Poverty and Social Impact Analysis (PSIA)

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2 Poverty and Social Impact Analysis (PSIA) Chief Minister s Initiative for Primary Healthcare District Lodhran, Punjab Pakistan Research Team: Kanwar Muhammad Javed Iqbal Mohsin Ali Kazmi Zaheer Abbas Mehwish Javed Ishfaq Ahmed Advisory Team: Dr. abid Qaiyum Suleri Dr. Vaqar Ahmed Edited By: Saleem Khilji Formatted By: Syed Adnan Hassan Asad Ullah SUSTAINABLE DEVELOPMENT POLCIY INSTITUTE 38 Embassy Road, G-6/3, Islamabad, Pakistan 2 P a g e

3 Table of Contents List of Tables... 7 List of Figures... 7 Acknowledgement Executive Summary Chapter 1: INTRODUCTION BACKGROUND General Pakistan Poverty Reduction Strategy Strengthening the Poverty Reduction Strategies Monitoring Project (SPRSMP) Purpose of SPRSMP Key Achievements of SPRSMP in Pakistan UNDP-SPRSMP IN PSIA-CMIPHC DISTRICT LODHRAN OVERVIEW OF CMIPHC Poverty-Health Nexus Health Status of Pakistan Need for a New Health Initiative Programme background and Its Duration Project Concept & Design Problems the Programme Seeks To Address Main Stakeholders Expected Outcomes of CMIPHC PSIA-CMIPHC Scope of PSIA-CMIPHC, Lodhran Programme Scope Geographic Scope Aims & Objectives Key Issues/Parameters Addressed STRUCTURE METHODOLOGY P a g e

4 1.6.1 Desk Review Meetings and Discussion Inception Report Field Action Plan Finalization of Survey Tools Enumerators Training Approval of Report s Contents PSIA Tools and Data Verification Mechanism a) Sample Size b) Data Collection Research Instruments Protocol a) Structured Interview b) Open Ended Questionnaire Interview c) Discussion Guides Data Collection and Management a) Field Work b) Data Management Data Analysis Research Ethics Chapter 2: REVIEW OF INSTITUTIONAL FRAMEWORK INSTITUTIONAL FRAMEWORK FOR HEALTH SECTOR IN PAKISTAN UNIVERSAL DECLARATION OF HUMAN RIGHTS (UDHR) CONSTITUTION OF PAKISTAN MILLENNIUM DEVELOPMENT GOALS (MDGS) FOR PAKISTAN THE CONTEXT OF HEALTH SECTOR AND NFC AWARD TH AMENDMENT: THE POLITICAL AND FINANCIAL CONTEXT OF HEALTH IN PAKISTAN Pre-18th Amendment Scenario Post-18th Constitutional Amendment Position Financial Capacities of Provinces Functions of Federal Ministry of Health PAKISTAN BUDGET Provincial Health Care Delivery and Allocations ANNUAL DEVELOPMENT PROGRAMME OF PAKISTAN P a g e

5 2.8 NATIONAL HEALTH POLICY OF PAKISTAN OF 2009 & ONWARD MEDIUM TERM BUDGETARY FRAMEWORK - PUNJAB CURRENT STATE OF HEALTH IN PUNJAB PUNJAB MILLENNIUM DEVELOPMENT GOALS REPORT IMPLEMENTATION OF ADP : KEY PRIORITIES OF PUNJAB HEALTH DEPARTMENT Focus on Health Social Protection/Social Inclusion regarding health Public-Private Partnership (PPPs) PUNJAB HEALTH-POVERTY FOCUSED INVESTMENT STRATEGY (PFIS) THE PUNJAB HEALTH SECTOR REFORMS PROGRAM (HSRP) CMIPHC IN PUNJAB A PUBLIC PRIVATE PARTNERSHIP PAST EVALUATIONS OF CMIPHC Rural Support Network Evaluation USAID Evaluation World Health Organization Evaluation Insaf Research Wing Evaluation Present PSIA Chapter 3: IMPACT ANALYSIS GENERAL POVERTY AND ECONOMIC TRENDS SOCIAL AND HEALTH OUTCOMES ANALYSIS Access and Availability of Health Facilities Basic Service Delivery Social Inclusion Social Influences of Programme Effectiveness of Programme Accountability and Transparency Grievance Redresser Mechanism Mother & Child Health INSTITUTIONAL IMPACT ANSLYSIS PPP Model - Overcoming PHC Challenges Impact of Medicine Purchase and Distribution System Programme Monitoring & Evaluation P a g e

6 3.4.4 Strength and Weakness of Programme Sustainability of the Programme POLICY IMPACT ANALYSIS National VS Provincial Commitments Privatization Policies VS PPP Model of CMIPHC CONCLUSION Chapter 4: KEY FINDINNGS AND RECOMMENDATIONS GENERAL KEY FINDINGS Institutional Framework Programme Design, Capacities and Activities PPP Model Poverty and Social Impact Improved OPD Service Functional Level of BHUs Effectiveness of Programme Social Inclusion Improved Health Outcomes Medicine Purchase and Distribution Role of Community Support Groups Strengthened Institutional Capacity Programme Outreach Risk to M&E System Programme Challenges and Sustainability RECOMMENDATIONS BIBLIOGRAPHY Annex-I: Questionnaire for Quantitative Survey of Beneficiaries Annex-II: FGD Checklists for Qualitative Survey Annex-III: KII Questionnaire for Qualitative Survey P a g e

7 List of Tables Table 1: UNICEF s Basic Indicators Table 2: Sample Size and Geographic Distribution Table 3: ToR Objective-wise Parameters Distribution Table 4: Selected Health Status Indicators: Pakistan VS Asian Countries ( ) Table 5: Health Indicators Pakistan ( ) List of Figures Figure 3.1: Common Diseases Figure 3.2: Frequency of Sickness Figure 3.3: Duration and Loss of Sickness Figure 3.4: Women Illness and Extra Economic Burden Figure 3.5: Savings from Maternity Service Figure 3.6: Savings due to timely BHU Services Figure 3.7: Nearest Health Facility Figure 3.8: BHU Distance Figure 3.9: Ambulance Service Figure 3.10: Visits of Vaccinaators Figure 3.11: Vaccination Satisfaction Figure 3.12: Normal Time to Reach BHU Figure 3.13: Health facility Cost Figure 3.14: Transport for BHU Figure 3.15: Travel Cost Figure 3.16: Accessibility by Road Figure 3.17: Seeking Medical Care Figure 3.18: Not Seeking Medical Care Figure 3.19: Household Decisions for Health Care Figure 3.20: Children Delivery Places Figure 3.21: Mother Visiting BHU during Pregnancy Figure 3.22: Year-wise Comparison of Total OPDs ( ) Figure 3.23: Month-wise Comparison of Total OPDs ( ) Figure 3.24: Perception about BHU Services Figure 3.25: Provision of Free Medicine at BHU Figure 3.26: Availability of relevant staff at BHU Figure 3.27: Alternative Staff Solutions by Patients Figure 3.28: Transport for Patient s Referral Figure 3.29: Timely Medicine availability at BHU P a g e

8 Figure 3.30: Punctuality of BHU Staff Figure 3.31: Tehsil & Sex-wise Response on BHU Staff Punctuality Figure 3.32: People s Participation in BHU Affairs Figure 3.33: Tehsil wise response regarding People s Participation in BHU Affairs Figure 3.34: Women and CSGs Figure 3.35: Women Representation in CSGs Figure 3.36: CSG Activities Figure 3.37: School Health Clubs Figure 3.38: Health Session Benefits Figure 3.39: Women and CSGs Figure 3.40: Ethnic Minority in area Figure 3.41: Minority and CSG Figure 3.42: Sex-wise Response - Religious Minority in Area Figure 3.43: Sex-wise Response - Ethnic Minority in Area Figure 3.44: Poor and CSG Figure 3.45: Social Influence Figure 3.46: Actions for Community Involvement Figure 3.47: Trust on BHU Services Figure 3.48: Sex-wise Trust on BHU Services Figure 3.49: Suggested Actions for Enhancing Trust on BHU Services Figure 3.50: Public Participation in Preventive Care Figure 3.51: Visible improvements at BHU Figure 3.52: Common People VS Campaigns Figure 3.53: Common People VS Campaigns Figure 3.54: BHU Performance Ranking Figure 3.55: Success of PPP Model Figure 3.56: Success of PPP Model Tehsil wise response Figure 3.57: Benefits of Community Support Groups Figure 3.58: Steps to Strengthen CSGs Figure 3.59: CSG Role for Improvements in PHC Figure 3.60: Access to data and management Figure 3.61: Transparency in BHU Operations Figure 3.62: Priority to General Patients Figure 3.63: Priority to Special Patients Figure 3.64: In-place Grievance Mechanism and Effectiveness Figure 3.65: Complaints Taken by PRSP Figure 3.66: Satisfaction with MCH Services Figure 3.67: Handling of Complex Women Matters Figure 3.68: Women Staff for Women Figure 3.69: Availability of Family Planning Services Figure 3.70: BHU role in Saving Mother & Child life Figure 3.71: CSG for Monitoring Figure 3.72: Present Monitor Figure 3.73: Suggestions for Right Monitor P a g e

9 Figure 3.74: Staff Commitment Figure 3.75: Community Willingness to Play Role Figure 3.76: Facilities VS Financial Limitations Figure 3.77: Presence of Influential Staff Figure 3.78: Un-visible Role of CSG Figure 3.79: Mobilization and Awareness Component Figure 3.80: Type of Irregularities in BHU Operations Figure 3.81: Security Issues for FMOs Figure 3.82: Negative Elements in Normal BHU Functions Figure 3.83: Referral System VS Ambulance Figure 3.84: Sustainability of BHU Services Figure 3.85: Funds from Community Figure 3.86: BHU Services without PRSP P a g e

10 Acknowledgement I appreciate the efforts of the SDPI research team for successfully completing the Poverty and Social Impact Analysis (PSIS) of Chief Minister s Initiative for Primary Health Care (CMIPHC) in District Lodhran, Punjab, Pakistan. The scope of work was, no doubt, completed within the tight time schedule which could be possible only on account of energetic and enthusiastic participation of all the team members. The Institute feels pride for being selected to carry out the work on a significant theme of PSIA of Primary Health Care services being delivered with the concept of PPP model. I acknowledge with great appreciation the contribution of Mr. Kanwar Muhammad Javed Iqbal, the Deputy Project Director / Project Leader PSIA of CMIPHC, for his valuable guidance to his team fellows for successfully accomplishing the task along with his intellectual inputs in the form of liaison with UNDP SPRSM, questionnaire development, planning analysis, literature and data analysis, and writing of the report. I wish also to place it on record my appreciation for the role of other SDPI research team members including Mr. Mohsin Ali Kazmi, Ms. Mehwsih Javed, Mr. Ishfaq Ahmed and Mr. Zaheer Abbas who substantially contributed in the preparation of the report in the form of their intellectual inputs i.e., developing draft questionnaires, writing different portions of the report, supporting the field work and coordinating the data analysis. I would extend my gratitude to Dr. Vaqar Ahmed, Mr. Saleem Khilji, Syed Adnan Hassan and Mr. Asad Ullah for the review, editing and formatting of the report respectively. I would also extend my appreciation to Mr. Ansar Mehmood Janjua (Manager, Admin & Logistics), Ms. Saira Kanwal (Sr. Manager Finance) and Mr. Muhammad Shaban (Manager Finance) for their management support at all level of the study requirement. It is my pleasure to record my grateful acknowledgement of the most helpful assistance extended by Mr. Zaman Watto, Provincial Manager SPRSM UNDP Punjab, Mr. Gulbaz Ali Khan, M&E Officer - SPRSM UNDP Punjab and Mr. Aman Ullah Khan, Project Director - CMIPHC Punjab, PRSP in the form of their inputs during the intellectual discourse with the research team. They also provided the forum to the research team to have scholarly interaction with the stake-holders and to get their feedback. I also express my gratitude to CMIPHC Punjab project team for extending support and knowledge sharing which was especially helpful for converting the findings into a useful and relevant report. Finally, I wish to thank all the respondents for being open to the intrusions, questions, and for opening their hearts to our researcher colleagues during interviews, discussions etc. to make the work meaningful and factual near to reality. I hope that the findings of the report will be helpful to adopt the desired policies to go ahead in shaping the future. Dr. Abid Qaiyum Suleri Executive Director 10 P a g e

11 11 P a g e Executive Summary (1) Poverty and Social Impact Analysis (PSIA) involves the analysis of the distributional impact of policy reforms on the well-being of different stakeholders with a particular focus on the poor and vulnerable. PSIAs are analytical exercises that attempt to understand the likely poverty and social impact of particular policy choices. PSIAs often draw on a wide range of analytical tools and data sources in attempting to understand policy impact. These tools range from those that are highly qualitative and participatory to those that are quantitative and often driven by economic theory. The scope and content of PSIAs are usually driven by the policy agenda of the day and the timeframe in which the studies need to be completed. (2) Under UNDP SPRSM project, a Strengthening PRS Monitoring provincial secretariat has been established in Planning & Development (P&D) Department in Punjab. The project has a strong focus on research studies, impact evaluations and assessments under which the project, in consultation with the Health Department and Punjab Rural Support Programme, has planned to undertake a Poverty & Social Impact Analysis of the project Chief Minister s Initiative for Primary Healthcare (CMIPHC) being run by Punjab Rural Support Programme (PRSP). (3) Chief Minister s Initiative for Primary Healthcare (CMIPHC) project was started for the welfare of the poor and aimed at catalyzing the health care needs of the poor and marginalized sections of rural society through improved community participation and inclusiveness. Its asserted objective is to create a wholesome impact on the health status of the poor and marginalized and thereby help them improve their livelihoods. PSIA will provide a better understanding of impact assessment of the Chief Minister s Initiative for Primary Healthcare (CMIPHC). (4) For the purpose of present PSIA, Sustainable Development Policy Institute (SDPI) was outsourced by UNDP SPRSM Punjab to furnish Poverty and Social Impact Analysis (PSIA) report of CMIPHC in Lodhran district. This PSIA was planned to inform the project design on strategies for poverty and social impact of health services related aspects. The overarching aim of the PSIA study is to analyze poverty and social nexus in the context of health care services to different segments of the society. (5) The objective of the PSIA study is to help take informed policy decisions through measuring the social and poverty impact of Chief Minister s Initiative for Primary Health Care of Lodhran district. The CMIPHC in Lodhran district was ranked top based on periodic performance. The selection of Lodhran district for present PSIA becomes very relevant so as to measure the impact trends of the intervention and represent the maximum benefit so far achieved in a unit district for the entire programme. (6) This assignment was expected to play an important role in informing the policy discourse through measuring the poverty and social impact of Chief Minister s Initiative for Primary Healthcare on access of different segments of society to quality health care services.

12 (7) This PSIA study entails consultation with UNDP-SPRSM and PRSP team at each stage. All designed tools and methodology was shared and discussed with UNDP SPRSM team. SDPI research team worked on both qualitative and qualitative tools to cover all possible dimensions of this PSIA study. (8) For secondary research, after acquiring relevant data from SPRSM UNDP and PRSP, the SDPI research team reviewed it. On the basis of review, it was able to devise comprehensive qualitative and quantitative research tools. Moreover, the data set, shared by the PRSP, also served in putting up a quality report after the completion of the PSIA exercise. Desk review was meant for initial review and preparation of tools together with policy and model analysis purpose for mid-term analytical work through triangulation prior to produce a quality report. (9) SDPI research team developed quantitative and qualitative tools for primary survey which were shared with UNDP SPRSM team. Structured questionnaires were developed for beneficiary survey which included interviews with adults and children of high school level. The beneficiary questionnaire carried information on 13 parameters of Economic Impact, Access and availability of health facilities, Basic service delivery, Mother & child health, social inclusion, social influences of programme, effectiveness of programme, programme monitoring, strength and weakness of programme, challenges to programme, sustainability of the programme, Accountability and transparency, and grievance redresser mechanism. The questionnaires contained information on UNDP SPRSM interventions at community level, benefit gained by different social groups and limitations and beneficiaries recommendations to improve it. (10) The technique employed is relatively simple and was found very effective for Key Informant Interviews during the course of this study. A set of opening questions with short unambiguous responses are followed by main questions phrased in such a way that they are easily understood and descriptive. For Focus Group Discussions (FGDs), the discussion guides were developed to facilitate the working of field team. The focus of these discussion guides were the issues widely covered in the individual interviews. (11) For quantitative segment of research, the stratified-random sampling was done with a sample size of 1,440 by covering the geographic areas of all 48 BHUs in three Tehsils i.e; Lodhran, Kahror Pakka and Dunya Pur. The originally envisaged quantitative sample size of 1,200 beneficiaries in ToRs was revisited by SDPI research team and increased to 1,440 in order to facilitate representative sample size by covering the geography of all BUs. Four FGDs and 10 KIIs were carried out in each Tehsil. (12) CMIPHC model was based on a localized experiment done in Lodhran district in the year The success of Lodhran Pilot Project was started in Rahim Yar Khan district, which was later expanded to 12 other districts of the Punjab. More recently, two more districts have been added to the project. It has been concluded that BHU facilities are giving economic and social benefits to beneficiaries in terms of recovery time due to timely treatment and cost of medicine and transportation that in turns are utilized for improvements in livelihood and can be invested on their children or taking other social benefits. The overall analysis depicts good social and health outcomes while comparing the baseline before the start of CMIPHC in Lodhran. 12 P a g e

13 (13) The study depicts the good level of satisfaction on functional level of BHU services under the scope of the PHC for vertical and other programme. This was a kind of public-private partnership model that set new trends in health sector due to which social and economic gains were brought forward to the poor and marginalized groups. The relationship brought new horizon of service delivery by ensuring system in place without any new agenda. The model of this institutional setup with PPP model was then extended under CMIPHC to overcome the challenges those critical for PHC and meeting the targets of MDGs. Following were the key challenges and related issues at the time of initiation of the programme which were addressed and overcome upto a major extent with the PPP model of the programme. 13 P a g e Provision of Primary Health Care (PHC) services to the poor and marginalized: The programme created a positive trend and brought drastic improvement through this PPP approach of institutional model in order meet the milestones of MDGs. The local governance for PHC was a major problem and the programme has given a good governance model though a lot need to be done for further improvements in the system for service delivery but the to date progress depicts a good image and need to be continued with some improvement in the existing institutional mechanism like resolving the issues with double-barrel management over the programme and staff matters. Besides, there is complete lack of Regulation of Private Practices and need to be formulated. There was an absence of Social Protection/Insurance / or Inclusion which the programme is still trying to overcome the challenge but budgetary and other limitations are critical in order to bring real agenda on board with visible outcomes. The creation of Community Support Groups (CSGs) was helpful to overcome the lack of emphasis on Community Participation and Public-Private Partnership but the actual role need to be improved through proper institutionalization of CSGs. Special focus was given to Health Education through School Health Sessions and Promotional Campaigns. This component needs further improvement especially through budgetary provision as no budget allocation could be seen in current year programme budget for district Lodhran. There are still some underlying gaps, which need attention and should be addressed in order to overcome the ambiguous status between provincial and national segments. These issues include review of Drugs Policy, Cross-Sectoral Linkages of Programme, Improved Research Mechanism and its Analytical framework, proper Human Resource Management System in the context of PPP, weak capacity for Planning Costs and Budgets, Lack of proper strength of Health Professionals / Nurses / Paramedics etc., more focus on preventive health and to actively target MDGs with pro-poor approach, lack of strong referral system between PHC and SHC Facilities, proper planning and ownership creation etc. (14) The BHU performance has been improved over the past years gradually and can be raked fair-to-good with the overall research analysis. It is important to mention here that there is still a lot to be done in order to get good level of satisfaction at all level.

14 The performance of the BHUs is satisfactory as a whole in spite of poor functions and role of Community Support Groups (CSGs). The BHU operations have found some financial constraints in order to ensure 100% performance in line with the objectives of the programme. The economic gains are much higher than the actual budget input in the programme. During the year 2011 and 2012, the beneficiaries saved up to an estimated value of PKR 441,792,000/- and PKR 458,552,250/- respectively from free treatment at BHU viz-a-viz treatment cost if could have been treated privately in urban areas. When compared the total budget PKR 61,938,166/- of CMIPHC in Lodhran for year with the economic gains in area, it has been seen that the direct economic benefits to the community in the areas were 7.13 and 7.5 times greater, for year 2011 and 2012 respectively, than the said budget value. (15) The BHU operations are almost transparent and PRSP system of monitoring is in place to ensure staff attendance and provision of services. As far as the medicine purchase is concerned, PRSP has a centralized system and CSGs have no role wither in purchase or distribution of medicines. At present, there is no major flaw observed which could be big threat for the PPP model and overall progress towards MDGs. Over the years, the system is gradually moving towards maturity in which the continuity in process and system improvement could further improve basic service delivery with more transparent operations in place. The display of medicine record at BHU, involvement of CSGs in medicine purchase, setting annual performance targets and systematic grievance redresser mechanism could bring further accountability and transparency in the system. The maintenance of financial and operational data and its analysis is critically important prior to gauge the performance over period of time. The current assessment highlights that there are more underlying gaps that need to be addressed for creation and existence of effective organizational mechanisms for grievance redresser. The CSGs can be instrumental for Social inclusion, Social influences of programme, Grievance redresser mechanism, Monitoring Progress and Sustainability of the programme. The CSGs need a proper institutional setup and active role in BHU affairs. The Government policies supports PPP model and therefore continuity of programme with certain improvement would bring further visible outcomes towards MDG targets. (16) Key actions have been suggested through recommendations which are based on cumulative assessment for each parameter of social assessment led by key findings as a net outcome of the study indicated above. The implementation of recommendations through PRSP management review would bring improvements in future endeavors. Following key recommendations have been made through this PSIA. Evaluation of Progress on Health Related MDGs. Synchronization of Policy and Procedures and need for efficient Coordination B/W Multiple Authorities. Definition of Set of Targets to achieve would add proper direction to the programme and help in periodic evaluations in future. Strengthening & Institutionalization of Community Support Group Women Representation in Community Support Group More Structure Awareness Campaigns 14 P a g e

15 Improved Mobilization Strategy would be value addition and help in achieving MDGs. Provision of proper budget for Capacity Enhancement for Soft-Core Component and there is a need for rationalization of Budgetary Provisions for different segments of associated activities. Development and implementation of Proper communication Protocol for CSGs. Development and implementation of Project Operational Guidelines Development and Implementation of Proper Grievance Redresser Mechanism Streamlining the qualification criteria for Nutrition & Health Supervisors Mainstreaming Gender for Nutrition & Health Component Introduction of Time Cluster Approach for introduction of 24 hour services at BHU Fund Generation for long-term sustainability of programme Address the need for Social Inclusion and Equity in CSGs. Improved Medicine Purchase, Distribution and Issuance System through active involvement of CSG members at District / or Tehsil level. Improving community trust on BHUs through addressing the Super-natural Bellies in Social Mobilization. Establishment of Diagnostic Centre in future plans for increasing the scope of BHU services and maximizing the facilitation to community at their door step. 15 P a g e

16 Chapter 1: INTRODUCTION 1.1 BACKGROUND General 16 P a g e Poverty is a hydra that is not so easy to pin down and eradicate. Cutting off one or two of its multiple heads may not bring visible outcomes, so we need to do more comprehensively. We have also learnt that development is a process and can only be sustained if it is owned and led by the targeted population while the social and economic development cannot be imposed and results can only be achieved through facilitation at all levels by ensuring an enabling environment with the active involvement of all stakeholders. It requires ownership, participation and empowerment but not harangues and dictates. Developing countries have to assume full ownership and responsibility for their development. Bilateral donors, multilateral agencies and externally-funded NGOs are entitled to demand transparency and evidence of results. But they must be ready to genuinely acknowledge enough space for the developing countries to innovate, develop and pilot their policy frameworks and processes like the one CMIPHC in the context of Punjab Province in Pakistan. Chief Minister s Initiative for Primary Healthcare (CMIPHC) heralds a new approach of public-private partnership in health sector in the Punjab province. It was implemented in the aftermath of an agreement between district government, Lodhran and Punjab Rural Support Program (PRSP) in August Three Basic Health Units (BHUs) were established in the district on the basis of experiences gained from Rahim Yar Khan. The overall goals and objectives were to provide free primary healthcare facilities to the poor and marginalized groups, at their doorsteps. Strengthening Poverty Reduction Strategy Monitoring Project (SPRSMP) is a joint initiative of the Ministry of Finance (MoF), United Nations Development Program (UNDP) and the Swiss Agency for Development and Cooperation (SDC) from 2008 to The main objective of the SPRSMP is to strengthen institutional capacities for results-based monitoring and evaluation of Poverty Reduction Strategies (PRS). SPRSMP also endeavors to facilitate the achievement of Millennium Development Goals through PRS implementation. Under this project, a Strengthening PRS Monitoring provincial secretariat has been established in Planning & Development (P&D) Department, Punjab. The project mainly focuses on research studies, impact evaluations and assessments in consultation with the Health Department and Punjab Rural Support Programme to undertake a Poverty & Social Impact Analysis of the project. Chief Minister s Initiative for Primary Healthcare (CMIPHC) is being run by Punjab Rural Support Programme (PRSP). Analyzing essentially on the work carried out under PRSP-CMIPHC, the study seeks to poverty and social impact assessments, the social transformation role of PRSP and factors that influence the outcomes of its development intent. The assessment of key

17 issues entail analyses of quality of basic service delivery, access and availability of health facilities, community participation, social inclusion of various economic and social groups, roles and responsibilities of community support groups, social mobilization strategy of the project, economic and social benefits affecting the sampled beneficiaries, grievance redresser mechanism, success or failure of PPP model and sustainability of programme triggered by the project etc. The assessment provides information on the needs and aspirations of basic service delivery and institutional model. This study also provides the impact of intervention in primary health on targeted groups by analyzing the existing scenario Pakistan Poverty Reduction Strategy According to Pakistan Economic Survey, 66 % population earns less than two dollars per day. In absolute numbers, 58.7 million people are living below the poverty line in Pakistan out of the total population of estimated 180 million. Eighty eight per cent of Baluchistan s population, 51 per cent of NWFP, 21 per cent of Sindh and 25 per cent of the Punjab s population is prey to poverty and deprivation (ANWAR, 2006). Keeping in view the prevailing nationwide conditions, Pakistan Poverty Reduction Strategy (PPRS) was launched by the Government of Pakistan in 2001 in response to the rising trend in poverty during 1990s in order to gauge their progress in meeting the targets set by Pakistan for achieving the seven UN Millennium Development Goals (MDGs) by According to MDGs, Pakistan is required to reduce poverty by half by 2015 from the level of PPRS was critically important and attained a great momentum while addressing the needs of health sector reforms and became one of key rationales for conceiving and launching CMIPHC in the Punjab due to its strong nexus with poverty and social wellbeing, which are the priority outlined MDGs Strengthening the Poverty Reduction Strategies Monitoring Project (SPRSMP) 17 P a g e The Poverty Reduction Strategy Paper (PRS Paper) offers a powerful tool to forge a consensus on policies, priorities and resources needed at all levels of the government to reduce poverty and inequities, impeding the pace of economic and social development in Pakistan. The PRS Paper emphasized the importance of a welldeveloped and extensive M&E system for assessing the impact of the government s poverty reduction strategies and resource allocations along with a feedback mechanism for informed decision-making. The PRS Paper Secretariat underpins the government's institutional mechanism for poverty monitoring. Provincial focal points, based in the Planning & Development Departments, were identified to support the PRS Paper Secretariat in executing their M&E functions. The PRS Paper Secretariat, Ministry of Finance, Government of Pakistan underpins the government's institutional mechanism for poverty monitoring. The Secretariat has

18 been mandated with the overall lead in coordinating, monitoring, evaluating and tracking the implementation of the PRS Paper besides reporting progress on antipoverty public expenditures, intermediate social indicators and final outcomes on regular basis. A critical input in achieving the targets set out in the PRS Paper is the effective utilization of anti-poverty public expenditures. Ministry of Finance and UNDP Pakistan have jointly signed an agreement for the initiation of a Strengthening PRS Monitoring Project ( ). The objective of the Project is to strengthen institutional capacities for results-based monitoring and evaluation of poverty reduction strategies at federal and provincial levels Purpose of SPRSMP One of the key components of SPRSMP is the strengthening of institutional capacities for results-based monitoring and evaluation (M&E) of poverty reduction strategies (PRS). The purpose of the project is to strengthen institutional capacities for resultsbased monitoring and evaluation of poverty reduction strategies (PRS). The Strengthening PRS Monitoring initiative is consisted of following outputs: Public spending and allocations in pro-poor sectors reviewed and analyzed through gender lens to better understand the contribution and needs of men and women. Quality, collection, analysis and management of PRS data improved at national and province levels. National engagement in PRS monitoring mobilized through participatory processes. The monitoring framework is envisaged to ensure an ongoing and sustainable system, developed to deliver timely and reliable data against a set of well-selected indicators, and feed into the policy process whilst engaging both national and subnational levels Key Achievements of SPRSMP in Pakistan Following are the key achievements of SPRSMP in Pakistan reported by UNDP (2012): Federal ( , , and ) and Provincial (Punjab , ; KP , ; and Balochistan ) budgets were analyzed through a gender lens. This analysis was conducted to determine and better address the existing inequities in resource allocation. It is also effective in measuring progress on relevant national and international commitments towards gender and poverty reduction. A comprehensive training programme was conducted for 250 government officials on Medium Term Budgetary Framework (MTBF). This will facilitate ministries to collect gender-related data and feed into the analysis of gender based pro-poor expenditure. 18 P a g e

19 Pakistan s first-ever Time Use Survey conducted in collaboration with the Federal Bureau of Statistics to profile the quantum and distribution of paid/unpaid work. This will infer policy and programme implications from gender perspective. A comprehensive monitoring mechanism envisaged in PRSP II devised to evaluate progress towards operationalizing the policies enshrined in the Nine- Point Agenda of Government. The project also provided technical support for results based monitoring and evaluation and established a monitoring framework for PRSP II. First-ever provincial Millennium Development Goals (MDGs) Reports produced. These will support the Government of Pakistan with its international commitment of MDG reporting specifically after the 18th Amendment. These reports will serve as an important policy guidance tool for provincial governments of Sindh, Punjab, Baluchistan and Khyber Pakhtunkhwa to assess the situation and devise MDGdriven pro-poor policies and budgetary frameworks. 1.2 UNDP-SPRSMP IN PSIA-CMIPHC DISTRICT LODHRAN The PRS Paper Secretariat, Ministry of Finance, Government of Pakistan underpins the government's institutional mechanism for poverty monitoring. The PRS Paper Secretariat has been mandated with the overall lead in coordinating, monitoring, evaluating, and tracking the implementation of the PRSP; and reporting progress on anti-poverty public expenditures, intermediate social indicators, and final outcomes on regular basis. A critical input in achieving the targets set out in the PRSP is the effective utilization of anti-poverty public expenditures. Strengthening Poverty Reduction Strategy Monitoring Project (SPRSMP) is a joint initiative of the Ministry of Finance (MoF), United Nations Development Program (UNDP) and the Swiss Agency for Development and Cooperation (SDC) The main objective of the SPRSMP is to strengthen the institutional capacities for results-based monitoring and evaluation of poverty reduction strategies (PRS). SPRSMP also endeavors to facilitate the achievement of Millennium Development Goals through implementation of Poverty Reduction Strategy. This project played an important role in informing the policy discourse through measuring poverty and social impact of Chief Minister s Initiative for Primary Health Care, on access to quality healthcare services to different segments of society, in the Punjab. Strengthening Poverty Reduction Strategy Monitoring Project (SPRSMP) by UNDP awarded the task of Poverty & Social Impact Analysis (PSIA) of the Chief Minister s Initiative for Primary Healthcare (CMIPHC) by PRSP in Lodhran district as an impact evaluation that how much it was proved to beneficial in addressing the poverty reduction. It was further monitoring the implementation of Public-Private Partnership (PPP) to address the primary health issues that cost a large of household income especially for the people living under poverty line. Further it was also monitored for PSIA-CHMIPHC. How do the MDGs and PRSPs fit together? 19 P a g e

20 To what degree does the project team understand the task? Have the important aspects of the task been addressed in sufficient detail? Is the conceptual framework adopted appropriately for the task? To what extent does the proposal reflect the knowledge of the firm about the similar research and analysis? Does the proposal reflect competency and understanding of the firm in conducting the mentioned research study? Is the presentation clear and is the sequence of activities and the planning logical, realistic and promise efficient implementation to the project? Whether Proposed Work Plan and Approach was appropriate and achieved its objectives? Whether it was measuring as accurately as possible the impact of interventions 1.3 OVERVIEW OF CMIPHC Poverty-Health Nexus Poverty and health has a strong link as shown in figure 1.1 below. Lack of knowledge, Social norms, weak institutions & infrastructure are the reasons behind poverty in community while lack of access & inputs, low quality and exclusion from health finance system are factors responsible for poor health provisions in Pakistan. Figure 1.1: Poverty-Health Nexus Health Status of Pakistan Pakistan is the 6 th most populous country in the world. Per capita GDP was estimated at $2600 (PPP) in 2007 in the lower half of countries in South Asia. The overall situation of health is critical as compared to other endemic countries like Nigeria, India and Afghanistan. Pakistan is now reporting more polio cases than the combined total cases of Nigeria, India and Afghanistan. On the other hand, infant mortality rate is also highest (more than 90%) in Pakistan among developing Asian countries with a ratio of 9.1% poverty ratio viz-a-viz Bangladesh s better infant mortality ratio (about 50%) though it has higher poverty index of 9.4 %, as shown in figure 1.2 below. 20 P a g e

21 Figure 1.2: Infant Mortality and Poverty Index in Asia Need for a New Health Initiative 21 P a g e Health has a strong bond with Poverty and Social well-being especially for poor communities and marginalized people per-urban areas. The past service delivery and weak institutional system was the key factor behind the high rate of infant mortality (as highlighted by UNICEF Index in Table 1 below and figure 1.2 above) and mother and child health had a big question mark at the level of Primary Health Care system in Pakistan. Table 1: UNICEF s Basic Indicators Basic Indicators Under-5 mortality rank 33 Under-5 mortality rate, Under-5 mortality rate, Infant mortality rate (under 1), Infant mortality rate (under 1), Neonatal mortality rate, Total population (thousands), Annual no. of births (thousands), Annual no. of under-5 deaths (thousands), GNI per capita (US$), Life expectancy at birth (years), Total adult literacy rate (%), * 56 Primary school net enrolment ratio (%), * 66 % share of household income *, lowest 40% 21 % share of household income *, highest 20% 42 Source. During the late 90s, there was a growing realization at civil society level to bring forward some concrete steps in order to resolve the issues of primary healthcare especially in peri-urban areas. Realizing the need in order to improve the functioning of BHUs, a pilot program was initiated in 1999 in three BHUs in Lodhran district with

22 the leading role of civil society organization where the BHUs management was contracted out to Punjab Rural Support Program (PRSP). The pilot was later expanded to the Rahim Yar Khan district in The perceived success of the expansion resulted in an initiative to further expand the innovation to all four provinces of Pakistan under the President s Primary Healthcare Initiative. In each province, management of the BHUs was contracted out to the provincial Rural Support Program and the initiative was supported by respective provincial government through Chief Minister s Initiative for Primary Health Care (CMIPHC) Programme background and Its Duration The initiative was started from Lodhran district back in August 1999 from a mere three Basic Health Units (BHUs) and is still delivering services. These BHUs were taken over from the Punjab Government by the National Rural Support Program (NRSP). The three BHUs were run by one Medical Officer (MO), engaged by the NRSP at an enhanced salary. A Revolving Fund of Rs 100,000 was created with private resources for maintaining a store of high-quality medicines. Patients had the option of purchasing or receiving free medicines from this store that are supplied by the government at all BHUs. The Fund revolved as many as 22 times during 36 months showing a strong public preference for quality medicines. The turn-out of patients at the BHUs registered a quantum increase during the NRSP management. It is difficult to say in what way the Lodhran experience inspired the Rahim Yar Khan Pilot. Both are conceived around BHUs and both clustered three BHUs under the care of one Medical Officer. While the similarity may not go beyond these two features, the Lodhran experience admittedly encouraged more ambitious plans. For the Punjab Rural Support Program (PRSP), the Initiative was important for one predominant reason the acknowledged importance of Primary Healthcare (PHC) to Poverty. That s why the delivery of primary healthcare services to the rural poor has always been seen as being eminently in line with the PRSP Charter. It comprised six initiatives, which are as follows: Reproductive Health Project Resource Group Community Support Groups FMO Programme School Health Community Health Project Concept & Design 22 P a g e The 1973 Constitution of Pakistan, Article 38(d), guarantees that the State shall provide the basic necessities of life, including the provision of health care. Yet, the apparent priority is given to national security while overlooked the human development agenda means that the Government of Pakistan remained unable to fulfill constitutional promise to bring reforms to health sector. The provision of basic

23 health services in Pakistan is inadequate and is a major obstacle to human development. In Pakistan, the concept of co-operation between public and private provision of health care was instituted in the national health policy in 1960 as a model of corporate social responsibility to serve the nation s health needs. Public-private partnerships (PPPs) are a health sector reform to create long-term, task-oriented and formal relationships among the public-private sectors to share their core competency and resources, including some degree of joint decision-making and innovative interaction to provide sustainable improvements in the provision and enhanced utilization of health care services and also to address emerging health challenges for the benefit of society. A core set of objectives of PPP in basic health services delivery relate to improving service provision such as coverage, quality and infrastructure, as well as raising the demand for health by the community. Keeping in view the limited fulfillment of promises by the government, civil society embarked upon the issue of primary health care in Pakistan and produced success stories through pilot runs. Based on success story of pilots, the concept of public private model was employed in PHC in Pakistan whereby the CMIPHC in the Punjab was launched with the same objectives to meet MDGs through supportive activities for health sector reform agenda Problems the Programme Seeks To Address Ultra poor, marginalized groups as well as other vulnerable groups like women, youth, disabled people and minorities are being focused in this program and their problems like poverty, lack of participation and sustainability are being addressed as an integral part of all type of interventions across Pakistan. CMIPHC has an integrated and multi-sectoral design in order to address issues like social adherence, transparency and accountability, sustainability, social binding and gender equity. Following is the criteria set as parametres for the impact of PSIA of CMIPHC: Strengthened institutional capacity for RBM&E BHUs made functional OPD increased Social and Poverty impact of CMIPHC Effectiveness of Program Prospect/ changes required in program design Evaluating transmitting channels, including outreach services and their capacity to reach to the poor Factors detracting or adding to the intended impact of the program Evaluating the role played by the program in enhancing the health outcomes at the local level Evaluating the M&E system associated with the program and the risk factors Role of community support groups towards strengthening or otherwise of the primary health care system 23 P a g e

24 Reviewing the process of medicine distribution and identifying the actions needed for better implementation Main Stakeholders Major stakeholders in PPP model were Punjab health department, respective district government & PRSP while district monitoring team and community support group members, beneficiaries and health services providers were also stakeholders Expected Outcomes of CMIPHC Though, a substantial amount of funds was invested in BHUs in Pakistan, most of the BHUs in the country remained dysfunctional. Quality of care in the public sector was seen poor. A recent quality of care study shows that the government facilities have high rate of absence, vacant and mismanagement of staff as well poor supplies of medicines and inadequate functioning of equipment. The focus of CMIPHC was mainly to reactivate and improve the functioning of BHUs in the district. While a major focus of the initiative was to restore the dysfunctional facilities, another component improved the availability of doctors by allowing PRSP to hire doctors on contract and assign them to cover three facilities (clustering). Expected outcomes of this project were improvement in PHC, MCH, RH and decrease in IMR, MMR, NMR and increase in life expectancy rate. It will improve the economic situation of household as FLHFs are provided free at doorstep that can save the transportation cost too. 1.4 PSIA-CMIPHC Poverty and Social Impact Analysis (PSIA) involves the analysis of the distributional impact of policy reforms on the well-being of different stakeholders with a particular focus on the poor and vulnerable. PSIAs are analytical exercises that attempt to understand the likely poverty and social impact of particular policy choices. PSIAs often draw on a wide range of analytical tools and data sources in attempting to understand policy impact. These tools range from those that are highly qualitative and participatory to those that are quantitative and often driven by economic theory. The scope and content of PSIAs are usually driven by the policy agenda of the day and the timeframe in which the studies need to be completed. Under UNDP SPRSM project, a Strengthening PRS Monitoring provincial secretariat has been established in Planning & Development (P&D) Department in Punjab. The project has a strong focus on research studies, impact evaluations and assessments under which the project, in consultation with the Health Department and Punjab Rural Support Programme, has planned to undertake a Poverty & Social Impact Analysis of the project Chief Minister s Initiative for Primary Healthcare (CMIPHC) being run by Punjab Rural Support Programme (PRSP). Chief Minister s Initiative for Primary Healthcare (CMIPHC) was started for the welfare of the poor. PSIA will provide a 24 P a g e

25 better understanding of impact assessment of the Chief Minister s Initiative for Primary Healthcare (CMIPHC). For the purpose of present PSIA, Sustainable Development Policy Institute (SDPI) was outsourced by UNDP SPRSM Punjab to furnish Poverty and Social Impact Analysis (PSIA) report of CMIPHC in Lodhran district. This PSIA was planned to inform the project design on strategies for poverty and social impact of health services related aspects. This assignment was expected to play an important role in informing the policy discourse through measuring the poverty and social impact of Chief Minister s Initiative for Primary Healthcare on access of different segments of society to quality health care services Scope of PSIA-CMIPHC, Lodhran The CMIPHC in Lodhran district was ranked top based on periodic performance. The selection of Lodhran district for present PSIA becomes very relevant so as to measure the impact trends of the intervention and represent the maximum benefit so far achieved in a unit district for the entire programme. It was necessary to evaluate the socio-economic benefits that the poor are getting together with the type of respective changes occurring in health indicators, which in turn play influential role on large amount of household income thus affecting the social well-being with extra economic burden Programme Scope 25 P a g e The programme scope of PSIA study encompassed the following by employing primary and secondary research methods as an integral part of the study in line with the given ToRs: A comprehensive desk review of the current primary health care service delivery status in the province together with review of policy documents & initiatives including Annual Development Plans, Medium Term Development Framework, Health Sector reforms Programme, horizontal and vertical programmes. Assessment of the effectiveness of the programme while focusing on the inputs, outputs and outcomes. The programme progress towards its indicative expected outcomes and objectives Identifying prospective change(s) required in programme design to enhance the progress and meet the targets/expected outcomes within the timeframe of programme. Evaluating transmission channels, including outreach services and their capacity to reach the poor; their impact on different groups of population and the analysis of groups to benefit the most from them. Analyzing the health related factors adding to or detracting from the intended impact of the programme. Evaluating the role played by the programme in enhancing the health outcomes at local level.

26 Evaluating the monitoring & evaluation system associated with the programme and the risk factors. Role of community support groups towards strengthening or otherwise of the primary health care system. Reviewing the process of medicine distribution identifying the actions needed for better Implementation. Assessing the extent of integration of outreach services with the BHU and suggesting measures for making the BHU a composite whole of PHC. For primary research, 1240 beneficiaries' interviews were conducted on structured questionnaire while FGDs and KIIs were also used to cover the data errors, logical inferences and other relevant stakeholders Geographic Scope The present PSIA study was carried out in Lodhran district covering all 48 BHUs in three Tehsils i.e; Lodhran, Dunya Pur and Kahror Pakka Aims & Objectives The CMIPHC project aimed at catalyzing the health care needs of the poor and marginalized sections of rural society through improved community participation and inclusiveness. Its asserted objective is to create a wholesome impact on the health status of the poor and marginalized and thereby help them improve their livelihoods. The overarching aim of the PSIA study is to analyze poverty and social nexus in the context of health care services to different segments of the society. The objective of the PSIA study is to help take informed policy decisions through measuring the social and poverty impact of Chief Minister s Initiative for Primary Health Care of Lodhran district Key Issues/Parameters Addressed For PSIA-CMIPHC, following 13 parameters were used to identify the impact trends in the context of poverty and social outcomes of the project. (1) Access and availability of health facilities (2) Basic service delivery (3) Mother & child health (4) Social inclusion (5) Social influences of programme (6) Effectiveness of programme (7) Economic impact (8) Programme monitoring (9) Strength and weakness of programme 26 P a g e

27 (10) Challenges to programme (11) Sustainability of the programme (12) Accountability and transparency (13) Grievance redresser mechanism 1.5 STRUCTURE The study began with preparation of the Inception Report, its revision and finalization incorporating feedback of the SPRSM unit and management staff of district concerned of PRSP for the implementation of CMIPHC. The findings of the survey and qualitative and quantitative research work were analyzed together in the Zero Draft report and subsequently in Draft version of report submitted as second deliverable, and the Final Report was submitted as the third and last deliverable after incorporation of comments from various stakeholders. The Report begins with an overview of CMIPHC, scope of the study and assessment of parameters, expected results and key issues addressed in the report. Thereafter, methodology of the social assessment study is explained. This is followed by detailed review of related institutional framework and impact analysis which entails an objective assessment of study objectives based on the PSIA standard approach and method with different parameters covered for the sector concerned. This is followed by findings of the study in the form of quantitative and qualitative analysis. At the end are the recommendations based on findings and lessons learnt so that the study informs and gives a picture to program partners about its interventions and can be used as future reference to determine direction and proactive measures for achieving the ultimate results in line with the core philosophy of Health Sector Policies. 1.6 METHODOLOGY This PSIA study entails consultation with UNDP-SPRSM and PRSP team at each stage. All designed tools and methodology was shared and discussed with UNDP SPRSM team. SDPI research team worked on both qualitative and qualitative tools to cover all possible dimensions of this rapid assessment study. This chapter provides information on research tools, research protocols, sample selection & geographical coverage, data acquisition, data management and data analysis. 27 P a g e

28 1.6.1 Desk Review Desk review was carried out for initial review and preparation of tools together with policy and model analysis purpose for mid-term analytical work through triangulation prior to produce a quality report. The SDPI team examined existing available literature on the subject and relevant documentation for the project in particular and PSIA in general. The studies, which were the primary source of information for this research study, were used to establish a baseline for final recommendations especially for some indicators, which are at early stage of achievement. For this purpose, SDPI, besides other relevant documents, has also used the evaluation and baseline study reports of PRSP, UNDP and other sources, institutional and management polices of PRSP and agreement with district government. The desk review has particularly been helpful in developing the qualitative and quantitative questionnaires, while it was also helpful in writing a quality report ensuring this poverty and social impact analysis (PSIA) exercise Meetings and Discussion Various consultative meetings and discussions were held with UNDP SPRSM and PRSP at different stages of the study. The objective of the meetings and discussions was to take feedback of SPRSM unit and PRSP at all levels involved. Besides, meetings were also held at local level with the officials of different stakeholders and relevant government departments and feedback was recorded in the form of semistructured Key Informant Interviews (KIIs) Inception Report An inception report was prepared and shared with UNDP SPRSM unit prior to get start with the activities. The detailed methodology was part of inception report based on which the detailed sampling strategy was devised Field Action Plan A detailed Field Action Plan was prepared whereby sampling strategy was devised and shared with UNDP SPRSM prior to get start with the primary data collection. The detailed action plan was helpful in assigning the simultaneous tasks to different field teams in all Tehsils and also extended help to UNDP SPRSM unit in planning their surprise field monitoring. 28 P a g e

29 1.6.5 Finalization of Survey Tools SDPI research team developed quantitative and qualitative tools for primary survey which were shared with UNDP SPRSM team over . A detailed discussion on these survey tools was done over skype. It was mutually agreed upon with the consensus of SDPI and UNDP SPRSM that it is a kind of PSIA study so it was decided to employ quantitative and qualitative tools both given the importance to the original TORs of the study in order to get unbiased and reliable results to meet the requirement of timeline of this assessment Enumerators Training A good survey is not possible without better understanding of the research objectives and designed tools. For this purpose two days enumerators training was held at a local hotel in Lodhran on November 15-16, SDPI research team explained the objective of this research study while survey unit equipped the enumerators with probing techniques and understanding of the questionnaire. The training was concluded with an exercise on pre-testing of research tools Approval of Report s Contents Research team designed the contents of the study report in line with UNDP SPRSM reporting format, which was shared with SPRSM Unit team via . Report contents were finalized after a detailed discussion PSIA Tools and Data Verification Mechanism PSIA Study took an indepth analysis of SPRSM core values through a mix of verifiable research instruments covering the scope of CMIPHC in the Punjab. The research instruments deployed were selected from the set of qualitative and quantifiable tools in participatory manner. a) Sample Size For quantitative segment of research, the stratified-random sampling was done with a sample size of 1,440 by covering the geographic areas of all 48 BHUs in three Tehsils i.e; Lodhran, Kahror Pakka and Dunya Pur. The originally envisaged quantitative sample size of 1,200 beneficiaries in ToRs was revisited by SDPI research team and increased to 1,440 in order to facilitate representative sample size by covering the geography of all BUs. Four FGDs and 10 KIIs were carried out in each Tehsil. The primary research covered the following sample size and its geographic distribution for qualitative and quantitative work: 29 P a g e

30 Table 2: Sample Size and Geographic Distribution # of Qualitative Quantitative (Beneficiaries Interviews) S # Tehsil BHUs FGDs KIIs Male Female Boys Girls Total 1. Lodhran Kahror Pakka Dunya Pur Total b) Data Collection Data collection was comprised two components Primary data collection and Secondary data collection 1) Secondary Data Collection After acquiring relevant data from SPRSM UNDP and PRSP, the SDPI research team reviewed it. On the basis of review, it was able to devise comprehensive qualitative and quantitative research tools. Moreover, the data set, shared by the PRSP, also served in putting up a quality report after the completion of the PSIA exercise. 2) Primary Data Collection On the basis of the questionnaires for qualitative and quantitative data collection, the SDPI field research team duly collected data from three Tehsils of Lodhran district. The bifurcation of this exercise is given below: QUALITATIVE For Focus Group Discussions (FGDs 12 in total), the SDPI field research team invited doctors, paramedics, beneficiaries and community support groups for conducting 4 FGDs (2 with male groups and 2 with female groups ) in one Tehsil. Moreover, 10 indepth interviews (Key Informant Interviews) were also carried out in each Tehsil. The team also collected different case studies from each Tehsil in order to analyze the success/ failure or bottlenecks of the programme. QUANTITATIVE A total 1,440 direct beneficiaries (480 married males, 480 married females, 240 school going girls and 240 boys) were interviewed across the district through a stratified-random sampling plan. 30 P a g e

31 1.6.9 Research Instruments Protocol a) Structured Interview Structured questionnaires were developed for beneficiary survey. The beneficiary questionnaire carried information on 13 parameters of Economic Impact, Access and availability of health facilities, Basic service delivery, Mother & child health, social inclusion, social influences of programme, effectiveness of programme, programme monitoring, strength and weakness of programme, challenges to programme, sustainability of the programme, Accountability and transparency, and grievance redresser mechanism. The questionnaires contained information on UNDP SPRSM interventions at community level, benefit gained by different social groups and limitations and beneficiaries recommendations to improve it. b) Open Ended Questionnaire Interview The technique employed is relatively simple and was found very effective for Key Informant Interviews during the course of this study. A set of opening questions with short unambiguous responses are followed by main questions phrased in such a way that they are easily understood and descriptive. c) Discussion Guides Focus Group Discussions (FGDs) is the commonly used qualitative technique in research methodology. It is quite different from the individual interviews which are administered in person and recount personal experiences and perceptions of the individuals are observed in a group. Nonetheless, FGD focuses on the group of respondents in an organized way to gain maximum insights into the key problems being investigated. The discussion guides were developed to facilitate the working of field team. The focus of these discussion guides were the issues widely covered in the individual interviews. Discussion guides provided guidelines to the moderator and assistant moderator for smooth conduct of FGDs Data Collection and Management a) Field Work The research team along with the Survey and Monitoring and Evaluation (M&E) Units prepared the field plan for data collection. Prior to the field plan, research team with the support of Survey Unit decided to engage local supervisors and enumerators. The local enumerators were contacted at the planning stage of the field plan due to the sensitivity of the data collection in the crisis prone region. Survey Unit conducted interviews in Lodhran district for the selection of enumerators. For each Tehsil, a team of four enumerators comprising two female and two male enumerators was formed. 31 P a g e

32 The training was an important element in quality data collection as the enumerators were to be equipped with basic understanding of the questions and their implications to ensure authenticity of data being collected. The survey team held a two-day interactive training session with the field teams in Lodhran. The training was divided into three different sessions focusing upon interviewing and probing techniques, overview of SPRSM and CMIPHC working and indicators used for PSIA study. The sessions were arranged in a way that it provided maximum information and conceptual clarity to the enumerators. The survey unit fully understood the sensitivity of the questions, which they passed on to the enumerators so that the indepth responses might be obtained from the key respondents in the field. At the end, mock sessions were conducted to provide a real survey environment and to highlight the weak areas of each enumerator for improvement. b) Data Management The data for the study was collected from different sources by using different instruments. This raw data was categorized into data files. The beneficiary survey questionnaires were coded and entered to the CS-PRO computer programme and then transformed to SPSS for analysis. The findings of the focus group discussion were also used to support the field data Data Analysis The data collection exercise was followed by data entry in SPSS, data cleaning and analysis on a carefully put up analysis plan in line with the agreed SPRSM UNDP PSIA needs. A total of 13 selected parameters of quantitative questionnaire were used for analysis plan as given in following table. The distribution of parameters was done in accordance with the study ToRs. 32 P a g e Table 3: ToR Objective-wise Parameters Distribution S. No. ToR Objectives Distribution of Questionnaire Parameters 1 Strengthened institutional capacity for Result based monitoring and evaluation (RBM&E) Programme Monitoring Strength and Weakness of Programme 2 BHUs made functional Access and availability of health facilities Basic service delivery Effectiveness of programme Accountability and transparency 3 OPD Increased Basic Service Delivery Social influences of programme 4 Social and Poverty impact of CMIPHC Social Influences of programme Social Inclusion Economic Impact 5 Effectiveness of Program Effectiveness of programme Strength and weakness of programme Grievance redresser mechanism 6 Prospect/ changes required in program design Effectiveness of programme

33 S. No. ToR Objectives Distribution of Questionnaire Parameters Accountability and transparency Social inclusion Programme monitoring Challenges to programme Grievance redresser mechanism Sustainability of the programme Strength and weakness of programme 7 Evaluating transmitting channels, including outreach services and their capacity to reach to the poor 8 Factors detracting or adding to the intended impact of the program 9 Evaluating the role played by the program in enhancing the health outcomes at the local level 10 Evaluating the M&E system associated with the program and the risk factors 11 Role of community support groups towards strengthening or otherwise of the primary health care system 12 Reviewing the process of medicine distribution and identifying the actions needed for better implementation 13 Assessing the extent of integration of outreach services with the BHU and suggesting measures for making the BHU a composite whole of PHC Social inclusion Social influences of Programme Accountability and Transparency challenges to programme sustainability of the programme strength and weakness of programme mother & child health economic impact social influences of programme social inclusion access and availability of health facilities programme monitoring strength and weakness of programme challenges to programme sustainability of the programme grievance redresser mechanism Social inclusion Social influences of programme Grievance redresser mechanism Sustainability of the programme effectiveness of programme accountability and transparency programme monitoring basic service delivery social inclusion social influences of programme sustainability of the programme Research Ethics (1) Informed and voluntary consent 33 P a g e It is a mechanism to ensure that the participants understand the ongoing research exercise so that they can decide to become participants in a non-coercive, conscious and deliberate way. This is essential for the self-esteem and satisfaction of the person engaged in this work. The study clearly underscores the need for informed and voluntary consent from different types of respondents at different stages of the project cycle. Administrative authorities of different departments and stakeholders were informed through letter of invitation elaborating the objectives of the study. Informal consents were given through negotiations. The degree of participation and involvement varied in keeping with the levels of consent, sought from the participants. Once the team arrived for the field data collection, verbal consent was

34 again taken from households and individuals for their participation in interviews and focus group discussions. In our case, the participants did not sign any consent form. (2) Confidentiality of information It is important to record and maintain data in a way it was passed on by the participants to researchers and vice versa. It is a common practice that the participants freely talk with researchers and share their personal observations and experiences of their real life. It would be highly imprudent to pass on the information of one participant to another, which might harm inter-personal relations to guard against such a situation, utmost care has been taken while conducting the individual interviews and focus group discussions. It helped to build mutual trust and encouraged the participants to disclose information without any risk or fear. (3) Anonymity of the participants It is always desirable that original names of the participants were not shared while presenting the information and findings of the research study, so when the issues discussed and information contained in it was of a sensitive nature. Pseudonyms were, therefore, used while quoting the important messages throughout the text. (4) No harm to participants Reflexive and participatory nature of the research report turns it into a mutually beneficial exercise for the participants. However, the outcome of the research could potentially lead conflict tensions. The research team was suitably advised prior to the start of the field work to avoid any adverse fallout of the research findings and try to mitigate the risk involved. 34 P a g e

35 Chapter 2: REVIEW OF INSTITUTIONAL FRAMEWORK 2. INSTITUTIONAL FRAMEWORK FOR HEALTH SECTOR IN PAKISTAN The institutional framework normally covers Policy, Legislation, Rules & Regulations, Executing Institutions and International Obligations. The relevant national and sub-national (Province) level institutional framework was reviewed in this section in which international obligation and legal aspects were covered so as to analyze the rationale and impact of Public-Private Context of CMIPHC. The chapter is primarily based on desk review through scrutinizing the relevant secondary documents, reports and other legal and binding international agreements, other relevant material and extract from consultative meetings with the officials of UNDP SPRSM and PRSP. The review was important and linked the institutional impact analysis in next chapter in order to sketch the real picture to set way forward for future endeavors. 2.1 UNIVERSAL DECLARATION OF HUMAN RIGHTS (UDHR) This declaration is directly or indirectly linked with the MDGs and covers the aspects of PSIA study. According to the article 25 of the Declaration of Human Rights (UDHR, 1948), everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family, including medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. 2.2 CONSTITUTION OF PAKISTAN The constitution of Pakistan is the guarantor of providing the basic health facilities and livelihood opportunities to its every citizen. According to the Article 38(a) and (d) of Constitution of the Islamic Republic of Pakistan (1973), the state shall secure the well-being of the people, irrespective of sex, caste, creed and race, provide basic necessities of life, such as medical relief, for all such citizens, irrespective of sex, caste, creed or race, as are permanently or temporarily unable to earn their livelihood on account of infirmity, sickness or unemployment. The Article addresses the both poverty and social aspects of life of everyone. 35 P a g e

36 2.3 MILLENNIUM DEVELOPMENT GOALS (MDGS) FOR PAKISTAN 36 P a g e Pakistan along with other world leaders adopted the Millennium Declaration in year 2000, now with only five years remaining; efforts for the achievement of the Millennium Development Goals (MDGs) become increasingly important. 18 global targets and 48 indicators adopted in 2000 have been translated into 16 national targets and 37 indicators keeping in view Pakistan s specific conditions, priorities, data availability and institutional capacity. The Goal-1 is directly addressing the poverty and hunger while three Goals i.e. 4, 5 and 6 are addressing health issues in which Goal 4 is for child mortality issue, Goal 5 is for maternal health and Goal 6 is directly related to the CMIPHC s preventive measures component as it addresses the need to reduce HIV and Malaria cases. Among 6 indicators of goal 4, the first indicator is the decline in under five mortality from 140 in to 52 by Over the to the child mortality has declined to 100, a decline of 40 percentage points. MTDF target is to reduce child mortality rate to 77 in 5 years and then a further reduction of 25 percentage points if the target for 2015 is to be met. Second, infant mortality rate of 102 in is to be reduced to 40 by Over the last 14 years the mortality has declined by 29 percentage point and the MTDF has a target of 65. Third, proportion of fully immunized children of month should exceed 90 percent by Since in the proportion was 75 percent the target looked within reach but by the proportion barely increased to 77. Fourth, proportion of children immunized against measles in the age bracket of less than 1 year has to increase to more than 90 percent. There has been slippage in this target as well; proportion declined from 80 to 78 and the MTDF target is 90. Fifth indicator relates to the children suffering from diarrhea and the proportion fell from 26 in to 16 in Since the proportion has already declined from 26 to 16 percent the target is likely to be achieved. Sixth, Lady Health workers coverage is to be universal by In the coverage was 33.6 % and it had reached to 80 percent by The target seems to be easily achievable. Goal 5 has five indicators as contained in the following table. The first two indicators of Goal 5 relate to the reduction of the mortality ratio and increase in the proportion of births attended by skilled health personnel. In terms of these two indicators, Pakistan while attaining some success has a considerable distance to go to meet the MDG targets by A third indicator relating antenatal care also shows low progress towards the 2015 target. From the available data it is clear that many of the specific targets for Goal 5 will not be met in the immediate future, and it will be challenging to meet the targets in Among five indicators of goal 6, first indicator is the reduction in HIV prevalence among year old pregnant women by one half. Since the incidence has been low and there are various programs to combat HIV the target is expected to be achieved. Second, HIV amongst the vulnerable groups is also to be met due to various programs that have been launched by the government and civil society. Third, proportion suffering from malaria under high risk getting treatment to rise from 20 percent in to 75 percent. The proportion increased to 30 percent in and MTDF target is 50 percent and that can only be met through more concerted efforts. Fourth, incidence of tuberculosis to decline form 177 in to 45 per 100,000 in Since the

37 incidence is still 180 in the target seems to be far distant away. Fifth, proportion of TB cases detected and managed through DOTS strategy to rise from 79 percent in to 85 percent by 2015 and at present during it is 80 percent (MDG Report, 2010). There seems very little possibility of meeting the MDGs in most of the indicators except for lady health workers coverage, reduction in diarrheal cases and HIV target. The case of TB is critically important and needs more focused efforts. There is a need to examine as to why there has been slow progress towards most of the other targets. Special efforts would be required to meet the target. Why the progress has been so slow needs to be examined? The MCH component of the CMIPHC programme is critically important as all health related goals are directly or indirectly linked with it. The scope of activities under CMIPHC covers more or less or components but the mobilization and awareness component needs more focused efforts. 2.4 THE CONTEXT OF HEALTH SECTOR AND NFC AWARD According to the Economic Survey of Pakistan ( ), Pakistan is the 6 th largest state of the world having a huge flux of population living in rural and urban areas. There is one doctor for every 1,222 people in the country, one dentist for 16,854 people, and one hospital bed to 1,701 people. Target set for the national health policy was to increase the number of doctors by 5000, dentists by 450, and have another 35,000 nurses, 5,500 paramedics and 500 traditional health attendants. For rural areas, there were to be 14 new Rural Health Centers (RHCs), 40 new Basic Health Units (BHUs) and the upgrade of 45 RHCs and 900 BHUs. Regarding primary health care, 8.5 million children were to be immunized by the end of The resurgence of polio virus in Pakistan and a record increase in the number of cases was a cause for international concern. Pakistan has a population of about 160 million with the per capita gross national income (GNI) of 870 US$ and only 1.5% of the total central budget is spent on health. Table 4 & 5 gives comparison of Health Indicators of Pakistan with other Asian countries and Health Indicators of Pakistan respectively. In the current scenario, the success and sustainability of public private partnership model of CMIPHC becomes critically important and relevant in order to meet the MDGs together with National and Provincial health policies so as to provide the constitutional right to the poor and marginalized segment of the society at large especially residing in per-urban areas. The role of community support groups and other stakeholders becomes critically important in order to create self-sustained programme on long-run basis. 37 P a g e

38 Table 4: Selected Health Status Indicators: Pakistan VS Asian Countries ( ) Life Expectancy Annual Under 5 Growth HDI H. Exp.% Country Male Female IMR Mortality MMR Rate Rank GDP Pakistan India Sri Lanka Bangladesh Nepal China Iran Thailand Malaysia Philippines Indonesia Sources: UNDP, Human Development Report, 2006; Economic Survey , Pakistan MDGR , PDHS Indicators Infant mortality rate/ 1000 live births Under 5 child mortality rate/1000 live births Crude death ratio /1000 live births Maternal mortality rate/100,000 live births Table 5: Health Indicators Pakistan ( ) 1988/ / / / / / / / / Life expectancy male 57.1 n/a Life expectancy female 57 n/a n/a 60 n/a Low birth weight babies %age Malnourished children under 5 years % age n/a 45 n/a Sources: UNDP, Human Development Report, 2006; Economic Survey , Pakistan MDGR , PDHS P a g e The National Finance Commission (NFC) award is a revenue distribution formula between the federation and the provinces for the revenues collected by the federal government. The latest 7 th NFC is effective from the year 2011 and will be implemented till Its two distinct features from previous awards have contributed towards the transfer of revenues from federal to province level. Firstly the share of the federation is smaller than the previous awards i.e. 44% instead of 52.5% (in 6th award). Secondly, the distribution of the 56 % provinces share among provinces has been revised on a new formula. Both of these formulas have impacted an improved financial position of all four provinces. In addition, there are specific transfers from the federal government to the provinces. Firstly, additional grants from the federal government to the three small provinces namely Sindh, Khyber Pakhtunkhwa (KPK)

39 and Balochistan and secondly, transfer of funds as a result of compensation to the province for exploiting Hydel and Gas resources in KPK and Balochistan (Mustafa, 2011). Provincial departments of health deliver the public health and curative care services while the federal government is concerned with planning and policy-making. District health system was introduced in 2001, and the districts were independent in administrative and financial matters regarding the health care. Still, the federal government after taking her due share from NFC award has a promise to fulfil four major objectives i.e. security, education, health and sanitation. Unfortunately, only 1.5% of entire budget is allocated to health and sanitation due to federal share reduction and also the devolution of powers to provinces. The proportionate for national level health agenda is quite insufficient. In the current scenario of NFC award and national level promises viz-a-viz allocation entails extended role on the shoulder of provincial government whereby the CMIPHC becomes more important to get continued support from all stakeholders, including the provincial government and community involved in order to meet the MDGs and provide the constitutional and human rights to the poor and marginalized TH AMENDMENT: THE POLITICAL AND FINANCIAL CONTEXT OF HEALTH IN PAKISTAN Policy formulation for the health care services should be based on the knowledge regarding the health-seeking behaviors of community and the factors influencing it. The factors determining trends in the health seeking behavior may be seen in various contexts like demographic, socio-economic and cultural. Most countries have diverse health systems according to the local circumstances while a multi-sectorial and multilevel coordination is essential for better health profile of the nation. Features of the health facility and confidence in health care workers also play a major role in decision making the choice and relevance of the health facility. The 18th Amendment not only brought a major change in the powers of the President but also in the structures, resource generation and service delivery of the Federal and Provincial governments. It is mainly a shift in federal-provincial relations. While the principle of subsidiarity is a positive concept but, experience of other countries show that whether the system is relatively centralized or decentralized, service delivery only improves when governance systems and mechanisms are put effectively in place. The health policy, MDGs and implementation instruments in Pakistan are critically important to be investigated as there are overlaps of certain tasks through federal and provincial interventions and control over certain matters like drugs control, special measure for contagious diseases and national level health programme. At the same time, the double-barrel control over the affairs of BHU staff in public-private model of CMIPHC also a matter of great concern for the effectiveness and success of programme in its true letter and spirit. 39 P a g e

40 2.5.1 Pre-18th Amendment Scenario 40 P a g e Health was also a residuary responsibility, which vested in the provinces before the 18 th amendment in the Constitution. In spite of provincial role, the federal government extended presence in the provinces using provisions of Concurrent Legislative List related to drugs and medicines, prevention of extension of contagious and infectious diseases from one province to another and mental illness (entries 20-23). Entries 3, 16, 19, 25, 27, 32 and 57 of Federal Legislative List are related to the implementation of international obligations, research and professional training, quarantine, Intellectual Property Rights, import/export of goods, planning and statistics respectively that were supporting ends for federal interventions and control over certain matters. The coordination between provincial and federal departments was a major challenge for effective and coordinated efforts in order to achieve MDG targets Post-18th Constitutional Amendment Position After the 18th Amendment, it was perceived that now health would fall exclusively in the domain of provinces. This, however, did not happen functionally and departments related to health devolved or retained/reassigned by the federal government. An important aspect is that only 35% of population benefits from public health services while the rest are catered by the private sector; however, the private sector remains practically unregulated due to ineffective role of Pakistan Medical and Dental Council established under PMDC Ordinance Financial Capacities of Provinces National School of Public Policy (2012) reported that details of financial and human resources after devolution are still being worked out between the federal and provincial governments, to effectively implement the process, though technically devolved institutions and responsibilities have taken effect from July 1, However, with the expected increase in share in the total revenues of the provinces (in the NFCAward), there are significant enhancements in allocation in all the four provinces on recurrent and development sides. In comparison to ADP and budget , substantial percentage increases have been made by the provinces on health in ADP and budget : Baluchistan (138% and 451%), KP (141% and 142%), Sindh (139% and 100%), and Punjab (208% and 101%). It is also less likely that management and services delivery of the vertical programs would suffer due to inadequate financial resources Functions of Federal Ministry of Health The current responsibilities of Health Ministry can be classified in terms of functions as national planning, regulation, policy standardization, medical education, research, preventive and infectious disease control and curative health care. The current responsibilities of the ministry include those assigned to it under the Rules of Business 1973 also assigned various institutions as attached departments of the

41 41 P a g e Ministry in Schedule III (Rule-4(4)). The attached departments are listed below followed by their budgets in recent years. Directorate of Central Health Establishments Directorate of Malaria Control Directorate of Tuberculosis Control Jinnah Post-Graduate Medical Centre Federal Government Services Hospital (FGSH), Islamabad National Institute of Malaria Research and Training, Lahore National Institute of Child Health, Karachi Pakistan Institute of Medical Sciences, Islamabad During the last decade or so, a number of important health related projects have been launched at the national level with the support of bilateral and multilateral donors. These projects aimed to achieve national policy objectives and targets of international development goals. Some vertical programmes focused narrowly on immunization, malaria, tuberculosis and HIV/AIDS while others were more broadly defined projects, such as the Women s Health Project, Reproductive Health Project and/or National Nutrition Project. Currently there are eleven vertical programmes: (1) Expanded Programme on Immunization (EPI) (2) Prime Minister s Programme for Prevention and Control of Hepatitis (3) Roll Back Malaria in Pakistan (4) National Programme for Family Planning and Primary Health Care The Lady Worker s Programme (5) Enhanced HIV/AIDS Control Programme (6) National Tuberculosis Control Programme Strengthening National Tuberculosis Control Programme by Ensuring Uninterrupted Drug Supplies (7) Improvement of Nutrition Through Primary Healthcare and Nutrition Education/Public Awareness (8) National Programme for Prevention and Control of Avian and Pandemic Influenza (9) Maternal Neonatal and Child Health Programme (10) National Programme for Prevention and Control of Blindness (11) Improvement of Nutrition through PHC The transfer of vertical programmes to the Provinces has an ambiguity while the federal level budget allocations have limitations in order to overcome the national needs. 2.6 PAKISTAN BUDGET The total size of the budget is Rs 2.96 trillion. The running or current expenditures are Rs billion. Out of such expenditures Rs billion has been specified for general public services whereas Rs 545 billion is for defence services. The size of the developmental budget is Rs 873 billion out of which Rs 536 billion will be spent by the federal government and Rs 337 billion by the provincial government.

42 As far as the health sector budget is concerned, the curative segment has the biggest share of total current budget. The curative segment constitutes 84% of the total federal current budget Preventive Programmes/ Selective PHC constitute 57% of the total federal PSDP. While preventive Programmes allocations are rather evenly distributed between different provinces and areas, probably on the basis of population and burden of diseases. The population has increased overtime while the health expenditures at national and sub-national level have almost yearly decreasing trend from fiscal years (0.72 % of GDP) to onward (0.27 % of GDP in fiscal year ) while comparing as %age of GDP (GoP, 2012). Federal Health Ministry s total allocations to curative service (current and development) are mainly concentrated in ICT (50% of total) and Sindh (27 % of total). Interestingly, most of the curative service facilities in Sindh are situated in Karachi. Federal financial through-forward liabilities are mainly on development side with the exception of Sindh, where current budget liabilities (mostly curative facilitates) are 12% of Sindh health department total current budget Preventive programmes account for 57% of the ministry s total resources and 73% of its PSDP. Most of the foreign assistance is for these vertical Programmes. The approved foreign assistance for Ministry of Health (MoH) is Rs 1.77 billion, which accounts for 10 % of the PSDP and 8% of total MoH budget. The foreign assistance component is mainly for three Programmes i.e. HIV/AID, EPI and MNCH Programme. The federal government solely funds the other key Programmes such as national Programme for PHC and FP, Hepatitis Control Programme and National Tuberculosis Control Programme etc. The MoH has various types of health facilities throughout the country and it continues to expand these through the PSDP funds. These establishments account for 31% of the total MoH budget (84% of the current budget and 15% of the PSDP). These facilities are mainly of two kinds 1) providing curative and rehabilitative service in federal areas and provinces 2) check posts at the international borders Provincial Health Care Delivery and Allocations Health care delivery is mainly financed and administered at the provincial level. Both secondary and tertiary cares as well as primary health care are administered at the provincial level. However, a general trend is that tertiary and secondary care hospitals are under the jurisdiction of the provincial government and PHC facilities are under the control of district government. With the expected increase in share in the total revenues of the provinces, all the four provinces are allocating substantial funds to health sector. There are significant enhancements in allocation in all the four provinces on recurrent and development sides. However in the absence of any conditions/ restriction by the federal MoH, these allocations are meant for the indigenously set priorities that are supplementing the federal Programmes. For example Government of Sindh has allocated more resource to the federal Hepatitis control Programme (Rs. 850 million during ) and Government of Punjab is starting mobile hospitals in the province (Rs.614 million during ) out of its development funds in healthcare (Government of the Punjab. 2011). 42 P a g e

43 43 P a g e The Provincial delivery and allocations are critically important for the PHC while addressing the aspirations and needs of poor and marginalized viz-z-viz concentrated health service in urbanized areas of Punjab Province in particular and all over Pakistan in general. 2.7 ANNUAL DEVELOPMENT PROGRAMME OF PAKISTAN The ADP has been formulated within a Medium Term Development Framework (MTDF), a rolling plan providing development estimates for a three-year period. The major objectives of the ADP are to achieve equitable growth embracing all sectors and regions, extend social sector coverage and generate employment, enhance productivity and competitiveness in the production sector, encourage public private partnership and infrastructure development, its rehabilitation and consolidation, provide more resources for the less developed areas. The salient features of the ADP include regional balance in the allocation of resources with extra weight for less developed districts, continued focus on undertaking projects that can be completed within one year to control throw forward, and continued strategic intervention in large cities to realize their potential as engines of growth and enabling medium cities to share the urbanization pressure. According to the budget documents, out of the total ADP allocation, Rs billion has been made available for ongoing schemes while Rs billion would be for new schemes in the next year. A major junk of the ADP goes to Social Sector with Rs billion, out of which Rs billion would be spent on different schemes in the education sector, while health gets Rs billion, Water Supply and Sanitation Rs billion, Social Protection Rs 1.2 billion, Regional Planning Rs 15.5 billion, Local Government and Community Development Rs 910 million and District Development Packages Rs billion. In the education sector, Rs 15 billion has been allocated for school education, Rs billion higher education, Rs 700 million for special education, Rs 915 million for literacy and Rs. 1.8 billion for the sports. The programme contains portfolio of development schemes for the Financial Year and projections for the next two years & While undertaking this exercise, efforts may be made to identify / include projects in each sector which may be implemented in the Public Private Partnership mode with clear policy objectives, sectoral priorities, strategic interventions, targets and achievements, and special linkages to the Millennium Development Goals (MDGs). 2.8 NATIONAL HEALTH POLICY OF PAKISTAN OF 2009 & ONWARD Like every segment of health related agenda, the Pakistan s National Health Policy 2009 also meant to improve the health indicators of the country by delivering a set of basic health services that include improving health manpower, gathering and using reliable health information to guide program effectiveness and design, and strategic use of emerging technology. It also aimed to improve health status of the population by achieving policy objectives of enhancing coverage and access of essential health

44 services, measurable reduction in the burden of diseases and protecting the poor and under privileged population subgroups against risk factors. Several national programs, especially vertical programs, are under way with major thrust to improve health care, coverage and to help in achieving Millennium Development Goals (MDGs) pertaining to health indicators. Special attention is being given to the training of nurses and several training centers are already in operation. 2.9 MEDIUM TERM BUDGETARY FRAMEWORK - PUNJAB 44 P a g e Earlier to the MTBF , Government of the Punjab concluded and reported in year 2010 that the PRS Paper had the endeavors of the finance departments in the country. It further emphasized to ensure active and vibrant engagement in the formulation of Annual Development Programme (ADP) in the form of medium term budgetary frameworks. Revenues and expenditures have been projected over a medium term horizon. Planning within the resource envelope is bringing in prioritization and consideration for efficiency, economy and value for money. The MTBF process requires ministries to lay out policy priorities based on a ministerial review, develop specific indicators, compute resource allocations for achieving them and lay down the manners in which they will be achieved. In an analytical sense, the reform means that the ministries will be accountable for their own targets and the budgets will be provided once clearer policy objectives have been worked out and agreed upon. The MTBF process, initiated in Population Welfare and Health in FY06 and being rolled out in FY07 in other ministries as well include Education, Food, Agriculture & Livestock, Women Development and Finance, comprises of following steps (the process was undertaken for FY06 and will be repeated to update the baseline budgets and created indicators and ceilings for the three year period FY 07-09) CURRENT STATE OF HEALTH IN PUNJAB With the current commitments and vision statements, the Government of Punjab can be given credit of comparatively greater focus on improving the health in the province. However, it is unlikely that the province will achieve health related Millennium Development Goals (MDGs) by There has been some improvement in terms of health outcomes. Though there are improvement trends over the last two decades but Maternal and child health services have been underemphasized within the health system, resulting in a high rate of maternal and child deaths. From childhood to old age, communicable diseases account for a large proportion of deaths and disability in the province. Among children, burden of disease is largely associated with diarrhea, pneumonia and vaccine preventable diseases, whereas in adults, TB and hepatitis are major contributors to communicable disease burden. While communicable diseases still account for a dominant share of morbidity and mortality in the province, prevalence of non-communicable diseases (NCDs) is rising rapidly. NCDs and injury are amongst the top ten causes of death and disability in Punjab. Yet few significant attempts have been made to study NCD patterns in Punjab and

45 45 P a g e existing data sources do not monitor the incidence and prevalence of NCDs very well. Nutritional status of the population is generally poor especially for the children, women of reproductive age and the elderly. Similarly, micronutrient deficiencies are also frequent and there is widespread lack of awareness about malnutrition PUNJAB MILLENNIUM DEVELOPMENT GOALS REPORT 2011 Government of Punjab in collaboration with United Nations Development Programme (UNDP) launched the Punjab Millennium Development Goals (MDGs) report The report is the first of its kind that tracks progress against various MDGs in the province. The report concluded that despite all the adverse situations like floods, law and order and global economic meltdown having impact on the economy of the province. The performance of Punjab Province is reported better than other provinces as its performance is ahead of national average in many indicators. It was desired that further research on the causes of slow progress in certain indicators needs to be seen in depth so that reasons are well identified and addressed by the Government of Punjab. It was hoped that such kind of reports would be made an annual feature of UNDP and Punjab Government activities. The Government of Punjab has undertaken many important initiatives which aim at improving healthcare services, literacy rate and infrastructure services in the province. "Such initiatives of the Government have started yielding positive results and are bringing improvement in the lives of the masses. For providing the best of the best medical services the budget of Rs million has been aloof. "In the current financial year, the Punjab Government has increased the size of social sector budget to billion rupees which is 49% of the total development portfolio." According to the Government of Punjab and UNDP (2011) report, for MDG 4, progress to date suggests that targets for some indicators could be met by Reducing Child Mortality targets on three indicators out of six will not be met. Targets for immunization in the province might be met as estimates from 2010/11 suggest that 86 percent of children from 12 to 23 months of age have been fully immunized whereas 14 districts out of 34 have already met the target of over 90 percent immunization. For the indicator of proportion of children between the ages of months immunized against measles, in 2010/11 the rate stood at 86 which was 6 points above the national average and close to the required rate of over 90. Finally, for the indicator on proportion of children suffering from diarrhea, Punjab recorded a rate of 11 percent in 2010/11, equal to national targets. Despite promising performance on these indicators, variations manifested themselves between districts and across urban/rural divides. Targets for reducing the Infant Mortality Rate to 40 per 1000 live births and the Under 5 Mortality Rate to 52 per 1000 live births are unlikely to be met. An insufficient rate of decline marks the former, which has fallen from deaths per 1000 live births in 1991 to only 82 deaths per 1000 births in For the latter, the rate has remained constant at 77 deaths between 2004 and Targets for the

46 46 P a g e indicator of Lady Health Worker (LHW) coverage will also not be met as only 55 percent of the province s targeted population had access to LHW as of May On MDG 5, Improving Maternal Health, with the exception of targets on contraceptive prevalence rates (CPR), which stood at 32 percent in 2007/08, targets on other indicators are unlikely to be met. The Maternal Mortality Ratio which must be brought down to 140 maternal deaths per 100,000 live births stood at 227 in 2006/07. On the indicator of total fertility rate there has been a very slight decline, from 5.4 to 3.58, in the mean number of children born per adult female between 1991 and However, an increase between 2007 and 2008 from 3.9 to 4.3 was recorded which indicated that perhaps targets for this indicator will not be met. Subsequent decrease between 2008 and 2011, however, from 4.3 to 3.58 suggests improvement in the indicator. Finally, ante-natal care coverage in the province was recorded at 68 percent in 2010/11 with access in rural areas at 60 percent, which was 8 percentage points below the access that expectant mothers have in urban areas. Tracking these indicators over time is problematic though as the data comes from different sources, which do not always use similar methodologies. On MDG 6, Combating HIV/AIDS, Malaria, and Other Diseases, the available data on prevalence was limited to high risk groups, and available for only four districts. HIV prevalence was found to be highest amongst injecting drug users. Awareness of HIV/AIDS stood at only 18 percent of the population on average. Data on hepatitis B and C prevalence indicated fairly high rates in Punjab, at an average of 2.5 percent for Hepatitis B and 6.5 percent for Hepatitis C. Data from the National TB Control Program indicates that case detection rates were about 78 percent, and treatment success rates were 92 percent in Punjab in 2008 and 2009 respectively. Lack of sufficient data on key indicators makes it difficult to determine the province s progress on the goal. On MDG 7, Ensuring Environmental Sustainability, Government claimed that the targets have already been achieved on the indicator of the overall population having access to an improved source of drinking water. On the other hand, the actual situation is not good and beyond the claim. In 2011, access to improved water source was 1.1 percentage points above MDG targets of 93 percent. Targets for sanitation related indicators maybe met despite large variations amongst districts as 72 percent of the population in Punjab already had access to proper sanitation facilities (underground, covered or open drains) by 2007/08 compared to 58 percent in 2004/05 whereas improper disposal of sanitary waste is in practice IMPLEMENTATION OF ADP : KEY PRIORITIES OF PUNJAB HEALTH DEPARTMENT The ADP-Punjab includes Rs 40 billion for 15 special initiatives, Rs1.5 billion for a low income housing scheme, Rs 3 billion for a population welfare programme Rs 2 billion for the Danish Schools System, Rs 2 billion for the Punjab Education Endowment Fund, Rs 6.5 billion for the Punjab Education Foundation; Rs1.5 billion

47 47 P a g e for the Technical Education and Vocation Training Authority, Rs 5.5 billion for the Directorate of Labour Inspections, Rs1 billion for establishing the Punjab Technical University in Lahore, Rs 3 billion for a self-employment scheme; Rs1 billion for women s development; Rs 500 million for an innovation development fund, Rs1.5 billion for an internship programme, Rs600 million for Parks and Horticulture Authorities, Rs5 billion for vertical health programmes; and Rs 5.4 billion for various government sector companies established under the Companies (GOP, 2012). The ADP has major focus on health, social protection/inclusion and publicprivate partnership approach in order to achieve sector specific agenda and its milestones Focus on Health Followings are the major health related focus in ADP-Punjab ( ): Measurable impact on Millennium Development Goals (MDGs). Reduction in mortality through focus on preventive health. Implementation of Minimum Service Delivery Standards (MSDS). Ensuring regional equity in the developmental portfolio. Improvement of diagnostic and treatment facilities at primary, secondary & tertiary care levels. Complement the current side pro-poor investments effectively and strategically. Overcome shortage of doctors and paramedics. Greater focus on preventive health care though control of TB, Malaria, Hepatitis, HIV / AIDS, Dengue and others. Upgradation / Improvement of DHQ / THQ Hospitals. Establishment of Centers of Excellence for Cardiac, Burn, Kidney and Child Care. Development of infrastructure and facilities in newly-established Medical Colleges in line with standards of PMDC. Training of Paramedics. Ensuring maintenance of standards in public & private sectors under Punjab Health Care Commission. Continuation of Mobile Health Service for remote areas. Implementation of Minimum Service Delivery Standards. Improving Health Management System. Water Supply & Sanitation Resource distribution for demand driven projects be encouraged for greater issues of developmental activities. Major focus on less developed areas for removal of regional disparities. Preference to complete maximum number of on-going schemes initiated during Only technically and financially viable / feasible schemes to be considered for provision of resources during

48 Rehabilitation of need based non-functional health schemes. Ensuring community participation/mobilization in identification and execution of Urban / Rural Water Supply projects for their sustainability. Ensuring proper O&M system to make the schemes more sustainable. Quality assurance through third party validation Social Protection/Social Inclusion regarding health Followings are the major Social Protection related focus in ADP-Punjab ( ): Creation of welfare facilities and healthy living opportunities of vulnerable groups including destitute and old age women and children. Gender mainstreaming in Public and Private Setup Eradication of child beggary from the society. Imparting marketable skills for generation of self-employment to the Neglected & Destitute Segments of the Society Empowerment and Capacity Building of the out of school, dropout youth (Mustehqeen-e-Zakat) hailing from the less fortunate fragment of the society covered by Zakat distribution. Dissemination of technical and vocational training to the poorest of the poor with the rationale to re-habilitate them in the society as beneficial members of the society. Assessment & Mapping of Child Protection Initiatives. Socio-economic Development of the Destitute and Neglected Children s families. Local Government &Community Development Development of Katchi Abadies. Provision of basic amenities through Punjab Development Programme. Provision of Municipal infrastructure and solid waste management. Planning & Development Responding to the challenges of poverty reduction, employment generation and Sustainable development for socio-economic transformation of Punjab. Good governance reforms. Extending social sector coverage. Improved delivery of public services. Reducing poverty and inequality. Enhancement of private sector participation through public private partnership. Ensuring balanced urban, regional and gender development. Accelerated and balanced economic growth. Supporting policy and governance reforms through Punjab Government Efficiency Improvement Programme (PRMP- III). Urban Sector Reforms through Urban Sector Policy and Management Unit. Capacity Building of civil servants through Master Degree and PhDs programme. Sustainable development of Walled City of Lahore. 48 P a g e

49 Capacity Development of P&DD for improved policy planning and monitoring of development process in Punjab Public-Private Partnership (PPPs) 49 P a g e The Punjab Government has set priority, with certain arrangements, to consider PPP implementation model for all infrastructure projects including the ones for social sectors. The health sector is also included in indicative areas as local government service agenda that supports the present setup of CMIPHC in Punjab. The projects should be within the capability of the private sector and at the same time the project should be able to attract strong market interest and have the potential to operate as a commercially viable venture. Following are the indicative areas for PPP: Local government services including water supply and sanitation, solid waste management; low cost housing, and education and health facilities. Transport and logistics including provincial and municipal roads, as well as warehousing, wholesale markets, slaughter houses and cold storage. Mass urban public transport including integrated bus systems as well as intra and inter-city rail systems. Energy projects including hydro and thermal power generation projects other than those being undertaken at the federal level. Tourism projects including cultural centers, entertainment and recreational facilities and other tourism-related infrastructure. Industrial projects including industrial parks and special economic zones PUNJAB HEALTH-POVERTY FOCUSED INVESTMENT STRATEGY (PFIS) Comprehensive reforms in the Health Sector are in the vanguard of the provincial reform agenda. The Punjab Government finalized the Poverty Focused Investment Strategy (PFIS) in July 2005 that consists of in-depth analysis of the issues confronting the health sector and recommendations to effectively address them with in the broader framework of the devolution program. The PFIS provided the groundwork for the development of the Punjab Health Sector Reform Framework (HSRF) under the aegis of the Punjab Resource Management Program (PRMP). The Government of the Punjab is committed to undertaking policy and governance reforms for economic emancipation of the masses and improved public services in the province. The Chief Minister of Punjab reiterated this commitment in his Vision 2020 that enunciates a strategic direction for the province and provides a framework for continuation of reforms over the medium to long term. In line with the commitments contained in Vision 2020, the Punjab Government launched the Punjab Health Sector Reforms Program (HSRP) to improve the coverage and quality of primary health

50 50 P a g e services, and to achieve the Millennium Development Goals through provision of missing health facilities THE PUNJAB HEALTH SECTOR REFORMS PROGRAM (HSRP) The Punjab Health Sector Reforms Program (HSRP) was launched in with block allocations of Rs. 700 million and Rs. 500 million during ADP and ADP , respectively. The scope of the first phase of PHSRP broadly includes provision of missing human and physical facilities at the Basic Health Units (BHUs) and Rural Health Centers (RHCs), improvement in health service delivery, human resource development, timely supply of essential medicines, and health awareness/health education. Civil works constitute about 70% of the program, while the remaining 30% of it is concerned with provision of equipment. The program envisaged the signing of terms of partnership between the district governments (DGs) and the provincial government, whereby the provincial government has committed to provide the DGs with the missing infrastructure to strengthen the existing medical facilities at the BHU and RHC levels. The HSRP provides for a comprehensive needs analysis of the missing facilities (physical and manpower) at the BHU and RHC level with the assistance of DGs. Under the program, the Health Department is expected to standardize the staff, medicines and equipments at the public health care (PHC) level by clearly defining the yardsticks for recruitment and procurement (G0Pb, 2006) The Health Sector Reform Agenda of the Punjab Government is, undoubtedly, holistic and ambitious, yet with the support of the present political leadership and the guidance of its domestic and international partners, it is hoped that in the months and years ahead, Punjab will witness phenomenal improvements in the coverage of health service delivery, which will not only be equitable and pro-poor, but would also meet the most stringent measures of quality, and comprehensiveness. Characterized by public-private partnerships, redesigned and reoriented public sector agencies, innovative financial arrangements, market-driven employment mechanisms, and institutionalized monitoring, evaluation and accountability frameworks, the reformed public health system will set the tone and direction for realizing the overarching objective of a prosperous, and poverty free Punjab (G0Pb,2006). The major reform initiative being proposed in this framework would have far reaching outcomes for Punjab and Pakistan. The reform program being envisaged would cover many areas. There however would be basic common areas and convergences of actions to Improve Performance of Health Sector as a whole through achieving different targets from Policy to Implementation level. Based on situation of health status of the people of Punjab and performance of health sector, the strategy development process has been outlined in following six set of directions: Enhance access to achieve universal coverage (social inclusion) Focus on primary healthcare Improve quality of care Private sector mainstreaming

51 Redefining role of government Strengthening of institutional collaborations Given the importance of the roadmap for actions, the Strategy can be concluded as a comprehensive motivation for actions in health sector of Punjab and its wide scope will be focusing on outcomes for each of the six pillars of health system, which shall be achieving the MDG targets CMIPHC IN PUNJAB A PUBLIC PRIVATE PARTNERSHIP The concept of co-operation between public and private provision of health care was instituted in Pakistan in national health policy in 1960 and started as a model of corporate social responsibility to serve the nation s health needs. Public private partnerships (PPP), as they are now called, are a health sector reform to create longterm, task-oriented and formal relationships among the public and private sectors in sharing their core competency and resources, including some degree of joint decisionmaking and innovative interaction to provide sustainable improvements in the provision and enhanced utilization of health care services and also to address emerging health challenges for the benefit of society. A core set of objectives of PPP in basic health services delivery relate to improving service provision, such as coverage, quality and infrastructure, as well as raising the demand for health by the community. Given the vision and provision in current MTBF for public private partnership for local government level initiatives in health sector, the CMIPHC Programme is one of the example of functional PPP model in local level health services in Punjab that has set trends for its success. It was started from Lodhran District, back in August 1999, from a mere three Basic Health Units (BHUs) and still in action in delivering the services. These BHUs were taken over from the Punjab Government (GOPb) by the National Rural Support Program (NRSP). The three BHUs were run by one Medical Officer (MO), engaged by the NRSP at an enhanced salary. A Revolving Fund of Rs. 100,000 was created, with private resources, for maintaining a store of high-quality medicines. Patients had the option of purchasing medicines from this store or of receiving free medicines that are supplied by the Government at all BHUs. The Fund revolved as many as twenty two times during 36 months showing a strong public preference for quality medicines. The turn-out of patients at the three BHUs registered a quantum increase during the NRSP management. It is difficult to say in what way the Lodhran experience inspired the Rahim Yar Khan (RYK) Pilot. Both are conceived around BHUs and both clustered three BHUs in the care of one Medical Officer. While the similarity may not go beyond these two features, the Lodhran experience admittedly encouraged more ambitious plans. Punjab Rural Support Program (PRSP) claims that the Initiative was important for one predominant reason the acknowledged importance of Primary Healthcare (PHC) to Poverty. It is comprised of six initiatives as follows: 51 P a g e

52 Reproductive Health Project Resource Group Community Support Groups FMO Programme School Health Community Health 2.16 PAST EVALUATIONS OF CMIPHC Rural Support Network Evaluation 52 P a g e RSPN. (2012) reported that to achieve health-related MDG targets, the government has been pushed towards finding alternative ways of delivering health services. The innovative CMIPHC is a radical departure from established practice in government, and marks the first time that management of some aspects of basic health services delivery has been outsourced to a non-governmental agency. Though the intervention started with exemplary political support at provincial level, this dwindled over time. However, the Programme carries on due to the momentum of its success, support from District Governments, and has recently been replicated at the national level. Following challenges were noted from evaluation. Resistance from vested interests hinders project planning and implementation Lack of capacity of government staff Compared to curative health services, outreach services have suffered due to a lack of requisite facilities, power and infrastructure A largely passive role of district health staff Issues with sustainability once private sector partner has exited the project cycle USAID Evaluation According to USAID (2009), Issues and Challenges Faced by CMIPHC are following that need to be addressed, for example: Non-integration of national programs at BHU level; Obstacles in transferring budget to PIUs by districts; Indifferent attitude of district health officials; Delays in deciding the references regarding disciplinary action and grant of long leaves to doctors and paramedics; Frequent/ repeated training; review and assessment of various primary health care models in Pakistan. Interference by local politicians and elite groups to influence the decisions/actions taken against corrupt/defaulting employees; The security situation in sub-urban areas is unfavorable; The Union Council Nazims do not actively participate in rehabilitation and repair process of BHUs.

53 World Health Organization Evaluation 53 P a g e WHO report includes the recommendation for PPP model in health sector of Pakistan in order to get the following outcomes; Improve access to services Expand service provision for culturally sensitive issues HIV/AIDS Enhanced recognition of NGOs by the population Expansion of programme activities Delay in release of payment s adversely affects contracts Block payments made, concerned only with quantity Information system has limited capacity, Most programmes unable to monitor quality of services Insaf Research Wing Evaluation According to the Insaf Research Wing (IRW, 2009), success of the model PRSP- CMIPHC is that the doctors presence increased to 90% and so did the availability of essential medicines at each BHU. Outpatient visits increased 3 folds, and there was a visible improvement in staff discipline and attitude towards patients. Even though there was substantial increase in the salary of doctors, all other staff personnel continued to be paid by the Ministry of Health at the previous rate. Incentives were not available, which led to a lack of motivation on part of staff. This translated into substantial amount of unfilled jobs. BHU doctor living facilities were upgraded but no provisions were made to improve the dismal state of paramedical staff residences. The coordination between PRSP and Government s relevant health care programs like family planning and immunization drives was poor. Provision for joint monitoring and mechanism for conflict resolution was not in place. Monitoring of overall health indicators was not given much thought. Detailed financial reporting was not available which is requirement if the project has to be expanded. Financial reporting was treated in a cursory manner. Purchase of medicines remained a challenge. First, quality of medicines supplied to BHU could not be ensured because it had to follow the same purchasing process as the government. Secondly, there is still no essential drugs list for BHUs. Thirdly, the essential medications were still not being delivered in a timely. The project became a turf battle and implementation challenges due to Health Systems failure. The reason is lack of clarity of roles and direction, no clear and easy way to problem-solve issues as they come along. There is lack of consensus between stakeholders because of lack of communication and because many of them were not taken into confidence in the first place. The model is being scaled up to other districts rather quickly when basic problems of systems failure have not been fully addressed. The issue of decreasing funds for

54 Health Care is not considered in this model that will require substantial increase in funding. Since the essence of this model still remains Biomedical, one can clearly see the gaps in its ability to provide comprehensive health care to the people Present PSIA This PSIA-CMIPHC has multidimensional approach by considering the situational analysis. It is also mixed approach with qualitative and quantitative tools focusing on cultural believes also that other evaluations were neglecting. It will present a border picture of poverty analysis in accessing the primary health facilities. 54 P a g e

55 Chapter 3: IMPACT ANALYSIS 3.1 GENERAL The impact analysis is important in many aspects as it not only provides the strength and weaknesses of an organization or institution, but also highlights the gray areas/ gaps where improvement is required for its effective functioning. In the present study, the data was gathered and analyzed to take stock of different activities created and implemented under CMIPHC in order to provide better health services to the poor and marginalized in particular and meet the targets of MDGs in general. Moreover, data was also gathered to look over the relation of varying social groups with these institutions and with the public and private (e.g. market) institutions (including the norms, values and behavior that have been institutionalized through these relationships). This chapter provides analyzes of impact trends of CMIPHC through various parameters. 3.2 POVERTY AND ECONOMIC TRENDS There were frequency of sickness of children & adults was recorded and evaluated together with the number of sickness for common and seasonal diseases in the area. Normally people remain reluctant to visit nearby city in case of common diseases. Before the BHUs were not functional, the diseases imposed some serious outcomes in the form of convergence to silent diseases or increased wages lost. The present functional BHUs are playing a significant role by saving the time and money of the poor and marginalized in the area. 35 % of total respondents reported that they fall sick 2-3 times in a year, 44% said they suffered from sickness in every season (4 months) while 19 % of the respondents fall sick 3-6 times in a year, 34 % of the children reported that they or their family member occasionally visit the BHU, 22% visit weekly and 23% visit monthly basis. The overall analysis shows that every visit to BHU saves the cost of medicines, consultancy fee and transport expenses that they were previously bearing from their own pocket. It is evident from all three Tehsils of Lodhran district with minor difference in % that duration of the most (55%) of the respondents is two days, 29% reported this duration from 3-5, 14% told of one day sickness and only 2% reported sickness duration up to ten days. In case of sickness, 34% respondents told that they face daily loss up to Rs 200, 16% of the respondents lose Rs 100, 15 % lose Rs and 4% suffer the daily economic loss of Rs Most of the respondents (55%) claimed that they have to cost extra economic burden (100-10,000) in case of women sickness while observing the routine household services smoothly. On the other hand, about 45% respondents reported that they could manage in joint family pattern or neighborhood 55 P a g e

56 relationships. Out of 5 of 5% of respondents, 29%, 27%, 17%, 14% and 13% were suffering from extra burden of Rs 200, 300, , 100 and respectively in case of women sickness. Although the increased OPD is not the indicator in achieving MDG targets but at the same time it an indicator for increased savings and social well-being in the areas. The economic analysis indicates economic benefits with a good contribution towards GDP and extended social benefits through multiple benefits to the community including community empowerment. During progress year 2011 and 2012, the total OPDs were and respectively that account for about and individuals respectively who visited BHU with different ratio of their individual visits. The number of beneficiaries has increased on yearly basis, who took benefits, free of cost consultation and medicine facilities at BHUs in Lodhran district. It was evident that BHU facilities are giving economic benefits to beneficiaries in terms of recovery time due to timely treatment and cost of medicine and transportation that in turns are utilized for improvements in livelihood and can be invested on their children or taking other social benefits. No Consultancy fee or medicine cost is levied at BHU viz-a-viz the private consultation fee in the urban periphery that varies from PKR for normal consultation and exclusive of medicine cost. At the same time the charges for special issues like delivery of baby may vary from PKR Transportation cost becomes a challenge in case if someone has to go to private facility in city or from remote areas of village. The economic gains are much higher than the actual budget input in the programme. During the year 2011 and 2012, the beneficiaries saved upto an estimated value of PKR 441,792,000/- and PKR 458,552,250/- respectively from free treatment at BHU viz-a-viz treatment cost if could have been treated privately in urban areas. When compared the total budget PKR 61,938,166/- of CMIPHC in Lodhran for year with the economic gains in area, it has been seen that the direct economic benefits to the community in the areas were 7.13 and 7.5 times greater, for year 2011 and 2012 respectively, than the said budget value. Sugar, Hepatitis, Blood and Pregnancy tests are saving money from PKR per person which in turn also incremental factor in the estimated saving figures from direct consultation and medicine costs. In addition to above economic gains, the beneficiaries also reported that the BHU service is also supplementing early recover due to timely attention of patients keeping in view the free and accessibility of health facilities. It was estimated that a patient normally save wages of 2 days from early recovery of common disease cycle. In absence of BHU service, 2 days lapse time was normally reported for the attention and visit to nearby city hospital. The 2-days productivity is an additional value that supplement towards national GDP. In year 2011 and 2012, an estimated figure of and man-days were saved respectively that a big contribution towards GDP. Most of the farmers cultivate crops by taking micro credit or bank loans in the area. The extension and improved free of cost health facilities at BHU could be instrumental for their loan return and uplift of social and economic wellbeing. This would also help increase the purchase power for the kitchen items, as it was noted that 56 P a g e

57 more than 30% of the income was consumed in kitchen of most of the respondents thus create good portfolio of nutrition in the area under discussion. The efforts to mobilize trust building on BHU services, advocacy and raising awareness remained question mark in almost all sampled areas. Both advocacy and raising awareness have special importance in terms of core values of development, so it should be integrated into one package together with physical intervention. Figure 3.1: Common Diseases Figure 3.2: Frequency of Sickness Figure 3.3: Duration and Loss of Sickness 57 P a g e

58 Figure 3.4: Women Illness and Extra Economic Burden Most of the respondents (86%) reported that they had experienced the maternity services at BHU while 14% did not experience the same either due to low level of trust or timings of BHU limiting the services round the clock as most of the deliveries took place during odd hours, which were not suitable to BHU timing. The normal delivery service fee in private facility ranges from so the same being saved in case if the service is availed at BHU but it is again luck dependent due to current opening hours of BHU. The savings are beyond the above financial calculations as done for other savings, and adding further towards national savings. Figure 3.5: Savings from Maternity Service Figure 3.6: Savings due to timely BHU Services 58 P a g e

59 3.3 SOCIAL AND HEALTH OUTCOMES ANALYSIS It has been observed that the BHU is the nearest health facility available to the general public. More than 80 % of the people reported that the distance of BHU is not a big challenge but the BHU referral system is not quite good so as to avail secondary and tertiary care beyond the scope of BHU services. The overall analysis depicts good social and health outcomes from BHU services while comparing the baseline before the start of mass-scale services in the form of CMIPHC in Lodhran district Access and Availability of Health Facilities The geographic location of the BHU is suitable as most of the people said that BHU is the nearest health facility available to the people. When we compare the results of three Tehsils, more than 90 % of the people both from Lodhran and Dunya Pur reported that BHU is the nearest health facility while the same was reported by 67% of the people from Kahror Pakka. The results depicts that most of the people in the project area did not show concerns regarding the location of the BHUs and they were of the view that they can easily manage to approach their nearest BHU. The results of children interviews also depict the same results for the nearest health facilities as reported by adults. It has been shown in the chart below that 99% of the people reported that the distance between their home and the BHU is 0-10 KM while only 1 percent said that we have to travel almost KM to reach to BHU. If we compare the results between three tehsils, there is no significant difference between the results of Lodhran and Dunya Pur while seen a little difference in %age response from Kahror Pakka as 96.5 % of the people have to travel 0-10 KM while the rest of the people KM. The ratio between the Male and Female responses is almost similar when we compare the results regarding distance of BHU. It has been observed that 53% of the people responded that they have to travel almost 1-15 minutes by foot to reach the nearest health facility (BHU). Almost 37% of the people said that they have to travel almost 30 minutes by foot to reach the BHU. About 10 % of the people said that they have to travel for almost 1 hour by foot to reach the BHU. The geographic location of the BHU is suitable as most of the people have to travel between 1-15 minutes to reach to BHU for the medical checkup. It was reported that some places have been facilitated with Ambulance facility as are provided by some welfare trust due to which 6% response was in favour of availability of ambulance facility due to some kind of other goodwill facilitators in the area. At the same time, 91% of the people reported that they have no facility of ambulance in their area while 3% of the people had no clear idea about ambulance facility or either they never seen the ambulance in their area or vicinity. The inability of people for right response could be due to poor literacy and awareness conditions in the area where mobilization component needs to be improved. 59 P a g e

60 Figure 3.7: Nearest Health Facility Figure 3.8: BHU Distance Figure 3.9: Ambulance Service Figure 3.10: Visits of Vaccinaators 60 P a g e

61 The community is satisfied with the availability of staff members at BHU. 95% of the people reported that LHW / LHV vaccinator team regularly visit their homes. 98 % of the people are satisfied with the performance of LHWs/LHVs. When we compare the results between three Tehsils, the percentage from Dunya Pur and Kahror Pakka of both male and female are the same with 99.3 % and 99.0% respectively who are satisfied with the performance of LHWs/LHVs while Lodhran being a total of 96.9 % of male and female said that they are satisfied with the performance. Figure 3.11: Vaccination Satisfaction Figure 3.12: Normal Time to Reach BHU Almost 78% of the people don t consider 1 Rupee Parchi (Payment Slip) as a big cost of services and consider it nominal or no cost towards free medical checkup. In case of severe injury of sickness medical officer prescribe the medicine from medical store which people are considering as large payments have to be given for the checkup. It has been observed that almost 87 % of the people said they have to spend around 50 rupees to reach to BHU while 7% of the people said they have to spend around rupees to reach to the BHU. 4% said around 500 rupees and 2% said more than 500 have to be spending to reach to the BHU. When we compare the results between the three tehsils it has been observed that not much difference between the opinion of the people form Dunya Pur and Lodhran with 91.1 % and 90.9% respectively said that they have to spend between 1-50 Rupees to reach to the BHU while the rest of the people said that more than 50 Rupees have to be spent to reach to the BHU by availing Auto-Rickshaw or other mode of travel. 61 P a g e

62 Figure 3.13: Health facility Cost Figure 3.14: Transport for BHU Figure 3.15: Travel Cost Figure 3.16: Accessibility by Road 62 P a g e

63 The results shows that about 92% of the people said that the road infrastructure is suitable to reach to the BHU while 8% of the people said that Health unit is not accessible by road as the infrastructure of the road is not properly developed. When we compare the results between the tehsils of the project area it has been shown that around 98% of the people in Duny Pur said that health unit is accessible by Road while 96.1 % of the people in Lodhran said that the health unit is accessible by road. On the other hand when we talk about Kahror Pakka about 83.5 % of the people said that BHUs is accessible by Road while 16.5 % of the people said the road infrastructure is not properly developed to reach to the BHU easily. During the course of this study, the field data collection team also observed the similar results. The far-flung and least developed rural vicinities have poor road connectivity. The connectivity is critically important for MCH component and also for BHU referral system. It has been observed that more than 87% of male and females are satisfied with the medical treatment at the BHUs. When we compare the results with the tehsils of the project area it has been observed that a total of 6.7 % male and female from Dunya Pur didn t take medical assistance while 13% male and female from Kahror Paka didn t take medical assistance from the BHU and about 17.8% of the male and female from Lodhran didn t take medical assistance form BHU. The reason include that most of the community is illiterate and they didn t give importance to their health and take serious steps when they normally feel it very severe and panic. The results clearly show (in figure 3.18) that the lack of money is the main issue behind not taking medical assistance whereas the BHUs functional services have resolved the issues to a very much extent. Around 69% of the people said lack of money is the major problem in taking the medical assistance in general while lack of awareness being the second highest factor around 18% doesn t prefer to address the common diseases simply because they don t give importance to their health. On the other hand 9% of the people didn t take medical assistance simply because proper medical facility is far away from their houses. Figure 3.17: Seeking Medical Care 63 P a g e

64 Figure 3.18: Not Seeking Medical Care The results show that the decision is being taken by the household elder in the form of father / or husband in most of the cases related to family health care in households. It has been observed that most of the children are being delivered in the home with around 61 % ratio while 21% people said their children are being delivered in the hospital. While comparing the data of three Tehsils, it has been observed that in Dunya Pur 60.4 % male and 65.2% females have said that their children are being delivered at homes by employing services of local DAIES. On the other hand in Kahror Pakka about 67.9 % male and 38.9 % females said that their children are being delivered in the homes by employing services of local DAIES. When we look at the figure of Lodhran still home attendants births have high ratio of around 66.1 %. It has been observed that around 51% people said they didn t visit BHU regularly during pregnancy. With around 42% people said they regularly visit BHU during pregnancy. When we compare the results it has been observed that in all three tehsils males have said that they regularly visit the BHU during pregnancy of their wives. But females in all three tehsils respond negatively and said they didn t visit the BHU regularly during pregnancy and the response of female was relatively poor as compare to males. Figure 3.19: Household Decisions for Health Care 64 P a g e

65 Figure 3.20: Children Delivery Places Figure 3.21: Mother Visiting BHU during Pregnancy Basic Service Delivery PRSP has significantly improved the OPD increase but as it has been proved from various research findings that the incremental ratio of OPD numbers is not the only indicator of success of the programme. The increase in OPD with the passage of time is the sign of improved budget, good staff attendance and extended scope of services. For instance, in year 2003 the service was just started with low geographic coverage and with clustering approach which then replaced with blanket coverage thus the increase in OPD is also related to extended geographic coverage. The average annula OPD from 2005 to 2012 is 1,005,063. There are seasonal variations in the OPD that includes month of March and August-September as visible in following figures 3.22 and The OPD numbers were very low in year 2005 when the CMIPHC programme was at its initial life stages and cluster approach was more common which later replaced with blanket approach by employing more medical officers and other relevant staff as was deemed appropriate in the existing health department employment gaps. Therefore, the OPD numbers seemed more in subsequent years with a big incremental ratio and a peak numbers achieved during the year 2009 which gradually declined and a lag phase can been seen in figure 3.22 during the years 2010 and 2011while the numbers further declined in year Apart from the reasons of cluster and blanket approach, 65 P a g e

66 other actual reasons behind these trends are wage due to unavailability of annual evaluations, detailed OPD database (gender and age wise), annual health profile of the area, unavailability of budget figures of all previous years (as PRSP only provided budget figures for year 2012), and lack of evaluation studies seasonal trends of diseases over the years in the area. Figure 3.22: Year-wise Comparison of Total OPDs ( ) Figure 3.23: Month-wise Comparison of Total OPDs ( ) 66 P a g e

67 It has been observed that the people are apparently satisfied with the services of the BHUs. 69% score ranks satisfactory towards excellent while if we add 26% fair score further to it then majority reporting is apparently satisfied as whole in all tehsils. The overall ranking is about When we compare the results between three tehsils, it has been observed that about 50.5 %, 43.6% and 36% in Dunya Pur, Kahror Pakka and Lodhran respectively people are satisfied with the results of the BHUs. The results have a little confusion due to poor literacy and awareness in the area about present model of BHU services and basic understanding at the level of respondents. It was evident that the people are getting free of cost medicines as about 95% of the people reported that they are getting free medicines from BHUs. With around 5% of the people said they sometime did not get free medicines from the BHUs due to either unavailability in the stock or prescribed medicine sometimes out of the scope of BHU medicines. When we compare the results between three tehsils it has been observed that most of the people are getting free medicines in all three tehsils. As some respondents said that some time they are referred to medical store in case on unavailability of particular medicine so it s not free. Figure 3.24: Perception about BHU Services Figure 3.25: Provision of Free Medicine at BHU 67 P a g e

68 Figure 3.26: Availability of relevant staff at BHU Figure 3.27: Alternative Staff Solutions by Patients It has been observed that around 91% of the people said that the relevant staff is not available in the BHU especially related to maternity services. The high ratio is because of the official timing of the BHU and also the limited number of FMOs available. Otherwise staff was found to be relevant but it was lack of mobilization and awareness of the community. The local community members have to seek alternative arrangement in case of unavailability of relevant staff or after the official timings. About 61% patients approach either the nearby RHC or City hospital in the absence of relevant BHU staff. On the other hand around 39% respondents informed the people normally engage local Daie (local midwife) for delivery and related matters. The BHU working hours are critically important for mother and child segment of Primary health care and it needs to be improved and taken into consideration for next phase planning. It has been observed that 95% of the people said there is no ambulance available in case of shifting of a patient to nearby RHC or hospital. About 5% of the people said that they have the facility of ambulance donated by the Community. 68 P a g e

69 Figure 3.28: Transport for Patient s Referral Figure 3.29: Timely Medicine availability at BHU The results depicts that around 87 % of the people said that medicines are available in time at the BHUs, while 13 % said medicines are not available timely. The reasons are mainly the budget constraints and direct relation with the amount of the medicine and the population. Normally 2-3 days 3-4 times in a year were reported from qualitative data. When we compare the results between three tehsils it has been observed that the availability of the medicines are satisfactory with more than 90% of the people from Dunya Pur and 92% of the people from Kahror Pakka are satisfied with the availability of the medicines in time. With a slight difference in the ratio of 78% of male and female from Lodhran said that in time medicines are available. Most of the people said that the staff at the BHU is punctual. Around 75% of the people said that the staff is doing their duty with honesty and they are punctual and honest with their Work. When we look at the following chart the response decreases from Dunya Pur to Kahror Pakka and Lodhran. 69 P a g e

70 Figure 3.30: Punctuality of BHU Staff 100.0% 80.0% 60.0% 40.0% 20.0%.0% Figure 3.31: Tehsil & Sex-wise Response on BHU Staff Punctuality Tehsil-wise Response BHU Staff Punctuality 91.8% 8.2% Dunyia Pur 80.3% 19.7% Karor Pakka 57.2% 42.8% Lodhran Yes No 100.0% 80.0% 60.0% 40.0% 20.0%.0% Sex-wise response BHU Staff Punctuality 80.0% 20.0% Male 70.4% 29.6% Female Yes No Social Inclusion Inclusion here refers to taking on board the poor segments of the society including men, women, youth, minorities and people with special needs, in the community organizations poverty uplift programme. In this regards, the research team assessing the ground situation in the target BHU areas collected data against and analyzed the processes, practices and institutional model that perpetuate the exclusion and develop a workable framework to challenge the exclusionary practices at local level for the overall effectiveness and sustainability of the CMIPHC programme. It has been shown in the results that most of the people (about 53%) reported that they don t have clear understanding about their potential role regarding BHU affairs. The unclear role situation further worsens when we add further 18% poor response regarding it viz-a-viz 12 % reporting good which is very poor response. 70 P a g e

71 According to PRSP, it has a prime focus on the poor so that they could not be discriminated. Usually, equal priority is given to all the patients except for disabled or old people, who are preferred for checkups which is a good sign in BHU functions. CSG are only formality they exist on paper, sometimes members of CSG are called for just to show that they exist whenever any health campaigns or any monitoring team from external body visits. It was found that people have so much economic problem that they said its govt. job to provide health it was so because they hadn t any idea about PPP and their role, nether they have not been told nor they tried due to unawareness. There is no women representation in the CSGs whereas representation of poor people has been observed but it was noticed that those were included just either from nearby areas of the BHU or were maid / servants /or guards of the school. Figure 3.32: People s Participation in BHU Affairs Figure 3.33: Tehsil wise response regarding People s Participation in BHU Affairs 71 P a g e

72 Figure 3.34: Women and CSGs Figure 3.35: Women Representation in CSGs It has been observed that most of the people (around 68%) said they don t know any representation of women in the community support groups. In qualitative research, we have come to know that there is no women representation in the CSGs at any level. Most of the people (around 66%) said that they don t know about the training and awareness raising campaigns provided by any support groups in their area according to their up to date knowledge on the issue concerned. When we compare the results with all three tehsils most of the people from Dunya Pur including both male and female around 71.8% didn t know about the training for basic health care facilities. In Kahror Pakka around 60.3% of the people including male and females don t know about the training given by the support groups regarding basic health facilities. In Lodhran around 66.2% of the people including male and female don t know about the training given to the people regarding basic health care. The results show that around 78.7% males and 80.1% females reported that there is no health club formed by CSG. Only about 20% of male and female said that health clubs are formed by the CSG or PRSP in their areas. 72 P a g e

73 The results from the children show that they are getting benefits through active involvement in health activities and awareness. With around 59.1%, 59.7% and 70.4% children from Lodhran, Kahror Pakka and Dunya Pur respectively were agreed for taking benefits through active involvements. Figure 3.36: CSG Activities Figure 3.37: School Health Clubs Figure 3.38: Health Session Benefits 73 P a g e

74 Figure 3.39: Women and CSGs The figure 3.39 shows that around 52% of the people said that there is no priority given to the disabled persons and only 48% of the people said yes priority is given to the disabled persons. When we look at the results between all three tehsils the results depicts that in Dunya Pur the results are negative with 56.2% of people said that there is no priority given to the disabled people as compared to Kahror Pakka with around 69.1% of the people said that priority given to the disabled persons. On the other hand, in Lodhran, the result is again negative with around 66.9% of the people said there is no priority given to the disable people. There overall picture depicts certain improvements are required at the level of BHU local management so as to ensure priority to the disabled persons and old age groups. The results show that there is no religious minority in the area. As far as the different ethnic groups are concerned, around 93% of the people reported no discrimination or feelings about any ethnic minority even if it was present in the area with a proportion of 7% responses. The ethnic and religious groups are important for the structure and function of community support groups and other aligned activities so as to take into account the concerns of deprived persons / or groups. About 88% of the people reported that CSGs have no representation of minority groups apart from absence of women in the system which is further worsening the critical situation about women and other minority representation in CSGs. Figure 3.40: Ethnic Minority in area 74 P a g e

75 Figure 3.41: Minority and CSG Figure 3.42: Sex-wise Response - Religious Minority in Area Figure 3.43: Sex-wise Response - Ethnic Minority in Area Figure 3.44: Poor and CSG 75 P a g e

76 3.3.4 Social Influences of Programme The overall observations reflect that the programme was quite successful in extending social benefits and attracting the local people with enhanced level of trust for CMIPHC programme. Over the past years of programme period, the people were able to get better health facilities at local level. The satisfaction of a good number of respondents is the evidence that the programme has influenced the people for their social benefits through extended health services and giving cushion to their economy through free of cost service which in turn converted to social benefits and well-being of those who enjoyed the services at maximum. The results depicts that around 76% of the people said that they are getting social benefits from this program. On the other hand 15 % respondents can also be counted towards success ratio although they acknowledged little benefits while 9% had no clarity on this typical aspect due to their poor literacy rate. The mobilization factor is weak in this regard and needs attention with proper budget allocations. For poor mobilization factor, people suggested that different approaches like, more focused awareness campaigns (by 44% respondents), specialized capacity building program (by 10% respondents) like MCH and door to door awareness (by 6% respondents) and further mobilization (by 17% respondents) could be productive. As far as level of trust on BHU services is concerned, the results show that about 81% of the people have shown their trust on BHU services. The percentage ratio is important in order to take future course of action for more mobilization and awareness raising efforts in order to build the trust at large. The response from female group is also important that depicts the consciousness of females, who have less trust as compare to male community members in the area. About 92% of the people are actively participating in the preventive care. About 72% of the respondents acknowledged improvement in the services of BHU. Figure 3.45: Social Influence 76 P a g e

77 Figure 3.46: Actions for Community Involvement Figure 3.47: Trust on BHU Services Figure 3.48: Sex-wise Trust on BHU Services 77 P a g e

78 Figure 3.49: Suggested Actions for Enhancing Trust on BHU Services Figure 3.50: Public Participation in Preventive Care Figure 3.51: Visible improvements at BHU Visible Improvement in BHU Services 28% 72% YES NO 78 P a g e

79 3.3.5 Effectiveness of Programme The BHU performance has been improved over the past years and can be ranked fairto-good with the overall research analysis. It is important to mention here that there is still a lot to be done in order to get good level of satisfaction at all level. The performance of the BHUs is satisfactory as a whole in spite of poor functions and role of Community Support Groups (CSGs). The performance of BHU increased gradually over the period past years. The BHU operations have found some financial constraints in order to ensure 100% performance in line with the objectives of the programme. Figures 3.52 to 3.59 give detail overview on different aspects of this section. About 70% of the people were unaware of health campaigns held in the past for which the reasons could be either the persons belong to far-flung areas without proper outreach of the programme or less number of campaigns without proper tools to mobilize the vast majority of local people. About one third of respondents acknowledged the health campaigns among which female group had limited information with their less participation as observed in following charts. The acknowledgement was mostly received from urbanized areas, however the mobilization component need improvements for addressing the need in far-flung rural areas. School health sessions are improving the health condition of the community and are critically important for awareness and preventive care. Different health campaigns are conducting at BHUs like dengue fever/mother child health week are conducted at BHUs. The soft-core component is weak in this case as there are no proper budget allocations for mobilization work. Free medical checkups and free medicines are the key strength of the programme. Loosed structure and poor involvement of CSGs in mobilization is critically weak aspect of the programme. Unavailability of Ambulance service is limiting factor for BHU referral system and a hindrance in achieving the MDG especially for MCH. Majority of the people are unaware of the concept of Public Private Partnership (PPP) model of CMIPHC. A few learned respondents from urban areas agreed with the success of this model while some people did not consider it a success to be replicated. The PPP model is with double-barrel role of PRSP and Health Department over the affairs of BHU management. This is causing unrest among BHU staff members and may pose a big threat to the sustainability of the programme on long-run basis. CSGs were considered to be ineffective by most of the respondents (78%) as these were inactive. People suggested that measures like; more activities in CSGs (32%), institutionalization of CSGs (31%), improvement of coordination b/w PRSP & health department (7%) should be taken in order to get maximum benefits from the programme and ensure its sustainability on long-run basis. There is high risk of job security found for the contractual staff of PRSP which includes not only the doctors but also the paramedics. The staff is the core strength for the overall effectiveness and sustainability of the programme. There is a need to bring reforms in staff contracts with fringe-benefits like provision of provident fund etc. The qualification of Nutrition Supervisor was remained question mark as all nontechnical people hired and addressing the real issue is a big challenge. On the other hand, there is no female nutrition officers found for girl schools that can play role for 79 P a g e

80 nutrition and RH. There is a need to revisit the qualification criteria of Nutrition Supervisors and Female Inductions needs to be put in place. The current assessment highlights that there are more underlying gaps that need to be addressed for the creation and existence of effective organizational mechanisms for grievance redressal. There is a serious lack of proactive approach and there is a need to devise a proper mechanism almost everywhere so as to facilitate the practical steps before the problems may arise. Unless such mechanism are put in place, CSG's effectiveness vis-a-vis working for PHC by PRSP under PPP model while having all the members of society on board would not be deemed effective. Almost all BHU geographical areas need greater work to be done for this component. Figure 3.52: Common People VS Campaigns Figure 3.53: Common People VS Campaigns Figure 3.54: BHU Performance Ranking 80 P a g e

81 Figure 3.55: Success of PPP Model Figure 3.56: Success of PPP Model Tehsil wise response Figure 3.57: Benefits of Community Support Groups Figure 3.58: Steps to Strengthen CSGs 81 P a g e

82 Figure 3.59: CSG Role for Improvements in PHC Accountability and Transparency The BHU operations are almost transparent and PRSP system of monitoring exists in place to ensure staff attendance and provision of services. As far as the medicine purchase is concerned, PRSP has a centralized system and CSGs have no role in purchase or distribution of medicines. At present, there is no major flaw observed which could be a big threat to the PPP model and overall progress towards MDGs. Over the years, the system is gradually moving towards maturity in which the continuity in process and system improvement could further improve basic service delivery with more transparent operations in place. The display of medicine record at BHU, involvement of CSGs in medicine purchase and systematic grievance redresser mechanism could bring further accountability and transparency in the system. The maintenance of financial and operational data and its analysis is critically important prior to gauge the performance over period of time. About 87% respondents reported that they had no access to BHU data. This segment of progress is weak and need focused attention in future operation in order to bring further accountability and transparency in the system. Doctors are paramedics are punctual and honest with their profession and apparently equal priority is given to all patients but negligible ratio of negative response was also observed but it is not too big to pose negative trends over the overall transparency of operations at the level of BHUs concerned. As literacy & awareness level was low so it was reported that the people had no proper information about their rights over the BHU affairs or whether they can take the basic data and day-to-day picture of the BHUs concerned that s why they neither had access nor tried. Figures 3.60 to 3.63 give different ratio towards responses during the course of primary data collection. 82 P a g e

83 Figure 3.60: Access to data and management Figure 3.61: Transparency in BHU Operations Figure 3.62: Priority to General Patients Figure 3.63: Priority to Special Patients 83 P a g e

84 3.3.7 Grievance Redresser Mechanism About 85% respondents were unable to properly comment on grievance mechanism among which 65% were not aware of any grievance mechanism and effectiveness while 20% categorically denied the presence of such mechanism in place. The claim of PRSP regarding presence complaint register could not be physically verified on confirmatory steps of field research group. This is critically important for various components of the programme in order to achieve real outcomes and achieve the MDG targets in true letter and spirit. Figures 3.64 to 3.65 give research results against different aspects of this parameter. The current assessment highlights that there are more underlying gaps that need to be addressed for the creation and existence of effective organizational mechanisms for grievance redresser. There is a serious lack of proactive approach and there is a need to devise a proper mechanism almost everywhere so as to facilitate the practical steps before the problems may arise. Unless such mechanism are put in place, CSG's effectiveness vis-a-vis working for PHC by PRSP under PPP model while having all the members of society on board would not be deemed effective. The almost all the BHU geography needs greater work to be done for this component. Figure 3.64: In-place Grievance Mechanism and Effectiveness Redresser Mechanism at CSG Effectiveness of Existing Mechanism at CSG 65% 15% 20% YES NO Don't know 14% 8% 78% Very effective effective to some extent Not effective Figure 3.65: Complaints Taken by PRSP 84 P a g e

85 3.3.8 Mother & Child Health It is evident from the following pie chart that 56 % of respondents were satisfied with MCH services rest of 44 % were not satisfied due to lack of ambulance, delivery services 24 hours availability of MCH services. Level of satisfaction is high in Dunyia Pur (male 58% & female 58%) while satisfaction level is lowest in Lodhran is 31% (male 31% & female 29%) while in Karo Pakka it is 44% (male 42% & female 44%). 68% respondents reported that complications during pregnancy are sometime handled at the BHUs as well provided if the FMO is present at that BHU while rest of respondents (32%) were not satisfied. Figures 3.66 to 3.70 give detailed analytical ratio on various aspects of this parameter of success. The repeated frequency of BHU visits by an individual beneficiary is a sign of satisfaction on improved OPD service. In a year, 19% of respondents reported their 6 times BHU visits where as 44% and 35% people reported 4 and 3 times respectively which in turn reflects a good level of satisfaction on the improved BHU service. It is evident that BHU facilities give economic benefits to the beneficiaries and people are also taking other benefits from FLHF and saved economic resources over past few years in the context of their seasonal health and recovery from common diseases thus the improved health supplementing towards their socio-economic well-being. There is visible progress seen towards improved MCH services at BHU level. Normally, females take medicine from BHU for their day-to-day affairs and also consult for pre-natal and post-natal matters. At the same time, a majority prefer the private hospitals for delivery purposes due to odd delivery timings as well as the issues in mobilization too. Due to functional aspect of BHU, the available services like family planning and MCH play a significant role towards progress on MDG targets. 50% of the total respondents reported that BHU services have played a significant role in saving life of mother and child while 50 % had no relevant answer in place. It also shows that free FLHS could be significant in improving the socioeconomic wellbeing of the people in the area. At the same time it has no significant or notable effects on the local economy if the poverty graph is increasing without any link with the potential benefits. Much improvements were seen in Dunya Pur (72%) while from total of 50%, lowest change was observed in Lodhran (35%) and then in Kahror Pakka (46%). Lodhran is more urbanized than other parts so here expenses are more and saving are less. A limited number of Female Medical Officers (FMOs) are available at many BHUs while the other female paramedics deal the female related matters on other BHUs. The dealing of women by women staff is quite encouraging in all Tehsils and a good example of improved health indicator related to the effectiveness of the programme. According to the results, 78% respondents reported that all women related matters are dealt by the women staff at BHU while 22% reported that males are involved too. It is due to unavailability of FMO and other male staff like dispenser, MO or any other person having little bit supportive role. Highest level of satisfaction regarding all women related matters are dealt by the women staff was in Dunya Pur 92% (responses from male 92% & female 92%) and lowest (64%) is in Lodhran while satisfaction can also be seen in Kahror Pakka (79%). 85 P a g e

86 Most of the respondents (70%) were satisfied about the availability of all types FP services while 30% of respondents were not satisfied. Results are satisfactory in Dunya Pur (92%) & Kahror Pakka (75%) while average is low in Lodhran (48%) that is due to male & female perspectives as females are relatively more aware than males regarding RH. Figure 3.66: Satisfaction with MCH Services Figure 3.67: Handling of Complex Women Matters Figure 3.68: Women Staff for Women 86 P a g e

87 Figure 3.69: Availability of Family Planning Services Availability of Family Planning Services for Mother Care 100.0% Availability of Family Planning Services for Mother Care 80.0% 30% 70% YES NO 60.0% 40.0% 20.0% YES NO.0% Dunyia Pur Karor Pakka Lodhran Figure 3.70: BHU role in Saving Mother & Child life 87 P a g e

88 3.4 INSTITUTIONAL IMPACT ANSLYSIS PPP Model - Overcoming PHC Challenges CMIPHC model was based on a localized experiment done in Lodhran district in the year 1999 when National Rural Support Programme (NRSP) acquired three Basic Health Units (BHUs) and grouped them into a cluster. Here, villages were scattered and roads were rough so, it was not easy to convince the health services providers to join the BHU due to geographic situation. The results were encouraging. The three dysfunctional BHUs were made functional. OPD increased manifold as a result of availability of medical & paramedical staff and a wide range of medicines. The success of Lodhran Model encouraged the provincial government to experiment it in other districts as well. The pilot project was started in Rahim Yar Khan district, which was later expanded to 12 other districts of the Punjab. More recently, two more districts have been added to the project. The study depicts the good level of satisfaction on functional level of BHU services under the scope of the PHC for vertical and other programme. This was a kind of public-private partnership model that set new trends in health sector due to which social and economic gains were brought forward to the poor and marginalized groups. The relationship brought new horizon of service delivery by ensuring system in place without any new agenda. The model of this institutional setup with PPP model was then extended under CMIPHC to overcome the challenges those critical for PHC and meeting the targets of MDGs. Following were the key challenges and related issues at the time of initiation of the programme which were addressed and overcome upto a major extent with the PPP model of the programme. Provision of Primary Health Care (PHC) services to the poor and marginalized: The programme created a positive trend and brought drastic improvement through this PPP approach of institutional model in order meet the milestones of MDGs. The local governance for PHC was a major problem and the programme has given a good governance model though a lot need to be done for further improvements in the system for service delivery but the to date progress depicts a good image and need to be continued with some improvement in the existing institutional mechanism like resolving the issues with double-barrel management over the programme and staff matters. Besides, there is complete lack of Regulation of Private Practices and need to be formulated. There was an absence of Social Protection/Insurance / or Inclusion which the programme is still trying to overcome the challenge but budgetary and other limitations are critical in order to bring real agenda on board with visible outcomes. The creation of Community Support Groups (CSGs) was helpful to overcome the lack of emphasis on Community Participation and Public-Private Partnership but the actual role need to be improved through proper institutionalization of CSGs. Special focus was given to Health Education through School Health Sessions and Promotional Campaigns. This component needs further improvement especially 88 P a g e

89 through budgetary provision as no budget allocation could be seen in current year programme budget for district Lodhran. There are still some underlying gaps, which need attention and should be addressed in order to overcome the ambiguous status between provincial and national segments. These issues include review of Drugs Policy, Cross-Sectoral Linkages of Programme, Improved Research Mechanism and its Analytical framework, proper Human Resource Management System in the context of PPP, weak capacity for Planning Costs and Budgets, Lack of proper strength of Health Professionals / Nurses / Paramedics etc., more focus on preventive health and to actively target MDGs with pro-poor approach, lack of strong referral system between PHC and SHC Facilities, proper planning and ownership creation etc Impact of Medicine Purchase and Distribution System The medicine purchase and distribution for all districts is centralized at the level of project secretariat in Lahore while the purchase is normally done as per requirement of individual districts based on previous year s OPD record and budget for running year. The BHU level distribution of medicine is managed at District Support Unit level. There was no role of Community Support Groups (CSGs) observed for the purchase of medicine as the system is very much centralized. On the other hand, it was concluded that CSGs are also not briefed about the availability of medicines as per current budget and certain targets of BHUs for curative and preventive services. Un-institutionalized and less involved Community Support Groups have limited role in community mobilization, awareness raising, BHU ownership and ensuring sustainability of the programme through fund generations and management. The strengthening and active involvement of CSGs through briefing on BHU monthly review including the medicine data would be helpful in increasing the local level ownership of BHU and ensuring the long-term sustainability of the service delivery through self-reliance basis Programme Monitoring & Evaluation It has been observed that the general public, beneficiaries and other stakeholders have no clear understanding on monitoring and evaluation responsibilities. They don t have any idea that who would be the right monitor. Most of the respondents favoured the health department monitoring while 12 % said that PRSP should monitor. A few of the learned respondents discussed the role of CSGs and third party should be the monitor. During FGDs, it was critically noted that the doctors and paramedics were interested on the role of health department for monitoring purpose as they were unhappy with the present monitoring role of PRSP. Most of the respondents (66%) of quantitative survey agreed with the suggestion to have CSGs a significant role for monitoring the BHU services for primary health care in their area while 17% said that CSG did not play significant role and 17% respondents had no idea due to lack of awareness and poor literacy in the area. Most of the respondents (74%) were of the view that the CSG should also be given the role 89 P a g e

90 in this PPP model for the better management of service delivery. Most of the respondents (74%, 52%, 71%) in Dunya Pur, Kahror Pakka and Lodhran said that the CSGs have significant role for monitoring the BHU services for primary health care, 18%, 15% and 17% of the respondents said that they had no clear idea about the matter concerned. Few respondents (8%, 32% and 11%) in Dunya Pur, Kahror Pakka and Lodhran respectively said that CSGs should have a role in monitoring. Most of respondents (50%) said that Health Department is probably the monitor while 26% said that field staff of PRSP is doing this role at present. 28%, 71% and 38% respondents from Dunya Pur, Kahror Pakka and Lodhran respectively said that the programme is being monitored by at least some mean. 12%, 4% and 18% of the respondents rejected the idea as no monitoring happen while 59%, 24% and 44% respondents from Dunya Pur, Kahror Pakka and Lodhran respectively rejected that program is even being monitored by any means. It has been observed that most of the people around 78% said enhanced monitoring could bring further improvements. The present controversial status of monitoring system of the programme may pose serious risks to PPP model and long-term sustainability of the programme. There is a need to revisit the existing monitoring mechanism and roles need to be clarified. The CSGs may be instrumental if their role could also be brought forward but institutionalization and strengthening of CSGs is a pre-requisite in line with other recommendation in this document for CSG roles for way forward in this regard. There is no third party monitoring and evaluation system present to knock the system on regular intervals with a defined frequency. The frequency of such monitoring and evaluation needs to be defined and proper budgetary provision should be made in order to bring system improvements on regular basis. As PRSP is the implanting agency so it would be fruitful if regular monitoring task could be taken care of Independent Monitoring Consultants (IMCs) by involving a third-party institution. Figure 3.71: CSG for Monitoring Figure 3.72: Present Monitor 90 P a g e

91 Figure 3.73: Suggestions for Right Monitor Strength and Weakness of Programme Most of the respondents (78%) reported that there is a significant impact of the programme on social and economic uplift. Improved happiness due to improved health services, economic gains through private consultation savings and betterment in livelihood of children were key important impacts highlighted by the beneficiaries as well as by other relevant stakeholders during the course of qualitative research. As far as the core strength is concerned, the programme has achieved a good level of staff ownership through their punctual, honest, dedicated and committed norms which were only possible through improvements over period of time and better management of the programme though the programme has double-barrel control over its affairs. It is evident that a majority of respondents (81%) reported that BHU staff is dedicated and committed with their duties for which they concluded based on their past experience through visiting BHUs in their respective areas. The free of cost medical advice together with medicines and activities for MCH component (including prenatal and post natal care services) are also the strengths of the programme in order to achieve health related MDGs. Most of respondents (52%) said more facilities should be added but there are financial limitations. Respondents (46%, 37% and 63%0 in Dunya Pur, Kahror Pakka and Lodhran said that more facilities should be added but there are financial limitations. While 54%, 63% and 37% of the respondents rejected the idea in Dunya Pur, Kahror Pakka and Lodhran that further facilities could not added due to financial limitations. The mobilization component has been concluded a critical weakness in the programme when it was found that a majority (69%) of respondents were reluctant to play their role in the delivery of health services in PPP. Highest reluctance (72%) was in Lodhran while in Dunya Pur and Kahror Pakka it was 64% & 69%. People were unaware of whole model so most of them hesitated to play their role in the PPP system for PHC in the area concerned. 91 P a g e

92 Figure 3.74: Staff Commitment Figure 3.75: Community Willingness to Play Role Community Willingness to play its role 69% 31% YES NO 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0%.0% Willingness to play their role - Tehsil wise 35.6% 64.4% 31.0% 69.0% 27.9% 72.1% Dunyia Pur Karor Pakka Lodhran YES NO Figure 3.76: Facilities VS Financial Limitations It was frequently reported during qualitative research that the old permanent staff are influential and use influential channels (like politicians and landlords etc.) for getting some relaxation and extra edge over other staff members. The reason behind this gray area was double-barrel management over the affairs of BHU. On the other hand, the results of quantitative research were quite surprising as most of respondents in Dunya Pur, Kahror Pakka and Lodhran (80%, 80% and 49% respectively) disagreed and 92 P a g e

93 were of the view that the staff is not too much influential to compromise its basic responsibility. In Lodhran, almost half of respondents were agree with the opinion of influential channels being under use but the actual situation could be due to medicine delays and demand for self-medication that is why the people were showing anger by responding in such a negating way. On the other hand, it could also be the truth as some cases were recorded by PRSP monitors that few staff member were so influential that they even not care any rule and regulations too. Influential people have their say in BHU affairs as most of the respondents (69%) told that issue. Infact the presence of influential people were observed in health committee and different health sessions so the people in Lodhran might be true. Role of CSGs is not visible to ensure transparency and accountability of the programme although there are no major issues reported regarding the transparency and accountability but the role of CSGs is important and needs to be addressed. 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0%.0% Figure 3.77: Presence of Influential Staff Influence of staff members tehsil wise Influential people enjoying more benifits 19.9% 80.1% 24.1% 75.9% 51.3% 48.7% Dunyia Pur Karor Pakka Lodhran YES NO 69% 31% YES NO Figure 3.78: Un-visible Role of CSG The mobilization and awareness component needs to be improved as level of awareness of common person in area is not achieved up to a visible level. On the other hand the CSGs are also not clear about their clear functions while PRSP itself agreed with the improper functioning of CSGs as PRSP has not achieved satisfaction 93 P a g e

94 on the level of expected outcome from the concept of CSG in PHC reform agenda. People suggested that there be more school sessions required for awareness and better health outcomes for which PRSP s capacity enhancement is required. People had a good opinion towards transparency of project overall, most of the respondents (65%) reported the transparency while 35% reported fraud in medicine inventory, service charges for maternity services and sometimes proving expired medicines. In qualitative research segment, a majority reported that everything is running with smooth functions and there is no issue of corruption in routine business affairs at BHUs. Some of the people were annoyed with the issue of delays of medicine while the medical staff reported that such type of people belong to a negligible proportion of the actual beneficiaries in the area and involved in selfmedication as well. In fact, the CSGs are not given the scope to perform in this domain that is why people are unaware of PPP model and procedures of this programme and consider everything is coming from the government directly for which they were complaining. The blame of medicine corruption becomes irrelevant in the case of prevalence of self-medication in the area. Figure 3.79: Mobilization and Awareness Component Figure 3.80: Type of Irregularities in BHU Operations Almost every person supported the idea that BHU should be open for 24 hours even they know that there were financial constraints. At present, this is a critically gray area where serious attention are required in order to achieve MDG milestones for 94 P a g e

95 MCH component as normally majority of baby births being reported during night time whereby the BHUs are observed out of service and people have to go for alternate in the form of Daies (local nurses) and/or other nearby private clinics or city hospitals. In most of the cases, the people use to go to city hospitals as the number of private maternity clinics are very rare in remote areas. Most of respondents (88%) reported that there are no security issues for mobility of FMOs & paramedics although few cases of robbery and snatching of mobiles from general public were reported from Kahror Pakka in peri-urban areas. As a whole it was concluded that the environment is work and movement friendly in Lodhran district while at the same time transportation for female staff could be a problem for their movement on daily basis. Therefore, the question of security for FMOs and other female paramedics is not challenging and new FMOs need to be encouraged for their active involvement in this programme for which special job places and promotional campaigns with package revision may be helpful to attract more FMO recruitment. Figure 3.81: Security Issues for FMOs Ict There were few reports (13%) about the presence of negative elements in the community, who normally create troubles and playing an obstacle type role in the normal functions of BHUs. Out of these 13%, average is high in Lodhran (18%) & Kahror Pakka (16%) while most of these elements were religious extremist (60%) then landlords (26%) & notables (3%). Apart from it, ethnic conflicts were also reported by 11% respondents. The special focus on Social Inclusion, Participation with equity and Grievance Redresser Mechanism together with improved mobilization could play instrumental role to remove this gray element. 95 P a g e

96 Figure 3.82: Negative Elements in Normal BHU Functions The BHU referral system has been found weak due its limited office timing and unavailability of ambulance service. These aspects are important for MCH component and at present can be considered a limiting factor in excellent performance of the BHUs. There is a growing demand to improve this component so as to take maximum benefit and meet the target of MDGs. Figure 3.83: Referral System VS Ambulance Sustainability of the Programme Sustainability definitely is one of the most important factors for an organization striving towards a cause as important as improving social and financial lives of the ordinary, marginalized and vulnerable people. Understandably, if an organization does not make efforts to remain alive when a specific donor s financial support is withdrawn, the sustainability of the work it has devoted itself for also comes under serious questions. In the present research study, while measuring the organizations potential to survive at their own, data was gathered and analyzed against the challenges faced by the PPP model in developing effective linkages and size and scale of resource utilization both internally and externally. Moreover, realization of durable solutions that the communities envisage for institutionalization of CSGs with extended role and its implementation in real work was also considered and analyzed. 96 P a g e

97 Finally, an attempt was also made to bring up the success stories and to highlight the lessons learnt in attaining self reliance and sustainability. There were issues of difficulties (40%) in getting the medicines. This is a handsome percentage but during evaluation it was noted that there are issues of self-medication and delays of medicines and lack of proper socialization. Most of the people were aware that these delays are due to purchase issues (74%), medicine shipment (21%) and surplus sue (5%) at BHUs. It was reported that children, their parents, teacher and community members were in favour of achievements of PHC initiatives which they said will be more stable if more emphasis will be on nutrition and health session in school as well as in community. Moreover, it was noted that children share their acquired knowledge in family, friend and peer that is a good sign. Only 20% of the respondents claimed that CSGs are important and playing their right role for the sustainability of the programme? Majority of community denied as it was evident that CSGs were not functioning and it was admitted by PRSP authorities too at all levels. Most of the respondents suggested awareness campaign (32%), capacity building (18%) and institutionalization of CSGs. It was reported that most of the respondents (79%) believe that BHU services would not sustain, if there is a financial crunch on CMIPHC. 21% respondents suggested that it can be run by community donation (44%) and donor assistance (41%). A few of the respondents have no idea so they said that it s already sustainable but there are issues in budget allocations and release at different levels from different stakeholders. Most of the respondents were of the view that community can also raise funds as people were impressed by PRSP. Even mobilization factor was not visible but still majority (57%) is willing to assist the PRSP by different means. People were satisfied with PRSP Performance; they said BHUs cannot be run by the government itself as past record is evident. BHUs were served as store and stable for livestock and dogs of the feudal lords. Few people (21%) said Health Department can also run the BHUs with honesty and dedication but it doesn t exist at visible level. Privatization policies in Pakistan remain largely unexamined and insensitive to the need for basic health services that are accessible, available, affordable and of acceptable quality. This could be due mainly to downsizing of social capital and inadequate financial resources or to disparities in power and lack of trust between the public and private sectors that inhibits collaboration at the policy and operational level in provision of health care in Pakistan. As a result, the health sector in Pakistan is far from developing a consistent form of interaction. This in turn is reflected in a high burden of disease, lack of health care staff, staff absenteeism and poor access to health facilities for patients. The CSGs can be instrumental for Social inclusion, Social influences of programme, Grievance redresser mechanism, Monitoring Progress and Sustainability of the programme. The CSGs need a proper institutional setup and active role in BHU affairs. The chair of CSG needs to be elected from community members and MOs could be given a role of a technical or ex-officio members in CSG so as to ensure 97 P a g e

98 proper transparency and accountability at local level. This would create local ownership and funds can be generated for long-term sustainability of the programme with extension of basic health services and enhanced functions of BHU. Figure 3.84: Sustainability of BHU Services Figure 3.85: Funds from Community Figure 3.86: BHU Services without PRSP 98 P a g e