(Herams) in Health Facilities of FATA, Pakistan

Health Resource Availability and Mapping System (HeRAMS) in Health Facilities of FATA, Pakistan

Prof Dr. Zia Ul Haq (PhD, MPH, MBBS), Dean Faculty of Public Health & Social Sciences Khyber Medical University, Peshawar, Pakistan 1 [email protected], +92 91 9217258

Forward

Federally Administered Tribal Areas (FATA) of Pakistan is one of the disadvantaged regions in Pakistan and has been through a turbulent phase since 2008, due to reprobate activities by the non-state actors, resulting in displacement of millions of people from FATA to nearby districts of Khyber Pakhtunkhwa and other provinces. The destabilization affected the delivery of social services within FATA.

Over the last few years, the security situation in FATA has markedly improved due to concerted efforts of the government law enforcement agencies and civil institutes and more than 1.6 million displaced populations have voluntarily returned to their homes in FATA. The government of Pakistan has developed a 10 year Socio-economic Development plan for FATA to revive the infrastructure and social sector. To that effect, the development partners are also aligning their support through a 3 Year FATA Transition Plan in line with that of the government. Availability of comprehensive and reliable data to inform planning and measuring achievement of health program is paramount. The Health Resource Availability and Mapping (HeRAMS) is the first comprehensive health facility assessment in FATA. We envisage that findings of this assessment will provide the basis for policy development, planning and research. Program managers will also use the results of the findings for planning, implementation, monitoring and evaluation of the program.

To achieve the desired effect, results of this assessment will be widely disseminated at the different planning level using different dissemination techniques to reach the different segments of the society.

Lastly, we express our appreciation to the colleagues from FATA Health Directorate and Khyber Medical University for successfully conducting HeRAMS in FATA. We look forward to continue working with you towards improvement of the health indicators in FATA and an overall improvement in the health status of the people of FATA.

Dr. Nima Saeed Abid Head of WHO Office in Pakistan(a.i)

Acknowledgement

The Directorate of Health FATA in collaboration with Khyber Medical University Institute of Public Health & Social Sciences (KMU-IPH&SS), Peshawar, Pakistan and World Health Organization Pakistan has successfully completed health facilities assessment “Health Resource Availability and Mapping (HeRAMS)” in FATA. The assessment was commissioned in November 2017 to assess the health infrastructure and services in all government health facilities in all seven Agencies and six Frontier Regions (FRs), and was completed in April 2018. The FATA Health Directorate is extremely grateful for the technical cooperation from the Khyber Medical University leadership and senior management, more especially the Vice Chancellor Prof. Dr. Arshad Javed for facilitating the KMU research team. The Directorate is grateful for the excellent research work carried out by Professor Dr. Zia Ul Haq, Dean IPH&SS and his team and congratulates him on the successful execution and completion of the exercise. The FATA Health Directorate is also extremely grateful to Dr. Muhammad Assai Ardakani, ex-Head of Office, WHO Pakistan and Dr. Nima Saeed Abid current Head of WHO office in Pakistan; who led the exercise by bringing in their expertise as Health Systems Specialist and the comparative advantage of World Health Organization as the lead technical Agency for health. The Directorate equally acknowledges the technical expertise and cooperation of Dr. Michael Lukwiya, Team Lead Health Emergencies, WHO Pakistan; Dr. Muhammad Saeed Akbar Khan, Head of WHO office for KP/FATA and Dr. Sardar Hayat Khan, NPO Surveillance and Health Emergencies, WHO Pakistan who extended their technical assistance throughout the exercise. The Directorate is also grateful to the wonderful support extended by its team at the Directorate, all program managers, Agency Surgeons of all FATA agencies and assistant Agency Surgeons at the FRs for facilitating and supporting the exercise. This report provides invaluable information about health sector in FATA but the ground situation is frequently changing and hence changing context therefore, before making any important decision, the FATA health directorate must be consulted.

Dr. Jawad Habib Khan Director Health Services, FATA

Acronyms

AHQ H Agency Headquarter Hospital AIDS Acquired Immune Deficiency Syndrome BCC Behaviour Change Communication BHU Basic Health Unit CD Community Dispensary CHC Community Health Center CH Civil Hospital CMWs Community Mid Wives CPR Contraceptive Prevalence Rate DEWS Disease Early Warning System DHS Directorate of Health Services DHIS District Health Information System EHSDP Essential Health Service Delivery Package EmONC Emergency Obstetric and New-born Care EPI Expanded Programme on Immunization FATA Federally Administered Tribal Areas FMT Female Medical Technician FR Frontier Regions HeRAMS Health Resource Availability and Mapping System HFA Health Facility Assessment HIS Health Information System HIV Human Immunodeficiency Virus IDSRU Integrated Disease Surveillance and Response Unit IMNCI Integrated Management of Neonatal and Childhood Illnesses IPH&SS Institute of Public Health & Social Sciences KMU Khyber Medical University LHS Lady Health Supervisor LHV Lady Health Visitor LHW Lady Health Worker LS Labor Suite MCH Maternal and Child Health MDGS Millennium Development Goals MHSDP Minimum Health Service Delivery Package MICS Multi-Indicator Cluster Survey MISP Minimum Initial Service Package MNCH Maternal Neonatal & Child Health MO Medical Officer MT Medical Technician MUAC Mid Upper Arm Circumference OPD Out Patient Department ORS Oral Rehydration Salt/Solution PDHS Pakistan Demographic and Health Survey PHC Primary Health Care PHSA Provincial Health Services Academy PMU Project Management Unit 4

PSDP Public Sector Development Project PSWN Persons with Specific Needs RHC Rural Health Center RTIs Respiratory Tract Infections SDGs Sustainable Development Goals SRH Sexual and Reproductive Health STIs Sexually Transmitted Infections TB Tuberculosis TBA Traditional Birth Attendant TDP Temporarily Dislocated Persons THQ Tehsil Headquarter Hospital TT Tetanus Toxoid UN United Nations UNFPA United Nations Population Fund UNHCR United Nations High Commissioner for Refugees UNICEF United Nations International Children's Emergency Fund WASH Water, Sanitation and Hygiene WFP World Food Program WHO World Health Organization WMO Women Medical Officer

Table of Content

Forward ...... 1 Acknowledgement ...... 3 Executive Summary ...... 12 BACKGROUND OF THE PROJECT: ...... 14 Health System of FATA ...... 17 Civil Dispensary ...... 18 CHC (Community Health Center): ...... 18 Basic Health Unit: ...... 19 MCH Center ...... 20 Labor Suite ...... 20 Lady Health Workers - LHW (Health Homes) ...... 20 Community Mid-Wives (CMW) ...... 20 Lady Health Supervisor (LHS) ...... 20 Vaccinator ...... 20 SECONDARY LEVEL SERVICES: ...... 21 THQ Hospital: ...... 21 CATEGORY “D” Hospital: ...... 21 AHQ HOSPITALS Hospital: ...... 21 Definition of terms; ...... 23 Permanent buildings: ...... 23 Temporary buildings: ...... 23 Permanent buildings: ...... Error! Bookmark not defined. Accessibility: ...... 23 Key tracer medicines: ...... 23 A. Background: ...... 25 a. Health Infrastructure ...... 25 b. Distribution of the 996 health facilities in FATA and FR areas by level: ...... 26 c. Distribution of the 800 health facilities reporting to DHIS in FATA and FR areas: ...... 27 d. The distribution of the 851 Health facilities visited by the team by level and Agency/FR: ... 27 e. The distribution of the 92 Health facilities visited by the team and not providing services some of the basic services by Agency/FR in the Overall FATA: ...... 28 f. The distribution by level of the 92 Health facilities visited by the team and not providing some of the basic services: ...... 29 g. The distribution of the 753 Health facilities (providing all the basic services) visited by the team by level and Agency/FR: ...... 30

h. Distribution of functional health facilities by damage ...... 30 i. Distribution of fully damaged but functional health facilities by level in the overall FATA: .. 31 j. Distribution of partially damaged but functional health facilities by level: ...... 32 k. Ownership of the health facilities infrastructure ...... 32 l. Distribution of health facilities housed in a rented infrastructure by level of the facility: .... 33 m. Type of health facility infrastructure (permanent vs. semi-permanent building) ...... 33 n. Accessibility of the functional health facilities ...... 34 B. Human Resources for Health ...... 35 a. Availability of Human Resources at Basic Health Units ...... 35 i. Availability of Medical officers ...... 35 ii. Availability of LHVs at BHU/CHC ...... 35 iii. Availability of Technicians at BHU/CHC ...... 36 iv. Availability of Laboratory Technicians at BHU/CHC ...... 36 v. Availability of Health Educators at BHU ...... 37 vi. Availability of Dai at BHU/CHC ...... Error! Bookmark not defined. vii. Availability of computer operators at BHU ...... 38 b. Availability of Human Resources at Civil Dispensary ...... 38 i. Availability of Dispenser/ Medical Technician at CD in FATA ...... 38 ii. Availability of LHVs at CDs in FATA ...... 39 iii. Availability of EPI Technician at CDs in FATA ...... 39 c. Availability of Human Resources at RHC level ...... 40 i. Availability of Medical officers at RHC level in FATA ...... 40 ii. Availability of Nurses at RHC level in FATA ...... 40 iii. Availability of LHVs at RHC level in FATA ...... 41 iv. Availability of Medical Technicians at RHC level in FATA ...... 41 v. Availability of Health Educators at RHC level in FATA ...... 42 vi. Availability of Ambulance Drivers at RHC level in FATA ...... 42 d. Availability of Human Resources at AHQ HOSPITALS level ...... 42 i. Availability of Physicians at AHQ hospitals in FATA ...... 42 ii. Availability of Dental Surgeons at AHQ hospitals in FATA ...... 43 iii. Availability of eye specialist at AHQ hospitals in FATA ...... 43 v. Availability of General Surgeons at AHQ hospitals in FATA ...... 44 vi. Availability of Gynecologist AHQ hospitals in FATA ...... 45 vii. Availability of Pediatrician AHQ hospitals in FATA ...... 45 viii. Availability of Anesthetists AHQ hospitals in FATA ...... 45 ix. Availability of Psychiatrist AHQ hospitals in FATA ...... 46

x. Availability of Medical Officers in AHQ hospitals in FATA ...... 46 C. Provision of basic services in FATA ...... 47 a. Provision of basic Lab services in FATA by health facility level: ...... 47 * Available ...... 47 b. Routine Immunization Services: ...... 47 c. Application of IMNCI Protocols in FATA by the level of health facility: ...... 48 d. Availability of screening services for under nutrition/malnutrition/growth monitoring (MUAC or W/H, H/A) in Children: ...... 48 e. Availability of Antenatal services at health facilities (ANC): ...... 50 f. DHIS reporting...... 50 g. Basic EmONC Services in FATA ...... 51 h. Availability of Post-Partum care services by level and Agency ...... 51 D. Availability of basic equipment’s and key medical supplies ...... 53 a. Availability of refrigerator in FATA by the level of health facility ...... 53 b. Availability of safe delivery kit by the level of health facility ...... 53 c. Availability of sterilization equipment (mainly Autoclave) by the level of health facility ..... 54 d. Availability of microscope by the level of health facility ...... 54 e. Availability of delivery table by the level of health facility ...... 55 f. Availability of key antibiotics at a health facility ...... 56 g. Availability of analgesics, antipyretics, non-steroidal anti-inflammatory medicines in FATA by the level of health facilities ...... 56 h. Availability of Oxytocin by the level of health facilities in FATA ...... 57 i. Availability of ORS by the level of health facilities in FATA ...... 57 E. Amenities/others ...... 58 a. Waste management at health facility level ...... 58 b. Source of water at the health facility ...... 58 F. Outpatients Department Services (OPD) ...... 59 a. Availability of services ...... 59 b. OPD consultations ...... 59 c. Consultation during the month of the survey ...... 60 G. Conclusion &Recommendations ...... 61 The functionality of health facility ...... 61 Human Resources for health ...... 61 Basic services ...... 63 Source of water for the health facility ...... 64 Outpatient’s department services ...... 64 Limitations: ...... 64 8

List of Tables

Table 1: Distribution of total number of HF in FATA by Agency/FRs: ...... 25 Table 2 showing the distribution of Total health facility by level and by Agency/Frontier: ...... 26 Table 3 below showing the distribution of the 800 health facilities (reporting to DHIS, FATA) by level and by Agency/Frontier: ...... 27 Table 4 showing details of the distribution of health facilities by Agency/FRs ...... 28 Table 5 showing the Health facilities (not providing some of the basic services) by Agency/FR: ...... 29 Table 6 showing the distribution of health facilities which are not providing some of the basic services by level and Agency: ...... 29 Table 7 shows the distribution of health facilities by Agency/FRs and level ...... 30 Table 8 showing the distribution of damaged health facility by level of structural damage: ...... 30 Table 9 Distribution of extensively damaged health facilities by level in the overall FATA: ...... 31 Table 10 showing the distribution of partially damaged health facilities by Level: ... 32 Table 11 showing the distribution by Agency of functional health facilities housed in a rented building: ...... 32 Table 12 showing the distribution of health facilities housed in a rented infrastructure by level and by Agency/FR...... 33 Table 13 showing the distribution of health facilities building (permanent vs. semi- permanent building) ...... 33 Table 14 showing the distribution of inaccessible health facilities by Agency/FR ..... 34 Table 15 showing the availability of MOs/WMOs at BHUs by Agency/FR level...... 35 Table 16 shows the availability of LHVs at BHUs/CHCs providing basic services by Agency Level ...... 35 Table 17 showing the availability of Technicians at BHUs/CHCs providing basic services at Agency/FR Level: ...... 36 Table 18 showing the availability of Laboratory Technicians at BHUs/CHCs providing basic services by Agency/FR Level: ...... 37 Table 19 showing the availability of health educators at BHUs by Agency ...... 37 Table 20 showing the availability of Dai at BHUs/CHCs providing basic services by Agency/FR level ...... Error! Bookmark not defined. Table 21 showing the availability of computer operators at BHUs by Agency ...... 38 Table 22 showing the availability of Dispenser/ Medical Technician at Civil Dispensaries in FATA by Agency ...... 38 Table 23 Showing the availability of LHVs at Civil Dispensaries providing basic services in FATA by Agency/FR Level: ..... 39 Table 24: Showing the availability of EPI Technicians at Civil Dispensaries providing basic services in FATA by Agency/FR Level: 39 Table 25 showing the availability of Medical officers at RHC level in FATA by Agency ...... 40 Table 26 showing the availability of nursing officers at RHC level in FATA by Agency ...... 41 Table 27 showing the availability of LHV at RHC level in FATA by Agency ...... 41

Table 28 showing the availability of Medical Technicians at RHC level in FATA by Agency ...... 41 Table 29 showing the availability of health educators at RHC level in FATA by Agency ...... 42 Table 30 showing the availability of Ambulance Drivers at RHC level in FATA by Agency ...... 42 Table 31 showing the availability of Physicians at AHQ Hospital level in FATA by Agency ...... 43 Table 32 showing the availability of Dental Surgeons at AHQ HOSPITALS level in FATA by Agency ...... 43 Table 33 showing the availability of Eye Specialist at AHQ HOSPITALS level in FATA by Agency ...... 43 Table 34 showing the availability of Radiologist at AHQ HOSPITALS level in FATA by Agency ...... 44 Table 35 showing the availability of General Surgeons at AHQ HOSPITALS level in FATA by Agency ...... 44 Table 36 showing the availability of Gynecologist at AHQ HOSPITALS level in FATA by Agency level ...... 45 Table 37 showing the availability of Pediatricians at AHQ HOSPITALS level in FATA by Agency ...... 45 Table 38 showing the availability of Anesthetists at AHQ HOSPITALS level in FATA by Agency ...... 45 Table 39 showing the availability of Medical Officers at AHQ HOSPITALS level in FATA by Agency ...... 46 Table 40 showing the availability of basic laboratory services by Agency ...... 47 Table 41: Showing the availability of Routine Immunization at health facility by Agency ...... 47 Table 42 showing the application of IMNCI at health facility by Agency ...... 48 Table 43 Availability of screening services for under nutrition/malnutrition/growth monitoring (MUAC or W/H, H/A) in Children ...... 49 Table 44 showing the availability of ANC services at health facility level by Agency 50 Table 45 showing DHIS reporting at health facility level by Agency: ...... 50 Table 46 showing availability of Basic EmONC at Agency ...... 51 Table 47 showing the availability of post-partum care by facility level in each Agency ...... 52 Table 48 showing the availability of refrigerator at health facility by the Agency .... 53 Table 49 showing the availability of safe delivery kit at health facility by the Agency: ...... 53 Table 50 showing the availability of sterilization equipment at health facility by the Agency: ...... 54 Table 51 showing the availability microscope at health facility by the Agency: ...... 55 Table 52 showing the availability of delivery table at health facility by the Agency . 55 Table 53 showing the availability of key antibiotics at health facility by the Agency . 56

Table 54 showing the availability of analgesics, antipyretics, non-steroidal anti- inflammatory medicines in FATA by the level of health facilities ...... 56 Table 55 showing the availability of Oxytocin by the level of health facilities in FATA ...... 57 Table 56 showing the availability of ORS by the level of health facilities in FATA ... 57 Table 57 showing waste management by facility level in Agency ...... 58 Table 58 showing the availability of safe water at health facility by Agency ...... 58 Table 59 showing availability of outpatient services by level of a health facility in FATA ...... 59 Table 60 showing the average OPD consultations in the last month by the level of health facility: ...... 59 Table 61 Average OPD consultations in the last month: ...... 60

Executive Summary

The overall security situation in FATA has markedly improved. Over 1.6 million people who were initially displaced in KP and other provinces have returned to FATA. Access to health care in the return areas of FATA is poor. A study conducted in October 2017 in FATA by UN agencies revealed that 24% of women who gave birth in the past three years did not seek medical attention during their pregnancy, and utilization of Expanded Programme on Immunization (EPI) is also very low. During the meetings of Director Health Services FATA with WHO Representative in Pakistan, he put forth the need of a scientific assessment of the health facilities in order to facilitate the process of informed decision making. These findings and many others prompted WHO to support FATA Health Directorate to conduct HeRAMS in FATA with the objective of:

1. Assessing and evaluating the public sector Primary and Secondary level health care facilities using WHO HeRAMS tool. 2. Identifying the gaps and needs in resources and services at the Primary and Secondary level health care facilities.

Findings from the assessment revealed that there are 996 health facilities in FATA/FR Areas, out of which 851 health facilities (that were visited) provided all the basic health care services. Total of 300 health facilities have some form of damage to the infrastructure. Concerning infrastructure, 46 health facilities were housed in a temporary/rented building and 49 health facilities were housed in a semi-permanent building. The Agencies most affected in terms of infrastructure are North, South Waziristan, Orakzai and Mohmand Agency.

The available Human resource position at Basic Health Unit are 75% for Medical Officers/Women Medical Officers, 63% Lady Health Visitor, 72% Primary Health Care/Pharmacy, 14% Laboratory Technician and 6% Dai. For Civil Dispensary, the available human resource position is; 71% dispenser/ medical technician, 69% Lady Health Visitor and 39% Expanded Program on Immunization technician. For the Rural Health Centre the filled human resource positions are 53% for Medical officers, 7% Nursing Officers, 30% Lady Health Visitor’s position and 77% medical technicians. There are no Health educators at the RHC in FATA. At the AHQ hospitals level the human resource positions were: 29% Physicians, 36% Dental surgeons, 29% eye specialist, 43% Radiologist, 71% General Surgeons, 36% Gynecologist, 21% Anesthetist and 22% Medical officers. The Agency most affected by the Human Resource challenges is North and South Waziristan Agency and Mohmand Agency.

Regarding provision of services, 40% of the RHCs, 57% of the THQ and 39% of the CHs provide basic Laboratory Services. Only 29% of CDs, 62% BHUs and 80% of RHCs were providing EPI services. Regarding use of IMNCI protocols, only 7% of the Civil Dispensaries, 22% of BHUs, 39% of Civil Hospitals and 43% of THQs were following IMNCI protocols. Child screening for malnutrition were being conducted in 57% of AHQ Hospitals. The availability of Ante-Natal Care services was very low at all levels except AHQ Hospitals. Only 25% of CH, 43% of THQH, 36% of RHC, 16% BHU, 7% of CHC and 5% CDs offers ANC services. Basic EmONC services were being provided in only 23% out of the 252 health facilities (BHU, RHC, THQs where as Basic EmONC services are supposed to be provided in 100% facilities). The most affected Agency/FRs where most of these services were not provided includes; South Waziristan, Mohmand Agency, Khyber Agency, FR Tank, FR Kohat and FR D.I.K.

Availability of equipment and other medical supplies was also a challenge in many of the health facilities. For instance only 46.7% of the health facilities had refrigerator, 22% of health facilities had safe delivery kit, 19% of health facilities had sterilization equipment, 23.7% of the health facilities had delivery table. It is worth mentioning here that some Agencies/ FRs like North Waziristan, South Waziristan and Kurram were more affected as compared to other Agencies/FRs.

There is an urgent need to support FATA to construct new health facilities especially where the infrastructure is totally damaged, repair/renovation of damaged facilities, recruitment of more health workers especially medical officers, nurses and medical technicians. Other areas of support should include training and capacity building of health workers on standard protocols such as IMNCI, ENC etc., provision of medical equipment/supplies and support to FATA health Directorate and Agency/FR health offices regarding monitoring and supervision of the health facilities.

BACKGROUND OF THE PROJECT:

Context

The Federally Administered Tribal Areas (FATA) of Pakistan has a population of 4.5 million. The Region is bordered to the north and west by Afghanistan, to the east by Khyber Pakhtunkhwa (KP) Province and to the south by Baluchistan Province. Administratively, the Region consists of seven Agencies (Mohmand, Orakzai, Bajaur, Khyber, Kurram, North Waziristan, and South Waziristan) and six Frontier Regions (Kohat, Peshawar, Lakki Marwat, Dera Ismail Khan, Tank, and Bannu). There are approximately 3,000 rural villages in FATA. FATA Region is semi-autonomous tribal area and is under the direct control of the Federal Government of Pakistan through a special set of laws called the Frontier Crimes Regulation (FCR). FATA has been a victim of conflict and political instability. According to the Multi- indicator cluster survey (MICS) 2007-08, supported by UNICEF, the health indicators of the region are poor as compared to other regions of the country. Below are some of the indicators;

1. 60 percent of the population lives below the poverty line. 2. Maternal mortality ratio is 380/100,000 as compared to 275/100,000 for KP. 3. The total fertility rate is 5, higher than national average of 3.8. 4. The under 5 mortality rate is 104/1000 live births 5. Infant mortality rate is at 86/1000 live births 6. Neo natal mortality rate is 55 per 1000 live births. 7. The proportion of fully immunized children aged 12-23 months is 33.9%, (29.4% in FRs and 34.4% in Agencies overall) which is extremely low compared to the National average of 76%.

8. Only 49.5% of the women aged 15 to 49 years received antenatal care from skilled health personnel at least once during their last pregnancy (49.2% for Frontier Regions overall and 49.6% for Agencies overall). 9. Only 29.5% of births were attended by skilled health personnel who fall far short of the national average (86%). 10. The proportion of women who were seen by a health provider within six weeks after delivery is 26.5% for FATA as a whole (22.2% for FR and 27.1% for Agencies overall).

Current situation;

The security situation in FATA has markedly improved and the return of Temporary Displaced Persons (TDPs) to their native homes in Khyber, Kurram, Orakzai, South Waziristan and North Waziristan has been on since 2015. About 98% TDPs have voluntarily returned to their homes, while only 2% remain in displacement. Access to health and other social services in the return areas are poor as a result of damaged hospitals, schools and water facilities. No comprehensive assessments have been conducted in the region to assess the availability of health services till date, therefore, the Health Department of FATA requested WHO for facilitation to conduct HeRAMS. Objectives 1. To assess and evaluate the public sector Primary and Secondary level health care facilitates in FATA using WHO tool HeRAMS. 2. To identify the gaps and needs in resources and service delivery at the Primary and Secondary level health care facilities.

Methodology: A consensus building meeting was conducted with Director Health Services FATA. Team members in the meeting comprised of: The Director, Deputy Directors, all Program Managers, WHO technical members from KP/FATA provincial office and a team from Khyber Medical University (KMU) led by Prof. Dr. Zia Ul Haq. The team modified and adapted HeRAMs tool. A follow up meeting was held with the Agency Surgeons from the 7 Agencies and 6 FR’s. This meeting was chaired by the Director Health Services FATA in the presence of KMU and WHO team. The objective of this meeting was to consult and brief Agency/FR administrators about HeRAMs assessment and to consult them on administrative arrangements, monitoring, and supervision arrangements for the purpose.

The data collectors were given three days extensive training of data collection using HeRAMs tool. The training was conducted at Khyber Medical University including a mock exercise. After the training, data collectors were dispatched to the field to collect data. In addition the tool was previously piloted and field tested in Kurram Agency, from the data collection to the analysis. Data collection was conducted over a period

of two weeks. The data collection was supervised by the study consultants. They were aided by the Agency Surgeons but had no role in data collection or analysis. Data was recorded on hardcopy and transported to the provincial office at KMU for conversion into a softer version.

Data were entered and analyzed using STATA version 14. Descriptive analyses were performed. Data analysis is presented in the form of tables showing number and percentages for the ease of understanding. Results are stratified on Agency level and level of health facilities. The assessment findings were evaluated against the available standards set by FATA Health Directorate, however; FATA does not have a proper approved Minimum/Essential Health Service Delivery Package (MHSDP/EHSDP). The HeRAMs assessment team comprised of the Principal Investigator, responsible for the overall assessment. He was assisted by the Co-Principal Investigators who provided assistance to the Principal Investigators in the modification and adaption of the data collection tools, coordinating data collection activities, identification and recruitment of data collectors, training of data collectors, facilitation in the training of Agency Surgeons and data collectors. The Agency Surgeons with support from Agencies focal persons supervised the exercise in their areas of jurisdiction but had no role in data collection. The data collectors who are graduates of Khyber Medical University with Masters of Public Health were responsible for data collection for all the health facilities.

Data variables:

Following is the list of variables analyzed: 1. Health infrastructure a. Total number b. Distribution i. By level ii. Functionality iii. Geographic location iv. Damage v. Ownership vi. Infrastructure type vii. Accessibility 2. Human Resources for Health a. Human resources at BHU b. Human resource at CD c. Human resource at RHC d. Human resource at AHQ HOSPITALS 3. Provision of basic services a. Laboratory services b. Routine immunization services c. Application of IMNCI 16

d. Nutrition services e. ANC services f. DHIS reporting g. Basic EmONC h. Post-Partum care i. Medical Waste management 4. Availability of basic equipment and medical supplies a. Refrigerator b. Safe maternal delivery kit c. Sterilization equipment d. Microscope e. Delivery table f. Anti-biotics g. Analgesics, antipyretics, anti-inflammatory medicines h. Oxytocin i. ORS 5. Amenities a. Source of water what about power supply/electricity? b. Waste management 6. Outpatient department a. Availability b. Utilization

Health System of FATA

Health Service delivery in FATA is through Primary and Secondary level health care facilities. Primary Health care services are provided either through community based care services or facility-based care. Community health workers include Lady Health Workers (LHWs) and Community Mid Wives (CMWs). Facility-based services are offered via a network of civil dispensaries (CD), Basic Health Units (BHUs), and Rural Health Centers (RHCs). FATA has one additional type of health facility, Community Health Centre (CHC), which is a modified form of BHU. They also have some of the BHUs called as model BHU(Needs to be defined). Specialized curative services are provided through Secondary Care level referral centers like Tehsil Headquarter Hospitals and Agency Head quarter Hospitals. FATA does not have a Tertiary Care Hospital hence patients requiring tertiary care are referred to the Tertiary Care Hospital in Khyber Pakhtunkhwa. Note that with a few exceptions, the general structure of PHC in FATA and five provinces of Pakistan are comparable. Below are details of services offered through the Primary Health Care facilities. Civil Dispensary

A Civil Dispensary should function at least six hours/day and is supposed to offer the following services: General treatment and referral services for locally endemic disease, Basic MNCH services, Immunization services, Health education and promotion services, Screening and referral services, Pharmacy services, Infection control services, Emergency and disaster preparedness, Water and sanitation services and DHIS reporting.

The human resource requirement for CDs as recommended in the minimum health delivery package are; one Pharmacy technician/Dispenser/Medical Technician one LHV, one EPI Technician, One Chowkidar/orderly and one Behishti cum sweeper. Note that in some areas of the country CD may also have a Medical Officer/Women Medical Officer. CHC (Community Health Center):

CHC are expected to offer all services offered by the Civil Dispensary in addition CHC must provide antenatal care, maternal delivery care, Basic EmONC services, postpartum care, family planning (Condoms, Oral Contraceptives), Immunization, IMNCI, Treatment of Malaria and Tuberculosis (general treatment and referral services for locally endemic disease), health education and promotion services, infection control, emergency and disaster preparedness, water and sanitation, DHIS reporting.

A CHC is expected to take care of a population of 10,000 (5000 needs verification) people. Minimum staff required for a CHC is Two Medical Technicians, Two Midwives, Two LHVs, and Two Vaccinators.

Basic Health Unit:

BHUs are expected to function all the time (24 hours, seven days a week). However, the provinces may decide the duration based on their finances and human resource availability. The minimum working hours should be six hours per day. The services offered at BHUs include: MNCH services including Basic EmONC*, Family planning, Immunization services, prevention and control of locally endemic disease, Disaster Preparedness and Emergency Services, Mental health services, Oral health services**, environmental health including water and sanitation services, disability prevention, Infection control, Health Education and Promotion, School Health Services, Health Information generation and DHIS reporting, pharmacy services, limited lab and diagnostic services and referral service. Note that *Assisted vaginal deliveries are provided only if WMO is present. In addition oral health are offered **Based on availability of a dental surgeon

The human resource requirement for BHUs include:01 MO/WMO (Ideally with a diploma in Family Medicine), 01 Medical technician, 01 LHV, 01 School health and nutrition supervisor, 01 Dispenser, 02 Midwives, 01 Lab technician, 01 Vaccinator, 01 Computer operator, 01 Sanitary patrol, 01 Naib Qasid, 01 Aaya, 01 Chowkidar and 02 Sanitary workers.

Rural Health Centers:

The RHC is required to be open all day long (24/7) and must offer the following services: MNCH services including Comprehensive EmONC*, Family Planning services including birth spacing, Immunization services, prevention and control of locally endemic disease, disaster preparedness and emergency services, mental health services, oral health services, environmental health including water and sanitation services, disability prevention, Infection control, health education and promotion, school health services, health information generation and DHIS reporting, pharmacy services, limited lab and diagnostic services and referral service. Note that Comprehensive EmONC is offered subject to availability of blood transfusion services Gynecologist or General Surgeon, and anesthesia staff.

The human resource requirement for RHC includes:01 Senior Medical Officer (I/C), 03 MO (Ideally with a diploma in Family Medicine), 02 WMO (Ideally with a diploma in Family Medicine) Anesthetist, 01 Dental surgeon, 01 Dental Technician, 03 LHV, 06 Dispenser, 06 Charge nurse, 04 Midwife, 02 Lab technician, 02 X-ray technician, 01 Operation theatre assistant/anesthesia assistant, 02 Vaccinators, 01 Dresser, 02 Computer operators, 01 Senior clerk, 01Sanitary Inspector, 02 Sanitary patrols, 01 Store keeper, 02 NaibQasid, 02 Mali, 04 Ward servants, 02 Aaya, 03 Chowkidars and 03 Sanitary workers.

MCH Center

MCHC facilities During the literature review, no description could be found regarding Mother and Child Health Center (MCHC). An obvious subjective analysis reflects on the type of services been provided are Antenatal, Natal and Postnatal services, immunizations and health education. Labor Suite An overview of maternal services to be offered through PHC outreach staff and also to normalize birth as far as is possible. Lady Health Workers - LHW (Health Homes) A lady Health Worker should be available 24 hours and should offer the following services: health education and promotion for oral hygiene, prevention and control (limited) of locally endemic disease, MNCH services, Ante and post-natal services, new born care, Family Planning services including birth spacing, Immunization services, child health services, nutrition, counseling and screening of various health conditions in the community, disability prevention services, emergency and disaster preparedness services, Water and Sanitation services, referral to appropriate providers and facilities. Community Mid-Wives (CMW)

A community Mid-Wife should be available 24 hours and is expected to offer the following services: Community assessment and rapport building, MNCH services, Ante, intra, and post-natal services, Newborn care, Family Planning services including birth spacing, Immunization services, dispensing of oral contraceptives, health education and promotion, screening services, referral services. In addition CMW is responsible for building linkages; report/interact with Lady Health Supervisor (LHS); LHWs, WMO; Lady Health Visitor (LHV). Lady Health Supervisor (LHS) A LHS is expected to work for limited hours and to provide the following services; Supervision and support to LHWs and CMWs, in a BHU’s catchment area, liaison between the community workers and the Agency Health Management team including National Program Coordinators, monitoring of workers progress, conduct health education and promotion sessions, water and sanitation services, emergency and disaster preparedness services, should identify the training and support needs of the health workers under her supervision and provide training and support accordingly and DHIS reporting. Vaccinator

Should be available during OPD timing at BHU and should offer the following services: health promotion and education, routine immunization services, record maintenance of Immunization services, limited MNCH services (Vaccination), liaison with the LHWs 20

and CMWs for follow up with the defaulter children and complete their immunization course and community mobilization during outreach services. SECONDARY LEVEL SERVICES: Tehsil Headquarter, Category “D” hospitals and Agency Headquarter Hospitals are specialized centers where complicated cases are referred from the Primary care centers for diagnosis and treatment by specialist doctors and also for intensive care and emergency care services. For highly specialized diagnosis and treatment beyond the scope of THQ and AHQ Hospitals, cases are referred to Tertiary Care Hospital in big cities of Khyber Pakhtunkhwa. THQ Hospital: The following specialist services both outdoor and in patients facilities are provided in the THQ hospitals:  Medicine,  Surgery,  Gynecology and Obstetrics,  Pediatric Medicine,  Dentistry,  Accident & Emergency Services. CATEGORY “D” Hospital: The category D secondary care hospitals have both in-patient and outpatient services in addition to emergency, diagnostic and other day care facilities, and is intended to serve a population of approximately 100,000 people in its catchment 24/7. The clinical specialties that are available at a category D hospital are:  Medicine,  Surgery,  Gynecology and Obstetrics,  Pediatric Medicine,  Dentistry,  Accident & Emergency Department. AHQ HOSPITALS Hospital: The following specialist services both outdoor and in patients facilities are provided in the AHQ Hospitals:  Medicine,  Surgery,  Gynecology and Obstetrics,  Pediatric Medicine,  Dentistry,  ENT,

 EYE,  Orthopedics,  ICU,  CCU,  Accident & Emergency Services. In addition to the above mentioned specialized services, other allied services like EPI, nutrition, general OPD, laboratory, pharmacy and radiology services are also provided in these secondary level health care facilities.

Definition of terms

Permanent buildings:

These types of structures take long to erect. On average at least 2 to 6 months is required to complete the building. The buildings are built to last more than 10 years. They are usually made of brick, concrete and steel, with a wooden or fabricated steel frame. Temporary buildings:

Temporary buildings are designed to be fast to erect. This means a lead time of 7 to 28 days, depending on the size and style of the building. It simply reflects their modular and prefabricated nature. Some temporary structures are designed to be fixed to any hard standing surface using bolts or spikes, without any foundations or ground preparation. Temporary buildings can be either aluminium box framed, for structures designed for two years of use or less, or steel framed and clad, for longer term temporary buildings. Temporary buildings are designed for a shorter period of use than permanent buildings. Accessibility:

In this assessment accessibility means that the services are available and there is an adequate supply of services; the community has available resources to afford the services, the health facility is within reach of the community and the services are relevant and acceptable to the community. Key tracer medicines:

We selected four key tracer medicines from the list of essential medicines. Note that essential medicines are group of medicines that addresses the majority and priority health care needs of the population. Essential medicines are selected based on disease prevalence and public health need of the population. In this assessment we selected key tracer medicines as proxy for analysis of availability of essential medicines at the health facilities. The tracer medicines are; Oral Rehydration Salt, Oxytocins, Analgesics (Ibuprofen), Antibiotics (Amoxicillins).

Safe water source:

Safe water means water without any form of contamination. The most common use of this term applies to drinking water, but it could also apply to water for swimming or other uses.

Unsafe water source:

Unsafe water means water that will harm you if you come in contact with it and usually refers to biological or chemical contamination.

Average consultation:

The mean (average) number of out-patient consultation in the last month at a health facility.

Damage to health facility

Fully damaged health facility: based on the finance actually if the total cost of the hospital rehabilitation is 70% or more than 70% of its total reconstruction cost, it’s fully damaged

Partially damaged: if the cost of rehabilitation is less than 70% of the total reconstruction cost then the facility infrastructure is defined as partially damaged.

Functionality of the health facility:

Functional health facility: the facility is providing some/whole of the mandated health services it’s supposed to provide based on the availability of patients record during the month of the survey. That means that the health facility is providing services to the community.

Non-Functional health facility: the facility is not providing health services. There is no patient’s record during the month of the survey.

Key findings

A. Background: a. Health Infrastructure

There are 996 health facilities in FATA. Among these 800 of the health facilities are reporting to DHIS FATA. Of the total 996 HF KMU team visited 851 HF, rest of the HF 145 health facilities could not be accessed by the team due to security reasons. The assessment team visited 851 health facilities in FATA. Looking at the Agency/FR specifics, the team visited over 90% of the health facilities in FR Tank, FR D I Khan, FR Lakki, FR Kohat, Kurram Agency, Mohmand Agency and Bajaur Agency. See details in the table 1 below showing the distribution of total number of health facilities by Agencies/FRs.

Table 1: Distribution of total number of HF in FATA by Agency/FRs: Agency/FR Total # of HF by Facilities reporting HF visited Proportion of HF Agency/FRs to DHIS visited (%) Bajaur 44 41 41 93.18 Mohmand 85 85 76 89.41 Khyber 62 52 52 83.87 Kurram 78 70 77 98.72 Orakzai 71 57 53 74.65 NWA 313 255 270 86.26 SWA 135 45 86 63.70 FR Peshawar 20 17 17 85.00 FR Kohat 19 19 19 100.00 FR Bannu 79 69 70 88.61 FR Lakki 20 20 20 100.00 FR D I Khan 19 19 19 100.00 FR Tank 51 51 51 100.00 Total number of HF by 996 800 851 85.44 level

b. Distribution of the 996 health facilities in FATA and FR areas by level:

Majority of the 996 health facilities (Details provided by Directorate FATA) in FATA are located in North Waziristan and South Waziristan Agency. In addition most of the health facilities are Community Dispensary (461), Community Health Centers (215) or Basic Health Units (174). The AHQ HOSPITALS are only found in the Agencies not Frontier Regions. See table 2 below for details.

Table 2 showing the distribution of Total health facility by level and by Agency/Frontier: AHQ Cat. D MH CH Agency/FR HOSPI THQH CH RHC BHU CD MNCH LS Total Hosp. F C TALSH Bajaur 1 0 1 1 3 0 19 8 11 0 0 44 Mohmand 1 0 0 1 3 0 25 19 36 0 0 85 Khyber 1 1 0 2 0 0 13 26 17 2 0 62 Kurram 1 2 0 1 0 0 22 49 2 1 0 78 Orakzai 1 0 0 3 2 0 27 30 8 0 0 71 NWA 1 1 0 7 1 0 16 147 53 71 16 313 SWA 1 0 5 4 0 1 16 56 50 2 0 135 FR Peshawar 0 0 0 1 1 0 7 6 5 0 0 20 FR Kohat 0 0 0 1 0 0 9 8 1 0 0 19 FR Bannu 0 0 0 0 0 0 11 56 10 2 0 79 FR Lakki 0 0 0 0 0 0 3 11 6 0 0 20 FR D I Khan 0 0 0 1 0 0 2 7 9 0 0 19 FR Tank 0 0 0 1 1 0 4 38 7 0 0 51 Total # of HF 7 4 6 23 11 1 174 461 215 78 16 996 by level

Agency wise distribution of Health facilites in FATA 313

135 85 78 71 79 44 62 51 20 19 20 19

c. Distribution of the 800 health facilities reporting to DHIS in FATA and FR areas:

There are 800 health facilities reporting to DHIS which are not totally destroyed. The majority 256 (32%) are in North Waziristan Agency. Note that North Waziristan Agency has Maternal &Child Health Centers and LS/SHC centers which are not found in other Agencies/FR. This could partially explain the high number of health facilities found in NWA. See table 3 below for details of the distribution of the HF by level and Agency/FR

Table 3 below showing the distribution of the 800 health facilities (reporting to DHIS, FATA) by level and by Agency/Frontier:

AHQ Cat D LS/ Agency/FR THQ CH RHC MHF BHU CD CHC MCH Total HOSPITALS Hosp SHC Bajaur 1 0 1 1 3 0 19 8 8 0 0 41 Mohmand 1 0 0 1 3 0 25 19 36 0 0 85 Khyber 1 1 0 2 0 0 12 22 12 2 0 52 Kurram 1 2 0 0 0 0 20 44 2 1 0 70 Orakzai 1 0 0 3 2 0 23 23 5 0 0 57 NWA 1 1 0 5 1 0 12 123 47 52 14 256 SWA 1 0 3 3 0 1 6 27 4 0 0 45 FR Peshawar 0 0 0 1 1 0 7 5 3 0 0 17 FR Kohat 0 0 0 1 0 0 9 8 1 0 0 19 FR Bannu 0 0 0 0 0 0 11 49 9 0 0 69 FR Lakki 0 0 0 0 0 0 3 11 6 0 0 20 FR D I Khan 0 0 0 1 0 0 2 7 9 0 0 19 FR Tank 0 0 0 1 1 0 4 38 7 0 0 51 Total FATA / 7 4 4 19 11 1 153 384 148 55 14 800 FR

Agency wise distribution of Functional Halth facilities (DHIS)

256

85 70 69 41 52 57 45 51 17 19 20 19

d. The distribution of the 851 Health facilities visited by the team by level and Agency/FR:

The team visited and assessed 851 health facilities in FATA and FR. The health facilities are distributed as follows: 7 AHQ HOSPITALS, 7 THQ, CH 20, 11 RHC, 203 BHUs, 414 CD,

104 CHC, 64 MNCH and 15 LS/SHC. The table 4 below shows the details of the distribution of health facilities by Agency/FRs and level in FATA.

Table 4 showing details of the distribution of health facilities by Agency/FRs

Agency/FR AHQ THQ CH RHC BHU CHC CD MNCH Other Total Bajaur 1 2 0 3 14 16 5 0 0 41 Mohmand 1 0 0 3 53 5 13 0 0 76 Khyber 1 1 2 0 12 10 24 2 0 52 Kurram 1 2 2 0 19 2 49 0 1 77 Orakzai 1 0 2 2 20 5 22 0 0 53 NWA 1 1 7 1 32 15 138 61 13 270 SWA 1 1 3 0 12 19 47 1 1 85 FR Peshawar 0 0 1 1 6 3 5 0 0 17 FR Kohat 0 0 1 0 9 2 7 0 0 19 FR Bannu 0 0 0 0 12 7 51 0 0 70 FR Lakki 0 0 0 0 6 6 8 0 0 20 FR DI Khan 0 0 1 0 4 7 7 0 0 19 FR Taank 0 0 1 1 4 7 38 0 0 51 Total 7 7 20 11 203 104 414 64 15 851

Agency wise distribution of total visited health facilities in the overall FATA

269

85 76 75 70 52 52 51 41 20 19 19 16

e. The distribution of the 92 Health facilities visited by the team and not providing services some of the basic services by Agency/FR in the Overall FATA:

Out of the 851 health facilities visited 92 (12%) health facilities were not providing services based on the absence of patients records in the month of the assessment. Majority of these health facilities are in South Waziristan (37%), Mohmand Agency (17%) and North Waziristan (10%). See table below for details.

Table 5 showing the Health facilities (not providing some of the basic services) by Agency/FR: Agency/ FR Total Providing Not providing a number % of health facilities not visited All Basic of basic services providing a number of basic services services Bajaur 41 41 0 0 Mohmand 76 63 13 17 Khyber 52 52 0 0 Kurram 77 70 7 9 Orakzai 53 47 6 11 NWA 270 243 27 10 SWA 86 54 32 37 FR Peshawar 17 17 0 0 FR Kohat 19 18 1 5 FR Bannu 70 66 4 6 FR Lakki 20 20 0 0 FR DI Khan 19 18 1 5 FR Taank 51 50 1 2 Total 851 759 92 10 f. The distribution by level of the 92 Health facilities visited by the team and not providing some of the basic services:

Majority of the 92 health facilities which are not providing health services are either BHUs (19%), or CHC (13%) or CDs (49%). Most of the health facilities are located in South Waziristan (32%), North Waziristan (27%) of Mohmand Agency (13%). See details in the table 6 below

Table 6 showing the distribution of health facilities which are not providing some of the basic services by level and Agency:

Agency/FRs BHU CD CH CHC MNCH Other RHC Total Mohmand 12 1 0 0 0 0 0 13 Kurram 1 5 1 0 0 0 0 7 Orakzai 1 4 0 0 0 0 1 6 NWA 1 15 1 2 3 4 1 27 SWA 4 17 0 11 0 0 0 32 FR Kohat 0 1 0 0 0 0 0 1 FR Bannu 0 4 0 0 0 0 0 4 FR DI Khan 0 1 0 0 0 0 0 1 FR Taank 0 1 0 0 0 0 0 1 Total 19 49 2 13 3 4 2 92

g. The distribution of the 753 Health facilities (providing all the basic services) visited by the team by level and Agency/FR:

Most of these health facilities are found in NWA (242), Kurram (69), FR Bannu (66), Mohmand Agency (62), and Khyber Agency 52. Majority of the health facilities are either CD or BHU or CHC. See details in table 7below:

Table 7 shows the distribution of health facilities by Agency/FRs and level

Agency/FR AHQ THQ CH RHC BHU CD CHC MNCH Other Total Bajaur 1 2 0 3 14 5 16 0 0 41 Mohmand 1 0 0 3 41 12 5 0 0 62 Khyber 1 1 2 0 12 24 10 2 0 52 Kurram 1 2 1 0 18 44 2 0 1 69 Orakzai 1 0 2 1 19 18 5 0 0 46 NWA 1 1 6 0 31 123 13 58 9 242 SWA 1 1 3 0 8 30 8 1 1 53 FR Peshawar 0 0 1 1 6 5 3 0 0 16 FR Kohat 0 0 1 0 9 6 2 0 0 18 FR Bannu 0 0 0 0 12 47 7 0 0 66 FR Lakki 0 0 0 0 6 8 6 0 0 20 FR DI Khan 0 0 1 0 4 6 7 0 0 18 FR Taank 0 0 1 1 4 37 7 0 0 50 Total 7 7 18 9 184 365 91 61 11 753 h. Distribution of functional health facilities by damage

Out of the total 753 health facilities (providing services based on the availability of patient records at the time of assessment) in the FATA, 300 (39 %) health facilities have damage to the infrastructure. Among this 256 (85%) are partially damaged while 42 (15%) have extensive damage to the health facilities infrastructure but continue to offer services. The most affected Agency/FR in terms of fully damaged is FR Lakki, FR Peshawar, North Waziristan Agency, Mohmand Agency and FR Tank. See table 8 below for details.

Table 8 showing the distribution of damaged health facility by level of structural damage:

Agency/FR Overall Damage Partially Damaged Extremely damaged Bajaur 30 29 1 Mohmand 12 10 2 Khyber 28 20 8 Kurram 21 19 2 Orakzai 27 21 6 NWA 48 45 3 SWA 21 18 3 30

FR Peshawar 11 10 1 FR Kohat 8 8 0 FR Bannu 37 37 0 FR Lakki 19 18 1 FR DI Khan 15 13 2 FR Taank 23 10 13 Total 300 256 42

Agency wise distribution of Structural Damage Assessment

90 80 70 60 50 40 30 20 10 0

Damaged Partially Damage Extensively damage

i. Distribution of fully damaged but functional health facilities by level in the overall FATA:

Out of the 42 extensively damaged health facilities in the overall FATA, the majority of the health facilities were Civil dispensaries (n=25) followed by Basic Health units (n=10). See Table 9 below for details;

Table 9 Distribution of extensively damaged health facilities by level in the overall FATA: Agency BHU CD CHC MNCH Total Bajaur 0 0 1 0 1 Mohmand 1 1 0 0 2 Khyber 1 5 2 0 8 Kurram 1 1 0 0 2 Orakzai 1 3 2 0 6 NWA 0 1 1 1 3 SWA 1 2 0 0 3 FR Peshawar 1 0 0 0 1 31

FR Lakki 0 1 0 0 1 FR DI Khan 1 1 0 0 2 FR Taank 3 10 0 0 13 Total 10 25 6 1 42 j. Distribution of partially damaged but functional health facilities by level:

Of the 300 damaged health facilities, 254 (84%) health facilities are partially damaged. The most affected level of HF are CD, BHUs and CHCs. Note that 9 CH and 1 THQ were also damaged. North Waziristan has the highest number (45) of the partially damaged HFs followed by FR Bannu i.e. 37 HF. Bajaur Agency has about 27 HF of the total partially damaged health facilities. See table 10 below for details

Table 10 showing the distribution of partially damaged health facilities by Level:

Agency/FR AHQ THQ CH RHC BHU CD CHC MNCH Other Total Bajaur 1 0 0 2 12 3 9 0 0 27 Mohmand 0 0 0 0 6 4 0 0 0 10 Khyber 0 1 1 0 4 9 4 1 0 20 Kurram 0 0 0 0 6 12 1 0 0 19 Orakzai 0 0 2 1 11 6 0 0 0 20 NWA 0 0 2 0 6 26 4 6 1 45 SWA 0 0 1 0 2 11 4 0 0 18 FR Peshawar 0 0 1 1 2 3 2 0 0 9 FR Kohat 0 0 0 0 6 2 0 0 0 8 FR Bannu 0 0 0 0 6 27 4 0 0 37 FR Lakki 0 0 0 0 6 6 6 0 0 18 FR DI Khan 0 0 1 0 2 4 6 0 0 13 FR Taank 0 0 1 1 1 6 1 0 0 10 Total 1 1 9 5 70 119 41 7 1 254 k. Ownership of the health facilities infrastructure

Out of the total 850 health facilities in FATA, 46 (5%) health facilities are housed in rented buildings. Among these 46 health facilities, Mohmand Agency has the highest number of health facilities housed in a rented building (n=19), followed by South Waziristan Agency (n= 7), North Waziristan Agency and the Khyber Agency (n=5). See details in Table 11below:

Table 11 showing the distribution by Agency of functional health facilities housed in a rented building: agency Government owned Rented Total Bajaur 40 1 41 Mohmand 57 19 76 Khyber 47 5 52 Kurram 76 1 77 Orakzai 49 4 53 32

NWA 264 5 269 SWA 79 7 86 FR Peshawar 16 1 17 FR Kohat 19 0 19 FR Bannu 69 1 70 FR Lakki 19 1 20 FR DI Khan 19 0 19 FR Taank 50 1 51 Total 803 46 850 l. Distribution of health facilities housed in a rented infrastructure by level of the facility:

Most of the health facilities which are housed in a rented building are BHUs (14), CD, 14 and CHC (17). See table12 below for details

Table 12 showing the distribution of health facilities housed in a rented infrastructure by level and by Agency/FR.

Agency/FR CH BHU CHC CD Total Bajaur Agency 0 0 1 0 1 FR Bannu 0 0 0 1 1 FR Lakki 0 0 0 1 1 FR Peshawar 0 0 0 1 1 FR Tank 0 0 1 0 1 Khyber Agency 0 0 2 3 5 Kurram Agency 0 0 0 1 1 Mohmand Agency 0 14 1 4 19 North Waziristan 1 0 4 0 5 Orakzai Agency 0 0 1 3 4 South Waziristan 0 0 7 0 7 Total 1 14 17 14 46 m. Type of health facility infrastructure (permanent vs. semi-permanent building)

49 service providing health facilities in FATA are housed in the semi-permanent building. Khyber Agency has the highest number of health facilities housed in semi- permanent buildings (11); followed by Mohmand Agency (9) followed by FR Tank (8) and then North Waziristan Agency (6). For details see table 13 below

Table 13 showing the distribution of health facilities building (permanent vs. semi-permanent building) agency Permanent Semi permanent Total Bajaur 40 1 41 Mohmand 67 9 76 Khyber 41 11 52

Kurram 76 1 77 Orakzai 49 4 53 NWA 262 7 269 SWA 83 3 86 FR Peshawar 14 3 17 FR Kohat 19 0 19 FR Bannu 70 0 70 FR Lakki 19 1 20 FR DI Khan 18 1 19 FR Taank 43 8 51 Total 801 49 850 n. Accessibility of the functional health facilities

Among the functional health facilities, 8 facilities are inaccessible. 4 out of the inaccessible health facilities are BHUs and the other 4 are CDs. The major reasons reported for inaccessibility of the health facility is that the health facilities are far and hard to reach for the people. See details in table below

Table 14 showing the distribution of inaccessible health facilities by Agency/FR

Agency/FR CH BHU CHC CD Total FR Bannu 0 0 0 1 1 FR Peshawar 0 1 1 1 3 FR Tank 0 1 0 0 1 Khyber Agency 0 1 0 3 4 Kurram Agency 1 1 0 5 7 Total 1 4 1 10 16

B. Human Resources for Health a. Availability of Human Resources at Basic Health Units i. Availability of Medical officers

The minimum package recommends that each BHU should have one MO/WMO. Finding from this assessments indicate that of the total 185 medical officers required at BHU Level in FATA, only 142 (75%) Medical officers are available In FATA, among the Agencies South Waziristan had the worst situation i.e. only 3 Medical Officer at the BHU level, and followed by North Waziristan Agency i.e. only 12 BHU has the required Medical officers in place. See table 15 below for details.

Table 15 showing the availability of MOs/WMOs at BHUs by Agency/FR level Gap Agency/ FR Name Required Number Available Number

Bajaur Agency 14 12 2 FR Bannu 12 10 2 FR D.I.K 4 3 1 FR Kohat 9 9 0 FR Lakki 6 5 1 FR Peshawar 6 4 2 FR Tank 4 3 1 Khyber Agency 12 10 2 Kurram Agency 19 18 1 Mohmand Agency 53 38 15 North Waziristan Ag.. 19 12 7 Orakzai Agency 20 15 5 South Waziristan 7 3 4 Total 185 142 43 ii. Availability of LHVs at BHU/CHC

Of the required 266 LHVs at BHUs, FATA has only 175 (65%) LHV, There is a gap of 91 LHVs. See table 16 below for details.

Table 16 shows the availability of LHVs at BHUs/CHCs providing basic services by Agency Level

Name of Agency/FR Number of BHUs Available LHV Gap identified % LHVs available at BHUs FR Kohat 11 8 3 73 Bajaur Agency 30 20 10 67 Mohmand Agency 58 32 26 55 South Waziristan Ag. 10 6 4 60 FR Lakki 12 8 4 67 FR Bannu 19 13 6 68 35

FR D.I.K 10 7 3 70 Orakzai Agency 24 18 6 75 Kurram Agency 20 15 5 75 FR Tank 11 7 4 64 North Waziristan Ag. 30 21 9 70 FR Peshawar 9 5 4 56 Khyber Agency 22 15 7 68 Total 266 175 91 66 iii. Availability of Technicians at BHU/CHC

Each BHU requires at least two technicians. Findings from this assessment indicate that of the required 490 PHC/Pharmacy/Medical Technician only 351 (72%) are available. South Waziristan has the lowest number of technicians at the BHUs i.e. 13 (14%) technicians followed by FR DI Khan where 17 technicians are available. See table 17 below for details

Table 17 showing the availability of Technicians at BHUs/CHCs providing basic services at Agency/FR Level: Agency Name # of BHU # Required Available Gap % available at BHUs FR Peshawar 9 18 16 2 89 FR Kohat 11 22 18 4 82 Orakzai Agency 24 48 31 17 65 FR Lakki 12 24 19 5 79 Bajaur Agency 30 60 45 15 75 FR Bannu 19 38 29 9 76 FR Tank 11 22 18 4 82 FR D.I.K 10 20 17 3 85 Mohmand Agency 37 74 59 15 80 Kurram Agency 20 40 30 10 75 North Waziristan Ag. 30 60 34 26 57 South Waziristan Ag. 10 20 13 7 65 Khyber Agency 22 44 22 22 50 Total 245 490 351 139 72 iv. Availability of Laboratory Technicians at BHU/CHC

In the overall FATA the situation of lab technicians at BHU level is very critical i.e. only 34 (14%) out of the required 245 lab technicians are available at BHU level in the FATA. North Waziristan Agency, South Waziristan Agency, Bajaur and Kurram Agency have low number of Lab technician at BHU level. Among the Frontier region, FR Tank, FR Peshawar, FR Kohat and FR DI Khan have less number of Lab technician at BHU level.

This has an impact on quality of care to the patients at the health facilities. Also, it affects the identification of potential epidemic diseases. See table 18 below for details

Table 18 showing the availability of Laboratory Technicians at BHUs/CHCs providing basic services by Agency/FR Level:

Agency/FR Required Available Gap % of lab technicians available Orakzai Agency 24 7 17 29 FR Bannu 19 2 17 11 FR Lakki 12 1 11 8 Khyber Agency 22 1 21 5 Mohmand Agency 37 1 36 3 FR D.I.K 10 2 8 20 FR Kohat 11 2 9 18 FR Peshawar 9 2 7 22 FR Tank 11 2 9 18 Kurram Agency 20 3 17 15 North Waziristan 30 4 26 13 South Waziristan 10 3 7 30 Bajaur Agency 30 4 26 13 Total 245 34 211 14 v. Availability of Health Educators at BHU

In the overall FATA, there is no health educator available at BHU level. According to the data obtained from DHS FATA, there are no sanctioned posts of Health educators in the overall FATA. This has an impact on community mobilization, community sensitization and overall participation of the community in different healthcare activities. See table 19 below:

Table 19 showing the availability of health educators at BHUs by Agency

Agency Total BHUs Available Gap % of HE available at BHU Level Bajaur Agency 14 0 14 0 FR Bannu 12 0 12 0 FR D.I.K 4 0 4 0 FR Kohat 9 0 9 0 FR Lakki 6 0 6 0 FR Peshawar 6 0 6 0 FR Tank 4 0 4 0 Khyber Agency 12 0 12 0 Kurram Agency 19 0 19 0 Mohmand Agency 53 0 53 0 North Waziristan Ag. 19 0 19 0 Orakzai Agency 20 0 20 0 South Waziristan 7 0 7 0 37

Total 185 0 185 0 vi. Availability of computer operators at BHU

In FATA, at the level of Basic Health Unit, there is no computer operator available (0%). This has impacted negatively on disease surveillance and reporting. For details see table 21 below.

Table 20 showing the availability of computer operators at BHUs by Agency Total BHUs % of computer operators Agency Available Gap available at BHU Level Bajaur Agency 14 0 14 0 FR Bannu 12 0 12 0 FR D.I.K 4 0 4 0 FR Kohat 9 0 9 0 FR Lakki 6 0 6 0 FR Peshawar 6 0 6 0 FR Tank 4 0 4 0 Khyber Agency 12 0 12 0 Kurram Agency 19 0 19 0 Mohmand Agency 53 0 53 0 North Waziristan Ag. 19 0 19 0 Orakzai Agency 20 0 20 0 South Waziristan 7 0 7 0 Total 185 0 185 0 b. Availability of Human Resources at Civil Dispensary i. Availability of Dispenser/ Medical Technician at CD in FATA

In FATA, 71% of the Civil Dispensaries have Dispensers/Medical Technician. Among the Agencies, FR Peshawar is the only FR having only 2 Dispenser at the level of the civil dispensary. For details see table below:

Table 21 showing the availability of Dispenser/ Medical Technician at Civil Dispensaries in FATA by Agency Agency Total number of CD Available Gap % of Available Dispenser Dispenser /Medical Technician FR Kohat 6 6 0 100 FR Tank 37 37 0 100 Mohmand Agency 11 7 4 64 Orakzai Agency 16 10 6 63 North Waziristan Ag. 71 43 28 61 Kurram Agency 44 32 12 73 FR Bannu 47 35 12 74 South Waziristan Ag. 16 12 4 75 38

FR Lakki 8 6 2 75 FR D.I.K 6 3 3 50 Khyber Agency 24 14 10 58 Bajaur Agency 5 3 2 60 FR Peshawar 5 2 3 40 Total 296 210 86 71 ii. Availability of LHVs at CDs in FATA

In FATA, the situation of LHV presence at civil dispensaries is not satisfactory. Only 70% of the overall Civil dispensaries in FATA have LHV present at the time of data collection. For details see table 23 below Table 22 Showing the availability of LHVs at Civil Dispensaries providing basic services in FATA by Agency/FR Level: Agency Total number of CD LHV Gap % of LHV available Mohmand Agency 11 7 4 64 Orakzai Agency 16 12 4 75 FR Bannu 47 43 4 91 Bajaur Agency 5 3 2 60 FR D.I.K 6 4 2 67 FR Kohat 6 3 3 50 FR Lakki 8 5 3 63 FR Peshawar 5 4 1 80 FR Tank 37 30 7 81 Khyber Agency 24 16 8 67 Kurram Agency 44 40 4 91 North Waziristan 71 29 42 41 South Waziristan 16 10 6 63 Total 296 206 90 70 iii. Availability of EPI Technician at CDs in FATA

In FATA, there are only 39% of civil dispensaries having EPI technicians, the rest of 61% civil dispensaries have no available EPI technician. Among the Frontier Regions, FR Taank has lowest number of EPI technician available at the level of the civil dispensary. For details see table 24 below.

Table 23: Showing the availability of EPI Technicians at Civil Dispensaries providing basic services in FATA by Agency/FR Level: Agency / FR Total # of CD Available Gap % of EPI technicians available Bajaur Agency 5 5 0 100 FR Peshawar 5 5 0 100 FR Lakki 8 4 4 50

Orakzai Agency 16 7 9 44 Mohmand Agency 11 7 4 64 FR D.I.K 6 3 3 50 FR Kohat 6 4 2 67 Khyber Agency 24 14 10 58 South Waziristan 16 10 6 63 FR Bannu 47 19 28 40 North Waziristan 71 22 49 31 Kurram Agency 44 12 32 27 FR Tank 37 4 33 11 Total 296 116 180 39 c. Availability of Human Resources at RHC level i. Availability of Medical officers at RHC level in FATA

In FATA, only 53% of the required Medical Officers are available. There is no medical officer (Male/Female) available at the RHC level in South Waziristan Agency. The available Medical Officers are all males and therefore no Female Medical Officer is available at RHC level in FATA. For details see table 25 below: Table 24 showing the availability of Medical officers at RHC level in FATA by Agency Agency/FR RHCs Required Available Not available Available Number number / Gap percentage Bajaur Agency 3 12 5 7 42 FR Peshawar 1 4 2 2 50 FR Tank 1 4 3 1 75 Mohmand Agency 3 12 9 3 75 North Waziristan Ag 1 4 1 3 25 Orakzai Agency 2 8 3 5 38 Total 11 44 23 21 52 ii. Availability of Nurses at RHC level in FATA

Only 7% of the required nurses are available at the RHC. Among the Agencies, there is no Nurse available in any of the Agencies or FRs except Bajaur Agency where 2 i.e. 22% of the required nurses are available. This impact on the health care provided to patients at this level of health facilities because RHC provides in-patient care facility and it is very important that the facility must have nurses available in order to provide 24/7 services to the patients. For details see table 26 below:

Table 25 showing the availability of nursing officers at RHC level in FATA by Agency Agency/FR Number of Required Number Available number of Gap % of RHCs of Nurses Nurses Nurses available at RHC Bajaur Agency 3 9 2 7 22 FR Tank 1 3 0 3 0 Orakzai Agency 1 3 0 3 0 Mohmand Agency 3 9 0 9 0 FR Peshawar 1 3 0 3 0 South Waziristan Agency 1 3 0 3 0 Total 10 30 2 28 7 iii. Availability of LHVs at RHC level in FATA

Only 30% of the required LHVs are present at RHC level. Mohmand Agency reported being lowest among all the Agencies i.e. having only 11% of the required LHVs at RHC level. Such a low rate of LHVs presence in context with the required number of LHVs at RHC level will affect the health care of the women of childbearing ages (15-49 Years) in the FATA and specifically in Mohmand Agency. For details see table 27 below:

Table 26 showing the availability of LHV at RHC level in FATA by Agency Agency/FR Number of RHC The required Total Gap % of LHV number of LHVs Available available at RHC FR Peshawar 1 3 2 1 67 FR Tank 1 3 2 1 67 Bajaur Agency 3 9 4 5 44 Orakzai Agency 1 3 1 2 33 South Waziristan Agency 1 3 1 2 33 Mohmand Agency 3 9 1 8 11 Total 10 30 9 21 30 iv. Availability of Medical Technicians at RHC level in FATA

In FATA, 77% of the required medical technicians are available at the RHC Level. South Waziristan is the only Agency in FATA where no medical technician is available at the RHC Level. For details see table below:

Table 27 showing the availability of Medical Technicians at RHC level in FATA by Agency Agency / FR Number of # of Required Medical Available Gap % of Available RHCs Technicians Medical Technicians FR Tank 1 3 5 -2 167 Orakzai Agency 1 3 3 0 100 Mohmand 3 9 7 2 78 Agency Bajaur Agency 3 9 6 3 67 FR Peshawar 1 3 2 1 67

South Waziristan 1 3 0 3 0 total 10 30 23 7 77 v. Availability of Health Educators at RHC level in FATA

There was no health educator at the RHC level. This will affect the community mobilization and sensitization for seeking health care and participation in different health care programs in the catchment population of the concerned health facilities. For details see table below. Table 28 showing the availability of health educators at RHC level in FATA by Agency Agency / FR Number of Required Available Gap % of Available Health Educators Health Educators Bajaur Agency 3 0 3 0 FR Peshawar 1 0 1 0 FR Tank 1 0 1 0 Mohmand Agency 3 0 3 0 Orakzai Agency 1 0 1 0 South Waziristan 1 0 1 0 total 10 0 10 0 vi. Availability of Ambulance Drivers at RHC level in FATA

Only 15% of the RHCs have the required number of ambulance drivers. This seriously affects referral service at the RHC level. In FATA the limited presence of the ambulance was only in Mohmand Agency (33%) and Bajaur Agency (17%), while the rest of the Agencies have no ambulance driver at RHC level. For details see table below: Table 29 showing the availability of Ambulance Drivers at RHC level in FATA by Agency Agency / FR Number of Required Available Gap % of Available Ambulance drivers Ambulance rivers Mohmand Agency 6 2 4 33 Bajaur Agency 6 1 5 17 FR Peshawar 2 0 2 0 FR Tank 2 0 2 0 Orakzai Agency 2 0 2 0 South Waziristan 2 0 2 0 Total 20 3 17 15 d. Availability of Human Resources at AHQ HOSPITALS level i. Availability of Physicians at AHQ hospitals in FATA

Only 29% of the required physicians were available at AHQ Hospitals. In Kurram Agency, Mohmand Agency, North Waziristan Agency and South Waziristan Agency, there was no physician at AHQ Hospitals. For details see table below: 42

Table 30 showing the availability of Physicians at AHQ Hospital level in FATA by Agency Agency Required Number Total Available Gap % of Medical of Physician Specialist available Bajaur Agency 2 2 0 100 Khyber Agency 2 1 1 50 Orakzai Agency 2 1 1 50 Kurram Agency 2 0 2 0 Mohmand Agency 2 0 2 0 North Waziristan Agency 2 0 2 0 South Waziristan Agency 2 0 2 0 Total 14 4 10 29 ii. Availability of Dental Surgeons at AHQ hospitals in FATA

Only 36% of the required dental surgeons were available at AHQ HOSPITALS level. There was no Specialist for Dental care in South Waziristan and Bajaur Agency, while rest of the Agencies have 50% of the required number of Dental Surgeons. For details see table below: Table 31 showing the availability of Dental Surgeons at AHQ HOSPITALS level in FATA by Agency Agency Required Dental Available Gap % of the available Surgeons Dental surgeon Khyber Agency 2 1 1 50 Kurram Agency 2 0 2 100 Mohmand 2 1 1 50 North Waziristan 2 1 1 50 Orakzai Agency 2 0 2 100 Bajaur Agency 2 1 1 50 South Waziristan 2 0 2 0 Total 14 5 9 36 iii. Availability of eye specialist at AHQ hospitals in FATA

Only 29% of the required eye specialists were present at AHQ HOSPITALS level. There is no Eye specialist in Kurram, Mohmand and North Waziristan Agency at AHQ HOSPITALS level. For details see table below: Table 32 showing the availability of Eye Specialist at AHQ HOSPITALS level in FATA by Agency Agency Required Available Not available % of Eye Specialist available /Gap Bajaur Agency 2 0 2 0 Khyber Agency 2 1 1 50 Orakzai Agency 2 0 2 50 South Waziristan 2 1 1 50

Kurram Agency 2 0 2 0 Mohmand Agency 2 0 2 0 North Waziristan 2 0 2 0 Total 14 2 12 29 iv. Availability of Radiologist at AHQ hospitals in FATA Around 43% of the required Radiologists were available at the AHQ HOSPITALS level. South Waziristan Agency, Kurram Agency, Orakzai Agency and Bajaur Agency have no radiologist at AHQ HOSPITALS level. For details see table below: Table 33 showing the availability of Radiologist at AHQ HOSPITALS level in FATA by Agency Agency Required number of Available number Ga % of Radiologists Radiologist of p available Radiologist Khyber Agency 1 1 0 100 Mohmand Agency 1 1 0 100 North Waziristan 1 1 0 100 Ag. Bajaur Agency 1 0 1 0 Kurram Agency 1 0 1 0 Orakzai Agency 1 0 1 0 South Waziristan 1 0 1 0 Total 7 3 4 43 v. Availability of General Surgeons at AHQ hospitals in FATA

71% (Needs verification) of the required General Surgeons were available at the AHQ HOSPITALS level. Mohmand Agency is reported with no General Surgeon at AHQ HOSPITALS level. For details see table below: Table 34 showing the availability of General Surgeons at AHQ HOSPITALS level in FATA by Agency Agency Required Available Not available / Gap % of General surgeon availability Bajaur Agency 2 2 0 100 Kurram Agency 2 2 0 100 North Waziristan 2 2 0 100 Orakzai Agency 2 2 0 100 Khyber Agency 2 1 1 50 South Waziristan 2 1 1 50 Mohmand 2 0 2 0 Total 14 10 4 71

vi. Availability of Gynecologist AHQ hospitals in FATA

In FATA, around 36% of the required gynecologists were available at AHQ HOSPITALS level. There was no Gynecologist in South Waziristan Agency, North Waziristan Agency and Bajaur Agency. See table below for details. Table 35 showing the availability of Gynecologist at AHQ HOSPITALS level in FATA by Agency level Agency Required Available Gap % of available gynecologists Kurram Agency 2 2 0 100 Khyber Agency 2 1 1 50 Mohmand Agency 2 1 1 50 Orakzai Agency 2 1 1 50 Bajaur Agency 2 0 2 0 North Waziristan 2 0 2 0 South Waziristan 2 0 2 0 Total 14 5 9 36 vii. Availability of Pediatrician AHQ hospitals in FATA

In FATA, 36% of the required Pediatricians were present at AHQ HOSPITALS level. Among the Agencies, North Waziristan Agency, Kurram Agency and Mohmand Agency had no pediatrician at AHQ HOSPITALS level. See table below for details. Table 36 showing the availability of Pediatricians at AHQ HOSPITALS level in FATA by Agency Agency Required Available Gap % of available Pediatrician Bajaur Agency 2 2 0 100 Khyber Agency 2 1 1 50 Orakzai Agency 2 1 1 50 South Waziristan 2 1 1 50 Kurram Agency 2 0 2 0 Mohmand Agency 2 0 2 0 North Waziristan Agency 2 0 2 0 Total 14 5 9 36 viii. Availability of Anesthetists AHQ hospitals in FATA

There were 21% of the required Anesthetists at the AHQ HOSPITALS level. Among the Agencies, South Waziristan, North Waziristan, Mohmand Agency and Kurram Agency had no Anesthetists at AHQ HOSPITALS level. The remaining three Agencies have the 50% of the required Anesthetist available at AHQ HOSPITALS level. See table below for details. Table 37 showing the availability of Anesthetists at AHQ HOSPITALS level in FATA by Agency Agency Required Available Gap % of Anesthetist available Bajaur Agency 2 1 1 50 Khyber Agency 2 1 1 50 45

Orakzai Agency 2 1 1 50 Kurram Agency 2 0 2 0 Mohmand Agency 2 0 2 0 North Waziristan 2 0 2 0 South Waziristan 2 0 2 0 Total 14 3 11 21 ix. Availability of Psychiatrist AHQ hospitals in FATA

There is no Psychiatrist throughout FATA at any level. x. Availability of Medical Officers in AHQ hospitals in FATA

Around one fifth (22%) of the required Medical officers were available at AHQ HOSPITALS level (Assuming all AHQ hospitals as category A hospitals) Mohmand Agency had reported the least number of Medical Officers at AHQ HOSPITALS level i.e. 10%, followed by Khyber Agency i.e. 14%. See table below for details: Table 38 showing the availability of Medical Officers at AHQ HOSPITALS level in FATA by Agency Agency Required Available Gap % of Medical officer available Bajaur Agency 108 53 55 49 Kurram Agency 108 23 85 21 South Waziristan 108 23 85 21 Orakzai Agency 108 20 88 19 North Waziristan Ag. 108 18 90 17 Khyber Agency 108 15 93 14 Mohmand Agency 108 11 97 10 Total 756 163 593 22

C. Provision of basic services in FATA a. Provision of basic Lab services in FATA by health facility level:

This assessment looks at the capacity of a health facility to conduct basic laboratory service. Basic Laboratory Service means the capacity of the health facility to conduct Complete Blood Count (CBC). The minimum service package recommends that all health facilities above Civil Dispensary must offer laboratory services. Finding from this assessment indicates that only 2% of the BHUs, 40% of the RHC, 57% of the THQ and 39% of the CH provide Basic Laboratory Services i.e. CBC. The worst affected Agency is South Waziristan where no facility offers basic lab services. See table below for details. Table 39 showing the availability of basic laboratory services by Agency S.No Agency/FR CH THQ RHC BHU *A Gap A Gap A Gap A Gap 1 Bajaur Agency 0 0 1 2 1 3 1 14 2 FR Bannu 0 0 0 0 12 3 FR D.I.K 1 1 0 0 0 0 0 4 4 FR Kohat 1 1 0 0 0 0 0 9 5 FR Lakki 0 0 0 0 0 0 2 6 6 FR Peshawar 0 1 0 0 1 1 0 6 7 FR Tank 1 1 0 0 0 1 0 4 8 Khyber Agency 1 2 1 1 0 0 0 12 9 Kurram Agency 1 1 1 2 0 0 0 19 10 Mohmand Agency 0 0 0 0 1 3 0 53 11 North Waziristan 0 6 1 1 0 0 0 19 12 Orakzai Agency 2 2 0 0 1 1 1 20 13 South Waziristan 0 3 0 1 0 1 0 7 Total 7 18 4 7 4 10 4 (2%) 185 (39%) (57%) (40%) * Available b. Routine Immunization Services:

The minimum health care package recommends that all health facilities (CD, BHU, RHC and AHQ HOSPITALS) should provide immunization services. The availability of immunization services was generally poor except AHQ Hospitals, where all the AHQ Hospitals of FATA has the provision of immunization services i.e. 100%. On part of the remaining level of health facilities, the provision of immunization services was not satisfactory i.e. only 27% of the CDs were providing EPI services, followed by BHU i.e. 64%, followed by RHC where 64% of the health facilities were providing immunization services. See table below for details: Table 40: Showing the availability of Routine Immunization at health facility by Agency Agency/FR AHQ CH THQ RHC BHU CHC CD HOSPITALS *A **E A E A E A E A E A E A E Bajaur Agency 1 1 0 0 2 2 2 3 14 1 16 4 5 13 FR Bannu 0 0 0 0 0 0 0 0 12 5 7 9 51 5 47

FR D.I.K 0 0 1 1 0 0 0 0 4 7 7 1 7 0 FR Kohat 0 0 1 1 0 0 0 0 9 2 2 3 7 9 FR Lakki 0 0 0 0 0 0 0 0 6 0 6 7 8 6 FR Peshawar 0 0 1 1 0 0 1 1 6 0 3 3 5 3 FR Tank 0 0 1 1 0 0 1 1 4 5 7 4 38 0 Khyber Agency 1 1 1 2 1 1 0 0 12 8 10 12 24 8 Kurram Agency 1 1 1 2 1 2 0 0 19 1 2 24 49 18 Mohmand 1 1 0 0 0 0 2 3 53 2 5 1 13 27 North Waziristan 1 1 2 7 1 1 0 1 19 15 15 0 85 6 Orakzai Agency 1 1 2 2 0 0 1 2 20 1 5 11 22 17 South Waziristan 1 1 1 3 1 1 0 0 7 12 19 13 33 6 Total n (%) 7 7 11 20 6 7 7 11 118 185 59 104 92 347 % (100) (55) (86) (64) (64) (57) (27) *Available **Expected c. Application of IMNCI Protocols in FATA by the level of health facility:

The overall situation of application of IMNCI protocols at a health facility in FATA is not satisfactory. All of the AHQ hospitals were following the IMNCI components. In the remaining levels of health facilities only 6% of the civil dispensaries were following IMNCI protocols, followed by BHUs i.e. 24%, Civil Hospital i.e. 35% and then THQ i.e. 43%. See table below for details: Table 41 showing the application of IMNCI at health facility by Agency Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC CD A E A E A E A E A E A E A E Bajaur Agency 1 1 0 0 1 2 1 3 4 14 2 16 1 5 FR Bannu 0 0 0 0 0 0 0 0 3 12 0 7 0 51 FR D.I.K 0 0 1 1 0 0 0 0 0 4 0 7 0 7 FR Kohat 0 0 0 1 0 0 0 0 5 9 0 2 0 7 FR Lakki 0 0 0 0 0 0 0 0 0 6 3 6 2 8 FR Peshawar 0 0 1 1 0 0 1 1 2 6 1 3 0 5 FR Tank 0 0 1 1 0 0 1 1 0 4 0 7 1 38 Khyber Agency 1 1 1 2 0 1 0 0 0 12 0 10 0 24 Kurram Agency 1 1 1 2 1 2 0 0 5 19 1 2 3 49 Mohmand Agency 1 1 0 0 0 0 2 3 11 53 1 5 1 13 North Waziristan 1 1 0 7 1 1 0 1 1 19 0 15 1 85 Orakzai Agency 1 1 2 2 0 0 1 2 12 20 3 5 7 22 South Waziristan 1 1 0 3 0 1 0 0 1 7 1 19 4 33 Total n (%) 7 7 7 20 3 7 6 11 44 185 12 104 20 347 Percentage 100 35 43 55 24 12 6 d. Availability of screening services for under nutrition/malnutrition/growth monitoring (MUAC or W/H, H/A) in Children:

In FATA, the situation of child screening for malnutrition i.e. MUAC, W/A, H/A was poor. Even at the AHQ HOSPITALS level, only 57% had services of child screening for malnutrition. The most affected (Lack of screening services for malnutrition in children) were; South Waziristan, Mohmand Agency, Khyber Agency, FR Tank, FR Kohat and FR D.I.K. Moreover, Health facilities are supported by UNICEF, WFP & WHO for their

nutrition related activities through MNCH Program, Directorate of Health Services FATA. There is no government run program for Nutrition yet, however, Nutrition Strategy for FATA is in its final stages of approval and Draft PC-1 for Nutrition has also been developed. See table below for details: Table 42 Availability of screening services for under nutrition/malnutrition/growth monitoring (MUAC or W/H, H/A) in Children Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC CD A E A E A E A E A E A E A E Bajaur Agency 1 1 0 0 0 2 0 3 1 14 0 16 0 5 FR Bannu 0 0 0 0 0 0 0 0 1 12 0 7 0 51 FR D.I.K 0 0 0 1 0 0 0 0 0 4 0 7 0 7 FR Kohat 0 0 0 1 0 0 0 0 0 9 0 2 0 7 FR Lakki 0 0 0 0 0 0 0 0 0 6 1 6 0 8 FR Peshawar 0 0 1 1 0 0 1 1 3 6 1 3 1 5 FR Tank 0 0 0 1 0 0 0 1 4 7 0 38 Khyber Agency 1 1 0 2 1 1 0 0 1 12 0 10 1 24 Kurram Agency 1 1 1 2 1 2 0 0 7 19 1 2 3 49 Mohmand Agency 0 1 0 0 0 0 1 3 2 53 0 5 2 13 North Waziristan 1 1 2 7 1 1 0 1 1 19 0 15 1 85 Orakzai Agency 0 1 1 2 0 0 2 2 14 20 3 5 4 22 South Waziristan 0 1 0 3 0 1 0 0 0 7 1 19 0 33 Total 4 7 5 20 3 7 4 11 30 185 7 104 12 347 Percentage 57 25 43 36 16 7 3

e. Availability of Antenatal services at health facilities (ANC):

ANC services were available in 120 (18.8%) health facilities. The availability of ANC services was very low at all levels except AHQ HOSPITALS (CH 40%, THQ 57%, RHC 55%, BHU 35%, CHC 18% and 3% CDs). Frontier regions were the most lagging behind in terms of the concerned service provision. For details see table Table 43 showing the availability of ANC services at health facility level by Agency Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC CD A E A E A E A E A E A E A E Bajaur Agency 1 1 0 0 2 2 0 3 7 14 4 16 0 5 FR Bannu 0 0 0 0 0 0 0 0 4 12 1 7 0 51 FR D.I.K 0 0 1 1 0 0 0 0 0 4 1 7 7 FR Kohat 0 0 1 1 0 0 0 0 2 9 0 2 7 FR Lakki 0 0 0 0 0 0 0 0 3 6 2 6 0 8 FR Peshawar 0 0 1 1 0 0 1 1 3 6 2 3 1 5 FR Tank 0 0 1 1 0 0 0 1 0 4 3 7 38 Khyber Agency 1 1 2 2 1 1 0 0 7 12 2 10 1 24 Kurram Agency 1 1 1 2 1 2 0 0 11 19 0 2 3 49 Mohmand 1 1 0 0 0 0 1 3 16 53 1 5 2 13 North Waziristan 1 1 0 7 0 1 0 1 4 19 1 15 1 85 Orakzai Agency 1 1 1 2 0 0 2 2 7 20 2 5 4 22 South Waziristan 1 1 0 3 0 1 0 0 0 7 0 19 0 33 Total 7 7 8 20 4 7 6 11 64 185 19 104 12 347 Percentage 100 40 57 55 35 18 3 f. DHIS reporting FATA DHIS reporting was 100% at the AHQ HOSPITALS level only, rest of the health facilities had lesser reporting i.e. around 80%. See details in table below:

Table 44 showing DHIS reporting at health facility level by Agency: Agency/FR AHQ CH THQ RHC BHU CHC CD HOSPITALS A E A E A E A E A E A E A E Bajaur Agency 1 1 0 0 2 2 2 3 12 14 16 16 4 5 FR Bannu 0 0 0 0 0 0 0 0 11 12 7 7 43 51 FR D.I.K 0 0 1 1 0 0 0 0 0 4 2 7 0 7 FR Kohat 0 0 1 1 0 0 0 0 9 9 1 2 5 7 FR Lakki 0 0 0 0 0 0 0 0 5 6 5 6 5 8 FR Peshawar 0 0 1 1 0 0 1 1 5 6 2 3 5 5 FR Tank 0 0 1 1 0 0 1 1 3 4 7 7 34 38 Khyber Agency 1 1 2 2 1 1 0 0 12 12 7 10 22 24 Kurram Agency 1 1 1 2 1 2 0 0 18 19 2 2 44 49 Mohmand 1 1 0 0 0 0 2 3 33 53 3 5 11 13 North Waziristan 1 1 2 7 1 1 0 1 20 19 7 15 87 85 Orakzai Agency 1 1 2 2 0 0 2 2 19 20 4 5 14 22 50

South Waziristan 1 1 0 3 0 1 0 0 6 7 4 19 18 33 Total 7 7 11 20 5 7 8 11 153 185 67 104 292 347 Percentage 100 55 71 73 83 64 84 g. Basic EmONC Services in FATA Availability of EmNOC services were determined by the availability of Parental antibiotics, anticonvulsant drugs, manual removal of placenta and assisted vaginal delivery. Only (23%) of the 252 health facilities (Excluding CDs, MCH Centers, Labour Suits) were offering Basic EmONC services. Agencies with low availability of Basic EmONC services include Bajaur Agency, Khyber Agency, Kurram Agency and South Waziristan. Note that the provision of Basic EmONC at facility level is of paramount importance in reducing maternal mortality. See table below for details: Table 45 showing availability of Basic EmONC at Agency Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC A E A E A E A E A E A E Bajaur Agency 1 1 0 0 0 2 0 3 2 14 0 16 FR Bannu 0 0 0 0 0 0 0 0 0 12 0 7 FR D.I.K 0 0 0 1 0 0 0 0 0 4 0 7 FR Kohat 0 0 1 1 0 0 0 0 1 9 0 2 FR Lakki 0 0 0 0 0 0 0 0 3 6 3 6 FR Peshawar 0 0 0 1 0 0 0 1 0 6 0 3 FR Tank 0 0 0 1 0 0 0 1 1 4 1 7 Khyber Agency 1 1 1 2 1 1 0 0 4 12 0 10 Kurram Agency 1 1 1 2 1 2 0 0 8 19 1 2 Mohmand Agency 1 1 0 0 0 0 1 3 6 53 0 5 North Waziristan 1 1 1 7 0 1 0 1 2 19 2 15 Orakzai Agency 1 1 1 2 0 0 1 2 6 20 2 5 South Waziristan 1 1 0 3 0 1 0 0 0 7 0 19 Total 7 7 5 20 2 7 2 11 33 185 9 104 Percentage 100 25 29 18 18 9 h. Availability of Post-Partum care services by level and Agency

There were 94 health facilities in FATA that offered post-partum care (36.9%). The provision of post-partum care was poor in all Frontier regions. See table below for details:

Table 46 showing the availability of post-partum care by facility level in each Agency Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC Bajaur Agency 1 1 0 0 1 2 3 3 10 14 7 16 FR Bannu 0 0 0 0 0 0 0 0 0 12 0 7 FR D.I.K 0 0 1 1 0 0 0 0 0 4 2 7 FR Kohat 0 0 1 1 0 0 0 0 5 9 0 2 FR Lakki 0 0 0 0 0 0 0 0 2 6 3 6 FR Peshawar 0 0 0 1 0 0 1 1 2 6 0 3 FR Tank 0 0 1 1 0 0 0 1 0 4 0 7 Khyber Agency 1 1 0 2 1 1 0 0 2 12 0 10 Kurram Agency 1 1 1 2 1 2 0 0 16 19 1 2 Mohmand Agency 1 1 0 0 0 0 1 3 11 53 0 5 North Waziristan 1 1 1 7 1 1 0 1 2 19 0 15 Orakzai Agency 1 1 1 2 0 0 1 2 6 20 2 5 South Waziristan 1 1 0 3 0 1 0 0 0 7 0 19 Total 7 7 6 20 4 7 6 11 56 185 15 104 Percentage 100 30 57 65 30 14

D. Availability of basic equipment and key medical supplies a. Availability of refrigerator in FATA by the level of health facility 297 (46.7%) health facilities in FATA have a refrigerator (Any kind and functional). Availability of refrigerators at BHU was 68% and at CDs is only 43%. See details in table below:

Table 47 showing the availability of refrigerator at health facility by the Agency Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC CD A E A E A E A E A E A E A E Bajaur Agency 1 1 0 0 2 2 3 3 12 14 14 16 5 5 FR Bannu 0 0 0 0 0 0 0 0 6 12 2 7 9 51 FR D.I.K 0 0 1 1 0 0 0 0 4 4 7 7 7 7 FR Kohat 0 0 1 1 0 0 0 0 9 9 2 2 5 7 FR Lakki 0 0 0 0 0 0 0 0 3 6 4 6 7 8 FR Peshawar 0 0 1 1 0 0 1 1 3 6 3 3 1 5 FR Tank 0 0 1 1 0 0 0 1 3 4 6 7 14 38 Khyber Agency 1 1 1 2 1 1 0 0 8 12 3 10 9 24 Kurram Agency 1 1 2 2 2 2 0 0 14 19 0 2 16 49 Mohmand Agency 1 1 0 0 0 0 3 3 41 53 3 5 8 13 North Waziristan 1 1 5 7 1 1 1 1 9 19 3 15 24 85 Orakzai Agency 1 1 2 2 0 0 1 2 13 20 2 5 10 22 South Waziristan 1 1 2 3 1 1 0 0 1 7 8 19 2 33 Total 7 7 16 20 7 7 9 11 126 185 57 104 117 347 Percentage 100 80 100 82 68 55 43 b. Availability of safe delivery kit by the level of health facility

Safe delivery kits (available and functional) were found in 141 (22%) health facilities. Most health facilities in the Frontier region did not have safe delivery kits. See details in table below: Table 48 showing the availability of safe delivery kit at health facility by the Agency: Agency AHQ HOSPITALS CH THQ RHC BHU CHC A E A E A E A E A E A E Bajaur Agency 1 1 0 0 1 2 2 3 10 14 2 16 FR Bannu 0 0 0 0 0 0 0 0 0 12 0 7 FR D.I.K 0 0 1 1 0 0 0 0 4 4 7 7 FR Kohat 0 0 1 1 0 0 0 0 9 9 2 2 FR Lakki 0 0 0 0 0 0 0 0 4 6 1 6 FR Peshawar 0 0 1 1 0 0 1 1 2 6 0 3 FR Tank 0 0 0 1 0 0 0 1 3 4 4 7 Khyber Agency 1 1 1 2 1 1 0 0 5 12 3 10 Kurram Agency 1 1 2 2 1 2 0 0 16 19 1 2 Mohmand Agency 1 1 0 0 0 0 3 3 33 53 3 5 North Waziristan 1 1 3 7 1 1 1 1 3 19 4 15

Orakzai Agency 1 1 2 2 0 0 1 2 7 20 2 5 South Waziristan 1 1 2 3 1 1 0 0 1 7 7 19 Total 7 7 13 20 5 7 8 11 97 185 36 104 Percentage 100 65 71 73 52 35 c. Availability of sterilization equipment (mainly Autoclave) by the level of health facility

Only 125 (19%) of health facilities in FATA have sterilization equipment. The availability of these equipments was very low at the CHC (56%), RHCs 60%) and BHUs (38%). See details in table below: Table 49 showing the availability of sterilization equipment at health facility by the Agency: Agency AHQ HOSPITALS CH THQ RHC BHU CHC A E A E A E A E A E A E Bajaur Agency 1 1 0 0 1 2 2 3 12 14 9 16 FR Bannu 0 0 0 0 0 0 0 0 1 12 1 7 FR D.I.K 0 0 1 1 0 0 0 0 4 4 7 7 FR Kohat 0 0 1 1 0 0 0 0 8 9 2 2 FR Lakki 0 0 0 0 0 0 0 0 2 6 2 6 FR Peshawar 0 0 1 1 0 0 1 1 3 6 6 3 FR Tank 0 0 1 1 0 0 0 1 3 4 3 7 Khyber Agency 1 1 1 2 1 1 0 0 1 12 3 10 Kurram Agency 1 1 2 2 2 2 0 0 8 19 1 2 Mohmand Agency 1 1 0 0 0 0 2 3 27 53 2 5 North Waziristan 1 1 3 7 1 1 1 1 18 19 3 15 Orakzai Agency 1 1 1 2 0 0 1 2 12 20 2 5 South Waziristan 1 1 1 3 1 1 0 0 6 7 7 19 7 7 12 20 6 7 7 11 104 185 47 104 Percentage 100 60 86 64 56 45 d. Availability of microscope by the level of health facility

Only 220 (32 %) out of 681 health facilities in FATA had a microscope. The availability of a microscope at BHU (37%) and CD (22%) was very low. The Agencies were more affected than the Frontier Regions. The most affected Agency was South Waziristan and Kurram Agency. See details in the table below.

Table 50 showing the availability microscope at health facility by the Agency: Agency AHQ HOSPITALS CH THQ RHC BHU CHC CD A E A E A E A E A E A E A E Bajaur Agency 1 1 0 0 1 2 2 3 6 14 2 16 1 5 FR Bannu 0 0 0 0 0 0 0 0 5 12 0 7 3 51 FR D.I.K 0 0 1 1 0 0 0 0 4 4 7 7 7 7 FR Kohat 0 0 1 1 0 0 0 0 9 9 2 2 4 7 FR Lakki 0 0 0 0 0 0 0 0 1 6 1 6 5 8 FR Peshawar 0 0 1 1 0 0 1 1 2 6 2 3 0 5 FR Tank 0 0 1 1 0 0 0 1 3 4 6 7 13 38 Khyber Agency 1 1 1 2 1 1 0 0 4 12 3 10 3 24 Kurram Agency 1 1 2 2 2 2 0 0 1 19 1 2 5 49 Mohmand Agency 1 1 0 0 0 0 2 3 21 53 2 5 3 13 North Waziristan 1 1 4 7 1 1 1 1 5 19 4 15 28 85 Orakzai Agency 1 1 2 2 0 0 1 2 6 20 1 5 4 22 South Waziristan 1 1 1 3 1 1 0 0 1 7 9 19 2 33 Total 7 7 14 20 6 7 7 11 68 185 40 104 78 347 Percentage 100 70 86 64 37 38 22 e. Availability of delivery table by the level of health facility

The maternal delivery table was found available at 151 (23.7%) health facilities. Most Frontier Regions did not have a delivery table. For details see table below: Table 51 showing the availability of delivery table at health facility by the Agency Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC A E A E A E A E A E A E Bajaur Agency 1 1 0 0 1 2 2 3 10 14 11 16 FR Bannu 0 0 0 0 0 0 0 0 3 12 1 7 FR D.I.K 0 0 1 1 0 0 0 0 4 4 7 7 FR Kohat 0 0 1 1 0 0 0 0 9 9 1 2 FR Lakki 0 0 0 0 0 0 0 0 2 6 3 6 FR Peshawar 0 0 1 1 0 0 1 1 2 6 1 3 FR Tank 0 0 1 1 0 0 0 1 2 4 4 7 Khyber Agency 1 1 2 2 1 1 0 0 4 12 3 10 Kurram Agency 1 1 2 2 2 2 0 0 9 19 1 2 Mohmand Agency 1 1 0 0 0 0 3 3 23 53 2 5 North Waziristan 1 1 3 7 1 1 1 1 5 19 4 15 Orakzai Agency 1 1 2 2 0 0 1 2 15 20 4 5 South Waziristan 1 1 2 3 1 1 0 0 1 7 8 19 Total 7 7 15 20 6 7 8 11 89 185 50 104 Percentage 100 75 86 73 48 48

f. Availability of key antibiotics at a health facility

Key antibiotics were available in 467 (72%) health facilities. Only 74% of BHUs and 69% of CDs had available the key antibiotics. See details in the table below. Table 52 showing the availability of key antibiotics at health facility by the Agency Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC CD A E A E A E A E A E A E A E Bajaur Agency 1 1 0 0 2 2 3 3 13 14 15 16 4 5 FR Bannu 0 0 0 0 0 0 0 0 10 12 5 7 29 51 FR D.I.K 0 0 1 1 0 0 0 0 1 4 6 7 5 7 FR Kohat 0 0 1 1 0 0 0 0 9 9 1 2 5 7 FR Lakki 0 0 0 0 0 0 0 0 2 6 4 6 2 8 FR Peshawar 0 0 1 1 0 0 1 1 5 6 1 3 4 5 FR Tank 0 0 1 1 0 0 1 1 3 4 4 7 36 38 Khyber Agency 1 1 2 2 1 1 0 0 12 12 6 10 21 24 Kurram Agency 1 1 1 2 2 2 0 0 14 19 2 2 33 49 Mohmand Agency 1 1 0 0 0 0 2 3 29 53 3 5 8 13 North Waziristan 1 1 4 7 1 1 0 1 14 19 1 15 63 85 Orakzai Agency 1 1 2 2 0 0 1 2 19 20 5 5 12 22 South Waziristan 1 1 0 3 0 1 0 0 6 7 3 19 18 33 Total 7 7 13 20 6 7 8 11 137 185 56 104 240 347 Percentage 100 65 86 73 74 54 69 g. Availability of analgesics, antipyretics, non-steroidal anti-inflammatory medicines in FATA by the level of health facilities

These categories of basic medicines were found available in 330 (51.8%) of health facilities. Note that the availability of these medicines was low at BHUs (62%) and CD (42%). See details in table below: Table 53 showing the availability of analgesics, antipyretics, non-steroidal anti-inflammatory medicines in FATA by the level of health facilities Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC CD A E A E A E A E A E A E A E Bajaur Agency 1 1 0 0 2 2 3 3 14 14 13 16 3 5 FR Bannu 0 0 0 0 0 0 0 0 6 12 3 7 20 51 FR D.I.K 0 0 1 1 0 0 0 0 2 4 4 7 3 7 FR Kohat 0 0 1 1 0 0 0 0 9 9 1 2 6 7 FR Lakki 0 0 0 0 0 0 0 0 2 6 3 6 3 8 FR Peshawar 0 0 1 1 0 0 1 1 6 6 2 3 4 5 FR Tank 0 0 1 1 0 0 1 1 3 4 7 7 35 38 Khyber Agency 1 1 2 2 1 1 0 0 10 12 6 10 21 24 Kurram Agency 1 1 1 2 1 2 0 0 17 19 2 2 19 49 Mohmand Agency 1 1 0 0 0 0 2 3 28 53 2 5 10 13 North Waziristan 1 1 3 7 1 1 0 1 0 19 2 15 7 85 Orakzai Agency 1 1 2 2 0 0 1 2 18 20 4 5 11 22 South Waziristan 0 1 0 3 0 1 0 0 0 7 2 19 4 33 Total 6 7 12 20 5 7 8 11 115 185 51 104 146 347 Percentage 86 60 71 73 62 49 42

h. Availability of Oxytocin by the level of health facilities in FATA Oxytocin was found available in 60 (9.4%) of health facilities in FATA. The availability of Oxytocin was poor at all level of the facility. See details in the table below.

Table 54 showing the availability of Oxytocin by the level of health facilities in FATA Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC A E A E A E A E A E A E Bajaur Agency 1 1 0 0 1 2 0 3 1 14 0 16 FR Bannu 0 0 0 0 0 0 0 0 1 12 0 7 FR D.I.K 0 0 1 1 0 0 0 0 1 4 1 7 FR Kohat 0 0 0 1 0 0 0 0 1 9 0 2 FR Lakki 0 0 0 0 0 0 0 0 1 6 2 6 FR Peshawar 0 0 0 1 0 0 1 1 0 6 0 3 FR Tank 0 0 0 1 0 0 0 1 1 4 6 7 Khyber Agency 1 1 2 2 1 1 0 0 8 12 5 10 Kurram Agency 1 1 1 2 1 2 0 0 3 19 1 2 Mohmand Agency 1 1 0 0 0 0 1 3 8 53 0 5 North Waziristan Ag. 1 1 1 7 1 1 0 1 1 19 0 15 Orakzai Agency 1 1 1 2 0 0 0 2 7 20 2 5 South Waziristan 1 1 0 3 0 1 0 0 1 7 1 19 Total 7 7 6 20 4 7 2 11 34 185 18 104 Percentage 100 30 57 18 18 17 i. Availability of ORS by the level of health facilities in FATA

ORS was found available in 354 (58%) health facilities. The availability of ORS was low in CH (67%), THQ (71%), BHU (67%) and CD (65%). Note that all health facilities must have ORS in order to reduce avoidable mortality from the Diarrheal disease. See details in the table below Table 55 showing the availability of ORS by the level of health facilities in FATA Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC CD A E A E A E A E A E A E A E Bajaur Agency 1 1 0 0 2 2 3 3 11 14 13 16 5 5 FR Bannu 0 0 0 0 0 0 0 0 9 12 6 7 27 51 FR D.I.K 0 0 1 1 0 0 0 0 1 4 4 7 2 7 FR Kohat 0 0 1 1 0 0 0 0 9 9 1 2 4 7 FR Lakki 0 0 0 0 0 0 0 0 3 6 3 6 4 8 FR Peshawar 0 0 1 1 0 0 1 1 4 6 0 3 1 5 FR Tank 0 0 1 1 0 0 1 1 2 4 7 7 31 38 Khyber Agency 1 1 2 2 1 1 0 0 9 12 5 10 17 24 Kurram Agency 1 1 1 2 1 2 0 0 16 19 2 2 40 49 Mohmand Agency 1 1 0 0 0 0 2 3 26 53 3 5 10 13 North Waziristan Ag. 1 1 3 7 1 1 0 1 13 19 2 15 57 85 Orakzai Agency 1 1 2 2 0 0 1 2 15 20 5 5 12 22 South Waziristan 1 1 0 3 0 1 0 0 6 7 3 19 17 33 Total 7 7 12 20 5 7 8 11 124 185 54 104 227 347 Percentage 100 60 71 73 67 52 65

E. Amenities/others a. Waste management at health facility level

Healthcare waste (HCW) is defined as the total waste generated from a healthcare facility (HCF). It is of two types. 75-90% is similar to domestic waste and is referred to as healthcare general waste (HCGW) and is made of paper, plastic packaging, food preparation, etc. that haven't been in contact with patients.

10-25% is infectious/hazardous waste that requires special treatment and is referred to as healthcare risk waste (HCRW) and is usually composed of infections agents, sharps, and hazardous chemicals, biological or radioactive waste and poses risk both to human health and the environment. Ideally health facilities should have guidelines and systems available to safely collect, segregate and dispose such waste to reduce the associated risk to human health and environment. Only 300 (47%) of the health facilities in FATA have the capacity for limited waste management like safe collection, segregation and disposal. The capacity for waste management is low at all Frontier regions. See table below for details: Table 56 showing waste management by facility level in Agency Agency/FR AHQ HOSPITALS CH THQ RHC BHU CHC CD A E A E A E A E A E A E A E Bajaur Agency 1 1 0 0 1 2 3 3 14 14 14 16 5 5 FR Bannu 0 0 0 0 0 0 0 0 9 12 6 7 28 51 FR D.I.K 0 1 0 0 4 7 7 FR Kohat 0 0 0 1 0 0 0 0 5 9 1 2 0 7 FR Lakki 0 0 0 0 0 0 0 0 1 6 2 6 3 8 FR Peshawar 0 0 1 1 0 0 1 1 6 6 3 3 5 5 FR Tank 0 0 1 1 0 0 1 1 3 4 7 7 36 38 Khyber Agency 1 1 1 2 1 1 0 0 1 12 0 10 5 24 Kurram Agency 1 1 1 2 2 2 0 0 17 19 2 2 22 49 Mohmand Agency 1 1 0 0 0 0 2 3 31 53 3 5 11 13 North Waziristan Ag.. 1 1 0 7 1 1 0 1 4 19 0 15 2 85 Orakzai Agency 1 1 0 2 0 0 0 2 14 20 3 5 7 22 South Waziristan 1 1 0 3 0 1 0 0 1 7 3 19 3 33 Total 7 7 4 20 5 7 7 11 106 185 44 104 94 347 Percentage 100 20 71 64 57 42 27 b. Source of water at the health facility

33% of the health facilities in FATA use an unsafe source of water. The most effected Agency includes FR Lakki (60%), Mohmand Agency (47%) and North Waziristan (26%). See table for details Table 57 showing the availability of safe water at health facility by Agency Agency/FR Safe source of water Unsafe source of water Total Bajaur Agency 26 15 41 58

FR Bannu 52 29 81 FR D.I.K 16 13 29 FR Kohat 13 5 18 FR Lakki 8 12 20 FR Peshawar 11 6 17 FR Tank 37 18 55 Khyber Agency 40 24 64 Kurram Agency 51 25 76 Mohmand Agency 44 40 84 North Waziristan 188 68 256 Orakzai Agency 39 9 48 South Waziristan 46 13 59 Total 571 277 848

F. Outpatients Department Services (OPD) a. Availability of services

Of the 851 health facilities assessed for availability of OPD services 752 health facilities provided OPD services. The remaining 99 health facilities did not have OPD services. See details in table below: Table 58 showing availability of outpatient services by level of a health facility in FATA OPD Consultation AHQ THQ CH RHC BHU CHC CD MNCH Other Total Yes 7 7 18 9 184 91 364 61 11 752 No 0 0 2 2 19 13 50 3 10 99 Total 7 7 20 11 203 104 414 64 21 851 b. OPD consultations

The average consultations at all level were low. The average consultation at AHQ HOSPITALS was 10141.86, Civil Hospital 758, THQ 1302.71, RHC 661.88, BHU 331.64, CD 281.41, MCH centre 142.27. For details see figure: Table 59 showing the average OPD consultations in the last month by the level of health facility: S. No Over Mean [95% CI] 1. AHQ HOSPITALS 10141.86 3364.46 16919.25 2. CH 758 380.23 1135.76 3. THQ 1302.71 418.32 2187.10 4. RHC 661.88 342.27 981.50 5. BHU 323.16 281.13 364.15 6. CD 281.41 194.79 368.02 7. MNCH 142.27 -28.42 312.97 8. Other 133.33 -128.55 395.22 59

c. Consultation during the month of the survey

Table below showing the average OPD consultations in the last month by type of health facility (Medical officer present): Table 60 Average OPD consultations in the last month: S. No Over Mean [95% CI] 1. AHQ HOSPITALS 10141.86 3337.154 16946.56 2. CH 979.45 532.1235 1426.786 3. THQ 1528.66 5.662602 3051.671 4. RHC 813.14 486.5632 1139.723 5. BHU 422.21 354.1096 490.3294 6. CD 294 229.806 358.194

G. Conclusion &Recommendations

The functionality of health facility

Functionalize all the health facilities especially in South Waziristan, North Waziristan and Mohmand Agency through repair and rehabilitation of the facilities, deployment of human resources and equipment, training of staff and provision of support supervision to the health facilities. The temporary or renting infrastructure should be shifted to purposely build facilities.

Human Resources for health

1. BHUs a. MO/WMO: There was some gap in Medical Officers at the BHU level. The worst situation was in North Waziristan Agency where only 53% of the BHUs have the required Medical Officers in place. FATA needs overall employment of MOs to fill the gaps at urgent basis. b. LHVs: We could verify only 65% of the LHVs presence in the BHU, however in the official record majority of the seats are filled. Urgent employability of 91 LHVs or the presence of filled seats in these BHUs should be ensured. Modern methods for ensuring staff attendance during mandated duty hours need to be adopted. Available donors support may be requested for strengthening of the monitoring system regarding man and material/HR & Equipment. c. Technicians: Only 72% of the BHUs have PHC/Pharmacy/Medical Technician. There is an urgent need to recruit and deploy 139 Technicians to the BHUs in FATA or the presence of filled seats in these BHUs should be ensured. d. Laboratory Technicians: Only 14% of the lab technicians are available at BHU level in the FATA. The PHC facilities should have some basic lab test to support the diagnosis and prompt treatment. For which this cadre of staff needs to be deployed or if absent, their presence need to be ensured through regular monitoring & supervision. e. Health Educators: There was no Health educator available at PHC level. The existing health staff may be able to have some impact on community mobilization, community sensitization and overall participation of the community in different healthcareactivities; however a specialized cadre may be introduced. 2. Civil Dispensary a. In FATA, 71% of the Civil Dispensaries have dispensers/Medical Technician. There is urgent need to recruit and deploy 86 dispensers/ Medical Technician at CDs or ensure their presence at the health facilities. b. In FATA, the situation of LHV presence at civil dispensaries is low i.e. only 69% of the overall Civil dispensaries in FATA have LHV. Recruitment and deployment of 90 LHVs are required immediately. One observation was noted that most of these staff members 61

were present on paper but the assessment team couldn’t verify them in the health facilities. Therefore, a mechanism should be devised to ensure the regular presence of the staff. c. EPI technicians: Only 39% of civil dispensaries having EPI technicians, the worst affected areas were FR Tank where only 4 EPI technicians at the level of the civil dispensary were present. There is a need of urgent recruitment and deployment of 180 EPI technicians with proper monitoring & reporting. 3. RHCs a. Medical Officers: Only 53% of the required Medical Officers were available and all were male. South Waziristan Agency had no Medical Officer. There is an urgent need to recruit and deploy 19 Medical Officers at the RHC level in FATA. b. Only 7% of the required nurses were available at the RHCs. There is an urgent need to recruit and deploy 28 Nurses at the RHC level in FATA. c. LHVs: Only 30% of the required LHVs were present at RHC level. Such a low rate of LHVs presence in context with the required number of LHVs at RHC level will affect the health care of the women in the childbearing ages (15-49 Years) in FATA. There is an urgent need to deploy 21 LHVs at the RHC level in FATA. d. Medical Technicians: Only 77% of the required Medical Technicians were available at the RHC level. South Waziristan was the only Agency in the overall FATA where no Medical Technician was available at the RHC level. There is an urgent need to recruit and deploy 23 Medical Technicians at the RHC level in FATA. e. Health Educators: There was no Health Educator at the RHC level. Recruit and deploy 10 health educators. f. Ambulance drivers: Only 15% of the required RHCs had ambulance drivers. There is a dire need to recruit and deploy 19 Ambulance drivers.

4. AHQ Hospitals a. Physicians: Only 29% of the required Physicians were available at AHQ Hospitals level. There is an urgent need to Recruit10 Physicians and deploy them at AHQ Hospitals. b. Dental Surgeons: Only 36% of the required Dental Surgeons were available at AHQ Hospitals level. Recruitment and deployment of 9 Dental Surgeons are required. c. Eye Specialist: Only 29% of the required Eye Specialists were present at AHQ HOSPITALS level. Recruit and deploy of Eye Specialists to the AHQ Hospitals are required.

d. Radiologist: In the overall FATA, 43% of the required Radiologists were available at the AHQ HOSPITALS level. Recruit and deployment of radiologists to the AHQ Hospitals are required. e. General Surgeon: 71% of the required General Surgeons were available at the AHQ HOSPITALS level. Recruit and deploy 4 General Surgeons to the AHQ Hospitals are required. f. Gynecologist: Only 36% of the required Gynecologists were available at AHQ HOSPITALS level. Recruit and deploy 9 Gynecologist to the AHQ Hospitals are urgently needed g. Pediatrician: Overall FATA, 36% of the required pediatricians were available at AHQ HOSPITALS level. Recruit and deploy 9 Pediatrician to the AHQ Hospitals. h. Anesthetists: Only 21% of the required Anesthetists were available at the AHQ HOSPITALS level. Recruitment and deployment of 11 Anesthetists to the AHQ Hospitals are urgently needed. i. Psychiatrist: There was no Psychiatrist in FATA. Recruit and deploy 14 Psychiatrist to the AHQ Hospitals in FATA are required. j. Medical Officers: Only 22% of the required Medical Officers were available at AHQ HOSPITALS level. Recruit and deploy of 593 Medical Officers to the AHQ Hospitals are required.

Basic services

1. Availability of laboratory services was poor at all level and in all regions. There is urgent need to establish laboratories at all health facilities as recommended in the minimum Primary Health Care services provision guidelines. 2. Availability of EPI services was poor in all regions especially North Waziristan, FR Tank and FR D.I.K. There is urgent need to establish these services at all health facility level especially in North Waziristan, FR Tank and FR D.I.K. 3. The application of IMNCI protocol in FATA province was poor at all levels except AHQ HOSPITALS where its 100%. There is urgent need to ensure that IMNCI protocol is applied at all level through recruitment of staff, training of health workers in the application of the protocol, provision of the protocol to all health facilities and monitoring the application of IMNCI protocol by the health facilities. 4. Availability of screening services for malnutrition/growth monitoring (MUAC or W/H, H/A) in Children: In FATA, the situation of child screening for malnutrition was very poor especially in South Waziristan, Mohmand Agency, Khyber Agency, FR Tank, FR Kohat and FR D.I.K. There is urgent need to ensure that all facilities screen children for malnutrition/growth monitoring. This can be achieved through recruitment of staff, training of health workers in nutrition screening and growth monitoring, provision of growth monitoring tools and monitoring the application of the tools.

5. In FATA, reporting on DHIS is 100% only at the AHQ HOSPITALS level, rest of the health facilities have less than 80% of reporting on DHIS. Note that for the information to be reliable at least 80% of health facilities must submit a report. There is urgent need to ensure that health facilities must provide report through recruitment, training, provision of tools and monitoring and supervision of the staff.

Source of water for the health facility

Availability of safe water at a health facility is very important in preventing infection at a health facility, however, in FATA, most health facilities use water from unsafe sources. There is urgent need to provide safe water to all health facilities to reduce on the spread of infections at health facility level.

Outpatient’s department services

Urgently identify causes of the low OPD utilization. The causes may include inadequate human resources, lack of equipment’s, stock out of medicines, poor motivation of the staff, inadequate community awareness of services availability at the facility, poor accessibility of the health facility or poor attitude of the service providers.

Limitations:

We could not visit 84 health facilities in North Waziristan due to the security reasons. The exact location of GPS would have been very helpful. However, we have the photos of the majority of the visited health facilities and will be provided to the DHS FATA with this report. This was a cross sectional study so the appointment letters were not seen. We did not recruit the female data collectors. The HR data is reported on the basis of availability of staff not on the sanctioned and filled seats. Our data collectors have asked the health facilities incharge and filled the form accordingly. Furthermore, there are frequent posting, transfers, leave, and resignation in FATA similar to any other department/organization, therefore the HR data frequently changes and should be read with cautious, particularly in AHQs. There is discrepancy in the definition of functionality as discussed between our report and the DHIS reporting system of FATA. The health facility is considered functional if it is reporting regardless of the provision of services; however we have recorded it functional if they are providing some services to the community. This has lead to the differences in the FATA directorate and this report. This report may function as a baseline data but before making any important decision the FATA health directorate should be consulted.

Some glimpses of the activities:

Meeting all Agency Surgeons of FATA for HeRAMS assessment

Training of DATA collectors Combine data analysis at WHO Office

Combine data analysis