USAID’s MCH Program Component 5: Health Systems Strengthening

Quarterly Report January-March 2014

Cooperative Agreement No. AID-391-A-13-00002

This Report has been submitted to the United States Agency for International Development for consideration and approval.

It was submitted by JSI Research & Training Institute, Inc. and prepared by JSI Research & Training Institute, Inc. in collaboration with Contech, Rural Support Programmes Network, and Heartfile.

USAID’s MCH Program Component 5: Health Systems Strengthening

Quarterly Report January-March 2014

Cooperative Agreement No. AID-391-A-13-00002

Disclaimer: “This study/report is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of JSI Research & Training Institute, Inc. and do not necessarily reflect the views of USAID or the United States Government.”

Component 5: Health Systems Strengthening Quarterly Report January-March 2014 2

Contents

Acronyms 4 I. Executive Summary 5 II. Health Systems Strengthening Component’s Vision of Success 6 III. Activities and Results 8 IR 3.1 Increased Accountability and Transparency of Health System 8 IR 3.2 Improved Management Capacity at Provincial and District levels within the 21 Health Department

IR 3.3 Strengthened Public Private Partnerships 25 IV. Coordination 29 V. Monitoring, Evaluation, and Reporting 30 VI. Issues and Challenges 35 VII. Activities Planned for Next Quarter 35 VIII. Annexes Annex 1: District-wise Details of Private Health Facilities 36 Annex 2: District-wise Details of Quarterly Meetings and Formation of VHCs 37 Annex 3: MTBF Planning Committee Notification 38

Component 5: Health Systems Strengthening Quarterly Report January-March 2014 3

Acronyms

CMWs Community Midwives DAP District Action Plan DHIS District Health Information System DHN District Health Network DHO District Health Officer DHPC District Health Planning Committee DHPMT District Health & Population Management Team DOH Department of Health EPI Expanded Programme on Immunization GOS Government of Sindh HCF Health Care Financing HHF Heartfile Health Financing HSS Health Systems Strengthening HSRU Health Sector Reforms Unit IR Intermediate Result JSI JSI Research & Training Institute, Inc. LHV Lady Health Visitor LHW Lady Health Worker MCH Maternal and Child Health MCHIP Maternal and Child Health Integrated Program M&E Monitoring and Evaluation MIS Management Information System MNCH Maternal, Newborn and Child Health MSS Marie Stopes Society MTBF Medium Term Budgetary Framework PHDC Provincial Health Development Center RMNCH Reproductive, Maternal, Newborn and Child Health RSP Rural Support Program RSPN Rural Support Programmes Network UCHCs Union Council Health Committees USAID United States Agency for International Development VHCs Village Health Committees

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I. Executive Summary

During the January-March 2014 quarter, the Government of Sindh’s District Health Departments completed drafts of all 22 District Action Plans (DAPS), which are three- year rolling operational plans for the implementation of the Sindh Health Sector Strategy with accompanying goals and strategies to enable each District Health office to meet the health needs of their populations. This enormous accomplishment was made possible with the guidance, support, and leadership of the Health Systems Strengthening Component and is the culmination of eight months of preparation and technical assistance, which include the development of District Profiles and capacity building training. In addition, the Health Systems Strengthening Component provided technical support to District Health & Population Management Teams (DHPMTs) to establish a routine quarterly performance review process, and during this quarter, 21 districts successfully organized and executed these performance review meetings.1

The Health Systems Strengthening Component continued its support for Village Health Committees (VHCs), and during the January-March quarter, 536 VHCs held meetings. Overall, since October 2013, 738 VHCs have met at least once, and 276 VHCs have held two quarterly meetings. 65% of VHC members who participated in these meetings were women.

As part of its role to advocate on issues related to accountability and transparency in Pakistan’s mixed health system, the Health Systems Strengthening Component issued a Request for Procurement (RFP) for the production of a documentary on Choked Pipes, a 2010 publication which focuses on Pakistan’s health systems issues and offers reforms.

Under Heartfile Health Financing (HHF), the Health Systems Strengthening Component supported 56 patients for medical treatment during the January-March quarter. Of these 56 patients, 39 were female and 17 were male children. The total number of patients supported to date is 104. HHF enrolled three additional hospitals in the scheme to support increased scale up.

The Health Systems Strengthening Component entered into negotiations with the Health Services Academy, Islamabad, to explore long-term capacity building options for Government of Sindh Department of Health (GOS/DOH) staff. During this quarter, the Health Services Academy agreed to initiate a new batch for 30 mid-level managers from Sindh for Masters of Science in Public Health.

At the special request of USAID, the Health Systems Strengthening Component began providing technical assistance to Jacobabad Institute of Medical Sciences (JIMS) to: 1) draft key job descriptions; 2) develop a business plan; and 3) design a human resources strategy and management plan.

1 DHPMT Tharparkar did not meet during the reporting quarter because the health authorities were dealing a famine emergency (see page 8 of the report for more details).

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II. Health Systems Strengthening Component’s Vision of Success

At the end of the project, the Government of Sindh’s Department of Health (GOS/DOH) will have the management capacity and systems necessary to move towards universal coverage and address equity issues with a particular focus on the poor and vulnerable. The GOS will have tested and scaled proven public private partnerships (PPPs) and have the capacity to manage and sustain these partnerships and to identify and develop new ones over time. Additionally, the capacity of civil society to effectively engage in policy dialogue will have been built, and there will be a sustained increase in financial risk protection to move towards universal health coverage.

Goal

The goal of the Health Systems Strengthening Component is to develop and support innovative, cost effective, integrated, and quality programs and services to strengthen systems around reproductive, maternal, newborn and child health (RMNCH) services for improved outcomes. The primary focus of the program proposed under the Health Systems Strengthening Component is:

1. Strengthening systems that will foster improved RMNCH service delivery and outcomes, including accountability and transparency; 2. Strengthening management capacity at the provincial and district levels; 3. Developing innovative approaches to catalyze community outreach services and access to health services for marginalized populations (including financing schemes); and 4. Strengthening private sector delivery for the urban and rural poor populations.

The Health Systems Strengthening Component will also engage in the coordination, alignment, and calibration of RMNCH activities undertaken by technical partners of USAID’s MCH Program to ensure there is no duplication of effort and that all critical elements for achieving results reinforce each other and are laid out to achieve synergy and the desired results of USAID’s Maternal and Child Health (MCH) Program objectives.

Health Systems Strengthening Component’s Intermediate Results

The results of Health Systems Strengthening Component will follow USAID’s Results Framework. Most of the project’s activities will fall under IR 3.

IR 3: Strengthened Health System IR 3.1: Increased Accountability and Transparency of Health System IR 3.2: Improved Management Capacity at Provincial and District Levels within the Health Department IR 3.3: Strengthened Public Private Partnerships

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Overall Approach and Strategic Principles

JSI and its sub-partners RSPN, Contech International, and Heartfile implement the Health Systems Strengthening Component to improve the capacity of the Government of Pakistan (GOP), and particularly the GOS, to develop and implement innovative, cost-effective, integrated, and quality programs and services to strengthen systems around RMNCH services. Throughout the project, the Health Systems Strengthening Component will strictly adhere to and promote the following strategic principles:  Using a customized approach to capacity building that will be fit to each specific entity. This is reflective of the project’s overall commitment to flexibility and adaptability in implementation;  Strengthening strategic partnerships and coordination to effectively manage an integrated health system;  Promoting a culture and practice of results-oriented approach;  Strengthening local expertise and focusing on local innovation to promote sustainability and ownership;  Focusing on demand and supply side financing schemes to strengthen the health system;  Promoting community actions for accountability and transparency of the health system; and  Special consideration to gender will be made to ensure that it is mainstreamed within the Health Systems Strengthening Component’s implementation approach.

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III. Activities and Results

IR 3.1 Increased Accountability and Transparency of Health System

3.1.1 Foster the Development of RMNCH Steering Committee

Although the Reproductive, Maternal, Newborn, and Child Health (RMNCH) Steering Committee was notified in August 2013, its first meeting was delayed because the GOS had not notified its Member/Secretary. On March 5, 2014, the GOS notified the Chief of the Health Sector Reforms Unit (HSRU) as Member/Secretary of the RMNCH Steering Committee, and the first meeting of the RMNCH Steering Committee is scheduled for April 21. Discussion of the meeting outcomes will be included in the next quarterly report.

3.1.2 Advocate with Policy-makers and Parliamentarians to Improve Governance and Accountability

The Health Systems Strengthening Component is currently developing Terms of Reference for a comprehensive set of advocacy activities and has approached potential consultants (and expects to have an individual onboard by mid-April). As preparatory work, JSI has held several meetings with parliamentarians and key stakeholders to explore potential avenues of engagement. Additionally, during this quarter, JSI developed a study protocol to track commitments for the health sector made by the major political parties before the May 2013 general elections. Tracking commitments of political parties for the health sector is part of the overall advocacy strategy of the Health Systems Strengthening Component with the aim to prioritize health funding and institutionalize accountability.

3.1.3 Provide Technical Support to Strengthen Supportive Supervision and Monitoring and Evaluation Function

During this quarter, the Health Systems Strengthening Component, in collaboration with the office of Director General Health Services, continued its work towards developing a monitoring, supervision, and accountability framework – critical to which is the establishment of an M&E Cell. The new Director General Health Services, who took over the charge of his office on March 8, has appointed a Provincial Coordinator and Monitoring Officer. This is a positive first step in the establishment of an M&E Cell, and during its meeting with the Director General Health Services, JSI secured a commitment for allocated office space for this new M&E Cell.

3.1.4 Provide Technical Support to Strengthen District Health System

District Health & Population Management Teams

During this reporting period, 21 DHPMTs held their second quarterly meetings. The one district that did not organize a meeting was Tharparkar, in which there was a famine emergency that required diverted resources and attention. While District Health Officers (DHOs) are responsible for scheduling the DHPMT meetings (and issuing the

Component 5: Health Systems Strengthening Quarterly Report January-March 2014 8 accompanying notices and agendas), the Health Systems Strengthening Component (through its sub-partner Contech) provides technical assistance for the preparation of meetings, including the development of presentations/working paper on district specific data. Contech staff also participate in the meetings and provide support in the preparation of meeting minutes and remain in contact with the secretary of the DHPMTs to facilitate the circulation of minutes and ensure follow-up of key implementation decisions.

This quarter, District Project Officers of RSPN (a sub-partner in the project) in Umerkot, Thatta, and Tando Allah Yar attended DHPMT meetings and briefed the members about the process of information dissemination in communities related to public and private sector service delivery points. They also shared information about the process of documentation of community feedback and its presentation in DHMPT meetings.

It is worth noting that a community representative in a DHPMT meeting in Naushero Feroze raised his concern over non-satisfactory performance of health facilities regarding provision of medicines and obstetrical services. This is important as it demonstrates active community participation in DHMPTs. The chair answered that health facilities in the district needed more staff, including consultant doctors for their main hospitals and hoped that high level authorities will support increased staffing in this respect. Additionally, the Office of District Health Officer in Naushero Feroze has made efforts to seek female staff by approaching provincial MNCH Program. The chair also expressed his appreciation for the work DHMPTs were doing to discuss and resolve issues and added that coordination between stakeholders would gradually improve.

Using data from last quarter, the Health Systems Strengthening Component analyzed the first DHPMT meetings (held during October-December 2013 quarter) using information from performance analysis tools specifically developed for DHPMTs. Information collection included attendance of participants, meeting notices, minutes, as well as decisions taken during the meeting using the following scoring criteria:  DHPMT meeting held within 100 days of the last meeting.  Meeting chaired by designated chair.  Meeting agenda circulated.  Meeting minutes circulated.  80% participation of members.  Progress on DAP discussed and reviewed (tasks and responsibilities).  Data from various management information systems (MISs), including the District Health Information System (DHIS) presented.  Number of decisions implemented (decisions made in the previous meeting).  Performance shared with provincial authorities.

Table 1 on page 11 shows the performance scores for the aforementioned DHPMT meetings. In all districts (except Tharparkar), the designated official chaired the meeting and meeting minutes were shared with all members of DHPMTs. Progress on DAP development was discussed in 21 districts and the performance was shared with the provincial authorities. However, the agenda was not circulated in four districts prior to the meeting and in 13 districts the participation was less than 80%, whereas DHIS and

Component 5: Health Systems Strengthening Quarterly Report January-March 2014 9 other MIS were not presented in nine districts. This performance data allowed the Health Systems Strengthening Component to follow up with district management with targeted recommendations for improvement.

Performance assessment of quarterly meetings of DHPMTs in all districts will be done on quarterly basis and reported in the subsequent quarter. For example, performance assessment of DHPMT meetings held during January-March will be reported in the April-June quarterly report. In subsequent quarters, JSI will provide technical support to the Office of the Director General Health Services to transfer responsibility of performance monitoring (including sharing the tools and methodology) to enable the Office of the Director General Health Services to assume the role of oversight and feedback.

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Table 1: First Set of Performance Scores for DHPMT Nine Point Scoring Criteria Performance

1 2 3 4 5 6 7 8 9 Score

Meeting Sr # Districts Period

date and asks

t

Total

resented

100 days 100

Authority Achieved

circulated

p

discussed and and discussed

with Provincial Provincial with

including DHIS DHIS including

responsibilities)

Meeting minutes minutes Meeting

Progress on DAP DAP on Progress

Participation 80% Participation

Agenda circulated Agenda

previous meetings previous

Meeting chaired by chaired Meeting

implemented out of of out implemented

Meeting held within within held Meeting

reviewed ( reviewed

Performance shared shared Performance

Number of decisions decisions of Number

designated chairman designated Data from various MIS MIS various from Data PY2 1 Badin 24.12.2013 NA 1 1 1 1 1 1 NA 1 7 7 Qtr-1 PY1 30.09.2013 NA 1 1 1 1 1 0 NA 1 7 6 Qtr-2 2 Dadu PY2 19.12.2013 1 1 1 1 1 1 1 1 1 9 9 Qtr-1 PY2 3 Ghotki 20.12.2013 NA 1 1 1 0 1 1 NA 1 7 6 Qtr-1 PY2 4 Hyderabad 31.12.2013 NA 1 1 1 1 1 0 NA 1 7 6 Qtr-1 PY2 5 Jacobabad 25.11.2013 NA 1 1 1 1 1 0 NA 1 7 6 Qtr-1 PY2 6 Jamshoro 23.12.2013 NA 1 1 1 0 1 0 NA 1 7 5 Qtr-1 Kamber PY2 7 Shahdad 31.12.2013 NA 1 1 1 0 1 0 NA 1 7 5 Qtr-1 Kot PY2 8 Kashmore 26.12.2013 NA 1 1 1 1 1 1 NA 1 7 7 Qtr-1 PY2 9 Khairpur 20.12.2013 NA 1 1 1 0 1 1 NA 1 7 6 Qtr-1 PY2 10 Larkana 30.12.2013 NA 1 1 1 0 0 0 NA 1 7 4 Qtr-1 PY2 11 Matiari 31.12.2013 NA 1 1 1 0 1 1 NA 1 7 6 Qtr-1 PY2 12 Mirpurkhas 19.12.2013 NA 1 1 1 0 1 1 NA 1 7 6 Qtr-1 Naushero PY2 13 24.12.2013 NA 1 1 1 1 1 1 NA 1 7 7 Feroze Qtr-1 PY2 14 Nawabshah 24.12.2013 NA 1 1 1 1 1 1 NA 1 7 7 Qtr-1 PY2 15 Sanghar 26.12.2013 NA 1 0 1 1 1 1 NA 1 7 6 Qtr-1 PY2 16 Shikarpur 31.12.2013 NA 1 0 1 1 1 0 NA 1 7 5 Qtr-1 PY2 17 Sukkur 27.11.2013 NA 1 1 1 0 1 1 NA 1 7 6 Qtr-1 Tando Allah PY2 18 25.11.2013 NA 1 1 1 0 1 0 NA 1 7 5 Yar Qtr-1 Tando PY2 19 Mohammad 24.12.2013 NA 1 1 1 0 1 1 NA 1 7 6 Qtr-1 Khan PY2 20 Tharparkar 31.12.2013 NA 0 1 1 0 1 1 NA 1 7 6 Qtr-1 PY2 21 Thatta 26.12.2013 NA 1 0 1 0 1 0 NA 1 7 4 Qtr-1 PY2 22 Umerkot 20.12.2013 NA 1 0 1 0 1 1 NA 1 7 5 Qtr-1

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Table 2 (on the next page) presents the status of decisions taken in both first and second quarterly meetings of DHPMTs. Meeting minutes from the second round of DHPMT meetings were received during this quarter and demonstrated that out of the 12, nine districts implemented all of the decisions!

A few examples of decisions showing use of data and request for support at the provincial level include: 1. Office of DHO Kashmore will write to the Director General Health Services to fill the vacant posts of Women Medical Officers and specialist doctors. 2. Office of DHO Sukkur will write to the Director General Health Services to fill the vacant posts in the district. 3. Office of DHO Tando Mohammad Khan will approach the Director General Health Services and Secretary Health for immediate sanctioning of scheduled new expenditures and posting of specialist and general doctors and paramedical staff to operationalize the new hospital building. He will also request the Director General Health Services for setting targets for all vertical programs so that they coincide with each other. 4. The quality of DHIS data to be improved in Umerkot. All health facilities should set DHIS targets for DAP and submit reports. 5. DHIS Coordinator and Statistical Assistant will review monthly DHIS reports and share feedback (Sanghar). 6. DHIS Coordinator and District Officer Medical & Public Health will collect data regarding MNCH (Shikarpur). 7. All health facilities, including experimental dispensaries, must submit DHIS reports in future (Dadu). 8. Office of DHO will request Director General Health Services for specialist doctors and Women Medical Officers. It will also request relevant authorities for removing the encroachment on hospital premises (Kamber Shahdad Kot). 9. The difference between data in DHIS monthly reports for the months of October and November 2013 will be re-checked (Shaheed Benazirabad).

The Director General Health Services will share relevant provincial level decisions with Secretary and the RMNCH Steering Committee. Regarding the impact of these meetings, this intervention is proving to be helpful in resolving issues of varying scales in different districts. If regularly held, these meetings will help strengthen the district health system. The Health Systems Strengthening Component will focus its technical guidance on those districts which need improvement in their performance and will support the Office of the Director General Health Services to organize regular review meetings.

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Table 2: Status of DHPMT Meetings

# of Decisions # of Decisions # of Decisions Taken in S.No District Taken in 1st Implemented (Reported nd 2nd DHPMT Meeting DHPMT Meeting in 2 DHPMT Meeting)

Minutes not received by Minutes not received by 1 Hyderabad 3 technical team for analysis technical team for analysis 2 Jamshoro 10 2 5 Minutes not received by Minutes not received by 3 Matiari 9 technical team for analysis technical team for analysis Tando Allah Minutes not received by Minutes not received by 4 2 Yar technical team for analysis technical team for analysis Tando 5 Mohammad 2 2 7 Khan Minutes not received by Minutes not received by 6 Thatta 6 technical team for analysis technical team for analysis 7 Badin 4 4 6

8 Dadu 6 6 9

9 Sanghar 2 2 3 Minutes not received by Minutes not received by 10 Mirpurkhas 2 technical team for analysis technical team for analysis Shaheed 11 1 1 1 Benazirabad 12 Sukkur 3 0 8 Naushehro 13 5 3 4 Feroze Minutes not received by Minutes not received by 14 Khairpur 5 technical team for analysis technical team for analysis 15 Ghotki 5 5 3

16 Larkana 1 1 3 Kamber Minutes not received by Minutes not received by 17 5 Shahdad Kot technical team for analysis technical team for analysis 18 Shikarpur 5 5 13 Minutes not received by Minutes not received by 19 Jacobabad 2 technical team for analysis technical team for analysis Minutes not received by Minutes not received by 20 Kashmore 2 technical team for analysis technical team for analysis 21 Umerkot 13 13 10 Minutes not received by Minutes not received by 22 Tharparkar 2 technical team for analysis technical team for analysis

District Action Plans (DAPs) The Health Systems Strengthening Component has been providing technical assistance to the Office of DHO in 22 districts of Sindh to prepare District Action Plans (DAPs), which are three-year rolling operational plans for the implementation of the Sindh Health

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Sector Strategy. These DAPs also set out the goals and strategies that will enable a district to best meet the health needs of its population.

The Health Systems Strengthening Component started preparing DAPs in August 2013 and included a process that incorporated capacity building workshops and hands-on support to District Health Planning Committees (DHPCs). The DHPCs had been constituted by the DOH specifically for the preparation of DAPs. In previous quarters, the Health Systems Strengthening Component had conducted capacity building workshops in 18 districts. During this reporting period, the Health Systems Strengthening Component conducted capacity building workshops in the remaining four districts: Larkana, Kashmore, Sanghar, and Kamber Shahdad Kot. These workshops focused on the planning process, DAP outline, gap analysis and problem identification, causation, prioritizing and designing interventions, and costing. Through hands-on support, provided to relevant DHOs, the Health Systems Strengthening Component helped DHPCs analyze data from primary and secondary sources to obtain a holistic picture of districts’ respective situations, highlighting district specific issues.

The DAPs consist of the following sections: (i) health situation; (ii) rationale, objectives, process, and organization of DAP; (iii) problem analysis; (iv) plan development, including interventions and activities to address key issues in districts with targets; (v) plan implementation, monitoring, and evaluation; and (vi) costs and financing plan.

On January 7, the Secretary Health chaired a provincial level review of the draft DAP for Dadu. The review was attended by provincial managers of vertical programs, representatives from the DOH, development partners, the Population Welfare Department, and People’s Primary Healthcare Initiative (PPHI). Meeting participants recommended including sections of “About the Plan” and “Stakeholders Analysis” in DAPs. This recommendation has since been incorporated into all DAPs as it was decided in a meeting chaired by the Director General Health Services that the DAP for Dadu would serve as a proto-type for other districts.

To monitor the progress and implementation of DAPs, the Health Systems Strengthening Component decided to identify key performance indicators and set targets for each district at each level (Basic Health Units, Rural Health Centers, Taluka heath hospitals, and district health hospitals). The project provided support to Dadu district managers in identifying key performance indicators and setting targets. The draft report was shared with the DOH and USAID. Since there are three stakeholders at the district level (DOH, Population Welfare Department, and PPHI), it was necessary to gather information from each level prior to the development of tools to gather baseline data from the three stakeholders.

USAID’s feedback on key performance indicators and setting targets at both the district and health facility levels was also included in DAPs. Accordingly, a list of select key performance indicators, based on DHIS and MIS of vertical programs, was prepared. The office of the Director General Health Services provided specific data for 2013, taken as baseline, on selected key performance indicators.

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For target setting, the Health Systems Strengthening Component provided hands-on support to DHOs and their staff, civil surgeons in district headquarters hospitals, medical surgeons in Taluka headquarter hospitals, Rural Health Center in-charges, and the District Support Managers of PPHI. The Population Welfare Department did not participate in target setting stating it did not have a policy for target setting in districts. It also did not provide baseline information for family planning related indicators.

The cost of each activity has been identified with respect to relevant “object codes” and “cost centers” to be reflected in Medium Term Budgetary Framework (MTBF) format. This will facilitate the process of linking DAP costs with budget demand for which the Health Systems Strengthening Component will provide technical support. DHOs will submit final DAPs in April 2014 to the Sindh DOH. These DAPs will be accompanied by budget requests for the 2014-15 fiscal year to fund the activities outlined in them.

Mapping of Private Sector Facilities

During the reporting period, the Health Systems Strengthening Component prepared lists of private health facilities and health care providers in Umerkot, Tharparkar, Thatta, and Tando Allah Yar districts. It also validated the listing of private sector health facilities and health care providers in Dadu district. The private sector facilities included clinics managed by Lady Health Visitors (LHVs), doctors, and technicians, and clinics managed by NGOs working in rural areas. The mapping activity was undertaken to collect information about the types of health facilities being run in the private sector in these districts and provides information regarding the concentration of private sector facilities in urban and rural areas. The information generated from the mapping exercise will be used in DAPs.

The Health Systems Strengthening Component will share the collected information with Component 2 of USAID’s Maternal and Child Health Program, led by MCHIP/Jhpeigo, to help it select facilities for quality of care improvement in private health facilities. It will also share this information with rural communities through Village Health Committees (VHCs) to provide option to avail public or private sector heath facilities in their areas. A summary of the data collected about private sector health facilities is given in Annex 1.

3.1.5 Utilize Existing Community Organizations of RSPN to Improve Health Services and Advocacy

Development of Information Package and Training of Staff

The Health Systems Strengthening Component has developed an information package in Sindhi for VHCs. The information package, which was finalized with feedback from USAID, contains information about the types of services offered by both public and private health facilities functioning in areas where VHCs have been formed. The material is being printed by PSI/Greenstar and will be shared with VHCs during the April-June 2014 quarter. The Health Systems Strengthening Component has also prepared materials in the form of charts in Sindhi for RSPN field staff; they will use the charts to disseminate information about health services and facilities in meetings of VHCs and Union Council Health Committees (UCHCs) with the aim of strengthening

Component 5: Health Systems Strengthening Quarterly Report January-March 2014 15 accountability. The charts, which were finalized after incorporating feedback from USAID, are being printed by PSI/Greenstar.

From February 6-8, RSPN conducted training for its field staff and focal persons. The workshop covered: 1. Developing an understanding of the concept of accountability and its importance in the health systems. 2. Developing, through role play, skills for supporting and strengthening community level organizations to improve health services through their continuous engagement with public health managers. 3. Disseminating information about health services and documenting community feedback about the health services using forms developed for this purpose by RSPN. 4. Presenting information clearly and effectively to get the message across to better advocate for health services of communities in DHPMT meetings and seek their support to address issues related to health services.

The training also focused on skills building for staff to better engage with District Health Networks (DHNs) for advocacy purposes. A DHN is a coalition of all UCHCs in a district. Membership of a DHN comprises representatives from UCHCs and health sector NGOs in the district, including MSS and MCHIP/Jhpeigo. The Health Systems Strengthening Component formed a total of four DHNs in Tharparkar, Dadu, Tando Allah Yar, and Umerkot districts during January-March quarter. DHNs will meet on quarterly basis and interface with DHPMTs in their districts to advocate for improved health services.

As RSPN will be supporting activities related to the strengthening of M&E of routine EPI in Thatta, Tharparkar, Jacobabad, and Kashmore districts, JSI’s EPI consultant briefed the participants on mapping of areas not covered by Lady Health Workers (LHWs), registration of new births in Union Council registers, identification of defaulters and drop-outs, and coordination with EPI vaccinators for vaccination of all eligible children and women of reproductive age through VHCs. Staff from MCHIP/Jhpiego and MSS also attended the training on the last day and facilitated the discussion about the role of RSPN for community level support for their respective components. This helped the participants understand the coordination mechanism among the MCH Program partners at the district level and the role of VHCs in dissemination of information.

Village Health Committees

During the reporting period, the Health Systems Strengthening Component began supporting the formation of VHCs in nine additional Union Councils;2 this resulted in the establishment of 211 new VHCs and revitalization of 34 existing community organizations (for a total of 245 VHCs). New, as well as revitalized VHCs, include representation of women, poor, and socially marginalized groups. Out of these 245 VHCs, 27 have all male members; 89 have all female members; and 129 include a mix.

2 Previous to this quarter, the Health Systems Strengthening Component supported VHCs in 13 Union Councils; with the addition of these nine, the total is now 22 Union Councils.

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The nine Union Councils were selected in consultation with the MNCH Component the previous quarter and are as follows:  Thatta district: Gujjo, Gharo, and Sakro  Tando Allah Yar district: Paksinghar and Shaikh Moosa  Dadu district: Kakar and Phulji Station  Tharparkar district: Manjthi and Diplo

Each of the newly formed/revitalized VHCs elected its president and secretary general through majority vote. The president and secretary general of a VHC will represent their respective VHC in UCHCs. A summary of VHC formation and meetings is provided in Annex 2.

During the reporting period, 536 VHCs in Dadu, Tando Allah Yar, Tharparkar, Thatta, and Umerkot districts held their quarterly meetings. Overall, since October 2013 when VHCs started to hold meetings, 738 VHCs have held one quarterly meeting and 276 VHCs have held two quarterly meetings; 65% of VHC members who participated in these meetings were women. The second quarterly meetings of remaining VHCs were delayed for two reasons: delay in the approval and printing of the information package to be distributed among VHC members and formation of VHCs in nine additional Union Councils.

In VHC meetings, the Health Systems Strengthening Component shared information about public health facilities and plans for the establishment of MNCH Centers by MCHIP/Jhpiego. The Health Systems Strengthening Component distributed community feedback forms during the meetings and trained VHC office bearers (the president and the general secretary) on documentation of community feedback. The feedback received from VHCs identified the following issues which were referred to UCHCs.  Non-availability of medicines at Basic Health Units.  Unprofessional attitude of health care providers.  Non-availability of syringes at Tehsil headquarters hospital.  Non-functional dispensaries.  Lack of supplies.  Lack of proper place for patients to sit.

Recognizing the significant impact of communities in improving health services, VHCs have already started to play their role. For example, in Union Council Beggan Jarwar of Tando Allah Yar district, on the intervention of VHC members, the parents of eight children allowed an LHW to give their children polio drops. This was after the parents had refused an LHW to vaccinate their children against polio previously.

Union Council Health Committees

During the reporting period, the Health Systems Strengthening Component established 11 new Union Council Health Committees (UCHCs), including two in Dadu, two in Tharparkar, four in Tando Allah Yar, and three in Thatta districts. The president and the secretary general of all VHCs are members of UCHC in their Union Council. The total number of UCHCs formed so far under the project is now 18.

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The Health Systems Strengthening Component conducted orientation training for all UCHCs on the role of VHCs and UCHCs in improving health services, specifically: collecting, compiling and analyzing community feedback, and then appropriately using this feedback as an advocacy tool in forums, such as DHNs and DHPMTs. During the orientation training, the Health Systems Strengthening Component also provided information on reproductive health rights, the role of community organizations in improving EPI coverage, and USAID’s MCH Program. MCHIP/Jhpeigo’s field staff in Dadu and Tharparkar attended the training and provided information about the services available at the Maternal, Newborn and Child Health (MNCH) Centers MCHIP/Jhpeigo has established. DHO Dadu and District Coordinator LHW Program, Dadu, attended part of the training in Dadu and assured UCHCs of their support.

UCHCs have now started their engagement with health sector stakeholders to address issues faced by the communities. In Tharparkar district, for example, on getting feedback from one of the VHCs about the non-availability of medicines at a BHU, UCHC Bhakuo approached the Basic Health Unit in-charge and resolved the issue of medicine availability at that particular Basic Health Unit. In Dadu district, one UCHC, upon receiving a complaint from a VHC about the un-professional treatment of pregnant women at a PPHI-managed MCH Center, had a meeting with District Support Manager of PPHI. As a result, the responsible doctor was not only held accountable for her action, but PPHI also immediately rectified the lack of supplies at the MCH Center.

MCHIP/Jhpeigo has established 19 MNCH Centers in selected Union Councils of Dadu, Tharparkar, Thatta, and Tando Allah Yar districts. In VHC meetings, the Health Systems Strengthening Component shared information about these MNCH Centers and encouraged community members to visit them for health care services. During March, 19 VHCs shared their feedback about MNCH Centers, and this feedback was shared with MCHIP/Jhpeigo. The issues highlighted by VHCs included lack of water and electricity, unsuitable location for women because of security reasons, lack of medicines and supplies, and Centers either not open at all or open for only few hours. Discussing the last issue, VHCs mentioned that the CMW supposed to provide services in the area was either not providing them at all, or was living in one Union Council but had been assigned to another Union Council, or opened the Center in the afternoon only because she had a morning job.

During this quarter, RSPN shared lists of VHCs and UCHCs with MSS. When deployed by MSS, its Field Health Educators and Field Health Supervisors will join VHCs and UCHCs respectively. The Health Systems Strengthening Component had agreed with MSS that it will collect and share community feedback on MSS’s Suraj Clinics. However, no Suraj Clinics had been established in target Union Councils by the end of the reporting period.

Identification of Traditional Birth Attendants and Non-Active Community Midwives

As reported in the October-December quarterly report, RSPN, under its revised scope of work, will identify non-active CMWs and Traditional Birth Attendants (TBAs) in areas

Component 5: Health Systems Strengthening Quarterly Report January-March 2014 18 not covered by LHWs. Although this activity was meant to start in the April-June quarter, on the request of MCHIP/Jhpeigo, it was started during the current reporting period.

With input from MCHIP/Jhpeigo, the Health Systems Strengthening Component developed formats for data collection. So far, data about CMWs has been collected from all Union Councils of Dadu, Tharparkar, Tando Allah Yar, and Umerkot districts. Data collection is in process in Thatta (see Table 3 below.) VHCs and UCHCs provided support in collection of information about CMWs in their areas.

Table 3: District-wise Details About CMWs Total No. of No. of No. of No. of Non- CMWs No. of CMWs CMWs Not Name of the Deployed Deployed as per CMWs Deployed Deployed District CMWs not CMWs Not MNCH Traced Out of Out of 3 4 Working Working Data Traced Traced Tharparkar 32 26 26 0 4 0 Dadu 145 74 21 53 11 12 Tando Allah Yar 55 52 47 5 18 3 Umerkot 80 76 65 11 9 8 Total 312 228 159 69 42 23

Table 4 provides data on TBAs. The data was collected with support from VHCs.

Table 4: District-wise Details About TBAs No. of Union No. of TBAs Name of the Councils From No. of TBAs Trained by NGOs Untrained TBAs District Where Data Was Identified Under Different Collected Projects Dadu 5 53 35 18 Tando Allah Yar 4 51 04 47 Umerkot 3 119 107 12 Tharparkar 5 126 53 73 Thatta 5 165 165 0 Total 22 489 361 128

3.1.6 Provide Technical Support to Strengthen and Improve Coordination of Health Functions at Federal Level and Between Federal and Provincial Governments

During this quarter, JSI met the Federal Health Minister and the Director General of Ministry of National Health Services, Regulations, Coordination, to discuss areas of collaboration and support. The Director General promised to hold a meeting of Health Systems Strengthening Component and Health Services Academy to finalize the technical assistance required such as EPI, health information resource center, and

3 A few CMWs are working at private clinics. 4 A few non-deployed CMWs are also working at private clinics.

Component 5: Health Systems Strengthening Quarterly Report January-March 2014 19 coordination mechanism between federal and provincial governments. This activity will start in the next quarter.

3.1.8 Advocate on Issues Related to Accountability and Transparency in Pakistan’s Mixed System

The Health Systems Strengthening Component finalized and circulated a Request for Procurement (RFP) to produce a documentary based on the book Choked Pipes with the purpose of generating public demand for better health care quality and coverage in Pakistan by highlighting the need for certain reform to improve health governance, financing, and service delivery. The RFP included USAID’s feedback and a request to waive marking requirements for the documentary was approved by the Mission.

The RFP was advertised on Heartfile and JSI’s websites on February 21, 2014, and by March 30, which was the closing date for submission of bids, five bids had been received. Heartfile constituted a Technical Committee and a Procurement Committee and drafted their separate Terms of Reference. In addition to representation from Heartfile and JSI on both the committees, the Technical Committee included independent experts on documentary making. As per the Terms of Reference, the duties of the Technical Committee include:  Providing technical oversight of the procurement process, including oversight of communications.  Participating in conference/video calls with bidders, if scheduled.  Developing technical criteria and related norms for rating bidders.  Selecting the most suitable bidder on technical grounds.  Participating in the final selection meeting, which will be a joint meeting with the Procurement Committee.

During the documentary making process, the Technical Committee will:  Participate in review meetings and provide feedback during the pre-production phase  Participate in review meetings and provide feedback during the testing phase before screening

The mandate of the Procurement Committee is as follows:  Develop criteria for rating bidders based on financial robustness of the bidding organizations.  Develop criteria for rating bidders based on financial robustness of the financial proposals.  Scrutinize financial bids.  Participate in the final selection meeting, which will be a joint meeting of the Technical Committee and the Procurement Committee.

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IR 3.2 Improved Management Capacity at Provincial and District levels within the Health Department

3.2.1 Provide Technical Support to Design and Develop Capacity Building Strategy

Systems Level

The Health Systems Strengthening Component is currently supporting the DOH to design and develop a capacity building strategy which will help the DOH in articulating desired performance levels based on mandate and priorities. As a first step, a comprehensive assessment of existing capacity to determine performance gaps is necessary – followed by the development of an operational plan to enable government stakeholders and development partners to identify prioritized, action-oriented interventions in which to invest. During this quarter, USAID and the DOH approved the Terms of Reference for the capacity building strategy, and JSI began the process of hiring two international consultants for the assignment. They are expected to start work during the April-June quarter.

Organizational Level

During this quarter, the Health Systems Strengthening Component provided technical assistance to the DOH to conduct assessment of the Provincial Health Development Center (PHDC), Jamshoro. The purpose was to propose recommendations for strengthening and/or upgrading the PHDC after reviewing its current capacities. SoSec Consulting Services, which was hired by the Health Systems Strengthening Component for the assessment, submitted draft of the assessment report on March 25. The report makes the following recommendations: 1. The DOH should ensure that pre-service induction training and in-service programs are made mandatory and are designed to enhance the professional competence of health care providers, especially those in the rural areas who teach at college and university levels. In this context, the PHDC may be upgraded as a full-fledged in-service training institute, modeled on the Civil Services Academy Lahore or National Institute of Provincial Administration, with a full-time head/director and professional trainers. In-service training should be made mandatory for all newly selected health providers in the DOH. Preference may be given to those health providers who have undertaken at least one training management course from the PHDC. 2. The PHDC should review and update all training modules in line with the current needs of the DOH. This will involve assessing the training needs of the various cadres of the service delivery and management staff. Furthermore, efforts should be made to access technical assistance to introduce additional tailor-made training courses as per the needs of public and private sector health providers. The course duration for a pre-service induction training program should be three weeks and a six week in-service program may be instituted for other cadres of health staff. 3. The PHDC should undertake operations research activities for guiding the DOH to improve service delivery and address the health challenges in the province.

Component 5: Health Systems Strengthening Quarterly Report January-March 2014 21

They can be assisted by the HSRU in policy level research to guide the health department in setting its priorities. 4. Courses related to the preparation and presentation of lectures, research paper writing, and computers training, specifically emphasizing the use of e-mail and the internet, may be included in the program. A more extensive and participatory approach may be used for training, while training about the use of modern audio- visual aids, like video conferencing, multi-media, the internet, and projectors may be offered. Additional experts in various disciplines will also be invited, including those from foreign universities. 5. The DOH should take necessary actions pertaining to the fiscal autonomy of the PHDC to generate revenue. 6. Efforts should be initiated for the preparation and approval of the act for making PHDC into the Independent Health Development Center. The DOH should identify and form a body to initiate and oversee the process over a period of 2-3 years.

Individual Level

At the individual level, the Health Systems Strengthening Component is planning to build the capacity of the health workforce of the DOH, both on a short-term and long- term basis. For short-term training, two courses offered by Aga Khan University were selected in consultation with the DOH, including quality management in health services and health sector reforms. The first batch, selected by the Capacity Building Oversight Committee, will be enrolled in April 2014. For long-term training, the Health Systems Strengthening Component held discussions with the Health Services Academy which agreed to start an additional batch of 30 mid-level managers from Sindh for Masters of Science in Public Health. The following selection criteria, which have been approved by the Capacity Building Oversight Committee, were prepared to meet the requirements of the Health Services Academy and the Quaid-e-Azam University, Islamabad, which is the degree granting institution.

1. The candidate must possess MBBS (Bachelor of Medicine & Bachelor of Surgery) or BSN/BSc Nursing degree. 2. The candidate should be a permanent employee of the DOH. 3. The candidate should have at least eight years of service in the DOH. 4. Candidates working in management positions will be given preference. 5. At least 25% of the candidates should be women. 6. The candidate must have at least 15 years of government service remaining before retirement. 7. Scoring of candidates: admission test - 50%, English language skills - 25%, analytical skills - 25%. 8. An interview of shortlisted candidates. 9. Final result will be based on academics (20%), written test scores (50%), and interview score (30%). 10. An applicant's acceptance in the course is contingent upon the receipt of all required documents, including official transcripts, by the Health Services Academy.

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Each selected candidate will submit a surety bond to the effect that he/she will serve the DOH for at least five years after completing the training.

3.2.3 Provide Technical Support to Strengthen Knowledge Management of the DOH

The Health Systems Strengthening Component held several meetings during this reporting period with the Director General Health Services and the HSRU to come to a decision about which of the two offices will lead the publication of an e-bulletin. Although it is the responsibility of HSRU to collate and disseminate quarterly reports of DHIS, the Director General Health Services was of the opinion that the responsibility for the e- bulletin should be with his office.

After the appointment of new Director General Health Services in March, the Health Systems Strengthening Component, HSRU, and representatives from the Office of the Director General Health Services met on March 21 to discuss the e-bulletin issue. It was decided that the HSRU would be responsible for developing the e-bulletin in consultation with the Office of the Director General Health Services. Nominations to the editorial board of the e-bulletin were made and the material for the inaugural issue of the e-bulletin was decided. The first issue of the e-bulletin will be published in April 2014.

3.2.4 Provide Technical Support to Institutionalize Medium Term Budgetary Framework

Although the Health Systems Strengthening Component had initiated capacity building of DOH staff on Medium Term Budgetary Framework (MTBF) in workshops arranged for the preparation of DAPs, the project had to delay the activity until the Finance Department notified the MTBF Planning Committee. The notification was issued on March 26. (See Annex 3 for the notification.)

MTBF-based budgeting is a fairly extensive process, pre-arranged on cost centers (each district, on average, having 25 cost centers) and involves identification of functions of each cost center, assessment of all resources required to perform the specific functions, identification of new initiatives (resources), key output, input indicators, costing, etc. Through the DAP development process, the Health Systems Strengthening Component provided technical assistance to districts to identify their priorities and also set key performance indicator targets for each health facility. Districts are currently preparing their budget requests using MTBF Form S-1, and the Health Systems Strengthening Component will support districts to prepare MTBF Form S-2 based on set performance targets. (Forms S-1 and S-2 are the prescribed budgeting formats under MTBF.)

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3.2.5 Provide Support to Enhance the Capacity of the DOH to Implement HRH Plan

The Human Resource for Health Strategy Sindh is being developed by WHO. Once the Strategy is finalized and approved by the DOH, the Health Systems Strengthening will start this activity.

3.2.6 Strengthen M&E of Routine EPI in Sindh

The Health Systems Strengthening Component is providing technical support to the EPI Cell of the DOH in the following areas that were identified in consultation with the relevant stakeholders: 1. Improving coordination between PPHI and the DOH 2. Registration of newborns and women of childbearing age 3. Reaching out to defaulter cases 4. Developing a monitoring framework for Sindh EPI

During this quarter, JSI’s EPI Consultant assessed the current situation of routine EPI in Sindh and submitted an inception report, along with situation analysis of routine EPI, in January 2014. As planned, the consultant conducted refresher trainings for vaccinators according to the following schedule: 1. District Kashmore (two batches) February 3 and 4 2. District Jacobabad (two batches) February 5 and 6 3. District Thatta (three batches) February 10, 11, and 12 4. District Tharparkar (two batches) February 13 and 14

One Mid-Level Managers Course was organized in Hyderabad from February 18-22 for health managers involved in routine EPI activities in Thatta and Tharparkar districts. A Mid-Level Managers Course for health managers in Kashmore and Jacobabad will be held in April. The Health Systems Strengthening Component will involve VHCs in improving routine EPI activities, particularly for the registration of the newborns and women of child bearing age on permanent EPI registers and for tracing EPI vaccine defaulters.

Component 5: Health Systems Strengthening Quarterly Report January-March 2014 24

IR 3.3 Strengthened Public Private Partnerships

3.3.1 Provide Technical Support to Explore Options and Health Care Financing Mechanisms to Address Equity and Coverage of Health Services

Short-Term Technical Assistance on Health Care Financing

As part of the short-term technical assistance to the DOH, the Health Systems Strengthening Component had engaged two consultants in October-December quarter to explore health care financing options. The technical assistance had two objectives: 1) an analysis of international and local health financing experience; and 2) recommendations of ways to adapt these experiences to the Sindh health system. The consultants submitted a report based on a literature review on health care financing in Pakistan during the October-December quarter.

In January 2014, the consultants visited Pakistan and met with stakeholders from public and private sector, including the DOH and USAID, to seek insights and clarifications around challenges of health care financing in Pakistan. They held meetings with Secretary Health, HSRU, USAID and MCH Program partners (MCHIP/Jhpeigo, PSI/Greenstar, Marie Stopes Society), Benazir Income Support Program, The World Bank, PPHI, Heartfile, and Pakistan Bait-ul Mal. They reviewed health care financing plan of Punjab and Khyber Pakhtunkhwa. They also attended the third meeting of the Health Care Financing Working Group in which the Working Group discussed different strategies to be examined by the consultants.

In February, the consultants submitted their report, titled “Sindh Province Healthcare Financing Analysis and Recommendations” to JSI. In the report they made the following recommendations for a Sindh health care financing strengthening plan.

1. Prioritize and Rationalize Health Financing  Develop a comprehensive health financing plan for Sindh.  Conduct a pilot in two hospitals in Sindh to coordinate Bait-ul-mal, zakat, hospital funds, Heartfile, and other equity fund sources. 2. Strengthen Contract Management Capacity in the DOH  Support the formal establishment of a DOH role in the management of health sector contracts.  Provide training and capacity building to DOH in contracts management. 3. Introduce/Expand Results-based Financing  Support the DOH to implement performance-based contracting of outsourced service delivery programs, such as PPHI.  The DOH should consider performance-based financing with non-contracted health facilities delivering primary health care services. 4. Support Innovative Methods to Finance Human Resources  Support the development of a human resources strategy.  Support the establishment of a temporary health worker fund using temporary contracts.

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5. Improve Public Budgeting and Financial Management  Conduct public financial management assessment for the health sector.  Provide support to MTBF process for health.  Support resource tracking for budget planning and execution.

The Health System Strengthening Component is now working with the DOH to establish, as part of HSRU, a Healthcare Financing Cell to follow up on these recommendations.

3.3.2 Provide Technical Support to Scale up Supply Side Health Equity Model in Sindh

The Heartfile Health Financing (HHF) program is being scaled up incrementally. Since the program’s commencement under the Health Systems Strengthening Component, 104 patients have been supported for the medical treatment they needed. Of these 104 patients, 83 were female and 21 were male children. The figure of 104 includes 56 commitments during the January-March 2014 quarter, of which 39 were female and the remaining 17 male children. See Table 5 and Table 6 below for details.

Table 5: Commitments to Date Since the Start of the Project Name of the Hospital No. of Commitments

Liaquat University Hospital, Hyderabad 85 Benazir Bhutto Hospital, Rawalpindi 7 Pakistan Institute of Medical Sciences, Islamabad 12

Total 104

Table 6: Commitments During January-March 2014 Name of the Hospital No. of Commitments Liaquat University Hospital, Hyderabad 48 Benazir Bhutto Hospital, Rawalpindi 4 Pakistan Institute of Medical Sciences, Islamabad 4 Total 56

Up-gradation of mHealth Enabled Technology Platform for MNCH

The mHealth technology component of HHF required some additional/advanced features to effectively execute assistance operations in the maternal and child health arena in Sindh. The Health Systems Strengthening Component has commissioned work to develop software modules/upgrades in this respect. HHF conducted eight detailed sessions during the reporting period with its software development partners to formalize these requirements. These features include: 1. Advanced request initiation where multiple items can be requested for a patient at the time when a financing request is being initiated. 2. Advanced communications: The system generated SMS/email communication capabilities of the system need further refinement for preview, multiple email/SMS lists, configuration tool, etc.

Component 5: Health Systems Strengthening Quarterly Report January-March 2014 26

3. Service Delivery Loops are needed to more efficiently handle repeated service deliveries for a single patient at different points in time. 4. Advanced workflow: The financing requests current workflow is at a disadvantage when it comes to handling various real life scenarios. An advanced workflow with some intelligence put into it is likely to alleviate such a disadvantage 5. Reports: Existing reports are being upgraded to implement better oversight, monitoring and fiduciary control from the Heartfile central office in Islamabad. 6. HHF Web: The HHF web is being revamped. Enhancements are planned which will enable it to fully capitalize upon all other features ordered in this release. 7. Integration of the in-use accounting software with the mhealth platform for MNCH will allow export of data automatically eliminating errors.

New Unit Enrollments

During the quarter, the Health Systems Strengthening Component scaled up HHF program to three more hospitals, bringing the total number of partner hospitals under HHF to five. The three hospitals enrolled this quarter include Benazir Bhutto Hospital, Rawalpindi, National Institute of Cardiovascular Diseases, Karachi, and Children’s Hospital at the Pakistan Institute of Medical Sciences, Islamabad.

Department of Obstetrics and Gynecology, Benazir Bhutto Hospital, Rawalpindi

In March 2014, the Health Systems Strengthening Component visited Benazir Bhutto Hospital’s Department of Obstetrics and Gynecology and conducted a needs assessment workshop with the objective of explaining the HHF program, the modalities of identifying patients who run the risk of spending catastrophically on health care or foregoing care in the process, and the logistics of registration. The needs assessment tools have been shared with the relevant staff of the hospital and follow up is being done.

National Institute of Cardiovascular Diseases, Karachi

Following several earlier discussions with the Chief of the Pediatrics Department at the National Institute of Cardiovascular Diseases in Karachi, HHF extended an invitation to enroll the Pediatric Department in March, and then organized a one-day orientation workshop on March 24. Heads of the HHF patient enrollment and hospital liaison departments conducted the workshop using audio visual tools (multimedia and presentations) to demonstrate request initiation, eligibility and priority determination, as well as service delivery and its tracking.

Pediatric Surgery, Children’s Hospital, Pakistan Institute of Medical Sciences

The Pediatric Surgery Unit at Pakistan Institute of Medical Sciences was enrolled in the HHF program in March 2014. The Unit is a referral site for a vast catchment area and is the leading institution for the correction of congenital malformations, and other lifesaving and disability averting surgically treatable conditions. A preliminary needs assessment workshop was followed by staff orientation.

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Exploring Needs

Jinnah Post-graduate Medical Institute is one of the USAID approved sites for heath financing. However, its related child health institution, the National Institute of Child Health, although physically and functionally contiguous with Jinnah Post-graduate Medical Institute, now exists as a separate hospital. Since the enrollment of National Institute of Child Health is critical to the mission of financial risk protection as far as children are concerned in Karachi, an exploratory meeting was conducted with the senior officials of National Institute of Child Health on March 24 to assess need and gauge the potential of collaboration. A report is being currently being compiled.

Supporting Existing Enrollments: Liaquat University Hospital Units

On March 25, the Health Systems Strengthening Component visited Liaquat University Hospital, Hyderabad, for follow up meetings. The agenda encompassed the following: 1. An overview of patient statistics in Liaquat University Hospital since its registration in HHF; 2. Issues regarding change in treatment packages; 3. Discussion on introduction of new vendors in the system; 4. Issues in service delivery and consumption monitoring; and 5. Initiation of new treatment packages for registration in some units.

To strengthen fiduciary oversight, the Health Systems Strengthening Component organized a meeting with the vendors at the Liaquat University Hospital to discuss several parameters. Implementation of IT and financial controls on various modules were reinforced. These included the following modules: modes of request initiation, eligibility ascertainment, service delivery, invoicing and payments, and variation in brands. During the reporting period, HHF conducted training via skype for new service requesting individuals for Liaquat University Hospital on request processing. The training included process reconfiguration for Out-Patient Department patients, request initiation process, service delivery, and consumption tracking. The training also focused on issues regarding food and travel of patients, variations in brands, and patients requiring long term follow up, etc. By the end of the training, service requesting individuals were equipped with the templates required for request initiation on their cell phones.

Training of Socio-economic Verifiers – Karachi and Hyderabad

Heartfile conducted capacity building workshops of socio-economic verifiers in Hyderabad and Karachi from March 24 to March 26. The objective of the workshops was to orient socio-economic verifiers on how to log in and interact with the HHF technology platform. Tracking of tasks for completion and archiving of relevant activities for complete documentation, including patient pictures, medical documents, patient financial agreement, etc., were also part of the workshop. Simulation exercises were also included, and a thematic assessment form was discussed in detail. Verifiers were trained in the use of IT equipment with hands-on practice.

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3.3.3 Provide Technical Support to Improve Stakeholder Coordination to Strengthen Health System

DHPMTs provide a promising opportunity for inter-sectoral coordination at the district level. A DHPMT provides a platform for sharing and exchanging views, information, experiences, and resources for improving the health system at the district level. The Health Systems Strengthening Component is providing technical support at the district level to utilize this important forum to improve coordination between various projects, programs, and departments working on health and population issues.

The RMNCH Steering Committee is another forum with the potential to ensure coordination at a high level. The Steering Committee is mandated to set policies, prioritize strategies, identify targets, oversee the agreed plan of actions, etc. The Health Systems Strengthening Component, along with the DOH and Population Welfare Department, provides technical support to the Steering Committee.

3.3.4 Provide Technical Support to Build an Urban Primary Health Care (UPHC) System through Public-Private Partnerships for Addressing Needs of Low-income Urban Settlements

During this quarter, the Health Systems Strengthening Component began drafting a concept paper on UPHC system.

3.3.5 Provide Technical Support to Jacobabad Institute of Medical Sciences to Maximize Effectiveness and Efficiency of its Board of Governors

The Health Systems Strengthening Component is currently providing technical support to Jacobabad Institute of Medical Sciences (JIMS) to: (i) develop and document comprehensive rules and regulations; (ii) develop a human resources strategy and human resources management plan; and (iii) develop a business plan.

IV. Coordination

Coordination with the DOH

During the reporting quarter, the Health Systems Strengthening Component held meetings with the Director General Health Services and his staff and HSRU to discuss technical support it is providing to the DOH in various areas. JSI leadership met with the EPI, MNCH Program, Finance Department, Population Welfare Department, PPHI, and other stakeholders. A provincial level meeting chaired by Secretary Health was organized to share the concept paper and roadmap for the technical assistance in the following areas:  Strengthening of M&E of routine EPI  Assessment of PHDC  Separation of management cadre  Health care financing

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The purpose of the meeting was to apprise all stakeholders on the above-mentioned technical assistance to avoid duplication and to build synergies with ongoing programs.

Coordination with USAID’s MCH Program Partners

On March 6, JSI attended the sixth quarterly meeting of USAID’s MCH Program implementing partners. Additionally, the Health Systems Strengthening Component’s staff regularly participated in meetings of the M&E and Behavior Change Communication (BCC) Working Groups. In addition, JSI organized the third meeting of the Health Care Financing Working Group, which it chairs, during this quarter The Health Systems Strengthening Component also participated in USAID’s mission-wide Communications Working Group meetings organized by the Office of Development, Outreach, and Communications.

V. Monitoring, Evaluation, and Reporting

During the reporting period, the Health Systems Strengthening Component revised its Performance Indicator Reference Sheets and submitted them to USAID. JSI also submitted 12 weekly activity reports and a quarterly report. With feedback from USAID and MCH Program partners, the project prepared and designed a poster using the data from Pakistan Demographic and Health Survey 2012-13. The poster presents urban- rural differentials in demography and maternal and child health in Sindh. The poster will be printed by PSI/Greenstar and distributed among key stakeholders. In addition, the project developed tools for setting targets for key performance indicators for DAPs, as well as tools for monitoring and validation of activities of RSPN. The Health Systems Strengthening Component held regular reviews meetings with its three consortium partners, Heartfile, RSPN, and Contech International, to support performance monitoring of these sub-awards.

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Success Story

1. A Catastrophe Averted: Aqsa’s Story

“We will be forever thankful to you for saving our child… it was beyond our imagination that we would ever be able to treat this child.” These were a father’s reactions when our follow-up officer called to enquire about Aqsa’s health on her fifth post-operative day. Calling to check up on patients is a routine procedure at Heartfile Health Financing. Aqsa’s father’s voice was emotional, and tears welled up in the eyes of the follow-up officer while narrating the account.

Aqsa at Liaquat University Hospital, Hyderabad, where she received treatment

Aqsa’s father, Waris, had borne his share of hardship in life. After the 2005 earthquake ravaged his home and razed it to the ground, a stroke of luck gave him refuge in Hyderabad. There, he set up home in a one-room house amid the city’s squalor with his wife, two children, and elderly parents. His meager earnings as a low-end salesman were barely sufficient to provide for anything other than very basic necessities.

Memories of that nightmare on October 8, 2005, which took a massive human toll, still plagued his thoughts. His disaster-related ordeal and poverty were not the only two tragedies in his life: recently there had also been another.

Waris’ daughter, Aqsa, was diagnosed with ventricular septal defect, a congenital heart condition, when she was just a year old. As a result, Aqsa’s growth was stunted, and she suffered from repeatedly fell unconscious. She was perpetually ill, with shortness of breath and a persistent cough. Waris had taken her to three hospitals, but the treatment plan recommended in all three was the same: Aqsa required surgery. Waris’ predicament was his inability to afford it. The cost of a heart operation was expensive, even in a public hospital: Waris did not have enough money to pay for the surgery. He and his wife watched, powerless, as Aqsa suffered and her condition worsened. It had almost become a cycle—the child complaining of spells of dizziness, suddenly becoming unconscious, a doctor’s visit, surgery suggested, and then silence—a tragedy by any standard.

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Ventricular septal defect is a correctable congenital condition. In layman’s terms, it refers to a hole in the heart connecting the right and the left sides, mixing the clean and the unclean blood. It afflicts 2 in every 1,000 live births. Thirty percent of babies born with the defect have hearts that close spontaneously, but in cases when it doesn’t, surgery becomes imperative. Timely and appropriate treatment can lead to a normal life span; absence of treatment dooms a child to heart failure complications, often leading to death in early adulthood.

Waris had lost all hope when his child had another spell of unconsciousness in Hyderabad. With a heavy heart, he took her again to the hospital, knowing well what the outcome would be. But to his surprise, this time around Waris was told that with support from the American people, a project was offering support for patients with conditions like Aqsa’s. A speedy assessment followed, and Aqsa’s eligibility was confirmed within 72 hours with PKR 150,000 committed for the needed surgical disposables for Aqsa’s heart surgery. [Can you add 2 sentences about how – right now it seems like a charitable donation. We don’t want to send that message. Need to have 1-2 sentences to explain (in layman’s terms) the health financing model that makes this possible]

Four weeks later, Aqsa is doing well and in full recovery. She is healthy and can now lead a comfortable, long life with a healthy heart. Other infants and children worldwide suffer and die from ventricular septic defect every year. Through this innovative health care financing model, the MCH Program is privileged to have the capability to help children like Aqsa and their families.

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2. A Village Health Committee Demands Better Health Services

After five hours in labor, Kainat gave birth to a healthy baby at a nearby health facility. Unfortunately, Kainat began bleeding profusely soon after her delivery. The doctor informed her family that she could not treat Kainat at the health facility because of a lack of equipment and supplies – the family would have to take Kainat to the next higher level facility for immediate treatment: a district level hospital for immediate treatment. In distress, Kainat was moved to the district headquarters hospital where she was given emergency treatment that saved her life, but the medical staff there confirmed that it had been a close call: if she had arrived any later, Kainat would have died from blood loss.

18-year old Kainat, holding her baby as she relates her story

The Village Health Committee (VHC) discussed the case of Kainat. The VHC comprises men and women from the community who take note of problems faced by people in accessing health care and liaise with health care providers to resolve them or bring them to the notice of higher level forums such as Union Council Health Committees and District Health Networks. After visiting Kainat’s doctor at the facility where she delivered, VHC members learned that the facility totally lacked equipment and supplies to properly handle emergencies. The president of the VHC discussed this issue with the District Monitoring Officer of the People’s Primary Healthcare Initiative who runs the health facility. On the president’s persistence, supported by VHC members, the paperwork was completed immediately, guaranteeing emergency equipment and supplies to the healthcare facility.

As Sikander-e-Azam from Bhakuo Union Council said: “For the first time, we have a platform where we can discuss our health related issues and hold the government service providers accountable. The people feel that these committees have given them the opportunity to make a difference.” The health committees identify gaps in the public healthcare system, and then determine whom to speak to improving the system, but they can also be used to disseminate valuable information to community members.

Managed entirely by the people themselves, VHCs and Union Council Health Committees, established in 23 Union Councils in five districts of Sindh, are playing an important role in ensuring quality health services for their communities. By the end of

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March 2014, 983 VHCs had been formed or revitalized -- with over 26,000 households participating. As more families join, more people like Kainat are guaranteed to receive the healthcare they deserve.

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VII. Issues and Challenges

The coordination issues between the Director General Health Services and the HSRU continued to pose challenges during most of the January-March quarter. After the news broke out about the famine in Tharparkar, the Government of Sindh appointed a new Director General Health Services who joined in March.

Working with the Government entails another challenge: cancellation/postponement of meetings already agreed with the Government. For example, the meeting of the RMNCH Steering Committee was scheduled to be held in March but had to be cancelled because of the schedule of the Additional Chief Secretary who chairs the Steering Committee.

Establishing linkages and better coordination with the Population Welfare Department remained a challenge during the reporting period. The Population Welfare Department participated in target-setting meetings for DAPs but did not provide baseline information for family planning related targets stating that it cannot set targets for family planning as a matter of policy. It is hoped that with the formal signing of a Memorandum of Understanding between USAID and the Population Welfare Department, this situation will improve.

VIII. Activities Planned for Next Quarter  Manifesto study to track commitments of major political parties.  Advocacy with policy-makers and parliamentarians to improve governance and accountability.  Work on documentary on Pakistan’s health and general governance issues.  Publication of e-bulletin.  Orientation of DHN on local accountability through community engagement and interface with the health system and engage them with district health management to improve health services.  Quarterly meetings of VHCs and UCHCs and documentation of the community feedback about the services.  Facilitate the communities for interface with elected representatives to share the health services related issues and seek their support for improvement in service delivery.  Initiate activities related to community support to strengthen M&E of routine immunization in those areas of Thatta, Tharparkar, Kashmore, and Jacobabad districts which are not covered by LHWs.  Meetings of DHPMTs.  Finalization of DAPs.  Technical support to Jacobabad Institute of Medical Sciences.  Coordination at federal level.  Provide support to DOH for the establishment of M&E Cell.

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IX. Annexes Annex 1: District-wise Details of Private Health Facilities

Type and Number of Health Facilities Other (BDS, Medical Facilities Facilities Technician, District Major Minor Nursing Maternity LHV Midwife Nursing Doctor Located Located in Medical Total Hospital Hospital Home Home Clinic Clinic Clinic MBBS in Urban Rural areas Assistant, Areas Dispenser’s clinic) Tando 7 1 0 13 7 2 2 30 20 82 33 49 Allah Yar Dadu 18 15 2 38 23 3 2 195 75 371 229 142 Thatta 4 7 0 26 14 3 1 115 25 195 41 154 Umerkot 4 2 0 4 3 1 0 76 3 93 73 20 Tharparkar 3 11 0 1 3 0 0 40 2 60 24 36 Total 36 36 2 82 50 9 5 456 125 801 400 401

*A complete list of health facilities with addresses and contact details is available.

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Annex 2: VHCs Formed, Meetings Held, Households Organized, and Participation of Women

No. of VHCs by number of No. of No. of VHC members meetings held during % of VHCs Total Total No. of meetings who October2013-March 2014 Total households women formed households VHCs as of conducted attended District Union Council organized as of who during organized December during meetings December 2013 One Two attended Jan- as of March 2013 January- during meeting meetings meetings March 2014 March 2014 Jan-March 20 14 2014 Chatto Chand 82 1504 82 1226 82 61 51% 0 1524 Makli 29 540 29 560 29 27 91% 1 558 Thatta Gujjo 0 0 0 0 0 0 17 426 Gharo 0 0 0 0 0 0 39 1100 Sakro 0 0 0 0 0 0 34 912 Atta Mohd Pali 72 1307 44 832 72 0 59% 0 1318 Umerkot Kharoro Sayed 54 843 36 827 54 6 63% 0 864 Mir Wali 65 1222 39 1081 65 12 60% 0 1307 Muhammad Began Jarwar 69 1201 23 380 69 16 64% 0 1204 Tando Messen 47 832 6 85 47 6 48% 0 832 Allah Yar Pak Singhar 0 0 0 0 0 0 28 996 Shaikh Moosa 0 0 0 0 0 0 39 1100 Khudaabad 64 2024 59 994 64 33 36% 0 2036 Kamal Khan 52 1267 48 867 52 30 51% 0 1269 Yar Muhammad Dadu 49 1792 37 714 49 18 44% 0 1829 Kalhoro Kakar 0 0 0 0 0 0 19 445 Phulji Station 0 0 0 0 0 0 19 572 Malanhore 42 1833 41 682 42 29 93% 0 1838 Vena Bhakuo 39 2299 30 782 39 7 96% 0 2344 Tharparkar Mohrano 74 2445 62 964 74 31 92% 0 2445 Manjthi 0 0 0 0 0 0 35 859 Diplo 0 0 0 0 0 0 14 315 Total 738 19,109 536 9,994 738 276 65% 245 26,093

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Annex 3: MTBF Planning Committee Notification

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