Health Facility Assessment Punjab Provincial Report TRF. Technical Resource Facility

Transcription

1 Health Facility Assessment Punjab Provincial Report TRF Technical Resource Facility

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

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

4 Status of drugs and supplies Status of support services SHCs conformance to required inputs Tehsil headquarter (THQ) hospitals Status of infrastructure Status of human resources Status of functional equipment Status of drugs and supplies Status of support services THQHs conformance with assessed inputs Management basics Human resources Provision of staff by the NMNCHP MNCH staff training CMWs training and deployment Management basics and supervision Management information system Drugs and supplies Infection control Death review Donor contributions Procurement estimates Equipment Civil works Section 4: Clients Perspectives Key findings Reasons for visiting public sector health facilities Quality of care Overall satisfaction Section 5: Health Managers Perspective Rationale Key findings of the in-depth interviews Infrastructure Human resources iii

5 Procurement and logistical management Management information system Planning and intersectoral collaboration Monitoring and supervision Financial management Donor contributions Section 6: Key Findings Infrastructure Human resources Drugs, supplies and equipment Support services Management and organisation Work coordination and supervision Infection control Service delivery protocols Donor contributions Monitoring and evaluation Management information system Death reviews Client satisfaction ANNEX Objectives of the NMNCH programme ANNEX Input criteria for MNCH services ANNEX Assessment of health facilities functionality by district iv

6 List of Tables Table 1.1: Scope of HFA Table 2.1: Key indicators for Punjab Table 2.2: Number of public sector health facilities Table 3.1: Status of assessed infrastructure in BHUs Table 3.2: Status of MNCH related staff in BHUs Table 3.3: Status of functional equipment in BHUs Table 3.4: Status of drugs and supplies in BHUs Table 3.5: Status of support services in BHUs Table 3.6: Status of assessed infrastructure in RHCs Table 3.7: Status of MNCH related staff in RHCs Table 3.8: Status of equipment in RHCs Table 3.9: Status of drugs and supplies in RHCs Table 3.10: Status of support services in RHCs Table 3.11: Status of support services in RHCs Table 3.12: Status of assessed infrastructure in SHC hospitals Table 3.13: Status of MNCH related staff in SHC hospitals Table 3.14: Status of functional equipment in SHC hospitals Table 3.15: Status of drugs and supplies in SHC hospitals Table 3.16: Status of support services in SHC hospitals Table 3.17: Status of support services in SHC hospitals Table 3.18: Status of assessed infrastructure in THQHs Table 3.19: Status of MNCH related staff in THQHs Table 3.20: Status of functional equipment in THQHs Table 3.21: Status of drugs and supplies in THQHs Table 3.22: Status of support services in THQHs Table 3.23: Status of support services in THQHs Table 3.24: Status of HR reported by surveyed health facilities Table 3.25: Number of health facilities having staff provided by NMNCHP Table 3.26: Number of MNCH staff provided by NMNCHP Table 3.27: Number of staff trained on delivering MNCH services Table 3.28: Number of health facilities received MNCH training Table 3.29: Status of CMWs training and deployment in Punjab v

7 Table 3.30: Status of infection prevention at the surveyed health facilities Table 3.31: Status of mortality reviews at surveyed health facilities Table 3.32: Status of donor contributions at surveyed health facilities Table 3.33: Summary of estimated cost for equipment and civil works Table 4.1: Number of CEIs conducted in Punjab Table 4.2: Clients reasons for visiting public sector health facilities Table 5.1: Districts in Punjab contacted for in depth interviews vi

8 List of Figures Figure 2.1: Map of Punjab Figure 3.1: Range of services that signal fully functional MNCH services Figure 3.2: Average functionality of assessed inputs at surveyed BHUs Figure 3.3: District-wise status of conformance of BHUs to required inputs Figure 3.4: Average availability of assessed inputs at RHCs Figure 3.5: District-wise status of conformance of RHCs to required inputs Figure 3.6: Average availability of assessed inputs at SHC hospitals Figure 3.7: District-wise status of conformance of DHQHs to required inputs Figure 3.8: District-wise status of conformance of THQHs to required inputs Figure 3.9: Average availability of assessed inputs at THQHs Figure 3.10: District-wise status of conformance of THQHs to required inputs Figure 3.11: Status of management basics at surveyed facilities Figure 3.12: Status of work coordination Figure 3.13: Status of supervision Figure 3.14: Status of MIS Figure 3.15: Facility specific reasons for stock out of drugs and supplies Figure 4.1: Types of services accessed at public health facilities Figure 4.2: Average time taken by the clients to reach the facility Figure 4.3: AVerage waiting time at the facility Figure 4.4: Clients' level of satisfaction with availed services Figure 4.5: Provision of medicines, lab services and education material Figure 4.6: Overall satisfaction of the interviewed clients vii

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

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

11 Executive Summary The first national health facility assessment (HFA) was conducted from October 2010 to May 2011covering all the provinces and regions of Pakistan as part of the implementation of the monitoring and evaluation (M&E) framework of the national maternal newborn and child health programme (NMNCHP). The Punjab HFA report synthesises the findings of 36 district level assessments, covering 902 health facilities assessed in the Punjab province.thirty four (34) district headquarter (DHQH) hospitals and 84 tehsil headquarter (THQH) hospitals, were assessed for the provision of 24/7 comprehensive emergency obstetric and newborn care (EmONC) services. 291 rural health centres (RHCs) were assessed for the 24/7 basic EmONC services and 493 (approximately 20% sample) basic health units (BHUs) were assessed for the availability of 8/6 preventive MNCH services. The HFA also aims to describe the availability and level of functioning of the health services, in public health sector facilities, based on the availability of required inputs. Assessment criteria were used to ascertain gaps in the availability,against the optimal level of inputs 1 for infrastructure, human resources (HR), drugs and supplies; equipment, level-specific support services and management basics in the surveyed health facilities. Regarding the availability of inputs, major issues faced by the facilities were lack of MNCHrelated staff at the facilities, like WMOs at RHCs and specialists including gynaecologists, anaesthetists and paediatricians at SHC hospitals. Infrastructure components were mostly available in the assessed health facilities, although the availability of staff residences was a major problem in ensuring 24/7 availability of EmONC services. Infrastructure components required for paediatric care were deficient at most of the THQH hospitals. Major gaps were also revealed in the availability of required equipment, drugs and supplies, as at the time of the assessment, none of the health facilities in Punjab had been provided with the complete range of assessed items required to perform basic functions. Based on the health facility asssessment findings and the health managers perspective, interventions and actions are proposed to address the identified issues for bridging the gaps (details provided in Section 6 Key Findings), including: 1) establishing an effective mechanism of human resource planning and development based on determined needs; 2) 1 Optimal level of inputs are proposed in the Planning Commission Proforma 1 (PC-1) of NMNCHP required to deliver level specific MNCH services. Contents of these inputs are given in Annexure 1. 20

12 the preparation of a district-specific action plan using the HFA findings, for the provision of necessary equipment and renovations to the health facilities; 3) ensuring an uninterrupted provision of sufficient drugs and supplies to the health facilities; 4) improving management basics practices through training and supportive supervision; 5) providing equipment and material for infection control practices and training of facility staff on waste management; 6) notifying death review committees up to the level of RHCs; 7) developing and implementing a mechanism for streamlining donor contributions, at both the facility and district level. Findings related management basics, revealed a lack of work coordination among the facility staff. (It was assessed through the record of monthly performance review meetings held at the facility.) Supervision at the surveyed facilities was assessed through the regularity of supervisory visits of the district level managers and their feedback to facilities. Although the majority of the facilities reported supervisory visits, the receipt of their feedback was not a common practice. Staff job descriptions and service delivery protocols were lacking at the majority of the health facilities.the management information system was well-placed in the form of the district health information system (DHIS). However, gaps were identified in the infection control practices, due to the lack of trained staff and availability of materials for personal protection, waste collection and waste treatment. Due to the inconsistent documentation of maternal, neonatal deaths and lack of death review committees, these deaths had rarely been reviewed at the health facilities. Despite the inherent challenges faced by the public sector health facilities, these recommendations based on the health facility assessment findings, shall help improve the quality and accessibility of MNCH services to the vulnerable communities, thus reducing mortality and morbidity to meet the country s commitment to MDGs. Report organisation The HFA provincial report has been structured in seven sections: 1. Section 1 has the Introduction to the survey, its objectives, scope and duration. 2. Section 2: Provincial information comprises of an overview of the province, key indicators at a glance, as well as the organisation of the public sector health care delivery system. 3. Section 3: Assessment of functional capacities, contains the details ofhealth facilities assessed against the availability of the 5 specified inputs which would enable them to perform their level-specific services, (infrastructure, human resources, drugs and supplies, equipment and level specific support services). 21

13 4. Section 4: Clients perspective contains information about the perceptions of the clients regarding the MNCH services provided at the public sector health facilities. 5. Section 5: Health Managers Perspective provides the findings of the in-depth interviews of health managers. 6. Section 6: This section describes the health facility assesment key findings. 22

14 Section 1: Introduction In Punjab, more than 227 women die out of 100,000 live births during pregnancy, childbirth or soon afterwards; with devastating effects on families 2 and livelihoods. Skilled and responsive care, at and after birth, can avert nearly all of the fatal outcomes and disabling consequences and ease much of the suffering. The health of mothers and newborns are so intricately related, preventing deaths requires, in many cases, the same interventions. The government of Pakistan is committed to achieving the millennium development goals (MDGs) and the Ministry of health has established the national maternal newborn and child health programme (NMNCHP), for achieving the 2015 targets for the health related MDGs 4 and 5. The overarching goal of the programme is to improve the health status of mothers, newborns and children, with a focus on poor and marginalized populations. Survey objectives The health facility assessment (HFA) Pakistan is part of the overall monitoring and evaluation framework for the NMNCH and aims to describe the availability, level of functioning and quality of MNCH service delivery, at the public sector health facilities with a focus on the district level. Specific objectives of the health facility assessment were: 1. To assess the health facility status and quality of MNCH services (comprehensive and basic EmONC, preventive MNCH and family planning) at the district level; 2. To assess the clients satisfaction and perception of MNCH services; 3. To provide information for the systematic planning of procurement and supply of goods and commodities (listing the medical equipment and instruments which need to be replaced or purchased); and 4. To update and assess the contributions made by the development partners for improving MNCH and family planning services in the selected districts. Although, the HFA is intended to help district and provincial health managers, in assessing performance benchmarks and realigning their activities, for bridging the gaps existing in MNCH services for achieving the MDGs the scope of the HFA does not cover the overall situation of the health sector in the district. 2 Pakistan Demographic and Household Survey

15 Assignment duration The Technical Resource Facility (TRF) is supporting the NMNCHP with technical assistance (TA) in the design and implementation of the health facility assessment (HFA) across Pakistan. The technical assistance was assigned to Contech International. The estimated duration of the assignment was 7 months. The assignment started in October 2010 and ended in May Scope of HFA The survey included the district headquarter hospital (DHQH), tehsil/taluka headquarter hospitals (THQHs), rural health centres (RHCs) and 20% of the basic health units (BHUs) randomly selected from within the district. The selection of the BHUs was done through geographical stratification on the basis of proportionate distribution. Client exit interviews were conducted at the surveyed facilities (10 at DHQH, 5 at each THQH and RHC), excluding the BHUs. Table 1.1 shows the numbers of health facilities in the district and the health facilities surveyed. TABLE 1.1: SCOPE OF HFA Punjab province Number of health facilities by type DHQH THQHs RHCs BHUs Total Number of facilities ,454 2,863 Number of facilities surveyed

16 Section 2: Provincial Information 3 This section gives an overview of Punjab and the organisation of the public sector health care services in the province, derived from secondary data sources. Punjab An overview Punjab is comprised of 36 districts and is the most populous and second largest province of Pakistan. The name Punjab, means five waters, or five rivers, and signifies the land irrigated by the rivers Indus, Jhelum, Chanab, Ravi and Satluj passing from north-west to the south-west. Punjab has one of the world s largest irrigation systems and vast areas of fertile land. It also includes the Cholistan desert, plateau of Potohar and the hills of Margalla and Murree. It is bordered by the Balochistan and Khyber Pakhtunkhwa provinces to the west, Islamabad capital territory to the north, Indian states of Punjab and Rajhistan to the east and the province Sindh to the south. The provincial capital, Lahore, is located in the east-central region, near the border with India. FIGURE 2.1: MAP OF PUNJAB 3 HFA Source: District Level Questionnaire (DLQ), refer Methodology Annex, National Health Facilities Assessment Report 25

17 Key indicators Punjab has approximately 56% of the country's total population, estimated at 92,869,000 in 2010, based on an annual growth rate of It has a 1998 census population of 72,585,000.The status of key indicators for Punjab is presented in Table 2.1. TABLE 2.1: KEY INDICATORS FOR PUNJAB Demography Value Health & socio-economic Value Geography Health Number of districts 36 Area (in square Km) 205,345 Demography Infant mortality rate (/1,000 live births) Under 5 mortality rate (/1,000 live births) Maternal mortality ratio (/100,000 live births) Total population 81,330,000 Malnutrition (Women) 56% Population (Urban : Rural) 68 : 32 Malnutrition (Children) 43% Population (Male : Female) 103 Immunisation (children <12 months all vaccinations) 53% Annual growth rate % 2.64 Economy Under 1 year 2195,910 (2.7%) GDP Annual growth rate (2009) 6% Under 5 years Under 15 years 10898,220 (13.4%) 34134,201 (41.9%) Human development index 0.67 Education Women years 17,892,600(22%) Literacy rate (Overall) 59% Married women of child bearing age (CBAs) 13,012,800(16%) Literacy rate (Male : Female) 70 : 48 Pregnant women 2,765,220(3.4%) Literacy rate (Urban: Rural) 72 : 53 Sources: Punjab Development Statistics 2010, MICS Punjab , Economic Survey of Pakistan , Demographics and Health Survey Pakistan,

18 Public sector health facilities Although health care services in Punjab are provided by public and private providers, the government is considered by far, the main provider of preventive care throughout the province and the major provider of curative services in most of the rural areas. In the public sector, health services are provided through a tiered referral system of health care facilities; with increasing levels of complexity and coverage from primary, to secondary and tertiary health facilities. Primary care facilities include basic health units (BHUs), rural health centres (RHCs), government rural dispensaries (GRDs), mother and child health (MCH) centres and TB centres. All of these facilities, provide 8/6 OPD services for preventive and a limited number of curative services. RHCs provide a broader range of curative services, 24/7. Primary care facilities also provide outreach preventive services to the communities, through vaccinators, sanitary inspectors and the sanitary patrol. Tehsil and district headquarter hospitals provide increasingly specialized secondary health care, while teaching hospitals form the tertiary level tier. Information about the number of health facilities, ranging from teaching hospital to sub-health centres, in each district of Punjab was collected from the respective district health departments. Details about the public sector facilities are given in Table 2.2. TABLE 2.2: NUMBER OF PUBLIC SECTOR HEALTH FACILITIES Type of health facility Number Teaching hospitals 19 District headquarter hospitals 34 Tehsil headquarter hospitals 84 Rural health centres 291 Basic health unitss 2,454 Dispensaries 499 MCH centres 289 Sub-health centres 443 The role of the provincial department of health (DoH) includes policy and strategy development, intra-provincial coordination, monitoring and evaluation; medical and nursing education and tertiary care delivery. The role of the district department of health is implementation, monitoring and supervision, management of health care delivery at and below DHQH hospitals and the implementation of vertical programmes at the district level. 27

19 Section 3: Assessment of Functional Capacities This section describes the HFA findings, status of MNCH service packages against assessment criteria (Annex 2), and status of management basics, service utilization, client satisfaction, and social protection. In addition, procurement estimates for required equipments and civil works are also contained in the section. MNCH services The packages of MNCH services assessed include preventive MNCH services at BHUs, basic EmONC services at RHCs and comprehensive EmONC services at the THQH and DHQH hospitals 4. The range of MNCH services are given in figure 3 below. FIGURE 3.1: RANGE OF SERVICES THAT SIGNAL FULLY FUNCTIONAL MNCH SERVICES BHUs: Facility available for 8/6 Preventive MNCH Services 1. Antenatal checkup 2. Lab (Anemia, Malaria, pregnancy test, urine test for sugar & Protein) 3. Normal delivery 4. Family planning services (at least 3 methods) 5. TT immunisation 6. EPI vaccination 7. Growth monitoring 8. Nutritioncounsellin g 9. HR (at least one LHV or Doctor) RHCs: Facility available for 24/7 Basic EmONC Services 1. Parenteral antibiotics 2. Parenteral oxytocic drugs 3. Parenteral anticonvulsants for pregnancy induced convulsions (due to hypertension) 4. Manual removal of placenta 5. Removal of retained products 6. Assisted vaginal delivery (vacuum extraction, forceps) 7. Newborn resuscitation 8. Post abortion care 9. HR (skilled female providers-wmo and LHVs), and 10. Preventive MNCH DHQ/THQ Hospitals: Facility available for 24/7 Comprehensive EmONC services 1. Surgery (Csection) 2. Blood transfusion 3. Newborn care (resuscitation & incubator) 4. Gynaecological care 5. Comprehensive family planning services including sterilisation 6. HR (skilled staff for conducting, C- section, blood transfusion and anaesthesia), + 7. Preventive MNCH and 8. Basic EmONC 4 PC-1 NMNCHP 28

20 The health facilities were assessed against the availability of 5 specified inputs which would enable them to perform their level-specific services. The functional capacity of health facilities was assessed, against 5 specified inputs, which include: 1. Infrastructure 2. Human resources 3. Drugs and supplies 4. Equipment 5. Level specific support services The health facilities assessment findings are presented against two levels of inputs including: 1. Optimal level of inputs, these are those proposed in the PC-1 of the national MNCH programme, required to make a health facility fully functional for the provision of the level specific package of MNCH services (Annex 2). 2. Minimal level of inputs, which are the bare minimum requirement of the inputs, required for delivering the package specific MNCH services at the health facilities. This section describes the functionality of the assessed facilities, against the availability of the optimal level of inputs by facility type. An analysis is also provided, against a minimal or essential level of inputs, for comparative purposes. Basic health units (BHUs) Status of infrastructure The infrastructure of the BHUs has been assessed, for the availability of an OPD/ LHV s room and labour room as service provision areas and residences for the accommodation of required staff. The findings are presented for the availability and functional status of infrastructure components assessed at the BHUs, both in numbers and percentages in Table 3.1. The assessment of the infrastructure in BHUs revealed that OPD and LHV s rooms were available in 99% and 90% of the BHUs, with only 7% of those available requiring major repair works (exceeding 75%). LHV residences while available in 90% of the BHUs were only liveable in 33% of them. This implies that the LHV residence in nearly 78% of the BHUs, either required major repair work or construction from scratch. 29

21 TABLE 3.1: STATUS OF ASSESSED INFRASTRUCTURE IN BHUS Assessed infrastructure Status of surveyed BHUs (N=493) Number Percentage OPD Labour room Residence - LHV Available % Functional % Available % Functional % Available % Functional % Status of human resources A doctor or LHV is required for the provision of preventive MNCH services. The availability (both regular posted and provided by NMNCHP) of both of these categories of human resources, against the required number mentioned in PC-1 of NMNCHP, is presented in Table 3.2. Out of the surveyed BHUs, 461 had staff available for providing preventive MNCH services. While 32 of the BHUs, had neither a doctor nor a LHV posted. Further analysis revealed that out of 493 BHUs, 339 had a doctor posted, while a LHV was available at 436 of the BHUs. TABLE 3.2: STATUS OF MNCH RELATED STAFF IN BHUS Staff categories Status of surveyed BHUs having required staff (N=493) Number Percentage Doctor or LHV % Status of functional equipment BHUs are categorized in four groups 5, according to the percentage availability of functional equipment items in each BHU, as presented in Table 3.3. An assessment analysis of the functional equipment items in BHUs revealed that only 1 BHU had >75% general equipment items.the majority (381) of the BHUs, had even less than 25% of the general equipment items. Only 50 BHUs had >75% OPD equipment items, while 242 BHUs had 51-75% of the required items. Most of the BHUs (368 of 493) had more than 50% of the LHV s room equipment. 5 This is arbitirary categorisation to present availability of assessed items. 30

22 TABLE 3.3: STATUS OF FUNCTIONAL EQUIPMENT IN BHUS Equipment Number of surveyed BHUs having functional equipment items (N=493) >75% available 51 to 75% available 25 to 50% available <25% available General items OPD LHV s room Status of drugs and supplies BHUs are categorized in four groups, according to the percentage availability of items in each group of supplies, Tracer drugs, vaccines and family planning commodities, as presented in Table 3.4. An analysis of the available tracer items in BHUs, showed that the majority of the BHUs (237 out of 493), had more than 75% of the supplies. Whereas, 169 BHUs had less than 50% of the required drugs available. More than 75% of the assessed vaccines were available at 88% BHUs. However 91 of the BHUs, had less than 25% of the family planning commodities. TABLE 3.4: STATUS OF DRUGS AND SUPPLIES IN BHUS Number of surveyed BHUs with available tracer items 6 (N=493) Item groups >75% available 51 to 75% available 25 to 50% available <25% available Supplies Drugs Vaccines Family planning commodities Status of support services The BHUs are categorized into three groups, according to the percentage availability of the inputs for basic laboratory tests (test strips and human resources) required for performing these services,as presented in Table 3.5. The analysis shows that 25% of the BHUs were 6 List of essential drugs and supplies for MNCH services is contained in PC-1 of NMNCHP. Tracer items were selected from the list (Annex 2) for assessing their availability at surveyed facilities. 31

23 fully functional, with all of the items available, with the majority of BHUs (70%) with at least 50% functionality. TABLE 3.5: STATUS OF SUPPORT SERVICES IN BHUS Support services Number of assessed BHUs with available support services (N=493) All items available 50% available No item available Basic lab tests BHUs conformance to required inputs The assessment findings were analyzed to determine the conformance of surveyed BHUs, to the inputs required to deliver preventive MNCH services.the calculation is based on the Average functionality of the number of inputs for each criterion, including infrastructure 7, human resources, equipment, drugs and supplies and support services, against PC-1 of the national MNCH programme. Based on this analysis, the functionality status of the assessed BHUs, with reference to the availability of required inputs, is presented in Figure 3.2. FIGURE 3.2: AVERAGE FUNCTIONALITY OF ASSESSED INPUTS AT SURVEYED BHUS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 89% 84% 64% 60% 49% Infrastructure HR Equipment Drugs & Supplies Support Services Average functionality was also assessed for BHUs by district in order to benchmark districts. For the purpose of this benchmarking, each input criterion is given equal weighting and a maximum equivalency of 20%. 7 Conformance to infrastructure has been ascertained on the availability of key building components only, as for example presence of consultation area in OPD, leaving aside examination area and handwashing facility. However, all these components have been assessed collectively to identify scope of civil works and cost estimates. 32

24 A calculation was carried out in an attempt to present status of the districts based on conformance to required inputs, on following assumptions: District represented by a single bar, composed of five sub-sections each representing one of the 5 input criteria, Standard bar was taken as 1 (100), and each input component was allocated equal space in the bar i.e., one fifth of bar (20), Each component could maximum contribute to one fifth or 20 to the bar, Each component occupied its allocated space proportionate to its average availability, Five components make a component bar to give overall average availability of inputs by type of health facility in the district. Example: Calculation of component bar Average availability of inputs for CEmONC in each THQH of district Attock was: Component Number of Proportionate Average required Calculation ( 1 / 5 ) of availability inputs standard bar Infrastructure =(8.60/19*100)*0.2 9 HR =(14.40/41*100)*0.2 7 Equipment =(81/106*100)* Drugs & Supplies =(34.60/42*100)* Support services =(63/87*100)* Infrastructure HR Equipment Drugs & Supplies Support services Attock It is evident that none of the required inputs meet the mark of 20 and comulative average availability of inputs in THQHs is 61 out of 100, in district Attock. Based on the above calculations, following graph (Figure 3.3) presents the district-wise status of average component availability of inputs at surveyed BHUs. 33

25 FIGURE 3.1: DISTRICT-WISE STATUS OF CONFORMANCE OF BHUS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Kasur Lodhran Lahore TT Singh Attock Faisalabad Chakwal Hafizabad Gujrat Bahawalpur Rawalpindi Jhang Gujranwala Jhelum Mianwali Layyah Sialkot Vehari Pakpattan RY Khan Bhakhar Narowal Okara Multan Muzafargarh Sahiwal Sheikhupura Nankana Sahib Rajan Pur Chiniot Bahawalnagar Khanewal DG Kahn Mandi Baha uddin Sargodha Khushab

26 Rural health centres (RHCs) All 291 RHCs operating in Punjab were assessed for availability of optimal levels of the 5 input criteria. Status of infrastructure The infrastructure of the RHCs has been assessed, for the availability of an OPD, indoor ward, LHV s room, labour room and clinical laboratory, as service provision areas and residences for the accommodation of required staff. The findings are presented as the availability and functional status of infrastructure components assessed at the RHCs, both in numbers and percentages in Table 3.6. Over 95% of the RHCs in Punjab had OPDs in a good condition. A total of 263 RHCs had a WMO s residence, but it was inhabitable (i.e. not damaged and repair/maintenance work not exceeding 75% of the available infrastructure) at 63% of the RHCs. TABLE 3.6: STATUS OF ASSESSED INFRASTRUCTURE IN RHCS8 Infrastructure OPD Female ward Labour room Clinical lab LHV s room Residence - Doctor Residence - LHV Status of RHCs (N=291) Number Percentage Available % Functional % Available % Functional % Available % Functional % Available % Functional % Available % Functional % Available % Functional % Available % Functional % 8 Service provision areas have been assessed as single room having facilities like consultation, examination and hand washing etc. Available infrastructure might be requiring repair or maintenance. Available components were labelled non-functional if the structure was found damaged or repair needs exceeded 75%. 35

27 Status of human resources PC-1 of the NMNCHP contains the category and number of staff required, for the provision of basic EmONC services. The availability of human resources (both regular posted and provided by NMNCHP) at the RHCs at the time of survey, against the required numbers is presented in Table 3.7. Major gaps were found in the availability of 2 out of 5 cadres - WMOs and operating theatre (OT) technicians, at 26% and 19% respectively. Lab technicians were not available at almost half of the RHCs. TABLE 3.7: STATUS OF MNCH RELATED STAFF IN RHCS Staff categories RHCs having required staff (N=291) Number Percentage WMO 75 26% LHV % Lab technician % OT technician 56 19% Ambulance driver % Status of functional equipment The availability of equipment items for various service components at RHCs, as listed in PC- 1 of NMNCHP, was assessed and categorized in four groups, according to the percentage availability equipment items in each RHC and is presented in Table 3.8. The assessment of functional equipment items at RHCs revealed that very few RHCs have more than 75% of the equipment. Of particular note are the Female ward and the WMO OPD at 13%. However, 57% to 78% of the RHCs, have more than 50% the of equipment available, with the exception of the general items, which remains low with more than a third of RHCs having less than 25% of them available. TABLE 3.8: STATUS OF EQUIPMENT IN RHCS Number of RHCs by % of available equipment items (N=291) Equipment >75% available % 51 to 75% available % 25 to 50% available % <25% available % General items 2 1% 70 24% % 99 34% 36

28 Female ward WMO OPD Labour room LHV s room 39 13% % 83 29% 41 14% 38 13% % 80 27% 14 5% 84 29% % 56 19% 8 3% 97 33% 85 29% 66 23% 43 15% Status of drugs and supplies The list of essential drugs and supplies for MNCH services is contained in PC-1 of NMNCHP. Tracer items were selected from the list (Annex 2) for assessing their availability at surveyed facilities. RHCs are categorized in four groups according to percentage availability of items in each group of supplies, Tracer drugs, vaccines and family planning commodities, as presented in Table 3.9. Analysis of available tracer items in RHCs showed that majority of the RHCs (280 out of 291) had more than 50% supplies, with 95% of RHCs with more than 75% of the assessed vaccines. TABLE 3.9: STATUS OF DRUGS AND SUPPLIES IN RHCS Number of RHCs by % of available tracer items (N=291) Item groups >75% available % 51 to 75% available % 25 to 50% available % <25% available % Supplies % 84 29% 8 3% 3 1% Drugs 64 22% % 90 31% 13 4% Vaccines % 12 4% 2 1% 0 0% Family planning commodities % 78 27% 28 10% 53 18% Status of support services The RHCs were assessed for the functionality of basic laboratory tests (space, test strips and human resources) and ambulance services (functional vehicle and driver).whereas none of the RHCs had more than 50% of the basic lab tests available, 91% had a functional ambulance and driver. The details are presented in the Tables 3.10 and 3.11 respectively. 37

29 TABLE 3.10: STATUS OF SUPPORT SERVICESIN RHCS Number of RHCs with available support services (N=291) Item groups >75% available % 51 to 75% available % 25 to 50% available % <25% available % Basic lab tests 0 0% 0 0% % 6 2% TABLE 3.11: STATUS OF SUPPORT SERVICESIN RHCS Support services RHCs with available inputs (N=291) Number Percentage Functional ambulance % Ambulance driver % RHCs conformance to required inputs The health facility assessment findings were analyzed, in order to determine the conformance of the RHCs, to the inputs required to deliver basic EmONC services. The calculation is based on the Average functionality of the number of inputs for each criterion, against PC-1, including infrastructure, human resources, equipment, drugs and supplies, and support services. Based on this analysis, the conformance status of the assessed RHCs with reference to the availability of the required inputs is presented in Figure

30 FIGURE 3.4: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT RHCS 100% 90% 86% 80% 70% 67% 60% 57% 55% 50% 40% 43% 30% 20% 10% 0% Infrastructure HR Equipment Drugs & Supplies Support Services The following graph (Figure 3.5) presents the district-wise status of average component availability of inputs at the RHCs. 39

31 FIGURE 3.2: DISTRICT-WISE STATUS OF CONFORMANCE OF RHCS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Lahore Attock Jhang Bahawalpur Chiniot Rawalpindi Narowal Okara Faisalabad Pakpattan Muzafargarh Bhakhar Gujrat Gujranwala Lodhran Sheikhupura Sargodha Chakwal DG Kahn Multan Rajan Pur Jhelum TT Singh Khushab Nankana Sahib Sialkot Kasur Vehari Mianwali RY Khan Bahawalnagar Layyah Sahiwal Hafizabad Khanewal Mandi Baha uddin

32 Secondary health care (SHC) hospitals All of the 34 DHQHs and 84 THQHs in Punjab (secondary health care (SHC) hospitals), were assessed for the provision of comprehensive EmONC services, available for 24 hours a day, 7 days a week and for the availability of the optimal level of the 5 input criteria. Status of infrastructure The infrastructure of the SHC hospitals has been assessed, for the availability of an OPD, indoor wards, LHV s room, labour room, operation theatre, paediatric nursery, blood bank, ultrasound room and clinical laboratory, as service provision areas and residences for the accommodation of required staff. The findings are presented as availability and functional status of infrastructure components assessed at the SHC hospitals, both in numbers and percentages in Table In general all of the DHQH hospitals clinical areas, particularly those for maternal services, were over 90% functional, with paediatric services and ultrasound support services over 75%. However, apart from the nurses residences at 74% functional, doctors residences were not readily available (ranging from 35 to 50%), and even less of the technicians residences were in workable condition, (around 12%). The THQHs were also generally assessed as having high levels of functionality for maternal services. They had low functionality for paediatric services (27-37%). Although generally at lower levels than the DHQHs, the functionality for LHV rooms was higher at 75% as compared to 59% in DHQHs. The availability of residences was low, worse than at DHQHs. Except in the case of WMO s residences and for available facilities at THQHs, functionality was always lower, which was not the case at DHQHs for example 64% of the THQHs had WMO s residences, as compared to 50%. Only 46% were functional as compared to all of them at DHQHs. TABLE 3.12: STATUS OF ASSESSED INFRASTRUCTURE IN SHC HOSPITALS Status of infrastructure in SHC hospitals Infrastructure DHQHs (N=34) THQH (N=84) Number Percentage Number Percentage OPD Available % 83 99% Functional % 82 98% Female ward Available 32 94% 54 64% Functional 32 94% 50 60% Labour room Available % 80 95% 41

33 Operation theatre Paediatric ward Paediatric nursery Clinical lab Blood bank LHV s room Ultrasound room Residence - Gynaecologist Residence - Anaesthetist Residence - Paediatrician Residence - WMO Residence - LHV Residence - Nurses Residence - Lab technician Residence - Blood bank technician Residence - Anaesthesia technician Functional % 78 93% Available 32 94% 77 92% Functional 32 94% 70 83% Available 28 82% 35 42% Functional 28 82% 31 37% Available 25 74% 26 31% Functional 25 74% 23 27% Available % 83 99% Functional % 82 98% Available 31 91% 33 39% Functional 31 91% 31 37% Available 21 62% 67 80% Functional 20 59% 63 75% Available 27 79% 45 54% Functional 26 76% 40 48% Available 19 56% 26 31% Functional 16 47% 20 24% Available 12 35% 17 20% Functional 11 32% 12 14% Available 16 47% 26 31% Functional 15 44% 23 27% Available 17 50% 51 61% Functional 17 50% 39 46% Available 11 32% 47 56% Functional 9 26% 38 45% Available 25 74% 65 77% Functional 25 74% 60 71% Available 15 44% 28 33% Functional 15 44% 24 29% Available 8 24% 10 12% Functional 8 24% 9 11% Available 4 12% 3 4% Functional 4 12% 3 4% Status of human resources The availability of human resources, by the category and number of staff (both regular posted and provided by NMNCHP) at SHC hospitals, as compared against the required numbers is presented in Table Overall, the DHQHs have higher levels of available staff than the THQHs. Particularly gynaecologists and nurses at 82% and 68% positions filled. However, in the case of anaesthetists, paediatricians, WMOs and LHVs, the levels are very low, at around 24 to 42

34 29%. Support service technicians are at even lower levels, from 0 to 15%, with neither the DHQHs nor THQHs having blood bank or anaesthesia technicians. TABLE 3.13: STATUS OF MNCH RELATED STAFF IN SHC HOSPITALS Availability of human resources in SHC hospitals Staff categories DHQHs (N=34) THQHs (N=84) Number Percentage Number Percentage Gynaecologist 28 82% 48 57% Anaesthetist 9 26% 33 39% Paediatrician 8 24% 59 70% WMOs 10 29% 9 11% OT technician 4 12% 2 2% Blood bank technician 0 0% 0 0% Lab technician 5 15% 20 24% Anaesthesia technician 0 0% 0 0% Nurses 23 68% 32 38% LHVs 8 24% 2 2% Ambulance drivers 20 59% 0 0% Status of functional equipment The equipment items for various service components at SHC hospitals are categorized in four groups according to the percentage availability of functional equipment items in each SHC hospital. The details are presented in Table Close to 70% of the DHQH hospitals, had more than 75% ofthe equipment available for OPD, labour room, operating theatre and general items. Nearly all (95%) of them, have more than 50% availability. Exception to note is that only 56% of the DHQHs, had 75% availability of operating theatre equipment.44% of the DHQHs have less than 50% of the equipment for female wards available. The overall percentage availability of equipment CEmONC at THQHs is lower than at the DHQHs. With only 40% of the THQHs having more than 75% ofthe equipment available for OPD, labour room, operating theatre and general items. 80% of them have more than 50% availability of the items. The one exception of note, is the very low availability of equipment 43

35 for paediatric nurseries, with only 7% of the THQHs having more than 75 % availability.64% of them, with less than 50% availability.likethe DHQHs, equipment availability for female wards is also low, with 48% of the THQHs having less than 50% availability of equipment. TABLE 3.14: STATUS OF FUNCTIONAL EQUIPMENT IN SHC HOSPITALS Number of SHC hospitals having functional equipment items DHQH (N=34) THQH (N=84) Equipment >75% available 51 to 75% available 25 to 50% available <25% available >75% available 51 to 75% available 25 to 50% available <25% available General items Female ward OPD Paediatric nursery Paediatric ward Labour room Operation theatre Clinical laboratory Status of drugs and supplies Tracer items were selected from the list of essential drugs and supplies for MNCH (Annex 2), for assessing their availability at the surveyed facilities. The SHC hospitals are categorized into four groups, according to the percentage availability of the items in each group of supplies, Tracer drugs, vaccines and family planning commodities.the details are presented in Table 3.15 below. Around 80% of the DHQHs had more than 75% availability of supplies, vaccines and family planning commodities and nearly all of them, have more than 50% availability. Only 15% of the DHQHs had more than 75% availability of drugs 61% of the DHQHs have less than 50% of the required drugs available. The THQHs show a similar pattern, with 79% of them, having more than 75% availability of supplies, vaccines and family planning commodities. Nearly all of the THQHs have more 44

36 than 50% availability. However, although higher than the DHQHs, only 25% of the THQHs had more than 75% availability of drugs. 39% of the THQHs had less than 50% of the required drugs available. A point to note is the full availability of vaccines at both the DHQH and THQH hospitals and the high availability of family planning commodities. TABLE 3.15: STATUS OF DRUGS AND SUPPLIES IN SHC HOSPITALS Number of SHC hospitals having tracer items DHQH (N=34) THQH (N=84) Item groups >75% available 51 to 75% available 25 to 50% available <25% available >75% available 51 to 75% available 25 to 50% available <25% available Supplies Drugs Vaccines Family planning commodities Status of support services The facilities for support services, including laboratory tests (space, test strips and human resources), blood transfusion services (space, supplies and human resources), ambulance services (a functional vehicle and driver), operating theatre (space, drugs and supplies, equipment items and human resources) were assessed, at the surveyed SHC hospitals. Based on the percentage availability of the inputs required for performing these services, SHC hospitals are categorized in four groups. The details are presented in Table Around 50% of the DHQHs had more than 75% availability of support services for laboratory tests, blood transfusion and the operating theatre. 93% of them had more than 50% availability. Only 32% of the DHQHs had more than 75% availability of support services for the operating theatre. The THQHs had lower levels of availability than the DHQHs. With 19% of the THQHs having more than 75% availability of support services, mainly due to, only 11% and 19% of THQHs 45

37 having more than 75% availability of support services, for laboratory tests and the operating theatre, respectively. 74% of the THQHs have over 50% availability for all three of them. 15% of the THQHs have less than 25% of the support services available for blood transfusion. TABLE 3.16: STATUS OF SUPPORT SERVICES IN SHC HOSPITALS Number of SHC hospitals by % availability of support services Item groups DHQH (N=34) THQH (N=84) >75% available 51 to 75% available 25 to 50% available <25% available >75% available 51 to 75% available 25 to 50% available <25% available Basic laboratory tests Blood transfusion Operating theatre Ambulance and radiology services were assessed separately and the results are provided in Table Overall, both the DHQH and THQH hospitals have functional ambulances and drivers. The availability of radiology services is around 60% for both. TABLE 3.17: STATUS OF SUPPORT SERVICES IN SHC HOSPITALS Number of SHC hospitals having the required items Item groups DHQH (N=34) THQH (N=84) Number Percentage Number Percentage Functional ambulance % 81 96% Ambulance driver 33 97% 82 98% Radiology services 20 59% 53 63% SHCs conformance to required inputs The assessment findings were analyzed to determine the conformance of SHC hospitals to the inputs required to deliver comprehensive EmONC services. The calculation is based on the Average availability of the number of inputs for each criterion, including infrastructure, human resources, equipment, drugs and supplies and support services. Based on this 46

38 analysis, the conformance status of the DHQHs and THQHs to the required inputs is presented in Figure 3.6. FIGURE 3.6: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT SHC HOSPITALS Infrastructure HR Equipment Drugs & Supplies Support Services 80% 60% 66% 62% 72% 72% 68% 68% 61% 54% 63% 40% 42% 20% 0% DHQ Hospitals THQ Hospitals The following graphs (Figures 3.7 and 3.8) present the district-wise status of average component availability of inputs at the DHQHs and THQHs. 47

39 FIGURE 3.3: DISTRICT-WISE STATUS OF CONFORMANCE OF DHQHS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Muzafargarh Lahore Vehari TT Singh Chakwal Sheikhupura Jhang Pakpattan Attock Chiniot Bhakhar Sargodha Gujrat Rajan Pur Gujranwala Mianwali DG Kahn Okara Jhelum Khanewal Sialkot Sahiwal Layyah Bahawalnagar Khushab Kasur Nankana Sahib Hafizabad Narowal Lodhran Mandi Baha uddin

40 FIGURE 3.4: DISTRICT-WISE STATUS OF CONFORMANCE OF THQHS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Jhang Rawalpindi Faisalabad TT Singh Muzafargarh Pakpattan Vehari Okara Attock Sheikhupura RY Khan Rajan Pur Sargodha Multan Bhakhar Mandi Baha uddin Gujranwala Bahawalpur Narowal Chiniot Sialkot Gujrat Lahore Sahiwal Kasur Khanewal Jhelum DG Kahn Layyah Bahawalnagar Khushab Hafizabad Chakwal Mianwali Lodhran

41 Tehsil headquarter (THQ) hospitals The THQ hospitals were also assessed for their capacity to provide 24/7 basic EmONC services, on similar inputs as those used for the assessment of the RHCs. All of the 84 THQHs in Punjab, were assessed for the availability of the optimal level of inputs required in order to deliver 24/7 basic EmONC services. Status of infrastructure The infrastructure of the THQHs has been assessed for the availability of an OPD, indoor ward, LHV s room, labour room and clinical laboratory, as service provision areas and the residences for accommodation of required staff. Service provision areas have been assessed as a single room, having facilities like consultation, examination and hand washing etc. The findings for the availability and functional status of infrastructure components assessed at the THQHs, both in numbers and percentages are presented in Table The functional status of the available infrastructure components in the following table refers to its condition, in terms of its required repair and not the operational state. The available components were labelled non-functional if the structure was found damaged or the repair needs exceeded 75%. TABLE 3.18: STATUS OF ASSESSED INFRASTRUCTURE IN THQHS Infrastructure OPD Female ward Labour room Clinical laboratory LHV s room Residence - Doctor Residence - LHV Status of THQHs (N=84) Number Percentage Available 83 99% Functional 82 98% Available 54 64% Functional 50 60% Available 80 95% Functional 78 93% Available 83 99% Functional 82 98% Available 67 80% Functional 63 75% Available 51 61% Functional 39 46% Available 47 56% Functional 38 45% 50

42 The assessment of the infrastructure of the THQHs, for the delivery of Basic EmONC services, showed that almost all of the THQHs in Punjab had OPDs in a good condition. A total of 51 THQHs had a WMO s residence but it was inhabitable only at 45% of the THQHs. Status of human resources PC-1 of the NMNCHP contains the category and number of staff required for the provision of basic EmONC services. The availability of human resources (both regular posted and provided by NMNCHP) at the THQHs, against the required numbers is presented in Table 3.19 below. TABLE 3.19: STATUS OF MNCH RELATED STAFF IN THQHS Staff categories Status of THQHs having required staff (N=84) Number Percentage WMO 46 55% LHV 33 39% Lab technician 45 54% OT technician 11 13% Ambulance driver 82 98% Major gaps were found in the availability of WMOs and technical staff, as the required number of WMOs, were available only at 55% of the THQHs. Lab technicians were not available at almost half of the THQHs. Ambulance drivers were available at 98% of the THQHs. Status of functional equipment The equipment items for various service components, for the provision of basic EmONC services at the THQHs, are listed in PC-1 of the NMNCHP. The THQHs are categorized in four groups, according to the percentage availability of the functional equipment items at each THQH. The details are presented below, in Table

43 TABLE 3.20: STATUS OF FUNCTIONAL EQUIPMENT IN THQHS Equipment Number of THQHs having functional equipment items (N=84) >75% available 51 to 75% available 25 to 50% available <25% available Basic EmONC The assessment of the functional equipment items at THQHs, against the criteria of basic EmONC services, revealed that only 31 out of the 84 health facilities had more than 75% of the equipment items. 47 THQH hospitals had 51 to 75% of the items available, while 2 THQHs had even less than 25% of the equipment items. Status of drugs and supplies A list of essential drugs and supplies for MNCH services is contained in PC-1 of the NMNCHP. Tracer items were selected from the list (Annex 2) for assessing their availability at the surveyed facilities. The THQHs are categorized in four groups, according to the percentage availability of the items in each group of supplies, Tracer drugs, vaccines and family planning commodities, as presented in Table TABLE 3.21: STATUS OF DRUGS AND SUPPLIES IN THQHS Item groups Number of THQHs with available tracer items (N=84) >75% available 51 to 75% available 25 to 50% available <25% available Supplies Drugs Vaccines Family planning commodities The analysis of available tracer items in THQHs showed that the majority of the THQHs (64 out of 84) had more than 75% of the supplies. Whereas, 22 THQHs had less than 50% of the required drugs available. More than 75% of the assessed vaccines were available at 81 of the THQHs. However, 15 of the THQHs had less than 25% of the family planning commodities available. 52

44 Status of support services The facilities for support services including basic laboratory tests (space, test strips and human resources) and ambulance services (a functional vehicle and driver) were assessed at the THQHs. Based on the percentage availability of the inputs required for performing these services, the THQHs were categorized in four groups, as presented in Tables 3.22 and TABLE 3.22: STATUS OF SUPPORT SERVICES IN THQHS Support services Number of THQHs with available support services (N=84) >75% available 51 to 75% available 25 to 50% available <25% available Laboratory tests TABLE 3.23: STATUS OF SUPPORT SERVICESIN THQHS Support services Number of THQHs with available support services (N=84) Available % Available Functional ambulance 81 96% Ambulance driver 82 98% THQHs conformance with assessed inputs The assessment findings were analysed to determine the conformance of the THQH hospitals, to the inputs required to deliver basic EmONC services. The calculation is based on the Average availability of the number of inputs for each criterion, including infrastructure, human resources, equipment, drugs and supplies and support services. Based on this analysis, the conformance status of the THQHs to required inputs is presented in Figure

45 FIGURE 3.9: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT THQHS 100% 80% 79% 72% 79% 60% 40% 20% 27% 30% 0% Infrastructure HR Equipment Drugs and Supplies Support Services The following graph (Figure 3.10) presents the district-wise status of average component availability of inputs at THQHs required to deliver basic EmONC services. 54

46 FIGURE 3.5: DISTRICT-WISE STATUS OF CONFORMANCE OF THQHS TO REQUIRED INPUTS Infrastructre Human resources Equipment Drugs and supplies Support services Sheikhupura Muzafargarh Jhang Bhakhar Pakpattan TT Singh Faisalabad Rawalpindi Rajan Pur Chiniot Sargodha Multan Layyah Mandi Baha uddin Attock Bahawalpur Okara Narowal DG Kahn Lodhran RY Khan Gujranwala Gujrat Vehari Jhelum Hafizabad Sialkot Khushab Lahore Sahiwal Kasur Khanewal Mianwali Chakwal Bahawalnagar

47 Management basics 9 The findings related to management basics at the surveyed health facilities are as follows. Human resources The status of staff categories filled includes regular posting only, as reported by the respective facility on the day of the survey. The details are given in Table 3.24 below. TABLE 3.24: STATUS OF HR REPORTED BY SURVEYED HEALTH FACILITIES Number of posts filled at RHCs DHQ hospitals (34) THQ hospitals (84) RHCs (291) BHUs (493) Staff Sanctioned Filled Sanctioned Filled No. % No. % No. % No. % Sanctioned Filled Sanctioned Filled Gynaecologist Anaesthetist Paediatrician WMO* OT technician Blood bank technician Lab technician Anaesthesia technician Nurses 1,598 1, , ,702 1, LHV Ambulance drivers *MO/WMO for BHUs Provision of staff by the NMNCHP The NMNCHP provides support in terms of human resources at targeted health facilities, including specialists, doctors and paramedics. The details of NMNCHP support regarding 9 HFA Tools for this section include the District Level Questionnaire (DLQ) and the Provincial Level Questionnaire (PLQ). 56

48 staff provision in the province, collected from the district health offices, during the survey are given in the Tables 3.25 and TABLE 3.25: NUMBER OF HEALTH FACILITIES HAVING STAFF PROVIDED BY NMNCHP DHQHs THQHs RHCs TABLE 3.26: NUMBER OF MNCH STAFF PROVIDED BY NMNCHP Staff cadre Number of staff provided DHQH THQHs RHCs Gynaecologist 9 3 Anaesthetist 0 0 Paediatrician / Neonatologist 0 0 WMO Operation theatre technician Blood bank technician 0 0 Laboratory technician Anaesthesia technician 0 0 Nurses LHVs Ambulance drivers Total MNCH staff training One of the targets of the NMNCHP is to build the capacity of 29, MNCH related staff, through conducting skill development training in the standards of service provision, counselling techniques and client centreedness. Information on the training of MNCH staff, during the last three years was collected from district NMNCHP cells during the survey. It is presented in the Tables 3.27 and PC-1 NMNCHP Table 4 List of training and approximate unit cost, Page 31 57

49 TABLE 3.27: NUMBER OF STAFF TRAINED ON DELIVERING MNCH SERVICES MNCH staff EmONC ENC IMNCI IMPAC Number of staff trained FP surgical FP counselling Client centreedness Anaesthetists Gynaecologist LHV MO Nurse OT technician Paediatrician WMO Total TABLE 3.28: NUMBER OF HEALTH FACILITIES RECEIVED MNCH TRAINING MNCH staff Number of health facilities DHQHs THQHs RHCs BHUs EmONC ENC IMNCI IMPAC Family planning - Surgical Family planning - Counselling Client centredness

50 CMWs training and deployment The NMNCHP aims to train and deploy community mid-wives for improving community based MNCH services, to the ensure availability of a skilled birth attendant in every village. The target for Punjab is to train 10, of them by The distribution of the community mid-wives will be done by the provincial MNCH cell, before the recruitment process begins. The following table presents the aggregate information related to the training and deployment of community mid-wives, collected during the survey, from all of the district NMNCH cells. TABLE 3.29: STATUS OF CMWS TRAINING AND DEPLOYMENT IN PUNJAB 2010 Training and deployment of community mid-wives (NMNCHP) Number of selected community mid-wives verified for their residential status 2,836 Number of community mid-wives withtraining completed 2,462 Number of community mid-wives deployed by the NMNCHP 1,721 Management basics and supervision Health facilities in all of the districts were assessed for management basics and supervisory activities, including the availability of job descriptions, service delivery protocols, facility staff meetings and the participation of the facility in-charges in district level meetings, district managers conducting supervisory visits and providing feedback to the facilities. The findings of these activities in the surveyed health facilities are presented in Figures 3.11, 3.12 and PC-1 NMNCHP, CMW Component, page

51 FIGURE 3.11: STATUS OF MANAGEMENT BASICS AT SURVEYED FACILITIES 70% 60% 50% 40% 30% 20% 10% 0% 58% 53% 50% 44% 45% 46% 44% 38% 31% 25% 15% DHQHs THQHs RHCs BHUs MNCH related JDs for staff available 35% MNCH related service delivery protocols available FIGURE 3.12: STATUS OF WORK COORDINATION 120% 100% 80% 60% 40% 20% 0% 100% 100% 99% 94% 92% 95% 89% 83% 48% 46% 42% 38% DHQHs THQHs RHCs BHUs Facility staff meeting Meeting record maintained Participation of HF incharges in district meeting 60

52 FIGURE 3.13 : STATUS OF SUPERVISION 120% 100% 80% 94% 94% 100% 99% 81% 79% 77% Visited for supervision 60% 40% Feedback received (Visited HFs) 20% 19% 0% DHQHs THQHs RHCs BHUs Management information system In Punjab, all of the districts are using the district health information system (DHIS) for recording and reporting purposes. The surveyed facilities were assessed for the availability and maintenance of DHIS tools (14) and their findings are presented in Figure FIGURE 3.14: STATUS OF MIS 120% 100% 80% 100% 98% 100% 85% 84% 86% 84% 85% 83% 78% 73% 97% Tools available 60% Tools maintained 40% Monthly DHIS reporting 20% 0% DHQHs THQHs RHCs BHUs 61

53 Drugs and supplies The availability of drugs and supplies has been described under individual MNCH service packages. The reasons for being out of the stock of essential drugs and supplies were identified at the surveyed facilities. A break-down of the reasons is given in Figure FIGURE 3.15: FACILITY SPECIFIC REASONS FOR STOCK OUT OF DRUGS AND SUPPLIES 80% 60% 62% 40% 36% 20% 0% 25% 6% 11% 3% 19% 21% 3% Infection control The health facilities were assessed for practices of infection control and waste management, and the availability of related material. The findings of the surveyed facilities are presented in Table TABLE 3.30: STATUS OF INFECTION PREVENTION AT THE SURVEYED HEALTH FACILITIES Infection prevention DHQHs (Total=34) Number of health facilities THQHs (Total=84) RHCs (Total=291) BHUs (Total=493) Availability of material Waste management plans Waste collection materials Personal protection materials Waste treatment equipment 3 4 Functional incinerator

54 Infection prevention DHQHs (Total=34) Number of health facilities THQHs (Total=84) RHCs (Total=291) BHUs (Total=493) Infection prevention practices Hand washing practices of care providers Disinfection of service provision areas Vaccination of staff against Hepatitis B Practice of waste segregation Disposal through throwing away Disposal through municipal arrangements Death review Information about maternal and neonatal deaths occurring at the surveyed facilities was collected by using the SD&MB questionnaire. In Punjab, a total of 240 maternal deaths and 3067 neonatal deaths were reported at the surveyed facilities. All of the surveyed facilities, excluding the BHUs, were assessed for the availability and functioning of death review committees. Maternal and neonatal deaths reviewed by the committee are presented in Table TABLE 3.31: STATUS OF MORTALITY REVIEWS AT SURVEYED HEALTH FACILITIES Mortality review DHQHs (Total=34) Number of health facilities THQHs (Total=84) RHCs (Total=291) Availability of death review committee Functional death review committees Donor contributions Donor contributions (excluding budgetary support) during the last three years were assessed regarding human resources, infrastructure, equipment (including ambulances), drugs and supplies. The findings are presented in Table

55 TABLE 3.32:STATUS OF DONOR CONTRIBUTIONS AT SURVEYED HEALTH FACILITIES Number of health facilities Donor contributions DHQHs THQHs RHCs BHUs (Total=34) (Total=84) (Total=291) (Total=493) Infrastructure Construction of new building Renovation of existing building Equipment Provision of equipment Provision of vehicles/ ambulances Drugs and supplies Provision of medicines Provision of consumables Procurement estimates Equipment Based on the information collected, the procurement needs for the provision of required equipment, have been identified for the individually surveyed facilities, in order to strengthen MNCH services. A summary of estimated cost, for the procurement of required equipment is given below. A list of required equipment for each surveyed facility is presented in the annexes of each district report. A summary of the estimated cost for procurement of equipment is given in Table Civil works A yardstick has been used for assessing the scope of civil works, of the various MNCH related building components (Annex 2). A cost estimate based on the identified scope of work, required to complete the infrastructure needs of the individually surveyed facilities, is presented in the annexes of the district reports. A summary of the estimated cost for the execution of civil works, including repair and maintenance, renovation and new construction of missing facilities, is given in Table

56 TABLE 3.33: SUMMARY OF ESTIMATED COST FOR EQUIPMENT AND CIVIL WORKS Procurement Estimated cost (PKR in Millions) DHQHs THQHs RHCs BHUs (Surveyed) Total Equipment , Civil works , , , ,

57 Section 4: Clients Perspectives For clients and communities, assessing quality care means gaining an understanding of their stated needs. Since these can vary from individual to individual, assessing client satisfaction ultimately depends on a mixture of their perceptions and expectations. While subjective in nature, and open to interpretation, the clients perspectives are important for improving the delivery of quality health care services. Client exit interviews (CEIs) were conducted within the scope of the health facility assesment survey to assess the clients perspectives on the services provided at RHCs, THQHs and DHQHs. In Punjab, a total of 2,215 clients were interviewed and break-down of the information, by facility is presented in Table 5.1. Married women of child bearing age visiting the facility for MNCH related services (Gynae/Obs and child health services for under 5 years of age) and fathers accompanying their children (under 5 years of age) to the facility for child health services were targeted for the client exit interviews. TABLE 4.1: NUMBER OF CEIS CONDUCTED IN PUNJAB Type of health facility Number of client exit interviews District headquarter hospitals 340 Tehsil headquarter hospitals 420 Rural health centres 1,455 Total 2,215 Key findings For the client, accessibility means that the health care services are unrestricted by barriers such as geography, finance or culture. Reasons for visiting public sector health facilities Overall, the health facilities at all levels were visited mostly for maternal health, child health and general medical problems. The reasons are illustrated in Figure

58 FIGURE 4.1: TYPES OF SERVICES ACCESSED AT PUBLIC HEALTH FACILITIES 25% 10% 2% 35% ANC PNC General medical problems Child health 21% 7% FP services Others 24% of the clients interviewed, stated that they prefer public sector facilities over private health care. They cited the affordabiltiy of services, proximity to their homes and good quality as the main reasons for using public sector facilities. The lack of choice was a minor factor in the decision, indicating that other options were available to the clients. TABLE 4.2: CLIENTS REASONS FOR VISITING PUBLIC SECTOR HEALTH FACILITIES Reasons for visiting public health facilities Number of clients DHQHs THQHs RHCs TOTAL % % % N=340 N=420 N=1455 N=2155 % Affordability % % % % Close to home 91 27% % % % Good quality 90 26% % % % Staff attitude 55 16% 84 20% % % Lack of choice 31 9% 41 10% 130 9% 202 9% The proximity to their home was a key reason to use the facilities, as is substantiated by the findings that 85% to 95% of the clients took less than 30 minutes to reach the facility, as illustrated in Figure 4.2. FIGURE 4.2: AVERAGE TIME TAKEN BY THE CLIENTS TO REACH THE FACILITY 67

59 80% 70% 60% 54% 63% 68% Less than 30 minutes 50% 30 minutes to 1 hour 40% 30% 29% 29% 27% More than 1 hour 20% 16% 10% 8% 5% 0% DHQHs THQHs RHCs Waiting time was counted as a measure of quality for the clients at the facility.the findings showed on average a longer waiting time at the DHQHs, with 55% of the clients reporting waiting less than 20 minutes at the DHQHs. As compared to close to 80% and 90%, at the THQHs and RHCs, respectively. FIGURE 4. 3: AVERAGE WAITING TIME AT THE FACILITY 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 47% 40% 41% 39% 33% 32% 21% 14% 12% 9% 8% DHQHs THQHs RHCs 4% Less than 10 minutes 10 to 20 minutes 20 to 30 minutes More than 30 minutes Quality of care The important dimensions of the quality of care assessed, included the clinical examination and attitude of the health care provider; provision of prescribed medicines and laboratory tests; and the provision of health care education material. In order to assess the clients perceptions about the quality of care, they were asked about 68

60 their satisfaction with the clinical examination, the attitude of the health care provider and other facility staff, and communication regarding illness, course of treatment and the followup.nearly 95% of the clients were satisfied or very satisfiedwith these individual aspects of care as shown in Figure 4.4. FIGURE 4. 4: CLIENTS' LEVEL OF SATISFACTION WITH AVAILED SERVICES Communication 19% 74% 7% Attitude of other staff 17% 74% 6% Very Satisfied Attitude of HCP 21% 74% 5% Satisfied Not Satisfied Clinical examination 25% 70% 5% 0% 20% 40% 60% 80% 100% Of those clients who were prescribed medicines or laboratory tests, only about 10% received no services 38% reported receiving all of the prescribed medicines and 50% some of the prescribed medicines. As for prescribed laboratory tests, 68% reported receiving all and 22% received some of them. Only 3% of the interviewed clients, reported receiving health care education material from the facility and very few said that their health care providers had been explained their illness and the course of treatment to them. FIGURE 4. 5: PROVISION OF MEDICINES, LAB SERVICES AND EDUCATION MATERIAL Received (complete) Received (partial) Not received Lab services 68% 22% 9% Medicines 38% 50% 12% 0% 20% 40% 60% 80% 100% 69

61 Received Not received Education material 3% 97% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Overall satisfaction The clients were asked about their overall satisfaction with the visitand the results are shown in Figure 4.6. About 20% of them were very satisfied and 75% were satisfied with the provided services. Only 5% were not satisfied at all with the quality of services provided at the public sector health care facilities. FIGURE 4. 6: OVERALL SATISFACTION OF THE INTERVIEWED CLIENTS RHCs 22% 73% 4% Very satisfied THQHs 17% 79% 4% Satisfied Not satisfied DHQHs 13% 79% 9% 0% 20% 40% 60% 80% 100% 70

62 Section 5: Health Managers Perspective 12 Rationale Whereas facility based assessments were conducted, to provide information on the availability and functioning of the health facilities, in order to deliver level-specific MNCH services. In-depth interviews (IDIs) were conducted with the health managers preferably the EDO health - todevelop a better understanding of the management issues at the district level and to clarify some of the issues identified during the physical site visits. The in-depth interviews also provided opportunities to seek inputs and suggestions for improvement, within the current system. Districts located in geographical proximity to each other, are grouped into divisions in the public administration setup. One health manager was randomly selected from each division for the IDI. A total of 9 IDIs were conducted in Punjab, from February to April 2011.The names of these districts are providedin Table 5.1. TABLE 5.1: DISTRICTS IN PUNJAB CONTACTED FOR IN DEPTH INTERVIEWS Names of districts 1. Rawalpindi 2. Sargodha 3. Vehari 4. Muzaffargarh 5. Okara 6. Faisalabad 7. Bahawalnagar 8. Sialkot 9. Nankana Key findings of thein-depth interviews The provision of MNCH services, form a part of the routine services provided by the district health system. The NMNCHP has additionally sanctioned the posts of public health specialist and social organizer, in each district for collaboration with the EDOH office, for the implementation of MNCH activities within the district. Most participants described this to be well-integrated, (with) a District Project Implementation Unit (DPIU) established at the district.however, two participants did report vacancies in the key position of public health specialist. Infrastructure Sufficient infrastructure was available for the delivery of MNCH services. However, some facilities required renovation or an upgrade. One informant suggestedpoorly located facilities, as the cause of low utilization of MNCH services. Some health facilities are at such 12 Source: In Depth Interviews (IDIs) of the EDO- Health 71

63 an odd location that female patients prefer not to go there, despite the availability of WMOs...a dispensary in the main city, attracts more patients than these facilities, despite the fact that the dispensary has no WMO. Human resources The NMNCHP has stationed LHVs, WMOs and gynaecologists at various facilities, throughout the province. The programme has also undertaken the training and deployment of community mid-wives (CMWs), within the province to serve as skilled birth attendants in the community. Inspite of these initiatives, the condition has not significantly improved in the province. Almost all of the informants reported continued shortages of skilled staff at health facilities for various cadres, particularly WMOs and specialists, including gynaecologists and anaesthetists. Poorly located and maintained facilities were considered to be the leading cause for the vacant posts of woman medical officers (WMOs), particularly in rural areas. The location of these health facilities had created security concerns for the live-in staff. Staff shortages were also attributed to low pay scales and the lack of performance based incentives. Medico-legal responsibilities which formed part of the job description of WMOs were thought to be one of the main reasons for their non-deployment at all levels. One informant suggested the removal of medico-legal responsibilities from the job descriptions of WMOs, One very important point is that WMOs should be exempted from medicolegal duties and they shall exclusively be for provision of MNCH services. It was highlighted that the lack of political commitment had been a major concern in the availability of staff. As one of the informants commented We invest in equipment and buildings but we don t invest much in human resources. Due to these demotivating factors, qualified staff was not interested in joining the public sector health facilities, as commented Posts for MOs and WMO have been advertised recently and only 2 applications were received against 14 posts of WMOs, and 9 applications were received against the 17 posts of MO. We invest in equipment and building but we don t invest much in human resources. WMO should be exempted from medicolegal duties 72

64 Staff competency for the provision of MNCH services was thought to be sufficient, though most of the respondents felt that there was a need for continued refresher training and skill development among staff of all cadres. All of the respondents credited the NMNCP, PAIMAN and DHDC for imparting training to staff. However concerns were raised about the continuation of these activities. Procurement and logistical management The districts reported sufficient arrangements in place for the procurement and logistical management of drugs, supplies and equipment. The planning and budgeting for purchase is done through a purchase committee, headed by the district coordination officer (DCO); having the EDO health (EDOH) and EDO finance and planning (EDO F&P) as key members. District plans for procurement are based on the cumulative demands of the individual health facilities. However, the purchase of drugs and supplies can only be done according to rate contracts established and approved by the health department. Equipment purchases are also guided by a provincial approved standardized list limiting equipment procurement at the district level. To prevent running out of stock or to meet emergency needs, the facility in-charges are also entitled with level-specific purchasing powers (for local purchase). The quality control of drugs is done through a central drug testing lab (DTL). Further distribution to the health facilities and the payment of vendors is dependent on the report of the DTL. This report is usually delayed due to a heavy workload and the shortage of such labs. The districts also lack technical expertise, particularly for electro medical equipment. Informants also mentioned a lack of storage arrangements at the district level. A paucity of funds and the delayed approval of rate contracts at the provincial level were described by the informants to be one of the major causes of delays in the provision of supplies and subsequent running out of stock. One of the informants commented A list of 124 medicines has been prepared. However, nine months have passed and the rate contract for this financial year has not been finalized yet. Nine months have passed and rate contracts for this financial year have not been finalized Information is mostly used in provincial planning but not at the district level 73

65 Management information system All of the respondents reported having adopted the newly introduced district health information system (DHIS). Data from individual health facilities is consolidated into a district report by the functioning DHIS cell, housed at the EDOH office and is subsequently forwarded,on a monthly basis, to the director general health services (DGHS) office, at the provincial level for decision making. All of the participants reported timely submission of reports from the facilities; only one participant reported shortages of material resources preventing the efficient functioning of the DHIS cell. The respondents did note that...information is mostly used in provincial planning but not at the district level. Except for only one respondent, who reported using the data at the district level. Planning and intersectoral collaboration Health planning at the district level was described by the informants as an annual activity for the purpose of preparing budgetary demands. This macro-level plan is comprised of the department s major activities related to service delivery and management. This budgetary demand is presented to the committee - headed by the DCO - for approval. The committees match the department s demand with available financial resources and the plans are adjusted accordingly. Commenting on the rationale for budgetary allocation, two informants thought allocation was rarely based on a rationale, with another two describing it as a (routine activity) every year (a) 10% increment is provided on the last year s budget. Only one participant said...the trend is shifting towards activity-based budgeting. Detailed work plans are also prepared in some of the districts by using the district data, as two of the informants described planning as evidence-based. In a few of the districts, informants DHMTs, mentioned that district health management teams (DHMTs) were despite notified, but despite the notification, these teams were not active in the planning process. The lack of integration of planning with vertical notification, programmes at the district level was also identified by two informants were not as a cause of concern. Plan implementation is monitored mainly through monthly progress active in the review meetings of the health facilities staff and supervisory visits planning performed by the health managers. Implementation was described by process two respondents to be suffering from a delayed transfer of funds. As an informant mentioned, efforts are being made but a major inference in implementation of these plans is the lack of required financial 74

66 resources. One informant pointed a lack of its ownership in the lower level managers owing to the non-involvement in the planning process, also hampers plan implementation. The lack of recognition and performance-based incentives were also described by a respondent as a source of discouragement in the implementation of plans. Conducted under the aegis of the district coordination officer (DCO), collaboration between different departments was described to exist through a variety of mechanisms, including the district health forum and district health management teams. These forums had been actively involved in the implementation of certain activities, like national immunisation days (NIDs), Polio campaigns,etc....conducting community mobilization, health education, and awareness and promotion activities in the district but such collaborations have only been restricted to time-bound activities and campaigns. Various mechanisms for involving community groups and the local NGOs, included public consultation meetings. However, no mechanism was described for involving the private sector, due to the lack of necessary regulation. Resource Monitoring and supervision constraints The EDOH, supported by the DOH are responsible for the monitoring and supervision of health facilities, throughout the district. In order to limit streamline this process, tour diaries are made outlining inspection effective schedules which are shared with and approved by the district coordination officer (DCO). Most participants reported, that the supervisory minimum number of supervisory visits for each managerial post is activities clearly outlined in the job descriptions. However, none of them mentioned if these job descriptions had been made available to them at the time of appointment. Most of the participants, expressed their satisfaction with the capacity of the current staff for conducting supervisory visits. Training for this staff occurred during orientation and the monthly review meetings; these forums however, were informal and one participant highlighted the need for continuous training of the staff for conducting monitoring and supervision visits. One respondent described the EDOH office staff as skilled enough to conduct the supervision, but their posting is not permanent. The utilization of standardized monitoring and supervision checklists was reported by most of the participants; with two respondents reporting monitoring being based on targets set forth in the district health plans and the DHIS reports. Describing the supervisory visits as 75

67 supportive supervision, the respondents did indicate that these could be followed by administrative actions against the facility staff. Several mechanisms of feedback are employed by the managers; these include verbal onthe-spot feedback, notes in the facility-based visitor s book, report compilation and submission to the EDOH office and feedback to the facilities for action, followed by monthly review meetings with the facility in-charge. Resource constraints limit effective supervisory activities, which include POL, functional..collaborations vehicles and vacant positions of supervisory staff. have only been Financial management District health departments receive their financial allocations from the district government. Provincial programmes like HSRP also provide tied grants to the district health departments, for the implementation of specific activities. The districts reported a sufficient capacity for managing these funds; however, a few of the informants mentioned difficulties in implementing the PIFRA guidelines and tools. Regarding the allocation of funds, one informant explained that only 50 Rupees were kept in the medicines head for keeping it functional, otherwise all the powers lie with the EDO F&P, including the re-appropriation of funds. Therefore, DDOs have to ask for the allocation of funds time and time again, leading to the delay in the provision of medicines and supplies. The lack of finances is a big challenge for the delivery of services, as one of the informants mentioned, The situation of financial resources can be judged from the fact that Rs. 15 million have been allocated for the procurement of medicines for the whole district; which is sufficient only for the procurement of medicines for the DHQH hospital and there is no strategy in the district to overcome shortages. restricted to time-bound activities and campaigns...districts have no mechanism to ask donor support for supplying required commodities Donor contributions Collaboration with donors is initiated at the federal or provincial levels. These contributions are usually in the form of development projects, which are focusing on a specific area. 76

68 Donors coordinate with the identified districts through the office of the EDOH and districts have no mechanism to directly access donor agencies for assistance, in district specific priority areas, as an informant mentioned, Districts have no such mechanism to ask the donors for support for supplying the required commodities. Out the districts where donor agencies were active, there was no reported financial contribution; instead, the focus of the donors was on project-specific civil work, supplies, equipment and staff capacity building. These development projects are time-bound and the districts are left with no arrangement for sustainability. As for local donors, two of these districts reported an active community involvement in the upgrading and maintenance of health facilities, purchase of equipment and establishment of patient welfare societies. The interaction of these local donors was limited to the level of the individual health facility. 77

69 Section 6: Key Findings This section contains the key findings based on the results of the health facility assessment This is the first nationwide facility survey to be completed. It is important to note that the health facility assessment is only one tool of the national monitoring and evaluation system, usually conducted every 3 to 4 years, to supplement the routine reporting systems not to replace it. However, since this is the first health facility assessment, and the routine M&E systems are still being implemented, some additional instruments were applied, so that baselines could be identified for the NMNCH programme as appropriate. In Punjab, a total of 902 health facilities were assessed under the health facility assessment: 34 DHQHs, 84 THQHs, 291 RHCs and 493 BHUs. Infrastructure The majority of the infrastructure components (81% on average), were both available, as well as, functional at the BHUs. However, gaps existed in the availability of sub-components like scrub areas in labour rooms; hand washing facilities in OPDs; and LHV residences, which although available, at 445 out of the 493 BHUs, were in a good condition at only 162 of them. On average, 89% of the infrastructure components were available at the RHCs. When the THQHs were assessed on this criterion to assess their readiness to deliver basic EmONC services, on average, only 76% of the required infrastructure was available at each THQH. Apart from the facilities missing in the available components, an independent Ob/Gyn ward was not available at 30 of the THQHs. Residences for the WMOs were available at 263 RHCs and 51 THQHs, but were inhabitable at only 183 of the RHCs and 39 THQHs. The average availability of infrastructure components was 65% at the DHQHs and 51% at THQHs. Major gaps were noticed, regarding the availability of a paediatric ward, which was not available at 6 DHQHs and 49 THQHs; a paediatric nursery (not available at 9 DHQHs and 61 THQHs); blood bank (not available at 51 THQHs); and residences for the gynaecologist (not available at 15 DHQHs and 58 THQHs), anaesthetist (not available at 22 DHQH and 67 THQHs) and paediatrician (not available at 18 DHQHs and 58 THQHs). Human resources The availability of required staff was not a problem at the BHU level, as a doctor or LHV was available at 461 of the 493 BHUs. For basic and comprehensive EmONC services, (which should be available for 24 hours a day and seven days a week, since demand for EmONC 78

70 services cannot be predicted), a key issue faced by the surveyed health facilities, was the lack of MNCH-related staff. The minimum requirement of staff, as proposed by the national MNCH programme was not met at the majority of the health facilities. As 95 of RHCs in Punjab, were not provided with a WMO. At the DHQH and THQH hospitals, the availability of specialists, including gynaecologists (not available at 1 DHQH and 36 THQHs), anaesthetists (not available at 10 DHQHs and 56 THQHs) and paediatricians (not available at 3 DHQHs and 25 THQHs) was far less than the minimum requirement. Little commitment to clinical training and professional development, unless specifically funded by external donors, is evident in the public sector. The lack of trained staff was acting as a barrier to the provision of reproductive health and family planning services. Out of the RHCs, as well as the THQH and DHQH hospitals, 80% were not performing assisted vaginal delivery, due (in part) to the lack of training. In this regard, the NMNCHP has been doing its share and has trained a total of 2,421 MNCH related staff, through skill development in the standards of service provision, counselling techniques and client centreedness. The majority of the facilities were lacking trained staff, as staff at 60% of the facilities had not received any of the MNCH related trainings. Health facilities were also reported to be performing vital functions in the absence of formally trained staff, e.g. the DHQ and THQ hospitals performing caesarean sections, in the absence of a qualified gynaecologist or anaesthetist. In order to increase the skilled birth attendance in the rural communities, the NMNCHP has also trained a community-based cadre of community mid-wives. A total of 2,462 community mid-wives were trained, which is almost 25% of the target set for the province. At the time of survey, a total of 1,721 community mid-wives had been deployed in the community. Drugs, supplies and equipment The limited availability of medicines, supplies and functional equipment was a frequent barrier for the surveyed health facilities, preventing them from delivering high quality MNCH services, with the notable exception of vaccines, which were almost always available, at all of the facilities. At the time of assessment, no health facility in Punjab was provided with the complete range of items required to perform the MNCH functions. It should be noted, that although not all of the items (equipment, drugs and supplies) required for the operating theatre and blood bank were fully available at any of the DHQH and THQH hospitals, the majority of them reported having performed,either or both, caesarean sections and blood transfusions prior to the assessment. 79

71 Large quantities of non-functional equipment were also identified at the facilities, which could not be repaired due to lack of maintenance arrangements, routine or repair, at the district level, as well as budgetary constraints preventing their procurement. Facility supervisors reported frequently running out of the stock of essential drugs, supplies and family planning commodities (vaccines to a much lesser extent), due to either their demand not being fully met and/or delays in distribution by the district health department. A discrepancy was noted between policy and practice, as some new drugs and equipment proposed by the NMNCHP had not been procured. For example, a vacuum extractor was included in the standard list of equipment for the RHCs and SHC hospitals, yet most these health facilities did not have them. Support services Support services varied by the facility type and included basic laboratory tests, operating theatre, blood transfusion services, and radiology and ambulance services. Overall, all of the facilities, which had designated ambulance services, had functionality ratings on the average of about 90% for both vehicles and drivers. DHQH hospitals had a higher level of functionality across all of the support services, when compared to the THQHs, with over 90% of all the DHQHs assessed as more than 50% functional for all support services. As compared to about 70% of the THQHs. The biggest difference being noticed in the Blood transfusion services at the THQHs. Management and organisation Work coordination and supervision Monitoring performance allows the facility staff to better understand their deficiencies and helpsininitiating attempts at improvement. Regular monthly performance review meetings were being conducted and the facility staff in-charge, reported regular participationin the meetings used to assess intra-facility work coordination. The records of these meetings were not apparentat these facilities. Supervisory activities of the district health managers at the health facilities were also conducted regularly, but sending the feedback of these supervisory visits to the facility, was not a common practice. Infection control Although availability of waste management plans were reported by the majority of the assessed health facilities, infection control practices were found to be inadequate in the 80

72 service provision areas of all of them. Gaps in infection control practices occured mainly due to the lack of materials and equipment required for waste collection, personal protection and waste treatment. Only 30 of the assessed health facilities had a functional incinerator and the majority of the facilities were not segregating infectious waste from other waste. Service delivery protocols Service delivery protocols are a tool used for the continuous medical education of the MNCH related staff. Service delivery protocols were not available at the majority of the surveyed health facilities. Where they wereavailable, they were not displayed at the proper place. Donor contributions Information about donor contributions was collected from both the surveyed facilities and district health departments. A total of 277 health facilities reported having received donor contributions, while only two districts Gujrat and Chakwal were able to provide the monetary value to the support provided by the donor agencies. Monitoring and evaluation Management information system An adequate information system existed in the form of the district health information system (DHIS), in all of the districts of Punjab. Most of the recording and reporting tools were available and maintained at the surveyed facilities. However, the recording of obstetric complications or the treatment provided in response was deficient at the health facilities, with the exception, of caesarean sections. It can be attributed to the lack of training of the staff responsible for maintaining these tools. There were deficiencies in the DHIS tools which limited the recording of certain key MNCH indicators. For example, the obstetric register contained no space for recording 2 nd, 3 rd or 4 th antenatal visits and these were cumulatively reported as ante natal care revisits. Similarly, there was no separate record for cases of pneumonia under 5 years of age, treated at the health facilities and these were recorded along with the acute respiratory infections. Death reviews The national and provincial health policy endorses the constitution of death review committees for reviewing maternal and neonatal deaths occurring at the health facilities. In 81

73 the surveyed health facilities of Punjab, neither maternal deaths nor the causes thereof were clearly or consistently documented. The death review committees were only functional at 4 DHQHs and 1 THQH hospital. Client satisfaction In Punjab, 2,215 client exit interviews were conducted at the RHCs, THQHs and DHQHs. Less than 25% of the clients interviewed, stated that they preferred public sector facilities over private. Overall levels of satisfaction were high, ranging from 91% to 96% reporting satisfied or very satisfied. Affordability and the ease of access are the main reasons given for choosing the public sector health facilities. Perceptions of standards of care were also notably good, with 80 to 90 percent of the clients waiting for less than 20 minutes to be seen. Close to 95% of the clients were satisfied with the quality of care received and the attitude of the staff. The biggest gaps identified, and a lost opportunity in terms of prevention, is that 97% of clients reported not receiving any education material during their visit and only 38% received all of the medicines prescribed. 82

74 Annexes 83

75 ANNEX 1 Objectives of the NMNCH programme The national MNCH programme (NMNCHP) was initiated in 2006, with its goal to improve maternal, newborn and child health of the population, particularly among Pakistan s poor, marginalized and disadvantaged communities. This is a comprehensive programme aiming at strengthening, upgrading and integrating ongoing interventions, as well as introducing newstrategies. The programme s objectives are to: 1. Strengthen the district health systems, through improvement in technical and managerial capacity at all levels and upgrading institutions and facilities. 2. Streamline and strengthen services for the provision of basic and comprehensive emergency obstetric and newborn care (EmONC). 3. Integrate all services related to MNCH at the district level. 4. Introduce a cadre of community-based skilled birth attendants. 5. Increase demand for health services through targeted, socially acceptable communication strategies. The programme aims to ensure level specific MNCH services at the public health facilities. These are composed of 24/7 comprehensive EmONC services in all of the DHQHs and THQHs; 24/7 basic EmONC services in all of the RHCs; and preventive MNCH services at all of the BHUs. In order to strengthen the public sector health facilities, the programme has taken a number of measures in the provinces, including construction and renovation of infrastructure in the health facilities; provision of key MNCH staff including specialists, doctors, paramedics and ambulance drivers; their capacity building; provision of equipment, drugs and supplies at selected health facilities, to ensure delivery of MNCH services. At national level, a federal MNCH project implementation unit has been established which is led by the national programme manager. The role of the federal MNCH project implementation unit is to facilitate and monitor the programme, by providing assistance to provinces and districts in the implementation of programme s activities. A provincial NMNCHP project implementation unit (PIU) in Punjab has been set up in Lahore in July 2007, which is headed by the provincial coordinator NMNCHP 13. The project implementation unit does not have adequate space for the staff, as proposed in PC-1 of the 13 Information acquired from Provincial Coordinator - NMNCHP (Punjab) using Provincial Level Questionnaire 84

76 programme. As for human resources, all of the sanctioned posts are not filled, as the posts of epidemiologist, communications officer and monitoring and evaluation officer are currently vacant. Sufficient equipment is available for the project implementation unit. The provincial MNCH project implementation unit is responsible for the planning and efficient execution of the programme activities, through district MNCH cells, which are established at each district of Punjab. These cells are headed by the EDO health and are staffed with a public health specialist, a social mobilizer and an accounts assistant. District MNCH cells implement the programme s activities in coordination with the district health department, through the existing structure, with technical assistance from the provincial project implementation unit. The project implementation unit has developed an implementation plan for the programme activities; but is facing difficulties due to financial constraints. A monitoring and evaluation framework has also been developed by project implementation unit; information is gathered, analyzed and used in review meetings. The programme has developed links with donor agencies, vertical programmes and governmental departments for functional integration, in order to make the best use of available resources. Collaboration with donor agencies like UNICEF, UNFPA and WHO has been established for conducting MNCH related training, organizing review meetings and the provision of staff. The national programme for family planning and primary health care (also known as the LHW programme) has a synergistic effect on the activities of the NMNCHP. Some of the major responsibilities of LHWs related to MNCH services include, the registration of pregnant women; reporting of skilled birth attendance, maternal and neonatal deaths, and modern famiy planning methods users in the community. The community mid-wives deployed in the community, are supported by the LHWs network for developing their community links and the community mid-wives are attending their monthly progress review meetings. The collaboration of the NMNCHP with the EPI programme has included the support of community mid-wives for reinforcing the messages for vaccination and in the provision of TT vaccination to pregnant women. The programme has developed links with the nutrition programme, regarding the management of severe malnutrition, provision of micronutrient supplements and training of staff on nutritional services. Connections were also developed with disease specific programmes, to ensure that the MNCH strategy is part of the 85

77 implementation strategies of these programmes like the national AIDS control programme, national tuberculosis control programme, national malaria control programme, etc. The programme is collaborating with the Ministry of population welfare, in implementing the family planning strategy in the province. It is of particular importance in meeting the logistic and training needs of the health facilities to deliver comprehensive family planning services. 86

78 ANNEX 2 Input criteria for MNCH services A. Civil works criteria OPTIMAL ITEMS Ob/Gyn OPD or LHV s room 1. Consultation area Labour room 1. Delivery room CIVIL WORKS SCOPE FOR BHUS 2. Examination area 3. Hand washing facilities 2. Scrub area 3. Functional attached washroom for patients WMO or LHV s residence 1. Available 2. Good condition MINIMAL ITEMS LHV s room Available OPTIMAL ITEMS Ob/Gyn OPD 1. Consultation area Ob/Gyn ward 1. Patient area Labour room 1. Delivery room Clinical laboratory 1. Laboratory room LHV s room 1. Consultation area Residence - WMO Residence - LHV MINIMAL ITEMS Ob/Gyn OPD Ob/Gyn ward Labour room CIVIL WORKS SCOPE FOR RHCS 2. Examination area 3. Hand washing facilities 2. Functional attached washroom 2. Scrub area 3. Functional attached washroom for patients 2. Working area 3. Functional attached washroom 2. Examination area 3. Hand washing facilities 1. Available 2. Good condition 1. Available 2. Good condition Available Available Available 87

79 OPTIMAL ITEMS LHV s room Residence - WMO Residence - LHV CIVIL WORKS SCOPE FOR RHCS Available 1. Available 2. Good condition 1. Available 2. Good condition OPTIMAL ITEMS Ob/Gyn OPD 1. Consultation area Ob/Gyn ward 1. Patient area 2. Nursing station CIVIL WORKS SCOPE FOR THE DHQH & THQH 2. Examination area 3. Privacy of examination area 4. Hand washing facilities 3. Store for general items/drugs 4. Functional attached washroom Labour room 1. Delivery room 2. Preparation/ stage room 3. Scrub area 4. Staff duty room 5. Store for general items/drugs 6. Store for equipment 7. Functional attached washroom for patients 8. Functional attached washroom for staff Operation theatre 1. Patient preparation room 2. Operating room 3. Recovery room 4. Scrub area 5. Sterilization area 6. Doctor s room 7. Support staff duty room 8. Store for general items/drugs or equipment 9. Store of equipment 10. Functional attached washroom for staff Paediatric ward 1. Patient area 2. Nursing station 3. Store for general items/drugs or equipment 4. Functional attached washroom Paediatric nursery 1. Patient area 2. Nursing station Clinical laboratory 1. Laboratory room 2. Working area Blood bank 1. Blood collection room 2. Working area 3. Store for general items/drugs or equipment 4. Change room 3. Doctor s duty room 4. Store for chemical / reagents or equipment 5. Functional attached washroom 3. Staff duty room 4. Store for equipment / reagents 5. Functional attached washroom 88

80 LHV s room 1. Consultation area 2. Examination area 3. Privacy of examination area 4. Hand washing facilities Ultrasound room Examination area Residence - Gynaecologist Residence - Anaesthetist Residence - Paediatrician Residence - WMO Residence - LHV Residence - Nurse Residence - Lab technician Residence - Blood bank technician Residence - Anaesthesia technician Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition MINIMAL ITEMS Ob/Gyn OPD Available Ob/Gyn ward Available Labour room Available Operation theatre Available Paediatric ward Available Clinical laboratory Available Residence - Gynaecologist Available Good condition 89

81 Residence - Anaesthetist Residence - Paediatrician Residence - WMO Residence - Lab technician Available Good condition Available Good condition Available Good condition Available Good condition B. Human resources criteria HUMAN RESOURCES FOR PREVENTIVE EmONC OPTIMAL HR FOR BHUS HUMAN RESOURCES FOR 24/7 BASIC EmONC OPTIMAL HR FOR RHCS Category Number Category Number MO, or 1 WMOs 2 LHV 1 OT technician Lab technician LHVs Ambulance driver 1 MINIMAL HR FOR BHUS MINIMAL HR FOR RHCS MO, or 1 WMO 1 LHV 1 Lab technician LHV 1 HUMAN RESOURCES FOR 24/7 COMPREHENSIVE EmONC OPTIMAL HR FOR DHQHS OPTIMAL HR FOR THQHS Category Number Category Number Gynaecologist 2 Gynaecologist 1 Anaesthetist 2 Anaesthetist 1 Paediatrician 2 Paediatrician 1 WMOs 6 WMOs 4 OT technician 4 OT technician 4 Blood bank technician 4 Blood bank technician 4 Lab technician 3 Lab technician 2 Anaesthesia technician 4 Anaesthesia technician 4 Nurses 20 Nurses 12 LHVs 4 LHVs 4 Ambulance drivers 4 Ambulance drivers 4 MINIMAL HR FOR DHQHS MINIMAL HR FOR THQHS Gynaecologist 1 Gynaecologist 1 Anaesthetist 1 Anaesthetist 1 Paediatrician 1 Paediatrician 1 WMOs 4 WMOs 2 90

82 OT technician 1 OT technician 1 Lab technician 1 Lab technician 1 Nurses 6 Nurses 4 LHVs 1 LHVs 1 C. Equipment criteria OPTIMAL ITEMS General hospital equipment 1. Electric water cooler EQUIPMENT FOR BHUS 2. Water filter 3. Incinerator OPD / WMO s office 1. Office / Plain chairs 2. Examination couch 3. Office tables with drawers 4. Steel almirah (Large) 5. Patient stool 6. Weighing machine (Adult) 7. Weighing machine (Infant) 8. Height measuring board 9. Height measuring device 10. B.P Apparatus mercury-desk type 11. Foetal stethoscope 12. Steam inhaler 13. Nebulizer 14. Examination lamp Lady health visitor s room 1. Weight scale (Adult) 2. Weight scale (Infant) 3. Height measuring device 4. Height measuring board 5. Disposable syringe cutter 6. D & C instruments set 7. P.V. examination light 8. Examination couch 9. Office chairs 10. Office tables with drawers 11. Patient stool 12. Steel almirah (Large) MINIMAL ITEMS 1. Office chairs 2. Office tables with drawers 3. B.P Apparatus mercury-desk type 4. Foetal stethoscope 5. Weight scale (Adult) 6. Weight scale (Infant) 7. Height measuring device 8. Height measuring board 9. D & C instruments set 10. Examination couch OPTIMAL ITEMS General hospital 1. Ambulance 2. Electric water cooler EQUIPMENT FOR RHCS 3. Water filter 4. Incinerator 91

83 OPTIMAL ITEMS Female ward items 1. Fowler bed (Iron) 2. Attendant's bench 3. Bed side locker 4. Overhead food trolley EQUIPMENT FOR RHCS 5. Dust bin (Stainless steel) 6. Screen folding (Complete) 7. Baby cot 8. B.P Apparatus mercury-desk type 9. Stethoscope OPD / WMO s office 1. Office chairs 2. Plain chairs 3. Examination couch 4. Office tables with drawers 5. Steel almirah (Large) 6. Patient stool 7. Weighing machine (Adult) 8. Weighing machine (Infant) 9. Height measuring board 10. Height measuring device 11. B.P Apparatus mercury-desk type 12. Foetal stethoscope 13. Steam inhaler 14. Nebulizer 15. Examination lamp Labour room 1. UPS power supply system (2000W) 2. Suction machine electric 3. Infant weighing machine 4. Foetal stethoscope 5. Electric instrument sterilizer (12 x6 ) 6. Jar for forceps 7. Spring type dressing forceps (S.s) 8. Sim s speculum (Right angle, small) 9. Sim s speculum (Right angle, medium) 10. Sim s speculum (Right angle, large) 11. Sponge forceps 12. Artery forceps (Long, straight) 13. Uterine sound 14. Vulsellum forceps 15. Scissors (Dissecting, blunt pointed) 16. Artery forceps 17. Blunt-ended scissors 18. D & C instruments set 19. Infant ambo bag Lady health visitor s room 1. Weight scale (Adult) 2. Weight scale (Infant) 3. Height measuring device 4. Height measuring board 5. P.V. examination light 6. Examination couch 7. Office chairs 8. Office tables with drawers 9. Patient stool 10. Steel almirah (Large) MINIMAL ITEMS Female ward items 1. Fowler bed (Iron) OPD / WMO s office 1. Office chairs 2. Examination couch Labour room 1. Electric instrument sterilizer (12 x6 ) 2. Sim s speculum (Right angle, medium) 3. Sponge forceps 4. Uterine sound 2. B.P Apparatus mercury-desk type 3. Stethoscope 3. Office tables with drawers 4. B.P Apparatus mercury-desk type 5. Foetal stethoscope 5. Vulsellum forceps 6. Scissors (Dissecting, blunt pointed) 7. Artery forceps 8. D & C instruments set 92

84 OPTIMAL ITEMS Lady health visitor s room 1. Office chairs 2. Office tables with drawers 3. Weight scale (Adult) EQUIPMENT FOR RHCS 4. Weight scale (Infant) 5. Height measuring device 6. Height measuring board 7. Examination couch OPTIMAL ITEMS General hospital 1. Ambulance 2. Defibrillator EQUIPMENT FOR THE DHQ HOSPITAL 3. Desktop computer with monitor and accessories 4. Electric water cooler Gynae/Obs. ward items 1. Cabinet instrument (Large) 2. Fowler bed (Iron) 3. Attendant's bench 4. Bed side locker 5. Screen folding (Complete) 6. Weighing machine (Adult) 7. Artery forceps (7 inch) 8. B P Apparatus mercury desk type 9. Dissecting forceps (Plain, 7 inch) OPD / Gynaecologist s office 1. Weighing machine (Adult) 2. Infant weighing machine 3. Screen folding (Complete) 4. Ultrasound machine 5. Examination lamp Paediatric nursery 1. Air ways 2 size 2. Infant ambo bag 3. Infant laryngoscope set 4. Suction apparatus: electrically operated 5. Infant incubators Paediatric ward 1. Suction machine 2. Infant B.P apparatus (Cuff 2.5 cm) 3. Stethoscope Paediatric Littman type 4. Nebulizer 5. Oxygen cylinder complete with trolley 10. Scissors (Curved, 5 inch) 11. Scissors (Sharp, 5 inch, straight) 12. Chital forceps 13. Kidney tray (S.s, 10 inch) 14. Jar for forceps 15. Infusion / drip stands 16. Foetal monitor (foetal doppler - desk type) 17. Infant B.P apparatus 18. Infant weighing machine 19. Baby cot 6. Stethoscope (Adult size) 7. B.P apparatus desktop type 8. Office chair 9. Office table with drawers 10. Patient stool 11. Patient waiting bench 12. Examination couch 6. Phototherapy unit 7. Baby warmer 8. Infant B.P apparatus (Cuff 2.5 cm) 9. Room thermometer 10. Baby cot 11. Steam inhaler 12. Oxygen cylinder complete with trolley 13. Infusion / drip stands 6. Emergency medicine trolley 7. Patient's attendant bench 8. Fowler bed (Iron) 9. Bed side locker (S.s top) 10. Screen folding (Complete) 93

85 OPTIMAL ITEMS EQUIPMENT FOR THE DHQ HOSPITAL Labour room 1. Foetal stethoscope 2. Electric instrument sterilizer (12 x6 ) 3. Jar for forceps 4. Spring type dressing forceps (S.s) 5. Sim s speculum (Right angle, small) 6. Sim s speculum (Right angle, medium) 7. Sim s speculum (Right angle, large) 8. Sponge forceps 9. Artery forceps (Long, straight) 10. Uterine sound 11. Vulsellum forceps 12. Scissors (Dissecting, blunt pointed) 13. Artery forceps 14. Blunt-ended scissors 15. Episiotomy instruments set (Complete) 16. D&C instruments set (Complete) 17. Delivery forceps set 18. Infant ambo bag 19. Portable light & rechargeable batteries 20. Sterilizing drum 21. Vacuum extractor 22. Delivery table 23. Infusion / drip stands 24. Oxygen cylinder complete with trolley Operation theatre 1. Needle holder 2. Stitch scissors 3. Dissecting forceps (Toothed) 4. Sim s speculum (Large) 5. Sim s speculum (Medium) 6. Vacuum extractor 7. Obstetric forceps 8. Rectangular instrument tray & lids 9. Towel clips 10. Sponge forceps (22.5 cm) 11. Artery forceps (Straight,16 cm) 12. Uterine homeostasis forceps (20 cm) 13. Hysterectomy forceps (Straight, 22.5 cm) 14. Mosquito forceps (12.5 cm) 15. Tissue forceps (19 cm) 16. Needle holder (Straight, 17.5 cm) 17. Surgical knife handle # Surgical knife handle # Abdominal retractors, double-ended (Richardson) 20. Curved operating scissors, blunt pointed (Mayo), 17 cm 21. Straight operating scissors, blunt pointed (Mayo), 17 cm 22. Aesthetic face masks (3 sizes) 23. Anaesthesia machine 24. Laryngoscopes 25. X-Ray illuminator 26. Gynae Instrument set 27. General Instrument set 28. Adult ambo bag and mask 29. D & C instruments set 30. Myomectomy screw 31. Air conditioners Laboratory 1. Spin machine 2. Chemistry analyzer 3. Counter (Hand tally differential) 4. Steel almirah (Large) 5. Lab cabinet MINIMAL ITEMS Gynae/Obs. ward items 1. Fowler bed (Iron) OPD / Gynaecologist s office 1. Weighing machine (Adult) 2. Examination lamp 3. Stethoscope (Adult size) 4. B.P apparatus desktop type 5. Office chair 6. Office table with drawers 7. Examination couch 94

86 OPTIMAL ITEMS Paediatric nursery 1. Air ways 2 size 2. Infant ambo bag 3. Infant laryngoscope set EQUIPMENT FOR THE DHQ HOSPITAL 4. Suction apparatus: electrically operated 5. Infant incubators 6. Phototherapy unit Paediatric ward 1. Stethoscope Paediatric Littman type 2. Nebulizer 3. Oxygen cylinder complete with trolley 4. Fowler bed (Iron) Labour room 1. Foetal stethoscope 2. Electric instrument sterilizer (12 x6 ) 3. Spring type dressing forceps (S.s) 4. Sim s speculum (Right angle, medium) 5. Sponge forceps 6. Uterine sound 7. Vulsellum forceps 8. Episiotomy instruments set complete 9. D&C instruments set complete 10. Delivery forceps set 11. Delivery table Operation theatre 1. Anaesthesia machine 2. Laryngoscopes 3. Gynae Instrument set 4. D & C instruments set OPTIMAL ITEMS General hospital 1. Ambulance 2. Defibrillator EQUIPMENT FOR THE THQ HOSPITALS 3. Desktop computer with monitor and accessories 4. Electric water cooler Gynae/Obs. ward items 1. Cabinet instrument (Large) 2. Fowler bed (Iron) 3. Attendant's bench 4. Bed side locker 5. Screen folding (Complete) 6. Weighing machine (Adult) 7. Artery forceps (7 inch) 8. B P Apparatus mercury desk type 9. Dissecting forceps (Plain, 7 inch) OPD / Gynaecologist s office 1. Weighing machine (Adult) 2. Infant weighing machine 10. Scissors (Curved, 5 inch) 11. Scissors (Sharp, 5 inch, straight) 12. Chital forceps 13. Kidney tray (S.s, 10 inch) 14. Jar for forceps 15. Infusion / drip stands 16. Foetal monitor (foetal doppler - desk type) 17. Infant B.P apparatus 18. Infant weighing machine 19. Baby cot 3. Screen folding (Complete) 4. Ultrasound machine 5. Examination lamp 95

87 OPTIMAL ITEMS EQUIPMENT FOR THE THQ HOSPITALS Paediatric nursery 1. Air ways 2 size 2. Infant ambo bag 3. Infant laryngoscope set 4. Suction apparatus: electrically operated 5. Infant incubators 6. Phototherapy unit 7. Baby warmer 8. Infant B.P apparatus (Cuff 2.5 cm) 9. Room thermometer 10. Baby cot 11. Steam inhaler 12. Oxygen cylinder complete with trolley 13. Infusion / drip stands Paediatric ward 1. Suction machine 2. Infant B.P apparatus (Cuff 2.5 cm) 3. Stethoscope Paediatric Littman type 4. Nebulizer 5. Oxygen cylinder complete with trolley 6. Emergency medicine trolley 7. Patient's attendant bench 8. Fowler bed (Iron) 9. Bed side locker (S.s top) 10. Screen folding (Complete) Labour room 1. Foetal stethoscope 2. Electric instrument sterilizer (12 x6 ) 3. Jar for forceps 4. Spring type dressing forceps (S.s) 5. Sim s speculum (Right angle, small) 6. Sim s speculum (Right angle, medium) 7. Sim s speculum (Right angle, large) 8. Sponge forceps 9. Artery forceps (Long, straight) 10. Uterine sound 11. Vulsellum forceps 12. Scissors (Dissecting, blunt pointed) 13. Artery forceps 14. Blunt-ended scissors 15. Episiotomy instruments set complete 16. Infant ambo bag 17. Portable light & rechargeable batteries 18. Sterilizing drum 19. Vacuum extractor Operation theatre 1. Needle holder 2. Stitch scissors 3. Dissecting forceps (Toothed) 4. Sim s speculum (Large) 5. Sim s speculum (Medium) 6. Vacuum extractor 7. Obstetric forceps 8. Rectangular instrument tray & lids 9. Towel clips 10. Sponge forceps (22.5 cm) 11. Artery forceps (Straight,16 cm) 12. Uterine homeostasis forceps (20 cm) 13. Hysterectomy forceps (Straight, 22.5 cm) 14. Mosquito forceps (12.5 cm) 15. Tissue forceps (19 cm) 16. Needle holder (Straight, 17.5 cm) 17. Surgical knife handle # Surgical knife handle # Abdominal retractors, double-ended (Richardson) 20. Curved operating scissors, blunt pointed (Mayo), 17 cm 21. Straight operating scissors, blunt pointed (Mayo), 17 cm 22. Aesthetic face masks (3 sizes) 23. Anaesthesia machine 24. Laryngoscopes 25. X-Ray illuminator 26. Gynae Instrument set 27. General Instrument set 28. Adult ambo bag and mask 29. D & C instruments set 30. Myomectomy screw 31. Air conditioners 96

88 OPTIMAL ITEMS Laboratory 1. Spin machine 2. Chemistry analyzer EQUIPMENT FOR THE THQ HOSPITALS 3. Counter (Hand tally differential) 4. Steel almirah (Large) 5. Lab cabinet MINIMAL ITEMS Gynae/Obs. ward items 6. Fowler bed (Iron) OPD / Gynaecologist s office 1. Weighing machine (Adult) 2. Examination lamp Paediatric nursery 1. Air ways 2 size 2. Infant ambo bag 3. Infant laryngoscope set 4. Suction apparatus: electrically operated 5. Infant incubators 6. Phototherapy unit Paediatric ward 1. Stethoscope Paediatric Littman type 2. Nebulizer 3. Oxygen cylinder complete with trolley 4. Fowler bed (Iron) Labour room 1. Foetal stethoscope 2. Spring type dressing forceps (S.s) 3. Sim s speculum (Right angle, medium) 4. Sponge forceps 5. Uterine sound 6. Vulsellum forceps 7. Episiotomy instruments set complete Operation theatre 1. Anaesthesia machine 2. Laryngoscopes 3. Gynae Instrument set 4. D & C instruments set D. Drugs and supplies criteria OPTIMAL ITEMS DRUGS & SUPPLIES FOR BHUS Supplies 1. Gloves 2. Clean / Safe delivery kit 3. Disposable/ Auto disable syringes 4. Reagents/ strips for routine lab tests 5. Surgical spirit 6. Oral Rehydration Salt ORS Tracer drugs 1. Capsule Amoxicillin 2. Syrup Amoxicillin 3. Tablet Metronidazole 4. Syrup Metronidazole 5. Tablet Iron 6. Tablet Folic acid 7. Tetracycline Ointment 8. Injection Oxytocin 9. IV solutions 10. Syrup Salbutamol 11. Syrup Chloroquine 12. Syrup Zinc Sulphate 97

89 OPTIMAL ITEMS Vaccines 1. BCG 2. OPV Family planning commodities 1. Condoms 2. COC 3. POP DRUGS & SUPPLIES FOR BHUS 3. Penta-valent 4. Measles 5. TT 4. IUCDs 5. Injection DMPA 6. Injection Net-En MINIMAL ITEMS Supplies 1. Clean / Safe delivery kit 2. Disposable/ Auto disable syringes 3. Reagents/ strips for routine lab tests Tracer drugs 1. Tablet Iron 2. Tablet Folic acid Vaccines 1. BCG 2. OPV 3. Penta-valent 4. Measles 5. TT Family planning commodities (any three) 1. Condoms 2. IUCDs 3. COC or POP 4. Injection DMPA or Net-En OPTIMAL ITEMS DRUGS & SUPPLIES FOR RHCS Supplies 1. Gloves 2. Clean / Safe delivery kit 3. Disposable/ Auto disable syringes 4. Reagents/ strips for routine lab tests 5. Surgical spirit 6. Oral Rehydration Salt ORS Tracer drugs 1. Injection Dexamethasone 2. Injection Adrenaline 3. Injection Atropine 4. Injection Ampicillin 5. Capsule Amoxicillin 6. Syrup Amoxicillin 7. Tablet Metronidazole 8. Syrup Metronidazole 9. Tablet iron 10. Tablet Folic acid 11. Tetracycline Ointment 12. Injection Oxytocin 13. Injection Magnesium Sulphate 14. IV solutions 15. Syrup Salbutamol 16. Syrup Chloroquine 17. Syrup Zinc Sulphate 18. Injection Diclofenac Sodium Vaccines 1. BCG 2. OPV 3. Penta-valent 4. Measles 5. TT 98

90 OPTIMAL ITEMS Family planning commodities 1. Condoms 2. COC 3. POP DRUGS & SUPPLIES FOR RHCS 4. IUCDs 5. Injection DMPA 6. Injection Net-En MINIMAL ITEMS Supplies 1. Clean / Safe delivery kit 2. Disposable/ Auto disable syringes 3. Reagents/ strips for routine lab tests Tracer drugs 1. Injection Ampicillin 2. Injection Oxytocin 3. Injection Magnesium Sulphate Vaccines 1. BCG 2. OPV Family planning commodities (any three) 1. Condoms 2. IUCDs 3. Penta-valent 4. Measles 5. TT 3. COC or POP 4. Injection DMPA or Net-En OPTIMAL ITEMS DRUGS & SUPPLIES FOR THE DHQHS & THQHS Supplies 1. Gloves 2. Clean / Safe delivery kit 3. Disposable/ Auto disable syringes 4. Reagents/ strips for routine lab tests 5. Screening kits for Hep B,C & HIV 6. Blood grouping reagents 7. Blood bags with transfusion sets 8. Surgical spirit 9. Oral Rehydration Salt ORS Tracer drugs 1. Injection Dexamethasone 2. Injection Adrenaline 3. Injection Atropine 4. Injection Ampicillin 5. Capsule Amoxicillin 6. Syrup Amoxicillin 7. Tablet Metronidazole 8. Syrup Metronidazole 9. Tablet Iron 10. Tablet Folic acid 11. Tetracycline Ointment 12. Injection Oxytocin 13. Injection Magnesium Sulphate 14. IV solutions 15. Syrup Salbutamol 16. Syrup Chloroquine 17. Syrup Zinc Sulphate 18. Injection Diclofenac Sodium 19. Injection Thiopentone Sodium 20. Injection Neostigmine 21. Injection Propofol Vaccines 1. BCG 2. OPV 3. Penta-valent 4. Measles 5. TT 99

91 Family planning commodities 1. Condoms 2. COC 3. POP 4. IUCDs 5. Injection DMPA 6. Injection Net-En 7. Implants MINIMAL ITEMS Supplies 1. Gloves 2. Clean / Safe delivery kit 3. Disposable/ Auto disable syringes 4. Reagents/ strips for routine lab tests 5. Screening kits for Hep B,C & HIV 6. Blood grouping reagents Tracer drugs 1. Injection Dexamethasone 2. Injection Adrenaline 3. Injection Atropine 4. Injection Ampicillin Vaccines 1. BCG 2. OPV Family planning commodities (any three) 1. Condoms 2. IUCDs 5. Injection Oxytocin 6. Injection Magnesium Sulphate 7. Injection Thiopentone Sodium 8. Injection Neostigmine 9. Injection Propofol 3. Penta-valent 4. Measles 5. TT 3. COC or POP 4. Injection DMPA or Net-En 5. Implants E. Support services criteria SUPPORT SERVICES FOR BHUS OPTIMAL CRITERIA Basic lab tests 1. Doctor or LHV 2. Reagents and strips SUPPORT SERVICES FOR RHCS OPTIMAL CRITERIA Basic lab tests 1. Space 2. Doctor or LHV or lab technician 3. Reagents and strips Ambulance services 1. Functional ambulance 2. Ambulance driver MINIMAL CRITERIA FOR BHU Basic lab tests 1. Doctor or LHV 2. Reagents and strips MINIMAL CRITERIA FOR RHC Basic lab tests 1. Space 2. Doctor or LHV or Lab technician 3. Reagents and strips SUPPORT SERVICE CRITERIA FOR SHC HOSPITALS OPTIMAL CRITERIA 100

92 Basic lab tests 1. Space 2. Laboratory technician 3. Reagents and strips 4. Laboratory equipment Blood transfusion services 1. Blood bank technician or lab technician 2. Screening strips for Hep B, C & HIV Radiology services 1. Space Operation theatre services 1. Space 2. Anaesthetist 3. OT technician Ambulance services 1. Functional ambulance 2. Ultrasound equipment 4. Anaesthesia technician 5. OT equipment 6. Drugs and supplies 2. Ambulance driver MINIMAL CRITERIA Basic lab tests 1. Space Blood transfusion services 1. Laboratory or blood bank technician 2. Lab technician 3. Reagents and strips 2. Screening strips for Hep B, C & HIV Radiology services 1. Space 2. Ultrasound equipment Operation theatre services 1. Space 2. Anaesthetist or anaesthesia technician 3. OT equipment 4. Drugs and supplies F. Infection control & waste management criteria Infection control Hand washing ASSESSMENT CRITERIA 1. Hand washing basin with running water 2. Soap 3. Towel 4. Gloves Personal protection materials 1. Face masks 2. Safety goggles 3. Heavy duty leather gloves 4. Gowns 5. Industrial boots Waste collection materials 1. Safety boxes 2. Colour-coded plastic bags Waste treatment equipment 101

93 1. Autoclave for waste treatment 2. Autoclave test strips Disinfection of service provision areas 1. Cleaning materials 2. Chemical disinfectant G. Input criteria for basic EmONC services at the THQ hospitals A Civil works CIVIL WORKS SCOPE OPD 1. Consultation area Female ward 1. Patient area 2. Examination area 3. Hand washing facilities 2. Functional attached washroom Labour room 1. Delivery room 2. Scrub area 3. Functional attached washroom for patients Clinical laboratory 1. Laboratory room LHV s room 1. Consultation area Residence - WMO Residence - LHV 2. Working area 3. Functional attached washroom 2. Examination area 3. Hand washing facilities Available Good condition Available Good condition B Human resources HUMAN RESOURCES Category Number Category Number WMOs 2 LHVs 2 OT technician 1 Ambulance drivers 1 Lab technician C - Equipment EQUIPMENT General hospital 1. Ambulance 2. Electric water cooler 102

94 Female ward 1. Fowler bed (Iron) 2. Attendant's bench 3. Bed side locker 4. Screen folding (Complete) 5. B P Apparatus mercury desk type 6. Baby cot OPD 1. Weighing machine (Adult) 2. Infant weighing machine 3. Examination lamp Labour room 1. Foetal stethoscope 2. Electric instrument sterilizer (12 x6 ) 3. Jar for forceps 4. Spring type dressing forceps (S.s) 5. Sim s speculum (Right angle, small) 6. Sim s speculum (Right angle, medium) 7. Sim s speculum (Right angle, large) 8. Sponge forceps 9. Artery forceps (Long, straight) 10. Uterine sound 11. Vulsellum forceps 12. Scissors (Dissecting, blunt pointed) 13. Artery forceps 14. Blunt-ended scissors D Drugs and supplies DRUGS & SUPPLIES Supplies 1. Gloves 2. Clean / Safe delivery kit 3. Disposable/ Auto disable syringes 4. Reagents/ strips for routine lab tests 5. Screening kits for Hep B,C & HIV 6. Blood grouping reagents Tracer drugs 1. Injection Dexamethasone 2. Injection Adrenaline 3. Injection Atropine 4. Injection Ampicillin 5. Capsule Amoxicillin 6. Syrup Amoxicillin 7. Tablet Metronidazole 8. Syrup Metronidazole 9. Tablet Iron 10. Tablet Folic acid 11. Tetracycline Ointment 12. Injection Oxytocin 13. Injection Magnesium Sulphate 14. IV solutions 15. Syrup Salbutamol 16. Syrup Chloroquine 17. Syrup Zinc Sulphate 18. Injection Diclofenac Sodium Vaccines 1. BCG 2. OPV 3. Penta-valent 4. Measles 5. TT Family planning commodities 1. Condoms 2. COC 3. POP 4. IUCDs 5. Injection DMPA 6. Injection Net-En 103

95 E - Support services SUPPORT SERVICES Laboratory services 1. Basic laboratory tests Ambulance services 1. Functional ambulance 2. Ambulance driver 104

96 ANNEX 3 Assessment of health facilities functionality by district Methodology for benchmarking district performance A calculation was carried out in an attempt to present the status of the districts based on the conformance to required inputs, on following assumptions: 1. The district is represented by a single bar, composed of five sub-sections, each representing one of the 5 input criteria, 2. Standard bar was taken as 1 (100), and each input component was allocated equal space in the bar i.e., one fifth of bar (20), 3. Each component could at maximum contribute to one fifth or 20 to the bar, 4. Each component occupied its allocated space proportionate to its average availability, 5. Five components, make a component bar give an overall average availability of inputs by type of health facility in the district. Example: Calculation of component bar Average availability of inputs for CEmONC in each THQH of district Attock was: Component Number of required inputs Average availability Calculation Proportionate ( 1 / 5 )of standard bar Infrastructure =(8.60/19*100)*0.2 9 Human resources =(14.40/41*100)*0.2 7 Equipment =(81/106*100)* Drugs & Supplies =(34.60/42*100)* Support services =(63/87*100)* Infrastructure HR Equipment Drugs & Supplies Support services Attock It is evident that none of the required inputs meet the mark of 20 and comulative average availability of inputs in THQHs is 61 out of 100, in district Attock. 105

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