7.1.6. LHSS Annual Report 2023.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: Dr. Ghulam Shams Bigana, Activity Manager, USAID Office of Social Services, USAID/Afghanistan and Jodi Charles, 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 2024. Afghanistan FY 2024 Activity Year 2 Annual Progress Report, October 1, 2023 - September 30, 2024. 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: FY24 Annual Review

HIGHLIGHTS YEAR FIVE

● LHSS strengthened the capacity of the Afghan Social Marketing Organization (ASMO) to strategically expand coverage of new and underserved markets and introduce the low-touch network of private service providers. These activities aimed to meet the dual goals of increasing access to health products and services, while enhancing the organization's financial sustainability. With LHSS support, ASMO significantly improved access to essential health commodities for women and children through sales growth, expanded retail distribution of its products, and consolidation of a network of midwifery clinics and hospitals to equitably serve low-income populations and women.

● The Activity assisted ASMO in expanding its role from product social marketing to include priority health services by assuming the role of the social franchisor with technical oversight of Greenstar Pakistan. In this new role, ASMO serves as the manager of standalone provider networks owned by six LHSS grantees. Additionally, ASMO is managing its own network of private midwifery clinics, hospitals, community-based delivery agents and pharmacies across five large urban provinces in Afghanistan.

● LHSS supported six grantees in expanding coverage and patient mobilization by increasing grantee staffing, especially women health workers, and stepping up training to local private health providers in priority health areas during Year 5. The grantees also facilitated the expansion of community outreach and mobilization initiatives through integrated financing to optimize available subsidies and other schemes for more cost-effective programming. Finally, LHSS assisted the grantees in adopting the patient equity assessment tool for effectively targeting indigent patients. This effort contributed significantly to increased access to priority health services among women and low-income populations.

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.

LHSS mentored ASMO in conducting its sixth annual organizational development assessment covering technical, institutional, and financial capacities. Findings from this assessment informed targeted efforts to strengthen and expand ASMO’s operations in consultation with its senior management team. The Activity also completed Global Knowledge Strategy (GKS) activities in Afghanistan documenting with ASMO and other key stakeholders' performance improvements achieved in family planning and maternal and child health services between 2022-2024.

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. The assessment results highlighted a marginal drop in overall organizational capacity score of 95 percent as compared to 91 percent in previous round due to human resources gaps in social marketing, institutional sales, research, monitoring and evaluation, internal audit, and organizational communication and business development functions, linked to overseas migration of professional Afghans, lack of training and professional development. The assessment also underscored the importance of strengthening gender institutionalization by reinforcing the gender committee's effectiveness, ensuring better gender balance in the senior management level, and revising ASMO's human resources policy in line with gender equity social inclusion (GESI) considerations to strengthen institutional capacity. The Activity in consultation with ASMO finalized a plan to train two ASMO staff on the assessment methodology and the tool to institutionalize the process within ASMO, starting with the seventh round of the assessment that will be conducted in May-June FY25.

The Activity also conducted Global Knowledge Strategy activities in Afghanistan documenting with ASMO and other key stakeholders' performance improvements achieved by ASMO in technical, management, and financial functions of ASMO to sustain delivery of family planning (FP) and maternal and child health (MCH) products across five urban hubs in Afghanistan between 2022-2024. An online assessment among the participants from two virtual workshops helped quantify and identify the relative importance of the enabling and inhibiting determinants, and finalize the vision statement, conditions, actions and actors to sustain ASMO’s performance improvement over the next three years.

Additionally, LHSS co-developed ASMO’s two-year organizational strategy and sustainability plan covering January 2025-December 2026 using desk review, key informant interviews of internal and external stakeholders, and validation workshops with ASMO management team.

The Activity assisted ASMO in expanding its role from product social marketing to include priority health services by assuming the role of the social franchisor with technical oversight of Greenstar Pakistan. In the new role, ASMO serves as the manager standalone provider networks owned by six LHSS grantees. In addition, ASMO is managing its own network of private midwifery clinics, hospitals, community-based distribution agents and pharmacies across five large urban provinces of Afghanistan.

LHSS, through ongoing technical assistance and mentoring, enabled ASMO to:

● Increase access to and availability of its products in low-income areas of the peri-urban districts and slums by covering 112 new markets (9 percent increase over FY23), 126 new and 1,614 reactivated retail outlets, and sustain its network of over 300 committed and motivated health providers (144 midwives, 32 hospitals and 126 pharmacies); who referred 2,106 patients (3 times higher than FY23) to higher level health facilities in the relevant localities; and with ASMO’s ensuring affordable pricing using trade discounts and in-clinic patient sensitization of superior quality of its products, more than doubled its revenue contribution to reach five percent of ASMO’s total sales revenue in FY 2024 compared to 2 percent in FY23.

● Offer FP information and counseling through over 2,000 social marketing outlets (10 percent clinics and hospitals and 90 percent retail pharmacies and stores) and reach 4,539,291 people (19 percent decrease over FY23 due to reduced use of mass media) through social media including 9 percent female, and 43,599 people through interpersonal communication (35 percent increase over FY23), 95 percent female, ensuring all social behavior change

(SBC) messages align with gender equity and social inclusion (GESI) principles established by ASMO.

By expanding access to products and information through appropriate social marketing channels ensuring affordability of products, ASMO increased significantly higher health outcomes compared to FY23. ASMO delivered 136,971 Couple Years Protection or CYPs (9 percent increase over FY23) through the sale of contraceptives, and 96,945 Person Years of Protection or PYPs (136 percent increase over FY23) through the sale of MCH products.

Additionally, ASMO protected 33,047 people (62 percent increase over FY23) from waterborne diseases through sales of approximately 81 million water disinfectants (65 percent increase over FY23) and treated 315,629 childhood diarrheal episodes (78 percent increase over FY23) through the sale of Oral Rehydration Salts (ORS) and zinc. ASMO also generated over 700,000 USD in program income from sales of its products during FY24 (27 percent increase over FY23), resulting in 54 percent cost recovery ratio (8 percent increase over FY23).

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.

Following successful onboarding and co-designing technical capacity and business model strengthening interventions in FY 2023, LHSS supported six grantees in expanding coverage and patient mobilization through increased staffing, especially women health workers, and providing training/retraining to local private health providers in priority health areas during FY2024. With LHSS support, grantees strengthened and expanded coverage, access, quality, affordability, and efficiency of priority healthcare services in the catchment areas. This was achieved through a variety of community outreach initiatives using both static and mobile health delivery channels. To assist grantees in targeting indigent patients more effectively in Year 5, LHSS provided technical assistance (TA) to help grantees implement integrated financing schemes using the patient equity assessment tool. This initiative boosted the capacity of grantees to increase access to and use of priority health services among women and low-income populations in the catchment areas. These initiatives resulted in: -

● Training 2,518 local private health providers (65 percent increase over FY23) during FY24 focusing on sexual and reproductive health, community-based prevention and treatment of illnesses for community health workers (CHWs), antenatal and prenatal checkups, basic and comprehensive emergency obstetric and newborn care, the emergency triage assessment and treatment, infection prevention, neonatal intensive care unit care, anesthesia, ultrasound, echocardiography, breast and cervical cancer screening, cardiac catheterization, hematology and polymerase chain reaction testing.

● Reaching 1,095,250 people (37 percent increase over FY23), about 48 percent female, through mass media and 413,558 people (6 times increase over FY23) through interpersonal communication, about 59 percent female, with GESI-compliant SBC messages on topics of family planning, MCH, nutrition, and noncommunicable diseases.

Increased staffing, community outreach, patient mobilization, and improved strategic planning with LHSS support helped the grantees contribute to increased equitable patient mobilization as follows: -

● Providing 695,724 people in FY24 with priority health services through 115 USG-supported health service providers and facilities (over 200 percent increase over FY23). Over 60 percent of the patients were women, and in health areas: 30 percent FP, 25 percent maternal health, 24 percent noncommunicable diseases (NCDs), 12 percent child health, newborn and pediatric care and 9 percent tuberculosis, malnutrition, and others.

● Delivering 211,168 clients (17 times higher over FY23), 91 percent women, with high quality FP counseling, through 607 USG-assisted sites offering FP services and approximately 34,000 CYPs, despite restrictions on family planning promotion, primarily contributed by the fully trained and functional clinics, operational over a full year (as compared partial operation to FY23) and improved capturing and reporting of family planning data by the grantees (compared to FY23) .

● Serving 17,638 children under five with nutrition-specific interventions (34 percent increase over FY23), that include growth monitoring, screening for wasting and stunting, management of moderate acute malnutrition (MAM) for outpatient service delivery and severe acute malnutrition (SAM) for inpatient services following the MOPH guideline.

To assist grantees in targeting indigent patients more effectively in FY24, LHSS provided TA for grantees to implement integrated financing schemes, supported by adoption of the patient equity assessment tool (PESAT). The PESAT tool, adapted by LHSS for the Afghanistan context, supports grantees to identify beneficiaries in the bottom three wealth quintiles (1, 2, and

3) for integrated financial scheme eligibility. The initiative catalyzed grantees to significantly increase access to and use of priority health services among women and low-income populations in the catchment areas. In FY24, the grantees served 356,010 indigent patients (about 300 percent increase over FY23) utilizing the financing schemes, 86 percent of whom were women. Interestingly, despite increasing access to low-income population, objective 2 grantees increased their revenue and cost recovery ratio to 83 percent in FY24 (41 percent increase over FY23).

LHSS and Greenstar co-designed a low-touch private provider networking and franchising model to 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. In Year 5, LHSS facilitated a consensus building workshop with LHSS grantee directors and Greenstar. The purpose of the workshop was to finalize the launch of the provider network, nominate ASMO to manage this network with technical oversight of Greenstar Pakistan, and sign the memorandum of understanding between ASMO and five standalone networks of private service providers. Following the workshop, ASMO held the inaugural meeting of the network secretariate comprised of the heads of the standalone networks. Meeting participants finalized roles, responsibilities and composition of the advisory council and technical advisory groups to oversee implementation of the network’s standard operating procedure.

The Activity assisted the Afghan Family Guidance Association in finalizing its Business and Sustainability plan to establish a user-paid Comprehensive Reproductive Health Center. The Center aims to streamline referrals of sexual and reproductive health cases from primary level static clinics and community midwives. The inclusion of the Center to the grantee’s business model will transition the Association into a social enterprise model with increased financial sustainability. Additionally, LHSS helped the Association explore potential partnerships with the USAID’s Urban Health Initiative (UHI) project and LHSS’s grantee Be Team International (BTI)-Cure Hospital. The center plans to begin operations in FY24 with co-funding by LHSS and the Norwegian Agency for Development Cooperation and technical assistance from USAID UHI project and BTI-Cure Hospital.

In early FY24, LHSS observed that the senior management and leadership teams of the grantees are skilled and experienced in operations management and in identifying and addressing operational capacity gaps but lacked strategic thinking skills, which affect sustainable business planning. To 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 worked closely with senior management and board members of three grantees, ASMO, BTI-Cure and Hassanzai Hospital to identify gaps and provide assistance by observing the board and management team meetings, collecting information using the strategic management and organization capacity assessment and strengthening tool, and providing feedback to the grantees for taking corrective actions. Key inputs were as follows: -

1. All three grantees conducted regular and inclusive senior management team meetings, developed strategic and operational plans. They, however, focused on the day-to-day tasks, paying minimal attention to the overall business performance, impact and sustainability, and the cross-departmental/ functional collaboration.

2. BTI, with a strong board, demonstrated active engagement of the members in providing strategic direction and oversight. In contrast, Hassanzai Hospital, being a privately owned, mid-sized hospital, didn’t have a board. ASMO's governing board was restored after the dissolution of the earlier board in FY24. The new board has been showing its commitment to move away from a symbolic presence to a more proactive and engaged body.

3. ASMO followed a systematic process to develop its strategic plan, however, both BTI and Hassanzai Hospital lacked use of management tools including strengths, weaknesses, opportunities, and threats analysis, while developing their plans. Their management teams need to improve the decision making, documentation and tracking processes. BTI's management team should empower all members to actively and transparently participate in the decision-making processes.

OPPORTUNITIES PURSUED TO CREATE GREATER GENDER

EQUALITY AND SOCIAL INCLUSION

The Activity reviewed the workplans, policy and procedure manuals, and promotional materials to support all grantees to better integrate GESI in their social marketing activities. The Activity has continued to provide TA to improve the capacity of its grantees in planning and management functions. With this support, ASMO continued expanding its coverage in low-income areas of peri-urban districts and slums, prioritizing outreach to women in these areas. Grantees supported under Objective 2 increased staffing, especially women health workers, and served approximately 356,010 low-income patients (86 percent of whom were 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 Initial Environment Examination (IEE), with mitigation measures contained in the Climate Risk Management Plan and the relevant sections of the approved LHSS Afghanistan FY24 Annual Work Plan, and with host country laws and regulations.

PROGRESS ON PERFORMANCE INDICATORS

Objective 1: LHSS TA resulted in increased access to and availability of ASMO products in low-income areas of the peri-urban districts and slums by expanding to 112 markets (LHSS Indicator #7), including opening 126 new and reactivating 1,614 retail outlets, and by sustaining its network of 144 midwives collaborating with 32 hospitals and 126 pharmacies located in such localities. ASMO offered family planning information and counseling through 2,001 social marketing outlets, reaching 4,539,291 people through social media and interpersonal communication channels (LHSS Indicator #9) with GESI-compliant social and behavior change messages. ASMO delivered 136,971 couple years of protection in U.S. government- supported programs (LHSS Indicator #1/USAID HL.7.1-1), 96,945 person years of protection through iron folic acid, chlorhexidine, and micronutrients (LHSS Indicator #2), protected 33,047 people from waterborne diseases (LHSS Indicator #4), and treated 304,408 childhood diarrheal episodes in USG-assisted programs (LHSS Indicator #3/USAID HL.6.6-1).

Objective 2: The Activity supported its grantees in training 2,518 private providers in priority technical areas (LHSS Indicator #14). In sum, these grantees served 695,724 patients with priority health services (LHSS Indicator #12), (approximately 72 percent of whom were women), 356,010 indigent patients using integrated financing schemes (86 percent of whom were women) (LHSS Indicator #16) through 115 U.S. government-supported health service providers and facilities (LHSS Indicator #17). LHSS grantees offered 211,168 clients family planning counseling and services at 21 percent (607) of U.S. government-assisted sites (LHSS Indicator #5/USAID HL.7.1-2). A total of 17,638 children under five years old (approximately 51 percent of whom were girls) received USG-supported nutrition-specific interventions (LHSS Indicator #15).

The table reporting against all indicators is as follows:

Indicators FY 2024 FY2023 Change in

FY24 over

FY23 (%)

Remark on

FY24

performance Annual goal

Annual achieved (#)

Annual achieved (%)

Annual achieved (#)

Purpose: Expanded scale, quality, availability and affordability of the private health provisions, and strengthened readiness of market aggregators to deliver sustained health impact Couple Years of Protection in U.S. government-supported programs (HL.7.1-1)

175,000 170,860 98% 148,189 +15% Met 80%+ threshold

Person Years of Protection through iron folic acid, chlorhexidine and micronutrients

50,000 101,030 202% 42,379 +138% Achieved

Number of cases of child diarrhea treated in USG-assisted programs

(HL.6.6-1)

300,000 315,629 105% 183,983 +72% Achieved

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

(HL.7.1-2)

2,845 2,637 93% 3156 -16% Met 80%+ threshold

Percent of USG-assisted organizations with improved performance (CBLD-9)

100% 0% 0%

NOTE: ASMO’s SMODAT score dropped slightly from 95% (FY23) to 91% (FY24), therefore we report as 0%. For two Obj 2 grantees (BTI and HCH), SMOCAST baseline set at 35% in FY24 - progress to be reported in Q1/FY25 CBLD 9.

Objective 1: Expanded role and improved capabilities of ASMO to deliver sustained health impact Number of new markets covered to increase product availability among poor population

100 112 112% 103 +9% Achieved

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

1 0 0% NA NA

CBD launch postponed due to funding delay

Number of people reached with social, and behavior change messaging

4,000,000 4,539,291 113% 5,593,473 -19%

Achieved, dropped due to low use of

TV

Average cost recovery ratio 55% 54% 98% 46% +17% Achieved

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

135 115 85% 115 No change Met 80%+ threshold

Number of individuals provided with priority health services through a health facility receiving USG support

550,000 695,724 126% 223,338 +212% Achieved

Number of people reached with social behavior change (SBC) messaging

1,500,000 1,508,808 101% 870,469 +73% Achieved

Number of private providers trained in priority technical areas with LHSS support

1,964 2,518 128% 1,524 +65% Met 80%+ threshold

Number of <5 children reached with nutrition-specific interventions with USG support

20,000 17,638 88% 13,196 +34% Met 80%+ threshold

Percent of USG assisted facilities offering one or more integrated financing schemes

135 115 85% 115 No change Met 80%+ threshold

Number of clients that utilized any integrated demand side financing schemes at a health facility receiving USG support

200,000 356,010 178% 89,304 +299% Achieved

Average cost recovery ratio 60% 83% 138% 59% +41% Achieved

Percentage of LHSS grantees successfully capturing and reporting data into HMIS

100% (6 out of 6 grantees)

67% (4 out of 6 grantees)

67% 67% No change

AMC and FMIC not reporting fearing harassment

EMERGING LESSONS

● The Global Knowledge Strategy exercise identified the need for ASMO to collaborate with other private providers on advocacy and engagement with local authorities at national and subnational levels. This effort would aim to sustain ASMO’s performance achievements by addressing the key challenges and barriers.

● The pilot exercise carried out to finalize the Patient Equity Support Assessment Tool highlighted the grantees’ lack of objectivity and consistency in targeting and providing subsidies and the amounts of subsidies offered by the grantees’ existing welfare programs.

LHSS recommended use of the tool to identify low-income patients in wealth quintiles 1-3 with priority given to women and offer incremental subsidy as household wealth index decreases to enhance program efficiency.

CHALLENGES

Visa restrictions for Afghans inhibit Afghan health professionals from attending trainings, business meetings, conferences, and knowledge exchange programs. Delays in signing memorandums of understanding between grantees and the Ministry of Public Health continue to affect timely project implementation. Moreover, excessive scrutiny and interference by the de facto authority on project functioning, family planning promotions, and revenue generation by the grantees have disrupted and delayed project operations. The Activity provided guidance and assistance to the grantees in being transparent and cooperative in their communications, using local experts to raise awareness and advocate with ministry officials for the timely resolution of these delays.

In addition to Taliban restrictions on female health providers and Afghan women’s access to health in general, its guidelines on creative development for mass media, and limitations of using community sensitization and mobilization for demand generation continue to greatly affect consistent performance. Moreover, Taliban raised objections to procurement of long-acting reversible contraceptives for the private market and this affected DKT’s ability and performance to increase its access and use as specifically planned under LHSS. The Activity decided to close out DKT’s grant which will have adverse implications on the Activity’s performance in CYP and FP counselling services in FY25. LHSS supports its grantees in taking precautions and to ensure compliance with Taliban guidelines. The Activity has advised grantees to use precautions by conducting in-facility patient sensitization as far as possible, in procuring long-acting contraceptives (e.g., using non-USG funding) and refer family planning clients for counseling to grantee’ trained clinic-based providers.

DELIVERABLES SUBMITTED TO USAID DURING THIS YEAR

1. Capacity Strengthening: Round-VI Assessment Findings and Action Plan for Afghan Social

Marketing Organization (Q3/FY24)

2. Targeting demand-side financing: Patient Equity Support Assessment Tool for Efficient Targeting of Patient Subsidy in Afghanistan (Q3/FY24)

EVENTS NEXT QUARTER

There are no upcoming events planned for Quarter 1/FY25.

PRIORITIES NEXT QUARTER

LHSS in consultation with the grantees will continue expanding and implementing the planned activities under FY25. Under Objective 1, the Activity will help ASMO conduct the Distribution Coverage and Monitoring Survey, and the Pricing Assessment and scale up the midwifery clinic network and launch piloting CBD initiative. Similarly, under Objective 2, the Activity will prioritize rolling out the provider network and the AFGA’s Comprehensive Reproductive Health Center.

ENGAGING LOCAL AUDIENCES

LHSS supported its grantees in engaging local stakeholders including the Ministry of Public Health, Afghanistan Food and Drug Authority, and provincial health directorates through workshops, media campaigns, and community outreach sessions geared toward raising awareness of services provided by the grantees. LHSS supported grantee capacity building workshops for national and sub-national health and administrative officials, pharmacists, and other health providers for training, refresher courses, and shared grantees’ activities with their peer organizations.

ANNEX 1: PHOTOS FOR LHSS AFGHANISTAN

See the attachment in the email.

ANNEX 2: ENVIRONMENTAL MITIGATION AND MONITORING REPORT FOR LHSS

AFGHANISTAN FY24 ACTIVITIES

Activity Mitigation Measure(s) Status of Mitigation Measures List any outstanding issues relating to required conditions

Remarks

Objective 1: Provide financial and technical support to ASMO aimed at expanding its role and improving its organizational capabilities to deliver sustained health impact to both men and women.

Intervention 1.1: Support ASMO in increasing access to and availability of priority health products among low-income populations in large urban provinces.

Task 1.1.1: Expand ASMO’s coverage and distribution methods to increase access to and availability of priority health products among low-income populations.

Task 1.1.2: Strengthen ASMO’s product sales and coverage targeting, monitoring, and reporting system.

Task 1.1.3: Build on ASMO’s new product development and introduction system to launch new products

A list of expired commodities (procured with USAID funds) with its quantities will be prepared and sent to the Mission activity manager to be shared with the Mission environmental officer before disposal. Disposal of all commodities follows ASMO’s policy for damaged and expired goods. Expired pharmaceuticals are delivered to a qualified private medical waste management vendor for disposal. The number of expired pharmaceuticals to be disposed of is expected to be extremely low. Expired commodities will be disposed of properly by a private medical waste management vendor in an environmentally safe and sound manner.

Not applicable (N/A); no stock disposal in FY24

ASMO staff handling commodities and waste are trained on the storage and disposal of commodities under ASMO’s Warehousing and Logistics Policies and Procedures.

Q1: N/A Q2: Warehouse and sales staff trained on the storage and disposal of commodities.

including medicines and low-cost, point-of-care diagnostic devices.

Q3: N/A Q4: ASMO staff trained on stock and waste management

Warehouses are inspected quarterly to assess the implementation of warehousing practices under ASMO’s Warehousing and Logistics Policies and Procedures Manual. Warehouse staff and other individuals handling expired commodities and waste should be trained in first aid response. All staff handling waste will be equipped with proper personal protective equipment.

Q1: N/A Q2: All warehouses are inspected.

Q3: N/A Q4: ASMO warehouses are inspected.

ASMO staff, through information, education, and communication materials, will promote to the registered outlets the importance of providing injections, having a sharps disposal bin, a needle cutter disposal boxes.

Q1: 400 Environment Management System (EMS) posters installed in the outlets of 5 large urban provinces. The outlet owners were informed on safe disposal of ASMO products waste through one-to-one interaction.

Q2: 329 Environment Management System (EMS) posters installed in the outlets of 5 large urban provinces. The outlet owners were informed on safe disposal of ASMO products waste through one-to-one interaction.

Q3: 280 Environment Management System (EMS) posters installed in the outlets of 5 large urban provinces. The outlet owners were informed on safe disposal of ASMO products waste through one-to-one interaction.

Q4: 300 Environment Management System (EMS) posters installed in the outlets of 5 large urban provinces. The outlet owners were informed on safe disposal of ASMO products waste through one-to-one interaction.

Intervention 1.2: Support ASMO in increasing consumer and provider knowledge of and demand for priority health products.

Task 1.2.1: Develop and implement consumer-focused SBC interventions.

Task 1.2.2: Develop and implement provider-focused detailing and trade promotion.

Interventions involve:

1. Stakeholder engagement, systematic multi-disciplinary analyses of advances and challenges, technical consultation, consensus building, and communication within and across regional, national, and local settings

2. Document and/or knowledge transfer

All these activities are recommended for Categorical Exclusion and do not require mitigation measures.

N/A N/A N/A

3. Secondary data analysis

4. Education and technical assistance

5. Communications campaign

Intervention 1.3: Increase ASMO’s capacity to expand private sector engagement and deliver sustained health impact.

Task 1.3.1: Strengthen ASMO’s technical capacity to conduct and use market analysis for sales growth.

Task 1.3.2: Strengthen ASMO’s financial, institutional, and gender capacities to mitigate organizational and financial risks arising with the regime change and deliver sustained health impact.

Interventions involve:

1. Stakeholder engagement, systematic multi-disciplinary analyses of advances and challenges, technical consultation, consensus building, and communication within and across regional, national, and local settings

2. Document and/or knowledge transfer

3. Secondary data analysis

4. Education and technical assistance

All these activities are recommended for Categorical Exclusion and do not require mitigation measures.

N/A N/A N/A

Objective 2: Increase product coverage and support establishment of franchising and provider network models to improve service provision through partnerships with additional social marketing/franchising organizations.

Intervention 2.1: Support private sector organizations to strengthen and expand existing and innovative new user-paid delivery models.

Task 2.1.1: Execute and evaluate planned activities to support increased access to priority health services and finalize geographic and health areas requiring further action.

Task 2.1.2: Co-finalize and address capacity strengthening areas to ensure success and sustainability of the

Interventions involve:

1. Stakeholder engagement, systematic multi-disciplinary analyses of advances and challenges, technical consultation, consensus building, and communication within and across regional, national, and local settings

2. Document and/or knowledge transfer

3. Secondary data analysis

All these activities are recommended for Categorical Exclusion and do not require mitigation measures.

LHSS- supported initiatives.

4. Training and technical assistance

Intervention 2.2: Explore and implement integrated demand- and supply-side grantee strategies.

Task 2.2.1: Implement integrated demand-and supply-side grantee strategies.

Interventions involve:

1. Stakeholder engagement, systematic multi-disciplinary analyses of advances and challenges, technical consultation, consensus building, and communication within and across regional, national, and local settings

2. Document and/or knowledge transfer

3. Secondary data analysis

4. Training and technical assistance

All these activities are recommended for Categorical Exclusion and do not require mitigation measures.

N/A N/A N/A

Intervention 2.3: Explore appropriate provider aggregation models and develop sustainable private sector engagement and networking practices.

Task 2.3.1: Implement and scale up agreed networking model(s) and transition to a network manager.

Interventions involve:

1. Stakeholder engagement, systematic multi-disciplinary analyses of advances and challenges, consensus building, and communication within and across regional, national, and local settings

2. Document transfer

3. Secondary data analysis

4. Training and technical assistance

All these activities are recommended for Categorical Exclusion and do not require mitigation measures.

N/A N/A N/A

Intervention 2.4: Strengthen and standardize data reporting capacity and system for the grantees and integrate into health management information system.

Task 2.4.1: Support grantees in capturing service and business performance data and

Interventions involve:

1. Stakeholder engagement, systematic multi-disciplinary analyses of advances and

All these activities are recommended for Categorical report standardized data into HMIS.

challenges, consensus building, and communication within and across regional, national, and local settings

2. Document transfer

3. Secondary data analysis

4. Training and technical assistance

Exclusion and do not require mitigation measures.