Health Facility Assessment Regional Report Federally Administered Tribal Areas (FATA) TRF. Technical Resource Facility

Transcription

1 Health Facility Assessment Regional Report Federally Administered Tribal Areas (FATA) 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 Sancho, HLSP Health Systems Consultant, and Ms. Pamela Sequeira, M&E Specialist TRF. 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: Regional Information Federally Administered Tribal Areas 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 SHC hospitals conformance to required inputs Civil hospitals (CHs) Status of infrastructure Status of human resources Status of functional equipment Status of drugs and supplies Status of support services CHs 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 Work coordination and supervision Management information system Drugs and supplies Infection control Death review Facility utilization Donor contributions Procurement estimates Equipment Civil works Section 4: Clients Perspective Key findings Quality of care Preference for health care services Overall satisfaction Section 5: Health Managers Perspective Rationale Key findings of the in-depth interviews iii

5 Infrastructure Human resources Procurement and logistical management Management information system Planning Monitoring and supervision Inter-sectoral collaboration Financial management Donor contributions Section 6: Key Findings Infrastructure Human resources Training of staff Drugs, supplies and equipment Work coordination and supervision Service delivery protocols Management information system Infection control Death reviews Donor contributions ANNEX Objectives of the NMNCH programme ANNEX Input criteria for MNCH services iv

6 List of Tables Table 1.1: Scope of HFA Table 2.1: Key figures of Federally Administered Tribal Areas 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 functional 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 CHs Table 3.19: Status of MNCH related staff in CHs Table 3.20: Status of functional equipment in CHs Table 3.21: Status of drugs and supplies in CHs Table 3.22: Status of support services in CHs Table 3.23: Status of support services in CHs 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 Federally Administered Tribal Areas 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: Utilization of MNCH services at surveyed health facilities Table 3.33: Utilization of family planning services at surveyed health facilities Table 3.34: Status of donor contribution at surveyed health facilities Table 3.35: Summary of estimated cost for equipment and civil works Table 4.1: Number of CEIs conducted in Federally Administered Tribal Areas Table 4.2: Clients reasons for visiting public sector health facilities Table 5.1: Names of agencies in Federally Administered Tribal Areas contacted for IDIS56 vi

8 List of Figures Figure 2: Map of Federally Administered Tribal Areas Figure 3.1: Range of services that signal fully functional MNCH services Figure 3.2: Average availability of assessed inputs at surveyed BHUs Figure 3.3: Agency-wise status of conformance of BHUs to required inputs Figure 3.4: Average availability of assessed inputs at RHCs Figure 3.5: Agency-wise status of conformance of RHCs to required inputs Figure 3.6: Average availability of assessed inputs at SHC hospitals Figure 3.7: Agency-wise status of conformance of AHQHs to required inputs Figure 3.8: Agency-wise status of conformance of CHs to required inputs Figure 3.9: Average availability of assessed inputs at CHs Figure 3.10: Agency-wise status of conformance of CHs to required inputs Figure 3.11: Status of management basics at surveyed facilities Figure 3.12: Work coordination Figure 3.13: Supervision Figure 3.14: Status of MIS Figure 3.15: Facility specific reasons for running out of the stock of drugs and supplies46 Figure 4.1: Reasons for visiting health facility Figure 4.2: Average time taken by the clients to reach the facility Figure 4.3: Average waiting time at the facility Figure 4.4: Clients' level of satisfaction with availed services Figure 4.5: Provision of medicines, lab services and education material Figure 4.6: Overall satisfaction of interviewed clients vii

9 ACRONYMS ANC AVD BB technician BHU CBA CEI CH CMW CWAQ CDC DCO DDCT DHO DHDC DHIS DHQH DLQ EDOs EmONC ENC EAQ EPI FP & PHC HF HFA HID HIV HMIS HR IDI EDOH IMNCI IMPAC JD LHS LHV LHW MDGs M&E MICS Antenatal Care Assisted Vaginal Deliveries Blood Bank Technician 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 Family planning and Primary Health Care 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 Lady Health Supervisor Lady Health Visitor Lady Health Worker Millennium Development Goals Monitoring and Evaluation Multiple Indicator Cluster Survey viii

10 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 Regional Report Federally Administered Tribal Areas (FATA ) Executive Summary The first national health facility assessment (HFA) was conducted from October 2010 to May 2011 covering all of the provinces and regions of Pakistan, as part of the implementation of the monitoring and evaluation (M&E) framework of the national maternal newborn and child health programme (NMCHP). This regional report synthesizes the findings of 55 health facilities assessed in all of the agencies (excluding South and North Waziristan) and frontier regions of Federally Administered Tribal Areas. Secondary health care (SHC) hospitals including 4 agency headquarter (AHQ) hospitals and 14 civil hospitals were assessed for the provision of 24/7 comprehensive emergency obstetric and newborn care (EmONC) services; 9 rural health centres (RHCs) were assessed for 24/7 basic EmONC services and 28 sampled basic health units (BHUs) were assessed for the availability of 8/6 preventive MNCH services. The status of civil hospitals was also assessed for their readiness to deliver 24/7 basic EmONC services. The health facility assessment also aims to describe the availability and level of the functioning of health services in the public sector health facilities, based on the availability of the required inputs. Assessment criteria were used to ascertain gaps in the availability against the optimal level of inputs for infrastructure, human resources (HR), drugs and supplies, equipment, level-specific support services and management basics at the surveyed health facilities. Regarding the availability of inputs, the major issues faced by the facilities were mainly due to the lack of MNCH-related staff at the facilities, like WMOs at RHCs and specialists including a gynaecologist, anaesthetist and paediatrician at SHC hospitals. Infrastructure components are mostly available in the assessed health facilities. Although the availability of staff residences is a major problem in ensuring the 24/7 availability of EmONC services. Infrastructure components required for paediatric care were deficient at most of the civil hospitals. Major gaps were also revealed in the availability of required equipment, drugs and supplies as at the time of assessment, none of the health facilities in Federally Administered Tribal Areas were provided with the complete range of assessed items required to perform signal functions. 10

12 Findings related to management basics revealed the lack of work coordination among the facility staff. It was assessed through the record of monthly performance review meetings held at the facility. Supervision at the surveyed facilities was assessed through the regularity of supervisory visits of the district level managers and the receipt of their feedback to the facility. Although the majority of the facilities reported having received supervisory visits, their feedback was not a common practice. Staff job descriptions and service delivery protocols were deficient at the majority of the health facilities. 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 inconsistent documentation of the maternal, neonatal deaths and lack of death review committees, these deaths had rarely been reviewed at the health facilities. Report organisation The health facility assessment report has been structured in six sections: 1. Section 1 has the Introduction to the survey, its objectives, scope and duration. 2. Section 2: Provincial information comprises of an overview of the province, key indicators at a glance, as well as the organisation of the public sector health care delivery system. 3. Section 3: Assessment of functional capacities contains the details of health facilities assessed against the availability of the 5 specified inputs which would enable them to perform their level-specific services, (infrastructure, human resources, drugs and supplies, equipment and level specific support services). 4. Section 4: Clients perspective contains information about the perceptions of the clients regarding the MNCH services provided at the public sector health facilities. 5. Section 5: Health Managers Perspective provides the findings of the in-depth interviews of health managers. 6. Section 6: This section describes the health facility assessment findings and key actions recommended, based on the assessment s findings and in-depth interviews provided in Sections 2 to 6. Section 1: Introduction In the Federally Administered Tribal Areas, more than 380 mothers out of 100,000 live births die during pregnancy, childbirth or soon after; with devastating effects on families and 11

13 livelihoods. Skilled and responsive care, at and after birth, can avert nearly all fatal outcomes and disabling consequences and ease much of the suffering. The health of mothers and newborns are so intricately related, preventing deaths requires, in many cases, the same interventions. The government of Pakistan is committed to achieve the millennium development goals (MDGs) and the Ministry of Health has established the national maternal newborn and child health programme (NMCHP) for achieving the 2015 targets for the health related MDGs 4 and 5. The overreaching goal of the programme is to improve health status of mothers, newborns, and children with focus on poor and marginalized populations. Survey objectives The health facility assessment was aimed at assessing the availability, functioning and quality of the health care delivery system in the public sector facilities, with a focus on maternal, newborn and child health services. Some of the specific objectives of the health facility assessment were: To assess the health facility status and quality of MNCH services (comprehensive and basic EmONC, preventive MNCH and family planning) at the district level; To assess the clients satisfaction and perception of MNCH services; To provide information for the systematic planning of procurement and supply of goods and commodities (listing the medical equipment and instruments which need to be replaced or purchased); and To update and assess the contributions made by the development partners for improving MNCH and family planning services in the selected districts Whereas the HFA is intended to help the 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 districts. 12

14 Assignment duration The Technical Resource Facility (TRF) is supporting the NMNCHP with technical assistance (TA) in the design and implementation of the health facility assessment (HFA) across Pakistan. The TA 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 agency headquarter hospital (AHQH), tehsil headquarter / civil hospitals (CHs), rural health centres (RHCs) and 20% of 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 AHQH, 5 at each CH and RHC), excluding the BHUs. Table 1.1 shows the numbers of health facilities in all agencies (excluding North and South Waziristan) and frontier regions, and health facilities surveyed. TABLE 1.1: SCOPE OF HFA Federally Administered Tribal Areas Number of health facilities by type AHQHs CHs RHCs BHUs Total Number of facilities Number of facilities surveyed

15 Section 2: Regional Information This section gives an overview of the Federally Administered Tribal Areas region and the organisation of public sector health care services in the state, derived from secondary data sources. Federally Administered Tribal Areas An overview Federally Administered Tribal Areas (FATA) is a semi-autonomous tribal region in the northwest of Pakistan, lying between the province of Khyber Pakhtunkhwa, Balochistan, and the neighbouring country of Afghanistan. Federally Administered Tribal Areas is composed of seven agencies (tribal districts) and six FRs (Frontier regions). The frontier regions are named after their adjacent settled districts. The administration of the frontier regions is carried out by the DCO / DC of the neighbouring named district. The overall administration of the frontier regions is carried out by the Federally Administered Tribal Areas secretariat, based in Peshawar which reports to the governor of Khyber-Pakhtunkhwa. FIGURE 2: MAP OF FEDERALLY ADMINISTERED TRIBAL AREAS The seven tribal areas lie in a north-tosouth strip that is adjacent to the west side of the six frontier regions, which also lie in a north-to-south strip. The areas within each of those two regions are geographically arranged in a sequence from north to south. The geographical arrangement of the seven tribal areas in order from north to south is: Bajaur, Mohmand, Khyber, Orakzai, Kurram, North Waziristan and South Waziristan. The geographical arrangement of the six frontier regions in order from north to south is: Peshawar, Kohat, Bannu, Lakki Marwat, Tank and Dera Ismail Khan. Each agency is administered by a political agent, assisted by a number of assistant political agents, tehsildars 14

16 (administrative head of a tehsil) and naib tehsildars (deputy tehsildar), as well as members from various local police (khassadars) and security forces (levies, scouts). Key indicators The population of the Federally Administered Tribal Areas constitutes 2.4% of the population of Pakistan as per the 1998 census. According to the 1998 census, the population of the region was 3,176,331; with an annual growth rate of 2.19 and population density of per square kilometre. The status of key indicators of Federally Administered Tribal Areas is presented in Table 2.1. TABLE 2.1: KEY FIGURES OF FEDERALLY ADMINISTERED TRIBAL AREAS Demography Value Health and socio-economic Value Geography Number of agencies 7 Number of frontier regions 6 Area (in square kilometres) 27,220 Health Infant mortality rate (/1,000 live births) Under 5 mortality rate (/1,000 live births) Maternal mortality ratio (/100,000 live births) Demography Malnutrition (Women) 13.7% Total population 3,341,000 Malnutrition (Children) 13.1% Population (Urban) 2.7% Economy Under 1 year 2.70 Share in national economy 1.5% Under 5 years Per capita monthly income (in US $) 663 Under 15 years Education Women years Literacy rate (Overall) 22% Married women of child bearing age (CBAs) Literacy rate (Male : Female) 35.8 : 6.7 Pregnant women 3.40 Literacy rate (Urban: Rural) 49.2 : 20.6 Sources: MICS FEDERALLY ADMINISTERED TRIBAL AREAS 2009, Pakistan Demographics and Health Survey (PDHS), , Population Census 1998, Administered Tribal Areas.gov.pk 15

17 Public sector health facilities Although health care services in Federally Administered Tribal Areas are provided by public and private providers, the government is considered by far to be the main provider of preventive care throughout the province and the major provider of curative services in most rural areas. Health care services are provided by both public and private sectors. In the public sector, health services are provided through a tiered system of health care facilities; with increasing levels of complexity and coverage from primary to secondary level health facilities. The department of health has been striving to promote a healthy society through a network of facilities and services. The directorate of health Federally Administered Tribal Areas is headed by a director who manages the health services through his representative head of department in each agency. The directorate plans, executes, operates and maintains agency headquarter hospitals, civil hospitals, rural health centres, basic health units, dispensaries, clinics and health centres. The health department has a major responsibility in providing basic health services to people, preventing the spread of diseases, ensuring a healthy and safe environment, products, eating habits and safe food, safety and security in maternal and child health and encouraging the community participation in health services. The private sector is primarily a fee for service, highly fragmented and unregulated profit driven entity. The government is by far the major provider of curative services in the rural areas and it is also the main provider of preventive care throughout the region. Details about public sector facilities are given in Table 2.2: TABLE 2.2: NUMBER OF PUBLIC SECTOR HEALTH FACILITIES Type of health facility Number Teaching hospital 0 Agency headquarter hospitals 4 Civil hospitals 14 Rural health centres 9 Basic health units

18 Section 3: Assessment of Functional Capacities MNCH services The packages of MNCH services assessed include preventive MNCH services at BHUs, basic EmONC services at RHCs and comprehensive EmONC services at the civil and AHQ hospitals 1. The range of MNCH services are given in Figure 3.1. FIGURE 3.1: RANGE OF SERVICES THAT SIGNAL FULLY FUNCTIONAL MNCH SERVICES BHUs: Facility available for 8/6 Preventive MNCH Services 1. Antenatal checkup 2. Lab (Anemia, Malaria, pregnancy test, urine test for sugar & Protein) 3. Normal delivery 4. Family planning services (at least 3 methods) 5. TT immunisation 6. EPI vaccination 7. Growth monitoring 8. Nutrition counseling 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), 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 1 PC-1 NMNCHP 17

19 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: a. 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). b. Minimal level of inputs, which are the bare minimum requirement of the inputs, required for delivering the package specific MNCH services at the health facilities. The findings related to the minimal level of inputs are given as Annex 2. This section describes the functionality of the assessed facilities, against the availability of the optimal level of inputs by facility type. An analysis is also provided, against a minimal or essential level of inputs, for comparative purposes. Basic health units (BHUs) 28 BHUs were assessed for the availability of the optimal level of inputs. 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. An OPD and LHV s room have been assessed as a single room having facilities for consultation, examination and hand washing; similarly a labour room has also been assessed as a single room having facility for delivery, scrub area and attached toilet facility for patient. The findings are presented for the availability and functional status of the infrastructure components assessed at the BHUs, both in numbers and percentages in Table

20 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%. TABLE 3.1: STATUS OF ASSESSED INFRASTRUCTURE IN BHUS Assessed infrastructure Status of surveyed BHUs (N=28) Number Percentage OPD Labour room Residence - LHV Available 27 96% Functional 24 86% Available 8 29% Functional 5 18% Available 27 96% Functional 25 89% The assessment of the infrastructure in BHUs revealed that, an OPD was available in 96% of the BHUs. Out of these, 24 of the OPDs were in a workable state and major repair work (exceeding 75%) was required at 14% of the BHUs. A LHV s residence was available at 96% and was liveable at 89% of the BHUs. 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. TABLE 3.2: STATUS OF MNCH RELATED STAFF IN BHUS Staff categories Status of surveyed BHUs having required staff (N=28) Number Percentage Doctor or LHV 22 78% 19

21 Out of the surveyed BHUs, 78% of them had staff available for preventive MNCH service provision. 6 of the BHUs had neither a doctor nor a LHV posted. Further analysis revealed that out of the 28 surveyed BHUs, 6 BHUs had a doctor posted, while a LHV was positioned in 14 of the BHUs. Status of functional equipment Equipment items (general items, equipment for OPD and LHV s room) for BHUs are listed in PC-1 of NMNCHP (Annex 2). BHUs are categorized into four groups 2 according to the percentage availability of functional equipment items in each BHU, as presented in Table 3.3. TABLE 3.3: STATUS OF FUNCTIONAL EQUIPMENT IN BHUS Equipment Number of surveyed BHUs having functional equipment items (N=28) >75% available 51 to 75% available 25 to 50% available <25% available General items OPD LHV s room The assessment analysis of functional equipment items in BHUs revealed that, none of the BHUs had more than 50% of the general equipment items. The majority (24 out of 28) BHUs had even less than 25% of the general equipment items. Only 3 of the BHUs had more than 75% of the OPD equipment items. The majority of the BHUs (20 out of 28) had more than 50% of the LHV s room equipment. Status of drugs and supplies A 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. BHUs are categorized into 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 This is arbitirary categorisation to present availability of assessed items. 20

22 TABLE 3.4: STATUS OF DRUGS AND SUPPLIES IN BHUS Item groups Number of surveyed BHUs with available tracer items (N=28) >75% available 51 to 75% available 25 to 50% available <25% available Supplies Drugs Vaccines Family planning commodities An analysis of the available tracer items in BHUs showed that, the majority of the BHUs (18 out of the 28) had more than 50% of the supplies and 15 of the BHUs had more than 50% of the required drugs available. More than 75% of the assessed vaccines were available at 71% of the BHUs. However, 16 of the BHUs had less than 25% of the 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. TABLE 3.5: STATUS OF SUPPORT SERVICES IN BHUS Support services Number of assessed BHUs with available support services (N=28) All items available 50% available No item available Basic lab tests BHUs conformance to required inputs The assessment findings were analyzed to determine the conformance of surveyed BHUs, to the inputs required to deliver preventive MNCH services. The calculation is based on the Average functionality of the number of inputs for each criterion, including infrastructure 3, human resources, equipment, drugs and supplies and support services, against PC-1 of the 3 Conformance to infrastructure has been ascertained on the availability of key building components only, as for example presence of consultation area in OPD, leaving aside examination area and handwashing facility. However, all these components have been assessed collectively to identify scope of civil works and cost estimates. 21

23 national MNCH programme. Based on this analysis, the functionality status of the assessed BHUs, with reference to the availability of required inputs, is presented in Figure 3.2. FIGURE 3.2: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT SURVEYED BHUS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 74% 55% 50% 42% 45% Infrastructure HR Equipment Drugs & Supplies Support Services A calculation was carried out in an attempt to present status of the districts based on conformance to required inputs, on following assumptions: District represented by a single bar, composed of five sub-sections each representing one of the 5 input criteria, Standard bar was taken as 1 (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 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)*

24 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, the following graph (Figure 3.3) presents the district-wise status of average component availability of inputs at surveyed BHUs. FIGURE 3.2: AGENCY-WISE STATUS OF CONFORMANCE OF BHUS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services FR Tank Kurrum Agency Khyber Agency Mohmand Agency Orakzai Agency FR Lucky Marwat FR Kohat Bajour Agency FR Bannu FR Peshawar

25 Rural health centres (RHCs) All of the 9 RHCs in the Federally Administered Tribal Areas were assessed for the availability of the optimal level of inputs. 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 the residences for accommodation of required staff. Service provision areas have been assessed as single room having facilities like consultation, examination and hand washing etc. The findings are presented for availability and functional status of infrastructure components assessed at the RHCs, both in numbers and percentages in Table 3.6. 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%. TABLE 3.6: STATUS OF ASSESSED INFRASTRUCTURE IN RHCS Infrastructure OPD Female ward Labour room Clinical lab LHV s room Residence - Doctor Residence - LHV Status of RHCs (N=9) Number Percentage Available 9 100% Functional 7 78% Available 9 100% Functional 4 44% Available 9 100% Functional 3 33% Available 9 100% Functional 3 33% Available 9 100% Functional 5 56% Available 8 89% Functional 6 67% Available 9 100% Functional 5 56% The assessment of the infrastructure of RHCs revealed that, all of the RHCs in the Federally Administered Tribal Areas had an OPD, female ward and labour room available. However extensive repair work was required at the majority of the RHCs. A total of 89% of the RHCs 24

26 had a WMO s residence but it was inhabitable (i.e. not damaged and not needing repair/maintenance work exceeding 75% of the available infrastructure) at only 67% of the RHCs. 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. TABLE 3.7: STATUS OF MNCH RELATED STAFF IN RHCS Staff categories RHCs having required staff (N=9) Number Percentage WMO 0 0% LHV 2 22% Lab technician 3 33% OT technician 0 0% Ambulance driver 3 33% Major gaps were found in the availability of WMOs, as the required number of WMOs was not available at any of the RHCs. The required number of ambulance drivers and lab technicians were not available at about two thirds of the RHCs. Status of functional equipment The availability of equipment items for various service components at RHCs, as listed in PC- 1 of NMNCHP, was assessed and categorized in four groups, according to the percentage availability equipment items in each RHC and is presented in Table 3.8. TABLE 3.8: STATUS OF FUNCTIONAL EQUIPMENT IN RHCS Equipment Number of RHCs having functional equipment items (N=9) >75% available 51 to 75% available 25 to 50% available <25% available General items Female ward WMO OPD

27 Labour room LHV s room The assessment of functional equipment items at RHCs revealed that, none of the RHCs had more than 50% of the female ward equipment. 6 out of the 10 RHCs had less than 50% of the WMO and OPD equipment items. Similarly, the number of equipment items for the labour room was also deficient, as none of the RHCs had more than 75% of the required number. 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. TABLE 3.9: STATUS OF DRUGS AND SUPPLIES IN RHCS Item groups Number of RHCs with available tracer items (N=9) >75% available 51 to 75% available 25 to 50% available <25% available Supplies Drugs Vaccines Family planning commodities An analysis of the available tracer items in RHCs showed that the majority of the RHCs (6 out of the 10) had less than 25% of the assessed supplies items. 78% of the RHCs had less than 50% of the required drugs available. More than 75% of the assessed vaccines were available at 5 of the RHCs. 6 RHCs had less than 25% of the family planning commodities. Status of support services The RHCs were assessed for the functionality of basic laboratory tests (space, test strips and human resources) and ambulance services (functional vehicle and driver). The details are presented in the Tables 3.10 and 3.11, respectively. 26

28 TABLE 3.10: STATUS OF SUPPORT SERVICES IN RHCS Support services Number of RHCs with available support services (N=9) 25 to 50% available <25% available Basic lab tests 4 5 TABLE 3.11: STATUS OF SUPPORT SERVICES IN RHCS Support services Number RHCs with available inputs (N=9) Percentage Functional ambulance 3 33% Ambulance driver 4 44% RHCs conformance to required inputs The health facility assessment findings were analyzed, in order to determine the conformance of the RHCs, to the inputs required to deliver basic EmONC services. The calculation is based on the Average functionality of the number of inputs for each criterion, against PC-1, including infrastructure, human resources, and equipment, drugs and supplies, and support services. Based on this analysis, the conformance status of the assessed RHCs with reference to the availability of the required inputs is presented in Figure 3.4. FIGURE 3.4: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT RHCS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 30% 29% 24% 26% Infrastructure HR Equipment Drugs & Supplies Support Services 27

29 The findings of average availability of each criterion have been shown collectively, stacked in a component bar to give an overall status of RHCs in a particular agency. Each agency of the Federally Administered Tribal Areas is represented by a single bar, which is subdivided in five equal sub-sections. Each sub-section contributes equal (one fifth) to the standard, and represents proportionate average availability of each criterion. The following graph (Figure 3.5) presents the agency-wise status of average component availability of inputs at the RHCs. FIGURE 3.3: AGENCY-WISE STATUS OF CONFORMANCE OF RHCS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Bajour Agency Orakzai Agency FR Peshawar Mohmand Agency FR Tank Secondary health care (SHC) hospitals All of the 4 agency headquarter hospitals and 14 civil hospitals were assessed for the availability of the optimal level of inputs. Status of infrastructure 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. 28

30 Service provision areas have been assessed for the availability of essential space in the respective areas e.g., consultation area, examination area and hand washing in OPD; patient area, nursing station, store rooms and attached washrooms in indoor wards, etc. The findings are presented for the availability and functional status of infrastructure components assessed at the SHC hospitals, both in numbers and percentages in Table The 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%. TABLE 3.12: STATUS OF ASSESSED INFRASTRUCTURE IN SHC HOSPITALS Status of infrastructure in SHC hospitals Infrastructure AHQH (N=4) CH (N=14) Number Percentage Number Percentage OPD Female ward Labour room Operation theatre Paediatric ward Paediatric nursery Clinical lab Blood bank LHV s room Ultrasound room Residence - Gynaecologist Available 4 100% 12 86% Functional 4 100% 11 79% Available 3 75% 7 50% Functional 3 75% 6 43% Available 4 100% 11 79% Functional 4 100% 9 64% Available 4 100% 6 43% Functional 4 100% 3 21% Available 3 75% 6 43% Functional 3 75% 3 21% Available 3 75% 2 14% Functional 3 75% 0 0% Available 4 100% 11 79% Functional 4 100% 9 64% Available 3 75% 5 36% Functional 3 75% 2 14% Available 3 75% 10 71% Functional 3 75% 6 43% Available 4 100% 4 29% Functional 3 75% 2 14% Available 3 75% 3 21% Functional 3 75% 2 14% Residence - Available 3 75% 3 21% 29

31 Anaesthetist Functional 2 50% 3 21% Residence - Paediatrician Residence - WMO Residence - LHV Residence - Nurses Residence - Lab technician Residence - Blood bank technician Residence - Anaesthesia technician Available 3 75% 5 36% Functional 2 50% 3 21% Available 2 50% 10 71% Functional 1 25% 7 50% Available 3 75% 11 79% Functional 2 50% 8 57% Available 3 75% 5 36% Functional 3 75% 4 29% Available 2 50% 8 57% Functional 2 50% 6 43% Available 3 75% 4 29% Functional 3 75% 3 21% Available 1 25% 1 7% Functional 1 25% 1 7% The assessment of infrastructure at the SHC hospitals revealed that, all of the AHQ hospitals had an OPD, labour room, operation theatre and clinical lab which were in a workable condition. The residences of the gynaecologist, anaesthetist and paediatrician were not available at 1 AHQH. As for civil hospitals, the assessment of the infrastructure indicated that 86% of the civil hospitals had OPD. A female ward was not available at 50% of the civil hospitals. A paediatric nursery was available only at 14% of the civil hospitals. Residences for the gynaecologist and anaesthetist were available at 21% and for paediatrician at 36% of the civil hospitals. 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 TABLE 3.13: STATUS OF MNCH RELATED STAFF IN SHC HOSPITALS Availability of human resources in SHC hospitals Staff categories AHQH (N=4) CH (N=14) Number Percentage Number Percentage 30

32 Gynaecologist 0 0% 0 0% Anaesthetist 0 0% 0 0% Paediatrician 0 0% 0 0% WMOs 0 0% 0 0% OT technician 0 0% 0 0% Blood bank technician 0 0% 0 0% Lab technician 2 50% 0 0% Anaesthesia technician 2 50% 0 0% Nurses 2 50% 0 0% LHVs 0 0% 0 0% Ambulance drivers 1 25% 0 0% At all of the agency headquarter and civil hospitals, all of the specialists including the gynaecologist, anaesthetist and paediatrician were not available. Similarly WMOs, OT and blood bank technicians were also not available at any of the SHC hospitals. 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 TABLE 3.1: STATUS OF FUNCTIONAL EQUIPMENT IN SHC HOSPITALS Number of SHC hospitals having functional equipment items AHQH (N=4) CH (N=14) 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

33 Paediatric ward Labour room Operation theatre Clinical laboratory The assessment of functional equipment items at SHC hospitals showed, that only 1 agency headquarter hospital had more than 75% of the assessed general items and female ward equipment items. 2 agency headquarter hospitals had even less than 25% of the paediatric nursery equipment. Regarding civil hospitals, the assessment indicated that none of the civil hospitals had more than 50% of paediatric nursery equipment items. 13 civil hospitals had less than 25% of the paediatric nursery items. 11 civil hospitals had less than 25% of the operation theatre equipment items. Status of drugs and supplies A 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. SHC hospitals are categorized into 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 TABLE 3.15: STATUS OF DRUGS AND SUPPLIES IN SHC HOSPITALS Number of SHC hospitals having tracer items Item groups >75% available AHQH (N=4) 51 to 75% available 25 to 50% available <25% available >75% available 51 to 75% available CH (N=14) 25 to 50% available <25% available Supplies Drugs Vaccines Family planning commodities

34 An analysis of the available tracer items in agency headquarter and civil hospitals showed that, all the AHQHs had more than 75% of the supplies. Only none of the AHQHs or civil hospitals had more than 75% of the required drugs available. More than 75% of the assessed vaccines were available at all of the AHQHs and 10 CHs. 5 civil hospitals had less than 25% of the family planning commodities. Status of support services The facilities for support services, including laboratory tests (space, test strips and human resources), blood transfusion services (space, supplies and human resources), ambulance services (a functional vehicle and driver), operating theatre (space, drugs and supplies, equipment items and human resources) were assessed, at the surveyed SHC hospitals. Based on the percentage availability of the inputs required for performing these services, SHC hospitals are categorized in four groups. The details are presented in the Tables 3.16 and TABLE 3.16: STATUS OF SUPPORT SERVICES IN SHC HOSPITALS Number of SHC hospitals having tracer items AHQH (N=4) CH (N=14) Item groups >75% available 51 to 75% available 25 to 50% available <25% available >75% available 51 to 75% available 25 to 50% available <25% available Basic laboratory tests Blood transfusion Operation theatre TABLE 3.17: STATUS OF SUPPORT SERVICES IN SHC HOSPITALS Number of SHC hospitals having required items Item groups AHQH (N=4) CH (N=14) Number Percentage Number Percentage Functional ambulance 4 100% 10 71% Ambulance driver 4 100% 7 50% Radiology services 2 50% 2 14% 33

35 SHC hospitals conformance to required inputs The assessment findings were analyzed to determine the conformance of SHC hospitals to the inputs required to deliver comprehensive EmONC services. The calculation is based on the Average availability of the number of inputs for each criterion, including infrastructure, human resources, equipment, drugs and supplies and support services. Based on this analysis, the conformance status of the DHQHs and THQHs to the required inputs is presented in Figure 3.6. FIGURE 3.6: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT SHC HOSPITALS 80% 60% Infrastructure HR Equipment Drugs & Supplies Support Services 76% 62% 65% 69% 50% 54% 40% 20% 27% 14% 23% 31% 0% AHQ Hospitals Civil Hospitals The following graphs (Figures 3.7 & 3.8) present the district-wise status of average component availability of inputs at the DHQHs and THQHs. FIGURE 3.4: AGENCY-WISE STATUS OF CONFORMANCE OF AHQHS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Bajour Agency Mohmand Agency Khyber Agency Kurrum Agency

36 FIGURE 3.5: AGENCY-WISE STATUS OF CONFORMANCE OF CHS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services Orakzai Agency Kurrum Agency Khyber Agency Bajour Agency FR Kohat FR DI Khan FR Peshawar FR Tank Mohmand Agency Civil hospitals (CHs) All of the 14 civil hospitals in the Federally Administered Tribal Areas were assessed for the availability of the optimal level of inputs to required to deliver 24/7 basic EmONC services Status of infrastructure The infrastructure of the civil hospitals 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 the 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 are presented in Table 3.18, for the availability and functional status of infrastructure components assessed at the civil hospitals, both in numbers and percentages. Available infrastructure might be requiring repair or maintenance. The available components were labelled non-functional, if the structure was found damaged or the repair needs exceeded 75%. 35

37 TABLE 3.18: STATUS OF ASSESSED INFRASTRUCTURE IN CHS Infrastructure OPD Female ward Labour room Clinical lab LHV s room Residence - Doctor Residence - LHV Status of CHs (N=14) Number Percentage Available 12 86% Functional 11 79% Available 7 50% Functional 6 43% Available 11 79% Functional 9 64% Available 11 79% Functional 9 64% Available 10 71% Functional 6 43% Available 10 71% Functional 7 50% Available 11 79% Functional 8 57% The assessment of the infrastructure of civil hospitals for the delivery of basic EmONC services showed that, 86% of the civil hospitals in FATA had OPDs available. A female ward was not available in 50% of the civil hospitals. A total of 10 civil hospitals had a WMO s residence, but it was inhabitable only at 50% of the civil hospitals. 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 civil hospitals, against the required numbers is presented in Table 3.19 below. TABLE 3.19: STATUS OF MNCH RELATED STAFF IN CHS Staff categories Status of CHs having required staff (N=14) Number Percentage WMO 1 7% LHV 1 7% Lab technician 6 43% 36

38 OT technician 3 21% Ambulance driver 7 50% Major gaps were found in the availability of WMOs and technical staff, as the required number of WMOs was available at only 1 civil hospitals. Lab technicians were not available at more than half of the civil hospitals. The required number of ambulance drivers was available at 50% of the civil hospitals. Status of functional equipment The equipment items for various service components, for the provision of basic EmONC services at the civil hospitals, are listed in PC-1 of the NMNCHP. The civil hospitals are categorized in four groups, according to the percentage availability of the functional equipment items at each civil hospital. The details are presented below, in Table TABLE 3.20: STATUS OF FUNCTIONAL EQUIPMENT IN CHS Equipment Number of CHs having functional equipment items (N=14) >75% available 51 to 75% available 25 to 50% available <25% available Basic EmONC The assessment of functional equipment items at civil hospitals against the criteria of basic EmONC services revealed, that only 1 out of 14 the civil hospitals had more than 75% of equipment items, while 3 civil hospitals 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 civil 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, as presented in Table

39 TABLE 3.21: STATUS OF DRUGS AND SUPPLIES IN CHS Item groups Number of CHs with available tracer items (N=14) >75% available 51 to 75% available 25 to 50% available <25% available Supplies Drugs Vaccines Family planning commodities An analysis of available tracer items in civil hospitals showed that the majority of the civil hospitals (9 out of the 14) had less than 75% of the supplies. 10 civil hospitals had less than 50% of the required drugs available. More than 75% of the assessed vaccines were available at 10 civil hospitals. 5 civil hospitals had less than 25% of the family planning commodities. Status of support services The facilities for support services including basic laboratory tests (space, test strips and human resources) and ambulance services (a functional vehicle and driver) were assessed at the civil hospitals. Based on the percentage availability of the inputs required for performing these services, the civil hospitals were categorized into four groups, as presented in Tables 3.22 and TABLE 3.22: STATUS OF SUPPORT SERVICES IN CHS Support services Number of CHs with available support services (N=14) >75% available 51 to 75% available 25 to 50% available <25% available Laboratory tests TABLE 3.23: STATUS OF SUPPORT SERVICES IN CHS Support services Number of CHs with available support services (N=14) Available % Available Functional ambulance 10 71% Ambulance driver 7 50% 38

40 CHs conformance with assessed inputs The assessment findings were analyzed to determine the conformance of the civil 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 civil hospitals to required inputs is presented in Figure 3.9. FIGURE 3.9: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT CHS 80% 73% 60% 49% 40% 39% 20% 17% 18% 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. 39

41 FIGURE 3.6: AGENCY-WISE STATUS OF CONFORMANCE OF CHS TO REQUIRED INPUTS Infrastructure Human resources Equipment Drugs and supplies Support services FR Kohat FR Peshawar Orakzai Agency Bajour Agency Khyber Agency FR Tank Kurrum Agency FR DI Khan Mohmand Agency Management basics The findings related to management basics at the surveyed health facilities are as follows. Human resources The status of staff categories filled includes regular posting only, as reported by the respective facility on the day of the survey. The details are given in Table 3.24 below. TABLE 3.24: STATUS OF HR REPORTED BY SURVEYED HEALTH FACILITIES Number of posts filled at RHCs Staff AHQ hospitals (4) Sanctioned Filled Sanctioned Civil hospitals (14) Filled Sanctioned Rural health centres (9) Filled Sanctioned Basic health units (28) Filled No. % No. % No. % No. % Gynaecologist Anaesthetist

42 Number of posts filled at RHCs Staff AHQ hospitals (4) Civil hospitals (14) Rural health centres (9) Basic health units (28) Sanctio ned Filled Sanctio ned Filled Sanctio ned Filled Sanctio ned Filled Paediatrician WMO* Operation theatre technician Blood bank technician Lab technician Anaesthesia technician Nurses 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 staff provision in the region, 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 AHQHs CHs RHCs

43 TABLE 3.26: NUMBER OF MNCH STAFF PROVIDED BY NMNCHP Staff cadre Number of staff provided AHQHs CHs RHCs Gynaecologist 0 0 Anaesthetist 0 0 Paediatrician / Neonatologist 0 0 WMO Operation theatre technician Blood bank technician 0 0 Lab technician Anaesthesia technician 0 0 Nurses LHVs Ambulance drivers Total MNCH staff training Part of the mandate of the programme is to build the capacity of MNCH related staff through conducting skill development training, in the standards of service provision and counselling techniques. Information on the training of MNCH staff during last three years, collected from the district NMCHP cells during survey is presented in the Table 3.27 and TABLE 3.27: NUMBER OF STAFF TRAINED ON DELIVERING MNCH SERVICES MNCH staff Number of staff trained EmONC ENC IMNCI IMPAC FP surgical FP counselling Client centeredness Anaesthetists Gynaecologist LHV MO Nurse OT technician

44 MNCH staff Number of staff trained EmONC ENC IMNCI IMPAC FP surgical FP counselling Client centeredness Paediatrician WMO Total TABLE 3.28: NUMBER OF HEALTH FACILITIES RECEIVED MNCH TRAINING MNCH staff Number of health facilities AHQHs CHs RHCs BHUs EmONC ENC IMNCI IMPAC FP surgical FP counselling Client centeredness CMWs training and deployment Part of the mandate of the programme is to train and deploy community mid-wives for improving community based MNCH services, in all the districts of the province. In order to ensure the availability of a skilled birth attendant in every village of the province. The distribution of the community mid-wives will be done by the provincial MNCH cell, before the recruitment process begins. The following table presents aggregate information related to training and deployment of the community mid-wives, collected during the survey from all of the district NMNCH cells. TABLE 3.29: STATUS OF CMWS TRAINING AND DEPLOYMENT IN FEDERALLY ADMINISTERED TRIBAL AREAS Training and deployment of community mid-wives (NMNCHP) Number of selected CMWs verified for their residential status - Number of CMWs with completed training - Number of CMWs deployed by NMNCHP - 43

45 Management basics and supervision Health facilities were assessed for the availability of job descriptions for the MNCH staff and availability of service delivery protocols (11 nos.) for MNCH services. The findings related to these indicators are presented in Figure FIGURE 3.11: STATUS OF MANAGEMENT BASICS AT SURVEYED FACILITIES 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 84% 45% 31% 25% 21% 12% 11% 11% 0% 0% 0% AHQHs CHs RHCs BHUs MNCH related JDs for staff available MNCH related service delivery protocols available MNCH related service delivery protocols displayed 26% Work coordination and supervision Health facilities in all of the districts were assessed for coordination and supervisory activities, including facility staff meetings, participation of facility in-charges in district level meetings, district managers conducting supervisory visits and providing feedback to the facilities. The findings of these activities in surveyed health facility are presented in Figures 3.12 and

46 FIGURE 3.12: WORK COORDINATION 80% 75% 75% 75% Facility staff meeting 60% 40% 20% 0% 50% 50% 54% 33% 21% 22% 25% 0% 0% AHQHs CHs RHCs BHUs Meeting record maintained Participation of HF incharges in district meeting FIGURE 3.13: SUPERVISION 100% 80% 75% 75% 79% Visited for supervision 60% 54% 40% 36% 29% 44% Feedback received (Visited HFs) 20% 11% 0% DHQHs THQHs RHCs BHUs Management information system In Federally Administered Tribal Areas, the agencies are adopting district health information system (DHIS) now, for recording and reporting purposes. The surveyed facilities were assessed for the availability and maintenance of MIS tools (14 nos.) and their findings are presented in Figure

47 FIGURE 3.14: STATUS OF MIS 100% 80% 80% 77% 60% 40% 50% 51% 42% 57% 34% 33% 29% 50% 37% 64% Tools available Tools maintained Monthly DHIS reporting 20% 0% AHQHs CHs RHCs BHUs Drugs and supplies The availability of drugs and supplies has been described under individual MNCH service packages. The reasons for being out of the stock of essential drugs and supplies were identified at the surveyed facilities. A break-down of the reasons is given in Figure FIGURE 3.15: FACILITY SPECIFIC REASONS FOR RUNNING OUT OF THE STOCK OF DRUGS AND SUPPLIES 60% 45% 40% 38% 33% 20% 7% 11% 4% 20% 22% 4% 0% 46

48 Infection control The health facilities were assessed for practices of infection control and waste management, and the availability of related material. The findings of the surveyed facilities are presented in Table TABLE 3.30: STATUS OF INFECTION PREVENTION AT THE SURVEYED HEALTH FACILITIES Number of health facilities Infection prevention AHQHs (Total=4) CHs (Total=14) RHCs (Total=9) BHUs (Total=28) Availability of material Waste management plans Waste collection materials Personal protection materials Waste treatment equipment 0 2 Functional incinerator 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 the Federally Administered Tribal Areas, a total of 29 maternal deaths and 174 neonatal deaths were reported at the surveyed facilities. All of the surveyed facilities, excluding BHUs, were assessed for the availability and functioning of death review committees. Maternal and neonatal deaths reviewed by the committee are presented in Table

49 TABLE 3.31: STATUS OF MORTALITY REVIEWS AT SURVEYED HEALTH FACILITIES Mortality review AHQHs (Total=4) Number of health facilities CHs (Total=14) RHCs (Total=9) Availability of death review committees Functional death review committees Facility utilization Monthly utilization of MNCH services was assessed month-wise for the period of July to December 2010 and the average monthly utilization of services is presented in Table TABLE 3.32: UTILIZATION OF MNCH SERVICES AT SURVEYED HEALTH FACILITIES MNCH services Average monthly utilization of MNCH services AHQH THQH RHC BHU 1st Antenatal care visits (ANC-1) Normal vaginal deliveries Assisted vaginal deliveries C-sections 2 0 1st Postnatal care visits (PNC-1) Pregnant women given TT2 vaccine Diarrhoea/dysentery cases treated (U5 years of age) Pneumonia cases treated (U5 years of age) The utilization of family planning services was also assessed at the surveyed facilities and the average monthly utilization of these services is presented in Table TABLE 3.33: UTILIZATION OF FAMILY PLANNING SERVICES AT SURVEYED HEALTH FACILITIES Family planning services Average monthly utilization of family planning services AHQH THQH RHC BHU 48

50 COC POP DPMA Net-en Condoms IUCDs Implants Vasectomy 0 0 KEY: COC=Combined Oral Contraceptive, POP=Progesterone-Only Pills, DPMA=Depot Medroxyprogesterone Acetate, Net-en=norethisterone enanthate, IUCDs=Intrauterine Contraceptive Devices. Donor contributions Donor contributions (excluding direct budgetary support) during the last three years were assessed regarding human resources, infrastructure, equipment (including ambulances), drugs and supplies. The findings are presented in Table TABLE 3.34: STATUS OF DONOR CONTRIBUTION AT SURVEYED HEALTH FACILITIES Number of health facilities Donor contributions AHQHs (Total=4) CHs (Total=14) RHCs (Total=9) BHUs (Total=28) 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

51 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 TABLE 3.35: SUMMARY OF ESTIMATED COST FOR EQUIPMENT AND CIVIL WORKS Procurement Estimated cost (PKR in millions) DHQHs THQHs RHCs BHUs (Surveyed) Total Equipment Civil works

52 Section 4: Clients Perspective The clients perspective on the quality of health care services is too important to neglect. For clients and communities, quality care is something that meets their perceived needs. Since a client's needs often differ, their personal satisfaction ultimately depends on the perception, attitude and expectations of each individual. Client exit interviews (CEIs) were conducted within the scope of the health facility assessment survey to assess the clients perspective on the services provided. In the Federally Administered Tribal Areas, a total of 155 clients were interviewed and a facilitywise breakup is presented in Table 5.1. Married women of child-bearing age visiting the facility for MNCH related services (Gynae/Obs and child health services for under 5 years of age) and fathers accompanying their children (under 5 years of age) to the facility for child health services were the preferred targets for client exit interviews. TABLE 4.1: NUMBER OF CEIS CONDUCTED IN FEDERALLY ADMINISTERED TRIBAL AREAS Type of health facility Number of CEIs Agency headquarter hospitals 40 Civil hospitals 70 Rural health centres 45 Total 155 Key findings The findings of these interviews were analyzed for assessing the clients viewpoint on health care services availed at the surveyed facilities. The clients reasons for visiting the facilities are presented in Figure

53 FIGURE 4.1: REASONS FOR VISITING HEALTH FACILITY 0% General medical problem Child health care 7% 8% 32% Antenatal examination Postnatal checkup Family planning 27% Others 26% Accessibility to the client means that the health care services are unrestricted by barriers such as geography, finances or culture. It was assessed by interviewing the clients about the time taken by them to reach the facility and the findings are presented in Figure 4.2. FIGURE 4.2: AVERAGE TIME TAKEN BY THE CLIENTS TO REACH THE FACILITY 60% 50% 50% 52% 56% Less than 30 minutes 40% 30% 20% 32% 18% 34% 14% 24% 20% 30 minutes to 1 hour More than 1 hour 10% 0% DHQHs CHs RHCs Waiting time for clients at the facility varied according to the level of the facilities. The facilitywise waiting time is presented in Figure

54 FIGURE 4.3: AVERAGE WAITING TIME AT THE FACILITY 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 46% 44% Less than 10 minutes 37% 10 to 20 minutes 35% 20 to 30 minutes 30% 28% More than 30 minutes 25% 16% 14% 12% 10% 3% DHQHs THQHs RHCs Quality of care The important dimensions of the quality of care assessed, included the clinical examination and attitude of the health care provider; provision of prescribed medicines and laboratory tests; and the provision of health care education material. In order to assess the clients perceptions about the quality of care, they were asked about their satisfaction with the clinical examination, the attitude of the health care provider and other facility staff, and communication regarding illness, course of treatment and the followup. The findings are presented in Figure 4.4. Out of the interviewed clients, the majority was satisfied with their clinical examination and the attitude of the health care providers. FIGURE 4.4: CLIENTS' LEVEL OF SATISFACTION WITH AVAILED SERVICES Communication 11% 72% 17% Attitude of other staff 15% 68% 17% Very Satisfied Attitude of HCP 22% 68% 10% Satisfied Not Satisfied Clinical examination 22% 73% 5% 0% 20% 40% 60% 80% 100% 53

55 Clients were asked if they were prescribed any medicines and laboratory tests. Out of those who were prescribed any medicines or laboratory tests, the number of clients receiving them is provided in Figure 4.5. FIGURE 4.5: PROVISION OF MEDICINES, LAB SERVICES AND EDUCATION MATERIAL Received (complete) Received (partial) Not received Lab services 45% 42% 13% Medicines 17% 31% 52% 0% 20% 40% 60% 80% 100% Received Not received Education material 3% 97% 0% 20% 40% 60% 80% 100% Preference for health care services The majority of the clients interviewed preferred visiting private health care facilities and only 24% stated that they prefer public sector facilities. The reasons for visiting public sector facilities included their close location to the homes of the clients and the clients inability to afford private health care services. Some of clients also attributed it to the good level of care and attitude of the care providers at the public facilities. TABLE 4.2: CLIENTS REASONS FOR VISITING PUBLIC SECTOR HEALTH FACILITIES Reasons for visiting public facilities Number of clients AHQHs CHs RHCs Close to home Good quality Staff attitude Affordability Lack of choice

56 Overall satisfaction The clients satisfaction with the overall services has a tremendous impact on the future health of communities. During these interviews, when inquired about the overall satisfaction with the visit, about 8% were very satisfied and 79% were satisfied with the provided services, whereas only 13% were not satisfied at all with the quality of services. FIGURE 4.6: OVERALL SATISFACTION OF INTERVIEWED CLIENTS RHCs 16% 80% 4% Very satisfied THQHs 80% 78% 9% Satisfied Not satisfied DHQHs 0% 11% 10% 0% 20% 40% 60% 80% 100% 55

57 Regional Report Federally Administered Tribal Areas (FATA ) Section 5: Health Managers Perspective Rationale A mixed methodology was adopted for health facility assessment, using both quantitative and qualitative research techniques. Facility based assessments were conducted to provide information on the availability and functioning of these health facilities to deliver level specific MNCH services. In-depth interviews (IDIs) were conducted with the health managers preferably the agency surgeon - for developing a better understanding of the health services provision and their management at the agency level. IDIs were also helpful in elaborating the issues identified at the health facilities. Inputs and suggestions were sought for bringing an improvement within the system currently in place. Health managers were randomly selected for in-depth interviews. A total of 3 IDIs were conducted in the Federally Administered Tribal Areas from February to April The names of these agencies are presented in Table 5.1. TABLE 5.1: NAME OF AGENCIES IN FEDERALLY ADMINISTERED TRIBAL AREAS CONTACTED FOR IDIS Names of agencies 1. Khyber Agency 2. Mohmand Agency 3. DH&PWS Peshawar Key findings of the in-depth interviews Healthcare services in the Federally Administered Tribal Areas are provided through a tiered system of health care facilities; with increasing levels of complexity and coverage from primary to secondary health facilities. Primary care facilities include basic health units (BHUs), rural health centres (RHCs), mother and child health (MCH) centres, civil dispensaries (CDs) and sub-health centres (SHCs). BHUs have recently been renamed community health centres (CHCs). All of these facilities provide OPD services for preventive and a limited number of curative services; from 8am to 2 pm. RHCs provide a broader range of curative services. Primary care facilities provide outreach preventive services through vaccinators and sanitary inspectors. However, these services are not uniformly provided in all of the agencies of the Federally Administered Tribal Areas. Civil hospitals and agency head quarter hospitals (CH, AHQH) provide increasingly specialised secondary health care services through incremental bed strength. Primary 56

58 healthcare facilitates are managed by senior medical technicians (MT), while medical officers are posted at secondary care facilities. A newly instituted mobile hospital programme has been introduced in the region to serve the needs of far-flung populations. There is no tertiary care facility or teaching hospital in the Federally Administered Tribal Areas region and patients have to be relocated to the nearest city, Peshawar or in Dera Ismail Khan (DIK) for healthcare. The NMNCHP has sanctioned posts of public health specialist and social organizer in each agency (except Kurram Agency) for collaboration with the agency surgeon office for implementation of MNCH activities within the agency. We have yet to Infrastructure Infrastructure includes the physical location of the health facility along with access to and the condition of the health facilities. Continued insurgency and army intervention in the region has resulted in the destruction of a number of health facilities; one participant identified the destruction of one civil hospital and 2 RHCs (which) have been rendered non-functional since ages, as these were destroyed by the militants. Some of these damaged facilities were described to be in the process of being rebuilt. Human resources have a gynecologist and a pediatrician. About 21 posts of MO are currently lying vacant Provision of MNCH services is through staff employed by the regional health department 4. Lack of human resources, particularly female staff employed to provide MNCH services was a major issue identified by all of the participants. Staff shortages were reported for various cadres, from LHVs and mid-wives to WMOs and specialists, including gynaecologists and anaesthetists. Attributing poor staff availability and retention to the continued security concerns of the entire region, one participant said, Because of the consistent security threat, 70% of the LHWs are deployed in the lower agency; a part where only 30% of the population resides. In response to the poor availability of trained human resources, the NMNCHP undertook the training of community mid-wives (CMWs) in one agency. Meant to serve as out-reach workers, this cadre aims to provide an alternate to services provided by traditional birth attendants (TBAs). Although training of community midwives is being conducted, the deployment has suffered delays. 4 These personnel include Lady Health Visitors (LHVs), WMOs/MOs (Women/Medical Officers) and Specialists, including Gynaecologists and Paediatricians 57

59 One respondent indentified the phenomenon of ghost employees, a result of undue political influence on the health department. Many grade-iv staff or of lower grade (including sweepers and guards) exist on papers only (ghost staff) as they are never seen in any health facility, but their salaries regularly go into the kitty of local influentials, including politicians and big land lords. Staff competency for the provision of MNCH services was also thought to be insufficient. As described by one participant; We neither have sufficient nor competent human resources for the provision of quality MNCH services. While identifying a need for the continued training and skill development among all staff cadres, one respondent reported a lack of funds for the routine organisation of staff trainings. Procurement and logistical management Logistical management involves the processes of procurement, quality control, storage and distribution of drugs, supplies and equipment. Maintenance and repair of equipment and information systems used for procurement are also included. Approval of rate contracts is a centralised function performed by the medical coordination committee, housed at the Federally Administered Tribal Areas health secretariat. Headed by the secretary administration & coordination, this committee conducts product selection and rate negotiations following which, the rate lists are issued. These are binding for all of the agency-based purchases of supplies. An agency-based procurement committee, headed by the agency surgeon, is tasked with the finalisation of the procurement plan based on the (identification of) need, stock-in-hand and (availability of) safety stock. Quality control of medicine supplies is the responsibility of the agency drug inspector. Storage of purchased medicines is done at the agency stores, from where supplies are distributed to individual health facilities. Lack of logistical arrangements in one agency led to supply distribution being conducted by suppliers. One respondent identified the need for an agency store, as agency supplies were currently being held at the agency headquarter hospital (AHQH). Running out of the stock of antibiotics, antipyretics and anti-diarrhoeal drugs was reported by one participant. There was however, no reason provided for explaining this shortfall. To prevent running out of stock or meet to emergency needs, about 10% of the annual budget of 3-4 million rupees for medical supplies is set aside for discretionary use by the agency surgeon. None of the participants commented on the sufficiency of these emergency funds. There is no established logistical management information system (LMIS) in place, with the participants indicating that figures of running out of stock and utilization data reported through the existing district health information system (DHIS) formed the basis of decision 58

60 making for procurement planning. Maintenance and repair of equipment and buildings was reportedly performed within allocated budgets. Management information system The management information system includes the production, analysis and dissemination of useful information on the performance of the health system. The newly introduced district health information system (DHIS) was being adopted across all of the regions; however this process was non-uniform and one participant said...we are in the transition phase and conversion to DHIS in certain agencies is in process. Consolidation of data from individual health facilities into an agency report is done by the functioning DHIS/HMIS cell housed at the agency surgeons office. Monthly reports are subsequently forwarded to the director health and population welfare services (DH&PWS) office at the directorate level for decision making. Regular submission of reports from all of the concerned facilities and agency surgeons offices is stressed upon. More than 70 % of health facilities are now routinely sending their reports to the MIS cells in the agencies. All of the participants described the DHIS as a useful decision making tool; DHIS has certainly helped us in informed and improved decision making. Identified gaps causing delays in the relay of information included poor telecommunication and power networks and a facility level shortage of human resources. Planning We take strict action against the facility which does not send the report in time. This may mean hold up of a salary of the in charge till the The development of agency health plans was described by the receipt of report participants as an annual activity conducted by members of the agency health department. The role of agency health management teams (AHMTs) was variably described by participants; this was explained as the limited capacity of existing teams in some agencies. Where, active team members include the agency surgeon, coordinators of vertical programmes and financial staff of the agency surgeon. However, a participant stated that where AHMT was not formed, planning was conducted in collaboration with senior clerk(s) appointed to the development wing of the agency surgeon s office. These annual health plans are forwarded to the health directorate, where they are finalized in the planning and development wing and submitted for approval to the chief secretary 59

61 Federally Administered Tribal Areas, at the Federally Administered Tribal Areas secretariat. None of the participants clarified if the development of plans was guided by evidence or a strategy. Plan implementation is determined through the monthly progress meetings and monitoring/supervisory visits performed by the managerial staff. Highlighting the political pressure affecting the planning process, one participant described we also need to take into account will and approval of the political agent 5 who rules the agency like a king. Monitoring and supervision Being the administrative in-charge, the agency surgeon, assisted by his staff, is responsible for the monitoring and supervision of health facilities throughout the agency, including the monitoring and supervision of all of the activities conducted by vertical programmes. Participants responded variably about the description of supervisory responsibilities in job descriptions. One participant stated that written job descriptions are available, while another disagreed. However, neither participant shared whether these job descriptions were made available to them at the time of appointment. All of the participants expressed a need to develop the capacity of staff currently involved in conducting supervisory visits. No regular arrangements for the training of this staff were identified, though Because of the ongoing insurgencies and military operations in the region, the campaigns cannot be carried out successfully without military s support one participant mentioned a time to time (arrangement) of training of supervisors...with the support of donor agencies. The non-availability of standardised monitoring and supervision checklists was identified by two participants. However, one participant reported the provision of training material/guidelines... on target setting and supervisory supervision to those who received training. This indicates a lack of dissemination of training and the practical application of the training to improve managerial functions. Several mechanisms of feedback are employed by the managers; these include verbal and written feedback. Monthly review meetings with facility in-charges and staff are also held. 5 Political Agents are administrative head of the agencies who are appointed by the Chief Secretary Federally Administered Tribal Areas from the pool of Federal or Provincial civil service officers. They report directly to the Chief Secretary Federally Administered Tribal Areas 60

62 Inter-sectoral collaboration Monthly review meetings held under the aegis of the political agent provide a good platform for developing inter-sectoral coordination. Attended by heads of all of the line departments, these meetings serve for helping in progress review and collaboration. The volatile security situation of the Federally Administered Tribal Areas has led to the launch of a civil military coordination committee -initially developed to develop and implement polio campaigns to address the alarming rise of polio cases in the region. Headed by the political agent, this team includes focal persons from all of the line departments, including the health and commanding officer (CO) of the military command of the concerned agency. The role of the military is to provide security and logistical arrangements for the movement of polio teams. Coordination with the military high command is very much warranted in the agency to provide protection to the polio team, especially when they plan to visit highly volatile regions... where sometimes a curfew is imposed before the campaign. Notwithstanding the role of the army in these activities, collaboration is extended to ensure the safety of staff and the provision of logistical support. None of the participants identified any significant collaborative effort with the local communities. Financial management Financial management includes the development and submission of rationalised budgets and the efficient management of allocated funds. Development of budgetary demands for the agency is an annual activity conducted by the agency surgeon s office. Budgets submitted to the health directorate, are finalised by the development wing of the directorate and forwarded to the Federally Administered Tribal Areas secretariat for approval. The monetary value of these submitted budgets exceeds Rs 20 million; budgetary allocations for health worth less than Rs 20 million can be approved by the political agent. Commenting on the rationale for budgetary allocation, one participant thought allocation was based on actual need and ground realities. Budgetary sufficiency for development programmes in health, as approved in annual development plans (ADP) was thought by two of the participants to be sufficient. One participant, however, considered allocations for the purchase of equipment and furniture to be insufficient. Participants felt insufficient allocations were made for fuel purchase, which affected their capacity for logistical arrangements. To overcome budgetary gaps, requests have to be submitted to the Federally Administered Tribal Areas secretariat, a process assisted by good coordination with the secretariat. 61

63 Donor contributions All of the participants described a significant contribution by international donor agencies, over the span of the last few years - ranging from infrastructure, equipment and supplies to staff training and technical support. Donors also provided financial support for the organisation of special days e.g. child health days, provision of human resources for conducting polio campaigns and the launch of special projects e.g. the community malnutrition & marasmus project (CMAM). There was however, no reported direct financial contribution by donor agencies. Participants did not describe receiving support or contributions from the local community. Collaboration with donors is initiated and planned at the federal and secretariat levels, with inputs sought from the director health in the initial stages of coordination with donors. One participant considered the lack of consultation with the agency during the design phase as resulting in a mismatch between the contributions and needs; commodities that we have been provided often do not match with our actual needs; sometimes these are surplus in amount and sometimes quite insufficient. An earlier involvement of the agencies in the planning process was suggested as a means to overcome these gaps. 62

64 Section 6: Key Findings This section contains the key findings and recommendations based on the results of the health facility assessment 2011, which demonstrate gaps in existing MNCH services at the public sector health facilities of the Federally Administered Tribal Areas, mainly in the areas of availability of inputs and management basics at the surveyed facilities. Based on these gaps, specific recommendations are suggested in areas where improvements can be made in order to make good quality of care accessible to the community. In the Federally Administered Tribal Areas, a total of 55 health facilities including 4 AHQHs, 14 CHs, 9 RHCs and 28 BHUs were assessed under the health facility assessment. Salient findings are given below: Infrastructure A functioning infrastructure at a health facility is essential for the delivery of its level-specific package of MNCH services. Within the ambit of the HFA, infrastructure was assessed for the availability and functional status of MNCH-related building components at each facility. In order to deliver preventive MNCH services, three infrastructure components are required to be in place at each BHU, including an OPD, labour room and a residence for the LHV. Although BHUs are supposed to provide services 8 hours a day and 6 days a week, but a residence for the LHV was included in the scope of the HFA, keeping in view the location of BHUs and travel arrangements in the rural areas of the Federally Administered Tribal Areas. On average, 68% of the infrastructure components were available at the BHUs and major gaps existed in the availability of labour rooms, which were not available in 71% of the BHUs. In order to deliver basic EmONC services at the RHC, the required infrastructure components included an OPD, female ward, labour room, clinical lab, LHV s room and residences for the WMO and LHV for the delivery of services 24 hours a day and 7 days a week. On average, 75% of these infrastructure components were available at the RHCs. When civil hospitals 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 civil hospital. Besides the missing facilities in the available components, an independent OBGYN ward was available at 50% of the civil hospitals. Residences for the WMOs were available at 8 of the RHCs and 10 civil hospitals, but were inhabitable at only 6 RHCs and 7 civil hospitals. 63

65 In order to deliver comprehensive EmONC services at the secondary health care hospitals including AHQ and civil hospitals, the required infrastructure components included an OPD, female ward, labour room, operation theatre, paediatric ward, paediatric nursery, blood bank, clinical laboratory and residences for the MNCH related staff for delivery of services 24 hours a day, 7 days a week. Average availability of the infrastructure components was 73% at AHQHs and 40% at civil hospitals. Major gaps were noticed regarding the availability of a paediatric ward (which was not available at 1 AHQHs and 8 CHs); paediatric nursery (not available at 1 AHQHs and 12 CHs); blood bank (not available at 1 AHQHs and 9 CHs); and residences for the gynaecologist (not available at 1 AHQHs and 11 CHs), anaesthetist (not available at 1 AHQH and 11 CHs) and paediatrician (not available at 1 AHQHs and 9 CHs). Human resources The availability of required staff was not a problem at the level of BHUs, as a doctor or LHV was available at 22 out of the 28 BHUs. For basic and comprehensive EmONC services which should be available for 24 hours a day and seven days a week (since demand for EmONC services cannot be predicted), 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. 5 of the RHCs in the Federally Administered Tribal Areas were not provided with a WMO. At SHC hospitals, the availability of specialists including a gynaecologist (not available at 4 AHQH and all CHs), anaesthetist (not available at 3 AHQHs and all CHs) and paediatrician (not available at 3 AHQHs and all CHs) was far less than the minimum requirement. Training of staff Capacity building training and continuing medical education are critical for the service providers to deliver quality MNCH services. Little commitment to clinical training and professional development is evident in the public sector, unless specifically funded by external donors. The lack of trained staff was a barrier to the provision of reproductive health and family planning services. In the RHCs, civil and AHQ hospitals, 83% were not performing an assisted vaginal delivery due in part to the lack of training. In this regard, the NMNCHP has been doing its part and has trained MNCH related staff, through skill development in the standards of service provision, counselling techniques and client centeredness. However, the majority of the 64

66 facilities were lacking trained staff, as staff at 65% of the facilities had not received any MNCH related training. Health facilities were also reported to be performing a signal function in the absence of formally trained staff, e.g. AHQ and civil hospitals performing caesarean section in the absence of a qualified gynaecologist or anaesthetist. Drugs, supplies and equipment Lack of medicines, supplies and functional equipment was a frequent barrier for the surveyed health facilities in delivering MNCH services. At the time of assessment, none of the health facilities in the Federally Administered Tribal Areas had been provided with the complete range of these items required to perform signal functions. Items required for the operation theatre and blood bank were not fully available at any of the AHQ and civil Hospitals. Despite lacking equipment, drugs and supplies for caesarean section or blood transfusion, the majority of the health facilities reported having performed such procedures prior to the assessment. Large quantities of non-functional equipment were also identified during the assessment of the health facilities which could not be repaired, due to the lack of such arrangements at the district level, as well as the budgetary constraints. Facility in-charges reported that their demands were not fully met by the district health department and distribution was also delayed resulting in frequent running out of the stock of essential drugs, supplies, vaccines and family planning commodities. A discrepancy was noted in policy and practice, as some new drugs and equipment had been proposed by the NMNCHP but failure to procure these drugs and equipment had prevented their use. For example, a vacuum extractor was included in the standard list of equipment for RHCs and SHC hospitals, yet most these health facilities did not have this equipment. 65

67 Work coordination and supervision Monitoring performance allows facility staff to better understand their deficiencies for the initiation of improvements. Regularity of monthly performance review meetings is utilized to assess the intra-facility work coordination. Although the majority of the health facilities are conducting such meetings but their record is hardly being maintained at these facilities. Facility in-charges also reported regular participation in the agency level performance review meetings. As for supervisory activities of the district health managers, although health facilities had continuously been visited but the sending of feedback from these supervisory visits to the facility is not a common practice. Service delivery protocols Service delivery protocols are a tool used for the continuous medical education of the MNCH related staff. Service delivery protocols were not available at the majority of the surveyed health facilities. Wherever they were available, they were not displayed at the proper place. Management information system The agencies were in the process of adopting the district health information system (DHIS) at the time of survey. Most of the recording and reporting tools were available and being maintained at the surveyed facilities. However, gaps existed at the RHCs, where only 34% of the tools were available. The recording of obstetric complications or the treatment provided in response is deficient at the health facilities, with the exception of caesarean sections. It can be attributed to lack of training of staff responsible for maintaining these tools. There are deficiencies in the MIS tools which restrict the recording of certain key MNCH indicators. For example, the obstetric register contained no space for recording 2 nd, 3 rd or 4 th antenatal visits and these were cumulatively reported as ante natal care revisits. Similarly, there was no separate record for cases of pneumonia under 5 years of age, treated at the health facilities and these were recorded along with the acute respiratory infections. 66

68 Infection control Infection control practices were found to be inadequate in the service provision areas of all of the surveyed health facilities. Although the availability of waste management plans was reported by the majority of the assessed health facilities, infection control practices were found to be inadequate in the service provision areas of all of them. Gaps in infection control practices occurred mainly due to the lack of materials and equipment required for waste collection, personal protection and waste treatment. Only 5 of the assessed health facilities had a functional incinerator and the majority of the facilities were not segregating infectious waste from other waste, as waste collection material was not available at any of the health facilities. Death reviews The national and provincial health policy endorses the constitution of death review committees for reviewing maternal and neonatal deaths occurring at the health facilities. Such detailed case reviews are essential for better understanding the deficiencies in service delivery and the reasons why, so that the health facilities can initiate improvements. In the surveyed health facilities of the Federally Administered Tribal Areas, neither maternal deaths nor the causes thereof were clearly Gaps related to the inputs Deficient human resource and lack of trainings Deficiencies in infrastructure Irregular supply of drugs and consumables Deficient functional equipment Gaps related to the management basics Non-availability of JDs for staff and service delivery protocols Lack of performance review at facility level Lack of supportive supervision Deficiency of MIS tools Poor infection control and hospital waste management Lack of death review committees Lack of donor contribution record or consistently documented. Therefore, death review committees which are available at only 2 of the surveyed health facilities of the Federally Administered Tribal Areas were not functional at any of the health facilities. Donor contributions Information about donor contributions was collected from both the surveyed facilities and district health departments. A total of 14 health facilities reported donor contributions. The monetary value of the support provided by the donor agencies was not available at any of the agencies health departments. 67

69 Annexes 68

70 ANNEX 1 Objectives of the NMNCH programme The national MNCH programme (NMNCHP) was initiated in 2006, with its goal to improve maternal, newborn and child health of the population, particularly among Pakistan s poor, marginalized and disadvantaged communities. This is a comprehensive programme aiming at strengthening, upgrading and integrating ongoing interventions, as well as introducing new strategies. The objectives of the programme are to: Strengthen the district health systems, through improvement in technical and managerial capacity at all levels and upgrading institutions and facilities. Streamline and strengthen services for the provision of basic and comprehensive emergency obstetric and newborn care (EmONC). Integrate all services related to MNCH at the district level. Introduce a cadre of community-based skilled birth attendants. Increase demand for health services through targeted, socially acceptable communication strategies. The programme aims to ensure level specific MNCH services at the public health facilities which are comprised of 24/7 comprehensive EmONC services in all of the AHQHs and CHs; 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 regions, 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 the delivery of MNCH services. At the 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 regions and agencies in the implementation of the activities of the programme. A regional NMNCHP project implementation unit (PIU) for the Federally Administered Tribal Areas was set up in Peshawar in 2007, which is headed by the regional coordinator 69

71 NMNCHP 6. The space, equipment & vehicles available in the current setup of PIU are enough for its functioning. Presently there is no staff shortage at PIU. All sanctioned positions are filled in by personnel having adequate qualification and experience. The project implementation unit developed an implementation plan for the programme activities, but low financial allocations have been creating difficulties. The project implementation unit is well connected to the programme at the national level, as well as to its implementing units at the agency level. The most common mode of communication between various units is either telephonic or electronic (through s), followed by formal written correspondence. The regional MNCH project implementation unit is responsible for the planning and efficient execution of the programme activities. A public health specialist as director M & E is positioned at the project implementation unit, who supervises the M & E activities in the region, through the NMNCHP agency team of social organizers, headed by public health specialists. A total of three public health specialists were deputed in Mohmand, Bajour and Orakzai agencies. In agencies where public health specialists are not positioned, agency surgeons and MS of AHQ hospitals also act as focal persons for NMNCHP in the agencies and a formal coordination between them and PC-NMNCHP & the Federally Administered Tribal Areas Directorate does exist in this regard. As an incentive, agency surgeons were paid Rs. 10,000/- per month and MS- AHQHs were paid Rs. 5000/- by the programme. The programme has carried out a recruitment process for social organizers and account assistants for all of the seven agencies, in the month of April and finalized their selection in May, They will be deputed shortly. The programme has developed links with donor agencies, vertical programmes and governmental departments for functional integration, 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. PC- NMNCHP Federally Administered Tribal Areas collaborates with the donor agencies. 6 Information acquired from Regional Coordinator - NMNCHP (FEDERALLY ADMINISTERED TRIBAL AREAS ) using Provincial Level Questionnaire 70

72 ANNEX 2 Input criteria for MNCH services 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 71

73 OPTIMAL ITEMS CIVIL WORKS SCOPE FOR RHCS LHV s room Residence - WMO Residence - LHV 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 AHQH & CH 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 Operation theatre 1. Patient preparation room 2. Operating room 3. Recovery room 4. Scrub area Paediatric ward 1. Patient area 2. Nursing station 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 LHV s room 1. Consultation area 2. Examination area 5. Store for general items/drugs 6. Store for equipment 7. Functional attached washroom for patients 8. Functional attached washroom for staff 5. Sterilization area 6. Doctor s room 7. Support staff duty room 8. Store for general items/drugs & equipment 9. Store of equipment 10. Functional attached washroom for staff 3. Store for general items/drugs & equipment 4. Functional attached washroom 3. Store for general items/drugs & equipment 4. Changing 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 3. Privacy of examination area 4. Hand washing facilities 72

74 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 MINIMAL ITEMS Ob/Gyn OPD Ob/Gyn ward Labour room Operation theatre Paediatric ward Clinical laboratory Residence - Gynaecologist Residence - Anaesthetist Residence - Paediatrician Residence - WMO Residence - Lab technician Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition Available Available Available Available Available Available Available Good condition Available Good condition Available Good condition Available Good condition Available Good condition 73

75 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 HUMAN RESOURCES FOR 24/7 COMPREHENSIVE EmONC OPTIMAL HR FOR AHQH OPTIMAL HR FOR CH 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 AHQH MINIMAL HR FOR CH Gynaecologist 1 Gynaecologist 1 Anaesthetist 1 Anaesthetist 1 Paediatrician 1 Paediatrician 1 WMOs 4 WMOs 2 OT technician 1 OT technician 1 Lab technician 1 Lab technician 1 Nurses 6 Nurses 4 LHVs 1 LHVs 1 74

76 Equipment criteria OPTIMAL ITEMS General hospital equipment 1. Electric water cooler OPD / WMO s office 1. Office / Plain chairs 2. Examination couch 3. Office tables with drawers 4. Steel almirah (Large) 5. Patient s stool 6. Weighing machine (Adult) 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 EQUIPMENT FOR BHUS 2. Water filter 3. Incinerator 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 7. P.V. examination light 8. Examination couch 9. Office chairs 10. Office tables with drawers 11. Patient s 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 EQUIPMENT FOR RHCS OPTIMAL ITEMS General hospital 1. Ambulance 2. Electric water cooler Female ward items 1. Fowler bed (Iron) 2. Attendant's bench 3. Bed side locker 4. Overhead food trolley 3. Water filter 4. Incinerator 5. Dust bin (Stainless steel) 6. Screen folding (Complete) 7. Baby cot 8. B.P Apparatus mercury-desk type 9. Stethoscope 75

77 OPTIMAL ITEMS EQUIPMENT FOR RHCS OPD / WMO s office 1. Office chairs 2. Plain chairs 3. Examination couch 4. Office tables with drawers 5. Steel almirah (Large) 6. Patient s stool 7. Weighing machine (Adult) 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) 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 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 s 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 Lady health visitor s room 1. Office chairs 2. Office tables with drawers 3. Weight scale (Adult) 2. B.P Apparatus mercury-desk type 3. Stethoscope 4. Office tables with drawers 5. B.P Apparatus mercury-desk type 6. Foetal stethoscope 5. Vulsellum forceps 6. Scissors (Dissecting, blunt pointed) 7. Artery forceps 8. D & C instruments set 4. Weight scale (Infant) 5. Height measuring device 6. Height measuring board 7. Examination couch 76

78 OPTIMAL ITEMS EQUIPMENT FOR AHQ HOSPITAL General hospital 1. Ambulance 2. Defibrillator 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 3. Desktop computer with monitor and accessories 4. Electric water cooler 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 s 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) 77

79 OPTIMAL ITEMS EQUIPMENT FOR AHQ 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) 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) Laboratory 1. Spin machine 2. Chemistry analyzer 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 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 3. Counter (Hand tally differential) 4. Steel almirah (Large) 5. Lab cabinet MINIMAL ITEMS Gynae/Obs. ward items OPD / Gynaecologist s office 1. Weighing machine (Adult) 2. Examination lamp 3. Stethoscope (Adult size) Paediatric nursery 1. Air ways 2 size 2. Infant ambo bag 3. Infant laryngoscope set 1. Fowler bed (Iron) 4. B.P apparatus desktop type 5. Office chair 6. Office table with drawers 7. Examination couch 4. Suction apparatus: electrically operated 5. Infant incubators 6. Phototherapy unit 78

80 OPTIMAL ITEMS EQUIPMENT FOR AHQ HOSPITAL Paediatric ward 1. Stethoscope (Paediatric Littman type) 2. Nebulizer 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 Operation theatre 1. Anaesthesia machine 2. Laryngoscopes 3. Oxygen cylinder complete with trolley 4. Fowler bed (Iron) 6. Uterine sound 7. Vulsellum forceps 8. Episiotomy instruments set (Complete) 9. D&C instruments set (Complete) 10. Delivery forceps set 11. Delivery table 3. Gynae instrument set 4. D & C instruments set OPTIMAL ITEMS General hospital 1. Ambulance 2. Defibrillator EQUIPMENT FOR CIVIL 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 Paediatric nursery 1. Air ways 2 size 2. Infant ambo bag 3. Infant laryngoscope set 4. Suction apparatus: electrically operated 5. Infant incubators 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 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 79

81 OPTIMAL ITEMS EQUIPMENT FOR CIVIL HOSPITAL 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) 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) Laboratory 1. Spin machine 2. Chemistry analyzer 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 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 3. Counter (Hand tally differential) 4. Steel almirah (Large) 5. Lab cabinet MINIMAL ITEMS Gynae/Obs. ward items OPD / Gynaecologist s office 1. Weighing machine (Adult) 2. Fowler bed (Iron) 2. Examination lamp 80

82 OPTIMAL ITEMS EQUIPMENT FOR CIVIL HOSPITAL Paediatric nursery 1. Air ways 2 size 2. Infant ambo bag 3. Infant laryngoscope set Paediatric ward 1. Stethoscope (Paediatric Littman type) 2. Nebulizer Labour room 1. Foetal stethoscope 2. Spring type dressing forceps (S.s) 3. Sim s speculum (Right angle, medium) Operation theatre 1. Anaesthesia machine 2. Laryngoscopes 4. Suction apparatus: electrically operated 5. Infant incubators 6. Phototherapy unit 3. Oxygen cylinder complete with trolley 4. Fowler bed (Iron) 4. Sponge forceps 5. Uterine sound 6. Vulsellum forceps 7. Episiotomy instruments set (Complete) 3. Gynae instrument set 4. D & C instruments set Drugs and supplies criteria OPTIMAL ITEMS DRUGS & SUPPLIES FOR BHUS Supplies 1. Gloves 2. Clean / Safe delivery kit 3. Disposable/ Auto disable syringes Tracer drugs 1. Capsule Amoxicillin 2. Syrup Amoxicillin 3. Tablet Metronidazole 4. Syrup Metronidazole 5. Tablet Iron 6. Tablet Folic acid Vaccines 1. BCG 2. OPV Family planning commodities 1. Condoms 2. COC 3. POP 4. Reagents/ strips for routine lab tests 5. Surgical spirit 6. Oral Rehydration Salt ORS 7. Tetracycline Ointment 8. Injection Oxytocin 9. IV solutions 10. Syrup Salbutamol 11. Syrup Chloroquine 12. Syrup Zinc Sulphate 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 81

83 OPTIMAL ITEMS DRUGS & SUPPLIES FOR BHUS Tracer drugs Vaccines 1. BCG 2. OPV Family planning commodities (any three) 1. Condoms 2. IUCDs 1. Tablet Iron 2. Tablet Folic acid 3. Penta-valent 4. Measles 5. TT 3. COC or POP 4. Injection DMPA or Net-En DRUGS & SUPPLIES FOR RHCS OPTIMAL ITEMS Supplies 1. Gloves 2. Clean / Safe delivery kit 3. Disposable/ Auto disable syringes 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 Vaccines 1. BCG 2. OPV Family planning commodities 1. Condoms 2. COC 3. POP MINIMAL ITEMS Supplies 1. Clean / Safe delivery kit Tracer drugs 1. Injection Ampicillin Vaccines 1. BCG 2. OPV 4. Reagents/ strips for routine lab tests 5. Surgical spirit 6. Oral Rehydration Salt ORS 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 3. Penta-valent 4. Measles 5. TT 4. IUCDs 5. Injection DMPA 6. Injection Net-En 2. Disposable/ Auto disable syringes 3. Reagents/ strips for routine lab tests 2. Injection Oxytocin 3. Injection Magnesium Sulphate 3. Penta-valent 4. Measles 5. TT 82

84 OPTIMAL ITEMS DRUGS & SUPPLIES FOR RHCS Family planning commodities (any three) 1. Condoms 2. IUCDs 3. COC or POP 4. Injection DMPA or Net-En OPTIMAL ITEMS DRUGS & SUPPLIES FOR AHQH & CH Supplies 1. Gloves 2. Clean / Safe delivery kit 3. Disposable/ Auto disable syringes 4. Reagents/ strips for routine lab tests 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 Vaccines 1. BCG 2. OPV Family planning commodities 1. Condoms 2. COC 3. POP 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 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 3. Penta-valent 4. Measles 5. TT 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 Tracer drugs 1. Injection Dexamethasone 2. Injection Adrenaline 3. Injection Atropine 4. Injection Ampicillin 4. Reagents/ strips for routine lab tests 5. Screening kits for Hep B,C & HIV 6. Blood grouping reagents 5. Injection Oxytocin 6. Injection Magnesium Sulphate 7. Injection Thiopentone Sodium 8. Injection Neostigmine 9. Injection Propofol 83

85 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 5. Implants 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 BHUS Basic lab tests 1. Doctor or LHV 2. Reagents and strips MINIMAL CRITERIA FOR RHCS Basic lab tests 1. Space 2. Doctor or LHV or Lab technician 3. Reagents and strips SUPPORT SERVICES CRITERIA FOR SHC HOSPITALS OPTIMAL CRITERIA Basic lab tests 1. Space 2. Laboratory technician Blood transfusion services 1. Blood bank technician or lab technician Radiology services 1. Space Operation theatre services 1. Space 2. Anaesthetist 3. OT technician Ambulance services 1. Functional ambulance 3. Reagents and strips 4. Laboratory equipment 2. Screening strips for Hep B, C & HIV 2. Ultrasound equipment 4. Anaesthesia technician 5. OT equipment 6. Drugs and supplies 2. Ambulance driver 84

86 MINIMAL CRITERIA Basic lab tests 1. Space Blood transfusion services 1. Laboratory or blood bank technician Radiology services 1. Space Operation theatre services 1. Space 2. Anaesthetist or anaesthesia technician 2. Lab technician 3. Reagents and strips 2. Screening strips for Hep B, C & HIV 2. Ultrasound equipment 3. OT equipment 4. Drugs and supplies Infection control and 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 1. Autoclave for waste treatment 2. Autoclave test strips Disinfection of service provision areas 1. Cleaning materials 2. Chemical disinfectant 85

87 Input criteria for basic EmONC services at the civil hospital G.1 Civil works CIVIL WORKS SCOPE OPD 1. Consultation area Female ward 1. Patient area Labour room 1. Delivery room Clinical laboratory 1. Laboratory room LHV s room 1. Consultation area Residence - WMO Residence - LHV 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 Available Good condition Available Good condition G.2 Human resources HUMAN RESOURCES Category Number Category Number WMOs 2 LHVs 2 OT technician 1 Ambulance drivers 1 Lab technician G.3 Equipment EQUIPMENT General hospital 1. Ambulance Female ward 1. Fowler bed (Iron) 2. Attendant's bench 3. Bed side locker OPD 1. Weighing machine (Adult) 2. Electric water cooler 4. Screen folding (Complete) 5. B P Apparatus mercury Desk type 6. Baby cot 2. Infant weighing machine 3. Examination lamp 86

88 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 G.4 Drugs and supplies Supplies 1. Gloves 2. Clean / Safe delivery kit 3. Disposable/ Auto disable syringes 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 Vaccines 1. BCG 2. OPV Family planning commodities 1. Condoms 2. COC 3. POP DRUGS & SUPPLIES 4. Reagents/ strips for routine lab tests 5. Screening kits for Hep B,C & HIV 6. Blood grouping reagents 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 3. Penta-valent 4. Measles 5. TT 4. IUCDs 5. Injection DMPA 6. Injection Net-En G.5 Support services SUPPORT SERVICES Laboratory services 1. Basic laboratory tests Ambulance services 1. Functional ambulance 2. Ambulance driver 87

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