Appendix B
Illustrative Memorandum of Understanding for Implementation of a District Health Plan

This is an example of a memorandum of understanding between the Division of Health Services (DHS) of the East Timor Transitional Administration and any particular NGO. XXX indicates the occurrences of customized information.

A Introduction

  1. This letter of agreement between NGO-HSP and the Division of Health Services (DHS) of the East Timor Transitional Administration details a mutually agreed upon cooperative framework for the provision of basic health services in XXX District, East Timor, for the period ____ 2000 to ____ 2001.

  2. The agreement reached is based on a consultative process involving NGO-HSP, DHS (at the central and regional level), other national and international NGOs, East Timorese health personnel, and XXX District community representatives. The consultative process has produced the XXX District Health Plan (dated ____ 2000), which was reviewed and agreed upon in principle by DHS.

(1) To avoid the duplication of services and the installation of services that may be unsustainable in the future and to respect minimum standards



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Initial Steps in Rebuilding the Health Sector in East Timor Appendix B Illustrative Memorandum of Understanding for Implementation of a District Health Plan This is an example of a memorandum of understanding between the Division of Health Services (DHS) of the East Timor Transitional Administration and any particular NGO. XXX indicates the occurrences of customized information. A Introduction This letter of agreement between NGO-HSP and the Division of Health Services (DHS) of the East Timor Transitional Administration details a mutually agreed upon cooperative framework for the provision of basic health services in XXX District, East Timor, for the period ____ 2000 to ____ 2001. The agreement reached is based on a consultative process involving NGO-HSP, DHS (at the central and regional level), other national and international NGOs, East Timorese health personnel, and XXX District community representatives. The consultative process has produced the XXX District Health Plan (dated ____ 2000), which was reviewed and agreed upon in principle by DHS. (1) To avoid the duplication of services and the installation of services that may be unsustainable in the future and to respect minimum standards

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Initial Steps in Rebuilding the Health Sector in East Timor for health service delivery in East Timor for the transition period, guidelines for District Health Plans were agreed upon in May/June 2000 and supplemented by additional guidelines in July 2000, which are attached as Appendix I. (2) The District Health Plan for XXX District, prepared by NGO-HSP and reviewed and agreed upon by DHS, details the range of services agreed upon by both signatories to this Letter of Agreement to be provided in compliance with the attached guidelines. B Agreement NGO-HSP agrees to implement the agreed plan with due diligence, to keep DHS informed of implementation progress through quarterly progress reports, and to seek DHS prior agreement to any substantial departure from the plan in schedule, content, and/or budget. The agreed upon distribution of fixed facilities, the overall number of staff to be paid by DHS, and an initial distribution of staff are provided in Appendix II. NGO-HSP agrees that it will seek prior written approval from DHS concerning all matters related to : distribution and location of all fixed and mobile facilities, any construction, reconstruction and/or rehabilitation of health facilities, numbers and distribution of staff, including voluntary staff and those paid by sources other than DHS, and agreements with third parties. Where not explicitly detailed in the XXX District Health Plan, NGO-HSP undertakes by signing this Letter of Agreement that, in addition to the activities detailed in the District Health Plan, it will: participate, under the guidance of DHS, in the acceleration of priority activities, such as immunization, vitamin A supplementation, TB control, and health promotion, inform the DHS in advance of any pharmaceutical supplies or equipment obtained from sources other than the Central Pharmacy Warehouse/Autonomous Medical Store, whether purchased or donated,

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Initial Steps in Rebuilding the Health Sector in East Timor follow any DHS needs assessment, guidelines, and training plans for on-the-job and short-term training to develop the capacity of East Timorese health personnel, maintain records of patient contacts and other services using national protocols as they become available, and use a standard reporting format prescribed by DHS, maintain financial accounts in accordance with internationally recognized practices, provide a six-monthly consolidated report of expenditures by categories to be specified by DHS, and not enter into any third party agreement where the DHS may, as a result of that agreement, be liable for any claims, debt, damage or demand arising out of the implementation of the district health plan. In recognition of the above, DHS agrees: (1) to provide salary and benefits at the official ETTA levels for personnel as detailed in Appendix II, (2) to provide pharmaceuticals and supplies in accordance with nationally determined levels ensuring an equitable distribution (from all sources) across all districts, and (3) further undertakes to finalize by November 2000, in close consultation with NGO-HSP and within the framework of the agreed XXX District Health Plan, the level of support to be provided by DHS for transport, communications, and related operational costs. C Monitoring and Evaluation Implementation of the District Health Plan for XXX District will be monitored by DHS using quantitative and qualitative indicators. NGO-HSP will provide DHS with a quarterly report of implementation progress in the format provided in Appendix III of this agreement. Should the number of beneficiaries of the District Health Plan significantly change from the number originally envisaged, or if for any reason, changed circumstances reduce or increase the need for financial and/or other inputs, DHS shall be immediately informed so that, after mutual consultation, DHS may adapt its participation to the new situation.

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Initial Steps in Rebuilding the Health Sector in East Timor D Termination of the Agreement This agreement will terminate on ____ 2001, at which time a further agreement for the period ____ 2001 to ____ 2002 based on a revised, or new District Health Plan for the XXX District may be prepared by mutual agreement between the undersigned in consultation with appropriate representation of East Timorese health personnel and community representatives of the XXX District. The agreement may be terminated at an earlier date should NGO-HSP fail to address, within thirty (30) days of receiving written advice from the DHS, any substantial departure from the framework agreement in the XXX District Health Plan. Agreed, this day ____ 2000 _________________ Authorized Representative of NGO-HSP ______________________ Authorized Representative of DHS Attachments : Appendix I Guidelines for the District Health Plan Appendix II Personnel and Facilities to be provided by DHS Appendix III Quarterly Reporting Format FURTHER GUIDELINES FOR REVISION OF DHP, JULY 2000 It should be recalled that the access target by September 2001 is 90 percent. Access to a mobile clinic within 2 hours walk twice per week will be considered as access to a "permanent" source of services. There will be one fixed facility (generally a CHC"”without beds) in each subdistrict. This may be functioning only as a HP at present but can serve as the center for subdistrict activities including mobile clinics. In general, during the transition period (i.e., the period of the current DHPs), to maintain flexibility in placement of permanent structures, the IHA prefers the use of more mobile clinics and fewer HPs.

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Initial Steps in Rebuilding the Health Sector in East Timor The IHA prefers the use of motorcycles (or horses) rather than 4WD vehicles for mobile clinics. If 4WD vehicles are used, there must be a clear justification. In general, mobile clinics should be operated from the subdistrict CHC. For the sake of clarity, mobile clinics operating from HPs will be referred to as "outreach services." Current HPs should continue to function where they do not exceed the basic access criteria. Those that exceed the access criteria should be closed. New or reopened HPs should only be established in villages or groups of villages that a mobile clinic can not reach within 1 hour, that have a collective population of 1,000 or more, and that are justified by the workload. No more (new or expanded) inpatient facilities (beds) should be established anywhere without prior written approval from the IHA. This will, in general, not be given within the context of the current DHP negotiations. In any case, no new inpatient facilities will be paid for by NGO funding sources. Where needed they will be supported by the IHA. Planned staffing levels for staff to be paid for by the IHA should be within the ceiling provided for the district. In addition, HSPs may, with other sources of funding, employ an additional number of health professional staff equivalent to no more than 10 percent of the ceiling and an equivalent number of administrative staff For a CHC, a maximum staff of five should be considered. As a guide, this would be one nurse manager, two nurse/midwives, two nurses but there should be some flexibility. IHA-supported staff for inpatient facilities will be at the number foreseen for the facility in the future, not at the current unapproved level of functioning. Additional staff must be paid by the HSP. HPs should be staffed by one nurse/midwife. Any additional staff would require clear justification.

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Initial Steps in Rebuilding the Health Sector in East Timor Each expatriate staff should have an assigned East Timorese counterpart. Expatriate staffing should be according to the following guidelines: Districts without a hospital - one coordinator (doctor or MPH) - one doctor (if no East Timorese doctor available) - one nurse/midwife as trainer Hospitals - one manager - one doctor (if no East Timorese doctor available) - one nurse/midwife as trainer Administrative staff - up to two persons (including those in Dili)