7.1.5. LHSS Annual Report 2022.pdf

LOCAL HEALTH SYSTEM SUSTAINABILITY PROJECT

The Local Health System Sustainability Project (LHSS) under the USAID Integrated Health Systems IDIQ helps low- and middle-income countries transition to sustainable, self-financed health systems to support access to universal health coverage. The project works with partner countries and local stakeholders to reduce financial barriers to care and treatment, ensure equitable access to essential health services for all people, and improve the quality of health services. Led by Abt Associates, the five-year, $209 million project will build local capacity to sustain strong health system performance, supporting countries on their journey to self-reliance and prosperity.

Submitted to: Sarah Illingworth, Activity Manager, USAID Office of Health and Nutrition, USAID/Afghanistan and Scott Stewart, COR, USAID Office of Health Systems, USAID Bureau for Global Health

USAID Contract No: 7200AA18D00023 / 7200AA19F00014

Recommended Citation: The Local Health System Sustainability Project (LHSS) under the USAID Integrated Health Systems IDIQ. October 2023. Afghanistan FY 2023 Activity Year 1 Annual Progress Report, October 1, 2022 - September 31, 2023. Rockville, MD: Abt Associates.

This report was made possible by the support of the American people through the United States Agency for International Development (USAID). The contents are the sole responsibility of the authors and do not necessarily reflect the views of USAID or the United States government.

ANNUAL ACTIVITY PROGRESS REPORT

LHSS AFGHANISTAN

Activity Lead: Soumitra Ghosh, Chief of Party Period of Performance: FY23 Annual Review

HIGHLIGHTS YEAR FOUR

● LHSS strengthened the capacity of the Afghan Social Marketing Organization (ASMO) to strategically expand to new markets and enhance the organization's financial sustainability, with the goal of delivering sustained health impact at scale. With LHSS support, ASMO strengthened sales, expanded distribution to 100 new district areas and urban slums, grew their new network of midwifery clinics and hospitals in and around low-income areas to serve women more effectively, and finalized a blueprint for launching a sustainable community-based distribution model in FY24.

● In April 2023, LHSS awarded grants to six private health service providers and provided complementary technical assistance to strengthen their organizational and network capacity for more efficient and sustainable operating models. During a short period of six months, LHSS supported the grantees in training more than 1,300 local management and technical staff (e.g., private community midwives, health workers and family planning counsellors), focusing mainly on sexual and reproductive health (SRH), community based prevention and treatment of illnesses for CHWs, antenatal and prenatal checkups, basic and comprehensive emergency obstetric and newborn care (BEmONC/CEmNOC), the emergency triage assessment and treatment (ETAT), infection prevention, neonatal intensive care unit (NICU) care, anesthesia, ultrasound, echocardiography, breast and cervical cancer screening, cardiac catheterization, hematology and polymerase chain reaction (PCR). The project also capacitated and activated more than 3,100 US Government-supported private sector service delivery sites providing family planning services. The introduction of a sustainable integrated financing scheme helped grantees increase access to and use of priority health services among women and low-income populations in the catchment areas. These initiatives resulted in an increase of between 10 to15 percent in patient uptake and increased revenue for the grantees, including an estimated cost recovery increase of 5 percent.

ANNUAL ACTIVITY PROGRESS

Objective 1: Provide Financial and Technical Support to the Afghan Social Marketing Organization Aimed at Expanding its Role and Improving its Organizational Capabilities to Deliver Sustained Impact.

In Year 4, LHSS provided strategic technical assistance to ASMO to strengthen its capacity to expand into new markets, implement new models to reach women and low-income populations, and increase financial sustainability. For example, with LHSS support, ASMO increased its earned revenue by growing its private provider network to include 144 solo practicing midwives, 31 hospitals, and 126 nearby pharmacies across low-income communities in Herat, Nangarhar, and Kabul. The midwifery sales channel doubled its revenue contribution within a year to reach two percent of ASMO’s total sales revenue, at a cost recovery rate of 22 percent. To expand product access for underserved communities with a focus on reaching women, LHSS also supported ASMO in assessing the feasibility and design of a sustainable community-based distribution model. Contingent on funding availability, ASMO and LHSS will pilot the new model in FY 2024. Finally, LHSS supported ASMO in conducting an annual capacity assessment and addressing institutional capacity gaps including strengthening practices for evidence-based sales and marketing, commodity procurement efficiency, gender equality and social inclusion, and strategic thinking among the senior management team.

Objective 2: Increase Product Coverage and Support Establishment of Franchising and Provider Networking Models to Improve Service Provision by Partnering with Additional Social Marketing/Franchising Organizations.

In April 2023, LHSS onboarded seven new grantees including six private sector service delivery providers and one regional social franchise organization (Greenstar) whose scope is to strengthen the capacity of the other grantees and aggregate them into a low-touch private provider networking and franchising model for more efficient and sustainable operations. As part of this work, LHSS collaborated with the grantees to design and implement integrated financing strategies to align organizational business goals with clinical capacity improvements. LHSS’s support to improve grantees’ strategic planning capacity contributed to increased patient mobilization (about 243,000) and provision of services to approximately 88,000 indigent patients, 78 percent of whom were women. Grantees also served approximately 35,000 children under five with nutrition-specific interventions, that include growth monitoring, screening for wasting and stunting, management of MAM (OPD) and SAM (IPD) following the MOPH guideline, and delivered approximately 15,000 couple years of protection through long-acting contraceptive methods (2/3rd IUD and 1/3rd Implant).

LHSS and Greenstar co-designed a low-touch private provider networking and franchising model for launch in FY24. The process involved a) co-reviewing of global evidence, including existing local networks, Greenstar’s own experience and learning from Pakistan, other global networking models and co-identified factors that influence the viability of each networking option, b) undertaking key informant interviews with LHSS Afghanistan grantees to identify expectations and motivations and c) co-designing of the strategy and implementation plan. The assessment prioritized overall and grantee-wise need-gaps in infrastructural, staff, clinical capacity, skills and resources for effective community outreach, mobilization and incentivization, to increase private sector uptake and revenue for impact and sustainability. The model will aggregate the existing grantees to standardize quality of care, patient referrals, community sensitization, and patient mobilization practices to increase access to quality health services at affordable prices. Moreover, this plan is expected to improve operational efficiency, patient uptake, provider revenue, and mobilize additional resources for increased sustainability. For more details, please refer to the technical deliverable titled LHSS Afghanistan - Private Provider Networking submitted in Q4/FY23.

OPPORTUNITIES PURSUED TO CREATE GREATER GENDER

EQUALITY AND SOCIAL INCLUSION

The Activity worked closely with the grantees to obtain approvals to reinstate female staff following the December 2022 Taliban directive restricting women in the workforce. Grantees maintained a balanced representation of male and female staff among their new recruits. In addition, LHSS successfully recruited a female staff member to the role of Monitoring, Evaluation, and Learning (MEL) Associate. Her inclusion added significant value in supporting and monitoring health clinics and counselling sessions that primarily target female clients in Afghanistan. LHSS supported ASMO in strengthening its gender committee, better integrating gender and social inclusion into promotional materials, and holding refresher training sessions for staff on its revised Code of Conduct and Sexual Harassment policy. With LHSS assistance, the grantees served approximately 88,000 low-income clients (78 percent women) with free or discounted services using integrated financing schemes.

WASTE, CLIMATE RISK MANAGEMENT

LHSS Afghanistan is committed to conducting environmentally responsible operations. The Activity ensured compliance with conditions set out in the IEE, with mitigation measures contained in the CRMP and WMP/SOP sections of the approved LHSS FY23 Annual Workplan, and with host country laws and regulations.

PROGRESS ON PERFORMANCE INDICATORS

Please reference Afghan Info and the Power BI dashboard for further data analysis and disaggregation.

Indicators

FY 2023

Goal Achieved

Achieved

Purpose: Expanded scale, quality, and availability and affordability of the private health provisions, and strengthened readiness of market aggregators for potential strategic purchasing to deliver sustained health impact

Couple Years of Protection in U.S. government-supported programs 267,781 148,149 55%

Person years of protection through iron folic acid, chlorhexidine and micronutrients 65,947 42,355 64%

Number of cases of child diarrhea treated in USG-assisted programs 204,494 183,983 90%

Number of persons protected from water-borne diseases 38,747 20,433 53%

Percent of USG-assisted organizations with improved performance (CBLD-9) 1 out of 7 (15%)

1 out of 7 (15%) 100%

Objective 1: Expanded ASMO role and improved organizational capabilities to deliver sustained health impact

Percent of USG-assisted service delivery sites providing FP counseling and/or services 100% 100% 100%

Number of new markets covered to increase product availability among poor population 90 100 111%

Number of new channels opened to increase product availability among women, poor 1 1 100%

Number of people reached with social, and behavior change messaging 3,000,000 5,593,476 186%

Average cost recovery ratio 55% 46% 84%

Objective 2: Increased product coverage and strengthened provider networking models to improve service provision

Number of private facilities providing priority health services with USG support 626 613 98%

Number of individuals provided with priority health services through a health facility receiving USG support 294,396 243,524 83%

Percent of USG-assisted service delivery sites providing FP counseling and/or services 100% 100% 100%

Number of people reached with social behavior change (SBC) messaging 954,950 870,469 91%

Number of private providers trained in priority technical areas with LHSS support 781 1,524 195%

Number of <5 children reached with nutrition-specific interventions with USG support 8,476 13,196 156%

Percent of USG assisted facilities offering one or more integrated financing schemes 97% 98% 101%

Number of clients that utilized any integrated demand side financing schemes at a health facility receiving USG support 116,110 87,436 75%

Average cost recovery ratio 29% To report

Q1/FY24 NA

Percentage of LHSS grantees successfully capturing and reporting data into Health Management Information System 67% 67% 100%

EMERGING LESSONS

The senior management and leadership teams of the grantees are skilled and experienced in operations management and in identifying and addressing operational capacity gaps. However, they lack strategic thinking skills, which affects sustainable business planning. The LHSS Afghanistan team can help strengthen strategic thinking capacity within the grantees to ensure successful and sustainable integration and scale up of LHSS-supported initiatives within the existing business of the grantees. LHSS is working closely with senior management and board members of the grantees through mentoring and coaching models to pinpoint strategic thinking and planning gaps and providing targeted capacity strengthening assistance in response to their specific needs.

In addition, LHSS Afghanistan originally intended to use demand-side financing models to increase equitable and sustainable health impact. However, after conducting a desk review of global models and learning more about grantees’ business and client needs, LHSS identified that an integrated financing strategy that combines supply-side financing, e.g., expansion to new geographies, improving facility functionality and quality of care, and improving procurement efficiencies, with demand-side financing mechanisms, e.g., including reaching indigent clients and using vouchers, would be more suitable. This approach would focus on increasing the financial viability of private providers while improving demand for and access to priority health services among the poorest individuals and families.

CHALLENGES

Long commodity importation lead time impacts social marketing sales. LHSS continues working closely with the Global Health Supply Chain Program – Procurement and Supply Chain Management and ASMO teams to reduce the adverse impact of these delays (e.g., through adjustments in re-ordering schedules, quantities, and buffer stocks). In addition, Provincial Health Departments and urban district authorities have increasingly required approval of LHSS-supported project activities of both objectives 1 and 2 before implementation, considerably slowing activity progress. Periodic coordination meetings and orientation on LHSS operations and health impact help accelerate the process. Finally, the restrictions imposed by the Taliban on woman-focused community sensitization and mobilization activities and distribution channels, health promotions in general and specifically endorsement by woman in media campaigns disrupted SBC initiatives of ASMO and objective 2 grantees. LHSS worked with grantees to identify alternative media strategies, moving away from television campaigns, and focusing on radio, outdoor advertising, and social media platforms.

DELIVERABLES SUBMITTED TO USAID DURING THIS QUARTER

All Year 4 deliverables were submitted to USAID before September 29, 2023.

ENGAGING LOCAL AUDIENCES

LHSS Afghanistan has effectively engaged and connected with local audiences, stakeholders, and networks through their work with local grantees by utilizing platforms such as workshops, TV, radio, and billboard campaigns, and conducting community outreach sessions. These techniques provided unique opportunities for LHSS Afghanistan grantees to raise awareness and understanding among their beneficiaries. Knowledge Management (KM) products developed in Year 4 include a success story and country fact sheet published on the LHSS website and acceptance of an oral case study presentation and a poster to the World Social Marketing Conference to be held in Cali, Colombia in November 2023.

https://lhssproject.medium.com/restoring-reproductive-health-choices-in-afghanistan-9d9b95a3dc80 https://www.lhssproject.org/sites/default/files/resource/2023-09/LHSS%20Afghanistan%20Factsheet_508C.pdf