USAID’s MCH Program Component 5: Health Systems Strengthening

Quarterly Report, January-March 2016

USAID Cooperative Agreement: No. AID-391-A-13-00002 JSI Research & Training Institute, Inc. HSS Component 44 Farnsworth Street House #6, Street No. 5, F-8/3 Boston, MA 02210 Islamabad, Pakistan 44000 +1 617-482-9485 +92 051-111-000-025 www.jsi.com

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

Table of Contents

Acronyms .................................................................................................................................... 2

I. Executive Summary ............................................................................................................. 4

II. Activities and Results ........................................................................................................... 5

IR 2.1 Increased Accountability and Transparency of Health System .................................................. 5 IR 2.2 Improved Management Capacity of Health Department .......................................................... 6 IR 2.3 Strengthened Health System through Public Private Partnerships .......................................... 10

III. Coordination ..................................................................................................................... 11

IV. Monitoring, Evaluation, and Reporting ............................................................................... 11

V. Issues and Challenges ........................................................................................................ 13

VI. Activities Planned for Next Quarter .................................................................................... 14

VII. Progress Highlights ............................................................................................................ 14

IX. Annexures ......................................................................................................................... 17

2

2

Acronyms

ADHOs Assistant District Health Officers

AKU Aga Khan University

AMR Antimicrobial Resistance

BCC Behaviour Change Communication

BCG Bacille Calmette Guérin

CEO Chief Executive Officer

CHX Chlorhexidine

DAP District Action Plan

DEO District Education Officer

DG Director General

DGHS Director General Health Services

DHIS District Health Information System

DHO District Health Officer

DHPMT District Health & Population Management Team

DHQ District Headquarter

DOH Department of Health

DPT Diphtheria, Pertussis, Tetanus

DRAP Drug Regulation Authority of Pakistan

EPI Expanded Program on

Immunization FBR Federal Board of Revenue FP Family Planning

GST General Sales Tax

HFs Health Facilities

HFA Health Facility Assessment

HHF Heartfile Health Financing

HPSIU Health Planning, System Strengthening & Information Analysis Unit

HSS Health Systems Strengthening

IEC Information, Education and Communication

IHR International Health Regulation

ISO International Organization for Standardisation

JSI R&T JSI Research & Training Institute

KPIs Key Performance Indicators

LHW Lady Health Worker

LMIS Logistics Management and Information System

LQAS Lot Quality Assurance Sampling

MCH Maternal and Child Health

MCHIP Maternal and Child Health Integrated Program

M&E Monitoring & Evaluation

MIS Management Information System

MNCH Maternal, Newborn, and Child Health

MNHSR&C Ministry of National Health Services, Regulations and Coordination

MS Medical Superintendent

MTBF Medium Term Budgetary Framework

NAM New Accounting Model

NMR Neonatal Mortality Rates

OPV Oral Polio Vaccine

ORS Oral Rehydration Salts

3

3

PC Project Cycle

PCV Pneumococcal Conjugate Vaccine

PHDC Provincial Health Development Center

PIRS Performance Indicators Reference Sheet

PKR Pakistani Rupee

POL Petroleum, Oil & Lubricants

RHC Rural Health Center

RMNCH Reproductive, Maternal, Newborn, and Child Health

RSPN Rural Support Program Network

SAP Systems, Applications and Products

SHC Sindh Healthcare Commission

SNEs Statement of New Expenditures

UNICEF United Nations Children’s Emergency Fund

USAID United States Agency for International Development

WHO World Health Organization

4

4

I. Executive Summary

The HSS Component’s activities to strengthen health systems sustained momentum during the second quarter

of project year 3. Technical assistance to reinforce the district health system has improved coordination and

performance at district level to address health-related issues and challenges. The performance analysis of the

ninth District Health & Population Management Team (DHPMT) meeting held in all districts showed that 10

districts scored above average in last four meetings, according to the DHPMT performance scoring criteria.

To improve the quality of District Health information System (DHIS)/Logistics Management Information

System (LMIS) evidence-based decision-making, the HSS Component’s team continued its technical support to

health facilities and monitoring and evaluation (M&E) cells in the offices of respective district health officers.

In addition, the lady health supervisors in 11 Sindh districts were given class room training and hands on

practice to enter LHWs monthly report on how to start data entry in LHW-MIS. During the month of March

2016, performance of 74% of the LHWs was entered in the software by the respective LHSs. Technical

backstopping was continued to institutionalize medium-term budgeting, in collaboration with Economic

Reforms Unit of the Finance Department Government of Sindh, to all district-level cost centers, including six

districts of Karachi, in preparation of their respective annual budgets 2016–17.

In compliance with the Sindh Local Govt. Act XLII of 2013 to revert power to the provincial level, the HSS

Component is providing technical assistance to the DOH to improve management functions and to refine

structures at three levels: provincial (Directorate of General Health Services Sindh), divisional (director of

health services), and district (district health office). Technical and financial assistance also continued in four

pilot districts of Sindh to broaden the immunization coverage. The total number of children 0-23 months and

pregnant women registered was 35,908 and 14,724 respectively. The increase of children ages 0-23 months

who received DPT1, DPT2, and DPT3 from Oct–Dec, 2015 to Jan–Mar, 2016, was 93 percent to 96 percent; 79

to 86 percent; and 67 to 77 percent, respectively.

The reports generated to reflect findings of health facility assessment at the levels of tehsil headquarter

hospitals and rural health centers were completed, while the report generation for basic health units

continues. The report on district headquarter hospitals was finalized. The HSS Component, in collaboration

with the respective departments of health, helped the Ministry of National Health Services Regulation and

Coordination (MNHSR&C) develop provincial plans for chlorhexidine (CHX) scale-up in Sindh and Punjab. In

addition, the HSS Component facilitated the first-ever meeting between all CHX scale up stakeholders

(MNHSR&C, Drug Regulatory Authority of Pakistan, development partners, and pharmaceutical companies) to

explore the possibility of register and local manufacture of CHX in Pakistan.

Under Heartfile Health Financing, 84 people received medical care worth PKR. 3,427,789. Since project

inception, 773 clients have received financial support for health recovery.

One-hundred-and four health managers from 21 districts of Sindh were trained to strengthen supportive

supervision and monitoring and evaluation. The HSS Component paid for district health managers to attend

provincial stand-alone short courses offered at Aga Khan University: 15 attended strategic planning, and nine

attended program monitoring and evaluation.

5

5

II. Activities and Results

IR 2.1 Increased Accountability and Transparency of Health System

2.1.3 Provide technical assistance to strengthen district health system

The HSS Component's cluster coordinators helped organize and conduct the 10th quarterly DHPMT meetings by leading discussion on various issues and ensuring follow-up on decisions made during previous meetings. This support has improved district-level coordination and performance. However, JSI has discussed with Contech Int. to phase out technical support to organize DHPMT meetings. In this regard HSSC has developed an SOP on importance of DHPMT and how to organize an effective DHPMT meeting with the districts. The role of HSS will be of an observer to ensure that meetings are convened and achieve the desired

objectives. We are also strategizing the cluster coordinators approach that was introduced two years back

from technical assistance to ensure compliance and implementation of HSS package by district management.

Highlights of critical decisions made during 10th DHPMT meetings include:

Ghotki: MS DHQ Hospital will be requested to improve the key performance indicators by achieving the set

targets.

Tando Muhammad Khan: The district health officer (DHO) will ask the Expanded Program on Immunization (EPI)

program director to prioritize provision of syringes for Bacillus Calmette–Guérin (BCG) vaccination.

Badin: While reviewing DHIS data, it was noticed that oral rehydration salts (ORS) remain out of stock at many

People’s Primary Health Care Initiative (PPHI)-managed health facilities. The manager of PPHI will be asked to

fix the issue.

Naushahro Feroze: A male community member will be taken on board for vertical program activities to promote

preventive health care.

Thatta: Based on community concerns regarding unlicensed practitioners, it was decided to issue them final

notices and report them to the civil judge if action is not taken.

Performance Analysis of 9th DHPMT meeting in all districts

The provincial M&E cell conducted a quarterly performance assessment of 9th DHPMT meeting in all 23

districts of Sindh and found that DHPMT performance has improved. The analysis showed that 10 districts

(Jacobabad, Shikarpur, Ghotki, Khairpur, Sanghar, Shaheed Benazirabad, Badin, Jamshoro, Sukkur, and Thatta)

scored above averages in last four meetings according to the DHPMT performance criteria. The gradual

improvement in functioning of DHPMTs and tracking the implementation status of decisions made is

attributable to the participation of DHOs and the cluster coordinators' follow-up efforts. Often,

implementation of provincial level decisions takes more time than that implementation by the district.

Status of decisions of 9th DHPMT, by type of decision

6

6

IR 2.2 Improved Management Capacity of Health Department

2.2.2 Provide technical support to improve the quality of DHIS/LMIS for evidence-based decision-making

To promote the use of DHIS data for evidence-based decision-making, the HSS Component’s cluster

coordinators visited 31 health facilities and DHIS cells at DHO to provide hands-on support to improve health

facility data reporting. Activities included orientation of facility in-charges and DHIS focal persons on applied

lot quality assurance sampling (LQAS) techniques to check DHIS data quality and accuracy; preparation of

complete monthly reports to be submitted within specified

timelines; discussion on availability of tools and extracting

information from them to enter data into DHIS; helping health

facility staff understand key performance indicators; and

assisting health facility in-charges with conducting monthly

performance review meetings. After each visit, the cluster

coordinators shared written feedback with respective DHOs

and in-charge health facility person and asked them to take

corrective measures. In addition, regular technical assistance is

being provided to the M&E cell at DGHS Sindh office for

reviewing data to provide feedback to the districts about the

quality of their reported data using DHIS. Moreover, the lady

health supervisors in 11 districts of Sindh (Hyderabad, Sujawal,

Tharparkar, Larkana, Kember, Sanghar, Shaheed Benazirabad,

Jacobabad, Shikarpur, Jamshoro, and Karachi) were

coordinated on how to start data entry in the lady health worker management information system (LHW-MIS).

2.2.3 Provide technical support to institutionalize medium-term budgetary framework (MTBF)

To institutionalize medium-term budgeting, the HSS Component is providing continuous technical

backstopping in collaboration with Economic Reform Unit of the Finance Department Government of Sindh, to

all district-level cost centers for preparation of respective annual budgets 2016-17. Technical assistance is also

provided to the DOH for consolidation of budget demand 2016–17 in the Economic Reform Unit database

format and if required, for submission to Finance Department for further review and revision.

2.2.4 Provide support to enhance the capacity of DOH to implement human resource for health plan

78 69

4 27

32 16

3

31

-

50

100

150

Admin Coordination Policy Resources

Decisions Implemented Pending Decisions

The technical support covered:

Use of computer-based tools to conduct gap analysis of human resource and equipment to prepare SNEs (statement of new expenditures) request for physical assets.

Review of need-based operating expenses in accordance to KPIs for the procurement of:

1) laboratory consumables 2) medicine and supplies

Applying appropriate tools and methods to rationalize demand for non-salary expenses, such as utility bills and general stores.

7

7

The HSS Component is providing technical assistance to the DOH to improve management functions and

refine structures at three levels: provincial (Directorate General Health Services Sindh), divisional (Director

Health Services) and district (district health office). The job descriptions of health managers are modified

according to promulgation of Sindh Local Govt. Act XLII of 2013 which reverts power to provinces, reviving the

Director General Health Services (DGHS) Sindh Office in the Govt. of Sindh Health Department Letter No. E&A

(HD) 10-14/2016 dated 26th February 2016. The HSS Component’s team helped DGHS revise its organogram

and key areas and functions of proposed positions at the aforementioned three levels.

8

8

2.2.5 Strengthen M&E of Routine EPI in Sindh

The HSS Component continued technical and financial assistance in the four pilot districts of Sindh (Jacobabad,

Kashmore, Tharparkar, and Thatta) to broaden immunization coverage. Details of total children registered and

vaccinated with antigens as of March 2016 since project inception in all pilot districts are available in annex 2.

Activities to support immunization coverage (Jan–Mar 2016)

Description Status

Total number of children (0-23 months) registered 35,908

Total number of pregnant women registered 14,724

Percent increase of children receiving DPT 1 from Oct–Dec,

2015 to Jan–Mar, 2016

93% to 96%

Percent increase of children receiving DPT 2 from Oct-Dec, 2015 to Jan-Mar, 2016

79% to 86%

Percent increase of children (0-23 months) receiving DPT 3

from Oct–Dec, 2015 to Jan–Mar, 2016

67% to 77%

Total number of immunized pregnant women 25,601

Total number of awareness sessions conducted 4,680, attended by 22,950 men and 27,437 women.

% of card retention 2,742 villages randomly visited and card retention for children and women was 90% and 87%, respectively.

Number of text messages sent More than 10,000

Number of meetings to help local support organizations accelerate immunization coverage.

280

2.2.6 Provide technical support to the Sindh Health Care Commission

The Secretary of Health expressed keen interest to accelerate the process of establishing Sindh Health Care

Commission (SHC) when the HSS Component team presented a concept note on the subject during a meeting.

At the request of the HSS Component’s Chief of Party, the DOH nominated Dr. Ejaz Khanzada as the person to

accelerate SHC activities. In anticipation of the volume of documentation that will be involved and to avoid

delays after receiving go-ahead from DOH, the HSS Component started preparing for a series of upcoming

meetings. The assigned technical team worked on: 1) initial drafts for stakeholders’ review on the rules of

governance and licensing regulations; 2) a business plan structure; 3) a comparative analysis of available

standards including the Punjab Healthcare Commission, Pakistan Standards and Quality Control Authority,

Ministry of Science and Technology, and Khyber Pakhtunkhwa’s Improving Quality of Healthcare Services

project; 4) drafts of key documents to support the work of technical committees and the board of

commissioners (terms of reference for the committee to nomination a board of commissioners; code of

conduct for an SHC technical advisory committee of SHC, and a policy document for board of commissioners).

Once the commission is operational and technical committees are in place, these draft documents will

expedite processes for developing standards and licensing and regulations.

2.2.8 Health Facility Assessment

Following completion of the data entry and analysis of the information collected for the health facility

assessment (HFA), reports for tehsil headquarter hospitals and rural health centers are complete and being

reviewed by USAID. The report on basic health units is being drafted. The report on DHQ Hospitals has been

reviewed by the Director General Health Services Sindh and USAID and is complete. It is also expected that

9

9

the HFA findings will be uploaded on Pakistan Health Information System dashboard for use in policy-making

and planning activities. Events to coincide with the release of the data are being planned.

2.2.9 Provide technical support to strengthen and improve coordination of health functions at federal

level and between federal and provincial governments

The HSS Component provided technical support to MNHSR&C for the following:

National Health Vision Document

A draft of the National Health Vision document written and has been submitted to MNHSR&C for review. The

HSS Component also helped MNHSR&C prepare presentations for meetings about the document.

Establishment of Health Planning, System Strengthening, and Information Analysis Unit (HPSIU) at

MNHSR&C

On Jan 12th, the HSS Component-sponsored consultant for HPSIU briefed the Minister of State for Health,

Secretary Health, and DG Health at MNHSR&C about different initiatives in the health sector such as the

revitalization of National Health Information Resource Center. The Balochistan DOH was supported to develop

trainings on using DHIS, district user-names/passwords domain formulation for accessing DHIS, and

preparation of related documents to conduct DHIS orientation in Quetta. In Feb 2016, a brief on malnutrition

in Pakistan was prepared for MNHSR&C representatives and was presented at the National Parliamentary

Moot Session on Feb 17-18, 2016. The HPSIU will support the health system approach; equity and coverage

across country; oversight and coordination for equitable, universal, and high-quality health services; and help

planners/managers access a single knowledge hub and comply with international commitments through

improved reporting.

Framing rules of business for ISO certification of MNHSR&C

Following the MNHSR&C’s approval, the International Organization for Standardization (ISO) certification

implementation plan will start in the upcoming quarter.

Developing a national policy document for antimicrobial resistance (AMR) containment

Following the formation of technical working group for AMR surveillance and a strengths, weaknesses,

opportunities, and threats analysis of major laboratories with microbiology facilities, a national consultative

workshop involving experts from all related fields—veterinary, animal, agriculture, and education

departments (national and provincial), and public and private health sector representatives including Drug

Regulatory Authority (DRAP)of Pakistan—was held. Workshop participants discussed ensuring patient safety,

increasing coordination across sectors (human and veterinary medicine, agriculture, environment, academia,

and consumers), strengthening surveillance system, developing national infection-prevention standards, and

cultivating provincial ownership for effective implementation of a national policy document on AMR

containment. In addition, a meeting with the DRAP CEO was held to discuss how to improve implementation

of drug act and policies. All AMR stakeholders assured their contributions in the formulation of national policy.

The policy formulation on AMR containment will reduce mortality and morbidity, hospitalization costs, and

will strengthen health systems continuity and sustainability.

10

10

2.2.10 Provide technical support to federal and provincial governments in scale-up of CHX

The HSS Component, in collaboration with respective departments of health, has helped MNHSR&C develop

provincial plans for CHX scale-up in Sindh and Punjab.

Date of meeting

Outcome

Jan 20, 2016 At a meeting in Lahore it was decided to pilot CHX scale up in three Punjabi districts (Attock,

Gujranwala, and Rajanpur). It will later be scaled to nine additional districts: Bahawalnagar,

Chakwal, D. G. Khan, Khanewal, Lahore, Mianwali, Okara, Sargodha, and Sheikhupura.

Feb 18, 2016 At a meeting in Karachi it was decided that CHX scale up in Sindh will begin in two pilot districts:

Tando Allah Yar and Tharparkar. Scale up will later begin in 15 more districts.

In addition, the HSS Component helped MNHSR&C and DRAP convene a technical working group meeting on

Feb 3rd, 2016 about registration and local manufacture of CHX. This was the first time that all stakeholders

including pharmaceutical companies like Zafa, Medi Search, Akai, Friends, and global and development

partners like USAID, UNICEF, WHO, MCHIP, the USAID | DELIVER PROJECT, and Mercy Corps, came together.

The possibility of chlorhexidine manufacture in Pakistan was explored, as was stability testing in the DRAP.

2.2.11 Provide technical support to federal government in establishing International Health Regulation unit

The HSS Component-sponsored public health and finance manager has completed the costing of all the

activities identified in draft PC-1 developed for the establishment of International Health Regulation (IHR) unit.

The draft is with MNHSR&C for review. The establishment of an IHR unit will facilitate improved international

collaboration and governance to contain the spread of infectious diseases and will strengthen health systems

continuity and sustainability.

2.2.13 Strengthen the capacity of DOH to improve public financial management and explore options to

mitigate equity and coverage challenges

To improve public financial management of the DOH, the HSS Component’s team has discussed, with the

Economic Reforms Unit of the Finance Department, the options to do capacity building of Drawing &

Disbursing Officer on budgeting and expenditure tracking through use of Controller General of Accounts

Pakistan’s dashboard. The idea of giving orientation on use of basics of SAP (Systems, Applications, and

Products) tools along with NAM (New Accounting Model) and training of accountants and budget related staff

on MS Excel for further improving MTBF Budgeting at cost center level has also discussed. This proposal is now

under review of Director General Health Services Sindh for organizing orientation workshops.

IR 2.3 Strengthened Health System through Public Private Partnerships

2.3.1 Scale up supply side health equity model in Sindh

The Heartfile Health Financing (HHF) program disbursed a total of PKR. 3,427,789.00 to 84 beneficiaries for

medical care under USAID’s MCH program-sponsored HSS Component. Of these 84 beneficiaries, 24 were

boys, 19 girls, and 41 adult females. A total of 773 clients have received financial support for health recovery

since project inception date. Business process reengineering is now operational for HHF across all the health

facilities.

11

11

III. Coordination

The HSS Component continued to provide technical support to improve stakeholder coordination to

strengthen the health system. Coordination activities included institutionalizing capacity-building efforts. A

meeting with DGHS Sindh, Director PHDC and USAID’s MCH program partners on District Action Plan (DAP)

preparation training implementation was held. All agreed that all MCH program partners will provide staff to

facilitate training of trainers. The partners will share: manuals, curriculum, and BCC messages to be used

during training; with DGHS Sindh and PHDC for endorsement and printing. The HSS Component will provide

short-term technical coordination through IntraHealth to develop the training database. The HSS Component’s

cluster coordinators will facilitate district trainings on using DHIS for evidence-based decision-making.

IV. Monitoring, Evaluation, and Reporting

The HHS Component team conducted five monitoring visits to track performance of different health systems

strengthening initiatives in Sindh:

1. The HSS Component’s director of operations, program manager, and M&E program manager

supervised trainings in Jamshoro and Sukkur to train district health managers on monitoring and

supervisory tools and checklists.

2. The HSS Component’s director of operations and deputy chief of party observed the DHIS status and

the monitoring and supervisory activities at the M&E cell in DHO Jamshoro

3. The HSS Component’s team participated in the quarterly performance review meeting of DHPMT at

DGHS Sindh Office in Hyderabad. More than 80 percent attendance of notified members is ensured in

the quarterly DHPMT meetings held at Badin, Ghotki, Jacobabad, Kashmore, Shaheed Benazirabad,

Shikarpur, and Sukkur.

4. The HSS Component’s M&E program manager monitored the HSS cluster coordinator’s provision of

support to health facilities at RHC Gharo, DHQ Hospital, and the M&E cell at the DHO in Thatta.

5. In Matiari, the HSS Component’s director of operations reviewed the implementation status of the

DHIS at the health facility and the district M&E cell.

6. The HSS Component’s Immunization Specialist followed up vaccination activities in the district

Jacabobad, Kashmore and Tharparkar as well as facilitating mid-level managers’ training course for the

district Dadu and Tando Allah Yar at Karachi.

At all the monitoring activities, the HSS Component’s team noted improvements and recommended

measures to improve performance quality where deficiencies were found.

Few of the observations are given below:

It was observed that some of the health care providers in visited health facilities of Matiari and Thatta

were not recording complete data in OPD registers due to heavy OPD load.

Some of doctors did not follow daily counts of cases and count total number of cases at the last row

of each page.

In general OPD & Pediatrics OPD diagnosis columns were either found empty or with non-readable

words and phrases.

In DHQ hospital Thatta 326 normal deliveries were reported in the month of Feb 2016 whereas

PNC visits were only 3. When, M.S was asked about the reason he replied although PNC visits

12

12

were less than the deliveries but it could not be 3 only. He admitted the deficiencies in recording of

data and requested for one more round of training of staff to improve the data quality.

Few health Facilities in Thatta, Mirpur Khas and Matiari were not having CRP counter.

DHIS tools like OPD Ticket, requisition slips were found out of stock in one facility of Mirpur Khas

and was requested to the provider to get these tools from the DHO office.

Hospital waste was not properly disposed-off in visited facilities of Mirpur khas (No Pit or Incinerator

was available)

LQAS concepts were clear with care providers but some room for more improvement was available

No Nutritional Corner was found during the visit of HF in Mirpur khas

Children under 5 years were not screened for malnutrition

Some of medicine were found out of stock like Co-trimoxazole Syp, Paracetamol Syp and Tablets,

Dextrose water and Ringer lactate, ORS etc.

Tracking of follow up cases was also grey area in some of the health facilities in Thatta and Matiari.

Updated IEC material in MNCH section, X-Ray, Ultra Sound section and EPI room was not displayed

in visited HF of Mirpur khas and Matiari

During Visit of M&E Cell Mirpur khas following gaps were identified;

Condition of M&E Cell was very poor, needs repair and renovation

There was no provision of power generator or UPS for computer

No Air Conditioner was installed in M&E Cell

No Separate landline and Internet connection was available.

13

13

Reporting on USAID PIRS Progress

The performance on the selected USAID reporting Performance Indicators Reference Sheet (PIRS) is given in

the following table.

Indicator Reporting quarter performance

Indicator – 5.3.2a: Number of

trained health and

population managers posted.

During Jan– Mar, 2016, 24 people completed the provincial stand-alone short courses at

AKU. Of these, 15 completed the short course on strategic planning, and nine

completed the course on program M&E.

Indicator – 5.3.2b: Number of

districts with improved

institutional capacity scores

in management and

oversight of FP/MNCH.

80% of the districts showed improved institutional capacity in management and

oversight of FP/MNCH during the period October 2015 to March 2016.

Percentage of health facilities reporting on DHIS: In 20 of 24* (83%) districts, all HFs

submitted the DHIS reports by the due date.

DHPMT meeting performance measurement through scores obtained during the last

quarter: 21 of 23 districts scored more than seven, which is counted as excellent

performance: 21/23=91%

Districts receiving feedback on DHIS reports from the provincial M&E cell/vertical

programs: During the reporting quarter, the M&E cell provided feedback on monthly

performance on different aspects of reports generated using DHIS to all districts.

*Karachi is included in 24 districts because in this district, DHIS reporting is monitored.

Indicator – 5.1d: Number of

children who received DPT3

by 12 months of age in USG-

assisted programs.

12,639 children were given DPT 3.

V. Issues and Challenges

A few of HSS Component’s planned activities could not be accomplished during Jan–Mar, 2016 because of

compliance to interim guidelines on tax exception. Response from FBR is pending.

• The implementation of CHX plan in Gilgit Baltistan and Skardu was delayed because the scheduled training of tutors (TOT) during April, 2016 was postponed due to non-availability of the GST exception. • The CHX provincial trainings in Muzaffarabad and Peshawar was also postponed due to non-availability of GST. • The meeting on Theory of Change was scheduled during May 2016 and that has been postponed as hotels required confirmation and tax exemption 15 days in advance of the event. • The procurement of equipment is also delayed as the GST exemption is not yet received against the submitted Exception Request Package (ERP). • The vendors have cancelled the credit facility of JSI due to delay and non-payment of taxes on invoices for lodging and events. Hotel Serena and PC Peshawar have already cancelled the credit facility.

14

14

• JSI has also received the tax notice from FBR regarding non-payments of GST. This has been brought into the notice of AOR on April 30, 2016. JSI has not yet received any exception certificate against the submitted ERPs since January 26, 2016.

Progress on routine immunization coverage in all four districts (Jacobabad, Kashmore, Thatta, and

Tharparkar), was affected by vaccinators’ time being occupied with the polio campaigns instead of

routine immunization; a shortage of BCG syringes for more than six months; the month-long

vaccinators’ strike in district Jacobabad and district Tharparkar for five days; and long-vacant

vaccination posts.

Health services delivery is frequently interrupted because of human resource issues such as shortage

of paramedical staff, doctors, health specialists, and stock outs of BCG syringes.

In DHPMT quarterly meetings, the tendency to discuss management instead of the health issues

persists. Hence, in DHPMT quarterly meeting minutes, presented data does not reflect the strategy to

cope with the emerging diseases. District Education Officer (DEO) participation in these meetings is

still lacking. It was also noted that focus is on provincial level decisions as compared to district level in

DHPMT meetings.

Frequent transfers of key health personnel hampers implementation of activities, especially for DAP.

VI. Activities Planned for Next Quarter

A three-day workshop on theory of change is intended to explore and map pathways of change from

USAID investment to health systems performance improvement in Sindh. Two senior JSI staff

members will visit Pakistan in May 2016 to conduct the workshop.

The team of Heartfile Health Financing will conduct program and supply chain monitoring visits of

health care financing units in Karachi, Hyderabad, Rawalpindi, and Islamabad.

Technical and assistance to DOH to seek approval for MTBF budget 2016-17 and implementation of

DAP (2015-16) activities.

Technical assistance to:

o DHO offices in all 23 districts of Sindh to prepare monitoring and supervision plans for tracking

progress of MNCH, LHW, and EPI-related activities. Quarterly coordination meetings with

district managers to ensure the implementation of the M&E plan will be held.

o DGHS Sindh office and district managers to redefine job descriptions according to 1979 rules

of business.

o DGHS Sindh office to disseminate health facility assessment findings.

o All 23 districts for DHPMT quarterly meetings and performance assessment.

o Districts for hands-on practice and review of DHIS performance at provincial level.

o Develop linkages among DHPMTs, the M&E cell at DGHS Sindh office, and the RMNCH steering

committee to facilitate policy-level decisions.

o Local support organizations to hold community awareness-raising meetings on the importance

of immunization and card retention.

o Hold review meetings to track progress of routine immunization activities at union council,

taluka, and district levels.

VII. Progress Highlights

The HSS Component supports 7.1 percent chlorhexidine digluconate scale-up to reduce neonatal mortality

15

15

Despite the decade-long push of the

Millennium Development Goals, global

progress to dramatically reduce neonatal

mortality rates (NMR) has been less than

satisfactory. According to the World Health

Organization (WHO), approximately 45

percent of under-five deaths in 2015

occurred during the first month of life.

According to the Pakistan Demographic and

Health Survey 2012-13, for the last 15 years,

the NMR of the country has been stagnant at

55 per 1,000 live births. The chief causes of

neonatal deaths in Pakistan are

complications from asphyxia, severe

infections, and congenital abnormalities. In

2013, the application of chlorhexidine (CHX) digluconate 7.1 percent as an antiseptic to prevent umbilical cord

infections has emerged as one of the most promising innovations for newborn health. Following the WHO

recommendations on using CHX for newborn postnatal care, the MNHSR&C is, with the help of international

collaboration, scaling up CHX use across the country. At MNHSR&C’s request, USAID has entrusted the HSS

Component as the lead for strengthening coordination to prevent neonatal sepsis among all CHX stakeholders

in Pakistan.

The HSS Component team began the CHX scale up coordination process and provided short-term technical

and financial assistance in June 2015. Penny Dawson, a senior technical advisor at JSI and Leela Khanal, project

director of JSI’s Chlorhexidine Navi Care program in Nepal, visited the HSS Component’s team in Pakistan to

discuss how to adapt best practices for mass distribution of CHX in Nepal to Pakistan’s cultural context. They

agreed that a national action plan for CHX scale up should be developed and endorsed by all the key

stakeholders (MNHSR&C, DRAP, provincial departments of health, WHO, UNICEF, MCHIP, and Mercy Corps). In

addition, they proposed the organization of hands-on training sessions to show neonatal care-related staff

how to apply CHX. They also discussed incorporating CHX in DHIS and LMIS recording and reporting systems.

In addition to assessing the need for and importation of CHX product supplies for one year; the formation of

technical working groups to standardize training manuals, job aids, behavior change communication and IEC

material to build consensus among stakeholders; and developing provincial plans for CHX implementation

were also assigned to the HSS Component’s team. A series of meetings and trainings were initiated to

accelerate the CHX scale-up process.

The HSS Component is working with the DRAP and pharmaceutical companies to assess the feasibility of in-

country CHX manufacturing. On February 3, 2016, the HSS Component convened the technical working group

meeting to discuss registration and local manufacturing of CHX. This is for the first time in Pakistan that such

type of technical working group meeting is convened.

National Action Plan Development workshop on CHX scale-up

16

16

Building Medium-Term Budgetary Framework

capacity

In 2010, the Ministry of Finance launched the

Medium-Term Budgetary Framework (MTBF) to make

the link between resources allocated through the

federal budget and the results to be achieved in

service delivery (outputs) and impact (outcomes)

more transparent.

In 2014, the Department of Health Sindh, with

technical assistance from the HSS Component team,

became the first province in Pakistan to prepare and

submit budget estimates in accordance with MTBF

guidelines to Finance Department for the release of

funds. The HSS Component team has trained the staff

at all 580 cost centers (the budgetary unit of MTBF) in

Sindh to identify priorities and make realistic health service delivery goals so that budgeting can be done

accordingly.

Notable outcomes of this technical support were:

1. Separate allocations for health awareness campaigns, capacity building, and monitoring and

supervision activities.

2. Districts noticed that the monitoring activities were being charged to codes like ‘POL charges,’ which

are usually used for activities related to travelling. In the presence of limited resources, administrative

activities are usually prioritized and monitoring activities are not. Therefore, each district prepared

budget estimates for a minimum of two vehicles to transport teams of eight-to-ten health managers

for field monitoring, amounting to a total of PKR 37 million.

3. For many years, no allocations for in-service training programs, orientation, or staff refresher trainings

were made. All districts planned a number of staff trainings, for a total budget demand of PKR 120

million.

4. All administrative departments requested that provincial IT/communication departments pay for

printing, publications, and any other media campaign. To expedite procedural formalities and

disseminate health awareness messages to local populations in a timely manner, all districts prepared

budget demands based on local market rates for printing and airing on FM radio and cable networks,

amounting to a total budget demand of PKR 224 million.

During Dec 2015 and Jan 2016, another round of trainings was organized to prepare budget estimates for

fiscal year 2016–17. Four-hundred-and nineteen participants from the 580 cost centers were trained on the

modified MTBF forms. Trainees were randomly selected to discuss their impressions of the training contents.

All agreed that these trainings are vital for knowledge enhancement on technical components of MTBF.

MTBF training workshop

17

IX. Annexures

Annex 1 – Details of key trainings held during Jan–Mar, 2016

Activity

ID

Topic Training details Participants Results

2.1.2 Strengthening

supportive supervision,

monitoring, and

evaluation functions

Feb 23–Mar 1 & Mar 7–10: Five training sessions (2 days each): first day for classroom orientation on monitoring and supervisory concepts and current status of DOH monitoring and supervisory system; second day was the field visit to different health facilities to perform exercises on filling the DOH predesigned monitoring and supervisory tools.

DHOs, ADHOs, DHIS

coordinators, focal persons of

MNCH, EPI, and LHW, and

LHW district coordination

officers.

104 health managers representing 21 districts of Sindh, (except Tando Allah Yar and Thatta), were trained.

2.2.1 Capacity building to

strengthen health

systems

Jan–Mar 2016: Two provincial stand-alone short courses at AKU: 1) strategic planning; and 2) program M&E

District health managers 15 health managers completed the strategic planning course; nine completed the program M&E course

2.2.7 Capacity development

for HSS Component’s

consortium partners

March 11, 2016:

Workshop at Heartfile’s office on

USAID’s Office of Management and

Budget “Super Circular”

Finance and admin personnel

from Contech International,

RSPN, and Heartfile.

Hands-on support to follow Super

Circular rules and regulations. The

trainees were briefed on new

interim guidance on GST to minimize

risk of disallowed cost.

18

Annex 2 – Number of antigen-vaccinated children under two-years of age as of March 2016

(pilot districts)

Overall: Four Districts Baseline Jan–Mar

2015

Apr–Jun

2015

Jul–Sep

2015

Oct–Dec

2015

Jan–Feb

2016

BCG 44,825 57,777 71,390 86,244 181,699 203,227

OPV0 23,781 30,018 35,529 42,211 108,628 122,872

OPV1/Penta1/PCV1 36,968 62,817 83,818 108,839 250,838 293,635

OPV2/Penta2/PCV2 30,869 50,742 67,837 87,991 212,888 262,265

OPV3/Penta3/PCV3 19,732 36,716 47,407 66,149 181,797 237,281

Measles 1 18,018 33,508 50,174 67,422 139,295 208,173

Measles 2 9,840 20,395 30,789 42,007 63,612 124,068

Total children registered 151,892 175,406 228,961 243,727 270,767 306,675

Annexure 3: District-wise scores obtained in nine DHPMT meetings and comparison of average

scores of 1-4 meetings and 6-9 DHPMT meetings

Sr. #

District Total Score 1st 2nd 3rd 4th 5th 6th 7th 8th 9th

Average 1st 4

meetings

Average last 4

meetings

1 Badin 9 7 9 7 9 9 8 7 8 9 8.0 8.0

2 Dadu 9 9 8 8 8 8 8 6 6 8 8.3 7.0

3 Ghotki 9 6 8 8 8 8 7 7 8 9 7.5 7.8

4 Hyderabad 9 6 8 7 7 7 9 7 8 8 7.0 8.0

5 Jacobabad 9 6 9 5 8 8 6 8 8 9 7.0 7.8

6 Jamshoro 9 5 6 8 9 9 8 8 8 8 7.0 8.0

7 Kambar Shahdadkot

9 5 7 7 6 6 6 6 9 7 6.3 7.0

8 Kashmore 9 7 8 6 5 5 7 5 8 8 6.5 7.0

9 Khairpur 9 6 7 8 7 7 6 8 8 9 7.0 7.8

10 Larkana 9 4 6 6 7 7 8 8 7 8 5.8 7.8

11 Matiari 9 6 8 7 7 7 8 7 8 8 7.0 7.8

12 Mirpurkhas 9 6 6 5 5 5 7 7 8 8 5.5 7.5

13 Nausheroferoze 9 7 6 8 5 5 7 7 8 8 6.5 7.5

14 Sanghar 9 6 7 8 8 8 8 8 9 9 7.3 8.5

15 S.Benazirabad 9 7 6 7 7 7 8 7 8 8 6.8 7.8

16 Shikarpur 9 5 8 7 6 6 8 8 9 9 6.5 8.5

17 Sujawl 9 0 7 0.0 7.0

18 Sukkur 9 6 8 5 6 6 9 7 8 9 6.3 8.3

19 Tando Allah Yar 9 5 8 6 8 8 9 6 7 7 6.8 7.3

20 Tando Muhammad Khan

9 6 8 8 7 7 8 7 7 8 7.3 7.5

21 Tharparkar 9 6 0 8 7 7 6 7 8 7 5.3 7.0

22 Thatta 9 4 8 7 8 8 8 8 8 8 6.8 8.0

23 Umerkot 9 5 9 8 6 6 6 7 8 9 7.0 7.5

19

0.0

-1.3

0.3

1.0

0.8

1.0

0.8

0.5

0.8

2.0

0.8

2.0

1.0

1.3

1.0

2.0

2.0

0.5

0.3

1.8

1.3

0.5

District

Badin

Dadu

Ghotki

Hyderabad

Jacobabad

Jamshoro

Kambar Shahdadkot

Kashmore

Khairpur

Larkana

Matiari

Mirpurkhas

Nausheroferoze

Sanghar

S.Benazirabad

Shikarpur

Sujawl

Sukkur

Tando Allah Yar

Tando Muhammad Khan

Tharparkar

Thatta

Umerkot

Average Score Increase/Decrease on the Average of first 4 and last four DHPMT meetings

20

The Health Systems Strengthening Component is funded by the United States Agency for International Development and implemented by JSI Research & Training Institute, Inc., in collaboration with Contech International, Rural Support Programmes Network, and Heartfile.