Health Facility Assessment – Khyber Pakhtunkhwa ......and 77 tehsil headquarter (THQH) and civil...

Health Facility Assessment –

Khyber Pakhtunkhwa

Provincial Report

TRFTechnical Resource Facility

i

Acknowledgement

TRF acknowledges the cooperation and support of Contech International Health

Consultants, Lahore who worked on the assignment and authored the report. The final

reports are quality assured by Jennifer Sanchos, HLSP Health Systems Consultant.

Disclaimer

This document is issued for the party which commissioned it and for specific purposes

connected with the above-captioned project only. It should not be relied upon by any other

party or used for any other purpose.

We accept no responsibility for the consequences of this document being relied upon by any

other party, or being used for any other purpose, or containing any error or omission which is

due to an error or omission in data supplied to us by other parties.

June 2012

ii

Table of Contents

Acknowledgement ................................................................................................................ i

Acronyms .......................................................................................................................... viii

Executive Summary ............................................................................................................. 1

Report organisation .......................................................................................................... 2

Section 1: Introduction ........................................................................................................ 3

Survey objectives .............................................................................................................. 3

Assignment duration ......................................................................................................... 4

Scope of HFA .................................................................................................................... 4

Section 2: Provincial Information ....................................................................................... 5

Khyber Pakhtunkhwa – An overview ................................................................................. 5

Key indicators ................................................................................................................... 6

Public sector health facilities ............................................................................................. 7

Section 3: Assessment of Functional Capacities .............................................................. 9

MNCH services ................................................................................................................. 9

Basic health units ............................................................................................................ 10

Status of infrastructure ............................................................................................... 10

Status of human resources......................................................................................... 11

Status of functional equipment ................................................................................... 11

Status of drugs and supplies ...................................................................................... 12

Status of support services .......................................................................................... 12

BHUs’ conformance to required inputs ....................................................................... 13

Rural health centres ........................................................................................................ 13






RHCs’ conformance to required inputs ....................................................................... 18

SHC hospitals ................................................................................................................. 19



iii




SHC hospitals’ conformance to required inputs .......................................................... 26

THQ hospitals ................................................................................................................ 29






THQs’ conformance with assessed inputs .................................................................. 32

Management basics ....................................................................................................... 32

Human resources ....................................................................................................... 34

Provision of staff by the NMNCHP .............................................................................. 35

MNCH staff training .................................................................................................... 35

CMWs’ training and deployment ................................................................................. 36

Work coordination and supervision ............................................................................. 37

Management information system................................................................................ 38

Drugs and supplies .................................................................................................... 39

Infection control .......................................................................................................... 40

Death review .............................................................................................................. 41

Facility utilization ............................................................................................................. 41

Donor contributions ......................................................................................................... 43

Procurement estimates ................................................................................................... 43

Equipment .................................................................................................................. 43

Civil works .................................................................................................................. 43

Section 4: Clients’ Perspective ......................................................................................... 45

Key findings .................................................................................................................... 45

Quality of care ............................................................................................................ 47

Overall satisfaction .................................................................................................... 48

Section 5: Health Managers’ Perspective ......................................................................... 50

Rationale ......................................................................................................................... 50

Key findings of the in-depth interviews ............................................................................ 50

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Infrastructure .............................................................................................................. 50

Human resources ....................................................................................................... 51

Procurement and logistical management.................................................................... 52

MIS ............................................................................................................................ 53

Planning ..................................................................................................................... 54

Monitoring and supervision......................................................................................... 54

Inter-sectoral collaboration ......................................................................................... 55

Financial management ............................................................................................... 56

Donor contributions .................................................................................................... 57

Section 6: Key Findings..................................................................................................... 59

Infrastructure ................................................................................................................... 59

Human resources ............................................................................................................ 60

Training of staff ............................................................................................................... 60

Drugs, supplies and equipment ....................................................................................... 61

Work coordination and supervision ................................................................................. 62

Service delivery protocols ............................................................................................... 62

Management information system .................................................................................... 62

Infection control ............................................................................................................... 62

Death reviews ................................................................................................................. 63

Donor contributions ......................................................................................................... 63

ANNEX 1 ............................................................................................................................. 65

Objectives of the NMNCH programme ................................................................................. 65

ANNEX 2 ............................................................................................................................. 68

Input Criteria for MNCH services ..................................................................................... 68

A. Civil works criteria ................................................................................................... 68

B. Human resources criteria ....................................................................................... 70

C. Equipment criteria .................................................................................................. 71

D. Drugs and supplies criteria .................................................................................... 78

E. Support service criteria .......................................................................................... 80

F. Infection control and waste management criteria ................................................... 81

G. Input criteria for basic EmONC services at THQ hospital ....................................... 82

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List of Tables

Table 1.1: Scope of HFA ....................................................................................................... 4

Table 2.1: Key figures of Khyber Pakhtunkhwa ..................................................................... 6

Table 2.2: Number of public sector health facilities ................................................................ 8

Table 3.1: Status of assessed infrastructure in BHUs .......................................................... 11

Table 3.2: Status of MNCH related staff in BHUs ................................................................ 11

Table 3.3: Status of functional equipment in BHUs .............................................................. 12

Table 3.4: Status of drugs and supplies in BHUs ................................................................. 12

Table 3.5: Status of support services in BHUs ..................................................................... 13

Table 3.6: Status of assessed infrastructure in RHCs .......................................................... 16

Table 3.7: Status of MNCH related staff in RHCs ................................................................ 17

Table 3.8: Status of functional equipment in RHCs .............................................................. 17

Table 3.9: Status of drugs and supplies in RHCs ................................................................. 18

Table 3.10: Status of support services in RHCs ................................................................... 18

Table 3.11: Status of support services in RHCs ................................................................... 18

Table 3.12: Status of assessed infrastructure in SHC hospitals ........................................... 21

Table 3.13: Status of MNCH related staff in SHC hospitals ................................................. 23

Table 3.14: Status of functional equipment in SHC hospitals ............................................... 24

Table 3.15: Status of drugs and supplies in SHC hospitals .................................................. 24

Table 3.16: Status of support services in SHC hospitals ...................................................... 25

Table 3.17: Status of support services in SHC hospitals ...................................................... 25

Table 3.18: Status of assessed infrastructure in THQHs ..................................................... 29

Table 3.19: Status of MNCH related staff in THQHs ............................................................ 30

Table 3.20: Status of functional equipment in THQHs ......................................................... 30

Table 3.21: Status of drugs and supplies in THQHs ............................................................ 31

Table 3.22: Status of support services in THQHs ................................................................ 31

Table 3.23: Status of support services in THQHs ................................................................ 32

Table 3.24: Status of HR reported by surveyed health facilities ........................................... 34

Table 3.25: Number of health facilities having staff provided by NMCHP ............................. 35

Table 3.26: Number of MNCH staff provided by NMCHP .................................................... 35

Table 3.27: Number of staff trained on delivering MNCH services ....................................... 36

Table 3.28: Number of health facilities received MNCH training .......................................... 36

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Table 3.29: Status of CMWs training and deployment in Khyber Pakhtunkhwa ................... 37

Table 3.30: Status of infection prevention at the surveyed health facilities ........................... 40

Table 3.31: Status of mortality reviews at surveyed health facilities ..................................... 41

Table 3.32: Utilization of MNCH services at surveyed health facilities ................................. 41

Table 3.33: Utilization of FP services at surveyed health facilities ....................................... 42

Table 3.34: Status of donor contributions at surveyed health facilities ................................. 43

Table 3.35: Summary of estimated cost for equipment and civil works ................................ 44

Table 4.1: Number of CEIs conducted in Khyber Pakhtunkhwa ........................................... 45

Table 5.1: Names of districts in Khyber Pakhtunkhwa contacted for IDIs ............................. 50

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List of Figures

Figure 2.1: Map of Khyber Pakhtunkhwa ............................................................................... 6

Figure 3.1: Range of services that signal fully functional MNCH services .............................. 9

Figure 3.2: Average availability of assessed inputs at surveyed BHUs ................................ 13

Figure 3.3: District-wise status of conformance of BHUs to required inputs ......................... 15

Figure 3.4: Average availability of assessed inputs at RHCs ............................................... 19

Figure 3.5: District-wise status of conformance of RHCs to required inputs ........................ 20

Figure 3.6: Average availability of assessed inputs at SHC hospitals .................................. 26

Figure 3.7: District-wise status of conformance of DHQHs to required inputs ...................... 27

Figure 3.8: District-wise status of conformance of THQHs to required inputs ...................... 28

Figure 3.9: Average availability of assessed inputs at THQHs ............................................ 32

Figure 3.10: District-wise status of conformance of THQHs to required inputs .................... 33

Figure 3.11: Status of management basics at surveyed facilities......................................... 37

Figure 3.12: Work coordination ........................................................................................... 38

Figure 3.13: Supervision ..................................................................................................... 38

Figure 3.14: Status of MIS................................................................................................... 39

Figure 3.15: Facility specific reasons for stock out of drugs and supplies ............................ 40

Figure 4.1: Reasons for visiting health facility...................................................................... 46

Figure 4.2: Average time taken by the clients to reach the facility ....................................... 46

Figure 4.3: Average waiting time at the facility .................................................................... 47

Figure 4.4: Clients' level of satisfaction with availed services .............................................. 47

Figure 4.5: Provision of medicines, lab services and education material ............................. 48

Figure 4.6: Overall satisfaction of interviewed clients .......................................................... 49

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ACRONYMS ANC Antenatal Care

AJK Azad Jammu Kashmir

AVD Assisted Vaginal Deliveries

BB technician Blood Bank Technician

BEmONC Basic Emergency Obstetric and Newborn Care

BHU Basic Health Unit

CBA Child Bearing Age

CEI Client Exit Interview

CH Civil Hospital

CMW Community Midwives

CWAQ Civil Works Assessment Questionnaire

CDC Communicable Disease Control

DCO District Coordination Officer

DDCT District Data Collection Teams

DHO District Health Officer

DHDC District Health Development Centre

DHIS District Health Information System

DHQH District Headquarter Hospital

DLQ District Level Questionnaire

EDOs Executive District Officers

EmONC Emergency Obstetric and Newborn Care

ENC Emergency Newborn Care

EAQ Equipment Assessment Questionnaire

EPI Expanded Programme of Immunisation

FATA Federally Administered Tribal Areas

FP & PHC Family planning and Primary Health Care

GBR Gilgit Baltistan Region

HF Health Facilities

HFA Health Facility Assessments

HID Health Institution Database

HIV Human Immunodeficiency Virus

HMIS Health Management Information System

HR Human Resource

IDI – EDOH In-depth Interview of EDO Health

IMNCI Integrated Management of Neonatal and Childhood Illnesses

IMPAC Integrated Management of Pregnancy and Childbirth

JD Job Description

KPK Khyber Pakhtunkhwa

LHS Lady Health Supervisor

LHV Lady Health Visitor

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LHW Lady Health Worker

MDGs Millennium Development Goals

M&E Monitoring and Evaluation

MICS Multiple Indicator Cluster Survey

MIS Management Information System

MNCH Maternal, Neonatal and Child Health

MO Medical Officer

NMNCHP National Maternal Newborn and Child Health Programme

NVD Normal Vaginal Deliveries

OBGYN Obstetrics and Gynaecology

OPD Out Patient Department

OT Operation Theatre

PC-1 Planning Commission Proforma – 1

PDHS Pakistan Demographic and Health Survey

PNC Post Natal Care

PPHI Peoples Primary Health Care Initiative

PSLM Pakistan Social & Living Standards Measurement Survey

RHC Rural Health Centre

SBA Skilled Birth Attendants

SD&MB Service Delivery and Management Basics

SE Socioeconomic

SHC hospitals Secondary Health Care

SPSS Statistical Package for the Social Sciences

TA Technical Assistance

THQ Tehsil Headquarter hospital

TRF Technical Resource Facility

TT Tetanus Toxoid

WMO Women Medical Officer

WBC Well Baby Clinics

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Executive Summary

The first national health facility assessment (HFA) was conducted from October 2010 to May

2011 covering all of the provinces and regions of Pakistan, as part of the implementation of

the monitoring and evaluation (M&E) framework of the national maternal newborn and child

health programme (NMCHP).

The Khyber Pakhtunkhwa health facility assessment report synthesises the findings of 350

health facilities assessed in all of the 25 districts of Khyber Pakhtunkhwa province.

Secondary health care (SHC) hospitals including 21 district headquarter (DHQH) hospitals

and 77 tehsil headquarter (THQH) and civil hospitals (CH) were assessed for the provision

of 24/7 comprehensive emergency obstetric and newborn care (EmONC) services. 90 rural

health centres (RHCs) were assessed for 24/7 basic EmONC services and 162 basic health

units (BHUs) were assessed for the availability of 8/6 preventive MNCH services. The status

of THQHs / civil hospitals was also assessed for their readiness to deliver 24/7 basic

EmONC services.

Regarding the availability of inputs, the major issues faced by the facilities were mainly due

to the lack of MNCH-related staff at the facilities, e,g. WMOs at RHCs and specialists

(including gynaecologist, anaesthetist and paediatrician) at DHQ and THQ hospitals.

Infrastructure components were mostly available at the assessed health facilities. Although

the availability of staff residences was a major problem in ensuring the 24/7 availability of

EmONC services. Infrastructure components required for paediatric care were deficient at

most of the THQ hospitals. Major gaps were also revealed in the availability of required

equipment, drugs and supplies. At the time of the assessment, none of the health facilities in

Khyber Pakhtunkhwa had been provided with the complete range of assessed items

required to perform signal functions.

Findings related to management basics revealed the lack of work coordination among the

facility staff. It was assessed through the record of monthly performance review meetings

held at the facility. Supervision at the surveyed facilities was assessed through the regularity

of supervisory visits of the district level managers and the receipt of their feedback to the

facility. Although the majority of the facilities reported having received supervisory visits, their

feedback was not a common practice. Staff job descriptions and service delivery protocols

were deficient at majority of the health facilities. A management information system was well-

placed in the form of the health management information system (HMIS). Gaps were

identified in infection control practices, due to the lack of trained staff and non-availability of

2

materials for personal protection, waste collection and waste treatment. Due to inconsistent

documentation of maternal, neonatal deaths and the lack of functioning death review

committees, these deaths had rarely been reviewed at the health facilities. A total of 1,045

clients were interviewed. Findings from the client exit interviews revealed that about 20% are

very satisfied and 75% are satisfied with the services provided, whereas only 5% are not

satisfied at all with the quality of services.

Report organisation

The health facility assessment report has been structured in six sections:

1. Section 1 has the ‘Introduction’ to the survey, its objectives, scope and duration.

2. Section 2: ‘Provincial information’ comprises of an overview of the province, key

indicators at a glance, as well as the organisation of the public sector health care

delivery system.

3. Section 3: ‘Assessment of functional capacities’ contains the details of health

facilities assessed against the availability of the 5 specified inputs which would

enable them to perform their level-specific services, (infrastructure, human

resources, drugs and supplies, equipment and level specific support services).

4. Section 4: ‘Clients’ perspective’ contains information about the perceptions of the

clients regarding the MNCH services provided at the public sector health facilities.

5. Section 5: ‘Health Managers’ perspective’ provides the findings of the in-depth

interviews of health managers.

6. Section 6: ‘Key Findings’ This section describes the health facility assesment findings

and key actions recommended, based on the assessment’s findings and in-depth

interviews provided in Sections 3 to 5

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Section 1: Introduction

This section includes the survey background, its objectives, the scope and duration and

organisation of the provincial report.

In Khyber Pakhthunkhwa, more than 275 maternal deaths occur per 100,000 live births with

devastating effects on families and livelihoods. Skilled and responsive care, at and after

birth, can avert nearly all fatal outcomes and disabling consequences and ease much of the

suffering. The health of mothers and newborns are so intricately related, preventing deaths

requires, in many cases, the same interventions. The Government of Pakistan is committed

to achieve the Millennium Development Goals (MDGs) and the Ministry of Health has

established the National Maternal Newborn and Child Health Programme (NMCHP) for

achieving the 2015 targets for the health related MDGs 4 and 5. The overreaching goal of

the programme is to improve health status of mothers, newborns, and children with focus on

poor and marginalized populations.

Survey objectives

The health facility assessment was aimed at assessing the availability, functioning and

quality of the health care delivery system in the public sector facilities, with a focus on

maternal, newborn and child health services.

Some of the specific objectives of the health facility assessment were:

• To assess the health facility status and quality of MNCH services (comprehensive

and basic EmONC, preventive MNCH and family planning) at the district level;

• To assess the clients’ satisfaction and perception of MNCH services;

• To provide information for the systematic planning of procurement and supply of

goods and commodities (listing the medical equipment and instruments which need

to be replaced or purchased); and

• To update and assess the contributions made by the development partners for

improving MNCH and family planning services in the selected districts

Whereas the HFA is intended to help district and provincial health managers in assessing

performance benchmarks and realigning their activities for bridging the gaps existing in

MNCH services for achieving the MDGs, the scope of the HFA does not cover the overall

situation of health sector in the district.

4

Assignment duration

The Technical Resource Facility (TRF) is supporting the NMNCHP with technical assistance

(TA) in the design and implementation of the health facility sssessment (HFA) across

Pakistan. The TA was assigned to Contech International.

The estimated duration of the assignment was 7 months. The assignment started in October

2010 and ended in May 2011.

Scope of HFA

The survey included the district headquarter hospital (DHQH), tehsil/taluka headquarter

hospitals (THQHs), rural health centres (RHCs) and 20% of the basic health units (BHUs)

randomly selected from within the district. The selection of the BHUs was done through

geographical stratification on the basis of proportionate distribution. Client exit interviews

were conducted at the surveyed facilities (10 at the DHQH, 5 at each THQH and RHC),

excluding the BHUs.

Table 1.1 shows the numbers of health facilities in the district and the health facilities

surveyed.

TABLE 1.1: SCOPE OF HFA

Khyber Pakhtunkhwa Province

Number of health facilities by type

DHQH THQHs/CHs RHCs BHUs Total

Number of facilities 21 77 90 822 1,010

Number of facilities surveyed 21 77 90 162 350

5

Section 2: Provincial Information

This section gives an overview of Khyber Pakhtunkhwa province and the organisation of the

public sector health care services in the province, derived from secondary data sources.

Khyber Pakhtunkhwa – An overview

Khyber Pakhtunkhwa previously known as the North-West Frontier Province, is located in

the north-west of the country. It borders Afghanistan to the north-west, Gilgit-Baltistan to the

north-east, Pakistan administered Kashmir to the east, the Federally Administered Tribal

Areas (FATA) to the west and south and Punjab and the Islamabad capital territory to the

south-east. The provincial capital is Peshawar, locally referred to as Pekhawar.

The province has an area of 74,521 km². According to the 1998 census, the population of

the province is approximately 21 million of whom 52% are males and 48% are females. The

density of population is 187 per km² and the intercensal change of population is of about

30%. The largest ethnic group are the Pashtuns who form about two-thirds of the population.

The northern zone is cold and snowy in winters with heavy rainfall and pleasant summers

with the exception of the Peshawar basin, which is hot in summer and cold in winter. It has

moderate rainfall. The southern zone is arid with hot summers and relatively cold winters

and scanty rainfall. The major rivers that criss-cross the province are Kabul, Swat, Chitral,

Kunar, Siran, Panjgora, Bara, Kurram, Dor, Haroo, Gomal and Zhob.

6

FIGURE 2.1: MAP OF KHYBER PAKHTUNKHWA

Key indicators

The population of Khyber Pakhtunkhwa constitutes 13.40% of the population of Pakistan, as

per 1998 Census. According to 1998 census population of the province is 17,743,645 with

an annual growth rate of 2.82; it has now increased to 24,248,465. Status of Key indicators

of Khyber Pakhtunkhwa is presented in Table 2.1.

TABLE 2.1: KEY FIGURES OF KHYBER PAKHTUNKHWA

Demography Value Health & socio-economic Value

Geography Health

Number of districts 25 Infant mortality rate (/1,000 live

births) 63

Area (in square Km) 74,521 Under 5 Mortality rate (/1,000 live

births) 75

7

Demography Maternal mortality ratio (/100,000

live births) 275

Total population 20,215,000 Malnutrition (Women) -

Population (Urban) 16.87% Malnutrition (Children) -

Population (Male : Female) 108 Immunisation (children

8

communities through vaccinators, sanitary inspectors and a sanitary patrol. Tehsil and

district headquarter hospitals provide increasingly specialized secondary health care, while

teaching hospitals form the tertiary level tier. Information about the number of health

facilities, ranging from teaching hospital to sub-health centres, in each district of Khyber

Pakhtunkhwa is collected from respective district health departments. Details about public

sector facilities are given in Table 2.2:

TABLE 2.2: NUMBER OF PUBLIC SECTOR HEALTH FACILITIES

Type of health facility Number

Teaching hospitals 9

District headquarter hospitals 21

Tehsil headquarter hospitals / civil hospitals 77

Rural health centres 90

Basic health units 822

Dispensaries 307

Mother and child health centres 49

Sub-health centres 30

The role of the provincial department of health (DoH) includes policy and strategy

development, intra-provincial coordination, monitoring and evaluation; medical and nursing

education and tertiary care delivery. The role of the district department of health is

implementation, monitoring and supervision, management of health care delivery at and

below DHQ hospitals and the implementation of vertical programmes at the district level.

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Section 3: Assessment of Functional Capacities

MNCH services

The packages of MNCH services assessed include preventive MNCH services at BHUs,

basic EmONC services at RHCs and comprehensive EmONC services at the THQ and DHQ

hospitals1. The range of MNCH services are given in Figure 3 below.

FIGURE 3.1: RANGE OF SERVICES THAT SIGNAL FULLY FUNCTIONAL MNCH SERVICES

1 PC-1 NMNCHP

BHUs: Facility

available for

RHCs: Facility

available for

DHQ/THQ

Hospitals: Facility

available for

8/6 Preventive MNCH Services

1. Antenatal

checkup

2. Lab (Anemia,

Malaria,

pregnancy

test, urine test

for sugar &

Protein)

3. Normal

delivery

4. Family

planning

services (at

least 3

methods)

5. TT

immunisation

6. EPI

vaccination

7. Growth

monitoring

8. Nutrition

counseling

9. HR (at least

one LHV or

Doctor)

24/7 Basic EmONC

Services

1. Parenteral

antibiotics

2. Parenteral oxytocic

drugs

3. Parenteral

anticonvulsants for

pregnancy induced

convulsions (due

to hypertension)

4. Manual removal of

placenta

5. Removal of

retained products

6. Assisted vaginal

delivery (vacuum

extraction, forceps)

7. Newborn

resuscitation

8. Post abortion care

+ 9. HR (skilled female

providers-WMO

LHVs),

and

10. Preventive MNCH

24/7

Comprehensive

EmONC services

1. Surgery (C-

section)

2. Blood transfusion

3. Newborn care

(resuscitation &

incubator)

4. Gynaecological

care

5. Comprehensive

family planning

services

including

sterilisation

6. HR (skilled staff

for conducting,

C-section, blood

transfusion and

anaesthesia),

+ 7. Preventive

MNCH and

8. Basic EmONC

10

The health facilities were assessed against the availability of 5 specified inputs which would

enable them to perform their level-specific services.

The functional capacity of health facilities was assessed, against 5 specified inputs, which

include:

1. Infrastructure

2. Human resources

3. Drugs and supplies

4. Equipment

5. Level specific support services

The health facilities’ assessment findings are presented against two levels of inputs

including:

• Optimal level of inputs, these are those proposed in the PC-1 of the national MNCH

programme, required to make a health facility ‘fully functional’ for the provision of the

level specific package of MNCH services (Annex 2).

• Minimal level of inputs, which are the bare minimum requirement of the inputs,

required for delivering the package specific MNCH services at the health facilities.

The findings related to the minimal level of inputs are given as Annex 2.

This section describes the functionality of the assessed facilities, against the availability of

the optimal level of inputs by facility type. An analysis is also provided, against a minimal or

essential level of inputs, for comparative purposes.

Basic health units (BHUs)

Status of infrastructure

The infrastructure of the BHUs has been assessed, for the availability of an OPD/ LHV’s

room and labour room as service provision areas and residences for the accommodation of

required staff. The findings are presented for the availability and functional status of

infrastructure components assessed at the BHUs, both in numbers and percentages in Table

3.1.

The assessment of infrastructure in the BHUs revealed that an OPD is available at 95% of

the BHUs. Out of these, 143 OPDs are in a workable state and major repair work (exceeding

11

75%) is required at 12% of the BHUs. Similarly, a LHV’s residence is available at 85% of the

BHUs and is liveable at only 41% of them.

TABLE 3.1: STATUS OF ASSESSED INFRASTRUCTURE IN BHUS

Status of human resources

A doctor or LHV is required for the provision of preventive MNCH services. The availability

(both regular posted and provided by NMNCHP) of both of these categories of human

resources, against the required number mentioned in PC-1 of NMNCHP, is presented in

Table 3.2. Out of the surveyed BHUs, 89% had staff available for preventive MNCH service

provision, while 18 of the BHUs had neither a doctor nor a LHV posted. Further analysis

revealed that out of 162 BHUs, 85 of them had a doctor posted. A LHV is positioned in 140

of the BHUs.

TABLE 3.2: STATUS OF MNCH RELATED STAFF IN BHUS

Staff categories Status of surveyed BHUs having required staff (N=162)

Number Percentage

Doctor or LHV 144 89%

Status of functional equipment

BHUs are categorized into four groups2, according to the percentage availability of functional

equipment items in each BHU, as presented in Table 3.3 An assessment analysis of the

functional equipment items in BHUs, revealed that only one BHU had more than 75% of the

general equipment items. The majority (132 out of 162) of the BHUs had even less than

25% of the general equipment items. Only 7 BHUs had more than 75% of the OPD

2 This is arbitirary categorisation to present availability of assessed items.

Assessed infrastructure Status of surveyed BHUs (N=162)

Number Percentage

OPD Available 154 95%

Functional 143 88%

Labour room Available 17 10%

Functional 14 9%

Residence - LHV Available 138 85%

Functional 66 41%

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equipment items. 97 BHUs had less than 50% of the required items. 71 of the 162 BHUs had

less than 50% of LHV room equipment.

TABLE 3.3: STATUS OF FUNCTIONAL EQUIPMENT IN BHUS

Equipment

Number of surveyed BHUs having functional equipment items (N=162)

>75% available 51 to 75% available 25 to 50% available 75% available 51 to 75% available 25 to 50% available

13

TABLE 3.5: STATUS OF SUPPORT SERVICES IN BHUS

Support services Number of assessed BHUs with available support services (N=162)

All items available 50% available No item available

Basic lab tests 43 100 19

BHUs’ conformance to required inputs

The assessment findings were analyzed to determine the conformance of surveyed BHUs,

to the inputs required to deliver preventive MNCH services. The calculation is based on the

‘Average functionality’ of the number of inputs for each criterion, including infrastructure3,

human resources, equipment, drugs and supplies and support services, against PC-1 of the

national MNCH Programme. Based on this analysis, the functionality status of the assessed

BHUs, with reference to the availability of required inputs, is presented in Figure 3.2.

FIGURE 3.2: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT SURVEYED BHUS

A calculation was carried out in an attempt to present status of the districts based on

conformance to required inputs, on following assumptions:

• District represented by a single bar, composed of five sub-sections each representing

one of the 5 input criteria,

• Standard bar was taken as 1 (100), and each input component was allocated equal

space in the bar i.e., one fifth of bar (20),

• Each component could maximum contribute to one fifth or 20 to the bar,

3 Conformance to infrastructure has been ascertained on the availability of key building components only, as for example

presence of consultation area in OPD, leaving aside examination area and handwashing facility. However, all these components have been assessed collectively to identify scope of civil works and cost estimates.

64%

75%

39%

50%58%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Infrastructure HR Equipment Drugs & Supplies

Support Services

14

• Each component occupied its allocated space proportionate to its ‘average

availability’,

• Five components make a component bar to give overall ‘average availability’ of

inputs by type of health facility in the district.

Example: Calculation of component bar

‘Average availability’ of inputs for CEmONC in each THQH of district Attock was:

Component Number of required inputs

‘Average availability’

Calculation Proportionate

(1/5) of standard bar

Infrastructure 19 8.60 =(8.60/19*100)*0.2 9

HR 41 14.40 =(14.40/41*100)*0.2 7

Equipment 106 81.00 =(81/106*100)*0.2 15

Drugs & supplies 42 34.60 =(34.60/42*100)*0.2 16

Support services 87 63.00 =(63/87*100)*0.2 14

It is evident that none of the required inputs meet the mark of 20 and comulative

‘average availability’ of inputs in THQHs is 61 out of 100, in district Attock.

Based on the above calculations, the following graph (Figure 3.3) presents the district-wise

status of average component availability of inputs at surveyed BHUs.

9 7 15 16 14

0 20 40 60 80 100

Attock

Infrastructure HR Equipment Drugs & Supplies Support services

15

FIGURE 3.1: DISTRICT-WISE STATUS OF CONFORMANCE OF BHUS TO REQUIRED INPUTS

6

7

10

15

13

11

13

15

13

13

13

10

14

13

13

13

16

13

11

13

18

13

13

13

12

6

5

9

7

7

9

10

7

10

13

16

18

11

18

15

18

20

10

20

16

12

19

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18

17

3

8

8

5

5

7

6

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12

7

9

9

7

8

9

9

9

7

5

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13

10

6

5

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10

5

4

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11

9

8

10

7

8

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10

9

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8

14

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11

14

12

12

12

14

6

5

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6

7

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10

6

8

9

10

10

14

12

15

10

10

20

16

19

8

13

18

19

15

0 10 20 30 40 50 60 70 80

Kohistan

Tor Ghar

Upper Dir

Lower Dir

Hangu

Abbottabad

Tank

Mansehra

Buner

DI Khan

Swat

Chitral

Bannu

Peshawar

Kohat

Shangla

Karak

Lucky Marwat

Malakand

Swabi

Battagram

Haripur

Charsada

Mardan

Noshera

Infrastructure Human resources Equipment Drugs and supplies Support services

16

Rural health centres (RHCs)

All the 90 RHCs operating in Khyber Pakhtunkhwa were assessed for the availability of the

optimal levels of the 5 input criteria.


The infrastructure of the RHCs has been assessed, for the availability of an OPD, indoor

ward, LHV’s room, labour room and clinical laboratory, as service provision areas and

residences for the accommodation of required staff. The findings are presented as the

availability and functional status of infrastructure components assessed at the RHCs, both in

numbers and percentages in Table 3.6.

TABLE 3.6: STATUS OF ASSESSED INFRASTRUCTURE IN RHCS

Infrastructure Status of RHCs (N=90)

Number Percentage


Functional 85 94%

Female ward Available 69 77%

Functional 47 52%


Functional 47 52%

Clinical lab Available 84 93%

Functional 74 82%

LHV’s room Available 83 92%

Functional 76 84%

Residence - Doctor Available 53 59%

Functional 34 38%


Functional 48 53%


PC-1 of the NMNCHP contains the category and number of staff required, for the provision

of basic EmONC services. The availability of human resources (both regular posted and

provided by NMNCHP) at the RHCs at the time of survey, against the required numbers is

presented in Table 3.7.

17

TABLE 3.7: STATUS OF MNCH RELATED STAFF IN RHCS

Staff categories RHCs having required staff (N=90)

Number Percentage

WMO 9 10%

LHV 43 48%

Lab technician 63 70%

OT technician 7 8%

Ambulance driver 69 77%


The availability of equipment items for various service components at RHCs, as listed in PC-

1 of NMNCHP, was assessed and categorized in four groups, according to the percentage

availability equipment items in each RHC and is presented in Table 3.8.

TABLE 3.8: STATUS OF FUNCTIONAL EQUIPMENT IN RHCS

Equipment

Number of RHCs having functional equipment items (N=90)

>75% available 51 to 75% available 25 to 50% available

18

TABLE 3.9: STATUS OF DRUGS AND SUPPLIES IN RHCS

Item groups Number of RHCs with available tracer items (N=90)


19

FIGURE 3.4: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT RHCS

The following graph (Figure 3.5) presents the district-wise status of average component

availability of inputs at the RHCs.

86%

30%

40%

51%

43%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Infrastructure HR Equipment Drugs & Supplies Support Services

20

FIGURE 3.2: DISTRICT-WISE STATUS OF CONFORMANCE OF RHCS TO REQUIRED INPUTS

6

14

13

16

14

18

17

17

16

16

20

16

17

18

16

13

19

17

16

19

20

20

8

6

10

7

9

11

10

13

12

10

9

8

9

7

14

16

11

17

18

12

16

16

10

7

8

6

9

2

6

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6

9

6

13

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7

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9

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10

12

13

12

11

10

8

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12

17

7

9

8

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8

8

8

8

8

9

8

7

10

10

10

10

9

10

10

10

10

10

0 10 20 30 40 50 60 70 80

Mansehra

Swat

Karak

Hangu

Swabi

Malakand

Noshera

Lower Dir

Abbottabad

Haripur

Tank

Buner

Lucky Marwat

Chitral

Mardan

Peshawar

Charsada

DI Khan

Kohistan

Kohat

Bannu

Battagram

Infrastructure Human resources Equipment

Drugs and supplies Support services

21

Secondary health care (SHC) hospitals

All of the 21 DHQHs and 77 THQHs in Khyber Pukhtunkhwa (Secondary health care

hospitals) were assessed for the availability of the optimal levels of the 5 input criteria.


The infrastructure of the SHC hospitals has been assessed, for the availability of an OPD,

indoor wards, LHV’s room, labour room, operation theatre, paediatric nursery, blood bank,

ultrasound room and clinical laboratory, as service provision areas and residences for the

accommodation of required staff. The findings are presented as availability and functional

status of infrastructure components assessed at the SHC hospitals, both in numbers and

percentages in Table 3.12.

TABLE 3.12: STATUS OF ASSESSED INFRASTRUCTURE IN SHC HOSPITALS

Infrastructure

Status of infrastructure in SHC hospitals

DHQHs (N=21) THQH (N=77)

Number Percentage Number Percentage

OPD Available 20 95% 67 87%

Functional 20 95% 60 78%

Female ward Available 19 90% 36 47%


Labour room Available 19 90% 50 65%


Operation theatre Available 19 90% 50 65%


Paediatric ward Available 15 71% 15 19%


Paediatric nursery Available 12 57% 7 9%


Clinical lab Available 20 95% 63 82%


Blood bank Available 16 76% 11 14%


LHV’s room Available 10 48% 54 70%


Ultrasound room Available 16 76% 12 16%

22


Residence -

Gynaecologist

Available 13 62% 7 9%


Residence -

Anaesthetist



Residence -

Paediatrician

Available 10 48% 11 14%


Residence - WMO Available 14 67% 38 49%


Residence - LHV Available 6 29% 35 45%


Residence -

Nurses

Available 16 76% 19 25%


Residence - Lab

technician



Residence - Blood

bank technician



Residence -

Anaesthesia

technician



23


The availability of human resources, by the category and number of staff (both regular

posted and provided by NMNCHP) at SHC hospitals, as compared against the required

numbers is presented in Table 3.13.

TABLE 3.13: STATUS OF MNCH RELATED STAFF IN SHC HOSPITALS

Staff categories

Availability of human resources in SHC hospitals

DHQHs (N=21) THQHs (N=77)


Gynaecologist 6 29% 3 4%

Anaesthetist 1 5% 1 1%

Paediatrician 6 29% 10 13%

WMOs 4 19% 2 3%

Operation theatre

technician 11 52% 1 1%

Blood bank technician 3 14% 1 1%

Lab technician 17 81% 21 27%

Anaesthesia technician 10 48% 1 1%

Nurses 18 86% 7 9%

LHVs 5 24% 3 4%

Ambulance drivers 8 38% 5 6%


The equipment items for various service components at SHC hospitals are categorized in

four groups according to the percentage availability of functional equipment items in each

SHC hospital. The details are presented in Table 3.14.

24

TABLE 3.14: STATUS OF FUNCTIONAL EQUIPMENT IN SHC HOSPITALS

Equipment

Number of SHC hospitals having functional equipment items

DHQH (N=21) THQH (N=77)

>7

5%

av

ail

ab

le

51 t

o 7

5%

av

ail

ab

le

25 t

o 5

0%

av

ail

ab

le

<2

5%

av

ail

ab

le

>7

5%

av

ail

ab

le

51 t

o 7

5%

av

ail

ab

le

25 t

o 5

0%

av

ail

ab

le

<2

5%

av

ail

ab

le

General items 6 6 7 2 1 7 14 55

Female ward 1 9 9 2 1 16 19 41

OPD 10 8 2 1 15 19 18 25

Paediatric nursery 3 6 4 8 2 5 5 65

Paediatric ward 5 14 0 2 1 16 5 55

Labour room 8 10 0 1 10 31 15 21

Operation theatre 12 7 0 2 8 16 21 32

Clinical laboratory 7 7 4 3 13 13 19 32

Status of drugs and supplies

Tracer items were selected from the list of essential drugs and supplies for MNCH (Annex

2), for assessing their availability at the surveyed facilities. The SHC hospitals are

categorized into four groups, according to the percentage availability of the items in each

group of supplies, Tracer drugs, vaccines and family planning commodities. The details are

presented in Table 3.15 below.

TABLE 3.15: STATUS OF DRUGS AND SUPPLIES IN SHC HOSPITALS

Item groups

Number of SHC hospitals having tracer items


>7

5%

av

ail

ab

le

51 t

o 7

5%

av

ail

ab

le

25 t

o 5

0%

av

ail

ab

le

<2

5%

av

ail

ab

le

>7

5%

av

ail

ab

le

51 t

o 7

5%

av

ail

ab

le

25 t

o 5

0%

av

ail

ab

le

<2

5%

av

ail

ab

le

Supplies 14 6 1 0 15 21 37 4

Drugs 2 9 8 2 3 14 50 10

Vaccines 20 0 0 1 70 1 2 4

25

Family planning

commodities 11 4 2 4 15 18 8 36

Status of support services

The facilities for support services, including laboratory tests (space, test strips and human

resources), blood transfusion services (space, supplies and human resources), ambulance

services (a functional vehicle and driver), operating theatre (space, drugs and supplies,

equipment items and human resources) were assessed, at the surveyed SHC hospitals.

Based on the percentage availability of the inputs required for performing these services,

SHC hospitals are categorized in four groups. The details are presented in the Tables 3.16

and 3.17.

TABLE 3.16: STATUS OF SUPPORT SERVICES IN SHC HOSPITALS

Item groups

Number of SHC hospitals having tracer items


>7

5%

av

ail

ab

le

51 t

o 7

5%

av

ail

ab

le

25 t

o 5

0%

av

ail

ab

le

<2

5%

av

ail

ab

le

>7

5%

av

ail

ab

le

51 t

o 7

5%

av

ail

ab

le

25 t

o 5

0%

av

ail

ab

le

<2

5%

av

ail

ab

le

Basic laboratory tests 9 11 1 0 7 33 25 12

Blood transfusion 17 3 1 0 9 12 22 34

Operation theatre 7 12 1 1 3 16 26 32

TABLE 3.17: STATUS OF SUPPORT SERVICES IN SHC HOSPITALS

Item groups

Number of SHC hospitals having required items



Functional ambulance 20 95% 50 65%

Ambulance driver 20 95% 66 86%

Radiology services 7 33% 15 19%

26

SHC hospitals’ conformance to required inputs

The assessment findings were analyzed to determine the conformance of SHC hospitals to

the inputs required to deliver comprehensive EmONC services. The calculation is based on

the ‘Average availability’ of the number of inputs for each criterion, including infrastructure,

human resources, equipment, drugs and supplies and support services. Based on this

analysis, the conformance status of the DHQHs and THQHs to the required inputs is

presented in Figure 3.6.

FIGURE 3.6: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT SHC HOSPITALS

The following graph (Figures 3.7 & 3.8) presents the district-wise status of the average

component availability of inputs at the DHQHs and THQHs.

60%

34%

68%

19%

62%

29%

62%

46%

70%

36%

0%

20%

40%

60%

80%

DHQ Hospitals THQ Hospitals

Infrastructure HR Equipment Drugs & Supplies Support Services

27

FIGURE 3.3: DISTRICT-WISE STATUS OF CONFORMANCE OF DHQHS TO REQUIRED INPUTS

7

17

-

15

13

6

15

11

13

12

13

13

17

13

13

11

20

9

16

13

13

6

18

11

6

12

10

15

16

15

13

15

15

15

15

17

8

17

15

20

7

2

15

9

16

13

14

12

13

12

13

15

12

15

13

16

12

13

12

15

12

13

10

11

10

13

11

12

9

11

13

9

9

11

15

12

16

16

19

15

6

11

10

13

16

16

12

13

15

15

14

15

14

14

15

15

17

17

17

17

- 10 20 30 40 50 60 70 80 90

Shangla

Malakand

Mansehra

Battagram

Abbottabad

Bannu

Upper Dir

Peshawar

Kohat

Chitral

Swabi

Karak

Lower Dir

Buner

Noshera

DI Khan

Lucky Marwat

Haripur

Charsada

Mardan


28

FIGURE 3.4: DISTRICT-WISE STATUS OF CONFORMANCE OF THQHS TO REQUIRED INPUTS

7

6

8

1

5

6

8

8

7

6

4

6

12

9

6

10

9

13

8

11

10

9

11

1

2

2

2

3

6

3

3

10

4

3

6

4

6

1

3

6

2

3

5

10

5

15

3

4

0

9

5

5

6

4

3

4

8

6

4

6

10

8

8

6

6

7

6

9

12

9

7

10

9

7

7

6

9

9

10

9

9

11

9

11

10

9

15

17

13

9

14

12

4

5

5

6

8

6

7

6

4

8

9

8

8

10

10

11

10

7

8

8

10

9

13

- 10 20 30 40 50 60 70

Abbottabad

DI Khan

Malakand

Mansehra

Swabi

Peshawar

Karak

Haripur

Lower Dir

Shangla

Mardan

Swat

Tank

Noshera

Buner

Chitral

Upper Dir

Kohat

Battagram

Lucky Marwat

Charsada

Hangu

Bannu


29

Tehsil headquarter (THQ) hospitals

The THQ hospitals were also assessed for their capacity to provide 24/7 basic EmONC

services, on similar inputs as those used for the assessment of the RHCs. All of the 77

THQHs in Khyber Pakhtunkhwa, were assessed for the availability of the optimal level of

inputs required in order to deliver 24/7 basic EmONC services.


The infrastructure of the THQHs has been assessed for the availability of an OPD, indoor

ward, LHV’s room, labour room and clinical laboratory, as service provision areas and the

residences for accommodation of required staff. Service provision areas have been

assessed as a single room, having facilities like consultation, examination and hand washing

etc. The findings for the availability and functional status of infrastructure components

assessed at the THQHs, both in numbers and percentages are presented in Table 3.18.

Available infrastructure might be requiring repair or maintenance.

The assessment of the infrastructure of the THQ and civil hospitals for the delivery of basic

EmONC services, showed that 87% of the THQHs/CHs of Khyber Pakhtunkhwa had OPDs

available. A female ward is not available at 53% of the THQHs/CHs. A total of 38

THQHs/CHs had a WMO’s residence, but it was inhabitable at only 32% of the THQH/CHs.

TABLE 3.18: STATUS OF ASSESSED INFRASTRUCTURE IN THQHS

Infrastructure Status of THQHs (N=77)

Number Percentage


Functional 60 78%

Female ward Available 36 47%

Functional 25 32%


Functional 40 52%

Clinical lab Available 63 82%

Functional 53 69%

LHV’s room Available 54 70%

Functional 51 66%

Residence - Doctor Available 38 49%

Functional 25 32%


Functional 24 31%

30


PC-1 of the NMNCHP contains the category and number of staff required for the provision of

basic EmONC services. The availability of human resources (both regular posted and

provided by NMNCHP) at the THQHs, against the required numbers is presented in Table

3.19 below.

Major gaps were found in the availability of WMOs and technical staff. As the required

number of WMOs is available at only 16% of the THQHs/CHs. Lab technicians are not

available at 25% of the THQHs/CHs. The required number of ambulance drivers is available

at 86% of the THQHs/CHs.

TABLE 3.19: STATUS OF MNCH RELATED STAFF IN THQHS

Staff categories Status of THQHs having required staff (N=77)

Number Percentage

WMO 12 16%

LHV 33 43%

Lab technician 58 75%

OT technician 28 36%



The equipment items for various service components, for the provision of basic EmONC

services at the THQHs, are listed in PC-1 of the NMNCHP. The THQHs are categorized in

four groups, according to the percentage availability of the functional equipment items at

each THQH. The details are presented below, in Table 3.20.

The assessment of functional equipment items at THQHs/CHs against the criteria of basic

EmONC services, revealed that only 4 out of the 77 THQHs had more than 75% of the

equipment items. 22 THQHs had even less than 25% of the equipment items

TABLE 3.20: STATUS OF FUNCTIONAL EQUIPMENT IN THQHS

Equipment

Number of THQHs having functional equipment items (N=77)


31

Status of drugs and supplies

A list of essential drugs and supplies for MNCH services is contained in PC-1 of the

NMNCHP. Tracer items were selected from the list (Annex 2) for assessing their availability

at the surveyed facilities. The THQHs are categorized in four groups, according to the

percentage availability of the items in each group of supplies, tracer drugs, vaccines and

family planning commodities, as presented in Table 3.21.

An analysis of the available tracer items in the THQ and civil hospitals showed, that 15 of the

77 THQHs/CHs had more than 75% of the supplies. 45 THQHs/CHs had less than 50% of

the required drugs available. More than 75% of the assessed vaccines were available at 70

of the THQHs/CHs. 36 THQHs/CHs had less than 25% of the family planning commodities.

TABLE 3.21: STATUS OF DRUGS AND SUPPLIES IN THQHS

Item groups

Number of THQHs with available tracer items (N=77)

>75% available 51 to 75% available 25 to 50% available 75% available 51 to 75% available 25 to 50% available

32

TABLE 3.23: STATUS OF SUPPORT SERVICES IN THQHS

Support services Number of THQHs with available support services (N=77)

Available % Available

Functional ambulance 50 65%


THQs’ conformance with assessed inputs

The assessment findings were analyzed to determine the conformance of the THQ hospitals,

to the inputs required to deliver basic EmONC services. The calculation is based on the

‘Average availability’ of the number of inputs for each criterion, including infrastructure,

human resources, equipment, drugs and supplies and support services. Based on this

analysis, the conformance status of the THQHs to required inputs is presented in Figure 3.9.

FIGURE 3.9: AVERAGE AVAILABILITY OF ASSESSED INPUTS AT THQHS

The following graph (Figure 3.10) presents the district-wise status of average component

availability of inputs at THQHs required to deliver basic EmONC services.

64%

28%

18%

51%

68%

0%

20%

40%

60%

80%

Infrastructure HR Equipment Drugs and Supplies

Support Services

33

FIGURE 3.5: DISTRICT-WISE STATUS OF CONFORMANCE OF THQHS TO REQUIRED INPUTS

2

10

14

14

11

13

15

12

16

12

12

15

13

10

19

18

14

17

16

17

20

20

20

5

5

3

6

6

9

5

6

3

6

7

6

6

7

8

7

9

9

7

9

9

3

9

6

2

0

2

2

2

2

4

2

4

2

3

6

6

5

5

5

4

4

3

4

6

4

10

8

11

8

7

9

10

7

10

10

12

10

13

11

11

10

13

14

15

10

13

17

19

8

13

9

11

15

11

12

16

14

15

14

15

15

19

15

17

18

15

17

20

18

18

16

- 10 20 30 40 50 60 70 80

Mansehra

Swabi

Malakand

DI Khan

Peshawar

Lower Dir

Abbottabad

Karak

Haripur

Swat

Shangla

Noshera

Buner

Mardan

Chitral

Upper Dir

Bannu

Lucky Marwat

Hangu

Charsada

Tank

Kohat

Battagram


34

Management basics

The findings related to management basics at the surveyed health facilities are as follows.

Human resources

The status of staff categories filled includes regular posting only, as reported by the

respective facility on the day of the survey. The details are given in Table 3.24 below.

TABLE 3.24 STATUS OF HR REPORTED BY SURVEYED HEALTH FACILITIES

Staff

Number of posts filled at RHCs

DHQ hospitals (21) THQ/ civil

hospitals (77) RHCs (90) BHUs (162)

San

cti

on

ed

Filled

San

cti

on

ed

Filled

San

cti

on

ed

Filled

San

cti

on

ed

Filled

No. % No. % No. % No. %

Gynaecologist 35 24 69 28 3 11

Anaesthetist 21 9 43 14 1 7

Paediatrician 25 21 84 30 11 37

WMO* 84 58 69 77 40 52 74 24 32 144 84 58

OT technician 121 95 79 71 45 63 21 6 29

Blood bank

technician 39 37 95 19 12 63

Lab technician 117 107 91 114 94 82 81 65 80

Anaesthesia

technician 100 78 78 56 32 57

Nurses 995 729 73 393 261 66 49 34 69

LHV 22 21 95 73 74 101 109 95 87 162 140 86

Ambulance

drivers 70 61 87 101 89 88 87 73 84

*MO/WMO for BHUs

35

Provision of staff by the NMNCHP

The NMNCHP provides support in terms of human resources at targeted health facilities,

including specialists, doctors and paramedics. The details of NMNCHP support regarding

staff provision in the province, collected from the district health offices, during the survey are

given in the Tables 4.25 and 4.26.

TABLE 3.25: NUMBER OF HEALTH FACILITIES HAVING STAFF PROVIDED BY NMCHP

DHQHs THQHs RHCs

16 41 48

TABLE 3.26: NUMBER OF MNCH STAFF PROVIDED BY NMCHP

Staff cadre Number of staff provided

DHQH THQHs RHCs

Gynaecologist 2 2

Anaesthetist 0 0

Paediatrician / Neonatologist 2 0

WMO 17 20 21

OT technician 1 1 1

Blood bank technician 0 3

Lab technician 0 0 1

Anaesthesia technician 0 0

Nurses 3 2 0

LHVs 18 31 49

Ambulance drivers 11 24 13

Total 54 61 85

MNCH staff training

Part of the mandate of the programme is to build the capacity of 9,3124 MNCH related staff

through conducting skill development training, in the standards of service provision and

counselling techniques. Information on the training of MNCH staff during last three years,

4 PC-1 NMNCHP Table 4 List of training and approximate unit cost, Page 31

36

collected from the district NMCHP cells during survey is presented in the Table 3.27 and

3.28.

TABLE 3.27: NUMBER OF STAFF TRAINED ON DELIVERING MNCH SERVICES

MNCH staff

Number of staff trained

EmONC ENC IMNCI IMPAC FP surgical FP counselling Client

centeredness

Anaesthetists 2 0 2 0 0 0 0

Gynaecologist 6 2 6 0 1 3 0

LHV 115 26 114 0 0 31 0

MO 46 0 94 0 0 0 0

Nurse 27 0 69 0 1 13 0

OT technician 6 0 19 0 0 0 0

Paediatrician 3 0 14 0 0 0 0

WMO 37 2 45 0 0 1 0

Total 242 30 363 0 2 48 0

TABLE 3.28: NUMBER OF HEALTH FACILITIES RECEIVED MNCH TRAINING

MNCH staff Number of health facilities

DHQHs THQHs RHCs BHUs

EmONC 11 10 23 14

ENC 2 5 10 3

IMNCI 12 22 22 32

IMPAC 1 4 3 1

FP surgical 3 0 0 0

FP counselling 6 13 0 0

Client centeredness 0 0 0 0

CMWs’ training and deployment

Part of the mandate of the programme is to train and deploy community mid-wives for

improving community based MNCH services, in all the districts of the province. In order to

ensure the availability of a skilled birth attendant in every village of the province. The

37

distribution of the community mid-wives will be done by the provincial MNCH cell, before the

recruitment process begins. The following table presents aggregate information related to

training and deployment of the community mid-wives, collected during the survey from all of

the district NMNCH cells.

TABLE 3.29: STATUS OF CMWS TRAINING AND DEPLOYMENT IN KHYBER PAKHTUNKHWA

Training and deployment of community mid-wives (NMNCHP)

Number of selected CMWs verified for their residential status 447

Number of CMWs with completed training 665

Number of CMWs deployed by NMNCHP 52

Health facilities are assessed for the availability of job descriptions for the MNCH staff and

the availability of service delivery protocols (11 nos.) for MNCH services. The findings

related to these indicators are presented in Figure 3.11.

FIGURE 3.11: STATUS OF MANAGEMENT BASICS AT SURVEYED FACILITIES

Work coordination and supervision

Health facilities in all of the districts were assessed for coordination and supervisory

activities, including facility staff meetings, participation of facility in-charges in district level

meetings, district managers conducting supervisory visits and providing feedback to the

14%

1% 1%

9%

58%

32%

41%

23%18%

14%

28%

18%

0%

10%

20%

30%

40%

50%

60%

70%


MNCH related JDs for staff available

MNCH related service delivery protocols available

MNCH related service delivery protocols displayed

38

facilities. The findings of these activities in surveyed health facility are presented in Figures

3.12 and 3.13.

FIGURE 3.12: WORK COORDINATION

FIGURE 3.13: SUPERVISION

Management information system

In Khyber Pakhtunkhwa, the districts are now adopting the district health information system

(DHIS) for recording and reporting purposes. Surveyed facilities were assessed for the

67%

60%

73%70%

38%

13%

27% 25%

71%

78% 76%80%

0%

20%

40%

60%

80%

100%


Facility staff meeting

Meeting record maintained

Participation of HF in-charges in district meeting

90% 91% 88% 90%

52%48%

56%

63%

0%

20%

40%

60%

80%

100%


Visited for supervision

Feedback received (Visited HFs)

39

availability and maintenance of MIS tools (14 nos.) and their findings are presented in Figure

3.14.

FIGURE 3.14: STATUS OF MIS

Drugs and supplies

The availability of drugs and supplies has been described under individual MNCH service

packages. The reasons for being out of the stock of essential drugs and supplies were

identified at the surveyed facilities. A break-down of the reasons is given in Figure 3.15.

80%

70%75%

72%69%

59%

65% 63%62%

81%

91%94%

0%

20%

40%

60%

80%

100%


Tools available

Tools maintained

Monthly DHIS reporting

40

FIGURE 3.15: FACILITY SPECIFIC REASONS FOR STOCK OUT OF DRUGS AND SUPPLIES

Infection control

The health facilities were assessed for practices of infection control and waste management,

and the availability of related material. The findings of the surveyed facilities are presented in

Table 3.30.

TABLE 3.30: STATUS OF INFECTION PREVENTION AT THE SURVEYED HEALTH FACILITIES

Infection prevention

Number of health facilities

DHQHs

(Total=21)

THQHs

(Total=77)

RHCs

(Total=90)

BHUs

(Total=162)

Availability of material

Waste management plans 8 26 29 66

Waste collection materials 1 3 8 9

Personal protection materials 1 1 0 2

Waste treatment equipment 2 5

Functional incinerator 5 15 18 14

Infection prevention practices

Hand washing practices of care providers 11 33 31 64

41%

7% 9%

3%

51%

35%

25%21%

3%

0%

20%

40%

60%

41

Infection prevention


DHQHs

(Total=21)

THQHs

(Total=77)

RHCs

(Total=90)

BHUs

(Total=162)

Disinfection of service provision areas 17 28 27 34

Vaccination of staff against Hepatitis B 6 25 25 40

Practice of waste segregation 4 14 8 8

Disposal through throwing away 8 16 19 40

Disposal through municipal arrangements 7 7 3 2

Death review

Information about maternal and neonatal deaths occurring at the surveyed facilities was

collected by using the SD&MB questionnaire. In Khyber Pakhtunkhwa, a total of 375

maternal deaths and 2,155 neonatal deaths were reported at the surveyed facilities. All of

the surveyed facilities, excluding BHUs were assessed for the availability and functioning of

death review committees. Maternal and neonatal deaths reviewed by the committee are

presented in Table 3.31.

TABLE 3.31: STATUS OF MORTALITY REVIEWS AT SURVEYED HEALTH FACILITIES

Mortality review


DHQHs

(Total=21)

THQHs

(Total=77)

RHCs

(Total=90)

Availability of death review committee 3 4 3

Functional death review committees 0 1 1

Facility utilization

Monthly utilization of MNCH services was assessed month-wise for the period of July to

December 2010 and the average monthly utilization of services is presented in Table 3.32.

TABLE 3.32: UTILIZATION OF MNCH SERVICES AT SURVEYED HEALTH FACILITIES

MNCH services Average monthly utilization of MNCH services

DHQH THQH RHC BHU

1st Antenatal care visits (ANC-1) 393 122 57 26

42

Normal vaginal deliveries 302 27 17 6

Assisted vaginal deliveries 86 1 0 0

C-sections 21 1

1st Postnatal care visits (PNC-1) 97 23 14 8

Pregnant women given TT2 vaccine 84 57 45 21

Diarrhoea/dysentery cases treated

(U5 years of age) 260 116 46 37

Pneumonia cases treated

(U5 years of age) 71 39 24 24

Utilization of the family planning services was also assessed at the surveyed facilities and

the average monthly utilization of these services is presented in Table 3.33.

TABLE 3.33: UTILIZATION OF FP SERVICES AT SURVEYED HEALTH FACILITIES

Family planning services Average monthly utilization of family planning services

DHQH THQH RHC BHU

COC 40 24 8 9

POP 7 7 2 3

DPMA 44 19 8 9

Net-en 38 4 4 2

Condoms 461 84 28 53

IUCDs 18 7 2 1

Implants 0 0 0 0

Vasectomy 3 0

KEY: COC=Combined Oral Contraceptive, POP=Progesterone-Only Pills, DPMA=Depot Medroxyprogesterone Acetate,

Net-en=norethisterone enanthate, IUCDs=Intrauterine Contraceptive Devices.

43

Donor contributions

Donor contributions (excluding direct budgetary support) during the last three years were

assessed regarding human resources, infrastructure, equipment (including ambulances),

drugs and supplies. The findings are presented in Table 3.34.

TABLE 3.34: STATUS OF DONOR CONTRIBUTIONS AT SURVEYED HEALTH FACILITIES

Donor contributions


DHQHs (Total=21)

THQHs (Total=77)

RHCs (Total=90)

BHUs (Total=162)

Infrastructure

Construction of new building 3 10 9 7

Renovation of existing building 6 15 15 10

Equipment

Provision of equipment 9 25 25 23

Provision of vehicles/ ambulances 5 6 6 1

Drugs and supplies

Provision of medicines 10 27 24 15

Provision of consumables 2 6 3 3

Procurement estimates

Equipment

Based on the information collected, the procurement needs for the provision of required

equipment, have been identified for the individually surveyed facilities, in order to strengthen

MNCH services. A summary of estimated cost, for the procurement of required equipment is

given below. A list of required equipment for each surveyed facility is presented in the

annexes of each district report. A summary of the estimated cost for procurement of

equipment is given in Table 3.35.

Civil works

A yardstick has been used for assessing the scope of civil works, of the various MNCH

related building components (Annex 2). A cost estimate based on the identified scope of

work, required to complete the infrastructure needs of the individually surveyed facilities, is

presented in the annexes of the district reports. A summary of the estimated cost for the

execution of civil works, including repair and maintenance, renovation and new construction

of missing facilities, is given in Table 3.35.

44

TABLE 3.35: SUMMARY OF ESTIMATED COST FOR EQUIPMENT AND CIVIL WORKS

Procurement

Estimated cost (PKR in millions)

DHQHs

(Total=21)

THQHs

(Total=77)

RHCs

(Total=90)

BHUs

(Surveyed=162) Total

Equipment 344.0 1,239.75 288.78 87.27 1,959.8

Civil works 274.72 1,113.00 536.47 498.26 2,422.45

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Section 4: Clients’ Perspective

Clients’ perspective on the quality of health care service is too important to neglect. For

clients and communities, quality care is something that meets their perceived needs. Since a

client’s needs often differ, their personal satisfaction ultimately depends on the perception,

attitude and expectations of each individual.

Client exit interviews (CEIs) were conducted within the scope of the health facility assesment

survey to assess the clients’ perspectives on the services provided at RHCs, THQHs and

DHQHs. In Khyber Pakhtunkhwa, a total of 1,045 clients were interviewed and a facility-wise

breakup is presented in Table 5.1.

Married women of child bearing age visiting the facility for MNCH related services

(Gynae/Obs and child health services for under 5 years of age) and fathers accompanying

their children under 5 years of age to the facility for child health services were targeted for

client exit interviews.

TABLE 4.1: NUMBER OF CEIS CONDUCTED IN KHYBER PAKHTUNKHWA

Type of health facility Number of CEIs

District headquarter hospitals 215

Tehsil headquarter hospitals 380

Rural health centres 450

Total 1,045

Key findings

The findings of these interviews were analyzed for assessing the clients’ viewpoint on health

care services availed at the surveyed facilities. The clients’ reasons for visiting the facilities

are presented in Figure 4.1.

46

FIGURE 4.1: REASONS FOR VISITING HEALTH FACILITY

FIGURE 4.2: AVERAGE TIME TAKEN BY THE CLIENTS TO REACH THE FACILITY

Waiting time for clients at the facility varied according to the level of the facilities. The facility-

wise waiting time is presented in Figure 4.3.

29%

33%

31%

9%

8%

3%

General medical problem

Child health care

Antenatal examination

Postnatal checkup

Family planning

Others

44%

58%

53%

38%

32%

37%

18%

9% 10%

0%

10%

20%

30%

40%

50%

60%

70%

DHQHs THQHs RHCs

Less than 30 minutes

30 minutes to 1 hour

More than 1 hour

47

FIGURE 4.3: AVERAGE WAITING TIME AT THE FACILITY

Quality of care

The important dimensions of the quality of care assessed, included the clinical examination

and attitude of the health care provider; provision of prescribed medicines and laboratory

tests; and the provision of health care education material.

In order to assess the clients’ perceptions about the quality of care, they were aske

Health Facility Assessment – Khyber Pakhtunkhwa ......and 77 tehsil headquarter (THQH) and civil...

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