GLOBAL HEALTH CLUSTER SUPPORT MISSION TO PAKISTAN AUGUST 2009 (FOLLOW UP TO THE INTER-CLUSTER DIAGNOSTIC MISSION OF JULY 2009)

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1 GLOBAL HEALTH CLUSTER SUPPORT MISSION TO PAKISTAN AUGUST 2009 (FOLLOW UP TO THE INTER-CLUSTER DIAGNOSTIC MISSION OF JULY 2009) Table of contents: 1. Acronyms 2. Mission composition 3. Background 4. Highlights 5. Consolidated Report of the two Pakistan Health Cluster Strengthening Workshops: A: Islamabad Workshop: 19 August 2009 B: Peshawar Workshop: 20 August Matrix of GHC Support Mission Action Points 7. Matrix of the Relevance of the Health Cluster Functions against the Pakistan Health Cluster Operational Strategies 1. ACRONYMS AWD: Acute Watery Diarrhoea BHU: Basic Health Unit CD: Civil Dispensary CH: Civil Hospital DCO: District Coordination Officer DEWS: Disease Early Warning System DHQ: District Headquarters DTC: Diarrhoeal Treatment Centre DSM: District Support Manager EDO: Executive District Officer of MoH ERU: Emergency Response Unit FATA: Federally Administered Tribal Areas FP: Family Planning GHC: Global Health Cluster HC/FPA: Health Cluster Focal Point Agency at District level HeRAMS: Health Resources Availability and Mapping System HC: Health Cluster HCC: Health Cluster Coordinator ICCG: Inter Cluster Coordination Group IEHK: Inter-agency Emergency Health Kit IRA: Initial Rapid Assessment LHV: Lady Health Visitor LHW: Lady Health Worker MCHC: Maternal Child and Health Centre MEHK: Mini Emergency Health Kit MMO: Male Medical Officer MMT: Mobile Medical Team MNCH: Maternal, Neonatal and Child Health NADRA: National Database Registration Authority NGOs: Nongovernmental Organizations NWFP: North West Frontier Province ORS: Oral Rehydration Salts ORT: Oral Rehydration Treatment PHD: Provincial Health Department PHRP: Pakistan Humanitarian Response Plan PPHI: People's Primary Healthcare Initiative PWDs: Persons With Disabilities RH: Reproductive Health RHC: Rural Health Centre THQ: Tehsil Headquarters WMO: Woman Medical Officer WPCO WHO Pakistan Country Office WRO: WHO Regional Office 2. MISSION COMPOSITION The Global Health Cluster (GHC) support mission was composed of the following members: Mr Mahmoud Daher, WHO/oPt ; Mr Osama Ali Maher, WHO/EMRO; Dr Nevio Zagaria, WHO/HQ. The mission was conducted at the request of the WHO Pakistan Country Office (WPCO), which is the Health Cluster (HC) lead in Pakistan. Considering the burning health sector issues identified by the inter-cluster diagnostic mission of July 2009, the WPCO asked that the GHC support mission take place before the end of August Several GHC members who were invited to participate (IRC, SC-UK, SC-US, Merlin) were not able to attend due to the very short notice. Nevertheless, all GHC members will be fully briefed on the outcome of the mission and will be actively involved in any follow-up action taken by the GHC in support of the HC in Pakistan. 3. BACKGROUND In July 2009, representatives from OCHA and Global Clusters travelled to Pakistan to diagnose the overall state of the cluster system in the country, following the request of the Humanitarian Coordinator. Several of the recommendations formulated by this diagnostic mission were specific to the HC, including the need to train HC members on 1) humanitarian reform; 2) the cluster approach; 3) HC implementation

2 modalities; and 4) HC roles and responsibilities in humanitarian crisis response. The GHC undertook a follow-up mission to Pakistan from 11 to 22 August 2009 to address the above recommendations. The HC in Pakistan set the following terms of reference for the follow-up GHC mission of August 2009: 1. Provide information and train HC partners/stakeholders, including government counterparts, on the main principles of humanitarian reform and the Principles of Partnership ; 2. Improve understanding of the cluster approach among relevant WRO and WPCO staff and HC partners; 3. Identify priority areas and linkages for inter-cluster coordination; 4. Assist and guide the HC in drafting its terms of reference and roles and responsibilities at federal, provincial and district levels. The GHC support mission undertook the following main activities: 12 August Held individual meetings with selected Pakistan HC members (Merlin, UNICEF, WPCO staff). 13 August: Attended HC meeting in Peshawar and inter-cluster coordination meeting in Islamabad. Visited IDP camp and health facilities in Peshawar. 14 August: Met with WHO Representative and selected WHO staff; undertook preparatory work for the HC workshops. 15 August: Travelled to Nowshera District to visit health facilities in IDP camps as well as the Diarrhoeal Treatment Centre and Reproductive Health Unit in Nowshera Satellite Hospital. Held meeting with the EDO. 17 August: Ran a one-day workshop for WHO staff involved in the HC and the humanitarian health sector response. 18 August: Reviewed documents, reports, DEWS data analyses, health assessments and other documents. 19 August: Ran the HC strengthening workshop in Islamabad. 20 August: Ran the HC strengthening workshop in Peshawar. 21 August: Consolidated preliminary mission findings and recommendations. Met and held debriefing sessions with the WHO Representative, selected WPCO staff, the Humanitarian Coordinator and the UNFPA Representative (debriefing conducted by telephone). 4. HIGHLIGHTS 4.1 Context: In April 2009, military operations in NWFP resulted in sudden and huge population movements. In early June, the numbers of displaced people had peaked at around 3.5 million, of whom 90% were hosted by local communities in six districts (see figure 1) and 10% were living in over 20 camps. Between the end July and the end of August, almost half the displaced population returned home. Over half the IDP camps shut down, and several international humanitarian organizations and NGOs transferred operations to the IDPs' areas of return. Following the IDPs' swift return, the Provincial Relief Commissioner Emergency Response Unit (ERU), originally established to support IDPs from Buner, Swat, Lower Dir and Upper Dir districts, was dissolved and the NWFP Provincial Relief, Rehabilitation and Settlement Authority (PaRRSA) took over responsibility for planning and coordinating humanitarian activities. Although the return process is continuing, some parts of the IDPs' areas of return remain inaccessible. Overall, the situation in NWFP remains extremely volatile: tensions are running high, and a scaling up of military operations in the FATA territories remains a possibility. The overall humanitarian operation must be flexible enough to adapt and react to this highly fluid and rapidly changing situation. Despite the Government's commitment, and in a macro-economic context that showed an average of 6% annual economic growth between 2002 and 2006, only around 1% of the country's GDP seems to be spent on public health. The private health sector plays a very important role: around 70% of total spending on health is thought to be paid from out-of-pocket expenses. The high level of poverty varies across

3 provinces and districts; in rural areas it is well above the national average of 24% 1. Other important indicators such as female literacy and maternal mortality rates and the percentage of fully vaccinated children (less than 60% in 54 out of 134 districts) reveal huge differences across provinces and districts, showing major inequalities in the availability and utilization of health services. These few statistics serve to highlight the complexity of the context in which humanitarian health interventions have to be delivered, which is further exacerbated by the continuing return process. The vulnerability of the IDPs - both those who remain in the hosting districts and those who have either returned home or are in transit - is very high. They must be provided with adequate social safety nets and FREE basic health care, in order to avoid a deterioration in their health status and a corresponding increase in the number of households faced with catastrophic health expenditures. Pre-crisis inequalities and inequities need to be identified at district level, particularly when planning the support to be provided both in districts of return and in those areas that continue to host huge numbers of IDPs. 4.2 Main outcomes of the mission: The main outcomes of the mission are summarized below and presented in more detail in the joint report of the two workshops that took place with HC partners in Islamabad and Peshawar (see chapter 5 below). Discussions were frank and far-reaching. Several suggestions and ideas that came up during the workshops need further in-depth discussions, particularly at Peshawar level, in order to secure the agreement of all HC partners to proceed along the lines delineated during the workshops. There is a clear need to improve efforts to build the capacity of HC partners and the MoH, particularly at district level, on contingency planning, needs assessment, data analysis and reporting. Moreover, HC meetings, particularly in Peshawar, must focus on strategic issues rather than simply sharing information. To this end, a follow up mission of GHC partners by the end of October is highly recommended. The four priority action points that emerged from the workshops are: Strengthen sexual and reproductive health and define the role and responsibility of UNFPA as lead agency in this area within the HC; Appoint one agency per affected district to act as HC focal point; Establish a small, time-limited task force to develop the principles and main strategies for health service delivery during the period of return; Support the districts conducting assessments and, even more importantly, help them monitor and report on services delivered and gaps to be filled. The GHC needs to remain fully engaged in following up on the recommendations of the Pakistan global inter-cluster support mission. This implies: Remaining available for any distance technical support that may be requested by HC members, including WHO as HC lead agency; Actively contributing to preparations for the second global inter-cluster mission scheduled for October; Supporting, if needed, WHO as HC lead agency in preparing and conducting the workshops and other training courses as outlined in the action points of the workshops below. Chapter 6 of this report sets out the GHC action points and recommendations for each of the issues identified by the diagnostic inter-cluster mission of July. A few changes have been made to the diagnostic mission's original findings; while most of them are language-related, two are more substantial: 1. The application of standards was included as an area of work in both section 1 (leadership/partnership/coordination) and section 2 (planning and management). We have chosen to leave this crucial area of work only in section 2, in order to avoid duplication. 2. Recovery and reconstruction for the application of standards has been moved to section 2 (planning and management). We believe the challenges posed by health sector recovery are not linked to the application of national standards. Rather, the reverse is true: national norm and standards must be adapted to specific recovery needs, particularly early recovery that takes place in a humanitarian context. This implies the flexibility to identify and choose, over time, the most appropriate strategies for delivering basic health services depending on the evolution and context of the crisis. 1 In

4 Chapter 7 presents a matrix ranking the relevance of the HC functions against each of the 13 operational strategies presented in the Health Cluster Draft Strategy Document of July 2009, on which the HC work plan is based. This matrix was developed following the workshop with WHO staff on 17 August. It should be considered as a preliminary but useful draft that may be periodically re-assessed and revised as the crisis evolves. The Health Cluster Draft Strategy has been developed following extensive consultation among HC partners during the month of July. As the context has changed dramatically since then, it is recommended that this strategy be reviewed to take account of the new challenges of the return and the corresponding recovery of the health system in these areas. This revision can be an opportunity to streamline the strategy, focusing on a reduced number of high-priority operational strategies and distributing responsibility per HC partner and per function against each revised operational strategy.

5 5. CONSOLIDATED REPORT OF THE PAKISTAN HEALTH CLUSTER STRENGTHENING WORKSHOPS The GHC follow-up mission held two workshops (one in Islamabad on 19 August and a second in Peshawar the following day). The agenda and list of participants for both workshops are attached. The following section summarizes the main discussion and action points from each workshop. For Islamabad, action points are grouped under each of the priority issues identified by workshop participants. For Peshawar, action points are organized by subject. Health Cluster functioning at national and sub-national levels: 19 August 2009, Islamabad I.1 The Health Cluster (HC) in Pakistan should be seen as one entity with different levels of functioning : national, provincial and district. HC partners interact, operate, and work together at each level. The figure below presents the main challenges and responsibilities at each level. I.2 The appointment of one full-time Health Cluster Coordinator (HCC) based in Peshawar, who works across all three levels, reflects the vision of the HC as one entity (see figure 1). I.3 Currently, the provincial level (Peshawar), where partners and decision-makers are based and where strategic, planning and operational work is carried out, is pivotal to the functioning of the HC. This should be reflected in the allocation of the HCC's time, with more than 70% spent in this location and in districts (security permitting). No more than 30% of the HCC's time should be spent in Islamabad. I.4 Should other provinces be involved in this evolving crisis in the near future, HC working modalities will need to be adjusted accordingly. I.5 HC meetings, particularly in Peshawar, should focus more on strategic discussions and less on information sharing and situation updates. This issue should be raised at the Peshawar HC workshop on 20 August (see action point P.5 of the Peshawar workshop). Some examples of data analysis to feed strategic discussions are illustrated in the attached Power point presentation that was used during the two workshops and subsequently updated to reflect workshop discussions and feedback from the WHO Representative. I.6 More detailed discussions on HC functioning at district level should take place during the Peshawar HC Workshop on 20 August (see action point P.4 of the Peshawar workshop). I.7 In future, HC meeting minutes should be promptly circulated and the HCC should ensure that there is a full record of deliberations and decisions, both to ensure all HC partners are informed and updated and to allow proper follow up. Figure 1: Health Cluster Architecture in Pakistan, and main responsibilities, by National, Provincial and District levels. Health Cluster ISLAMABAD: policy & strategy development, norms & standards PESHAWAR: strategic planning & monitoring of operations, inter cluster coordination & planning for multisectoral responses DISTRICTS: Need assessments, monitoring, gap analysis, planning, implementation of operations, reporting Mar dan Swa bi Pesha war Char sadda Now sherra D.I. Khan Bajawer agency Buner Swat Lower Dir Upper Dir Mala kand Tank Districts of IDP arrival (2009): 6 Districts of return: 6 District unstable: 1

6 Inter Cluster Coordination Group (ICCG): I.8 ICCG is a key forum for discussing strategic and operational issues, particularly those that are cross-cutting, as well as other issues that require multisectoral interventions involving more than one cluster (e.g. cholera outbreak response, gender-based violence (GBV), mental health and psychosocial support, etc.). I.9 The agenda of ICCG coordination meetings should be sent to HC partners in advance, in order to have proper discussions at HC meetings and reach a consensus on the points to be reported to the ICCG. HC members should consider, when appropriate, the possibility of suggesting specific agenda items relevant to the work of the health sector, to be discussed at the ICCG. I.10 The HC has decided to propose to the Humanitarian Country Team to expand the participation to the Inter Cluster Coordination Group meetings from one to at least two members from each cluster. HC participants could be the HCC and one other member either to attend on a rotating basis and/or be invited to contribute to specific agenda items (e.g. early recovery focal point, GBV specialist, etc.). Information Management (IM): I.11 The HC should improve the utilization and analysis of data from different sources (DEWS, MoH District Health Information System, NGO reporting, assessments done by different organizations). The knowledge generated through the analysis of this information can contribute to strategic discussions at HC meetings. By way of an example, figure 2 compares the different types of health workers in IDP camps in Swabi District versus those in district public health facilities. While the overall health worker ratio is five times higher in the camps, the difference increases fifteen-fold for medical doctors. Figure 2: Availability of Human Resources, by type, in IDPs Camps versus in Public Health Facilities outside IDPs camps SWABI District, May 2009 District* HR Type N Ratio (N / 10,000) N Camps** Ratio (N / 10,000) Male Medical Officer Female Medical Officer Lady Health Visitor Lady Health Workers EPI Technician Medical technicians TOTAL *Estimate resident Swabi district pop. + IDPs hosted in the communities: 2,033,422 (source Nadra) ** Estimated IDPs living in camps in Swabi District as of week (23): 31,963 (source WHO) A similar analysis should be undertaken for all other districts affected by the crisis, particularly those where the return of IDPs has already begun. This is particularly important given the exodus of a significant number of health workers from health facilities in these areas at the beginning of the crisis.

7 I.12 The HC should review a core set of indicators proposed by the GHC (and distributed at both workshops). Relevant indicators should be selected and adapted to the local context, and the source of the data needed to produce the numerator and denominator of each final indicator should be identified. It will also be crucial to generate a trend analysis of some of these core indicators. I.13 Priority should be given to indicators related to the availability of services and coverage, given that the HC is responsible for identifying gaps, agreeing on priority issues to be tackled and coordinating the allocation of resources available to address the gaps. I.14 Joint monitoring of needs as well as health services provided at district/field level should be encouraged with the involvement of all HC partners and reflected in the updates to be provided by districts to the weekly HC meeting in Peshawar. Co-chairing versus co-leading with Government/MoH: I.15 HC is a mechanism to improve the efficiency and effectiveness of the international response in support of national/local health authorities during humanitarian crises. The role of the Federal MoH, Provincial Health Departments (PHD) and Executive District Officers (EDO) in co-chairing HC meetings and working daily with the HCC and health partners is crucial. The adoption of the HC should facilitate and support the involvement at district level of other national and local health actors (PPHI managers, district hospital directors, local NGOs) that are not under the management of the EDO but that play a key role in health service delivery. I.16 Leadership of the health sector, at the respective levels, remains with the Federal MoH, the Provincial Health Department and the Executive District Officers. Leadership of the HC remains with the HCC and the head of the Health Cluster Lead Agency, in this case the WHO Representative, Funding Mechanisms: I.17 The HC has primary responsibility for joint situation analyses, needs assessments and monitoring of the health status and services delivered, priority settings (thematic and geographical) driven by a solid gap analysis, and identification and articulation of strategies for health services delivery. I.18 HC partners have to develop different projects in line with the outcome of the work described in the above action point I.17, and should share information on resources that may become available through bilateral advocacy and fund-raising efforts by individual agencies and NGOs. I.19 When funds are channelled through the HC and HC members are invited to submit proposals, a review committee should be convened by the HC lead agency. The committee should include at least one representative of the different HC constituencies (one member from the NGO community, one from a UN agency and one from other international agencies). I.20 In conjunction, there has to be transparency on bilateral funds raised by HC partners as well as on other funding mechanisms available for the health sector, in order to have a comprehensive picture of the overall health sector funds envelope, including government resources, in the different geographical areas affected by the humanitarian crisis. The way forward: I.21 A capacity building plan should be developed and articulated by HC partners (issue to be discussed at the Peshawar workshop, see action points: P.8, P.9 and P.10 of the Peshawar workshop). I.22 The assessment tools used so far by HC partners should be evaluated based on the quality of the reports produced using these tools and how the reports themselves have been used (outcomes). Based on the findings of this evaluation, these assessment and monitoring tools should be revised with the close involvement of HC partners and taking into account the assessment and monitoring tools (HeRAMS and IRA) developed by the GHC. I.25 The contingency planning process should be undertaken jointly by all HC partners at district level under the leadership of the EDO, and taking into account the specific needs and risks of districts with frequent natural disasters. This element should be part of the capacity building plan of the HC. Concrete indications on these issues emerged during the Peshawar workshop (see below action point P.8). I.26 The application of Sphere and other internationally adopted standards should be taken into account when planning or re-planning interventions and improving the quality of health service coverage.

8 I.27 The HC should undertake to strengthen the monitoring and reporting of activities in the field as a priority, and should transfer responsibility to partners operating in the affected districts as soon as a core set of common indicators has been agreed by all concerned. The information systems of vertical programmes such as TB, Malaria and Lady Health Workers should be used as much as possible to yield critical information. Table 1: The following is the outcome of the exercise conducted at the Islamabad workshop to assign responsibilities and accountabilities within the Health Cluster, based on the RASCI 2 diagram. Functions 1. Coordination mechanisms and inclusion of key actors within the Health Cluster and inter-cluster 2. Relations with other key stakeholders 3. Needs assessment, situation monitoring & analysis including identifying gaps in health response Cluster Lead Agency Representative Health Cluster Coordinator (HCC) Health Cluster Partners A,R R,S R,C A,R R,I R,S,C A,R R, S R,S,C 4. Strategy development & gap filling A R R,S 5. Contingency planning A,R R R,S 6. Application of standards R,S,C R,S,I A,I,R 7. Training and capacity building, including emergency preparedness A,S,C R R,C,I 8. Monitoring and reporting A,R R,I R,S,C,I 9 Advocacy and resource mobilization A,R R,I R,S,C,I 10. Provider of last resort A,R S C,S RESPONSIBLE Those who do the work to achieve the task. There can be multiple resources responsible. ACCOUNTABLE The person/people ultimately answerable for the correct and thorough completion of the task. There can be only one person accountable. SUPPORT Those who may help in the task. CONSULTED Those whose opinions are sought. Two-way communication. INFORMED Those who are kept up to date on progress. One way communication. 2 Responsible, Accountable, Support, Consulted, Informed

9 Health Cluster functioning at District and Provincial levels: 20 August 2009, Peshawar P.1 Following the stabilization of large areas in some districts, IDPs have begun returning to their places of origin. HC partners will need to expand their geographical areas of operation considerably (from six to 13 districts, see figure 1). P.2 Figure 3 illustrates the main Governmental actors at district level managing the public health infrastructures, and the relationships among them. The continuing line represents direct managerial relationships, while the intermittent line represents only communication relationships, not structured by formal mechanisms. Figure 3 illustrates the multiplicity of actors in the public health sector, and highlights the need for a more systematic involvement of PPHI managers in the HC's work, considering the critical primary health care role of Basic Health Units (BHUs). Figure 3: Ministry of Health PPHI National Initiative Provincial Health Department PPHI Provincial Office District Hospital EDO PPHI District Office Civil Hospital Tahsil Hospital LEP TB MCH CD RH BHUs Satellite Hospital P.3 Participants discussed and agreed on a proposal to appoint an HC focal point agency (HC/FPA) with a consolidated presence in a particular district, in order to improve the overall HC partners' operations at district level (see figure 4). The main role of the HC/FPA would be to provide daily support to the EDO in HC-related work (conducting assessments; monitoring the situation; identifying gaps, setting priorities; joint planning with all health actors; daily coordination and weekly reporting to the HC coordination meeting in Peshawar). Figure 4 Proposed mechanism for enhancing coordination among Health Cluster Partners at District level LEP TB District Hospital MCH Health Cluster Partners HC Focal point agency EDO CD RHC Civil Hospital BHU PPHI BHU Tahsil Hospital BHU BHU Satellite Hospital

10 P.4 The HC/FPA and the EDO should co-chair the regular district meeting of all health actors, but also, and more importantly, work on a daily basis on the HC priority functions at district level highlighted in paragraph P.3. P.5 Further discussion on the appointment of an HC/FPA at district level should take place at the next HC meetings in Peshawar. WHO as Cluster lead agency should take on the role of HC/FPA only for districts where there are no HC partners for the time being. P.6 Concise weekly reports of needs assessments, monitoring of services available and gap analysis in the affected districts should be sent to all HC members the day before the weekly HC meeting in Peshawar. Currently, a lot of time is wasted just sharing this information during the HC meetings. Sharing of the information prior to the meetings will enable participants to focus on well informed strategic deliberations and reach agreement on key matters. Reproductive Health: P.7 Participants discussed and agreed on the need to pay more attention to reproductive health (RH) in the present health sector response. It was an agreed that an agenda item on RH would be included at all weekly HC meetings in both Peshawar and Islamabad. P.8 UNFPA has been asked to take responsibility for leading the RH response within the HC. The possibility of a separate sub-cluster on RH was not seen as appropriate, considering the need to have a comprehensive primary health care approach promoted and adopted by the HC. Further discussion should take place at the next HC meetings in order to identify and agree on specific initiatives to be undertaken by UNFPA in support of HC partners' efforts to improve RH service coverage. Two initial activities were identified during the discussions: 1) identify and illustrate best practices in delivering RH services during the past six months, in order to promote them and scale up MISP and other RH service coverage; 2) map the present availability of comprehensive and basic emergency obstetric care and the capacity of the referral system in all affected districts in order to identify the health facilities that need to be immediately upgraded to deliver these lifesaving services, and prepare a proposal for funding. Capacity building: P.9 A specific request to support a workshop on contingency planning and emergency preparedness for staff of the EDO office was initially formulated by Mardan District, in view of the frequent natural disasters affecting this area. It was agreed such training was crucial for all EDO offices in the province and that the HC should treat the proposed workshop as a priority. A workshop proposal will be formulated; WHO agreed to review and give feedback on this proposal. P.10 Participants agreed another priority should be a workshop with PHD and EDO officers and HC partners on the key functions of the HC, the tools available, HC responsibilities and working methods at national provincial and district levels. The workshop should be organized in the very near future. P.11 The two workshop proposals described in P.8 and P.9 are critical; the details and content of these two workshops should be carefully defined. The GHC should provide any support that may be requested to implement these workshops. Return and health sector recovery : P.12 Participants agreed to set up a time-limited task force of three to five members (at least one per level) to produce a short concept note outlining key principles to be adopted by health partners during the delivery of health services in areas of return and, more broadly, for health sector recovery in all affected districts. The need to identify and address pre-existing inequalities as well as those generated by the crisis should drive the formulation of these principles.

11 A. Agenda: Health Cluster Strengthening Workshop, Islamabad, Wednesday 19 August 2009, 10:00 17:00 9:00 10:30 hrs: First Session Opening Remarks by WR Speech of the HC Introduction of Participants Introduction on Cluster approach ToR of health cluster constituencies at country level Plenary Discussion 10:45 11:00 hrs: Coffee break 11:00-13:30 Second Session Principles of Partnership Group work on HC accountability framework Presentation of group work and plenary discussion 13:30 14:00 hrs: Lunch Break 14:00 17:00 hrs: Third session Open discussion on Challenges faced by HC and ways to tackle them (e.g. HC as resource mobilization mechanism..?) Way forwards B. Agenda: 54 th Health Cluster meeting and Workshop on Cluster Approach and Coordination, Peshawar, Thursday, 20 August 2009, 10:00 15:00, Co Chair: Director General Health Services, NWFP&WHO 10:00am-11:00am: First session: Health Cluster Meeting - Recitation - Welcome address by DHS, NWFP - Updates by Districts host/conflict area representatives - AOB 11:00-11:20 am : Tea/Coffee break 11:20-03:00 pm Second session: Workshop on Cluster approach and Coordination 11:20am - 03:00pm - Introduction on cluster approach - Health Cluster Architecture - Leadership skills in cluster approach 01:30 pm - 02:00 pm - TOR of the Health Cluster Partners - Strategic Operations

12 6. GHC Support Mission Action Points for the Health Cluster Performance Improvement Plan 1. Leadership/Partnership/Coordination Areas of Work SR # Issues (new issues added by the GHC support mission in bold) Action Points (by inter cluster diagnostic mission, July 2009) Action Points, Recommendations, Areas of Concerns (by GHC support mission, August 2009) Remarks 1.1 Inclusiveness (Partners, CLA, Govt, RCM) Dissemination and application of Principles of Partnership Application of the Principles of Partnership in defining and improving HC working modalities in future work of the HC. Several of the action points agreed (see box on the right) in the two workshops include concrete proposals to enhance inclusiveness. They need to be adopted and, in some cases, further discussed among partners and better defined See action points of Islamabad and Peshawar HC workshops:i.7, I.9, I.14, I.19, P.2, P.7, P.11 Coordination mechanisms and inclusion of all actors within the HC and inter-cluster coordination especially with WASH, NUT, Protection and Shelter a Strengthening the role and skills of the cluster lead in ISB and PSH Strengthening the coordination, synergies and operational capacity of HC partners at District level Put in place dedicated, full time Health Cluster Coordinator (HCC) in Islamabad (international) and HCC (international) in Peshawar partnered with strong national officer. Train cluster coordinator (ISB & PSH) and cluster members on responsibilities and roles of the health cluster in emergencies, humanitarian principles and partnership, meeting facilitation/ management skills, etc. Deploy only one senior (P5) full-time Health Cluster Coordinator (HCC) who should be based in Peshawar in order to interact with partners based in the affected districts, and with ad hoc travel to Islamabad to attend the ICCG and other relevant meetings. First two workshops conducted. Action points P.8, P.9 and P.10 to be implemented as a priority. HC capacity building workshops in Islamabad and Peshawar should be run back to back with the second inter-cluster mission planned for October Empowerment of district HC partners through active participation of cluster members in district level coordination. One HC Focal Point Agency to be appointed in each district. WHO to cover this role only if no HC partner available/present in a district. The HCC has to travel frequently to districts to support gap analysis and planning of health sector operations and the coordination role of the EDO. See action points of Islamabad HC workshops: I.2, I.3 See action points P.1; P.2, P.3, P.4 and P Weak health cluster representation in other clusters at ISB and PWR levels Ensure appropriate level attendance and participation of Cluster representation at all appropriate coordination meetings with government and local actors at ISB, PWR and district levels and in meetings of other clusters Urgent need to reduce number of meetings, mainstream cross-cutting issues within each cluster and not set up new sub-clusters or working groups. Also, need to enhance the operational and strategic coordination of the ICCG in order to plan and share responsibilities in responding to humanitarian needs that require a multisectoral response through the ICCG. Point to be discussed in the HCT, and followed up by OCHA See action points: 1.4 Inadequate inter-cluster coordination Emphasize ICC in ISB, start and emphasize ICC in PSH & at district levels Enhance ICCG functions end capacities in Peshawar and limit ICCG meetings and functions in Islamabad to selected policy and broad strategic issues. Improve HC and ICCG, shifting from information sharing platform to strategic and operational focus. Shift the focus of HC and ICCG coordination meetings from information sharing platform to strategic and operational mechanisms. Coordination with national authorities & other local actors 1.5 Very limited capacities of government and cluster at district level to coordinate, especially service delivery linkages with PPHI run BHUs Support DCO and EDO through training, HR and financial resources Systematic and institutional linkages and arrangements with PPHI in the areas of service provision, DEWS reporting and referral services for secondary and tertiary care Same as diagnostic mission, plus: The above-mentioned appointment of an HC Focal Point Agency Training of EDOs and HC Focal Point Agency on key HC functions to be performed at district level; introduction and adaptation of standard tools for needs assessment and monitoring of health needs and services delivered (HeRAMMS, IRA). Initial support to regularly produce monitoring updates for the Peshawar weekly meetings. Daily relationships by EDO/HC focal point agency with key players such as PPHI district manager, and joint needs assessment and gap analysis. 1.6 National requirement for strategic thinking and training in health emergency preparedness and response Strengthen existing MOH Health Emergency Preparedness & Response Center (HEPR) as a platform for strategic thinking and for training? All training to held at HEPR, contingency planning process to be lead by HEPR, international exposure visits of HEPR team. Workshop to be conducted in Peshawar for EDO offices on contingency planning (see action points of Peshawar workshop).

13 1.7 Incomplete W3, regular updates not undertaken, and dissemination patchy Strengthen IM capacities at ISB, PWR and district levels, and joint analysis with other key clusters i.e. WASH, NUT, Shelter and Protection The focus should be at district level, in applying a bottom-up approach outlined in the above action points, particularly in giving districts responsibility for producing written short regular situation reports. Produce templates for presentation of information in an analytical way and to monitor allocation of resources and identify gaps (adoption of HeRAMS as a tool to regularly feed the WWW matrix. (In addition to what the diagnostic mission recommended.) Needs assessment & analysis including identifying gaps Asset mapping and its matching with gaps and unmet needs Analyses of information to guide decision making missing Strengthen IM capacities at ISB, PWR and district levels, and joint analysis with other key clusters i.e. WASH, NUT, Shelter and Protection Hire National Technical officer for asset mapping and in depth analysis of all information collected and use it for gaps and needs identification for intra and inter-cluster planning, service delivery coverage and accessibility, and outcomes Strengthen Peshawar capacity to utilize the outcome of issue 1.7 to update and produce thematic maps on availability and utilization of health services( availability of CEmOC and BEmOC and percentage of Caesarean sections over expected deliveries performed per district per month). The form of the standardized assessment used so far are very good and produce reliable information, there is the need to apply the EDO form, after appropriate revision, also for interviewing the PPHI managers at district level. National technical officer to be based in Peshawar under the responsibility of the HCC, with advanced capacity to process and analyse data, and utilize GIS software, in order to support the action point of issue 1.8. The analysis of data on deployment of staff in IDP camps versus District public health facilities (see example presented in figure 2), as well in areas of return should be regularly monitored in ALL the district affected by the crisis, and inform the decision in allocation of resources and coordination on the decision of the geographical operational areas of health cluster partners Service delivery coordination Deploy a PH Specialist (Int) health care delivery services (PHC and referral care) This function needs to be performed by the senior health cluster coordinator (HCC), and not by an additional staff, as per the generic ToRs presented in the Health Cluster Guide. The role of the HCC in supporting the districts in planning the delivering of basic health services is crucial, as well the appointment of a focal point agency delineated in the above action point on issue 1.2a. The two actions need to go hand to hand Service delivery needs especially for IDPs outside camps Work with service delivery partners including GOP, INGOS and NNGOS to ascertain needs for the next 6 months Refer to analysis presented at the workshop. Needs to be completed for all districts and lessons learnt to be developed by a task team led by the HCC, two NGOs and one other UN agency besides the cluster lead agency. 2. Planning and Management Areas of Work SR # Issues (new issues added by the GHC support mission in bold) Action Points (by inter cluster diagnostic mission, July 2009) Action Points, Recommendations, Areas of Concerns (by GHC support mission, August 2009) Remarks 2.1 Reproductive Health, CH, MH, Gender Essential Drugs National experts/staff appointed to deal with and coordinate area specific issues UNFPA appointed as lead agency for reproductive health, with responsibility for documenting lessons learnt and best practices from previous activities, e.g. mobile clinics, LHW, etc. and making them available to HC members UNFPA to take the lead in carrying out RH assessments and gap analysis and, together with HC members, exploring ways to address these gaps. Strategy development & planning, including: Community based approaches, attention to priority cross cutting issues, and filling gaps 2.2 Continue development, dissemination and use of Pakistan Health Cluster Draft Strategy for the Crisis in NW Pakistan Finalize the Pakistan Health Cluster Draft Strategy for the Crisis in NW Pakistan with Cluster partners, including the Govt. and disseminate it. Coordinate revision of work plans with Cluster partners, including the Govt. to reflect the agreed upon strategic direction. Coordinate implementation of actions called for in Operational Strategies of the 13 Strategy points with Cluster partners, including the Govt. Further discussions are needed to tackle other cross cutting issues. The revision of the Halth Cluster Strategy and related work plan seem to be necessary, deu to the scale of the return process and the changes of he scenario. IN conducting the revision, it may be useful to streamline the 13 operational steategies outlined in the draft July version of the Health CLuster Strategy, and focus on a reduced number of priority action, as per the evolution of the crisis. 2.3 Recovery and Reconstruction Develop and share standards Set up a task force to develop key principles and health service delivery strategies during the return phase and recovery process.

14 In addition to developing new standards for health sector recovery, existing national standards need to be tailored to the challenges and situation of each affected district, with solutions that may differ from one district to the next. Monitoring and reporting 2.4 Project M&R weak at field level Develop M&R plan with partners to Identify and agree on monitoring tools and through a consensus building workshop develop capacity of all partners to use it. Shift the focus from project monitoring and reporting to monitoring of the services made available by all HC partners by location type, over time, and delivered by the health sector as a whole during the humanitarian response as primary responsibility of the Health Cluster, while individual project monitoring and reporting should be responsibility of the agencies in their accountability framework with donors Same. Using existing standards, conduct DoH/NGO project monitoring Support the adoption of the new District PHC facility monthly report by all local and international NGOs and international agencies, as a monitoring tool to be used for planning at district level. Application of standards 2.5 Need to ensure technical health leadership role Identify and disseminate appropriate technical standards to all partners: Govt, NGOs, RCM Some standards at national level need to be revised, considering the requirements and the nature of the health response to the crisis: for example the replacement in the emergency kits of the zinc syrup formulation with the dispersible zinc tablets of 20 mg in blisters of 10 tablets, as standard treatment of all acute diarrhoea cases in children under 5. This requires the introduction of this item in the monthly PHC facility report, where at the moment there is only the ORS as item 17 of section XII-A. The change of the zinc formulation should be discussed at national level as a temporary measure for having a more efficient response to the crisis Training and capacity building Unfamiliarity with Cluster system (Govt, WHO, NGO) Weak soft skills (meeting mgmt, coordination, etc.) Familiarization seminars on Cluster system to be conducted in collaboration with OCHA in ISB/PSH Quick, initial training to improve WHO, partner and Govt soft skills The two workshops conducted during the GHC mission should be considered a first step. The workshops' action points indicate the need for more capacity building workshops at district level for MoH HC partners in the near future See workshops action points Advocacy and resource mobilization and reporting 2.8 Weak communication and advocacy capacities Appoint a dedicated Communications/Advocacy Officer (Intl) partnered with national officer. Same. Done by WHO as CLA 3. Response and Preparedness Areas of Work SR # Issues (new issues added by the GHC support mission in bold) Action Points (by inter cluster diagnostic mission, July 2009) Action Points, Recommendations, Areas of Concerns (by GHC support mission, August 2009) Remarks 3.1 Monsoon floods Under leadership from HEPR and in coordination with ERU and HC partners draft CP, pre-positioning of stocks, surveillance/outbreak response capacities Contingency planning (and preparedness) Additional out flux from Waziristan On and off displacement in NWFP with varying levels of continued violence in returnee areas CP, health care provision planning CP, health care service provision planning See specific recommendation of the Peshawar workshop. In addition, GHC partners, particularly WHO as Cluster Lead Agency, should support the workshops of the MoH District Health Teams and of the HC partners, during which specific contingency planning for natural disasters and civil unrest should be prepared. 3.4 Other natural hazards CP, earthquakes and other hazards across Pakistan

15 Provider of Last Resort (POLR) 3.5 Capacity within the system Work with intra and inter-cluster partners to develop mechanisms to jointly ensure gaps are filled as and when required. Same. Security 3.6 Need to improve capacity to work in insecure environments Increase infrastructure capacity to work in insecure environments WHO as HC lead agency should be prepared for a possible deterioration of security conditions: at least one armed car is urgently needed, plus radio communication equipment, to guarantee security standards. Work with HC partners to identify working methodologies ASAP

16 7. MATRIX OF HEALTH CLUSTER FUNCTIONS AGAINST THE PAKISTAN HEALTH CLUSTER OPERATIONAL STRATEGIES Health Cluster Functions Pakistan Health Cluster Operational Strategies Coordination Mechanism and inclusion of key actors within the HC and inter cluster Relations with other key stakeholders Needs assessment, situation monitoring & analysis, including identifying gaps in health response Strategy development & gap filling Contingency planning Application of standards Training & capacity building, including emergency preparedness Monitoring and reporting Advocacy and resource mobilization Provider of last resort 1. To ensure a coordinated response for the IDPs and conflict affected communities 2. Ensuring the quality of all health interventions 3. To ensure the delivery of essential health service package to IDPs in the camps and in host communities, with focus on Maternal, Neon. & Child Health Support to Referral hospitals Monitor Disease trends for early investigation and response to potential outbreaks through the DEWS network and DHIS 6. Mental Health and Psychosocial support 7. Nutritional Surveillance and facility based management of Severe Acute Malnutrition 8. Drinking Water Quality Control Access to essential Drugs Assistance and Rehabilitation to Persons with Disabilities (PWDs) and Victims of Violence 11. Health Promotion and Community Participation 12. Building the Capacity of National Authorities for Emergency Disaster Preparedness and Response and Step up Readiness of Health Partners Initiate Early Recovery of the Health Sector in the Areas of Return Not Relevant + Relevant ++ Very Relevant +++ Extremely Relevant