Improving Maternal Health by Scaling Up Contractual

Management of Basic Health Units in Sindh Province,

Pakistan: A Health Systems Approach

Anna Heard, Imran Chandio, and Riaz Memon

Commissioned Paper for the International Conference on Scaling Up

Dec 3-6, 2008
Dhaka, Bangladesh

Abstract
In an effort to improve delivery of basic health services, the government of Pakistan has
contracted in management of lower level health facilities with a group of government
managers in a unique model that seconds the managers to an NGO to give them more
authority to make decisions. The increased accountability created by a need to prove
themselves, and flexibility to make management decisions including hiring and transfers,
has enabled the new managers to improve availability of medicines and supplies, hire
doctors on contract, and improve provider performance through increased monitoring.
The changes have dramatically increased utilization of services at facilities.

Introduction
After considerable investment in primary healthcare, the lowest level health facilities in
Pakistan, Basic Health Units (BHUs), were still underperforming (Loevinsohn et al
2006). Pakistan had a history of linking the public sector with non-state providers. The
acronym GoNGO has been penned to describe the non-governmental organizations
(NGOs) that have close ties to government or originated from government support. To
improve the functioning of BHUs, a pilot program was initiated in 1999 in three BHUs in
Lodhran district under the guidance of Jehangir Tareen where the management of the
BHUs were contracted out to Punjab Rural Support Program (PRSP), a GoNGO. The
pilot was later expanded to the district of Rahim Yar Khan in 2003. The perceived success
of the expansion resulted in an initiative to further expand the innovation to all four
provinces of Pakistan under the Presidents Primary Healthcare Initiative. In each
province, management of the BHUs was contracted out to the provincial Rural Support
Program. This paper is a case study of the implementation of the initiative in Sindh
province and assesses the changes implemented by the initiative and the results they were
able to achieve. The paper is organized in four sections. The next section is an overview
of the health system in Pakistan and current health status of Sindh. The following section
describes the unique characteristics of the contracting model. A comparison of before and
after the model was implemented and a comparison of contracted versus non-contracted
districts is presented next. Finally, conclusions and lessons learned are presented.

Context
Health in Pakistan
Pakistan is the 6th most populous country in the world. While population growth has
slowed over the last few decades, it remains high at around 2% in 2008 (CIA World
Factbook 2008). Per capita GDP was estimated at $2600 (PPP) in 2007 (CIA 2008)in
the lower half of countries in South Asia. Although life expectancy at birth is one of the
highest in the region64.6 years (slightly higher than India at 63.7 and Bangladesh at
63.1), most health indicators in Pakistan are among the worst in South Asia. The total
fertility rate is high at 4 children/woman) for 2000-2005 compared with 3.1 in India and
3.2 in Bangladesh (HDR 2007/2008). The infant mortality rate was 78 in 2005 compared
with 56 in India and 54 in Bangladesh, second highest only to Afghanistan (165) in the
South Asia region (HDR 2007/2008).

Health system in Pakistan

Health care in Pakistan is provided by both the public and private sector providers. About
70% of care is received at private hospitals and clinics, 20% at public hospitals and
clinics, and the rest from pharmacies, homeopaths, and traditional healers (Federal
Bureau of Statistics 2007). The private sector consists of well qualified doctors and
facilities as well as less qualified and unqualified practitioners such as traditional healers.
The public sector is built on a tiered system. It is composed of dispensaries, maternal and
child health centers, maternity homes, Basic Health Units (BHUs), Rural Health Centers
(RHCs), Taluka and District level hospitals, and a number of tertiary care facilities in

urban areas. The Department of Population Welfare also provides family planning,
reproductive health and maternal services through Reproductive Health Services-A
Centers (RHS-A), Family Welfare Centers in urban, semi-urban, and rural areas (FWC),
and mobile service units (MSU).
BHUs are first-level health care facilities and provide basic curative and preventive care.
BHUs are generally staffed with one doctor, one dispenser (pharmacist), and a male
technician who aids in registering patients, handing out medicines and frequently sees
patients in the absence of a doctor, although they are not fully trained to do so.
Dispensers can also fill the role of seeing patients in the absence of a doctor. In some
facilities there is also a lady health visitor (LHV) who sees female patients. LHVs
generally have minimal maternal health care trainingthey are trained to provide
antenatal care, aid in deliveries, provide post-natal care, and occasionally provide
contraception. Lady Health Workers, a recent addition, work for a federal (vertical)
program to provide community outreach for health education and contraception. They are
the primary government providers of contraception.
Dispensaries are even more basic and are normally staffed by either a doctor or a doctor
and a male technician/dispenser. Maternity homes and Maternal and Child Health (MCH)
centers provide pregnancy-related health care to women, and some basic care for children
and are generally staffed by LHVs. MCHs are usually second-level health care centers,
but can also serve as first-level care centers. They should be able to address more
complicated cases and employ a few specialists. In some cases they are able to perform
surgery involving anesthesia. Taluka and District hospitals are referral hospitals and
should be able to provide emergency care and major surgery.

Sindh
Sindh is the southern-most province and home to about 30 million people, about 50% of
which live in urban areas and of which over 11 million live in Karachi. Over the last few
decades there has been increasing poverty and disparity, and slowing educational and
health trends. According to the 2006-2007 Pakistan Social and Living standards
Measurement survey (PSLM) 43% of women over 10 years of age were literate
compared with the 44% for the country (Federal Bureau of Statistics 2007). Compared to
other provinces, Sindh has gone from slightly above average in 2004-05 (41% compared
with the national average of 40%) to slightly below average (Federal Bureau of Statistics
2005. The disparity between urban and rural areas is stark. Literacy for women in rural
Sindh has not improved and may have even worsened (18% in 2004-05 to 17% in 200607, compared to the national averages 29% and 32% respectively). Urban literacy rates
for women in Sindh are closer to the national urban average at 65% (national average
66%) in 2006-07 compared with 62% for both in 2004-05 (Federal Bureau of Statistics
2005, 2007).
According to the National Human Development Report 2003, urban Sindh ranked highest
in development among all provinces, with rural Sindh the lowest, demonstrating the huge
disparity in Sindh (Hussain 2003). Sindh lags behind other provinces in many social
indicators. Immunization rates are decent at around 80%, but Sindh ranks 3 rd out of 4

provinces, and again only 70% of rural compared with 93% of urban children age 12-23
months were fully immunized (PSLM 2006-07). Infant mortality is estimated at 81/1000
live births in Sindh, compared with 78 for all Pakistan. Total fertility is higher in Sindh
(4.3) than other provinces and for Pakistan overall (3.3). While Sindh ranks second for
any (26.7%) and modern (22%) contraceptive use by married women age 15-49,
contraceptive use is low in Pakistan overall. However, Sindh is not underperforming in
all indicators. A large number (73.1%) of women receive at least some antenatal care
(national average 65.3%), 44.4% have a skilled health professional present at delivery
and 41.7% delivery in a health facility, the highest of the four provinces for peri-natal
indicators (PDHS 2006-07).

Presidents/Peoples Primary Health Care Initiative

While a substantial amount of funds were invested in BHUs in Pakistan, most of the
BHUs in the country remained non-functional. They were the provider of choice in less
than 5% of rural visits and 1% of urban visits (PSLM 2006-07). The public sector overall
is responsible for about 26% of care in rural areas and 15% in urban areas. The average
number of outpatient visits per BHU per day was 28 in 2003 (World Bank 2005). Quality
of care in the public sector was seen as poor. A recent quality of care study found that
government facilities have high rates of absenteeism, vacancy, and maldistribution of
staff, as well poor supplies of medicines and inadequate functioning of equipment (AAA
unpublished). To address problems of low utilization and quality, the Chief Minister of
Rahim Yar Khan (RYK) district in Punjab created an initiative to improve the delivery of
health services at BHUs. Through the Chief Ministers Initiative on Primary Health Care
(CMIPHC), the government of Rahim Yar Khan decided to enter into an agreement with
the parastatal Punjab Rural Support Program (PRSP) to rebuild or renovate and manage
their 104 BHUs. The choice of PRSP was non-competitivePRSP was an organization
with ties to the government. After a proliferation of Non-Governmental Organizations
(NGOs) in the 1990s, Rural Support Organizations were created in each of the provinces
by the federal government and given financial support to run independently and serve the
people in a similar manner as not-for-profit NGOs. As mentioned previously, these
organizations are called GoNGOs. It has been suggested that this may have been an
attempt to balance the growing influence of the NGOs (Bano 2008).
The focus of the CMIPHC was mainly to reactivate and improve the functioning of the
districts BHUs. While a major focus of the initiative was on renovating the dysfunctional
facilities, another component improved availability of doctors by allowing PRSP to hire
doctors on contract and assign them to cover three facilities (visiting each facility twice a
week) and pay them more. By allowing three facilities to contract for the same doctor, it
allowed them to pay nearly triple the regular salary, attracting doctors to regions
otherwise uncovered. The CMIPHC was declared a success citing a massive increase in
the utilization of the public health facilities. The success was noted by the president of
Pakistan, and a plan to spread a similar initiative to all four provinces was made. The
Presidents (now Peoples) Primary Healthcare Initiative (PPHI) was to be implemented
separately in all four of Pakistans provinces, to parastatal organizations similar to PRSP,
and the program in RYK expanded to all of Punjab. While the CMIPHC aimed mostly at

making the BHUs functional by improving infrastructure and hiring doctors to improve
curative care, PPHI generally had a larger mandate to not only improve BHUs and hire
doctors, but also to address health services at BHUs more generally, including preventive
services and demand generation by involving the community.
The success of PPHI largely rests on the ability of PPHI to increase utilization rates.
However, improved functioning of the BHUs can also be measured by the quality of
services they are services they are able to provide and ultimately by whether health
indicators improve. It is too soon to measure changes in health indicators, but initial
service measures can give a good indication of whether the new management system is
likely to affect health outcomes. Some process measures that may provide information
include: availability of medicines and supplies, availability of personnel, and utilization
of services.

PPHI in Sindh
To implement PPHI in Sindh, the government of Sindh entered into an agreement with
Sindh Rural Support Organization (SRSO), the Sindh branch of the Rural Support
Program GoNGO, to cover the provision of services from all BHUs within 10 different
districts. SRSO functions like a regular non-governmental organization (NGO), relatively
independently of the government.
While the Health Department signed the contract with SRSO, a provincial manager was
hired by SRSO and approved by federal program advisors in the government. The
provincial manager hired 10 District Support Managers (DSMs) on contract and all
managers were seconded from their government posts to the project. The PPHI managers
form a unit, hereafter referred to simply as PPHI, that is in charge of managing the BHUs.
The DSMs receive their budget from SRSO in one line item (not including salaries) with
the money for vacant positions included, and PPHI has the ability to hire staff on contract
to fill vacant posts. The tight management ties to the government and a close interest by
the founder of the initiative, Jehangir Tareen, has resulted in SRSO taking a functional
backseat. Its role has been functionally relegated to writing checks, co-approving the
annual budget (along with the provincial government), and performing an annual
financial audit. Most required posts are currently filled by government employees.
Government health staff remain within the government system, but are managed by
PPHI. This means that although technically the government is contracting with the
private NGO sector, in actuality, the government has created a mechanism to contract
between two levels of government. PPHI has been left to implement the initiative without
any real direction from SRSO and takes full responsibility for fulfilling the contract with
the Executive District Officer (Health) of each district.

Funding
PPHI in Sindh is a fully government-funded program. PPHI is funded from three separate
levels. The federal government funds the management structure of PPHI (the provincial
managers and the district support managers, and their offices). The federally government
has also provided a one-time allocation for capital investment (equipment, furniture, etc).

The provincial government has committed to funding some of the repair and maintenance
of facilities. The district government has transferred the existing budget for the facilities,
including a negotiated amount for vacant positions and repair and maintenance of
facilities.

Selection of managers
The selection of the provincial manager was initiated by SRSO and approved at the
highest federal levels. The individual selected was chosen based on merit. It was also felt
the selected individual was honest and relatively immune to pressures of high ranking
politicians to transfer or hire people based on favors. Interviews with the provincial
Project Director (PD) indicated that a major criteria in his selection of DSMs was honesty
an ability to resist bribery, favoritism and other illicit behavior. DSMs were selected
from all areas of government, not just health. Many had backgrounds in civil works and
finance and few were doctors.

Infrastructure
PPHI was given a one-time grant from the federal government for equipment and
furniture for the facilities, and has initiated repair and renovation of facilities through a
formal government request process (PC-1), at the provincial level. Additionally, day-today maintenance will be covered by budgetary allocations from the district. While a
substantial amount of new money has been provided to overhaul the existing system,
continued maintenance will be funded from traditional budgetary allocations. Repairs
have begun, but due to a history of corruption and lack of trust in contractors, sign-off for
approval of various purchases and project steps are the responsibility of 1-2 engineers
on staff in each of the district support units.

Supplies
District managers were tasked with improving the supplies of medicines and ensuring
proper dispensing and record keeping. A list of required medicines was established. Some
drugs were acquired at the provincial level, others at the district level from known
suppliers, with a quality control protocol that tested unverified drugs for quality against a
national standard. DSMs were also responsible for increased monitoring of drug use to
cut down and eliminate wastage due to improper use of medicines (i.e. selling drugs in
the private sector that should be given free of charge to patients in the public sector). To
ensure proper function and supply of equipment, the medical officer in-charge (MOIC)
was required to submit a monthly report that lists all equipment and whether anything
needed replacing or repairing. MOICs could also immediately notify the DSM if anything
broke or needed to be replaced.

Hiring
The ability of PPHI to hire doctors on contract to fill vacant positions, and to pay
contracted doctors according to market rates, has allowed PPHI to fill positions that the
government had not been able to fill. By hiring on contract the government is not
required to provide those doctors with government stability or benefits, but they are able
to pay them substantially higher salaries than traditional government positions would

allow, providing additional incentive to work in the most remote and difficult areas.
Additionally this new flexibility allowed the hiring of female medical officers (FMOs) to
cover multiple facilities, one day a week each (and in some cases more than one day per
week) and leading health sessions at a school convenient to shared facilities one day a
week. At the same time, contracted doctors who did not perform according to
expectations were easily fired and a replacement sought. The fear of losing the relatively
lucrative post generally guaranteed good performance from contracted doctors.

Supervision and Accountability

PPHI Sindh practices supportive supervision. This means that supervisors visit health
facilities frequently so that problems can be identified quickly and resolutions found or
provided. Although visits are a way of monitoring performance, the primary activity
during such supervisory visits is problem solving.
District support managers and their staff are also expected to visit several BHUs every
day to monitor activities and provide supportive supervision. During site visits managers
and staff solve problems, check registers to ensure they are maintained properly, match
medicine supplies with medicine dispensing to ensure that medicines are not being
misappropriated (as was the perceived common practice), and ensure all staff are present.
If activities are not being performed correctly, DSMs either provide suggestions for
improvement, or if there is inappropriate behavior, write up complaints and submit them
to the district government. If several complaints against the same individual are made,
procedures to sanction, transfer, or fire the individual are initiated. Currently more than a
few transfers and firings have been completed, some self-initiated, and the remaining
staff are generally performing well.
PPHI Sindh has implemented two additional procedures to improve accountability.
District managers are required to sign off on attendance rolls before salaries are paid. If
staff such as doctors, paramedics, or support staff do not show up for work, their salaries
are withheld. Also, when major works are ordered, district managers must sign off on the
work completion notice that allows the contractor to be paid.
The PD and DSMs have also instituted several fraud-detection mechanisms. For example,
the ratio of medicines supplied to patients served is calculated for each facility and
facilities with extraordinarily high ratios are tagged for review.
The PD and DSMs implemented the new management style slowly by first suggesting
slightly improved performance before requiring correct performancee.g. the first
actions were to suggest that doctors show up at least once or twice a week, and then later
they were encouraged to come daily, and finally required to come daily. Doctors were
also trained in how to correctly keep registers and were warned that inaccurate registers
could result in audits and sanctions.

Challenges
The expansion of PPHI to all provinces has met challenges. In Sindh, although there was
support for the initiative from the highest levels of government, mid-level government

was not convinced it would work. Some felt that it was unrealistic to think that simply
putting in new management would improve the situation. Additionally there was some
resistance within the health sector and district level government due both to fear of losing
control of the services, and lack of confidence in the new program. The resistance was
evident from the beginning where offices were not even allocated until an official
memorandum of understanding between the provincial government and SRSO was
signed, even though personnel had been hired (Memon, unpublished). However, meetings
with provincial and district level government staff introduced the idea of PPHI, and
explained the expectations and transparencies built into the program, along with the
responsibilities of each actor. District governments were generally supportive of the plan
to improve BHUs as there was a general understanding that they were dysfunctional.
Additionally, new systems for fund transfers and for determining the allocation of the
budget for BHUs, separately from other health facilities, had to be created. Systems for
transferring and hiring medical personnel had to be adjusted, and this process still
remains problematic in some areas as district officials have used the ability to hire and
transfer as political security.
Lack of government oversight had caused infrastructure to deteriorate substantially, with
some facilities falling into local hands and being used for personal activities.
Additionally, some facilities had been built by the district without provincial sanctions,
and were therefore not officially in the budget. A large allocation for repair and
renovation was made by the federal and provincial governments, but non-sanctioned
facilities were not accounted for, and yet the district governments expected all facilities to
be made functional.

Results
After approximately one year of implementation, improvement in BHU functioning is
clearly evident. PPHI was able to negotiate budget allocations from the district
governments, provide medicines, equipment, and civil works for lower than expected
costs, and set up systems for fund transfers. They have also been fairly successful in
obtaining hiring and transfer powers from the district governments and preventing
interference.
Medicine and equipment supply has been dramatically improved. Medicine supply has
increased both in variety of medicines available and in quantity of each supplied. Prior to
PPHI implementation, an average of approximately 30 different types of medicines were
available. After implementation over 60 are available. Supplies of other medical
equipment have also improveddysfunctional equipment has been replaced and new
equipment ordered to ensure that all BHUs and providers have the necessary equipment.
A recent quality of care study showed that of 32 non-PPHI BHUs surveyed in early 2008,
32% did not have paracetamol (acetaminophen) available on the day of the visit, and
more than half of facilities were lacking iron, and/or antibiotics and/or oral rehydration
packets for diarrhea (AAA unpublished), and no facility had all medicines. On average a
little over 30% of drugs were available. Due to recent economic problems, all facilities in
PPHI districts also experienced stockouts (unavailability of drugs) in October 2008, but

on average only 20% of drugs were unavailable. In July only about 10% of drugs were
unavailable at the end of the month, and for most of the year stockouts only occurred in
Larkhana where the budget was smaller (authors data). During site visits by the author,
all facilities had basic equipment such as needle cutters, thermometers, blood pressure
(BP) cuffs, stethoscopes, and scales. In non-PPHI districts BP cuffs were present and
working in 57% of BHUs, thermometers 59%, and adult scales 47%. Stethoscopes were
available and functional in all facilities (AAA unpublished).
Renovations of facilities to repair cracking walls and ceilings, repaint, and install
electrical and water connections have been started. While progress is relatively slow
about 13% of facilities have been fully renovatedplans to speed up the process have
been made (such as hiring additional engineers to inspect and approve work completed).
Additional doctors have been hired on contract and female medical offices (FMOs) have
been hired to cover 5 facilities for weekly visits. Additionally, an ultrasound service
covering 10 facilities (once every two weeks) with a female ultrasound technician has
been piloted in three districts with success and will be expanded to all districts. Prior to
PPHI 50% of facilities in Sindh did not have a doctor. The additional hires of FMOs, and
full coverage of facilities by doctors has been done without additional budget allocations.
The salaries are being paid out of savings from other areas, such as less wastage of
medicines.
Perhaps the most impressive result is the enormous increase in utilization of facilities. On
average, in PPHI districts, the number of outpatients seen each day has grown from
approximately 20 prior to PPHI (through June 2007) to 30 for period from July 2007 to
February 2008, to nearly 40 for the period from March to June 2008, and approximately
50 for July and August 2008. According to a recent quality of care study, the number was
about 29 per day in non-PPHI districts of Sindh in early 2008 (AAA, unpublished).

Figure 1

Average OPD per Facility by District

90
PPHI started

80

PPHI expanded

70

OPD

60
50
40
30
20
10

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Date
Kashmore

Sukkur

Khairpur

Mirpur Khas

Larkana

Jacobabad

Mithi

Tando Allahyar

N/Feroze

Overall Average

Badin

Further, with the addition of previously unavailable female medical officers (FMOs),
services for women and children have dramatically increased. On average FMOs see
around 40-50 patients per day, although some locations and FMOs are busier, with the
busiest seeing as many as 180-200 patients (data not shown). These numbers are in
addition to the regular outpatient numbers mentioned above.
Due to the success of the program, between approximately May and July of 2008, PPHI
was expanded to an additional 7 districts.

Discussion
While PPHI is an expansion of a model that has generally been perceived as successful,
acceptance of the program has been at times difficult to obtain. At the beginning of its
implementation in Sindh, the bulk of the support for the model was at the federal level,
with provincial officials still unsure of whether the model would be desirable.
Uncertainties and lack of support at the provincial level seem to have motivated the
provincial director to prove PPHIs worth. The provincial director has taken great care to
build support within the provincial and federal government at the highest levels. This
tenuous support has created a mechanism of accountability, requiring results.
PPHI allows for an alternative management model. The new model provides a much
increased level of autonomy at the district level. The one-line budget would not be
possible within the current government system. However, although it seems PPHI has

been granted a considerable amount of autonomy in managing the BHUs in each district,
PPHI is not contracted by the health department. Instead they were hired by SRSO on the
recommendation of the provincial government and seconded to SRSO. All the managers
are still government employees. This has created a bifurcation in the reporting structure.
While on paper they are responsible for implementing the contractual arrangement
between the health department and SRSO, they are government employees with strong
ties to the federal government managers who approved the hires. The result is that day-today activities are monitored by the PPHI unit who seek approval of government
authorities, with only a token responsibility of SRSO.
There are some advantages to this situation. The PPHI management structure is
intimately familiar with government protocols, regulations, and politics. While too much
attention to these factors could be a hindrance, some of the best and brightest managers
within the public system were chosen. These managers appear, for the most part, to be
able to negotiate the system using their prior knowledge, while still implementing their
newly acquired flexibility and autonomy.
Taking management of the BHUs outside the traditional government system has created a
mechanism for the new management unit to implement innovative strategies to eliminate
vacancies and hire FMOs. The ability of PPHI to hire male doctors and FMOs on
contract, with high salaries, covering more than one facility, has led to the expansion of
services. New flexibilities in the budget and management have allowed for expansion of
the quantity and types of medicines provided at facilities. Better monitoring and
supervision, improved working conditions due to improved supplies and renovation, and
the greater accountability created by the rocky acceptance of the project have also
improved the performance of health staff, with fewer problems with absenteeism. All of
these improvements have led to huge increases in utilization of the facilities. By all these
measures, improved availability of medicines, supplies and equipment, staff, and
increased utilization, PPHI has been a success.
At the same time, PPHI is rather narrowly focused on only the lowest level of mostly
rural health facilities. There are several vertical programs that are not included in the
initiative such as immunization and family planning. The effect is that PPHI has very
little influence on improving immunization coverage or use of contraception, even with
the addition of FMOs, since it is primarily a separate provider (LHW) who dispenses
contraceptives. A pilot initiative has been proposed to include these vertical programs and
the first level referral facilities in the program in one district, and PPHI has committed to
ensuring all facilities have contraceptives available regardless of whether the national
family planning program is functional, with FMOs and LHVs able to dispense
contraceptives.
The success that PPHI has had, while not substantially affecting immunization and
contraception, is still encouraging. It is important to note, however, that the general
success of PPHI is in large part due to the buy-in, ownership, and enthusiasm of a small
group of managers, both at the federal and provincial levels. The creation and expansion
of the initiative were primarily pushed from the highest levels of the federal government.

Institutional support for the program, careful selection of key personnel, especially the
provincial project director, but an environment that still requires proof in the form of
results have been key to its success. Sustainability and continued improvement will
require a full adoption and integration of the new accountability felt by PPHI, especially
as support grows. Integrating the national programs and next level health facility (Rural
Health Centers) into the program and applying the lessons learned could make even more
substantial impacts on basic health services in Sindh, and start to close the urban/rural
disparity.
Overall, the greater flexibility and accountability of PPHI management has permitted and
required improved monitoring and supervision and quicker and more innovative
responses to problems. As a result, functioning of facilities, performance of staff, and
utilization of facilities have all greatly improved under PPHI.

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