Completion Report
Project Numbers: 41641-013 and 41641-023 Loan Numbers: 2485 and 2644 February 2015
Pakistan: Punjab Millennium Development Goals
Program
This document is being disclosed to the public in accordance with ADB's Public Communications
Policy 2011.
CURRENCY EQUIVALENTS Currency Unit – Pakistan rupee/s (Pre/PRs)
At Appraisal At Completion Loan 2485 Loan 2644 Loan 2485 Loan 2644 15 Oct 2007 26 Aug 2009 4 Feb 2009 30 Jun 2010
PRe1.00 = $0.0164 $0.0121 $0.0126 $0.0117 $1.00 = PRs60.62 PRs82.75 PRs79.11 PRs85.83
ABBREVIATIONS
ADB – Asian Development Bank
BHU – basic health unit
DFID – Department for International Development of the United Kingdom DHIS – district health information system
DHQ – district headquarter hospital
GOP – Government of Punjab
HSRF – health sector reform framework
IMF – International Monetary Fund
IMR – infant mortality rate
LHW – lady health worker
MDG – Millennium Development Goal
MMR – maternal mortality ratio
MNCH – maternal, neonatal, and child health
MSDS – minimum service delivery standard
MTBF – medium-term budget framework
ODGHS – Office of the Director General of Health Services
PCR – program completion review
PDSSP – Punjab Devolved Social Services Program
PGEIP – Punjab Government Efficiency Improvement Program
PHCC – Punjab Healthcare Commission
PIFRA – Project for Improved Financial Reporting and Accounting
PMDGP – Punjab Millennium Development Goals Program
PMU – project management unit
RHC – rural health center
SMP – standard medical protocol SOP – standard operating procedure SP1 – subprogram 1 SP2 – subprogram 2 SP3 – subprogram 3 TA – technical assistance
THQ – town headquarter hospital
NOTES
(i) The fiscal year (FY) of the government and its agencies ends on 30 June. FY before a calendar year denotes the year in which the fiscal year ends, e.g., FY2009 ends on 30 June 2009.
(ii) In this report, “$” refers to US dollars.
Vice-President W. Zhang, Operations 1 Director General K. Gerhaeusser, Central and West Asia Department (CWRD) Director B. Wilkinson, Public Management, Financial Sector, and Trade Division,
CWRD Country Director W. Liepach, Pakistan Resident Mission, CWRD Team leader M. Abro, Senior Project Officer, CWRD Team member M. Bukhari, Project Analyst, CWRD
In preparing any country program or strategy, financing any project, or by making any designation of or reference to a particular territory or geographic area in this document, the Asian Development Bank does not intend to make any judgments as to the legal or other status of any territory or area.
CONTENTS
Page
BASIC DATA i
I. PROGRAM DESCRIPTION 1
II. EVALUATION OF DESIGN AND IMPLEMENTATION 2
A. Relevance of Design and Formulation 2 B. Program Outputs 4 C. Program Costs 10 D. Disbursements 11 E. Program Schedule 11 F. Implementation Arrangements 11 G. Conditions and Covenants 12 H. Performance of the Borrower and the Executing Agency 12 I. Performance of the Asian Development Bank 12
III. EVALUATION OF PERFORMANCE 13
A. Relevance 13 B. Effectiveness in Achieving Outcome 13 C. Efficiency in Achieving Outcome and Outputs 13 D. Preliminary Assessment of Sustainability 14 E. Impact 14
IV. OVERALL ASSESSMENT AND RECOMMENDATIONS 14
A. Overall Assessment 14 B. Lessons 15 C. Recommendations 15
APPENDIXES
1. Updated Design and Monitoring Framework 16 2. Policy Matrix 21 3. Minimum Service Delivery Standards Package 32 4. Utilization of PMDGP Funds by Districts 34 5. Gender Action Plan 36 6. Actual Status of Compliance with Loan Covenants (Subprograms 1 and 2) 40 7. Assessment of Overall Program Performance 51
BASIC DATA
A. Loan Identification 1. Country 2. Loan Number 3. Program Titles
Loan 2485
Loan 2644 4. Borrower
Loan 2485 Loan 2644
5. Executing Agency Loan 2485 Loan 2644
6. Amount of Loan Loan 2485 Loan 2644
7. Program Completion Report Number
Pakistan 2485 Loan 2485-PAK, Loan 2644-PAK Punjab Millennium Development Goals Program—Subprogram 1 Punjab Millennium Development Goals Program—Subprogram 2 Islamic Republic of Pakistan Health Department Government of Punjab Health Department Government of Punjab SDR63,730,000 SDR102,318,000
B. Loan Data 1. Appraisal – Date Started/Completed
Loan 2485 Loan 2644
2. Loan Negotiations – Date Started
Loan 2485 Loan 2644
– Date Completed Loan 2485 Loan 2644
3. Date of Board Approval Loan 2485 Loan 2644
4. Date of Loan Agreement Loan 2485 Loan 2644
5. Date of Loan Effectiveness – In Loan Agreement
Loan 2485 Loan 2644
– Actual Loan 2485 Loan 2644
– Number of Extensions Loan 2485 Loan 2644
6. Closing Date – In Loan Agreement
Loan 2485
15–27 Aug 2008 1–15 Mar 2010 25 Sep 2008 20 May 2010 26 Sep 2008 20 May 2010 11 Dec 2008 24 Jun 2010 17 Dec 2008 24 Jun 2010 16 Jan 2009 23 Jul 2010 28 Jan 2009 30 Jun 2010 none none 30 Apr 2009
ii
Loan 2644 – Actual
Loan 2485 Loan 2644
– Number of Extensions Loan 2485 Loan 2644
7. Terms of Loan – Interest Rate
Loan 2485
Loan 2644 – Maturity (number of years)
Loan 2485 Loan 2644
– Grace Period (number of years) Loan 2485 Loan 2644
8. Terms of Relending (if any) – Interest Rate
Loan 2485 Loan 2644
31 Dec 2010 4 Feb 2009 30 Jun 2010 none none 1% per annum during grace period, and 1.5% per annum thereafter
1% per annum during grace period, and 1.5% per annum thereafter
24 24
8 8 1% per annum during grace period, and 1.5% per annum thereafter 1% per annum during grace period, and 1.5% per annum thereafter
9. Disbursements a. Dates
i. Loan 2485
Initial Disbursement Final Disbursement Time Interval
30 Jan 2009 30 Jan 2009 0
Effective Date Original Closing Date Time Interval
28 Jan 2009 30 Apr 2009 3 months
ii. Loan 2644
Initial Disbursement Final Disbursement Time Interval
30 Jun 2010 30 Jun 2010 0
Effective Date Original Closing Date Time Interval
30 Jun 2010 31 Dec 2010 6 months
b. Amount
Category or Subloan
Original
Allocation
Last Revised
Allocation
Amount
Canceled
Net Amount
Available
Amount
Disbursed
Undisbursed
Balance
i. Loan 2485 SDR ii. Loan 2644 SDR
63,730,000
102,318,000
0
0
0
0
63,730,000
102,318,000
63,730,000
102,318,000
0
0
iii
C. Program Data 1. Program Cost (SDR)
Cost Appraisal Estimate Actual
Loan 2485 Foreign Exchange Cost Not applicable Not applicable Local Currency Cost Not applicable Not applicable Total Loan 2644 Foreign Exchange Cost Not applicable Not applicable Local Currency Cost Not applicable Not applicable
Total
63,730,000
Not applicable Not applicable 102,318,000
63,730,000
Not applicable Not applicable 102,318,000
2. Program Schedule
Item Appraisal Estimate Actual
Loan 2485 Overall program cost
Oct 2008
30 Jan 2009
First tranche Loan 2644 Second tranche
Oct 2008
Nov 2009
30 Jan 2009
30 Jun 2010
3. Program Performance Report Ratings
Implementation Period
Ratings
Development Objectives Implementation Progress
Loan 2485 From 31 Dec 2008 to 28 Feb 2009
Satisfactory
Satisfactory
From 31 Mar 2009 to 31 Dec 2009 Loan 2644 From 30 June 2010 to 31 December 2010
Satisfactory
Satisfactory
Partly Satisfactory
Satisfactory
iv
D. Data on Asian Development Bank Missions
Name of Mission
Date
No. of Persons
No. of Person-Days
Specialization of Member
Loan 2485 Reconnaissance
24–30 Ap 2008
2
10
a,b
Fact-finding Appraisal
28 May–13 Jun 2008 15–27 Aug 2008
6 5
90 65
a,b,c,d,e,f a,f,g,h,i,
Inception 19–27 Feb 2009 6 31 a,f,g,j,k,l Program review 29 Jun–8 Jul 2009 4 40 a,f,j,m Loan 2644 Fact-finding 1 Fact-finding 2 Consultation Program review (phase 1) Program review (phase 2) Special loan administration Project completion
13–26 Aug 2009 1–15 Mar 2010
22–29 Apr 2010 7–11 Feb 2011
15–16 Mar 2011 29–30 Jul 2013 26–30 Aug 2013
5 1 5 4 3 1 2
70 15 40 20 9 2
10
a,b,c,d,e
c b,c,d,f,e c,d,g,h
c,g h h,i
Loan 2485 a = senior social sectors specialist, b = staff consultant (public finance management specialist), c = fiscal management specialist, d = senior counsel, e = maternal and child health consultant), f = consultant (financial specialist), g = principal health specialist, h = project implementation officer (health), i = advisor (health j = health economist, k = consultant (health reform specialist), l = social sector specialist, m= consultant (health economist) Loan 2644 a = senior social sectors specialist, b = economist, c = social sectors specialist, d = consultant (financial specialist), e = consultant (health economist), f = director, g = project officer (public resource management), h = senior project officer (health), I = project analyst.
I. PROGRAM DESCRIPTION
1. Public health care in Pakistan has been persistently underfinanced by the three levels of government responsible for it: federal, provincial, and district. Pakistan’s per capita public health expenditure is lower than that of South Asian countries such as Bangladesh, India, Nepal, and Sri Lanka. During the appraisal by the Asian Development Bank (ADB) of the Punjab Millennium Development Goals Program (PMDGP) in 2008, health sector spending in the country’s Punjab Province averaged 0.5% of gross domestic product and 8% of total public spending. This was insufficient to meet the minimum health services requirements of the population. Both overall and at the district level, recurrent spending, which was largely for salaries, absorbed 80%–90% of funds. Due to a significant resource gap in health care services, key health indicators for Pakistan and for Punjab Province lag behind. This was particularly true of indicators related to maternal and child health. In an effort to improve progress on two important Millennium Development Goals (MDGs), the provincial government of Punjab (GOP) set targets in 2000 for reductions by 2015 in the infant mortality rate (IMR) from 77 to 40 per 1,000 live births (MDG 4) and in the maternal mortality ratio (MMR) from 300 to 140 per 100,000 live births (MDG 5).1 Significant additional efforts were needed to achieve these targets. 2. Responding to a GOP request for support, ADB designed the PMDGP as a cluster of three subprograms.2 The program was approved on 11 December 2008 together with a loan for subprogram 1 (SP1) amounting to SDR63,730,000. Subprogram 2 (SP2) of SDR102,318,000 was approved on 24 June 2010.3 Subprogram 3 (SP3) could not be processed due to the termination of an International Monetary Fund (IMF) program in Pakistan.4 The intended impact of the PMDGP was to help the GOP achieve MDGs 4 and 5 in Punjab Province. The envisaged outcome was to improve access to quality health services and make them more equitable. Delivering health services that met the minimum service delivery standards (MSDSs), especially in maternal, neonatal, and child health (MNCH), was adopted as the core strategy for attaining MDGs 4 and 5.5 The PMDGP was to assist the GOP in reaching the MDGs by undertaking reforms in the following areas of the health sector:
(i) Improving the availability and quality of primary and secondary health services. The PMDGP was to help the GOP ensure that certain MSDSs for primary and secondary health services were implemented by incorporating the
1 A health sector reform framework launched by the GOP in 2006 identified bottlenecks hampering the improvement
in health indicators and recommended a shift from quantity to quality of health care, from fragmented vertical programs to integrated service delivery, and from tertiary to primary and secondary health care.
2 ADB. 2008. Report and Recommendation of the President to the Board of Directors on a Proposed Program
Cluster and Loan for Subprogram 1 to Islamic Republic of Pakistan for Punjab Millennium Development Goals Program. Manila (Loan 2485-PAK, for $100 million equivalent, approved on 11 December 2008).
3 ADB. 2010. Report and Recommendation of the President to the Board of Directors on a Proposed Loan for
Subprogram 2 to Islamic Republic of Pakistan for Punjab Millennium Development Goals Program. Manila (Loan 2644-PAK, for $150 million equivalent, approved on 24 June 2010).
4 In October 2011, the IMF discontinued its Stand-By Arrangement with Pakistan as the government failed to meet
its commitments on implementing certain agreed reforms. The IMF country assessment letter for Pakistan—a prerequisite for ADB’s program loans—was not issued. After delays in moving the IMF program forward, ADB and the government agreed to cancel SP3 and reallocate the planned funds to other ADB projects in Pakistan.
5 The MSDSs define the minimum package of services that the public is entitled to, a set of performance indicators, and minimum acceptable levels of performance by service providers at each level of health care, along with the required physical and human resource requirements. Comprehensive referral guidelines, standard operating procedures (SOPs), and standard medical protocols (SMPs) were developed to facilitate the implementation of MSDSs. MSDS, SOPs, and SMPs together had well-defined accountability parameters at each level of health care for different health professionals and benchmarks against which performance of the health system as a whole and that of each worker was to be monitored and evaluated. The MNCH-related MSDS package is in Appendix 3.
2
MSDS into provincial and district health sector plans and increasing the quality and quantity of human resources in the health sector.
(ii) Strengthening management of health service delivery. The PMDGP was to
help the GOP improve the daily management of health service delivery by reducing delays in the procurement of essential drugs, institutionalizing the contracting of health services to nongovernment organizations, and improving performance monitoring and evaluation.
(iii) Establishing a sustainable pro-poor health financing system. The PMDGP
was to assist the GOP in substantially increasing the health care budget and improving planning and management of the budget, introducing a targeted program for reducing out-of-pocket health expenditure by the poor, and developing a sustainable health care financing and provider payment system.
II. EVALUATION OF DESIGN AND IMPLEMENTATION
A. Relevance of Design and Formulation
3. The program design was less than relevant at appraisal. Despite the fact that SP3 was not processed, the design remained less than relevant at completion. The attainment of the MDGs was seen as crucial to achieving inclusive economic growth, one of the three strategic agendas of ADB’s long-term strategic framework for 2008–2020 (Strategy 2020), which also calls for selective support for achieving the MDGs.6 Strategy 2020 identifies the strengthening of public expenditure management for cost-effective delivery of health services as an area of comparative advantage for ADB. ADB’s 1999 health sector policy stressed the need to ensure that the poor, women, and children have access to health services. 7
ADB’s 2008 health operational plan emphasized the need for ADB to focus more on governance work, especially public expenditure management for cost-effective delivery of health programs and services.
8 In
line with Strategy 2020 and the health sector policy, ADB’s country partnership strategy for Pakistan for 2009–2013 highlighted the need for improved governance of health service delivery and better management of public resources.9 The PMDGP adopted a programmatic approach to help ensure sustained GOP focus on health sector needs. At the request of the GOP, the conceptual framework for the proposed PMDGP was included as part of ADB’s Punjab Government Efficiency Improvement Program (PGEIP), thus making the program an integral part of the PGEIP cluster approved by ADB in December 2007.10 4. Pakistan’s national government recognized the need to improve health outcomes as an important part of its poverty alleviation plan. Pakistan’s 2001 national health policy prioritized primary and secondary health care, with good governance set as the basis of health sector reform.11 In its 2004 MDGs report, the government made a firm commitment to achieve the
6 ADB. 2008. Strategy 2020: The Long-Term Strategic Framework of Asian Development Bank, 2008–2020. Manila. 7 ADB. 1999. Policy for the Health Sector. Manila.
8 ADB. 2008. Operational Plan for Improving Health Access and Outcomes. Manila.
9 ADB. 2009. Country Partnership Strategy: Pakistan, 2009–2013. Manila. At the time of the PMDGP’s design, the
CPS was still under preparation. 10 ADB. 2007. Report and Recommendation of the President to the Board of Directors: Proposed Program Cluster,
Loan for Subprogram 1, Technical Assistance Loan, and Technical Assistance Grants to Islamic Republic of Pakistan: Punjab Government Efficiency Improvement Program. Manila. para. 6.
11 Ministry of Health, Government of Pakistan. 2001. National Health Policy 2001: The Way Forward. Islamabad.
http://siteresources.worldbank.org/PAKISTANEXTN/Resources/Pakistan-Development- Forum/NationalHealthpolicy.pdf
3
3 A
ppe
nd
ix 5
MDGs and expressed optimism that most of the MDG targets were achievable.12 Based on the strategic direction provided under the national health policy, the GOP developed a health sector reform framework (HSRF) in 2005.13 The GOP had initiated service delivery reforms in 2003 with the support of ADB under the Punjab Resource Management Program14 and in 2004 under the Punjab Devolved Social Services Program (PDSSP). 15 The former program sought to increase fiscal space for social service delivery by improving provincial government operational efficiency, while the PDSSP aimed at strengthening district systems and developing necessary service delivery standards for devolved social services, including health (65% of total program cost), education, water supply, and sanitation services. A 2005 sector assistance program evaluation by ADB’s Independent Evaluation Department noted that, while the need was great, making a difference in social sector outcomes in Pakistan was difficult. The report found that persistent poor performance showed that a new approach was needed that would support private provision for the better-off, innovative funding arrangements to give choices to the poor, and improved data on social sector performance.16
5. The design of the PMDGP was consistent with GOP plans. It built on the reforms in the health sector initiated in 2006, including higher financial allocations, increased salaries for doctors, and autonomy and outsourcing of health care management units at the primary health level. The design incorporated lessons learned from earlier ADB-supported interventions and from the 2005 sector assistance program evaluation. The intended reforms were expected to improve efficiency in both supply of and demand for health care by institutionalizing MSDSs, SOPs, referral guidelines, and SMPs. However, the challenges were formidable. They included a very small budget allocation for health, the degree of impoverishment of those seeking health services, and a chronic shortage of skilled workers. Ensuring minimum standards required a complete shift in the health service delivery paradigm, and the GOP lacked the financial and human resources to carry it out. In addition, the GOP had to respond to natural calamities, including repeated floods and a dengue epidemic. These absorbed the Punjab health department’s resources and diverted attention from the PMDGP’s implementation. The security situation in the province over the implementation period was also challenging. These circumstances overwhelmed the government and slowed district utilization of the ADB program’s funding.
6. While the PMDGP’s design fit ADB and government approaches, its results targets and management requirements were beyond reach. The number and nature of policy reform activities in the design made it difficult for the executing agency and implementing agencies to implement the PMDGP due to their limited capacity at both the provincial and district levels. The performance indicators set in the design and monitoring framework were too ambitious. For example, increasing full immunization from 53% to a target of 80% was unrealistic—a change of
12
Government of Pakistan. 2004. Pakistan Millennium Development Goals Report 2004. Islamabad. 13
The GOP finalized its poverty-focused investment strategy in July 2005. It incorporated in-depth analysis of the issues confronting the health sector and made recommendations on how to effectively address them within the broader framework of the devolution program. The strategy provided the groundwork for the development of the Punjab HSRF under the ADB-funded Punjab Resource Management Program. The HSRF, launched in 2006, set the direction for health sector reforms by clearly defining the strategy and milestones for enhancing service delivery systems in the health sector. The HSRF is available at http://www.punjab-prmp.gov.pk/dl.php?f=Health%20Sector%20reforms%20Framework.pdf
14 ADB. 2003. Report and Recommendation of the President to the Board of Directors: Proposed Program Cluster of Loans to the Islamic Republic of Pakistan for the Punjab Resource Management Program. Manila. (Loan 2030-PAK, $200 million, approved on 4 December 2003).
15 ADB. 2004. Report and Recommendation of the President to the Board of Directors: Proposed Program Loans and Technical Assistance Grant to the Islamic Republic of Pakistan for the Punjab Devolved Social Services Program.
Manila. (Loans 2144 and 2145-PAK, $150 million, approved on 20 December 2004). 16
ADB. 2005. Sector Assistance Program Evaluation: Social Sectors in Pakistan. Manila.
4
this magnitude in key indicators of public health generally occurs over decades.17 Setting lower targets and providing additional technical assistance (TA) to support program implementation and management and at least 2 years of additional time for implementation of each subprogram would have helped make the program results goals achievable. 7. High-level GOP ownership of health sector reforms existed at the appraisal stage. These were championed by the secretaries of the planning and development department and the health department. However, GOP ownership of the PMDGP diminished with a 2008 change in government and a partial rollback of devolution efforts. The project preparatory TA resources were mainly used to recruit national consultants who had good understanding of the ongoing health sector reforms.18 The inclusion of a separate set of conditions on governance and the introduction of a regulatory system for the private sector led to the approval of the Punjab Healthcare Act 2010 and the establishment of the Punjab Healthcare Commission (PHCC), which started MSDS implementation in the private sector. In 2013, the World Bank approved a health sector reform project, supported by the Department for International Development of the United Kingdom (DFID), building on key policy reforms initiated under the PMDGP.19 B. Program Outputs
8. The intended and actual delivery of outputs is discussed below in terms of the PMDGP’s core policy areas and actions and activities undertaken in each to achieve the outputs.
1. Improving Availability and Quality of Primary and Secondary Health
Services
9. Activities in this core policy area supported the introduction of service standards, first in the public sector and ultimately in private sector health services; by incorporating the MSDSs in provincial and district health sector plans to increase the quality and quantity of human resources in the health sector. The core policy area is considered not achieved.
10. Introducing minimum service delivery standards in primary and secondary health services. The objective of this policy action was not achieved. The aim was to introduce public services standards that would also eventually need to be observed by private practitioners. The MNCH-related MSDS package spelled out a set of services to be available at each health facility and coverage targets for each service (Appendix 3). Under SP1, all 36 districts agreed to reach the MSDSs by 2012 and signed a memorandum of understanding with the GOP to achieve this result. It specified the responsibilities of both the provincial and district governments. At least 7 districts were expected to substantially conform to MNCH-related MSDSs under SP2, followed by 15 under the SP3. All others were to comply by 2012. The policy conditions of SP1 and SP2 were achieved, and one of the indicative triggers under SP3 was achieved. An independent third-party assessment of MSDS implementation conducted in 2012 found that progress had been made toward achievement of MDGs 4 and 5, but it was not
17
According to the Pakistan demographic and health survey of 2013, the full immunization rate was 65%. 18
ADB. 2007. Technical Assistance Grant to Assist in the Preparation of the Proposed Punjab Millennium Development Goals and Access to Justice Programs. Manila. (TA7004-PAK). ADB approved project preparatory
TA of $900,000 on 10 December 2007, which became effective on 13 May 2008. The TA was originally planned to be completed by 31 December 2009, but it was extended until 31 December 2010. The TA aimed to support the formulation of the PMDGP cluster through policy dialogue, diagnostic assessments, and stakeholder consultations. Nine consultants were recruited. This accounted for $280,230 or 31% of the TA amount.
19 World Bank. 2013. Punjab Health Sector Reform Project. Washington. ($100 million). DFID. 2012. Pakistan: Provincial Health and Nutrition Program. London. (£160 million).
5
5 A
ppe
nd
ix 5
enough to meet the targets by 2015. The assessment found an increase in the number of patients and an improvement of quality and access to key health services. A shortage of female staff continues at the primary health care level, as well as a shortage of specialists at town headquarter hospital (THQ) level. Financial constraints remain, which has serious implications for the sustainability of MSDS. 11. The districts prepared 3-year rolling plans and annual utilization plans in 2009 that followed the MSDS implementation guidelines, but the funds received under the conditional grant mechanism for the program were minimally utilized in the districts (Appendix 4). The health department had serious concerns about the activities the districts proposed in the annual utilization plans, as these were not relevant enough to the PMDGP’s objectives, and did not approve them until 2012. 12. Meeting the MSDSs required more than physical improvements. It also involved the internalization and institutionalization of service delivery standards. This represented a substantial paradigm shift. For the health system to become accountable, communities, particularly women of reproductive age, needed to fully understand the MSDSs. Under SP2, all the province’s districts organized awareness campaigns for public health workers in their facilities. The district health authorities relied on such methods as posters, pamphlets, and banners to increase the awareness of communities and health care workers about the MSDSs, rather than the programs used in current public health practice internationally.20 At PMDGP completion, therefore, the level of awareness of the MSDSs among health care staff and in the target populations was generally inadequate. Moreover, the teaching faculty at the provincial health development center in Lahore and a sample of district-level master trainers interviewed during the program completion review (PCR) mission had very limited knowledge of the MSDSs. In 2013, the health department developed an essential package of health services for primary and secondary health care facilities in support of the MSDSs.21 13. Primary and secondary health facilities staffed and equipped according to minimum service delivery standards. The PMDGP did not achieve its objective of meeting the MSDSs in the staffing and equipping of primary and secondary health facilities. To ensure minimum service delivery, the districts required large numbers of skilled workers, anesthetists, gynecologists, neonatologists, and female doctors and staff. These were not present in the health facilities or available in the labor market when the PMDGP was designed. In 2010, the GOP took steps to resolve these issues. The measures included the relaxation of the recruitment age of women medical officers, crash training programs for anesthetists, ad hoc recruitment of specialists, rotation of students from training hospitals, and regularization of contractual posts. This led to an improved human resources situation for key MNCH-related positions. A barrier to achieving the MSDSs was the lack of appropriately established and maintained physical facilities and needs, such as well-kept buildings; uninterrupted supply of electricity, water, and gas; incinerators; and hospital waste disposal systems. A comprehensive
20
The PMDGP might have employed established approaches of knowledge, attitude, and practice and behavioral change communication models to bring about the desired change in communities and among the health providers. It could have also drawn upon the national government-funded MNCH program’s national communication strategy framework and evolved a common behavioral change communication strategy, targeting MDGs 4 and 5.
21 The essential services package spells out major service components in such areas as nutrition; maternal health; and newborn, infant, and child health. It provides details of the support elements needed to ensure service delivery, which include (i) essential equipment and supplies; (ii) essential medicines; (iii) diagnostic services; (iv) pharmacy services; (v) infrastructure; (vi) human resources; (vii) a referral system and linkages; (viii) a monitoring and reporting system; (ix) scope of work for providers; (x) infection control guidelines for facilities; and (xi) cost of resources.
6
exercise was conducted in 2010 to map equipment gaps against the standard specified list. Some of the equipment was procured by the districts.
14. While the policy conditions of SP1 and SP2 were achieved, the human resources situation in primary and secondary health care facilities remained problematic throughout the province. Many positions established remained vacant due to delayed administrative approvals, lack of skilled staff, and the challenging work conditions, particularly for female staff. At the basic health unit (BHU) level, the minimum requirement of having one lady health visitor, one nurse, or one midwife at each BHU was achieved, as it is not required to have a women medical officer at BHUs level. The situation at higher levels of care was unsatisfactory. Of the 9 rural health centers (RHCs) visited by the PCR mission, only 4 had a woman medical officer. The district headquarter hospital (DHQ) visited had filled only 5 specialist positions out of 23. 15. The large number of unfilled positions affected efforts to meet the MSDSs. For example, the SOPs required certain routine practices to be carried out to maintain hygiene and cleanliness at health facilities. However, due to the ban on recruitment to fill vacant general services staff positions, a chronic shortage of janitors in health facilities province-wide made this impossible.22 ADB felt that it was not possible to ensure basic and comprehensive emergency obstetric and neonatal care23 in health facilities without improved staffing. Under SP2, the Chief Minister approved a health human resource plan, rationalizing the service structure and staffing. The situation generally remained unchanged. This had been an important target under the PMDGP and was not achieved.
16. Measures adopted to improve quality of health workers and their practices. The PMDGP did not deliver the improvement in the quality of health workers and their practices that was one of its objectives. The quality of services is largely dependent upon the knowledge, skills, and attitude of health workers. Paramedics, nurses, lady health visitors, lady health workers (LHWs), and midwives constitute a major part of the health services staff. The province has 5 paramedic and 30 nursing schools that produce most of these staff members. Urgently improving the physical conditions and the training capacity of these schools under the PMDGP was crucial to improving the quality of service delivery. Under the PMDGP, the GOP committed to implement a plan to improve health school service structures, examination systems, personnel management, and quality of both pre- and in-service training. A number of schools were visited in December 2010 by ADB consultants.24 They reported that none of these schools had started upgrades that were to be undertaken with the conditional grants provided under the PMDGP. The training contents and pedagogical methods being used by the faculties were outdated. The national government-funded MNCH program also included a major component to upgrade these schools and to strengthen the management of nursing schools and district health offices. A lack of coordination between the PMDGP, the provincial MNCH program, the Office of the Director General of Health Services (ODGHS), and the office of the director general of
22
The district health office of the city of Rawalpindi reported to the PCR mission in August 2013 that against 5 sanctioned posts of janitors in the THQ at Kalar Sayadan 1 post was filled and against 12 sanctioned positions in THQ at Kahuta, only 4 posts were filled.
23 About 15% of women in Pakistan develop complications during pregnancy or after giving birth, leading to their deaths or disability and/or to the deaths or disability of newborns. Most of this is avoidable. While most life-threatening complications during pregnancy and childbirth cannot be predicted or prevented, nearly all can be successfully treated with effective, timely emergency obstetric and neonatal care.
24 In late 2010, a two-person team of ADB consultants (a public health specialist and a financial specialist) conducted an in-depth assessment of progress on implementing the PMDGP. They submitted a report to ADB in January 2011 containing findings based on field visits to 12 project districts, review of progress reports, and interviews with district health authorities, health facilities staff, patients, and communities.
7
7 A
ppe
nd
ix 5
nursing resulted in overlapping, gaps, and lack of ability to assess what steps were being taken by which program. 17. Under SP1, the provincial health development center provided training to 127 master trainers, including at least 3 from each district. District health development centers trained 9,809 health personnel province-wide, compared with a target of 10,914. The training covered MSDSs, SOPs, SMPs, and referral protocols. In interviews with ADB’s monitoring consultants in 2010 (footnote 24) and with the PCR mission, health staff members reported that the training was weak in terms of pedagogy, methodology, logistics, medium of instruction, and the selection of trainees and tutors. Under SP2, examinations of paramedics were to be conducted by the University of Health Sciences. A draft curriculum was prepared by the university, but it was not approved by the Punjab Medical Faculty Board due to resistance from various paramedic staff associations. For similar reasons, no practical steps were taken to establish a system of accreditation for continuing medical education and professional development for doctors and paramedics. 18. Introducing minimum service delivery standards to the private sector. The PMDGP achieved its objective of introducing the MSDSs in private health care services. In 2010, the Public Healthcare Act was promulgated. The PHCC was established as an autonomous health regulatory body, aiming to improve the quality, safety, and efficiency of health care service delivery by all public and private health care establishments. The PHCC is responsible for enforcing MSDSs at all levels of health care, and all health care establishments are required to implement MSDSs to acquire a license to deliver health care services in Punjab. The PHCC is now operational 25 and is receiving support for further operationalization from the World Bank/DFID-supported health sector reform project (footnote 19).
2. Better Management of Health Service Delivery
19. The PMDGP partly achieved the objectives of its activities in this core policy area. Improved management of health service delivery should result in improved quality and efficiency of health services. The objective was to make health managers more results- and performance-oriented, improve district health information reporting, determine the effectiveness of alternative service delivery models, and create greater efficiencies in primary health care by integration of programs.
20. Improved management and performance monitoring. The PMDGP partly achieved its objective of improving management and the monitoring of performance. The PMDGP assigned the responsibility for monitoring province-wide progress on the implementation of MSDSs to the ODGHS. After the devolution of powers from the provincial to district level in 2001, district health authorities were no longer under the administrative control of the ODGHS, although the executive district officer for health reported to the ODGHS.26 Under SP1, the health department commissioned a study to review the structure and functions of the ODGHS. It recommended numerous changes in both structure and functions. The health department adopted a capacity development plan. Under SP2, the ODGHS was restructured to support district governments, especially those with capacity development needs in planning and
25
Punjab Healthcare Commission. http://www.phc.org.pk/home.aspx 26
The 2001 Punjab Local Government Ordinance devolved political power and decentralized administrative and financial authority from the provincial government to the local governments for good governance, effective delivery of services, and transparent decision-making through institutionalized participation of the people at a grassroots level. However, during the PMDGP, the ordinance was revised to extend GOP’s powers to remove the elected local council heads and have executive district health officers report to the provincial authorities.
8
financial management. The PMDGP supported the training of 246 of 260 key managers of the district health teams. All key managers are trained in the meantime, in line with the indicative trigger for SP3. However, ODGHS capacity for monitoring is still limited. A district health information system (DHIS) was successfully rolled out in almost all districts by 2009, with the assistance of Japan International Cooperation Agency, and many districts used the PMDGP funds for the printing and use of DHIS forms and reporting tools. The district health authorities generally appreciated this support for the DHIS. The World Bank-funded health program is building on the initial efforts in performance management by formalizing results-based performance management contracts in all 36 districts between the health department and the district health offices. 21. Improved procurement efficiency of drugs and equipment. Efforts to make the procurement of drugs and equipment more efficient were only partly successful. Under SP2, the health department developed health sector guidelines for purchase of medicine, medical equipment and supplies to ensure timely and cost effective provision of relevant goods needed at health facilities. Although districts were required to follow these new procurement guidelines, there were ad hoc changes in the procedures, particularly for medicines. For example, the health department on one occasion collected each district’s requirements and placed the order. Actual payments were made by the districts. These changes caused confusion at the district level and tension between the two tiers of government. Maintaining adequate stocks of drugs and supplies stocks remained problematic, and districts frequently had none when they were needed. The district health information system captured data only on essential drug stocks, but not on supplies, equipment, and nonessential drug stocks. In 2013, the health department approved the establishment of a provincial procurement cell to support the district procurement of all kinds of medicines and equipment. This may improve the situation. 22. The procurement of equipment was a critical input that required much closer monitoring by GOP. The ODGHS undertook a province-wide mapping exercise in 2011 to assess district equipment needs and determine what had been achieved since 2008. This was used to assess the PMDGP’s results. In some districts, the equipment that had been procured and distributed to health facilities was found lying unused. In other districts visited by a team of ADB consultants in late 2010 (footnote 24), the procured equipment was sitting in district warehouses pending distribution. Some districts had not procured any equipment. A few health facilities reported to ADB missions that their labor rooms lacked essential instruments and equipment, and in some cases the existing instruments were rusted. With better coordination between the two levels of government, and better tracking by the project management unit (PMU), equipment and drug supplies might have been better provided. 23. Alternative models of health service delivery institutionalized. The institutionalization of alternative models of health service delivery was only partly achieved. The GOP was to institutionalize the outsourcing of primary health service delivery in line with the Punjab Rural Support Program model or the National Commission for Human Development model. Under SP1, a third-party evaluation confirmed the achievement of significant improvements in the use of outsourced health facilities and in outpatient attendance. Based on the findings of the evaluation, the GOP decided to institutionalize viable contracting arrangements where feasible and expanded the contracting approach to two underdeveloped districts in the southern part of the province, bringing the total of contracted districts to 14. The GOP decided that district governments should be given the same flexibility as the contractors, thereby mainstreaming the evaluation results. Under SP2, the health department developed a
9
9 A
ppe
nd
ix 5
project aimed at achieving the MDGs.27 This project was implemented in 7 districts and featured the provision of around-the-clock basic emergency obstetric and neonatal care services in all RHCs and in select BHUs. This two-pronged approach is being continued in 2014 with further strengthening of the contracting arrangements in 14 districts and the results-based financing and alternative financing models in other districts. Regarding the functional integration of primary health services, the ADB mission was informed in 2011 that family planning, MNCH, nutrition, and the LHWs program were going to be integrated under a single reproductive health program. However, the planned integration was not implemented as designed.
3. Sustainable Pro-Poor Health Care Financing
24. Public health care has been underfinanced in Punjab. In addition to increasing the health care budget, the GOP needed to improve the targeting of public health financing for pro-poor health care. Achieving this output required (i) an increase in the allocations and expenditure in the health sector to achieve objectives in the medium term, (ii) measures to improve financial management, and (iii) implementation of reforms to improve pro-poor health care financing. The output was not delivered, and the objectives in this core policy area were not achieved.
25. Increased and better allocated budget for the health sector, in particular for primary and secondary health care. The PMDGP did not achieve its objective of having the health sector, the health department, and the districts increase and better allocate financing for primary and secondary health care. This significantly impacted the PMDGP’s outcome in a negative way. Contrary to its agreement under the PMDGP to increase budget allocations for primary and secondary health care, the GOP increased funding for tertiary care and decreased it for primary and secondary care. The GOP’s draft medium-term budget framework (MTBF) for 2010–2013 showed this trend as a percentage of the total budget. District health expenditure showed an increase each year, excluding the additional PMDGP funds.
26. Under SP1, a conditional grant mechanism was established to provide guaranteed additional funding to the districts for the PMDGP activities. In FY2009, per the agreed formula, the GOP transferred PRs3.5 billion into the accounts of 36 districts for the implementation of the MSDSs. Under SP2, the GOP transferred PRs6.4 billion in FY2010 to be disbursed as conditional grants to those districts that showed they had used at least 80% of the grant released under SP1. However, due to a financial crunch, the conditional grants were used by a majority of the district governments to pay for a 50% salary increase for government staff announced by the GOP in the FY2010. The GOP’s finance department then made a commitment to ADB that it would reimburse the PMDGP funds used by the district governments to finance the salary increase. Subsequently, the GOP decided to transfer PMDGP funds into newly opened special drawing accounts. The finance department believed the use of these accounts would provide better control over expenditure, but it had to revalidate the accounts annually and unused funds had to be returned at the end of each fiscal year. The district governments cited late releases in the fiscal year as one of the reasons for low utilization of the PMDGP funds. Only PRs2.9 billion (30%) of a total PRs9.8 billion earmarked for conditional grants were used from FY2009 until FY2013. 27. Improved financial management and reporting in the health sector. The PMDGP was partly successful in improving the health sector’s financial management and reporting. The MTBF was introduced in 7 provincial departments, including the health department, with TA support under ADB’s PGEIP. A financial management cell was established by merging the
27 The Chief Minister’s Initiative for Attainment and Realization of MDGs (CHARM).
10
health department’s development wing and the budget wing so that the MTBF could play a meaningful role in its financial management, but the cell never became fully operational due to inadequate staffing. The PCR mission made vigorous efforts to obtain financial data from this financial management cell but it provided the mission with no information. A financial management and reporting mechanism was established under SP2, based on new account codes. Separate codes were allocated to DHQs, THQs, RHCs, and BHUs. The World Bank-funded Project to Improve Financial Reporting and Auditing (PIFRA) began generating reports for primary and secondary care facilities in 2010 using the new codes. Given this progress and the enhanced capacity of the health department for financial reporting using the PIFRA interface, this PMDGP objective can be considered to have been achieved in part. 28. Improved internal control and audits in the health sector. The PMDGP failed in its efforts to improve internal control and audits in the health sector. Under SP1, the health department settled more than 1,000 audit observations, and its accounts committee conducted frequent meetings to expedite settlement of pending audit issues. Under SP2, the department strengthened its internal audit wing by filling the vacant positions of director and deputy director. A manual on internal audit was developed for the audit wing to follow. However, the capacity of the wing remained weak due to a lack of experienced staff. It also had inadequate support and recognition of its functions from the department. The districts failed to appoint internal auditors, as had been called for in the PMDGP design. The audit responsibility was instead assigned to the local fund audit officers or town accounts officers. This was a conflict of interest and violated the Local Government (Internal Audit) Rules, 2004. 29. Pro-poor health care financing developed. The PMDGP did not achieve its objective of developing pro-poor health care financing. A pro-poor social safety initiative was piloted in two districts,28 but no further work was done on the modeling. C. Program Costs
30. The estimated cost of the first phase of MSDS implementation, with a focus on MNCH, was PRs7 billion ($88 million), apart from expenditure for capacity building and enhancement of information systems. The GOP would transfer 50% of the PMDGP funds in local currency as conditional grants to district governments to carry out the appraised reforms. The allocation was based on a careful assessment of the district health systems’ absorptive capacity, given that sizeable resources were allocated for district governments under the MNCH program. The loan size for the cluster program was based on the facts that (i) maintaining basic health services for the poor required PRs13 billion ($162 million) for July 2008–June 2009; (ii) rollout of the MSDSs
required PRs34 billion ($425 million) during FY2009-FY2011; and (iii) scaling up per capita public health expenditures by at least 40% per year during FY2009-FY2011. The PMDGP cost estimates appear to have been calculated properly, but funds were not spent as projected. The budget allocation for health in Punjab increased from PRs38.5 billion to PRs79.6 billion from FY2009 to FY2012. In real terms, this represented an increase from PRs16.5 billion in FY2009 to PRs20 billion in FY2012. The districts share in current expenditure on health remained stable around 50%, while the share in development expenditure declined significantly from just under 30% in FY2010 to 7% in FY2012, indicating an increased centralization of development expenditures in the health sector, limiting the ability of the district governments to respond to service delivery needs.
28
The health facility (Sehat Sahulat) initiative was piloted in 2010 in the rural areas of Kasur and Rawalpindi districts
with the assistance of DFID. The health facility vouchers were provided to disadvantaged women to increase their accessibility to MNCH services.
11
11 A
ppe
nd
ix 5
D. Disbursements
31. The loan proceeds were disbursed to the Government of Pakistan as the borrower for onward lending in local currency to the GOP on the same terms and conditions. The borrower received ADB’s $100 million SP1 loan on 30 January 2009 and the $150 million SP2 loan on 30 June 2010. The equivalent of each was released in local currency to the GOP—PRs7.6 billion for SP1 on 7 February 2009 and PRs12.9 billion for SP2 on 30 June 2010, for a total of PRs20.5 billion. According to the financial data provided by the executing agency (Appendix 4), the finance department transferred PRs12.6 billion29 to 36 district governments over a period of 5 years (FY2009 to FY2013), of which the district government spent PRs2.9 billion. This amounted to 30% of the PRs9.8 billion earmarked under the PMDGP for conditional grants to be used by district governments. The unutilized amount was returned to finance department.
E. Program Schedule
32. SP1 was to be implemented during January–October 2008, SP2 during November 2008–November 2009, and SP3 during January–December 2010. After completion of three subprograms, the PMDGP was expected to be completed by 30 June 2011. The SP1 was approved on 11 December 2008, and the SP2 on 24 June 2010, reflecting the achievements from January 2009 until June 2010. Although the SP3 was not processed, the completion of the PMDGP was delayed by about 1 year. Changes in the schedule did not materially affect the outcome. F. Implementation Arrangements
33. The GOP’s health department was the executing agency, and all 36 district governments were responsible for the implementation of the program. The PMU established for the health sector reform program was responsible for daily coordination and management of the PMDGP. The existing program steering committee for the health sector reform program was to act as a program steering committee for the PMDGP and oversee policy decisions. 30 It was chaired by the chairman of the planning and development board, and comprised the secretary of health, the secretary of finance, the secretary of local government, and a representative of health care providers. The program steering committee was to meet at least once every 6 months. However, according to the PMU records, the steering committee met only twice during PMDGP implementation. A working group was to be constituted to develop alternate pro-poor health care financing and provider payment models but was never active. The ODGHS was responsible for monitoring progress on the implementation of the MSDSs and providing technical guidance to district governments in planning and management. 34. The implementation arrangements were inadequate for the numbers of institutions concerned and the complexity of the task of delivering the PMDGP’s intended outputs. The thinly-staffed PMU31 faced a huge challenge that involved day-to-day coordination and problem solving with 36 districts—including more than 3,000 separate offices, centers, and hospitals.
29
The financial data provided by the PMU varied significantly from the data provided by district governments, finance departments and PIFRA. ADB sent repeated requests to PMU over a period of 6 months, and to finance department through economic affairs division on 25 September 2013 for reconciled data, to no avail. The figures used in this document were those provided by the PMU.
30 The GOP had constituted a program steering committee in 2006 to provide policy guidance for the implementation of HSRF (see footnote 12).
31 The PMU had 18 sanctioned posts, of which 7 were filled and 11 were vacant in 2011. At the time of PCR mission, only 5 were filled and 13 were vacant. During the floods in 2010 and 2011, the project director was given the additional responsibility of overseeing a significant part of the flood relief effort.
12
The PMU included only one public health professional. The rest of the staff, including the project director, had no health background. The systems of the executing agency and the PMU for monitoring the physical and financial progress of the PMDGP were weak. TA was needed to implement the complex program, especially the utilization of the conditional grants by the district governments, but was not incorporated into the design. The PMU and ADB might have benefitted by accessing TA resources funded by the DFID for the PDSSP that were unused and available to support program implementation.32 Frequent changes in key PMDGP staff, lack of sufficient guidance from ADB, and lack of ownership and supervision by senior GOP management were among the major factors that negatively affected implementation.
G. Conditions and Covenants
35. The PMDGP had 94 subprogram conditions—21 for the release of funding for SP1, 36 for SP2, and 37 for SP3. All the tranche conditions for SP1 and SP2 were deemed met prior to the tranche releases. SP3 was not processed. 36. SP1 had 14 loan covenants and 18 program covenants and SP2 had 13 loan covenants and 12 program covenants, in addition to the policy conditions for release of funds. The covenants were relevant, apart from the covenant on disposal of hazardous and medical waste, for which no monitoring mechanism was set up. Two covenants were not complied with and require follow-up, as indicated in para. 49. Appendix 6 summarizes the status of actual compliance with loan covenants of SP1 and SP2. H. Performance of the Borrower and the Executing Agency
37. The performance of the borrower and executing agency is rated less than satisfactory. The PMU staff was greatly understaffed and lacked sufficient technical expertise to successfully implement such a wide range of reforms. The PMU performed well despite these limitations, and the World Bank opted to use the same PMU team for the implementation of its Punjab health sector reform project, which began in 2013 (footnote 19). Despite the roll-back of some devolution reforms introduced under the Local Governance Ordinance, the ODGHS with PMU support maintained monthly meetings with the executive district officers-health of the district governments, and provided the required technical assistance to district governments for delivery of MNCH. The importance of the health care reforms, the GOP did not always demonstrate the level of leadership and commitment that was needed for the PMDGP to achieve its intended results. This was largely due to the challenges of natural calamities, such as floods and dengue outbreak, which required the full attention of the GOP in general and the health department in particular during the implementation period. The late releases of funds earmarked for the conditional grant from the GOP to the districts resulted in low use of these funds, as explained in para. 26. I. Performance of the Asian Development Bank
38. The performance of ADB is rated less than satisfactory. During appraisal, the ADB team held extensive consultations with the GOP, including a high-level workshop to agree on the overall concept and implementation arrangements of the PMDGP. However, the change of government in 2008, the subsequent revisions of the devolution arrangements, and the natural
32
DFID provided $20 million in TA to support implementation of the PDSSP, but only 50% of this was used. TA resources were used to prepare MSDSs and the draft legislative framework for the Punjab Healthcare Commission Act, which was passed by the provincial assembly in 2010. The PMU did not use these TA resources because districts were sending in satisfactory progress reports.
13
13 A
ppe
nd
ix 5
disasters during program implementation resulted in slower than expected implementation and weaker results. The original risks and assumptions should have been reassessed when these changes occurred, and mitigating measures should have been put in place. While ADB inquired during the review missions about the PMU staffing gaps and late releases of the conditional grant transfers to the districts, no satisfactory solution was worked out to resolve these issues during implementation.
III. EVALUATION OF PERFORMANCE
A. Relevance
39. The design of the PMDGP is rated less than relevant. During appraisal, the design built on health sector reforms reflected in the GOP’s HSRF of 2005. At completion, the reforms were being pursued under the GOP health sector strategy for 2012–2020. The PMDGP’s design was in line with ADB’s health sector policy, operational plan, and country planning. Strategic interventions then being pursued included a focus on primary health care and the improvement of the quality of care through the adoption of service standards. The GOP still aims to improve results for the two MDGs related to child and maternal health. Clearly, more time and more management resources should have been provided to complete the reforms under the PMDGP. The policy reforms aimed at creating functional and qualitative changes in almost all tiers of the health system. The executing agency had insufficient capacity and time to implement and manage these changes. The intended reforms would have involved a complete shift in processes, procedures, and behavior of both the health providers and the target population in a period of 3 years. This was unrealistic. Some of the outcome performance indicators in the design and monitoring framework were too ambitious. More TA resources should have been made available to address the inherent system inefficiencies and the limited capacity. B. Effectiveness in Achieving Outcome
40. The PMDGP is rated ineffective in achieving the planned outcome. The PMDGP was not able to deliver substantially on the expected outputs (paras. 8–29) and thus failed to achieve its outcome. Of the six outcome performance indicators, only one was achieved (proportion of women who delivered at the health facility). Two were partly achieved—substantial progress was made on the number of antenatal examinations, and the proportion of deliveries attended by skilled birth attendants. The indicator related to immunization of children was not achieved. No improvements were made during the PMDGP on maternal and infant mortality. SP3 was never processed, resulting in a loss of momentum. The level of financial and physical progress achieved in target districts during the program was insufficient to produce the desired improvement in the health indicators for MDGs 4 and 5. The implementation arrangements were inadequate to producing the desired results. C. Efficiency in Achieving Outcome and Outputs
41. The program is rated inefficient. No financial or economic analysis was done at appraisal. Instead, using the past trends of IMR and MMR, projections were made for saving the lives of up to 11,000 women and 235,000 infants by 2015, provided the PMDGP succeeded in attaining MDGs 4 and 5. Without sufficiently robust data, no post-program composite index could be developed. It is too early to assess the program’s internal and external efficiency, as there are extensive time lags in changes in the IMR, MMR, and other indicators. The Pakistan MDGs report for 2013 stated that the country was unlikely to achieve MDGs 4 and 5 by 2015, since it was lagging far behind on its targets. Some tangible benefits remain after program
14
completion. These include the establishment of the PHCC, which is responsible for enforcing MSDSs at all levels of health care and for the licensing of health care providers; the improvement of health monitoring; and the development of alternative models of health service delivery. Due to the poor progress on health care financing, the absence of the intended increase in budget allocations for primary and secondary health care, and the low disbursement of the conditional grants to the districts, the higher share of salaries in the district budgets, leaving less resources for non-salary items.
D. Preliminary Assessment of Sustainability
42. The sustainability of the PMDGP’s outcome is rated less than likely. The sustainability of a program is largely dependent on two factors: the extent of the delivery of the program outputs and outcome, and government engagement in subsequent actions to continue progress on the reform agenda. The program was successful in achieving only some of its objectives: the improvement of the human resources situation for key MNCH-related positions, the establishment of the PHCC, the improvement of the health monitoring mechanism, and the two-pronged approach for alternative health service delivery. The Punjab Health Sector Development Project, supported by DFID and the World Bank, approved in late 2013, is carrying the work of the PMDGP forward (footnote 19). It includes support for the PHCC; the contracting out of BHUs to the Punjab Rural Support Program; and improved monitoring, building on the available DHIS system. The World Bank project will finance results-based payments to districts, using a fund flow mechanism similar to that used under the PMDGP for conditional grants. Thus, prospects for sustaining the limited benefits achieved under the key reforms of the program, and for carrying forward the larger reform agenda, appear to be likely. A key determining factor will be the willingness of both provincial and district governments to invest in human capital and enforce staff performance metrics over time, as well as to ensure sufficient budget allocations and expenditure to ensure success.
E. Impact
43. The small civil works appraised for nursing schools aimed at improving existing facilities and did not involve resettlement or did not cause any environmental adverse effects. The environmental impact of hospital waste disposal was not monitored. SP2 was categorized as a program with gender equity theme in design, provided with a separate gender action plan. The vast majority of the activities in the plan were not carried out. However, the one explicit gender policy condition in the policy matrix was done, namely that at least 95% of BHUs were able to recruit at least one female medical officer or midwife. The program appears to have had a moderate impact on the understanding and knowledge of the executing agency, the PMU, and district health staff engaged in health planning and standards setting. This may be helpful in implementing the government-funded MNCH program and the sector reform project being funded by DFID and the World Bank (footnote 19).
IV. OVERALL ASSESSMENT AND RECOMMENDATIONS
A. Overall Assessment
44. Despite being consistent with the country’s development strategy as well as its needs, the program failed to achieve its outcome. Overall, the project is rated unsuccessful (Appendix 7). It was less than relevant, ineffective, inefficient, and less than likely to be sustained. It performed poorly in delivering most outputs (paras 8–29).
15
15 A
ppe
nd
ix 5
B. Lessons
45. One of the PMDGP’s principal lessons is that interventions in countries with difficult socioeconomic conditions and generally weak implementation capacity require more comprehensive due diligence during design. When large complex programs are prepared in this context, ADB needs to carry out detailed, rigorous, and objective analysis of the potential implementation risks, especially those related to the executing agency. Once that is done, all necessary mitigation measures must be built into the design.
46. A well-thought-out conceptual design is a key to the success of any program. In the case of the PMDGP, the design set a commendable goal in the intended outcome, but it seems to have overestimated the capacity of the GOP to help achieve it. It also relied too heavily on the establishment of the MSDSs as a strategy for attaining MDGs 4 and 5. In addition, the challenges commonly faced in such programs and projects due to the rotation of managers and inadequate ability to attract and retain suitably qualified staff should have been taken into account when considering the PMDGP timelines and setting the outputs and targets.
47. Given the weak capacity of the executing agency, a large, well-conceived, and properly structured TA project should have been piggybacked on the program to address the obstacles presented by inherent system inefficiencies and limited capacity.
C. Recommendations
1. Program Related
48. Further action or follow-up. Under the program, PRs3.5 billion was earmarked for conditional grants under SP1 and PRs6.4 billion under SP2. These funds were intended to be used in addition to each district government’s regular health sector budget to implement MNCH-related MSDSs and other selected activities agreed between the GOP and the district government. A minimum of 10% of the base conditional grant needed to be allocated for capacity-building activities. So far, the executing agency has reported on the use of PRs2.9 billion (see Appendix 4). If all of the funds ADB provided have been fully used, the executing agency should submit a utilization report for the full amount of the earmarked funds. If the full amount has not yet been released and used, the executing agency should be asked to provide ADB with a target date for when this is expected to happen.
2. General
49. During appraisal of ADB programs, sufficient time should be spent on assessing the policy areas being targeted; engaging with the political leadership to create ownership; reaching consensus on the appropriate scope of reforms, along with an action plan; and properly assessing the ability of the government to successfully implement the program. A conservative view of the time needed for implementation and of budget absorption and management capacity, as well as of the potential for change in conditions on the ground is probably helpful, given the history of complex program implementation in Pakistan. Future interventions should ensure a government’s sustained commitment to providing adequate funding and staffing for the activities. During implementation, ADB should undertake very regular review missions with staff with the appropriate technical skills sets to ensure that the program remains on track. This will also allow for necessary adjustments to be made to the design.
16 Appendix 1
16
Ap
pe
ndix
2
UPDATED DESIGN AND MONITORING FRAMEWORK
Design Summary Performance Indicators/Targets
Monitoring Mechanisms
Status at Program Completion
Impact
The government of Punjab attains health MDGs 4 and 5
By 2015, IMR reduced from 77 infant deaths per 1,000 live births in FY2004 to 40
MICS DHS PSLM
Per MICS Punjab 2011a
Unlikely to be achieved. The IMR for Punjab is 82 per 1,000 live births. The IMR is 90 per 1,000 live births for rural areas and 61 per 1,000 for urban areas
b
MMR reduced from 300 maternal deaths per 100,000 live births in FY2004 to 140
Unlikely to be achieved. The MMR is 300 per 100,000 live births
Outcome
Improved access to equitable quality health services
By 2011, Proportion of pregnant women having received four antenatal examinations by skilled birth attendant increased from 61% in FY2007 to 80%
c
MICS, DHS PSLM DHIS reports lady health workers’ reports
Per MICS Punjab 2011: Partly achieved. Women receiving 4 antenatal examinations during their pregnancy increased from 28% in FY2007 to 41% in 2011, and women receiving one ante-natal visit increased from 61% to 81%
. Number of women having delivered at health facilities increased from 33% in FY2007 to 50%
Achieved. 53.5% women delivered at health facilities
Proportion of deliveries attended by skilled birth attendants increased from 38% in FY2007 to 70%
Partly achieved. 58.5% of deliveries were attended by skilled birth attendants
Proportion of fully immunized children between 12 and 23 months of age increased from 53% in FY2007 to 80%
Not achieved. 46.8% of children between 12 and 23 months of age were fully immunized
Current use of modern contraceptive among married women increased from 23% in FY2007 to 40%
Not achieved. 29% of married women were currently using modern contraceptive methods
Difference in the indicators presented above between rural and urban areas reduced by 50%
Not achieved. Difference between rural and urban MNCH-related indicators could not be reduced by 50%
Outputs
1. Improved availability and quality of primary and secondary health care
By 2011, 80% of BHUs, RHCs, and MNCH-related departments of THQs and DHQs equipped up to or beyond 95% according to MSDS
HRSP progress reports
Achieved (SP2 target). SP3 target of 100% was not achieved
Appendix 1 17
17 A
ppe
nd
ix 5
Design Summary Performance Indicators/Targets
Monitoring Mechanisms
Status at Program Completion
At least 90% of all health providers trained in the MSDS, SOPs and SMPs
ODGHS DHIS reports on equipment, training and service provision
Partly achieved. 90% of 10,914 MNCH-related workers in Punjab completed training on MSDSs
At least 70% of health care workers at BHUs, RHCs, THQs, and DHQs providing MNCH services according to MSDS, SOPs, and SMPs
EDO health reports Partly achieved. While inputs required for MNCH services are available in at least 70% of the primary health facilities and more than 70% in the secondary health care facilities, shortages of female staff at the primary health care level and of specialists at the secondary health care level remain
90% DHQs and THQs are operating and providing comprehensive obstetric care 24-hours a day, 7-days a week
PRMP Study on Facility Based Quality of Care
90% RHCs operating for obstetric care 24-hours a day, 7-days a week
PRMP Study on Facility Based Quality of Care
2. Better management of health service delivery
By 2011, Necessary drugs available at each primary and secondary health facility, out-of-stock situations reduced by half
DHIS tracer drug report EDO health drug monitoring report
Not achieved. There was no substantial improvement in drug availability over the program period
Alternative models of health service delivery institutionalized
Contracts between districts and contracted organizations
Partly achieved. PRSP model expanded to 14 districts and is being strengthened. Remaining districts receive same flexibility as contractor (CHARM initiative being piloted)
Reorganized ODGHS providing technical assistance to districts for delivery of MNCH
ODGHS Performance monitoring Reports
Partly achieved. ODGHS is having monthly meetings with EDO-H of the districts to analyze DHIS reports. ODGHS capacity for monitoring is still limited
80% of districts producing DHIS monthly reports; 80% of districts receiving feedback from province on DHIS submitted report on quarterly basis; 80% of facilities in each district receive feedback from district officer on DHIS monthly report on monthly basis; Evidence-based district and provincial decision making based on DHIS report
Quarterly and annual DHIS reports comparing progress by districts on the key health indicators
Achieved. DHIS was rolled out in all 36 districts. Data are regularly analyzed
ODGHS semiannual analysis of DHIS reporting
ODGHS performance monitoring reports
Not achieved. The semiannual reports were not produced
3. Sustainable pro-poor health financing
By 2011, Increase in health sector budget and a commensurate increase in provincial and district expenditure, above the normal increment
Provincial and district government annual budget statements
Partly achieved. The health sector budget is showing some increase due the increase in current budget allocation, but the development budget decreased
18 Appendix 1
Design Summary Performance Indicators/Targets
Monitoring Mechanisms
Status at Program Completion
District governments preparing plans and receiving conditional grants in addition to their regular budgets
Provincial and district government annual budget statements
Partly achieved. DGs prepared plans and received conditional grants for the program, but utilization was low. See Appendix 4
Medium-term health sector strategy prepared by the Strategy and Policy Unit, in accordance with MTDF
Provincial government MTBF document
Not achieved. Draft Punjab health sector strategy was prepared in April 2012 for 2012–2020 with the technical assistance of DFID, not under the program
Consolidated health sector MTF
Provincial government MTBF document
Not achieved. MTF was prepared at the provincial level, not at the district level
Institutionalized internal audit conducted in the provincial and district departments of health
Report of Internal Audit (Office of the Special Secretary, Health)
Partly achieved. The capacity of HD’s audit wing remained weak due to lack of experienced staff and inadequate support for and recognition of its functions. However, HD succeeded in settling a large number of pending audit observations. Districts failed to appoint internal auditors
At least 50% of poor pregnant women provided with health cards
HSRP progress reports Not achieved
Pro-poor health financing system adopted by the provincial government
HSRP progress reports Not achieved. Sehat Sahulat card system was piloted in two districts, but no further work was done on the modeling
Activities by Milestones (to be completed by June 2010) Inputs
1. Core Policy Area 1: Improved Availability and Quality of Secondary Health Care
1.1 At least 7 districts substantially conform to the minimum acceptance levels for MNCH-related MSDS by 30 March 2010.
1.2 All 35 districts to include implementation of the priority MNCH-related MSDS for FY2010 in their 3-year rolling sector plans by 20 March 2010.
1.3 Office of Director General Health Services (ODGHS) to provide technical assistance and publish an annual report on achievement of MNCH-related MDGs and MSDS attainment by 15 April 2010.
1.4 80% of BHUs, RHCs, and maternal and child health-related departments of THQs and DHQs are fully equipped or equipped beyond 95% by 15 April 2010.
1.5 80% of crucial MNCH-related positions are filled as per the MSDS by 25 April 2010. BHUs without WMOs and facilities with insufficient number of nurses to have adopted alternative arrangements.
1.6 All 35 districts to adopt the comprehensive patient referral system approved by the Health Department, and commence implementation by 30 April 2010.
1.7 Quality assurance regulatory framework for private health providers notified by 15 June 2010.
$100 million loan for SP1, $150 million loan for SP2 Technical assistance report
1.8 90% of MNCH-related workers trained in relevant part of SMPs, and SOPs disseminated by 31 March 2010.
1.9 50% of the training institutions for nurses and paramedics to be upgraded by 10 April 2010. 1.10 Separation of examination and regulatory function of GOP Medical Faculty by 30 April 2010. 1.11 Continuing education system for medical doctors and paramedics with respect to doctors’
Appendix 1 19
19 A
ppe
nd
ix 5
Design Summary Performance Indicators/Targets
Monitoring Mechanisms
Status at Program Completion
promotion and relicensing established by 30 April 2010. 1.12 Government to develop and adopt the Human Resource Plan by 20 April 2010. 1.13 Feasibility study on creating a focal point for regular updating of clinical practice guidelines
and SMPs, based on scientific evidence, completed by 30 April 2010. 2. Core Policy Area 2: Better Management of Health Service Delivery
2.1 The Health Department to assess and improve restructuring of ODGHS by 25 March 2010. 2.2 35 district governments to strengthen their planning and budgeting capacity by submitting to
the Health Department costed medium-term sector plans, including implementation of the priority MNCH-related MSDS with indication of possible funding sources over the medium term by 5 April 2010.
2.3 All 35 districts implementing and regularly analyzing the DHIS data. 2.4 ODGHS to publish a quarterly summary report on the district health situation and service
performance based on the DHIS by 20 March 2010. 2.5 ODGHS to prepare quarterly consolidated reports on the use of drugs and medicines by the
health facilities and take necessary actions to ensure availability of drugs through EDOs, health, by 30 March 2010.
2.6 Integration of programs and services for primary health care piloted in five districts and the experiences evaluated by 30 March 2010.
2.7 EDOs, health, to develop a monitoring system of drug and medicine availability at each primary and secondary health care facility by 30 March 2010.
2.8 Based on the evaluation results, provincial government to identify measures that produce improved outcomes and outputs in contracting health services, and an action plan developed for institutionalizing such measures by 10 April 2010.
2.9 The Health Department to develop health sector-specific procurement guidelines for purchase of drugs, equipment, and supplies by 15 May 2010.
3. Core Policy Area 3: Sustainable Pro-Poor Health Financing
3.1 The HD to develop a consolidated medium-term framework (including provincial and district information) for the health sector that reflects heath sector policy by 30 April 2010.
3.2 ODGHS to prepare report on spending of the first conditional grant by 15 April 2010. 3.3 The Health Department and district governments to undertake and finalize a comprehensive
assessment of fiduciary risk in the health sector and mitigation measures by 8 April 2010. 3.4 Those districts that received conditional grant support for MSDS implementation to submit to
the Health Department quarterly progress reports, including financial and nonfinancial information in agreed formats.
3.5 Financial reporting for the health sector in Punjab to be based on classification codes of accounts that reflect the functional attributions of each tier of government by 10 April 2010.
3.6 Provincial government to ensure that health expenditure in all district governments has increased in proportion to allocations, through the regular budgets of district governments, and the conditional grants transferred to district governments are in addition to the regular budget by 30 March 2010.
3.7 The Health Department to fully staff its Internal Audit Wing and develop an internal audit plan by 15 April 2010.
3.8 Ten district governments to appoint internal auditors to strengthen internal controls by 25 March 2010.
3.9 Steering committee has formulated a program for reducing health expenditure burden on the poor, in particular, pregnant women, and children. PDD to pilot and evaluate the program in two districts by 20 March 2010.
3.10 GOP to identify options for health financing and provider payment reforms by 31 May 2010. 3.11 User charges to be institutionalized and retained by health facilities by 31 May 2010.
ADB = Asian Development Bank; BHU = basic health unit; DHIS = district health information system; DHQ = district headquarter hospital; DHS = demographic and health survey; DMO = district monitoring officer; EDO = executive district officer; HSRP = Health Sector Reform Program; IMR = infant mortality rate; MEA = monitoring and evaluation assistants; MDG = Millennium Development Goal; MICS = multiple indicators cluster survey; MMR = maternal mortality ratio; MNCH = maternal, neonatal, and child health; MOU = memorandum of understanding; MSDS = minimum service delivery standard; MTBF = medium-term budget framework; MTDF = medium-term development framework; MTF = medium-term framework; NCHD = National Commission for Human Development; ODGHS = Office of the Director General of Health Services; PDD = Planning and Development Department; PGEIP = Punjab Government Efficiency Improvement Program;
20 Appendix 1
PSLM = Pakistan Social and Living Standard Measurement Survey; RHC = rural health center; SMP = standard medical procedure; SOP = standard operating procedure; THQ = town headquarter hospital; WMO = woman medical officer. a Bureau of Statistics, Planning and Development Department, Government of Punjab, Multiple Indicator Cluster
Survey, Punjab 2011, Lahore. b Punjab health department http://health.punjab.gov.pk/?q=Punjab_Health_Profile.
c There was an error in the formulation of the indicator. Under SP1, the indicator referred to several antenatal
examinations, while SP2 referred to four antenatal examinations. Both SP1 and SP2 used the target of one antenatal visit.
Source: ADB.
Ap
pe
ndix
2
21
POLICY MATRIX
Outputs Actions under Subprogram 1
Actions under Subprogram 2
Indicative Triggers for Subprogram 3
Status of Indicative Triggers for Subprogram 3
at Program Completion
1. Improved Availability and Quality of Primary and Secondary Health Services
1.1. The MSDS introduced for primary and secondary health services
MSDS implementation guidelines developed and disseminated to all district governments; and MOUs on achieving MSDS by no later than 2012 signed and 3-year rolling plans for implementing MNCH-related MSDS adopted by at least 30 district governments
Each of the DGs, based on feedback from ODGHS, has updated its 3-year rolling plan previously adopted under SP1 for implementing MNCH-related MSDSs, and at least 7 DGs have substantially conformed to the minimum level of MNCH-related MSDS
HD has completed MNCH-related MSDS information campaigns, targeting the general public and health workers and facilities in all districts of Punjab.
Each of the DGs, based on feedback from ODGHS, has updated its 3-year rolling plan previously adopted under SP1 and updated under SP2 for implementing MNCH-related MSDSs, and at least 15 DGs have substantially conformed to the minimum level of MNCH-related MSDS
A third party assessment and a citizen satisfaction survey conducted on MNCH-related MSDS implementation
3-year rolling plans were prepared by the district planning teams, with full involvement of ODGHS. The target of 15 DGs was not met.
Several assessments were conducted. The latest was in 2012 by a private sector firm hired by a DFID-funded technical resource facility.
1.2. Primary and secondary health facilities staffed and equipped according to MSDS
At least one additional midwife position per BHU (about 2,500 in total) and about 150 additional gynecologist positions for THQs and DHQs sanctioned and budgeted; and at least 90% of the vacant lady health visitor positions (about 400) filled
Out of 2,446 functional BHUs, 290 RHCs, 78 THQs, and 35 DHQs in Punjab, at least 80% have been equipped with 95% or more of the MNCH-related equipment notified by HD At least 95% of BHUs in Punjab have a minimum of one women medical officer, lady health visitor,
Out of 2,446 functional BHUs, 290 RHCs, 78 THQs, and 35 DHQs in Punjab, 100% have been fully equipped with MNCH-related equipment notified by HD
Each BHU in Punjab a minimum of one women medical officer, lady health visitor, or midwife.
93% of the facilities had functional MNCH-related equipment as notified by HD.
SP3 target was achieved.
22
Ap
pe
ndix
2
Outputs Actions under Subprogram 1
Actions under Subprogram 2
Indicative Triggers for Subprogram 3
Status of Indicative Triggers for Subprogram 3
at Program Completion
or midwife At least 80% of 14,403 essential MNCH-related positions identified under the Punjab Health Sector Reforms Program have been filled
The vacancies for each category of essential MNCH workers are reduced by half at end of SP2, and a plan is developed and approved for filling 100% of essential MNCH vacancies in the medium term
SP3 target was not achieved.
1.3. Measures adopted to improve quality of health workers and their practices
Conceptual framework adopted and financial needs for strengthening pre- and in-service training estimated, with focus on upgrading of training institutions
SMPs, SOPs, and patient referral protocols adopted, and training plan for all health staff prepared
Of 30 nursing schools and 5 paramedic schools regulated by district health authorities in Punjab, at least 50% have been upgraded in the areas specified by and in accordance with the requirements of ODGHS and director general of nursing of Punjab Of the 10,914 MNCH-related workers in Punjab, at least 90% have completed the training on MSDSs and relevant parts of the SMPs, SOPs, and referral protocols endorsed by the HD
All training institutions for nurses and paramedics upgraded in the areas specified by and in accordance with the requirements of ODGHS and director general of nursing of Punjab.
Out of all non-MNCH-related health workers in Punjab, at least 75% have completed training on MSDS and relevant parts of the SMPs, SOPs, and referral protocols endorsed by HD, and a plan approved for completion of training of all non-MNCH-related health workers
SP3 target was not achieved.
SP3 target was not achieved.
Ap
pe
ndix
2
23
Outputs Actions under Subprogram 1
Actions under Subprogram 2
Indicative Triggers for Subprogram 3
Status of Indicative Triggers for Subprogram 3
at Program Completion
Responsibility for conducting examinations for paramedics has been assigned to the University of Health Sciences, Lahore from the Punjab Medical Faculty, and measures for improving the existing service structure for paramedics in Punjab have been approved by the chief minister
The chief minister has approved establishment of continuous medical education for public sector doctors and paramedics, and two committees have been established by HD to guide further implementation The comprehensive Health Human Resources Plan, proposing inter alia rationalization of service structures and staff, has been approved by the chief minister, and census and computerized registration of all health workers in Punjab have been completed by HD
Examination system under University of Health Sciences commenced, and the role of PMF reviewed and revised The continuous education system for private doctors and paramedics established, and implementation commenced
HD has substantially implemented key reforms under the Health Human Resources Plan
SP3 target was not achieved.
SP3 target was not achieved.
Partly achieved. In 2010, the GOP took steps leading to the improvement of the human resources situation in HD, such as relaxation of recruitment age of WMOs and the rotation of students from training hospitals.
24
Ap
pe
ndix
2
Outputs Actions under Subprogram 1
Actions under Subprogram 2
Indicative Triggers for Subprogram 3
Status of Indicative Triggers for Subprogram 3
at Program Completion
1.4. The MSDS introduced to the private sector
Stocktaking of private practitioners, covering (among other things) categories of services, qualifications (with or without a license), and location published
A proposed bill for the Punjab Healthcare Commission Act, with a focus on improved regulation of healthcare delivery, has been developed and submitted to the Provincial Assembly.
90% of (qualified) private health care providers have been registered with the designated authority
A mechanism for registration of all private practitioners established under the PHCC, and a detailed action plan with timelines for framing and approving rules, bylaws, and regulations developed and approved
In accordance with the PHCCA, accreditation and inspection of health care facilities established, as well as a mechanism for ensuring adherence to MSDSs by private health care providers.
Achieved. PHCC has majority of qualified private health care providers registered
Achieved. The PHCC has been established and is operational (and receiving support for further strengthening under World Bank project).
Achieved. PHCC started on accreditation and inspection of both public and private health care facilities.
2. Better Management of Health Service Delivery
2.1. Improved district health management and monitoring
ODGHS has been reorganized and strengthened to monitor health system performance, including the implementation of MSDS
A capacity development plan for district health
HD has assessed the effectiveness of ODGHS restructuring, and based on this assessment, ODGHS has adopted relevant measures for further improvement
The capacity development plan
ODGHS continues effective monitoring of health system performance, including implementation of MSDS
The capacity development plan
Partly achieved. ODGHS is responsible for monitoring, but has limited capacity. Efforts to formalize performance management through results-based performance management contracts in all 36 districts is ongoing.
Partly achieved. A training plan was
Ap
pe
ndix
2
25
Outputs Actions under Subprogram 1
Actions under Subprogram 2
Indicative Triggers for Subprogram 3
Status of Indicative Triggers for Subprogram 3
at Program Completion
teams and managers developed and implementation started, including the establishment of a district support team at ODGHS
DHIS operational in at least 10 districts, and district health situation and service performance reported by the 10 DGs to ODGHS
adopted under SP1 for district health managers has been implemented, and at least 50% of the 260 district health managers in Punjab have completed the training according to such plan DHIS is operational in all districts of Punjab. Each DG's progress in MSDS implementation has been monitored by ODGHS through regular reporting by DGs via DHIS, and the technical assistance plan for each DG has been adjusted based on the results of such monitoring
adopted under SP1 for district health managers has been implemented, and all 260 EDOs, DoHs, and DDOHs in Punjab have completed the training according to such plan.
All 36 districts equipped to provide accurate and regular data to the DHIS, and districts have sufficient staff to analyze DHIS reports
Each DG's progress in MSDS implementation has been monitored by ODGHS through regular reporting by DGs via DHIS, and the technical assistance plan for each DG has been adjusted based on the results of such monitoring.
prepared, approved, and implemented, and a capacity-building firm was hired to provide this training. All targeted managers have completed the training.
Partly achieved. DHIS rolled out in all 36 districts. There has been a sustained increase in capacity to analyze DHIS reports
Achieved. Every month, EDOs-health meet in Lahore in ODGHS to present their DHIS analyzed reports. DGHS remains as technical head
2.2. Improved efficiency of procurement of drugs and equipment
Drug and equipment procurement and supply management system reviewed and strategic options and recommendations for their improvement prepared
HD has developed health sector procurement guidelines for purchase of medicine, medical equipment, and supplies to ensure timely and cost-effective provision of relevant goods needed at health facilities in Punjab
New procurement guidelines for purchase of medicine, medical equipment, and supplies implemented
Partly achieved. A procurement cell is being set up in HD to support procurements by preparing bid documents, not to do procurements.
26
Ap
pe
ndix
2
Outputs Actions under Subprogram 1
Actions under Subprogram 2
Indicative Triggers for Subprogram 3
Status of Indicative Triggers for Subprogram 3
at Program Completion
Each EDO-health has developed a monitoring system of drug and medicine availability at each primary and secondary health facility
Punjab, through regular monitoring of 18 different tracer drugs in all districts, has reduced the percentage of stock outs to 35% of reporting facilities
EDOs health regularly monitoring drug and medicine availability, and necessary drugs regularly available at health facilities
Tracer drug list revised according to MSDS requirements for primary and secondary care facilities, and the number of stock outs of necessary drugs reported in SP2 reduced by half
The essential drug list reviewed and revised according to MSDS requirements for primary and secondary healthcare facilities
Not achieved. The district health information system captures data on essential drug stocks, but not on supplies
Partly achieved. The tracer drug list was revised and new drugs were added.
Partly achieved. The essential drug list was revised for primary health care facilities.
2.3. Alternative models of health service delivery institutionalized
Third party commissioned to evaluate impact of contracting of health services (to PRSP, and NCHD) on health outcomes and outputs, and to compare them with the outcomes and outputs of those districts that did not contract health services
Conceptual framework on functional integration of
Based on the results of the third-party evaluation commissioned under SP1 on the impact of contracting primary health care service delivery to PRSP and NCHD, Punjab has developed and approved an action plan for institutionalizing the measures recommended by the said evaluation Integration of primary health programs and
District governments to have implemented the approved action plan
Primary health programs and services functionally
Partly achieved. The contracting followed a two-pronged approach, with further institutionalization of PRSP in 14 districts, and introduction of the same flexibility for the remaining DGs as the contractors (CHARM).
Partly achieved. A plan was prepared for
Ap
pe
ndix
2
27
Outputs Actions under Subprogram 1
Actions under Subprogram 2
Indicative Triggers for Subprogram 3
Status of Indicative Triggers for Subprogram 3
at Program Completion
various primary health programs and services finalized
services has been piloted in 5 districts and the results assessed by HD
integrated in all district governments
integration of vertical programs and is being implemented.
3. Sustainable Pro-Poor Health Care Financing
3.1. Increased and better allocated budget for the health sector, in particular for primary and secondary health care
Revised budget manual published and disseminated by the to all provincial departments
SPU in the HD fully staffed to improve templates designed for planning and budgeting of MNCH-related MSDSs, and consolidate medium-term financing plan for implementation of MNCH- related MSDSs
Conditional grant mechanism established and PRs3.5 billion in counterpart funds set aside by the Finance Department for allocation in FY2009 as conditional grants to all district governments (in addition to their regular budget) for implementation of the MNCH-related MSDSs
A consolidated medium-term framework for the health sector at the provincial level has been developed by HD to include provincial- and district-level information, with a focus on MDG attainment Punjab’s budget allocation for the health sector has been increased by at least 15% from FY2009 to FY2010.
Spending by DGs of the conditional grants provided under SP1 has been evaluated by HD to ensure conformity with related sector plans
50% of SP2 amount in counterpart funds has been set aside by the Finance Department for allocation in FY2010 as conditional grants to all
The MTF developed under SP2 is expanded and evolved into an MTEF
The share of the health sector allocation in the consolidated district-provincial budget for FY2011 to have increased in relation to total allocations.
Spending by DGs of the conditional grants provided under SP2 evaluated by HD to ensure conformity with related sector plans.
50% of SP3 amount in counterpart funds has been set aside by the Finance Department for allocation in FY2011 as conditional grants to all
Not achieved. A consolidated MTF was prepared at the provincial level, not at the district level.
Not achieved. District health expenditure increased each year— e.g. 16% in FY2010, 13% in FY2011, 28% in FY2012 on a year to year basis—excluding the PMDGP funds.
Not achieved. HD evaluated the spending by DGs of the conditional grant transfers under SP1, not under SP2.
Not achieved. The required amounts under SP1 and SP2 were set aside for allocation as conditional grants. Only 30% of funds have been
28
Ap
pe
ndix
2
Outputs Actions under Subprogram 1
Actions under Subprogram 2
Indicative Triggers for Subprogram 3
Status of Indicative Triggers for Subprogram 3
at Program Completion
district governments (in addition to their regular budget) for implementation of MSDSs The conditional grants for FY2010 have been disbursed to those DGs that have utilized 80% of the conditional grants provided under SP1, based on the minimum conditions and performance indicators previously established by HD A regular reporting system between DGs and ODGHS, with reporting guidelines on utilization of the conditional grants, has been established Health expenditure in all DGs has been increased, at least in proportion to allocations, through the regular budget of DGs, and the conditional grants transferred to DGs in addition to the normal budget.
DGs (in addition to their regular budget) for implementation of MSDSs
The conditional grants for FY2011 have been disbursed to those DGs that have utilized 80% of the conditional grants provided under SP2, based on the minimum conditions and performance indicators previously established by HD
Regular reporting on use of conditional grants by districts to CGS
Health expenditure in DGs to have increased in proportion to allocations, through the regular budgets of district governments, and the conditional grants transferred to district governments in addition to the normal budget.
used for PMDGP purposes.
Not achieved. Conditional grants for FY2010 were disbursed based on the minimum conditions and performance indicators previously established by HD.
Achieved. Districts were reporting use of conditional grants to PMU using new codes.
Not achieved. District health expenditure increased each year— e.g., 16% in FY2010, 13% in FY2011, 28% in FY2012 on a year to year basis—excluding the PMDGP funds.
3.2. Improved financial
The budget wing and the development wing within
A financial reporting system has been adopted
Operationalized financial reporting system for the
Not achieved. The financial reporting system
Ap
pe
ndix
2
29
Outputs Actions under Subprogram 1
Actions under Subprogram 2
Indicative Triggers for Subprogram 3
Status of Indicative Triggers for Subprogram 3
at Program Completion
management and reporting in the health sector
the health department merged into an FMC tasked to prepare the recurrent and development budgets for the health sector and to monitor their execution Financial reporting mechanism to consolidate financial information on the health sector including districts and all primary and secondary health care facilities instituted by FMC, and PIFRA interface established
by Punjab for the health sector based on classification codes of accounts that reflect the functional attributions of each tier of health services
health sector producing reports reflecting the functional attributions of each tier of health services
reflecting the functional attributions of each health services tier was operationalized using new subfunction created by controller general of accounts.
3.3. Improved internal control and audit in the health sector
Through regular DAC meetings, the HD to have cleared at least 1,000 of outstanding audit observations for major cases
Conceptual framework prepared by the Health Department for improving internal controls based on an assessment of past audit issues
HD and DGs have undertaken a comprehensive assessment of fiduciary risk in the health sector, and mitigation measures have been recommended DAC to have cleared at least 1,200 outstanding audit observations
Mitigation measures to contain fiduciary risks implemented. DAC to have cleared 1,400 outstanding audit observations
DAC to have cleared 1,400 outstanding audit observations
Partly achieved. HD developed a comprehensive 3-year risk mitigation plan, based on findings of the 2012 fiduciary risk assessment of the health sector and the updated public expenditure and financial accounting (PEFA) score. Now under implementation
Partly achieved. A large number of audit observations were settled through DAC meetings; yet pre-2008 paras existed
30
Ap
pe
ndix
2
Outputs Actions under Subprogram 1
Actions under Subprogram 2
Indicative Triggers for Subprogram 3
Status of Indicative Triggers for Subprogram 3
at Program Completion
10 DGs have appointed internal auditors to strengthen internal controls, based on the detailed job descriptions and the terms of service prepared and approved by FD HD has taken steps to restructure its internal control system
All vacant positions at grade-level 16 or above in the internal audit wing of HD have been filled, and a plan for internal audit of HD for FY2010 has been developed
All local governments to have appointed internal auditors to strengthen internal controls, based on the detailed job descriptions and terms of service prepared and approved by the Finance Department
Health Department to have restructured the internal control system, with a functioning internal control wing undertaking internal audit
Not achieved. Internal audit capacity at district level is low. Support is underway through outsourcing a TA firm
Not achieved. Internal audit is functioning at the provincial level, in line with the Local Governance Ordinance 2001.
3.4. Pro-poor health care financing and provider system developed
A steering committee and working group on health financing constituted, and the work plan for such working group developed The Health Department to have identified studies required for designing pro-poor health financing system, including an out of pocket expenditure study, and developed terms of reference for
Options have been identified by HD for Punjab’s health financing and provider payment reforms New pro-poor health financing programs have been developed and piloted in two districts, and the results of such pilot programs have been evaluated by an entity endorsed by the Planning
Appropriate health financing and provider payment reforms determined, and necessary regulations for implementing the reforms adopted
Based on the evaluation, recommendations and an action plan for scaling up pro-poor health financing programs developed and approved
Partly achieved. Appropriate health financing and provider payment reforms are determined (PRSP, CHARM). The pace of implementation is slow. Not achieved. The scaling up of pro-poor health financing programs is included in the health sector strategy. The implementation of the scaling up is still under preparation (PC-1 being
Ap
pe
ndix
2
31
Outputs Actions under Subprogram 1
Actions under Subprogram 2
Indicative Triggers for Subprogram 3
Status of Indicative Triggers for Subprogram 3
at Program Completion
such studies
A conceptual framework prepared for reducing health care expenditure burden on the poor
and Development Department
A plan to rationalize, institutionalize, and retain user charges for health services has been developed by HD and submitted for approval of chief minister
developed).
BHU = basic health unit; DAC = departmental accounts committee; DHIS = district health information system; DHQ = district headquarter hospital; EDO = executive district officer; FMC = financial management cell; FY = fiscal year; GOP = government of the Punjab; MDG = Millennium Development Goal; MNCH = maternal, neonatal, and child health; MOU = memorandum of understanding; MSDS = minimum service delivery standard; MTEF = medium-term expenditure framework; NCHD = National Commission for Human Development; ODGHS = Office of the Director General of Health Services; PFC = provincial finance commission; PIFRA = Project for Improved Financial Reporting and Accounting; PRSP = Punjab Rural Support Program; RHC = rural health center; SMP = standard medical protocol; SOP = standard operating procedure; SPU = strategy and policy unit; THQ = town headquarter hospital.
a The first survey was conducted as a condition under the Punjab Government Efficiency Improvement Program.
32 Appendix 3
32
Ap
pe
ndix
4
MINIMUM SERVICE DELIVERY STANDARDS PACKAGE (MATERNAL AND CHILD HEALTH RELATED SERVICES)
No Services Intervention
Standard of Care Minimum Acceptable Standard
A. Preventive Services
1 Immunization for mother and children
Every child under the age of 1 year should be fully immunized against seven diseases in accordance with expanded program of immunization schedule.
At least 90% of all children aged 1 year should be immunized against seven diseases.
Every mother of childbearing age should receive 5 doses of tetanus toxoid or 2 doses of tetanus toxoid during current pregnancy.
Minimum of 80% of mothers of childbearing age should receive 5 doses of tetanus toxoid or two doses during pregnancy.
2 Antenatal care All pregnant women should have at least four properly spaced antenatal care assessments by or under supervision of a skilled attendant.
More than 80% of all pregnant women should have at least three properly spaced antenatal care assessments done by or under supervision of a skilled attendant.
3 Natal care Natal care by a skilled birth attendant at institutions in principle, and at home for exceptional cases
All the complicated deliveries should be referred to facilities that can handle them.
All the complicated deliveries should be referred to health facilities that can handle them. (However, many complications during labor and delivery are unpredictable. Therefore, women should be informed of danger of delivering at home for any delivery and should be taken to institutions as much as possible.)
All women with complications of deliveries should be properly handled and referred to facilities that can handle them appropriately.
4 Postnatal care Two postpartum visits; first visit within 24 hours of delivery by a skilled personnel
At least two-thirds of all women should receive postpartum care on prescribed criteria.
Inter-natal care Family planning services, nutritional counseling, and health education
Every woman of childbearing age should be provided with these services childbearing
5 Prevention and management of STIs and RTIs
All women during pregnancy, childbirth, and the postnatal period should be appropriately examined for STIs and RTIs and be treated according to WHO protocols of syndromic case management.
All women during pregnancy, childbirth, and the postnatal period should be appropriately examined and treated.
6 Family planning services
All eligible couples will be provided with the necessary information and services on family planning.
Nearly two-thirds of all eligible couples should be provided with knowledge and information on family planning methods to make informed decisions regarding family planning.
Appendix 3 33
Ap
pe
ndix
2
33
No Services Intervention
Standard of Care Minimum Acceptable Standard
7 Major micronutrient deficiencies
All deficiency cases seen at any facility should be recorded, supplemented, and followed.
Universal awareness campaigns in media; fortification of salt for iodine, vegetable oils for vitamins A and D, wheat for iron and folic acid
B. Promotive Services
8 Health education All health care providers should deliver health education messages to patients through interpersonal communication, visual displays in the facility, and health education videos running on TVs in the outpatient departments.
Regular national and local campaigns in media (print and electronic) for important health issues
C. Curative Services
9 Basic EmONC services
All facilities should provide basic EmONC.
All facilities should have arrangements for basic EmONC.
10 Comprehensive EmONC services
All DHQs and THQs should provide comprehensive EmONC.
All DHQs and THQs should have arrangements for comprehensive EmONC services.
11 Management of sick child up to 5 years of age
IMCI approach recommended by WHO and UNICEF
IMCI as recommended by WHO is implemented in all health facilities
12 Blood transfusion services
All THQs and DHQs should provide blood transfusion services around the clock.
All THQs and DHQs should provide blood transfusion services.
DHQ = district headquarter hospital, EmONC = emergency obstetric and newborn care, IMCI = integrated management of childhood illnesses, RTI = reproductive tract infection, STI = sexually transmitted infection, THQ = town headquarter hospital, UNICEF = United Nations Children’s Fund, WHO = World Health Organization. Source: ADB. 2008. Report and Recommendation of the President to the Board of Directors on a Proposed Program Cluster and Loan for Subprogram 1 to Islamic Republic of Pakistan for Punjab Millennium Development Goals Program.
Manila.
34
Ap
pe
ndix
4
UTILIZATION OF PMDGP FUNDS BY DISTRICTS (PRs million)
No. Name of District
FY2009 FY2010 FY2011 FY2012 FY2013 Total Returned to GOP R U R U R U R U R U R U
1 Attock 0.0 0.0 94.9 46.9 184.4 0.0 45.5 18.4 2.6 0.0 327.4 65.4 262.0
2 Bahawalnagar 193.2 48.0 144.2 127.5 165.3 0.0 46.9 5.9 17.5 0.0 567.0 181.4 385.6
3 Bahawalpur 0.0 0.0 28.4 0.2 333.3 0.0 52.3 27.5 4.0 0.0 418.0 27.7 390.2
4 Bhakkar 0.0 0.0 65.4 40.4 167.1 0.0 41.0 13.8 1.4 0.0 274.9 54.2 220.7
5 Chakwal 94.6 0.2 87.7 54.8 170.9 0.0 32.3 9.9 13.8 2.8 399.3 67.7 331.6
6 Chiniot 0.0 0.0 12.0 2.3 107.4 0.0 30.1 4.5 1.4 0.0 150.9 6.8 144.2
7 D.G. Khan 3.8 3.8 127.9 107.9 145.1 0.0 16.5 12.8 13.3 6.6 306.7 131.1 175.6
8 Faisalabad 0.0 0.0 182.2 95.6 312.1 0.0 57.6 3.3 2.4 1.9 554.4 100.8 453.6
9 Gujranwala 122.4 0.3 122.4 64.1 234.9 0.0 41.5 0.0 2.5 0.0 523.6 64.3 459.3
10 Gujrat 84.6 0.4 84.6 52.0 200.8 0.0 57.8 34.3 2.8 0.0 430.6 86.6 344.0
11 Hafizabad 140.8 42.5 42.9 34.8 90.6 0.0 26.1 11.4 1.4 0.9 301.8 89.6 212.2
12 Jhagh 0.0 0.0 70.1 38.0 180.5 0.0 50.0 18.6 11.9 10.0 312.6 66.7 245.9
13 Jhelum 75.7 13.0 62.7 43.7 157.9 9.2 29.5 26.8 1.0 0.8 326.7 93.5 233.2
14 Kasur 117.6 87.7 32.0 24.6 208.5 0.0 60.0 21.5 0.7 0.0 418.8 133.8 285.0
15 Khanewal 68.8 63.4 48.3 28.0 186.2 0.0 52.5 4.3 9.6 1.3 365.4 97.1 268.3
16 Khushab 1.1 1.1 95.0 47.1 133.1 4.3 38.3 15.6 1.5 0.3 269.1 68.4 200.6
17 Lahore 78.8 63.8 15.0 12.5 129.2 0.0 35.9 0.0 22.7 0.0 281.6 76.4 205.2
18 Layyah 6.2 5.7 8.0 5.0 0.0 0.0 35.3 17.3 3.0 0.0 52.6 28.1 24.5
19 Lodhran 134.0 0.5 202.5 47.2 167.9 0.0 35.0 10.1 14.5 0.0 553.8 57.7 496.1
20 M.B. DIN 0.0 0.0 67.4 31.2 163.7 0.3 29.5 13.9 21.1 19.0 281.7 64.4 217.3
21 Mianwali 4.2 4.4 6.9 6.0 0.0 0.0 37.1 5.3 9.3 2.6 57.5 18.3 39.2
22 Multan 0.0 0.0 91.3 57.5 196.1 0.0 49.6 5.4 15.0 3.6 351.9 66.5 285.5
23 Muzaffargarh 53.8 27.0 140.2 78.0 191.8 0.0 56.4 19.4 20.0 0.0 462.2 124.5 337.7
24 Nankana Sahib 38.0 15.9 41.8 38.0 156.4 0.0 41.2 9.2 15.4 15.0 292.7 78.0 214.8
25 Narowal 118.7 76.7 127.0 39.2 0.0 0.0 18.1 2.7 6.1 1.0 269.9 119.6 150.3
26 Okara 105.3 14.8 90.5 70.9 245.1 0.0 42.9 2.8 17.1 15.2 500.9 103.7 397.2
27 Papakpattan 62.9 21.7 69.2 60.6 0.0 0.0 29.2 2.7 4.8 1.5 166.1 86.5 79.5
28 R. Y Khan 0.0 0.0 113.0 35.8 339.1 0.0 60.3 0.0 31.9 0.0 544.4 35.8 508.6
29 Rajanpur 141.0 88.8 51.5 15.0 145.8 0.0 37.1 0.0 27.3 25.2 402.6 128.9 273.7
30 Rawalpindi 0.0 0.1 142.9 43.4 302.1 0.0 54.0 10.7 12.9 12.4 209.8 66.7 143.0
Ap
pe
ndix
4 35
No. Name of District
FY2009 FY2010 FY2011 FY2012 FY2013 Total Returned to GOP R U R U R U R U R U R U
31 Sahiwal 9.3 9.3 108.1 70.8 189.7 0.0 36.4 2.4 13.0 11.9 356.5 94.5 262.0
32 Sargodha 157.7 39.5 279.6 59.1 264.8 0.0 47.1 0.4 15.0 14.9 764.2 113.9 650.3
33 Shiekhupura 76.8 13.6 78.2 32.1 193.4 0.0 34.0 0.8 2.2 0.0 384.6 46.5 338.1
34 Sialkot 0.0 0.0 61.9 61.9 0.0 0.0 41.4 41.4 19.5 0.0 122.9 103.4 19.5
35 T.T. Singh 90.1 15.0 75.0 51.2 0.0 0.0 31.8 0.2 23.1 13.1 220.0 79.6 140.5
36 Vehari 55.9 27.1 81.6 38.6 191.9 0.0 36.0 3.5 18.2 17.2 383.6 86.4 297.2
Total 2,035.3 684.4 3,152.2 1,661.9 5,855.0 13.8 1,466.1 376.9 400.0 177.2 12,606.5 2,914.2 9,692.3
FY = fiscal year, R = returned, U = utilized. Source: GOP. 2013. PMU’s Government Program Completion Report. Lahore.
36
Ap
pe
ndix
5
GENDER ACTION PLAN
SP2 was categorized as a program with gender equity theme in design, provided with a separate gender action plan. The vast majority of the activities in the plan were not carried out. However, the one explicit gender policy condition in the Policy matrix was done, namely that at least 95% of BHUs were able to recruit at least one female medical officer or midwife. Despite the progress made under the program, a sustained effort is required to meet the 2015 targets of the MDGs 4 and 5 goals. More female staff is required at PHC level, and more specialists are required at THQ level to improve the quality of the services. At the same time, more financial resources are required to improve the access to the services. Rationale/Objectives Activity/ies Performance Target Indicators Status
Component 1 : Improve availability and quality of primary and secondary health care
1.1 To integrate preventive, promotive and curative MNCH services within the broader perspective of comprehensive reproductive health care.
1.1.1 Conduct a gender assessment of information/behavior change campaigns that were undertaken within the Province of Punjab
a) A gender assessment report on information/behavior change campaigns done in the district is completed
b) A KAP survey report with an assessment of the factors that facilitate and impede health-seeking behaviors among men and especially women living in poor communities is completed
1.1.2 Conduct a Knowledge Attitudes and Practices (KAP) survey on health-seeking behavior of women and men based on the assessment conducted change behavior campaigns
c) A plan for sustaining and expanding information/behavior change campaigns is developed using the results of the gender assessment report and the KAP survey on health seeking behavior of women and men
d) The plan for sustaining and expanding information/behavior change campaigns is adopted and implemented by the Ministry of Health of Punjab at least one pilot area
There is no evidence available that any of the surveys have been undertaken
1.1.3 Conduct a Survey on the KAP of community health workers especially Lady Health Workers (LHW) and the Cadre of Midwives
e) A KAP survey report with an assessment of gender-sensitivity and responsiveness of LHWs and the Cadre of Midwives is completed
f) A capacity building plan for community health workers which addresses gender issues identified in the KAP survey is developed, and implemented by the Ministry of Health of Punjab
Ap
pe
ndix
5 37
Rationale/Objectives Activity/ies Performance Target Indicators Status
1.1.4. Mainstream gender in mandatory staff training seminars
g) Development and inclusion of a gender-sensitivity orientation module in the training curriculum for continuing education of MNCH staff and medical professionals
h) Doctors, paramedics, lady health workers, BHU staff,
and other primary and secondary health care workers render competent and gender-sensitive maternal and child health care services
No evidence available that this was achieved The improved doctor-patient relations over time led to an increase in four antenatal visits from 28% in FY2007 to 41% in FY2011, and to an increase in four antenatal visits from 61% to 81% visit
1.1.5 Review the congruence of the MNCH plans and policy instruments generated by the Program to laws and the Pakistan government’s commitments to gender equality
i) SMPs, SOPs, and referral protocols on MNCH, and the 3-year rolling plans of districts on MSDS are compliant to the GRAP (Gender Reform Action Plan) and other legal/policy instruments on gender equality
SMPs, SOPs, and referral protocols were designed to be gender-and culture-sensitive to encourage pregnant women to optimally utilize the MNCH services. SMPs, SOPs, and referral protocols were designed to be gender-and culture-sensitive to encourage pregnant women to optimally utilize the MNCH services
j) MSDS implementation guidelines, include mechanisms for immediate detection and appropriate interventions on hidden gender issues in relation to reproductive health care concerns
The MSDS catered for the prevention and management of sexually-transmitted infections and reproductive tract infections
38
Ap
pe
ndix
5
Rationale/Objectives Activity/ies Performance Target Indicators Status
1.1.6 To address the lack of female MNCH staff in health facilities, especially in rural areas
k) A plan for recruitment, retention of female health workers that include incentives as well as protection for female staff assigned in rural areas, is prepared and implemented within the 1
st year of the project
Age for intake in the government service was increased to 40 for female staff to provide women an opportunity to serve in the health sector after they have completed their family. Additional monetary incentives were also introduced to retain female staff in health sector jobs, particularly in rural areas
l) Majority of government health facilities in the Province of Punjab, especially at the village level, have at least one (1) female medical staff
Due to various limitations (e.g., death of skilled workers, remoteness of health facilities, security situation in rural areas) this target could not be achieved
Component 2: Better management of health service delivery
2.1 To improve district health management and monitoring
2.1.1 Mechanisms to systematically capture and analyze data on maternal and child health are instituted
a) Feedback system and instruments (i.e., citizen’s report card) that measure health worker’s gender sensitivity are developed, implemented, and results are inputted into the annual planning process
b) Comprehensive district health information (DHIS) system obtains, analyses, and disseminates sex-disaggregated data
No evidence available that this was achieved The DHIS was developed by JICA, and collects and disseminates gender—disaggregated data
Component 3: Sustainable pro-poor health financing
3.1 To provide targeted assistance to very poor women in especially difficult circumstances
3.1.1 Evaluate the Sehat Sulalat Card System
a) Action Plan for institutionalizing the Sehat Sahulal Card System is developed
b) Increased rate of maternal and child survival among very poor women
Sehat Sahulal Card System was piloted in two districts
Ap
pe
ndix
5 39
Rationale/Objectives Activity/ies Performance Target Indicators Status
Component 4: Plan Implementation and Monitoring
4.1 to establish a working structure and process that will ensure implementation of this gender action plan
4.1.1 Strengthening gender expertise in the project
a) A gender specialist is hired on an intermittent basis b) Selection criteria for other project staff members include
qualities that demonstrate openness to, and familiarity with gender mainstreaming principles
A gender specialist was not hired No evidence available that his was achieved
c) A gender sensitivity training program is designed and implemented for the project staff.
No evidence available that this was achieved.
4.1.2 A project Gender Focal Point committee is created to oversee implementation of this Gender Action Plan
d) TOR, official appointment, and approved work plan of project Gender Focal Point Committee members
e) MOU with the Ministry on Women Development
There is no evidence available that a gender focal point committee was established
4.1.3 Incorporation of the indicators in this gender plan to the regular project monitoring tools/formats
f) GAP Monitoring and reporting tool developed and implemented
No evidence available that this was achieved
Source: ADB. 2010. Report and Recommendation of the President to the Board of Directors on a Proposed Loan for Subprogram 2 to Islamic Republic of Pakistan for Punjab Millennium Development Goals Program. Manila.
40 Appendix 6
40
Ap
pe
ndix
7
ACTUAL STATUS OF COMPLIANCE WITH LOAN COVENANTS Loan 2485 – Punjab Millennium Development Goals Program Subprogram 1
Covenants Reference in
Loan/Program Agreements
Status of Compliance
The Borrower shall, and shall cause Punjab to, carry out the Program with due diligence and efficiency and in conformity with sound administrative, financial, environmental, and health sector practices.
LA, Article IV Section 4.01. (a)
Complied with
In the carrying out of the Program, the Borrower shall, and shall cause Punjab to, perform all obligations set forth in Schedule 5 to this Loan Agreement.
LA, Article IV Section 4.01. (b)
Complied with
The Borrower shall maintain records and documents adequate to identify the Eligible Items financed out of the proceeds of the Loan, and shall cause Punjab to maintain records and documents adequate to record the progress.
LA, Article IV Section 4.02. (a)
Complied with
The Borrower shall enable ADB's representatives to inspect any relevant records and documents referred to in paragraph (a) of this Section.
LA, Article IV Section 4.02. (b)
Complied with
As part of the reports and information referred to in Section 6.05 of the Loan Regulations, the Borrower shall furnish, or cause to be furnished, to ADB all such reports and information as ADB shall reasonably request concerning (i) the Counterpart Funds and the use thereof; and (ii) the implementation of the Program, including the accomplishment of the targets and carrying out of the actions set out in the Policy Letter.
LA, Article IV Section 4.03. (a)
Complied with
Without limiting the generality of the foregoing or Section 6.05 of the Loan Regulations, the Borrower shall furnish, or cause to be furnished, to ADB quarterly reports on the carrying out of the Program and on the accomplishment of the targets and carrying out of the actions set out in the Policy Letter.
LA, Article IV Section 4.03. (b)
Partially complied with. Quarterly reports were irregular and were generally substandard.
The Borrower shall cause Punjab to appoint HD as the Program Executing Agency to be responsible for the overall implementation of the Program, including coordinating the implementation of policy actions by various departments, Program administration, disbursements, and maintenance of Program records.
LA, Schedule 5 (Para 1)
Complied with
The Borrower shall, and shall cause Punjab to: (a) carry out the policies and Actions in accordance with the schedule of reforms in the Policy Matrix and ensure that the reforms are sustained for and beyond the duration of the Program period; and (b) carry out its obligations as stipulated in this Schedule, this Loan Agreement and the Program Agreement, in a timely manner.
LA, Schedule 5 (Para 2)
Complied with
Appendix 6 41
Ap
pe
ndix
5 41
The Borrower shall ensure that adequate information be made available to Punjab to facilitate implementation of policies and actions in the Program that are connected with, or can be affected by, federal initiatives
LA, Schedule 5 (Para 3)
Complied with
The Borrower shall, and shall cause Punjab, to keep ADB informed of, and the Borrower and ADB shall from time to time exchange views on, the progress made in carrying out the Program.
LA, Schedule 5 (Para 4)
Complied with
The Borrower shall, and shall cause Punjab to, engage in policy dialogue with ADB, in a timely manner, on problems and constraints encountered during Program implementation and on appropriate measures to overcome or mitigate such problems and constraints.
LA, Schedule 5 (Para 5)
Complied with
The Borrower shall, and shall cause Punjab to, keep ADB informed of policy discussions with other multilateral or bilateral agencies that have implications for implementation of the Program, and shall provide ADB with an opportunity to comment on any resulting policy proposals. The Borrower shall, and shall cause Punjab to, take ADB’s views into consideration before finalizing and implementing any such proposals.
LA, Schedule 5 (Para 6)
Complied with
The Borrower shall maintain separate accounts and records for the Loan in accordance with sound accounting principles. The accounts shall be audited annually in accordance with standards acceptable to ADB, and the Borrower shall provide ADB with certified copies of the audited accounts promptly after their preparation (and no later than six months after the close of the Financial Year for the relevant accounts).
LA, Schedule 5 (Para 7)
Partially complied with. Separate accounts and records were maintained for the funds earmarked for the conditional grants. Audits are being done of provincial and district health accounts on an annual basis. There were no certified copies provided to ADB.
The Borrower shall, and shall cause Punjab to, ensure that the Counterpart Funds are used to meet the reform and other financing needs relating to the implementation of the Program, including allocation of Rupees 3.5 billion of such Counterpart Funds to finance conditional grants to DGs for the health sector.
LA, Schedule 5 (Para 8)
Complied with. Counterpart funds were used to meet the reforms under SP1, which were met. Allocation for conditional grants was transferred to Account VI of the districts.
Without limiting the generality of Section 4.03 of this Loan Agreement, the Borrower shall, and shall cause Punjab to: (a) prepare quarterly progress reports and an annual report on Program implementation for submission to ADB and regularly update the Program website; and (b) prepare an annual report on its budget performance not later than six months after the conclusion of each Financial Year.
LA, Schedule 5 (Para 9)
Partially complied with. Quarterly reports were irregular and lacked data to substantiate reported progress. Annual reports on budget performance were produced/provided.
The Borrower shall, and shall cause Punjab to, undertake review of the Program, with the participation of ADB, for the design of subprograms 2 and 3 for the Program Cluster based on experiences gained under the Program and
LA, Schedule 5 (Para 10)
Complied with
42 Appendix 6
changes in circumstances to the external environment. Pursuant to the review, Punjab shall submit a report to ADB recommending any revisions to the indicative reforms for subprograms 2 and 3.
The Borrower acknowledges, and shall cause Punjab to acknowledge, that the review process described in paragraph 10 of this Schedule does not obligate ADB to make loans for any further subprogram under the Program Cluster and that any further subprogram is subject to ADB Board approval.
LA, Schedule 5 (Para 11)
Complied with
Punjab shall carry out the Program with due diligence and efficiency, and in conformity with sound administrative, financial, environmental, and health sector practices.
PA, Article II [Section 2.01 (a)]
Complied with
In the carrying out of the Program and operation of the Program facilities, Punjab shall perform all obligations set forth in the Loan Agreement to the extent that they are applicable to Punjab.
PA, Article II [Section 2.01 (b)]
Complied with
Punjab shall make available, promptly as needed, the funds, facilities, services, equipment and other resources which are required, in addition to the proceeds of the Loan, for the carrying out of the Program
PA, Article II [Section 2.02]
Complied with
In the carrying out of the Program, Punjab shall employ competent and qualified consultants and contractors, acceptable to ADB, to an extent and upon terms and conditions satisfactory to ADB.
PA, Article II [Section 2.03]
Complied with
Punjab shall maintain, or cause to be maintained, records and accounts adequate to identify the Rupees 3,500,000,000 in Counterpart Funds to finance conditional grants to DGs as specified in paragraphs 5, 6 and 9 of the Schedule to this Program Agreement, and to disclose the use thereof under the Program.
PA, Article II [Section 2.04]
Partially complied with. Funds were released promptly. Records were maintained at the district level, with data accessible through PIFRA.
ADB and Punjab shall cooperate fully to ensure that the purposes of the Loan will be accomplished.
PA, Article II [Section 2.05 (a)]
Complied with
Punjab shall promptly inform ADB of any condition which interferes with, or threatens to interfere with, the progress of the Program, the performance of its obligations under this Program Agreement, or the accomplishment of the purposes of the Loan.
PA, Article II [Section 2.05 (b)]
Complied with
ADB and Punjab shall from time to time, at the request of either party, exchange views through their representatives with regard to any matters relating to the Program and the Loan.
PA, Article II [Section 2.05 (c)]
Complied with
Punjab shall furnish to ADB all such reports and information as ADB shall reasonably request concerning: (i) the Counterpart Funds and the use thereof; (ii) the Program; (iii) the administration, operations and financial condition of Punjab to the extent relevant to the Program; and (iv) any other matters relating to the purposes of the Loan.
PA, Article II [Section 2.06 (a)]
Complied with
Appendix 6 43
Ap
pe
ndix
5 43
Without limiting the generality of the foregoing, Punjab shall furnish to ADB and the Borrower an annual report on its budget performance not later than six months after the conclusion of each Financial Year and quarterly and annual reports on the implementation of the Program during the Program period. Such reports shall be submitted in such form and in such detail and within such a period as ADB shall reasonably request, and shall indicate, among other things, progress made and problems encountered during the period under review, steps taken or proposed to be taken to remedy these problems and proposed program of activities and expected progress during the following period.
PA, Article II [Section 2.06 (b)]
Partially complied with. There was no regular periodic reporting by Punjab, providing all information required under this covenant.
Promptly after the completion of the Program, but in any event not later than three (3) months thereafter or such later date as ADB may agree for this purpose, Punjab shall prepare and furnish to ADB a report, in such form and in such detail as ADB shall reasonably request, on the execution and implementation of the Program, including its cost, the performance by Punjab of its obligations under this Program Agreement and the accomplishment of the purposes of the Loan.
PA, Article II [Section 2.06 (c)]
Late complied with. The draft PCR was received by ADB after a delay of about 2 years, and that too with incomplete information.
Punjab shall enable ADB's representatives to inspect the Program facilities and relevant records and documents relating to the Program, including the application of Counterpart Funds as specified in paragraph 9 of the Schedule to this Program Agreement.
PA, Article II [Section 2.07]
Complied with
Punjab shall, promptly as required, take all action within its powers to implement and carry out the Program.
PA, Article II [Section 2.08 (a)]
Complied with
Punjab shall at all times conduct its business in accordance with sound administrative, financial, environmental and health sector practices.
PA, Article II [Section 2.08 (b)]
Complied with
Except as ADB may otherwise agree, Punjab shall apply the proceeds of the Loan to the financing of expenditures on the Program in accordance with the provisions of the Loan Agreement and this Program Agreement, and shall ensure that all expenditures financed out of such proceeds are used exclusively in the carrying out of the Program.
PA, Article II [Section 2.09]
Partially complied with. While allocation for conditional grants was transferred to the districts, the amount was only partially used. (see Appendix 4)
Punjab shall appoint HD as the Program Executing Agency to be responsible for the overall implementation of the Program, including coordinating the implementation of policy actions by various departments, Program administration, disbursements, and maintenance of Program records.
PA, Schedule (Para 1)
Complied with
A Steering Committee, chaired by the Chairman, Planning and Development Board and comprising the Secretary of Health, Secretary of Finance, Secretary of the Local Government and Community
PA, Schedule (Para 2)
Partially complied with. Per PMU’s record, only two meetings of steering committee were held during
44 Appendix 6
Development Department, representatives of the health care providers and the Program Director who will serve as the Secretary of the Steering Committee, shall oversee policy decisions and overall Program implementation. The Steering Committee shall meet at least once every six (6) months. A working group shall be established for developing a pro-poor health care financing and provider payment system. The Program Management Unit, which has been established for the Health Sector Reform Program, shall be responsible for daily coordination and management of Program activities.
the entire life of the program. The PMU was inadequately staffed, thus remained weak in coordination and management functions.
Punjab shall ensure that (a) the objectives achieved, policies adopted, and actions taken prior to the date of the Loan Agreement, as set forth in the development policy letter, will continue to be in full force and effect for the duration of the Program Cluster and subsequently; and (b) once achieved, adopted, complied with and implemented, the objectives, policies and actions set forth in the Policy Letter will continue to be in full force and effect during and subsequent to the Program Cluster period.
PA, Schedule (Para 3)
Complied with .
Punjab shall ensure that primary and secondary health services continue to be the responsibility of DGs, and are integrated and operating as one coherent health services system.
PA, Schedule (Para 4)
Complied with
Punjab shall establish a mechanism for conditional grants (“CG”) to finance DGs’ implementation of MSDS and related activities as follows: (i) The Program Steering Committee shall be the
oversight body for the mechanism, and shall be responsible for approving the formula for allocating the CGs among the districts, based on the recommendation of the Conditional Grants Secretariat (“CG Secretariat”) in ODGHS;
PA, Schedule (Para 5)
Complied with
(ii) the CG Secretariat shall propose the CG indicators for receiving base allocations and performance-based allocations and the allocation formula, and determine the reporting obligations of the DGs. The CG Secretariat shall assess the eligibility of DGs to receive CGs, be responsible for monitoring financial and non-financial performance of DGs, make any necessary revisions to the CG structure, and provide guidance as necessary to the DGs;
PA, Schedule (Para 5)
Complied with
(iii) the Finance Department shall be responsible for allocating the CGs based on the formula to the DGs;
PA, Schedule (Para 5)
Complied with
(iv) CGs will be shown separately in the annual budget; and
PA, Schedule (Para 5)
Complied with
Appendix 6 45
Ap
pe
ndix
5 45
(v) the Finance Department and HD shall prepare and submit to ADB annual financial and activity monitoring reports of DGs’ performance.
PA, Schedule (Para 5)
Complied with
Punjab shall also ensure that: (i) each DG has to allocate at least 10% of its base CG allocation to capacity building; and (ii) CG allocations shall be in addition to Provincial Financial Commission (PFC) awards. Punjab shall ensure that the CGs are disbursed by the Finance Department to an eligible DG within one month from the date such DG becomes eligible.
PA, Schedule (Para 6)
Partially complied with. While allocation for conditional grants was transferred to the districts, the amount was only partially used. (see Appendix 4)
Punjab shall cause HD to ensure that the existing policy guidelines on transfers and tenure are adhered to in order to ensure appropriate job tenure and effective implementation of the Program.
PA, Schedule (Para 7)
Partially complied with. High turnover in in executing agency, PMU, and DGs.
Punjab shall ensure that the Program is carried out in accordance with the environmental rules and regulations applicable in Pakistan and ADB's Environment Policy (2002). Punjab shall also ensure implementation of any environmental monitoring and mitigation measures, including development and implementation of any service standards and operating procedures for disposal of hazardous and medical waste.
PA, Schedule (Para 8)
Partially complied with. No monitoring mechanism was set up to monitor hospital waste disposal.
Punjab shall ensure that the Counterpart Funds are used to meet the reform and other financing needs relating to the implementation of the Program, including allocation of Rupees 3.5 billion of such Counterpart Funds to finance conditional grants to DGs for the health sector.
PA, Schedule (Para 9)
Partially complied with. While allocation for conditional grants was transferred to the districts, the amount was only partially used. (see Appendix 4)
ADB = Asian Development Bank, CG = conditional grant, DG = director general, HD = health department, LA = loan agreement, ODGHC = Office of Director General Health Services, PA = program agreement.
46 Appendix 6
ACTUAL STATUS OF COMPLIANCE WITH LOAN COVENANTS Loan 2644 – Punjab Millennium Development Goals Program Subprogram 2
Covenants Reference in
Loan/Program Agreements
Status of Compliance
The Borrower shall, and shall cause Punjab to, carry out the Program with due diligence and efficiency and in conformity with sound administrative, financial, environmental, and health sector practices; and
LA, Article IV Section 4.01. (a)
Complied with
In the carrying out of the Program, the Borrower shall, and shall cause Punjab to, perform all obligations set forth in Schedule 5 to this Loan Agreement. The Borrower shall also cause Punjab to perform all obligations set forth in the Program Agreement.
LA, Article IV Section 4.01. (b)
Complied with
The Borrower shall maintain, or cause to be maintained, records and documents adequate to identify the Eligible Items financed out of the proceeds of the Loan and to record the progress of the Program.
LA, Article IV Section 4.02 (a)
Complied with
The Borrower shall enable ADB's representatives to inspect any relevant records and documents referred to in paragraph (a) of this Section.
LA, Article IV Section 4.02 (b)
Complied with
As part of the reports and information referred to in Section 6.05 of the Loan Regulations, the Borrower shall furnish, or cause to be furnished, to ADB all such reports and information as ADB shall reasonably request concerning the implementation of the Program, including the accomplishment of the targets and carrying out of the actions set out in the Policy Letter.
LA, Article IV Section 4.03 (a)
Complied with
Without limiting the generality of the foregoing or Section 6.05 of the Loan Regulations, the Borrower shall furnish, or cause to be furnished, to ADB semiannual reports on the carrying out of the Program and on the accomplishment of the targets and carrying out of the actions set out in the Policy Letter
LA, Article IV Section 4.03 (b)
Partially complied with. Semiannual reports were irregular and were generally substandard.
As the Program Executing Agency, HD shall be responsible for the overall implementation of the Program, including coordinating the implementation of policy actions by various departments, Program administration, disbursements, and the maintenance of Program records.
LA, Schedule 5 (Para 1)
Complied with
The Borrower shall, and shall cause Punjab to: (a) carry out the policies and actions in accordance with the schedule of reforms in the Policy Matrix; and (b) carry out its obligations as stipulated in this Loan Agreement and the Program Agreement, all in a timely manner.
LA, Schedule 5 (Para 2)
Complied with
The Borrower shall ensure that adequate information and resources be made available to Punjab to facilitate implementation of policies and
LA, Schedule 5 (Para 3)
Complied with
Appendix 6 47
Ap
pe
ndix
5 47
actions in the Program that are connected with, or can be affected by, federal initiatives.
The Borrower shall, and shall cause Punjab to: (a) ensure that the policies adopted and actions taken, as described in the Policy Letter and the Policy Matrix, prior to the date of this Loan Agreement continue in effect for the duration of, and beyond, the duration of the Program Cluster; and (b) adopt other policies and take other actions as specified in the Policy Letter and the Policy Matrix in accordance with the planned schedule, and ensure that such other policies and actions shall continue in effect during and after the Program Cluster period.
LA, Schedule 5 (Para 4)
Complied with
The Borrower shall, and shall cause Punjab to, keep ADB informed of, and the Borrower and ADB shall from time to time exchange views on, the progress made in carrying out the Program.
LA, Schedule 5 (Para 5)
Complied with
The Borrower shall, and shall cause Punjab to, engage in policy dialogue with ADB, in a timely manner, on problems and constraints encountered during Program implementation and on appropriate measures to overcome or mitigate such problems and constraints.
LA, Schedule 5 (Para 6)
Complied with
The Borrower shall, and shall cause Punjab to, keep ADB informed of policy discussions with other multilateral or bilateral agencies that have implications for implementation of the Program, and shall provide ADB with an opportunity to comment on any resulting policy proposals. The Borrower shall, and shall cause Punjab to, take ADB’s views into consideration before finalizing and implementing any such proposals.
LA, Schedule 5 (Para 7)
Complied with
The Borrower shall, and shall cause Punjab to, ensure that the Counterpart Funds are used to meet the reform and other financing needs relating to the implementation of the Program, including allocation of 50% of such Counterpart Funds to finance conditional grants to DGs for the health sector of Punjab.
LA, Schedule 5 (Para 8)
Partially complied with. Counterpart funds were used to meet the reforms under SP2, which were met. Allocation for conditional grants was initially fully released through Account IV, but used to cover salary increase of staff. The government later on committed to release the same amount, through Special Deposit Accounts. Only part of the amount has been released so far.
The Borrower shall, and shall cause Punjab to, carry out review of the Program with the participation of ADB for the design of the third subprogram of the Program Cluster. The review shall take into account experiences from the implementation of the Program and changes in circumstances to the external environment. Pursuant to the review, Punjab shall submit a report
LA, Schedule 5 (Para 9)
Complied with
48 Appendix 6
to ADB recommending any revisions to the indicative reforms for the third subprogram. The Borrower acknowledges that the review described in this paragraph does not obligate ADB to provide loans for any further subprogram under the Program Cluster and that any such loans are subject to the approval of the Board of Directors of ADB.
Consistent with its commitment to good governance, accountability, and transparency, ADB reserves the right to investigate, directly or through its agents, any alleged corrupt, fraudulent, collusive, or coercive practices relating to the Program. The Borrower agrees to cooperate, and shall cause Punjab and any and all other government offices, organizations and entities involving in implementing the Program to cooperate, fully with any such investigation and to extend all necessary assistance, including providing access to all relevant books and records, as may be necessary for the satisfactory completion of any such investigation.
LA, Schedule 5 (Para 10)
Complied with
Punjab shall carry out the Program with due diligence and efficiency, and in conformity with sound administrative, financial, environmental, and health sector practices.
PA, Article II [Section 2.01 (a)]
Complied with
In the carrying out of the Program and operation of the Program facilities, Punjab shall perform all obligations set forth in the Loan Agreement to the extent that they are applicable to Punjab.
PA, Article II [Section 2.01 (b)]
Complied with
Punjab shall make available, promptly as needed, the funds, facilities, services, equipment and other resources which are required, in addition to the proceeds of the Loan, for the carrying out of the Program
PA, Article II [Section 2.02]
Partially complied. See LA, Schedule 5 (Para 8)
Punjab shall maintain, or cause to be maintained, records and accounts adequate to identify the goods, services and other items of expenditure financed out of the Counterpart Funds, to disclose the use thereof under the Program, to record the progress of the Program (including the cost thereof) and to reflect, in accordance with consistently maintained sound accounting principles, its operations and financial condition.
PA, Article II [Section 2.03]
Complied with
ADB and Punjab shall cooperate fully to ensure that the purposes of the Loan will be accomplished.
PA, Article II [Section 2.04 (a)]
Complied with
Punjab shall promptly inform ADB and the Borrower respectively of any condition which interferes with, or threatens to interfere with, the progress of the Program, the performance of its obligations under this Program Agreement, or the accomplishment of the purposes of the Loan.
PA, Article II [Section 2.04 (b)]
Complied with
ADB and Punjab shall from time to time, at the request of either party, exchange views through their representatives with regard to any matters relating to the Program and the Loan.
PA, Article II [Section 2.04 (c)]
Complied with
Appendix 6 49
Ap
pe
ndix
5 49
Punjab shall furnish to ADB and the Borrower all such reports and information as ADB shall reasonably request concerning: (i) the Counterpart Funds and the use thereof; (ii) the Program; (iii) the administration, operations and financial condition of Punjab to the extent relevant to the Program; and (iv) any other matters relating to the purposes of the Loan.
PA, Article II [Section 2.05 (a)]
Complied with
Without limiting the generality of the foregoing, Punjab shall furnish to ADB and the Borrower an annual report on its budget performance not later than six months after the conclusion of each Financial Year and quarterly and annual reports on the implementation of the Program during the Program period. Such reports shall be submitted in such form and in such detail and within such a period as ADB shall reasonably request, and shall indicate, among other things, progress made and problems encountered during the period under review, steps taken or proposed to be taken to remedy these problems and proposed program of activities and expected progress during the following period.
PA, Article II [Section 2.05 (b)]
Partially complied with. There was no regular periodic reporting by Punjab, providing all information required under this covenant.
Promptly after the completion of the Program, but in any event not later than three (3) months thereafter or such later date as ADB may agree for this purpose, Punjab shall prepare and furnish to ADB a report, in such form and in such detail as ADB shall reasonably request, on the execution and implementation of the Program, including its cost, the performance by Punjab of its obligations under this Program Agreement and the accomplishment of the purposes of the Loan.
PA, Article II [Section 2.05 (c)]
Late complied with. The draft PCR was received by ADB after a delay of about 2 years, and that too with incomplete information.
Punjab shall enable ADB's representatives to inspect the Program facilities and records and documents relating to the Program.
PA, Article II [Section 2.06]
Complied with
Except as ADB may otherwise agree, Punjab shall apply the Counterpart Funds to the financing of expenditures on the Program in accordance with the provisions of the Loan Agreement and this Program Agreement, and ensure that all expenditures financed out of such proceeds are used exclusively in the carrying out of the Program.
PA, Article II [Section 2.07]
Partially complied with. The allocation transferred for conditional grants to the districts was only partially used. See Appendix 4.
HD, as the Program Executing Agency, shall be responsible for the overall implementation of the Program, including coordinating the implementation of policy actions by various departments, Program administration, disbursements, and the maintenance of Program records. HD shall cause that the management unit for the Punjab Health Sector Reforms Program continues to: (a) act as the subprogram management unit as was under SP1; and (b) coordinate day-to-day implementation requirements and arrangements. HD shall also cause that ODGHS continues to be responsible for tracking performance by districts in meeting MNCH-
PA, Schedule (Para 1)
Complied with
50 Appendix 6
related MSDS and for ensuring that data provided by districts meets quality standards.
Punjab shall ensure that primary and secondary health services continue to be functionally integrated and are operating as one coherent system.
PA, Schedule (Para 2)
Complied with
Punjab shall ensure that: (a) the conditional grants are disbursed by FD to a DG within 1 month from the date on which such DG has satisfied the relevant minimum conditions set by Punjab for receiving such grant; and (b) the conditional grants are in addition to each DG's regular health sector budget, and used for implementing MNCH-related MSDS and other selected activities agreed between Punjab and such DG, including a minimum of 10% of the base conditional grants allocated for capacity building activities.
PA, Schedule (Para 3)
Partially complied with. Allocation for conditional grants was only partially transferred to the districts, and the amount was only partially used. See Appendix 4.
Punjab shall ensure that: (a) the Program is carried out in accordance with the Borrower's all applicable environmental laws and regulations and ADB's Safeguard Policy Statement (2009); and (b) proper environmental monitoring and mitigation measures, including development and implementation of any service standards and operating procedures for disposal of hazardous and medical waste, are duly implemented. If there is any discrepancy between the Borrower's relevant laws and regulations, and the requirements of Safeguard Policy Statement (2009), ADB's requirements shall apply.
PA, Schedule (Para 4)
Partially complied with. No monitoring mechanism was set up to monitor hospital waste disposal.
Consistent with its commitment to good governance, accountability, and transparency, ADB reserves the right to investigate, directly or through its agents, any alleged corrupt, fraudulent, collusive, or coercive practices relating to the Program. Punjab agrees to cooperate, and shall cause any and all government offices, organizations and entities involving in implementing the Program to cooperate, fully with any such investigation and to extend all necessary assistance, including providing access to all relevant books and records, as may be necessary for the satisfactory completion of any such investigation.
PA, Schedule (Para 5)
Complied with
ADB = Asian Development Bank, HD = health department, LA = loan agreement, PA = project agreement.
Appendix 7 51
ASSESSMENT OF OVERALL PROGRAM PERFORMANCE
Highly successful (HS): Overall weighted average is greater than 2.7. Successful (S): Overall weighted average is between 1.6 and less than 2.7. Less than successful (PS): Overall weighted average is between 0.8 and less than 1.6. Unsuccessful (U): Overall weighted average is less than 0.8.
Criterion Assessment Rating (0-3) Weight (%) Weighted Average
Relevance Less than relevant 1 25 0. 25
Effectiveness Ineffective 0 25 0.00
Efficiency Inefficient 0 25 0.00
Sustainability Less than likely 1 25 0.25
Overall Rating Unsuccessful 0.50
