Health Facility Assessment Khyber Pakhtunkhwa Provincial Report TRF. Technical Resource Facility

Transcription

1 Health Facility Assessment Khyber Pakhtunkhwa Provincial Report TRF Technical Resource Facility

2 Acknowledgement TRF acknowledges the cooperation and support of Contech International Health Consultants, Lahore who worked on the assignment and authored the report. The final reports are quality assured by Jennifer Sanchos, HLSP Health Systems Consultant. Disclaimer This document is issued for the party which commissioned it and for specific purposes connected with the above-captioned project only. It should not be relied upon by any other party or used for any other purpose. We accept no responsibility for the consequences of this document being relied upon by any other party, or being used for any other purpose, or containing any error or omission which is due to an error or omission in data supplied to us by other parties. June 2012 i

3 Table of Contents Acknowledgement... i Acronyms... viii Executive Summary... 1 Report organisation... 2 Section 1: Introduction... 3 Survey objectives... 3 Assignment duration... 4 Scope of HFA... 4 Section 2: Provincial Information... 5 Khyber Pakhtunkhwa An overview... 5 Key indicators... 6 Public sector health facilities... 7 Section 3: Assessment of Functional Capacities... MNCH services... Basic health units... Status of infrastructure... Status of human resources Status of functional equipment Status of drugs and supplies Status of support services BHUs conformance to required inputs... Rural health centres... Status of infrastructure Status of human resources Status of functional equipment Status of drugs and supplies Status of support services RHCs conformance to required inputs SHC hospitals... 1 Status of infrastructure Status of human resources ii

4 Status of functional equipment Status of drugs and supplies Status of support services SHC hospitals conformance to required inputs THQ hospitals... 2 Status of infrastructure... 2 Status of human resources Status of functional equipment Status of drugs and supplies Status of support services THQs conformance with assessed inputs Management basics Human resources Provision of staff by the NMNCHP MNCH staff training CMWs training and deployment Work coordination and supervision Management information system Drugs and supplies... 3 Infection control Death review Facility utilization Donor contributions Procurement estimates Equipment Civil works Section 4: Clients Perspective Key findings Quality of care Overall satisfaction Section 5: Health Managers Perspective Rationale Key findings of the in-depth interviews iii

5 Infrastructure Human resources Procurement and logistical management MIS Planning Monitoring and supervision Inter-sectoral collaboration Financial management Donor contributions Section 6: Key Findings... 5 Infrastructure... 5 Human resources Training of staff Drugs, supplies and equipment Work coordination and supervision Service delivery protocols Management information system Infection control Death reviews Donor contributions ANNEX Objectives of the NMNCH programme ANNEX Input Criteria for MNCH services A. Civil works criteria B. Human resources criteria C. Equipment criteria D. Drugs and supplies criteria E. Support service criteria F. Infection control and waste management criteria G. Input criteria for basic EmONC services at THQ hospital iv

6 List of Tables Table 1.1: Scope of HFA... 4 Table 2.1: Key figures of Khyber Pakhtunkhwa... 6 Table 2.2: Number of public sector health facilities... 8 Table 3.1: Status of assessed infrastructure in BHUs Table 3.2: Status of MNCH related staff in BHUs Table 3.3: Status of functional equipment in BHUs Table 3.4: Status of drugs and supplies in BHUs Table 3.5: Status of support services in BHUs... Table 3.6: Status of assessed infrastructure in RHCs Table 3.7: Status of MNCH related staff in RHCs Table 3.8: Status of functional equipment in RHCs Table 3.: Status of drugs and supplies in RHCs Table 3.: Status of support services in RHCs Table 3.11: Status of support services in RHCs Table 3.12: Status of assessed infrastructure in SHC hospitals Table 3.: Status of MNCH related staff in SHC hospitals Table 3.14: Status of functional equipment in SHC hospitals Table 3.15: Status of drugs and supplies in SHC hospitals Table 3.16: Status of support services in SHC hospitals Table 3.17: Status of support services in SHC hospitals Table 3.18: Status of assessed infrastructure in THQHs... 2 Table 3.1: Status of MNCH related staff in THQHs Table 3.20: Status of functional equipment in THQHs Table 3.21: Status of drugs and supplies in THQHs Table 3.22: Status of support services in THQHs Table 3.23: Status of support services in THQHs Table 3.24: Status of HR reported by surveyed health facilities Table 3.25: Number of health facilities having staff provided by NMCHP Table 3.26: Number of MNCH staff provided by NMCHP Table 3.27: Number of staff trained on delivering MNCH services Table 3.28: Number of health facilities received MNCH training v

7 Table 3.2: Status of CMWs training and deployment in Khyber Pakhtunkhwa Table 3.30: Status of infection prevention at the surveyed health facilities Table 3.31: Status of mortality reviews at surveyed health facilities Table 3.32: Utilization of MNCH services at surveyed health facilities Table 3.33: Utilization of FP services at surveyed health facilities Table 3.34: Status of donor contributions at surveyed health facilities Table 3.35: Summary of estimated cost for equipment and civil works Table 4.1: Number of CEIs conducted in Khyber Pakhtunkhwa Table 5.1: Names of districts in Khyber Pakhtunkhwa contacted for IDIs vi

8 List of Figures Figure 2.1: Map of Khyber Pakhtunkhwa... 6 Figure 3.1: Range of services that signal fully functional MNCH services... Figure 3.2: Average availability of assessed inputs at surveyed BHUs... Figure 3.3: District-wise status of conformance of BHUs to required inputs Figure 3.4: Average availability of assessed inputs at RHCs... 1 Figure 3.5: District-wise status of conformance of RHCs to required inputs Figure 3.6: Average availability of assessed inputs at SHC hospitals Figure 3.7: District-wise status of conformance of DHQHs to required inputs Figure 3.8: District-wise status of conformance of THQHs to required inputs Figure 3.: Average availability of assessed inputs at THQHs Figure 3.: District-wise status of conformance of THQHs to required inputs Figure 3.11: Status of management basics at surveyed facilities Figure 3.12: Work coordination Figure 3.: Supervision Figure 3.14: Status of MIS... 3 Figure 3.15: Facility specific reasons for stock out of drugs and supplies Figure 4.1: Reasons for visiting health facility Figure 4.2: Average time taken by the clients to reach the facility Figure 4.3: Average waiting time at the facility Figure 4.4: Clients' level of satisfaction with availed services Figure 4.5: Provision of medicines, lab services and education material Figure 4.6: Overall satisfaction of interviewed clients... 4 vii

9 ACRONYMS ANC AJK AVD BB technician BEmONC BHU CBA CEI CH CMW CWAQ CDC DCO DDCT DHO DHDC DHIS DHQH DLQ EDOs EmONC ENC EAQ EPI FATA FP & PHC GBR HF HFA HID HIV HMIS HR IDI EDOH IMNCI IMPAC JD KPK LHS LHV Antenatal Care Azad Jammu Kashmir Assisted Vaginal Deliveries Blood Bank Technician Basic Emergency Obstetric and Newborn Care Basic Health Unit Child Bearing Age Client Exit Interview Civil Hospital Community Midwives Civil Works Assessment Questionnaire Communicable Disease Control District Coordination Officer District Data Collection Teams District Health Officer District Health Development Centre District Health Information System District Headquarter Hospital District Level Questionnaire Executive District Officers Emergency Obstetric and Newborn Care Emergency Newborn Care Equipment Assessment Questionnaire Expanded Programme of Immunisation Federally Administered Tribal Areas Family planning and Primary Health Care Gilgit Baltistan Region Health Facilities Health Facility Assessments Health Institution Database Human Immunodeficiency Virus Health Management Information System Human Resource In-depth Interview of EDO Health Integrated Management of Neonatal and Childhood Illnesses Integrated Management of Pregnancy and Childbirth Job Description Khyber Pakhtunkhwa Lady Health Supervisor Lady Health Visitor viii

10 LHW Lady Health Worker MDGs Millennium Development Goals M&E Monitoring and Evaluation MICS Multiple Indicator Cluster Survey MIS Management Information System MNCH Maternal, Neonatal and Child Health MO Medical Officer NMNCHP National Maternal Newborn and Child Health Programme NVD Normal Vaginal Deliveries OBGYN Obstetrics and Gynaecology OPD Out Patient Department OT Operation Theatre PC-1 Planning Commission Proforma 1 PDHS Pakistan Demographic and Health Survey PNC Post Natal Care PPHI Peoples Primary Health Care Initiative PSLM Pakistan Social & Living Standards Measurement Survey RHC Rural Health Centre SBA Skilled Birth Attendants SD&MB Service Delivery and Management Basics SE Socioeconomic SHC hospitals Secondary Health Care SPSS Statistical Package for the Social Sciences TA Technical Assistance THQ Tehsil Headquarter hospital TRF Technical Resource Facility TT Tetanus Toxoid WMO Women Medical Officer WBC Well Baby Clinics ix

11 Executive Summary The first national health facility assessment (HFA) was conducted from October 20 to May 2011 covering all of the provinces and regions of Pakistan, as part of the implementation of the monitoring and evaluation (M&E) framework of the national maternal newborn and child health programme (NMCHP). The Khyber Pakhtunkhwa health facility assessment report synthesises the findings of 350 health facilities assessed in all of the 25 districts of Khyber Pakhtunkhwa province. Secondary health care (SHC) hospitals including 21 district headquarter (DHQH) hospitals and 77 tehsil headquarter (THQH) and civil hospitals (CH) were assessed for the provision of 24/7 comprehensive emergency obstetric and newborn care (EmONC) services. 0 rural health centres (RHCs) were assessed for 24/7 basic EmONC services and 162 basic health units (BHUs) were assessed for the availability of 8/6 preventive MNCH services. The status of THQHs / civil hospitals was also assessed for their readiness to deliver 24/7 basic EmONC services. Regarding the availability of inputs, the major issues faced by the facilities were mainly due to the lack of MNCH-related staff at the facilities, e,g. WMOs at RHCs and specialists (including gynaecologist, anaesthetist and paediatrician) at DHQ and THQ hospitals. Infrastructure components were mostly available at the assessed health facilities. Although the availability of staff residences was a major problem in ensuring the 24/7 availability of EmONC services. Infrastructure components required for paediatric care were deficient at most of the THQ hospitals. Major gaps were also revealed in the availability of required equipment, drugs and supplies. At the time of the assessment, none of the health facilities in Khyber Pakhtunkhwa had been provided with the complete range of assessed items required to perform signal functions. Findings related to management basics revealed the lack of work coordination among the facility staff. It was assessed through the record of monthly performance review meetings held at the facility. Supervision at the surveyed facilities was assessed through the regularity of supervisory visits of the district level managers and the receipt of their feedback to the facility. Although the majority of the facilities reported having received supervisory visits, their feedback was not a common practice. Staff job descriptions and service delivery protocols were deficient at majority of the health facilities. A management information system was wellplaced in the form of the health management information system (HMIS). Gaps were identified in infection control practices, due to the lack of trained staff and non-availability of 1

12 materials for personal protection, waste collection and waste treatment. Due to inconsistent documentation of maternal, neonatal deaths and the lack of functioning death review committees, these deaths had rarely been reviewed at the health facilities. A total of 1,045 clients were interviewed. Findings from the client exit interviews revealed that about 20% are very satisfied and 75% are satisfied with the services provided, whereas only 5% are not satisfied at all with the quality of services. Report organisation The health facility assessment report has been structured in six sections: 1. Section 1 has the Introduction to the survey, its objectives, scope and duration. 2. Section 2: Provincial information comprises of an overview of the province, key indicators at a glance, as well as the organisation of the public sector health care delivery system. 3. Section 3: Assessment of functional capacities contains the details of health facilities assessed against the availability of the 5 specified inputs which would enable them to perform their level-specific services, (infrastructure, human resources, drugs and supplies, equipment and level specific support services). 4. Section 4: Clients perspective contains information about the perceptions of the clients regarding the MNCH services provided at the public sector health facilities. 5. Section 5: Health Managers perspective provides the findings of the in-depth interviews of health managers. 6. Section 6: Key Findings This section describes the health facility assesment findings and key actions recommended, based on the assessment s findings and in-depth interviews provided in Sections 3 to 5 2

13 Section 1: Introduction This section includes the survey background, its objectives, the scope and duration and organisation of the provincial report. In Khyber Pakhthunkhwa, more than 275 maternal deaths occur per 0,000 live births with devastating effects on families and livelihoods. Skilled and responsive care, at and after birth, can avert nearly all fatal outcomes and disabling consequences and ease much of the suffering. The health of mothers and newborns are so intricately related, preventing deaths requires, in many cases, the same interventions. The Government of Pakistan is committed to achieve the Millennium Development Goals (MDGs) and the Ministry of Health has established the National Maternal Newborn and Child Health Programme (NMCHP) for achieving the 2015 targets for the health related MDGs 4 and 5. The overreaching goal of the programme is to improve health status of mothers, newborns, and children with focus on poor and marginalized populations. Survey objectives The health facility assessment was aimed at assessing the availability, functioning and quality of the health care delivery system in the public sector facilities, with a focus on maternal, newborn and child health services. Some of the specific objectives of the health facility assessment were: To assess the health facility status and quality of MNCH services (comprehensive and basic EmONC, preventive MNCH and family planning) at the district level; To assess the clients satisfaction and perception of MNCH services; To provide information for the systematic planning of procurement and supply of goods and commodities (listing the medical equipment and instruments which need to be replaced or purchased); and To update and assess the contributions made by the development partners for improving MNCH and family planning services in the selected districts Whereas the HFA is intended to help district and provincial health managers in assessing performance benchmarks and realigning their activities for bridging the gaps existing in MNCH services for achieving the MDGs, the scope of the HFA does not cover the overall situation of health sector in the district. 3

14 Assignment duration The Technical Resource Facility (TRF) is supporting the NMNCHP with technical assistance (TA) in the design and implementation of the health facility sssessment (HFA) across Pakistan. The TA was assigned to Contech International. The estimated duration of the assignment was 7 months. The assignment started in October 20 and ended in May Scope of HFA The survey included the district headquarter hospital (DHQH), tehsil/taluka headquarter hospitals (THQHs), rural health centres (RHCs) and 20% of the basic health units (BHUs) randomly selected from within the district. The selection of the BHUs was done through geographical stratification on the basis of proportionate distribution. Client exit interviews were conducted at the surveyed facilities ( at the DHQH, 5 at each THQH and RHC), excluding the BHUs. Table 1.1 shows the numbers of health facilities in the district and the health facilities surveyed. TABLE 1.1: SCOPE OF HFA Khyber Pakhtunkhwa Province Number of health facilities by type DHQH THQHs/CHs RHCs BHUs Total Number of facilities ,0 Number of facilities surveyed

15 Section 2: Provincial Information This section gives an overview of Khyber Pakhtunkhwa province and the organisation of the public sector health care services in the province, derived from secondary data sources. Khyber Pakhtunkhwa An overview Khyber Pakhtunkhwa previously known as the North-West Frontier Province, is located in the north-west of the country. It borders Afghanistan to the north-west, Gilgit-Baltistan to the north-east, Pakistan administered Kashmir to the east, the Federally Administered Tribal Areas (FATA) to the west and south and Punjab and the Islamabad capital territory to the south-east. The provincial capital is Peshawar, locally referred to as Pekhawar. The province has an area of 74,521 km². According to the 18 census, the population of the province is approximately 21 million of whom 52% are males and 48% are females. The density of population is 187 per km² and the intercensal change of population is of about 30%. The largest ethnic group are the Pashtuns who form about two-thirds of the population. The northern zone is cold and snowy in winters with heavy rainfall and pleasant summers with the exception of the Peshawar basin, which is hot in summer and cold in winter. It has moderate rainfall. The southern zone is arid with hot summers and relatively cold winters and scanty rainfall. The major rivers that criss-cross the province are Kabul, Swat, Chitral, Kunar, Siran, Panjgora, Bara, Kurram, Dor, Haroo, Gomal and Zhob. 5

16 FIGURE 2.1: MAP OF KHYBER PAKHTUNKHWA Key indicators The population of Khyber Pakhtunkhwa constitutes.40% of the population of Pakistan, as per 18 Census. According to 18 census population of the province is 17,743,645 with an annual growth rate of 2.82; it has now increased to 24,248,465. Status of Key indicators of Khyber Pakhtunkhwa is presented in Table 2.1. TABLE 2.1: KEY FIGURES OF KHYBER PAKHTUNKHWA Demography Value Health & socio-economic Value Geography Health Number of districts 25 Area (in square Km) 74,521 Infant mortality rate (/1,000 live births) Under 5 Mortality rate (/1,000 live births)

17 Demography Maternal mortality ratio (/0,000 live births) 275 Total population 20,215,000 Malnutrition (Women) - Population (Urban) 16.87% Malnutrition (Children) - Population (Male : Female) 8 Immunisation (children <12 months all vaccinations) 46.% Annual growth rate 2.04 Economy Under 1 year 2.70 GDP annual growth rate (200) - Under 5 years.40 Human development index Under 15 years 41.7 Education Women 15-4 years Literacy rate (Overall) 50% Married women of Child Bearing Age (CBAs) Literacy rate (Male : Female) 6 : 31 Pregnant women 3.40 Literacy rate (Urban: Rural) 62 : 47 Sources: Development Statistics 20, MICS KP , Economic Survey of Pakistan 200-, Demographics and Health Survey Pakistan, , PSLM 2008, Population Census 18, Public sector health facilities Although health care services in Khyber Pakhtunkhwa are provided by public and private providers, the government is considered by far to be the main provider of preventive care throughout the province and the major provider of curative services in most rural areas. In the public sector, health services are provided through a tiered referral system of health care facilities; with increasing levels of complexity and coverage from primary, to secondary and tertiary health facilities. Primary care facilities include basic health units (BHUs), rural health centres (RHCs), government rural dispensaries (GRDs), mother and child health (MCH) centres and TB centres. All of these facilities provide 8/6 OPD services for preventive and a limited number of curative services, while RHCs provide a broader range of curative services, 24/7. Primary care facilities also provide outreach preventive services to the 7

18 communities through vaccinators, sanitary inspectors and a sanitary patrol. Tehsil and district headquarter hospitals provide increasingly specialized secondary health care, while teaching hospitals form the tertiary level tier. Information about the number of health facilities, ranging from teaching hospital to sub-health centres, in each district of Khyber Pakhtunkhwa is collected from respective district health departments. Details about public sector facilities are given in Table 2.2: TABLE 2.2: NUMBER OF PUBLIC SECTOR HEALTH FACILITIES Type of health facility Number Teaching hospitals District headquarter hospitals 21 Tehsil headquarter hospitals / civil hospitals 77 Rural health centres 0 Basic health units 822 Dispensaries 307 Mother and child health centres 4 Sub-health centres 30 The role of the provincial department of health (DoH) includes policy and strategy development, intra-provincial coordination, monitoring and evaluation; medical and nursing education and tertiary care delivery. The role of the district department of health is implementation, monitoring and supervision, management of health care delivery at and below DHQ hospitals and the implementation of vertical programmes at the district level. 8

19 Section 3: Assessment of Functional Capacities MNCH services The packages of MNCH services assessed include preventive MNCH services at BHUs, basic EmONC services at RHCs and comprehensive EmONC services at the THQ and DHQ hospitals 1. The range of MNCH services are given in Figure 3 below. FIGURE 3.1: RANGE OF SERVICES THAT SIGNAL FULLY FUNCTIONAL MNCH SERVICES BHUs: Facility available for 8/6 Preventive MNCH Services 1. Antenatal checkup 2. Lab (Anemia, Malaria, pregnancy test, urine test for sugar & Protein) 3. Normal delivery 4. Family planning services (at least 3 methods) 5. TT immunisation 6. EPI vaccination 7. Growth monitoring 8. Nutrition counseling. HR (at least one LHV or Doctor) RHCs: Facility available for 24/7 Basic EmONC Services 1. Parenteral antibiotics 2. Parenteral oxytocic drugs 3. Parenteral anticonvulsants for pregnancy induced convulsions (due to hypertension) 4. Manual removal of placenta 5. Removal of retained products 6. Assisted vaginal delivery (vacuum extraction, forceps) 7. Newborn resuscitation 8. Post abortion care +. HR (skilled female providers-wmo LHVs), and. Preventive MNCH DHQ/THQ Hospitals: Facility available for 24/7 Comprehensive EmONC services 1. Surgery (Csection) 2. Blood transfusion 3. Newborn care (resuscitation & incubator) 4. Gynaecological care 5. Comprehensive family planning services including sterilisation 6. HR (skilled staff for conducting, C-section, blood transfusion and anaesthesia), + 7. Preventive MNCH and 8. Basic EmONC 1 PC-1 NMNCHP

20 The health facilities were assessed against the availability of 5 specified inputs which would enable them to perform their level-specific services. The functional capacity of health facilities was assessed, against 5 specified inputs, which include: 1. Infrastructure 2. Human resources 3. Drugs and supplies 4. Equipment 5. Level specific support services The health facilities assessment findings are presented against two levels of inputs including: Optimal level of inputs, these are those proposed in the PC-1 of the national MNCH programme, required to make a health facility fully functional for the provision of the level specific package of MNCH services (Annex 2). Minimal level of inputs, which are the bare minimum requirement of the inputs, required for delivering the package specific MNCH services at the health facilities. The findings related to the minimal level of inputs are given as Annex 2. This section describes the functionality of the assessed facilities, against the availability of the optimal level of inputs by facility type. An analysis is also provided, against a minimal or essential level of inputs, for comparative purposes. Basic health units (BHUs) Status of infrastructure The infrastructure of the BHUs has been assessed, for the availability of an OPD/ LHV s room and labour room as service provision areas and residences for the accommodation of required staff. The findings are presented for the availability and functional status of infrastructure components assessed at the BHUs, both in numbers and percentages in Table 3.1. The assessment of infrastructure in the BHUs revealed that an OPD is available at 5% of the BHUs. Out of these, 143 OPDs are in a workable state and major repair work (exceeding

21 75%) is required at 12% of the BHUs. Similarly, a LHV s residence is available at 85% of the BHUs and is liveable at only 41% of them. TABLE 3.1: STATUS OF ASSESSED INFRASTRUCTURE IN BHUS Assessed infrastructure Status of surveyed BHUs (N=162) Number Percentage OPD Labour room Residence - LHV Available 154 5% Functional % Available 17 % Functional 14 % Available 8 85% Functional 66 41% Status of human resources A doctor or LHV is required for the provision of preventive MNCH services. The availability (both regular posted and provided by NMNCHP) of both of these categories of human resources, against the required number mentioned in PC-1 of NMNCHP, is presented in Table 3.2. Out of the surveyed BHUs, 8% had staff available for preventive MNCH service provision, while 18 of the BHUs had neither a doctor nor a LHV posted. Further analysis revealed that out of 162 BHUs, 85 of them had a doctor posted. A LHV is positioned in 140 of the BHUs. TABLE 3.2: STATUS OF MNCH RELATED STAFF IN BHUS Staff categories Status of surveyed BHUs having required staff (N=162) Number Percentage Doctor or LHV 144 8% Status of functional equipment BHUs are categorized into four groups 2, according to the percentage availability of functional equipment items in each BHU, as presented in Table 3.3 An assessment analysis of the functional equipment items in BHUs, revealed that only one BHU had more than 75% of the general equipment items. The majority (2 out of 162) of the BHUs had even less than 25% of the general equipment items. Only 7 BHUs had more than 75% of the OPD 2 This is arbitirary categorisation to present availability of assessed items. 11

22 equipment items. 7 BHUs had less than 50% of the required items. 71 of the 162 BHUs had less than 50% of LHV room equipment. TABLE 3.3: STATUS OF FUNCTIONAL EQUIPMENT IN BHUS Equipment Number of surveyed BHUs having functional equipment items (N=162) >75% available 51 to 75% available 25 to 50% available <25% available General items OPD LHV s room Status of drugs and supplies BHUs are categorized in four groups, according to the percentage availability of items in each group of supplies, Tracer drugs, vaccines and family planning commodities, as presented in Table 3.4. An analysis of the available tracer items in BHUs showed that only 23 out of the 162 BHUs had more than 75% of the supplies. 86 BHUs had less than 50% of the required drugs available. More than 75% of the assessed vaccines were available at 80% of the BHUs. 65 BHUs had less than 25% of the family planning commodities. TABLE 3.4: STATUS OF DRUGS AND SUPPLIES IN BHUS Item groups Number of surveyed BHUs with available tracer items (N=162) >75% available 51 to 75% available 25 to 50% available <25% available Supplies Drugs Vaccines Family planning commodities Status of support services The BHUs are categorized into three groups, according to the percentage availability of the inputs for basic laboratory tests (test strips and human resources) required for performing these services, as presented in Table

23 TABLE 3.5: STATUS OF SUPPORT SERVICES IN BHUS Support services Number of assessed BHUs with available support services (N=162) All items available 50% available No item available Basic lab tests BHUs conformance to required inputs The assessment findings were analyzed to determine the conformance of surveyed BHUs, to the inputs required to deliver preventive MNCH services. The calculation is based on the Average functionality of the number of inputs for each criterion, including infrastructure 3, human resources, equipment, drugs and supplies and support services, against PC-1 of the national MNCH Programme. Based on this analysis, the functionality status of the assessed BHUs, with reference to the availability of required inputs, is presented in Figure 3.2. FIGURE 3.2: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT SURVEYED BHUS 0% 0% 80% 70% 60% 50% 40% 30% 20% % 0% 64% 75% 3% 50% Infrastructure HR Equipment Drugs & Supplies 58% Support Services A calculation was carried out in an attempt to present status of the districts based on conformance to required inputs, on following assumptions: District represented by a single bar, composed of five sub-sections each representing one of the 5 input criteria, Standard bar was taken as 1 (0), and each input component was allocated equal space in the bar i.e., one fifth of bar (20), Each component could maximum contribute to one fifth or 20 to the bar, 3 Conformance to infrastructure has been ascertained on the availability of key building components only, as for example presence of consultation area in OPD, leaving aside examination area and handwashing facility. However, all these components have been assessed collectively to identify scope of civil works and cost estimates.

24 Each component occupied its allocated space proportionate to its average availability, Five components make a component bar to give overall average availability of inputs by type of health facility in the district. Example: Calculation of component bar Average availability of inputs for CEmONC in each THQH of district Attock was: Component Number of required inputs Average availability Calculation Proportionate ( 1 / 5 ) of standard bar Infrastructure =(8.60/1*0)*0.2 HR =(14.40/41*0)*0.2 7 Equipment =(81/6*0)* Drugs & supplies =(34.60/42*0)* Support services =(63/87*0)* Infrastructure HR Equipment Drugs & Supplies Support services Attock It is evident that none of the required inputs meet the mark of 20 and comulative average availability of inputs in THQHs is 61 out of 0, in district Attock. Based on the above calculations, the following graph (Figure 3.3) presents the district-wise status of average component availability of inputs at surveyed BHUs. 14

25 FIGURE 3.1: DISTRICT-WISE STATUS OF CONFORMANCE OF BHUS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Noshera Mardan Charsada Haripur 1 12 Battagram Swabi Malakand Lucky Marwat Karak Shangla Kohat Peshawar Bannu Chitral Swat 16 8 DI Khan 7 8 Buner Mansehra Tank 6 8 Abbottabad Hangu Lower Dir Upper Dir Tor Ghar Kohistan

26 Rural health centres (RHCs) All the 0 RHCs operating in Khyber Pakhtunkhwa were assessed for the availability of the optimal levels of the 5 input criteria. Status of infrastructure The infrastructure of the RHCs has been assessed, for the availability of an OPD, indoor ward, LHV s room, labour room and clinical laboratory, as service provision areas and residences for the accommodation of required staff. The findings are presented as the availability and functional status of infrastructure components assessed at the RHCs, both in numbers and percentages in Table 3.6. TABLE 3.6: STATUS OF ASSESSED INFRASTRUCTURE IN RHCS Infrastructure OPD Female ward Labour room Clinical lab LHV s room Residence - Doctor Residence - LHV Status of RHCs (N=0) Number Percentage Available 85 4% Functional 85 4% Available 6 77% Functional 47 52% Available 60 67% Functional 47 52% Available 84 3% Functional 74 82% Available 83 2% Functional 76 84% Available 53 5% Functional 34 38% Available 62 6% Functional 48 53% Status of human resources PC-1 of the NMNCHP contains the category and number of staff required, for the provision of basic EmONC services. The availability of human resources (both regular posted and provided by NMNCHP) at the RHCs at the time of survey, against the required numbers is presented in Table

27 TABLE 3.7: STATUS OF MNCH RELATED STAFF IN RHCS Staff categories RHCs having required staff (N=0) Number Percentage WMO % LHV 43 48% Lab technician 63 70% OT technician 7 8% Ambulance driver 6 77% Status of functional equipment The availability of equipment items for various service components at RHCs, as listed in PC- 1 of NMNCHP, was assessed and categorized in four groups, according to the percentage availability equipment items in each RHC and is presented in Table 3.8. TABLE 3.8: STATUS OF FUNCTIONAL EQUIPMENT IN RHCS Equipment Number of RHCs having functional equipment items (N=0) >75% available 51 to 75% available 25 to 50% available <25% available General items Female ward WMO OPD Labour room LHV s room The assessment of functional equipment items at RHCs revealed, that only 2 RHCs had more than 75% of the female ward equipment items. 54 out of the 0 RHCs had less than 50% of the WMO OPD equipment items. Status of drugs and supplies The list of essential drugs and supplies for MNCH services is contained in PC-1 of NMNCHP. Tracer items were selected from the list (Annex 2) for assessing their availability at surveyed facilities. RHCs are categorized in four groups according to percentage availability of items in each group of supplies, Tracer drugs, vaccines and Family planning commodities, as presented in Table

28 TABLE 3.: STATUS OF DRUGS AND SUPPLIES IN RHCS Item groups Number of RHCs with available tracer items (N=0) >75% available 51 to 75% available 25 to 50% available <25% available Supplies Drugs Vaccines Family planning commodities Status of support services The RHCs were assessed for the functionality of basic laboratory tests (space, test strips and human resources) and ambulance services (functional vehicle and driver). The details are presented in the Tables 3. and 3.11, respectively. TABLE 3.: STATUS OF SUPPORT SERVICES IN RHCS Support services Number of RHCs with available support services (N=0) 25 to 50% available <25% available Basic lab tests TABLE 3.11: STATUS OF SUPPORT SERVICES IN RHCS Support services RHCs with available inputs (N=0) Number Percentage Functional ambulance 61 68% Ambulance driver 6 77% RHCs conformance to required inputs The health facility assessment findings were analyzed, in order to determine the conformance of the RHCs, to the inputs required to deliver basic EmONC services. The calculation is based on the Average functionality of the number of inputs for each criterion, against PC-1, including infrastructure, human resources, and equipment, drugs and supplies, and support services. Based on this analysis, the conformance status of the assessed RHCs with reference to the availability of the required inputs is presented in Figure

29 FIGURE 3.4: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT RHCS 0% 0% 86% 80% 70% 60% 51% 50% 43% 40% 40% 30% 30% 20% % 0% Infrastructure HR Equipment Drugs & Supplies Support Services The following graph (Figure 3.5) presents the district-wise status of average component availability of inputs at the RHCs. 1

30 FIGURE 3.2: DISTRICT-WISE STATUS OF CONFORMANCE OF RHCS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Battagram Bannu Kohat Kohistan DI Khan Charsada Peshawar Mardan Chitral 18 7 Lucky Marwat Buner Tank Haripur 16 Abbottabad Lower Dir Noshera Malakand Swabi Hangu Karak Swat Mansehra

31 Secondary health care (SHC) hospitals All of the 21 DHQHs and 77 THQHs in Khyber Pukhtunkhwa (Secondary health care hospitals) were assessed for the availability of the optimal levels of the 5 input criteria. Status of infrastructure The infrastructure of the SHC hospitals has been assessed, for the availability of an OPD, indoor wards, LHV s room, labour room, operation theatre, paediatric nursery, blood bank, ultrasound room and clinical laboratory, as service provision areas and residences for the accommodation of required staff. The findings are presented as availability and functional status of infrastructure components assessed at the SHC hospitals, both in numbers and percentages in Table TABLE 3.12: STATUS OF ASSESSED INFRASTRUCTURE IN SHC HOSPITALS Status of infrastructure in SHC hospitals Infrastructure DHQHs (N=21) THQH (N=77) Number Percentage Number Percentage OPD Available 20 5% 67 87% Functional 20 5% 60 78% Female ward Available 1 0% 36 47% Functional 1 0% 25 32% Labour room Available 1 0% 50 65% Functional 18 86% 40 52% Operation theatre Available 1 0% 50 65% Functional 16 76% 30 3% Paediatric ward Available 15 71% 15 1% Functional 15 71% % Paediatric nursery Available 12 57% 7 % Functional 11 52% 6 8% Clinical lab Available 20 5% 63 82% Functional 20 5% 53 6% Blood bank Available 16 76% 11 14% Functional 14 67% 5 6% LHV s room Available 48% 54 70% Functional 48% 51 66% Ultrasound room Available 16 76% 12 16% 21

32 Functional 15 71% 12% Residence - Gynaecologist Residence - Anaesthetist Residence - Paediatrician Residence - WMO Residence - LHV Residence - Nurses Residence - Lab technician Residence - Blood bank technician Residence - Anaesthesia technician Available 62% 7 % Functional 62% 4 5% Available 2 % 1 1% Functional 2 % 1 1% Available 48% 11 14% Functional 48% % Available 14 67% 38 4% Functional 14 67% 25 32% Available 6 2% 35 45% Functional 5 24% 24 31% Available 16 76% 1 25% Functional 16 76% 14 18% Available 6 2% 12 16% Functional 5 24% % Available 4 1% 2 3% Functional 4 1% 2 3% Available 4 1% 4 5% Functional 4 1% 3 4% 22

33 Status of human resources The availability of human resources, by the category and number of staff (both regular posted and provided by NMNCHP) at SHC hospitals, as compared against the required numbers is presented in Table 3.. TABLE 3.: STATUS OF MNCH RELATED STAFF IN SHC HOSPITALS Availability of human resources in SHC hospitals Staff categories DHQHs (N=21) THQHs (N=77) Number Percentage Number Percentage Gynaecologist 6 2% 3 4% Anaesthetist 1 5% 1 1% Paediatrician 6 2% % WMOs 4 1% 2 3% Operation theatre technician 11 52% 1 1% Blood bank technician 3 14% 1 1% Lab technician 17 81% 21 27% Anaesthesia technician 48% 1 1% Nurses 18 86% 7 % LHVs 5 24% 3 4% Ambulance drivers 8 38% 5 6% Status of functional equipment The equipment items for various service components at SHC hospitals are categorized in four groups according to the percentage availability of functional equipment items in each SHC hospital. The details are presented in Table

34 TABLE 3.14: STATUS OF FUNCTIONAL EQUIPMENT IN SHC HOSPITALS Number of SHC hospitals having functional equipment items DHQH (N=21) THQH (N=77) Equipment >75% available 51 to 75% available 25 to 50% available <25% available >75% available 51 to 75% available 25 to 50% available <25% available General items Female ward OPD Paediatric nursery Paediatric ward Labour room Operation theatre Clinical laboratory Status of drugs and supplies Tracer items were selected from the list of essential drugs and supplies for MNCH (Annex 2), for assessing their availability at the surveyed facilities. The SHC hospitals are categorized into four groups, according to the percentage availability of the items in each group of supplies, Tracer drugs, vaccines and family planning commodities. The details are presented in Table 3.15 below. TABLE 3.15: STATUS OF DRUGS AND SUPPLIES IN SHC HOSPITALS Number of SHC hospitals having tracer items DHQH (N=21) THQH (N=77) Item groups >75% available 51 to 75% available 25 to 50% available <25% available >75% available 51 to 75% available 25 to 50% available <25% available Supplies Drugs Vaccines

35 Family planning commodities Status of support services The facilities for support services, including laboratory tests (space, test strips and human resources), blood transfusion services (space, supplies and human resources), ambulance services (a functional vehicle and driver), operating theatre (space, drugs and supplies, equipment items and human resources) were assessed, at the surveyed SHC hospitals. Based on the percentage availability of the inputs required for performing these services, SHC hospitals are categorized in four groups. The details are presented in the Tables 3.16 and TABLE 3.16: STATUS OF SUPPORT SERVICES IN SHC HOSPITALS Number of SHC hospitals having tracer items DHQH (N=21) THQH (N=77) Item groups >75% available 51 to 75% available 25 to 50% available <25% available >75% available 51 to 75% available 25 to 50% available <25% available Basic laboratory tests Blood transfusion Operation theatre TABLE 3.17: STATUS OF SUPPORT SERVICES IN SHC HOSPITALS Number of SHC hospitals having required items Item groups DHQH (N=21) THQH (N=77) Number Percentage Number Percentage Functional ambulance 20 5% 50 65% Ambulance driver 20 5% 66 86% Radiology services 7 33% 15 1% 25

36 SHC hospitals conformance to required inputs The assessment findings were analyzed to determine the conformance of SHC hospitals to the inputs required to deliver comprehensive EmONC services. The calculation is based on the Average availability of the number of inputs for each criterion, including infrastructure, human resources, equipment, drugs and supplies and support services. Based on this analysis, the conformance status of the DHQHs and THQHs to the required inputs is presented in Figure 3.6. FIGURE 3.6: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT SHC HOSPITALS Infrastructure HR Equipment Drugs & Supplies Support Services 80% 60% 40% 20% 60% 68% 62% 62% 70% 34% 1% 2% 46% 36% 0% DHQ Hospitals THQ Hospitals The following graph (Figures 3.7 & 3.8) presents the district-wise status of the average component availability of inputs at the DHQHs and THQHs. 26

37 FIGURE 3.3: DISTRICT-WISE STATUS OF CONFORMANCE OF DHQHS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Mardan Charsada Haripur Lucky Marwat DI Khan Noshera Buner Lower Dir Karak Swabi 14 Chitral Kohat Peshawar Upper Dir Bannu Abbottabad Battagram Mansehra Malakand Shangla

38 FIGURE 3.4: DISTRICT-WISE STATUS OF CONFORMANCE OF THQHS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Bannu Hangu 5 14 Charsada 6 Lucky Marwat Battagram Kohat Upper Dir 6 8 Chitral Buner Noshera 6 6 Tank Swat Mardan Shangla Lower Dir Haripur Karak Peshawar Swabi Mansehra Malakand DI Khan Abbottabad

39 Tehsil headquarter (THQ) hospitals The THQ hospitals were also assessed for their capacity to provide 24/7 basic EmONC services, on similar inputs as those used for the assessment of the RHCs. All of the 77 THQHs in Khyber Pakhtunkhwa, were assessed for the availability of the optimal level of inputs required in order to deliver 24/7 basic EmONC services. Status of infrastructure The infrastructure of the THQHs has been assessed for the availability of an OPD, indoor ward, LHV s room, labour room and clinical laboratory, as service provision areas and the residences for accommodation of required staff. Service provision areas have been assessed as a single room, having facilities like consultation, examination and hand washing etc. The findings for the availability and functional status of infrastructure components assessed at the THQHs, both in numbers and percentages are presented in Table Available infrastructure might be requiring repair or maintenance. The assessment of the infrastructure of the THQ and civil hospitals for the delivery of basic EmONC services, showed that 87% of the THQHs/CHs of Khyber Pakhtunkhwa had OPDs available. A female ward is not available at 53% of the THQHs/CHs. A total of 38 THQHs/CHs had a WMO s residence, but it was inhabitable at only 32% of the THQH/CHs. TABLE 3.18: STATUS OF ASSESSED INFRASTRUCTURE IN THQHS Infrastructure OPD Female ward Labour room Clinical lab LHV s room Residence - Doctor Residence - LHV Status of THQHs (N=77) Number Percentage Available 67 87% Functional 60 78% Available 36 47% Functional 25 32% Available 50 65% Functional 40 52% Available 63 82% Functional 53 6% Available 54 70% Functional 51 66% Available 38 4% Functional 25 32% Available 35 45% Functional 24 31% 2

40 Status of human resources PC-1 of the NMNCHP contains the category and number of staff required for the provision of basic EmONC services. The availability of human resources (both regular posted and provided by NMNCHP) at the THQHs, against the required numbers is presented in Table 3.1 below. Major gaps were found in the availability of WMOs and technical staff. As the required number of WMOs is available at only 16% of the THQHs/CHs. Lab technicians are not available at 25% of the THQHs/CHs. The required number of ambulance drivers is available at 86% of the THQHs/CHs. TABLE 3.1: STATUS OF MNCH RELATED STAFF IN THQHS Staff categories Status of THQHs having required staff (N=77) Number Percentage WMO 12 16% LHV 33 43% Lab technician 58 75% OT technician 28 36% Ambulance driver 66 86% Status of functional equipment The equipment items for various service components, for the provision of basic EmONC services at the THQHs, are listed in PC-1 of the NMNCHP. The THQHs are categorized in four groups, according to the percentage availability of the functional equipment items at each THQH. The details are presented below, in Table The assessment of functional equipment items at THQHs/CHs against the criteria of basic EmONC services, revealed that only 4 out of the 77 THQHs had more than 75% of the equipment items. 22 THQHs had even less than 25% of the equipment items TABLE 3.20: STATUS OF FUNCTIONAL EQUIPMENT IN THQHS Equipment Number of THQHs having functional equipment items (N=77) >75% available 51 to 75% available 25 to 50% available <25% available Basic EmONC

41 Status of drugs and supplies A list of essential drugs and supplies for MNCH services is contained in PC-1 of the NMNCHP. Tracer items were selected from the list (Annex 2) for assessing their availability at the surveyed facilities. The THQHs are categorized in four groups, according to the percentage availability of the items in each group of supplies, tracer drugs, vaccines and family planning commodities, as presented in Table An analysis of the available tracer items in the THQ and civil hospitals showed, that 15 of the 77 THQHs/CHs had more than 75% of the supplies. 45 THQHs/CHs had less than 50% of the required drugs available. More than 75% of the assessed vaccines were available at 70 of the THQHs/CHs. 36 THQHs/CHs had less than 25% of the family planning commodities. TABLE 3.21: STATUS OF DRUGS AND SUPPLIES IN THQHS Item groups Number of THQHs with available tracer items (N=77) >75% available 51 to 75% available 25 to 50% available <25% available Supplies Drugs Vaccines Family planning commodities Status of support services The facilities for support services including basic laboratory tests (space, test strips and human resources) and ambulance services (a functional vehicle and driver) were assessed at the THQHs. Based on the percentage availability of the inputs required for performing these services, the THQHs were categorized in four groups, as presented in Tables 3.22 and TABLE 3.22: STATUS OF SUPPORT SERVICES IN THQHS Support services Number of THQHs with available support services (N=77) >75% available 51 to 75% available 25 to 50% available <25% available Laboratory tests

42 TABLE 3.23: STATUS OF SUPPORT SERVICES IN THQHS Support services Number of THQHs with available support services (N=77) Available % Available Functional ambulance 50 65% Ambulance driver 66 86% THQs conformance with assessed inputs The assessment findings were analyzed to determine the conformance of the THQ hospitals, to the inputs required to deliver basic EmONC services. The calculation is based on the Average availability of the number of inputs for each criterion, including infrastructure, human resources, equipment, drugs and supplies and support services. Based on this analysis, the conformance status of the THQHs to required inputs is presented in Figure 3.. FIGURE 3.: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT THQHS 80% 60% 64% 51% 68% 40% 28% 20% 18% 0% Infrastructure HR Equipment Drugs and Supplies Support Services The following graph (Figure 3.) presents the district-wise status of average component availability of inputs at THQHs required to deliver basic EmONC services. 32

43 FIGURE 3.5: DISTRICT-WISE STATUS OF CONFORMANCE OF THQHS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Battagram Kohat Tank Charsada Hangu Lucky Marwat Bannu Upper Dir Chitral Mardan Buner Noshera Shangla Swat Haripur Karak Abbottabad Lower Dir 2 11 Peshawar DI Khan Malakand Swabi Mansehra

44 Management basics The findings related to management basics at the surveyed health facilities are as follows. Human resources The status of staff categories filled includes regular posting only, as reported by the respective facility on the day of the survey. The details are given in Table 3.24 below. TABLE 3.24 STATUS OF HR REPORTED BY SURVEYED HEALTH FACILITIES Number of posts filled at RHCs Staff DHQ hospitals (21) THQ/ civil hospitals (77) RHCs (0) BHUs (162) Sanctioned Filled Sanctioned Filled Sanctioned Filled Sanctioned Filled No. % No. % No. % No. % Gynaecologist Anaesthetist Paediatrician WMO* OT technician Blood bank technician Lab technician Anaesthesia technician Nurses LHV Ambulance drivers *MO/WMO for BHUs 34

45 Provision of staff by the NMNCHP The NMNCHP provides support in terms of human resources at targeted health facilities, including specialists, doctors and paramedics. The details of NMNCHP support regarding staff provision in the province, collected from the district health offices, during the survey are given in the Tables 4.25 and TABLE 3.25: NUMBER OF HEALTH FACILITIES HAVING STAFF PROVIDED BY NMCHP DHQHs THQHs RHCs TABLE 3.26: NUMBER OF MNCH STAFF PROVIDED BY NMCHP Staff cadre Number of staff provided DHQH THQHs RHCs Gynaecologist 2 2 Anaesthetist 0 0 Paediatrician / Neonatologist 2 0 WMO OT technician Blood bank technician 0 3 Lab technician Anaesthesia technician 0 0 Nurses LHVs Ambulance drivers Total MNCH staff training Part of the mandate of the programme is to build the capacity of,312 4 MNCH related staff through conducting skill development training, in the standards of service provision and counselling techniques. Information on the training of MNCH staff during last three years, 4 PC-1 NMNCHP Table 4 List of training and approximate unit cost, Page 31 35

46 collected from the district NMCHP cells during survey is presented in the Table 3.27 and TABLE 3.27: NUMBER OF STAFF TRAINED ON DELIVERING MNCH SERVICES MNCH staff Number of staff trained EmONC ENC IMNCI IMPAC FP surgical FP counselling Client centeredness Anaesthetists Gynaecologist LHV MO Nurse OT technician Paediatrician WMO Total TABLE 3.28: NUMBER OF HEALTH FACILITIES RECEIVED MNCH TRAINING MNCH staff Number of health facilities DHQHs THQHs RHCs BHUs EmONC ENC IMNCI IMPAC FP surgical FP counselling Client centeredness CMWs training and deployment Part of the mandate of the programme is to train and deploy community mid-wives for improving community based MNCH services, in all the districts of the province. In order to ensure the availability of a skilled birth attendant in every village of the province. The 36

47 distribution of the community mid-wives will be done by the provincial MNCH cell, before the recruitment process begins. The following table presents aggregate information related to training and deployment of the community mid-wives, collected during the survey from all of the district NMNCH cells. TABLE 3.2: STATUS OF CMWS TRAINING AND DEPLOYMENT IN KHYBER PAKHTUNKHWA Training and deployment of community mid-wives (NMNCHP) Number of selected CMWs verified for their residential status 447 Number of CMWs with completed training 665 Number of CMWs deployed by NMNCHP 52 Health facilities are assessed for the availability of job descriptions for the MNCH staff and the availability of service delivery protocols (11 nos.) for MNCH services. The findings related to these indicators are presented in Figure FIGURE 3.11: STATUS OF MANAGEMENT BASICS AT SURVEYED FACILITIES 70% 60% 50% 40% 30% 20% % 0% 58% 41% 32% 28% 23% 18% 14% 14% % 1% 1% DHQHs THQHs RHCs BHUs MNCH related JDs for staff available MNCH related service delivery protocols available MNCH related service delivery protocols displayed 18% Work coordination and supervision Health facilities in all of the districts were assessed for coordination and supervisory activities, including facility staff meetings, participation of facility in-charges in district level meetings, district managers conducting supervisory visits and providing feedback to the 37

48 facilities. The findings of these activities in surveyed health facility are presented in Figures 3.12 and 3.. FIGURE 3.12: WORK COORDINATION 0% 80% 60% 40% 20% 0% 78% 80% 76% 71% 73% 70% 67% 60% 38% 27% 25% % DHQHs THQHs RHCs BHUs Facility staff meeting Meeting record maintained Participation of HF incharges in district meeting FIGURE 3.: SUPERVISION 0% 0% 1% 88% 0% 80% Visited for supervision 60% 40% 52% 48% 56% 63% Feedback received (Visited HFs) 20% 0% DHQHs THQHs RHCs BHUs Management information system In Khyber Pakhtunkhwa, the districts are now adopting the district health information system (DHIS) for recording and reporting purposes. Surveyed facilities were assessed for the 38

49 availability and maintenance of MIS tools (14 nos.) and their findings are presented in Figure FIGURE 3.14: STATUS OF MIS 0% 1% 4% 80% 60% 40% 20% 80% 6% 62% 70% 5% 81% 75% 65% 72% 63% Tools available Tools maintained Monthly DHIS reporting 0% DHQHs THQHs RHCs BHUs Drugs and supplies The availability of drugs and supplies has been described under individual MNCH service packages. The reasons for being out of the stock of essential drugs and supplies were identified at the surveyed facilities. A break-down of the reasons is given in Figure

50 FIGURE 3.15: FACILITY SPECIFIC REASONS FOR STOCK OUT OF DRUGS AND SUPPLIES 60% 51% 40% 41% 35% 20% 7% % 3% 25% 21% 3% 0% Infection control The health facilities were assessed for practices of infection control and waste management, and the availability of related material. The findings of the surveyed facilities are presented in Table TABLE 3.30: STATUS OF INFECTION PREVENTION AT THE SURVEYED HEALTH FACILITIES Number of health facilities Infection prevention DHQHs (Total=21) THQHs (Total=77) RHCs (Total=0) BHUs (Total=162) Availability of material Waste management plans Waste collection materials Personal protection materials Waste treatment equipment 2 5 Functional incinerator Infection prevention practices Hand washing practices of care providers

51 Number of health facilities Infection prevention DHQHs (Total=21) THQHs (Total=77) RHCs (Total=0) BHUs (Total=162) Disinfection of service provision areas Vaccination of staff against Hepatitis B Practice of waste segregation Disposal through throwing away Disposal through municipal arrangements Death review Information about maternal and neonatal deaths occurring at the surveyed facilities was collected by using the SD&MB questionnaire. In Khyber Pakhtunkhwa, a total of 375 maternal deaths and 2,155 neonatal deaths were reported at the surveyed facilities. All of the surveyed facilities, excluding BHUs were assessed for the availability and functioning of death review committees. Maternal and neonatal deaths reviewed by the committee are presented in Table TABLE 3.31: STATUS OF MORTALITY REVIEWS AT SURVEYED HEALTH FACILITIES Mortality review DHQHs (Total=21) Number of health facilities THQHs (Total=77) RHCs (Total=0) Availability of death review committee Functional death review committees Facility utilization Monthly utilization of MNCH services was assessed month-wise for the period of July to December 20 and the average monthly utilization of services is presented in Table TABLE 3.32: UTILIZATION OF MNCH SERVICES AT SURVEYED HEALTH FACILITIES MNCH services Average monthly utilization of MNCH services DHQH THQH RHC BHU 1st Antenatal care visits (ANC-1)

52 Normal vaginal deliveries Assisted vaginal deliveries C-sections st Postnatal care visits (PNC-1) Pregnant women given TT2 vaccine Diarrhoea/dysentery cases treated (U5 years of age) Pneumonia cases treated (U5 years of age) Utilization of the family planning services was also assessed at the surveyed facilities and the average monthly utilization of these services is presented in Table TABLE 3.33: UTILIZATION OF FP SERVICES AT SURVEYED HEALTH FACILITIES Family planning services Average monthly utilization of family planning services DHQH THQH RHC BHU COC POP DPMA Net-en Condoms IUCDs Implants Vasectomy 3 0 KEY: COC=Combined Oral Contraceptive, POP=Progesterone-Only Pills, DPMA=Depot Medroxyprogesterone Acetate, Net-en=norethisterone enanthate, IUCDs=Intrauterine Contraceptive Devices. 42

53 Donor contributions Donor contributions (excluding direct budgetary support) during the last three years were assessed regarding human resources, infrastructure, equipment (including ambulances), drugs and supplies. The findings are presented in Table TABLE 3.34: STATUS OF DONOR CONTRIBUTIONS AT SURVEYED HEALTH FACILITIES Number of health facilities Donor contributions DHQHs (Total=21) THQHs (Total=77) RHCs (Total=0) BHUs (Total=162) Infrastructure Construction of new building 3 7 Renovation of existing building Equipment Provision of equipment Provision of vehicles/ ambulances Drugs and supplies Provision of medicines Provision of consumables Procurement estimates Equipment Based on the information collected, the procurement needs for the provision of required equipment, have been identified for the individually surveyed facilities, in order to strengthen MNCH services. A summary of estimated cost, for the procurement of required equipment is given below. A list of required equipment for each surveyed facility is presented in the annexes of each district report. A summary of the estimated cost for procurement of equipment is given in Table Civil works A yardstick has been used for assessing the scope of civil works, of the various MNCH related building components (Annex 2). A cost estimate based on the identified scope of work, required to complete the infrastructure needs of the individually surveyed facilities, is presented in the annexes of the district reports. A summary of the estimated cost for the execution of civil works, including repair and maintenance, renovation and new construction of missing facilities, is given in Table

54 TABLE 3.35: SUMMARY OF ESTIMATED COST FOR EQUIPMENT AND CIVIL WORKS Estimated cost (PKR in millions) Procurement DHQHs (Total=21) THQHs (Total=77) RHCs (Total=0) BHUs (Surveyed=162) Total Equipment , ,5.8 Civil works , ,

55 Section 4: Clients Perspective Clients perspective on the quality of health care service is too important to neglect. For clients and communities, quality care is something that meets their perceived needs. Since a client s needs often differ, their personal satisfaction ultimately depends on the perception, attitude and expectations of each individual. Client exit interviews (CEIs) were conducted within the scope of the health facility assesment survey to assess the clients perspectives on the services provided at RHCs, THQHs and DHQHs. In Khyber Pakhtunkhwa, a total of 1,045 clients were interviewed and a facility-wise breakup is presented in Table 5.1. Married women of child bearing age visiting the facility for MNCH related services (Gynae/Obs and child health services for under 5 years of age) and fathers accompanying their children under 5 years of age to the facility for child health services were targeted for client exit interviews. TABLE 4.1: NUMBER OF CEIS CONDUCTED IN KHYBER PAKHTUNKHWA Type of health facility Number of CEIs District headquarter hospitals 215 Tehsil headquarter hospitals 380 Rural health centres 450 Total 1,045 Key findings The findings of these interviews were analyzed for assessing the clients viewpoint on health care services availed at the surveyed facilities. The clients reasons for visiting the facilities are presented in Figure

56 FIGURE 4.1: REASONS FOR VISITING HEALTH FACILITY 3% General medical problem Child health care % 8% 2% Antenatal examination Postnatal checkup Family planning Others 31% 33% FIGURE 4.2: AVERAGE TIME TAKEN BY THE CLIENTS TO REACH THE FACILITY 70% 60% 50% 40% 30% 44% 38% 58% 32% 53% 37% Less than 30 minutes 30 minutes to 1 hour More than 1 hour 20% % 18% % % 0% DHQHs THQHs RHCs Waiting time for clients at the facility varied according to the level of the facilities. The facilitywise waiting time is presented in Figure

57 FIGURE 4.3: AVERAGE WAITING TIME AT THE FACILITY 60% 50% 40% 30% 20% % 47% 24% 17% 12% 31% 53% 52% % 6% 23% 16% % Less than minutes to 20 minutes 20 to 30 minutes More than 30 minutes 0% DHQHs THQHs RHCs Quality of care The important dimensions of the quality of care assessed, included the clinical examination and attitude of the health care provider; provision of prescribed medicines and laboratory tests; and the provision of health care education material. In order to assess the clients perceptions about the quality of care, they were asked about their satisfaction with the clinical examination, the attitude of the health care provider and other facility staff, and communication regarding illness, course of treatment and the followup. The findings are presented in Figure 4.4. Out of the interviewed clients, the majority is satisfied with their clinical examination and the attitude health of care providers. But very few had been explained to about their illness and course of treatment by the care providers. FIGURE 4.4: CLIENTS' LEVEL OF SATISFACTION WITH AVAILED SERVICES Communication 20% 65% 15% Attitude of other staff 18% 65% 17% Very Satisfied Attitude of HCP 22% 68% % Satisfied Not Satisfied Clinical examination 30% 61% % 0% 20% 40% 60% 80% 0% 47

58 Clients were asked if they had been prescribed any medicines and laboratory tests. Out of those who said yes, the number of clients receiving them is provided in Figure % of the interviewed clients, received all of the prescribed medicines from the facility and 50% of the clients received some of the prescribed medicines. Regarding the provision of laboratory services, 68% of the interviewed clients received all of the prescribed tests. Regarding health education material, only 3% of the interviewed clients received health education material from the facility. FIGURE 4.5: PROVISION OF MEDICINES, LAB SERVICES AND EDUCATION MATERIAL Lab services Received (complete) Received (partial) Not received 40% 43% 17% Medicines 1% 45% 35% 0% 20% 40% 60% 80% 0% Received Not received Education material 8% 2% 0% 20% 40% 60% 80% 0% Overall satisfaction Clients were asked about their overall satisfaction with the visit, and the results are shown in Figure 4.6. About 20% are very satisfied and 75% are satisfied with the provided services, whereas only 5% are not satisfied at all with the quality of services. 48

59 FIGURE 4.6: OVERALL SATISFACTION OF INTERVIEWED CLIENTS RHCs % 78% % Very satisfied THQHs 20% 71% % Satisfied DHQH s 22% 67% % Not satisfied 0% 20% 40% 60% 80% 0% 4

60 Section 5: Health Managers Perspective Rationale Whereas facility based assessments were conducted, to provide information on the availability and functioning of the health facilities, in order to deliver level-specific MNCH services. In-depth interviews (IDIs) were conducted with the health managers preferably the EDO health - to develop a better understanding of the management issues at the district level and to clarify some of the issues identified during the physical site visits. The in-depth interviews also provided opportunities to seek inputs and suggestions for improvement, within the current system. Districts located in geographical proximity to each other, are grouped into divisions in the public administration setup. One health manager was randomly selected from each division for the IDI. A total of 6 IDIs were conducted in Khyber Pakhtunkhwa, from February to April The names of these districts are provided in Table 6.1. TABLE 5.1: NAMES OF DISTRICTS IN KHYBER PAKHTUNKHWA CONTACTED FOR IDIS Names of districts 1. Buner 2. Charsada 3. Dera Ismail Khan 4. Kohat 5. Mansehra 6. Swat Key findings of the in-depth interviews The provision of MNCH services, form a part of the routine services provided by the district health system. The NMNCHP has additionally sanctioned the posts of public health specialist and social organizer, in each district for collaboration with the EDOH office, for the implementation of MNCH activities within the district. Most participants described this to be well-integrated, (with) a District Project Implementation Unit (DPIU) established at the district. However, two participants did report vacancies in the key position of public health specialist. Infrastructure Infrastructure includes the physical location of the health facility, along with access to and the condition of health facilities. No participant commented on the status of facilities and their location. Two participants highlighted the acute shortage of equipment and furniture in office 50

61 and health facilities preventing staff from providing quality services at the affected health facilities. Storage of medical supplies and equipment is described to be at rented facilities by one respondent, highlighting the need for the construction of a district store. Human resources The NMCHP has stationed LHVs, WMOs and gynaecologists at various facilities throughout the province. Despite this additional deployment of human resources, all of the participants reported continued shortages of skilled staff at health facilities, one said the staff position with respect to the NMCHP is pathetic at the moment. Shortages are reported for various cadres, from LHVs and mid-wives to WMOs and specialists, including anaesthetists....in facilities...out of 3 sanctioned posts of Gynaecologists, we don t have other than the a single one filled. Caesarean section operations are DHQH, out of 34 performed by the General Surgeon at the DHQ hospital sanctioned posts of MOs half are Staff shortages are attributed to a variety of factors, including lying vacant and delays in salary release owing to a financial crunch facing the not a single WMO program, political interference in proper placement of staff posted at present and the poor law and order situation preventing the occupation of residences in 50% of the BHUs. Program implementation is thought to be affected by the absence of key staff of the program, including the district program coordinator and social organizers. The provision of safe and functional work and living arrangements for WMOs and efforts to keep health department out of any political interference, are suggested to improve the deployment of human resources. Two participants underscored a need to address the structure of staff hiring; (there are) no separate posts of WMOs in the district, besides seeking an increase in sanctioned staff strength. There are no separate sanctioned posts for WMOs as they are inducted against the sanctioned posts of MOs... our policy (should be) to encourage the maximum number of WMOs to join public service against these posts Staff competency for the provision of MNCH services is thought to be sufficient, though most of the respondents felt that there is a need for continued training and skill development 51

62 among all of the staff cadres. Respondents credited the NMNCP, PAIMAN and implementing partners, e.g. Merlin for imparting training to staff...capacity building is an ongoing process; there is always a room for more learning. We therefore would welcome any more input in this regards. Procurement and logistical management Logistical management involves the processes of procurement, quality control, storage and distribution of drugs, supplies and equipment. Maintenance and repair of equipment and information systems used for procurement are also included. The approval of the rate contracts is a centralised function performed by the medical coordination cell in the provincial health department. This committee conducts product selection and rate negotiations following which, rate lists are issued. These are binding for all of the district-based purchase of supplies. district-based procurement committee headed by the EDOH, is tasked with the finalisation of the procurement plan based on patient load, facility need, stock-in-hand, safety stock and available budget. One participant reported procurement planning to be conducted by ad hoc committees, rather than a notified one. This demand list is forwarded to the DG Health for approval and subsequently to the accounts section, for placing the supply orders and budgetary release....arrangements are made on the ad hoc basis from time to time according to the need within the approved budgetary limits. There are no set written guidelines for logistic managements and an age old routine is followed Quality control of medicine supplies is the responsibility of the drug inspector. Samples of supplied medicines are collected and sent for quality testing to a drug testing lab (DTL); action is taken if drugs are found to be below standard. Only one respondent identified the need to focus on the quality of medicines, describing them to often be sub-standard. Storage of purchased medicines is initially done at the main store of the EDO office, from where it is distributed to individual health facilities. Only one respondent identified a need to construct a warehouse, as currently supplies are kept in a rented warehouse before disbursement. Only one respondent reported an acute shortage of vehicles... for the transfer of goods. Two participants reported running out of the stock of antibiotics and family planning supplies from their districts; this is explained to be resulting from limited supplies received through 52

63 the Population Welfare division. To prevent running out of stock or to meet emergency needs, EDOHs are entitled with powers for the local purchase of medicines; two participants described these funds to be insufficient. There is no established logistical management information system in place, with all of the participants indicating, that figures of stock outs and utilization data reported through the existing district health information system (DHIS), formed the basis of decision making for fresh demands from facilities. Most participants reported inventory maintenance through a variety of registers and random stock checks to ensure proper record maintenance. Maintenance and repair of equipment and buildings is performed following the submission of requests to the repair and maintenance cell. One participant described the process of inspection and inquiry into the requested repair to cause unnecessary procedural delays and suggested the establishment of the repair and maintenance call at the district level. Vehicular and infrastructure repairs are approved by the district accounts office, after the submission and approval of a PC-1 prepared by EDOH office. Only one participant highlighted the need to increase budgetary allocation for repair and maintenance. Shortage of ambulances and transport arrangements for staff was reported by one participant. MIS All respondents reported having adopted the newly introduced district health information system (DHIS). The consolidation of data from individual health facilities into a district report is not being done at four of the interviewed districts. Participants explained this to be because of unresolved issues in the DHIS software....district gets only 30-40% financing it...issues relating to the entry of data in the software due to requires to properly which consolidated reports are not being generated. Either implementing the these is an issue of software or capacity to handle the new system. With the software. result stationary is Only one participant reported timely submission of reports short in many from the affiliated facilities; others held low budgetary facilities, particularly allocation responsible for this gap. This is described to result in in hospitals poor stationery supplies and internet connections allowing remote submission of information. Delayed submission from the PPHI controlled BHUs and different reporting formats used by PPHI are also described by participants. 53

64 Monthly reports are either not consistently generated from these facilities or the information is sent through PPHI s own formats...which does not cover all the indicators used in DHIS All of the participants said that, despite limitations, the collected information is useful in decision making. To improve reporting and consolidation of data, participants recommended enhanced budgetary allocation for stationery and material and staff training. Planning The development of district health plans is described by the participants as an annual activity conducted by members of the district health department. Regarding the role of the district health management teams (DHMTs), one respondent described the formulation and working of the team under the aegis of the PAIMAN project. This team however discontinued its work once the project was over. Two other respondents identified the presence of notified teams actively involved in health planning and management of services through a collective effort. Only one respondent described the plan to follow the direction of the provincial department, which sets priorities, other participants did not comment on the vision guiding plan development. These district health plans are regular plans and there is no contingency planning for emergency situations, which tended to be need-based through (formulation of) ad hoc committees. The implementation of district plans is described to be determined through monthly progress meetings and monitoring/supervisory visits performed by the managerial staff. Budgetary limitations, shortage of trained human resources for the development of district plans, insecurity and political interference are thought to limit plan implementation. Suggestions to overcome these shortages included enhanced financial allocation to achieve planned targets, appointment of trained staff through merit Health is not and reactivation of DHMTs. a priority of political will is required at the policy making level to the reactivate DHMT and involving district health managers in Government the decision making processes of vital issues. decisions are made on Monitoring and supervision political will The EDOH, supported by the DOH are responsible for the monitoring and supervision of health facilities throughout the district; on average monitoring the facilities every 3-4 months. 54

65 Being the custodian of the district public health delivery system, the EDO is responsible for the overall monitoring of all health related activities Only three participants reported the availability of written job descriptions and TORs for the supervisors and managers; none mentioned if these job descriptions are made available to them at the time of appointment. Most participants expressed their satisfaction with the capacity of the current staff for conducting supervisory visits, training for the staff is conducted through the aegis of donor agencies. A comprehensive training on M & E is provided by PRIDE, a partner NGO in development. As a result of it, the existing staff has the understanding of supportive supervision and also applies it during supervisory visits. One participant highlighted the need for continuous training of the staff for conducting monitoring and supervision visits. The availability and utilization of standardised monitoring and supervision checklists is reported by only two participants; one of these reported having received recent training on monitoring and supervision thorough donor agencies. There were three participants who reported having received training and supervisory checklists through donor agencies, which had gradually fallen into disuse. We have been using a check list during the supervisory visits but not anymore for the past couple of months Those trainings are very useful but the capacity needs to be re-enforced. Such trainings should be an ongoing process to consolidate the learning processes and achieve desired results Several mechanisms of feedback are employed by the managers; these included mostly verbal on-the-spot feedback and monthly review meetings with the facility in-charges. Inter-sectoral collaboration Conducted under the aegis of the district coordination officer (DCO), collaboration between different departments is described to exist through a variety of mechanisms, including district population and health management committees (DPHMC). Described as a good forum to interact with the line departments to discuss bilateral issues, only one respondent reported the lack of an existing mechanism promoting intersectoral collaboration. Two respondents reported active collaboration with line departments and the community for successful 55

66 implementation of polio eradication campaigns. One participant highlighted the need to enhance public trust in the MNCH program... to increase coverage and utility of services. Suggestions to improve community awareness and involvement included the adoption of incentive-based strategies including nutritional support and free medical supplies of (enrolled) mother and child. There is however, no mechanism described for involving the private sector. As these projects Financial management do provide Financial management includes the development and submission substantial of rationalised budgets and efficient management of the allocated assistance to us in funds. the delivery of The development of budgetary demands for the district is an health services and annual activity conducted by the EDOH office, with the district meet emergency government determining the final non-developmental allocation for requirements, we the health department. Headed by the DCO, these pre-budget whole heartedly meetings in the district health and population management team cooperate with (DHMPT) are attended by planning, finance and administration them in the best EDOs. The developmental budget for districts is determined at the interest of the provincial level; this is described to be according to its own public assessment of the situation and usually districts are not consulted. We however keep the provincial department informed about our needs so as to facilitate decision making. Only one respondent reported that the submission of health plans is done when DHMT is functional but not now. Commenting on the rationale for budgetary allocation, two participants described recommendations for budgetary allocation (are made) on the basis of our annual health plan, however, one participant described in usual practice, some pre-determined increment (keeping in view of inflation) is added to the amount released the previous year and district health authorities The total are seldom consulted. district health budget at Actual budgetary allocations are thought to be insufficient by all of present is the participants,...they have their own priorities according to which calculated to be they approve a certain amount, which is sufficient only for 25-30% of about 20 paisa our specified budgetary needs per patient 56

67 One participant thought availability of finances to be favourable prior to devalution, before devalution, district health budget was significantly more than at present. Allocation for the health budget has steeply come down to only 2 lakhs (Rs 20,000) in 2011 from one crore previously (Rs 00,000). To overcome budgetary gaps, requests have to be submitted to district administration, though these are rarely approved, unless they are for medical supplies. One participant recommended the allowance of revenue generation by the health department for improving the availability of finances. Donor contributions All of the respondents reported contribution from international donor agencies and collaborating partners within their districts. The gencies included UNFPA, WHO, UNICEF, USAID (through the PAIMAN project), Save the Children, Merlin and International Medical Corps (IMC). As the government has limited resources, we rely heavily on the support of NGOs aided by international donor agencies in times of crises Support provided included, the development of infrastructure and civil works, provision of supplies and equipment, capacity building of staff, provision of staff salaries and management focused though training, including the formation of DHMTs and provision of monitoring and supervisory checklists. None of the participants reported receiving direct financial contributions from any donor agency. Collaboration with donors is initiated and planned at the federal and provincial levels. Once a policy decision is taken, coordination with the identified districts is then begun; The district health department is usually not consulted in the designing and planning of any project. We are brought into the picture just before the implementation phase. One respondent reported a gap in appraising the donors about the local needs of the district seldom has any donor asked us to provide the demand list. Even if it is shared it is not given due importance. Coordination with implementing partners is done at the district level, the regularity of which depended on local need Like other 3rd world countries, health and education feature less on the priority list of either the national or provincial governments. Due to political pressures, more money is diverted to the civil works department than to the social sector 57

68 in times of crisis, such as floods, we have been holding cluster meetings as frequently as every other day. As the acute phase subsided,the frequency of meetings gradually diminished 58

69 Section 6: Key Findings This section contains the key findings and recommendations based on the results of the health facility assessment This is the first nationwide facility survey to be completed. It is important to note that the health facility assessment is only one tool of the national monitoring and evaluation system, usually conducted every 3 to 4 years, to supplement the routine reporting systems not to replace it. However, since this is the first health facility assessment, and the routine M&E systems are still being implemented, some additional instruments were applied, so that baselines could be identified for the NMNCH programme as appropriate. Based on these findings and the in-depth interviews (IDIs) summarised in Section 6, recommendations have been made for the areas where access to quality of care can be improved to the community. These findings and recommendations are intended to be used by the provincial and district health managers in their planning processes. In Khyber Pakhtunkhwa, a total of 822 health facilities including 21 DHQHs, 77 THQHs and CHs, 0 RHCs and 162 BHUs were assessed under the health facility assessment. The findings of the health facility assessment are as follows. Infrastructure Functioning infrastructure at a health facility is essential for the delivery of its level-specific package of MNCH services. Within the ambit of the health facility assessment, infrastructure is assessed for the availability and functional status of MNCH-related building components of each facility. In order to deliver preventive MNCH services, three infrastructure components are required to be in place at each BHU, including an OPD, labour room and a residence the for LHV. Although BHUs are supposed to provide services 8 hours a day and 6 days a week, but the residence for the LHV is included in the scope of the HFA, keeping in view the location of BHUs and travel arrangements in the rural areas of Khyber Pakhtunkhwa. On average, 63% of the infrastructure components are available at the BHUs and major gaps existed in the availability of labour rooms, which are not available in 0% of the BHUs. Also a LHV s residence which is available at 8 out of 162 BHUs, but is inhabitable at only 66 of the BHUs. In order to deliver basic EmONC services at the RHC, the required infrastructure components included an OPD, female ward, labour room, clinical lab, LHV s room and 5

70 residences for the WMO and LHV for delivery of services 24 hours a day and 7 days a week. On average, 72% of these infrastructure components were available at the RHCs. When THQHs and CHs are assessed on this criterion, to assess their readiness to deliver basic EmONC services, on average, only 76% of the required infrastructure is available at each THQ hospital. Besides the missing facilities in available components, an independent OBGYN ward is available at 77% of the RHCs, and 47% of the THQHs and CHs. Residences for the WMO are available at 53 of the RHCs and 38 of the THQHs and CHs, but are inhabitable at only 34 of the RHCs and 24 THQHs and CHs. In order to deliver comprehensive EmONC services at the secondary health care hospitals including the DHQH, THQH and civil hospitals, the required infrastructure components included an OPD, female ward, labour room, operation theatre, paediatric ward, paediatric nursery, blood bank, clinical laboratory and residences for MNCH related staff, for delivery of services 24 hours a day, 7 days a week. The average availability of infrastructure components is 5% at DHQHs and 30% at THQHs and CHs. Major gaps were noticed regarding the availability of a paediatric ward, which is not available at 6 DHQHs and 62 THQHs. A paediatric nursery is not available at DHQHs and 70 THQHs. A blood bank was not available at 5 DHQHs and 66 THQHs. Residences for the gynaecologist (not available at 8 DHQHs and 70 THQHs), anaesthetist (not available at 1 DHQHs and 76 THQHs) and paediatrician (not available at 11 DHQHs and 66 THQHs) were not readily available either. Human resources The availability of required staff is not a problem at the level of BHUs. A doctor or LHV is available at 144 out of 162 of the BHUs. For basic and comprehensive EmONC services, which should be available for 24 hours a day and seven days a week, (since demand for EmONC services cannot be predicted), the key issue faced by the surveyed health facilities is the lack of MNCH-related staff. The minimum requirement of staff as proposed by the national MNCH programme, is not met at the majority of the health facilities. 5 RHCs in Khyber Pakhtunkhwa were not provided with a WMO. At the DHQH and THQ hospitals, the availability of specialists including a gynaecologist (not available at 4 DHQH and 74 THQHs), anaesthetist (not available at DHQHs and 76 THQHs) and paediatrician (not available at 4 DHQHs and 67 THQHs) is far less than the minimum requirement. Training of staff Capacity building training and continuing medical education are critical for the service providers, in order to deliver quality MNCH services. Little commitment to clinical training 60

71 and professional development is evident in the public sector, unless specifically funded by external donors. The lack of trained staff is a barrier to the provision of reproductive health and family planning services. Out of the RHCs, THQ and DHQ hospitals, 80% are not performing an assisted vaginal delivery, due in part to the lack of training. In this regard, the NMCHP has been doing its part and have trained a total of 685 MNCH related staff, through skill development in standards of service provision, counselling techniques and client centredness. However, the majority of the facilities are lacking trained staff, as staff at 85% of the facilities had not received any MNCH related training. Health facilities are also reported to be performing a signal function in absence of formally trained staff, e.g. DHQ and THQ hospitals are performing caesarean section in the absence of a qualified gynaecologist or anaesthetist. In order to increase the skilled birth attendance in the rural communities, the NMCHP has also trained a community-based cadre of community mid-wives. A total of 665 community mid-wives were trained and at the time of the survey, a total of 52 community mid-wives had been deployed in the community. Drugs, supplies and equipment The lack of medicines, supplies and functional equipment is a frequent barrier for the surveyed health facilities in delivering MNCH services. At the time of assessment, none of the health facilities in Khyber Pakhtunkhwa was provided with the complete range of these items, required to perform signal functions. Items required for the operation theatre and blood bank are not fully available at any of the DHQ and THQ hospitals. Despite lacking equipment, drugs and supplies for caesarean section or blood transfusion, the majority of the health facilities reported having performed such procedures, prior to the assessment. Large quantities of non-functional equipment was also identified, during the assessment of the health facilities, which could not be repaired due to the lack of such arrangements at the district level, as well as the budgetary constraints. Facility in-charges reported that their demands are not fully met by the district health department and distribution is also delayed resulting in frequent running out of the stock of essential drugs, supplies, vaccines and family planning commodities. A discrepancy has been noted in policy and practice as some new drugs and equipment had been proposed by the NMCHP, but failure to procure these drugs and equipments had prevented their use. For example, a vacuum extractor is included in the standard list of equipment for RHCs and SHC hospitals, yet most these health facilities did not have this equipment. 61

72 Work coordination and supervision Monitoring performance allows facility staff to better understand their deficiencies for the initiation of improvements. Regularity of monthly performance review meetings is utilized to assess the intra-facility work coordination. Although the majority of the health facilities are conducting such meetings but their record is hardly being maintained at these facilities. Facility in-charges also reported regular participation in the district level performance review meetings. As for supervisory activities of the district health managers, although health facilities had continuously been visited but the sending of feedback from these supervisory visits to the facility is not a common practice. Service delivery protocols Service delivery protocols are a tool used for the continuous medical education of the MNCH related staff. Service delivery protocols were not available at the majority of the surveyed health facilities. Where they were available, they were not displayed at the proper place. Management information system The districts were in the process of adopting the district health information system (DHIS) at the time of survey. Most of the recording and reporting tools were available and being maintained at the surveyed facilities. However, gaps existed at THQHs and CHs where only 70% of the tools were available. The recording of obstetric complications or the treatment provided in response is deficient at the health facilities, with the exception of caesarean sections. It can be attributed to lack of training of staff responsible for maintaining these tools. There are deficiencies in the MIS tools which restrict the recording of certain key MNCH indicators. For example, the obstetric register contained no space for recording 2 nd, 3 rd or 4 th antenatal visits and these were cumulatively reported as ante natal care revisits. Similarly, there was no separate record for cases of pneumonia under 5 years of age, treated at the health facilities and these were recorded along with the acute respiratory infections. Infection control Infection control practices were found to be inadequate in the service provision areas of all surveyed health facilities. Although the availability of waste management plans was reported by the majority of the assessed health facilities, infection control practices were found to be inadequate in the service provision areas of all of them. Gaps in infection control practices 62

73 occured mainly due to the lack of materials and equipment required for waste collection, personal protection and waste treatment. Only 52 assessed health facilities had a functional incinerator and the majority of the facilities were not segregating infectious waste from other waste. Waste collection material is available at only 21 health facilities. Death reviews The national and provincial health policy endorses the constitution of death review committees for reviewing maternal and neonatal deaths occurring at the health facilities. Such detailed case reviews are essential for better understanding the deficiencies in service delivery and the reasons why, so that the health facilities can initiate improvements. In the surveyed health facilities of Khyber Pakhtunkhwa, neither maternal deaths nor the causes thereof were clearly or consistently documented. Therefore, death review committees which are available at only the surveyed Gaps related to the inputs Deficient human resource and lack of trainings Deficiencies in infrastructure Irregular supply of drugs and consumables Deficient functional equipment Gaps related to the management basics Non-availability of JDs for staff and service delivery protocols Lack of performance review at facility level Lack of supportive supervision Deficiency of MIS tools Poor infection control and hospital iste management Lack of death review committees Lack of donor contribution record health facilities of Khyber Pakhtunkhwa, are functional at only 1 THQ hospital and 1 RHC. Donor contributions Information about donor contributions was collected from both the surveyed facilities and district health departments. A total of 12 health facilities reported having received donor contributions. The monetary value of the support provided by the donor agencies is not available at any of the health departments. 63

74 Annexes 64

75 ANNEX 1 Objectives of the NMNCH programme The national MNCH programme (NMNCHP) was initiated in 2006, with its goal to improve maternal, newborn and child health of the population, particularly among Pakistan s poor, marginalized and disadvantaged communities. This is a comprehensive programme aiming at strengthening, upgrading and integrating ongoing interventions, as well as introducing new strategies. The programme s objectives are to: Strengthen the district health systems, through improvement in technical and managerial capacity at all levels and upgrading institutions and facilities. Streamline and strengthen services for the provision of basic and comprehensive emergency obstetric and newborn care (EmONC). Integrate all services related to MNCH at the district level. Introduce a cadre of community-based skilled birth attendants. Increase demand for health services through targeted, socially acceptable communication strategies. The programme aims to ensure level specific MNCH services at the public health facilities. These are composed of 24/7 comprehensive EmONC services in all of the DHQHs and THQHs; 24/7 basic EmONC services in all of the RHCs; and preventive MNCH services at all of the BHUs. In order to strengthen the public sector health facilities, the programme has taken a number of measures in the provinces, including construction and renovation of infrastructure in the health facilities; provision of key MNCH staff including specialists, doctors, paramedics and ambulance drivers; their capacity building; provision of equipment, drugs and supplies at selected health facilities, to ensure delivery of MNCH services. At national level, a federal MNCH project implementation unit has been established which is led by the national programme manager. The role of the federal MNCH project implementation unit is to facilitate and monitor the programme, by providing assistance to provinces and districts in the implementation of the programme s activities. A provincial NMNCHP project implementation unit (PIU) in Khyber Pakhtunkhwa is set up in Peshawar in July 2007 and became fully functional by August 2008, which is headed by the provincial coordinator NMCHP 5. The space, equipment and vehicles available in the current setup of PIU are enough for its functioning. Presently there is no staff shortage at PIU. All of 5 Information acquired from Provincial Coordinator - NMNCHP (Khyber Pakhtunkhwa) using Provincial Level Questionnaire

76 the sanctioned positions are filled by personnel having adequate qualifications and experience. PIU is well connected to the programme at the national level, as well as to its implementing units at the district level. The most common mode of communication between various units is either telephonic or electronic (through s), followed by formal written correspondence. PIU developed a plan but its implementation is lagging due to the paucity of financial resources. The provincial MNCH PIU is responsible for the planning and efficient execution of the program activities. A public health specialist is positioned at PIU as the Director M & E, who supervises M & E activities in the province, through the NMCHP district team of social organizers, headed by district coordinators. In the districts where districts coordinators are not positioned, EDOH themselves provide this support. PIU has developed a one page proforma through which information is collected from each district, on a monthly basis and the reports are compiled in the provincial office. A consolidated report is then generated at the PIU and shared with the national program. PIU conducts performance review meetings of each district at least once every quarter. The programme has developed links with donor agencies, vertical programs and governmental departments for functional integration, in order to make the best use of available resources. Collaboration with donor agencies like UNICEF, UNFPA and WHO has been established for conducting MNCH related training, organizing review meetings and the provision of staff. The national programme for family planning and primary health care (also known as the LHW programme) has a synergistic effect on the activities of the NMNCHP. Some of the major responsibilities of LHWs related to MNCH services include, the registration of pregnant women; reporting of skilled birth attendance, maternal and neonatal deaths, and modern famiy planning methods users in the community. The community mid-wives deployed in the community, are supported by the LHWs network for developing their community linkages and the community mid-wives are attending their monthly progress review meetings. The collaboration of the NMNCHP with the EPI programme has included the support of community mid-wives for reinforcing the messages for vaccination and in the provision of TT vaccination to pregnant women. The programme has developed links with the nutrition programme, regarding the management of severe malnutrition, provision of micronutrient supplements and training of staff on nutritional services. Connections were also developed 66

77 with disease specific programs, to ensure that the MNCH strategy is part of the implementation strategies of these programs like the national AIDS control programme, national tuberculosis control programme, national malaria control programme, etc. The programme is collaborating with the Ministry of population welfare, in implementing the family planning strategy in the province. It is of particular importance in meeting the logistic and training needs of the health facilities to deliver comprehensive family planning services. 67

78 ANNEX 2 Input criteria for MNCH services A. Civil works criteria CIVIL WORKS SCOPE FOR BHUS OPTIMAL ITEMS Ob/Gyn OPD or LHV s room Consultation area Labour room Delivery room WMO or LHV s residence Available Good condition MINIMAL ITEMS LHV s room Available Examination area Hand washing facilities Scrub area Functional attached washroom for patients OPTIMAL ITEMS Ob/Gyn OPD Consultation area Ob/Gyn ward Patient area Labour room Delivery room Clinical laboratory Laboratory room LHV s room Consultation area Residence - WMO Residence - LHV MINIMAL ITEMS Ob/Gyn OPD Ob/Gyn ward Labour room LHV s room CIVIL WORKS SCOPE FOR RHCS Examination area Hand washing facilities Functional attached washroom Scrub area Functional attached washroom for patients Working area Functional attached washroom Examination area Hand washing facilities Available Good condition Available Good condition Available Available Available Available 68

79 Residence - WMO Residence - LHV Available Good condition Available Good condition OPTIMAL ITEMS Ob/Gyn OPD Consultation area Ob/Gyn ward Patient area Nursing station CIVIL WORKS SCOPE FOR DHQH & THQH Examination area Privacy of examination area Hand washing facilities Store for general items/drugs Functional attached washroom Labour room Delivery room Preparation/ stage room Scrub area Staff duty room Operation theatre Patient preparation room Operating room Recovery room Scrub area Paediatric ward Patient area Nursing station Paediatric nursery Patient area Nursing station Clinical laboratory Laboratory room Working area Blood bank Blood collection room Working area LHV s room Consultation area Examination area Ultrasound room Residence - Gynaecologist Store for general items/drugs Store for equipment Functional attached washroom for patients Functional attached washroom for staff Sterilization area Doctor s room Support staff duty room Store for general items/drugs & equipment Store of equipment Functional attached washroom for staff Store for general items/drugs & equipment Functional attached washroom Store for general items/drugs & equipment Changing room Doctor s duty room Store for chemical / reagents or equipment Functional attached washroom Staff duty room Store for equipment / reagents Functional attached washroom Privacy of examination area Hand washing facilities Examination area Available Good condition 6

80 Residence - Anaesthetist Residence - Paediatrician Residence - WMO Residence - LHV Residence - Nurse Residence - Lab technician Residence - Blood bank technician Residence - Anaesthesia technician MINIMAL ITEMS Ob/Gyn OPD Ob/Gyn ward Labour room Operation theatre Paediatric ward Clinical laboratory Residence - Gynaecologist Residence - Anaesthetist Residence - Paediatrician Residence - WMO Residence - Lab technician Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Available Available Available Available Available Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition B. Human resources criteria HUMAN RESOURCES FOR PREVENTIVE EmONC OPTIMAL HR FOR BHUS HUMAN RESOURCES FOR 24/7 BASIC EmONC OPTIMAL HR FOR RHCS Category Number Category Number MO, or 1 WMOs 2 LHV 1 OT technician Lab technician 1 70

81 - - LHVs Ambulance driver 1 MINIMAL HR FOR BHU MINIMAL HR FOR RHC MO, or 1 WMO 1 LHV 1 Lab technician LHV 1 HUMAN RESOURCES FOR 24/7 COMPREHENSIVE EmONC OPTIMAL HR FOR DHQH OPTIMAL HR FOR THQH Category Number Category Number Gynaecologist 2 Gynaecologist 1 Anaesthetist 2 Anaesthetist 1 Paediatrician 2 Paediatrician 1 WMOs 6 WMOs 4 OT technician 4 OT technician 4 Blood bank technician 4 Blood bank technician 4 Lab technician 3 Lab technician 2 Anaesthesia technician 4 Anaesthesia technician 4 Nurses 20 Nurses 12 LHVs 4 LHVs 4 Ambulance drivers 4 Ambulance drivers 4 MINIMAL HR FOR DHQH MINIMAL HR FOR THQH Gynaecologist 1 Gynaecologist 1 Anaesthetist 1 Anaesthetist 1 Paediatrician 1 Paediatrician 1 WMOs 4 WMOs 2 OT technician 1 OT technician 1 Lab technician 1 Lab technician 1 Nurses 6 Nurses 4 LHVs 1 LHVs 1 C. Equipment criteria OPTIMAL ITEMS General hospital equipment Electric water cooler OPD / WMO s office Office / Plain chairs Examination couch Office tables with drawers Steel almirah (Large) Patient s stool Weighing machine (Adult) EQUIPMENT FOR BHUS Water filter Incinerator Weighing machine (Infant) Height measuring board Height measuring device B.P Apparatus mercury-desk type Foetal stethoscope Steam inhaler Nebulizer Examination lamp 71

82 Lady health visitor s room Weight scale (Adult) Weight scale (Infant) Height measuring device Height measuring board Disposable syringe cutter D & C instruments set P.V. examination light Examination couch Office chairs Office tables with drawers Patient s stool Steel almirah (Large) MINIMAL ITEMS Office chairs Office tables with drawers B.P Apparatus mercury-desk type Foetal stethoscope Weight scale (Adult) Weight scale (Infant) Height measuring device Height measuring board D & C instruments set Examination couch OPTIMAL ITEMS General hospital Ambulance Electric water cooler Female ward items Fowler bed (Iron) Attendant's bench Bed side locker Overhead food trolley OPD / WMO s office Office chairs Plain chairs Examination couch Office tables with drawers Steel almirah (Large) Patient s stool Weighing machine (Adult) EQUIPMENT FOR RHCS Water filter Incinerator Dust bin (Stainless steel) Screen folding (Complete) Baby cot B.P Apparatus mercury-desk type Stethoscope Weighing machine (Infant) Height measuring board Height measuring device B.P Apparatus mercury-desk type Foetal stethoscope Steam inhaler Nebulizer Examination lamp Labour room UPS power supply system (2000W) Suction machine (Electric) Infant weighing machine Foetal stethoscope Electric instrument sterilizer (12 x6 ) Jar for forceps Spring type dressing forceps (S.s) Sim s speculum (Right angle, small) Sim s speculum (Right angle, medium) Sim s speculum (Right angle, large) Sponge forceps Artery forceps (Long, straight) Uterine sound Vulsellum forceps Scissors (Dissecting, blunt pointed) Artery forceps Blunt-ended scissors D & C instruments set Infant ambo bag 72

83 Lady health visitor s room Weight scale (Adult) Weight scale (Infant) Height measuring device Height measuring board P.V. examination light MINIMAL ITEMS Female ward items Fowler bed (Iron) OPD / WMO s office Office chairs Examination couch Labour room Electric instrument sterilizer (12 x6 ) Sim s speculum (Right angle, medium) Sponge forceps Uterine sound Lady health visitor s room Office chairs Office tables with drawers Weight scale (Adult) Examination couch Office chairs Office tables with drawers Patient s stool Steel almirah (Large) B.P Apparatus mercury-desk type Stethoscope Office tables with drawers B.P Apparatus mercury-desk type Foetal stethoscope Vulsellum forceps Scissors (Dissecting, blunt pointed) Artery forceps D & C instruments set Weight scale (Infant) Height measuring device Height measuring board Examination couch OPTIMAL ITEMS General hospital Ambulance Defibrillator EQUIPMENT FOR DHQ HOSPITAL Desktop computer with monitor and accessories Electric water cooler Gynae/Obs. ward items Cabinet instrument (Large) Fowler bed (Iron) Attendant's bench Bed side locker Screen folding (Complete) Weighing machine (Adult) Artery forceps (7 inch) B P Apparatus mercury Desk type Dissecting forceps (Plain, 7 inch) OPD / Gynaecologist s office Weighing machine (Adult) Infant weighing machine Screen folding (Complete) Ultrasound machine Examination lamp Scissors (Curved, 5 inch) Scissors (Sharp, 5 inch, straight) Chital forceps Kidney tray (S.s, inch) Jar for forceps Infusion / drip stands Foetal monitor (foetal doppler-desk type) Infant B.P apparatus Infant weighing machine Baby cot Stethoscope (Adult size) B.P apparatus-desktop type Office chair Office table with drawers Patient s stool Patient waiting bench Examination couch 73

84 Paediatric nursery Air ways 2 size Infant ambo bag Infant laryngoscope set Suction apparatus: electrically operated Infant incubators Paediatric ward Suction machine Infant B.P apparatus (Cuff 2.5 cm) Stethoscope( Paediatric Littman type) Nebulizer Oxygen cylinder complete with trolley Phototherapy unit Baby warmer Infant B.P apparatus (Cuff 2.5 cm) Room thermometer Baby cot Steam inhaler Oxygen cylinder complete with trolley Infusion / drip stands Emergency medicine trolley Patient's attendant bench Fowler bed (Iron) Bed side locker (S.s top) Screen folding (Complete) Labour room Foetal stethoscope Electric instrument sterilizer (12 x6 ) Jar for forceps Spring type dressing forceps (S.s) Sim s speculum (Right angle, small) Sim s speculum (Right angle, medium) Sim s speculum (Right angle, large) Sponge forceps Artery forceps (Long, straight) Uterine sound Vulsellum forceps Scissors (Dissecting, blunt pointed) Operation theatre Needle holder Stitch scissors Dissecting forceps (Toothed) Sim s speculum (Large) Sim s speculum (Medium) Vacuum extractor Obstetric forceps Rectangular instrument tray & lids Towel clips Sponge forceps (22.5 cm) Straight (Artery forceps, 16 cm) Uterine homeostasis forceps (20 cm) Hysterectomy forceps (Straight, 22.5 cm) Mosquito forceps (12.5 cm) Tissue forceps (1 cm) Needle holder (Straight, 17.5 cm) Artery forceps Blunt-ended scissors Episiotomy instruments set (Complete) D&C instruments set (Complete) Delivery forceps set Infant ambo bag Portable light & rechargeable batteries Sterilizing drum Vacuum extractor Delivery table Infusion / drip stands Oxygen cylinder complete with trolley Surgical knife handle # 3 Surgical knife handle # 4 Abdominal retractors, double-ended (Richardson) Curved operating scissors, blunt pointed (Mayo), 17 cm Straight operating scissors, blunt pointed (Mayo), 17 cm Aesthetic face masks (3 sizes) Anaesthesia machine Laryngoscopes X-Ray illuminator Gynae instrument set General instrument set Adult ambo bag and mask D & C instruments set Myomectomy screw Air conditioners 74

85 Laboratory Spin machine Chemistry analyzer MINIMAL ITEMS Gynae/Obs. ward items OPD / Gynaecologist s office Weighing machine (Adult) Examination lamp Stethoscope (Adult size) Paediatric nursery Air ways 2 size Infant ambo bag Infant laryngoscope set Paediatric ward Stethoscope( Paediatric Littman type) Nebulizer Labour room Foetal stethoscope Electric instrument sterilizer (12 x6 ) Spring type dressing forceps (S.s) Sim s speculum (Right angle, medium) Sponge forceps Operation theatre Anaesthesia machine Laryngoscopes Counter (Hand tally differential) Steel almirah (Large) Lab cabinet Fowler bed (Iron) B.P apparatus-desktop type Office chair Office table with drawers Examination couch Suction apparatus: electrically operated Infant incubators Phototherapy unit Oxygen cylinder complete with trolley Fowler bed (Iron) Uterine sound Vulsellum forceps Episiotomy instruments set (Complete) D&C instruments set (Complete) Delivery forceps set Delivery table Gynae Instrument set D & C instruments set EQUIPMENT FOR THQ HOSPITAL OPTIMAL ITEMS General hospital Ambulance Defibrillator Gynae/Obs. ward items Cabinet instrument (Large) Fowler bed (Iron) Attendant's bench Bed side locker Screen folding (Complete) Weighing machine (Adult) Artery forceps (7 inch) B P Apparatus mercury Desk type Dissecting forceps (Plain, 7 inch) Desktop computer with monitor and accessories Electric water cooler Scissors (Curved, 5 inch) Scissors (Sharp, 5 inch, straight) Chital forceps Kidney tray (S.s, inch) Jar for forceps Infusion / drip stands Foetal monitor (foetal doppler-desk type) Infant B.P apparatus Infant weighing machine Baby cot 75

86 EQUIPMENT FOR THQ HOSPITAL OPTIMAL ITEMS OPD / Gynaecologist s office Weighing machine (Adult) Infant weighing machine Paediatric nursery Air ways 2 size Infant ambo bag Infant laryngoscope set Suction apparatus:electrically operated Infant incubators Paediatric ward Suction machine Infant B.P apparatus (Cuff 2.5 cm) Stethoscope( Paediatric Littman type) Nebulizer Oxygen cylinder complete with trolley Labour room Foetal stethoscope Electric instrument sterilizer (12 x6 ) Jar for forceps Spring type dressing forceps (S.s) Sim s speculum (Right angle, small) Sim s speculum (Right angle, medium) Sim s speculum (Right angle, large) Sponge forceps Artery forceps (Long, straight) Screen folding (Complete) Ultrasound machine Examination lamp Phototherapy unit Baby warmer Infant B.P apparatus (Cuff 2.5 cm) Room thermometer Baby cot Steam inhaler Oxygen cylinder complete with trolley Infusion / drip stands Emergency medicine trolley Patient's attendant bench Fowler bed (Iron) Bed side locker (S.s top) Screen folding (Complete) Uterine sound Vulsellum forceps Scissors (Dissecting, blunt pointed) Artery forceps Blunt-ended scissors Episiotomy instruments set (Complete) Infant ambo bag Portable light & rechargeable batteries Sterilizing drum Vacuum extractor 76

87 EQUIPMENT FOR THQ HOSPITAL OPTIMAL ITEMS Operation theatre Needle holder Stitch scissors Dissecting forceps (Toothed) Sim s speculum (Large) Sim s speculum (Medium) Vacuum extractor Obstetric forceps Rectangular instrument tray & lids Towel clips Sponge forceps (22.5 cm) Straight (Artery forceps, 16 cm) Uterine homeostasis forceps (20 cm) Hysterectomy forceps (Straight, 22.5 cm) Mosquito forceps (12.5 cm) Tissue forceps (1 cm) Needle holder (Straight, 17.5 cm) Laboratory Spin machine Chemistry analyzer MINIMAL ITEMS Gynae/Obs. ward items OPD / Gynaecologist s office Weighing machine (Adult) Paediatric nursery Air ways 2 size Infant ambo bag Infant laryngoscope set Paediatric ward Stethoscope( Paediatric Littman type) Nebulizer Labour room Foetal stethoscope Spring type dressing forceps (S.s) Sim s speculum (Right angle, medium) Operation theatre Anaesthesia machine Laryngoscopes Surgical knife handle # 3 Surgical knife handle # 4 Abdominal retractors, double-ended (Richardson) Curved operating scissors, blunt pointed (Mayo), 17 cm Straight operating scissors, blunt pointed (Mayo), 17 cm Aesthetic face masks (3 sizes) Anaesthesia machine Laryngoscopes X-Ray illuminator Gynae Instrument set General Instrument set Adult ambo bag and mask D & C instruments set Myomectomy screw Air conditioners Counter (Hand tally differential) Steel almirah (Large) Lab cabinet Fowler bed (Iron) Examination lamp Suction apparatus: electrically operated Infant incubators Phototherapy unit Oxygen cylinder complete with trolley Fowler bed (Iron) Sponge forceps Uterine sound Vulsellum forceps Episiotomy instruments set (Complete) Gynae Instrument set D & C instruments set 77

88 D. Drugs and supplies criteria OPTIMAL ITEMS Supplies Gloves Clean / Safe delivery kit Disposable/ Auto disable syringes Tracer drugs Capsule Amoxicillin Syrup Amoxicillin Tablet Metronidazole Syrup Metronidazole Tablet Iron Tablet Folic acid Vaccines BCG OPV Family planning commodities Condoms COC POP MINIMAL ITEMS Supplies Clean / Safe delivery kit DRUGS & SUPPLIES FOR BHUS Reagents/ strips for routine lab tests Surgical spirit Oral Rehydration Salt ORS Tetracycline Ointment Injection Oxytocin IV solutions Syrup Salbutamol Syrup Chloroquine Syrup Zinc Sulphate Penta-valent Measles TT IUCDs Injection DMPA Injection Net-En Disposable/ Auto disable syringes Reagents/ strips for routine lab tests Tracer drugs Vaccines BCG OPV Family planning commodities (any three) Condoms IUCDs Tablet Iron Tablet Folic acid Penta-valent Measles TT COC or POP Injection DMPA or Net-En OPTIMAL ITEMS Supplies Gloves Clean / Safe delivery kit Disposable/ Auto disable syringes DRUGS & SUPPLIES FOR RHCS Reagents/ strips for routine lab tests Surgical spirit Oral Rehydration Salt ORS 78

89 OPTIMAL ITEMS Tracer drugs Injection Dexamethasone Injection Adrenaline Injection Atropine Injection Ampicillin Capsule Amoxicillin Syrup Amoxicillin Tablet Metronidazole Syrup Metronidazole Tablet Iron Vaccines BCG OPV Family planning commodities Condoms COC POP MINIMAL ITEMS Supplies Clean / Safe delivery kit DRUGS & SUPPLIES FOR BHUS Tablet Folic acid Tetracycline Ointment Injection Oxytocin Injection Magnesium Sulphate IV solutions Syrup Salbutamol Syrup Chloroquine Syrup Zinc Sulphate Injection Diclofenac Sodium Penta-valent Measles TT IUCDs Injection DMPA Injection Net-En Disposable/ Auto disable syringes Reagents/ strips for routine lab tests Tracer drugs Injection Ampicillin Vaccines BCG OPV Family planning commodities (any three) Condoms IUCDs Injection Oxytocin Injection Magnesium Sulphate Penta-valent Measles TT COC or POP Injection DMPA or Net-En OPTIMAL ITEMS Supplies Gloves Clean / Safe delivery kit Disposable/ Auto disable syringes Reagents/ strips for routine lab tests DRUGS & SUPPLIES FOR DHQH & THQH Screening kits for Hep B,C & HIV Blood grouping reagents Blood bags with transfusion sets Surgical spirit Oral Rehydration Salt ORS 7

90 Tracer drugs Injection Dexamethasone Injection Adrenaline Injection Atropine Injection Ampicillin Capsule Amoxicillin Syrup Amoxicillin Tablet Metronidazole Syrup Metronidazole Tablet Iron Tablet Folic acid Vaccines BCG OPV Family planning commodities Condoms COC POP MINIMAL ITEMS Supplies Gloves Clean / Safe delivery kit Disposable/ Auto disable syringes Tracer drugs Injection Dexamethasone Injection Adrenaline Injection Atropine Injection Ampicillin Vaccines BCG OPV Family planning commodities (any three) Condoms IUCDs Tetracycline Ointment Injection Oxytocin Injection Magnesium Sulphate IV solutions Syrup Salbutamol Syrup Chloroquine Syrup Zinc Sulphate Injection Diclofenac Sodium Injection Thiopentone Sodium Injection Neostigmine Injection Propofol Penta-valent Measles TT IUCDs Injection DMPA Injection Net-En Implants Reagents/ strips for routine lab tests Screening kits for Hep B,C & HIV Blood grouping reagents Injection Oxytocin Injection Magnesium Sulphate Injection Thiopentone Sodium Injection Neostigmine Injection Propofol Penta-valent Measles TT COC or POP Injection DMPA or Net-En Implants E. Support service criteria SUPPORT SERVICES FOR BHUS OPTIMAL CRITERIA Basic lab tests Doctor or LHV Reagents and strips SUPPORT SERVICES FOR RHCS OPTIMAL CRITERIA Basic lab tests Space Doctor or LHV or Lab technician Reagents and strips Ambulance services Functional ambulance Ambulance driver 80

91 MINIMAL CRITERIA FOR BHUS Basic lab tests Doctor or LHV Reagents and strips MINIMAL CRITERIA FOR RHCS Basic lab tests Space Doctor or LHV or Lab technician Reagents and strips SUPPORT SERVICE CRITERIA FOR SHC HOSPITALS OPTIMAL CRITERIA Basic lab tests Space Laboratory technician Blood transfusion services Blood bank technician or lab technician Radiology services Space Operation theatre services Space Anaesthetist OT technician Ambulance services Functional ambulance MINIMAL CRITERIA Basic lab tests Space Blood transfusion services Laboratory or blood bank technician Radiology services Space Operation theatre services Space Anaesthetist or anaesthesia technician Reagents and strips Laboratory equipment Screening strips for Hep B, C & HIV Ultrasound equipment Anaesthesia technician OT equipment Drugs and supplies Ambulance driver Lab technician Reagents and strips Screening strips for Hep B, C & HIV Ultrasound equipment OT equipment Drugs and supplies F. Infection control and waste management criteria Infection control Hand washing ASSESSMENT CRITERIA Hand washing basin with running water Soap Towel Gloves Personal protection materials Face masks Safety goggles Heavy duty leather gloves Gowns Industrial boots 81

92 Waste collection materials Safety boxes Colour-coded plastic bags Waste treatment equipment Autoclave for waste treatment Autoclave test strips Disinfection of service provision areas Cleaning materials Chemical disinfectant G. Input Criteria for basic EmONC services at THQ hospital i. Civil works CIVIL WORKS SCOPE OPD Consultation area Examination area Hand washing facilities Female ward Patient area Labour room Delivery room Clinical laboratory Laboratory room LHV s room Consultation area Residence - WMO Residence - LHV Functional attached washroom Scrub area Functional attached washroom for patients Working area Functional attached washroom Examination area Hand washing facilities Available Good condition Available Good condition ii. Human resources HUMAN RESOURCES Category Number Category Number WMOs 2 LHVs 2 OT technician 1 Ambulance drivers 1 Lab technician

93 iii. Equipment EQUIPMENT General hospital Ambulance Female ward Fowler bed (Iron) Attendant's bench Bed side locker OPD Weighing machine (Adult) Labour room Foetal stethoscope Electric instrument sterilizer (12 x6 ) Jar for forceps Spring type dressing forceps (S.s) Sim s speculum (Right angle, small) Sim s speculum (Right angle, medium) Sim s speculum (Right angle, large) Electric water cooler Screen folding (Complete) B P Apparatus mercury Desk type Baby cot Infant weighing machine Examination lamp Sponge forceps Artery forceps (Long, straight) Uterine sound Vulsellum forceps Scissors (Dissecting, blunt pointed) Artery forceps Blunt-ended scissors iv. Drugs and supplies DRUGS & SUPPLIES Supplies Gloves Clean / Safe delivery kit Disposable/ Auto disable syringes Tracer drugs Injection Dexamethasone Injection Adrenaline Injection Atropine Injection Ampicillin Capsule Amoxicillin Syrup Amoxicillin Tablet Metronidazole Syrup Metronidazole Vaccines BCG OPV Family planning commodities Condoms COC POP Reagents/ strips for routine lab tests Screening kits for Hep B,C & HIV Blood grouping reagents Tablet Iron Tablet Folic acid Tetracycline Ointment Injection Oxytocin Injection Magnesium Sulphate IV solutions Syrup Salbutamol Syrup Chloroquine Syrup Zinc Sulphate Injection Diclofenac Sodium Penta-valent Measles TT IUCDs Injection DMPA Injection Net-En 83

94 v. Support services SUPPORT SERVICES Laboratory services Basic laboratory tests Ambulance services Functional ambulance Ambulance driver Example: Calculation of component bar Average availability of inputs for CEmONC in each THQH of district Attock was: Component Number of required inputs Average availability Calculation Proportionate ( 1 / 5) of standard bar Infrastructure =(8.60/1*0)*0.2 Human resources =(14.40/41*0)*0.2 7 Equipment =(81/6*0)* Drugs & supplies =(34.60/42*0)* Support services =(63/87*0)* Infrastructure HR Equipment Drugs & Supplies Support services Attock It is evident that none of the required inputs meet the mark of 20 and comulative average availability of inputs in THQHs is 61 out of 0, in district Attock. 84

95 TRF is funded by UKaid from the Department for International Development and AusAID, and managed by HLSP