USAID Social Health Protection Project Implementing ...

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USAID Social Health Protection Project Implementing Partner: University Research Co., LLC Semi-Annual Progress Report to USAID|Cambodia

Reporting Period: October 1st, 2016, through March 31st, 2017 Date Submitted: May 26th, 2017 Agreement Number: AID-442-A-14-00002 Agreement Duration: December 26th 2013 to December 25th 2018

Disclaimer: This report is made possible by the generous support of the American People through the United States Agency for International Development (USAID.) The contents of this study are the sole responsibility of the Social Health Protection Project and do not necessarily reflect the views of USAID or the United States Government.

SOCIAL HEALTH

PROTECTION PROJECT

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Table of Contents

1 OVERALL PROGRESS ERROR! BOOKMARK NOT DEFINED.

1.1 SUB-AWARDS AND PERFORMANCE ERROR! BOOKMARK NOT DEFINED. 1.2 HUMAN RESOURCE DEVELOPMENT AND STAFF CHANGES ERROR! BOOKMARK NOT DEFINED. 1.3 INTERNATIONAL TRAVEL ERROR! BOOKMARK NOT DEFINED. 1.4 PROCUREMENTS ERROR! BOOKMARK NOT DEFINED. 1.5 SUMMARY OF PROGRAM FINANCIAL INFORMATION ERROR! BOOKMARK NOT DEFINED. 1.6 1.6 PROGRAM DESCRIPTION MODIFICATIONS AND BUDGET REALIGNMENTS ERROR! BOOKMARK NOT DEFINED.

2 PROGRAM COMPONENT ACCOMPLISHMENTS 3

2.1 INSTITUTIONAL DEVELOPMENT 3 2.2 INDEPENDENT MONITORING AND TECHNICAL ASSISTANCE TO THE HEALTH EQUITY FUND 4

2.2.1 HEF SYSTEM UPDATE 4 2.2.2 INDEPENDENT MONITORING OF THE HEF SYSTEM 5 2.2.3 TECHNICAL ASSISTANCE TO HEF SYSTEM GOVERNANCE 6 2.2.4 COMMUNITY-BASED ORGANIZATION (CBO) HEF OPERATORS ERROR! BOOKMARK NOT DEFINED.

2.3 BENEFITS AND TARGETING 6 2.3.1 LEVERAGING THE HEF SYSTEM TO IMPROVE QUALITY OF CARE – HEF BENEFIT PACKAGE

DEVELOPMENT 6 2.3.2 URBAN PRE-IDENTIFICATION ERROR! BOOKMARK NOT DEFINED. 2.3.3 RURAL PRE-IDENTIFICATION 7

2.4 COMMUNITY MOBILIZATION 7 2.4.1 COMMUNITY MANAGED HEF COVERAGE 8 2.4.2 CMHEF COMMITTEE MEMBERSHIP 9 2.4.3 CMHEF TARGET POPULATION 9 2.4.4 CMHEF FINANCING 10 2.4.5 UTILIZATION OF CMHEF BENEFITS 10 2.4.6 CMHEF SUSTAINABILITY PLAN 10

2.5 HEALTH INFORMATICS 12 2.5.1 PATIENT MANAGEMENT AND REGISTRATION SYSTEM (PMRS) 12 2.5.2 MOH PMRS AS PART OF THE MOH OPENHIE ARCHITECTURE FOR HEALTH INFORMATION SYSTEMS 12 2.5.3 UPDATES AND NEW FUNCTIONS ADDED TO THE PMRS 13 2.5.4 MOH PMRS AT THE HEALTH CENTER LEVEL 14 2.5.5 EXPANSION OF THE FULL PMRS TO REFERRAL HOSPITALS 14 2.5.6 WARD-BASED PMRS MODULES 16 2.5.7 PROJECT DATA SYSTEM (PDS) 17

2.6 SPECIAL SECTION: THE ADVANTAGES CLOUD COMPUTING BRINGS TO HEALTH INFORMATION SYSTEMS 17 2.7 MONITORING AND EVALUATION 19

2.7.1 USAID SOCIAL HEALTH PROTECTION INDICATORS 19 2.7.2 COMMENTS ON PROJECT INDICATORS 21

3 PROJECT COORDINATION ERROR! BOOKMARK NOT DEFINED.

4 FAMILY PLANNING COMPLIANCE ERROR! BOOKMARK NOT DEFINED.

5 PEPFAR NARRATIVE ERROR! BOOKMARK NOT DEFINED.

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1 PROGRAM COMPONENT ACCOMPLISHMENTS

1.1 Institutional Development

During the first half of PY4, the project has worked closely with MOH and the H-EQIP to move forward the process of establishing the Payment Certification Agency (PCA). The MOH and MEF established the PCA Inter-Ministerial Working Group (PCA/IMWG) which is chaired by H.E. Youk Sambath, MOH Director General for Administration and Finance, and includes representatives from the Ministry of Economy and Finance; the Ministry of Labor; the Ministry of Social Affairs, Veterans, and Youth; as well as H-EQIP Development Partners. The PCA/IMWG is primarily focused on the development and approval of the Royal Sub-Decree which will formally establish the PCA as a Public Administrative Entity within the RGC. It is expected that the PCA Royal Sub-Decree will be signed by the Prime Minister in July 2017. Supporting the work of the PCA/IMWG is the MOH PCA Working Group which is chaired by Dr. Mey Sambo. This smaller MOH-only group is tasked with working on the key documents that will support the establishment of the PCA. During the reporting period, the project provided key inputs to the development of the PCA Transition Manual which was reviewed by the PCA/IMWG and signed by the Minister of Health in January 2017. The transition manual lays out the clear steps required to establish the PCA and effect handover of responsibilities from the project by June 2018. The key steps outlined in the approved PCA Transition Manual include:

Step 1: Develop and Adopt PCA Transition Manual This step was included even though it is self-referential because approval of PCA Transition Manual is a pre-requisite for the qualification of the Disbursement Linked Indicator (DLI) #5 during the first year of the project. Step 2: Draft, Review, and Finalize Sub-Decree for Establishment of the PCA This step refers to the work of the PCA-IMWG which started meeting in the second week of November 2016. They have a goal of having the PCA establishment Sub-Decree signed by the end of July 2017. The PCA Transition Manual has a annex which provides the detailed roadmap for the drafting and approval of the PCA Sub-Decree. Step 3: Develop the PCA Operational Manual Concurrent with the ongoing process of developing the Sub-Decree, the MOH PCA Working Group is working on the PCA Operational Manual, another key output required under DLI #5. It is expected that the draft PCA Operational Manual will be submitted to the H-EQIP Project Director by the end of May 2017. Step 4: Establish the PCA Governing body and the PCA Executive Director Immediately following the submission of the draft Sub-Decree for establishment of the PCA to the Council of Ministers, two further Sub-Decree will be drafted by the MOH which appoint the PCA Governing Board and the PCA Executive Director. It is expected that these will be formally signed within two month after the establishment of the PCA. Step 5: Mobilization of PCA Employees The step envisions that PCA will be mobilized by the MOH through an Prakas that appoints existing civil servants to PCA positions. Additional employees may be directly contracted to work for the PCA by the PCA Executive Director. The staff of the HEF Implementer employed by the USAID SHP Project will also be seconded to the PCA through June 2018. Step 6: Establish PCA Capacities After establishment of the basic structures and staffing, the PCA Executive Director and senior staff will move forward with the establishment of monitoring and verification capacities as describe in the H-EQIP Program Description. Step 7: Transition from the Third Party Performance-based Ex-post Verification and HEFI to PCA This final step describes the final assumption of responsibilities by the PCA of both HEF and SDG monitoring by the end of June 2018.

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As evidenced throughout the PCA Transition Manual, the USAID SHP Project is expected to provide ongoing technical assistance to the process of establishing the PCA as the institution which will assume the responsibilities that are currently supported by USAID through the project. The key technical areas which are included in this transfer of responsibilities include the independent monitoring of the HEF system as well as the maintenance and ongoing development of the MOH PMRS. Additionally, the German development bank, KfW, will be supporting the development of the ex-post SDG monitoring protocol which will also become a responsibility of the PCA.

1.2 Independent Monitoring and Technical Assistance to the Health Equity Fund

1.2.1 HEF System Update

During the reporting period the Health Equity Fund system has just started to recover from the contractual and financial gaps that were unfortunately part of the final year of the MOH HSSP2 and the start-up of the MOH H-EQIP. As seen in the graphs on the right, utilization of public health services at Referral Hospitals by beneficiaries of the HEF system saw their peak in September and August 2015 and then started a decline that got worse in July 2016 at the start of H-EQIP. Starting in July 2016, public health facilities stopped receiving their monthly reimbursements from the HEF system for services that they provided to the poor. This was because the financing of the H-EQIP was not yet fully in place at the time that the MOH HSSP2 stopped and MOH H-EQIP started. Payments to facilities, retroactive to July 1st, were made by H-EQIP in November 2016. During this time no single hospital or health center suspended their treatment of the poor and the continued to enter the necessary data into the MOH PMRS and submit monthly invoices, confident that eventually they would be paid. From July 2016 through the end of this reporting period, the standard HEF Implementer monitoring conducted by the project was changed to provide much closer support and monitoring of Referral Hospitals for two key objectives: 1) Ensure that key Referral Hospital senior staff remained confident that the HEF system would resume its normal functioning when H-EQIP was fully up and running and 2) Continue close monitoring of the Referral Hospital staff as they assumed their new

Start of H-EQIP

Start of H-EQIP

Start of H-EQIP

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HEF responsibilities which they had taken over from the HEF Operators which finished their contracts at the end of June 2016. In support of the MOH H-EQIP efforts to ensure that all health system managers at the RH, OD, and PHD levels had a clear understanding of HEF and SDG financial management the project worked closely with the MOH and H-EQIP partners to facilitate a nationwide training on financial management. This included 1 day of sessions that specifically address HEF one-time advances for non-medical benefits and how on a monthly basis they are required to submit invoices to the HEF in order to receive reimbursements. Six regional trainings were conducted by a joint MOH Department of Budget and Finance, Department of Planning and Health Information, and USAID SHP Project team. The costs of the trainings were paid for by the MOH as part of their contributions towards achievement of the Disbursement Linked Indicators under DLI #6. The table below provides details of these trainings.

In February 2017, the MOH H-EQIP Director, H.E. Professor Eng Huot, provided written agreement to restart the provision of non-medical benefits (transportation reimbursements, caretaker food allowances, and funeral grants) which were accompanied by a one-time 3 month advance to hospital facilities. No advances for non-medical benefits were provided to Health Centers. The USAID SHP Project HEF and M&E Teams conducted a nationwide training of all Referral Hospitals and Operational Districts to provide guidance on the proper procedures for provision of non-medical benefits which were resumed and March showed some improvement in utilization rates. All of this training was conducted within a 2-week period in on-site session with key staff. During the training staff were provided with training on:

1. The HEF benefit package and provider payment mechanism. This was based on the version currently in use which was signed by H.E. Professor Eng Huot on August 29 th, 2014.

2. How to manage the one-time 3-month advance for the startup of providing non-medical benefits and how all transactions are recorded into the PMRS.

3. The monthly HEF invoice paperless submission process to the MOH through the HEF Implementer. In total, a 107 separate training sessions were conducted during the first three weeks of February that included 802 participants, giving an average of approximately 8 participants per session. After the training the USAID SHP Project conducted follow-up activities at each hospital, OD and at select HC locations to provide additional support to facilities during March and April of 2017. Given the essential nature of the information being imparted during the training, no per-diems were paid for attendance. The graph on the right illustrates the total monthly payments by the HEF of non-medical benefits to the poor.

1.2.2 Independent Monitoring of the HEF System

During the reporting period, the standardized monitoring conducted by the project in our role as the HEF Implementer was adapted to meet the needs of the HEF system as it continues to adjust to the new structures

No Date of Training Venue Participants Facilitators

1 16-17 January 2017 MoH- Phnom Penh 86 DBF/DPHI/USAID-SHP

PHD-Kampong Cham 70 DBF/DPHI/USAID-SHP

PHD- Prey Veng 70 DBF/DPHI/USAID-SHP

Hotel - Siem Rieap 68 DBF/DPHI/USAID-SHP

Hotel - Battambang 80 DBF/DPHI/USAID-SHP

PHD- Kampot 86 DBF/DPHI/USAID-SHP

Total 460

19-20 January 2017

24-25 January 2017

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and processes introduced under the H-EQIP starting in July 2016. This transition required that HEF Monitors play dual role of both providing support and coaching to Referral Hospital staff in the day-to-day administrative requirements of processing HEF beneficiaries and recording their use of public health services as well as monitoring to make sure that all records (both hard and soft copy) were properly generated, saved, and are accurate. The standard monitoring process which includes household interviews is set to resume in May 2017. Under the new MOH H-EQIP which started on July 1st, 2016, significant improvements to the HEF system have been put in place designed to improve efficiency and transparency. This has included the development of an online process that facilitates the paperless submission of monthly facility invoices to the HEF system using the MOH PMRS for the services and benefits that have been provided to the poor. Facilities are required to submit their online invoice within 5 working days after the end of each calendar month. The invoices are then reviewed and certified by the HEF Implementer and submitted to the MOH Department of Budget and Finance (MOH/DBF) within the following 5 working days. The MOH/DBF then has 5 additional working days to complete direct payments to health facilities through bank-to-bank transfers. This new invoice submission, certification, and payment process was first used for the invoices submitted for the period of February 2017. 86% of all 1,253 public health facilities submitted their first online invoice within the allotted 5 working days. A 48-hour extension was granted to allow time for the remaining 14% to resolve some minor confusions about the process. By the 10th working day of March, the HEF Implementer certified and submitted to the MOH DBF a consolidated invoice which included 100% of facilities within the HEF system. The MOH DBF completed their review, approval, and bank-to-bank transfers by the 15th working day March. This is the fastest turnaround time for a monthly HEF invoice from the end of the calendar month to actual payment ever recorded by the HEF system.

1.2.3 Technical Assistance to HEF System Governance

In addition to the independent monitoring of the HEF system, the HEF Monitoring and Technical Assistance team has continued to advocate for the restart of the governance structures that oversee HEF activities and problem solving through the Provincial and District Health Financing Steering Committees (P/DHFSC) and their respective sub-monitoring groups since the beginning of the project. On a monthly basis each HEF Monitor generates and distributes to the P/DHFSC members a detailed report of all of their findings from household interviews, document reviews, and key informant interviews. These reports keep the identity of HEF beneficiaries who report problems anonymous, except in cases where they explicitly agree to be identified and wish to participate in the investigation and solution. In addition to the detailed narrative report, a summary of the information received through the official HEF Complaint Mechanism is included along with some basic analysis about the types of complaints received and the number of complaints that have been resolved and those that remain outstanding, and a summary of the information about the bedside monitoring to oversee HEFOs performance of providing the day to day food, and transportation base on the benefit packages Each member of a P/DHFSC receives a copy of this HEF Monitor report every month. Following each quarter of the year the P/DHFSCs meet to discuss progress of the HEF, discuss new problems encountered during most recent quarter, and review progress to solutions of problems previously addressed. The detailed HEF Monitor reports, along with the regular attendance of the Health Financing Technical Officer to the meetings, have resulted in these steering committee meetings having real relevance and utility. During the reporting period there were very few P/DHSFC meetings following the departure of the HEF Operators and suspension of facility payments and non-medical benefits which were problems that these committees do not have the ability to address. The project Health Financing Technical Officers have been advocating for a restart of the P/DHFSC meetings as directed in the HEF Operation Manual however there is concern about how PHDs, ODs, and Referral Hospitals will charge their MOH budgets for the necessary expenditures to make the meetings happen.

1.3 Benefits and Targeting

1.3.1 Leveraging the HEF System to Improve Quality of Care – HEF Benefit Package Development

During the reporting period, the project continued to work with the MOH DPHI on the finalization of the new draft “National Guidelines of the Benefit Package and Provider Payment Mechanism for the Health Equity Fund”. This critical upgrade for the HEF system will initiate a move by the HEF towards purchasing services using defined Specific service packages that will eventually replace the current more General service

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packages such as “in-patient,” “in-patient with surgery,” or “out-patient” classifications. A more precise set of benefits will allow for better tracking of how the HEF is being used and allows the HEF to link to the sets of available MOH clinical practice guidelines, clinical protocols, national program protocols and guidelines, and standard operating procedures and guidelines. The MOH protocols and guidelines in turn allow the HEF to define an acceptable standard of quality, to get reimbursed for treatment “X” you must perform the following steps “1,2,3,4,5,6” as defined in MOH clinical protocol “A”. And the steps must be recorded in the patient dossier or in the registers in a pre-determined way so that the HEF can used to verify the service and key elements of the quality of its delivery. In this conceptual approach, the new proposed HEF benefit package builds off of existing MOH protocols and guidelines for care, distills them down to their essence to determine a minimum level of care necessary for the service to be reimbursed by the HEF, encourages better charting beyond the minimum by including the results from charting in a quality-adjusted payment scheme, which in turn will lead the MOH to formalize more guidelines and protocols that can be used to establish new treatment packages. Throughout this reporting period, the USAID SHP Project has been actively responding to the request of the Director of DPHI to lead the revision of the HEF Benefits Package and Provider Payment Mechanism. The DPHI Director wanted a concise national guideline which will be endorsed by a Ministerial Prakas which will include the actual payment rates. This document would refer to, and be accompanied by technical annexes which provide the details of both medical and non-medical benefits. This revised structure is intended to allow periodic revision by DPHI of the day-to-day details of how the HEF functions without requiring a new version of the national guideline. The revision of the HEF Benefits Package and Provider Payment Mechanism has led to a healthy debate within DPHI and with national programs and other health partners during the reporting period. DPHI and the Department of Preventive Medicine requested the scope of the service packages to be extended from the national programs to cover screening for diabetes and hypertension and the USAID Social Health Protection Project responded to this request. A final consultative meeting to review the draft guideline is expected to take place with USAID SHP Project support in the second half of PY4.

1.3.2 Rural Pre-Identification

During the reporting period, the USAID SHP Project has provided orientation of CMHEF committee members to the IDPoor process in the 7 Operational Districts which are covered under Round 10. One positive development has been the introduction by the IDPoor Program of a small guideline for Commune Working Groups and Village Working Groups to provide guidance and encouragement to increase community participation. This was a major finding from the USAID SHP Project monitoring of the IDPoor process that was fed back to the IDPoor Program and seems to have resulted in action.

1.4 Community Mobilization

After more than two years in which established Community Managed Health Equity Funds (CMHEFs) have started providing benefits they have shown a greater than expected ability to raise funds for the poor and vulnerable, utilization rates are growing as the poor and vulnerable learn about the new benefits to which they are entitled. There are currently 270 CMHEFs which have been established in the USAID target provinces which include 13,319 committee members (of whom 2,954 are female) which include monks, imams, local authorities and active community members. The CMHEFs cover 3,507 villages in 344 Communes located in 39 Administrative Districts within the 8 of the 9 USAID target provinces. During the reporting period, the Community Mobilization Team has focused on the general activities: 1) Development of CMHEF Technical and Financial Guidelines. The CMHEF Technical and Financial Guidelines for CMHEF provide a detailed elaboration of the important steps and procedures based on best practice. 3,400 copies of these two manuals have been printed and distributed to relevant stakeholders at the field level including the District Facilitation Teams, CMHEF Leader Groups, and members of the Finance and Feedback subcommittees. These documents provide them with a reference to guide them in the implementation of the CMHEF in an efficient and effective manner. 2) The two-day workshops in each Administrative District that focused on “Strategies for Increased Utilization, Improved Community Feedback, and Sustainability of CMHEFs” were attended by 4 key members of each committee along with each Health Center Chief, District Facilitation Team members, and a representative of the MOH Operational District. In total, there were 11,175 participants in these workshop. The workshop

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provided guidance on the following topics:

• How to analyze the current situation of a CMHEF including its strengths, weaknesses, and areas for improvement.

• Methodologies for collection of data and dissemination back to concerned stakeholders.

• Awareness raising strategies through plenary meetings with CMHEF committee members on the provision of transportation vouchers for beneficiaries and promotion activities.

• Joint agreements on activities and milestones to put in place the necessary arrangements for sustainability after the withdrawal of support from the USAID SHP Project.

3) District Facilitation Team workshops were conducted to focus on building the technical capacity of DFT members to augment their technical support of CMHEFs. During the reporting period, a total of 12 of these workshops were conducted covering 17 out of the total 39 Administrative Districts. It was noted during these workshops that individual DFT members had remarkably increased their capacity to support CMHEFs in their area and demonstrated independence by starting to conduct meetings with individual CMHEFs on their own without support from the USAID SHP Project. 4) In 36 out of the total 39 Administrative Districts, CMHEF Support Funds have been established. The source of financing for these funds comes from an annual contribution of approximately $50.00 from each CMHEF committee within the District. The fund is used by the District Facilitation Team to provide technical assistance to the CMHEF committees through-out the year and in some cases provide direct financial support to a CMHEF that has urgent need. In addition, it will fund an Annual or Semi-Annual meeting of CMHEF representatives at the district level to share experiences and plan for District wide fundraising activities. The fund is augmented through a variety of strategies that include:

• Contributions collected through a charity box at the Administrative District Offices;

• Fundraising letters to district level private institutions such as banks and micro-finance lenders; and

• In some Administrative Districts local authorities plan to allocate District Council discretionary funds to support activities in 2018.

During the reporting period, approximately 18,000,000 Riel ($4,500) has been contributed by CMHEF committees to their respective support fund at the Administrative District level. With the phase-out of support from the USAID SHP Project, all District Facilitation Teams will have their field activities funded by their support fund as of July 2017. 5) After all the above workshops, the Community Mobilization Team conducted follow-up and coaching visits with District Facilitation Teams and select CMHEF leader groups to ensure that the agreed actions are implemented as planned.

1.4.1 Community Managed HEF Coverage

The table below provides details of the numbers of CMHEF committees in each Province and Operational District where they have been established by the project in USAID target areas.

Province Operational

District # Dist. #CMHEF/HC # Com. # vill. # Pago. # Mos. Other faith

based

B. Meanchey

P. Net Preah

9

15 15 185 54 1 4

Poipet 17 16 173 55 0 2

Thma Puok 13 18 157 78 3 13

Mongkol Borey 22 20 205 77 1 5

Battambang

Sangkei

14

15 32 231 115 10 81

Battambang 25 17 105 68 8 43

Mung Russei 14 19 161 74 18 15

Sampow Loun 10 17 127 48 4 1

Thma Kol 18 18 161 60 8 9

Pailin Pailin 2 6 8 99 26 1 1

K Speu Kong Pisey 2 21 28 459 98 0 13

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Udong 2 9 16 233 54 0 14

Phnom Srouch 1 6 12 149 47 0 2

K. Cham

Prey Chhor 1 11 17 174 57 2 1

Cheung Prey 1 7 13 72 44 0 2

Bateay 1 7 12 80 39 0 3

Chamka Leu 1 4 4 23 6 0 1

Tbong Khmum

Ponhea Krek 1 11 17 164 53 16 0

Dambei 1 6 7 84 20 19 1

Memut 1 11 14 187 34 14 1

Pursat Bakan 1 11 11 154 53 9 9

Prey Veng Kampong Trabeik 1 11 13 124 44 0 0

Total 22 OD 39 270 344 3507 1204 114 221

1.4.2 CMHEF Committee Membership

Total Female

Religious leader

Local Authority VHSG

Service Providers Others Buddhist

Other Religion

Total Members 13,319 2,954 2,700 252 4,818 3,029 1,581 939

Percentages 100% 22% 20% 2% 36% 23% 12% 7%

1.4.3 CMHEF Target Population

Each CMHEF on an annual basis develops a plan which includes the specific populations that they will target and provide support at the local health center that adds to the existing coverage by the national HEF system. Based on their target population they project anticipated levels of utilization, the corresponding amount of revenue they will need to generate and a plan of how the revenue will be raised. The following table provides the basic breakdown of the CMHEF target population by Operational District.

Province Operational District Elder. 60 up Poor Disabled Poor WRA Total

B. Meanchey

P. Net Preah 2,492 408 778 3,678

Poipet 2,629 1,093 2,315 6,037

Thma Puok 2,590 546 358 3,494

Mongkol Borey 1,241 312 300 1,853

Battambang

Sangkei 4,804 1,254 348 6,406

Battambang 6,090 1,619 1,256 8,965

Mung Russei 5,044 1,565 0 6,609

Sampow Loun 3,093 1,845 499 5,437

Thma Kol 5,032 598 0 5,630

Pailin Pailin 600 307 422 1,329

K Speu

Kong Pisey 7,586 1,490 1,809 10,885

Udong 1,627 328 438 2,393

Phnom Srouch 2,015 102 155 2,272

K. Cham

Prey Chhor 3,666 746 1,030 5,442

Cheung Prey 2,362 565 788 3,715

Bateay 2,124 377 698 3,199

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Chamka Leu 419 0 0 419

Tbong Khmum

Ponhea Krek 2,898 667 939 4,504

Dambei 1,513 460 647 2,620

Memut 2,536 668 1,056 4,260

Pursat Bakan 4,267 154 254 4,675

Prey Veng Kampong Trabek 2,914 402 716 4,032

Total 22 OD 67,542 15,506 14,806 97,854

Percentages 69% 16% 15% 100%

1.4.4 CMHEF Financing

The following table provides a summary of the income collected by the 270 CMHEF committees as of December 2016.

Year Quarter Balance Carried Forward

Income by Source Total Income

Charity Boxes

Annual Donations

Opening Ceremony

Flowering Ceremony

Other Sources

2015

Q1 0 $4,169 $11,598 $2,030 $298 $1,649 $19,743

Q2 $17,987 $4,564 $8,060 $1,700 $433 $219 $14,974

Q3 $31,174 $2,331 $19,316 $2,871 $60 $529 $25,107

Q4 $51,640 $16,649 $12,453 $1,152 $46 $373 $30,668

2016

Q1 $71,117 $3,616 $10,792 $1,368 $295 $395 $16,465

Q2 $76,353 $11,235 $16,849 $1,437 $25 $441 $29,987

Q3 $95,604 $3,691 $7,560 $635 $161 $159 $12,205

Q4 $92,171 $27,281 $10,427 $1,025 $200 $312 $39,245

Total $436,046 $73,535 $97,055 $12,217 $1,517 $4,077 $188,395

1.4.5 Utilization of CMHEF Benefits

The table below provides a summary by quarter of the utilization supported by the 270 CMHEF committees in 2015 and 2016.

Utilization by Quarter: 2015- 2016

Year Quarter Total Cases Supported

Expenses by Beneficiary Category

Total in USD Elderly Disabled Poor WRA Orphans Others

2015

Q1 261 $1,141 $5 $26 $64 $62 $1,418

Q2 1,142 $1,466 $22 $193 $31 $76 $1,787

Q3 3,971 $3,406 $189 $634 $240 $172 $4,641

Q4 5,679 $7,525 $294 $2,340 $735 $299 $11,192

2016

Q1 6,142 $6,870 $804 $2,618 $254 $683 $11,229

Q2 5,472 $7,722 $504 $2,150 $89 $271 $10,736

Q3 9,521 $12,745 $401 $1,957 $154 $383 $15,639

Q4 10,853 $14,603 $807 $3,491 $705 $594 $20,199

Totals 43,041 $54,598 $3,282 $13,644 $2,469 $2,739 $75,684

1.4.6 CMHEF Sustainability Plan

During the reporting period, a significant revision to the USAID SHP Project Program Description was

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approved by USAID. One of the key areas of the Program Description that was changed related to the work by the project to ensure the long-term sustainability of the CMHEF approach and investments made to date. As mentioned in the Program Description the following provides details of the CMHEF Sustainability Plan. A key to the long-term viability of CMHEFs is the establishment of District Facilitation Teams (DFT) which are organized at the Administrative District level and are composed of motivated local authorities from various district offices of line ministries. The DFTs report to the District Governor or Vice Governor. Each DFT member is responsible for providing support, advice, and follow-up to 1-3 CMHEF committees including collection of their quarterly reports for aggregation and submission to the Health Financing Steering Committees. Following the expansion of the CMHEF mechanism to 278 health center areas in the nine USAID target provinces during the first 36 months of the project, SHP has stopped any further expansion of CMHEFs. During FY2017 the project will support the local sub-partner, Buddhism for Health (BFH), to continue capacity building of newly formed CMHEFs and put in place sustainability plans with all of the existing CMHEFS. The sustainability plans for CMHEF committees focus on the collective financing of the DFT by all CMHEF committees within an Administrative District. In each Administrative District the precise arrangements will vary slightly but follow the same basic model which includes:

• Each CMHEF committee contributes $50 per year to a central Administrative District Solidarity Fund (ADSF) which is either managed by a central pagoda or the District Governor’s Office.

• In some Administrative Districts there is a possibility for additional contributions to the ADSF at the District level either through additional fund raising or by the District Council.

• The ADSF is used to support the travel and expenses of the DFT members who follow-up with each CMHEF on a monthly or quarterly basis to provide technical support and collect quarterly reports on utilization and finances.

• A relationship of mutual trust and cooperation is created by the direct relationship between provision of funding by CMHEFs and the support provided by DFT team members.

The development of the sustainability plans for all 278 CMHEF committees in 38 Administrative Districts will

be completed during FY 2017 and support by the USAID SHP Project can be defined in two phases:

Phase I: From October 2016 through September 2017 BFH will focus their efforts in the field on two main areas which include continued capacity building of CMHEFs that were initiated in late FY 2016 and facilitation of sustainability plans for all 38 Administrative Districts where CMHEFs have been established to date in USAID target provinces. By October 1st, 2017, all 38 Administrative Districts will have agreed, finalized, and initiated similar sustainability plans thereby achieving a milestone of ending direct USAID SHP Project support to CMHEF committees and DFTs. Phase II: From October 2017 through September 2018, BFH will maintain three team members based in Phnom Penh who will continue to monitor the quarterly CMHEF reports collected by the DFTs in the 38 Administrative Districts, provide targeted technical assistance where issues arise, and work on documenting the tools, processes and results of the CMHEF experience under the USAID SHP Project for future reference by interested partners. This investment in the sustainability planning and monitoring of the CMHEF activities will help to ensure that USAID’s investment has a higher chance of creating durable structures that provide complimentary HEF benefits to the elderly, disabled, and poor.

12

1.5 Health Informatics

1.5.1 Patient Management and Registration System (PMRS)

The Patient Management and Registration System (PMRS), is an e/mHealth application used by public health facilities in Cambodia for the longitudinal management of patient and financial data. It is used by the Health Equity Fund system in all Operational Districts in the country and 58 public hospitals use it to manage all their patient level data (both HEF and non-HEF). With the support of USAID through the Better Health Services Project (2009-2013), and the current Social Health Protection and Quality Health Services Projects (2014-2018), the PMRS has been developed under the stewardship of the MOH/DPHI. The PMRS is an integrated part of the Cambodian Health Information System (HIS). As a strategic investment by USAID, this work supports a variety of health system strengthening efforts that include quality improvement, health financing, social health protection, and general transparency of the public health system. The PMRS is linked to the MOH National Client Registry MOH/NCR database which is a national system that manages patient profiles that include assignment of unique National Health Identification (NHID) numbers that work at any health facility using the PMRS. The MOH NCR is built to international standards on open-source software (OpenEMPI – which stands for Enterprise Master Patient Index) and is designed to ensure the unique identification of patients with any patient level system. As of the end of this reporting period more than 1,400,000 unique patients have been registered into the MOH NCR and this number is expected to grow even faster in the future with the expansion of the PMRS at the health center level. The graph on the right illustrates the growth in the number of unique patient NHIDs in the system during the USAID SHP Project. Furthermore, the MOH National Client Registry is designed to link the NHID with any other patient identification that a patient may have received from another system (NCADS VCCT, RHAC ID, MARPs card, etc.). With this function the PMRS can serve as a central repository that links fragmented identification systems. Housing such information is by definition, sensitive and the MOH/NCR is designed to protect sensitive patient data. Facility level staff that use the PMRS are provided with unique usernames/passwords and assigned customized roles that limit their access to patient information according to the strict requirements of their job and current task. With nation-wide use of the MOH PMRS, there are on average over 550 unique users of the system on standard work days Monday through Friday. The following graph provides a sample from April that was prepared for this report. As the PMRS at Health Center Level rolls out and expands to additional Operational Districts, it is expected that the number of unique patients registered and the number of users accessing the MOH PMRS system will grow dramatically. The system is currently hosted at Amazon Web Services in Singapore providing the distinct advantages of instant scalability to meet the needs as they grow.

1.5.2 MOH PMRS as Part of the MOH OpenHIE Architecture for Health Information Systems

As the text below explains, creation of an OpenHIE Architecture is a key step for Cambodia to move forward toward creation of a system that achieves the strategic direction laid out in the draft HIS Strategic Plan of the MOH. A description of the concepts behind the OpenHIE approach is provided below as reference.

“As health systems have evolved, care delivery has increasingly been distributed amongst a broad assortment of

healthcare personnel - primary care physicians, specialists, nurses, technicians, public health practitioners,

community health workers, and corresponding health system management personnel. Each member of the team

has specific, limited interactions with an individual patient and differing vantage points into their health. In effect,

the health care team's view of the patient has become fragmented into disconnected facts and clusters of

information.

13

Health information systems, like healthcare personnel, also typically operate independent from one another. The

result is disaggregated information stored in different locations and formats, making it impossible for data to be

harmonized, and for healthcare personnel to share knowledge, collaborate in care, and truly understand the full

breadth of an individual’s health history. Those who manage and oversee the health system have little ability to

make inferences from these data for monitoring and evaluation purposes. Many other healthcare personnel are

forced to make life-altering decisions for their population without key health information.”1

“A Health Information Exchange (HIE) makes the sharing of health data across information systems possible. Like

a universal translator, an HIE normalizes data and secures the transmission of health information throughout

databases, between facilities, and across regions or countries.

OpenHIE’s architecture is made up of six open-source software components, all interacting/interoperating to

ensure that health information from various external systems is gathered into a unified person-centric medical

record. To accomplish this, the exchange normalizes the context in which health information is created across four

dimensions: 1) who received health services, 2) who provided those services, 3) where did they receive the

services, 4) and what specific care did they receive. By focusing on the “For Whom”, ”By Whom”, “Where”, and

“What” of a patient's health visit we help to bring relevant information directly to the point of care. This supports

enhanced decision-making, improves the quality, safety and continuity of care, and facilitates the appropriate use

of information to improve population health.”2

The USAID SHP Project Health Informatics Team has been working to directly put in place key elements of this architecture for the last two years. Currently, the team has worked on the elements that include the “Hospital” and “Lab” external systems, the Interoperability Layer, as well as the OpenHIE Components including the “CR” (Client Registry which includes IDPoor data), the “SHR” (Shared Health Records), as well as a module dedicated to the management of the HEF system.

1.5.3 Updates and New Functions Added to the PMRS

During the reporting period, the Health Informatics Team continued to maintain the existing functions of the MOH PMRS system ensuring that all hospitals and health centers are able to access their patient level data on a day-to-day basis. In addition, new features were added as well as existing functions updated. At the hospital level this included:

• An update to the data entry pages to make them more convenient to use as well as reduce data entry errors;

• Improvements to the pages that display a list of patients currently registered for services allowing improved search functions to quickly locate a patient;

• Updated the display of a patients shared health record with a new format for ease of use;

1 This text is quoted directly from http://www.regenstrief.org/resources/openhie/ 2 This text is quoted and the image above are directly from https://wiki.ohie.org/display/documents/OpenHIE+Architecture

14

• Included tutorial help videos on many pages to provide support to users and reduce the amount of phone support required.

At the Health Center level the new features and updates include:

• An updated display of patient shared health records;

• The ability to update a case that has already been discharged without having to re-enter the case;

• The ability to update the price of transportation for a specific case and delete a previous entry that was wrong prior to submission of an invoice to the HEF Implementer.

In November 2017, the Health Informatics Team provided technical assistance to WHO in their efforts to integrate the Cambodia Laboratory Information System (CamLIS) into the OpenHIE architecture in which the MOH PMRS functions. By integrating the CamLIS into the overall OpenHIE architecture of the MOH, it will be possible in the future for hospitals to link their laboratory information with the shared health records of the PMRS thereby moving in the strategic direction of upgrading the MOH PMRS towards and electronic medical record system. On November 22, 2017, after receiving a full data set of the Round 0 (zero) data from IDPoor for the urban areas in Cambodia, the Health Informatics Team loaded this into the PMRS making it available for official use nationwide. On January 22nd, 2017, all users of the MOH PMRS were forced to change their passwords for security purposes. This was done by created a popup form that led users through the process of changing their passwords that are now require to contain at least 8 digits that include characters, numbers, or symbols. In addition to these updates, the Health Informatics Team joined the national Consultative Workshop for Development of Health Information Master Plan in Siem Reap on the 29 th of March, 2017.

1.5.4 MOH PMRS at the Health Center Level

A conspicuous gap in the development of electronic patient level data systems exists at the Health Center level where all data is still recorded in the hardcopy registers which are then summarized to create monthly aggregate reports (HC1). Starting in July 2014, development began on an Android-based tablet application that focused on registration of HEF patients and their utilization only. This tablet application began field-testing by the MOH/DPHI and the USAID SHP Project in all Health Centers in Bakan Operational District in July 2015. Following this success first field test of the system, the MOH/DPHI requested that the PMRS for health centers be expanded to include both HEF support and non-poor patients. This required a significant expansion of the functionality of the system and opens the opportunity for use by other social health protection schemes in the future. Also at the request of MOH/DPHI a web-based version of the system for Health Centers was developed for those that already have laptops and/or desktops. The Health Center PMRS is now ready to start rolling out nationwide. During the reporting period, the USAID SHP Project M&E Team has developed a promotional video designed to inform and encourage Health Center Chiefs to adopt the system in their facilities. A copy of the video can be viewed at the following link.

https://youtu.be/wWk8i_pCB0k

1.5.5 Expansion of the Full PMRS to Referral Hospitals

The expansion of the Full PMRS to referral hospitals is an activity that is led by the Monitoring and Evaluation team which works very closely and under the guidance of the MOH/DPHI. The USAID SHP Project work plan in PY4 set the goal of expanding the use of the Full PMRS to 31 hospitals. During this reporting period covering the first half of PY4, 15 hospitals have been trained to use the Full PMRS with a total of 320 staff (clerks, cashiers, and managers) trained by the project. Each of these hospitals were required to provide at a minimum 50% cost share to the installation of the system. All of the training was done onsite and provided by a joint MOH/DPHI team with no per-diems paid to participants. After a series of technical lectures and presentations, participants were given a change to practice on each topic of the course. The table below provides details of the hospitals covered during this reporting period.

15

At the end of the reporting period a total of 73 out of the 116 hospitals (63%) in Cambodia are using the Full PMRS to manage all patient registration, management of hard copy dossiers, payment of user fees or invoicing of the HEF, and discharge data collection.

Installation of the Full PMRS at a referral hospital is done through on-site trainings provided by MOH/DPHI and the USAID SHP Project M&E where no per-diems are paid to participants. After a series of technical lectures and presentations, participants were given a chance to practice on each topic of the course. The USAID SHP Project has started to produce and use videos in both trainings and as an online resource within the PMRS as these have been found to greatly enhance the uptake of information by users of the PMRS. For an example of the training videos being produced by the project please click on the link below:

https://www.youtube.com/watch?v=bQJBLDZoVGk

No Name of Hospital Start Date End Date Female Male Total

1 Srei Santhor 21-03-2017 23-03-2017 0 11 11

2 Borkeo 14-03-2017 16-03-2017 7 22 29

3 Municipal Hopsital 06-03-2017 10-03-2017 43 17 60

4 Koh Andeth 14-02-2017 16-02-2017 11 16 27

5 Ou Reang Ov 14-02-2017 16-02-2017 7 11 18

6 Kroch Chhmar 07-02-2017 09-02-2017 7 8 15

7 Mondul Kiri Prov Hosp. 24-01-2017 26-01-2017 4 10 14

8 SraeAmbel 17-01-2017 19-01-2017 9 24 33

9 Krakor 10-01-2017 12-01-2017 2 10 12

10 Bun Rany Hun Sen Koh Sla 22-11-2016 24-11-2016 7 11 18

11 Pognealeu 01-11-2016 03-11-2016 8 12 20

12 Svay Antor 25-10-2016 27-10-2016 9 7 16

13 Baphnom 18-10-2016 20-10-2016 5 3 8

14 Choeung Prey 18-10-2016 20-10-2016 15 13 28

15 Preah Sdach 11-10-2016 13-10-2016 4 7 11

Total 138 182 320

16

The training provided by MOH/DPHI and the Project at any given hospital that is implementing the MOH/PMRS lasts for one week following which there is a one-week period of on-the-job coaching and regularly schedule structured follow-up visits that document the actual use of competencies. The training team does extensive observation of all participants to ensure that they are able to demonstrate the competencies required. The hospital management team, physicians, and staff from each wards of the hospital were also briefed on how PMRS works, what the flow of patient’s document is and what they what do should do after PMRS comes into operations. Below please find a table with details the number of trainings conducted for the PMRS including details of the participants in these trainings.

The first follow-up is done one week after the training, the second after a month, a third after 3 months, and a final fourth 6 months. Both MOH/DPHI and the USAID SHP Project provide phone-based and web-based support for any hospital staff who is having a problem or has a question. The average cost of installing the PMRS system at a referral hospital averages between $5,000 and $15,000, depending on the size of the facility. Before installation of the PMRS can occur at any public hospital, it is required that the hospital provide a minimum 50% of the cost of installation of the system. This typically includes the construction and or renovation of a central registration center, cashier’s office, a patient dossier repository, hiring of new contract staff to serve as registration clerks, and installation of an internet connection. The USAID SHP Project typically provides the necessary computer hardware and supports the costs of the required training that is all done on-site and includes on-the-job competency based follow-up visits at regular intervals. Corresponding to the rapid increase in the number of hospitals that have adopted the Full PMRS to manage patients, the graph below shows the month total of both IPD and OPD visits recorded into the PMRS from non-HEF patients nationwide. During the last two months of the reporting period the total number of non-HEF cases went over 70,000 per month.

1.5.6 Ward-Based PMRS Modules

There are four wards – web-based modules developed for the out-patient department (OPD), general medicine ward, and the emergency room (ER) and pediatric ward. These ward-based PMRS modules were developed at the request

Time Period Number of

Training

Course

Number of

Participants

Medical

Doctors

Medical

Assistants

Nurses Midwives Others

PY1 8 134 14 2 34 2 82

PY2 16 264 39 6 99 27 93

PY3 31 548 71 15 292 70 100

PY4 ( Semi - Annual) 15 320 61 14 101 50 94

Total 70 1266 185 37 526 149 369

17

of many hospital managements in order to help further relieve the workload of the Clerks on discharge data entry and facilitate the collection of more electronic health information that can be used to inform patient care and calculate automatically more of the HO2 monthly aggregate report. The modules are being tested in some hospitals which expanded during the reporting period as per the table below.

The key advantage to the adoption of the ward-based PMRS modules include collection of additional information that supports additional automation of the monthly aggregate HO2 report to the MOH and a decentralization of the hospital discharge process away from the clerks and cashiers who are already very busy with patient registration, HEF management, and the collection of user fees.

1.5.7 Project Data System (PDS)

As part of the USAID SHP Project Monitoring and evaluation efforts the Project Data System originally developed under the USAID BHS project has been modified and updated to manage information and data relevant to the calculation of project level indicators according to the Monitoring and Evaluation Plan. This system is the repository for all data and calculations used in determining indicator baselines and results. It is also the data system where all data from training conducted under the USAID SHP Project is entered in order to produce the necessary reports required by the TraiNet system of USAID. During PY3 this system has continued to be refined and all project related data to training and calculation of our indicators as per our USAID approved Monitoring and Evaluation Plan. The following table provides a summary of the total amount of training provided by the USAID SHP Project during the 12 months of PY3.

No Description # of

Courses

# of trainees Expenditure

Male Female Total

1 Full PMRS Training at 31 Provincial and Referral Hospitals 31 410 307 717 $7,063.96

2 Health Equity Fund Management by Health Facilities under H-EQIP 7 485 257 742 $36,636.80

3 High-Level Social Health Protection and HEF Standard Benefit Package Workshops 2 56 25 81 $2,172.00

4 Community Managed HEF Trainings 457 10,259 3,206 13,465 $158,423.57

1.6 Special Section: The Advantages Cloud Computing brings to Health Information Systems

In 1995, the MOH achieved nationwide coverage of a routinized data collection system for health facilities to report monthly aggregate utilization statistics. This was supported by the development of a MS Access database which was used on individual computers nationwide to input the data which was then copied to CD ROMS or memory sticks that would be physically passed up through the system where it was fully combined at the national level in Phnom Penh. At the time, this was a significant step forward that allowed the MOH to collect and analyze utilization aggregate monthly data in a digital format. There were significant challenges to the management of the distributed MS Access database. It required installation on hundreds of computers nationwide and every time there was an update to the software, each computer had to be to individually updated. In order to aggregate the data to the national level, a tremendous amount of effort and coordination was required to enter the data, copy it onto memory devices and pass it up

No Hospital Name Start Date

Ward-based PMRS

Pediatric OPD Medicine ER

8 Ponhea Kraek_RH 15-Jan-17 ✓ ✓ ✓ ✓

7 Kirivong_RH 05-Jan-17 ✓ ✓ ✓ ✓

6 Kampot_PH 15-Sep-16 ✓ ✓ ✓ ✓

5 Svay Rieng _PH 15-Feb-16 ✓ ✓ ✓ ✓

4 Maung Russei_RH 12-Jan-16 ✓ 3 Thma Puok_RH 26-Dec-15 ✓ 2 Cambodia-Japan Friendship_PH 23-Dec-15 ✓ 1 Battambang_PH 03-Jun-15 ✓

18

through each level of the system. This also facilitated the sharing of viruses between computers. It also meant that after the end of the month it could take several weeks at best for managers of the health system to have a complete data set to understand what was happening. Reporting into this system (% of facilities that reported within 30 days of the end of the month) always hovered around 80% however this dropped dramatically in 2009 after an update to the MS Access resulted in the loss of many of the Khmer language data entry screens and most critically, renumbered the facilities leaving many users unable to enter their data. Reporting dropped down to 35%. In 2010, with support of the USAID Better Health Systems Project, the MOH upgraded the HMIS to a web-based system. The initial programming of the new web-based HMIS took about 6 months and was followed by an extensive training of the relevant staff within the MOH who manage HMIS data. Reporting into the new HMIS surged immediately, soon reaching 100% reporting within 10 days after the end of each month. Data which had not been entered into the old MS Access because of the bad update was back filled into the new web-based version. This upgrade to the system dramatically improved the availability and quality of data available for analysis. This was the Cambodian health system’s first experience with a cloud based computing solution and it was an immediate success. There were however challenges. Initially the system was hosted by a local Internet Service Provider and the software developers of the system found it very difficult to put in place the necessary security measures to keep the system safe from hackers. At no point was any data lost, there were always a multitude of backups that allowed the system to continue service very quickly after each breach, bit it highlighted a key problem. After extensive analysis of these security problems and an exploration of the options, it was quickly realized that hosting the HMIS at an internationally based cloud computing service provided a tremendous number of advances that included:

• Greatly enhanced security for much less effort. Cloud based computing services tend to be extremely large companies that have extensive server installations that have the latest advanced security hardware and software giving the individual clients huge advantages.

• Improved data base performance. Given the wide variety of server specification options provided by cloud based computing services, a client choose and adjust the server services that they rent to optimize the performance of their data system.

• Faster connectivity. When the HMIS was first moved from a locally hosted server to Amazon Singapore one of the first things that was immediately clear is that connecting to the database became much faster. This was due to the very large internet connection available from the Amazon Singapore cloud which meant that they limiting factor on the speed of the internet connection was the end user’s connection speed and not the HMIS server connection speed.

• Flexibility as the system grows and needs more resources (storage, memory, CPU, etc.). When you choose to purchase your own hardware you have to make a choice about the basic specifications that you are likely to need during the estimated lifespan of the equipment that you buy. The possibility of upgrading you hardware to improve performance is limited and will incur additional hardware costs. With a cloud based computing solution there is always the option to upgrade almost any aspect of the rented server space at any time with the click of a few buttons which result in incremental increases to the monthly rental costs.

In addition to the three significant advantages listed above, by far the greatest is the reduced cost of hosting a web-based system with a cloud based computing provider when compared with the option of purchasing the necessary hardware and setting it up with the necessary space, internet connection, electricity, and a technician to keep the hardware all functioning correctly. The best example of this comparison can be seen in the largest MOH health information system currently in use in Cambodia known as the Patient Management and Registration System or PMRS. This web-based system is used in nearly all hospitals in the country to record and maintain patient level data that includes basic demographics as and summary details of each hospital visit. Additionally, the PMRS is used to manage the Health Equity Fund (HEF) system which includes the poverty targeting data generated by the Ministry of Planning IDPoor Program, the online financial invoice submission by facilities for HEF reimbursements, and the independent monitoring tools used by the HEF Implementer. The following table provides detailed estimated costs comparing the options of hosting the MOH PMRS either in the cloud, as is currently done at Amazon Singapore, or through the establishment and maintenance of a local hosted server. These costs cover a three-year time period which is equivalent to the expected life

19

expectancy for a purchased server and are for systems with equivalent performance to the extent possible given these two options. The costs below do not include the necessary hardware or internet connections needed by end users of the system as these would be equal for both options.

Item Locally Managed and

Hosted Server Cloud Based Server

Physical Server (Web Server) $18,315.59 $27,880.56

Physical Server (MySQL) $15,205.80 $13,940.28

Firewall Security Protection (ASA5555-IPS-K9) $25,647.00 $0.00

Internet Bandwidth (20Mbps UP and DOWN) $48,600.00 $0.00

Server UPS Hardware (8H OPERATION) $22,575.98 $0.00

Air Conditioner $1,000.00 $0.00

Router (C2951-WAAS-SEC/K9) $8,328.00 $0.00

External HD Backup (8TB) $419.00 $1,656.00

Electricity Charges $29,709.50 $0.00

System Maintenance Technician Labor $21,600.00 $0.00

Total $191,400.87 $43,476.84

Hosting of the MOH PMRS in the cloud is 23% the estimated cost of buying and hosting a dedicated set of hardware to achieve the same level of performance. Or to put it another way, buying and hosting your own server is more than 4 times as expensive of hosting the system with a cloud based computing service such as Amazon Singapore. When you add the other advantages of hosting in the cloud that include enhanced security, improved database performance, and flexibility as the system grows, the choice of buying your own hardware and self-hosting it is difficult to justify.

1.7 Monitoring and Evaluation

The USAID SHP Project is maintaining a database that is dedicated to recording all data and analysis related to the USAID SHP Project indicators. This system known as the second Project Data System, or PDS2, was initially developed under the USAID BHS Project and has been updated for use by the Project. The PDS2 also keeps track of all training completed by the USAID SHP Project in addition to and with greater detail than the official USAID TraiNet system. The following table provides a summary of the total training provided by the USAID SHP Project during the reporting period as was entered in the USAID TraiNET system.

1.7.1 USAID Social Health Protection Indicators

Res

ult

Lev

el o

f In

dic

ato

r

Indicator Name

Bas

elin

e

Year1 Year2 Year3 Year4

Target Actual Target Actual Target Actual Target Semi-

Annual

Objective 1: Increase capacity and accountability of government staff and institutions.

Com

pone

nt 1

.1

Out

put Percentage of HEFO/Health Facility invoices

certified for payment within 30 days of submission.

100% 100% 99.44% 100% 99.68% 80% 98.63% 90% 98.68%

Out

com

e

Ratio of HEF technical and administrative staff supervised by the Project to the total number

of public health facilities covered by the HEF.

1:12 1:16 1:14 1:16 1:20 1:50 1:21 1:75 1:21

Out

com

e Ratio of HEF technical and administrative staff

at the MOH/HSSP2 - H-EQIP and MOH/DPHI-

DBF (or responsible institution) to the total number of public health facilities covered by

the HEF.

1:112 1:112 1:73 1:120 1:141 1:25 1:145 1:21 1:96

Out

put Number of social health protection related

national policies or guidelines endorsed by the

RGC that have had contributions and/or support by the Project.

0 1 1 1 0 1 1 1 2

Com

pone

nt 1

.2

Out

com

e

Percentage of HEF direct benefit costs reported in HEFO/ Health Facility invoices that

are certified as valid.

99.9% >97% 99.81% >97% 99.92% >97% 99.94% >97% 100%

Out

co

me Percentage of HEF beneficiaries

interviewed through systematic Male 6% <5% 4.20% <5% 5.81% <5% 4.11% <5% n/a

20

Res

ult

Lev

el o

f In

dic

ato

r

Indicator Name

Bas

elin

e

Year1 Year2 Year3 Year4

Target Actual Target Actual Target Actual Target Semi-

Annual

monitoring at the household level

that report fraudulent practices at hospitals within the HEF system.

Female 5.23% <5% 4% <5% 7.55% <5% 6.05% <5% n/a

Out

com

e

Percentage of HEF beneficiaries

interviewed through systematic monitoring at the household level

that report fraudulent practices at health centers within the HEF

system.

Male 0% <5% 0.56% <5% 1.01% <5% 0.51% <5% n/a

Female 1.20% <5% 1.46% <5% 5.77% <5% 7.18% <5% n/a

Out

put

Percentage of HEF monitoring costs directly

supported by the USAID SHP Project. 100% 100% 100% 100% 100% <100% 100% 0% 100%

Out

put Number of public health facilities covered by a

social health protection mechanism using the

MOH PMRS for full patient registration.

3 7 11 17 27 42 58 66 84

Com

pone

nt 1

.3

Out

put

Percentage of CBO HEFO Board of Director members who come from civil society.

14% 15% 19% 15% 19% 15% 19% 15% n/a

Out

com

e

Percentage of USAID target ODs with

Community Managed HEF arrangements. 0% 5% 8% 34% 32% 66% 42% 100% 42%

Out

com

e Utilization rate of HEF supported

services by the identified poor of HCs and RHs (IPD and OPD) in

USAID target ODs with Community Managed HEF arrangements.

HC 0.65 0.65 0.87 0.85 0.87 0.9 0.86 0.95 0.84

RH-OPD 0.073 0.073 0.14 0.08 0.1 0.09 0.097 0.1 0.041

RH-IPD 0.041 <0.10 0.045 <0.10 0.05 <0.10 0.05 <0.10 0.037

Out

put Number of LNGOs, CBOs, FBOs

and other civic groups trained or oriented to SHP schemes by the

Project.

LNGOs 0 0 4 5 15 5 19 5 3

CBOs 0 0 1 4 3 0 0 0 0

FBOs 0 84 225 429 843 420 715 585 520

Objective 2: Reduce financial barriers

Com

pone

nt 2

.1

Out

put Number of ODs covered by a BCC campaign

to increase participation in the ID Poor

process and knowledge of HEF benefits. 0 0 0 38 0 81 0 81 0

Out

put

Number of ODs in USAID target areas where a Community Based HEF has been

established and provided with orientation to participate in and provide oversight to the ID

Poor process.

0 2 0 13 5 25 6 38 7

Com

pone

nt 2

.2

Out

com

e Utilization rate of HEF

supported services by the identified poor of HCs, RHs

(IPD&OPD).

HC 0.66 0.66 0.7 0.75 0.76 0.8 0.68 0.85 0.58

RH-OPD 0.07 0.07 0.071 0.075 0.112 0.08 0.11 0.09 0.047

RH-IPD 0.049 <0.10 0.048 <0.10 0.063 <0.10 0.063 <0.10 0.041

Out

put Number of people covered by

HEF through technical

assistance from USG.

Male 1,591,384 1,551,599 1,524,359 1,512,809 1,39,4950 1,474,989 1,418,437 1E+06 1302654

Female 1,625,510 1,584,872 1,632,262 1,545,250 1,534,434 1,506,619 1,559,269 1,468,954 1,451,781

Out

com

e

Percentage of expected deliveries by HEF

beneficiaries that are supported by the HEF 47.1% 50% 46% 55% 63% 60% 60.69% 65% 45%

Out

put Percentage of ODs, RHs, HCs

and HPs with HEF contracts to provide services to the

identified poor.

OD 63% 75% 75% 85% 100% 95% 100% 100% 100%

RH 53% 64% 64% 75% 76% 85% 92% 95% 91%

HC 46% 50% 50% 65% 97% 75% 98% 85% 97%

HP 15% 54% 54% 65% 81% 75% 85% 85% n/a

Com

pone

nt 2

.3

Out

put Number of policies, guidelines, or contracts

that improve social health protection and

access to services for the non-poor

0 1 0 1 1 1 1 1 0

Objective 3: Increase demand for quality services.

Com

pon

ent 3

.1

Out

put Percentage of HEF covered facilities

assessed by MOH Level 2 Quality Assessment tool in last 12 months.

15.9% 25% 36% 50% 93% 100% 0% 100% 0%

21

Res

ult

Lev

el o

f In

dic

ato

r

Indicator Name

Bas

elin

e

Year1 Year2 Year3 Year4

Target Actual Target Actual Target Actual Target Semi-

Annual

Out

com

e

Percentage of HEF facilities self-funding assessments by the MOH Level 2 Quality

Assessment tool in last 12 months.

0% 0% 0% 50% 0% 100% 0% 100% 0%

Out

com

e

The average summary assessment score

achieved by HEF covered facilities from the MOH Level 2 Quality Assessment tool.

30% 35% n/a 40% 35.67% 45% n/a 50% n/a

Out

put

Number of policies , guidelines and/or contracts that improve the quality of services

for SHP through linkages to Level 2 quality assessments, access to voluntary family

planning methods, access to services for PLHIV and MARPs, and access to non-free

HIV, STI, and TB services.

0 1 0 1 1 1 0 1 0

Objective 4: Increase access to targeted Health services (PLHIV and MARPs)

Com

pone

nt 4

.1

Out

put Number of PLHIV and MARPs

individuals covered by a Targeted Benefit Contract (TBC) arrangement

that increases access to services.

Male 0 0 0 tbd 207 tbd 185 tbd 84

Female 0 0 0 tbd 78 tbd 30 tbd 12

Com

pone

nt 4

.2

Out

put

Number of individuals covered by a Targeted Benefit Contract (TBC)

arrangement that provides access to non-free HIV, STI, and/or TB

services.

Male 0 0 0 tbd 0 tbd 0 tbd 0

Female 0 0 0 tbd 0 tbd 0 tbd 0

1.7.2 Comments on Project Indicators

Objective 1, Component 1.1: Percentage of HEFO invoices certified for payment within 30 days of submission. The USAID SHP Project has continued to receive and certify HEFO invoices received from HEFOs during the reporting period until June 30th, 2016. Starting on July 1st, HEFOs are no longer be a part of the HEF system and invoices are now being generated directly by individual health facilities and submitted electronically through the MOH/PMRS. The timeframe for submission as has been changed, health facilities now have 5 working days to submit their invoices after which the HEF Implementer has 5 working days to certify and submit to the MOH for payment. Therefore, this indicator is in need of revision. During the reporting period 98.68% of invoices were certified for payment within 30 days of submission. Objective 1, Component 1.1: Ratio of HEF technical and administrative staff supervised by the Project to the total number of public health facilities covered by the HEF. & Ratio of HEF technical and administrative staff at the MOH/HSSP2 and MOH/DPHI (or responsible institution) to the total number of public health facilities covered by the HEF. This indicator was originally conceived the track the progress of capacity development and handover of responsibilities from the HEF technical staff in the USAID SHP Project to the MOH/DPHI (or responsible institution). Given the delays experienced in PY1 and PY2 in the formation of the National Social Health Protection Fund (NSHPF) and the subsequent decision by the RGC and H-EQIP development partners to establish the Payment Certification Agency by June 2018, the USAID SHP Project has not been able to meet our indicator targets as originally planned. Objective 1, Component 1.2: Percentage of HEF direct benefit costs reported in HEFO/Health Facility invoices that are certified as valid.

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Similar to the first indicator discussed in this section, as currently written this indicator is n need of revision as currently written after June 30th. Objective 1, Component 1.2: Percentage of HEF beneficiaries interviewed through systematic monitoring at the household level that report fraudulent practices at hospitals within the HEF system. & Percentage of HEF beneficiaries interviewed through systematic monitoring at the household level that report fraudulent practices at health centers within the HEF system. During the reporting period the project is unable to report on these two indicators given that the standard monitoring process has been modified to respond to the needs of the system during the transition from MOH/HSSP2 to H-EQIP. It is expected that the standard process of interviewing households will resume in May 2017. Objective 1, Component 1.2: Percentage of HEF monitoring costs directly supported by the USAID SHP Project. In PY3 the USAID SHP Project had the goal of reducing the percentage of HEF monitoring funding from USAID below 100% which was not possible given the delays in the establishment of the NSHPF, as originally envisioned, and the subsequent PCA. Objective 1, Component 1.3: Percentage of CBO HEFO Board of Director members who come from civil society. With the end of the MOH/HSSP2 Program and the phase out of the HEFO role under the new H-EQIP which started on July 1st, this indicator will not be relevant to future reporting by the USAID SHP Project as it is currently written. Objective 1, Component 1.3: Percentage of USAID target ODs with Community Managed HEF arrangements. The USAID SHP Project was not able to achieve the target of 34% of USAID target ODs in PY2 or 66% in the reporting period for two principle reasons. The first is that the number of ODs within the 9 USAID target provinces (originally 8) has been growing as the MOH continues to split existing ODs into smaller pieces and align them with the Administrative District boundaries. This effectively increases the denominator reducing the percentage achievement by the USAID SHP Project. The second reason is that in July 2016 the project received instruction from USAID/OPHE that we should stop expansion of the CMHEF and focus on the quality of their work and benefits that they provide to the poor and vulnerable. This instruction was confirmed with the USAID modification to the project in February 2017 which included a modified Program Description to this effect. We very much supported this instruction given the difficulties of community organization and the realization that achieving full coverage of CMHEF in all USAID target ODs may have been overly ambitious. Objective 1, Component 1.3: Utilization rate of HEF supported services by the identified poor of HCs and RHs (IPD and OPD) in USAID target ODs with Community Managed HEF arrangements. The USAID SHP Project did not meet the goal of achieving a 0.95 visits/person/year utilization rate of health center services by the identified poor in ODs with CMHEF arrangements. However, as shown above the utilization rate of health center services in CMHEF areas is higher than the average for all HEF areas which does indicate that the CMHEF arrangement is resulting in higher utilization rates. The overall context of HEF utilization rates has been driven by the suspension of non-medical benefits (transportation reimbursements, caretaker food support, and funeral grants) at the start of H-EQIP on July 1st, 2016. During the reporting period non-medical benefits were resumed in March and there is an expectation that utilization rates will start to once again rise. Objective 2, Component 2.1: Number of ODs covered by a BCC campaign to increase participation in the ID Poor process and knowledge of HEF benefits.

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Since the start of the project in January 2014 we have been eager to develop and deploy a BCC campaign to increase participation in the IDPoor process and increase knowledge of HEF benefits. However, the project has been unable to get the approval for the drafted materials or permission from the MOH to start this activity. We believe that the underlying reason for this lack of approval stems from the financial insecurity of the HEF system and the fear that an effective BCC campaign by the USAID SHP Project could result in increases in HEF utilization further compounding the shortage of funding available at the end of MOH/HSSP2 and startup of MOH/H-EQIP. Objective 2, Component 2.1: Number of ODs in USAID target areas where a Community Based HEF has been established and provided with orientation to participate in and provide oversight to the ID Poor process. All CMHEFS that exist in USAID target ODs that overlap with the provinces covered by the IDPoor process in Round 10 were provided with orientation about how they can participate in an provide oversight of the IDPoor process. However, the USAID SHP Project has been unable to achieve the target of 25 ODs for this indicator in PY4 given the slower than expected expansion of the CMHEF arrangements in provinces covered under Round 10 of the IDPoor identification process during the reporting period. Objective 3, Component 3.1: Percentage of HEF covered facilities assessed by MOH Level 2 Quality Assessment tool in last 12 months. & Percentage of HEF facilities self-funding assessments by the MOH Level 2 Quality Assessment tool in last 12 months. & The average summary assessment score achieved by HEF covered facilities from the MOH Level 2 Quality Assessment tool. During the reporting period there were no Level 2 Quality Assessments by the MOH to report which has led to the USAID SHP Project not achieving its indicator of 100% of HEF covered facilities as anticipated. The MOH under the H-EQIP has determined that in the future Level 2 assessments will only be done every two years. Therefore, this indicator should be either omitted from the M&E Plan or rewritten accordingly.