1. District Dera Ghazi Khan 01-Dec-2011 to 31-Dec-2012 P ROMOTING AND E NSURING W OMEN ’ S R IGHT TO H EALTH THROUGH V OUCHERS FOR H EALTH

2. MNCH S ITUATION IN P AKISTAN (M ATERNAL H EALTH I NDICATORS ) Sr. No.IndicatorPercentage 1. Women who received skilled care during pregnancy; 39.1% 2. Percentage births attended by unskilled birth attendant; 61.2% 3.Births delivered at home;65.7% 4. Women who did not receive postpartum care by skilled provider; 73.7% 5.Contraceptive Prevalence Rate.30% Source: PDHS 2006-07 2 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

3. I NEQUITY IN B IRTH P REPAREDNESS RAHSTA-PPAF: PEWRH-VH P ROJECT DGK 3 Percent Source: PDHS 2007

4. S UPPLY S IDE F INANCING  In Pakistan Health Care (HC) is financed through Supply Side Subsidies (SSS) that is to ensure that the entire Population has the access to “Low Priced” or “Free” Public Health Care;  Supply Side Financing has limitations in terms of efficiency and equity, it can result in inequalities in terms of access and utilization of health services;  The poor benefits less from SSS and results in seeking better quality HC in the private sector. This adds to the financial constraints of the poor. 4 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

5. D EMAND S IDE FINANCING  Given the limitations of Supply Side Financing (SSF) there has been a paradigm shift to Demand Side Financing (DSF).  This approach channels government subsidy for health services directly to consumers allowing them to purchase health services themselves;  PPAF funded project implemented by RAHSTA is one of the few initiatives in Pakistan to introduce DSF through the use of Health Vouchers. 5 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

6. T HE P ROJECT Project Name:Promoting and Ensuring Women’s Right to Health through Vouchers for Health (PEWRH-VH) Project Area:7-Selected Unions Councils7-Selected Unions Councils in Tehsil Dera Ghazi Khan, District DGK Donor:Pakistan Poverty Alleviation Fund (PPAF) Budget:PKR 20.332 million (Financial Assistance under PPAF-III Health) Project Duration:01-Dec-2011 to 30-Nov-2012 6 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

7. T HE P ROJECT G OAL  The Goal of project is to reduce maternal and newborn mortality and morbidity through subsidizing the cost and providing equitable essential health services including RH and FP services to poor and marginalized pregnant women. 7 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

8. P ROJECT O BJECTIVES OBJECTIVE-1Improving knowledge and behaviors on Maternal and Newborn health of the identified community OBJECTIVE-2Improving access to the quality Maternal and Newborn health services to the pregnant ladies belonging to poor strata of population OBJECTIVE-3Improving Health System through evidences based interventions 8 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

9. T ARGET B ENEFICIARIES  1,680 Poor and Marginalized (under poverty line) pregnant women in their 2 nd and 3 rd trimester of pregnancy. 9 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

10. P OPULATION OF THE S ELECTED P ROJECT A REA 10 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

11. P ROJECT I MPLEMENTATION F LOW MAPPING - PA Selection -Identification of TG - Identification of HFs BASELINE SURVEY Constitution of VMA Trainings & Orientation Capacity Building of Stakeholders SG Meetings and Male Health Sessions and Internships Sale of HVBs Reimbursement Voucher Collection Compliance Service Delivery Reporting Follow-up Success Stories Lessons Learnt 11 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

12. P ROJECT I MPLEMENTATION A PPROACH Supply Side Approach Voucher SaleComplianceService DeliveryReimbursement Demand Side Approach Support Group Meetings Individual Counseling Follow Up Male Health SessionOrientation/ Trainings 12 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

13. S ELECTION OF P ROJECT A REA  The Project Area was selected in consultation with District Health Department of DGK. consultation  Project Area comprises 7 Union Councils in Tehsil DGK7 Union 13 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

14. K EY A CTIVITIES  PEWRH-VH project has been implemented through SIX KEY STEPS: SIX KEY STEPS: Step-1Project Area, Orientation & Baseline Step-2Target Beneficiaries, HCPs, IEC Material and Monitoring & Verification Protocols Step-3Follow-up, Redemption of Vouchers and SG meetings Step-4Assured Financial and Technical Management Step-5Sustainability Step-6Impact and Dissemination 14 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

15. V OUCHER M ANAGEMENT A GENCY (VMA)  VMA membership includes Representatives from (RAHSTA, DHD, SWD, PWD, BISP, BAITULMAL and local NGO). VMA  Role of VMA is to:  Participate in Monthly Meetings;  Help in identification of Target Group, project area and HCPs;  Facilitate in mapping and base line survey;  Help in sales of Health Voucher Booklets;  Monitor the Redemption of Vouchers;  Help in ensuring the quality of services provided by SBAs; and  Facilitate in resolving challenges and constraints faced by field staff. 15 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

16. M APPING /B ASELINE  A Mapping/Baseline Study was carried out in the selected Project Area during Jan-Feb 2012;  Baseline Data was collected with the help of RAHSTA team, DHD, DCNP and LHWs through specifically designed data collection tools. 16 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

17. O RIENTATION M EETINGS  Orientation Meetings were held with:  Newly hired RAHSTA field staff;  Voucher Management Agency (VMA);  District Health Department officials;  LHSs, LHWs and CMWs; and  Health Care Providers 17 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

18. V OUCHER M ANAGEMENT A GENCY (VMA) Constitution of VMAVMA Follow-up Meeting 18 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

19. S ELECTED H EALTH F ACILITIES 1.Ali Surgical Hospital 2.Jannat Maternity Home 3.Abdullah Hospital 4. Muhammad Surgical Hospital 5.Ali Hospital, Paigah 6.Jinnah Community Hospital, Shakar Town 7.Ali Clinic, Al-Asar Complex, Kot Chutta 19 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

20. S IGNING OF A GREEMENTS Orientation and Signing of Contract Agreements with Selected Health Care Providers (HCPs) 20 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

21. S ALE OF H EALTH V OUCHERS RAHSTA-PPAF: PEWRH-VH P ROJECT DGK 21  Specially Designed Health Voucher Booklets (HBVs) sold to beneficiaries during the period from 9 th April to 12 th July 2012.  1,680 HVBs were sold at a cost of Rs. 100 per HVB.

22. S UPPORT G ROUP M EETINGS 1.SG Meetings Started from March 2012 2.171 LHWs have been trained in SG Methodology 3.Each LHW holds minimum of 2 SG meetings every month. 4.In each SG there are 12-15 Participants (Voucher Beneficiaries, Mothers- in-Law (MIL), Married Women of Reproductive Age (MWRA), Pregnant Women, etc.) 22 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

23. T RAININGS ON SG M ETHODOLOGY Training of Trainers (TOT) was held at District Level and Trickle Down Trainings (TDTs) were held at Facility Level. 19 Participants including MOs, WMOs, LHVs and LHSs participated in TOT on SG Methodology. Venue: DHDC 200 Participants including LHWs and CMWs participated in the TDTs on SG Methodology. Venue: RHC and BHUs in selected UCs 23 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

24. S UPPORT G ROUP (SG) SG SG is a Behavior Change tool where women share experiences, ideas and knowledge with each other and solve problems. In the selected Project Area there are 171 LHWs. During the period from March 2012 to December 2012 1.Number of SG Meetings held by 171 LHWs in the Selected Project Area were: 3,362 2.Total Number of participants were:44,133 3.Among the participants Number of Pregnant Women were:10,662 4.Among the participants the Number of Women that had Postnatal Checkup 6,357 5.Among the participants Number of Health Voucher Beneficiaries were: 2,826 24 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

25. C APACITY B UILDING OF S TAKEHOLDERS Capacity Building of the following Stakeholders was carried out:  District Health Department;  Population Welfare Department;  Social Welfare Department; and  Local NGOs. 25 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

26. M ALE C OUNSELING (H EALTH S ESSIONS ) Male Health Counseling Sessions were conducted by Male Voucher Field Officers (Started in July 2012) Each session comprises 8 – 12 participants. Target participants are Husbands of Health Voucher Beneficiaries, Youth (expected husbands), and other community members. TOPICS:  Birth Preparedness;  Danger signs during pregnancy;  Danger signs during delivery and after delivery;  Importance of SBA, etc. 26 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

27. C OST OF S UBSIDIZED S ERVICES O FFERED THROUGH V OUCHERS Voucher No. ActivityServices Provided by HCP Cost for HCP Transport Allowance Total (PKR) V-1First AntenatalANC + Filling of ANC Card + Medicines10050200 Checkup (ANC)TT Injection50 V-2Second ANCANC + Filling of ANC Card + Medicines10050150 V-3Third ANCANC + Filling of ANC Card + Medicines10050200 TT Injection50 V-4Lab InvestigationsBlood CP, B-Group, Urine RE, Blood Hb & HCV200- V-5Ultra SoundOne Ultra Sound15050200 V-6SVDSimple Vaginal Delivery + Medicines + ANC Card2,5002502,750 V-7Postnatal CheckupPNC + Filling of ANC Card + Medicines10050150 V-8FPCFamily Planning Counseling (FPC) + FP Services10050150 V-9C-SectionC-Section + Medicines (On Need Basis)10,00025010,250 TotalSVD PackageSVD + Medicines + Filling of ANC Card3,4505504,000 C-Section PackageC-Section + Medicines + Filling of ANC Card10,95055011,500 27 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

28. M ONITORING F RAMEWORK RAHSTA STAFF VMA DCNP/EDOH COMMUNITY Voucher Verification SG Monitoring Feedback HEALTH FACILITY Quality Assurance Monitoring and Verification Feedback 28 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

29. I MPACT OF H EALTH V OUCHERS ON ANC C HECKUPS AND TT S HOTS UPTO D EC 2012 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK 29

30. L AB I NVESTIGATIONS & U LTRASOUND C HECKUP UPTO O CT 2012 After Introduction of Health Vouchers Women for whom Lab Investigations were carried out 94.2% Women for whom Ultrasound was conducted 85.6% Important Finding:  Hb% for all women is in the range of 6 to 7.  100% Health Voucher Beneficiaries are ANEMIC. 30 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

31. S TATUS OF DELIVERIES UPTO D EC 2012 31 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

32. I MPACT OF H EALTH V OUCHERS ON DELIVERIES RAHSTA-PPAF: PEWRH-VH P ROJECT DGK 32 STATUSIMPACT Deliveries Expected Upto December 2012 1680 Deliveries Not Delivered (Deferred to January 2013) 8 Deliveries Delivered Upto December 2012 1575

33. S TATUS OF V OUCHERS R EDEEMED U PTO D EC 2012 33 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

34. O VERALL S HIFT OF D ELIVERIES FROM TBA (H OME B ASE ) TO SBA (H OSPITAL B ASE ) A significant shift from TBA to SBA 34 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

35. S UCCESS S TORIES  Following four Success Stories are shared:Success Stories  Success Story of RABIA from UC Chorhatta  Success Story of LAL MAI from UC Mana Ahamadani  Success Story of Amjad from UC Maimoori  Success Story of Khan Muhammad from UC Mana Ahamadani 35 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

36. L ESSONS L EARNT  During the project implementation some of the Lessons Learnt & Problems encountered were:Lessons Learnt  Quality Assurance for Service Delivery  Delivery at Home by TBA  Misunderstanding on the use of Voucher for C-Section  Impact of Rains and Flood  Impact of Polio Campaign  Lack of Trust on HV Scheme  Cost of Health Vouchers  Project Operational Cost 36 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

37. S USTAINABILITY  To ensure SUSTAINABILITY following efforts are being undertaken:  Constitution of VMA for transparency, monitoring and effective management;  Involvement of DHD, PWD, BISP, BAITULMAL, SWD and Local NGOs;  Initiation of INTERNSHIP Program for on the job – step by step training on the health voucher program;  Regular implementation of SGs and male counseling sessions;  Regular counseling and refresher sessions for awareness for all stakeholders. 37 RAHSTA-PPAF: PEWRH-VH P ROJECT DGK

38. THANK YOU! RAHSTA-PPAF: PEWRH-VH P ROJECT DGK 38