YEAR1 ANNUAL REPORT

ADVANCING UNIVERSAL HEALTH COVERAGE (AUHC) ACTIVITY IN BANGLADESH (OCT 2017-SEPT 2018)

Program Title: Advancing Universal Health Coverage (AUHC) Activity in Bangladesh Sponsoring USAID Office: USAID/Bangladesh Contract Number: AID-388-C-17-00001 Contractor: Chemonics International Inc. Partners: Ad Din, Green Delta, Population Services International (PSI) and ThinkWell LLC Date of Publication: November 15, 2018 Author: AUHC

The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

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CONTENTS

ACRONYMS ................................................................................................................................................................ 7 EXECUTIVE SUMMARY ........................................................................................................................................... 9 GOALS AND OBJECTIVES.................................................................................................................................... 12 RESULT FRAMEWORK .......................................................................................................................................... 13 YEAR 1 ACHIEVEMENTS FOR AUHC SERVICE INDICATORS ................................................................ 14 ACHIEVEMENTS BY RESULTS ............................................................................................................................. 16

RESULT 1. SMILING SUN NETWORK TRANSFORMED INTO A CENTRALLY MANAGED, SUSTAINABLE, PRIVATE SOCIAL ENTERPRISE: THE SURJER HASHI NETWORK ....................... 16

Overview of Accomplishments ............................................................................................................................... 16

IR 1.1 Existing Smiling Sun Network Consolidated into a Centrally Managed Single Entity .............. 16

Establishment of SHN ............................................................................................................................................ 16

Clinic transition. ....................................................................................................................................................... 16

Market landscape ................................................................................................................................................... 17

IR 1.2 Standardized Corporate Operating Systems Designed and Implemented ................................. 18

Electronic MIS, HNQIS, EMR ................................................................................................................................ 18

IR 1.3 Financial Sustainability and Cost Efficiency of SHN Improved ...................................................... 18

SHN business strategy ........................................................................................................................................... 18

IR 1.4 Value-Based Payments Implemented to Drive Performance ......................................................... 22

RESULT 2: ACCESS TO AND UPTAKE OF ESSENTIAL SERVICE PACKAGE EXPANDED ......... 23

Overview of accomplishments ............................................................................................................................... 23

Special Section: Analysis of service use in SHN clinics................................................................................ 23

Service channels ...................................................................................................................................................... 24

Maternal Health ..................................................................................................................................................... 25

IR 2.1 Enhanced Service Package Offered Through SHN .......................................................................... 27

Tuberculosis (TB) .................................................................................................................................................... 27

Eye Care ................................................................................................................................................................... 27

Nutrition ................................................................................................................................................................... 27

Family Planning ........................................................................................................................................................ 28

Guidelines ................................................................................................................................................................. 28

SHN referral system ............................................................................................................................................... 28

Satellite and CSP Assessment ................................................................................................................................ 28

Client Satisfaction .................................................................................................................................................... 28

Partnership with Pharmaceuticals ......................................................................................................................... 28

IR 2.2 Increased Informed Demand for Essential Services Package ......................................................... 29

Demand generation ................................................................................................................................................ 29

BANGLADESH AUHC YEAR 1 ANNUAL REPORT

Social Behavior Change Communication .............................................................................................................. 29

RESULT 3: SUSTAINABLE FINANCIAL SYSTEMS DEVELOPED TO FACILITATE EXPANDED COVERAGE AND TO ENSURE EQUITABLE ACCESS TO HEALTH SERVICES.............................. 30

Overview of accomplishments ............................................................................................................................... 30

IR 3.1 Subsidy Funding to Cover the Poor Operationalized ..................................................................... 30

Review of the current policy and practices of poverty targeting ........................................................................ 30

IR 3.2 Prepayment/insurance package developed and available ................................................................ 30

Insurance pilot ......................................................................................................................................................... 30

IR 3.3 Optimal Client Mix Secured to Balance Financial Sustainability and Pro-Poor Mandate ........ 31

Review of the current financial system ................................................................................................................. 31

RESULT 4: IMPROVED QUALITY OF CARE ............................................................................................... 32

Overview of accomplishments ............................................................................................................................... 32

IR 4.1 Improved Customer Experience .......................................................................................................... 32

Mystery Clients ........................................................................................................................................................ 32

IR 4.2 Continual Quality Improvement Systems Implemented ................................................................. 32

Service delivery tools ............................................................................................................................................... 32

Adverse event reporting .......................................................................................................................................... 32

IR 4.3 SHN Staff Are Skilled and Retained ..................................................................................................... 33

Staff satisfaction and motivation schemes for SHN ........................................................................................... 33

RESULT 5: IMPROVED PROGRAM STRATEGIES DRAWN FROM LESSONS LEARNED ............. 34

Overview of accomplishments ............................................................................................................................... 34

IR 5.1 Capture Learning through Documentation, Research, and Analysis ........................................... 34

Research quality control ......................................................................................................................................... 34

SSK Collaboration ................................................................................................................................................... 35

Supporting the EMR/MIS development ................................................................................................................ 35

Development of the Learning Framework ............................................................................................................ 35

IR 5.2 Apply Learning to Activities ................................................................................................................... 36

Lessons learned ....................................................................................................................................................... 36

Clinic management transition ................................................................................................................................ 36

Data management .................................................................................................................................................. 37

Lack of standardization .......................................................................................................................................... 37

Compliance monitoring systems ............................................................................................................................ 37

Gender ...................................................................................................................................................................... 37

Pause and Reflect workshop .................................................................................................................................. 38

Annual Reflection Workshop ................................................................................................................................. 38

IR 5.3 Disseminate Learning on UHC to Target Audiences ...................................................................... 39

Learning Platform for SHN .................................................................................................................................... 39

SHN database for error validation ........................................................................................................................ 39

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Reporting systems for project activities................................................................................................................. 39

Data quality assessment ........................................................................................................................................ 40

SHN business strategy workshop .......................................................................................................................... 40

Compliance monitoring systems ............................................................................................................................ 40

Communication materials ...................................................................................................................................... 40

PARNTERSHIPS AND COLLABORATION ...................................................................................................... 42 Leveraging partnerships ......................................................................................................................................... 42

Collaboration............................................................................................................................................................ 42

PROJECT MANAGEMENT .................................................................................................................................... 43 Programmatic .......................................................................................................................................................... 43

AUHC key personnel .............................................................................................................................................. 43

Non-key staff ........................................................................................................................................................... 44

Financial management ........................................................................................................................................... 44

Operational cost containment ............................................................................................................................... 44

Technical cost containment.................................................................................................................................... 44

Family Planning Compliance Update ..................................................................................................................... 45 RESULTS TO DATE ................................................................................................................................................. 46 Annex-A: AUHC Organogram .............................................................................................................................. 54 Annex-B: SHN organogram .................................................................................................................................... 55 Annex C: Financial Report ...................................................................................................................................... 56

BANGLADESH AUHC YEAR 1 ANNUAL REPORT

ACRONYMS AUHC Advancing Universal Health Coverage

BEmOC Basic Emergency Obstetric Care

BOD Board of Directors

BDHS Bangladesh Demographic and Health Survey

CEO Chief Executive Officer

CEmOC Comprehensive Emergency Obstetric Care

COP Chief of Party

DCOP Deputy Chief of Party

DHIS2 District Health Information System 2

CTB Challenge TB

EMR Electronic Medical Record

ESP Essential Service Package

FAA Fixed Award Amount

GDIC Green Delta Insurance Company

GBV Gender-based Violence

GFATM Global Fund AIDS, Tuberculosis, and Malaria

GoB Government of Bangladesh

GH Pro Global Health Program Cycle Improvement Project

HMIS Health Management Information System

IR Intermediate Result

HNQIS Health Network Quality Information System

JTS Jatiyo Tarun Sangha

LARC Long-Acting and Permanent Method

MERL Monitoring, Evaluation, Research, and Learning

NGO Non-Governmental Organization

NHSDP NGO Health Service Delivery Project

PMU Project Management Unit

QA/QI Quality Assurance/Quality Improvement

QMS Quality Management System

RF Results Framework

SBCC Social Behavior Change Communications

SHN Surjer Hashi Network

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UHC Universal Health Coverage

USAID United States Agency for International Development

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EXECUTIVE SUMMARY Year 1 Overview. AUHC’s first year was dedicated to project start-up, ensuring clinic services remain accessible while AUHC was transitioning clinic management responsibilities from 25 NGOs to SHN. In the context of the development and final submission of the final version of the AUHC Year 1 work plan, the decision was made to transfer 374 of the 399 clinics to SHN as opposed to doing it over a period of several years. This transition started in Year 1 and will culminate by the first Quarter of Year 2. The first tranche of clinics transferred in Year 1 were the 79 clinics managed by JTS, PSTC, Kanchan Samity and UPGMS. Those clinics were transferred to Ad-din who was acting as a temporary management agent until SHN was able to receive AUHC funds. Orchestrating this transition required a significant amount of coordination and effort. AUHC is in the process of transferring 6,000 clinic staff, clinic assets, and securing the requisite licenses and registrations needed to enable SHN to operate clinics. To do this in Year 1, AUHC had to shift priorities to this transition and building SHN’s capacity as a single entity while continuing to keep clinics operational and providing services. In addition to the transfer of clinic management responsibilities, AUHC also dedicated considerable effort into establishing SHN by building SHN systems and processes with the aim of preparing SHN to receive a grant from AUHC to manage a network of clinics. SHN registration and licensing, along with establishing a board governance structures as well as beginning to staff SHN were all accomplished this year. SHN received a fix award amount grant from AUHC on October 1, 2018. AUHC worked with SHN to begin to define a business strategy. This strategy will serve as the basis for the SHN business plan that will be finalized in Year 2. AUHC launched four research activities in Year 1. The intent of these studies is to further define service packages and products, target populations and delivery channels for SHN services. In terms of service delivery, SHN clinics were responsible for 49.20 million total service contacts. Included in that were 2.06 million ANC and 324,206 PNC service contacts. The overall service contacts, as well as the service contacts for ANC and PNC met the AUHC Year 1 target and outstripped the performance of the network in the last year of NHSDP (FY2016-2017). Quite apart from meeting a contractual obligation, this indicates that the clinic management transition did not significantly disrupt services. AUHC almost met the target for births attended by a skilled birth attendant; 45,186 as compared to a target of 45,232. However, the facility-based births at SHN clinics increased by 10%; 37,153 compared to a target of 33,896. AUHC collaborated with the Challenge TB project to increase the notification and treatment of TB cases in urban clinics. The uptake of IUD and implants continues to be a challenge for SHN. Neither target was met in Year 1, and there is significant variability between quarters. See the section under Result 2 that has an additional analysis of Year 1 service achievements.

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Focus of Year 2. This year is a critical period for AUHC. After the completion of the management transition of the remainder of the SHN clinics, all attention will be on the systems that support the delivery of SHN services and products. Considerable emphasis will be on re-invigorating the SHN network. This work will include minor clinic infrastructure improvements, equipment procurement, staff training, implementing quality improvements, improving data quality and reporting systems. AUHC will work with SHN to expand services packages and products by prototyping service ideas. At the same time, AUHC will work with SHN to enhance clinic management expertise through the SHN regional structure. All these aspects will be critical as SHN takes on the challenge of directly managing this clinical network. AUHC will assist SHN to define its approach for serving the poor by reviewing pricing strategies and the effectiveness of methods to identify the poor. AUHC will continue working with The Green Delta to develop an insurance pilot that will create additional access SHN services.

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GOALS AND OBJECTIVES To support USAID’s development objective to improve health and human capital in Bangladesh, this activity will develop a sustainable, gender-sensitive, and pro-poor social enterprise — the Surjer Hashi network— to advance progress toward universal health coverage. The Advancing Universal Health Coverage (AUHC) activity focuses on five results:

1. Develop and implement a program to transform the Smiling Sun network into a centrally managed, sustainable private social enterprise

2. Adopt proven innovative approaches to create new strategies to expand access to and uptake of essential service packages

3. Develop and implement sustainable financial systems to facilitate expanded coverage and ensure equitable access to health services

4. Improve the quality of care 5. Improve program strategies drawn from lessons learned (crosscutting)

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YEAR 1 ACHIEVEMENTS FOR AUHC SERVICE INDICATORS Introduction. The table below compares Year 1 baseline targets for the 15 AUHC service indicators against Year 1 achievements. For a complete comparison of Year 1 achievements refer to the PMP section.

1 AUHC didn’t set a target for this indicator in Year 1. We will Year 1 achievement for the baseline for subsequent project years.

Indicators Annual Target

Annual Achievement

Percent Deviation

Number of service contacts provided through the AUHC project 46m 49.2m +6.96

Number of youth service contacts (15-25 years) accessing FPRH counseling and or services 20,000,000 20,606,435 +3.03

Couple Years Protection (CYP) provided by AUHC N/A 1.05m1 -

Number of total permanent methods (Male sterilization) provided by AUHC clinics 171 173 +1.17

Number of service contacts with pregnant women that provided counseling on nutrition or adoption of IYCF practices

1,032,434 1,039,544 +0.69

Total number of facility deliveries in AUHC supported sites 33,896 37,153 +9.61

Number of births delivered by a skilled birth attendant supported by AUHC 45,232 45,186 -0.10

Case notification of TB from AUHC supported clinics as part of Zero Urban TB Initiative 4,636 5,837 +25.91

Number of health service contacts with males provided by AUHC 4,100,000 4,171,937 +1.75

Number of ANC service contacts provided by AUHC 2,020,115 2,064,285 +2.19

Number of newborns receiving PNC within 48 hours of birth from AUHC supported skilled provider 317,753 324,206 +2.03

Number of newborns receiving essential newborn care (ENC) service within 72 hours of birth 352,934 352,534 -0.11

Number of ANC and/or PNC visits where 30 IFA is provided or prescribed 1,681,931 1,680,448 -0.09

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Discussion. Of the 15 service indicators in the AUHC PMP, in Year 1, AUHC met 10 of them. Noteworthy successes are in the total number of services contacts, number of youth service contacts for FP/RH counseling or services, the number of deliveries in AUHC supported facilities, the number of male service contacts, ANC and PNC service contacts, and the number of cases of child pneumonia treated. The number of service contacts is important to AUHC as we worked hard to ensure that service disruption in the face of a significant clinics management transition effort was not affected. We believe that, for the most part, transition did not have a significant effect on services. The high number of males served by AUHC is directly related to TB services. That target needs to be revised to be more in line with the TB service delivery service delivery reality in 45 SHN clinics that provide TB services. Two areas of concern, as they are by comparison noticeably below target, are the treatment of child diarrhea, and the number of services contacts for children under 5 included in growth monitoring. The number of cases of diarrhea is understandable as SHN clinic staff can only treat children that present to SHN clinics with diarrhea. It also must be acknowledged that there is a considerable amount of home treatment of diarrhea cases with oral rehydration solution (ORS). AUHC CSPs sell ORS solution and it is possible that children are being treated by the products sold by CSPs and not recorded as such. Other areas where AUHC did not meet the Year 1 target are negligible. It is important to point out that AUHC used projected data from NHSDP and AUHC three quarters to set baseline targets. There are concerns about the accuracy of SHN data overall, including service statistics. Once we have a full year’s worth of service statistics and install a system to more accurately track service data, we will be better able to set targets and report against them. Moreover, SHN will employ a data error mapping exercise on a random basis to set up realistic target for service indicators.

2 We didn’t set a target for Year 1. SHN clinics participates in Government led NID program twice a year and distributes Vitamin A. This data is not entered into the regular clinic database. The AUHC MERL team collected this information. We have used these numbers as the basis for setting targets for subsequent years. 3 This is a new indicator included in the PMP in Quarter 4. The MERL team collected this information at the end of year and set baseline. We have set targets for subsequent years.

Number of women giving birth who received uterotonics (misoprostol/ oxytocin) in the third stage of labor (or immediately after birth)

37,210 37,153 -0.15

Number of children less than 12 months of age who received Penta3 from AUHC clinics 310,076 309,196 -0.28

Number of service contacts of children aged 6-59 months who received Vitamin A in AUHC catchment areas (including NID)

N/A 1,840,1742 -

Number of cases of child diarrhea managed through AUHC clinics 2,407,662 2,323,558 -3.49

Number newborns not breathing at birth who were resuscitated in AUHC clinics N/A 5,6963 -

Number of cases of child pneumonia treated with antibiotics through AUHC 283,016 288,254 +1.85

Number of service contacts with children under 5 included in growth monitoring program (GMP) in AUHC target areas

1,311,590 1,302,445 -0.70

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ACHIEVEMENTS BY RESULTS RESULT 1. SMILING SUN NETWORK TRANSFORMED INTO A CENTRALLY MANAGED, SUSTAINABLE, PRIVATE SOCIAL ENTERPRISE: THE SURJER HASHI NETWORK

Overview of Accomplishments. In Year 1, the transition of the management of the Surjer Hashi clinics from 25 NGO to SHN occurred at a more accelerated pace than originally planned. The AUHC NGO transition team with assistance for the AUHC grants team re-oriented their work to accomplish this transition. Completing this transition is an integral part of establishing SHN. Equally as important, to position SHN to take on this management responsibility, AUHC had to fast-track the operationalization of SHN. Company registration, licensing, establishing a functioning board, developing a board governance system, as well as establishing key policies and operational systems became an immediate priority. Part of this also included identifying and onboarding several SHN staff, including the SHN Chief Executive Officer (CEO). SHN staff requirements were done through a mix of direct recruitments and temporary secondments of AUHC staff with the idea that AUHC staff would return to the project once qualified SHN staff could be identified and hired. Essential systems such as an integrated information management system for SHN clinics, and an SHN business strategy was initiated this year. All this work occurred while Smiling Sun clinics provided 49.2 million service contacts. Year 2 Focus. Under this result, AUHC will continue to transition NGO clinics with the aim of completing this process, except for 18 managed by Greenhill in Chattogram Hill Tracts (CHT), by January 2019. By that point SHN will also have an approved business plan. This plan will define SHN business strategies, service and product expansion ideas, revenue generation targets, product sales, and service targets. Throughout Year 2, AUHC will work to build management systems and processes that will help SHN manage 374 clinics and approximately 6,500 staff. IR 1.1 Existing Smiling Sun Network Consolidated into a Centrally Managed Single Entity

Establishment of SHN. The fifth meeting of SHN Board of Directors was held on September 18, 2018 at the AUHC office. The Board approved the SHN Human Resources and Administrative Manual, the Accounts and Finance Manual, and the Procurement Manual. SHN began officially transitioning and welcoming the clinic staff through a series of Town Hall meetings. The first of its kind took place in Sylhet where 187 clinic staff from 16 SSKS clinics received employment letters. Dutch Bangla Bank Limited facilitated the opening of their bank accounts for payroll transfer. SHN signed a Service Agreement with E Zone HRM Limited on September 19, 2018 to outsource recruitment, payroll and benefits administration and human resources management services for SHN. Clinic transition. AUHC continued transitioning clinics from NGO management to SHN. By September 2018, 95 clinics transitioned -- 79 to Ad-din who is acting as an interim management agent, and the remaining 16 to SHN. AUHC developed a detailed transition plan for all clinics to be transferred to SHN by the end of calendar year 2018.

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Market landscape. Responding to market needs and dynamics is central to SHN’s approach. To better understand the market, PSI embarked on a comprehensive market landscape. As an initial step in the Market Landscape process, PSI conducted a desk review that included health-seeking behavior, effective, relevant behavior change interventions, primary healthcare market, and health financing in Bangladesh. It reviewed information from more than 200 secondary data sources including ethnographies, cross-sectional studies, government publications, project documents from NGOs, the GOB, WHO, and World Bank websites. The Market Landscape Specialist Kathleen MacDonald identified gaps in the available secondary data to shape the plan for the primary research that would be conducted for the Market Landscape. PSI selected two research agencies through a competitive process to conduct provider and consumer research under the market landscape. The ResInt was selected to manage the provider research, and MRCB was selected to manage the consumer research. Following the identification of the two firms, the study design was submitted to PSI’s Ethical Board for approval, which was granted. Data collection for both provider and consumer research studies began in September 2018. This information will be critical as SHN finalizes its business plan in January 2019.

Figure 1: Status of Transition by end of Year 1

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From the business strategy workshop, a series of shortlisted ideas were organized by three stages of implementation:

After the workshop, a AUHC results leaders and the SHN CEO went through an additional exercise to prioritize and make final decisions on ideas to be implemented in Year 2. Those ideas include:

Figure 4: SHN Short-Listed Business Ideas and Stages

Figure 3: Business Idea Implementation Process

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One of the main Year 1 achievements under this result was developing a shared understanding of sustainability for SHN, by agreeing on an approach or process for defining the business model for SHN. In the process of business planning for SHN, ThinkWell and the rest of the incubator team facilitated discussions among the partners of the AUHC project to clarify key concepts, approaches, and overarching business strategy decisions for SHN. ThinkWell and the AUHC MERL teams worked closely with the market landscape research to bring in data, evidence, and analysis to understand the network’s complete operational picture. In-depth analysis of historical data from SHN clinics have identified some critical challenges that SHN will need to address going forward. For example, in terms of value proposition of the network, the main takeaways were that breadth and depth of services is insufficient; family planning service use is mainly condoms and pills. More effective long-acting reversible and permanent method uptake is lacking. Similarly, for MCH services the notion of a continuum of care across the entire MCH spectrum --- prenatal care, labor and delivery, postnatal care, neonatal and well- child care is not being realized. This data analysis also revealed that there is a lack of standardization across the network. This touches on almost all aspects of clinic services from the implementation of quality standards to the price of services. Specifically related to revenue data, there are concerns around the disparity in the range of service prices across the network, the manual invoicing system, and the cash collection approach. The CEO and SHN board were aligned with the vision for a sustainable network of clinics, offering high quality, customer-oriented and affordable healthcare services for the poor. Its success to be measured in terms of health impact and sustainability. Sustainability was understood and agreed to as financial health (profit and loss) of the company, surplus (through other sources of fund and capital) to support pro-poor service delivery while not wasting subsidy on those that are able to pay for services. AUHC and SHN recognize the need for further information and validation of SHN’s business model assumptions and questions. This led to agreeing to a process of coming together as a group on several iterations of the business strategies and business model assumptions based on review of what we know now, what new information we have collected through study and evidence by prototyping. Prototyping is a way of answering a business question through rapid experimentation with clearly defined metrics of success and failure that results in learning and informed programming. The types of prototypes identified during the strategy workshop fell into

Figure 5: Initial SHN Business Ideas

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five basic categories: services, pricing, customer service orientation, customer acquisition, and efficiency. Each successful prototype is going to contribute to growth of SHN, and eventually diversification in services and revenue streams. During Year 1, significant progress was made on the development of the overall SHN business strategy and corresponding business plan. This process has been building off the work that culminated in the weeklong workshop of all AUHC partners that included development of the transition plan and initial business strategy approach. The AUHC transition plan and business strategy for SHN is a two-pronged approach (Refer to Figure 6) comprising of a maintain phase and a Prototype-Grow-Diversify phase. During the maintain phase, AUHC will continue to support all the clinics transitioned from NGOs to SHN. These clinics will be supported through continued grant funding. The SHN business plan delineates a sub-set of clinics having strong customer acquisition capacity and revenue generation potential. It was decided that these clinics will be managed by applying commercial business principles of profit and loss under a separate SHN Business Unit. They would still be grant funded but viewed as a precursor to an SHN for-profit subsidiary that will eventually be formed to provide SHN with the flexibility to attract private capital and investment by managing profitability, thereby balance sustainability and pro-poor health impact. Referring to the diagram, the objective of the maintain phase is to protect revenue and assets of the clinics and continue to deliver on the network’s commitment to the clients and stakeholders.

AUHC incubator has undertaken an extensive effort to collect and analyze historical data from the Smiling Sun clinics. This included data extracted from the existing management information system (MIS), monthly financial reports (MFRR), and data collected directly from paper-based systems. AUHC used this information to arrange clinics into six clusters based on type. The table below provides a basic description of the six cluster types now being used in the analysis. (see Figure 7 below). These cluster definitions are a core analysis unit within the business plan and associated research efforts by AUHC that include the suite of market landscape studies.

Name Clinics # Type Urban/Rural Cluster 1 EMO-C Urban 39 EMO-C Urban Cluster 2 EMO-C Rural 9 EMO-C Rural Cluster 3 Vital - with

extended Lab 18 VITAL both

Cluster 4 EMO-B 13 EMO-B both

Figure 7: SHN Clinic Clusters

Figure 6: SHN Business Model

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Cluster 5 Vital - with extended OBS

8 VITAL both

Cluster 6 all other 13 VITAL both Total 100

IR 1.4 Value-Based Payments Implemented to Drive Performance

There has been a lack of clarity in defining how value-based payments relate to the AUHC project since clinics are transitioning from NGOs to a central platform that will own and manage revenue and costs. The project also did not decide on a strategy of expanding the network by getting into purchasing agreements with health service providers outside the network. After the first quarter of the project, the scope of value-based payment was reoriented towards strategies for incentivizing performance of the service providers and staff of the SHN network. After SHN was registered as a legal entity, the board and the CEO assumed office, it was decided that a performance management strategy will be developed for SHN in year 2 to drive performance of clinics under a regional management structure. The CEO of SHN argued that SHN will have a strategy to allocate targets and incentives at the regional level for the regional management to redeploy and allocate targets and resources to drive performance of individual clinics.

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RESULT 2: ACCESS TO AND UPTAKE OF ESSENTIAL SERVICE PACKAGE EXPANDED

Overview of accomplishments. During the Year I, the project focused on exploring opportunities and strategies for expanded and improved services. The project team considered ways of adding specialized services as well as improved diagnostics and treatment through partnerships with other organizations. Strategies for leveraging relationships with other USAID implementing partners to build on existing resources was also considered. Initial steps were made to improve services at the network level such as establishing referral centers and linking services to the QA/QI system. Several research and evaluation activities were launched including a study of SHN’s Satellite spots. All these efforts will contribute to SHN facilities offering comprehensive, high-quality services network wide. Year 2 focus. AUHC and SHN will make decisions on service and product packages to expand SHN services and products. AUHC will prototype new service and product ideas prior to taking them to scale. Significant emphasis will be placed on rationalizing services based on client demand, local market dynamics and competition. AUHC will work to create efficiencies at the clinics level as they are the point of service in the SHN network. The aim is to structure clinics, so they can serve as many people as they can as efficiently as possible. With this, clinic staffing configurations need to be evaluated to ensure that they can effectively support the new service packages that SHN intends to introduce. To support services, AUHC will introduce a regional structure to oversee SHN clinics through teams to support improved clinic services. Special Section: Analysis of service use in SHN clinics

Introduction. The AUHC MERL team has reviewed the service data from Year 1. The aim is to determine if there are any service trends, what influences them, and what can AUHC and SHN do to capitalize on the positive one and negate the negative one. In the graphs that follow, we focus on child health, family planning, maternal health and other health services. The table describes specific services under each category in each of the four areas.

SHN Services by Category Child Health Maternal Health

• ENC within/after 3 days of birth • Newborns Treated with Antibiotic • Vaccination • Dehydration, Dysentery • Vitamin-A • Pneumonia • IMCI (Excluding ARI and CDD) • GMP • Breastfeeding • De-worming tablets

• Ante natal care • Post-natal care • Home delivery • Normal delivery • Delivery by C-Section • Infant young child feeding counselling • Vitamin A supplements to mothers • 30 IFA tablets to ANC and PNC mothers • Post abortion care • Vaccinations

Family Planning Other Health • Pill • Condoms • Injectable • IUD • Implants • Emergency contraceptive pills • Sterilization (Male & Female) • FP counselling

• Tuberculosis screening • TB DOT service • NCD (Hypertension, Diabetes) • Diarrhea • Dysentery • Pneumonia • Cough • Malaria • Dengue

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Conclusion. There are several conclusions that can be drawn from this data. The first is to determine what is driving rural residents, regardless of economic status to deliver at home. Culture is certainly part of it, but there must be other access related factors. Creating better access through the expansion of emergency obstetrical care centers, whether they be basic or comprehensive would is an attractive value proposition for SHN. Also, in addition to creating more outlets, it may be advantageous for SHN to bolster the community workforce to include midwives who can provide competent home delivery care for those women who opt for that service. We also know that some of the EMOCs both basic and comprehensive have had trouble retaining doctors forcing women to consider other non-SHN options. AUHC needs to work hard to correct this. AUHC expects that a significant amount of information on delivery services will be revealed during the market landscape, the CSP and Satellite Assessments. Regardless, clearly there is a challenge ahead for AUHC and SHN as expanding maternal health services, which will include ANC, delivery services as well as PNC. The aim should be, as was discussed during the SHN business strategy workshop, focusing on an approach that will increase more facility-based births. IR 2.1 Enhanced Service Package Offered Through SHN

Tuberculosis (TB). During Year 1, 45 SHN clinics provided diagnostic and treatment services through funding from BRAC, the primary recipient for the Global Fund to Fight AIDS, Malaria, and Tuberculosis (GFATM). In collaboration with the Challenge TB project, AUHC also introduced verbal screening to identify presumptive TB cases in seven SHN clinics in Dhaka South City Corporation. Twenty-one SHN clinic staff received training from the Challenge TB project on the screening tools, checklists and referral linkages with designated facilities for X-ray and GeneXpert for the diagnosis of presumptive TB cases. Going forward, AUHC will place and operationalize GeneXpert and X-Ray machines in five SHN clinics. USAID is purchasing the GeneXpert machines, AUHC is responsible for ensuring that they are installed correctly, a maintenance plan is in place and operational, staff are trained, and clients receive the services. In preparation for this, the Senior Service Delivery Advisor along with the QA/QI Director visited a BRAC clinic, where they are using GeneXpert machines, as well as X-Ray for TB diagnosis. Following this visit, members of the AUHC project team conducted a simple assessment in 45 SHN clinics that are currently providing TB services, to assess the readiness of each clinic to do TB screening and diagnosis, in terms of equipment, instruments and staff training. The result of this assessment determined that none of the clinics have the equipment necessary to provide TB services, and it will be necessary to invest in the clinics laboratories and infrastructure to allow them to do quality TB diagnosis and treatment. Eye Care. AUHC and The Fred Hollow Foundation (FHF) are joining forces to pilot eye services in a select number of SHN clinics. Five SHN clinics will be equipped to treat uncorrected refractive error, and at least one clinic will be upgraded to offer cataract surgery. During the piloting and potential scale-up of these services the AUHC project will collaborate with FHF to utilize their expertise in training staff, costing services, equipment procurement and service organization. Nutrition. USAID’s Improving Nutrition through Community-based Approach (INCA) Project shared examples of several IEC materials that may be helpful tools for providers to better counsel and provide information to clients at SHN clinics. Examples include materials to provide nutrition information for children under five to caregivers, a game for adolescent girls that help them understand their reproductive health and posters about nutrition for pregnant women. FHI is conducting a qualitative research to improve the minimum acceptable diet for children. The results from this study will be useful to the AUHC project to determine strategies to improve nutrition outcomes.

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Family Planning. SMC shared an update of the number of family planning products (including IUDs, Implants and Injectables) they have delivered during 2017. AUHC will continue to look for ways to collaborate with SMC and learn from their experience of transitioning from a donor reliant project to a social enterprise. Guidelines. Building on the work done by NHSDP, AUHC reviewed all relevant clinic operations guidelines, including clinic management guideline, human resources management manual, financial and accounting manual, monitoring and evaluation plan, MIS database guideline, poor and PoP selection guideline, branding and marking manual. The team aligned these guidelines with SHN operational model and continue to work to integrate them into SHN clinic operations. Throughout the year, a series of visits to SHN clinics were conducted by the NGO Transition team to evaluate various aspects of monitoring and supportive supervision to validate financial and inventory management, reporting practices, data management, and overall clinic operations. Through these visits the team had the opportunity to interact with clinic and project implementation teams of relevant NGOs about the transition of clinics from individual NGOs to SHN. SHN referral system. During the fourth quarter of Year 1, AUHC and partner Ad-din initiated discussions on establishing an effective referral system. For SHN to offer comprehensive services, a designated referral center to provide secondary or tertiary levels of care, or to manage complications must be established. For a facility to become a referral center they must first meet SHN’s minimum standards of quality. Once that has been established, an MOU with the facility must be developed that confirms that they are willing to accept the clients that have been sent by SHN clinics and will manage the problem until it is resolved. Additionally, a referral form will also need to be developed. Clinics within the catchment area of an Ad-din facility can use their hospitals as a referral center. An MOU with them will be developed in Q1 of Year 2 along with the referral form. Satellite and CSP Assessment. During Year 1, Capacity Building Services Group (CBSG) was selected to conduct research on the network’s satellite spots – temporary clinic sites where paramedics and nurses provide on-site care and counseling services. This study will help provide information on the exact role satellites are currently playing in terms of service provision and quality, and how satellite clinics can be further integrated into the service offerings of the SHN. AUHC conducted a training for data collectors and launched the data collection phase of the assessment. The findings from this study will be presented to AUHC during the first quarter of Year 2. During this reporting period, a tender was also released to assess functionality of Community Service Providers (CSP). Specifically, this research would help AUHC determine if the scope of the services and products that CSPs is appropriate for SHN. If it is, what exact role can CSP play. During the proposal review, it was determined that none of the submissions met the minimum requirements of the RFP, so the decision was made to rebid the proposal. This process was relaunched in August 2018, with proposals evaluated in September and selection finalized in October. Client Satisfaction. A questionnaire for assessing client satisfaction was developed and will be implemented in Year 2. Clients will be randomly selected from clinic files to respond to a brief client satisfaction survey via phone. The questions will evaluate how the clinics are meeting to the five global standards of quality (technical expertise, safety, privacy and confidentiality, informed choice and continuity of care. The results of this client Satisfaction survey will be used to develop an improvement plan that will provide the quality improvement team with a set of priorities to address at the clinic level. Partnership with Pharmaceuticals. In February 2018, AUHC signed Memoranda of Understanding (MoU) with 15 pharmaceutical companies to ensure uninterrupted supplies of medicines to all 399 clinics. Through this support, clinics will be earning additional markup from drug sales as well as

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subsidizing poorest-of-poor (PoP) clients. The MoUs also allowed the clinics to receive a one-month drug supply on credit. This is a key step to replenishing the revolving drug fund account of each clinic assuming that NGOs are unwilling or unable to turn over their RDF to SHN after the clinics transition. IR 2.2 Increased Informed Demand for Essential Services Package

Demand generation. In the Year 1, AUHC focused on maintaining services and ensuring the quality of services maintained properly during the clinic transition. AUHC also explored future opportunities to expand services in some of these clinics, including provision of evening services and positioning part-time specialist doctors at rural clinics. Social Behavior Change Communication. Members of the AUHC team met with USAID’s Ujjiban project to discuss potential areas of collaboration related to SBCC and mass media communication. Their media spots and other materials respond to AUHC needs in terms of SBCC. AUHC drafted materials to improve motivation among providers and promote normal deliveries. These items included bay T-shirts and caps with the SHN logo. These materials will be tested during clinic visits during the first quarter of Year 2. Throughout the year, clinics across the network collaborated with the government of Bangladesh and other stakeholders to observe the International Women’s Day, World Health Day, World Population Day and World TB Day. AUHC supported the clinics with required guidelines and logistics to bring uniformity across the network to observe those days. During the observation day, the clinics were engaged to promote the services by introducing health fair and special service campaign to address specific target groups. Going forward, a comprehensive demand generation plan will be developed in Year 2.

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RESULT 3: SUSTAINABLE FINANCIAL SYSTEMS DEVELOPED TO FACILITATE EXPANDED COVERAGE AND TO ENSURE EQUITABLE ACCESS TO HEALTH SERVICES

Overview of accomplishments. During Quarter 4, AUHC conducted a review of poverty targeting mechanisms to pin point the gaps, challenges, and opportunities for SHN clinics to balance subsidy funding. AUHC also reviewed existing initiatives within and outside of clinic network targeting the ready-made garment (RMG) industry and producer/self-help groups to explore and identify opportunities for SHN to pilot employer-based group benefits. AUHC also developed a draft framework for monitoring and assessment of SHN performance in balancing financial sustainability and its pro-poor mandate. Year 2 focus. With learning from Year 1, AUHC will assist SHN to define its approach for serving the poor by reviewing pricing strategies and the effectiveness of methods to identify the poor. AUHC learned improvement of poverty targeting mechanism and financial protection strategy will be a core foundation for developing sustainable financial coverage with knowledge gathered from local and global practices. With additional learning from the NHSDP guidelines, HFG workshop and Ad-Din’s experience and practice operating 79 SHN clinics, AUHC has been able to define the scopes to compare various targeting tools and recommend strategies to sharpen this mechanism so that the poor and those that are unable to pay have affordable access to services, and those that can pay do so at a level or above that helps SHN recover costs. In the process, AUHC will work with SHN to align its service provision, targeting, and client service orientation to the requirements and expectations of the Government of Bangladesh (GoB) so that SHN could potentially be a preferred provider network for strategic purchasing of services on behalf of the poor. Green Delta, working with AUHC will develop insurance and prepayment products to create greater access SHN clinics. IR 3.1 Subsidy Funding to Cover the Poor Operationalized

Review of the current policy and practices of poverty targeting. As the first step, the functional review within Smiling Sun and project years have already started to showcase interesting findings. In Quarter 4 of Year 1, AUHC reviewed the subsidy funding sources and poverty targeting guidelines currently in practice within SHN clinics. A first level observation and desk review indicated for an in-depth functional review of current policies and practices for poverty targeting. This learning has also been complimented by the knowledge of MIS data that shows distorted numbers between clinic level revenue and discounts provided to poor and pro-poor. Hence, setting the course right with a functional review of the targeting mechanism has been prioritized before jumping in to recommendations. IR 3.2 Prepayment/insurance package developed and available

Insurance pilot. AUHC continued working with Green Delta Insurance Company (GDIC) to structure an insurance pilot. In the last quarter of Year 1, The AUHC incubator and Green Delta together started looking at the data of SHN clinics to understand the scope of a potential pilot, in terms of locations and clinics, services and benefits to offer to the target population. The initial idea with which the team goes into the workshop is to focus on a cohort (size to be determined) of clinics and their respective catchment population, from the SHN Business Unit Clinics. The most important milestone of this area has been defining the first level scope of work for Green Delta that will compliment SHN pricing strategy and revenue growth strategy by serving the pro-poor mandate.

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IR 3.3 Optimal Client Mix Secured to Balance Financial Sustainability and Pro-Poor Mandate

Review of the current financial system. AUHC is continuing to use the current system for identifying poor and poorest-of-poor clients. The Incubator began reviewing the existing mechanism for forecasting optimal client mix, and different examples and case studies to develop a draft framework for monitoring and assessment of SHN performance in balancing financial sustainability and its pro-poor mandate. However, this task has a long-lasting impact on SHN’s financial sustainability plan and will build up gradually by end of Year 2. There were recommendation and general understanding to highlight this IR as a connecting piece to multiple indicators for SHN. Optimal client mix is not a stand-alone activity, rather a multiplication effect of pro-poor targeting and subsidy funding, bundling of services and overall SHN pricing strategy for revenue growth and protection. Thus, by end of Year 2, AUHC will start to build up the sustainable financial mix with components from different results and activities across AUHC project.

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RESULT 4: IMPROVED QUALITY OF CARE

Overview of accomplishments. During Year I, AUHC Quality Assurance team put substantial effort into protocols, guidelines and checklists designed to assist clinical staff to deliver high-quality health services. A PSI QA and QI consultant worked with the AHUC quality team to develop protocols, guidelines and checklist for measuring the quality of services offered by SHN. Family planning and ANC service checklists were piloted in three clinics in Rajshahi region, while others are waiting to be tested in other SHN clinics in Year 2 Quarter1. The QA team worked with the MERL team worked to ensure that PMP indicators were structured in a way where they could be measured. The QA team began working with the transitioned clinics. The team visited six clinics and confirmed the 2017 GHPRO findings of significant clinical training needs within SHN. Most clinic staff have not received training in the last 24 months. In September, AUHC undertook a training need assessment for 52 clinics and prepared a training plan for Year 2 based on this assessment. In the AUHC Year1 work plan, we planned to recruit regional quality assurance managers who could work in the regions. That recruit took longer than expected. Candidates have been identified, screened and will be onboarded in Quarter 1 of Year 2. Year 2 focus. The AUHC approach to quality focuses on three main points: SHN customers, SHN staff, and the broader SHN system. AUHC will work to empower clinic staff to make their own decisions related to quality of care. This will include an approach that re-orients and trains staff to have a stronger customer focus. To support this, AUHC will introduce tools for clinic managers and staff to gauge and improve customer experience and implement the AUHC quality assurance and quality improvement system. AUHC regional staff will also place more emphasis on observing procedures, and will play more of a support role by providing more supportive training and mentoring as opposed to oversight and inspection. IR 4.1 Improved Customer Experience

Mystery Clients. In this quarter, AUHC developed questionnaires for “Mystery Clients” for prototyping a tool to measure customer experience. In addition, another set of questionnaires have been developed for telephone follow-up of the clients whenever supervisors visit the clinic. These are open-ended questions and will be asked over telephone by random selection method and documented in health record card at the clinic. Clinic managers will also use these questionnaires to follow-up with 10 clients per month to assess client satisfaction. These questionnaires will be tested at clinic level in first quarter of the Year 2.

IR 4.2 Continual Quality Improvement Systems Implemented

Service delivery tools. The QA team developed checklists for FP, MCH, adolescent health, TB service and non-communicable diseases services in line with GoB, and existing NHSDP quality management systems. Standards and Protocols were also developed. The standards and protocols of SHN that are in line with the GoB guidelines that will be implemented in SHN clinics. Services areas covered in the protocols include FP, ANC, PNC, C-section, and Normal Delivery. The QA team also developed protocols for general readiness areas as in indoor and outdoor patient management, infection prevention, cleanliness and referrals. The team defined processes and oriented 20 clinic staff from SHN Business Unit clinics for piloting the implementation of the five quality assurance standards. Standards and Protocols will help improve quality of care, health system effectiveness as well as client's satisfaction. National (GOB) Family Planning protocol is collected and distributed among SHN Business Unit Clinics. Adverse event reporting. AUHC also developed an “adverse event reporting” guideline for the clinics. In this guideline, adverse events will be reported according to FP, MNH and other services. When adverse event occurs, the case will be investigated for learning purposes as well as preventing future

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events. Clinic managers will be oriented in the adverse event guideline as they are the person responsible for reporting an event to the SHN Regional Quality Assurance Manager. The Quality Assurance Regional Manager will inform the AUHC QA & QI Director who will inform the AUHC Chief of Party. The QUHC QA & QI Director will assume overall responsibility for ensuring that lessons learned are documented and staff are trained to prevent future occurrences. IR 4.3 SHN Staff Are Skilled and Retained

Staff satisfaction and motivation schemes for SHN. The QA team is working to test several staff satisfaction and motivation schemes in SHN clinics. These will be tested in Year 2. AUHC also developed a training plan for 100 SHN business unit clinics.

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RESULT 5: IMPROVED PROGRAM STRATEGIES DRAWN FROM LESSONS LEARNED

Overview of accomplishments. The MERL team finalized the research methodology and ensured quality data collection for Satellite Spot assessment. The team also provided research oversight for the Market Landscape research. The final report for both the studies is due in the first quarter of Year 2. The CSP functionality assessment procurement was re-advertised in September 2018 as the initial set of proposals were considered non-responsive. The project submitted draft version of the MERL plan to USAID in June 2018. Related to this, the project organized a workshop with USAID and the AUHC team to finalize the AUHC PMP indicators. AUHC consulted with USAID and AUHC Results Team leaders on the Collaborating, Learning and Adapting (CLA) approach. The result of which was a draft Learning Framework. The purpose of this framework was to build a systematic learning sharing culture in the project. AUHC also organized the annual reflection workshop and captured Year I lessons learned. AUHC MERL built on the existing database management systems used by NHSDP and oriented NGO M&E officers to align their work with AUHC PMP indicators. In addition, the MERL team has implemented a SQL database for faster and smoother data management at the central level. Alongside, we have introduced an online based clinic monitoring systems-SurveyCTO to analyze data quality and compliance monitoring at the clinic level. Year 2 focus. The MERL team will continue ensuring quality control of the data for research and prototyping activities undertaken by AUHC project. The team will work closely with the agencies to ensure that the results are aligning with the intended objectives for the research. The team will provide feedback on the preliminary results and final reports as needed. The team will place a heavy emphasis capturing lessons learned from the program implementation, different research and prototyping agenda. The team will work with the AUHC incubator on three prototyping concepts; a) extended clinic hours with existing services, b) extended services, and c) expanded laboratory and diagnostic capacity. The team will be responsible for rolling out and managing the Chemonics DevResults system. This project data management tool will be tailored to meet AUHC’s project management needs. The system has the capacity to provide access for USAID to see aggregated indicators updates in the system dashboard. As part of capturing the lessons learned throughout the year, the MERL team will organize quarterly “pause and reflect” and annual portfolio reflection workshops. The team will also work closely with SHN for publishing monthly newsletter and developing communication materials. IR 5.1 Capture Learning through Documentation, Research, and Analysis

Research quality control. The AUHC MERL team consulted with Measure Evaluation, GHPro and NHSDP to internalize readily available data and information. We have built on the Measure Evaluation analysis and preliminary findings of “NHSDP Impact Evaluation” to draft methodology and tools for Market Landscape, Satellite Spot assessment and CSP functionality assessment. In August AUHC awarded the Satellite Spot Assessment activity to Capacity Building Services Group (CBSG). The aim of this activity is to gain more knowledge about the characteristics of satellites spots, the perceived quality of care provided at satellite spots, and a cost benefit profile of Satellite Spot. CBSG used both qualitative and quantitative approaches for this study. AUHC finalized the methodology and tools for data collection incorporating feedback from USAID. AUHC randomly monitored real time data collection to ensure data quality. Moreover, MERL team conducted three onsite data collections observations. The first draft of the study report is due in mid-November 2018. AUHC contracted out the market landscaping study to the ResInt and MRCB for managing providers’ research, and consumer research respectively. AUHC has applied best practices to enable quality of data collected for both studies. We have received approval from the PSI ethical review

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board for the study design. In that, the agencies are contractually required to adhere to the ethical guidelines outlined in the approved study design. At the end of Year I, consumer research data analysis has been completed and data collection for the provider research is continuing. The functionality assessment of CSPs is in the phase of contracting out. This activity will be completed by January 2018. The status of research activities by the end of Year I is shown below.

Figure 13: Status of different research activities in the Year I. SSK Collaboration. The MERL team collaborated with SSK (Shasthyo Surokhsha Karmasuchi) to acquire first-hand knowledge from pilot implementation in 3 Upazillas (Kalihati, Ghatail and Modhupur) in the Tangail district. We have partnered with SSK to organize SSK lessons learned workshop in September 2018. We have visited the implementation sites as part of PSI-electronic management systems in July 2018. Supporting the EMR/MIS development. AUHC MERL team worked very closely with the PSI EMR/MIS development team. The MERL team helped facilitate visits to on observe field implementation of other existing systems implementing under MOHFW. MERL team provided all required documents to the development team; updated indicators table, service codes and service list, and existing MIS data. We also provided technical input on the initial design of the paper-based systems. Going forward, the MERL team will engage in the final design of the systems including training of the clinic staff and monitoring of the pilot implementation. Development of the Learning Framework. The MERL team has drafted the Learning Framework exploring Collaborating, Learning and Adapting toolkit in the USAID Learning Lab. The components of the framework are; a) Sources of lessons, b) Process of collecting lessons, and c) Capitalization of the lessons learned. The framework incorporated key tools-After Action Review, and Lessons Learned Practical Approach for capturing lessons learned. The team has captured Year I lessons learned using the tools after discussion with program team. Going forward, AUHC will engage Home Office MEL expert to finalize the Learning Framework.

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IR 5.2 Apply Learning to Activities

Lessons learned. During Year 1, AUHC gained considerable practical experience. The MERL team captured important lessons applying After Action Review and Lessons Learned Practical Approach tools in different stages of implementation. Below are some of the critical lessons learned: Clinic management transition. Because clinic transition was such a significant activity in many ways in Year 1, we learned more about that process than others. Also, the transition itself unfolded differently during Year 1 than we had anticipated. Initially, AUHC envisaged a more gradual transition. However, in consultation with USAID, the project accelerated the pace of transition to move management of the entire network under SHN management by the end of Year 2. This process yielded valuable lessons that required midcourse adjustments that help guide AUHC’s transition efforts, but will also be valuable to SHN as it takes over the management of the clinics; • NGO resistance: AUHC We anticipated resistance to the clinic management transition from the

NGOs, which we did experience. The opposition and tension around the clinic management transition varied from reasonably mild and understandable to outright hostile. Regardless of the degree, AUHC was prepared for it. The phenomenon that AUHC did not anticipate, was that the resistance was far more pronounced at the NGO HQ level than it was in the clinics. On one hand, this is understandable because in most cases, apart from those few NGO HQ staff that were being picked up by AUHC or SHN, NGO HQ staff were losing their jobs. Conversely, AUHC made it clear to all clinic staff that, assuming they wanted to be, they would be hired by SHN for an initial period. Nonetheless, we had expected more resistance from clinic staff as many staff had worked for a very long time with the NGO or in a clinic. However, our experience has been that clinic staff welcomed the transition and were extremely supportive of the notion of being employed by SHN.

• Clinic managers as assets: Somewhat related to the point above, during many of the transition

meetings it became clear that many SHN clinic managers that are committed to their work and dedicated to the cause of SHN. It This was evidenced by the fact that many Swanirvar staff had not been paid for the period May to October due to an internal legal case. Despite this, almost all staff continued to work and provide good service. Furthermore, many of the SHN clinic managers had been underutilized in terms of their capacity to expand and improve SHN services. As a result, the AUHC Year 2 work plan places considerable emphasis on the clinic managers seeking to further engage them and build their capacity.

• Pace of the transition: AUHC in consultation with USAID decided to accelerate the transition of

the NGO clinics to SHN. During the first half of Year 1, it became increasingly clear that a short and complete transition would allow SHN to spend more time and resources to strengthening quality, expanding revenue generation opportunities, and building financial protection mechanisms that would better ensure the long-term sustainability of the network. Considering all factors, and recognizing the limits to a more accelerated pace, AUHC ultimately employed a geography-based transition (as opposed to NGO-based) transition strategy. This allowed more people to be transitioned at one time.

• Clinic hiring practices: As AUHC transitions clinics, we have come to learn that several relatives of

clinic managers and others NGO are currently employed in SHN clinics. Quite apart from the fact that this is a violation of the SHN policy we have learned that many of them are not qualified or certified. This came to light when Ad-din did a training assessment of the 79 clinics that they inherited from JTS, PSTC, Kanchan Samity and UPGMS. We learned that many need training, a fact that has been broadly recognized. However, the issue is that a proportion of

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these paramedics have not graduated from an accredited paramedic training program. This has implications as SHN moves forward with training paramedic staff.

• Communications: We discovered early in Year 1 that we needed to garner the support of local

government officials and communities to help facilitate the clinic management transition. The best way to do that was a multi-pronged communication approach that combined face to face meetings as well as written communication. We also learned that doing this well in advance of the actual transition date was useful.

Data management. SHN data on all levels has proven to be challenging in unexpected ways. This includes but is not limited to financial data, service statistics, drug consumption and equipment inventory. In some cases, the issue is the system itself. The former NGO network was not engineered to capture and present data in standard way that will be valuable to SHN without a considerable amount of manipulation. Said another way, NGOs have collected and recorded data differently leading to a lack of standardization making it difficult to make comparisons between clinics run by different NGOs. In other cases, it is a question of data quality. This is more related to collection systems where field data is manually recorded and then transferred to a master list or ledger. Specific issues include: • Data quality: We have found that data from CSPs is unreliable. In some cases, it is a question of

the system they use to capture the data. There is also an accentuality issue here. Community Service Provider’s work in the community is often unsupervised; at least directly. As a result, the opportunity to do real time or meaningful data quality checks are not possible. This is important when you consider that a large proportion of SHN service contacts are from CSPs.

• Data use: Under the SHN system, clinics and NGO project directors collected a voluminous

amount of information; all of which takes time and money. People don’t know why they are collecting the data, nor how to use it to make management decisions. In most cases it is not presented in a useable form to allow for managers to make informed decisions. AUHC’s experience thus far is that the current data architecture provides little or no sense of what is going on in the Surjer Hashi Network. Furthermore, the current data system lacks accountability. Input or providing poor quality data has no consequences. Because SHN’s business philosophy is based on product and service quality, data, business discipline and rigor the SHN data situation will need considerable attention.

Lack of standardization. The lack of standardization throughout the Smiling Sun network is far-reaching and the extent of it unexpected. This phenomenon is cross-cutting, affecting almost every aspect of the network from finance and accounting, to clinical practices, staffing, product and service pricing, and drug inventories. AUHC is responding by ensuring that there is a behavior change component in as many interventions as needed. This is based on the system that standardization is more related to human behavior and adherence to protocols and guidelines than anything else. Compliance monitoring systems. As per recommendation of the AUHC family planning compliance committee, MERL team has introduced an online application-based tool

that helps AUHC capture, transport, and process data collection during clinic site visits. The system incorporates six clinic monitoring checklists that cover sixteen different areas. They include branding and marking, family planning compliance, gender, hygiene and cleanliness, data quality, and clinic management. The MERL team will observe the submission on a trial and error basis for several months and update and fine-tune checklists as needed. Gender. AUHC organized a training for the project team to understand gender integration. The objectives of the training were to understand USAID’s policy on gender, to learn about how gender

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is integrated into each intermediate result for the project and to build an understanding on how gender should be taken into consideration across SHN clinics. Additionally, AUHC has developed gender policy for SHN in the Year 1. The goal of this policy was to ensure equal access of both men and women to quality services at SHN facilities. This will continue to be updated throughout the life of the project. Pause and Reflect workshop. As part of Pause and Reflect workshop, MERL team organized a workshop for NGO M&E officers twice in the Year I. The first one organized in March 2018, the aim was to orient staff on project level indicators with an emphasis on data quality. Second workshop organized in September 2018 with in-depth analysis on the reported data. We shared many improvement areas in terms of improving data quality. The M&E officers shared their experience and limitations and agreed to move with the revised data quality control guidelines. We have also oriented them on new service codes related to TB, FP and MNCH services to report on. Annual Reflection Workshop. AUHC organized the annual reflection workshop in July 2018. The annual progress against approved year-one work plan activities was reviewed in this workshop. Several observations came out of that meeting, they were: • SHN should form a board sub-committee that can work on the establishment of an SHN for

profit subsidiary. • A new strategy for Chattogram Hill Tracks aligned with GoB’s policy must be initiated. • Clinic upgrades such as painting, repairing and replacing furniture and clinical equipment needs

to be a priority and will increase customer experience. • Ad-din is doing a training needs assessment for the 32 former JTS clinics. After this, AUHC

needs to develop a training plan to train all clinic staff starting with direct service providers. • All abstracts and study findings must be shared with USAID before international dissemination. • “Pause and Reflect” workshop” should be a regular event to share lessons learned. • Share draft Learning Framework with USAID. • AUHC will explore DevResults as a project management tool.

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Data quality assessment. The USAID conducted a DQA visit to SHN clinics managed by Ad-din and CWFD clinics in Gazipur, Mymensingh, Netrokona from in September. The DQA team has collected three months (April-June 2018) clinic data for cross checking with clinic’s database. In most cases they found data are consistent. At the Atpara clinic, the team found that CSP reported data follows a pattern. The team visited a Satellite clinic run by Purbadhala clinic and discussed with service providers. They met with the paramedics, service promoters and CSPs there. The USAID team talked with SPs and CSPs and identified that the data patterns occurred because of the CSPs are not completing the service record sheet on daily basis. In the Year 1, MERL team visited 14 clinics including satellite and CSP activities in Sylhet, Mymensingh and Rangpur region. The objective of these visits was to verify the data collection, entry, reporting quality and use of data for decision making. The team talked with clinic managers, service providers and the data person to collect information on the generation of data providing services to the clients. The team visited the Satellite clinics and talked to the Paramedics, service promoters and CSPs who are basically providing service remotely. The key findings are highlighted below:

• Service Promoters are performing data reporting on behalf of the CSPs which raises a huge recall error in data reporting. Sometimes, it is difficult for CSPs to fill the customer record sheet due to their limited educational backgrounds. In most of the cases they didn’t complete 8th grade of education.

• The CSPs are commonly distributing health and hygiene products oral pills, condoms, oral rehydration salts (ORS), sanitary napkins, safety kits for delivery, and zinc tablets. The commodities are widely varied from NGO to NGO and clinic to clinic.

• MERL team founds inconsistency in data reporting mostly at static and CSP level. • Revenue data from MIS system were not matched with MFRR because of poor data cleaning. • The team found there is very limited use of data for decision making at the clinic level. • The clinics are maintaining good data entry systems. • NGO HQ provides very limited feedback on improving data quality to the clinics.

The MERL team disseminated the findings with the clinic staff and NGO management and provide them clear guidance to improve the overall data management systems at different levels. SHN business strategy workshop. The MERL team presented the price and cost information from the desk review of the CSP and Satellite Spot assessments in the business planning workshop. As part of the outcome decision from the workshop, the team involved largely in the prototyping ideas led by Incubator team. MERL team has established hypothesis and measurable indicators for selected prototyping ideas; a) Extended clinic hours; b) Expansion of specialized services; and c) Expansion of diagnostic services. Going forward, MERL team will work closely with Incubator to set up the baseline information to measure the outcome of prototyping ideas. Compliance monitoring systems. In the Year I, MERL team has introduced an online application-based tool that helps AUHC capture, transport, and process data collection during clinic site visits. The AUHC FP compliance committee strongly recommended for this development. The system incorporates six clinic monitoring checklists that covers sixteen different areas, such as branding, family planning compliance, gender, hygiene and cleanliness, data quality and clinic management. The MERL team oriented AUHC team on the SurveyCTO tool. We will analyze the submission on a trial and error basis for the first few months and continue updating the checklists down the road. Communication materials. AUHC developed communications materials for the project as well as SHN. This includes, AUHC project fact sheet, transition one pager, transition letters for the district

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administration and health and family planning officials, SHN fact sheet, and project administrative materials. A monthly newsletter for SHN has been developed that is disseminated internally. The project also developed social media platform including Facebook and twitter. The AUHC outreach activities have been continuously updated in the Facebook page. The Facebook page became popular among the network and it has counted 1,200 followers till September 2018.

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PARNTERSHIPS AND COLLABORATION Leveraging partnerships. AUHC signed MOU with 15 pharmaceutical companies to receive drugs approximately 10% below the trade price. AUHC also leveraged one month deferred payment for clinics. Chevron has a history of supporting three clinics in Kalapur, Swastipur, Karimpur clinics in Sylhet region. Chevron is shifting their approach and preliminarily agreed to provide $50,000 per year for extending eye services in selected SHN clinics in Sylhet. The scope of services will focus on correcting refractory error. AUHC is also finalizing discussions with Jeeon to leverage their 500 plus pharmacy outlets to act as referral agents for SHN services. Collaboration. AUHC has ties to several other USAID health programs for leveraging resources, including:

USAID Program Area of Cooperation Ujjiban SBCC Advancing Universal Access to Family Planning (AUAFP)

Family Planning

Challenge TB TB (technical assistance and coordination) Social Marketing Company (SMC) Referral opportunities through Blue Star

pharmacies, TB (pharmacy referrals and notification applications), social marketing best practices and experience sharing

Icddr,b Operational research, TB Integrated Community Health Worker (ICHW) Activity

CSP

Measure Evaluation Clinic assessments MaMoni MCH

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PROJECT MANAGEMENT Programmatic. The AUHC project has employed an operator-incubator model to complete the transition of Smiling Sun clinics to SHN, build and operationalize systems to ensure SHN’s readiness to manage a grant from AUHC, and develop innovative strategies for improving service quality and promoting sustainability. From the outset, AUHC established a project management unit (PMU) with Chemonics International Home Office members (director, managers, and associates). AUHC mobilized a home office start-up team comprising the PMU, as well as grants and security specialists to initiate field office operations and establish financial and administrative procedures. Simultaneously, remaining PMU members in Washington, DC, continued subcontract negotiations with ThinkWell and PSI, facilitated consulting agreements with local staff (for the period before registration and/or subcontracting with a Bangladeshi payroll firm), procured initial IT equipment, and facilitated vendor payments. The Chief of Party has designated results team leaders for management responsibility to ensure all the planned activities completed in a cohesive manner maintaining quality standards. Incubator Director leads Result 1. Service Delivery Advisor

is responsible for Result 2. Revenue Generation Advisor leads Result 3, and , director of quality improvement and quality assurance, leads Result 4.

, the AUHC MERL Director, is responsible for Result 5. The AUHC COP convenes a weekly result leader meeting with the results leaders and other key AUHC technical staff to check progress on activities and coordinate implementation between result areas. In addition, to facilitate communication and coordination between partners and their respective home office staff, the AUHC CoP convenes weekly partner call with PSI, Thinkwell, and Chemonics home office staff. Because the PSI and ThinkWell home office teams play a significant short-term technical assistance role, these have proven to be useful discussions. In Year 1, SHN CEO , supported by the AUHC Operator, began recruiting for key management positions for SHN. To enable SHN’s operation, AUHC will second or share staff from the Operator until SHN recruits the most suitable candidate for the position. Staff who share (up to 70 percent level of effort) with SHN include: IT Manager , Finance Director

as interim chief financial officer, Senior NGO Transition Advisor as the chief operating officer, and the other NGO transition advisors as the regional advisors

overseeing the clinics. AUHC has provided operational support to SHN in finance, human resources, IT, and procurement, as needed. AUHC key personnel. The COP, and the directors of the MERL and Incubator teams have been with AUHC since its inception. The original quality assurance and improvement director was replaced in June 2018. The director of strategic financing has been a very difficult recruit and remains vacant.

Name of Staff Designation Location Level of Effort Chief of Party Dhaka 100%

Incubator Director Dhaka 100%

MERL Director Dhaka 100% Quality Assurance and

Improvement Director Dhaka 100%

TBD Strategic Finance Director

Dhaka 100%

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Non-key staff. AUHC continues to fill out the staffing chart. Some positions are those that have recently been added to align with programmatic needs. Examples of this included the hiring of regional transition advisors. These are short-term appointments that will help negotiate and manage the clinic management transition. Similarly, AUHC has recruited regional quality managers that can work with the SHN regional staff to improve the quality in SHN clinics. Vacant incubator non-key staff positions are in the process of being filled. Candidates have been identified and screened. ThinkWell is in the process of finalizing those recruits (see Annex A for the AUHC organogram). Financial management. AUHC’s very mandate is the financial sustainability of the Surjer Hashi Network of clinics. As such, the project’s financial management strategy prioritizes cost-benefit-based decision making and cost containment. Project operating expenses are carefully balanced against technical expenses, with priority given to interventions that serve as investments in service delivery, quality improvements, and operational efficiency. Operational cost containment. All project expenditures are managed by Chemonics’ rigorous procurement rules that reduce cost and ensure accountability. Chemonics also purchases equipment on behalf of subcontractors and grantees, thereby eliminating additional overhead expenditures. Additionally, AUHC has developed some initial cost saving measures for SHN – such as office sharing and seconding of operational staff. These measures have reduced initial expenditures that SHN would otherwise incur during start-up. Technical cost containment. Unsurprisingly, Surjer Hashi clinic operations and capacity development are the largest cost drivers. For Year 1, the network was funded through a combination of FAA grants and program income. Each NGO budget was evaluated for its value proposition and grounded in historical spending trends and service delivery outcomes. While the Operator team ensured day-to-day funding for clinic operations, the Incubator team developed prototyping tools to increase revenue generation within the network. These tools were adapted to SHN’s individual business case, and were developed to plan, execute, and measure improvements to the networks’ ability to capture market share and generate sufficient funds to compensate for gradual reductions in grant funding.

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Family Planning Compliance Update AUHC hired as the Compliance Director, and one of her responsibilities is the management of the AUHC family planning compliance plan, as stated in the Year I work plan. The first FP compliance committee meeting was held July 3, 2018, and is comprised of the following members: the COP, Compliance Director, Director QA/QI, Director MERL, and Director of Grants. The Compliance Committee is responsible for ensuring that the health service delivery through the Surjer Hashi clinics is in compliance with all family planning compliance regulations and policy. The chief of party provides ultimate oversight and direction to the FP Compliance committee. During the first committee meeting, the mandate of the committee was established, a review of the responsibilities of the committee were reviewed, and a discussion of how best to monitor AUHC’s family planning compliance efforts was had. One outcome of this committee was the decision to develop an electronic monitoring system that facilitates AUHC’s overall data collection, including but not limited to family planning compliance data at the clinic level. The team selected SurveyCTO-and various monitoring checklists have been uploaded into the system which all staff who visit clinics are required to fill out. Such checklists are not exclusive to just monitoring family planning compliance, but also overall clinic monitoring including clinic quality service provision, financial compliance, compliance with branding and marking requirements and more. Additionally, the Compliance Director began an ongoing process to ensure that all new staff take the two-required e-learning courses: Family Planning Legislative and Policy Requirements and Protecting Life in Global Health Assistance. During the second quarterly family planning compliance committee meeting held on October 18, 2018 data reported from SurveyCTO specifically on family planning compliance from five clinic visits was reviewed by the committee to highlight any areas of concern or additional follow-up. The committee determined no additional investigation or information was required at that time. Data collected from SurveyCTO will be the principal source of data that the family planning compliance committee will continue to monitor during its scheduled quarterly meetings. All AUHC staff have been trained on how to fill out the SurveyCTO forms, with specific responsibility for family planning compliance data collection falling principally to the regional Quality Assurance Managers (along with other AUHC staff members as appropriate). To date, 95% of AUHC staff have completed the two e-learning courses, as AUHC has recently onboarded additional staff. The Compliance Director will provide an in-person all staff training (including onboarded SHN staff) on the applicable USG policies including the Tiahrt Amendment, Helms Amendment, and Protecting Life in Global Health Assistance Policy prior to her departure from Bangladesh. Additionally, AUHC has developed the relevant IEC materials for FP compliance and submitted a requisition of the Tiahrt posters to USAID for distributing at clinic levels.

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RESULTS TO DATE AUHC PMP indicators table with baseline, Year I target, and achievement have been shown in the below matrix. It has been discussed with USAID several times to reach to this draft final version of the indicators list. However, USAID suggested AUHC to continue discussion on the PMP indicators to be finalized in the first quarter of Year II.

Sl #

Indicators Baseline FY17/18

FY18 Target

FY18 Achievement

Q1 FY18

Q2 FY18

Q3 FY18

Q4 FY18

Remarks

1. Number of service contacts provided through AUHC project.

46m4 46m 49.2m 12.2m 12.5m 12.5m 12.0m

2. Number of clients brought under SHN financial protection mechanism.

0 NT N/A N/A N/A N/A N/A There is no target for Y1.

3. Percentage of clinics operating in accordance with SHN developed standard operating procedures (SOP) for business.5

0% NT N/A N/A N/A N/A N/A There is no target for Y1.

4. Percentage of cost recovery for AUHC clinics.

38%6 38% 49.5% - 47.5% - 51.5%

5. Number of Smiling Sun clinics fully transitioned into the SHN network.

0 407 95 - - 32 63 JTS-32 UPGMS-6 PSTC-24 Kanchan Samity-17

4 NHSDP Annual Report December 2017 5 AUHC will develop SOPs for SHN clinics 6 Bangladesh Smiling Sun Clinic assessment inclusion criteria by GH Pro 2018 7 First year target set according the work plan and subsequent year’s target set from GH Pro data

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Sl #

Indicators Baseline FY17/18

FY18 Target

FY18 Achievement

Q1 FY18

Q2 FY18

Q3 FY18

Q4 FY18

Remarks

SSKS-16 6. Percentage of SHN clinics

using MIS developed by AUHC.

0 NT N/A N/A N/A N/A N/A We didn’t set a target for Y1

7. Number of clinics brought under some form of value-based payment mechanism.

0 TBD N/A N/A N/A N/A N/A We didn’t set a target for Y1

8. Percentage of AUHC service delivery sites providing family planning (FP) counseling and/or services

100%8 100% 100% 100% 100% 100% 100%

9. Number of youth service contacts (15-25 years) accessing FPRH counseling and or services.

20,000,000 20,000,000 20,606,435

4,868856

5,211,736 5,406,919 5,118,924 We have recalculated the target and achievements based on imposing logic in the database.

10. Couple Years Protection (CYP) provided by AUHC

1.05m - 1.05m 273,991

265,977 253,467 257,914 We didn’t set a target for Y1

11. CYPs for LARCs (IUD) provided by AUHC clinics

50,744 51,759 50,761 14,485

16,546 8,202 11,528

12. CYPs for LARCs (Implant) provided by SH clinics

17,771 18,126 16,985 5,348 5,903 3,250 2,485

13. Number of short acting modern family planning methods (Injectable) provided by AUHC clinics

1,872,596 1,872,596 1,736,486 409,071

433,707 446,840 446,868

14. Number of total permanent 1,324 1,324 1,056 296 277 264 219

8 AUHC database

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Sl #

Indicators Baseline FY17/18

FY18 Target

FY18 Achievement

Q1 FY18

Q2 FY18

Q3 FY18

Q4 FY18

Remarks

methods (Female sterilization) provided by AUHC clinics

15. Number of total Permanent methods (Male sterilization) provided by AUHC clinics

171 171 173 48 82 37 6

16. Number of facilities offering Permanent Methods (Female/Male sterilization)

75 75 77 77 77 77 77

17. Number of facilities offering LARC modern contraceptive methods (IUD, Implant)

359 359 359 359 359 359 359

18. Number of facilities offering short acting modern contraceptive methods (condom, oral pill, & injectable)

398 399 399 399 399 399 399

19. Number of service contacts with pregnant women that provided counseling on nutrition or adoption of IYCF practices.

1,032,434 1,032,434 1,039,544 236,558

258,617 272,303 272,066

20. Total number of facility deliveries in AUHC supported facilities

33,896 33,896 37,153 10,490

8,982 8,696 8,985

21. Number of births delivered by a skilled birth attendant supported by AUHC

45,232 45,232 45,186 12,764

11,078 10,591 10,753

22. Number of LARCs provided within seven days of delivery among women who delivered at AUHC clinics or whose

- - - - - - - This is new indicator. We have included in the new service codes in the clinic database to collect

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Sl #

Indicators Baseline FY17/18

FY18 Target

FY18 Achievement

Q1 FY18

Q2 FY18

Q3 FY18

Q4 FY18

Remarks

child birth was assisted by AUHC health providers.

information for setting up baseline and targets in Year 2.

23. Number of AUHC clinics offering NCD (hypertension, DM) screening.

2889 370 378 378 378 378 378

24. Case notification of TB from AUHC supported clinics as part of zero urban initiatives.

4,636 4,636 5,837 1,474 1,519 1,404 1,440

25. Number of health service contacts with males provided by AUHC

4,100,000 4,100,000 4,171,937 839,569

1,070,642 1,148,678 1,113,048

26. Number of ANC service contacts provided by AUHC

1,980,505 2,020,115 2,064,285 488,529

525,161 539,344 511,251

27. Number of ANC service contacts that included PPFP counseling

- - - - - - This is new indicator and will be reported in Year 2.

28. Number of newborns receiving PNC within 48 hours of birth from AUHC supported skilled provider

305,532 317,753 324,206 77,580

83,566 85,025 78,035

29. Number of newborns receiving ENC service within 72 hours of birth.

352,934 352,934 352,534 82,954

91,598 92,610 85,372

30. Number of ANC and/or PNC visits where 30 IFA is provided

1,681,931 1,681,931 1,680,448 385,86

429,933 450,811 413,839

9 Indicator 26-29 and 31-33: NHSDP Year Five (Jan-Dec 2017) database.

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Sl #

Indicators Baseline FY17/18

FY18 Target

FY18 Achievement

Q1 FY18

Q2 FY18

Q3 FY18

Q4 FY18

Remarks

or prescribed 5 31. Number of women giving

births who received uterotonics (misoprostol/ oxytocin) in the third stage of labor (or immediately after birth).

37,210 - 37,153 10,490

8,982 8,696 8,985 We didn’t set a target for Year 1

32. Number of AUHC facilities that provide appropriate lifesaving maternity care (7 functions for BEmONC).

4510 45 45 45 45 45 45 45

33. Number of AUHC facilities that provide appropriate lifesaving maternity care (9 functions for CEmONC .

48 48 48 48 48 48 48 48

34. Number of children less than 12 months of age who received Penta3 from AUHC clinics.

310,076 310,076 309,196

77,372

83,196 73,528 75,100 We have set the target on Penta3 plus Polio. We are calculating the progress in same manner.

35. Number of service contacts of children aged 6-59 months who received Vitamin A in AUHC catchment area (including NID)

1,840,174 - 1,840,174 - - - - We didn’t set any target for Year 1. Vitamin A is distributed during the NID usually in July and December. This data is not reported into clinic regular database. We have collected this information

10 This includes 18 midway homes run by Green Hill

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Sl #

Indicators Baseline FY17/18

FY18 Target

FY18 Achievement

Q1 FY18

Q2 FY18

Q3 FY18

Q4 FY18

Remarks

in a separate format. We have target and regular information from Year 2.

36. Number of cases of child diarrhea managed through AUHC clinics.

2,407,662 2,407,662 2,323,558

606,157

594,217 589,687 533,497

37. Number newborns not breathing at birth who were resuscitated in AUHC clinics

5,696 - 5,696 - - - This a new indicator. We have collected information in a separate format. From Year 2, we have target and regular data for quarterly reporting.

38. Number of cases of child pneumonia treated with antibiotics through AUHC.

277,467 283,016 288,254

66,156

76,288 75,070 70,740

39. Number of service contacts with children under 5 included in growth monitoring program (GMP) in AUHC target areas.

1,311,590 1,311,590 1,302,445 338,712

351,005 314,414 298,314

40. Percent of population in AUHC catchment areas who are aware of AUHC clinics

36%11 - - - - - - No target for Year 1. This indicator will be calculated in mid-term evaluation or any population-based survey.

41. Number of families covered under any form of financial protection mechanisms

- - - - - - Baseline and target will be set up in Year 2

11 MEASURE Evaluation NHSDP Impact Evaluation data-2017

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Sl #

Indicators Baseline FY17/18

FY18 Target

FY18 Achievement

Q1 FY18

Q2 FY18

Q3 FY18

Q4 FY18

Remarks

42. Percent of poor AUHC clients who are benefiting from subsidy fund/discount

- - - - - - Baseline and target will be set up in Year 2

43. Number of people enrolled in SHN insurance schemes

- - - - - - Baseline and target will be set up in Year 2

44. Number of clients who are making full payment for services.

- - - - - - Baseline and target will be set up in Year 2

45. Percentage of customers satisfied with AUHC services

TBD TBD - - - - Baseline and target will be set up in Year 2

46. Number of clinics implementing a continuous quality improvement plan developed by AUHC

- - - - - - - Baseline and target will be set up in Year 2

47. Number of staff trained in FP (pill, condoms, injectable, LARC, PM), delivery, ANC, ENC, Sick child care, child health, nutrition, NCD & RH IPP, waste management within last 24 months.

- - - - - - - Baseline and target will be set up in Year 2

48. Percentage of staff satisfied in SHN clinics.

TBD12 - - - - - - Baseline and target will be set up in Year 2

49. Percentage of staff retention in AUHC clinics

86.4%13 86.4% 87.6% - - - 87.6% This is annually reported indicator. We have

12 Baseline and target will be set from the AUHC customer satisfaction survey conducted in year 1. 13 NHSDP report “Report on The Study of Causes of Employee Turnover in SH NGOs And Development at a Customized Employee Retention Strategies-2016”

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Sl #

Indicators Baseline FY17/18

FY18 Target

FY18 Achievement

Q1 FY18

Q2 FY18

Q3 FY18

Q4 FY18

Remarks

collected data in separate format.

50. Number of research/ studies conducted under AUHC project

0 4 4 - - 3 1 ­ Market Landscape: Consumer Research ­ Market Landscape: Provider Research ­ Satellite Spot Assessment ­ CSP Functionality Assessment

51. Number of learning activities conducted (pause and reflect workshops and attend or arrange conferences.)

0 4 3 0 0 3 -

52. Number of learning agenda or lessons incorporated or adapted in program implementation.

0 4 4 0 0 2 2

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Annex-B: SHN organogram

Annex C: Financial Report AUHC Expenditures for the reporting period

AUHC Expenditures

FY 2018 Planned Expenditures

FY 2018 Actual Expenditures

FY 2019 Planned Expenditures

*Based on Chemonics accounting systems accrued but not invoiced amounts are

included in subsequent invoices ** The line item includes (per our proposal budget),

and other kinds of costs that go to NGOs or SHN to manage and operate clinics.