Improving Reproductive Health in Punjab Review of the Punjab Health Sector Strategy

Punjab Health Sector Strategy (PHSS) 2012 – 2020 Approved in February 2013 Strategic Direction Achieve universal coverage of health services Focus on Primary Healthcare Improve Quality of care Mainstreaming private sector health services Redefining the Government’s role to one of facilitator Strengthening of institutional collaborations

Reproductive Health Strategies identified in the PHSS 2012-2020

Focus and strengthen MNCH, family planning and nutrition services at all levels as part of Essential Package of Health Services (EPHS). Integrate all MNCH, family planning and nutrition activities at community and primary health facility level as part of Essential Package of Health Services (EPHS). Create referral backup for community-level health workers, like CMWs to cater maternal complications Strengthen routine immunization services for full immunization of all children and women Provide family planning services through uninterrupted supply of family planning commodities to all the primary and secondary level health facilities and outreach workers Upgrade a minimum of one third of the BHUs to BHU-plus model for delivery of services on 24/7 basis in 20 low performing districts Ensure full package of 24/7 Basic EmONC services at all RHCs and develop RHCs as hub of primary health care system; with services, management and supervision support fanning out to the adjoining BHUs

Focus and strengthen MNCH, family planning and nutrition services at all levels as part of Essential Package of Health Services (EPHS). Upgrade RHCs to RHC-plus model for provision of 24/7 Comprehensive EmONC services in each of 20 low performing districts of Punjab Upgrade and strengthen all THQ and DHQ hospitals to provide full package of 24/7 Comprehensive EmONC services, including neonatal intensive care units with qualified staff Upgrade, strengthen and realign all tertiary care level hospitals to cater MNCH related management and referral Institute mass and interpersonal communication focusing key issues of MNCH, family planning and nutrition Conduct training of staff at all levels on Integrated Management of Newborn and Childhood Illnesses (IMNCI) with a functional follow-up after training mechanism

Strengthening of Nutritional services for mothers and children as part of EPHS Integrate nutritional services in pregnancy care both at health facilities and through outreach workers and provide management of severe acute malnutrition in targeted health facilities. Ensure availability of nutrition supplements and build capacity of healthcare providers, both public and private, on nutritional assessment and management of malnutrition Protect all pregnancies through provision of micronutrient supplements including iron, calcium, zinc, vitamins and folic acid

Integration of preventive healthcare (vertical) programmes Ensure functional and managerial integration of vertical programmes under EPHS at primary level and for the interim period regroup programmes having common objectives. Optimize healthcare service delivery arrangements through adopting integrated models, like SRH-HIV and family planning service for reproductive health

Areas for Improvement The budgetary allocations present no prioritization for correcting reproductive health situation Budgetary allocation focuses on structural actions such as building infrastructure. Demand generation i.e. stimulating health seeking behaviour, is ignored. Phasing of interventions is not described. Contents (and their prioritization) of Essential Package of Health Services (EPHS) are not defined. Annual targets and operational plans to achieve targets are missing. LHW Programme - one of the largest vertical programs focusing on MNCH and family planning has not been discussed in the strategy Capacity building initiatives for community outreach workers such as the LHWs or the CMWs are not well defined

Areas for Improvement Missing Reproductive Health issues: Safe abortions Youth Reproductive health Reproductive Health education Rights based approach

Recommendations for Government An integrated approach to Reproductive Health through Interdepartmental coordination and planning including departments of Population Welfare, Education, Women Development, Planning & Development, Human Rights, Social Welfare and Law. Scaling Up, to poor districts, of : Health cards by Punjab Health Sector Reform Program(PHSRP) Chief Minister’s Health Initiative for Attainment and Realization of MDGs (CHARMS) Protect and advance women’s reproductive health rights by strengthening the legal frameworks in Punjab Health education to raise awareness about sexual and reproductive health & rights in the province.

Recommendations for Government Focus on adolescent and youth reproductive health Include safe abortions and post abortion care in health strategy. Gender based Violence be made part of health strategy, including identification, management and referral of GBV cases. Prioritization and strengthen reproductive health and family planning services including counselling and referrals by LHW and MNCH Programmes. Contracting out government services, in case of low utilization and closing down of underperforming public facilities Income pro-rated payments (i.e. no fees or subsidized payments from the poor based on their income and more complete payments from more affluent users of health services) for services at public sector facilities and allow facilities to retain the user fees they collect.

Recommendations for Government Create performance standards and performance related incentives for both facility and outreach workers to provide reproductive health services. Partnering with private sector and donors to improve supply and uptake of reproductive health services in rural and remote areas Strengthen information management and logistics systems to minimize stock outs for family planning and reproductive health commodities. The strategies must be followed by SMART (Specific, Measurable, Attainable, Relevant, Time-bound) action plans.

Recommendations for Non State Actors Generate evidence for issues and challenges in maternal &Reproductive Health among different population groups. Generate feedback on successful pilots, innovative programs, international programmatic strategies that have worked to improve Reproductive Health. Provide research and advocacy services to the government Improve information sharing Develop and implement innovative campaigns to improve awareness about Reproductive Health rights, benefits of family planning

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