The Socio Economic Performance Report, Khyber Pakhtunkhwa (2015-16) Health Department Government of Khyber Pakhtunkhwa

Health Department
The Socio Economic Performance Report, Khyber Pakhtunkhwa (2015-16)
 Health Department Govt; of Khyber Pakhtunkhwa
Improved health status of individuals adds to the socio-economic productivity of a society and the nation at large. Health Systems aim to improve the health status of individuals, families and communities, to defend the population against what threatens its health, protect people against the financial consequences of ill-health, provide equitable access to people-centered care and make the individual attain the highest possible health status to live a socio-economic productive life in the community. The Department of Health developed Khyber Pakhtunkhwa Health Sector Strategy 2010 – 2017 based on the strategic directions and priorities outlined in the National Health Vision.
The Department of Health Government of Khyber Pakhtunkhwa is headed by Secretary Health who is assisted by One Special Secretary , two Additional Secretaries and a Chief Planning Officer. The Additional Secretaries who are assisted by 4 Deputy Secretaries, 13 Section Officers, One Deputy Director (IT) and one Computer Programmer deal with health matter related to establishment, administration and current budget. The Chief Planning Officers who is assisted by 3 Senior Planning Officers, 5 Planning Officers and one Economist deal with new developments in the health sector. A small project called Health Sector Reforms Unit (HSRU) was established in the Department to carry out research activities and work on reforms being introduced in the Health Department. The Chief of HSRU, heads the unit and is assisted by one Deputy Chief and four Coordinators. 
Health Department’s further break up and allied institutes are as under:
Directorate General Health Services (DGHS), Provincial Health Services Academy (PHSA), Medical Faculty, Medical Teach Institutes (MTIs), Pharmacy Council, Health Care Commission (HCC) , Health Foundation , Khyber Medical University. Further at district level the Health Department has District Health Offices and District Headquarter Hospitals.
Health Department Khyber Pakhtunkhwa has a  total of 1594 Health Care Facilities / Hospitals of different categories which include; 09 Teaching Hospitals, 21 District Head Quarter Hospitals , 23 Tehsil Head Quarter Hospitals, 06 Women & Children Hospitals , 04 Category C Hospitals , 20 Category D Hospitals, 43 Civil Hospitals , 04 Police Hospitals , 04 Jail Hospitals , 784 Basic Health Units , 447 Civil Dispensaries, 92 Rural Health Centers , 23 Health Sub Facilities , 56 Mother Child Health Centers, 24 Leprosy Centers, 35 TB Centers in the province.
The Department has a workforce of around 60,000 employees, that include; 997 Specialists , 7,986 Medical Officers, 274 Dental Surgeons, 352 Health Managers, 3,707 Nurses, 15,000 LHWs, 1,450 CMWs, 14,542 Paramedics and others staff at the health care facilities across Khyber Pakhtunkhwa.
Functions of the Health Department
I. Leadership and evidence-based direction setting for health sector
     i.                   Health policy and reforms.
    ii.                   Health planning, financing and budget.
II. Health Support and Development.
             iii.         Health promotion
         (a) Health education; and
         (b) Community involvement and advocacy
            iv.         Disease Prevention and control
         (a) Communicable diseases; and
         (b) Non-communicable diseases
             v.         Occupational Health
            vi.         Environmental Health
           vii.         Curative and rehabilitative care.
            (a) Primary, secondary and tertiary level curative services including                mental health; and
            (b) Rehabilitative care
          viii.         Health related preparedness and response to disasters
III. Health Regulation and Enforcement
            ix.         Health personnel, facilities and services.

             x.         Levying of fees and charges by medical professionals and facilities.

            xi.         Quality assurance and control.

           xii.         Facilities and services.

          xiii.         Drugs control.

         xiv.         Alternative systems of medicine.

          xv.         Food and sanitation:
 (a) Prevention and control of adulteration in food; and
 (b) Monitoring & reporting upon safe drinking water supply and sanitation  
         xvi.         Devices and technology
IV. Management Support Services.
        xvii.         Health human resource planning.
 Health human resource development:
 (a) Provision of quality medical and allied education;
       (b) Pre-service training of support medical and health professions; and
       (c)  In-  service training of health human resource
       xviii.         Health human resources management.
         xix.         Logistics and procurement.

          xx.         Internal audit and accounting in the Health Department
         xxi.         Legal services:
      (a) Propose medico-legal advice and litigation;
      (b) Propose law review, amendment, formulation relating to Health  
          Department; and
      (c) Facilitate Law Department in litigation related to Health Department.
V. Monitoring and evaluation
        xxii.         Generation of evidence:
 (a) Performance assessment;
       (b) Information and communication systems; and
       (c) Health, medical and allied research
       xxiii.         Knowledge management for evidence based decision making.
VI. Co-ordination on health related matters with Ministries, Departments, Local and      
      International Partners and donors
Vision /Objectives of Health Department
The mission of the Department of Health Government of Khyber Pakhtunkhwa is to protect the Health of all citizens in Khyber Pakhtunkhwa Province.
The Department of Health will reorganize the Health Sector in Khyber Pakhtunkhwa Province with clear distinction between regulation, financing and provision of health services in order to achieve the optimum benefit within the available resources for the people of Khyber Pakhtunkhwa Province. The government’s role as a guardian for the health of the citizens of Khyber Pakhtunkhwa Province is to regulate according to international standards the quality of health care services and health care providers and medical training institutions.
The goal of the Health Department Khyber Pakhtunkhwa is to improve the health status of the populations in the province through ensuring access to a high quality, responsive healthcare delivery system which provides acceptable and affordable services in an equitable manner. The priority areas of health from the Comprehensive Development Strategy have been formulated into five health outcomes. These are:
Outcome 1: Enhancing coverage and access to essential health services especially for the poor  and vulnerable.
Outcome 2: A measurable reduction in morbidity and mortality due to common diseases especially among vulnerable segments of the population.
Outcome 3: Improved human resource management
Outcome 4: Improved governance and accountability
Outcome 5: Improved regulation and quality assurance  
Situation Analysis
Khyber Pakhtunkhwa has a population of over 25 million out of which more than 31% live below the poverty line and almost 50% are illiterate. The health indicators demonstrate a serious need to improve the service delivery in terms of both coverage and quality. 
The Maternal Mortality Rate in KP is 275 per 100,000 live births, infant mortality rate is 63 per 1,000 live births and the Under Five Mortality Rate is 75 per 1,000 live births. Total fertility rate @ 5.6 is one of the highest in the country. The ratio of Lady Health Workers per client is 923:1 and that of doctors is 5230:1 per patient. 
There are 92 Rural Health Centres and 784 Basic Health Units in the province which are not enough to cater to the rising population, the coverage being especially low in the rural areas, where the average distance to a primary healthcare facility is 10 km, three times more than in the urban centres.  
Staff shortages and non-availability of medicines are some of the prevalent systemic issues.  According to the Community Information Empowerment and Training Survey 2004, only 9% of the patients who had used a government medical facility were able to receive all the prescribed medicines. 
According to Pakistan Demographic and Health Survey (PDHS) 2012-13, in KP 60.5 percent women consulted a skilled healthcare provider for antenatal care; and this proportion was even lower in rural areas (55.9 percent).  Less than half (48.3 percent) of the total deliveries in the province were conducted by a skilled birth attendant; and the situation was even worse in the rural areas of the province (44.1 percent). Furthermore, 52.3 percent children in KP were fully immunized.  The proportion of children who did not receive any vaccine was 12 percent, as compared to the national average of 5.4 percent.
KP spends approximately US$6.4 per head on health expenditure and patients have to rely largely on the Out Of Pocket Expenditure, which constitutes 76.6%6, one of the highest in the country. 
Public spending on health is limited due to the overall budget constraints and only 7.1% of the provincial budget (Rs. 38 billion) was allocated to the health sector in 2015, despite the increase in the federal transfers resulting from the 7th NFC Award which raised the overall envelope for KP to 14.62%.
Health Financing in KP Health is one of the priority areas for the Government of Khyber Pakhtunkhwa and the government has considerably increased the budgetary allocation for the sector during the period from 2013-14 to 2016-17. 
Sector allocation has shown annual growth rate of 56.9% and has increased from PKR 32.8915 billion in 2013-14 to PKR 42.616 billion in 2016-17 but this still constitutes only 8.43% of the total provincial budget. Per capita health expenditure has also shown an annual growth rate of 56.9% from PKR 1,154.22 to 1,493.29. 
Analysis of the budget for the period 2013-14 to 2016-17 indicates that the development budget on an average constitutes 33% of the total sector budget and the remaining 67% budget is allocated for the operational expenses i.e. the current budget. Current budget is mainly tied up in the fixed costs. The major element of the current budget is the employee related expenditure which constitutes 76.4% of the total current budget over the period of four years. 
The Department of Health has been effectively utilizing the budget and the utilization rate of the department has been on average 92% during three years from 2013-14 to 2015-1618.
However, the fiscal space for ensuring universal health coverage is highly constrained with the result that the province has limited flexibility to finance health services. Hence a shift toward Public Private Partnership (PPP) is a natural and appropriate policy option and can lead to the achievement of the health service delivery targets as set out in the Provincial Strategy; provided workable initiatives are implemented through reputable institutes / organizations in the province.
Reform Agenda of Government of Khyber Pakhtunkhwa
Reforms Initiatives in Khyber Pakhtunkhwa 2013 – 2017
Health is key priority sector for  Government of Khyber Pakhtunkhwa and major focus is bringing systematic changes to build strong institutions that can deliver quality services. Government of Khyber Pakhtunkhwa initiated Health Reforms in year 2013. Improving performance of the health sector under the following areas/heads:
      I.         Institutions’ building :
               i. Khyber Pakhtunkhwa Health Foundation (KPHF)
§    KP Health Foundation Act 2016
§    Health Foundation restructured to become prime agent for Public            Private Partnerships (PPPs)
              ii. Health Care Commission (HCC) Khyber Pakhtunkhwa
§    Health Care Commission Act 2015
§    The ex-Health Regulatory Authority (HRA) is in process of
            transformation into to a vibrant Organization; HCC Khyber            Pakhtunkhwa; entrusted with the role to regulate public and private            sector health   facilities in the province.
§     Developed Standards for ensuring Quality of Services at Primary and
           Secondary Health Care Facilities  
§    And a mechanism for regulating both public and private sectors through            the       Health Care Commission to meet service demands as per            standards        described in the Minimum Health Service Delivery            Package (MHSDP)
            iii. Medical  Teaching Institutions (MTIs) Reforms
§    Khyber Pakhtunkhwa Medical Teaching Institutions Reforms Act, 2015
§    Autonomous and fully empowered boards of Governors formed at each            MTI level
§    Improved utilization of hospital resources, quality of healthcare            services,
financial performance and medical performance
§       Enhanced utilization of services in the public sector autonomous   
            iv. Social Health Protection (SHP)
§    SHP is  state sponsored insurance  scheme for the deserving            population
§    Social Health Protection Program expanded to all the 25 districts of 
           Khyber Pakhtunkhwa
§    SHP’s  Sehat Insaf Cards are in process of distribution on the analogy
            BISP in all districts of Khyber Pakhtunkhwa.
§    Enhancing the coverage to 50% of population with a cost of Rs. 5.4            billion (2 years).
§    This will benefit 1.8 million households i.e. 12 million individuals.
§    The covered cost per family  is enhanced to Rs 210, 000 with a tertiary            care add-on of PKR 300,000 per family.
§    The package include post-delivery transport cost and referral transport
              v. Independent Monitoring Unit (IMU)
§    Monitoring and supervision on modern ICT tools in real-time
§    To reduce staff absenteeism, improve quality of services and conduct            patients interviews using latest smart phones
            vi. Drugs and Food Regulation
§    KP Food Safety Authority Act 2014
§    Food Safety Authority established, is in process of implementation
§    KP Protection of Breast-Feeding and Child Nutrition Act, 2015 has been
           Implemented through the Health Department Provincial Drugs            Inspectors
            vii.  Pharmaceutical / Medicines Sector Control
§    Drug Inspectors fully mobilized across KP and Rs 28million allocated to            ease out their mobility.
§    Provincial Quality Control Board decided almost 2000 in numbers that            were lying pending for want of decision since 2005.
§    Khyber Pakhtunkhwa Pharmacy Council issued 2800 licenses of            various categories for retail, wholesale and distribution of drugs in order            to resource pharmacies with qualified human resource, thereby            strengthening the economic base of the society.
         viii. Revised Health Management Structure
§    Up-gradation / restructuring of 226 positions at provincial and district            management level
§    Bio metric system for attendance operational at DGHS Office,            Secretariat, Teaching Hospital
§    E-Office system implemented at provincial level 
            ix. District  Management Committees for   District Hospitals
§    Hospital Management Committees at District level with involvement of            with the District Government and  Community Representatives /            Stakeholders
              x. Emergency Services:
§    Government has allocated Rs 1 billion per year since 2013-14 for            providing free emergency medicines. More than 20 million patients are            benefiting annually
            xi.Treatment of Chronic Diseases:
§    To provide free treatment to Diabetic and Renal diseases patients the            Govt    of Khyber Pakhtunkhwa has allocated Rs 925 million so far.
           xii. Increase Immunization Coverage:
§    Government allocated Rs 6.17 billion for Immunization Support            Programme for five years benefiting 2.3 million children of Khyber            Pakhtunkhwa
         xiii. Treatment of cancer patients
§    Government of KP allocated an additional Rs 1.9 Billion for free            treatment of cancer patients
         xiv. Establishment of Gajju Khan, Swabi and Nowshera Medical Colleges 
           xv.   Improvement and beautification of Medical Teaching Institutes (MTIs) and refurbishment of District Head Quarter Hospitals
          xvi.  Standardization of District Head Quarter Hospitals and THQ Hospitals
         xvii.  Injured Persons & Emergency (Medical Aid Act) 2014
        xviii.  Human Organ Transplantation Act, 2014
     II.         Primary Health Care
§    Integrate the full range of Primary Healthcare (PHC) specially MNCH,            immunization and other Preventive services at the BHU and make BHU            the hub of all PHC
§    Forty six BHUs for 24/7 MCH services in the province and work in this            regard has been initiated in 34 BHUs.
§    Mobile health services (MCH) are launched in District Mansehra,            Nowshera, Charsadda, Peshawar, Haripur, Mardan and Swat
§    Minimum Health Services Delivery Package (MHSDP) introduction in            Primary Health Care Facilities of Khyber Pakhtunkhwa
   III.         Human Resource Recruitment and Sustainability
§    The present Government has created over 22,000 posts out of            which 15000 have been created in current budget  year 2016-17
§    Vacant Positions filled in all cadres in all the districts across            Khyber            Pakhtunkhwa
§    Incentive Packages for Health Care Workers
                        To motivate the health work force this government is spending an                           additional amount of Rs 5.46 Billion which includes incentive                                    packages for doctors, Trainee Medical Officers, House Officers, Nurses                            and Para-medics.
§    PHSA Mandate revised; Promotion tied trainings of different            cadres             launched at PHSA; further resources would be allocated            to         ensure             sustainability
§    Human Resource Information System (HRIS) established /    developed            linked with PIFRA and FMIS, staff       capacities built            with            generation of information for all cadres in HR Unit     established at DG            Office resourced with HR Specialists.
§    Service structure revised for cadres and amended service rules            where             required and measures for their in-time  implementation
§    Master plan for Human Resource Management; HRD Plan     developed;            HR Retention Strategy in place
§    To improve the quality of Paramedics Training; Post Graduate            courses           are started with the collaboration of KMU
  IV.         E-Health
§    E-health / telemedicine PC1 has been approved and is in process    of            administrative approval.
§    The PC1 project includes
o     Feasibility Study for this innovative intervention
o     Service contract with Service provider after feasibility on pilot basis in two districts
o     Toll free helpline
o     Performance management through KPI
o     HMC Hospital computerized
o     Maternal Child Health awareness increased using electronic communication tools
    V.         Chief Minister Special Initiatives
            In addition to Health Sector Reforms Chief Minister also announced certain             special initiatives to further improve Health Status of the population of the             province. These initiatives include :
1)              Establishment of Insulin Bank  (Insulin for life)
2)           Health Insurance for Critical Illnesses
3)           Improving Maternal and Child Health- Incentivised anti-natal, natal and             postnatal care
4)           Immunization Services
5)           Improvement of Emergency Services
Previously Ongoing Reforms / Initiatives
1.     Rules of Business of Health Department were revised; Restructuring as per functions mentioned therein is awaited
2.     Health Sector Strategy- approved; operational plans being prepared and needs to be implemented
3.     Procurement reforms are underway
4.     Skill Development Program for nurses and physiotherapists is ongoing at PHSA; Skill Development Program for doctors and technicians may be launched
5.     District Conditional Grant was successfully implemented; it needs to be replicated and scaled up in other districts
6.     GIS training conducted; there is need to establish a small GIS unit at Planning cell to facilitate planning and rationale decision making
7.     Water and Sanitation-policy, strategy and action plan inputs, given to concerned department; implementation is awaited
8.     Financial Management reforms under way
Other Recent Developments
1.     Dengue Fever Prevention and Control, a project has been approved worth Rs 59 Million
2.     Integrated HIV/AIDS , Hepatitis and Thalassemia Control Program PC1;  worth Rs 500 m approved and is in process of implementation.
Challenges / Gaps
1)    Khyber Pakhtunkhwa always took lead in health reforms and  piloting of innovative health care models in Pakistan. But sustainability and scaling up of the new initiatives has been a challenge.  Political instability, lack of ownership by the successors, commitment level of the health professionals and unstable financial sources are some of the reasons.
2)    The fast-growing population in the province has implications for the health sector both in terms of human and financial resources. There is need to allocate more resources both financial and human for increasing coverage of quality services to the population, improve health outcomes by refurbishment and renovation of health facilities, appointment of skilled staff against the vacant and new positions.
3)    Capacity building of the existing health providers so as to utilize the available resources efficiently; especially of the management cadres , if desired targets are to be achieved.
4)    Despite a huge investment in health infrastructure in the last decade, the health facilities are still not enough, especially in the rural areas, for catering to the needs of increasing population.
5)    Non-availability of medicines is also among the prevalent systemic issues. Equitable funds allocation and efficient Procurements and Supply Chain Management  (PSM) is needed to address these grave issues.
6)     Private sector or out of pocket expenditure on health care is highest in Khyber Pakhtunkhwa among all the provinces of Pakistan. Improved quality and availability of services in the public hospitals are a few of the measures that would possibly flip this ratio.  
7)    Disproportionate allocation of sector budget , the development budget constitutes 33% and the remaining 67% budget is allocated for the operational expenses i.e. the current budget. Current budget is mainly tied up in the employee related expenditure which constitutes 76.4%17 of the total current budget. 
Recommendations and way forward
1.     Focus on maternal and child health care and coverage of critical illnesses 
2.     Improving governance through restructuring if required, and upgrading Basic Health Units, Rural Health Centers, and Tehsil Headquarter Hospitals.
3.     Targeting of the districts with the lowest health indicators 
4.     Revitalization of the Health Foundation  setting a clear policy direction in favor of entering into public private partnerships in healthcare service delivery. 
5.     Improving access of essential and cost effective health services especially for the poor and vulnerable
6.     Protecting poor strata of population from catastrophic health expenditures
7.     Emphasizing more on quality of care and services at all levels
8.     Improving the institutional arrangements and  management of health care delivery system
9.     Improving the availability (specially female) and motivation of  health workforce
10.  Aligning outputs of the academic institutes in line with the needs of health system and improving the quality of education and training.  
11.  Effectively engaging private health sector and civil society organizations to improve health outcomes
12.  Develop pharmaceutical sector and ensuring access to quality medicines
13. Ensure effective research, monitoring & surveillance system to measure results and evidence based decision making at all levels.