GBHDP Evaluation Report Jan 20 2015

GILGIT-BALTISTAN HEALTH

DEVELOPMENT PROJECT

PHASE- 2

END OF PROJECT EVALUATION REPORT

By

Dr. Sohail Amjad

Result Based Consulting

Islamabad

[email protected]

mailto:[email protected]

Contents

Abbreviations and Acronyms ...................................................................................................... 1

Acknowledgement ...................................................................................................................... 3

Executive summary .................................................................................................................... 4

Introduction ................................................................................................................................ 8

Health system in Gilgit Baltistan ............................................................................................10

Provincial health profile .........................................................................................................11

Project background ...................................................................................................................12

Project inception and objectives ............................................................................................12

Description of project components .........................................................................................13

Monitoring and evaluation......................................................................................................17

Purpose of final project evaluation ............................................................................................18

Evaluation methods ..................................................................................................................19

Evaluation design ..................................................................................................................19

Quantitative methods, study population and tools ..................................................................20

Qualitative methods, study population and tools ....................................................................23

Data management & analysis ................................................................................................23

Findings ....................................................................................................................................24

Summary of findings ..............................................................................................................24

District wise distribution of health facilities .............................................................................27

Characteristics of respondents ..............................................................................................28

Physical condition of health buildings ....................................................................................29

Infrastructure ......................................................................................................................29

Human resource ................................................................................................................30

Availability of basic equipment ...............................................................................................31

Availability of essential stocks/supplies ..................................................................................32

Availability of drugs................................................................................................................33

Outcome of trainings .............................................................................................................33

Knowledge of health care providers ...................................................................................33

Provision of health services ...............................................................................................35

Utilization of health services ...............................................................................................35

Quality of health services ...................................................................................................37

Financial analysis ..................................................................................................................39

Qualitative findings ................................................................................................................43

Recommendations and way forward .........................................................................................46

Conclusion ................................................................................................................................48

ANNEX-I: Quantitative tools ......................................................................................................49

ANNEX-II: Qualitative tools .......................................................................................................68

ANNEX-III: District wise physical condition of health facilities ....................................................70

ANNEX-IV: Financial Analysis of Gupis Civil Hospital ...............................................................72

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Abbreviations and Acronyms

AKDN Aga Khan Development Network

AKF, P Aga Khan Foundation, Pakistan

AKHS, P Aga Khan Health Service, Pakistan

ANC Antenatal care

BHUs Basic Health Units

CBHW Community Based Health Worker

CHN Community Health Nurse

CMW Community Midwife

DOH Department of Health

DC Deputy Commissioner

DHS Demographic and Health Survey

DHO District Health Officer

DHQ District Head Quarter

FHCs Family Health Centers

FP Family Planning

FAPs First Aid Posts

FLHCF First Level Health Care Facilities

ECD Early Childhood Development

EmONC Emergency Obstetric and Newborn Care

EHSP Essential Health Services Packages

EPI Expanded Programme on Immunization

GB Gilgit-Baltistan

GBHDP Gilgit-Baltistan Health Development Project

HIS Health Information System

HR Human Resource

IMCI Integrated Management of Childhood Illnesses

IUCD Intra-uterine contraceptive devise

KIIs Key Informant Interviews

KPK Khyber Pakhtunkhwa

LHV Lady Health Visitor

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LHW Lady Health Worker

LMO Lady Medical Officer

LSO Local Support Organization

MIS Management Information System

MMR Maternal Mortality Ratio

MDGs Millennium Development Goals

MHSP Minimal Health Services Package

M&E Monitoring and Evaluation

MCH Mother and Child Health

NGO Non-governmental Organization

NA Northern Area

OT Operation Theatre

OPD Outdoor Patient Department

PDHS Pakistan Demographic Health Survey

PNC Postnatal Care

PPP Public-private partnership

RHCs Rural Health Centers

SLHCF Secondary Level Health Care Facility

SARA Service Availability and Readiness Assessment

SBAs Skilled Birth Attendants

TT Tetanus Toxoid

TFR Total Fertility Rate

TB Tuberculosis

TBA Traditional Birth Attendant

WHO World Health Organization

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Acknowledgement

The Result Based Consulting (RBC), The Team Leader and research team extends profound

gratitude to the focal team of Aga Khan Foundation/ Aga Khan Health Services, Pakistan, in

particular to Dr. Babar Tasneem Shaikh (Director Health and Built Environment, AKF), Dr. Sharif

Ullah Khan (Senior Programme Officer, AKF), Ms. Malika Saba (Project Manager, GBHDP) and

Mr. Siffat Ullah (General Manager, AKHSP GB) for their guidance and support to execute this

formative research and vision to benefit from the study outcomes.

RBC is grateful to the government authorities of the districts for sparing time for discussion. We

highly appreciate the Field Health Officers (FHOs) of AKHSP, GB for extending their support

and facilitation for meetings and data collection from health facilities.

We are thankful to the whole research team including our core consultants for their untiring

efforts and dedication to complete the task in the given timeline. Thanks are also due to Mr.

Danish Sohail for his tremendous assistance to compile and analyze financial data.

January 2015

Result Based Consulting, Islamabad

Dr. Sohail Amjad (Team Leader),

Result-based Monitoring and Evaluation

Specialist, Email: [email protected]

Disclaimer

“The views expressed in this publication are those of the author(s) and do not necessarily represent the

views of Aga Khan Foundation or KfW or any of its affiliated organizations.”

The Result Based Consulting has made every effort to provide the most accurate information, data,

statistics, facts, figures, drawings and procedural descriptions contained in this document. The limitations

of the accuracy of the information at the source, however, remain. The document may thus contain

human or mechanical errors or omissions. No liability for such errors, or omissions, or un-intentional

misrepresentations will be accepted. The Consultants reserve the right to make corrections and changes

in any information contained in this and in subsequent versions of this document.

mailto:[email protected]

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EXECUTIVE SUMMARY

Background

Despite certain health reforms in Pakistan, progress on health related Millennium Development

Goals (MDGs) lags behind many regional countries with cultural, economic and geographic

similarities. The Department of Health (DOH) and the Aga Khan Health Service, Pakistan

(AKHS, P) are the two primary formal sector providers of healthcare services in Gilgit-Baltistan

(GB), attempting to ensure equitable coverage at scale (in 5/7 districts) throughout the

province. KfW provided financial support to AKHS, P for GB region under the Gilgit-Baltistan

Health Development Project Phase II (GBHDP) in 2009 for a period of 5 years up to June, 2014

with a financial cap of two (2) Million Euros. The aim of the project was to contribute to the

improvement of the health status of the population of GB with particular attention to the women

and children. The project components included Rehabilitation/construction of five (5) health

facilities, procurement of medicine, equipment and vehicles, training of staff and community

based health workers, and coverage of operation cost of AKHSP in Gilgit-Baltistan at Gupis civil

hospital including support, supervision and facility operation on pro rata basis on a declining

trend over the project period. Although the project was planned to be completed in June 2014,

but a no cost extension of the project till December 2014 was availed to complete certain project

milestones. The purpose of evaluation is to underpin the contribution of the project towards

achieving key health indicators in the population served.

Evaluation Methods

End-line evaluation design consisted of a participatory mixed-methods approach using both

quantitative and qualitative data supplemented by physical verifications and field observations,

discussions with stakeholders in terms of performance on key result indicators by adapting

WHO tools. Part of the study was essentially based on secondary data review. For the

quantitative component, „Service Availability and Readiness Assessment‟ (SARA) survey was

employed in 12 sampled health facilities to evaluate physical status of buildings, availability of

services and outcomes of trainings. SARA is a health facility assessment tool designed to

assess and monitor the service availability and readiness of the health facility. Key Informant

Interviews (KIIs) were organized with health managers to record their perceptions on this PPP

arrangement; but essentially to evaluate the operational cost of health facility.

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Findings

Physical condition of health buildings: Overall, 83% (10 out of 12 sampled facilities ) of the

health facilities were found to be seismic proof whereas retrofitting work was not required in

17% health facilities. Piped water supply and intact boundary wall were found in all the health

facilities. All the health facilities had appropriately displayed sign boards and enough seating

arrangements for the waiting area. Out of twelve (12) health facilities, eleven (11) were

maintained/renovated last year except Gupis Civil Hospital which took longer than usual for

completion of physical works. All the inspected health facilities had functional labor room

(nursery, OT, sterilization room) and functional telephone lines. Labor rooms of five health

facilities were insulated for proper heating.

Human resource for health: Findings revealed that 58% (7/12 sample facilities) of health

facilities were functioning without a Lady Medical Officer (LMO), Lady Health Visitor (LHV) was

found present in all health facilities, and a dispenser was available in nine (9) out of twelve (12)

health facilities suggesting 25% of the health facilities were without dispenser/MHT staff. At

least one support staff was available in all inspected health facilities.

Availability of equipment: Basic equipment was present as well as functional at all inspected

sites of three districts. The basic equipment includes BP apparatus, stethoscope, thermometer,

sterilizer, safe delivery kit, and the delivery table. Other project funded equipment available and

being utilized at civil hospital Gupis. However, x-ray machine, and baby incubators were

procured and being supplied in two weeks.

Availability of essential drugs and supplies: Drugs which were available in all health facilities

are oral antibiotics syrup for children and adults, antipyretic drugs, folic acid tablets, antiseptic

solution and antihypertensive drugs. About 83% (10 out of 12) of the health facilities were not

experiencing any stock out of essential drugs. Modern Family Planning (FP) material was

available in all surveyed health facilities. Health information system (HIS) stationary was present

and maintained regularly in all health facilities.

Knowledge of health care providers: Health facility staff had adequate knowledge on delivery

of reproductive Health, antenatal care (ANC), postnatal care (PNC) services, integrated

management of childhood illnesses (IMCI), nutrition and referrals. Knowledge of MNCH related

staff, i.e. LHV and LMO, was satisfactory on safe delivery practices, infection prevention and

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control, and management of ante-partum and post-partum hemorrhage. Understanding of

temporary FP methods and intra-uterine contraceptive device (IUCD) and its procedure for its

insertion was satisfactory among LHVs and LMOs.

Provision of health services: All surveyed health facilities were providing services specific to

ANC, PNC, tetanus toxoid (TT) immunization, treatment for minor curative services, facility

based normal vaginal delivery and provision of FP services and materials. SARA survey

revealed that 92% health facilities are providing Expanded Programme on Immunization (EPI)

services except at Singal medical center.

Utilization and quality of health services: There has been a significant uptake of services

with regard to outpatient department (OPD), ANC and PNC visits, after the improvement and

renovation of the facilities was carried out. Average number of institutional deliveries and

vaccination of children (11-23 months) against measles also increased significantly in 2014 as

compared to 2013. Average number of institutional deliveries increased to twelve (12) by 2014

as compared to seven (7) deliveries in 2013. The number of OPD visits at Gupis civil hospital in

2014 also increased by four (4) times as compared to 2013. Findings reveal that 59% of the

respondents‟ categorized quality of health services as „good‟ whereas 29% ranked as

„excellent‟. Among respondents who categorized health services „good‟, 69% were female and

31% were male service users. About 76% of the respondents informed that they wait for 15-30

minutes at health facility to see doctor whereas 24% wait for more than 30 minutes.

Financial analysis: There were only two sources of revenue generation for the Gupis civil

hospital, i.e. AKHS, P allocations through KfW funds and user fees. Financial inputs by the

government were nil for the last two years to support public-private partnership (PPP) model.

Under the PPP model of the Gupis, government has allocated insufficient funds to sustain

operations at Gupis hospital for the fiscal year 2015. AKHSP allocations for Gupis in the year

2014 increased by 12% and user fee decreased by 11% as compared to year 2013. The total

funds generation for the year 2014 decreased by 1% over the year 2013-14. For year 2015, the

forecasted AKHSP allocations for Gupis would increase by 7% and user fee generation would

increase by 106% over the years 2014-15. Financial inputs and expenditures at Gupis civil

hospital were recorded at a breakeven in the last two fiscal years. In view of mere financial

allocations by the government under PPP at Gupis for 2015, there is increased likelihood that

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the hospital may go through loss if alternate modes of financing or other arrangements are not

available. Financial deficit is being covered by GBHDP and remaining through user fee income.

Under the memorandum of understanding of the PPP, it is expected the government will

allocate sufficient funds to sustain operational cost of the Gupis hospital.

Conclusion and Recommendations

GBHDP has achieved remarkable results in terms of contributing to the overall goal of health

system strengthening , improvements in health outcomes to improve infrastructure of health

facilities, availability of services (HR, drugs, supplies), and improved knowledge and skills of

health care providers. PPP model at Gupis is operational and providing specialized health care

to the catchment population. PPP model at Gupis provides AKHSP and DOH with opportunities

to develop effective strategies and arrangements for continuity of quality services at the

hospital. While government has committed a handful of funds for the current fiscal year, there is

dire need for proactive lobbying with DoH and GB government by AKHSP in general, to

increase budget or to take remedial steps to sustain operational cost at Gupis civil hospital.

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INTRODUCTION

Pakistan ranks quite low in Human Development Indices, with poor health and other

development indicators. Despite certain reforms undertaken by successive governments to

reorient the health system,, the progress of health related Millennium Development Goals

(MDGs) lags behind many regional countries, having same cultural, economic and geographic

dynamics. According to the World Health Statistics, under-five mortality rate in neighboring

countries is low as compared to Pakistan with a higher rate of 86/1000 live births. Evidence

suggests that under-five mortality rate is fairly low in Iran (18/1000), India 56/1000) and

Bangladesh (41/1000). Likewise maternal mortality ratio (MMR) in Pakistan has been projected

to be around170/100,000 live births, which is still high when compared to adjoining countries

having similar or poor socio-economic status1. Inequities in health remain large between high-

income and low-income countries even though expanded investments have been made by

leading development partners of the world. Reducing these inequities across countries and

saving the lives of more women and children by rolling out essential health intervention ought to

be the key priorities of developing countries like Pakistan.

Health system of Pakistan has undergone administrative and fiscal reforms with the effect of the

18th constitutional amendment in 2011, which posed many implications on health care provision

with the devolution of many social sector portfolios, including health2. Although health reforms

are prioritized in the wake of this devolution, health system performance indicators in Pakistan

are below par as discussed above. While constitutional amendment has created many

opportunities for improving service delivery, it has also presented serious lacunae in Pakistan.

Empowering provinces without proper mechanisms in place for implementation and conflict

resolution can actually result in poor performance of the health system. Pre-requisites of a

successful devolution were overlooked by the Federal government of Pakistan which include a

strong central state, and an optimal technical and managerial capacity of provincial health

systems. Nevertheless, recently elected government has a unique opportunity to push through

reforms and take advantage of these constitutional changes that devolve health care to the

provinces3.

Pakistan Demographic Health Survey (PDHS) Pakistan conducted under the umbrella of the

global Demographic and Health Survey (DHS) program provides information on the status of

1 World Health Organization. World Health Statistics. Geneva: WHO; 2014.

2 Nishtar S. Health and the 18th Amendment, need for a national structure. Islamabad: Heartfile; 2011.

3 Pakistan Institute of Legislative Development and Transparency. Health and the 18th Amendment: An analysis. Islamabad:

PILDAT; 2011.

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health development indicators in all provinces including Gilgit-Baltistan (GB). The Total Fertility

Rate (TFR) is higher in rural areas than in the urban areas, reaching 4.2 births per women in

Baluchistan. TFR in Gilgit-Baltistan and Punjab is 3.8 births per women as compared to 3.9

births per women in Sindh and Khyber Pakhtunkhwa (KPK). One quarter of the Pakistani

women use modern contraceptive methods of family planning. Twenty eight (28) percent of

married women use modern contraceptives in GB, suggesting a high unmet need. Over the

years, gap between the supply side and the demand side has remained stagnant to reach

mothers with unmet need. Recent data from the PDHS 2012-13 reveals a declining trend of

infant and under-five mortality rates in the country except the neonatal mortality. Comparison

with adjoining province of KPK reveals that infant and under-five mortality rates are much higher

in GB 4 . Main contributors to neonatal deaths are the birth asphyxia, intra-uterine growth

retardation, acute respiratory infections and diarrhea, whereas under-five mortality is attributed

to preventable causes such as diarrhea and pneumonia5. The top three causes of maternal

death are postpartum hemorrhage, followed by eclampsia and sepsis6. Due to poor maternal

care during pregnancy, one out of every three babies born in Pakistan has a low-birth weight.

Although some service delivery indicators appear to have improved over the last two decades,

women‟s access to prenatal health care continues to be low in Pakistan, and GB has even

worse picture where a woman struggles to seek timely health care7. Approximately two-thirds of

all births (61%) take place at home due to limited access to health facilities. Home based

deliveries are usually attended by traditional birth attendant (TBA), or a family member in rural

Pakistan. Limited skilled human resource at health facilities and community especially in the

context of GB is key concern. Four (4) out of ten (10) mothers are delivered by the skilled birth

attendants in GB and only 19% seek PNC from the skilled birth attendant4. About 64 percent of

mothers seek at least one ANC in GB as compared to 73% in Pakistan, whereas 45% of the

mothers receiver two or more TT in GB as compared to 59%in Pakistan. 47% under-five

children receive basic vaccinations. In GB regions, only 22% of pregnant women attend four or

more ANCs as compared to 38% in the adjoining province of KPK4,8. It is worth mentioning that

4 National Institute of Population Studies/ICF international/USAID. Pakistan Demographic and Health Survey 2012-13. Islamabad:

NIPS; 2013. 5 Jehan I, Harris H, Salat S, Zeb A, Mobeen N, Pasha O, McClure EM, Moore J, Wright LL, Goldenberg RL: Neonatal mortality, risk

factors and causes: a prospective population-based cohort study in urban Pakistan. Bull World Health Organ 2009, 87(2):130-138. 6 National Institute of Population Studies and Macro International Inc. Pakistan Demographic and Health Survey (PDHS) 2006–07.

Islamabad: Government of Pakistan; 2008. 7 Shaikh BT, Haran D, Hatcher J. Where do they go, whom do they consult and why: an ethnographic study on health seeking

behaviours in the Northern areas of Pakistan. Qual Health Res 2008; 18(6): 747-755.

8 National Institute of Population Studies. Gilgit and Baltistan Demographic and Health Survey. Islamabad: NIPS; 2008.

10

population doctor ration in GB is 1:4100 as compared to 1:1183 at national level9. According to

PDHS 2012-13, 69% respondents recalled unavailability of transport as a major barrier to

access health services.

The service structure for health workers is poorly defined which favors tenure over competence,

largely ignores technical capacities and does not allow incentives or rewards for performance.

Community Midwives (CMWs) of the Maternal, Neonatal, Child and health (MNCH) program is

the example in this case. Lady Health Worker (LHW) program and MNCH program are indeed

positive efforts by the government of Pakistan to provide door-step health care services.

Nevertheless, the coverage of these programs to provided Essential Health Services Packages

(EHSP) is a concern. Likewise, limited availability and capacity of health facility staff is one of

the major impediments in provision of quality health services. Other system related constraints

in provision of health services are poor infrastructure, fragmented service delivery structures,

poor quality of equipment, stock out of essential drugs and lack of integrated health information

system. In addition to these non-financial constraints, low level of health spending further

compound the sub-optimal performance of the health sector in Pakistan 10 . All of these

limitations restrain the utilization of the health service in the public sector, therefore leading to

unresponsiveness of health system.

Health System in Gilgit Baltistan

Gilgit-Baltistan, formerly known as the Northern Areas borders Pakistan's Khyber Pakhtunkhwa

province at the west, Afghanistan's Wakhan Corridor to the north, China at the north-east, Azad

Kashmir at the south and the disputed territory of Jammu & Kashmir state of India at the south-

east. Gilgit-Baltistan covers an area of 72,520 KM and has an estimated population approaching

over million in seven districts. In Gilgit-Baltistan, the devolution never granted hence each

district is headed by the Deputy Commissioner (DC) assisting the Divisional Commissioner and

is accountable to him. The DC coordinates with District Officers who head each of the district

offices including health. In public sector, health care delivery system is managed by the District

Health Officer (DHO) who is assisted by deputy district health officers, district coordinator/ public

health specialist of national programmes11.

Government of Gilgit-Baltistan has formulated health sector strategy in response to challenges

related to quality of service delivery and coverage, a competent health workforce, governance

9 Research and Advocacy Fund. Provincial & regional stakeholders consultation meetings report-Gilgit Baltistan. Islamabad: RAF;

2012. 10

Mazhar A, Shaikh BT. Reforms in Pakistan: Decisive times for improving maternal and child health. Healthcare Policy 2012; 8(1):24-32. 11

Technical Resource Facility/Department of Health-GB. Health Facility Assessment – Gilgit Baltistan District Gilgit. Evaluation report. Islamabad: TRF; 2012.

11

and regulation of health sector. The salient features of the strategy emphasizes on development

of costed Minimal Health Services Package (MHSP), improved availability of quality essential

medicines in health facilities, increased coverage and utilization quality services at primary &

secondary health care facilities12. These are high times for the department of health, GB to

strategize, plan and act for the improvement of health sector.

Provincial Health Profile

DOH and AKHS, P are the two primary formal sector providers of healthcare services in GB,

ensuring equitable coverage at scale throughout the province. Other formal and informal sector

private providers such as private clinics, traditional healers, traditional birth attendants (TBAs)

and homeopaths also operate in the area, along with a few small non-governmental

organizations (NGOs) programs. The government is considered by far, the main provider of

preventive care throughout the region and the major provider of curative services in seven

districts of GB. The vast majority of curative and preventive services in Gilgit, Hunza-Nagar and

Ghizer are sought out in the private sector, which includes AKHS, P. This is mainly attributable

to the real and perceived quality of care in the private vs. public sector. In general, people

access health services primarily for preventive and curative care, through DOH and AKHS, P.

Health services in public sector are provided through a tiered referral system of health care

facilities; with increasing levels of complexity and coverage from primary, to secondary level

health facilities. Primary care facilities include basic health units (BHUs), rural health centers

(RHCs), government rural dispensaries, mother and child health (MCH) centers, tuberculosis

(TB) centers and First Aid Posts (FAP). Primary care facilities also provide outreach preventive

services to the communities through LHWS and vaccinators. Secondary health care services

are provided in the District Headquarters (DHQ) and civil hospital. A recent health facility

assessment of the region suggests there are 5 DHQs, 27 civil hospitals, 2 RHCs, 15 BHUs, 190

rural dispensaries, 93 MCH centers, and 154 sub-health centers11.

AKHS, P is a not-for-profit non-governmental organization complementing government efforts

since 1962 and primarily providing MCH services in an equitable manner, irrespective of

socioeconomic status or religion. In GB region, AKHSP operates 21 health centers, 9 Family

Health centers (FHCs), 2 Extended Family Health Centers (EFHCs) and 2 medical centers in

addition to having 599 community-based workers13.

12

Shaikh BT. Devolution in health sector: Challenges & opportunities for evidence based policies. Occasional Paper Series. Islamabad: LEAD, Pakistan; 2013. 13

Aga Khan Health Services, Pakistan. Health facility MIS data-Regional office. Gilgit: AKHSP; 2013.

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PROJECT BACKGROUND

Project Inception and Objectives

In relation of aforementioned constraints and limiting factors to avail and access health service,

KfW provided financial support to AKHS, P for Gilgit-Baltistan (GB) region under the GBHDP,

Phase II in 2009 for a period of 5 years up to June, 2014 with a financial cap of two (2) Million

Euros. The aim of the project is to contribute to the improvement of the health status of the

population of GB with particular attention to women and children. After approval of KFW funding

the AKHS, P Board organized a detailed planning to prioritize activities for best utilization of the

funds. An inception workshop was organized in Karachi from June 3-4, 2009, which provided a

unique opportunity to reflect on and revisit Northern Area (NA) programmes and to propose

steps to move it towards a more effective, efficient, accessible, quality assured and more

sustainable healthcare system.

The key issues/challenges faced by AKHS, P programme in NAs were highlighted. These

issues included poor status and infrastructure of AKHS, P facilities, scarcity and limited capacity

of skilled health care providers, unavailability of equipment e.g. C-arm X-ray machine, CT

scanner and new lab equipment, and stock of medicines and supplies at health facilities. All of

these limitations adversely affect the quality of care, ambience and comfort of clients; which are

cornerstone of AKHS, P health facilities. Deliberations of the inception meeting also concluded

that support provided by the KfW is a unique opportunity to improve health care services in

primary and secondary health care facilities. Objectives for the GBHDP were outlined in the

inception meeting along with the project components. The project objectives of AKHS, P

component are:

1. Improvement of health care services at first and second level of the referral system

2. Improved access to health services of underprivileged groups, especially women and

children (adequate and efficient lifesaving medical facilities).

In order to attain objectives of the GBHDP, following components were strengthened:

1. Rehabilitation/construction of health facilities

2. Procurement of medicine, equipment and vehicles

3. Training of staff and community based health workers

4. Coverage of operation cost including support, supervision and facility operation on pro

rata basis on a declining trend over the project period.

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Although the project was planned to be completed in June 2014 but due to unfinished

construction work and to strengthen fourth component at Civil Hospital Gupis on PPP basis,

AKF, P requested KfW for six months no cost extension of the project till December 2014, which

was approved. This additional period of intervention was meaningful to support PPP model at

the Civil Hospital Gupis which incorporated coverage of operation cost including support,

supervision and facility operation on pro rata basis by AKHS, P on a declining trend over the

project period.

Description of Project Components

1. Rehabilitation/construction of rented health facilities

Poor infrastructure of the health facilities in northern areas of Pakistan has been a chronic issue

in provision of responsive and quality health service. Health facilities of the AKHSP faced similar

issue due to constrained financial resources with no major programmatic expansion or

investment in infrastructure and capital development for many years. In 2009 the long-awaited

KfW funding under GBHDP for five years provided an opportunity for AKHSP to enter into a

“sustainability phase” of AKDN programmes in GB. Rehabilitation and construction of five

AKHSP facilities was initiated and planned to be completed by June 2014. However, no cost

extension till December 2014 was requested by AKHSP to complete physical works which

included insulation, retrofitting and improvement of general infrastructure (waiting room,

boundary wall etc.) in health facilities. Following table-1 lists the five (5) health facilities of district

Ghizer, Hunza-Nagar and Gilgit where rehabilitation and construction work was completed.

Table-1: Type of construction/renovation work in health facilities

District Health facility Type of renovation/physical work

Ghizer Civil Hospital Gupis

Retrofitting for earthquake resilience; Insulation of labor

rooms; General infrastructure improvement of waiting

room and boundary wall; Sanitary, plumbing electrical

work

Ghizer Family Health Center, Yasin

Construction of additional rooms services; General

infrastructure improvement of waiting room and

boundary wall; Sanitary, plumbing electrical work

Ghizer Family Health Center – Chator

Khand




14


Hunza-

Nagar Family Health Center – Sost




Gilgit Family Health Center –

Jaffarabad




2. Procurement of medicine, equipment and vehicles

Quality services at health facilities is much contingent upon uninterrupted supply of medical

equipment and medicines. Timely procurement of quality medical equipment and

drugs/medicines is considered crucial for the continuity of improved health service provision at

health facilities. In the context of GB where geographic terrain is difficult and health services are

much inaccessible, vehicles play important role in smooth service delivery and support of staff.

At the time of the inception of GBHDP, the need was felt to strengthen supply chain of essential

medicine and procurement of equipment. During the course of the project, hospital and

diagnostic equipment was provided to ensure quality care e.g. C-arm machine, X-ray machine,

baby incubator, endoscopy and new lab equipment. Seven (7) vehicles were procured for the

support staff to support four components of the project. In total GBHDP supported procurement

of medicines and equipment in 33 health facilities.

Table-2: Themes and expected outcomes for the trainings of different healthcare providers

Type of healthcare

providers Theme of training Expected outcomes/results

Doctors, Lady Health

Visitors, Community

Health Nurse

New Integrated

Management of

Neonatal and

Childhood Illnesses

(IMNCI)

- Enhanced understanding of common preventable

childhood illnesses in order to manage them efficiently

through early detection, diagnosis, treatment and timely

referral.

-Created supportive and enabling environment at the

community level for the child survival, growth and

development by the trained staff.

-Enhanced knowledge to identify common problems

associated with pregnancy, their management and

timely referral of complicated cases.

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Type of healthcare

providers Theme of training Expected outcomes/results


Visitors, Community

Health Nurse, Lady

Health Workers (LHWs)

and Traditional Birth

Attendants (TBAs)

Reproductive Health

Trainings, Nutrition

and Referrals

-Enabled staff to learn recent advances in diagnosis

and treatment of gynecological problems, contraceptive

techniques and counseling skills.

-Quality assured services provided to the community at

their doorsteps according to AKHSP protocols.


Visitors, Community

Health Nurse

Mental health

-Enhanced understanding to identify and manage

common mental illnesses

-Improved referrals of cases with complicated mental

illnesses to next level facilities.

AKHSP health managers Advanced MS Excel

-Increased knowledge and enhanced excel skills of the

employees to perform their job related tasks (data

analysis, data compilation) efficiently.


Visitors, Community

Health Nurse

Early Childhood

Development (ECD)

- Enabled health facility staff to understand and

implement ECD focusing on stimulation, health and

hygiene.

3. Training and deployment of staff and community based health workers

Human Resource related issues in Northern Areas of Pakistan include non-availability of

appropriately trained health care providers in health facilities and communities. This hampering

factor leads to inappropriate level of staffing in clinical units such as Gupis Civil Hospital; putting

existing staff under pressure compounded by low motivational levels. In order to fill this gap,

GBHDP provided training for clinical doctors, AKHSP health managers, general nursing staff,

Midwives and Community Based Health Workers (CBHWs). CBHWs trained were LHWs and

TBAs. Induction of doctors, LHVs, field officers, and Community Health Nurses (CHNs) were

supported by the GBHDP where needed. Table-2 presents various themes and expected

outcomes for the trainings of different healthcare providers.



Retrofitting for earthquake resilience; Insulation of labor rooms;

General infrastructure improvement of waiting room and boundary

wall; Sanitary, plumbing and electrical work

Ghizer Family Health

Center, Yasin

Construction of additional rooms for services; General infrastructure

improvement of waiting room and boundary wall; Sanitary, plumbing

and electrical work

16


Ghizer

Family Health

Center – Chator

khand

Construction of additional rooms for service provision ; General

infrastructure improvement of waiting room and boundary wall;

Sanitary, plumbing electrical work

Hunza-

Nagar

Family Health

Center – Sost

Construction of additional rooms for service; General infrastructure


and electrical work

Gilgit

Family Health

Center –

Jaffarabad



and electrical work


Retrofitting for earthquake resilience; Insulation of labor rooms;

General infrastructure improvement of waiting room and boundary

wall; Sanitary, plumbing and electrical work

Ghizer Family Health

Center, Yasin



and electrical work

Ghizer

Family Health

Center – Chator

khand

Construction of additional rooms for service provision ; General

infrastructure improvement of waiting room and boundary wall;

Sanitary, plumbing electrical work

Hunza-

Nagar

Family Health

Center – Sost

Construction of additional rooms for service; General infrastructure


and electrical work

Gilgit

Family Health

Center –

Jaffarabad



and electrical work

4. Coverage of operation cost

In the context of GB region, overall financial position of DOH and AKHSP is weak leading to

fiscal deficit to manage quality health services in health facilities. GBHDP was an opportunity

for the DOH and AKHSP to enter in PPP at Civil Hospital Gupis. In addition to project support of

constructing facility, providing equipment, medicines and trainings; this PPP model was unique

in terms of covering operation cost. The operational cost of the Gupis Civil Hospital included

support, supervision and facility operation which were covered by AKHSP on pro rata basis on a

declining trend over the project period.

17

A formal inauguration ceremony of first PPP initiative in GB was organized on September 9,

2014. Key representatives in the inauguration ceremony included Director Health Services-GB

as well as Chairperson of AKHSP. Civil Hospital Gupis became operational since the day of

inauguration. Review of the project documents suggest that PPP model now offers OPD

services, radiology, laboratory services and inpatient facility. Three male and one female doctor,

couple of nursing staff and technicians have been deployed in the facility to provide range of

health services.

Monitoring and Evaluation

A baseline survey was conducted before the start of the project, which gave a good snapshot of

where do the population health indicators stand and what is the state of affairs of the health

facilities as well as services in the project districts. Regular monitoring of the GBHDP was

conducted by the AKHSP and AKFP, where latter provided technical assistance to the

implementing agency. Project outputs and outcomes were developed against activities through

a consultative process. AKHSP-MIS was as well as the facility records were utilized to report

outputs and outcomes of the project. Mid Term Review of the project was conducted by and

positive notes were documented about all the project components.

Some of the key outcome indicators measured throughout the project duration were proportion

of mother completing at least one ANC from a skilled health care provider, percent of delivered

mothers with TT vaccination, percent of deliveries conducted by the skilled birth attendants

(SBAs), and proportion of infants with EPI vaccination coverage. Output level indicators

measured and documented in the project documents were number of constructed/renovated

health facilities, health facilities furnished with medicines and equipment, number of individuals

benefitting from new equipment, number of newly deployed and trained health care providers,

frequency of outreach activities such as school health assessment and adult health screening,

and number of beneficiaries visiting LHV/CHN in OPD clinics. An end-line evaluation was

initially planned by June 2014 but could not be completed due to the no cost extension of the

project. This final end-line evaluation of the GBHDP was concluded in December 2014.

18

PURPOSE OF FINAL PROJECT EVALUATION

While all the four components of the project have contributed in improvement of the health

system for the population of GB with particular attention to women and children, it is pivotal to

measure impact of project interventions through a well-designed end of project evaluation. The

purpose is to underpin the contribution of the project towards achieving key health indicators in

the population served. The findings and results are intended to be broadly accessible to various

audiences including Ministries/Departments of Health and provide evidence relevant to global

initiatives such as the Global Health Initiative and Post-2015 Development Agenda of United

Nations.

This evaluation has been an opportunity for all project stakeholders to take stock of

accomplishments to date and to listen to the beneficiaries at all levels, including health care

providers, mothers and caregivers, community health workers, policy makers, district and

provincial health authorities, and local partners. The findings will also inform the broader Health

Sector Strategy of GB. This evaluation has four key objectives. End-line objectives were

achieved by answering key questions set specifically for each objective of the evaluation. The

types of questions identified were objective as well as quantifiable, descriptive as well as

normative and were meant to capture information on four components of GBDHP. Following

final evaluation key questions were identified for each objective of the end-line evaluation:

O1. To determine physical condition of health buildings in five sites for safety, thermal

efficiency, spaciousness for different services and comfort to service providers and

patients

a) What is the physical status of five health facilities where renovation and construction

work was completed?

b) Does each facility have safety, thermal efficiency and spaciousness for different

services?

c) Are clients satisfied with the tangible (infrastructure improvement) and non-tangible

(spaciousness, enabling environment) dimensions of quality in health facilities?

19

O2. To evaluate status and availability of essential equipment, drugs and supplies by

capturing views of services beneficiaries, health service providers and government

health officials

a. What is the status (availability and functioning) of essential equipment provided to health

facilities under GBDHP?

b. How many beneficiaries utilized services from newly installed essential equipment?

c. What is the physical status and availability of drugs and supplies in health facilities?

d. What is the opinion of health care providers and beneficiaries about availability of

services?

O3. To measure outcomes of different trainings received by the AKHSP staff and

community based health workers

a) Do trainings have improved knowledge and skills of AKHSP staff and CBHWs?

b) What is the status of service delivery and utilization (OPD, ANC and PNC visits, normal

and complicated deliveries, children vaccinated etc) in health facilities?

c) Has there been any increase in uptake of services in health facilities?

O4. To conduct a financial analysis of health care facilities budget supported by the

project

a) How much is the operation budget of the health facilities?

b) What proportion of the operational cost was supported by the project?

c) What is the status of declining trend of the health facility operational cost supported by

the project?

d) Were there any challenges to sustain operational cost by AKHSP when funding was

declined by the project?

In the forthcoming section different methods to answer these questions are discussed.

EVALUATION METHODS

Evaluation Design

The evaluation design consisted of a participatory mixed-methods approach using both

quantitative and qualitative data supplemented by physical verifications and field observations,

discussions with stakeholders in terms of performance on key result indicator, i.e. physical

condition of health buildings, availability of equipment, medicines and supplies, outcomes and

20

impact of different trainings, and financial analysis of health care facilities budget. Part of the

study was essentially based on secondary data review, M&E reports, project progress reports,

baseline survey and midterm evaluation carried out during various stages of GBHDP

implementation. Figure-1 demonstrates the design of the end-of-project evaluation.

Quantitative Methods, Study Population and Tools

„Service Availability and Readiness Assessment‟ (SARA) survey was conducted to evaluate

physical condition of health buildings, status and availability of essential equipment, drugs and

supplies, diagnostic capacities, and on the readiness of health facilities to provide basic health-

care interventions relating to family planning, maternal health, child health services, basic and

comprehensive EmONC, and other services to address communicable and non-communicable

diseases. SARA, commonly used at World health Organization14, is a health facility assessment

tool designed to assess and monitor the service availability and readiness of the health facility in

order to generate evidence for supporting planning and management of health services.

Figure-1: End-line evaluation design of the GBHSP

Evaluation components Evaluation design Methods and tools

a. Physical condition of health

buildings

Quantitative

SARA survey

(Hospital & facility checklist,

structured self-administered

questionnaire for health care

providers/managers , exit poll)

b. Status and availability of

essential equipment, drugs and

supplies

Quantitative

c. Outcomes of different trainings Quantitative SARA survey (Structured self-

administered questionnaire for

health care providers/managers,

exit poll)

d. Financial analysis of health care

facility

Qualitative and secondary

data review

SARA survey (Structured self-

administered questionnaire for

health managers, Key Informant

Interviews (KIIs)

14

World Health Organization. Service availability and readiness assessment: Health statistics and information systems. Geneva: WHO; 2014.

21

The SARA survey required health facility visits with data collected based on observation,

physical verification and self-administered questionnaires. Out of 33 health facilities, five (5)

were purposely selected to evaluate physical works, as construction/renovation was only

executed in these facilities. Rest of the twenty eight (28) health facilities was listed, coded and

10% of the sample was randomly selected from each district based on the basis of

representative and proportionate sampling. This sampling strategy allowed selecting one (1)

facility from Hunza-Nagar, four (4) from Gilgit, and three (3) from Ghizer. Hence eight (8)

facilities were selected randomly and five were purposively selected. This resulted in selection

of thirteen (13) health facilities in total. This sample has been selected based on the consensus

developed during the inception phase with major stakeholders, i.e. AKFP and AKHSP. Two

types of checklists were introduced to capture information on infrastructure, human resource,

basic equipment, essential stocks/material, knowledge of service providers, provision of health

services, infection prevention/waste management, service delivery and utilization. List of health

facilities as well as two types of checklists (A1 and B1) selected for the SARA survey is

presented in table-3. Out of 13 health facilities selected for the end-line survey, six (6) were

from Ghizer, four (4) from Gilgit and three (3) from Hunza-Nagar. Furthermore, two types of

checklists (A2 and B2) were used to capture data on services utilization during month of

November 2014 & 2013 for comparison of trends over the year.

Table-3: Selected health facilities for end-line evaluation

Name of health facility Sampling

criteria Questionnaires

Gupis Civil Hospital

Family Health Center, Yasin

Family Health Center –

Chator khand

Family Health Center – Sost

Family Health Center –

Jaffarabad

Purposive

Checklist A-1: Structured Assessment Checklist

for Hospital

Form B 1: Structured Assessment Checklist for

Health Facilities (EFHCs, FHCs)

Questions cover information on infrastructure,

human resource, basic equipment, essential

stocks/material, knowledge of service providers,

provision of health services, infection

prevention/waste management, readiness of

service delivery and utilization (OPD, ANC, & PNC

visits, skilled deliveries, vaccination coverage, C-

sections, minor operations etc)

Checklist A-2: Structured Assessment Checklist

for Hospital Services Utilization during month of

November 2013 & 2014

Form B 2: Structured Assessment Checklist for

Health Facilities (EFHCs, FHCs) Services

Utilization during month of November 2013 & 2014

Nomal health facility

Zulifqarabad health facility

Danyore health facility

Nasirabad health facility

Extended family health

Center Aliabad

Sher Qilla health facility

Sumal health facility

Singal medical center

Random

22

In addition to aforementioned checklist, exit poll survey of users (Form D), structured self-

assessment questionnaire for health care service providers and health managers (Form C1&

C2) was also developed and introduced with the respondents. In total, 13 health care service

providers and health managers‟ as respondents completed structured self-assessment.

Structured self-assessment questionnaire for health care service providers and health

managers included information on types of trainings, overall effectiveness of trainings, self-

assessment of knowledge and skills, and usefulness of trainings conducted under GBHDP. Exit

poll survey administered to service users of 13 selected health facilities covered information on

experience of health services utilization, quality of care, availability of diagnostic services and

medicines and user fee charges. Overall, fifty nine (59) beneficiaries were interviewed using exit

poll survey. Table-4 presents study respondents of the structured self-assessment

questionnaire and exit poll.

Table-4: Study respondents for structured self-assessment questionnaire and exit poll

Type of questionnaire

Study respondents

Number of respondents Contents of questionnaire

Form C1& C2:

Structured

self-

assessment

questionnaire

Health facility

staff, Community

health Workers

and AKHSP

managers.

13

Gender disaggregation (10F,

3M)

Types of trainings, overall

effectiveness of trainings, self-

assessment of knowledge and

skills, and usefulness of trainings

Form D: Exit

poll

Beneficiaries

including mothers

and men

59

Gender disaggregation (40F,

19M)

Experiences of health services

utilization, quality of care,

availability of diagnostic services

and medicines and user fee

charges

Therefore, five different types of tools were introduced at health facility and to study

respondents in order to attain first three objectives of the en-line evaluation, i.e. assessment of

physical works, status and availability of equipment/supplies/drugs, outcomes of trainings and

services utilization.

After preparation of research tools in English they were translated into Urdu language for easy

understanding by the respondents in the field. Translated research tools were pre-tested to

detect any possible problems in the translations or flow of the questions, and estimates of the

time required for SARA survey. The pre-test provided valuable experience for the lead

investigator regarding research tools design and fieldwork logistics before finalization.

23

Qualitative Methods, Study Population and Tools

The qualitative component of the evaluation design included KIIs with the health mangers of

AKHSP and DOH, GB. The aim was to record the performance on key result indicators, status

of physical works, availability of resources, knowledge of service providers, equipment and

supplies, service delivery management and utilization, and operational cost specific to Gupis

Civil Hospital. This part of the evaluation was essentially based on secondary data review, M&E

reports, project progress reports and previous surveys carried out during various stages of

GBDHP implementation. The detail of qualitative data collection is as follows.

Semi-structured interviews with key informants, i.e. District Health Officer (DHO) of Ghizer

district, Project Manager-GBHDP, AKHS, P General Manager, and Director Health Services, GB

were carried out. The interview guides for the AKHSP managers included questions on type of

support provided under KfW project, experience of working with government through PPP at

Gupis, financial status of the operational cost at Gupis, and status of health services utilization

in the intervened health facilities of GBHDP. Questions for the DOH health managers were

more focused on key challenges and obstacles in the PPP model as well as sustainability of

operational cost at Gupis Civil Hospital.

The KIIs were recorded for accuracy and later transcribed and translated by at least two

persons independently. To ensure quality control, information collected through note-taking was

cross-checked for completeness and consistency before and during data processing by the

research team. Informed consent was taken from the study respondents both for the

quantitative and qualitative components. Quantitative tools of the SARA survey (facility

checklist, structured self-administered questionnaire, exit poll) and the KIIs with the health

mangers are attached as ANNEX-I and ANNEX-II.

Data Management & Analysis

Following steps were ensured in the data analysis of the quantitative and qualitative

components.

Data collected from the districts was daily scrutinized by lead investigator for completeness

and accuracy. Quality assurance of data was ensured by spot checking and verifying the

data collected by the research assistants on a regular basis by the lead consultant. The data

was kept secured in hard and soft copies, and backup was kept for any mishap and avoid

data loss.

24

In order to analyze quantitative component of the evaluation, all five (5) SARA tools were

entered in SPSS version 18. Checks were performed to ensure that all responses of the

hospital/facility checklists, structured self-administered questionnaires for health care

providers and mangers, and exit poll of beneficiaries were within expected parameters by

reviewing the entered data followed by analysis. Univariate analysis was performed in the

SPSS to generate descriptive statistics (tables, bar graphs) regarding physical status of

buildings as well as human resource; status and availability of equipment, medicines and

supplies; service delivery and utilization; and outcomes of project trainings. Descriptive

statistics incorporated frequencies and percentages of various variables.

Qualitative manifest and latent content analysis was applied to analyze the qualitative data

from all KIIs. Content analysis was done in stepwise manner aimed at finding manifest and

latent meaning of data. The data was initially read several times by lead consultant and

content analysis method was used to analyze transcribed data. At first stage the

segmentation of information was done i.e. segments and sub-segments. At second stage

the common views of the respondents were put together i.e. common views of respondents

were merged at one place. At third stage data was coded (different responses highlighted)

and then these codes were grouped into categories and abstracted into sub-themes and a

main theme. At final stage the meanings of themes/descriptions were interpreted by keeping

in view and considering the cultural context of the participants. Having this approach, the

themes of the qualitative component were chalked out as presented in the findings.

FINDINGS This section of the assessment study presents findings of the quantitative and qualitative

components of the study. Main themes of the findings are:

Physical condition of health buildings

Availability of essential equipment, drugs and supplies

Outcomes of trainings

Financial analysis of health care facilities

Summary of findings

Physical condition of health buildings: Overall, 83% (10 out of 12 sampled facilities ) of the

health facilities were found to be seismic proof whereas retrofitting work was not required in

17% health facilities. Piped water supply and intact boundary wall were found in all the health

facilities. All the health facilities had appropriately displayed sign boards and enough seating

25

arrangements for the waiting area. Out of twelve (12) health facilities, eleven (11) were

maintained/renovated last year except Gupis Civil Hospital which took longer than usual for

completion of physical works. All the inspected health facilities had functional labor room

(nursery, OT, sterilization room) and functional telephone lines. Labor rooms of five health

facilities were insulated for proper heating.

Human resource for health: Findings revealed that 58% (7/12 sample facilities) of health

facilities were functioning without a Lady Medical Officer (LMO). Lady Health Visitor (LHV) was

found present in all health facilities, and a dispenser was available in nine (9) out of twelve (12)

health facilities suggesting 25% of the health facilities were without dispenser/MHT staff. At

least one support staff was available in all inspected health facilities.

Availability of equipment: Basic equipment

was present as well as functional at all

inspected sites of three districts. The basic

equipment include BP apparatus, stethoscope,

thermometer, sterilizer, safe delivery kit, and the

delivery table. Other project funded equipment

available and being utilized at civil hospital,

Gupis were x-ray machine, x-ray machine,

anesthesia machine, and baby incubators.

Availability of essential drugs and supplies:

Drugs which were available in all health facilities

are oral antibiotics syrup for children and adults,

antipyretic drugs, folic acid tablets, antiseptic

solution and antihypertensive drugs. About 83%

(10 out of 12) of the health facilities were not

experiencing any stock out of essential drugs.

Modern Family Planning (FP) material was

available in all surveyed health facilities. Health

information system (HIS) stationary was present

and maintained regularly in all health facilities.

26

Knowledge of health care providers:

Health facility staff had adequate knowledge

on delivery of reproductive Health, antenatal

care (ANC), postnatal care (PNC) services,

integrated management of childhood

illnesses (IMCI), nutrition and referrals .

Knowledge of MNCH related staff, i.e. LHV

and LMO, was satisfactory on safe delivery

practices, infection prevention and control,

and management of ante-partum and post-

partum hemorrhage. Understanding of temporary FP methods and intra-uterine contraceptive

device (IUCD) and its procedure for its insertion was satisfactory among LHVs and LMOs.

Provision of health services: All surveyed health facilities were providing services specific to

ANC, PNC, tetanus toxoid (TT) immunization, and treatment for minor curative services, facility

based normal vaginal delivery and provision of FP services and materials. SARA survey

revealed that 92% health facilities are providing Expanded Programme on Immunization (EPI)

services except at Singal medical center.

Utilization and quality of health services:

There has been a significant uptake of

services with regard to outpatient department

(OPD), ANC and PNC visits, after the

improvement and renovation of the facilities

was carried out. Average number of

institutional deliveries and vaccination of

children (11-23 months) against measles also

increased significantly in 2014 as compared

to 2013. Average number of institutional

deliveries increased to twelve (12) by 2014 as

compared to seven (7) deliveries in 2013. The number of OPD visits at Gupis civil hospital in

2014 also increased by four (4) times as compared to 2013. Findings reveal that 59% of the

respondents‟ categorized quality of health services as „good‟ whereas 29% ranked as

27

„excellent‟. Among respondents who categorized health services „good‟, 69% were female and

31% were male service users. About 76% of the respondents informed that they wait for 15-30

minutes at health facility to see doctor whereas 24% wait for more than 30 minutes.

Financial analysis: There were only two

sources of revenue generation for the Gupis

civil hospital, i.e. AKHS, P allocations

through KfW funds and user fees. Financial

inputs by the government were nil for the

last two years to support public-private

partnership (PPP) model. Under the PPP

model of the Gupis, government has

allocated insufficient funds to sustain

operations at Gupis hospital for the fiscal

year 2015. AKHSP allocations for Gupis in

the year 2014 increased by 12% and user fee decreased by 11% as compared to year 2013.

The total funds generation for the year 2014 decreased by 1% over the year 2013-14. For year

2015, the forecasted AKHSP allocations for Gupis would increase by 7% and user fee

generation would increase by 106% over the years 2014-15. Financial inputs and expenditures

at Gupis civil hospital were recorded at a breakeven in the last two fiscal years. In view of mere

financial allocations by the government under PPP at Gupis for 2015, there is increased

likelihood that the hospital may go through loss if alternate modes of financing or other

arrangements are not available. Financial deficit is being covered by GBHDP and remaining

through user fee income.

Under the memorandum of understanding of the PPP, it is expected the government will

allocate sufficient funds to sustain operational cost of the Gupis hospital.

District wise Distribution of Health Facilities

Out of 33 health facilities intervened during the course of the project, thirteen (13) health

facilities were selected based on representative and proportionate sampling in three districts.

i.e. Ghizer, Hunza-Nagar, and Gilgit. Out of thirteen selected facilities, one (1) qualify for the

secondary level health care facility (SLHCF) whereas twelve (12) were first level health care

facilities (FLHCFs). Therefore, comparative analysis of twelve (12) health facilities was

performed. SLHCFs selected for the end-line evaluation was Gupis Civil hospital. Following

28

Figure-2: Presents district wise distribution and type of health facilities selected for the

end-line evaluation.

Figure-2: District wise distribution and type of health facilities for end-line evaluation

Characteristics of Respondents

Respondents of the structured self-assessment questionnaire included 13 respondents (Health

facility in charges) of the surveyed health facilities. Out of 13 respondents, ten (10) were

females and three (30 were males. Out of fifty nine (59) beneficiaries of the exit poll, forty (40)

were women and nineteen (19) were men. Figure-3 portrays gender wise age distribution of

respondents for the exit poll. About 37% of the respondents were young, 15-24 age group.

Figure-3: gender wise age distribution of respondents (exit poll)

Ghizer Hunza-Nagar Gilgit SLHCF Total

Series1 5 4 3 1 13

0

2

4

6

8

10

12

14

Nu

mb

er

of

He

alth

fac

iltie

s

.0%

10.0%

20.0%

30.0%

40.0%

50.0%

15-24 25-34 35-44 45-44 Older than54

12

.8

17

.9 10

.7

5.1

4.6

24

.5 9.7

5.1

4.6

5.1

Age Groups

Female Male

29

Physical Condition of Health Buildings

Overall condition for the five (5) health facilities was assessed in terms of infrastructure, human

resource, health services provision, and readiness for service delivery and improved utilization.

Health services utilization in health facilities was compared for two years, i.e. 2013 and 2014.

Infrastructure

Infrastructure of the health facilities

was assessed for safety, thermal

efficiency, spaciousness and

availability of functional rooms in

twelve health facilities. Proportion of

the seismic proof health facilities in

Ghizer, Gilgit and Hunza-Nagar were

80%, 67% and 100% respectively.

Overall, 83% of the health facilities

were seismic proof whereas

retrofitting work was not required in

17% health facilities. Piped water

supply and intact boundary wall were

found in all the health facilities. All the health facilities had appropriately displayed sign boards

and enough seating arrangements for the waiting area. All five (5) were maintained/renovated

last year except Gupis Civil Hospital which took longer than usual for completion of physical

works. General cleanliness of the female OPD, beds with mattresses & clean bed sheets, and

toilets were clean in all facilities. It was evident that all the inspected health facilities had

functional labor room, nursery, OT sterilization room, and functional telephone lines. The labor

rooms in all inspected health facilities were available and functional whereas labor rooms of five

health facilities were insulated for proper heating. District wise physical condition of health

facilities is attached as ANNEX-III. Figure-4 captures overall physical condition of the health

buildings.

30

Figure-4: Physical condition of health facilties

Human Resource

Availability of human resource in the

health facilities was assessed in three

districts of GB. Findings revealed that

seven (7) out of twelve (12) health facilities

(58%) were functioning without a Lady

Medical Officer (LMO). Presence of a

female doctor was least in the Hunza-

Nagar (25%) and maximum (100%) in

Gilgit. Sixty (60) percent of the health

facilities of Ghizer had a working female

doctor. Findings suggest unavailability of

skilled human resource in far-flung areas of GB such as Hunza-Nagar. Lady Health Visitor

(LHV) was found present in all health facilities, although dispenser/MHT was available in nine

(9) out of twelve (12) health facilities suggesting 25% of the health facilities were without

dispenser/MHT staff. Presence of dispense/MHT staff was lowest in Gilgit (25%) and highest in

Hunza-Nagar (100%). At least one support staff was available in all inspected health facilities.

Figure-5 demonstrates availability of human resource in health facilities selected for the end-line

evaluation.

83%

100%

100% 100%

92%

100%

The health facility is seismic proof

Availability of piped water supply

Intact facility boundary wall

All sign boards/sign plates appropriately displayed

Facility building maintained last year

Enough seating available in the waiting area

31

Figure-5 demonstrates availability of human resource in health facilities

Availability of Basic Equipment

The assessment analysis of functional equipment items in health facilities revealed that basic

equipment was present as well as functional at all inspected sites of three districts. Basic

equipment items which were available and functional were BP apparatus, stethoscope,

thermometer, sterilizer, delivery kit, and the delivery table. Other project funded equipment

available and being utilized at civil hospital, Gupis were anesthesia machine,, x-ray machine,

and baby incubators. On further probing, findings of the secondary data revealed that 1911

images were taken by using new x-ray machine, more than 1,000 major and 791 procedures

were performed using anesthesia machine, over 10 diagnostic procedures were carried out by

newly installed endoscopy machine, C arm machine was utilized for 8 major operations, and 30

children benefited from incubator. Figure-6 captures the status of basic equipment in the

surveyed health facilities.

42%

100% 75% 100%

0%

20%

40%

60%

80%

100%

120%

Lady Medical Officer (LMO)Lady Health Visitor (LHV) Dispenser/MHT Support staff (at least one)

Total Gilgit Hunza Nagar Ghizer

32

Figure-6: Availability of basic equipment in health facilities

Availability of Essential Stocks/Supplies

Findings of the SARA survey revealed that HIS stationary was present in all health facilities. On

further probing, it was found that HIS stationary was maintained regularly with functional

information sharing mechanism with the regional office of AKHS, P in Gilgit. Out of 12 surveyed

facilities, two (2) had stock out of essential

tracer drugs. Thus, 83% of the health

facilities were not experiencing any stock

out of essential drugs. Stock out of

essential drugs in Ghizer and Hunza-

Nagar was 25% and 20% respectively.

There was no stock out drugs in health

facilities of Gilgit. Soap for hand washing

was present in all surveyed health

facilities. Modern Family Planning FP

material was available in all surveyed

health facilities (figure-7).

100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%

120%

Total Gilgit Hunza Nagar Ghizer

33

Figure-7: Availability of essential stocks/supplies in health facilities

Availability of drugs

Review of the secondary data revealed that

essential medicines were provided to 33

health facilities during the course of the

GBHDP. Surveyed facilities of the SARA

validate availability of essential drugs in all

districts. Drugs which were available in all

health facilities are oral antibiotics syrup for

children and adults, antipyretic drugs, folic

acid tablets, antiseptic solution and

antihypertensive drugs as shown in figure-8.

Outcome of trainings

Knowledge of Health Care Providers

Review of the secondary data reveals that training were organized for clinical doctors, AKHS, P

health managers, general nursing staff, Midwives and CBHWs, i.e. LHWs and TBAs. Different

themes of the trainings were IMNCI, reproductive health, nutrition and referrals of MNCH cases,

mental health, and ECD. Results of the SARA survey disclosed that health facility staff had

adequate knowledge on aforementioned themes of the trainings. Knowledge of health care

HISstationary

Stock outof any

essential(tracer)drugs

Soap forhand

washing

ModernFP

materialavailable

Ghizer 100% 20% 100% 100%

Gilgit 100% 100% 100% 100%

Hunza Nagar 100% 25% 100% 100%

Total 100% 17% 100% 100%

0%

20%

40%

60%

80%

100%

120%

34

providers was sufficient with regards to delivery of ANC ad PNC services. Likewise, knowledge

of MNCH related staff, i.e. LHV and WMO, was satisfactory on safe delivery practices, infection

prevention and control, and management of ante-partum and post-partum hemorrhage.

Knowledge of IUCD was satisfactory among LHVs and LMOs. Similarly, acquaintance with

regards to drugs stock keeping was adequate among dispenser/ or MHT staff. Figure-9

captures knowledge of health care providers on various themes in the surveyed health facilities.

Figure-8: Availability of essential drugs in health facilities

Figure-9: Knowledge of health care providers in health facilities

Oralantibioticsyrup forchildren

Oralantibioticfor adults

Antipyreticdrug

Folate/folicacid tablet

Antisepticsolution

Antihypertensive drug

Oralrehydrationsalt (ORS)

sachet

Ghizer 100% 100% 100% 100% 100% 100% 100%

Gilgit 100% 100% 100% 100% 100% 100% 100%

Hunza Nagar 100% 100% 100% 100% 100% 100% 100%

Total 100% 100% 100% 100% 100% 100% 100%

0%

20%

40%

60%

80%

100%

120%

35

Provision of Health Services

Secondary data was analyzed to assess types of health services provision in the health

facilities. The provision of health services is directly linked with the knowledge as well as skills of

health care providers. Therefore, this section of the findings links effectiveness of trainings with

provision of health services in the health facilities. At the time of the visit, all surveyed health

facilities were providing services specific to ANC, PNC, TT immunization, treatment of minor

health problems, facility based normal vaginal delivery and provision of FP services and

commodities. However, one (1) out of twelve (12) health facilities was not providing EPI

services. Singal medical center was not providing EOI service as they are being offered in the

nearby MCH center. Provision of different types of health services are highlighted in figure-10.

Figure-10: Provision of health services in health facilities

Utilization of Health Services

Information on the utilization of health services was primarily obtained from secondary data

review at health facilities. While enhanced knowledge of the health care providers improves

health care provision, it also increases the utilization of health services by the communities.. For

this reason utilization of health services in the health facilities was compared for two years, i.e.

November 2013 and November 2014. The month of November was selected due to

completeness of data in health facilities. Findings of the evaluation suggest that there was

remarkable uptake of health services in health facilities of the GBHDP. Average number of OPD

AntenatalCare

Services(ANC)

TTImmunizati

on

Post-natalcare

ServicesEPI Services

Treatmentof minorcurativeservices

Facility-based

normalvaginaldelivery

Provision ofcontracepti

ves (FPmaterial)

Ghizer 100% 100% 100% 80% 100% 100% 100%

Gilgit 100% 100% 100% 100% 100% 100% 100%

Hunza Nagar 100% 100% 100% 100% 100% 100% 100%

Total 100% 100% 100% 92% 100% 100% 100%

0%

20%

40%

60%

80%

100%

120%

36

patients increased from 220 to 291 in 2014; whereas average number of institutional deliveries

increased to twelve (12) by 2014 as compared to seven (7) in 2013. Average number of ANC

and PNC as well as vaccination of children (11-23 months) against measles also improved

signifying better utilization of health services (figure-11).

Figure-11: Year wise utilization of health services for 2013 and 2014

Health services utilization was also assessed

at the Gupis civil hospital through analysis of

the secondary data. Findings suggest that

responsiveness towards utilization of health

services increased significantly while

comparing year 2103 with year 2014. The

number of OPD visits in 2014 increased by

four (4) times as compared to

2013.However, indoor admissions

decreased in 2014 as compared to last year due to construction work at the hospital. For the

year 2013, total 1,738 admissions were recorded with 2,203 OPAs which accumulated for

3,941. For 2014, admission volumes reduced by 32% to 1,203 (2013: 1,738) and OPAs showed

37

a considerable increase over the year by 3 times to 8,765 (2013: 2,203). The total volume for

2014 turned out to 9,968 (2013: 3,941) with 152% increase recorded over the year 2013-14.

For 2015, it is forecasted that admission

volumes would be reported for 2,409

(2013: 1,203) with 104% increase over

the years 2014-15. The forecast for OPAs

would increase by 30% to 11,379 (2013:

8,765). The total volume forecast for 2015

would turn out to be 13,788 (2013: 9,968)

with estimated 39% increase recorded

over the forecasted year 2014-15. The

forecast for the year 2015 is also captured

in figure-12.

Figure-12: Health services utilization at PPP model Civil Hospital Gupis and forecast for

2015

Quality of Health Services

SARA survey was meaningful to capture viewpoints of the service users through exit polls.

Findings reveal that 59% of the respondents‟ categorized quality of health services as „good‟

whereas 29% ranked as „excellent‟. Among respondents who categorized health services

„good‟, 69% were female and 31% were male service users. Likewise, most of the women

(20%) ranked quality of health service „excellent‟ as compared to men (8.5%). Figure-13

presents findings with regards to quality of health services at health facilities.

1738

1203

2409

2203

8765

11379

Jan-Dec 2013

Jan-Dec 2014

Forecast Jan-Dec 2015

OPD attendents Admissions

38

Figure-13: Quality of health services according to health service users (n=59)

Findings of the SARA survey revealed that all of the study respondents were satisfied with the

behavior and attentiveness of healthcare providers as well as general cleanliness of the health

facilities. Laboratory test services and medicines were available according to the study

respondents. All of the respondents stated that building of health facility is better than previous

and there is no gender discrimination while availing health services.

Findings of the end-line evaluation also revealed that most of the respondents were satisfied

with the waiting time to meet doctors. About 76% of the respondents informed that they wait for

15-30 minutes at health facility to see doctor whereas 24% wait for more than 30 minutes

(Figure-14).

Figure-14: Waiting time to meet doctor/service provider

Satisfactory 11.9% Good,

59.3%

Excellent, 28.8%

.0%5.0%

10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%

6.8%

40.7%

20.3%

5.1%

18.6%

8.5%

Female Male

15-30 Minutes 76.0%

30-45 Minutes 24.0%

39

Financial Analysis

Financial analysis of the Gupis Civil Hospital

was performed through review of secondary

data analysis as well as KIIs with the key

stakeholders to evaluate types of revenue

and financial inputs for Gupis civil hospital.

Findings of the evaluation suggest that

financial allocations by the government were

nil for the last two years where major modes

of financial input was through user fees and

AKHS, P allocations for the Gupis. AKHS, P

financial allocations for Gupis were secured

through KfW funds to support human resource, equipment and supplies. Under the PPP model

of the Gupis, government has allocated funds to sustain operations at Gupis hospital for the

fiscal year 2015. However, these funds allocated by the government are insufficient and do not

match with the required financial inputs for the Gupis hospital. Findings also reveal that trend of

generating financial inputs through user fee charges are encouraging.

Revenue from user fees for the year

2013 was more than 1.5 times as

compared to AKHS, P allocations in

the same year. The actual AKHS, P

allocations for Gupis in the year 2013

were reported for Rs 5.756 M and user

fee were reported for Rs 8.839 M. The

total funds generated in 2013

amounted to Rs 14.595 Million.

AKHSP allocations for Gupis in the

year 2014 increased by 12% over the

year to Rs 6.474 M (2013: Rs 5.756 M) and user fee decreased by 11% to Rs 7.903 M (2013:

Rs 8.839 M). The total funds generation for the year 2014 amounted to Rs 14.377 M (2013: Rs

14.595 M) with 1% decrease over the year 2013-14. Reason for this decreasing trend of

revenue generation was further probed indicating minimum indoor admissions due to

construction and expansion work at Gupis hospital.

40

For 2015, the forecasted AKHSP allocations for Gupis would be reported for Rs 6.959 M (2013:

Rs 6.474 M) with 7% increase over the years 2014-15. It is forecasted that user fee would

increase by 106% to Rs 16.291 M (2013: Rs 7.903 M). Increase in forecast for the financial

inputs through user fee suggest upsurge in utilizing health services as well as availability of

services at the Gupis hospital. The total funds generation forecast for 2015 would turn out to be

Rs 23.650 M (2014: Rs 14.377 M) with estimated 64% increase recorded over the forecasted

year 2014-15. Table-5 elaborates type of revenue and financial inputs for operationalization of

the hospital.

Table-5: Type of revenue/financial input for Gupis hospital

Secondary data analysis also captured

expenditure to run operations at Gupis

hospital for the last two years. Expenditure

items reviewed were salaries, utilities,

maintenance/repair, drugs/supplies, and

remissions (welfare). In-depth review of

data revealed that salaries and

drugs/supplies alone contribute to 84% of

the total operational cost at the Gupis

hospital. In 2014, salaries expenditure were

reported for Rs 9.035 M (2013: Rs 9.083 M)

a. Government allocations (to AKHSP Assignment A/C) - - - - - - 200 200 400

b.AKHSP allocations for Gupis (KfW funds for staff,

equipment, supplies)3,038 2,718 5,756 2,977 3,498 6474 3,730 3,229 6,959

c. User fee 3,495 5,344 8,839 4,259 3,643 7903 7,983 8,308 16,291

July-Dec 2014

Actuals

Amount PKR

('000')

Total 2014

Actuals

Amount PKR

('000')

Jan-June 2015

Forecast

Amount PKR

('000')

July-Dec 2015

Forecast

Amount PKR

('000')

Total 2015

Forecast

Amount PKR

('000')

Jan-Jun 2013

Actuals

Amount PKR

('000')

July-Dec 2013

Actuals

Amount PKR

('000')

Total 2013

Actuals

Amount PKR

('000')

Jan-June2014

Actuals

Amount PKR

('000')

Type of Revenue/financial Input for Gupis Hospital

41

which decreased by 1% during the period 2013-14, with funds coming from GBHDP of AKHSP.

The forecasted expenditure for the year 2015 would be Rs 11.516 M which would increase by

27% over the forecasted period 2014-15. Overall, Salaries remained largest expense against

total expenditure which accounted to around 62% of total expenses for the year 2013 & 2014

and it accounted to 49% for the forecasted year 2015 showing reduction in salaries expense as

%age of total expenditures.

In 2014, drugs and supplies were the

second largest expense that were

reported for Rs 2.710 M (2013: Rs

3.090 M) which decreased by 12%

during the period 2013-14. The

forecasted expenditure for the year

2015 would be Rs 8.468 M which

would increase by 2 times over the

forecasted period 2014-15. Overall,

drugs and supplies remained second

largest expense against total

expenditure which accounted to around 20% of total expenses for the year 2013 & 2014 and it

accounted to 36% for the forecasted year 2015. Table-6 presents expenditure at Gupis hospital

for two years, i.e. 2013 and 2014, as well as expense forecast for the 2015.

Table-6: Operational cost of the Gupis civil hospital

a. Salaries 4,307 4,776 9,083 4,569 4,467 9,035 5,643 5,873 11,516

b. Utilities 510 535 1,045 590 394 984 612 637 1,249

c. Maintenance/Repairs 325 583 909 548 733 1,281 1,394 788 2,182

d. Drugs and Supplies 1,270 1,819 3,090 1,368 1,342 2,710 4,149 4,319 8,468

e. Remissions (welfare) 121 349 470 161 205 367 115 120 235

6,533 8,063 14,595 7,236 7,141 14,377 11,913 11,737 23,650

Jan-Jun 2013

Actuals

Amount PKR

('000')

July-Dec 2013

Actuals

Amount PKR

('000')

Total 2013

Actuals

Amount PKR

('000')

Jan-June2014

Actuals

Amount PKR

('000')

Expenditure items of Gupis Hospital July-Dec 2014

Actuals

Amount PKR

('000')

Total 2014

Actuals

Amount PKR

('000')

Jan-June 2015

Forecast

Amount PKR

('000')

July-Dec 2015

Forecast

Amount PKR

('000')

Total 2015

Forecast

Amount PKR

('000')

42

Further in-depth analysis of the expenditures at Gupis found that revenue and expenditures for

last two years are much even, however forecast for the current year, i.e. 2015 is very high as

shown in the figure-15.

Figure-15: Year wise revenue and expenditures at Gupis civil hospital

In order to evaluate that Gupis hospital is running operations in profit, break even or loss, a

comparative analysis of revenue/financial inputs and expenditures for the last two years were

performed. As shown in the figure-17, financial inputs and expenditures at Gupis civil hospital

were breakeven in the last two fiscal years indicating balance between making either a profit or

a loss. However, it is worth mentioning that reason for this balanced financials was due to the

support for the GBHDP which was most in 2014. In view of mere financial allocations by the

government under PPP at Gupis for 2015, there is increased likelihood that the hospital may go

through loss if alternate modes of financing or other arrangements are not available (figure-16).

Financial deficit is being covered by GBHDP and remaining through user fee income. Under the

memorandum of understanding of the PPP, it is expected the government will allocate sufficient

funds to sustain operational cost of the Gupis hospital

Figure-16: Year wise comparison of financial inputs and expenditures at Gupis civil

hospital

A detailed financial analysis is attached as ANNEX-IV.

Total Revenue

Total Expenditures -

5,000

10,000

15,000

20,000

25,000

PKR ('000')PKR ('000')

PKR ('000')20132014

2015

Total Revenue

Total Expenditures

0

20000

40000

2013 2014

Revenue/financial input

Expenditure PKR '000'

43

QUALITATIVE FINDINGS

Qualitative findings encompass on type of support provided under KfW project, experience of

PPP at Gupis, financial status of the operational cost at Gupis, and status of health services

utilization in the intervened health facilities of the project. Findings also highlight key challenges

and obstacles in the PPP model as well as sustainability of operational cost at Gupis civil

hospital. Themes, categories and sub-categories of the qualitative analysis are presented in the

following matrix (Table-7).

Table-7: Matrix of qualitative analysis

Themes Categories Sub-categories

Status of health services

Health service provision is improved

Improved infrastructure for health services

provision

Availability of skilled healthcare providers

Availability and functioning of equipment for

health care provision

Health service utilization is improved

Increase number of OPD, ANC and PNC clients

Enhanced utilization of specialized services at

Gupis hospital

Revenue generation from user fee charges

Experience and financial status of PPP model

Improved availability,

quality and utilization of

services in Gupis hospital

Enhanced coordination of

DOH and AKHSP

Cost sharing by the project improved

infrastructure, HR availability, drugs and

supplies

AKHSP and DOH coordinated proactively to roll

out PPP model

Financial support by the

project and user fee

Lack of financial support

from DOH for last two years

PPP at Gupis was breakeven with no loos and

no profit

Government of GB has allocated funds at Gupis

hospital for fiscal year 2015.

Recommendations to strengthen PPP model

Fewer funds committed by

DOH to sustain PPP

More financial support is

required

Lobbying with DOH and GB government to

increase budget of Gupis

Advocacy for alternate financing

Pay for performance to sustain quality services

Role of civil society for community ownership

Status of health services is much improved in terms of health services provision and

utilization. KII findings suggest that project interventions has not only improved infrastructure in

the health facilities but also ensure availability of skilled health workers as well as equipment,

supplies and drugs. Readiness of health facilities to provide basic services increased utilization

of outpatient and inpatient clinics at health facilities. Qualitative findings also suggest that

revenue generation from user fees was increased during the project duration. ‘Through KfW

funding, infrastructure was improved, equipment was provided along with medicines. These

44

interventions enhanced availability and quality of health services’. (KII-1, Project Manager-

AKHS, P), ‘OPD, ANC and PNC clients have increased. Enhanced utilization of specialized

services at Gupis hospital was also observed. People are willing to pay for services’. (KII-2,

District Health Officer, Ghizer-DOH)

Experience and financial status of PPP

model at Gupis resulted in better

coordination between DOH and AKHS, P

which was meaningful to ensure

availability, quality and utilization of

services in Gupis hospital. Findings of KIIs

revealed that GBHDP project improved

infrastructure; availability of HR, drugs and

supplies. Only two sources of revenue

generation/financial inputs at Gupis civil

hospital were project contributions and the

user fees. It is worth mentioning that

substantial revenue was generated through

user fee charges; indicating better

responsiveness of communities towards

health services. ‘We had very proactive

coordination and communication with

provincial and district governments.

Considerable amount of revenue was

generated through user fees.’ (KII-3,

General Manager-GB, AKHS, P)

‘We couldn’t allocate funds for the hospital

operations at Gupis. For the year 2015, we

have allocated founds’. (KII-4, Director Health-GB, DOH)

Recommendations to strengthen PPP model at Gupis civil hospital were also shared by the

respondents of the KIIs. While government has committed fewer funds for the current fiscal

year, there is dire need for proactive lobbying with DOH and GB government to increase budget

of Gupis. Some of the recommendations to sustain PPP at Gupis include alternate modes of

45

financing from donors, pay for performance and role of civil societies. ‘Government has

allocated funds for the Gupis but they are not sufficient to run operations’. (KII-2, District Health

Officer, Ghizer-DOH)

‘Alternate financing is needed to sustain PP model at Gupis. Government contribution is very

low’. (KII-3, General Manager-GB, AKHS, P)

‘We shall not ignore role of civil societies to support this partnership’. (KII-1, Project manager-

AKHS, P)

46

RECOMMENDATIONS AND WAY FORWARD

Based on the findings of the end-evaluation, some of the recommendations are highlighted in

the following section:

Despite the fact that GBHDP has achieved remarkable results in terms of overall goal,

outcomes and outputs particularly in improving infrastructure, availability of equipment,

drugs and supplies, and improved skills of health professionals; it is foremost to continue

quality services in the programmed areas of GBHDP. Concentrating on improvement of

quality services necessitate maintenance of improved infrastructure and equipment,

continuity of supply chains for essential medicines, and ongoing refreshers for health care

providers and health mangers of the AKHSP health facilities. Likewise, DOH has to play an

imperative role to ensure sustainability of specialized services at Gupis civil hospital where

financial inputs are negligible so far by the government of GB.

Like other health programmes of northern areas, dearth of skilled HR, i.e. medical doctors,

was observed in AKHSP facilities. There is dire need to invest more in developing human

resources to ensure a steady supply of highly trained professionals and concentrating on

continuous professional development in remote areas of GB.

PPP model at Gupis civil hospital was well designed to provide specialized health services

to people living in mountainous region and has shown good results, however, it could have

been more useful if there was a clear exist strategy inbuilt in the proposal and initial design.

While financial inputs by the government are negligible to support PPP, it is foremost to

propose various models for the continuity of PPP. Following are some of the

recommendations to ensure sustainability of services at Gupis civil hospital.

- Lobbying with DOH and GB government to increase budget of Gupis is foremost as

government has not allocated sufficient funds for the current fiscal year.

- Advocacy for alternate financing by the development partners ought to be proactive to

bridge and finance transition phase of the PPP at Gupis.

- Innovative approaches such as „pay for performance‟ ought to be envisaged during the

exit phase of GBHDP to reward doctors, health care providers, and to sustain operations

47

at Gupis civil hospital. Such approach can be meaningful to attain targeted service

goals, like meeting health care quality or efficiency standards.

- Role of civil society organizations such as Local Support Organizations (LSOs) cannot

be overlooked to sustain quality of services in health facilities. Representation of the

LSOs in the health facility management committees can be meaningful to ensure

tangible and non-tangible dimensions of quality and day to day management issues.

LSOs can play an imperative role to keep health care providers/mangers accountable for

availability of services as well as to mobilize communities to enhance health services

utilization.

48

CONCLUSION

It was learned that project has achieved remarkable results in terms of contributing to the overall

goal of health system development in GB and improvement in health outcomes through making

major inputs for improving infrastructure of health facilities and availability of services in three

districts. Trainings have increased clinical knowledge and skills of health care service providers

and managerial skills of the health managers. Availability of essential health care packages and

readiness to deliver quality services was observed in health facilities. PPP model at Gupis is

operational and providing specialized health care to the catchment population. End-of project

evaluation concluded that health services utilization has improved in the project intervened

health facilities; however, its overall impact on maternal and infant deaths has to be measured

in the longer run. GBHDP was implemented in close accordance with what was spelled out in

the initial plan and the four major components were achieved during the course of the project.

PPP model at Gupis provides GBHDP and DOH with opportunities to develop effective

strategies and arrangements for continuity of quality services at the hospital. While government

has committed fewer funds for the current fiscal year, hence there is dire need for proactive

lobbying with DOH and GB government to increase budget of Gupis or to take remedial steps to

sustain operational cost at Gupis civil hospital. Coordination mechanisms ought to be improved

within department of health. Provincial department of health must envisage an integrated

approach for effective coordination between provincial and district health departments

particularly to roll out PPP model.

49

ANNEX-I: QUANTITATIVE TOOLS

Structured Assessment Checklist for Hospital—Checklist A-1

For office use only

Section I: Identification

1 Hospital ID

Name of Respondent

2 Health Facility Name and type

Gupis Hospital, Secondary hospital

Designation of Respondent

3 Catchment Population

Name of Interviewer

4 Tehsil/District

Signature of Interviewer

Section II: Infrastructure (Check, Observe and report by ticking ‘Yes’ or ‘No’)

S. No. Yes No

1 Hospital building is seismic proof (Retro-fitting)

2 Availability of functional electricity supply

3 Availability of piped water supply

4 Intact facility boundary wall

5 All sign boards/sign plates appropriately displayed

6 Facility building maintained last year

7 Enough seating available in the waiting area

8 Female OPD painted & Looks clean

9 Hospital look clean

10 Functional toilet for female patients

11 Labor room functional

12 Beds with mattresses & clean bed sheets

13 Functional Nursery

14 Functional OT sterilization room

15 Proper heating/cooling in labor room

Month and Year

50

16 Separate room/bed for management of Eclampsia

17 Functional telephone available in emergency department

Section III-A: Resources (Check, Observe and report by ticking ‘Yes’ or ‘No’)

S. No. Basic Equipment Yes No

1 Functional BP apparatus available in emergency department

2 Functional stethoscope available in OPDs

3 Functional Thermometer available

4 Functional weighing machine available in pediatric OPD

5 Functional small sterilizer available Emergency department

6 Functional delivery table available in labor room

7 Height Scale available

8 Fetoscope

9 Measuring tape

10 Autoclave in labor room/OT

11 Delivery Forceps

12 Fetal monitor

13 Anesthesia machine in OT

14 Incubator

15 OT lights are all functional

16 Biochemistry analyzer in laboratory

17 Suction machines in OT

18 Functional suction machines in OT

19 Functional suction machines in labor room

20 Baby Warmer

21 Nebulizer

22 Baby cot

23 Oxygen Cylinder

24 Nitrous Oxide

25 Laryngoscope

26 Anesthesia Face Mask

27 Ambu bag for Adult

28 Ambu bag for Infants

51

Section III-B: Resources (Check, Observe and report by ticking ‘Yes’ or ‘No’)

S. No. Human Resource Yes No

1 Availability of medical officer in the health facility

2 Availability of lady health visitor (LHV) in the health facility

3 Availability of dispenser/MHT in the health facility

4 Availability of at least one support staff in the health facility

5 Availability of Gynecologist

6 Availability of Anesthetist

7 Availability of WMO

8 Availability of Nurse

9 Availability of Midwife

10 Availability of OT Technician

11 Availability of Blood bank Technician

12 Availability of Laboratory technician

13 Availability of Ambulance driver

14 Availability of Sanitation staff

Section III-C: Resources (Check, Observe relevant facility stock registers and report by ticking ‘Yes’ or ‘No’)

S. No. Essential Stocks/Material Yes No

1 Availability of HIS stationary

2 Stock out of any essential (tracer) drugs

3 Availability of anesthetic gases/drugs

4 Modern FP material available

Section III-D: Resources (Check, Observe facility stock register and report by ticking ‘Yes’ or ‘No’)

S. No. Essential Drugs Yes No

1 Availability of any type of oral antibiotic syrup for children

2 Availability of any type of oral antibiotic for adults

3 Availability of any type of antipyretic drug

52

4 Availability of folate/folic acid tablet

5 Availability of any type of antiseptic solution

6 Availability of any type of antihypertensive drug

7 Filled cylinders of nitrous oxide

8 Availability of any type of injectable antibiotic emergency department

9 Availability of any type of injectable analgesic in emergency department

10 Availability of functional and filled oxygen cylinder in OT

11 Availability of functional and filled oxygen cylinder in labor room

12 Availability of oral rehydration salt (ORS) sachet

Section IV: Knowledge of Service Providers (Check, Observe and report by ticking ‘Yes’ or ‘No’) Use pre-agreed criteria for knowledge assessment of relevant staff

S. No. Yes No

1 Knowledge on Antenatal Care (ANC) service package delivery

2 Knowledge on Postnatal Care (PNC) service package delivery

3 Knowledge of LHV on normal delivery

4 Knowledge of LHV on assisted delivery

5 Knowledge of LHV on APH management

6. Knowledge on management of eclampsia/pre-eclampsia

7. Knowledge about MISP

8. Knowledge about management of excessive vaginal bleeding after delivery

9. Knowledge about puerperal Pyrexia

10. Knowledge about Management of prolonged labor

11. Knowledge of LHV on PPH management

12. Knowledge of Gynecologist/SWMO/WMO on performing C-Section

13. Knowledge on infection prevention/sterilization

14. Knowledge on post operative care

15. Knowledge of dispenser/ or MHT on drugs stock keeping

53

Section V: Provision of Health Services (Check, Observe and report by ticking ‘Yes’ or ‘No’)

S. No.

Yes No

1 Antenatal Care Services (ANC)

2 Post Natal Care Services (PNC)

3 TT Immunization

4 EPI Services

5 Hospital based normal vaginal delivery

6 Provision of contraceptives (FP material)

7 Cesarean Section

8 Management of Eclampsia

9 Medical Indoor services

10 Gynecology and Obstetrics indoor services

11 Laboratory services

12 Radiological services

13 Ultrasonography

14 Blood grouping performed

15 Blood transfusion performed

16 Parenteral antibiotics administered

17 Parenteral oxytocic drugs administered

18 Parenteral anticonvulsant administered

19 Manual removal of placenta performed

20 Removal of retained products performed

21 Assisted vaginal delivery performed

Section VI: Infection prevention/waste management (Look for availability and functioning of the items)

S. No. Variable Yes No

1 Functional autoclave

2 Functional sterilizer

3 Disposable gloves available

54

4 Aprons

5 Shoe covers/slippers in the LR/OT

6 Waste bins

7 Needle/sharp disposal box

8 Needle cutter

9 Antiseptic solution

10 Disposable syringes

11 Masks

12 Caps

13 Macintosh

14 Intact sewage system

15 Fly proofing

55

Hospital Service Utilization and Key Performance Indicators for Comprehensive EmONC Services—Checklist A-2

[Check and transfer data from relevant health facility registers]


1 Hospital ID

Name of Respondent

2 Hospital Name and type

Designation of Respondent


Name of Interviewer

4 Tehsil/District

Signature of Interviewer

Section II: Service Delivery and Utilization (Check, Observe and report by writing appropriate figures)

1. Total number of OPD patients attended

in the hospital

Please write total number of patients from OPD /Pirchi register during November 2013______________ November 2014_______________

2. Total number of patients admitted in

the hospital

Please write total number of patients from Indoor register during November 2013______________ November 2014_______________

3. Total number of deliveries attended in

the hospital labor room?

Please write number of deliveries from Labor Room register during November 2013______________ November 2014_______________

4. Total number of C-Section done in the

hospital

Please write number of C-Section from OT Register during November 2013______________ November 2014_______________

5. Total number of Surgeries done in the

hospital

Please write number of Surgeries from OT Register during November 2013______________ November 2014_______________

56

6. Total number of Antenatal Care (ANC)

clients attended in the health facility?

Please write number of ANC visits from MCH/OPD register during November 2013______________ November 2014_______________

7. Total number of Post-natal Care (PNC) clients attended in the health facility.

Please write number of PNC visits from MCH/OPD register during November 2013______________ November 2014_______________

8. Total number of children (11-23

months) vaccinated against measles by the hospital EPI Center.

Please write number of vaccinated children receiving measles vaccination from EPI register during November 2013______________ November 2014_______________

9. Total number of laboratory tests

performed in the hospital.

Please write number of deaths from Laboratory register during November 2013______________ November 2014_______________

10. Total number of X-rays performed in the

hospital.

Please write number of deaths from Radiology register during November 2013______________ November 2014_______________

11. Total number of maternal deaths in the

hospital.

Please write number of deaths from Indoor register during November 2013______________ November 2014_______________

12. Total number of neonatal deaths in the

hospital.

Please write number of deaths from Indoor register during November 2013______________ November 2014_______________

57

Structured Assessment Checklist for Health Facilities (EFHCs, FHCs) Form B 1

For office use only


1 Facility ID Signature of Study Team Member:

2 Facility Name and type


Name:

4 Tehsil/District

Section II: Infrastructure (Check, Observe and report by ticking ‘Yes’ or ‘No’)

S. No. Yes No

1 The health facility is seismic proof (Retro-fitting)

2 Availability of piped water supply

3 Intact facility boundary wall

4 All sign boards/sign plates appropriately displayed

5 Facility building maintained last year

6 Enough seating available in the waiting area

Section III-A: Resources (Check, Observe and report by ticking ‘Yes’ or ‘No’)

S. No. Basic Equipment Yes No

1 Functional BP apparatus available

2 Functional Stethoscope available

3 Functional Thermometer available

4 Functional weighing machine available

5 Functional small sterilizer available in the health facility

6 Functional delivery table available

Section III-B: Resources (Check, Observe and report by ticking ‘Yes’ or ‘No’)

S. No. Human Resource Yes No

1 Availability of LMO in the health facility

2 Availability of lady health visitor (LHV) in the health facility

3 Availability of dispenser/MHT in the health facility

4 Availability of at least one support staff in the health facility

Section III-C: Resources (Check, Observe relevant facility stock registers and report by ticking ‘Yes’ or ‘No’)

S. No. Essential Stocks/Material Yes No

1 Availability of HIS stationary

2 Stock out of any essential (tracer) drugs

3 Availability of soap for hand washing

4 Modern FP material available

Month and Year

58

Section III-D: Resources (Check, Observe facility stock register and report by ticking ‘Yes’ or ‘No’)

S. No. Essential Drugs Yes No

1 Availability of any type of oral antibiotic syrup for children

2 Availability of any type of oral antibiotic for adults

3 Availability of any type of antipyretic drug

4 Availability of folate/folic acid tablet

5 Availability of any type of antiseptic solution

6 Availability of any type of antihypertensive drug

7 Availability of oral rehydration salt (ORS) sachet

Section IV: Knowledge of Service Providers (Check, Observe and report by ticking ‘Yes’ or ‘No’) Use pre-agreed criteria for knowledge assessment of relevant staff

S. No. Yes No

1 Knowledge on Antenatal Care (ANC) package delivery

2 Knowledge on Postnatal Care (PNC) service delivery

3 Knowledge of LHV/WMO on Assisted Vaginal Delivery

4 Knowledge of LHV/WMO on APH management

5 Knowledge of LHV/WMO on PPH management

6 Knowledge on infection prevention

7 Knowledge of dispenser/ or MHT on drugs stock keeping

8 Knowledge of LHV/LMO on IUD insertion

Section V: Provision of Health Services (Check, Observe and report by ticking ‘Yes’ or ‘No’)

S. No. Yes No

1 Antenatal Care Services (ANC)

2 TT Immunization

Post-natal care Services

EPI Services

3 Treatment of minor curative services

4 Facility-based normal vaginal delivery

5 Provision of contraceptives (FP material)

59

Structured Assessment Checklist for Health Facilities (EFHCs, FHCs) Form B 2

Section VI: Service Delivery and Utilization (Check, Observe and report by ticking ‘Yes’ or ‘No’)

1. Total number of OPD patients attended

in the health facility?

Please write total number of patients from OPD /Pirchi register during November 2013______________ November 2014_______________

2. Total number of deliveries attended in

the health facility?

Please write number of deliveries from MCH/Labor Room/OT register during November 2013______________ November 2014_______________

3. Total number of Antenatal Care (ANC)

clients attended in the health facility?

Please write number of ANC visits from MCH/OPD register during November 2013______________ November 2014_______________

4. Total number of Post-natal Care (PNC) clients attended in the health facility.

Please write number of PNC visits from MCH/OPD register during November 2013______________ November 2014_______________

5. Total number of children (11-23

months) vaccinated against measles by the health facility.

Please write number of vaccinated children receiving measles vaccination from EPI register during November 2013______________ November 2014_______________

60

Structured Self Assessment Questionnaire for Health Facility Managers (Overall Impact and Effectiveness of Training)

The usefulness of training coursesprimarily the knowledge and skills learnedis often determined only after training participants return to their work setting. Please complete this post-training self-assessment questionnaire. We‟d like to know how useful the training you attended is in your present situation, assess the training’s effectiveness in terms of processes, learning objectives, knowledge and skills attained, quality of training and overall post-evaluation rating , and identify any gaps or needs for improvements. THANK YOU for your help!

Course Information

Courses title: 1- 2- 3-

Courses attended with date(s): 1- 2- 3-

Course location (s):

Did you attend all sessions? Yes No

Individual Information

Your Name: Your Designation

Contact numbers Cell: Office: Fax: E-mail address:

Mailing address:

Please indicate your primary responsibility as Health Manager: Health Facility In-charge/Manager Others (Please specify)

What type of facility do you work in? Hospital EFHC FHC HC Others _____________________________

Overall Effectiveness of Training

1. Have you used new information/ knowledge gained from the training in your daily work?

Yes No If no, please explain:

2. Have you used new skills from the training in your daily work?


3. Please rate your willingness to implement training skills.

Very willing Somewhat willing Unsure Do not want to work for Safe Motherhood Please explain

4. Please rate your ability to manage your health facility team?

I am very knowledgeable and skilled I have moderate skills I have few skills I have no knowledge and skills to manage Please explain:

5. Please rate your ability on planning skills for health facility services?

I am very knowledgeable and skilled I have moderate skills I have few skills I have no knowledge and skills Please explain:

61

6. What additional skills related to Safe Motherhood planning and management do you feel you still need?

Please tell us

Self Assessment

Please review the following list of topics and give some thought to what you currently know about each. Circle the number that best represents your level of knowledge and skills now, post training. RATING SCALE 1 = VERY

LOW 2 = LOW 3 =

MEDIUM 4 = GOOD

5 = HIGH

SELF-ASSESSMENT OF KNOWLEDGE AND SKILLS RELATED TO: POST TRAINING NA

Concepts of Health facility management and team building 1 2 3 4 5

Solid waste management in health facilities 1 2 3 4 5

Health Facility Infection Control 1 2 3 4 5

Knowledge of ALL components of MNCH Services 1 2 3 4 5

Knowledge on Project Design Matrix 1 2 3 4 5

Knowledge on various research methods 1 2 3 4 5

Use of data for planning and management 1 2 3 4 5

Monitoring and evaluation of Health Programs 1 2 3 4 5

Knowledge on three delays encountered during management of pregnancy

1 2 3 4 5

Knowledge on various causes of maternal mortality in Pakistan 1 2 3 4 5

Preparation of operational plans 1 2 3 4 5

Weaknesses in integrated referral system in the district 1 2 3 4 5

Decision-making by consensus 1 2 3 4 5

Management of labor room and operation theatre supplies 1 2 3 4 5

Disposal of human viscera/products safely 1 2 3 4 5

Health Facility Financial Management 1 2 3 4 5

Health Facility MIS 1 2 3 4 5

Management of Procurement and supplies 1 2 3 4 5

Usefulness of the Training

1. What were the three most important things [or aspects] of the training workshop, did you like? (Please tick at least three preferred boxes)

Training Material Training Methods

Training Facilitators

Training Venue Facilities for Participants

2. Has training made difference in your skills to do your job? (Please tick the appropriate box)

No Difference Some Difference Much Difference Tremendous Difference

3. Has training made difference in your knowledge to do your job? (Please tick the appropriate box)


4. Was an appropriate amount of subject material covered during the training? (Please tick the appropriate box)

No Small Mostly Yes

5. Was on-hand training enough/sufficient to cover the training course material? (Please tick the appropriate box)

No Small Mostly Yes

6. Would you recommend this course/training to a co-worker/colleague?

No Not sure Yes

62

Structured Self Assessment Questionnaire for Health Care Service Providers

(Overall Impact and Effectiveness of Training)

The usefulness of a training courseprimarily the knowledge and skills learnedis often determined only after training participants return to their work setting. Please complete this post-training follow-up questionnaire. We‟d like to know how useful the training you attended is in your present situation, assess the training’s effectiveness in terms of processes, learning objectives, knowledge and skills attained, quality of training and overall post-evaluation rating , and identify any gaps or needs for improvements. THANK YOU for your help!

Course Information

Courses title: 1- 2- 3-

Courses attended with date(s): 1- 2- 3-

Course location (s): 1- 2- 3-

Did you attend all sessions? Yes No

Individual Information

Your Name:

Your Designation:

Contact numbers Cell: Office: Fax: E-mail address:

Mailing address:

Please indicate your primary responsibility: Gynaecologist (Specialist) Obstetric Doctor (WMO) Lady Health Visitor (LHV) Staff Nurse (SN)

What type of facility do you work in? Hospital EFHC FHC HC Other _______________________________ (Please specify)

Overall Effectiveness of Training

7. Have you used new information/ knowledge gained from the training in your daily work?


8. Have you used new skills from the training in your daily work?


9. Please rate your willingness to care for MNCH Clients.

Very willing Somewhat willing Unsure Do not want to work for Safe Motherhood Please explain

63

10. Please rate your ability to manage complications of pregnancy?

I am very knowledgeable and skilled I have moderate skills I have few skills I have no knowledge and skills to manage Please explain:

11. Please rate your ability on life saving skills?

I am very knowledgeable and skilled I have moderate skills I have few skills I have no knowledge and skills Please explain:

12. What additional skills related to MNCH services do you feel you still need?

Please tell us

Self Assessment

Please review the following list of topics and give some thought to what you currently know about each. Circle the number that best represents your level of knowledge and skills now, post training. RATING SCALE 1 = VERY

LOW 2 = LOW 3 = MEDIUM 4 =

GOOD 5 = HIGH

SELF-ASSESSMENT OF KNOWLEDGE AND SKILLS RELATED TO: POST TRAINING NA

Concepts of team work and team building 1 2 3 4 5

Clinical diagnosis of breech presentations 1 2 3 4 5

Solid waste management in hospitals/health facility 1 2 3 4 5

Normal vaginal delivery (NVD) 1 2 3 4 5

Hands-on training on Safe Motherhood (ward rounds) 1 2 3 4 5

Neonatal Resuscitation 1 2 3 4 5

Manual removal of placenta 1 2 3 4 5

Hospital/health facility Infection Control 1 2 3 4 5

Post-partum haemorrhage management (PPH) 1 2 3 4 5

Diagnosis of pre-eclampsia Management of cervical tears 1 2 3 4 5

Management of cervical tears 1 2 3 4 5

Patient management in emergency operations 1 2 3 4 5

AMTSL (Active Management of Third Stage of Labor) 1 2 3 4 5

Clinical diagnosis and Management of PV bleeding (APH) 1 2 3 4 5

Knowledge of ALL components of Comprehensive EmOC 1 2 3 4 5

Preparation of patient for C-Section 1 2 3 4 5

IUD insertion 1 2 3 4 5

Hands-on training on Safe Motherhood (Labor Room) 1 2 3 4 5

Management of ALL three stages of labor 1 2 3 4 5

Management of pre-eclampsia cases 1 2 3 4 5

Management of vaginal tears 1 2 3 4 5

Post operative management of C-Section 1 2 3 4 5

Newborn care after obstructed labor 1 2 3 4 5

Care of post-operative wounds 1 2 3 4 5

64

Usefulness of the Training

1. What were the three most important things [or aspects] of the training workshop, did you like? (Please tick at least three preferred boxes)

Training Material

Training Methods

Training Facilitators

Training Venue Facilities for Participants

2. Has training made difference in your skills to do your job? (Please tick the appropriate box)


3. Has training made difference in your knowledge to do your job? (Please tick the appropriate box)


4. Was an appropriate amount of subject material covered during the training? (Please tick the appropriate box)

No Small Mostly Yes

5. Was on-hand training enough/sufficient to cover the training course material? (Please tick the appropriate box)

No Small Mostly Yes

6. Would you recommend this course/training to co-worker/colleague?

No Not sure Yes

65

GILGIT-BALTISTAN HEALTH DEVELOPMENT PROJECT

Structured Questionnaire for Exit Poll/ Community Satisfaction Interview

Before Starting the Interview, Please ensure that consent form is signed by the respondent

1 IDENTIFICATION SECTION

Please ensure response in the relevant box for each question;

ID #

Interview By:

[Heath Facility Type]

Date:

Signature:

2 REVIEW SECTION

Reviewed By:

Date of Review:

Data Entry

Date:

Data Enter By:

INTERVIEWER's NOTE: Interviewer should clarify the respondent that if s/he does not understand any of the question, s/he can ask interviewer to repeat the question.

SECTION A

INTERVIEW

A1. How old are you? A2 Gender

# Years

If respondent does not know the age, probe approximate age and write in above box.

A3. What is your purpose to visit health facility?

A4 How do you feel about quality of services provided?

Disease

Bad

Other

Poor

A5. How was the behaviour of doctor/service provider?

Satisfactor

y

Good

1- Friendly

66

2- Rude

Excellent

3- Compassionate

4- Empathetic

A6. Was doctor/ service provider attentive to you?

Yes No

A7. If doctor has suggested the lab test, was that service available there?

A8. If no, then from where you get the service?

Yes

Other Govt

Hospital

No

Private Hospital

Private Lab

None

A9. If lab test was available, did you pay for the test?

Yes

No

A10. Did the health facility provide medicines? A11. Did you pay for the medicines?

Yes Yes

No

No

A11. What was the approximate waiting time to meet the doctor/service provider?

15-30 minutes

More than one hour

30-45 minutes

Two hours

one hour

67

A12. How much time has doctor/service provider spent for your check up?

less than 15 minutes

15-30 minutes

More than 30 minutes

A13. Do you think, building of health facility is better than previous?

Yes No

Do not Know?

A14. Does health cleanliness acceptible?

Yes No

A15. Is there any discrimination on the basis of gender?

Yes

No

A16. Did you paid any informal payment for the services utilized (other than Govt./ health facility fee)

Yes No

E1 What are your suggestions to improve health services provision in the health facility?

INTERVIEWER's NOTE: Please make sure that all responses have been collected. Once again say thanks to the respondent for sparing valuable time to feed into this research.

68

ANNEX-II: QUALITATIVE TOOLS

Semi-structured questionnaires for Key informants

Key Informants: DHO-Ghizer, Director Health Services-GB, Project manager-GBHDP,

General Manager-AKHSP

Reason for Interview: The aim was to record the performance on key result indicators, status of

physical works, availability of resources, knowledge of service providers, equipment and

supplies, service delivery management and utilization, and operational cost specific to Gupis

Civil Hospital.

Instructions for the Interviewer:

Before the interview:

Make an appointment with the AKDN Managers and DOH Managers and explaining him/her the

objective of the Study and the reason for doing the interview.

At the time of interview:

a) Felicitate the AKDN and DOH Managers and introduce yourself. Clearly explain

him/her the objective of the Study and the reason for doing the interview with him/her.

Explain how he/she was selected for the interview. Also, request the Managers to

allow you enough time for conducting the interview highlighting the importance of the

views expressed him/her. Discourage prompting by other people in the room if their

presence there is unavoidable.

b) Ask the questions one by one and note down the replies clearly. If the Managers seem

not to clearly understand the question, explain him/her further but avoid putting any

leading question that suggests answer in itself. Facilitate discussion, if any, to remain

within the context of the interview. If you are not clear about the answer provided to

you, request the respondent to repeat his/her view on that particular question.

c) Before ending the interview session, reconfirm that all questions have been asked.

Thank the respondent at the end of the session.

After the interview:

Organize the answers according to the questions. Collate all other views expressed by the

AKDN & DOH Managers that do not fall directly under any question in a separate section.

Prepare a summary of the interview session with each respondent.

DHO Ghizer:

- What the key challenges to operate health facilities in your district?

- How was your experience with the AKHSP on the PPP at Civil hospital Gupis?

- What kind of support was provided to support civil hospital Gupis and other facilities by

AKHSP?

69

- Which component of the support (by project) was most meaningful? (Probes:

Rehabilitation/construction of health facilities, Medicine, and Equipment and vehicles

Training of staff and community based health workers (CHWs and TBAs of AKHS and

LHWs of government), Coverage of operation cost)

- What is the trend with regards to utilization of services at health facilities? (Probe:

Increasing or decreasing)

- Are there any issues of operational management at health facilities? (Probes: particularly

Gupis Civil Hospital)

- If yes, what are those challenges for operational management?

- How you envisage the role of AKHSP to support district health systems and project

health facilities in future?

- As the coverage of operation cost has been no more from AKHSP for the Gupis

Hospital, how you envisage future sustainability of operations at health facility.

- Do you have enough resources at district level to support such PPP model?

- If yes, what resources are available to support such PPP model?

- What kind of support is required from Provincial health department to support such PPP

model?

Director Health Services-GB:

- How is your experience working with AKHSP for the GB Health Development Project?

- What support was provided by AKHSP to government in the project?

- How was your coordination with the AKHSP on the project activities and interventions?

- What were the key challenges and obstacles in the PPP model with AKHSP?

- Which component of the project was most meaningful to improve health development

indicators? (Probes: introduce components if needed)

- What are your plans to carry on with this PP model?

- Do you have enough resources to support PPP?

- If no, what are you plans to support PPP model?

Project Manager-GBHDP & GM-AKHSP

- How is your experience working with Government for the GB Health Development

Project?

- What support was provided by AKHSP to government in the project?

- How was your coordination with the government on the project activities and

interventions?

- What were the key challenges and obstacles to support PPP model?

- How was government response to support PPP model?

- How was your experience with the fourth component of project, i.e. coverage of

operation cost at Gupis Hospital?

- How was government response to support operations at Gupis Civil Hospital when the

coverage cost from AKHSP declined over time?

- In future, which building block in govt. health system AKHSP like to support in PPP?

(Probes: ask about six building blocks)

70

ANNEX-III: DISTRICT WISE PHYSICAL CONDITION OF HEALTH

FACILITIES

80%

100%

100% 100%

80%

100% Infrastructure of Health Facility at Ghizer

The health facility is seismic proofAvailability of piped water supplyIntact facility boundary wallAll sign boards/sign plates appropriately displayed

67%

100%

100% 100%

100%

100%

Infrastructure of Health Facility at Gilgit

The health facility is seismic proofAvailability of piped water supplyIntact facility boundary wallAll sign boards/sign plates appropriately displayedFacility building maintained last yearEnough seating available in the waiting area

71

100%

100%

100% 100%

100%

100%

Infrastructure of Health Facility at Hunza Nagar

The health facility is seismic proofAvailability of piped water supplyIntact facility boundary wallAll sign boards/sign plates appropriately displayedFacility building maintained last year

72

ANNEX-IV: FINANCIAL ANALYSIS OF GUPIS CIVIL HOSPITAL

Organization Aga Khan Health Service, Pakistan

District Ghizer

Hospital Gupis civil hospital

IMPORATANT AREAS

PROFIT/LOSS - Analysis

Volumes:

(Major Products, Quantities

Sold, AVG sale Price and

Reason for

Increase/Decrease, Future

Estimate of Sales Price and

quantities), Comparison

with other competitors)

For the year 2013, total 1,738 admissions were recorded with

2,203 OPAs which accumulated for 3,941. For 2014, admission

volumes reduced by 32% to 1,203 (2013: 1,738) and OPAs

showed a considerable increase over the year by 3 times to

8,765 (2013: 2,203). The total volume for 2014 turned out to

9,968 (2013: 3,941) with 152% increase recorded over the year

2013-14.

For 2015, It is forecasted that admission volumes would be

reported for 2,409 (2013: 1,203) with 104% increase over the

years 2014-15. The forecast for OPAs would increase by 30% to

11,379 (2013: 8,765). The total volume forecast for 2015 would

turn out to be 13,788 (2013: 9,968) with estimated 39% increase

recorded over the forecasted year 2014-15.

Funds Generation

(Allocations)

(Reasons for

Increase/Decrease,

Inventory profit/ Loss and

fuel payments, Comparison

with other competitors)

% Change in CGS over

Years

Year-2 Year-Latest

The actual AKHSP allocations for Gupis in the year 2013 were

reported for Rs 5.756 M and user fee were reported for Rs

8.839 M. The total funds generated in 2013 amounted to Rs

14.595 M. In year 2014. The AKHSP allocations for Gupis in the

year 2014 increased by 12% over the year to Rs 6.474 M (2013:

Rs 5.756 M) and user fee decreased by 11% to Rs 7.903 M

(2013: Rs 8.839 M). The total funds generation for the year

2014 amounted to Rs 14.377 M (2013: Rs 14.595 M) with 1%

decrease over the year 2013-14.

For 2015, the forecasted AKHSP allocations for Gupis would be

reported for Rs 6.959 M (2013: Rs 6.474 M) with 7% increase

over the years 2014-15. It is forecasted that user fee would

increase by 106% to Rs 16.291 M (2013: Rs 7.903 M). The total

funds generation forecast for 2015 would turn out to be Rs

23.650 M (2014: Rs 14.377 M) with estimated 64% increase

recorded over the forecasted year 2014-15.

73

Admin, Selling, Other

Expenses (Reason for

Increase/Decrease)

In 2014, salaries expenditure were reported for Rs 9.035 M

(2013: Rs 9.083 M) which decreased by 1% during the period

2013-14. The forecasted expenditure for the year 2015 would be

Rs 11.516 M which would increase by 27% over the forecasted

period 2014-15. Overall, Salaries remained largest expense

against total expenditure which accounted to around 62% of

total expenses for the year 2013 & 2014 and it accounted to

49% for the forecasted year 2015 showing reduction in salaries

expense as %age of total expenditures.

In 2014, drugs and supplies were the second largest expense

that were reported for Rs 2.710 M (2013: Rs 3.090 M) which

decreased by 12% during the period 2013-14. The forecasted

expenditure for the year 2015 would be Rs 8.468 M which would

increase by 2 times over the forecasted period 2014-15. Overall,

drugs and supplies remained second largest expense against

total expenditure which accounted to around 20% of total

expenses for the year 2013 & 2014 and it accounted to 36% for

the forecasted year 2015 showing reduction in salaries expense

as %age of total expenditures.

GBHDP Evaluation Report Jan 20 2015

Documents

Transcript of GBHDP Evaluation Report Jan 20 2015