MANAGEMENT REFORMS

SUPPLIES & LOGISTICS

This program envisages building management capacity and integrating different MNCH related activities under one management structure at the district level. It also outlines creating and strengthening management and organizational structures at the three levels of government. In addition various options/innovations for strengthening organizational and management systems will be tested.

In addition, emphasis will be given to strengthening of support systems like referral system, logistics system, availability of essential drugs, etc. At the district level, the services provided through various MNCH related vertical programs (e.g., nutrition, malaria control in pregnancy, EPI, LHW program, population welfare, NACP, etc.) will be operationally integrated, whereby a District MNCH Cell will coordinate or manage all such activities.

District Focus

Pakistan is diverse country having wide variations in development of infrastructure and availability, quality and accessibility of health services. These differences dictate that a pre-designed, fit-for-all solution of MNCH problems cannot be devised even at the provincial level.

About one third of Punjab’s districts have MMR of less than 200, whereas the predominantly rural districts of all other provinces have MMR of over 200. Nearly all districts of Punjab and Sindh have MMR of less than 500, while all districts of NWFP except Kohistan have MMR ranging between 200 and 500. Finally, almost 75% of Balochistan’s districts have MMR in excess of 500.

Each district will have to adapt the MNCH strategies according to their unique local situation. Therefore, a comprehensive program is needed to strengthen, upgrade and integrate the ongoing interventions at the district level and to introduce new strategies at the district level. The overarching goal of the proposed project is to improve accessibility of quality MNCH services through development and implementation of an integrated and sustainable MNCH program at all levels of the health care delivery system.

Service Delivery Package

The global experience of the last decade suggests that there are no real alternatives to serve as a vehicle for a continuum of integrated care for mothers, newborns and children except the district health systems; providing primary health care through networks of health centers, family practices or equivalent decentralized structures, backed up by referral hospitals and functioning transportation systems.

To provide a systematic assessment of what is required at each level of health care a basic services package is being proposed. The package of services comprises of two parts; the first part is the minimum (core) component of the program that needs to be in place to reduce morbidity and mortality and is recommended for adoption on an as is basis the second component comprises of proposed interventions which can be modified/ substituted as per local requirements and priorities.

First Level Care Facility:
The proposed package of the First Level Care Facility (FLCF) envisages a health facility, which has a catchment area population of around 15-20,000 and need not necessarily be staffed by a medical doctor, but should have a skilled birth attendant like an LHV available. The FLCF comprises not only the physical facility but also includes the outreach and community based health workers, as such the staff at the FLCF is also responsible for monitoring and ensuring the outputs for the population base of the FLCF. In the current setup the FLCF is represented by the Basic Health Unit and in some places the Rural Health Center.

The minimum service package required at this level of care is proposed as follows:

CORE Package:

• Curative care for common illnesses (including provision of essential medicines)
• EPI (plus) services
• Integrated Management of Newborn and Childhood Illnesses
• Nutrition advice/services including child growth and monitoring
• Prenatal and postnatal care
• Birth preparedness counseling
• Information and Education for Empowerment and Change (Family Members, pregnant women, traditional care providers)
• Newborn Care
• Family Planning counseling and services

Additional Services:

• Handling normal deliveries only if transportation and referral to higher level is available and can be ensured
• Laboratory support for antenatal care(urine, blood sugar, Hb)
• Malaria control program/CDC
• TB- DOTS program
• Promotion of Iodized Salt
• HIV/AIDS counseling and referral
• Training of community based workers
• Sanitation services (inspection/support for water and food)

 

Mid Level Facility
This is envisaged as a health facility which is open 24/7 and staffed by medical doctors. The envisaged catchment population of this health facility is around 50,000-100,000. This estimate is based on a workload of 150-300 complications of pregnancy arising in the area that may require referral to this level. This type of facility at the initial stages of the program will mostly be THQs; however at a later stage as experience is gained from the implementation of the program in the districts and district capacity is increased RHCs can be designated as Mid Level Facilities.

The minimum service package required at this level of care is proposed as follows:

CORE Package:

• Curative care for common illnesses (including provision of essential medicines)
• Basic Laboratory Services (urine, blood sugar, Hb)
• EPI (plus) services
• Integrated Management of Newborn and Childhood Illnesses
• Prenatal and postnatal care
• Birth preparedness counseling
• Information and Education for Empowerment and Change
• Handling normal deliveries
• Basic EmONC Package of services
• Newborn Care including resuscitation and care for minor complications of newborn
• Transportation (Ambulance Service)
• Family Planning counseling and services
• Nutrition advice/services including child growth and monitoring
• Malaria control program
• TB- DOTS program
• HIV/AIDS counseling and referral
• Dental Services
• Radiography/ imaging services

 

Additional Services:

• Advanced Laboratory Services
• Blood Bank and Blood Transfusion Service
• Promotion of Iodized Salt
• Minor Surgical Operations
• Mental health services
• Training of midwives
• Training of Community based workers
• Sanitation services (inspection/support for water and food)

 

First Referral Hospital
THQ/DHQ: In addition to services offered at the mid level facility for MNCH

• Comprehensive EmONC services, including post-abortion care
• Newborn care, incubator
• Gynecological care
• Comprehensive family planning services including surgical sterilization services for men and women
• Training of community skilled birth attendants
• Training of healthcare providers in clinical skills
• Training of paramedical workers
• Postgraduate teaching and research
• Ambulance services

Strengthen Program Management

A major challenge in the health sector is to ensure effective implementation of public health programs in the devolved system. Devolution can be conducive to program implementation in health care through increased local accountability and improved management. All planned interventions for achieving MDGs should be translated to District Implementation Plans based on information from surveys and other district based data. Strengthening the capacity of districts is imperative in good governance i.e. planning and management particularly financial, human resource and operations management.
The “National Maternal and Child Health Strategic Framework” outlines strengthening management and organizational structures at three levels of government. It also envisages building management capacity and integrating different projects, programs and interventions under one management structure. In addition it recommends that various options for strengthening organizational and management systems should be tested which could include: alternate management arrangements, e.g. contracting out, contracting in technical assistance, community management and franchising model, private sector provision of MNCH services and performance based incentives for district and health care providers.

Trainings for Program Management

Program will design/ organize following training courses/ workshops to strengthen management functions at different levels.

• Training courses will be organized to strengthen management functions including Supervision and monitoring, Use of information, logistics system, financial system and administration, etc. Curriculums would be developed/revised through consultative workshops.
• The Program will collaborate with national / international public health institutions and will make efforts to offer courses to Program managers.
• From 2006, the Program will also offer up to 25 scholarships every year for post graduate studies in public health management, epidemiology and allied subjects at leading national institutions like HSA, AKU. The selected candidates must fill a bond for working for at lest five years in the MCH program at an appropriate position. The program will also offer 25 scholarships for qualified nurses to do advanced 2-3 year courses subject to their filling a bond for working for at least five years.

Partnership Building

The tasks facing the government to achieve the targets set by the Program are enormous. The National Maternal and Child Health Policy covers all the crucial areas that are required to achieve the goals. However, the program will not be funding many of the projects which are essential to reaching these goals e.g. EPI, LHW Program.
                                                                                   
Moreover, the government will ensure and coordinate technical cooperation from all national and international agencies including NGOs on issues related to the objectives and strategies of the Program. In this context critical Program areas where collective efforts are needed will be identified. In some districts, international organizations like UNFPA, UNICEF and JSI (PAIMAN-USAID) are already investing in MNCH activities. These activities have been considered and accounted for in the costing of this program. The Federal MNCH Cell will assist in the implementation of these programs to meet the objectives of the MNCH strategy.

Linkages with other programs

The program will not be funding many of the MNCH related areas covered by other programs like EPI (for TT and EPI), Nutrition and LHW Program. Functional linkages will have to be developed with social marketing organizations like Greenstar and Key. This will require close cooperation between the various programs and MNCH program managers at all levels. The managers of these programs will be members of coordination/steering committees to be constituted for this program. It is also proposed that government’s MNCH related programs should be under one leadership of MNCH Cell/directorates at least at district level.

Financial and Material Resources Management

The successful implementation of the Program will depend on mobilizing the necessary and timely financial and material resources. Although this implies first of all making the most efficient use of existing resources, additional resources will be needed. To assess the magnitude of the total financial needs to implement the Program, an analysis of the cost of Program components will be undertaken to provide a realistic estimate of the cost involved and for sustainability of the program.

Although the resources for the Program during its first two phases of implementation will be undertaken by the Federal Government, alternative ways of financing of this priority health Program have to be considered. This includes action to utilize/involve the resources of the provincial and district governments or seek local community solutions.

 

Strengthening procurement & distribution of Supplies and Logistics

The Program will procure and then distribute a large number of equipments and supplies and non-drug items to Health Facilities and CMWs. The economies of scale due to bulk purchasing by the program will result in lower costs although it has the capacity to raise transportation costs but these can be reduced by specifying the quantity required at the time of contracting. For the MNCH program it is proposed that the procurement process be streamlined with different functions at different levels.