Infant, under five and maternal mortality rates amongst the highest in the world:
One in five children do not see their fifth birthday
One in eight mothers risk dying during childbirth
Malaria, diarrhoea, measles and respiratory infections major causes for child deaths
Access to health services severely limited</li></ul>UNICEF<br />
The Free Health Care Policy<br /><ul><li>FHC is an important policy intervention to remove user fees that helps achieve the objectives of the RCH national strategy within the NHSP policy.
FHC was successfully launched on April 27th after 6 months of intensive work.
Process was led by a steering committee and supported by 6 subcommittees – HR, M&E, Logistics and Supply, Infrastructure, Finance, Communication - all chaired by MoHS.
UNICEF has been actively involved throughout the preparation period as co-chair of the Logistic and Supplies sub-committee and a member of all other committees.</li></ul>UNICEF<br />
The Free Health Care Policy contd.<br /><ul><li>Implementation is facing many challenges, e.g. clearance of medical items and distribution to PHUs, M&E, community mobilisation.
The health sector has undergone a number of reforms during the last 6 months, e.g. payroll cleaning, revised salaries, recruitment.
Committees are continuing their work to ensure successful delivery of FHC.
Strategy to be developed for both short and long term management in order to ensure sustainability.</li></ul>UNICEF<br />
Impact – after an unexpected decrease in utilization prior to launch here has been asignificant increase in utilization of health facilities<br />The M&E subcommittee has formed a taskforce to strengthening the existing health management information<br />system. Recently completed a baseline review of FHC with support from WHO and participation from all districts<br />with objective to review health sector performance against key sector indicators and setting baselines and targets<br />for the FHC. A national level review is planned for August.<br />It is working with CSOs to strengthened community ownership and monitoring of health services through the<br />revitalisations of health management committees at community level and is working to improve supervision.<br />
Impact – in spite of increase in utilization the lack of drugs and delays in patients<br />presenting themselves means there has been a increase in fatality rates<br />An immediate investigation has been carried out to find the determining causes which include lack of paediatric<br />drugs available and the number of patients which are admitted late and die within a short timeframe of being<br />admitted. Work will be done through health education to ensure population sensitized and aware to come to the<br />health facility as soon as symptoms present themselves<br />
Payrollreformsimplemented to ensurelegitimatehealthworkerspaidappropriately.
Health workersreceived a substantialincrease in salaries attractsstaff, ensuresfeesarenotbeingcharged.
Challenges: payment transfer, accommodation for new staff, shortfall of staff</li></ul>UNICEF<br />
Supply and Logistics<br /><ul><li>33% of UNICEF ordered drugs and medical supplies have been received as at 28th May 2010.
88 % of the received drugs and medical supplies have been distributed to the districts and the PHUs, while a balance of 12% buffer is kept at the Central Medical Stores (CMS) to meet the call forwards needs from the districts and PHUs.
Additional 30% of FHC-I drugs in 20 containers and 3 packages have been received and are awaiting clearance at the ports after which they will be distributed.</li></ul>UNICEF<br />
Supply and Logistics contd.<br /><ul><li>Government intervention is required to expedite clearance and reduce the delays experienced in clearing the goods from the ports as it impacts drug availability
UNICEF in addition to clearing the supplies is also providing transport for the distribution of supplies from the CMS to the Districts.
UNICEF is providing ongoing support to the CMS on effective warehouse management and LMIS operations.</li></ul>UNICEF<br />
Supply and Logistics contd.<br /><ul><li>Challenges: delay in power connection at the CMS, clearance of drugs, transportation of supplies to districts and PHUs in mid to long term not adequate</li></ul>UNICEF<br />
Long term PSM system<br /><ul><li>First phase: first 4 months – PSM assessment, conceptualization, strategic planning, proposal of road map concluded with report on PSM models. Consensus workshop June 15th-16th 2010.
Second phase: implementation, capacity building and handing over to MoHS (phase out) expected to commence soon.
High level steering committee (oversight).</li></ul>UNICEF<br />
Distribution and Transport –with Plan B<br />SUPPLIERS VIA UNICEF<br />CMS or WFP Warehouse - Water Quay, Cline Town 3,500 CBM<br />DISTRICT HEALTH MANAGEMENT TEAM<br />REGIONAL HOSPITAL STORES<br />DISTRICTS MEDICAL STORES<br />DISTRICTS HOSPITAL STORES<br />COMMUNITY HEALTH POST<br />DISTRICT<br />HOSPITAL PHARMACY<br />COMMUNITY HEALTH CENTER<br />REG.HOSPITAL PHARMACY<br />MATERNAL CHILD HEALTH POST<br />Risks: <br /><ul><li>Difficult road terrains in most districts, PHUs which are accessible only by boats availability of transport mechanisms
Fuel costs, operating cost for maintenance of vehicles planned routes, mileage, days, drivers salaries
Inventory Control System, warehouse racking and shelving
Timely release of funds for completion and refurbishments of DMS.
Security of medicines at all levels</li></li></ul><li>Infrastructure<br /><ul><li>UNICEF supported 65 BEmONCcentres (Basic Emergency Obstetric and Neonatal Care) with provision of basic water and sanitation facilities by 27April.
In process to support 112 PHUs and 7 district hospitals with pipe borne water and sanitation facilities. In addition, the 65 BEmONCcentres will also get pipe born water facilities by the end of the year.
Planning to support rehabilitation of pediatric wards in 7 district hospitals and strengthening of BEmONC services in 65 PHUs.</li></ul> <br />UNICEF<br />
Infrastructure contd.<br /><ul><li>Supporting construction of a maternity hospital in Pujehun district; to be completed by July.
Process designed to identify problems, allocate responsibilities and track progress.
Funds available for further refurbishment of hospitals from Arab donors.
District level responsibility and accountability.</li></ul> <br />UNICEF<br />
Monitoring and Evaluation<br /><ul><li>Supported printing and distribution of registers and cards (General clinic, under fives, maternity/Delivery and in-patient registers) for PHUs and government hospitals.
Supported development of FHC-I baseline and monitoring indicators in collaboration with WHO, MoHS and District Health Management Teams (DHMTs).
Supporting Health for All Coalition in the monitoring of FHC-I at facility level nationwide.</li></ul>UNICEF<br />
Monitoring and Evaluation contd.<br /><ul><li>Supporting printing of community monitoring checklists to be used by CSOs.
UNICEF will participate in the quarterly review of progress on FHC monitoring indicators, in collaboration with MOHS, other UN agencies (WHO, UNFPA) and DHMTs.
Major challenges: development of system to capture data still on going
Urgent need for baseline data to prove performance and thereby ensure future funds</li></ul>UNICEF<br />
Communication<br /><ul><li>Prior to the launch, UNICEF supported district and chiefdom level social mobilisation to inform the target beneficiaries, communities and key stakeholders about the impending policy change.
Supported engagement with health workers and health workforce associations to allay their fears, communicate the policy and clarify doubts and misconceptions.
Supported planning and implementation of National and District level launch on April 27, 2010.</li></ul>UNICEF<br />
Communication contd.<br /><ul><li>Supporting districts (through the MOHS) till the end of 2010 in communication and social mobilisation activities and chiefdom level awareness raising on FHC-I.
Supporting 5-6 CSOs for community level awareness on FHC-I, to compliment MoHS communication activities at the sub-national level.</li></ul>UNICEF<br />
Finance<br /><ul><li>Costing of the activitiesrequired for launch ($27.5m available, $29.7m costsresulting in a gap of $2.2m).
Realignment of somedonorfunding to meetfinancinggaps.
Costing of activitiesrequired for the remainder of 2010 ($1.3m available, $4.4m costsresulting in a gap of $3.1m).
Forecasting of salaryscenarios –detailedbudgeting and forecasting of salaryscenarios to providetechnicalbackup to salaryreform for healthtechnicalworkers. </li></ul>UNICEF<br />
Finance contd.<br /><ul><li>Cash for Facilities –the devolvedtertiaryhospitalsallreceivedtheir new operationalbudgets in time for the launch. Thisserves as an effectivemeasure to enablethem to delivercriticalservices and ensuresthatadditionalfeesarenotcharged to patients for legitimateexpenditure. </li></ul>UNICEF<br />
Towards sustainability<br />Critical factors<br /><ul><li>Predictability of funding, donor enthusiasm
Governance, accountability and continued commitment (leadership and funds)