Punjab health sector: International agencies mulling providing $235 million for reforms

International Development Association (IDA) is considering to provide $135 million for Punjab Health Sector Reform Project, while UK British Department for International Development will provide $100 million to enable Punjab Government strengthen health system and improve services of the same, particularly for the poor.
According to World Bank Project Report, this project will be completed with a total cost of $250 million. WB report revealed that provision of technical and financial support through the proposed project would focus on: (a) service delivery and management reforms, (b) systems development interventions including generation and use of data for increased accountability, and (c) improved governance in the health sector and restructuring of the DOH to perform its enhanced stewardships functions in light of the 18th constitutional amendment to the constitution.
In an update study report, Inaam Haq, senior health specialist of World Bank pointed out that the proposed project will use a programmatic approach using a result-based financing mechanism. The project design will be based on Punjab government's strategic sectoral plan with robust result framework and well-defined qualitative and quantitative targets.
The WB anticipates providing in IDA funding $135 million over a five year period to this program, accompanied by support from the bank's Health Results Innovation Trust Fund ($15 million) and co-financing from DFID ($100 million). He mentioned that the project will support Punjab government's programme under four components:
Under first Component, Improving Health Services will be completed with the total cost of $150 million. The objective of first component is to enhance coverage, quality and access to a package of essential health care services, especially for the poor and in underdeveloped districts of the province. The component will focus on the districts mostly in southern part of the province where the health outcomes are lagging. The package will include following services: neonatal, child, and maternal health, family planning, nutrition, and communicable diseases' control. Primary Health care will be reorganised with expansion of 24/7 Comprehensive EMOC services in all RHCs and selected BHUs.
The following approaches will be used:
a) Contracting out - management of all RHCs and BHUs in at-least 15 districts with contracted management organisations responsible for health facilities including provision of preventive and primary health care to the catchment area population under a results-based contract linked to achieving district-wide annual performance targets for outputs.
b) Contracting in - Strengthening the district health leadership in poor performing districts by deploying competitively selected managers through an internal or external selection process under performance based contracts.
c) District Partnership model - Strengthening current district health management model with a focus on delivering better results. In addition, the component will support improvement of quality of secondary care services in the province through analytical work. The component will also support specialised provision of preventive, treatment and care services for population subgroups vulnerable to HIV infection (IDUs, MSM and 'sex workers') in targeted cities.
Under second component, Reforms for Enhanced Accountability will be completed with a total cost of $85 million. The objective will be to strengthen systems to enhance accountability and governance. This component will focus on the following two strategic areas:
a) Enhancing governance and accountability mechanisms including: i) Functional/capability review, organisational restructuring, ii) Regulatory and legislative reforms including operationalization of Punjab Health Commission, and iii) strengthening social accountability through empowerment of communities/people by third party validation of results through Regular Health Facility Assessments and household survey, data dissemination for greater accountability, community-based monitoring/auditing using modern technologies, and facilitating development of public health surveillance system, establishment of effective complaints mechanisms, and third party monitoring and auditing of performance and results.
b) Strengthening the DOH's management systems including: i) Human resource management systems focusing on development of HR strategy, establishment of HR cell, and separation of management cadre from the general cadre, ii) Strengthening evidence based decision making with a robust (internal and external) M&E system to measure and disseminate results concurrently improving quality, through third party validation and use of data from District Health Information System, and iii) improving procurement systems in the health sector through implementation of Public Procurement Regulatory Authority Reforms.
Under the third component, Improving Capacities in Technical Areas for Equitable Health Services to All will be completed with the cost of $15 million. This component will support strengthening of existing analytical capacities in technical areas and health care financing and operational research, training. Health care financing aspect will focus on improving quality and efficiency of the sector expenditures, focusing on reducing OOP, enhancing public expenditures on primary and preventive service provision, exploring other models to finance hospital care, increasing non-salary expenditures, and piloting alternative financing models including health insurance/social protection.
WB updates revealed that the bank and DFID will jointly appraise Punjab government's sector programme based on the overall strategic plan of the government and select five to six Eligible Expenditure Programme out of a range of Punjab government's budget line items that reflect the desired outcomes of the program. Determination of eligibility of disbursements will be based on i) expenditure reports (this requires adequate financial reporting arrangements); and ii) performance reports to track accomplishment of pre-specified results, as measured by disbursement linked indicators (DLIs). (An agreed percentage of EEP will be disbursed contingent on the verification of the achievement of agreed DLIs and achievement of agreed level of expenditures eg, 70 percent of allocation) by the government.
In implementing such a results-based financing mechanism, it will be essential that the DOH's financial management system be strengthened to track, record, analyse and summarise financial transactions and to provide reliable periodic financial reports for the whole sector/programme rather than tracking the bank funds only, report added.
WB update report disclosed that Punjab's overall health outcomes are comparable to the national average but the pace of change remains slow and uneven with significant disparities among regions, rural-urban, and by economic status. Punjab has successfully reduced child mortality over the decade (reduction in infant mortality rate from 104 to 81 and under-five mortality rate from 133 to 97). The current IMR and U5MR are similar to the national average but still about twice the levels of Bangladesh and Nepal. Child nutrition, a key to lower early child morbidity and mortality, is in poor shape in Punjab with 34 percent of children under five are moderately or severely underweight and 11 percent are severely underweight.
Similarly, 57 percent of children aged 12-23 months in Punjab are fully immunised in 2008-09 as compared the national average of 51 percent. Maternal and reproductive health outcome and service indicators have shown a steady progress though not yet ideal. The maternal mortality ratio of 227 per 100,000 live births is substantially lower than the national average of 276. However, only 43 percent of deliveries assisted by skilled health personnel. Punjab's current total fertility rate is 3.9 per woman, which is the lowest among four provinces with the lowest unmet need for family planning at 23 percent.
Furthermore, Punjab faces a concentrated epidemic of HIV/AIDS among high-risk groups and a significant burden of endemic TB. Major cities in Punjab such as Lahore, Faisalabad and Multan are known to have sizeable numbers of vulnerable or at risk populations for HIV/AIDS.
Punjab's slow progress in improving HNP outcomes is due to various factors including external and internal factors. Factors external to the health sector include persisting high levels of poverty mainly in the southern part of the province, low levels of education, inadequate availability of safe water and poor sanitation systems. Factors internal to the health sector are many and government of Punjab is struggling in delivering expected results to their people as performance remains less than desired due to weak management, particularly at district level, lack of accountability mechanisms, low levels of motivation of staff to perform and work in rural and remote southern districts and low levels of public expenditures on health as compared to most developing countries.