District Health Plan for Bagh 2006-07

DISTRICT HEALTH PLAN
BAGH
2006-07
Department of Health Government of AJK
Ministry of Health Government of Pakistan
Earthquake Reconstruction & Rehabilitation Authority
World Health Organization Pakistan
DISTRICT HEALTH PLAN
BAGH
2006-07
Prepared by
DHO and DHMT

Assisted by
DRU and partners

Reviewed by
Chief Planning (Health)/AJK

Verified by
Director General Health/AJK

Endorsed by
DoH/AJK and ERRA/Pakistan

Technically supported by
World Health Organization
Department of Health, AJK

All rights reserved. This document is the sole property of DoH/AJK, and cannot be modified, reproduced or used in any form without prior approval of the concerned authorities. Furthermore, the circulation of this document is limited to the concerned offices only and cannot be publicized, advertised or marketed for commercial purposes. While developing this document, all rational measures have been taken to ensure the quality, reliability and accuracy of the available information. However, the Department of Health/AJK and District Health Office reserve all the rights to add, amend or delete any information or contents in this planning document without prior permission. DoH/AJK or DHO should be contacted for any query relating to this plan. Pointing out errors, omissions or contradictions will also be appreciated. This District Health Plan is intended to give a course of action for the district health system and services rendered during the early recovery phase and beyond. This plan does not aim at restricting the health actions by different stakeholders if they are in line with the government policies and district needs. However, the health partners are encouraged to obtain directions from this document while planning their health activities in the district and provide assistance in the implementation of proposed actions directly communicating and collaborating with the DoH/AJK. 16 November 2006
th
Table of Contents
Acronyms .................................................................................................................................... 2 Acknowledgments...................................................................................................................... 4 Preface......................................................................................................................................... 5 Prologue ...................................................................................................................................... 6 Prelude ........................................................................................................................................ 7 Foreword ..................................................................................................................................... 8 Executive summary.................................................................................................................... 9 Introduction............................................................................................................................... 11 Methodology ............................................................................................................................. 12 The district health plan ............................................................................................................ 15
I II III IV V VI VII Undertaking needs analysis and prioritization.......................................................................15 Formulation of objectives and targets.....................................................................................20 Designing solution interventions.............................................................................................25 Preparing the implementation plan..........................................................................................29 Identifying resources and budget ............................................................................................38 Organization and management planning ................................................................................64 Monitoring and evaluation planning ........................................................................................66
Conclusion ................................................................................................................................ 67 Annexes..................................................................................................................................... 68

Annex-1: District Health Profile.......................................................................................................69 Annex-2: Organizational chart - DHO office Bagh ........................................................................71 Annex-3: Human resources.............................................................................................................72 Annex-3.1: Health staff - DHO office ........................................................................................72 Annex-3.2: Health staff and health facilities .............................................................................73 Annex-3.3: Health staff - DHQ hospital ....................................................................................74 Annex-4: ERRA plan.........................................................................................................................76 Annex-5: Assessment of public health facilities - 2006 ---- a summary report ..........................81 Annex-6: List of prefab / pre-engineered health facilities District Bagh..................................83 Annex-7: Who is doing what and where? ......................................................................................84 Annex-8: Maps ..................................................................................................................................87 Annex-8.1: Map - Administrative division of the District ...........................................................87 Annex-8.2: Map - All categories of health facilities ..................................................................88 Annex-8.3: Map - Prefab HFs constructed by UN & INGOs ....................................................89 Annex-8.4: Map - Prefab / pre-engineered BHUs and RHCs constructed by WHO ................90 Annex-9: Gantt chart format for proposed activities ....................................................................91
District Health Plan - Bagh/AJK (2006-07)
Acronyms
S. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Acronym AC A/C A&E AIMS AJK/AJ&K AKDN ARI BHU BOD C CBA CBI CBR CD CDC CDRS CH CME CMH Col CP (H) CPR DALY DCO DDHO DEWS DGHS DHMT DHO DHP DHQ DHQH DHS DoH DOTS DPIU DRU Ds Dr. DSI EDO EDO (H) EmONC Detail Air Conditioner Activity Accident & Emergency Abbas Institute of Medical Sciences Azad Jammu and Kashmir Aga Khan Development Network Acute Respiratory Infection Basic Health Unit Burden of Diseases Curative Child Bearing Age Community Based Initiatives Community Based Rehabilitation Civil Dispensary Community Development Committee Comprehensive Disaster Response Services Civil Hospital Continuous Medical Education Combined Military Hospital Colonel Chief Planning (Health) Contraceptive Prevalence Rate Disability Adjusted Life Years District Coordination Officer Deputy District Health Officer Disease Early Warning System Director General Health Services District Health Management Team District Health Officer District Health Plan/Planning District Headquarter District Headquarter Hospital District Health System Department of Health Directly Obscured Treatment Short course District Programme Implementation Unit District Reconstruction Unit Days Doctor District Sanitary Inspector Executive District Officer Executive District Officer (Health) Emergency Obstetrics and Neonatal Care S. No. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 Acronym EPI EPR EQ ERRA FHT FLCFs FAPs FMT FP H&D HEO HFs HLS HMIS HR ICRC IDD IHD IMCI IMR IRC INGOs Km LBs LIDs LG&RD LHS LHV LHW LSS M M&E MCH MCHC MI MIS M&F MMR MO MoH Ms MS MT Detail Expanded Programme of Immunization Emergency Preparedness & Response Earthquake Earthquake Reconstruction and Rehabilitation Authority Female Health Technician First Level Care Facilities First Aid Posts Female Medical Technician Family Planning Health and Development Health Education Officer Health Facilities Healthy Life Styles Health Management Information System Human Resource International Committee of Red Cross Iodine Deficiency Disorder Ischemic Heart Disease Integrated Management of Childhood Illness Infant Mortality Rate International Rescue Committee International Non Governmental Organizations Kilometer Live Births Local Immunization Days Local Government and Rural Development Lady Health Supervisor Lady Health Visitor Lady Health Worker Logistic Support System Management Monitoring and Evaluation Maternal and Child Health Maternal and Child Health Centre Micronutrients Initiative Management of Information System Male and Female Maternal Mortality Ratio Medical Officer Minister of Health Miss / Mrs. Medical Superintendent Medical Technician
S. No. 87 88 89 90 91 92 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114
Acronym NCDs NCHD NGO NIH NP NRSP NWFP O&T O&M OPD ORT P Ps PC-1 PIMA PHC PHC/FP PHC/NP PHE PL PM PO POL QALY RH RHC RTI
Detail Non Communicable Diseases National Commission for Human Development Non-Governmental Organization National Institute of Health National Programme National Rural Support Programme North West Frontier Province Objectives and Targets Organization and Management Out Patient Department Oral Rehydration Therapy Preventive Persons Planning Commission Performa No. 1 Pakistan Islamic Medical Association Primary Health Care Primary Health Care/Family Planning Primary Health Care/National Programme Public Health Engineering Pregnant Ladies Programme Manager Planning Officer Petrol Oil and Lubricants Quality Adjusted Life Year Reproductive Health Rural Health Center Respiratory Tract Infection
S. No. 115 116 117 118 119 120 121 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142
Acronym S&M SHS SIAs SMART SNE SOPs SPO SWOT TB TBA THQ THQH TORs TOT TSI TT TV UC UN UNICEF UNFPA Vit. WFP WHO WMO WR WPT
Detail Supervision and Monitoring School Health Service Supplementary Immunization Activities Specific, Measurable, Achievable, Realistic, Time bound Schedule of New Expenditure Standard Operating Procedures Senior Planning Officer Strengths, Weaknesses, Opportunities, Threats Tuberculosis Traditional Birth Attendant Tehsil Headquarter Tehsil Headquarter Hospital Terms of Reference Training of Trainers Tehsil Sanitary Inspector Tetanus Toxoid Television Union Council United Nations United Nations Children Fund United Nations Population Fund Vitamin World Food Programme World Health Organization Workmen Medical Officer WHO Country Representative Water Purifying Tablets
Acknowledgments
The District Health Plan of Bagh is an insightful joint venture of the DHMT Bagh, with technical support by WHO. The planning process started with the District Health Planning Workshop and concluded on this product that provides realistic illustration of the most rampant health problems of the area and their most optimal solutions. I want to express my special thanks to Maj. General Abdul Malik Secretary Health AJ&K, Dr Muhammad Qurban Mir DG Health and Dr Shabbir Dar Chief planning for health who provided leadership and extended every possible support in finalizing the plan. My sincere gratitude for all of the health partners, especially for HE Dr Khalif Bile Mohamud WR Pakistan and Dr Rayana Bouhaka WHO Operations Officers who helped us in hard times and provided us with technical and material support. I am grateful for the sincere efforts of my team in preparation of this district health plan, especially: 1. 2. 3. 4. 5. Dr. Muhammad Tariq Khan, Deputy DHO Bagh Dr. Masood Bukhari, MS DHQ Hospital Bagh Mr. Akhtar Mehmood Dar, District Planning Officer Health Mr. Javed Akber, District Health Education Officer Mr. Muhammad Tayab, Computer operator
My special thanks to the following WHO team for their valuable facilitation during the DHP training workshop and technical support in developing the district plan: 1. 2. 3. 4. Dr. Mohammad Mehmood Afzal Dr. Musa Rahim Dr. Haroon Rasheed Afridi Dr. Khawaja Aftab Ahmed
I truly hope that this district master plan will be helpful to address the health problems of district Bagh, AJ&K
Preface
Prologue
Prelude
Foreword
Executive summary
After the earthquake of 8th October 2005, the health sector has experienced a significant level of destruction where 65% of the health infrastructures were either destroyed or heavily damaged, with human resources loss and a near total breakdown of the health system organization in the affected areas. These broad based challenges warranted comprehensive and specific changes. In order to mitigate the sufferings and miseries, and revitalize the health services system, the reorganization of local institutions, and the support of partners under the leadership of MoH/DoH and ERRA is strongly desired. The government policy to Build Back Better has provided a chance to convert this adversity into an opportunity by undertaking a process of rehabilitation and reconstruction of the health department and accelerate the recovery and rehabilitation of service delivery. ERRAs reconstruction and rehabilitation strategy also provided a broader vision to reframe the health actions and possible partners support. In the health sector, the success of an Early Recovery Phase (ERP) is primarily determined by the level of services delivered within an appropriate infrastructure with the need of a solid District Action Plan. In order to assist governmental planning in the early recovery phase, a WHO mission visited Pakistan during May 2006. The mission met with key stakeholders and delineated a set of operational strategies. In pursuance of that, WHO assisted the government in developing a road map on District Health Planning and initiated a capacity building process of the provincial and district health authorities. Subsequent to this, the earthquake affected districts of NWFP (Abbottabad, Mansehra, Batagram, Shangla and Kohistan) and those of AJK (Muzaffarabad, Neelum, Bagh, and Poonch) developed their own District Health Plans. In this context, WHO provided the necessary technical support by deploying experts who operated in the districts and assisted in the development of these plans on a common format agreed by the departments. After extensive deliberations of the District Health Management Team (DHMT), the priority problems were identified by analyzing the available health information. The major health problems were classified into three groups i.e. those related with Preventive services, Curative services and Managerial support. The list of identified health problems in each category or group was examined within the perspectives of their magnitude, severity, population vulnerability and socio-political perceptions. A ranking of the problems potential impact was made to delineate priority consideration to be incorporated in the plan. Once the areas requiring action were identified, steps were taken to formulate objectives, targets and indicators along with marking risks for each problem consistent with the 12 months period of Early Recovery Phase. Subsequent to this, the most appropriate solution interventions were designed to attain desired objectives and targets. The mechanisms to carry out these targets were specified in the plan. In the implementation plan, each proposed solution of the identified health problems was translated into activities and each activity into sub-activities, with a feasible time frame and responsibilities. The budgeting was worked out considering the estimated cost of each sub-activity with possible identification of resources both at governmental and partners level. The SWOT analysis of the District Health System was carried out to substantiate the feasibility of the plan. The Organization and Management framework was prepared comprising of key strategic actions to improve various components of the health system in order to make it capable to solve the priority health problems. In order to carry out monitoring and evaluation of the plan, key health indicators in relation to major activities have been identified with specified baseline and projected targets.
The key stakeholders of this entire process were the District Health Management Team (DHMT), and the Health Department. The representatives of each district prepared their DHP in accordance with the above process. The plan was subsequently reviewed by the senior planning team of the respective heath department as well as ERRA, MoH and the concerned programmes. Furthermore, health partners have been oriented about the planning exercise and vital information. The DHMT and Planning cell of health departments of NWFP and AJK expressed their endorsement for these plans and commitment for its implementation. The district has identified 19 priority problems (eight of preventive nature, five of the curative domain and six related to managerial support). In order to carry out the proposed solutions and activities, the estimated cost is as mentioned below:
Currency Committed and/or expected partners support Preventive Curative Managerial Construction Government contribution Annual Govt. Health budget (DHO programmes office /HFs) budget 100,280,000 1,671,333 12,025,000 200,416 Grand total
Pak Rs USD
49,716,000 828,600
23,025,000 383,750
7,640,000 127,333
445,151,000 7,419,183
637,837,000 10,630,616
A considerable number of potential risks may constrain the implementation process i.e. limitation of financial resources, scarcity of skilled health manpower, poor managerial support, inability to integrate the health gains, obtained during the relief period and the occurrence of environmental hazards etc. However the optimal strategies are workable for a guide map with futuristic approach. Though there is an ambitious projection of requirement of funds for speedy execution of ongoing projects; however, resources should be optimized to address the major health problems. The important pre-requites for affective implementation of this plan include; making the health facilities fully functional, filling up the vacant posts of staff, development of human resources, implementation of HMIS as a major priority, integrating DEWS with other programmes, making time table for supervision and monitoring to prepare financial plan with quarterly review of the plan. This comprehensive district plan provides a detailed outlines on future projections of the district health system. That will allow the implementation of quality health services both at the primary and secondary health care levels. This plan will complement the provincial health plan, as efforts have been made to align it with the planned government budgetary outlays. The plan provides the opportunity to institutionalize the district planning process into the overall system and assist in bringing about an improvement in the health services. Moreover, it would be a management instrument to monitor the future developments and progress, made to ensure quality health services in the district. This plan would also serve as a success experience and role model for the other districts of the country. We need more rationalization of resources, more partnerships building and more efforts for intersectoral collaboration.
10
Introduction
Bagh district is adjoins to district Muzaffarabad that lies in its north. In the south, it borders with district Poonch. In the northwest, it is adjacent to the district Mansehra; whereas in the west is the districts of Abbottabad and Rawalpindi. The Line of control is situated in its east. Total area of the district is 1,368 Square Kilometers. Its projected population is 485,853, majority of which lives in the rural settings scattered in different small valleys, only its small proportion lives in urban settlements. Administratively the district is divided into three tehsils and 27 union councils, two municipal committees and one town committee. The overall topography of the district is mountainous. Its rural communities make their livelihood from agricultural; whereas the urban population usually earn from trading and employment. The earthquake of 8th October 2005 caused extensive damage to the health infrastructure and resultantly the health care services were severely disrupted. Federal Relief Commission estimates place the death toll at 73,000 people, while 150,000 individuals were injured and 2.8 million persons displaced. In Bagh district, 84 health facilities were destroyed or damaged in the earthquake including one DHQ Hospital, one THQ Hospital, six RHCs, 20 BHUs, 19 Civil Dispensaries and 37 First Aid Posts. As a result, the district is confronted with multiple challenges warranting comprehensive and specific responses targeting the health sector. With the transition from the Relief to the Early Recovery Phase on 1st April 2006, the district has undertaken greater responsibilities with limited resources and capabilities. The government policy to Build Back Better provides an opportunity to convert adversity into an opportunity substantiated in the revitalization of the district health system and developing prepare a plan that addresses all the current and emerging priority needs. The stipulated plan covers the following major components of the health system that were delineated by the provincial health authorities, MoH and ERRA in collaboration with WHO: 1. Revitalizing the disrupted health system 2. Revival of District Health Management structures of AJK and NWFP 3. Strengthening the planning and managerial capacity at the district and state/provincial levels; 4. Developing coordination platforms with all critical stakeholders around District Master Plans using the cluster approach; 5. Mainstreaming epidemiologic surveillance and early warning system into the regular provincial and district operations; 6. Maintaining an adequate level of functionality of essential drugs and equipment supply mechanisms; 7. Ensuring adequate levels of access and referral to secondary and tertiary care with basic diagnostic facilities; 8. Streamlining coordination among the stakeholders and promoting intersectoral collaboration; 9. Building capacity for emergency preparedness and response The current district health plan provides a sound yet flexible platform covering a range of essential health services that enable different partners and stakeholders to identify their programmatic roles and responsibilities. These choices however, need to be closely negotiated with the provincial and district health authorities to ensure complementarities and prevent duplication of services.
11
Methodology
The district health planning framework In pursuance of the ERRAs strategies for reconstruction and rehabilitation and the recommendation by the mission for early recovery phase, WHO Pakistan took the initiative to assist the health departments of AJK and NWFP for developing health plans for the earthquake affected districts. To benefit from the global knowledge base of WHO in district health planning, the DHMTs were exposed to the methodological processes and WHO guidelines pertaining to the district health planning. This planning exercise was led by the district health management core team. The latter consisted of the District Health Officer (DHO), Deputy DHO, the district planning officer, the district health education officer and the district programme managers. This team was complemented by members from the provincial health departments, planning cells, the programme managers of DRUs, and the national and international health partners operating in the district. WHO ensured the necessary requisite technical support throughout the process. As a result of this initial exercise, the following simplified planning processes were developed: 1: 2: 3: 4: 5: 6: 7: Undertaking needs analysis and prioritization Formulation of objectives and targets Designing solution interventions Preparation of an implementation plan Identifying resources and budget Organization and management planning Monitoring and evaluation planning
The DHP processes were reviewed and finalized by district and provincial teams in workshops organized for this purpose. The planning process District health planning constitutes a fundamental step in revitalizing the regular operations of the District Health System. Joint efforts were therefore carried out during this early recovery phase by WHO, ERRA, MoH/Pakistan and health departments of NWFP and AJK aimed at enhancing the planning capacity of the DHMT in the earthquake affected areas. To promote this initiative, District Health Planning workshops were conduced in Islamabad: from 04 to 07 July 2006 for NWFP from 25 to 29 July 2006 for AJK respectively. These workshops were intended to impart planning skills to the districts and provincial health teams, inculcate on operational road map for developing an evidence-based district health master plans for action. The DHP workshop for NWFP was supported by the presence of senior health officials that include Abdus Samad Khan (Secretary, Health, NWFP), Mr. Seerat Asghar (Director General, Planning, ERRA/Pakistan) and Mr. Younis Javed (Additional Secretary Health, NWFP). This workshop was attended by the health authorities from the DoH/NWFP of the affected districts i.e. Mansehra, Abbottabad, Shangla, Batagram and Kohistan; and joined by the programme managers of DRUs, key staff members from WHO. Likewise, the DHP workshop for AJK was presided by Maj. General Abdul Malik (Secretary Health, AJK) along with Dr. Qurban Mir (Director General Health Services, AJK). The workshop was attended by health authorities from DoH/AJK and those from the districts Muzaffarabad, Neelum, Bagh and Rawalakot/Poonch, in addition to the programme managers of DRUs, key staff members from WHO hubs, and the WHO operations officer. The partner agencies like UNCEF, UNFPA and some NGOs have actively participated in the AJK workshop. The UNFPA extended its technical cooperation by deputing a Programme Officer for this initiative. Moreover, the health sector team of ERRA has played a key role through their coordination and facilitation.
12
The technical sessions of the workshop were based on the above outlined seven process components of District Health Planning. Each session started with orientation presentations and illustration of the relevant tools, followed by group work and plenary sessions for consensus building. The participants were grouped according to their respective districts, complemented by provincial and NGO participants. Each group was assigned to carry out planning exercise according to the DHP processes. To accomplish the assigned task, the groups consulted the available health data of their districts and debated for the challenging health issues with the aim to generate consensus on the core health points to be incorporated in the plan. By the end of the training and planning workshops, the DHMTs developed their district plans based on nine priority health problems. The DHMTs where then advised to return to their districts and share the drafted plan with their local health partners and district authorities. In all districts, the health planning started with the review and analysis of the available health data. In each district, the DHMT consulted the available HMIS data, the data of other programmes (i.e., NP/PHC), the Human resource data, WHO assessment reports, ERRA plan for rehabilitation and reconstruction, annual budget plans and the disease pattern assessed from OPD/indoor patient records. The problems were analyzed through a process of active debate and consensus building. This exercise substantiated the significance of evidence-based decision making as an inevitable pathway for improving the performance of the district health system. The identified health problems were categorized into three operational areas i.e. preventive services, curative services and the DHS managerial support. These identified problems were analyzed and examined in relation to their magnitude, severity, population vulnerability and socio-political perception and sensitivity. A priority ranking was made by comparing the total score of each recognized problem and subsequently described in terms of its current status, its underlying causes, impact and effects on the health status of the population. This process has provided an opportunity for the DHMT to recognize the determinants of ill health and envisage a holistic approach to resolve these prevailing health problems. To pursue a problem solving framework, the planning teams embarked on a sequential exercise entailing the formulation of objectives, targets, indicators and potential risks for each problem. Subsequently the most appropriate solution interventions were designed to meet the set objectives and targets. For each proposed solution, a brief description was given in order to illustrate its implementation modalities. During this process, many innovative and practical operational strategies were evolved, discussed and incorporated in the plan. The design of these solution interventions led to the development of an implementation plan for each district. In the plan, each intervention was translated into activities and sub-activities to be carried out over a period of 12 months. In the budgeting process, the activities were classified into sub-activities and their unit cost identified. The cumulative budget for each planned activity was then indicated as a committed government allocation or a resource component expected from the collaborating health partners. To address the factors that could impede the implementation of the plan and envisage the essential pre-requisites for its success, a SWOT analysis was carried out by the planning team. As a result of this exercise, a district based organization and management framework was designed. The latter was aimed to evolve a continuing process of reassessment and problem solving. To institutionalize this process, the plan was concluded with a section on monitoring and evaluation, in which the most relevant indicators were illustrated along with their respective baseline status and target values.
13
Each district plan was subsequently reviewed by the senior planners of the AJK health department and NWFP respectively. Dr Shabbir Ahmed Dar Chief Planning (Health) AJK and Dr Sardar Mahmood Khan DHO Muzaffarabad led the review of the AJK district plans, while Mr Rahim Zada Khan Chief Planning (Health) and Mr Hafeez Ahmed Senior Planning Officer led this task for NWFP districts. The DHMT and Planning cell of health departments of NWFP and AJK expressed their commitment for the implementation of these plans and showed their dedication to institutionalize the district planning process as an integral managerial component of the district health system.
14
The district health plan

I
1.
a)
P-1
Undertaking needs analysis and prioritization

Preventive services
Priority health problems
Health problems High Incidence of water born diseases, especially diarrhoea Inadequate MCH and EmONC services Low coverage of PHC/FP services through national programme Social deprivations and unhealthy lifestyles Nutritional Deficiencies including IDD, Anaemia, and Malnutrition in women and children Absence of school health services High Incidence of scabies Low EPI coverage, especially TT among PLs/CBAs Magnitude Severity Population vulnerability +++ +++ ++ ++ Socio-political effects ++ ++ ++ +++ Total score 12 12 10 10 Priority ranking 1 2 3 4
++++ ++++ +++ +++
+++ +++ +++ ++
P-2 P-3
P-4 P-5
+++
++
+++
++
10
P-6 P-7 P-8
+++ +++ +++
+ + ++
++ +++ ++
+++ ++ +
9 9 8
6 7 8
b)
No. P-1
Problems analysis
Identified major Health problems High Incidence of water born diseases especially diarrhoea Current status of the problem Diarrhoea is 21 % of total priority disease consultations reported at FLCFs. Underlying causes o Lack of safe drinking water, Lack of awareness, Poor hygienic practices, o Damaged sanitary system o Lack of Infrastructure o Insufficient Human Resources, No residential facility for LHVs, Inadequate skills of LHV, Inadequate referral services Consequences and effects High morbidity and mortality especially among children Affected groups All the population in general and children in particular
P-2
Inadequate MCH and EmONC Services
P-3
Low coverage of PHC/FP services through national programme
Out of 26 only 6 facilities (23%) are providing MCH services. MMR 350/100000, Safe delivery access 20%, IMR 70/1000. 1 LHV per Facility No staff accommodation at premises Only one comprehensive EmONC service facility available at DHQ Out of total 362 health houses, 254 are affected No training rooms,
High maternal and neonatal deaths
Pregnant women and newborn child
o Infrastructure Destructed due to earthquake o Poor salary
Increase burden of preventable diseases and related mortalities
All population especially women and children
15
No.
Identified major Health problems
Current status of the problem stores LHWs overloaded CPR 40%
Underlying causes package for LHWs & high expectations o Population displaced o Poor resources, lack of awareness, no government policy, lack of solid waste and waste water disposal facilities
Consequences and effects
Affected groups
P-4
Social deprivation and unhealthy lifestyles
P-5
P-6
P-7
P-8
High prevalence of poverty, social deprivations, gender imbalance, unhealthy lifestyles, improper drainage system and waste disposal procedures. Nutritional 50% of mothers and o Warm Infestation, deficiencies including children are anaemic o IDD Endemic in IDD, Anaemia and 80% of population the area, Eating Malnutrition amongst having IDD (UNICEF Habits, Poverty, women and children Survey) o Non availability of Iodized salt, Lack of nutrition awareness Absence of School No school health o School health Health Service service program in service was the district functional previously as a vertical program, rather than an integrated PHC component and was discontinued High incidence of Almost 10% of o Poor hygiene and Scabies population consulted living conditions, for scabies in year unhealthy 2005 however local lifestyles and health practitioners shortage of water. estimates the burden to be much high Low EPI coverage, Among pregnant o Inadequate cold especially TT among women and CBAs, chain PLs/CBAs the TT coverage is o Insufficient Human 35% and 13% Resources respectively. o Lack of Logistics o Irregular power supply
Impact on health situation, unhealthy living conditions and surrounding cases high BOD
Whole population and especially poor communities.
Low resistance and CBAs and vulnerability to children of all infections and IDD age groups related morbidities and mortalities
Poor health status School going and health children screening of school age children
Physical and mental agony and involving more community.
Whole population and especially poor communities.
High prevalence of vaccine preventable diseases and deaths
Mother and children
2.
a)
C-1 C-2 C-3
Curative services
Health problems Inadequate specialized and general medical services High prevalence of ARI Inadequate diagnostic services at secondary and primary care levels Increased incidence of psychological and mental health disorders Magnitude +++ +++ ++ Severity +++ +++ +++ Population vulnerability +++ +++ ++ Socio-political effects +++ ++ ++ Total score 12 11 9 Priority ranking 1 2 3
C-4
++
++
++
+++
16
Health problems C-5 Inadequate dental care services in the District
Magnitude ++
Severity ++
Population vulnerability ++
Socio-political effects +
Total score 7
Priority ranking 5
b)
No. C-1
Problems analysis
Identified major Health problems Inadequate specialized and general medical services Current status of the problem Required specialist not available at the hospitals. In DHQ Bagh out of 9 sanctioned specialists positions only 5 are available. In THQ Kahuta out of 5 sanctioned specialists positions only 1 is available (attached to DHQ Bagh). In DHQ, THQs, RHCs and BHUs out of total sanctioned posts of 49 MOs only 17 are available; Out of total 22 sanctioned nurses 20 are available. Almost half (49.7%) of priority health cases reported through HMIS are of ARI. Non availability of the laboratory equipment in 50% secondary and primary health facilities Only one sanctioned filled pathologist in DHQ Bagh on deputation. In whole district out of total 10 sanctioned posts of Lab technicians 7 are filled Number of cases has increased after earthquake. No psychiatrist/ psychologist available in whole district. Underlying causes o Non availability of specialists o Low staff salary & incentives o Inadequate accommodation o Lack of quality education facilities for children o Lack of political commitment Consequences and effects Unavailability of specialized services and increase mortality /complications Affected groups Population at large
C-2
High incidence of ARI
o Inadequate PHC services, Cold weather and poor living conditions. o Lack of planning and resources, non availability of trained staff
High morbidity and mortality especially in children
Whole population and particularly children.
C-3
Inadequate diagnostic services at secondary and primary care levels
Poor diagnosis and All patients for delay in management management of of cases cases
C-4
Increased incidence of psychological and mental health disorders
C-5
Inadequate dental care services in the district
DHQ hospital sanctioned posts for dental Surgeon 3, available 2 THQ Hospital
o Social and psychological trauma, poverty and economic burden, natural disaster causing damage to property and loss of close relatives o Non availability of Dental Surgeons o Unattractive salary package o Insufficient
Social and family Population in disturbances, loss general of QALY and DALY
No dental services to the majority of population
Population at large
17
No.
Identified major Health problems
Current status of the problem sanctioned 2, available 1 RHCs sanctioned at 4, available 4,( 02 RHCs have not sanctioned Dental Surgeons/ Technicians Dental Technicians), Dental Technicians sanctioned 8, available 7
Underlying causes equipments o Damaged facilities
Consequences and effects
Affected groups
3.
a)
M-1
Managerial support
Health problems Damaged Infrastructure of the Health facilities including the DHO office and storage places Low managerial capacity of District Health office Inadequate HMIS Weak monitoring and supervisory system Poor referral and communication system Inappropriate drugs and supplies management system Magnitude Severity Population vulnerability +++ Socio-political effects +++ Total score 14 Priority ranking 1
++++
++++
M-2 M-3 M-4 M-5 M-6
+++ ++++ +++ +++ ++
+++ +++ +++ ++ ++
+++ ++ ++ ++ ++
+++ ++ +++ ++ +
12 11 10 9 7
2 3 4 5 6
b)
No. M-1
Problems analysis
Identified major Health problems Damaged infrastructure of the health facilities including DHO office and storage places Current status of the problem Buildings DHQ Hospital 01 damaged, THQ H 01 damaged, RHCs; 1 fully damaged 4 partially damaged, BHUs; 16 fully damaged 4 partially damaged, All units functional: 34 in tents, 12 prefabs, 14 in private shops / buildings and 26 in the same building No training opportunities for DHM members Underlying causes o Earthquake destruction: o Delay in reconstruction process and insufficient intermediate arrangements Consequences and effects Unavailability of health services to some areas Affected groups Population living in affected areas
M-2
Low managerial capacity of district health system
o Top down planning approach o Insufficient resources, insufficient logistic support, office working in tents under stress full working condition.
Poor management of health services and the existing staff is overburdened
Health system of the district
18
No. M-3
Identified major Health problems Inadequate HMIS
M-4
M-5
M-6
Current status of the problem Only 60% H/F are reporting, mostly delayed, incomplete or not valid. Weak monitoring and Supervision and supervisory system monitoring not done on regular basis. Only two admin vehicle on road and two off road. Insufficient funds for POL and maintenance of vehicles Poor referral and Poor communication communication Out of 15 system ambulances 8 are off road. Lack of funds for POL and maintenance, Lack of communication (telephones, Fax, emails) Inappropriate drugs Medicine available and supplies from normal budget management system allocation and AF, MSD, WHO is managed through hiring of houses. District drug inspector is present No Pharmacist in the whole district
Underlying causes o Obsolete training, less facilitation and no incentives o Over engagement of DHM in coordination and master planning activities after earthquake. Lack of supervisory tools
Consequences and effects Low quality data affecting district health planning and management Poor quality of supervision
Affected groups District Health Population
District health services
o Lack of resources and less priority to the problems
Delayed information on outbreaks and other managerial issues
Population at large
o No Permanent Warehouse. Non availability of Pharmacist, and standard drug list for facilities. Poor storage facilities at Units. Lack of proper transportation. No funds for regular sampling and drug testing from laboratories, self medication , no training of staff regarding drug management , no provision of driver for drug inspector for field visits for drug inspection
Increase drug resistance Financial burdens, Malpractices.
Ailing community
19
II
1.
P. No. P-1
Formulation of objectives and targets

Preventive services
Problems High incidence of water born diseases especially diarrhoea Objectives To Reduce morbidity and mortality due to diarrhoea and water born diseases (Hepatitis and enteric fever) by the end 2007 To provide the basic maternal health services in RHCs and BHUs, and EmONC services in all Tehsils of the district in one year period Targets o Reduce the diarrhoea and water born disease consultations in health facilities by 5% (from 21% to 16%) in one year period o To provide EmONC service from 0 to 2 centres (DHQ & THQH) and strengthening of maternal health services in 6 RHCs (100%) and 12 BHUs (60%) in one year period Indicators o % of diarrhoeal disease consultations in health facilities o Number of ORT centres established. o % of deaths due to diarrhoea o Number of secondary care health facilities providing EmONC services o % of RHCs providing maternal health services o % of BHUs providing maternal health services o % of deliveries conducted by trained /skilled personals o No and % of Maternal deaths due of obstetric complications o Number & % of health houses revitalized o Number & % of training room revitalized o Number of new LHWs inducted Risks o Non receptive Community. o Local taboos.
P-2
Inadequate MCH & EmONC services
o Inadequate infrastructure o Nonavailability of logistics o Non availability of skilled staff o Non availability of funds
P-3
Low coverage of PHC /FP services through National programme
Revitalization of NP for FP&PHC in one year.
P-4
Social deprivation and unhealthy lifestyles /
To empower the communities for the health interventions and
o Establishment of 50 % health houses on self help bases by motivating LHWs in one year period o Revitalization of 30 % training room for LHWs at their respective health facilities in one year period o Provision of logistics to 80% of health workers in one year period o Recruitment of 100 % of sanctioned vacant positions of LHWs in one year period o Implement the health and hygiene practices
o Non compliance because of less incentives to LHWs
o Number of union councils practicing health and development
o Non compliance. o Less political commitment
20
P. No.
Problems practices
Objectives promotion of healthy lifestyles in 30% union councils in one years period
Targets approach in 10 union councils in one year period
Indicators initiatives o Number of community orientation sessions in one year o Number of union councils having community organizations o % of families using iodine supplements. o %age of mothers with Hb level below 10 mg /dl o %age of children below 15 years of age with Hb level below 10 mg /dl o Percentage of families using iodized salts o No. age of women of child bearing age using folic acid and iron o No.& % of health workers/ staff trained in school health services. o No & % of schools covered with school health services during one year. o Number of health education cessions conducted regarding school health services. o Number of scabies cases reported o # and % of total consultation at facility level o Number and % of health staff trained in scabies prevention and treatment o No.& % of pregnant mothers received at least 2 doses of TT o No.& % of CBAs received at least 2 doses of TT o No.& % of children under 1 year fully immunized
Risks o Resources limitation
P-5
Nutritional Deficiencies including IDD, Anaemia & Malnutrition amongst women and children
To reduce the prevalence of iodine deficiency disorders and iron deficiency anaemia in one year period.
o To reduce anaemia from 50% to 40 % in mother & children in one year period o To reduce IDD burden from 80% to 70% in one year period
o Non compliance by the target population. o Non availability of resources
P-6
Absence of school health services
To Establish school health services as an integrated PHC component in one year period
o To provide school health services in 15% of the schools in the district in one year period
o Lack or resources o Delayed procedures
P-7
HIGH Incidence OF SCABIES
To reduce the number of reported scabies cases in the district in one year.
o To reduce the number of reported cases in all health facilities by 20% of total scabies cases reported in 2006 in one year period o To increase TT2 coverage of PLs from 35% to 50% in one year period o Increase TT2 coverage of CBAs from 13% to 40% in one year period o Increase the
o Lack of resources
P-8
Low EPI coverage especially TT among PLs/ CBAs
To improve the TT2 coverage of pregnant ladies and of CBAs in one year.
o Interrupted supply of logistics o Storage and cold chain problems o Simultaneous activities
21
P. No.
Problems
Objectives
Targets BCG coverage by 05% in one year period o To train100% of vaccinators (54 vaccinators) and 28 LHVs on EPI in one year period
Indicators o No. & % of EPI centres with cold chain equipments. o No.& % of vaccinators and LHVs trained
Risks
2.
P. No. C-1
Curative services
Problems Inadequate specialized and general medical services Objectives To improve the specialized, medical and Nursing care at DHQ & THQ hospitals by end of 2007. Targets o Recruitment of 50 % specialists against vacant sanctioned positions in DHQ and THQ hospitals in one year period o Recruitment of 50% of sanctioned vacant posts of MOs in DHQ and THQ hospital in one year period o To reduce the number of ARI cases from 21% to 15% in all age groups in one year period Indicators o Nurse bed Ratio o No of medical officers working in THQ and DHQ hospitals. o Number of specialist staff recruited and working o Doctor bed Ratio Nurse bed Ratio o No of paramedics available Risks o Nonavailability specialist medical and paramedical staff. o Nonavailability of required budget.
C-2
High prevalence of ARI
To reduce the disease burden due to ARI in the district in one year.
C-3
Inadequate Diagnostic services at secondary and primary care levels
C-4
Increased incidence of psychological and mental disorder
To improve the quality of diagnostic services in secondary level health care facilities RHCs and BHUs in one years period. To improve the mental health care through involving all of the FLCFs and DHQH in one year period.
o To improve Diagnostic services in 100 % of DHQ (01) and THQ (01) and RHCs (06) and 20% (04) of BHUs in one year period o Provision of basic mental health services through involving 100% RHCs and 60% of BHUs in one
o % of OPD cases of health facilities reporting for ARI o Number of health education and public awareness sessions conducted o Number of health staff trained in prevention and treatment of ARI. o Number of health facilities having adequate medicines for ARI Treatment. o No of required pathologists available at DHQ hospital o No. & % of labs fully equipped. o No & % of labs fully functional o Number of psychiatrist at DHQ level o No. & %age of FLCF providing psychosocial services.
o Limitation of health services o Lack of resources
o Lack of resources o Procedural delay o Non availability of technical staff
o Non availability of technical staff o Lack of resources o Procedural delays
22
P. No.
Problems
Objectives
Targets year period
Indicators o Number of facilities having trained personnel o Number of health facilities with essential psychotropic drugs o No of Dental surgeons available o No and % of Health Facilities with functional Dental Units.
Risks
C-5
Inadequate Dental care services in the district
To improve dental services at the secondary level hospitals and RHCs by end of 2007
o To strengthen the dental health and hygiene services in 100 % of secondary level hospitals (1 DHQH, 1 THQH) and 100% of RHC (06) in one year period
o Non availability of Dental Surgeons o Non availability of Budget
3.
P. No. M-1
Managerial support
Problems Damaged infrastructure of health facilities including DHO office and storage places. Objectives To Reconstruct the fully damaged buildings and technical assessment for retrofitting of partially damaged buildings in one year. Targets o Reconstruction of 30% (DHO Office Building 01, DHQH 01, THQH 02, Chest diseases Hospital Dheer Kot 01, RHCs 02, BHUs 12) of the Fully damaged HF buildings in one year period o Technical assessment of partially damaged HF buildings in one year period o To impart training to 80% DHMT members in one year period o Induction of qualified HR officer 01, IT officer 01 & Finance manager 01 in one year period o Increase HMIS reporting sites from 60% to 100% in one year period o Training of staff in one year period Indicators o No and % of HF buildings constructed o No of HF buildings technically assessed for retrofitting: Risks o Delay in construction activities o Harsh weather o Procedural Delays o Nonavailability of Technical assistance
M-2
Low managerial capacities of district health office
To strengthen to managerial capacities of district health management team by June 2007.
o No of the trained DHMT member o No of the training/ refresher courses organized for DHMT member
o Non availability of resources
M-3
Inadequate HMIS
To strengthen the HMIS in one year period.
o No & % of the health facilities reporting o % of HF reporting timely o % of HFs sending complete reports o No of the training/ refresher courses
23
P. No. M-4
Problems
Objectives
Targets
Indicators arranged o Number and % of supervisors having monthly supervisory plans. o Number and % of supervisors using monitoring checklists during the supervisory visits. o No and % of the health facilities visited by supervisors and feedback given during one month o No. & % of health facilities with ambulances. o No. & % of health facilities with telephone
Risks
Week Monitoring and supervisory system
To improve the monitoring and supervisory system in one year.
o To strengthen the supervisory capacity of the DHMT and introduce appropriate monitoring mechanisms in one year period
o Nonavailability of resources.
M-5
Poor Referral and communication system
To develop a strong referral and communication system in the district in one year.
M-6
Inappropriate drugs and supplies management system
To improve the drug and supplies management system by end 2007
o Ensure availability of Ambulances with POL at 100% of RHCs, THQ and DHQ hospital in one year period o Ensure telephone communication at 100% of RHCs and 60% of BHUs in one year period o Pharmacy management by using LSS at DHO Office and DHQH and THQH by using LSS in one year period
o Availability of resources
o No of health facilities in charges trained on essential drugs management.
o Unavailability of resources
24
III
1.
P. No. P-1
Designing solution interventions

Preventive services
Priority health Suggested solution problems interventions High Incidence of water Health awareness born diseases, especially campaigns on related diarrhoea aspects Description of solution interventions (What to do & how?) Carry out integrated health education campaigns through media, health facilities, and LHWs, and include health messages like washing hands before handling meals and after defecation, breast feeding, and use of ORS in case of diarrhoea, HLS, safe drinking water etc. Establishment of ORT Organize one ORT centre in each health facility centres in the FLCF and ensure related supplies and logistics Early diagnosis and Capacity building of health department to detect, management of diarrhoea, diagnose and manage the problems related water cholera, enteric fever and at district level and prevent their spread hepatitis Promotion of safe drinking Coordination with PHE and LG&R departments for water provision of safe drinking water, and quality control Improve hygienic Improve sanitary conditions in the community conditions and practices settings through promotion of safe disposal of solid waste and waste water Strengthening of EmONC Posting of relevant staff at DHQH and extending services in the DHQH and the EmONC coverage in THQH Kahuta through expansion in one THQH providing facilities for labour room, operation theatre, nursery and blood transfusion Strengthening of labour Identify need and procure essential equipment suits in the RHCs and required for the maternity centres/delivery units BHUs/MCHCs and ensure the availability of female health care providers through Capacity building of related Retraining of the TBAs and midwives / LHVs on health care workers modern aspects of maternal health Revitalization of damaged Revitalization of the health houses through health houses and fill up providing support to the displaced LHWs and the gaps filling of the gaps to be identified through assessment Expansion of the PHC/FP To ensure the coverage to all population through service to remaining creating new positions for LHWs and LHS, with population provision of enabling factors Adaptation of health and Adapt the CBI approach with health cantered development approach in development paradigm and orient/mobilize the the local perspectives, and authorities and stakeholders to built consensus consensus of authorities, and commitment related sectors and departments Involvement of the related Mobilize the communities and related sectors, sectors and communities organize and train them on health & development for health objectives approach Carry out health Prepare project proposals, generate local development initiatives with resources and partnerships, conduct baseline focus on healthy lifestyles survey, assess priority needs and carry out need and health promotion based activities Promotion of healthy and Promotion of use of healthy foods including all its balanced foods, use of aspects like raw materials, cooking, storage, use micronutrients, particularly etc and use of essential micronutrients like iodine. in risk groups This should focus on mother and children addressing the gender discrimination aspects and be integral part of comprehensive health education package Screening of anaemic Screening of the mother and children through mothers and children, and LHWs to identify anaemia and make intense
P-2
Inadequate MCH and EmONC services
P-3
Low coverage of PHC/FP services through national programme
P-4
Social deprivation and unhealthy lifestyles
P-5
Nutritional deficiencies including IDD, Anaemia, and Malnutrition amongst women and children
25
P. No.
Suggested solution interventions follow up Food fortification
P-6
Provision of micronutrients to pregnant and lactating woman Absence of school health Capacity building of the services FLCFs staff and include school health as integral PHC function Coordinate with education sectors on school health
Description of solution interventions (What to do & how?) follow up WFP and other partners will be contacted for the provision of fortified food /iron supplements to pregnant woman, Promote food fortification to the communities and private sector through seminars and routine health education campaigns Regular supply of iron + folic acid supplements to pregnant woman through LHWs and FLCFs
P-7
High Incidence of scabies
P-8
Low EPI coverage, especially TT among PLs/CBAs
Include school health in the TORs of the FLCFs and training the concerned staff like medical officers, LHVs, medical technicians on the school health Conduct regular meetings with the education and related sectors for promoting school health and make follow up of actions Training of school teachers Organize short course for training of school on school health teachers on all aspects of school health like health particularly health promotion, physical health, school hygiene and Education of children environmental health, health screening of children and identification of risk cases, referral, treatment of minor ailments, first aid, routine medical examination and health records of children Provision of related tools Procure and supply the school health related tools and supplies to the schools and materials like health education books, first aid and FLCFs boxes, water coolers, physical health equipment, sports items, plants and trees etc. Recruitment of School Raise SNE for the school Health Team comprising Health Team in the district of a Medical Doctor and 3 Nurses Health awareness and Carry out the health awareness on the personal promotion of personal hygiene like cleanliness hygiene Refresher training of field Training of medical and health staff on the early health staff on case diagnosis, and management and referral of skin detection and management problems Provision of drugs and Identify requirement, procure drugs and supply to supplies health facilities accordingly Strengthen routine EPI Improve routine EPI coverage through involving coverage LHWs in EPI activities, strengthening vaccine supply and streamline supervision and monitoring activities Conduct special campaigns Conduct special sessions to vaccinate the to vaccinate children and mothers, based upon the assessment results CBAs/PLs
2.
P. No. C-1
Curative services
Priority health problems Inadequate care at primary, secondary and tertiary levels Suggested solution interventions Placement of required medical and nursing/ paramedical staff through government and other means Placement of the required specialist, medical and nursing/paramedical staff through government and other means Development of multipurpose PHC workers Description of solution interventions (What to do & how?) To meet the needs and fill gaps in medical services, resources to be optimised and mobilised through govt and partners support.
C-1
Inadequate specialized and general medical services
To assess the needs and gaps in medical/curative services and make comprehensive plan, as well as optimizing all resources to provide the services for immediate care Assess the needs, make plans and facilitate multipurpose training s of health staff at PHC level
26
P. No.
C-2
High prevalence of ARI
Suggested solution interventions Replenishment of the obsolete and damaged equipment Repair and maintenance of the old/out of order equipment Ensure availability of essential skilled staff in the Health Facilities Strengthening of the capacity of health care providers and facilities for early diagnosis and management of ARI Improve referral system to link FLCFs with paediatric services in secondary care Awareness of families on ARI prevention and early detection of danger signs Capacity building and strengthening the existing diagnostic facilities in DHQH, THQH and RHCs
Description of solution interventions (What to do & how?) Conduct assessment of the existing equipment, identify needs and procure the required equipment to replenish the obsolete /damaged ones To asses the needs and organize the repair/maintenance of the repairable equipment
C-3
Inadequate diagnostic services at secondary and primary care levels
C-4
Increased incidence of psychological and mental health disorders
C-5
Inadequate dental care services in the District
Practice international/national standards and protocols of diagnostic services Integrate the mental health To include the mental health in the PHC through in the routine PHC services training of staff and LHWs and developing related tools Provision of mental health Provide the mental health care through services at DHQH establishing a unit in DHQH Mobilize other sectors Collaborate with the related NGOs and partners /partners and communities on mental health and ensure active involvement of for social interventions communities in management and follow up of cases Strengthening of dental Provision of dental units in DHQH, THQH and one health services at DHQH, RHC and recruitment of staff through government THQH and RHCs Promotion of dental Health education of the masses through health hygiene care providers, community organizations and other means
Capacity building through refresher training course of the health care providers and LHWs on ARI( its prevention, early diagnosis and management, and referral of risk cases) and provision of essential drugs Streamline referral system through provision of essential tools like refer forms, equipment, transport means, as well as retraining of the related PHC staff Health education of families having under 5 years children on prevention of ARI and detection of early signs Identify needs and replenish the obsolete equipment and provide modern equipment for the diagnostic services, Refresher training of staff engaged in diagnostic services on modern techniques and skills To comprehend and adapt the standards for quality control applicable to diagnostic services, their promotion to the related staff and monitoring
3.
P. No. M-1
Managerial support
Priority health problems Damaged Infrastructure of the Health facilities including the DHO office and storage places Low managerial capacity of District Health office Suggested solution Description of solution interventions interventions (What to do & how?) Reconstruction of damaged To construct prefab for early recovery phase and health facilities with then permanent structures of BHUs and RHCs (ref assistance of ERRA/donors :ERRA plan and pledges by other agencies) Strengthening and building of managerial and supervisory capacity of district health office Revitalization of the HMIS Improving physical capacity and managerial skills of the DHO office including IT skills and modern financial and HR management systems To assess the existing HMIS, provide tools , resources and HMIS instruments and impart trainings and re-trainings
M-2
M-3
Inadequate HMIS
27
P. No. M-4
Priority health problems Weak monitoring and supervisory system
M-5
Poor referral and communication system
Suggested solution interventions Arrange the logistics and resources through regular budget and partner agencies Introduce integrated supervisory approach Improve the referral system Provide communication facilities to the field health facilities Introduce modern management systems for drugs and supplies
Description of solution interventions (What to do & how?) Identify the needs and discuss them with government and partner agencies for streamlining the supervision and monitoring of the health services Develop and implement a system and tools for integrated supervision and monitoring Strengthen the existing referral system through coordination, logistics, supplies and trainings Provide telephone connections in THQH RHCs and BHUs, and fax in all THQH/RHCs Adapt the LSS, provide related logistics/tools and develop the skills of the health staff.
M-6
Inappropriate drug and supplies management system
28
IV
1.
Preparing the implementation plan

Preventive services
P-1: High Incidence of water born diseases, especially diarrhea

Solutions Health awareness campaigns on related aspects Activities Carry out integrated health education campaigns on water born diseases especially diarrhoea Sub activities Development of health education materials, printing and supply Training of health staff and LHWs Development of message for electronic media Launching of media campaigns through radio (FM) Launching of media campaigns through cable network Advocacy campaigns through seminars Public walks at Tehsils levels Develop project proposal for ORT centers Establishment of ORT centers in 45 FLCFs (6 RHCs, 20 BHUs,19 CDs) Development of plans and tools Refresher training of health staff Enhancing the capacity of the labs in DHQH and THQH for diagnosis of water born diseases. Logistic support to DHO office for early response. Regular monthly meetings with related sectors and partners Time frame Month 1 - 3 Responsibilities DHO and Health education officer
Month 4 onwards
Use of local media for health awareness
Month 1 - 3
Health education officer and coordinator PHC DHO and Health education officer DHO and Health education officer DHO and Health education officer DHO and Health education officer Health education officer and HFs Planning officer and Health education officer DHO and planning officer
Month 4 onwards
Month 4 onwards
Month 4 onwards Month 4 onwards Month 1 2
Establishment of ORT centers in the FLCFs
Organize one ORT centre in each health facility
Month 2 3
Early diagnosis and management of diarrhoea, cholera , enteric fever and hepatitis
Month 3 4 Month 4 onwards Month 1 onwards
DHMT DHMT DHO and partners
Month 1 onwards
Partners and DOH
Promotion of safe drinking water
Coordination with government departments and partners for provision of safe drinking water Establish quality control system through establishing district lab for water testing with mobile units
Month 1 onwards
DHO
Promotion of use of safe drinking water Improve hygienic Promote sanitation
Development of proposal and approval Procurement of equipment and supplies Training of related staff on water testing Provision of water purification tablets in risk areas Mobilization and
Month 1 2
Planning officer
Month 3 4
DHO and planning officer Planning officer DHO, planning officer and health education officer Health education
Month 3 6 Month 1 onwards
Month 1 onwards
29
Solutions conditions and practices
Activities and hygiene in the community settings with focus on safe disposal of solid waste and waste water
Sub activities orientation of the community leaders / organizations Coordination with the related departments with focus on urban areas
Time frame
Responsibilities officer
Month 1 onwards
DHO and health education officer
P-2: Inadequate MCH and EMNOC services

Solutions Strengthening of EmONC services in the DHQH and expansion in one THQH (Khautta). Activities Provision of skilled staff for EmONC services. Sub activities Placement of gynecologist at DHQ and THQ hospitals. Proposal for one new position of gynecologist for DHQH. Development of project proposal Development of project proposal Time frame Month 1 6 2007 Responsibilities DHO, UNFPA, ERRA DHO
Month 1 3
Establishment of nursery at DHQH Establishment of blood transfusion unit at THQH and strengthening of BTU at DHQH Strengthening of labour suits in DHQ and THQ hospitals
Month 1 3 Month 1 3
DHO DHO
Strengthening of labour suits in the RHCs an BHUs / MCHCs
Make assessment, plan and supply of essentially required equipment
Capacity building of related health workers
Capacity building of related health care providers on modern techniques of maternal health
Assessment and Provision of required equipment Provision of required staff Provision of regular supplies Need based proposal development for strengthening of maternal services Procurement and provision of equipment for 6 RHCs Procurement and provision of equipment for 10 BHUs/MCHCs Refresher training of TBAs Provision of new delivery kits to TBAs Refresher training of LHVs and midwives
Month 4 - 6
DHO, UNFPA, ERRA DGHS and UNFPA DHO DHO, UNFPA, UNICEF and WHO
Month 4 onwards Month 4 onwards Month 1 2
Month 3 onwards
UNICEF, UNFPA and WHO
Month 3 onwards
UNICEF, UNFPA and WHO
Month 1 onwards Month 1 onwards Month 1 onwards
DHMT and partners DHO and partners DHMT and partners
P-3: Low coverage of PHC/FP services through National Programme

Solutions Revitalization of damaged health houses and fill up the gaps Activities Need based construction of damaged health houses Sub activities Assessment and proposal writing Time frame Month 1 Responsibilities DHO office with the assistance of WHO, UNFPA, UNICEF and ERRA UNFPA and other partners National Programme for PHC/FP , WHO
Construction to replace the damaged health houses Provision of logistics
Month 2 onwards
Month 4 onwards
30
Solutions Expansion of the PHC /FP services to remaining population
Activities Recruitment of new LHWs for un covered population
Sub activities Need assessment and project proposal Ad-hoc arrangement through alternative means
Time frame Month 1 Month 2 onwards
Responsibilities and UNFPA Coordinator PHC and DHO DHO, UNICEF and partners
P-4: Social deprivations and unhealthy lifestyles

Solutions Adaptation of health and development approach in the local perspectives, and consensus of related/local authorities, and departments Involvement of the related sectors and communities for health objectives Activities Adapt and promote CBI approach for health and development Sub activities Development of concept paper and implementation plan by adapting of the H&D model of CBI in local perspectives Orientation to district stakeholders for consensus building Orientation and mobilization of the health and local representatives at union council level Orientation to the communities on the H&D approach Mobilizing the committees in organizing their committees Identify priority needs through baseline survey and situation analysis procedures Development of need based proposals Time frame Month 1 2 Responsibilities Planning officer with support of WHO
Month 3 4
DHO, MOH and WHO Planning officer with support of WHO/partners
Conduct orientation sessions for the health facilities, and community leaders at local levels Mobilize and organize the communities
Month 3 4
Month 5 6
Month 5 6
Planning officer and HFs with support of partners Planning officer and HFs with support of WHO Planning officer, HFs and community organizations Communities with support of local health staff and partners Communities and DHMT Communities and local focal points
Carry out health development initiatives with focus on healthy lifestyles and health promotion
Implement need based intervention for health and development
Month 6 - 8
Month 9 - 10
Identify and mobilize local resources and partners Implement projects
Month 9 onwards
Month 10 onwards
P-5: Nutritional Deficiencies including IDD, Anaemia, and Malnutrition amongst Women and Children
Solutions Promotion of healthy and balanced foods, and use of micronutrients, particularly in risk groups Screening of anaemic mothers and malnourished children, and follow up Activities Impart health education through health facilities, LHWs and health committees Sub activities Development of health education materials Orientation and refresher trainings of health care providers and communities Training of LHWs Time frame Month 1 3 Responsibilities DHO and Health education officer assisted by WHO Health education officer
Month 3 onwards
Identification, referral and follow up of the anaemic and malnourished cases Provision of micronutrients to
Month 2 3
Provision of screening tools Regular supply of iron + folic acid
Month 3 Month 3 onwards
Coordinator NP/PHC and health education officer DHO assisted by WHO DHO/DGHS and partners
31
Solutions
Activities pregnant and lactating woman
Food fortification
Mobilization all possible resources through coordination with the WFP, food department etc. and others private sector for food fortification initiatives
Sub activities supplements to pregnant woman through LHWs and FLCFs Regular follow up of the malnourished children Coordination meetings with the partners and resources mobilization Orientation and awareness of the private sector for food fortification through conducting seminars
Time frame
Responsibilities
Month 4 onwards
Month 1 onwards
Coordinator NP/PHC, LHS and LHWs DHO and health education officer
Month 4 onwards
Health education officer
P-6: Absence of school health services

Solutions Capacity building of the FLCFs staff and include school health as integral PHC function Activities Include school health as an essential part of PHC Sub activities Appoint a focal point in the DHO office for school health Develop a school health services plan including protocols Orientation and training of medical/health staff of FLCFs on school health Share the school health proposal with education department and agreement Regular meetings to review progress Develop a training plan Develop/adapt training materials and their printing Development of TOTs Organize training course in collaboration with education departments Identify requirements, and develop joint proposal with education department Procure and supply of related materials Get sanction for the required positions Time frame Month 1 Responsibilities DHO
Month 2 3
FP/SH
Month 3 4
FP/SH and DHMT
Coordinate with education sectors on school health
Collaborate with the education sector for effective school Health services
Month 3 4
DHO
Month 4 onwards Month 2 3 Month 1 3
DHO and FP/SH FP/SH FP/SH
Training of school teachers on school health
Organize short courses for school teachers
Month 4 Month 5 onwards
DHMT FP/SH
Provision of related tools and supplies to the schools and FLCFs Appoint School Health Team in District
Procure and supply of school health related tools and materials
Month 3 - 5
DHO and DHMT
DHO and partners DHO
Recruit 1 Medical, 3 School Health Nurses
P-7: High Incidence of scabies

Solutions Health awareness Activities Carry out the health Sub activities Integrate with health Time frame Month 1 onwards Responsibilities DHMT
32
Solutions and promotion of personal hygiene Refresher training of field health staff on case detection and management
Provision of drugs and supplies
Activities awareness on the personal hygiene Training of medical and health staff on the early diagnosis, management and referral of skin problems Ensure availability of essential drugs and supplies
Sub activities education campaigns (as referred before) Develop training plan Arrange training and other necessary material Conduct trainings Identify needs and develop plan Arrange/procure drugs and supplies and disseminate to facilities
Time frame
Responsibilities
Month 1 2 Month 3
DHMT DHMT
Month 3 - 5 Month 2 3 Month 4 onwards
DHMT DHMT DHO and partners
P-8: Low EPI coverage, especially TT among PL/CBAs

Solutions Strengthen routine EPI coverage Activities Strengthening routine EPI coverage Sub activities Train LHWs on EPI vaccination Develop and implement vaccination plan for LHWs Monitoring through LHS, facilities in charge and supervisory staff Identify weak areas/pockets Develop SIA, out reach and mobile vaccination plans Arrange logistics required for SIAs Conduct SIAs for vaccination, especially TT Time frame Month 1 3 Month 3 onwards Responsibilities EPI coordinator EPI and PHC coordinator
Month 4 onwards
PHC coordinator
Conduct special campaigns to vaccinate children and CBAs/PLs
Conduct special sessions to vaccinate the mothers, based upon the assessment results
Month 1 3 Month 4
EPI coordinator EPI coordinator
EPI coordinator EPI coordinator
2.
Curative services
C-1: Inadequate specialized and general medical services

Solutions Placement of the required specialist, medical and nursing/Paramedi c staff through government and other means Activities Ensure availability of all essential specialist services at the DHQH and THQH Sub activities Make assessment of the needs and gaps in specialist services including the related medical and nursing and paramedical services Prepare a plan and proposal to fill up the gaps and submit proposal Make arrangement for temporary phase with support of partners Need assessment Training and logistic plans Time frame Month 1 2 Responsibilities DHMT
Month 3
DHO and DHMT
Month 3 onwards
DHO and partners
Development of multipurpose PHC workers
Capacity building of all health staff in all important components of PHC
Month 1 2 Month 3
DHMT and coordinator PHC DHO and DHMT
33
Solutions
Activities services
Replenishment of obsolete and damaged equipment Repair and maintenance of the old/out of order equipment Ensure availability of essentially skilled professional staff in the health facilities
Ensure replacement of the damaged equipment Optimize the available equipment resources
Ensure availability of essential professional staff for/in all health facilities
Sub activities Conduct training sessions Monitoring and evaluation Identify needs and prepare plan Procure/arrange the necessary equipment Develop/adapt repair and maintenance protocols and plans Implement the protocols and plans Make needs assessment and the plan Fill up vacant positions and move SNEs for additional requirements Develop special packages for staff working in hard and difficult to reach areas with a special focus on female staff Stop gap arrangement with support of partners
Time frame Month 4 onwards Month 5 onwards Month 1 2 Month 3 4 Month 2 4
Responsibilities DHO and DHMT DHMT DHO and DHMT DHO, DOH and partners DHO and DHMT
Month 5 onwards Month 1 2
DHO and DHMT DHMT
Month 3 - 6
DHO and DOH
Month 1 3
DOH
Month 1 onwards
DHO, DOH and partners
C-2: High prevalence of ARI

Solutions Strengthening the capacity of health care providers and facilities for early diagnosis and management of ARI Activities Capacity building of the health staff on ARI Sub activities Adaptation of training materials and tools and printing Development of master trainers Refresher trainings of Health staff of facilities and LHWS Procurement and provision of essential drugs Provision of tools/forms for referral of ARI cases Provision of related equipments (Ref to other related activities) Time frame Month 1 2 Responsibilities DHO with assistance from consultants of DHQH/WHO DHO with assistance from consultants of CMH DHO
Month 2 3
Month 3 5
Month 5 - 6
DGHS and DHO
Improve referral system to link FLCFs with paediatric services in DHQH
Streamline referral system
Month 3
DHO
Month 5 onwards
DHO and partners
C-3: Inadequate diagnostic services at secondary and primary care levels

Solutions Capacity building and extending the existing diagnostic facilities in DHQH, THQ and RHCs Activities Build the physical and technical capacity of the existing diagnostic units of the health facilities Sub activities Identify needs and prepare plan Procure and supply the required equipment Refresher training of the technical staff Time frame Month 1 3 Month 3 - 6 Responsibilities DHMT DHO and partners
Month 6 - 7
DHO and partners
34
Solutions Practice international/natio nal standards and protocols of diagnostic services
Activities Ensure quality control in diagnostic services
Sub activities Adapt and disseminate the standard protocols for quality diagnostic services Develop and implement M & E plan
Time frame Month 6 - 7
Responsibilities DHO and partners
Month 8
DHMT
C-4: Increased incidence of psychological and mental health disorders

Solutions Integrate the mental health in the routine PHC services Activities Include mental health as an integral part of PHC Sub activities Needs assessment and develop a plan Develop/adapt related tools and materials Orientation and training of the PHC staff and LHWs on mental health Recruitment of psychiatrist and psychologist with support of partners Move SNE (proposal) for psychiatrist through DGHS Procurement and provision of essential drugs and supplies Orientation of the partners and stakeholders on the technical and social aspects of the mental health problems Involvement of the communities in social actions and follow up of the cases Time frame Month 1 2 Month 3 5 Month 6 onwards Responsibilities DHMT DHMT with support of partners DHMT with support of partners
Strengthening of mental health services at DHQH
Provision of additional support to strengthen and Improve the mental health care at DHQH
Month 1 3
DHO and partners
Month 3
DHO
Month 3 - 5
DHO and partners
Mobilize other sectors /partners and communities for social interventions
Collaborate with partners and stakeholders on mental health issues and related interventions
Month 1 3
DHO and partners
Month 3 onwards
DHMT and HFs
C-5: Inadequate dental care services in the District

Solutions Strengthening of dental health services at DHQH, THQH and RHCs Activities Provision of dental units in the DHQH, THQH and one RHC Sub activities Assess of the need and make plans Procurement and installation of dental units including instruments Placement of one dental surgeon on temporary basis through support of partners Move SNE (proposal) for new post of two dental surgeons and 2 dental technicians Time frame Month 1 3 Month 3 - 6 Responsibilities DHMT DHO, DOH and partners
Provision of professional and technical staff in one Tehsil head quarter hospital and one RHC
Month 1 - 3
DHO and partners
Month 3
DHO
35
3.
Managerial support
M-1: Damaged Infrastructure of the Health facilities including the DHO office and storage places
Solutions Reconstruction of damaged health facilities with assistance of ERRA/donors Activities Make stop gap arrangement for continuation of PHC services in the areas having damaged health facilities Sub activities Plan and construct prefab health facilities in the identified area Procure and supply of equipment, furniture, drugs and supplies Posting of essential health staff in the prefab facilities Plan and construct permanent facilities in place of damaged facilities Procure and supply of equipment, furniture, drugs and supplies Posting of essential health staff in the permanent facilities Time frame Month 1 onwards Responsibilities DHO, ERRA and WHO ERRA and WHO
Month 1 onwards
Month 1 onwards
DHO and DOH
Construct permanent structures in place of damaged health facilities
Month 1 onwards
DHO, ERRA and partners
Month 1 onwards
ERRA and partners
Month 1 onwards
DHO and DOH
M-2: Low managerial capacity of District Health office

Solutions Strengthening and building of managerial and supervisory capacity of district health management Activities Improvement of the physical capacity of District Health Management Enhance managerial skills of health staff of District health Management Sub activities Provide essential equipment and furniture for the DHO office Need assessment of DHMT skill development Training of DHMT in public health management and office tools (short and long term courses) Move proposal for additional skilled / technical staff for district health office Adhoc arrangement of managerial staff through partners support Time frame Month 1 3 Responsibilities DOH and Partners
Month 1 - 2
DOH and partners
Month 3 6
DOH and Partners
Month 3
DHO
Month 3 6
DHO and partners
M-3: Inadequate HMIS

Solutions Revitalization of the HMIS Activities Improve the coverage of HMIS reporting Sub activities Assessment of present HMIS to identify the shortfalls Provision of tools/ instruments Provision of resources Training of health staff Time frame Month 2 Responsibilities DHMT
Month 1 - 3 Month 2 - 3 Month 4 onwards
DHO/WHO Partners Partners
36
M-4: Weak monitoring and supervisory system

Solutions Arrange the logistics and resources through regular budget and partner agencies Activities Optimize the available resources and work out the feasible options for supervision and monitoring Sub activities Needs assessment and develop M&E plan Approach government for the required resources Mobilize partners for support M&E plans Make supervisory checklist and other tools for joint supervision Prepare plans for integrated supervision Additional financial support for operational expenditure Time frame Month 2 3 Responsibilities DHO and DHMT
Month 4 onwards
DHO
Month 4 6 Month 3 4
DHO DHO and DHMT
Introduce integrated supervisory approach
Develop and implement a system and tools for integrated supervision and monitoring
DHO and DHMT DOH and partners
M-5: Poor referral and communication system

Solutions Improve the referral system Activities Strengthen the existing referral system Sub activities Coordination with partners and facilities for referral system for optimizing the resources Development of referral network with earmarked linkages between RHCs and BHUs/CDs/FAPs Install telephone connections in 6 RHCS and 20 BHUs and fax in all THQH/RHCs Time frame Month 2 3 Responsibilities DHO
Month 2 4
DHO with support of partners
Provide communication facilities to the field health facilities
Establishment of communication between health facilities and health mangers
Month 2 onwards
DHO with support of partners
M-6: Inappropriate drugs and supplies management system

Solutions Introduce modern management systems for drugs and supplies Activities Develop and implement the modern LSS for drugs and supplies Sub activities Adaptation of LSS being used by WHO/MoH for district and local use Provide related logistics and tools Training of the related staff on LSS Time frame Month 1 Responsibilities WHO
Month 2 onwards Month 2 onwards
WHO and partners WHO and partners
37
V
1.
Identifying resources and budget

Preventive services
P-1: High Incidence of water born diseases, especially diarrhea

Solutions Health awareness on prevention of water born disease Health awareness campaigns on related aspects Activities Sub-activities Description Develop health education material Health education packages for 40,000 house holds 22 training sessions with 30 participates each for one day 5 messages Current resource status Quantity Available Gap required 1 0 Unit price 1 5,000 Total Government Requirement allocation 5,000 0 Expected and/or Potential committed source of partners support funding 5,000 Partners
Health awareness Develop and campaigns print health through LHWs education materials Carry out integrated health education campaigns on water born diseases especially diarrhea Development of health education materials, printing and supply Training of health staff and LHWs
40,000
40,000
200,000
200,000 Partners
22
22
15,000
330,000
330,000 WHO,UNICE F,IRC
Use of local media for health awareness
Development of message for electronic media Launching of media campaigns through radio (FM)
5,000
25,000
Launching of media campaigns through cable network Advocacy campaigns through seminars Public walks at Tehsils levels
360 times for 2 minutes each message (3 times per day for 4 months) 200 times 2 minutes each
360
360
2,000
720,000
25,000 WHO, UNICEF, IRC 720,000 WHO,UNICE F, save the children, OXFAM, IRC
200
200
500
100,000
6 seminars
6,000
36,000
6 walks at Tehsil level, needs banner,
3000
18,000
100,000 WHO, UNICEF, save the children, OXFAM, IRC 36,000 WHO,UNICE F, save the children, OXFAM, IRC 18,000 WHO, UNICEF, save the children, OXFAM, IRC
38
Solutions Establishment of ORT centers in the FLCFs
Activities Organize one ORT centre in each health facility
Sub-activities Develop project proposal for ORT centers Establishment of ORT centers in 45 FLCFs (6 RHCs, 20 BHUs,19 CDs)
Description Prepare a need based project proposal Procure and supply essential furniture, accessories etc (ORS for all ORT centers will be provided by DHO Office) Prepare project proposal and Tools, recording register: 50 and reporting forms: 50 books 2 sessions x 1 day x 25 P Strengthenin g 2 lab units with lab supplies, refrigerators 2, related investigation kits: 2 POL and per-diem support
Current resource status Quantity Available Gap required 1 0
Unit price 1 0
Total Government Requirement allocation 0 0
Expected and/or Potential committed source of partners support funding 0 DHO
45
45
15,000
675,000
675,000 Seek partners
Early diagnosis and management of diarrhoea, cholera , enteric fever and hepatitis
Development of plans and tools
100
100
200
20,000
20,000 Partners
Refresher training of health staff Enhancing the capacity of the labs in DHQH and THQH for diagnosis of water born diseases.
12,500
25,000
25,000
75,000
150,000
150,000 Partners
Promotion of safe drinking water
Coordination with government departments and partners for provision of safe drinking water Establish quality control system
Logistic support to DHO office for early response. Regular monthly Refreshment meetings with for meetings related sectors and partners
100,000
100,000
100,000 Partners
12
12
500
6,000
6,000
Development of proposal and
Prepare a project
50,000
50,000
50,000
39
Solutions
Activities through establishing district lab for water testing with mobile units
Sub-activities approval
Description proposal consultancy (short term 1) Procure essential equipment for lab 1 week training for 10 participates Water purifying tablets for 1.5 liters 3 seminars (2 in each Tehsil), 50 participates each District Coordination committee, one per month.
Current resource status Quantity Available Gap required
Unit price
Total Government Requirement allocation
Expected and/or committed partners support
Potential source of funding
Procurement of equipment and supplies Training of related staff on water testing
300,000
300,000
300,000
70,000
70,000
70,000
Promotion of use of safe drinking water
Improve hygienic conditions and practices
Promote sanitation and hygiene in the community settings with focus on safe disposal of solid waste and waste water
Provision of water purification tablets in risk areas Mobilization and orientation of the community leaders / organizations Coordination with the related departments with focus on urban areas
1,000,000
1,000,000
2,000,000
2,000,000
5,000
15,000
15,000
12
12
500
6,000
6,000
0 DHO
Sub-total P-1:
4,851,000
12,000
4,839,000
P-2: Inadequate MCH and EMNOC services

Solutions Strengthening of EmONC services in the DHQH and expansion in one THQH. Activities Provision of skilled staff for EmONC services. Sub-activities Placement of gynecologist at DHQ and THQ hospitals. Description Recruit 2 gynecologist with addition incentives for one year at Rs. 45000/m (45000 x 12= Rs 540,000) (2 gynecologist s are budgeted by Current resource status Quantity Available Gap required 2 0 Unit price 2 720,000 Total Government Requirement allocation 1,440,000 360,000 Expected and/or Potential committed source of partners support funding 1,080,000 Partners
40
Solutions
Activities
Sub-activities
Description
Unit price
Establishment of nursery at DHQH
Establishment of blood transfusion unit at THQH and strengthening of BTU at DHQH
Strengthening of delivery suites in DHQ and THQ hospitals
Govt. @ 15000 each per month with additional incentives 45000/m each for the 2 gynecologist s.) Proposal for one Forward new position of SNE to DG gynecologist for health for DHQH. sanctioning of 1 new post of gynecologist, (Short term arrangement ) Development of Prepare a project proposal project proposal for establishme nt of nursery at DHQH Procurement of Essential blood equipment transfusion unit and supplies at DHQH and for 2 blood THQH units SNE for Staffing 1 x blood (Blood transfusion transfusion officer, 1x officer in DHQH blood & blood transfusion transfusion technician technician in for 12 THQH) months and support staff Assessment 2 delivery and Provision of tables x 2 required OT tables x equipment 2 vacuum extractors x 2 anesthetic package x 2
720,000
720,000
720,000 DHO / MS + Partners
0 DHO
1,000,000
2,000,000
2,000,000
240,000
240,000
240,000 Partners
1,000,000
2,000,000
2,000,000 Seek partners
41
Solutions
Activities
Sub-activities
Description incubators x 2 oxygen delivery sets & other necessary equipment. Local adjustments Essential supplies on contingency bases Make assessment and prepare document
Unit price
Provision of required staff Provision of regular supplies
1 1
0 0
1 1
0 200,000
0 200,000
0 0
0 DHO and MS 200,000 Seek Partners
Strengthening of labour suits in the RHCs an BHUs / MCHCs
Make assessment, plan and supply of essentially required equipment
Need based proposal development for strengthening of maternal services Procurement and provision of equipment for 6 RHCs Procurement and provision of equipment for 10 BHUs/ MCHCs
25,000
25,000
Capacity building of related health workers
Capacity building of related health care providers on modern techniques of maternal health
Provision of need based equipment and supplies Need based equipment and supplies (6 delivery tables will be provided by DHO office) Refresher Retraining of training of TBAs 100 TBAs for 2 weeks in 5 sessions Provision of new 100 delivery kits to disposable TBAs kits containing essential supplies Refresher 30 training of LHVs LHVs/Midwiv and midwives es, 3 days/ session
120,000
720,000
10
10
35,000
350,000
350,000 Partners
60,000
300,000
300,000 Partners
2,000
2,000
200
400,000
400,000 Partners
55,000
55,000
55,000 Partners
Sub-total P-2:
8,450,000
360,000
8,090,000
42
P-3: Low coverage of PHC/FP services through National Programme

Solutions Revitalization of damaged health houses and fill up the gaps Activities Need based construction of damaged health houses Sub-activities Assessment and proposal writing Description Current resource status Quantity Available Gap required 1 0 Unit price 1 0 Total Government Requirement allocation 0 0 Expected and/or Potential committed source of partners support funding 0 DHO and partners
Expansion of the PHC /FP services to remaining population
Recruitment of new LHWs for un covered population
Situation analysis and prepare document Construction to facilitation to replace the LHWs in damaged health reconstructio houses n of 254 health Houses Provision of Regular logistics supplies and reporting tools Need Situation assessment and analysis and project proposal prepare document Ad-hoc arranging of arrangement 100 CHW through alternative means
254
254
100,000
25,400,000
25,400,000 Partners
362
362
10,000
3,620,000
3,620,000
0 NP/PHC
5,000
5,000
5,000 Seek partners
100
100
3,000
300,000
300,000 Partners like UNICEF
Sub-total P-3:
29,325,000
3,620,000
25,705,000
P-4: Social deprivations and unhealthy lifestyles

Solutions Adaptation of health and development approach in the local perspectives, and consensus of authorities, related sectors and departments Activities Adapt and promote CBI approach for health and development Sub-activities Development of concept paper and implementation plan by adapting of the H&D model of CBI in local perspectives Orientation to district stakeholders for consensus building Description Prepare document Current resource status Quantity Available Gap required 1 0 Unit price 1 0 Total Government Requirement allocation 0 0 Expected and/or Potential committed source of partners support funding 0 Partners
Seminar of district stake holer,1 session, 1 day,50 participants
15,000
15,000
15,000
43
Solutions Involvement of the related sectors and communities for health objectives
Activities Conduct orientation sessions for the health facilities, and community leaders at local levels Mobilize and organize the communities
Sub-activities Orientation and mobilization of the health and local representatives at union council level Orientation to the communities on the H&D approach Mobilizing the committees in organizing their committees.
Description 10 orientation session , 1 day, 10 union council up to 50 participants Community session through health facilities Facilitate community organization through health facility in charges Survey activity through surveyor and supervisors Develop proposal documents Advocacy and mobilization of resources from donors and partners implementati on plan and above mentioned budget
Current resource status Quantity Available Gap required 10 0 10
Unit price 5,000
Total Government Requirement allocation 50,000 0
Expected and/or Potential committed source of partners support funding 50,000 Seek partners
10
10
5,000
50,000
10
10
2,000
20,000
Carry out health development initiatives with focus on healthy lifestyles and health promotion
Implement need based intervention for health and development
Identify priority needs through baseline survey and situation analysis procedures Development of need based proposals Identify and mobilize local resources and partners
10
10
40,000
40,0000
10
10
20,000
200,000
200,000 Government and partners 20,000 Government and partners
20,000
20,000
Implement projects
60
60
50,000
300,0000
Sub-total P-4:
3755,000
3,755,000
P-5: Nutritional Deficiencies including IDD, Anaemia, and Malnutrition in women and children
Solutions Promotion of healthy and Activities Sub-activities Description Current resource status Quantity Available Gap required 1 0 Unit price 1 500,000 Total Government Requirement allocation 500,000 0 Expected and/or Potential committed source of partners support funding 500,000 Partners
Impart health Development of Develop and education through health education print
44
Solutions balanced foods, and use of micronutrients, particularly in risk groups
Activities health facilities, LHWs and health committees
Sub-activities materials
Description brushers, pamphlets, leaflets, booklets for health workers and community 6 orientation seminars at Tehsil level
Unit price
Screening of anaemic mothers and malnourished children, and follow up
Identification, referral and follow up of the anaemic and malnourished cases
Orientation and refresher trainings of health care providers and communities Training of LHWs
5,000
30,000
30,000
Provision of screening tools
Provision of micronutrients to pregnant and lactating woman
Food fortification
Regular supply of iron + folic acid supplements to pregnant woman through LHWs and FLCFs Regular follow up of the malnourished children Mobilization all Coordination possible meetings with resources through the partners and coordination with resources the WFP, food mobilization department etc. Orientation and and private awareness of sector others for the private food fortification sector for food initiatives fortification through conducting
Training of 362 LHW, One day, 13 session Developmen t and printing of recording registers and reporting forms Supply through 365 LHWs
13
13
12,000
156,000
365
365
200
73,000
365
365
3,000
1,095,000
1,095,000
0 DHO
Monitoring plan for LHWs Quarterly coordination meeting, 4 meetings at district level 4 orientation seminars per year
0 Seek partners
1000
4,000
4,000
0 DHO
10,000
40,000
40,000 Partners
45
Solutions
Activities
Sub-activities seminars
Description
Unit price
Total Government Requirement allocation 1,898,000 1,099,000
Expected and/or committed partners support 799,000
Sub-total P-5:
P-6: Absence of school health services

Solutions Capacity building of the FLCFs staff and include school health as integral PHC function Activities Include school health as an essential part of PHC Sub-activities Appoint a focal point in the DHO office for school health Develop a school health services plan including protocols Description Local adjustment Current resource status Quantity Available Gap required 1 0 Unit price 1 0 Total Government Requirement allocation 0 0 Expected and/or Potential committed source of partners support funding 0 DHO
Coordinate with education sectors on school health
Collaborate with the education sector for effective school Health services
Orientation and training of medical/health staff of FLCFs on school health Share the school health proposal with education department and agreement
Developmen t and printing of SH Plans and protocols, printing of 200 booklets on SHS Training in1 session, 30 participants, 3 days Orientation seminar meeting at DHO Office and MoU agreement for school health services Monthly review meetings with line department/s Prepare document Printing of training materials 6 master trainers to be
200
200
100
20,000
20,000
50,000
50,000
6,000
6,000
6,000
0 DHO
Regular meetings to review progress
12
12
500
6,000
6,000 Partners
Training of school teachers on school health
Organize short courses for school teachers
Develop a training plan Develop/adapt training materials and their printing Development of TOTs
1 300
0 0
1 300
0 400
0 120,000
0 0
0 Seek partners 120,000
24,000
24,000
24,000
46
Solutions
Activities
Sub-activities
Description
Unit price
Provision of related tools and supplies to the schools and FLCFs
Procure and supply of school health related tools and materials
trained, one session, 5 days Organize Training of training course 200 school in collaboration teachers in 8 with education sessions for departments 5 days each Identify Joint requirements, proposal and develop developed in joint proposal collaboration with education with Dept. of department Education Procure and Supply supply of related package of materials essential items for school health promotion
50,000
400,000
400,000 Partners
80
80
40,000
3,200,000
3,200,000
Sub-total P-6:
3,826,000
6,000
3,820,000
P-7: High Incidence of scabies

Solutions Health awareness and promotion of personal hygiene Refresher training of field health staff on case detection and management Activities Carry out the health awareness on the personal hygiene Training of medical and health staff on the early diagnosis, management and referral of skin problems Sub-activities Description Current resource status Quantity Available Gap required 1 0 Unit price 1 0 Total Government Requirement allocation 0 0 Expected and/or committed partners support 0 Potential source of funding
Integrate with Integrate health education with related campaigns (as activity referred before) Develop training plan Arrange training and other necessary material Conduct trainings Prepare document Make essential arrangement s Integrate with other trainings Assess the diseases burden by health facility and estimate
1 1
0 0
1 1
0 0
0 0
0 0
0 0
250,000
250,000
250,000 Seek partners 0 Seek partners
Provision of drugs and supplies
Ensure availability Identify needs of essential drugs and develop and supplies plan
47
Solutions
Activities
Sub-activities
Description drug requirements by DHO office Procure anti scabies drugs and supply to 84 health facilities
Unit price
Arrange/procure drugs and supplies and disseminate to facilities Sub-total P-7:
84
84
12,000
1,008,000
1,258,000
1,258,000
P-8: Low EPI coverage, especially TT among PL/CBAs

Solutions Strengthen routine EPI coverage Activities Strengthening routine EPI coverage Sub-activities Train LHWs on EPI vaccination Description Train 100 LHWs from remote areas with low EPI coverage specially TT for 7 days in 5 sessions Develop joint plan Current resource status Quantity Available Gap required 5 0 Unit price 5 30,000 Total Government Requirement allocation 150,000 0 Expected and/or Potential committed source of partners support funding 150,000 Partners
Conduct special campaigns to vaccinate children and CBAs/PLs
Conduct special sessions to vaccinate the mothers, based upon the assessment results
Develop and implement vaccination plan for LHWs Monitoring through LHS, facilities in charge and supervisory staff Identify weak areas/pockets
Develop SIA, out reach and mobile vaccination plans Arrange logistics required for
Regular Monitoring, through involving LHS 3rd party Assessment in all union councils (28) Developmen t of Joint micro plans
120,000
120,000
28
28
10,000
280,000
0 seek partners
Prepare logistic plans for 3 rounds
300,000
900,000
900,000 SEEK partners
48
Solutions
Activities
Sub-activities SIAs
Description of SIAs provide, POL and allowances (100 mobile teams for 5 days each round, Rs 100/ day, 20 supervisors for 10 days) Conduct 3 rounds of SIAs as per requirements in the whole district
Unit price
Conduct SIAs for vaccination especially TT
0 Government
Sub-total P-8:
1,450,000
1,450,000
2.
Curative services
C-1: Inadequate specialized and general medical services

Solutions Placement of the required specialist, medical and nursing/plannin g staff through government and other means Activities Ensure availability of all essential specialist services at the DHQH and THQH Sub-activities Make assessment of the needs and gaps in specialist services including the related medical and nursing and paramedical services Prepare a plan and proposal to fill up the gaps and submit proposal Make arrangement for temporary phase with support of Description Assessment though local staff Current resource status Quantity Available Gap required 1 0 Unit price 1 0 Total Government Requirement allocation 0 0 Expected and/or committed partners support 0 Potential source of funding
Prepare document
0 DHO
Collaborate with partners for timely arrangement s
2,000,000
2,000,000
2,000,000
49
Solutions
Activities
Sub-activities partners Need assessment
Description
Unit price
Development of multipurpose PHC workers
Capacity building of all health staff in all important components of PHC services
Replenishment of the obsolete and damaged equipment
Repair and maintenance of the old/out of order equipment
Ensure availability of essentially skilled professional staff in the health facilities
Make assessment through local staff resources Training and Prepare a logistic plans plan with the support of partners Conduct training 4 sessions sessions each for 2 weeks x 25 P Monitoring and Through evaluation regular system Ensure Identify needs Make replacement of and prepare assessment the damaged plan and prepare equipment proposal Procure/arrange Need based the necessary procurement equipment and supply of equipment Optimize the Develop/adapt Hire an available repair and expert and equipment maintenance development resources protocols and of document plans Implement the Implementati protocols and on through plans routine system Ensure availability Make needs Make of essential assessment and assessment professional staff the plan and prepare at all health document facilities Fill up vacant Fill positions and sanctioned move SNEs for posts and additional prepare requirements proposal for extra needs
0 DHO
250,000
1,000,000
1,000,000
0 DHO and partners 0
3,000,000
3,000,000
3,000,000
60,000
60,000
60,000
50
Solutions
Activities
Sub-activities Develop special packages for staff working in hard and difficult to reach areas with a special focus on female staff Stop gap arrangement with support of partners
Description Collaborate with MoH and partners for additional centers
Unit price 1 4,000,000
Total Government Requirement allocation 4,000,000 0
Expected and/or committed partners support 4,000,000
Collaborate with partners for provision/po sting of staff till the approval by govt.
2,000,000
2,000,000
2,000,000
Sub-total C-1:
12,060,000
12,060,000
C-2: High prevalence of ARI

Solutions Activities Sub-activities Adaptation of training materials and tools and printing Development of master trainers Refresher trainings of Health staff of facilities and LHWS Description Printing of materials Current resource status Quantity Available Gap required 500 0 500 Unit price 300 Total Government Requirement allocation 150,000 0 Expected and/or Potential committed source of partners support funding 150,000 Partners and NP
Strengthening Capacity building the capacity of of the health staff health care on ARI providers and facilities for early diagnosis and management of ARI
Procurement and provision of essential drugs Improve referral system to link FLCFs with pediatric services in Streamline referral system Provision of tools/forms for referral of ARI cases
1 session of 6 P x 5 days Training of MOs, LHVs and paramedical staff for 3 days x 6 sessions x 25 P Need based procurement and supply of the drugs Procurement /printing and supply of registers /forms
1 6
0 0
1 6
30,000 55,000
30,000 330,000
0 0
30,000 330,000 Seek partners
1,500,000
1,500,000
60,000
60,000
51
Solutions DHQH
Activities
Sub-activities
Description
Provision of Integrated related activity equipments (Ref to other related activities)
Unit price 1 0
Expected and/or Potential committed source of partners support funding 0 Seek partners
Sub-total C-2:
2,070,000
2,070,000
C-3: Inadequate diagnostic services at secondary and primary care levels

Solutions Capacity building and extending the existing diagnostic facilities in DHQH, THQ and RHCs Activities Build the physical and technical capacity of the existing diagnostic units of the health facilities Sub-activities Identify needs and prepare plan Procure and supply the required equipment Description Prepare proposal Easylite 01, micro labs 2, sysmex hematology analyzer 1, cell pack 15, and essential supplies, Microscopes 05, computer with printer 1 Training of 10 technicians 1 session x 10 days at tertiary care hospital Hire consultant and prepare standard operating procedures for lab and disseminatio n prepare and implementati on of plan Current resource status Quantity Available Gap required 1 0 Unit price 1 0 Total Government Requirement allocation 0 0 Expected and/or Potential committed source of partners support funding 0 Partners
3,800,000
3,800,000
3,800,000 Partners
Refresher training of the technical staff
200,000
200,000
Practice international/na tional standards and protocols of diagnostic services
Ensure quality control in diagnostic services
Adapt and disseminate the standard protocols for quality diagnostic services
70,000
70,000
70,000 WHO
Develop and implement M & E plan Sub-total C-3:
0 Seek partners 4,070,000
4,070,000
52
C-4: Increased incidence of psychological and mental health disorders

Solutions Integrate the mental health in the routine PHC services Activities Include mental health as an integral part of PHC Sub-activities Description Current resource status Quantity Available Gap required 1 0 Unit price 1 0 Total Government Requirement allocation 0 0 Expected and/or Potential committed source of partners support funding 0 Partners
Strengthening of mental health services at DHQH
Provision of additional support to strengthen and Improve the mental health care at DHQH
Mobilize other sectors /partners and communities for social interventions
Collaborate with the partners and stakeholders on the mental health issues and related interventions
Needs Need assessment and assessment, develop a plan Developmen t of action plan for Integration of Mental Health in PHC, Develop/ adapt Adaptation related tools of protocol and materials and printing of tool, (100 Manuals and tools) Orientation and 600 training of the participants, PHC staff and 20 sessions, LHWs on I day mental health Recruitment of Recruit 1 psychiatrist and Psychiatrist psychologist and 1 with support of Psychologist partners at DHQ Hospital for one year (Rs 60000/m each) Move SNE for Move SNE psychiatrist for through DGHS psychiatrist Procurement Procurement and provision of of additional essential drugs Psychiatric and supplies drugs and supplies @ 50000 / month Orientation of 3 Orientation the partners and seminar at stakeholders on Tehsil level the technical 30 and social participants aspects of the mental health
100
100
200
20,000
20,000
20
20
9,000
180,000
1,440,000
1,440,000
0 MS/DHQ
600,000
600,000
600,000 Government & partners
5,000
15,000
15,000 Partners
53
Solutions
Activities
Sub-activities problems Involvement of the communities in social actions and follow up of the cases
Description
Unit price
Total Government Requirement allocation 140,000 0
Advocacy seminars for orientation of village health committees in all union councils
5,000
140,000 Government and Partners
Sub-total C-4:
2,395,000
2,395,000
C-5: Inadequate dental care services in the District

Solutions Strengthening of dental health services at DHQH, THQH and RHCs Activities Provision of dental units in the DHQH, THQH and one RHC Sub-activities Assess of the need and make plans Description Need assessment for dental care and prepare plan of action Procurement of 3 dental units (@ Rs 600000/ unit), 10 dental sets and accessories Recruit 1 Dental Surgeon @ Rs 40000 / month for one year Prepare document and disseminate Current resource status Quantity Available Gap required 1 0 Unit price 1 0 Total Government Requirement allocation 0 0 Expected and/or Potential committed source of partners support funding 0 Partners
Procurement and installation of dental units including instruments
650,000
1,950,000
1,950,000 Partners
Provision of professional and technical staff in one Tehsil head quarter hospital and one RHC
Placement of one dental surgeon on temporary basis through support of partners Move SNE for new post of two dental surgeons and 2 dental technicians
480,000
480,000
480,000 Partners
0 DHO
Sub-total C-5:
2,430,000
2,430,000
54
3.
Managerial support
M-1: Damaged Infrastructure of the Health facilities including the DHO office and storage places
Solutions Reconstruction of damaged health facilities with assistance of ERRA/donors Activities Make stop gap arrangement for continuation of PHC services in areas with g damaged health facilities Sub-activities Plan and construct prefab health facilities in the identified area Description Prefab RHC 1, MCH Centers 2, additional 40 bedded ward at DHQH Bagh (by WHO) Equipment and supplies as per approved list for respective units (by WHO) Local adjustment Current resource status Quantity Available Gap required Unit price Total Government Requirement allocation Expected and/or committed partners support Potential source of funding Refer to construction budget
Procure and supply of equipment, furniture, drugs and supplies
Refer to construction budget
Construct permanent structures in place of damaged health facilities
Posting of essential health staff in the prefab facilities Plan and construct permanent facilities in place of damaged facilities
Refer to Government budget Refer to construction budget
Permanent construction of 30% damaged health facilities (DHQH 1, CDH 1, THQH 2, RHCs 2, BHUs 11 and DHO office complex) 1 RHC will be upgraded to THQH, and 2 BHUs will be upgraded to RHCs in the above mentioned list.
55
Solutions
Activities
Sub-activities Procure and supply of equipment, furniture, drugs and supplies
Description Provision of equipments and supplies as budgeted in the reconstructio n package Move SNE for new positions for upgraded Facilities and fill vacant post available
Unit price
Potential source of funding Refer to construction budget
Posting of essential health staff in the permanent facilities
Refer to Government budget
Sub-total M-1:
As referred
M-2: Low managerial capacity of District Health office

Solutions Strengthening and building of managerial and supervisory capacity of district health management Activities Improvement of the physical capacity of District Health Management Enhance managerial skills of health staff of District health Management Sub-activities Provide essential equipment and furniture for the DHO office Need assessment of DHMT skill development Training of DHMT in public health management and office tools (Short and long term courses) Move proposal for additional skilled / technical staff for district health office Adhoc arrangement of Description Provide multi media 1, scanner 1, essential office furniture Assessment be DHO, DoH and partners Courses for 12 persons Current resource status Quantity Available Gap required 1 0 Unit price 1 300,000 Total Government Requirement allocation 300,000 0 Expected and/or Potential committed source of partners support funding 300,000 Partners
12
12
30,000
360,000
Move SNE for new posts of Finance, HR, IT Officers Hiring of essential
0 DHO
240,000
720,000
56
Solutions
Activities
Sub-activities managerial staff through partners support
Description staff for the above positions for one year @ Rs 20000 / m
Unit price
Sub-total M-2:
1,380,000
1,380,000
M-3: Inadequate HMIS

Solutions Revitalization of the HMIS Activities Sub-activities Description Assessment and review of existing HMIS through experts Printing of HMIS Tools for 84 health facilities for one year Computer, printer, Telephone (Provide 50% facilities with mobile phones) Training of 180 Health Care Providers (84 facility in charges, 28 LHVs, 54 Vaccinators, 15 TB Technicians) for 3 days each in 6 sessions. Current resource status Quantity Available Gap required 1 0 Unit price 1 90,000 Total Government Requirement allocation 90,000 0 Expected and/or Potential committed source of partners support funding 90,000 Partners
Improve the Assessment of coverage of HMIS present HMIS to reporting identify the short falls
Provision of tools/instrument s
84
84
5,000
420,000
420,000
Provision of resources
150,000
150,000
Training of health staff
55,000
330,000
Sub-total M-3:
990,000
990,000
57
M-4: Weak monitoring and supervisory system

Solutions Arrange the logistics and resources through regular budget and partner agencies Activities Optimize the available resources and work out the feasible options for supervision and monitoring Sub-activities Needs assessment and develop M&E plan Description Current resource status Quantity Available Gap required 1 0 Unit price 1 0 Total Government Requirement allocation 0 0 Expected and/or Potential committed source of partners support funding 0 DHO / PO
Introduce integrated supervisory approach
Develop and implement a system and tools for integrated supervision and monitoring
assessment of monitoring and supervisory system and develop plans for improvement Approach Forward government for demand for the required required resources financial resources, Repair of 4 supervisory Vehicles and POL support Mobilize Procurement partners for of 2 support M&E supervisory plans vehicles, 2 drivers and POL and maintenance support for one year Make Develop and supervisory print checklist and supervisory other tools for checklist and joint supervision manuals for supervisors Prepare plans Develop joint for integrated plans and supervision implement Additional Operation financial support cost for for operational communicati expenditure on, stationary and Miscellaneou s Expenditure
200,000
800,000
800,000 Govt. / Partners
1,670,000
3,340,000
50,000
50,000
0 Seek partners 240,000 Seek partners
240,000
240,000
58
Solutions
Activities
Sub-activities
Description for 7 supervisors, for one year
Unit price
Sub-total M-4:
4,430,000
4,430,000
M-5: Poor referral and communication system

Solutions Improve the referral system Activities Strengthen the existing referral system Sub-activities Coordination with partners and facilities for referral system for optimizing the resources Description Current resource status Quantity Available Gap required 6 0 Unit price 6 10,000 Total Government Requirement allocation 60,000 0 Expected and/or Potential committed source of partners support funding 60,000 Partners
Provide communication facilities to the field health facilities Sub-total M-5:
Establishment of communication between health facilities and health mangers
develop coordination mechanism, Repair and maintenance of 7 existing ambulances, acquire 2 new ambulances and provide POL Development of Developmen referral network t of Linkage with earmarked mechanism linkages and between RHCs orientation of and BHUs/CDs/ facility in FAPs charges Install telephone As budgeted connections in 6 in the HMIS RHCS and 20 section BHUs and fax in all THQH/RHCs
0 Seek partners
60,000
60,000
M-6: Inappropriate drugs and supplies management system

Solutions Introduce modern management systems for drugs and supplies Activities Develop and implement the modern LSS for drugs and supplies Sub-activities Adaptation of LSS being used by WHO/MoH for district and local use Training of the Description Adaptation of LSS with support of WHO in the district Training of Current resource status Quantity Available Gap required 1 0 Unit price 1 0 Total Government Requirement allocation 0 0 Expected and/or Potential committed source of partners support funding 0 WHO
60,000
180,000
180,000 Seek
59
Solutions
Activities
Sub-activities related staff on LSS
Description 90 facility incharges and warehouse staff on LSS drug management for 3 days in 3 sessions Repair of existing truck and funds for POL and maintenance
Unit price
Potential source of funding partners
Provide related logistics and tools
600,000
600,000
600,000 Partners
Sub-total M-6:
780,000
780,000
60
Problem wise summary of available and required resources

Preventive services
Problems P-1: High Incidence of water born diseases, especially diarrhoea P-2: Inadequate MCH and EmNOC services P-3: Low coverage of PHC/FP services through National Programme P-4: Social deprivations and unhealthy lifestyles P-5: Nutritional Deficiencies including IDD, Anaemia, and Malnutrition in women and children P-6: Absence of school health services P-7: High Incidence of scabies P-8: Low EPI coverage, especially TT among PL/CBAs Sub- Total (Preventive services) Total requirement 4,851,000 8,450,000 2,932,5000 3,755,000 1,898,000 3,826,000 1,258,000 1,450,000 54,813,000 Government allocation 12,000 360,000 3,620,000 0 1,099,000 6,000 0 0 5,097,000 Expected and/or committed partners support 4,839,000 8,090,000 25,705,000 3,755,000 799,000 3,820,000 1,258,000 1,450,000 49,716,000
Curative services
Problems C-1: Inadequate specialized and general medical services C-2: High prevalence of ARI C-3: Inadequate diagnostic services at secondary and primary care levels C-4: Increased incidence of psychological and mental health disorders C-5: Inadequate dental care services in the District Sub- Total (Curative services) Total requirement 12,060,000 2,070,000 4,070,000 2,395,000 2,430,000 23,025,000 Government allocation 0 0 0 0 0 0 Expected and/or committed partners support 12,060,000 2,070,000 4,070,000 2,395,000 2,430,000 23,025,000
Managerial support
Problems M-1: Damaged Infrastructure of the Health facilities including the DHO office and storage places (ref to reconstruction/government budget) M-2: Low managerial capacity of District Health office M-3: Inadequate HMIS M-4: Weak monitoring and supervisory system M-5: Poor referral and communication system M-6: Inappropriate drugs and supplies management system Sub- Total (Managerial support) Total requirement 1,380,000 990,000 4,430,000 60,000 780,000 7,640,000 Government allocation 0 0 0 0 0 0 Expected and/or committed partners support 1,380,000 990,000 4,430,000 60,000 780,000 7,640,000
Construction budget
Reconstruction Total requirement 13,019,900 9,652,100 334,979,000 87,500,000 445,151,000 Government allocation 334,979,000 87,500,000 422,479,000 Expected and/or committed partners support 13,019,900 9,652,100 22,672,000
Prefab structure (by WHO) Prefab equipment (by WHO) Permanent structure and equipment Repair and up-gradation Total (reconstruction)
Note: The cost of prefabs by other partners will be included when updated
61
Government budget for DHO office and HFs

Salaries and allowances - (annual budget 2006-07) Salaries and allowances Staff salaries Regular allowances Communication Utilities Travel and transportation General Telephone, postage etc. Electricity, Hot and cold weather charges, gas charges Rent of buildings T/A POL Stationary Printing and publication News paper Uniform Advertising and publicity Purchase of machinery Repair and maintenance Furniture and fixture Transport Machinery and equipment Building Others Other contingencies Bedding and utensils Cost of drugs and medicines Diet of patients Unani medicines Medical surgical equipments Medicines for Govt. servants Total DHO Office 28,650,000 17,250,000 110,000 1,539,000 90,000 255,000 200,000 43,000 50,000 0 10,000 1,000 40,000 250,000 60,000 300,000 50,000 100,000 5,500,000 0 273,000 200,000 0 54,971,000 DHQ Hospital 11,860,000 6,838,000 110,000 1,712,000 60,000 205,000 200,000 40,000 100,000 10,000 6,000 1,000 0 200,000 100,000 50,000 60,000 350,000 4,200,000 3,000,000 0 800,000 4,500,000 34,402,000 THQ Hospital 5,230,000 2,910,000 60,000 255,000 3,000 105,000 100,000 20,000 50,000 10,000 3,000 1,000 0 150,000 50,000 0 60,000 100,000 800,000 300,000 0 100,000 600,000 10,907,000 Total 45,740,000 26,998,000 280,000 3,506,000 153,000 565,000 500,000 103,000 200,000 20,000 19,000 3,000 40,000 600,000 210,000 350,000 170,000 550,000 10,500,000 3,300,000 273,000 1,100,000 5,100,000 100,280,000
Budget for health programmes

Salaries and allowances - (annual budget 2006-07) Chest disease In-service Training GAVI and general School (Govt. allocation) hospital 3,440,000 725,000 1,400,000 2,233,000 390,000 0 Total
Salaries and allowances
Staff salaries Regular allowances
5,565,000 2,623,000
62
Salaries and allowances - (annual budget 2006-07)
Communication Utilities Travel and transportation General
Telephone, postage etc. Electricity, Hot and cold weather charges, gas charges Rent of buildings T/A POL Stationary Printing and publication News paper Uniform
Chest disease In-service Training GAVI and general School (Govt. allocation) hospital 55,000 22,000 15,000 735,000 0 130,000 200,000 35,000 0 0 3,000 200,000 10,000 50,000 100,000 600,000 900,000 100,000 100,000 0 8,891,000 47,000 17,000 65,000 100,000 13,000 7,000 17,000 1,000 80,000 0 40,000 0 0 0 0 0 0 1,524,000 0 0 100,000 55,000 0 0 0 0 15,000 0 5,000 0 0 0 0 0 20,000 1,610,000
Total
92,000 782,000 17,000 295,000 355,000 48,000 7,000 17,000 4,000 295,000 10,000 95,000 100,000 600,000 900,000 100,000 100,000 20,000 12,025,000
Repair and maintenance Others
Transport Machinery and equipment Other contingencies Bedding and utensils Cost of drugs and medicines Diet of patients Medicines for Govt servant Medical surgical equipments Repair of cold chain
Total
Overall summary
Currency Preventive Pak Rs USD Committed and/or expected partners support Curative Managerial Construction 23,025,000 383,750 7,640,000 127,333 445,151,000 7,419,183 Government contribution Annual Govt. budget Health programmes (DHO office /HFs) budget 100,280,000 1,671,333 12,025,000 200,416 Grand total
49,716,000 828,600
637,837,000 10,630,616
63
VI
1.
Organization and management planning

SWOT analysis of District Health System
Findings/Attributes
Strengths 1. District health management is familiar with health problems 2. Government is committed for rehabilitation and reconstruction of health facilities 3. Sufficient stock of medicines is available Weaknesses 1. Less motivation of the staff 2. Insufficient capacity of health management staff to address the challenges of health system 3. 4. 5. 6. 7. 8. Damaged infrastructure Deficient resources like Vehicles, ambulance, IT/communication and POL Inappropriate logistics management system Inadequate coordination and joint planning among health partners and stakeholders Difficult terrine to provide public health services Lack of capacity for preparedness and response to disasters
9. Weak monitoring system Opportunities 1. Build back better strategy by government 2. Many national and international organizations are available to assist 3. 4. More funds may be allocated for health sector Conducive environment to pre-test and introduce innovative initiatives in the district
Threats 1. Withdrawal of NGOs/UN agencies can create health services gaps 2. 3. 4. 5. 6. 7. Funds may not be provided timely and/or according to the needs Skilled HR may not be available for essential services Sporadic outbreaks of communicable diseases Delay process and decision making Delay in the reconstruction may hamper the targets for services delivery Targets may not be achieved in hard to reach areas or due to adverse weather conditions
2.
O & M development framework

Existing system DHO office and stores/warehouses were destroyed and now placed at temporary shelter. No residential accommodation for DHO and staff. Deficient staff for different programmes and services. Proposed change/s Construction of building for DHO office and storage /ware house Mechanism / process Prepare PC-1 and include in the ERRA plan; and construction of phase 1.
O & M Component Infrastructure
Human resources
Proposal for additional positions Assigning capable manpower for CDC, RH, H&D, Planning/ Development, CBI and other essential areas of work Capacity building and skills development of the staff in related aspects
SNEs and temporary support from partners Local adjustments along with focused trainings
LSS
Obsolete and manual system for logistics
Introduce computerized LSS
Conduct refresher training courses and support the staff in improving their qualification and skills through short/long courses Adapt modern LSS being used by WHO in the emergency
64
O & M Component Financial management
Existing system management Obsolete and manual system for financial management Inadequate communication means in remote health facilities hindering the performance DHMT comprises of 5 members visiting HF monthly regularly. This system interrupted due to extra commitment after EQ
Proposed change/s Introduce computerized financial management system
Communication means
Improve communication system
Mechanism / process office Adapt the financial management system being used by WHO in the central office and field offices Use modern communication technologies like telephone connections
Monitoring and Supervision
Ensure regular and planed visits of DHMT using supervisory checklist and monitoring tools. Ensure logistic support for supervisory visits
Visit Plan Feedback Develop Checklist Visit reports Monthly DHMT meetings Provide transport and facilitate activities
65
VII
Monitoring and evaluation planning

Indicators Baseline 350/100,000 70/1,000 30% 20% 65% 45% Less than 30% of population 0 0 0 0 0 Targets 250/1Lac in one year 45/1000 in one year 50% in one year 15% in one year 55% in one year 35% in one year 45% of population in one year 30% of schools in one year 35% of Union councils in one year 100% union councils in one year 10 union councils in one year 10 in one year When to Monitor Ongoing activity Ongoing activity Ongoing activity Ongoing activity Ongoing activity Ongoing activity Ongoing activity When to Evaluate Month 12 Month 12 Month 12 Month 12 Month 12 Month 12 Month 12
MMR IMR TT coverage Number of diarrhoea case reported to health facilities Prevalence of nutritional deficiencies Number of RTI cases reporting in hospital Number of new Safe water supply schemes Number of schools having School health services Number of U/C having IDEWS and disease surveillance Number of U/C having Integration of mental health and CBR Number of U/C having CBI for H&D Number of RHCs/CH having Accident and emergency centers
Ongoing activity Ongoing activity Ongoing activity Ongoing activity Ongoing activity
Month 12 Month 12 Month 12 Month 12 Month 12
66
Conclusion
This District Health Plan was prepared by the DHMT and has been approved by DoH and ERRA. The plan highlights the key areas in order to improve the health system and services in the earthquake affected areas. It is hoped that it would open new avenues, introducing a more predictable need-based health services delivery. The plan has also the potential to forge greater collaborative environment among the health partners The DHMT is fully aware of the risks that might constraint in the implementation process, such as limitation of resources, insufficient managerial support, unavailability of skilled manpower, and the limited accessibility of many of the catchment areas in the district. However, the operational strategies of the plan are workable and promise a more effective performance in the future. To ensure the successful implementation of the plan, the District Health Management Team has to closely monitor the service delivery support systems, promote the functional integration of PHC essential interventions and rationalize the utilization of committed resource allocations. This sound managerial process will undoubtedly facilitate the necessary resource mobilization that would allow the comprehensive implementation of the planned PHC service package. Along with this, the other important pre-requites for effective implementation of this plan include: making the health facilities fully functional, filling up the vacant posts of staff, development of human resources, implementation of HMIS as a major priority, integrating DEWS with other programmes, making time table for supervision and monitoring, and undertaking a quarterly review of the plan. The promulgated strategic actions outlined in the plan are envisaged to ensure an equitable and more promptly accessible health system and services in the earthquake affected areas.
67
Annexes
Annex-1: District health profile Annex-2: Organizational chart DHO office Bagh Annex-3: Human resources Annex-3.1: Health staff DHO office Annex-3.2: Health staff health facilities Annex-3.3: Health staff DHQ hospital Annex-4: ERRA plan Annex-5: Assessment of public health facilities 2006 a summary report Annex-6: List of prefab/ pre-engineered health facilities District Bagh Annex-7: Who is doing what and where? Annex-8: Maps Annex-8.1: Map Administrative division of the district Annex-8.2: Map All categories of health facilities Annex-8.3: Map Prefab HFs constructed by UN & INGOs Annex-8.4: Map Prefabs / pre-engineered BHUs and RHCs constructed by WHO Annex-9: Gantt chart format for proposed activities
68
Annex-1:
District Health Profile
District Bagh has total population about 485853, and its total area is 1368 Sq Km with a population density 304 people per Sq. Km. It has three Tehsils (Bagh, Dhirkot and Haveli) and 27 Union Councils, two Municipal and one town committees. The following table indicates the number of health facilities before earthquake and its effects on these: Earthquake effects in the district
Earthquake effects on the HFs
S. No 1 2 3 4 5 6 Type of health facilities DHQ Hospital THQ Hosp. RHCs BHUs CDs FAPs Total health facilities 01 01 06 20 19 37 Fully damaged 01 01 01 16 11 25 Partially damaged 05 04 08 12
Earthquake effects on the population and houses

Tehsils Bagh Dhirkot Haveli Total Deaths 6366 1345 451 8162 Injured 3050 1857 1762 6669 Displaced 173791 61405 78164 313360 Houses Damaged 24016 9290 9174 45980
Health situation in the district

Health indicators (revealed from national, state and district data)
National programme of PHC & FP data from January to July 2006 31/1000 09/1000 70/1000 350/100000 2 8818 97000 5705 1250 40%
Indicator No. of children more than 3 years weighed and recorded No. of children with 3 years with low weight No. of newly registered pregnant women No. of pregnant women visited for ANC No. of deliveries by skilled person No. of pregnant women referred for FLCFs/Hospital No. of eligible couples No. of new clients for FP Number 311680 33750 3546 9735 1066 1156 32961 2394
CBR CDR IMR MMR Growth Rate Population/Doctor Population/dental Surgeon Population/Health facility Population/LHW CPR
69
Pattern of HMIS reported diseases HMIS of LHWs NP/PHC

S. No. 1 2 3 4 5 6 7 8 Diseases Diarrhoea ARI Fever Anaemia among children Anaemia above 5 years Scabies RTI Diagnosed TB cases
January to July 2006

# of Cases 15815 19064 39165 9594 18207 11387 3984 1739
HMIS of FLCFs Bagh

S. No. 1 2 3 4 5 6 7 8 9 10 Diseases ARI Fever including malaria Diarrhoea Scabies Dysentery Cough more than two weeks Goiter Dog bite Suspected viral hepatitis Measles
January to December - 2005

# of Cases 43076 18843 13566 6294 4251 299 136 79 40 6
70
Annex-2:
Organizational chart - DHO office Bagh Director General Health, AJ& K
MS DHQH
District Health Officer
MS CD & GH HILL
DDHO
MS THQH
Assistant DHO
Drug Inspector
Health Educator
Planning Officer
CMOs
DCO
Store Suptt QM Store Keeper Drivers
DLC SLT JLT Field Attendant
DSV ASV Vaccinator Dispenser
Health Inspector LHV Dai HT Field Sup. Driver LHWs
ADCO Ac. Sup.
Accountant
Stenographer
Computer Operator
Head Clerk
Stat. Asstt.
Junior Clerk
Senior Clerk
Helping Staff
71
Annex-3:
Annex-3.1:
Human resources
Health staff - DHO office
Categories of Staff BPS/ Grade Sanctioned Total Filled Vacant Sanctioned Male Filled Vacant Sanctioned Female Filled Vacant
EDO (H) Office Administrative Staff EDO (H) / DHO Deputy DHO Coordinator NP/PHC Assist District Coordinator / NP/PHC Accounts supervisor NP Drug Inspector Assistant Inspectress Health Services Distt. Sanitary Inspector Sanitary supervisor EPI Staff Coordinator EPI (GAVI) Distt. Suprin. Vaccination TSV TB Control Office District TB control officer Lab. Tech X-Ray Tech. Malaria District education officer District planning officer Clerical Staff statistical assistant computer operator Senior clerk Junior clerk store keeper/Medicine/Article lady health supervisor NP Senior / Junior EPI technician
19 18 17 12 9 17 16 6 5 17 14 12 14 6 6 17 17 11 12 7 5 7 5
1 1 1 1 1 1 1 2 1 1 1 2 1 6 6 1 1 1 1 3 5 2 19 1
1 1 1 1 1 1 1 2 1 0 1 2 1 3 6 1 1 1 1 3 5 2 19 1
0 0 0 0 0 0 0 0 0 1 0 0 0 3 0 0 0 0 0 0 0 0 0 0
19
19
72
Annex-3.2:
Health staff and health facilities

Categories of Staff BPS/ Grade 18 18 18 18 18 18 17 15 17 6 9 14 6 6 9 9 6 16 9 6 9 9 11 5 6 1 1 6 1 5 Total Filled 0 0 0 0 0 0 16 5 3 5 13 3 7 19 53 31 3 3 4 2 4 2 1 2 1 17 2 1 12 6 Male Filled 0 0 0 0 0 15 Female Filled
(THQH/RHCs/CHs/BHUs/CDs/MCHCs)
Medical Specialist Surgical specialist Gynecologist Anesthetist Pediatrician Senior Medical Officer Medical Officer Hakeem Dental surgeon Dental tech Medical tech Charge Nurse Radiographer Dispenser Health Technician Lady Health Visitor Mid Wife Medical Assistant Laboratory Technician Laboratory Assistant Operation Theater Assistant / Technician TB Technician Leprosy Supervisor CDC Supervisor / Workers Dental Attendant Sanitary Assistant Operation Theater Attendant Dawa Saz Ward Boy Electrician Sanctioned 1 1 1 1 1 1 36 5 6 5 16 6 7 21 53 31 3 3 7 2 9 3 1 2 1 17 2 1 12 7 Vacant 1 1 1 1 1 1 20 0 3 0 3 3 0 2 0 0 0 0 3 0 5 1 0 0 0 0 0 0 0 1 Sanctioned 1 1 1 1 1 28 Vacant 1 1 1 1 1 13 Sanctioned Vacant
6 10 31 3
3 8 31 3
3 2 0 0
73
Categories of Staff Driver Others Lady Health Worker Lady Health Supervisor Vaccinator TBA/Dai
BPS/ Grade 4 1
5 1
Sanctioned 13 146 418 19 36 + 15 = 51 43
Total Filled 13 146 367 19 51 43
Vacant 0 0 50 0 0 0
Sanctioned
Male Filled
Vacant
Sanctioned
Female Filled
Vacant
418 19 5 43
367 19 5 43
50 0 0 0
Annex-3.3:
Health staff - DHQ hospital

Categories of Staff BPS/ Grade 19 18 17 18 18 18 18 18 18 18 18 18 18 17 16 14 6 9 17 9 9 6 9 9 Sanctioned 1 1 13 1 1 1 1 1 1 1 1 1 1 1 1 16 7 2 2 2 5 1 1 1 Total Filled 0 1 8 1 1 0 1 1 1 1 1 1 1 0 1 16 7 2 2 2 4 1 1 0 Vacant 1 0 5 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 1 Sanctioned Male Filled Vacant Sanctioned Female Filled Vacant
MS DMS MO Medical specialist Surgical specialist Gynecologist Pediatrician Anesthetist Pathologist Radiologist ENT specialist Cardiologist Eye specialist Nursing superintendent Head nurses Charge nurses Dispenser Radiographer Dental surgeon Dental tech OT tech OT assistant ECG tech Electro medical tech
1 16
1 16
0 0
74
Categories of Staff LHV Lab tech Lab assist Store keeper Blood bank BTO Tech
BPS/ Grade 9 9 6 5 17 9
Sanctioned 2 2 2 1 1 1
Total Filled 2 1 2 1 0 1
Vacant 0 1 0 0 1 0
Sanctioned
Male Filled
Vacant
Sanctioned 2
Female Filled 2
Vacant 0
75
Annex-4:
ERRA plan
2006-07 Repair/ Upgradation 0 0 3 5 0 0 0 8 2007-08 Repair/ Upgradation 0 0 0 0 0 0 0 0 2008-09 Repair/ Upgradation 0 0 0 0 4 0 0 4
4.1: Phasing for start of reconstruction work

DHQH THQH RHC/CH BHU CD Other HF Other HO Total Reconstruction 1 2 3 0 0 1 1 8 Reconstruction 0 0 0 22 0 0 1 23 Reconstruction 0 0 0 0 7 0 0 7
4.2: Physical targets (2006-09)

Referral hospitals RHC/CH BHU/CD Other health facilities Other health outlets Total Reconstruction 3 3 0 1 1 8 2006-07 Repair/ Upgradation 0 3 5 0 0 8 Reconstruction 0 0 22 0 1 23 2007-08 Repair/ Upgradation 0 0 0 0 0 0 Reconstruction 0 0 7 0 0 7 2008-09 Repair/ Upgradation 0 0 4 0 0 4 Total (2006-09) 3 6 38 1 2 50
4.3: Cost Estimates of reconstruction and repair / upgradation work

2006-07 Reconstruction DHQH THQH RHC/CH BHU CD Other HF Other HO Total 108.32 106.66 75.00 0.00 0.00 35.00 10.00 334.98 Repair/ Upgradation 0.00 0.00 52.50 35.00 0.00 0.00 0.00 87.5 2007-08 Reconstruction 108.32 106.66 75.00 220.00 0.00 35.00 20.00 564.98 Repair/ Upgradation 0.00 0.00 22.50 15.00 0.00 0.00 0.00 37.5 2008-09 Reconstruction Repair/ Upgradation 108.32 0.00 106.66 0.00 0.00 0.00 220.00 0.00 35.00 14.00 0.00 0.00 10.00 0.00 479.98 14 2009-10 Reconstruction 0.03 0.03 0.00 0.00 35.00 0.00 0.00 35.06 Repair/ Upgradation 0.00 0.00 0.00 0.00 6.00 0.00 0.00 6
76
4.4: Pledges for reconstruction/ retrofitting of HFs

S. No Health Outlet Tehsil UC Village Damages (Fully/ Partially) F F P F F P P P P F F F F F F F F F F F P F P F F F F P 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 DHQ H THQ H R 1 P 1 R 1 1 P 1 1 RHC R P BHU R P Other R P Pledges for Reconst. Sponsor KFW KFW USA ADB USA USA USA USA USA USA USA IBC Turkey IBC Turkey USA USA USA USA USA USA USA USA USA USA USA Governer Punjab USA Governer Punjab USA Proposed Phase I I I I I I I I I I II II II II II II II II II II II II I II II II II II
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
DHQ Hospital Bagh Tehsil Headquarter Hospital Rural Health Center Chest Diseases & General Hospital Rural Health Center Rural Health Center Rural Health Center Rural Health Center Rural Health Center Basic Health Unit Civil Dispensary Basic Health Unit Basic Health Unit Basic Health Unit Civil Dispensary Basic Health Unit Civil Dispensary Basic Health Unit Basic Health Unit Basic Health Unit Civil Dispensary Basic Health Unit Basic Health Unit Basic Health Unit Basic Health Unit Basic Health Unit Basic Health Unit Civil Dispensary
Bagh Haveli Dhirkot Dhirkot Bagh Bagh Dhirkot Dhirkot Haveli Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot
Bagh Kahuta Dhirkot Dhirkot Dhery Topi Dhirkot Mallot Khurshidabad Bir Pani Bagh Bhount Bhian Bhount Bhian Juglari Nar Sher Ali Khan Rawali Rawali Rawali Rerban Swanj Thub Topi Chirala Dhirkot Makhala Mallot Rangla Sahlian
Bagh Kahuta Dhirkot Hill Chater No.2 Chitra Topi Sessar Arja Khurshid Abad Bir Pani Khawaja Ratnohi Kharal Abbasia Kharal Maldylan Kafal Ghar Rai Kot Hari Gahal Nariola Sirsydian Seri Piran/ Dhundar Rerra Thub Ghel Topi Sohawa Neela Butt Gaziabad Mallot Rangla Sahlian
77
S. No Health Outlet
Tehsil
UC
Village
29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64
Civil Dispensary Basic Health Unit Basic Health Unit Basic Health Unit Civil Dispensary Basic Health Unit Basic Health Unit Basic Health Unit Civil Dispensary Civil Dispensary Civil Dispensary Civil Dispensary Civil Dispensary Civil Dispensary Civil Dispensary Civil Dispensary Civil Dispensary Civil Dispensary Civil Dispensary Civil Dispensary DHDC DHO Office First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post
Haveli Haveli Haveli Haveli Haveli Haveli Haveli Haveli Haveli Bagh Bagh Bagh Bagh Dhirkot Dhirkot Haveli Haveli Haveli Haveli Haveli Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh
Bhedi Budhal Budhal Chanjal Chanjal Dagwar Kalali Kalamula Kalamula Bagh Bagh Bhount Bir Pani Chamyati Dhirkot Bhedi Kalamula Khurshidabad Sangal Sangal Bagh Bagh Bagh Bagh Bagh Bhount Bir Pani Bir Pani Dhery Dhery Dhery Juglari Nar Sher Ali Khan Rawali Thub Topi
Bhedi Bhatakot Gugdar Chanjal Mondhar Dagwar Toungari Halan Shamali Kalamula Chowki HQ Bagh Kharal Panyali Bani Minhasan Sanghar Pathera Kotli Khawaja Bandi Solli Hillan Naga Nari Siryan Bagh Bagh Koteri Qandil Kotlakulain Noorgala Bisuti Rarar Bun Suddengali Dhery M.CampChattar2 Salian Maldulian Juglari Azad Bara Chak Serian Bangran Kothian
Damages (Fully/ Partially) F F F P P F F P P F F F F F P F P P F P F F F F F F F F F F F F F P P F
DHQ H THQ H R P R P
RHC R P
BHU R 1 1 P 1 1 1 1 1 1 1 1
Other R P
1 1 1 1 1 1 1
1 1
1 1
1 1 1 1 1
Pledges for Reconst. Sponsor Islamic Relief USA USA USA USA UNICEF (T) UNICEF (T) USA USA USA USA USA USA USA USA USA USA USA USA USA Mercy Malasia Mercy Malasia
Proposed Phase II II II I II I II I II III III III III III III III III III III III II I
USA
78
S. No Health Outlet
Tehsil
UC
Village
65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102
First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post First Aid Post MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center
Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot Haveli Haveli Haveli Haveli Haveli Haveli Haveli Haveli Haveli Haveli Haveli Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Bagh Dhirkot Dhirkot Dhirkot Dhirkot
Chamyati Cherala Cherala Cherala Hill Surung Makhala Makiala Malot Rangla Rangla Salian Baddal Baddal Degwar Kalali Kalamula Kalamula Khurshidabad Khurshidabad Khurshidabad Sangal Sangal Bagh Bagh Bhount Baian Birpani Dhery Juglari Nar Sher Ali Khan Rawali Rawali Swang Thub Topi Chamyati Chirala Dhirkot Dhirkot
Chamyati Cherala Narakot Riala Surung Dhavi Poth Makhila Suddengali Gali Per Khana Rangoly Dhar Sikandarabad Badhal Ziaratmore Rankeri Khas Jabri Hajipir Bringbun Charian Hajjibal Kacher Bun Sher Pur Chirikot Plangi Choki DHQ Bagh Kharal Abbasia Bir Pani Chattar No. 2 Kafal Ghar Rai Kot Hari Gahal Sirsydian Rerrah Thub Chittra Topi Sanger Pathara Sohawa Sharif Dhirkot Sessor
Damages (Fully/ Partially) F F P P F F P F F F F F P P F F P P P P P F F F F F F P P F F P P P P P F P
DHQ H THQ H R P R P
RHC R P
BHU R P
Other R P
Pledges for Reconst. Sponsor
Proposed Phase
79
S. No Health Outlet
Tehsil
UC
Village
103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127
MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center MCH center TB Center TB Center TB Center TB Center TB Center TB Center TB Center TB Center TB Center TB Center TB Center TB Center TB Center TB Center
Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot Haveli Haveli Haveli Haveli Haveli Haveli Bagh Bagh Bagh Bagh Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot Dhirkot Haveli Haveli Haveli Haveli
Makhyala Mallot Mallot Rongla Sahlian Badhal Sharif Bhedi Chanjal Kalali Kalamula Khurshidabad Bani Pasari MC Bagh Swang Topi Dhirkot Dhirkot Hill Surung Mallot Mallot Rangla Behdi Budhal Sharif Kalali Khurshidabad
Ghaziabad Arja Mallot Rongla Sahlian Dhondan Gugdar Bhedi Chanjal Kahuta Kalamula Khurshid Abad Bani Pasari DHQ Bagh Rehara Chittra Topi Dhirkot Sessor CDH Hill Arja Mallot Rangla Behdi Gugdar Kahuta Khurshid Abad
Damages (Fully/ Partially) P F F P P P F P F P P F F F P P P F P F F F F F P
DHQ H THQ H R P R P
RHC R P
BHU R P
Other R P
Pledges for Reconst. Sponsor
Proposed Phase
80
Annex-5:
Assessment of public health facilities - 2006 ---- a summary report
An assessment of public health facilities was conducted in all the eight earthquake affected districts (Mansehra, Kohistan, Shangla and Batagram in NWFP and Muzaffarabad, Bagh, Poonch and Neelum in AJK) to assess the functionality of public health facilities in the district (staffing, services, supplies, utilization etc.), to perform a comprehensive mapping of all facilities, to identify issues relating to quality health service delivery and to establish baseline data on health facility status for future assessments and evaluation of interventions. This report presents the information collected in the field as well as the secondary data compiled from many sources including regular monitoring reports of partner organizations and brings forward recommendations for further interventions relating to recovery and reconstruction. A pre-tested questionnaire was used for this cross-sectional survey and consisted of close-ended questions regarding facility information, access indicators, and physical infrastructure, staffing position, equipment, and supplies, and reporting. The selection criteria were Functioning First Level Health Care facilities including Basic Health Units (BHUs) and Rural Health Centers (RHCs). GPS coordinates were also taken as was visual documentation. The assessment was carried out in almost 300 facilities (106 from AJK 130 in NWFP). Of all the facilities assessed, about 28% are being supported by an external agency (NGOs or the Pakistan Army) with some districts like Shangla and Kohistan where none of the facilities are being supported by any agency. Most of the facilities assessed (65%) were located close to a tarmac or jeep road and were accessible by all types of vehicles. However 47 BHUs (25%) were accessible only by 4X4 jeeps and 19 (10%) were accessible only by foot. The average time taken to reach the facilities from the closest population pocket by foot was 22 minutes (range: 2 minutes to 60 minutes) while the time taken to reach the farthest catchments village was 141 minutes (range 25 minutes to 720 minutes). In three cases, clients would have to walk for up to two days to get to the closest health facility). The average time to reach preferred referral facility by vehicle was 108 minutes (range 10 minutes to 960 minutes). On the whole, the original structures were being used in 60% of all facilities. In many places, the damage is either minimal, or parts of the original structures like a single room are being used. Tents are still being utilized in 9%, pre-fabricated units in 8% while multiple structures (a combination of tents, buildings, shelters and pre-fabricated) were being used in 23% of all the facilities. With regard to the utilities available, 68% of all facilities had a functional toilet, only 49% had a functional water supply within the facility premises and 65% had an electric supply. As for waste disposal 118 facilities (50%) burned their waste, 27 (19%) threw it away, and 27 (11%) buried their waste. Forty-six (20%) used multiple methods. In locations where staff claimed to bury their waste, the team noticed improper techniques of disposal with shallow pits overflowing with hazardous waste. By and large, the most regularly available staff on duty in all the districts is the medical technician or dispenser (88%), followed by a vaccinator (67%), an LHV (63%) and male Medical Officer (47). A female Medical Officer was available at only 13% of all facilities. With regard to services provision, the most common service is out-patient consultation (96%), followed by ORS provision (89%), EPI (80%), minor surgical procedures like stitches (69%) and Family Planning (68%). The least available service was laboratory services (21%), access to ambulance (27%) and inpatient facility (29%). Only 23 (10%) facilities were classified as well equipped, 108 (46%) were average and 105 (45%) were classified as poorly equipped. The situation was similar in both the provinces. However there was great variation amongst districts, Kohistan having the most number of facilities (72%) equipped poorly followed by Neelum (55) and Poonch (48). The most well equipped district is Muzaffarabad (21%), followed by Batagram (14%) and Bagh (13%). Most facilities (46%) were classified as average. The table below shows the status of equipment district wise.
81
When asked about their needs, the staff mentioned several issues similar to other districts including construction of staff quarters, improving the water supply, appointing appropriate staff, strengthening reproductive health services, supply of furniture and essential equipment and office supplies, provision of a regular and sufficient drug supply, laboratory services and staff training. A complete services package needs to be introduced, in addition, the minimum standard must include maternal and child health services like ante/post-natal care and regular EPI services. Second quality of services need to be improved as well. The water and sanitation issues in health facilities need to be addressed. Referral sites need to be strengthened in case of emergency and effective delivery of health services. The Government may consider better incentives to retain doctors at peripheral health care facilities. Whereas the 8th October earthquake has caused disruption and devastation, it has also provided a unique opportunity to reassess and improve the situation and, ultimately, improve the quality of peoples lives in the affected areas. The flowing table summarizes assessment results from district Bagh: Assessment findings Bagh (AJK)
# supported by external agency Facility level Total facilities # assessed BHU 31 31 (100%) Total facilities RHC 6 2 (100%) 13 (33%) Hospitals 2 6 (100%) Total 39 39 (100%) Accessible by all vehicles Accessible by 4X4 only Accessible by foot only Access 30 (77%) 9 (23%) 0 (0%) Building 16 (41%) Functional toilet 33 (85%) Tent 5 (13%) Water supply 24 (62%) Current structure Utilities available Prefab 8 (20%) Electricity 32 (82%) Multiple structures 10 (25%) Services available MO (male) 16 (41%) MO (female) 3 (8%) OPD 38 (97%) TB management 20 (51%) Staff available Dispenser/ technician 37 (95%) IPD 17 (44%) EPI 34 (87%) LHV 28 (72%) Peri-natal care 26 (67%) ORS provision 37 (95%) Vaccinator 33 (85%) Delivery 15 (39%) Laboratory 10 (26%) Well equipped 5 (13%) Family planning 28 (72%) Minor surgery 28 (72%) Status of equipment Average 18 (46%) Growth Monitoring 18 (46%) Access to ambulance 20 (51%) Poorly equipped 16 (41%) The information presented in this table has been reported by health team visited during the assessment of public health facilities and may occasionally differ from Department of Health figures
82
Annex-6:
List of prefab / pre-engineered health facilities District Bagh

Contributing agency WHO MSF-B Paterian Foundation Merci Malaysia No. of facilities 9 3 1 Localities Bhatakot, Doba Behdi, Juglari, Ghaziabad, Kahuta1, Kahuta-2, Kharal Abbasian, Tuangeri, Rangla Behdi, Mallot, Bhirpani, Rerra Bagh Chattar No.2, Kafal Garh Bagh Ghaziabad
Facilities BHUs/RH Units
1 2 1 1
18
RHCs DHQ hospital Other hospitals Total
WHO MSF-B Ibadat Welfare Trust
83
Annex-7:
Sr. No.
Who is doing what and where?

Name of organization Location Type of services Relevant comments
UN organizations 1 World Health Organization District Bagh Technical support to DOH in: Revitalizing District Health System, Health Cluster Coordination, Surveillance & DEWS, Drug management and supply, Environmental Health. Constructing Prefab BHUs (9) & RHCs (2) and providing equipments Reproductive Health Services (MCH, Deliveries, FP, EMOC) Reproductive Health Services (MCH, Deliveries, FP, EMOC) WHO is working in the whole district, directly supporting department of health in the district
UNFPA
DHQ Hospital Bagh 1 RHCs in each Tehsil (Dhirkot, Bagh, Havelli)
UNICEF
District Bagh
1. Capacity building: training of 895 CHW in areas where no LHWs exist, training of DOH staff in EPI, EMOC. 2 drug supply. 3. Equipments. 4. Establishing Nutrition centers with nutrition supplements. 5. Repair and maintenance of all DHO vehicles. 6 supplying cold chain equipments. 7 Funding implementing partners (NCHD, NRSP, ARC) 8 Permanent construction of 2 health facilities
provided female doctor/Gynecologist, 2 LHVs 2 Dais at DHQ hospital UNFPA planning to construct 3 prefab RHC in Bagh and provide staff (2 female doctors, 2 LHVs and 2 Dias and support staff in each), equipment and supplies UNICEF is working in the whole district, directly supporting department of health and through funding the other implementing partners in health
International organizations 1 MSF-Belgium Bhirpani Mallot Constructed prefab BHU at Bhirpani and Mallot, Providing PHC Services, Surveillance, Psychosocial counseling, Health Education and Mobile Clinics Constructed 60 beds container hospital providing full administrative and operational support to the DHQ Hospital Mercy Malaysia in involved in construction of DHO office complex Reconstruction of Health Houses in tehsil Bagh Field Hospital: OPD, IPD (20 beds), X-Ray, Lab, EPI, Operation Theater, Out reach clinics, Trainings, Health Education PHC, MCH, OPD, EPI Surveillance Continue up to March 2007
DHQ Hospital, Bagh
2 3 4
Mercy Malaysia Mercy Corp Qatar Red Crescent Tehsil Bagh Field Hospital Dhulli
Health care services support closed Beside this Mercy Corp is working in Water and Sanitation sector Services extended up to April 2007
American Refugee Committee Int (ARC)
BHU Harigale
ARC provide staff at the BHU to support MOH staff
84
Sr. No.
Name of organization
Location IDP Camp Naumanpura RHC Dhirkot
Type of services PHC, MCH, OPD, EPI, Surveillance ARC deputed 1 male and 1 female doctor at RHC
Relevant comments Daily clinics are conducted at the IDP Camp ARC supporting the DoH by placing two doctors male & female at RHC in strengthening services ARC has posted one doctor at the RHC. After the prefab structure is completed additional staff along with a female doctor will be placed Services extended for one year
RHC Chattar II
OPD, MCH, EPI, Surveillance
Qatar Charity
Actionaid International-UK
International Rescue Committee (IRC)
Padhar, Bagh Ratonoi RHC, Chitra Topi DHQ Hospital Bagh BHU Tungari BHU Seripiran BHU Khothian BHU Thub BHU Kalamula Field Health Center, Panyali (UC Banipasari) Field Health Center, Makhdoomkot (UC Banipasari) Field Health Center, Kotera (UC Banipasari) Field Health Center, Choor (UC Mallot) Field Health Center, Channat (UC Mallot) District Bagh
PHC, MCH, OPD, Surveillance, RH, MH, Lab PHC, MCH, OPD Surveillance OPD, IPD, MCH, TB, EPI, Surveillance 2 Doctors (1 Male & 1 Female) 1 Doctor 1 Doctor 1 LHV 1 LHV 1 LHV OPD, Health Education, CHW Training, Medicine
Services extended to December 2006
Services will continue till June 2007 with possibility of extension
Capacity development, improve accessibility and quality of PHC services and community mobilization in the whole district
Long term
National organizations 1 National Commission for Human Development National Rural Support Programme (NRSP) Chattar-I, Bagh BHU, Halan Shumali in Tehsil Havelli Ghaniabad Kahutti Bazaar RHC Arja PHC, Surveillance, Mobile Team, OPD Support will continue
Field Health Clinic: OPD, Medicine, ANC, Deliveries, Outreach, Ambulance, WATSAN & Community Based programmes OPD, MCH, EPI, TB, ANC, PNC Deliveries, Surveillance, IPD (12 beds), X-Ray, Ultrasound,
Services will continue
AKHSP phased out and NRSP is replacing the support
85
Sr. No. 3 4 PIMA
Name of organization
Location
Type of services Laboratory, Ambulance, WATSAN IPD, 40 beds, mainly trauma surgery, OPD, MCH, OT, X-Ray, Lab Community Health Programme & Field Hospital: OPD, IPD with 10 beds capacity with focus on MCH Family Health Clinic, Reproductive Health. Fixed facility and outreach activities PHC Mobile Medical Teams, Surveillance
Relevant comments
Bagh Ghaziabad
IBADAT Trust
Field Hospital having long term commitment The hospital has started functioning from 1st October 2006 Facility started in September staffed with one Female doctor 2 LHVs and Dias Sarbuland village established by an Army unit for affected people with support from Turk govt. Health services are being provided by Petarion Foundation
5 6
Family Planning Association of Pakistan (FPAP) Petarian Foundation / Abdalian Association
Bagh Sarbuland Village
Note: This information need to be updated regularly and incorporated in the district planning profile.
86
Annex-8:
Annex-8.1:
Maps
Map - Administrative division of the District
87
Annex-8.2:
Map - All categories of health facilities
88
Annex-8.3:
Map - Prefab HFs constructed by UN & INGOs
89
Annex-8.4:
Map - Prefab / pre-engineered BHUs and RHCs constructed by WHO
90
Annex-9:
Gantt chart format for proposed activities

Expected results
1 2 3 4
Activities
Months (mark the relevant boxes)

5 6 7 8 9 10 11 12
91

District Health Plan for Bagh 2006-07

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DISTRICT HEALTH PLAN

Department of Health Government of AJK

Ministry of Health Government of Pakistan

Earthquake Reconstruction & Rehabilitation Authority

World Health Organization Pakistan

DISTRICT HEALTH PLAN

DHO and DHMT

DRU and partners

Chief Planning (Health)/AJK

Director General Health/AJK

DoH/AJK and ERRA/Pakistan

World Health Organization

Department of Health, AJK

Conclusion ................................................................................................................................ 67 Annexes..................................................................................................................................... 68

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

District Health Plan - Bagh/AJK (2006-07)

The district health plan

Undertaking needs analysis and prioritization

++++ ++++ +++ +++

+++ +++ +++ ++

P-6 P-7 P-8

+++ +++ +++

Inadequate MCH and EmONC Services

Low coverage of PHC/FP services through national programme

High maternal and neonatal deaths

Pregnant women and newborn child

o Infrastructure Destructed due to earthquake o Poor salary

Increase burden of preventable diseases and related mortalities

All population especially women and children

District Health Plan - Bagh/AJK (2006-07)

Identified major Health problems

Current status of the problem stores LHWs overloaded CPR 40%

Consequences and effects

Social deprivation and unhealthy lifestyles

Whole population and especially poor communities.

Physical and mental agony and involving more community.

Whole population and especially poor communities.

High prevalence of vaccine preventable diseases and deaths

Mother and children

District Health Plan - Bagh/AJK (2006-07)

Health problems C-5 Inadequate dental care services in the District

High incidence of ARI

High morbidity and mortality especially in children

Whole population and particularly children.

Inadequate diagnostic services at secondary and primary care levels

Increased incidence of psychological and mental health disorders

Inadequate dental care services in the district

No dental services to the majority of population

District Health Plan - Bagh/AJK (2006-07)

Identified major Health problems