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A Policy Analysis of Punjab Health Sector Strategy(PHSS)

A Brief Review of Punjab Health Sector Strategy 2012-2020

By: Laila Rubab Jaskani

7 September 2015

Punjab Pakistan

Empowerment, Voice and Accountability for Better Health and

Nutrition Project Pakistan

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Table of Contents Policy Analysis of Punjab Health Sector Strategy 2012-2020 ........................................................................

Acronym ....................................................................................................................................................

1. Executive Summery ................................................................................................................................. 4

2. Overall Objective ..................................................................................................................................... 4

3. Specific Objectives ................................................................................................................................... 4

4. Methodology ........................................................................................................................................... 4

5. The Rational for EVA-BHN Policy Advocacy for RMNCH and Nutrition ................................................... 4

6. Landscape of Health and Nutrition Services Delivery in PHSS ................................................................ 5

7. Issues and Gap Analysis of PHSS ............................................................................................................. 6

8. The Trends of Demand Creation through Empowerment, Accountability and Responsiveness in PHSS

................................................................................................................................................................. 6

9. Crticial Gaps and Actionable Recommendations .................................................................................... 7

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Acronym: MI Micronutrients Initiative

SUN Scaling up Nutrition Movement in Pakistan (Pakistan is signatory of SUN)

IRMNCH Integrated Reproductive Maternal Newborns and Child Health

GAIN Global Alliance for Integrated Nutrition

BHN Better Health and Nutrition

EVA Empowerment, Voice and Accountability

PHC Punjab Health Care Commission

EPHS Essential Package for Health Services

MSDS Minimum Service Delivery Standards

PHSS Punjab Health Sector Strategy

CMIT Chief Minister Inspection Team

PITB Punjab Information Technology Board

WB World Bank

NNS National Nutrition Strategy

PINS Pakistan Integrated Nutrition Strategy

SUN Scaling Up Nutrition

NWG Nutrition Working Group

MNCH Maternal Newborn Child Health

MTDF Medium Term Development Framework

NNSP National Nutrition Strategic Plan

TWG Technical Working Group

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1. Executive Summary:

Primary Health Care and Reproductive Maternal Newborns Child Health and Nutrition is priority for

Government of Punjab.This is according to the reliable sources; that Chief Ministor of Punjab is committed to

provide the essential health services to the citizens of Punjab.Health reforms are expected and even in the

mandate and priority of current Government of Punjab.

The Government of Punjab has developed broader Health Sector Strategy with aim to improve health of

citizens of Punjab; and ensure the access and provision of equitable health services delivery for all in Punjab.

The strategy entails series of goals and particularly the strategies and strategic ations that essentially

reconstruct and reform the health system and particulalry services delivery system in Punjab.Essential Health

Services Package and Minimum health services delivery statndareds are playing the role of spine in

PHSS.Punjab Health Care Commission has been established by the Government of Punjab aimed at ensuring

the health sector regularites and with the sole aim of immplementation of Minimum Services Delivery

Standards(MSDS).

Health and Nutrition Reforms in the services providing institutions and service providers are essential for

brining about improvemetns in the ways and means of serivces delivery at the door step of vulnerable and

marginlised communities and particularly for women and childrem.There are certain gaps at the facility level

and outreach level/community level and in the coverge of uncovered areas or non-catchment areas by Lady

Health Workers,Community Midwivers(CMWs) and Vaccinators.If we think for a moment with the perspective

and lense of vulnerable and marginlised families access towards services providing instituions than we will see

that there is lack of mean of transportations,lack of indiginous means of transportations,lack of trained birth

attandents,lack of emergency obstetric services at the BHU level,lack of medical equipments and

mediciens,lack of family planning counsling services and limitied numbers of institutional deliveries,limitied

use and trust on contraceptive methods,low aptitud towards polio,Phnmonia,measels,inappropriate

nutritious diet before,ducring and after the pregnancies, vaccinations,TT vaccination before and during the

pregnancy,anti-natal and neo-natal care,post-natal care.

This analysis briefly discribes the lack of community based monitoring through empowerment, voice and

accountability, responsiveness and grievances redress mechaisms at the distirct level in Punjab and suggests

policy advocacy actionable recommendations for the Government and world leaders and international Donor

community to advocate for the better health and nutrition in Punjab Pakistan.

2. Overall Objective: To explore the problem areas and areas of health and nutrition reforms with the perspectives of EVA for

further developments and improvements

3. Specific Objectives: 1) To discribe key problem areas with the perspectives of EVA-BHN CBM and GRM in Punjab Health

Sector Strategy 2012-2020

2) To discribe areas of improvements for meanstreaming equity and citizens inclusion and grievances

redress mechisms in the policies and straetgies’ planning,immplementation and monitoring

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3) To elaborate policy level recommendations in PHSS for empowerment,accountability and

responsiveness in health sector of Punjab

4. Methdology: Desk review/background research conducted for reviewing and analysing the current situation in the cadre of

health and nutrition and in particularly RMNCH.Specifically, Punjab Health Sector Strategy 2012-2020, Pakistan

demographic health survey report 2013,Pakistan’s Polio Program is a disaster report.Consultative meetings

and interviews conducted with key government stakehodlers,independent consultants and health seniour

experts.Responses compiled,synthacised and analysed with the lenses of EVA demand creation perspectives

of CBM and GRM.

5. The Rational for EVA-BHN Policy Advocacy for RMNCH and Nutrition: Unfortunatly,Pakistan is tracked off in attaining MDGs 4 and 5 therefore Reproductive maternal and newborn

child health is top priority for government of punjab.1 Under-five morality fell from 117 deaths in 1990/91 to

89 deaths per 1,000 live births in 2012/13; and the infant mortality rate in this period from 102 to 74 deaths

per 1,000 live births. However, both are still short of the MDG targets of 52 deaths per 1,000 live births for

under-ve mortality, and 40 deaths per 1,000 live births for infant mortality.2The coverage for fully immunized

children increased from 75 to 80 percent and of measles immunization from 80 to 81 percent in this period;

both are still short of the target of above 90 percent coverage.

Therefore;this is in the light of mentioned MDGs targets status that EVA-BHN is trying to identify and set the

key problem areas for policy advocacy so that EVA would be able to give contirbutions to PHNP in achieving

MDGs targets 4 and 5 through collaborative and right based policy advocacy efforts.

The PHSS includes analysis of health and Nutrition.Challanges are boradly discribed in the PHSS.The strategic

actions involve integration of and lists a comprehensive set of issues and health service providers.It is found

that, PHSS lacks in addressing and improving access to and challenges relating to accountability,citizens

inclusion in monitoring and reporting of issues or gaps and grievences redress mechanisms established at the

lower tiers e.g. facility level/BHU/RHCs level and districts level.

6. Landscape of Health Services Delivery in PHSS: Generally, when we says landscape of health and nutrition services delivery than we try to discribe the different tiers of services delivery at three levels including in Primery level leads to community level,Secondry level leads to facility level and tehsil level and tartiery level leads to district level. It is critical and difficult to gauging the performance and progress of the public health services in Punjab. The situation is even more worrying when we look at “differences in EPHS and MSDS service provision and utilization among citizens residing in the rural areas and particularly the women and children in the vulnerable and marginlised families. They are at a clear disadvantage in terms of the use of primary and tertiary health services and emergency obstetric services.They don’t have necessery information and knowldege on the MSDS and EPHS itself so that is why they are unable to monitor and report the issues and gaps to the concerns.Illiteracy and lack of access to information is major constraint for common citizen to monitoring and reporting services gaps to the concerns and higher authorities.

1 Pakistan Demographic Health Survey 2013 2 Millennium Development Goals Report 2013 By UNDP and Planning Commission Government of Pakistan

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7. Empowerment,Voice and Accountability and Responsiveness within

the Punjab Health Sector Strategy- A Specific Gap Analys: Given the current situation, there is much that needs to be done, possibly in every domain of the health sector. Women and children still have the most to lose. There is a dire need for citiznes centred interventions to strengthen the network of health services, expand the outreach of health programs, and introduce the “citizens driven demands,monitoring and reporting trends to better monitor and strengthen the health programs in place”. The Department of Health the government of the Punjab has developed Punjab Health Sector Strategy 2020 in 2012.Although this PHSS is well elaborated on the key challenges encountering in Punjab health sector but also comprehensively elaborated on enormous goals, strategies and strategic actions for addressing those gaps. Apparently, it is good strategic document by the Government of Punjab towards bringing about health sector reforms in it. However,this is analyzed that the necessary “citizens inclusion or engagement” with the perspectives of government “services utilization and reporting the complaints or grievances in the light of malfunctioning regarding the provision of services has not been focused in detail in the PHSS. It has been analyzed that PHSS emphasized on EPHS and MSDS in all the health services facilities which is chain of services delivery but it has been elaborated that “Punjab Health Care Commission which is established at the Punjab Province level and emphasized that in case of maladministration or mismanagement in the implementation and utilization of EPHS and MSDS the PHCC will be ensuring the compliances and MSDS specific regularities at the health facilities. Empowerment,Accountability and Responsiveness within the Punjab Health Sector Strategy is not comprehensivly elaborated for achieving the services delivery objectives and improving the status of citizens and particularly for the women and children in Punjab. Approaches to promoting Empowerment and Accountability aim to support poor and marginalized people to build the resources, assets, and capabilities they need to exercise greater choice and control over their own development and, in the process of doing so, hold decision-makers to account. It is analyzed and concluded that the role of Punjab health care commission is only limited at the provincial level which needs to be expended at the lower level tiers for complimenting the “citizens based monitoring and reporting of grievances” the aggrieved person or the complainant must be the central focus in reporting of the grievances after careful monitoring of MSDS/health standards. The necessary reforms and actions are needed in PHSS in the cadre of “reporting and monitoring of MSDS by the citizens” and relieve should be provided at their door-steps. For the adaptation of this necessary reform it is essential that Punjab Health Care Commission may be established at the regional level and district level and PHCC cell needs to be established at the BHU level.

8. The Trends of Demand Creation through Empowerment, Accountability

and Responsiveness in PHSS:

There is greater need of piloting and than scaling up and institutionlizing the Citizens Based Monitoring Systems on sustainable bases in Punjab Health sector.CBMSs can be helpful for collecting and local level information using for services delivery improvements and policy planning process.

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It is reported in Minimum Services Delivery Standads under the main heading of “supervision” that; “supervisory system is weak in terms of regularity and citizens’ feed back to facilities”3.The urgent need should be to sacrify due attention on monitoring and assessments of EPHS and MSDS after every six months. The empowerment and accountability agenda may be incorporated into health sector strategies as: (a) an overall approach and a means of achieving a health rights objective; or (c) as an objective in itself. Primarily, however, empowerment and accountability interventions involve long-term change in the health seeking behaviours and attitudes of common citizens are transformed by citizens themselves. The main dilemma in implementation of PHSS is that its interventions are being conducted through IRMNCH and Nutrition Program with the support of LHWs and CMWs. It is noteworthy that, LHWs and CMWs are the only health workforce for the implementation of community level of outreach activities. All the vertical health programs are undertaken by LHWs and CMWs. Health committees and women support groups are formulated at the community level. Efforts to empower citizens need to be accompanied by district level and facility level mechanisms to ensure accountability and responsiveness. Major gap indicates capacity and performances issues of LHWs and CMWs. The Punjab Growth Strategy 2018 first draft reported that; “It is now clear that a major constraint for improving government services is the absence of reliable information about performance and service delivery, which limits accountability. Government departments lack high quality and timely data which makes performance tracking difficult and weakens accountability, and consequently, results in poor outcomes4”.We now analyzed that although the Punjab Growth Strategy 2018 indicated this phenomena holistically but it is in the context of health and nutrition that the department of health has its separated MISs including in EPI and LHWs,Nutrition MIS which needs to be “common data dashboard” for all program in order to easily access information by the decision makers for policy planning and gaps assessments.

9. Critical Gaps and Actionable Recommendations: We call for action our government, international donor organizations, UN agencies, civil society

partners and relevant duty bearers to take the following actions for ensuring citiens center monitoring

and reporting of Gaps in services:

1) Citizens must be engage directly with the services providers at the facility level through Citizens

Based Monitoring Systems and other oversight processes and particularly ‘demand-side’

accountability processes.

2) Capacity building of LHWs and CMWs on mobilization, counselling and advocacy skills for

undertaking empowerment and accountability interventions at the facility level and district level.

3) There must have citizens’ response and facilitation centres at the facility level and district level. So

that citizens would be able to get efficient responses and feedback in response to feedback given to

services providers for improving services.

4) The decentralization and establishment of “Grievances Redress Mechanisms” at he facility level to

district level should be ensure by the Punjab Health Care Commission as it is in the “Strategic

Business Plan” of Punjab Health Care Commission to establish regional offices and district offices for

Punjab Health Care Commission.

3 MSDS document retrieved on 22th December,2014 4 The Punjab Growth Strategy Draft 2018; Retrieved on 13 December,2014

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5) Citiznes centered monitoring and reporting of grievances rules and standard operating procedures

needs to formulaized by the PHCC for the establishment and functioning of “Grievances Redress

Mechanisms” at he facility level to district level so that citizens oriented monitoring and reporting

should be at the soul aim of GRM established by the PHCC.There should have easy “access” to GRM

established by PHCC at the door step of every ctizens in Punjab.

6) It should be in the TORs of Lady health workers,CMWs and Vaccinators to inform and mobilize the

citizens about established GRM systems of PHCC at all teirs because LHWs have wider and door to

door outreach access.The PHCC should issued notifications to the district level authorities.

7) Capacity Building of BHU level staff regarding best record keeping and maintainance of lounched

grievances by the agrieved person.There must have appropriate and adiquate monitoring and

followups actions for reported grievances by agrieved person among the citizens.

8) Mid-term and annual Evaluation of EPHS and MSDS needs to carried out so that government would

be able to modifiy and bring about policy changes keeping in view the citizens needs in the light of

responses on the utilization of services by the citizens.

9) To increase the strength of Lady health workers(LHWs) and Community Mid-Wives(CMWs) for the

true immplementation of EPHS in the uncovered or Non-catchment areas for fullfilling of the

commitment regarding Community based management of acute malnutrition(CMAM) acservices

delivery to “every citienzes with borders limitations” including in MAM/SAM and PLWs.There should

be wider network of LHWs and CMWs at every litimized way.

10) This should be beyond the mere structural reforms regarding infrastructure and service delivery the

government of Punjab must generate demands through extensive empowerment voice and

accountability interventions for the citizens regarding preventive services such as safe deliveries,

vaccination and family planning and community based management of acute malnutrition (CMAM).

11) Effective implementation of comprehensive strategies mentioned in PHSS 2012-2020 EPHS and

MSDS require a citizen led monitoring and reporting initiatives needed to measure the service

delivery provisions

12) There should have centratlised and common data dashboard and data validation systems connected

at all the tiers in the department of health including in LHWs MIS,EPI MIS,MNCH MIS so that it

should be convinenet for decisison makers to access validated data for monitoring the data and

devising apporpriate policy planning or modifications for improvements.

13) There is lack of intigration between Population Welfare Department and other vertical programs of

health.Therefore,there is need to design the advocacy and counsiling strategy at the provincial level

for immplementation at the district level for reducing the unwanted pregnencies through awareness

raising and demand creation of essential FP supplies.