Delivery of Primary Healthcare in Rural Pakistan
It was necessary to provide these few pages as a prefix to the Manual of Operations for two reasons. First, because it is important to sketch a perspective for every one of our associates when he comes aboard and begins to make use of this Manual. It is necessary that s/he is made familiar with all the important facets of our work and with what makes it difficult, demanding and educative. The second reason has to do with a moral obligation. All that has been possible to achieve, starting from the Punjab, has been on account of a small group of men. They have persevered in the face of frustrations that would have crushed ordinary men. They have shown themselves to be extraordinary men with a spirit to match. They have been gallantly supported by hundreds of medical professionals and thousands of Paramedics and other staff. They deserve to be recognized for standing their ground against the vested interests and against every conceivable opposition. They have stoutly borne opposition even when it comes from where the well-spring of support should have existed. Their story could have been an epic of service to the poor if someone better was telling it. May God Bless them for their labours. May He Bless all those who help them serve the poor. And may He Guide those aright who have opted to neglect or oppose such work. Ameen.
It started in August 1999 from a mere three Basic Health Units (BHUs) in Lodhran District in the southern Punjab.*
* The man behind the Lodhran experiment was Mr. Jahangir Khan Tareen, at that time Chairman of the Task Force of the Punjab Government for the Agriculture sector. In 2003, he was an MNA from Rahim Yar Khan District and an Advisor to the Punjab Chief Minister on “New Initiatives in the Social Sectors”. He is now the Federal Minister for Industries, Production and Special Initiatives. He organized support for the RYK Pilot, for its extension to 11 other Punjab Districts and, finally, he prepared the stage for the PPHI. More is owed to him than can be adequately recorded here.
The management of these BHUs was taken over by the National Rural Support Program (NRSP) from the Punjab Government (GOPb). The three BHUs were run by one Medical Officer (MO) engaged by the NRSP at an enhanced salary. A “Revolving Fund” of Rs. 100,000 was created, with private philanthropic resources, for maintaining a store of high quality medicines. Patients had the option of purchasing medicines from this store or of receiving free Government medicines that are ordinarily supplied at all BHUs – albeit irregularly. The Fund revolved as many as twenty two times during 36 months. The out-turn of patients at the three BHUs registered a quantum increase during the NRSP management.
It is difficult to say in what way the Lodhran experience inspired the Pilot in District Rahim Yar Khan (RYK). Both were conceived around BHUs and both happened to cluster three BHUs in the care of a single Medical Officer. Similarities, however, may not go beyond these two features. Looking back, it is clear that the Lodhran experience encouraged the making of more ambitious plans.
The road to the President’s Primary Healthcare Initiative (PPHI):*
The acknowledged importance of the Primary Healthcare (PHC) to poverty should make it hugely eligible for inclusion in every poverty alleviation program. In January 2003, the GoPb has initiated the Programme in Raheem Yar Khan district in partnership with Punjab Rural Support Programme.
In 2005, the President of Pakistan apprised himself of the results that had been possible to achieve in the Punjab. He evinced keen interest in extending the scope of the work to other parts of the country. At a high level meeting he and the Prime Minister co-chaired in September of the year, a number of landmark decisions were taken which included:
a. taking the operation to all other Provinces, the Azad Jammu and Kashmir (AJK) and to the Northern Areas (NAs) and extending it to all the Districts in the country in a phased manner;
b. the cost of the Provincial Support Units, and of the Support Units for each taken-up District, to be borne by the Federal Government which would also provide funds for a one-time up-gradation /rehabilitation of each BHU;
c. the District Health management to be re-engineered in the light of the experience of the operation. It shall be to this re-engineered District management that the BHUs shall be handed back;
d. the operation would be called the “President’s Primary Healthcare Initiative” (PPHI) with the President seen as personally driving it. Subsequently, after the 18th constitutional amendment, Federal Government has kept themselves out of it. Syed Qaim Ali Shah, Chief Minister Sindh has continued to support the programme and approved the administrative cost as well as signing of an agreement with PPHI – a Company registered under the Companies Ordinance 1984.
What is the PPHI?
The PPHI represents a new way of working. It is driven by a passion, by a commitment and a resolve to serve the poor. It is commonly observed that such norms of work are only privately subscribed to by individuals. These norms rarely drive public service delivery in Pakistan. The sharp focus on the assignment, close oversight and untiring facilitation of every key element of the operation by its managers have few parallels. It denotes an altogether new work culture. The description may appear immodest, unreal – perhaps even esoteric. However, the spirit that drives the PPHI is precisely what sets it apart from the delivery of every other public service. To describe the PPHI, it is necessary to describe the driving spirit. Without understanding the spirit that defines it, it is not possible to comprehend its unique–ness nor its accomplishments.
The PPHI has been patterned on the CMIPHC in the Punjab. The operation in the Punjab is the mother plant upon which four scion operations have been grafted. In other words, the CMIPHC has matured into the PPHI. Prominent features of the Punjab operation, and its national version, are outlined here.
i. Following broad understanding reached with a Provincial Government, a Program Director (PD) is appointed to lead the Provincial Support Unit (PSU).
ii. Where governance has been devolved, the District Government is competent to assign – out the management of RHFs. A District Support Manager (DSM) is appointed to lead the District Support Unit (DSU) in every District where the assignment is taken up. A typical Agreement which outlines the terms and conditions of assignment, is annexed at the end of this Manual.
iii. One of the first steps upon the conclusion of the Agreement(s) is the establishment of a “Resource Group”. The Group comprises widely respected specialists in every service that the BHU is expected to deliver. The Group is constituted with the greatest care so as not to lose sight of any of the eight PHC constituents – a balance often not easy to maintain.
iv. After taking a thorough stock of the staff availability, the DSU clusters the
RHFs so as to arrange for the medical staff to serve at more than one facility and appoints new contract staff where necessary and possible. The principle in this regard is that scarce resources, like the services of medical professionals, must be as equitably shared as practicable. It is because medical professionals are not always available for service at every RHF where vacancies exist.
This is also connected with the funds made available by the Government. District Budgets for the RHFs can commonly suffice not merely for engaging fresh staff but also for financing incentives to staff for performing additional services.
v. A regular and adequate supply of medicines and materials is ensured at the earliest possible stage. This is not only necessary for restoring the confidence of those who use the RHFs but also makes staff presence purposeful. In the new environment at the RHFs, responsibility with corresponding authority is placed with the medical professionals. This empowerment, in our experience, yields rich dividends.
vi. “Monthly Review Meetings” (MRM) are institutionalized to bring together the medical staff, the District Support staff and the relevant field officers of the Government. These meetings, held during the first week of every month, provide opportunity for participative discussion on the services delivered, on new measures taken at the RHFs, on resolution of old and new issues, etc. Most importantly, the MRM positions the medical professional at the centre of the operation – this being a corner-stone of the PPHI strategy.
vii. Capacity Building of medical and paramedic staff is a major area of focus. Quality issues are also a serious concern and are addressed in different forms across the entire range of services.
viii. Monitoring work at the RHFs is a major activity and a distinguishing feature of the PPHI. This is undertaken as part of “facilitation” from the District Support Unit. Visits to the RHFs are an important way to observe the staff at work and to ascertain ways for supporting them. There is a fine, though obvious, line that sets apart “facilitation” from “inspection.” PPHI has a strong preference for the first of the two methods.
ix. Starting new and re-starting dormant services, like the School Health Sessions, Community Health Sessions, Family Planning services, Female Health Program, community participation, computerization, etc to name only a few, is a continuing preoccupation. All these receive reference in this Manual.
Why the PPHI ….?
For delivering Primary Healthcare in rural Pakistan, we have an elaborate network of physical facilities worth billions of rupees. Having seen hundreds of BHUs in the Punjab and elsewhere, one can vouch for these being generally in a state of advanced neglect though built spaces are wastefully over-provided in many cases. We have thousands of professional staff employed at these. We have medical materials worth billions of rupees and huge budgets flowing in every year, albeit erratically. We also have a labyrinthian network of Rules, Codes, Policies, Procedures, etc. that govern these financial, human and physical resources. Every now and then we launch high-profile Programs while earlier ones roll into oblivion. But what about the services that these resources, systems and Programs are intended to deliver? What is the Judgement of the intended recipients of these services? That Judgment is as unanimous as it is damning. For a reality check, all that one has to do is to go out; stand at the right place and persuade the right people to feel free to give the right answers.
One is not convinced that the absence of vital services from our villages, over the past many decades, is fully realized. The common man in the countryside has no reason to believe that there is any such realization in the relevant places. New ideas and alternatives; new options shall receive serious consideration only if the failure of services is recognized and is attached importance. The angels that watch over the “poverty sector”, it seems, have not yet smiled upon the PHC as a vitally important need of the poor.