Meeting minutes 2nd nhsc (5 3-12)

Minutes of 2nd NHSC Meeting (29-12-2011)

The 2nd NHSC meeting was conducted on the 29th of December 2011, in the Department of Health’s Conference hall, with the key objective to:

1. Update the NHSC members on the implementation of GAVI HSS activities and expenditure status for the last three months.

2. Seek NHSC’s endorsement on the GAVI HSS work plan for next three months.3. Present the process of drafting Coordinated Township Health Plans (CTHP) for the first twenty townships and share

broad findings from the Health system assessments to the NHSC members. 4. Seek NHSC’s endorsement on the Coordinated Township Health Plans for the first twenty townships for

implementation

Members present (list attached):

Agenda 1: Opening Speech by Chair NHSC:

Deputy Director General, Disease Control, Department of Health chaired the meeting on behalf of the Director General, DOH. Chairperson welcomed the members of NHSC to the 2nd NHSC meeting and shared his best wishes for the New Year. In his opening speech, he acknowledged the GAVI Focal (Director, Planning, and Department of Health) and the team for the job well done. He also informed very briefly to the members about the process of drafting the CTHP which took a bottom-up and participatory approach by involving all the health workers from Township and Rural Health Centers. The chairperson also said that the added value of CTHP is best demonstrated through iterative costing of the plan.

Initiatives on demand side financing through the development of Maternal Voucher Scheme and Hospital Equity Fund were also highlighted as some of the health system interventions undertaken to improve the access to essential maternal and child health services.

The Chairperson then opened the floor to deliberate further. He urged the members to share their opinions and strategic ideas to guide the Ministry of health to sustain the Health System Strengthening interventions.

Agenda 2: Update on GAVI HSS activities, Assessment and CTHP, Update on GAVI missions and their suggestions/recommendations, Expenditure update and GAVI work plan for next three months.

Dr. Nilar Tin, GAVI Focal Point (Director Planning, DoH) updated the members on GAVI HSS activities implemented in the last three months. Her presentation emphasized much on the process and steps adopted in drafting CTHPs. The CTHP for one of township was presented as an example, for the members to understand better.

Further, broad findings from the Health System Assessments on Human resource and Infrastructure were presented to the forum. The presentation demonstrated pictorial formats of the hard to reach areas, manual recording of the health information and data’s in the sample townships.

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Nonetheless, the presentation could not display the detailed analysis of the findings on Health financing; Human Resource, Data Quality and service quality, since analysis on these findings were still under process. However, the forum was informed that detailed findings from the assessments will be shared in the next NHSC meeting.

Dr. Nilar Tin also informed the forum about the recruitment of health System Strengthening officers (HSSOs) and their contribution in conducting Health systems assessments and drafting of CTHPs. She said, they will be involved in implementation of CTHPS, monitoring and supervision and financial management. In addition to that she said; HSSOs will be reporting to the concerned departments/agencies through the GVAI Focal on any problems observed in their townships with recommendations.

In order to facilitate them in performing these additional tasks, she said, HSSOs were given technical briefing by the specific technical departments (Epidemiology (EPI), MCH, Health Financing, Health Information, on 27 th and 28th of December 2011.

The second half of her presentation made an update on the GAVI mission that visited Myanmar from 15-17 th

November 2011. Presentation highlighted the key discussions with the Mission as follows:

o New vaccine application of Myanmar (Penta) and related co-financing and financial sustainability issues.

o Cold chain status and plans.

o HSS implementation and 3rd party identification issues

o Financial Management Assessment (FMA) and the Aide Memoire

o Liaise with other Partners, DFID and AusAID.

The members were informed on the issues in implementing the infrastructure component. She mentioned that the previous proposal that was drafted in 2007 did not include management cost and forecast inflations and exchange rate fluctuations. Now the proposal from 3rd party includes management cost which is quite high consuming approximately 20 % of the planned budget. Further, 3rd party’s cost projection using UN standards shows financial gap and huge cost hike. That further shows reduction in number of product delivery (renovation of RHCs and constructions of sub- RHCs).

Following this her presentation flagged some of the suggestions received from the mission on Infrastructure component and GAVI HSS’s governing body. The suggestions were presented to the members for their guidance.

On infrastructure: she highlighted that GAVI suggested reprogramming the infrastructure component to priority areas linking to country’s current policy.

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On GAVI HSS’s governing body: she highlighted that GAVI suggested either clubbing ICC and HSS or using CCM as the governing body.

In the final segment of her presentation, Dr. Nilar Tin briefed the forum on activities planned for next three months for endorsement with the overall expenditure status till date. The main activities planned for next three months were:

Analysis, Compilation and documentation of HSS assessments reports. Implementation of CTHPs in 20 townships Provision of basic PHC service and essential health supplies to HTR areas.(recurrent cost

covered), Supply transport capital to 20 townships as identified in CTHP. Community involvement (Health Committee activities-Quarterly Review Meeting), Development and production of policy brief and guidelines for initiation of Maternal Voucher

Scheme (MVS) Advocacy meeting & training for central level and township on MVS Training/recruitment of CHW/AMWs in HTR areas(20 tsps) Refresher training for CHWs in 20tsps.

Actual overall expenditure incurred was presented as 21%, however she explained that it is as per the statement generated from WHO system which displays only the liquidated expenses. Nonetheless, the actual expenses would be around 50% including the un-liquidated expenses.

Discussion:

Medical officer from WHO supported the implementation of such activities that facilities access for the community living in hard to reach areas to achieve the MDG goals. He said, findings from the assessments are also expected to identify system constraints in the area of HR, Infrastructure, Financing and health information that would be brought to the notice of policy makers to consider policy actions. Saying that, he submitted WHO’s concurrence on endorsing the CTHP and GAVI HSS work plan for next three months for implementation.

The chair person enquired whether CTHP and assessment looked at covering the migrant workers and immigrants to address cross border issues.

- To this the GAVI Focal (Dr. Nilar Tin) responded that all these issues were considered to cover the whole township. During the assessment specific example was found in Sgwe Gu township where the workers from the mines who were staying around the township yet they were found to be inaccessible to the township hospital and public health care services as they were migrant workers from different townships.

Representative from MERLIN asked on the management of the CTHPs; the role of central and states/regions in longer run once the coverage is expanded from 20 townships and beyond. Further he also asked whether all the actual costs are included in the plan.

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- The members were informed by the GAVI Focal (Director, Planning, DoH) that in longer run the states and regions are expected to take more responsibility in managing the CTHPs, with central only giving technical support when needed. She also informed the forum on the upcoming plan to conduct leadership and management training to upgrade the capacity of state and regional health directors on planning and management.

- Regarding the query on costing, she explained the difficulty to include all the foreseen cost, rather she said; costing is done for the priority activities and interventions in negotiations with the BHS and other health workers.

The representative from MERLIN recommended sensitizing the developing partners and NGOs on the CTHP through dissemination meeting.

- Chairperson noted this recommendation as valid and suggested dissemination of the CTHPs through appropriate forums for further collaboration.

Chairperson enquired whether any discussion was held with the township health workers on their plans to sustain the provision of package of services once the program phases out. He also highlighted it will be important to think through these areas to maintain sustainability. Responding to this query, the GAVI Focal (Director Planning, DoH), mentioned that initially it’s very important to motivate and incentivize the basic health staff to initiate the new approach. CTHP approach will be implemented with the intention to test its feasibility and if found feasible, the findings shall be brought to the notice of policy makers for institutionalization of hardship allowances/ per diem or increasing transport allowances in the government system.

The forum expressed the need to have more inputs to strengthen and improve the Health system components mainly the HR, Health Financing components/policies.

- To this effect GAVI focal shared other ongoing activities on the Assessment of HR retention that is expected to demonstrate ground realities and issues on the Human Resource Management and Retention. Further she highlighted other activities on demand side financing like provision of seed money to hospital equity fund and Maternal Voucher Scheme which are in pipeline.

The EPI Director expressed the need to discuss the Infrastructure component. He said it would be important to think about reprioritizing this fund to priority areas. Due to the fluctuation in exchange rate and inflation, around 25% of projected budget will be lost if the fund is to be used for infrastructure building. Further, he also enquired the possibility of re-channeling this fund to support the implementation of Penta vaccine next year. On the suggestion to club ICC and NHSC, he suggested keeping them separate as of now and, NHSC can oversee GAVI HSS while ICC will oversee the EPI activities. He also enquired the possibility of including micro plans for EPI in the CTHP.

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- On the infrastructure component, Dr. Nilar said, discussion/negotiation is still ongoing with UNOPs and if at all the management cost doesn’t come down, then reprioritization can be done as per the current health system need and government policy.

- GAVI Focal (Director, Planning, DoH) said, noting the need to involve partners from other development partners like DIFID and USAID in the NHSC, Honorable Minister endorsed the proposal to incorporate their representation in the NHSC as members.

- On the query to capture micro plan for EPI in the CTHP, the Chairperson expressed the impossibility of incorporating all the micro plans for different programs in the CTHP and he further recommended the programs to prepare separate micro plans for specific programs.

Decision and Recommendation by Members:

After detailed deliberation on CTHP, the infrastructure component and clubbing of ICC/HSS or using CCM as the governing body. Following decision and recommendations were made:

1. It was recommended to disseminate the CTHPs to the other development partners through appropriate forum to facilitate further collaboration and support.

2. On the clubbing of ICC/HSS or using CCM as the governing body, it was recommended to do proper analysis to assess the value addition and the challenges on this. Following that a proposal may be submitted to the ministry for policy directives. It was then decided to follow the current practice: Keep NHSC and ICC separate, with NHSC overseeing the GAVI HSS and ICC overseeing the EPI components, until further directive is received from the ministry.

Agenda 3: Update on Technical support by WHO

Medical Officer from WHO briefed the forum on the commitments by WHO in the Aide Memoire as follows:

o Overall management and administration of the GAVI HSS funds for the HSS programme and activities contained in the GAVI HSS proposal excluding construction and renovation of health centers and procurement of supplies and equipment.

o Technical assistance to all aspects of the programme including cross cutting support in capacity building, research, planning and monitoring and evaluation.

o Facilitate the recruitment of technical staff and international consultants as and when needed

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Following this, he informed that WHO has assigned and recruited One Medical Officer, one International Technical Officer, 2 National Technical officers, one Administration and Finance Officer, one Administration Assistant, 2 Finance Assistants and one office secretary in WHO country office.

These staffs are basically mandated to facilitate GAVI HSS planning and reporting to WHO and GAVI. They are facilitating coordination between (MoH, WHO and GAVI) and establish synchronization between the different technical and administrative requirements of WHO, MOH and GAVI. They are providing necessary technical support for implementation and management of GAVI HSS activities.

Further he mentioned, the recruitment 18 Health System Strengthening officers, 4 placed at the central level and 14 in the townships. Health System strengthening officers are mandated to conduct HSS assessments, CTHP drafting and Implementation. They will also over look the financial management at the township level and further monitor and manage the fund flow from central to townships.

Ultimately he said, this whole team is working in close consultation and collaboration with the GAVI focal point (Director, planning, DOH) who is leading the GAVI HSS initiatives in Myanmar.

No further discussion was raised on this agenda.

Agenda 4: Status update on UNICEF Component of GAVI HSS:

The representative from UNICEF presented the status update on the supplies till date. Kits for medicine and equipment are in the pipeline and will soon reach the CMSD for further distribution to 20 townships.

Discussion:

Considering the variation in catchment population which will drive the utilization rate, members raised concerns on the disbursement of same amount of kits to all the townships. The concerns were in relation to management of surplus and shortage of kits.

- Responding to this the UNICEF focal said, for this year Ministry of Health will accept whatever has been dispatched by UNICEF. Further, UNICEF will rationalize the distribution from year two based on the report on surplus and stock outs from the townships.

- The chairperson also encouraged the HSSOs and TMOs to report on surplus and stock out to create baseline for next distribution.

The members also urged the need to appoint someone at the central level to conduct close monitoring of supply management.

- To this effect, GAVI focal informed that one Health System Strengthening Officer is already recruited at the central to monitor and evaluate the supply management.

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Agenda 5: Presentation on Hospital Equity Fund:

GAVI focal Dr.Nilar Tin presented the objective and management plan of Hospital Equity Fund. Through her presentation she informed the forum that this fund is indented to provide free hospital services to poor mother and children. Through the GAVI HSS initiatives each hospital in the sample townships will be given a seed money of $ 10,000(approximately 800, 0000 kyats). For each patient maximum budget of 100,000 kyats to cover the food, transport and direct medical costs (consultation, investigation and drugs) for the poor mother and children.

Discussion:

Representative from Myanmar Medical Association shared his experience on the Referral fund for the high risk pregnant women in Northern Rakhine state. In his statement, he said such intervention can bring positive changes. His experience showed nearly 100% turnouts of the high risk pregnant women to seek service. Nonetheless, he said there is difficulty to sustain such measures in longer run. He therefore recommended to advocate the outcome of such interventions to the policy makers and highlighted need to explore strategies to generate additional funds from internal and external donors.

Chair of the Myanmar Maternal and Child Welfare Association said, on an average a woman has to spend almost 40,000 kyats for referral services in Rakhine state. She said, currently MMCWA is planning to donate money to the hospital equity fund to support referral services in many townships including the 20 GAVI HSS townships.

Representative from the Office of the Auditor General requested GAVI focal to submit complete data and information of the OA (other accounts) to the AG office.

Representative from Save the Children enquired whether Advocacy will be done to inform the community on the Hospital Equity fund. To this Dr.San San Aye, Director of Health Planning and Dr.Nilar Tin Director Planning, DOH clarified the prime objective of fund to support only the poor mothers and children visiting the hospital. They said, advocacy is not encouraged basically to avoid moral hazard (unnecessary demand by both rich and poor).

Former Deputy Minister for Health, who is currently the Member of Parliament (chairman of maternal and child welfare committee of Myanmar) happened to attend the discussion at the end part of the meeting while visiting the DOH. During the discussion he had given his vast experience in the management of maternal and child health care and also given input for health financing component.

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Closing Remarks by Chairperson:

In his closing remarks, the chairperson thanked all the members for attending the 2nd NHSC meeting and making constructive contribution in guiding the GAVI team to further implement the planned activities.

He formally endorsed the CTHP for the twenty townships and the GAVI work plan for next three months for implementation. Also the Hospital Equity Fund was included in the endorsement.

The meeting adjourned at 12:30.

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Health & Medicine

Meeting minutes 2nd nhsc (5 3-12)