October 2012 lec ir E tion Fa N e & t w e e o FAFEN r r k F Health Institution Monitor A report based on the monitoring of FAFEN 144 Rural Health Centers in 91 districts in September 2012 Vol: 4, Issue: 134/Nov 2012 RHCs lack medical equipment and basic amenities - Low occupancy rate of medical staff

Among the 144 Rural Health Centers monitored in September, 88 lacked ECG machines, 54 were without x-ray facilities, 33 had no oxygen tents and 24 did not have sterilizers. However, FAFEN observers who visited 144 rural health centers in 91 districts reported four-fifths of the centers had syringe cutters (132), stretchers (127) and delivery kits (127). Besides, 131 RHCs had wards for in-patients; 121 had x-ray rooms with 115 having dental rooms. In contrast, the monitors found no labour rooms at 37 RHCs, operation theaters lacking at 35 centers and no laboratories for conducting medical tests at 21 facilities. Fifty two centers did not have backup in case of power cut down; 26 lacked arrangements for drinking water, 133 had no Sui gas and 75 were without landline telephones. Moreover, five health facilities were without electricity connections and eight had no fans. Four RHCs did not have proper roads leading to them; 25 had no boundary walls and 32 operated out of buildings in dilapidated condition. As for patients' care, 107 facilities were not providing food commodities to vulnerable groups (lactating mothers and malnourished children); 29 had no trained staff for TB patients while 35 lacked such personnel for Control of Diarrheal Disease (CDD) program. Regarding the sanctioned and appointed positions at RHCs, the average occupancy rate was lower for medical staff (64%) than other staff categories. For paramedical staff this stood at 86%; technical staff (77%) and 92% for support staff. Eight staffers faced disciplinary action during the June-August quarter. Doctors and admin staff (two each), technician (one) and peons (three) were penalized for different reasons including poor performance, absence from duty and uncooperative behaviour with patients. Graph A: Percentage of monitored RHCs by region During the quarter, government/elected officials made 93 FATA, 2% visits to the monitored RHCs with the Executive District Balochistan, Officers (EDOs/Health) making the most visits (63), followed 13% by some other government officials (23), elected representatives (4) and Member National Assemblies (3). RHCs in Punjab had the most such visitors (49), followed by Punjab, 45 % (23), KP (14), Balochistan (6) and FATA (1). KP, 17% Geographical coverage

FAFEN governance monitors visited 144 Rural Health Centers Sindh, 22% in 91 districts – 65 in 31 Punjab districts, Sindh (32 RHCs; 20 districts), Khyber Pakhtunkhwa (25; 21), Balochistan (19; 16) and Federally Administered Tribal Areas (3; 3 agencies).

1. General overview The monitors reported proper roads connected 140 RHCs; 119 had boundary walls and 112 had buildings in good condition. Of the 25 facilities without boundary walls, nine were in Sindh, Khyber Pakhtunkhwa and Balochistan (6 each) and Punjab (4). Thirty two RHCs, housed in dilapidated buildings, included 11 each in Sindh and Balochistan, Khyber Pakhtunkhwa (8) and Punjab (2). The observers found 132 centers clean with 139 having electricity and 136 equipped with fans. However, 133 centers lacked Sui gas connections– Punjab (59), Sindh (30), Khyber Pakhtunkhwa (25), Balochistan (17) and FATA (2). Similarly, 75 RHCs had no landline telephones – Sindh (23), Khyber Pakhtunkhwa (18), Balochistan (17), Punjab (15) and FATA (2). Twenty-six centers did not have drinking water available for patients – Balochistan (11), Sindh (9), Khyber Pakhtunkhwa (3), Punjab (2) and FATA (1). On the other hand, 25 RHCs lacked washrooms (with running water) for patients. However, 129 centers had proper shades/places for waiting patients. Twenty-nine RHCs had no residential accommodation for doctors on the centers' premises – 12 in Sindh, Balochistan (8), Khyber Pakhtunkhwa (6) and Punjab (3). Thirty-one centers lacked such a facility for staff - Sindh (12), Balochistan (10), Khyber Pakhtunkhwa (6) and Punjab (3).

S. # Questions Punjab Sindh KP Balochistan FATA Total

Yes 65 32 25 15 3 140 1. A proper road leads to health facility No 0 0 0 4 0 4 There is a boundary wall around the health Yes 61 23 19 13 3 119 2. facility No 4 9 6 6 0 25 Yes 63 21 17 8 3 112 3. The building is in a good condition No 2 11 8 11 0 32 There is a residential house for the doctors Yes 62 20 19 11 3 115 4. on the premises of health facility No 3 12 6 8 0 29 There are residential quarters for staff in the Yes 62 20 19 9 3 113 5. premises of health facility No 3 12 6 10 0 31 Yes 6 2 0 2 1 11 6. The health facility has a Sui gas connection No 59 30 25 17 2 133 The health facility has a landline telephone Yes 50 9 7 2 1 69 7. connection No 15 23 18 17 2 75 Yes 65 31 25 15 3 139 8. The health facility has electricity No 0 1 0 4 0 5 Yes 65 30 22 16 3 136 9. The health facility has fans No 0 2 3 3 0 8 Yes 65 29 20 15 3 132 10. The health facility is clean No 0 3 5 4 0 12 The health facility has clean drinking water Yes 63 23 22 8 2 118 11. arrangements for patients No 2 9 3 11 1 26 The health facility has wash room (with Yes 65 27 18 8 1 119 12. running water) for patients No 0 5 7 11 2 25 There is proper place/shade for waiting Yes 64 31 22 9 3 129 13. patients No 1 1 3 10 0 15 2. General facilities There were wards for in-patients at 131 RHCs; laboratories at 123 RHCs, dental rooms (115) and operation theaters (109). Thirty five centers that lacked operation theatres included 15 in Sindh, Balochistan (13), Khyber Pakhtunkhwa (4), Punjab (2) and FATA (1). Thirty-seven centers lacked operational labour rooms – Balochistan (12), Sindh and Khyber Pakhtunkhwa (10 each), Punjab (4) and FATA (1). A total of 125 RHCs did not have ophthalmology rooms.

2 FAFEN Health Institution Monitor

Although 121 centers had x-ray rooms, only 90 of them had functional machines. Of the 54 facilities that did not have x-ray machines included 17 in Balochistan, Sindh (16), Khyber Pakhtunkhwa (10), Punjab (9) and FATA (2). Eighty eight facilities – 29 in Sindh, Khyber Pakhtunkhwa (20), Balochistan (19), Punjab (18) and FATA (2) – lacked ECG machines. Similarly, 41 centers were without wheel chairs – Sindh (14), Khyber Pakhtunkhwa (10), Punjab and Balochistan (8 each) and FATA (1). However, 127 centers had stretchers. As many as 132 facilities had delivery kits available - syringe cutters (127 RHCs) and sterilizers (120), besides medico-legal services (109). Thirty five facilities that lacked medico-legal services included Punjab (13 RHCs), Sindh (9), Khyber Pakhtunkhwa (7) and Balochistan (6). Moreover, 33 facilities lacked oxygen tents – Balochistan (12), Khyber Pakhtunkhwa (10), Sindh (8) and Punjab (3). As many as 143 RHCs has medicines in the in-house pharmacy while 140 were selling them free-of-cost. Moreover, 111 RHCs had ambulances in running condition while 92 had generators for power backup.

S. # Questions Punjab Sindh KP Balochistan FATA Total

There is a ward for in-patients at the health Yes 65 27 22 14 3 131 1. facility No 0 5 3 5 0 13 Yes 61 22 15 7 2 107 2. The RHC has an operational labour room No 4 10 10 12 1 37 Yes 62 22 23 11 3 121 3. The health facility has an x-ray room No 3 10 2 8 0 23 Yes 61 19 18 10 3 111 4. The health facility has a functional ambulance No 4 13 7 9 0 33 Yes 47 3 5 0 1 56 5. The health facility has a working ECG machine No 18 29 20 19 2 88 Yes 65 22 20 10 3 120 6. The health facility has a sterilizer No 0 10 5 9 0 24 Yes 62 24 15 7 3 111 7. The health facility has a working oxygen tent No 3 8 10 12 0 33 Free medicines are available at the in-house Yes 65 31 23 18 3 140 8. pharmacy No 0 1 2 1 0 4 Yes 64 30 22 14 2 132 9. The health facility has a delivery kit No 1 2 3 5 1 12 The health facility has a generator for power Yes 55 16 13 6 2 92 10. backup No 10 16 12 13 1 52 Yes 64 28 21 12 2 127 11. The health facility has a stretcher No 1 4 4 7 1 17 Yes 57 18 15 11 2 103 12. The health facility has a wheel chair No 8 14 10 8 1 41 The health facility has an ophthalmology (eye) Yes 7 8 3 1 0 19 13. room No 58 24 22 18 3 125 Yes 64 23 21 5 2 115 14. The health facility has a dental room No 1 9 4 14 1 29 Yes 52 23 18 13 3 109 15. The health facility has medico-legal services No 13 9 7 6 0 35 Yes 65 27 19 14 2 127 16. The health facility has a syringe cutter No 0 5 6 5 1 17

3 S. # Questions Punjab Sindh KP Balochistan FATA Total

Yes 62 23 22 13 3 123 17. The RHC has a laboratory No 3 9 3 6 0 21 There is an operation theater for minor Yes 63 17 21 6 2 109 18. operations at the health facility No 2 15 4 13 1 35 Yes 56 16 15 2 1 90 19. X-ray machine at the health facility is functional No 9 16 10 17 2 54 Yes 1 0 0 0 0 1 20. The in-house pharmacy is out of medicines No 64 32 25 19 3 143 3. Patient perception FAFEN observers interviewed three out-patients at each RHC to assess the quality of services being provided to them. Although 91% percent RHCs had doctors available to attend to patients; 18% complained the doctors did not give them enough time. On the other hand 22% expressed dissatisfaction over doctors' attitude while 29% held similar views for technical staff. Another 19% patients found technical staff unsupportive. Fourteen percent of the interviewed patients did not get free-of-cost medicines from the in-house pharmacies. Twelve percent complained they were overcharged and another 4% said money was sought in return for services supposed to be provided for free. Punjab Sindh KP Balochistan FATA S. # Question Yes No Yes No Yes No Yes No Yes No 1. Was doctor present on his/her duty at RHC? 172 16 92 3 60 7 45 12 9 0 2. Do you think doctor has given you enough time? 167 18 81 14 56 11 41 16 7 2 3. Was technical staff of RHC supportive to you? 166 18 85 10 60 7 47 10 5 4 Are you getting medicines free-of-cost from the 4. 168 20 93 2 54 13 41 16 8 1 in-house pharmacy as per doctor’s prescription? 5. Is RHC technical staff available today to patients? 180 8 89 6 62 5 49 8 7 2 Are you satisfied with the overall behaviour of the 6. 171 14 84 11 61 6 43 14 4 5 doctor? Are you satisfied with the overall behaviour of the 7. 165 20 77 18 57 10 39 18 3 6 technical staff of the RHC? 8. Are you overcharged at the RHC? 7 181 19 76 8 59 7 50 1 8 Did anyone at the RHC demand illegal money for 9. 4 184 7 88 0 67 5 52 0 9 providing services? 4. Pa tient care To attend to female patients, 133 RHCs had female staff. However, 11 centers did not have such staff in Balochistan (5 centers), Khyber Pakhtunkhwa (4) and Sindh (2). Similarly, 29 facilities had no specially trained staff to treat TB patients –Balochistan (10 centers), Sindh (8), Khyber Pakhtunkhwa (7), Punjab (3) and FATA (1). Another 35 RHCs did not have staff to run Control of Diarrheal Disease (CDD) program. Moreover, 26 facilities – KP (10 RHCs), Balochistan and Sindh (six each), Punjab (three) and FATA (one) – lacked staff to run Malaria Control Program (MCP). Staff for basic vaccination program (EPI program) was not available at nine RHCs. As many as 107 RHCs – 47 in Punjab, Sindh (22), Khyber Pakhtunkhwa (19), Balochistan (17) and FATA (2) – were not providing food commodities to vulnerable groups (lactating mothers and malnourished children). Twenty six centers did not offer advisory services to breastfeeding mothers - KP and Balochistan (8 each), Sindh (5), FATA (3) and Punjab (2). A total of 140 facilities referred patients in serious condition to Tehsil Headquarter Hospitals/District Headquarter Hospitals.

4 FAFEN Health Institution Monitor

S. # Questions Punjab Sindh KP Balochistan FATA Total

Yes 65 30 21 14 3 133 1. Female staff is present to attend to female patients No 0 2 4 5 0 11 RHC provides food commodities to vulnerable Yes 18 10 6 2 1 37 2. groups (lactating mothers and malnourished children) No 47 22 19 17 2 107 The RHC has specially trained staff to treat TB Yes 62 24 18 9 2 115 3. patients No 3 8 7 10 1 29 The RHC has staff to offer basic vaccination Yes 65 30 23 15 2 135 4. facilities (EPI Program) No 0 2 2 4 1 9 The RHC has staff to run Control of Diarrheal Yes 55 26 16 11 1 109 5. Diseases (CDD) program? No 10 6 9 8 2 35 The RHC has staff to run Malaria Control Program Yes 62 26 15 13 2 118 6. (MCP)? No 3 6 10 6 1 26 The RHC offers advisory services to breastfeeding Yes 63 27 17 11 0 118 7. mothers No 2 5 8 8 3 26 The RHC staff is referring patients with serious Yes 65 30 24 19 2 140 8. conditions to THQ/DHQ No 0 2 1 0 1 4 5. Occupancy rate The detailed picture of the occupancy rates of medical, paramedical, technical and support staff is as under. 5.1 Medical staff Out of the total 668 sanctioned positions in the monitored RHCs, 430 were occupied with 36% left vacant. The positions of specialists had the lowest occupancy rate (23%), followed by ophthalmologists (30%), female medical officers (49%), medical officers (TB, 65%), dental surgeons (71%) and male medical officers (79%). Regions-wise, Balochistan (48%), Khyber Pakhtunkhwa (59%) and Sindh (62%) had occupancy rates below the national average of 64%. This was however, better in Punjab (72%) and FATA (73%).

Monitoring methodology The Free and Fair Election Network (FAFEN) has launched a nationwide initiative to monitor governance processes under its Supporting Transparency Accountability and Electoral Processes in (STAEP) in line with its mandate to strengthen all forms of democratic accountabilities in Pakistan. Objective information about governance processes is vital to encourage informed engagement of citizenry with elected and public institutions for progressive outputs. FAFEN Governance Monitoring aims at enriching the public discourse and debate on governance and developing research-based recommendations for reforms. FAFEN advocates for transparency, accountability, responsiveness, representativeness and public participation as essential elements of democratic governance to enhance the output, efficiency and effectiveness of all elected and public institutions. FAFEN Governance Monitors visit schools and colleges, heath facilities, police stations and other public institutions to monitor and evaluate their efficiency and efficacy in 200 National Assembly constituencies of 119 districts in Punjab, Khyber Pakhtunkhwa (KP), Balochistan, Sindh, Federally Administered Tribal Areas (FATA) and Islamabad Capital Territory (ICT). In addition, FAFEN is also monitoring complaints handling mechanisms of various public institutions to gauge their effectiveness. Trained FAFEN Governance Monitors fill out standardized checklists during their monitoring visits, employing interviewing and observation techniques, and then transmit the data to the FAFEN Secretariat in Islamabad for data entry, cleaning and analysis. FAFEN plans to produce monthly thematic reports such as this one. This information will also contribute to FAFEN Bi-Annual State of Governance in Pakistan Reports. FAFEN Governance Monitoring reports are based on non-probability sampling, and their findings should not be considered national or provincial generalizations. However, FAFEN's outreach across the country allows it to access most districts as well as urban and rural areas. Standardized methodology is applied across Pakistan to draw information in a uniform way through observation and interviewing. The observation and interviews are recorded on a standardized checklist. All information received at the FAFEN Secretariat is verified through multiple sources for authenticity and accuracy. These reports provide data analysis and inferences only for the monitored institutions within the sample. These reports are meant to present to relevant stakeholders a consolidated and current snapshot of the state of governance in public institutions in order to inspire public dialogue and as a contribution towards targeted interventions and reforms. However, FAFEN's unique methodology to assess and evaluate governance processes continues to evolve. Any inaccuracies that may be noticed in the data or suggestions for improvement in the methodology can be sent to the email address at the end of this report.

5 For medical officers, Balochistan had the lowest occupancy rate - male (58%), female (31%) and TB (0%). It was also the lowest for dental surgeons (44%). No post of specialist was sanctioned in the mo nitored RHCs in th e province. Medical offi cers Medical office rs Medical officers Dental Province Name of post Specialists Ophthalmologists Total (female) (male) (TB) surgeons

Sanctioned strength 5 3 82 107 3 65 265

Posted 2 0 45 89 1 54 191 Punjab RHC sharing 2 7 64 64 3 64 20 4 information Occupancy rate 40% 0% 55% 83% 33% 83% 72%

Sanctioned strength 26 14 49 97 19 22 227 Posted 5 5 25 79 15 11 140

Sindh RHC sharing 14 14 28 28 19 19 122 information

Occupancy rate 19% 36% 51% 81% 79% 50% 62%

Sanctioned strength 7 1 18 43 6 22 97

Posted 2 0 6 32 3 14 57

KP RHC sharing 4 4 16 25 6 22 77 inform ation Occupan cy rate 29% 0% 33% 74% 50% 64% 59%

Sanctioned str ength 0 1 16 36 2 9 64 Posted 0 1 5 21 0 4 31

Balochistan RHC sharing 0 1 13 16 2 8 40 information

Occupancy rate 100% 31% 58% 0% 44% 48%

Sanctioned strength 1 1 2 6 1 4 15 Posted 0 0 1 6 1 3 11 FATA RHC sharing 1 1 2 3 1 3 11 information

Occ upancy rate 0% 0% 50% 100% 100% 75% 73% Sanctione d strength 39 20 167 289 31 122 66 8 Posted 9 6 82 227 20 86 430

Total RHC sharing 21 27 123 136 31 116 454 information Occupancy rate 23% 30% 49% 79% 65% 71% 64%

5.2 Paramedic al staff

The situation was better for paramedical staff compared with medical staff - 92% Lady Health Visitors and 86% nurses appointed. Out of the 256 sanctioned positions of LHVs, 236 were filled while 367 nurses were posted against the sanctioned 425. On average, FATA registered the lowest rate (67%) of paramedical staff while it was above three-fourths in Sindh (75%), Balochistan (79%), Khyber Pakhtunkhwa (84%) and Punjab (92%). No position of nurse was sanctioned in FATA. Province Name of post Lady health visitors Nurses Total Sanctioned strength 151 374 525 Posted staff 144 338 482 Punjab RHC sharing information 64 64 128 Occupancy rate 95% 90% 92% Sanctioned strength 45 34 79 Posted staff 35 24 59 Sindh RHC sharing information 27 19 46 Occupancy rate 78% 71% 75% Sanctioned strength 32 11 43 Posted staff 34 2 36 KP RHC sharing information 24 5 29 Occupancy rate 106% 18% 84%

6 FAFEN Health Institution Monitor

Province Name of post Lady health visitors Nurses Total Sanctioned strength 22 6 28 Posted staff 19 3 22 Balochistan RHC sharing information 16 5 21 Occupancy rate 86% 50% 79% Sanctioned strength 6 0 6 Posted staff 4 0 4 FATA RHC sharing information 3 0 3 Occupancy rate 67% 67%

Sanctioned strength 256 425 681 Posted staff 236 367 603 Total RHC sharing information 134 93 227 Occupancy rate 92% 86% 89% 5.3 Te chnical staff Among RHCs that shared information, 77% positions of technical staff were occupied with 323 staffers appointed against the sanctioned 418. On average, the lowest occupancy rate recorded was for ECG technicians (32%). It was better for dental technicians though (75%), x-ray technicians (79%) and laboratory assistants (88%). Among regions, Sindh recorded the lowest occupancy rate (73%). However, Khyber Pakhtunkhwa had a better percentage (76%), Punjab (78%), Balochistan (82%) and FATA (100%). No ECG technician was posted against the six sanctioned positions in Sindh. Province Name of post Dental technicians ECG technicians Laboratory assistant X-ray technician Total Sanctioned strength 59 14 63 61 197 Posted staff 42 6 56 49 153 Punjab RHC sharing information 59 14 60 60 193 Occupancy rate 71% 43% 89% 80% 78% Sanctioned strength 30 6 27 25 88 Posted staff 24 0 21 19 64 Sindh RHC sharing information 24 6 23 23 76 Occupancy rate 80% 0% 78% 76% 73% Sanctioned strength 24 5 24 23 76 Posted staff 20 1 20 17 58 KP RHC sharing information 23 5 23 21 72 Occupancy rate 83% 20% 83% 74% 76% Sanctioned strength 13 2 18 16 49 Posted staff 8 1 18 13 40 Balochistan RHC sharing information 12 2 17 16 47 Occupancy rate 62% 50% 100% 81% 82% Sanctioned strength 1 1 4 2 8 Posted staff 1 1 4 2 8 FATA RHC sharing information 1 1 3 2 7 Occupancy rate 100% 100% 100% 100% 100% Sanctioned strength 127 28 136 127 418 Posted staff 95 9 119 100 323 Total RHC sharing information 119 28 126 122 395 Occupancy rate 75% 32% 88% 79% 77%

7 5.4 Support staff Ninety two percent positions of support staff were occupied in RHCs that shared information - 1,313 staff posted against the sanctioned 1,429. The occupancy rate was above 90% in all regions. On average, 86% sanctioned positions of sanitary workers were occupied. It was 89% for those of gardeners, 94% for watchmen's and 95% for dispensers. Province Name of post Dispensers Sanitary wor kers Gardeners Peons/ watchme n Total Sanctioned strength 291 248 64 213 816

Posted staff 284 212 56 199 751 Punjab RHC sharing information 65 63 62 65 255 Occupancy rate 98% 85% 88% 93% 92% Sanctioned strength 99 61 24 109 293 Posted staff 91 54 24 103 272 Sindh RHC sharing information 28 27 22 28 105

Occupancy rate 92% 89% 100% 94% 93%

Sanctioned strength 42 30 30 88 190 Posted staff 36 24 26 85 171 KP RHC sharing information 19 20 24 24 87 Occupancy rate 86% 80% 87% 97% 90% Sanctioned streng th 38 18 12 45 113 Posted staff 36 16 10 41 103 Balochistan RHC sharing information 19 14 11 19 63

Occupancy rate 95% 89% 83% 91% 91%

Sanctioned strength 6 1 3 7 17

Posted staff 6 1 2 7 16 FATA RHC sharing information 3 1 3 3 10 Occupancy rate 100% 100% 67% 100% 94% Sanctioned s trength 476 358 133 462 1429 Posted staff 453 307 118 435 1313 Total RHC shari ng information 134 125 122 139 520

Occupancy rate 95% 86% 89% 94% 92% 6. Disciplinary actions Information regarding disciplinary action taken against the stationed staff was not available at 24 centers. Of the RHCs that shared information, one doctor was warned due to poor performance and another transferred on the basis of his uncooperative behaviour. Two administrative staffers received warnings for being absent without informing the relevant authorities. Moreover, a technician got suspended because of his/her weak reporting in the polio campaign. Notices were issued to three peons because of their absence and poor performance. Number of staff Nature of Reason for disciplinary Information not Information S. # Personnel faced disciplinary disciplinary action action available not shared action

Medical staff 1 Warning Poor Performance 4 0 1. (doctors) 1 Transfer Uncooperative to people Paramedical staff 2. 4 0 (nurses etc.) Admin staff (clerks, peons 3. Admin staff 2 Warning etc.); two w arnings because 4 0 of absence without informing 4. Technician s 1 Suspension Weak polio reporting 4 0 Absence and poor 5. Peons 3 Notice 4 0 performance

6. Clerks 4 0

Total 8 24 0

8 FAFEN Health Institution Monitor

7. Government oversight During the July-September 2012 quarter, 93 visits were made by government/elected officials to the monitored health facilities, the highest being made to RHCs in Punjab (49), followed by Sindh (23), KP (14), Balochistan (6) and FATA (one). Executive District Officers (EDOs/health) made the most visits (63). Government officials other than EDOs made 23 visits. Four visits were made by elected representatives with Members National Assembly (MNAs) making three visits. S. # Designation Punjab Sindh KP Balochistan FATA Total 1. MNA 1 1 1 - - 3 2. MPA - - - - - 0 3. EDO/health 31 16 11 4 1 63 4. Any other government official 17 4 1 1 - 23 5. Any other elected representative - 2 1 1 - 4 Total 49 23 14 6 1 93 Annexure: List of monitored RHCs

S. # Name of the health facility District Province 1. Rural Health Center, Ladgasht, Mashkail Washuk Balochistan 2. Rural Health Center, Pringabad Mastung Balochistan 3. Rural Health Center, Zard Ghulam Jan Kalat Balochistan 4. Rural Health Center, Padag, Dalbadin Chagai Balochistan 5. Rural Health Center, Drug Musakhel Balochistan 6. Rural Health Center, Mazai Addhha Killa Abdullah Balochistan 7. Rural Health Center, Ahmedwal Nushki Balochistan 8. Rural Health Center, Khan Mehtarzai, Muslim Bagh Killa Saifullah Balochistan 9. Rural Health Center, Murgha Kibzai Zhob Balochistan 10. Rural Health Center, Jiwani Gwadar Balochistan 11. Rural Health Center, Mir Alikhel, Manikhawa Sherani Balochistan 12. Rural Health Center, Jhal Magsi Jhal Magsi Balochistan 13. Rural Health Center, Rojhan Jamali Jaffarabad Balochistan 14. Rural Health Center, Meer Wah, Tamboo Nasirabad Balochistan 15. Rural Health Center, Khatan, Sanni Bolan Balochistan 16. Rural Health Center, Kalatuk, Turbat Kech Balochistan 17. Rural Health Center, Gaddani Lasbela Balochistan 18. Rural Health Center, Karkh, Moola Khuzdar Balochistan 19. Rural Health Center, Ismail Shear, Duki Loralai Balochistan 20. Rural Health Center, Hassankhel FR Peshawar FATA 21. Rural Health Center, Ekka Ghund, Yakka Ghund Mohmand Agency FATA 22. Rural Health Center, Kuriz, Lower Orakzai Agency FATA 23. Rural Health Center, Kala Pani Abbottabad KP 24. Rural Health Center, Kuzabanda Battagram KP 25. Rural Health Center, Halli Haripur KP 26. Rural Health Center, Shinkiari Mansehra KP 27. Rural Health Center, Ayun Chitral KP 28. Rural Health Center, Kot, Batkhel Malakand KP 29. Rural Health Center, Badabher, Peshawar Town-4 Peshawar KP 30. Rural Health Center, Yar Hussain, Razar Swabi KP 31. Rural Health Center, Deolai, Kabal Swat KP 32. Rural Health Center, Pirpai Nowshehra KP 33. Rural Health Center, Shergarh, Takhtabai Mardan KP 34. Rural Health Center, Pattan Kohistan KP 35. Rural Health Center, Nawagai, Daggar Buner KP 36. Rural Health Center, Gambilla Lakki Marwat KP 37. Rural Health Center, Chuprial, Matta Swat KP 38. Rural Health Center, Usterzai Kohat KP 39. Rural Health Center, Gumbat Mardan KP 40. Rural Health Center, Domel Bannu KP

9 S. # Name of the health facility District Province 41. Rural Health Center, Gul Imam Tank KP 42. Rural Health Center, Karora, Alpuri Shangla KP 43. Rural Health Center, Naryab, Thull Hangu KP 44. Rural Health Center, Lassan Nawab Mansehra KP 45. Rural Health Center, Batagram, Shabqadar Charsadda KP 46. Rural Health Center, Nari Panus, Banda Daud Shah Karak KP 47. Rural Health Center, Marghuz Swabi KP 48. Rural Health Center, Manthar Rahimyar Khan Punjab 49. Rural Health Center, Ahmedpur Lama, Sadiqabad Rahimyar Khan Punjab 50. Rural Health Center, Qabula, Arifwala Pakpattan Punjab 51. Rural Health Center, Fatehpur, Karor Layyah Punjab 52. Rural Health Center, Jhatla, Talagang Chakwal Punjab 53. Rural Health Center, Qaimpur, Hasilpur Bahawalpur Punjab 54. Rural Health Center, Narang Mandi, Muridke Sheikhupura Punjab 55. Rural Health Center, Khutri Bunglow, Yazman Bahawalpur Punjab 56. Rural Health Center, Awan Dhai Wala, Wagah Town Lahore Punjab 57. Rural Health Center, Changa Manga, Chunian Kasur Punjab 58. Rural Health Center, Shah Bore Okara Punjab 59. Rural Health Center, Baddomalhi Narowal Punjab 60. Rural Health Center, Jamke Cheema, Daska Sialkot Punjab 61. Rural Health Center, Sankhatra, Zafarwal Narowal Punjab 62. Rural Health Center, Dahranwala, Chishtian Bahawalnagar Punjab 63. Rural Health Center, Khanqah Dogran, Safdarabad Sheikhupura Punjab 64. Rural Health Center, Luddan Vehari Punjab 65. Rural Health Center, Allahabad, Liaqatpur Rahimyar Khan Punjab 66. Rural Health Center, Balkasar Chakwal Punjab 67. Rural Health Center, Akhtarabad, Renala Khurd Okara Punjab 68. Rural Health Center, Kalaswala, Pasrur Sialkot Punjab 69. Rural Health Center, Tabi Sar, Isakhel Mianwali Punjab 70. Rural Health Center, Bunga Hayat, Arifwala Pakpattan Punjab 71. Rural Health Center, Chak No.8/11-L, Chichawatni Sahiwal Punjab 72. Rural Health Center, Farooqa, Sahiwal Sargodha Punjab 73. Rural Health Center, Wasawaywala, Depalpur Okara Punjab 74. Rural Health Center, Miana Gondal, Malikwal Mandi Bahauddin Punjab 75. Rural Health Center, Mustafabad Kasur Punjab 76. Rural Health Center, Chani Goth, Ahmedpur Bahawalpur Punjab 77. Rural Health Center, Dullewala, Darya Khan Bhakkar Punjab 78. Rural Health Center, Bagho Bahar, Khanpur Rahimyar Khan Punjab 79. Rural Health Center, Rajanpur Kalan Rahimyar Khan Punjab 80. Rural Health Center, Dunga Bunga Bahawalnagar Punjab 81. Rural Health Center, Roda Khushab Punjab 82. Rural Health Center, Makhdoom Rasheed, Mumtazabad Town Multan Punjab 83. Rural Health Center, Dera Bakha Bahawalpur Punjab 84. Rural Health Center, Behal Bhakkar Punjab 85. Rural Health Center, Shadiwal Gujrat Punjab 86. Rural Health Center, Chak No.112/9-L Sahiwal Punjab 87. Rural Health Center, Hawaili Korangi, Kabirwala Khanewal Punjab 88. Rural Health Center, Mubarikpur, Ahmedpur Bahawalpur Punjab 89. Rural Health Center, Sarwar Wali Punjab 90. Rural Health Center, Domel, Jand Attock Punjab 91. Rural Health Center, Mandi Sadiq Ganj, Minchinabad Bahawalnagar Punjab 92. Rural Health Center, Ganda Singwala Kasur Punjab 93. Rural Health Center, Rangoo, Hazro Attock Punjab 94. Rural Health Center, Chak No.56/WB Vehari Punjab 95. Rural Health Center, Pindi Sultanpur, Kharian Gujrat Punjab 96. Rural Health Center, Kassoki Hafizabad Punjab 97. Rural Health Center, Sharaqpur Sheikhupura Punjab 98. Rural Health Center, Makhdoompur Khanewal Punjab

10 FAFEN Health Institution Monitor

S. # Name of the health facility District Province 99. Rural Health Center, Makhdoom Aali, Dunyapur Lodhran Punjab 100. Rural Health Center, Chak No.231/WB, Dunyapur Lodhran Punjab 101. Rural Health Center, Kot Mitthan Rajanpur Punjab 102. Rural Health Center, Noor Shah Sahiwal Punjab 103. Rural Health Center, Fazilpur Rajanpur Punjab 104. Rural Health Center, Jamman Shah Layyah Punjab 105. Rural Health Center, Mandra, Gujar Khan Rawalpindi Punjab 106. Rural Health Center, Khalaspur Jhelum Punjab 107. Rural Health Center, Hafizwala, Piplan Mianwali Punjab 108. Rural Health Center, Chak No.316/GB Toba Tek Singh Punjab 109. Rural Health Center, Chak No.104/NB Sargodha Punjab 110. Rural Health Center, Bahtar , Fatehjang Attock Punjab 111. Rural Health Center, Mochiwala Jhang Punjab 112. Rural Health Center, Bagh Jhang Punjab 113. Rural Health Center, Islamkot, Mithi Tharparkar Sindh 114. Rural Health Center, Bachal Shah Miani, New Sukkur Sukkur Sindh 115. Rural Health Center, Tando Jan Muhammad, Digri Mirpurkhas Sindh 116. Rural Health Center, Dando, Tando Ghulam Haider Tando Mohammad Khan Sindh 117. Rural Health Center, Murad Memon Goth, Malir Town Malir Sindh 118. Rural Health Center, Drigh Bala, Juhi Dadu Sindh 119. Rural Health Center, Bhale Dino Kaka, Saeedabad Matiari Sindh 120. Rural Health Center, Tando Ghulam Ali, Matli Badin Sindh 121. Rural Health Center, Qadirpur Jacobabad Sindh 122. Rural Health Center, Unarpur, Manjhand Jamshoro Sindh 123. Rural Health Center, Tando Qaiser, Hyderabad Sindh 124. Rural Health Center, Umaid Ali Khan Junejo, Shahdadkot Kamber Shahdadkot Sindh 125. Rural Health Center, Kadhan Badin Sindh 126. Rural Health Center, Khanpur Shikarpur Sindh 127. Rural Health Center, Trighati, Rohri Sukkur Sindh 128. Rural Health Center, Mirwah Gorchani Mirpurkhas Sindh 129. Rural Health Center, Chuhar Jamali, Shah Bandar Thatta Sindh 130. Rural Health Center, Baghan, Keti Bandar Thatta Sindh 131. Rural Health Center, Ranipur, Sobho Dero Khairpur Sindh 132. Rural Health Center, Qubo Saeed Khan, Qubo Saeed Khan Kamber Shahdadkot Sindh 133. Rural Health Center, Radhan, Mehar Dadu Sindh 134. Rural Health Center, Injam Colony, Baldia Town Karachi West Sindh 135. Rural Health Center, Daur Shaheed Benazirabad (Nawabshah) Sindh 136. Rural Health Center, Naserpur Tando Allahyar Sindh 137. Rural Health Center, Jam Nawaz Ali Sanghar Sindh 138. Rural Health Center, Sonahri Farm, Moro Naushero Feroz Sindh 139. Rural Health Center, Kheensar, Chachro Tharparkar Sindh 140. Rural Health Center, Bhirya Naushero Feroz Sindh 141. Rural Health Center, Atta Muhammad Hamid, Kot Diji Khairpur Sindh 142. Rural Health Center, Wagan, Warah Kamber Shahdadkot Sindh 143. Rural Health Center, Shahpur Chakar, Shahdadpur Sanghar Sindh 144. Rural Health Center, Jhol Sanghar Sindh

11 Free and Fair Election Network (FAFEN), established in 2006, is a coalition of 42 leading civil society organizations, working to strengthen all forms of democratic accountabilities in Pakistan. Governed by Trust for Democratic Education and Accountability, FAFEN's key achievements are: n Observed the public display of Pakistan's draft electoral rolls and conducted the country's first statistically-valid voters' list audit in 2007 n Deployed more than 18,829 trained, neutral Election Day observers nationwide to watch the February 18, 2008 polls and 264 long-term observers to monitor the pre-election process n Fielded long-term observers nationwide and published 19 pre-election reports n For the February 18, 2008, General Elections, FAFEN conducted 260 simultaneous Parallel Vote Tabulations (PVTs)- the largest effort in the world n Conducted its first survey, Constituents Aspirations Survey, in December 2008 with a sample size of 3,124 respondents to get the description of the state of public opinion and also to get a deeper understanding of the values, attitudes and beliefs of people living in the constituencies n Conducted mapping of organizations working for human rights within Pakistan n Observed general elections at Gilgit-Baltistan in 2009 and by-elections in various constituencies of the Punjab, Balochistan and Khyber Pakhtunkhwa in 2010 n Implemented a unique methodology to observe parliamentary proceedings under its Parliament Watch Project n Monitors public institutions across Pakistan and issues monthly reports on the state and performance of educational, health and other local level institutions. In addition, monthly reports on prices, crimes, incidence of disease, caseload in lower courts and political and electoral violence are issued. FAFEN continues to implement robust programs in-between elections related to monitoring parliamentary affairs, connecting constituents to their elected representatives, monitoring the performance of public and elected institutions and advocating electoral and democratic reforms. FAFEN is also monitoring political and electoral violence, peace activities and promoting active citizenry through ongoing civic education activities across the country. FAFEN is currently implementing Supporting Transparency, Accountability and Electoral Processes in Pakistan (STAEP) in 200 National Assembly constituencies in 119 districts across Pakistan.