Name of the Project - Punjablhwp.punjab.gov.pk/Downloads/PC-I Integrated 16 th Apri… · Web viewThe integrated program will focus on reproductive, maternal, newborn and child

PC-I

PUNJAB

Integrated Reproductive Maternal Newborn & Child Health (RMNCH) & Nutrition Program

2013 - 2016

Department of HealthGovernment of the Punjab

ACRONYMS1

AIDS Acquired Immune Deficiency Syndrome

ANC Ante Natal Care

ARI Acute Respiratory Infection

BHU Basic Health Unit

CBR Crude Birth Rate

CDD Control of Diarrhea Diseases

CDR Crude Death Rate

C-IMNCICommunity based– Integrated Management of Newborn and Childhood

Illnesses

CMAM Community based Management of Acute Malnutrition

CMT Community Midwifery Tutor

CMW Community Midwife

CPR Contraceptive Prevalence Rate

DCHC District Community Health Council

DCO District Coordinating Officer

DEC District Evaluation Committee

DFID Department for International Development

DHQ District Headquarter Hospital

DOH Department of Health

DOTS Directly Observed Therapy Short Course

DMU District Program Management Unit

DSC District Steering Committee

EDO Executive District Officer

EDO (H) Executive District Officer (Health)

EmONC Emergency Obstetric and Newborn Care

ENC Essential Newborn Care

EPI Expanded Program on Immunization

FHT Female Health Technician

FLCF First Level Care Facility

FMT Female Medical Technician

FP Family Planning

FWC Family Welfare Center

HO Health Officer

HEB High Energy Biscuits2

ICU Intensive Care Unit

IDD Iodine Deficiency Disorders

IMNCI Integrated Management of Newborn & Childhood Illness

IMR Infant Mortality Rate

IYCF Infant & Young Child Feeding

IPC Inter Personal Communication

ISO International Standards Organization

CSG Community Support Group

LHS Lady Health Supervisor

LHV Lady Health Visitor

LHW Lady Health Worker

MIS Management Information System

MMR Maternal Mortality Ratio

MNCH Maternal, Newborn and Child Health

MNT Maternal and Newborn Tetanus

MO Medical Officer

MS Medical Superintendent

MSDS Minimum Service Delivery Standards

MUAC Mid Upper Arm Circumference

NEB Nursing Examination Board

NGO Non-Government Organization

NID National Immunization Day

NNMR Neonatal Mortality Rate

NTT Newborn Tetanus Toxoid

Ob/Gyn Obstetrics Gynecology

OPD Out Patient Department

ORS Oral Rehydration Salt

ORT Oral Rehydration Therapy

OTP Out Patient Therapeutic Program

P&D Planning and Development Department

PC-1 Planning Commission – Performa 1

PDHS Pakistan Demographic Household Survey

PDS Pakistan Demographic Survey3

PHC Primary Health Care

PIHS Pakistan Integrated Household Survey

PMU Provincial Program Management Unit

PNC Pakistan Nursing Council

PSC Provincial Steering Committee

PSDP Public Sector Development Program

PSLM Pakistan Social and Living Standards Measurement survey

PTS Principle Training Site

RHC Rural Health Center

RHP Reproductive Health Project

RHSC Reproductive Health Service Center

RUTF Ready to Use Therapeutic Food

RUSF Ready to Use Supplementary Food

TBAs Traditional Birth Attendants

TCHC Tehsil Community Health Council

THQ Tehsil Headquarter Hospital

UC Union Council

UNFPA United Nation’s Population Fund

UNICEF United Nation’s Child Fund

VCC Vehicle Condemnation Committee

WB World Bank

WHO World Health Organization

WHP Women Health Project

WMO Women Medical Officer

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PC-1 PERFORMACode Number for Project_____________(To be filled in by Planning Commission)

PART “A”PROJECT DIGEST1.1 Name of the Project Integrated Reproductive Maternal Newborn & Child

Health (RMNCH) &Nutrition Program

1.2 Location of the Project

All 36 districts of Province of Punjab

1.3 Authorities Responsible for:

i. Sponsoring.

ii. Execution.

iii. Operation & maintenance.

iv. Concerned federal ministry

Government of PunjabDepartment of Health, Punjab and District Governments in PunjabDepartment of Health, Punjab

Planning & Development Division

1.4 (a) Plan provisioni. If the project is

included in the Medium Term/five-year plan, please specify actual allocation.

The National Programs i.e. Lady Health Workers’ Program (LHWP), National Maternal, Newborn and Child Health (MNCH) Program and Nutrition Program, were included in the Ten-Year Perspective Development Plan 2001-11 and Medium Term Development Framework 2005-10. The Programs have also been identified as major health sector interventions in the Poverty Reduction Strategy Papers-I and II. The Government of Pakistan is a signatory to the Millennium Declaration and this effort is aimed to achieve health related goals. This Program will also contribute to all three key health & nutrition sector reform areas of the Economic Growth Framework announced by the Planning Commission in May 2012.

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ii. If the project is proposed to be financed out of block provision for a program indicate

(b) Provision in the current year PSDP/ADP

Total Block Provision: Rs. 40.28 Billion for PHC Programs for the period 2005-10. After the 18th Constitutional Amendment, the Federal Government committed to continue funding for vertical national health programs till 2014-15 i.e. by the announcement of the next National Finance Commission Award.The Program will require federal funds. Some donor funding may also be available in the form of grants, results based aid and technical assistance.

Punjab Government Share Rs.9424.006 (M) for 2013-2016.UNICEF Share for 2013-2014 Rs.260.155 (M)WFP Share for 2013-2016 Rs130.010 (M).Total Cost: Rs. 9814.171 Millions

1.5 Project Objectives and its relationship with Sectoral Objectives

This program is inspired by the desire of the government to reduce maternal, newborn and child morbidity and mortality, promote family planning services and improve nutritional status of women and children. The achievement of this objective is also part of the government’s commitment to make speedy progress to achieve health related ‘Millennium Development Goals’ by 2015 and setting the roadmap towards achieving ‘Universal Coverage’ of health services in Punjab. This program will contribute in achieving health sectoral priorities in line with ‘Poverty Reduction Strategy Paper –II’.The salient features of the currently proposed program are that it adds on to what is already being done in the MNCH and LHWs Programs to achieve Millennium Development Goals 4 & 5. It will act as catalyst to assist ongoing initiatives. Additionally, new initiatives being proposed address malnutrition and aim to increase accessibility of MNCH services by provision of 24/7 service delivery at selected BHUS, all RHCs, THQs and DHQs. BHUs will be selected by a notified Provincial Management Committee (see Administrative Structure); the criteria for selection

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includes geographical distribution of and the community’s accessibility to individual facilities.The program will contribute to all health& nutrition sectoral priorities set in the ‘Economic Growth Framework’ of the Planning Commission, i.e.1: Revamping/management of primary, secondary and

tertiary healthcare;2: Healthcare Financing Reforms; and3: Governance reforms in health sector (especially setting

quality standards; essential services package; aid effectiveness, service structure; capacity; access to affordable medicine; etc.)

Recently, the Government of Punjab has developed a draft ‘Punjab Health Sector Strategy (HSS) 2012-20’. Punjab HSS outlines six key areas of reforms in line with the six building blocks of the health system. Accordingly, implementation strategies have been defined to achieve these policy objectives. This program is contributing to all six outcomes of the Punjab Health Sector Strategy i.e.

Outcome 1: Improved access and quality of healthcare;Outcome 2: An efficient system of health sector

governance, accountability and regulation;Outcome 3: A management system that provides

incentives for performance and ensures accountability;

Outcome 4: Adequate and skilled workforce available to fulfill population health needs;

Outcome 5: A comprehensive, timely, accurate and functional information foundation for health policy and planning decisions; and

Outcome 6: Uninterrupted supply of quality essential drugs for healthcare facilities and outreach workers.

Continuing and expanding services through national and provincial health programs and setting up an integrated system to be implemented in all districts of Punjab is the most important aspect of the agenda for change. This Program will constitute the main thrust of outreach and

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facility based services in rural and less developed urban areas for provision of improved reproductive, maternal, newborn, child health and nutrition services in Punjab.

GOAL:

To improve maternal, new-born and child health in Punjab, especially of the poor thereby making real progress towards achieving health related MDGs and contribute to reduction in: maternal mortality ratio from 227/100,000 live births in

2006-07 to less than 140/100,000 live births by end 2016;

under-five mortality rate from 104/1000 live births in 2011 to 52/1000 live births byend2016;

total fertility rate from 3.6 in 2011 to 3.2 by end 2016; and

prevalence of stunting from 36% in 2011 to 32% by end 2016

PURPOSE/OBJECTIVES:

The Program objective is to improve access to Reproductive health, Child health and Nutrition services in the province especially for the poor through: improving contraceptive prevalence rate for modern

methods from 23% in 2011 to 35 % by end 2016; increasing skilled birth attendance from 59% in 2011 to

80% by end 2016; increasing institutional deliveries from 53% to 70% by

end 2016; increasing coverage of complete immunization from

35% in 2011 to 70% by end 2016; increasing percentage of children suffering from

diarrhea treated with ORS and Zinc, up to 40% by end 2016;

Increase in the proportion of severe acute malnourished (with complications) children 0-59 months successfully treated (for discharge) up to 75%by end 2016;

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Increasing percentage of early initiation of breast feeding from 15% in 2011 to 40% by the end of 2016;

Increasing percentage of exclusive breast feeding from 22% (0-5 months) in 2011 to 35% by the end of 2016;

Increased percentage of utilization of adequately Iodized salt at household level from 34% to 50%

increase in the distribution of iron & folate tablets among pregnant women from 20% in 2012 to 50% by end 2016;

increase in proportion of children 6-23 months fed in accordance with all three infant and young child feeding (IYCF) practices (food diversity, feeding frequency, consumption of breast milk or milk), up to 40% in 2016

All district implementing MNCH related MSDS by end 2016

The principal sources for the verification of Program performance against set targets will be independent Program evaluations; National and Provincial surveys e.g. Punjab MICS, PDHS and PSLM, in addition to Program monitoring and supervisory systems.

1.6 Description, Justification & Technical Parameters

Pakistan’s health MDGs’ targets have improved over last two decades but they still lag well behind other countries at similar levels of income and it is unlikely that Pakistan will achieve its health targets by 2015.Challenges include huge social, cultural and economic barriers to health, particularly for women, and service delivery in rural and insecure areas of the country. Because of competing budgetary and security priorities, the Government of Pakistan currently invests only about 0.86% of its GDP in the health sector which is among the lowest in South Asia, other than Afghanistan.Punjab, being the largest province with a population of 95 million greatly skews national outcome indicators. Progress on achieving health MDGs in Punjab is slow, though comparatively better than other provinces. The maternal mortality ratio in Punjab is 227/100,000 live births (PDHS 2006-07), under five mortality rate is 104/1000 live births

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(MICS 2012) and total fertility rate is 3.6 (MICS 2012). Prevalence of nutritional disorders, infectious diseases and access to reproductive, maternal, newborn and child health care services, although better compared to other provinces remains poor compared to other South Asian countries.Since Independence, public health financing in the country has given priority to curative healthcare. Although a considerable number of health facilities have been made, their rate of utilization is limited. Recognizing this, the government of Pakistan launched a number of national health program over the last two decades which were designed to improve health outcomes through cost effective interventions.

Provinces, including Punjab proactively implemented these national health programs. However, as an implication of the 18thConstitutional Amendment, these programs have been completely devolved to the provinces from 30 June 2011. As per decision of the Council of Common Interest, the Federal Government agreed to continue funding of these national programs till the next Finance Commission Award (NFC) in 2014-15, except the LHWP which will be funded till 2017.The Punjab Government considers this as an opportunity not only to develop its capacity to play a new role in the health sector but also to deliver primary and preventive health care interventions through an integrated and cost effective approach. This will also help the provincial government to shift its priorities from curative care/private goods to predominantly primary and preventive health care/public goods.

To meet the challenge, the Department of Health developed its Health Sector Strategy (HSS) 2012-20, to set a roadmap to ensure this paradigm shift in the health sector. One of the priority strategic areas of the HSS is to deliver ‘Essential Package of Health Services (EPHS)’ at primary,

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secondary and tertiary level.

Recent devolution of the vertical national health programs will help the government in materializing the concept of delivery of EPHS at the district level initially for primary health services. However, a phased approach is required first to integrate primary and preventive health care services through an integrated provincial program for a period of three years; in the meantime enabling Districts to take over all primary & preventive health care implementation responsibilities for the delivery of EPHS.

Development of this program is a way forward not only to continue existing interventions through an integrated approach but to expand their scope and introduce new interventions. Some of the program/ interventions which will be integrated and implemented through this program are as following:

1: The National Program for Family Planning and Primary Health Care, also known as the Lady Health Workers Program (LHWP), launched in 1994. The Program objectives contribute to the overall health sector goals of improvement in maternal, newborn & child health and provision of Family Planning services. This country wide initiative extended outreach health services to rural populations and urban slum communities through deployment of over 100,000 Lady Health Workers (LHWs) and contributed to bridge the gap between health facilities and communities.

2: National Maternal, Newborn and Child Health (MNCH)Program (2006-2012) was lunched nationwide with a goal to improve maternal, newborn and child health of the population, particularly among its poor, marginalized and

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disadvantaged segments. The program is contributing to strengthen Emergency Obstetric care services at DHQ, THQ hospitals and RHCs. Further, this program has introduced a new cadre of Community-Midwives (CMWs) for skilled deliveries at community level.

3: A network of BHUs, RHCs, THQ and DHQ hospitals which are managed by the District Governments play a critical role in provision of reproductive, maternal, newborn and child health services. In Punjab, some of the resource gaps related to MDG 4 and MDG 5 services are proposed to be filled by this Program.

4: Punjab is also moving towards functional integration of Family Planning services offered through the Department of Population Welfare. This initiative of functional integration will be strengthened through this proposed program.

5: The Chief Ministers’ Health Initiative for Attainment and Realization of MDGs 4 & 5 (CHARM) was launched in seven districts of Punjab, with the assistance of UNICEF & UNFPA, following severe floods in the year 2010. The program is helping in revival and utilization of the existing infrastructure of the Department of Health and expansion of round the clock Basic EmONC services through skilled paramedical staff in selected RHCs and BHUs. It is proposed to expand and upscale this initiative initially in 16 districts having poor health indicators related to MDGs 4 & 5.By 2016, the initiative will be expanded to 20 Districts.

6: The preventive nutrition interventions are being proposed for all 36 districts; additionally, curative component addressing malnutrition is proposed in

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12 targeted Districts and urban peripheries of 9 mega-Districts of Punjab.

In view of the compelling requirements to address health needs of women and children, the Government of Punjab, with support from development partners, implemented successfully above mentioned interventions in an integrated manner. But with new strategic responsibilities, the Department has decided to play a new role and integrate all above mentioned interventions to set up a roadmap for the delivery of EPHS at District level and strengthen the stewardship role at Provincial level. A two stage implementation mechanism will help the Department to gradually shift some of the interventions from development to recurrent budget, while generating more evidence on what works. The integrated program will focus on reproductive, maternal, newborn and child health and nutrition services with improvements in governance, financing and M&E mechanisms. Integration of interventions will help the Government to avoid duplication of activities, effective use of meager resources and ensuring enhanced efforts in the province which would facilitate achievement of health MDGs.

IMPLEMENTATION STRATEGIES:

The program will strengthen the health system by integrating different interventions, improving service delivery and introducing innovative strategies. The program will:

1. Strengthen district health system through integration of quality reproductive, maternal, newborn, child health and nutrition services at community, BHU,RHC, THQ and DHQ level and focusing on rural areas and gradually move towards delivery of EPHS (primary) at the district level;

2. Strengthen linkages of community based health services with health facilities through LHWs and

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CMWs focusing on rural areas& urban slums;3. Streamline and strengthen services for provision of

Basic and Comprehensive Emergency Obstetric and Newborn care (EmONC);

4. Enhance comprehensive Family Planning services at community and facility level;

5. Enhance Nutrition services at community and facility level through multi-sectoral coordination mechanism

6. Increase coverage of micronutrient supplementation and fortified food through advocacy from consumer to production line;

7. Implementing a Woman Focused Approach by using the 1000 days Plus Model for nutrition, which focuses on the critical window of 1000 days from conception to the first 24 months of the child’s life;

8. Involve local communities at different levels to enable them to participate in health improvement process;

9. Improve technical and managerial capacities at all levels of health care delivery system and expand accountability mechanism vis a vis performance based incentives in health care delivery system;

10. Introduce and implement e- monitoring and e-reporting system

11. Increase demand for preventive and primary healthcare services through targeted, socially acceptable communication strategies

12. Strengthen referral linkages between community outreach staff, primary facilities and secondary facilities

13. Improve client/ patient satisfaction from provision of services

1.7 The Project Costs

Local: GOP:

Foreign exchange

Date when capital expenditure estimates were prepared: February 2013. The costs have been estimated on the prevailing rate of the market and based on previous work done.Punjab Government Share Rs.9424.006 (M) for 2013-2016.

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cost:

Total:

UNICEF Share for 2013-2014 Rs.260.155 (M)WFP Share for 2013-2016 Rs130.010 (M).Total Cost: Rs. 9814.171 Millions

1.8 Annual Operating and Maintenance cost after completion of the project: (Item wise annual Operating Cost)

Average Annual Operating Cost is Rs. 3271.390 Millions for the FY 2013-16.

Employees Related Expenses 822.955Communication 1.160Utilities 0.600Occupancy Cost 0.500Training Domestic (All Trainings of LHWs, LHSs etc., TOT) 44.133TA/DA 0.500Transportation of Goods 10.333POL 33.600Local Conveyance Charges 0.010Stationary 0.100Printing & Publication 3.333Conference/Seminars 0.600Newspaper, Periodicals & Books 0.010Advertisement & Publicity 2.000Law Charges 0.005Purchase of Drugs & Medicines 518.615Others (Supplies for Nutrition Components & Consumables) 1.920Pension Contribution. 0.313Entertainment & Gifts 0.010Software (Physical Assets) 1.267IT Equipment (Physical Assets) 2.133Medical Store(Contraceptives) 283.333Others Store & Stock 1389.970Machinery Equipment 150.850Furniture & Fixture 2.192Transport Repair 0.848Soft Ware Repair 0.100Total 3271.390

1.9 Sources of Financing: The source of funding will be the Provincial Government ( Provincial ADP)

Funds may also be available from bilateral and multilateral donors and lending agencies.

This project will direct available funds at the District level

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for providing services.1.10 Demand and Supply

AnalysisThe Government’s health expenditure in Pakistan is very low – only 0.85% of the Gross Domestic Product (GDP) and 38.5% of the total health expenditure (both public and private) for the year 20101. Government’s per capita health expenditure is $8 per person per year (increased from $4 in 2003).Though doubled in Us dollar terms since 2003,it remains very low compared to the recommended expenditure of $34 per person per year on essential health services by the Commission on Macroeconomic and Health. Total (both public and private) per capita health expenditure is $22 per person per year (2010 figures)1. Majority of the expenditure in the private sector is in the form of ‘out of pocket’ expenses of service users. In general, utilization of public health facilities is low, resulting into high per capita cost of service provision.The proposed program will attempt to fulfill the unmet health needs of the general population in the province through provision of family planning, maternal, newborn and child health care, EmONC services and nutrition services.

The program aims to achieve its objectives through strengthening health system through improving facility based and community based interventions and ensuring community participation at all levels. One of the important aspects that the program plans to address is to restore the trust of communities on public sector health services. The increased utilization of public sector, in turn, will reduce per capita costs of healthcare delivery, particularly with regard to general health and MNCH. A major constraint in improving availability and quality of health services is inadequate financial space available for provision of these services. The proposed program will increase cost-effectiveness and efficiency of health services by increasing

1WHO National Accounts for Pakistan16

their quality and access through synergistic action with the ongoing initiatives. The distribution of health services is disparate with a majority of skilled health personnel being concentrated in urban areas. This program will improve the quality, access, affordability and utilization of health services in the rural areas by providing 24/7 EMNOC services at selected BHUs, all RHCs.

The number of deliveries conducted by skilled birth attendants has recently increased to 59% in Punjab but still significant deliveries are being conducted by unskilled traditional birth attendants or family members. In case of obstetric and newborn complications, the availability of emergency care is severely limited. There is a limited supply of technology intensive services limited to large urban conglomerates while on the other hand in the rural areas there is a shortage of qualified practitioners.

The supply side of health services especially in the public sector is limited due to non-availability of trained human resources, and appropriate equipment, in spite of availability of a vast network of health facilities throughout the country.Although at present the share of individual household’s out of pocket expenditure on health care is very high, the total expenditure on health is still below the optimum levels when compared internationally. This can only be improved through infusion of additional resources into health system either through Government expenditures, or alternative financing mechanisms. Given the level and distribution of poverty the need for a Government subsidy essentially remains and therefore the best mechanism would be targeting the subsidy to the poorer part of the population. This would create a healthier population base which has access to higher quality of care. The program targets rural areas and urban slums for provision of subsidized services and will lead to a decreased out of pocket expenditure on

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health care while providing improved quality of care to the population.

1.11 Financial Plan and mode of financing

1. Punjab ADB2. Grants/Results Based Aid from WB and DFID are

expected to cover the program. In this respect EAD has formally requested WB for financing in Punjab

3. In addition, TA support from DFID, USAID, UNICEF, WFP, UNFPA, WHO, WFP and other international agencies are also expected.

1.12 Project benefits and analysis:a) Financial, Social and environmental Benefits

Financial

Social Benefits with Indicators

Employment generation (direct and indirect)

No direct financial gains are expected from the program. However, reduction in morbidity and mortality in the population, control in population and improvement in nutritional status would lead households to have more resources and spend on improving quality of their lives, better learning on children and health life styles.

Considering that health is a basic right of every human being, the program will improve access to health care to all individuals of the society, especially the poor and more deprived. Access to primary, reproductive and nutrition health care will improve health status of communities leading to improvement in the overall quality of life. Improvement in social benefits will be measured by reduction in:

1. Under five Mortality Rate;2. Maternal Mortality Ratio;3. Population Growth Rate;4. Total Fertility Rate5. Crude Birth Rate; and6. Improvement in literacy rate.

Health and poverty are closely linked with each other; already poor people who are also unhealthy and vice versa. It is envisaged that health status improvements will enable individuals to avail more choices/opportunities that can help in improving quality of their lives like attaining education, competing for better employment opportunities and contributing towards their families and society’s

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Environmental impact

betterment, hence enjoying their life.

Improved health behaviors and ensured access to primary health care services will not only reduce the suffering at individual level but will also reduce the cost of treatment if preventive measures were taken on time or when treated at an early stage. In the end, investment on treatment of complicated cases will be decreased and would allow planning for the development projects. It is difficult to put these benefits in figures but their significance cannot be overlooked.Another feature of the program is to organize communities in such a manner that ensures their active participation in planning, administration and management of health care system in their area. This will facilitate the functioning of health delivery system on one hand and empowering the communities on the other hand. Moreover, in the process, the organized communities are expected to take other development initiatives to identify and solve their local issues.Program will build capacities of local communities by increasing their awareness regarding health issues and adopting healthy behaviors; of local staff by enhancing their skills and knowledge in health care services provision; of community representatives in planning small projects, administering and managing health services; and district health management teams in management, supervision, target setting & better planning for health care delivery system.

Although majority of service providers and management cadre are currently working, but over the program period effort would be made to absorb service providers in the DOH and District Health Office as part of the structural reforms. Indirect employment opportunities will also emerge related to the management/ organizational functions of the Program.

The program will certainly have a positive impact on the environment, with improved reproductive health outcomes.

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Impact of delays on project cost and viability

b) Project Analysis:

Quantifiable outputs of the project:

Unit cost analysis:

The improved health behaviors will lead to healthy life styles which are not possible without maintaining self-cleanliness (including hand washing), cleanliness at the household, street and society level. The appropriate disposal of human, liquid and solid wastes will further help improving the environment.

There is enormous amount of hospital waste which is not handled safely and generally leads to spread of killer diseases like hepatitis, etc. The program will make sure that, in all health facilities, hospitals and at community level, waste is adequately disposed of through implementation of infection control protocols.

This program is a high priority for the government to make speedy progress on health & nutrition outcomes. Delays in the undertaking will lead to increased cost in achieving health and nutrition MDGs. Majority of the interventions in the program are having very low cost per DALYs provided these are implemented on time. Delay in implementation will lead to continued high burden of mortality and morbidity and serious cost implication on the households. Currently, the government is indicating commitment to absorb different interventions as regular function of the public health sector.The program will be having four major outputs: 1: Improved delivery of maternal, newborn, child,

family planning and nutrition services under Essential Package of Health Services;

2: Increased demand side interventions for Reproductive health, Child health and Nutrition services;

3: Effective management of the Program at provincial and district level; and

4: Improved decision making through high quality information and research

Please refer to the Logical Framework (next section) of the Program which includes indicators for each output along

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with milestones and targets.

Average Cost of Married Women & Children Rs. 116/-1.13 Management

Structure & Manpower Requirement

The ultimate objective for implementation of the program at operational level will be through the current Government structure of the Health Department. Additional management staff will not be required as it is proposed to be implemented with integrated approach with MNCH & LHWS Program. For all practical purpose three programs will be implemented under one umbrella. Staff employed for the management of the program through development budget will be shifted to recurrent side as part of structural reforms at Provincial and District levels.

The program management and manpower requirement is discussed in detail in the relevant section. The brief roles and responsibilities, qualification and remuneration are also discussed in the section of job descriptions.

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PREPARED BY:

Dr. AkhtarRashidProvincial Coordinator

Lady Health Workers’ ProgrammeDepartment of Health, Punjab

CHECKED BY:

Mr. FarasatIqbalProject Director

Health Sector Reform ProgrammeDepartment of Health, Punjab

Dr. ZafarIkramProvincial Programme Manager

MNCH ProgrammeDepartment of Health, Punjab

Dr.NisarCheemaDirector General Health

ServicesDepartment of Health, Punjab

APPROVED BY:

Capt (R) ArifNadeemSecretary Health

Department of Health, Punjab

Dated: 25-02-2013

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LOGICAL FRAMEWORK:

PROGRAM NAME Integrated Reproductive Maternal Newborn & Child Health &Nutrition Program

GOAL Indicator Baseline Milestone 12013-2014

Milestone 22014-15

Milestone 32015-16

Target 2017 Assumptions

To improve maternal, new-born and child health in Punjab especially of the poor thereby making progress towards achieving health related MDGs

Maternal Mortality Ratio (MMR)

227/100,000 lb – PDHS 2006-07

190/100,000 180 170 140/100,000 lb

SourcePakistan Demographic & Health Survey (PDHS)

Indicator Baseline Milestone 12013-2014

Milestone 22014-15

Milestone 32015-16

Target 2017

Neonatal Mortality Rate (NMR)

58/1,000 lb (PDHS 2006-07)

52 50 48 44

SourcePakistan Demographic & Health Survey (PDHS)


Milestone 22014-15

Milestone 32015-16

Target 2017

Infant Mortality Rate (IMR)

82/1,000 lb –MICS 2011

80 75 70 40

SourcePakistan Demographic & Health Survey (PDHS) / MICS


Milestone 22014-15

Milestone 32015-16

Target 2017

Under 5 Mortality Rate

97/1000 lb – PDHS 2006-07

104/1000 lb - MICS 2011

102 98 92 52/1,000 lb

Source

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Multiple Indicator Cluster Survey (MICS), Pakistan Demographic & Health Survey (PDHS)Indicator Baseline Milestone 1

2013-2014Milestone 22014-15

Milestone 32015-16

Target 2017

Total Fertility Rate (TFR)

3.9 – PDHS 06-07

3.6 - MICS 2011

3.5 3.4 3.3 3.2

SourceMultiple Indicator Cluster Survey (MICS), Pakistan Demographic & Health Survey (PDHS)


Milestone 22014-15

Milestone 32015-16

Target 2017

Stunting (moderate & severe) prevalence

36% - MICS 2011 35 34 33 32%SourceMultiple Indicator Cluster Survey (MICS)

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PURPOSE Indicator Baseline Milestone 12013-2014

Milestone 22014-15

Milestone 32015-16


To improve access to quality Reproductive health, Child health and Nutrition services especially for the poor

Contraceptive Prevalence rate (Modern methods)

23% – MICS 2011 26% 30% 35% 35% Macro-economic situation (both at national & provincial level) improves and economic growth accelerates

Political and security situation in the country improves

No major humanitarian disaster in the province

Institutional risks related to devolution and formation of new administrative areas are appropriately mitigated

Improvement in literacy rate

Health, Population and Nutrition programs, projects and

SourceMultiple Indicator Cluster Survey (MICS), Pakistan Demographic & Health Survey (PDHS)


Milestone 22014-15

Milestone 32015-16

Target 2017

Skilled Birth Attendance (SBA)

46% (37R, 64U) - PSLM 10/11

59% - MICS 2011

65% 75% 80% 75% (72R, 80U)

SourceMultiple Indicator Cluster Survey (MICS), Pakistan Social & Living Standard Measurement Survey (PSLM)


Milestone 22014-15

Milestone 32015-16

Target 2017

Institutional Deliveries 43% (34R, 63U) - PSLM 10/11

53% - MICS 2011

56% 60% 70% 75% (70R,80U)



Milestone 22014-15

Milestone 32015-16

Target 2017

Fully Immunized Children

34.6%-(Fully immunized with Measles 2)MICS 2011

45% 55% 70% 80%


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interventions are harmonized provincial and district level


Milestone 22014-15

Milestone 32015-16

Target 2017

Per cent of Children suffering from diarrhea treated with ORS and Zinc

NA 15% 25% 35% 40%SourceMultiple Indicator Cluster Survey (MICS), Pakistan Social & Living Standard Measurement Survey (PSLM)


Milestone 22014-15

Milestone 32015-16

Target 2017

Percent of registered children, in the 12 priority districts, successfully treated for severe acute malnutrition (with complications).

20% 40% 50% 60% 75%SourceMultiple Indicator Cluster Survey (MICS) 2011


Milestone 22014-15

Milestone 32015-16

Target 2017

Percentage of identified SAM children enrolled for treatment in 12 priority districts

- 50% 55% 60% 80%SourceProgram Database


Milestone 22014-15

Milestone 32015-16

Target 2017

Percentage of registered pregnant women receiving iron folic acid tablets

20 30% 40% 50% 60% in 2016SourceNational Nutrition Survey (NNS)

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Milestone 22014-15

Milestone 32015-16

Target 2017

No of districts implementing MNCH related Minimum Services Delivery Standards

18 districts 30 districts All districts MSDS reviewed All districts implementing MNCH related MSDS

SourceThird party assessments

INPUTS (HR) FTEs 48,000 LHWs deployed9,000 CMWs trainedRequired staff in health facilities (BHUs, RHCs, THQ & DHQ hospitalsRequired Management staff at provincial and district level

OUTPUT 1 Indicator Baseline Milestone 12013-2014

Milestone 22014-15

Milestone 32015-16


Improved delivery of maternal, child, family planning and nutrition services under Essential Package of Health Services

Average number of FP clients per month per primary and secondary level facilities

Average 60FP clients per month per facility in 2011 – DHIS

Average 80FP clients per month per facility




Increased and sustained political commitment to reproductive, maternal and child health service delivery reflect increased government investment in health sector

Funding support from federal government continues/ enhanced and fiduciary risks mitigated

Provincial funding and

SourceDistrict Health Information System (DHIS)


Milestone 22014-15

Milestone 32015-16

Target 2017

Average FP users per month per LHW catchment population

Average 50 FP users per month per LHW catchment population – LHW-MIS 2011

Average 53 FP users per month per LHW catchment population




SourceProgram Management Information System

27

donor assistance is available to fill the funding gaps

Appropriate skilled human resource (particularly female) available/ deployed especially in hard to reach/ remote areas

Devolution of powers does not have negative impact on service delivery

Effective coordination between IntegratedPrograms and effective joint coordination and supervision mechanism.

Regular and un-interrupted supply of essential medicines and contraceptives to districts.

Districts ownership to the program and reforms.


Milestone 22014-15

Milestone 32015-16

Target 2017

DHQ, THQ hospitals and RHCs providing Comprehensive EmONC services

28/36 DHQ and 40/84 THQ hospitals and Nil/291 RHCs providing 24/7 Comprehensive EmONC services in 2011 – HFA 2011

32/36 DHQ and 50/84 THQ hospitals and 10/291 RHCs providing 24/7 Comprehensive EmONC services




SourceHealth Facility Assessment Surveys, Program Management Information System


Milestone 22014-15

Milestone 32015-16

Target 2017

RHCs and BHUs providing Basic EmONC services (24/7)

150/291 RHCs and 88/2454 BHUs providing 24/7 Basic EmONC services in 2011

200/291 RHCs and 300/2454 BHUs providing 24/7 Basic EmONC services

(Served on)

250/291 RHCs and 500/2454 BHUs providing 24/7 Basic EmONC services

275/291 RHCs and700/2454 BHUs providing 24/7 Basic EmONC services

All RHCs and 425/2454 BHUs providing 24/7 Basic EmONC services

SourceProgram Database


Milestone 22014-15

Milestone 32015-16

Target 2017

Establishment of Stabilization Centers (SC) for Nutrition

5 12 in priority districts

30 (21 in priority

districts)

36 36


28


Milestone 22014-15

Milestone 32015-16

Target 2017

Establishment of OTP sites at 30% BHUs and all RHCs

111 OTP sites established

Establishment of OTP sites in 179/291 RHCs and 438/2466 BHUs in 12 priority Districts and 9 peri-urban areas of mega-cities

Establishment of OTP sites in 228/291 RHCs and 572/2466 BHUs in 30 Districts

Establishment of OTP sites in 291/291 RHCs and 640/2466 BHUs in 30 Districts



Milestone 22014-15

Milestone 32015-16

Target 2017

Exclusive breastfeeding till age of 6 months

22% 25% 30% 35% 40% in 2015

SourceMICS 2011


Milestone 22014-15

Milestone 32015-16

Target 2017

Early initiation of breastfeeding

15% 20% 30% 40% 50%SourceMICS 2011


Milestone 22014-15

Milestone 32015-16

Target 2017

Proportion of registered children 6-23 months fed in accordance with all three infant and young child feeding

NA 10% 20% 30% 40%SourceProgram Management Information System

29

(IYCF) practices (food diversity, feeding frequency, consumption of breast milk or milk)Indicator Baseline Milestone 1

2013-2014Milestone 22014-15

Milestone 32015-16

Target 2017

Iodized salt consumption

34% - MICS 2011 40% 46% 50% 50%SourceMultiple Indicator Cluster Survey (MICS)

Increased demand side interventions for Reproductive health, Child health and Nutrition services

% of mothers able to identify at least 2 danger signs in early childhood illness (e.g. Pneumonia)

7% of mothers able to identify at least 2 danger signs in childhood illness

20% of mothers able to identify at least 2 danger signs in childhood illness

25% of community members able to identify at least 2 danger signs in childhood illness

40% of community members able to identify at least 2 danger signs in childhood illness

50% of community members able to identify at least 2 danger signs in early childhood illness

Increased and sustained political commitment to reproductive, maternal and child health service delivery reflect increased government investment in demand side interventions

Human resources (particular women) required available, deployed and retained

Private sector facilitates the public sector in creating awareness and changing behaviors related with RCN

Effective coordination

SourceMultiple Indicator Cluster Survey (MICS)


Milestone 22014-15

Milestone 32015-16

Target 2017

% of mothers aware of at least two benefits of exclusive breast feeding

NA 30 35 40 50%SourceCommunity-based survey


Milestone 22014-15

Milestone 32015-16

Target 2017

% of district implementing awareness interventions during

NA 10% 40% 80% 100%SourceDistrict Communication Intervention reports

30

World Health Day, World Population Day, World Midwifery Days, World Child Day, Mother & Child

between program and projects for coordinated communication interventions

System of regular monitoring/ assessment functional


Milestone 22014-15

Milestone 32015-16

Target 2017

% of patients/ clients visiting health facilities who are very satisfied with provision of RCN services

20% very satisfied and 75% satisfied

35% 45% 55% 60% very satisfied patients/ clients

SourceHealth Facility Assessment Surveys 2011

31


Milestone 22014-15

Milestone 32015-16


Effective management of the Program at provincial and district level

Office of Integrated Implementation Unit established

- 100% 100% 100% Strong strategic leadership at provincial and district level reflected through performance of steering committee and DHMTs

Required competent health managers/ staff available and deployed at appropriate level

Macro-economic stability and availability of appropriate funds

Fiduciary and institutional risks appropriately mitigated

Effective system of performance of managers functional

SourceAdministrative data


Milestone 22014-15

Milestone 32015-16

Target 2017

No of Health Care providers Trained on Training Package (IYCF & HTSP)

- 1 LHV at every health facility and all LHWs and LHS in 7 Districts

1 LHV at every health facility and all LHWs and LHS in 12 Districts

1 LHV at every health facility and all LHWs and LHS in all 36 Districts

Atleast 15,000 LHWs trained on Training Package

SourceAdministrative data


Milestone 22014-15

Milestone 32015-16

Target 2017

Days out of stock for contraceptive methods (minimum 4 at health facilities and CMW level and minimum 3 at LHW level), ORS, Zinc, Amoxicillin, Tab Iron/Folic acid/ B12 and Tab Paracetamol at all levels.

100% in 2011 – HFA 2011

50% 30% 25% 10%

SourceHealth Facility Assessments, District Health Information System (DHIS)

Indicator Baseline Milestone 1 Milestone 2 Milestone 3 Target 201732

2013-20142014-15 2015-16

Days out of stock for Inj Magnesium Sulphate, Injection Oxytocin, Inj Ampicillin and Mesoprostol at health facility level

100% in 2011 –HFA 2011

50% 30% 20% 5%

SourceHealth Facility Assessments, Program database


Milestone 22014-15

Milestone 32015-16

Target 2017

e-monitoring and complaint mechanism established and made functional

Under piloting 7 districts 12 districts All districts Accountability and complaint mechanism established in all districts

SourceProgress Reports

33


Milestone 22013-14

Milestone 32014-15


Improved decision making through high quality information and research

Performance review of districts organized at provincial level using information data

Quarterly review held

Quality review meetings

Annual performance review

Annual District performance disseminated through DOH website










Strong commitment at provincial level to integrate health information systems with strong leadership

Availability of effective organizations able to produce quality evidence and influencing policies

Effective strategic partnership among development partners and the government to generate demand and provision of quality RCN services

Security situation conducive to research and advocacy in all provinces/ areas.

SourceMinutes


Milestone 22014-15

Milestone 32015-16

Target 2017

Improved quality of data

LQAS in DHIS only Internal validation of data

External validation review

Internal validation of data

Regular validation data

SourceValidation results


Milestone 22014-15

Milestone 32015-16

Target 2017

Verbal autopsy system functional for maternal deaths

Irregular implementation

10 districts having functional system

25 districts having functional system

All districts having functional system

All districts having functional Verbal autopsy system

Annual provincial report

34

Annual provincial report published



published

SourceVerbal autopsy reports

INPUTS (Rs.) Total CostRs. 9814.171 Millions

Total Rs. 9814.171 Millions

INPUTS (HR) FTEs

35

PROGRAM DESCRIPTION

Introduction and Rationale

The global community under auspices of United Nations assembled in the year 2000 to identify and propose targets and indictors to improve the lives of people everywhere. At the culmination of this “Millennium Summit”, a joint charter for improving lives of people, especially marginalized segments including the poor, disabled and women and children was announced. This charter outlined eight goals/action points addressing poverty, health, food security and environment; these goals are referred to as Millennium Development Goals (MDGs), with two goals, MDGs 4 and 5 specifically addressing health of women and children. Millennium Development Goals thus define a contemporary framework for gauging success of a country/region toward achieving development and uplift for its people.

Current Health Situation

Pakistan houses the world’s seventh largest population, currently estimated at 180 million people2. Punjab is the most populated province; it is also considered an affluent region of the country. This is largely attributed to the rich agricultural base of the region, which remains the main source of employment for inhabitants of the province.

Despite relative affluence, analysis reveals a dismal picture of woman and child health in Punjab. The province houses an estimated population of 92 million3, growing at an annual rate of 1.9 percent. Total Fertility Rate (TFR) is a health indicator reflecting a woman’s reproductive burden and risk of related morbidity and mortality associated with child birth; Punjabs’ TFR is currently reported at 3.64.

Skilled Birth Attendant (SBA)5 play a crucial role in protecting lives of mothers and newborns by ensuring clean and medically sound delivery practices, early identification and prompt management of complications6. According to MICS 2011, 74% of women in Punjab receive only one Antenatal Care (ANC) visit from SBAs during pregnancy; this reflects missed opportunities for identifying and managing high risk pregnancies. Additionally, with more than 41%7of births attended by unskilled attendants, the risk of delivery-related complications among mother and child are compounded. The MMR for Punjab (227 per 100,000 live births8) is lower as compared to other regions of the country; however, it is still high when compared with neighboring countries of South Asia. The High TFR and MMR in the province are also indicative of the fact

2 State of the World’s Children, UNICEF, 20113 www.statepak.gov.pk4 MICS 20115 Healthcare professional trained in pregnancy, delivery and newborn care

6 http://wbln0018.worldbank.org/news/pressrelease.nsf.7MICS 20118 The Pakistan Demographic and Health Survey 2006-07

36

that the experience of pregnancy and other reproductive health related aspects among women in Punjab predispose them to a high risk of morbidity and mortality.

Adequate nutrition influences the health status of women and children to a great extent. The prevalence of anemia is significantly high amongst pregnant women9; this coupled with low caloric intake during pregnancy has a negative impact on the growth of the foetus, resulting in nearly 28% of births being low weight. Globally 26% of children under the age of five years are moderately or severely malnourished10. The prevalence of underweight, stunted and wasted children is higher in South-eastern Asia as compared to other regions of the world, in Pakistan, 37% of children under the age of five years are underweight for age, among which 12% suffer from severe malnutrition; 37% are stunted and 13% suffer from wasting11. In Punjab every third child below the age of five is estimated (34%) to be underweight. Women and children in Punjab also suffer from high rates of deficiencies in essential vitamins and minerals.

To understand the health status of children (those less than 5 years of age), the Infant Mortality Rate (IMR) and Under 5 Mortality Rate (U5MR) are considered to be the key indicators for assessing the health in this age group in a population. The infant mortality rate is 82 per 1,000 live births for Pakistan and 77 for Punjab as compared to 41 in Indonesia and 15 in Sri Lanka12.These indicators reflect the rates of mortality among those less than one year and those less than 5 years of age respectively. In Punjab, the IMR and U5MR have steadily declined since 1990; however, the rate of decline over the last fifteen years has been considerably slower than its South Asian neighbors. The U5MR for the Punjab is estimated to be 94 per 1,000 live births. These translate as one in every thirteen children born in the province does not survive till the first birthday, while one in eleven newborns does not make it to the fifth birthday.

This data reflect the abysmal conditions of health among the more vulnerable segments of the population that include the women and children of the province. This snapshot of health status indicates that Punjab is far from achieving the health related MDG targets. Such health indicators on the part of the provincial health department also warrant a comprehensive and effective plan of action on a war footing, to improve the existing deplorable health conditions and indictors for the women and children.

Keeping in view the state of health conditions among women and children of the province, the Government of Punjab is currently implementing a wide range of initiatives focused towards the health of women and children. These include the Nutrition Program for Mothers and Children, Chief Minister’s Health Initiative for Attainment & Realization of MDGs (CHARM), National Program for Family Planning and Primary Health Care (i.e. the Lady Health Workers Program), Maternal Newborn and Child Health Program (MNCH), and the People’s Primary Health Care Initiative.

9 National Nutritional Survey, Government of Pakistan, 2001-2;10 State of the World Children, UNICEF, 2006;11 UNICEF - Global Database on Child Malnutrition http://www.childinfo.org/areas/malnutrition/underweight.php12 World Development Indicators, 2002;

37

http://www.childinfo.org/areas/malnutrition/underweight.php

In their respective domains, all of these initiatives focus on various dimensions of health, healthcare and services use among women and children. The presence of multiple programs which function in silos leads to low levels of integration at the basic health facility and the community level. It is proposed that LHW Program, MNCH Program and Nutrition Program may be implemented under a single management structure.

The Government of Punjab envisages to achieve measurable impact on MDGs through improving the performance of health management system; improving access and quality of trained manpower, enhancing medicines and technology in health services system, reviewing existing policy framework; improving infrastructure; creating health mass awareness; introducing public private partnerships and broadening health financing mechanisms.

Introduction & rationale to upscale CHARM pilot project

In the month of July & August 2010, floods affected millions of people in Pakistan. Unfortunately, the flood affected districts in Punjab were those where indicators of maternal, newborn and child health were not good even before they became flood-hit. The situation would have been aggravated if extra ordinary measures were not taken to improve reproductive health services in these areas. Taking into this consideration the entire situation, there was an urgent need to implement a comprehensive strategy at community and health facility level in order to prevent and reduce excess maternal and newborns mortality and morbidity.

The Government of Punjab, with financial and technical support from UNICEF and UNFPA, started provision of 24/7 EmONC services and ensured primary health care services during the day time at BHUs and RHCs of the flood affected districts. By December 2011, 81 BHUs and 60 RHCs were equipped and started functioning round the clock, providing Basic EmONC services and reporting regularly on a monthly basis. The progress shown by converting almost nonfunctional BHUs to round the clock maternal and child care centers is remarkable and community feedback to these services is extremely positive. BHUs where not more than one delivery was conducted every month now boast of an average of over 40 verifiable deliveries per BHU. A strong referral system has also been established for referral of high risk and complicated pregnancies from house hold to basic health facility and onward to district hospitals to avert mortality and morbidity. 38 ambulances have been provided at the BHUs to provide emergency transport services to pregnant women from community to higher centers of care; these pick and drop pregnant women from the community to health facility on a phone call and in case of complications and high risk pregnancies, women are transferred to DHQ/ Tertiary care hospitals without any delay.

By December 2012, 24/7 services are being provided at 89 BHUs and 60 RHCs in seven districts. Significant and sustained improvements in service provision and utilisation of services have been recorded at these facilities compared to baseline and provincial average monthly utilization.

38

ANC Delivery PNC

251 2

43

6 9

172

40

76

Baseline (Nov 2010) Provincial Average (Aug-2012) CHARM Average (Aug 2012)

It is a common observation that the existing management system at district level has failed in delivering the desired outputs expected out of it. Thus, an innovative approach for management and supervision of the health services using e-monitoring and e-reporting is being implemented and tested, resultantly absentee rate of staff even at remotest facility is nearly zero percent. Thus, an innovative approach for service delivery with e-tech management system and incentivizing staff is tested and showed unbelievable results.

The cost – benefit analysis has shown that minor interventions done with dedication can lead to unbelievable performance. Rather than creating new vertical structures, strengthening of the existing systems and covering the gaps is the key to success of CHARM Program. Up-scaling the CHARM model across other districts of Punjab would be a major leap towards achievement of MDGs 4 and 5.

The manifold improvement in service uptake is due to an innovative implementation model, major factors are pay for performance, provision of free of charge ambulance services and use of E-monitoring and reporting system. Looking at the successful implementation and progress

39

of the pilot project in the seven districts, it is imperative to scale up the venture and spread it across the province, including all the 36 districts of Punjab. It is proposed to scale up the initiatives across the province in phased manner. In year 2013 initially in 16 districts at 300 BHUs , then 200 BHUs in 2014, then 200 BHUs in 2015 and almost all RHCs will be included in this initiative to ensure provision of services to the vast majority of the rural areas. The selection of BHUs will be on the basis of geographical distances, ensuring maximum coverage in each district.

40

PROGRAM COMPONENTS AND DESCRIPTION

The proposed program aims at reducing newborn, infant, child mortality and maternal mortality in line with Government’s commitment of achieving health related MDGs. The program has seven main strategic components:

1. Improving Basic and Comprehensive EmONC services at primary and secondary level health care facilities

2. Mainstreaming family planning services and interventions as a maternal health improvement strategy

3. Prevention and management of malnutrition by implementing Pakistan Integrated Nutrition Strategy

4. Strengthening of community-based outreach services focusing on PHC, MNCH, RH/FP and Nutrition through improved performance of LHWs and CMWs

5. Strengthening linkages between community outreach health workers with health facilities

6. Establishing e-monitoring and e-reporting system and a web-based program MIS with linkages to DHIS

7. Strengthening linkages between community and health facilities

Each program component is discussed in detail in the following sections of this document.

1. IMPROVING BASIC AND COMPREHENSIVE EMONC SERVICES AT PRIMARY AND SECONDARY LEVEL HEALTH CARE FACILITIES

Direct obstetric causes such as postpartum hemorrhage, sepsis and complications of abortion are responsible for close to 50% of maternal deaths. A majority of these maternal and early newborn deaths can be avoided by provision of prenatal, delivery, postnatal and newborn care services within reasonable travel distance& travel time. According to UN process Indicator for a population of 500,000, there must be 4 Basic EmONC facilities and one Comprehensive EmONC health facility. According to an estimated figure, 85 % of the pregnancies end up normally while 15 % of them undergo complications. It is imperative that every district should be mapped accordingly taking into account the problem of scattered population and hard terrain (travel time) at various places and in those cases within a travel time of one hour there must be a Comprehensive EmONC health facility apart from the population size.

Under this program all DHQs and 70/84 THQs and selected RHCs (36/297) would be equipped/upgraded to provide Comprehensive EmONC services, while all remaining RHCs and 700/2454 BHUs would provide Basic EmONC services.

41

Key activities:

a) Availability of minimum agreed staff at the identified health facilities by the year 2013 for provision of 24/7 Basic and Comprehensive EmONC services

b) Availability of logistics, equipment, medicines and supplies for all HF designated for provision of 24/7 Basic and Comprehensive EmONC services

c) Strengthening of neonatal units at the Comprehensive EmONC health Facilitiesd) Implementation of MSDS and SOPs relevant to provision of Basic and Comprehensive

EmONC services at the health facilities like protocols for antenatal, normal delivery, surgical procedure and postnatal procedures

e) Training &Capacity building of staff at Basic and Comprehensive EmONC facilities on Basic and Comprehensive EmONC, IYCF and Nutrition, IMNCI, ENC, HTSP/FP and Infection Prevention and Control

f) Development and implementation of transport services, including Provision of ambulances at the 24/7 Basic EmONC facilities Ensure availability of POL and other logistics for transport Provision of drivers for ambulances

g) Strengthening of health facilities for the provision of Basic and Comprehensive EmONC services Provision of conducive environment for female HCPs by provision of separate

waiting area, wash room and ensuring safetyh) Monitoring and supervision of Health Facilities for the provision of Basic and

Comprehensive EmONC services in terms of accessibility, availability and quality of EmONC services

Preventive and Basic EmONC Services at BHUs

The course of nature gives adequate time of nine months to the woman, family and the healthcare delivery system to timely identify potential risks to mother and child during this normal physiological process, to correct them and to plan for the delivery accordingly. The network of LHWs, CMWs and BHUs working as a team in this program will be enabled to effectively perform these functions through provision of regular antenatal care and advice on nutrition and supplements.

The Basic EmONC services include but are not limited to: intravenous and intra-muscular administration of medicines such as antibiotics, oxytocin and anticonvulsants; assisted vaginal delivery; manual removal of placenta; manual removal of retained products of an abortion or miscarriage; and stabilization, referral and transferring the patients of obstetric emergencies not managed at the basic level to referral facility.

42

In terms of newborn care, the required services at the basic EmONC level include resuscitation, management of neonatal infection, very low birth weight infants, complications of birth asphyxia and severe neonatal jaundice. Furthermore, skills and supplies for intravenous fluid therapy, thermal care including radiant warmers, Kangaroo mother care, oxygen supply, parenteral antibiotics, intra-gastric feeding, oral feeding using alternative methods to breast feeding and breast feeding support.

Under this program preventive and basic EmONC services will be provided at a total of 700 BHUs (28%) in all 36 districts but with phased manner, to start with 16 districts having poor health indicators will be selected for implementation of a specifically designed less resource intensive package, replicating the CHARM model.

Selection of BHUs for Basic EmONC Services

The selection of 28% BHUs (700 BHUs) will be done on the basis of geographical spread, distance from existing basic and comprehensive EmONC facilities, accessible by the community and secure for female staff and patients during evening and night rotations. The notified Provincial Management Committee will determine selection of BHUs for program implementation. Table 1 below shows program implementation in a phased manner.

43

44

Year Wise Implementation of Phasing 24/7 EmONC facilities

Phase 1Sr. NO District DHQ THQ RHC Total

BHU24/7 BHU

SBA Rate

Implementation of 24/7 in Phasing in

2013-14

1 Rajanpur 1 2 6 31 15 172 DG Khan 1 1 9 52 16 263 Muzafargarh 1 2 13 71 21 364 Bahawalpur 1 4 10 73 22 375 Bahawalnagar 1 4 10 103 31 426 Rahim Yar Khan 0 3 19 104 31 447 Khanewal 1 3 4 82 23 498 Layyah 1 3 4 40 12 499 Bhakkar 1 3 3 40 10 50

10 Narowal 1 1 7 56 16 5511 Pakpatan 1 1 4 53 15 5712 Hafizabad 1 1 5 32 11 7013 Sargodha 1 4 14 122 30 6114 Mianwali 1 1 9 40 11 6515 Multan 0 2 7 77 18 6516 Jhung 1 2 9 58 16 52

Total 14 38 133 1064 300

Phase 2 Sr. NO District DHQ THQ RHC Total

BHU24/7 BHU

SBA Rate


2014-15

1 Faisalabad 0 5 12 168 47 702 Lahore 1 2 6 36 10 823 Rawalpinidi 0 4 10 98 27 794 Sialkot 2 3 7 88 25 725 Khushab 1 3 5 41 11 616 Chakwal 1 3 9 65 19 757 Vehari 1 2 14 74 21 508 T. T. Singh 1 2 6 66 18 589 Sahiwal 1 2 10 76 21 26

Total 8 26 79 712 200

Phase 3 Sr. NO District DHQ THQ RHC Total

BHU24/7 BHU

SBA Rate


2015-16

1 Attock 1 5 5 60 17 612 Chiniot 1 2 3 36 10 583 Gujrat 1 1 10 90 26 734 Jhang 1 2 9 58 17 525 Jhelum 1 2 5 45 13 806 Kasur 1 2 12 82 24 537 Lodhran 1 2 4 48 14 438 Naknaka 1 0 7 48 14 609 Okara 2 2 10 96 28 51

10 Sheikhupura 1 1 9 79 23 6511 M. B. Din 1 1 9 49 14 52

Total 12 20 83 691 200Grand Total 34 84 295 2467 700

Human Resource Requirement &Staff Incentives at BHU

The already appointed staff at BHUs i.e., health officer, LHV, midwife and dispenser will be given financial incentives to ensure 24/7 preventive and basic EmONC services. In addition, to ensure basic EmONC services on 24/7 basis, skilled birth attendants, aya, Guards and driver will be appointed on contract basis to complement the efforts of existing facility staff at selected BHUs. It will be ensured that each health facility has at least 4 skilled birth attendants deployed, one for each of the three shifts and one as a reliever. In case of overburdened health facilities, a fifth SBA maybe appointed for additional support during the morning shift only.

Equipment & Supplies

The equipment and supplies required to ensure preventive and refined basic EmONC package include contraceptives, medicines, IMNCI package of medicines, basic newborn care kit, clean delivery kits, and other basic equipment.

Physical Infrastructure

At BHUs no additional construction will be required as most of the BHUs are already renovated under health sector reform program in Punjab. However, minor repairs may be required for delivery rooms, and LHV and midwife residences.

Basic & Comprehensive EmONC Services at RHCs

This program proposes to ensure complete package of basic EmONC services at all the RHCs and comprehensive EmONC at 36 RHCs (15%) in the province.

Basic EmONC at RHCs

The program proposes to provide basic EmONC services at each of 297 RHC on 24/7 basis. This will be done by ensuring the presence of existing HR. The 162 RHCs that come within the 20 low indicator districts may be provided temporary support in the form of missing equipment and/or supplies, etc. on a need basis as identified by the DHMT. However, efforts will be made to ensure the availability of services from the existing budget and resources allocated for the RHCs by the Department of Health through the DHMT and the PHSRP.

Human Resource Requirement

The existing staff will be trained in provision of EmONC services. The requirement of additional staff may be fulfilled through temporary contract on a need basis.


The provision of basic EmONC services in the facility requires a functioning labor room/operation theater and indoor ward. The RHCs may be provided with funds for minor repairs but not for new construction. Most of the RHCs already have provision for 20 beds for treatment of indoor patients, an operation theater, laboratory and X-ray facility.

45

Equipment and Supplies

The equipment and supplies required to ensure basic EmONC package at RHCs include laboratory support and equipment for a minor operation theatre. The supplies include contraceptives, medicines, IMNCI package of medicines, basic newborn care kit, clean delivery kits, and other basic equipment.

Comprehensive EmONC at Selected RHCs

The Comprehensive EmONC Services include all of the services provided at the basic level, in addition to cesarean section, blood transfusion services and newborn special care. In case of acute obstetric emergency, the case may be referred to DHQ hospital.

Human Resource Requirement and Strategy

In addition to staff required to ensure basic EmONC services at RHCs, some additional staff will be required to provide comprehensive EmONC services at selected RHCs or existing staff may be trained.

The program proposes following ways to engage professionals in provision of comprehensive EmONC services at selected RHCs:

i. Engaging public sector specialists on need basis: The specialists working at THQ and DHQ hospitals may be called on need basis on as and when required. They may be compensated on a case to case basis on already agreed upon terms and conditions.

ii. Engaging private sector specialists on need basis: The specialists practicing nearby may be contracted to provide services on as and when required basis on mutually agreed upon terms and conditions. They shall be paid on market rates for their services.

iii. Appointment of postgraduate trainees at RHCs, THQs and DHQs on rotation basis.

iv. The attachment of RHC staff for hands on training in gynecology, anesthesia, pediatrics and neonatology.

The program will ensure services of specialists through implementing a mix of these strategies or developing another more workable strategy for the purpose.

The lab technician will be trained in blood transfusion techniques and relevant equipment will be made available at each of 36 RHCs.


The equipment and supplies required to ensure comprehensive EmONC package at RHCs include laboratory support, blood transfusion services, and equipment for operation theatre and a functioning ambulance/vehicle. The supplies include contraceptives, medicines, IMNCI package of medicines, newborn care kit, clean delivery kits, and other basic equipment.

46


The provision of comprehensive EmONC services in the facility requires a functional labor room/operation theater and inpatient ward. The RHCs will be provided with funds for minor repairs and not for new construction. Most of the RHCs have provision for 20 beds for treatment of indoor patients, an operation theater, laboratory and X-ray facility.

At each of these RHCs beds will be allocated for EmONC services in the inpatient wards.

Comprehensive EmONC Services at THQ and DHQ Hospitals

This program proposes that at each of 80 THQ and 35 DHQ hospitals in Punjab, complete package of comprehensive EmONC services shall be offered. At THQs and DHQs the referrals from BHUs and RHCs as well as from the field will be catered for.

Human Resource Requirement and Strategy

In order to ensure comprehensive EmONC services at THQ and DHQ hospitals, no additional staff will be required. However the gynecologist, anesthetist and pediatrician may not be available at all the THQs and DHQs in the province.

The program proposes similar ways to engage these specialists as are suggested above under human resource requirement for RHCs. The program will ensure services of specialists through implementing a mix of these strategies or developing other workable strategies for the purpose.


The hospitals in Punjab have a majority of equipment available for EmONC services therefore only some additional equipment will be provided to these hospitals. The THQ and DHQ hospitals will be dealt with on a case to case basis. It is also proposed to provide these hospitals with incinerators for adequate disposal of hospital wastes through the Hepatitis control program. However for chemical disposal of hospital waste the recurrent costs shall be met from the regular budget of the hospital. All hospitals will need to be equipped with laboratory support, X-ray, Blood Bank, Operation Theatre and Anesthesia facilities. The list of equipment (Table 8) covers all the essential equipment for DHQ/THQ hospitals for comprehensive EmONC services. It is anticipated that majority of the THQ and DHQ hospitals would not require complete set of equipment, as it is provided through regular provincial budget and other sources.

Similarly, the hospitals will conduct a review of available equipment in comparison with the list of equipment proposed and categorize it into three parts i.e., available and functional, available but repairable, and not functional/available and required.

It is envisaged that this exercise should not take more than three months to complete and the detailed compilation of this information should be available with the district program

47

management unit and then with the program management unit within six months of launch of the program.

The equipment will be provided under warranty and service contract will be made with the supplier to perform at least one maintenance visit every four-six months. Provision has been made for service contracts for electrical equipment.


The infrastructure at the THQ and DHQ hospitals has sufficient capacity to enable provision of EmONC services. These facilities have recently undergone repairs therefore it is anticipated that immediate repairs will not be required. However the need for minor repairs and maintenance may be carried out from District Government funds.

48

Table 2 List of equipment for DHQ and hospitals providing comprehensive EmONC servicesPediatric Ward Gynae/Obst. Ward Items Pediatric Nursery

Medical equipment General Equipment Neonatal Resuscitation

Suction machine Air conditioner Mucus extractor disposable

Infant BP apparatus (Cuff 2.5 cm) Cabinet Instrument large Infant face mask (2 different sizes-each)

Stethoscope Pediatric Littman type Fowler bed (Iron ) Infant ambo bag

Nebulizer Refrigerator 10 cubit Suction catheter Ch10 &12

Oxygen cylinder complete Screen folding complete Infant laryngoscope

Glucometer Weight machine adult Endotracheal tubes no. 3.5

Infusion pump Medical Equipment Suction apparatus:

Ophthalmoscope Artery forceps 7 inch Miscellaneous equipment

Emergency medicine trolley B P Apparatus mercury – Desk type Infant Incubators

Pulse oxymeter Dissecting forceps plain 7 inch Phototherapy unit

Lumber puncture Kit Fetal Monitor Baby Resuscitation Kit

Disposable syringe cutter Infant B.P apparatus& weight machine Disposable oxygen mask

Operation Theatre Disposable syringe cutter Baby cot ē heating facility

Perineal/Vaginal/Cervical Repair Furniture Baby warmer

Sponge forceps Baby Cot Infant BP apparatus (Cuff 2.5 cm)

Needle holder Labour Room UPS power supply system

Stitch scissors General Equipment Air conditioner ē heating system

Dissecting forceps, toothed UPS power supply unit Room thermometer

Sim's speculum large& medium Basic Equipment Disposable syringe cutter

Vacuum Extraction or Forceps Delivery Infant weight machine Baby cot

Vacuum extractor Fetal stethoscope Steam inhaler

Obstetric forceps Electric instrument sterilizer 12 x 6 Laboratory

Obstetric Laparotomy/Caesarean Section Jar for forceps General Equipment

Rectangular instrument tray ē lids Spring type dressing forceps (ss) Refrigerator 10 cbft

Towel clips Insertion and Removal of IUD Air conditioner

Sponge forceps, 22.5 cm Sim's Speculum right angle, small, medium Miscellaneous equipment

Straight artery forceps, 16 cm Sim's Speculum right angle, large Incubator

Uterine hemostasis forceps, 20 cm Sponge forceps Spin Machine

Hysterectomy forceps, straight, 22.5 cm Long straight artery forceps Chemistry Analyzer

Mosquito forceps, 12.5 cm Uterine sound Water Distillation unit

Tissue forceps, 19 cm Vulsellum forceps Hematology analyzer

Needle holder, straight, 17.5 cm Scissors dissecting blunt pointed Computer System with UPS+Printer

Surgical knife handle& blades Normal Vaginal Delivery Furniture

Triangular point suture needles Artery forceps Steel Almirah large& Lab cabinet

Round-bodied needles No. 12, size 6 Blunt-ended scissors General Hospital Equipment

Abdominal retractors, Neonatal Resuscitation Defibrillator

Curved & straight operating scissors, Mucus extractor UPS power supply system

Anesthesia Infant face mask (2 different sizes) Computer system ē UPS& printer

Anesthetic face masks Infant ambo bag Electric Water Cooler ē water filter

Anesthesia Machine Suction catheter Ch10 &12 Power Generator 50 Kva (Diesel), or

Laryngoscopes Miscellaneous equipment OPD / Gynecologist office

Epidural sets ECG Machine General Equipment

Miscellaneous Equipment Portable Light ē rechargeable batteries (OT) Weight machine adult& infant

X-Ray illuminator Sterilizing Drum Screen folding complete

General &Gynae Instrument set Vacuum Extractor Ultrasound machine

Adult ambo bag and mask Pulse oxymeter Miscellaneous equipment

D & C instruments set C.T.G. machine Steam inhaler& nebulizer

Air conditioners Examination lamp

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Table3:Distribution of trainees by hospitalS

No Health Facility # Trainees

Total Trainees

1 RHC 2 5782 THQ Hospital 3 2403 DHQ Hospital 4 140

Total 958

Strengthen Specialized Services at RHCs, THQs and DHQs

The targets of MDGs and ensuring services to improve communities’ health will be hard to achieve if the specialized services, specifically in gynecology, anesthesia and neonatology, are not made available at health facilities which are set to providing comprehensive EmONC.

This program proposes following strategies to strengthen specialized services at RHCs, THQ and DHQ hospitals:

i. Attachment of doctors from RHC, THQ and DHQ hospitals at tertiary hospitals specifically for gynecology, anesthesia and neonatology training;

ii. Appointment of post graduate trainees at RHCs, THQ and DHQ hospitals for three-months on rotation basis through an institutionalized mechanism;

iii. Engaging private sector specialists in providing services on need basis at RHC, THQ and DHQ hospitals;

Each of these strategies is discussed in the following paragraphs.

Attachment of Doctors from RHCs, THQs &DHQs at Tertiary Hospitals

Keeping in view the paucity of avenues for practical training and an expected delay/ shortfall in finding the number of specialists required at the facilities providing comprehensive EmONC services, a short term proposed solution is to train the doctors already working at these facilities.

For each facility being setup for Comprehensive EmONC services, it is proposed that one to three woman medical officers may be trained in Obstetrics (C-section), two woman medical officers or medical officers in pediatrics/neonatology and one medical officers in anesthesia and one additional according to the need of the hospital. It is estimated that a total of 958 doctors will be trained (Table 3).

For facilities providing Basic EmONC services it is proposed to train two woman medical officers in obstetrics and one to two medical officers in pediatrics/neonatology. These trainings can be imparted by providing three months attachment at the nearest teaching hospital or at a DHQ hospital having a qualified specialist.

These trainees shall be entitled for an allowance of Rs 15,000 per month for the period of attachment. The lodging should be arranged by the program, preferably at doctors’ hostels, for the length of training period.

The trainer shall be entitled for an allowance of Rs. 40,000 per month for a group of 5-7 trainees. This means each trainer will receive an allowance of Rs. 120,000 for training 5-7

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doctors in their respective specialties for three months against minimum acceptable targets set for trainers.

The selection of doctors for this training program will be done by the respective hospital in consultation with district program management unit and EDO (H) and approved by provincial program management units. The minimum criteria shall include six months service at that hospital and a commitment to continue working after the training for at least 2 years. It is proposed that a mechanism should be developed and institutionalized with College of Physicians and Surgeons of Pakistan (CPSP) to recognize this period in regular PG training afterwards.

Each district program management unit (DMU) will figure out its requirements for staff and will make a yearly plan in coordination with EDO (H). The plan will be submitted to provincial program management unit (PMU). The PMU will consolidate district requirements and will arrange for training of doctors from the districts in coordination with health department and teaching hospitals. This component shall be operational within six months of commencement of the program.

Rotation of Post Graduate Students in Institutionalized Manner

In majority of the DHQ and THQ hospitals the specialists staff positions can be supplemented by appointment of post graduate (PG) students in specialties of gynecology, anesthesia and neonatology on a three-month rotation basis at these hospitals.The PG students will be given an additional incentive of Rs. 20,000 per month for working in addition to their regular remunerations.

It is proposed to develop institutionalized mechanism within the health system by the Government of Punjab with the CPSP to regularize this three-month rotational appointment as a compulsory part of the post graduate training during their third and fourth years of training.

At RHC, THQ and DHQ hospitals the PG trainees will be provided with decent accommodation from respective hospital resources. Each district program management unit (DMU) will figure out its requirements for specialist service and will make a yearly plan in coordination with EDO (H). The plan will be submitted to provincial program management unit (PMU). The PMU will consolidate district requirements and will arrange for appointment of PG trainees in coordination with health department and teaching hospitals. This program component shall be operational within one year of commencement of program.

Engaging Local Private Sector Specialists

In areas where specialists are practicing locally in the private sector they may be engaged to provide services at Government health facilities on need basis. The terms and conditions may be developed and finalized which will include a retainer fee and service fee.

For example if at a THQ anesthetist is not available however there is one practicing in the private sector S/he will be engaged to provide services at THQ on as and when required and

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priority basis. For these services s/he will be paid a retainer fee of Rs 20,000 per month so that his/her availability on priority basis could be ensured. In addition he will be paid a service fee on case to case basis for providing anesthetist services.

It is estimated that specialist services through private sector specialists will be required at 10% of total health facilities.

Each district program management unit (DMU) will figure out its requirements for specialist services through private sector and will make a yearly plan in coordination with EDO (H). The plan will be submitted to provincial program management unit (PMU). The PMU will consolidate district requirements and will arrange for appointment of private sector specialists in coordination with health department. This program component shall be operational within one year of commencement of program.

Establish Referral System

The establishment of a functional and efficient referral system is considered as the key to ensuring adequate access to healthcare delivery services for the program area population.

Under this program, the referral system will be established through creating functional links between ‘Household-Outreach staff-BHU-RHC-THQ-DHQ’ i.e., linking all health service providers and services operating at various levels of health care delivery system.

The Government of Punjab will notify the implementation of referral system and roles and responsibilities of health care providers at various levels of the service provision.

The referral system will essentially have four functional levels of referral system:

1. First Level: Household to CMW and BHU

2. Second Level: BHU to RHC and THQ Hospital

3. Third Level: RHC to THQ and DHQ Hospital; and

4. Fourth Level: THQ to DHQ and Tertiary Care Hospital

The functioning of these levels is described in detail in the following paragraphs.

First Level of Referral System – “Household – BHU”

At the household level, this program has community based staff members i.e., LHW, CMW and LHS. Each household is registered with the respective LHW as well as with the BHU. Each LHW is linked with CMW and the BHU. Moreover each CMW is linked with LHS and the BHU. Therefore each household is functionally connected with the BHU in case a referral is made by the LHW or CMW. The LHW, CMW and the BHU i.e., the primary functionaries of PHC system constitute the first level of referral system for the population residing within the catchment area of a BHU.

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In order to establish functional first level of referral system, the program will take the following essential steps:

1. Each LHW, being the first direct link between the health care delivery system and the household, will have a detailed knowledge of services being provided by the CMW of her area and the BHU. She will have a chart displayed at her health house showing this information. This chart will be modified with any change in services, even if that occurs for a short duration. For example if the LHV at BHU proceeds on leave for two months or has been transferred without any replacement or has resigned, the chart will be accordingly modified. Such changes will be timely conveyed to all LHS for onward transferring of this information to LHWs and CMWs.

2. The LHW will refer cases to CMW or BHU that are beyond her capacity on prescribed “LHW Referral Form”. She, for example, will refer pregnant women for antenatal, natal and postnatal care to CMWs;

3. On receiving a referral from the LHW, the CMW providing services will give feedback to LHW on the same referral form;

4. Similarly the health care provider at BHU, on receiving referrals from LHWs or CMWs, will provide feedback to respective LHW or CMW.

5. This communication between referring and referral facilities will be part of records at corresponding levels of the referral system.

Second Level of Referral System – “BHU – RHC & THQ”

The second level of referral system will be established between BHU and RHC/THQ level. The patients presented at or referred to BHU will be managed at that facility or will be referred to RHC or THQ depending upon the nature of requirement. The health care providers at BHU i.e., health officer, LHV, medical technicians and dispenser and health care providers at RHC and THQ constitute the second level of referral system.

In order to establish functional second level of referral system, the program will take the following essential steps:

1. The health care providers at BHU will have detailed knowledge of services being provided by the RHC and THQ hospital. Each BHU will have a chart displayed showing this important information. This chart will be modified with any change in services at RHC and THQ hospital, even if that occurs for a short duration. For example if a gynecologist deputed at RHC or working at THQ proceeds on leave for two months or has been transferred without any replacement or has resigned, the chart will be accordingly modified. Such changes will be timely conveyed to all concerned levels of health facilities;

2. The BHU will refer patients to RHC or THQ hospital that are beyond its capacity on prescribed “BHU Referral Form”;

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3. On receiving a referral from BHU, the health care providers at referral facility i.e., RHC or THQ after providing services will give feedback to the BHU on the same referral form.

4. This communication between referring and referral facilities will be part of records at the corresponding levels of the referral system.

Third Level of Referral System – “RHC – THQ& DHQ”

The third level of referral system will be established between RHC and THQ/DHQ level. The patients presented at or referred to RHC will be managed at that facility or will be referred to THQ or DHQ depending upon the nature of requirement. The health care providers at RHC i.e., health officer, woman medical officer, LHV, nurse, medical technician and dispenser and the health care providers at THQ and DHQ constitute the third level of referral system.

In order to establish functional third level of referral system, the program will take the following essential steps:

1. The health care providers at RHC will have detailed knowledge of services being provided by the THQ and DHQ hospitals. Each RHC will have a chart displayed showing this important information. This chart will be modified with any change in services that takes place at THQ and DHQ hospitals, even if that occurs for short duration. For example if a surgeon deputed at THQ or working at DHQ proceeds on leave for two months or has been transferred without any replacement or has resigned, the chart will be accordingly modified. Such changes will be timely conveyed to all concerned levels of health facilities;

2. The RHC will refer patients to THQ and DHQ hospitals that are beyond its capacity on prescribed “RHC Referral Form”. If that patient is already referred from BHU on BHU Referral Form, that will be attached to RHC referral form;

3. On receiving a referral from RHC, the health care providers at referral facility i.e., THQ and DHQ hospitals will provide feedback to RHC on the same referral form.

4. This communication between referring and referral facilities will be part of records at corresponding levels of the referral system.

Fourth Level of Referral System – “THQ – DHQ& Tertiary Care Hospital”

The fourth level of the referral system will be established between THQ and DHQ/Tertiary Care Hospital. The patients presented at or referred to THQ will be managed at that facility or will be referred to DHQ or Tertiary Care Hospital depending upon the nature of requirement. The health care providers at THQ and the health care providers at DHQ and Tertiary Care Hospital constitute the fourth level of referral system.

In order to establish functional fourth level of referral system, the program will take the following essential steps:

1. The health care providers at THQ will have detailed knowledge of services being provided by the DHQ and Tertiary Care Hospital. Each THQ will have a chart displayed on at least

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two places showing this important information. This chart will be modified with any change in services that takes place at DHQ or Tertiary Care Hospital, even if that occurs for short duration. For example if a neurosurgeon working at Tertiary Care Hospital proceeds on leave for two months or has been transferred without any replacement or has resigned, the chart will be accordingly modified. Such changes will be timely conveyed to all concerned levels of health facilities;

2. The THQ will refer all those patients to DHQ or Tertiary Care Hospital that are beyond its capacity on prescribed “THQ Referral Form”. If that patient is already referred from BHU and/or RHC on Referral Form, that/those will be attached to THQ referral form;

3. The DHQ will refer all those patients to Tertiary Care Hospital that are beyond its capacity on prescribed “DHQ Referral Form”. If that patient is already referred from BHU, RHC and/or THQ on Referral Form, that/those will be attached to DHQ referral form;

4. On receiving a referral from THQ, the health care providers at referral facility i.e., DHQ and Tertiary Care Hospital will provide feedback to referring facility on the same referral form.

5. This communications between referring and referral facilities will be part of records at corresponding levels of the referral system.

Performance Incentives

Honorarium/bonus will be admissible to the Officers and support staff of the program on recommendations of the Steering Committee. This will create a sense of competition and aid in effective implementation of the program strategies. The PMU, through a consultancy, will define deliverables for facility based staff which will be measurable along with performance indicators. These will determine incentives for facility-staff. Quality of work will have important bearing on these bonuses. Based on the results performance incentives will be given to provincial and district program managers on achievement of performance targets.

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2. MAINSTREAMING FAMILY PLANNING SERVICES AND INTERVENTIONS AS A STRATEGY TO IMPROVE MATERNAL HEALTH

Birth Spacing or Family Planning is one of the most important and cost effective preventive health interventions for reducing maternal, child and neonatal mortality. Voluntary family planning is recognized as the only acceptable means of regaining proper balance between fertility and mortality. The imbalance between these two, i.e., high fertility and declining mortality leads to excessive population growth. Pakistan is facing the same situation which has become a barrier in economic growth of the country.

Despite tremendous investments, the child spacing could not become part of our family life because of poor quality and inaccessibility of services, lack of effective communication policy and its patch implementation, fear of side effects, religious and cultural misperceptions. Moreover instead of understanding ‘child spacing’ the major focus has been given to making services available.

Currently, there is almost 18% unmet need for FP services. The social marketing in urban and semi-urban areas and LHWs’ program in the rural areas are the major interventions for increasing contraceptive prevalence rate in the country. There are about 4,000 health facilities in the Punjab but their share in provision of family planning services is generally less than 1%.

The current facilities offering family planning services are generally underutilized. For instance, one evaluation showed that, on an average, a family welfare center received only 2 clients per day13. One reason for this is the limited access of Pakistani women to health or family planning services.

There are many ways to expand access beyond static clinics and, over the past 30 years, many of them have been tried in Pakistan. The training of traditional birth attendants, or dais, has been tried on many occasions in South Asia, but their low social status prevents them from being plausible agents of social change, and their impact on family planning has been negligible.

All health facilities would be equipped to provide a full range of contraceptive and follow up services. Surgical contraception would be provided at the Comprehensive EmONC facilities. Capacity building of staff of all Comprehensive and Basic EmONC facilities would be done in FP, HTSP, Postpartum FP and Supply Chain management system.

At grassroots level LHWs and CMWs have been providing FP services and data of the community based workers will be consolidated and integrated at the BHU level. These community based workers of health and PWD would refer the clients to the most appropriate health facilities if required. Unmet need can be decreased and CPR can be greatly enhanced if both health and PWD would work in close collaboration with one another at micro, meso and macro level. The following activities will be undertaken to address FP services as an integrated strategy to address maternal health

13Cernada GP, Rob AKU, Ameen SI, Ahmad MS. A Situation Analysis of Family Welfare Centers in Pakistan.Islamabad, Pakistan: Population Council; 1993.

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a) Linkages building with PWD at all levels including UC, district and provincial levelb) Ensure un-interrupted provision of FP supplies to health facilities, CMWs and LHWs by

putting in place an effective Supply Chain Management Systemc) Capacity building of LHWs, CMWs and health facility staff on HTSP, PPFP counseling and

skillsd) Integrated MIS regarding FP data at the community and facility levele) Regular District Technical Committee Meeting (DTC) on monthly basis

Under the proposed program, efforts would be made to ensure that preferably all health facilities are providing maximum range of family planning services for HTSP. The program will meet all logistics and training needs.

a. Strategy

Healthy Timing and Spacing of Pregnancy (HTSP) strategy will be adopted at community and facility-based level.

b. Interventions and Targets

In order to achieve its objectives, the program will have the following interventions and targets:

1. Training of 4,000 health care providers in birth spacing counseling techniques;

2. Ensuring surgical contraception services at all RHCs, THQ and DHQ hospitals;

3. Ensuring availability of at least three month stock of contraceptives at minimally 80% of health facilities;

4. Ensuring reduction in stock outs of contraceptives at BHUs to less than 20%;

5. Ensuring availability of LHVs at all DHQ, THQ and RHC and at least 90% of BHUs;

c. Essential Components of Birth Spacing Services

In order to achieve its birth spacing objectives, the program will need to have the following essential components:

1. Ensuring Multi-sectoral Participation: The program will need to combine the efforts of Government, NGOs, social marketing, private sector and international partners;

2. Presentation as Health Intervention: In program’s communication strategy, the birth spacing will be presented as health intervention with carefully developed concept and wording;

3. Broad Range of Service Outlets: The birth spacing services will be made available at wide range of outlets including Government, NGOs, private clinics, pharmacies and community workers;

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4. Inclusion in Postpartum Care: The postpartum period is the most appropriate timeframe during which birth spacing counseling and provision of supplies can achieve tremendous and efficient results.

d. Trainings on Birth Spacing Counseling

The program plans to train all the health facility staff on birth spacing counseling. A manual will be developed for this purpose. The trainings will be held in collaboration with Regional Training Institutes wherever possible.

The training process will be of the cascade type: first a batch of provincial master trainers will be trained. These will train district master trainers, preferably from the DHQ hospitals, who will impart training to the staff of the health facilities i.e., DHQ, THQ, RHC and BHU.

Before the commencement of the training cascade, a two day orientation and planning workshop at the provincial level will be conducted. The list of available facilitators from each district will be discussed and availability of training aids at different training sites will be reviewed. According to the training plan decided at the provincial level the training cascade will be initiated, and adhered to.

The first workshop will be of 10 participants at the provincial level with facilitation from a team of experts. These trainers will then hold district training workshops for staff of DHQ hospital, from where district trainers will be identified to impart training to the rest of the health facilities in the district.

The staff to be trained at the DHQ and THQ will include: WMO, MO, LHV, and other technical staff involved in provision of birth spacing services. At the RHC and BHU the WMO, MO, LHV, FMT, Dispenser, MT and other technical staff involved in provision of birth spacing services will be trained. The total number of facility staff to be trained is envisaged to be around 4,000, with each of the training proposed to be of 3 working days.

e. Trainings on Surgical Contraceptive Techniques

Three staff members from each health facility providing EmONC (comprehensive or basic) shall be trained in surgical contraceptive techniques. The trainings shall take place at regional training institutes (RTI centers).

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3. PREVENTION AND MANAGEMENT OF MALNUTRITION BY IMPLEMENTING PAKISTAN INTEGRATED NUTRITION STRATEGY

The findings of the 2011 National Nutrition Survey reveal a very grave picture of Punjab showing prevalence of chronic malnutrition among children under-5 years of age at 39.2 % and maternal anemia at 49.6%. Similarly the prevalence of acute malnutrition among children is 13.7% and child anemia in Punjab is 60.4%. (NNS 2011)

The Punjab Policy guidance note on Nutrition shows that there is a strong association between factors such as poverty and women’s education and malnutrition. Special efforts will thus be made to reach the poorest households and the communication for behavior change will be designed in a way to effectively communicate with illiterate and less educated mothers.

The NNS data reflect the abysmal condition of nutrition among the more vulnerable segments of the population, which include women and children of the province. Such indicators on the part of the provincial health department also warrant a comprehensive and effective plan of action on a war footing, to improve the existing deplorable health conditions and indictors for the women and children. The integrated nutrition strategy will be implemented in districts having poor indicators related to nutrition and health.

A comprehensive nutrition strategy will be implemented to address malnutrition through preventive and curative services. The preventive nutrition interventions are being proposed for all 36 districts; additionally, curative component addressing severely acute malnutrition is proposed for 12 priority Districts and urban peripheries of 9 mega-Districts of Punjab in the first phase. Then phase wise extension is also proposed for Curative component to address severely acute Malnutrition throughout the province.

It is proposed to implement Nutrition activities especially curative services in a phased manner. This will not only help in testing ease of implementation and identify bottlenecks but will also provide an opportunity for piloting some of the interventions before their scale up through subsequent PC-1s.

Preventive services will be implemented in all 36 districts through advocacy and Community-based Nutrition services.

The Nutrition Initiative has been developed to provide benefit to the entire population of the province with the introduction of proven, cost-effective interventions. The undertaking within this program includes implementation of a province-wide Nutrition Education Package with an aim to enhance knowledge within the community about nutrition and alter behaviors and practices which hinder improved nutrition. This will help create linkages between health, hygiene and immunization and will serve to improve health systems’ efforts to address malnutrition.

This component will focus on prevention of malnutrition among the general population, with particular focus on pregnant and lactating women and under 5 children and adolescent girls.

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Capitalizing latest research findings on impact of maternal nutrition on child nutrition, the 1000+ days approach, with focus on the period of the life cycle from conception till the first 24 months of the child’s life (when irreversible damage from malnutrition is likely to occur), will be utilized. It is envisaged that by focusing on maternal health both before and during pregnancy through integrated nutrition and reproductive health interventions, improved maternal and neonatal nutritional and survival outcomes will be realized.

The nutrition package will include nutrition education campaign, community based IYCF activities (counseling for breastfeeding and adequate complementary feeding).

Provision of iron and folic acid tablets to adolescent girls, with particular focus on pregnant and lactating mothers,

Biannual de-worming of children Vitamin A supplementation for children will be continued, with a focus on improving

performance in lower performing areas. Zinc supplementation will also be provided and advocated with ORS as treatment of

diarrhea. Provision of MMS to MAM children

Advocacy with policy makers and legislating bodies for compulsory fortification of food will also be part of this component.

Curative/Therapeutic Nutrition interventions

This component will be implemented in a phased manner, addressing those most marginalized and poorest sections of society within rural and peri-urban areas. The first phase will include 12 districts having poor nutrition indicators and urban slums of 9 mega districts. In the 2 nd and 3rdphases, therapeutic nutrition services will be extended to all 36 Districts. Proposed activities include:

Treatment of Severely Acute Malnourished children (SAM) with Ready to Use Therapeutic Food (RUTF).

Treatment of SAM with complications at Stabilization Centers (SC) in all 36 districts of Punjab

Treatment of moderately acute malnourished pregnant and lactating women (MAM PLWS) and moderately acute malnourished (MAM) children through provision of supplementary food with the support of WFP and UNICEF will be part of program in District Rajan Pur and D.G. Khan only.

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IMPLEMENTATION OF NUTRITION PROGRAM IN PHASING

Sr.No 2013-14 2014-15 2015-161 Narowal Narowal Narowal2 Layyah Layyah Layyah3 Mianwali Mianwali Mianwali4 Multan Multan Multan5 Khushab Khushab Khushab6 Rahimyar Khan Rahimyar Khan Rahimyar Khan7 Pakpattan Pakpattan Pakpattan8 D. G. Khan D. G. Khan D. G. Khan9 Muzaffargarh Muzaffargarh Muzaffargarh

10 Bhakkar Bhakkar Bhakkar11 Rajanpur Rajanpur Rajanpur12 Bhawal Nagar Bhawal Nagar Bhawal Nagar13 Gujranwala Gujranwala Gujranwala14 Sargodha Sargodha Sargodha15 Rawalpindi Rawalpindi Rawalpindi16 Faisalabad Faisalabad Faisalabad17 Bhawal Pur Bhawal Pur Bhawal Pur18 Sahiwal Sahiwal Sahiwal19 Khanewal Attock Attock20 Sialkot Chiniot Chiniot21 Lahore Gujrat Gujrat22 Hafizabad Hafizabad23 Jhang Jhang24 Jhelum Jhelum25 Kasur Kasur26 Khanewal Khanewal27 Lodhran Lodhran28 Vehari M.B. Din29 Sialkot Chakwal30 Lahore Nankana Sahib31 Okara32 Sheikhupura33 T.T. Singh34 Vehari35 Sialkot36 Lahore

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Implementation Strategies

The proposed program aims at reducing maternal and child malnutrition in line with Government’s commitment of achieving health related MDGs through:

a) Strengthening of community outreach services focusing on Nutrition Education Package through training &improved performance of LHWs.

b) Prevention and management of malnutrition by providing community outreach and facility based services

c) Addressing Micronutrient Malnutrition

a) Strengthening of community outreach services focusing on Nutrition including MNCH/RH and FP through improved capacity building and performance of LHWs

LHWS will be fully trained on the Nutrition Education Package including IYCF, micronutrient deficiency and WASH messages. This preventive Nutrition Education Package will be used for awareness raising and promoting healthy behaviors among the population, especially, women, children and adolescent girls.

Additionally, in areas where the Therapeutic component will be undertaken, LHWs will be strengthening the Nutrition program through effective screening, referral and followup. LHWs will screen, refer and follow up pregnant and lactating women and malnourished children to the health facility for nutrition services.

Key Interventions

Provision of Logistics and Equipment

o Provision of iron and folic acid tablets, zinc syrup , ORS, RUTF and micronutrient sachet to LHWs

o Weighing scale (Salter)

o Provision of MUAC tapes, height & length board

Strengthening of Monitoring and Supervision of CMWs and LHWs

o Capacity building of LHSs on supervision of CMAM and IYCF activities of LHWs

o Monthly reporting of screening, referrals and follow-ups.

o Monitoring visits to all LHWs by LHS at least once a month

o Off and on Monitoring visit to all LHWs by the District Nutrition focal person

o Development of E-monitoring and reporting through SMS based system

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Establishment of Multi sectoral Coordination Committees at provincial, district and union council levels

Membership for the Provincial Malnutrition Eradication committee includes:

i. Department of Health

ii. Food Department

iii. Agriculture Department

iv. Livestock Department

v. Education Department

Membership for the District Malnutrition Eradication committee includes:

i. Department of Health

ii. Food Department

iii. Agriculture Department

iv. Livestock Department

v. Education Department

Membership for the Union Council Malnutrition Eradication committee includes:

i. School health nutrition supervisor (convener )

ii. LHS

iii. UC Secretary

iv. Representatives of agriculture, livestock and education departments

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b) Prevention and management of malnutrition by providing community outreach and facility based services

Therapeutic/Curative Nutrition along with Preventive services will be provided in 12 districts and 9 peri-urban areas of mega-districts. Two intervention arms are being implemented in these districts; in Districts DG Khan and Rajanpur treatment of SAM and MAM children and MAM PLWs will be undertaken, in other districts, only treatment of SAM children with and without complications will be undertaken.

Key Activities:

1. Facility based CMAM (Community based Management of Acute Malnutrition) in Districts DG Khan and Rajanpur

Provision of supplementary foods for distribution among identified cases will be supported by WFP and UNICEF. The following commodities will be used for treatment of identified cases

a. Supplementary Feeding Program

i. Provision of Fortified Blended Food (FBF) to MAM PLWs

ii. Provision of Micro nutrient tablets to MAM PLWs

iii. Provision of RUSF (Ready to Use Supplementary Food) for MAM Children 6-59 months in two districts

iv. Provision of High Energy Biscuits (HEB) to siblings of identified SAM & MAM children

v. Provision of Micronutrient sachet to MAM children and

vi. Provision of Nutrition advocacy package (IYCF, immunization Wash, Fortification)

b. Outpatient Therapeutic Program (OTP)

i. Provision of RUTF (Ready to Use Therapeutic Food) to SAM children without complication

ii. Provision of Nutrition advocacy package (IYCF, immunization Wash, Fortification)

c. Stabilization Centers at DHQHs and teaching hospitals.

I. Provision of F75, F100 and advised medicines to SAM children with medical complication

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Recruitment and training of human resource for implementation of the above activities includes:

1. 51 Nutrition Assistants in Districts DG Khan and Rajanpur for facility-based nutrition service provision.

2. 72 staff nurses at Stabilization Centers for inpatient Nutrition Care. Each SC will require a minimum of three member-staff for 24/7 operations: one existing staff will be utilized for this initiative, while other two members will be hired by the program.

2. In priority 12 Districts plus peri-urban areas of 9 mega districts (total of 21 districts), key interventions will be as following

a. Supplementary Feeding Program

i. Provision of Micro nutrient tablets to MAM PLWs

ii. Provision of Micronutrient sachet to MAM children

iii. Provision of Nutrition advocacy package (IYCF, immunization Wash, Fortification)

b. Outpatient Therapeutic Program (OTP)

iv. Provision of RUTF to SAM children without complication

v. Provision of Nutrition advocacy package (IYCF, immunization Wash, Fortification)

c. Stabilization Centers at DHQHs

II. Provision of F75, F100 and advised medicines to SAM with medical complication

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c) Addressing Micronutrient Malnutrition

Micronutrient deficiencies are widespread in Punjab. Data for under-five years of age children reveals an alarming situation, with 40% children having iron deficiency anemia and 14% of preschool children having vitamin A deficiency. Micronutrient deficiency results from a complex interplay of factors, including poverty, limited access to a balanced diet, repeated infections and poor health and nutrition service delivery.

Micronutrient (Iron, Folic Acid, Iodine, Zinc, Vitamin A and Vitamin D) deficiencies are multifaceted and are considered “silent hunger” which is hidden from everyone, from mothers’ to policy makers. Micronutrient deficiencies even at minor levels can leave an irreversible impact on growth and development of children. Hence in such context where the levels of acute and visible malnutrition are at critical levels of emergency, micronutrient deficiencies, specifically Iron deficiency Anemia and Iodine Deficiency Disorders are highly significant.

Micronutrients are vital to healthy living, robust growth and intellect development. Fortifying flour and other staple food with folic acid and iron, can help in addressing micro nutrient deficiencies i-e reducing anaemia and birth defects; salt iodization reduces goiter and improves intellectual/ cognitive development; vitamin A supplementation plays an important role in reduction of child mortality and zinc supplementation reduces duration and severity of diarrhoea, one of the leading cause of deaths among children.

The program seeks to address micro nutrition deficiencies, particularly among children of 6-59 months of age, PLW and adolescent girls, particularly from the lower income quintile and disadvantaged groups.

Key activities

Vitamin A supplementation campaigns

Provision of iron folic supplements and counseling to pregnant and lactating women and adolescent girls

Advocacy with policy makers and private industry for expansion of the wheat flour fortification program

Advocacy with private salt processors for expansion of salt iodization program

Creation of demand for iodized salt and wheat flour, through the BCC campaigns

Setting up a system of sustainable supply of KIO3 (iodine fortificant)

Treatment of diarrhea in children 6-24 months using zinc and ORS, ensuring continuous supply of Zinc and ORS and training of health workers

Vitamin A supplementation

Vitamin-A supplementation is being implemented with support from the Micronutrient Initiative (MI) and UNICEF administered through Polio NIDS for children 06 to 59 months. Currently Vitamin-A capsules are being administered through the Polio NIDs

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Implementation status of provision of vitamin A through NIDs will be evaluated to assess coverage. The response would be designed accordingly.

Expansion of Salt Iodization Program

The province-wide expanded program will be made sustainable with effective behaviors. Legislation for compulsory salt iodization will be developed and promoted for ratification by provincial legislature with support of MI, WFP and UNICEF. It is anticipated that development partners will continue to support the production side with continuous monitoring of the salt processors and enabling regular access to potassium Iodate.

Zinc Supplementation during Treatment of Diarrhea

In many countries zinc supplementation during treatment of diarrhea has shown to have both curative (reduction in diarrhea) and preventive (fewer future episodes) effects. The commodity will be provided through HCP and LHWs for treatment of diarrhea.

Behavior Change

Behavior change is critical for practicing positive health related interventions. However, this requires assessments of behaviors and socio-cultural practices and translations of these into strategic health communications models. Along with communication efforts focused at ultimate beneficiaries, the project will entail advocacy interventions targeted at key stakeholders especially target population, policy makers and other players to garner relevant allocation of resources, oversight and support.

Positive behaviors for adopting good health practices is a major resource for social, economic and personal development and an important dimension to quality of life. Political, economic, social, cultural, environmental, behavioral and biological factors can all favor health or be harmful to it. Health promotion action aims at making these conditions favorable through behavior change for health and nutrition.

In our settings, income related poverty, illiteracy/ ignorance, socio-cultural practices, unemployment, dwelling style at rural, sub urban and urban slums contribute to household food insecurity/ inadequate food intake, inadequate care and unhealthy household environment. In this scenario, behavior change is significantly critical for practicing positive health and nutrition related interventions. However, this requires assessments of behaviors and translations of these into strategic health communications models.

The objective of this component is:

“To enhance levels of knowledge and increased awareness of nutrition intervention among men and women who have children less than 5 years of age and pregnant / lactating women” with special attention given to adolescent health

The outcomes of the component are:

Increased level of awareness among households about the nutrition interventions in the province with a focus on poor and disadvantaged.

Increased knowledge about nutrition issues among households having children less than five years of age

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Key activities

Develop the tools and materials for communicating the key gender sensitive messages for behavior change and field test them before actual implementation

The intervention will use multiplicity of channels, including face-to-face communication sessions, social mobilization and I.E.C. materials. The scope of communications component will focus on pregnant & lactating women and will address issues like breastfeeding, complementary feeding, use of multiple micronutrients, & use of iodized salt. In line with the use of latest technologies and methods for promoting healthy behaviors, the NPS will pilot the use of mobile phones for disseminating messages on nutrition promotion in one district, which should help in designing further strategies for promoting healthy nutrition behavior.

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4. STRENGTHENING OF COMMUNITY-BASED OUTREACH SERVICES FOCUSING ON PHC, MNCH, RH/FP AND NUTRITION THROUGH IMPROVED PERFORMANCE OF LHWs AND CMWs

Strengthening of PHC services including reproductive and family planning services is one of the most important components of the Program. Community based health workers already working at the community level for the above said purposes are LHWs and CMWs, that most of the deliveries in rural population (41% of the total) of Punjab takes place at homes through traditional birth attendants (TBAs) and unskilled birth attendants such as family members. Keeping in view illiteracy, poverty and access in terms of socio cultural and physical, it is necessary to provide skilled birth attendants at the doorstep of the community to conduct normal delivery with aseptic measures and at the same time identify and enhance uptake of facility-based deliveries through timely referral of cases to the most appropriate health facility.

LHWs are working in catchment area population of 1200-1300 and providing PHC services. In Punjab almost 48,500 LHWs have been providing services regarding antenatal, postnatal and FP. They have also been providing service regarding IMNCI, immunization, control and prevention of malnutrition among women and children. CMWs are being trained and deployed to community-based need for SBA; they will work in close collaboration with LHWs of their area, providing trained prenatal and partum care at community level and refer high risk pregnancies and complicated cases to the most appropriate health facilities.

Integration of service delivery at community-level will be developed by engendering linkages between CMWs and LHWs working within the communities. LHWs would refer pregnant mothers to SBAs for antenatal and normal delivery and both of them would work in a coordinated manner. However, strategies to improve coordination and service provision at community level, necessitates skills development, capacity building, effective monitoring and create strong referral linkages with health facilities. The following activities will be undertaken to integrate and improve community-based service provision.

i. Capacity Building of community-based health workers

a) Capacity building of deployed CMWs on EMNC, CIMNCI, HTSP& PPFP counseling, IYCF and vaccination

b) Capacity building of deployed LHWs on CIMNCI, IYCF, vaccination, HTSP and Postpartum Family Planning Counseling

c) Refresher training of all CMWs and LHWs after periodic technical assessment

ii. Strengthening of Monitoring and Supervision of CMWs and LHWs

d) Integration and consolidation of RH/MNCH data of CMWs and LHWs at the health facility level and dissemination to district DHIS and RH/MNCH office

e) Monitoring visits to all LHWs and CMWs by LHS once a monthf) Monitoring visit to all LHWs and CMWs by the District RH/MNCH focal person /

district Monitoring officer at least twice biannually.69

iii. Interventions for Hard to Reach Areas and urban slums

g) Identification of hard to reach areas (in all districts) and urban slums (in bigger districts) in all districts after district mapping

h) Review and revision of existing training manuals of CMW for LHW cum CMW training.

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5. STRENGTHENING LINKAGES BETWEEN COMMUNITY OUTREACH HEALTH WORKERS WITH HEALTH FACILITIES

Linkages of community based workers (LHWs& CMWs) with health facilities have not been established to the extent it was desired due to various reasons which may be poor quality of health services, limited scope, non availability of health care providers, poor physical access and improper provider’s behavior and direct and indirect cost associated with use of health care. At the same time socio cultural barriers are equally important in utilization of health care. One of the important reasons is the absence of well established referral protocols at the health facilities and referred patients/clients are not treated on priority basis. Therefore it is necessary to improve the access and availability of well trained and competent human resources at the health facilities. There is a dire need to develop referral protocols in terms of establishment of referral desk at THQ and DHQ level. There is also need to provide a gender friendly environment at the health facilities in terms of separate waiting area and wash room for the female patients.

The following activities will be undertaken to improve linkages of community-based workers with health facilities.

a) Development and implementation of referral protocols for referral of high risk cases to Basic and Comprehensive EMONC facilities

b) Implementation of referral and follow up system for SAM Children with medical complication to established SC centers.

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6. ESTABLISHING E-MONITORING AND E-REPORTING SYSTEM AND A WEB-BASED PROGRAM MIS WITH LINKAGES TO DHIS

A strong monitoring and evaluation system is necessary to ensure proper functioning of the program in order to achieve the desired outputs and outcomes. M&E system of the program will be linked regular national Program monitoring system.

Strong e-reporting and monitoring system will be prepared and launched at provincial level for example the monitoring reports submitted by all levels of supervisors and monitors (LHS, supervisors, district managers, provincial monitors, and provincial monitors) will be entered directly into the software through text messages and mobile phone based web applications.

Soft ware engineer will be appointed on Provincial implementation unit level, s/he will be responsible for the up gradation of this reporting and monitoring software. The monitoring reports of these monitors will be submitted using web based mobile phone applications, and shall be immediately accessible to the managers.

A robust program management information system is important to record the program implementation activities at ground level, preparation of program performance reports and planning of subsequent activities as well as policy designs.

The program MIS will be web-based and deployed on a central server at the provincial office. District offices will be able to access and add information to the MIS by logging in at the program website. District monthly reports will be submitted online through web based data entry forms. A dashboard will be developed on the program website for provision of live streaming data based on the reports received. The software will generate analyzed reports for each level of management staff. These reports will be available to the managers on logging in to their personal accounts at the website.

Key Activities

1. Development of key performance indicators will be for all program management and support staff at the PMU and DMU.

These KPIs shall be used for annual performance evaluation reports and renewal of contractual staff.

Recommendations for transfer of poor performing management staff working on deputation will be made to the competent authority based on the performance evaluation reports.

2. Development of e-monitoring module and integration with the program MIS3. Provision of tracking SIMs to all community staff4. Provision of handsets having monitoring software and GPS technology to the district and

provincial monitoring staff to ensure their presence in the field and timely submission of monitoring reports

5. Purchase of required hardware and equipment for implementation of e-monitoring 6. Hiring of relevant staff

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Field Monitoring by Health Officer

Under this program, as a leader of the health team, each health officer will conduct a monitoring and supervisory visit in the field every week to provide support to field staff. S/he will validate progress reports of LHWs, LHS, CMW, vaccinator, health and nutrition supervisor and male mobilizers and provide guidance and support to field staff in their activities.

Monthly Meeting of BHU Health Team

Each member of BHU health team will meet once every month at the BHU. The primary purpose is to prepare monthly progress reports, discuss progress made and issues faced during the last month and receive refresher training/Continuing Medical Education (as and when required), on the basis of findings of the field monitoring.

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Conceptual Framework for E-Management

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7. STRENGTHENING LINKAGES BETWEEN COMMUNITY AND THE HEALTH FACILITIES

Linkages of community with the health facility would be created by constituting community support group at the health facility through Lady Health Worker and School Health and Nutrition Supervisors (SHNs). The objective is to ensure effective community participation and public accountability. This program views the communities not as merely the passive recipients of the benefits but as the key contributors in the overall process of health promotion and health improvements. Their participation initially will lead to communities’ capacity building through organizing and training them, and involving them in the implementation process. Thereafter, the communities start performing as active partners in planning, governing and owning of the health interventions alongside the professional and technical staff. This combination will certainly multiply the outcome of the interventions manifolds.

The key to the success of this program is building communities’ trust on their health care delivery system. This can only be achieved through ensuring their active participation and providing space for them to play their supportive role in the process. There are two important explanations for seeking participation from the community:

1. The communities, which are otherwise alienated from the health service delivery system, develop ownership; and

2. Community members, being the sole benefactors of the health care delivery system, start contributing towards its further improvement.

This process of community participation will lead to the establishment of “Community Governance Structure” starting with the formation of “Community Support Group (CSG)” within the catchment area of each of the program BHUs and leading to the district level.

This is, in fact, an evolution of bringing the community members, who otherwise live and generally act in isolation, at a common platform for contributing and performing together in a cohesive manner. This cohesiveness strengthens the communities’ efforts leading to outcomes which are otherwise not possible through individual efforts.

These CSGs will identify and discuss issues, find solutions and implement them in order to support the health interventions being carried out for their benefit. Moreover, they will provide support to field level health workers like LHWs, LHS, vaccinators and CDC supervisors.

Formation of Community Support Group

The process of organizing communities into CSG starts from the village level and involves all the population of the village. This essentially consists of the following steps:

1. Determining the number of communities (villages) in the catchment area of a BHU;

2. Establishing contact with each community through broad based community meeting;

3. Introduction of health program components to each community;

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4. Facilitating each community to identify its 1-2 representatives14 through a process that best suits them;

5. Bringing all these community representatives together at a platform to discuss and formalize this platform in the form of Community Support Group;

6. Strengthening these community platforms through regular technical training e.g., in general management, problem solving techniques, financial management, and small scale project planning, etc.;

7. Facilitating the members of “Community Support Group” to share the discussions and decisions of the forum with their fellow community members (whom they are representing) in order to continuously seek their inputs and advice;

8. Formalizing these community structures as “Community Support Group (CSG)” to take active part in the process along with the technical staff;

9. Holding regular meetings of the CSG at least once every month.

Membership of CSG

In addition to community representatives, health officer of the BHU and SHNS (as secretary of CSG) will be permanent members of the CSG. The CSG may include more members with the consent of its members.

14 A community representative is the community member who is well trusted and respected by that community in all walks of life.

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STRENGTHENING DISTRICT HEALTH SYSTEM

This part of the program focuses at enhancing capacity of district health system to deliver essential package of healthcare (EPHC) at primary and secondary levels. The district health system undergoes process of strengthening which starts at the household level and reaches to the highest level of health care service delivery within the district.

The following strategies are will be used to implement proposed interventions.

Ensuring Essential Package of Health Services

Ensuring EPNH (Essential newborn package) Services in the Field

Under this program, the essential newborn package prepared by WHO and UNICEF and adopted by Ministry of Health, Government of Pakistan will be implemented at the community level through CMWs and LHWs. This program will develop training manual for community essential newborn package and will include it in LHWs and CMWs curriculum.

Refresher training will be given and all the LHWs and CMWs will be trained in neonatal care which include immediate and critical life support to a new born by mouth-to-mouth resuscitation, prevention from hypothermia by keeping baby warm through Kangaroo mother care and delayed bathing, early initiation of breast feeding and ensuring cord care with Chlorhexidine. The LHWs and CMWs will educate pregnant women and their family on ENC package during antenatal care. The LHW will also assist the birth attendant in resuscitation of newborn at the time of delivery. She will conduct follow up visits for postnatal and neonatal care on day,1 3, 7, 14 and 28th days of birth. The LHWs and CMWs will be trained in identification of any sign of illness and to provide immediate pre-referral care to the newborn and refer to health facility.

Ensuring Child Spacing Services

Child spacing is an essential part of LHWs and CMWs training. The LHWs and CMWs will educate their respective communities on importance of Healthy Time Spacing (HTSP) . They will offer child spacing health education with information on their side effects, and help the willing women in selecting a method of their choice and provide them with that method or refer them to BHU to obtain that method. The LHWs and CMWs will counsel the women facing any side effects of child spacing methods and refer them to BHU, for appropriate treatment and guidance.

Ensuring EMNC Services

Care provision for common illnesses among neonates and infants especially infections, complications of preterm birth and of birth asphyxia, and prevention from hypothermia save

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significant number of lives. This program will ensure these services at all health facilities through training of respective staff members as well as provision of specialized equipment at referral facilities.

The components of ENC package include immediate life support for newborn by mouth to mouth breathing, prevention from hypothermia by keep warm through Kangaroo mother care and delayed bathing, early initiation of breast milk, and cord care with 4% chlorhexidine solution.

BHUs & RHCs

The health care provider at all the 2,456 basic health units and 289 rural health centers will be trained in ENC package during the currency of the program duration. The preference will be given to female health care providers who deal with the newborn in the labor room. The twenty districts where CHARM and CMAM interventions will be replicated shall be given priority

The health care providers at BHUs and RHCs will identify the serious neonatal conditions and will provide pre-referral care including first dose of intravenous antibiotic where required. All the required items including Ambo bag, oxygen and antibiotics will be made available at all BHUs and RHCs.

The neonatal cases referred from the field will be entertained at BHUs and RHCs for management and further referrals to THQ and DHQ hospitals where required.

Newborn Care Protocols

The protocols for newborn resuscitation and immediate care have already been developed in Pakistan by Women’s Health Project. These protocols will be provided to all the labor rooms at BHUs, RHCs, THQ and DHQ hospitals in public sector and in around 1,500 maternity homes in the private sector.

THQ & DHQ Hospitals

At all THQ and DHQ hospitals, newborn care units would be established to become part of the comprehensive and basic emergency obstetric care services. All the facility staff handling deliveries would be trained in essential newborn care. However, for emergency newborn care specialized units would be established with adequate staff and equipment. Staff would be given specialized training for the purpose and will be permanently deployed in the unit rather than on rotation basis (especially the nursing staff) .All health facilities providing comprehensive EmONC services will have functional newborn units.

Each newborn unit will require minimally the presence of a pediatrician, one medical officer / woman medical officer specifically for the unit in addition to at least two staff nurses to run the unit. This staff strength is included in the minimum staff requirement for 24/7 EmONC services which is given in the EmONC section.

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Strengthen Program Management

In order to strengthen overall program management the program will:

1. Develop standard operational procedures (SOPs) for program operations, personnel management and logistics management;

2. Set minimum service delivery standards (MSDS) for each of the program interventions with specified levels and dimensions;

3. Develop modalities for pre-service and induction training for various staff categories working in the program;

4. Develop and implement monitoring and supportive supervision system consisting of monitoring checklists, schedules, data base and mechanism for feedback and follow up on suggested corrective actions.

Field Monitoring Officers/M&E Officers

The Provincial Office will conduct monitoring and supervision of program field-activities through a cadre of Field Monitoring Officers. This cadre will be developed by re-designating existing FPOs (of LHW Program) and social organizers (of MNCH Program) for supervision. The M& E Officer is a BPS 17 position.

Provincial PMU officers will also conduct regular supervision activities in the districts and support the FPOs.

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INNOVATIONS

The aforementioned interventions will continue throughout the period of PC-1 from 2013-2016. The program will also begin testing new models and innovations. The Program aims to take advantage of important new evidence on the impact of certain maternal and child health interventions in order to fine-tune the package of services provided by the LHWs. Though the evidence on some of these interventions appears to be quite promising, some would need to be pilot-tested prior to their introduction in the program. Some programmatic interventions to be pilot-tested would be chosen following a screening process by the “Technical Committee on Interventions” with membership from within Program and technical experts on maternal health, child health and public health with experience of using scientific research methods and tools.

Funding for the pilot of these innovations will be sought from donor organizations and partners like UNICEF, UNFPA, etc.

Suggested avenues for exploration include

1. Health systems research, including

Pilot test impact of field monitoring through use of mobile phones Pay for performance initiatives for community-based and facility-based

healthcare staff Pilot test establishment and assess impact of EPI Centers at LHW Health House

2. Nutritional interventions research, including

Evaluation of efficacy of Wheat-Soy Blend (WSB) in treatment of PLWs and impact of nutrition status of index case and birth weight of newborn in Districts DG Khan and Rajanpur

Development and field-based evaluation of local low-cost nutritional alternatives to Ready to Use Therapeutic Food (RUTF)

Feasibility of follow-up and treatment of SAM children by LHWs

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MANAGEMENT STRUCTURE

Administrative Arrangements

The administrative arrangements for program implementation consist of establishment of:

1. Provincial and district steering committees2. Provincial and district management units

Provincial Steering Committee (PSC)

Provincial steering committee shall comprise of:

• Chairman Planning & Development Department /Member Social Sector Chairman• Secretary Health Member• Director General Health Member• Program Director PHSRP Member• Program Director Secretary• DG Population Welfare Department Member• Secretary Finance Department Member

District Steering Committee (DSC)

District steering committee shall comprise of:

• District Coordination Officer Chairman• Executive District Officer (Health) Member• District Coordinator Secretary• District Officer Health Member• EDO F&P Member

Provincial Level Management Committee

A Provincial level Management Committee will be notified for the purpose of selection of Districts and health facilities for implementation of the proposed program activities. Headed by Secretary Health, the Committee will comprise of the memberships:

Program Manager Representative from DGHS Office Representative from PHSRP/PSU Office

This committee will be responsible for District-based mapping of health facilities and determining selection of sites for program implementation in a phased manner for Nutrition, Primary Health and Reproductive Health interventions.

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Department of

Health

PHC, FP, RH & nutrition Policy for the program, Service specification, Funding,

Program Monitoring and Evaluation

PMU

PHC Policy Advice, National Reporting, Internal Supervision and Monitoring,

Evaluation, Training, Program, Procurement/Distribution, Operational Planning

and budgeting, Financial Accounting, LHW-MIS System

Internal Supervision and Monitoring, Program Reporting, District LHW Allocation,

Operational Plan Implementation, Accounting and Budgeting, Organization of

Training, Distribution, LHW-MIS Data Collation and analysis.

DMU

LHW, CMW, LHS-District Supervision, LHW & LHS Hiring /Firing, Training,

Operational Plan Implementation, Distribution, Vehicle maintenance, Accounting,

Program Reporting, MIS Data Collation, analysis and use of information in

management

FLCF (all)

Recommendation for hiring of LHWs & LHSs by the Medical Officer/Woman

Medical Officer, Training of LHWs, Collation of MIS, Organizing Kit replenishment,

Providing meeting point for LHWs and LHS, and collaboration with CMWs and

PWD staff.

Selected RHCs for

Comprehensive

EmONC Services

Provision of comprehensive EmONC services and serve as a referral facility for

obstetric cases

All RHCs and

Selected BHUs for

24/7 Basic

EmONC &

Nutrition Services

Provision of basic EmONC services round the clock, provision of outdoor obstetric

care, routine EPI, family planning services and nutrition services (CMAM/OTP).

Additional HR, equipment and supplies will be ensured to enhance the capacity

of these facilities for provision of services beyond the existing ToRs.

LHW PHC & FP service provision to community, community organization

CMW MNCH & FP service provision to community

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THE PMU

Role

The program management unit shall be based at the provincial head quarter and will be headed by the Program Director/ ADGHS. The PMU shall be responsible to provide leadership role in addition to this program to MNCH & LHWs Program;

1. Play steward ship role in formulation of program policy guidelines in consultation with all stakeholders and dissemination of the same to all district managers.

2. Constitute and notify the technical advisory groups ( TAG) on different themetic areas for formulation of technical guidlines

3. Development of training and capacity building strategies, training modules, training of master trainers

4. Monitoring and evaluation of program activities, internal evaluations, coordination for third party evaluations

5. Conduct performance audit and internal financial audit of the districts6. Hearing of appeals against the district management unit

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JOB Description Designation &Pay scale Eligibility Criteria ToRs / Responsibilities

Deputy Program Manager Nutrition

BPS 19/18 by transfer/ Deputation/open competition

A medical doctor with post graduate qualification in public health

At least 15 years of experience at mid and senior level positions including 5 years of project management experience for implementation of field based projects

Deputy Program Manager Nutrition, reporting to the Provincial Coordinator, shall be responsible for affairs related to Project activities, finances, procurement and logistics and assignments given by the Provincial Coordinator time to time.

He will be employed through transfer/deputation from Health Department. In case Health Department not depute any officer within six months after the requisition by this office and repeated requests the officer may be appointed on contract basis through open competition.

Nutrition Officer

BPS 17-

S/he is having at least 1st Division Degree in MSC Nutrition alongwith 02 years experience in Public Health Sector or implementing nutrition based projects.

Nutrition Officer will be reporting to the Deputy Program Director, is responsible for overall management, planning ,provision of technical support and successful nutrition trainings. Or assignments given by the Provincial Coordinator/Deputy Program manager nutrition time to time.

The remuneration for this position will be equivalent to grade 17 officer as admissible under the Government rules in case of an existing Government employee or Rs. 100,000 per month in case of non- Government candidates.

Research Officer BPS 17 Or market based @ Rs. 80,000/-

i. 1st class Master’s Degree in Bio Statistic.

ii. 02 years experience of monitoring demonstrated experience and competence in monitoring and evaluation, Nutrition project management and training.

iii. Knowledge of computerized database

Research Officer will be reporting to the Deputy Program Director is responsible for overall management, planning,provision of technical support and successful nutrition trainings. Or assignments given by the Provincial Coordinator/Deputy Program manager nutrition time to time.

The remuneration for this position will be equivalent to grade 17 officer as admissible under the Government rules in case of an existing Government employee or Rs. 100,000 per month in case of non- Government candidates.

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& statistical analysis software.

iv. Proven management experience for minimum of three years

v. Master’s level university or vocational training in Social Sciences, Management or Public Health.

Data Entry BPS-12 Or market based @ Rs. 35,000/-

S/he at least D.COM having 02 year experience in Data Entry in Public Health Sector or Implementing field services projects.

Data Entry Operator, reporting to the research officer for reporting nutrition project data or any assignment given to him / her by Nutrition / Research Officer

The remuneration for this position will be equivalent to grade 12 officer with a project allowance as admissible under the Government rules in case of an existing Government employee or Rs. 35,000/- per month in case of non- Government candidates.

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Facility & Field Staff

Designation & Pay scale

Eligibility Requirement Roles & Responsibilities

WMO MBBSPreference will be given to those with post graduate diploma/fellowships in obstetrics & gynecology or pediatrics

LHV LHV courseAt least six months of experience in public sector

1.1 Budget:

Budget of the Program will be prepared by PMU, in accordance with the provisions of the PC-1. Finance Officer of PMU will prepare NISs (New Items Statements) i.e. budget statements for coming financial year(s) (mentioned in Table-A below) according to accounting circle and he will submit the NISs to Department of Health for signature of Section Officer (Development) and endorsement of Deputy Financial Advisor (Health).

Sr. No.

NISs of each office of the Program Accounting Circles

1 PMU-Punjab, Lahore (includes budgets of DMUs).AG Punjab, Lahore & District

Accounts Offices in all District of Punjab.

1.2 Releases and Fund Flow Mechanism at PMU Punjab.

The PMU will submit the budget demand as per approved cash plan or according to instructions of Ministry of Finance regarding release/ utilization of funds to Health Department Govt. of the Punjab for release of funds from Planning Division, Govt. of Pakistan under PSDP Sr. No. 31 as per CCI decision dated 28-04-2011. Planning Division Islamabad will release the budget on quarterly basis to Govt. of Punjab through Planning & Development Department Govt. of Punjab Lahore to Health Department Govt. of Punjab for further release into Assignment A/c maintained in NBP Main branch Lahore and in A/c-I to all districts in Punjab on the request of Provincial PIU to SDAs of development funds maintained by District Coordination Officers and Executive Districts Officers (F & P) through District Accounts Offices concerned. Health Department, Govt. of Punjab will forward the budget request of PMU to Finance Department, Govt. of Punjab for release of budget.

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1.3 Releases and Fund Flow Mechanism at District Level.

On request of PMU, the Finance Department, Govt. of Punjab through Health Department will release the budget in systems against the Cost Centers of development funds to all districts in Punjab and as well as ceiled copy to District Accounts Offices concerned and intimation copies to all relevant departments. The District Accounts Offices concerned on receipt of ceiled budget copy from Finance Department, Govt. of Punjab Lahore will release budget into SDA A/c maintained in the O/o EDO (F & P) with the signatures of DCO & EDO (F & P). The District Coordinator National Program of concerned district will sign the all object head claims and will forward to EDO (F & P) through EDO (Health) for payment. The EDO (F & P) will forward the claims to DAO concerned for pre-audit and after pre-audit, the EDO (F&P) office will issue the SDA cheque in the name of vendors after ensuring that all payments are being made through bank without any encashment of cheque. The SDAs of DMUs will contain funds on account of Telephone & Trunk Calls, Courier & Pilot Services, POL, Stationary, Others Miscellaneous & Repair of Vehicles. All payments from the SDAs will be made by PMU with the approval of competent authority. District Coordinator National Program and his staff will carry out reconciliation of the receipts and expenditure pertaining to the SDAs on monthly basis. It is responsibility of the District Coordinator/Account Supervisor that outstanding cheques are cleared for payments and no outstanding balance will remain in the SDAs.

1.4 Assignment Accounts of PMU

PMU Assignment Account has the approval of Finance Department and Finance Department is placing funds in the PMUs Assignment A/cs through the funds ceiling sanction letter addressed to the AG Punjab. The AG Punjab then issue sealed authority letter to Treasury Officer Lahore for its crediting through challan form/receipt voucher into Assignment A/c No. 103 maintained at NBP Main branch, Lahore for admitting expenditure up to the amount mentioned in the sanction letters. The AAs of PMUs will contain funds on account of employee related expenses; purchase of assets and for all PMU operational costs/expenses. Payments of stipends of LHWs, LHSs, and all Programs employees including employees working at DMUs levels are made from Provincial AAs. Two authorized signatories will operate the AA. All payments from the AA will be made by PMU with the approval of competent authority. The AA cheques will be issued under the signature of two authorized signatories. The schedule of the cheques will be sent to the concerned NBPs. Finance and Accounts (F&A) Section of PMU will carry out reconciliation of the receipts and expenditure pertaining to the AA on monthly basis. It is responsibility of the F&A Section of PMUs that outstanding cheques are cleared for payments and no outstanding balance will remain in the AA.

88

1.5 Reconciliation with DAO/TO and Banks

Reconciliation with AG Punjab/Treasury Office of Assignment Account and SDAs A/cs with District Accounts Offices will be made on monthly basis by the Finance Officer of PMU and the District Coordinators and Accounts Supervisors respectively.

1.6 Finance and Accounts Staff

Finance Officer, Audit Officers, Cashiers will be hired on deputation basis from AGP/CGA however, existing working officers/staff will continue to work if they have been appointed on contract basis with the approval of competent authority. In case AGP/CGA offices do not fill in the position within four (4) months of the submission of requisitions and repeated requests, the position will be filled in on contract basis in consultation/approval of the Department of Health. Accountants and Senior Auditor posts will be filled on contract basis however during the recruitment on contract basis, PMU will give priority to existing staff.

1.7 Internal Audit:

Internal audit of Program units i.e. PMUs and DMUs will be carried out by the DGHS on regular basis. Internal audit of PMU will be carried out annually whereas the PMU will also conduct audit of the districts in such a way that each district should be audited once in 02 years. However, PMU should also conduct internal audit of DMUs.

1.8 External Audit:

Audit Team of the Auditor General of Pakistan will conduct audit of accounts of the Program at PMU and DMUs level. Audit Officer of PMU will coordinate external audit task.

89

Schedule of Activities for Nutrition Program Punjab

Annexure

Activity Year 1 Year 2 Year 3

1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th

Selection of Centre for Nutrition Activities

Component 1: Addressing General Malnutrition

among Children, Pregnant and Lactating Women

Sub Component 1.1 Infant and Young Child Feeding

(IYCF)

1.1.1 Provincial level dissemination of IYCF Strategy

1.1.2 Training of district master trainers on IYCF) in 12 districts (02 Master trainers per districts)

1.1.3 Training of Health care facility staff on IYCF component at District level

1.1.4 Training of LHWs, CMWs on IYCF component at facility level

1.1.5 Training of LHS on IYCF and Nutrition supportive monitoring

1.1.5.1 Development of MIS monitoring and reporting tools

1.1.5.2 Preparation of Training manual for reporting and monitoring tools

1.1.5.3 Training of LHS on monitoring and reporting tools

1.1.6 Implementation of IYCF activities

Sub Component 1.2 Community Management of

90

Acute Malnutrition for children and pregnant and lactating women

1.2.1 Training of district master trainers on Nutrition

1.2.2 Training of health care facility staff (BHU, RHC) on nutrition

1.2.3 Training of LHWs on Screening referral

1.2.4 Implementation of CMAM activities

1.2.11

Strengthening/operationalization of Health facilities as OTPs (BHUs and RHCs)

1.2.11.1 Provision of OTP supplies and equipment

1.2.11.2 Procurement and distribution of Ready to use therapeutic food (RUTF)

1.2.12

Strengthening/operationalization of stabilization centers at the DHQ level

1.2.12.1 Recruitment and training of SC staff

1.2.12.2 Provision of SC supplies and equipment

1.2.12.3 distribution of F100 and F75

1.2.12.4 distribution of Ready to use Therapeutic food


1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th

91

Sub-Component 1.3 Management of Maternal

Malnutrition

1.3.1 Procurement and Distribution of Iron Folic Acid tablets

1.3.2 Provision of Iron Folic Acid tablets to Pregnant women and Adoscolent girls

Component 2: Addressing Micronutrient

Malnutrition:

Sub Component 2.2 Universal salt iodization program:

2.1.2 Developing and designing the legislative/Enforcement mechanisms for solt iodization fortification of all food items to be fortified

Consultative Meetings with Private Sector for arrangements for procurement and distribution of KOI at commercial rates

Refresher training of health managers and District Focal Persons on management, monitoring and quality control of iodized salt.

Refresher training of salt processors on salt iodization techniques & internal quality control.

Bi Annual meeting of provincial steering committee on IDD/USI and district IDD Control Committees

Sub Component ___Vitamin A Supplementation Program

2.1.1 Provincial level seminars on VAS with the line departments and development partners for

92

advocacy and sensitization on VAS

Refresher training of health managers and district EPI focal persons on management of Vitamin A supplementation campaign and its monitoring.

Awareness raising sessions of Medical Officers, School Health and nutrition supervisors, vaccinators and Lady health supervisors.


1st Q 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th

Sub Component 2.4 Zinc supplementation during

treatment of diarrhea

2.4.1 Procurement and distribution of Zinc sulphate

2.4.2 Training of Health Facility Staff

2.4.3 Training of LHWs/CMWs

2.4.4 Treatment of Diarrhea with Zinc Sulphate and ORS

Subcomponent 2.5 Use of Multimicronutrient

Powder through LHWs program

2.5.1 Procurement and distribution of Multi Micronutrient Powder Sachet

2.5.2 Training of Lady Health Workers, LHSand CMWs

2.5.3 Provision of Multimieronutrient Sachet to children 06-23 months of age

Component 3 Communication For Development

93

3.1.1 IEC matrial for distribution to Health Facility and Community based staff

3.1.4 Material Field tested and implemented

3.1.2 Distribution of IEC matrial to Districts

Component 4. Strengthening Institutional

Arrangements

4.1.1 Placing of appropriate staff at provincial and district level

4.1.3 Meeting of the provincial Integrated Nutrition committee

4.1.1 Meetings of Provincial coordination committee

4.1.2 Meetings of District Coordination Committee

4.1.3 Meetings of Thematic Working Group

4.1.4 Collaboration meeting with partners

Strengthening Research, Monitoring and Evaluation Systems

5.1.1 Annual Assessments

5.1.2 Integration of different infromation systems

94

95

96

DGHSProgram DirectorAdditional PD IFinance Officers I and IIAccountantsLogistics OfficerProcurement OfficerLogistic Assistant/ Store KeeperInternal AuditorAdditional PD IIDeputy PD Human ResourceDeputy PD Training and Capacity BuildingTraining Coordinator Health Education OfficerR&D OfficerResearcherData Analysts Deputy PD MIS/M&ESoftware DeveloperMIS Coordinator Data AnalystsData Entry OperatorsAdditional PD IIIDeputy PD Community Based InterventionsNutrition OfficerDeputy PD Facility Based Interventions

Annex: Organogram 97

EDO (H) DDOH (PHC & RH)M&E (Adm)M&E (Tech)Accounts AssistantLogistics AssistantData Entry Operator

Annex: Facility Based Services

98

99

ANNEXURES

100

STAFF STRENGTH

S.No Cadre

No of FLCF BPS/Fixed Salary Strength No of FLCF BPS/Fixed

Salary Strength No of FLCF BPS/Fixed Salary Strength

FINANCIAL YEAR 2013-14 FINANCIAL YEAR 2014-15 FINANCIAL YEAR 2015-16

Field Staff

1 Nursing Staff (for DHQ Nutrition)

34 DHQ +2 Teaching hospital

Fixed Salary

72 34 DHQ +2 Teaching hospital

Fixed Salary

72 34 DHQ +2 Teaching hospital

Fixed Salary

72

2 WMO 292 RHCs 292 292 RHCs 292 292 RHCs 2923 Computer Operator PMU 2 PMU 2 PMU 24 LHVs (CHARM) 300 BHUs 600 500 BHUs 1000 700 BHUs 14005 Aya (CHARM) 300 BHUs 600 500 BHUs 1000 700 BHUs 1400

6 Ambulance drivers (CHARM) 200 333 466

7 Gaurds (CHARM) 300 BHUs 300 500 BHUS 500 700 BHUs 1400Total Field Staff (2013-14) 2066 Total Field Staff (2014-15) 3199 Total Field Staff (2015-16) 5032

PMU STAFF

1 Program Manager Nutrition 18/19 1 Program Manager Nutrition 18/19 1 Program Manager

Nutrition 18/19 1

2 Nutrition Officer 17 1 Nutrition Officer 17 1 Nutrition Officer 17 1

3 Software Engineer 17 1 Software Engineer 17 1 Software Engineer 17 1

4 Statestical Officer 17 1 Statestical Officer 17 1 Statestical Officer 17 1Total PMU Staff (2013-14) 4 Total PMU Staff (2014-15) 4 Total PMU Staff (2015-16) 4

Total PMU + Field Staff (2013-14) 2070 Total PMU + Field Staff (2014-15) 3203 Total PMU + Field Staff (2015-16) 5036

101

Targeted Married Women & Children Per Beneficiary Cost

Total Population

16 % Married Women of Total

Population

14 % Children of Total

Population

Total Population of

Married Women & Children

Average Cost 2013-16

Average Annual Cost of Married Women

& Children

94,000,000 15,040,000 13,160,000 28,200,000 3,271,390,359 116

Total Population

Targeted Population of


Average Annual Cost of


94,000,000 28,200,000 116

102

020,000,00040,000,00060,000,00080,000,000

100,000,000

Series1

Total Required Cost for Procurement of Contraceptives

Total Population

Urban Population

(30% of Total

Population)

Rural Population

(70% of Total

Population)

Eligible Couples in Urban Area

(16% of Urban Population)

Eligible Couples in Rural Area

(16% of Rural

Population)

Targeted Eligible

Couples in Urban/Users of Contraceptives

(25% of Eligible

Couples in Urban Area)

Targeted Eligible

Couples in Rural/Users of Contraceptive

s (50% of Eligible

Couples in Rural Area)

Contraceptive Cost per Couple

per month in Urban (Targeted Eligible Couple s in Urban x 30x

12)

Contraceptive Cost per Couple

per month in Rural (Targeted Eligible Couple s in Rural x 30x

12)

Total Cost of Contraceptives for per couple

per month

94,157,907

28,247,372

65,910,535 4,519,580 10,545,68

6 1,129,895 5,272,843 406,762,158 1,898,223,405

2,304,985,563

Budget Demand for Procurement of Contraceptives in PC-I by the Vertical Program

S.No Name of Program FY Budget

Demanded

1

Lady Health Worker

Program

2011-17 575364924

2National MNCH

Program2012-16 800,000,00

0

3 Nutrition + CHARM 2013-16 850000000

Total 2225364924

103

1 2 3 Total0

500000000

1000000000

1500000000

2000000000

2500000000

Name of ProgramFYBudget Demanded

Year wise Cost Sheets for UNICEF & WFP Shares

S.No FY

UNICEF Share (Cost of Mobendazoal+Cost per SAM Child in 07

Districts)

WFP Share (Cost Per PLW for Rajanpur &

D.G.Khan)

Total UNICEF & WFP Share

1 2013-14 260,155,109 43,336,800 303,491,909

2 2014-15 - 43,336,800 43,336,8003 2015-16 - 43,336,800 43,336,800

Total 260,155,109 130,010,400 390,165,509

104

-

100,000,000

200,000,000

300,000,000

400,000,000

123Total

District wise phasing of Implementation of MCH and Nutrition Interventions

Sr. No Name Of District

2013-14 2014-15 2015-16

Nutrition Interventions 24/7 Nutrition

Interventions 24/7 Nutrition Interventions 24/7

1 Narowal 2 Layyah 3 Mianwali 4 Multan 5 Hafizabad 6 Rahimyar Khan 7 Pakpattan 8 D. G. Khan 9 Muzaffargarh

10 Bhakkar 11 Rajanpur 12 Bhawal Nagar 13 Jhang 14 Sargodha 15 Bahwalpur 16 Khanewal 17 Rawalpindi 18 Sahiwal 19 Faisalabad 20 Sialkot 21 Lahore 22 Attock 23 Chiniot 24 Gujrat 25 Khushab 26 Jhang 27 Jhelum 28 Kasur 29 Lodhran 30 Vehari 31 M.B. Din 32 Chakwal 33 Nankana Sahib 34 Okara 35 Sheikhupura 36 T.T. Singh

105

PAY OF OFFICERS Basic Pay Pay of Contract Staff ALLOWANCESREGULAR ALLOWANCES House Rent Allowance Conveyance Allowance Medical AllowanceDeputation Allowance Special Travelling Allowance (FTA) Non Practicing Allowance Special Additional Allowance (50%

2010)Adhoc Relief Allowance (15% 2011)

OTHER ALLOWANCES Over Time Allownace Honorarium/Incentive for per-formance/

Medical Charges Contingent Paid staff Other (Stipend of LHVs, Ayas, Ambulance Drivers & Guards)

OPERATING EXPENSES

COMMUNICATION Postage and Telegraph Telephone and Trunk Calls Charges

Telex. Teleprinter and Fax

Electronic communication ( E - Governance + Internet Charges)

Courior and Pilot Services UTILITIES Electricity Charges

OCCUPANCY COSTS Rates & Taxes( Vehicles Tax & Toll Tax)

TRAVEL & TRANSPORTATION GOVT. SERVANTS

Training -Domestic (all training s &TOT) for 03 trainings

T.A (Govt. Servants) Transportation of Goods POL Charges

Local Conveyance Charges GENERAL Stationary Printing and Publication ( MIS Tools, Training manuals , BCC Ma-terial etc

Conference /Siminars/Work-shops/Symposium/ Review Meet -ings

News Papers, Periodicals & Books Advertising & Publicity Law Charges

Purchase of Drug and Medicines & Tab Iron Folic Acid for Nutrition

Others ( Supplies for nutrition components & consumables)

EMPLOYEES RETIREMENT BENEFITS PENSION

Pension Contribution Social Security Benefits to Contract Employees (30%)

Entertainment & Gift Entertainment & Gift

PHYSICAL ASSETS COMPUTER EQUIPMENT Software ( Call Response center+ Web based MIS etc)

IT Equipment

OTHER STORE AND STOCK Medical Stores OTHER STORE AND STOCK PLANT AND MACHINERYMACHINERY AND EQUIPMENT FURNITURE AND FIXTURE Furniture and Fixture REPAIRS AND MAINTENANCETRANSPORT Transport COMPUTER EQUIPMENT

106

Integrated Reproductive Maternal Newborn & Child Health &Nutrition ProgramYearwise Phasing for the Financial Year 2013-16

Object Heads Financial Year 2013-14

Financial Year 2014-15

Financial Year 2015-16 Total 2013-16 Average 2013-16

A01 EMPLOYEE RELATED EXPENSES 588,210,384 789,970,384 1,090,684,384 2,468,865,152 822,955,051

PAY 1,719,600 1,719,600 1,719,600 5,158,800 1,719,600

PAY OF OFFICERS 1,719,600 1,719,600 1,719,600 5,158,800 1,719,600

A01106 Pay of Contract Staff 1,119,600 1,119,600 1,119,600 3,358,800 1,119,600

A012 ALLOWANCES 586,490,784 788,250,784 1,088,964,784 2,463,706,352 821,235,451

REGULAR ALLOWANCES 53,930,784 53,930,784 71,450,784 179,312,352 59,770,784

A01202 House Rent Allowance 229,296 229,296 229,296 687,888 229,296

A01203 Conveyance Allowance 240,000 240,000 240,000 720,000 240,000

A01217 Medical Allowance 146,544 146,544 146,544 439,632 146,544

A01236 Deputation Allowance 72,000 72,000 72,000 216,000 72,000

A01243 Special Travelling Allowance (FTA) 52,560,000 52,560,000 70,080,000 175,200,000 58,400,000

A01252 Non Practicing Allowance 48,000 48,000 48,000 144,000 48,000

A01964 Special Additional Allowance (50% 2010) 488,400 488,400 488,400 1,465,200 488,400A0

1970 Adhoc Relief Allowance (15% 2011) 146,544 146,544 146,544 439,632 146,544

OTHER ALLOWANCES 532,560,000 734,320,000 1,017,514,000 2,284,394,000 761,464,667

A01271 Over Time Allownace 10,000 10,000 10,000 30,000 10,000

A01273 Honorarium/Incentive for performance/ 44,160,000 44,160,000 44,160,000 132,480,000 44,160,000

A01274 Medical Charges 50,000 6,804,000 6,804,000 13,658,000 4,552,667

A01277 Contingent Paid staff 25,500,000 25,500,000 18,300,000 69,300,000 23,100,000

A01299 Other (Stipend of LHVs, Ayas, Ambulance Drivers & Guards) 462,840,000 657,846,000 948,240,000 2,068,926,000 689,642,000

A03 OPERATING EXPENSES 553,534,213 602,678,846 696,046,618 1,852,259,677 617,419,892

A032 COMMUNICATION 1,160,000 1,160,000 1,160,000 3,480,000 1,160,000

A03201 Postage and Telegraph 20,000 20,000 20,000 60,000 20,000

A03202 Telephone and Trunk Calls Charges 100,000 100,000 100,000 300,000 100,000

A03203 Telex. Teleprinter and Fax 40,000 40,000 40,000 120,000 40,000

A03204 Electronic communication ( E - Governance + Internet Charges) 800,000 800,000 800,000 2,400,000 800,000

A03205 Courior and Pilot Services 200,000 200,000 200,000 600,000 200,000

A033 UTILITIES 600,000 600,000 600,000 1,800,000 600,000

A03303 Electricity Charges 600,000 600,000 600,000 1,800,000 600,000

A034 OCCUPANCY COSTS 500,000 500,000 500,000 1,500,000 500,000

A03407 Rates & Taxes( Vehicles Tax & Toll Tax) 500,000 500,000 500,000 1,500,000 500,000

A038 TRAVEL & TRANSPORTATION 131,860,000 57,874,000 75,996,000 265,730,000 88,576,667

GOVT. SERVANTS 131,860,000 57,874,000 75,996,000 265,730,000 88,576,667

A03801 Training -Domestic (all training s &TOT) for 03 trainings 82,350,000 22,300,000 27,750,000 132,400,000 44,133,333

A03805 T.A (Govt. Servants) 500,000 500,000 500,000 1,500,000 500,000

A03806 Transportation of Goods 25,000,000 3,000,000 3,000,000 31,000,000 10,333,333

A03807 POL Charges 24,000,000 32,064,000 44,736,000 100,800,000 33,600,000

107

A03808 Local Conveyance Charges 10,000 10,000 10,000 30,000 10,000

A039 GENERAL 419,414,213 542,544,846 617,790,618 1,579,749,677 526,583,226

A03901 Stationary 100,000 100,000 100,000 300,000 100,000

A03902 Printing and Publication ( MIS Tools, Training manuals , BCC Material etc 4,000,000 4,000,000 2,000,000 10,000,000 3,333,333

A03903Conference /Siminars/Workshops/Symposium/ Review Meetings

600,000 600,000 600,000 1,800,000 600,000

A03905 News Papers, Periodicals & Books 10,000 10,000 10,000 30,000 10,000

A03907 Advertising & Publicity 2,000,000 2,000,000 2,000,000 6,000,000 2,000,000

A03917 Law Charges 5,000 5,000 5,000 15,000 5,000

A03927 Purchase of Drug and Medicines & Tab Iron Folic Acid for Nutrition 410,299,213 533,429,846 612,115,618 1,555,844,677 518,614,892

A03970 Others ( Supplies for nutrition components & consumables) 2,400,000 2,400,000 960,000 5,760,000 1,920,000

A04 EMPLOYEES RETIREMENT BENEFITS 312,804 312,804 312,804 938,412 312,804

A041 PENSION 312,804 312,804 312,804 938,412 312,804

A04101 Pension Contribution 140,004 140,004 140,004 420,012 140,004

A04115 Social Security Benefits to Contract Employees (30%) 172,800 172,800 172,800 518,400 172,800

A06 Entertainment & Gift 10,000 10,000 10,000 30,000 10,000

A06301 Entertainment & Gift 10,000 10,000 10,000 30,000 10,000

A09 PHYSICAL ASSETS 1,302,996,603 2,108,327,890 2,077,909,344 5,489,233,837 1,829,744,612

A092 COMPUTER EQUIPMENT 5,200,000 2,600,000 2,400,000 10,200,000 3,400,000

A09202 Software ( Call Response center+ Web based MIS etc) 2,000,000 1,000,000 800,000 3,800,000 1,266,667

A09203 IT Equipment 3,200,000 1,600,000 1,600,000 6,400,000 2,133,333

A094 OTHER STORE AND STOCK 1,117,946,603 1,975,427,890 1,926,534,344 5,019,908,837 1,673,302,946

A09401 Medical Stores (Contraceptives) 550,000,000 300,000,000 850,000,000 283,333,333

A09470 OTHER STORE AND STOCK 1,117,946,603 1,425,427,890 1,626,534,344 4,169,908,837 1,389,969,612

A096 PLANT AND MACHINERY 177,000,000 128,400,000 147,150,000 452,550,000 150,850,000

A09601 MACHINERY AND EQUIPMENT 177,000,000 128,400,000 147,150,000 452,550,000 150,850,000

A097 FURNITURE AND FIXTURE 2,850,000 1,900,000 1,825,000 6,575,000 2,191,667

A09701 Furniture and Fixture 2,850,000 1,900,000 1,825,000 6,575,000 2,191,667

A13 REPAIRS AND MAINTENANCE 948,000 948,000 948,000 2,844,000 948,000

A130 TRANSPORT 848,000 848,000 848,000 2,544,000 848,000

A13001 Transport 848,000 848,000 848,000 2,544,000 848,000

A137 COMPUTER EQUIPMENT 100,000 100,000 100,000 300,000 100,000

A13702 Software 100,000 100,000 100,000 300,000 100,000

TOTAL 2,446,012,005 3,502,247,924 3,865,911,150 9,814,171,078 3,271,390,359

108

Integrated Reproductive Maternal Newborn & Child Health &Nutrition Program

Budget Requirement for Financial Year 2013-14

Object Heads Budget Demand

A01 EMPLOYEE RELATED EXPENSES 588,210,384

PAY 1,719,600

PAY OF OFFICERS 1,719,600

A01101 Basic Pay 600,000

A01106 Pay of Contract Staff 1,119,600

A012 ALLOWANCES 586,490,784

REGULAR ALLOWANCES 53,930,784

A01202 House Rent Allowance 229,296

A01203 Conveyance Allowance 240,000

A01217 Medical Allowance 146,544

A01236 Deputation Allowance 72,000

A01243 Special Travelling Allowance (FTA) 52,560,000

A01252 Non Practicing Allowance 48,000

A01964 Special Additional Allowance (50% 2010) 488,400A0

1970 Adhoc Relief Allowance (15% 2011) 146,544

OTHER ALLOWANCES 532,560,000

A01271 Over Time Allownace 10,000

A01273 Honorarium/Incentive for performance/ 44,160,000

A01274 Medical Charges 50,000

A01277 Contingent Paid staff 25,500,000

A01299 Other (Stipend of LHVs, Ayas, Ambulance Drivers & Guards) 462,840,000

A03 OPERATING EXPENSES 553,534,213

A032 COMMUNICATION 1,160,000

A03201 Postage and Telegraph 20,000

A03202 Telephone and Trunk Calls Charges 100,000

A03203 Telex. Teleprinter and Fax 40,000

A03204 Electronic communication ( E - Governance + Internet Charges) 800,000

A03205 Courior and Pilot Services 200,000

A033 UTILITIES 600,000

A03303 Electricity Charges 600,000

A034 OCCUPANCY COSTS 500,000

A03407 Rates & Taxes( Vehicles Tax & Toll Tax) 500,000

A038 TRAVEL & TRANSPORTATION 131,860,000

GOVT. SERVANTS 131,860,000

A03801 Training -Domestic (all training s &TOT) for 03 trainings 82,350,000

A03805 T.A (Govt. Servants) 500,000

A03806 Transportation of Goods 25,000,000

A03807 POL Charges 24,000,000

109

A03808 Local Conveyance Charges 10,000

A039 GENERAL 419,414,213

A03901 Stationary 100,000

A03902 Printing and Publication ( MIS Tools, Training manuals , BCC Material etc 4,000,000

A03903 Conference /Siminars/Workshops/Symposium/ Review Meetings 600,000

A03905 News Papers, Periodicals & Books 10,000

A03907 Advertising & Publicity 2,000,000

A03917 Law Charges 5,000

A03927 Purchase of Drug and Medicines & Tab Iron Folic Acid for Nutrition 410,299,213

A03970 Others ( Supplies for nutrition components & consumables) 2,400,000

A04 EMPLOYEES RETIREMENT BENEFITS 312,804

A041 PENSION 312,804

A04101 Pension Contribution 140,004

A04115 Social Security Benefits to Contract Employees (30%) 172,800

A06 Entertainment & Gift 10,000

A06301 Entertainment & Gift 10,000

A09 PHYSICAL ASSETS 1,302,996,603

A092 COMPUTER EQUIPMENT 5,200,000

A09201 Hardware

A09202 Software ( Call Response center+ Web based MIS etc) 2,000,000

A09203 IT Equipment 3,200,000

A094 OTHER STORE AND STOCK 1,117,946,603

A09401 Medical Stores (Contracepitves)


A096 PLANT AND MACHINERY 177,000,000

A09601 MACHINERY AND EQUIPMENT 177,000,000

A097 FURNITURE AND FIXTURE 2,850,000

A09701 Furniture and Fixture 2,850,000

A13 REPAIRS AND MAINTENANCE 948,000

A130 TRANSPORT 848,000

A13001 Transport 848,000

A137 COMPUTER EQUIPMENT 100,000

A13702 Software 100,000

TOTAL 2,446,012,005

110

Budget Requirement for transport ( Ambulances ) For the Financial Year 2013-14

Sr. No. Name of District No. of Vehicles A-03807 POL A-13001 ROT Total Budget

Required

1 Ambulances 100 24,000,000 4,200,000 28,200,000

Total Budget Required 41,472,000 848,000 49,952,000

111

Budget Requirement of POL (A-03807)For the Financial Year 2013-14

Sr. No.

Name of District No. of Vehicles Rate Per Month No. of

MonthsTotal POL

Budget Required

1 Ambulances 100 20,000 12 24,000,000

Total Budget Required 24,000,000

112

Budget Requirement of A-13001 Repair (Vehicle/Transport) For the Financial Year 2013-14

Sr. No. Name of District

No. of Vehicle

s

Repair of Vehicle @ Rs.

2500/- P.m.Total Budget for Repair of

Vehicle Required

1 Ambulances 100 4,200,000 4,200,000


113

Budget Demand under the Head A-03801 Training Domestic for the Financial Year 2013-14

Sr. No. Cadre No. of

Posts Unit CostTraining No. of Days

Total Amount

1 Training of HCPs on Nutrition and IYCF 300 2000 5 3,000,000.00

2 Training on IMNCI 300 3000 11 9,900,000.00

3 Training of LHWs & CMWs on Nutrition & IYCF 8000 900 4 28,800,000.00

4 Training of Medical officer on PHC & Nutrition 300 2500 3 2,250,000.00

5 Training of HCPs on EmONC & FP 600 2000 7 8,400,000.00

6 Training of LHWs LHSs on HTSP & FP 15000 500 4 30,000,000.00

Total 82,350,000.00Grand Total 82,350,000.00

114

COST OF MEDICINES CHARAM (24/7)

Category # of Units Unit Cost per month # of Months Total

RHCs 162 3000 12 5832000

Basic Health Units 300 2500 12 9000000

Total 14,832,000

115


Recurring Costs

Category Managerial Staff Number Unit Cost/ Monthly

Monthly Total

Annual Total (Rs)

Annual Total $

PMU

Chairperson 1 - - - -Program Director 1 - - - -Deputy PD 1 - - -Human Resource Manger 1 - - - -Finance Manager 1 - - - -MIS Manager 1 - - - -Office Assistant 1 - - -

DSU

District Manager - - -M & E Officer - - -Data Entry - - -Program Assistant - -Accounts Officer - - -

BHU

FTA for WMO 292 15000 4,380,000 52,560,000 611,162.79WMO 292 55000 16,060,000 192,720,000 2,240,930.23LHVs 600 15000 9,000,000 108,000,000 1,255,813.95Ayas 600 7000 4,200,000 50,400,000 586,046.51Security Guards 300 7500 2,250,000 27,000,000 313,953.49Drivers 200 10000 2,000,000 24,000,000 279,069.77Medicines 300 2500 750,000 9,000,000 104,651.16FP Material 0 0 - - -Pay for performance 40 50000 2,000,000 24,000,000 279,069.77Consumables (Lab Kits and gloves) 300 2000 600,000 7,200,000 83,720.93

Petty Cash 300 2000 600,000 7,200,000 83,720.93POL for ambulances 100 16500 1,650,000 19,800,000 230,232.56

PMU

Operational Cost ( POL & Office suplies) 1 0 - - -

TA/DA 1 0 - - -Miscellaneous 0 0 - - -

DSU

Operational Cost ( POL, Repair of transport & Office suplies)

20 0 - - -

Miscellaneous 20 10000 200,000 2,400,000 27,906.98

RHCsAdditional HR 20 50000 1,000,000 12,000,000 139,534.88Medicines 162 3500 567,000 6,804,000 79,116.28

THQAdditional HR 45 25000 1,125,000 13,500,000 156,976.74PGRs 40 0 - - -

Overall Operationa

l Costt

Advertisements 1 - 2,000,000 23,255.81MRM @ District 20 10000 200,000 2,400,000 27,906.98Quarterly Review Meeting & Dissemination 4 150000 600,000 600,000 6,976.74

Call Response Center 20 100000 2,000,000 2,000,000 23,255.81

116

Printing 4 150000 600,000 600,000 6,976.74Total 561,584,000 6,530,046.51

One Time Cost

BHU

Basic Equipment for BHUs 300 150000 45,000,000 45,000,000 523,255.81UPS with Battries 300 35000 10,500,000 10,500,000 122,093.02F&F for BHUs 300 9500 2,850,000 2,850,000 33,139.53Computers & Printer 0 35000 - - -Ambulances 100 0 - - -

DSU/RSU

Furniture & Fixture for DSU 16 0 - - -

IT Equipment (Laptop, PC, desktop, Printer, Fax) 16 200000 3,200,000 3,200,000 37,209.30

USG Portable 150 500000 75,000,000 75,000,000 872,093.02 Repair & Renovation 15 0 - - -RHCs Equipment for RHCs 20 800000 16,000,000 16,000,000 186,046.51THQ& DHQ

Equipment for THQs/DHQs 50 400,000 20,000,000 20,000,000 232,558.14

0 - - -Total - - -

172,550,000 2,006,395.35-

Annual Cost Two Years

Cost One Time Cost Total (Rs) Total $

561,584,000 1,123,168,000 172,550,000 1,295,718,000 14,724,068

117

Budget Requirement under Head A-01299 Others (Stipend of LHVs/Ayas/Ambulance Drivers & Guards for the Financial Year 2013-14

Sr. No. Cadre # of Health Facilities BPS Strength Net Pay Period

Budget Requirement in

Rs.

1 Nursing Staff (for DHQ Nutrition) 34 DHQ +2 Teaching hospital

Fixed Salary

72 30000 12 25920000

2 WMO 292 RHCs 292 55000 12 192720000

3 Computer Operator PMU 2 25000 12 600000

4 LHVs (CHARM) 300 BHUs 600 17000 12 122,400,000

5 Aya (CHARM) 300 BHUs 600 9000 12 64,800,000

6 Ambulance drivers (CHARM) 200 10000 12 24,000,000

7 Gaurds (CHARM) 300 BHUs 300 9000 12 32,400,000

Total 2066 462,840,000.00

118

Summary for Budget Requirement of Salary of Nutrition Program Staff working in Scales for the period July-2013 to June 2014 during the financial year 2013-14

Sr. No.

Particulars

A01101 Basic Pay

A01105

Qualif. Pay

Personal Pay

A01106 Pay of

Contract Staff

A01156 Pay of

Contract Staff

A01202 House Rent

Allow.

A01203 Conv Allow.

A01236 Deput. Allow.

A01252 NPA

A01224 Entertainmen

t Allow.

A01217 Medical Allow

A01964 SAA (2010) SPHA

Comp

Allow

A04115 Social Security 30%

A-01970 Adhoc Relief Allow. 15%

20% Adhoc Relief

Allowance (2012)

Total

1Staff Salary July to Nov-13

250,000 0 0 456,000 0 95,540 100,000 30,000 20,000 0 61,060 203,500 56,000 0 72,000 61,060 91,200 1,496,360

2Staff Salary Dec to June-14

350,000 0 0 663,600 0 133,756 140,000 42,000 28,000 0 85,484 284,900 78,400 0 100,800 85,484 132,720 2,125,144

Total Budget Requirement for

2013-14600,000 0 0 1,119,60

0 0 229,296 240,000 72,000 48,000 0 146,544 488,400 134,400 0 172,800 146,544 223,920 3,621,504

119

Budget Requirement of Salary for the staff of Nutrition Program Punjab for the period Dec-13 to June-2014

Sr. No.

Particulars BPS

A01101 Basic Pay

A01105 Qualif.

PayPersonal

Pay

A01106 Pay of

Contract Staff

A01156 Pay of

Contract Staff

A01202 House Rent

Allow.

A01203 Conv Allow.


A01252 NPA

Entertainment Allow


SAA (2010) SPHA Comp

AllowSocial

Security 30%

Adhoc Relief Allow. 15%


Total

01 Posts of BPS-18

1Program Manager Nutrition

19 50000 5809 5000 6000 4000 4448 14825 11200 4448 0 105730

Total 50000 0 0 0 0 5809 5000 6000 4000 0 4448 14825 11200 0 0 4448 0 105730

03 Posts of BPS-17

1 Nutrition Officer 17

31600 4433 5000 2588 8625 4800 2588 6320 65954

2 Software Engineer 17

31600 4433 5000 2588 8625 4800 2588 6320 65954

3 Statestical Officer 17

31600 4433 5000 2588 8625 4800 2588 6320 65954

Total 0 0 0 94800 0 13299 15000 0 0 0 7764 25875 0 0 14400 7764 18960 197862

Total PMU Salary for one Month 50,000 0 0 94,800 0 19,108 20,000 6,000 4,000 0 12,212 40,700 11,200 0 14,400 12,212 18,960 303,592

Budget for Dec-13 to June-14 350,000 0 0 663,600 0 133,756 140,000 42,000 28,000 0 85,484 284,900 78,400 0 100,800 85,484 132,720 2,125,144

120

Budget Requirement of Salary for the staff of Nutrition Program Punjab for the period July-13 to Nov-13

Sr. No. Particulars BPS

A01101 Basic Pay

A01105 Qualif.

PayPersonal

PayA01106 Pay of Contract

Staff

A01156 Pay of Contract

Staff

A01202 House Rent

Allow.

A01203 Conv Allow.


A01252 NPA

Entertainment Allow



AllowSocial

Security 30%


Adhoc Relief Allow.

20%Total

01 Posts of BPS-18


18 50000 5809 5000 6000 4000 4448 14825 11200 4448 0 105730

Total 50000 0 0 0 0 5809 5000 6000 4000 0 4448 14825 11200 0 0 4448 0 105730

03 Posts of BPS-17


30400 4433 5000 2588 8625 4800 2588 6080 64514


30400 4433 5000 2588 8625 4800 2588 6080 64514


30400 4433 5000 2588 8625 4800 2588 6080 64514

Total 0 0 0 91200 0 13299 15000 0 0 0 7764 25875 0 0 14400 7764 18240 193542


Budget for July 13 to Nov-13 250,000 0 0 456,000 0 95,540 100,000 30,000 20,000 0 61,060 203,500 56,000 0 72,000 61,060 91,200 1,496,360

121

Cost Sheet of Nutrition Budget for the Financial Year 2013-14

S.No Districts

Total population of districts

50%Target

Population For

12 District & for 09 Urban slam

Districts is 25%

Total childr

en age 6 to 59 month 14

%

MICs 2010-11

# of target

Children

SAM 30 % + 2% relapse & incidence rate ( 4% of Total target population)

Cost per SAM Child

# children age

6 month

to 2 years

Cost per Multinutrie

nt supplementation for 6 month to 2

years

# childr

en age 2 to 5

years

Cost for tab.

Mebandazole

Total PLW7.5 %

13 % MAM

PLW + 1.5 %

Relapse &

Incidence rate

Cost per PLW

Cost for Tab.Iron Folic Acid

SC Cost (F 75 & F 100)

Cost for Anthropometry Equipment

Total Cost for Supplies

1

Narowal1516173 758086.5

10613216

16981 5298 21192460 30323 6822779 56856 341139 56856 7650 12240065 7107061 100000 500000 48303503

2

Layyah1486000 743000

104020 14 14563 4544 18174374 29720 6687000 55725 334350 55725 7498 11996478 6965625 100000 500000 44757827

3

Mianwali1309000 654500

91630 21 19242 6004 24014390 26180 5890500 49088 294525 49088 6573 10516506 6135938 100000 500000 47451859

4

Multan3994000 1997000

279580 20 55916 17446 69783168 79880 17973000 149775 898650 149775 20055 32087796 18721875 100000 500000 140064489

5

Khushab1131786 565893

79225 19.7 15607 4869 19477947 22636 5093037 42442 254652 42442 5683 9092769 5305247 100000 500000 39823651

6

Rahimyar Khan 4198000 2099000

293860 19 55833 17420 69680083 83960 18891000 157425 944550 157425 30698 49116600 19678125 100000 500000 158910358

7

Pakpattan1617000 808500

113190 19 21506 6710 26839613 32340 7276500 60638 363825 60638 11824 18918900 7579688 100000 500000 61578525

8

D. G. Khan 2219000 1109500

155330 19 29513 9208 36831850 44380 9985500 83213 499275 83213 16226 25962300 10401563 100000 500000 84280487

9

Muzaffargarh 3579000 1789500

250530 17 42590 13288 53152445 71580 16105500 134213 805275 134213 26171 41874300 16776563 100000 500000 129314082

10

Bhakkar1368150 684075

95771 26 24900 7769 31075612 27363 6156675 51306 307834 51306 10005 16007355 6413203 100000 500000 60560679

11

Rajanpur1485000 742500

103950 13.7 14241 4443 17772955 29700 6682500 55688 334125 55688 10859 17374500 6960938 100000 500000 49725018

12

Bhawal Nagar 2566000 1283000

179620 17 30535 9527 38108179 51320 11547000 96225 577350 96225 18764 30022200 12028125 100000 500000 92882854

13

Gujranwala 4404000 880800

123312 13 16031 5002 20006139 35232 7927200 66060 396360 66060 12882 20610720 8257500 500000 57697919

14

Sargodha3189000 637800

89292 12 10715 3343 13372370 25512 5740200 47835 287010 47835 9328 14924520 5979375 500000 40803475

15

Rawalpindi 4321000 864200

120988 13 15728 4907 19629093 34568 7777800 64815 388890 64815 12639 20222280 8101875 500000 56619938

16

Faisalabad 6822000 1364400

191016 14 26742 8344 33374316 54576 12279600 102330 613980 102330 19954 31926960 12791250 500000 91486106

17

Bhawal Pur 3217000 643400

90076 14 12611 3935 15738079 25736 5790600 48255 289530 48255 9410 15055560 6031875 500000 43405644

18

Sahiwal2242000 448400

62776 16 10044 3134 12535112 17936 4035600 33630 201780 33630 6558 10492560 4203750 500000 31968802

19

Khanewal2585000 517000

72380 21 15200 4742 18969350 20680 4653000 38775 232650 38775 7561 12097800 4846875 500000 41299675

20

Sialkot3435000 687000

96180 12 11542 3601 14403917 27480 6183000 51525 309150 51525 10047 16075800 6440625 500000 43912492

21

Lahore8650000 1730000

242200 14 33908 10579 42317184 69200 15570000 129750 778500 129750 25301 40482000 16218750 500000 115866434

####### ####### ###### 493949 154112 ########## 840302 ######## ###### 9453400 1575567 285,686 ######## ########## ######## 10,500,000 1,480,713,817

122




A01 EMPLOYEE RELATED EXPENSES 789,970,384

PAY 1,719,600

PAY OF OFFICERS 1,719,600A0110

1 Basic Pay 600,000


A012 ALLOWANCES 788,250,784

REGULAR ALLOWANCES 53,930,784A0120

2 House Rent Allowance 229,296






A01964 Special Additional Allowance (50% 2010) 488,400

A0 1970 Adhoc Relief Allowance (15% 2011) 146,544

OTHER ALLOWANCES 734,320,000A0127

1 Over Time Allownace 10,000


A01274 Medical Charges 6,804,000




A032 COMMUNICATION 1,160,000A0320

1 Postage and Telegraph 20,000





A033 UTILITIES 600,000A0330

3 Electricity Charges 600,000

A034 OCCUPANCY COSTS 500,000A0340

7 Rates & Taxes( Vehicles Tax & Toll Tax) 500,000


123

GOVT. SERVANTS 57,874,000A0380

1 Training -Domestic (all training s &TOT) for 03 trainings 22,300,000



A03807 POL Charges 32,064,000


A039 GENERAL 542,544,846A0390

1 Stationary 100,000







A03970 Others ( Supplies for nutrition components & consumables) 2,400,000


A041 PENSION 312,804A0410

1 Pension Contribution 140,004


A06 Entertainment & Gift 10,000A0630

1 Entertainment & Gift 10,000


A092 COMPUTER EQUIPMENT 2,600,000A0920

2 Software ( Call Response center+ Web based MIS etc) 1,000,000


A094 OTHER STORE AND STOCK 1,975,427,890A0940

1 Medical Stores (Contraceptives) 550,000,000


A096 PLANT AND MACHINERY 128,400,000A0960

1 MACHINERY AND EQUIPMENT 128,400,000

A097 FURNITURE AND FIXTURE 1,900,000A0970

1 Furniture and Fixture 1,900,000


A130 TRANSPORT 848,000A1300

1 Transport 848,000

A137 COMPUTER EQUIPMENT 100,000A1370

2 Software 100,000

TOTAL 3,502,247,924

124

125

Budget Requirement for DPIU's/PPIUs in PunjabFor the Financial Year 2014-15

Sr. No. Name of District No. of

Vehicles A-03807 POL A-13001 ROT Total Budget Required

1 Ambulances 167 32,064,000 6,509,000 38,573,000


126



Vehicles Rate Per Month No. of Months

Total POL Budget Required

1 Ambulances 167 17,000 12 32,064,000


127

Budget Requirement of A-13001 Repair (Vehicle/Transport)For the Financial Year 2014-15

Sr. No.

Name of District No. of

Vehicles

Repair of Vehicle @ Rs. 22500/- P.m.

Budget required for major repair and change of tyres

Total Budget for Repair of Vehicle

Required

1 Ambulances 167 4,509,000 2,000,000 6,509,000


128

Budget Demand under the Head A-03801 Training DomesticFor the Financial Year 2014-15


PostsUnit Cost

Training No. of Days

Total Amount


2 Training on IMNCI 0 3000 11 -


4 Training of Medical officer on PHC & Nutrition 200 2500 3 1,500,000.00


Total 22,300,000.00

129

COST OF MEDICINES (Charam 24/7)

Category # of Units

Unit Cost per month # of Months Total

RHCs 162 3000 12 5832000Basic Health Units 500 3000 12 18000000

Total 23,832,000

130


Recurring CostsCategory Managerial Staff Number Unit Cost/

Monthly Monthly

Total Annual Total

(Rs) Annual Total

$

PMU


DSU


BHU

FTA for WMO 292 15000 4,380,000 52,560,000 611,162.79WMO 292 55000 16,060,000 192,720,000 2,240,930.23LHVs 1000 15000 15,000,000 180,000,000 2,093,023.26Ayas 1000 7000 7,000,000 84,000,000 976,744.19Security Guards 500 7500 3,750,000 45,000,000 523,255.81Drivers 333 9000 2,997,000 35,964,000 418,186.05Medicines 500 2500 1,250,000 15,000,000 174,418.60FP Material 0 0 - - -Pay for performance 40 50000 2,000,000 24,000,000 279,069.77Consumables (Lab Kits and gloves) 500 2000 1,000,000 12,000,000 139,534.88

Petty Cash 200 2000 400,000 4,800,000 55,813.95POL for ambulances 167 16000 2,672,000 32,064,000 372,837.21

PMU



DSU


20 0 - - -

Miscellaneous 20 10000 200,000 2,400,000 27,906.98

RHCsAdditional HR 20 50000 1,000,000 12,000,000 139,534.88Medicines 162 3500 567,000 6,804,000 79,116.28


Overall Operationa

l Costt


Call Response Center 10 100000 1,000,000 1,000,000 11,627.91

131

Printing 4 150000 600,000 600,000 6,976.74Total 716,612,000 8,332,697.67

One Time Cost

BHU


DSU/RSU

Furniture & Fixture for DSU 0 50000 - - -



Equipment for THQs/DHQs 40 500000 20,000,000 20,000,000 232,558.14

0 - - -Total - - -

116,900,000 1,359,302.33-


CostOne Time

Cost Total (Rs) Total $

716,612,000 1,433,224,000 116,900,000 1,550,124,000 17,615,045

132


Sr. No. Cadre # of Health

Facilities BPS Strength Net Pay PeriodBudget

Requirement in Rs.

1 Nursing Staff (for DHQ Nutrition)

34 DHQ +2 Teaching hospital

Fixed Salary

72 31000 12 26784000

2 WMO 292 RHCs 292 57500 12 201480000


4 LHVs (CHARM) 500 BHUs 1000 18000 12 216,000,000

5 Aya (CHARM) 500 BHUs 1000 9500 12 114,000,000

6 Ambulance drivers (CHARM) 333 10500 12 41,958,000

7 Gaurds (CHARM) 500 BHUS 500 9500 12 57,000,000

Total 3199 657,846,000.00

133


Sr. No.

Particulars

A01101 Basic Pay

A01105

Qualif. Pay

Personal Pay

A01106 Pay of

Contract Staff

A01156 Pay of

Contract Staff

A01202 House Rent

Allow.

A01203 Conv Allow.


A01252 NPA

A01224 Entertainmen

t Allow.


A01964 SAA

(2010)SPHA

Comp

Allow


A-01970 Adhoc Relief

Allow. 15%

20% Adhoc Relief

Allowance (2012)

Total

1Staff Salary July to Nov-14

250,000 0 0 456,000 0 95,540 100,000 30,000 20,000 0 61,060 203,500 56,000 0 72,000 61,060 91,200 1,496,360

2Staff Salary Dec to June-15

350,000 0 0 663,600 0 133,756 140,000 42,000 28,000 0 85,484 284,900 78,400 0 100,800 85,484 132,720 2,125,144


2014-15600,000 0 0 1,119,600 0 229,296 240,000 72,000 48,000 0 146,544 488,400 ##### 0 172,800 146,544 223,920 3,621,504

134



A01101 Basic Pay

A01105 Qualif.

PayPersonal

Pay

A01106 Pay of

Contract Staff

A01156 Pay of

Contract Staff

A01202 House Rent

Allow.

A01203 Conv Allow.


A01252 NPA

Entertainment Allow



AllowSocial Security 30%



Total

01 Posts of BPS-18


19 50000 5809 5000 6000 4000 4448 14825 11200 4448 0 105730

Total 50000 0 0 0 0 5809 5000 6000 4000 0 4448 14825 11200 0 0 4448 0 105730

03 Posts of BPS-17


31600 4433 5000 2588 8625 4800 2588 6320 65954


31600 4433 5000 2588 8625 4800 2588 6320 65954


31600 4433 5000 2588 8625 4800 2588 6320 65954

Total 0 0 0 94800 0 13299 15000 0 0 0 7764 25875 0 0 14400 7764 18960 197862Total PMU Salary for one

Month 50,000 0 0 94,800 0 19,108 #### 6,000 4,000 0 12,212 40,700 11,200 0 14,400 12,212 18,960 303,592

Budget for Dec-14 to June-15 350,000 0 0 663,600 0 133,756 #### 42,000 28,000 0 85,484 #### #### 0 #### 85,484 132,720 #####

135


Sr. No.

Particulars BPSA01101 Basic Pay

A01105 Qualif.

PayPersona

l Pay

A01106 Pay of

Contract Staff

A01156 Pay of

Contract Staff

A01202 House Rent

Allow.

A01203 Conv Allow.


A01252 NPA

Entertainment Allow



AllowSocial

Security 30%



Total

01 Posts of BPS-18


18 50000 5809 5000 6000 4000 4448 14825 11200 4448 0 105730

Total 50000 0 0 0 0 5809 5000 6000 4000 0 4448 14825 11200 0 0 4448 0 105730

03 Posts of BPS-17


30400 4433 5000 2588 8625 4800 2588 6080 64514


30400 4433 5000 2588 8625 4800 2588 6080 64514


30400 4433 5000 2588 8625 4800 2588 6080 64514

Total 0 0 0 91200 0 13299 15000 0 0 0 7764 25875 0 0 14400 7764 18240 193542Total PMU Salary for one

Month 50,000 0 0 91,200 0 19,108 20,000 6,000 4,000 0 12,212 40,700 11,200 0 14,400 12,212 18,240 299,272


136

Cost Sheet of Nutrition Budget for the Financial Year 2014-15S.No Districts


50%Target Population For

21 District & for 09 Urban slam Districts is 25%

Total children age

6 to 59 month 14 %

MICs 2010-11

# of target

Children


Cost per SAM Child

# children age 6

month to 2 years

Cost per Multinutrient supplementati

on for 6 month to 2

years

# children age 2 to 5 years

Cost for tab.

Mebandazole

Total PLW7.5 %

13 % MAM PLW + 1.5 % Relapse & Incidence rate

Cost per PLW

Cost for Tab.Iron Folic

Acid

SC Cost (F 75 & F 100)

Cost for Anthropometry

EquipmentTotal Cost for Supplies

1 Narowal 1516173 758086.5 106132 16 16981 5298 21192460 30323 6822779 56856 341139 56856 7650 12240065 7107061 100000 500000 48303503

2 Layyah 1486000 743000 104020 14 14563 4544 18174374 29720 6687000 55725 334350 55725 7498 11996478 6965625 100000 500000 44757827

3 Mianwali 1309000 654500 91630 21 19242 6004 24014390 26180 5890500 49088 294525 49088 6573 10516506 6135938 100000 500000 47451859

4 Multan 3994000 1997000 279580 20 55916 17446 69783168 79880 17973000 149775 898650 149775 20055 32087796 18721875 100000 500000 140064489

5 Khushab 1131786 565893 79225 19.7 15607 4869 19477947 22636 5093037 42442 254652 42442 5683 9092769 5305247 100000 500000 39823651

6 Rahimyar Khan 4198000 2099000 293860 19 55833 17420 69680083 83960 18891000 157425 944550 157425 30698 49116600 19678125 100000 500000 158910358

7 Pakpattan 1617000 808500 113190 19 21506 6710 26839613 32340 7276500 60638 363825 60638 11824 18918900 7579688 100000 500000 61578525

8 D. G. Khan 2219000 1109500 155330 19 29513 9208 36831850 44380 9985500 83213 499275 83213 16226 25962300 10401563 100000 500000 84280487

9 Muzaffargarh 3579000 1789500 250530 17 42590 13288 53152445 71580 16105500 134213 805275 134213 26171 41874300 16776563 100000 500000 129314082

10 Bhakkar 1368150 684075 95771 26 24900 7769 31075612 27363 6156675 51306 307834 51306 10005 16007355 6413203 100000 500000 60560679

11 Rajanpur 1485000 742500 103950 13.7 14241 4443 17772955 29700 6682500 55688 334125 55688 10859 17374500 6960938 100000 500000 49725018

12 Bhawal Nagar 2566000 1283000 179620 17 30535 9527 38108179 51320 11547000 96225 577350 96225 18764 30022200 12028125 100000 500000 92882854

13 Gujranwala 4404000 1321200 184968 14 25896 8079 32317609 52848 11890800 99090 594540 99090 19323 30916080 12386250 500000 88605279

14 Sargodha 3189000 956700 133938 15 20091 6268 25073194 38268 8610300 71753 430515 71753 13992 22386780 8969063 500000 65969851

15 Rawalpindi 4321000 1296300 181482 13 23593 7361 29443640 51852 11666700 97223 583335 97223 18958 30333420 12152813 500000 84679907

16 Faisalabad 6822000 2046600 286524 14 40113 12515 50061473 81864 18419400 153495 920970 153495 29932 47890440 19186875 500000 136979158

17 Bhawal Pur 3217000 965100 135114 14 18916 5902 23607118 38604 8685900 72383 434295 72383 14115 22583340 9047813 500000 64858466

18 Sahiwal 2242000 672600 94164 16 15066 4701 18802668 26904 6053400 50445 302670 50445 9837 15738840 6305625 500000 47703203

19 Attock 1562000 390500 54670 13 7107 2217 8869661 15620 3514500 29288 175725 29288 5711 9137700 3660938 500000 25858523

20 Chiniot 1156000 289000 40460 14 5664 1767 7069171 11560 2601000 21675 130050 21675 4227 6762600 2709375 500000 19772196

21 Gujrat 2509000 627250 87815 9 7903 2466 9863381 25090 5645250 47044 282263 47044 9174 14677650 5880469 500000 36849012

22 Hafizabad 1024000 204800 28672 14 4014 1252 5009572 8192 1843200 15360 92160 15360 2995 4792320 1920000 500000 14157252

23 Jhang 2333331 466666.2 65333 14 9147 2854 11415029 18667 4199996 35000 210000 35000 6825 10919989 4374996 500000 31620009

24 Jhelum 1134000 226800 31752 13 4128 1288 5151444 9072 2041200 17010 102060 17010 3317 5307120 2126250 500000 15228074

25 Kasur 3016000 603200 84448 21 17734 5533 22132132 24128 5428800 45240 271440 45240 8822 14114880 5655000 500000 48102252

26 Khanewal 2585000 517000 72380 21 15200 4742 18969350 20680 4653000 38775 232650 38775 7561 12097800 4846875 500000 41299675

27 Lodhran 1504000 300800 42112 19 8001 2496 9985597 12032 2707200 22560 135360 22560 4399 7038720 2820000 500000 23186877

28 Vehari 2671000 534200 74788 23 17201 5367 21467148 21368 4807800 40065 240390 40065 7813 12500280 5008125 500000 44523743

29 Sialkot 3435000 687000 96180 12 11542 3601 14403917 27480 6183000 51525 309150 51525 10047 16075800 6440625 500000 43912492

30 Lahore 8650000 1730000 242200 14 33908 10579 42317184 69200 15570000 129750 778500 129750 25301 40482000 16218750 500000 115866434

####### ####### ###### 626653 195516 ######### 1082811 243,632,436 2030270 12181622 2030270 374,353 ######## ########## ######## ######### 1,906,825,736

Potassium Iodate for Salt Iodization

1,906,825,736

137




A01 EMPLOYEE RELATED EXPENSES 1,090,684,384

PAY 1,719,600

PAY OF OFFICERS 1,719,600A0110

1 Basic Pay 600,000


A012 ALLOWANCES 1,088,964,784

REGULAR ALLOWANCES 71,450,784A0120

2 House Rent Allowance 229,296






A01964 Special Additional Allowance (50% 2010) 488,400

A0 1970 Adhoc Relief Allowance (15% 2011) 146,544

OTHER ALLOWANCES 1,017,514,000A0127

1 Over Time Allownace 10,000


A01274 Medical Charges 6,804,000




A032 COMMUNICATION 1,160,000A0320

1 Postage and Telegraph 20,000





A033 UTILITIES 600,000A0330

3 Electricity Charges 600,000

A034 OCCUPANCY COSTS 500,000A0340

3 Rent of Residential Bilding -

A03407 Rates & Taxes( Vehicles Tax & Toll Tax) 500,000

138


GOVT. SERVANTS 75,996,000A0380

1 Training -Domestic (all training s &TOT) for 03 trainings 27,750,000



A03807 POL Charges 44,736,000


A039 GENERAL 617,790,618A0390

1 Stationary 100,000







A03970 Others ( Supplies for nutrition components & consumables) 960,000


A041 PENSION 312,804A0410

1 Pension Contribution 140,004


A06 Entertainment & Gift 10,000A0630

1 Entertainment & Gift 10,000


A092 COMPUTER EQUIPMENT 2,400,000A0920

2 Software ( Call Response center+ Web based MIS etc) 800,000


A094 OTHER STORE AND STOCK 1,926,534,344A0940

1 Medical Stores (Contraceptives) 300,000,000


A096 PLANT AND MACHINERY 147,150,000A0960

1 MACHINERY AND EQUIPMENT 147,150,000

A097 FURNITURE AND FIXTURE 1,825,000A0970

1 Furniture and Fixture 1,825,000


A130 TRANSPORT 848,000A1300

1 Transport 848,000

A137 COMPUTER EQUIPMENT 100,000A1370

2 Software 100,000

TOTAL 3,865,911,150

139

140

Budget Requirement for DPIU's/PPIUs in PunjabFor the Financial Year 2015-16

Sr. No. Name of District No. of Vehicles A-03807 POL A-13001 ROT Total Budget

Required

1 Ambulances 233 44,736,000 11,184,000 55,920,000


141



Vehicles Rate Per Month No. of Months

Total POL Budget Required

1 Ambulances 233 20,000 12 44,736,000


142

Budget Requirement of A-13001 Repair (Vehicle/Transport)For the Financial Year 2015-16

Sr. No.

Name of District No. of Vehicles

Repair of Vehicle @ Rs. 2500/- P.m. ( Major& Minor repair)

Total Budget for Repair of Vehicle Required

1 Ambulances 233 11,184,000 11,184,000


143

Budget Demand under the Head A-03801 Training DomesticFor the Financial Year 2015-16


PostsUnit Cost

Training No. of Days Total Amount


2 Training on IMNCI 0 3000 11 -


4 Training of Medical officer on PHC & Nutrition 100 2500 3 750,000.00


Total 27,750,000.00

144

COST OF MEDICINES(Charam 24/7)

Category # of Units Unit Cost per month # of Months Total

RHCs 162 2500 12 4860000

Basic Health Units 700 2500 12 21000000

Total 25,860,000

145


Recurring Costs

Category Managerial Staff Number Unit Cost/ Monthly

Monthly Total

Annual Total (Rs)

Annual Total $

PMU


DSU


BHU

FTA for WMO 292 20000 5,840,000 70,080,000 814,883.72WMO 292 60000 17,520,000 210,240,000 2,444,651.16LHVs 1400 15000 21,000,000 252,000,000 2,930,232.56Ayas 1400 7000 9,800,000 117,600,000 1,367,441.86Security Guards 1400 7500 10,500,000 126,000,000 1,465,116.28Drivers 466 9000 4,194,000 50,328,000 585,209.30Medicines 700 2500 1,750,000 21,000,000 244,186.05FP Material 0 0 - - -Pay for performance 40 50000 2,000,000 24,000,000 279,069.77Consumables (Lab Kits and gloves) 700 2000 1,400,000 16,800,000 195,348.84

Petty Cash 700 2000 1,400,000 16,800,000 195,348.84POL for ambulances 233 16000 3,728,000 44,736,000 520,186.05

PMU



DSU


20 0 - - -

Miscellaneous 8 10000 80,000 960,000 11,162.79

RHCsAdditional HR 8 50000 400,000 4,800,000 55,813.95Medicines 162 3500 567,000 6,804,000 79,116.28


Overall Operationa

l Costt


Call Response Center 8 100000 800,000 800,000 9,302.33

146

Printing 4 150000 600,000 600,000 6,976.74Total 980,648,000 11,402,883.72

One Time Cost

BHU


DSU/RSU

Furniture & Fixture for DSU 8 50000 400,000 400,000 4,651.16



Equipment for THQs/DHQs 40 500000 20,000,000 20,000,000 232,558.14

0 - - -Total - - -

132,575,000 1,541,569.77-


CostOne Time

Cost Total (Rs) Total $

980,648,000 1,961,296,000 132,575,000 2,093,871,000 23,793,989

147


Sr. No. Cadre # of Health Facilities BPS Strengt

h Net Pay PeriodBudget

Requirement in Rs.

1 Nursing Staff (for DHQ Nutrition) 34 DHQ +2 Teaching hospital

Fixed Salary

72 32000 12 27648000

2 WMO 292 RHCs 292 58000 12 203232000


4 LHVs (CHARM) 700 BHUs 1400 19000 12 319,200,000

5 Aya (CHARM) 700 BHUs 1400 10000 12 168,000,000

6 Ambulance drivers (CHARM) 600,000 466 11000 12 61,512,000

7 Gaurds (CHARM) 700 BHUs 1400 10000 12 168,000,000

Total 5032 948,240,000.00

148


Sr. No.

Particulars

A01101 Basic Pay

A01105

Qualif. Pay

Personal Pay

A01106 Pay of

Contract Staff

A01156 Pay of

Contract Staff

A01202 House Rent

Allow.

A01203 Conv Allow.


A01252 NPA

A01224 Entertainme

nt Allow.


A01964 SAA

(2010)SPHA

Comp

Allow


A-01970 Adhoc Relief Allow. 15%

20% Adhoc Relief

Allowance (2012)

Total

1

Staff Salary July to Nov-15

250,000 0 0 456,000 0 95,540 100,000 30,000 20,000 0 61,060 203,500 56,000 0 72,000 61,060 91,200 1,496,360

2

Staff Salary Dec to June-16

350,000 0 0 663,600 0 133,756 140,000 42,000 28,000 0 85,484 284,900 78,400 0 100,800 85,484 132,720 2,125,144


2015-16600,000 0 0 1,119,600 0 229,296 240,000 72,000 48,000 0 146,544 488,400 134,400 0 172,800 146,544 223,920 ######

149



A01101 Basic Pay

A01105 Qualif.

PayPersonal

PayA01106 Pay of Contract

Staff

A01156 Pay of

Contract Staff

A01202 House Rent

Allow.

A01203 Conv Allow.


A01252 NPA

Entertainment Allow



AllowSocial

Security 30%


Adhoc Relief

Allow. 20%Total

01 Posts of BPS-18


19 50000 5809 5000 6000 4000 4448 14825 11200 4448 0 105730

Total 50000 0 0 0 0 5809 5000 6000 4000 0 4448 14825 11200 0 0 4448 0 105730

03 Posts of BPS-17


31600 4433 5000 2588 8625 4800 2588 6320 65954


31600 4433 5000 2588 8625 4800 2588 6320 65954


31600 4433 5000 2588 8625 4800 2588 6320 65954

Total 0 0 0 94800 0 13299 15000 0 0 0 7764 25875 0 0 14400 7764 18960 197862


Budget for Dec-15 to June-16 350,000 0 0 663,600 0 133,756 140,000 42,000 28,000 0 85,484 284,900 78,400 0 100,800 85,484 132,720 2,125,144

150



A01101 Basic Pay

A01105 Qualif.

PayPersonal

Pay

A01106 Pay of

Contract Staff

A01156 Pay of

Contract Staff

A01202 House Rent

Allow.

A01203 Conv Allow.


A01252 NPA

Entertainment Allow



AllowSocial

Security 30%


Adhoc Relief

Allow. 20%Total

01 Posts of BPS-18


18 50000 5809 5000 6000 4000 4448 14825 11200 4448 0 105730

Total 50000 0 0 0 0 5809 5000 6000 4000 0 4448 14825 11200 0 0 4448 0 105730

03 Posts of BPS-17


30400 4433 5000 2588 8625 4800 2588 6080 64514


30400 4433 5000 2588 8625 4800 2588 6080 64514


30400 4433 5000 2588 8625 4800 2588 6080 64514

Total 0 0 0 91200 0 13299 15000 0 0 0 7764 25875 0 0 14400 7764 18240 193542



151

152

Cost Sheet of Nutrition Budget for the Financial Year 2015-16

S.No Districts


50%Target

Population

Total childr

en age 6 to 59 month 14

%

MICs 2010-

11

# of target

Children


Cost per SAM Child

# children age 6

month to 2 years

Cost per Multinutrient

supplementation for 6 month

to 2 years

# children age 2 to 5 years

Cost for tab.

Mebandazole

Total PLW7.5 %

13 % MAM PLW + 1.5 % Relapse & Incidence rate

Cost per PLW Cost for Tab.Iron Folic Acid

SC Cost (F 75 & F 100)

Cost for Anthropometry Equipment Total Cost for Supplies

1 Narowal 1516173 758086.5 106132 16 16981 5298 21192460 30323 6822779 56856 341139 56856 7650 12240065 7107061 100000 500000 48303503

2 Layyah 1486000 743000 104020 14 14563 4544 18174374 29720 6687000 55725 334350 55725 7498 11996478 6965625 100000 500000 44757827

3 Mianwali 1309000 654500 91630 21 19242 6004 24014390 26180 5890500 49088 294525 49088 6573 10516506 6135938 100000 500000 47451859

4 Multan 3994000 1997000 279580 20 55916 17446 69783168 79880 17973000 149775 898650 149775 20055 32087796 18721875 100000 500000 140064489

5 Khushab 1131786 565893 79225 19.7 15607 4869 19477947 22636 5093037 42442 254652 42442 5683 9092769 5305247 100000 500000 39823651

6 Rahimyar Khan 4198000 2099000 293860 19 55833 17420 69680083 83960 18891000 157425 944550 157425 30698 49116600 19678125 100000 500000 158910358

7 Pakpattan 1617000 808500 113190 19 21506 6710 26839613 32340 7276500 60638 363825 60638 11824 18918900 7579688 100000 500000 61578525

8 D. G. Khan 2219000 1109500 155330 19 29513 9208 36831850 44380 9985500 83213 499275 83213 16226 25962300 10401563 100000 500000 84280487

9 Muzaffargarh 3579000 1789500 250530 17 42590 13288 53152445 71580 16105500 134213 805275 134213 26171 41874300 16776563 100000 500000 129314082

10 Bhakkar 1368150 684075 95771 26 24900 7769 31075612 27363 6156675 51306 307834 51306 10005 16007355 6413203 100000 500000 60560679

11 Rajanpur 1485000 742500 103950 13.7 14241 4443 17772955 29700 6682500 55688 334125 55688 10859 17374500 6960938 100000 500000 49725018

12 Bhawal Nagar 2566000 1283000 179620 17 30535 9527 38108179 51320 11547000 96225 577350 96225 18764 30022200 12028125 100000 500000 92882854

13 Gujranwala 4404000 1321200 184968 13 24046 7502 30009208 52848 11890800 99090 594540 99090 19323 30916080 12386250 500000 86296878

14 Sargodha 3189000 956700 133938 12 16073 5015 20058555 38268 8610300 71753 430515 71753 13992 22386780 8969063 500000 60955212

15 Rawalpindi 4321000 1296300 181482 15 27222 8493 33973430 51852 11666700 97223 583335 97223 18958 30333420 12152813 500000 89209698

16 Faisalabad 6822000 2046600 286524 14 40113 12515 50061473 81864 18419400 153495 920970 153495 29932 47890440 19186875 500000 136979158

17 Bhawal Pur 3217000 965100 135114 14 18916 5902 23607118 38604 8685900 72383 434295 72383 14115 22583340 9047813 500000 64858466

18 Sahiwal 2242000 672600 94164 16 15066 4701 18802668 26904 6053400 50445 302670 50445 9837 15738840 6305625 500000 47703203

19 Attock 1562000 468600 65604 13 8529 2661 10643593 18744 4217400 35145 210870 35145 6853 10965240 4393125 500000 30930228

20 Chiniot 1156000 346800 48552 14 6797 2121 8483005 13872 3121200 26010 156060 26010 5072 8115120 3251250 500000 23626635

21 Gujrat 2509000 752700 105378 9 9484 2959 11836057 30108 6774300 56453 338715 56453 11008 17613180 7056563 500000 44118814

22 Hafizabad 1024000 307200 43008 14 6021 1879 7514358 12288 2764800 23040 138240 23040 4493 7188480 2880000 500000 20985878

23 Jhang 2333331 699999.3 98000 14 13720 4281 17122543 28000 6299994 52500 315000 52500 10237 16379984 6562493 500000 47180013

24 Jhelum 1134000 340200 47628 13 6192 1932 7727167 13608 3061800 25515 153090 25515 4975 7960680 3189375 500000 22592112

25 Kasur 3016000 904800 126672 21 26601 8300 33198198 36192 8143200 67860 407160 67860 13233 21172320 8482500 500000 71903378

26 Khanewal 2585000 775500 108570 21 22800 7114 28454026 31020 6979500 58163 348975 58163 11342 18146700 7270313 500000 61699513

27 Lodhran 1504000 451200 63168 19 12002 3745 14978396 18048 4060800 33840 203040 33840 6599 10558080 4230000 500000 34530316

28 M.B. Din 1523583 457074.9 63990 9 5759 1797 7187411 18283 4113674 34281 205684 34281 6685 10695553 4285077 500000 26987399

29 Chakwal 1435872 358968 50256 11 5528 1725 6899078 14359 3230712 26923 161536 26923 5250 8399851 3365325 500000 22556502

30 Nankana Sahib 1230000 307500 43050 14 6027 1880 7521696 12300 2767500 23063 138375 23063 4497 7195500 2882813 500000 21005884

31 Okara 2783000 556600 77924 22 17143 5349 21394813 22264 5009400 41745 250470 41745 8140 13024440 5218125 500000 45397248

32 Sheikhupura 2888000 577600 80864 13 10512 3280 13119375 23104 5198400 43320 259920 43320 8447 13515840 5415000 500000 38008535

33 T.T. Singh 1967000 393400 55076 16 8812 2749 10997576 15736 3540600 29505 177030 29505 5753 9205560 3688125 500000 28108891

34 Vehari 2671000 534200 74788 23 17201 5367 21467148 21368 4807800 40065 240390 40065 7813 12500280 5008125 500000 44523743

35 Sialkot 3435000 687000 96180 12 11542 3601 14403917 27480 6183000 51525 309150 51525 10047 16075800 6440625 500000 43912492

36 Lahore 8650000 1730000 242200 14 33908 10579 42317184 69200 15570000 129750 778500 129750 25301 40482000 16218750 500000 115866434

####### ####### ###### 711443 221970 887,881,068 1245696 280,281,570 2335680 14014079 2335680 433,908 694253276 291,959,969 ######## 18,000,000 2,187,589,962

Potassium Iodate for Salt Iodization

2,187,589,962

153

Program Reform Milestones including Disbursement Linked Indicators (DLIs) developed by WB/DFID

Reform Area 2013-14 2014-15 2015-16 2016-17Component 1: Improving health service delivery

Essential Health Service Package at primary level defined, and approved

EPHS for secondary care finalized and approved

Minimum Services Delivery Standards (MSDS) revised considering primary level EHSP and implementation started in all districts

Plan developed for strengthening secondary care hospital developed

Assessment of MSDS in all districts of Punjab completed and more than 70% of the RMNCH and nutrition related quality standards met

EPHS for tertiary care finalized and approved

i) Integrated management of MNCH and LHW Programs

Punjab has operationalized the integrated management of three community based programs (Lady Health Workers, Maternal, Neonatal, and Child Health, and Nutrition programs), and approved the PC-1s for: (a) the integrated management for reproductive health, primary health care, and nutrition; (b) Lady Health Workers Program; and (c) Maternal, Neonatal, and Child Health.

Punjab has attained: (i) at least 35% in the use of modern contraceptive methods; and (ii) at least 70% skilled birth attendance.

MNCH Implementation of 24/7 comprehensive RMNCH program rolled out in 20 focus districts

17 of DHQ and 30 THQ hospitals providing full package of 24/7 comprehensive EmONC services

34 DHQ and >55 THQ hospitals providing complete package of 24/7 comprehensive EmONC services and >15 RHCs meeting 24/7 C-section signal function

>200 RHCs providing complete package of basic EmONC services and >150 BHUs meeting 24/7 Assisted delivery signal function

36 DHQ and >65 THQ hospitals providing complete package of 24/7 comprehensive EmONC services along with >30 RHCs meeting C-section signal function

>250 RHCs providing complete package of basic EmONC services and >300 BHUs meeting 24/7 Assisted delivery signal function

LHWP At least 15,000 LHWs in the priority districts trained on a) family planning and b) nutrition.

Training of LHWs in delivering routine immunization started in 4 districts completed

Evaluation of “LHWs involved in routine immunization” initiated

154

ii) Introduction of Nutrition Services

Comprehensive Nutrition interventions implementation initiated in 12 priority districts with materials and funding available and training completed

IYCF training module for community workers developed and rolled out in 36 districts

In the 12 priority districts, at least 20% of children with SAM registered for treatment

15 Stabilization centers and 200 Outpatient Therapeutic Program centers made functional

At least 20% of households receive a core package of nutrition services in 12 districts

At least 80% of community-based workers in the 12 high-priority districts trained on nutrition

In the 12 priority districts, at least 40% of children with SAM registered for treatment

35 Stabilization centers and >600 Outpatient Therapeutic Program centers made functional

Review of regulatory monitoring system for food fortification carried out and new system agreed

At least 60% of children identified with severe acute malnutrition in all 12 high priority districts have been registered for treatment.

At least 75% of households receive a core package of nutrition services in 12 districts

More than 80% of LHWs have knowledge and skills scores (using case studies scenario) of above 80%

155

DFID’s Disbursement Linked Indicators for Punjab (Aligned with HSS,

Operational Plan and PC-1s)

The disbursement linked indicators for Provincial Health and Nutrition Programme – Punjab, for the period

2013-17

.

AREA2013-14 2014-15** 20015-16** 2016-17**

Punjab: £14 million




Service Delivery

Weightage

45%

- Approval of 3 year provincial PC-1 of Integrated RMNCH and nutrition programme with commitment of the provincial government to invest development funds in this programme;

- Essential/ Minimum Health Service Package (E/MHSP) at primary level defined, costed and approved in Punjab;

- Piloting of implementation of Infection Control Management Protocols started in at least one district in the province.

Disbursement linked to the DLI for FY 2013/14: £6.3 million

- Results based contracts defined (considering EHSP/ MHSP and including RMNCH and nutrition interventions at primary health facilities and community level) and signed for 14 districts in Punjab;

- Minimum Services Delivery Standards (MSDS) revised considering primary level EHSP/MHSP and implementation started in all districts Punjab;

- 15 Stabilisation centres (with availability of RUTF - Ready-to-use therapeutic food) and 200 Outpatient Therapeutic Programme (OTP) centres made functional with government financing in

- Assessment of MSDS in all districts of Punjab completed and more than 80% of the RMNCH and nutrition related quality standards met;

- 35 Stabilisation centres (with availability of RUTF) and >600 Outpatient Therapeutic Programme (OTP) centres made functional with government financing in Punjab;

- 60% of DHQ and THQ hospitals providing COMPLETE PACKAGE of 24/7 comprehensive EmONC services in Punjab;

- Successful implementation of Infection Control Protocols in >20 districts of the Punjab.

- Third Party evaluation of the management models for service delivery and implementation of EPHS completed and following results achieved in Punjab.o Modern

methods CPR increased to 33%

o Exclusive breast feeding rate increased to >40%

o Immunisation coverage (fully) in the province increased to >75%

o >60% of identified children treated for Severe Acute Malnutrition (SAM) in last month/quarter

o >80% of DHQ and THQ hospitals providing COMPLETE PACKAGE of 24/7 comprehensive EmONC services

o Skilled Birth Attendance (SBA) increased to

156

Punjab;- 40% of DHQ

and THQ hospitals providing COMPLETE PACKAGE of 24/7 comprehensive EmONC services in Punjab.


Disbursement linked to the DLI for FY 2015/16:£12.15 million

>70%


Stewardship/

Governance

Weightage

15%

- Approval of HSS, Operational plan and notification of governance mechanism for its implementation oversight in the province;

- Approval of PC-1 for continuation of Policy and Strategic Planning Unit (PSPU) in Punjab;

- Business plan for Punjab Health Care Commission (PHCC) approved by the board in Punjab.


- Minimum two meetings of the steering committee/ task force of HSS implementation held during 2013-14 in Punjab

- Review of restructuring of DGHS office completed in Punjab;

- In case of successful results, e-management interventions scaled up in all districts of Punjab.


- Minimum two meetings of the steering committee/ task force of HSS implementation held during 2014-15 in Punjab;

- Restructuring of DGHS office completed in Punjab;

- Implementation of plan to strengthen consumer complaints system started by PHCC in Punjab.


- Minimum two meetings of the steering committee/ task force of HSS implementation held during 2015-16 in Punjab;

- >90% of the management positions at provincial level and that of EDO(H) filled with qualified/ competent personals in Punjab.


Human Resource

Weightage

5%

- Training of another batch of >1000 Community Midwives (CMWs) started in 2012 in Punjab.

- Training of another batch of >1000 and 200 Community Midwives (CMWs) started in 2013 in Punjab;

- Training of another batch of >1000 and 200 Community Midwives (CMWs) started in 2014 in Punjab respectively;

- Training of another batch of >1000 and 200 Community Midwives (CMWs) started in 2015 in Punjab;

157


- Human Resource Strategy and In-service training strategy developed and Human Resource Cell established in DoH Punjab;

- All LHWs trained on IYCF in both provinces and training of LHWs in delivering routine immunisation started in 4 districts of Punjab.


- All LHWs trained on family planning and trained LHWs immunising children and women in their catchment areas.


- More than 80% of LHWs have knowledge and skills scores (using case studies scenario) of above 80%;

- Results of evaluation of “LHWs involved in routine immunisation” available.


Information

Weightage

10%

- Development of health sector M&E plan of action started in Punjab.


- Health sector M&E plan of action including disease surveillance available and accordingly PC-1 approved in Punjab;

- Second round of Annual Health Facility Assessment completed.


- M&E unit in DGHS office fully functional and Disease surveillance system operationalized in selected districts in Punjab;

- Third round of Annual Health Facility Assessment completed.

Disbursement linked to the DLI for FY 2015/16:£2.7million

- Fourth round of Annual Health Facility Assessment completed.


Financing

Weightage

- Development of fiduciary risks mitigation plan in Punjab;

- Written

- Minimum 70% increase in development health expenditure (mainly for

- Further 20% increase in development health expenditure (mainly for

- tbd - considering expected shift of provincial RMNCH and nutrition expenditures from provincial budgets to

158

15% commitment for inclusion of HSS’s policy objectives in the next year MTBF cycle in Punjab.


RMNCH interventions and excluding federal grants) at provincial level and 15% increase in Districts non-salary expenditure in Punjab;

- Successful implementation of Fiduciary risk mitigation plan in Punjab;

- Options for health financing including testing of Vouchers Scheme explored.


RMNCH interventions and excluding federal grants) at provincial level and 20% additional increase in non-salary district expenditure in Punjab;

- Successful implementation of Fiduciary risk mitigation plan in Punjab;

- Implementation of Voucher Scheme started.


district current budgets;

- Reassessment of fiduciary risk showing improvement Punjab;

- Intervention of Voucher Scheme evaluated.


Medical Products

Weightage

10%

- Procurement cell in DoH -Approval of PC-1 and progress towards strengthening of the cell; and standard operating procedures (SOPs) for procurement developed in Punjab.


- Procurement cell ensuring implementation of PPRA rules and regulations in Punjab;

- More than 60% of health facilities having no stock out of 3 contraceptive methods in Punjab;

- More than 70% of LHWs having no stock out of Zinc, ORS, Iron/ folic acid tablets and deworming tab/syp and contraceptives over last one month in Punjab.


- Procurement of contraceptive commodities for health facilities and community workers completed using provincial government resources initiated in Punjab;

- More than 80% of LHWs having no stock out of Zinc, ORS, Iron/ folic acid tablets and deworming tab/syp and contraceptives over last one month in Punjab;

- Misoprostol available in all RHCs in Punjab.

Disbursement linked to the DLI for FY 2015/16:£2.7million

- Government procured contraceptive commodities available in all districts of Punjab;

- More than 85% of LHWs having no stock out of Zinc, ORS, Iron/ folic acid tablets and deworming tab/syp and contraceptives over last one month in Punjab.


*DLIs in bold are pre requisite for the disbursement** DLIs to be reassessed and updated following reviews.*** Reviews to be held bi-annually or annually and will be agreed after discussion

159

**** Funds disbursed on the achievement of DLIs will only be used for delivery of EHSP/ RMNCH (including nutrition) interventions through the development budget at provincial level or districts grants for the implementation of EHSP.

160

Documents

Name of the Project - Punjablhwp.punjab.gov.pk/Downloads/PC-I Integrated 16 th Apri… · Web viewThe integrated program will focus on reproductive, maternal, newborn and child