Content

Proposals in 2014


In the first call for proposals for 2014 the BMZ task force health selected the following proposals for documentation

  • Psycho-social counselling for youths in South Africa
  • Social audits in remote Nepal: a community responsive participatory tool for improved quality health service
  • Strengthening Bangladesh's Health Information Systems through Integrated Interventions

_________________________

In a second call for proposals for 2014, the BMZ task force health selected the following proposals for documentation:

  • Every Person Counts - Inclusion of persons with disabilities in Health and Social Protection in Cambodia
  • The ESTHER-approach – Peers succeeding in working for capacity development, scientific evidence and better patient care in Africa and Europe
  • Sustainable Development of a Postgraduate Public Health Academic Institute in Pakistan

These had been the proposals:

Strengthening Bangladesh's Health Information Systems through Integrated Interventions

1.    Date of Submission: 20 December 2013
2.    Applicants

Name of German programme(s) submitting this application:
Support to the Health Sector Programme, Bangladesh    

Name, title, organisation, email and phone number of main applicant from German Development Cooperation:
Kelvin Hui, Technical Advisor, GIZ   

Name, title, organisation, email and phone number of main applicant from the partner organisation(s):
Professor Abul Kalam Azad, Additional Director General (Planning & Development) & Director (Management Information Systems) Directorate General Health Services, Ministry of Health and Family Welfare 

3.    Responsible experts

Name one German Development Cooperation expert and one partner expert who will be available
a) to provide the necessary information about the approach and its results to the writer
b) to read and comment – within 14 days - on the first and the final drafts of the publication 

(Please note that individuals who made substantial contributions to the development of the programme and to its documentation will be credited as ‘Authors of the approach’. The professional writer will be credited as the ‘Writer’.)

Name, title, organisation, email of responsible partner expert:
Professor Abul Kalam Azad, Additional Director General (Planning & Development) & Director (Management Information Systems) Directorate General Health Services, Ministry of Health and Family Welfare 

Name, title, organisation, email and phone number of responsible German Development Cooperation expert:
Kelvin Hui, Technical Advisor, GIZ   

Name the German Development Cooperation staff member who will be our contact for organizing the writer’s mission in your country, setting up meetings and visits to programme sites etc.

Name, title, organisation, email and phone number of responsible German Development Cooperation staff member:
Kelvin Hui, Technical Advisor, GIZ

4.    Working title for the proposed publication

Strengthening Bangladesh's Health Information Systems through Integrated Interventions    

5.    Why should this approach be documented in the German Health Practice Collection?

Describe in what ways this approach is a) innovative and conforms to the ‘state of the art’ in its field; b) contributes to raising the profile of German Cooperation in its field (refer to policy briefs, sector strategy papers and the profile of German Development Cooperation in health or social protection, respectively); c) meets the GHPC criteria of transferability to other contexts, participation and empowerment, gender-sensitivity, sustainability

A well-functioning health information system (HIS) incorporates data across all the different levels of the health system. In Bangladesh this is exactly where the challenge lies as its health system is pluralistic and heavily fragmented. The Ministry of Health and Family Welfare (MoHFW) offers healthcare services to the citizens via a network of facilities, i.e. secondary and tertiary care services throughout the country and primary health care services in the rural districts up to community level. In the cities however, primary healthcare falls under the jurisdiction of the Ministry of Local Government, Rural Development and Cooperatives (MoLG). In most cities, MoLG does not have a network of its own health facilities and, hence, provides primary healthcare services in partnership with private not-for-profit (NGOs) healthcare service providers. These are usually funded by various development partners. Of course, all the different ministries and NGOs funded by different donors have developed their own independent health information systems. On top of this, MoHFW itself is fragmented. It has six directorates general (Health Services and Family Planning) and 32 line directors. Almost all of them have developed their own health information system, many times developed with the support of different development partners. Additionally, due to various shortcomings of the current public health care delivery system, the private not-for-profit and private for-profit healthcare services sectors are mushrooming, which also have their own health information system.

All these developed systems were all running in parallel and were unable to interchange data amongst and with each other. This resulted in an inadequate HIS with incomplete and unreliable data on health in Bangladesh. Policy makers could not tell which information was correct since different systems used by different departments yielded different data which was often of poor quality. Also, health workers were overburdened by excessive data and reporting demands from multiple and poorly coordinated sub-systems. This time consuming task resulted in loss of time for patient care and other inefficiencies.

Based on a recommendation from an evaluation report of the Sector Wide Approach (SWAP) to harmonize HIS in Bangladesh dating back to 2008, GIZ agreed to assist the MoHFW in developing a system which could do this. At this point of time no strategy or policy document on HIS was in place (nor is it now). In the absence of such a policy, GIZ Health BD opted for a pragmatic approach which brings together the government, international organizations, donor agencies, health planners and statisticians, communities, and health providers to generate the health information needed by all. GIZ Health BD recognized the need for structural reforms, and that the thematic area of a harmonized HIS is often neglected by other development partners. Hence, in 2009, an innovative and integrated approach towards HIS strengthening was started which goes beyond the collection of data only, i.e.

  • Supporting the adaption of a uniform software and infrastructure development
  • Capacity development (individual and institutional, building national and international networks)
  • Strengthening HIS governance
  • Building a culture of use of information

In line with this, the following section details the technical support provided by GIZ Health.

Creating a uniform Health Information System for Bangladesh

DHIS2 (District Health Information System version 2) and OpenMRS (Open Medical Record System) are internationally recognized (state of the art) free and open source software which have been successfully adopted in health systems of over 30 developing countries. The OpenMRS software complements DHIS2 to collect patient specific data hospitals. The global DHIS2 and OpenMRS community is supported by various development partners and philanthropy organizations, making it highly sustainable with new improved versions of the products released constantly. After a careful analysis and comparison of different options GIZ Health BD introduced the two software platforms in Bangladesh, thus, reducing costs and gaining time by adopting, instead of developing, the already established distinct software packages. In the initial stages of GIZ support, it required significant advocacy to adopt a free software against the vested interests of vendors advising the Ministry. Both softwares allow countries to collect, store and distribute health data electronically with minimal cost and ensure interoperability as they follow WHO data exchange standards. It must be emphasized that it is not only the introduction of the software which has made the approach successful. The two open source communities are prime examples of networks which are highly active offering mutual support. There are social media functions for chatting, tutorials for download and many other functions which are continuously used. Improvements done to the software and user-experiences from Bangladesh are being fed back to the network, hence contributing to further improvements, which in turn benefits other developing countries. Whereas at first Bangladesh relied on the network for support, they are now a prominent example of successful usage of DHIS2 to other countries.

Using these softwares, GIZ has supported MoHFW to develop an electronic data central repository for national health data called the National Data Warehouse. It aims to bridge the gap between the fragmented systems by bringing together information from various databases. In addition, the Data Warehouse provides rich data mining functions to generate reliable and accurate data. It is such data that decision makers need to plan and monitor health interventions across all levels of the health system.

An innovative solution to sustainability beyond GIZ support

To support the maintenance and operation of the DHIS2 software GIZ helped founding a local non-profit organization called “HISP Bangladesh”. This model of having such an independent association has proven to be successful and sustainable in other countries like South Africa, India, Vietnam and Tanzania. HISP Bangladesh is now successfully registered and will be attached to the global HISP network of non-profit organizations working on DHIS2. In the coming years, GIZ Health will continue to provide support to ensure HISP Bangladesh becomes a self-sustaining local entity, which is able to provide technical support to MoHFW and other stakeholders on DHIS2. Creating a NGO like HISP Bangladesh is an approach to ensure technical support at a high technical level to partners even after the end of GIZ’s direct support. Additionally, HISP Bangladesh receives capacity building support through trainings and on the job knowledge transfer (through actively involvement in the various MoHFW - GIZ Health Informatics initiatives).

Building local human capacity in the field of Health Informatics

Bangladesh has made impressive progress in building local capacity in public health and Information Technology. But the necessary capacity in the field of health informatics is still lacking. Professionals working in the domain of health informatics usually have other basic qualifications, i.e. medicine, public health or Information technology. To drive the country’s eHealth and HIS strengthening initiatives further, a pool of specialized Health informatics professionals is necessary. To build up local institutional capacity, GIZ is twinning a local university (BRAC University, Dhaka) with an international reputed academic institution (University of Oslo) in the field of health informatics. The output of this cooperation is a locally conducted, low cost short course for professionals working in health informatics.  Additionally, GIZ Health also facilitates capacity building of key MoHFW staff working in the area of health information system strengthening through international training and conference attendance.

The next step: Promoting the use of information

Now that the software is firmly established with the MoHFW and more and more vertical programs are adopting it, the data is more comprehensive and readily available for usage and even the quality of data has improved. As the system is in place and rolling out to other line departments is underway, the new focus of GIZ Health BD is to support partners with measures to build a culture of use of information.

Recognition of progress made in Bangladesh

The recognition of the HIS success story are directly linked to GIZ Health BD, and hence German Development Cooperation. At the same time international recognition is a strong reinforcing factor for partners that they are on the right track and motivation to further expand. The following indicators of success have been achieved:

  • UN Digital Health for Digital Development Award 2011
  • National Digital Innovation Award 2010 & 2011
  • Shortlisted as one of eleven top global innovations of 2011 by the United Nations Foundation and mHealth Alliance
  • Featured in the WHO Publication on mHealth 2011
  • The success story of Bangladesh is often presented in various international conferences and MoHFW has been consistently showing appreciation to GIZ for its assistance during these conferences
  • On a regional level GIZ Health BD is often engaged by WHO for sharing experience on the successes of its technical cooperation in this area.

Success factors

  • Change agent: The identification and continuous collaboration with a change agent in MoHFW has been a significant factor.
  • Approach: Introduction and adaptation of a state of the art approach is a major factor for the wide acceptance in the Ministry and among development partners. The approach perfectly fits the requirements of MoHFW.
  • Effectiveness and efficiency tools: Using a free and open software and its networks reduces costs substantially and increases sustainability. The continuous cycle of improvement of the DHIS2 network and its resources ensures that the software is always updated.
  • Learning environment: The support network of the DHIS2 community created a positive working environment which allowed individuals and groups to transform from a recipient of advice to provider of expertise to the network.
  • Success as reinforcing factor: National and international recognition, workshops, seminars with BD as an example create motivation to do more.
6.    What evidence on outputs and outcomes (“results”) is available to show that this approach is effective and that it has been scaled up to cover a significant proportion of the partner country’s population?

List all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach and summarize the results that they found.

Also, please explain how long this approach has been implemented and to what level/coverage it has been scaled up.

  • The implementation of DHIS2 in Bangladesh has been very successful (see above). Since it was introduced by GIZ, it is now being used across the nation primarily through GoB funding (training, procurement of hardware). The GIZ support includes capacity building of HIS personnel on DHIS2, backstopping the software customization process and training of trainers on system usage and implementation. in the meantime, health data is collected routinely, from community clinics (approx. 13.000), union sub-centres (approx. 4.000) the upazila (sub-district) health centre (459), to Government Hospitals at secondary and tertiary level (124), up to the national level, thus making Bangladesh one of the largest implementation site in the world for the DHIS2 software. The data warehouse’s central servers are set up at the MIS department of the DGHS, and are operated 15 ICT experts supported by several DP’s funding. This department is in charge of systems development, maintenance and data management. 
  • More and more departments within MoHFW are seeing the benefits of a centralized data warehouse and are now adopting DHIS2 (“ripple effect”). These include specific health programmes, such as the Integrated Management of Child Diseases, Emergency Obstetric Care, Disease Surveillance, and HIV/AIDS data (under piloting). Currently, preparations are underway to include TB service, Nutrition Surveillance of the National Nutrition Programme and the Extended Programme on Immunization. In addition, the Urban Primary Healthcare project under MoLG is working on adopting DHIS2.
  • OpenMRS, is currently being implemented in three hospitals of Dhaka through GoB funding and are currently preparing to roll out the software to another three hospitals soon.

List all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach and summarize the results that they found.

  • The GIZ SHSP programme Results Based Monitoring system, which is based on operational plans. (available internally)
  • The GIZ SHSP Project Progress Review - September 2013. (available internally)
  • Bangladesh health sector programme (Health, Population, & Nutrition Sector Development Programme). Annual Programme Review Report for the M&E thematic area, 2012 and 2013.
  • Directorate General of Health Services – MIS department bulletin/report 2012 http://www.dghs.gov.bd/licts_file/images/Health_Bulletin/HealthBulletin2012_en.php
  • Links to customized software platforms
7.    What kind of photo and film material is available and can be used for the documentation?

Please note that – should your programme be selected for documentation – you will be requested to provide 15 to 20 high resolution photographs of your programme context and your programme in action.

 Project stock photos (taken by professional photographers).     

8.    Which didactic or operational materials (manuals, guides, IEC materials, protocols) or similar can be made available for downloading from the online toolbox that will accompany the publication of this approach? 

Links to the open source community and Bangladesh customized version:
Customized DHIS2 Bangladesh:
http://dghs.gov.bd/index.php/en/component/content/article?id=456 

In addition:
DHIS2 Video Tutorial: http://www.youtube.com/watch?v=VEGpY-IWDwA 

DHIS2 community can be accessed via http://dhis2.org 

OpenMRS is usually a localized system; making it is only accessible from inside the hospital only. The OpenMRS community can be accessed here: http://openmrs.org/ 

A localized curriculum has been designed and made available, allowing BRAC University and others to conduct training and ToT’s on eHealth and HIS
http://hpnconsortium.org/materials/material-detail/72/2/10 

Factsheet GIZ SHSP – Health Information Systems
http://hpnconsortium.org/materials/material-detail/128/2/10

9.    Which itinerary and schedule would you recommend for the writer who will visit your programme to do the necessary journalistic research for this GHPC report? Whom should he or she meet and interview? Which sites should he or she visit?

Give an indication of the places the writer charged with the documentation of this approach should visit, interviews to be done, the persons who should be interviewed and sites/events/activities that should be visited/witnessed and documented. 

Day 1

Detailed briefing with GIZ staff

Day 2

Briefing with MoHFW DGHS MIS department, detailed software demonstration

Day 3

Travel to community clinic, upazila (sub district) health complex, tertiary level hospital for site evaluation on system usage

Day 4

Information compilation, discussion of document structure with GIZ

Day 5

Debriefing and next steps, travel home


10.    At which occasions, to which audiences and in which language (in addition to English) would your partner organisation and you like to distribute the resulting publication?

Name upcoming conferences and routine events and information channels through which you hope to distribute the publication:

A special event launching the publication (funded by the local project), distribution via the health sector programme and MoHFW website.     

Please note that we will contact you one year after the publication date to find out whether you were able to distribute the report as planned.

Development Work for the Benefit of Human Life - Ivory Coast

1.    Date of Submission: December 23, 2013
2.    Applicants

Family Planning and Prevention of HIV I-IV, Ivory Coast
Financing Organisation: KFW, Palmengartenstr. 5-9, 60325 Frankfurt / M. Germany                                                                                          
Programme Manager: Ms Elke BINDEWALD                                                                     

Partner Organisation:
AIMAS (Agence Ivoirienne de Marketing sociale) 06 BP 1724 Abidjan 06 / Côte d'Ivoire
Executive Director : Mr Koudou Lazare GOUSSOU                                                          

3.    Responsible experts

AIMAS / Executive Director   Mr Koudou Lazare GOUSSOU
KFW / Programme Manager  Ms Elke BINDEWALD

 4.    Working title for the proposed publication

Development Work for the Benefit of Human Life
Travail de développement au bénéfice de la vie humaine

5.    Why should this approach be documented in the German Health Practice Collection?

The Programme, which is intended to contribute to stabilisation of sexual and reproductive health and rights of Ivorian people, is working for the benefit of 6 million people: Thanks to gender based Family planning and Prevention of HIV and other sexually transmittable diseases, people are enabled to actively take care of their own lives.

In Ivory Coast an increasing demand has been expressed for modern methods of Family planning. However, as regards financial resources only a fraction of the demand is available. Taking into consideration the principle of additionality of Donors’ means, a shift towards investment in Family planning has been realized throughout the last years by the Programme and will be continued in the years to come. The new Phase of the Programme will put a focus on gender based Family planning with two thirds of financial means on this component.

Concerning the substantial under-financing of Family planning, the Ivory Coast is not unique: Reduction of maternal death and universal access to means of reproductive health represents the Millennium goal which shows the largest gap between what was intended in the year 2000 and what has been achieved by now.

The Programme is embedded in the leading sector policies outlined in the following publications:

Positionspapier „ Bevölkerungsdynamik in der EZ / BMZ“
Sektorpapier „Gesundheit in der deutschen Entwicklungspolitik“ / BMZ
„Gesundheit und Menschenrechte“ / BMZ
„Sexuelle und Reproduktive Gesundheit und Rechte, Bevölkerungsdynamik“ / BMZ „Privatsektorbeteiligung im Gesundheitsbereich“ / KFW
„Qualitatives Wachstum und Gesundheitsförderung“ / KFW
„Gender strategy of KFW Entwicklungsbank“ / KFW
„Gender und HIV/AIDS“ / KFW

6.    What evidence on outputs and outcomes (“results”) is available to show that this approach is effective and that it has been scaled up to cover a significant proportion of the partner country’s population? 

A recently published study of the United Nations gave evidence that the Ivory Coast is belonging to one out of three countries which has most successfully reduced transmission rates among young urban people: The Ivory Coast does not belong any more to those 30 countries identified in 2001 as a high prevalence country. The Programme implemented by AIMAS is the most important player in the sector.

Sixteen years ago, the proportion of people from 15 to 49 years who are living with HIV had been measured by 12 %. Today, new measurement tools indicate a level of 3,7 %. Communication campaigns have been playing an essential part in HIV prevention. This was already cited in the publication of GHPC, “TV soap operas in HIV education” in which the author Stuart Adams addressed three best practices in 2009, one of them the above mentioned Programme.

Talking about gender based Family planning, throughout the last 16 years, the proportion of women using modern contraceptive means has risen from 2,8 % to almost 13 %. Taking into account the increase of population during this period of time, this means that the number of users has doubled. Thanks to Family planning, effective birth spacing is feasible. This is a crucial factor for reducing maternal mortality which has come down from 1.000 women at the outset of the Programme to 690 women at present (maternal mortality is defined as number of women dying due to complications of births and pregnancies in relation to 100.000 life births). The reduction of undesired pregnancies with a special focus on poor population groups contributes to improve maternal health, to reduce child mortality and also to diminish poverty.

The executing agency AIMAS has steadily been increasing the efficiency of its organisation, and it is now in the state of maturity to launch the product of the IUD (intrauterine diaphragm). As the product costs of this contraceptive method are ten times less than those of the condom and seven times less than those of the hormonal pill, a wide spread impact can be achieved by the IUD. However, maturity of the implementing agency is required: In addition to on-going activities such as sensitization campaigns and sales of subsidized hormonal contraceptives (pills and injections) and condoms (male and female), AIMAS will be in charge of certifying, training and supervising public and private medical service suppliers in line with quality criteria agreed upon with the Ministry of Health.

Key Reports

“Trends in HIV prevalence and sexual behaviour among young people aged 15e24 years in countries most affected by HIV” by UNAIDS, Strategic Intelligence and Analysis Division

“Etude CAP (Connaissance, attitudes, pratiques)” by Research International

« Evaluation de l’intégration du gendre dans le Programme de Planification familiale en Côte d’Ivoire » by CARID

« Perceptions et attitudes vis-à-vis des contraceptifs injectables en Côte d’Ivoire » by CARID

« Perception, attitude et utilisation du condom féminin en Côte d’Ivoire » by CARID

Appraisal Reports by KfW

7.    What kind of photo and film material is available and can be used for the documentation?

Since communication campaigns are an essential element of AIMAS’ activities, a film production studio is belonging to the Programme which for the last 18 years has been producing an impressive variety of photos and film material of high quality. Lots of the produced films are knows not only in the Ivory Coast, but in different African countries (e.g. “SIDA dans la Cité” cited in the above mentioned publication of GHPC). The educational Soap opera “Ma femme, mon amie” (“My wife, my friend”) comprises 20 episodes and represents the largest didactic material on gender based Family planning in West Africa.

8.    Which didactic or operational materials (manuals, guides, IEC materials, protocols) or similar can be made available for downloading from the online toolbox that will accompany the publication of this approach?

A rich selection of didactic and operational materials are available for example in the online toolboy www.aimas.org with its sections « publication » and « galérie ». The online toolbox contains only a selection of the vast material available. AIMAS will highly acknowledge any further interest in their communication

9.    Which itinerary and schedule would you recommend for the writer who will visit your programme to do the necessary journalistic research for this GHPC report? Whom should he or she meet and interview? Which sites should he or she visit?

Germany / Frankfurt   KFW

Ivory Coast
Abidjan / AIMAS      Executive Director, GOUSSOU Koudou Lazare
                                    Manager Marketing Mr. APPIA SERGE-PATRICK
                                    Manager Family Planning Dr. OBODOU EVELYNE-PATRICE
                                    Manager HIV Mr. SIBOUOH GROH PHILIPPE
                                    Manager Communication Mr. BELLA KOUASSI GILBERT
                                    Mr MARIBOU, Film Director
                                    International Consultant (in selection procedure)
                                    Head of Administrative Board, Mr GABOU Vincent

Abidjan / AIBEF       Directeur Exécutif, Mr. KEI FLORENT

Communication sessions in the field and meetings with the beneficiaries should be attended. Also health posts of the official sector in which activities of AIMAS take place are recommended to be visited. Should a film production be on-going, it will be worth while witnessing. AIMAS is well prepared to organize an itinerary fitting to the purpose of the publication.

10. At which occasions, to which audiences and in which language (in addition to English) would your partner organisation and you like to distribute the resulting publication?

Apart from English, the publication should also be made available in French language

Channels for distribution:

-              International Conference on Reproductive Health / Berlin
-              Other international conferences attended by KFW members

Ivory Coast

-              Development Partners such as World Bank in Ivory Coast
-              Ministry of Health, Division of Reproductive Health and of HIV
-              Ministry of Youth
-              Ministry of Finance, Health Committee
-              Ministry of Planning
-              Atelier de restitution du Plan Stratégique de AIMAS 2012 – 2016
-              Social franchise net to be built by AIMAS
-              Health posts of the official sector

Digital channel: Web site www.aimas.org

Psycho-social counselling for youths in South Africa


1.    Date of Submission: 14.10.2013
2.    Applicants

Name of German programme(s) submitting this application:
MHIVP GIZ ZA

Name, title, organisation, email and phone number of main applicant from German Development Cooperation:
Cornelia Jager, Technical Advisor Field Support and Quality Assurance, GIZ/loveLife

Name, title, organisation, email and phone number of main applicant from the partner organisation(s):
Friederike Subklew-Sehume, Executive Manager Programme Measurement and Design, loveLife

3.    Responsible experts

Name one German Development Cooperation expert and one partner expert who will be available
a) to provide the necessary information about the approach and its results to the writer
b) to read and comment – within 14 days - on the first and the final drafts of the publication  

(Please note that individuals who made substantial contributions to the development of the programme and to its documentation will be credited as ‘Authors of the approach’. The professional writer will be credited as the ‘Writer’.) 

Name, title, organisation, email of responsible partner expert:
Scott Burnett, Senior Executive Manager: Strategy, loveLife

Name, title, organisation, email and phone number of responsible German Development Cooperation expert:
Bernd Appelt, GIZ MHIVP Programme Manager

Name the German Development Cooperation staff member who will be our contact for organizing the writer’s mission in your country, setting up meetings and visits to programme sites etc.

Name, title, organisation, email and phone number of responsible German Development Cooperation staff member:
Cornelia Jager, Advisor Field Support and Quality Assurance, GIZ/loveLife

4.    Working title for the proposed publication

Does psycho-social counselling provided through a national call centre enable young people and/ or their parents to take appropriate actions and empower them to resolve difficult circumstances in their life and thus minimize sexual and reproductive health risks including HIV infection and AIDS disease for young people in South Africa?

5.    Why should this approach be documented in the German Health Practice Collection?

Describe in what ways this approach is a) innovative and conforms to the ‘state of the art’ in its field; b) contributes to raising the profile of German Cooperation in its field (refer to policy briefs, sector strategy papers and the profile of German Development Cooperation in health or social protection, respectively); c) meets the GHPC criteria of transferability to other contexts, participation and empowerment, gender-sensitivity, sustainability

a)    Innovation:

The loveLife Call Centre receives about 500,000 calls a year. In 2012 493,603 calls were received out of which 43% were counselling calls. In 2012 more than half of the callers were female (54%) and 46% were male. As such the potential impact of the services offered to people in need is large considering that approximately 1 million people are in each age group. Further, while other telephonic counselling services exist in South Africa, loveLife’s Call Centre is the only one providing in-depth psycho-social support of this magnitude. Even globally, telephonic psycho-social support with such call volumes is exceptional and studies that measure the psycho-social impact of call centre interventions are not to be found to this date, neither locally nor internationally.

The different possibilities that people in need have to get in touch with the loveLife Call Centre are pioneering. They include toll-free hotlines, SMS requesting a call back and social media (MIXit, facebook). Amongst these the call back option is most often used by callers. It also sets loveLife apart from other call centre services in South Africa as none of them offers comparative services.

loveLife’s general approach combines HIV prevention with the promotion of youth development and fosters youth leadership. loveLife’s national Call Centre promotes open discussion around sex, sexuality and gender relations among adolescents and parents. By providing a safe space for discussion and counselling it empowers adolescents and parents to change difficult circumstances they find themselves in. The Call Centre increases the uptake of adolescent and youth friendly sexual and reproductive health services and link young people to loveLife’s life skills programmes. As such the Call Centre’s service offering is varied and ranges from providing information on loveLife existing services in communities and career guidance to detailed advice on HIV prevention and AIDS treatment including post-exposure prophylaxis and teenage pregnancy prevention as well as psycho-social support and referral services.

In the absence of published research on the effectiveness of psycho-social telephonic counselling through large volume call centres lofeLife decided to systematically review its approach and results in order to assess the impact of their call centre services. The approach used for the study is unique. It sought to test how the services are rated by its callers, how much it enable them to act and change things for the better in their own life in particular to risks related to sexual and reproductive health and rights. The study was based on a quantitative and a mixed-methods component. A quantitative questionnaire was administered to a sample of adolescents and parents who had called the loveLife Call Centre via the Plz (Please) Call Me line between 10 July and 17 October 2012. A total of 420 people who had used the Plz Call Me function were interviewed telephonically – this was 6% of the total number of callers in the specified timeline who talked to counsellors at the loveLife Call Centre for more than 10 minutes. The study population mirrored the gender breakdown of the overall callers in 2012 with 54% being female and 46% being male. The mixed-methods component involved one-on-one interviews with Call Centre counsellors and operators, who were asked to assess their own services, reflect on issues raised by callers and discuss how they thought the Call Centre could be improved.

The study showed high satisfaction levels amongst callers. Nine out of ten respondents (91%) were satisfied with the counselling they received; 76% were very satisfied and 15% were satisfied. Over nine out of 10 respondents (93%) fully agreed that they could speak openly and honestly with the counsellor. More than four out of five participants (84%) said the counselling they received was appropriate and made it easier for them to make a decision on how to proceed in addressing a problem.

In addition, the study showed that the Call Centre particularly reaches vulnerable population groups from informal settlements which are at greatest risk of new HIV infections.

b)    Raises profile of GDC

loveLife’s approach fits well within the conceptual framework of the HIV response promoted by GDC focussing on prevention with the aim of changing individual behaviour and addressing adverse living conditions. Both of these are central objectives of loveLife’s work.

GDC supports national HIV prevention strategies through strengthening multi-sector cooperation at all levels through effective AIDS councils. loveLife is part of the Youth Sector in AIDS Councils at various levels and actively involved the strategic discussions around Know Your Epidemic and Know Your Response at national and sub-national level. loveLife is the largest South African youth organisation implementing HIV prevention programmes and receives around 80% of its funding through the South African government. We therefore consider this a strategic partnership. Recognizing the role the organisation plays in the field of HIV prevention amongst young people in South Africa, GDC supports its work through the secondment of three development advisers in the areas of knowledge management (fit for the future), monitoring and evaluation (effective and efficient implementation of programmes and quality improvement of programmes (e.g. loveLife Call Centre),. While significantly funded by the South African government, loveLife as an organisation looks to diversify is funding base and strives for self-sustainability through innovative fundraising and sales approaches.

c)    Meets the GHPC criteria of transferability

Everybody in South Africa has access to the service offered by the Call Centre, whether they have money to make a call or not. As such everybody is able to participate and make use of the services offered.

The Call Centre’s approach is gender-sensitive. Callers can speak to male or female counsellors. The service offering further seems to be well received by women as 54% of the callers were female. In general, barriers to participation for men and women and adolescents have found to be low in the Call Centre.

The provision of telephonic psycho-social support that reaches and empowers the most vulnerable population groups and significant numbers of women is a programmatic approach that can be transferred to other countries. The please call me function as a free service offering to get in touch with the call centre is a low cost solution and offers great potential for other countries to partner with local cell phone providers to create such an option.

loveLife continually works on optimising the unit cost of the service offering. In 2012 nearly 500,000 calls were serviced with an annual budget of 4,7 million Rand. As such the average cost for the service offering for a call was 9.50 Rand equalling about 75 Euro cents. Given the high satisfaction levels among users this is a good foundation for making the service offering sustainable.

6.    What evidence on outputs and outcomes (“results”) is available to show that this approach is effective and that it has been scaled up to cover a significant proportion of the partner country’s population?

List all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach and summarize the results that they found.

The loveLife Call Centre has a Call Monitoring System called Avaya, which records all calls received, through which line they came and the choices the caller made at the introductory automated voice response (AVR) system. Both systems are routinely used to extract reports on the Call Centre performance. The types of reports include call duration, average handling time, line occupancy, etc. as real time reports as well as historical reports can be extracted.

In addition the Call Centre has a google-docs questionnaire through which thematic areas are covered like age, gender and origin of the caller, living circumstances and reason for calling. About 50% to 90% of the calls received and recorded on the Avaya system are captured on google-docs by the Call Centre agents. In 2012 nearly one in five callers that reached loveLife through the call back line (Plz Call Me function) wanted information on loveLife (23%). Nearly the same amount of callers (22%) wanted to discuss relationships. A further one in ten (9%) were calling about HIV, and 6% called about pregnancy. On the toll-free parent line one in three adults wanted to discuss relationship matters. Eighteen percent wanted to discuss HIV/Aids and 8% psychological issues. A further 17% called to receive info material or general information on loveLife.

Once a month the data analysis of the Avaya system and google-docs are presented to loveLife’s Management team. On a quarterly basis reports based on both systems are presented to funders.

In addition to these two systems callers are consistently asked to rate the service they received at the end of a counselling call. The data is also analysed monthly. On average about one in five callers rates the service they received and about four out of five callers regard the service as “good” on a three point scale offering bad and average as other options.

The Call Centre has an internal monitoring system that continuously monitors log in and log out times for staff and the duration of phone activities, via an auxiliary code used.

In order to underpin the existing process and output data lofeLive in 2013 embarked on a qualitative study assessing the effectiveness of the Call Centre. According to lofeLife's own research this approach is unique. It sought to test how callers are rating the counselling services, how much it enables them to act and change things for the better in their life’s in particular with reference to sexual and reproductive health and rights. While not conducted by an external agency, the Programme Measurement and Design Department of lofeLife is not linked at all to the Call Centre and drives independently internal learning processes. Unconnected field workers were recruited to administer the study overseen by the Management of lofeLife’s Measurement and Design Department. The study was based on a quantitative and a mixed-methods component. A quantitative questionnaire was administered to a sample of adolescents and parents who had called the loveLife Call Centre via the Plz Call Me line between 10 July and 17 October 2012. A total of 420 people who had used the Plz Call Me function were interviewed telephonically – this was 6% of the total number of callers in the specified timeline who talked to loveLife for more than 10 minutes. The study population mirrored the gender breakdown of the overall callers in 2012 with 54% being female and 46% being male. The mixed-methods component involved one-on-one interviews with Call Centre counsellors and operators who were asked to assess their own services, reflect on issues raised by callers and discuss how they thought the Call Centre could be improved.

The study showed high satisfaction levels amongst callers. Nine out of ten respondents (91%) were satisfied with the counselling they received; 76% were very satisfied and 15% were satisfied. Over nine out of 10 respondents (93%) fully agreed that they could speak openly and honestly with the counsellor. More than four out of five participants (84%) said the counselling they received was appropriate and made it easier for them to make a decision on how to proceed in addressing a problem.

In addition, the study showed that the Call Centre particularly reaches vulnerable population groups from informal settlements which are at greatest risk of new HIV infections. Almost half of the callers using the Plz Call Me function, whose dwelling type was recorded, lived in an urban informal settlement (46%). A quarter of the callers (24%) reported that they lived in a rural settlement, with 29% stating that their place of residence was an urban settlement. Callers were also asked about their current educational or employment status. Almost half of the callers (49%) using the Plz Call Me function reported that they were at school, with almost a third (29%) reporting that they were unemployed. A further one in ten (12%) stated that they were currently employed.

Also, please explain how long this approach has been implemented and to what level/coverage it has been scaled up.

The Call Centre has been in existence since 2000 with the two toll-free helplines. The please call me line was added in 2009 as an additional service offering. loveLife is the largest Call Centre providing psycho-social support in South Africa. It is already a national Call Centre reaching people from all provinces of the country. In 2012 nearly one in four callers (23%) were from Gauteng, followed by callers from KwaZulu-Natal (17%) and the Free State (15%). The lowest number of callers were from the Western Cape and the Northern Cape (2%). loveLife continues to promote the Call Centre also in provinces that have lower user rates. If demand increases scaling up can easily be achieved through the recruitment of additional Call Centre counsellors/operators.

7.    What kind of photo and film material is available and can be used for the documentation?

Please note that – should your programme be selected for documentation – you will be requested to provide 15 to 20 high resolution photographs of your programme context and your programme in action.

The Call Centre has a lot of interesting pictures that have been taken in the past. A little bit of film material also exists and has been used for example for the organisation’s promotional DVD. Nevertheless, additional pictures can be taken during a possible visit and onsite filming is also possible.

8.    Which didactic or operational materials (manuals, guides, IEC materials, protocols) or similar can be made available for downloading from the online toolbox that will accompany the publication of this approach?

The Call Centre team developed a Handbook about Counselling Practice as well as Guidelines for loveLife Call Centre Counsellors. A Checklist for Call Centre counsellors also exists and an Incentive Model, a Coaching Model and a Calibration Model. The Call Centre team further developed a questionnaire for quality assurance of service delivery of the Call Centre agents. With the questionnaire the team leaders are able to:

  1. assess the quality of the calls
  2. rate different aspects of the call and
  3. coach the Call Centre agents

The results are automatically translated into a performance rating. As such team leaders get an idea of what is required for further trainings. The advantage of a digital questionnaire is that one can easily get a comprehensive assessment of the quality of the call centre that the quality can be compared from month to month.

9.    Which itinerary and schedule would you recommend for the writer who will visit your programme to do the necessary journalistic research for this GHPC report? Whom should he or she meet and interview? Which sites should he or she visit?

Give an indication of the places the writer charged with the documentation of this approach should visit, interviews to be done, the persons who should be interviewed and sites/events/activities that should be visited/witnessed and documented.

The Call Centre is based at loveLife’s National Office in Johannesburg. The writer would need to visit the National Office, where interviews with loveLife’s Senior Leadership and the CEO could be conducted. Then the Call Centre can be visited and operations can be observed. Interviews can be conducted with the Call Centre Manager, a team leader, a counsellor, an operator and a groundBREAKER (loveLife volunteer). In addition the Executive Manager of the Programme Measurement and Design Department should be interviewed regarding the study design and implementation. For the interviews two days will be sufficient. On a third day a visit to one of loveLife’s implementation sites around Johannesburg could be organised so that the writer can get a feel for the living reality of the Call Centre target group and to see how the Call Centre offering is complemented with face to face engagements of young people in South Africa in the communities where they live.

10.   At which occasions, to which audiences and in which language (in addition to English) would your partner organisation and you like to distribute the resulting publication?

Name upcoming conferences and routine events and information channels through which you hope to distribute the publication:

loveLife would like to present the information to South African and international donors, the South African government and other governments in the region as well as to NGOs in general and in particular those organisations which are currently running call centres or are considering of opening up similar services.

Additionally, loveLife would like to initiate a Call Centre Exchange Platform with other South African Call Centres where best practices are shared. The publication could be used for the inception this forum. South Africa has several call centres which offer psycho social support on different topics e.g. around child support, HIV or drug abuse. The Call Centre Exchange Platform could present an opportunity to exchange experiences to discuss best practices and find synergies for the improvement of our services. The platform could further be used for mutual training, staff exchange, analysis of target group trends, the development of new processes and for discussions on the formation of a national database for people that accessed services.

loveLife can also imagine that Call Centres in Germany might be interested in the publication.

Please note that we will contact you one year after the publication date to find out whether you were able to distribute the report as planned.

"Inclusion of persons with disabilities in Health and Social Protection" – approaches from Indonesia and Cambodia

1.    Date of Submission: 20 December 2013
2.    Applicants

Name of German programme(s) submitting this application:
Sector Initiative Inclusion of persons with disabilities

Name, title, organisation, email and phone number of main applicant from German Development Cooperation:
Ingar Düring, head of Sector Initiative Inclusion of persons with disabilities

Name, title, organisation, email and phone number of main applicant from the partner organisation(s):

For the example of Indonesia
GIZ Indonesia, Social Protection Programme (SPP)
Partner: Ms. Vivi Yulaswati, Director for Social Protection and Welfare, National Planning Agency (Bappenas)

For the example of Cambodia
GIZ Cambodia, Social Health Protection Project
Partner: Cambodian Ministry of Health  (contact person tbc)

3.    Responsible experts

Name one German Development Cooperation expert and one partner expert who will be available
a) to provide the necessary information about the approach and its results to the writer
b) to read and comment – within 14 days - on the first and the final drafts of the publication  

(Please note that individuals who made substantial contributions to the development of the programme and to its documentation will be credited as ‘Authors of the approach’. The professional writer will be credited as the ‘Writer’.)

Name, title, organisation, email of responsible partner expert:

For the example of Indonesia
Ms. Vivi Yulaswati, Director for Social Protection and Welfare, National Planning Agency (Bappenas)

For the example of Cambodia
Cambodian Ministry of Health  (contact person tbc)

Name, title, organisation, email and phone number of responsible German Development Cooperation expert:

For the example of Indonesia
Bastian Veigel, Principal Advisor of the Social Protection Programme

For the example of Cambodia
Bernd Schramm, Principal Advisor of the Social Health Protection Project
Heike Krumbiegel, advisor at the Social Health Protection Project

Name the German Development Cooperation staff member who will be our contact for organizing the writer’s mission in your country, setting up meetings and visits to programme sites etc.

Name, title, organisation, email and phone number of responsible German Development Cooperation staff member:

For the example of Indonesia
Frank Schneider, advisor at the Social Protection Programme

For the example of Cambodia
Heike Krumbiegel, advisor at the Social Health Protection Project, heike.krumbiegel@giz.de

4.    Working title for the proposed publication

“Inclusion of persons with disabilities in Health and Social Protection” – approaches from Indonesia and Cambodia 

5.    Why should this approach be documented in the German Health Practice Collection?

Describe in what ways this approach is a) innovative and conforms to the ‘state of the art’ in its field; b) contributes to raising the profile of German Cooperation in its field (refer to policy briefs, sector strategy papers and the profile of German Development Cooperation in health or social protection, respectively); c) meets the GHPC criteria of transferability to other contexts, participation and empowerment, gender-sensitivity, sustainability

Inclusion of persons with disabilities is a relatively new area within international development cooperation. The enhanced consideration of persons with disabilities is linked to many questions and challenges but also offers great opportunities on the programme side. By implementing an inclusive approach, development cooperation programmes can extend the impact. Germany has committed to make its development cooperation more inclusive of persons with disabilities, a goal enshrined in art. 32 of the Convention of Persons with Disabilities and the Action Plan Inclusion of Persons with Disabilities launched by the Federal Ministry of Economic Cooperation and Development in 2013. The majority of the action plan’s measures are currently implemented, however little articles have been produced to actually show the relevance of inclusive approaches in partner countries. Generally, good practise studies published by many multilateral and bilateral organisations and civil society organisations about inclusive projects exist, however good quality articles showing the different steps towards achieving inclusion in a specific context are limited. The approaches taken by the German Development Cooperation can serve as examples on how inclusion of persons with disabilities has been integrated into specific development programmes and projects, what lessons have been learned during the process and which first outcomes can be reported in order to encourage other development cooperation stakeholders.

In Indonesia, German Development Cooperation is closely cooperating with the State Ministry of National Development Planning called Bappenas. It has a coordinating role and many key areas such as poverty reduction under its responsibilities. The partnership and resulting measures implemented jointly are crucial for systematically including persons with disabilities. German Development Cooperation advises the Ministry on how to advance the systematic inclusion of persons with disabilities in the current social security reform process covering various aspects such as social security or social services.

Regarding the Cambodian- German Technical Cooperation, the political commitment of both Cambodia and German has been translated into practice by different state and non-governmental actors such as the Cambodian Ministry of Health, GIZ operating on behalf of the German Federal Ministry for Economic Cooperation and Development, Handicap International as well as various local civil society organisations including Disabled People Organisations. The partners progressively integrated aspects of the inclusion of persons with disabilities into the design and the activities of the ‘Cambodian-German Social Health Protection Project’. The activities ranged from awareness raising workshops over trainings to community health center services more accessible to clients with disabilities. Disabled People Organisations have been involved both in planning and in implementation, thus playing a key role in the process. 

a) Inclusion as innovative approach

Indonesia: from the beginning of the intervention the process has been shaped and guided by the partner institution, which resulted in highly demand-oriented measures and outcomes (enforces sustainability and effectiveness). The approach focuses on strengthening the ownership of the partner organisation to coordinate and further develop the political dialogue on inclusion.  

Cambodia: involvement of stakeholders with different expertise and perspectives, e.g.  Handicap International with its long-tern experience in the field of disability in the country and its close networking capacities with regard to the local civil society organisations; Disabled People Organisations (DPOs) have contributed with their internal knowledge of the gaps and challenges. 

b) Inclusive programmes raise German Development Cooperation profile

Indonesia: at the beginning of the interventions in 2010, Germany was one of the first donors providing policy advice in the field of disability inclusion in Indonesia; based on the results  of a situation analysis relevant stakeholders have started a dialogue on disability inclusion at national policy level which has also influenced cooperation with other international partner organisations;

Cambodia: even before the launching of the BMZ Action Plan on the Inclusion of Persons with Disabilities in 2013, the German government committed itself to support the inclusion of persons with disabilities in the Cambodian Health Sector. Aspects of the inclusion of persons with disabilities were progressively integrated into the design and activities of the ongoing Social Health Protection Project.

c) Meeting GHPC criteria

Indonesia:

1. Transferability to other contexts: in all countries successful processes highly depend on the commitment and the capacities of the most relevant stakeholders. The approach of both identifying and bringing together  different stakeholders working and advocating on inclusion and health as well as  taking as priority measures to strengthen their coordination and technical abilities are highly relevant for similar processes  in other countries

2. Participation and empowerment: Indonesian academia and Disabled People’s Organisations were involved into the implementation of the measures, national stakeholders as well as local organisations have been empowered to steer the process of mainstreaming inclusion in political decision processes.

3. Gender-sensitivity: gender has been considered throughout the intervention

4. Sustainability: see above

Cambodia:

1. Transferability to other contexts: the focus on contribution and inclusion of different stakeholders among with Disabled People’s Organisations (DPO) themselves and their cooperation within the process is also realisable in other countries

2. Participation and empowerment: involvement of DPOs and civil society organisations was an important success factor for extending the project’s reach out and improving the access for health service clients.

3. Gender-sensitivity: gender has been considered throughout the intervention

4. Sustainability: the combination of both interventions at policy level (commitment of the Ministry of Health, awareness raising amongst government staff); as well as interventions at the community health centre level (trainings etc.) ensures long term commitment and ownership by the involved partners. 

6.    What evidence on outputs and outcomes (“results”) is available to show that this approach is effective and that it has been scaled up to cover a significant proportion of the partner country’s population?

List all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach and summarize the results that they found.

Indonesia: Progress reports, Monitoring reports,  study on disability, documentation from Berlin Conference and other publications. 

Cambodia: Progress reports, Monitoring reports, study on disability and health, Project Briefing Paper

Also, please explain how long this approach has been implemented and to what level/coverage it has been scaled up.

Indonesia: since 2010, scale up: intensity of the national dialogue, stakeholders involved, national events on disability, existing coordination mechanisms etc.

Cambodia: since 2010, , study on disability and health etc.scale up in 2013, reports by the Cambodian Ministry of Health, invested national budget etc.

7.    What kind of photo and film material is available and can be used for the documentation?

Please note that – should your programme be selected for documentation – you will be requested to provide 15 to 20 high resolution photographs of your programme context and your programme in action.

Indonesia: movie and trailer on disability, photos by Donal Husni (meet the criteria described above)

Cambodia: poster prepared for the SNHeSP, etc.

Which didactic or operational materials (manuals, guides, IEC materials, protocols) or similar can be made available for downloading from the online toolbox that will accompany the publication of this approach?

Project briefing papers and articles publications, partner publications including manuals on how to include persons with disabilities in development programmes.

8.    Which itinerary and schedule would you recommend for the writer who will visit your programme to do the necessary journalistic research for this GHPC report? Whom should he or she meet and interview? Which sites should he or she visit?

Give an indication of the places the writer charged with the documentation of this approach should visit, interviews to be done, the persons who should be interviewed and sites/events/activities that should be visited/witnessed and documented.

Indonesia: Jakarta, visit of the relevant national ministries; visit to the district where the analysis on the living conditions of persons with disabilities was done; interviews with GIZ Indonesia, Social protection Programme staff, other international donors working in the country (CBM, Worldbank etc.), DPOs and academia

Cambodia: Cambodian Ministry of Health, GIZ Cambodia, the Social Health Protection Project, Handicap international, Epicarts, local NGOs including DPOs, etc.

9.    At which occasions, to which audiences and in which language (in addition to English) would your partner organisation and you like to distribute the resulting publication?

Name upcoming conferences and routine events and information channels through which you hope to distribute the publication:

BMZ Events, other international organisations (Worldbank, ILO etc), EU
Language: German, Indonesian, Cambodian

Please note that we will contact you one year after the publication date to find out whether you were able to distribute the report as planned.

Read the factsheet: Making Health Services Inclusive

For a full-screen view click the symbol Full-screen icon below.

Social audits in remote Nepal: a community responsive participatory tool for improved quality health service

1.    Date of Submission: 30 December 2013
2.    Applicants

Name of German programme(s) submitting this application:
Nepali-German Health Sector Support Programme (HSSP)

Name, title, organisation, email and phone number of main applicant from German Development Cooperation:
Dr. Susanne Grimm, Program Manager, Health Sector Support Programme (HSSP), GIZ, Kathmandu, Nepal

Name, title, organisation, email and phone number of main applicant from the partner organisation(s):
Mr. Rup Narayan Khatiwada, Section Officer, Primary Health Care- Revitalization Division, Department of Health Services, Teku, Kathmandu, Nepal

3.    Responsible experts

Name one German Development Cooperation expert and one partner expert who will be available
a) to provide the necessary information about the approach and its results to the writer
b) to read and comment – within 14 days - on the first and the final drafts of the publication  

(Please note that individuals who made substantial contributions to the development of the programme and to its documentation will be credited as ‘Authors of the approach’. The professional writer will be credited as the ‘Writer’.)

Name, title, organisation, email of responsible partner expert:
Mr. Rup Narayan Khatiwada, Section Officer, Primary Health Care-Revitalization Division, Department of Health Services, Teku, Kathmandu, Nepal

Name, title, organisation, email and phone number of responsible German Development Cooperation expert:
Mr. Amit Aryal, National Deputy Programme Manager, HSSP, GIZ-Nepal

Name the German Development Cooperation staff member who will be our contact for organizing the writer’s mission in your country, setting up meetings and visits to programme sites etc.

Name, title, organisation, email and phone number of responsible German Development Cooperation staff member:
Mr. Tirtha Kumar Sinha,Senior Programme Officer, HSSP, GIZ-Nepal

4.    Working title for the proposed publication

Social audits in remote Nepal: a community responsive participatory tool for improved quality health service

5.    Why should this approach be documented in the German Health Practice Collection?

Describe in what ways this approach is a) innovative and conforms to the ‘state of the art’ in its field; b) contributes to raising the profile of German Cooperation in its field (refer to policy briefs, sector strategy papers and the profile of German Development Cooperation in health or social protection, respectively); c) meets the GHPC criteria of transferability to other contexts, participation and empowerment, gender-sensitivity, sustainability

 Social accountability tools such as social audits, community score cards, community monitoring and public hearings can improve efficiency and effectiveness of public services. It empowers citizens to demand accountability, exercise their right to information, raise awareness of providers’ responsibilities, increase awareness of entitlements, ensure participatory decision-making, and client-centred services. Social auditing in Nepal supports Nepal’s evolving democracy and growing social drive to increase equity and promote human rights.

The Ministry of Health and Population (MOHP) with support from GIZ and other development partners, is scaling up the use of social audits in remote public health facilities. Perhaps, for the first time in a newly formed republic, historically marginalized groups and women are provided a meaningful platform to participate and discuss their grievances with relevant government authorities and stakeholders. Participation of these communities are innovatively in-built into the process through multiple perspective gathering approaches: one-on-one interviews and focused-group discussions with women and disadvantaged groups (e.g. dalits) and a culminating mass gathering of the entire community. The one-on-one interviews and focused group discussions with marginalized communities foster their confidence to voice their grievances without fear of reprisals.

The social audit process being implemented in Nepal’s public health sector is widely accepted by the community and stakeholders. It is an easily transferrable process that culminates with a mass-gathering where information is transparently exchanged and facilitated by an independent team. An innovation in the process has been to link priorities derived through social audits and unresolved at the local level to the government.  It is integrated with the government’s bottom-up planning process to be addressed by central authorities, which has also ensured its sustainability.

This process has led to efficient use of limited financial and technical resources to mitigate difficulties being faced by the community, thereby making health services responsive to local needs. Preliminary evidence has also shown that local governments have responded to issues raised during social audits and prioritized them with future budgeting.

6.    What evidence on outputs and outcomes (“results”) is available to show that this approach is effective and that it has been scaled up to cover a significant proportion of the partner country’s population?

List all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach and summarize the results that they found.

Based on a review of social audit performance in health, the MOHP revised and updated the Social Audit Guidelines in 2012 to streamline social audits for more effective planning and utilisation. To date 21% of health facilities in 20 districts across Nepal now conduct social audits as per MOHP guidelines (STS 2012). This number surpasses the national target of 15% for 2013 suggesting that social auditing is on track to becoming institutionalised as a process for local health planning.

Achieving this commendable target required significant capacity building of local non-government organisations in independent social auditing, as well as significant building of trust, awareness and acceptability of the social audit process to health facility users, health workers, health managers and local governing bodies. The ability of social audits to effectively empower and unite communities, particularly disadvantaged populations (e.g. Dalits) with historically no outlet to voice opinions in Nepal, to address local health needs is one of the strongest outcomes of social audits. As social audits are implemented in more districts, it is evident that the process is becoming popular with local communities as an opportunity to vent concerns with health providers, and for health providers to explain their shortfalls or to share important health and service information (Nepali Times, July 2012). The process of social audits has also been noted to promote local ownership of health facilities due to the principle of joint participation of users and providers in data collection, analysis and planning (NHSSP 2011).

Additional capacity building was also developed of health facility operations and management committees to ensure effective planning based on social audit results. Local health plans contribute to district health planning and budgeting, which is in line with national policies and plans to decentralise health governance from the current highly centralised MOHP process of local health planning. In addition to supporting social audit implementation, GIZ also provided technical assistance to the MOHP in local health governance by implementing a pilot of the Local Health Governance Strengthening Programme in 2 districts. The pilot demonstrated that strengthening local governance increased the ability of health facilities to conduct social audits and to implement the findings into village health plans (81.6% of health facilities in programme compared to 33% of health facilities in non-programme) (Endline LHGSP Report 2013).

Social audits increased local financial resource mobilisation for health. Village development councils (the local government body at village level) were more motivated to invest in health upon the deliberations of social audit results. Health facilities have limited funds beyond vertical health programmes, for example to maintain infrastructure/equipment or employ critical staff. Social audits effectively highlight issues that compromise service quality and utilisation directly to responsible local governing bodies in an open public forum that stimulates their effective action. As a result, health facilities in remote districts such as Achham and Bardiya have seen a 50% increase in budgets supplemented by village development councils (GIZ HSSP flyer 2012).

With increased financial funds agreements made between health facility operations and management committees and communities are being incorporated into health plans and are being acted upon. Social audits have driven quality improvement initiatives such as improvements to ambulance transport, installation of power back systems, hiring of essential health workers, and provision of drug stocks. Each quality improvement initiative is customised to local health needs based on participatory planning. Importantly, social audits have also fostered healthier relationships between health workers and their local community to promote health worker motivation and health facility management (GIZ internal reports).    

Also, please explain how long this approach has been implemented and to what level/coverage it has been scaled up.

Although fragmented approaches to social audits existed in the public health sector, in 2010 the ministry, with support from GIZ and other development partners, consolidated multiple approaches into a comprehensive process; it was further revised by the government in 2012.  It has been scaled up in 176 public health facilities in 20 districts in 2011/12 and in 2013/14 the budget has been approved to implement social audits in 552 public health facilities in 40 out of a total of 75 districts.

The social audit process being implemented since 2011/12 is a 5-day event, which culminates with a mass-gathering on the 5th day.  Independent facilitators are used to conduct social audits to encourage the community to speak candidly and openly about their issues. 

The facilitator conducts one-on-one interviews and focused group discussions with women and ethnic minorities prior to the mass gatherings which are then presented at the mass meeting. Additionally, the facilitator also reviews the financial, programmatic, and managerial performance of the health facility and its workers, which are also presented during the mass event. The gathering is attended by the community, representatives from district health office, local leaders, political parties, NGOs, and other such stakeholders. Issues raised during the mass gathering are recorded along with the commitments made by these leaders and followed up during the social audit in the following year.

7.    What kind of photo and film material is available and can be used for the documentation?

Please note that – should your programme be selected for documentation – you will be requested to provide 15 to 20 high resolution photographs of your programme context and your programme in action.

Field photographs are available, for example photos of the social audit process (e.g. mass meetings, participants) and photos of health facility improvement as a result of a social audit (e.g. new ambulance, new staff hired).

A video documentary is available showing preparations and conduction of social audit in front of a mass gathering.  

8.    Which didactic or operational materials (manuals, guides, IEC materials, protocols) or similar can be made available for downloading from the online toolbox that will accompany the publication of this approach?
  1. MOHP “Health Sector Social Audit Operational Guidelines 2012”
  2. GIZ HSSP Flyer “Knitting local health governance tools together: quality improvement, social audit and local planning” 2012
  3. GIZ HSSP Flyer “Social audit of health facilities in Doti” 2012
  4. Publication on social audit for quality improvement of health service in the Annual Bulletin “Good Governance Campaign” (Nepali)
  5. GIZ internal reports
  6. MOPH internal reports (Nepali)
9.    Which itinerary and schedule would you recommend for the writer who will visit your programme to do the necessary journalistic research for this GHPC report? Whom should he or she meet and interview? Which sites should he or she visit?

Give an indication of the places the writer charged with the documentation of this approach should visit, interviews to be done, the persons who should be interviewed and sites/events/activities that should be visited/witnessed and documented.    

Date

Activities

Person/ participants

Location

Remarks

19 March 2014

Meeting and interaction

HSSP team

HSSP office, Teku, Kathmendu

 

20 March

Meeting with PHC-RD

Director & Mr Khatiwada

PHC-RD, Teku, Kathmendu

 

21 March

Meeting with Homnath Subedi

Homnath Subedi

 HSSP office, KTM

 

23 March

Interaction with district health officer and staff

DHO and focal person

Bardiya, Mid Western Region

 

23 March

Observation of health facilities conducting Social audit

HF incharge and HFOMC members, FCHV

Saurahawa PHCC, Bagnaha HP in Bardiya

 

24 March

Meeting with independent SA facilitator

Ashal Shasan (NGO), LDO, DHO

DHO Surkhet

 

25 March

Observation of health facilities conducting Social audit

HF incharge and HFOMC members, FCHV

Salkot PHCC, Surkhet

 

26 March

Interaction with district health officer and staff

DHO and focal person

Kailali, Far Western Region

 

27 March

Meeting with regional director

regional director of Far Western region

Far Western Regional health directorate, Dipayal

 

28 March

Meeting DHO and staff

DHO and DDCstaff.

Achham,

 

29 March

Observation of health facilities conducting Social audit

HF incharge and HFOMC members, FCHV

Kamal Bazar PHCC, Accham

 

30 March

Return to Dadeldhura

 

 

 

31 March

Dadeldhura to Kathmandu via Dhangadi

 

10. At which occasions, to which audiences and in which language (in addition to English) would your partner organisation and you like to distribute the resulting publication?

Name upcoming conferences and routine events and information channels through which you hope to distribute the publication:
Regional Annual Health Performance Review FY 2013/2014
Mid and Far Western Region, Nepal

Please note that we will contact you one year after the publication date to find out whether you were able to distribute the report as planned.

_________________________

In a second call for proposals for 2014, the BMZ task force health selected the following proposals for documentation:

  • Every Person Counts - Inclusion of persons with disabilities in Health and Social Protection in Cambodia
  • The ESTHER-approach – Peers succeeding in working for capacity development, scientific evidence and better patient care in Africa and Europe
  • Sustainable Development of a Postgraduate Public Health Academic Institute in Pakistan

These had been the proposals:

Every Person Counts - Inclusion of persons with disabilities in Health and Social Protection in Cambodia

1.    Date of Submission: 20 December 2013
2.    Applicants

Name of German programme(s) submitting this application:
Sector Initiative Inclusion of persons with disabilities

Name, title, organisation, email and phone number of main applicant from German Development Cooperation:
Ingar Düring, head of Sector Initiative Inclusion of persons with disabilities

Name, title, organisation, email and phone number of main applicant from the partner organisation(s):

For the example of Indonesia
GIZ Indonesia, Social Protection Programme (SPP)
Partner: Ms. Vivi Yulaswati, Director for Social Protection and Welfare, National Planning Agency (Bappenas)

For the example of Cambodia
GIZ Cambodia, Social Health Protection Project
Partner: Cambodian Ministry of Health  (contact person tbc)

3.    Responsible experts

Name one German Development Cooperation expert and one partner expert who will be available
a) to provide the necessary information about the approach and its results to the writer
b) to read and comment – within 14 days - on the first and the final drafts of the publication  

(Please note that individuals who made substantial contributions to the development of the programme and to its documentation will be credited as ‘Authors of the approach’. The professional writer will be credited as the ‘Writer’.)

Name, title, organisation, email of responsible partner expert:

For the example of Indonesia
Ms. Vivi Yulaswati, Director for Social Protection and Welfare, National Planning Agency (Bappenas)

For the example of Cambodia
Cambodian Ministry of Health  (contact person tbc)

Name, title, organisation, email and phone number of responsible German Development Cooperation expert:

For the example of Indonesia
Bastian Veigel, Principal Advisor of the Social Protection Programme

For the example of Cambodia
Bernd Schramm, Principal Advisor of the Social Health Protection Project
Heike Krumbiegel, advisor at the Social Health Protection Project

Name the German Development Cooperation staff member who will be our contact for organizing the writer’s mission in your country, setting up meetings and visits to programme sites etc.

Name, title, organisation, email and phone number of responsible German Development Cooperation staff member:

For the example of Indonesia
Frank Schneider, advisor at the Social Protection Programme

For the example of Cambodia
Heike Krumbiegel, advisor at the Social Health Protection Project, heike.krumbiegel@giz.de

4.    Working title for the proposed publication

“Inclusion of persons with disabilities in Health and Social Protection” – approaches from Indonesia and Cambodia 

5.    Why should this approach be documented in the German Health Practice Collection?

Describe in what ways this approach is a) innovative and conforms to the ‘state of the art’ in its field; b) contributes to raising the profile of German Cooperation in its field (refer to policy briefs, sector strategy papers and the profile of German Development Cooperation in health or social protection, respectively); c) meets the GHPC criteria of transferability to other contexts, participation and empowerment, gender-sensitivity, sustainability

Inclusion of persons with disabilities is a relatively new area within international development cooperation. The enhanced consideration of persons with disabilities is linked to many questions and challenges but also offers great opportunities on the programme side. By implementing an inclusive approach, development cooperation programmes can extend the impact. Germany has committed to make its development cooperation more inclusive of persons with disabilities, a goal enshrined in art. 32 of the Convention of Persons with Disabilities and the Action Plan Inclusion of Persons with Disabilities launched by the Federal Ministry of Economic Cooperation and Development in 2013. The majority of the action plan’s measures are currently implemented, however little articles have been produced to actually show the relevance of inclusive approaches in partner countries. Generally, good practise studies published by many multilateral and bilateral organisations and civil society organisations about inclusive projects exist, however good quality articles showing the different steps towards achieving inclusion in a specific context are limited. The approaches taken by the German Development Cooperation can serve as examples on how inclusion of persons with disabilities has been integrated into specific development programmes and projects, what lessons have been learned during the process and which first outcomes can be reported in order to encourage other development cooperation stakeholders.

In Indonesia, German Development Cooperation is closely cooperating with the State Ministry of National Development Planning called Bappenas. It has a coordinating role and many key areas such as poverty reduction under its responsibilities. The partnership and resulting measures implemented jointly are crucial for systematically including persons with disabilities. German Development Cooperation advises the Ministry on how to advance the systematic inclusion of persons with disabilities in the current social security reform process covering various aspects such as social security or social services.

Regarding the Cambodian- German Technical Cooperation, the political commitment of both Cambodia and German has been translated into practice by different state and non-governmental actors such as the Cambodian Ministry of Health, GIZ operating on behalf of the German Federal Ministry for Economic Cooperation and Development, Handicap International as well as various local civil society organisations including Disabled People Organisations. The partners progressively integrated aspects of the inclusion of persons with disabilities into the design and the activities of the ‘Cambodian-German Social Health Protection Project’. The activities ranged from awareness raising workshops over trainings to community health center services more accessible to clients with disabilities. Disabled People Organisations have been involved both in planning and in implementation, thus playing a key role in the process. 

a) Inclusion as innovative approach

Indonesia: from the beginning of the intervention the process has been shaped and guided by the partner institution, which resulted in highly demand-oriented measures and outcomes (enforces sustainability and effectiveness). The approach focuses on strengthening the ownership of the partner organisation to coordinate and further develop the political dialogue on inclusion.  

Cambodia: involvement of stakeholders with different expertise and perspectives, e.g.  Handicap International with its long-tern experience in the field of disability in the country and its close networking capacities with regard to the local civil society organisations; Disabled People Organisations (DPOs) have contributed with their internal knowledge of the gaps and challenges. 

b) Inclusive programmes raise German Development Cooperation profile

Indonesia: at the beginning of the interventions in 2010, Germany was one of the first donors providing policy advice in the field of disability inclusion in Indonesia; based on the results  of a situation analysis relevant stakeholders have started a dialogue on disability inclusion at national policy level which has also influenced cooperation with other international partner organisations;

Cambodia: even before the launching of the BMZ Action Plan on the Inclusion of Persons with Disabilities in 2013, the German government committed itself to support the inclusion of persons with disabilities in the Cambodian Health Sector. Aspects of the inclusion of persons with disabilities were progressively integrated into the design and activities of the ongoing Social Health Protection Project.

c) Meeting GHPC criteria

Indonesia:

1. Transferability to other contexts: in all countries successful processes highly depend on the commitment and the capacities of the most relevant stakeholders. The approach of both identifying and bringing together  different stakeholders working and advocating on inclusion and health as well as  taking as priority measures to strengthen their coordination and technical abilities are highly relevant for similar processes  in other countries

2. Participation and empowerment: Indonesian academia and Disabled People’s Organisations were involved into the implementation of the measures, national stakeholders as well as local organisations have been empowered to steer the process of mainstreaming inclusion in political decision processes.

3. Gender-sensitivity: gender has been considered throughout the intervention

4. Sustainability: see above

Cambodia:

1. Transferability to other contexts: the focus on contribution and inclusion of different stakeholders among with Disabled People’s Organisations (DPO) themselves and their cooperation within the process is also realisable in other countries

2. Participation and empowerment: involvement of DPOs and civil society organisations was an important success factor for extending the project’s reach out and improving the access for health service clients.

3. Gender-sensitivity: gender has been considered throughout the intervention

4. Sustainability: the combination of both interventions at policy level (commitment of the Ministry of Health, awareness raising amongst government staff); as well as interventions at the community health centre level (trainings etc.) ensures long term commitment and ownership by the involved partners. 

6.    What evidence on outputs and outcomes (“results”) is available to show that this approach is effective and that it has been scaled up to cover a significant proportion of the partner country’s population?

List all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach and summarize the results that they found.

Indonesia: Progress reports, Monitoring reports,  study on disability, documentation from Berlin Conference and other publications. 

Cambodia: Progress reports, Monitoring reports, study on disability and health, Project Briefing Paper

Also, please explain how long this approach has been implemented and to what level/coverage it has been scaled up.

Indonesia: since 2010, scale up: intensity of the national dialogue, stakeholders involved, national events on disability, existing coordination mechanisms etc.

Cambodia: since 2010, , study on disability and health etc.scale up in 2013, reports by the Cambodian Ministry of Health, invested national budget etc.

7.    What kind of photo and film material is available and can be used for the documentation?

Please note that – should your programme be selected for documentation – you will be requested to provide 15 to 20 high resolution photographs of your programme context and your programme in action.

Indonesia: movie and trailer on disability, photos by Donal Husni (meet the criteria described above)

Cambodia: poster prepared for the SNHeSP, etc.

Which didactic or operational materials (manuals, guides, IEC materials, protocols) or similar can be made available for downloading from the online toolbox that will accompany the publication of this approach?

Project briefing papers and articles publications, partner publications including manuals on how to include persons with disabilities in development programmes.

8.    Which itinerary and schedule would you recommend for the writer who will visit your programme to do the necessary journalistic research for this GHPC report? Whom should he or she meet and interview? Which sites should he or she visit?

Give an indication of the places the writer charged with the documentation of this approach should visit, interviews to be done, the persons who should be interviewed and sites/events/activities that should be visited/witnessed and documented.

Indonesia: Jakarta, visit of the relevant national ministries; visit to the district where the analysis on the living conditions of persons with disabilities was done; interviews with GIZ Indonesia, Social protection Programme staff, other international donors working in the country (CBM, Worldbank etc.), DPOs and academia

Cambodia: Cambodian Ministry of Health, GIZ Cambodia, the Social Health Protection Project, Handicap international, Epicarts, local NGOs including DPOs, etc.

9.    At which occasions, to which audiences and in which language (in addition to English) would your partner organisation and you like to distribute the resulting publication?

Name upcoming conferences and routine events and information channels through which you hope to distribute the publication:

BMZ Events, other international organisations (Worldbank, ILO etc), EU
Language: German, Indonesian, Cambodian

Please note that we will contact you one year after the publication date to find out whether you were able to distribute the report as planned.

Read the factsheet: Making Health Services Inclusive

For a full-screen view click the symbol Full-screen icon below.

The ESTHER-approach – Peers succeeding in working for capacity development, scientific evidence and better patient care in Africa and Europe

1. Working title for the proposed publication

We propose two options for the working title:

The ESTHER-approach – Peers succeeding in working for capacity development, scientific evidence and better patient care in Africa and Europe

Or

ESTHER - the Peer-to-Peer Approach for Global Health

2. Applicants

Name of German programme(s) submitting this application:
Partnership between the Medical Department University of Rostock/Germany and Limbe Regional Hospital Cameroon

Partnership between Department of Anaesthesiology and Intensive Care Medicine,Charite University Medicine Berlin/Germany and Bombo Regional Hospital Tanzania

German ESTHER Secretariat, Yvonne Schoenemann; Deutsche Gesellschaft für Technische Zusammenarbeit (GIZ) GmbH, Köthener Str. 2; 10785 Berlin/Germany

Dr. Pius KUWOH, Regional Hospital Limbe, Cameroon

Mr Adam Lyatuu, Regional Hospital Tanga/Tanzania

3. Responsible experts

Name, title, organisation, email of responsible partner expert:
Mr Adam Lyatuu, Bombo Hospital/Tanzania

Name, title, organisation, email and phone number of responsible German Development Cooperation expert:
Dr Brigitte Jordan-Harder

Name, title, organisation, email and phone number of the German Development Cooperation staff member who will be our contact for organising the logistics of the writer’s mission in your country, setting up meetings and visits to programme sites etc.:
Dr Brigitte Jordan-Harder

4. Description of the approach
Describe the approach that the GHPC should document as good practice or promising practice: Which challenge(s) does it address, and how, and what have been the particular contributions of German Development Cooperation.

Challenges

  • Health institutions in low-and-middle income countries are continuously and increasingly confronted with new treatment schemes and guidelines and new diagnostic means available because of increased scientific knowledge and research results evidence. For good quality of care and improved health outcomes these innovations must be implemented.
  • The epidemiology in these countries changes and non-communicable diseases (NCDs) become increasingly relevant beside the existing infectious diseases, which have not yet lost their relevance for the health of the population.
  • The system of postgraduate and continuous medical education is not well developed and inadequate.

This situation calls for improved health systems, continuous capacity strengthening of health professionals for patient care and research.

  • Diseases do not know borders.
  • Health professionals in European countries are confronted with diseases not common in Europe and need to learn more to be able to diagnose and treat them effectively and are in need of cooperation with health professionals in low-and-middle income countries.

Global Health calls increasingly for joint work of health professionals across borders and continents.

  • The huge professional knowledge and experience available in German health institutions is not used systematically in development and international cooperation to contribute the urgently needed improvement of the capacity of health professionals in low-and middle income countries for patient care and research.  
  • German health institutions have limited or no access to similar institutions in low-and middle income countries and vis versa.

The approach

The major approaches of ESTHER Germany are:

  1. Capacity strengthening for health care and operational research through direct and continuous peer to peer cooperation of health professionals
  2. Shared and bi-directional learning
  3. Pooling of experiences and knowledge in a two way flow between developed and developing countries
  4. Networking
  5. Operational research
  6. Linking practical experiences and scientific evidence with political decision makers

The BMZ has joined the European ESTHER Alliance (EEA) in 2004.The EEA was initiated by France in 2002 and is a network of 12 European countries with the common objective to improve health outcomes in low and middle-income countries by strengthening the capacity of health professionals through partnerships of health institutions. Since 2002 the EEA has supported 350 health partnerships in 40 countries across Africa, Asia, Latin America, and the Middle East

The BMZ has commissioned GIZ to implement the membership. The German ESTHER Initiative facilitates and supports 9 partnerships between health institutions and health professionals in Germany and in countries of Sub-Saharan Africa. All German partner institutions are universities and therefore have up-to-date knowledge of actual state of the art diagnostic means, care and treatment, are experienced in teaching and carry out research.

Regional hospitals and university hospitals are the partner institutions in Sub-Saharan Africa. The respective Ministries of Health are always closely involved in the planning of partnerships and continuously informed about progress made, facilitating the use of new developed approaches and research results for national policy development and practical use beyond the partner institutions.

The area of the partnership varies from country to country, is identified based on the countries’ needs, aligned with the national strategies and defined in a contract between GIZ and the German partner institution. 

Areas covered are strengthening of laboratory systems, improved diagnosis and treatment of HIV/TB co-infection, improved adherence to ART and second line treatment, quality management, improved hospital hygiene, cervical cancer screening to mention only some.

The partnerships strengthen the capacity of health professionals through continuous professional education and enable the institutions to provide quality health services and operational research leading to better health outcomes.

The basis of the partnership is a peer to peer cooperation and exchange. Health professionals from the African countries visit the German partner institution and work with them there for a period of time, which varies between one week and three months. These visits are repeated.

German health professionals visit repeatedly the African institutions, work with their African partners together, carry out trainings, develop research proposals and implement operational research.

Together they visit national and international conferences and publish in internationally recognised journals to share their experiences and research results internationally.

Health professionals value support coming from people who are doing exactly the same work elsewhere. This approach contributes to trust, mutual respect and reciprocal benefits. It enhances listening to each other and accommodating the needs and interests of both partners in an equal way.

A recent external evaluation of the European Alliance indicated that the ESTHER Initiative is delivering partnerships that have benefits beyond traditional forms of technical cooperation. It supports practicing health professionals and parts of the health service often overlooked by international partners. In addition, it is an approach which is particularly valued by Southern governments and implementing partners. These peer-to-peer partnerships are capable of inspiring institutions and individuals to change the way they work and improve quality of service delivery.

Being part of a bigger network allows partners in Europe and African partner countries to extend the cooperation to more countries inside Germany, with other European and African countries, initiate joint projects and research and widen their opportunities for experience exchange and learning and building wider professional networks.

The German ESTHER secretariat is part of the German Development Cooperation and facilitates the establishment of the partnerships and brings together potential partners with similar interests and according to competencies.

The secretariat contributes with the following responsibilities and activities to the successful implementation of the partnerships:

  • Development of the proposal, log frame and budget
  • Communication with the BMZ and GIZ
  • Preparation and administration of the contract
  • Financial support
  • Technical support
  • Management of the network of German ESTHER partners
  • Cooperation with the European ESTHER Alliance and network of European partners
  • Networking with other important partners like EDCTP, EC, WHO and others

The example of two ESTHER-Germany partnerships will demonstrate how the partnership approach works, how effective it is and how it leads to sustainable changes. We show that it is an approach, which has an important role to play within international cooperation.

One partnership brings together health professionals from the Tanga Regional Hospital in Tanzania and those from the Charité University Medicine Berlin. This partnership contributed to a significant improvement of structural and process quality of patient care in the Tanzanian hospital. The partners developed jointly an instrument for assessing quality of care. Quality teams were established and trained in carrying out the self assessment bi-annually,  developing and implementing  action plans and adjusting them according to the changing situation. Other instruments for quality management like quality circles wer introduced as well. The instrument was also introduced in all district hospitals of the region and has been accepted by the government for nationwide use.

The second partnership includes health professionals from the Provincial Hospital in Limbe in Cameroon and the University of Rostock. The partnership focused on the diagnosis and treatment of opportunistic infections to improve the morbidity and mortality of PLHIV and has contributed to a significant reduction of the mortality of HIV+ patients under antiretroviral treatment.

The laboratory was equipped and health professionals trained in using the equipment through repeated bi-directional exchange. Service providers increasingly used the available diagnostic tools leading to the above mentioned improvement.

The Hospital has become a referral centre for HIV care and treatment for the whole province and neighbouring provinces as well.

The work of these partnerships is very well recognised by the respective Ministries of Health allowing that practical experiences are used for policy and guideline development.

5. Arguments why this approach should be documented in the GHPC
Describe in what ways this approach is
  1. innovative;
  2. state of the art’ in its field;
  3. relevant to the priorities of German Development Cooperation (you may want to refer to sector strategies, position papers etc.) and contributes to raising the international profile of German Development Cooperation;
  4. in accordance with the other GHPC criteria of transferability to other contexts, participation and empowerment, gender-sensitivity, sustainability

The approach is innovative, because the normal instruments of German development Cooperation do not offer the possibility of partnering between German and African institutions. University departments are up to date in regard to all areas of the partnerships and teach and transfer ‘state of the art’ approaches.

Considering the missing continuous professional education of health professionals the partnership approach is very relevant. As research is an important part of all partnerships and developed and implemented jointly, capacity for research is strengthened and with this innovative thinking enhanced

The approach is also aligned with other GHPC criteria. It is:

Transferrable: The partnership approach works well between different partners in different countries and contexts as shown by the multiple ESTHER partnerships of 12 European countries with 40 low-and middle income partner countries.

Participatory : As it is a partnership it is participatory.   

Sustainable: Partners contribute to the cost in kind and in cash. Being part of this network increases their chance of finding additional funds from other sources as it has been already shown. This include funds from BMBF, DFG, CDC, EDCTP and others. This contributes to the sustainability of the partnerships and continuation of the approach.

Evidence on results and scaling up

What documented evidence on outputs, outcomes and impact is available to show that this approach is effective? Can you show that it has been scaled up to cover a significant proportion of the partner country’s population?

The core results are:

  1. Strengthened regional and national health institutions
  2. Strengthened continuous professional education and development
  3. Strengthened capacity for health care and research
  4. Quality improvement of health services
  5. Improved health of population reached
  6. Contribution to national policy development

These core results specified for selected partnerships are:

  • The provincial hospital in Limbe/Cameroon became a reference centre for district hospitals of two provinces.
  • The quality of care improved significantly for HIV+ patients under treatment (selected examples) in Bombo Hospital/Tanzania:
      • Counselling from 55% to 80% (p-value <0.001)
      • Initial assessment of patients from 50% to 75% (p-value <0.001)
      • Treatment of patient at the outpatient department from 50% to 87.5% (p-value <0.001)
  • The quality management approach developed was accepted by the Ministry of Health and Social Welfare for nationwide us.
  • In the provincial hospital in Limbe the mortality of patients under treatment was reduced from 6.8% to 2% one year after initiation of treatment.
  • Joint development of research proposals with the African partner as principle investigator and multiple publications in international journals.

Other results to be mentioned of other partnerships are:

The Komfo Anokye Hospital Kumasi/Ghana has become a reference centre for care and treatment of PLWH.

In Komfo Anokye teaching Hospital Kumasi/Ghana the number of HIV+patients screened for TB increased from 15% to 89%. This is an increase by 86%.

List all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach and summarize the results that they found. Also, please explain how long this approach has been implemented and to what level/coverage it has been scaled up.

  • 6monthly reports oriented on the log frame.
  • huge number of publications in international journals show the results of the partnerships and can be provided.
  • External evaluation of the European ESTHER Alliance

The approach has been implemented as part of German Development cooperation since 2007. It started with three partnerships and has extended to 9, but could be extended to much more partners with more funding available, because the interest in very high.

Other European countries started in 2002.  370 partnerships have been established involving 40 countries from Africa, Asia and Latin America.

6. Photo and film material
What kind of photo and film material is available for the documentation? If selected for documentation, you will be requested to provide 15-20 high resolution photographs of your programme context and your programme in action.

Photographs are available.

7.  Supplementary materials
Which didactic or operational materials (manuals, guides, IEC materials, protocols etc.) can be made available for download as part of an online toolbox to accompany the publication?

European ESTHER Alliance website; ESTHER Alliance brochure; evaluation report; strategy and roadmap of the European ESTHER Alliance;

Guidelines German ESTHER Initiative

Format for proposals and reporting

Strengthening capacity of anaesthesiologists and resuscitation specialists on maternal health in Kyrgyzstan and Tajikistan through regional expertise and networking

1. Working title for the proposed publication

 ‘Strengthening capacity of anaesthesiologists and resuscitation specialists on maternal health in Kyrgyzstan and Tajikistan through regional expertise and networking’

2. Applicants

Name of German programme(s) submitting this application:
Regional Programme ‘Health in Central Asia’ Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH

Name, title, organisation, email and phone number of main applicant from German Development Cooperation:
Evi-Kornelia Gruber, Director Regional Health Programme in Central Asia, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH

Name, title, organisation, email and phone number of main applicant from the partner organisation(s):
Dr. Guljan Dshuzumalieva, Chief specialist in resuscitation and anaesthesiology under the   Ministry of Health, Kyrgyz Republic

3. Responsible experts

Name, title, organisation, email of responsible partner expert:
Anara Eshhodjaeva, Head of the management healthcare department at the Ministry of Health, Kyrgyzstan

Dinara Mambetalieva, Head of the resuscitation and intensive care unit, Bishkek city perinatal centre

Name, title, organisation, email and phone number of responsible German Development Cooperation expert:
Cholpon Asambaeva, Team Leader, Regional Health Programme in Central Asia/Kyrgyzstan

Name, title, organisation, email and phone number of the German Development Cooperation staff member who will be our contact for organising the logistics of the writer’s mission in your country, setting up meetings and visits to programme sites etc.:

Aigul Tokocheva, Programme Officer, Regional Programme “Health in Central Asia/Kyrgyzstan”, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH,

Halima Boboeva, Programme Officer Regional Programme  “Health in Central Asia/Tajikistan" Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH

4. Description of the approach
Describe the approach that the GHPC should document as good practice or promising practice: Which challenge(s) does it address, and how, and what have been the particular contributions of German Development Cooperation.

The challenge

Despite significant achievements in maternal and child health in recent years, both Kyrgyzstan and Tajikistan are struggling to reduce the high maternal mortality rates. In Kyrgyzstan, maternal mortality declined at an average annual rate of only 0.2 per cent between 1990 and 2010, compared with a global average of 3.1 per cent. With a maternal mortality rate of 38.2 deaths per 100,000 live births in 2013, the country is unlikely to meet the national MDG target of 15.7 deaths per 100,000 live births by 2015. In Tajikistan, official statistics place the maternal mortality rate at 33.3 deaths per 100,000 live births, but the World Health Organization estimates that the actual rate may be twice as high.

In both countries, more than half of maternal deaths in recent years are considered to be preventable. Approximately 80 per cent are due to direct obstetric causes, including post-partum haemorrhage, hypertensive disorders, post-partum infections (mainly sepsis) and obstructed labor.[1] Most of these cases have arisen as a result of improper and inadequate Emergency Obstetric Care (EmOC), as well as the lack of access to such services. The quality of EmOC directly affects the process of delivery, as untimely and inappropriate actions during pregnancy complications of pregnancy may pose a threat to the life of a pregnant woman. With early diagnosis of complications and surgical interventions, however, a lethal outcome can often be prevented. The inadequate and belated provision of anaesthetic and resuscitation care is one of the main contributing factors to the high maternal death rates in both countries. 

The main challenges in provision of EmOC in Kyrgyzstan and Tajikistan include:

  • Major shortage of anaesthesiologists and resuscitation specialists in rural areas, aggravated by health worker emigration;
  • Concentration of anaesthesiologists and resuscitation specialists in urban settings due to the lack of motivation and incentives in rural areas;
  • Inadequate system of postgraduate and continuous medical education of anaesthesiologists and resuscitation specialists  (e.g. no training programme focused specifically on EmOC, limited attention to practical skills, teaching not in accordance with international standards);
  • Inadequate referral system among primary health care facilities and secondary and tertiary levels of perinatal care;
  • Low capacity of health staff involved in EmOC (i.e. teams of anaesthesiologists, neonatologists, obstetricians, gynaecologists and midwives) and weak culture of teamwork; and
  • Poor infrastructure and lack of essential equipment.

A number of development partners, including WHO, UNICEF, UNFPA, USAID and GIZ, have committed themselves to support the Ministries of Health and national partners in both countries to improve the quality of EmOC through:

  • The development and introduction of legal regulations, standards, clinical guidelines and protocols, and tools for routine monitoring of EmOC; and
  • Quality management improvement of EmOC services and supply of essential resources for the provision of EmOC;

The approach

The GIZ regional programme ‘Health in Central Asia’ supports the Ministries of Health in Kyrgyzstan, Tajikistan, and Uzbekistan to implement national strategies and policies, with a particular focus on reproductive health. In 2012 the programme began to implement capacity building measures on EmOC for anaesthesiologists and resuscitation specialists from Kyrgyzstan and Tajikistan, in line with the respective governments’ strategies to improve maternal health. At the heart of the approach was the innovative idea to build upon regional knowledge and expertise by engaging the services of specialists from the National Perinatal Centre in Uzbekistan who have been part of a successful nationwide effort to improve the skills of anaesthesiologists and resuscitation staff in that country.[2]

The capacity development measures supported by GIZ are aimed to improve emergency services to women with complicated deliveries. The approach is modelled on the Uzbek experience and is focused on building the practical skills of Kyrgyz and Tajik anaesthesiologists and resuscitation staff and on developing clinical guidelines, standards and protocols on EmOC for the application in Kyrgyzstan and Tajikistan. Activities conducted to date have included:

  • A rapid assessment of EmOC in Kyrgyzstan and Tajikistan, conducted by Uzbek experts, to revel challenges and training needs;
  • The development of a 6-day training curriculum on EmOC for anaesthesiologists and obstetrician/gynaecologists by a working group of Uzbek, Kyrgyz and Tajik colleagues;
  • A practical training programme, facilitated by Uzbek experts and trainers, for 50 Kyrgyz and Tajik specialists in anaesthesiology and intensive care, focused on the team-based provision of EmOC.
  • A 10-day study tour to the Republican Perinatal Center in Uzbekistan for a group of 10 Kyrgyz anaesthesiologists and obstetrician/gynaecologists, including training and practical sessions on the management of anaesthesia during surgery, respiratory support and the rational use of medicine and equipment. 
  • Practical trainings for specialists from maternity facilities in both Kyrgyzstan and Tajikistan on key clinical practices, with a focus on team work and resolving clinical situations.      

The second phase of the approach will be implemented between now and December 2015. In Kyrgyzstan, activities will focus on sustainability: preparing a cadre of qualified Kyrgyz trainers (anaesthesiologists and obstetrician/gynaecologists) who can provide ‘cascade on-the-job trainings’ to colleagues at the national level; improving the existing postgraduate training programme for anaesthesiologists, obstetricians/gynaecologists and intensive care specialists in the country; establishing an EmOC training and resource centre for continuous education at the national level; advising the Ministry of Health on a national mentoring system for anaesthesiologists and intensive care specialists; and developing a monitoring and evaluation system which facilities can use to assess the quality of EmOC services.

In Tajikistan, the focus will be on preparing a group of Tajik EmOC trainers; undertaking a monitoring and quality assessment of EmOC in the country; integrating the EmOC training curriculum for anaesthesiologists and obstetrics/gynaecologists into Tajik medical training institutions; and supporting the development and adaptation of local clinical protocols and standards on anaesthesia and resuscitation in obstetrics care.

The leading specialists in anaesthesia and resuscitation in obstetrics care in both countries under the leadership of the MoH have been working jointly, as a team, in capacity development measures. By supporting measures in the above areas, the Programme has enhanced their skills and increased the demand for sustaining and improving EmOC measures.

Arguments why this approach should be documented in the GHPC

Describe in what ways this approach is

  1. innovative;
  2. ‘state of the art’ in its field;
  3. relevant to the priorities of German Development Cooperation (you may want to refer to sector strategies, position papers etc.) and contributes to raising the international profile of German Development Cooperation;
  4. in accordance with the other GHPC criteria of transferability to other contexts, participation and empowerment, gender-sensitivity, sustainability

GIZ’s approach to build the capacity of anaesthesiologists and obstetric/gynaecologists in Kyrgyzstan and Tajikistan is innovative in a number of ways. First, it draws upon regional expertise which is relevant, available and cost-effective. Kyrgyzstan, Tajikistan and Uzbekistan are facing many similar challenges in their efforts to reduce maternal deaths; they also share a common language and historical legacy as former Soviet republics. Following a series of lengthy discussions, GIZ secured agreement from all three Ministries of Health to support this transfer of regional expertise – the first time such an approach has been endorsed in the area of EmOC.

Second, the approach not only focuses upon improving health workers’ clinical skills, but also focuses upon thorny issues of workplace processes and culture. The failure of various specialists – anaesthesiologists, neonatologists, obstetricians/gynaecologists and midwives – to work together as teams to address complicated deliveries is a major contributing factor to maternal deaths. The GIZ approach seeks to demonstrate the potential of teamwork to produce better maternal health outcomes.

Third, the approach lays the groundwork for long-term changes by working at multiple levels (i.e. from training for specialists to promoting clinical guidelines and improvements in the system of medical education) and by establishing a regional network of qualified specialists who can share their expertise with others.

The approach is relevant to the priorities of German Development Cooperation, most notably the BMZ’s ‘Initiative on Rights-based Family Planning and Maternal Health,’ which aims to strengthen health systems in partner countries with high maternal and child mortality rates. In the GDC sectoral paper, special attention is focused on improving the availability and quality of sexual and reproductive health (SRH) services, including better access to perinatal obstetric care and emergency obstetrics; improving the quality of SRH services through training for obstetric/gynaecological health professionals; and taking into account evidence-based methods and ensuring work of medically appropriate quality. In terms of content, the programme is aligned with the position papers Sexual and Reproductive Health and Rights, and Population Dynamics (August 2008).

The GIZ programme makes a direct contribution to securing basic social services as one of the three priorities specified by BMZ in its Central Asia strategy (2005). The programme implements major elements of the paper, including a commitment to better networking of existing bilateral projects, transfer of knowledge and experience, and cross-border exchanges between experts and other partners. The related transfer of knowledge and experience may influence other areas of relevance to development policy and provide incentives for political and economic modernisation. The cross-boundary exchange between expert staff and relevant groups of actors as promoted by the strategy may ‘contribute to reducing political tension between individual countries and have a direct crisis prevention effect’.

The approach is well-aligned with the Kyrgyz and Tajik governments’ strategies and frameworks for improving maternal and child health. In Kyrgyzstan, these include the Den Sooluk national health reform programme (2012-2016), which highlights MCH as a priority area, and the MDG Acceleration Framework, which aims to identify and overcome bottlenecks to achieving MDG5 (such as the availability of high-quality EmOC). In Tajikistan, the approach supports the national plan on safe pregnancy, as well as the implementation of evidence-based approaches to care during pregnancy, labour and delivery which the Ministry of Health promotes countrywide.

The approach described here is also aligned with other GHPC criteria. It is:

  • Transferrable: The idea of drawing upon relevant regional expertise could be an effective and cost-effective solution in other settings and in relation to other health issues.
  • Participatory and empowering: It seeks to empower anaesthesiologists to think about their jobs differently, to work more closely with obstetric/gynaecological colleagues, and to benefit from and contribute to the growing regional expertise on EmOC. Many aspects of the approach are participatory, including the creation of working groups of different health specialists to develop clinical protocols and guidelines.
  • Gender sensitive: The approach is explicitly aimed at reducing the number of preventable deaths among pregnant women, and also promotes active male involvement in safe motherhood through the support and care for pregnant and delivering women. Care was taken to ensure that all capacity building measures included the equal participation of male and female health professionals.     
  • Sustainable: Many of the measures are aimed at the sustainability of the approach, including the introduction of clinical guidelines and protocols with application at the national level; changes in the medical education system; and the development of regional training expertise and professional networks across three countries. The approach is also well-harmonised with existing efforts, thereby avoiding duplications and the use of parallel structures. 
5. Evidence on results and scaling up
What documented evidence on outputs, outcomes and impact is available to show that this approach is effective? Can you show that it has been scaled up to cover a significant proportion of the partner country’s population?

List all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach and summarize the results that they found. Also, please explain how long this approach has been implemented and to what level/coverage it has been scaled up.

Capacity development measures on EmOC for anaesthesiologists and resuscitation specialists have been focused at the national level in both countries with the active involvement of leading health professionals from key maternity and perinatal centres. More than 150 anaesthesiologists and resuscitation staff have been equipped with sound knowledge and skills in EmOC management and have gained training skills, which has allowed them to conduct on-the job trainings at facility level for a large number of non-trained anaesthesiologists. They now do this with the active involvement of obstetricians/gynaecologists, who have begun working in intensive care units as one team.

There is already some indication that the number of facilities using regional anaesthesia for Caesarean deliveries in Kyrgyzstan is growing as a result of GIZ’s interventions.  While in 2011 it was only used at private clinics and a few public maternity hospitals, by 2014 more than 10 out of 53 facilities (18%) used it.[3]

Another notable result is that intensive care in relation to the main obstetric emergencies (pre-eclampsia, haemorrhage, sepsis) is now being conducted according to accepted clinical protocols and guidelines.

New clinical protocols and recommendations for EmOC, developed on the basis of Uzbekistan’s practical guidelines by a regional working group of anaesthesiologists and obstetrician/gynaecologists, have been adopted in both Kyrgyzstan and Tajikistan. In Kyrgyzstan, the Ministry of Health has approved them as mandatory clinical protocols; in Tajikistan they serve as clinical recommendations. Also in Tajikistan, a training package on EmOC for anaesthesiologists was developed and approved by the Ministry of Health, and integrated into the medical education system; a group of leading health professionals from pilot regions was already trained using the approach.

Practical trainings on the use of medical equipment in EmOC, simulations of emergency cases, and mentoring at the facility level have enhanced the knowledge and skills of anaesthesiologists and created a huge demand to sustain these measures at the national and regional level. Based on the feedback from the MoH and MCH partners, there exists a great interest to continue capacity development measures on EmOC for anaesthesiologists and obstetric/gynaecologists and to institutionalise it further at the national level. The innovative approach developed and tested by the programme will be included in national policies and implemented countrywide. In both countries a partnership agreement has been reached with UNFPA, UNICEF and USAID to introduce EmOC training for anaesthesiologists nationwide.

These achievements were discussed and profiled at a national forum entitled ‘Towards Achieving the MDGs 4 and 5 in Kyrgyzstan,’ held in Bishkek in June 2014, which included the participation of Tajik and Uzbek anaesthesiologists as well as Kyrgyz officials, development partners and MCH partner organisations.

Measuring results

The approach described in this proposal has been implemented since 2012 and most achievements to date are at the output level. In the longer term, four indicators will be used to measure the results of the approach by the end of 2015[4]:

  1. Reduction in percentage of women requiring blood transfusion for treatment of post-partum haemorrhage;
  2. Increase in the proportion of Caesarean deliveries performed with regional anaesthesia;
  3. Increase in the number of natural deliveries among women with severe hypertensive disorders; and
  4. Increase in the proportion of facilities using regional anaesthesia for Caesarean deliveries (target: from 15% to 30%)  

There is a set of indicators developed for each clinical standard and protocol that will help to measure and evaluate quality of EmOC provided by anaesthesiologists and resuscitation staff at facility level. At each facility, an internal monitoring and quality assessment system will be developed and introduced by a quality assurance multidisciplinary team (managers, obstetricians/gynaecologists, leading anaesthesiologists, midwife, nurse, etc.) who will monitor the quality of services against the indicators. At the national level a team of certified trainers (anaesthesiologists and resuscitation staff, obstetricians/gynaecologists) will visit facilities twice a year to mentor and coach on EmOC. This will be supported by Development Partners (UNFPA, GIZ, and UNICEF) and coordinated by the MoH[5].

6. Photo and film material
What kind of photo and film material is available for the documentation? If selected for documentation, you will be requested to provide 15-20 high resolution photographs of your programme context and your programme in action.

Within the GIZ health programme we could provide the photos of capacity development measures on EmOC for anaesthesiologists and resuscitation specialists from the:

  • Study tour of Kyrgyz health professionals to Uzbekistan, May 2013;
  • Practical trainings for specialists from maternity facilities in both Kyrgyzstan and Tajikistan on key clinical practices, with a focus on team work and resolving clinical situations, 2013-2014;
  • National Forum “Towards achieving MDG 4 and 5”, June 2014;
  • Programme website - in English: http://health-centralasia.org/en/
  • Publications in programme infochannel of GIZ website;     
7.  Supplementary materials
Which didactic or operational materials (manuals, guides, IEC materials, protocols etc.) can be made available for download as part of an online toolbox to accompany the publication?

Within the GIZ health programme we could provide the following products of capacity development measures on EmOC for anaesthesiologists and resuscitation specialists:

  • Training manual for participants on intensive care and anaesthesia in EmOC, Uzbekistan, 2010 (in Russian);
  • 6-day training introductory curriculum on EmOC for anaesthesiologists and obstetrician/gynaecologists developed by a working group of Uzbek, Kyrgyz and Tajik experts, 2013 (in Russian);
  • Clinical Protocols on EmOC for anaesthesiologists, resuscitation specialists and obstetrician/gynaecologists in Kyrgyzstan, July 2014 (in Russian);
  • Clinical recommendations on EmOC for anaesthesiologists and resuscitation specialists and obstetrician/gynaecologists in Tajikistan, June 2014 (in Russian);
  • Training package on EmOC (training program, training manual for participant and trainer, evaluation forms) for anaesthesiologists, resuscitation specialists and obstetrician/gynaecologists, Tajikistani, August 2014 (in Russian);
  • Presentations of trainings, conferences and regional events on EmOC for health professionals,  2013-2014 (in Russian and English);
8. Indicative itinerary for documentation
Which itinerary and schedule would you recommend for the writer who will visit your programme to do the necessary journalistic research for this GHPC report? Whom should he or she meet and interview? Which sites should he or she visit?

Kyrgyzstan:

Name of organizations

Contact person

Duration

Ministry of Health, health care management department

Anara Eshhodjaeva, Head

1 hour

Professional association of anaesthesiologists and resuscitation specialists of Kyrgyzstan, NGO

Members of the associations actively involved into GIZ measures 

3 hours

Bishkek city Perinatal Centre

Dinara Mambetalieva, head of Intensive Care Unit 

0,5 day

Chuy oblast maternity hospital

Lilya Kiyzbaeva, head of Intensive Care Unit 

0,5 day

Resource Center on EmOC for anaesthesiologist and resuscitation specialists

Head of the Resource Centre

3 hours

Department of anaesthesiology and intensive care of continuous medical education institute

Head of the department

2 hours

Development partners (UNFPA, UNICEF)

Programme staff

2 hours

TOTAL

 

3 days + 2 days travelling

 

Tajikistan:

Name of organizations

Contact person

Duration

Ministry of Health, Maternal and Child health department

Head

2 hours

Dushanbe city maternity hospital 

Head of Intensive Care Unit 

3 hours

Sogd oblast maternity hospital

Head of the Intensive Care Unit 

1 day (in-country traveling)

Department of anaesthesiology and intensive care of continuous medical education institute

Head of the department

3 hours

Development partners (UNFPA, UNICEF, USAID)

Programme staff

2 hours

TOTAL

 

3 days + 2 days travelling

 

9.  Publication audiences and languages

At which occasions, to which audiences and in which language (in addition to English) would your partner organisation and you like to distribute the publication? Name upcoming conferences and routine events and information channels through which you hope to distribute the publication. Please note that we will contact you some months after the publication date to find out whether you were able to distribute the report as planned.

The distribution of the publication will be at the different levels (in English and Russian):

Policy level

  • During the annual Ministry of Health national conferences and events on Maternal and Child health in all three countries (e.g. Perinatal Forums, Conferences on Confidential Enquiry into Maternal Death, conferences and events of the professional association of anaesthesiologists and resuscitation specialists, etc.);   
  • During the joint annual review meetings on implementation of health sector programme in Kyrgyzstan (SWAp mechanism) and Tajikistan (JAR mechanism); 

Service delivery level including continuous medical education system

  • At pilot maternity hospitals and Perinatal Centres in all three countries;
  • At department of anaesthesiology and intensive care of qualification improvement  and continuous medical education institutes in Kyrgyzstan and Tajikistan;

GIZ health programme (in English and Russian)

  • Programme website: http://health-centralasia.org/
  • GIZ Intranet
  • Programme Fact Sheet on best practice of the regional measures;
  • SN HESP, Task Team 5: Hospital Management, Quality Improvement;
  • Programme evaluation;

Target Audience:

  • Ministry of Health key decision makers;
  • Members of professional association of anaesthesiologists and resuscitation specialists;
  • Heath professionals in EmOC;
  • Development Partners;
  • GIZ management and national staff in all three countries;   
  • GIZ HQ;

Footnotes:

[1] MDG Acceleration Framework, Improving Maternal Health in the Kyrgyz Republic, November 2013

[2] Over the period 2008-2012 more than 600 Uzbek anaesthesiologists were trained with the support of UNFPA, a mentoring system was established at the national level, and a new training module on Anaesthesia for Emergency Obstetric Care (developed at the University of California) was integrated into the country’s training institutions. With financial support from the Asian Development Bank, more than 190 maternity and perinatal centres were renovated and equipped with modern and essential equipment. As a result of these measures, clinical protocols on EmOC for anaesthesiologists were developed and introduced into routine practice; the proportion of Caesarean section deliveries taking place under regional anaesthesia rose to 45% countrywide; and the knowledge and practical skills of anaesthesiologists in dealing with the main EmOC challenges, including hypertensive disorders, sepsis and obstetric haemorrhage, increased significantly.

[3] Full anaesthesia during Caesarean deliveries was a more suitable approach in past and this is an example of how medical education has not been following international norms. Regional anaesthesia is the WHO recommendations on Safe Motherhood programme, one of the leading and priority programme in Central Asia. Regional anaesthesia has become the preferred technique for Caesarean delivery. Compared to general anaesthesia, regional anaesthesia is associated with reduced maternal mortality, the need for fewer drugs, and more direct experience of childbirth, faster neonatal-maternal bonding, decreased blood loss and excellent postoperative pain control through the use of neuraxial opioid. This is the approach to change the routine practice according to the WHO recommendations and international standards.

[4] It is not possible to provide clear data on progress regarding maternal deaths at national/regional or facility level that could be archived by GIZ programme by the end of 2015. Therefore, in the longer term the programme include four indicators that will be used to measure the results of the approach.

[5] Summary of annual reports of the health facilities, internal partners data, interviews of health professionals and progress reports of Development Partners will be used to provide evidence for the effectiveness of this approach.  

Sustainable Development of a Postgraduate Public Health Academic Institute in Pakistan

1. Working title for the proposed publication

Sustainable Development of a Postgraduate Public Health Academic Institute in Pakistan

2. Applicants

Name of German programme(s) submitting this application:
Health Sector Support Programme (HSS) Pakistan

Name, title, organisation, email and phone number of main applicant from German Development Cooperation:
Jasmin Dirinpur, Technical Advisor, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH

Name, title, organisation, email and phone number of main applicant from the partner organisation(s):
Dr. Shahzad Ali Khan, Course Coordinator Health Financing, Health Services Academy

3. Responsible experts

Name, title, organisation, email of responsible partner expert:
Dr. Shahzad Ali Khan, Course Coordinator Health Financing, Health Services Academy,

Name, title, organisation, email and phone number of responsible German Development Cooperation expert:
Dr. Imran Durrani, Senior Technical Advisor, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH

Name, title, organisation, email and phone number of the German Development Cooperation staff member who will be our contact for organising the logistics of the writer’s mission in your country, setting up meetings and visits to programme sites etc.:
Hasnat Ahmed, Knowledge Manager, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH

4. Description of the approach
Describe the approach that the GHPC should document as good practice or promising practice: Which challenge(s) does it address, and how, and what have been the particular contributions of German Development Cooperation.

A critical input to any health system is its human resources. The lack of qualified personnel is one of the key bottlenecks in Pakistan’s underfinanced health system. In particular, there is a scarcity of professionally trained health administrators, managers and health economists in the public health sector, and to a lesser extent in the private health sector as well. Insufficient capacity of relevant training institutions and ineffective human resource policies in the state-run part of the health system have been leading to migration, wrong personnel choices and a high staff turnover.

Approximately 5000 health professionals need to be capacitated to smoothly and efficiently manage the public health sector of Pakistan. In addition, NGOs and the private sector also need competent managers. About fifty private and public medical schools in the country require teachers and researchers in the field of public health. The limited availability of qualified managerial staff and the enormous capacity gap in health systems planning and management is jeopardizing implementation of ambitious health reforms; reforms that were initiated to provide better access and quality services to poor and disadvantaged segments of the population.

The Health Services Academy (HSA) was established in 1988 as a department within the Ministry of Health of the Government of Pakistan. Its primary mission was to serve as the continuing in-service professional training unit within the Ministry, specifically within the sphere of health management education and related public health skills. The promulgation of HSA Ordinance, 2002, gave it an autonomous status. Over the years, it has established itself as the premier research and teaching institution of public health. Today, it is the only institution that offers a PhD in Public Health in Pakistan. The Academy remains committed to strengthen the capacity of public health professionals by excellence in teaching, research and policy advice.

The Ministry of Health was aware that strengthening the extant academy to graduate as an academic institute for developing managerial capacities in the health sector would need technical capacities which were non-existent in the country. As a result, the Government of Pakistan requested the German Government for technical assistance to develop HSA into an academic institute of Public Health. The Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, since 1993, has been providing technical assistance to HSA in developing an institutional framework for high quality teaching and research and as HSA executive director Prof. Assad Hafeez mentioned in one of his speeches is “part of the history of HSA.” Over the years, the scope of support to HSA has evolved from technical assistance to a facilitative partnership.

In the first phase commencing from 1993, GIZ (at that time GTZ) started the process of developing HSA into an academic institute of Public Health for delivering of Masters’ Program and short courses in Public Health. To achieve this, a state of the art curriculum for Masters of Public Health (MPH) was developed and disciplines were defined. Development of qualified faculty was recognized as the first need to sustain any academic program and to assure quality and to attain accreditation by the National accrediting body - Pakistan Medical and Dental Council (PMDC). Therefore, faculty was assigned to the core disciplines and a number of faculty members were sent on higher training (Masters and Doctoral) to reputable universities around the world.

Process for accreditation with PMDC was initiated and for grant of degree Quaid-e-Azam University (QAU) was approached. As a result of these efforts, the Health Services Academy pioneered in formalizing Public Health discipline in Pakistan and was able to offer its first Master’s degree in Public Health in 1996 recognized by PMDC and affiliated with QAU. Due to refusal of the government to provide the institute autonomy and political changes happening in the country the project could not be continued.

The Health Services Academy was granted an autonomous status in 2003 by the Ministry through a legislative act. The Ministry’s renewed commitment, including assurances that HSA has been granted an autonomous status and allocation of money for development of a purpose built campus at the cost of Euro 4.4 Million, led to GIZ’s resumption of the project in 2004.

As a first step in consonance with the main partners, keys essentials were defined and agreed upon. Based on these key essentials, a need for defining a renewed mission, vision and objectives for the institute arouse. The new mission, vision, goal and objectives articulated by the faculty and supported by the stakeholders were consistent with HSA’s official charge from the Ministry of Health and with international expectations for designation as a school of public health. 

GIZ contributions towards building the Health Services Academy were guided by the concept of “sustainable development”. This concept defined GIZ’s unique approach and modus operandi. The key strategy was “Capacity Development” (CD) taken as the development of the capability of people and organization to manage resources effectively and efficiently in order to realize their own goals on a sustainable basis. Technical Cooperation by GIZ to HSA aimed to support capacity development at four levels. It was also realized that neglecting the interactions between the four dimensions of capacity development would lead to imbalances and weaken the change process.

5. Arguments why this approach should be documented in the GHPC
Describe in what ways this approach is
  1. innovative;
  2. state of the art’ in its field;
  3. relevant to the priorities of German Development Cooperation (you may want to refer to sector strategies, position papers etc.) and contributes to raising the international profile of German Development Cooperation;
  4. in accordance with the other GHPC criteria of transferability to other contexts, participation and empowerment, gender-sensitivity, sustainability

Technical assistance to develop and retain a high quality faculty, foster research and establish collaboration with national and international universities was highly innovative at the time GIZ started its long-standing cooperation with HSA. The approach remained always on strengthening the health system through improving competencies of its managers to manage the system effectively. In absence of such a program in the country very few trained people were available, even those trained were not working for the system. Development of a National Institute which was considered equivalent to any International School of Public Health provided not only competent managers to the health system but also triggered major sector reforms like the reorganization of the district health system where these cohorts were placed as managers. Today, an increasing number of actors invests in strengthening teaching and research at public health institutes. GIZ’s approach is unique in that it is guided by the principle of sustainable development and an understanding of comprehensive capacity development that addresses the four levels of

i) Institutional Frameworks Development:

Focus was on building legal, political and socioeconomic frameworks that are conducive to CD so that people, organization and their networks developed and raised their performance capability.

ii) Organizational Development:

Organizational learning and raising of the performance and flexibility of HSA was an essential area for sustainable development.

iii) Human Resource Development:

Individual learning, capability, self-reflection, discussion of values, abilities and skills was promoted.

iv) Network Development:

Cooperation between organization and networks was developed and strengthened for knowledge exchange, coordination and co-production.

Health workforce training and management is one of the key areas of German Development Cooperation with Pakistan in the health sector. The Health Sector Strategy paper also highlights leadership and governance issues that need to be addressed in order to achieve the higher goal of better population health for all (Health Sector Strategy Paper, March 2013). The HSA vision to become a regional academic centre of excellence in public health training, policy formulation and applied research that is nationally and internationally accredited is perfectly in line with the GDC priorities in the health sector. HSA in particular aims to produce competent, committed and skilled public health professionals; to create and disseminate new knowledge in the field of public health; and to assist in the translation of knowledge into sound evidence-based policies and practices.

Assistance in developing and implementing national health policies, strategies and health workforce plans; adapting training systems for health care professionals (pre- and in-service) to specific country needs; and introducing modern, flexible, gender-sensitive personnel management tools are part of the health workforce related portfolio that GIZ is implementing on behalf of the Federal Ministry for Economic Cooperation and Development in a number of GDC partner countries (Health Workforce Fact Sheet). Though evidence is only one of many factors that influences policies and practices, its use and the work at the interface of research and practice has gained increased importance over the past years. Lessons learned from the long-term support to HSA on how technical assistance within a change process ideally should be initiated, consolidated and sustained are available and could be of value added to GDC programmes in other contexts.

6. Evidence on results and scaling up
What documented evidence on outputs, outcomes and impact is available to show that this approach is effective? Can you show that it has been scaled up to cover a significant proportion of the partner country’s population?

List all internal monitoring and evaluation reports, external evaluations and other studies that provide evidence for the effectiveness of this approach and summarize the results that they found. Also, please explain how long this approach has been implemented and to what level/coverage it has been scaled up.

Initially, HSA was established as a department within the Ministry of Health. It has developed into a postgraduate autonomous academic institute and positioned itself as a leader in public health education not only in Pakistan, but in the region as well.

Up till today, 400 students have graduated from Master’s programmes at HSA and more than 5000 public health managers and practitioners completed short term training courses on different subject matters related to public health at HSA.

GIZ’s multi-level capacity development support over the years has triggered the following key results:

Development of peer reviewed international level curricula; implementation of faculty good governance mechanisms; an improved learning environment; introduction of financial and administrative rules for managing an autonomous academic institute. A high quality faculty has been developed and retained, research has been fostered and collaborations with national and international universities have been established. In 2010, HSA became the first institution in the region to offer an internationally accredited Master’s programme in Human Resources for Health Management, carried out jointly with Queen Margaret University in Edinburgh. The quality of graduating students is reflected in the demand for them in the market and their ready absorption in the health system (HSA case study, Durrani/Siddique 2011).

A tracer study conducted in 2008 assessed the contribution of HSA graduates to public health and society in terms of their involvement in research and consultancies; their management influence on decision making or implementing change for the improvement of the health system; teaching; and policy advice. The study found that a total of 188 students completed their MPH and 30 students successfully completed MSPH from Health Services Academy till the year 2008, while 42 students were enrolled in MSPH and ExMSPH programs by end 2008. Overall, the study found the MPH and MSPH programs to be useful in building capacities. The majority of the participants stated that the Masters’ program had either moderate or great influence over their work organization and career. The students were pleased with the profile of the instructors. They stated that they returned to their organization with the enhanced knowledge and skills, exposure and confidence needed to serve their organization, implemented their new knowledge and skills and acted as change agents, which contributed to the better management of the health sector (Tracer study/Self-assessment, 2008).

7. Photo and film material
What kind of photo and film material is available for the documentation? If selected for documentation, you will be requested to provide 15-20 high resolution photographs of your programme context and your programme in action.

Photo material is available with a sequence of images documenting the development story of HSA over the years. Photo captions: a) Board of governors meeting headed by Federal Minister of Health; b) HSA in making; c) Library at HSA; d) The Computer Laboratory; e) The conference room; f) The core faculty for first batch of MSPH 2007-08; g) Prof. Amy Tsui (John Hopkins University) Delivering Reproductive Health Courses at HSA; h) The first batch of MSPH (2007-08).

Additional film material can be produced with support of the writer.

8. Supplementary materials
Which didactic or operational materials (manuals, guides, IEC materials, protocols etc.) can be made available for download as part of an online toolbox to accompany the publication?

Public Health Journal and other material from HSA library

BMZ glossary

Close window

 

Share page