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Proposals for 2015


In November 2015, the BMZ division health, population policy and social protection followed the recommendation that emerged from the participatory proposal assessment process in which many health and social protection experts from German-supported programmes worldwide took part: They decided that the GHPC should undertake case studies on Opium-Supported Substitution Therapy (OST) in Nepal and on Results-based Financing of Maternal and Newborn Health Services in Malawi.

Introducing psychosocially assisted Opioid Substitution Therapy (OST) in Nepal: A Systematic Approach from a Pilot to Sustainable Programme

1. Working title for the proposed case study

Introducing psychosocially assisted Opioid Substitution Therapy (OST) in Nepal: A Systematic Approach from a Pilot to Sustainable Programme

2. Description of the approach to be documented in a GHPC case study

In this section we ask you describe the approach that the GHPC should. This includes also the results and the learning process during implementation. We also ask you for arguments why the case study should be documented.

Important: Please provide solid evidence for your arguments and figures, in particular for the results (d) and for the lessons (e) that have been drawn during implementation. Cite or list all documented evidence that is relevant (e.g. internal monitoring and evaluation reports, external evaluations and other studies).

a) Which relevant development challenge(s) does the approach address?

Magnitude of the problem: Nepal has a concentrated HIV epidemic, which mostly affects at risk groups, such as people who use drugs (PWUDs), sex workers and migrant labourers. There are an estimated 91,000 PWUDs in Nepal (Central Bureau of Statistics 2012); of these, 57% (51,000) are people who inject drugs (PWID). Population mapping in 2011 placed the highest number of PWIDs in the highway districts (especially Kaski, Chitwan and Morang districts) and the Kathmandu Valley (HIV and STI Control Board /NCASC 2011).

Complexity of the problem: Apart from drug addiction (disease), a high percentage of PWUDs suffer from multiple other health problems, especially HIV/AIDS (in different regions ranging from 6–17%), hepatitis C (50–80% among PWIDs) and tuberculosis (no data available, but expected to be higher than in the general population), which require special treatment. If PWUDs who participate in OST are not referred for immediate, adequate treatment they can die from these diseases. Exactly this happened when HIV/AIDS treatment was not yet available to all who needed it in Nepal with the result that a high number of PWUDs died within a few years, consequently bringing the number of PWUD down dramatically and making OST efforts redundant.

The HIV prevalence in Nepal among PWUDs ranges from 6.2% in the Kathmandu valley, to 11% in the Mid and Far Western Development Regions and 17% in the Eastern Terai. HIV is most prevalent among PWUDs in Nepal (Integrated Biological and Behavioral Surveillance Survey 2007- Eastern and Western region; IBBS 2011 Kathmandu).

Since the treatment of HIV has become more accessible, chronic viral hepatitis C is one of the most relevant, transmissible and preventable causes of death among people affected by substance use disorder. A few published and unpublished data from Nepal show hepatitis C virus (HCV) antibody prevalence rates to be very high (50–85%) among PWIDs. HCV infection leads to fibrosis, cirrhosis, hepatocellular carcinoma and liver related death in up to 30% of those chronically infected.

When the project started, the lack of awareness about OST, its potential and misconceptions among stakeholders – both government officials and beneficiaries – was a major challenge. Drug use is considered a criminal act in Nepal and PWUDs were considered criminals, which made it complicated to offer OST without coming into conflict with the police. All partners had to realise that OST is a highly effective, evidence based harm reduction measure for PWUDs. It is a medical treatment that involves replacing an illegal opiate, such as heroin, with a longer acting, but less euphoric, opioid, such as methadone or buprenorphine, and the drug is taken under medical supervision. OST Programmes enable PWUDs to shift from risky and illicit drug using behaviour to safe and supervised medicine intake. OST Programmes are effective in substantially reducing illicit opiate use, HIV and hepatitis C risk behaviours, death from overdose and criminal activity, as well as the financial and other stress on drug users and their families. These programmes also improve adherence to antiretroviral therapy and the physical and mental health of people who inject drugs. Many people who inject drugs who would otherwise have no contact with any health services are attracted by these programmes, which then act as gateways to other services including primary health care, HIV testing, antiretroviral therapy and services for tuberculosis, hepatitis C and sexually transmitted infections.

An additional challenge was to convince partners that an effective OST Programme consists not only of medical treatment and care, but also psychosocial support. There is a large body of evidence worldwide that OST combined with social support is more effective and has higher retention rates.

Nepal suffers from having inadequate number of qualified health professionals and social workers. In 2007, there were only two medical experts with some OST experience, but not a single social worker had such experience. In Nepal, there is no formal education programme at university level to qualify social workers in the field of drug use. At the start of the programme, not a single non-governmental organisation (NGO) was involved in OST and, consequently, there were only informal networks working in this area. But already in 2006, protests started to be organised by former PWUDs to get access to OST.

Before the support from GIZ, Nepal had limited experience with OST. In 1994, the Mental Hospital Lagankhel in Patan established the first methadone OST Programme in Nepal, which ran until 2002. This programme could not continue due to lack of social support to patients and other technical aspects. Another reason for discontinuation was the lack of coordination among key stakeholders, particularly the two responsible ministries. The consequence was the abrupt interruption of services, which left patients without support, leading to increased risk behaviour and, consequently, many patients died. Hence, the challenge was to overcome this damaging experience regarding the usefulness and reputation of an OST Programme and ensure the sustainability of this approach beyond any project’s timeframe.

Women constitute about 7% of PWUDs in Nepal (5,500); however, only a fraction of them (less than 1%) are currently receiving OST. Reaching underprivileged target groups is a challenge. Women in Nepalese society experience a high degree of gender inequality, including more stigma and discrimination than men and, consequently, have difficulty seeking help in government institutions with an OST site. They do not want to be exposed in public hospitals and are often unable to make their own decisions. Decisions are general made for them by their husbands and parents (or parents-in-law).

The fact that OST sites in public hospitals are not easily reachable, as many of these hospitals are not situated in easily accessible locations, is leading to high expenditure on transport and demands a significant amount of travel time, during which women cannot work, which also hampers their access to OST sites. Although OST is offered free of cost at these sites, the amount that PWUDs have to spend for travel on a daily basis is substantial and can be up to 25% of an average monthly household income. As the majority of PWUDs are jobless and cannot afford such expenditure, some prefer spending whatever money they have on drugs rather than transport. The overall challenge was, and is, how to make OST services easily accessible to the beneficiaries.

b) How has it addressed this challenge and what have been the particular contributions of German Development Cooperation?

Considering the long list of development challenges, the Harm Reduction Project in its different forms (see section 4.d) focused on implementing the most effective internationally recommended harm reduction strategies, which were adapted to the Nepalese context. The Government of Nepal supported the design and implementation of relevant harm reduction services with a focus on scaling-up and the expansion of a national OST Programme.

Fostering cooperation and coordination between different stakeholders: The OST Programme was initially established as a pilot project under the Ministry of Home Affairs (MoHA). GIZ gradually contributed to initiating collaboration with the Ministry of Health and Population (MoHP). Under this collaboration, both the MoHA and the MoHP have clear roles and responsibilities. MoHA is responsible for all legal aspects of the programme, including the monitoring of the compliance of the OST Programme with national OST guidelines and the supervision of the supply chain management of OST medicines (e.g., buprenorphine and methadone), as these medicines fall under controlled substances as per national drug law. Since 2011, GIZ‘s political partner has been MoHP and the main implementing organisation is the National Centre for AIDS and STD Control (NCASC). GIZ facilitated and promoted the process of shifting the OST Programme from a pilot project under the MoHA to a national priority one programme under the lead of MoHP in order to ensure sustainability.

The cooperation of both ministries is also essential to create an enabling policy environment to improve access to OST and reduce the criminalisation of PWUDs. An ongoing challenge is that the staff in these ministries are continuously being transferred, with the effect that, especially staff in MoHA and police personnel, need to be repeatedly familiarised with the concept of OST (through training done by NCASC).

GIZ supported the coordination of all stakeholders and partners involved in setting-up and operating OST sites, initially in six public hospitals, including a referral system within the same premises to needed health and social support services. All sites are equipped with IT-based dispensing systems and received technical support in planning and designing the sites, as well as conducting information sharing/advocacy workshops and stakeholder meetings in cooperation with civil society partners.

Currently, the national OST Programme is being jointly implemented by NCASC, under the leadership of t MoHP, and Save the Children, the Principal Recipient of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) in Nepal. Since 2014, GIZ has supported the scaling up of the programme into the NGO sector through capacity development and establishing new sites (see below para d) under “Capacity Development”). This is a breakthrough because, previously, NGOs were not allowed to operate OST sites. This breakthrough can be considered the result of the good and trusting cooperation between all partners.

GIZ also assisted in making steering structures functional. In 2013, GIZ took the lead to revive Harm Reduction Steering Committee that was not functional from couple of years.  This Harm Reduction Steering Committee meets once a year. This committee comprises representatives from the NCASC, MoHA, Save the Children Fund (SCF), World Health Organization (WHO), United Nations Office on Drugs and Crime (UNODC), Department of Drug Administration (DDA), Recovering Nepal (a network organisation of 162 NGOs working with PWUDs) and GIZ. In addition, GIZ also facilitated to arrange regular OST Technical Working Group meetings and now this group meets on a bimonthly basis. The working group is chaired by NCASC and includes representatives of the same organisations mentioned above, as well as social workers from different NGOs.

GIZ intensively supports  Recovering Nepal both technically through the secondment of a Development Advisor and financially with a local subsidy in its advocacy function, capacity building and coordination of member NGOs. It is important to note that the number of NGOs addressing PWUDs has increased dramatically over the last eight years, which requires a lot of coordination.

Addressing the complexity of harm reduction – developing adequate policies and guidelines: The German Development Cooperation contributed significantly, to the development of an enabling environment, and the legal framework for harm reduction measures in Nepal, especially for the OST. The guiding principle was to introduce and adapt existing international standards to the context in Nepal. The Harm Reduction Project was relevant in its contribution to the implementation of the Joint United Nations Programme on HIV and AIDS (UNAIDS) ‘Getting to Zero’ Strategy (2011–2014) in Nepal (i.e., zero new infections, zero stigmatisation and discrimination, and zero HIV-related deaths).

The harm reduction approach is also very relevant in the discussions leading up to the Special Session of the United Nations General Assembly on the World Drug Problem 2016 and the Sustainable Development Goals 2015: At the World Health Assembly 2015, Kofi Annan, the former UN Secretary General said that “Strengthening a public health approach when addressing the world drug problem is one of the main issues”. He added that current drug policies have to be reformed to ensure that they encourage prevention and treatment based on evidence of what works. Harm reduction measures are one of the main approaches in this context.

Over the last years, the focus of the Harm Reduction Project was on developing core policy documents, like the national OST guidelines and Standard Operating Procedures, as well as the development of a National Harm Reduction Strategy and a national strategy for viral hepatitis B and C. GIZ also facilitated the process of the Narcotic Drug Policy reform.

Accessing hard to reach populations/reaching out to underprivileged groups: With the assistance of GIZ, the OST Programme was designed to be more effective and to make the treatment programme easily accessible in order to achieve a high retention in treatment. This could be achieved only by establishing linkages between the OST Programme and essential social and health care services.

A peer approach was adopted by establishing social support units as drop-in centres. At these centres, community people who are trained to provide counselling (‘lay counsellors’) and social workers work closely with medical doctors and nurses of the programme. New OST sites established in cooperation with NGOs have the advantage of being closely situated to the target groups. This peer-led approach is very successful in accessing PWUDs in terms of offering confidential counselling, reducing stigma and discrimination, and reaching out to hidden populations of PWUDs in the community.

In cooperation with SPARSHA, an NGO working with PWUDs and people with HIV in Nepal for many years, GIZ has developed an innovative approach to reach PWUDs who have difficulty in accessing healthcare. SPARSHA assembled a mobile health clinic team comprised of social workers, peer educators, counsellors and a medical doctor that goes directly to PWUD hotspots offering free HIV testing and primary health care (PHC) services and referring PWUDs to existing OST sites. It is expected that through this approach more female PWUDs can be reached, who have difficulty accessing fixed public or NGO healthcare providers.

Supporting capacity development at all levels: Capacity development measures have been one of the major contributions of the Harm Reduction Project. At the policy level, MoHA and MoHP were supported to develop essential policy documents, including OST guidelines, Standard Operating Procedures and manuals (see above).

At the institutional level, Recovering Nepal, the national umbrella organisation of NGOs working with PWUDs, was strengthened in its coordination function (networking) and in the development of sustainable training and technical assistance structures for NGO staff. The Tribhuvan University Teaching Hospital was been built up to become a national training institution for medical staff working in OST. In cooperation with GIZ, training curricula were developed and have been institutionalised. These curricula have become the national standard for the training of OST staff and are mandatory for every health professional working in this field.

Capacity development at an individual level was targeted at social workers, nurses and medical doctors working in OST. This included the joint development of curricula to train medical staff and social workers on substitution therapy, comprehensive health care and psychosocial support for PWUDs, as well as the training of trainers and a national pool of trainers.

All measures implemented by the programme have been aligned and coordinated with national organisations, as well as other international donors in the field – especially with the Global Fund to Fight AIDS, Malaria and Tuberculosis, the NCASC (former Principal Recipient of the Global Fund until May 2014), Save the Children (current Principal Recipient of the Global Fund), government hospitals and NGOs – with the aim to achieve comprehensive medical and psychosocial care for people who use drugs. The capacity building measures undertaken by the programme have complemented HIV and harm reduction activities, which were financed by a Global Fund grant.

c) How long has this approach been implemented and to what level/coverage has it been scaled up?

GIZ started working on OST in Nepal in December 2007 in the context of a public private partnership (PPP) project. This work continued under different projects and will last until June 2016. Projects and activities included the following:

  • December 2007 to December 2011: Regional GIZ Public Private Partnership (PPP) project on methadone-substitution in Nepal, India, Malaysia, Kyrgyzstan, Tajikistan and Kazakhstan (PN 04.1003.5-404.13)
  • August 2010 to August 2012: ESTHER Partnership Initiative, a university and clinical partnership between Klinik Hamburg-Eppendorf and Tribhuvan University Teaching Hospital in Kathmandu (PN 10.2173.2)
  • May 2011 to June 2014: Harm Reduction Project (PN 2010.2246.6)
  •  July 2014 to date: Harm reduction is a thematic area under the Nepali-German Health Sector Support Programme (PN 2012.2202.5)

The technical cooperation through a regional GIZ PPP project started with only one OST pilot site at Tribhuvan University Teaching Hospital, which was initially financed by UNODC. Currently, the national programme consists of 10 OST sites, (6 in public hospitals and 4 in NGOs). It is planned to establish two additional sites in government hospitals by the end of 2015. The sites are currently serving 820 patients on a daily basis nationwide. The programme aims at providing treatment for 150–200 patients per site by June 2016.

The national scale-up plan aims at establishing a total of 9 government and 12 NGO sites by July 2016. The Global Fund will cover the running costs of all sites as well as the training and coordination costs of Tribhuvan University Teaching Hospital and Recovering Nepal, even after the phasing out of the GIZ-assisted programme in July 2016.

d) Describe the results of the approach (e.g., outputs/outcome). Provide evidence for each result and state the source for it.

Policy level: With the support of the Harm Reduction Project it was possible to shift the reponsibility for the OST Programme from MoHA alone to a shared responsibility under the lead of MoHP and to transform the programme from a small-scale pilot project into a national priority prgramme on a large scale. As result, a number of important policy documents were produced and implemented:

The Guidelines for Opioid Substitution Therapy 2013 were developed in cooperation with MoHP and MoHA. These guidelines allow for expansion, and also ensure the quality, of the substitution programme. The guidelines triggered a strategic change in OST in Nepal. In the past, only public hospitals were allowed to offer OST, but these hospitals often lacked the resources to provide sufficient coverage. Now, OST is offered through the private sector through the involvement of NGOs, registered doctors, private practitioners and hospitals. Through this measure more PWUDs can be reached. Policy reforms have also resulted in the permission to use other substances besides methadone, like buprenorhine, allowing for the more personalized and effective treatment of patients. Standard Operating Procedures for the Social Support Units were developed to ensure an equal standard in the psychosocial support of patients.  Another important and relevant milestone is the National Harm Reduction Strategy (which is yet to be endorsed).

Implementation level: At present,6overnmental OST sites and 4 NGO sites are serving a total of 820 patients per day nationwide (out of which 28 are female, 3.4%). By the end of July 2015, a total of 2,100 PWUDs  were enrolled in the OST Programme (no disaggregated data available). To date, 745 persons have completed the OST Programme; some of them have started a rehabilitation programme (no disaggregated data available). The number of drop-outs is comparatively low at 375 out of 2100 (defined as quitting without a proper plan). Clinical guidelines on OST have been developed and need to be approved by NCASC. Given the situation in Nepal this is already a big achievement. The project supported the introduction and the establshment of the necessary frame conditions for scaling up - what is actually planned over the next years with funds of the Global Fund.

Although there are no quantitative data on the impact of psychosocial counselling in combination with OST there is qualitative evidence that this kind of support contributed to improve the quality of life among PWUDs. Many are now actively involved in income-generating activities and are more integrated into their families and communties (see documentary film mentioned below).

Capacity development:

a) Training curricula:For NGOs running social support units, a curriculum has been developed that targets especially the capacity building needs of the staff of these NGOs, who are usually former drug users without formal training or education in social work. A national curriculum for medical staff has been developed. This is the basis for the education and advanced training of medical personnel. This curriculum is also embedded in the psychiatric education of medical students at the Tribhuvan University Teaching Hospital. GIZ and Tribhuvan University Teaching Hospital were involved in the development of a blended learning/e-learning course ‘Comprehensive health care for people who use drugs’ for doctors who want to engage in OST.

b) Capacity building: Since 2012, a total of 52 medical staff were trained in OST and 90% of them are working in the existing sites. During the same period, 88 social workers participated in psychosocial counselling training courses. All training programmes were based on the developed curricula. Eight physicians were qualified as master trainers for OST and five master trainers were qualified to conduct training on psychosocial counselling.

In addition, a training manual called ‘Hepatitis C treatment Advocates’, containing information on the prevention and treatment of viral hepatitis, was adapted to the Nepalese context and translated into Nepali. A total of 20 individuals were trained based on this manual on pre- and post counselling for hepatitis C treatment.

e) As this approach was implemented, what has been learned and how has this led to adaptations and ‘course corrections’ in the implementation? Please note that interesting case studies should explore both what worked and what did not work. Often it is the second which generates more learning and therefore particularly interesting for a case study. Here too, provide evidence and sources.

During implementation, the following  was  learnt:

  • A comprehensive approach, i.e. amedical treatment combined with psychosocial counselling, is more effective.
  • International practices need to be adapted to the local context: Introducing psychosocially assisted OST with a peer approach was an innovative methodology never used before in other countries. As there were no social workers with a formal education readily available in Nepal it was found that lay counsellors, who are usually former drug users, can be effectively used as peer counsellors.
  • The cooperation of the government and private sector (NGOs) achieves better results in terms of outreach and acceptance by the target groups. The cooperation with NGOs to offer OST was a major change of the original approach (starting only in 2014). Coordination is key for success. The direct involvement of the PWUD community via NGOs is instrumental to reach other PWUDs. This special target group is very mobile and more open with peers than with professionals. NGOs play a major role and complement the government as they are the vital service providers for drug treatment and rehabilitation. Over the years, mutual trust was established and the working environment became more favourable for constructive cooperation.
  • GIZ can play an important and effective role as a facilitator and mediator between different ministries and other government institutions, NGOs, and target groups. As a ‘neutral’ partner, GIZ and its staff are accepted at all levels on the basis of its technical competence and expertise. GIZ’s non-threatening reputation allows it to co-work with everyone.
  • Repeated refresher courses achieve better results in terms of better motivation, knowledge and practices. Over the last few years, the core group working on OST has been very stable and committed to the cause.
  • Female PWUDs are still difficult to reach in the Nepalese socio-cultural and socioeconomic context. Many attempts and approaches for reaching women have not yet achieved the expected results and the reasons for this failure need to be analysed to develop more effective approaches.
  • Even having a sound and agreed exit strategy is no guarantee that it is implemented smoothly. Although the Global Fund to Fight AIDS, Tuberculosis and Malaria had committed to cover the running costs of OST sites established under the former Technical Cooperation Harm Reduction Project, MoHP reduced the number of personnel after the official end of the GIZ assisted project in July 2014 and did not request the GFATM funds on time for the months of July to October 2014, with the result that OST staff had not received any salary by the end of 2014. Only after long negotiations was it eventually agreed to pay the outstanding salaries retrospectively.
  • It is necessary to invest in a good information system right from the start in order to be able to show the impact of a project. Only recently (in 2014), information on PWUDs was included into the national health information system, however there is still no systematic disaggregated data collection on OST.
  • The OST programme works even after a major disaster: Despite the earthquake of 25 April 2015, all OST sites continued functioning and dispensing methadone to patients without disruption of these crucial services. This is due to the motivated staff.

f) As this approach was implemented, what has been learned and how has this led to adaptations and ‘course corrections’ in the implementation? Please note that interesting case studies should explore both what worked and what did not work. Often it is the second which generates more learning and therefore particularly interesting for a case study. Here too, provide evidence and sources.

A case study of this approach could analyse the success factors and show how these contributed to the programme’s success in order to design and implement a national OST Programme in cooperation with all relevant partners and key stakeholders. It could show how inter-sector cooperation and the strengthening of local capacities can result in a sustainable programme with national ownership.

Especially, in the context of the fight against HIV with a focus on key populations and also in the context of hepatitis C, as a global problem, which is getting more and more attention internationally, the importance of harm reduction measures, with OST as a main approach is growing.

There are several countries in Asia, but also in Africa that have just started OST or are planning to. This comprehensive approach is unique worldwide and provides a best practice example that can be replicated in other countries. A ‘one-stop shop’ model is preferable, in which all the required services for physical and mental health and drug use are located in the same setting. If this is not possible, it is important to have referral pathways and linkages to other local services.

Another important programme enabler for investment is the collection, generation, analysis, translation and use of relevant and reliable strategic information. Social enablers include investments in programmes to address gender violence, starting with mobile drug user populations, and for social cohesion, accountability, punitive laws and their interpretation, and zero tolerance of all forms of HIV-related discrimination.

g) Describe in what ways a case study about this approach contributes something new to what we know about health and social protection systems and service delivery.

Working on OST is not a mainstream topic in public health. There are not many developing countries that have started offering OST; it is hence the uniqueness of this approach that makes it a special case to learn from. The recommendations from this experience will serve not only to assist Nepal in scaling up the approach but could also become a way forward for other countries that face the same or a similar problem. The OST Programme in Nepal offers a unique opportunity to learn from 20-years of experience in implementing such an approach in a developing country. The scope of this experience ranges from policy development under initially not very favourable circumstances (no inter-ministerial coordination, no cooperation with NGOs) to innovative implementation measures (including a ‘one-stop shop’ model and turning PWUDs into peer counsellors) and includes vast experience in developing training and communication materials, which can be easily adapted to other country contexts. Nepal also offers an opportunity to study what did not work very well, for instance, reaching the female who inject drugs.

Over the years, a number of approaches have been tested, adopted and adapted, and some rejected. It is interesting to analyse how and why interventions worked and what factors led to failure. As this very interesting and successful collaboration will end in 2016, it is worthwhile for GIZ, GDC and BMZ to share the lessons learned with other countries.

3. Supporting material

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

The following audio/visual documentary materials are available:

  • Role model (www.youtube.com under ‘GIZ Health Nepal’ channel)
  • The other choice (www.youtube.com under ‘GIZ Health Nepal’ channel)
  • Professional, high-resolution photographs are also available with the project team.

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

  • National Opioid Substitution Therapy Operational Guideline (local language)
  • Standard Operating Procedure for Social Support Unit in Methadone Maintenance Treatment Programme (Draft)
  • Training Curriculum for Service Providers: Comprehensive Health Care & Opioid Substitution Therapy
  • Training Curriculum for Staff in Psychosocial Support Units
  • E-Learning tool for medical staff of OST
  • Treatment Advocates – Training Manual on Hepatitis B, C and HIV Co-infection (local language)
4. 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 case study? Whom should he or she meet and interview? Which sites should he or she visit?

Name

Organisation

Designation

Interviews

  1. German Development Cooperation

Dr Paul Rueckert

GIZ-HSSP

Chief Technical Advisor

Ujjwal Karmacharya

GIZ-HSSP

Senior Programme Officer

Mr Bikash Nepal

GIZ-HSSP

Programme Officer

  1. Partner organisations

Dr Deependra Raman Singh

National Centre for AIDS and STD control, Ministry of Health and Population

Director

Dr Bhesh Raj Pokharel

National Centre for AIDS and STD control, Ministry of Health and Population

OST Programme Focal Person

Fanindra Pokharel

Ministry of Home Affairs

Under Secretary

Mr Rajan Bhattarai

Save the Children, Global Fund to Fight AIDS Tuberculosis and Malaria Programme

Deputy Chief of Party

Dr  Sagun Ballav Pant

Tribhuvan University Teaching Hospital

Medical Officer, Trainer and co-author of National Training Curriculum for OST doctors

Anan Pun

Recovering Nepal

President

Mr Prawachan KC

SPARSHA Nepal

Programme Manager

  1. 3.      Distance interviews

Patricia Kramarz

GIZ-HSSP, Consultant

Consultant and former Programme Manager, Harm Reduction Project

Dr Hans Tilmann Kinkel

 

Former Medical Advisor, Harm Reduction Project

Philippe Creac’H

The Global Fund to Fight AIDS, Tuberculosis and Malaria

Portfolio Manager, Nepal

  1. 4.      Site visits

SAARATHI Nepal, Dhumbarahi, Kathmandu, Nepal (public OST site)

SPARSHA Nepal (NGO-based OST site)

Department of Mental Health and Psychiatry, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu (training focal point institution for medical staff of OST Programme)


5. Publication audiences and languages; printing arrangements

On which occasions, to which audiences and in which language (in addition to English) would your partner organisation and you like to distribute the case study? 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 case study as planned.

National (in English):

  • International Day Against Drug Abuse and Illicit Drug Trafficking, 26 June 2016
  • World AIDS Day, 1 December 2016

International (in English):

  • International AIDS Conference 17–22 July 2016, Durban South Africa
  • International Harm Reduction Conference, Kuala Lumpur, Malaysia, 2017
  • 12th International Congress on AIDS in Asia and the Pacific (ICAAP) 2016
  • United Nations General Assembly Special Session (UNGASS) of the World Drug Problem, New York, 2016

Printing arrangements: If we sent you the complete final print files for the short and long versions of the case study in the language of your partner country, can you print the number of copies you require for the partner and the interested public in your country?

Yes

6. Financial contribution

The GHPC is jointly financed by the health and social protection sector initiatives. When it documents programmes in partner countries, these are expected to contribute (normally at least a third) to the cost of the writer’s contract. Which amount can your programme contribute to the costs of the writing of the English version of the publication (30 expert days plus travel costs for a 5-day visit of your programme)?

One –third of the cost, as suggested

7. Date of submission

Date of submission:

30.07.2015   

Strengthening Adolescents’ Sexual Reproductive Health and Rights in Malawi through a Multisector Cascade of Care Model

1. Working title for the proposed case study

Strengthening Adolescents’ Sexual Reproductive Health and Rights in Malawi through a Multisector Cascade of Care Model

2. Description of the approach to be documented in a GHPC case study

In this section we ask you describe the approach that the GHPC should. This includes also the results and the learning process during implementation. We also ask you for arguments why the case study should be documented.

Important: Please provide solid evidence for your arguments and figures, in particular for the results (d) and for the lessons (e) that have been drawn during implementation. Cite or list all documented evidence that is relevant (e.g. internal monitoring and evaluation reports, external evaluations and other studies).

a) Which relevant development challenge(s) does the approach address?

While the national HIV prevalence of Malawi is 10.3% and has declined from 12% since 2004, the prevalence rate among young people aged between 15 and 24 has increased among girls from 3.6% to 5.2 % (Malawi National Aids Commission, 2014). In 2014, over a million Malawians were living with HIV of which 310,000 were young people below the age of 24 (Malawi National Aids Commission, NAC, 2014).

Despite those numbers and the fact that adolescents (age 10-19) comprise of nearly a quarter of the total population and are at a high risk of being infected with HIV, they are hardly prioritised in most HIV interventions (Malawi Ministry of Health, MoH, 2014, national HIV estimates). By not deliberately focusing sexual and reproductive health services on the 10-19 year olds, adolescents are left in a position of vulnerability. In addition, studies indicate that adolescents living with HIV (ALHIV) require close clinical and psychosocial support by both health facilities and communities as they are less likely than adults to adhere to treatment and more likely to suffer from HIV-related morbidity and mortality (NAC, 2013).

Most cases of HIV infection are linked to sexual and reproductive health and rights. HIV is primarily acquired through sexual relations (United Nations Population Fund, UNFPA, 2013). Adolescents in Malawi experience challenges to access information for HIV prevention; treatment, care and support; as well as for teenage pregnancy prevention. There is low access to and uptake of modern family planning methods; poor nutritional status of adolescents, especially adolescents living with HIV; and inadequate follow up and support systems for adolescents experiencing sexual abuse (MoH / United Nations Children's Fund, UNICEF, 2012).

Only 42% of young women and 45% of young men have comprehensive knowledge of HIV resulting in low utilization of HIV testing and counselling (HTC), particularly among young men and non-pregnant young women, as well as low access to and utilization of condoms (Malawi Demographic and Health Survey, MDHS 2010). Furthermore, only two of every five sexually active men age 15-19 (40%) are using condoms (MDHS 2010). Consequently there is a high HIV incidence of 3,200 annually among adolescents (NAC, 2013) coupled by a high number of teenage pregnancies at 106,000 annually representing 26% of all pregnancies in Malawi (MDHS, 2010). This is partly due to an unmet need for contraceptives of 39% among young people (age 10-24) (Youth Friendly Health Services Evaluation, 2014). Malawi has the highest adolescent fertility rate (143/1,000) in Sub-Saharan Africa. This has negative health implications on adolescent girls and contributes to increased maternal and child mortality (MoH, 2014).

b) How has it addressed this challenge and what have been the particular contributions of German Development Cooperation?

GIZ through, the Malawi German Health Programme is supporting the Malawian Ministry of Health (MoH) in collaboration with other delivery partners in increasing access to comprehensive HIV prevention information and utilization of modern family planning methods, treatment and support services among 10-19 year olds (i.e. adolescents) in ten[1] out of 28 districts, with a focus on rural and hard to reach areas with a HIV prevalence rate higher than average in Malawi. The project is implemented in two phases. The first phase (Jan. 2013 – Dec. 2014) was entitled “Narrowing the gap: scaling up adolescents’ access to quality information and utilization of HIV prevention, treatment, care and support” and was carried out in collaboration with UNICEF being the main managing and coordinating institution of the project. The second phase (Jan. 2015 – June 2015) is implemented in the same previously selected ten districts in collaboration with Norwegian Church Aid. It is entitled “Health systems strengthening with a focus on reproductive health: addressing sexual and reproductive health (SRH) and rights and unintended teen pregnancy”.

The overall objective of the project is to strengthen adolescents’ SRH and rights in Malawi. In order to pursue this, the project is using an integrated HIV mainstreaming and continuum of care cascade model and addresses three areas of interventions, namely schools, health facilities and communities. The multi-sectoral approach aims at mainstreaming adolescent sexual health in all key sectors of health, education, youth and social services via strengthening coordination, synergy and referrals among the various sectors. Through such an approach not only health workers but teachers and communities in the ten target districts become responsive to the needs and rights of adolescents to access age appropriate SRH information and services. The approach therefore prioritises access to comprehensive sexuality information and access to quality youth appropriate HIV and pregnancy prevention services while at the same time trying to create an enabling environment in the community that reduces risky behaviours.

The outreach project interventions for adolescents in schools focus on the sensitisation of teachers, the establishment of adolescents peer education clubs at school, the development and distribution of media packages, and the establishment of a national child helpline to increase knowledge and promote services among adolescents in schools.

The comprehensive sexuality education (CSE) is given as part of formal learning in schools where teachers are sensitised to deal with cultural inhibitions in offering classes on sex and sexuality and curriculums are revised to incorporate CSE in line with the accountability framework of the Eastern and Southern Africa (ESA) ministerial commitment to support sexuality education and SRH services for adolescents and young people. In addition, HIV prevention information is offered in school youth clubs after classes to those learners who opt for HIV prevention youth clubs. The school-based interventions use TV services and radio talk shows with adolescents, booklets, pamphlets, calendars, rulers and t-shirts to channel correct information on vulnerability and risks related to unintended pregnancy and how to prevent HIV infection.

The health facility based interventions include the establishment of teen clubs for adolescents living with HIV and mobile HIV testing and counselling (HTC) campaigns. The Ministry of Health (MoH) through health centres and district hospitals or health facilities of the Christian Health Association of Malawi (CHAM) have partnered with local non-governmental organisations such as Banja La Mtsogolo (BLM), Pakachere Institute for Health Development and Communication (IHDC), Story Workshop and Youth Net and Counselling (YONECO) and Baylor College of Medicine Children’s Foundation Malawi to provide mobile adolescent HTC and modern contraceptives to adolescents in hard to reach geographic sites during weekends. The mobile campaigns are organised by a multi-sectoral team of officers from health, education, social services, youth and traditional leaders to best capture the comparative advantages of each sector in responding to adolescent SRH needs. The campaigns are offered in a fun filled edutainment manner full of music, dance and drama to ensure high attendance and uptake of the SRH services.

Through teen clubs, adolescents living with HIV are supported to understand their HIV infection, manage opportunistic infections, deal with stigma and challenges of growing up positive, and most importantly, adhere to treatment. The clubs are provided for two age groups 10-14 and 15-19 years and work with social workers who help with disclosure of a positive HIV status to adolescents and follow up on child protection issues, such as stigma and discrimination within the home and schools.

In order to improve the delivery of youth friendly health services (YFHS) to adolescents, health workers including nurses and clinicians were trained and equipped with knowledge and skills in the provision of SRH services to adolescents in a friendly manner tailored for young people by using a cascade training approach. These services are provided either as static services at the health facility or through outreach services.

The intervention to address adolescent and youth friendly SRH services and rights at community level, was planned to begin only in year two of the project, i.e. after the schools and health facility interventions have been rolled out. This was so as to utilise the sensitised adolescents to carry out community strengthening and also to ensure that the district teams are first trained in YFHS. Between January 2015 and June 2016, religious and traditional leaders are being engaged so they do not act as barriers to the uptake of SRH services by adolescents. The leaders are equipped with correct sex and sexuality information in order to pass those on to the adolescents who attend initiation camps after puberty.

Processes have been initiated with District Social Welfare Departments to conduct journey of life community awareness workshops to mobilise communities to take action against SRH rights violations by addressing cultural, social, economic, policy and legal barriers. Within those workshops, communities develop bylaws to address some of the negative social cultural norms and action plans including the establishment of children’s’ corners providing services such as life skills education, orientation on SRH and psychosocial support.

c) How long has this approach been implemented and to what level/coverage has it been scaled up?

During the first project phase from January 2013 to December 2014, GIZ through the Malawi German Health Programme (MGHP) and in collaboration with UNICEF Malawi supported the Ministry of Health in strengthening adolescents’ access to quality information on HIV and AIDS, modern family planning methods and to HIV testing and counselling (HTC) as an entry point to prevention, treatment, care and support in ten out of 28 districts reaching about 40% (1.84 million) of the 10-19 year old adolescent population in Malawi. The ten districts were selected in 2012 based on the high HIV prevalence which was either equal to or higher than the national HIV prevalence of 10.6% (Bertfely and Blaalid, 2012).

In January 2015, the project duration was extended until June 2016 to strengthen integration of sexual and reproductive health and rights and unintended teen pregnancy in HIV care and treatment services. The collaborating partner of the second phase changed from UNICEF to Norwegian Church Aid (NCA). NCA has the comparative advantage of working with religious leaders to address religious inhibitions that cause barriers to adolescent’s uptake and adherence to modern contraceptives. The implementing partners of the project however remained the same.

Intervention area

Implementing Partner

Role

School based interventions

District Education Managers of the ten target districts supported by District Youth Officers and District Social Welfare Officers

In-school Youth Clubs

Pakachere Institute for Health Development & Communication

In-school Youth Clubs

Health Facility Based interventions

Banja La Mtsogolo

Mobile HIV Testing Clinics, modern contraceptive services, screening of sexually transmitted infections, condom distribution

Government Health Facilities

Static HIV testing and counselling

Christian Health Association of Malawi health facilities

Static HIV testing and counselling

Baylor Children’s Foundation

Care, treatment of adolescent living with HIV in static health facilities

District Councils of the ten target districts

Delivery of YFHS in static health facilities;

ensure policy and standards are maintained in the mobile clinics and offer treatment and care to HIV positive adolescents in the static facilities; custodians on the data

Community based interventions

District AIDS Coordinators; Ministry of Gender, Youth and Social Welfare

Journey of Life addressing sexual health risks and vulnerabilities of adolescents with traditional leaders

Youth Net and Counselling (YONECO)

Airs adolescent targeted messages on the SRH and rights, Radio, Television

Coordination leadership, monitoring and reporting

UNICEF

Jan. 2014 – Dec. 2014; roll out the HIV intervention

Norwegian Church Aid

Jan. 2015 – Jun. 2016; Strengthen community support for SRH and rights of adolescents and intensify monitoring and referral services


d)
Describe the results of the approach (e.g. outputs/outcome). Provide evidence for each result and state the source for it.

During the first project phase (Jan. 2013 – Dec. 2014), progress was made towards addressing barriers that prevent adolescents from accessing HIV prevention, treatment, and care and support services as reported in the midterm review (UNICEF, 2014). Overall, the project has contributed to the following:[2]

  • Since January 2013, the project has targeted and reached 33,000 adolescents aged from 10-19 years with HTC.
  • Through outreach service delivery and the use of age appropriate, youth sensitive SRH and rights messages and services in 10 out of 28 districts, 13,302 adolescents in hard to reach areas were able to access HTC and post-test support services, including screening and treatment for STIs, within walking distance of their communities and accessed 66,505 condoms (64,901 male, 1,604 female). 876 adolescents were referred to family planning services including long acting reversible contraceptives (LARCs).
  • By September 2014 1,100 adolescents living with HIV have been enrolled in 21 monthly health facility based teen clubs run in ten districts. In these clubs, 7,754 adolescents have received family planning services, 1,479 have been treated against sexually transmitted infections and 136,559 have been provided with condoms. Adherence to treatment and the psychosocial impact of the clubs have been reported by adolescents living with HIV as some of the immediate benefits of the health facility based clubs.
  • Recognising the benefits of the teen clubs in addressing the treatment and psychosocial needs of adolescents living with HIV, District Councils through District Health Officers (DHOs) have taken the initiative to support and sustain the teen clubs.
  • Disaggregated into the two main adolescent age groups (age 10-14 and age 15-19) and by 2014, the proportion of adolescents (age 10-14) reached through mobile HTC campaigns is 35,000 which is roughly three times more than the proportion reached by static HTC services (11,000) and more than five times (7,000) the proportion reached through static HTC services in 2011 and 2012.
  • Demand side barriers were addressed through adolescent peer education clubs. For example, while 53% of adolescents accessing HIV testing and counselling at static sites are pregnant females due to the Prevention of mother-to-child transmission (PMTCT) programme, nearly 52% of adolescents accessing HTC during outreach clinics are young males who normally are not captured in static clinics. Adolescent club members demonstrated higher access to HIV testing than other adolescents. 97% of adolescents in adolescent clubs reported testing for HIV due to having correct information on the process and benefits of HIV testing.
  • Through the child helpline, 3,991 calls were completed, providing adolescents with information on HIV, SRH and psycho-social support. Adolescents also received face-to-face help provided by trained counsellors, while 26,523 text messages were sent on a range of topics, including HIV, SRH and sexual abuse.
  • Adolescent-oriented programmes were broadcast on popular radio and TV stations which have a combined national viewership and listenership of more than 50% of the population.
  • The adolescent club model based at schools also demonstrated its effectiveness by contributing to a substantial reduction of school dropout due to teenage pregnancies in schools with active adolescents’ clubs. The sharpest decline in teenage pregnancies was observed during the project intervention period between 2013 and 2014.

e) As this approach was implemented, what has been learned and how has this led to adaptations and ‘course corrections’ in the implementation? Please note that interesting case studies should explore both what worked and what did not work. Often it is the second which generates more learning and therefore particularly interesting for a case study. Here too, provide evidence and sources.

During the implementation of the first phase of the project (i.e. in May 2013), a joint field monitoring mission involving the Malawi German Health Programme (MGHP), UNICEF and other key implementing partners was undertaken to Thyolo, Mzimba North and Mzimba South District. The districts were chosen for the monitoring visit because Thyolo was the most affected district with a HIV prevalence rate of 22%and Mzimba was with 6.6% HIV prevalence the least effected district of the ten target districts. The objective of the monitoring visit was to see how the intervention was rolled out. Four key issues emerged from observations and discussions with health workers during the joint field monitoring mission:

  • apparent moderate to severe malnutrition among adolescents, especially adolescents living with HIV but hardly any nutrition interventions targeting adolescents (age 10-19);
  • a high level of school dropout due to teen pregnancy among adolescent girls. 17,510 adolescents (22%) dropped out of primary school and 1,909 adolescents (19%) dropped out of secondary school in 2013 due to marriage or pregnancy;
  • most of the adolescent pregnancies were due to relationships (both consensual and non-consensual) with men in their 30s or older (some were even teachers); and
  • men who committed sexual violence were rarely followed up and punished.

From the monitoring supportive visits the project also learned that adolescents are not targeted by nutrition interventions and yet adolescents who are on HIV medication need to access a minimum of three nutritious meals a day for proper utilization of the medication. Without adequate food intake, drug adherence becomes poor. Stunted growth was also observed to be an issue. Based on those findings, the school and health facility based interventions in all ten districts started to consider and address these emerging issues, in particular with learning units on nutrition, family planning and prevention of unplanned pregnancies, and child abuse and protection.

While the first phase of the project therefore focused on rolling out the school and health facility based interventions, the second phase is addressing community religious and traditional leaders to ensure that there is an enabling environment for adolescents to maintain non-risky behavior after comprehensive sexuality education and being linked up to youth friendly SRH services.

The initial stage of the intervention was led and coordinated by UNICEF and the final phase of the project is led and coordinated by Norwegian Church Aid (NCA) who is tasked with strengthening the community traditional and religious leaders in adolescent SRH support. The activities at community level were planned to be started after two years of implementation, and the takeover of NCA to lead the project is also to ensure that the project strengthens its working relations with religious and traditional leaders so they can support a more conducive environment for transfer of SRH information to the adolescents.

Child protection systems are limited and are further weakened by a culture of silence around issues of sex and sexuality. Underage sex between married adolescents is not outlawed by the constitution of Malawi. Due to gender norms, men are much less involved in sexual and reproductive health work, yet culturally it is men who make SRHR-related decisions. The strengthening of the third intervention area therefore becomes crucial to the achievement of the project’s objectives.

f) Describe in what ways a case study about this approach contributes something new to what we know about health and social protection systems and service delivery.

The multi-sectoral cascade of care model is a new approach to Malawi and is piloted in the ten target districts in the framework of this project. It is particularly suited to strengthen the adolescents’ access to correct HIV prevention information and sexuality education in a continuous and holistic manner and understands adolescents as recipients of SRH services as promoted by the Eastern and Southern Africa (ESA) ministerial commitment to support sexuality education and SRH services for adolescents and young people.

Due to the fact that adolescents are mainly excluded from such services in static health facility care, the project’s experiences are of relevance to other resource poor settings and heavily HIV affected Sub-Saharan countries. The multi-sectoral approach links up all the key actors and sectors working towards adolescents friendly SRH services (i.e. health, education, youth and social services) and strengthens the development and implementation of joint planning and accountability frameworks at national and district level. It leads to the best outcome in ensuring YFHS of high quality at any given time for adolescents who themselves have different preferences of how to access SRH services.

The project responds to those diverse demands by addressing them at three different levels. Firstly, through mobile outreach clinics held at schools on weekends in geographically hard to reach areas, the project generates demand for youth friendly health service uptake. Within the framework of additional school based activities, further demand is created and peer education interventions are offered through Youth Clubs. The school based Youth Clubs are open to any 10-19 year old. Secondly, the adolescents who test HIV positive during mobile clinics or have sexually transmitted infections are referred and linked to health facilities where they are organised in Teen Clubs. At community level, which is the third level of the cascade of care model, the religious and traditional leaders are engaged to strengthen child protection systems that provide an enabling environment for adolescents to maintain desired sexual behaviour.

3. Supporting material

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

The Malawi German Health Programme will be able to provide 15 – 20 high-resolution photos on the programme context, but only 5 – 10 of the approach in action.

However, a photo documentation is available that has more than 20 pictures reflecting the project’s interventions which were taken by UNICEF. The use of the pictures from UNICEF would be possible under the following conditions: 1.) permission from UNICEF to GIZ to use the pictures if credit is given; and 2.) release form to be prepared between UNICEF and GIZ with the condition that the pictures will not be used for commercial purpose (source: conditions communicated by Kennedy Warren on 23.042015). Hence, an additional professional photo assignment might need to be considered.

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

The following materials can be made available for download as part of an online toolbox to accompany the case study:

  • Adolescent Contraception Flipbook (by Baylor Children’s Foundation), and
  • Youth Club Resource Material Level 1 and 2 (by Pakachere for Development Health and Communication).
4. 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 case study? Whom should he or she meet and interview? Which sites should he or she visit?

The best time to document this programme would be between early-November and mid-December 2015 as the partner organisations usually take a Christmas break between mid-December and mid-January. This timeframe would allow for the greatest possible interaction with stakeholders and beneficiaries including the following:

Partner Organisation

Contact Person

Ministry of Health, Reproductive Health Directorate

Director of Reproductive Health Directorate

Mrs Fanny Kachale; Email: fankachale@yahoo.co.uk; Tel: + 265 (0) 1751 552; Cell: + 265 (0) 888 586 485

Youth Friendly Health Service Coordinator

Mr Hans Katengeza;; Email: hanskatengeza@yahoo.co.uk; Tel: + 265 (0) 1751 552; Cell: + 265 (0) 995 525 455

Norwegian Church Aid

Head of Programmes

Mrs Esther Masika; Email: esther.masika@ncy.no; Tel: +265 (0) 1759 511/512; Cell: +265 (0) 888 201 634

UNICEF

Programme Specialist for Donor Relations

Jennifer Shortt-Banda, Email: jebanda@unicef.org; Tel: + 265 (0) 1770 770

Baylor College of Medicine Children’s Foundation Malawi

Head of Institution

Dr Peter Kazembe M.D.; Email: pnkazembe@baylor-malawi.org; Cell: +265 (0) 882 547 196

Technical Coordinator of the Project

Susan Hrapcak M.D.;  Email: Susan.Hrapcak@gmail.com; Cell: +265 (0) 994 360 185

Success story teller from Teen Club

Josephine Jiyani; Email: josephinejiyani@gmail.com; Cell: +265 (0) 888 466 601

Pakachere Institute of Health & Development Communication

Head of Institution

Simon Sikwese; Email: ssikwese@pakachere.org; Cell: +265 (0) 999 269 677

Project Manager

Fred Penjani Kalua; Email: fkalua@pakachere.org; Cell: +265 (0) 999 269 677

Banja La Mtsogolo

Director of Programmes

Caitlin Goggin; Email: caitlin.goggin@banja.org.mw; Cell: +265 (0) 882 010 922

Key actors of Lilongwe and Dedza Districts

(Chosen due to proximity to Lilongwe and other partners)

District AIDS Coordinator

District Youth Officer

HIV Testing and Counselling (HTC) Coordinator

Youth-friendly Health Service Coordinator

HIV and AIDS Focal Person at District Education Management Office


The project is implemented in ten target districts.[3] Districts to be visited can be Dedza and Lilongwe. This would allow the writer to look at the multisector cascade of care model in its entirety. The school based interventions (i.e. school youth club) and health facility based interventions (i.e. Teens club at one of the health centres, district hospitals or CHAM facilities) would be covered in Lilongwe, the community based interventions (i.e. journey of life community awareness workshop) in Dedza.

5. Publication audiences and languages; printing arrangements

At which occasions, to which audiences and in which language (in addition to English) would your partner organisation and you like to distribute the case study? 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 case study as planned.

The publications should be printed in English only. Potential occasions and audiences for the distribution of the case study after May 2016 could be the following:

  • Africa Symposium for HIV Prevention and Sexual Reproductive Health in 2016 arranged by the Eastern and Southern Africa (ESA) Ministerial Commitment (supporting sexuality education and sexual and reproductive health services for adolescents and young people)
  • International Conference on AIDS and STI’s in Africa (ICASA) Forum in Nov./Dec. 2017
  • International Conference on Family Planning in 2017
  • Annual National AIDS Commission (NAC) Research Dissemination Forum in Malawi in 2016

Printing arrangements: If we sent you the complete final print files for the short and long versions of the case study in the language of your partner country, can you print the number of copies you require for the partner and the interested public in your country?

Printing copies of the publication is in principal possible in Malawi, but not cost-effective. All copies of the publication should be printed in Germany.

6.  Financial contribution

The GHPC is jointly financed by the health and social protection sector initiatives. When it documents programmes in partner countries, these are expected to contribute (normally at least a third) to the cost of the writer’s contract. Which amount can your programme contribute to the costs of the writing of the English version of the publication (30 expert days plus travel costs for a 5-day visit of your programme)?

The Malawi German Health Programme (PN: 2011.2090.6) is able to contribute 30% to the cost of the writer’s contract.

7.  Date of submission and signatures

Date of submission:

02.09.2015

[1]Balaka; Blantyre; Chikwawa; Dedza; Lilongwe; Mchinji; Mzimba; Nsanje; Ntcheu; and Thyolo.

[2]The source for the below mentioned figures is a baseline study that was conducted in the target districts in October 2012. They apply to the ten target districts of the intervention and are compared to the results of the midterm review from June 2014 and the project monitoring reports.

[3]Balaka; Blantyre; Chikwawa; Dedza; Lilongwe; Mchinji; Mzimba; Nsanje; Ntcheu; and Thyolo.

Results Based Financing – A promising Approach for improved Maternal and New-born Health in Malawi

1. Working title for the proposed case study

Results Based Financing – A promising Approach for improved Maternal and New-born Health in Malawi

2. Description of the approach to be documented in a GHPC case study

In this section we ask you describe the approach that the GHPC should document. This includes also the results and the learning process during implementation. We also ask you for arguments why the case study should be documented.

Important: Please provide solid evidence for your arguments and figures, in particular for the results (d) and for the lessons (e) that have been drawn during implementation. Cite or list all documented evidence that is relevant (e.g. internal monitoring and evaluation reports, external evaluations and other studies).

a) Which relevant development challenge(s) does the approach address?

In 2010 an estimated 287,000 maternal deaths[1] occurred worldwide,[2] 99 percent of which occurred in developing countries.[3] Despite recent improvements, sub-Saharan Africa is still the most dangerous region in the world to give birth: more than half of all maternal deaths happen in this region, the majority during or immediately after childbirth.

This is also the situation in Malawi, a country with one of the highest rates of maternal mortality in Africa, estimated to be 675/ 100,000 live births in 2010[4] and 574 per 100,000 live births in 2014[5].  Although the rate has declined since 2004 (984 per 100,000 live births), it remains unacceptably high. Reduction of maternal mortality is therefore one of the priorities of the Ministry of Health (MoH) of Malawi and reflected in the Health Sector Strategic Plan (HSSP) for the period from 2011 to 2016.

Maternal deaths in Malawi are preventable: the major cause of the high number of these deaths is delayed and/or limited access to quality delivery care.[6] As outlined in paragraph b) below, the RBF approach contributes to addressing these quality of care issues at participating health facilities

The Malawi 2010 Emergency Obstetric and Newborn Care Needs Assessment showed that out of 89 hospitals that were assessed, only 42 (47%) were offering services comprehensively (all 9 signal functions) whereas only five (2%) out of the 210 health centers assessed could offer services at basic level (7 of 9 signal functions).[7]

On the supply side, reasons for this situation include both human resources-related challenges (e.g. shortage of skilled health workers leading to high workload of existing staff, limited clinical and managerial competence of health staff as well as low motivation and morale, poor staff housing especially in rural areas leading to difficulty to attract and retain staff in these areas) as well as infrastructure and procurement problems which hinder the functionality of health facilities in Malawi (e.g. lacking buildings, poor water and electricity supply, lack of equipment, irregular supply of essential drugs).

Physical access to MNH services is a further challenge, particularly in rural areas, where 80% of the Malawian population lives. In fact, 20% of the population in Malawi lives outside an 8 kilometer radius of a public health facility. Overall, some 13 percent of pregnant women do not seek delivery care in health facilities due to geographical (seasonal difficulties of travelling, poor availability of transport) and financial barriers (costs associated with an institutional delivery including informal costs of providing medicines, food and clothing for both mother and baby) as well as traditional beliefs and poor awareness.

b) How has it addressed this challenge and what have been the particular contributions of German Development Cooperation?

Despite large investments by development partners and governments in the health and other sectors in Malawi over many years, the country, like many other countries in Sub-Saharan Africa, still struggles to develop a functioning health system and provide good quality care. It seems that solving this problem requires broader and more innovative approaches than those so far adopted.  A growing body of evidence suggests that Results Based Financing (RBF)[8] can be an effective tool for increasing the quantity and quality of maternal and new-born and other health services provided.

RBF is an umbrella term for approaches linking payment or investments to verifiable or measurable results. RBF approaches are divided into two groups. While demand side RBF targets individuals (e.g. conditional cash transfers that pay a predefined amount to targeted population against complying with specific requirements, such as taking their children to get vaccinated), supply-side RBF targets service providers and aims at setting incentives for these service providers to deliver good performance of healthcare service.

Traditional input-based financing requires payment (in advance) for line items such as salaries, drugs, supplies, and operating costs, resulting in a link between funding and results that is tenuous at best and expenses that are only justified after payment has been made (e.g., through financial audits). Paying for outputs indicates that money will only be paid for services that have been delivered or goals that have been met, establishing a direct link between funding and results or other performance measures.[9]  

As a result of these differences in underlying process, the RBF mechanism:

  • Increases autonomy and responsibility of providers;
  • Rewards creativity, efficiency, and innovation at service provision level, as managers devise their own strategies to achieve performance targets;
  • Increases provider motivation and rewards proportional to achievements;
  • Allows for decentralized autonomy and flexibility in the use of available funds;
  • Pays providers based on actual results achieved, rather than simply incurred costs; and
  • Ensures that performance is independently measured on a set of pre-determined indicators.

It seemed possible that RBF could address at least some of the most important supply-side barriers outlined above impeding the provision of good quality maternal and new-born care in Malawi. A pilot RBF intervention was therefore developed during 2011 – 12 with financing from the governments Norway and Germany, through KfW, called the Results Based Financing for Maternal and New-born Health (RBF4MNH) Initiative.  This Initiative of the Malawi Ministry of Health links payments with results, with the aim of strengthening the delivery of maternal and newborn health services and strengthening the overall performance of the Malawi health system.

Unlike many RBF programmes in neighbouring countries, the initiative introduces rewards (incentives) based on measurable results on both the supply-side (for health service providers), as well as the demand-side (for clients of the services).

The Initiative is being implemented by the Reproductive Health Directorate (RHD) of the MoH and operates in four districts of Malawi: Mchinji, Ntcheu and Dedza in the Central West zone and in Balaka district in the South East zone in Malawi.

RBF4MNH encompasses three principal components:

1) Minor infrastructure works and provision of essential equipment to bring selected health facilities up to a minimum standard as a basis for the provision of good quality care. Investments were based on an assessment of availability and functionality according to MoH guidelines;

2) A supply-side component. This is focused on the introduction of Quality and Performance Contracts (QPC) for (i) qualified public and private facilities from the Christian Health Association of Malawi (CHAM) offering maternal and new-born care services as well as (ii) health management staff at the district level (district health management teams, DHMTs), by which they can earn financial rewards for performance achieved according to a jointly agreed list of performance indicators and targets (rewarding attainment of pre-agreed targets, results-based). Payments for performance on the core indicators for facilities are conditional on their performance on quality indicators (see list of indicators attached). Financial rewards are divided between individual bonuses for staff members and an amount to be invested in improving working and living conditions. The approach is intended to incentivize the delivery of better quality care through adherence to national standards and protocols, enhanced morale, autonomy and pro-active behavior at lower levels of the health system which, in turn, should improve the quality of health services, leading to a virtuous cycle of improvement.  The desired outcome is improvement in maternal and newborn health;

3) A demand-side component which encompasses a small conditional cash transfer that compensates women delivering at facilities for out-of-pocket expenditure, including travel costs to and from the facility and costs associated with remaining at the facility for 48 hours post-delivery, the time when most of the complications and deaths occur. With this, the Initiative addresses the financial barriers to institutional deliveries particularly for the poorest and most remote households by compensating the out-of-pocket household costs.

Options Consultancy Services Ltd. (Options) has been contracted by MoH to design and manage the programme. Options is drawing on international and local expertise to build capacity of the MoH and RHD in implementing the RBF approach.The team comprises a regional manager, a local RBF specialist, a local M&E specialist and six supporting staff in Malawi. The Options team in London and three international consultants provide intermittent backstopping.

Instead of working with a large number of facilities in each of the selected districts, the RHD and other partners in the MoH at central and district level indicated a preference for the WHO promoted Concentration Model of one Comprehensive Emergency Obstetric Newborn Care (CEmONC) per 500,000 population and four Basic Emergency Obstetric and Newborn Care (BEmONCs) per CEmONC. Thus, for each District, the RHD contracts with at least one health facility providing Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) (the District Hospital), and selected referring health centres providing Basic Emergency Obstetric and Neonatal Care (BEmONC).

At the core of the supply side approach is the quality and performance agreement entered into between the RHD, the health facilities and DHMTs, which defines the outputs and targets based on which the rewards are paid. The agreements are valid for one year and are reviewed and renewed annually to allow adaptions.

At the outset of the programme, rewards were calculated and provided to participating facility and management teams on a six monthly basis, and this was changed from October 2014 to three monthly payment cycles (reasons for this change can be found under lessons learnt below).

The health facilities and DHMTs report monthly the data necessary to decide if the agreed targets have been reached. An independent agency verifies the reported data at the end of each reward cycle to avoid and also to identify any false or incorrect reporting and to ensure reward payments are based on actual achievements.

Until now, women have been defined as eligible for the conditional cash transfer (CCT) if they live within the catchment area of a RBF-facility and attend at least one ANC appointment during their current pregnancy. They receive part of this cash on arrival at the facility for delivery as compensation for transport costs and other small costs associated with immediate needs for the delivery (i.e. a chitenje or wrapper). They then receive additional payments after the delivery in order to buy food and to encourage them to remain at the facility for 48 hours, which is a critical time for the health of both the new-born and the mother (an overview on the amounts of the cash transfers disbursed to women is outlined in Annex 2 to this document). The eligibility criteria for the CCT are currently the subject of an in-depth review, with the aim of introducing poverty targeting criteria so that the CCT reaches very poor women who could not otherwise afford to come to a facility for delivery (see also under chapter: lessons learnt).

The Initiative is strongly embedded in all levels: from the community, through the districts to the central ministry. It is also highly appreciated by the communities and Traditional Authorities (TA), who have been involved from the beginning and have played a key role in the continuous development of the activities. For example, the Paramount Chief Gomani V, a powerful chief and head of the ethnic groups Maseko Ngoni in all four Initiative districts, is playing a leading role in the newly setup Task Force to review and up-date the above mentioned eligibility criteria for the conditional cash transfer, and has been important in mobilizing village elders and TAs to support the Initiative in the community. Considering that the chief system is still very strong and relevant in Malawi this is a decisive level of support for the Initiative

c) How long has this approach been implemented and to what level/coverage has it been scaled up?

The RBF4MNH Initiative started in 2012 with funding from both the Norwegian and the German Government through KfW. Funding has been provided in two phases, with a first phase made up of equal contributions by the German and Norwegian governments of up to USD 10 million, and the second phase (10 million Euros provided by the German Government) ending in December 2017.

During the design phase in 2012, four out of 28 districts in Malawi were selected for implementation, in consultation with the Directorate for Policy and Planning of the MoH. The projected population size for the four participating districts in 2012 was about two million. Together with the RHD of the MoH and the District Health Management Teams (DHMTs), of these four districts, 18 health facilities (4 district hospitals and 14 health centres) were selected to be included in the RBF4MNH Initiative on the basis of an in-depth baseline assessment of EmONC capacity and readiness and the WHO concept of CEmONC/BEmONC clusters as described on page number 5 of this document. With the aim of increasing coverage in the four RBF districts, ten additional health centres were added in September 2014 bringing the total number of health facilities currently participating in the programme to 28. With this addition, more than 75% of people in the four districts will have access to an improved RBF facility for delivery and new-born care and over 74% of the deliveries will take place in health facilities which are now part of the RBF Initiative. A further 5 facilities will be added in October 2015 in the districts already included in the Initiative with the lowest coverage so that all health facilities in the four districts with the capacity to provide EmONC services will be included in the RBF Initiative. This is the maximum of scale- up possible in the four districts.

After intensive training and orientation of health workers, district managers and administrators the first quality and performance contracts were signed with individual health facilities and the implementation started with the first reward cycle on 1st April 2013.

The Initiative has been presented several times at a high level within the government of Malawi and many Directors of the MoH have visited RBF participating facilities and expressed their appreciation. This has led to proposals to extend and scale-up the approach nationwide and for directing incentives to the improvement of health outcomes beyond maternal and new-born health.

The Initiative works closely together with the experts responsible for the work area “quality” of GIZ, which was planned from the very start to complement the RBF4MNH Initiative and work in the same districts and health facilities.

d) Describe the results of the approach (e.g., outputs/outcome). Provide evidence for each result and state the source for it.

Central to the understanding of this RBF4MNH Initiative is the importance of continuous results oriented monitoring, reviewing and revising the different areas of the approach. Active, continuous and experience-based learning is being used for the development of new solutions, while delivery bottlenecks are addressed by non-bureaucratic adjustments to the approach, with inputs by those who are working with the Initiative and understand it best. Through these processes, crucial insights emerge during an intervention, and the intervention itself becomes the main driver of learning.

An independent impact evaluation of the programme has been built into the programme’s design from the very beginning. This evaluation[10] aims at assessing the quality impact on both the interventions directly targeted by the RBF programme and the complete range of other relevant maternal and child care services. The external evaluation uses mixed methods controlled before and after design. A baseline study was carried out from March to May 2013 followed by a mid-term study from June to August 2014 14 months after the start of the implementation. The final round of data collection has started in May 2015. Most of the data have been analyzed and respective results will replace those of the mid-term evaluation included in this proposal. The positive trends shown in the results of the mid-term evaluation have already been confirmed.

The results presented below are based on data continuously collected and analyzed by the Initiative, as well as those summarized in the report of the mid-term external evaluation.[11] The following points are highlighted:

–  30% increase of deliveries taking place in the participating facilities[12]. This might be the result of increased quality that the women follow and cash provided for cost recovery;

Figure 1:  Institutional deliveries in all districts July 2013-June 2014 and July2014-June 2015 (Source: monitoring data of the Project)

 – Significant improvement of performance of health workers indicated by verified reward indicators[13];

 

Figure 2: Achievement for reward indicators over the time of implementation (Source: monitoring data of the Project)

 

–      Continuous increase in rewards earned as understanding of the Initiative grows and performance improves[14];

 

Figure 3: Percentage of the possible rewards earned over the time of implementation (Source: monitoring data of the Project)

–      Shift of women delivering from control to RBF participating facilities[15]: women following quality;

 

From Assessing the Acceptability and Adoption of Implementing a Results Based Financing Intervention to Improve Maternal and Neonatal Health in Malawi by Wilhelm, Muula, Brenner and De Allegri.

“The results clearly indicate that a much larger proportion of deliveries took place in intervention facilities at MIDTERM as compared to BASELINE. This is likely to indicate that a substantial spill-over effect took place, with women travelling outside their catchment area to seek care at the intervention facilities (…). The result is also supportive of the national policy to concentrate EmOC care in a few selected facilities within each district.”

 

 

–      Improved satisfaction with different and improved working conditions[16];

–      Appreciation of increased autonomy to invest additional funds[17];

–      High acceptability of the approach[18]

From Assessing the Acceptability and Adoption of Implementing a Results Based Financing Intervention to Improve Maternal and Neonatal Health in Malawi by Wilhelm, Muula, Brenner and De Allegri.

“…all stakeholders responded positively to the RBF4MNH Initiative.”

“In addition, stakeholders took on functions not directly incentivized by the intervention, suggesting that they turned adoption into actual ownership.”

“The MoH members then realized the RBF4MNH Initiative could produce improved maternal health results.”

Intervention facility staff (BEmONCs) recorded higher ‘positive change’ responses compared to colleagues in control facilities across all areas except workload.  For example, increased:

    • Influence on what happens at the health centre
    • Freedom to decide how to go about ones work
    • Idea of what is expected at work
    • Collaboration amongst staff
    • Supervisor support
    • Performance feedback

From baseline to mid-term:

  • Availability of hand soap increased in RBF facilities from 53.9 to 78.6%
  • Proportion of facilities with availability of sterile delivery kits (at least 5 kits at day of survey) increased from 38.5 to 78.6%
  • Proportion of facilities with availability of topical skin disinfectant increased from 53.9 to 71.4%     

Reflecting the increased funds available for investment at the facility level

Positive results triangulated with research done by masters student on how facilities spend their RBF investment funds (i.e. IP materials)


e)
As this approach was implemented, what has been learned and how has this led to adaptations and ‘course corrections’ in the implementation? Please note that interesting case studies should explore both what worked and what did not work. Often it is the second which generates more learning and therefore particularly interesting for a case study. Here too, provide evidence and sources.

Below we have set out some of the most important lessons which have emerged over the period of both design and implementation of the Initiative, as well as how the challenges were addressed:

1) The importance of promoting institutional sustainability – investment in design and preparation. Before the implementation started in April 2013, many instruments had to be developed, processes defined and familiarisation meetings held, because this approach was new for the partners at all levels and very different to the more traditional input-based approach to health sector support which they were used to.  From the beginning, partners at all levels (particularly government partners at district level and below) were continuously consulted and involved in the preparation and development of the new approach. This required substantial time (12 months) and resources for design and preparation.

However, the time and resources invested in this participatory approach have led to a high level of understanding among stakeholders and increased ownership by the government of the Initiative. 

The Project team also found that non-participating facilities became keen to join the Initiative for Phase 2, and that this enthusiasm led to a significantly higher learning curve among health workers from these new facilities than for the first group of facilities which joined in 2013. This has been seen in the quality improvements demonstrated by many of the 18 new health facilities which joined the Initiative in October 2014. Thus the resources needed for scaling-up preparation reduce over time.

2) Embedding the approach in government systems at all levels. Linked to point 1 above, the Initiative team has prioritized efforts to promote government support for, and understanding and ownership of the Initiative. While performance-based financing interventions usually tend to focus on the policy level to begin with, the RBF4MNH Initiative focused efforts at the district level first. In the decentralized health system in Malawi, this proved to be the right approach. The district health teams and district councils, together with community level structures (TAs and village heads) have played a key role in publicizing and advocating for the RBF approach within the wider MoH, including at central level. This effect has been strengthened as the power and authority of the district administrations has increased in the country. There is now a marked interest in RBF from the central MoH, as demonstrated by the fact that all of the MoH directors have recently visited health facilities implementing the approach and shown interest in the Initiative.

3) Setting and adjusting outputs so that incentives are effective. During the preparation phase of the programme, twelve outputs related to quantity, quality and systems strengthening, together with corresponding weights and targets, were defined and contracts developed. Defining appropriate and easy-to-verify indicators, particularly for quality improvement (see below), proved to be more difficult than anticipated, and requires a certain level of knowledge on the part of those participating in the process in order for them to participate effectively. This was particularly relevant for government stakeholders at district level and below whose participation in the setting of indicators (as well as other aspects of the design) has been crucial.

The outputs of the DHMTs aim at improving their performance across the whole district and not only for the targeted health facilities. This is beginning to have an important spill-over effect on quality across the whole districts, particularly as the Initiative becomes better known and is more widely publicised. It is also important to constantly monitor the achievement of these outputs and to adjust them to meet gaps in performance and quality on a regular basis. RBF is not a static approach. Therefore the outputs were reviewed and adjusted after 18 months of implementation based on the experience gained. For instance, a small number of indicators have been added to incentivise family-planning and improved maintenance of buildings while some indicators have been amended to take account of recent changes in Malawi (i.e. the neonatal indicator).

4) Setting objectively verifiable indicators for quality. It has been demonstrated that it is important to identify rewarded outputs that relate directly to the aspect of quality which needs to improve; performance follows payment. However, finding outputs, which can be objectively verified for rewarding quality, is a difficult task. For example, it is impossible to know whether health staffs are washing their hands outside the period of direct observation and many important infection prevention measures fall into this group of difficult-to-measure activities. The team is currently incentivising the use of infection prevention checklists as part of a package of quality improvement measures and looking at how to further refine and improve these outputs. The soon available results of the end-term evaluation will also be used to revise the indicators.

5) Setting absolute targets to measure performance. Setting absolute targets was found to be quite demotivating. If the target is not met, this approach does not reward the actual progress which has been made at all. And this progress can be substantial. We have addressed this by changing the way in which rewards are allocated and now reward according to progress made on each of the outputs (see Annex 1: Revised reward indicators for RBF Phase 2).

1) The need for on-going supervision and support. In addition to the time and resources needed for health workers to understand and adopt the RBF concepts (see above), there is a need for on-going intensive supervision and support. Moving from theory to practice and implementation is not easy and many additional questions arise. Quick wins cannot be expected; rather performance-based financing encourages more sustainable medium- to longer-term wins which are so important for systems strengthening, and which we are now seeing emerge in Malawi in the RBF districts.

2) Setting rewards. We have found, through experience, that the reward envelop has to be high enough to: a) provide a real addition to the income of those individuals participating in the RBF Initiative (through the payment of the individual bonus payments); and, b) allow for substantial investments in quality improvements (through the facility investment portion). The rewards envelop needs to be regularly reviewed to address the impact of the economic situation in the country (i.e. very high inflation eroding the benefits earned by the health workers). It was also found that the provision of the facility investment portion has been crucial in enabling facility staff to direct fund and cover the purchase of missing supplies and medicines, and to undertake minor maintenance works. From April 2013 until March 2015, the Initiative has spent EUR 350 000 for rewards. For cash transfers, which started delayed by half a year, EUR 250 000 were spent until June 2015.

3) Reward cycles. Reward cycles of six months proved to be too long; payment of the rewards was too far removed from the underlying efforts to improve performance, reducing the incentive effect. Health workers prefer to be rewarded every three months and this is the model, which we moved to from October 2014. However, it is also important to bear in mind that this has implications for the management of shorter cycles, with the increased costs of RBF verification and payments systems.

f) Describe in what ways a case study about this approach contributes something new to what we know about health and social protection systems and service delivery.

While the results from various RBF programmes have been encouraging, particularly in terms of incentivising increased service utilisation (the quantity), more rigorous evaluations are still required to draw conclusive evidence on the impacts of RBF on the quality of services. A systematic review and critical appraisal of four evaluations of RBF schemes conducted in 2008 by the Norwegian Knowledge Centre for Health Services highlighted the fact that, as RBF is often part of a wider package of interventions it can be difficult to isolate its impacts.

The RBF4MNH Initiative in Malawi contributes further to existing evidence for the effectiveness of the approach and provides experiences, lessons and tools to be used by others who want to take up this approach. Documentation of the processes employed and their effectiveness also provides a strong base from which to extend the RBF approach to a wider package of services, and to expand the approach to new areas of the country.

3. Supporting material

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

There are no high resolution photo and film material available.

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

  • Guidelines for supervision of CCT registration and verification
  • RBF4MNH Guidelines for Cash Transfers
  • District Financial Reconciliation Tools and Guidelines
  • RHD integrated MNG care supervision tool - BEMONC
  • M&E Guidelines
  • Contract formats
  • Indicator lists with weights
  • Programme Leaflets (Chichewa and English)
4. 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 case study? Whom should he or she meet and interview? Which sites should he or she visit?

We would recommend that the journalist visit the Initiative for a period of some 10 days which will provide time to hold in-depth discussions with the project team and with stakeholders at each level (community, facility, district administration and central level ministry of health) as well as site visits to the participating facilities to observe the project in action. Visits to two of the participating districts would be ideal and the journalist could accompany the RBF4MNH project team on their routine work.  There should also be a period of desk-based research prior to this visit for reading of reports and other documents which can be provided by the Options team in London.  If the journalist is not familiar with the RBF approach, additional materials on RBF which explain how this works can be provided. This should happen during the second week of November.

5. Publication audiences and languages; printing arrangements

At which occasions, to which audiences and in which language (in addition to English) would your partner organisation and you like to distribute the case study? 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 case study as planned.

The audience would comprise national and international partners as well as participants of respective workshops and conferences on issues/subjects related to the Initiative. Internal events include dissemination workshops on specific best practices/lessons learnt from Projects in the health sector. External events include, inter alia, meetings of the Health Results Innovation Trust Fund.

Printing arrangements: If we sent you the complete final print files for the short and long versions of the case study in the language of your partner country, can you print the number of copies you require for the partner and the interested public in your country?

The printing can take place in Germany. KfW will arrange the transport from Germany (KfW Headquarters) to Malawi.

6. Financial contribution

The GHPC is jointly financed by the health and social protection sector initiatives. When it documents programmes in partner countries, these are expected to contribute (normally at least a third) to the cost of the writer’s contract. Which amount can your programme contribute to the costs of the writing of the English version of the publication (30 expert days plus travel costs for a 5-day visit of your programme)?

Meeting arrangements and logistics costs in Malawi can be borne by the programme. In order to better determine whether any additional costs can be funded by the programme, it would be useful to obtain a budget estimate of the costs of the writing of the English version of the publication.

Annexes:

  1. Revised reward indicators for RBF Phase 2
  2. Overview of cash transfers disbursed to pregnant women

[1] Definition of maternal mortality: “the death of a woman whilst pregnant or within 42 days of delivery or termination of pregnancy, from any cause related to, or aggravated by pregnancy or its management, but excluding deaths from incidental or accidental causes” (Source: WHO. International Classification of Diseases and Related Health Problems. World Health Organization, Geneva; 1992).

[2] WHO, UNICEF, UNFPA, The World Bank: Trends in maternal mortality: 1990 to 2010. WHO, UNICEF, UNFPA, and The World Bank Estimates, 2012.

[3] WHO: Maternal Mortality, Fact sheet Nr. 348, May 2014.

[4] DHS Malawi 2010

[5] UNICEF, WHO, UNFPA, MFA, USAID (2014): Malawi MDG End line survey 2014.

[6] Although the number of women giving birth at a health facility has increased in recent years, reaching 87 percent in 2014, this increase has not lead to a significant reduction of the number of maternal deaths.

[7] ibid with definition of signal functions

[8] A cash payment or non-monetary transfer made to a national or sub-national government, manager, provider, payer or consumer of health services after predefined results have been attained and verified” Musgrove P: Financial and Other Rewards for Good Governance or Results: A Guided Tour of Concepts and Terms and a Short Glossary. Washington: World Bank; 2011.

[9] The AIDSTAR-Two Project. The PBF Handbook: Designing and Implementing Effective Performance-Based Financing Programs. Version 1.0. Cambridge: Management Sciences for Health, 2011.

[10] This research project “Assessing the impact of using performance-based financing to improve the quality of obstetric and neonatal care in Malawi” is made possible through Translating Research into Action, TRAction, and is funded by United States Agency for International Development (USAID). The project team includes prime recipient, University Research Co., LLC (URC), Harvard University School of Public Health (HSPH), and sub-recipient research organization, University of Heidelberg, see Brenner et al. (2014).

[11] Midterm Results Report, RBFMNH Initiative Impact Evaluation; Research Team Members University of Heidelberg and College of Medicine, June 2015

[12] Results based Monitoring of the Initiative

[13] Results based Monitoring of the Initiative

[14] ibid

[15] Midterm Results Report, RBFMNH Initiative Impact Evaluation; Research Team Members University of Heidelberg and College of Medicine, June 2015

[16] ibid

[17] ibid

[18] ibid

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