April 19, 2010 Regional Workshop Asian Development Bank Headquarters 19-20 April Manila Philippines Dr Amanullah Senior Director Health & Nutrition Strengthening.

April 19, 2010

Regional WorkshopAsian Development Bank Headquarters

19-20 AprilManila Philippines

Dr AmanullahSenior Director Health &

Nutrition

Strengthening and providing PHC services

in Pakistan through public private partnership

Background

180 Million People

MMR 276/100,000IMR 78/1000NMR 54/1000

CPR 30%

Background 270 District/Sub DistrictHospitals

5500Basic Health

Units

800Rural Health

Centers

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

Weak management capacity & ineffective monitoring and supervision

Emergency prone country

Influx ofAfghan

RefugeesIn

1985

2005Earthquake

2009IDPs

Rural Health Center, Banna, Allai

Pakistan Earthquake 2005

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.

Management of PHC services

The Model

Regional Evidence

Revitalization of PHC services

Local Evidence

Revitalization of

PHC services

Public Private Partnership

Performance Based IncentivesThe HUB Approach

Capacity BuildingManagement of PHC

services

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

BHUTailoos

BHUBiari

BHURoopkani

BHUPashto

BHU Rashang

CDKashgran

BHUKuztandol

BHUSukargah

BHUBrachar

RHCBanna

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

18

31

0

5

10

15

20

25

30

Before Project After Project

Staff Deployment

2 1

52

21

1

2620

6

58

31

10

40

0

10

20

30

40

50

60

70

MO WMO MT LHV Dispenser EPI Tech

Before Project After Project

24/7 EmNOC Facilities

0

3

0

0.5

1

1.5

2

2.5

3

3.5

Before Project After Project

HMIS Reporting

12%

100%

0%

20%

40%

60%

80%

100%

120%

Before Project After Project

Average Monthly Consultations

7029

20568

33550

Year 2007 Year 2008 Year 2009

Month

ly aver

age

Antenatal Registration

1515 1546 1578

83854%

122378%

45130%

0

200

400

600

800

1000

1200

1400

1600

1800

Year 2007 Year 2008 Year 2009

Reg

istr

atio

n fo

r A

NC

Expected Monthly Pregnancies Average Monthly Registration

Deliveries by Skilled Birth Attendants

1363 1392 1420

322%

18914%

36326%

0

200

400

600

800

1000

1200

1400

1600

Year 2007 Year 2008 Year 2009

Del

iver

ies

Expected Monthly Deliveries Average Monthly Deliveries

TT-2 Vaccination

1515 1546 1578

52133%388

25%1379%

0

200400

600800

10001200

14001600

1800

Year 2007 Year 2008 Year 2009

Pre

gnan

t Lad

ies

Rec

eive

d T

T2

Expected Monthly Pregnancies Average Monthly TT2 Vaccination

Children Fully Immunized

1278 1305 1331

79360%

51039%

12810%

0

200

400

600

800

1000

1200

1400

Year 2007 Year 2008 Year 2009

Expected <1 year Children Average Monthly Coverage

Family Planning Services

56

306

446

0

50

100

150

200

250

300

350

400

450

500

Year 2007 Year 2008 Year 2009

Mon

thly

ave

rage

Clie

nts

OTP & SFP Centers Established

OTP and SFP Centers

30

23

31

25

0

5

10

15

20

25

30

35

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

2008 2009

Years

No. o

f Fac

ilitie

s

CMAM Beneficiaries

Registered Patients

354

0

330

419

84

219

298

389

511

46

0

100

200

300

400

500

600

SAM MAM Pregnant Lactating Cured SAM MAM Pregnent Lactating Cured

2008 2009

Years

No

. o

f P

ati

en

ts

Before/After

Mid Term Review

Human Resources

020406080

100120

Human

Res

ource

Policy

Availa

bility

of S

taff

Train

ing &

Cap

acity

Ince

ntives

& P

rivile

ges fo

r Sta

ff

Comm

itmen

t of S

taff

Overa

ll

Before Project

After Project

Mid Term Review

Services

0

20

40

60

80

100

Range of healthcare services

Patient utilizationof services

Quality ofservices

Outreach healthcare services

Before Project After Project

Mid Term Review

78%81%76%75%

0

10

20

30

40

50

60

70

80

90

100

Environment &Services

OverallSatisfaction

Staff Accessibility

Client Satisfaction by various domains

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