policy dialogue oblast level on improving IS in through a quarterly meeting conducted with TB and using data for evidence- health authorities in each pilot region: Kiev based decisionmaking. City on January 31; Odessa on February 2; Lviv on February 23; Poltava on March 17 and 29, 2017. Conduct rapid assessment at Completed in all pilot regions in previous oblast/city level on types of period. existing IS, current capacities, and gaps in using IS at TB provider and oblast/city level.
5. FIELD SUPPORT ACTIVITIES: UKRAINE - 215 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Provide training on standards Completed in all pilot regions. and IS using for discharged patients reporting for statisticians and selected medical staff from health departments and TB hospitals Prepare and install the An electronic system for entering discharged HFG will work with Kyiv City and software in TB dispensaries in patients’ data was installed in all TB hospitals. Odessa Oblast health authorities to new regions and provide work Procurement of computers for TB hospitals complete procurement process. stations for data entry on in Kyiv City and Odesa Oblast is in progress. discharged patients. Develop a database at the The discharged patient database is fully HFG will work with each oblast to oblast level for TB hospital functioning in all TB hospitals in four pilot complete multivariate analysis of TB discharge data (form 66) that regions and includes information on ~ 37,000 hospitalization structure. includes relevant clinical discharged patients: information. • Poltava: 10,864 cases from eight TB hospitals • Kyiv City: 5,714 cases from five TB hospitals • Odessa: 10,444 cases from six TB hospitals • Lviv: 9,972 cases from 11 TB hospitals Using discharged patients TB hospital performance monitoring reports In Q3, HFG will prepare TB database, produce quarterly for 2016 were produced for all TB providers hospitals performance monitoring reports on monitoring TB in Kyiv City, Poltava, and Odessa Oblasts. reports for the first quarter of 2017 hospitalization structure for TB Operational dashboards for oblast/city health for Poltava Oblast, Kiev City, and providers and oblast health authorities were updated and discussed in Odessa Oblast, and produce authorities. each region. reports based on 2016 and the first quarter of 2017 for TB hospitals in Lviv Oblast. National level Continuously liaise with MOH HFG conducted a series of meetings with the and partners on cost Deputy Minister of Health, Pavlo Kovtanuyk, accounting and hospital on February 3 and March 28, 2017, to follow discharge database to enable up on overall health financing reforms and implementation and harmonize supporting establishment of strategic health oblast and national health purchasing in Ukraine financing reforms. HFG conducted a series of meetings with WB to coordinate development and implementation of DRG payment system. Develop recommendations on HFG refined the monitoring instrument and HFG will work with health development and operational dashboards and supported authorities to introduce the TB implementation of TB scaling up of the system to Kyiv City and hospital monitoring system (KPI hospitalization monitoring Odessa Oblast. dashboards) in Lviv Oblast. system for each oblast health department.
216 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Combine cost accounting data HFG supported the second round of cost HFG will work with the MOH to from Poltava, Odessa, Lviv accounting analysis based on actual 2016 define housing for costing data and Oblasts, and Kyiv City to budget and statistical data in four pilot use database for TB/DRG estimate average costs for TB regions. HFG conducted an assessment of development. cases using for TB-DRG costing data from all TB hospitals to ensure development. data standardization and quality requirements and combined data from all pilot regions. Calculate average cost per TB Planned for Q3. case by agreed categories to be used for national TB-DRG system. Combine discharged patient HFG worked with the MOH Medical HFG will work with health databases from Poltava, Statistics Center to combine discharged authorities from pilot regions to Odessa, Lviv Oblast, and Kyiv patients’ data from all TB hospitals in four continue data analysis for City for further analytical work regions. developing TB-DRG module. HFG analyzed 36,994 cases of discharged patients from 30 TB hospitals in pilot regions and presented results at the National TB Conference on March 29, 2017. Define clinical hierarchy and HFG finalized clinical hierarchy for TB develop clinical groups using grouping for further development of TB- combined database. DRG module. Create analytical model to HFG developed a prototype of the HFG will work with key national develop TB DRG classification simulation model. experts at national level and pilot and relative payment rates regions on TB-DRG modeling. (includes combining clinical and cost accounting data to attach cost to each case). Clinical and financial specialists Planned for Q3. conduct iteration of options to reach final TB DRG classification and relative payment rates using data from Poltava, Odessa, Lviv, and Kyiv. Create simulation model and HFG refined a simulation model for TB HFG will continue working with simulating impact for each hospitals optimization using different national counterparts and oblast. scenarios for TB hospital admission criteria collaborate with international and bed optimization. Updated model was organizations on further presented and discussed with pilot regions refinements. and presented at the National TB Conference on March 29, 2017.
5. FIELD SUPPORT ACTIVITIES: UKRAINE - 217 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 2: Coordinate, leverage, and create synergies between oblast- and national-level health financing reforms, disseminate TB DRG methodology at national level, and support replication of Poltava Oblast strategic TB purchasing and TB DRGs in another oblast. Coordinate, leverage, and Ongoing: HFG participated in the policy HFG will start new program create synergies between dialogue at the national level on overall implementation and provide national and oblast health health financing and establishment of Health extensive technical assistance to system and financing reforms. Purchaser in Ukraine. the MOH in rolling out cost HFG finalized technical SOW for expanding accounting and discharged patients HFG technical assistance to support the systems in general hospitals. MOH in improving strategic health purchasing. Develop recommendations to Planned for Q3–Q4. improve TB purchasing system at oblast level including TB DRGs, accompanying changes in budget formation, funds flow and facility autonomy and implementation steps Prepare a technical document Planned for Q3–Q4. describing step-by-step development of TB DRG and share with the MOH and World Bank. Document and disseminate Planned for Q3–Q4. strategic TB purchasing methodologies to national level and other oblasts.
218 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.4 Latin America and Caribbean 5.4.1 Dominican Republic Program Objectives - HFG’s overall objective is to contribute to the Government of the Dominican Republic’s goal of strengthening health systems to address the health needs of the population, and in particular to contribute to the GODR’s response to the HIV epidemic through a coherent and comprehensive HIV financial sustainability strategy. Year 5 Activities - HFG's work in Year 5 of the project will consist of one activity: Support the development of a comprehensive HIV and AIDS financial sustainability strategy. This activity is composed of five subactivities:
Subactivity 1.1: Comprehensive HIV Financing Gap Analysis.: The first phase of work will focus on the development of a comprehensive HIV financing gap analysis. Drawing upon recent analyses that have been conducted, including the costing of the National Strategic Plan, the financing gap analysis will measure: (1) the gap between resource needs and availability and (2) the financial resources necessary to address the epidemic over the medium term, including different investment scenarios.
Subactivity 1.2: Update the HIV Investment Case. USAID has asked HFG to finance and coordinate an update of the Dominican Republic's HIV Investment Case. The update will include adding an additional scenario that models the resources needed and infections averted by the adoption of the “Test and Start” strategy. The results of the updated investment case will be used alongside the gap analysis to determine the quantity of resources needed to pursue different epidemic control strategies.
Subactivity 1.3: Opportunities for Improving Efficiency. The next phase of the activity will identify and explore various policy options for mobilizing the resources identified through the gap analysis. Based on an extensive desk review and on key informant interviews in country, HFG will draft a document highlighting opportunities for improving the efficiency of the Dominican Republic's response to HIV and AIDS. HFG will work with UNAIDS to facilitate a workshop where various stakeholders will discuss, and reach consensus on, a short list of priority interventions for improving efficiency.
Subactivity 1.4: New Sources of Revenue.During this phase of the activity, HFG will assist the sustainability group to analyze options for new sources of revenue to finance the HIV response, including increases in existing “sin taxes,” potential financing options. HFG will estimate potential revenue generated from these and other sources for the HIV response.
Subactivity 1.5: Sustainability Strategy Development and Consensus-Building. During the final phase of the activity, HFG will consolidate findings from the prior subactivities and conduct further analysis of selected priority financing options identified by the sustainability group. HFG will prepare a draft comprehensive sustainability strategy and coordinate with UNAIDS to facilitate discussion with, feedback from and consensus-building with the technical working group. The final strategy will outline agreed-upon resource mobilization options to finance the GODR’s HIV response and to improve efficiency.
5. FIELD SUPPORT ACTIVITIES: DOMINICAN REPUBLIC - 219 Year 5 Progress against Objectives - In the first two quarters of Year 5, HFG completed a scoping trip and stakeholder interviews, completed a Sustainable Financing Initiative scoping trip, hired a consultant to conduct an HIV financing gap analysis, and engaged partner organization Avenir Health to update the HIV/AIDS Investment Case. HFG also assisted UNAIDS to convene an HIV sustainability working group, developed a document highlighting opportunities for improving efficiency of the HIV response in the Dominican Republic, and facilitated a workshop with the sustainability group to prioritize interventions for improving efficiency. Q2 Challenges - HFG experienced delays in identifying a local consultant to conduct the HIV gap analysis. Therefore HFG decided to hold the first workshop with the sustainability group in early March, instead of February as originally planned. HFG also decided the topic of the first workshop would be efficiency, and that the gap analysis results could be disseminated in late April and early May. Table 47 provides additional activity-specific updates. TABLE 47. DOMINICAN REPUBLIC ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity: Support the development of a comprehensive domestic resource mobilization strategy. Efficiency Facilitate consultation meeting HFG, in partnership with UNAIDS, facilitated The results of the prioritization on efficiency. a workshop on improving the efficiency of the exercise served to focus the efforts Dominican Republic's HIV and AIDS response. of various stakeholders on six The workshop was conducted on March 1, interventions that they believe 2017 in Santo Domingo. Approximately 20 should be implemented within one participants attended from government year. The results of the exercise ministries, international organizations, and will be incorporated into the final nonprofit organizations. They listened to HIV and AIDS financial sustainability presentations on technical and allocative strategy. efficiency and participated in a prioritization exercise. Through the exercise, the participants reached consensus on six priority interventions for improving efficiency of the HIV response: 1) improve human resources planning, 2) strengthen HIV treatment guidelines, 3), modernize the procurement of antiretrovirals, 4) improve the switch to second-line ART, 5) improve the implementation of rapid HIV testing, and 6) optimize provision of ART in ambulatory services. Conduct rapid efficiency HFG drafted a brief document that highlights HFG will incorporate any assessment. opportunities for the Dominican Republic to comments into the draft document, improve the efficiency of its HIV and AIDS finalize it, and disseminate the response. The highlighted opportunities were document. based on previous recommendations made to stakeholders in the Dominican Republic and HFG's experience working on improving efficiency in other countries. The document was disseminated during the March 2017 efficiency workshop.
220 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps HIV Financing Gap Analysis HIV Financing Gap Analysis HFG's consultant is currently conducting the HFG will complete the gap analysis financing gap analysis. The consultant has in April 2017 and is planning to collected past expenditure data and disseminate the findings during a expenditure projections from government, joint UNAIDS/HFG workshop civil society, and international funders of HIV tentatively scheduled for early May and AIDS programs in the Dominican 2017. Republic. These data will be used to estimate the resources available for the HIV and AIDS response. The consultant also analyzed cost projections of the Dominican National Strategic Plan for HIV and AIDS to estimate the resources needed to control the epidemic. The consultant is currently finishing the data analysis and preparing the report. HIV Investment Case Update the HIV Investment HFG facilitated a conference call between Avenir Health is expected to Case USAID, UNAIDS, and HFG consortium provide an updated investment case member Avenir Health to discuss the document for the end of April assumptions for adding a “Test and Start” 2017. UNAIDS will hold a meeting scenario to the HIV Investment Case. The with several top decisionmakers to stakeholders agreed on the assumptions and validate the findings. HFG and Avenir Health is currently updating the UNAIDS will jointly host a analysis. dissemination of the updated investment case in early May 2017. New Revenue Sources Develop HIV/AIDS sustainable HFG is in the process of hiring a consultant to HFG expects to complete the financing options paper conduct an analysis of new potential revenue analysis in June 2017 and sources for financing the HIV and AIDS disseminate the findings that month. response, including increases in existing alcohol and tobacco taxes and the enactment of a “sugary beverage” tax. HFG has identified a candidate and is initiating the contracting process.
5. FIELD SUPPORT ACTIVITIES: DOMINICAN REPUBLIC - 221
5.4.2 Eastern and Southern Caribbean Program Objectives - The overall objective of the USAID Eastern and Southern Caribbean field- supported activities is to support Barbados, the Bahamas, Guyana, Suriname, and Trinidad and Tobago in planning, financing, and monitoring a financially sustainable, effective, and efficient HIV response. The activities are designed to support domestic resource mobilization and targeted financing through the institutionalization of data collection systems, as well as the analysis and use of financial data for decisionmaking. In HFG Project Years 4 and 5, this will entail leveraging existing systems and data sources to ensure that countries have strong evidence that speaks both to their advocacy needs and to their planning requirements for sustainable domestic financing of the HIV/AIDS response. HFG will provide targeted technical assistance in line with the USAID Eastern and Southern Caribbean mission's request to ensure that existing and envisaged increases in financial resources are allocated to the most effective activities in the most efficient manner; and they should support a more geographically focused, sustainable response that focuses on key populations. HFG will tailor the approach to each country's specific context. The work plan includes a portfolio of activities that include anticipated PEPFAR Regional Operating Plan FY 2015 funding per mission request. Year 5 Activities - HFG plans to implement activities in five countries plus one regional activity, described as follows:
Bahamas Program: HFG will support implementation of a Sustainability Index Dashboard (SID) exercise, prioritization process, and development of a sustainability plan for the HIV response. As a result of the prioritization process, we expect that the MOH and National HIV/AIDS Center leadership will want HFG to support a public expenditure review for HIV and resource needs analysis, building on the costing exercise currently being finalized by the CDC. As part of this process, HFG will work with the National HIV/AIDS Center to track expenditures on HIV and AIDS, assess current financing sources and levels of funding, and determine where efficiencies may be sought and current donor funding may be replaced by domestic sources. A financial sustainability strategy for improving efficiencies, increasing domestic resources, and monitoring and evaluating spending against targets will also be developed.
Barbados Program: To assist the government of Barbados in sustaining its HIV/AIDS response, HFG will provide guidance to the Barbadian Ministry of Health on health financing technical support options and conduct the SID exercise. In a context of limited resources for HIV/AIDS, identifying cost-effective interventions is critical for the government of Barbados to understand opportunities for efficiency gains at the programmatic policy level. One area that is seen as a promising way forward is the engagement of civil society organizations (CSOs) and other community-level interventions intended to support facility-based testing and treatment services. Data on the cost- effectiveness of these interventions in the Caribbean region is not available. HFG therefore proposes to conduct an economic evaluation of community-level HIV/AIDS interventions to provide the Ministry of Health the data it needs to improve the allocation of its existing resources and to advocate for more funding for these interventions. Lastly, HFG will design and conduct an assessment of the supply chain management systems for HIV-related pharmaceuticals and laboratory commodities in Barbados, with the purpose of identifying opportunities for efficiency gains and cost savings.
Guyana Program: HFG will work with the government of Guyana to update their SID and sustainability plan for the HIV response to ensure that the new costs and program needs associated with the Test and Treat strategy are reflected. HFG will then work with the MOH and relevant national stakeholders to track expenditures on HIV and AIDS, assess current financing sources and levels of funding, and determine where efficiencies may be sought and current donor funding may be replaced by domestic sources through a health accounts exercise.
222 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Suriname Program: HFG proposes to initiate the SID exercise, prioritization process, and development of a sustainability plan for HIV with the MOH and other stakeholders in Suriname. In addition, HFG will conduct an assessment and cost-benefit analysis of supply chain management in Suriname, in support of the country's domestic resource mobilization needs.
Trinidad and Tobago Program: HFG will initiate the SID exercise and prioritization process, followed by a health accounts activity that will be carried out in collaboration with the University of the West Indies -Health Economic Unit (UWI-HEU).
Support for a Regional Sustainable Response: This group of activities includes providing technical oversight of this coordinated regional work plan, including collaboration with regional donors and implementing partners, and presenting and participating in regional meetings and events as needed. HFG will also provide targeted capacity development support to the Pan Caribbean Partnership Against HIV-AIDS (PANCAP) in the area of resource mobilization in order to strengthen the organization as an important resource to the regional response. Year 5 Progress against Objectives - In Trinidad and Tobago the SID and the psychosocial support addition to the SID were finalized and distributed. HFG developed and validated the psychosocial support indicators and assessment method as an add-on to the PEPFAR SID tool. The SID validation meeting was the first time that stakeholders providing psychosocial support have been brought together for this kind of discussion in that country. It is a conversation that will be continued. Since the validation workshop, the Caribbean Public Health Agency (CARPHA) has taken the initiative to provide feedback and to refine the psychosocial support indicators. As CARPHA is an institution supporting public health in 26 countries in the Caribbean, CARPHA's interest in contributing to and owning the process represents a significant step forward in the sustainability of psychosocial support in Trinidad and Tobago and the region.
In Barbados, HFG facilitated the finalization of the SID.
HFG participated in a meeting of PANCAP's Resource Mobilization Advisory group and agreed on a plan of support.
In Barbados and Suriname, HFG developed an HIV supply chain management cost-effectiveness assessment tool and conducted data collection for these SCM efficiency studies in collaboration with the Global Health Supply Chain Management project.
In Guyana, HFG participated in a joint PEPFAR-Global Fund mission to map out technical support needs for the HIV response in light of declining donor funding. HFG developed a scope of work and agreed-upon timetable to conduct a health accounts estimation in that country and to assist transition planning from PEPFAR and Global Fund support. Q2 Challenges - In the Bahamas, early in the quarter, due to sensitivities unrelated to HFG, USAID/Eastern and Southern Caribbean requested that HFG discontinue communication with counterparts in Bahamas until further notice. Thus, activities were not initiated. At the very end of the quarter, USAID/Eastern and Southern Caribbean informed HFG that activities that have not started in the Bahamas should be canceled. Thus, the work plan will be revised to reprogram funds originally allocated to these activities. In Trinidad and Tobago, there was a delay in receiving official approval from the MOH to reallocate UNDP funding to support essential cost-sharing for the health accounts training. This approval was received at the end of Q2, but had the result of delaying the initiation of the SHA estimation by some months. In Barbados, HFG determined during a scoping trip that the economic study of community-based interventions as originally envisioned is not feasible at this time given the lack of data and short implementation time of the activities. This has been communicated to USAID, and
5. FIELD SUPPORT ACTIVITIES: EASTERN AND SOUTHERN CARIBBEAN - 223 other technical support is being considered that could assist the government of Barbados to strengthen its understanding of the value of these interventions. Table 48 provides additional activity-specific updates. TABLE 48. EASTERN AND SOUTHERN CARIBBEAN ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 7: Barbados Program Sustainability Index Dashboard Steve Musau, Activity Lead, travelled to HFG is writing the final SID report development Barbados to assist the MOH to finalize the to send to the MOH for final SID tool and facilitate a half-day meeting with review before sharing with PEPFAR stakeholders to validate the results of the for dissemination. SID assessment and agree on sustainability activities that the ministry can implement to strengthen its HIV/AIDS program. The SID stakeholder workshop was held on March 24, 2017, and was well-attended. The group then reviewed the Dashboard and agreed that it presented a fair view of the reality regarding the sustainability of the HIV program. Economic evaluation of HFG team members met with local Based on discussions with community-level HIV/AIDS stakeholders to agree on the scope of work stakeholders, HFG determined that interventions for a study on the cost- effectiveness of the community interventions have community-level HIV interventions, including started only recently, with no defining the research question and study baseline data available, and design, and to identify data sources. conducting the study as originally envisioned is not feasible at this time. This has been communicated to USAID. HFG will consider other possible economic evaluation activities that may be undertaken with the kind of data that exists, and propose these to USAID and the MOH for consideration. Assessment and cost-benefit Altea Cico, Study Lead, travelled to Barbados Next steps are to finalize data analysis of supply chain to conduct in-country data collection for the collection by talking to the Pan management systems for costing and efficiency assessment of the American Health Organization HIV/AIDS pharmaceuticals and national supply chain for HIV-related (PAHO). laboratory commodities commodities, which was conducted in (PAHO) to understand the exact collaboration with the Global Health Supply cost including delivery to the health Chain-Procurement and Supply Management facility/warehouse if the country project. Preliminary recommendations were chooses to procure ARVs through shared with the MOH (Permanent Secretary) the Strategic Fund. and the Director of the Barbados Drug Conduct data analysis and prepare Service. final report.
224 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 8: Guyana Program Sustainability Plan Updating Abt Consultant Sarah Insanally travelled to Next steps for HFG include: Support Guyana February 26 to March 4, 2017 to 1. Determine scope and participate in a joint PEPFAR-Global Fund timeframe for sustainability mission including meetings with national plan to be developed in government counterparts, the Global Fund, consultation with MOPH and the Health Policy Plus (HP+) project, and Global Fund; USAID/Guyana and USAID/Eastern and Southern Caribbean, to discuss technical 2. Work with partners to assistance that is available from HFG, HP+, determine scope of work for and the Global Fund, and to agree on next economic costing of civil steps. During the visit, the Guyana Ministry society service provision; of Public Health (MOPH) and Guyana Global 3. Consult with HP+ and PEPFAR Fund Country Coordinating Mechanism to ensure coordination and endorsed the proposed HFG technical harmonization of technical assistance to conduct Health Accounts assistance to the extent estimation and develop a sustainability plan. possible. Health Accounts with a focus HFG has developed a scope of work and plan on funding of the HIV/AIDS for Health Accounts in consultation with the Response Planning Unit of the MOPH, National AIDS Programme Secretariat, and PAHO. Began initial planning and implementation steps, including identifying possible prior resource tracking work and training conducted by PAHO, and identifying and coordinating next steps with local counterparts. Activity 9: Suriname Program Assessment and cost-benefit HFG conducted data collection for a costing Follow up with stakeholders to analysis of supply chain and efficiency assessment of Suriname’s collect outstanding data, and finalize management systems for supply chain management systems for HIV- data analysis and report. HIV/AIDS pharmaceuticals and related pharmaceuticals and laboratory laboratory commodities commodities. HFG is collaborating with the Global Health Supply Chain-Procurement and Supply Management on this study. The team worked closely with the National AIDS Program to implement the study, and conducted interviews and collected available data from numerous facilities. The report is currently being drafted.
5. FIELD SUPPORT ACTIVITIES: EASTERN AND SOUTHERN CARIBBEAN - 225 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 10: Trinidad and Tobago Program Health Accounts with focus on HFG worked with UWI-HEU and the The training will be funded using the funding of the HIV/AIDS MOH to begin the health accounts UNDP funds that the MOH needs Response exercise. UWI-HEU facilitated a to re-program to the health Sensitization Meeting with HFG support in accounts exercise. The team was February. HFG created the materials for delayed in organizing the training the upcoming SHA 2011 training, which it while awaiting the MOH to issue will co-lead with UWI-HEU. HFG has also the necessary letter to do this. been working with UWI-HEU to complete certain aspects of the data collection process, such as compiling a census list (which will be used to identify psychosocial support organizations) and obtaining government expenditure data. Activity 11: Support for a Sustainable Regional Response Regional program coordination Participated in LAC-III virtual planning The LAC III meeting, originally and technical leadership meeting held in March and convened by planned for fall 2016, has been UNAIDS. postponed to September 2017 as a result of the 2016 hurricane. The meeting will be held in Haiti. Regional resource mobilization Participated in the PANCAP virtual Advisory Next quarter HFG will provide capacity strengthening through Group meeting held in February. Reviewed PANCAP with a draft updated PANCAP the Advisory Group’s Resource Mobilization resource mobilization strategy. Plan.
226 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.4.3 Haiti Program Objectives - USAID/Haiti asked the HFG project to continue to work closely with the Haitian Ministry of Public Health and Population (Ministère de la Santé Publique et de la Population, MSPP) to strengthen the ministry's capacities in human resources for health (HRH) management, health financing, hospital costing and business planning, and capacity building, enabling it to carry out its role as an effective steward of the health sector. HFG works directly on institutional and technical capacity building, as well as technical implementation support, with five MSPP operational units: Unité d'Appui à la Décentralisation Sanitaire (UADS) (Decentralization Unit), Unité d'Etude et de Programmation (UEP) (Planning and Evaluation Unit, formerly called the UPE), Direction de l'Administration et du Budget (DAB) (Budget and Administration Directorate), Direction des Ressources Humaines (DRH) (Human Resources Directorate), and Direction de Formation et Perfectionnement de Sciences de la Santé (DFPSS) (Training Directorate). In Year 5, this program aims to build technical and institutional capacity in a sustainable fashion across the key MSPP directorates in which HFG works. Year 5 Activities - In Year 5, the HFG project continues to strengthen the institutional and technical capacity of the MSPP to ensure that health financing strategies, human resource management policies and plans, and management and coordination systems can be implemented, monitored, and improved upon in a sustainable and MSPP-led manner through improved governance and accountability of the health sector. These institutional capacity-building efforts are designed to improve core management functions. In addition to the five aforementioned MSPP operational units, HFG works with two other units: Direction de l’Organisation des Services de Santé (DOSS) (Health Services Directorate) and Département Sanitaire de l’Ouest (DSO) (West Geographical Health Department). For technical capacity building, HFG is working with the DRH on developing a national HRH strategy, strengthening the Human Resources Information System (HRIS), and using the HRIS data for planning and decisionmaking, in addition to improving career and performance management processes. HFG supports the DFPSS’s transition to ownership and independent implementation of an “accreditation process,” which consists of effective processes to ensure minimum standards are followed in health pre- service institutions and in-service trainings across Haiti. HFG continues to strengthen MSPP's capacity through the UEP to effectively develop a national health financing strategy, and budget and execution processes, and improved public investment planning and resource tracking, including HIV funding. HFG continues to reinforce the institutional capacity of UEP, DRH, DAB, UADS, DOSS, DSO, and DFPSS to more effectively manage their respective units through leadership and management (L&M) training. HFG provides ongoing support to hospitals across the Haitian health system to cost their health services and better understand how to sustain operations in an increasingly donor-constrained, domestic resource- dependent financial environment. Year 5 Progress against Objectives - HFG continues to support leadership and management development across MSPP: In Q1 HFG and DRH identified professional development needs pertinent to MSPP central- and department-level managers. In collaboration with DRH, HFG developed an eight-session L&M training series approved by USAID/Haiti. In Q1, HFG organized three of the eight training sessions. Building upon training sessions held in the first quarter of Year 5 (Q1), in Q2, HFG continued to provide MSPP staff with skills that they had identified as valuable toward being more-effective managers. Specifically, HFG developed and facilitated four training sessions on leadership and management techniques for MSPP central-, regional-, and facility-level administrators. HFG facilitated a session on Leadership Behavior from February 15 through 18, 2017, and facilitated two training sessions on Fundamental Techniques of Management on March 12–15, 2017 and March 29–31, 2017. HFG also facilitated a repeat session on Advanced Management Techniques on March 26–29, 2017. These HFG training sessions essentially aimed at improving participant competencies such as setting
5. FIELD SUPPORT ACTIVITIES: HAITI - 227 strategic direction, mobilizing coalitions, motivating staff, planning, organizing work, and team- building. To date, 74 MSPP staff members have participated in the L&M management sessions and 24 in the L&M leadership sessions. Training participants have expressed great levels of satisfaction with the trainings and are eager to put into practice what they have learned. The knowledge and skills developed during the trainings will allow participants to be more-effective managers and to improve the quality of services that their units deliver.
HFG technical assistance expands institutionalization of MSPP’s performance management system: In Q2, HFG continued to provide support to the MSPP in scaling up the performance management system, the Systeme d’Evaluation de la Performance (SYSEP). Initially, the activity was intended to cover five units within the MSPP, but two additional directions have asked HFG to extend the system to their sections. Additionally, on March 14, 2017 an orientation workshop was conducted for MSPP units’ leadership about the methodology of the SYSEP.
HFG and DFPSS partner to make the Reconnaissance process sustainable: In Q1, HFG continued to support the DFPSS in the revision and finalization of the “Reconnaissance” tools, including the reference manual of the Reconnaissance process. Additionally, HFG, with the assistance of the Canadian Association of Schools of Nursing (CASN), completed detailed video tutorial materials on information, resources, and strategies necessary for evaluators to carry out their Reconnaissance-associated duties. Also in Q1, the DFPSS conducted 18 additional evaluation visits to nursing institutions. In Q2, HFG supported the DFPSS in institutionalizing the Reconnaissance process. First, HFG accompanied the DFPSS in finalizing a Reconnaissance reference manual that details the full Reconnaissance process and its adopted tools. This manual will be fully available on the website by the end of April. In addition, HFG has supported the DFPSS to develop the DFPSS’s capacity to advocate for resource mobilization, trainings, and expansion of the current Reconnaissance process. In collaboration with HFG, DFPSS has developed an understanding of the estimated cost of maintaining Reconnaissance in future years and begun to identify resources in order to sustain the process. HFG started work with DFPSS to draft a transition plan for the DFPSS’s complete ownership of the Reconnaissance process; HFG plans to help finalize the plan in Q3.
Elaboration of Health Financing Strategy: In Q2, HFG continued to support the development of Haiti’s health financing strategy. HFG worked with the MSPP, World Bank, and PAHO to finalize the health financing strategy draft document, including an analysis of possible health financing options. In addition, HFG participated in the presentation to the Minister of Health and the Director General of the MSPP. As a next step, a consultation plan and timeline with different stakeholders has been validated by the MSPP to generate more buy-in and inputs from civil society, policymakers, and health experts.
HFG builds costing capacity development of MOH’s UEP: In Q1, HFG supported the UEP in completing costing data collection in the remaining (tenth) geographical department of Haiti. Specifically, HFG helped the UEP organize a field visit and facilitate a workshop to gather relevant information in the Nippes geographical department (DSNi). In addition, HFG provided technical assistance to the UEP in the data processing and analyses phases of this work. In Q2, HFG continued preparations for a multi-day hospital costing training for UEP and other MOH staff. The training, planned for Q3, will utilize real on- the-ground data from the four hospital costing exercises already completed by HFG in Haiti. To set the foundation for this training, the HFG is currently collaborating with UEP staff on the costing of Justinian University Hospital (JUH) in Cap Haitian. In consultation with the administrative leadership of the JUH, HFG launched the data collection
228 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
process in January with a workshop attended by 28 JUH employees. The launch workshop facilitated shared understanding among staff of the importance of the costing activity and staff buy-in for the costing activity processes. In addition to participating in the launch workshop and data collection, the UEP staff members were engaged in inventory/equipment data collection and plans for data cleaning and data analysis. As a result of this work Justinian hospital staff have also expressed interest in the training.
HFG strengthening hospital financial reporting: HFG continued to support the revision of training materials on hospital financial reporting processes, including completing revisions to some of the training materials. HFG also assisted in drafting the mandate and role of the technical committee for the MSPP Director General’s signature, expected before the end of Q2. This will provide an official recognition of the committee and its assignment. HFG assisted in the execution of a three- day workshop held the first week of February. During the workshop, tools for the hospital financial reporting processes were reviewed and a subset was validated. The MSPP has requested HFG’s support in procuring an electronic cashier for better financial reporting and resources tracking. Q2 Challenges - During Q2, HFG faced challenges from staffing availability in some MSPP units and reluctance on the part of some units’ leadership to move forward on activities before the swearing-in of the new government. Q2 Additional Information - From February 19 to 23, 2017, HFG Project Director Bob Fryatt and HFG Haiti Country Manager Lisa Nichols visited Haiti to better understand the current context of the health sector and how HFG can best support the MSPP in Year 6. Table 49 provides activity-specific updates. TABLE 49. HAITI ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 1: Strengthening the DRH Capacity to Manage the Health Workforce Support DRH in the Pending: Continuation of the process is The re-launch of the draft training implementation of the draft contingent upon DFPSS feedback. HFG plan process did not occur due to Process for the Development of a had developed the draft plan in Year 4. the scheduling constraints of the Training Plan (provided to MSPP key DFPSS stakeholders. by Office de Management et des Ressources Humaines). Complete ERHIS-2. Complete: The final ERHIS-2 report was Dissemination of the final ERHIS-2 finalized and presented to the MSPP’s report is contingent upon the Director General on February 23, installation of the multisectoral 2017. Both English and French versions steering committee toward the of the ERHIS-2 abstract were also development of the HRH Strategy submitted to USAID/Haiti. 2017/22 (CMP). The CMP installation is likely to occur in May following the installation of the new Minister of Health. Conduct data quality control DRH’s Q1 review process was postponed In Q3, HFG will support the DRH’s through quarterly review. because of transition within the MSPP. Q1 and Q2 reviews, which are scheduled to be conducted simultaneously on April 25–29, 2017.
5. FIELD SUPPORT ACTIVITIES: HAITI - 229 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Assist DRH to conduct field The supervision activity in the South supervision visits in geographical geographical department (Direction departments. Sanitaire du Sud) has been postponed to Q3. Conduct a situational analysis for HFG has completed a first draft of the The final version of the situational the development of HRH Strategy situational analysis for HRH. This draft analysis is expected to be ready by using the results of ERHIS-1 and will be reviewed and edited by the the end of Q3, pending installation ERHIS-2. relevant technical working groups of the of the CMP. The installation of the CMP. CMP scheduled for the end of January was postponed to early May due to the new government transition. Develop and implement training HFG organized and facilitated four L&M HFG will conduct the last session of plan for L&M skill building within training sessions in Q2: two training the L&M training series in Q3, MSPP. sessions on fundamental techniques of tentatively scheduled for April 24– management, one on advanced 28, 2017. management techniques, and one on leadership behavior. Develop HRIS Management Re-planned for Q3. training materials. Facilitate the development of a Contingent upon the installation of comprehensive, national HRH the CMP and the availability of the strategy for HRH development. situational analysis expected by the end of Q3, the HRH strategy development process will be launched and facilitated by HFG in collaboration with the DRH, the CMP, and international donors. HFG aims to complete the HRH strategy by the end of September 2017. Assist with the development of This activity is contingent upon the costed HRH operational plan. completion of the HRH strategic plan. Conduct training of trainers Re-planned for Q3. workshops for DRH on HRIS management, including HRH data quality control. Activity 2: Support the MSPP/DRH in Developing an HRH Performance Management System and Institutionalizing Civil Service Reform Continue to support MSPP The technical expert that will lead personnel orientation sessions to the development of the national strengthen the skills of care nursing care protocol has not yet providers. been hired.
230 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Complete the revision of HRH Re-planned for Q3. This activity depends upon the employment and competencies completion of the MSPP job index. description revision process through SYSEP as well as the career plan for HRH currently in development. Support MSPP in scaling up the In progress: HFG has supported MSPP HFG will continue to assist the performance management system. and its three elected champions in DFPSS in institutionalizing the extending the performance management SYSEP process by validating system to seven MSPP units (DPM, DOSS, reference tools and evaluation UEP, CAN, DPEV, DSF, and DSI). HFG guidelines including an organized and facilitated an orientation organizational chart, job workshop for the head of each direction descriptions, and employees’ on the SYSEP methodology from March performance goals. This 14-17, 2017. institutionalization support will occur through a two-day workshop from April 6-7, 2017. In addition, a mid-term evaluation of the SYSEP is scheduled to take place from April 17–21, 2017 in the North- East Department. Finalize the development of This will start in Q3. The development of performance- performance-specific indicators specific indicators will occur in Q3 tools for doctors, nurses, and following the completion of the midwives, based on the package of career development plan for the essential services. health care workforce and the development of HRH allocation standards for health care institutions. Finalize the strategy and plan for HFG continues to support progress in the HFG will support a validation career development for the health development of the strategy and plan for workshop for the draft career care workforce. career development for the health care profile once the CMP is installed. A workforce. HFG facilitated the fifth final draft of the strategy and plan technical working group session, which for career development for the occurred on January 19–20, 2017. This health care workforce will follow. work was followed by a workshop on the definition of a health care workforce mobility card, held from January 29 through February 1, 2017. Finalize the development of an This was re-planned to start in Q3 with a HRH rural retention plan. survey on motivating factors of health care workers.
5. FIELD SUPPORT ACTIVITIES: HAITI - 231 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Develop HRH allocation in the HFG has supported the development of HFG will next support the public sector based on the PES HRH allocation standards in the public development of targets for the norms. sector based on the PES norms through quantitative indicators that were two workshops: a launch workshop held defined in Q2. on February 2–4, 2017 and a workshop to define quantitative variables and performance indicators on March 6–10, 2017. Develop DRH standard operating HFG drafted a TOR to develop DRH DRH standard operating procedures manuals. standard operating procedures manuals. procedures manuals will be developed in Q3. Organize a workshop for the final This was re-planned for Q3. review of implementation of the SYSEP. Develop MSPP plan for scaling up This was re-planned for Q3. SYSEP. Support DRH in promoting health This event is scheduled to occur in Year 6 With the recently announced HFG workforce valorization, including (November 2017). extension into a sixth year, HFG the participation of two DRH will follow up with USAID/Haiti and managers at the 4th HRH Global the MSPP on planning this activity. Forum. Activity 3: Support Reconnaissance Activity Train the DFPSS and nursing HFG continued to work with CASN, the The website revision will be educational institutions on the MSPP’s CIFAS (Le Centre d’Information et finalized by end of April, after which improved online management of de Formation en Administration de la Santé HFG will collaborate with CIFAS to the Reconnaissance system. or the Health Administration Information support two training sessions for and Training Center), and the DFPSS to DFPSS staff and other key MSPP update the online management of the staff, to enhance their skills and Reconnaissance system. enable them to use the revised website for the reconnaissance process. Build capacity of DFPSS and MSPP HFG conducted a workshop to support The tools revision process will be evaluators in using the on-site the institutionalization of the completed by early Q3. school evaluation process. Reconnaissance process at DFPSS with CASN on January 10-12, 2017. Assist DFPSS staff to update the HFG finalized the Reconnaissance video In Q3, HFG will organize a DFPSS orientation process for new tutorial and integrated it into the staff training session on the use of evaluators. Reconnaissance website. The video the video tutorial. tutorial will help orient new evaluators and heads of health training institutions. Finalize video tutorials for the HFG completed the final validation of the DFPSS accreditation website. video training tutorials during the January 2017 Reconnaissance workshop. HFG, CASN, and the DFPSS have finalized the video tutorials and integrated them into the Reconnaissance website.
232 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Conduct the final review of the HFG conducted the final review of the pilot phase of the Reconnaissance Reconnaissance process pilot phase process. during the January 2017 Reconnaissance workshop. Update for MSPP a reference HFG continued to support the DFPSS in The Reference Manual will be made document on the Reconnaissance finalizing the Reference Manual that available on the Reconnaissance process (objectives, planned details the full Reconnaissance process website in Q3. results, how to use results). and adopted tools. Organize a validation workshop of HFG, CASN, and the DFPSS validated the the revised tools and process. suggested revisions to the Reconnaissance tools and process during the workshop in January 2017. Complete evaluation of Phase 2 During Q2, HFG supported the DFPSS Q2 was marked by the same training nursing institutions evaluation team in conducting three new difficulties encountered by the through the Reconnaissance visits and 24 re-evaluation visits. In DFPSS months before and that have process (visit). addition, 10 institutions were granted the still impeded execution of the Reconnaissance status. planned number of evaluation visits. These include: (1) the limited number of evaluators in charge of conducting evaluations; and (2) DFPSS’s competing priorities such as managing state exams and developing plans for internship/residency placement. Develop DFPSS capacity to As part of its transition of Reconnaissance HFG will continue to work closely advocate for resources work to the DFPSS, HFG worked with with the DFPSS on developing the mobilization, trainings, and the DFPSS to finalize estimates of the Reconnaissance transition plan, expansion of the current average costs to maintain the expected to be finalized in Q3. Reconnaissance process. Reconnaissance process. Conduct data collection/analysis to Planned for Q3. better understand impact of Reconnaissance process. Develop Reconnaissance logo for HFG worked closely with the DPM/MT HFG aims to complete this process DPM’s Reconnaissance pharmacy to develop and transmit their awaited in Q3, contingent upon the process. specifications on the Reconnaissance availability and input of key MSPP pharmacy logo of their choosing. stakeholders. HFG launched the procurement process for 300 Reconnaissance pharmacy logos.
5. FIELD SUPPORT ACTIVITIES: HAITI - 233 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 4: Support Implementation of Health Financing Strategy and Build Capacity in Resource Mobilization Finalize the draft strategy HFG helped finalize the first draft of the HFG will support the completion of document. health financing strategy document. In the health financing strategy addition, HFG supported the presentation process through a series of of this document to the Minister of stakeholder consultations in Q3 Health and Director General of the and Q4 (see “Support strategy MSPP. outreach by MSPP/UEP” for more detail). Consolidation and finalization of the Health Financing Strategy is expected by September 2017. Support strategy outreach by HFG continued to support strategy Upcoming sessions and MSPP/UEP. outreach by the MSPP/UEP. HFG has consultations planned: contributed to the process of deciding on Presentation to all MSPP services sessions and consultations to occur in Q3 and directions : April 19–21, 2017 and Q4. Consultation with the public sector and civil society : May 24–26, 2017 Consultation with the private sector and informal sector: June 7- 9, 2017. Workshop on learnings with other countries in the Caribbean region that have developed their Health Financing Strategy: June 28–29, 2017. Consultation session with political stakeholders: July 27–28, 2017. Organize a validation workshop of Re-planned for Q4. Waiting for the Health Financing the health financing strategy. Strategy to be finalized. National validation workshop planned for September 2017. Assist with the development of This will be re-planned for Q1 of Year 6. The launch of this activity will costed operational plan follow the finalization of the health financing strategy, expected by the end of Q4. Strengthen advocacy capacity in This will be re-planned for Q1 of Year 6. The launch of this activity will resource mobilization. follow the finalization of the health financing strategy, expected by the end of Q4. Support health financing strategy This will be re-planned for Q1 of Year 6. The launch of this activity will implementation follow the finalization of the health activities/interventions. financing strategy, expected by the end of Q4.
234 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Set up mechanisms to follow up This will be re-planned for Q1 of Year 6. The launch of this activity will and sustain the momentum of the follow the finalization of the health health financing strategy financing strategy, expected by the implementation. end of Q4. Activity 5: Support MSPP Capacity in Hospital Financial Reporting and PFM System Support training follow-up and Through a workshop in February and HFG will support two additional implementation of hospital other meetings, HFG continued to workshops in Q3: 1) completing financial reporting processes, support the revision of training materials the validation of tools for the including equipment. on hospital financial reporting processes, hospital financial reporting including completing revisions to some of processes; 2) reviewing the hospital the training materials. financial reporting process. HFG also assisted in drafting the mandate Also in Q3, HFG will support the and attribution of the technical training of MSPP accountants and committee for the MSPP Director administrators on (1) the new MEF General’s signature. financial procedures and internal and (2) reporting tools With HFG support, the technical committee is expected to meet in Q3 to conduct a needs assessment of reporting equipment, and will continue to work on the harmonization of reporting tools. Finally, HFG will support the acquisition and implementation of an electronic cashier by the end of Q3. Support DAB with technical This support is contingent upon a The MSPP’s pending decision was expertise on PFM as needed. decision from the top-level management due to the period of government at the MSPP (Haute Instance du MSPP) transition. about their continued interest in this support activity. Support DAB in conducting field Participants took part in the validation HFG will support the DAB’s supervision in selected public process for supervision tools during a supervision visit in Les Cayes, hospitals. workshop held on March 28, 2017. The scheduled to occur April 24–28, TOR for the supervision has also been 2017. HFG will also aid the DAB in finalized and the DAB has selected four producing the supervision visit sites in Les Cayes and Jérémie. report, complete with lessons learned and recommendations. Support data quality control of This has been re-planned for Q3. The launch of this data quality hospitals reporting processes control process will follow the through quarterly review. implementation of harmonized tools (see “Support training follow- up and implementation of hospital financial reporting processes, including equipment”).
5. FIELD SUPPORT ACTIVITIES: HAITI - 235 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity 6: Assist MSPP in Resource Strategic Planning (Target Setting) Complete data collection and Data have been collected for all 10 Finalize data collection for the costing of the Plan Directeur 2012– departments, and 20 out of 23 MSPP three remaining central units. 2022 (remaining part covering the units. Finalize the costing for all the units. subsequent tree-year 2020–2022) HFG completed the first step (costing of The Plan Directeur costing will be using the OHT. activities) for the costing of all 10 available in May. departments for the Plan Directeur. Disseminate the operational This has been re-planned for Q3. Waiting for the draft operational costed plan 2017–2019, part of costed plan 2017–2019 to be the Plan Directeur 2012–2022. completed, before any dissemination. Support costing exercise for This has been re-planned for Q3. The launch of this activity was budgeting the Package of Essential delayed due to lack of UEP staff Services (PES). availability. Activity 7: Assist MSPP in Resource Tracking, including HIV Funding (NHA) Support translation of NHA HFG supported the completion of the HFG will support the completion of results into process and systems NHA 2013–2014 final report using the NHA 2013–2014 in April 2017, improvements. updated SHA 2011 methodology. This followed by the NHA 2013–2014 report included HIV Funding (NHA). publication in May 2017. HFG will support the UEP in launching data collection for NHA 2014–2015 and NHA 2015–2016. Develop and implement financial HFG supported the UEP in incorporating HFG and the MSPP will launch the information system for automated the automated data collection system into system in May 2017. data collection. SHA. Update NHA 2014–2015, HFG continued to support the MSPP in This NHA 2014–2015 update will including an HIV subaccount. converting previous Health Accounts be completed by Q3. studies using the Health Accounts Production Tool. The Conversion of Health Accounts Study 2012–2013 was also completed. Activity 8: Assist Hospitals in Costing Health Services and Developing Business Plans Assist St Damien Hospital with Completed: Final report sent on January developing its business plans. 27, 2017. Assist Sacré Coeur of Milot Completed: Final report sent on January Hospital with developing its 13, 2017. business plan. Develop a course on costing and HFG completed the English version of the HFG will translate all course hospital business planning costing training module. materials into French upon processes for public and private completion of the English module in hospitals. order to finalize the materials in Q3.
236 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Cost services of Justinien HFG completed the hospital services HFG will conduct a data quality University Hospital costing data collection at Justinien assessment, data cleaning, and data University Hospital (JUH) during Q2, analysis in Q3 with the aim of including the practical training of two UEP producing the costing study report staff members. by the end of Q3. Work closely with UEP to assist Planned for Q4. HFG’s launch of the JUH business JUH with developing its business plan development is pending the plan. finalization of the JUH costing report. Organize training sessions for UEP HFG finalized the training agenda and The training will be conducted in costing hospital services and began preparation of training materials during the last week of May 2017 business plan development. (see the “Develop a course on costing for UEP staff and beneficiary and hospital business planning processes hospitals. for public and private hospitals” activity above). Organize training sessions for Pending discussion with USAID/Haiti. USAID/Haiti has preferred that HSD and HSCM managers in HFG focus on public institutions. costing hospital services and business plan development. Work closely with HSD and Pending discussion with USAID/Haiti. USAID/Haiti has preferred that HSCM managers to develop their HFG focus on public institutions. capacity to perform rapid cost- benefit analysis for their resources mobilization strategies. Cost emergency services of Pending discussion with USAID/Haiti MSPP’s 10 departmental hospitals. Activity 9: Support MSPP's Units' Institutional Capacity Building Improve MSPP (DFPSS, DAB, Following mission approval for each HFG’s transfer of the procured DRH) filing system capacity, directorate’s (DFPSS, DAB, DRH) specific items to the MSPP was delayed due including the development of filing system needs, HFG has procured to changes in the Haitian reference document for MSPP the recommended furniture, supplies, and government in Q2. HFG anticipates archiving system management. consumables for the MSPP filing system. that the equipment will be transferred to MSPP in Q3. Implement UEP priority HFG completed an adequacy analysis that In collaboration with the UEP, organizational strengthening compared current staffing to the staff HFG’s next steps include updating recommendations at UEP. targets from the new UEP structure UEP’s current reinforcement plan proposal. The adequacy analysis provides according to the adequacy analysis. information that would facilitate optimal In addition, the operationalization use of current staff by better aligning staff of the SYSEP at UEP (under HFG to the desired qualifications of available Haiti Activity 2) will also be part of positions. the process to implement priority organizational strengthening recommendations at UEP.
5. FIELD SUPPORT ACTIVITIES: HAITI - 237 Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Assist DRH, DFPSS, UADS, DOSS, In Q2, HFG made the following progress Besides overarching challenges of and DSO in putting the new by directorate: government transition, delays to structure (including equipment DFPSS: HFG continued to provide activity are due to the limited when applicable) into place. technical assistance to DFPSS to availability of the MSPP strengthen the directorate. directorates, as most personnel were involved in developing the
post-Hurricane Matthew phased UADS: HFG supported discussions response plan. related to the MSPP decentralization
process through an internal group initiated by UADS (see the “Develop, in HFG postponed addressing collaboration with MSPP, a PFM transition and sustainability matters decentralization operational plan” activity with key directorates until Q4. below). DOSS: HFG finalized the DOSS capacity- building plan. Support DAB capacity to oversee HFG continued to support the DAB in Most likely the IT equipment and the financial report system implementing the computerized software will be transferred to (through supervision, training and accounting system at the Hôpital de MSPP in early April, now that the quarterly financial report reviews) l'Université d'Etat d'Haiti. new government has been sworn in. Activity 10: Support MSPP's Public Financial Management for Decentralization Develop, in collaboration with This activity will be re-planned for a The launch of this activity will MSPP, a PFM decentralization future quarter. follow the finalization of the health operational plan. financing strategy, expected by the end of Q4. Develop, in collaboration with In Q2, HFG supported the launch of the In Q3, with HFG technical support, MSPP, a PFM decentralization UADS’ internal group exploring PFM the internal group’s three-member strategy. decentralization in Haiti. HFG also commission is expected to generate actively participated in the group, a findings report that will be used expected to continue through Year 5. to re-initiate the development of an implementation plan for health sector decentralization according to the National Health Policy and the Plan Directeur de Santé 2012– 2022.
238 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
5.5 Middle East
5.5.1 Middle East Bureau
Program Objectives - During the first year of this activity (FY2017), the USAID HFG and SHOPS Plus Projects will jointly produce a paper compiling available data on health financing and the private health sector in MER countries of interest to USAID and countries where USAID has a bilateral mission. The paper will begin with a broad landscape analysis by HFG of health financing. In the second part of the paper, SHOPS Plus will delve into the private health sectors of the same countries. This paper will inform USAID and other donors ‘investments in health in the MER region. Year 1 activities will inform the design of Year 2 activities, anticipated to include up to three “deep dive” papers on specific topics and a consultative meeting to discuss the implications of their findings with key stakeholders. SHOPS Plus, HFG, ICF International, and the USAID MER bureau will meet at the beginning of FY18 to revise this work plan for and determine the exact topics and deep dive products expected for Year 2. Year 5 Activities - HFG landscape analysis of health financing. Year 5 Progress against Objectives - In Q2, USAID approved the work plan prepared by SHOPS Plus and HFG, and the program began the data collection process. For this, ICF International produced DHS data tables, and HFG and SHOPS Plus completed desk reviews and compiled a list of key informants for all 11 countries. At the end of Q2, USAID, SHOPS Plus, ICF International, and HFG had a quarterly consultative meeting with USAID Middle East Region bureau representatives to report on the data collection progress and ask them to share additional resources that would be helpful for the activity. Moving forward, implementing partners will conduct key informant interviews to complete the data collection process. Q2 Additional Information - HFG and SHOPS Plus produced a draft detailed outline for the joint regional report. Table 50 provides activity-specific updates. TABLE 50. MIDDLE EAST REGIONAL ACTIVITY DETAIL
Critical Assumptions/Problems Year 5 Q2 Planned Tasks Year 5 Q2 Progress Encountered/Follow-up Steps Activity: HFG Landscape analysis of health financing MER Consultative meetings with MER Q2: the second quarterly meeting Bureau was held in March 2017. Data collection and analyses (trends, Q2: Completed desk reviews for all health financing initiatives, identifying 11 countries, and began key gaps) informant interviews. Partners’ meeting to formulate To be completed in the next quarter. overall data interpretations and conclusions First draft of regional overview paper Q2: The first draft of the detailed outline for the joint regional report was completed.
5. FIELD SUPPORT ACTIVITIES: MIDDLE EAST - 239
6. FINANCIAL UPDATE
The financial overview for Year 5 Q2 is presented in the table below: TABLE 51. FINANCIAL OVERVIEW
Client USAID
Project Director Bob Fryatt Total Potential Worth $199,702,730 Obligated to Date $154,748,661.42 Expensed to Date $127,943,380 (thru March 2017) Funded Backlog Remaining $26,805,281.42 Project End Date 09/29/2018
Cost Share - Through the end of March 2017, the HFG project had obtained $6,741,568.79 in actual cost-share contributions. Sources of these contributions include the Namibia Social Security Commission; the Benin Ministry of Health (MOH); the Botswana MOH; the Health Systems Board; the UK Department for International Development; Abt Associates; the World Bank Haiti Living Standards Measure Survey; Results 4 Development Ghana; the Ghana National Health Insurance Scheme; the USAID Africa Bureau; in Ethiopia, the Ethiopian Health Insurance Agency and the regional health bureaus of Addis Ababa City Administration, Amhara, Benishangul-Gumuz, Oromia, Tigray, and SNNP regions, as well as other regional sources; the Southern Africa Development Community (SADC) conference in Pretoria; the World Bank-Asia Regional Flagship Course; the Vietnam MOH; the Tanzania Ministry of Health and Social Welfare; the Tanzania Commission for AIDS; the World Bank WHO- DRC; Avenir Health; Broad Branch Associates; WHO-DRC; and UNAID TSF/WCA Nigeria.
6. FINANCIAL UPDATE - 241
7. KNOWLEDGE MANAGEMENT/
COMMUNICATIONS UPDATE8
Prince Mahidol Award Conference HFG organized a USAID Global Health side meeting at PMAC 2017 with the SHOPS Plus and HP+ projects. The session, "Extending Coverage to Marginalized Groups," saw 70 participants. Jennifer Adams, Acting Assistant Administrator for USAID's Bureau for Global Health, gave opening remarks, and Kelly Saldana, new Director for the Office of Health Systems, closed the session. HFG's Adam Koon, Bob Fryatt, and Jeanna Holtz presented during the session.
Institutionalizing Community Health Conference At the Institutionalizing Community Health Conference, held March 27-30 in Johannesburg, South Africa, HFG's Hailu Zelelew presented on community-based health insurance alongside a representative from the Ethiopian Ministry of Health. HFG participated actively in the conference through Twitter both in helping to advertise the event (put on by USAID's Maternal and Child Survival Program) and in promoting HFG work during the conference. The organizers hosted a one-hour #HealthForAll Twitter Chat on March 14 that the project participated in.
International Women's Day In celebration of International Women's Day on March 8, 2017, HFG put together a web story and sent out an e-blast to its external listserv of 5,000+. The e-blast highlighted HFG's work in maternal health. The project also participated in portions of an all-day Twitter Chat hosted by the Asian Development Bank-#IWDChat17-on March 7, titled "Fostering Gender Equality around the World."
World TB Day To mark World TB Day on March 24, the HFG project put together a web story and sent out an e- blast. The story highlighted HFG's global TB financing work. The project also used Twitter to highlight its TB work on March 24, with the #WorldTBDay and #StopTB hashtags.
Newsletters HFG sent out three external newsletters this first quarter of 2017, highlighting work across the project's portfolio of activities. The first, sent January 20, was a "year-in-review" newsletter, highlighting the most popular stories on the website from 2016. The second and third newsletter were HFG's standard external newsletter.
8 H:\IHA\HFG\Knowledge Management\Website\Website Analytics\readership for reporting.xls
7. KNOWLEDGE MANAGEMENT/COMMUNICATIONS UPDATE - 243 Below are the analytics for the three newsletters:
January 20 HFG Year In Review
• Sent to 4,888 subscribers
• Open rate: 15.3 percent
• Click rate: 3.7 percent
February 27 Newsletter
• Sent to 4,926 subscribers
• Open rate: 15.5 percent
• Click rate: 3.9 percent
March 31 Newsletter
• Sent to 5,035 subscribers
• Open rate: 12.6 percent
• Click rate: 2.5 percent
Technical Briefings This quarter, HFG held two technical briefing sessions. The first one, in January, was a longer version of an oral presentation given at the Health Systems Research Symposium in Vancouver during Y5Q1. Jose Gutierrez and Carlos Avila presented the webinar session, "Power, politics, and resilience: A comparative analysis of health reform in post-conflict El Salvador and Guatemala" on January 19, to an audience of 48 online. The second technical briefing of the quarter was an in-person session at the USAID/GH offices in Crystal City on recently completed work funded by the Maternal and Child Health Office. Jenna Wright presented "Strategic Purchasing to Improve the Quality of Maternal Health Services" on March 9 to an audience of 15, in person.
HFG Website In Y5Q2, HFG posted six new success stories, 15 announcements, and 41 new publications to the project website. Traffic to the website was consistent with the previous quarter, but lower than in the same quarter the previous year and lower than the Year 4 average. The project is looking into the reasons behind the drop. One possible reason is that the annual Global Health Mini-University conference was not held in March as it had been in previous years (Y2, Y3, and Y4) and will instead be held in September 2017.
Website Readership
Total session: 41,828 (vs. 45,008 in Y5Q1)
Unique pageviews: 55,474 (vs. 57,583 in 5Q1)
Users: 36,876 (vs. 39,906 in Y5Q1)
Users: 36,876 (vs. 39,906 in Y5Q1)
244 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
FIGURE 3. HFG OVERALL READERSHIP (BY QUARTER) JANUARY 2016 TO MARCH 2017
250,000
200,000
150,000
Total # Total 100,000
50,000
0 Y4 Q2 Y4 Q3 Y4 Q4 Y5 Q1 Y5 Q2 (1/2016 - (4/2016 - (7/2016 - (10/2016 - (1/2017 - 3/2016) 6/2016) 9/2016) 12/2016) 3/2017) Users 61,790 63,322 63,637 38,986 36,876 Unique Pageviews 79,176 82,861 82,097 55,740 55,474 Sessions 67,101 68,869 69,023 43,837 42,746
Quarter
Downloads Despite the overall drop in numbers from the previous year, traffic seems to be of higher quality, in that downloads are up—part of an overall trend. In Y5Q2 there were 13,891 total downloads of 77,188, a 20 percent increase compared to last quarter’s 11,191 downloads. This appears to indicate an increase in quality, also indicated by a 10.64 percent increase in session duration on the website, as well as a 1.87 percent increase in pages per session. The top 25 downloads for the quarter are shown in the table below, with their download numbers from the previous quarter to the right of the current quarter.
Downloads Publication (Current) (Previous) Y5Q2 Y5Q1 Synopsis: Impact of Health Systems Strengthening on Health 515 397 Financing of Universal Health Coverage and Family Planning: N/A 408 A Multi-Regional Landscape Study and Analysis of Select West African Countries (Y5Q2) Demystifying Universal Health Coverage 369 332 N/A HFG Region de l'Afrique de l'Ouest Rapport Financement Francais Final 328 (Y5Q2) Impact of Health Systems Strengthening on Health 321 232 Essential Package of Health Services Country Snapshot: Kenya 202 163 Health Systems Benchmarking Tool 175 318
7. KNOWLEDGE MANAGEMENT/COMMUNICATIONS UPDATE - 245 Downloads Publication (Current) (Previous) Y5Q2 Y5Q1 Understanding the Linkages between Governance and Health: Concepts and N/A 155 Evidence (Y5Q2) The Link between Provider Payment and Quality of Maternal Health Services: N/A 142 A Framework and Literature Review (Y5Q2) Expanding Coverage to Informal Workers: A Study of EPCMD Countries’ Efforts N/A 118 to Date (Y5Q2) Governing Quality in Health Care on the Path to Universal Health Coverage: N/A 117 A Review of the Literature and 25 Country Experiences (Y5Q2) Essential Package of Health Services Country Snapshot: Uganda 108 133 HSB Tool Manual 108 158 The Link between Provider Payment and Quality of Maternal Health Services: N/A Case Studies on Provider Payment Mechanisms in Kyrgyz Republic, Nigeria, and 88 (Y5Q2) Zambia Essential Package of Health Services Country Snapshot: Bangladesh 78 71 Tax Reform and Resource Mobilization for Health 77 59 Introduction: A Toolkit for Ministries of Health to Work More Effectively with 76 68 Ministries of Finance Developing Key Performance Indicators: A Toolkit for Health Sector Managers 74 72 Guide for the Monitoring and Evaluation of the Transition of Health Programs 71 29 Essential Package of Health Services Country Snapshot: Malawi 69 70 The Health Finance and Governance Briefing Kit 68 72 Domestic Innovative Financing for Health: Learning From Country Experience 66 55 Ethiopia’s Community-based Health Insurance: A Step on the Road to 62 68 Universal Health Coverage Universal Health Coverage: An Annotated Bibliography 57 43 N/A HSFR/HFG Project Activities and Results Summary 57 (Y5Q2)
Social Media Stats Twitter Total Followers: 2,062 New followers since last quarter: 231
246 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017
YouTube Total views: 462 Total watch time (total minutes of viewing time, all videos, all viewers): 26 hours and 52 minutes Average view duration: 3 minutes, 29 seconds New subscribers: seven (up 250 percent from Y5Q1) Likes: 1 Top five countries by total minutes watched:
Country Watch Time (minutes) Total Views Average View Duration United States 364 (23%) 123 (27%) 2:57 Vietnam 180 (7.5%) 96 (18%) 1:52 United Kingdom 397 (25%) 56 (12%) 7:05 Bangladesh 37 (2.3%) 14 (3.0%) 2:39 Canada 25 (1.5%) 24 (5.2%) 1:01
Slideshare Total views: 10,886 (7.8 percent increase from Y5Q1) Total downloads: 333 (56 percent increase from Y5Q1) Top 3 by views:
• Governance and Leadership Indicators Reference Sheets 2015 (291 Views)
• Manuel de Procedures Administrative, Financière et Comptable des Unions ou Mutuelles Communales de Sante au Benin (264 Views)
• Health Financing Indicators Reference Sheet 2014 (206 Views) Facebook Likes since last quarter: 74 Total organic (unpaid) reach: 32,637 Total page likes: 9,964 Total engagement (link clicks, other clicks): • Total clicks: 472 (4 percent increase from Y5Q1) • Link clicks: 233 (56 percent increase from Y5Q1)
7. KNOWLEDGE MANAGEMENT/COMMUNICATIONS UPDATE - 247
8. GENDER UPDATE
In Q2, the HFG Gender Advisor provided support across the project and on the issues of gender equality, female empowerment, and social inclusion. The gender team continued to work with country teams to articulate plans to mainstream gender considerations into their technical assistance, in line with USAID's Gender Equality and Female Empowerment Policy. To date, the team has worked with 20 country teams, enhancing the treatment of gender issues in technical documents, sharing technical resources, developing success stories and supporting teams in responding to gender-related requests from missions.
8. GENDER UPDATE - 249
9. M&E UPDATE
For Y5Q2, M&E focus continued with country Performance Monitoring Plan (PMP) development/management, MandE (M&E system) updating, reporting, internal review, and data quality audits. The M&E team is currently working to update the global HFG PMP with results for Year 4. The updated global HFG PMP will be submitted to the AOR team in Y5Q3. The M&E team is also beginning to organize and document evidence of results to facilitate end-of-project reporting and documentation. Country PMP development and updating continued to progress, with the following updates:
PMPs developed/updated with FY 2016 results and FY 2017 targets and submitted to respective missions: Guinea, Nigeria, South Africa, West Africa, Vietnam, Ukraine, Haiti, and Eastern & Southern Caribbean.
PMPs to be developed: Mali, South Africa, Dominican Republic.
PMPs to be updated: Côte d’Ivoire, DRC, Bangladesh, Cambodia, and Peru. MandE development also continued with both enhancements and ongoing maintenance and support:
Quarterly reporting: All past quarterly reports are integrated in the system. All teams use MandE for quarterly reporting. Over 200 team members have contributed to the quarterly report across 25 countries.
Data/deliverable loading: All teams are using MandE for deliverables/supporting information. Nearly all four years of project deliverables are in MandE.
MandE Improvements: The M&E team is working to enhance the functionality of MandE as a project management tool through the development of a customizable dashboard on MandE. Data quality audits continued, on reported accomplishments/deliverables/supporting files, on the following programs: IR3, IR1, Global Health Security, Benin, Ethiopia, Nigeria, and India.
9. M&E UPDATE - 251
10. MANAGEMENT UPDATE
The HFG project received a no-cost extension in January 2017; the project will now end on September 29, 2018. In Q2, staff focused on preparing for the final 18 months of the project and how we will ensure that HFG ‘finishes strong’ in delivering on the USAID work it is doing in countries around the globe. Developing a cross-project consensus on HFG ‘finishing strong’: All HFG project staff have been engaged in this process in a variety of ways. HFG held a leadership management retreat in January to define finishing strong, building on past lessons and experience. A consultation was held with HQ staff and separately with all HFG country offices to get their input on how best to handle the project’s final 18 months. Two orientation sessions also were held with staff to emphasize the importance of this final phase of the project. In addition, a survey of staff garnered information on their past experience with closing out projects, focusing on the most challenging and rewarding aspects of close-out. As the figures below show, HFG staff have a wealth of experience with project close-out; in particular, they are well prepared for smooth close-out in the key areas of project finance and administrative operations and M&E. Another finding was that project close-out activities offer a valuable skill set for staff who have not yet been through the process. FIGURE 4. HOW LONG HAVE YOU WORKED ON THE HFG PROJECT OR ONE OF ITS PREDECESSORS?
24 25 19 17 16 Non-field Field 7
< 1 Year 1 - 3 Years > 3 Years
10. MANAGEMENT UPDATE - 253 FIGURE 5. HAVE YOU WORKED ON THE FINAL YEAR OF A USAID OR OTHER DONOR PROJECT BEFORE?
39
27 23 19 Non-field Field
Yes No
The HFG 'finishing strong' vision: The extensive consultation and engagement of staff described above led to agreement on what was meant by 'finishing strong,' as summarized below. 1. Technical Excellence: Project results, impacts, achievements, and lessons learned are defined and aligned with USAID and country partner interests, while maintaining technical quality. 2. Country transition: Country-specific strategies are in place to sustain HFG results and continued improvement beyond the life of the project. 3. External communication: Telling the HFG story in engaging, innovative, and effective ways to ensure project impact is broadly known and respected, particularly by USAID and external partners. 4. Engaged staff and effective teams: In-country, home office, and partner staff/teams are motivated, productive, and informed through the end of project. 5. Project management: Management structures and processes, in the field and Bethesda, are aligned with the rapid expansion and contraction over project close-out (reporting, technical, financial, contractual, etc.). A final all-headquarters HFG staff retreat on April 4 revolved around this vision: subgroups prepared detailed guidance (priority tasks and actions) for each of the five areas. Next steps include:
HFG project management: The project management structures will be amended and re-enforced to enable all areas of 'finishing strong' to be taken forward as a systematic part of HFG work planning and implementation.
Year 6 work plan: The work plan format will address country transition (field programs) and external communications (all); and the calendar for preparing the work plan will be adjusted to allow more time for teams to prepare and for technical review.
HFG evaluation: HFG will undertake an internal assessment to consolidate evidence that HFG has achieved its project objectives globally and in-country. This will also help communicate project achievements and impacts, and lessons from HFG work. This will be complemented by the HFG knowledge and learning strategy, which focuses on the thematic areas where most of HFG's efforts have gone in responding to global and country demands.
254 - HFG PROJECT - QUARTERLY PERFORMANCE MONITORING REPORT - JANUARY 01, 2017 - MARCH 31, 2017