District Health Plan Nowshera 2015

DISTRICT HEALTH PLAN

NOWSHERA

District Health Plan Nowshera

TEAM ACKNOWLEDGEMENT

The team appreciates and acknowledges the contributions made by the Provincial and District Health Departments in undertaking this assignment, particularly the guidance provided by Mr. Mushtaq Jadoon Secretary Health, Dr. Pervez Kamal Khan Director General Health Services, Dr. Ali Ahmad Director Health Services and Dr Shaheen Afridi Deputy Director Public Health, Khyber Pakhtunkhwa. The team appreciates the continuous support provided by Dr. Arshad Ahmed Khan District Health Officer Nowshera and his team which led to the successful completion of this assignment.

The team appreciates and acknowledges the guidance provided by Mr. Farooq Azam, Team Leader TRF+. The team also appreciates and acknowledges the valuable inputs, facilitation and technical review provided by Dr. Shabina Raza Provincial Team Leader and Dr. Mohammad Rahman Khattak District Health Specialist TRF+ Khyber Pakhtunkhwa.

The team hopes, this document sets the stage and provide the necessary impetus for districts to improve the performance in service delivery.

DISCLAIMER

This document is issued for the party which commissioned it and for specific purposes connected with the captioned assignment 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.

Date: 28th April 2015, Islamabad

AUTHORS

1. Dr. Nasir Idrees; Team Leader 2. Dr. Asma Bokhari; Public Health Specialist3. Dr. Nadeem Ahmad.; Public Health Specialist 4. Mr. Ali Asghar Khan; M&E Specialist5. Mr. Jamal Afridi; M&E Specialist 6. Mr. Syed Faheem Ahmad; PFM Specialist 7. Mr. Umair Azhar: PFM Specialist

ii


TABLE OF CONTENTS

1. TEAM ACKNOWLEDGEMENT................................................................................................. ii

2. DISCLAIMER............................................................................................................................ ii

3. AUTHORS................................................................................................................................. ii

4. TABLE OF CONTENTS........................................................................................................... iii

5. LIST OF TABLES..................................................................................................................... iv

6. LIST OF FIGURES................................................................................................................... iv

7. LIST OF ACRONYMS.............................................................................................................. vi

8. SECTIONS OF DISTRICT HEALTH PLAN...............................Error! Bookmark not defined.

9. SECTION 1: DISTRICT PROFILE............................................................................................1

10. SECTION 2: SITUATION ANALYSIS.......................................................................................3

11. KEY HEALTH INDICATORS....................................................................................................3

12. DISEASE PATTERN.................................................................................................................3

13. HEALTH FACILITIES................................................................Error! Bookmark not defined.

14. HUMAN RESOURCE................................................................Error! Bookmark not defined.

15. UTILISATION OF SERVICES...................................................Error! Bookmark not defined.

16. PREVENTIVE PROGRAMMES................................................Error! Bookmark not defined.

17. INTEGRATED PREVENTIVE PROGRAMMES........................Error! Bookmark not defined.

18. EXPANDED PROGRAMME ON IMMUNIZATION (EPI)...........Error! Bookmark not defined.

19. MATERNAL, NEW-BORN & CHILD HEALTH PROGRAMME..Error! Bookmark not defined.

20. NATIONAL PROGRAMME FOR FAMILY PLANNING & PRIMARY HEALTH CARE (LHW PROGRAMME).........................................................................Error! Bookmark not defined.

21. STANDALONE PREVENTIVE PROGRAMMES.......................Error! Bookmark not defined.

22. MALARIA..................................................................................Error! Bookmark not defined.

23. TB CONTROL PROGRAMME..................................................Error! Bookmark not defined.

24. HEPATITIS CONTROL PROGRAMME....................................Error! Bookmark not defined.

25. FISCAL ANALYSIS.................................................................................................................12

26. SECTION 4: KEY CHALLENGES...........................................................................................14

27. SECTION 4: ROLLING OUT MHSDP & INTEGRATED PC-1................................................22

28. INFRASTRUCTURE...............................................................................................................22

29. HUMAN RESOURCE.............................................................................................................22

30. COSTING OF THE HR & INFRASTRUCTURE FOR ROLLING MHSDP IN 50% OF PHC FACILITIES............................................................................................................................. 23

31. ADDITIONAL MANAGEMENT POSITIONS...........................................................................24

32. SECTION 5: OUTCOMES & OUTPUTS.................................................................................25

33. PRIORITIZATION OF OUTCOMES........................................................................................25

34. PRIORITIZATION OF OUTPUTS...........................................................................................25

35. SECTION 6: OPERATIONAL FRAMEWORK.........................................................................26

iii


36. PLANNING STRUCTURE......................................................................................................26

37. IMPLEMENTATION STRUCTURE.........................................................................................26

38. ROLLING PLAN MODEL........................................................................................................26

39. ROLLING PLAN MODEL........................................................................................................28

40. OPERATIONAL FRAMEWORK..............................................................................................29

41. SECTION 7: ..........M&E STRUCTURE, QUARTERLY REVIEW MECHANISM AND RESULT BASED 38

42. FRAMEWORK........................................................................................................................ 38

43. M&E STRUCTURE................................................................................................................. 38

44. QUARTERLY REVIEW MECHANISM....................................................................................38

45. RESULT FRAMEWORK.........................................................................................................39

46. SECTION 8: DETAILED COST ESTIMATES OF DISTRICT HEALTH PLAN........................51

47. COSTING OF OUTCOMES & OUTPUTS..............................................................................51

48. ANNEXURES - ANNEXURE I................................................................................................65

49. ANNEXURE II......................................................................................................................... 66

50. ANNEXURE III........................................................................................................................ 67

51. ANNEXURE IV....................................................................................................................... 68

52. MONITORING & REPORTING MATRIX................................................................................68

LIST OF TABLES

1. TABLE 1: DISTRICT HEALTH OFFICE, NOWSHERA.............................................................1

2. TABLE 2: SOURCE: *MICS 2007-08, PDHS 2012-13; (INDICATORS NOT SHOWN IN DISTRICT ARE NOT CALCULATED BY MICS/PDHS 2012-13...............................................3

3. TABLE 3: SOURCE DISTRICT HEALTH DEPARTEMENT NOWSHERA..............................11

4. TABLE 4: SOURCE DISTRICT HEALTH DEPARTEMENT NOWSHERA.....Error! Bookmark not defined.

5. TABLE 5: DISTRICT DHIS REPORT 2014.............................................................................10

6. TABLE 6: SOURCE PROVINCIAL MNCHP-2014.....................Error! Bookmark not defined.

7. TABLE 7: SOURCE PROVINCIAL MNCHP-2014.....................Error! Bookmark not defined.

8. TABLE 8: SOURCE DISTRICT HEALTH DEPARTEMENT NOWSHERA-2014...............Error! Bookmark not defined.

9. TABLE 9: BURDEN OF VECTOR BORNE DISEASES IN NOWSHERA, IVCMP KP..............9

10. TABLE 10: SHARE OF DISTRICT NOWSHERA HEALTH BUDGET IN TOTAL DISTRICTS HEALTH BUDGET OUTLAY..................................................................................................12

11. TABLE 11: ADDITIONAL HUMAN RESOURCE & INFRASTRUCTURE REQUIREMENT FIR IMPLEMENTATION OF MHSDP............................................................................................24

LIST OF FIGURES

1. FIGURE 1: MAP OF DISTRICT NOWSHERA..........................................................................1

iv


2. FIGURE 2: DISEASE PATTERN IN DISTRICT NOWSHERA PRIORITY DISEASE – SOURCE DHIS -2014...............................................................................................................4

3. FIGURE 3: THE PHC LEVEL MANAGED CASES OF DIFFERENT DISEASES IN DISTRICT NOWSHERA DURING 2014 (SOURCE DHIS REPORT 2014) Error! Bookmark not defined.

4. FIGURE 4: EPI COVERAGE, SOURCE DHIS -2014.............................................................10

5. FIGURE 5: DISTRICT DHIS REPORT 2014..........................................................................11

6. FIGURE 6: SOURCE TBCP KP................................................................................................9

7. FIGURE 7: MICS 2007-8 (DISTRICT) AND PDHS 2012-13 (PROVINCIAL).........................16

8. FIGURE 8: HR GAPS FOR ROLLING OUT MHSDP................Error! Bookmark not defined.

9. FIGURE 9: PROPOSED STRUCTURE IN INTEGRTAED PC-1............................................24

v


LIST OF ACRONYMS

ADP Annual Development Programme

CDS Comprehensive Development StrategyDFID Department for International DevelopmentDHIS District Health Information SystemDoH Department of HealthFD Finance DepartmentGDP Gross Domestic ProductHSRU Health Sector Reforms UnitHSS Health Sector StrategyIDS Integrated Development StrategyM&E Monitoring & EvaluationMTBF Medium Term Budgetary FrameworkMTDF Medium Term Development FrameworkNFC National Finance Commission (NFC)NGO Non-Government OrganizationMHSDP Minimum Health Service Delivery PackageKP Khyber PakhtunkhwaUC Union CouncilMNA Member National AssemblyOP Operational Plan Khyber PakhtunkhwaDHP District Health PlanDHO District Health OfficerKPI Key Performance IndicatorPHC Primary HealthcareDGHS Director General Health ServicesQM Quality ManagementPPHI Peoples Primary Healthcare ImitativeBHU Basic Health UnitRHC Rural Health CentreTHQ Tehsil HeadquarterDHQ District HeadquarterCD Civil DispensaryMCH Mother & Child HealthIMR Infant Mortality RateMMR Maternal Mortality RateCPR Contraceptive Prevalence RateSBA Skilled Birth AttendantLHW Lady Health WorkerLHV Lady Health VisitorLHS Lady Health SupervisorCMW Community MidwifeMNCH Maternal, Newborn and Child HealthMP Malarial ParasitePSDP Public Sector Development ProgrammesEmONC Emergency Obstetric & Newborn CarePPP Public - Private PartnershipTFR Total Fertility RateANC Antenatal CarePDWP Provincial Development Working PartyDDWP Departmental Development Working PartyFY Financial YearBE Budget EstimatesAE Actual Expenditures

vi


SECTION 1: DISTRICT PROFILE

Nowshera is considered to be one of the most historical place and is also one of the largest cities of the province and lies on the Grand Trunk Road, 27 miles due east of Peshawar. It has great significance due to its strategic positioning in the province of Khyber Pakhtunkhwa as it is situated to the west of Peshawar, to the east of Swabi and Northwest Charsadda and Mardan. Thus, Nowshera is the centrally located region of the province. The name of the district is locally known as “Naw” “khaar”. The total area of the district is 1,748 km². The population density is 608 persons per square kilometer. Total agricultural area is 52,540 hectors. The main source of income of the region is agriculture. Until 1988 Nowshera was a tehsil (sub division) of Peshawar; in 1988 it became a district.Generally, winters are cold from November to February and summers are hot from June to August.

Area 1,748 km²Population 1,305,660Number of Tehsils 5

Number of Union Councils (UCs) 47TABLE 1: DISTRICT HEALTH OFFICE, NOWSHERA

Nowshera city is notable for its colonial era cantonment, which is located at 33°59'48N 72°0'47E and is home to the Pakistan Army School of Artillery, School of ASC, ASC centre, Armour centre, Armed Forces Medical Stores Depot and School of Armour. The area is the home of many Pakhtuns tribes, including the Babars, Yousafzais, Muhammadzais, Parachas, Awankhel, Kaka Khels, Mankikhel and Khattak.

FIGURE 1: MAP OF DISTRICT NOWSHERA

Historically locals use to speak Jandali (Hindko) dialect of Punjabi which is spoken in areas of Nowshera Kalan, Akora Khattak, Shaidu, Jehangira and several other villages situated along the Grand Trunk Road. After demographic changes in recent decades due to Afghan Refugees and Tribal people’s arrival, Pashto language speakers are in majority today. Urdu being National language is also spoken and understood. The major tribes in the district include the Khattak, especially their sub-tribe Akora Khattak, Babar, Kakakhel. The Kakakhels are a prominent Syed clan of Khyber Pakhtunkhwa.

1


Khattaks are the largest tribe in District Nowshera with approximately 65%-70% of total district population. Nizampur area, Khairabad, AkorraKhattak, MeraAkorra, Misribanda, Jehangira, MerraJehangira, Shaidu, Wattar, Surya Khel, Cherat area, Manki Sharif, and all surrounding areas of these villages are dominated by Khattak tribe.

Nowshera is home to big industries, such as Paper International Ltd (previously known as Adam jee paper and board mill) Amman Garh, Nizampur Cement Company (AWT), Fauji Corn Complex at Jehangira, Nowshera Sheet Glass Industries at Adamzai, Pakistan Tobacco Company at Akora Khattak, Associated Industries Ltd. at Amman Garh, Ferozsons pharmaceutical at Amman Garh, Locomotive factory at Risalpur, and Special Export Processing Zone at Risalpur. Similarly, a number of various industrial units situated at Pabbi, Risalpur, Amman Garh, Akora Khattak, Jehangira and Cherat areas are also making progress from industrial point of view.

Nowshera has an overall literacy rate of 79 percent and with female literacy at a lower level of 481 percent. In Nowshera poverty is a major concern like rest of Khyber Pakhtunkhwa where 27.982percent of the population is living below the poverty line; and ranked 28th among the cities of the country. The poverty level is relatively better since the city has an industrial base. Only 33.93 percent of the households have tap water leading to a high prevalence of water borne diseases.

The law and order situation in the district is better than rest of the province, in addition to natural disasters like floods from time to time has adversely affected health facilities especially during 2010 and 2011. The facilities were damages along with the equipment and require strengthening of routine services at the district level with additional resources to respond effectively to emergencies and disasters both natural and manmade.

1 District Education Profile 2011-12, National Education Management Systems, Academy of Educational Planning and Management, Ministry of Education, Trainings and Standards in Higher Education, Govt. of Pakistan. www.aepam.edu.pk2http://www.spdc.org.pk/pubs/rr/rr70.pdf3 Important District-Wise Socio Economic Indicators of Khyber Pakhtunkhwa2014, Bureau of Statistics, Planning and Development Department-www.kpbos.gov.pk

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SECTION 2: CURRENT SITUATION

KEY HEALTH INDICATORS

In Khyber Pakhtunkhwa, as in other parts of the country, health indicators are poor showing low impact of health outcomes. Women and children are particularly disadvantaged by socioeconomic and cultural barriers with estimates of only 30% of women and children having access to medical care4. The total fertility rate is high (3.9) and the CPR (19.5)5 is not rising fast enough to achieve MDG goals. The situation is further compounded by high maternal (275/100,000) and infant mortality rates (58)6 and insufficient access to quality

Key Indicators Nowshera Khyber PakhtunkhwaMaternal Maternity Ratio (MMR) - 275/100,000Infant Mortality Rate (IMR) - 58/1000Under 5 Mortality Rate (U5MR) - 70/1000Fully Immunised Children* 87% 52.7/1000Contraceptive Prevalence Rate (CPR)* 20.6% 28%Antenatal Coverage (ANC)* 65.2% 60.5%Skilled Birth Attendants (SBA)* 55.5% 48.3%Institutional Deliveries* 53.1% 40.5TT2 coverage among pregnant women 71 % 65 %Fertility Rate (TFR) 2.9 births per women 3.9 Birth per Women

TABLE 2: SOURCE: *MICS 2007-08, PDHS 2012-13; (INDICATORS NOT SHOWN IN DISTRICT ARE NOT CALCULATED BY MICS/PDHS 2012-13

District Nowshera is performing better than provincial average on most of the health indicators. The coverage of fully immunized children is very high at 87 percent (provincial 52.7); ANC coverage is way better (65.2) compared to provincial average of 60.5percent, Skilled Birth Attended (SBA) deliveries is high at 55.5 percent as compared to provincial 48.3%,while the institutional deliveries are better at 53.1 percent in comparison to provincial average 40.5. The population growth rate at 2.9 is better than provincial average of 3.9 births per women. The overall scenario of health in the district needs major improvements especially in the area of maternal and child health outcomes.

DISEASE PATTERN

The burden of disease in the district shows predominance (33%) of cases due to Acute Respiratory Infections, followed by Diarrhoea/Dysentery in children under five and more than five years of age (18%) , skin diseases (7%), UTI, fever, dental carries at (5%) respectively and Hypertension at4%. The data below from the 2014 DHIS reveals the pattern of diseases in district Nowshera:

4http://www.ayubmed.edu.pk/JAMC/PAST/20-4/Moazzam.pdf5 PDHS 2012-13

6

3


33%

18%7%

5%

5%

5%

4%

3%3%

3%3%

2%2%

2%

6%

OPD-Disease PatternARI(upper) - Diarrhoea/Dysentery - Skin diseases - Urinary Tract Infections - Fever other causes - Dental Caries - Hypertension - Diabetes Mellitus - Pneumonia - Road traffic accidents - Suspected Malaria - Worm infestation - Peptic Ulcer Diseases - Depression - Other

FIGURE 2: DISEASE PATTERN IN DISTRICT NOWSHERA PRIORITY DISEASE – SOURCE DHIS -2014

OUTREACH SERVICES

The outreach services at the district level are provided by three categories of outreach workers which include Lady Health Workers (LHWs) supervised by Lady Health Supervisors (LHS), Community Midwives (CMWs) and Vaccinators. There are a total of 758 LHWs recruited and deployed in the district. However, under the PRISM Model envisaged under the Integrated PC-1, the LHS will be responsible for administrative supervision of both LHWs and CMWs. With the available LHWs, the LHWs service coverage stands at 70 percent. In addition a total of 74 CMWs were also recruited and trained for providing midwifery services at the community level. All 74 have been deployed meaning coverage of all 47 UCs, with many UCs having more than one skilled birth attendants. Minimum requirement is one CMW for each Union Council (UC). However, with the current population size, in order to ensure full coverage additional 108 CMWs are required. The current status of the outreach workers along with the number envisaged under the integrated PC-1 and the gaps in the district are given in the table below:

PROGRAMME DATA 2014 INTEGRATED PC-1

PH

C W

ork

er

Pop

ulat

ion

Wor

king

/D

epl

oye

d

Pop

ulat

ion

Co

vere

d

Co

vera

ge

Ave

rage

P

op/L

HW

IPC

-1 T

arge

t

Un

cove

red

Pop

ulat

ion

Ga

p

LHW 1,305,660 758 920,212 70% 1,214 1,044,528 124,316 102

CMW 74 108 34

LHS 34 34 0

Vaccinators 52 52

TABLE 3: SOURCE KP BUREAU OF STATISTICS AND DISTRICT DATA-2014

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The LHWs are managed by the District LHW Coordinator; under the programme a total of 758 LHWs positions are allocated for Nowshera and all stand filled. The currently working LHWs provide 70 percent population coverage, however to improve the coverage to 80 percent, as envisaged in the Integrated PC-1, additional 102 LHWs need to be recruited to improve coverage. The 34 LHSs are responsible for monitoring 758 LHWs. Thus, presently each LHS is supervising on an average 22.29 LHWs. As per standard one LHS is responsible for 25 LHWs thus there is no current gap of LHS with 70 percent coverage. However with coverage increased to 70 percent the LHS gap would still be 0.

The LHW Programme was among the three major programmes (the other two being MNCHP and EPI) integrated under the Department of Health’s recent initiative to strengthen the district health services.

Since devolution the supply of medicines and supplies to LHWs has been erratic. However, the department took a number of steps to ensure continuity of supplies to LHWs, but the situation continued to be problematic. Further, under the integrated PC-1 ample allocation has been made for procurement of necessary medicines and supplies on regular basis. In addition, provision of contraceptives other than oral such as injections and skin patch etc. has been included.

Moreover, MNCH Programme previously being vertically implemented is now integrated under the DOH integration initiative. The current requirement of CMWs as per the working LHWs is 95 whereas only 74 CMWs are deployed having a gap of 21. The programme needs to recruit and induct additional 34 CMWs for full operationalization of the PRISM model under the Integrated PC-1 with coverage of 80 percent. According to MNCH programme and DHIS-2014 data a total of 46,970 pregnancies were registered against which 8,582 women were delivered with no reported maternal death; 39 neonatal deaths were reported. The selected data from the year 2012 to 2014 report from the DHIS is given below;

Yea

r

Exp

ecte

d

Pre

gn

anci

es (

3.4%

)

Exp

ecte

d B

irth

s (2

.9%

)

Pre

gn

ant

Wo

men

re

gis

tere

d (

AN

C1

)

An

ten

ata

l car

e R

evi

sit(

s) (

AN

C-

Re

visi

t)

Pre

gn

ant

Wo

men

re

gis

tere

d (

AN

C-1

) R

ece

ived

TT

-2

Vac

cin

e

TT

-2 c

ove

rag

e

De

liver

ies

C

on

du

cted

at

H

eal

th F

acili

ties

PN

C-1

of

exp

ect

ed

b

irth

s

Ne

on

atal

De

ath

in

th

e F

acili

ty

2014 46970 40063 30130 21452 15670 39% 8582 25527 39

2013 43520 37120 12011 9591 9788 26% 3157 4712 11

2012 43520 37120 12905 10759 11579 31% 3461 3330 53

TABLE 4: SOURCE PROVINCIAL DHIS-2012, 2013 AND 2014

The immunization coverage in the district is high at 87 percent through long and concerted efforts in the district. The scarcity of vaccinators to perform outreach services has been addressed by training the LHWs in injection practices, who are addressing the issue by providing services to missed and default cases. The efforts are further supported through the DFID support District Conditional Grant (DCG) initiative which further provide support by placement of female health providers and vaccinators supplemented by provision of needed supplies and equipment of maternal health and immunization.

5


37864

2078915670

Nowshera

FIGURE 3: EPI COVERAGE, SOURCE DHIS -2014

However, with commitment and additional support over the past few years through the DCG grants, the percentage of fully Immunised children 0-23 months in the district has risen substantially i.e. 87 percent, way better than the provincial average of 52.7 percent. The TT2 coverage of CBA reporting live births is only 39 percent way below the provincial average of 57 percent7.In order to meet the targets set under the HSS, a lot of effort need to be put for improving immunization coverage for both children 0-23 months and also women of child bearing age to meet the MDG targets. The district needs to mobilize all available resources both human and in kind through concerted efforts for improving EPI service delivery especially in the hard to reach rural areas through outreach services.

DistrictTarget

population

Children <12 months 3rd dose of Pentavalent

Children <12 months

received 1st dose of

Measles

Children <12 months

fully immunized

Pregnant women

received TT2TT2

coverage

Total 1,305,660 26718 23505 20789 15670 39%

TABLE 5: DISTRICT DHIS REPORT 2014

As per the integrated PC-1, with the induction of additional LHWs, the coverage will be increased to 80 percent; however, in order to improve coverage to 100 percent for immunization, 52 vaccinators will be required in LHWs uncovered areas. These steps are expected to increase the routine immunization coverage to more than 90 percent.

Additionally, it is also envisaged as per the cMYP (Comprehensive Multi Year Plan) for Immunization that these workers will also be involved in the special Polio and measles campaigns currently in practice to eradicate these diseases.

PRIMARY HEALTHCARE

In the district Primary Health Care level services are provided through a network of health facilities which includes RHC, MCH centres, CDs, BHUs and Sub-Health Centres. The remaining higher level facilities are being used for referral services such as Civil, THQ and

7 PDHS 2012-13

6


Teaching Hospitals. The details of the health facilities in the district are given in the table below;

Teaching DHQ/Teaching THQ/Civil Hospital

RHCs BHUs CDs MCH Centres

Total

01 01 05 05 38 10 03 63

TABLE 6: SOURCE DISTRICT HEALTH DEPARTMENT NOWSHERA -2015

There are a total of 63 health facilities in the public sector in the district, which include a teaching hospital providing specialized care and one District Headquarter Hospital, 5 Civil Hospitals all serve as referral facilities. There are 5 RHCs in the district having 90% staff in place, while 38 BHUs are providing both preventive and curative services. In addition to above, maternal and child health services are provided through 3 MCH centres and general outpatient services from 10 CDs with an average of 61.61 patients /clients / facility per day.

HUMAN RESOURCE

There are a total of 1643 positions in various categories (details given in table 4) at the primary health care facility level. However, against all the sanctioned posts, currently only 254 positions being lying vacant. The vacancies are against the positions of doctors, senior and junior clinical and PHC technicians and others. This situation is liable to have adverse implications for service delivery in the district. The details of category wise vacant positions against sanctioned posts are given in table below:

Positions Sanctioned Filled VacantDoctors 107 47 60Senior and Junior Clinical Technicians

233 142 91

Junior PHC Technician (MCH) 37 25 12Nurses 34 34 0Vaccinators/DFS 90 90 0LHSs 34 34 0LHWs 758 758 0CMWs 74 74 0Other staff 276 185 91Total 1643 1389 254

TABLE 7: SOURCE DISTRICT HEALTH DEPARTMENT NOWSHERA

UTILISATION OF SERVICES

During the year 2014, a total of patients 1,393,953 visited the Outpatient Departments (OPD) of the Primary Health Facilities i.e. CDs, MCH Centre, BHUs, RHCs and DHQ Hospital. It is interesting to see that both males and females access the PHC facilities in equal manner, a trend which is different than rest of the other districts. The primary health facility utilization data from the last three years is given in the figure below;

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Male Female Total

3904

75 5943

29

9848

04

1591

97 2997

66 4589

63

1593

27 2963

05 4556

32

PHC LEVEL: OPD Workload

FIGURE 4: THE PHC LEVEL OPD ATTENDENCE AT PHC FACILITIES IN DISTRICT NOWSHERA DURING 2014 (SOURCE DHIS REPORT 2014)

Among those visiting, the key presenting complaints included Respiratory Infections, Pneumonia, Suspected TB, Chronic Obstructive Pulmonary Diseases and Diarrhoea etc. Among those accessing various PHC facilities, 984,804 patients were diagnosed, treated or referred for various diseases.

ARI(upper)

-

Diarrhoea/D

ysentery

-

Skin dise

ases -

Urinary

Tract Infecti

ons -

Fever o

ther cause

s -

Dental Carie

s -

Hyperte

nsion -

Diabetes Mellit

us -

Pneumonia -

Road traffic a

ccidents

-

Suspecte

d Malaria

-

Worm

infesta

tion -

Peptic Ulce

r Dise

ases -

Depression -

Other

37

%

16

%

7%

4% 5%

4%

4%

3%

3%

1% 3

%

2%

2%

1%

7%

OPD Disease pattern

FIGURE 5: DISEASE PATTERN IN DISTRICT NOWSHERA– SOURCE DHIS-2014

In addition, services are also provided through vertical programmes including Malaria, TB, and Hepatitis. Most of these preventive programmes, with the exception of HIV/AIDS, have historically been funded federally and implemented provincially. However, in the post devolution scenario, these programmes are provincially funded with large number of interventions at the primary level i.e. preventive, diagnostic and treatment.However, in compliance with the HSS, Khyber Pakhtunkhwa took initiative to integrate and consolidate three of the nine vertical programmes and also integrating nutrition and family planning interventions for bringing in economies of scale as a first step and secondly to improve coverage of MNCH, Nutrition and family planning services especially at the PHC level with standardized and quality services. The integrated programmes include LHW

8


Programme, MNCH and EPI. In addition, the province also developed a Minimum Health Services Delivery Package (MHSDP) which includes a comprehensive set of services to be delivered at the primary health care level.

As per the DHIS during 2014 there were 14,271 suspected malaria cases were reported from the district. The district statistics for malaria over the last two years are given in the table below:

Diseases 2013 2014

Cases Cases

Malaria 5286 14271

Cutaneous Leishmaniasis 1138 1195

CCHF 9 5

Total 81,404 74,616

TABLE 8: BURDEN OF VECTOR BORNE DISEASES IN NOWSHERA, IVCMP KP – DHIS 2015

The Malaria Programme has staff deployed at the district level, who is exclusively for malaria related diagnostic activities. However all positions are regular with no project related staff positions under the programme PC-1.

At the district level the programme focuses on both detection and treatment through TB DOTS. All health facilities at the primary and secondary level with exception of sub health centres and civil dispensaries offer sputum microscopy for TB, while advanced diagnostics are offered by category C and D hospitals. In addition, the programme interventions are also supported under the Global Fund to fight AIDS, TB and Malaria. The services under the programme are provided through the district primary health care facilities. There is no staff exclusively designated at the district level for programme implementation.

CNR ALL CNR FOR B+ TSR DF Rate Cat-II Cases

Q4-2013 52 22 99 1 10

Q4-2014 58 24 95 4 19

52

22

99

110 ,2%

58

24

95

419, 3%

Nowshera

FIGURE 6: SOURCE PROVINCIAL TB CONTROL PROGRAMME 2015 - KP

Nowshera data reveals that there were 2056 suspected TB cases reported during 2014 (DHIS report) of which currently 1267 are receiving treatment.

The District has a number of interventions under the hepatitis programmes to address hepatitis which including the Benazir Health Support Programme which is being launched to provide free treatment to poor patients with hepatitis C and a National Programme for the Prevention and Control of hepatitis which was established in 2005. In Khyber Pakhtunkhwa

9


all five distinct types of hepatitis viruses, A-E are prevalent. The current estimated prevalence of hepatitis B is 0.7852 Million and for hepatitis C is 1.1778 million8.

In the district Nowshera 53 percent of the children aged 12-23 months are fully immunized against the 7 EPI diseases. At the District EPI Staff includes one District Coordinator and 69vaccinators. In addition, 9 staff is working as the district field supervisors. The Health Department has also trained 685 LHWs on injection practices at the community level with the objective to meet the outreach staff shortages and enhancing EPI coverage by building and enhancing skills of the available staff in the district.

37864

2078915670

Nowshera

FIGURE 7: EPI COVERAGE, SOURCE DHIS -2014

The percentage of fully Immunised children 12-23 months in the district is quite high at 87%. The TT2 coverage of CBA reporting live births is only 26% (MICS) way below the provincial average of 57%9. The district needs to put more concerted efforts into improving EPI service delivery especially to pregnant women through outreach services.

DistrictTarget

population

Children <12 months 3rd dose of Pentavalent

Children <12 months

received 1st dose of

Measles

Children <12 months

fully immunized

Pregnant women

received TT2TT2

coverage

Total 1,305,660 26718 23505 20789 15670 39%

TABLE 9: DISTRICT DHIS REPORT 2014

While during the year 2014 as per the DHIS reports there were 239 suspected cases of measles and 2 cases of neonatal tetanus reported from the district. In addition there were also 4 cases of Acute Flaccid Paralysis reported at the same time period.

8 Hepatitis Control Programme PC-1

9 PDHS 2012-13

10


Suspected Measles Neonatal Tetanus suspects Acute Flaccid Paralysis

239

2 4

FIGURE 8: DISTRICT DHIS REPORT 2014

SECONDARY HEALTHCARE

HEALTH FACILITIES

At the secondary health care level, the services are being provided through a network of 7 facilities that include 1 DHQ hospital and 5 Civil Hospitals. In addition, there is a Teaching Hospital for providing advanced specialist services defined under the tertiary level of care. The DHQ and Teaching hospitals are under the management of the respective MS, while Civil Hospitals are under the DHO. The details are in table below;

Teaching District Headquarter Hospital

Civil Hospitals Total

01 01 05 07TABLE 10: SOURCE DISTRICT HEALTH DEPARTEMENT NOWSHERA

HUMAN RESOURCE

There is a total of 472 staff available with the secondary care facilities against which only 61 positions are lying vacant. The vacancies are mostly against the positions of specialist doctors and medical officers with eight positions of the nurses vacant too. The situation is depictive of the deficiencies in human resource for managing complications and dealing with emergencies especially MNCH. Positions Sanctioned Filled VacantDHQ HospitalSpecialist Doctors 16 14 2Medical Officers 47 43 4Medical Technicians/Dispensers 56 40 16Nurses 62 54 08Other staff 104 93 11Total 285 244 41Civil Hospitals – 5 Nos.Doctors 37 27 10Medical Technicians/Dispensers 56 47 09Nurse 34 34 0Other staff 60 59 1Total 187 167 20

Source: District Health Office Nowshera

11


HEALTH SERVICES DELIVERY

The secondary care level facilities are responsible for providing management of emergencies and complications. All cases referred from the primary level too are managed at this level. The integrated PC-1 envisages provision of Comprehensive EmONC services at the secondary level along with establishment of Stabilization Centres for management of nutritional complications. However, to provide quality services, it is important that all relevant trained staff is available along with necessary supplies and equipment for ensuring standardized quality services to the people.

FISCAL ANALYSIS

The aggregate health allocations for district Nowshera for FY 2014-15 are Rs. 633 Million against a budget allocation of Rs.154 Million in FY 2008-09 showing a growth of 311% of over FY’s 2008-09 to 2014-15.

Details BE2010-

11

AE2010-

11

BE2011-

12

AE 2011-

12

BE2012-

13

AE2012-

13

BE 2013-

14

AE 2013-

14

BE 2014-

15

AE2014-

15 Health budget GoKP

12,512 11,408 14,304 16,587 20,263 17,102 23,725 15,914 26,393 19,584

Total District Health

4,784 5,281 5,506 6,872 7,048 8,295 8,619 8,882 9,422 10,386

District Health Nowshera

252 268 365 351 450 422 551 471 633 302

Total 17,548 16,957 20,175 23,810 27,761 25,819 32,895 25,267 36,448 30,272

TABLE 11: SHARE OF DISTRICT NOWSHERA HEALTH BUDGET IN TOTAL DISTRICTS HEALTH BUDGET OUTLAY

Under object classification, employee related expenses have been the major component of consolidated health budget for district Nowshera and has shown an overall increase of 358% in FY 2014-15 from FY 2008-09. The allocated budget for the FY 2008-09 in employee related expenses were Rs.128 Million and for the FY 2014-15 were Rs. 588 Million.

Nowshera District Budget (2010-11 to 2014-15)Budget by Object: (Rs. In Millions)Object Object Description B.E

2010-11A.E

2010-11B.E

2011-12A.E

2011-12B.E

2012-13A.E

2012-13B.E

2013-14A.E

2013-14B.E

2014-15

A01 Employee Related Expenses 219.179 216.457 329.816 291.626 414.040 336.298 512.172 388.265 588.997

A03 Operating Expenses 28.049 45.778 31.651 52.725 32.490 69.643 36.609 75.280 42.100

A04 Employees Retirement Benefits - - - - - - - -

A05 Grants, Subsidies & Write Off Loans

1.000 2.000 - 1.200 - 1.500 0.800 -

A06 Transfer Payments - - - - - - - -

A09 Physical Assets 1.090 1.548 1.270 2.429 1.255 2.169 0.016 3.918 0.001

12


A12 Civil Works 0.800 0.800 0.600 0.800 0.650 10.439 0.650 - -

A13 Repair & Maintenance 1.415 1.584 1.495 2.295 1.667 2.137 1.884 2.739 2.166

Total 251.534

268.166

364.832

351.074

450.102

422.185

551.330

471.001

633.265

Budget by Sub Detail Function:

Function

Object Description B.E2010-11

A.E2010-11

B.E2011-12

A.E2011-12

B.E2012-13

A.E2012-13

B.E2013-14

A.E2013-14

B.E2014-15

071102 Drug Control 0.894

0.650

1.680

0.844 1.722

0.975

2.068

1.088

2.378

073101 General Hospital Services 156.631

173.583

259.691

221.538

326.867

266.623

354.190

276.002

407.319

073301 Mother and Child Health 1.407

1.520

2.591

1.787 2.689

8.828

10.616

2.802

12.208

074101 Anti-malaria - - - - - - 8.816

8.776

10.138

074105 EPI (Expanded Program of Immunization)

- - - - - - 27.216

33.861

31.298

074120 Others(other health facilities & prevent

15.596 16.182 15.895 21.014 17.057

24.064

37.685

30.057

43.338

076101 Administration 77.005

76.230

84.975

105.890

101.767

121.696

110.740

118.415

127.351

Total 251.534

268.166

364.832

351.074

450.102

422.185

551.330

471.001

633.265

2008

-09

2008

-09

2009

-10

2009

-10

2010

-11

201

0-11

2011

-12

201

1-12

2012

-13

201

2-13

2013

-14

201

3-14

2014

-15

201

4-15

BE AE BE AE BE AE BE AE BE AE BE AE BE AE

0

100

200

300

400

500

600

700

District Nowshera

YEAR 1

YEAR 2

YEAR 3

YEAR 4

YEAR 5

YEAR 6

YEAR 7

0

200

400

600

800

1,000

1,200

A.EB.E

Under functional classification, of district Nowshera general hospital services consumed over 65% of the consolidated health budget. Other noticeable budget heads under functional classification are Anti Malaria, Mother and Child Health, EPI and Administration.

13


otal health budget allocation for districts is Rs. 10,055 Million for FY 2014-15 registering a growth of 100% (nominal terms) since FY 2010-11. Annual average growth for last 5 years has been around 23%.

Total Health budget for district Nowshera is Rs. 588 Million for FY 2014-15 registering a growth of 358% (nominal terms) since FY 2008-09. Major budget of district budget comprises of salary more than 92% and remaining non salary is 8% which shows in regular budget the main expense is salary and very nominal portion of the budget are spend in non-salary heads.

BE 2008-09

B.E 2009-10

B.E 2010-11

B.E 2011-12

B.E 2012-13

B.E 2013-14

B.E 2014-15

0.000

100.000

200.000

300.000

400.000

500.000

600.000

700.000

Salary Non Salary

ANALYSIS A03927 - PURCHASE OF DRUGS AND MEDICINES

Budget Estimates 2008-09







Current Budget Allocation

5.955 7.420 9.400 9.650 10.700 12.091 13.663

% of Total Budget Nowshera

2% 3% 4% 3% 2% 2% 2%

PER CAPITA ANALYSIS

Analysis of budget and expenditure in suggest that there is an overall increase in health allocation and spending in Nowshera during the analysis period of 2010-14. Total per-capita allocation Fig 6 shows a consistent increase during the analysis period indicating Government priorities shifting towards better health

2010-11 2011-12 2012-13 2013-14 2014-150

100

200

300

400

500

600

Per-Capita AllocationPer-Capita Exp

FIGURE 9 PER CAPITA EXP & ALLOCATION

14


SECTION 3: ISSUES

The District Nowshera is faced with a number of challenges in meeting the targets set under the Health Sector Strategy of the province. The key overarching challenges outlined in the provincial health strategy are also found to be the main challenges in district setup. These are described briefly in the lines below:

In line with the province the household out-of-pocket (OOP) spending remains the main source for financing healthcare. There is minimal social protection and a lack of access to social protection, given a majority of the population is below the poverty line, the cost of healthcare can result in families becoming completely impoverished.

Low level of Women and Children’s Health Status

Women and children are particularly disadvantaged by socioeconomic and cultural barriers with estimates of only 3010 percent of them having access to medical care. The total fertility rate is high but less than provincial 3.9 and the contraceptive prevalence rate (CPR) at 20.611 percent is not rising fast enough to achieve the MDG targets. Owing to high TFR, there is high maternal and infant mortality and available services are insufficient to meet the challenges posed by a fast growing population.

Insufficient Provision of High Quality Public Health Care Services

Staff shortages and non-availability of essential medicines is common across all facilities contributing towards underutilisation of services12. The quality of services provided by public health care providers is variable. There is lack of capacity in planning and implementation at district level to respond to emergencies, epidemics and disasters appropriately. The Minimum Health Service Delivery Package and Primary and Secondary Health quality Standards for Khyber Pakhtunkhwa, approved by the province provide the impetus to bring quality in service delivery. However, the understanding is lacking about quality assurance mechanisms and a comprehensive capacity building effort is needed to improve the situation.

The available staff and skill mix is inadequate13 to meet the quality standards set out in the MHSDP. The capacities are deficient all across i.e. from oversight to service delivery. The absence of management skills is a major hurdle to improve quality of health services available to the population.

In addition, infrastructure has not been at pace with the population growth due to little or no investments in health. The already run down health facilities have inadequate infrastructure as per standards required under the MHSDP.

Further, the supplies and equipment position in the district is not enough to implement the MHSDP. The procurement planning and logistics management capacities are non-existent with the result that many a times the facilities are faced with medicine and supplies stock outs.

There are only a small number of ambulances available, often without drivers and sufficient funds to meet POL and repair requirements. The situation is of serious concern as demand

10 World Bank Economic Review 201411 MICS 2006-0712 Health Facility Assessment 2010 by TRF13 Health Facility Assessment 2010 and MNCH Evaluation 2012 by TRF

15


for emergency services has increased due to increased security risks, bomb blasts resulting in mass casualties, and the increase in road traffic accidents (15,733 road traffic reported by DHIS 2014) while services for rehabilitation are insufficient.

Low Coverage and Access to Health Services

A significant number of people, particularly in remote rural areas have difficulty accessing primary healthcare. Given that when the primary health care system was established in the country14 it detailed that there should be I BHU per Union Council and RHC for 3-4 UCs or population of 100,000 for rural population. According to this formula there should be 12 RHCs and 47 BHUs. There are however only 4 RHCs, 38 BHUs, 3 MCH centres and 10 dispensaries in the District.

As per DHO record, by 2014, there are 758 posts of the LHWs against which all 758 Lady Health Workers (LHWs) are currently working in the district providing 70% coverage against the 80% target of integrated PC-1.By 2014 there were 74 CMWs students trained under the Maternal and Neonatal, Child Health (MNCH) programme, of which all 74 had been deployed to their villages in the district. Keeping in view the limited number of LHWs, CMWs and their placement, implementation of Prism model will be easy to implement in the district.

Weak Referral System

The interventions focusing on women of child bearing age and children under 5 years, which are introduced under integrated PC-1 for nutrition and maternal and child interventions requires strong linkages between the outreach workers, PHC facilities and at secondary level hospitals. However, at present referral system is weak and this failure can be attributed to lack of referral protocols, health worker attitudes, weak organisational and functional linkages between different level of services and ambulance services.

Improving Access for Health Care for Women and Children

The Pakistan Demographic and Health survey (PDHS) of 2007 has established a Maternal Mortality Ratio (MMR) for the province of 275 maternal deaths per 100,000 live births. Most of these deaths are caused by postpartum haemorrhage, puerperal sepsis or due to Eclampsia.

FIGURE 10: MICS 2007-8 (DISTRICT) AND PDHS 2012-13 (PROVINCIAL)

The provincial neonatal mortality rate is 41, infant mortality rate is 58 and under-five mortality rate is 70 per 1000 live births. The attendance of skilled birth attendants (SBAs) at delivery has increased significantly from 28 % in the MICS 2001 to 41% in the MICS 2008.

14 Ministry of Health

16

ANC coverage SBA deliveries Insitutional Delivery CPR TT2 coverage TRF

60.548.3

40.5

19.5

65

3.9

63.955.5 53.3

20.6

71

2.9

Province vs. District Nowshera

Provincial Nowshera


At the district level the key indicators are substantially lower than the provincial average such as ANC coverage is 65.2 compared to provincial figure of 60.5, the SBA attended deliveries are 55.5 higher than the provincial avg. 48.3 and institutional deliveries are 53.3 percent compared to provincial average of 40.5. The CPR of Nowshera is relatively better at 20.6 percent in comparison to 19.5 of the province. The fertility rate of the district is much better at 2.9 than the provincial figure of 3.915.

Major challenge is to expand maternal health services to RHCs, as Emergency Obstetric and Neonatal Care (EmONC) services are available at only 54 percent of hospitals. Nowshera compared to other districts has a better place of female workers in the rural areas and situation evident from better health indicators.

Family Planning or CPR: The CPR for Nowshera was measured at 20.6 percent in the MICS 2008 and is somewhat higher than the provincial 19.5% measured by the same survey seven years previously. The CPR though low, but the total fertility rate at 2.9 is way better than the provincial figure and is indicative of the fact that the people are using some sort of contraception however it is not being fully reported. The situation can be attributed to high literacy rate among the population. However the CPR is not rising fast enough to achieve the national MDG target of 55 percent as only 20 percent of women are using modern methods (sterilisation, pill, IUD, injection, condom).

Reducing the Prevalence of Communicable Diseases

Like rest of the country, the situation of communicable diseases is among important health problems in Nowshera. According to DHIS reports for 2014, the common causes of death and illness are; Acute Respiratory Tract Infections, Pneumonia, Diarrhoeal Diseases, Tuberculosis and Vaccine Preventable Infections. Epidemic prone diseases such as Meningococcal Meningitis, Cholera, Hepatitis and Viral Haemorrhagic Fevers are also prominent health threats

Acute Respiratory Infections and Diarrhoea: Pneumonia remains a leading cause of child mortality accounting for a quarter of all post neonatal deaths with most deaths caused by a failure to seek treatment at a health facility. In Nowshera18467 cases were reported in the PHC health facilities during 2014.Diarrhoea accounted for over 98142 of all children under and greater than 5 years of age in the district.

Polio: Pakistan is one of the four remaining countries, where polio is endemic; there were 306 confirmed cases of Polio in 2014of which more than 90 percent were reported from Khyber Pakhtunkhwa. By March 2015, twenty nine cases had been reported from Nowshera there has been no case of polio reported during 2014.

Other important communicable diseases are Tuberculosis (TB), Hepatitis and Malaria. Nowshera is high prevalence district for Malaria and during 2014,a total of 14,271 suspected cases were reported by DHIS. There were 2,057 suspected TB and 1153 suspected Hepatitis cases reported by DHIS.

Health Sector Coordination

There is weak coordination between different sectors and stakeholders working in the areas related to health and responsible for improving the health status of the population of the

15 MICS 2006-07

17


district. The district lacks the information related to private sector, non-governmental organization and other stakeholders involved in service delivery. There is a dire need to improve coordination among various actors for improvements in health outcomes. Moreover, the coordination within the health sector also leaves much to be desired.

Within the context, challenge is to establish effective coordination and collaborating mechanisms to maximize results and systems that ensure greater transparency and accountability.

No Linkage between Resource Allocation and Disease Burden

Disease burden is not taken into account while allocating resources in budgetary process. Preparation of budget is historical and input based with 10% incremental increase every year. DHP attempts to link resource allocation and disease burden on development side; defining outputs and allocating resources; however, this would be a major challenge to shift on recurrent side.

Lack of Synergies with Private Sector

Presently, there are no formal linkages between public and private sector. PPP Act is enacted which provides opportunities for collaboration between public and private sector, challenge would be to identify areas where PPP proposals can be developed and implemented. There is a need to focus on private sector and development of effective linkages with private sector for proposed intervention such as setting up of Hepatitis Filter Clinics and TB referral for MDR cases is identified as major challenge. Another key challenge in such PPP models is clarifying roles and responsibilities of partners and to develop capacity to manage contract.

Insufficient community involvement

Some formal community involvement mechanism in form of community health committee of LHW program and Community Support Group at Facility level by KPHI exists. Both mechanisms represent community involvement for need identification at community and facility levels. DHP proposes establishment of management committee at facility level headed by a community member involving community in decision making processes. Health plans will be developed at facility and union council level and these plans will feed into DHP. In this context, making community health committees functional (majority are not functional) and establishing PCMCs and building capacity of these committees for desired roles/responsibilities is an uphill task. Apart from community involvement at community and facility levels mechanism to involve community in decision making processes at district level needs to be developed.

Risk of Blood Borne Diseases

There is the increased risk of blood-borne diseases from unsafe blood transfusion practices in public and private health facilities. Lack of mechanisms for regulating ensuring rational use of blood are major contributors to transmission of major infectious disease like HIV, Hepatitis B and C, STIs etc.

Weaknesses in Human Resource Management

The district employs more than1647 employees, with 15.42 percent sanctioned positions lying vacant. Other than an administrative superintendent, there is no designated personnel

18


section in the DHO office, there are lack of HR guidelines, recruitment planning and there is obvious lack of capacity to manage core human resource management functions.

While the working of district health sector is very dependent on the calibre of its staff, there is insufficient planning and budgeting to fill vacancies when they arise. There are no forecasts of the skills required to provide high quality services and to staff new facilities and hospitals. Little attention is given to selection, managing for performance and providing on-going training & skill development. There is no human resource management information system in place despite the fact there are more than 1457 staff working under the DHO. The lack of HR database makes it impossible to track employees and their performance.

However, under the Integrated PC-1, the department envisages to strengthen the district management both through placement of additional qualified and skilled manpower, but also improved performance monitoring by linking it to regular reviews at the provincial level.

Shortage of Staff Prepared to Work in the Peripheral Health Facilities

Although there are adequate numbers of post graduate qualified specialists for government facilities, there is an overall shortage of specialists especially at the district level due to the unwillingness of staff to serve in remote areas, resulting in vacant positions.

Shortage of Nurses and Paramedics available for Public Service Delivery

Like the rest of the province, there are acute shortages of nurses and paramedics in the public sector facilities e.g. there are only 34 sanctioned posts of nurses in the district against 107 positions of doctors. According to International standards the nurse doctor ratio should be 4:1. As per the recommended criteria there are 394 nurses required to provide services, and situation of other categories of health workers too is not much different.

There is no planning and forecasting mechanism in place to calculate the needs of paramedics in the district and then plan accordingly to meet the gaps.

Issues in On-going Skills Training and Professional Development

At present there is no planning and allocation for capacity building of the staff working in the district. The in-service training mechanism was introduced in the 1990’s and was provided through the PHDC and DHDCs is only partially functional. There are no formal policies, national standards or guidelines to ensure that health care providers have up-to-date skills and knowledge. There are also no programmes for continuing medical education and systems of re-accreditation for doctors, nurses and paramedics.

At present, all training activities are conducted either by the vertical programmes or the by UN and International NGOs through various projects. NO training need assessment has ever been conducted to identify the skill gaps and neither a training plan prepared which addresses the district gaps. Most trainings conducted are adhoc and without any linkages with the ground realities. Also there is no mechanism to gauge the quality of trainings and its effects on the service delivery.

There is specially lack of professional training and development opportunities for medical and paramedic staff in peripheral areas and a lack of training for the provision of medical care at the primary health care level. Unclear Roles and Responsibilities

Management of health services is divided amongst DHO, MS and KPPHI with ambiguities in reporting mechanisms. BHUs are managed by DSM of KPHI whereas other Primary Care

19


Facilities e.g. MCH centres, CDs and RHCs are under administrative control of DHO. In secondary care facilities civil hospital and Tehsil Head Quarter Hospital, and category C and D are managed by DHO, whereas DHQ is responsibility of Medical Superintendent of the Headquarter hospitals. DSM reports to PPHI and is accountable for its performance to KPHI provincial office and MS is accountable to DGHS; under local government Act, MS will continue to report to DGHS office instead of DHO.

With so many different channels of hierarchy and with no sharing of information between various entities at the district level, it is imperative that the coordination linked with improved service delivery outcomes cannot be guaranteed.

Inadequate Management Capacity

DHO has inadequate management staff to carry out management function effectively i.e. there are no qualified persons to conduct financial and procurement management functions. In addition, there has been no mid-level management trainings for staffs at various levels impacting quality of service delivery. Most staffs in absence of an organized in-service training programme lack the necessary updated skills required to improve quality and continuum of care. The key skills lacking at the district management level include areas particularly health management, change and result based management, financial management, information systems and procurement and logistics.

Lack of Results Based Decision Making

There is a dearth of management related information at district level. Information collected is not being used sufficiently to inform decision making, leading to a reduced incentive to improve data quality. The information even when collected is hardly ever analysed by either the district or the DoH to inform policy and planning. There is a District Health Information System (DHIS) that has been developed and rolled out to the PHC and secondary levels, however information collected is not quality assured as per standards and accords low accountability for performance and duty of care (within the district, to the DoH and to the people).

Poor Health Management

Performance management is annual, confidential and used for promotion purposes, in addition, the results are not shared with staff or used for setting targets or improving skills. Capacity to effective health management is compromised by weak Monitoring and Evaluation systems in districts.

Inadequate Financial Accountability and Internal Controls

There is absence of a comprehensive performance evaluation system in place both at the provincial and district level. The system in place is very subjective and not linked to a reward mechanism. There is lack of incentives for professionals to improve the quality of their work. The Performance review is annual using a document known as ACR (annual confidential report), confidential and used for promotion purposes only. In addition, the results are not shared with staff or used for setting targets and timelines for improving skills and performance. Capacity to effective health management is compromised by weak Monitoring and Evaluation systems in districts.

Compliance to Notified Standard by HCC

20


Health Care Commission which has replaced HRA has been mandated to regulate both public and private sector. Public sector health faculties will be required to meet standards notified by the HCC and putting in quality assurance mechanism for complying with standards will be difficult challenge ahead for district.

However, in the absence of a mechanism for orientation of district facility level staff on quality standards, availability of protocols at all levels and absence of a quality monitoring system, it is not surprising that compliance to notified standards is almost non-existent.

Inadequate Drug Control

In district there is only one sanctioned position of drug inspector who is responsible for implementation of Drug Act at the district level and number need to be increased for better drug control.

Inter-Sectoral Coordination

The lack of collaboration among the relevant departments (Health, Food, Agriculture, Public Health Engineering Department and Local Government) has resulted in implementation lacunae. The area of Water and Sanitation is also neglected by the health sector. No elaborate policies and strategies prevail to address and implement the standards for drinking water. Challenge is to put in place inter-sectoral coordination and collaboration mechanisms for ensuring compliance to notified minimum standards.

SECTION 4: ROLLING OUT MHSDP

21


The Department of Health developed and approved a Minimum Health Service Delivery package (MHSDP) for the Primary Health Care level to standardize services and to ensure quality of services. The MHSDP is being rolled out at the district level through operationalization of Integrated PC-1. The MHSDP sets out certain infrastructure and human resource requirements to implement the services at the PHC level. However, the current status of health services as highlighted in the section on situation analysis clearly identify the gaps starting from infrastructure, supplies and equipment, human resources and staff skills to name a few.

The roll out of health sector strategy of Khyber Pakhtunkhwa and achievement of desired outcomes in envisaged through a number of initiatives aimed at increasing health services coverage such as implementation of MHSDP and roll out of integrated PC-1. The investments in the infrastructure at the primary health care level have been far and few over the years. However, if the department is to improve service delivery to the population, substantial improvements and renovations will need to be carried out at the facility level as per the standards set out in the MHSDP.

INFRASTRUCTURE

The operationalization of MHSDP lays out certain infrastructure and workforce requirements that are mandatory for providing the desired set of services envisaged in the package. The assessment of the facilities in the DI Khan District revealed a number of gaps against the standards defined in the package ranging from lack of boundary wall to nonexistence of waiting area.

In addition, the current human resource and available skill mix too is insufficient against the set standards. The district HR review revealed that there are critical positions that are required for delivery of services in addition to the infrastructure requirements. The details of the infrastructure and human resource gaps with cost implications are given below.

SR. NO

MHSDP Infrastructural STANDARDS Infrastructural Gaps In total Number of Facilities as per defined MHSDP StandardsRHC BHU THQ CD Total Cost

Budget PKR Millions

1 Pit for disposal 7 - 1 2 0.122 Waiting area is present - 19 - - 5.03- Space for waiting area is sufficient - 3 - - 3.08- Adequate seating space - 3 - - 0.68- Posters imparting health education 7 3 - - 0.12- Booklets / leaflets in waiting Area 7 3 1 2 0.11- Cleanliness is ensured - 3 - - 0.123 Record room exists - - - - 7.374 Drug dispensing room is present - - - - 1.235 Toilets are present - - - - -- Toilets are functional - 1 - - 0.08- Toilets are separate for staff and patients 7 21 - 2 7.00- Toilets are separate for male and female 7 21 - 2 7.006 Complaint/suggestion box placed 7 - - 2 0.127 Safe water supply is present - - - - 0.168 Water storage facility is present - - - - 0.169 Examination rooms for Pharmacy Technician exists - - - - 7.3710 Examination rooms for LHV exists - - - - 1.2311 Examinations are separated by curtains to maintain privacy - - - - 0.3612 Dressing Room/Injection Room/Vaccination Room is present - - - - 4.91

22


13 Dressing Room/Injection Room/Vaccination Room with all the emergency drugs, instruments and vaccines

- - - - 1.80

14 Adequate storage area is available - - - - 0.8815 Storage area is pests free 7 - 1 2 0.1216 5 male beds and 5 female beds are present - - - - 1.6017 Cooking arrangement is available for patients 7 - 1 2 0.1218 Operation theatre is present (minor OT) - - - - 8.00- Changing room - - - - 13.20- Sterilization area 7 - - - 0.12- Operating area - - - - 4.00- Washing area ( a sink and Tap water available) 7 - - - 0.2419 OT is equipped with equipment (partially) - - - - 0.4020 Labour Room is available - - - - 12.00- Toilets are attached - - - - 7.50- Drinking water facility is present 7 - - 2 0.10- Place available for new born care - - - - 3.0021 Laboratory is present - - - - 0.64- Separate area for collection and screening - - - - 0.50- Sufficient space is available - - - - 0.8022 General Store is present - - - - -23 Dispensing cum store area is present - - - - 0.5024 Vaccine storage and immunization area - - - - 0.1025 BCC and family planning counsel area 7 - - - 0.6026 Office room is present 7 30 - - 8.0027 Utility room for dirty linen and used items 7 30 - - 12.0028 Laundry 7 - - - 12.0029 Decent Residential Accommodation present for - 22 - - -- Medical officer - 22 - - 12.00- Paramedical staff - 21 - - 10.80- Support staff - - - - 12.0030 Electricity without generator - - - - 1.50- POL back-up 6 30 - - 6.00- Solar system is installed - 30 1 2 42.0031 Telephone - - - - 0.0432 Garden is available - 2 - - 0.60

HUMAN RESOURCE

The Department of Health developed and approved a Minimum Health Service Delivery (MHSDP) for the primary health care level to standardize services and to ensure quality of services. The MHSDP is being rolled out at the district level through operationalization of Integrated PC-1. The MHSDP sets out certain infrastructure and human resource requirements to implement the services at the PHC level. The currently available staff positions, not completely filled, are insufficient to meet either the standards or the needs of the facilities. Following graph shows the human resource requirements needed at the three levels i.e. RHC, BHU to fully implement the package at the PHC level (details in Annexure I and II).

Facility Type Health Facilities to be Rolled out on MHSDP in three years

MHSDP Proposed Positions in Selected Facilities

Current Sanctioned Positions in Selected Facilities

Human Resource Gap to be filled out in Selected facilities

Rural Health Care 4 144 64 72Basic Health Unit 15 165 105 45Civil Dispensaries 10 50 40 10

23


COSTING OF THE HR & INFRASTRUCTURE FOR ROLLING MHSDP IN 50% OF PHC FACILITIES

The current available resources do not cover the estimated costs for meeting MHSDP requirements. This means that the government will have to increase the resource base to fund the GAP and the district will prioritize the activities in a phased approach to cover and fill in these gaps over the period of the DHP.

DISTRICTS HUMAN RESOURCE Phase out of HR Costing in three

years

Phase out of Infrastructure

Costing in three years

TOTAL

NOWSHERA

RURAL HEALTH CARE

BASIC HEALTH UNITS

Year I

Year II

Year III

Year I

Year II

Year III

27.44 13.26 11.98 19.91 8.81 44.83 75.73 50.25 211.52

TABLE 12: ADDITIONAL HUMAN RESOURCE & INFRASTRUCTURE REQUIREMENT FIR IMPLEMENTATION OF MHSDP

ADDITIONAL MANAGEMENT POSITIONS

The integrated PC-1 which operationalizes MHSDP defines the following structure for rolling out the MHSDP. The management structure takes an integrated approach and synergises the four integrated programmes to deliver at the optimum.

SECTION 5: OUTCOMES & OUTPUTS

24

District Health Officer (DHO)District Level Planning, Budgeting, HR Management and

Oversight etc. - BPS 19/20

Deputy DHOMgmt Support

Services & Coordination

BPS 18/19

Communication &Health Education

Officer(BPS 17)

Coordinator ISurveillance

and DHISBPS 17

Coordinator IICommunicable &

Non-Communicable

DiseasesBPS 17/18

Coordinator III

Reproductive & Child Health

BPS 17

Coordinator IV

Special Interventions and Nutrition& Emergencies

BPS 17

Coordinator V

Quality Management &

OversightBPS 17

Food & Sanitary Inspector

Drug Inspector

Financial Management and

oversightBPS 17

Assistant logistic officer

FIGURE 11: PROPOSED STRUCTURE IN INTEGRTAED PC-1


PRIORITIZATION OF OUTCOMES

The HSS KP and IDS identifies a number of critical areas for action to improve health status in Khyber Pakhtunkhwa. HSS and IDS were developed through consultative process, and peer reviewed by external experts and Development Partners. The priority areas for health from the HSS and the IDS have been formulated into five health outcomes, budgeted in the MTBF.

These are:

Outcome 1: Enhancing coverage and access to essential health services especially for the poor and vulnerable.

Outcome 2: A measurable reduction in morbidity and morbidity due to common diseases especially among vulnerable segments of the population.

Outcome 3: Improved human resource management. Outcome 4: Improved governance and accountability. Outcome 5: Improved regulation and quality assurance.

PRIORITIZATION OF OUTPUTS

For the purpose of alignment of DHP with HSS & IDS the outcomes are kept the same, however, outputs given in HSS KP under each outcome are prioritized for district through a consultative process. Alignment of DHP with HSS & IDS, rolling out of integrated PC-1 and MHSDP were key considerations of this prioritization process. Relevance of HSS/IDS outputs in district setup was also taken into account. In addition, as per reflection in the provincial MTBF statement 50% of the facilities have been taken for rolling out of MHSDP and Integrated PC-1; this also takes into account the cost implications for the Government in taking forward these initiatives. During this process outputs were;

1. HSS/IDS output is prioritized as district output; however with different set of activities.2. HSS/IDS output is rephrased or adjusted according to district need3. HSS output is not prioritized and new outputs are identified for districts.

Key indicators are targets for each outcome are given in M &E framework.

25


SECTION 6: OPERATIONAL FRAMEWORK

PLANNING STRUCTURE

Through district health planning outcomes and outputs are linked with implementation activities describing timelines and through identified inputs. This provides basis and justification for annual budgetary requests and allocations. This implies that the DHP is not a one-off activity but is repeated annually.

District Health Plan provides a midterm vision for the district with broadly defined objectives, targets, timelines and guidance for implementation. The DHP provides a prioritized list of outcomes and outputs organized in a timeline in the Operational Framework. The targets and the indicators for implementation of the Framework and its monitoring are given in the Result Framework, while the cost implications of the plan are reflected in the Detailed Cost Estimates Sections. The plan proposes an integrated planning and M&E system that can support implementation of DHP proposed in M&E section.

The analysis of the log-frame reveals that majority of activities would require technical inputs in one or the other form. This is an uphill task and implementation would not be possible without a dedicated management structure and well planned technical support.

IMPLEMENTATION STRUCTURE

Implementation structure is critical to ensure the following three essentials in the context of DHP.

Annual Planning: All interventions are clearly defined, prioritized and appropriately sequenced ensuring synergy, complementarity, manageability of envisaged change, implementation capacity and resources availability. This has to be reviewed and adjusted every year depending on implementation pace, resources availability and to accommodate change in strategies. This annual planning has to be aligned with planning process of the district.

Detailed Planning: Necessary information and details including concept note, basic design features, resources requirement would be required for preparation of budget proposals for securing non-development allocations and PC I for development expenditure.

ROLLING PLAN MODEL

Rolling Planning is an established mechanism to implement long and medium term vision through short term implementation plans aligned with the budgetary system of the country. A simpler version of this planning tool that provides prospect of extensive implementation review to develop plan for the next year based on lessons learned during previous year will work in the indicated planning environment. As proposed in the model given with the Operational Framework, the plan for a particular year will contain three lists of projects/ proposals considered necessary for the implementation of DHP indicated below:

List A: Projects/ Proposals where implementation details have been agreed/ approved List B: Projects/ Proposals where implementation details have to be worked/ agreed List C: Projects/ proposals where conceptual development has to be progressed

The authority responsible to coordinate DHP implementation will continue work on all three lists with objective to complete projects/proposals in list A, move projects/ proposals in list C to list B and those in list B to list A in next year’s version of rolling plan. As years advance,

26


the items in lower level list gradually move to upper level depending upon planning level achieved. This process continues till such time the component agreed in strategy is either implemented or deleted from the list due to lowering priority compared to other pressing needs.

27


ROLLING PLAN MODEL

The annual rolling planning tool that provides a flexible planning mechanism is best for DHP implementation. A simpler version of rolling plan is suggested to be adopted that provides prospect of extensive implementation review during a particular year and developing plan for the next year based on lessons learned during past year will work in the indicated planning environment. As proposed in the model given below, the plan for a particular year will contain three lists of projects/ proposals considered necessary for the implementation of DHP indicated as below.

List A: Projects/ Proposals where implementation details have been agreed/ approvedList B: Projects/ Proposals where implementation details have to be worked/ agreedList C: Projects/ proposals where conceptual development has to be processed

DHT responsible to coordinate DHP implementation will continue work on all three lists with objective to complete projects/proposals in list A, move projects/ proposals in list C to list B and those in list B to list A in next year’s version of rolling plan. As years advance, the items in lower level list gradually move to upper level depending upon planning effort. This process continues till such time components agreed in DHP is either implemented or deleted from the list due to dropping priority compared to other pressing needs of the sector.

2014-15Rolling Plan I

2015-16Rolling Plan II

2016-17Rolling Plan III

Completed and removedfrom rolling plan list

List AProjects/ Proposals where implementation details have been agreed/approved


List B Projects/ Proposals where implementation details have to be worked/ agreed List A

Projects/ Proposals where implementation details have been agreed/approved


List CProjects/ proposals where conceptual development has to be progressed

List B Projects/ Proposals where implementation details have to be worked/ agreed

List AProjects/ Proposals whereimplementation detailshave been agreed/approved

List C Projects/ proposals where conceptual development has to be progressed List B

Projects/ Proposals whereimplementation details haveto be worked/ agreed

List CProjects/ proposals where conceptual development has to be progressed

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OPERATIONAL FRAMEWORK

Sr. No Outcomes/Outputs Priority Primary Timeframe Primary Input RemarksActivities Responsibility I II III III+ Status

1. Enhancing Coverage and Access to Essential Health Services especially for Poor and Vulnerable1.1 Implement MHSDP at PHC Level1.1.1 Conduct Orientation Workshop for MHSDP High Province X TA Lack of

understanding on MHSDP

1.1.2 Select Health Facilities for rolling out MHSDP High DHT X Staff Time 50% to be rolled out in three years of the DHP

1.1.3 Baseline assessment of HF to identify gaps against the MHSDP

High DHT X TA -

1.1.4 Based on assessment develop a proposal for filling in gaps

High X Staff-Time Integrated PC-1

1.1.5 Fill in the gaps in HF outlined by the assessment High DHT X Staff time Integrated PC-11.1.6 Prepare SNE for new positions and

infrastructureHigh DHT x Staff -

1.1.7 Training of district and Programme staff on MHSDP

High DHT X Staff time and TA Integrated PC-1 /TA support

1.1.8 Start Implementation of MHSDP High DHT X Staff time selected HF1.2 Improved RMNCH and Nutrition Services at Outreach level1.2.1 Recruit additional LHWs, LHSs CMWs and

Vaccinators (non LHW covered area) given in Integrated PC-1

High DHT X X X X Integrated PC-1

1.2.2 Conduct initial and refresher training of outreach workers

High DHT X X X X Programmes Integrated PC-1

1.2.3 Ensure regular supplies per MHSDP and Integrated PC-1 standard

High DHT/DGHS X X X X Integrated PC-1 /recurrent

1.2.4 Train District trainers (3-4) for Outreach Workers High DHT X X X X District staff1.2.5 Implement PRISM model High DHT X X X TA support Development of

protocols, SOPs trainings and advocacy guidelines

1.2.6 Strengthen existing and Establish Primary Care Management Committees at Facility level

High DHT X X X X Increased community

29


participation and involvement in health action

1.2.7 Operationalize Male and Female health Committees at Community level

Medium DHT X X X X Health committees established under LHW Programme

1.2.8 Regularly conduct facility and outreach sessions with community

Medium DHT X X X X IEC Material & entertainment

-

1.2.9 Recruit Health Education Officer High DHT X Integrated PC-1/recurrent

1.2.10 Dissemination of specific messages on MNCH, Nutrition, Family Planning, IYCF etc.

High Health Education Officer

X X X X IEC Material

1.2.11 Implement the necessary trainings e.g. (IMNCI, IYCF) at all levels

High DHT X X X X staff time and trainers Integrated PC-1

1.3 Improved access to RMNCH and Nutrition services at Facility level1.3.1 Prepare Union Council Health Plans on Result

Based Management techniquesHigh DHT X X X TA support Onwards routine

feature1.3.2 Recruit Planning Officer at the District level High DHT X - Local Government

involves planning at the district level

1.3.3 Train facility In-charge and related staff on developing Union Council Plans

High DHT X TA support Existent Capacity Gap at District

1.3.4 Train MOs on MHSDP assessment tools and planning tools

DHT X TA support Existent Capacity Gap at District

1.4 Increased availability of services as per MHSDP at Facility level1.4.1 Recruit service delivery staff on contract basis at

the Facility level to meet MHSDP requirementsHigh DHT X Staff time Integrated PC-1

1.4.2 Prepare SNE to regularize contract staff High DHT X Staff time1.4.3 Ensure availability of supplies, medicines,

stationary, equipment and printing material at MHSDP selected facilities

High DHT X X X X Staff time Integrated PC-1 and additional on recurrent

1.4.4 Recruit Supply Logistic Officer at the District level

High DHT X Staff time

1.4.5 Capacity building of mid-level staff on Procurement Management processes

High DHT X X X X TA support Existent Capacity Gap at District

1.4.6 Implementation of E-Procurement System developed by the Province

High DHT X X X TA support TRF has already developed the E-Procurement

30


System1.4.7 Ensure one month Buffer Stock at the facility

levelHigh DHT X X X X Staff time -

1.4.8 Select health facility for providing 24/7 services (Basic EmONC)

High DHT X Staff time -

1.4.9 Implementing approved Quality Standards High Coordinator Quality Management

X X X X TA support and Staff time

-

1.4.10 Fill the gaps in selected health facilities High DHT X X X X Staff time Integrated PC-1 and SNE

1.4.11 Implementation of 24/7 services at the selected facilities

High DHT X X X X Staff time -

1.4.12 Deliver Nutritional services as per approved standard National Nutrition Guidelines


1.4.13 Revise LHWs, LHSs and CMWs curriculum and add Community based management of acute and moderate Malnutrition chapter

High Province X TA support -

1.4.14 Train LHWs, LHSs and CMWs Community based management of acute and moderate Malnutrition

High DHT X X X X Training Module Integrated PC-1

1.4.15 Select health facilities for establishing Outpatient Therapeutic Points (OTPs) – for CMAM without complications

High DHT X Staff time Integrated PC-1

1.4.16 Prepare a Plan of Action for Nutritional Screening and Interventions in LHW uncovered areas

High DHT X TA support -

1.4.17 Ensure availability of IFA and Zinc supplements, RUTF, RUSF and other related medicines and supplies


1.4.18 Calculate and communicate district needs to Director Health (Integrated PC-1)

High DHT Place demand to province for procurement and supply

1.4.19 Train Facility relevant staff on Nutrition intervention and services

High DHT X X

1.4.20 Ambulance availability for referrals in selected 24/7 facilities

High DHT X Purchase and M&R cost

Integrated PC-1

1.5 Improve Mortality Surveillance System

31


1.5.1 Develop Birth Registration System at District and Facility level

High DHT X X X X Stationary and training -

1.5.2 Develop Death Registration System at District and Facility level

High DHT X X X X Stationary and training -

1.6 Improve access to maternal and child nutrition intervention at secondary level1.6.1 Establish Stabilisation Centres at the DHQ level

for CMAM with ComplicationsHigh MS DHQ X Staff/Supplies &

EquipmentIntegrated PC-1

1.6.2 Ensure availability of staff as per requirement of Stabilisation Centres

High DHT X Staff time Integrated PC-1

1.6.3 Provide incentives to Stabilisation Centre Staff High DHT X X X X - Integrated PC-11.6.4 Ensure availability of medicines, supplies,

equipment, stationaryHigh DHT X X X X Staff time Integrated PC-1

1.6.5 Train DHQ staff for Nutrition Interventions High MS DHQ X Workshops -1.6.6 Availability of Ambulance specifically for

Stabilisation CentresHigh MS DHQ X X X X Purchase/PPP

arrangement-

1.7 Improve Emergency Response1.7.1 Conduct an assessment of facilities and

equipment for A & E response centresHigh DHT X Staff time -

1.7.2 Develop plan for providing resources and facilities to fill identified gaps


1.7.3 Provide missing equipment required for Accident and Emergency

High DHT X Staff time/PC-1/Recurrent

-

1.7.4 Conduct Trainings Need Assessment for Accident and Emergency response staff

High DHT X TA support/staff time -

1.7.5 Train staff on Standard Operating Procedures for Accident and Emergency services

High DHT X X X Staff time/Workshops Province will provide SOPs

1.7.6 Develop a system for Emergency Preparedness and Response Plan (EPRP) at District level

High DHT X Staff time/TA support -

1.7.7 Establish a budget line for EPRP implementation


1.7.8 Contingency supplies and stocks availability and its replenishment on annual basis


1.7.9 Strengthen DEWS at the District level High DHT X X X X Staff time -1.7.10 Equip BHU for provision of First Aid services Medium DHT X X X X Staff time -1.8 Implement approved quality standards at primary and secondary level1.8.1 Conduct an assessment to identify gaps against

the standards (staff, skills, equipment, supplies and operational budget)

High DHT X Staff time/TA support -

32


1.8.2 Based on the assessment develop a plan/ proposal for filling the gaps


1.8.3 Implement Standards at selected target Health Facilities

High DHT X X Staff time -

1.9 Construction or up gradation of Hospitals / Facilities based on MHSDP1.9.1 Develop guidelines and design for construction

of new health facilities based on the MHSDPHigh CPO X Staff time Provincial Activity

1.9.2 Renovate/refurbish/construct the additional requirements based on MHSDP in selected health facilities

High DHT X X X X Staff time Integrated PC-1

1.9.3 Develop proposal of the number of facilities to be upgraded/renovated/refurbished based on MHSDP


1.10 Strengthen Rehabilitation Services1.10.1 Provide selected rehabilitation services up to

THQ levelHigh DHT X X X X Staff time/Supplies -

1.10.2 Explore the option of engaging the private sector in provision of rehabilitation services

High DHT X X X X Staff time/TA support -

2. A Measurable Reduction in Morbidity & Mortality due to Common Diseases2.1 Prevention from Common Diseases through Promotion, Early Detection and Subsidized Curative Support2.1.1 Ensure timely supplies of Preventive

ProgrammesHigh DHT X X X X Staff time Calculate and place

demand for supplies to preventive programmes

2.1.2 Improve EPI Coverage to meet with the Provincial Targets

High DHT X X X X Filling Vaccinator gaps and mobility

NISP PC-1

2.1.4 Uninterrupted supply of vaccines High DHT X X X X Staff time Calculate and place demand for supplies to preventive programmes

2.1.5 Develop Logistics procurement and distribution plans

High DHT X X X X Staff time NISP PC-1

2.1.6 Replacement of out-dated Cold Chain Equipment including cold rooms and procure new cold chain equipment

High DHT X X X X Procurement and maintenance of cold chain

-

2.1.7 Effective Vaccine Management (EVM) Assessment System


2.1.8 Vaccine Logistic Management Information High DHT X X X X Procurement/Hiring of -

33


System (vLMIS) strengthening and scaling up Staff and Staff time2.1.9 Train staff including LHWs on Behaviour Change

CommunicationHigh DHT X Workshop NISP PC-1

2.1.10 Hold Advocacy Seminars with parliamentarians, religious leaders and other stakeholders


2.1.11 Hold Mother and child health weeks and arrange special immunization days


2.1.12 Improve case detection rate and treatment success rate of TB

High TB Programme staff

X X X X Staff time, supplies and diagnostic facilities

TB Control Programme

2.1.13 Ensure availability of Larvicides/Insecticides & spray equipment at the district

High Malaria staff X X X X Staff time, supplies and diagnostic facilities

Malaria Control Programme

2.1.14 Conduct Health Education Sessions for Vector Control

High Malaria staff X X X X Staff time, supplies and diagnostic facilities

Malaria Control Programme

2.1.15 Establish Infection Control Committee in selected Health Facilities

High Facility In charge X Staff time, supplies Hepatitis Control Programme supported

2.1.16 Conduct District level Seminar on Infection Control at District level

High DHT X X X X Staff time and Workshop

Hepatitis Control Programme

2.1.17 Conduct Seminar on Injection Safety at District Level

High DHT X X X X Staff time and Workshop


2.1.18 Make a list of Healthcare providers /facilities including laboratories for partnership development with Hepatitis Control Programme

High DHT X Staff time Hepatitis Control Programme

2.1.19 Hold one day training workshop for general practitioners for Hepatitis B&C

High DHT X X X X Staff time and Workshops


2.1.20 Identification of Volunteers and GPs for inclusion in Hepatitis Filter Clinics

High DHT X Staff time and workshops


2.1.21 Hold Health Education Sessions for HIV/AIDS at district level

Medium DHT X X X X Staff time and workshops

HIV/AIDS Control Programme

2.2 Strengthening of Disease Surveillance System2.2.1 Conduct Burden of Disease Study Medium DHT X TA support Provincial Activity

with District involvement - TA

34


support2.2.2 Establishment of District Surveillance Response

Unit in line with Provincial setupMedium DHT X - -

2.2.3 Training of staff on Disease Surveillance Medium DHT X X X2.2.4 Implementation of Surveillance Response

SystemMedium DHT X X Staff time -

2.2.5 Recruitment of District Epidemiologist and support staff

Medium DHT X Staff time NISP PC-1

3. Improved Human Resource Management3.1 Strengthen Human Resource Management Function at District level3.1.1 Review current functions and staffing of DHT in

the context of MHSDP and Local GovernmentHigh DHT X Staff time -

3.1.2 Fill identified HR gaps Medium DHT X Staff time Provided/Costed in outcome 1 and 4

3.1.3 Develop District HR management information system (e-system) in line with Provincial

Medium DHT X TA support -

3.1.4 Train relevant staff on HR Management System High DHT X X TA support -3.1.5 Implement HR management information system High DHT X X Staff time -3.1.6 Develop a proposal to introduce incentive

mechanism for health workers for geographic locations and performance

Medium DHT X X Staff time / TA support -

3.1.7 Conduct Training Need Assessment for all categories of staff and prepare Training Plan

Medium DHT X X TA support -

3.1.8 Development of Training Database for district staff

Medium DHT X X TA support -

4. Improved Governance and Accountability4.1 Strengthening of Management Function at district level4.1.1 Improve Planning Capacity at District level for

development of District Health PlanHigh DHT X Staff recruitment Placement of District

Planning Officer4.1.2 Develop district level health plans using Result

based planning and management techniquesHigh DHT X TA support The district requires

support for initial 2-3 yrs.

4.1.3 Hold regular Quarterly district review meeting and district level monthly review meetings

High DHT X X X X Staff time and entertainment cost

-

4.1.4 Recruit Coordinator for Quality Management and Oversight, Financial Management Officer, Nutrition Coordinator

High DHT X Staff recruitment Integrated PC-1

4.1.5 Increased community participation in service High DHT X X X X Staff time and -

35


delivery management and oversight through regular involvement in DHT meetings

entertainment cost

4.1.6 Train DHT staff on Planning, Procurement and Financial Management and Rules & regulations (PPRA etc.)

High DHT X X Training/Staff time Integrated PC-1

4.1.7 Recruit Data Analyst , Computer programmer/IT Officer, Account Supervisor, Procurement and Logistic Officer

High DHT X Recruitment of staff Integrated PC-1

4.2 Improving Results Based Management4.2.1 Strengthening of Financial Systems and

introduction of Internal Audit mechanismsHigh DHT X X X X Staff time Integrated PC-1

4.2.2 Notify and Establish a Sectoral Coordination Committee on the pattern of SDPF (Strategic partnership Development Framework)

High DHT X Staff time and meetings

Integrated PC-1

4.2.3 Introduction of Result Based Financing Mechanism through introducing OBB and MTBF approach

High DHT X Training on OBB -

4.2.4 Coalition and Integration of Programme MIS and DHIS

High DHIS Coordinator X X Staff time and trainings

-

4.2.5 Conduct Health Facility Assessment (HFA) on annual basis that feeds into District Health Plan

High DHT X X X X TA support and staff time

Support required for 2-3 yrs.

4.2.6 Conduct Situation Analysis (SA) on annual basis that feeds into District Health Plan



4.2.7 Develop reporting system on Performance Linked Incentive System and report regularly in Quarterly Reports



4.3 Strengthen M&E Function at District Level4.3.1 Recruitment of Technical staff for monitoring at

all levels of health careHigh DHT X Staff time -

4.3.2 Procurement of supplies, stationary, printing equipment

High DHT X X X X Procurement and staff time

-

4.3.3 Trainings of staff on M & E and research methodology

High DHT X TA support and staff time

-

4.3.4 Online Linkup Performance Based Dashboard System at District level

High DHT X X X TA support and staff time


4.4 Health Financing and Alternate Models of Service Delivery4.4.1 Explore opportunities for Public Private

Partnership (PPP)High DHT X TA support -

36


4.4.3 Explore options for different models of health financing including voucher schemes and micro-health insurance

Medium DHT X TA support -

5. Improved Health Regulation5.1 Implement Standards Notified by the Healthcare Commission5.1.1 Assess the readiness of the HCF to implement

the notified standardsMedium DHT X TA support -

5.1.2 Develop a proposal for meeting the requirements of the notified standards

Medium DHT X TA support /staff time -

5.2 Drug Regulation5.2.1 Train district drug control staff on Healthcare

Commission standardsMedium DHT X TA support -

5.2.2 Increase number of Drug Inspectors to meet the quality standard requirements

Medium DHT X Recruitment of Drug Inspectors/ SNE development

-

5.3 Food Regulation5.3.1 Collaborate with the Food Authority for effective

Food Security regulationMedium DHT X X X X Staff time -

Note: Text in the matrix shown in brown includes activities that are in addition to the MHSDP activities or those supported through Preventive Programmes PC-1s and the district can decide to include or remove from their Annual Work Plans

37


SECTION 7: M&E STRUCTURE, QUARTERLY REVIEW MECHANISM AND RESULT BASED

FRAMEWORK

M&E STRUCTURE

A high degree of coordination, time and skills will be required for implementation of DHP. In order to link the district planning and budgeting with provincial priorities and fill the gap of weak and missing capacities in the district health planning, a review process at the district level has been laid out as follows. This review process further provide for multi sectoral approach by sharing the health sector plans with other sectors to build consensus on reaching the desired and planned outcomes in coordinated manner.

A Monitoring Committee under the chairmanship of DHO may be constituted having multi sectoral representation. This committee should meet quarterly and review progress against agreed milestones given in result framework. The proposed terms of reference are as follows:

Oversee and steer the implementation of the DHP Monitor progress on the implementation through regular quarterly review Grant approval to work-plans, project proposals and other documents submitted

with regards to the implementation of the DHP Review the provisions of the DHP on annual basis to approve any modifications

if required

QUARTERLY REVIEW MECHANISM

Month ActivitiesJuly -September Data collection and update on implementation of HSS rolling plan for the last year

Review of past year’s rolling plan Prepare a comprehensive review report Prepare Annual plan for DHP Start implementation of project/ proposals contained in List A and address issues

relating to release of funds and deciding on implementation details.

October First Quarter ReviewSeptember- December Preparations of budget proposals and development of PC I form of the projects

contained in list B. Follow up budget proposals and PC I with relevant authorities for approval. Arrange technical support if required Give responsibility to specific person/ group/ organization for working components

of list C Start consultative process for preparation of rolling plan for the next year.

January Second Quarter ReviewJanuary-March Finalize draft rolling plan

Prepare review report for third quarterly meetingMarch Third Quarter ReviewApril Share draft Rolling with district government and DGHS tApril-June Follow up on inclusion of proposals in the budget for the next year.July End Year or Annual Review

38


RESULT FRAMEWORK

Nowshera, District Health Plan, Performance Frame WorkOUTCOME Indicators

Sr. No

Outcome Indicator Baseline Year-Source

Targets for 2018

Verification Responsibility DHP Timeline

2015-16 2016-17 2017-18

Means Frequency

1 Increase in contraceptive prevalence rate (CPR modern methods)

28% 2012/13-PDHS

>40% PCSLM/DHIS/district level survey

- - 30% 35% >40%

2 Skilled Birth Attendance

40% 2010-11 PSLM


- - 50% 55% >60%

3 Fully immunized children coverage

62% 2012-13 PSLM


- - 70% 80% >90%

OUTCOME 1: Enhanced coverage and access to minimum health services especially for the poor and vulnerableOutput 1: Implement MHSDP at PHC Level

Sr. No

Output Indicator Baseline Year-Source

Targets for 2018

Verification Responsibility

DHP TimelineMeans Freque

ncy2015-16 2016-17 2017-18

1 Number of PHC facilities implementing MHSP in district

- - 19 Admin Record DHO Quarterly

6 15 19

2 OPD attendance at the PHC facilities

762423 2014-DHIS

(adjusted for

Missing reports)

991150 DHIS DHIS Coordinator

Monthly 838665 914908 991150

3 OPD attendance at the Secondary level facilities

644176 2014-DHIS

(adjusted for

837429 DHIS DHIS Coordinator

Monthly 708594 773011 837429

39


Missing reports)

Output Milestones Baseline Targets for 2018


DHP Timeline

Means Frequency

2015-16 2016-17 2017-18

a Number of DHT staff oriented on MHSDP

- - 12 Training Report/TDB

Bi-Annually

12 0 0

b Number of HCPs trained on MHSDP

- - 189 Training Report/TDB

Bi-Annually

56 91 42

c Number of HFs renovated and refurbished as per assessment

- - 19 Admin record Bi-Annually

6 9 4

OUTPUT: 2 Improved RMNCH and Nutrition Services at Outreach levelSr. No


Targets for 2018



ncy2015-16 2016-17 2017-18

1 Proportion of population access to outreach services (LHW,CMWs,)

71% 2014-LHWPMI

S

80% DHIS/LHWs/ CMWs/IP MIS

DHIS Coordinator

Quarterly

75% 80% 80%

2 Proportion of deployed CMWs attached with LHWs as per Prism Model

- - >95% DHIS/LHWs/ CMWs/IP MIS

Coordinator IV Quarterly

50% 70% >95%

3 Proportion of Outreach workers repotting stock outs of at least two essential drugs during a month

- - 5% DHIS/LHWs/ CMWs/IP MIS

Coordinator IV Monthly 20% 10% 5%

4 Proportion of delivery conducted by CMWs in program covered population

1547/21460=7%

2014-MNCH

prog MIS

9357/31190=30%

DHIS/LHWs/ CMWs/IP MIS

Coordinator IV Monthly 10% 20% 30%

40


5 Proportion of newborn started breastfeeding within 24 hour in LHWs, CMWs covered Population

79% 2014-LHWs MIS

>90% DHIS/LHWs/ CMWs/IP MIS

DHIS/Coordinator iv

Monthly 85% 90% >90%

Output Milestones Baseline Year-Source

Targets for 2018


DHP Timeline

Means Frequency

2015-16 2016-17 2017-18

a # of working LHWs at the outreach level

758 2014-LHWP

860 LHWs/ CMWs/IP MIS

Coordinator IV Monthly 816 860 860

b # of CMWs deployed at the outreach level

51 2014-MNCHP

MIS



c # of Working LHS at outreach level

30 2014-LHWP



d # of Vaccinator working in the LHW uncovered areas.

- - 52 EPI MIS EPI coordinator

Monthly 39 42 52

# of LHWs, LHs, CMW trained in refresher training (CMAM, IYCF, IMNCI, IFA)

- - 1,004 LHWs/ CMWs/IP MIS

Coordinator IV Quarterly 930 996 1004

OUTPUT: 3, 4 &6 Improved Access to Maternal, child and nutrition interventions at Facility care level (PHC & Secondary Level)1 Number of the target

PHC facilities providing basic EmONC services

- - 41 Admin record Coordinator IV Quarterly

29 37 41

2 Number of the target secondary level HFs (CHs, THQs, DHQ) providing selective Comprehensive EmONC services ( 24/7)

1 Admin record/D

HIS

2 Admin Record Coordinator IV Quarterly

1 2 2

3 Number of OTP - - 41 Admin Record/ Coordinator IV Monthly 10 31 41

41


centers providing services as per standard guidelines.

DHIS

4 Stabilization center at DHQ established and is functional

- - 1 Admin Record/DHIS


1 1 1

5 Proportion of registered PL (ANC-1) delivered at facility

28% 2014-DHIS

>50% DHIS DHIS Coordinator

Monthly 30% 45% >50


Targets for 2018


DHP Timeline

Means Frequency

2015-16 2016-17 2017-18

a # of secondary level HFs as fulfilling the staffing requirement ( per standard guidelines) for comprehensive EmONC services.

- - Secondary Hospital staffing requirement met

Admin record/Payroll/DHIS

DHO Yearly 1 2 2

b # of HCPs trained on basic EmONC services

- - 52 TNA/ Training Database/Training reports


39 13 0

c # of HCPS trained on comprehensive EmONC services

- - The identified staff trained

TNA/ Training Database/Training reports


6 6 6

d # of staff trained on OTP guidelines

- - The identified staff trained

TNA/ Training Database/Training reports


21 62 82

e Number of DHT staff trained on nutrition interventions



10 0 0

f Training of MHSP implementing facility staff on IMNCI



13 20 9

Output 4: Improved Mortality surveillance system1 Proportion of HFs - - 80% Admin DHIS/ 10% 50% 80%

42


implementing birth and death registration system

record/IPMIS Coordinator IV


Targets for 2018


DHP Timeline

Means Frequency

2015-16 2016-17 2017-18

a Training of facility staff on recoding and reporting tools (DHIS/LHW/CMW/IPMIS).


Coordinator IV, DHIS

coordinator

Quarterly

3 13 16

Output 5: Improve emergency response system1 Proportion of

emergencies responded

- - 80% of epidemics

and emergencies appropriately responded

40% 70% 80%

Output 6: Strengthening of rehabilitative services1 Proportion of HFs

upgraded to provided selected rehabilitative services

- - DHQ/THQ upgraded to

meet the requirement as per policy

Admin record/ Physical

verification report

DHIS/Coordinator

IV, coordinator

Yearly As per approved plan and guidelines

OUTCOME 2: A Measurable Reduction in Morbidity & Mortality due to Common DiseasesOutput 1: Prevention from Common Diseases through Promotion, Early Detection and Subsidized Curative Support

Sr. No


Targets for 2018



ncy2015-16 2016-17 2017-18

1 Proportion of under one year children

56% 2014-LHWs

>90% LHWs/ CMWs/IP

DHIS/Coordinator

Monthly 70% 80% >90%

43


started immunization in program covered population (LHWs).

MIS MIS/DHIS IV, coordinator

2 Proportion of registered PL (ANC-1) receiving TT-2 vaccination

52% 2014-DHIS

90% DHIS DHIS/Coordinator

IV, coordinator

Monthly 65% 75% 90%

3 Proportion of deliveries conducted by SBA at the public health facilities

21.42% 2014-DHIS

55% DHIS DHIS Coordinator

40% 50% 55%

4 Number of health facilities reporting no stock outs of 3 contraceptive methods, misoprostol and magnesium sulphate

- - 80% DHIS DHIS/Coordinator

IV, coordinator

Monthly 60% 75% 80%

5 Number of health facilities reporting no stock out of essential medicines as per MHSDP


IV, coordinator

Monthly 60% 75% 80%

6 Reduction in prevalence of anemia in pregnant women (Hb less than 11g,/dl) in the diagnosed cases at Public health facilities.

- - 22% DHIS/IPMIS DHIS/Coordinator

IV, coordinator

Monthly 26% 24% 22%

7 Proportion of immunization centers with no stock out of vaccines ( BCG, penta, Polio, TT., Measles)

- - 95% EPI/IP MIS/DHIS

DHIS/Coordinator

IV, coordinator

Monthly 80% 90% 95%

8 Malaria slide - - <4% Malaria/IVCP Malaria/AVCP <4% <4% <4%

44


( Microscopy & RDT) positivity rate

Coordinator

9 Treatment success rate for T.B

95% 2014- TBCP

KP

>85% DHIS, TBCP DHIS Coordinator

>85% >85% >85%

10 Proportion of Children diagnosed with diarrhea at public health facilities treated with ORS and Zinc


IV, coordinator

80% 90% 90%


Targets for 2018


DHP Timeline

Means Frequency

2015-16 2016-17 2017-18

a Annual assessment of cold equipment

- - At least two assessment are carried out with reports available

Assessment report

EPI Coordinator

Yearly Assessment report with requirement available

Assessment report with requirement available

Assessment report with requirement available

b Replacement of the cold chain equipment as per assessment report

- - Key Major Equipment are available and functional

Assessment report

EPI Coordinator

Yearly Repair and Purchase of key equipment

Repair and Purchase of key equipment

Repair and Purchase of key equipment

c Number of advocacy seminars with parliamentarians , religious leaders and other stakeholders at the district level

- - 1 seminar yearly

Admin record & Activity report


1 1 1

d # of health education - - 4 Admin record Coordinator IV Quarterl 4 4 4

45


sessions for vector control conducted at district level

& Activity report

y

e Number of district level seminars on Infection control at the district level

- - 2 seminar yearly

Admin record & Activity report


2 2 2

f Number of general practitioners trained on Hepatitis BCC



coordinator

Quarterly

0 25 0

g Number of GPs included in Hepatitis Filter clinic initiative at the district level

- - 25 Admin record, MIS report


coordinator

Quarterly

0 25 25

h Establishment of District Surveillance Response unit at the district level

OUTCOME 3: Improved Human Resource ManagementOutput 1: Strengthening human resource management at the district level

Sr. No


Targets for 2018

Verification Responsibility DHP TimelineMeans Freque

ncy2015-16 2016-17 2017-18

1 DHT positions filled at the district level

- 2014-DHO

record

All DHT position filled

Admin Record/ DHIS/Pay Roll

DHO Monthly 90% Position Filled as per the approved JDs

100% position Filled as per the approved JDs

100% position filled as per the approved JDs

2 Proportion of HR gaps filled as per MHSP and standard list of secondary level care facilities

- 2014-DHO

record

90% of position filled


DHO/KPHI DPM

Monthly 70% Position Filled as per the approved JDs

80% Position Filled as per the approved JDs

90% Position Filled as per the approved JDs

3 # district health team staff trained on MHSP

- 2014-DHO

10 Staff member

Admin Record/ DHIS

DHO Bi-Annuall

10 0 0

46


record trained on district planning

y


Targets for 2018


ncy2015-16 2016-17 2017-18

a Yearly HF gap analysis based on periodical assessment.

- 2014 Yearly HF gap analysis reports available

Admin Record DHO/KPHI DPM

Annually

Gap analysis reports available



b Development of yearly training plan per training need assessment

- 2014 Yearly training available

Admin Record Coordinator IV Annually

Training plan available



c Development and maintenance of training data base

- 2014 Training data`base updated

Training Database/DHIS/IPMIS

DHIS/ Coordinator IV Coordinator

Quarterly Training Database developed and updated

Training Database developed and updated

Training Database developed and updated

OUTCOME 4: Improved governance and accountabilityOutput 1: Strengthening management function at the district level

Sr. No


Targets for 2018


DHP Timeline

Means Frequency

2015-16 2016-17 2017-18

1 Proportion of the vacant positions of management support team filled per IPC-1

- 2014 100% positions filled


DHO Annually

80% 100% 100%

2 Number of quarterly district review meetings held &

- 2014 12 Meeting conducted with minutes

Admin Record/Minutes of the

DHO Quarterly

4 4 4

47


minutes available available meeting


Targets for 2018


DHP Timeline

Means Frequency

2015-16 2016-17 2017-18

a Number of DHT staff trained ( planning , Procurement, Financial management rules and regulations, DHIS and LMIS)

- 2013-14 10 Staff Members trained

Admin Record/ DHIS/Training Database


Periodically

5 5 0

Output 2: Improved results based managementSr. No


Targets for 2018


DHP Timeline

Means Frequency

2015-16 2016-17 2017-18

1 Budget Utilization rate against release

95% 2014-DHO

record

100% Yearly Reconciliation report

DHO/Accounts officer

Annually

95% 100% 100%

2 Number of internal audits reports shared with DHO periodically

- 2014 3 Internal Audit reports Available

Admin Record DHO Annually

1 1 1

3 Annual operational plan in line with DHP available

- 2014 3 Annual Operational planes developed


1 1 1

4 Budget prepared as per Integrated budget call circular

- 2014 3 Budget prepared and submitted as per Guidelines


1 1 1

Output Milestones Baseline Year- Targets for Verification Responsibilit DHP Timeline

48


Source 2018 yMeans Freque

ncy2015-16 2016-17 2017-18

a Health facility assessment report available

- 2014 HFA assessment Report available

Admin Record DHO Once in three years

1 0 0

b Training of staff on preparing budget as per integrated budget call circular

- 2014 4 person trained

Training Database/DHIS/IPMIS

DHO Once in three years

4 0 0

Output 3: Strengthening M&E function at the district levelSr. No


Targets for 2018


DHP Timeline

Means Frequency

2015-16 2016-17 2017-18

1 Proportion of field monitoring visits conducted by DHT as per approved monthly monitoring plan and reports available

- - >90% Signed Visit reports with Pictures

DHO/Coordinator

Monthly 166/208=80%

187/208=90%

198/208=95%

2 Proportion of facility monthly DHIS reports submitted timely to district

- 2014-DHIS

>95% Signed DHIS reports-DHIS

DHIS Coordinator

Monthly 510/636=80%

572/636=90%

604/636=95%

3 Proportion of LHWs monthly reports submitted timely to Facility (LHWs reporting compliance)

95% 2014-LHWs MIS

95% LHWs/ CMWs/IP MIS/DHIS


Monthly 95% 95% 95%

4 Proportion of CMWs monthly reports submitted timely to Facility

95% LHWs/ CMWs/IP MIS/DHIS


Monthly 80% 90% 95%

5 Number of DHIS - 2014 4 meetings Signed DHIS Quarterl 2 4 4

49


quarterly review meeting with facility DHIS focal point and minutes.

Yearly Conducted

Meeting reports with attendance and Photos

Coordinator y

6 Proportion of facilities monthly feedback report provided.

- - >80% facilities provided feedback

Signed copy of feedback reports

DHIS Coordinator

Monthly 60% 70% >80%

7 Number of on sight data verification/ Validation conducted and reports available

- - 1 OSDV conducted yearly

OSDV report available with recommendation for improvement

DHIS Coordinator

Yearly 1 1 1

8 Number of MMC (LHS meeting at District level) held

12 2014-LHWs MIS

12 Meetings yearly

Minutes of the meeting, IP-MIS

Coordinator IV Coordinator

Monthly 12 12 12


Targets for 2018


DHP Timeline

Means Frequency

2015-16 2016-17 2017-18

a Approved field monitoring and supervision plan by designated officers ( DHT team as approved in integrated PC-1.

- - 4 Quarterly FM&S approved planes available

Approved quarterly M&S visit plan

DHO Quarterly

4 4 4

a Integration reports of program MISs and DHIS generated as per integrated system provided by the provincial DHIS.

- - Integrated MIS implemented and Monthly reports generated

Integrated District MIS monthly reports


Monthly 0 6 12

b Number of DHIS staff trained of M& E and research methodology

- - As per integrated PC-1

Admin Record/IPMIS


As per nomination by DoH

50


c Implementation of performance linked incentives system

- - - Admin Record/IPMIS


As per agreed criterion by the DoH

OUTCOME 5: Improved Health RegulationOutput 4: Implement standards notified by the healthcare commission

Sr. No


Targets for 2018


ncy2015-16 2016-17 2017-18

1 Number of health facilities implementing quality standards notified by the health care commission

- - - Admin Record/IPMIS


As per the notification

51


SECTION 8: DETAILED COST ESTIMATES OF DISTRICT HEALTH PLAN

COSTING OF OUTCOMES & OUTPUTS

The district health plan contains detailed activities to increase access and the quantity of quality essential services sufficient to meet the targets as laid down under the district health Plan Nowshera. Implementation of these activities will require considerable amounts of investment by the government and development partners in the public health sector of Khyber Pakhtunkhwa. A costing model was designed to meet the needs of the costing the activities under the plan. The model uses a combination of input and out-put based costing methods, where the former is used to determine indirect costs and the later to determine direct costs.

79% of the DHP cost is covered by integrated PC-1 and the remaining 21% gap can be covered from District Management Plan as mentioned a lump sum figure in integrated PC-1.

It is estimated that a total of PKR 1331 Million excluding inflation will be required to implement the District Health Plan over the period of 3 years. This section of the document presents the summary of costs required to implement the activities as defined under the District Health Plan.

Major investment is required for achieving outcomes 1 and 4 which comprise approximately 95% of the total costs of the District Health Plan; these two outcomes will enhance and improve the access to essential health services for poor and Improved Governance and Accountability hence bringing in a paradigm shift in major portion of resource allocation from employees related expenses to services. The detail outcomes costing in relation with activities are given below.

PKR IN MILLION

COST ESTIMATES YEAR 1 YEAR 2 YEAR 3

DHP COST 426.80 459.70 444.28

MET THROUGH INTEGRATED PC-1

326.53 349.94 374.49

ADDITIONAL GAP 100.26 109.75 69.78

52


District Health plans - NowsheraSummary of Total Cost By Outcomes

All Figs in Million.Sr. No.

Outcomes Cost Estimates TotalYear I Year II Year III

1 Enhancing Coverage and Access to Essential Health Services especially for Poor and Vulnerable

346.90 418.59 408.95 1174.45

2 A Measurable Reduction in Morbidity & Mortality due to Common Diseases

21.69 17.05 13.40 52.14

3 Improved Human Resource Management 11.61 2.43 2.74 16.78

4 Improved Governance and Accountability 45.14 20.04 17.37 82.55

5 Improved Health Regulation 1.44 1.59 1.83 4.86

Total Cost for District Nowshera: 426.80 459.70 444.28 1330.77

1. Staff Salaries calculations are based on standard pay package of the Government of KPK. 2. For providing comfortable environment to the participants of the meeting during meeting/workshop/seminar/training sessions, Daily Allowance @ Rs. 2050x2 apropos accommodation has been fixed. Besides a rate of Rs. 3000 has also be defined for payment of daily training/facilitator allowance to the Facilitators. 3. The target activities along with item costs are flexible. 4. Need based changes in activities during implementation may be done with the approval of Project Steering Committee.

Outcome 1. Enhancing Coverage and Access to Essential Health Services especially for Poor and Vulnerable

53


S. No. Outputs/Activities Unit Physical Target Financial Targets Total Defined Cost Year I Year II Year III Year I Year II Year III

1.1 Output 1.1: Implement MHSDP at PHC level1.1.1 Conduct Orientation Workshop for

MHSDPCost/

Workshop0.07 1 1 1 0.07 0.07 0.07 0.21

1.1.2 Select Health Facilities for rolling out MHSDP

Policy Decision Notification 6 15 19 0.00 0.00 0.00 0.00

1.1.3 Baseline assessment of HF to identify gaps against the MHSDP

Technical Assistance

2.36 1 0 0 2.36 0.00 0.00 2.36

1.1.4 Based on assessment develop a proposal for filling in gaps

Policy Decision Notification 0 0 0 0 0 0 0.00

1.1.5 Fill in the gaps in HF outlined by the assessment


1.1.6 Prepare SNE for new positions and infrastructure

Costed Gaps Annex 6 15 19 56.81 95.64 59.07 211.52


Training Workshop

0.06 2 2 1 0.12 0.12 0.06 0.29

1.1.8 Start Implementation of MHSDP Policy Decision Notification 0 0 0 0 0 0 0.00Sub Total 15 32 39 59.36 95.82 59.19 214.37

1.2 Improved RMNCH and Nutrition Services at Outreach level1.2.1 Recruit additional LHWs, (non LHW

covered area) given in Integrated PC-1

Cost/ person 0.14 816 860 860 117.50 123.84 123.84 365.18

1.2.1(A) Recruit additional LHS (non LHW covered area) given in Integrated PC-1

Cost/ person 0.31 34 36 36 10.39 11.00 11.00 32.39

1.2.1(B) Recruit additional CMWs (non LHW covered area) given in Integrated PC-1

Cost/ person 0.06 80 100 108 4.80 6.00 6.48 17.28

1.2.1(C) Recruit additional Vaccinators, (non LHW covered area) given in Integrated PC-1

Cost/ person 0.18 39 42 52 7.02 7.56 9.36 23.94

1.2.1(D) POL for LHS & others Monitoring Purposes

Lump sum 1.00 1 1 1 1.00 1.00 1.00 3.00

1.2.2 Conduct initial and refresher training of outreach workers

Training Workshop

0.14 19 21 21 2.72 2.91 2.97 8.60

1.2.3 Ensure regular supplies to LHWS per MHSDP and Integrated PC-1

Cost/ LHW 0.0028 816 860 860 2.26 2.38 2.38 7.03

54


standard1.2.3(A) Ensure regular supplies to CMWs

per MHSDP and Integrated PC-1 standard

Cost/CMWs 0.0038 80 100 108 0.31 0.38 0.41 1.10

1.2.4 Train District trainers (3-4) for Outreach Workers

Training Workshop

0.06 1 1 1 0.06 0.06 0.06 0.19

1.2.5 Implement PRISM model Orientation Workshop

0.05 1 0 0 0.045 0.000 0.000 0.05

1.2.6 Strengthen existing and Establish Primary Care Management Committees at Facility level

Policy Decision 0.00 0 0 0 0 0 0 0.00

1.2.7 Operationalize Male and Female health Committees at Community level

Policy Decision 0.00 0 0 0 0 0 0 0.00

1.2.8 Regularly conduct facility and outreach sessions with community

Cost/Session 0.89 5 5 5 4.425 5.09 5.09 14.60

1.2.9 Recruit Health Education Officer Cost/ person 0.83 1 1 1 0.83 0.83 0.83 2.481.2.10 Dissemination of specific messages

on MNCH, Nutrition, Family Planning, IYCF etc.

Lump sum 0.50 1 1 1 0.5 0.5 0.5 1.50

1.2.11 Implement the necessary trainings e.g. (IMNCI, IYCF) at all levels

Training Workshop

0.59 2 2 2 1.19 1.36 1.57 4.12

Sub Total 1896.38 2029.76 2056.12 153.05 162.92 165.49 481.461.3 Improved access to RMNCH and Nutrition services at Facility level

1.3.1 Prepare Union Council Health Plans on Result Based Management techniques


2.63 1 0 0 2.63 0.00 0.00 2.63

1.3.2 Recruit Planning Officer at the District level

Cost/ person 0.83 1 1 1 0.83 0.95 1.09 2.87

1.3.3 Train facility In-charge and related staff on developing Union Council Plans

Dissemination Workshop

0.40 1 0 0 0.40 0.00 0.00 0.40

1.3.4 Train MOs on MHSDP assessment tools and planning tools

Training Workshop

0.11 1 1 1 0.11 0.11 0.11 0.34

Sub Total 4.00 2.00 2.00 3.97 1.06 1.20 6.241.4 Increased availability of services as per MHSDP at Facility level

1.4.1 Recruit service delivery staff on contract basis at the Facility level to

Budgetary Support &

0.00 0 0 0 0 0 0 0.00

55


meet MHSDP requirements Additional Gaps Costed

out in 1.161.4.2 Prepare SNE to regularize contract

staff Notification/ Staff Time

0.00 0 0 0 0 0 0 0.00

1.4.3 Ensure availability of supplies & medicines at MHSDP selected facilities

Cost/District/ Year

68.03 68.03 78.24 89.97 236.24

1.4.3 (A) Ensure availability of stationary at MHSDP selected facilities

Cost/Facility 0.05 6 15 19 0.30 0.75 0.95 2.00

1.4.3 (B) Ensure availability of equipment at MHSDP selected facilities

Cost/Facility 1.59 6 9 4 9.54 14.32 6.36 30.23

1.4.3 (C) Ensure availability of printing material at MHSDP selected facilities

Cost/Facility 0.0500 6 15 19 0.30 0.75 0.95 2.00

1.4.4 Recruit Supply Logistic Officer at the District level

Cost/ person 0.83 1 1 1 0.83 0.95 1.09 2.87

1.4.5 Capacity building of mid-level staff on Procurement Management processes

Capacity Building

Workshop

0.23 2 1 1 0.45 0.23 0.23 0.90

1.4.6 Implementation of E-Procurement System developed by the Province


4.92 1 0 0 4.92 0 0 4.92

1.4.7 Ensure one month Buffer Stock at the facility level

Cost of Buffer stock

5.6694 1 1 1 5.67 6.52 7.50 19.69

1.4.8 Select health facility for providing 24/7 services (Basic EmONC)

Staff Time Notification 1 3 3 0 0 0 0.00

1.4.9 Implementing approved Quality Standards


1.4.10 Fill the Infrastructure gaps in selected health facilities

Already Budgeted

0 0 0 0 0 0 0 0.00

1.4.11 Implementation of 24/7 services at the selected facilities

Cost/Facility Lump Sum 6 15 19 6 15 19 40.00

1.4.12 Deliver Nutritional services as per approved standard National Nutrition Guidelines

Policy Decision 0 0 0 0 0 0 0 0.00

1.4.13 Revise LHWs, LHSs and CMWs curriculum and add Community based management of acute and


56


moderate Malnutrition chapter1.4.14 Train LHWs, LHSs and CMWs

Community based management of acute and moderate Malnutrition

Training Workshop

0.027 19 21 21 0.52 0.56 0.57 1.64

1.4.15 Select health facilities for establishing Outpatient Therapeutic Points (OTPs) – for CMAM without complications

Cost/OTP Centre

1.00 10 31 41 10 31 41 82.00

1.4.16 Prepare a Plan of Action for Nutritional Screening and Interventions in LHW uncovered areas

Policy Decision 0.00 0 0 0 0 0 0 0.00

1.4.17 Ensure availability of IFA and Zinc supplements, RUTF, RUSF and other related medicines and supplies

Procurement of Supplies

0.007 269 717 1612 1.78 4.75 10.68 17.21

1.4.18 Calculate and communicate district needs to Director Health (Integrated PC-1)

Policy Decision 0.00 0 0 0 0 0 0 0.00

1.4.19 Train Facility relevant staff on Nutrition intervention and services

Training Workshop

0.03 2 1 1 0.05 0.03 0.03 0.11

1.4.20 Ambulance availability for referrals in selected 24/7 facilities ( 1 RHC Selected for MHSDP Roll Out)

Repair &Maintenance of Ambulances

0.20 1 1 1 0.20 0.20 0.20 0.60

Sub Total 331.12 830.34 1743.38 108.60 153.28 178.53 440.411.5 Improve Mortality Surveillance System

1.5.1 Develop Birth Registration System at District and Facility level


6.50 1 0 0 6.50 0.00 0.00 6.50

Sub Total 1.00 0.00 0.00 6.50 0.00 0.00 6.501.6 Improve access to maternal and child nutrition intervention at secondary level

1.6.1 Establish Stabilisation Centres at the DHQ level for CMAM with Complications

Cost/ Centre 0.784 1 1 1 0.784 0.784 0.784 2.352

1.6.2 Ensure availability of staff as per requirement of Stabilisation Centres

Policy Decision 0.000 0 0 0 0 0 0 0.000

1.6.3 Provide incentives to Stabilisation Centre Staff

Incentives/ Stabilisation

Centre

0.372 1 1 1 0.372 0.372 0.372 1.116

1.6.4 Ensure availability of medicines, Supplies 1.145 1 0 0 1.145 0.000 0.000 1.145

57


supplies, equipment, stationary &Procurement1.6.5 Train DHQ staff for Nutrition

InterventionsTraining

Workshop0.03 1 0 1 0.031 0.000 0.031 0.062

1.6.6 Availability of Ambulance specifically for Stabilisation Centres

Cost/ Ambulance

0.20 3 3 3 0.600 0.600 0.600 1.800

Sub Total 7.00 5.00 6.00 2.93 1.76 1.79 6.471.7 Improve Emergency Response

1.7.1 Conduct an assessment of facilities and equipment for A & E response centres


3.85 1 0 0 3.850 0.000 0.000 3.850

1.7.2 Develop plan for providing resources and facilities to fill identified gaps

Cost/ Seminar 0.027 1 0 0 0.027 0.000 0.000 0.027

1.7.3 Provide missing equipment required for Accident and Emergency


( LUMPSUM)

1.000 1 1 1 1.000 1.000 1.000 3.000

1.7.4 Conduct Trainings Need Assessment for Accident and Emergency response staff

Training Workshop

0.027 2 1 1 0.054 0.027 0.027 0.107

1.7.6 Develop a system for Emergency Preparedness and Response Plan (EPRP) at District level

Policy Decision Staff Time 0 0 0 0 0 0 0.000

1.7.7 Establish a budget line for EPRP implementation

Policy Decision Staff Time 0 0 0 0 0 0 0.000

1.7.8 Contingency supplies and stocks availability and its replenishment on annual basis


Already Costed

0 0 0 0 0 0 0.000

1.7.9 Strengthen DEWS at the District level

Supported By WHO

Policy Decision

0 0 0 0 0 0 0.000

1.7.10 Equip BHU for provision of First Aid services

Cost/BHU – Lumpsum

0.50 10 11 6 3.000 2.000 1.000 6.000

Sub Total 15.00 13.00 8.00 7.93 3.03 2.03 12.981.8 Implement approved quality standards at primary and secondary level

1.8.1 Conduct an assessment to identify gaps against the standards (staff, skills, equipment, supplies and operational budget)


3.85 1 0 0 3.850 0.000 0.000 3.850

1.8.2 Based on the assessment develop a plan/ proposal for filling the gaps

Policy Decision 0.00 0 0 0 0 0 0 0.000

58


1.8.3 Implement Standards at selected target Health Facilities

Policy Decision 0.00 0 0 0 0 0 0 0.000

Sub Total 1.00 0.00 0.00 3.85 0.00 0.00 3.85

1.9 Construction or up gradation of Hospitals / Facilities based on MHSDP1.9.1 Develop guidelines and design for

construction of new health facilities based on the MHSDP

Policy Decision Already Done

0 0 0 0 0 0 0.00

1.9.2 Renovate/refurbish/construct the additional requirements based on MHSDP in selected health facilities

Already Budgeted

0.00 0 0 0 0.00 0.00 0.00 0.00

1.9.3 Develop proposal of the number of facilities to be upgraded/renovated/refurbished based on MHSDP

Policy Decision 0.00 0 0 0 0 0 0 0.00

Sub Total 0.00 0.00 0.00 0.00 0.00 0.00 0.001.10 Strengthen Rehabilitation Services

1.10.1 Provide selected rehabilitation services up to THQ level


1.10.2 Explore the option of engaging the private sector in provision of rehabilitation services

Contract 0.72 1.00 1 1 0.720 0.720 0.720 2.16

Sub Total 1.00 1.00 1.00 0.72 0.72 0.72 2.16 Outcome 1 Sub Total 2271.50 2913.10 3855.50 346.90 418.59 408.95 1174.45

Outcome 1: Total 346.90 418.59 408.95 1174.45

Outcome 2. A Measurable Reduction in Morbidity & Mortality due to Common DiseasesAll Figs in Million (Rs.)

S. No. Outputs/Activities Unit Physical Target Financial Targets Total Defined Cost Year I Year II Year III Year I Year II Year III

2.1 Prevention from Common Diseases through Promotion, Early Detection and Subsidized Curative Support2.1.1 Ensure timely supplies of Preventive

ProgrammesThrough Program

0.00 0 0 0 0.00

59


2.1.2 Improve EPI Coverage to meet with the Provincial Targets

Policy Decision 0.00 0 0 0 0 0 0 0.00

2.1.3 Uninterrupted supply of vaccines Provincial Activity

0.00 0 0 0 0 0 0 0.00

2.1.4 Develop Logistics procurement and distribution plans

Policy Decision Policy Decision

0 0 0 0 0 0 0.00

2.1.5 Replacement of outdated Cold Chain Equipment including cold rooms and procure new cold chain equipment

Cost/ Cold Chain

2.09 2 2 1 4.19 4.19 2.09 10.46

2.1.6 Effective Vaccine Management (EVM) Assessment System

Covered by NISP - PCI

0.00 0 0 0 0 0 0 0.00


Training 1.18 5 2 0 5.91 2.36 0.00 8.27

2.1.8 Vaccine Logistic Management Information System (vLMIS) strengthening and scaling up

Supported By Donors

0.00 0 0 0 0 0 0 0.00

2.1.9 Train staff including LHWs on Behaviour Change Communication

Training Workshops

0.15 19 21 21 2.82 3.02 3.07 8.90

2.1.10 Hold Advocacy Seminars with parliamentarians, religious leaders and other stakeholders

Cost/Seminar 0.06 4 4 4 0.25 0.25 0.25 0.76

2.1.11 Hold Mother and child health weeks and arrange special immunization days

Donor Aided ( UNICEF)

0.00 0 0 0 0 0 0 0.00

2.1.12 Improve case detection rate and treatment success rate of TB

To be undertaken by Tb Program

0.00 0 0 0 0 0 0 0.00

2.1.13 Ensure availability of Larvicides/Insecticides & spray equipment at the district

Lump sum 0.02 47 47 47 0.94 0.94 0.94 2.82

2.1.14 Conduct Health Education Sessions for Vector Control

Cost/Session 0.05 4 4 4 0.19 0.19 0.19 0.57

2.1.15 Establish Infection Control Committee in selected Health Facilities

Policy Decision 0.00 0 0 0 0 0 0 0.00

2.1.16 Conduct District level Seminar on Infection Control at District level

Cost/Seminar 0.05 2 2 2 0.10 0.10 0.10 0.29

2.1.17 Conduct Seminar on Injection Safety at District Level

Cost/Seminar 0.05 2 1 1 0.10 0.05 0.05 0.19

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2.1.18 Make a list of Healthcare providers/facilities including laboratories for partnership development with Hepatitis Control Programme

Policy Decision 0.00 0 0 0 0 0 0 0.00

2.1.19 Hold one day training workshop for general practitioners for Hepatitis B&C

Training Workshops

0.05 3 2 1 0.14 0.10 0.05 0.29

2.1.20 Identification of Volunteers and GPs for inclusion in Hepatitis Filter Clinics

Policy Decision 0.00 0 0 0 0 0 0 0.00

2.1.21 Hold Health Education Sessions for HIV/AIDS at district level

Cost/Session 0.05 3 1 1 0.14 0.05 0.05 0.24

Sub Total 91.38 85.76 82.12 14.77 11.23 6.78 32.782.2 Strengthening of Disease Surveillance System

2.2.1 Conduct Burden of Disease Study Technical Assistance

1.80 1 0 0 1.80 0.00 0.00 1.8

2.2.2 Establishment of District Surveillance Response Unit in line with Provincial setup

Supported by WHO

0.00 0 0 0 0 0 0 0

2.2.3 Training of staff on Disease Surveillance

Training Workshops

0.06 2 1 0 0.13 0.06 0.00 0.1902

2.2.4 Implementation of Surveillance Response System

Supported by WHO

0.00 0 0 0 0 0 0 0

2.2.5 Recruitment of District Epidemiologist and support staff

Lump sum 5.00 0 0 0 5.00 5.75 6.6125 17.3625

Sub Total 3.00 1.00 0.00 6.93 5.81 6.61 19.35Outcome 2 Sub Total 94.38 86.76 82.12 21.69 17.05 13.40 52.14

Outcome 2: Total 21.69 17.05 13.40 52.14

Outcome 3. Improved Human Resource ManagementAll Figs in Million

(Rs.)S. No. Outputs/Activities Unit Physical Target Financial Targets Total

Defined Cost Year I Year II Year III Year I Year II Year III3.1 Strengthen Human Resource Management Function at District level

3.1.1 Review current functions and staffing of Technical 2.93 1 0 0 2.93 0.00 0.00 2.93

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DHMT in the context of MHSDP and Local Government

Assistance

3.1.2 Fill identified HR gaps Already Costed 0.00 0 0 0 0 0 0 0.003.1.3 Develop District HR management

information system (e-system) in line with Provincial


2.58 1 0 0 2.93 0.00 0.00 2.93

3.1.4 Train relevant staff on HR Management System

Training Workshop

0.05 2 1 0 0.10 0.05 0.00 0.14

3.1.5 Implement HR management information system

Policy Decision 0.00 0 0 0 0 0 0 0.00

3.1.6 Develop a proposal to introduce incentive mechanism for health workers for geographic locations and performance

Cost/ Incentives/ Health Workers

2.07 1 1 1 2.07 2.38 2.74 7.19

3.1.7 Conduct Training Need Assessment for all categories of staff and prepare Training Plan


2.58 1 0 0 2.58 0.00 0.00 2.58

3.1.8 Development of Training Database for district staff

Lump sum 1.00 1 0 0 1.00 0.00 0.00 1.00

Sub Total 7.00 2.00 1.00 11.61 2.43 2.74 16.78 Outcome 3 Sub Total 7.00 2.00 1.00 11.61 2.43 2.74 16.78

Outcome 3: Total 11.61 2.43 2.74 16.78

Outcome 4. Improved Governance and AccountabilityS.

No.Outputs/Activities All Figs in Million (Rs.)

Unit Physical Target Financial Targets Total Defined Cost Year I Year II Year III Year I Year II Year III

4.1 Strengthening of Management Function at district level4.1.1 Improve Planning Capacity at District

level for development of District Health Plan

Supported By Technical Resource

Lump Sum

1 1 1 5 5 5 15.00

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Facility4.1.2 Develop district level health plans using

Result based planning and management techniques

Supported By Technical Resource

Facility

Lump Sum

1 1 1 2 2 2 6.00

4.1.3 Hold regular Quarterly district review meeting and district level monthly review meetings

Cost/Meeting 0.09 6 6 6 0.55 0.55 0.55 1.65

4.1.4 Recruit Coordinator for Quality Management and Oversight, Financial Management Officer, Nutrition Coordinator

Cost/Person 2.48 1 1 1 2.48 2.85 3.28 8.60

4.1.5 Increased community participation in service delivery management and oversight through regular involvement in DHMT meetings

Cost/Meeting 0.05 3 2 2 0.14 0.16 0.19 0.50

4.1.6 Train DHMT staff on Planning, Procurement and Financial Management and Rules & regulations (PPRA etc.)

Training Workshop

0.05 2 2 2 0.10 0.10 0.10 0.29

4.1.7 Recruit Data Analyst , Computer programmer/IT Officer, Account Supervisor, Procurement and Logistic Officer

Cost/Person 2.47 1 1 1 2.47 2.84 3.27 8.58

Sub Total 15.00 14.00 14.00 12.74 13.50 14.38 40.61

4.2 Improving Results Based Management4.2.1 Strengthening of Financial Systems and

introduction of Internal Audit mechanismsTechnical

AssistanceLump Sum

1 5 0 0 5.00

4.2.2 Notify and Establish a Sectoral Coordination Committee on the pattern of SDPF (Strategic partnership Development Framework)

Policy Decision

0.00 0 0 0 0 0 0 0.00

4.2.3 Introduction of Result Based Financing Mechanism through introducing OBB and MTBF approach


3.55 1 1 0 3.55 3.55 0.00 7.09

4.2.4 Coalition and Integration of Programme MIS and DHIS


3.77 1 0 0 3.77 0.00 0.00 3.77

4.2.5 Conduct Health Facility Assessment Technical 3.77 1 0 0 3.77 0.00 0.00 3.77

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(HFA) on annual basis that feeds into District Health Plan

Assistance

4.2.6 Conduct Situation Analysis (SA) on annual basis that feeds into District Health Plan


3.77 1 0 0 3.77 0.00 0.00 3.77

4.2.7 Develop reporting system on Performance Linked Incentive System and report regularly in Quarterly Reports


3.77 1 0 0 3.77 0.00 0.00 3.77

Sub Total 6.00 1.00 0.00 23.61 3.55 0.00 27.164.3 Strengthen M&E Function at District Level

4.3.1 Recruitment of Technical staff for monitoring at all levels of health care

Cost/Person 1.95 1 1 1 1.95 1.95 1.95 5.84

4.3.2 Procurement of supplies, stationary, printing equipment

Lump sum 1.00 1 1 1 1.00 1.00 1.00 3.00

4.3.3 Trainings of staff on M & E and research methodology

Training Workshop

0.05 2 1 1 0.10 0.05 0.05 0.19

4.3.4 Online Linkup Performance Based Dashboard System at District level


2.14 1 0 0 2.14 0.00 0.00 2.14

Sub Total 5.00 3.00 3.00 5.18 2.99 2.99 11.174.4 Health Financing and Alternate Models of Service Delivery

4.4.1 Explore opportunities for Public Private Partnership (PPP)


2.61 1 0 0 2.61 0.00 0.00 2.61

4.4.2 Explore options for different models of health financing including voucher schemes and micro-health insurance

Study 1.00 1 0 0 1.00 0.00 0.00 1.00


Outcome 4: Total 45.14 20.04 17.37 82.55Outcome 5. Improved Health Regulation

All Figs in Million (Rs.)S.

No. Outputs/Activities Unit Physical Target Financial Targets Total

Defined Cost Year I Year II Year III Year I Year II Year III5.1 Implement Standards Notified by the Healthcare Commission

5.1.1 Assess the readiness of the HCF to implement the notified standards

Policy Decision

0.00 0 0 0 0 0 0 0.00

5.1.2 Develop a proposal for meeting the requirements of the notified standards

Policy Decision

0.00 0 0 0 0 0 0 0.00

Sub Total 0.00

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5.2 Drug Regulation5.2.1 Train district drug control staff on Healthcare

Commission standardsTraining

Workshop0.03 2 0 0 0.06 0.00 0.00 0.06

5.2.2 Increase number of Drug Inspectors to meet the quality standard requirements

Cost/ Person

0.69 2 2 2 1.38 1.59 1.83 4.79

Sub Total 4.00 2.00 2.00 1.44 1.59 1.83 4.865.3 Food Regulation

5.3.1 Collaborate with the Food Authority for effective Food Security regulation

Policy Decision

0.00 0 0 0 0 0 0 0.00


Outcome 5: Total 1.44 1.59 1.83 4.86Note: Text in the matrix shown in brown includes activities that are in addition to the MHSDP activities or those supported through Preventive Programmes PC-1s and the district can decide to include or remove from their Annual Work Plans

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SECTION 9: ANNEXURESANNEXURE I

66


ANNEXURE II

67


ANNEXURE III

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ANNEXURE IV

MONITORING & REPORTING MATRIX

Monitoring & Reporting Matrix of District Health PlanMilestones Primary & Secondary Responsibility (Focal Points)

Program DGHS DHO M&E Cell

Reporting System

Remarks

Annual Reporting including Targets and Results Document

Primary: DHOSecondary: District Program

officers Partners district

Copied

Copied Manual All submissions for the Monthly and Annual Reports including Narrative Reports, Activities Matrices, formative and summative research and Summary of Targets and Results data from stakeholders/Partners and from all programs sections (Admin, Finance, ) to be provided to DGHS

Stakeholder/ Partners’ Monthly, Quarterly Activity Monitoring Sheets

Primary: PartnersSecondary: DHO DHT

Copied

Copied Off line Periodic cross checks with Summary of Targets document to be made on quarterly basis of all the stakeholders working in the district in the health sector.

DHIS/Dashboard Primary: DHO / DHIS Coordinator.Secondary: District Program

officers Partners district

Program officers

Copied

Copied Online Analysis of data findings will be provided for the district by DHIS coordinator and for the districts and province by provincial M&E cell.

HMIS (LHW, HMIS, EPI) data

Primary: DHIS Coordinator.Secondary: Program Managers

Copied

Copied Copied Software/Manual Quarterly submission of district-based MIS data to be made by Program managers for collation coordinator DHIS; Data entry and file maintenance will be undertaken jointly by program managers and coordinator DHIS; Analysis of data findings will be provided by DHT coordinator.

LQAS results Primary: DHIS Coordinator Secondary: DHT, Provincial M&E cell

Copied

Copied Manual DHIS coordinator responsible for conducting all training, activities implementation and reporting on all LQAS; Technical assistance will be provided by provincial M&E cell.

PRISM Primary LHW coordinator.Secondary : CMW coordinator, LHS

Software/ Manual

CMW coordinator. Responsible for conducting training, activities implementation, reporting. Technical assistance will be provided by DHS DGHS office

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Operational Plan targets

Primary: DGHS/M&E cellSecondary: DHO, Partners

Copied

Copied Dashboard. With overall oversight of DGHS, DHO/DHT working with partners responsible for development and implementation and monitoring of annual Operations plans.

Monitoring and Supervision

Primary: DHIS Coordinator, Secondary: DHMT, DHT

Monitoring Reports

DHIS/DHT/DHMT coordinator to act as focal person for overall field monitoring. All monitoring tools will be filled out, analyzed and followed up on by individual focal persons, but copies will be made available to all concerned; DHIS coordinator. Will be responsible for developing monitoring Plan for the senior management at the district level.

Training both in service and pre-service

Primary: PHSASecondary: DHDC/DHO/DHS

Copied

Copied Manual Training reports

DHO along with PHSA and with DHT members responsible for overall monitoring of midwifery school functioning, quality of training, new batches; logistics and administrative trouble shooting

.Monitoring of Partners/stakeholders

Primary: PartnersSecondary: DHO

Copied

Copied Monitoring Reports

Primary responsibility with partners. DHO responsible for monitoring of Partners performance with support of DHT.

Health Systems (DHMTs, DHIS, DAOP)

Primary: DGHS/DHSSecondary: DHT

Dashboard Director health services is responsible for monitoring the quality of DHSS in districts including training aspects, DHMT functioning with assistance from DGHS office.

Health facilities refurbishments/Civil Works

Primary: P&D/ C&WSecondary: DHO

Copied

Copied Manual DHO for monitoring of close out civil works and procurement of equipment. DHO also responsible for monitoring all aspects of health facilities up gradation / civil works

Equipment & supplies Primary: DGHSSecondary: DHO

Copied

Copied Manual/procurement orders

DGHS in consultation with DHO responsible. In case of procurement of more than Rs. 50 million NAB is also part of the exercise.

DHPC Meeting Primary: DHTSecondary: DHMT

Manual/ Minutes of Meeting

DHO with the support of DHT responsible for DHPC meeting agenda, participants and logistics

PHPC Meeting Primary: Secretary/DGHS Secondary: DHO

Manual/ Minutes of Meeting

Secretariat and DGHS responsible for acting as focal person for all stakeholders/partners and DHS for document and data repository for evaluations, research, lessons learnt.

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District Health Plan Nowshera 2015

Healthcare

district health departments

district health plan

team acknowledgement

team leader trf

district profile

nasir idrees team leader

ali asghar khan

nadeem ahmad