The views expressed in this presentation are the views of the author(s)

Strengthening and providing PHC
services in Pakistan through public
private partnership
and do not necessarily reflect the views or policies of the Asian
Development Bank (ADB), or its Board of Directors or the governments
they represent. ADB does not guarantee the source, originality, accuracy,
completeness or reliability of any statement, information, data, finding,
interpretation, advice, opinion, or view presented, nor does it make any
representation concerning the same.

April 19, 2010

Regional Workshop
Asian Development Bank Headquarters
19-20 April
Manila Philippines

Dr Amanullah
Senior Director Health & Nutrition
Background

CPR 30%

180 Million People

MMR 276/100,000
IMR 78/1000
NMR 54/1000
Background 270 District/
Sub District
Hospitals

800
Rural Health
Centers

5500
Basic Health
Units

96000
LHWs
 Background

• Over 60% of peripheral health facilities under utilised:

– Inaccessible health facilities- Inappropriate site
selection
– Health Human Resource Management problems like
– Gender and skill imbalances
– Staff absenteeism.
– Ill planned & frequent postings and transfers.
– Inverted pyramid of health professionals
– Lack of funds for maintenance & repair
– Irrational financial allocations- less resources for
primary health care
Emergency prone country

Influx of
Afghan
2005 2009
Refugees
Earthquake IDPs
In
1985
Rural Health Center, Banna, Allai
The Objective

To revitalize, strengthen and provide primary health

care services in district Batgram through a public
private partnership initially for a period of two years
The Process

• SC signed an agreement with

WB on January 11, 2007
• WB provided 2.99 million US $
• SC signed MoU with DoH
NWFP on October 2, 2007
• Salary and non-salary budget of
all positions transferred to Save
the Children in February 2008.
• SC took over the management
of all primary health care
facilities from February 2008.
 Regional Evidence

The Model Management of PHC

services

Revitalization of
PHC services

Public Private Partnership

Revitalization
of
PHC services

Capacity
Management of PHCBuilding
services

Local Evidence
The HUB Approach Performance Based Incentives
The Hub Approach

•Integrating RHC with cluster of 6-10 BHUs

•24/7 Basic EmONC facility
•Referral facility for attached BHUs
•Housing & recreational facility
•Mobility for supervision and rotation
• Some financial and administrative authority
delegated to Hub I/C
•Services, timings, telephone numbers displayed
at each facility
•Ambulance service for timely referrals
Hub-1
Performance Based Incentives

― Keeping in view the trauma of the district

staff and to rationalize the gap between
Government and private organizations
pay packages, performance based
incentives were introduced in line with
the policy of Go NWFP.
― 20% of the basic was provided across the
board
― 21-35 % was linked to performance
― Total performance score was 100%
― 40% - monthly checklists of monitors and
supervisors
― 60% - monthly HMIS reports
― Payment of incentives is along with next
monthly salary
Community Involvement

District Health Management Team

District Health Management Team

Quality Improvement Team

# of Health facilities operationalised

30

25 31

20

15 18

10

0
Before Project After Project
Staff Deployment

70
58
60 52
50
40
40 31
30 26
20 21
20
10
10 6
2 1 1
0
MO WMO MT LHV Dispenser EPI Tech

Before Project After Project

 24/7 EmNOC Facilities

3.5
3
3
2.5
2

1.5
1
0.5
0
0
Before Project After Project
 HMIS Reporting

120%
100%
100%

80%

60%

40%

20% 12%

0%
Before Project After Project
Average Monthly Consultations

33550
M o n th ly a v e r a g e

20568

7029

Year 2007 Year 2008 Year 2009

Antenatal Registration

1800
1515 1546 1578
1600 1223
Registration for ANC

1400 78%
1200 838
1000 54%
800 451
600 30%
400
200
0
Year 2007 Year 2008 Year 2009

Expected Monthly Pregnancies Average Monthly Registration

Deliveries by Skilled Birth Attendants

1600 1420
1363 1392
1400
1200
Deliveries

1000
800
600 363
189 26%
400
32 14%
200 2%
0
Year 2007 Year 2008 Year 2009

Expected Monthly Deliveries Average Monthly Deliveries

TT-2 Vaccination

1800 1578
Pregnant Ladies Received TT2

1515 1546
1600
1400
1200
1000
800 521
388 33%
600 25%
400 137
9%
200
0
Year 2007 Year 2008 Year 2009

Expected Monthly Pregnancies Average Monthly TT2 Vaccination

Children Fully Immunized

1305 1331
1400 1278
1200
793
1000
60%
800 510
600 39%

400 128
200 10%

0
Year 2007 Year 2008 Year 2009

Expected <1 year Children Average Monthly Coverage

Family Planning Services

500 446
450
400
Monthly average Clients

350 306
300
250
200
150
100 56
50
0
Year 2007 Year 2008 Year 2009
OTP & SFP Centers Established

OTP and SFP Centers

35
31
30
30
25
25 23
N o . o f F acilities

20

15

10

0
Total Health Centers OTP & SFP Centers Total Health Centers OTP & SFP Centers

2008 2009
Years
CMAM Beneficiaries

Registered Patients

600
511
500
419
389
400
No. of Patients

354
330
298
300
219
200

84
100
46
0
0
SAM MAM Pregnant Lactating Cured SAM MAM Pregnent Lactating Cured

2008 2009
Years
Before/After
Mid Term Review

Human Resources
120
100
80 Before Project
60 After Project
40
20
0
Mid Term Review

Services
100

80

60 Before Project
After Project
40

20

0
Range of health Patient utilization Quality of Outreach health
care services of services services care services
 Mid Term Review

Client Satisfaction by various domains

100
90
80
70
60
50
40 76% 81% 78%
75%
30
20
10
0
Envir onm e nt & Ove r all Staff Acce s s ibility
Se r vice s Satis faction
 Lessons Learnt

• Keeping district stakeholders on board helped to

overcome resistance from Government staff

• Performance based incentives coupled with clarity

around job descriptions, capacity building and improved
supervision brought staff absenteeism to zero and
HMIS reporting to 100%

• Providing conducive working & living conditions

ensured deployment of female staff
 Lessons Learnt

• Improvement in availability and quality lead to

enhanced utilization of PHC services

• Delegating more powers to accountable managers at

HUB level paved the way for improved supervision

• More time required to implement the transition strategy

of delegating more authority to HUB managers and
institutionalisation of AHMTs and QITs into district
health system
Thanks