Improving Programme Implementation through Embedded Research (ipier) EMRO Region PROJECT SUMMARIES

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1 Egypt Factors contributing to the failure of the health system to regulate private facilities in Egypt Mohammed NOUR EL-DIN and Population Despite efforts by the to increase the proportion of institutional deliveries and attended births, the maternal mortality ratio in Egypt actually rose to 52.2 deaths per 100,000 live births in The large number of maternal deaths caused by malpractice or medical errors in private health facilities indicates that poor quality of service delivery has become a barrier to implementation of the maternal health program. The current health system has not been effective at regulating private facilities or providing routine training to health workers. To generate knowledge that may be used to improve the quality of maternal health services, the and Population will explore the factors contributing to the failure of the system to regulate private facilities. To collect this information, a series of interviews will be carried out with key stakeholders responsible for overseeing private clinics at the central and local levels in five representative governorates. During each interview, a questionnaire will be administered prior to and following a presentation on the problem of maternal deaths. The data will be used to understand the current system and identify factors contributing its failure. Egypt Supply-side factors contributing to poor performance of primary health centers delivering family planning services in Egypt Atef ELSITANY The unmet need for family planning among women of reproductive age has been increasing in Egypt, rising to 12.6% in Previous efforts by the to improve family planning coverage through universal access at facilities and community outreach have not been successful at responding to the growing demand. A major barrier to implementation of the family planning program is the poor performance of primary health centers delivering services. There are multiple system failures that may be contributing to the problem. To generate knowledge that may be used to improve family planning service delivery, the will lead a study that seeks to identify the supply-side factors that have contributed to poor performance at primary health centers. Farshout District in Qena Province, Egypt was selected as a case because of its exceptionally low rate of contraceptive use and feasible number of facilities. 12 primary health facilities will be visited to assess the availability of essential supplies and equipment for service delivery. In-

2 depth interviews, focus group discussions, and exit surveys will be used to determine the knowledge and motivation of health workers in family planning, as well as women's satisfaction with the care they received. An analysis of data on multiple aspects of service delivery will enable the researchers to identify the supply-side factors that have contributed to poor performance. Lebanon System failures hindering implementation of a cardiovascular disease intervention at primary health facilities in Lebanon Rouham YAMOUT Ministry of Public Health In 2014, cardiovascular disease accounted for 47% of deaths in Lebanon. To respond to the growing burden, the introduced a package of services to screen and manage risk factors at primary health facilities. Currently, the intervention is facing numerous implementation barriers, including poor compliance to guidelines. Experience from the pilot study indicates that the challenges in implementation may stem from the system s failure to motivate and regulate health workers providing services at primary health facilities. To generate knowledge that may be used to improve implementation of the cardiovascular disease intervention, the Ministry of Public Health, in consultation with the University of Beirut, will conduct a study that aims to identify the system failures that have hindered implementation. Five primary health facilities within the Beirut area will be visited. First, data on implementation of the cardiovascular disease intervention will be collected through a review of program reports and medical records. This information will be used to guide key informant interviews and focus group discussions at the facility-level to explore factors that have contributed to poor implementation. Representatives from the will also participate in interviews and focus group discussions about the specific barriers and failures associated with accountability and regulation. Multiple perspectives will enable the researchers identify the systems failures that have hindered implementation of the cardiovascular disease intervention. Lebanon Opportunities for stakeholder engagement in the development of a performance-based contracting system for hospitals in Lebanon Jade FHALIFE Ministry of Public Health In an effort to improve the delivery of health services at hospitals in Lebanon, the Ministry of Public Health introduced a new financing scheme in which hospital payment was based on the

3 achievement of performance standards. Experience from the first round of contracts revealed that poor understanding of performance contracting undermined hospital's commitment to targets and resulted in minimal improvements in service delivery. Limited engagement during the development process may have contributed to the challenges encountered during implementation of the new financing scheme. To generate knowledge that may be used to inform the second round of performancebased contracts, the Ministry of Public Health will conduct a study to identify opportunities to strengthen stakeholder engagement during the development process. A series of interviews will be conducted with key informants at the Ministry of Public Health, Syndicate of Private Hospitals, and 10 hospitals operating within the Beirut and Mount Lebanon regions. Topics discussed will include the development process and communication during the first round of performance-based contracts, factors that hindered stakeholder engagement, how the approach to stakeholder engagement affected acceptability of the scheme, and important concepts and definitions related to performance-based contracting. Opportunities to strengthen stakeholder engagement will be identified from an analysis of the data collected. Morocco Options to improve the use of process indicators to inform delivery of maternal health services in Morocco Bouchra ASSARAG Morocco has experienced significant increases in access and use of maternal and neonatal health services, reaching coverage of antenatal care and assisted delivery at 77% and 74% respectively. However, these successes have resulted in minimal reductions in maternal and neonatal mortality. Limited use of process indicators to inform service delivery has become a barrier to implementation of the maternal and neonatal health program. Multiple failures within the system may be contributing to the problem, including fragmented sources of data, unclear guidelines for reporting and response, and limited capacity and motivation of health workers. To generate knowledge that may be used to improve the maternal and neonatal health program in Morocco, the will work in collaboration with the National School of Public Health to carry out a study to explore the failures in the system that have contributed to limited use of process indicators to inform service delivery. Meknes and Rabat provinces were selected as representative cases for the study. Key informant interviews will be conducted with facility managers and health providers at all levels of the health system in order to determine

4 where the system is failing and how it may be contributing to the problem. This information will be corroborated by health facility assessments that include observations of service delivery along with a review of operations documents and medical records. From this information, options to improve the use of process indicators to inform delivery of maternal health services will be identified.. Morocco Options to improve management of high-risk pregnant women in Morocco Lahlou KHALID The maternal mortality ratio in Morocco has remained at 112 deaths per 100,000 live births, despite significant efforts by the Ministry of Health to reduce it. The large number of maternal deaths that are due to preventable causes indicates that the management of women who are at high risk during pregnancy poses a barrier to implementation of the maternal health program. The challenge may stem from multiple failures within the system, including poor coordination among different levels, lack of guidelines for the management of high-risk pregnancies, and limited health worker capacity. To generate knowledge that may be used to the improve the maternal health program, the Ministry of Health, in collaboration with the National School of Public Health, will carry out a study to identify the system failures that have contributed to improper management of high-risk pregnant women. The provinces of Meknes and Rabat were selected as representative cases for the study. Failures in the health system will be explored using surveys with high-risk pregnant women, in-depth interviews with health providers, observations of antenatal care delivery, and a review of operations documents and medical records. From the information, options for actions to improve the management of high-risk pregnant women will be identified. Pakistan Recommendations to improve compliance to The Breastfeeding Code in Pakistan Shahzad ALI KHAN Services Regulation and Coordination Malnutrition is one of the leading causes of child mortality in Pakistan, in part due to poor feeding practices. During the past three decades, there has been a steady decline in the proportion of children who were breastfed, dropping to 65.9% in In an attempt to improve the nutritional status of children, the Government of Pakistan implemented a policy that requires health workers

5 to promote proper breastfeeding practices to caregivers, called the Breastfeeding Code. A major barrier to implementation has been poor compliance to the code by health workers. In a context in which manufacturing companies offer incentives for prescribing formula, the regulatory mechanisms to hold health workers accountable to the code have not been effective. In order to generate knowledge that may be used to improve compliance to the code, the Services Regulation and Coordination will lead a study that aims to explore the factors that have contributed to the failure of the system to hold health workers accountable to the code. First, a document review will be conducted to determine the barriers that have been faced by past nutrition interventions. The review will be followed by a series of key informant interviews with government officials at the federal, provincial, and district levels, as well as in-depth interviews with health providers, community leaders, and other stakeholders. An analysis of the information collected will enable the identification of system failures that have contributed to poor accountability in order to inform recommendations that may be used to improve compliance to the code. Pakistan Barriers to and facilitators for an integrated system of malaria surveillance in Pakistan Nahid JAMALI Government of Sindh Province Malaria remains a leading cause of morbidity and mortality in Pakistan. In order to contribute to health improvements, the Government of Pakistan introduced a comprehensive package of interventions to control the disease. However, poor quality of data has become a barrier to implementation of the malaria control program, resulting in poor planning and decision-making, uncoordinated activities, and missed opportunities for funding. There are multiple health information systems currently operating in the country, each managed by a different organization using distinct indicator definitions. To generate knowledge that may be used to improve the quality of malaria data, the Government of Sindh will conduct a study to identify the barriers to and facilitators for an integrated system of malaria surveillance. This information will be collected using in-depth interviews and focus groups discussions with decision-makers, managers and other stakeholders involved in the implementation of the program. The data will be analysed to identify opportunities to improve the quality of data to support planning and decision-making for the malaria control program.

6 Pakistan Options for incentivizing health providers to provide tuberculosis control interventions in private facilities in Pakistan Syed Sharaf Ali SHAH Government of Sindh The burden of tuberculosis in Pakistan is the fifth highest in the world, with an annual incidence of 97 new cases per 100,000 people. A package of tuberculosis control interventions, collectively known as Directly Observed Treatment, Short Course (DOTS), is being implemented at facilities across the country. Poor compliance to guidelines among health workers at private facilities has been a barrier to implementation of the tuberculosis control program, resulting in low rates of detection and treatment. The current system is not effective at motivating private health providers to deliver tuberculosis control interventions. To generate knowledge that may be used to improve compliance to guidelines at private facilities, the Government of Sindh will work closely with Bridge Consultants Foundation to explore the options for incentivizing health workers to provide tuberculosis control interventions and describe the mechanisms that must be established to support the provision of incentives at private facilities. To collect this information, in-depth interviews and focus group discussions will be conducted with health managers and providers at private facilities. The data will be analysed to elaborate the options and mechanisms that may be put in place to improve compliance to tuberculosis guidelines among health providers in private facilities. Palestine Options to improve reporting and response to adverse events following immunization in Palestine Jehad Awad AHMED Immunization has proven to be one of the most effective interventions to improve child morbidity and mortality. In Palestine, the Expanded Program for Immunizations had achieved 99% coverage in children. Despite this success, poor response to adverse events following immunization due to severe underreporting of cases poses a major barrier to implementation of the program by contributing to growing vaccine hesitancy among caregivers. The current surveillance system for adverse events is characterized by a lack of standard guidelines, limited knowledge and motivation of health providers, and poor management and coordination of tasks among different levels of the system. To generate knowledge that may be used to improve the response to adverse events following immunization, the Ministry of

7 Health will lead a study to understand the failures undermining the current surveillance system. Health facility assessments at five hospitals and 19 health centers located in the Gaza region of Palestine will be used to assess existing guidelines and health worker knowledge, determine the process for data collection and management, and explore mechanisms for reporting and responding to cases of adverse events. System failures will be identified through indepth interviews and focus group discussions with decision-makers, managers, providers, and other stakeholders. Data will be analysed to identify options that may be used to improve reporting and response for adverse events following immunization. Somalia Options to strengthen the monitoring and evaluation system for maternal health in Somalia Hussein Jama HAD Somalia has one of the highest maternal mortality ratios in the world, at 1,440 deaths per 100,000 live births. Pre-eclampsia remains one of the leading causes of maternal death in the country and numerous interventions introduced in an effort to reduce it have not been successful. A barrier to implementation of the maternal health program has been the inadequate use of data to inform the health system response due to multiple failures within the monitoring and evaluation system. To generate knowledge that may be used to improve the monitoring and evaluation system, the Ministry of Health, in collaboration with the African Network for the Prevention and Protection Against Child Abuse and Neglect, will carry out a study to understand the operation of the monitoring and evaluation system and identify the challenges it is facing. The study will begin with a document review to determine the design of the system. This will be followed by observation and in-depth interviews with health system experts, program managers, and monitoring and evaluation officers in all six regions of the country to explore the system's operationalization and current challenges. From the data collected, options to strengthen the monitoring and evaluation system for maternal health will be identified. Sudan System failures contributing to poor coverage of iodized salt in Sudan Nada Gaafer Osman AHMED Iodine deficiency is common in Sudan and has severe implications for the health of the population. The national prevalence of goitre, a

8 disorder due to severe iodine deficiency, was 22% in To respond, the adopted a policy to reduce deficiency through universal coverage of iodized salt. Despite these efforts, coverage of iodized salt remains exceptionally low, at less than 1% of households in Multiple system failures may be contributing to the problem. In order to generate knowledge that may be used to improve coverage of iodized salt, the will lead a study to identify failures within the system affecting distribution, enforcement, and demand for iodized salt. First, a review of documents will be used to determine the distribution and regulatory mechanisms for iodized salt that are currently in place. Failures in the system will be identified through focus group discussions with managers, inspectors, distributors and vendors. In addition, a survey of households in Gadarif State will be used to determine the characteristics that are associated with demand and coverage of iodized salt. An analysis of the data collected will enable identification of the failures affecting distribution, enforcement, and demand of iodized salt that may be addressed to strengthen the system. Yemen Options to improve monitoring and evaluation of the outpatient therapeutic feeding program in Yemen Abdulla Salem Bin GHOUTH The nutritional status of children in Yemen remains critical, with chronic and acute malnutrition at 47% and 13% of children under five respectively. In 2008, Yemen launched a national program for the management of severe acute malnutrition with the aim of contributing to reductions in childhood morbidity and mortality. Limited information to inform program planning and decision-making has become a barrier to implementation of the outpatient therapeutic feeding program. The current monitoring and evaluation system does not provide information on case detection, reporting procedures, or feedback mechanisms for this program. In order to generate knowledge that may be used to improve the outpatient therapeutic feeding program, the Ministry of Health, in collaboration with Hadramout University College of Medicine, will carry out a study to understand the processes for case detection, reporting and feedback and to identify barriers for monitoring and evaluation. This data will be collected from a health facility assessment and in-depth interviews with health managers and providers in 20 districts. From the data, options for improving monitoring and evaluation of the outpatient therapeutic feeding program will be identified.