proposal form -...

ROUND 10

R10_CCM_PKS_MHSS_PF_s1-2_27Sep10_En.doc 1/28

Deadline for submission: 20 August 2010, 12 Noon CET Clarified: Malaria HSS Response in table below

Applicant Name Country Coordination Mechanism (CCM) Pakistan

Country Pakistan

Income Level Refer to Annex 1 in the Round 10 Guidelines

Low Income

Applicant Type CCM

Sub-CCM

Non-CCM

If your country is also part of a Round 10 multi-country proposal, indicate for which disease(s)

HIV

Tuberculosis

Malaria

Currency USD

Euro

Disease Title

Does the proposal include cross-cutting health systems strengthening interventions? Indicate yes or no and Include sections 4B and 5B in one proposal only

Is this being submitted as a consolidated disease proposal?

Indicate yes or no

HIV

Choose either Regular or MARPs reserve

Regular

Cannot submit request for cross-cutting health systems strengthening with a MARPs reserve proposal

MARPs Reserve

Tuberculosis

Malaria

Expanding Coverage of Malaria Control Interventions in 38 Highly Endemic Districts of Pakistan.

Establishing and Integrated SLM System and Strengthening Human

Yes No

PROPOSAL FORM – ROUND 10 SINGLE COUNTRY APPLICANT SECTIONS 1-2

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Resource Management

MANDATORY SECTIONS OF THE PROPOSAL FORM:

A) Complete sections 1-2 only once per applicant1

Section 1 Funding Summary and Contact Details Section 2 Applicant Summary and Eligibility

Membership Details (CCM or Sub-CCM) Eligibility Form (if applicable)

B) Complete sections 3-5 once for each disease proposal2 Section 3 Proposal Summary Section 4 Program Description

Performance Framework or Consolidated Performance Framework Pharmaceutical and Health Products List (if applicable) Work Plan

Section 5 Funding Request

Detailed Budget OPTIONAL SECTIONS OF THE PROPOSAL FORM: If relevant, complete sections 4B and 5B only once per applicant and include with only one disease proposal Section 4B Cross-cutting health systems strengthening interventions

Section 5B Cross-cutting health systems strengthening funding

1 The applicant only needs to submit a single section 1-2 as part of the application, even when applying for multiple diseases. 2 The applicant needs to submit a section 3-5 for each disease proposal submitted.

INDEX OF ALL PROPOSAL SECTIONS

IMPORTANT NOTE:

We strongly recommend applicants use the information below as an essential reference while

completing the Proposal Form and other application documents. It is very important to carefully read each section in the Round 10 Guidelines at the same time as filling out the proposal and other application documents in order to submit a complete application. All other Round 10

documentation is available on the Global Fund’s website.

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SECTION 1: FUNDING SUMMARY AND CONTACT DETAILS

1.1 Funding summary

Disease Round 10 Funding Request

Year 1 Year 2 Year 3 Year 4 Year 5 Total

HIV

Tuberculosis

Malaria $18,718,247 $6,358,597 $16,588,071 $9,118,011 $5,350,254 $56,133,180

Cross-cutting HSS interventions

Insert disease name

$8,503,020 $6,696,720 $2,081,720 $1,681,720 $2,631,720 $21,594,900

Total Round 10 Funding Request $77,728,080

1.2 Contact details

Primary contact Secondary contact

Name Khushnood Akhtar Lashari Zarina Kausar

Title Secretary Health & Chair CCM Executive Secretary CCM

Organization Ministry of Health CCM Secretariat

Mailing address Ministry of Health, Block C, Pak. Secretariat, Islamabad NIH, Chack Shahzad, Islamabad.

Telephone 00 92 51 9201782, 9211622 00 92 51 9255 602

Fax 00 92 51 920 5481 00 92 51 9255614

E-mail addresses [email protected] [email protected]

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1.3 List of Abbreviations and Acronyms used by the Applicant

Acronym/ Abbreviation

Definition

ACD Association for Community Development ACT’s Artemisinin-containing Therapies ADP Annual Development Programs AFB Acid Fast Bacillus AIDS Auto Immunodeficiency Syndrome AJK Azad Jammu and Kashmir API Annual Parasitic Index ASD Association for Social Development BCC/IEC Behavior Change Communication BER Blood Examination Rate

BHU Basic Health Unit

BHU Basic Health Unit CBO’S Community Based Organization CCM Country Coordinating Mechanism CDC Communicable Disease Control CHW’s Community Health Workers

CMW Community Mid Wife

COs Community Organization

CPD Continuous Professional Development

DFID Department of International Development

DHIS District Health Information System

DHIS District Health Information System DHMT District Health Management Team DHQ District Head Quarters DMC Directorate of Malaria Control

DOH Department of Health

EDO Executive District Officer

EHSP Essential health Services Package

EOI Expression of Interest

EPI Expanded Programme of Immunization

EPI Expanded Program on Immunization FATA Federally Administered Tribal Area FHI Family Health International

FLCF First level care Facility

FLCF First Level Healthcare Facility FP Family Planning GIS Global Implementation Support GMP Global Malaria Program GoP Government of Pakistan GPs General Practitioners HIMS Health Information Management System HIPC Highly-Indebted Poor Country HIV Human Immunodeficiency Virus

HR Human Resources

HR Human Resource

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HSA Health Services Academy

HSS Health System Strengthening

HSSPU Health System Strengthening and Policy Unit

ICHP Improved Child Health Program IDP Initially Displaced Person IMNCI Integrated Management of Neonatal and Childhood Illness IRS Indoor Residual Spraying ITNs Insecticides Treating Nets IVM Integrated Vector Management JSDF Japan Social Development Fund

KPK Khyber Pakhtonkha Province

KPK Khyber Pakhtunkhwa

LHW Lady Health Worker

LHW’s Lady Health Workers LLIN’s Long Lasting Insecticide treated bed Nets M&E Monitoring and Evaluation MCH Maternal and Child Health

MCP Malaria Control Program

MDG’s Millennium Development Goals MIS Management Information Systems

MNCH Maternal Neonatal and Child Health Programme

MNCH Maternal Newborn and Child Health

MOH Ministry of Health

MOH Ministry of Health

MSD Medical Stores Depot

MTDF Mid-term Development Framework NDL National Drug Testing Laboratories NDMC National Directorate of Malaria Control NGO Non Government Organization

NHP National Health Policy

NMCP National Malaria Control Program NRSP National Rural Support Program PACP Provincial AIDS Control Programmes PHC Primary Healthcare PIU Program Implementing Unit PkR Pakistani Rupee PLYC Pakistan Lions Youth Council PMUs Project Management Units PPRA Public Procurement Regulatory Authority PR’s Principal Recipient PRSP Poverty Reduction Strategy Paper PSDP Public Sector Development Program QA Quality Assurance RCC (PG30) Role Continuation Challenge RDT Rapid Diagnostic Test

RHC Rural Health Centre

RHCs Refugee Health Care SC Save the Children SDA Service Delivery Area

SLM Supplies Logistic Management

SPR Slide Positivity Rate

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SR Sub-Recipient STGs Standard Treatment Guidelines TA Technical Assistance TB Tuberculosis TRP Technical Review Panel TVCs Television Commercials TWG Technical Working Group UK United Kingdom UN United Nation UNFPA United Nations Fund for Population UNOCHA United Office of Coordination on Humanitarian Assistance UNODC United Nations Office on Drug and Crime US United States USAID Joint United Nation Program on HIV/AIDS WHO World Health Organization WPF World Population Fund

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SECTION 2: APPLICANT SUMMARY AND ELIGIBILITY

2.1 Members and operations

2.1.1 Membership summary tick the relevant box

Sector Representation Number of members

Academic/educational sector 02

Government 12

Non-government organizations (NGOs)/community-based organizations

04

People living with the diseases 01

People representing key populations3 01

Private sector 02

Faith-based organizations 02

Multilateral and bilateral development partners in country 05

Other specify -

Total Number of Members: Must equal the number of members in the Membership Details form4

29

3 See the definition of key populations found in the Round 10 Guidelines.

CCM applicants

Complete sections 2.1 & 2.2 Delete sections 2.3 & 2.4

Sub-CCM applicants

Complete sections 2.1, 2.2 & 2.3 Delete section 2.4

Non-CCM applicants

Complete section 2.4 Delete section 2.1, 2.2 & 2.3

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2.1.2 Broad and inclusive membership

Since your last eligible application to the Global Fund:

(a) Have there been any changes in members since the last time the CCM (or Sub-CCM) was determined eligible?

No

go to section 2.1.2 (c)

Yes

go to section 2.1.2 (b)

(b) If ‘Yes’ in part (a), describe in the space below how those new members were selected.

ONE PAGE MAXIMUM

The two years term for the Key Affected Communities ended on June 23, 2010. In line with the Global Fund guidelines, CCM Secretariat notified to CCM and to the Key Affected Constituency representative.

In line with CCM Bylaws, a CCM member could continue for another two terms provided his constituency endorsed this extension. Dr. Altaf H. Tariq, representing the Key Affected Communities on CCM forum, wrote to CCM (Annexure-1) intimating CCM for allowing him to lead the election or endorsement for continuing for next two years terms.

Upon getting CCM approval, he invited constituency organizations to attend the Key Affected Community consultation meeting for finalizing the proposed extension for next two years term. In this regard, he circulated e mail at country level (Invitation letter for meeting is attached (Annexure-2).

On July 17, 2010 the meeting of the Key Affected Community organization was held. Minutes of meeting and the attendance sheet are attached. (Annexure 3). In addition to constituency endorsement during the meeting, the constituency organizations who could not attend the meeting registered their endorsement for Dr. Altaf H. Tariq electronically. (Emails endorsing his membership for next two years attached (Annexure – 3-a).

The Key Affected Community constituency representatives as endorsed by this constituency organizations and he submitted the original documents describing the evidence and the process of selection of Key Affected Community representative for CCM. CCM Secretariat kept the Key Affected Communities membership endorsement for CCM approval and endorsement. CCM in its meeting held on August 17, 2010 endorsed the process and his nomination as CCM member. (Attached Annexure 3-b).

(c) Is there continuing active membership of people living with and/or affected by the diseases?

No

Yes

(d) Is there continuing active membership of both males and females and/or any improvement toward gender balance among members?

No

Yes

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2.1.3 Member knowledge and experience in cross-cutting issues

(a) Health Systems Strengthening: Describe the capacity and experience of the CCM (or Sub-CCM) on health systems strengthening issues

The Ministry of Health has realized the importance of harmonization with other programmes focusing the efficient out puts and cost effectiveness to be the ultimate results. The cross cutting approach is being critically reviewed. JICA and USAID are CCM member representing bilateral development partners sector on CCM. Both partners have taken initiative for developing the District Health Information Management Information System (DHIMS) and USAID has started piloting the Health System Strengthening project – The Human Resource Management Development to strengthen the Health System in Pakistan. DMC has taken initiative of sharing the laboratory facilities with TB programme and also has proposed training of TB technicians also to be trained in Malaria diagnosis for which DMC has allocated financial resources which means cross cutting approach to be practiced in the filed of the Human Resource (Technical) skills development for both TB and Malaria control progrmmes. (PC-I of DMC clearly depicting the cost allocations is attached) (Annexure -4). The composition (Annexure 5 - Composition of CCM) of the CCM (29 total members) includes Chair CCM (Federal Secretary MOH), representatives from the federal government and provincial governments (12), academic and research institutions (2), private sector (2), Vice Chair CCM from Civil Society, NGOs/ Community Based Organizations/Faith Based Organizations (6) Multilateral and Bilateral Agencies (05) Key Affected Communities Representatives (01) is indicative of the broad range of expertise available to the CCM to cater the time to time emerging needs for addressing the impediments including the health system strengthening. In addition CCM members from the broad range of the stakeholders also contribute to remove constraints by putting in efforts to accelerate the programme implementation. Monitoring mechanisms that are in place to ensure that the resources, human and financial, that are allocated are utilized solely to combat the three diseases. The CCM oversight includes keeping strategic track of progress and challenges and offer appropriate recommendations to the PR(s) on improving performance. As an integral part of the Health System Strengthening, the Federal and Provincial Government’s who are also CCM members encourage as a matter of policy the involvement of the people affected by the three diseases into the CCM forum to ensure priority focus and help develop policies that address social and legal rights of those most affected. The federal and provincial programme managers bring operational management expertise to the CCM forum in areas of implementation including monitoring and evaluation, supply chain issues, service delivery, and coordination. The representatives of the academic and research institutions bring knowledge and expertise based on the latest research conducted in the field to guide prioritization of resource allocations according to the changing and/or emerging trends. The representatives of the NGOs/ Community Based Organizations / Faith Based Organizations besides presenting practical service delivery issues, they also provide insight into issues based on social/cultural/religious biases prevalent in society and contribute to policy initiatives to bridge those biases most effectively by facilitating the TGF grants Sub Recipients during the programme implementation.

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(b) Gender: Describe the capacity and experience of the CCM (or Sub-CCM) in gender and also issues concerning sexual orientation and gender identities.

Expertise and skills in methodologies to assess gender differentials in disease burdens and their consequences (including differences between men and women, boys and girls), and in access to and the utilization of prevention, treatment, care and support programs; and

Comprehensive knowledge of the factors that make women and girls and sexual minorities vulnerable such as harmful gender norms, behavior, attitudes and practices that underlie the differentials in the spread of HIV (e.g. gender based violence, discrimination and stigma, sexual female mutilation, early marriage, masculinity, etc).

Capacity and Experience of CCM in Gender and Issues Concerning Sexual Orientation and Gender Identities :

The constitution of CCM reflects multi sectoral approach and all these sectors are fully equipped to address various social sector development aspects concerning sexual orientation and gender identities in the perspectives of methodologies to assess gender differentials in disease burden and their consequences and differences between women, men, girls and boys) in terms of access to and utilization of prevention, treatment care and support programs. The government sector comprising of the Ministry of Health, National Disease Control Programmes, HIV/AIDS, TB and Malaria, provincial health secretaries, Economic Affairs Division (EAD), Ministry of Women Development (MoWD), Ministry of Education and Planning Commission are the CCM members whereas the non government sector comprising of FBOs, CSO, Private Corporate Sector, Research and Academia, Multilateral /Bilateral, Key Affected Communities, People Living and or Affected by disease. CCM Pakistan has taken its initiative to address Gender more closely and in this regard, CCM gender focused group has already been formed. Report of Gender Group Formation Group Annexure- 5 (a) or refer to website: www.ccmpakistan.org.pk The CCM members representing public sector are in decision making i.e. Planning commission of Pakistan reviews and approve overall national level strategies including the strategic plans for the MOH. The national programme of MNCH, HIV/AIDS, TB and Malaria, lady health workers programme closely focuses on Gender balance and capacity building of women on health issues by raising awareness level of the women and girls at grassroot levels. The Ministry of Women Development, which is CCM member, has established Gender Reforms Action Plan (GRAP). Its strategic policy planning exercise will be carried out with all stake holders including donors and CSOs to help develop a policy framework for women’s empowerment. And the Government has shown its political will and commitment to this end. MoWD to realign its current setup with Gender Reform Agenda Focus and will be integrated within the administrative structures of MoWD. Please refer to website www.mowd.gov.pk Similarly other CCM members from the public sector do align their gender friendly policies by increasing female workforce in their working departments. CCM members from non govt. sector organizations activities are also gender focused in the sector of health and education. The CSO donor supported programmes of MNCH and awareness raising in adolescent boys and girls are the example of CCM members capacity to address the gender aspects. The Key Affected Communities constituency is represented on CCM to highlight issues on Sexual minorities and gender identities. CCM Pakistan endorsed the regional proposal in Round-9 addressing MSM which will be implemented in Pakistan to strengthen capacity of NGOs & CBOs in addressing sexual minorities (MSM) component which will also include the transgenders and male sex workers. The Ministry of Health and the provincial Health departments do make sure that gender balance is addressed in their policies for ensuring an easy access to the treatment and care services by all in need of services. MOH entity the Health Services Academy (HAS) especially focuses on Gender balance education strategy. Annexure – 5-b. Referring to two sub points, the operational research methodologies are the basis for assessing the differentials in disease burden to determine the impediment in accessing the treatment and care services by man, women, girls and boys and the other sexual minorities. For example, Nai Zindagi conducted formation/operational research to assess the magnitude of HIV and its associated vulnerability among female partners of IDUs. Similarly the need of placing male or female staff in the treatment and care centers is also determined in result of the operational researches. Some of the needs of women are addressed through involvement of Lady Health Workers. International development (WHO’s) research reports are also referred as baseline in the health sector.

The operational research results, the regular programmes (HIV/AIDS, TB and Malaria) Advocacy, Communication and Social Mobilizations (ACSM) and community interactive activities also contribute to

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assess the harmful gender norms, behavior, attitudes and practices that underlie the differentials in the spread of HIV (e.g. gender based violence, discrimination and stigma, sexual female mutilation, early marriage, masculinity, etc). Nai Zindagi formation/operational research “Hidden Truth” has highlighted the factors causing increased transmission of HIV/AIDS among partners of IDUS. 2009 report the gender distribution in Pakistan shows that in 2007 more women are notified with new sputum smear positive TB in the age groups 0-14, 15-24 and 25-34. Only in the age groups above 45 significantly more men are notified (table 2). Country wide age and gender distribution shows similar patterns since 2002 in contrary to the sex distribution reported by most TB programs.

(c) How many members of the CCM (or Sub-CCM) have considerable expertise in one or both of the areas described in section 2.1.3 (b)?

20-25 Members

(d) Multi-sectoral planning: Describe the capacity and experience of the CCM (or Sub-CCM) in multi-sectoral program design.

CCM Pakistan strongly adhere towards the multi-sectoral programme design. In this regard, multisectoral approach with multi and bilateral development partners is the most recent practice i.e. MoH has designed multi-sectoral programmes involving Ministry of Education, Ministry of Narcotics, Ministry of Defense and Ministry of Women Development, Ministry of religious affairs, have designed programmes for HIV/AIDS, TB and Malaria. MoH is implementing many of these health programmes in collaboration with international development partners i.e. MOH & DIFID’s National Maternal and Child Health Project (NMCH), similarly, USAID (HSS & Safe Drinking Water), JICA (HIMS for TB), (SDC-Health and Social Sector Development Programmes), (CIDA- HASP Study on HIV/AIDS) and Basic Development Needs (BDN) of WHO are the multisectoral approach progrmmes in implementation involving different development partners also contributing in health sector in liaison with MOH. In addition MOH is also putting its efforts to enhance the civil society and private sector organizations to implement and to monitor and evaluate its health programmes. CCM Oversight Committee has its members representing Civil Society organizations, multi lateral and bilateral and PLWHA as its committee members. (CCM Oversight Committee Members List, Annexure – 6).

Multisectoral Interactive Health Programmes Implementation - National Programmes of the MOH are disseminating and implementing health sector interventions through non government sector, private corporate sector, Civil Society Organizations i.e. World AIDS Day, World TB Day and World Malaria Day and similar various activities’ partners are mostly the Civil Society Organizations. In Pakistan there is noticeable increase in the role of Civil Society Organizations for the Social and Health Sector Development. In addition to aforementioned multisectoral approaches, collaboration with the private sector and the Civil Society Sector is also being focused. Please refer to report with private sector for enhancing their inputs for strengthening Health Sector in Pakistan. (Annexure 6.a.)

Enhanced involvement of Civil Society Sector in Health sector development -Vice Chair of CCM Pakistan is from Civil Society Sector. Recently elected Civil Society Organizations (CSOs) as CCM member constituency is reasonably large. Al Punjab AIDS Consortium which is CCM member have 200 plus Civil Society Organizations as its constituency members. Similarly KPK AIDS Consortium also have quite a large number of Civil Society Org. as its constituency. CCM Civil Society members are constantly sharing word about the health initiative and the Global Fund grants in Pakistan. Due to at large constituency consultation with Civil Society Organizations, in result, when CCM Pakistan invited the Expression of Interest (EOIs) for Round-10 for PR and SRs selection, over 90 Civil Society Org. submitted their interest to be partners for GF grants application (lists of NGOs are attached as annexure – 7).

2.2 Eligibility

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2.2.1 Application history

Recently applied for funding in Round 8, or Round 9, or RCC Waves 5-8 and was determined eligible

Complete sections 2.2.2 to 2.2.7

Last applied for funding before Round 8 or RCC Wave 5

Complete Eligibility Form


Do not complete sections 2.2.2 to 2.2.4

Determined ineligible at last application

Complete Eligibility Form


Do not complete sections 2.2.2 to 2.2.4

2.2.2 Proposal development process

(a) Describe the process used to invite submissions for possible integration into the proposal from a broad range of stakeholders including civil society and the private sector, at the national, sub-national and community levels, as well as from key populations, where applicable.

Explain the process for each disease proposal in the application

ONE PAGE MAXIMUM

CCM Pakistan followed the same process to invite submissions for possible integration in to GFATM Round-10 Malaria Control and the Health System Strengthening proposal to ensure receiving from a broad range of stakeholders which included both the government and non government sectors in Pakistan.

Step – I :Upon receiving the Global Fund announcement of Round-10 on May 20, 2010 CCM and Non CCM members were intimated so that CCM could review the possible plans for Round-10. Annexure – 8.

Step-II: CCM Pakistan decided to apply in Round-10 for Malaria and the Health System Strengthening proposal. CCM in its meeting constituted sub committees to short list PRs, SRs and a sub committee to oversee the HSS proposal for Round-10. The committee to review submission and short list PRs comprised of UNAIDS, USAID, DFID, WHO and CCM member representing Private Sector. Where as the committee to short list SRs comprised of Civil Society Organization, Key Affected Communities, DFID, WHO, UNAIDS and the potential PRs for GFATM Round-10 malaria proposal. Minutes of Meeting held on June 02, 2010 are attached – Annexure – 9 in which proposal objectives were finally approved by CCM. Upon receiving CCM approval for the Roun-10 Malaria and HSS objectives, the contents of the Expression of Interest (EOIs) for inviting submissions for PRs and SRs were finalized and approved by CCM.

Step-III: In order to ensure a wide range of circulation at national level, with the support from WHO, the Expression of interest (EOIs) were published in the nation wide newspaper in English and Urdu (national language) so that the information reaches to the grassroots level to a wider range of people, government and non government sector organizations. Annexure – 10. In response there were 28 EOIs for PRs for Malaria (10) and HSS (18) were received whereas 61 submissions for SRs were received for HSS (22) and Malaria (39).

In addition, the EOIs were also placed on CCM Website to ensure access of the wider range of national and international stakeholders.

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In addition, the EOIs contained telephone numbers of CCM Secretariat for providing opportunity for the interested stakeholders from government and non government sector for exploring information regarding the Global fund grant application.

CCM sub committees to review and carry out short listing of PRs and SRs reviewed the submission received for the potential PRs and SRs. Firstly, the PRs were recommended by the CCM Sub committee members and endorsed by CCM. As the second step, CCM Sub committee members and PRs jointly reviewed and selected SRs. For HSS Proposal, both PRs selected their SRs and CCM endorsed the selected SRs.

PRs invited their SRs and conducted consultation for finalizing the proposal strategy for implementation. Minutes of PRs and SRs consultation Meeting Annexure-10.a. Once the initial draft was ready, it was presented to the local and international stakeholders for their inputs and comments. Simultaneously the inputs and comments were also taken from the international stakeholders i.e. EMRO, WHO, local experts and non CCM members. The final proposal was shared with CCM members on Aug. 17, 2010 for endorsement for final submission to the Global Fund.

(b) Describe the process used to transparently review the submissions received for possible integration into the proposal.

Explain the process for each disease proposal in the application

A uniform process was used to invite submissions for possible integration in to the proposal development from a broad range of stakeholders including civil society and the private sector and at national, sub-national and community levels.

Step-I: Upon receiving information on Call for Proposal for Round-10 by TGF, all the national programmes and CCM members were intimated regarding the GF call for proposal and programmes to look in to aspects for Round-10 plans related to proposal submission. For detailed consultation on Round-10, CCM meeting was held on February 26, 2010 at MOH in which programmes were invited to share the rationale that why HIV/AIDS, TB and Malaria should submit proposal and its way forward. (Minutes of CCM meeting held on Feb. 26, 2010 Annexure-11). Based on the rationales presented by the programmes, CCM approved that DoMC to start preparations for the submission of disease specific proposals and HSS to review Round-9 proposal in line with re submission plan while identifying the most priority areas required to address immediate gaps in HSS GFATM Round-10 proposal. Step – I: Publishing of the Expression of Interest (EOIs): The draft contents of EOIs were approved by CCM and on June 16, 2010 CCM published its Expression of Interest (EOI) for inviting submissions for possible integration into the proposal from a broad range of stakeholders including civil society and the private sector, and at the national, sub-national and community levels, CCM approved Expression of Interest (EOIs) inviting the government and non government sector to submit EOIs in line with the areas as identified in the text of advert. The advertisements for inviting organizations to submit their concept as PR and SRs were published in the nation wide newspapers in local (Urdu) and English languages (Annexure-12). At the first step, the Expression of Interest to identify the potential PRs for GFATM Round-10 Malaria and HSS proposal were advertised. In response, CCM received ten EOI for Malaria proposal where as nine EOIs were received for PRs for HSS proposal. The CCM Sub committee met on July 15, 2010 and sorted out and discussed the PRs selection strategy in line with the short listing criteria and committee met again on July 19, 2010 and recommended RPs for GFATM Round-10 malaria where as no PR could be identified for HSS (Minutes of Meetings, Score Sheets attached Annexure-13). The committee recommended to reach to the wider group of CCM for the way forward to finalize PRs for HSS Round-10 proposal. CCM approved that date for submissions for PRs for HSS to be extended and in this context, an advertisement to be published. The date for EOIs for PRs was again published in the nationwide newspapers on July 30, 2010 with closing date of Aug.5, 2010. In response nine EOIs were received. The committee members met again on Aug. 6, 2010 and recommended PRs for HSS proposal . Minutes of Meetings and Score sheets of PRs are attached (Annexure -14). The CCM sub committee recommended PRs were approved by CCM electronically. (Annexure-15).

CCM in its meeting held on June 02, 2010 constituted its sub committee to review submission received for SRs, for GAFTM Round-10 malaria and HSS proposal. The committee comprising of Civil Society, Key Affected Community Representative, DFID, UNAIDS, Research and Academic Sector and USAID met on July 30, 2010. The meeting was also attended by both the potential PRs for malaria proposal. The CCM sub committee members and both the PRs reviewed the submission of SRs for

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malaria and discussed in detail the Round-10 objectives and submission of SRs for subsequently scoring the SRs. (Minutes of Sub committee meeting and Score sheets are attached Annexure-16). The SRs EOIs for HSS were not reviewed since there were no PRs identified so far.

The CCM committee members met on Aug. 6, 2010 to review EOIs received for PRs for HSS and recommended two PRs from public and private sector for Round-10 HSS proposal. The committee members had their concerns over the turn over of HAS which was duly verified in due course of time and on Aug. 10, 2010 the committee finally recommended PRs for HSS. CCM Secretariat circulated to CCM for its electronic endorsement of PRs for HSS. Upon receiving CCM endorsement, PRs were intimated and invited to take over the SRs EOIs for HSS for review and selection of SRs. Both PRs met on Aug. 13, 2010 and reviewed (22) EOIs of SRs in line with the short listing criteria approved by CCM sub committee members and with mutual agreement, selected their SRs. Short listing Criteria, Lists of SRs and Score Sheets are attached at annexure-17.

Electronic endorsement of CCM was taken for both the PRs and SRs. Once approved by CCM, PRs invited their SRs to discuss and finalize their submission for the Round-10 proposal. The minutes of meeting of PRs and SRs coordination for finalizing their submission are attached Annexure – 18.

(c ) Describe the process used to ensure the input of people and stakeholders other than CCM members

in the proposal development process.

(If a different process was used for each disease, explain each process.)

Programmes prepared the draft of the proposal in consultation with its private sector PRs, CCM members and potential SRs of Round-9.

CCM treat held on January 28, 2010 included the Round-10 proposal development bench marks and its related other matters for ensuring CCM and non CCM members consensus regarding the way forward with respect to proposal development process. CCM Retreat report Annexure- 18 (a).

First Review of Submissions Received for Round-10 Proposal: (Wide Range of Stakeholders)

As the draft was ready, the Malaria Control Programme shared the draft proposal with the WHO EMRO regional office for comments and inputs.(Annexure-19). Simultaneously the inputs from local experts were also taken by the Malaria control programme. (Annexure – 20).

Inputs form NGOs, Private Corporate Sector and In Country Development Partners:

The inputs from the civil society organizations delivering services to the grassroots level – directly to the communities in Pakistan were taken. The Vice Chair is from Civil Society. The civil society constituency organizations meeting was arranged in CCM Secretariat in which Round-10 proposals of HSS and Malaria Control were presented to them for their review and comments. Despite of the fact that the emergency flood situation in Pakistan, participants from different parts managed to attend the meeting. Each proposal was presented by the respective consultants and it was duly commented and inputs were shared. Consultation meeting with the Civil Society Organizations – Annexure 21

In order to ensure inputs and comments from the wider group of stakeholders and international development partners, CCM constituted a technical group comprising of international and local experts for reviewing the CCM draft proposal and to share their inputs. Meeting of the technical group members was held on Friday Aug. 13, 2010 at CCM Secretariat in which both proposal were presented and discussed. The members shared their inputs and comments which were noted down by the presenting consultants for addressing and incorporating accordingly in to the proposal. Annexure – 21.a.

The final drafts of both proposals (HSS & Malaria) were electronically shared with CCM and non CCM members after incorporating inputs from various stakeholders and non CCM members. Annexure -22.

(d) Attach a signed and dated version of the minutes of the meeting(s)at which

the CCM (or Sub-CCM) members decided what to include in each disease

proposal. (Annex-30CCM meeting held on Feb.26, 2010, Annex-31 June 02,

2010, Annex-32, CCM Sub Committee for HSS, Meeting Minutes ) Annex -33

Approval by CCM for HSS Priority Areas

Annexure -30

Annexure-31

Annexure-32

Annexure-33

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2.2.3 Process to oversee program implementation

(a) Describe the process used to ensure the input of stakeholders other than CCM (or Sub-CCM) members in the ongoing oversight of program implementation.

To ensure effective oversight over the Global Fund Grants, CCM Pakistan has ascribed oversight role to CCM Oversight Committee. CCM has constituted another its subcommittee Technical which addresses the technical matters pertaining to GF grants. The CCM subcommittee technical comprising of WHO, USAID, UNAIDS, PLWHA, Civil Society, National Managers of NACP, NTP and Malaria Control Progamme and DS. Budget of MOH. CCM Technical Committee facilitates CCM oversight committee in addressing technical aspects related to TGF grants ranging from gender to health systems strengthening. The CCM Oversight Committee consists of experts who provide technical expertise to the CCM on institutional and technical issues related to the grant performance. CCM Pakistan has developed its annual oversight Farm work document which is duly approved by the CCM Oversight Committee and full CCM forum. Annexure – 22. In line with the CCM approved oversight plan, the Oversight sub-committee reviews the quarterly progress reports of the PRs for the Global Fund grants and shares its findings (achievements and or bottlenecks in implementation) with the CCM. In case of any bottlenecks, CCM constitutes temporary committees which comprise of relevant experts which could include other than CCM members to address the specific matters to look in to the possibilities of recommending efficient remedial actions. Similarly CCM forms other task oriented temporary committees to provide technical support for addressing matters related to TGF grants to the CCM. To fulfill CCM oversight role, CCM sub-committees are assigned specific tasks. These committees do not take decisions but suggests recommendations for addressing the gaps to resolve the outstanding issues for the Global Fund grants and are required to report back to the CCM for final approval. In order to cater the inherent conflict of interest, Programme Managers NACP, NTP and Malaria have been excluded from CCM oversight committee. CCM has approved TORs for the CCM Oversight committee (Annexure- 22-a). CCM oversight committee members invite PRs on regular quarterly basis and PRs present their quarterly progress reports to CCM oversight committee members. Minutes of CCM Oversight committee meetings held on Jan. 13, 2010 and May 11, 2010 along with presentations by the PRs. (Annexure– 22-b). In addition to overall grants performance, CCM oversight committee also performs oversight role over the PR performance. The rational for providing oversight is to facilitate speedy implementation process of the TGF grants. A): The process exercised by the CCM to oversee programme implementation is very transparent and effective. PR office prepares quarterly progress reports for TGF grants and submits to CCM for review. CCM Secretariat shares quarterly reports (financial and programmatic) with all CCM members. CCM Sub Committee members review the quarterly progress reports. In case there is any below targets reporting of GF grant for the respective quarter, it is notified to CCM. The Chair CCM who is from the public sector, Secretary Health as the Chair CCM directly notices the reason for causing low achievement of targets. The impediment is immediately addressed and the concerned department is immediately approached. B): In order to review PRs performance and the programme implementation status, CCM Oversight Committee calls for meeting in which PRs are required to present their performance and the level of progress achieved. During these meetings, PRs also present their constraints/impediments for which CCM Chair issue instructions to facilitate the process. Green Star’s request for facilitation in getting Tax Waiver through the office of the Chair CCM, (Annexure–23). CCM oversight committee members review PRs progress reports and in case of any performance concerns either identified in the PR’s progress reports or raised by TGF in form of management letters, CCM advises remedial actions to be taken by the PR to address TGF issues. In addition, the CCM forum also identifies the areas of support required to meet the time bound actions and concerned sector/department is immediately reached. Minutes of Oversight Committee inviting PR to present time bound actions to address GF concerns Oversight Committee Meeting dated May 11, 2010 (Annexure – 24). CCM members representing on CCM i.e. Planning Commission of Pakistan has its own M&E component to monitor health projects in Pakistan and while conducting routine M&E TGF grants monitoring is also part of this activity. The programme managers who are also CCM members, when their respective programmes conduct M&E of the TGF grants and in case of any matter related to the TGF grant implementation, the concerns are raised at CCM forum during CCM meetings and are adequately addressed. The subject of oversight is given very close attention to ensure a vigilant oversight over TGF grants and the PRs. CCM Oversight is functional and in this regard, in addition to aforementioned regular activities, CCM oversight committee members had planned their field visits (WHO & PLHIV) – Annexure 25. Email to WHO for oversight visits. But due to serious flood situation in Punjab and Sindh province, these visit have been postponed till the flood situation is clear (Annexure-26).

ROUND 10


(b) Describe the process(es) used to ensure the input of stakeholders other than CCM (or Sub-CCM) members in the ongoing oversight of program implementation.

CCM Pakistan prefer to involve inputs of stakeholders other than CCM members in the on going activities of CCM including CCM Oversight role over the Global Fund grants. It is evident from the CCM Oversight TORs which clearly states that it is mandatory that the Chair and Vice Chair CCM are the members of CCM Oversight and rest of the members could be other stakeholders (other than CCM members) which is evidence of involving other stakeholders for an effective oversight and to ensure in puts of stakeholders other than CCM in the ongoing oversight TGF grants. In addition to CCM Oversight Committee members, the CCM Sub Committee technical complement its technical expertise where technical inputs are solicited by the CCM Oversight Committee members. Both CCM Committees (Oversight and Technical Committee) involve expertise ranging from gender to health systems strengthening. The CCM sub-committees (technical and Oversight consists of experts from stakeholders experts in Monitoring and Evaluation. These M&E professionals also oversee GF grants while reviewing progress of their own components while conducting routine M&E activities. Their M&E reports also address GF grants. International third party review missions for TB grant monitor the TB programem performance as a whole including GF grants. CCM observer group members i.e. World Bank, UN agencies etc being the CCM observer members do include GF grants while monitoring their own programmes. The PRs quarterly progress reports are constantly shared with all CCM members and the observer group members. In addition, they also attend CCM meetings in which CCM Oversight related matters are discussed. There, members other than CCM attending the forum meeting do share their comments and also support for CCM Oversight initiatives. CCM also involve experts other than CCM members while constituting CCM task specific Sub committees to provide technical support to the CCM. The sub-committees are assigned specific tasks and report back to the CCM for final approval. In addition to the aforementioned oversight activities, the Ministry of Health in its routine activities, plans third party evaluations to review MOH health initiatives which also include donor funded programmes including GF grants. MOH also conduct the impact assessments by hiring third parties out side the MOH. The Health System Strengthening (HSS) unit set up is in its final stage which has M&E built in mechanism. Through this unit, all MOH progammes will be monitored and its related output will be recorded by the National Health Information Management System.

2.2.4 Process to select Principal Recipient(s)

(a) Describe the process used to make a transparent and documented selection of each of the Principal Recipient(s) nominated in this proposal.

Explain the process for each Principal Recipient for each disease

ONE PAGE MAXIMUM

CCM in its meeting held on June 2, 2010 reviewed and approved the document stating the transparent process for selecting PR for Round-10 proposal (Annex-27). In addition, constituted a sub committee to sort list PRs for GFATM Round-10 proposals of Malaria and HSS. The committee comprised of CCM members representing WHO, USAID, DFID, UNAIDS and Private sector representative on CCM. Annexure – 28. Minutes of CCM Meeting held on June 02, 2010.

The five members committee approved the PRs short listing criteria for both Round-10 proposal components (Annexure – 29).

The draft contents of EOIs for inviting submission for the potential PRs for GFATM Round-10 for Malaria and HSS proposals were approved by CCM and on June 16, 2010 CCM published its Expression of Interest (EOI) for inviting submissions from a broad range of stakeholders including civil society and the private sector, and at the national, sub-national and community levels, CCM approved Expression of Interest (EOIs) inviting the government and non government sector to submit EOIs in line with the areas as identified in the text of advert.

The advertisements for inviting organizations to submit their concept as PR was published in the nation wide newspapers in local (Urdu) and English languages (Annexure-12). At the first step, the Expression of Interest to identify the potential PRs for GFATM Round-10 Malaria and HSS proposal were advertised. In response, CCM received ten (10) EOI for Malaria proposal whereas nine EOIs were received for PRs for HSS proposal. The CCM Sub committee met on July 15, 2010 and sorted out and discussed the PRs selection strategy in line with the CCM sub committee approved short listing criteria and committee met again on July 19, 2010 and recommended RPs for GFATM Round-10

ROUND 10


malaria whereas no PR could be identified for HSS (Minutes of Meetings, Score Sheets attached Annexure-13). The PRs short listing committee recommended reaching to the wider group of CCM for the way forward to finalize PRs for HSS Round-10 proposal. CCM approved that date for submissions for PRs for HSS to be extended and in this context, an advertisement to be published. The date for EOIs for PRs was again published in the nationwide newspapers on July 30, 2010 with the closing date of Aug.5, 2010. In response nine EOIs were received. The committee members met again on Aug. 6, 2010 and recommended PRs for HSS proposal. Minutes of Meetings and Score sheets of PRs are attached (Annexure -14).

The CCM committee members met on Aug. 6, 2010 to review EOIs received for PRs for HSS and recommended two PRs from public and private sector for Round-10 HSS proposal. The committee members had their concerns over the turn over of HSA which was duly verified in due course of time and on Aug. 10, 2010 the committee finally recommended PRs for HSS. CCM Secretariat circulated to CCM for its electronic endorsement of PRs for HSS. Upon receiving CCM endorsement, PRs were intimated and invited to take over the SRs EOIs for HSS for review and selection of SRs. Both PRs met on Aug. 13, 2010 and reviewed (22) EOIs of SRs in line with the short listing criteria approved by CCM sub committee members and with mutual agreement, selected their SRs. Short listing Criteria, Lists of SRs and Score Sheets are attached at annexure-15. The CCM sub committee recommended PRs were approved by CCM electronically. (Annexure-16).

(b) Attach the signed and dated minutes of the meeting(s) at which the CCM (or Sub-CCM) members nominated the Principal Recipient(s) for each disease. Minutes of CCM Meeting Held on Aug. 17, 2010.

Annexure-34

2.2.5 Non-implementation of dual track financing

Dual track financing means that at least one government sector and one non-government sector Principal Recipient have been nominated for each disease in this proposal. If relevant, provide an explanation below as to why dual track financing has not been applied for any of the disease proposals in this application.

HALF PAGE MAXIMUM

Not Applicable to CCM Pakistan Since both proposal components are of dual track financing approach.

2.2.6 Managing conflicts of interest

(a) Are the Chair and/or Vice-Chair of the CCM (or Sub-CCM) from the same entity as any of the nominated Principal Recipient(s) for any of the disease proposals in this application?

Yes

go to (b) and then section 2.2.7

No

go to section 2.2.7

(b) If yes, attach the plan for the management of actual and potential conflicts of interest.

Annexure-35

2.2.7 Proposal endorsement by members

The Membership Details form has been completed with the signatures of all members of the CCM (or Sub-CCM).

Tick this box to confirm that the Membership Details form, with signatures, is attached to the application

ROUND 10


2.3 Sub-CCM applicant further details

2.3.1 Status of Sub-CCM

(a) Does the Sub-CCM operate under the authority of the CCM to focus on a particular region or issue?

Yes

answer sections 2.3.2 and 2.3.3

(b) Does the Sub-CCM claim an independent basis to operate without oversight of the CCM?

No

answer sections 2.3.2 and 2.3.4

2.3.2 Rationale

Why does a Sub-CCM approach represent an effective approach in the circumstances of your country?

ONE PAGE MAXIMUM

2.3.3 CCM endorsement

(a) Attach the signed and dated minutes of the CCM meeting at which the CCM agreed to endorse the Sub-CCM proposal

insert annex number

(b) Attach a letter from the CCM Chair or Vice-Chair confirming the CCM’s endorsement of the Sub-CCM proposal

insert annex number

2.3.4 Justification of independence of Sub-CCM

Explain how the Sub-CCM has a right to operate without endorsement from the CCM.

ONE PAGE MAXIMUM

ROUND 10


2.4 Non-CCM applicants

2.4.1 Sector of work check one box only

Academic/educational sector

Government

Non-government organization (NGO)/community-based organizations

People living with the diseases

People representing key populations5

Private sector

Faith-based organizations

Other: specify

2.4.2 Justification for Non-CCM proposal

(a) Identify the main justification for submitting a Non-CCM proposal check one box only:

(i) Country in conflict, facing a natural disaster or in a complex emergency situation

Yes go to section

2.4.3

(ii) Country that suppresses, or has not established partnerships with civil society and non-governmental organizations, which may include, but is not limited to, key populations

Yes complete (b)

below and go to section 2.4.3

(iii) State without a legitimate government, and not being administered by a recognized interim administration

Yes go to section

2.4.3

(b) If (ii) applies:

Describe, chronologically, all attempts by the Non-CCM to communicate with the CCM on the inclusion of the Non-CCM proposal’s activities in the larger CCM proposal.

ONE PAGE MAXIMUM

(c) Describe how the Non-CCM will be able to implement the proposal and achieve the outputs/outcomes when the CCM has not supported the proposal.

ONE PAGE MAXIMUM

5 See the definition of key populations found on page 3 of the Round 10 Guidelines.

ROUND 10


2.4.3 Expected benefit of proposal

Describe how the proposal addresses gaps in the existing country efforts for HIV, tuberculosis, and/or malaria as relevant.

ONE PAGE MAXIMUM

2.4.4 Non-CCM knowledge and experience in cross-cutting issues

(a) Health Systems Strengthening: Describe the capacity and experience of the Non-CCM on health systems strengthening issues.

HALF PAGE MAXIMUM

(b) Gender: Describe the capacity and experience of the Non-CCM in gender issues and also issues concerning sexual orientation and gender identities.

The Global Fund recognizes that inequality between males and females, and the situation of sexual minorities are important drivers of epidemics, and that effective programming requires:

Expertise and skills in methodologies to assess gender differentials in disease burdens and their consequences (including differences between men and women, boys and girls), and in access to and the utilization of prevention, treatment, care and support programs; and

Comprehensive knowledge of the factors that make women and girls and sexual minorities vulnerable such as gender harmful norms, behavior, attitudes and practices that underlie the differentials in the spread of HIV (e.g. gender based violence, discrimination and stigma, sexual female mutilation, early marriage, masculinity, etc).

HALF PAGE MAXIMUM

(c) How many members of the Non-CCM have considerable expertise in one or both of the areas described in 2.4.4 (b)?

insert number

(d) Multi-sectoral planning: Describe the capacity and experience of the Non-CCM in multi-sectoral program design.

HALF PAGE MAXIMUM

2.4.5 Non-implementation of dual track financing

Dual track financing means that at least one government sector and one non-government sector Principal Recipient have been nominated for each disease in this proposal. If relevant, provide an explanation below as to why dual track financing has not been applied for any of the disease proposals in this application.

HALF PAGE MAXIMUM

2.4.6 Signature by authorized representative of Non-CCM applicant

Position Printed Full Name Signature

use "Tab" key to add extra rows if needed

ROUND 10


Section 2: Eligibility List annex name and number

CCM and Sub-CCM applicants only

2.2.2(a) Process used to invite submissions for possible integration into each disease proposal

Annex-8 :

(Upon receiving the Global Fund announcement of Round-10 on May 20, 2010 CCM and Non CCM members were intimated so that CCM could review the possible Plans for Round-10)

Annex-9 :

(CCM Pakistan decided to apply in Round-10 for Malaria and the Health System Strengthening proposal. CCM in its meeting constituted sub committees to short list PRs, SRs and a sub committee to oversee the HSS Proposal for Round-10. Minutes of Meeting held on June 02, 2010 are attached)

Annex-10 :

(In order to ensure a wide range of circulation at national level, with the support from WHO, the Expression of Interest (EOIs) were published in the nation wide Newspapers in English & Urdu. In response there were 28 EOIs for PRs for Malaria (10) and HSS (18) were received whereas 61 submissions for SRs were received for HSS (22) and Malaria (39)

Annex-10.a : (PRs invited their SRs and conducted consultation for finalizing the proposal strategy for implementation. Minutes of

PROPOSAL CHECKLIST: SECTIONS 1 AND 2

ROUND 10


PRs and SRs consultation Meeting)

2.2.2(b) Process used to review submissions for possible integration into each disease proposal

Annex-11: (For detailed consultation on Round-10, (Minutes of CCM Meeting held on Feb. 26, 2010)

Annex-12:

(The advertisements for inviting organizations to submit their concept as PR and SRs were published in the nation wide newspapers in local (Urdu) and English languages)

Annex-13: (The CCM Sub committee met on July 15, 2010 and sorted out and discussed the PRs selection strategy in line with the short listing criteria and committee met again on July 19, 2010 and recommended PRs for GFATM Round-10 malaria where as no PR could be identified for HSS (Minutes of Meetings, Score Sheets attached) Annex-14: CCM approved that date for submissions for PRs for HSS to be extended and in this context, an advertisement to be published. The date for EOIs for PRs was again published in nationwide newspapers on July 30, 2010 with closing date of Aug.05, 2010. In response nine EOIs were received. The committee members met again on Aug 6, 2010 and recommended PRs for HSS proposal. Minutes of Meetings and Score Sheets of PRs are attached. Annex-15: (The CCM Sub Committee recommended PRs were approved by CCM electronically)

ROUND 10


Annex-16: (CCM in its meeting held on June 02, 2010 constituted its sub committee to review submission received for SRs, for GFATM Round-10 Malaria and HSS proposal. (Minutes of Sub Committee Meeting and Score Sheets are attached) Annex-17: The CCM Committee members met on Aug. 6, 2010 to review EOIs received for PRs for HSS and recommended two PRs from Public and Private Sector for Round-10 HSS Proposal. CCM Secretariat circulates to CCM for its electronic endorsement of PRs for HSS. Upon receiving CCM endorsement, PRs were intimated and invited to take over the SRs EOIs for HSS for review and selection of SRs. Both PRs met on Aug. 13, 2010 and reviewed (22) EOIs of SRs in line with the short listing criteria approved by CCM sub committee members and with mutual agreement, selected their SRs. Short listing Criteria, Lists of SRs and Score Sheets are attached. Annex-18: Electronically endorsement of CCM was taken for both the PRs and SRs. Once approved by CCM, PRs invited their SRs to discuss and finalize their submission for the Round-10 proposal. The minutes of meeting of PRs and SRs coordination for finalizing their submission are attached.

ROUND 10


2.2.2(c) Process used to ensure the input of a broad range of stakeholders in the proposal development process

Annex-18 (a): Programmes prepared the draft of the proposal in consultation with its private sector PRs, CCM members and potential SRs of Round-9. CCM Treat held on January 28, 2010 included the Round-10 Proposal development bench marks and its related other matters for ensuring CCM and non CCM members consensus regarding the way forward with respect to proposal development process. CCM Retreat report. Annexure-19 As the draft was ready, the Malaria Control Programme shared the draft proposal with the WHO EMRO regional office for comments and inputs. Annexure-20 (Simultaneously the inputs from local experts were also taken by the Malaria Control Programme). Annexure-21 The input from the civil society organizations delivering services to the grassroots level-directly to the communities in Pakistan was taken. The Vice Chair is from Civil Society. The Civil societies constituency organizations meeting was arranged in CCM Secretariat in which Round-10 proposals of HSS and Malaria Control were presented to them for their review and comments. Each proposal was presented by the respective consultants and it was duly Commented and inputs were shared. Consultation meeting with the Civil Society Organizations.

ROUND 10


Annexure-21-a Meeting of the Technical group members to ensure and comments from the wider group of stakeholders and international development partners was held on Friday Aug. 13, 2010 at CCM Secretariat in which both proposal were presented and discussed. The members shared their inputs and comments which were noted down by the presenting consultants for addressing and incorporating accordingly in to the proposal. Annexure-22: (The final drafts of both proposals (HSS & Malaria) were electronically shared with CCM and non CCM members after incorporating inputs from various stakeholders and non CCM members)

2.2.3(a) Process to oversee grant implementation by the CCM (or Sub-CCM)

Annexure-22-a:

CCM Pakistan has developed its annual oversight Frame work document which is duly approved by the CCM Oversight Committee and full CCM forum.

Annexure-22-b

To fulfill CCM oversight role, CCM sub-Committees are assigned specific tasks. These Committees do not take decisions but suggests recommendations for addressing the gaps to resolve the outstanding issues for the Global Fund grants and are required to report back to the CCM for final approval. In order to cater the inherent conflict of Interest programme Managers

ROUND 10


NACP, NTP and Malaria have been excluded from CCM oversight Committee. CCM has approved TORs for the CCM Oversight Committee. Annexure-23 In order to review PRs performance and the programme implementation status, CCM Oversight Committee calls for meeting in which PRs are required to present their performance and the level of progress achieved. During these meetings, PRs also present their constraints / impediments for which CCM Chair issue instructions to facilitate the process. Green Star’s request for facilitation in getting Tax Waiver through the office of the Chair CCM. Annexure-24 Minutes of Oversight Committee inviting PR to present time bound actions to address GF concerns Oversight Committee Meeting dated May 11, 2010 Annexure-25 CCM Oversight is functional and in this regard, in addition to aforementioned regular activities, CCM oversight Committee members had planned their field visits (WHO & PLHIV). Annexure-26 Email to WHO for oversight Visits. But due to serious flood situation in Punjab and Sindh province, these visits have been postponed till the flood situation is clear.

2.2.3(b) Processes used to ensure the input of a broad range of stakeholders in grant oversight process

ROUND 10


2.2.4(a) Process used to select and nominate the Principal Recipient(s) for each disease proposal

Annexure-27

CCM in its meeting held on June 2, 2010 reviewed and approved the document stating the transparent process for selecting PR for GF-Round-10 Proposal

Annexure-28

In addition, constituted a sub committee to short list PRs for GFATM Round-10 proposals of Malaria and HSS. The Committee comprised of CCM members representing WHO, USAID, DFID, UNAIDS and Private Sector representative on CCM (Minutes of CCM Meeting held on June 02, 2010) Annexure-29 The five members committee approved the PRs short listing criteria for both Round-10 proposal components.

2.2.6 Conflict of Interest policy

Annex-35:

If yes, attach the plan for the management of actual and potential conflicts of interest.

2.2.7 Minutes of the meeting at which the proposal was finalized and endorsed by the CCM (or Sub-CCM)

Annex-36

Minutes of CCM Meeting at which GF Round-10 Proposal was endorsed

2.2.7 Endorsement of the proposal by all CCM (or Sub-CCM) members

Annex-37a: CCM Members Proposal endorsement sheet on plain paper.

Annex-37-b

CCM Members details form contains complete information about CCM Members but the sheet could not be unlock therefore CCM endorsement has been taken on separate sheets attached with the CCM members details form.

ROUND 10


Sub-CCM applicants only

2.3.3 CCM Endorsement

Process used to show that the CCM reviewed and endorsed the proposal

2.3.4 Documented evidence justifying the Sub-CCM’s right to operate without guidance from the CCM

Non-CCM applicants only

2.4.1 Documentation describing the organization, and the key governance arrangements, and a summary of the main sources and amounts of funding

2.4.2(a) Documentation justifying the exceptional circumstance for submitting a Non-CCM proposal

2.4.2(b) Documentation of communication to the CCM for consideration of the proposal

Other documents relevant to sections 1 and 2 attached by applicant: Add extra rows to this section of the table as required to ensure that documents directly relevant are attached

ROUND 10 – Malaria

R10_CCM_PKS_M_PF_s3-5_30Sep10_En.doc 1/78

3. PROPOSAL SUMMARY

3.1 Transition to a single stream of funding

(a) Select only one of the three options:

Option 1: Transition to a single stream of funding by submitting a consolidated disease proposal

go to section 3.1 (b)

Relevant sections are marked in RED throughout the proposal form

Option 2: Transition to a single stream of funding during grant negotiation

go to section 3.1 (b)


Option 3: No transition to a single stream of funding in Round 10


(b) For options 1 or 2, list the grant numbers. PKS-708-G08-M (MALARIA)

3.2 Duration of Proposal Planned Start Date To

Month and year: July 2011 June 2016

3.3 Alignment to in-country cycles

Describe:

(a) how the proposal duration was selected in section 3.2 and how it contributes to alignment with the national fiscal cycle(s), programmatic reporting, or in-country program reviews; and

(b) the systems in place for regular national program reviews and evaluations (including Operations and Implementation research).

The proposal duration was selected by CCM and PRs based on the Government of Pakistan’s and the Ministry of Health’s financial and procurement cycles. The fiscal year of GoP starts from July 1st and

PROPOSAL FORM – ROUND 10 SINGLE COUNTRY APPLICANT SECTIONS 3-5: Malaria



ends on June 30th. Every year all the financial records are closed on June 30th. Similarly, GoP’s procurement cycle for the year also closes on June 30th. As per MoH reporting schedule, periodic program reviews take place for all the programs including malaria program. External reviews of these programs also take place once in three years. Regular monitoring of program based on Health Management Information System (HMIS)/District Health Information System (DHIS), LHW MIS and Malaria Information system takes place on monthly basis.

3.4 Summary of Round 10 Proposal (MALARIA) Provide a summary of the malaria proposal.

Title of the Proposal: Expanding Coverage of Malaria Control Interventions in 38 Highly Endemic Districts of Pakistan

Pakistan is a malaria endemic country with an estimated annual number of malaria cases at 1.6 million.1 Approximately 24.84 million of the population residing in 38 highly malaria endemic districts are at risk of malaria. The majority (80%) of malaria in Pakistan is caused by Plasmodium vivax, while the remaining 20% is caused by P. Falciparum2. Malaria endemicity is heterogeneous in Pakistan. Thirty seven percent of malaria cases3 are reported from the districts and agencies of Federally Administered Tribal Areas (FATA) and Balochistan bordering Afghanistan and Iran. Malaria transmission is seasonal, with peaks in summer (June-September) for vivax malaria and late-summer and winter (August-November) for falciparum malaria. The Government of Pakistan is implementing Malaria Control Program (MCP) in 72 malaria endemic districts of Pakistan with the public sector resources and in 19 highly endemic districts with the support from the Global Fund (Round 7).

The proposal for Round 10 has a goal to reduce burden of malaria by 75% in 38 highly endemic districts of Pakistan. This goal has been set in accordance with MDG targets because Round 10 proposal coincides with MDGs timeline. The target 38 districts for Round 10 proposal include 19 current districts of the Global Fund Round 7 and proposed 19 additional districts for Round 10. The total target population living in these 38 highly malaria endemic districts are estimated at 24.84 million people. Main emphasis of this proposal is on effective case management, multiple prevention measures, including universal coverage with LLINs and IRS and community awareness.

In light of experiences and lessons learnt from Global Fund Rounds 7 implementation in Pakistan, the national malaria strategic framework has been revised. The proposed interventions in Round 10 are based on national strategic framework and TRP comments on Round 9 proposal. In addition, this proposal has specifically taken into consideration current flood emergency situation in the country and its potential implications on malaria epidemiology in the endemic districts.

This proposal will be managed by two PRs, selected by the CCM through a transparent open bidding process. The PRs include Directorate of Malaria Control (Public Sector PR) and Save the Children Federation Inc. (Private Sector PR). The two PRs in coordination with CCM have shortlisted five organizations as potential SRs. These SRs have been selected in light of EOIs submitted for Round 10. However, their scope of work will be decided after completion of their pre-award assessments. DMC through respective SRs will be primarily responsible for implementation of Round 7 and Round 10 activities in existing 19 districts which are also the target districts of GF Round 10. Save the Children through respective SRs will implement Round 10 activities in additional 19 districts. The total budget estimated for implementation of Round 10 proposal is US$ 56,133,180.

A summary of SDAs and activities proposed in 38 highly endemic districts is as follows:

Objective 1:To enhance access of population at risk to quality assured early diagnosis and prompt treatment services

In order to enhance access to diagnostic and treatment services selected SDAs include: diagnosis; and prompt and effective anti-malaria treatment.

1 WHO 2008 World Malaria Report, Page 102 2 M. Rowland, M.A. Raba, T. Freeman, N. Durrani, N. Rehman. Afghan refugees and the temporal and spatial distribution of malaria in Pakistan. Social Science and Medicine, 2002, Vol 55 (11); 2061-72 3 Directorate of Malaria Control, Annual Surveillance Data 2008



In addition to 276 existing microscopy centers in 19 districts of Round 7, 171 additional microscopy centers will be established in 19 Round 10 districts. In the new 19 districts where microscopy facilities are not available or difficult to access, 380 (20 per district) new RDT centers will be established. These centers will be provided with 3.5 million pan specific RDTs. A total of 171 microscopists from public sector and 200 from the private sector will be trained on malaria microscopy. Similar training will also be organized for 276 microscopists from Round 7 target districts. In addition, 380 health personnel will be trained on the use of RDTs in 19 Round 10 districts and 380 health personnel will be given refresher trainings on RDTs in 19 Round 7 districts.

In order to strengthen malaria case management, it is proposed that 09 malaria program staff receive advanced level malaria case management training. These trained staff will train 76 master trainers who will then facilitate trickle down trainings for 1,359 healthcare providers from the public first level care facilities, 300 from secondary and tertiary level healthcare facilities, and 200 from private sector in malaria case management. These trained care providers will be supported by providing job aids. In addition, anti-malaria drugs will be procured to treat approximately 2 million malaria cases. It is expected that approximately 700,000 people will be diagnosed with RDTs at the BHU level and approximately 1.3 million people will avail microscopy diagnostic facilities at RHCs. Recent floods in Pakistan have destroyed most of the health service infrastructure in the affected districts. It is envisaged that the reconstruction of health infrastructure will take minimum two to three years during which it is proposed to provide malaria diagnostic, treatment and prevention outreach services through mobile malaria vans. For this purpose 10 mobile malaria vans (2 per district) will be procured.

Objective 2: To scale-up multiple prevention interventions especially LLINs and IRS to the level of universal coverage in target population For scaling up coverage of prevention interventions, service delivery areas selected include: provision of Long Lasting Insecticides Treated Nets (LLINs); Indoor Residual Spraying (IRS); information system (epidemiological surveillance); monitoring drug resistance; and monitoring insecticide resistance. A total of 2.75 million LLINs will be distributed free of cost benefiting approximately 6.9 million people in 19 districts including women and children. Malaria supervisors, LHWs, EPI technicians and local NGOs/CBOs will be involved in LLINs distribution process. A total of 380 distribution outlets (20 per district) will be established. For ensuring correct use of LLINs, information material will be developed and 84 master trainers from public sector will be trained on national LLINs guidelines.4 These master trainers will further train 380 district level public health staff and 380 staff of local NGOs and CBOs on LLINs distribution. In addition, 15% of the target population (approximately 1.2. million) at risk of malaria outbreaks will benefit from two rounds of Indoor Residual Spraying (IRS) per year. For strengthening epidemiological surveillance, 41 Communicable Disease Control (CDC) officers will be trained in malaria data management and surveillance. Also 1,407 healthcare providers from the districts will be trained on accurate surveillance and early detection of malaria outbreaks. Two studies 1) sentinel site surveillance of anti-malaria drug efficacy and 2) monitoring insecticides resistance have been proposed under this objective. In order to prevent potential malaria outbreaks due to recent flood in the endemic districts, the mapping of larval breeding sites and selective larvaciding will be carried out in the affected communities with the public sector resources.

Objective 3: To enhance technical and management capacity of malaria control program for improved planning, management and monitoring of malaria control interventions Enhancing of program management capacity includes SDAs on leadership and governance; M&E and evidence building; and program management support for both the public and private sector PRs and their implementation partners (SRs and SSRs). At the national level a Technical Working Group on malaria will be constituted and formalized. MCP will procure 1 international and 4 national TAs through WHO in the areas of planning and management, monitoring and surveillance. Also, 42 MCP staff will be trained in Vector Control and Medical Entomology through 1 year diploma at Health Services Academy, Pakistan.

4 National LLINs guidelines



As part of M&E and evidence building, three research studies will be conducted including studies on malaria prevalence, malaria costing, and quality of antimalaria drugs used in the private sector. Monitoring of the Global Fund supported interventions will be carried out at the federal, provincial and district levels through field visits and periodic review meetings. This objective also includes program management activities of DMC and Save the Children (PRs) and their implementation partners including SRs and SSRs. These activities include hiring of staff, planning and administration, staff capacity building, and strengthening and establishment of PMUs. In view of post 18th constitutional amendment in Pakistan resulting into further decentralization of program implementation to provincial and district levels, it has been proposed that PMUs will be established and strengthened in the provinces and districts. Objective 4: To improve health seeking behaviors and practices of target communities in highly malaria endemic districts through enhanced community awareness and participation Strengthening behavior change communication (BCC) for malaria; BCC through mass media; and BCC through community outreach are the SDAs selected under this objective. BCC activities are expected to lead to improved utilization of preventive behaviors and health facilities for malaria diagnosis and treatment. A national TA will be procured for reviewing and updating existing national malaria BCC strategy. The strategy will be finalized with consensus of the key stakeholders and BCC experts in Pakistan. In light of the agreed strategy, a set of mass media, print and electronic IEC material in local languages will be developed and disseminated. In this regard, 80 district level health staff including public sector and NGO/CBO workers will be trained on effective use of IEC material. Mass media activities will be supplemented by advocacy, community mobilization and awareness raising activities at the community level. A total of 304 advocacy events will be carried out in the districts with the involvement of 15,200 community based activists and stakeholders including LHWs, CBOs, NGOs, religious and faith based organizations, religious leaders, elected representatives and local elders (i.e. Jirga – local decision-making body in KPK, FATA, and Balochistan). Also, in the communities, 18,240 awareness-raising sessions on malaria prevention and care seeking will be organized benefiting approximately 364,800 community members including women, IDPs and refugee populations. LHWs will organize these sessions in their catchment populations. In this regard, malaria protocols in LHW’s curriculum will be reviewed and updated. The areas where LHWs are not available, local CBOs and NGOs will organize awareness raising sessions for the community members including women. Save the Children (Private Sector PR) has successfully implemented this community outreach strategy in Pakistan. In the proposed project period, two national level advocacy seminars will be organized with an objective to share evidence and experiences from the Global Fund supported malaria programming and advocate for mobilizing additional resources and political commitment for malaria control in Pakistan.

4. PROGRAM DESCRIPTION

4.1 National program

Describe:

(a) current malaria national prevention, treatment, and care and support strategies;

(b) how these strategies respond comprehensively to current epidemiological situation in the country;and

(c) the improved malaria outcomes expected from implementation of these strategies.

The National Malaria Control Strategy is based on Global Malaria Program (GMP) recommendations, adapted to the country context. These have been tailored to meet the specific needs of program beneficiaries and takes full account of local epidemiological considerations (biological, cultural, etc.).



The proposed interventions and services are consistent with the Millennium Development Goal, Mid-term Development Framework (MTDF)5 initiative of Pakistan and “Vision 2030 Program”.6 Malaria has remerged as a major cause of morbidity and mortality amongst the poor communities and in less developed areas of Pakistan. The goals of the current malaria control program are directly linked to the current GMP and MDGs.

The National Strategic Framework for Malaria Control (2011-15)7 has the following key elements: Case management: Early diagnosis, rapid and appropriate treatment. Prevention through multiple strategies Epidemic preparedness Building capacity at national and sub-national levels. Advocacy, communication and social mobilization. Partnerships with private and informal sector Focused operational research.

Malaria Control Program: Directorate of Malaria Control (DMC) is implementing the malaria control program and is largely funded through national resources. However, these are insufficient to achieve the required coverage of interventions in the target population. This gap requires additional support of donors. Current malaria specific funding exists through the Global Fund Round 7. The Global Fund funded interventions are focused on 19 high endemic districts in Khyber Pukhtunkhwa (KPK), Federally Administered Tribal Area (FATA), Balochistan, Sindh and Punjab and employ strategies including improving case management, preventative measures amongst pregnant women and children (through LLINs distribution), and community awareness and outbreak detection and control. The Global Fund Round 7 supported interventions will continue through 2013. The public sector health coverage is supported by the non-government organizations including both not-for-profit NGOs and for-profit private sector. Early Diagnosis and Treatment: As per policy of the DMC for case management of malaria cases, parasitological confirmation of all suspected cases is mandatory for the administration of anti-malarial drugs except for children under 5 years with uncomplicated malaria in areas where diagnostic services are not available. The national malaria strategic framework mandates RHCs and above level health facilities as microscopy centers and BHUs as rapid diagnostic tests (RDT) centers. Recent advances in rapid diagnostic technologies have allowed use of RDTs for diagnosis of malaria. Currently, the focus is on identifying cases of falciparum malaria using Pf specific RDTs, but the inclusion of tests which can identify both species of malaria (i.e. falciparum and vivax) are required. P vivax constitutes a major proportion of all malaria cases diagnosed through the existing microscopy centers. Diagnosis of malaria at community level is scarce with few community based health staff (such as government supported lady health workers (LHWs), and NGOs supported community health workers (CHWs) having access to diagnostic tools. The National HMIS suggests 16% of out-patient consultations are due to malaria, while the available malaria diagnostic centers report only 2% out of 16% to have parasitological confirmation. The provision of early diagnosis and prompt treatment with effective antimalarial drugs soon after the patient develops the symptoms of malaria, is the most important intervention in the current National Malaria Strategic Framework 2011-2015. As clinical grounds are the main diagnostic tool in most endemic areas, there is excessive and irrational use of antimalarial drugs with resultant loss of efficacy due to high level resistance development in the parasite. A focus of the current national malaria strategy is to improve community based diagnostics and targeting of effective treatment by providing/strengthening RDT or microscopy centers functioning from the existing public sector health care delivery system in all malaria endemic areas. Provisioning and strengthening of the diagnostic facilities will be coupled with training of healthcare providers for correct management of malaria cases.

5 Mid term Development Framework, Pakistan 6 Pakistan Vision 2030 Program 7 National Malaria Strategic Framework 2011-15



A range of antimalarial drugs are available for the treatment of malaria. Chloroquine remains the drug of choice for treatment of vivax malaria, however, Artemesisin Combination Therapies (ACTs) are the first line drug for confirmed falciparum cases, in line with WHO-EMRO regional recommendations. Expected Outcomes

80% of malaria cases are diagnosed and provided correct treatment within 24 hours of onset of symptoms (through facility or community services);

100% of public health facilities have adequate anti malarial drugs and diagnostic supplies; 100% of cases diagnosed as P. falciparum malaria in public sector facilities to be treated with

ACTs; 50% of private sector health care providers involved in malaria case management according to

the national treatment guidelines; All four provincial sentinel sites doing regular monitoring of efficacy of antimalarial drugs.

Preventive measures: Long Lasting Insecticide treated bed Nets (LLINs) are an effective tool employed by MCP for malaria prevention both through personal protection and density reduction of adult mosquitoes. This environment friendly intervention has been the mainstay of malaria control in the country and has reduced reliance on blanket coverage with Indoor Residual Spraying (IRS). The malariometric survey (2009)8 showed that only 4.3% of households surveyed had an LLIN and 10.7% had any mosquito net (i.e. not insecticide treated). Amongst those households who did possess an LLIN, these were used by 85%, suggesting that once distribution has occurred, usage rates will be sufficiently high to make this intervention a cornerstone of malaria control in Pakistan. Indoor Residual Spraying has a long history in Pakistan, since the eradication era, and it is currently considered effective. There are a number of other personal protection methods which have proven efficacy in Pakistan. These include insect repellents and insecticide treated chadors and top-sheets. These may have a use in certain settings and epidemiological situations (such as outbreaks, epidemics and in areas of population movement such as complex emergencies). In addition, the preferred current approach to vector control uses integrated approaches, based on the Integrated Vector Management (IVM).

Expected Outcomes

85% of the target communities sleep under LLIN in malaria transmission season; 15% of target localities received 02 rounds of IRS coverage annually; All four provincial sentinel sites doing regular monitoring of insecticide resistance.

Malaria epidemiology of Pakistan is heterogeneous and the disease burden is focal with a variable degree of transmission intensity across different geographical locations. These malaria hot-spots are mainly in 38 high priority districts with approximately 24.84 million people. Improved infrastructure in endemic areas, increased coverage by community based health workers, improved skills of health workers at the community and facility level for correct diagnosis and management of malaria, and raising awareness of the communities regarding causes and prevention of malaria are needed. Prioritizing these areas will lead to the greatest and most cost-effective gains in malaria control.

4.2 Epidemiological profile of target populations for MALARIA (a) Describe the current epidemiological profile of the target populations, and how this profile is changingwith respect to malaria.

Pakistan is a malaria endemic country; estimated annual numbers of malaria cases are 1.6 million. An approximate population of 24.84 million is at risk residing in 38 highly malaria endemic districts. However, confirmed cases from public sector health facilities with malaria microscopy centres are only 120,1099, reflecting low public sector utilization and poor reporting mechanisms. The majority (80%) of malaria in Pakistan is caused by Plasmodium vivax, while the remaining is mainly due to P. Falciparum2. Malaria endemicity is heterogeneous in Pakistan. Some areas are entirely malaria free like Northern highlands and desert areas. Other areas provide ideal conditions for transmission such as breeding sites include areas close to water sources in all provinces.

8 Malariometric Survey, Final Report, 2009, Page 32 9 MCP Annual Surveillance Data for 38 target districts 2009



Malaria transmission is seasonal, with peaks in summer (June-September) for vivax and late-summer and winter (August-November) for falciparum malaria. Because P vivax forms a latent liver stage, there is a peak of relapse episodes seen in early summer (April-June) resulting from transmission in the previous year. This hypnozoite reservoir of disease in humans contributes to stable disease transmission in winter months. Certain areas of Sindh and Balochistan have year round transmission with falciparum predominance. Thirty seven percent of malaria cases come from districts and agencies of FATA and Balochistan bordering Afghanistan and Iran. The predominant malaria species in the border areas is P. vivax. However, the proportion of P. falciparum varies among the bordering districts with a range of 6 – 60% and an average PF rate of 32% 3. There is a high malaria prevalence (34%) with high falciparum positivity rate (>90%) in nomad populations10 following their seasonal route from central Afghanistan to FATA and Balochistan provinces in the north and west of Pakistan is a major threat for local populations residing in border districts of Pakistan. A malariometric survey was conducted in 19 highly endemic districts of Sindh, Balochistan, FATA and KPK in early 2009. The highest positivity rate was recorded in FATA followed by Balochistan. In the survey, the parasite prevalence was found to be higher than the API for the same districts. A strong correlation with socio-economic status exists, those in the lowest stratum having the highest risk of malaria. Children represent the highest risk group, with those under the age of 10 years accounting for majority of cases. The border districts are characterized by extremely difficult terrain, chronic conflict and poor access to health services. They live in scattered settlements with low socioeconomic status, low literacy rate and gender inequity. Security problems in this area are one of the limiting factors for implementation of developmental projects and disease control including malaria. It is characterized by large and frequent population movements to Iran and Afghanistan due to ethnic and family ties on both sides of the border, nomadic life style based on seasonal migration, legal and illegal trade and pilgrimage to different religious sites. Malaria outbreaks frequently occur in Pakistan with a history of unstable transmission. Outbreaks can occur given the right conditions, including population movement, lack of control methods and unpredictable weather11. Early detection of outbreaks requires timely disease surveillance through routine reporting of caseloads. Specific requirements for outbreak detection include analysis of data based on seasonal trends. Outbreak response requires specific measures, including prolonged clinic hours, active case detection, and urgent application of personal protection and vector control measures. This is more important in the circumstances when there is a flood situation in Pakistan affecting a large number of malaria endemic districts, which are now epidemic prone.

Most malaria cases occur in a few priority districts of the country. There are 38 priority districts amongst110 districts which report any malaria cases out of a national total of 134 districts. The 38 districts areprioritised based on incidence of disease delineated from 5 year Malaria Program data (2004-2009).Focusing on these 38 priority districts will have the greatest impact in reducing the national burden ofdisease and contributing to MDG 4, 5 & 6. Greater emphasis on identifying malaria risk is required, usingGIS and risk-mapping techniques. Targeting interventions in high risk areas will be the most efficient wayof reducing disease burden and will contribute significantly to achievement of Millennium DevelopmentGoals.

(b) Do the activities in the proposal target:

Whole country Specific geographic region(s) Specific population group(s)

10 Rolling Back Malaria in Pakistan: Progress and Challenges 2009, DMC (unpublished data) 11 Leslie T, Kaur H, Mohammed N, Kolaczinski K, Ord RL, Rowland M, Epidemic of Plasmodium falciparum malaria involving substandard antimalarial drugs, Pakistan, 2003.. Emerg Infect Dis. 2009 Nov;15(11):1753-9.



12 Un-published data, Planning Commission of Pakistan, Data Collected by National Institute of Population Studies, 2010

(c) Size of population group(s) If national data is disaggregated differently then type over the categories proposed

Population Groups Population Size Source of Data Year of Estimate

Total country population (all ages) 173.51 million

National Institute of Population Studies, Islamabad Government of Pakistan 12

2010

Females five years old and above 73.27 million

National Institute of Population Studies, Islamabad Government of Pakistan

2010

Males five years old and above 78.43 million


2010

Children: females

1-4 years 8.27 million


2010

Children: males

1-4 years 8.85 million


2010

Infants: females

< 1 year 2.21 million


2010

Infants: males

< 1 year 2.38 million


2010



(d) Malaria epidemiology of target population(s)

Population Groups Estimated Number Source of Data Year of Estimate

Episodes of malaria in past 12 months (all populations, all ages)

101419 GFATM R-7 data (19 districts) April 2009 –March 2010

Episodes of malaria in past 12 months: females 14 years and above


Episodes of malaria in past 12 months: males 14 years and above


Episodes of malaria in past 12 months: females 5 – 14 years


Episodes of malaria in past 12 months: males 5 – 14 years old


Episodes of malaria in past 12 months: pregnant females


Episodes of malaria in past 12 months: female children under five


Episodes of malaria in past 12 months: male children under five


Episodes of malaria in past 12 months: infant females 12 months and under

- GFATM R-7 data (19 districts) April 2009 –March 2010

Episodes of malaria in past 12 months: infant males 12 months and under

- GFATM R-7 data (19 districts) April 2009 –March 2010

Other:

specify

use "Tab" key to add extra rows if needed

4.3 Major constraints and gaps in disease, health, and community systems

4.3.1 Malaria program

Describe:

(a) the main weaknesses in the implementation of current malaria strategies; (b) existing gaps and inequities in the delivery of services to target populations; and (c) how these weaknesses affect achievement of planned national malaria outcomes. The provision of services for malaria diagnosis and treatment has been integrated with the Primary health care (PHC) infrastructure of the districts since 1978, while the prevention and vector control component of the program remained vertical at provincial and district level. The huge network of PHC facilities in the country has improved the access of populations to the public sector health services in many parts of the country, but this objective remains to be achieved in bordering provinces and regions of the country where majority of highly malaria endemic districts are located. Weak health infrastructure, lack of trained human resource, weak disease surveillance system, problems in supply



chain management of antimalarial drugs and lack of resources for the operations are the major health system constraints which hamper the implementation of current malaria control strategies in these regions. The situation is further compounded due to lack of proper community awareness program. Lack of skilled staff to diagnose and treat malaria, lack of diagnostic equipment and supplies, regular stock outs of antimalarial drugs including ACTs and weak surveillance are the major obstacles in ensuring the access of population at risk to quality assured diagnosis and effective antimalarial treatment. Lack of resources for the procurement and distribution of LLINs and the application of other vector control measures is the major challenge to reduce the transmission potential of highly endemic regions and districts. There is huge unregulated private sector catering malaria curative services for about 50% (REF) of the population in endemic areas, which does not follow the national policy guidelines for malaria treatment. Indiscriminate use of antimalarial drugs without confirmed diagnosis has been playing major role in the propagation of drug resistance. Restrictions on treatment seeking by women without the permission of husbands, fathers and family elders due to Local social taboos has resulted in limited access of women to healthcare hampering the achievements of the program in this target group. Many areas of Pakistan are prone to natural and man-made disasters. Earthquakes and frequent flooding on alluvial plains destroy infrastructure and promote vector breeding, while at the same time disrupting healthcare infrastructure and delivery. Fragile security situation in country especially in the areas bordering Afghanistan and Iran – the areas which are highly endemic for malaria– is a major constraint in smooth delivery of malaria control interventions. Military operations in 2008 in FATA and growing security concerns in the province of Balochistan has made the situation more challenging, resulting in over 2 million Internally Displaced People (IDPs). These IDPs migrating from low endemic districts to high endemic districts and vice versa have changed the disease epidemiology in either situation, increasing the curative and preventive needs of both the IDPs and the hosting populations. Low coverage of interventions due to insufficient program resources has affected the program outcomes and achievements in malarious areas of the country.

4.3.2 Health Systems (MALARIA)

Describe the main weaknesses of and/or gaps in health systems that affect malaria outcomes.

Information System and M&E:

The currently used Malaria Information System (MIS) is not fully responsive to malaria program needs for example data cannot be disaggregated by gender and age group. The data generated is not consistently used at the provincial and the district level for planning purposes. In addition, the monitoring and evaluation of malaria control activities including supportive supervision and field visits is often lacking because of limited staff, expertise and budget.

Logistic Management System:

There are frequent interruptions in supply of commodities from the provincial to the district level, in the field; there is often insufficient and inappropriate storage space for these commodities. Supply management is not demand-based.

Planning and Management Capacity:

The planning and program management capacity at the provincial level is weak in terms of qualified and trained human resource and available expertise. The same situation is found at the district level where the health managers have limited capacity in planning of the healthcare services specifically for malaria control.

Health Services Delivery Capacity: While the diagnostic facilities are available in these higher level district facilities, these services are not available at the Basic Health Unit (BHU) level, which makes the coverage inadequate for malaria control. Delayed Diagnosis leads to unnecessary illnesses and deaths. A structured supervisory system is not in place and this leads to poor performance at all levels. There is a lack of quality assurance mechanisms both in the public and private facilities. Physician’s knowledge on clinical management of



uncomplicated and severe malaria is largely inadequate due to lack of proper training and limited training opportunities. Inadequate arrangements for timely replenishment of stock outs of anti-malarial drugs and supplies at the peripheral health facilities. The residual efficacy of synthetic pyrethroids used for IRS is 3 to 4 months, but only single round of IRS is being carried out which does not cover the transmission season.

The private sector is the major provider of healthcare services to a large segment of the population. Private providers not yet enabled to deliver malaria care as per national guidelines. The private sector health care is therefore largely unregulated and does not follow National Drug Policy for treatment of malaria patients. The private sector is the major provider of healthcare services to a large segment of the population.

In general, health service delivery infrastructure including facilities for diagnosis, prevention and case management are in poor condition. This becomes more relevant in rural and far flung areas and most of the malaria endemic areas fall into this category.

4.3.3 Community Systems (MALARIA)

Describe the main weaknesses of and/or gaps in community systems that affect malaria outcomes.

Inadequate community based systems for promotion of malaria prevention interventions including LLINs and IRS

The current community systems are not strong enough to help achieve malaria outcomes to the desired level. LHWs are covering 65% of the population; however, their services are being sub-optimally used for malaria interventions. The situation is even more challenging in areas which are not covered by LHWs. Inadequate women participation in the community awareness events. Due to socio-cultural reasons women’s access to health care is limited in majority of malaria endemic areas. That has resulted in low utilization of public health services by the women. In rural areas, women’s interaction with men and participation in health awareness campaigns in the communities is generally not appreciated. Lack of women friendly environment at the public health facilities including non availability of female care providers is yet another challenge that has further aggravated the situation. This has been seriously addressed in the current Round 10 GF proposal. Lack of involvement of grass root leadership and communication channels in malaria

prevention and control The existing community structures including community activists, community representatives (e.g. Jirga), elected community representatives, religious leaders and CBOs in the endemic areas involved in local social welfare activities rarely actively participate in various health related events. There is a need to capitalize upon these CBOs for raising awareness regarding malaria at the community level so that awareness levels of preventive measures and health seeking behaviors regarding malaria improve among the communities. There is also a need for communities to realize the consequences of drug resistance and expectations related to correct treatment. CBOs may act as activists to support the community in this matter. The current proposal has taken into consideration these weaknesses while designing community outreach and BCC interventions.

4.3.4 Efforts to resolve weaknesses and gaps (MALARIA)

Describe what is being done, and by whom, to respond to health and community system weaknesses and gaps that affect malaria outcomes, as outlined in sections 4.3.2 and 4.3.3.

There is increasing awareness in the country at the policy level about the need to invest more in the formation of social capital through increased public spending on health and education; Equity and social protection are high on the political agenda as reflected in the poverty reduction strategy paper (PRSP);13

13 Poverty Reduction Strategy Paper



The Government of Pakistan’s “Vision 2030” initiative provides a long term vision and strategy for national development including health whereby malaria is cited as a priority area ; Disease specific vertical programs are being integrated at the district level; There is a functioning network of >100,000 LHWs across the country, linking the health services to the families in the target communities. This network functions as the backbone of the Primary Health Care and family Planning activities at the community level. LHWs are being involved in distribution of LLINs to women including expected mothers and children <5 years using the “Health Houses” of these LHWs. This not only results in enhanced confidence of the LHWs on one hand and increase the “trust” of the catchment area population on the service package of these workers on the other hand. The following aspects are being strengthened directly or indirectly through the Global Fund Round 7 proposal.

Clear evidence based vision for health needs; A better managed and regulated public private mix that harnesses the private health sector to

help achieve public health goals; A balanced, skilled, well distributed and motivated health workforce; Improved access to a well defined package of quality healthcare services; A well functioning district health system aligned to the devolution process; A health information system that provides valid, reliable and disaggregated information on

important health determinants, programs and system functions for informed decisions and is backed up by an effective disease surveillance system in the country.

4.4 Proposal strategy

Complete this version of section 4.4.1 if the applicant selected option 2 or 3 in section 3.1 of the Proposal Form

Option 2 = Transition to a single stream of funding during grant negotiation Option 3 = No transition to a single stream of funding in Round 10

4.4.1 Interventions for MALARIA

The goal of the current proposal is to reduce burden of malaria by 75% in 38 highly endemic districts of Pakistan. These 38 districts also include 19 districts of the Global Fund Round 7. The target population in these 38 high risk districts is estimated at 24.84 million. This goal will be achieved through following objectives: Objective 1: To enhance access of population at risk to quality assured early diagnosis and prompt treatment services Objective 2: To scale-up multiple prevention interventions especially LLINs and IRS to the level of universal coverage in target population Objective 3: To enhance technical and management capacity of malaria control program for improved planning, management and monitoring of malaria control interventions Objective 4: To improve health seeking behaviors and practices of target communities in malaria endemic districts through enhanced community awareness and participation

Under each objective, specific Service Delivery Areas and activities have been planned. These SDAs and activities are in line with the National Malaria Strategic framework, key lessons learnt from the previous Global Fund Rounds, and the current flood emergency situation in Pakistan. The progress and achievements of the project will be measured through a set of impact and outcome indicators which are as below:

Impact Indicator: Annual Parasitic Index (API) Outcome Indicators 1. % of uncomplicated malaria cases correctly managed at health facilities in 38 highly endemic

districts 2. % of pregnant women with confirmed malaria who received anti-malarial treatment at health

facilities in 38 highly endemic districts 3. % of rural households with at least 1 LLIN in 38 highly endemic districts



4. % of rural households protected by IRS in 38 highly endemic districts The public and private sector PRs along with their SRs will be responsible for implementation of the project activities in their respective target districts. DMC (public sector PR) will implement activities in the existing 19 Round 7 districts through single stream funding mechanism, and Save the Children (private sector PR) will implement the proposed activities in the additional 19 districts. Consolidation of Round 7 and 10 will take place at the time of grant negotiation.

Objective 1: To enhance the access of population at risk to quality assured early diagnosis and prompt treatment services Most of the 38 high endemic districts are located along the Southern borders of Afghanistan and Eastern borders of Iran with Pakistan. Communication is difficult in most of the areas of these districts. Health facilities and number of service providers and their skills are inadequate which result in lack of at-risk-populations’ access to diagnosis and treatment facilities. Based on the experiences from Round 7, it is planned that the coverage of both diagnostic and treatment services will be enhanced in all 38 target districts. 1.1. SDA: Diagnosis Under this SDA, the coverage of quality assured malaria diagnosis will be enhanced through upgrading of existing and establishment of new microscopy and RDT centers. Activity 1.1.1: Strengthen Existing Diagnostic Services in 19 Districts

Sub-Activities 1.1.1.1 Repair, renovate & furnish existing new microscopy centers (76 & 95 respectively) 1.1.1.2 Refresher training of 447 public sector microscopists in malaria microscopy (10 days) 1.1.1.3 Refresher training of 200 private sector microscopists in malaria microscopy in 10 pilot districts for

private sector involvement (10 days) 1.1.1.4 Purchase of 152 microscopes (1 per newly established 95 centers, 2 per DHQ in newly proposed 19

districts, and 1 per DHQ in the Round 7 districts) 1.1.1.5 Procurement and supply management cost of microscopes 1.1.1.6 Procurement of chemicals, reagents and lab supplies, twice a year 1.1.1.7 Maintenance of 447 centers

In the 19 additional targeted districts, 76 existing microscopy centers will be renovated and upgraded. In the same districts, 95 structures, which can be utilized as microscopy centers, will be mapped and transformed into new microscopy centers. The up-gradation and establishment of the centers includes repair, renovation of the structures, provision of furniture/fixtures and essential chemicals, reagents, microscopes and other equipments as per national guidelines. A total of 447 microscopists/lab technicians will be provided with refresher training on malaria microscopy as per national guidelines. Out of these 447 microscopists, 76 will be from the upgraded microscopy centers, 95 from the newly established microscopy centers and 276 will be from microscopy centers in the current 19 target districts of The Global Fund Round 7. In addition, 200 microscopists from the private sector in 10 districts will be trained on malaria microscopy. A total of 371 microscopists (76+95+200) will be provided with two rounds of refresher trainings using Round 10 resources in project year 1 and 3. The 1st round of refresher training of 276 microscopists will be supported by Round 7 funds and the 2nd through Round 10 funds in year 4.

It is expected that approximately 700,000 people will be diagnosed with RDTs at the BHU level and approximately 1.3 million people will avail microscopy diagnostic facilities at RHCs. Majority of the people will use microscopy centres at RHCs which are more functional as compared to BHUs.

To avoid duplication and ensure effective use of existing resources, it is planned to integrate malaria microscopy with TB AFB testing in 10 districts (2 centers per district). These centers will be identified during the mapping exercise for the microscopy centers. Activity 1.1.2. Establishment of RDT Centers at FLCFs Sub-Activities 1.1.2.1 Up-gradation of existing 380 (19x20) existing Public Health Facilities as RDT Centers in 19 Districts 1.1.2.2 Purchase, & supply of 3.5 million Pan specific RDTs (Pv.pf) for 5 years 1.1.2.3 Procurement and supply management cost of pan specific RDTs 1.1.2.4 Use of 3.5. million Pan Specific RDTs in 380 RDT Centers 1.1.2.5 Training of 380 health personnel in the use of RDTs (02 days) for the 19 Round 10 districts 1.1.2.6 Refresher Training of 380 health personnel in the use of RDTs (02 days) for the 19 Round 7 districts

For strengthening malaria diagnosis in areas where microscopy centers are not available or inaccessible for the communities including IDPs in KPK, 380 existing structures will be mapped and equipped and used as RDT centers in new 19 districts under Round 10. A total of 3.5 million Pan specific RDTs will be



purchased and distributed to existing and newly established RDT centers. The overall need in 38 districts is 5 million RDTs. Out of these, 1.5 million RDTs will be procured through Round 7 resources for Round 7 districts. A total of 380 health personnel (20 per district in the 19 districts) will be trained on the use of RDTs. In addition, 380 health personnel from the Round 7 districts will be provided with refresher training on RDTs. The private sector PR (Save the Children) and its respective SRs will be responsible for establishing RDT centers. The public sector PR (DMC) will be responsible for procurement of RDTs and the refresher trainings. Activity 1.1.3. Training of 43 lab Supervisors on Quality Assurance in Malaria Diagnosis A total of 43 lab supervisors will be trained in Quality Assured malaria microscopy. Out of these, 38 will be from the target districts, three from the provinces, and one each from FATA and DMC. The DMC in collaboration with the partners will review and update guidelines on quality control of malaria microscopy. Save the Children and respective SRs will implement this activity.

1.2. SDA: Prompt and Effective Anti-Malaria Treatment As outlined in section 4.3.2, the skills and capacities of healthcare providers play important role in the correct management of malaria cases. Under this SDA, capacity building of different cadres of public healthcare providers and private providers in management of malaria cases will be carried out. In addition, under this SDA, populations in severely affected districts by the recent floods (5 out of target 38 districts) will be provided with access to prompt diagnosis and treatment facilities for malaria. Activity 1.2.1: Enhance the Capacity of Healthcare Providers in Proper Malaria Case Management Sub-Activities 1.2.1.1 International Training of 09 staff members from Provincial Program and from PRs on advanced level

malaria case management from recognized centers of excellence (one week) 1.2.1.2 Development & Printing of 2,500 malaria case management training manuals 1.2.1.3 Training of 76 master trainers on malaria case management (03 days) in 38 districts 1.2.1.4 Training (02 days) 1,359 of public sector health care providers on uncomplicated malaria case

management at first level health care facilities in 38 districts 1.2.1.5 Training (02 days) 300 of public sector health care providers on severe and complicated malaria case

management at secondary and tertiary level health care facilities 1.2.1.6 Printing & distribution of 1300 treatment flowcharts and job aids for microscopists in 447 (76+276+95)

microscopy centers and 760 RDT centers (380 Round 10 + 380 Round 7) 1.2.1.7 Procurement & storage of anti-malarial drugs (including for ACT and other regimens) for 2,100,000

people 1.2.1.8 Procurement and supply management cost of anti-malarial drugs including ACT 1.2.1.9 Supply & use of ACT drugs and other anti-malarial drugs, for correct treatment of 2.0 million

confirmed malaria cases

Under this activity different cadres of healthcare providers will be trained in management of malaria cases. Total 09 staff members (2 from national program, 5 from provincial programs and 2 from implementing partners) will receive one-week advanced level case management training from internationally recognized centers of excellence. Private Sector PR (Save the Children) will be responsible for carrying out this activity. The health staff trained at the international level will further train 76 master trainers (2 per each of the 38 target districts) on malaria case management. These master trainers will be provided with standardized training manuals on malaria case management, developed with inputs from national level experts. The master trainers will further train 1,359 healthcare providers from the first level facilities on management of uncomplicated malaria cases, and 300 from the secondary and tertiary level healthcare facilities on management of severe and complicated malaria cases. Women healthcare providers working at the public facilities will be given priority for their involvement in diagnosis trainings. Case management protocols including job aids and flowcharts will be developed and provided to all 760 RDTs and 447 microscopy centers (76 upgraded, 95 new, and 276 existing microscopy centers), further supporting quality diagnosis and treatment for the people.

A total of 2.1 million courses of anti-malaria drugs including ACTs will be procured in three batches to treat approximately 2 million malaria cases. Activity 1.2.2. Involve private sector in the provision of diagnostic and curative services according to national guidelines

Sub-Activity 1.2.2.1 Training of 200 private care providers on malaria case management in selected 10 districts

A total of 200 private healthcare providers (GPs) will be trained on management of malaria cases as per national guidelines in 10 districts. These healthcare providers will be monitored and provided supervisory support quarterly for ensuring quality case management. Involvement of women health



care providers in this activity will be encouraged. Based on this experience a roll out plan would be formulated for all 38 districts. Private sector PR through SRs will implement this activity.

Activity 1.2.3. Provision of mobile outreach malaria diagnostic and treatment services to severely flood affected population in 5 districts Sub-Activities 1.2.3.1. Procurement of 2 mobile malaria vans per district (10 vans) 1.2.3.2. Operationalize mobile outreach malaria services in 5 districts (1 in Balochistan and 4 in KPK)

Recent floods in Pakistan have severely affected populations in the whole country. UNOCHA has reported that 5 out of 38 Global Fund Round 10 target districts are among the most severally affected districts.14 These include Sibi (Balochistan), Tank, DI Khan, Charsada, and Nowshera (KPK). The population affected in these districts is estimated at 4.3 million constituting 17.4% of the total target population in Round 10 districts. The affected districts are highly vulnerable to malaria outbreaks and epidemics that might result in huge morbidities and mortalities. The local population of these districts is displaced and most of the health infrastructure in these five districts has been severely damaged and its reconstruction will require at least 2 to 3 years. It is therefore proposed to provide mobile diagnostic and treatment services to these displaced populations till the health facilities are rehabilitated. For this purpose, a total of 10 mobile malaria vans (2 per district) will be procured and equipped with diagnostic services (RDTs and microscopy), treatment services (anti-malarial drugs and trained healthcare providers) and LLINs for personal protection. Once the health infrastructure in these districts is in place and functional, these mobile malaria vans will be kept in the provincial pool to be used during outbreaks.

Objective 2: To scale-up multiple prevention interventions especially LLINs and IRS to the level of universal coverage in target population It is proposed that prevention interventions, specifically LLINs and IRS, which have been effective in Pakistan, need to be scaled up to the level of universal coverage from current 19 to an additional 19 malaria endemic districts. Approximately, 16.14 million of the target 24.84 million population lives in the rural areas of 38 districts and 50% (8 million) of this population lives in high risk areas for malaria. Under this SDA, 85% (6.9 million) of 8 million population living in high risk areas will be benefited through LLINs and the remaining 15% (1.2 million) of the population living in epidemic prone areas will benefit from IRS. SDA 2.1. Insecticide Treated Nets (Long Lasting ITNs) Malaria transmission in high risk groups will be reduced by providing LLINs. Through the Global Fund Rounds 2 and 7 experiences LLINs have been demonstrated as the most accepted and effective prevention tool. This experience has informed the national vector control guidelines15 and LLINs distribution policy, which highlights that more than 80% pregnant women and children less than 5 years of age will be protected through free distribution of LLINs. Overall 2.75 million LLINs will be distributed to people living in selected high risk districts over the project period. To promote the correct use of LLINs, target populations knowledge and awareness about LLINs will be improved through BCC/IEC campaigns using various promotion modes. Activity 2.1.1. Prevention through universal coverage of LLINs in target districts Sub-Activities 2.1.1.1 Procurement of 2.75 million LLINs 2.1.1.2 Procurement and supply management cost of LLINs 2.1.1.3. National consultation on development of LLINs distribution strategy & user guide 2.1.1.4 Printing of 2.75 million LLINs distribution voucher in local language 2.1.1.5 Printing of 2.75 million LLINs user guide in local language 2.1.1.6 Training (one-day) of 84 master trainers on LLIN distribution strategy, data management & user guide 2.1.1.7 Training workshops for 760 outlet staff (380 district-level malaria control program staff+380 NGO/CBO

staff) on LLIN distribution strategy, data management and user guide (20 persons per district) 2.1.1.8 Establishment of LLIN 380 distribution outlets in public sector facilities in 19 districts (20 per district) 2.1.1.9 Upgrading of 41 provincial & district stores for storage and supply of LLINs, RDTs & Drugs 2.1.1.10 Distribution of 2.75 million LLINs to the target communities

To improve supply chain and storage of LLINs, available facilities at provincial and district level will be upgraded. To ensure effective distribution of LLINs, 380 distribution outlets (20 per districts) in 19 new districts will be established, preferably in public sector facilities.

A national consultation workshop will be organized for development of LLINs distribution strategy, user guide and tools. Representatives from MNCH departments, TB control program, EPI, provincial and

14 UNOCHA Map issued on August 12, 2010 15 National Vector Control Guidelines



district level representatives etc. will also be involved in this process. Malaria supervisors in the districts will lead the distribution of 2.75 million LLINs in target communities with the support of LHWs and EPI staff. In this regard, EPI staff and LHWs will map beneficiary houses and provide each beneficiary household a voucher for collecting LLINs from the identified distribution point. Distribution of LLINs will be free of cost and will be planned in a phased manner. To ensure the correct use of LLINs particularly by the pregnant women and children under 5, BCC/IEC campaigns using various promotion modes will be organized. In this regard, information material will be developed and distributed to beneficiaries receiving LLINs. Simultaneously, 84 master trainers (2 master trainers per district = 76 and 2 per SRs = 8) will be trained on National LLINs guidelines inclusive of data management, and user guide as LLINs distribution will require effective data management and monitoring skills. They in-turn will train 760 outlet staff (380 district-level malaria control program staff+380 NGO/CBO staff) on LLIN distribution strategy and data management as per national guidelines. Both the PRs and their respective SRs will conduct trainings, ensure supply chain management, and monitoring of LLINs distribution. DMC will be responsible for procurement, while the private sector PR will facilitate the national consultation process for distribution and user guidelines. SDA 2.2. Indoor Residual Spraying (IRS) As per national vector control guidelines, IRS will be used for the protection of approximately 15% of the target population in epidemic prone areas. Identification of union councils for IRS will be made by both the PRs in consultation with provincial and district partners based on the reported data.

Activity 2.2.1. Selective IRS in Epidemic Prone Areas Sub-Activities 2.2.1.1 Procurement of insecticide as per national guidelines 2.2.1.2 Procurement of spray equipment and accessories (4 spray pumps per district) 2.2.1.3 Application of IRS to Households in Epidemic prone areas twice in a year

15% of the target population at risk of malaria outbreak will benefit from two rounds of IRS per year. Insecticides used in IRS will be with residual efficacy for minimum 03 months (synthetic pyrethroids are currently being used by the program). In the event of an outbreak, focal IRS will be carried out in the union councils where the outbreak was detected and in all adjacent union councils. In this regard, spray equipment and accessories will be procured by DMC. Both PRs through their respective SRs through the support of district malaria control staff will carry out IRS in the target population including mosques, refugee and IDP camps. Approximately 1.2 million people including IDP areas/camps in hosting districts/173,000 house structures including both human dwellings and animal sheds will benefit from IRS in 38 target districts.

In order to prevent potential malaria outbreaks due to recent flood in the endemic districts, the mapping of larval breeding sites and selective larviciding will be carried out in the affected communities with the public sector resources.

SDA 2.3. Information System Under this SDA, in addition to strengthening of provincial and district data management units, the capacity of public healthcare providers in carrying out epidemiological surveillance will be carried out.

Activity 2.3.1. Strengthening Epidemiological Surveillance Sub-Activities 2.3.1.1 Printing and distribution of 2,000 newly developed recording and reporting tools (revised under

Round 7 Phase 2) 2.3.1.2 Training of 4 provincial, 1 FATA, 1 DMC, and 38 CDC officers on malaria data management, M&E &

Early Detection of Malaria Outbreaks (03 days) 2.3.1.3 Training of 1,407 health personnel in surveillance tools, malaria data management, M&E & Early

Detection of Malaria Outbreaks (03 days) 2.3.1.4 Establishment of 19 data management units in new districts only 2.3.1.5 Strengthening of existing 25 data management units at provincial and district level 2.3.1.6. Support to 44 data management units (38 districts, 4 provinces, 1 FATA, and 1 DMC) with computers,

printers, surveillance tools, other recurrent costs, etc.

Malaria surveillance tools have been reviewed and updated during Round 7. In Round 10 these newly developed tools will be printed and disseminated to all districts. Both PRs and SRs will be responsible for implementing this activity. Also, a total of 41 CDC officers including 1 from DMC, 1 per province and 1 from FATA and the 38 district malaria supervisors will be trained in malaria data management, surveillance and early detection of malaria outbreaks. SC will be responsible for carrying out this activity. Furthermore, 1,407 district level public health personnel from all 38 districts will be trained on



accurate use of updated surveillance tools and early detection of malaria outbreaks. A total of 19 data management units (1 per new district) will be established within the district department of health and continuous support will be provided to all data management units including 19 units in old districts and 1 at each province, 1 at FATA level and 1 in DMC. Support includes repair and renovation, provision of computers, printers, furniture, surveillance tools and recurrent cost. CDC officers will be the in-charge of these centers. Both PRs and SRs will be responsible for implementing this activity. SDA 2.4. Monitoring Drug Resistance To guide the national case management policy, first line anti-malarial drugs need to be tested for their efficacy in uncomplicated malaria on alternate years during the proposed project period. Activity 2.4.1. Conduct Anti-Malaria Drug Efficacy monitoring surveys at existing sentinel sites In the proposed project two surveys on Anti-Malaria Drug Efficiency will be carried out at four sentinel sites established under Round 7. Private sector PR will be responsible for this survey.

SDA 2.5. Monitoring insecticides resistance To guide the program for selection of appropriate insecticides for IRS, monitoring of insecticides resistance will be carried out once over the project period. Activity 2.5.1. Conducting insecticide resistance monitoring survey at existing sentinel sites It is proposed to conduct a study in already existing four sentinel sites (one in each province). Private sector PR will be responsible for this survey.

Objective 3: To enhance technical and management capacity of malaria control program for improved planning, management and monitoring of malaria control interventions This objective will focus on strengthening management and leadership capacity of both the public sector and private sector PRs and SRs. In view of post 18th constitutional amendment in Pakistan resulting into further decentralization of program implementation to provincial and district levels, it has been proposed that PMUs will be established and strengthened in the provinces and districts.

SDA 3.1. Leadership and Governance This SDA will focus on strengthening governance, management and technical capacities of the implementation partners. Activity 3.1.1. Strengthening program management capacity (Supportive Environment)

Sub-Activities 3.1.1.1 One International TA for MCP through WHO 3.1.1.2 Four national staff for provincial MCP 3.1.1.3 Involvement of Technical Working Group (TWG) in program planning and monitoring and evaluation 3.1.1.4 International trainings for staff on Malaria Program Planning & Management (8-12 weeks duration) 3.1.1.5 Training of staff (38 districts and 04 provincial) on Vector Control & Medical Entomology through In-

country One Year Diploma Course at Health Services Academy, Islamabad.

A technical working group (TWG) will be constituted at DMC level. The TWG will be represented by disease control experts, scientific community, and representatives from MOH’s national programs including TB, FP&PHC, EPI and MNCH. TWG will be responsible for reviewing guidelines, tools, materials, and training curriculums. TWG will also provide guidance on planning, monitoring and evaluation activities. TWG will work as part of DMC through the project period. MCP will procure 1 international TA and 4 national staff recruited through WHO, who would work in areas including surveillance, monitoring, planning and management for the project period. A total of 06 MCP officials’ participation in international trainings on Malaria Program Planning & Management (8-12 weeks duration) will also be supported. A total of 42 (38 district and 04 provincial) staff will be trained on vector control & medical entomology through in-country, one year diploma course at Health Services Academy, Islamabad. Private Sector PR will be responsible for implementation of this activity. SDA 3.2 : Monitoring and Evaluation, Evidence Building Monitoring and evaluation is a key component of the National Malaria Strategic Framework 2011-2015. Monitoring will be carried out by the district, provincial and federal level officials and will be an integral part of the staff responsibilities. Monitoring will examine both process and output indicators.

Activity 3.2.1: Conduct operations research studies for evidence based programming Sub-Activities 3.2.1.1 Sub National Malaria Prevalence Survey 3.2.1.2 Malaria Costing Study 3.2.1.3 Quality of anti malarial drugs being used in the private sector Three research studies are being proposed over the project period to provide evidence for effective malaria programming. These include a sub-National Malaria Prevalence Survey, a costing study of



malaria control interventions, and a study on the quality of anti malarial drugs being used in the private sector. These studies will be awarded based on a transparent competitive process. The TWG constituted at the federal level will be responsible for technical evaluation of the research proposals. TWG will also be involved in monitoring these studies. The findings of these studies will be used for informing the program strategies and advocacy at the national level for additional resource mobilization for malaria control program. Save the Children (the private sector PR) will be responsible for implementing this activity. Activity 3.2.2: Program Monitoring and Supervision Sub-Activities 3.2.2.1 Monitoring & supervisory visits from federal & provincial level to the districts (2 visits per month) 3.2.2.2 Monitoring and supervision of case management practices in public & private sector (19 districts in

years 1 to 3 and 38 districts in years 4 to 5: 4 visits per month) 3.2.2.3 Monitoring and supervision of malaria interventions including LLIN distribution by District Health Management Teams

3.2.2.4 Organize annual program review meetings at National Level (05) 3.2.2.5 Organize quarterly review meetings at the Provincial level (48) 3.2.2.6 Organize monthly review meeting at the district level (1.920)

Monitoring and supervision of Global Fund supported interventions will take place at multiple levels. These include periodic monitoring visits from federal to provinces, provinces to the districts and routine monitoring visits within the districts. These visits will be followed by quarterly review meetings at the provincial level and monthly review meetings at the district level. At the national level, five annual program review meetings will be organized in the project period. District Health Management Team members will be involved in regular monitoring of the program activities in the districts. Both the PRs through SRs will be responsible for this activity.

SDA. 3.3. Program Management (Public Sector PR) This SDA will focus on ensuring effective management of the Global Fund Round 10 interventions by placing required structures and personnel in place at the national, provincial and districts levels. Activity 3.3.1. Program Management cost for DMC

Sub-Activities 3.3.1.1 Provision of essential equipment and furniture for PMU and district liaison offices Strengthening of 3.3.1.2 a. Project allowance for the staff of PMU (for 1st and 2nd year) 3.3.1.2 b. Hiring of Staff for PMU for remaining 3 years 3.3.1.3 Planning and Administration 3.3.1.4 Overhead 3.3.1.5 Vehicles for program monitoring

SDA. 3.4. Program Management (Save the Children) Activity 3.4.1.Program Management Costs for Save the Children

Sub-activities: 3.4.1.1 Provision of essential equipment & furniture for PMU and district liaison offices 3.4.1.2 Hiring of Staff 3.4.1.3 Planning and Administration 3.4.1.4 Overhead 3.4.1.5 Program learning for PR and SRs through participation in events, international workshops, cross visits

etc 3.4.1.6 Technical Assistance for periodic program reviews, report preparations, special event arrangements,

etc. 3.4.1.7 Capacity Building/Training (including for PR, SRs, and SSRs) 3.4.1.8 Vehicles for program monitoring

SDA. 3.5. Program Management (Implementation level) Activity 3.5.1.Program Management Costs for implementation

Sub-activities: 3.5.1.1 Provision of essential equipment & furniture for PMU and district liaison offices 3.5.1.2 a. Hiring of Staff at district level (19 districts for 1st two years) 3.5.1.2 b. Hiring of Staff at district level (for 38 districts for remaining 3 years) 3.5.1.2 c. Hiring of Staff by SRs (for 1st two years) 3.5.1.2 d. Hiring of Staff by SRs (for remaining three years)

3.5.1.3 a. Planning and Administration (19 districts) 3.5.1.3 b. Planning and Administration (38 districts) 3.5.1.4.a Overhead (19 districts) 3.5.1.4. b Overhead (38 districts)

DMC through respective SRs will be primarily responsible for implementation of Round 7 and Round 10 activities in existing 19 districts which are also the target districts of GF Round 10. Save the Children



through respective SRs will implement Round 10 activities in additional 19 districts.

Objective 4: To improve health seeking behaviors and practices of target communities in malaria endemic districts through enhanced community awareness and participation The National Malaria Control Strategy recognizes that effective advocacy, communication and social mobilization forms the foundation for any efforts to effectively change service-providers’ ability, community behaviors and overall demand for effective service utilization. In this regard, a combination of coordinated awareness raising and community outreach strategies will be employed including mass media, interpersonal communication, and malaria focused IEC material development and dissemination. SDA 4.1: Strengthening Behavior Change Communication For Malaria Activity 4.1.1. Review and finalization of national malaria BCC strategy

Sub-Activities 4.1.1.1 TA for Review and updation of the existing National Malaria BCC strategy 4.1.1.2 2 National consensus building workshop (02 days) 4.1.1.3 Printing and dissemination of BCC Strategy (200 copies)

A national TA for 3-4 months for review and finalization of existing National Malaria BCC strategy will be procured. During finalization of BCC strategy special attention will be given to make the strategy gender sensitive so that women are not deprived of accessing malaria related information and care. The revised national BCC strategy will be shared with wider stakeholders from public and private sector. Consensus will be sought on the final version through two national level workshops. A total of 200 copies of the national malaria BCC strategy will be printed and disseminated. Private Sector PR will be responsible for implementation of this activity.

SDA 4.2: BCC-Mass Media Activity 4.2.1. Develop and Disseminate Print and Electronic Media materials and messages Sub-Activities 4.2.1.1 Development & printing of 8 million IEC material in local languages 4.2.1.2 Training (02 days) of district and provincial level public sector and NGOs/CBOs staff on the use of IEC

material (4 Provincial BCC focal persons + 38 district level BCC focal persons + 38 NGOs/CBOs staff = 80 persons)

4.2.1.3 Branding of 1,407 malaria, RDT & microscopy centers (760+447) and private provider run centers (200)

4.2.1.4 Development of 5 types of malaria messages & products (TVC, radio jingles, etc.) for electronic media 4.2.1.5 Publish and telecast electronic media malaria messages through television & radio 48 times 4.2.1.6 Publish and broadcast electronic malaria messages & products through local radio in 38 districts

27,360 times

Round- 7 & 10 Activities in Existing 19 Districts

Public Sector PR Directorate of Malaria Control

Private Sector PR Save the Children US

Round- 10 activities in Additional 19 Districts

GFATM Malaria Round- 10, SRs Merlin, Association for Social Development (ASD), Association for Community Development (ACD), National

Rural Support Program (NRSP & Pakistan Lions Youth Council (PLYC)

GFATM Malaria Round 10 Management Structure



Guided by the BCC strategy for Malaria, IEC material will be developed in local languages and printed and disseminated widely at the community level. In this regard, a two-day training workshop will be organized to train 38 district and 4 provincial level malaria BCC focal persons and 38 NGOs/CBO staff in effective use of these IEC materials. Continuous monitoring of implementation of mass media will be carried out. A set of electronic media messages including TVCs and jingles will be developed and broadcasted/telecasted both on the national television and radio and local radio and cable networks. Branding of 1,407 malaria RDTs and microscopy centers (public sector 447 microscopy centers and 760 RDTs and 200 private sector outlets in all 38 districts) as malaria diagnostic centers will be carried out. Branding will be done in Urdu and local languages.

Activity 4.2.2. Advocacy and Mobilization activities Sub-Activities 4.2.2.1 Commemoration of World Malaria Day in April every year 4.2.2.2 National level experience sharing and learning advocacy seminars (02)

National and provincial level advocacy events will be organized. These will include supporting the commemoration of World Malaria Day events every year in April and experience sharing, learning and advocacy seminars twice in the proposed project period. National stakeholders and international agencies would be participants to these seminars which would be intended to enhance resource mobilization and political commitment for overall malaria control.

SDA 4.3: BCC - Community Outreach Mass media activities will be supplemented by advocacy, community mobilization and awareness raising activities at the community level. These activities will focus on identification of community level structures including decision-makers, religious leaders, community activist, and health committees formed by LHWs. Activity 4.3.1: Strengthening of community based systems for malaria behavior change communication Sub-Activities 4.3.1.1 Advocacy events with 15,200 community based activists including lady health workers, CBOs, NGOs,

Religious leaders, Local Elders, elected representatives for community awareness to enhance preventive and curative services utilization in 38 districts

4.3.1.2 Organize community awareness sessions at community and facility level in 38 districts by LHWs 4.3.1.3 Organize community awareness sessions at community and facility level in 38 districts by CBOs/NGOs 4.3.1.4 Review LHW’s curriculum and update malaria protocols

Advocacy events will be organized with the community based organizations and activists to involve them in raising awareness on malaria in their respective communities. In this regard, community level activists and systems will be identified and mapped. These systems will include community level activists including faith-based organizations, community based organization, elected representatives, religious leaders, and local elders i.e. Jirga – local decision-making body in KPK, FATA, and Balochistan. At the district level, 304 advocacy events are proposed. It is expected that approximately 15,200 community representatives from 38 districts including women will participate in these events. At the community level, 18,240 awareness raising events will be organized. It is expected that approximately 364,800 community members including women, IDPs, and refugee populations where relevant, will participate in these awareness sessions. LHWs will organize awareness raising sessions in their catchment populations including women. In this regard, malaria protocols in LHW’s curriculum will be reviewed and updated through a consultative process. For the areas where LHWs are not available, local CBOs and NGOs will organize awareness raising sessions for the community member including women. Save the Children (private sector PR) has successfully implemented this strategy in KPK province and FATA where LHW’s coverage is low. Save the Children will be responsible for carrying out these activities.

Complete this version of section 4.4.1(a) (b) and (c) if the applicant selected option 1 in section 3.1 of the Proposal Form

Option 1 = Transition to a single stream of funding by submitting a consolidated disease proposal

4.4.1 Interventions

This section should be completed in parallel with the Consolidated Performance Framework and detailed



budget and work plan

(a) Overview of programmatic activities Describe the objectives, service delivery areas (SDA), and activities of the consolidated disease application. The description must be organized in that exact order and the numbering system must match the Consolidated Performance Framework, detailed budget and work plan. The narrative description of the Round 10 interventions should reflect all objectives, service delivery areas (SDAs), and activities in the Round 10 consolidated disease proposal, but distinguish between what programming is being continued from existing grants versus new programming for Round 10.

The description must identify: (1) who will implement each area of activity (e.g. Principal Recipient, Sub-recipient or other

implementer); (2) the targeted population(s); (3) what changes in implementation and/or the targeted population(s) have occurred, if any, for

those elements which are from existing grants and continuing in this consolidated disease proposal;

(4) any links between the existing grant activities to be continued in the consolidated disease proposal, as these activities previously existed in separate grants;

(5) any links between the proposed activities and existing Global Fund grants for other diseases or HSS; and

(6) how duplication will be avoided if there are linkages identified in points (4) and (5) above.

NA

(b) Changes to existing SDAs, programmatic activities, indicators and targets

In the table below, list the SDAs and activities of existing grants consolidated within the Round 10 consolidated disease proposal. Explain whether each SDA and activity from an existing grant will be included in the Round 10 consolidated disease proposal by indicating an increase in scale, decrease in scale, continuation without change, or discontinuation. Provide justification for any proposed changes or discontinuation.

The proposed changes should be clearly and systematically reflected in the Consolidated Performance Framework

Round # Service Delivery Area (SDA)

Activity Proposed change Justification for change

NA

use “Tab” key to add extra rows

NA

(c) Changes to existing impact or outcome indicators and targets

Describe any major changes in indicators and targets that may have occurred due to the programming described above in sections (a) and (b) and that is supported by the Consolidated Performance Framework. In particular, if there has been discontinuation or change in indicators or if targets have been changed between previous grants and the Round 10 proposal, describe why this has occurred.

NA

4.4.2 Addressing weaknesses from a previous category 3 proposal

If relevant describe how the weaknesses identified in the TRP Review Form of a previous category 3



proposal have been addressed.

MALARIA:

Previous proposal submitted for Round 9 for malaria component was focused on pre-elimination of malaria in Punjab province of Pakistan. TRP categorized this proposal as Category 3. Major weaknesses identified were:

Weaknesses

Moving into a pre-elimination phase is a technically and conceptually demanding exercise. This proposal does not demonstrate that the full implications have been considered.

It is not clear that pre-elimination in the Punjab is well-coordinated with the control and reduction program in neighboring provinces and in India. While recognizing the arguments made for a provincial approach, the TRP is concerned that this proposal will risk fragmentation of malaria control and pre-elimination on a national scale, which the Global Fund policy discourages.

Response The current proposal focuses on reducing burden of malaria instead of pre-elimination. Also, current proposal focuses on 38 highly malaria endemic districts in Sindh, Balochistan, Khyber Pukhtunkhwa provinces and Federal Administered Tribal Areas including Frontier Regions. HSS: Weaknesses The linkage of the disease interventions vis-à-vis the HSS proposal is poorly elaborated. A vertical structure is proposed to manage the HSS (the HSS Project Management Unit), which will

operate separately from the NACP. No further information has been provided as to what management arrangements are envisaged, where the PMU will operate from and what role will have to ensure that HSS interventions are system wide to assure efficient implementation.

The proposal describes that GAVI's activities, which started in May 2009, will be in parallel to other HSS interventions. The lack of integration of HSS activities is unacceptable.

Response There are no real linkages between the HIV/AIDS proposal and the HSS proposal and so these could not be elaborated. The decision to attach the HSS proposal (as a part 4B) behind the HIV/AIDS proposal was made for other reasons. The links with the TB proposal were also not that significant – given the focus of the TB Rd 9 submission. The Rd 9 HSS proposal does highlight links with the prior Round TB submissions.. The case for the HSS submission was not really based on the immediate connections between the HSS proposal and the Round 9 disease submissions. Any progress in the 4 HSS areas (HR, diagnostics, supplies and information system) would, in the short, medium, and longer terms and bring benefits to the 3 respective National Programs. There are clearly articulated management arrangements for the implementation of the HSS inputs at Provincial and District levels. It is at these 2 levels that the overwhelming majority of the management responsibilities would have been discharged. At Federal level, the role of PMU would have been limited to “PR responsibilities” – Perhaps some uncertainty has arisen because of the choice of NACP as PR. There are no convincing arguments for NACP to take on a major role in HSS. As a result, the Round 9 text was an attempt to offer some reassurance that taking the HSS PR role would not disadvantage the NACP, and vice versa. The activities listed in the proposal show how integration with the GAVI HSS efforts would be attained at Provincial and District levels. Given the focus of the HSS Rd 9 proposal, this is where the linkages are the most important.



Patients seeking malaria treatment at public sector facilities2007 - 2009

0

5000

10000

15000

20000

25000

30000

0

500

1000

1500

2000

2500

3000

3500

4000

4500

4.4.3 Lessons learned from implementation experience in MALARIA

How do the implementation plans and activities described in 4.4.1 above draw on lessons learned from program implementation (from either Global Fund financed or non-Global Fund financed programs)?

Various surveys and reports suggest that public sector utilization has been very low in Pakistan for a variety of reasons including availability of fast and quality services. This picture with 2007 – 2009 data suggest above two fold increase in the number of patients seeking malaria diagnostic and curative services at public sector facilities since the facilities were upgraded to its full capacities with the Global Fund R-7 malaria grant. Utilization rates can further be improved if rehabilitation and establishment of

new centres is supported by aggressive IEC campaigns. A new and simplified malaria surveillance system launched in the Global Fund Round 7 supported districts, replacing the old eradication era complicated MIS. This new MIS helped in identification of hot spots and small sized out breaks in a timely manner, allowing time to respond efficiently. This picture with data (2007-2009) form FATA suggests a sharp increase in the number of P.falciparum cases in a few localities. The rocketing trend was captured well in-time and an efficient response was initiated that lead to curtailment of outbreak in less than 6 week, There were no malaria mortalities during the outbreak. The intervention mainly included: - Screening of febrile cases at village levels though temporary RDT centres. - On the spot treatment with ACTs - Health education and community mobilization - Establishment of Fast referral mechanism - Strengthening the capacities in the nearby hospital/s for management of complicated cases. - Establishment of a weekly reporting system to observe disease trends

Please note that section 4.4.4 has been removed from the malaria Proposal Form as it is only relevant for HIV and tuberculosis proposals.

4.4.5 Enhancing social and gender equality

Using specific references to objectives, SDAs, and activities included in section 4.4.1, explain how the Round 10 interventions address issues related to social and gender equality and confirm that these items have been properly costed in the budget.

The Round 10 proposal targets the entire population at risk in 38 districts of Pakistan and to provide equitable access to quality diagnosis and treatment services, LLINs and other support services for whole population in the target districts including women, IDPs, refugees and jail inmates. Diagnosis and treatment will be provided to all malaria cases irrespective of their age, sex, religion, social and ethnic status. Following interventions have been specifically proposed to ensure gender mainstreaming and inequality issues:

Efficiency of the Newly established malaria surveillance



Collection, analysis and reporting of data disaggregated by sex, age, socioeconomic status, education, and ethnicity and geographic location shall be performed systematically. Attention needs to be paid to the possibility that data may reflect systematic gender biases due to inadequate methodologies that fail to capture women's and men's different realities. Program performance indicators will include monitoring and evaluation of gender mainstreaming. Once collected, sex disaggregated data and gender sensitive indicators need to be considered through gender analysis that will reveal important insights in to the health of men and women and accordingly appropriate actions would be taken.

BCC strategy for malaria elimination will take in to account the principles of WHO’s gender

mainstreaming strategy. BCC strategy will concentrate on all levels, right from policy makers, planners, program mangers and care providers. It will also create awareness through print and electronic media among the populations to make informed decisions about their own health. IEC materials and tools for BCC will incorporate gender mainstreaming considerations.

Lady Health Workers have been included in malaria control activities with particular reference to

distribution of LLINs and BCC activities. Moreover while involving health care providers (qualified doctors) from the private sector; female care providers will be encouraged. Maximum female care providers will be taken on board. Such interventions will ensure the accessibility of malaria care services to women and children.

The use of Insecticide treated bed nets has been proved to be a powerful prevention tool world

wide. Pregnant women and children below 5 years of age are the major target groups for the use of bed nets, but universal coverage is now recommended by the WHO. The proposal contains the provision of WHO’s approved long-lasting insecticide treated bed nets (LLINs) (i.e. 2.5 nets per household) free of charge in the target districts.

Special attention will be given to providing preventive and diagnostic services (LLINs, IRS, and

RDTs) to the communities who normally do not have access to these facilities. These include refugee populations, IDPs, and jail inmates.

Women healthcare providers working at the public and private facilities will be given priority for

their involvement in diagnosis and case management trainings. Availability of trained women healthcare providers will facilitate women’s access to diagnostic and treatment services for malaria.

The proposed interventions will contribute to minimizing the gender inequities by bringing the quality malaria care closer to the remote rural communities, improving the staff skills and behavior, involving a network of Lady Health Workers in care delivery, promoting patient-friendly arrangements for treatment, and mobilizing communities. Community mobilization is expected to encourage the disadvantaged and poor groups (including women) to access malaria microscopy and treatment centers for free-of-charge services. Furthermore, malaria care through existing private practitioners will increase the “access” and the “choice” for the daily wagers and women patients.

4.4.6 Partnerships with the private sector for MALARIA Describe how contributions related to: (i) co-investment from the private sector, and (ii) donated goods or services, will add value to the planned outcomes of the proposal. Make specific reference to the associated objectives, SDAs, or activities to which they are linked.

The proposed project is planned to be implemented through partnership of both public and private sector PRs applying dual track financing mechanism. Implementation at the district level will be carried out by involving experienced non-governmental organizations as SRs. These include Merlin, National Rural Support Program (NRSP), Association for Community Development (ACD), Association for Social Development (ASD), and Pakistan Lions Youth Council (PLYC). Having partners with international and national experience in delivering malaria interventions will add considerable value in the form of technical skills and experiences for malaria control in Pakistan. The scope of private sector in this proposal has been designed to play a catalytic role by building its capacity in effective and efficient implementation of various project components.



It is also proposed that private healthcare providers will be trained on management of malaria cases in 10 districts. These healthcare providers will be monitored and provided supervisory support in order to ensure application of these trainings. Also, effective anti-malarial treatment will be rolled out in all 38 target districts both in public and private sector health facilities. This will facilitate involvement of private healthcare providers in diagnostic and curative services for malaria. Furthermore, it has been proposed that technical expertise of private sector are brought in for development of IEC material and messages. Also, private mass media channels at the local and regional level will be engaged in disseminating BCC messages to the communities at risk.

Only complete section 4.4.7 if the applicant selected Option 2 or 3 in section 3.1 of the Proposal Form, DO NOT COMPLETE section 4.4.7 if the applicant selected Option 1 in section 3.1 of the Proposal Form

Option 1 = Transition to a single stream of funding by submitting a consolidated disease proposal Option 2 = Transition to a single stream of funding during grant negotiation Option 3 = No transition to a single stream of funding in Round 10

4.4.7 Links to other Global Fund resources for MALARIA

Describe in the table below the linkages between this Round 10 proposal and existing Global Fund resources. It is important to list the SDAs and activities as outlined in the proposal in the left hand column, add a description as to how they relate to previous grants in the middle two columns, and then outline how the Round 10 proposal specifically addresses this in the right-hand column.

Key SDA and activity as proposed in the Round 10 proposal

Existing grants

Round 10 Proposal Round 2 Malaria Round 7

Malaria

1. 1. SDA Diagnosis

Activity 1.1.1: Strengthen Existing Diagnostic Services in Target Districts

116 microscopy centers established in 19 out target 23 districts. These 19 districts are the same as Round 7 districts.

160 microscopy centers established in 19 target districts of the Global Fund Round 7.

Round 10 will support functioning of these 276 microscopy centers (116 from Round 2 + 160 from Round 7) in addition to supporting functioning of 76 upgraded centers and 95 newly established microscopy centers in Round 10.

276 microscopists’ training in malaria microscopy will continue in R10 as well.

Activity 1.1.2 Establishment of RDTs Centers at FLCFs

NA Falciparum specific RDTs were used in 19 target districts

Out of required 5 million RDTs for 38 target districts of Round 10, 1.5 million RDTs will be procured using Round 7 resources for existing 19 target districts and Round



10 resources will be required for procuring remaining 3.5 million RDTs for new 19 districts.

1.2. SDA: Prompt and Effective Anti-Malaria Treatment

Activity 1.2.1: Enhance the Capacity of Healthcare Providers in Proper Malaria Case Management

NA Case management protocols including Job aids were developed

Case management protocols including job aids and flowcharts will be developed and provided to all 760 RDT centers (380 Round 7+380 Round 10) and 447 microscopy centers (171+276).

SDA 2.1. Insecticide Treated Nets (Long Lasting ITNs)

Activity 2.1.1. Distribution of LLINs

NA 1 million LLINs

distributed to pregnant women and children under 5 in 19 target districts

Provision of 2.75 million LLINs for universal coverage of target households in 19 new and 19 Round 7 districts.

SDA 2.4. Monitoring Drug Resistance & SDA 2.5. Monitoring Insecticides Resistance

Activity 2.4.1. Sentinel sites surveillance for anti-malaria drug efficacy

&

Activity 2.5.1. Monitoring insecticides resistance and entomological surveillance

Four sentinel sites established

Four sentinel sites sustained functioning

Four sentinel sites established for insecticides resistance and entomological surveillance

Sentinel sites for both the studies in Round 10 will be same as established under Round 7



4.4.8 Links to non-Global Fund resources for MALARIA

Describe whether the Round 10 interventions (e.g. goals, objectives, SDAs, and activities) listed in section 4.4.1 have linkages to programs financed through non-Global Fund resources. If such linkages exist, list the non-Global Fund financed programs and their activities, and explain how the proposal complements those programs and activities. In addition, explain how the Round 10 interventions do not duplicate existing programs and activities supported by non-Global Fund resources.

In order to achieve the overall objective of reducing the malaria disease burden by 75% by 2015, the national strategic framework envisages scaling up of malaria control interventions to the level of universal coverage in highly endemic districts. However, the scarcity of national and provincial resources may hinder the achievement of this objective. The current Round 10 proposal has been designed to address the gaps and support the Malaria Control program in achieving the overall objective. The major source of funding other than Global Fund grant includes “Public Sector Development Program (PSDP) at federal level and “Annual Development Programs’ (ADP) at the provincial level. A total of $ 21.16 million has been allocated by the federal and all provincial public sector sources which would meet only part of the total program needs over the next three years. In addition, the releases against the committed allocations have been reduced to less than 25% over the past two years thereby leaving a gap of almost 75% to be covered from non-government sources, such as the Global Fund. The chances of improvement of the economic situation are very bleak as the country is faced with financial crunch and challenges like militancy, extremism and natural disasters like earthquakes and floods. The available public funding is merely sufficient for the salary component of the field based staff. The Round 10 proposal has been developed in line with the national malaria strategic framework to help achieve the overall objective of disease burden reduction in highly endemic districts. The proposal seeks the Global Fund support for the provision of additional resources required to achieve enhanced coverage of the national strategy components. Duplication of the efforts have been avoided as the proposed budget in the current round will be used for the implementation of planned interventions excluding the salary component of staff working at the health facility level. Furthermore, the major interventions of this project such as provision of LLINs, Pan specific RDTs and operational research have not been planned and budgeted in the public sector plan for next three years.

4.4.9 Strategy to mitigate unintended consequences of additional program support on health systems for MALARIA

Describe:

(a) the potential risks and unintended consequences on health systems that may result from the implementation of the proposal; and

(b) the proposed strategy for mitigating these potentially disruptive consequences.

Implementation of Global Fund interventions in 38 endemic districts are expected to contribute in strengthening existing preventive, diagnostic, care and management systems. However, this may result in creating discrepancy between the Global Fund funded districts and the districts covered by the national program.

Mitigation Strategy

Evidence from Global Fund program districts will be used to advocate at the policy level for allocating more funds for strengthening malaria program systems in these districts, in order to ensure replication of stronger systems in non-Global Fund program districts. In this regard, two national level advocacy events have been planned in the proposed period.



4.5 Program Sustainability (MALARIA)

4.5.1 Strengthening capacity and processes in malaria service delivery to achieve improved health and social outcomes

Describe how the proposal contributes to overall strengthening and/or further development of public, private and community institutions and systems to ensure improved malaria service delivery and outcomes.

If available, refer to country evaluation reviews

Support explanation with excerpts from documents that the country has adopted, identifying the source, such as a National Disease Strategy

The proposed project aims to synchronize the current policies and the management system of the MoH particularly the planning, supply management, budgeting and M&E cycles. The project outcomes are expected to further strengthen the service delivery and drug management system at national, provincial and district levels. Public Procurement Regulatory Authority (PPRA) is the national level body for defining procurement rules and setting QA assurance standards in public health items procurements. The interactive community based BCC intervention will be investment in human capacities aiming at improving the knowledge of target population on the benefits of early diagnosis and treatment seeking behaviors and the cost effectiveness of adopting preventive measures such as LLINs. The cost benefits will be the impact on the disease burden reduction through better treatment seeking behaviors and preventive practices. Current proposal is also expected to strengthen linkages between public and private sector for prevention, diagnosis and treatment of malaria. Having a private sector PR and SRs with international and national experience in malaria programming will also contribute in strengthening malaria programming in Pakistan.

4.5.2 Alignment with broader developmental frameworks (MALARIA)

Describe how the proposal’s strategy aligns with broader developmental frameworks such as:

Poverty Reduction Strategies; The Highly-Indebted Poor Country (HIPC) initiative; The Millennium Development Goals; An existing national health sector development plan; and Any other important initiatives.

Pakistan ranks 141 among 182 countries for Human Development Index (2009)16. The government strategy for reviving growth rests on macroeconomic sustainability; market liberalization and deregulation; privatization; and targeted interventions to support small and medium size private enterprises. Pakistan’s broad development agenda has been defined in the “Poverty Reduction Strategy Paper for Pakistan - Accelerating Economic Growth and Reducing Poverty: The Road Ahead”. It outlays a comprehensive development agenda across all sectors with special emphasis on poverty reduction and social sector development. The Poverty Reduction Strategy Paper (PRSP) envisages increased financing and enhanced efficiency in the health sector through organizational and management reforms. The strengthening of district health systems as well as involvement of private sector under current program approaches are well placed in this context to alleviate poverty. On the programmatic aspects the focus is on control of communicable diseases (especially TB, malaria, HIV/AIDS, Hepatitis B, and cluster of immunizable childhood diseases), reproductive health, child health and nutrition. The proposed interventions and services are consistent with the Millennium Development Goal for communicable diseases and malaria initiative of Pakistan. The Government of Pakistan is in the process of finalization of the National Health Policy 2010-15 which exhibits firm commitment towards health sector reforms and gradual increase of resource allocation for the implementation of disease control interventions. The goals of the proposed project are directly linked to the current MD Goals.

16 Human Development Report 2009



4.5.3 Improving value for money for MALARIA

Explain how the program that the proposal contributes to represents good value for money. Specifically, given the context of the epidemic in the country and the definition of value for money provided in the Guidelines, describe how the key interventions in the proposal represent the best balance of costs and effectiveness, with consideration to the desired achievement of both short and long term impacts.

It has been ensured in the current proposal that balanced and well-focused interventions for personal protection, vector control, diagnosis and treatment of malaria are proposed for highly malaria endemic districts of Pakistan. Gender equity has been ensured so that women, who have generally limited access to healthcare, benefit from prevention activities including LLINs, IRS and BCC. Similarly, strengthening diagnosis and treatment facilities at the BHU level and below will facilitate women and children’s access to timely diagnosis and appropriate treatment of malaria. The populations living in malaria endemic rural areas of Pakistan are primarily dependant on agricultural economy. Malaria peak season coincides with harvesting season in these areas. Thus, suffering from malaria bears huge financial consequences for the population in these areas, majority of whom fall in lower socio-economic strata. Providing these populations with preventive, timely diagnosis and treatment services for malaria will contribute in enhanced productivity and reduction in the overall economic burden. The proposed interventions under Global Fund Round 10 will fill in existing gaps in Government of Pakistan’s malaria control program. The GoP commits to ensure sustainability of the Global Fund interventions. Awareness raising at the community level, upgrading of diagnostic facilities, and capacity building of the healthcare providers will contribute in sustaining these inputs.



4.6 Monitoring and Evaluation System (MALARIA)

4.6.1 Impact and outcome measurement systems Describe the impact and outcome measurement systems, including strengths and weaknesses, used to measure achievements of the program at impact and outcome level.

There is well established “Malaria Information System (MIS) and is functioning at health facilities where malaria microscopy services are available. The system collects information on confirmed malaria cases at facility level, which is consolidated at district level and reported to the provincial and malaria control programs on monthly basis. The progress and achievements of the program interventions are measured through the measurement of “Annual Parasite Index (API) using the total number of confirmed malaria cases detected/1000 population during 12 months period. The data received from all the districts is analyzed annually for the trend of API, Blood Examination Rate (BER) Slide Positivity Rate (SPR) and falciparum rate etc. The system also generates information on the number of malaria cases treated at public health facilities. Although the MIS generates reliable reports on API, its coverage is low and it is also deficient in generating age and sex distribution of malaria cases, malaria related mortality, severe malaria cases, use and coverage of prevention measures. The data reporting and recording tools being used in this system are >30 in number and have been used since Eradication Era (1960s). Many of these data tools have lost their value with the passage of time. Information on the use of insecticides for larviciding and indoor residual spraying in terms of the structures sprayed and localities targeted is also generated by MIS at district level periodically. Information on program achievement is also reflected in national HMIS, which is functioning at Primary Health Care facilities. Health Management Information System (HMIS) provides information mainly on clinical malaria cases. It has recently been reshaped into District Health Management Information System (DHIS) accommodating the district health information needs and including the data from hospitals within the district, which was not part of the HMIS. During the implementation of R-7 malaria component the Program has revised its data recording tools at all levels accommodating the program data needs of information including the information on LLINs distribution. These tools are successfully used by the SRs and the Program in the target districts and have been planned by the program to adopt these tools at all levels after making desired changes.



4.6.2 Impact and outcome measurement; (MALARIA)

(a) Has impact and/or outcome data been collected in the last 2 years?

Yes answer section

4.6.2 (b)

No go to

section 4.6.2 (c)

(b) What was the source(s) of the measurement?

insert source (large scale surveys, demographic surveillance, vital registration systems, other)

Routine Surveillance, Vital Registration Records & Special Surveys17.

(c) It is important to guarantee that there are systems in place to measure all impact and outcome indicators in the performance framework. In order to do this, fill in the table below, fully describing all planned surveys, surveillance activities and routine data collection in country used to measure impact and outcome indicators relevant to the proposal. Add rows as needed.

Data Source Funding Years of Implementation Impact/Outcome Indicators

relevant to the proposal to be measured by data source 2011 2012 2013 2014 2015

Source 1 (Routine Surveillance-MIS)

Total cost:965,163 592,457 93,176 93,176 93,176 93,176 API (Annual Parasite Index) of targeted population in 38 highly endemic districts

Secured funding amount and funding source:155,000 155,000 0 0 0 0

Funding gap: 810163 437,457 93,176 93,176 93,176 93,176 Round 10 funding request for Source 1:810,163 437,457 93,176 93,176 93,176 93,176

Source 2 (Sub-national survey: Periodic Surveys)

Total cost:100,000 100,000 % of uncomplicated malaria cases correctly managed at health facilities in 38 highly endemic districts % of pregnant women with malaria who received anti-malarial treatment at health facilities in 38 highly endemic districts % of rural households with at least one LLIN in 38 highly endemic districts % of rural households protected by IRS in 38 highly endemic districts

Secured funding amount and funding source 0

Funding gap 0 0 0 0 100,000

Round 10 funding request for Source 2 100,000

17 Refer to Malaria Control Program



4.6.3 Links with the National M&E System (MALARIA)

(a) Describe how the monitoring and evaluation (M&E) arrangements in the proposal (at the Principal Recipient, Sub-recipient, and other levels) use existing national indicators, data collection tools and reporting systems including reporting channels and cycles.

This proposal aims to build on existing program indicators and to make use of the revised national MIS tools for routine data collection on diagnosis, treatment and vector control interventions including IRS. Certain specialized components like ITN (LLIN) coverage and drugs/insecticide resistance will be monitored through National Vital Registration Record & Periodic Surveys18. The newly developed MIS tools will contribute to the national reporting framework by providing additional information on the data that has never been captured in the routine DHIS. This would help inform the national policy to review and revise the existing strategies for malaria control in the country. Monitoring: The progress of the program processes and outputs will be tracked by carrying out extensive field based monitoring using the existing newly developed M&E check lists/tools. These monitoring visits will be carried out by the district, provincial and federal level officials of respective health departments along with SRs and PRs.

Process Measurement: It will be conducted through the management structures of individual organisations, including DMC, its counterparts at provincial and district levels, as well as Save the Children and the SRs. An M&E plan will be developed with clear roles and responsibilities, frequency and timelines for malaria control program, PRs and SRs. The monitoring data collected at the district and provincial level will feed into the national database and process measurement reports will be generated from this.

Output Measurement: It will be accomplished by routine collection of the Malaria Information System. The efficacy of the anti-malarial drugs, as well as vector resistance to various insecticides would also be monitored at the sentinel sites established under Global Fund Round 7 grant. Data on LLIN distribution will be regularly compiled by distributors and categorised by districts to provide a measure of population “coverage”. The data on malaria related BCC outreach activities and events would be periodically compiled at the district level and reported to the province, where a provincial report would be generated. Data on LLIN “usage” will be collected through surveys.

Evaluation: The overall impact of the project will be assessed through a sub-national prevalence survey in year 5 of the project. Moreover, the Malaria Control Program will arrange program review missions planned at various intervals with support from WHO and other partner agencies. This will evaluate the program progress and achievements in all malaria endemic districts of the country including those where global fund supported project is being implemented. It will also measure a range of key indicators related to the targets as set in the Performance Framework and will provide independent reports on performance of the program and partners. Monitoring & Evaluation Units at the PRs: A) Directorate of Malaria Control: A full-fledged functioning M&E Unit is present in the DMC headed by a qualified epidemiologist supported by a statistical officer, data entry staff and 2 IT professionals. This unit is responsible for overall project monitoring and data quality assurance including the Global Fund Round 7 supported activities. It is also responsible for the designing of specialised Malariometirc & Epidemiological field surveys. The M&E unit in DMC has developed institutional links with Health Service Academy (HSA), Pakistan Medical Research Council (PMRC) and other regional institutes. B) Save the Children: Save the Children will establish an M&E unit staffed with M&E specialists and epidemiologist at the national and provincial level. M&E units of Save the Children and DMC will be linked through using the same set of data collection and monitoring tools, consolidation of data and joint reporting to the Ministry of Health and partners. In addition, the capacity of the M&E staff will be enhanced through trainings and experience sharing with Save the Children’s country offices in the region implementing Global Fund projects.

18 Refer to the Annexure on National M&E Plan for Phase 1 & Phase 2 of Round 7.



The flow of information from community as well as the health facilities to the PR M&E units at national level is depicted in the flow diagram illustrated below:

(b) Are all of the M&E arrangements planned for the proposal using the national M&E system?

Yes

go to section 4.6.4

No

continue to section 4.6.3 (c)

(c) If no, explain why not and list any service delivery areas (SDAs) and/or activities that will not be monitored through the national M&E system.

DMC is in the process of developing a revised national M&E framework in line with the requirements of the revised national malaria strategic framework. The national M&E framework will have the capacity to track and monitor the progress against all SDAs. The M&E plan for Round 10 proposal will be based on the new national M&E framework. The M&E plan for Round 10 proposal will be submitted at the grant negotiation stage.

4.6.4 Strengthening monitoring and evaluation systems

(a) Has a multi-stakeholder national M&E assessment been recently conducted (in last 2 years)?

Yes

continue to section 4.6.4 (b)

No go to section 4.7

(b) If yes, has a costed M&E action plan been developed or updated to include identified M&E strengthening measures?

Yes

continue to section 4.6.4 (c)

No

go to section 4.7

LOCAL FUNDING AGENT/ GLOBAL

FUND

BCC , LLINs, IRS reporting by Community

outreach



(c) Describe whether the proposal is requesting funding for any M&E strengthening measures. These strengthening measures may have been identified through a national M&E assessment or any other relevant evaluation or review process.

During the revision of national strategic framework the need for review of the existing M&E structure and tools was highlighted. Malaria surveillance tools have been reviewed and updated during Round 7. In Round 10 the use of these newly developed tools will be extended to all the districts including Global Fund target districts. A set of well-designed outputs have been planned for the strengthening of M&E systems at the national, provincial and district level. Both public and private sector PRs have planned activities for capacity building of M&E staff in the M&E framework of the global, regional and national malaria control program. A total of 41 CDC officers including 1 from DMC, 1 per province and 1 from FATA and the 38 district malaria supervisors will be trained in malaria data management, surveillance and early detection of malaria outbreaks. Furthermore, 1,407 district level public health personnel from all 38 districts will be trained on accurate use of updated surveillance tools and early detection of malaria outbreaks. Short and long term TA will also be procured through WHO to support the national and provincial M&E units. A total of 19 data management units (1 per new district) will be established within the district department of health and continuous support will be provided to all data management units including 19 units in old districts and 1 at each province, 1 at FATA level and 1 in DMC.


R10_CCM_PKS_M_PF_s3-5_30Sep10_En.doc35/78 35/78

4.7 Implementation Capacity

4.7.1 Principal Recipient(s) Describe the technical, managerial and financial capacities of each Principal Recipient (PR) to manage and oversee implementation. Include any anticipated limitations to strong performance and refer to any existing assessments of the PR, other than Global Fund reporting mechanisms. Copy and paste tables below if there more than three Principal Recipients

MALARIA

PR 1 Name Directorate of Malaria Control, Pakistan Sector Public Sector

Street Address Muhammad Aslam Khan, Directorate of Malaria Control, Allergy Centre, Chack Shahzad, Islamabad

The Directorate of Malaria Control was established in 1961 as an attached department of the Ministry of Health under a Parlimentary with an initial role to eradicate malaria from the country as per national commitment of the government of Pakistan. Being high on national health agenda, DMC was enjoying full political support from the government and the partners. The organization share the success story of bringing down the API to <1/1000 as compared with the baseline of 19/1000 in 1960 within just 8 years time. Technical capacities: Since the inception of Malaria Control Program in Pakistan since early sixties, DMC has been sustaining the wealth of technical experts as malariologists, entomologists, epidemiologists, statisticians and experienced field staff till early 90s when program interventions were integrated with the general health services and tangible number of experienced staff either retired or left the country for job seeking in Middle East countries. DMC has an extended human resource network from national down to union council level and has retained a number of skilled staff. It has an established structure of program management, epidemiology, entomology and M&E experts at national level. The DMC has further strengthened its capacities during Global Fund R-7 malaria component by recruiting a range of national and field staff well versed with the project implementation and donors funding mechanism particularly the Global Fund. DMC has the support of WHO technical staff since 2002 engaged with the program planning, management, implementation, surveillance and M&E. Directorate of Malaria Control was selected as PR for the implementation of Global Fund R-7 Malaria Component interventions in 19 target districts of Balochistan, FATA, Khyber Pukhtunkhwa and Sindh provinces dealing with the network of 5 SR organizations and provincial and district malaria control programs at one time. With the initiation of R-7 implementation the situation in FATA and Balochistan started deteriorating as the increasing militancy and insurgency was tackled with force. Majority of the target districts were falling in the same regions facing DMC with the challenge of achieving its planned targets in war situation. DMC and the concerned SRs adopted with the newly emerged situation and by changing the strategic approach were successful to achieve all its targets as planned. Strong Procurement and Supply Management (PSM) structure ensured timely availability of the procured items, which helped in timely implementation of project activities. DMC has been graded A1 for consecutive 4 periods during phase-1 of the project. DMC management approach is based on lessons learned from previous rounds and builds on long standing sprit of collaboration between public sector and NGOs partners. Partnership building with the nominated private sector PR for the current round and the development of joint proposal following the Global Fund new architecture for single stream funding and consolidation of successful rounds



is the product of joint collaboration with private sector organizations. M&E system: Functioning epidemiological and data management units at national and provincial level, newly established M&E unit in Program Management Unit of the PR office with the team of expert M&E Officers, newly designed surveillance tools and monitoring check lists are the M&E strengths of DMC which can assure the quality of the outputs and check the progress of the project.

MALARIA

PR 2 Name Save the Children Federation Inc. Sector Private Sector

Street Address Dr. Amanullah Khan, House 1, Street 15-A, F-7/2, Khayaban-e-Iqbal, Islamabad

Save the Children Federation Inc. is a preeminent provider of development and humanitarian assistance around the world. Implementing grants for the U.S. government and other donors for over three decades, Save the Children brings strong management and innovative strategies to programs in health, education, children in crisis, economic opportunities, food security and emergency response in order to achieve its mission: to create lasting, positive change in the lives of children in need. Active in 50 countries including the United States, Save the Children is recognized internationally for its capacity to mobilize communities, reach disadvantaged populations, and build bridges for effective communication among communities, facilities, local organizations, and government. Save the Children’s field programs receive technical and operational support from its headquarters office in Westport, Connecticut, office in Washington, DC, and regional offices. The organization’s operating budget of approximately US $ 403 million is financed by individual and corporate donations, grants, cooperative agreements, and contracts from major multilateral and bilateral donors, foundations, and other private voluntary organizations. Save the Children is a member of the International Save the Children Alliance, a worldwide network of 29 Save the Children organizations working in more than 120 countries to ensure the well-being and protect the rights of children everywhere. Save the Children is one of the leading development organizations in Pakistan implementing development programs with a unique focus on the needs and rights of children. Save the Children has been working in Pakistan since 1985, when SC started implementing program for Afghan refugees in Pakistan, and is governed by a memorandum of understanding with the Government of Pakistan. a. Technical Capacity Save the Children Federation Inc. has substantial experience of implementing the Global Fund grants globally and regionally. In Asia, Save the Children is PR in 3 countries (Bangladesh for R2, R6, and RCC for HIV/AIDs; Nepal Round 7, and Myanmar R9) and SR for R9 HIV/AIDs in Pakistan. A brief description of the work performed is given below. Save the Children has a global network of technical staff located at Headquarter and Country Office, therefore can draw on extensive technical assistance worldwide to support the Global Fund proposal development and implementation. Save the Children has technical experts and multi-disciplinary team familiar with and focused on the Global Fund programming and approaches, that can be mobilized for distant and direct support. Save the Children’s current health programs in Pakistan focus on maternal, newborn and child health and nutrition, Malaria, Tuberculosis, HIV/AIDS, school health and nutrition, safe motherhood and birth spacing. Operational presence at the district and community levels offers a unique opportunity to develop, test and evaluate new technologies and approaches to improve health services and behaviors. Save the Children works in close liaison with the National MNCH Program, National Program for Family Planning and Primary Health Care, National



Nutrition Wing, Directorate of Malaria Control, and Expanded Program on Immunization of the Ministry of Health. We also work in close coordination with the Ministry of Population Welfare, Ministry of Education, and Ministry of Social Welfare at the national and provincial levels. In Pakistan, Save the Children is implementing malaria interventions in synergy with maternal, child and reproductive health interventions. Through its Improved Child Health Project in FATA – a region with high prevalence of malaria – Save the Children is establishing 35 microscopy centers and 35 Rapid Diagnostic Test (RDTs) centers within the government health facilities in order to support timely diagnosis and treatment of positive cases in the seven agencies of FATA and six Frontier Regions. This activity is being supplemented by training laboratory technicians in correct diagnosis of malaria. Furthermore, Save the Children is working on strengthening Malaria Control Office at the FATA Health Directorate.

Save the Children’s Refugee Program in Balochistan and Haripur provides malaria preventive (Long lasting insecticide treated nets and insecticide sprays), diagnosis (Rapid Diagnostic Test Kits, microscopy) and treatment services as well as capacity building of health care providers as part of maternal, newborn, child and reproductive health package to Afghan Refugees through 13 health facilities in refugee villages in Balochistan and 6 health facilities in three refugee villages in Haripur. In addition, Save the Children collects disease specific information as part of its routine HMIS in both the locations.

Utilizing its in-country and global experiences in Malaria programming, Save the Children has provided technical assistance to the National Directorate of Malaria Control (NDMC) in carrying out situation analysis, gap analysis and strategic planning. Save the Children also provided technical assistance to NDMC for celebrating World Malaria Day in 2010.

b. Program Management Systems

Management Structure

The health projects detailed above demonstrate Save the Children’s strong capacity for managing large and complex grants and deliver the results. The health and nutrition programs are led by Senior Director Health and Nutrition with technical support from the Office of Health and Nutrition based in Washington DC; a cadre of expatriate and national senior managers for health and nutrition, and Program Development and Learning Unit. The core health program team comprises of four Senior Managers on Health and Nutrition reporting to Senior Director Health and Nutrition. The Senior Managers Health and Nutrition supervise a total of 46 managers implementing health and nutrition programs in four provinces of Pakistan, FATA/FR and Azad Jammu and Kashmir. Save the Children forms Technical Advisory Groups for large and complex projects in order to ensure quality implementation. The country office health program also has access to global and regional technical assistance which is procured as and when needed.

Monitoring and Evaluation

Project performance and results are monitored and evaluated in line with the Logic Model or Results Framework (as per donor criteria) and Performance Measurement Plan (PMP) contained for the projects. In this regard, M&E experts are hired for specific projects who provide technical support in monitoring processes and results. M&E advisors at the headquarters and regional M&E and research advisors and Program Development and Learning (PDL) unit at the country office level including an MIS specialist provide technical backstopping to the project on M&E. Also, PDL unit is responsible for ensuring quality, accuracy and timely submission of periodic reports to the donors. In order to build program staff’s capacity in M&E, the country office also organizes trainings on Design, Monitoring and Evaluation (DM&E). Save the Children has organizational standards for program evaluations. These standards are implemented organization wide and provide guidelines for baseline, mid-term and end-term evaluations. Save the



Children contracts out third-party evaluation for multi year projects to firms and individual consultants.

Human Resource Management

Save the Children’s HR processes are governed by Policy and Procedures Manual adapted to Pakistan context and local labour laws. Currently, Pakistan Country office is managing over 1,500 staff across Pakistan under a variety of short and long-term engagement models including a). direct implementation, b). third party contracts, c). public private partnership, and d). consultancies/technical assistance. The country office has demonstrated strength in recent years in rapid scale-up and rapid scale-down as necessitated in emergency response and development programs which require short turnaround time. The country office has an independent ombudsmen unit and internal audit to ensure accountability and compliance. We have comprehensive systems including online recruitment portal, human resource information system (HRIS), staffing and development, organizational wellness, and strategic workforce planning.

Financial Management, Accounting Policies and Procurement Procedures Save the Children has successfully managed donor funding from multiple sources in Pakistan. Following are some of our major donors:

1. USAID 2. World Bank 3. US Government’s Office of Foreign Disaster Assistance (OFDA) 4. Save the Children Alliance 5. Royal Netherlands Embassy 6. United Nations High Commissioner for Refugees (UNHCR) 7. US Government’s Bureau of Population, Refugees, and Migration (BPRM) 8. United Nations World Food Program (WFP) 9. UNICEF 10. European Union (EU) 11. DFID 12. WHO 13. The Bill & Melinda Gates Foundation. 14. PEPSI 15. Procter & Gamble

Save the Children in Pakistan’s annual expenditure in 2009 was over USD 39 million. Save the Children maintains integrated financial and management control systems in the field and at headquarters to ensure its accountability for funds. These systems (financial management, procurement, and others) support compliance with donor regulations and requirements. Data is recorded and reconciled at the country level using web-based Sun Systems software. This software enables Save the Children to generate accurate and timely financial, analytical and managerial reports as required, as well as standard monthly, quarterly, annual and life-of-program reports. Save the Children undertakes financial pre-award surveys, financial management training and annual internal audits to ensure partners have adequate financial systems and capacity. Save the Children has a very strong store-management system to safeguard all donor assets through a comprehensive policy and procedures manual, which regulates receiving of goods, coding, recording (using store software) and physical verification.

Internal Audits Save the Children has an internal auditing unit that has dual reporting to the country office and to headquarters to maintain independence. The



Country Office has designated Senior Manager who performs internal audits reporting to the Country Director. The majority of internal auditing, however, is carried out by, or at the direction of Save the Children’s Internal Audit Unit. The selection of field office sites for internal audit is based on a number of considerations, such as the size and complexity of the office, the coverage provided by external audits, special issues brought forward by field or agency management, as well as the need for ongoing rotational audits of all sites. Internal audit reports produced by Save the Children’s Internal Audit Unit report are shared with agency management staff and field-based management staff.

External Audits Save the Children undergoes external audits by an independent accounting firm to attest that the agency's financial statements present the financial position of Save the Children fairly and in conformity with generally accepted accounting principles. The agency's audited financial statements and the accompanying Management Letter of Comments are shared first with the Board of Trustees in January each year and later, in the form of the annual report, with banks, grantors, donors, and the general public.

Documentation and Record Keeping Save the Children is required to keep all original accounting records for as many years as required to be in compliance with donor requirements. An appropriate filing system and/or storage system for historical records is in place to ensure the required documents can be located when required.

Sub-grant Management Save the Children has both in-country and global experience of managing international and national sub-grantees. Save the Children has policies and procedures in place for ensuring transparency in selection of sub-grantees. Save the Children’s Grants Compliance Department along with internal audit department monitor and ensure effective use of financial resources, and compliance to donor rules and regulations. In this regard, Save the Children mentors sub-grantees and builds their capacity. Program staff conducts periodic reviews of sub-grantees’ progress against the workplan agreed at the time of contract signing.



HSS

PR 1 Name Health Services Academy Sector Public Sector, Government

Street Address Chak Shahzad, Islamabad

Background and Introduction: The Academy was established in 1988 as a department of the Ministry of Health, Government of Pakistan, and provided short courses and training for public health professionals. It has the additional mandate of research and training, evidence based policy making and taking the lead in developing a competent core group of public health professionals. The HSA is housed in a purpose built facility with ample space and a well equipped library to enable interactive discourses between faculty, students and decision makers.

Key accomplishments

Expansion of its MPH program to a 2 year MSPH program and a MEDVC program. Establishing new departments of Health Economics, recruitment of new faculty with specific Health system expertise, Establishing a fully staffed Research and Training Unit. Academy has been made a Regional Center by WHO for the development of Human Resource Capacity.

1. Technical Expertise

Collaboration with the Health System Strengthening and Policy Unit of GAVI HSS Activities The synergistic collaboration between the HSA and the HSSPU, brought on by the leadership of the Executive Director who is also Chief of the HSSPU has helped enhance the scale and scope of the activities undertaken by the HSSPU for GAVI HSS component such as: I) Capacity building of Lady Health Workers: One of the key objectives of the GAVI HSS project relates to increasing routine EPI coverage through training of

LHWs on vaccination. The GAVI project has been critical in jumpstarting this process by providing funding support for training of 20% of LHWs and will be scaled up through the PC 1 for the remaining 100,000 LHWs in the next phase.

II) Provision of Zinc Supplementation and Training on its Usage: Through GAVI-HSS support, 4.2 million bottles of Zinc Sulphate syrup (20mg/ 5ml in 60 ml bottles), worth US$ 2.2 million have been supplied to the LHWs program. The activity has been complemented with orientation / training of LHWs on the administration of Zinc Sulphate to children during diarrheal episodes.

III) LHW MIS Software Training: Under the guidance of the MOH, WHO has conducted these trainings for LHWs in AJ&K, FATA and FANA

IV) Trainings/Capacity building Workshops: on IMNCI and EMoNC for health care workers at the district level

V) Procurements : GAVI HSS funding has enabled procurement of critical items such as weighing scales, IMNCI recommended medicines and equipment, Zinc



Sulphate etc under the supervision of the HSSPU by UNICEF. By purchasing through UNICEF, quality assurance has been assured.

The HSA is conversant with the GFATM processes as it served as the first CCM Secretariat and has played a pivotal role of global fund grant oversight. 2.Management Capacity Monitoring and Evaluation Expertise: HSA has a very strong Monitoring and evaluation component due to its role as a leading public health academic institution of the Ministry of Health. The general steps followed in monitoring any of HSA teaching, training or research activities and their outcomes are:

Defining and measuring the indicator of interest from outputs, outcomes to impact. Data collection mechanisms, analysis and reporting Data quality assurance mechanisms and supportive supervision Routine ongoing monitoring that is further complemented by independent impact evaluations by various donor and granting support agencies (i.e

USAID, GTZ, Bill and Melinda Gates foundation etc)

In specific, the Academy was a focal point in 1) monitoring and evaluation of the emergency relief activities in health sector at federal level in the earthquake stricken Azad Jammu Kashmir and Hazara district in 2005, 2) routinely monitors and reviews its academic programs for quality assurance standards of its curriculum, teaching and training activities, 3) monitors and oversee’s its field research sites for maintaining international standards, and 4) collaborates with other government and non-government agencies for technical consultancy services. A detailed matrix of HSA’s monitoring and evaluation expertise is depicted below:

Areas Activities

Research Program Monitoring and Evaluation for UNICEF regarding ARI/CDD and EPI (2002). Establishment of Research & Development Department, itself

Teaching

Ongoing evaluation of teachers by the registrar. Evaluation of teachers by the end of each module by students through a

qualitative likert scale. Quantitative evaluation at the end of year by the Executive Director. End of year profile of teachers sent to the MoH. Successful accomplishment of degree through formal examination and defending

the thesis

Projects (Program evaluation)

Monitoring of National Program for Family Planning & Primary Health Care. Lead consultant for “United Nation Country Team” capacity assessment for One

UN Project in Pakistan (Sept 2008). Environmental Health Impact Assessment consultant (2006). Evaluation of Drug Management Systems in public sector in NWFP & Baluchistan



(2003) WHO Economic Evaluation of Health Care Programs. FELTP CDC Economic Evaluation of Health Care Programs. Mid-term review of “Revitalizing and improving PHC services in Batagram”

Project supported by Japan Social Development Fund (JSDF) through World Bank. 3rd Party Performance Evaluation of the three Autonomous Medical Institutions in

Punjab. Technical Review of the proposals submitted to “Global Fund” GFATM. Evaluation of Marie Adelaide Leprosy Centre Monitoring and Evaluation of Family Welfare Centers, Mobile Services Units and

RHS-As. July 26, 2007 to July 04, 2009 (Monthly Evaluations) Polio Eradication Initiative at district level in Swat. Third Party Evaluation of PRIDE Project 2010. Gateway Health Indicators of Pakistan 2006.

End of project evaluation

Evaluation of UNICEF health & Nutrition response to Earth Quake 2005 (Dec 2008). Independent progress review of USAID/Pakistan Safe Drinking Water & Hygiene

Promotion Project (PSDW-HPP). Evaluation of UNFPA’s Project on delivering emergency RH services to conflict

affected population of Nepal. “End-Project evaluation for GFATM community based drop-in centers for Street

children” End of the Project evaluation of “Improving the RH & Rights of marginalized and

underserved communities: DG Khan” End Of The Project Evaluation: Reproductive health and Family Planning For Men

Through an NGO/Public sector Intervention. Project Evaluation: Integrated Afghan Refugees Assistance Program. Maternal and neonatal Health Evaluation in South Asia. Evaluation of Family Health Project Sindh funded by World Bank 1999.

Developing Monitoring Framework

Quality Assurance of the Minimum Service Delivery Standards and Standard Operating Procedures for tertiary care health facilities.

Development of Research & Advocacy Strategy Document for Maternal and Newborn Health Programme – Research & Advocacy Fund.

Technical Assistance and capacity building in monitoring & evaluation in Pakistan Capacity building/Trainings for M&E role of PPHI Managers 2009. Capacity building of District level health Managers in PHC and Quality of Care &

M&E 2009. Tool for the evaluation of Family Health Project Sindh funded by World Bank 1999.



Oversight and Accountability by Board of Governors

The board of governors is responsible for general oversight of all the HSA activities including fiscal discipline and ensuring satisfactory progress on its designated mandate. The BoG is chaired by the Federal Minister Health with the Federal Secretary Health as the vice chair. The provincial health Secretaries, Federal DGH, prominent professionals and public health experts are other members of the board with Director HSA as member/secretary of the board. The board meets at least twice in a year but may meet more frequently if needed. The 6 monthly meetings review the performance of the academy, review the plans, financial plans, procurement processes and other relevant issues on the agenda. The Executive committee (headed by the director HSA along with Joint Secretary from MoH and a senior faculty member) has all the financial and administrative powers delegated by BoG to run the day to day affairs of the academy. Procurement and Supply Experience

Since its establishment in 1988, the Academy has worked with a number of donors such as USAID, GTZ, PAIMAN, WHO, UNFPA, Save the Children, and Bill & Melinda Gates Foundation - each with their own set of procurement and supply rules and regulations. In addition, HSA follows all Government of Pakistan PEPRA rules. Throughout this process the Academy has rigorously followed the defined procedures and gained extensive experience in procurement and supply management processes from purchase of equipment, commodities and supplies to efficient handling of faculty contract management. Details of this procurement management are: A. Procurement Process Management

Advise DONORS on advance procurement actions start-up procurement issues as necessary; help to prepare annual procurement plan;

Prepare and agree procurement plan with key stakeholders;

Review technical specifications, refine Terms of Reference (ToR) and prepare Request for Proposals (RFP) and bidding;

Documents for using standard PPRA formats for GoP procurement and Donor’s guidelines for donors procurement;

Review and evaluate procurement documents received and assist ORGANIZATION in the process of engaging consultants and bidders;

Prepare, review, and clear TORs and bidding documents for all procurement activities required under the project;

Follow up with concerned Government Departments and the Donors to have RFPs and bidding documents approved and issued in a timely manner according to the approved procurement plan;

Manage the advertising process involved in procurement, procurement correspondence, bid receipt, and bid opening in strict accordance with agreed procurement procedures;

Manage GoP / DONORS procurement filing system in a systematic manner;

Participate in contract negotiations on behalf of DONORS / GoP;

Prepare and execute purchase orders and requisitions;



Provide coaching, mentoring, training focus and transfer knowledge and expertise on Donors and Government of Pakistan procurement procedures to more junior team members; and

Supervise the Procurement to prepare, review and clear procurement plan/ documents for the next year of the project.

B. Procurement Reporting

Prepare and review evaluation reports to submit as per PPRA prescribed procedure and the Donors for approval;

Follow up with concerned Government Departments and the Donors to have the evaluation reports approved in a timely manner;

Monitor and report the procurement implementation status and progress to GoP and the Donors as required;

Procurement Committee: following the system approach all procurements are overseen by an internal procurement committee comprising of HSA faculty/staff members, finance and administration, and chaired by the Executive Director. Details and membership of the committee is shown in Annex 3 and TORs are depicted in Annex 4)

Procurement Budgets and Expenditure from 2004 – 2009 are shown in detail in Annex 5

3. FINANCIAL MANAGEMENT CAPACITY

With an annual turnover of US$ 1.2 million the HSA has a comprehensive financial management system and accounts section. The overall decision making responsibility lies with the Executive Director however, the ED is assisted by a Deputy Director Finance, an Assistant Director Finance, an Audit Account officer, and 2 Finance Assistants who all ensure that financial transparency and accountability are maintained in all transactions. The HSA is well versed in the fact that respective donor agencies have their own financial/accounting procedures including those required by the Government of Pakistan Rules of Audit. Therefore to date all audit reports of the HSA have been duly verified by external auditors and donor assessments. USAID has conducted a financial audit of HAS and cleared the academy to continuous funding through its various areas of support.

HSS

PR 2 Name HealthNet TPO Sector Private INGO

Street Address House #461, Street # 58, Sector I-8/3 Islamabad, Pakistan

1. Background & Introduction

HealthNet TPO is a Dutch knowledge-driven NGO (Non-Governmental Organization) that works on the structural rehabilitation of health care systems in fragile states (areas disrupted by war and disasters). By developing evidence-based interventions our aim is to reach better health care for all.

Our mission is to enhance the ability of communities in fragile states to better manage their own health care. We build en restore health systems in collaboration with communities that are excluded from functioning healthcare, by combining international public health expertise with local tradition.

Our vision is using ‘health’ as a universal goal to unite people, HealthNet TPO enables fragile communities to help themselves again. By also using ‘health’



as a means, we can build functional health services, aiming to rebuild community structures and trust after warfare. Evidence-based interventions are being made even more successful by HealthNet TPO’s in-depth understanding of local resources, capacities, beliefs and needs of the communities

HealthNet TPO is currently working in 10 countries around the globe. HealthNet TPO specializes in health systems development, infectious diseases control, maternal, newborn child health and birth spacing; mental health care and health finance including health insurance. HealthNet TPO adopts a development approach while implementing programmes in unstable situations and brings international expertise to its work in these technical areas.

HealthNet TPO builds health systems in post-disaster and post-conflict settings. The emphasis is on the inclusion of primary psychiatry, psychosocial care, sustainability of services and specific interventions as required in the situation (infectious disease control and health financing etc) since 1993. HNTPO has successfully implemented numerous initiatives in the health care sector in Pakistan and Afghanistan. Currently it implements a Malaria and Leishmaniasis control program in Afghanistan (consisting of control, prevention and research components) and two other large programs in Afghanistan; mental health program and a Health Care support program. HNTPO has been present and operating in Pakistan continuously since 1993, responding to calls from government and UNCHR (as in the Malaria epidemic in Sindh, 2000 WHO and in the October 8, 2005 earthquake in Mansehra District for Psychosocial support. In 2009 a support program for returning IDP’s in Buner district started.

2. Management Capacity

The foundation HealthNet TPO consists of: Board, the General Director and the Management Team. The management team comprises of General Director, the Directors of Public Health and Research Department, the Director of Operations and Director of Resource and Organization. The head office of HealthNet TPO is located in Amsterdam Netherland.

The board of HealthNet TPO monitors the identity and mission of the organization. The Operations Department has line-management responsibility for the projects. The Public Health and Research Department is responsible for content development and monitoring. The resource and organization department is responsible for communication, fund development and overall management, HRM and finance.

The Board of HealthNet TPO

Mr. A. Winkler, Chairman

Mr. H. Sondorp, Secretary

Mevr. E. Kalkhoven, Treasurer

Mevr. A. Papineau Salm, Member of the Board

The Management Team of HealthNet TPO at Head quarters

Drs. Willem van de Put, General Director

Drs. Hans Grotendorst, Director of Operations

Dr. Ivan Komproe, Director Research & Development

Mr. Allard Stevens, Director resource and organization

HealthNet TPO, Pakistan

Since 1993 HealthNet TPO has successfully implemented many health care programmes in Pakistan. The Pakistan programs are directed by a Country



Director, through a decentralized and delegated mechanism and are implemented by a team of qualified and experienced Pakistani staff. A team of experts at headquarters in Amsterdam provides technical support to the programs, including advice in the development and implementation of projects, research and capacity building of national staff.

Description of Monitoring, evaluation and reporting procedures:

HealthNet TPO has an independent autonomous M&E unit with in each project, which comprises a monitoring officer and assistants. The M&E Unit is a technical body that works closely with the program staff to monitor and evaluate project against their targets and quality standards. The unit conducts annual evaluation focusing on effectiveness, efficiency, equity and humanity. The unit is also responsible for conducting regular monitoring visits to the project sites.

An important function of the unit is to act as a central knowledgebase for the project. The unit is also responsible to organize and conduct surveys, assessments and field researches. The undertakings of this unit are as follows: a) developing annual M&E plans, b) coordination with programmes and other organizations, c) preparing ToRs for each monitoring and evaluation visit, d) development or adjustment of quality assurance tools, e) data collection, analysis, reporting and feedback.

Financial and Operational Capacity:

HealthNet TPO’s financial accounting system and procedures meet all international standards and also fulfill the donor requirements including those of Eurpoean commission (EC), World Bank (WB), Global Fund for AIDS, TB and Malaria (GFATM) and United Sates Agency for International Development (USAID). Currently a new double entry system is rolled out in all project countries in order to improve; correct record keeping of all transactions related to different donors and can support the preparation of regular reliable financial statements in all currencies.

Monthly book keeping is prepared and shared with HealthNet TPO’s HQ for internal audit. After the bookkeeping is finalized, the ledger of the bookkeeping is used for reporting purposes. Two types of reports are mainly produced. Firstly, a monthly financial report of each project is prepared for the project managers for understanding the expenses and balance of his/her project. This is mainly an internal arrangement. Secondly, periodic financial reports are prepared based on the requirements of different donors. Financial reporting is done in a timely manner and based on the donor’s policies and procedures. The financial management systems include a mechanism for effective communication with donors and other stakeholders to ensure funds are transferred on time.

Internal control is handled by a system of controls for safeguarding assets, promoting operational efficiency, encouraging adherence to organizational policies, ensuring accuracy and reliability in accounting and inspiring confidence in the organization by its various stakeholders and partners. Standard internal controls are in place to avoid misshapen and are as following:

Budgetary controls

Separation of duties

Accounting Controls

Authorization & Approval Controls



Physical Controls

Adherence to Organization’s Policy and Procedures

Management Control.

Overview of Supply and Procurement Management system:

HealthNet TPO compiles with comprehensive internationally accepted procurement, logistics and warehouse Management policies and procedures. The related key documents are used for procurement, storage, distribution of health products including LLINs, drugs, medical supplies and equipments, and non medical commodities. HealthNet TPO is very familiar with the donor requirements where HealthNet TPO is involved for procurement of huge amounts of medicine, LLINs, KOTab123. The policies and procedures of HealthNet TPO are made on principles ensuring transparency and sound business practice benefiting the organization both in terms of quality and costs. The adopted procurement procedures are very much based on the cost of the items; a) any item with cost less than US$ 100 is purchased by taking two quotations, b) any item between US$ 100 to US$30,000 is purchased through bidding process by directly collecting quotations from suppliers, c) national tenders with advertisement in local newspapers are applied for procurement of items with a total of between US$ 30,000 to US$ 120, 000, d) any acquisition above US$ 120,000 is purchased through a standard international tendering process.

The supply and procurement management system has four stages (selection, procurement, distribution and usage). All stages are managed according to written procurement policies and procedures. The steps for procurement include request by related department with estimated prices and approval by the line managers. Subsequently, the procurement department assigns a team from different department including finance to develop the procurement plan. HealthNet TPO awards the contract to the supplier that meets the administrative requirement, technical criteria and provides the lowest price. The quotations are sealed, kept by finance and opened only in the presence of all members of procurement committee. For international and national tenders suppliers are also invited. The contract is awarded to the selected supplier and standard contacts for different types of agreement are signed. The contract usually includes a certificate of quality of items to be supplied, a bank guarantee, and a time frame and destination for supply. It also includes a penalty for violation of the contractual obligations.

HealthNet TPO follows written standard procedures for storage of different items, stock record keeping and regular documented supply to outlets or health facilities. HealthNet TPO is implementing a comprehensive information system that includes monthly collection of data, compilation, analysis and feedback. The data provides management information to logistic staff to ensure smooth and need based supplies of items at different levels.

All procedures on finance, HRM, Logistics and procurement and security are laid down in a policy and procedure policy for the Pakistan operation.

HealthNet TPO has an extended history of working in Pakistan. Since 1993 the organization has implemented many initiatives to improve the overall health status of Pakistani communities. The programmes implemented include infectious diseases control (malaria, leishmaniasis), community mobilization for primary health care, provision of water and sanitation services and psychosocial support services. Details of implemented projects along with donor agencies are as following:

# Name of the Project

Start Date

Location Donor/value Partners

1 PRIDE Project of Health System Strengthening

2007 District Mansehra Province Khyber Pakhtunekhawa

IRC/USAID USD 857,679

Ministry of Health (MOH) and Community Based Organizations



Ministry of Health and Community Based Organizations

2 Provision of Psychosocial support to children and their families

2009 Buner [PKP] PLAN Pakistan PKR 21121485

Ministry of Health and Community Based Organizations

3 Preventing malaria in IDPs Camps

2009 Peshawar, Noshehra and Mardan [PKP]

WHO US$ 71662

MOH

4 Provision of Psychosocial support to IDPs

2009 Mardan and Sawabi

WHO/PLAN US$ 30000 PKR 8361716

MOH

5 Psychosocial support to earthquake affectees

2006 Mansehra {PKP] PLAN-Pak EURO 178986 US$ 287464

MOH and Local NGO

6 Rapid Appraisal of geographical Malaria Risk

2003 All Malaria affected areas

ECHO Ministry of Health/Global Fund US$ 133,000

MOPH. AIMS, Local and INGO

7 Malaria control 2003 Bajor, Kheyber agencies and district Sindh Province Pakistan

MOPH/Local NGOs

8 Preventing Malaria in the Aftermath of Cyclone and Flood

2000 Thatta and Badin, Districts of Sindh Province Pakistan

ECHO EURO 30,000,000

MOPH and Malaria Control program

9 Preventing Malaria in the Aftermath of food

1999 Thatta and Badin, Districts of Sindh Province Pakistan

MOPH and Malaria Control program

10 Malaria and Leishmaniasis control in Afghan refugee Villages

1993 NWFP/Punjab UNHCR EURO 15,000,000

MOH/Local NGOs



HealthNet TPO carried out following activities in Pakistan. 1. Program Title: “to enhance the health impact of public and private health services amongst target communities at risk and vulnerable to HIV, Pulmonary Tuberculosis and Malaria infection.” Donor: National AID Control Program on behalf of Ministry of Health government of Pakistan (GFTAM-Round-3) Program starting date: 1st September 2003 Program ending date: 31st March 2008 Program location: Bajor and Khyber Agencies of FATA and District Mustang of Balochistan Program Interventions:

1. Baseline survey in target areas to assess knowledge, attitude and practices on Malaria and use of insecticide treated nets. 2. promoting insecticide treated nets in selected areas of high epidemiological importance with public private partnership and community inputs to

reduce the endemicity of malaria to a level where it does not pose a major public health problem 3. Implementing a community awareness campaign for behavior change using all available media and interpersonal communication.

2. Program title: “Assistance to vulnerable Afghan Refugee in Pakistan, Malaria and Leishmaniasis control in Afghan refugees villages” Donor: UNHCR Grant Number: 00/AB/PAK/CM/2005 (f) HNI Program starting date: 1st September 1992 Program ending date: 31st December 2007 Program location: Afghan Refugee Villages in NWFP & Punjab Program Interventions:

1. Coordination of Partners in implementing a comprehensive and integrated program of Malaria and Leishmaniasis treatment and prevention. 2. Training of Health Workers in diagnosis, treatment, prevention and health education. 3. Training of community based volunteers in malaria/Leishmaniasis specific health education and personal protection measures. 4. Vector Control (residual spraying) in highly endemic camps. 5. Social Marketing of ITNs 6. Outbreak of investigation and response 7. Operational research

3. Program title: To extend psychosocial response to the earthquake affected areas [Plan supported Communities], children and their families in Siran and Konsh Valleys with the support of local stakeholders and line agencies.” Donor: PLAN International Program starting date: 15th Feb 2006 Program ending date: 30th June 2008 Program Location: Mansehra NWFP



Program Interventions: 1. Capacity building of PLAN Mansehra, Mountain Institute for Education Development [MIED] and Research, Advocacy and social training Institute

[RASTI] being responsible for the implementation, supervision, monitoring and evaluation of mental health and psychosocial services for children, adolescents and their caretakers in Siran and Konsh Valley.

2. A well-developed model of Mental Health Services is introduced at two levels of the health care structure (BHU and RHC) in Siran and Konsh valley.

3. A newly developed model for community based psychosocial services in introduced to the Siran and Konsh Valleys. 4. To transform the currant mental health module into locally appropriate module by conducting operational research and assessments of mental

health needs and problems of Siran and Konsh valleys of Mansehra District. 5. To establish referral system between different levels of health care structure in Siran and Konsh valleys and link it up with THQ/DHQ at Mansehra

District. 4. Program title: “to increase demand for and use of quality health services through active participation and involvement of target communities.” Donor: IRC (USAID) Program starting date: 1st September 2007 Program ending date: 30th June 2010 Program Location: Mansehra NWFP Program Objectives:

1. To enable women and men to work for the improvement of their health by establishing community based self help groups 2. To empower the project staff, women and men in community organizations and local government officers at the union councils level to organize

participatory planning and manage health interventions 3. To empower women and men at community level to define and prioritize their specific health needs and develop plan of action for health

improvement. 4. To enhance and develop the capacity of women and men in the community organizations to effectively advocate for the specific health priorities

with the focus on need of most vulnerable members of the community. 5. To ensure community participation in the planning and management of community health services at different levels of healthcare.

4.7.2 Sub-recipients for MALARIA

(a) Will Sub-recipients be involved in implementation? Yes go to section 4.7.2 (c)

No go to section 4.7.2 (b)

(b) If no, why not?



NA

(c) If yes, how many Sub-recipients will be involved? 1-6 7-20 21-50 50+

(d) Are all Sub-recipients already identified? Yes go to sections 4.7.2 (e) and (f)

No

go to section 4.7.3

(e) List the identified Sub-recipients and describe:

The work to be undertaken by each Sub-recipient; Past implementation experience of each Sub-recipient; Any challenges that could affect performance of each Sub-recipient as well as a mitigation strategy to address this.

The two PRs in coordination with CCM Pakistan have shortlisted five SRs. Through CCM EOI were invited in an open and transparent manner whereby invitation for EOIs was published widely in the national newspapers. After evaluating the submitted EOIs against a predefined criteria, following five EOIs of potential SRs have been shortlisted:

1. Merlin,

2. National Rural Support Program (NRSP),

3. Association for Community Development (ACD),

4. Association for Social Development (ASD), and

5. Pakistan Lions Youth Council (PLYC)

The scope of work for SRs will be finalized after completion of their pre-award assessments. A summary of the capacity of identified SRs is as under:

1. Merlin

Merlin is a UK based non-profit public health NGO which operates in both emergency and development contexts, providing primary and secondary healthcare services, health system strengthening, disease prevention and control and larger public health programs in more than 17 countries worldwide.

Merlin is one of six SRs in the Global Round 7 in Pakistan and is implementing malaria program in 9 out of total 19 target districts of Round 7 and is managing a grant of $1.9 million, in this regard. In addition, Merlin is international procurement agent for Round 7 and has carried out international procurements of health products including LLINs, anti-malarial drugs, microscopes and RDTs worth $8 million.

2. National Rural Support Program (NRSP)



Established in 1991, the National Rural Support Program (NRSP) is the largest Rural Support Program in Pakistan in terms of outreach, staff and development activities. It is a non-profit organization registered under Section 42 of Companies Ordinance 1984. The NRSP Objective is to foster a countrywide network of grassroots level organizations to enable rural men and women to plan, implement and manage developmental activities and programs for the purpose of ensuring productive employment, poverty alleviation and improvement in the quality of life. NRSP has a presence in 50 Districts in all four Provinces of Pakistan and Azad Jammu and Kashmir through Regional Offices and Field Offices. NRSP is currently working with more than a million poor households organized into a network of more than 92,000 Community Organizations (COs). With sustained incremental growth, it is emerging as Pakistan's leading engine for poverty reduction and rural development. NRSP is working in the sectors of finance and administration, engineering, natural resources management, human resources development, gender and development, social sector services and monitoring and evaluation. These technical staff members provide policy level inputs to the program and backstopping to the project teams in the implementation of the project interventions as well as in core program operations. NRSP also links the COs with Health, Education and Agriculture departments and NGOs. Partnerships have also been formed so that CO members are able to benefit from the services being offered by these departments and organizations. E.g.Meeting Community Needs for Eye Care: The Munawwar Memorial Hospital in Chakwal, LRBT, Shifa Eye Trust, Malaria Control Program: Partnership in GFATM Round 2 & 7- Malaria, Positioning of Family Planning as a Health Intervention - David & Leucile Packard Foundation. Now NRSP is mainstreaming the health, mother and child health in its core program. Apart from partnerships with International Aid Agencies such as the World Bank, USAID, and the International Labor Organization, the focus of NRSP’s programs and projects at the national level is built on government, NGO and CO collaborations as previously described. Being a support organization, NRSP attempts to complement the work of government by nurturing the network of COs as vehicles for delivery of projects to the poor. Some examples of this complementary work are the implementation of Prime Minister’s Livestock Project, Crop Maximization Project, Dera Ghazi Khan Rural Development Project, Barani Village Development Project, and National Program for Improvement of Watercourses, and Punjab Education Sector Reform Program. The government has also used the platform of NRSP for conducting dialogues with the communities for poverty reduction strategies and for doing surveys such as the poverty survey for implementing the Benazir Income Support Program

3. Association for Community Development (ACD)

ACD a national NGO, since the beginning has worked with the government health department, UN agencies, WHO, international and national partners and donors. During these years, international and national evaluators and auditors have assessed ACD’s technical, administrative and financial management capacities. So far, ACD has been entrusted by its partners and donors which is evident from the successful working relationship that ACD has with large number of partners. An important strength that ACD has is its contacts with the government departments, knowledge of the geographical area and effective working relationship at the district and provincial level. Moreover, as ACD has implemented community-based programs it has a good knowledge of social and cultural norms of the communities living in the North West Frontier Province and Baluchistan. With reference to the Global Fund program implementation experience, ACD has been involved in following rounds in Pakistan. 1. SR—TB component Global Fund Round 9 in the provinces of Khyber Pakhtunkhwa (KPK) and Punjab 2. SR—TB component Global Fund Round 6 in 6 FATA agencies and 5 districts of Khyber Pakhtunkhwa (KPK) 3. SR—Malaria component Global Fund Round 7.

4. Association for Social Development (ASD)

Association for Social Development is a non-government health systems research and development organization based in Islamabad. The Association is a non-political and non-profit registered professional organization, which was established in 1995 and is committed to improve the social well



being of poor and less advantaged people by developing, implementing, evaluating and expanding the interventions for enhanced effectiveness, access and utilization of health and social services.

The Association works in partnership with the national institutions and disease control programs as well as international teaching and research institutions and development partners. The Association also has strong working linkages with international technical bodies such as WHO and IUATLD. The Association capitalizes on over 15 years professional & development experience in Pakistan, Afghanistan and UK and a network of 06 field offices with various disease control programs in the four provinces & AJ&K.

The Association has developed an excellent reputation as a trusted partner of various national & provincial disease control programs of the Government of Pakistan on a wide range of development & implementation aspects. These include tuberculosis, Malaria, Nutrition, HIV/AIDS, maternal and child health, reproductive health and tuberculosis, in partnership with ADB, WHO, UNICEF, World Bank, the GFATM, COMDIS, Fidelis and many other bilateral and international donors.

The financial components of some major projects presently under implemented by the Association are:

Project Area Amount Currency Duration Scope

TGFR6 (TBs) 4M US$ 5 Years 05 Districts (Punjab & Balochistan) and 22 tertiary care hospitals (Punjab & KPK)

TGFR7 (Malaria) 615K US$ 5 Years 04 Districts (Sind)

TGFR8 (TB) 1.7M US$ 5 Years 50 Districts (Punjab, KPK, Sind, Balochistan, AJ&K)

TGFR9 (TB) Under process 5 Years 18 Districts (Punjab, KPK & Sind), 7 Parastatal hospitals (Punjab) and 11 tertiary care hospitals (Punjab)

5. Pakistan Lions Youth Council (PLYC)

Pakistan Lions Youth Council (PLYC) registered under societies Registration Act XXI of 1860 and Social Welfare Agencies Registration and Control Ordinance 1961 in Pakistan. Its mission is to promote sustainable human development by empowering and enabling the community folks, especially to those who are socially excluded, marginalized, destitute and neglected sections of society. PLYC’s major donors include USAID, UNFPA, UNODC, WPF, World Bank / PACP, FHI and Federal, Provincial and District Governments. PLYC has the feature of working in all the districts of Punjab Province and Sindh Province. PLYC has the distinction to manage the projects above Rs. 58.75 million in past 5 years. PLYC has qualified and professional staff in different areas including program management, trainings, social sector development, advocacy, public finance, citizen participation, financial management and Monitoring and Evaluation.

(f) If the private sector and/or civil society are not involved as Sub-recipients in implementation, or only involved in a limited way, explain why.

NA



4.7.3 Sub-recipients to be identified

Describe:

(a) why some or all of the Sub-recipients are not already identified; and (b) the transparent, time-bound process that the Principal Recipient(s) will use to select Sub-recipients and not delay program performance.

NA

4.7.4 Coordination between or among implementers for MALARIA Describe:

(a) how coordination will occur between multiple Principal Recipients if there is more than one nominated Principal Recipient for the proposal; and (b) how coordination will occur between each nominated Principal Recipient and its respective Sub-recipient to ensure timely and transparent

program performance.

Coordination between the two PRs and their respective SRs will be ensured at multiple levels. Both the PRs besides participating in annual national and provincial quarterly review meetings will have monthly coordination meetings. Also, where applicable, both PRs will participate in district level review meetings.

A Technical Working Group (TWG) will be formed consisting of technical advisors from both the PRs. Furthermore, private sector PR (Save the Children) and its SRs will place its provincial and district liaison personnel in close vicinity of MCP, preferably in the offices of respective directorate and ministries of health.

In this way continuous interaction between the two PRs and their respective SRs will be ensured so that experiences and lessons learnt can be shared amongst the key implementers of Global Fund Round 10.

4.7.5 Strengthening implementation capacity for MALARIA (a) The applicant is encouraged to include a funding request for management and/or technical assistance to achieve strengthened capacity and high quality services, supported by a summary of a technical assistance (TA) plan based on the indicative percentage range in the Guidelines. In the table below provide a summary of the TA plan.

Refer to the Strengthening Implementation Capacity information note for further background and detail

Management and/or technical assistance need

Management and/or technical assistance activity

Intended beneficiary of management and/or technical assistance Estimated timeline

Estimated cost

same as proposal currency

Technical Assistance Activity 3.1.1. Supportive Environment (strengthening

Public Sector PR (Directorate of Malaria Control)

International TA for 9 months

$336,600



program management capacity)

4 National TA for four years

Activity 3.4.1 Program Management Private Sector PR (Save the Children)

TA for periodic program reviews, reporting and special event arrangements etc.

$156,794

Activity 4.1.1 Strengthening BCC for Malaria

Private Sector PR (Save the Children)

1 national consultant for revising and finalizing national malaria BCC strategy

$20,000

Activity 4.1.1 Strengthening BCC for Malaria

Private Sector PR (Save the Children)

1 national consultant for reviewing and updating malaria protocols in LHWs’ curriculum

$5,000

(b) Describe the process used to identify the assistance needs listed in the above table.

The TA needs were identified during national consultations held for the review and finalization of National Strategic Framework.

(c) If no request for management and/or technical assistance is included in the proposal, provide a justification below. Or, if the funding request is outside the indicative percentage range, provide a justification below.

NA

4.8 Pharmaceutical and Other Health Products



4.8.1 Scope of Round 10 proposal

Does the proposal seek funding for any pharmaceutical and/or health products?

Yes go to section 4.8.2

No skip the remainder of section 4.8

4.8.2 Table of roles and responsibilities for MALARIA

Function Name of the organization(s) responsible for this function

Role of the organization(s) responsible for this function

Does the proposal request funding for additional staff or technical assistance? indicate Yes or No

Procurement policies, systems, and planning

-Ministry of Health

-WHO PRs No

Intellectual property regulations

Ministry of Health,

Government of Pakistan Public sector PR (Directorate of Malaria Control-DMC)

No

Quality assurance and quality control

-National Drug Testing Laboratory (NDL)/WHO Regional Drug and RDT Testing Centers

Ministry of Health listed and approved products will be procured

No

Management and coordination more details required in section 4.8.3

-DMC

-Save the Children PRs No

Product selection -DMC


Management Information Systems (MIS)

DMC PRs Yes

Forecasting -DMC


Storage and inventory management more details required in

-DMC

-Save the Children PRs Yes



section 4.8.4

Distribution to other stores and end-users more details required in section 4.8.4

-DMC

-Save the Children -SRs

PRs and SRs Yes

Ensuring rational use and patient safety

-DMC


PRs and SRs Yes

Pharmacovigilance

Drug resistance Surveillance

-DMC


PRs and SRs Yes

4.8.3 Past management experience (MALARIA)

Describe the past experience of each organization that will be involved in managing pharmaceutical and other health products.

Organization name Short description of management experience Total value procured during last financial year same currency as proposal

Public Sector PR (Directorate of Malaria Control)

DMC has the national and international experience of more than 50 years in procuring pharmaceutical and other health products for malaria control. DMC has strong experience of procuring pharmaceuticals and health products for both Global Fund funded projects and the projects supported by the government of Pakistan. DMC follows government of Pakistan’s elaborate and standard procurement rules for all national and international procurements.

$70,588(PkR 60,000,000) in regular program and worth

$8 million in Global Fund Round 7 Phase 1

Private Sector PR (Save the Children) For over the past 25 years the organization has the experience of managing pharmaceuticals and health products for afghan refugees and Pakistani beneficiaries for its various projects in Pakistan focused on management of health facilities and healthcare service delivery. Save the Children has strong procurement policies and rules ensuring transparency in the process. Major procurement done in the field of Pharmaceuticals

$2,012,658 (PkR171,075,902)



and medical equipment in current and last year only are as follows.

1. Procurement of Medicines for JSDF project a Japanese Government funded project. Medicine for BHUs & RHCs in Batagram and Allai following World Bank procurement guidelines amounting PKR 22,523,092 only.

2. Procurement of Medical Equipment for ICHP FATA a USAID funded project. Medical equipment for health facility improvement in FATA following USAID rules and Regulations amounting to PKR 49,792,358 only.

3. Procurement of Medicine for ICHP FATA. Medicines for child health days amounting PKR 54,007,487 only

4. Medical Equipment for IDP emergency program 5. Medicine for IDP emergency program

use the ‘Tab’ key to add extra rows

4.8.4 Alignment with existing systems (MALARIA)

Describe how the proposal uses existing country systems for the management of the additional pharmaceutical and health product activities that are planned, including pharmacovigilance and drug resistance surveillance systems. If existing systems are not used, explain why.

The existing Ministry of Health/DMC systems for the management of additional pharmaceutical and health products will be used in most of the case for PR-GoP. Focal persons for the DMC/Ministry of Health and PR-NGO will be responsible for coordinating the procurement and supply management plan. The public sector PR will follow the procurement rules as per the government rule. NGO-PR will follow their own rules for procuring the products. A national consultative meeting will be organized by the PRs to develop a “National LLIN distribution strategy and user guide”. The district level staff at the EDO Health office will be responsible for supply management of the products in accordance with the strategy developed. A one-day orientation of the facility based staff will be organized by the district officer for distribution of supplies, during which a distribution plan will be developed by staff of respective district outlets. The plans from all the project districts will be shared with the PRs. Similar infra-structure will be used by the NGO sector. However, in both the cases, the Global Fund Supplies Management guidelines will be strictly followed. Once the proposal is approved, PRs will submit the “Procurement and Supply Management Plan”. Drugs, products and health equipments will be procured through local suppliers and/or international procurement system through competent sources. However, in both the cases the PRs will ensure the quality of goods and products as well as the price. MoH/GoP will be responsible to ensure regular supplies from central levels to the districts. NGO PR will receive their supplies on quarterly basis. The NGO PR will be responsible to ensure that regular supplies are delivered to SR NGOs regularly.

The Director, Directorate of Malaria Control (DMC), Ministry of Health, GoP, will be responsible for procurement and storage of pharmaceuticals and health products. The procurement and supplies manager of the national and provincial Malaria Control Program will ensure that government regulations are strictly adhered to in the procurement and storage of the products for diagnosis, treatment and prevention. The products either procured by or received from DMC by the PR NGO on quarterly basis will be stored as per their warehouse rules for pharmaceuticals and health products. They will coordinate closely with the DMC/MoH to ensure that they comply with the government rules and that these products are safely



stored and maintain their quality.

The National Drug Testing Laboratory (NDL) located at the National Institute of Health oversees the testing of drug quality in the country. The PR NGO will also ensure that products procured by them maintain their quality and make use of the NDL services.

4.8.5 Storage and distribution systems for MALARIA

(a) Which organization(s) have primary responsibility to provide storage and distribution services under the proposal?

tick the corresponding boxes to the right and

enter the name of the organization(s)

National medical stores or equivalent

Directorate of Malaria Control, Ministry of Health, Pakistan

Sub-contracted national organization(s)

specify

Sub-contracted international organization(s)

specify

Other:

specify

(b) For storage partners, what is each organization's current storage capacity for pharmaceutical and health products? If the proposal represents a significant change in the volume of products to be stored, estimate the relative change in percent, and explain what plans are in place to ensure increased capacity.

e A sizable quantities of pharmaceuticals and health products have been proposed to be procured during the project period. DMC being the federal unit of the malaria control in Pakistan along with its provincial chapters has developed sufficient capacity to ensure the storage of pharmaceuticals and health products, following the standard guidelines. Storage facilities are available at national, provincial and down to the district level with in the program structure. These facilities have been used for the storage of insecticides and anti-malarial drugs in the past. There will be an increase of 83% in the number of LLINs procured under this proposal compared to the previous round (Round 7). Upgrading of 41 stores is being proposed to fulfill the storage requirement of LLINs, ACTs, RDTs and other items under this proposal. The proposed new storage spaces will especially cater for the pan-specific RDTs at the district level to fulfill its storage requirements.

© For distribution partners, what is each organization’s current distribution capacity for pharmaceutical and health products? If the proposal represents a significant change in the volume of products to be distributed or the area(s) where distribution will occur, estimate the relative change in percent, and explain what plans are in place to ensure increased capacity.

Directorate of Malaria Control is the federal unit for malaria Control in Pakistan. The DMC will directly supply the pharmaceuticals and health products to the districts from their central warehouse. The relevant SR organizations responsible for distribution of these pharmaceutical products will ensure the delivery of these items to the respective health facilities in the district as per their Procurement and Supply Plan.



4.8.6 Pharmaceutical and health products for initial two years for MALARIA

Complete the Pharmaceutical and Health Products List and list all of the products that are requested to be funded through the proposal.

If the pharmaceutical products included in the Pharmaceutical and Health Products List are not included in the current national, institutional or World Health Organization Standard Treatment Guidelines (STGs), or Essential Medicines Lists (EMLs), describe below the STGs that are planned to be utilized, and the rationale for their use.

Applicants are invited to justify the prices based on either the guidance provided in the Unit Costs for Selected Key Health Products information note or with another published international reference source. If the provided price is out of range, provide justification. Also, if local legislation is preventing access to low cost prices through local manufacturers or similar mandates, clarification should be provided as well as a plan for addressing such barriers over the life of the proposal.

The list of pharmaceuticals and health products are as follows:

1. Microscopes - 152

2. Chemicals, reagents for malaria microscopy- for 447 microscopy centers, twice a year

3. Lab supplies – for 447 microscopy centers

4. Pan Specific RDTs (WHO pre-qualified manufacturers) – 3.5 million

5. LLINs, 5 year longevity - 2.75 million

6. Tab. ACTs for treatment of uncomplicated falciparum– 800,000 (6+3 co-blister pack) including both adult and pediatric courses

7. Anti-malarial drugs (Cloroquine + Primaquine) for treatment of vivax- 1,200,000 courses. Primaquine has been calculated excluding 19% pregnant women and children under 5.

8. WHOPES approved Insecticides from pre-qualified manufacturers for IRS – 129,000 Kg.

9. Spray pumps (Hudson) – 152

We will be using national treatment guidelines for the treatment of malaria cases which have been developed in line with the international standards and WHO recommendations. The unit prices have been calculated using the WHO costing tool.



5. FUNDING REQUEST

The Round 10 Guidelines contain different guidance for sections 5.1 and 5.2 depending on whether the applicant selected Option 1, 2 or 3 in section 3.1 of the Proposal Form

Option 1 = Transition to a single stream of funding by submitting a consolidated disease proposal

Option 2 = Transition to a single stream of funding during grant negotiation

Option 3 = No transition to a single stream of funding in Round 10

5.1 Financial Gap Analysis

Clarified section 5.1: full figures (instead of round figures), line A.1 and line H Section D and H of the Gap Analysis table below must be completed differently depending on whether applicant selected Option 1, 2 or 3 (see above)

Summary Information provided should be described further in sections 5.1.1 – 5.1.3 Currency must be the same as identified on the proposal cover page Adjust the years as necessary in the table from calendar years to financial years to align with national planning and fiscal periods

Financial gap analysis

Actual Planned Estimated

2008 2009 2010 2011 2012 2013 2014 2015

SECTION A: Funding needs for the full national malaria program

LINE A Provide annual amounts 22,800,000 24,900,000 27,100,000 32,500,000 39,000,000 46,800,000 56,200,000 67,400,000

LINE A.1 Indicate the amount of the funding need for the full national malaria program over the full term of the Round 10 proposal

241,900,000

SECTIONS B, C AND D: Current and planned resources to meet the funding needs of the full national malaria program

Section B: Domestic

Domestic source B1:

Loans and debt relief

provide name of source here

0 0 0 0 0 0 0 0





2008 2009 2010 2011 2012 2013 2014 2015

Domestic source B2 National funding resources 3,398,761 3,632,490 4,974,553 4,478,918 4,424,224 4,067,412 4,257,647 4,282,353

Domestic source B3 Private sector contributions (national)

0 0 0 0 0 0 0 0

LINE B: Total current & planned DOMESTIC resources

Total of Section B entries 3,398,761 3,632,490 4,974,553 4,478,918 4,424,224 4,067,412 4,257,647 4,282,353

Section C: External (non-Global Fund)

External source C1 WHO 0 300,000 250,000 250,000 0 0 0 0

External source C2

provide source name here 0 0 0 0 0 0 0 0

External source C3 Private sector contributions (International)

0 0 0 0 0 0 0 0

LINE C: Total current & planned EXTERNAL (non-Global Fund) resources

Total of Section C entries

0 300,000 250,000 250,000 0 0 0 0

Complete this version of Section D if the applicant selected Option 2 or 3 in section 3.1 of the Proposal Form:

Section D: External (Global Fund) Insert additional lines below if there are more than two existing malaria Global Fund grants

Grant D1 Round 7 0 6,580,307 6,306,373 4,156,382 2,359,114 2,155,528 0 0

Grant D2 provide grant number here 0 0 0 0 0 0 0 0

LINE D: Total current & planned EXTERNAL (Global Fund) resources

Total of Section D entries 0 6,580,307 6,306,373 4,156,382 2,359,114 2,155,528 0 0





2008 2009 2010 2011 2012 2013 2014 2015

Complete this version of Section D if the applicant selected Option 1 in section 3.1 of the Proposal Form:

Section D: External (Global Fund) Insert additional lines below if there are more than two existing malaria Global Fund grants

Section D1: Grants not included in consolidated disease proposal

Grant D1-A

provide grant number here

0 0 0 0 0 0 0 0

Grant D1-B

provide grant number here 0 0 0 0 0 0 0 0

Section D2: Grants included in consolidated disease proposal and listed in section 3.1(b)

Grant D2-A

provide grant number here

0 0 0 0 0 0 0 0

Grant D2-B

provide grant number here 0 0 0 0 0 0 0 0

LINE D: Total current & planned EXTERNAL (Global Fund) resources

Total of Section D entries 0 0 0 0 0 0 0 0

LINE E : Total current and planned resources

Line E = Line B + Line C + Line D 3,398,761 10,512,797 11,530,926 8,885,300 6,783,337 6,222,940 4,257,647 4,282,353

Calculation of gap in financial resources and summary of total funding requested in Round 10 must be supported by detailed budget

LINE F: Total funding gap Line F = Line A – Line E 19,401,239 14,387,203 15,569,074 23,614,700 32,216,663 40,577,060 51,942,353 63,117,647

LINE G: Round 10 malaria funding request must be same amount as requested in tables 1.1, 5.3, 5.4 and detailed budget for this disease

18,718,247.03

6,358,596.60

16,588,071.33

9,118,010.97

5,350,254.22



Part H – Cost Sharing calculation for Lower-middle income and Upper-middle income applicants - Clarified

In Round 10, the total maximum funding request for malaria in Line G is:

(a) For Lower-Middle income countries, an amount that results in the Global Fund's overall contribution (all grants) to the national program being not more than 65% of the national disease program funding needs over the proposal term; and

(b) For Upper-Middle income countries, an amount that results in the Global Fund overall contribution (all grants) to the national program being not more than 35% of the national disease program funding needs over the proposal term.

Line H = Cost Sharing calculation as a percentage (%) of overall funding from Global Fund

Complete this cost sharing calculation if the applicant selected Option 2 or 3 in section 3.1 of the Proposal Form:

Cost sharing = (Total of Line D amounts for proposal period + Total of Line G amounts) X 100

Line A.1

Complete this cost sharing calculation if the applicant selected Option 1 in section 3.1 of the Proposal Form:

Cost sharing = (Total of Line D1 amounts for proposal period + Total of Line G amounts) X 100

Line A.1

26.79%

ROUND 10 – HIV

R10_CCM_PKS_M_PF_s3-5_30Sep10_En.doc

5.1.1 Explanation of financial needs and additionality of Global Fund financing

Describe how the annual amounts were:

(a) developed; (b) budgeted in a way that ensures that government, non-government and community needs were

included to reflect implementation of the country's malaria program strategies; and (c) developed in a way that demonstrates the funding requested in the proposal will contribute to

the achievement of outputs and outcomes that would not be supported by currently available or planned domestic resources.

NA

5.1.2 Domestic funding

corresponds to LINE B in Table 5.1

Describe the processes used in country to:

(a) prioritize domestic financial contributions to the national HIV program including HIPC [Heavily Indebted Poor Country] and other debt relief, and grant or loan funds that are contributed through the national budget; and

(b) ensure that domestic resources are used efficiently, transparently and equitably, to help implement treatment, prevention, care and support strategies at the national, sub-national and community levels.

NA

5.1.3 External funding

corresponds to LINE C in Table 5.1

Describe:

(a) any changes in contributions anticipated over the proposal term and the reason for any identified reductions in external resources over time; and

(b) any current delays in accessing the external funding identified in Table 5.1 that should be explained, including the reason for the delay, and plans to resolve the issue(s).

NA

5.2 Detailed Budget Instructions for completion of the detailed budget: For guidance on the level of detail required (or for a template) refer to the budget information available in Section 5.2 of the Guidelines 1. Submit a detailed budget in Microsoft Excel format. 2. Ensure that this detailed budget is consistent in numbering with the Round 10 interventions in

section 4.4.1 of the Proposal Form, the Performance Framework, and the detailed work plan. 3. From the detailed budget, prepare table 5.3, the summary by objective and service delivery

area. 4. From the detailed budget, prepare table 5.4, the summary by cost category. 5. Do not include a request for CCM or Sub-CCM funding in this Round 10 proposal. Requests for

funding are available through a separate application. The application is available at: http://www.theglobalfund.org/en/ccm/



5.3 Summary of Detailed Budget by Objective and Service Delivery Area Clarified total for year 4 Use the same objective and SDA numbering as the description in section 4.4.1, the Performance Framework, and the detailed budget and work plan. Annual totals at the end of this table must equal annual totals in the detailed budget and tables 1.1 and 5.4

Objective number

Service delivery area


1 SDA1.1: DIAGNOSIS 1,659,381.18 297,593.53 2,131,567.06 1,605,299.41 286,402.94 5,980,244.12

1 SDA 1.2: PROMPT & EFFECTIVE ANTI-MALARIAL TREATMENT

1,654,228.36 502,281.85 1,056,974.79 1,062,689.08 182,016.81 4,458,190.88

2 SDA 2.1: INSECTICIDE TREATED NETS (LONG LASTING)

10,905,733.51 422,800.00 5,555,064.73 69,000.00 0 16,952,598.24

2 SDA 2.2: INDOOR RESIDUAL SPRAYING

1,056,470.59 244,235.29 2,267,764.71 244,235.29 0 3,812,705.88

2 SDA 2.3: INFORMATION SYSTEM 437,457.06 93,176.47 93,176.47 93,176.47 93,176.47 810,162.94

2 SDA 2.4: MONITORING DRUG RESISTANCE 0 20,000.00 0 20,000.00 0 40,000.00

2 SDA 2.5: MONITORING INSECTICIDE RESISTANCE 0 20,000.00 0 0 0 20,000.00

3 SDA 3.1: LEADERSHIP & GOVERNANCE

111,670.59 271,452.94 96,094.12 271,452.94 16,894.12 767,564.71



Objective number

Service delivery area


3 SDA 3.2: MONITORING & EVALUATION, EVIDENCE BUILDING

286,870.59 526,694.12 566,811.76 641,552.94 414,364.71 2,436,294.12

3 SDA 3.3: PROGRAMME MANAGEMENT (DMC) 60,084.00 66,092.40 800,645.65 765,260.80 835,045.88 2,527,128.

73

3 SDA 3.4: PROGRAMME MANAGEMENT (SC USA) 1,090,252.36 1,063,520.13 1,112,197.80 1,274,118.86 1,246,800.90 5,786,890.

04

3 SDA 3.5: PROGRAMME MANAGEMENT (IMPLEMENTATION LEVEL)

463,157.63 455,938.10 1,157,680.13 1,263,836.94 1,380,128.87 4,720,741.67

4 SDA 4.1: STRENGTHENING BCC FOR MALARIA 50,494.11 1,176.47 0 0 0 51,670.59

4 SDA 4.2: BCC-MASS MEDIA 892,188.23 2,323,117.65 1,699,576.46 1,756,870.59 870,164.70 7,541,917.64

4 SDA 4.3: BCC-COMMUNITY OUTREACH 50,258.82 50,517.65 50,517.65 50,517.65 25,258.82 227,070.59

use “tab” key to add extra rows as needed

Round 10 malaria funding request: 18,718,247.03 6,358,596.60 16,588,071.33 9,118,010.97 5,350,254.22 56,133,180.15



5.4 Summary of Detailed Budget by Cost Category -

Clarified section 5.4: total for year 3

Summary information provided in the table below should be described further in sections 5.4.1 to 5.4.3 Annual totals at the end of this table must equal annual totals in the detailed budget and tables 1.1 and 5.3

Cost Category Year 1 Year 2 Year 3 Year 4 Year 5 Total

Human resources 857,249.36 942,974.29 2,102,311.01 2,312,542.11 2,543,796.32 8,758,873.10

Technical and management assistance 182,652.94 110,558.82 110,558.82 110,558.82 31,358.82 545,688.24

Training 607,297.35 1,335,884.12 214,731.76 501,367.06 52,294.12 2,711,574.41

Health products and health equipment 12,434,970.59 86,100.00 8,819,629.41 1,197,100.00 102,600.00 22,640,400.00

Pharmaceutical products (medicines) 811,176.47 0 811,176.47 811,176.47 0 2,433,529.41

Procurement and supply management costs 922,745.13 89,915.97 564,107.14 183,571.43 51,428.57 1,811,768.23

Infrastructure and other equipment 178,082.35 0 161,167.65 67,050.00 67,050.00 473,350.00

Communication materials 912,717.63 1,801,694.12 1,726,641.20 1,699,576.47 870,164.71 7,010,794.12

Monitoring & Evaluation 459,964.71 659,870.59 659,988.24 754,729.41 507,541.18 3,042,094.12

Living support to clients/target populations 844,140.00 759,934.12 614,576.47 560,576.47 247,341.18 3,026,568.24

Planning and administration 166,258.82 174,571.76 244,830.59 251,822.12 264,413.22 1,101,896.52

Overheads 340,991.68 397,092.81 558,352.57 667,940.61 612,266.10 2,576,643.76

Other (specify): 0 0 0 0 0 0

Round 10 malaria funding request: 18,718,247.03 6,358,596.60 16,588,071.33 9,118,010.97 5,350,254.22 56,133,180.15



5.4.1 Overall budget context Describe any significant variations in cost categories by year, or significant five year totals for those categories.

Human resource comprises 16% of the total cost of the planned out put over the project life cycle with significant variation of cost as part of total human resource cost would be covered from Round 7 in the first two years of the program. Year 3 onwards cost of human resource increases significantly as Round 10 will bear 100% cost.

Procurement of health items including pharmaceutical products, equipment and LLINs is another cost category comprising 40% of the overall cost and is planned to be implemented during phase-1 of the project life. This is linked with the establishment of diagnostic and treatment centres and to initiate the curative and preventive components at the start of the project for the timely achievement of the desired outcomes.

Development of communication materials is another major cost category (12% of the total budget) mainly consists of the development of IEC material, mass media products and community level awareness raising events, which is linked with the improvement of service delivery and utilization at facility and community level.

5.4.2 Human resources (a) Describe how the proposed financing of salaries, compensation, volunteer stipends, or top-ups will be consistent with agreed in-country salary frameworks, such as national salary or inter-agency frameworks.

Attach supporting information as evidence, including draft documents where applicable

Skilled and experienced staff will be recruited for PMUs of the PRs’ offices, provincial malaria control programs and the provincial/district SR offices in 38 target districts. The proposed salary and allownce packages are aligned with the Round 7, current market rates in the country, and PRs’ and SRs’ HR policies and salary scales. The HR cost includes salaries, fringe benefits and allowances.

(b) In cases where human resources represents an important share of the budget, summarize: (i) the basis for the budget calculation over the initial two years; (ii) the method of calculating the anticipated costs over years three to five; and (iii) to what extent human resources spending will strengthen service delivery.


In Round 10 the number of districts being covered has been doubled compared to Round 7 resulting in an increase in human resource cost. In the first two years the cost of human resource is 21% of the total cost under this head. The reason being that part of the cost is being covered by round 7 and only new positions or an allowance for existing position has been budgeted. In year 3 of the project there is an increase in the cost of human resource as Round 7 would have come to an end and the total cost would be borne by Round 10.

The suggested human resource is an integral part of the district project setup providing strength to the existing but weak district program structure. Recruitment of trained human resource in project management, disease surveillance, data management and quality assurance of diagnosis, treatment and prevention tools will ensure the delivery of case management and prevention services at the grass root level. The management and technical staff at provincial level will strengthen and enhance the program management, technical, monitoring and supervision capacities.



5.4.3 Other large expenditure items

If ‘other’ cost categories represent important amounts in the summary in table 5.4, (i) explain the basis for the budget calculation of those amounts; and (ii) explain how this contribution is important to implementation of the national malaria program.


“Health product and health equipment” comprises of 40% of the total budget and mainly consists of procurement of 171 microscopes, 3.5 million Pan Specific RTDs, 2.75 million LLINs and 129,000 kg of Insecticides. The per unit cost used for the above mentioned items has been calculated on the basis of current market prices as these items have also been procured under round 7.

It is important to mention that the delivery of both curative and preventive services at both facility and community level is directly linked with these procurements. The provision of correct diagnosis and effective treatment services can only be delivered through a functioning microscopy or RDT centres, which is directly linked with the timely procurement of equipment and reagents. All confirmed malaria cases need to be promptly treated with effective antimalarial drugs including ACTs, which is an important procurement item in the proposal.

LLINs have proved to be an effective tool for personal protection against malaria. It has proven efficacy to reduce mosquito vector density and transmission potential, if scaled up to cover> 80% of the target community. It helps reduce the morbidity and mortality in highly vulnerable groups including pregnant women and children less than 5.

The second main cost category is “Communication and Material” which is 13% of the total budget. It mainly consists of “development of 8 million units of IEC material” and “publishing and broadcasting of malaria messages through local radio”. The costs have been used on the basis of previous procurement of similar items.

5.4.4 Measuring service unit cost and cost effectiveness

Provide the following:

(a) where available, estimates of recent average service delivery unit costs at the program-level for key services with an explanation of how the estimates were developed;

(b) estimates of the expected average service delivery unit costs for key services that are included in the proposal; and

(c) a description of how key service delivery unit costs will be measured at the program-level, over time throughout the lifecycle of the grant.

Estimates of average service delivery cost at the program level are based on total program cost divided by the targeted population for different program components. The program includes four major components such as diagnosis of high risk population, treatment costs of malaria, costs of prevention and BCC for all beneficiaries.

The overall program will target 24.84 million population in 38 districts of Pakistan. Estimates of expected average service delivery costs are based on cost formula for total and average costs. The program intends to target high risk population of 10 million through RDT and microscopy with average cost of diagnosis of 0.56 $ and total cost of 5.62 million. Malaria treatment with ACT, Choloquin, Primaquine, and Quinine is proposed for 2 million population with total cost of 4.45 million and average cost of $ 2.22. Total cost of prevention is estimated at $ 21.0 million for a targeted population of 6.8 million and average cost of $3.08. For BCC for all beneficiaries (24.84 million population) total cost of $ 55.45 million and average cost $2.23 is estimated. Cost estimates are based on cost formula for total and average costs over all program years and for different program components.

Service delivery costs at the program level will be measured based on micro costing,



detailing all inputs necessary to carry out program activities. Different inputs will be required for different program components and unit cost will be measured based on specific inputs falling in that specific component. For example, diagnosis will require quite different inputs as compared to other components of treatment and prevention. Costs over program years will therefore be generated through identified inputs in each specific category.

5.5 Funding Requests in the Context of a Common Funding Mechanism In this section, common funding mechanism refers to situations where all funding is contributed into a common fund for distribution to implementing partners

5.5.1 Common funding mechanism

If the country’s response to malaria is through a program-based approach, does the proposal plan for some or all of the requested funding to be paid into a common-funding mechanism to support that approach?

Yes

complete all of section 5.5

No

do not complete section 5.5

5.5.2 Operational status of common funding mechanism

Describe the main features of the common funding mechanism, including the fund's name, objectives, governance structure and key partners.

NA

5.5.3 Measuring performance

Describe how program performance helps determine financial contributions to the common fund.

NA

5.5.4 Additionality of Global Fund request

Describe how the funding requested in the proposal will contribute to the achievement of outputs and outcomes that would not be supported by current or planned resources available to the common funding mechanism.

NA

5B. CROSS CUTTING HSS – FUNDING REQUEST



Read the Round 10 Guidelines to consider including optional cross-cutting HSS interventions

SECTION 5B can only be included in the Round 10 malaria proposal if:

the applicant submitted section 4B with malaria.

Section 5B can be downloaded from the Global Fund's website if the applicant intends to apply for cross-cutting HSS interventions.




Read the Round 10 Guidelines to consider including optional cross-cutting HSS interventions





PROPOSAL CHECKLIST: SECTIONS 3-5 Malaria

CHECKLIST

Section 3 and 4: Proposal Summary and Program Description for MALARIA PROPOSAL

Document attached?

mark an ‘X’ if attached

List document name and number

4.1 National Health Sector Development / Strategic Plan X Annex 1. National

Health Policy 2009- Draft

4.1 National Malaria Control Strategy and/ or Costed Implementation Plan

X Annex 2. National Malaria

Control PC-I

4.1 Sub-sector policies that are relevant to the proposal (e.g. national or sub-national human resources policy, norms

and standards, gender policies/strategies and plans, policies on community or CSO partnerships with

government health or other systems)

4.1 Most recent self-evaluation reports/technical advisory reviews, including any epidemiology report directly

relevant to the proposal

X Annex 3. Malariometric Survey-2009

4.1 National Monitoring and Evaluation Plan (e.g. health sector, disease-specific, or other)

4.1 National policies to achieve gender equality in regard to the provision of malaria prevention, treatment, and care

and support services to all people in need.

4.1 Most recent bio-behavioral surveillance of key population(s)

4.1 National report on gender specific operational research and any gender analysis/assessments that might have been

undertaken of the malaria response

4.1 National pharmacovigilance policy X Annex 4. National Drug

Policy

4.2 (b) Map if proposal targets specific region/population group X In the Proposal text

4.3.2 Any recent report on health system weaknesses and gaps that impact outcomes for the three diseases (and beyond

if it exists).

4.4 Document(s) that explain basis for coverage targets X Annex 5.

List of 38 target



districts

4.4.1 A completed Performance Framework (mandatory)

X Annex 6. Performance Framework

4.4.1 A detailed work plan (mandatory) X Annex 7. work plan

4.4.2 A copy of the Technical Review Panel (TRP) Review Form from Round 8 or 9, if relevant.

X Annex 8.

TRP Review Comments

from Round 9

4.6.1 A recent evaluation of the Impact Measurement Systems as relevant to the proposal (if one exists)

4.7.1 A recent assessment of the Principal Recipient capacities (other than Global Fund Grant Performance Report)

4.7.1

Documents describing the organization, such as official registration papers, summary of recent history of

organization, management team information

only for Non-CCM applicants

4.7.2

List of Sub-recipients already identified (including name, sector they represent, and SDA(s) most relevant to their

activities during the proposal term)

X Annex 9.

List of potential SRs

4.8.6 A completed malaria Pharmaceutical and Health Products List only mandatory if applicant is procuring these

products

X Annex 10.

List of medical products

Section 4B: Cross-cutting HSS (only one per country’s application)

Document attached?



4B.2 A completed separate cross-cutting HSS Performance Framework (mandatory, if applicable) X

HSS Performance Framework

4B.2 A detailed separate cross-cutting HSS work plan (mandatory, if applicable) X

HSS work plan

Section 5: Funding Request

Document attached?



5.2 A detailed budget (Mandatory)

X Annex 11.

Detailed budget



(MALARIA)

5.4.2

Information on basis for budget calculation and diagram and/or list of planned human resources funded by

proposal

5.4.3 Information on basis of costing for ‘other’ cost category items

5.5.1

Documentation describing the functioning of the common funding mechanism

only include if there is a common funding mechanism

5.5.2

Most recent assessment of the performance of the common funding mechanism

only include if there is a common funding mechanism

Section 5B: Cross-cutting HSS Funding Request

Document attached?



5B.1 A separate cross-cutting HSS detailed budget (mandatory, if applicable)

X HSS Detailed budget

5B.4.2

Information on basis for budget calculation and diagram and/or list of planned human resources funded by

proposal (only if relevant)

5B.4.3 Information on basis of costing for ‘other’ cost category items

Other documents relevant to sections 3, 4 and 5

attached by applicant for MALARIA PROPOSAL

Document attached?



World Malaria Report 2008 X

GF R10 Proposal Ref 1- WMR 2008

Afghan refugees and the temporal and spatial distribution of malaria in Pakistan X

GF R10 Proposal Ref 2 - Article

Malaria Annual Surveillance Data 2008

X

GF R10 Proposal Ref 3-Surveillance Data

National LLIN Guidelines, Directorate of Malaria Control X

GF R10 Proposal Ref 4- National LLIN



Guidelines

Mid-term Development Framework 2005-10, Pakistan

X

GF R10 Proposal Ref 5 - Pakistan MTDF 2005-10

GoP Vision 2030 Program

X

GF R10 Proposal Ref 6 - GoP Vision 2030

Pakistan National Strategic Framework for Malaria

X

GF R10 Proposal Ref 7 - Malaria NSF

Malariometric Survey Report 2009

X

GF R10 Proposal Ref 8 - Survey Report

MCP Annual Surveillance Data for 38 districts 2009

X

GF R10 Proposal Ref 9 -Surveillance Data

Kakar Q, Khan A, Bile KM. “Rolling Back Malaria in Pakistan: progress and challenges” (Unpublished data)

X

GF R10 Proposal Ref 10 -Unpublished data

M. Rowland et.al “Epidemic of Plasmodium falciparum Malaria involving substandard antimalarial drugs, Pakistan, 2003. Emerging Infectious Diseases, 2009. Vol 15 (11); 1753-59

X GF R10 Proposal Ref 11 - Article

Population Projections Data from National Institute of Population Studies

X

GF R10 Proposal Ref 12 - NIPS Population Data

Pakistan Poverty Reduction Strategy Paper 2004

X

GF R10 Proposal Ref 13 - Pakistan PRSP

UNOCHA Flood Disaster MAP of Pakistan August 12, 2010

X

GF R10 Proposal Ref 14 – UNOCHA Map

National Vector Control Guidelines X GF R10 Proposal Ref



15 – National Guidelines

Human Development Index Report 2009 X

GF R10 Proposal Ref 16 - HDI 2009

M&E Plans of Phase I & II, GF Round 7 Malaria

X

GF R10 Proposal Ref 17 - M&E Plans R7

Other documents relevant to sections 3, 4 and 5

attached by applicant for HSS PROPOSAL

Document attached?



EHSP Package –Dec- 2009

X HSS Annexure

- 1

GAVI HSS Annual Report 2009

X HSS Annexure

- 2

HSA Profile & Faculty Update

X HSS Annexure

- 3

EHSP Report Draft

X HSS Annexure

- 4

Feasibility warehouse

X HSS Annexure

– 5

HSSPU Report Final

X HSS Annexure

– 6

Draft Health Policy

X HSS Annexure

– 7

HRH Study

X HSS Annexure

– 8

HSS Review Feb 2007

X HSS Annexure

- 9

Manual For Logistics

X HSS Annexure

– 10

PC – 1 Report

X HSS Annexure

– 11

R10_CCM_PKS_MHSS_PF_s4B5B_27Sep10_En.doc 1/21

4B. CROSS-CUTTING HSS – PROGRAM DESCRIPTION

4B.1Description of cross-cutting HSS intervention

If including more than one intervention, copy this table (4B.1) - up to a maximum of five times - directly below, just before the following question (4B.2)

Title: Intervention1 Establishing an Integrated Supplies, Logistics and Management system at the district level to improve continuity and access to essential supplies and commodities.

Beneficiary Diseases: E.g. HIV,

tuberculosis, and malaria

All of HIV, TB and Malaria – as well as other main communicable and non-communicable diseases and primary health care services

Identify the HSS SDA from the HSS Performance Framework

A functional SLM system for providing equitable and continuous access to essential drugs, supplies and commodities leading to improved utilization of health services.

(a) Description of rationale for and linkages to improved/increased outcomes in respect of HIV, tuberculosis and/or malaria

List the overall objective of HSS support, what specific interventions and/or activities will be undertaken during the program term to achieve these outcomes, and which Principal Recipients will be responsible for overall implementation and achievement of outcomes and impact

General Introduction

This is a cross-cutting Health System strengthening proposal that focuses on developing a comprehensive Supplies, Logistics and Management system at the provincial and district levels to improve the efficiency, access to and continuity of essential drugs, supplies and commodities. This proposal seeks to address the identified gaps in the broader context of improving utilization of health care services in the public sector by those most in need and enabling efficient utilization of limited resources by the various health programs of the Ministry of Health to achieve results. The four interventions of Objective 1 are:

SDA 1.1: Develop an integrated and comprehensive SLM system in 10 selected districts of two provinces Punjab and KPK (Rahim Yar Khan, Multan, Khanewal, Gujrat, MandiBahaudin and Gujranwala in Punjab andSwabi, Buner, Charsada and Mansehra in KPK) that mainly includes all drugs, supplies and commodities of the HIV, TB and Malaria , PHC and FP programs. Implementation activities:

PROPOSAL FORM – ROUND 10

CROSS‐CUTTING HEALTH SYSTEMS STRENGTHENING


to review and streamline existing outdated inventory and distribution systems to integrate the different SLM systems in the vertical programs to become compatible and

linked together with other existing SLM systems in the country (i.e DELIVER through USAID, National TB Programme SLM System through GFATM Round 8)

The districts have beenjointly selected by the Federal Health System Strengthening and Policy Unit (HSSPU) and the Provincial Reform units based on 1) population density, 2) volume of procurements, 3) functionality based on NHPU district health ranking report 2006-7.

SDA 1.2 : Rehabilitation or refurbishment of existing Warehouses (provincial/district level) and distribution modalities (i.e transport vehicles) for improved storage, distribution, forecasting, availability of supplies from provincial to district and subsequently to facility level. Implementation activities:

The provincial health reform units will conduct a detailed feasibility and needs assessment of the existing warehouse facilities.

Based on this review, plans will be developed to modify existing warehouse layout to achieve standardized warehouse/storage conditions and to maximize efficiency and minimize travel time to facilities. We envision that this will lead to enhanced efficiency and increased utilization of public sector facilities which have suffered extensively due to frequent stock outs of essential medicines and supplies.


SDA 1.3: Training and enhancing “specialized skills” and capacity of staff for SLM, warehousing, distribution, and forecasting. Implementation activities:

This would entail recruitment (and where present training of existing staff)of dedicated staff along with on-going capacity building.HR hired for this purpose i.e. SLM district coordinators would be locally based in the EDO offices to enhance local ownership and sustainability.

It is envisioned that standard operating procedures will be put into practice that emphasize improved staff productivity through practical hands on training modules.

SDA1.4: Establish and/or operationalize linkages with existing DHIS and other national level supply management information systems (i.e. DELIVER/USAID, TB program Round 8 GF grant) for enhanced and coordinated information sharing to reduce resource wastage, duplication and stock outs. Implementation activities:

A series of consultations will be held in the initial design phase of SLM system with DHIS, Deliver project, relevant stakeholders at the provincial and district levels to devise means of creating these critical linkages. Significant work has already been undertaken by the National TB program through Round 8 Global Fund grant (only for TB drugs) and by the Deliver project (only for contraceptives). This proposal will build upon the work already underway and ensure that there is compatibility between these different systems. For example, at the district level the EDO will be able to review the overall stock positions (in real time) of different drugs, supplies, and commodities at various health care facilities (BHU, RHC, etc) in the district and if necessary be able to move supplies between facilities.

Test out compatibility and flexibility of the designed SLM system for expansion to include additional programs (example, EPI, MNCH etc) in the future

Background and Rationale for HSS Proposal Objective 1:

Gap 1: Currently the SLM and information systems in the country are all fragmented with many issues of reliability, duplication of supplies, commodities, drugs, staffing and costs, capacity issues, and lack of clarity the overall role of SLM in improving health outcomes. For example, many of the MOH vertical programs- HIV, TB, Malaria, MNCH, Lady Health Worker program- while having their own varying categories/levels of supply management and logistic systems are still unable to accurately track utilization at the end user level, lack appropriate warehousing or storage capacity, forecast needs, prevent stock outs or expirations, standardize costs and quality of procurements through electronic transparency mechanisms, maximize on economies of scale, and reduce pilferage and wastage. Furthermore, these “stand alone” supply management, information and logistics systems are costly and

Suppliers Donor Agencies

MoH/ DoH

Ministry of Health

Provincial Warehouse

District/ EDO Storage

Delivery Level


often do not feed into the national/provincial information systems (i.e DHIS) with the resulting absence of a reliable “overall picture” that can be monitored or validated through other independent information sources (for example, matching input to outputs through population based surveys looking at utilization). The dearth of trained HR to skillfully manage this process has led over the years to an increasingly weakened system that fails to meet international standards or deliver much needed results. Even within the national DHIS, SLM has been routinely neglected and is only now becoming recognized as a crucial element for successful health care utilization outcomes. It is envisioned that through this HSS proposal, Ministry of Health will be able to demonstrate in the selected districts the immense benefits of a well functioning SLM system. The MOH hopes then to scale up this successful model to other districts in Pakistan.

The draft National Health Policy 2010 (waiting final approval of the Cabinet) as part of its objectives aims at ensuring access to essential medicines and other health products by developing efficient SLM systems at the Provincial, District and Facility levels. The first step in addressing these gaps was taken by development of the Essential Health Service Package by the MOH/DOHs. Success of the EHSP depends on access and availability of drugs, supplies, and commodities including trained human resource to manage and provide services.

Cost Benefit: According to a Warehouse and LMIS feasibility assessment if wastage (i. e expiration, pilferage,) due to poor storage conditions at the MSD Lahore and district level storage facility is considered at 2.5%, the total loss to the Government Exchequer per annum is in the excess of US$ 500,000 in Punjab alone. Please note that these are very conservative estimates due to limited data availability, By harmonizing the SLM with resulting efficiencies in procurement the proposal will enable the Government programs to capitalize upon economies of scale and obtain the lowest possible prices. Benefits to HIV, TB and Malaria Programs The benefits to the programs will primarily be in the form of an established and effective system of supplies/commodities from the central to the end level health care facilities i.e. public sector first level facilities. This will increase public confidence through continuous availability of required supplies and likely translate into increased utilization of preventive and curative health care services. The ultimate benefits will lead to decreasing the high out-of-pocket payments that further aggravates household poverty and leads to under-utilization of public sector services. The three disease programs will ideally be able to share resources and avoid duplication. These activities aim to reduce the demand side constraints on utilization of public health services, thereby increasing case detection rates of all three diseases, improving utilization of antenatal services which promotes safe pregnancy and in turn increasing referrals for HIV testing if necessary and through early detection and treatment of TB and malaria.

Secondary Recipients

Implementation at District and Provincial levels will be handled through the Health System Policy unit Provincial Health Reform Units and District level EDO offices. The Principal Recipients (Health Services Academy and Health Net) will closely coordinate with the Health System and Policy Unit.

Primary Recipient

The PR responsibility will be managed jointly by the Health Service Academy and Health Net.

(b) Using a very short sentence, indicate below the planned outputs/outcomes/impact that will be achieved on an annual basis from support for this cross-cutting HSS intervention during the proposal term.

Year 1 Year 2 Year 3 Year 4 Year 5

Comprehensive strategic plan, forecasting and

100% 100% 100% 100%


tracking system (100%)

Training and recruitment of staff for SLM

Finalize plans for warehouses (in the post-NFC award scenario

50% 50% 100% 100%

Refurbishment of Warehouses and delineation of distribution mechanisms

50% 50% 100% 100%

Linkages with DHIS and other functioning SLM systems

25% 25% 50% 100%

Scale up dialogue and plans for other remaining districts with GoP/MOH

100% 100%

(c) Describe below other current and planned support for this action over the proposal term

In the left hand column below, please identify the name of other providers of HSS strategic action support. In the other columns, please provide information on the type of outputs

Name of supporting stakeholder

Timeframe of support for HSS action

Start date to end date

Amount of financial support provided over

proposal term same currency indicated

as part of the Proposal Form

Expected outcomes/impact from

this support

Federal Government 2009-2013 Poverty Reduction Support II

(budget support 20% of US$120 million for health)

Multi-sectoral support countrywide

KP Provincial Government

WB funding to the KP Government Technical cooperation

(5% of US$ 6.8 million for health)

Health reform process and units

Institutionalization of the reform process

Punjab Provincial Government

ADB (2005-2010)

DFID (2005-2010)

US$ 30 million for budgetary support and US$ 20 million for TA

65% of GBP 30 million for health

Defining Standards of care

Institutionalization of the process


Other Global Fund Grants (with HSS elements (if applicable)

None

GAVI HSS 2007-2012

US $ 23 million

Health Systems and Policy Unit institutionalized

District health management strengthening in 129 Districts

Other:

USAID DELIVER

USAID HealthServices Academy

USAID support for MNCH,EPI and LHW

2009 - 2011

2009 – 2013

2010-2015

$8m

$ 3.1 million

$ 52 million

Logistics management information systems for contraceptives and essential drugs

Training in health systems management and planning

Supporting the activities of the three programmes

Other:

One UN Plan

2009-2010 US$400,000

System for maintenance in health developed and piloted

Training for users of health technologies


4B.1 Description of cross-cutting HSS intervention

If including more than one intervention, copy this table (4B.1) - up to a maximum of five times - directly below, just before the following question (4B.2)

Title: Intervention 2 Strengthening Human Resource Management in the Health Sector – as one element within the framework of the newly developed National Health Policy and its key component the Essential Services Package (EHSP)

Beneficiary Diseases: E.g. HIV,

tuberculosis, and malaria

All of HIV, TB and Malaria – as well as other main communicable and non-communicable diseases and primary health care services

Identify the HSS SDA from the HSS Performance Framework

Mapping the existing HR situation and planning future HR requirements including trainings, career structure, and distribution for a skills-based health workforce

(a) Description of rationale for and linkages to improved/increased outcomes in respect of HIV, tuberculosis and/or malaria

List the overall objective of HSS support, what specific interventions and/or activities will be undertaken during the program term to achieve these outcomes, and which Principal Recipients will be responsible for overall implementation and achievement of outcomes and impact

Gap 2: Although there is a growing interest in human resource for health development, there is only partial realization and/or development of the HRH strategy and plans in the MOH or DOHs. The imbalances in workforce in terms of cadre, gender and distribution are further compounded by investment of scarce resources in the establishment of medical colleges rather than investing in improving the quality and quantity of nursing institutions, public health schools, and technicians training institutions. Some preliminary initiatives by the MOH (i.e CMW trainings, nursing schools etc) are addressing the identified shortcomings in human resources including scarcity of nurses, midwives, skilled birth attendants, dentists, and pharmacists. However, future scenarios and cost implications for addressing the misdistribution of health workforce and imbalances in skills mix across the country have yet to be developed. Pre-service training of health professionals continues to follow traditional hospital based care with little or no incentives to address the needs of the communities for promotive, preventive and rehabilitative services. The regulatory mechanisms are weak (for licensing) or non-existent (accreditation), and there is a lack of organized continuous professional development (CPD) for all cadres of the health workforce.

A significant progress has been made in the draft National Health Policy 2010 which has defined clear strategies for human resource development according to the long term stated health development vision for Pakistan and to the more pressing requirements of improving health service delivery in the country. These strategies include: • Mapping of both public and private sector health care providers and institutions through national human resources for health (HRH) observatory, that brings together all stakeholders involved in human resource development. • Develop a new function of strategic planning in human resource development at federal and provincial levels to include strengthening the role of regulatory bodies. • Establish a critical cadre/expertise at the Federal MOH and provincial DOH of health system specialists such as health and human resource planners, health economists, health information experts and health system managers. • Review the impact of the HRH observatory on performance of the two provinces and the selected districts within these provinces. Indicators of interest will be 1) better distribution and utilization of


trained human resources, 2) improved staff retention. • The Health Services Academy (PR 1) will strengthen partner institutions to include institutes of public health, academia, CSOs, and other professional institutions.

Human Resources Management in the Health Sector

The draft National Health Policy 2010 highlights the persistent human resource (HR) constraints which have hampered public health programs in Pakistan over the past 3 decades. The NHP aims at developing a comprehensive human resource strategy, based on an objective assessment of needs. The NHP further envisions the enactment of a health workforce law that will ideally encompass all health care providers, define career structures, institutionalize service promotion and recruitment rules, and review existing cadres to avoid duplication. The ultimate objective remains to promote multiple skilled workers that can better deliver services where the needs remain greatest.

This new approach will provide a unifying platform to include all stakeholders and shift the focus from existing practices which tend to be centered on vertical programs and hence may not address the larger perspective of national goals.

In order to implement the HR policy actions proposed in the NHP, a multi-track approach is envisaged, spanning the wide range of institutions and bodies (within the public and private sector). This aims to involve relevant tiers of Government. This will include Planning Commissions, the Ministry of Health (or Provincial Departments of Health), as well as such as the Professional Councils and Associations. Amongst international development partners, the UN Agencies (through the “One UN Plan”), and bilateral agencies such as DFID, and USAID, have committed their support to HR as a priority area within their spheres of support. The PR has selected by the Global Health Workforce Alliance to build HR capacity in Pakistan and the Region. Efforts are already underway at the Provincial level to address some of these issues. Examples in Punjab include updating job descriptions for allied health professionals to bring them in line with the recently modified service delivery standards. Similarly in KPK, a Provincial HR strategy has been developed and awaits implementation Addressing HR Through Round 10 HSS Proposal Objective2: Identify the HR management needs to improve the performance of priority health programs particularly for HIV/AIDS, TB and Malaria through the following inputs:

SDA 2.1 : Detailed mapping study of the public and private sector to review existing HR availability, gaps, distribution imbalances, and develop a Strategic HRH Plan based on the findings. Expertise to this effect exist in-country through International NGOs that have undertaken this type of mapping for USAID and other partners. The PR 2 will solicit technical proposals to carry out this task.

SDA 2.2: Formation of HRH observatories/databases for selected districts (10-15 districts) to improve HRH management capacity at the district level. The proposed observatories will have the capacity to be flexible and to provide up to date real time data. PR1 will lead this process.

SDA 2.3: Leadership Trainings of district managers from the selected districts based on standardized global techniques aimed at enhancing leadership capacity. These leadership trainings have been conducted by the Population Council in targeted districts with the capacity to adapt this as required.

SDA 2.4: Operational/Action Research to pilot initiatives for HR recruitment, retention, and improved performance. It remains vital to recognize that within the Pakistan devolution context outcomes will only be effective provided that appropriate interventions take place at the District level which remains the focus of implementation. This will involve inputs and participation from District health management with a focus on enhanced supervision and consolidating job descriptions. Over a longer span of time this ensures that appropriate human resource development needs are being met that focus on both technical skills and administrative capabilities. Three operational research studies are planned: 1) assessment of the impact of SLM and HR trainings on enhanced district level management, 2) pilot the impact of career structure on staff retention, and 3) role and impact of


supply side incentives on increasing worker productivity at different levels. In short the operation research will look at different approaches to maximize the human resource potential.

Benefits to the HIV/AIDS, TB and Malaria programs

Performances of national programs in the health sector have and remain sub-optimal despite significant GoP and donor financial investments. . The HIV, TB and Malaria programs have all been affected with shortage of trained HR, low productivity or their misdistribution. By having specialized observatories and greater availability of trained human resource, district managers will be in a better position to ensure program effectiveness and outcomes.

Primary Recipient

The HSA and HealthNet will serve as the Primary Recipients (PRs) for the HSS component.

Secondary Recipients

The SR will be the Health System Strengthening Policy Unit and will work closely with Provincial health reform units.

(b) Using a very short sentence, indicate below the planned outputs/outcomes/impact that will be achieved on an annual basis from support for this cross-cutting HSS intervention during the proposal term.

Year 1 Year 2 Year 3 Year 4 Year 5

Detailed mapping study of HRH situation and future needs100%

Develop a costed HRH Strategic Plan

Formation of HRH observatories

50% 50% 100% 100%

Leadership trainings of district managers

50% 50% 100% 100%

Operational research (pilots) 1 study 1 study 1 study

Scale up dialogue and plans for other remaining districts with GoP/MOHLessons Learned

50% 100%

(c) Describe below other current and planned support for this action over the proposal term

In the left hand column below, please identify the name of other providers of HSS strategic action support. Ihe other columns, please provide information on the type of outputs


Name of supporting stakeholder

Timeframe of support for HSS action

Start date to end date

Amount of financial support provided over

proposal term same currency indicated

as part of the Proposal Form

Expected outcomes/impact from

this support

GAVI HSS 2007-2012 US$ 23 million

Health Systems and Policy Unit

institutionalized

Limited District health management

strengthening in 129 Districts

Other:

DFID : Maternal and Neonatal Health

Programme (MNH)

DFID : Health Sector Support Programme

(currently being designed)

2008-2012

2009 – 2013

GBP 69 million

GBP 21 million (Technical cooperation)

TBD – may combine “budget support” and TA

HR issues addressed in relation to MNCH

HSS in general, and HR in particular,

emphasized and increased allocations

within context of annual federal health

budget. Possible support for “HR for

Health policy development” (through provision of technical

assistance and associated sector budget support)

Other:

USAID PAIMAN

2005-2010

$10m

(restricted) District health management strengthening in 25 districts, various capacity building

activities

USAID activities will continue to work in 25 priority districts, with

DHMT in capacity building efforts

Training in health systems management

and planning


Other : Global Health Workforce

Alliance US$200,000

HR Observatory

HR Case studies

HR issues reviewed in key programmes (eg

LHWs, CHWs, Community midwives)

4B.2 Engagement of HSS Key Stakeholders in Proposal Development

(a) Briefly describe which important HSS stakeholders (e.g. ministries of planning, finance etc, non-government sectors) have been involved in the identification and development of appropriate cross-cuttingHSS interventions for this Round 10 proposal. Explain why these stakeholders were selected and how they are the most relevant to a comprehensive assessment of health system weaknesses and responses in the particular country context?

The HSS proposal was developed following extensive consultation and involvement of the stakeholder This included:

a) Adherence to all GFATM processes led by the Pakistan CCM. Minutes of meetings are attached.

b) Efforts were made to build upon the extensive work undertaken in the preparation of 9 but using a more targeted approach in Round 10.

c) Create critical linkages with existing and potential Government and partner support and mechanisms to ensure appropriate implementation of the Round 10 HSS proposal.

d) Consultant support was provided at the request of the CCM.

e) Special efforts were made to address gaps in identified in the draft National Health Policy 2010.It has been ensured that defined priorities in the proposal are an integral component of the recently NHP 2010 without duplication of funding sources. In addition there has been an integration of the activities that form part of the health sector reform initiatives that are currently being developed in the Provinces of KPK and Punjab

Formal CCM Processes

CCM Pakistan as part of the GFATM process is a well-established and functional body with representation from bilateral partners and National and Provincial Governments. It calls on the participation of National Managers of the related programs for appropriate discussions and to seek consensus on proposed strategies as required. This process was followed in developing the Round 10 application through an initial CCM sub-committee meeting held in June 2010. The process was chaired by the Secretary Health, MOH and included participation by the Director General Health.

At the request of the CCM and with the approval of the CCM core-committee a consultant was hired to support the proposal development process through:

Reviewing appropriate national and provincial strategies and the HSS gaps.

Consensus building in the Provinces of Punjab and KPK. This was met through provincial level meetings with relevant MOH, Planning and Finance staff.

The CCM and partners were kept informed of the process of development through formal and informal communications and meetings.

Draft proposals were presented initially to the HSS core committee and then to the CCM. At all stages CCM endorsement was obtained on the technical merits and needs of this HSS proposal.


A further presentation of the HSS proposal was then made to the MOH – 2nd June, 2010.The CCM agreed that the proposal be narrowed to address the following:

a. To develop an integrated and comprehensive supply management and logistic system to include HIV, TB, Malaria and the PHC&FP programmes in selected districts of KP and Punjab.

b. To develop Human Resources for Health

The focus during the development of the proposal has been to ensure that duplication of resources is avoided and there is minimal or r no overlap from bilateral partner support.

A final CCM was held on August 13 to endorse the application. This was attended by CCM partners, the PR (Health Services Academy) and MOH officials. The meeting endorsed the application.

Selection of PR

The HSA and Health Net we reaffirmed as the PRs through a CCM sub-committee meeting on 10th August, 2010.Additionally the HSS proposal was endorsed by the CCM on August 17th 2010along with the Malaria program proposal.

Selection of SRs

The choice of SRs for the HSS submission was discussed in August 13 2010 after a preliminary evaluation. At that stage, the Health System Strengthening and Policy Unit was selected as the SR. The CCM sub-committee agreed to defer the further selection of the additional SRs until the post flood emergency situation had settled down and more clarity was available on the National Finance Commission awards.

Other HSS Dialogue

The CCM will continue dialogue with and oversight of partners to ensure that a viable process is developed in the run up to approval or request for clarification from the Global Fund TRP.

(b) Has the applicant ensured that:

(i) the cross-cutting HSS interventions in the proposal do not repeat any request for funding under any of the specific disease components (section 4.4.1of each disease)? And

x Yes

(ii) the detailed workplan and a Performance Framework for this disease including separate worksheets that clearly identify the cross-cutting HSS interventions by objective, SDA, and activity for the initial two years of the proposal?

x Yes


4B.3 Strategy to mitigate initial unintended consequences

If there are some perceived initial disruptive consequences of the planned investment in any or all of the cross-cutting HSS interventions set out in section 4B.1 above:

(a) What were the factors considered when deciding to proceed with the request for the financial support in any event?

(b) What is the applicant’s proposed strategy for mitigating these potential disruptive consequences?

A major factor that under the present circumstance is bound to be a factor of concern is the aftermath of the flood situation which has affected almost all major parts of the country. This has led to large scale destruction of the existing health facilities which will require refurbishment and reconstruction. While it is at this stage difficult to predict the overall effects but this will evolve in the coming 6-12 months. The inadequacies within the logistics management systems currently may benefit some vested interests and by shifting the way of business may be a cause of concern and possible hindrance which will need to be skillfully overcome.

HRH is a dynamic process and the concept of static observatories will require a fair degree of flexibility and change which will make the task challenging, but given the Provincial buy-in will be implementable.

This will be further challenged by the scenario created by the post-NFC award which as part of the 18th Amendment gives the onus of responsibility of health care to Provincial Governments. While this process is on-going there still exists some lack of clarity on the exact mechanisms. A draft assessment of the post NFC scenario has recently been completed and this does however enhance Provincial requirements in terms of HR needs which is a major focus of this proposal.


Read the Round 10 Guidelines to consider including

optional cross-cutting HSS interventions






Read the Round 10 Guidelines to consider including

optional cross-cutting HSS interventions





CROSS‐CUTTING HEALT SYSTEMS TRENGTHENING

INTERVENTIONS


Clarified Table 5B.3 and sections 5B.4.1 to 5B.4.3

SECTION 5B: –CROSS-CUTTING HSS INTERVENTIONS

Section 5B may only be included in one disease and under the following conditions:

the proposal identifies gaps and constraints in the health system that have an impact on HIV, tuberculosis and malaria outcomes;

the interventions required to respond to these gaps and constraints are cross-cutting and benefit more than one of the three diseases;

an accompanying Section 4B is included in same disease proposal; and the applicant has not included Section 4B or Section 5B in any other disease in the

Round 10 proposal

Copy sections 5B.1 to 5B.4 starting on the second page below into the Round 10 proposal form after Section 5.5 in the same disease proposal as the applicant included Section 4B (once only, in one disease only)

5B.1 Detailed Budget

Steps in budget completion:


CROSS‐CUTTING HEALTH SYSTEMS

STRENGTHENING INTERVENTIONS


CROSS‐CUTTING HEALTH SYSTEMS

STRENGTHENING INTERVENTIONS


1. submit a detailed budget of the cross-cutting HSS interventions in Microsoft Excel format using the same numbering for budget line items as in the description of cross-cutting HSS interventions in section 4B.1. The cross-cutting HSS interventions may be prepared either as a separate Excel worksheet of the disease budget, or as separate file in Microsoft Excel.

For guidance on details required (or to use a template if there is no existing in-country detailed budgeting framework) refer to the detailed budget guidance in section 5.1 of the Round 10 Guidelines

2. from that detailed budget, prepare a Summary by Objective and Service Delivery Area (section 5B.2).

It is important to note that SDAs for the purpose of cross-cutting HSS interventions are not the same as the SDAs for the disease section - refer to Section 5B.2 of the Round 10 Guidelines for more information

3. from the same detailed budget as in Step 2, prepare a Summary by Cost Category (section 5B.3); and

4. ensure the detailed budget is consistent in the numbering of objectives, SDAs, activities with the detailed work plan for cross-cutting HSS interventions, and the Performance Framework for cross-cutting HSS interventions.


5B.2 Summary of detailed budget for cross-cutting HSS interventions by objective and service delivery area

Budget breakdown by SDA

Objective Number

Service delivery area Year 1 Year 2 Year 3 Year 4 Year 5 Total

1 Develop an integrated and comprehensive SLM system 200,000 0 0 0 0 200,000

1 Detailed mapping study of the public and private sector 6,050,000 0 0 0 0 6,050,000

1 Rehabilitation or refurbishment of existing Warehouses 312,000 1,582,000 312,000 312,000 312,000 2,830,000

1 Formation of HRH observatories /databases for selected districts 12,500 152,600 57,600 57,600 57,600 337,900

1 Training and enhancing capacity of staff for SLM 702,200 292,800 292,800 292,800 292,800 1,873,400

1 Leadership Trainings of district managers from the selected districts 0 3,000,000 0 0 0 3,000,000

1 Establish and/or operationalize linkages with existing DHIS 300,000 750,000 0 0 0 1,050,000

1 Operational/Action Research to pilot initiatives for HR recruitment,

retention, and improved performance 0 0 500,000 100,000 200,000 800,000

1 HSS: Information system 0 18,000 18,000 18,000 868,000 922,000

1 HSS: Monitoring & Evaluations 480,000 480,000 480,000 480,000 480,000 2,400,000

1 Human Resource 325,320 325,320 325,320 325,320 325,320 1,626,600

1 Over Heads 121,000 96,000 96,000 96,000 96,000 505,000


Budget breakdown by SDA

Objective Number

Service delivery area Year 1 Year 2 Year 3 Year 4 Year 5 Total

use ‘Add Extra Row Below’ from ‘Table’ menu in Microsoft Word menu bar to add as many additional rows as required to ensure consistent with the Performance Framework

Total funds requested from Global Fund for cross-cutting HSS interventions

8,503,020 6,696,720 2,081,720 1,681,720 2,631,720 21,594,90

0


5B.3 Summary of detailed budget by cost category – Clarified: amounts for Health products and health equipment, Pharmaceutical products (medicines), Living Support to Clients/Target Populations, Planning and administration and Other.

Summary information provided in the table below should be supplemented with additional detail in section 5B.4 below

. Breakdown by cost category (same currency as selected by Applicant on face sheet of the Proposal Form)


Human resources 325,320 325,320 325,320 325,320 325,320 1,626,600

Technical and Management Assistance 6,131,000 4,866,00 761,600 261,600 1,311,600 8,952,400

Training 995,000 3,680,000 0 100,000 0 4,775,000

Health products and health equipment 0 0 0 0 0 0

Pharmaceutical products (medicines) 0 0 0 0 0 0

Procurement and supply management costs 109,700 598,800 88,800 88,800 88,800 974,900

Infrastructure and other equipment 0 700,000 0 0 0 700,000

Communication Materials 29,000 0 0 0 0 29,000

Monitoring & Evaluation 480,000 498,000 498,000 498,000 498,000 2,472,000

Living Support to Clients/Target Populations 0 0 0 0 0 0

Planning and administration 0 0 0 0 0 0

Overheads 433,000 408,000 408,000 408,000 408,000 2,065,000


. Breakdown by cost category (same currency as selected by Applicant on face sheet of the Proposal Form)


Other: avoid using the "other" category unless necessary – read the Round 9 Guidelines

0 0 0 0 0 0

Total funds requested from Global Fund for cross-cutting HSS interventions (Section 4B.1)

8,503,020

6,696,720

2,081,720

1,681,720

2,631,720

21,594,200


5B.4.1 Variations in costs – section initially not completed

Briefly explain any significant variations in cost categories by year, or significant five year totals for those categories.

Year 1: Total cost is higher than the other years because in this year contracts with the implementing partners require to be done. Purchase of office equipment and renovation of office are also required to be completed in year1. These activities cause the budget increase in year 1.

Year 2: In year 2 purchases of 26 vehicles and refurbishment of 12 warehouses are required to be done. Training of managers on leadership and

consultative meetings are also required to be conducted in year 2. These activities bear heavy budget, therefore budget of year 2 is high.

5B.4.2 Human resources – section initially not completed In cases where human resources represents an important share of the budget, summarize: (i) the basis for the budget calculation over the initial two years; (ii) to what extent human resources spending will strengthen health systems’ capacity at the client/target population level. Useful information to support the assumptions to be set out in the detailed budget may include: i) a list of the proposed positions that is consistent with assumptions on hours, salary etc included in the detailed budget; and, ii) the percentage of time that will be allocated to the work under this proposal


Human resource has not a great share in this budget, only need basis positions are budgeted.

5B.4.3 Other large expenditure items – section initially not completed

If other ‘cost categories’ represent important amounts in the summary in table 5B.4, (i) explain the basis for the budget calculation of those amounts. Also explain how this contribution is important to implementation of the national disease program.


No amount under this head is budgeted

ING

1

value Year Source Year 1Report due

dateYear 2

Report due date

Year 3 Year 4 Year 5

1 4.8 2009

Surveillance systems: Routine

MIS (Malaria Information

Systems) for 38 districts

6.00 Feb-13 10.00 Feb-14 15% decrease 50% decrease75%

decrease

value Year Source Year 1Report due

dateYear 2

Report due date

Year 3 Year 4 Year 5

1 13.13% 2009

Pakistan, Malaria, Round 7

Malariometric Survey Report

60%

2 15.9% 2006-07

Pakistan Demographic and

Health Survey, 2006-07

60%

Proposal ID:

Baseline

Reduction of malaria burden by 75% in 38 highly endemic districts

% of pregnant women with confirmed malaria who received anti-malarial treatment at health facilities in 38 highly endemic districts

The baselines is based on the following information from the Malariometric Survey, 2009 conducted in 19 districts:1. Place of treatment for those personswho suffered from fever (% government health facility): -50.5% (Table - 8 , page 59)2. PHC facilities fully equipped with trained staff for performing malaria microscopy:-26% (Table -24, page 36). see Pak Mal GF R10-PF Ref 2 .Similar survey (activity # 3.2.1.1) is planned to be conducted in 38 districts in year 4, and the information would be available by year 5. Numerator: # of uncomplicated malaria cases correctly managed at health facilities in 38 highly endemic districts Denominator: # of uncomplicated malaria cases confirmed in 38 highly endemic districts through strengthened diagnostic measures.

Outcome indicator formulation

As stated above, currently sex/pregnancy dissegregated data is not available in the malariometric survey. The baseline figure qouted is from the PDHS 2006-07 (table 12.5, page 151, see Pak Mal GF R10-PF Ref 3 ) and is based on the question put to the mother who had a live birth in five years preceding the survey and if she had malaria (reported, clinical) during pregnancy and was treated for malaria. However, the survey (activity # 3.2.1.1) will be providing the segregated data in year 5.Numerator: # of pregnant women with confirmed malaria who received anti-malarial treatment at health facilities in 38 highly endemic districts.Denominator: # of pregnant women with confirmed malaria in 38 highly endemic districts.

Goals:

Targets

API (Annual Parasite Index) of targeted population in 38 highly endemic districts

Impact indicator number

Outcome indicator number

Impact indicator formulationBaseline

Comments*

MalariaProgram Details

The baseline is calculated on the basis of data reported from Round 7 targeted districts and the 19 new districts being targetted for Round 10 using Malaria Information System 2009 report.( see Pak Mal GF R10-PF Ref 1)Indicator will be estimated using data from the malaria information system (DMC). The target is expressed as the decrease from the highest peak value. It is anticipated that use of RDT's and strengthened microscopy centers will result in increased case detection in years 1 and 2 in the new 19 districts, while the decrease will continue in the 19 districts covered by Round 7. Once all LLINs, IRS, improved case management and BCC are inplace and are being widely used, case detection will decrease rapidly, probably in year 3. The year 5 target is expressed in consistency with MDG 6. Experiences from Round 7 are being applied.

% of uncomplicated malaria cases correctly managed at health facilities in 38 highly endemic districts

Country:

Targets

Program Goals, impact and outcome indicators

Pakistan

Expanding Coverage of Malaria Control Interventions in 38 Highly Endemic Districts of Pakistan

Disease: Malaria

Comments*

PROPOSAL FORM – ROUND 10SINGLE AND MULTI-COUNTRY APPLICANT

Performance Framework: Indicators, Targets and Periods Covered

R10_CCM_PKS_M_PerfFW_27Sep10_En.xls Performance Framework 1/4

3 4.3% 2009



80%

4 approx. 4% 2009

WHO World Malaria Report - Country Profiles

2009 (http://www.who.int/malaria/publication

s/country-profiles/2009/en/in

dex.html)

80%

Objective Number

1234

Value Year Source 6 months 12 months 18 months 24 months Year 3 Year 4 Year 5

1 1 and 2

HSS: Medical Products, Diagnostic Materials and Technology

Number of upgraded and functioning infrastructures including microscopy and RDTcenters in 19 new districts and LLIN stores in 38 target districts 212 2010

Pakistan, Malaria, Round 7, P-6

Report232 547 804 804 804 804 804 GF Y - over program term Y Not Top 10

DMC & Save the Children

Baseline from Progress Update Report P6 for GF Round 7 Malaria, see Pak Mal GF R10-PF Ref 6 .Save the Children will upgrade 551 microscopy and RDT centers (Objective 1)DMC and Save the Children will upgrade 41 stores for LLINs (Objective 2)Data will be collected on a quarterly basis from set program reporting formats.

2 1

Diagnosis Number of RDTs used at FLCFs in 38 target districts and private clinics (in 10 selected districts).

364,965 2010Pakistan, Malaria,

Round 7, P-6 Report

364,965 614,965 964,965 1,364,965 2,114,965 2,964,965 3,864,965 GF Y - over program term Y Not Top 10 Save the Children

It is estimated that about 1,500-2,000 RDTs will be required/outlet/year; considering that about 22.1% people may have fever in a year and 90% would seek management support either at RDT outlets or microscopy centers. (Malariometric Survey-2009: Tables 7&8; pages 20-21) see Pak Mal GF R10-PF Ref 7 . Data on these people being reached with supportive diagnostic tools will be collected on a quarterly basis from set program reporting formats.

3 1

Diagnosis % of RDT-based diagnoses meeting all standard WHO guidelines/criteria (Performance of RDT technicians assessed by using WHO checklist through existing monitoring and supervision visits per year)

Not available

NA NA - 60% 60% 70% 70% 80% 80% GF N - not cumulative NTop 10

equivalentDMC & Save the

Children

Information would be generated yearly through compiling the findings obtained through monitoring and supervision visits by PRs & SRs using the WHO standard checklist, "RDT Center Monitoring Checklist" (see Pak Mal GF R10-PF Ref 8 ).Numerator: # of technitions/tests meeting all standardsDenominatot: # of technitions interviewed or tests observed

Comments Service Delivery

AreaIndicator formulation

Baseline (if applicable)

Targets cumulativeY-over program term

Y-cumulative annuallyN-not cumulative

DTF: Name of PR responsible for

implementation of the corresponding

activity

To scale up multiple prevention interventions especially LLINs and IRS to the level of universal coverage in target population.

Program Objectives, Service Delivery Areas and Indicators

Based on the reference, page 32, Table # 20, overall the % of households having ITN was 4.3% (see Pak Mal GF R10-PF Ref 4 ).It is targeted that similar survey (activity # 3.2.1.1) will be performed measuring LLIN use among the targeted rural households in the 38 districts. Numerator: # of rural households surveyed with at least one LLIN in 38 highly endemic districtsDenominator: # of rural households surveyed in the 38 highly endemic districts.The outcome target will be to achieve 80% coverage of the targetted 85% of half of rural population in 38 highly endemic districts.

Baseline Reference: Pakistan Chapter, Section III: Implementing malaria control, P/137 , WHO World Malaria Report 2009, Country Profiles (see Pak Mal GF R10-PF Ref 5 ). This data is not seggregated by urban & rural coverage and also does not reflect the WHO recommended two rounds of IRS per year for effective IRS coverage.It is targeted that 80% households of the remaining 15% of targetted 50% of rural households not covered by LLINs will be covered by IRS through the Round 10 grant (7 persons per household). Numerator: # of rural households protected by IRS in 38 highly endemic districtsDenominator: # of total targetted rural households in 38 highly endemic districts (173,000 households).The indicator will be measured through the survey (activity # 3.2.1.1) in year 5. The outcome target will be to achieve 80% coverage of the targetted 15% of half of rural population in 38 highly endemic districts.

* please specify source of measurement for indicator in case different to baseline source.

% of rural households with at least one LLIN in 38 highly endemic districts

% of rural households protected by IRS in 38 highly endemic districts

Top 10 indicator

To enhance the access of population at risk to quality assured early diagnosis and prompt treatment services.

Objective Number

Baselines included in

targets (Y/N)

Indicator Number

To improve health seeking behaviours and practices of target communities in highly malaria endemic districts through enhanced community awareness and participation

To enhance technical and program management capacity for improved planning, management and monitoring of malaria control interventions.

Objectives:

Targets for years 1 and 2 Annual targets for years 3, 4, and 5

Tied to


4 1

Prompt, effective anti-malarial treatment

Number of health care providers trained on national case management guidelines in public and private sectors


Round 7, P-6 Report

1,702 1,736 2,787 3,346 3,496 3,646 3,646 GF Y - over program term Y Top 10DMC & Save the

Children

Save the Children will train 209 persons (provincial, and PR staff and private health care providers) on malaria case management.DMC and Save the Children will train 2,011 persons on malaria case management.Data will be collected on a quarterly basis from set program reporting formats.

5 1


Number of lab/RDT confirmed malaria cases correctly treated as per national guidelines


Round 7, P-6 Report

38,769 181,626 381,626 610,198 1,038,769 1,524,483 2,038,769 GF Y - over program term YTop 10


Children

Population of 38 districts: 24.84 million; 65% are rural; 50% of the rural live in high endemic areas; ie. over 8 million. Considering that about 22.1% people may have fever in a year and 90% would seek management support (Malariometric Survey-2009 P/20&21) meaning that about 1.6 million would use management facilities / year and 20%; ie. 320,000 would be diagnosed positive. Thus it would be a total of 1.6 million people diagnosed over 5 years. Applying contextual matters as floods, IDPs, refugees, higher fever cases from highly endemic areas (22.1% represents the total population of the whole district, thus it is diluted) the figure is rounded to 2 million. DMC will be responsible for the 19 districts currently under the Round 7 grant; SCF will be responsible for the new 19 high endemic districts considered under the Round 10 grant. Data will be collected on a quarterly basis from set program reporting formats.

6 1


Number of children under 5 years of age correctly treated as per national guidelines

Not available

NA NA 5,195 24,338 51,138 81,766 139,195 204,281 273,195 GF Y - over program term YTop 10


Children

Proportion of children among general population is 13.4% (PDHS 2006-07, Table 2.1, P/12, see Pak Mal GF R10-PF Ref 9 ); thus the target is 13.4% of total lab/RDT confirmed malaria cases being correctly treated (2,038,769). Segregated reports will provide information for this indicator.Data will be collected on a quarterly basis from set program reporting formats. DMC will be responsible for the 19 districts currently under the Round 7 grant; SCF will be responsible for the new 19 high endemic districts considered under the Round 10 grant.

7 2

Insecticide-treated nets (ITNs-LLINs)

Number of LLINs distributed to the community

396,341 2010Draft WHO World

Malaria Report0 0 915,000 1,830,000 2,290,000 2,750,000 2,750,000 GF Y - over program term N Top 10

DMC & Save the Children

Baseline is not included because these LLINs are distributed to districts other than the 38 target districts as well and district-wise dissegregated data is not available. (see Pak Mal GF R10-PF Ref 10 )Considering over 8 million rural population are living in high endemic areas; 85% will be covered by LLINs @ 2.5 people per LLIN. Data will be collected on a quarterly basis from set program reporting formats. DMC will be responsible for the 19 districts currently under the Round 7 grant; SCF will be responsible for the new 19 high endemic districts considered under the Round 10 grant.

8 2

Malaria prevention among women and children under 5 years

Number of LLINs distributed for women (15 to 49 years) and children under 5 years


Round 7, P-6 Report

616,538 616,538 964,238 1,311,938 1,486,738 1,661,538 1,661,538 GF Y - over program term YTop 10


Children

Proportion of children among general population is 13.4% and that of women of child bearing age (15-49 years) is 24.6% (PDHS 2006-07, Table 2.1, P/12); thus the targets are 38% of total population receiving LLINs (2,750,000), and includes the baseline. Segregated reports will provide information for this indicator. Data will be collected on a quarterly basis from set program reporting formats. DMC will be responsible for the 19 districts currently under the Round 7 grant; SCF will be responsible for the new 19 high endemic districts considered under the Round 10 grant.

9 2

Indoor Residual Spraying

Number of times Selective Insecticide Residual Spraying was applied to the targeted households

Not applicable

NA NA 0 0 1 2 4 6 6 GF Y - over program term NTop 10


Children

Selective IRS will be applied to the targetted households twice per year. Data will be collected on a quarterly basis from set program reporting formats. DMC will be responsible for the 19 districts currently under the Round 7 grant; SCF will be responsible for the new 19 high endemic districts considered under the Round 10 grant.


10 2

HSS: Information system

Number of health personnel trained on malaria data management, M&E and early detection of malaria outbreaks

125 2010Pakistan, Malaria,

Round 7, P-6 Report

125 1,576 1,576 1,576 1,576 1,576 1,576 GF Y - over program term Y Top 10DMC & Save the

Children

Save the Children will train 44 master trainers on malaria data management, M&E & Early Detection of Malaria Outbreaks.DMC and Save the Children will train 1,407 health staff on malaria data management, M&E & Early Detection of Malaria Outbreaks.Data will be collected on a quarterly basis from set program reporting formats.

11 2 and 3

M&E evidence building

Number of reports on surveys and research

1 2009



1 1 1 3 4 6 7 GF Y - over program term Y Not Top 10 Save the Children

Baseline reference see Pak Mal GF R10-PF Ref 11 .Save the Children will conduct:-Under objective 2: two drug efficacy monitoring studies, one insecticide resistance monitoring study-Under objective 3: two operational research studies, one sub-national malaria prevalence survey.

12 3

HSS: Leadership and Goverance

Number of staff trained on malaria programme planning & management and vector control & medical entomology

13 2010

WHO supported International Trainings-

Training records

13 13 37 37 37 61 61 GF Y - over program term Y Top 10 Save the Children

Baseline reference see Pak Mal GF R10-PF Ref 12 .Save the Children will be responsible for international training of 06 staff on programme planning and management and also for national training of 42 staff on vector control and medical entomology.

13 4

BCC - community outreach

Number of people (leaders, health workers, activists, general population, etc.) benefitting from community-based BCC outreach activities


Round 7, P-6 Report

22,261 69,761 117,261 164,761 259,761 354,761 402,261 GF Y - over program term Y Top 10 Save the Children

Save the Children will be responsible for community outreach to 15,200 participants through community based advocacy events and 364,800 participants through community awareness events in the 19 districts under Round 7 grant as well as in the new 19 districts considered under Round 10 grant.
