This compendium serves as an unbiased performance measurement compiled by the Punjab Public Health Agency against the benchmarks set out, at the beginning of the term. It offers political parties and policymakers with the baselines information for building their roadmaps for the next five years in Punjab.
TRACKING PROGRESS OF DEPARTMENT OF HEALTH PUNJAB AGAINST HEALTH MANIFESTO 2013
With the astronomical population size of 110 million Punjab is confronted with the challenge of making quality healthcare available, accessible and affordable to the public which is their fundamental right. Catering to the healthcare needs of this burgeoning population is a mammoth task, particularly in the rural and hard to reach areas. 18th Amendment made fundamental changes to federal & provincial health mandates through changes in the legislative lists. The 18th Amendment to the Constitution of Pakistan awarded provincial autonomy with a devolution of legislative and executive authority in the health sector.
The Government of Punjab had outlined a comprehensive roadmap and developed a package of focused and effective interventions focusing on three key areas: improving vaccination coverage, ensuring safe deliveries, and strengthening functionality of primary healthcare facilities. The focus was kept on promoting universal health coverage through the launch of Prime Minister National Health Program. This was complemented by demand-driven and need-based interventions at the tertiary level along with a focus on scaling up and sustaining the production of health workers Comprehensive monitoring mechanism were established with periodic stock-takes, alongside external evaluations and annual surveys to track progress along the key health indicators.
Punjab Public Health Agency undertook a critical review of the performance of the department of health against the commitments made under the Health Manifesto 2013.
- IMPROVED HEALTH SPENDING
Punjab has seen a phenomenal increase in the health expenditure and a documented four-fold increase in the health budget. Historically, the health expenditure trends reveal a strong tilt on the curative side. During the last five years, the Governments of Punjab worked aggressively on strengthening the primary and secondary level of healthcare. Whereby the overall health budget increased four-fold over the last 5 years, priority was given to the primary health care for strengthening the preventive and promotive aspects of healthcare service delivery. After the bifurcation of the department of health in 2015-16, health budget on primary and secondary healthcare increased by 81% i.e. from Rs. 62 Billion in 2015-16 to Rs112 Billion in 2017-2018. This was complemented by demand-driven and need-based interventions at the tertiary level along with a focus on scaling up and sustaining the production of health workers with the requisite competencies to respond to population health needs. Health budget of specialized healthcare and medical education also increased by 66% i.e. from Rs.74 Billion in 2015-16 to Rs. 123 Billion in 2017-2018.
- LAUNCH OF NATIONAL HEALTH INSURANCE SCHEME
Prime Minister’s National Health Program (PMNHP) was introduced for providing social health protection to poor people of Pakistan through health insurance coverage. In Punjab, PMNHP was initially launched in 4 pilot districts i.e. Rahim Yar Khan, Khanewal, Narowal & Sargodha and successfully enrolled 0.69 million families constituting 3.7 million individuals. Around 28,000 patients are documented to receive in-patient treatment in these 4 districts since the launch of the scheme in October 2016. Cashless health services are provided in 30 secondary healthcare hospitals (1,739 beds) and 9 tertiary healthcare hospitals (3,763 beds). In the second phase, the Government of Punjab scaled up the program in 13 additional districts i.e. Layyah, Muzaffargarh, Vehari, Lodhran, Multan, Rajanpur, Dera Ghazi Khan, Mianwali, Bhakkar, Khushab, Bahawalnagar, Bahwalpur&Hafizabad. This is expected to add 2.5 million beneficiary families consisting of 13.2 million individuals. Nearly 6,700 patients are documented to have received in-patient treatment in 09 districts in 57 secondary healthcare hospitals (1,177 beds) and 9 tertiary healthcare hospitals (3,763 beds).
The program is planned to scale up in the remaining 19 districts of Punjab expanding the umbrella of this program to further 3.8 million poor beneficiary families consisting of 14 million individuals in these 19 districts. With the launch of PMNHP in all 36 districts of the Punjab, program aims to enroll 7.1 million poor families of Punjab with the individual population of 33.1 million, which is approx. 30% of the total population of the Punjab under this social health protection initiative. This program shall pave the roads for universal health insurance coverage in Punjab where all individuals shall get insurance coverage for health protection.
- STRENGTHENING PREVENTIVE HEALTHCARE
Preventive healthcare in the continuum of healthcare focuses on measures undertaken for disease prevention and include health awareness, counseling, screenings and other preventive and promotive interventions.
Hepatitis Control Program
The Government of Punjab allocated 5.67 Billion rupees for the period 2016-2019, in its fight against the rising incidence of Hepatitis in the country. Over the last two years, the Punjab Hepatitis Control Program launched five key initiatives and successfully achieved a number of milestones in both preventive and curative care. Hepatitis Prevention Ordinance 2017 was introduced for ensuring early diagnosis, surveillance, and prevention. Punjab Blood Transfusion Act 2016 also supported reducing risks of blood-borne disease transference. Punjab’s first BSL-III Bacteriology lab was established for advanced testing and diagnosis of infectious diseases. 108 Hepatitis Clinics were established across Punjab with Electronic Medical Record systems. Punjab also introduced the Hepatitis Birth dose and procured auto-disable syringes for health facilities to eliminate reuse of syringes. Licensing was initiated for Barbers and Salons after requisite training, provision of barber kits and awareness material with32,216 already registered across 36 districts of Punjab.
Tuberculosis Control Program
The program launched comprehensive public awareness and behavior change communication campaigns on TB. Single -window TB rooms with EMR facility were established in 125 public sector hospitals across Punjab for timely provision of treatment to TB cases. The diagnostic capacity of the Provincial TB Control Program was enhanced and improved case detection was noticed though utilizing the Lady Health Worker network for identification of potential TB patients. The Department also added TB to the list of notifiable diseases.
Aids Control Program
In Punjab 22 dedicated HIV treatment centers were established across Punjab. Intensive screening efforts were made for identification of HIV patients in high-risk groups i.e. trans-genders, heavy transport vehicle operators and jail inmates. Advanced testing and diagnostics for HIV are now available at the Provincial BSL III laboratory.
Ensuring the sustainability of this vital cadre, the Government of Punjab upgraded the 45000 posts of Lady Health Supervisors (LHS) to a minimum of BS10 and LHWs to a minimum of BS5.
Non- Communicable Disease Control Program
Punjab was the first province to launch a dedicated Provincial NCD Program in January 2017 and have the Provincial NDC Strategic Plan in place. Screening desks were established at 130 secondary and 18 primary health facilities; 1600 doctors and paramedics were trained on NCD management; health awareness sessions and screening camps were organized and 1,926,679 people were screened in its inception year for NCDs, The program registered 146,961 cases who are receiving treatment at the 40 NCD clinics established at secondary level facilities in every district across Punjab.
PDHS 2012-13 documented 54% immunization coverage in Punjab. The department of health picked this as a priority agenda in an attempt to reduce neonatal mortality. A multi-pronged approach was adopted focusing on low coverage in rural areas. E-vaccs, a tech-enabled initiative to identify pockets of low coverage for targeted interventions. 550 new vaccinators and supervisors were hired and were provided smartphones with an android application that digitized their fieldwork and provided real-time data for managing their performance. This was further verified through monitoring calls made to parents.
The success of this focused approach is reflected in the recently published Punjab Health Survey II which indicate that the 8 % differential that existed between the urban and rural population in 2014 was overcome. Immunization coverage in Punjab increased by 22% from 62.3% in 2014 to 84% in 2017. Punjab introduced Pneumococcal Vaccine (PCV) in 2012 and Rota virus in 2017. In contrast to the Global coverage for PCV at 32 percent, the coverage in Punjab in a short span of 5 years was reported at 90.3%. Pregnant women who are protected against tetanus increased from 76.4% into 82.5 %, in 2017. In 2017 WHO verified elimination of maternal and neonatal tetanus from Punjab, which was indeed a great achievement.
Punjab Public Health Agency
The launch of this “future institution” is a reflection of Government’s commitment to promote and safeguard the health and well-being of the present and future generations. The Punjab Public Health Agency (PPHA) is the first provincial public health institution that will offer a complete range of public health functions, setting set a precedence and benchmark for other provinces to follow. In its inception year, PPHA had received membership with the International Association of National Public Health Institutes (IANPHI) in Nov 2017 with the unanimous voting and endorsement by 108 members from 93 countries. This is expected to open doors to international expertise and collaborations. PPHA has also been awarded the lead role of serving as the secretariat for the South Asia IANPHI chapter. The Government of Punjab has committed PKR 1.3 billion towards the establishment of the PPHA. This institution is expected to the largest employer of public health professionals, with 285 approved public health positions at provincial and district level.
- STRENGTHENING PRIMARY HEALTHCARE
Strengthening of Basic Health Units
There are 2520 Basic Health Units (BHUs) at the union council level, which provide outdoor patient services to the rural population across the 36 districts of Punjab. During the last three years, 1000 BHUs across Punjab upgraded to 24/7 facility and strengthened for the provision of Basic Emergency Obstetric and New Born Care. 1000 ultrasound machines were procured and placed at each of the BHU 24/7 for early detection of complicated and high-risk pregnancies.
Central induction policy introduced by the Specialized Healthcare and Medical Education Department was pivotal in the recruitment of Medical Officers in BHUs whereby the number of MOs availability at BHUs increased from 58% in 2015 to 90% in 2018. Road map team records reveal that availability of medicine in BHUs increased from 73% in 2015 to 92% in 2018. The overall BHU outlook score, based on the availability of electricity, water supply, sewerage, fans, lighting, clean toilets and good whitewash significantly improved from 67% in 2015 to 94% in 2018. Electronic Medical Record (EMR) system have already been launched in 35 BHUs in phase 1. It is noteworthy that the availability of medicine in BHUs increased from 73% in 2015 to 92% in 2018. The department placed a high focus on quality and it is commendable that 110 BHUs in Punjab have received MSDS certification by Punjab Healthcare Commission and 8 of them have also acquired globally renowned ISO certification.
Mobile Health Units
The Government of Punjab launched 40 Mobile Health Units (MHU)s dedicated to serving the communities in underserved and far-flung areas. These are customized vehicles loaded with medical equipment, supplies, and skilled clinical staff bringing healthcare services closer to the people. These MHUs are providing outpatient, MCH, FP and basic lab services. They work closely with LHWs and school health supervisor. MHUs have provided valuable emergency services to areas affected by natural calamities. They brought critical emergency care to the people of Khyber Pakhtunkhwa during the dengue outbreak in 2017.
MHUs are Geo Tracked and effectively monitored both through video tracking and onsite surprise visits by PHFMC Monitoring Staff. High-quality medicines procured and disbursed to patients attended at the MHUs. They are linked to nearby health facilities and also with the Rescue 1122 for emergency transfers. Patient Data is being managed through EMR. The services being offered by MHUs are periodically audited though Third-Party Validation by renowned firms.
Reduction in Maternal and Infant Mortality
The Nielsen Survey in 2014 indicated that 1 in 3 deliveries in Punjab was not attended by a skilled health professional. The department of health employed three key strategies targeted at improving Skilled Birth Attendance (SBA) across Punjab. First was the upgradation of 1000 BHUs to operate 24/7 backed by trained staff, equipment, and medicines for the provision of Basic Emergency Obstetric and New Born Care. Second, a fleet of around 450 vehicles under the Rural Ambulance Service was dedicated to transferring pregnant women to health facilities. The Rural Ambulance Service partners with private service providers for the running and operations of the fleet. Even in its early months of operation approxe27,000 mothers are transported for safe institutional delivery every month. Third, 1000 ultrasound machines were procured for BHU 24/7 for early detection of complicated and high-risk pregnancies and potentially save lives by transferring the identified cases to a specialized facility through the Rural Ambulance Service.
Punjab Health Survey II indicated that the SBA in Punjab increased from 64.7% in 2014 to 78.7% in 2017. The number of deliveries at 24/7 BHUs were also found to increase from 25,000 in 2013 to 60,000 in 2018. From 2014 to 2017, in Punjab there has been 15.1 % increase in the institutional deliveries; 13.1 % increase in the deliveries at public health facilities; 14% increase in the number of newborns delivered by a skilled birth attendant; 87.2 percent newborn receiving a Post-Natal Health Check; 14 % increase in exclusively breastfed infants 21% increase in institutional deliveries amongst mothers from poorest wealth quintiles; 21% increase in institutional deliveries amongst mothers with no/preschool education; and 20% increase in SBA amongst mothers with no/preschool education.
With 79% women receiving ANC from a skilled health provider; 54.9 percent women receiving four or more ANC visits; 78.7% pregnant women being delivered by SBA; and 83.9 % mothers receiving a Post-Natal Health Check, Punjab has made tremendous progress towards positively impacting the health indicators that are documented to be linked to reducing the maternal and neonatal mortality rates.
Reduction in Population Growth Rate
The population growth rate of Punjab is 12.68% less than the national average despite migrant influx being highest in Punjab. PDHS 2012-13 recorded the CPR for Pakistan as 35% and that of Punjab as. 40.7%. FP Track 2020 projects CPR foe Pakistan as 43 % in 2017 and that of Punjab as 47%. This is despite the province housing over 55% of the total national population. There is still a long way to go. Punjab is adding population equivalent to a new district every year to its landscape with the 2.6 million births estimated annually. This is alarming and calls for the next health manifesto to place population growth control as the top most priority agenda.
- STRENGTHENING SECONDARY HEALTHCARE
Revamping of secondary level health facilities
There are 26 DHQs at a district level and 99 THQs at Tehsil level operating at the secondary level across 36 districts of Punjab. The Government of Punjab approved 40 billion for revamping and upgradation of secondary level hospitals across Punjab. Revamping of 25 DHQ and 15 THQ hospitals in phase 1 has been completed. In the second phase, the reform agenda is expected to roll out to the remaining 85 hospitals (1 DHQ and 84 THQs).
13,700 posts were created at THQ and DHQ level. All DHQ hospitals were provided CT scan facilities. Hemodialysis machines, x-ray units, and dental units were procured and fully equipped ICU cum CCU units were ensured in all secondary level hospitals. Today almost 85% of the medication received by the patients at the public health facilities are free of cost. Under public-private partnership model, for the first time, renowned ISO certified Laboratories became functional at public sector hospitals. The reform was supported by technological interventions like Hospital Information Management System for digitizing hospital processes. Non-clinical services, such as janitorial, security, horticulture and procurement of medical gases were outsourced. Intensive efforts were made to enhance the quality of service delivery at these hospitals. 27 secondary level facilities acquired ISO 9001 accreditation and another 23 ISO 14001 accreditation.
- STRENGTHENING TERTIARY HEALTHCARE
In the last two years, Punjab has added three dedicated burn facilities in Lahore, Multan and Faisalabad with 205 dedicated beds, ICUs, HDUs and OTs. A 385-bedded Surgical Tower has been established at Mayo Hospital, with 16 Operation Theatres, including 3 modular theatres. A 120-bedded Cardiology and Cardiac Surgery block and a Kidney Transplantation and Dialysis Unit has been established at Bahawal Victoria Hospital. In Wazirabad, a 10–bedded Institute of Cardiology has also been established. In Phase I, Recep Tayyip Erdogan Hospital (teaching) has been established in Muzaffargarh with 250 beds. A 9-story block, Ghazi Ilmuddin Shaheed Block has been operationalized in Services Hospital, with 160 beds dedicated to paeds medicine and 120 general beds.
In 2017, 680 beds and 16 OTs were added to the 400-bedded Children Hospital in Lahore, and 150 beds added to the 150-bedded Children Hospital in Multan. The 200-bedded Children Hospital in Faisalabad was recently inaugurated. Punjab Institute of Neurosciences, 500 bedded facility, also became fully operationalized. The Government of Punjab constructed two high-quality Regional Blood Centres (RBCs) in the South Punjab (Multan and Bahawalpur) in collaboration with German Government, for the provision of blood banking, donor grouping, screening, and supply.
To support this expansion, 7787 Nurses, 2723 Medical Officers, 262 Senior Registrars, 122 Assistant Professors, 96 Associate Professors and 30 Professors were recruited by the Department of Specialized Healthcare and Medical Education. In addition to these hiring, 12947 new positions were created in tertiary care facilities (77 Biomedical Engineers, 1129 paramedics, 5380 Nurses, 4988 General Doctors, 345 Specialist Doctors, 679 Senior Registrars, 149 Assistant Professors, 131 Associate Professors, 69 Professors).
An overall increase of 4500+ beds have been done in the last year, bringing the total bed strength in tertiary care to 28000+. Out of these, more than 2000 beds have been added in the last two years. The hospitals are reported to attend to 110,000 patients in outpatient department and 15000 in the emergency on a daily basis.
State of the art Pakistan Kidney & Liver Institute was established as the first public sector hospital in Pakistan designed as per Joint Commission International (JCI) Standards
- STRENGTHENING MEDICAL EDUCATION
During the last five years, Punjab upgraded 4 medical colleges to medical universities; four new medical colleges and 10 new nursing and midwifery schools and 6 allied health schools were established. In addition, 5 nursing schools were upgraded to colleges.
Today in Punjab there are 6 medical universities, 11 medical and dental colleges, 35 teaching hospitals, 14 specialized hospitals and institutes, 57 nursing schools and colleges, 70 institutes for paramedics and 8 institutes of allied health sciences operating under the aegis of specialized healthcare and medical education department. These include 18 autonomous medical institutions where the college and the hospital work as an autonomous unit reporting to a board of directors.
The six new allied health schools opened in the province has increased the production of allied health professionals to 1905 in 2018. A total of 70 public and 82 private sector institutions are also producing paramedics in Punjab, with 10,045 seats affiliated with Punjab Medical Faculty. To-date 78,686 paramedics have been produced by Punjab Medical Faculty. The registration system of the students has recently been digitized.
Punjab increased recognized postgraduate programs from 211 to 547 in last two years, with biannual induction cycle which was computerized to allow merit-based and transparent inductions. The number of postgraduates inducted per cycle was increased from 895 to 1750. Overall postgraduate training positions were increased from 4216 to 7500 and all honorary positions were converted to paid positions. With the introduction of Central Induction Policy whereby doctors serving in primary health facilities in rural areas gain additional marks for PG programs, the primary and secondary healthcare department has been able to fill vacant positions in BHUs and RHCs by 90 %.
- HOSPITAL HYGIENE AND WASTE DISPOSAL PROGRAMS
A comprehensive hospital waste management system has been implemented at both primary and secondary healthcare facility level across Punjab, as well as in 17 tertiary care hospitals. The system is supported by provision of standardized transport vehicles, temperature controlled yellow rooms and stringent monitoring of waste disposal protocols.26 incinerators are installed to treat pathological waste, and autoclaves were installed to treat infectious waste. At each stage, the processes are completely digitized to weigh waste and scan content at each step. Thirty-seven dedicated temperature controlled yellow vehicles were procured to collect contained hospital waste from different health facilities for adequate disposal.
- ESTABLISHMENT OF AN INDEPENDENT DRUG AND FOOD ADMINISTRATION
To institutionalize scientific testing for ingredients and quality of fertilizers, drugs, pesticides and food, Punjab Agriculture, Food, and Drug Authority (PAFDA) was launched through promulgation of The Punjab Agriculture, Food and Drug Authority Act 2016 (Act XXXII of 2016).
Punjab Drug Act 2017 aims to assure provision of quality drugs to people by enforcing and monitoring drug production. The office of Chief Drug Controller, Provincial Quality Control Board, and Provincial Drug Control Unit were also restructured and strengthened. Five drug testing laboratories were revamped and are now undergoing ISO certification. The validity of their results has been confirmed through International testing of Drug samples. Only FDA-approved drugs qualify for procurement. To assure the quality of drugs produced, drug manufacturing firms are undergoing GMP inspections. Drug Sale Licensing has been centralized and automated for improved supervision and curb spurious drugs
- ESTABLISHMENT OF DISTRICT HEALTHCARE AUTHORITIES
After the issuance of District Health Authority Rules of Business in 2016, district health authorities were established in all 36 districts of Punjab and CEOs were appointed to head the newly established institutions. Regular meetings are held at the provincial level whereby all CEOs overseeing the management of hospitals in their respective districts meet to discuss progress on rolled out interventions.
- PROVINCIAL SET UP FOR MEDICO LEGAL SERVICE PROVISION
The Forensic Science Agency in Punjab is the second biggest full-service forensic lab in the world and the biggest in Asia, rendering its services through fourteen forensic disciplines. The services include receipt of physical evidence from Law Enforcement Agencies on criminal and civil cases and analyzing the forensic evidence for stakeholders including Apex Courts, Investigating Agencies, Prosecutors, and others. PFSA is providing professional and technical support not only nationally to other provinces but also internationally to requests received from other countries.
- FINANCIAL ASSISTANCE TO QUALIFIED DOCTORS FOR SETTING UP NEW CLINICS
Punjab Health Foundation was established as an autonomous body under Punjab Health Foundation Act, 1992, to provide financial assistance to doctors and encourage their engagement in service delivery. During the last couple of years, it has been revitalized for the promotion, development, and financing of health services in the private sector. Financial assistance is being awarded in urban and rural areas to individual doctors, promoting their engagement into the service delivery network. Clinics financed by PHF are geo-tagged and digitized and equipped with online patient registration systems. An online application portal has been established and smart loan scheme for doctors and allied health professionals were introduced. PHF also offers interest-free medical education financing.
Punjab Public Health Agency is a member of the International Association of National Public Health Institutes and serves as the technical and scientific hub of public health expertise in the province.