NEEDS ASSESSMENT PRIMARY HEALTH CARE. Bhawalnagar

Transcription

1 NEEDS ASSESSMENT PRIMARY HEALTH CARE Bhawalnagar

2 Cover Photos: 2015 Sub-National Governance (SNG) Programme

3 NEEDS ASSESSMENT PRIMARY HEALTH CARE Bhawalnagar

4

5 Needs Assessment in Primary Health Sector Bhawalnagar Acknowledgements This report has been prepared to better understand the dynamics of budgeting of health service delivery at the district level in Punjab, Pakistan. The report is a combination of survey and desk based analyses developed in collaboration with several partners. The survey work and its report were undertaken by Contech International, a health sector consultancy firm based in Lahore. The Geographic Information Systems (GIS) maps and analyses were supported by the World Bank s team working on IT solutions for improving governance. The analyses of budget and financial statements were undertaken by the Sub-National Governance (SNG) Programme Punjab team. The SNG Programme acknowledges the services and support provided by all the partners in compilation of data and analyses of the data. 5

6 Table of Contents Acknowledgements Executive summary List of tables List of figures List of abbreviations 1 Background and introduction 1.1 Background 1.2 Introduction 1.3 Objectives 1.4 Scope of needs assessment 2 Literature review 2.1 Primary health care in Pakistan 2.2 Health MDGs (2015) 2.3 Medium Term Development Framework ( ) 2.4 Integrated Reproductive Maternal Newborn and Child Health (RMNCH) and Nutrition Programme (Punjab ) 2.5 EPHS Package (2012) 2.6 Punjab Health Sector Strategy ( ) Punjab Rural Support Programme (PRSP) model 2.8 Issues in primary health care System 2.9 Management and governance issues 2.10 Access 2.11 Coverage and service delivery 2.12 Quality 2.13 Why does governance matter to health?

7 Needs Assessment in Primary Health Sector Bhawalnagar 3 District profile of Bahawalnagar 3.1 History and geography of the district 3.2 Climate 3.3 Population 3.4 Education and economy 3.5 Health status 3.6 Issues in maternal healthcare 3.7 Highlights of poor maternal health in Bahawalnagar District 3.8 Status of child health 3.9 Immunisation-preventable diseases 3.10 Tuberculosis 3.11 Malaria 3.12 Hepatitis 3.13 Other communicable diseases 3.14 Rising burden of non-communicable diseases 3.15 Unsafe water and sanitation 3.16 Health seeking behaviour 3.17 Private sector facilities 4 Findings and results 4.1 Management and governance issues at provincial level 4.2 Management and governance issues at district level 4.3 Finance Access to services 4.5 Service delivery and coverage 4.6 Quality of services

8 5 Conclusions and recommendations 5.1 Conclusions 5.2 Recommendations 5.3 Non-salary budgetary proposals Annex A: Annex B : Annex C : Annex D : Annex E: Annex F: Methodology Missing Equipment in 15 BHUs Selection of BHUs in Bahawalnagar District Private Health Facilities in Bahawalnagar District Procurement Process Glossary of Terms 8

9 Needs Assessment in Primary Health Sector Bhawalnagar List of tables Table 3.1: Table 4.1: Table 4.2: Table 4.3: Table 4.4: Table 4.5: Table 4.6: Table 4.7: Table 4.8: Table 5.1: Table 5.2: Table 5.3: Table 5.4: Table A.1: Table A.2: Table A.3: Table A.4: Primary Health Care Facilities (BHUs) Allocations for Health Sector in Bahawalnagar and Budget Utilisation Medicine Budget and AE Primary Healthcare Current BE and AE BE and AE for BHUs Medicine Head Budget and AE Patient Cost as per Original Budget and AE (Rs.) ANC coverage by BHUs having appropriate facilities and HR in Bahawalnagar District Availability of Vaccines Among BHUs Proposed Allocations per BHU for Medicines/Supplies/Lab Investigations Budget and expenditure trends at RHCs, BHUs and THQs Total Cost of Standard Equipment at BHUs and Associated Maintenance and Repair DHDC budget allocations and expenditures Detailed sample size of stakeholders Selection Criteria for BHUs Data Collection at Provincial and District levels Data collection at facility and community level

10 List of figures 10 Figure 3.1: Figure 3.2: Figure 3.3: Figure 3.4: Figure 4.1: Figure 4.2: Figure 4.3: Figure 4.4: Figure 4.5: Figure 4.6: Figure 4.7: Figure 4.8: Figure 4.9: Figure 4.10: Figure 4.11: Figure 4.12: Figure 4.13: Figure 4.14: Figure 4.15: Figure 5.1: Map of Bahawalnagar District Situation of maternal health in Bahawalnagar Comparison of immunisation status in Bahawalnagar (fully immunised) Access to tap water and flush toilets in Bahawalnagar Share of Health Sector in Budget and Expenditure Health non-development budget and expenditure analysis Health salary and non-salary budget and expenditure analysis Utilisation of salary and non-salary budget Share of PHC in health budget PHC budget percentage utilisation Budget and actual expenditure at BHUs Major object wise breakdown of BHU budget and actual expenditure Access to Health Facilities by Travel Time Access to Health Facilities (Travel On and Off Road) Straight-line distance to the nearest health facility Travel distance by road to the nearest health facility Bahawalnagar Travel distance by road to the nearest health facilities with categorised health facilities Travel time to the nearest health facility with categorised health facilities Percentage of BHUs showing gap in availability of treatment for prevalent diseases in Bahawalnagar District Disease Pattern and OPD at BHUs (Number of Patients) Figure 5.2: Composition of Average Percentage Expenditure by DHDC ( ) Figure 5.3: DHDC budget allocations and expenditures

11 Needs Assessment in Primary Health Sector Bhawalnagar List of Abbreviations AE Actual Expenditure AFB Acid Fast Bacteria AIDs Acquired Immune Deficiency Syndrome ANC Antenatal Care ARI Acute Respiratory Infection BE Budgeted Expenditure BHU Basic Health Unit BOD Burden of Disease CDC Child Development Centre CDD Childhood Disintegrative Disorder CEI Client Exit Interview CEO Chief Executive Officer CMIPH Chief Minister Initiative for Primary Healthcare CMW Community Midwife CS Contraceptive Surgery DALYs Disability Adjusted Life Year DCO District Coordination Officer DFID Department for International Development (UK) DG Director General DGHS Director General of Health Services DHA District Health Authority DHDC District Health Development Centres DHIS District Health Information System DHQ District Headquarter Hospital DGHS Director General of Health Services DoH Department of Health DOH District Officer Health DOTS Directly Observed Treatment, Short-Course EDO Executive District Officer EDO (H) Executive District Officer (Health) 11

12 List of Abbreviations 12 EPHS EPI FGD FP FWW GDP GIS GPRS HCP HHs HIV HR HRH HSMB IDIs IUCD IMR INGOs JD KII KP KPIs LHS LHV LHW M&E MCH MDGs MICS MIS Essential Package for Health Services Expanded Programme on Immunisation Focus Group Discussion Family Planning Family Welfare Workers Gross Domestic Product Geographic Information Systems General Packet Radio Service Health Care Provider Health Houses Human Immunodeficiency Virus Human Resources Human Resources for Health Health Sector Ministerial Board In-Depth Interviews Intrauterine Contraceptive Device Infant Mortality Rate International Non-Governmental Organisations Job Description Key Informants Interview Khyber Pakhtunkhwa Key Performance Indicators Lady Health Supervisor Lady Health Visitor Lady Health Worker Monitoring and Evaluation Maternal Child Health Millennium Development Goals Multiple Indicator Cluster Survey Management Information System

13 Needs Assessment in Primary Health Sector Bhawalnagar List of Abbreviations MMR Maternal Mortality Ratio MNCH Maternal, Newborn and Child Health MO Medical Officer MSDS Minimum Service Delivery Standards MTBF Medium Term Budgetary Framework MTDF Medium Term Development Framework NGO Non-Governmental Organisation OPD Out-Patient Department OPV Oral Polio Vaccine ORS Oral Rehydration Salts OT Operation Theatre PBF Performance-Based Financing PDHS Pakistan Demographic Household Survey PET Post Exposure Treatment PHC Punjab Health Care Commission PHC Primary Health Care PHDC Provincial Health Development Centre POL Petroleum Oil and Lubricants PPP Public Private Partnership PSLM Pakistan Social and Living Standards Measurement Survey PRSP Punjab Rural Support Programme PSPU Punjab Health Sector Policy and Strategic Planning Unit PTB Punjab Technical Board PWD Population Welfare Department RH Reproductive Health RHC Rural Health Centre RHS Reproductive Health Services RTIs Reproductive Tract Infections SDA Special Drawing Account SH&NS School Health and Nutrition Supervisor 13

14 List of Abbreviations SMPs Standardised Medical Protocols SOPs Standardised Operating Procedure SNG Sub-National Governance STIs Sexually Transmitted Infections TBAs Traditional Birth Attendants TB Tuberculosis THQ Tehsil Head Quarters TNA Training Needs Assessment TT Tetanus Toxoid U5MR Under-Five Mortality Rate UC Union Council UN United Nations UNICEF United Nations Children s Fund WHO World Health Organization WMO Women Medical Officer 14

15 Needs Assessment in Primary Health Sector Bhawalnagar Executive Summary A. Introduction 1. The Sub-National Governance Programme The Sub-National Governance (SNG) Programme aims to strengthen governments capability to deliver health and education services by providing technical assistance to sub-national governments of 12 selected districts of Punjab and Khyber Pakhtunkhwa (KP) to enable them to: take decisions based on robust evidence; make services more responsive to people s needs; and strengthen government capability to deliver basic services. 2. The health needs assessment in Bahawalnagar District To support the achievement of these objectives, the SNG Programme conducted a health needs assessment in Bahawalnagar District, Punjab to: identify gaps and issues in the access to, coverage and quality of primary health services; highlight gaps in health sector performance indicators and identify the factors influencing these gaps (planning, budgeting and management processes); and inform relevant stakeholders about the service delivery gaps and identified needs. An integrated approach was adopted in the needs assessment, including a literature review, Key Informant Interviews (KIIs), Focus Group Discussions (FGDs), field visits for Client Exit Interviews (CEIs), Mystery Clients Interviews, stakeholder consultations, and GIS analysis. A review and analysis of budgetary allocations for the sector was also carried out. 3. Areas assessed The areas looked at in the needs assessment were: 15 Access to services, including: physical accessibility of primary health care facilities Basic Health Units (BHUs) for the catchment population (average distance and travel time of citizens to BHUs); other hindrances / constraints to accessibility (the local environment, local culture); and the availability of roads. To support analysis in this area, out-patient department (OPD) data was analysed and FGDs carried out to obtain citizens views of the ease of accessibility of their respective BHUs, especially for women, girls and minority groups.

16 Service delivery and coverage, including: whether Minimum Service Delivery Standards (MSDS) and Essential Package of Health Services (EPHS) and other services were provided; the disease patterns of the districts; and the availability of requisite staff, medicines and diagnostic services at the facility level. To support analysis in this area, information / data of BHU doctors, staff and medicines was gathered and feedback from citizens was sought during FGDs. Inspection of the facilities was also carried out. Quality of services, including: client satisfaction with primary health services; community feedback regarding the timeliness of service delivery; attitudes of BHU staff towards patients; the level of attention given by physicians; the provision of medicines; and the effectiveness of referrals. Management, governance and finance of services, including: the supply side or management practices, particularly financial management systems of the districts (such as budgeting, planning and management practices); the utilisation of resources; the effectiveness and efficiency of procurements, (especially of medicines and facilities); and decentralisation Results of assessment The findings of the assessment resulted in recommendations to improve the provision of primary health care, including improvements in the business processes for the services. These recommendations also include proposals regarding the district budget. B. Findings 1. Management and governance issues at provincial level 1.1 Limited use of data for planning health services 16 Most of the stakeholders involved in policy-making processes in Punjab province report limited use of data for planning health services. Absence of collated information at different levels and low quality reporting system results in constrained decisionmaking and planning at the provincial level. 1.2 Procurement of medicines and equipment Lack of planning for the timely procurement of medicines in accordance with patients needs is reported as being the major issue regarding provision of services. Although a specific timeframe is stipulated for each step of the procurement process, this is

17 Needs Assessment in Primary Health Sector Bhawalnagar seldom followed. The reasons given for this are a weak supervisory and monitoring mechanism and issues in planning. In addition, data used to forecast medicines is neither maintained nor reliable. The study revealed that the procurement of medicines does not follow the needs of the community: the disease patterns of the district are not considered when demanding and distributing medicines at BHU level. Also, the focus is on acquiring drugs at the cheapest rates so quality medicines are not procured. 1.3 Lack of structural integration A lack of inter provincial harmonisation between different health services programmes is a main concern highlighted by respondents to the study. A low level of coordination between regular health departments and vertical programmes gives rise to issues such as duplication of resources and services. Most of the vertical programmes have their own management, reporting and monitoring mechanism and work in isolation, with a low level of coordination with other programmes. 1.4 Poor management skills and capacity A lack of management skills and capacity issues at the provincial level is reported. Provincial health directors and members of their health management teams have clinical backgrounds, but very few of them are trained in public health planning or health management. They also lack guidelines. 1.5 Inadequate monitoring and evaluation (M&E) Inadequate monitoring and measuring of health system performance is reported, leading to a failure to achieve optimal service delivery outputs. Provincial managers highlight that although monitoring manuals have been designed for service providers, due to restricted resources these manuals are not followed: there is a lack of funds and human resources (HR) to enable effective monitoring. Moreover, delays in the provision of resources means that departments cannot make regular monitoring visits and evaluate workers. Finally, no grievance redress mechanism has been established at the BHU level till now, as due to limited resources the Punjab Health Care Commission (PHC) is not taking on this task Management and governance issues at district level 2.1 Autonomy at district level The study revealed that the district has weak resources and institutional capacity and no mechanism or reliable data is in place to prioritise and confirm the needs of the

18 community. District officials are not consulted when health policies are formulated or reviewed. However, implementation plans and issues are discussed every month at the Director General s (DG s) office, chaired by the Director General Health Services (DGHS). The District Coordination Officer (DCO), the head of the District Administration in a district, has the power to evaluate the performance of officers and direct them to achieve the set goals in the approved district action plans, as well as to deal with HR and finances. However, the DCO is subject to political interference in exercising this power. Similarly, the Executive District Officer (Health) (EDO(H)) and the District Officer Health (DOH) have autonomy to make health plans according to the needs of the community but limited capacities in this regard. 2.2 Inadequate M&E at district level Inadequate monitoring and health system performance evaluation makes achievement of service delivery outputs challenging. It was stated that Performance Evaluation Reports (PERs) assessing the performance of district managers and health care providers (HCPs) give good remarks to everyone, irrespective of actual performance. Promotions are made on a routine basis, rather than on the basis of performance, and there is no incentive system to motivate managers and employees to perform better. However, the study did reveal that the use of IT and tracking telecommunication (through android phone technology) to strengthen monitoring in the district was introduced in April Monitoring is carried out on set parameters, such as presence of staff, cleanliness and provision of medical supplies, etc. In April, Bahawalnagar District came first in respect of monitoring performance. 3. Finance and budgeting 3.1 Allocation of financial resources 18 Insufficient financial resources (Rs. 44, million in ) are allocated to health in the provincial budget. The negligible expenditure on health as a percentage of GDP (2.7%, last calculated in 2012) is insufficient to provide effective and quality health services to the community. It was reported that no evidence or data is used when making a budgetary plan for facilities in the district, and the prevalence of diseases and incidences in the district are not considered during the process of allocating finance resources. Also, most of the allocation is for tertiary healthcare facilities, at the expense of secondary and primary healthcare. Furthermore, the non-salary component of the budget is quite low for both the primary and secondary health care facilities. This non-salary component, which includes the budget for procurement of medicines and repair and maintenance of equipment, is critical for effective service delivery at the grass roots level. Thus, the basic community needs are not properly fulfilled.

19 Needs Assessment in Primary Health Sector Bhawalnagar 3.2 Utilisation of budget There is significant variance in the budgeted amounts and actual expenditures (AE) incurred by the Health Department, Bahawalnagar. This clearly highlights gaps in financial management practices at the district level. Moreover, even the low level of funding allocated for the non-salary component is not fully utilised by the district. A variation between budgeted amounts and AE for the 102 BHUs in Bahawalnagar District was found, clearly reflecting a lack of financial planning and absence of evidence-based budgeting for provision of primary health services during the last few years. BHU budgeted expenditure and AE mainly consists of employee-related expenses, operating expenses and repairs and maintenance costs. Most of the spending at BHUs is on the salaries of staff. Allocations for repairs and maintenance are very low. Nevertheless, the budgeted amounts for operating expenses and for repairs and maintenance are not being fully utilised. The budgeted amounts for procurement for medicines for BHUs were not utilised fully during the last four financial years, except in and , when the AE exceeded the budgeted amount by 61% and 11%, respectively. The per patient non-salary expenditure at the BHU level ranges from Rs. 7 to Rs. 13. This allocation is extremely low keeping in view the actual need for provision of medicines and diagnostic facilities etc. through BHUs. The actual figure of spending per patient in Bahawalnagar District is one tenth of the Government of Punjab s EPHS average cost for provision of BHU-related services of Rs. 62 per patient. 19

20 Details of finance and budgeting The share of the health expenditure in total expenditure at district level remained between 16% 18% during the four year period (FY to FY ). The health current budget was Rs , Rs , Rs , and Rs billion during , , and , respectively. The Year-on-Year (Y-o-Y) increase in the budget was 23%, 2%, and 13% during these years. The Y-o-Y increase in AE was -1%, 29%, and 11%, in , and The salary share of the health budget was 76%, 73%, 70%, and 66%, and the nonsalary share was 24% 27%, 30%, and 34% during , , and , respectively. Similarly, the share of salary in AE was 58%, 79%, 70%, and 65% and the non-salary share was 42%, 21%, 30%, and 35% during , , and , respectively. The budget utilisation of salary was 77%, 88%, 93%, and 100%, respectively, in the four years. The non-salary budget utilisation was 177%, 62%, 94%, and 105% during , , and , respectively. Generally the district has been allocating an adequate non-salary budget for health sector, keeping in view the generally accepted standard that a non-salary budget should be equal to 30% of the salary budget. The non-salary budget primarily comprises operating expenses and repair and maintenance. The operating budget includes the budget for drugs and medicines. In excessive procurement of medicines was undertaken, with the result that the budget allocation for was only utilised to the extent of 35% of allocation. The utilisation of the non-salary budget has been quite erratic over the years. The share of secondary health care in total health expenditure ranges from 30% to 34%. The rest of the budget is used for administration, other health facilities and general nursing schools, etc. The allocation for primary health care services was 42%, 41%, 29%, and 35% of the total health budget in the district from 2010 to The AE on primary health care was 33%, 44%, 38%, and 35% during these years. Utilisation of this budget was 80%, 87%, 123%, and 100% during , , and , respectively. There seems to be little predictability in utilisation of allocated funds for primary health care. 20

21 Needs Assessment in Primary Health Sector Bhawalnagar 4. Other 4.1 Access to services The majority of the study respondents stated that in the case of remotely located BHUs, accessibility is a major problem. The conditions of most of the roads to these BHUs are poor and transport is not available all the time. Where transport is available, high costs were highlighted as making it difficult to access remote BHUs. Where there is a BHU nearby, people are willing to seek health services from the BHU as they can approach it by walking or by motor cycle. However, a majority of respondents stated that the limited opening times of BHUs (from eight to two o clock) were another issue regarding accessing services from BHUs, causing respondents to take patients to private or city hospitals. Respondents demanded that the BHUs be kept open 24/7. The mean distance of residences from BHUs is 2.6 km. It was further reported that within one km, 64% of the citizens travel to a BHU by foot and 36% by motorbike. However, within two kms, 17% of the citizens travel by foot and 83% by motorbikes. Beyond two kms almost all use motorbikes to travel to BHUs. 74% of citizens reported having travelled on a bad road to a facility. 60% said that the main reason for their visit was access to the facility; 40% reported that both access and affordability were reasons. These findings were corroborated by GIS analysis. 4.2 Service delivery and coverage Due to the increasing population, the coverage of health services in the district is insufficient. Many service delivery gaps at the facility level were reported. The study found insufficient financial resources and lack of staff for delivering current provincial government approved and notified service packages. The majority of facility incharges reported unavailability of trained staff at their BHUs, due to which provision of primary health services at BHUs was not possible. To give an example, the target population for each Lady Health Worker (LHW) has increased from 1000 to 1400 since However, because of a ban on recruitments, retired staff cannot be replaced. LHWs are thus increasingly burdened and unable to cover the added patient load. There is also a shortage of qualified staff at BHUs. It was reported that around 50% of the clients were examined by dispensers, 30% by Lady Health Visitors (LHVs), 10% by lab technicians, 6% by School Health and Nutrition Supervisors (SH&NS) and only 3% by doctors. Around 75% of the respondents reported that they did not wait for more than 15 minutes before being examined by HCPs. 21 Unavailability of medicines and equipment was highlighted as another issue in providing services to the community: most of the BHUs either lack basic equipment, like weighing machines and blood pressure apparatus, or such equipment is nonfunctional. Regarding availability of medicines, around 86% of the citizens were prescribed medicines, of which only 73% received all of the medicine from the BHUs; the rest managed obtained their medicine from elsewhere. No BHU was found to have

22 all the required vaccines in Bahawalnagar. The population coverage of Bahawalnagar District in terms of general diseases was found to be inadequate when triangulated with the medicine stock of the sampled BHUs. None of the prevalent diseases in the District, except malaria, are covered by the BHUs. Children are less covered in the case of acute respiratory infections (ARIs) and asthma as compared to adults, putting them at a higher risk of a negative outcome. For all other diseases, both adults and children are equally uncovered. Underutilisation of services and stocks (medicine, equipment and allied) was noticed for antenatal care (ANC), delivery care, postnatal care and family planning, due to access and coverage issues. 4.3 Quality of services It was shared by many BHU in-charges that no document on the provision of good quality services had been provided to them. Instead, only verbal instructions are given to ensure quality health services in BHUs. The lack of trained staff was another issue identified in relation to providing quality services. A need to recruit efficient and skilled staff for vacant posts was stressed. Very poor conditions of staff residences have also led to absenteeism of staff. Non-availability of clean and safe water and electricity was also reported at BHUs. 77% of respondents were found to be satisfied with the overall hospital experience. 17% were unsatisfied and 6% were unsure. These client satisfaction figures are consistent with the percentage of clients who received medicines from the facility. C. Recommendations 1. Management and governance issues at provincial and district level recommendations Improve management skills and capacity, as well as use of data for planning health services It is recommended that the health planning capacity be enhanced in the short-term through outsourced technical assistance (TA). In the long-term, the institutionalisation of health planning within the Department of Health (DoH), especially at district level, is recommended. Additionally, the strengthening of the existing planning cells, supported through trained HR and linking with data resource units, would ensure evidence-based planning in the health sector. The Punjab Health Sector Strategy proposes setting up a Knowledge Store Unit a comprehensive data clearing warehouse. It is recommended that these units be established at the earliest opportunity, to help augment planning

23 Needs Assessment in Primary Health Sector Bhawalnagar at the provincial and district levels. Finally, improvement in the quality of data collected and included in the District Health Information System (DHIS) will also increase the comfort level of health sector planners, so that they will be more inclined to use the data for planning purposes. Therefore, it is recommended that measures be taken to improve the authenticity and validity of the data reported in DHIS. 1.2 Increase structural integration In order to minimise duplications and wastage of resources, it is recommended that a coordination mechanism be developed which effectively links the vertical programmes, the DoH and the Population Welfare Department (PWD) at the district level. Additionally, the model of the District Health Population Management (DHPMT) could be adopted to ensure that such inefficiency is reduced. In the long run, the functional integration/synergy of the vertical health care programmes at the provincial and district levels is recommended. 1.3 Improving M&E A robust M&E system is proposed for the primary health care sector, through the use of mandatory checklists, feedback, and follow-ups. Highlighting the issues of mortality and morbidity, based on evidence, would further help in this regard. Moreover, setting targets and costing activities would play an important role in achieving the objective of improved health care. Therefore, target setting through key performance indicators (KPIs) is recommended. For this purpose, a robust M&E framework/mechanism can be implemented and through health reforms a mechanism of accountability can be devised based on KPIs, to improve the health status. The setting of targets should form the basis for performance contracts between the provincial and district health authorities, in order to monitor progress. 2. Finance and budgeting 2.1 Increase allocation of financial resources and improve budgeting It is recommended that districts vigorously pursue additional budget allocations through the preparation of evidence-based district action plans for the health sector. Furthermore, clearly defined targets, specific activities and pre-set indicators might help to attract more sufficient funds. Timely releases of budget, at the provincial and district levels, will also ensure that the available funding is transferred and utilised efficiently. In the long-term, it is recommended that needs-based budgeting be linked to performance, outputs, and outcomes at the district level. 23 Detailed budget proposals are made later in this section.

24 3. Other 3.1 Access to services It is recommended that innovative approaches be adopted to resolve issues of access, such as the deployment of mobile health units at strategic locations. Moreover, measures for efficient patient transport, through arrangements such as community emergency ambulances, made available through Community Emergency Services (CES), are also recommended. In the long-term, it is recommended that a mapping of health facilities be carried out, with the objective of synchronising the placement of the health facilities with the community needs, using GIS. Furthermore, the issues of affordability of health services for the poor segments of the community should be addressed by using pro-poor initiatives, like voucher schemes. Linking a voucher scheme with a community-based transport model can additionally help in improving access to health facilities. 3.2 Service delivery and coverage To improve service delivery and coverage in the short-term, a rethinking of the service delivery system is recommended, through the use of innovative approaches, such as community midwives, pairing of Traditional Birth Attendants (TBAs) and LHWs, and involvement of the private sector and non-governmental organisations (NGOs). The matching of the burden and distribution of disease at the district level is also recommended. In the long-term, it is recommended that the options of out-sourcing health services, fostering public private partnerships and implementing health insurance models be considered. The implementation of task shifting is also proposed, meaning the redistribution of tasks among health worker teams, by enhancing their capabilities. Additionally, the possibilities of using telemedicine and mobile health (mhealth) to address the issues of coverage and access could also be explored. 3.3 Quality of services 24 In order to address issues regarding the quality of health services in the short-term it is recommended that the PHC be made fully operational so that it can contribute at all levels of service delivery in the public health sector, as envisaged in its Act. Additionally, in the long-term, it is recommended that there be implementation of, and strict compliance with, MSDS and operationalisation of district health authorities (DHAs), along with periodic skills development training for the staff of primary healthcare facilities in the various jobs/responsibilities assigned to them. Finally, it is proposed that performance-based financing be introduced, with pre-set indicators to measure the quality of health services. This may result in a substantial improvement in the quality of health services. Non salary budget proposals to address issues of access, coverage and quality of

25 Needs Assessment in Primary Health Sector Bhawalnagar primary health care services in Bahawalnagar are set out below. 4. Non-salary budget proposals 4.1 Access to services - non-salary budget proposals Medical camps In the short-term, it is imperative that the district government makes special arrangements to reach out to areas with poor access to health services periodically. The holding of medical camps in such areas is one option. The experience of the Punjab Rural Support Programme (PRSP) with such camps indicates that setting up these camps would require minimal logistics and cost as the medicines and equipment available at BHUs can be used for them. An indicative allocation of Rs.1.0 million for this purpose is proposed for Bahawalnagar District during FY Service delivery and coverage non-salary budget proposals Medicines/supplies/lab investigations In order to address the non-availability of required medicines, supplies and diagnostic facilities at BHUs it is imperative to procure and distribute the medicines at the primary level health facilities keeping in view the burden of disease and thus the requirement for medicines for those diseases. To align budgetary allocations with the burden of disease, and to ensure that the essential supplies and basic diagnostic facilities are available at the primary health care level, we calculated the funding requirements for providing these services at the primary health care facilities in the district. This requirement is Rs million. The cost per BHU is around Rs. 334,000. Additionally, Rs million is needed for the provision of requisite medicines at the BHU level, to address the burden of disease and patient load at these facilities. This would also include the provision of 25% as a buffer stock of medicine. It is recommended that the allocated budget be distributed among BHUs on the basis of patient load instead of using a constant budget allocation. Since the study identified certain areas where the utilisation ratio of the budget is very low the above funding requirement can be met from such areas. The study also indicated over-budgeting in health facilities in the district and over-budgeting in the salary component at the Rural Health Centre (RHC) level. This over allocation can easily be diverted to fund BHU medicines, supplies, and lab investigations. 25 Missing equipment To provide the equipment found to be missing at BHU level, EPHS-based costing of equipment has been used to calculate the funding requirements. The cost for the provision of the missing equipment at 15 sample BHUs has been calculated as Rs million. Using the list of missing equipment for sampled BHUs, the district government can extrapolate the cost of missing equipment for all 102 BHUs in the

26 district. It would, however, be useful to conduct a comprehensive assessment of missing facilities to accurately estimate the funding requirement for the provision of missing facilities / equipment in all BHUs in the district. The provincial ADP includes an allocation of Rs. 350 million for Purchase of Missing Equipment and Hospital Furniture etc. for Primary and Secondary Care Hospitals in Punjab. The district government is therefore recommended to approach the provincial government for funding to provide the missing equipment in BHUs of the district. It is also possible that the district government can provide the missing equipment in a phased manner, using its own budget. Resource provision for vaccination In order to ensure that the allocation for petrol, oil and lubricants (POL) to vaccinators is disbursed, it is proposed that a separate allocation be made in the budget for the provision of POL to vaccinators and the amount be disbursed through the use of fleet cards to vaccinators, if it is practical (considering the extent of availability of this facility in the district). 4.3 Quality of services non-salary budget proposals District health development centres (DHDCs) One of the main reasons for underutilisation of BHUs is a lack of qualified staff in the facilities. DHDCs have been established by the provincial government in each district, with a mandate to conduct training for health sector employees. These centres need to be made fully functional, by developing a training schedule with a robust monitoring mechanism to gauge their performance. It is proposed that a non-salary allocation for the centres be doubled during the next financial year to ensure adequate funding for DHDCs. 26

27 Needs Assessment in Primary Health Sector Bhawalnagar 1 Background and introduction 1.1 Background The SNG Programme aims to strengthen governments capability to deliver basic public services, i.e. education and health, in an improved, responsive and accountable manner. For this purpose it plans to provide TA to SNGs of 12 selected districts of Punjab and KP, to enable them to: i. take decisions based on robust evidence; ii. iii. make services more responsive to people s needs; strengthen government capability to deliver basic services. To achieve these results, The SNG Programme planned to conduct a needs assessment in the education and health sector, with a particular reference to women and girls. It initially focused on the health sector, to identify gaps and to align them to citizens needs. The findings of the assessment will be fed into the district budget, to identify gaps/deficits and the provision of funds to fill those gaps, so that the budgetary allocations are based on the needs of the people of the district, as regards the health sector, as determined through this primary survey. The SNG Programme is designed to promote SNG decision-making based on robust evidence. 1.2 Introduction The purpose of the needs assessment was to enable policy-makers and service managers to identify gaps in health sector performance indicators and factors influencing these indicators, especially with reference to access, quality and coverage. To increase the utility of this exercise and avoid duplication, an integrated approach was applied, including a literature review, KIIs, FGDs, district health sector budget review, GIS based analysis and field visits. Moreover, stakeholder consultations were carried out to validate identified needs and to provide a platform for stakeholders to suggest measures to address these needs. On the basis of the analyses and recommendations, adjustments are proposed in relation to the business processes, especially as regards aligning the budget to needs. 27 The report has been divided into five sections: the first three sections are introductory in nature and provide the background of the study, the literature review and a district profile of Bahawalnagar; the fourth section gives the findings and results of the needs assessment study, the budget review and GIS analysis and

28 the final section gives recommendations for improving primary healthcare service delivery in the district using evidence-based planning and budgeting, to target citizen s needs. The sections in the report are complemented by a number of graphs and tables. Annexes have also been added at the end of the report, to provide additional information. 1.3 Objectives The key objectives of this needs assessment are to: identify issues in the access to, coverage and quality of primary health services in the light of the needs of people in the district, especially women, girls and minority groups; highlight gaps in planning, budgeting and management processes, with a special focus on women, girls, and coverage of minority groups; and inform relevant stakeholders, including policy-makers, health managers and frontline service providers, about service delivery gaps and identified needs, along with recommendations to improve the provision of primary health care in line with the Provincial Health Sector Strategic Plan Scope of needs assessment The exercise was carried out in Hafizabad (in the northern cluster) and Bahawalnagar (in the southern cluster). The needs assessment exercises in these districts were useful for developing an understanding of health sector service delivery issues, especially for women, girls and minority groups. It encompassed the following key areas: Physical access of primary health care facilities (BHUs) According to the World Health Organization (WHO), access to health services relates to the perceptions and experiences of people as to their ease in reaching health services or health facilities in terms of location, time, and ease of approach 1. In the study, to examine access to primary health services in BHUs, the following important aspects of service delivery were studied: 1. Physical accessibility of BHUs for catchment population: Average distance and travel time of citizens from BHUs in their locality. In order to review this aspect, estimates of average distance and average travel time of 1

29 Needs Assessment in Primary Health Sector Bhawalnagar individuals of a catchment area from a BHU were looked at using secondary data, if such information was available, and compared with the distance and travel time norms. The views of citizens were also obtained through FGDs which discussed whether the average distance and travel time of citizens from BHUs is reasonable. 2. Other hindrances / constraints to accessibility: Such as local environment, local culture, denial of access by a landlord or an intervening structure. This aspect may have special relevance for women, girls and minority groups. This aspect was probed with the local population during FGDs. 3. Availability of roads: This is clearly linked to access to health services. This aspect of accessibility was examined with the help of a combination of primary (FGDs) and secondary data. This was further examined through GIS based analysis. 4. Analysis of OPD data: BHU wise OPD data was collected and reviewed, to examine its patient load using Provincial and/or DHIS Cell. The process enables the SNG to identify overburdened and underutilised BHUs. This will establish a relationship between accessibility and utility of BHUs. FGDs focused on ascertaining citizens views of the ease of accessibility of their respective BHUs, especially for women, girls and minority groups, looking at the dimensions mentioned above Coverage Coverage is the extent of interaction between the services and the people for whom they are intended. Coverage is not limited to a particular aspect of service provision, but ranges from resource allocation to the achievement of the desired objectives. 2 To evaluate coverage, the survey assessed: 1. Implementation of MSDS / EPHS and other services as per local needs. 2. Overview of disease patterns of the districts through secondary data and comparison of pattern with the scope of services offered by the district health system Needs of citizens/community, especially women and girls, minority groups (through FGDs). 2

30 4. Availability of requisite staff, medicines and diagnostic services at the facility level in accordance with requirement of MSDS / EPHS. Gathered information / data of BHU doctors, staff and medicines from district health managers. Feedback on this data was also sought from citizens during the FGDs and this was verified through inspection of the facilities (Observation Checklist) Quality According to the WHO, quality improvement means taking a snapshot of the whole system, paying close attention to individual service users and the community at large, and emphasising delivering effective, efficient, accessible, acceptable, equitable and safe health care services to all. 3 The needs assessment study focused on governance related aspects of quality, such as documentation of the client satisfaction level and the effectiveness of management practices to support delivery of healthcare services at the local level in accordance with local preferences and needs. The following aspects were examined: 1. Client satisfaction with primary health services through primary data collection. In the study, client satisfaction reported by respondents during CEIs was noted. The criteria regarding satisfaction were based on the perceptions of the clients. Community feedback was obtained through FGDs on the timeliness of service delivery, attitudes of BHU staff towards patients, the level of attention given by physicians, provision of medicines and effectiveness of referrals etc. 2. Supply side or management practices, particularly financial management systems of the districts, such as budgeting, planning and management practices and how these processes take into account local needs, especially those of women, girls and minority groups. Furthermore, the assessment reviewed the system for, and timeliness of release of, funds allocated to the sector Utilisation of resources: By comparing budget allocation and expenditure trends, along with the effectiveness and efficiency of procurements, especially medicines, resource utilisation trends were reviewed. 4. Decentralisation: Devolution of authority to local level to improve service delivery. In Punjab, proposed DHAs are likely to be formed after the upcoming local government elections. From this point of view, the system for monitoring of staff, medicine inventory control and management, and the system of public feedback and complaint / grievance redress was reviewed. 3 WHO, 2007

31 Needs Assessment in Primary Health Sector Bhawalnagar 2 Literature review A comprehensive review of the literature, research materials, articles, and evaluation reports has been carried out to assess the existing situation of health care services and policy interventions in Pakistan. The secondary evidence from the local and global literature highlights gaps, needs, lessons learnt and best practices, to emphasise the challenges in service provision of health care. 2.1 Primary health care in Pakistan Primary health care, often abbreviated as PHC, is the first level of contact between the individual and the health system, where the majority of prevailing health problems can be satisfactorily managed. Also, according to the WHO and the United Nations Children s Fund (UNICEF), primary health care is defined as essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. 4 In Pakistan, the model of primary health care was that adopted in the declaration of the International Conference on Primary Health Care held in Alma Ata in 1978 (known as the Alma Ata Declaration ) and became a core concept of the WHO s goal of health for all. During the 1980s, the Basic Health Services Project and Primary Health Care Project laid down a framework on the basis of population. The health infrastructure was expanded so that each Union Council (UC) had a BHU and at each Markaz/ Thana level a RHC was established. In Pakistan there is a large primary health care infrastructure. This includes 5000 BHUs, 600 RHCs, and 7500 other first-level care facilities. Primary health care focuses on the following components: Education concerning prevailing health problems and the methods of preventing and controlling them 31 Promotion of a safe food supply and proper nutrition An adequate supply of safe water and basic sanitation Maternal and child health care, including family planning Immunisation against major infectious diseases 4 International Conference on Primary Health Care Alma-Ata, U. (1978). Primary Health Care. USSR: WHO and UNICEF.

32 Prevention and control of locally endemic diseases Appropriate treatment of common diseases and injuries Provision of essential drugs Moreover, in 1994 the Government of Pakistan launched the Programme for Family Planning and Primary Health Care (the LHW programme) through the Ministry of Health. The programme recruited women and trained them to provide family planning and primary health care services in their own communities. These women, known as LHWs, were the frontline of primary health care in many low income communities of Pakistan. The major objectives of this Programme were to reduce poverty and improve national health indicators through the provision of essential primary health care services. The Programme contributes directly to Millennium Development Goals (MDGs) 1, 4, 5 and 6, and indirectly to MDGs 3 and 7. Presently LHWs are supposed to deliver a range of services related to maternal and child health, including promoting childhood immunisation, growth monitoring, and family planning and health promotion. They treat minor ailments and injuries and are trained to identify and refer more serious cases. Also LHWs are involved in supporting the implementation of many public health programmes including those on tuberculosis treatment, malaria control, immunisation, polio eradication, health education, maternal, newborn and child health and family planning. For capacity building of this cadre, the WHO and many other international non-governmental organisations (INGOs) provide technical support in relation to updating the knowledge and skills of supervisors, through regular refresher courses, and assist the health authorities in developing monitoring and supervisory checklists and creating a feasible health management information system for the Programme. Besides the above-mentioned initiatives, during recent years a number of policies and interventions have been adopted for the provision of better health care services at the primary level in Pakistan. A few of these are mentioned below: Health MDGs (2015) For the attainment of eight MDGs, the UN Millennium Declaration fixed 18 targets and 48 indicators, of which Pakistan has adopted 16 targets and 37 indicators. Three of the eight MDGs relate directly to the health sector, with four targets and 16 indicators. The MDGs include: Reducing Child Mortality (one target, six indicators); Improving Maternal Health (one target, five indicators) and Combating HIV/AIDS, Malaria and Other Diseases (two targets, five indicators)

33 Needs Assessment in Primary Health Sector Bhawalnagar 2.3 Medium Term Development Framework ( ) The first Medium Term Development Framework (MTDF), provided guidelines to ensure equitable development in all the regions of Pakistan. The MTDF acknowledged the MDG targets and strengthened the shift from curative services to preventive, promotive and primary health care. Moreover, MTDF also addressed the issues of health care financing, health insurance and employees social security, and public private partnerships in the health sector. Considering the on the ground health situation, the MTDF proposed a sound health care system and the practising of a healthy life style, in partnership with the private sector, including civil society. The MTDF health sector strategy was focused on: primary health care in rural areas and urban slums; vertical programmes, training and re-training of medical staff; subsidisation of health services for the poor segments; regulation of the private sector; and health education through skill development of health staff in communication techniques at all levels. Parallel to the MTDF, a Medium Term Budgetary Framework (MTBF) project had also been started by the Ministry of Finance, in collaboration with the UK s Department for International Development (DFID). MTBF was supposed to provide budgetary guidelines to the finance departments Integrated Reproductive Maternal Newborn and Child Health (RMNCH) and Nutrition Programme (Punjab ) This Programme is designed to reduce maternal, newborn and child morbidity and mortality, promote family planning services and improve nutritional status of women and children and help to achieve related MDGs by The Programme aims to increase accessibility of MNCH services by provision of 24/7 service delivery at selected BHUs, all RHCs, Tehsil Head Quarters (THQs) and District Head Quarter Hospitals (DHQs). A notified Provincial Management Committee will select the BHUs for this Programme; the criteria for selection include the geographical distribution of, and the community s accessibility to, individual facilities Mid Term Development Frame Work , Higher Education Commission. Pakistan 7 PC Government of Punjab, Integrated Reproductive Maternal Newborn and Child Health (RMNCH) and Nutrition Program.

34 2.5 EPHS Package (2012) The main objective for developing the EPHS at the primary care level in Punjab is to define minimum health services to be provided as an integrated package, at a given level of health service Punjab Health Sector Strategy ( ) Based on the current health status and delivery modalities in Punjab, a health sector strategy has been devised with a vision to enhance the health status and productive lives of the people of Punjab by improving maternal and child health, nutrition, and control of communicable and non-communicable diseases. The key emphasis of the Strategy is on integrating health services, supported by a strong M&E system. Main policy actions proposed in the strategy are: 9 A Health Sector Ministerial Board (HSMB) Implement Health Sector Strategy in a Phased Approach Effective M&E of Strategy implementation Measure progress through improvements in health outcomes Focus on key strategic areas 2.7 Punjab Rural Support Programme (PRSP) model 34 In order to improve the delivery of services, a number of alternative models have also been implemented during recent years in the province. One such model, of contracting out BHUs, was tried out in Punjab to reorganise and restructure the management of all the BHUs in the district, with a central role for community-based support groups. It started under the Chief Minister s Initiative on Primary Healthcare in Rahim Yar Khan District in The purpose of this initiative was to strengthen the curative and preventive services by handing over the management and finances of running the BHUs to the PRSP. This model was evaluated in 2005 by the World Bank, which recorded positive results in increasing the utilisations rates of these facilities. However, there has been no evaluation of improved health outcomes in the catchment populations Technical Resource Facility. (2013). Essential Package of Health Services for Primary Health Care in Punjab, Technical Component. Government of Punjab 9 PHSRP. (2012). Punjab Health Sector Draft Startegy Department of Health 10

35 Needs Assessment in Primary Health Sector Bhawalnagar 2.8 Issues in primary health care System In spite of the above-mentioned strategies and interventions, Pakistan is unsuccessful in achieving its targets and is far behind in meeting the MDGs. Various reasons have been being identified from a global perspective, through a literature review. This review highlights that inadequate resource allocations and low prioritisation of health by the government are the top reasons. 2.9 Management and governance issues For all health programmes, implementation largely lies with the district governments, with extensive network outlets at the district level: primary, secondary and tertiary. Executive District Officers Health (EDOs-H) are in charge of the district health system and are responsible for delivering promotive, preventive and curative services through outreach workers and primary care district facilities. The managers of all primary health facilities report to the EDO-H. The efficiency of the entire system, however, ultimately depends on a robust information system, the quality of data generated and the effective use of evidence for decision-making. However through the secondary literature, it was assessed that use of evidence has seldom taken place in crucial decision-making in Pakistan s health sector. 11 The main weaknesses found were: inadequate IT facilities and lack of trained manpower; a weak supporting and monitoring mechanism; a negligible budget; and almost no maintenance. The published literature suggests that many developing countries have benefited from the use of computer databases in the health sector and from the generation of evidence which has eventually been utilised for effective strategic planning for improved health system performance Access According to the WHO, accessibility of health services depends on a structure of health services or health facilities that enhance the ability of people to reach a health care practitioner, in terms of location, time, and ease of approach. 13 Access to facilities is an important component in the overall healthcare system and has a direct impact on the burden of disease that affects health conditions in many developing countries Yasir I, Shaikh BT. (2011). Use of evidence for decision making: A qualitative exploratory study of the MNCH Program. Pakistan: Pak J Public Health 12 Spero JC, McQuide PA, Matte R. Tracking and monitoring the health workforce: a new human resources information system (HRIS) in Uganda. Human Resource Health. 13

36 Transport, road infrastructure and distance play a dynamic role in access to and delivery of health services, and in the effectiveness of the referral process. According to Pakistan Standards, primary health care facilities are located within 5 km of patients. Research has shown that approximately 80 percent of maternal deaths could be averted if women had access to essential maternity and basic health care services. 14 Studies reveal that women who lack access to a road tend to have less access to health services in relation to receiving pregnancy care. In Indonesia, for instance, 64 percent of women living near a well-developed road receive ANC by a skilled service provider, compared to 38 percent of those living near a non-paved way. 15 In Malawi, rehabilitation of the road system in particular areas has increased the number of patients in the nearest hospital by 15 percent. 16 Similarly, after constructing new direct roads in Kenya the better roads increased utilisation of a district hospital. 17 Transportations costs are one of the primary factors deterring a community from seeking care from a health facility, if that community is remotely located. Even when a vehicle is available, its cost may inhibit utilisation in certain cases. A study in Bangladesh reveals that transport is the second biggest expense for patients, after medicines. 18 Likewise a study conducted in rural Sudan shows that half of families were unable to take their children to hospital even after referral due to transport costs. 19 As an intervention, in countries like Uganda, Malawi and Tanzania, transportation vehicles like bicycle or modified bicycle ambulances are quite common for transporting pregnant women. 20 Studies show that bicycle ambulances are a preferred choice by families for obstetric referral because of their cost effectiveness. Another study reveals that ambulance bicycles resulted in a reduction in home deliveries in Malawi. 21 These sorts of transport facilities are most commonly used for general medical problems, but are also utilised to carry pregnant women. Measuring access to healthcare facilities contributes to a wider understanding of health system performance within and between countries and facilitates the development of evidence-based health policies Ronsmans, Carine, Graham W. Maternal Mortality: who, when, where and why?, The Lancet, 2006; 368 (9542: 1193) Ishimori, Koichiro. (2003). The Impact of Road Development on the Health of Pregnant and Parturient Women. Results from collaborative research project between The Japan Bank for International Cooperation (JBIC) and the United Nations Population Fund (UNFPA). July October. 16 Ellis SD (1996). The economics of the provision of rural of rural transport services in developing countries. PhD Dissertation, Bedfordshire, UK: Cranfield University. 17 Airey, T. (1991). The influence of road construction on the health care behavior of rural households in the Meru District of Kenya. Transport Reviews; 11: Ensor, Tim, and Stephanie Cooper. Overcoming barriers to health services access: influencing the demand side Review article. Health Policy and Planning 19, No. 2 (2004): Oxford University Press. 19 Sumaia Mohammed al Fadil, Samira Hamid Abd Alrahman, Simon Cousens, Flavia Bustreo, Ahmed Shadoul, Suzanne Farhoud and Samia Moahmed El Hassan. (2003). Integrated management of childhood illness strategy. Sudan. 20 Ishimori, Koichiro. (2003). The Impact of Road Development on the Health of Pregnant and Parturient Women. Results from collaborative research project between The Japan Bank for International Cooperation (JBIC) and the United Nations Population Fund (UNFPA). July October. 21 Ahluwalia, I. B., Schmid, T., Kouletio, M., and Kanenda, O. (2003). An evaluation of a community based approach to safe motherhood in North-western Tanzania. International Journal of Gynaecology and Obstetrics, 82, pp Mainardi, S. (2007). Unequal Access to Public Healthcare Facilities: Theory and Measurement Revisited. Surveys in Mathematics and Its Application. 2:

37 Needs Assessment in Primary Health Sector Bhawalnagar The use of GIS for the measurement of physical accessibility is well established and has been applied in many areas, including retail analysis, transport, emergency services, and health care planning. For example, the Honduras Ministry of Health, along with Pan American Health Organization (PAHO) has undertaken a project to identify accessibility problems in relation to primary health care using GIS. A study in New Zealand has estimated the geographical accessibility of public hospitals. A cost path analysis was used to determine the minimum travel time and distance to the closest hospital via a road network. Local average time and distance statistics were calculated by modelling the total travel time of an individual, assuming that everybody visited a hospital at least once. These types of statistics can be generated for different population groups, and comparisons can be made between regions. 23 The WHO has been involved in measuring accessibility of healthcare facilities in developing countries, working in collaboration with a number of academic institutions. 24 The WHO has used AccessMod software to calculate accessibility, which determines the geographic extent of the catchment areas corresponding to an accumulated cost surface using the standard Cost Distance function available in the Spatial Analyst extension for ArcView 3.x. 25 The WHO has provided training on using this software to the Department of Health of the Philippines, the Ministry of Health of Cambodia and the Ministry of Health of Malawi Coverage and service delivery Coverage issues and inequitable service delivery have been identified as major hindering factors in providing services to far-flung areas of any country. The 2006 World Health Report proposes that density of health care provision is the key to achieving the fifth MDG: reduction of maternal mortality by 75% by One of the major challenges is securing the availability and effective use of HR in each part of a country, especially in remote areas. A relevant study conducted on the distribution of midwives in districts in Indonesia, reflects the same results: with inequitably distributed provision in remote villages as compared to urban areas. This translates into considerable advantages to urban residents. In contrast to rural villages, urban areas have a more stable and experienced workforce and are more likely to have resident midwives The lack of qualified HR for health care is a major limiting factor in implementing 23 Brabyn, L. and C. Skelly Modeling Population Access to New Zealand Public Hospitals. International Journal of Health Geographics 1(3): Black, M., Ebener, S., Aguilar, P. N., Vidaurre, M. and Morjani, Z. E Using GIS to Measure Physical Accessibility to Health Care. Geneva: World Health Organization Makowiecka, K., Achadi, E., Izati, Y., and Ronsman, C. (2007). Midwifery Provision in Two districts in indonesia: How Well are Rural Areas Served. Health Policy and Planning, 23(1), 67 75

38 health policies and health reforms in the developing world. 27 A recent study underlines this fact and states that progress toward health-related MDGs is seriously impeded by a lack of HR for health. 28 Being a low-resource country, Pakistan s health sector is also facing tremendous problems in meeting the health care needs of its people, mainly because of a dearth of trained HR in the rural areas where 65% of the population lives. 29 In the past decade much attention has been given to finding solutions to the health workforce crisis and, while some progress has been made, by 2011 the Global Health Workforce Alliance found that of the 57 countries they surveyed, less than half had developed a plan to strengthen their human resources for health (HRH) and even less had implemented the plan. 30 One of the major interventions to cope with HR deficiency is task shifting, defined by the WHO (2008) as the rational redistribution of tasks among health worker teams Many Sub-Saharan African countries are using task shifting as an ad hoc measure, largely in response to the need to scale up HIV/AIDS prevention and treatment. Sometimes tasks are redistributed to workers who do not normally carry out such tasks for example, nurses giving antiretroviral therapy (ART). In Mozambique, Zambia and Uganda task shifting has reduced the number of doctors required to deliver HIV/AIDS services and has improved some dimensions of service quality. 31 Similarly, a community health worker cadre has existed for many years and has been shown to extend access to services as well as improve quality. 32 Haynes et al have described the task shifting for community health workers as a partial solution to extending the reach of in adequate health systems, aiming to expand coverage of key interventions and to fill the unmet demand for health services in communities. 33 High-income countries, such as the United Kingdom, have also had practical experience with task shifting. Empowering nurses to prescribe routine medication has been successful both in expanding services and improving clinical outcomes for patients. 34 For countries where the majority of the population lives in rural areas and where health care facilities are inefficient and inadequate, telemedicine/ telehealth can contribute substantially in bridging the gap between demand and supply. The main uses of ehealth in developing countries have been to improve access to health care services, enhance the quality of care by making patient data and other relevant World Bank The Millennium Development Goals for Health, Rising to the Challenges. Washington, DC: World Bank. 28 Thomas S, Mooney G and Mbatsha S (2007) The MESH approach: Strengthening public health systems for the MDGs Health Policy 83(2 3): UNAIDS and WHO (2009) AIDS Epidemic 29 Kumar, R., Shaikh, B. T et al.,.(2013, Sep 10). The Human Resource Information System: A Rapid appraisal of Pakistan s Capacity to employ the Tool. Biomedical Informations & Decision Making. doi: / Global Health Work Force Alliance. (2011). Progress report on the Kampala Declaration and Agenda for Global Action: Reviewing Progress, Renewing Commitment. Geneva 31 IATT task Team on Human Resources. (2013). Human Resources for Health: A key component to achieve the plans of global health. 32 Celletti F, Wright A, Palen J e al. (2010). Can the deployment of community health workers for the delivery of HIV services represent an effective and sustainable response to health workforce shortages? Results of a multi-country study. AIDS.24:1:S Haines A, Sanders D, Lehmann U et al. (2007). Achieving child survival goals: potential contribution of community health workers. The Lancet, 369(9579), WHO. (2007). Task shifting to tackle health worker shortages.

39 Needs Assessment in Primary Health Sector Bhawalnagar information available to HCPs at the point of care. SUPARCO, the national space agency of Pakistan which has experience in satellite communications, has initiated a satellite communication based telemedicine network as a pilot project. This pilot has been successfully established. 35 The literature review highlighted Pathfinder s health work in Tanzania which began in 2008 with funding from the Centers for Disease Control. This project, housed under the Tutunzane project, uses mobile technology to improve communication and reporting between health clinics, home-based care providers, and clients. In collaboration with an NGO (D-Tree International), Pathfinder and its Tutunzane partners are using a mobile phone-based application, Care, to improve HIV and AIDS, tuberculosis, malaria, and family planning services offered at the community level. Community home-based care providers use mobile phones to provide better care during home visits, to follow referrals, and to improve client data management and use. Each month, CommCare sends a short message service (SMS) or text message summary of community home-based care activities to the home-based care providers supervisors. District level coordinators access the collected data online, which further improves communication and information-sharing between community-based providers, facility providers, and district coordinators. There are currently more than 300 home-based care providers in and around Dar Es Salaam using this mobile phone application Quality The literature review indicates that in many developing countries staff performance is not effectively monitored and evaluated. Assessment practices are unsatisfactory, quality standards are badly defined and little attention is paid to transparent processes and performance audits. 37 Having few resources, Pakistan also faces the same issues of monitoring, resulting in a compromised quality of primary health care. To address these issues of quality, the concept of Performance-Based Finance (PBF) has been introduced in several countries. Performance-based financing can be defined as a mechanism by which health providers are, at least partially, funded on the basis of their performance or, The transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target Engr.Zulfiqar Ali Junejo. n.d. Suparco Telemedicine Pilot Project Miller, Bennett et al., (2004) Determinants and consequences of health worker motivation in hospitals in Jordan and Georgia. Social Science and Medicine. 58: doi: /S (03)00203-X. 38 Eichler R. (2006). Can pay for performance increase utilization by the poor and improve the quality of health services? Discussion paper for the first meeting of the Working Group on Performance-Based Incentives. Washington: Center for Global Development. Available from: PBI%20Background%20Paper [1].

40 Findings from a study in Uganda confirm that PBF can stimulate important changes and set incentives that improve health care quality. In Cambodia, performancebased financing was applied to the public sector However, despite promising results, it did not materialise into a national policy. Such a breakthrough did, however, take place in Rwanda. Several pilots initiated in 2002 allowed for a better understanding of major issues. The country then rapidly adopted performancebased financing as its national policy and scaled up the approach to the entire country in Why does governance matter to health? According to one study by Pappas and Ghaffar, governance matters to health first because market forces alone cannot ensure equitable distribution of health care and health in populations. Governance in the health sector is closely related to the issue of equity because health care is guaranteed by the constitutions of many nations and by international treaties. Moreover, prevention measures, including road traffic injury control, provision of clean water and sanitation, or draining malaria swamps, are public goods with externalities that require social coordination to ensure action. Assuring conditions for health and well-being in populations can be fulfilled only by the assurance of adequate regulatory, legislative, and social measures. 45 Poor governance in the health sector has led to misdirected spending of funds intended to improve the health status of the population. Corruption, inefficiency, and poor regulatory authority undermine health care delivery in much the same way they do for police services, courts and customs. In Pakistan, the past few years have seen landmark constitutional developments, chief among them being the adoption of the 18th Constitutional Amendment, followed by the 7th National Finance Commission Award. 46 Prior to the adoption of the 18th Amendment, provinces and other federating units had been represented in the central legislature, with significant policy and economic development Van Damme W, Meessen B, von Schreeb J, Heng TL, Thomé JM, Overtoom R, et al. (2001). Sotnikum new deal, the first year better income for health staff; better service to the population. Phnom Penh: Médecins sans Frontières. 40 Barber S, Bonnet F, Bekedam H. (2004). Formalizing under-the-table payments to control out-of-pocket hospital expenditures in Cambodia. Health Policy Plan. 19: doi: /heapol/czh025 pmid: Soeters R, Griffiths F. (2003). Improving government health services through contract management: a case from Cambodia. Health Policy Plan, 18: doi: /heapol/ pmid: Meessen B, Musango L, Kashala J-P, Lemlin J. (2006). Reviewing institutions of rural health centres: The Performance Initiative in Butare, Rwanda. Trop Med Int Health, 11: doi: /j x pmid: Soeters R, Habineza C, Peerenboom PB. (2006). Performance-based financing and changing the district health system: experience from Rwanda. Bull World Health Organ, 84: pmid: Rusa L, Schneidman M, Fritsche G, Musango L. Rwanda. (2009). Performance-based financing in the public sector. In: Performance incentives for global health: potential and pitfalls. Eichler R, Levine R and the Performance-Based Incentives Working Group, editors. Washington: Center for Global Development 45 G Pappas, A Ghaffar, T Masud, A Hyder, S Siddiqi. Governance and health sector development: a case study of Pakistan. The Internet Journal of World Health and Societal Politics Volume 7 Number National Report: Situation Analysis of Children and Women in Pakistan Government of Pakistan, UNICEF.

41 Needs Assessment in Primary Health Sector Bhawalnagar responsibilities already devolved to the sub-national level. Under the Devolution Plan in 2001, a third tier of local government (comprising district, Tehsil and union administrations) was introduced. All these developments established a new framework of devolution of powers from the federal level to the provinces and carried with them the prospect of better service delivery and greater scope for public participation Ibid.

42 3 District profile of Bahawalnagar 3.1 History and geography of the district Bahawalnagar is a district of Punjab province in Pakistan, situated on the country s border with India. Before the independence of Pakistan, Bahawalnagar was part of Bahawalpur State and was governed by Nawab of Bahawalpur. Bahawalnagar District is spread over an area of 8,878 square kilometres comprising five tehsils, i.e. Tehsil Bahawalnagar, Tehsil Chishtian, Tehsil Fort Abbas, Tehsil Haroonabad and Tehsil Minchinabad, and 118 UCs. 48 The River Sutlej flows through this district. The boundaries of Bahawalnagar in the East and South touch Indian territory. While Punjabi is the language spoken by the majority of the population in the district, Urdu and Seraiki are also spoken. Bahawalnagar District is the only district of Bahawalpur Division in which the majority of the population speaks Punjabi, instead of Seraiki Climate 42 Bahawalnagar District has a very hot and dry climate in the summer. The maximum temperature touches 52 degrees centigrade. The climate in winter is very dry and cold. The average annual rainfall in the district is 119 mm. The district can be divided into three parts according to the soil condition, i.e., the riverine area, the canal irrigated plain and the desert area. The riverine area of the district lies close to the Sutlej River, which flows in the Northwest along its border with Okara, Pakpattan, Sahiwal and Vehari districts. Non-perennial canals irrigate the land in this area. During the summer monsoons, the area is generally inundated by river water. The desert area of the district is called Cholistan Three year rolling Plan Bahawalnagar District 49 Ibid. 50

43 Needs Assessment in Primary Health Sector Bhawalnagar Figure 3.1: Map of Bahawalnagar District 3.3 Population The total population of Bahawalnagar District is 2.7 million. Of this population, 51% are males and 49% are females. The majority of the total population (70%) lives in rural areas. The population density of the district is 259 persons per square kilometre. The annual population growth is estimated to be 2.4%. The highest proportion of the population lives in Tehsil Bahawalnagar (26 %), followed by Tehsil Chishtian (24%), Tehsil Haroon Abad (19%), Tehsil Minchin Abad (17%) followed by Tehsil Fort Abbas (14%) Education and economy According to the PSLM Survey , the overall literacy rate for the population aged 10 years or above is 54% and the district ranks 26th in the province. The adult literacy rate in Bahawalnagar is 50% and the district ranks 22nd in Punjab province. 51 National MNCH Program, Government of Pakistan Health Facility Assessment Pakistan

44 Geographical segregation reveals huge disparities. The literacy rate in urban areas for ages 10 years and above is 69%, while for ages 15 and above it is 66%. On the other hand, the literacy rate in rural areas for ages 10 years and above is 50% while for ages 15 years and above it is 49%. 52 Indicator Access to tap water 42 Access to flush toilet 67 Value Electricity 93.3 Household size 6.5 Infant mortality rate (IMR) 96 Institutional delivery 34 Under-five mortality rate (U-5) 124 Source: Multiple Indicator Cluster Survey (MICS) 2011 and Pakistan Social and Living Standards Measurement Survey (PSLM) The human development index (HDI) is a composite statistical index used for ranking an area for the level of its human development. Bahawalnagar District has an average HDI, out of the districts in the province, at The district has an HDI that is lower than the average HDI of Punjab (0.670) Health status Health indicators for Bahawalnagar have shown improvements in recent years but the situation is far from satisfactory when assessed against the MDGs. The current situation of the key health indicators of the district suggests a need for improvement. 44 The following description of the health sector in Bahawalnagar shows that there is a need to take action. It highlights major issues in each area of health and presents indicative issues for action planning. The areas are described according to their importance and linkage with key health goals, beginning with a discussion of maternal health. 52 Federal Bureau of Statistics, Government of Pakistan. Pakistan Social and Living Standard Measurement Survey, Jamal H, Khan AJ Trends in Regional Human Development Indices, Research Report and 54 ibid.

45 Needs Assessment in Primary Health Sector Bhawalnagar 3.6 Issues in maternal healthcare ANC is necessary to ensure optimal maternal health as well as to ensure a healthy beginning for new lives. Efforts have been made to achieve the targets in this area; however, despite these efforts, there has been minimal progress in reducing maternal mortality during the last decade. The current situation in Bahawalnagar is marked by a high maternal mortality rate placing pregnancy and childbirth related mortality on top of public health issues in the district. According to the Annual DHIS Report 2013, 49 maternal deaths were reported by public sector facilities. 55 In Bahawalnagar, 63% of pregnant women reported having antenatal consultations. However, only 18% of ANC services were provided by public sector health facilities. This proportion was even lower in rural areas (16%). Private clinics and hospitals provided ANC to 47% women. Tetanus Toxoid (TT) immunisation was provided to 67% of pregnant women and the district was ranked 37th in Punjab for TT immunisation. 56 According to the Annual DHIS Report 2013, 59,656 first antenatal care visits (ANC-I) were reported by public sector facilities, and 56,828 pregnant women were administered TT-2 immunisation 57. Skilled birth attendance is a pre-requisite for ensuring effective maternal care, and for reducing the burden of maternal morbidity and mortality. Currently, 40% of births are conducted by Skilled Birth Attendants (SBAs) in the district. However, the share of public sector facilities is a cause for concern, as only 13% deliveries took place in public sector facilities. The percentage of home deliveries is rather high: 57% of births occur at home and TBAs conduct 5% of all births that occur in the district. 58 Globally, the major proportion of maternal deaths occurs during the first 24 hours after delivery. In this time period, institutional readiness protocols to respond to emergencies are an area that can enhance survival. The situation of postnatal care in Bahawalnagar is also not good. Only 15% of mothers consulted a health facility for postnatal check-up, which is less than the provincial average of 28%. Out of the mothers who received postnatal care in Bahawalnagar, 27% visited a public sector facility for postnatal services, while 44% went to a private hospital or clinic Department of Health, Government of Punjab. Annual DHIS Report Federal Bureau of Statistics, Government of Pakistan. Pakistan Social and Living Standard Measurement Survey, Department of Health, Government of Punjab. Annual DHIS Report Federal Bureau of Statistics, Government of Pakistan. Pakistan Social and Living Standard Measurement Survey, ibid.

46 3.7 Highlights of poor maternal health in Bahawalnagar District During 2013, 49 maternal deaths were reported in public sector facilities. Only 18% of pregnant women receive ANC in public sector facilities; in rural areas this percentage is 16%. TT immunisation is provided to 67% of pregnant women Overall skilled birth attendance is 40%; and out of these, 13% of deliveries take place in public sector facilities. Postnatal care coverage is 15%. Figure 3.2: Situation of maternal health in Bahawalnagar 73% 81% 63% 67% 40% 32% 28% 15% Antenatal Care TT Immunisation Skilled Birth Attendence Postnatal Care Punjab Bhawalnagar 3.8 Status of child health 46 Infant and under-five mortality rates are the most widely used indicators of health status and socio-economic development because they reflect not only child mortality levels but also the health status of the broader population. The fourth MDG calls for a two third reduction in the under-five mortality rate (U5MR) and the IMR between 1990 and Similar to other districts in Punjab, Bahawalnagar relies on survey data to measure infant and childhood mortality because essential registration and health information systems are not adequate for this purpose. The last empirical estimates of childhood mortality thought to be reliable were collected from the Health Facility Assessment (HFA) Report Punjab, According to the MICS report, Bahawalnagar has an IMR of 96 deaths per 1,000 live births. 60 According to the DHIS report 2013, diarrhoea was the most common communicable disease in children under five years of age in Bahawalnagar. This finding is consistent with the pattern of disease burden reported in the literature. A review of national surveys revealed that 15% of children under five years of age suffered from diarrhoea during the 30 days prior to the survey, indicating the significant contribution of diarrhoea to the overall burden of disease. Preventing dehydration In 2013, 68,131 cases of diarrhea among children under 5 years of age were treated in the outpatient departments of primary and secondary level facilities in District Bahawalnagar. Source: Annual DHIS Report, Government of Punjab. Multiple Indicator Cluster Survey, 2011.

47 Needs Assessment in Primary Health Sector Bhawalnagar and malnutrition by increasing fluid intake through some form of oral rehydration therapy (ORT) and continuing to feed are key strategies for managing diarrhoea. Diarrheal can be cost effectively managed at community level with zinc and ORS use. 61 ORS use in children with diarrhoea has steadily increased in recent years, but Bahawalnagar is still ranked 32nd among the districts of Punjab in terms of cases of diarrhoea in which ORS is given to a child. In Bahawalnagar, healthcare providers are consulted in 91% of childhood diarrhoea cases; and 50% of these cases are given ORS to treat the dehydration. According to the Annual DHIS Report of 2013 for Bahawalnagar, the number of children (U5) having suspected pneumonia was 11, The low levels of awareness of danger signs contribute to mismanagement and delays in seeking appropriate care for children suffering from pneumonia. 3.9 Immunisation-preventable diseases The percentage of immunisation coverage in Bahawalnagar is 90%, which is higher than the provincial coverage of 89%. 63 Based on the available resources the district should be able to improve this coverage level. Figure 3.3: Comparison of immunisation status in Bahawalnagar (fully immunised) 92% 89% 89% 89% 89% 90% URBAN RURAL OVERALL Punjab Bahawalnagar 3.10 Tuberculosis 47 Pakistan is one of 22 countries that still have endemic levels of tuberculosis (TB), with an estimate of 353 cases per 1000 population. TB represents the main burden of disease among the poor. According to the Annual DHIS Report 2013 for Bahawalnagar, 13,263 suspected cases of TB were treated in the OPDs of public 61 Department of Health, Government of Punjab. Annual DHIS Report ibid. 63 Federal Bureau of Statistics, Government of Pakistan. Pakistan Social and Living Standard Measurement Survey,

48 sector facilities in the district. Moreover, intensive-phase TB directly observed treatment, short-course (DOTS) patients numbered 7,871, numbers of slides for acid fast bacteria (AFB) diagnosis were 11,824 and slides for AFB positive were Malaria In Bahawalnagar, a total of 30,866 cases of malaria were treated at public facilities in ; the number of slides examined was 20,566 and the numbers of slides with MP positive was Hepatitis In Bahawalnagar, 6,215 suspected cases of Hepatitis were treated in the OPDs of public sector facilities in The number of screened patients was 20,603, the number identified as Hepatitis B positive was 23 and the number identified as Hepatitis C positive was Other communicable diseases According to the Annual DHIS Report of 2013 for Bahawalnagar, in addition to the aforementioned communicable diseases, which represent the majority of these health problems, other common communicable diseases include scabies (10,660,8 cases), Typhoid Fever (4,713 cases), and Otitis Media (27,473 cases) Rising burden of non-communicable diseases 48 According to the Annual DHIS Report 2013, hypertension contributed 77,817 cases at public facilities, followed by ischaemic heart disease at 6,400 cases. Among respiratory disorders, asthma contributed 76,429 cases, while chronic obstructive pulmonary diseases contributed 25,599 cases. Peptic ulcer diseases contributed 155,403 cases, and diabetes contributed 40,714 cases to the burden of disease in Bahawalnagar District Department of Health, Government of Punjab Annual DHIS Report. 65 Department of Health, Government of Punjab Annual DHIS Report 66 Ibid. 67 Ibid. 68 Ibid. 69 Ibid. 70 Ibid.

49 Needs Assessment in Primary Health Sector Bhawalnagar 3.15 Unsafe water and sanitation According to PSLM , 42% of households in Bahawalnagar, overall, have access to tap water, which is higher than the provincial average of 22%. Bahawalnagar is ranked fourth among the districts of Punjab in terms of availability of tap water for households. Within the district, 76% of households in urban area have access to tap water; but in rural areas, only 34% of households have access to tap water. 71 The presence of a flush toilet is strongly associated with a reduced risk of infant death, with the IMR in households having a flush toilet being 22% lower than in households without such a toilet. 72 In Bahawalnagar, 67% households have access to flush toilet, which is less than the provincial average of 72%. The district is ranked 25 th in the province, in terms of access to a flush toilet 73. Figure 3.4: Access to tap water and flush toilets in Bahawalnagar 72% 67% 22% 42% Access to tap water Punjab Access to flush tiolet Bahawalnagar 3.16 Health seeking behaviour Only 15.86% of Bahawalnagar s population use public sector services, as compared to 17.60% in Punjab province % use private practitioners, versus 73.24% in the province. 74 In Bahawalnagar, 7.60% of the adult population and 10.71% of U5 children reported sickness during the two weeks preceding the PSLM survey, and 93.57% and 96.99% of these received care, respectively Ibid. 72 Jannifer Bennett. Correlates of Child Mortality in Pakistan: A Hazards Model Analysis. The Pakistan Development Review, 1999; 38(1): Federal Bureau of Statistics, Government of Pakistan. Pakistan Social and Living Standard Measurement Survey, Federal Bureau of Statistics, Government of Pakistan. Pakistan Social and Living Standard Measurement Survey, ibid.

50 According to the DHIS report, the following is the catchment population of BHUs in the district, with their coverage of population. Table 3.1: Primary Health Care Facilities (BHUs) Facility Catchment Population District Bahawalnagar Tehsil Bahawalnagar Number of New Visits Coverage Percentage BHU Kot Makhdom % BHU Muhar Wali % BHU PunjKossi % BHU Kot Rodha Singh % Tehsil Haroonabad BHU Chak No 58/4-R % BHU Chak No 154/3-L % BHU Chak No 24/3R % Tehsil Chishtian BHU Chak No. 112/M % BHU Chak No 127/M % BHU Jhadwan % Tehsil Fortabbas BHU Chak No 227/9-R % BHU Chak No. 297/HR % Tehsil Minchinabad BHU Haran wala % BHU Hasil Saroo % BHU Kabootri % Private sector facilities The private sector makes a significant contribution to healthcare provision in Bahawalnagar District, as in the rest of the province. However, the private health sector remains largely undocumented and unregulated despite the fact that it is a substantial and major source of health services and health financing in Pakistan. District Health Office Bahawalnagar reports 30 private health facilities in the district, ranging from specialised private institutions to single person clinics, including hospitals, clinics, and maternity homes. A detailed list of private sector facilities is provided in Annex D.

51 Needs Assessment in Primary Health Sector Bhawalnagar 4 Findings and results The findings and results of the study are presented in the following pages. In line with the objectives of this study, the results address areas such as: management and governance issues at provincial and district levels; district finance and budgetary allocations, and how they hamper or support primary healthcare service delivery in the district; access to services through qualitative and quantitative primary research and GIS based analysis; service delivery and coverage; and quality of services. 4.1 Management and governance issues at provincial level The primary and secondary data sources such as MICS, PDHS and HMIS are used for policy formation but before that there should be third party evaluation to ensure quality and reliability of data. If linkage between Population Welfare Department and LHW is developed it can overcome unmet needs. We have offered Population Welfare Department for space in Health facilities to maintain privacy of women who do not want community to know that she is using FP methods. This idea was appreciated but never implemented. There is no certain training mechanism for managers. They are unaware of their job description, only 10% from all would be good managers. Due to lack of capacity, mangers are dependable on other departments like they will be reliant on finance department for audits, without knowing themselves anything. Most of the stakeholders involved in policy decision-making in Punjab who responded to the study reported a limited use of data for planning health services. An absence of collated information and cross tabulation of data coming from different health departments and programmes (the PWD, the DoH, vertical programmes etc.) was stated as one of the major issues impeding effective use of evidence for decision-making. Moreover, the low quality reporting system has resulted in constrained decision-making and planning at the provincial level. A lack of inter provincial harmonisation between different health services programmes was the main concern highlighted by respondents to the study. A low level of coordination between regular health departments and vertical programmes gives rise to issues such as duplication of resources and services. Most of the vertical programmes have their own management, reporting and monitoring mechanism and work in isolation, with a low level of coordination with other programmes. An insufficient allocation of budget to the health system was by almost all of the respondents. The negligible expenditure on health as a percentage of GDP (2.7%, last calculated in 2012) 76 is unlikely to be sufficient to provide effective and quality health services to the community. Regarding allocation of finances, it was reported that no evidence or data is used while making a budgetary plan facilities in a district. Moreover, the prevalence of diseases and incidences in the district are not considered during the process of allocating finance resources. A lack of management skills and capacity issues was reported at the provincial level. It was assessed by the study that provincial health directors and members of their health management teams have clinical backgrounds, but very few of them are trained in public health planning or health management. Furthermore, no management guidelines have been provided to the provincial mangers to guide them in performing their management and leadership roles

52 A coverage issue, as a result of the increasing population, was reported: there is a major gap in the provision of health services. It was mentioned that initially one LHW was appointed for a population of households. After implementation of the Devolution Plan, government had increased the catchment population for LHWs to 1400, to enhance programme coverage. For a long time, recruitment was banned and retired staff could not be replaced; therefore it has become impractical to cover all the targeted population. In order to achieve 100% coverage, more HR are required, to cater to a population of The PWD faces the same issue as a result of their limited number of outreach staff. On average, each Family Welfare Worker (FWW) used to cover two to three UCs, but with the increase in population, FWWs are able to achieve only 25 30% of their targets. Inadequate monitoring and measuring of health system performance was reported in the study. The lack of a monitoring system has led to a failure to achieve optimal service delivery outputs. Provincial managers highlighted issues like lack of funds and HR which would enable effective monitoring. Moreover, delays in provision of resources mean that departments cannot make regular monitoring visits and evaluate workers. It was mentioned that although monitoring manuals have been designed for service providers, due to restricted resources they are not being followed. As no proper mechanism of monitoring exists, adherence to operational guidelines cannot be ensured. Moreover, no grievance redress mechanism has been established at BHU level till now, as the PHC is not taking up this task, because of limited resources. There are gaps in monitoring and evaluation mechanisms as LHWs are directly monitored by LHS; on LHWs one LHS is appointed, it is not easy for 40 field program officer to monitor all LHWs Procurement of medicines and equipment The procurement process, under the PPRA Rules 2009, is followed by the Health Department to procure medical supplies and equipment (see Annex E). It was reported that although a specific timeframe was stipulated for each step of procurement process, the schedule is seldom followed because of inadequate monitoring and supervision and issues with capacity in the planning process. The procurement of medicines should be based on patient load but on ground this principle is not strictly followed 52 The study revealed that the procurement of medicines is not according to the needs of the community. Disease patterns of the district are not considered while processing demand generation and distribution of medicines at BHU level. Moreover, data used to forecast medicines is neither maintained nor reliable. The reliability of data has become questionable because in many instances an appropriately trained person does not collect the information. Flaws in planning do not allow procurement of quality medicines as the focus has always been on acquiring drugs at the cheapest rates, which compromises quality. Improper storage for general medicines at BHUs, including light arrangements, and temperature maintenance was also highlighted in the study.

53 Needs Assessment in Primary Health Sector Bhawalnagar 4.2 Management and governance issues at district level Most of the information shared with us is not reliable; making informed decision making extremely difficult at our end, 95% of what we hear is noise and information not based on truth. District Manager The study revealed the very limited role of the district in the development of any implementation plans because of its weak resources and institutional capacity. No mechanism is in place to prioritise and confirm the needs of the community. Access to reliable evidence-based data sources needed for informed decision-making was reported as the main issue preventing understanding the needs of the community. One of the district officials supported these findings and shared that district officials were not consulted when health policies were formulated or reviewed. However, implementation plans and issues were discussed every month at day-long sessions at the DG s office, chaired by the DGHS Autonomy at district level The DCO is the head of the District Administration in a district. He has the power to evaluate the performance of the officers and direct them to achieve the set goals in the approved district action plans. The study revealed that apparently the DCO had ample administrative authority to deal with HR and finances, but there were often political interference in exercising this authority. It was stated that the DCO had authority to decide but limited powers to implement vis-à-vis politicians in the area. Regarding the hierarchy of the district health system, the EDO(H) is at the top of the management. He manages all the health projects of the district and also coordinates implementation of vertical programmes. The DOH is below him and specifically manages primary healthcare services in a district. The study shows that before devolution, the role of these managers was limited just to executing the health plans set by federal and provincial health ministries. However, after devolution, the districts were given both financial and functional authority to manage health services in the district. The district managers have autonomy to make health plans according to the needs of the community. However, the current study revealed limited district capacities in this regard. Moreover, it was mentioned that the EDO(H) is authorised to initiate disciplinary action and suspend staff up to grade 16. For all cases of above grade I6, the DCO is the final decision-making authority Monitoring and evaluation Traditionally, performance of the district managers and HCPs is judged on the basis of PERs. However, it was shared by the district officials that the report was usually stereotyped, giving good remarks to everyone, irrespective of actual performance. Even if negative remarks were mentioned in PER for any act of gross violation of

54 rules, poor performance or for disobedience, these were more often expunged sooner or later. Promotions were made on a routine basis, based on seniority, and were never linked with performance, according to existing civil service rules. It was reported that the present system does not distinguish between good, average and bad performers. There is no incentive system in place to motivate managers and employees to perform better. It was highlighted in the study that as the vertical programmes receive their budgets directly from the province, HR of vertical programmes, like LHWs, did not consider themselves bound to be answerable to BHUs in charge working under the control of the DoH. This situation has resulted in a lack of coordination and also monitoring of outreach staff by DoH staff. Most of the information shared with us is not reliable; making informed decision making extremely difficult at our end, 95% of what we hear is noise and information not based on truth. District Manager The study revealed a new mechanism to strengthen monitoring in the district was introduced in April, 2014: the introduction and use of IT and tracking telecommunication (through android phone technology). It was reported that performance of district managers was now being monitored by the provincial DoH through a General Packet Radio Service (GPRS) system. District management (EDOH, DHO and DDHO) were provided with android phones for this purpose in March by the Provincial Government. The information is transmitted and consolidated in the health sector dashboard maintained by the Punjab Information Technology Board (PITB). Monitoring is done on set parameters, such as presence of staff, cleanliness and provision of medical supplies, etc. Interestingly, during the month of April, Bahawalnagar District came first in respect of monitoring performance. 4.3 Finance 54 A budget analysis exercise, primarily focusing on health sector budget allocations and AEs incurred in Bahawalnagar during last four years (i.e. FY , , , and ) was also carried out by SNG, Punjab. The analysis was based on budget documents, out-patient data, and disease patterns of the district. All the relevant documents were obtained from the district government. An in-depth analysis of the health sector s current budget (salary and non-salary component) was also carried out. The focus of this analysis was primary health care delivered through BHUs District total non-development budget and expenditure analysis The non-development budget of the district was Rs billion in FY 2011, which increased to Rs in FY The non-development expenditures amounted to Rs billion in FY 2011, which increased to Rs billion in FY Utilisation of the budget remained above 93% during all four years.

55 Needs Assessment in Primary Health Sector Bhawalnagar District salary and non-salary budget and expenditure analysis In the district, the budget salary share was 92%, 91%, 91% and 89% during FY , , and , respectively. The budget utilisation of salary was over 90% during the period; whereas non-salary budget utilisation was much more volatile, ranging from 84% to 151% during the same four year period District health department and budgetary Allocations The health sector at the district level mainly constitutes primary and secondary health service delivery, i.e. BHUs, RHCs and THQ and DHQs. Table 4.1 below shows the budgeted expenditure (BE) and AE for the primary and secondary health care facilities over a period of four financial years. The share of primary healthcare in total health expenditure is a minimum of 33% in and a maximum of 44% in Similarly, the share of secondary healthcare in total health expenditure ranges from 30% to 34%. The rest of the budget is used for administration, other health facilities and general nursing schools, etc. Table 4.1: Allocations for Health Sector in Bahawalnagar and Budget Utilisation Years BE AE BE AE BE AE BE AE* Primary Health Care Percentage Utilisation Secondary Health Care Utilisation Percentage Total Health Current Budget Primary Percentage of Total Health Current Budget Secondary Percentage of Total Health Current Budget 383, , , , , , , ,015 80% 87% 123% 100% 273, , , , , , , , % 90% 95% 103% 904, ,772 1,112, ,034 1,252,280 1,166,849 1,280,657 1,300,979 42% 33% 41% 44% 29% 38% 35% 35% 30% 30% 31% 34% 30% 31% 30% 30% 55 AE* data is for 11 months only.

56 4.3.4 Health spending in district total budget and expenditure The share of the health budget and expenditure in the overall district budget and AEs is shown in the following figure, which shows that the share of health in total expenditure at district level remained between 16% 18% during the four year period. Figure 4.1: Share of Health Sector in Budget and Expenditure 8,000,000 7,000,000 Budget Estimates and Actual Expenditure (Rs.) 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000, % 17% 18% 17% 17% 17% 18% 16% BE AE BE AE BE AE BE AE Years District Current Budget and Expenditure District Health Budget and Expenditure Health non-development budget and expenditure analysis The health current budget was Rs , Rs , Rs , and Rs billion during , , , and respectively. The Year-on-Year (Y-o-Y) increase in the budget was 23%, 2%, and 13% during these years. The Y-o-Y increase in AE was -1%, 29%, and 11%, in , and (Figure 4.2). The utilisation of the budget was 101% and 102% in the financial years and , respectively, and AE was lower than the allocated budget in and , being 81% and 93% respectively. Generally, the utilisation of the health budget has been good, with the exception of FY where the variation between budget allocation and expenditure was 19%. Figure 4.2: Health non-development budget and expenditure analysis (Rs. in Billions) Current Budget Actual Budget

57 Needs Assessment in Primary Health Sector Bhawalnagar Health salary and non-salary budget and expenditure analysis In the health budget, the salary share was 76%, 73%, 70%, and 66%, and the nonsalary share was 24% 27%, 30%, and 34% during , , and , respectively. Similarly, the share of salary in AE was 58%, 79%, 70%, and 65% and the non-salary share was 42%, 21%, 30%, and 35% during , , and , respectively. This trend is depicted in Figure 4.3 below. The budget utilisation of salary was 77%, 88%, 93%, and 100% respectively in the four years. The non-salary budget utilisation was 177%, 62%, 94%, and 105% during , , and , respectively (Figure 4.4). Figure 4.3: Health salary and non-salary budget and expenditure analysis 2010/ / / / SALARY SHARE (BE) SALARY SHARE (AE) NON-SALARY SHARE (BE) NON-SALARY SHARE (AE) Figure 4.4: Utilisation of salary and non-salary budget 2013/ / / /11 62% 77% 105% 100% 94% 93% 88% 177% 0% 20% 40% 60% 80% 100% 120% 140% 160% 180% 200% 57 Utilisation of non salary Utilisation of salary The above analysis clearly shows that generally the district has been allocating an adequate non-salary budget for health sector, keeping in view the generally accepted standard that a non-salary budget should be equal to 30% of the salary budget. However, as shown in Figure 4.4, the utilisation of the non-salary budget has been quite erratic over the years.

58 4.3.7 Budget allocation for non-salary (especially medicines) The non-salary budget primarily comprises operating expenses and repair and maintenance. The operating budget includes the budget for drugs and medicines. Table 4.2 below shows the BE and AE for Operating Expenses and Repairs and Maintenance in the total health budget. Under the Operating Expenses the most significant head of accounts is Drugs and Medicines. Table 4.2 also shows the utilisation of the medicine budget. In excessive procurement of medicines was undertaken, with the result that the budget allocation for was only utilised to the extent of 35% of allocation. Table 4.2: Medicine Budget and AE Rs. in Significant Head BE AE BE AE BE AE BE AE* Operating Expenses Repair and Maintenance Drug and Medicine Utilisation of Medicine Budget 191, , , , , , , ,379 13,420 12,293 17,275 13,692 13,607 7,528 9,675 7, , , ,850 61, , , , , % 35% 101% 120% AE* data is only for 11 months. 58 It appears that there is no criterion to determine the quantity of medicines to be procured and the linkages of medicine procurement with the disease patterns prevailing in the district. The procurement of medicines is one of the most important tasks of a district health department. It is, therefore, extremely important that this task is undertaken in the light of evidence of need at different levels. Use of DHIS appears to be the most feasible option in this regard, as the burden of disease is captured in DHIS; by using this data the requisite medicines can be purchased. The needs assessment study also found that the medicine available at BHUs in the district had no relation to the burden of disease in that area or the requirements of the BHU District health non-development budget and AE in different sectors The district health non-development budget was divided into different sectors: Primary, Secondary, Administration, Other Health Facilities, and General Nursing School. This analysis is mainly focused on the primary healthcare services.

59 Needs Assessment in Primary Health Sector Bhawalnagar Primary healthcare services Table 4.3 provides the volume of primary health care funding in the district. The allocation for primary health care services was 42%, 41%, 29%, and 35% of the total health budget in the district from 2010 to The AE on primary health care was 33%, 44%, 38%, and 35% during these years (Figure 4.5). Utilisation of this budget was 80%, 87%, 123%, and 100% during , , and , respectively (Figure 4.6). Again, there seems to be little predictability in utilisation of allocated funds for primary healthcare. Table 4.3: Primary Healthcare Current BE and AE Rs. 000 Years BE AE BE AE BE AE BE AE* Primary Healthcare Primary Percentage of total health current budget Utilisation percentage 383, , , , , , , ,015 42% 33% 41% 44% 29% 38% 35% 35% 80% 87% 123% 100% *AE data is for 11 months only. Figure 4.5: Share of PHC in health budget % 35% % 38% % 41% % 42% 59 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% PHC AE (%age of Total) PHC BE (% of Total)

60 Figure 4.6: PHC budget percentage utilisation BHUS BE and AE There are 102 BHUs in District Bahawalnagar. These BHUs are under the administrative and financial control of the DOH; therefore budgeting for these BHUs is done at the district level by the DOH office. Table 4.4 examines the budgetary allocations and AE for BHUs during the studied period. Table 4.4 BE and AE for BHUs Rs BHUs (DO (Health) BWN) Utilisation (%) *AE data is for 11 months BE AE BE AE BE AE BE AE* 254, , , , , , , ,904 77% 81% 161% 111%

61 Needs Assessment in Primary Health Sector Bhawalnagar Figure 4.7: Budget and AE at BHUs 350, , , , , ,000 50,000 0 Budget and Actual Expenditure at BHUs 312, , , , , , , ,147 BE AE BE AE BE AE BE AE* The variation between budgeted amounts and AE for BHUs clearly reflects a lack of financial planning and absence of evidence-based budgeting for provision of primary health services during the last few years (Figure 4.7). The BHUs are responsible for providing the most important preventive and curative functions at the grassroots level, therefore it is important that budgeting and planning is improved at district level through the use of evidence / data Major object wise components of BHUs Figure 4.8 below shows that BHU BE and AE mainly consists of employee-related expenses, operating expenses and repairs and maintenance costs. The chart, however, also shows that most of the spending at BHUs is on the salaries of staff, whereas allocations for repairs and maintenance are so low that they are hardly visible in the chart (Figure 4.8). 61

62 Figure 4.8: Major object wise breakdown of BHU budget and actual expenditure Budget Estimates and AE 7, , ,012 10, , , ,127 6, , , , , , , , ,100 BE AE BE AE BE AE BE AE Years Employee related expenses Operating expenses Repair and maintenance The data also reveal that even the budgeted amounts for operating expenses and for repairs and maintenance are not being fully utilised. This is especially a concern as generally the non-salary allocations for BHU appear to be inadequate. If this inadequate allocation is not even fully utilised then the service delivery is bound to suffer Procurement of medicines for BHUs The budgetary allocations and AE for the procurement of medicines at BHUs can be seen in Table 4.5 below. The data reveals that budgeted amounts under this head have not been utilised fully during the last four financial years, except in and , when the AE exceeded the budgeted amount by 61% and 11%, respectively. Table 4.5 Medicine Head Budget and AE Rs BE AE BE AE BE AE BE AE* BHUs (DO (Health) BWN) 254, , , , , , , ,904 Utilisation (%) 77% 81% 161% 111% AE* data is for only 11 months Cost per patient at BHUs The per patient cost has been worked out using the number of out-patients treated at the BHUs, obtained from the district, and using the budgetary allocations for

63 Needs Assessment in Primary Health Sector Bhawalnagar BHUs and AE incurred during the last four years (Table 4.6). 77 Table 4.6 Patient Cost as per Original Budget and AE (Rs.) Patient cost as per total BHU Patient cost as per Non- Salary total of BHU BE AE BE AE BE AE BE AE* *AE data is only for 11 months. Table 4.6 shows that the per patient non-salary expenditure at the BHU level ranges from Rs. 7 to Rs. 13. This allocation is extremely low keeping in view the actual need for provision of medicines and diagnostic facilities etc. through BHUs, and calls for more evidence-based budgeting using the number of patients using BHUs and average cost of provision of health services. The EPHS average cost for provision of BHU-related services has been worked out by the Government of the Punjab, Department of Health, at Rs. 62 per patient. In comparison, the existing per patient spending is around one tenth of this standard. 4.4 Access to services Roads of villages are damaged; that is why a big car cannot be used there. In case of emergency we have to use transport like donkey cart, which requires a lot of patience. FGD BHU Kabutri Primary survey findings The majority of the study respondents during FGDs shared that in case of remotely located BHUs, accessibility has become a major problem. The conditions of most of the roads are poor and transport is not available all the time. The respondents of BHU Panj Kosi shared that lack of transport has resulted in many deaths in their village. Where transport is available, high costs were highlighted as another issue relating to accessing remote BHUs. Respondents shared that as the people living in villages cannot afford to rent a vehicle they prefer to seek services from the nearby TBAs. However, where there is a BHU nearby, people were willing to seek health services from the BHU as they could approach the facility by walking or by motor cycle. The limited opening times of BHUs (from eight to two o clock) was mentioned as another issue to access services from BHUs by the majority of the community 77 As reported by the district health officials of Bahwalnagar, the number of out-patients treated at BHUs was between 800,000 to 1 million during

64 respondents. Even women who could go to BHUs by foot shared that as BHUs did not offer services for 24 hours and were closed after two o clock, they had to go or take a patient to private or city hospitals. Socio cultural issues were identified as another hindering factor in relation to accessing health care facility. Women had to either seek permission of their motherin-law or had to wait for a male member of their family to visit the facility. They were not allowed to go out of their houses alone. Moreover, if a male was at the facility, women were not allowed to receive health services from the facility. We need a well trained staff. Posts of MO, S.I & M.W are still vacant; if we appoint them it shall be beneficial. BHU Incharge, Rodhasingh CEIs (n=30) revealed that the mean distance of residences from BHUs was 2.6 km (±2.2km; median distance 2km). As the CEIs were conducted with respondents who could access the facilities, it was reported that within one km, 64% of the citizens travelled by walking and 36% by motorbike to the BHUs. However, within two km, 17% of the citizens travelled by walking and 83% by motorbikes to the BHUs. Nonetheless, beyond 2 km all used motorbikes to travel to the BHUs. 74% (74%) of the citizens reported having travelled on a bad road to the facility. Also these clients (73%) were found to be repeatedly utilising the services from the facility. Moreover, 60% said that the main reason for their visit was access to the facility; 40% reported that both access and affordability were the reasons GIS analysis As part of the Needs Assessment Study, with the technical support of the World Bank, the issue of access to health facilities was looked at using GIS maps and by deploying various layers of data, such as BHU locations, presence of roads, availability of doctors etc., to determine whether a health facility is accessible or not and providing requisite service to the catchment area population Travel time to the nearest BHU (travel on and off the road) For this analysis, access is defined in terms of the time it takes to travel to the nearest BHU. Time is estimated based on travel speed on and off roads. 64 The road network is derived from a crowd-sourced road layer 78 that categorises roads into nine types, namely primary highway, major arterial, minor arterial, secondary road, local road, controlled access, limited access, non-traffic and terminal. Each category was assigned an average speed of travel using a motor vehicle. Where roads were not available, an average walking speed of 3 km/h was assumed. Based on these speeds, an average cost, i.e., time of travelling on each road, was estimated. By using spatial least cost distance calculation algorithms with this cost layer, a surface was generated that represents the minimum time it takes to travel to a 78 The offline version of the road layer provided by Google was last updated in 2012.

65 Needs Assessment in Primary Health Sector Bhawalnagar health facility from any location in the district. Figures 4.9 and 4.10 depict regions that are within 15, 30, 45 and 60 minutes of travel time to the nearest BHU. Uncoloured regions are those that are beyond 60 minutes of a health facility and therefore represent potentially under-served areas. Any settlements lying in these regions do not have realistic access to a public health facility. Some examples of potentially under-served villages (with latitude-longitude coordinates) are: Lahura ( , ) Chatteke ( , ) Trobari ( , ) Toba Baluchan ( , ) Bahu Sarhu ( , ) Dhinganwali ( , ) Jajjal Musa ( , ) Jajjal Sarhu ( , ) 65

66 Figure 4.9: Access to Health Facilities by Travel Time Figure 4.10: Access to Health Facilities (Travel On and Off Road) Distance to the nearest BHU as the crow flies In this component, access is defined according to how far a citizen is from the nearest health facility by straight-line distance. This was calculated by creating circular zones of 1 km radii up to 5 km around each health facility. These zones were subsequently overlaid with the road network to identify the roads falling in each zone, as well as those roads that are beyond the 5 km radius of any health facility. In Figure 4.11, settlements served by the road segments in black are those that are beyond a 5 km straight-line distance from the nearest health facility, and can be considered as under-served regions.

67 Needs Assessment in Primary Health Sector Bhawalnagar Figure 4.11: Straight-line distance to the nearest health facility Travel distance to the nearest BHU (travel by road to the nearest health facility) In this component, access is defined according to how far a citizen has to travel from any location along the road network to reach the nearest health facility, assuming that he or she travels along roads where they are available and on foot otherwise. Using a crowd-sourced road network layer and spatial least cost distance algorithms, the minimum distance that needs to be travelled to reach a health facility along roads was calculated. Road segments were then categorised according to this minimum distance. In Figure 4.12, settlements served by the road segments in black are those where a citizen needs to travel beyond a 5 km distance to reach the nearest health facility, and can be considered as under-served regions. 67

68 Figure 4.12: Travel distance by road to the nearest health facility Bahawalnagar Health facilities with doctors The above methodologies represent the perceived or planned access to public healthcare, as they are based on all established facilities, irrespective of whether they are functional or have a medical officer appointed and present. These access layers can be combined with facility level data about the functioning of a facility to capture the true access to health care. As a first step, data about filled and vacant doctor posts for each health facility was merged with the health facility map to categorise health facilities based on whether a doctor is currently appointed at that facility. 68 The figures below (Figures 4.13 and 4.14) show the perceived access to public health care maps, with health facilities categorised as follows: Blue = doctor s post filled; Red = doctor s post vacant; Grey = data not available.

69 Needs Assessment in Primary Health Sector Bhawalnagar Figure 4.13: Travel distance by road to the nearest health facilities with categorised health facilities Figure 4.14: Travel time to the nearest health facility with categorised health facilities Service delivery and coverage Many service delivery gaps at facility level were reported, which need to be bridged to bring improvements in primary health care services. The study found insufficient financial resources and lack of staff for delivering current provincial government approved and notified service packages. The majority of facility in-charges reported

70 unavailability of trained staff at their BHUs, due to which provision of primary health services at BHUs was not possible. Unavailability of medicines and equipment was highlighted as another issue in providing services to the community. During interviews with BHU in-charges, it was shared that that most of the BHUs either lack basic equipment like weighing machines and blood pressure apparatus, or such equipment is non-functional. Additionally, disposable gloves, sterilised-delivery kits, iodine, and spirits were also reported to be missing in many BHUs. It was stated that in Bahawalnagar district, LHWs/health houses (HHs) cover around 75% of the area, but these are not playing as effective role as they should be. Many HHs are not centrally located and have un-manageable targets. There are 89 CMWs deployed in this district for MNCH services at the grass roots level but their overall contribution in natal and peri-natal and referrals services are little so far and their role needs to be strengthened. (EDOH) Regarding health services in a BHU, many of the women mentioned seeking ANC either from BHUs or LHWs in the district. They mentioned the availability of iron tablets, folic acid, TT vaccination and health counselling about nutrition. For children under five years, almost all participants mentioned polio drops, vaccination and treatment of common ailments. However, if a child fell sick they had to seek services from private clinics or hospitals for treatment, because of distrust of the public sector health delivery system. No special services are provided to women, children and minority groups; also no additional budget has been allocated in this regard. During FGD with women beneficiaries at BHU Kabutri, all the women shared that no laboratory or diagnostics were available at many of the BHUs. In the case of a simple blood or urine test, community members have to go to private clinics or hospitals. The overall referral system was found to be weak. No ambulance services are available for community to BHU referrals and for referrals from BHUs to higher facilities. One ambulance is available at each RHC, which is not sufficient to serve the needs of the community. Government health center s EPI teams come to our village and gives injections to people while visiting door to door. FGD Women 70 The majority of vaccinators mentioned there was no proper arrangement to maintain a cold chain for vaccines. They reported having coolers filled with ice bags to store vaccines but in case of accessing far-flung areas, ice is not available, making it difficult to maintain the cold chain. There are no refrigerators available at HHs of LHWs for keeping cold chains. The quantitative study revealed that the population coverage of Bahawalnagar District in terms of general diseases, reported by BHU in-charges, seems to be inadequate when triangulated with the medicine stock of the sampled BHUs. As this set of diseases (Fig 4.15) is prevalent in the district, all the BHUs were required to maintain the appropriate treatment inventory as per the requirements of the EPHS. However, the aforementioned data shows that none of the prevalent diseases, except malaria, are covered by the BHUs.

71 Needs Assessment in Primary Health Sector Bhawalnagar It may also be noted that children are less covered in the case of ARIs and asthma as compared to adults, putting them at a higher risk of a negative outcome. Figure 4.15: Percentage of BHUs showing gap in availability of treatment for prevalent diseases in Bahawalnagar District n=15 BHUs 67% 73% 80% 67% 0% 27% 27% 33% Malaria Gastroenteritis/Cholera/ Typhoid ARI in Adults ARI in Children Asthama in Adults Asthama in Children Scabies APD Services related to pregnancy Underutilisation of services and stocks (medicine, equipment and allied) was noted for ANC, delivery care, postnatal care (PNC) and family planning. Pregnancy test sticks were not present which means that that the first contact of a pregnant woman with the facilities was lost. Again no baseline test facility was present. This might have resulted in underutilisation of services, however stocks of folic acid and iron tablets were found in almost every sampled BHU. 71

72 Table 4.7: ANC coverage by BHUs having appropriate facilities and HR in Bahawalnagar District n=15 BHUs Reported facilities in the BHUs % of BHUs where appropriate facilities were available % of BHUs having appropriate HR Pregnancy test 0% 100% Blood sugar 0% 10% Haemoglobin 0% 10% Protein in urine 0% 10% Weighing scale 67% 100% BP apparatus 73% 90% Iron and folic acid 93% 100% ANC card 73% -- Referral register 27% -- Referral system 0% -- Delivery Ergometrine 0.2mg/ml 100% Oxytocin 10 IU/ml 13.30% Misoprostol 200mcg 100% Delivery kits mostly incomplete 30% Normal delivery <40% Episiotomy <16% Delivery register 26% Family planning Male condoms 93% 100% IUCD 87% 30% Pills 53% 30% Resuscitation 40% 7% 72 The fact that only 30% of the BHUs had the required HR for service delivery and only 36% of them maintained a delivery register also underlines this finding. Less than 40% of BHUs had complete delivery kits for normal deliveries and <16% of BHUs had complete kits for episiotomy. Less than 40% of the BHUs had resuscitation facilities and only 7% of the BHUs had the appropriate HR to conduct such activity. Thus, conducting resuscitation in the BHUs is almost impossible. A referral system was not found to be in existence at any of the BHU. However, a quarter of BHUs maintained referral registers showing that they send their patients to higher facilities.

73 Needs Assessment in Primary Health Sector Bhawalnagar Table 4.8: Availability of Vaccines among BHUs Vaccines TT 86% BCG 73% OPV 86% Pentavalent 80% Measles 86% Pneumococcal 86% Available Percentage No BHU was found to have all the required vaccines in Bahawalnagar. However, 86% of the BHUs had a vaccine carrier with ice packs. 4.6 Quality of services We even do not want to have that medicine for ourselves; how can we suggest that for others BHU based staff It was shared by many BHU in-charges that no document on the provision of good quality services had been shared with them. Instead, only verbal instructions were given to ensure quality health services in BHUs. Lack of trained staff was another issue that was identified in relation providing quality services. A need was stressed to recruit efficient and skilled staff for vacant posts. Very poor conditions of staff residences had led to absenteeism of staff. Non-availability of clean and safe water and electricity was also reported at BHUs. People think that by the usage of the medicines provided by BHU, they can become blind. FGD with women Non-availability of medicines was the main reason mentioned for underutilisation of BHUs. Moreover, the quality of medicines was also reported to be unsatisfactory by facility-based staff. However, regarding the attitudes of service providers, the majority of the respondents including minority groups were satisfied. They mentioned that they were treated with dignity and attention. The quantitative study identified the following results about the quality of health services provided at BHUs. Regarding the composition of the healthcare providers (HCPs), it was reported that around 50% of the clients were examined by dispensers, 30% by LHVs, 10% by lab technicians, 6% by SH&NS and only 3% by doctors. Around 75% of the citizens reported that they did not wait for more than 15 minutes before being examined by the HCPs. Only one had to wait for around an hour, in one of the BHUs. The median waiting time was 10 minutes. Around 23% of the citizens stated that the services they received at the BHU were free of charge. The rest, which was a little over 75%, reported that they paid for all such services. Also, around 90% of the citizens shared that they paid Rs. 5/- or less for the services they received from the BHUs. Two citizens, however, paid Rs. 200 and Rs. 350 to their HCPs. These were two women who paid the amount to the LHVs for private consultation during the official working hours. 73

74 Regarding availability of medicines, around 86% of the citizens were prescribed medicines, out of which only around 73% received all of these from the BHUs; the rest managed to obtain the medicines from elsewhere. 37% of the citizens were advised to take a diagnostic test, 23% of which were conducted within the facility. The common tests conducted were blood pressure and weight measurement (13.3%). A urine sample was collected in one case and no blood sample was taken in any of the cases. 77% of the citizens were found to be satisfied with the overall hospital experience. 17% were, however, unsatisfied. 6% were unsure. 74

75 Needs Assessment in Primary Health Sector Bhawalnagar 5 Conclusions and recommendations 5.1 Conclusions This study involved conducting an in-depth situation analysis of the district health status to assess if the existing public health delivery system can respond to the health needs of the communities, including minority groups, both efficiently and effectively. The findings, both of the primary and secondary data, budget and GIS based analyses, have revealed gaps in coverage, accessibility and quality, particularly with reference to maternal and child healthcare. Moreover, gaps were also identified in processes, from policy and planning down to the implementation level. The key findings are analysed and discussed in the following paragraphs Management and governance issues at provincial/district level conclusions Limited use of data and evidence to plan health services Most of the senior management at the provincial health department currently involved in policy and decision-making processes are not appropriately utilising data for the provision of health services to the communities, although these datasets very much exist. Moreover, the DoH has already developed MSDSs and recently updated the EPHS. However, the latter has not yet been given significant importance in decision-making regarding the allocation of appropriate medicines and diagnostic facilities. Use of evidence was mostly found to be lacking at both provincial and district levels and disease incidence or prevalence is not generally taken into consideration while setting targets. This seemed to be attributed to a number of factors, namely: i. The questionable quality of data generated at the health facility, as paramedics, who lack the capacity to understand the value of quality and importance of complete and correct data entries, run most of the facilities. The issue is compounded as validation exercises are seldom conducted. 75 ii. The existing disease coverage model is outmoded and fails to provide an accurate health picture. For instance, Mouza/village population is not considered when estimating coverage since patient/client addresses are not reported in the DHIS. The geographical spread therefore technically cannot be estimated correctly. Moreover, repeated visits of the patients are not accounted for in reporting, which treats repeated visits of the same person for different ailments as new patients.

76 iii. There are also capacity issues regarding the analysis and correct use of data at both provincial and district levels. No mechanism in place to prioritise and confirm the needs to the community The study revealed a poor capacity of the provincial and district management team for carrying out community needs assessments. This disability leads to incorrect prioritisation of issues and inappropriate decision-making that does not match the on the ground realities and community needs. Lack of structural integration The findings show poor inter departmental linkages, as no structural and functional integration exists between the DoH, the PWD, and other departments. Although despite structural flaws in reporting mechanisms functional intra-departmental linkages are reported to be well in place among the district management team, including district coordinators of vertical programmes, such integration is nearly non-existent in community outreach (e.g. between LHWs and CMWs and LHWs and FWWs). Consequently, this results in less than expected outputs and referrals to health facilities. Lack of redress mechanism and accountability There is no effective redress mechanism or an accountability system in place at the facility and district level, nor is there any mechanism set for rewarding performers or sanctioning non-performers. The absence of these mechanisms adversely affects both demand and supply, thus contributing to underutilisation of the services offered at public sector health facilities. M&E Although interventions have been made in bringing improvements in the monitoring system, through embracing digital technology, in the absence of trained personnel, functional equipment and logistics support, it will be difficult to sustain the initiative to achieve meaningful outcomes Finance conclusions Funds are transferred from the province to the district through the Provincial Finance Commission, as a single line transfer. As health is a low priority, funds released by the province to the district are always short of actual demand, even though the DoH gets a reasonable share among 13 competing departments (17.7% estimated for ). Furthermore, there is sometimes delayed release to the health department by the district authorities, which causes issues in carrying out planned activities and meeting targets. The paucity of required funds adversely affects both health outputs and outcome.

77 Needs Assessment in Primary Health Sector Bhawalnagar Service delivery and coverage conclusions The study revealed wide service delivery gaps in BHUs. The presence of trained care providers and availability of free drugs are two major reasons why people would approach particular health facilities. The survey identified wide gaps pertaining to both. Out of the nine most prevalent diseases found in the community through a quantitative survey, the available medical stock was found to only be sufficient to treat one disease: malaria. This is further aggravated by poor attendance, low quality of drugs supplies and non-availability of transport facilities for referrals Quality of services conclusions There is compromised quality of HRs, poor quality of medicines, little or no training activities, de-motivated managerial and technical staff and less than scheduled monitoring activities for lack of POL. The net result is underutilisation of services plus loss of Disability Adjusted Life Years (DALYs). Although a training mechanism does exist, the provincial and district health development centres (PHDC and DHDC) are practically non-functional, except when provided with a specific assignment under an approved project with donor assistance. Similarly, the selection and training needs assessment (TNA) of HCPs and managers is also designed and implemented according to specifications provided by development partners. 5.2 Recommendations The following recommendations are presented, based on the discussions in the foregoing sections of the report regarding the core areas of governance, access, and quality of primary healthcare services. As this is a needs assessment report an attempt has been made to present only those recommendations that are practicable, without addressing the policy domain. However, some recommendations can only be implemented by policy interventions. The details are as follows: Management and governance issues at provincial/district level recommendations Capacity development for data and evidence-based planning of health services in line with needs of the community One of the findings of the study was that there is limited use of parameters or indicators for planning health services by the health sector managers. Additionally, it was also found that they had limited capacity to analyse and use evidence-based information.

78 Therefore, it is recommended that the health planning capacity is enhanced in the short-term through outsourced TA; in the long-term, the institutionalisation of health planning within the DoH, especially at district level, is recommended. Additionally, the strengthening of the existing planning cells, supported through trained HR and linking with data resource units, would ensure evidence-based planning in the health sector. The Punjab Health Sector Strategy proposes setting up a Knowledge Store Unit a comprehensive data clearing warehouse. It is recommended that these units be established at the earliest to help augment planning at the provincial and district levels. Finally, improvement in the quality of data collected and included in the DHIS will also increase the comfort level of health sector planners, so that they will be more inclined to use the data for planning purposes. Therefore, it is recommended that some measures be taken to improve the authenticity and validity of the data reported in DHIS. Structural integration of vertical programmes One of the findings of the study was that the low level of integration between the regular health department and the vertical programmes has raised issues, such as duplication of resources and services. It was found that most of the vertical programmes have their own management, reporting and monitoring mechanisms, and are generally working in isolation with minimal coordination with other programmes and district health staff. In order to minimise duplications and wastage of resources, it is recommended that a coordination mechanism be developed which effectively links the vertical programmes, the DoH and the PWD at the district level. Additionally, the model of District Health Population Management (DHPMT) could be adopted to ensure that these issues are reduced. In the long run, the functional integration/synergy of the vertical health care programmes at the provincial and district levels is recommended Improved M&E through robust monitoring systems 78 The study indicated that inadequate M&E of health service delivery outputs was conducted. A robust M&E system is proposed for the primary health care sector, through the use of mandatory checklists, feedback, and follow-ups. Highlighting the issues of mortality and morbidity, based on evidence, can further help in this regard. Moreover, setting targets and costing activities can play an important role in achieving the objective of improved health care. Therefore, target setting through KPIs is recommended. Accordingly, for this purpose, a robust M&E framework/ mechanism can be implemented; and through health reforms, a mechanism of accountability can be devised based on KPIs to improve the health status. The setting of targets can form the basis for performance contracts between the provincial and district health authorities, in order to monitor progress.

79 Needs Assessment in Primary Health Sector Bhawalnagar Finance recommendations Sufficient budget allocation to the health sector The study also found that insufficient budget allocations are made for the provision of health services. Additionally, at the district level, disease prevalence and incidence was not considered during the process of allocating financial resources. Moreover, the findings indicated that there was slow transfer of funds and an absolute lack of planning for the timely procurement of medicines as per the patients needs. It is recommended for the districts to vigorously pursue additional budget allocations through the preparation of evidence-based district action plans, in health sector. Furthermore, clearly defined targets, specific activities and pre-set indicators could attract sufficient funds. Timely releases of budget, at the provincial and district levels, will also ensure that the available funding is transferred and utilised efficiently. In the long-term, it is recommended for needs-based budgeting to be linked to performance, outputs, and outcomes at the district level Access to services recommendations The study found that most of the roads to remotely located BHUs were of poor condition and regular transport to BHUs was not available. Furthermore, in the case of remotely located BHUs, accessibility has become a major problem. Additionally, the non-affordability of transport by the community also hampered access to health facilities. Therefore, it is recommended that innovative approaches be adopted to resolve issues of access, such as the deployment of mobile health units at strategic locations. Moreover, measures for efficient patient transport, through arrangements such as community emergency ambulances, made available through CES, are also recommended. In the long-term, it is further recommended that a mapping of health facilities be carried out, with the objective of synchronising the placement of the health facilities with the community needs, using GIS. Furthermore, the issues of affordability of health services for the poor segments of the community should be addressed by using pro-poor initiatives like voucher schemes. Linking a voucher scheme with a community-based transport model can additionally help in improving access to health facilities Service delivery and coverage recommendations The study found that successful coverage of the needs of a growing population was reported as a major obstacle in the adequate provision of health services at the district level: no disease except malaria was found to be fully covered in Bahawalnagar District.

80 Additionally, the medicine formulations, in cases of ARIs and asthma, had better availability in BHUs for adults in comparison to those for children. For all other diseases, the coverage was equally low for adults as well as children. In the short-term, it is recommended that a rethinking of the service delivery system is required, through the use of innovative approaches, such as community midwives, paring of TBAs and LHWs, involvement of the private sector and NGOs. The matching of the burden and distribution of disease at the district level is also recommended. In the long-term, it is recommended that the options of out-sourcing health services, fostering public private partnerships and implementing health insurance models be considered. The implementation of the task shifting concept is also proposed, meaning the redistribution of tasks among health worker teams, by enhancing their capabilities. Additionally, the possibilities of using telemedicine and mobile health (mhealth) to address the issues of coverage and access can also be explored Quality of services recommendations The study found an absence of appropriate and trained HR: it was reported that around 50% of the clients were examined by dispensers, 30% by LHVs, 10% by lab technicians, 6% SH&NS and only 3% by doctors. In order to address issues regarding the quality of health services in the short-term it is recommended that, the PHC be made fully operational so that it can contribute at all levels of service delivery in the public health sector, as envisaged in its Act. Additionally, in the long-term, it is recommended that there be implementation and strict compliance of MSDS and operationalisation of DHAs, along with periodic skills development training for the staff of primary healthcare facilities in the various jobs/ responsibilities assigned to them, to address quality issues. 80 Finally, it is proposed that performance-based financing be introduced, with pre-set indicators to measure the quality of health services. This can potentially result in a substantial improvement in the quality of health services. 5.3 Non-salary budgetary proposals The detailed non-salary budget proposals are as follows: Access to services non-salary budgetary proposals Medical camps The needs assessment study also examined access to health services in the district

81 Needs Assessment in Primary Health Sector Bhawalnagar through a GIS based analysis. This identified areas with poor access to health services. It is imperative that the district government makes special arrangements to reach out to such communities periodically, if a more permanent arrangement cannot be immediately made. The holding of medical camps in such areas is one option. The PRSP is managing health service delivery in a few districts of the province and in such districts medical camps are regularly arranged for under-served areas of the district. The experience of the PRSP indicates that setting up these camps would require minimal logistics and cost as the medicines and equipment available at BHUs can be used for such camps. Therefore an indicative allocation of Rs.1.0 million is proposed for Bahawalnagar district during FY Service delivery and coverage non-salary budget proposals Medicines/supplies/lab investigations A key finding of the needs assessment report is the non-availability of required medicines (except for malaria) supplies, and diagnostic facilities at BHUs, in line with the EPHS approved by the provincial government. An analysis was carried out to look at the patient load and disease pattern at the BHU level in the district. This analysis clearly indicates the presence of a large number of ARI patients in the district. The graph below (Figure 5.1) also shows the number of patients receiving an OPD facility and the prevailing disease pattern in the district. 79 It is clearly evident from the graph that a large number of ARI patients visited the BHUs in the district. Figure 5.1 Disease Pattern and OPD at BHUs (Number of Patients) OPD Acute (Upper) Respiratory Infection (ARI) Pneumonia < 5 years Pneumonia > 5 years Asthama Diarrhoea / Dysentry in < 5 Diarrhoea / Dysentry in > 5 Peptic Ulcer Disease Urinary Tract Infections Suspected Malaria Diseases Fever due to other causes Hypertension Scabies Dermatitis Otitis Media Dental Caries Road Traffic Accidents 81 Upon further investigation, it was found that the ARI medicine for children for ARIs and asthma were not available at the BHU. This indicates that when procuring and distributing medicines at various BHUs in the district data on the burden of disease is apparently not used. As a result, the budgetary allocations made for the 79 Data obtained from DHIS.

82 procurement of medicine are also misplaced and not backed by any hard concrete data. In order to address the above issues, it is imperative to procure and distribute the medicines at the primary level health facilities keeping in view the burden of disease and thus the requirement for medicines for those diseases. To align budgetary allocations with the burden of disease, and to ensure that the essential supplies and basic diagnostic facilities are available at the primary health care level, the following calculations were carried out using a weighted average cost formula for the cost of drugs/medicines, supplies and lab investigations. The weighted average cost for provision of these services at the BHU has been calculated at Rs. 62 per unit. 80 Using this weighted average per BHU, it is possible to calculate the funding requirements for providing these services at the primary health care facilities in the district. To calculate the cost of medicines, 25% was added as buffer stock to the requirement of medicine. 81 Table 5.1 provides the budgetary allocation for provision of medicine, supplies, and basic diagnostic facilities at BHU level in the district, using the number of patients visiting BHU and multiplying it with the average cost per patient and further enhancing the product by a factor of 1.25 to ensure the availability of a buffer stock of medicine to offset price fluctuations. Table 5.1: Proposed Allocations per BHU for Medicines/Supplies/Lab Investigations Total patient load and per BHU patient load Weighted Average Per Patient Cost (Rs.) Multiple for Buffer Stock 549, ,079,168 5, ,118 Including buffer stock (1.25) 549, ,598,960 5, ,648 Medicine, Supplies and Lab Investigation Cost per BHU in Rs. 82 It is indicated in Table 5.1 above, Rs million is needed to provide essential supplies and basic diagnostic facilities at all the BHUs in the district. The cost per BHU is around Rs. 334,000. Additionally, Rs million is needed for the provision of requisite medicines at the BHU level, to address the burden of disease and patient load at these facilities. This would also include the provision of 25% as a buffer stock 80 The weighted average cost used for calculations here has been worked out in the Department of Health, Government of Punjab report titled: Costing of Essential Package of Health Services (Primary Healthcare Facilities in Punjab), The calculation of the weighted average cost is a three step process: Calculation of a multiple of per unit service cost for a service number of expected cases of that service Take the sum of the multiples calculated in step 1 Divide the sum computed above by the total number of cases to get the weighted average cost of services. 81 International literature on the subject recommends that buffer stocks of medicines be maintained in the range of 15%- 25%.

83 Needs Assessment in Primary Health Sector Bhawalnagar of medicine. It is recommended that the allocated budget be distributed among BHUs on the basis of patient load instead of using a constant budget allocation. The budget analysis carried out by SNG Punjab of Bahawalnagar District indicated certain areas where the utilisation ratio of the budget is very low; therefore the above requirement can be met from areas where the budget utilisation has historically been very low. This budget analysis indicated that over-budgeting in health facilities in the district resulted in a low budget utilisation ratio. Furthermore, The RHC budget analyses indicated substantial over-budgeting in the salary component at the RHC level (Table 5.2). This over allocation can easily be diverted to fund BHU medicines, supplies, and lab investigations. Table 5.2 Budget and expenditure trends at RHCs, BHUs and THQs Years Major object wise Employeerelated expenses Operating expenses Repairs and maintenance Medicines (L.P) at RHC Medicines at BHUs Operating expenses at THQ level *AE data for only 11 months. Missing equipment BE AE BE AE BE AE BE AE* 115,414 92, , , , , , ,869 13,168 15,388 14,324 12,775 17,007 14,478 19,659 15,918 1, , , , ,100 2,000 2,400 2,329 2,900 2,185 3,200 2,126 5,000 4,476 6,000 1,778 6,000 2,536 3,000 1,763 25,711 36,620 36,871 31,723 40,490 33,441 40,630 32,887 The needs assessment study revealed that basic diagnostic facilities were not available at BHUs except for blood pressure and weight measurement equipment. To provide the missing equipment at BHU level, EPHS-based costing of equipment has been used to calculate the funding requirements. 83 Table 5.3 shows the equipment cost at each facility (BHU), with depreciation applied. The equipment maintenance cost has also been calculated in this table, using 10% depreciation for equipment per year.

84 Table 5.3: Total Cost of Standard Equipment at BHUs and Associated Maintenance and Repair Amount in Rs. Total Cost of Equipment per BHU 1,600,261 Equipment Maintenance Cost 19,836 Total Cost for 102 BHUs 163,226,622 Equipment Maintenance Cost 2,023,281 In the needs assessment exercise undertaken by SNG an android based survey of equipment availability at the 15 sample BHUs was also carried out. Based on the survey, a list of missing equipment was developed for the 15 BHUs. The cost for the provision of the missing equipment at the 15 BHUs has been calculated as Rs million. Using the list of missing equipment for sampled BHUs, the district government can extrapolate the cost of missing equipment for all 102 BHUs in the district. It would, however, be useful to conduct a comprehensive assessment of missing facilities to accurately estimate the funding requirement for provision of missing facilities / equipment in all BHUs in the district. The provincial ADP includes a scheme titled Purchase of Missing Equipment and Hospital Furniture etc. for Primary and Secondary Care Hospitals in Punjab. An allocation of Rs. 350 million has been made against this scheme for this year. The district government is requested to approach the provincial government for funding to provide the missing equipment in BHUs of the district. However, it is also possible that the district government can take up the provision of missing equipment in a phased manner, using its own budget. Resource provision for vaccination 84 One of the issues identified by the SNG Programme while undertaking a review of the business processes of the Expanded Programme of Immunisation (EPI) was that necessary facilities, especially POL for motorcycles, is not provided to the vaccinators who are responsible for implementation of the EPI programme. A review of the district budget reveals that there is an allocation for provision of POL to the vaccinators; however, enquiries in the field suggest that this is not being disbursed. One of the reasons for non-disbursement is probably the apprehension that the POL would be misused. In order to ensure that this does not happen in the future, it is proposed that a separate allocation be made in the budget for the provision of POL to vaccinators and the amount be disbursed through the use of fleet cards to vaccinators, if it is practical (considering the extent of availability of this facility in the district).

85 Needs Assessment in Primary Health Sector Bhawalnagar Quality of services non-salary budget proposals DHDCs One of the main reasons for underutilisation of BHUs is a lack of qualified staff in these facilities. DHDCs have been established by the provincial government in each district, with a mandate to conduct training for health sector employees. These centres need to be made fully functional, by developing a training schedule with a robust monitoring mechanism to gauge their performance. Table 5.4 and Figure 5.2 indicate that in the last four financial years, total expenditure on DHDC has ranged from Rs million in to a maximum Rs million in However, 87% of this expenditure is employee-related, 11% is operating expenses and just 2% is for maintenance and repair (Figure 5.2). In the circumstances, Bahawalnagar District can also benefit from making these centres fully operational. It is proposed that a non-salary allocation for the centres be doubled during the next financial year to ensure adequate funding. Table 5.4: DHDC budget allocations and expenditures (Rs. In 000 ) BE AE BE AE BE AE BE AE* Employee-related Expenses 2,324 2,072 2,632 2,887 3,517 3,605 3,617 3,285 Operating Expenses Repairs and Maintenance Total 2,937 2,568 3,427 3,190 4,101 4,086 4,295 3,683 AE* data is only for 11 months. 85

86 Figure 5.2: Composition of Average Percentage Expenditure by DHDC ( ) 2 11% 3 2% 1 87% Figure 5.3: DHDC budget allocations and expenditures Rs. in millions ,324 2,072 2,632 2,887 3,517 3,605 3,617 3,285 BE AE BE AE BE AE BE AE* 2010/ / / /14 *AE data is for only 11 months. 86

87 ANNEXES

88

89 Needs Assessment in Primary Health Sector Bhawalnagar Annex A Literature review Before launching the needs assessment exercise, the team reviewed the available literature and secondary data to plan the needs assessment exercise and to avoid any duplication. The following literature and data sources were reviewed before developing instruments for data collection: Socio-economic data / profile of Bahawalnagar Sector service delivery performance status in the districts, based upon KPIs - The sources of this secondary data include Sector MIS data, PSLM, MICS 2007 and MICS 2011, Sector Roadmaps and performance charts Punjab Health Sector Strategic Plan Punjab Health Sector Operational Plan Three Years Rolling Plans of Bahawalnagar District MSDS EPHS Demand side survey conducted by AWAAZ Health Facility Assessment Report Charm project report on 24/7 BHUs Expenditure trends of health sector of Bahawalnagar District government 89 Other reports on financial management of Bahawalnagar District government The literature review included reference to some case studies of primary healthcare programmes in Pakistan or other countries, where service delivery issue(s) had been handled well through pilot interventions or by introducing an innovation in service delivery. Key stakeholder assessment An assessment of stakeholders identified incentives, viewpoints and problems in the provision of

90 primary health care services. This assessment covered the following stakeholders: Citizens: men and women who are the recipients and beneficiaries of public sector services. Frontline Service Providers: who are actually based in service delivery units, are responsible for providing services, and are in direct connection with the people of the area, such as LHWs, vaccinators etc. Service Delivery Managers: who are managing the service delivery units and are responsible for meeting and managing the needs and expectations of the people. Policy-Makers: who ensure that sector services are compatible with the needs of the people. Data collection tools The health sector needs assessment involved the collection of data and information on various aspects of service delivery from multiple stakeholders. A composite methodology and data collection tools were used, as mentioned below: KIIs KIIs involved one-to-one interviews with key stakeholders, including policy-makers (provincial level) and service delivery managers (district level) / government staff. The interviews aimed to gather a better understanding of the supply side of the sector services and possible concerns, including regarding the budget, that affect the performance of service providers in designing, managing and delivering the sector services. These include: Policy-makers 90 Provincial Health Department, Punjab Healthcare Commission, Health Sector Policy and Strategic Planning Unit (PSPU), the PWD, Chief Ministers Primary Healthcare Programme and National Programme for Family Planning (FP) and Primary Health Care. Service delivery managers DCO, Executive District Officer (Finance and Planning), EDO (H), District Population Welfare Officer and District representative of National Programme for FP and Primary Health Care.

91 Needs Assessment in Primary Health Sector Bhawalnagar FGDs The FGDs involved discussions with citizens, especially women, girls, minority groups, and frontline service providers, to assess the demand side of service provision. This covered the needs and expectations of the people from the service providers. The FGDs included: i. Citizens (general public users of sector services) ii. iii. iv. Women and girls Minority groups Frontline service providers (medical officers and paramedical staff based in BHUs and outreach) Field observations Field observations involved visiting (randomly selected) sampled service delivery units to assess the state, including physical infrastructure, of service delivery units. A comprehensive checklist was used to assess if: i. service delivery units were physically capable of performing their functions; ii. iii. frontline service providers were available in the units and are serving; and citizens, especially women, girls and minority groups, were accessing these units for needed services. CEIs CEIs were designed to assess how satisfied service beneficiaries are with the services provided at BHUs, the attitude of staff and the location of BHUs etc. Selection criteria of BHUs for CEIs 91 One BHU was randomly selected in each Tehsil Three males and three females were selected on the basis of the following criteria from each BHU: years (with attendant for child of <5y)

92 years - Above 50 years Mystery client interviews Mystery client interviews were included in the survey to gather detailed information of how patients were treated at health facilities. Selection criteria of BHU for mystery client interviews One BHU was randomly selected from each tehsil for a mystery client interview. Sample size The collection of data and information on people s needs related to the provision of health care services was carried out through a literature review, KIIs, and FGDs with policy-makers, service delivery managers, frontline service providers and citizens. The sample size was determined using the purposive sampling technique by taking into account the patient load and distance from the headquarters of health facilities. The details are as follows: Table A.1: Detailed sample size of stakeholders Stakeholder Assessment Tool Sample Size Bahawalnagar Qualitative Sample Policy-Makers (At provincial level) KIIs 06 District Managers KIIs 05 Facility In-Charges Semi-structured Interviews 15 FGD Service Providers and Service Beneficiaries Staff: Facility and outreach 3 (Medical and paramedical staff at BHUs, outreach staff and citizens) Community: Men and women 4 Minority Groups: Male and female 2 Quantitative Sample Beneficiaries CEIs 30 Mystery Client Mystery Client Interviews 05 Facility In-charges Observation Checklist 15

93 Needs Assessment in Primary Health Sector Bhawalnagar Selection of BHUs A purposive sample of BHUs was selected to ensure maximum representation of different types of BHUs, i.e. BHUs with high patient load and low patient load and BHUs near headquarters and BHUs far from headquarters. Table A.2: Selection Criteria for BHUs BHUs High patient load and far from headquarters 5 Low patient load and far from headquarters 5 High patient load and near to headquarters 2 Low patient load and near to headquarters 3 Total 15 Bahawalnagar A sample of three BHUs was selected from each tehsil with similar representation, i.e. five tehsils of Bahawalnagar (see Annex C), except for Tehsil Fort Abbas, where two BHUs were selected as the population there is fewer in number due to the mountain landscape. On the other hand, four BHUs were selected from Tehsil Bahawalnagar because of its high population. 93

94 Field work methodology The fieldwork is summarised in Table A.3 below: Table A.3: Data Collection at Provincial and District levels KIIs Level Department Respondent Provincial Health Department, Punjab Additional Secretary (Tech) Punjab Health Sector Policy and PSPU: Programme Director Provincial Health Care Commission Chief Minister s Primary Health Care Programme PWD CEO Programme Director Secretary PWD 94 District National Programme for FP and primary healthcare (LHW Programme) Provincial Programme Coordinator District Government DCO DoH EDO (H) Department of Finance and Planning PWD EDO (Finance and Planning) District Coordinator PWD National programme for FP and primary healthcare (LHW Programme) PRSP District Coordinator LHW Programme District Support Manager PRSP

95 Needs Assessment in Primary Health Sector Bhawalnagar Table A.4: Data collection at facility and community level Technique District Bahawalnagar 15 semi-structured interviews with in-charges of BHUs/ doctors Semi-structured Interviews (with check list) Observation of physical infrastructure, medicines and equipment of BHUs, with focus on maternal and child health (through checklist developed and administered on smart phones) Nine FDGs: Three FGDs with HCPs One FGD with WMOs/ LHVs/midwives One FGD with LHWs/ CMWs FGDs One FGD with CDC Supervisor/Vaccinator/Sanitary Inspector Six FGDs with community Two FGDs with male members To with women, girls Two with minority groups 95

96 Observation Survey of 15 BHUs on android based Customised software, and by using checklist, involved: a) Survey of physical infrastructure of BHUs Observation Survey b) Assessment of staffing, medicine and diagnostic facilities, comparing with standards (CEIs Mystery Client Interviews c) Provision of service delivery with the help of mystery clients Six (three males and three females) from each of five selected BHUs (30 CEIs) Five Mystery Client Interviews Three teams were deputed in the district, each comprising three members, as below: Teams a) Doctor/Team Leader One b) Moderator/FGD expert One c) Note Taker/Community Worker One Training of field teams 96 Training of interviewers and supervisors was conducted from 1st to 3rd May, The training consisted of instruction on interviewing techniques and field procedures, a detailed review of the qualitative and quantitative questionnaire content in separate groups, instruction and practice through mock interviews between participants in the classroom. Actual field simulations were conducted in Sheikhupura district, by practising interviews with respondents. Data management team and analysis Two senior members of the Contech team and the field supervisor were in the field during data collection. Data checking was done on a daily basis simultaneously as the data collection was going on. The field supervisor conducted data editing at the time of collection of questionnaires from the interviewers. For questions where additional information was provided, the codes were given by the senior member prior to electronic data entry. After the data was edited the completed dataset was double entered using a data entry program

97 Needs Assessment in Primary Health Sector Bhawalnagar designed in the software EPI data version 3.1. Two data entry operators simultaneously entered the data. The senior member performed a consistency check of the two datasets and corrected any discrepancy between them. Regarding qualitative analysis, a framework was developed for the qualitative component of the study, which was based on the key themes related to the needs assessment of the community, regarding primary healthcare services. The qualitative data was translated and transcribed for analysis. Qualitative software, Atlas.ti, was used for analysis of the qualitative data. A comprehensive list of codes was prepared, which was used for coding of the data in the software. After coding, the narrative was sorted into pre-identified themes. These findings were then analysed according to the objectives of the study, as stipulated in the research proposal. 97

98 Annex B Missing Equipment in 15 BHUs Missing Equipment/Diagnostic Facility BHUs where equipment was available BHUs where equipment was not available Adult ambu bag and mask 2 13 Adult stethoscope 9 6 Adult weighing scale 10 4 Adult weighing scale 10 4 Ambu bag for infant 3 12 Ambubag for child and adult 5 8 Artery forceps 11 4 Artery forceps curved 10 5 Artery forceps straight 12 3 Baby weighing scale 10 4 Baby weighing scale 4 10 Bedpans 4 11 Bench fibre glass 11 4 Blood pressure apparatus 8 7 Boiler/autoclave 7 7 Breast pumps 3 12 Chair for health worker 13 2 Cheatle forceps 8 6 Cold box refrigerator for EPI 13 2 Computer with accessories, including internet access 1 13 Couscous specula (Small, Medium, Large for each category) Dressing drum 12 3 Dressing scissors 14 1 Dressing trays 14 1 ENT diagnostic set 2 12 Episiotomy Scissors 5 10 Examination couch 15 0 Fetal Stethoscope 10 5 Gas Burner 0 15 Gas stove/ cylinder 0 15 Glucometer 0 14 Haemocyto meter 0 15 Haemoglobino meter 0 15 Ice box 13 2 Ice packs 13 2 ILR/Deep Freezer 12 3 IUD insertion kit 8 7 IV stand 9 6 Kidney tray- large size 13 2 Labour /Delivery Table with washable plastic cover 14 1 Nebulizer 0 14 Needle holder forceps 11 4 Non toothed tissue forceps 8 inches 2 13 Normal delivery set 14 1 Office Chairs 14 1 Office Rack Wooden 3 12 Office Table with 3 Drawers 3 12 Outlet forceps 5 10 Oxygen Gas Cylinders 10 4 Oxygen source (portable cylinder or central wall supply), 4 11 with Mask or nasal cannula; Tubing; Flow meter Oxygen Tubing and Masks 5 10 Patella hammer 2 13 Patient s stool 12 3 Pinard fetoscope 4 11 Pressure cooker autoclaves 3 12 Refrigerator 5 10 Revolving stool 14 1 Room Thermometer 0 15 Scalpel handle and blades 4 11 Scissors 14 1 Scissors 9 6 Screen four fold 6 9 Shadow less Lamps 5 9 Sim s vaginal speculum - single & double ended - (each of small, medium and large size)

99 Needs Assessment in Primary Health Sector Bhawalnagar Annex C: Selection of BHUs in Bahawalnagar District Far from headquarters Near to headquarters T-1 (Bahawalnagar) HL LL T BHU Kot Rodha Singh BHU Muhar Wali BHU PunjKossi 3 0 BHU Kot Makhdom 1 Total Far from headquarters Near to headquarters T-2 (Haroonabad) HL LL T BHU Chak # 154/3-L BHU Chak # 438/6-R 2 0 BHU Chak # 58/4-R 1 Total Far from headquarters Near to headquarters T-3 (Chishtian) HL LL T BHU Chak # 112/Murad BHU Jhadwan 2 0 BHU Chak # 127/Murad 1 Total Far from headquarters Near to headquarters Far from headquarters Near to headquarters T-4 (Fort Abbas) HL LL T BHU Chak # 297/HR 1 BHU Chak # 227/9-R 1 Total T-5 (Minchin Abad) HL LL T BHU Kabotri BHU Hasil Saru 2 BHU Haran Wala 1 Total * Limits for distance: <20 Near to HQ, >20 Far

100 Key: HL: High Patient Load LL: Low Patient Load (N.B: Considering population factor, four BHUs were selected in Tehsil Bahawalnagar and two in Tehsil Fort Abbas, Bahawalpur district. The rest of the sample remained the same). 100

101 Needs Assessment in Primary Health Sector Bhawalnagar Annex D Private Health Facilities in Bahawalnagar District Name of Private Health Facilities Bed Strength Location 1 CMH Hospital Bahawalnagar 50-Beds Bahawalnagar Cantt. 2 Bagh Ali Surgical Hospital Bwn. 10-Beds In front of City Police Station Bahawalnagar 3 Adrees Shafi Hospital Bwn. 10-Beds Woqala Colony Bwn. 4 Ali Hospital Bwn. 10-Beds Near Grain Market Bwn. 5 Shouqat Hospital Bwn. 10-Beds X- Rail Way Hospital Bwn. 6 Safdar Hospital Bwn. 10-Beds Baldia road Bwn. 7 Ali Hospital Bwn. 10-Beds Chishtian Road Bahawalnagar 8 Tayyab Surgical Hospital 10-Beds Khichiwala 9 Bismillah Hospital 5-Beds Khichiwala 10 Zenab Hospital 5-Beds Khichiwala 11 Rehman General Hospital 10-Beds Fortabbas 12 Children Hospital 10-Beds Fortabbas 13 Millat Surgical Hospital 10-Beds Fortabbas 14 Al Shifa Surgical Hospital 15-Beds Fortabbas 15 Matyana Surgical Hospital 20-Beds Chishtian 16 Husnain Surgical Hospital 20-Beds Chishtian 17 Allied Surgical Hospital 10-Beds Chishtian 18 Sahibzada Heart Hospital 5-Beds Chishtian 19 Ashraf Eye Hospital 10-Beds Chishtian 20 Millat Eye Hospital 10-Beds Chishtian 21 Waheed Anwar Children Hospital 05-Beds Chishtian 22 Ismail Shaheed Hospital 05-Beds Chishtian 23 Bajwa Hospital 2-Beds Chishtian 24 Hajra Memorial Surgical Hospital 6-Beds Chishtian 25 Ghani Eye Hospital 10-Beds Chishtian 26 Daud Surgical Hospital 10-Beds Chishtian 27 Jatala Eye and Surgical Hospital 10-Beds Chishtian 101

102 Name of Private Health Facilities Bed Strength 28 Al Shifa Surgical Hospital 5-Beds Chishtian 29 Mushtaq Surgical Hospital 10-Beds Chishtian 30 Adaina Surgical Hospital 10-Beds Chishtian Location 102

103 Needs Assessment in Primary Health Sector Bhawalnagar Annex E Procurement Process 103