Comprehensive multi-Plan
Immunization Program of Khyber Pakhtunkhwa
List of figures
Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa
List of Acronyms
AD Auto-destruct AEFI Adverse Events Following Immunization AFP Acute Flaccid Paralysis BCG Bacillus Calmette-Guerin BHU Basic Health Unit BPS Basic Pay Scale CD Civil Dispensary cMYP Comprehensive Multi-year Plan DGHS Director General Health Services DHO District Health Officer DHQH District Headquarters Hospital DTP Diphtheria Pertussis Tetanus DQS Data Quality Self-Assessment DSV District Superintendent Vaccination EPI Expanded Program on Immunization EVM Effective Vaccine Management FMT Female Medical Technician FTE Full Time Equivalent GAVI Global Alliance for Vaccines and Immunization GDP Gross Domestic Product GGE General Government Expenditure GGHE General Government Health Expenditure GHE Government Health Expenditure HMIS Health Management Information System HR Human Resources HSRU Health Sector Reform Unit ICC Inter-agency Coordinating Committee IEC Information, Education and Communication ILR Ice-Lined Refrigerator IP Immunization Practices IPV Inactivated Polio Vaccine JICA Japan International Cooperation Agency
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KAP Knowledge, Attitude and Practice KM Kilometer LHS Lady Health Supervisor LHV Lady Health Visitor LHW Lady Health Worker M&E Monitoring and Evaluation MCHC Maternal and Child Health Center MDG Millennium Development Goal MIS Management Information System MLM Mid-Line Manager MMR Measles, Mumps, and Rubella MNCH Maternal Neonatal and Child Health MT Medical Technician NIPS National Institute of Population Studies OPV Oral Polio Vaccine PITAG Provincial Immunization Technical Advisory Group P&D Planning and Development PC-1 Planning Commission Performa No.1 PCV-10 Pneumococcal Conjugate Vaccine - 10 PEI Polio Eradication Initiative PKR Pakistani Rupee POL Patrol Oil Lubricants PSDP Public Service Development Program RHC Rural Health Center SH Secretary Health SIA Supplementary Immunization Activity SIS Skilled Immunization Staff SOPs Standard Operating Procedures SWOT Strengths, Weaknesses, Opportunities and Threats THE Total Health Expenditure THQH Tehsil Headquarters Hospital TPV Third Party Validation TT Tetanus Toxoid
3 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa
UC Union Council UNICE United Nations Children's Fund F USD United States Dollar VPD Vaccine Preventable Disease WHO World Health Organization
4 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa
Executive Summary
Immunization System Analysis Current Immunization Status Immunization prioritized under Health Sector Strategy 82% immunization coverage 70% DTP3 coverage 2010-17 53% Fully immunized Strong Political Commitment DPT1 – DPT3 drop out being 11% Only 46% of districts with above 80% of DPT3 coverage Province specific target setting of all RI 96% polio SIA coverage Poor oversight and Monitoring systems Very low turnover of vaccinators Strong political commitment Well established PIU with qualified technical staff for Salaries of EPI service delivery staff on Recurrent surveillance, monitoring and evaluation and cold chain budget staff Functional AFP surveillance system management Aging and insufficient cold chain equipment LHWs involvement in RI activities
Health System Constraints
Incremental budget planning No practice of developing annual health plans Health department’s contribution to revenue generation remained 0.08% Fragmented health information system No HR policy for human resource management of the health department Lack of coordination between vertical health programs Security risks and poor law& Order situations
Baseline In Total Immunization Expenditures 21,210,243 Campaigns
4,979,795 Routine Immunization only 16,230,448 per capita
$ 0.63 per DTP3 child
$ 27.12 % Vaccines and supplies 5
43% % Government funding ExecutiveComprehensive Summary multi: Comprehensive-Plan | Immunization multi-Plan Program, 2014- 2018of Khyber | Expanded Pakhtunkhwa Programme on Immunization, KhyberPakhtunkhwa
Immunization Priorities Goals &Objectives 2014-18
Increasing immunization coverage and reducing vaccine preventable disease associated morbidity and mortality To increase coverage of fully immunized from 53% to 80% in Increasing the share of immunization services through outreach services and fixed EPI centers all districts by 2018 Expanding tending the reach of immunization services to To enhance Penta3 from 70% to 90% in all districts by 2018 marginalized populations and security compromised areas To increase TT2+ coverage from 56% to 80% by 2018 in all Strengthening and upgrading cold chain and logistics districts Introducing new vaccines (IPV/Rotavirus) To increase measles coverage from 58% to 80% Polio eradication Increase the proportion of population protected at birth Strengthening VPD Surveillance from neonatal tetanus from 56% to 80%
Programme Monitoring Framework Priority Immunization Strategies Indicator 2012 Enhancing programme staff capacities in policy, planning 2018 and guidelines/SOP development DTP3 coverage Introduce mechanisms of accountability through third party 70% 90% monitoring Measles 1 coverage 58% Increase the number of skilled immunization staff 80% Upgrade/maintain adequate cold chain equipment PCV-10 coverage 0 Develop and implement evidence based communication 90% strategies % of children fully immunized 47% 80% % of districts that have at or above 80% DTP3 coverage 52% 90% Dropout rate - % point difference between DTP1 and DTP3 coverage 10% 7% Partnerships & Sustainability Strategy Health and Development Impacts Enhance efficient utilization of human resources by Improve child survival through contribution to achievement developing synergies with other health initiatives of MDG Goal 5 Minimize wastage of resources under immunization Reduced disability in the community associated with program vaccine preventable disease (Polio) Advocacy for ensuring financial sustainability of Contribute to poverty reduction goals through reduction of immunization program preventable hospitalization for childhood illnesses Introduce mechanisms of accountability through third party monitoring
Cost and Financing projections
2014, 2015, 2016, 2017, 2018 Total Resources Required 66,573,771 71,366,278 83,553,150 84,098,539 81,145,668 per capita 1 , 1, 2, 2, 2 Total Secure Financing 63,853,429 55,992,582 14,663,937 16,840,934 15,325,660 Funding Gap $2,720,342 $15,373,696 $68,889,213 $67,257,605 $65,820,008 Total probable Financing 106,120 10,378,681 63,803,102 62,543,804 61,230,295 Funding Gap 2,614,222 4,995,016 5,086,111 4,713,801 4,589,7136
Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Executive Summary Situation Analysis Khyber Pakhtunkhwa (KP), one of the four provinces of Pakistan is among the least developed and crisis prone province in Pakistan. KP province accounts for 10 percent area of Pakistan with 13 percent of population residing in seven administrative divisions. About 69 percent of population lives in the rural areas, above national average size of 4.8 members per household compared to national average of 3.8, low literacy rate of 49 percent, less than 50 percent of population is having access to tap water connections, and high unemployment rates of 8.5 percent1. Its relative underperformance is due to low levels of growth, socio-economic development and absence of public services in comparison to other provinces of Pakistan. This province is also affected by geo-political developments (militancy) and devastations of mother-nature (earthquake 2005 and floods 2010); all calling for continued scaling-up of public interventions and investment to not only improve quality of life but, also, unlock economic potentials. The Khyber Pakhtunkhwa, has four administrative sub-regions– Hazara, Malakand, Central and Southern––that together contain 25 districts. The regions are further constituted of 25 districts, 72 tehsils and 1,040 union councils. Based upon 1998 census the projected population of KP for 2012 is estimated at 25,929,799. The population of districts ranges from 0.2 million to above 2 million (average of 0.7 million) with Thorghar and Peshawar being smallest and largest in terms of population respectively. The Province continues to establish new districts and union councils.
In Khyber Pakhtunkhwa, as in other parts of the country, the quality of health services is often poor, resulting in a waste of both government and household resources and providing a low impact on health outcomes. Women and children are particularly disadvantaged by socioeconomic and cultural barriers with estimates of only 30% of women and children having access to medical care.2 The total fertility rate is high (3.9) and the CPR (28.1)3 is not rising fast enough to achieve MDG goals. The situation is further compounded by high maternal and infant mortality rates (58)4 and insufficient services. Public as well as private services focus on curative care, with little attention to promotive, preventive care and rehabilitative care. Health facilities are underutilized due to shortages of staff and supplies. Chronic staff shortages and non-availability of essential medicines is common. In the CIET survey (2004), only 9% of the patients who had used a government facility had received all the prescribed medicines.5
The health outcomes in KP present a challenging picture showing improvements slowly over the years. The inter-district inequities in service provision and slow progress in improving
1 www.Worldbank.org 2 http://www.ayubmed.edu.pk/JAMC/PAST/20-4/Moazzam.pdf 3 PDHS 2012-13 4
5 http://www.ciet.org/en/documents/projects_library_docs/2006224175348.pdf 7 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa health status of the poor are a key challenge for the province. Many other factors are also responsible for the situation including; staff absenteeism, frequent transfers, poorly managed health infrastructure plagued by lack of equipment, medicines and other essential supplies in most of the health facilities. The frequent and continuous emergencies and natural disasters faced by the province over the past few years also have had a negative impact on health care provision, a situation further precipitated by gradually increasing security related incidents. The province has faced multiple challenges over the last decade both natural and man-made disasters. There is also an unstable macroeconomic situation. These events have displaced large population groups across the country, and challenged the system to ensure access and service delivery. Immunization coverage in the province has been stagnant over the years. The proportion of children under 12 months of age/two/five years of age who are fully immunized is around 53 percent.
EPI services are provided most exclusively through the public health delivery network through fixed centers and outreach services. The centers are managed by vaccinators with support from Lady Health Workers (LHW), BHU and other hospital staff but some of the EPI centers in the PPHI managed BHUs are managed by vaccinators with limited assistance from the BHU staff. In addition, following major political reform resulting from 18th Amendment, management of health services including immunization has been devolved to the provinces. Hence providing an opportunity to re-visit the immunization situation, identify the gaps and redesign EPI to achieve increased coverage and reduced deaths and illness episodes due to Vaccine Preventable Diseases (VPD). The challenge for Khyber Pakhtunkhwa is to strengthen the health system and improve the performance of the routine immunization coverage from the current stagnant low rates, while maintaining high rates of coverage in the ADCI campaigns.
Provincial immunization Programme Expanded Programme on Immunization (EPI) was started in 1976, as a pilot project confined to Peshawar and Nowshera, soon after the successful eradication of small pox. It was included in regular Annual Development Programme (ADP) in 1978 - 79. The basic aim of the program is reduction of death, disease and disability due to vaccine-preventable diseases (VPDs), and to contribute to the strengthening of national health systems and the attainment of the Millennium Development Goal 4 (MDG-4). The main objective of EPI Programme is to immunize all children between 0 and 23 months against eight vaccine preventable diseases that include: tuberculosis, poliomyelitis, diphtheria, pertussis, neonatal tetanus, hepatitis B, Haemophilus influenza type B (Hib) and measles with plans in future to introduce New Vaccines i.e. Pneumococcal (PCV) and Rota. The overall goal of the Provincial NIP is to decrease VPD associated morbidity and mortality:
To increase coverage of fully immunized from 53% to 80% in all districts by 2018 To enhance Penta3 from 70% to 90% in all districts by 2018 To increase TT2+ coverage from 56% to 80% by 2018 in all districts To increase measles coverage from 58% to 80%
8 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Increase the proportion of population protected at birth from neonatal tetanus from 56% to 80%
The programme strategies and most policies are generally in place for routine immunization activities, however there are a number of important issues that need immediate addressal if the targets are to be achieved. The main issues include, poor capacity of EPI human resources, poorly managed vaccine procurement and cold chain, under financing and lack of emphasis on demand generation are among the important ones. Another important contributor of the poor performance has been lack of emphasis on routine immunization compared to Polio and other accelerated disease initiatives. Most donors have been investing money and efforts in to these initiatives rather than routine immunization. While overall immunization coverage is improving, still 13 out of 25 districts are reporting less than 80% coverage with DTP3 (2012) and many reporting high drop-out rate. Outreach services are still problematic in many districts with hard to reach areas and populations. The situation is further aggravated by lack of trained human resources especially skilled immunization staff (SIS), poor quality of physical infrastructure (health facilities) and insufficient and aging cold chain equipment. Surveillance system for routine immunization is not performing optimally with most performance indicators not frequently monitored , AEFI guidelines are not yet fully implemented, and there is poor waste management (burning/burying of used syringes/needles in safety boxes) at many health facilities. In addition, significant communications challenges exist including fatwas given by certain extremist religious groups, misconceptions within the communities about vaccines, questions raised about the quality of vaccines made in certain countries and poor understanding of importance of immunization among the public and private health providers. All these factors contribute to less than optimal utilization of immunization services needing immediate addressal. Financial sustainability of the cMYP Significant progress has been made in recent years towards financial sustainability, particularly as regards government funding of vaccine and injection supplies, within the commitment to maintain and increase allocations to health care. There are many dedicated health staff, in general well provided with the right equipment, supplies and guidelines needed to do the job.
The estimated resource requirements for the cMYP (2014-2018) is $$453,715,927 million out of which more than half is need designated for service delivery component. The total resource requirement without shared cost amount to $386.737 million (and $227.911 million is for routine immunization only) out of which $66.794 million is supposed to be covered by the Provincial Government. The funding gap (with secured funds only) amounts to about $220.061 million, which is approximately 57% of the total resource requirement. The sustainability of immunization system is closely linked with resource allocation from the government health expenditures. The current financial projections indicate that the cost per DTP3 child will rise from US$43 in 2012 to US$78 in 2018. The government will continue its funding for immunization system. However, the resource requirement for immunization program as percentage of the government health expenditure will increase from nearly 32.78% in 2012 to 49.64% in 2018. 9 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa However, due to increased revenue transfers from the federal government’s payment of arrears of hydel power profits and additional resources from new NFC Award has sharply raised the provinces’ share of federal revenue. KP’s total revenue, which had been hovering around 7-8 percent of Provincial Gross Domestic Product (PGDP), increased to 8.7 percent in fiscal 2010 and 11.3 percent in 2011. As a consequence government of Khyber Pakhtunkhwa after the 9 NFC Award and share of Hydel profits has increased fiscal space and over the past few years has also increased spending on the development sector as a whole and health more specifically. It is pertinent to highlight that immunization is primarily funded by the government health expenditure. The contribution from out-of-pocket expenditure is mainly in the form of opportunity costs. Therefore, the resource requirement for routine and campaign immunization is more likely to be met through the Government Health budgets. It is highly likely that with the current financial situation and increased fiscal space, Khyber Pakhtunkhwa government will be able to bear this cost.
10 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 1. Situational Analysis 1. Background information (<3 pages)
Khyber Pakhtunkhwa (KP) is among the least developed and crisis prone province in Pakistan. KP province accounts for 10 percent area of Pakistan with 13 percent of population residing in seven administrative divisions. About 69 percent of population lives in the rural areas, above national average size of 4.8 members per household compared to national average of 3.8, low literacy rate of 49 percent, less than 50 percent of population is having access to tap water connections, and high unemployment rates of 8.5 percent6. Its relative underperformance is due to low levels of growth, socio-economic development and absence of public services in comparison to other provinces of Pakistan. This province is also affected by geo-political developments (militancy) and devastations of mother-nature (earthquake 2005 and floods 2010); all calling for continued scaling-up of public interventions and investment to not only improve quality of life but, also, unlock economic potentials.
Figure : Map of Khyber Pakhtunkhwa
1. Administrative and political structure The Khyber Pakhtunkhwa, one of the four provinces of Pakistan has four administrative sub- regions– Hazara, Malakand, Central and Southern––that together contain 25 districts. The population of districts ranges from 0.2 million to above 2 million (average of 0.7 million) with Thorghar and Peshawar being smallest and largest in terms of population respectively. Each district is having three layered administrative structure i.e. District, Tehsil and Union Council.
Figure : Administrative break up and Average population size per Unit Administrative Unit Number Average size of Population Districts 25 700,0007 Tehsils 72 350,000 Union Councils 1040 25,000
The province has a Provincial Assembly with 124 elected members which elect the Chief Minister of the Province who forms a Cabinet of Ministers to look after various Departments. The Chief Minister is the Chief Executive of the
6 www.Worldbank.org 7 smallest 200,000 and largest 2 million 11 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Province. In addition, Governor is appointed by the federal government as head of the Provincial Government. The bureaucratic machinery of the province is headed by a Chief Secretary, who coordinates and supervises functions of various Departments headed by Departmental Secretaries. All the Secretaries are assisted by Additional Secretaries, Deputy Secretaries, Section Officers and other support staff. Additionally, a Department may have other attached divisions and autonomous or semi-autonomous bodies to look after various functions.
The district is under the administrative control of Deputy Commissioner, who is responsible for all functions other than health and education. The health is managed by District Health Officer and his team directly reporting to Director General Health Services at the provincial level. 2. Landscape and climate The landscape of Khyber Pakhtunkhwa is composed of green plains, hilly areas and rugged mountain ranges. Khyber Pakhtunkhwa extends from the Hindu Kush mountains and Afghanistan in the north through the Indus-watered hills down to southern district bordering Balochistan. Geographically the province is divided into two zones: the northern zone which is cold and snowy and the southern one is arid with hot summers and relatively cold winters and scanty rainfall. The climate varies immensely for a region of its size, encompassing most of the many climate types found in Pakistan from the coldest to driest and hot. The climate has major implication for immunization program relates to continuous supply of electricity needed for maintenance of cold storage facilities both in southern and central regions, which is directly affected by lack of regular electricity supplies. Further, access is a major challenge in hilly areas especially during extremes of weather when parts of the province are cut off from the mainland due to heavy snowfall or rains.
The road transport network is important for access to health facilities and in particular for emergencies. 44% of the provincial roads and 78% of district roads are in poor or bad condition.8 The road network is old and in dire need of repair. In addition, the ongoing conflict in many districts has further resulted in damage or destruction of road infrastructure. Agriculture is key livelihood of the population with approximately 5592.63009 acres being used for cultivation. 3. Demographic According to the 1998 census, the population of the province was approximately 17 million i.e. 11% of country’s population. The density of population is 187 per km² and the intercensal change of population is of about 30%. However as per the revised estimates by Provincial Bureau of Statistics the province contributes 13 percent (26.92 million)10 to Pakistan population. With a young population base (one-quarter of the population are below age 15 yrs), the population is growing annually at the rate of (2.75%) and has the highest fertility rate (4.8)11, among the provinces. The province has four administrative sub-regions–Hazara, Malakand, Central and Southern––that together contain 25 districts with Malakand and Southern regions more under developed than other regions. Unskilled labor force mainly working in agriculture is the largest
8 Government of Khyber Pakhtunkhwa ‘Comprehensive Development Strategy, 2010-2017 9 http://www.khyberpakhtunkhwa.gov.pk/Departments/BOS/KP-in-Fingures.php 10 Table 270 – Provincial Bureau of Statistics Report 2013 11 PDHS 2012-13 12 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa employing sector. The province has a fast growing urban population with 69 percent residing in rural areas while 31 percent are urban. The fast growing population in the province has implications for immunization programme both in terms of human and financial resources. At the current population growth pace, in order to meet service demands, the province will need to allocate more funds for service delivery such as establishment of additional facilities, appointment of skilled staff for the new facilities, up gradation and expansion of cold chain etc. if desired targets are to be achieved. The detail of the population distribution as per 2012 baseline for the next five years is given in figure 2;
Figure : Population Statistics (baseline) 2012 Population Categories Year 2012 2014 2015 2016 2017 2018 Population 25,929,799 27,375,547 28,128,375 28,901,905 29,696,708 30,513,367 Rural (69%) 17,891,561 18,889,127 19,408,579 19,942,314 20,409,728 21,054,223 Urban (31%) 8,038,238 8,486,419 8,719,796 8,960,520 9,205,979 9,459,144 Live birth (3.5% of population) 907,543 958,144 984,493 1,011,567 1,039,385 1,067,968 Surviving infant (92.3% of LB) 854,905 905,446 932,315 959,977 988,455 1,017,773 Pregnant women (1.02 as a factor of birth) 925,694 977,307 1,004,183 1,031,798 1,060,172 1,089,327 Child Bearing Age Women 5,704,556 6,022,620 6,188,242 6,358,419 6,533,276 6,712,941 Source: Provincial Bureau of Statistics, Khyber Pakhtunkhwa During military operations against militants between April and mid-July 2009, around 2.7 million civilians fled as a result of generalized violence. As the operations by Pakistan military succeeded and increasingly more areas were cleared of insurgents, the IDPs started returning to their homes. By the end of 2009 more than 1.6 million people (237,000 families) who had been living in camps and host communities had returned to their places of origin in Swat and Buner. More recently operations were launched in Waziristan area causing further displacement from the Agency. It is estimated that over 260,000 people (37,000 families) had been displaced (registered and verified) from Waziristan mainly to DI Khan and Tank. For over three years, Kurram Agency has faced security related problems and a large number of families have moved as IDPs to Kohat, Hangu and Peshawar districts. The recent military operation in Orakzai Agency has also resulted in IDPs moving to Kohat, Hangu and Peshawar districts. The situation raises many challenges for the health department in delivery of health services especially immunization of women and children, since many do not possess record of previous vaccination. The government does have a mechanism of birth and death registry for maintaining vital statistics at the Union Council level. The data collected is collated and shared with district and provincial authorities. The birth registration is not mandatory and not practiced by everyone. However, the practice has improved due to requirement of birth certificate for issuance of Form-B by NADRA (National Database and Registration Authority) and for registration and admission in school. However, as yet performance is not satisfactory and optimal since still many people do not get their children registered especially females owing to traditional and cultural practices. 4. Social and political context Bordering Afghanistan, KP’s social and political landscape was significantly affected by regional conflict with large influx of refugees during 1980 and 1990. During the last 3 years, there has been increasing incidents of insurgency during which militants stepped up their activities in KP. Security personnel and their families, teachers and medical personnel were attacked, schools
13 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa destroyed (especially girls’ schools) and polio vaccination campaigns prevented to mention few. The security situation triggered movement of large population with around 2.7 million civilians fleeing generalized violence for safer places. The violence has also caused damages to health infrastructure in addition to population displacement. Overall the damages have been reported in approximately 29% of the total health facilities in the province; while maximum damage has been reported from Malakand.
1. Poverty Poverty is not just visualized as a kind of deprivation but also a form of vulnerability which refers to the risk of prevalence of poverty amidst internal and external macroeconomic shocks. Poor are not simply those who are below the prescribed threshold of income and consumption but also confronting a more constrained and difficult environment within which economic and social choices are to be opted with health and education being at the bottom of the list. Khyber Pakhtunkhwa is the third largest economy with forestry and mining being the main sectors for employment followed by agriculture. The high dependency ratio also signifies that average number of earners per household is smallest compared to other provinces. The dependency ratio in Khyber Pakhtunkhwa is around 100; for every independent person there is one dependent person. The national average is 88.3.12 While the districts of Haripur, Peshawar and Nowshera in Khyber Pakhtunkhwa are comparatively better off, the Districts of Kohistan, Shangla and Karak have very low levels of economic development. The proportion of the population living below the poverty line has declined significantly; to 17 percent in 2008 from 41 percent 10 years earlier, mainly due to the inflow of remittance from overseas workers (more recent data is not available). Poverty is highest in Shangla/ Upper Dir and is also high in Buner, Kohistan and Battagram In these areas landholding is small resulting in limited agriculture, self-employment or share-cropping and because of which job opportunities are negligible.13 Locational disadvantage, fallout from international tensions, insufficient investment in human and physical capital, and a policy environment that compounds, rather than alleviates, ill-effects of these deficiencies have conspired to bring KP to its current economic plight. Average monthly income in the province, at Rs: 7,709, is the lowest of all four provinces––10 percent lower than the national average and 18 percent lower than Balochistan (Figure 3). In the given situation, it is no surprise to find poverty being widespread in KP, especially in the rural areas.
Figure : Average monthly income by province and income quintile 2005/06 2007/08 2010/11 1st 2nd 3rd 4th 5th Punjab 5,596
12 Federal Bureau of Statistics, “Household Integrated Economic Survey 2005 – 06,” Government of Pakistan Statistics Division, Islamabad: 2007 13 Iftikhar A. Cheema, “A Profile of Poverty in Pakistan,” Center for Research on Poverty Reduction and Income Distribution, Planning Commission, Islamabad: 2005 14 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 6,623 8,541 8.4 10.6 14.2 20.8 46.0 Sindh 5,909 7,310 8,746 8.8 13.3 15.3 21.2 41.5 Khyber Pakhtunkhwa 4,949 6,146 7,709 11.4 16.8 19.6 24.1 28.1 Balochistan 4,938 6,441 9,439 8.8 20.4 24.3 25.4 21.1 Pakistan 5,578 6,740 8,540 8.8 12.3 15.5 21.4 42.0 Share of Income Quintiles in Household Income (2010/11) Average Monthly Household Income (Rs)
Source: Pakistan Bureau of Statistics, ‘Pakistan Integrated Economic Surveys’, various issues.
Poverty is one of the major determinants for low access to and utilization of health services. In addition, the poor economic status of the province has a definite implication on planning and allocation of resources for health services including immunization.
2. Education
With approximately half of the population illiterate the province lags behinds in education outcomes in Pakistan. The 10+literacy rate in Khyber Pakhtunkhwa is 50 percent, 7 percent less than the national average. The gap is even starker for female literacy, estimated at 31 percent, compared to national average 15 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa of 45 percent. The overall literacy rate in the Province has risen by 16 percent during the last 12 years making an improvement of 1.33% per annum. Women are considered to be disadvantaged in KPK with low levels of access to education. Despite an increase in the number of girls going to school, the school attendance is still much lower for girls than boys.
Khyber Pakhtunkhwa has 32,276 schools in which 24,719 are Primary, out of which 7858 are for girls and 2010 are co-education, 4504 are Middle schools in which 1043 are for girls and 1781 are co- education, 3161 are High schools in which 565 are for girls and 1190 are co-education schools and there are 624 Higher secondary schools in which 134 are for girls and 223 are co-education. The share of various sub-sectors is as follows: primary – 76.6%; Middle – 13.9%; Secondary – 9.8% and higher secondary – 1.9%. There are 4.826 million children at these various levels of education with bulk (58.97%) going to primary. Gender and regional disparity is evident in enrolment patterns. Urban net enrolment was 61 percent in 2008/09, compared to 50 percent for rural net enrolment. Female net enrolment was only 45 percent in 2008/09, compared to 56 percent for males. There are considerable variations in the Net Enrolment Rate (NER) within the province, much as there were for the literacy rates; in fact the trend for each district follows a very similar pattern as that of the literacy rate. Within districts, the highest overall NER was in Abbottabad (68 percent) and the lowest in Kohistan (37 percent). The lowest NER in the dataset was for rural females in Kohistan, estimated at 11 percent14.
3. Culture and traditions The province has diverse ethnic population including the largest ethnic group of Pashtuns, while other major ethnic groups include most notably the Hindkowans, Dards, Chitralis (who include the Kalasha) and Gujjars. In addition, it has large population of Afghan refugees majority of which are Pashtuns. The Pashtuns tribes are multiple and vary minutely in culture and traditions. The population subgroups also include non-Pashtun tribes: Dardic ethnic groups in Kohistan and Baloch tribe in the south. Most of the inhabitants of Khyber Pakhtunkhwa are Muslims, with a Sunni majority and significant minorities of Shias with very small communities of Animist/Shamanist and Hindus and Sikhs. Pushto, hindko and sariaki are the most commonly spoken languages with Persian, Sheena being minor ones. The official language is English, while urdu is generally well understood all across the province. Other languages which are written include Persian and Pashto. Gender is not a determining factor when it comes to routine immunizations as no significant statistical differential between males and females is observed, while, significant differentials are evident in education levels and access to health services and employment. Employment rates for women are low and representation in government and senior decision-making positions is very limited. Most women are economically dependent and carry out most of the household work. The traditional roles of women have changed little in the last decades and there are serious concerns about violence against women.
The restrictions on women mobility have direct implications on utilization of health services including immunization. The situation is further compounded by prevalent social and cultural norms which impose further restrictions on females. Being a patriarchal society, women’s role in family and its decision making process is considered to be secondary, a situation having direct
14 UNESCO Annual Education Sector Report 2011 16 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa bearing on the health care seeking behaviour of women and the authority to seek care for themselves and their children including immunization.
4. Security Issues The province has been in political and social crisis since almost a decade. As a result of which large populations from militancy and security affected areas has been displaced (IDPs estimated to number 2.3 million). Over the last 6 years, there has been an insurgency during which militants stepped up their activities in Khyber Pakhtunkhwa and FATA. Security personnel and their families, teachers and medical personnel were attacked, schools destroyed (especially girls’ schools), vaccination campaigns prevented, NGOs and journalists threatened and male children forced into the ranks of the militants. The government started an active campaign to curb the militancy in mid 2008 and 2009, military operations were launched on several fronts, including in Lower Dir, Buner and Swat Districts, leading to a sudden and massive movement of people to safer areas of the Province, in particular to the low-lying districts of the Peshawar valley (Peshawar, Mardan, Swabi, Charsadda, and Nowshera Districts).
Health conditions tend to deteriorate further as the security conditions remain unstable and the GoKP finds itself unable to reach fleeing tribal households thus making targeting for vaccination and other preventable actions more difficult. This situation has created many challenges for the provincial authorities especially those providing health services. As a result, preventable diseases such as polio had emerged in the Province thereby causing, for example, the incidence of polio to grow at its highest levels in many years. 5. Public expenditure management The 1973 Constitution (as amended) provides the overarching legislative framework for public financial management in Pakistan. A separate law for public finance is not yet in place. The Constitutional provisions, however, are relatively detailed and provide a basic enabling operational basis for public finance management of the Federation. The Constitution is supported by extensive General Financial Rules and Rules of Business. The annual budget appropriation law, prepared consistently with the Constitution and the financial regulatory framework, provides the legal basis for spending over the financial year, which is from July 1 to June 30 each year. An annual Finance Act covers the raising of public revenues in pursuance of the annual budget. KP province adopted a comprehensive fiscal reform program in fiscal 2001/02 based on four pillar namely to enhance resources; strengthen ex-ante and ex-post PFM reforms, decentralization and accountability and the results and positive. The reforms have focused on the following four key areas of public finances: (i) enhancing revenue; (ii) reprioritizing expenditures and improving expenditure management; (iii) improving budget preparation, execution, and oversight; and, (iv) strengthening the bounds of fiscal decentralization. During last few years reforms process has accelerated as government is displaying strong ownership of reform process. Some of the more recent initiatives are “The Integrated Public Financial Management Reforms Strategy”, Medium Term Budgetary Framework (MTBF) & Output Based Budgeting” and Districts Output Based Budgeting & Introduction of Conditional Grants” to name few. The historical incremental budgeting process is widely used in the public sector across Pakistan including KP. The Planning and Development and Finance departments are responsible for development and approval of provincial budgets. It is a simple, easy process based on cash accounting, and offers control orientation. Budgets are prepared by the sectoral ministries using historical budget information, and within the new revenue constraints put forward by the Ministry of Finance (for current budgets) and the Planning Commission (for development budgets). Current and development budgets are not linked in preparation discussions or in execution. The next year’s 17 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa current budgets would most probably include the previous year’s current budget (not actual spending) and the supplementary appropriations, and add to it inflationary adjustments. It usually therefore not accurately reflect actual needs. Recently, however, the KP Department of Health (DOH) has begun to experiment with output-based budgeting (OBB) and performance-based budgeting pilots and expects to scale up the use in due course.
Budget allocation is guided by incremental policy and is not tied to outputs. Incremental budget policy guides budget allocation; which lowers incentive to perform, limits freedom to move funds across performing activities, and reinforces artificial bifurcation of current and development expenditure. KP uses the process of line-item (also known as historical or incremental) budgeting, which means that the budgets do not necessarily reflect needs. The complete budget cycle is described in the table below.
Figure : Budget cycle and Development Calendar Date Activity July 1st Start of financial year July 10 Receipt of Annual Review Progress Reports from Line Departments along with details of lapses/excess of funds July end Sectoral annual review of ADP August start Joint Annual Review of ADP of previous year with Chief Minister/Governor September mid Circulation of proformae for 1st quarter review of ADP progress October mid Sectoral review 1st quarter November start Joint review November End Call letters to Line Department for Next year ADP schemes December start Submission of schemes to Finance Department for transfer to recurrent budget December end Submission of foreign aid revised estimates January start Approval of unapproved new schemes January mid Progress reports for mid-year review of ADP January mid Receipt of proposals for next year ADP from departments January end Tentative sectoral sizes of ADP endorsed to departments -do- Mid-year sectoral review February start Joint mid-year review February mid Priorities Committee Meetings March Finalization of ADP and submission to federal government Revision of schemes from PDWP April Incorporation of schemes/modifications in ADP 3rd quarter review Re-appropriations May Revised estimates for Finance Department for incorporation in Budget Final ADP draft APCC meeting in Federal Government for ADP approval June NEC meeting and final ADP Public sector health spending as a share of total government spending has more or less remained at around 8 percent for the past five years with current expenditure share in total health spending declining. Provincial health spending is more towards capital and ‘transfer payments’ while district health expenditure is more towards remuneration and maintenance. With lack of tied relationship between current and capital expenditure, channeling public expenditure to outputs is much more a challenge, if outcomes are to be achieved.
There is a regular budget monitoring system in place. Periodic reviews are undertaken on quarterly basis by both Planning and Development and Finance departments and necessary actions taken for non-utilization of funds and for re-appropriation or budget cuts.
Figure : Details of budgetary allocations and expenditures of the Health Department/KP Year Original Budget Final Grant Expenditure 2009-10 8,499,528,227 8,823,668,237 3,708,284,257
18 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 2010-11 6,541,779,500 6,589,825,500 4,695,187,835 2011-12 6,500,737,024 6,777,479,428 6,134,684,894 2012-13 7,136,014,123 7,144,290,701 5,039,079,649 Line-item or historical budgeting does not allow easy accounting for changes in activity, as funds are not fungible. The budgets are monitored under the following object classifications: (a) employee-related expenses, (b) operations and maintenance, (c) grants, subsidies and transfer payments, and (d) physical assets/civil works. Each of these line items is further separated under the following functional classifications: (i) hospitals and clinics, (ii) MCH program, (iii) laboratory and drugs, university-related expenses, and (iv) administration. If a particular item in the budget is under-spent, the sectoral ministries cannot easily transfer the unspent funds to other budgeted line items. Capital investment funds cannot be transferred to recurrent budgets, and remuneration funds cannot be transferred to any other line item. However, unused resources don’t seem to be lost due to option of supplementary appropriations for the overspending within the current budget line items. Adoption of Global budgeting i.e. output based budgeting could be one way to improve the efficiency and transparency of budget use. 2. Health Sector Analysis The health outcomes in KP present a challenging picture showing improvements slowly over the years. The inter-district inequities in service provision and slow progress in improving health status of the poor is a key challenge for the province. Many other factors are also responsible for this situation including; staff absenteeism, frequent transfers, poorly managed health infrastructure plagued by lack of equipment, medicines and other essential supplies in most of the health facilities. The frequent and continuous emergencies and natural disasters faced by the province over the past few years also have had a negative impact on health care provision, a situation further precipitated by gradually increasing security related incidents. Additionally, access to general health services and overall wellbeing of individuals has also been highly compromised due to large scale internal displacement of populations resulting both from floods and ongoing armed conflict in the current decade. Lack of qualified personnel especially female health staff too has adversely affected service provision. Although public sector is still used by a larger majority of population, but increasingly private sector preference is on the rise. All the above is contributing to slow progress in achieving Millennium Development Goals (MDGs) contrary to the satisfaction of local, provincial, national and international stakeholders. High infant mortality rate of 76 per thousand live births and high maternal mortality 275/100,000 live births15, percentage of fully immunized children at 53% 16, slowly improving intermediate health indicators including low levels of births attended by Skilled Birth Attendants (SBAs) at 48.3%7, less than the national coverage of lady health worker coverage at 58%17 and lack of availability of credible district level data on important indicators are some of the issues plaguing the HD and a key hurdle in achieving the desired targets defined under MDGs.
15 6 PDHS 2006-7 16 PDHS2012-13 8 Fourth Evaluation of the Lady Health Workers Programme 2011 17
19 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 1. Governance The governance structure of the health department can be divided into three levels namely provincial, district and Union Council. At the provincial level, Minister of Health is the political in charge of the Health Department, KP. While Secretary being the administrative head and Principal Accounting Officer is responsible for policy and planning functions of the department. The Director General Health Services reports to the Secretary Health and is overall responsible for technical aspects of the department and implementation including vertical programmes. The organogram of the health department is at fig 6.
20 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Figure : Organogram of Health Department,KP
21 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Mi nis ter forHe altHe alth H H D H P M M 4 Seh e l e e S G cr a a & d A a R H et l n i u t n E c t l U S ar h i a o t y n C l n P S F g e E o h o t o l d m l r u C l u o i u n e c u R d l a s e c c a l t y t t i H g u i o o u R r o n s n p l e e i a f s t o a t r u l s o m n r , d y h e e r a A l D u t i t h s h t o s r y i r s c i t t t e y m G * o s v t t M r g e m n t g , P t o h l e i n c i y n g & & D e v D e o l n o o p r m s e n C t ( o Q o M r d & i 22 n C a o t o i Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa *Autonomous Body
Under the current system, the Health Secretariat directly looks after the Provincial Health Services Academy (PHSA), Nursing Schools and Medical Colleges, all regulatory and quality related matters, the Health Sector Reform Unit, Planning Cell, and M&E Unit. The Directorate General Health Services (DGHS) is responsible for all other health services including vertical programmes i.e. EPI, maternal, neonatal and child health (MNCH), Reproductive Health (RH), other public health and preventative health programmes, and all administrative functions including human resource, schools of Nursing and Drug Control. The overall provincial arrangement has been provided in Figure 6. The current structure of the HD is deficient and there is a lack of appropriate regulatory and governance structures at the provincial level to carry out the required stewardship functions. As a result, the provincial setup provides inadequate emphasis on its stewardship role including monitoring and evaluation of sector performance as well as providing technical support to the districts. The emphasis on vertical health interventions such as Polio, over the years has to some extent compromised the overall health care delivery services. The situation has further been affected by lack of coordination among various vertical health programmes and duplication of interventions. In addition, the involvement of health providers in special and accelerated disease control initiatives has further compromised delivery of routine services including immunization. All these combined together has resulted in poor overall performance of the health department. Health delivery system in KP, if managed optimally, has the expanse and organizational reach to achieve much better results. Weak management remains a key concern at all levels. Governance and management of health system has three levels in the province; i.e., provincial health department, directorate, and district health offices. Although, these organizational structures are in place, mechanisms and processes to connect policy and planning goals with organizational mandates and performance are less than adequate. Both at individual and institutional level, non- transparent performance evaluation and lack of accountability has resulted in sub-optimal performance by levels. In general, stewardship and regulatory functions of the health department are weak and lack clear standards, and measurement instruments. The public and private health sectors do not work within a regulatory framework. KP Health Regulatory Authority, though operational and has only just recently started registering health facilities in the private sector. In order to strengthen the health sector, the Authority needs to be restructured and revitalized to play significant role in regulation of healthcare institutions and professionals in the near future. At all levels of the health sector in KP, problems are indicative of an over-centralized system that over time has diluted initiative at lower levels leading to de-motivation and lack of performance. KP government has made efforts in last two decades to improve management through steps such as granting autonomy to those teaching hospitals that showed less than desired results. Recent efforts include introduction of output based budgeting, introduction of results framework for monitoring and integration of vertical health programs of MCH, LHW Nutrition and immunization under integrated management. All these initiatives are recent and in early stages of implementation with results yet to be discerned. Moreover, the persisting poor health outcomes are indicative of poor management practices across health sector. Following 18th Amendment to the Constitution, the larger provincial role in health demands a re-evaluation of organisational structure, capacities at governance and management
23 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa levels. Further there is a need to consider provision of decision-making autonomy, both administrative and technical to the districts. The fate of local governments at the provincial level has been redefined following recent elections and repeal of the LGO 2000. The law related to local government outline roles and responsibility and administrative and financial powers at local level has been redefined. In the context of health, the role of Director General Health Services has been revived as per the following;
Khyber Pukhtunkhwa Local Government Act 2012 Following are the health related decision in pursuance of the above said ordinance;
The district set of government departments will stand segregated from local government institutions established under the Khyber Pukhtunkhwa Local Government Ordinance 2001 and shall re align with their administrative departments at provincial level under the new Act, The position of EDO at district level shall stand abolished, Health Department at district level shall be reorganized under the District Health Officers (DHOs) assisted by the Deputy District Health Officers (DDHOs) and Coordinators reporting to the Director General Health Services. In addition to the provincial level, the district plays a key role in service delivery to the population at large and in meeting health targets. The district level set up is critical to service delivery and serves as the backbone for the health systems. The district level setup for category “A” districts (Fig- 7) is given in the organogram below;
24 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Figure : District Health Set up - Category “A” District
25 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa D H O
M D e e d p i c u a t l y P C C S C C D D M r o o u o D o r i N i o o p o H o u s C O t H m r r e r ) r g r a d d r d d i C r i i i i i C c o o y n n t n n F t o o n T a a e a a t r C t t n t t o B d r d a o o d o o r o i C e r r e r r & l n E L n P l o o a F P H t u H S e I W b M r r t a D a o c l I n d H i S r i Q i i c t l n i H a a t H e r o a t i y o s l e r s p t I h i n t s a p l e c t o r
26 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa In order to improve the quality of services, at the primary health care level, the health facilities has been contracted out to KPH (Khyber Pakhtunkhwa primary Health), previously known as PPHI. The setup is responsible for delivering curative and preventive health services through an agreed package of services. The initiative is to promote public private partnership using transparent competitive procurement mechanism. The districts in the Malakand Division, an area which is underdeveloped and affected badly by militancy, an international NGO Save the Children is providing services in a manner similar to the KPH model. Health Department Khyber Pakhtunkhwa is implementing output/performance based funding model of service delivery focusing on increasing routine immunization, TT+2 and ANC coverage through district conditional grants supported by DFID and EU in six under developed districts. These partnership and coordination mechanisms are contributing towards not only enhancing coverage but also improving quality of care for better health outcomes. The hallmark of these conditional grants implementation is closer collaboration between immunization, MNCH and LHW Programme. In addition, a third party monitoring firm has been hired to ensure timely implementation of planned activities for achievements of targets. 2. Health workforce A skilled and competent workforce is central to delivering quality healthcare and vital for functioning of the health system i.e. planning, designing to implementation. WHO estimates that countries with fewer than 23 health care professionals (counting only physicians, nurses and midwives) per 10,000 population are unlikely to achieve adequate coverage rates. For Pakistan, WHO estimates 8 physicians, 4 nursing and midwifery personnel per 10,000 populations i.e., a total of 12 health worker in these categories18 , a situation that is less than half of what is needed to achieve the desired outcomes.
The health department has never undertaken any HR need assessment and nor developed a HR policy. Owing to lack of proper planning there is no mechanism for forecasting the needed skilled staff at various levels. Since, human resource development is a key area under the Health Sector Strategy 2010-17 and within this context, Health Sector Reform Unit in Khyber Pakhtunkhwa is currently in the process of designing a comprehensive HR policy to improve the management of its health workforce and align with the health needs of the province. In addition, it is also in process of discussion and consultations for restructuring the health department and developing an HR master plan, with workforce projections for the next ten years. In addition, the health department lacks a proper inventory of sanctioned and project posts at various levels. Historically, KP has had most facilities manned with trained manpower, however, in recent past due to security concerns the situation is not the same anymore and a brain drain of skilled professionals has been observed. Many staff has either left or got themselves posted to facilities located in safer areas especially females. In addition, lack of service structure and incentives are other reasons for health professionals opting for private sector, NGOs or international agencies.
Figure : Staff Strength of Health Department, Khyber Pakhtunkhwa Total Population as of 2012 baseline: 25,929,799 Population per doctor 5075 Employed with health department* Sr. No Cadre Number 1. Teaching 892
18 World Health Statistics 2010 27 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 2. District Specialists 355 3. Medical Officers 3649 4. Dental Surgeons 213 5. Nurses 3066 6. Lady Health Visitors 918 7. Technicians 1827 8. EPI Workers 1520 9. Dispensers 1381 10. Lady Health Workers 13007 11. Lady Health Supervisor 486 12. Drug inspector 25 13. Pharmacists 20 14. Drug Analysts 6 15. Others 2823 Total 30188 Source: www.healthdepartmentkhyberpakhtunkhwa.gov.pk In resource constraint settings it is important to assess and train currently available health providers in service provision for improving both coverage and quality of care. The health department provides various opportunities to the health professionals for improving their skills through various capacity building initiatives. The vertical health programmes including immunization are further facilitated by the UN Agencies and other development partners in improving their capacities by arranging training programme in management, surveillance, M&E, immunization, health information systems etc.
There are a number of institutions in the province that are providing the necessary skilled workforce for delivering health services including doctors, nurses, paramedics, technicians etc. the qualified professionals are registered and licensed by professional entities such as PMDC, PNC, Paramedic Association etc. these regulatory bodies ensure that the professionals possess the necessary skills and are trained from a reputable registered institution using standardized curriculum and by a qualified professionals.
The challenges related to Human Resources for Health (HRH) in KP include: absence of HR policy; weak HRH management system; non-regulated private sector primarily concentrated in urban areas; and health information systems not inclusive of HRH. In addition, health department is faced with shortage of doctors and nurses, staff absenteeism, dearth of female staff etc. especially in the peripheral health facilities. According to Health Department statistics (public sector) following are the key health delivery staff per 10,000 population ratios;
Figure : Health professionals per population (10,000): doctors (PHC), nurses, LHVs, LHWs Category of Health Provider Ratio per 10,000 population Doctors 2.0 Nurses 1.2 LHV .04 LHWs 4.9 Source: Health Department, KP Immunization programme in KP is headed by Deputy Director EPI/provincial programme manager reporting to the DGHS through Director Health. The provincial EPI section has sanctioned strength of 328 staff members and 201 filled positions are as shown in Figure 10. Some staff of provincial EPI section is on the recurrent budget such as Deputy and Assistant Directors, while remaining are programme posts funded through development budget under provincial government, GAVI and JICA financing. In addition to 1665 vaccinator positions under regular budget, there are additional 237 posts under the aforementioned development projects funded
28 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa through JICA and GAVI. The recruitment process is in progress for the remaining position. The district level staff is all on the recurrent budget except District Epidemiologists, who are funded through JICA support.
Figure : Staffing position EPI Programme (as per PC-1s) - Khyber Pakhtunkhwa Position Total Filled Vacant Dy. Director EPI (BPS 19) 1 1 0 Assistant Director EPI (BPS 17/18) 7 7 0 Provincial Epidemiologist (BPS 18) 1 0 1 District Epidemiologist (BPS 17) 25 10 15 Finance Manager (BPS 17) 1 1 0 Procurement Officer ((BPS 17) 1 0 1 Store Officer (BPS 16) 1 1 0 Health Education Officer (BPS 16) 1 0 1 Electrical Engineer (Cold Chain) (BPS 16) 1 1 0 Monitoring Coordinator (BPS 16) 1 1 0 District Monitoring Coordinators (BPS 16) 2 0 2 Data Analyst (BPS 16) 1 1 0 Program Analyst (BPS 16) 1 1 0 Office Superintendent (BPS 16) 1 0 1 Network Administrator (BPS 16) 1 0 1 DSV (BPS 16) for Ghar 1 0 1 DSO (BPS 16) for Ghar 1 0 1 Computer Supervisor (BPS 14) 2 0 2 Computer Operator (BPS 12) 2 1 1 Accountant (BPS 14) 1 0 1 Vaccinators (BPS 6) 235 157 73 Junior Clerk (BPS 7) 1 0 1 Drivers (BPS 4) 20 12 8 Naib qasid (BPS 2) 4 2 2 Chowkidar/security guard (BPS 2) 2 2 0 Cold Chain Technician (BPS 5/6) 8 3 5 Cold Chain Operator (BPS 5) 1 0 1 Plumber (BPS 4) 1 0 1 Other support staff (BPS 2) 3 0 3 Total 328 201 122 A key challenge for the workforce is lack of service structure and rules. The recruitment of the regular employees is through the Provincial Public Service Commission (PPSC), wherein the process is long and time consuming. While the vacancies under the development projects (vertical programmes), are filled through DPC (Departmental Selection Committee) chaired by the Secretary Health. These positions are for project duration and salary structure is as per the provincial government project policy document. The recruitment many a time is politically influenced, where merit takes a back seat because of political interference, influences. There is high staff turnover on project based positions due to uncertainty related to renewal of posts. 3. Finance Over the last two years, provincial finances have markedly improved. This is due mainly to increased revenue transfers from the federal government through the payment of arrears from hydel power profits and the new NFC Award. This sharply raised the provinces’ share of federal
29 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa revenue. KP’s total revenue, which had been hovering around 7-8 percent of Provincial Gross Domestic Product (PGDP), increased to 8.7 percent in fiscal 2010 and 11.3 percent in 201119. Fiscal deficit is on decline and was less than one percent of provincial GDP in 2010/11 and province continues to maintain a revenue surplus balance. Increased fiscal space funds an increase in development expenditure. A 3.5 percent of provincial GDP increase in fiscal space during the five year period (2006/07 to FY 2010/11) compared to earlier part of decade (FY 2001/02 to FY 2005/06) is reported. Three channels – federal transfer, revenue collection and savings from spending efficiency – have contributed to fiscal space expansion. This prompted the provincial government to increase its expenditure, with sharp increases in both current and development spending with later gaining the most. Public sector contributes only quarter of total health expenditure. Public sector contribution to total health sector expenditure has increased to 25 percent from 18 percent in FY 2008. Major non-state actors are private sector, households, and local NGOs at the community level. An implicit policy statement that health sector in the country is to some extent privatized given the share of non-state actors’ role in health financing. Provincial government funds capital expenditure while district governments fund operating expenses. Most regional hospitals, universities, and training institutions receive granted funds from provincial government while local government health expenditure is towards remuneration and operating health expenditures.
A brief overview of the General Government Health Expenditure (GGHE) by GoKP, during the last four years is given below in Figure .
Figure : Budget and Expenditures by the Health Department Development Data Year Original Budget Final Grant Expenditure 2009 -10 8,499,528,227 8,823,668,237 3,708,284,257 2010 -11 6,541,779,500 6,589,825,500 4,695,187,835 2011 - 12 6,500,737,024 6,777,479,428 6,134,684,894 2012 - 13 7,136,014,123 7,144,290,701 5,039,079,649
The Immunization programme primarily was funded by the Federal government, while the provincial government met the costs related to human resource and service delivery. However, following devolution as a result of 18th Amendment, the provincial share was transferred to the provinces. The province in order to utilize the federal share developed PC-1. In addition to resources from the federal share, the province has additional resources from JICA and GAVI. These are being implemented as projects through approved PC1s for each. The budget situation of the Provincial EPI programme for the last four years is given below:
Figure : Budget EPI Programme (as per PC-1s) - Khyber Pakhtunkhwa Year Recurrent Budget Development Total Budget 2010-11 Data not available 12,000,000 12,000,000 2011-12 Data not available 12,000,000 12,000,000 2012-13 Data not available 6,419,000 6,419,000 2013-14 384,171,910 26,235,000 410,406,910
19 Finance Deptt. KP and World Bank joint expenditure review 30 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa It is worthwhile to note that the programme faced serious budgetary constraints during the three years following devolution; however, the situation is much improved since FY 2013-14 4. Medical products and Technology Most public sector hospitals and healthcare facilities in KP suffer from frequent stock-outs of essential drugs. Issues in supply chain management and lack of quantification skills among the facility staff, cumbersome procurement process, inadequate budget, inadequate storage capacities and delayed supplies are associated with stock outs of essential medicines. There has been no periodic review of Essential Drugs List (EDL) which was developed in late 1990’s. As part of the Essential Package of Health Services, EDL has not been revised and mechanism for periodic update of the EDL is lacking. There is lack of storage capacities at district levels as Medical Store Depots (MSDs) are not available in a number of districts in KP. There is however adequate storage capacities for vaccines at the provincial and district level. Storage capacities of contraceptive and medicines in the districts are inadequate, resulting in on and off supply of the essential medicines to the healthcare facilities.
Vaccines, being biological substances are sensitive to heat and required to be stored in special equipment at the recommended temperature of +2 – +8 degree centigrade. As a policy, Federal EPI Cell, National Institute of Health (NIH), Islamabad provided vaccine, in conformity with the target population, a situation, which has changed in the post devolution scenario. The vaccines used in EPI are BCG, Combo (Tetra valent Vaccine), Measles, Tetanus Toxoid (TT) and Oral Polio Vaccine.
After its collection from Islamabad, vaccines are stored in the cold room, situated at provincial EPI headquarters. Besides the 5 provincial cold rooms, there are 7 other cold rooms installed at divisional level, one each at Malakand, Kohat, Bannu, D.I.Khan and Mansehra, catering to the needs of the respective divisions, while additional two located at Mardan and Swat serves the nearby districts. The vaccine is supplied from provincial to the divisional cold rooms and further distributed down to the districts, tehsils and Union Council levels. While working in the field, EPI technician keeps vaccine in vaccine carriers during outreach sessions, especially designed for the purpose to maintain temperature at the recommended level.
Drug regulatory system in the province suffers from serious issues of quality because of problems of inadequate staff, low skill level, lack of proper equipment, and inadequate implementation of existing laws. Large quantities of spurious drugs are being supplied in the market as well in the public hospitals. Further, there is little control on the quality assurance of alternative drugs used by hakims and homeopaths.
In order for the health department to procure any drugs or vaccines they have to be part of the essential drug list of the government. All drugs registration and licensing is regulated by the Drug regulatory mechanism. However, at present all procurements are done by the Federal EPI cell through UNICEF. Since all vaccines are procured through UN system therefore, all quality standards are ensured.
Moreover, at the provincial level all programme related procurements are managed at the Directorate General of Health Services. The Procurement Committee notified is responsible for all procedures by the Provincial Procurement Regulatory Authority. The committee is chaired by the Director General Health Services and is also responsible for ensuring quality standards and processes. 5. Service delivery The provincial and district departments of health are responsible for delivery and management of health services with a recently enhanced role of the latter in view of administrative devolution. “In theory, stewardship tasks in the health sector are entrusted to the Health Department at provincial level and the district health offices attempt to provide health care through a three-tiered healthcare 31 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa delivery system and a range of public health interventions. The former includes Basic Health Units (BHUs) and Rural Health Canters (RHCs) forming the core of the primary healthcare model; secondary care including first and second referral facilities providing acute, ambulatory and inpatient care through Tehsil Headquarter Hospitals (THQs) and District Headquarter Hospitals (DHQs) and tertiary care comprising teaching hospitals.
The provincial health department, under the leadership of DGHS, is managing the EPI programme with variable staffing strength. The provincial EPI section is headed by the EPI manager who report to the Secretary Health. The district health office is responsible for implementing EPI activities as part of the primary healthcare system. At the district level, the programme is supervised by the EPI Coordinator/ District and Assistant Superintendent Vaccination (DSV/ASV) under the leadership of DHO. At the community level, the services are provided by vaccinators, staff of health facilities and outreach services are also provided by 8000 trained LHWs. District health offices provide routine immunization services to the target children and women using three pronged strategies i.e. static centers, outreach services and mobile services. Each district maintains a variable number of fixed EPI centers on the premises of health facilities for vaccination of the children and women attending the health facilities. The number of service delivery centers by province/region is summarized in the table-10 below.
Figure : Service delivery capacity by type of public and private healthcare providers - static Type of service Number of facilities Required Functional Delivering EPI Public 1. Teaching hospitals +DHQ 31 29 29 2. THQ 72 19 19 3. Civil hospitals + specialized Institutions 125 125 125 4. RHC 208 86 86 5. BHU 1040 784 729 6. Others (MCH centers, CDs, sub health centers) 573 573 40 Private 7. Obstetric service No data No data No data 8. Other No data No data No data Source: Health Department/EPI Programme data There are total of 1616 health facilities in the province at all three levels of the health care delivery system and all are functional against required number of 2185. Of these functional facilities, only 104720 are providing EPI services through fixed centers while 588 are without EPI services. These 588 facilities without EPI services also include 94 UCs which are without an EPI center and covered through mobile outreach services by vaccinators from a neighboring EPI center.
At the primary level, one BHU is required in each of the 1,040 union councils whereas there are a total of 784 BHUs and 729 deliver EPI services. There are 86 RHCs (requirement is 208@ one RHC per 5 BHUs) and all of them have EPI services in place. There are 12,651 LHWs (requirement is 27,375 @ one per 1,000 population) and their role in EPI is to educate communities on importance of immunization.
At the secondary level 23 out of 25 districts have DHQ hospitals whereas in 72 tehsils there are only 19THQ hospitals and in 53 tehsils RHCs are functioning as THQ hospitals.
20 Annual Review Report Feb 2014 32 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa In addition to the fixed EPI centers, the staff also provides outreach services to ensure vaccination coverage of far flung areas and missed cases. The outreach services, apart from vaccinators are also provided by LHWs. The EPI Programme, KP has trained 8000 LHWs in providing vaccination and this workforce is actively involved in provision of services for both routine immunization and Polio eradication. Plans are also underway for training of remaining 4651 LHWs to ensure coverage enhancement.
Figure : Service delivery capacity per type of healthcare professional – community level Type of service Number of Providers Positions Available Filled Delivering EPI LHW 13,200 12,651 8,000 CMW - - - Vaccinator 1665 1645 1645 CDC - - - Sanitary patrol - - - Other - - - 6. Health Information management The province produces outcome and performance information at the provincial level through MICS survey. In addition, national level household surveys including PLSMS and PDHS provide additional information and data. At the sectoral level the District Health Information (DHIS) and vertical disease information systems including community based information generate performance and output level information and data. Overall information system in the province is fragmented as existing systems for facility based and community based information suffer lack of integration at provincial and district level. Therefore, planning with informed decision-making remains less than desired without this important component of analysis. There is no standardized and regular reporting mechanism for autonomous tertiary hospitals in KP as in other provinces. Similarly, current HIS does not cover private sector hospitals and healthcare facilities, which deliver healthcare services to a larger proportion of population in KP. The District Health Information system, updated health sector information systems has been operationalized in the province and reporting streamlined. Although reporting is not universal but all districts report regularly however the analysis and use of data is less than optimal. The data produced lacks validity due to absence of a data quality assurance mechanism. Additionally, trainings of staff are not need based and regular. Many partners undertake trainings which are sporadic and many a times fail to contribute towards improvement of the system since they are not targeted towards those who are in need.
The information is collected from all health facilities i.e. civil dispensaries, BHUs, RHCs, THQs and DHQs and other health facilities where EPI centers are located and collated and shared with the district health office. The record is maintained in the EPI Technicians (vaccinators) requisite registers. The TSV, DSV and others are responsible for oversight of the reporting mechanism. All collected information is shared with the DHIS coordinator and the relevant EPI coordinator at the district level. The DHIS reports are shared with the DHIS coordinator at the provincial level, while all EPI information is sent to the provincial EPI Programme.
However, it is important to note that all this information sharing is one way i.e. no feedback is provided to the reporting entity. Also the data quality support (DQS) systems are not in place to ensure quality and consistency. In addition, no analysis is done at any level other than collation and reporting to guide programme. There is no culture of using this information for future
33 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa planning and programme design. Another key gap is nonuse of this data for procurement planning and forecasting. There is no integrated disease surveillance system in the province, which is owned and implemented by the DOH or DGHS. WHO introduced Disease Early Warning System (DEWS) has limited implementation and poor integration in public health facilities. The only functional surveillance mechanism is for Polio as part of Global and National Polio Eradication program. Further, there is no inclusion or legal provision for private sector for establishing an extensive disease surveillance mechanism in the province. The information system faces a number of critical issues including: a) Despite a number of surveys and research studied conducted every year, there is no mechanism for central storage of data at the provincial level; b) There is no mechanism available for public dissemination of performance of health sector based on information collected through health information system; and c) Health related research in the province is still not catering to the research and information needs of the province. Research infrastructure in the province is poorly developed due to lack of expertise, resources and incentives 3. Immunization system
1. Routine Immunization
Figure : Situational Analysis – routine immunization Indicators 2010 2011 2012 Official Coverage Estimates DTP1 95% 94% 100% DTP3 84% 84% 89% Measles 1 73% 75% 85% Measles 2 25% 37% 52% OPV0 64% 67% 72% Vaccine 1 Vaccine 2 Vaccine 3 Most Recent Survey Coverage % DTP3 56% 70% % Fully Immunized Child 47% 53% Access and demand % Drop Out DTP1 - DTP3 11% 10% 11% % Drop Out DTP1 - Measles (1st dose) 22% 19% 14% % Drop out Measles 1st and 2nd dose 48% 38% 33% Immunization Equity No % gap in DTP3 between highest and lowest socio economic quintiles No data data 43%* 25 25 25 Number and proportion of districts with DTP3 coverage > 80% (28%) (32%) (48%) New vaccines introduced into the routine schedule in the last plan period New vaccine 1 New vaccine 2 *PDHS 2006-7 all other data from PDHS 2012-13 The data reported by the programme and that of the most recent Pakistan Demographic Health Survey (PDHS) 2012 -13 showed substantial variations. The overall coverage for DTP3 was reported by the program as 89% for the baseline year, while during the same period it was reported to be 70 % by the third party. Similarly, measles 1st dose coverage according to programme data was 85%, while PDHS reported it as 59% However after much deliberation 34 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa between various stakeholders from KP during the workshop it was mutually agreed to use findings from the PDHS 2012-13 survey to set the baseline for DTP3 at 70 % and Measles 1st dose at 59% and was officially accepted and endorsed by all partners. All partners agreed that they lacked data verification mechanisms both at district and provincial levels; therefore it makes more sense to use data from a source that is credible and accepted by all.
The percentage of fully immunized children at 53% shows slow progress over the years with less than 50% districts reporting more than 80% coverage rates. The dropout rate between DTP1 and DTP3 at 11% showed no decline during the period 2010-12. Similarly, measles also showed high dropout rate of 33% between 1st and 2nd dose during the same period. The comparison of findings from the last two rounds of PDHS i.e. 2006-7 and 2012-13 shows improvements in the overall immunization coverage. However the participants were of the view that the findings of different surveys have much variation in comparison to programme data. Therefore it is important that reporting and recording mechanisms are improved with institutionalization of data quality assurance mechanisms. 2. Accelerated Disease Control Initiatives
Figure : Situational Analysis - by accelerated disease control initiatives Indicators 2010 2011 2012 Polio OPV3 coverage 84% 84% 89% Number of rounds and sub-national rounds per year 10 11 11 Coverage Range 99% 98% 96% MNT TT2+ coverage 62% 67% 66% Number and proportion of districts reporting >1 case of neonatal tetanus per 1000 live birth 25 (20%) 25 (12%) 25 (40%) Was there an SIA? (Y/N) No No No Neonatal deaths reported and investigated 0 0 0 Delivery at Facility Rate 7% 13% 6% Measles & Rubella Measles / MR vaccination coverage (1st dose) 75% 75% 85% Measles / MR vaccination coverage (2nd dose) 25% 37% 52% Number of lab confirmed measles/rubella outbreaks 245 506 1,419 Selected Selected Selected Geographic extent National Immunization Day Districts Districts Districts Age Group (in months) 9-111 0 0 Coverage 95% 0% 0% Total Measles Cases (Lab/Clinical/epidemiological) 1959 1360 5967 Total Rubella Cases (Lab/Clinical/epidemiological) No data No data No data The province of Khyber Pakhtunkhwa reports high vaccine coverage for polio under the accelerated disease control initiative at 96%.However, with almost one round per month, KP continues to reports highest number of Polio cases after FATA. There have been no measles outbreaks reported in the province and the measles coverage is reported at 59% by the PDHS 2012-13, while it is reported to be 85% as per official reports. The dropout rate between measles 1st and 2 and dose continues to be high at 33%. A total of 230 measles cases were reported per 10,000,000 populations during 2012 showing an improvement in the measles surveillance across the province. The overall TT2 coverage being 66% as per official estimates with 40% districts reporting more than 1 case of neonatal tetanus. The province is planning a measles campaign in all districts during early 2014.
35 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 3. Analysis of Immunization system performance
1. Program Management Expanded Programme on Immunization (EPI) was started in 1976, as a pilot project confined to Peshawar and Nowshera, soon after the successful eradication of small pox. It was included in regular Annual Development Programme (ADP) in 1978 - 79. EPI programme is among the key vertical programme of the health department and follows National Immunization Policy and a priority area under the Provincial Health Sector Strategy 2010-17. In the pre devolution scenario, the major functions of procurement of vaccines, supplies and cold chain were responsibilities of the Federal EPI cell, while service delivery was a provincial responsibility. The immunization programme was least affected by 18th Amendment, since service delivery was purely provincial responsibility including staff and other operational costs, all these cost being part of the recurrent budget. In 1995 the EPI Programme was included in the recurrent budget with the understanding that the Federal Government shall be responsible for the supply of vaccine, syringes and other cold chain equipment while the Provincial Government shall bear the operational cost.
Indicators 2010 2011 2012 Program management 1. Law & Regulation 1.1 Is there legislation or other administrative order establishing a line item for Yes yes yes vaccines? 1.2 Is the line item for vaccines in regular / recurrent Budget No No No 1.3 Are regulations revised in the province to implement national or provincial No No No policies? 2. Planning 2.1 Does the country/Province have an annual work plan for immunization Yes Yes Yes funded through Health Authorities budgeting processes? 2.2 What is the number of UC with an annual micro-plan for immunization? 1040 1040 1040 (Please indicate denominator – Number of UC per province/area) 2.3 Number of planned supervision visits conducted vs. the number of planed No data No data No data visits 3. Coordination and advocacy 3.1 What were the Number of ICC (or equivalent) meetings held last year at 0 1 2 which routine immunization was discussed? 3.2 What were the Number of NITAG (or equivalent) meetings held last year? ------3.3 How many presentations on immunization performance, expenditures, were 0 0 1 made to Parliament? The provincial health department has developed and approved four PC-1 s for immunization programme which include a provincial PC-1 fully funded by the provincial budget and other three supported by PSDP, JICA and GAVI. The overall development budget for the immunization programme though still inadequate, has increased from Rs. 12 million in 2011-12 to Rs. 26.23 million during 2013-14 showing provincial government commitment towards strengthening immunization programme. Currently the health department is consultation with the World Bank for additional resources for the programme. Major partners of EPI are UNICEF, WHO, JICA and GAVI. Recently, the health department has developed an approved an Integrated PC-1 that also include immunization at a cost of Rs. 23 billion (2014-17) that include key immunization activities including staff, trainings, cold chain equipment and vaccine procurement. The programme has a well-functioning management unit at the provincial level. The provincial government has allocated resources for strengthening the programme and currently they are in the process of developing a comprehensive PC-1 with the World Bank support. There are management issues at the district level owing to lack of administrative control over EPI
36 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa coordinator and DHO. At the district level, routine immunization is not a priority area, lack of oversight by the district health authorities are in part responsible for poor performance. Moreover poor coordination between the KPH and district authorities also hinders smooth implementation of services. The UCs lack adequate capacities in proper planning and intensive capacity building efforts are needed. The EPI programme needs to strengthen its oversight role at all levels of the health services. There is also a need to undertake advocacy at the highest level for arranging more resources for the programme and moving it to the forefront of health agenda. The health department has set up a provincial task force to oversee the immunization programme achievements and monitor the progress. The Committee meets regularly under the Secretary Health and has representation from all relevant stakeholders including UN and other development partners.
2. Immunization Services Delivery The immunization services are delivered through three tiered system in the province. At the primary health care level the vaccinators and LHWs are front line workers involved in the delivery of immunization services. The vaccinators 60% time for outreach and 40% at the fixed sites while the LHWs are only performing outreach services spending 30% for immunization (50% for PEI and 50%for RI). The services are delivered using three pronged strategy through fixed EPI centers, static, mobile and outreach services. The efforts of the programme are evident from the recent PDHS 2012-13 results that shows overall immunization coverage of 70% with 53% being fully immunized (Penta3+measles1). The province has witnessed no measles outbreaks in recent years, which in itself an evidence of improving immunization coverage rates over the years.
Indicators 2010 2011 2012 Immunization services 4. Geographical access: 4.1 Number of Fixed EPI Centers - - 1047 4.2 Number of population per each EPI fixed sites 23,000 23,000 23,000 4.3 Proportion of area covered by immunization service to the total - - 80% populated area 4.4 Proportion of UC not having EPI centers - - 9%(94/1040) 4.5 Proportion of UC not having Skilled Immunization Staff (SIS) - 9%(94/1040) 9%(94/1040) 5. Efficiency of service delivery 5.1 Share of immunization services delivered by EPI centers 90% 90% 90% 5.2 Average time EPI Centers provide immunization service per day 8 hrs 8 hrs 8 hrs There are 1616 health facilities in the province with 994 functional EPI centers located in 1040 UCs. While 588 facilities lack EPI centers. About 9 percent of the UCs does not have any EPI center established. The health department has taken some important steps to improve immunization service delivery especially targeting areas without a fixed EPI center. Among these include training 8000 LHWs for providing immunization services and assigning skilled immunization staff from neighboring UCs to uncovered areas. The efforts made by the programme are commendable. Despite poor law and order situation, militancy threats and natural and manmade disasters the service delivery has not been impacted. In addition training plans are in the pipeline the remaining LHWs in delivery of immunization services and utilize them for achieving the targets set in the Provincial Health Sector Strategy. The government has recently approved and funded a plan for expanding immunization coverage to more than 90% under the Integrated PC-1. Under the plan additional immunization workers i.e. 500 vaccinators will be recruited for additional new EPI centers in uncovered UCs and training of 4000 LHWs in immunization service provision.
37 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa The programme however can further improve its interventions by streamlining and strengthening its oversight role i.e. monitoring and supervision. In addition, the government has allocated resources as incentive for the staff delivering RI services. Another factor contributing to quality of care is poor vaccine and cold chain management which directly impacts the quality of service delivery. This can easily be improved by timely planning out and coordinating activities at the district level.
3. Human Resource Management Human Resource Management 6. Availability of qualified workforce: 6.1 Number of healthcare skilled immunization staff per 10,000 population 1 1 1.9 6.2 % of vaccinator posts currently vacant - - 1.5% 6.3 Turnover rate of SIS (or vaccinators specifically) 1% 0% 0% 7. Capacity building 7.1 Number (and proportion) of immunization program staff trained in No data No data No data immunization services through MLM, IIP or other training modalities per year: a) Mid-wives and LHV - - - b) Nurses - - - c) Other Skilled immunization staff (vaccinators) - - - d) Managers - - - e) Technicians - - - f) Other(LHWs) - - 8000 7.2 % of immunization health workers Refreshing trained in immunization in the No data No data 25% last two years (data from PIE and EPI reviews) (vaccinators only) 7.3 Curriculum review for pre-service medical and nursing immunization n/a n/a n/a education conducted A total of 19,104 staff of various categories are available at the facility level including nurses, LHVs, dispensers, midwives, technicians and LHWs. When looking at their contributions towards immunization services only 1864 are available full time showing a deficit of 55% keeping in with the desired coverage of >90%. As we all understand, skilled immunization staff (SIS) is vital for coverage enhancement. The EPI programme has undertaken extensive efforts to address the human resource deficit in the province by tapping on the available staff strength at the district level. The programme through improved networking and coordination with the LHW programme has trained 8000 LHWs to deliver immunization services through outreach. The programme is in the process of training additional 4000 LHWs to take the current coverage to more than %. An important factor responsible for poor performance is lack of refresher trainings for the vaccinators. Over the past couple of years only 25 percent of vaccinators were exposed to any refresher training programme, while no mid-level management or other training were organized/conducted for the staff at any level. The main challenges for the staff especially in the security compromised area are poor security conditions. In many such locations staff is unable to deliver mobile and outreach services due to imposition of curfew or fear for life. While in many instances lack of resources for POL or transport are main hindrances to service delivery.
Figure : Availability and workload of skilled immunization staff (2012) Share of Total Share of FTE Total FTE Posts Operation Time immunization spent Available spent on occupied allocated to time spent on on (FTE) for immuniza Accredited EPI Service Providers (in FTE) Immunization PEI PEI EPI tion Vaccinators 1,645 100% 65% 1,069 576 1,645 Nurses 3,768 0% 0% 0 0 0 Dispensers 731 15% 100% 110 0 110 38 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Lady Health Visitors (LHVs) 1,256 20% 65% 163 88 251 Medical Technicians (MT) 2,918 20% 100% 584 0 584 Female Medical Technicians (FMT) ( Multi-Purpose Workers) 0% 0% Mid-wives 786 0% 0% 0 0 0 Lady Health Workers (LHWs) 8000 30% 50% 1200 1,200 2,400 3,126 1, 864 4,990 63% 37% 100% Total FTE available for EPI (except PEI) 1,864 Total FTE Needed for EPI (except PEI) 4,175 Deficit 2,311 55% The total number of skilled immunization staff (SIS) available is 4990 and include vaccinators, dispensers, LHVs, multipurpose workers (previously medical technicians) and LHWs. The available SIS i.e. 37% are providing routine immunization services while 63% are involved in PEI. The total numbers of vaccinators available are not adequate to provide total coverage to the population. Against 1665 total available posts of vaccinators, only 1645 are filled. As per the National immunization policy there should be two vaccinators in each UC. The available number of vaccinators falls short in meeting the total requirement by 441 vaccinators. The health department in order to meet this deficit has trained LHWs to provide RI services to the community. This has helped fill the gap of trained human resource for immunization to some extent. However, there is a need to undertake detailed staffs need and skill assessment to identify additional staff available which can be utilized by the programme in improving service delivery. There is also dearth of trained midlevel managers providing oversight and ensuring timely achievement of targets. According to available record, no training has been conducted for the mid- level managers during the past few years. In order to fill this important gap, the programme needs to develop a comprehensive training plan for effective programme management oversight.
4. Costing and Financing Indicators 2010 2011 2012 Costing and financing 8. Financial sustainability 8.1 What percentage of total routine vaccine spending was financed using No data No data No data government funds? (including loans and excluding external public financing) 8.2 What proportion of the line item in the provincial budget for 50% 50% 60% immunization was actually funded (actually allocated / planned)? 8.3 What % of immunization resources are being met by the domestic -- -- 80% health budget (as identified in the annual budget plan) 8.4 Government expenditures on routine immunization per surviving infant US $ 0.63 8.5 Are provincial immunization budgets and expenditures monitored and No No No reported at national level? The government of KP in the post devolution scenario has additional fiscal space available for increasing investments in the health sector. The additional resources from the net hydel power profits have further improved the fiscal outlook for the province. In the past the programme has been largely dependent upon external financing for delivering services. This situation had created uncertainties for long term sustainability. The Health department has developed a Minimum health services delivery package of services for the primary health level making provision of immunization services mandatory. This provides an
39 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa opportunity for the programme to develop a comprehensive costed plan and liaise with the government for financing it. Instead of managing multiple development initiatives it will be better to use this comprehensive document for improving services by filling in the existing gaps. Another weak area in the programme is financial and procurement management capacities of the staff. There is a need to strengthen this area of vital programme importance to ensure timely and efficient use of available resources for maximizing the outcomes.
5. Vaccine, Cold Chain and Logistics Indicators 2010 2011 2012 Vaccine supply, quality and logistics 9. Transport / Mobility 9.1 Percentage of districts with a sufficient number of 0 0 50% supervisory/EPI field activity vehicles /motorbikes/bicycles (based on their need) in working condition 9.2 Number of UC with vaccinators using transportation means for -- -- 436/946 21outreach 10. Vaccine supply 10.1 Was there a stock-out of any antigen at provincial or district -- -- Yes level during 2012? 10.2 If yes, specify duration in months -- -- Two weeks 10.3 If yes, specify which antigen(s) -- -- Polio 11. Cold chain / logistics 11.1 Number of UC with adequate numbers of appropriate and 946/1040 946/1040 946/1040 functional cold chain equipment vs. Number of UC with functioning health facilities a) With ILR - - 930/1040 b) With any kind of refrigerators - - 16/946 11.2 Availability of a cold chain replacement plan No No No 12. Waste disposal 12.1 Availability of a waste management policy (guidelines/SOP) Yes Yes Yes 12.2 Number of districts implementing waste management policy 25 25 25 In absence of an efficient vaccine forecasting system, occasional stock-out of certain vaccines and sometimes threat of expiry are key challenges faced by immunization programme. The federal EPI cell has been responsible for vaccine procurement and also forecasting. The programme lacks a system for using programme vaccine utilization data for calculating and forecasting the vaccine requirements for the next year. The dependence on the coverage data reported by the districts, which lacks validity, is high and no mechanism for data quality assurance is in place. There is a need to enhance programme staff capacities in this area, since provincial EPI programme will be responsible for most procurement after 2014. During 2012 there was a gap in availability of polio vaccine for two weeks in the province, wherein no vaccine was available for routine immunization services.
The cold chain available in the province is more than a decade old and unreliable and need replacement. Currently, there are 5 five cold stores each of 30 cubic meters at the provincial level and 7 divisional stores each of 30 cubic meters located in districts. The currently capacity of the stores is adequate for storage of vaccines; however there is a need to enhance this capacity over the next two years to meet additional storage needs. The programme also lacks adequate central and divisional cold stores and warehouses meeting requisite international standards. The EVM assessment has not been done to date. The programme lacks a logistic management plan in place. The vaccines are provided on need basis and in absence of vaccine utilization based forecasting model, the risk of vaccine wastage is high.
21 Programme data 40 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa There are only 3 Cold Chain technicians for the entire province and the EPI field staff are not trained in cold chain maintenance at district and divisional levels. Another challenge is lack of service rules for the cold chain staff. As a consequence of which demotivates for the current staff, which either leave the position or in case senior person retires the junior cannot be promoted.
At the district level, there are 50 Iceland Freezers, one Solar refrigerator and 50 ILRs. While at Union Council level, 1047 EPI centers have 1075 ILRs, 842 cold boxes and 3,163 large and 15930 small vaccine carriers. In addition, in order to address the electricity shortages the programme with help of UNICEF has installed 33 small solar systems in worst effected UCs.
Stock outs of vaccines is very rare in Khyber Pakhtunkhwa. In 2012 there were no stock outs reported by the programme despite shortage of vaccines at the federal level. Presently 5 medium refrigerated trucks and 2 refrigerated Toyota Hilux vans are available with the programme for collection and distribution of vaccines to the facilities. 3 of the vehicles are more than 8 years old and need replacement. The current transportation capacity is enough for the needs, however, with devolution assigning full responsibility on the provincial government and plans to introduce new vaccines, the transportation capacity of the programme needs strengthening.
6. Surveillance and Reporting Indicators 2010 2011 2012 Surveillance and Reporting 13. Routine Surveillance 13.1 Percentage of integrated VPD surveillance reports received at - - 100% provincial level from districts compared to number of reports expected: a) Timeliness - - 70% b) Completeness - - 90% 13.2 AFP detection rate/100,000 population under 15 year of age - - 7.5% 13.3 % suspected measles cases for which a laboratory test was conducted - - 8% 13.4 Number of neonatal deaths for which a follow up investigation was 0 0 0 conducted 13.5 Sentinel Surveillance for Rotavirus establish No No No 13.6 Sentinel Surveillance for meningitis (Hib/PCV) established No No No 13.7 % of suspected meningitis cases tested for Hib/pneumococcal disease No No No according to standard protocol 14. Coverage monitoring 14.1 % gap in match between DTP3 survey coverage and officially reported - - 19% figures 15. Immunization safety 15.1 % of districts (or UC?) that have been supplied with adequate (equal or 100% 100% 100% more) number of AD syringes for all routine immunizations 16. Adverse Events 16.1 National AEFI System is Active with a designated national/provincial ------committee 16.2 Number of serious AEFI cases reported and investigated 0 0 0 Monitoring plays a vital role in improving programme performance. Currently, there is no such role played by the programme. The programme has very weak monitoring and oversight mechanisms. The programme lacks trained manpower to undertake surveillance and monitoring functions fully. There is no practice of developing any monitoring or supervision plans, hardly ever any visits are made to the field to assess situation on the ground. Even when made there are no reports from field visits and the programme lack any tools like supervisory check lists etc. Twice a year review meeting with the districts being the only oversight mechanism in place being. The lack of resources both financial and transport are major hurdles in carrying out routine supervision and monitoring.
41 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa However, the programme has recently initiated a number of steps for strengthening surveillance and monitoring including recruitment of Epidemiologists at provincial and district levels. Also WHO and UNICEF both are providing technical support. In addition, other than AFP surveillance there is no active well developed VPD surveillance system in place. The WHO introduced DEWS (Disease Early Warning System) is there but it is inadequate for the immunization programme needs. The lack of a well-developed VPD surveillance system with a comprehensive data quality assurance mechanism is one reason for poor immunization services. Further lack of ownership at the district level is another reason for weak surveillance and monitoring. Another key hurdle is lack of capacity of the district level staff. The reporting been done at the district level is one way wherein information collected is collated and sent to the provincial programme without analysis and feedback to the reporting entity. There is need to streamline the surveillance and monitoring systems for effective and result oriented programme implementation.
7. Demand Generation, Communication and Advocacy Indicators 2010 2011 2012 Demand Generation and Communization 17. Communication strategy 17.1 Availability of a routine immunization communication plan - - - 17.2 KAP Study conducted in relation to immunization - - - 18. Evidence based communication 18.1 % of government funds on demand generation / communication: 0% 0% 0% EPI and PEI a) EPI (without PEI) 0% 0% 0% b) PEI 0% 0% 0% One of the key factor for poor programme coverage is focus only on supply side interventions at the cost of demand side activities. The programme lacks a comprehensive advocacy and communication strategy and plan to create demand for immunization services in the community. Further, the health communication section is the most neglected both in terms of human resource as well as BCC interventions. The UNICEF has conducted KAP surveys in the past the findings from which can be utilized to address the key barriers to low utilization of immunization services. There is evidence of awareness among the population, however, the barriers relates mostly to community behaviours and cultural practices. The programme needs to rethink its strategy for addressing these issues, if the utilization of immunization services and coverage is to be increased. There is currently no communication or advocacy specific sanctioned position in the immunization programme both at provincial and districts level. In the absence of a full time position and a trained professional, plugging advocacy and communication gaps remain a big challenge. The programme has not have a communication strategy developed over the years to guide advocacy and awareness intervention developed. The staff situation however being addressed under the newly approved integrated PC-1, which envisages placing senior communication person at the provincial level and a health education officer at the district level. In addition, there is a plan alongwith financial resources outreach workers i.e. LHWs and CMWs training in communication techniques for improving immunization coverage.
Another key impediment is lack of government resources for advocacy and communication. Over the last three years no budget has been allocated for advocacy and communication component. Media campaign previously was national governments responsibility and resources were allocated at the provincial level as a practice. However, in order to increase resources for immunization services, the programme needs to engage with the political leadership and bring immunization on the political agenda in the same way it has been done for polio. In addition, the outreach staff 42 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa should be tapped and used for creating awareness about immunization and its benefits. In the local contest the community involvement can be a major strength for the programme in creating awareness and mobilizing people.
43 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa
4. Summary – SWOT Programme Strength Weakness Opportunities Threats Component Program Immunization a Complicated Devolution Political and Management government administrative Partner support administrative priority under reporting for routine EPI interference provincial hierarchy Linkages with Natural and strategy and Highly KPH manmade development centralized Plan to integrate disasters strategy management health services Economic crisis Strong with limited administrative mid-level structures management Strong capacity coordination Poor record within the keeping program and Inadequate with health deptt monitoring and Government supervision commitment/ No control of coordination provincial with partners manager on staff placement, performance and rotation at district level Poor coordination within stakeholder at district level Routine EPI is low priority for district health team DHO not under EPI administrative structure Lack of coordination with KPH Component Strengths Weaknesses Opportunities Threats Human resource -A functional and No HR need HSRU in process Ban on Management experienced team (technical and assessment ever of developing recruitment by management) at done HR policy the provincial provincial level No HR policy availability of government Lack of trained paramedics for Frequent
secretarial staff involvements in changing of Lack of staff and EPI Programme skill mix at Manager district level Political Staff appointments
44 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa absenteeism at field level Unrealistic ratio of service provider to population No DDO power with EPI coordinator Lack of clearly defined roles and responsibilities and service rules Component Strengths Weaknesses opportunities Threats Costing and Government Low allocation Increased Fiscal Donor disinterest financing financing for EPI for EPI share in space District staff on current budget Donor interest the recurrent Weak financial and support budget and procurement management capacities Weak financial controls No Drawing and Disbursement Officer (DDO) Component Strengths Weaknesses opportunities Threats Vaccine and cold Availability of Weak cold chain Donors and poor law and chain & logistics cold rooms at system partners support order provincial and Inadequate for strengthening old cold chain divisional levels mobility support cold chain may top adequate and Available functioning timely vaccine resources are availability for less than the routine needed immunization More than 10 year old equipment Provincial warehouse not as per required Poor vaccine stock management at facility level poor vaccine reporting system at UC and district level, Low storage capacity of provincial, divisional and district stores, More than 10 45 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa years old CC equipment, Provincial ware house not as per standards, Poor vaccine stock management at facility and district level, Component Strengths weaknesses Opportunities Threats Immunization Trained / Compromised LHWs Poor Law and services technical work outreach services availability and order situation force for service Difficult access involvement in Hilly terrain delivery to for distance RI Large scale Increasing community Acceptance of migration services High population community of provision at to EPI provider EPI services doorsteps ratio No control over outreach workers by HF in-charge Difficulty in access distant communities in security compromised areas
Component Strengths Weaknesses opportunities Threats Surveillance and Management Provincial Level PEI monitoring PEI workload reporting structures Lack of training structures overshadowing available at in surveillance of availability routine programme and HR in provincial immunization district level EPI office use of -AFP surveillance District Level surveillance transport by
system in place Existing DHO and local monitoring Functional DHIS influentials and VPD structures reporting nonfunctional systems (low capacity, no mobility, dying cadre) Low capacity of surveillance staff Weak reporting record maintenance, Poor data management and compliance UC Level No VPD monitoring,
46 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Intermittent reporting and poor records at facility levels, Component Strengths Weaknesses Opportunities Threats Demand Strong No community PEI Outreach Traditional generation and communication involvement in workers for norms and communication network planning and community practices
community implementation mobilization illiteracy acceptability of levels Religious RI services Social taboos, extremism cultural barriers & misconceptions about routine immunization among mothers limited staff capacities in counselling and IPC skills Thousands of children die each year due to infectious diseases globally, which is a major health problem in Pakistan as well. Many more are blinded, and crippled for the rest of their lives. Fortunately, administering respective vaccine by Expanded Programme on Immunization can prevent these diseases. The programme provides vaccination services against the seven target childhood vaccine preventable diseases of Poliomyelitis, Neo Natal Tetanus, Measles, Diphtheria, Purtussis, Tuberculosis and Hepatitis B up to 2000 target diseases were six and in 2000 then Hepatitis B vaccine was included for the target age group and thus making the vaccine preventable diseases seven in number. In future there are plans of the inclusion of other vaccine like Hib and vaccine for Phenomena. The immunization coverage in KP declined considerably between fiscal 2002 and 2006 due to supply and demand deficiencies. The Department of Health (DOH) administers the vaccination service through its clinics, mobile outlets, and outreach workers (the vaccinators). The interruption of polio transmission, elimination of measles and neonatal tetanus programs all have yearly campaigns. Pakistan is among one of the few countries still plagued by polio, while KP face major challenges in reaching children through the polio campaigns. Cold and supply chains are old and face number of other challenges in delivering optimum immunization services such as poor or no maintenance, no electricity, especially in remote and mountainous regions and shortages especially in the hot season (summer time) to name a few. Operational budgets are limited, monitoring and supervision is weak, and workers do not have incentives to achieve or raise target levels. In KP, many vaccinator posts are unfilled,22, and fixed health centers do not offer regular vaccinations. In addition, despite adequate awareness levels among the community, many mothers know little about the importance of vaccinating their child or its schedule. As a consequence they fail to get their timely children immunized, or do so not according to schedule.23 Although child vaccinations
22 Hasan, 2010. 23 The EPI Coverage Evaluation Survey, 2006. 47 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa are provided free of charge at public clinics, travel may be arduous and cost prohibitive, especially for the poor. Cultural and social taboos and restriction on women’s mobility without a male escort inhibit women from traveling on their own to clinics; they might require accompaniment by their spouses or relative, which might be difficult to arrange for times that match clinic working hours.
48 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 2. Immunization objectives and strategies 1. Program objectives and milestones Goal of the Provincial NIP is to decrease VPD associated morbidity and mortality:
1. To increase coverage of fully immunized from 53% to 80% in all districts by 2018 2. To enhance Penta3 from 70% to 90% in all districts by 2018 3. To increase TT2+ coverage from 56% to 80% by 2018 in all districts 4. To increase measles coverage from 58% to 80% 5. Increase the proportion of population protected at birth from neonatal tetanus from 56% to 80% The objective of the Provincial NIP is to improve performance of the immunization system that is measured in terms of coverage and equity as listed below:
Indicators 2012 2014 2015 2016 2017 2018 1. Increase DTP3 coverage 70% 73 78 80 85 90 19. Increase Measles 1 coverage 58 60 65 70 75 80 20. Increase the proportion of population protected at 66* 60 65 70 75 80 birth from neonatal tetanus 21. Increase OPV3 coverage 76 78 82 86 90 95 22. Increase PCV (10) coverage 0 73 78 80 85 90 23. Increase the proportion of children fully immunized – 53 60 65 70 75 80 (% of children aged 12-23 months who receive all basic vaccinations in a country’s routine immunization program) 24. Improve geographical equity - % of districts (UC) that 52 60 65 75 85 90 have at or above 80% DTP3 coverage 25. Improve socio-economic equity - DTP3 coverage in the 43 35 30 25 20 15 lowest wealth quintile is +/- X % points of the coverage in the highest wealth quintile 26. Decrease drop out rate - percentage point difference 10 9 9 8 8 7 between DTP1 and DTP3 coverage 27. Increased demand - % of children whose mothers -- 10 20 25 30 35 intend to vaccinate children *reported programme coverage data 2. Strategies and main activities 1. Program Management The objective of the immunization system component is to increase program management performance. It means that by 2018: 1. The immunization programme is part of the integrated health services and aligned with health sector strategy 2. Immunization policy and guidelines are developed and integrated into the health services
3. Immunization program planning is integrated into provincial budgeting, namely: 1. EPI annual plans are developed and are consistent with the provincial cMYP 2. PC1 are adjusted as needed and aligned with the EPI annual plans
49 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 4. Implementation annual progress reports are produced and discussed with key stakeholders regularly 5. The provincial cMYP is updated regularly reflecting either changes in the context (epidemiological, vaccine availability, etc.), resource availability or immunization system outcomes (achievements) 1. Strengthening programme capacities at district levels 1. Strengthening accountability mechanisms at all levels 2. The turnover of EPI key managerial staff decreases 1. Improve coordination with departments, districts and interaction with EPI partners (donors, private entities and non-governmental organizations) (e.g. partners engage in decision-making (e.g. planning, assessment of achievements or challenges) regularly, as documented in meeting minutes) Strategies and activities to achieve the component objective are as follows: ISC Objective 1: Increase program management performance Strategy 1.1: enhancing programme staff capacities in policy, planning and guidelines/SOP development: Activity 1.1.1: Develop comprehensive multiyear plans with key stakeholders and align Programme PC-1 with cMYP
Activity 1.1.2: Develop and implement annual workplans Activity 1.1.3: Review and develop effective and efficient management structure and procedures (1) Revise job descriptions (2) Revise or introduce new standard operating procedures (3) Revise or introduce new reporting mechanisms Activity 1.1.4: Carry out regular supportive supervision visits including following up results/recommendations of the previous visits
Activity 1.1.5: Training of mid-level managers (MLM) (1) Training of trainers for MLM (2) Training of UC level staff on RI micro-plan development, data management, monitoring and supervision Activity 1.1.6: Assess competencies of key EPI management staff on a regular basis (1) Develop assessment criteria/methodology (2) Adjust regulations (introducing competency assessment as a mandatory procedure)
50 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa (3) Carry out assessments Activity 1.1.7: Mobilize Technical support as needed (e.g. for Annual Plan development, APR development, cMYP revision) (1) Recruit technical assistance for guidelines and SOP development (2) Orientation of relevant stakeholders on use of guidelines and SOPs (3) Printing and distribution of guidelines and SOPs Strategy 1.2: Management staff capacity building and motivation growth (see corresponding strategy under HR management component) Strategy 1.3: Strengthen and streamline accountability and oversight Activity 1.3.1: Annual meeting of Provincial Task Force and Provincial Immunization Technical Advisory Group(PITAG) (1) Develop and notify TORs (2) Establish Task force under Chief Secretary and PITAG under Minister for Health Activity 1.3.2: Develop and implement monitoring and supervision plan
(1) Conduct supportive supervision (2) Conduct regular district and field supervisory visits and provide feedback for effective programme implementation Activity 1.3.3: Biennial District Review Meetings (1) 25 district field reviews over five year period Strategy 1.4: Enhance coordination for effective partnerships building Activity 1.4.1: Produce regularly policy briefs/advocacy materials to share with high level officials
(1) Identification and mapping of key stakeholders (2) Quarterly Programme review under Health Secretary Activity 1.4.2: Attend high level meetings and present immunization program achievements, challenges and solutions (1) Advocacy meetings with parliamentarians and donors
Activity 1.4.3: Organize consultations meetings with EPI partners and follow up implementation of decisions and actions agreed in the past Activity 1.4.4: Explore possibility of engagement of non-state actors in the implementation of the immunization program and make corresponding arrangements
51 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 2. Human Resource Management The objective of the immunization system component is to increase the availability of qualified human resources for the immunization program. It means that by 2018: Proportion of population served to skilled immunization staff (SIS) increases from 70% to 90% Increase availability of managerial and technical staff positions for immunization programme at all levels Increase the number of SIS by integrating available qualified health professionals in delivery of routine immunization services Improve staff motivation through introduction of performance incentives
Figure : Modelling of SIS workload and availability scenarios and baseline Summary of Modeling Total FTE FTE spent Total FTE Total FTE GAP (in FTE and %) spent on on PEI available for Needed for immunizatio EPI (except EPI (except n PEI) PEI) Baseline 4,990 3,126 1,864 4,175 2,311 55% Scenario 1 5,859 3,126 2733 4175 1,442 35% Scenario 2 6,975 3,126 3849 4175 326 8% Scenario 3 7,102 3,126 3976 4175 199 5% The above scenario (figure 18) was developed using the HR modelling tool for strategies 2.1 and 2.2. in the current programme and health department situation, Scenario 2 was found to be most feasible. This so because of available donor support (JICA) the programme can induct additional vaccinators and train and involve all available LHWs to meet the deficit in trained manpower for delivering immunization services. By recruiting additional 279 vaccinators and training 4651 LHWs the gap from 35% can easily be reduced to 8%. Strategies and activities to achieve the component objective are as follows: ISC Objective 2: Increase the availability of qualified human resources for the immunization program Strategy 2.1: Increase the number of all technical staff for improving service delivery (surveillance, cold chain management, M&E, communication Activity 2.1.1: Create additional vacancies for technical staff (1) Fill existing vacant positions on merit (2) Assign vaccinators preferably to their home district (3) Review and revise job descriptions
Activity 2.1.2: Advertise all vacant positions in provincial/local media (1) Select and recruit new vaccinators Activity 2.1.3: Conduct meetings with local authorities/communities promoting job of vaccinators (could be part of communication campaign) 52 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Activity 2.1.4: Explore and provide professional/carrier growth opportunities to technical staff by developing and notifying service rules Strategy 2.2: Increase the number of SIS by integrating available qualified health professionals in the delivery of immunization services:
Activity 2.2.1: Assess opportunities (availability, readiness/willingness) for engagement of different categories of SIS into immunization program Activity 2.2.2: Carry out consultations with relevant health authorities (vertical program management) and agree on feasible and sustainable arrangements Activity 2.2.3: Revise the regulatory framework (standards/guidelines, scope of work) in order to ensure the engagement of SIS in the immunization as planned Activity 2.2.4: Carry out trainings in immunization for LHW and mid-wives (as needed) Strategy 2.3: Increase effectiveness of trainings of EPI medical and managerial staff: Activity 2.3.1: Conduct training need assessment (TNA) Activity 2.3.2: Develop or revise training material/guidelines in view of TNA recommendations
Activity 2.3.3: Develop and execute a training plan for SIS Activity 2.3.4: Carry out refresher training for each SIS at least once in 2 years (as per the national policy) Activity 2.3.5: Carry out training of managerial staff in planning (e.g. vaccine forecasting, budgeting), reporting, decision making and advocacy Activity 2.3.6: Develop and implement training assessment for monitoring quality and usefulness of the training
Activity 2.3.7: Assess periodically competency of selected category of healthcare professionals involved in immunization Activity 2.3.8: Introduce a system of pre and post trainings assessment of the knowledge of trainees Activity 2.3.9: Train immunization staff in medical, surveillance and logistics required for the introduction of new vaccines
Strategy 2.4: Increase motivation of key staff of the immunization program Activity 2.4.1: Assess regularly motivations of selected category of HR of the immunization system Activity 2.4.2: Develop and implement non-financial incentives (carrier growth opportunities, promotion, recognition/awards, etc.) 53 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Activity 2.4.3: Develop and introduce system of performance monitoring using key performance indicators Activity 2.4.4: Undertake annual performance reviews and audit Activity 2.4.5: Introduce financial rewards/incentives such as performance bonuses, performance based payments, etc.) and implement whenever feasible for good performers 3. Costing and Financing The objective of the immunization system component is to increase financial efficiency and sustainability of the immunization program. It means that by 2018: 1. Cost per fully immunization child: 1. Increases from PKR 131 to PKR 350 2. Immunization system outcome targets are balanced with the financial resources available: 1. Proportion of secured financial resources vs. planned 2. Coverage targets revised/adjusted to the availability of funding ISC Objective 3: Increase financial efficiency and sustainability of the immunization program.
The objective is likely to be achieved through integration initiative of the health department, which integrates all programmes focusing on maternal and child health. This will minimize costs by avoiding duplication of activities. Introduction of performance based funding model for districts is likely to enhance outcomes. Strategy 3.1: Introduce performance based funding and budgeting Activity 3.1.1: Strengthen financial management of EPI programme for maximizing implementation Activity 3.1.2: Develop and implement performance framework with clearly defined targets and monitoring indicators Strategy 3.2: Advocacy for balancing payments with outcomes through timely resource mobilization Activity 3.2.1: Incentivize and reward well performing districts Activity 3.2.2: Budget releases to be linked with achievement of targets Strategy 3.3: Develop and implement internal and external accountability mechanisms linked with performance
Activity 3.3.1: Regular programmatic and financial reviews and linking with achievements Activity 3.3.2: Align programme procurement functions with PPRA and use programme data for procurement planning
54 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Strategy 3.4: Advocacy for resource mobilization and sustainability Activity 3.4.1: Design and develop cMYP through a consultative process and cost it Activity 3.4.2: Advocacy with relevant fora for financing cMYP
Activity 3.4.3: Inclusion of all programme activities on the current/regular budget 4. Vaccine, Cold Chain and Logistics The objective of the immunization system component is to improve/sustain uninterrupted supply of vaccines to immunization service delivery. It means that by 2018: Timely collection and distribution of vaccine and injection devices is increased % of districts with average EVM score above 80% is increased Strategies and activities to achieve the component objective are as follows: ISC Objective 4: Improve/sustain uninterrupted supply of vaccines to immunization service delivery Strategy 4.1: Enhanced programme capacity in vaccine planning and forecasting Activity 4.1.1: Develop vaccine procurement plan as per need Activity 4.1.2: Ensure timely procurement of vaccines
Activity 4.1.3: Develop logistics and distribution plan Activity 4.1.4: Upgrade/maintain adequate cold chain equipment Activity 4.1.5: Assess of needs for cold chain update Activity 4.1.6: Develop specifications and procurement plan (aligned with the availability of funding) aligned with PPRA guidelines Activity 4.1.7: Purchase and install necessary activity Activity 4.1.8: Provide maintenance services on a regular basis Strategy 4.2: Improve vaccine management by implementing EVM Improvement plan Activity 4.2.1: Carry out EVM assessment Activity 4.2.2: Revise the annual work plan in accordance with the EVM improvement plan Activity 4.2.3: Report on the progress of implementation of the EVM improvement Plan Activity 4.2.4: Standardize cold chain equipment Strategy 4.3: Upgrade or install new cold chain equipment wherever needed Activity 4.3.1: Enhance provincial/divisional warehouse storage capacities
55 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Activity 4.3.2: Prepare cold chain and vaccine management for the introduction of new vaccine Activity 4.3.3: Expand cold chain storage capacity if needed Activity 4.3.4: Train vaccine management personnel (as needed) 5. Immunization Services Delivery The objective of the immunization system component is to strengthen capacity of immunization service delivery. It means that by 2018: 1. Proportion of area covered by immunization service to the total populated area is increased from 80% to 90% 1. Share of static/fixed immunization services delivered by EPI centers (vs. outreach) increased 2. Average time EPI Centers provide immunization service per day (increases from 6 to 8 hours per EPI center) 3. Proportion of UC not having EPI centers (decreased) from 9% to 0% 4. Proportion of UC not having Skilled Immunization Staff (SIS) decreased from 94 to 30 5. Increase proportion of children vaccinated in the Pilot area through public private partnership for improving immunization coverage
Strategies and activities to achieve the component objective are as follows: ISC Objective 5: Strengthen and optimize capacity of immunization service delivery Strategy 5.1: Make existing BHU/RHC functional (for EPI) Activity 5.1.1: Repair facility/infrastructure Activity 5.1.2: Recruit qualified staff (see corresponding strategy under component 2 “Human Resource Management”) Activity 5.1.3: Install cold chain equipment (see corresponding strategy under component 4 “Vaccine, Cold Chain and Logistics”) Strategy 5.2: Performance based contracting out Activity 5.2.1: Develop ToR/Scope of Work for contracting out Activity 5.2.2: Select and contract qualified immunization service providers Activity 5.2.3: Conduct oversight of contract implementation
Activity 5.2.4: Assess performance and efficiency of the contracting out mechanism (linked with Program management component) Strategy 5.3: Increase performance/efficiency (effective coverage) of existing EPI Centers Activity 5.3.1: Revise regulations
56 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Activity 5.3.2: Mobilize additional qualified staff SIS Activity 5.3.3: Introduce contracting/financing mechanism Activity 5.3.4: Improve micro-planning through regular supportive supervision of designated staff at EPI centers
Strategy 5.4: Strengthen districts and UCs in service delivery Activity 5.4.1: Capacity building of the UCs in development and implementation of micro plans for immunization Activity 5.4.2: Monitoring to ensure implementation of micro plan as per targets Strategy 5.5: Integration of RI and PEI Activity 5.5.1: Advocacy with key stakeholders and health authorities for integration of PEI activities in routine immunization 6. Monitoring, Surveillance and Reporting The objective of the immunization system component is to increase performance of surveillance and routine monitoring/reporting. It means that by 2018: 1. Reliability and accuracy of administrative data increased: 1. Discrepancy ratio (between administrative and survey data) is reduced
2. % of reporting units receiving satisfactory DQS score/mark 2. Ability of surveillance to detect and report on certain cases increased: 1. Number of non polio AFP cases detected and reported 2. Number of discarded measles cases per 100,000 population Strategies and activities to achieve the component objective are as follows: ISC Objective 6: Improve performance of surveillance and routine monitoring/reporting systems Strategy 6.1: Design and implement a comprehensive VPD surveillance system Activity 6.1.1: Strengthening of VPD surveillance mechanisms Activity 6.1.2: Review and update VPD surveillance indicators Activity 6.1.3: Sensitization and training of facility level staff in VPD surveillance
Activity 6.1.4: Revision of reporting tools Activity 6.1.5: Develop and implement DQS system to improve data quality and reliability Activity 6.1.6: Review and analysis of VPD reports and timely feedback to reporting entity
57 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Activity 6.1.7: Pilot real time online surveillance reporting in selected districts Strategy 6.2: Streamline data collection and reporting practices (integrate EPI routine monitoring into data management mainstream) Activity 6.2.1: Assess main causes of data quality flaws
Activity 6.2.2: Introduce regular (FORMAL) feedback mechanism on the administrative reports of subordinated entities Activity 6.2.3: Provide continuous supportive supervision Activity 6.2.4: Conduct immunization coverage survey Activity 6.2.5: Conduct DQS at regular interval Strategy 6.3: Expand surveillance network through integration with other disease control initiatives Activity 1.1.1: Provide logistical support Activity 1.1.2: Capacity building Activity 1.1.3: Revision of guidelines/forms Activity 1.1.4: Conduct proficiency tests for laboratories (% of lab of the tests) Activity 1.1.5: Introduce disease surveillance for Rota and Pneumococcal viruses 7. Demand Generation, Communication and Advocacy The objective of the immunization system component is to improve knowledge and attitude toward immunization among target population. It means that by 2018: 1. % of caregivers who understand benefits of immunization (or demonstrate proper knowledge of benefits) increased from 50% to 75% 2. % of caregivers will advise their friends/relatives/neighbors to vaccinate children regularly Strategies and activities to achieve the component objective are as follows: ISC Objective 7: Knowledge and attitude toward immunization improved among target population Strategy 7.1: (in short-run) continue community mobilization and communication interventions that proved being effective: Activity 7.1.1: Conduct KAP survey to find barriers to utilization of immunization services
Activity 7.1.2: Develop and implement BCC strategy and plan as per the national EPI Policy Activity 7.1.3: Community mobilization using suitable strategies Activity 7.1.4: Engage civil society in generating demand for services
58 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Activity 7.1.5: Develop and implement community mobilization interventions Strategy 7.2: (in long-run) Develop and implement evidence based communication strategies Activity 7.2.1: Conduct KAP studies of the target population
Activity 7.2.2: Develop and cost out communication plan in view of studies conducted Activity 7.2.3: Assess the effectiveness of the communication strategies
59 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 3. Implementation and M&E 1. Timelines for the cMYP
Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 ISC Objective 1: Increase program management performance
Strategy 1.1: enhancing programme staff capacities in policy, planning and guidelines/SOP development: Activity 1.1.1: develop comprehensive multiyear plans with key stakeholders and align Programme PC-1 with these Activity 1.1.2: develop and implement annual workplans Activity 1.1.3: Review and develop effective and efficient management structure and procedures
Activity 1.1.4: Carry out regular supportive supervision visits including following up results/recommendations of the previous visits Activity 1.1.5: Training of mid-level managers (MLM)
Activity 1.1.6: Assess competencies of key EPI management staff on a regular basis
Activity 1.1.7: Mobilize Technical support as needed (e.g. for Annual Plan development, APR development, cMYP revision)
Strategy 1.2: Management staff capacity building and motivation growth (see corresponding strategy under HR management component) Strategy 1.3: Strengthen and streamline accountability and oversight Activity 1.3.1: Annual meeting of Provincial Task Force and Provincial Immunization Technical Advisory Group(PITAG)
Activity 1.3.2: Develop and implement monitoring and supervision plan
Activity 1.3.3: Biennial District Review 60 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 Meetings
Strategy 1.4: Enhance coordination for effective partnerships building Activity 1.4.1: Produce regularly policy briefs/advocacy materials to share with high level officials
Activity 1.4.2: Attend high level meetings and present immunization program achievements, challenges and solutions
Activity 1.4.3: Organize consultations meetings with EPI partners and follow up implementation of decisions and actions agreed in the past Activity 1.4.4: Explore possibility of engagement of non-state actors in the implementation of the immunization program and make corresponding arrangements ISC Objective 2: Increase the availability of qualified human resources for the immunization program
Strategy 1.1: Increase the number of all technical staff for improving service delivery (surveillance, cold chain management, M&E, communication
Activity 2.1.1: Create additional vacancies for technical staff
Activity 2.1.2: Advertise all vacant positions in provincial/local media
Activity 2.1.3: Conduct meetings with local authorities/communities promoting job of vaccinators (could be part of communication campaign) Activity 2.1.4: Explore and provide professional/carrier growth opportunities to all technical staff by developing service rules ISC Objective 3: Increase the number of SIS by integrating available qualified health professionals in the delivery of
61 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 immunization services:
Activity 3.1.1: Assess opportunities (availability, readiness/willingness) for engagement of different categories of SIS into immunization program Activity 3.1.2: Carry out consultations with relevant health authorities (vertical program management) and agree on feasible and sustainable arrangements
Activity 3.1.3: Revise the regulatory framework (standards/guidelines, scope of work) in order to ensure the engagement of SIS in the immunization as planned
Activity 3.1.4: Carry out trainings in immunization for LHW and mid-wives (as needed)
Strategy 3.2: Increase effectiveness of trainings of EPI medical and managerial staff:
Activity 3.2.1: Conduct training need assessment (TNA)
Activity 3.2.2: Develop or revise training material/guidelines in view of TNA recommendations Activity 3.2.3: Develop and execute a training plan for SIS Activity 3.2.4: Carry out refresher training for each SIS at least once in 2 years (as per the national policy) Activity 3.2.5: Carry out training of managerial staff in planning (e.g. vaccine forecasting, budgeting), reporting, decision making and advocay Activity 3.2.6: Develop and implement training assessment for monitoring quality and
62 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 usefulness of the training Activity 3.2.7: Assess periodically competency of selected category of healthcare professionals involved in immunization Activity 3.2.8: Introduce a system of pre and post trainings assessment of the knowledge of trainees Activity 3.2.9: Train immunization staff in medical, surveillance and logistics required for the introduction of new vaccines
Activity 3.2.10: Assess regularly motivations of selected category of HR of the immunization system Activity 3.2.11: Develop and implement non- financial incentives (carrier growth opportunities, promotion, recognition/awards, etc.) Strategy 3.3: Increase motivation of key staff of the immunization program Activity 3.3.1: Develop and introduce system of performance monitoring using key performance indicators Activity 3.3.2: Undertake annual performance reviews and audit Activity 3.3.3: Introduce financial rewards/incentives such as performance bonuses, performance based payments, etc.) and implement whenever feasible for good performers ISC Objective 4: Increase financial efficiency and sustainability of the immunization program. Strategy 4.1: Introduce performance based funding and budgeting Activity 4.1.1: Strengthen financial management of EPI programme for maximizing implementation Activity 4.1.2: Develop and implement performance framework with clearly defined targets and monitoring indicators Strategy 4.2: Advocacy for balancing payments with outcomes through
63 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 timely resource mobilization Activity 4.2.1: Incentivize and reward well performing districts Activity 4.2.2: Budget releases to be linked with achievement of targets Strategy 4.3: Develop and implement internal and external accountability mechanisms linked with performance Activity 4.3.1: Regular programmatic and financial reviews and linking with achievements Activity 4.3.2: Align programme procurement functions with PPRA and use programme data for procurement planning Strategy 4.4: Advocacy for resource mobilization and sustainability Activity 4.4.1: Design and develop cMYP through a consultative process and cost it Activity 4.4.2: Advocacy with relevant fora for financing cMYP Activity 4.4.3: Inclusion of all programme activities on the current/regular budget ISC Objective 5: Improve/sustain uninterrupted supply of vaccines to immunization service delivery Strategy 5.1: Enhanced programme capacity in vaccine planning and forecasting Activity 5.1.1: Develop vaccine procurement plan as per need Activity 5.1.2: Ensure timely procurement of vaccines Activity 5.1.3: Develop logistics and distribution plan Strategy 5.2: Upgrade/maintain adequate cold chain equipment Activity 5.2.1: Assess of needs for cold chain update Activity 5.2.2: Develop specifications and procurement plan (aligned with the availability of funding) aligned with PPRA guidelines Activity 5.2.3: Purchase and install necessary equipment Activity 5.2.4: Provide maintenance services on a regular basis Strategy 5.3: Improve vaccine management by implementing EVM Improvement plan Activity 5.3.1: Carry out EVM assessment Activity 5.3.2: Revise the annual work plan in 64 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 accordance with the EVM improvement plan Activity 5.3.3: Report on the progress of implementation of the EVM improvement Plan Activity 5.3.4: Standardize cold chain equipment Activity 5.3.5: Upgrade or install new cold chain equipment wherever needed Activity 5.3.6: Enhance provincial/divisional warehouse storage capacities Strategy 5.4: Prepare cold chain and vaccine management for the introduction of new vaccine
Activity 5.4.1: Expand cold chain storage capacity if needed Activity 5.4.2: Train vaccine management personnel (as needed) ISC Objective 6: Strengthen and optimize capacity of immunization service delivery Strategy 6.1: Make existing BHU/RHC functional (for EPI) Activity 6.1.1: Repair facility/infrastructure Activity 6.1.2: Recruit qualified staff (see corresponding strategy under component 2.2.2 “Human Resource Management”) Activity 6.1.3: Install cold chain equipment (see corresponding strategy under component 2.2.4 “Vaccine, Cold Chain and Logistics”) Strategy 6.2: Performance based contracting out Activity 6.2.1: Develop ToR/Scope of Work for contracting out Activity 6.2.2: Select and contract qualified immunization service providers Activity 6.2.3: Conduct oversight of contract implementation Activity 6.2.4: Assess performance and efficiency of the contracting out mechanism (linked with Program management component) Strategy 6.3: Increase performance/efficiency (effective coverage) of existing EPI Centers Activity 6.3.1: Revise regulations Activity 6.3.2: Mobilize additional qualified
65 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 staff SIS Activity 6.3.3: Introduce contracting/financing mechanism Activity 6.3.4: Improve micro-planning through regular supportive supervision of designated staff at EPI centers Strategy 6.4: Strengthen districts and UCs in service delivery Activity 6.4.1: Capacity building of the UCs in development and implementation of micro plans for immunization Activity 6.4.2: Monitoring to ensure implementation of micro plan as per targets Strategy 6.5: Reduce SIS involvement in the PEI Activity 6.5.1: Advocacy with key stakeholders and health authorities for minimizing SIS involvement in PEI activities ISC Objective 7: Improve performance of surveillance and routine monitoring/reporting systems Strategy 7.1: Design and implement a comprehensive VPD surveillance system Activity 7.1.1: Strengthening of VPD surveillance mechanisms Activity 7.1.2: Review and update VPD surveillance indicators Activity 7.1.3: Sensitization and training of facility level staff in VPD surveillance Activity 7.1.4: Revision of reporting tools Activity 7.1.5: Develop and implement DQS system to improve data quality and reliability Activity 7.1.6: Review and analysis of VPD reports and timely feedback to reporting entity Activity 7.1.7: Pilot real time online surveillance reporting in selected districts Strategy 7.2: E x p a n d
66 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 s u r v e i l l a n c e
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t 70 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 h e
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c o n t i n u o u s
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b u i l d i n g Activity 7.3.3: R e v i s i o n
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i m m u n i z 80 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 a t i o n
i m p r o v e d
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p o p u l a t i o n Strategy 8.1: ( i n
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c o n t i n u e
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c o m m u n i c a 82 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 t i o n
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m o b i l i z a t i o n
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s t r a t e g i e s Activity 8.1.4: E 87 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 n g a g e
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a n d
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c o m m u n i t y
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89 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 i n t e r v e n t i o n s Activity 8.1.6: C o n d u c t
K A P
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t a r g e t
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a n d
c o s t
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c o m m u n i c a t i o n
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i 91 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 n
v i e w
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e f f e c t i v e n e 92 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Objective/strategies/activities 2 2 2 2 2 0 0 0 0 0 1 1 1 1 1 4 5 6 7 8 s s
o f
t h e
c o m m u n i c a t i o n
s t r a t e g i e s 2. Monitoring and Evaluation
M&E Frewmork 1. M&E Framework for immunization The file is attached (click the icon to open the file) 2. Monitoring and Evaluation Strategy and Plan Monitoring and evaluation are important for tracking the programmes progress. Presently the programme lacks a framework for monitoring programme progress using a set of indicators for tracking achievements against targets.
93 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa In order to monitor the EPI program progress towards achievement of objectives, specific set of indicators have been included in the M&E framework, which will be used to track progress against each activity. This M&E framework has been developed to assist the EPI program management in tracking its progress and achievements.
A three tiered system for monitoring will be used which will be both internal and external. The internal mechanism will consist of routine programme reports from each facility, collected on quarterly basis at the district level, collated and analyzed against predetermined set of indicators defined in the M&E framework and plan. The reports will be checked for accuracy, validity and completeness and feedback first at district level and feedback provided to each facility. The report from each district will be shared with the programme, where more extensive analysis including trend analysis be done and feedback provided. A system of Data Quality assurance will be developed and mainstreamed to ensure quality and validity of data. A Third Part Validation (TPV) firm will be hired to ensure accuracy, validity and quality of data and will be part of external monitoring mechanism for ensuring and verifying programme achievements and outcomes. In addition, a number of independent surveys will be conducted to ensure information quality. Regular programmes reviews at provincial and district levels will ensure that programme stays on track. All available reporting and recording formats will be reviewed and updated. The independent surveys and assessments include KAP survey, periodic immunization coverage assessment surveys, PDHS, etc. The program generated information will include routine annual and quarterly reports from districts, survey and assessment reports, minutes of meetings, government notifications, job descriptions, standard operating procedures, EPI and HR policy documents; PC1s, communication materials and plans, annual EPI plans, concept papers, training reports, monitoring reports, assessment reports, feedback documents, etc.
94 ComprehensivecMYP Costing multi Tool-Plan | Immunization Program of Khyber Pakhtunkhwa 4. Immunization Program Costing and Financing 1. Current program costs and financing In the year 2012 the EPI program, Khyber Pakhtunkhwa incurred approximately US$36.278 million (excluding NID and shared costs) on activities for routine immunization (Figure 12). The costs incurred on personnel (60%) constituted bulk of the expenditure, followed by costs on underused vaccines (22%), recurrent costs (7%), traditional vaccines (6%), injection supplies (3%) and transportation costs (2%). There were no costs expended on trainings, advocacy and communication, and surveillance and monitoring.
Figure : Baseline Cost Profile (shared costs and campaigns excluded)
1. Personnel The main driver of the costs in the immunization programme after vaccines and injection supplies procurement was head of personnel ($6,312,720) constituting 39% of the total expenditure during 2012. It included salaries, allowance for full-time EPI staff, per-diems for vaccinators and mobile teams and per-diems for supervision and monitoring staff at various levels i.e. provincial, district and UC. The baseline information for the cost category was compiled using standard government approved basic pay scales (BPS) and rates used for payment of travel allowances and per-diems. All relevant information was obtained from Planning Cell of the Health Department and Finance Department. All were agreed upon through detailed consultation with the Provincial EPI Office. The analysis highlights salaries and allowance as the major cost driver under this heading during 2012. Further analysis of the 39% Personnel cost category (2012) shows that US$ 6.217 million was incurred on salaries (98.5%) of the staff of on immunization programme at various levels, while the remaining meager cost 1.38% (US$ .0877) was spent of per diems of outreach workers and mobile teams. However, as identified the reason for weak supervisory and monitoring system is low allocation (.12%) of related activities. This analysis highlights that after vaccines/injection supplies procurement salaries and allowance were the major cost driver in 2012. 2. Vaccines, Injections and Supplies The most cost consuming category consuming at 44% ($7,057,094) of total expenditures during 2012 was vaccines and injection supplies procurement. It included Traditional Vaccines, Underused Vaccines, injections and related supplies. The Traditional Vaccines include BCG, OPV, Measles and Tetanus Toxoid whereas Underused Vaccines include Pentavalent (DTP-HepB-Hib). In post devolution period, all vaccines were procured through the Federal EPI Cell, and then supplied to the provincial governments. The province has a poor logistic management system and vaccines records are deficient at all levels i.e. Receipt, Issue and Used. In such scenario, the WHO’s forecasting tools are not used for estimating vaccines need for the next year and neither the procurement/vaccine use data used for the purpose. All procurement of vaccines was based on the estimated population size and projections made by NIPS (National Institute of Population Studies) and information provided by the Federal EPI Cell on the number of doses per antigen supplied during 2012. The total expenditure was calculated by using cost per dose per antigen and injection equipment cost provided in the costing tool. 3. Transportation 95 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa The expenditure on transportation was based on the type and number of vehicles available at provincial, district and union council levels. In addition, information was collected regarding average mileage per year of a given vehicle. The provincial EPI office provided the information on the quantity of fuel used per 100 KM.
The analysis shows that the expenditure on transportation was 1% (US$ 252,204) million) of the total expenditure in 2012. On the main reasons for less expenditure on transportation was non-availability of sufficient number of vehicles for the immunization staff. The vehicles include 28 single cabin of which 4 are at provincial level and 24 at district level available for supervision, monitoring and programme management component. At the UC level only 446 motorbikes were available/in working condition for 1645 vaccinators. Most vehicles at the district level were provided over the years by WHO and UNICEF and most were old and not good running conditions The repair, maintenance and POL was responsibility of the provincial government being the sole financier for costs incurred on transportation. 3. Other routine recurrent costs The other routine costs comprised expenditures for cold chain maintenance and overheads. The information was shared by the Finance and Stores/warehouse sections of Provincial EPI Programme. It is worth mentioning that the record was not well kept and no proper inventory mechanism existed. All information was patchy and incomplete. In view of which an exercise was held during the district review and inventory lists of all vehicles, equipment and supplies was prepared. This information was used to populate the cMYP costing tool and also used in the narrative.
The total expenditure against routine recurrent costs was estimated to be 16% (US$ 2,608,430) of the total expenditures during 2012 and was an expenditure category totally financed by the provincial government.
Figure : Baseline Financing Profile (shared costs and campaigns excluded) Provincial government was the main financier of the immunization programme, wherein 63% (US$ 10, 226,506) of the budget was provided. The second largest financier, after the provincial government was GAVI at 34% (US$ 5,466,032) for procurement of vaccines. In addition, 3% (US$ 522,355) was paid under the head of government co-financing for vaccine procurement. Wherein, US$ 15,556 was contribution of WHO. The situation appears reassuring from sustainability aspect, since the probability of government contributions discontinuation are low especially when it is committed to MDG achievements.
Figure : Immunization program baseline indicators Baseline Indicators 2012 Total Immunization Expenditures 21,210,243 Campaigns 4,979,795 Routine Immunization only 16,230,448 per capita $ 0.63 per DTP3 child $ 27.12 % Vaccines and supplies 43% % Government funding 48% % Total health expenditures 2% % Gov. health expenditures 21% % GDP 0.05% 9,639,054 Total Shared Costs 0 % Shared health systems cost 48.43 96 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa TOTAL 21,210,243 The Government of Khyber Pakhtunkhwa spent 0.05 % of its GDP on immunization programme during the year 2012. The amount constituted 48% of the government health expenditures and 2% of the total health expenditures. In total immunization expenditures the share of routine immunization was around 76.52% whereas 23.48% were spent on campaigns and approximately 70% of these expenditures was government’s own financing. The per capita cost for routine immunization of a child was US$ 0.63 (PKR 59.8), while the cost incurred on DPT3 vaccination was US$ 27.12(PKR 2,576). 2. Future resource requirements
Figure : Future resource requirements by cost categories (in million USD) Expen- Future Resource Requirements cMYP ditures Component 2012 2014 2015 2016 2017 2018 Total Vaccine Supply and Logistics 26,364,51 26,968,93 36,875,99 39,905,46 41,988,73 172,103,6 (routine only) 7,600,403 5 3 6 1 7 41 10,011,09 11,051,64 11,672,29 12,324,93 53,214,63 Service Delivery 6,564,924 8,154,657 7 8 9 0 0 Advocacy and Communication 1,387,899 166,600 228,402 266,870 312,438 258,846 1,233,156 Monitoring and Disease Surveillance 15,556 198,966 226,753 261,917 291,614 380,585 1,359,835 Programme Management 661,667 1,364,656 1,433,759 1,556,003 1,667,733 1,785,175 7,807,326 Supplemental Immunization Activities (SIA) (includes vaccine 30,324,37 32,497,33 33,540,71 30,248,99 24,407,39 151,018,8 and operation costs) 4,979,795 7 4 5 4 7 18 11,651,51 13,013,18 14,400,02 13,612,39 14,301,40 66,978,52 Shared Health Systems Costs 9,388,563 3 9 5 2 4 1 78,225,28 84,379,46 97,953,17 97,710,93 95,447,07 453,715,9 GRAND TOTAL 30,598,806 3 7 5 0 2 27 During 2014 61.2% (US$ 47.90M) of the total resources will be required for routine immunization, while 38.8% (US$30.32 M) is the total requirement for campaigns. The costs for routine immunization include personnel, vaccines, injection supplies, vehicles, cold chain and capital equipment, transportation and other recurrent costs. The overall requirements for routine immunization increases during the subsequent years i.e. 61.49% (2015), 65.76% (2016), 69.05% (2017) and 74.43%(2018), while that for campaigns shows a declining trend for the same periods at 38.51%, 34.24%, 30.95% and 25.57% respectively. The following figure provides strategy wise budgetary requirements (Figure ).
Figure : Costs by Strategy (in millions ) 2014 2015 2016 2017 2018 Routine Fix Site Delivery $16,765,317 $18,158,746 $22,544,361 $23,611,678 $24,863,886 Outreach Strategy $23,950,453 $25,941,066 $32,206,230 $33,730,968 $35,519,838 Mobile Strategy $7,185,136 $7,782,320 $9,661,869 $10,119,290 $10,655,951 Campaigns $30,324,377 $32,497,334 $33,540,715 $30,248,994 $24,407,397
3. Future financing and funding gaps of the immunization program
Figure : Future Secure Financing and funding gap (shared costs excluded)
Figure depicts future secure financing and the funding gaps from 2014 onwards to 2018. It is evident that the provincial government and GAVI is main financier of immunization programme with funding gap being 4% ($2.72million) for the year 2014, increasing to 22% ($15.37 million) during 2015 and reaching the maximum during 2016 at 82% ($68. 89 97 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa million). In the cMYP, the maximum investments in the transportation and cold chain up gradation are envisaged during this period. The following two years i.e. 2017 and 2018 see the gap marginally decrease to 80% ($67.25 million) and 81% ($ 65.82 million). Overall, 57% ($ 220.060 million) is funding gap for the five year duration of the project.
Figure : Total Costs and Funding Gap (in US$) YEAR 2014 2015 2016 2017 2018 TOTAL 71,366,27 Total Costs 66,573,771 8 83,553,150 84,098,539 81,145,668 386,737,406 Funding $15,373,6 $65,820,00 $220,060,8 GAP $2,720,342 96 $68,889,213 $67,257,605 8 64 % 4% 22% 82% 80% 81% 57% The detailed year wise total costs and funding gap are given in Figure above. The maximum investments in the project are envisaged during years 3 onwards of the project and therefore the funding gap during the period is higher.
The figure below presents details of the funding gap versus funding that is secure while excluding the shared costs. The contribution of the provincial government is likely to remain stable over the next five years along with probable contribution from GAVI. However in order to meet the program objectives and targets, the amount available in form of secure funding are short of the total resource requirement. Overall, the funding gap is highest during 2016-2017 and is vital for implementation of activities since it relates to cold chain and transportation, both important from management as well as programme outcomes point of view.
Figure : Future Secure and Probable Financing and Gaps (shared costs excluded)
98 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 4. Funding gap analysis
Figure : Composition of the Funding Gap
Figure above highlights the composition of the funding gap. In 2014, this gap is mainly of resources required for procuring vehicles, cold chain equipment and other recurrent costs for which US$ 2.70million are needed. The current cold chain is more than a decade old and in many places needs replacement, and with introduction of new vaccines for routine immunization, the capacity needs to be increased. During 2015, the US$ 15.37 million funding gap, is in the areas of logistics (vehicles, cold chain etc), transport and recurrent costs. The maximum funding gap is for the years 2016 to 2018 i.e. US$ 201.97 wherein major investments are needed for infrastructure strengthening, transport, replacement and expansion of cold chain and campaign costs .
99 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 5. Financial sustainability
Figure : Financial sustainability paramaters (in US$) Indicators 2012 2014 2015 2016 2017 2018
Per capita 8.5 1,332 1,372 1,414 1,456 1,500 GDP THE per 30 32 33 34 35 36 capita Population 25,929,799 27,375,547 28,128,375 28,901,905 29,696,708 30,513,367
GDP 32,567,827,544 36,464,229,078 8,592,130,373 40,867,293,978 43,238,406,282 45,770,050,606 THE 777,893,970 876,017,515 928,236,372 982,664,777 1,039,384,766 1,098,481,215 GHE 77,789,397 96,361,927 102,106,001 117,919,773 124,726,172 142,802,558
The projection of macroeconomic indicators shows that the government is likely to health expenditures over the next five years from the baseline of 2012.The provincial finances have markedly improved. This is due mainly to increased revenue transfers from the federal government through the payment of arrears from hydel power profits and the new NFC Award. This sharply raised the provinces’ share of federal revenue. KP’s total revenue, which had been hovering around 7-8 percent of Provincial Gross Domestic Product (PGDP), increased to 8.7 percent in fiscal 2010 and 11.3 percent in 2011. As a consequence government of Khyber Pakhtunkhwa after the 9 NFC Award and share of Hydel profits has increased fiscal space and over the past few years has increased spending on the development sector as a whole and health more specifically. The estimated resource requirements for the cMYP (2014-2018) is US$453.716 million out of which more than half is need designated for service delivery component. The total resource requirement without shared cost amount to US$386.74 million (and $235.72 million is for routine immunization only) out of which US$66.79 million is to be covered by the Provincial Government and US$49.86 by GAVI for vaccine procurement. The funding gap amounts to about $220.060million, which is approximately 57 %of the total resource requirement. However, in order to meet the increasing resource requirement per DPT3 child from US$ 43 in 2012 to US$ 78in 2018, it must allocate additional resources of nearly US$ 220.060 million for routine immunization and campaigns over the next five years to ensure increase in immunization coverage and in meeting the targets of the Health Sector Strategy. However, from the overall it is pertinent to highlight that immunization is primarily funded by the government health expenditure. The contribution from out-of-pocket expenditure is mainly in the form of opportunity costs. Therefore, the resource requirement for routine and campaign immunization is more likely to be met through the Government Health budgets. It is highly likely that with the current financial situation and increased fiscal space, Khyber Pakhtunkhwa government will be able to bear this cost, mainly for two reasons. Firstly, the total available space under government health expenditure is enough to accommodate this additional expenditure. Secondly, the additional expenditure will primarily be required for logistics, campaigns and related recurrent costs. Since most of these are project specific one- time costs, therefore these are unlikely to have a throw forward on the overall health budget. In view of the situation explained the sustainability of immunization interventions are high.
100 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa 5. Annexes
101 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Executive Summary
Annex : Costing and financing
Figure : Expenditures and future resource requirements by cMYP components (in PKR) Cost Category 2014 2015 2016 2017 2018 Routine Recurrent Cost Traditional Vaccines 121,468,320 133,110,840 143,364,480 257,780,880 251,841,240 Underused Vaccines 722,558,640 792,738,600 831,649,800 918,427,920 1,001,858,400 New Vaccines 1,889,289,000 1,700,738,400 2,681,300,520 3,067,381,080 3,395,472,360 Injection supplies 84,798,120 93,686,400 107,041,680 121,558,800 129,663,360 Personnel 915,044,520 1,075,057,920 1,128,810,840 1,185,251,400 1,244,514,000 Transportation 52,928,500 126,273,600 197,386,920 215,424,480 234,477,600 Other routine recurrent costs 330,463,200 418,436,160 484,730,520 528,543,000 538,444,080 Vehicles 76,060,800 151,165,440 159,563,520 0 0 Cold chain equipment 133,715,160 167,780,400 264,354,000 167,577,840 12,321,600 Other capital equipment 13,015,200 5,285,280 3,289,800 0 0 Campaigns 3,638,925,240 3,899,680,080 4,024,885,800 3,629,879,280 2,928,887,640 Total 7,978,266,700 8,563,953,120 10,026,377,880 10,091,824,680 9,737,480,280
Figure : Composition of the Funding Gap (Immunization Specific Only) Composition of the funding gap 2014 2015 2016 2017 2018 Avg. 2014 - 2018 Vaccines and injection equipment 0 0 29,274,587 33,215,076 36,644,423 99,134,086 Personnel 106,120 0 0 0 178,475 284,595 Transport 0 0 0 0 0 0 Activities and other recurrent costs 566,357 2,435,947 2,513,850 4,211,234 4,487,034 14,214,422 Logistics (Vehicles, cold chain and other equipment) 1,856,593 2,559,069 3,560,061 1,396,482 102,680 9,474,884 Campaigns 191,271 10,378,680 33,540,715 28,434,814 24,407,397 96,952,876 Total Funding Gap* 2,720,342 15,373,696 68,889,213 67,257,605 65,820,008 220,060,864
102 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Executive Summary
Figure : Sustainability Indicators
Macroeconomic and Sustainability Indicators 2012 2014 2015 2016 2017 2018
Per capita GDP ($) $ 1,256 $ 1,332 $ 1,372 $ 1,414 $ 1,456 $ 1,500
Total health expenditures per capita (THE per capita $) $ 30 $ 32 $ 33 $ 34 $ 35 $ 36
Population 25,929,799 27,375,547 28,128,375 28,901,905 29,696,708 30,513,367
GDP ($) $ 32,567,827,544 $ 36,464,229,078 $ 38,592,130,373 $ 40,867,293,978 $ 43,238,406,282 $ 45,770,050,606
Total Health Expenditures (THE $) $ 777,893,970 $ 876,017,515 $ 928,236,372 $ 982,664,777 $ 1,039,384,766 $ 1,098,481,215
Government Health Expenditures (GHE $) $ 77,789,397 $ 96,361,927 $ 102,106,001 $ 117,919,773 $ 124,726,172 $ 142,802,558
Resource Requirements for Immunization
Routine and Campaigns ($) $ 30,598,806 $ 78,225,283 $ 84,379,467 $ 97,953,175 $ 97,710,930 $ 95,447,072
Routine Only ($) $ 25,619,011 $ 47,900,906 $ 51,882,132 $ 64,412,459 $ 67,461,936 $ 71,039,675 per DTP3 child ($) $ 43 $ 72 $ 71 $ 84 $ 80 $ 78
% Total Health Expenditures
Resource Requirements for Immunization
Routine and Campaigns (Includes Vaccines and Operational Costs) 3.93% 8.93% 9.09% 9.97% 9.40% 8.69%
Routine Only 3.29% 5.47% 5.59% 6.55% 6.49% 6.47%
Funding Gap
With Secure Funds Only 0.48% 1.83% 7.18% 6.47% 7.27%
With Secure and Probable Funds 0.47% 0.62% 0.69% 0.45% 0.44%
% Government Health Expenditures
Resource Requirements for Immunization
Routine and Campaigns (Includes Vaccines and Operational Costs) 39.34% 81.18% 82.64% 83.07% 78.34% 66.84%
Routine Only (Includes Vaccines and Operational Costs) 32.93% 49.71% 50.81% 54.62% 54.09% 49.75%
Funding Gap
With Secure Funds Only 4.40% 16.64% 59.87% 53.92% 55.89%
With Secure and Probable Funds 4.29% 5.60% 5.76% 3.78% 3.42%
% GDP
Resource Requirements for Immunization
Routine and Campaigns (Includes Vaccines and Operational Costs) 0.09% 0.21% 0.22% 0.24% 0.23% 0.21%
Routine Only (Includes Vaccines and Operational Costs) 0.08% 0.13% 0.13% 0.16% 0.16% 0.16%
Per Capita
Resource Requirements for Immunization
103 Comprehensive multi-Plan | Immunization Program of Khyber Pakhtunkhwa Executive Summary
Macroeconomic and Sustainability Indicators 2012 2014 2015 2016 2017 2018
Routine and Campaigns (Includes Vaccines and Operational Costs) $ 1.18 $ 2.86 $ 3.00 $ 3.39 $ 3.29 $ 3.13
Routine Only (Includes Vaccines and Operational Costs) $ 0.99 $ 1.75 $ 1.84 $ 2.23 $ 2.27 $ 2.33
104