DtrCUMENTS~ 2 S R ISLAMIC REPUBLIC OF PAKISTAN PROVINCE OF PUNJAB

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1 Public Disclosure Authorized ISLAMIC REPUBLIC OF PAKISTAN PROVINCE OF PUNJAB DtrCUMENTS~ 2 S R 2013 Public Disclosure Authorized International Development Association 1818 H Street NW Washington, DC United States of America Re: Credit Number 5258-PK (Punjab Health Sector Reform Project) Performance Monitorina Indicators Dear Sir/Mesdames: Public Disclosure Authorized We refer to Section II A of the Schedule 2 of the Financing Agreement (Punjab Health Sector Reform Project) between the Islamic Republic of Pakistan ("Recipient") and the International Development Association ("Association") and Section II A. 1 of the Schedule to the Project Agreement between the Association and the Province of Punjab of even date herewith for the above-mentioned Project. We hereby agree that the Performance Monitoring Indicators to monitor and evaluate the carrying out of the above-mentioned Project and the achievement of the objectives thereof are those set forth in the Attachment to this letter. Public Disclosure Authorized Attachment Very truly yours, ISLAMIC REPUBLIC OF PAKISTAN By_ Authorized Representative PROXCE OF PUNJAB By W 111 Authorized Representative

2 Punjab Health Sector Reform Project Results Framework Project Development Objectives PDO Statement The development objective of the proposed project is to support the implementation of the Punjab Health Sector Strategy, by focusing on the improvement of the coverage and utilization of quality essential health services, particularly in the low performing districts of Punjab. The project will focus on building the capacity and systems to strengthen accountability and stewardship in DoH. Project Development Objective Indicators Responsibility Cumulative Target Values Data Source! for Unit of End Methodolog Data Collection Indicator Name Core Measure Baseline YRI YR2 YR3 YR4 Target Frequency gy Fully immunized PHSRP/ MIS children Percentage years MICS, DHS Cell, DoH months of age MICS 2011 Average for 18 Percentage (baseline) PHSRP/ MIS low performing Sub-Type disaggregated Cell, DoH districts Breakdown by district Births attended by PHSRP/ MIS skilled health Percentage years MICS, DHS Cell, DoH personnel Average for 18 Percentage MICS 2011 PHSRP/ MIS low performing Sub-Type (baseline) Cell, DoH districts Breakdown Contraceptive prevalence rate Percentage years MICS, DHS PHSRP/ MIS Cell, DoH (any modern methods)

3 Average for 18 Percentage MICS 2011 PHSRP/ MIS low performing Sub-Type (baseline) Cell, DoH districts Breakdown Proportion of Nutrition children 0-24 months of age Percentage ) Annual Project Program and receiving the progress report LHWP-MIS, basic package of DoH nutrition services Number of Category -1 Health Care Establishments issued with Punjab Health Punjab Health provisional Number Annual Commission Commission licenses annual report (certificate of registration) by Punjab Healthcare Commission community satisfied members Percentage Annual Health Facility MIS Cell, DoH Assessment with government health care services I _ Intermediate Results Indicators Responsibility Cumulative Target Values Data Source/ for Indicator Name Core Unit of Baseline YRI YR2 YR3 YR4 End Frequency Methodology Data Collection Measure Target Number of THQ hospitals MNCH providing 24/7 Number Annual MNCH-MIS Program, DoH comprehensive EmONC services _NCH Number of RHCs Number Annual MNCH-MIS PgC D Program, DoH providing 24/7

4 basic EmONC services Monthly average MIS Cell and number of Number Annual MNCH-MIS MNCH deliveries take Program, DoH place at one RHC Proportion of children with SAM registered Nutrition/MNC MNCH/Nutritio for treatment at Percentage Annual H-MIS n Program, DoH stabilization centres in target districts pregnant women Nutrition/MNC registered with Percentage Annual Nutrition/MNC H and LHW LHWs receiving H-MIS Programs, DoH IFA tablets during the last pregnancy Monthly average number of family planning clients Number Monthly DHIS MIS Cell, DoH provided products and services at one RHC IDUs reached by the Program who Percentage Annual HASP report HASP reported using a new syringe at their last injection Daily average Number number of OPD BHU Annual DHIS MIS Cell, DoH visits in one BHU RHC and RHC Annual Health Annual Health Yes/No No Yes Yes Yes Yes Yes Annual Report published Report MIS Cell, DoH Percts of Percentage Annual DHIS MIS Cell, DoH districts with their J

5 respective BHUs providing all essential drugs LHWs with stock- Percentage Annual LHW-MIS LHW Program, out of family DoH planning methods Non-salary line items in all 36 districts' health recurrent expenditures Percentage Annual DoH budget DoH represent at least 30% of the total recurrent expenditure the development budget allocated for preventive foprram e Percentage Annual Budget Book DoF programmes out of total provincial development health budget Indicator Name Fully immunized children months of age Description (indicator definition etc.) "Fully immunized" child should be immunized against eight vaccine preventable diseases, namely, BCG for TB, polio, DPT for diphtheria and pertussis, neonatal tetanus, hepatitis B, Haemophilus Influenza, and measles (one and two). This indicator encompasses the entire Punjab province. There are several data sources; however, figures significant vary depending on the sources (e.g.. PSLMS shows 72% in 201 1).MICS has disaggregated data by district. Average for 18 low performing districts The following 18 low performing districts (50% of total) are selected based on the MICS 2011 results for the combination of SBA, immunization, and CPR: D.G Khan, Rajanpur, Muzaffargarh, Jhang, Bhakkar, R.Y Khan, Narowal, Bahawalnagar, Bahawalpur, Pakpattan, Kasur, Vehari, Lodhran, Chiniot, Khanewal, Okara, Hafizabad and Layyah. Births attended by skilled health personnel Contraceptive prevalence rate (any modem methods) This indicator encompasses the entire Punjab province and is DLI for the 4"' year. "Skilled health personnel" includes doctors, nurses, Lady Health Visitors and midwives. currently married women age who are using modem contraceptive method. currently married women age who are using any modem contraceptive method. This indicator encompasses the entire Punjab province and is DLI for the

6 Proportion of children 0-24 months of age receiving the basic package of nutrition services Number of Category -1 Health Care Establishments issued with provisional licenses (certificate of registration) by Punjab Healthcare Commission 4 year. This indicator encompasses 12 priority districts in Punjab. IDA 16 Core Indicator. There are about 600+ large health care establishments with more than 50 beds (Category-1) in both public and private sectors in Punjab. Hospital licensing in Punjab is a staged process. Once a HCE submits an application to PHCC, as per the 2010 Act, the HCE shall be inspected to determine if it meets the standards set forth in the PHCC - Hospital Licensing Regulations, which provides procedures for obtaining a hospital license, minimum standards for hospital functions and services, patient rights standards, etc. Representatives of the PHCC/Inspection Team shall discuss the findings of the inspection with representatives of the HCE, and the HEC will then report back to PHCC once any deficiencies have been corrected. Following review of the report from the HCE, PHCC Inspection Team may schedule one or more inspections of the facility prior to issuance of provisional license (certificate of registration) by PHCC, in accordance with the provision of Chapter 3 of the PHCC Act The baseline and target figures are from their Business Plan. This is DLI for the Is year. For more information about PHCC, visit community satisfied with government health Health Facility Assessment (HFA) will be annually conducted for the entire province, and user care services satisfaction survey will be part of the HFA. Achievement in 50% satisfaction is DLI for the 4 year. Intermediate Results Indicators Indicator Name Number of THQ hospitals providing 24/7 comprehensive EmONC services Number of RHCs providing 24/7 basic EmONC services Description (indicator definition etc.) This indicator encompasses all 36 districts in Punjab. THQ hospitals are secondary level health facilities and currently total of 103 in Punjab (Page 3 of "draft DHIS Monthly comparison Report of Year 2012" prepared by MIS Cell, DoH). Comprehensive EmONC services should include the five basic EmONC functions (Administration of antibiotics/oxytocin/anticonvulsants, Manual removal of the placenta, Removal of retained products following miscarriage or abortion, Assisted vaginal delivery, preferably with vacuum extractor, and newborn care) plus Caesarean section, safe blood transfusion, and care to sick and low-birth weight newborns, including resuscitation, for 24/7. The 2012 Health Facility Assessment shows 28/36 DHQ and 40/84 THQ hospitals and 0/291 RHCs equipped for 24/7 comprehensive EmONC (HFA data extracted from the draft Integrated PC-1). This indicator encompasses all 36 districts in Punjab. There are currently 303 RHCs in Punjab (Page 3 of "draft DHIS Monthly comparison Report of Year 2012" prepared by MIS Cell, DoH). Basic EmONC services should include the five following functions - Administration of antibiotics/oxytocin/anticonvulsants, Manual removal of the placenta, Removal of retained products following miscarriage or abortion, Assisted vaginal delivery, preferably with vacuum extractor, and newborn care, for 24/7 or on call. The 2012 Health Facility Assessment shows 150/291 RHCs and 88/2454 BHUs equipped for 24/7 basic EmONC (HFA data extracted from the draft Integrated PC-1).

7 Monthly average number of deliveries take place at one RHC Proportion of children with SAM registered for treatment at stabilization centers in target districts pregnant women registered with LHWs receiving IFA tablets during the last pregnancy This indicator encompasses all 36 districts in Punjab. Page 20 of the "draft DHIS Monthly comparison Report of Year 2012" shows on average 33 deliveries for RHC per month. This indicator encompasses 12 districts focused under the government's nutrition program. The denominator is total number of children identified as Severe Acute Malnutrition (SAM), and the numerator is children with SAM who are registered for treatment at stabilization centers. This is DLI for the 4 h year. This indicator encompasses all 36 districts in Punjab. Monthly average number of family planning clients provided This indicator encompasses all 36 districts in Punjab. Total number of FP visits at RHCs in products and services at one RHC Punjab in 2012 was 225,734 (Data provided by the MIS Cell from DHIS on March 26, 2013). The baseline of 62 was calculated by: 225,734 visit divided byl2 months and 303 RHCs.

8 IDUs reached by the Program who reported using a new syringe at their last injection Daily average number of OPD visits in one BHU and RHC The denominator is total estimated number of IDUs in target cities, and the numerator is estimated number of IDUs preventive HIV/AIDS services to be covered by the initiatives by DoH. This indicator encompasses the entire Punjab province. Data has been collected monthly by DHIS with disaggregation by level of facility. Annual Health Report published The Report is expected to be published to the public within three months of the previous year by MIS Cell of DoH. districts with their respective BHUs providing This indicator encompasses all 36 districts in Punjab. The list of essential drugs has been all essential drugs defined as part of EPHS for BHUs. The data has been collected as part of DHIS. LHWs with stock-out of family planning This indicator encompasses 36 districts in Punjab. LHWs should be supplied with condoms and methods oral pills. Non-salary line items in all 36 districts' health recurrent This indicator encompasses the entire Punjabi 36 districts. The denominator is total 36 districts. expenditures represent at least 30% of the total recurrent A 5% increase is envisaged every year and target of 30% achieved by end of the project for all expenditure. districts. the development budget allocated for preventive This indicator focusses on the provincial development budget for the sector. The denominator programmes out of total provincial development health budget is total provincial development health budget. After a 5% increase in the first year, an increase between 2-3% is envisaged every year and target of 20% achieved by end of the project.

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