PC-I
PUNJAB
Integrated Reproductive Maternal Newborn & Child
Health (RMNCH) & Nutrition Program
2013 - 2016
Department of Health
Government of the Punjab
1
ACRONYMS
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-IMNCI
Community 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
2
FP
Family Planning
FWC
Family Welfare Center
HO
Health Officer
HEB
High Energy Biscuits
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
3
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 Survey
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 PERFORMA
Code Number for Project_____________
(To be filled in by Planning Commission)
PART “A”
PROJECT DIGEST
Integrated Reproductive Maternal Newborn & Child
Health (RMNCH) &Nutrition Program
1.1
Name of the Project
1.2
Location of the Project All 36 districts of Province of Punjab
1.3
Authorities
Responsible for:
i.
Sponsoring.
Government of Punjab
Department of Health, Punjab and District Governments in
ii.
Execution.
Punjab
Department of Health, Punjab
iii.
Operation &
maintenance.
iv.
Concerned
Planning & Development Division
federal
ministry
1.4
(a) Plan provision
i. If the project is
The National Programs i.e. Lady Health Workers’ Program
included in the
(LHWP), National Maternal, Newborn and Child Health
Medium Term/five-
(MNCH) Program and Nutrition Program, were included in
year plan, please
the Ten-Year Perspective Development Plan 2001-11 and
specify actual
Medium Term Development Framework 2005-10. The
allocation.
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.
5
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.
ii. If the project is
The Program will require federal funds. Some donor funding
proposed to be
may also be available in the form of grants, results based aid
financed out of
and technical assistance.
block provision for a
program indicate
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).
(b) Provision in the
Total Cost: Rs. 9814.171 Millions
current year
PSDP/ADP
1.5
Project Objectives and
This program is inspired by the desire of the government to
its relationship with
reduce maternal, newborn and child morbidity and mortality,
Sectoral Objectives
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 includes
geographical
distribution
of
and
the
community’s
6
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; and
3: 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
7
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;

Increasing percentage of early initiation of breast feeding
from 15% in 2011 to 40% by the end of 2016;
8

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,
Pakistan’s health MDGs’ targets have improved over last two
Justification &
decades but they still lag well behind other countries at
Technical Parameters
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
(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
9
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, 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
10
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 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
11
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 12
targeted Districts and urban peripheries of 9 megaDistricts 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
12
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 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
13
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 ereporting system
11.
Increase
healthcare
demand
services
for
preventive
through
and
primary
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
Date when capital expenditure estimates were prepared:
February 2013. The costs have been estimated on the
Local: prevailing rate of the market and based on previous work
GOP: done.
Punjab Government Share Rs.9424.006 (M) for 2013-2016.
Foreign exchange cost: UNICEF Share for 2013-2014 Rs.260.155 (M)
WFP Share for 2013-2016 Rs130.010 (M).
Total: Total Cost: Rs. 9814.171 Millions
1.8
Annual Operating and
Average Annual Operating Cost is
Maintenance cost
Rs. 3271.390 Millions for the FY 2013-16.
after completion of
the project: (Item wise
annual Operating
Cost)
Employees Related Expenses
Communication
Utilities
Occupancy Cost
Training Domestic (All Trainings of
LHWs, LHSs etc., TOT)
TA/DA
Transportation of Goods
POL
Local Conveyance Charges
Stationary
Printing & Publication
822.955
1.160
0.600
0.500
44.133
0.500
10.333
33.600
0.010
0.100
3.333
14
1.9
Sources of Financing:
Conference/Seminars
0.600
Newspaper, Periodicals & Books
0.010
Advertisement & Publicity
2.000
Law Charges
0.005
Purchase of Drugs & Medicines
518.615
Others (Supplies for Nutrition
Components & Consumables)
1.920
Pension Contribution.
0.313
Entertainment & Gifts
0.010
Software (Physical Assets)
1.267
IT Equipment (Physical Assets)
2.133
Medical Store(Contraceptives)
283.333
Others Store & Stock
1389.970
Machinery Equipment
150.850
Furniture & Fixture
2.192
Transport Repair
0.848
Soft Ware Repair
0.100
Total
3271.390
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 for
providing services.
1.10
Demand and Supply
The Government’s health expenditure in Pakistan is very low
Analysis
– 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.
1WHO National Accounts for Pakistan
15
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 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
16
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 health care while
providing improved quality of care to the population.
1.11
Financial Plan and
1.
Punjab ADB
mode of financing
2.
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:
No direct financial gains are expected from the program.
a) Financial,
However, reduction in morbidity and mortality in the
Social and
population, control in population and improvement in
environmental
nutritional status would lead households to have more
Benefits
resources and spend on improving quality of their lives,
better learning on children and health life styles.
Financial
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:
17
Social Benefits with
1.
Under five Mortality Rate;
Indicators
2.
Maternal Mortality Ratio;
3.
Population Growth Rate;
4.
Total Fertility Rate
5.
Crude Birth Rate; and
6.
Improvement in literacy rate.
Employment
Health and poverty are closely linked with each other;
generation (direct
already poor people who are also unhealthy and vice versa. It
and indirect)
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 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
18
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.
Environmental
impact
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
Impact of delays on
project cost and
viability
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.
19
b)
Project
The program will be having four major outputs:
Analysis:
1:
planning and nutrition services under Essential
Quantifiable outputs
of the project:
Improved delivery of maternal, newborn, child, family
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 with
milestones and targets.
1.13
Unit cost analysis:
Average Cost of Married Women & Children Rs. 116/-
Management
The ultimate objective for implementation of the program at
Structure &
operational level will be through the current Government
Manpower
structure of the Health Department. Additional management
Requirement
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.
20
PREPARED BY:
Dr. AkhtarRashid
Provincial Coordinator
Lady Health Workers’ Programme
Department of Health, Punjab
CHECKED BY:
Mr. FarasatIqbal
Project Director
Health Sector Reform Programme
Department of Health, Punjab
Dr. ZafarIkram
Provincial Programme Manager
MNCH Programme
Department of Health, Punjab
Dr.NisarCheema
Director General Health
Services
Department of Health, Punjab
APPROVED BY:
Capt (R) ArifNadeem
Secretary Health
Department of Health, Punjab
Dated:
25-02-2013
21
LOGICAL FRAMEWORK:
PROGRAM NAME
Integrated Reproductive Maternal Newborn & Child Health &Nutrition Program
GOAL
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
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
Assumptions
Source
Pakistan Demographic & Health Survey (PDHS)
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Neonatal
Mortality Rate
(NMR)
58/1,000 lb (PDHS
2006-07)
52
50
48
44
Source
Pakistan Demographic & Health Survey (PDHS)
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Infant Mortality
Rate (IMR)
82/1,000 lb –
MICS 2011
80
75
70
40
Source
Pakistan Demographic & Health Survey (PDHS) / MICS
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Under 5 Mortality
Rate
97/1000 lb –
PDHS 2006-07
102
98
92
52/1,000 lb
104/1000 lb
- MICS 2011
Source
Multiple Indicator Cluster Survey (MICS), Pakistan Demographic & Health Survey (PDHS)
22
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Total Fertility
Rate (TFR)
3.9 – PDHS 06-07
3.5
3.4
3.3
3.2
3.6 - MICS 2011
Source
Multiple Indicator Cluster Survey (MICS), Pakistan Demographic & Health Survey (PDHS)
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Stunting
(moderate &
severe)
prevalence
36% - MICS 2011
35
34
33
32%
Source
Multiple Indicator Cluster Survey (MICS)
23
PURPOSE
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Assumptions
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
Source
Multiple Indicator Cluster Survey (MICS), Pakistan Demographic & Health Survey (PDHS)
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Skilled Birth
Attendance (SBA)
46% (37R, 64U) PSLM 10/11
65%
75%
80%
75% (72R, 80U)
59% - MICS 2011
Source
Multiple Indicator Cluster Survey (MICS), Pakistan Social & Living Standard Measurement Survey (PSLM)
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Institutional Deliveries
43% (34R, 63U) PSLM 10/11
56%
60%
70%
75% (70R,80U)
53% - MICS 2011
Source
Multiple Indicator Cluster Survey (MICS), Pakistan Social & Living Standard Measurement Survey (PSLM)
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Fully Immunized
Children
34.6%-(Fully
immunized with
Measles 2)MICS
2011
45%
55%
70%
80%
Source
Multiple Indicator Cluster Survey (MICS), Pakistan Social & Living Standard Measurement Survey (PSLM)
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
24
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Per cent of Children
suffering from
diarrhea treated with
ORS and Zinc
NA
15%
25%
35%
40%
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Percent of registered
children, in the 12
priority districts,
successfully treated
for severe acute
malnutrition (with
complications).
20%
40%
50%
60%
75%
Indicator
Baseline
Milestone 3
2015-16
Target 2017
Percentage of
identified SAM
children enrolled for
treatment in 12
priority districts
interventions are
harmonized provincial
and district level
Source
Multiple Indicator Cluster Survey (MICS), Pakistan Social & Living Standard Measurement Survey (PSLM)
Source
Multiple Indicator Cluster Survey (MICS) 2011
Milestone 1
2013-2014
-
Milestone 2
2014-15
50%
55%
60%
80%
Source
Program Database
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Percentage of
registered pregnant
women receiving iron
folic acid tablets
20
30%
40%
50%
60% in 2016
Source
National Nutrition Survey (NNS)
25
INPUTS (HR)
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
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
Source
Third party assessments
FTEs
48,000 LHWs deployed
9,000 CMWs trained
Required staff in health facilities (BHUs, RHCs, THQ & DHQ hospitals
Required Management staff at provincial and district level
OUTPUT 1
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Assumptions
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
Average 100FP
clients per
month per
facility
Average 120FP
clients per
month per
facility
Average 120FP 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
Source
District Health Information System (DHIS)
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
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
Average 56 FP
users per month
per LHW
catchment
population
Average 60 FP
users per month
per LHW
catchment
population
Average 60 FP users per
month per LHW catchment
population
Funding support from
federal government
continues/ enhanced
and fiduciary risks
mitigated
Source
Program Management Information System
Provincial funding and
26
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
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
34/36 DHQ and
60/84 THQ
hospitals and
20/291 RHCs
providing 24/7
Comprehensive
EmONC services
36/36 DHQ and
70/84 THQ
hospitals and
36/291 RHCs
providing 24/7
Comprehensive
EmONC services
36/36 DHQ and 75/84 THQ
hospitals and 36/291 RHCs
providing 24/7
Comprehensive EmONC
services
Health Facility Assessment Surveys, Program Management Information System
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
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
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
(Served on)
Effective coordination
between
IntegratedPrograms
and effective joint
coordination and
supervision
mechanism.
Milestone 1
2013-2014
Regular and uninterrupted supply of
essential medicines
and contraceptives to
districts.
Source
Program Database
Baseline
Establishment of
Stabilization Centers
(SC) for Nutrition
5
Source
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
Source
Indicator
donor assistance is
available to fill the
funding gaps
12 in priority
districts
Milestone 2
2014-15
30 (21 in
priority
districts)
Milestone 3
2015-16
36
Target 2017
36
Districts ownership to
the program and
reforms.
Program Database
27
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
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 megacities
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
Target 2017
Source
Program Database
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Exclusive
breastfeeding till age
of 6 months
22%
25%
30%
35%
40% in 2015
Source
MICS 2011
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Early initiation of
breastfeeding
15%
20%
30%
40%
50%
Source
MICS 2011
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Proportion of
registered children 623 months fed in
accordance with all
three infant and
young child feeding
NA
10%
20%
30%
40%
Source
Program Management Information System
28
(IYCF) practices (food
diversity, feeding
frequency,
consumption of
breast milk or milk)
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Iodized salt
consumption
34% - MICS 2011
40%
46%
50%
50%
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
Source
Multiple 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
Source
Multiple Indicator Cluster Survey (MICS)
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
% of mothers aware
of at least two
benefits of exclusive
breast feeding
NA
30
35
40
50%
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
% of district
implementing
awareness
interventions during
NA
10%
40%
80%
100%
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
Source
Community-based survey
Source
District Communication Intervention reports
Private sector
facilitates the public
sector in creating
awareness and
changing behaviors
related with RCN
Effective coordination
29
World Health Day,
World Population
Day, World Midwifery
Days, World Child
Day, Mother & Child
health week and
World Hand Washing
Day
between program and
projects for
coordinated
communication
interventions
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
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
System of regular
monitoring/
assessment functional
Source
Health Facility Assessment Surveys 2011
30
OUTPUT 3
Indicator
Baseline
Effective
management
of the Program
at provincial
and district
level
Office of Integrated
Implementation Unit
established
Source
Indicator
Baseline
-
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
100%
100%
100%
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
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
Administrative data
No of Health Care
providers Trained on
Training Package (IYCF
& HTSP)
-
Assumptions
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
Source
Administrative data
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
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%
Source
Health Facility Assessments, District Health Information System (DHIS)
Macro-economic
stability and
availability of
appropriate funds
Fiduciary and
institutional risks
appropriately
mitigated
Effective system of
performance of
managers functional
31
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
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%
Indicator
Baseline
Milestone 1
2013-2014
Milestone 2
2014-15
Milestone 3
2015-16
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
Source
Health Facility Assessments, Program database
Source
Progress Reports
32
OUTPUT 4
Indicator
Baseline
Milestone 1
2012-13
Milestone 2
2013-14
Milestone 3
2014-15
Target 2017
Assumptions
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
Quality review
meetings
Quality review
meetings
Quality review meetings
Annual
performance
review
Annual
performance
review
Annual
performance
review
Strong commitment at
provincial level to
integrate health
information systems
with strong leadership
Annual District
performance
disseminated
through DOH
website
Annual District
performance
disseminated
through DOH
website
Annual District
performance
disseminated
through DOH
website
Annual performance review
Annual District performance
disseminated through DOH
website
Source
Minutes
Indicator
Baseline
Milestone 1
2013-14
Milestone 2
2014-15
Milestone 3
2015-16
Target 2017
Improved quality of
data
LQAS in DHIS only
Internal
validation of
data
External
validation
review
Internal
validation of
data
Regular validation data
Source
Validation results
Indicator
Baseline
Milestone 1
2013-14
Milestone 2
2014-15
Milestone 3
2015-16
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
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.
Annual provincial report
published
33
Annual
provincial
report
published
Annual
provincial
report
published
Annual
provincial
report
published
Source
Verbal autopsy reports
INPUTS (Rs.)
INPUTS (HR)
Total Cost
Rs. 9814.171 Millions
Total
Rs. 9814.171 Millions
FTEs
34
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, 2011
www.statepak.gov.pk
4
MICS 2011
3
5
6
Healthcare
professional trained in pregnancy, delivery and newborn care
http://wbln0018.worldbank.org/news/pressrelease.nsf.
MICS 2011
7
35
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.
8
The Pakistan Demographic and Health Survey 2006-07
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.php
12
World Development Indicators, 2002;
9
36
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.
37
Baseline (Nov 2010)
Provincial Average (Aug-2012)
CHARM Average (Aug 2012)
172
76
43
25
40
1
ANC
6
9
2
Delivery
PNC
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.
Cost Benefit Analysis ( BHU)
Baseline @Rs. 240,000 per month
Current Running Cost @Rs. 85,000 per month (additional)
1150
400
172
25
ANC
1
40
Delivery
2
76
PNC
OPD
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
38
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.
39
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.
40
Key activities:
a)
b)
c)
d)
e)
f)
g)
h)
Availability of minimum agreed staff at the identified health facilities by the year 2013
for provision of 24/7 Basic and Comprehensive EmONC services
Availability of logistics, equipment, medicines and supplies for all HF designated for
provision of 24/7 Basic and Comprehensive EmONC services
Strengthening of neonatal units at the Comprehensive EmONC health Facilities
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
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
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
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 safety
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.
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
41
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.
42
Year Wise Implementation of Phasing 24/7 EmONC facilities
Phase 1
Implementation of
24/7 in Phasing in
2013-14
Phase 2
Implementation of
24/7 in Phasing in
2014-15
Sr.
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Total
Sr.
NO
1
2
3
4
5
6
7
8
9
District
Rajanpur
DG Khan
Muzafargarh
Bahawalpur
Bahawalnagar
Rahim Yar Khan
Khanewal
Layyah
Bhakkar
Narowal
Pakpatan
Hafizabad
Sargodha
Mianwali
Multan
Jhung
District
Faisalabad
Lahore
Rawalpinidi
Sialkot
Khushab
Chakwal
Vehari
T. T. Singh
Sahiwal
Total
Sr.
District
NO
1
Attock
2
Chiniot
3
Gujrat
4
Jhang
5
Jhelum
Implementation of
24/7 in Phasing in
6
Kasur
2015-16
7
Lodhran
8
Naknaka
9
Okara
10
Sheikhupura
11
M. B. Din
Total
Grand Total
Phase 3
12
6
10
7
5
9
14
6
10
Total
BHU
31
52
71
73
103
104
82
40
40
56
53
32
122
40
77
58
1064
Total
BHU
168
36
98
88
41
65
74
66
76
24/7
BHU
15
16
21
22
31
31
23
12
10
16
15
11
30
11
18
16
300
24/7
BHU
47
10
27
25
11
19
21
18
21
26
79
712
200
DHQ
THQ
RHC
1
1
1
1
1
1
1
1
2
1
1
12
34
5
2
1
2
2
2
2
0
2
1
1
20
84
5
3
10
9
5
12
4
7
10
9
9
83
295
Total
BHU
60
36
90
58
45
82
48
48
96
79
49
691
2467
24/7
BHU
17
10
26
17
13
24
14
14
28
23
14
200
700
DHQ
THQ
RHC
1
1
1
1
1
0
1
1
1
1
1
1
1
1
0
1
14
2
1
2
4
4
3
3
3
3
1
1
1
4
1
2
2
38
6
9
13
10
10
19
4
4
3
7
4
5
14
9
7
9
133
DHQ
THQ
RHC
0
1
0
2
1
1
1
1
1
5
2
4
3
3
3
2
2
2
8
SBA
Rate
17
26
36
37
42
44
49
49
50
55
57
70
61
65
65
52
SBA
Rate
70
82
79
72
61
75
50
58
26
SBA
Rate
61
58
73
52
80
53
43
60
51
65
52
43
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.
Physical Infrastructure
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.
44
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.
Equipment and Supplies
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.
45
Physical Infrastructure
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.
Equipment and Supplies
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
46
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.
Physical Infrastructure
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.
47
Table 2 List of equipment for DHQ and hospitals providing comprehensive EmONC services
Pediatric 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
Disposable syringe cutter
Baby cot ē heating facility
Perineal/Vaginal/Cervical Repair
Furniture
Baby warmer
Sponge forceps
Baby Cot
Operation Theatre
Needle holder
Infant BP apparatus (Cuff 2.5 cm)
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
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
Laboratory
Examination lamp
48
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 threemonths 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
Table3:Distribution of trainees by hospital
S
#
Health Facility
No
Trainees
1
RHC
2
2
THQ Hospital
3
3
DHQ Hospital
4
Total
Total
Trainees
Keeping in view the paucity of
578
avenues for practical training and
240
an expected delay/ shortfall in
140
958
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
49
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
50
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.
51
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”;
52
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
53
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.
54
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
13
Cernada GP, Rob AKU, Ameen SI, Ahmad MS. A Situation Analysis of Family Welfare Centers in
Pakistan.Islamabad, Pakistan: Population Council; 1993.
55
a)
b)
c)
d)
e)
Linkages building with PWD at all levels including UC, district and provincial level
Ensure un-interrupted provision of FP supplies to health facilities, CMWs and LHWs by
putting in place an effective Supply Chain Management System
Capacity building of LHWs, CMWs and health facility staff on HTSP, PPFP counseling and
skills
Integrated MIS regarding FP data at the community and facility level
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;
56
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).
57
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 Communitybased 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.
58
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 2nd 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.
59
IMPLEMENTATION OF NUTRITION PROGRAM IN PHASING
Sr.No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
2013-14
Narowal
Layyah
Mianwali
Multan
Khushab
Rahimyar Khan
Pakpattan
D. G. Khan
Muzaffargarh
Bhakkar
Rajanpur
Bhawal Nagar
Gujranwala
Sargodha
Rawalpindi
Faisalabad
Bhawal Pur
Sahiwal
Khanewal
Sialkot
Lahore
2014-15
Narowal
Layyah
Mianwali
Multan
Khushab
Rahimyar Khan
Pakpattan
D. G. Khan
Muzaffargarh
Bhakkar
Rajanpur
Bhawal Nagar
Gujranwala
Sargodha
Rawalpindi
Faisalabad
Bhawal Pur
Sahiwal
Attock
Chiniot
Gujrat
Hafizabad
Jhang
Jhelum
Kasur
Khanewal
Lodhran
Vehari
Sialkot
Lahore
2015-16
Narowal
Layyah
Mianwali
Multan
Khushab
Rahimyar Khan
Pakpattan
D. G. Khan
Muzaffargarh
Bhakkar
Rajanpur
Bhawal Nagar
Gujranwala
Sargodha
Rawalpindi
Faisalabad
Bhawal Pur
Sahiwal
Attock
Chiniot
Gujrat
Hafizabad
Jhang
Jhelum
Kasur
Khanewal
Lodhran
M.B. Din
Chakwal
Nankana Sahib
Okara
Sheikhupura
T.T. Singh
Vehari
Sialkot
Lahore
60
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)
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
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
61
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
62
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
63
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
64
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
65
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
66
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.
67
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)
b)
c)
ii.
Capacity building of deployed CMWs on EMNC, CIMNCI, HTSP& PPFP counseling,
IYCF and vaccination
Capacity building of deployed LHWs on CIMNCI, IYCF, vaccination, HTSP and
Postpartum Family Planning Counseling
Refresher training of all CMWs and LHWs after periodic technical assessment
Strengthening of Monitoring and Supervision of CMWs and LHWs
d)
e)
f)
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
Monitoring visits to all LHWs and CMWs by LHS once a month
Monitoring visit to all LHWs and CMWs by the District RH/MNCH focal person /
district Monitoring officer at least twice biannually.
68
iii.
Interventions for Hard to Reach Areas and urban slums
g)
h)
Identification of hard to reach areas (in all districts) and urban slums (in bigger
districts) in all districts after district mapping
Review and revision of existing training manuals of CMW for LHW cum CMW
training.
69
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)
b)
Development and implementation of referral protocols for referral of high risk cases to
Basic and Comprehensive EMONC facilities
Implementation of referral and follow up system for SAM Children with medical
complication to established SC centers.
70
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.
2.
3.
4.
5.
6.
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.
Development of e-monitoring module and integration with the program MIS
Provision of tracking SIMs to all community staff
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
Purchase of required hardware and equipment for implementation of e-monitoring
Hiring of relevant staff
71
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.
72
Conceptual Framework for E-Management
73
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;
74
4.
Facilitating each community to identify its 1-2 representatives 14 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.
A community representative is the community member who is well trusted and respected
by that community in all walks of life.
14
75
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
significant number of lives. This program will ensure these services at all health facilities
76
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.
77
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.
78
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



2.
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
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
79
MANAGEMENT STRUCTURE
Administrative Arrangements
The administrative arrangements for program implementation consist of establishment of:
1.
2.
Provincial and district steering committees
Provincial and district management units
Provincial Steering Committee (PSC)
Provincial steering committee shall comprise of:
•
•
•
•
•
•
•
Chairman Planning & Development Department /Member Social Sector
Secretary Health
Director General Health
Program Director PHSRP
Program Director
DG Population Welfare Department
Secretary Finance Department
Chairman
Member
Member
Member
Secretary
Member
Member
District Steering Committee (DSC)
District steering committee shall comprise of:
•
•
•
•
•
District Coordination Officer
Executive District Officer (Health)
District Coordinator
District Officer Health
EDO F&P
Chairman
Member
Secretary
Member
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.
80
Department
of PHC, FP, RH & nutrition Policy for the program, Service specification, Funding,
Health
Program Monitoring and Evaluation
PHC Policy Advice, National Reporting, Internal Supervision and Monitoring,
Evaluation, Training, Program, Procurement/Distribution, Operational Planning
and budgeting, Financial Accounting, LHW-MIS System
PMU
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.
LHW, CMW, LHS-District Supervision, LHW & LHS Hiring /Firing, Training,
Operational
DMU
Plan
Implementation,
Distribution,
Vehicle
maintenance,
Accounting, Program Reporting, MIS Data Collation, analysis and use of
information in management
Recommendation for hiring of LHWs & LHSs by the Medical Officer/Woman
Medical Officer, Training of LHWs, Collation of MIS, Organizing Kit replenishment,
FLCF (all)
Providing meeting point for LHWs and LHS, and collaboration with CMWs and
PWD staff.
Selected RHCs for Provision of comprehensive EmONC services and serve as a referral facility for
Comprehensive
obstetric cases
EmONC Services
All
RHCs
and Provision of basic EmONC services round the clock, provision of outdoor obstetric
Selected BHUs for care, routine EPI, family planning services and nutrition services (CMAM/OTP).
24/7
EmONC
Basic Additional HR, equipment and supplies will be ensured to enhance the capacity
& of these facilities for provision of services beyond the existing ToRs.
Nutrition Services
LHW
PHC & FP service provision to community, community organization
CMW
MNCH & FP service provision to community
81
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.
2.
3.
4.
5.
6.
Play steward ship role in formulation of program policy guidelines in consultation with
all stakeholders and dissemination of the same to all district managers.
Constitute and notify the technical advisory groups ( TAG) on different themetic areas
for formulation of technical guidlines
Development of training and capacity building strategies, training modules, training of
master trainers
Monitoring and evaluation of program activities, internal evaluations, coordination for
third party evaluations
Conduct performance audit and internal financial audit of the districts
Hearing of appeals against the district management unit
82
JOB Description
Designation &Pay scale
Eligibility Criteria
ToRs / Responsibilities
Deputy Program Manager A medical doctor with post graduate Deputy Program Manager Nutrition, reporting to the Provincial Coordinator,
shall be responsible for affairs related to Project activities, finances,
Nutrition
qualification in public health
procurement and logistics and assignments given by the Provincial Coordinator
BPS
19/18
by
transfer/ At least 15 years of experience at mid
time to time.
Deputation/open competition
and senior level positions including 5
years of project management experience He will be employed through transfer/deputation from Health Department. In
for implementation of field based case Health Department not depute any officer within six months after the
projects
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 i.
market based @ Rs. 80,000/ii.
1st class Master’s Degree in Bio Research Officer will be reporting to the Deputy Program Director is responsible
for overall management, planning,provision of technical support and successful
Statistic.
nutrition trainings. Or assignments given by the Provincial Coordinator/Deputy
02
years
experience
of
Program manager nutrition time to time.
monitoring
demonstrated
experience and competence in The remuneration for this position will be equivalent to grade 17 officer as
monitoring
and
evaluation, admissible under the Government rules in case of an existing Government
Nutrition project management employee or Rs. 100,000 per month in case of non- Government candidates.
and training.
83
iii.
Knowledge of computerized
database & 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 S/he at least D.COM having 02 year Data Entry Operator, reporting to the research officer for reporting nutrition
experience in Data Entry in Public Health project data or any assignment given to him / her by Nutrition / Research Officer
based @ Rs. 35,000/Sector or Implementing field services
projects.
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 nonGovernment candidates.
84
Facility & Field Staff
Designation &
Pay scale
WMO
LHV
1.1
Eligibility Requirement
Roles &
Responsibilities
MBBS
Preference will be given to those with post
graduate diploma/fellowships in obstetrics &
gynecology or pediatrics
LHV course
At least six months of experience in public
sector
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.
1
1.2
NISs of each office of the Program
Accounting Circles
PMU-Punjab, Lahore (includes budgets of DMUs).
AG Punjab, Lahore & District
Accounts Offices in all
District of Punjab.
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.
85
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.
86
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.
87
Schedule of Activities for Nutrition Program Punjab
Annexure
Activity
Year 1
1st
2nd
3rd
Year 2
4th
1st
2nd
3rd
Year 3
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 Acute
Malnutrition for children and
pregnant and lactating women
1.2.1 Training of district master trainers
88
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
Activity
Year 1
1st
2nd
3rd
Year 2
4th
1st
2nd
3rd
Year 3
4th
1st
2nd
3rd
4th
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
89
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 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.
90
Activity
Year 1
1st
Q
2nd
3rd
Year 2
4th
1st
2nd
3rd
Year 3
4th
1st
2nd
3rd
4th
Sub Component
2.4
Zinc
supplementation
treatment of diarrhea
during
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
3.1.1 IEC matrial for distribution to
Health Facility and Community
based staff
3.1.4 Material
Field
implemented
tested
and
3.1.2 Distribution of IEC matrial to
Districts
Component
4.
Strengthening
Arrangements
Institutional
4.1.1 Placing of appropriate staff at
91
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
92
93
DGHS
Program
Director
Additional PD I
Finance
Officers I
and II
Accountan
ts
Logistics
Officer
Procureme
nt Officer
Logistic
Assistant/
Store
Keeper
Internal Auditor
Deputy PD
Human
Resource
Training
Coordinator
Deputy PD
Training
and
Capacity
Building
Health
Education
Officer
Additional
PD II
Deputy PD
MIS/M&E
R&D Officer
Researcher
Data Analysts
Software
Developer
Computer
Programmer
Field Monitoring
Officers
Additional
Deputy PDPD IIIDeputy PD
Facility
Community
Based
Based
Interventio Interventio
ns
ns
Nutrition
MIS Coordinator
Officer
Data Analysts
Data Entry
Operators
94
EDO (H)
DDOH (PHC & RH)
M&E (Adm)
M&E (Tech)
Accounts Assistant
Logistics
Assistant
Data Entry Operator
95
Annex: Organogram
96
Annex: Facility Based Services
97
98
ANNEXURES
99
STAFF STRENGTH
No of FLCF
S.No
Cadre
BPS/Fixed
Salary
Strength
No of FLCF
FINANCIAL YEAR 2013-14
BPS/Fixed
Salary
Strength
No of FLCF
FINANCIAL YEAR 2014-15
BPS/Fixed
Salary
Strength
FINANCIAL YEAR 2015-16
Field Staff
1
Nursing Staff (for
DHQ Nutrition)
34 DHQ +2
Teaching
hospital
2
WMO
292 RHCs
3
Computer Operator
PMU
4
LHVs (CHARM)
300 BHUs
5
Aya (CHARM)
300 BHUs
6
Ambulance drivers
(CHARM)
7
Gaurds (CHARM)
Fixed
Salary
72
34 DHQ +2
Teaching hospital
72
34 DHQ +2
Teaching hospital
72
292
292 RHCs
292
292 RHCs
292
2
PMU
Fixed Salary
2
PMU
Fixed Salary
2
600
500 BHUs
1000
700 BHUs
1400
600
500 BHUs
1000
700 BHUs
1400
200
300 BHUs
300
Total Field Staff (2013-14)
2066
333
500 BHUS
500
Total Field Staff (2014-15)
3199
466
700 BHUs
1400
Total Field Staff (2015-16)
5032
PMU STAFF
1
Program Manager Nutrition
18/19
1
2
Nutrition Officer
17
1
3
Software Engineer
17
1
4
Statestical Officer
17
1
Total PMU Staff (2013-14)
4
Total PMU + Field Staff (2013-14)
2070
Program Manager
Nutrition
Nutrition Officer
Software
Engineer
Statestical Officer
18/19
1
Program Manager
Nutrition
17
1
17
17
Total PMU Staff (2014-15)
Total PMU + Field Staff (201415)
18/19
1
Nutrition Officer
17
1
1
Software Engineer
17
1
1
Statestical Officer
17
1
4
Total PMU Staff (2015-16)
4
3203
Total PMU + Field Staff (2015-16)
5036
100
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
Married Women
& Children
Average
Annual Cost of
Married
Women &
Children
94,000,000
28,200,000
116
100,000,000
90,000,000
80,000,000
70,000,000
60,000,000
50,000,000
40,000,000
30,000,000
20,000,000
10,000,000
0
Series1
101
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)
94,157,907
28,247,372
65,910,535
4,519,580
Budget Demand for Procurement of
Contraceptives in PC-I by the Vertical Program
S.No
1
2
3
Name of
Program
Lady
Health
Worker
Program
National
MNCH
Program
Nutrition +
CHARM
Total
FY
Budget
Demanded
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
Contraceptives
(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
10,545,686
1,129,895
5,272,843
406,762,158
1,898,223,405
2,304,985,563
2.5E+09
2E+09
1.5E+09
2011-17
575364924
2012-16
800,000,000
2013-16
850000000
Name of Program
FY
1E+09
Budget Demanded
500000000
0
1
2
3
Total
2225364924
102
Year wise Cost Sheets for UNICEF & WFP Shares
S.No
FY
UNICEF Share (Cost of
Mobendazoal+Cost
per SAM Child in 07
Districts)
1
2013-14
260,155,109
43,336,800
303,491,909
2
3
2014-15
2015-16
-
43,336,800
43,336,800
43,336,800
43,336,800
260,155,109
130,010,400
390,165,509
Total
WFP Share
(Cost Per PLW
for Rajanpur &
D.G.Khan)
Total UNICEF & WFP
Share
400,000,000
200,000,000
-
1
2
3
Total
103
District wise phasing of Implementation of MCH and Nutrition Interventions
2013-14
Sr.
No
Name Of District
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
Nutrition
Interventions
2014-15
24/7
Nutrition
Interventions
2015-16
24/7
Nutrition
Interventions
24/7
104
PAY OF OFFICERS
Basic Pay
Pay of Contract Staff
ALLOWANCES
REGULAR ALLOWANCES
House Rent Allowance
Conveyance Allowance
Medical Allowance
Deputation Allowance
Special Travelling Allowance (FTA)
Non Practicing Allowance
Special Additional Allowance (50%
2010)
105
Integrated Reproductive Maternal Newborn & Child Health &Nutrition Program
Yearwise Phasing for the Financial Year 2013-16
A01
A01106
A012
Object Heads
Financial Year
2013-14
Financial
Year 2014-15
Financial Year
2015-16
Total 2013-16
Average 2013-16
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
Pay of Contract Staff
1,119,600
1,119,600
1,119,600
3,358,800
1,119,600
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
488,400
Adhoc Relief Allowance (15% 2011)
146,544
146,544
146,544
439,632
146,544
532,560,000
734,320,000
1,017,514,000
2,284,394,000
761,464,667
A0
1970
OTHER ALLOWANCES
A01271
Over Time Allownace
A01273
Honorarium/Incentive for performance/
10,000
10,000
10,000
30,000
10,000
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
UTILITIES
600,000
600,000
600,000
1,800,000
600,000
Electricity Charges
600,000
600,000
600,000
1,800,000
600,000
OCCUPANCY COSTS
500,000
500,000
500,000
1,500,000
500,000
Rates & Taxes( Vehicles Tax & Toll Tax)
500,000
500,000
500,000
1,500,000
500,000
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
A033
A03303
A034
A03407
A038
106
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
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
4,000,000
4,000,000
2,000,000
10,000,000
3,333,333
600,000
600,000
600,000
1,800,000
600,000
10,000
10,000
10,000
30,000
10,000
2,000,000
2,000,000
2,000,000
6,000,000
2,000,000
5,000
5,000
5,000
15,000
5,000
A03902
A03903
Printing and Publication ( MIS Tools, Training
manuals , BCC Material etc
Conference
/Siminars/Workshops/Symposium/ Review
Meetings
A03905
News Papers, Periodicals & Books
A03907
Advertising & Publicity
A03917
Law Charges
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
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
1,117,946,603
1,975,427,890
1,926,534,344
5,019,908,837
1,673,302,946
550,000,000
300,000,000
850,000,000
283,333,333
A06
A094
OTHER STORE AND STOCK
A09401
Medical Stores (Contraceptives)
A09470
OTHER STORE AND STOCK
A096
A09601
A097
A09701
1,117,946,603
1,425,427,890
1,626,534,344
4,169,908,837
1,389,969,612
PLANT AND MACHINERY
177,000,000
128,400,000
147,150,000
452,550,000
150,850,000
MACHINERY AND EQUIPMENT
177,000,000
128,400,000
147,150,000
452,550,000
150,850,000
FURNITURE AND FIXTURE
2,850,000
1,900,000
1,825,000
6,575,000
2,191,667
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
Transport
848,000
848,000
848,000
2,544,000
848,000
COMPUTER EQUIPMENT
100,000
100,000
100,000
300,000
100,000
Software
100,000
100,000
100,000
300,000
100,000
2,446,012,005
3,502,247,924
3,865,911,150
9,814,171,078
3,271,390,359
A13001
A137
A13702
TOTAL
107
Integrated Reproductive Maternal Newborn & Child Health &Nutrition Program
Budget Requirement for Financial Year 2013-14
Object Heads
A01
EMPLOYEE RELATED EXPENSES
588,210,384
PAY
1,719,600
PAY OF OFFICERS
1,719,600
A01101
Basic Pay
A01106
Pay of Contract Staff
A012
Budget Demand
600,000
1,119,600
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)
A01252
Non Practicing Allowance
48,000
A01964
Special Additional Allowance (50% 2010)
488,400
Adhoc Relief Allowance (15% 2011)
146,544
A0
1970
OTHER ALLOWANCES
52,560,000
532,560,000
A01271
Over Time Allownace
10,000
A01273
Honorarium/Incentive for performance/
A01274
Medical Charges
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
44,160,000
50,000
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
UTILITIES
600,000
Electricity Charges
600,000
OCCUPANCY COSTS
500,000
Rates & Taxes( Vehicles Tax & Toll Tax)
500,000
A033
A03303
A034
A03407
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)
A03806
Transportation of Goods
500,000
25,000,000
108
A03807
POL Charges
A03808
Local Conveyance Charges
24,000,000
10,000
A039
GENERAL
419,414,213
A03901
Stationary
100,000
A03902
Printing and Publication ( MIS Tools, Training manuals , BCC Material etc
A03903
Conference /Siminars/Workshops/Symposium/ Review Meetings
600,000
A03905
News Papers, Periodicals & Books
10,000
A03907
Advertising & Publicity
A03917
Law Charges
A03927
Purchase of Drug and Medicines & Tab Iron Folic Acid for Nutrition
A03970
Others ( Supplies for nutrition components & consumables)
4,000,000
2,000,000
5,000
410,299,213
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
Entertainment & Gift
10,000
A06301
Entertainment & Gift
10,000
A09
PHYSICAL ASSETS
1,302,996,603
A092
COMPUTER EQUIPMENT
A06
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
A09401
Medical Stores (Contracepitves)
A09470
OTHER STORE AND STOCK
A096
A09601
A097
A09701
1,117,946,603
1,117,946,603
PLANT AND MACHINERY
177,000,000
MACHINERY AND EQUIPMENT
177,000,000
FURNITURE AND FIXTURE
2,850,000
Furniture and Fixture
2,850,000
A13
REPAIRS AND MAINTENANCE
948,000
A130
TRANSPORT
848,000
Transport
848,000
COMPUTER EQUIPMENT
100,000
A13001
A137
A13702
Software
100,000
TOTAL
2,446,012,005
109
Budget Requirement for transport ( Ambulances )
For the Financial Year 2013-14
Sr.
No.
1
Name of District
Ambulances
Total Budget Required
No. of Vehicles
100
A-03807 POL
A-13001 ROT
Total Budget
Required
24,000,000
4,200,000
28,200,000
41,472,000
848,000
49,952,000
110
Budget Requirement of POL (A-03807)
For the Financial Year 2013-14
Sr.
No.
1
Name of District
Ambulances
No. of
Vehicles
Rate Per Month
No. of
Months
Total POL
Budget Required
100
20,000
12
24,000,000
Total Budget Required
24,000,000
111
Budget Requirement of A-13001 Repair (Vehicle/Transport) For
the Financial Year 2013-14
Sr.
No.
1
Name of District
Ambulances
No. of
Vehicles
Repair of
Vehicle @ Rs.
2500/- P.m.
Total Budget for Repair of
Vehicle Required
100
4,200,000
4,200,000
Total Budget Required
4,200,000
112
Budget Demand under the Head A-03801 Training Domestic
for the Financial Year 2013-14
Unit Cost
Training
No. of
Days
Total Amount
300
2000
5
3,000,000.00
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
Sr.
No.
Cadre
No. of
Posts
1
Training of HCPs on Nutrition
and IYCF
2
Total
82,350,000.00
Grand
Total
82,350,000.00
113
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
114
Integrated Reproductive Maternal Newborn & Child Health &Nutrition Program
Recurring Costs
Category
PMU
Managerial Staff
Number
Unit Cost/
Monthly
Monthly
Total
Annual Total
(Rs)
Annual Total
$
-
52,560,000
192,720,000
108,000,000
50,400,000
27,000,000
24,000,000
9,000,000
24,000,000
-
FTA for WMO
292
15000
WMO
292
55000
LHVs
600
15000
Ayas
600
7000
Security Guards
300
7500
Drivers
200
10000
Medicines
300
2500
FP Material
0
0
Pay for performance
40
50000
4,380,000
16,060,000
9,000,000
4,200,000
2,250,000
2,000,000
750,000
2,000,000
Consumables (Lab Kits
and gloves)
300
2000
600,000
7,200,000
83,720.93
Petty Cash
300
2000
100
16500
7,200,000
19,800,000
83,720.93
POL for ambulances
600,000
1,650,000
230,232.56
Operational Cost ( POL &
Office suplies)
1
0
-
-
-
TA/DA
1
0
0
0
-
-
Miscellaneous
-
Operational Cost ( POL,
Repair of transport &
Office suplies)
20
0
-
-
-
Miscellaneous
20
10000
20
50000
Medicines
162
3500
Additional HR
45
25000
PGRs
40
0
Advertisements
1
MRM @ District
20
10000
2,400,000
12,000,000
6,804,000
13,500,000
2,000,000
2,400,000
27,906.98
Additional HR
200,000
1,000,000
567,000
1,125,000
200,000
Quarterly Review Meeting
& Dissemination
4
150000
600,000
600,000
Chairperson
1
Program Director
1
Deputy PD
1
Human Resource Manger
1
Finance Manager
1
MIS Manager
1
Office Assistant
1
-
District Manager
M & E Officer
DSU
Data Entry
Program Assistant
Accounts Officer
BHU
PMU
DSU
RHCs
THQ
Overall
Operational
Costt
611,162.79
2,240,930.23
1,255,813.95
586,046.51
313,953.49
279,069.77
104,651.16
279,069.77
-
139,534.88
79,116.28
156,976.74
23,255.81
27,906.98
6,976.74
115
Call Response Center
20
100000
Printing
4
150000
2,000,000
600,000
Total
2,000,000
600,000
561,584,000
23,255.81
6,976.74
6,530,046.51
One Time Cost
BHU
0
35000
Ambulances
Furniture & Fixture for
DSU
IT Equipment (Laptop, PC,
desktop, Printer, Fax)
100
0
45,000,000
10,500,000
2,850,000
-
16
0
-
-
-
16
200000
3,200,000
3,200,000
37,209.30
USG Portable
150
500000
15
0
Equipment for RHCs
Equipment for
THQs/DHQs
20
800000
75,000,000
16,000,000
872,093.02
Repair & Renovation
75,000,000
16,000,000
50
400,000
20,000,000
20,000,000
232,558.14
-
-
-
172,550,000
2,006,395.35
Basic Equipment for BHUs
300
150000
UPS with Battries
300
35000
F&F for BHUs
300
9500
Computers & Printer
DSU/RSU
RHCs
THQ&
DHQ
0
Total
45,000,000
10,500,000
2,850,000
-
523,255.81
122,093.02
33,139.53
-
186,046.51
-
Annual Cost
561,584,000
Two Years
Cost
1,123,168,000
One Time
Cost
172,550,000
Total (Rs)
1,295,718,000
Total $
14,724,068
116
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
1
Nursing Staff (for DHQ Nutrition)
2
3
Budget
Requirement in
Rs.
Strength
Net Pay
Period
34 DHQ +2 Teaching hospital
72
30000
12
25920000
WMO
292 RHCs
292
55000
12
192720000
Computer Operator
PMU
2
25000
12
600000
600
17000
12
122,400,000
600
9000
12
64,800,000
200
10000
12
24,000,000
300
9000
12
32,400,000
4
LHVs (CHARM)
300 BHUs
5
Aya (CHARM)
300 BHUs
6
Ambulance drivers (CHARM)
7
Gaurds (CHARM)
Total
300 BHUs
BPS
Fixed
Salary
2066
462,840,000.00
117
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
Entertainment
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
1
Staff 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
2
Staff 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
600,000
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
3,621,504
Total Budget
Requirement for
2013-14
118
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.
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
Entertainment
Allow
A01217
Medical
Allow
SAA
(2010)
SPHA
4448
14825
11200
4448
14825
11200
Comp
Allow
Adhoc
Relief
Allow.
15%
Adhoc
Relief
Allow.
20%
Total
4448
0
105730
0
4448
0
105730
Social
Security
30%
01 Posts of BPS-18
1
Program
Manager
Nutrition
19
Total
50000
50000
0
0
0
0
5809
5000
6000
4000
5809
5000
6000
4000
0
0
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
Total PMU Salary for one
Month
Budget for Dec-13 to
June-14
0
0
0
94800
0
13299
15000
0
0
0
7764
25875
0
0
14400
7764
18960
197862
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
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
119
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.
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
Entertainment
Allow
A01217
Medical
Allow
SAA
(2010)
SPHA
4448
14825
11200
4448
14825
11200
Comp
Allow
Adhoc
Relief
Allow.
15%
Adhoc
Relief Allow.
20%
Total
4448
0
105730
0
4448
0
105730
Social
Security
30%
01 Posts of BPS-18
1
Program
Manager
Nutrition
18
Total
50000
50000
0
0
0
0
5809
5000
6000
4000
5809
5000
6000
4000
0
0
03 Posts of BPS-17
1
Nutrition
Officer
17
30400
4433
5000
2588
8625
4800
2588
6080
64514
2
Software
Engineer
17
30400
4433
5000
2588
8625
4800
2588
6080
64514
3
Statestical
Officer
17
30400
4433
5000
2588
8625
4800
2588
6080
64514
15000
25875
0
0
14400
7764
18240
193542
0
0
0
Total PMU Salary for one
Month
Total
91200
0
13299
50,000
0
Budget for July 13 to Nov-13
250,000
0
0
91,200
0
19,108
20,000
0
456,000
0
95,540
100,000
0
0
0
7764
6,000
4,000
0
12,212
40,700
11,200
0
14,400
12,212
18,240
299,272
30,000
20,000
0
61,060
203,500
56,000
0
72,000
61,060
91,200
1,496,360
120
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
children
age 6 to
59
month
14 %
Narowal
1516173
758086.5
1486000
743000
1
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
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
16
106132
16981
5298
21192460
30323
6822779
56856
341139
56856
7650
12240065
7107061
100000
500000
48303503
104020
14
14563
4544
18174374
29720
6687000
55725
334350
55725
7498
11996478
6965625
100000
500000
44757827
91630
21
19242
6004
24014390
26180
5890500
49088
294525
49088
6573
10516506
6135938
100000
500000
47451859
279580
20
55916
17446
69783168
79880
17973000
149775
898650
149775
20055
32087796
18721875
100000
500000
140064489
19.7
15607
4869
19477947
22636
5093037
42442
254652
42442
5683
9092769
5305247
100000
500000
39823651
293860
19
55833
17420
69680083
83960
18891000
157425
944550
157425
30698
49116600
19678125
100000
500000
158910358
113190
19
21506
6710
26839613
32340
7276500
60638
363825
60638
11824
18918900
7579688
100000
500000
61578525
155330
19
29513
9208
36831850
44380
9985500
83213
499275
83213
16226
25962300
10401563
100000
500000
84280487
250530
17
42590
13288
53152445
71580
16105500
134213
805275
134213
26171
41874300
16776563
100000
500000
129314082
95771
26
24900
7769
31075612
27363
6156675
51306
307834
51306
10005
16007355
6413203
100000
500000
60560679
103950
13.7
14241
4443
17772955
29700
6682500
55688
334125
55688
10859
17374500
6960938
100000
500000
49725018
179620
17
30535
9527
38108179
51320
11547000
96225
577350
96225
18764
30022200
12028125
100000
500000
92882854
123312
13
16031
5002
20006139
35232
7927200
66060
396360
66060
12882
20610720
8257500
500000
57697919
89292
12
10715
3343
13372370
25512
5740200
47835
287010
47835
9328
14924520
5979375
500000
40803475
120988
13
15728
4907
19629093
34568
7777800
64815
388890
64815
12639
20222280
8101875
500000
56619938
191016
14
26742
8344
33374316
54576
12279600
102330
613980
102330
19954
31926960
12791250
500000
91486106
90076
14
12611
3935
15738079
25736
5790600
48255
289530
48255
9410
15055560
6031875
500000
43405644
62776
16
10044
3134
12535112
17936
4035600
33630
201780
33630
6558
10492560
4203750
500000
31968802
72380
21
15200
4742
18969350
20680
4653000
38775
232650
38775
7561
12097800
4846875
500000
41299675
96180
12
11542
3601
14403917
27480
6183000
51525
309150
51525
10047
16075800
6440625
500000
43912492
242200
14
33908
10579
42317184
69200
15570000
129750
778500
129750
25301
40482000
16218750
500000
115866434
493949
154112
######
9453400
1575567
Layyah
2
Mianwali
1309000
654500
3994000
1997000
3
Multan
4
Khushab
1131786
565893
4198000
2099000
1617000
808500
5
79225
Rahimyar
Khan
6
Pakpattan
7
D. G. Khan
2219000
1109500
8
Muzaffargarh
3579000
1789500
1368150
684075
9
Bhakkar
10
Rajanpur
1485000
742500
11
Bhawal
Nagar
2566000
1283000
4404000
880800
12
Gujranwala
13
Sargodha
3189000
637800
14
Rawalpindi
4321000
864200
6822000
1364400
15
Faisalabad
16
Bhawal Pur
3217000
643400
17
Sahiwal
2242000
448400
18
Khanewal
2585000
517000
3435000
687000
19
Sialkot
20
Lahore
8650000
1730000
21
#######
#######
######
##########
840302
########
285,686
########
##########
########
10,500,000
1,480,713,817
121
Integrated Reproductive Maternal Newborn & Child Health &Nutrition Program
Budget Requirement for Financial Year 2014-15
Object Heads
A01
EMPLOYEE RELATED EXPENSES
789,970,384
PAY
1,719,600
PAY OF OFFICERS
1,719,600
A01101
Basic Pay
A01106
Pay of Contract Staff
A012
Budget Demand
600,000
1,119,600
ALLOWANCES
788,250,784
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)
A01252
Non Practicing Allowance
48,000
A01964
Special Additional Allowance (50% 2010)
488,400
Adhoc Relief Allowance (15% 2011)
146,544
A0
1970
OTHER ALLOWANCES
52,560,000
734,320,000
A01271
Over Time Allownace
10,000
A01273
Honorarium/Incentive for performance/
44,160,000
A01274
Medical Charges
6,804,000
A01277
Contingent Paid staff
25,500,000
A01299
Other (Stipend of LHVs, Ayas, Ambulance Drivers & Guards)
657,846,000
A03
OPERATING EXPENSES
602,678,846
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
UTILITIES
600,000
Electricity Charges
600,000
OCCUPANCY COSTS
500,000
Rates & Taxes( Vehicles Tax & Toll Tax)
500,000
A033
A03303
A034
A03407
A038
TRAVEL & TRANSPORTATION
57,874,000
GOVT. SERVANTS
57,874,000
A03801
Training -Domestic (all training s &TOT) for 03 trainings
22,300,000
A03805
T.A (Govt. Servants)
A03806
Transportation of Goods
500,000
3,000,000
122
A03807
POL Charges
A03808
Local Conveyance Charges
32,064,000
10,000
A039
GENERAL
542,544,846
A03901
Stationary
100,000
A03902
Printing and Publication ( MIS Tools, Training manuals , BCC Material etc
A03903
Conference /Siminars/Workshops/Symposium/ Review Meetings
600,000
A03905
News Papers, Periodicals & Books
10,000
A03907
Advertising & Publicity
A03917
Law Charges
A03927
Purchase of Drug and Medicines & Tab Iron Folic Acid for Nutrition
A03970
Others ( Supplies for nutrition components & consumables)
4,000,000
2,000,000
5,000
533,429,846
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
Entertainment & Gift
10,000
A06301
Entertainment & Gift
10,000
A09
PHYSICAL ASSETS
2,108,327,890
A092
COMPUTER EQUIPMENT
2,600,000
A09202
Software ( Call Response center+ Web based MIS etc)
1,000,000
A09203
IT Equipment
1,600,000
A06
A094
OTHER STORE AND STOCK
A09401
Medical Stores (Contraceptives)
A09470
OTHER STORE AND STOCK
A096
A09601
A097
A09701
1,975,427,890
550,000,000
1,425,427,890
PLANT AND MACHINERY
128,400,000
MACHINERY AND EQUIPMENT
128,400,000
FURNITURE AND FIXTURE
1,900,000
Furniture and Fixture
1,900,000
A13
REPAIRS AND MAINTENANCE
948,000
A130
TRANSPORT
848,000
Transport
848,000
COMPUTER EQUIPMENT
100,000
Software
100,000
A13001
A137
A13702
TOTAL
3,502,247,924
123
Budget Requirement for DPIU's/PPIUs in Punjab
For the Financial Year 2014-15
Sr.
No.
1
Name of District
Ambulances
Total Budget Required
No. of
Vehicles
A-03807 POL
A-13001 ROT
Total Budget Required
167
32,064,000
6,509,000
38,573,000
41,472,000
848,000
49,952,000
124
Budget Requirement of POL (A-03807)
For the Financial Year 2014-15
Sr.
No.
1
Name of District
Ambulances
No. of
Vehicles
Rate Per Month
No. of
Months
Total POL
Budget Required
167
17,000
12
32,064,000
Total Budget Required
32,064,000
125
Budget Requirement of A-13001 Repair (Vehicle/Transport)
For the Financial Year 2014-15
Sr.
No.
1
Name of District
Ambulances
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
167
4,509,000
2,000,000
6,509,000
Total Budget Required
6,509,000
126
Budget Demand under the Head A-03801 Training Domestic
For the Financial Year 2014-15
Sr.
No.
Cadre
No. of
Posts
Unit
Cost
Training
No. of
Days
Total Amount
200
2000
5
2,000,000.00
0
3000
11
-
1
Training of HCPs on Nutrition
and IYCF
2
Training on IMNCI
3
Training of LHWs & CMWs on
Nutrition & IYCF
10000
400
4
16,000,000.00
4
Training of Medical officer on
PHC & Nutrition
200
2500
3
1,500,000.00
5
Training of HCPs on EmONC &
FP
200
2000
7
2,800,000.00
Total
22,300,000.00
127
COST OF MEDICINES (Charam 24/7)
# of
Units
Unit Cost per
month
# of Months
Total
RHCs
162
3000
12
5832000
Basic Health
Units
500
3000
12
18000000
Category
Total
23,832,000
128
Integrated Reproductive Maternal Newborn & Child Health &Nutrition Program
Recurring Costs
FTA for WMO
292
15000
WMO
292
55000
LHVs
1000
15000
Ayas
1000
7000
Security Guards
500
7500
Drivers
333
9000
Medicines
500
2500
FP Material
0
0
Pay for performance
40
50000
Monthly
Total
4,380,000
16,060,000
15,000,000
7,000,000
3,750,000
2,997,000
1,250,000
2,000,000
Consumables (Lab Kits
and gloves)
500
2000
1,000,000
12,000,000
139,534.88
Petty Cash
200
2000
167
16000
4,800,000
32,064,000
55,813.95
POL for ambulances
400,000
2,672,000
372,837.21
Operational Cost ( POL &
Office suplies)
1
0
-
-
-
TA/DA
1
0
0
0
-
-
Miscellaneous
-
Operational Cost ( POL,
Repair of transport &
Office suplies)
20
0
-
-
-
Miscellaneous
20
10000
20
50000
Medicines
162
3500
Additional HR
45
25000
PGRs
40
0
Advertisements
1
MRM @ District
10
10000
2,400,000
12,000,000
6,804,000
13,500,000
2,000,000
1,200,000
27,906.98
Additional HR
200,000
1,000,000
567,000
1,125,000
100,000
Quarterly Review Meeting
& Dissemination
4
150000
600,000
600,000
Category
PMU
Managerial Staff
Number
Chairperson
1
Program Director
1
Deputy PD
1
Human Resource Manger
1
Finance Manager
1
MIS Manager
1
Office Assistant
1
Unit Cost/
Monthly
-
District Manager
M & E Officer
DSU
Data Entry
Program Assistant
Accounts Officer
BHU
PMU
DSU
RHCs
THQ
Overall
Operational
Costt
Annual Total
(Rs)
52,560,000
192,720,000
180,000,000
84,000,000
45,000,000
35,964,000
15,000,000
24,000,000
Annual Total
$
611,162.79
2,240,930.23
2,093,023.26
976,744.19
523,255.81
418,186.05
174,418.60
279,069.77
-
139,534.88
79,116.28
156,976.74
23,255.81
13,953.49
6,976.74
129
Call Response Center
10
100000
Printing
4
150000
1,000,000
600,000
Total
1,000,000
600,000
716,612,000
11,627.91
6,976.74
8,332,697.67
One Time Cost
BHU
0
35000
Ambulances
Furniture & Fixture for
DSU
IT Equipment (Laptop, PC,
desktop, Printer, Fax)
167
0
30,000,000
7,000,000
1,900,000
-
0
50000
-
-
-
8
200000
1,600,000
1,600,000
18,604.65
USG Portable
100
500000
20
0
Equipment for RHCs
Equipment for
THQs/DHQs
8
800000
50,000,000
6,400,000
581,395.35
Repair & Renovation
50,000,000
6,400,000
40
500000
20,000,000
20,000,000
232,558.14
-
-
-
116,900,000
1,359,302.33
Basic Equipment for BHUs
200
150000
UPS with Battries
200
35000
F&F for BHUs
200
9500
Computers & Printer
DSU/RSU
RHCs
THQ&
DHQ
0
Total
30,000,000
7,000,000
1,900,000
-
348,837.21
81,395.35
22,093.02
-
74,418.60
-
Annual Cost
716,612,000
Two Years
Cost
1,433,224,000
One Time
Cost
116,900,000
Total (Rs)
Total $
1,550,124,000
17,615,045
130
Budget Requirement under Head A-01299 Others (Stipend of
LHVs/Ayas/Ambulance Drivers & Guards for the Financial Year 2014-15
Strength
Net Pay
Period
Budget
Requirement
in Rs.
34 DHQ +2
Teaching
hospital
72
31000
12
26784000
292 RHCs
292
57500
12
201480000
2
26000
12
624000
1000
18000
12
216,000,000
1000
9500
12
114,000,000
333
10500
12
41,958,000
500
9500
12
57,000,000
Sr.
No.
Cadre
# of Health
Facilities
1
Nursing Staff (for
DHQ Nutrition)
2
WMO
3
Computer
Operator
PMU
4
LHVs (CHARM)
500 BHUs
5
Aya (CHARM)
500 BHUs
6
Ambulance
drivers (CHARM)
7
Gaurds (CHARM)
Total
BPS
500 BHUS
Fixed
Salary
3199
657,846,000.00
131
Summary for Budget Requirement of Salary of Nutrition Program Staff working in Scales for the period
July-2014 to June 2015 during the financial year 2014-15
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
Entertainment
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
1
Staff 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
2
Staff 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
600,000
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
Total Budget
Requirement for
2014-15
132
Budget Requirement of Salary for the staff of Nutrition Program Punjab for the period Dec-14 to June-2015
Sr.
No.
Particulars
BPS
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
Entertainment
Allow
A01217
Medical
Allow
SAA
(2010)
SPHA
4448
14825
11200
4448
14825
11200
Comp
Allow
Adhoc
Relief
Allow.
15%
Adhoc
Relief
Allow.
20%
Total
4448
0
105730
0
4448
0
105730
Social
Security
30%
01 Posts of BPS-18
1
Program
Manager
Nutrition
19
Total
50000
50000
0
0
0
0
5809
5000
6000
4000
5809
5000
6000
4000
0
0
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
Total PMU Salary for one
Month
Budget for Dec-14 to
June-15
0
0
0
94800
0
13299
15000
0
0
0
7764
25875
0
0
14400
7764
18960
197862
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
350,000
0
0
663,600
0
133,756
####
42,000
28,000
0
85,484
####
####
0
####
85,484
132,720
#####
133
Budget Requirement of Salary for the staff of Nutrition Program Punjab for the period July-14 to Nov-14
Sr.
No.
Particulars
BPS
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
Entertainment
Allow
A01217
Medical
Allow
SAA
(2010)
SPHA
4448
14825
11200
4448
14825
11200
Comp
Allow
Adhoc
Relief
Allow.
15%
Adhoc
Relief
Allow.
20%
Total
4448
0
105730
0
4448
0
105730
Social
Security
30%
01 Posts of BPS-18
1
Program
Manager
Nutrition
18
Total
50000
50000
0
0
0
0
5809
5000
6000
4000
5809
5000
6000
4000
0
0
03 Posts of BPS-17
1
Nutrition
Officer
17
30400
4433
5000
2588
8625
4800
2588
6080
64514
2
Software
Engineer
17
30400
4433
5000
2588
8625
4800
2588
6080
64514
3
Statestical
Officer
17
30400
4433
5000
2588
8625
4800
2588
6080
64514
Total
Total PMU Salary for one
Month
Budget for July 14 to Nov14
0
0
0
91200
0
13299
15000
0
0
0
7764
25875
0
0
14400
7764
18240
193542
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
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
134
Cost Sheet of Nutrition Budget for the Financial Year 2014-15
S.No
Districts
Total
population
of districts
50%Target Population
For 21 District & for
09 Urban slam
Districts is 25%
SAM 30 % + 2%
relapse & incidence
rate ( 4% of Total
target population)
Cost
per
SAM Child
1
Narowal
1516173
758086.5
106132
2
Layyah
1486000
743000
104020
16
16981
5298
21192460
30323
6822779
56856
341139
56856
7650
12240065
7107061
100000
500000
48303503
14
14563
4544
18174374
29720
6687000
55725
334350
55725
7498
11996478
6965625
100000
500000
3
Mianwali
1309000
654500
44757827
91630
21
19242
6004
24014390
26180
5890500
49088
294525
49088
6573
10516506
6135938
100000
500000
4
Multan
3994000
1997000
47451859
279580
20
55916
17446
69783168
79880
17973000
149775
898650
149775
20055
32087796
18721875
100000
500000
140064489
5
Khushab
1131786
565893
79225
6
Rahimyar Khan
4198000
2099000
293860
19.7
15607
4869
19477947
22636
5093037
42442
254652
42442
5683
9092769
5305247
100000
500000
39823651
19
55833
17420
69680083
83960
18891000
157425
944550
157425
30698
49116600
19678125
100000
500000
158910358
7
Pakpattan
1617000
808500
8
D. G. Khan
2219000
1109500
113190
19
21506
6710
26839613
32340
7276500
60638
363825
60638
11824
18918900
7579688
100000
500000
61578525
155330
19
29513
9208
36831850
44380
9985500
83213
499275
83213
16226
25962300
10401563
100000
500000
9
Muzaffargarh
3579000
1789500
84280487
250530
17
42590
13288
53152445
71580
16105500
134213
805275
134213
26171
41874300
16776563
100000
500000
129314082
10
Bhakkar
1368150
11
Rajanpur
1485000
684075
95771
26
24900
7769
31075612
27363
6156675
51306
307834
51306
10005
16007355
6413203
100000
500000
60560679
742500
103950
13.7
14241
4443
17772955
29700
6682500
55688
334125
55688
10859
17374500
6960938
100000
500000
12
Bhawal Nagar
49725018
2566000
1283000
179620
17
30535
9527
38108179
51320
11547000
96225
577350
96225
18764
30022200
12028125
100000
500000
13
92882854
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
2030270
12181622
2030270
######
MICs
2010-11
#########
# children
age 6
month to 2
years
Cost per
Multinutrient
supplementation
for 6 month to 2
years
# of
target
Children
Total children
age 6 to 59
month 14 %
1082811
243,632,436
# children
age 2 to 5
years
Cost for tab.
Mebandazole
Total
PLW7.5 %
13 % MAM PLW +
1.5 % Relapse &
Incidence rate
374,353
Cost per
PLW
########
Cost for
Tab.Iron Folic
Acid
##########
SC Cost (F
75 & F
100)
########
Cost for
Anthropometry
Equipment
#########
Total Cost for Supplies
1,906,825,736
Potassium
Iodate for Salt
Iodization
1,906,825,736
135
Integrated Reproductive Maternal Newborn & Child Health &Nutrition Program
Budget Requirement for Financial Year 2015-16
Object Heads
A01
EMPLOYEE RELATED EXPENSES
1,090,684,384
PAY
1,719,600
PAY OF OFFICERS
1,719,600
A01101
Basic Pay
A01106
Pay of Contract Staff
A012
Budget Demand
ALLOWANCES
REGULAR ALLOWANCES
600,000
1,119,600
1,088,964,784
71,450,784
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)
A01252
Non Practicing Allowance
48,000
A01964
Special Additional Allowance (50% 2010)
488,400
Adhoc Relief Allowance (15% 2011)
146,544
A0
1970
OTHER ALLOWANCES
70,080,000
1,017,514,000
A01271
Over Time Allownace
10,000
A01273
Honorarium/Incentive for performance/
44,160,000
A01274
Medical Charges
6,804,000
A01277
Contingent Paid staff
18,300,000
A01299
Other (Stipend of LHVs, Ayas, Ambulance Drivers & Guards)
948,240,000
A03
OPERATING EXPENSES
696,046,618
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
UTILITIES
600,000
Electricity Charges
600,000
OCCUPANCY COSTS
500,000
A033
A03303
A034
A03403
Rent of Residential Bilding
A03407
Rates & Taxes( Vehicles Tax & Toll Tax)
A038
500,000
TRAVEL & TRANSPORTATION
75,996,000
GOVT. SERVANTS
75,996,000
A03801
Training -Domestic (all training s &TOT) for 03 trainings
27,750,000
A03805
T.A (Govt. Servants)
500,000
136
A03806
Transportation of Goods
3,000,000
A03807
POL Charges
44,736,000
A03808
Local Conveyance Charges
10,000
A039
GENERAL
A03901
Stationary
A03902
Printing and Publication ( MIS Tools, Training manuals , BCC Material etc
A03903
Conference /Siminars/Workshops/Symposium/ Review Meetings
600,000
A03905
News Papers, Periodicals & Books
10,000
A03907
Advertising & Publicity
A03917
Law Charges
A03927
Purchase of Drug and Medicines & Tab Iron Folic Acid for Nutrition
A03970
Others ( Supplies for nutrition components & consumables)
960,000
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
Entertainment & Gift
10,000
A06301
Entertainment & Gift
10,000
A09
PHYSICAL ASSETS
2,077,909,344
A092
COMPUTER EQUIPMENT
A06
617,790,618
100,000
2,000,000
5,000
Software ( Call Response center+ Web based MIS etc)
A09203
IT Equipment
Medical Stores (Contraceptives)
A09470
OTHER STORE AND STOCK
A096
A09601
A097
A09701
800,000
1,600,000
OTHER STORE AND STOCK
A09401
612,115,618
2,400,000
A09202
A094
2,000,000
1,926,534,344
300,000,000
1,626,534,344
PLANT AND MACHINERY
147,150,000
MACHINERY AND EQUIPMENT
147,150,000
FURNITURE AND FIXTURE
1,825,000
Furniture and Fixture
1,825,000
A13
REPAIRS AND MAINTENANCE
948,000
A130
TRANSPORT
848,000
Transport
848,000
COMPUTER EQUIPMENT
100,000
A13001
A137
A13702
Software
100,000
TOTAL
3,865,911,150
137
Budget Requirement for DPIU's/PPIUs in Punjab
For the Financial Year 2015-16
Sr.
No.
1
Name of District
Ambulances
Total Budget Required
No. of Vehicles
A-03807 POL
A-13001 ROT
Total Budget
Required
233
44,736,000
11,184,000
55,920,000
41,472,000
848,000
49,952,000
138
Budget Requirement of POL (A-03807)
For the Financial Year 2015-16
Sr.
No.
1
Name of District
Ambulances
No. of
Vehicles
Rate Per Month
No. of
Months
Total POL
Budget Required
233
20,000
12
44,736,000
Total Budget Required
44,736,000
139
Budget Requirement of A-13001 Repair (Vehicle/Transport)
For the Financial Year 2015-16
Sr.
No.
1
Name of District
Ambulances
No. of
Vehicles
Repair of Vehicle @ Rs. 2500/P.m. ( Major& Minor repair)
Total Budget for Repair of
Vehicle Required
233
11,184,000
11,184,000
Total Budget Required
11,184,000
140
Budget Demand under the Head A-03801 Training Domestic
For the Financial Year 2015-16
Sr.
No.
Cadre
1
Training of HCPs on Nutrition
and IYCF
2
Training on IMNCI
3
4
5
Training of LHWs & CMWs on
Nutrition & IYCF
Training of Medical officer on
PHC & Nutrition
Training of HCPs on EmONC
& FP
Total
No. of
Posts
Unit
Cost
Training No.
of Days
Total Amount
200
1800
5
1,800,000.00
0
3000
11
-
8000
700
4
22,400,000.00
100
2500
3
750,000.00
200
2000
7
2,800,000.00
27,750,000.00
141
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
142
Integrated Reproductive Maternal Newborn & Child Health &Nutrition Program
Recurring Costs
Category
PMU
Managerial Staff
Number
Unit Cost/
Monthly
Monthly
Total
Annual Total
(Rs)
Annual Total
$
-
70,080,000
210,240,000
252,000,000
117,600,000
126,000,000
50,328,000
21,000,000
24,000,000
-
FTA for WMO
292
20000
WMO
292
60000
LHVs
1400
15000
Ayas
1400
7000
Security Guards
1400
7500
Drivers
466
9000
Medicines
700
2500
FP Material
0
0
Pay for performance
40
50000
5,840,000
17,520,000
21,000,000
9,800,000
10,500,000
4,194,000
1,750,000
2,000,000
Consumables (Lab Kits
and gloves)
700
2000
1,400,000
16,800,000
195,348.84
Petty Cash
700
2000
233
16000
16,800,000
44,736,000
195,348.84
POL for ambulances
1,400,000
3,728,000
Operational Cost ( POL &
Office suplies)
1
0
-
-
-
TA/DA
1
0
0
0
-
-
Miscellaneous
-
Operational Cost ( POL,
Repair of transport &
Office suplies)
20
0
-
-
-
Miscellaneous
8
10000
8
50000
Medicines
162
3500
Additional HR
45
25000
156,976.74
PGRs
40
0
Advertisements
1
MRM @ District
20
10000
960,000
4,800,000
6,804,000
13,500,000
2,000,000
2,400,000
11,162.79
Additional HR
80,000
400,000
567,000
1,125,000
200,000
Quarterly Review Meeting
& Dissemination
4
150000
600,000
600,000
6,976.74
Chairperson
1
Program Director
1
Deputy PD
1
Human Resource Manger
1
Finance Manager
1
MIS Manager
1
Office Assistant
1
-
District Manager
M & E Officer
DSU
Data Entry
Program Assistant
Accounts Officer
BHU
PMU
DSU
RHCs
THQ
Overall
Operational
Costt
814,883.72
2,444,651.16
2,930,232.56
1,367,441.86
1,465,116.28
585,209.30
244,186.05
279,069.77
520,186.05
-
55,813.95
79,116.28
23,255.81
27,906.98
143
Call Response Center
8
100000
Printing
4
150000
800,000
600,000
Total
800,000
600,000
980,648,000
9,302.33
6,976.74
11,402,883.72
One Time Cost
BHU
0
35000
Ambulances
Furniture & Fixture for
DSU
IT Equipment (Laptop, PC,
desktop, Printer, Fax)
250
0
22,500,000
5,250,000
1,425,000
-
8
50000
400,000
400,000
4,651.16
8
200000
1,600,000
1,600,000
18,604.65
USG Portable
150
500000
20
0
Equipment for RHCs
Equipment for
THQs/DHQs
8
800000
75,000,000
6,400,000
872,093.02
Repair & Renovation
75,000,000
6,400,000
40
500000
20,000,000
20,000,000
232,558.14
-
-
-
132,575,000
1,541,569.77
Basic Equipment for BHUs
150
150000
UPS with Battries
150
35000
F&F for BHUs
150
9500
Computers & Printer
DSU/RSU
RHCs
THQ&
DHQ
0
Total
22,500,000
5,250,000
1,425,000
-
261,627.91
61,046.51
16,569.77
-
74,418.60
-
Annual Cost
980,648,000
Two Years
Cost
1,961,296,000
One Time
Cost
132,575,000
Total (Rs)
Total $
2,093,871,000
23,793,989
144
Budget Requirement under Head A-01299 Others (Stipend of LHVs/Ayas/Ambulance Drivers & Guards for the
Financial Year 2015-16
Sr.
No.
Cadre
# of Health Facilities
1
Nursing Staff (for DHQ Nutrition)
2
Budget
Requirement in
Rs.
Strength
Net Pay
Period
34 DHQ +2 Teaching hospital
72
32000
12
27648000
WMO
292 RHCs
292
58000
12
203232000
3
Computer Operator
PMU
2
27000
12
648000
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)
466
11000
12
61,512,000
7
Gaurds (CHARM)
1400
10000
12
168,000,000
Total
Fixed
Salary
600,000
700 BHUs
BPS
5032
948,240,000.00
145
Summary for Budget Requirement of Salary of Nutrition Program Staff working in Scales for the
period July-2015 to June 2016 during the financial year 2015-16
SPHA
Comp
Allow
A04115
Social
Securit
y 30%
A-01970
Adhoc
Relief
Allow.
15%
20%
Adhoc
Relief
Allowanc
e (2012)
Total
203,500
56,000
0
72,000
61,060
91,200
1,496,36
0
85,484
284,900
78,400
0
100,800
85,484
132,720
2,125,14
4
146,544
488,400
134,400
0
172,800
146,544
223,920
######
Sr.
No
.
Particular
s
A01101
Basic
Pay
A0110
5
Qualif.
Pay
Persona
l Pay
A01106
Pay of
Contract
Staff
A01156
Pay of
Contrac
t Staff
A01202
House
Rent
Allow.
A01203
Conv
Allow.
A01236
Deput.
Allow.
A01252
NPA
A01224
Entertainmen
t Allow.
A01217
Medical
Allow
A01964
SAA
(2010)
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
2
Staff
Salary Dec
to June-16
350,000
0
0
663,600
0
133,756
140,000
42,000
28,000
0
Total Budget
Requirement for
2015-16
600,000
0
0
1,119,600
0
229,296
240,000
72,000
48,000
0
146
Budget Requirement of Salary for the staff of Nutrition Program Punjab for the
period Dec-15 to June-2016
Sr.
No.
Particulars
BPS
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
Entertainment
Allow
A01217
Medical
Allow
SAA
(2010)
SPHA
4448
14825
11200
4448
14825
11200
Comp
Allow
Adhoc
Relief
Allow.
15%
Adhoc
Relief
Allow. 20%
Total
4448
0
105730
0
4448
0
105730
Social
Security
30%
01 Posts of BPS-18
1
Program
Manager
Nutrition
19
Total
50000
50000
0
0
0
0
5809
5000
6000
4000
5809
5000
6000
4000
0
0
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
Total PMU Salary for one
Month
Budget for Dec-15 to
June-16
0
0
0
94800
0
13299
15000
0
0
0
7764
25875
0
0
14400
7764
18960
197862
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
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
147
Budget Requirement of Salary for the staff of Nutrition Program Punjab for the period July-15 to Nov-15
Sr.
No.
Particulars
BPS
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
Entertainment
Allow
A01217
Medical
Allow
SAA
(2010)
SPHA
4448
14825
11200
4448
14825
11200
Comp
Allow
Adhoc
Relief
Allow.
15%
Adhoc
Relief
Allow. 20%
Total
4448
0
105730
0
4448
0
105730
Social
Security
30%
01 Posts of BPS-18
1
Program
Manager
Nutrition
18
Total
50000
50000
0
0
0
0
5809
5000
6000
4000
5809
5000
6000
4000
0
0
03 Posts of BPS-17
1
Nutrition
Officer
17
30400
4433
5000
2588
8625
4800
2588
6080
64514
2
Software
Engineer
17
30400
4433
5000
2588
8625
4800
2588
6080
64514
3
Statestical
Officer
17
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
Total 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
Budget for July 15 to Nov15
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
148
Cost Sheet of Nutrition Budget for the Financial Year 2015-16
Total
children
age 6 to
59
month
14 %
MICs
2010-11
# of
target
Children
SAM 30 % + 2%
relapse
&
incidence rate (
4% of Total target
population)
16
16981
5298
21192460
30323
6822779
56856
341139
56856
7650
14
14563
4544
18174374
29720
6687000
55725
334350
55725
7498
91630
21
19242
6004
24014390
26180
5890500
49088
294525
49088
279580
20
55916
17446
69783168
79880
17973000
149775
898650
149775
19.7
15607
4869
19477947
22636
5093037
42442
254652
42442
5683
19
55833
17420
69680083
83960
18891000
157425
944550
157425
30698
113190
19
21506
6710
26839613
32340
7276500
60638
363825
60638
11824
155330
19
29513
9208
36831850
44380
9985500
83213
499275
83213
16226
250530
17
42590
13288
53152445
71580
16105500
134213
805275
134213
684075
95771
26
24900
7769
31075612
27363
6156675
51306
307834
742500
103950
13.7
14241
4443
17772955
29700
6682500
55688
334125
2566000
1283000
179620
17
30535
9527
38108179
51320
11547000
96225
Gujranwala
4404000
1321200
184968
13
24046
7502
30009208
52848
11890800
14
Sargodha
3189000
956700
133938
12
16073
5015
20058555
38268
15
Rawalpindi
4321000
1296300
181482
15
27222
8493
33973430
16
Faisalabad
6822000
2046600
286524
14
40113
12515
17
Bhawal Pur
3217000
965100
135114
14
18916
18
Sahiwal
2242000
672600
94164
16
15066
19
Attock
1562000
468600
65604
13
20
Chiniot
1156000
346800
48552
21
Gujrat
2509000
752700
22
Hafizabad
1024000
23
Jhang
24
S.No
Districts
Total
population
of districts
50%Target
Population
1
Narowal
1516173
758086.5
106132
2
Layyah
1486000
743000
104020
3
Mianwali
1309000
654500
4
Multan
3994000
1997000
5
Khushab
1131786
565893
79225
6
Rahimyar Khan
4198000
2099000
293860
7
Pakpattan
1617000
808500
8
D. G. Khan
2219000
1109500
9
Muzaffargarh
3579000
1789500
10
Bhakkar
1368150
11
Rajanpur
1485000
12
Bhawal Nagar
13
# 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
SC Cost (F
75 & F 100)
Cost for Anthropometry
Equipment
Total Cost for Supplies
12240065
7107061
100000
500000
48303503
11996478
6965625
100000
500000
44757827
6573
10516506
6135938
100000
500000
47451859
20055
32087796
18721875
100000
500000
140064489
9092769
5305247
100000
500000
39823651
49116600
19678125
100000
500000
158910358
18918900
7579688
100000
500000
61578525
25962300
10401563
100000
500000
84280487
26171
41874300
16776563
100000
500000
129314082
51306
10005
16007355
6413203
100000
500000
60560679
55688
10859
17374500
6960938
100000
500000
49725018
577350
96225
18764
30022200
12028125
100000
500000
92882854
99090
594540
99090
19323
30916080
12386250
500000
86296878
8610300
71753
430515
71753
13992
22386780
8969063
500000
60955212
51852
11666700
97223
583335
97223
18958
30333420
12152813
500000
89209698
50061473
81864
18419400
153495
920970
153495
29932
47890440
19186875
500000
136979158
5902
23607118
38604
8685900
72383
434295
72383
14115
22583340
9047813
500000
64858466
4701
18802668
26904
6053400
50445
302670
50445
9837
15738840
6305625
500000
47703203
8529
2661
10643593
18744
4217400
35145
210870
35145
6853
10965240
4393125
500000
30930228
14
6797
2121
8483005
13872
3121200
26010
156060
26010
5072
8115120
3251250
500000
23626635
105378
9
9484
2959
11836057
30108
6774300
56453
338715
56453
11008
17613180
7056563
500000
44118814
307200
43008
14
6021
1879
7514358
12288
2764800
23040
138240
23040
4493
7188480
2880000
500000
20985878
2333331
699999.3
98000
14
13720
4281
17122543
28000
6299994
52500
315000
52500
10237
16379984
6562493
500000
47180013
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
2335680
14014079
2335680
887,881,068
1245696
280,281,570
Total
PLW7.5 %
13 % MAM PLW
+ 1.5 % Relapse
& Incidence rate
Cost for Tab.Iron Folic
Acid
Cost per SAM Child
433,908
Cost per PLW
694253276
291,959,969
########
18,000,000
2,187,589,962
Potassium Iodate for
Salt Iodization
2,187,589,962
149
Program Reform Milestones including Disbursement Linked Indicators (DLIs) developed
by WB/DFID
Reform Area
Component 1:
Improving health
service delivery
i) Integrated
management of
MNCH and LHW
Programs
2013-14
Essential Health
Service Package at
primary level defined,
and approved
2014-15
EPHS for secondary
care finalized and
approved
2015-16
Plan developed for
strengthening
secondary care
hospital developed
Minimum Services
Delivery Standards
(MSDS) revised
considering primary
level EHSP and
implementation
started in all districts
Assessment of MSDS
in all districts of
Punjab completed and
more than 70% of the
RMNCH and nutrition
related quality
standards met
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
LHWP
At least 15,000
LHWs in the priority
districts trained on
a) family planning
and b) nutrition.
2016-17
EPHS for tertiary care
finalized and
approved
Training of LHWs in
delivering routine
immunization started
in 4 districts
completed
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
Evaluation of “LHWs
involved in routine
immunization”
initiated
150
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
In the 12 priority
districts, at least 40%
of children with SAM
registered for
treatment
15 Stabilization
centers and 200
Outpatient
Therapeutic Program
centers made
functional
35 Stabilization
centers and >600
Outpatient
Therapeutic Program
centers made
functional
At least 20% of
households receive a
core package of
nutrition services in
12 districts
Review of regulatory
monitoring system for
food fortification
carried out and new
system agreed
At least 80% of
community-based
workers in the 12
high-priority districts
trained on nutrition
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%
151
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
.
2013-14
AREA
Service
Delivery
Weightage
45%
2014-15**
20015-16**
2016-17**
Punjab: £14
million
Punjab: £25
million
Punjab: £27
million
Punjab: £24 million
- 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;
- 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;
- Assessment of
MSDS in all
districts of
Punjab
completed and
more than 80%
of the RMNCH
and nutrition
related quality
standards met;
- Third Party
evaluation of the
management
models for service
delivery and
implementation of
EPHS completed
and following
results achieved in
Punjab.
- 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
- 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 - Readyto-use
therapeutic
food) and 200
Outpatient
Therapeutic
Programme
(OTP) centres
made functional
with
government
financing in
Punjab;
- 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.
o
o
o
o
o
o
Modern
methods CPR
increased to
33%
Exclusive
breast feeding
rate increased
to >40%
Immunisation
coverage (fully)
in the province
increased to
>75%
>60% of
identified
children treated
for Severe
Acute
Malnutrition
(SAM) in last
month/quarter
>80% of DHQ
and THQ
hospitals
providing
COMPLETE
PACKAGE of
24/7
comprehensive
EmONC
services
Skilled Birth
Attendance
(SBA)
increased to
>70%
Disbursement
152
linked to the DLI
for FY
2015/16:£12.15
million
Disbursement
linked to the DLI for
FY 2016/17:£10.8
million
- Minimum two
meetings of the
steering
committee/ task
force of HSS
implementation
held during
2013-14 in
Punjab
- Minimum two
meetings of the
steering
committee/ task
force of HSS
implementation
held during
2014-15 in
Punjab;
- Minimum two
meetings of the
steering
committee/ task
force of HSS
implementation
held during 201516 in Punjab;
- Review of
restructuring of
DGHS office
completed in
Punjab;
- Restructuring of
DGHS office
completed in
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 2014/15:
£11.25 million
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.
Disbursement
linked to the DLI
for FY 2013/14:
£2.1 million
Human
Resource
Weightage
5%
- In case of
successful
results, emanagement
interventions
scaled up in all
districts of
Punjab.
Disbursement
linked to the DLI
for FY
2014/15:£3.75
million
- 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;
Disbursement
linked to the DLI
- Human Resource
Strategy and Inservice training
strategy
- Implementation
of plan to
strengthen
consumer
complaints
system started by
PHCC in Punjab.
Disbursement
linked to the DLI
for FY
2015/16:£4.05
million
- Training of
another batch of
>1000 and 200
Community
Midwives
(CMWs) started
in 2014 in
Punjab
respectively;
- All LHWs
trained on
family planning
- >90% of the
management
positions at
provincial level and
that of EDO(H)
filled with qualified/
competent
personals in
Punjab.
Disbursement
linked to the DLI for
FY 2016/17: £3.6
million
- Training of
another batch of
>1000 and 200
Community
Midwives (CMWs)
started in 2015 in
Punjab;
- More than 80% of
LHWs have
knowledge and
skills scores
(using case
153
for FY 2013/14:
£0.7 million
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.
and trained
LHWs
immunising
children and
women in their
catchment
areas.
Disbursement
linked to the DLI
for FY
2015/16:£1.35
million
studies scenario)
of above 80%;
- Results of
evaluation of
“LHWs involved in
routine
immunisation”
available.
Disbursement
linked to the DLI for
FY 2016/17:£1.2
million
Disbursement
linked to the DLI
for FY
2014/15:£1.25
million
Information
Weightage
10%
- Development of
health sector
M&E plan of
action started in
Punjab.
Disbursement
linked to the DLI
for FY 2013/14:
£1.4 million
- Health sector
M&E plan of
action including
disease
surveillance
available and
accordingly PC1 approved in
Punjab;
- Second round of
Annual Health
Facility
Assessment
completed.
Disbursement
linked to the DLI
for FY
2014/15:£2.5
million
Financing
Weightage
15%
- Development of
fiduciary risks
mitigation plan in
Punjab;
- Written
commitment for
inclusion of HSS’s
policy objectives in
the next year
MTBF cycle in
Punjab.
Disbursement linked
- Minimum 70%
increase in
development
health
expenditure
(mainly for
RMNCH
interventions and
excluding federal
grants) at
provincial level
and 15% increase
in Districts nonsalary
- 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.
- Fourth round of
Annual Health
Facility
Assessment
completed.
Disbursement
linked to the DLI for
FY 2016/17:£2.4
million
Disbursement
linked to the DLI
for FY
2015/16:£2.7million
- Further 20%
increase in
development
health
expenditure
(mainly for
RMNCH
interventions and
excluding federal
grants) at
provincial level
and 20%
additional
increase in non-
- tbd - considering
expected shift of
provincial RMNCH
and nutrition
expenditures from
provincial budgets to
district current
budgets;
- Reassessment of
fiduciary risk
showing
improvement
Punjab;
154
to the DLI for FY
2013/14: £2.1 million
expenditure in
Punjab;
- Successful
implementation of
Fiduciary risk
mitigation plan in
Punjab;
- Options for health
financing including
testing of Vouchers
Scheme explored.
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.
Disbursement linked
to the DLI for FY
2013/14: £1.4 million
salary district
expenditure in
Punjab;
- Successful
implementation of
Fiduciary risk
mitigation plan in
Punjab;
Disbursement linked
to the DLI for FY
2015/16:£4.05 million
- Procurement cell
ensuring
implementation of
PPRA rules and
regulations in
Punjab;
- Procurement of
contraceptive
commodities for
health facilities
and community
workers
completed using
provincial
government
resources
initiated 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.
Disbursement linked
to the DLI for FY
2014/15: £2.5 million
Disbursement linked
to the DLI for FY
2016/17:£3.6 million
- Implementation of
Voucher Scheme
started.
Disbursement linked
to the DLI for FY
2014/15:£3.75 million
- More than 60% of
health facilities
having no stock
out of 3
contraceptive
methods in
Punjab;
- Intervention of
Voucher Scheme
evaluated.
- 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;
- 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.
Disbursement linked
to the DLI for FY
2016/17:£2.4 million
- Misoprostol
available in all
RHCs in Punjab.
Disbursement linked
to the DLI for FY
2015/16:£2.7million
*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
**** 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.
155