1. April 19, 2010 Regional Workshop Asian Development Bank Headquarters 19-20 April Manila Philippines Dr Amanullah Senior Director Health & Nutrition Strengthening and providing PHC services in Pakistan through public private partnership

2. Background 180 Million People MMR 276/100,000 IMR 78/1000 NMR 54/1000 CPR 30%

3. Background 270 District/ Sub District Hospitals 5500 Basic Health Units 800 Rural Health Centers 96000 LHWs

4. Background Over 60% of peripheral health facilities under utilised: –Inaccessible health facilities- Inappropriate site selection –Health Human Resource Management problems like –Gender and skill imbalances –Staff absenteeism. –Ill planned & frequent postings and transfers. –Inverted pyramid of health professionals –Lack of funds for maintenance & repair –Irrational financial allocations- less resources for primary health care Weak management capacity & ineffective monitoring and supervision

5. Emergency prone country Influx of Afghan Refugees In 1985 2005 Earthquake 2009 IDPs

6. Rural Health Center, Banna, Allai Pakistan Earthquake 2005

7. The Objective To revitalize, strengthen and provide primary health care services in district Batgram through a public private partnership initially for a period of two years

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

9. Management of PHC services The Model Regional Evidence Revitalization of PHC services Local Evidence Revitalization of PHC services Public Private Partnership Performance Based IncentivesThe HUB Approach Capacity Building Management of PHC services

10. The Hub Approach Integrating RHC with cluster of 6-10 BHUs 24/7 Basic EmONC facility Referral facility for attached BHUs Housing & recreational facility Mobility for supervision and rotation Some financial and administrative authority delegated to Hub I/C Services, timings, telephone numbers displayed at each facility Ambulance service for timely referrals

11. Hub-1

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

13. Community Involvement District Health Management Team Quality Improvement Team

14. # of Health facilities operationalised

15. Staff Deployment

16. 24/7 EmNOC Facilities

17. HMIS Reporting

18. Average Monthly Consultations

19. Antenatal Registration

20. Deliveries by Skilled Birth Attendants

21. TT-2 Vaccination

22. Children Fully Immunized

23. Family Planning Services

24. OTP & SFP Centers Established

25. CMAM Beneficiaries

26. Before/After

27. Mid Term Review Human Resources 0 20 40 60 80 100 120 Human Resource Policy Availability of Staff Training & Capacity Incentives & Privileges for Staff Commitment of Staff Overall Before Project After Project

28. Mid Term Review Services 0 20 40 60 80 100 Range of health care services Patient utilization of services Quality of services Outreach health care services Before Project After Project

29. Mid Term Review Client Satisfaction by various domains

30. Lessons Learnt Keeping district stakeholders on board helped to overcome resistance from Government staff Performance based incentives coupled with clarity around job descriptions, capacity building and improved supervision brought staff absenteeism to zero and HMIS reporting to 100% Providing conducive working & living conditions ensured deployment of female staff

31. Lessons Learnt Improvement in availability and quality lead to enhanced utilization of PHC services Delegating more powers to accountable managers at HUB level paved the way for improved supervision More time required to implement the transition strategy of delegating more authority to HUB managers and institutionalisation of AHMTs and QITs into district health system

32. Thanks