YEAR 2 ANNUAL REPORT

ADVANCING UNIVERSAL HEALTH COVERAGE (AUHC) ACTIVITY IN BANGLADESH (OCT 2018-SEP 2019)

Program Title: Advancing Universal Health Coverage (AUHC) Activity in Bangladesh Sponsoring USAID Office: USAID/Bangladesh Contract Number: AID-388-C-17-00001 Contractor: Chemonics International Inc. Partners: Ad-din Foundation, Green Delta Insurance Company Ltd., Population Services International (PSI) and ThinkWell LLC Date of Publication: November 15, 2019 Author: AUHC

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

4 BANGLADESH AUHC YEAR 2 ANNUAL REPORT

CONTENTS CONTENTS ................................................................................................................................................................. 4 ACRONYMS ................................................................................................................................................................ 5 EXECUTIVE SUMMARY ........................................................................................................................................... 6 GOALS AND OBJECTIVES...................................................................................................................................... 8 RESULT FRAMEWORK ............................................................................................................................................ 9 YEAR 2 KEY ACHIEVEMENTS ............................................................................................................................. 10 ACHIEVEMENTS BY RESULTS ............................................................................................................................. 12

RESULT 1. SMILING SUN NETWORK TRANSFORMED INTO A CENTRALLY MANAGED, SUSTAINABLE, PRIVATE SOCIAL ENTERPRISE: THE SURJER HASHI NETWORK ....................... 12

IR 1.1 Existing Smiling Sun Network consolidated into a centrally managed single entity ................. 12

IR 1.2 Standardized Corporate Operating Systems Designed and Implemented ................................. 17

IR 1.3 Improved financial sustainability of Surjer Hashi Network (SHN) ............................................... 19

IR 1.4 Value-Based Payments Implemented to Drive Performance ......................................................... 24

RESULT 2: ACCESS TO AND UPTAKE OF ESSENTIAL SERVICE PACKAGE EXPANDED ......... 25

IR 2.1 Enhanced service package offered through Surjer Hashi Network ............................................. 26

IR 2.2 Increased informed demand for essential service package ............................................................. 28

RESULT 3: SUSTAINABLE FINANCIAL SYSTEMS DEVELOPED TO FACILITATE EXPANDED COVERAGE AND TO ENSURE EQUITABLE ACCESS TO HEALTH SERVICES .............................. 29

IR 3.1: Subsidy Funding to Cover the Poor Operationalized ..................................................................... 29

IR 3.2: Prepayment/insurance package developed and available ............................................................... 31

IR 3.3 Optimal Client Mix Secured to Balance Financial Sustainability and Pro-Poor Mandate ........ 32

RESULT 4: IMPROVED QUALITY OF CARE ............................................................................................... 33

IR 4.1 Improved Customer Experience .......................................................................................................... 33

IR 4.2 Continual Quality Improvement Systems Implemented ................................................................. 34

IR 4.3 SHN Staff Are Skilled and Retained ..................................................................................................... 36

RESULT 5: IMPROVED PROGRAM STRATEGIES DRAWN FROM LESSONS LEARNED ............. 38

IR 5.1 Capture Learning through Documentation, Research, and Analysis ........................................... 38

IR 5.2 Apply Learning to Activities ................................................................................................................... 40

IR 5.3 Disseminate Learning on UHC to Target Audiences ...................................................................... 41

Success Story ............................................................................................................................................................. 43 YEAR 2 LESSONS LEARNED ................................................................................................................................ 44 COLLABORATION ................................................................................................................................................. 45 RESULTS TO DATE ................................................................................................................................................. 49 Annex A: Financial Report ...................................................................................................................................... 55

5 BANGLADESH AUHC YEAR 2 ANNUAL REPORT

ACRONYMS AUHC Advancing Universal Health Coverage BEmOC Basic Emergency Obstetric Care BDHS Bangladesh Demographic and Health Survey CBSG Capacity Building Service Group CEO Chief Executive Officer CEmOC Comprehensive Emergency Obstetric Care COP Chief of Party CYP Couple Years of Protection DCOP Deputy Chief of Party DGHS Directorate General of Health Services DHIS2 District Health Information System 2 DQA Data Quality Assessment DTC District Technical Committee CTB Challenge TB EMR Electronic Medical Record ENC Essential Newborn Care ESP Essential Service Package FAA Fixed Award Amount FPRH Family Planning and Reproductive Health GDIC Green Delta Insurance Company GFATM Global Fund for AIDS, Tuberculosis, and Malaria GoB Government of Bangladesh HMIS Health Management Information System IYCF Infant and Young Child Feeding HNQIS Health Network Quality Information System MERL Monitoring, Evaluation, Research, and Learning NGO Non-Governmental Organization NHSDP NGO Health Service Delivery Project OBGYN Obstetrics and Gynecology PMP Performance Monitoring Plan PMU Project Management Unit QA/QI Quality Assurance/Quality Improvement QAM Quality Assurance Manager QMS Quality Management System RF Results Framework SBU Strategic Business Unit SHN Surjer Hashi Network UHC Universal Health Coverage UIC Unique Identifier Code USAID United States Agency for International Development

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EXECUTIVE SUMMARY Overview. AUHC’s second year was dedicated to finalizing the clinic management transition of the 3991 clinics. The clinic management transition was originally envisioned to begin in the middle of Year 3, but, at USAID’s request, AUHC accelerated the transition timeline and completed it at the end of March 2019. AUHC started the transition in Year 1, and it culminated in Year 2 with a 6-month fixed amount award (FAA) grant in September 2018 to SHN and subsequently a cost-reimbursement subcontract beginning on 1 April 2019 to support operations in 369 clinics. As in Year 1, AUHC continued to build SHN systems and processes in Year 2. AUHC helped SHN establish those requisite system to allow SHN to receive funds from AUHC, such as the finalization of the TALLY accounting system rollout. In parallel, AUHC dedicated time and attention to developing some of the business systems that SHN needed to run the network. Examples of those include, introducing a profit and loss (P & L) management approach, finalizing the SHN business strategy that AUHC began in Year 1. In addition, AUHC streamlined the SHN drug procurement system, introduced a minimum standard price for all SHN services, drugs and laboratory services. In tandem with the price standardization, a new discount policy was implemented. A critical piece of work was to redefine the SHN core service offerings. This exercise realigned SHN’s service delivery channels to better meet SHN’s value proposition. Instead of Comprehensive Emergency Obstetrical Care Center (CEmOC), Basic Emergency Obstetrical Care Center (BEmOC), Vital Clinics, and Satellite Spots, SHN new clinic typology includes Advanced Clinics, Basic Clinics, and Satellites. AUHC finalized four research activities in Year 2: a market landscape that had two distinct parts, a provider and a consumer component, a community service provider (CSP) functionality assessment and an assessment of the SHN Satellite spot system. Year 3 focus. There are six points of emphasis for AUHC in Year 3. They are 1) network optimization; 2) systems development and use; 3) expanding partnerships and looking for other sources of capital; 4) strengthening SHN’s service capacity by improving existing services and adding new services; 5) transitioning quality assurance to SHN; and 6) capturing and using lessons learned. • Network optimization, systems development and partnerships. There is an urgent need to implement

the network optimization decisions for the very poor and poor clinics that were agreed to in Year 2. Then, AUHC will develop and implement an approach to the 171 average clinics in the Surjer Hashi Network. At the same time, AUHC needs to work with SHN to ensure that the systems that were established in Year 2 are fully operational and being used by SHN to make decisions, both day-to-day management decisions as well as strategic decisions. Under result 1, AUHC needs to work with SHN to expand their partnerships and attract alternative sources of capital and revenue.

• Strengthening SHN’s service capacity. AUHC will focus on strengthening service delivery in SHN clinics to include service expansion, improvement in customer experience and client satisfaction, and improving client information and their capacity to make informed decisions. AUHC will introduce eye care services in five SHN clinics, bolster SHN’s capacity to mainstream TB services. AUHC will support the introduction of non-communicable disease (NCD) screenings, treatment, and follow up among all clinic types. Another need is the introduction of specialist medical services.

• Transitioning quality assurance to SHN. Building on the foundation from Years 1 and 2, in Year 3, AUHC will prioritize transitioning the role of quality assurance and oversight to SHN. Once this

1 There were originally 399 Smiling Sun clinics. Eighteen are in the Chattogram Hill Tracts (CHT) and are directly funded by AUHC via a grant to Green Hill. Twelve clinics were retained by the NGOs who were managing them. The remaining 369 clinics were transferred to SHN for oversight and management. AUHC is funding a total of 387 clinics.

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transition occurs in April 2020, AUHC will shift to an oversight and monitoring function to oversee the work of the regional quality assurance efforts by SHN.

• Capturing lessons learned. The priority for Year 3 will shift to capturing lessons learned and ensuring that those lessons serve as the basis for evidenced-based decision making. AUHC will continue to improve data quality through DQA visits and MIS data error feedback to SHN headquarter and clinic staff. The MERL team will also collaborate with AUHC’s service delivery team and USAID implementing partners for rapid research on changes in service utilization by poor people aligned with national as well as USAID priority areas.

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

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

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

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

4. Improve the quality of care

5. Improve program strategies drawn from lessons learned (crosscutting).

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YEAR 2 KEY ACHIEVEMENTS Introduction. AUHC categorizes Year 2 achievements into three categories: clinic services, AUHC monitoring and investments and interventions to improve SHN people, process and systems.

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SHN people, processes and systems. By the end of Quarter 2, AUHC had transitioned 369 clinics, staff and assets from NGO grantees to SHN. Beginning Quarter 3, AUHC awarded SHN a cost-reimbursement subcontract to manage and operate these clinics. To support the management of these 369 clinics, SHN established a regional management structure, and AUHC finalized the rollout of the SHN financial management and adverse event reporting systems. AUHC in conjunction with SHN completed a network optimization exercise to assess the degree to which SHN was meeting its value proposition of health impact and financial sustainability. This required visits to 140 SHN clinics to learn more about their market competition, performance of Satellite Spots and Community Service Providers (CSPs), and coordination with the Government of Bangladesh services. AUHC supported SHN in introducing a minimum standard price in 223 SHN clinics. This involved agreeing on the prices based on an analysis of the existing price schedule, training 765 SHN staff, adjusting a list of 80 service codes so the new price schedule can be captured in the management information system, establishing a mechanism for implementing the new discount policy, and training an SHN clinic staff member to fulfill the customer relations officer (CRO) function. AUHC also worked with SHN to protype optimized hours, which is offering the same menu of services in the evening to cater working populations. After the protype was completed SHN introduced optimized hours in 52 clinics. During Year 2, AUHC has trained total 1649 SHN staff; among them128 SHN staff in counseling, 244 in infection prevention, 380 in the rollout of the TALLY financial management software, 52 staff in Quality Assurance, 80 SHN as part of the MIS pilot and 765 SHN staff in minimum standard pricing and customer centered services. AUHC monitoring. The AUHC compliance monitoring unit (CMU) was established in June and became operational in July. Since that time, they have completed 33 clinic visits. During Year 2, the AUHC Regional Quality Assurance Managers (QAMs) have made 287 clinic visits, and the AUHC monitoring, evaluation, research and learning (MERL) team members have visited 62 SHN clinics to conduct data quality assessments. SHN services. In Year 2, AUHC was responsible for 35 million service contacts through the Surjer Hashi Network (SHN) clinics. Since the AUHC activity began, SHN has achieved 84.2 million service contacts. The Year 2 service delivery accomplishments include nearly 1.2 million service contacts for antenatal care and approximately 13 million service contacts for family planning. SHN clinics were responsible for 35,188 deliveries by skilled birth attendants, 586,424 infant and young child feeding (IYCF) counseling sessions, and 175,163 post-natal care visits within 72 hours of delivery.

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

Overview of Accomplishments. Under this result, SHN has firmly been established. Most of the SHN internal management systems have been installed and are functioning. These include the installation of TALLY and the introduction of a profit and loss (P&L) statement that can be used to measure SHNs financial performance. AUHC revised the agreements that SHN had with the various drug providers with the hope that SHN will realize greater profits from drug sales. All NGO clinic staff have been transitioned to SHN. The SHN regional management system is up and running. In terms of governance, SHN has held eight board meetings. AUHC and SHN jointly began the process of developing a marketing strategy for SHN. AUHC completed a network optimization exercise that made recommendations to SHN on ways that it can make better use of its resources and gain greater network efficiencies. Along the lines of efficiencies, AUHC worked with SHN to institute a minimum standard price and a revised discount policy.

Year 3 Focus. The most immediate need is to work with SHN to implement the network optimization decisions for the very poor and poor clinics, then embark on an approach to assess the 171 average clinics. In parallel, this result area will need to work with SHN to ensure that the systems that were established thus far are operational and being used by SHN. Also, this result needs to accelerate SHN’s partnership opportunities.

IR 1.1 Existing Smiling Sun Network consolidated into a centrally managed single entity Establishment of SHN. During Quarter 1, SHN held its sixth board meeting where the board of directors approved the annual budget for January to June 2019 and SHN’s revised organizational structure. Quarter 1 was significant in that it was during this time period that SHN began the management transition process of onboarded clinic staff. By the end of Quarter 1, 3,288 clinic staff have received employment letters through 21 town hall meetings. To support SHN management, the SHN board operationalized four subcommittees; program, human resources and administration, finance and budget, and procurement. In January 2019 (Quarter 2), SHN moved into their own office. SHN also filled several key positions during Quarter 2 in the regions as well as in the SHN headquarters. The regional positions are the Finance and Accounts Executives, HR and Administrative Executives, and the MIS Executives. At the headquarters level, SHN hired a Chief Financial Officer (CFO), Heads of Information Technology and Business Development, and a Procurement Manager. By the end of Quarter 3, SHN had 5,303 staff in 369 clinics; 22 in headquarters and 29 in regional offices. The SHN regional offices are in Dhaka, Mymensingh, Bogura, Sylhet, Chattogram, and Khulna2. In Quarters 2 and 3, SHN organized a series of orientation meetings for the SHN regional managers. The focus of the meetings was the SHN vision, mission, and values of SHN, roles and responsibilities of the regional managers and their key performance indicators, challenges and expectations in the effective management of the clinics, clinics licensing, human resources and administrative functions and responsibilities. In these meetings, the regional managers were briefed on the key policies and operations manuals of SHN that included human resources, procurement and financial management.

2 SHN divides Bangladesh into 6 regions combining parts of the normal administrative regions used by the Government of Bangladesh.

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To support the management of the regional offices, the SHN clinic operations team routinely conducted bi-monthly skype meetings with the regional teams. In Quarter 3, SHN applied for District Technical Committee (DTC) approval to serve GOB allocated population with family planning, EPI (extended program of immunization) and other public health mandate and began the process to obtain or update individual trade, fire, and environmental license as pre-requisites to hospital/clinic licenses. SHN also received an extension from the Directorate General of Health Services (DGHS) to submit applications for hospital/clinic licenses by September 30, 2019. Clinic management transition. The Bangladesh General Election on December 30, 2018 had an impact on the clinic management transition activities that occurred in Quarter 1. AUHC and SHN had to stop all travel for approximately three weeks. This delay in the transition process required AUHC to extend its grant agreement with Ad-din3 until February 2019 to continue managing the 79 clinics that were left to transition to SHN. The clinic management transition process of SHN clinics was completed on March 19, 2019 with the handover of Sherpur Clinic in Mymensingh region. With this, the total number of SHN clinics is 369. AUHC began the clinic management transition process with the intention of transitioning all 399 clinics. IMAGE, Niskriti and BAMANEH decided to retain 12 clinics bringing the number of clinics that SHN manages to 369. It is important to point out that these 12 clinics had received significant USAID investment in equipment and infrastructure, and were without exception, some of the best performing clinics in the network. Green Hill will continue managing 18 clinics in three districts in the Chattogram Hill Tracts through a fixed amount award grant from AUHC. While the physical transition of clinics and staff was completed by Quarter 2, AUHC had to finalize several administrative issues. Some NGOs had excess funds that needed to be transferred to SHN. By the end of Quarter 3, the NGOs transferred to SHN. By the end of Quarter 4, the NGOs transferred the remaining . As a result, through the clinic management transition, SHN received from the NGOs. With this, AUHC considers the clinic management transition complete. Incorporate primary research and desk review findings into SHN business plan. In Quarter 1, AUHC completed primary data collection for consumer and provider research for the market landscape. This activity was led by PSI who organized a data synthesis workshop to review the research findings and determine their usefulness for the SHN business plan (see text box for overview of market landscape findings). Following the workshop, AUHC hosted dissemination sessions and consultations, with USAID and SHN, and agreed on the next steps for incorporation and use of data in strategy and business planning for SHN. AUHC conducted the second data synthesis workshop in Quarter 2, to further distill findings from the market landscape, as well as the CSP and satellite assessments. AUHC did this in preparation for the SHN business strategy workshop that was held in March 2019. The presentation of these findings led to the revamping of the SHN core service offerings. A significant part of the market landscape dealt with consumer insights that was going to be integrated into the marketing strategy workshop PSI conducted in June 2019.

3 In Year 1, Ad-din agreed to act as a managing agent for 79 clinics that were run by 4 different NGOs. There were allegations of varying degrees of fraud and mismanagement among these NGOs that prohibited these organizations from receiving USAID funds from AUHC. Because SHN was not ready to take on this responsibility, Ad-din agreed to take on the management of these 79 clinics.

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SHN marketing strategy. In Quarter 3, PSI led a marketing strategy workshop. This activity clarified SHN’s vision for identifying the points of parity (POP) and points of difference (POD) for the network (as compared to other market actors both public and private) from the client’s perspective. Insights gathered from the market landscape were used to conceptualize SHN’s brand architecture (see Exhibit 1). This will serve as the basis for a creative agency to develop a branding and communication plan. The initial aim of this communication will focus on the new SHN image. Network optimization. During Quarter 2, AUHC initiated a network optimization exercise. The aim of this exercise was to determine how well the SHN clinics were meeting the needs of their target population and how to optimize service coverage. AUHC’s approach to this was categorize the 369 SHN clinics into four performance tiers: very poor, poor, average, and good4 (see graph below).

4 The performance tiers were based on service revenue, service contacts of the static and satellite outlets.

Overview of Market Landscape Findings

Customers: Providers:

Clinic look and layout: clients want a clean and tidy space with waiting room with good sanitation and ventilation

Pharmacies: Pharmacies all over the country are the closest competitors for the SHN, at the same time pharmacy network offer great opportunity for SHN to benefit from networking.

Service providers: clients want doctors who can provide a range of services in reproductive, maternal and neonatal care. Appearance and attitude of the clinic staff was cited as an important factor. Moreover, clients preferred providers that would answer all of their questions in an understandable manner.

Pricing: Prices of almost all SHN are below the market price, however SHN doesn’t seem to have stronger value proposition to clients compared to its competition. While it's possible to increase prices nominally in the short run, parallel efforts needed to offer better value from services in terms of service range, quality of provider and customer journey inside the clinic.

Operating hours: client’s want clinics to be available 24 hours a day for labor and delivery services.

Operating hours: Many of the (between 42 percent -92 percent) competitor outlets, as in private clinics and hospitals, operate in the evening hours and on holidays.

Clinic location: Proximity is major consideration for choice of a health service provider. SHN can build on its community outreach, particularly its

Exhibit 1: SHN Brand Architecture

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AUHC estimates that these changes, if fully implemented by SHN, would lead to a loss of 861,860 service contacts per year, and a loss per year in service revenue. At the same time, SHN would save per year in operations costs meaning that the net financial effect is that SHN would save per year. In terms of human resources, SHN would end up with 586 redundant staff that it will have to either retrench or redeploy. This does not consider the 550 vacancies that SHN currently has network wide. Nor does it account for the 82 new positions they would have to fill if they were to implement the upgrade (to Advanced and Basic clinics) decisions.

Key insights into AUHC’s network optimization recommendations. The optimization teams began to gather data prior to their field work. This information and information from their field work led to these recommendations. None of these clinics were offering the full range of services prescribed by the old SHN clinic architecture, let alone their capacity to do so with the new SHN typology which is more comprehensive. Many clinics lacked a doctor, trained birth attendant, lab technician, USG machine and the capacity to provided most of the basic lab services. The optimization exercise analyzed a clinic’s potential to increase service contacts with the provision of expanded services as well as the current service gaps to determine if upgrading to a SHN Basic Clinic would meet population demand and increase cost recovery. The factors that the teams considered in arriving at the decision to implement a complete closure of a static clinic included the following: • The clinic location is not suitable for the catchment population and is not attracting clients; • There are other SHN clinics within 3-5 km of this clinic; • Competition is strong from other GoB, NGO, and private clinics and/or hospitals offering a full

range of services; and • Satellites are either not generating a significant number of service contacts or they can be

merged with the nearest SHN clinic. No static presence is needed to continue the satellites.

For the clinics that AUHC suggested to be converted to satellite clinics, they were generating significant revenue and client footfall through their satellite outlets. In these cases, the static sites were not performing. Teams recommended existing clinics be converted to Satellite Clinics for the following reasons: • Satellites are generating more than 80 percent client contacts and more than 60 percent of the

revenue contribution of the static clinic is insignificant while incurring high operating costs; • If the static site is closed, satellites can maintain and generate equal or more client contacts and

revenue; • There are other options for health services, particularly with diagnostic and doctor’s

consultation services nearby; • Community level presence and reach through satellites is required for delivering health impact;

and • The cost of maintaining the existing level of static clinic operation is not justified, a much leaner

structure is needed to continue satellite spots. The recommendation to upgrade an existing clinic was made because the teams felt that investments in new equipment (lab, USG) and recruiting service providers (doctor, lab tech) were needed and was going to significantly increase the client base and health impact in the catchment area. The following insights underpinned this recommendation: • The clinic is in the city center or strategically placed to attract a much larger client base; • The clinic is in a densely populated area with fewer (than required) health service options;

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• The clinic has the potential to serve more clients in the locality because of the unmet need for lab services, especially USG and other services related to screening for non-communicable diseases; and

• Consultation with a medical doctor and other specialists are in demand and not currently met by the existing public and private health service providers in the locality.

Finally, the optimization teams recommended a few clinics be upgraded to Advanced Clinics, because: • The clinic is situated in an urban or semi-urban location with high population density; • There is an unmet demand in the locality for labor and delivery services, including cesarean

section capacity; • Although other private providers exist, SHN’s pro-poor pricing strategy offers comparative

advantage; and • The clinic has high acceptance to the community.

Network optimization implementation. In Quarter 4, AUHC and SHN conducted a workshop to develop an approach to implementing the network optimization decisions. Attendees included SHN headquarter staff, AUHC results leaders, and the SHN Regional Managers and HR Executives. The biggest concern was how to approach the staffing change since that will most likely pose the most risk in the process of implementing the optimization decisions. Fortunately, there are over 550 vacant positions in the network that can potentially absorb as many as people in different roles in other clinics in the same regions. SHN plans to offer opportunities to staff affected by the optimization decisions to transfer to other regions. For those unwilling to accept a transfer, (s)he will be offered a separation package as per the company policy (compliant to labor law). AUHC and SHN identified the following critical network optimization implementation milestones:

• Human resource realignment • Satellite spots redistribution • Legal closure of the rental agreements • Asset disposition and transfer, and • Stakeholder engagement (communication)

AUHC will assist SHN implement all these decisions by January 2020. IR 1.2 Standardized Corporate Operating Systems Designed and Implemented Financial management system. In Year 2, AUHC supported SHN in developing its financial management system, that included developing financial management policy, finance and accounting manual and an accounting software for use by the entire network. A chart of accounts was developed as part of the finance and accounting manual, ensuring that the financial data can report into a P&L (profit and loss) statement for SHN. Based on the number of transactions and activities of each business unit (clinic, region, head office), AUHC and SHN determined that full software capacity should be introduced in SHN regional offices, the SHN head office, and in 43 Advanced Clinics. Accordingly, by the end of Quarter 2 the accounting software was rolled out with full functionality in all Advanced (CEmOC) clinics and an excel based system was introduced in remaining clinics by the end of Quarter 3. It was also ensured that the excel based system could export data into the regional systems, and the SHN HQ could then import regional data into the central accounting system. As a result of implementing the accounting system, and cost data reporting into a uniform charts of accounts SHN was able to generate network level P&L statement starting from April 2019.

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SHN Health Management Information System. In Year 2, led by PSI, AUHC started developing an HMIS system for SHN that would allow the social enterprise to monitor and assess its health impact and contribution to the universal health coverage mandate of the GoB. At the core of this system is the Electronic Medical Record (EMR) for the client that will be used to capture data from different touchpoints of a patient journey from check-in (registration) through check-out (billing and payment) and follow-up. The HMIS will be built on the DHIS2 platform, an open source HMIS software, that will pull client/user data from the EMR, aggregate and provide necessary business analytics for SHN. It will be used by SHN HQ and regional offices to analyze service (including product) utilization and revenue data, using pre-designed dashboards. AUHC is also working on a Health Network Quality Improvement System, an application that synchronizes data into the DHIS2 platform and provides the analytical framework for quality assurance of a network. Using HNQIS, SHN QA staff will be able to score clinics on different aspects of quality, grade them, list and assign (to people) issues to work on and monitor progress. SHN users at all levels will also have the flexibility to customize their respective dashboards based on current and evolving business needs. Led by PSI, AUHC will build SHN’s capacity so that going forward, SHN is able to maintain the system, troubleshoot, improve and expand on the system as needed. SHN users at all levels will also have the flexibility to customize their respective dashboards based on current and evolving business needs. AUHC, led by PSI will build SHN’s capacity so that going forward, SHN is able to maintain the system, troubleshoot, improve and expand on the system as needed. Pilot the paper-based system for HMIS. PSI is continuing to advance the development of the Health Management Information System (HMIS) for SHN that was started in Year 1 in 20 SHN clinics. PSI conducted a training for the clinic staff that will be using the system. These clinic staff, in turn, organized training for other colleagues in their clinics. Starting in November, AUHC incubator and MERL team members monitored the progress through site visits providing on the spot direction and assistance as needed. Design and develop EMR. Due to the large number of the SHN clinics, the variations in client load, the range of services provided, the average revenue, and staffing structure and capacities, AUHC will use a modular and segmented approach to the EMR System implementation. AUHC aims to target the clinics with the highest client load and revenue for the full EMR to enable real time data capture, update and analysis and greater visibility of client and service data. Once all the static clinics have EMR Systems up and running, and its operation and use is stabilized, we will gradually include the satellite clinics into the EMR System. In Quarter 2, PSI invited technical and financial bids from prospective Bangladeshi vendors for development and implementation of DHIS2 Health Management Information System (HMIS) and Electronic Medical Records (EMR) System in Surjer Hashi Network (SHN) clinics. In March 2019, PSI formalized an agreement with mPower to develop SHN’s electronic medical records system (EMR). In April, mPower visited several clinics, analyzed different types of clinic operations, collected and reviewed the paper-based tools being used by the clinics. Based on several consultations with the AUHC MIS team, mPower submitted a draft requirement for software specifications in June. An EMR money receipt module was also developed in this quarter. mPower developed training materials for the money receipt module that were used to train 40 staff in 20 pilot clinics in June 2019. SHN’s MIS staff also took part in the training. Additionally, AUHC provided each pilot clinic a new laptop to run the money receipt module. In preparation for hosting the EMR system, PSI also released a request for proposals (RFP) for the procurement of a cloud-based server. Several mockups of the system design and patient workflow were developed in June for testing at SHN clinics, regional offices, and headquarters. The MIS team worked closely with the service delivery team, MERL team, and the incubator team to arrive at the list of standardized (by clinic types) services, align and update the existing service codes for integration into the new MIS system.

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Health Network Quality Information (HNQIS) system. The Regional Quality Assurance Managers (QAM) are currently using excel-based supervision checklists to be used for HNQIS development, filling them using hand-held tablets during their clinic visit and reporting back to the QA Director for compilation and further analysis. Based on this analysis, the AUHC QA team can grade clinics, record and provide recommendations for improvement in different aspects, that include physical facility improvement, infection prevention, service providers’ competence, infrastructure readiness and so on. Before introducing the digitized HNQIS on the DHIS2, this process and analysis will enable AUHC to understand the suitability of the QA tools for SHN. The next step in year 3 is to digitize all the checklists in DHIS2, create dashboards for different management tiers (clinic, region, HQ) of SHN and enable the management to make decisions and take actions for quality improvement in clinics. Centralized procurement of drugs and over-the-counter (OTC) products. Beginning in Quarter 1, led by the ThinkWell, AUHC began working on centralized procurement of products for SHN. The objective was to streamline the number of products, negotiate better prices and terms across a streamlined set of suppliers, optimizing stock levels at clinics and across the network. This process was difficult as there is a paucity of data on the inventory and sales of drugs. This was further exacerbated by the fact that clinic-level data was only available manually in paper files and records. As such, the Incubator team started to organize and analyze past data from drug and other product sales from 20 SHN clinics. This entailed transferring paper-based records into excel files, categorizing data by therapeutic and DAR (unique identifier provided by the Drug Administration) codes, cleaning, and sorting data. AUHC’s analysis indicated that the current approach to purchasing, management and sales of pharmaceutical products, is not optimizing the revenue and profitability potential that it could. For example, data shows that initially, SHN had over 6,000 different items Stock Keeping Units (SKUs) of drugs to deal with. Only 1,088 of these items sourced from 22 suppliers were regularly used. Furthermore, 80 percent of the revenue from sales of drugs comes from 163 items sourced from 13 suppliers. This confirmed that SHN was not taking advantage of its trade volume and scale to negotiate better prices, better delivery times, and payment terms with drug suppliers. Based on this analysis, AUHC developed a priority (by revenue and volume) list of generic drug categories. Then working with SHN developed a shortlist of suppliers and selecting up to three suppliers per category of drugs based on best price and other terms. By the end of Quarter 4, SHN began purchasing drugs and commodities from this new list of suppliers. The new agreements with the suppliers will change the sources and prices of drugs and OTC products, but the processes for drug procurement will not change, as clinics will continue to procure directly from the suppliers. SHN plans to introduce a centralized procurement system, by centralizing inventory management and ordering at the regional level. This could potentially involve consolidating payments at the regional level. During Year 3, the AUHC Incubator will support SHN to design and build out a centralized procurement system, by making sure that an inventory management system is in place that links to other systems like HMIS and accounting. AUHC will closely monitor the outcome of the new agreements with the suppliers to gauge financial outcomes as well as the actual volume uptake and utilization by the new prioritized list of drugs and OTC products. IR 1.3 Improved financial sustainability of Surjer Hashi Network (SHN)

In Year 2, through the process of SHN business strategy development, AUHC was able to define SHN’s approach to financial sustainability and initiated several strategic activities for SHN to embark on its sustainability journey. In the first strategy workshop conducted at the end of Year 1, AUHC envisioned SHN’s financial sustainability through revenue protection, revenue growth and income diversification. In that workshop, AUHC agreed to prototyping a number of ideas to start testing some of the revenue protection and growth ideas. In Quarter 2, those ideas were further refined in view of SHN’s baseline financial performance and capital needs assessment. After the second SHN

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4. Network Need i.e. COGS, clinic-expenditure and SHN HQ (including regional) does not change in the following years, Inflation adjustment and additional costs (e.g. seconded positions etc.) is assumed covered by efficiency gains

5. USAID funding for 2020 is assumed and will be adjusted by Chemonics.

During the SHN business strategy workshop, the AUHC incubator team recommended that SHN should focus on big gains in the short run, such as in pricing and discount strategy. Other recommendations include revenue protection in the top performing sites, and containing and prioritizing cost, particularly salary, fringe and honorarium/fees. Revenue diversification strategies that require high investment, for example capital expenditure, need to be prototyped on small scale to validate ideas, and decisions made based on the P&L. Finally, SHN would need to strategically plan for diversified sources of capital to fund growth and expansion.

Pricing strategy for SHN. Following the business strategy workshop in March 2019, AUHC and SHN agreed to establish minimum standard price for SHN services and products. It was evident that fees varied widely. Introducing a minimum standard price for the SHN’s service portfolio was the logical first step to reach a more standardized pro-poor pricing across the network. This, in combination with standardized services, would then allow SHN to track impact of pricing on client uptake and utilization of services as well as on its revenue. Experience from the minimum standardized price will inform SHN’s choices for more stable price points in future compared to the market. There also can be potential for SHN to benefit from differential prices across types and geographic locations. SHN’s two-pronged pricing strategy includes setting up a minimum standard price at first and then pursuing a Quintile 2 target price, which could still be 20-30 percent below the market price. This second level of price adjustment is recommended to take place in 2020. By that time, SHN is expected to significantly improve its service offerings, clinics’ physical infrastructure and facilities, as well as service quality.

The minimum standard pricing, initiated by the AUHC Incubator team, was an internal benchmarking exercise. The team, with the help of SHN, collected and analyzed price list data from 367 clinics using minimum, maximum, percentiles, mode, and median prices by clinic type, clinic location (urban and rural), and regions (Dhaka, Khulna, Mymensingh, Bogura, Chattogram and Sylhet). All the services in the price lists have been segregated into four categories: consultation, screening, and counselling services (by both Paramedic & Doctor); diagnostic services (lab & imaging); delivery (normal delivery, home delivery, & Cesarean); and others.

Exhibit 3: Benchmarking pricing strategy for SHN

Exhibit 2: SHN Projected Capitalization Plan

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community to gauge gaps in existing service provision, compared to the needs and expectations of the target community. GE Healthcare. GE Healthcare is looking to partner with AUHC project to develop a program in Bangladesh to support skills and capacity development of community outreach and other health workforce. AUHC sees this as an opportunity to mobilize resources for regrouping and channeling SHN’s community outreach cadre, known as the community service providers (CSPs). AUHC conducted a strategy workshop with a regional team from GE Healthcare from India in April 2019. AUHC and GE Healthcare discussed GE Healthcare’s capacity and willingness to support AUHC in maximizing the effectiveness of SHN’s CSPs by offering training, technology for operations and business development support in product marketing and service delivery at the community level. GE Healthcare also expressed their willingness and plan to mobilize resources from other potential partners and stakeholders to support their involvement. AUHC has been revisiting SHN’s outreach strategy, to reorient and recalibrate its CSPs through an entrepreneurship model where CSPs will have an expanded product basket and capacity to offer a range of primary care services at the doorstep of the community. AUHC has been in discussion with other potential partners to design a pilot for testing an entrepreneurship model for SHN CSPs. In the beginning of year 3, once the pilot design is finalized, AUHC would further assess resource requirements, and develop a concrete proposal for collaboration with GE Healthcare to jointly mobilize resources and implement the pilot. Local and multinational health/hygiene consumer products marketers. In Year 2, AUHC initiated discussions with a few local and multinational consumer brands for SHN to partner with, to source products for sales and distribution through the CSPs, as well as to leverage SHN’s last mile presence and create additional income streams for the CSPs by supporting campaigns of these consumer brands to increase health and hygiene seeking attitude of the target clients. AUHC met with ACI consumer products and Square Toiletries and received very positive response from these brands to collaborate on last mile distribution of products like sanitary napkin, Savlon/Dettol soap, fortified food and so on. Digital Financial Services. In Quarter 3, AUHC had discussions with ‘Nagad’ and Bkash, two revolutionary digital financial service (DFS) initiatives in Bangladesh that offer transaction solutions to the mass market, particularly the unbanked rural and semi-urban community. These discussions focused on identifying how the nationwide platform of millions of users (and growing everyday) of these DFS platforms, can be utilized to motivate them to seek health services from SHN. AUHC understood from these primary exchanges that it was possible to use the DFS platforms as a customer acquisition channel for SHN, leading to new service package development (bundling) tied to payment methods offered by the DFS partners. Also, AUHC thought that the CSPs of SHN could gainfully engage in the agent network of these DFS partners. AUHC plans to support SHN to advance these early exchanges through more concrete ideas in year 3. IR 1.4 Value-Based Payments Implemented to Drive Performance There was no activity under this sub intermediate result (IR). In September 2019, AUHC submitted proposal to USAID to remove this sub IR from the AUHC results framework. The justification was that the original aim was to provide financial incentives to motivate better performance by service providers and clinic staff based on a pre-determined set of indicators or outcomes. As it turns out, this would be very hard for SHN to manage and track, there is significant evidence to suggest that financial performance incentives are not sustainable.

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

Overview of accomplishments. During Year 2, AUHC prototyped the extension clinic hours to offer services in the evening through SHN clinics. Learning from this prototype (refer to the text box: extended clinic hours prototyping), SHN has scaled up and extended/ optimized hours of operation in 52 Basic clinics across the network. AUHC developed a referral strategy that can be used when SHN refers patients to facilities outside of the Surjer Hashi Network. We now have identified SHN clinics where we will rollout eye care services and place the GeneXpert machines. AUHC trained a total of 765 SHN staff in the rollout of the minimum standard price, counseling, infection prevention, the use of the TALLY software, and the SHN MIS system. AUHC also completed the Satellite and CSP assessments, finalized the SHN clinic typology and the SHN brand architecture. Year 3 focus. Under this result AUHC will focus on strengthening service delivery in SHN clinics to include service expansion, improvement in customer experience and client satisfaction, and improving client information and their capacity to make informed decisions. AUHC will also develop a comprehensive capacity building approach for SHN clinic staff. Part of this is developing standard operating procedures (SOP) that can give guidelines and regulations for the implementation and provision of services. In terms of strengthening services, AUHC will introduce eye care services in five SHN clinics. Substantial efforts will be made in Year 3 to further mainstream TB services in SHN network, in view of the different tiers of SHN clinics according to the new typology. Specific attention will be devoted to outreach activities through satellites and CSPs for TB screening and referral. In response to the incidence and prevalence of non-communicable diseases (NCDs) AUHC will support the introduction of NCDs

Extended Clinic Hours Prototyping: AUHC prototyped extended hours in six SHN Basic Clinics in Sylhet (urban clinic) and Rajshahi (rural clinic) regions. The prototyping started in April 7, 2019 in 3 urban clinics (Upashahar, Tukerbazar and Chhatak) and April 27, 2019 in 3 rural clinics (Paba, Singra and Baraigram). All clinics extended their operating hours by three hours from 5:00 pm to 8:00 pm. AUHC and SHN Regional staff visited each clinic during the inception and pilot period to steer the changes, provide oversight, and gather insights from the activities. The prototyping exercise in these clinics provided critical insights that are summarized below: • 30 percent of the clients that came during the extended hours

were new to SHN; • 34 percent clients were working men and woman and students • 24 percent of the clients were male. • 84 percent of the total number of clients who came to the

clinic came during 11:00 am - 7:00 pm AUHC learned the following that can be applied when scaling-up this intervention in other SHN clinics: • Shift clinic hours from 11:00 am to 7:00pm to cater to most

clients and ensure optimum use of resources and manpower, without having to incur additional costs.

• Split medical officer’s operating hours into two shifts and reallocate paramedic hours to cover for the gaps. Medical Officers prefer to work in shifts, like morning, afternoon/evening than committing to a full-time role.

• Plan and activate targeted marketing communication to promote 11:00 am to 7:00 pm as new clinic operation hours. Exceptions will be made for the Government of Bangladesh’s Expanded Program of Immunization (EPI) days. Point of service and interpersonal communication activities like public communication (miking), banners, leaflet distribution, and staff and CSP word-of-mouth communication bring new customers during the extended hours.

• Prototyping the roll-out requires working hands-on at clinic level to motivate clinic staff to bring changes. Providing only the guidelines alone will not ensure the success of the prototype activities. Presence of prototyping team at the clinics to check clinic and staff readiness, discussion to solve the staffing issue and guide the clinic staff in prototyping activities helps the clinic to roll out prototyping.

• Employ medical officer as soon as possible as SHN customers prefer medical officer over paramedics for most services.

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screening, treatment, and follow up among all clinic types. Another need is the introduction of specialist medical services. IR 2.1 Enhanced service package offered through Surjer Hashi Network

Tuberculosis. In Quarter 2, AUHC conducted an evaluation to determine where to install GeneXpert diagnostic machines, based on clinic infrastructure and alignment with the National Tuberculosis Program (NTP) geographic coverage needs. These findings and information were integrated into a more complete proposal that covers the full range of services that SHN must provide related to the prevention, screening, diagnosis, and treatment of tuberculosis at all levels of care, as well as follow-up after the establishment of treatment. Eye care. On behalf of SHN, AUHC finalized the scope of work with Fred Hollow’s Foundation to introduce eye care services in five of the SHN clinics in Year 3. The plan (described in Table 2 graphic below) is for Fred Hollows to introduce refractive error services in five SHN clinics. The first will be in three Basic Clinics in Mymensingh region, followed by two clinics in Sylhet region. The three clinics in Mymensingh region include SHN clinics in Jamalpur, Tangail Sadar and Melandah. Fred Hollows will use first three months of a one-year project to prepare clinics, procure necessary equipment. SHN referral strategy. In Quarter 3, AUHC drafted a patient referral protocol. This protocol includes information on who, why, and how patients are to be referred to other health facilities. Human Resource assessment for SHN. This activity will be delayed until after the first round of the clinic optimization exercise is completed.

Counseling training. In Year 1, AUHC determined that the counseling services currently being done in SHN clinics needs to be strengthened. Counseling tended to be one-way, and information-oriented; not based on the needs of the client. Moreover, there was no standard approach and in many cases knowledge of contraceptive technology was weak. AUHC developed a standard definition and framework for counseling and deployed these across all SHN services, not just family planning. SHN agreed that all service providers need to basic counseling skills so they can effectively assess customers’ needs, knowledge, and concerns, and to assist with decision making. AUHC hired and trained four counseling trainers who have in turn trained 128 SHN staff in counseling. Infection prevention training. As infection prevention plays a vital role in the delivery of clinical services AUHC has utilized the Ad-din Medical College Hospital as a venue for delivering infection prevention training for SHN clinic staff. The priority was to begin with the SHN Advanced clinics. In Year 2 a total of 244 SHN staff were trained in infection prevention. Quality Assurance training. 52 staff received quality assurance training in Year 2. Clinical training. AUHC met with the Obstetrical and Gynecological Society of Bangladesh (OGSB) regarding safe delivery, comprehensive newborn care package (CNCP) and clinical management training. Implants, IUD, Family Planning Clinical Services and Contraceptive (FPCST) training will be outsourced to government approved training institutions. This training will start after the network optimization exercise because the optimization exercise will review (and potentially redistribute or replace) clinic staff. AUHC conservatively estimates that about 890 SHN staff need to be trained in these key areas. Satellite and CSP Assessments. The satellite spot assessment report was finalized in Quarter 2 reporting period. The CSP functionality and sustainability assessment report was finalized in Quarter 3. Please refer to result 5 for details discussion.

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Motivation of service providers and client satisfaction. In Quarter 1, AUHC procured marketing materials to improve provider motivation and promote normal deliveries. These items included T-shirts and caps with the SHN logo and certificates for service providers. The certificates will be given to staff with an idea of client's preference to that staff who is the best in term of having good behavior and care from the client perspective. These materials have been tested in eight clinics during clinic visits during this quarter. SHN clinic typology. During the third quarter AUHC, as part of the network optimization exercise explained under IR 1.3, SHN revised its core service offerings in three types: Advanced, Basic, and Satellite.

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the brand architecture, the AUHC marketing team developed the narrative for a creative brief that will be shared with the advertising agency to plan and develop branding and communications for SHN. In Q4, SHN onboarded an advertising agency. It was agreed in the Marketing Planning Workshop that the next step in developing a marketing plan for SHN would focus on specific marketing activities geared toward a) communicating SHN’s service offering delivered through its channels- Advanced, Basic and Satellites and b) communicating specific services and benefits to existing and potential clients. AUHC will look at specific service areas like family planning, maternal and child health (MCH), NCDs, eye care services and tackle very specific objectives such as: - deepening uptake ANC services to ensure that clients are utilizing 4 ANCs, - promoting use of growth monitoring services, - NCD screening and referral to attract men into the SHN network.

The next marketing planning activity scheduled for year 3, will detail how different channels and tools could be enabled and utilized to achieve the communication goals. Part of this is about clarifying how AUHC is applying marketing strategies to support SHN business strategies like extending clinic hours, pricing, and the discount policy. In addition, the plan will demonstrate how social behavior change communication (SBCC) is related to specific marketing objectives, for example ‘promoting growth monitoring’ will require a concerted marketing effort at the center of which is ‘behavior change’. By fleshing out the marketing plan, it will be possible to demonstrate the role of SBCC through clinic staff and providers as well as the outreach arms (satellite and CSPs) of SHN.

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

Overview of accomplishments. During this year, AUHC completed a review of the various poverty targeting mechanisms, conceptualized a minimum standard price and discount strategy and help SHN roll it out to 223 clinics. Also, the AUHC incubator team developed a profit and loss (P&L) statement for SHN to use to measure their financial health. Year 3 focus. AUHC support to SHN will focus on assessing how the new prices are impacting customer contacts, uptake of services, and revenue. AUHC will collect qualitative insights and quantitative data to assess impact of these changes. After implementation of the minimum price and discount strategy that occurred in Year 2, AUHC’s goal in Year 3 is to get SHN on a trajectory of sound financial health by implementing revenue growth and diversifications measures, that include expanding on existing service reach and coverage, introducing new services as well as exploring new revenue sources through private sector, community and the Government of Bangladesh. It is also understood from a preliminary analysis of SHN’s existing funding pipeline that SHN must look for other sources of capital and funds to continue its investment on revenue growth strategies by improving on the existing infrastructure and human resources, technology and equipment. IR 3.1: Subsidy Funding to Cover the Poor Operationalized

Review of current policy and practices of poverty targeting. In Quarter 1, led by ThinkWell, AUHC began a review of poverty targeting mechanisms to pinpoint the gaps, challenges, and opportunities for SHN clinics to balance subsidy funding. The objective was to review existing practices, cross check MIS information, and monitoring by going to clinics and observing the discount operation for the report. The report was completed in Quarter 2. Key findings from the report include:

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• Vague and incomplete guidance. The basic criteria for identification of poverty by SHN is very general and vague with no corresponding tools or guidance to ensure consistency in how the criteria are interpreted or applied.

• Lack alignment with national trends and GoB initiatives. The criteria currently being used by SHN is

neither tracked with poverty trends in Bangladesh, nor aligned with any poverty identification mechanism used by GoB agencies to target the poor. This results in vast discrepancies in the current proportion of population that are in fact poor compared with the long-standing goal of 40 percent of service contacts targeting the poor. This target does not recognize significant reductions in poverty in the country over time. Similarly, the poverty identification processes used by different government initiatives have not been referenced to update the poverty identification process within SHN.

• Unverified and outdated data. Key informants within the SHN system reported that though the

community-level identification of the poor through mapping was completed in many locations, these were rarely endorsed by the local authorities and have not been updated since they were first completed following release of this policy in 2014.

• Complicated application process. The process of poverty identification as designed in the 2014

NHSDP Guideline is overly complicated given the central role of the counselor to apply the discount, and who typically does not have enough time or interest in faithfully following the process.

• High level of discretion and pressure of perverse incentives. Given the lack of clearly defined criteria,

standardized processes, performance indicators towards generating service contacts by identified poor clients, and a lack of systematic monitoring over the process, there is a large amount of discretion – primarily by clinic counselors – to make the sole decision on the poverty status of a client. This is particularly problematic given the target of 40 percent service contacts as it creates perverse incentives for clinic staff to provide discounts and free services.

Following on the detailed report and gap analysis, a robust pricing strategy along with guidance for discount policy development and rollout approach was proposed to SHN. The first task was to standardize services and prices in the network. The current range of services and the prices at which they are listed in the 369 clinics varies significantly. This prevents accurate revenue tracking and creates opportunities for corruption within the system. Through the current exercise of determining minimum standard prices across all service types, prices can be set that move towards overall standardization within the network. Price points should be set for affordability by clients in the second wealth quintile yet should aim to be below market prices. A companion to the standardization of the SHN price points is a revised discount policy. With prices set for the majority of SHN clients in Quintile 2 through Quintile 5, the discount policy can be an exception to ensure the potential clients from Quintile 1 are also able to access SHN services. A clear and simple policy, with very limited exceptions, will ensure consistent application. For this to happen, SHN should discontinue the FCC or family care cards that are for the able to pay, and HBC cards or health benefit cards that are for the poor. . As the SHN pricing strategy is targeting the poor (Quintile 2), the FCC for the able to pay and the HBC card for the poor are no longer needed. In Quarter 4, AUHC worked alongside SHN to roll out the new discount policy and introduced the Client Relations Officer (CRO) role to offer consistent front desk customer service across 223 clinics. As per the new discount policy only LA (Least Advantaged, poorest of the poor) card holders and any GoB social safety net beneficiaries receive discount at SHN clinics. Any exception to the policy or request for discount from the HBC card holders (health benefit card holders, for the poor) or FCC (family care card, for the able to pay) card holders would need regional managers approver and detailed justification from clinic managers. The discount policy remains the same for satellite

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clinics, except that HBC card holders would also be entitled up to 25% discount if they come for services at satellite spots. To track and control the new discount policy AUHC developed a discount tracker. The discount tracker will be maintained by the CRO, approved by the clinic manager, and reviewed by the respective regional manager. The discount tracker establishes accountability of clinic managers for taking the decisions to exercise their discretionary authority to offer discounts to anyone other than the poorest of the poor. The concept of CRO was introduced to create a front desk in each clinic for clients to approach, get registered and get information on their entitlements to discounts and other benefits according to the SHN policy. SHN developed a policy under which all counselors of 223 clinics were re-designated as CRO. The CRO’s role is defined as the first touch point at clinic level for customers, responsible for registration, preliminary client communications and transactions for services. On September 15, 2019, AUHC rolled out the minimum standard prices, new discount policy, and CRO across 223 clinics. To do so, AUHC conducted a robust orientation and training for SHN Regional team, clinic staff and CRO to understand the new policy, recording and reporting mechanics. Currently all 223 clinics of SHN are providing discount according to new discount policy maintained by CRO, approved by clinic managers.

IR 3.2: Prepayment/insurance package developed and available During the reporting period, Green Delta Insurance Company (GDIC) proposed an initial budget based on the scope of work drafted the previous quarter, which envisions initial piloting of their insurance product to up to 100,000 households in 6 regions. In Year 2 Quarter 3 the AUHC Team had reviewed and negotiated the time-and-materials subcontract budget and was prepared to execute the subcontract. However, AUHC found there was little or no evidence of a successful

Exhibit 5. SHN Discount Tracker

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RESULT 4: IMPROVED QUALITY OF CARE

Overview of accomplishments. In Year 2, quality assurance and improvement (QA/QI) team was fully operational with the onboarding of 10 regional quality assurance managers (QAMs). The team adapted SHN clinical services protocols on FP, MCH, adolescent health, TB, Nutrition and NCD services. This was guided by the Government’s approved Standard Operating Procedures (SOP), UNICEF and WHO guidelines, and USAID’s feedback. The team also developed the SHN Clinical Quality Assurance and Improvement System that includes clinical quality, supportive supervision, and physical facility checklists. AUHC QA/QI team visited 287 clinics prioritizing 43 Advanced clinics in the Year 2 to facilitate practice of these checklists in clinic settings and provided on-the-job orientations to the service providers aiming to improving clinical service quality. AUHC experienced 18 adverse events in Year 2. One of the focus areas for the QA/QI team in Year 2 was to embed a culture of reporting, adapting lessons and disseminating best practices network-wide to avoid adverse events. The team developed a medical emergency system that incorporates emergency response protocols within and outside SHN networks, as well as emergency referral mechanisms through the MOU with private and public organizations. The systems were implemented in March 2019 and AUHC installed oriented clinic managers from 43 SHN Advanced clinics SHN regional managers. The QA/QI team developed a phone call survey tool to capture customer experience that has been finalized with USAID and SHN and shared on May 29, 2019. The team has practiced this tool among 378 SHN clients and found that 87 percent of the clients were satisfied. Part of measuring SHN staff satisfaction, the team has developed a questionnaire set and surveyed 31 staff and found that 67 percent of the staff were satisfied. Year 3 focus. In Year 3, AUHC will be building on the foundation laid in Years 1 and 2 as this year AUHC will put a considerable amount of effort into transitioning the role of quality assurance and oversight to SHN. AUHC has developed the general approach, established the components of the quality monitoring system, developed the processes and tools, and trained the AUHC Regional Quality Assurance Managers (QAM). In Year 3, AUHC will transfer a minimum of 8 of the 10 QAMs to SHN. They will become SHN employees and report to the SHN Regional Managers. Once this transition occurs in April 2020, and the AUHC QAMs have been imbedded in the SHN regional teams, AUHC will take on more of an oversight and monitoring function to oversee the work of the regional quality assurance efforts by SHN. AUHC will retain a maximum of 4 QAMs who will support this function. In addition to the quality improvement transition, AUHC will continue to support the clinic upgrades. AUHC will also work with SHN to implement the new SHN counseling approach where all service providers are expected to be competent in counseling so they can provide this service when required. Additionally, in Year 3, AUHC will continue to measure customer satisfaction and providers retention through tailored questionnaires and interview processes. AUHC’s QA/QI will continue to use the PDCA (plan-do-check-act) framework to guide the quality assurance activities.

IR 4.1 Improved Customer Experience

Customer experience. AUHC’s Quality Assurance and Quality Improvements (QA/QI) team developed an open-ended phone call survey questionnaire to assess customer experience at SHN clinics for all services the client received. The team conducted a random pre-test with 56 clients from 14 SHN clinics. The team finalized the tool by incorporating lessons from the pre-test and feedback from USAID in November 2018. By the end of Year 2, the QA/QI team conducted phone call surveys to 378 SHN clients from 287 clinics and found 87 percent of the respondents were satisfied with the services they received from SHN. The AUHC QA/QI team analyzed the

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shortcomings mentioned as part of the phone surveys. Several examples include, long waiting times, cleanliness, gender sensitive sitting arrangements, service providers behavior, technical competency, and absence of doctors. AUHC addressed these issues with SHN. As part of institutionalizing the system, the team placed a client’s comment box in a visible place and provided required guidelines for analyzing and way of addressing client suggestions. Moving forward, the AUHC team will work with SHN to orient newly created Client Relations Officers (CROs) who will be the first contact person in the clinic to encourage every client to add in a comment.

Clinics physical facility improvement. In Year 2, the AUHC QA/QI team monitored 287 clinics with a view to improve physical facility as part of their regular supportive supervision visits. The team made recommendations for improving clinics service delivery layout, facility improvement, service delivery equipment, technical capacity development, and emergency preparedness, for example; drugs and supplies. The team has provided on-the-spot support finalizing list of emergency medicine and supplies and orient the service providers on the usability of these drugs and ensured live saving drugs are available in the clinics.

AUHC QA/QI team and NGO transition advisor provided technical assistance to SHN for preparing a physical facility improvement plan of 105 clinics. The assessment includes internal painting, sanitation and hygiene, furniture and fixtures. SHN onboarded regional vendors in September 2019 to complete all renovation activities. The physical facility improvement of those 105 clinics will be implemented in Year 3. Besides, AUHC provided regular technical support to SHN for relocating seven Advanced Clinics; Aftabnagar, Khulna, Sylhet, Saidpur, Newtown, Paharpur, Bagmara and seven basic clinics in a suitable place to improve service quality that will eventually increase client volume and revenue.

IR 4.2 Continual Quality Improvement Systems Implemented

Service delivery tools. In Year 2, the QA team was fully staffed with 10 regional quality assurance managers attached with SHN reginal offices to provide technical assistance part of building SHN’s capacity to ensure quality health services. The team finalized clinical service delivery protocols and tools for family planning (FP), maternal and child health (MCH), adolescent health, TB services, and non-communicable diseases services in line with the GoB service standards protocols, WHO and UNICEF guidelines. The QA/QI tools covered three thematic areas; supportive supervision checklists, service guidelines, and anatomical models. Supportive supervision checklists include 18 services for example; FP, ANC, PNC, C-section, normal delivery and newborn care. The anatomical models were MaMa-U for PPIUD, Pelvic model for IUD and Rita’s Arm for Implanon. The team also developed tools for general readiness of the clinics such as in- and out-patient management, infection prevention, cleanliness, and referrals. All these protocols and tools have been finalized with input from USAID, SHN and AUHC internal team in July 2019. To implement the tools, AUHC oriented QAMs, SHN regional and clinic mangers, and service providers. Supportive supervision. In Year 2, AUHC QAMs practiced the tools in 287 clinics as part of supportive supervision visits and made recommendations to SHN for improving service quality. The QA/QI team selected 100 clinics, prioritizing SHN Advanced Clinics, based on client flow, revenue and cost recovery to implement full-fledged QA/QI system that includes an assessment of the physical infrastructure, staffing equipment, ranges of services, number of clients served, and client satisfaction. The team developed a scoring system based on the input-process-output and categorized into four categories-excellent, very good, good and fair. The objective of this analysis was to understand the baseline situation of quality aspects of these 100 clinics with a goal to ensure all the clinic being in the excellent category.

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consultant in April 2019 and finalized in June 2019. SHN has been involved in this development process and upcoming internal quality audits will be undertaken by the AUHC QA/QI team. Adverse Events Reporting. The clinics reported a total of 18 adverse events in Year 2. Of these adverse events, six were maternal deaths and the rest were neonatal. AUHC analyzed all these adverse events to identify root causes by categories of death. In case of maternal deaths, most deaths occurred during transport of the patients who were being referred to other facilities. AUHC found there was a lack of consistent ANC checkups in SHN clinics. The patients were unaware about the danger signs of pregnancy and were admitted to SHN clinics without prior screening and referral. In case of neonatal deaths, we found most cases were related to Perinatal Asphyxia, Intrauterine death, and Pulmonary Aspiration. However, AUHC found that SHN clinic management and service providers have lack of knowledge about emergency patient management, readiness of clinics to deal with critical patients, referral mechanisms, timely reporting and recording systems. To better manage and respond to these events, the AUHC QA/QI team developed an adverse events guideline with the objective of implementing an adverse event management system in SHN clinics. This starts from timely reporting, recording, adapting lessons, and disseminating best practices and ends with a continuous quality improvement culture in SHN clinics. The team developed a medical emergency system that incorporates emergency response protocols within and outside SHN, as well as emergency referral mechanisms through MOUs with private and public organizations. The system was finalized with input from USAID in March 2019 and is now being implemented in SHN clinics. AUHC first oriented the QAMs and then 43 SHN Advanced Clinics managers and SHN regional managers in April 2019. The orientation focused on application of referral protocols, ensuring ANC checks, post-operative follow ups, delivery by skilled birth attendant in case of NVD and C-section by a trained Obstetrics and Gynecologists, presence of anesthesiologist for C-section. The QAMs then provided on-the-job training for SHN clinical service providers on partograph, crisis baby management, and the process of referral. They also provided on-site technical assistance to identify and repair emergency equipment part of their supportive supervision visits. The QA/QI systems to manage adverse events efficiently is now in place and practiced by SHN clinics. The QAMs discussed the lessons learned from each adverse event with the clinic staff to avoid repetition of such events. As a measure of improving service providers skills, some technical staff such as paramedics and midwives were sent to nearby Advanced Clinics for a month with specific learning and skills development objectives. In the course of investigating the adverse events, the QA/QI team identified incorrect usage of drugs such Tiemonium Methylesulphate to reduce labor pain. The team immediately prepared a memo ensuring alignment with national MNH SOPs and sent the memo to all SHN Advanced Clinics to stop using these drugs. SHN referral system. Most of the adverse events occurred due to appropriate referral systems linked with timely transportation management. Therefore, the QA/QI team developed a referral protocol to effectively manage emergency patients care systems at SHN clinics. The protocol includes, emergency patient’s management, transportation, availability of emergency drugs and supplies. The team also developed an adverse event tracker SHN clinics to analyze the data for taking efficient corrective action to avoid adverse events. IR 4.3 SHN Staff Are Skilled and Retained

Staff satisfaction and motivation schemes for SHN. In Year 2, AUHC developed an “Excellent Service Certificate” to acknowledge the contribution of SHN clinic staff. The QA team visited five clinics and interviewed the clients in each clinic for selecting clinic staff based on client feedback. This was a pilot and was rolled out as part of initiating non-financial incentives. In Q4 of Year 2, the QA team developed a questionnaire set and surveyed 31 staff to assess their satisfaction level at the clinic. In this survey, 10 areas were covered, including responsibility, workload, work assistance, work hour,

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training, non-monitory incentives, work environment, distance from residence and recommendations for future. These plans will be rolled out next quarter. AUHC calculated SHN staff retention rate was 97 percent in Year 2 based on SHN 369 clinics human resources data.

SHN clinical training. The QA/QI team worked with the training manager and developed the training plan for SHN staff. The team has specific input on the clinical services training for the SHN service providers, including infection prevention, counseling, management leadership, safe delivery, emergency management, comprehensive newborn care package, IUD. AUHC has already provided infection prevention training for 244 SHN service providers in collaboration with Ad-din, counseling training to 128 staff, and quality assurance training for 52 SHN staff (pls see above training plan section under Result 2 for details).

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RESULT 5: IMPROVED PROGRAM STRATEGIES DRAWN FROM LESSONS LEARNED

Overview of accomplishments. AUHC MERL completed two studies in Year 2 titled ‘Satellite Spot Assessment of Smiling Sun Network’ and ‘Functionality and Sustainability Assessment of CSPs’. Both assessments were initiated through several consultative meetings with USAID and SHN that began in October 2018 to finalize the research questions, methodology and tools. AUHC organized a two-day research synthesis workshop on February 6-7, 2019 and disseminated research findings to USAID and SHN. AUHC then incorporated USAID’s suggestions in the final research report and adapted recommendations into program implementation for effective utilization of SHN outreach service channels. The MERL team finalized the AUHC learning framework in February 2019 building on USAID collaborating, learning and adapting (CLA) approaches (www.usaidlearninglab.org). The framework incorporated USAID guidance and suggestion on CLA visual flow of information and implementation strategies in October 2019. AUHC submitted the fourth version of the MERL Plan to USAID in March 2019 and received feedback in June 2019 that entailed guidance for AUHC to organize a technical meeting with USAID to finalize indicators, targets considering transition and network optimization implementation scenarios. The MERL team conducted 62 data quality visits in this year, as part of the supportive supervision to SHN for ensuring data quality, accountability and the use of quality data for evidence-based business decisions. The MERL team identified a need for data quality improvement based on findings from a desk review of clinic data; the team conducted a deeper error mapping exercise in 29 clinics that indicated an estimated 13.8 percent data inaccuracy at the network level. Pressing on that, AUHC institutionalized the data quality improvement culture in SHN by providing on-the-job orientation, required tools and guidelines. AUHC also developed four SHN Newsletters in Year 2 and embedded the skills to strengthen SHN’s corporate communications capacity. AUHC with support from Chemonics home office expert developed the ‘SHN branding and marking guideline’ that incorporated SHN’s new tagline “Serving with a Smile”, SHN values, color code, and logos. Year 3 focus. The priority for Year 3 will be to codify lessons learned and ensure that those lessons serve as the basis for evidenced-based decision making. AUHC will continue to improve data quality through DQA visits and MIS data error feedback to SHN headquarter and clinic staff. The MERL team will also collaborate with AUHC service delivery results and USAID implementing partners for rapid research on changes in service utilization by poor people aligned with national as well as USAID priority areas. IR 5.1 Capture Learning through Documentation, Research, and Analysis Research and pilot quality control technical assistance. In Year 2, the MERL team provided quality control oversight and technical assistance for piloting of extended hours in 6 SHN clinics, Market Landscaping study on providers and consumers, and pricing research for SHN’s pro-poor pricing and discount strategy. The team conducted rigorous desk analysis for SHN clinic categorization based on service contact and revenue performance that led finalizing the network optimization exercise methodology. The MERL team spearheaded the network optimization exercise by analyzing data from 140 clinics pre-visit and visiting 75 SHN clinics for local level planning. The team also presented primary and secondary analysis on SHN service statistics, client segmentation, and outreach service channels at the SHN business strategy workshop on March 3-6, 2019 and marketing workshop in June 2019. The team conducted 40 in-depth interviews from influencers’ health seeking decisions at family level as part of providing more information in the marketing workshop. The MERL team provided extensive support for rolling out SHN’s pro-poor pricing strategy and discount policy

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record client’s information in the system to count individual clients. Going forward, the MERL and PSI MIS team will jointly roll out the EMR system and gradually decrease use of the ACCESS system. Supporting HMIS development and piloting EMR. The MERL team worked closely with the PSI MIS team to develop the paper-based systems part of building the electronic medical record systems for SHN. The team worked with PSI MIS team and oriented 40 SHN clinics staff for implementing the paper-based systems. At the same time, the team monitored the implementation side of it and flagged some challenges encountered at the clinic level. Initially, the clinics were struggling with generation of unique identifier code (UIC) and systematically managing files of patient records. The MERL team visited three clinics in Bogura district for capturing lessons from the field and developing a learning brief. The best part of this internal collaboration was that the MERL team incorporated 80 new service codes and UIC in the existing ACCESS database system that will eventually allow the team to record client’s information in the system to count individual clients. Going forward, the MERL and PSI MIS team will jointly roll out the EMR system and gradually decrease use of the ACCESS system. Program management system. AUHC practiced SurveyCTO data capturing system from each visit of the clinics through clinic monitoring checklist, FP compliance, clinical quality, financial compliance. The MERL team oriented AUHC staff to ensure usability of the system in the beginning of Year 2. The AUHC team completed 447 SurveyCTO forms on compliance and program monitoring in Year 2. The system also supported the team to validate 68 periodic reports for grants payment. Training database. The AUHC MERL team worked with the training team and designed a training database to archive relevant data for future analysis and outcome measurement. Moreover, AUHC got access to the USAID TraiNet system to report required training information per USAID guidelines. AUHC trained 1,649 SHN staff in Year 2 and the information has been uploaded into the TraiNet system. Learning framework. The AUHC MERL team developed the Learning Framework consulting USAID’s collaborating, learning and adapting (CLA) framework and desk review of national and international implementation processes. This development went through several interactive sessions with USAID. The team presented the layout and components to USAID on October 23, 2018 that was developed with technical assistance from the Chemonics home office monitoring, evaluation and learning department. Incorporating feedback from USAID and the AUHC technical team, the team drafted the framework and shared in AUHC learning sessions and finalized in February 2019. IR 5.2 Apply Learning to Activities Learning sharing approach. The AUHC learning framework integrates practical tools and approaches for capturing activity learnings through research, prototyping, and pilot implementation that eventually incorporates into project collaboration and adaptive management. The approach follows a rigorous desk review of project information that has been captured through regular project reported data, DQA visits, and select lessons learned from SHN periodic reports for further development. In Year 2, we have drafted 4 evidence-based learning briefs that we have selected through interactive sessions with the AUHC technical team in the pause and reflect workshops. We also followed an after-action review (AAR) approach: a participatory evaluation activity under which the project teams shared challenges, lessons learned and way forward in a structured format. The MERL team then documented and synthesized the lessons learned and developed learning briefs that have been shared with teams for adapting in project implementation. Pause and Reflect workshop. Referring to earlier sections on the development of learning framework and learning sharing approaches, AUHC boarded ‘pause and reflect’ as an approach to validate the evidence-based learnings through sharing of AUHC’s major accomplishments, challenges and way forward. The MERL team organized three pause and reflect workshops in Year 2. The outcome of these have been disseminated to AUHC and SHN moving forward to bring coherence in project implementation activities. The ultimate objective is to bring efficiency in the program implementation

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adapting learning from the past. AUHC will continue this learning and adapting culture throughout the project period with more emphasis in Year 3. Data quality monitoring. While performing a desk analysis of clinic service data for the SHN business strategy, revenue generation plan, pricing strategy, the MERL team identified significant data inconsistency in recording, reporting and data management systems. Giving priority to this issue, the AUHC MERL team embarked data quality assessment (DQA) to ensure data quality for SHN business decisions. In Year 2, the team conducted 62 DQA visits following a scientific method. The main objective was to collect data from the field and triangulate for further improvement. The MERL team found data entry errors in the ANC, PNC, family planning, and child health indicators. To determine the extent of inconsistencies, the MERL team conducted an ‘error mapping’ exercise in Quarter 2 and estimated the prevalence of erroneous data that reported network wide. We will discuss this process and lessons under the lessons learned sections below. Overall, we found 13.8 percent data reporting error. Given the severity of this issue, the MERL team further provided guidelines, process and on-the-job orientation to SHN’s data staff as part of supportive supervision to improve data accountability and management systems. Annual portfolio review meeting. The AUHC MERL team planned and organized the annual portfolio review meeting on July 01, 2019 with all partners. The objective of this meeting was to strengthen collaboration and comprehensive planning moving forward with producing quality deliverables in the rest of the Year 2 period. AUHC discussed Year 2 accomplishments to date and lessons learned, reviewed progress on work plan activities, and discussed strategic approaches and key activities in Year 3. Green Hill clinic management. The MERL team implemented SHN’s data management systems in all 18 clinics in the Chattogram Hill Tracts and oriented all MIS staff in May 2019. Similar to the network optimization exercise completed for 140 SHN clinics, AUHC will perform an assessment of the CHT clinics to optimize service delivery and management efficiency across the clinics. AUHC organized a strategic workshop with USAID, Greenhill and clinics management on July 3, 2019 for effective planning of the optimization exercise. Moving forward, CHT clinic management will complete a static relocation and satellite redistribution mapping exercise so AUHC can plan an optimization exercise for the CHT clinics. IR 5.3 Disseminate Learning on UHC to Target Audiences

AUHC periodic reporting. The MERL team supported the project management to produce periodic reports part of the contract deliverable. The team is the central coordination point to work with AUHC result leaders and collate portfolio updates in the reports. Apart from that, the MERL team prepared other USAID and GoB reports as requested. USAID PPR report and SBCC reports are the best examples of that. The MERL team analyzed the quarterly and annual service statistics with programmatic justification for any over or under performance. Moreover, the MERL team played a significant role to streamline SHN’s work plan and reports part of sub-contract management that comes into effect from April 2019. The MERL team also structured a quarterly program review meeting that discussed about SHN progresses on achieving double bottom lines- health impact and financial sustainability. Communication materials. During Year 2, AUHC developed SHN’s corporate communication strategy, including its new branding guideline and values. The strategy incorporates the revised Surjer Hashi logo, branding and tag line message. The tag line was revised with ‘Hashi Mukhe Sheba’ meaning ‘Serving with a Smile’. Consequently, SHN has taken initiative to replace all old clinic signage, directional signage, promotional materials and administrative materials with new ones per new brand guidelines. SHN introduced new standardized prices for general health services and lab services across the network and AUHC developed lists for standardized prices for general health services and lab services and the design layout was shared with all clinics through SHN Regional Offices for

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hanging at the clinic. AUHC also developed talking points for Customer Relations Officer (CROs) on frequently asked questions on the ‘price increase’ and ‘network optimization’. AUHC in collaboration with USAID partner project Ujjiban adapted 12 small promotional videos on maternal, child, nutrition, TB and adolescent health and co-branded with SHN logo. These TV spots will be played at Surjer Hashi clinics’ waiting areas for raising awareness of the customers. The shooting of these videos was taken place at different Surjer Hashi clinics and are useful to build awareness on maternal, child, TB and adolescent health. International conferences., AUHC submitted an abstract titled ‘Community Health Workers of Surjer Hashi Network: Scopes, Challenges and Prospects’ on July 25, 2019 to the second international symposium on community health workers. The abstract was accepted for oral presentation at the symposium in November 2019. Social media management. AUHC MERL team created different social media platform, including Facebook, Instagram, and Twitter. In Year 2, the Facebook page followers have been increased to 1600 from 500 in the last year. AUHC consistently monitors effective utilization of the social media by SHN, stakeholders, development sector partners. Basically, AUHC and SHN share development activities, including visits by dignitaries, observations days and successes of the network. The contents are uploaded after completion of an event. This a strong tool for media monitoring as people across the network can express their feelings and opinions using this media.

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Success Story Providing Affordable, High-Quality Healthcare with a Smile Access to affordable quality healthcare is critical to the poor in Bangladesh. With out-of-pocket expenditure on health care still being high in Bangladesh, the poor and the poorest of the poor do not have equitable access to quality healthcare.

Mahinur Begum, a 27-year-old woman new to the Bashabo area in Dhaka, was nervous about the recurring fever of her two-year-old daughter Elma. Mahinur knew that going to a private clinic would be out of her financial ability, and she was not familiar with other clinics being new to the area. She had recently moved from Jatrabari, and there her family had frequented a Surjer Hashi Clinic. Finding a Surjer Hashi Clinic in Bashabo, she immediately took Elma to the clinic.

The doctor carefully examined Elma and performed a Widal test that was readily available at the clinic. After analyzing the pathological test reports, the doctor diagnosed Elma’s condition as a viral infection and treated her with proper medication and reassured Mahinur that Elma would be okay.

The Surjer Hashi Clinic in Bashabo is one of 369 clinics managed by pro-poor social enterprise Surjer Hashi Network (SHN), which is supported by USAID’s Advancing Universal Health Coverage (AUHC) activity. Since 2018, SHN has been transforming the 369 clinics in its network to provide the people of Bangladesh with high-quality primary health care, while offering financial protection for those who cannot pay for services. The network provides services across Bangladesh with the new tagline Hashi mukhe seba, meaning ‘Serving with a smile’.

From April to June, the Surjer Hashi Clinic in Bashabo provided 4,172 service contacts in child health, 2,107 cases of immunization, and 768 services for maternal health.

“I have a special bond with the Surjer Hashi Clinic network as I have received healthcare services during my three pregnancies and delivered all three children at the Surjer Hashi clinics,” said Mahinur. She added, “they gave me complete guidance during the toughest and scariest point in my life. They also offered every possible

healthcare service needed for my children. Whenever I came here, I noticed that they treated my child with a smile, treating them like family. I am really grateful to the Surjer Hashi Bashabo clinic for everything they did for my child.”

USAID’s AUHC will continue to advance progress towards universal health coverage through pro-poor social enterprise Surjer Hashi Network (SHN) and serve many more individuals in need like Mahinur and Elma.

Mahinur Begum with her daughter Elma, at the Surjer Hashi Bashabo clinic.

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YEAR 2 LESSONS LEARNED

Data integrity. AUHC conducted an error mapping exercise that included 29 SHN clinics that were randomly selected. After triangulating secondary data that was captured through a desk review with clinic visits, AUHC estimated there was a 13.8 percent reporting error network-wide in clinic service data. The main lesson learned of error mapping exercise was that many of the errors were either intentional or due to a lack of attention to detail on the part of the clinic staff. Furthermore, we believe that this can be attributed to a long history of performance-based grants in the network that has led to culture of data falsification or inflation. More importantly, we have learned that this behavior is proving hard to correct. Hands on training and support. The AUHC Quality Assurance/Quality Improvement (QA/QI) team has been working to improve the clinical quality in all SHN clinics. This was carried out by the AUHC QAMs. One lesson learned is the that clinic staff tend to adopt and implement the procedures and processes more quickly when hands-on trainings are provided at the clinic level by AUHC QAMs. The QAMs presence in the clinics has allowed them to provide a more hand-on approach that has a much better effect than group-based training. We found the same phenomenon to be true with the rollout of the EMR and HMIS system. Hands-on training at the clinic level is an effective approach. The earlier the hand-on training is organized, better the uptake and results. Behavior change. All the interventions that AUHC has introduced at the clinic level have required a change in behavior on the part of the clinic staff. The new SHN discount policy, the interdiction of the Customer Relations Officer, the HIMIS system, the QA/QI system have all required a change in behavior. We have found that these changes in behavior is some not all instances have been hard to manage. As a rule, clinic staff have been resistant in some ways to new ideas. In some cases, it is because the change requires additional work or a change in the way that clinic staff do business. This resistance has been overcome by consistent follow up and hands on mentoring. Unfortunately, effecting this change in behavior has taken longer than anticipated. Part of this is due to the fact that all of these interventions have included a larger number of clinics and staff. Going forward AUHC will have to account for this in the way that we approach new interventions or changes at the clinic level.

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COLLABORATION AUHC has strong strategic collaboration with USAID implementing partners and Government of Bangladesh (GoB) particularly in the area of health service delivery, systems strengthening, health information management systems, and social and behavior change communication (SBCC). The main objective of this collaboration was to achieve expected outcome of AUHC as well as SHN that eventually contributes to the Government’s universal health coverage agenda and intermediate results of USAID DO3: Health Status Improved. In Year 2, AUHC collaboration with partners are delineated below. GoB institutions. AUHC provided technical support to SHN in extending collaboration with different GoB institutions that are ministry of health and family welfare (MOHFW) and its key entities like; directorate general of family planning (DGFP), directorate general of health services (DGHS), national tuberculosis programme (NTP); and ministry of local government, rural development and co-operatives (MOLGRD&C). This collaboration helped SHN to continue receiving family planning products and nutrition supplement from DGFP, vaccines from DGHS. AUHC collaboration with NTP extended with a greater scope for better positioning of SHN clinics in TB services. SHN clinic staff also received technical and reporting capacity building training on IUD, Implant, PPFP, dengue, child health, and GoB reporting. The activity also collaborated with city corporation and municipalities under MOLGRD&C to operate 30 SHN clinics in their buildings that saving the activity about per year. Ujjiban. AUHC partnered with Ujjiban-led Bangladesh Behavior Change Communication (BCC) Working Group in the MOHFW and provided technical input in the national framework for effective health, population and nutrition SBCC. AUHC collaborated with the Ujjiban activity by adopting their SBCC materials for SHN clinics. In Year 2, AUHC adapted 12 small promotional videos on maternal, child, nutrition, TB and adolescent health developed by Ujjiban and co-branded with SHN logo. AUHC also collaborated with this activity to adapt inter-personal communications materials to be used in SHN clinics. Accelerating Universal Access to Family Planning (AUAFP). AUHC collaboration with AUAFP has been multi-fold. First, we have incorporated AUAFP’s technical input in the SHN counseling assessment that AUHC conducted in Year 2. Second, AUHC included AUAFP staff in the training of trainers on counseling training in June 2019. The participants cascaded this training for the service providers of SHN clinics. Third, AUHC collaborated with AUAFP in discussion of USAID implementing partners working group on family planning that will be further extended to AUHC rapid assessment on ‘PPFP spectrum in SHN clinics: Knowledge, Attitude, Practice and Way Forward’ in Year 3. MaMoni maternal and newborn care strengthening. AUHC received Mamoni MNCSP’s technical assistance in developing SHN’s service guidelines on maternal health, child health, family planning and newborn care. We also collaborated on observing technical capacity of SHN clinic’s service providers for practicing these guidelines. AUHC and Mamoni MNCSP jointed made field visits to SHN clinics in Manikganj and considered their suggestion in AUHC training plan. Social marketing company (SMC). AUHC helped SHN to partner with SMC in accessing their family planning contraceptives, nutrition, and health and hygiene products. We also collaborated with SMC to learn more about their community service agent (CSA) model to develop SHN’s community service providers (CSP) entrepreneurship and product basketing model to better utilize this cadre for SHN’s value proposition.

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Challenge TB (CTB). AUHC used CTB’s hotspot mapping in selecting GeneXpert machine installation sites for SHN. We also materialized CTB’s readymade site selection criteria checklists and surveyed SHN potential clinics that they have developed with national tuberculosis programme (NTP).

Memorandum of understanding (MOU) with BRAC and Concern Worldwide. AUHC provided technical assistance to SHN for a tripartite MOU among SHN, BRAC and Concern Worldwide that came into effect from January 2019 and will last through November 2019. Under this memorandum, 40 SHN clinics will provide primary healthcare services to the extreme poor beneficiaries of BRAC in Dhaka north city corporation, Dhaka south city corporation, Chittagong city corporation and Mymensingh city corporation areas. The extreme poor beneficiaries will be identified by having the ‘Shashtho Seba Card’ health benefit card issued by BRAC. At the end of every month, BRAC reimburses the service fees to SHN upon producing a blanket bill.

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COMPLIANCE UPDATE Year 2 presented AUHC with a number of compliance challenges, specifically a nearly steady stream of investigations into financial misconduct on the part of clinic managers stemming from practices that in many cases began prior to the start of AUHC. With the official launch of SHN and the transition of clinics from NGO to SHN management throughout the first half of Year 2, clinic staff took the opportunity of a change in administration to raise concerns regarding misconduct. Additional such reports are expected as SHN deepens its compliance culture across the network and more and more staff feel empowered to report past waste, fraud, or abuse. With the clinic transition, the project’s compliance regime itself transitioned in Year 2 from one based on supportive supervision of SHN to one more singularly focused on oversight and enforcement. In Quarter 4, AUHC launched the Compliance Monitoring Unit (CMU). Project FP compliance monitoring also continued during this time, with the CMU providing additional oversight along with routine monitoring by regional QAMs. AUHC Compliance Monitoring Unit (CMU). Originally comprised of four teams of two members each – one program auditor and one financial auditor – the CMU audits all SHN clinics and Green Hill clinics in the CHT, for compliance with all required subcontract, USAID, and Government of Bangladesh regulations in the course of their operations. The first audit commenced in July 2019 and all visits are expected to be complete by Quarter 2 of Year 4. This is a quarter later than originally envisioned, as the CMU has been reduced to three teams in light of the project’s continuing incremental funding delays. In its first quarter of operation, the CMU audited 40 clinics – 36 Advanced and four vital. Program auditors use a comprehensive checklist that reviews each clinic’s adherence to licensing, branding, infrastructure, FP, data quality, clinical guideline, training and staff development, and pharmacy requirements. Financial auditor checklists review compliance with procurement, HR, and financial management policies and regulations. AUHC and SHN met to review the reports for this first tranche of clinics at the close of Year 2. Major findings revealed that most Advanced Clinics still lack many of the needed licenses required to operate in compliance with Government of Bangladesh law despite SHN’s corporate emphasis on and work addressing this problem throughout Quarters 3 and 4. Those clinics with pharmacies also lack accredited pharmacists, sales agents, and proper procedures for drug procurement and inventorying. Branding continues to be challenging due to incremental funding issues that prevent the widescale procurement of new uniforms, clinic curtains, and signboards. Clinics are largely in compliance with the project’s infrastructure requirements for them, as well as with all U.S. government FP regulations. Review of data quality showed numerous indications of incorrect customer record information. SHN is analyzing whether this is due mainly to either clinic staff capacity or inattention to detail. Training itself is challenged, as the CMU found that most clinics did not keep updated training files, and only half had had training needs assessment done since the transition. With few exceptions, program auditors found that clinics have all required and current guideline/SOP documents. Financial auditors found that, on the whole, clinics’ financial management evinced numerous control issues stemming from a lack of inherited staff member capacity. AUHC has been working with SHN to roll out continuing financial management training that will take place throughout Year 3. Auditors also found that in regard to HR management, personnel files were largely incomplete, staff could not fully describe their job descriptions, and attendance and leave records were not up to date. SHN’s regional HR office staff will be working with clinics in Year 3 to correct these deficiencies. The team, however, found no instances of apparent conflicts of interest in hiring or that recruitment protocols had not been followed. Regarding procurement processes, most clinics either did not

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have SHN’s procurement manual easily accessible for staff reference or staff could not satisfactorily articulate the basics of SHN’s procurement policy. Procurement files were also by and large incomplete. While SHN regional procurement staff must nevertheless devote more energy to capacity building in this area, no instances of an absence of competition where competition should have occurred over the USAID micropurchase threshold were found. The CMU will revisit all Advanced Clinics in Quarter 2 of Year 3 to monitor SHN’s progress in rectifying those deficiencies noted during Year 2’s first round of visits. FP Compliance Monitoring. AUHC continued its monitoring of adherence to U.S. government FP regulations throughout Year 2. All AUHC staff have successfully completed annual re-training on FP legislative and policy requirements and PLGHA, as have SHN headquarters and regional staff. AUHC and SHN worked together to create a comprehensive Bangla-language training covering U.S. abortion and FP requirements as well as PLGHA for roll out to all SHN and Green Hill clinic staff, all of whom are now certified as having completed the training. To ensure that clinic staff remain in compliance with FP regulations, the CMU has incorporated FP guideline reviews into its program audit checklist. During quarterly AUHC FP compliance committee meetings in Quarters 1 to 3, data from routine regional QAM visits were reviewed to ensure clinics were remaining in compliance. To this data were added the CMU program auditors’ checklist reviews in Quarter 4. To date, no violations of U.S. government abortion or FP regulations has occurred on the project. At the conclusion of Year 2, USAID’s AUAFP activity notified that the revised Tiahrt poster design had been finalized and was ready for distribution. AUHC customized the posters for SHN and Green Hill printing and display, which will occur in Quarter 1 of Year 3.

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RESULTS TO DATE In Year 2, there was a noticeable decline in service contacts. There are several reasons for this. One is the fact that during the clinic management transition, the NGOs opted to retain 12 of the high performing clinics they managed following the end of their grants; therefore, in Quarter 2, total service contacts are based on 12 fewer clinics in the network. AUHC set service indicators in the performance monitoring plan (PMP) with the idea that AUHC would be reporting results from 399 clinics. The network optimization exercise will be completed in Quarter 2 of Year 3. Once the number of SHN clinics is finalized, AUHC will work with SHN and USAID to finalize the service indicators in the PMP to more accurately reflect performance.

Another factor is data quality. AUHC conducted an error mapping exercise for the network the results of which indicated a 14 percent error rate. AUHC and SHN took several subsequent corrective measures that has impact in reducing inflated data leads achieving below the target for the FY19. AUHC and SHN has embarked the network optimization exercise with an objective to bring efficiency in the network in terms of service provision and financial sustainability. We are foreseeing an enormous change in the human resources and service provisioning channels of some clinics that are performing very poor.

There was a communication with USAID on finalizing AUHC PMP indicators and targets through a technical meeting with three assumptions. First, the actual number of clinics transitioned to SHN and CHT clinics in total 387 clinics whereas our initial target was based on 399 clinics. Second, 14 percent erroneous data correction as recommended by error mapping exercise. Third, SHN network optimization recommendations on clinics closure, linking satellites to nearby static clinics, and conversion of static clinics to satellite hubs.

Sl #

Indicators Baseline FY17/18

FY19 Target

FY 19 Result Remarks

1 Number of service contacts provided through Surjer Hashi (SH) clinics.

46m 46.5m 35m

2 Number of clients served through SHN - No target - Target will set once HMIS rolled out in SHN clinics. In Q4, we started pilot implementation of HMIS in 20 clinics that reported 47,155 clients.

3 Number of visits in SH clinics 27.38m No target 21.25 m 4 Percentage of clinics that achieve minimum passing

score for compliance with SHN developed standard operating procedures (SOPs) for business.

- 50 percent - AUHC compliance monitoring unit established and the protocol finalized. Baseline and target will set in Y3.

5 Number of clinics met minimum five criteria of Quality for excellence.

- 100 91

6 Cost recovery of SHN - 35 percent 35 percent

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7 Number of Smiling Sun clinics fully transitioned into the Surjer Hashi network (SHN).

0 374 369 Transition completed

8 Percentage of SHN clinics using DHIS2 compatible MIS developed by AUHC partner PSI.

0 50 percent 100 percent Currently, 20 SHN piloting clinics are ready to integrate data into DHIS2.

9 Average cost recovery for Surjer Hashi clinics. 38 percent 37 percent 37 Percent Original target was 50 percent but SHN revised the target to 37 percent in Q3.

10 Number of clinics brought under performance-based incentive programs.

0 369 369 SHN finalized KPI for clinics to drive and measure the performance part of regional workshop last quarter.

11 Percentage of Surjer Hashi Clinics providing family planning (FP) counseling or services

100 percent 100 percent 100 percent

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

20.0m 20.4 m 12.4m

13 CYP provided by Surjer Hashi clinics 1.05m 1.09m 1.02m

14 CYPs IUD provided by Surjer Hashi clinics 50,744 52,774 36,211

15 CYPs for Implant provided by Surjer Hashi clinics 17,771 18,482 10,884

16 CYP for LAPM (Female/Male sterilization provided by Surjer Hashi clinics

15,728 16,357 9,763

17 Number of injectable provided SH clinics 1,612,236 1,676,725 1,630,039

18 CYPs for short acting modern methods (Pills, Condoms, Injectable, ECP) provided by Surjer Hashi clinics

534,126 555,491 958,200

19 Number of Surjer Hashi clinics offering Permanent Method (Female/Male sterilization)

75 70 70

20 Number of Surjer Hashi clinics offering LARC modern contraceptive methods (IUD, Implant)

359 350 347

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

1,032,434 1,053,083 586,424

22 Number of births delivered by a skilled birth attendant supported by Surjer Hashi clinics

45,232 46,137 35,178

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23 Number of service contacts of post-partum women delivered in Surjer Hashi clinics who left with any modern contraceptive methods.

- No target 2656

24 Number of women delivered in SH clinics who received IUD as PPFP within 48 hours or 4-6 weeks after discharge

- No target 133

25 Number of male service contacts provided by Surjer Hashi clinics.

4.1 m 4.4 m 3.07 m

26 Number of ANC service contacts provided by Surjer Hashi clinics

1,980,505 2,059,725 1,187,485

27 Number of ANC service contacts that included PPFP counseling.

- No target 116,984

28 Number of service contacts of women receiving PNC within 48 hours of birth from SH skilled provider

305,532 329,975 162,038

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

352,934 359,993 175,163

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

1,681,931 1,715,570 950,005

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

37,210 38,000 19,329

32 Number of children less than 12 months of age who received Penta3 from Surjer Hashi clinics.

310,076 316,278 159,332

33 Number of children aged 6-59 months who received Vitamin A in Surjer Hashi clinics.

1,840,174 1,876,977 2,231,777

34 Number of cases of child diarrhea managed through Surjer Hashi clinics.

2,407,662 2,431,739 1,338,498

35 Number newborns not breathing at birth who were resuscitated in Surjer Hashi clinics.

5,696 5,696 1,600 This is a new indicator. We set the target based on one-month data. However, we will revise the target in Y3.

36 Number of cases of child pneumonia treated with antibiotics through SH clinics

277,467 288,566 127,584

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37 Number of service contacts with children under 5 included in growth monitoring program (GMP) in SH clinics.

1,311,590 1,337,822 823,649

38 Number of Surjer Hashi Clinics that provide BEmOC care

45 28 26

39 Number of Surjer Hashi Clinics that provide CEmOC care

48 48 43

40 Number of SH clinics offering NCD (hypertension, DM) screening.

288 369 369

41 Number of presumptive TB cases identified at the Surjer Hashi clinic and outreach

4,636 4,682 3,914

42 Number of presumptive TB cases undergo diagnostic investigation

- No target N/A Target will per AUHC TB activities in Year 3.

43 Number of TB cases diagnosed with TB - No target N/A Target will per AUHC TB activities in Year 3.

44 Number of TB cases started treatment at SH DOTS clinic

- No target N/A Target will per AUHC TB activities in Year 3.

45 Number of clinics where extended hour clinic operations were prototyped and later rolled out.

- No target 53

46 Number of clinics where specialized doctor services were prototyped and later rolled out.

- No target 4

47 Number of clinics where specialized eye care services were prototyped and later rolled out.

- No target 0 AUHC is facilitating a grant for Fred Hollows Foundation to implement eye care services.

48 Percent of population in Surjer Hashi catchment areas who are aware of Surjer Hashi clinics

36 percent No target N/A AUHC has no plan for mid-line survey. This indicator comes into effect in Year 5 end line survey.

49 Number of families covered under financial protection mechanisms developed by AUHC partner Green Delta

- No target N/A Based on changed scenario that AUHC will not go for any form of financial protection program with Green Delta.

50 Percent of poor Surjer Hashi clinic clients who are provided with subsidized or discounted service fees.

40 percent 40 percent 41.2 percent The number calculated from 20 HMIS piloting clinics. This is POP and Poor

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clients received discounted and free services from SHN clinics.

51 Number of people enrolled in SHN insurance schemes - No target N/A Same as 49 52 Percentage of revenue generated from different

categories of clients - No target Able to pay-60

percent Poor-39 percent POP- 1 percent

53 Number of women delivered at SH clinics with the use of the partograph

- No target 19,262

54 Number of women completed four ANC visits - No target 94,531

55 Number of women received ANC checkup according to SOP at SH clinics by skilled service provider

- No target - In the Year 3, we will set the target and develop an observation checklist to report this indicator.

56 Percentage of customers satisfied with Surjer Hashi services

- No target 87 percent

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

- No target 287

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

- 400 244 Infection Prevention training of 244 SHN clinic staff. Apart from that, AUHC provided 765 pricing implementation, 128 counseling training, 380 on tally, MIS 80 and quality assurance for 52 SHN staff.

59 Percentage of satisfied staff working in Surjer Hashi clinics.

- 80 percent 67 percent

60 Percentage of staff retention in Surjer Hashi clinics. 86.4 percent 90 percent 97 percent

61 Number of research/ studies conducted under AUHC project.

0 6 6 Market Landscape – provider and consumer research, Satellite, CSP, Optimized hour, and Counseling assessment.

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

0 4 4

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63 Number of learning agenda or prototyping incorporated or adapted in program implementation.

0 2 2 Learning from HMIS incorporated in HMIS piloting. Learning from extended hour prototyping adapted.

64 Number of case studies, success stories, SHN newsletters prepared.

0 6 12 Learning brief 4, Success story 4, Newsletter 4.