An initiative in Family Planning Services from Khyber Pakhtunkhwa , Pakistan suggests that citizen led performance monitoring employing community scored cards is leading to improvement in health services.
Improving Family Planning Services through Community Score Cards in Khyber Pakhtunkhwa – Community of Practitioners on Accountability and Social Action in Health
Background
Pakistan is one of the fastest growing countries on the globe with a population of over 180 Million at an annual growth rate of 2.03 percent. Based on current trends, Pakistan stands to double its population by 2050. The latest figures released from Pakistan Demographic and Health Survey (PDHS) 2012/13 point out that fertility rate stands at 3.8 with highest amongst rural poor women with low levels of literacy and education. Contraceptive Prevalence Rate (CPR), though slightly improved but hugely behind the anticipated targets, reflects 0.5% increase since the start of family planning programme in 1964. CPR has remained stagnant in 2000-11 and this has raised several questions about the efficiency and effectiveness of the Family Planning (FP) initiatives. Challenges identified in variety of reviews pointed out demand and supply constraints (Karim and Zaidi, 1999: Rukanuddin, 2001; TAMA, 2008). This has led to the argument that FP programmes could not perform as anticipated.
Budgetary allocations are also an area of immediate attention after the 18th amendment as FP is now a provincial subject. Khyber Pakhunkhwa (KP) is a conservative province with weak FP outcomes, critically hampering the national efforts of bringing fertility rate to the accepted levels. The KP Health sector strategy 2017 has promised to expand Health Services Package (HSP) for primary and secondary healthcare services to at least 70% of its population, increase the CPR to 55% by 2017, and revitalize the delivery of family planning services in public sector health facilities with a mechanism for forecasting contraceptive requirements and ensuring the uninterrupted supply of contraceptives to the facility, Lady Health Workers (LHWs) and Community Midwives (CMWs).
The current political government of KP has introduced visionary steps towards improvement of good governance while introducing pro-poor legislation and innovative oversight and feedback mechanisms. Independent Monitoring Unit (IMU) in the health sector is considered an agent of change in the service delivery, owing to the reason that it touches on the most pressing service delivery issues. KP government is also formulating its first ever-provincial Population Policy that will provide a basis for concrete actions towards positive outcomes.
EVABHN is a project managed by Palladium Pakistan and funded by DFID to strengthen empowerment, voice and accountability in health service delivery in KP and Punjab provinces. Under this demand side initiative, a Health Innovation Fund (HANIF) has been established to promote, adopt and replicate innovations in variety of areas affecting health services. CUP, a national organization, was awarded a pilot proposing a citizen led performance monitoring while employing Community Score Card (CSC) to solicit citizen feedback and closing the loop through establishing citizen joint monitoring committee to oversee and track the progress. This CSC was applied in nine selected Family Welfare Centres (FWCs) and Basic Health Units (BHUs) in district Peshawar.
Phase Three:
- Separate sessions held with men and women community members
- A total of seven performance indicators¹ agreed upon against which the perceptions were recorded.
- Voting was employed to determine modus operandi of perceptions of the community members in which a rank of 1-5 was employed.
- A total of 430 persons participated in the 18 sessions out of whom 233 were male and 197 were female.
Phase Four:
- A total of seven performance indicators were agreed upon
- A total of 90 staff members perception was recorded.
Phase Five:
- Three interface meetings conducted
- Nine joint action plans developed
- Three joint citizen monitoring committees established
Joint Citizen Monitoring Committees (JCMCs)
To effectively implement the agreed action plans, Joint Citizen Monitoring Committees (JCMCs) were developed and their TORs were shared with the community, being approved by the district Health and Population Welfare Departments. Each JCMC met three times in last 10 weeks time to follow-up on the implementation tasks. The cornerstone of JCMC is that it endeavours to implement its decisions expeditiously and through consensus. In circumstances where unanimity is not achieved, decisions are taken by a vote (simple majority of members present). This was headed by DPWO and DSM-PPHI with representation from facility staff, men and women community activists.
Outcomes of community engagement Improving Building and facilities: The condition of the buildings is extremely poor owing to the fact that FWCs are housed in rented buildings at the lowest rate of rent ranging between PKR1500 to PKR4000. This shows apathy on part of the policy and decisions makers who are unable to address this core issue of standardized building for FWCs. The DG-Population Welfare has now taken up the concerns of poor infrastructure and facilities, the District Mayor and Secretary Population Welfare too are equally committed to addressing these concerns. The FWCs located within BHUs is crippling with limited space, as the room that is allotted to FWC is actually in shambles. Majority of the FWCs are housed within a small room where IUCD insertion and client consultation is performed. After coordination between the Health and Population Departments at the facility level, it is mutually agreed that FWW can perform insertion in the labour room that is maintained by the BHU staff at Chamkani and Khanaza. An additional room is also allotted to FWC at BHU Jhagra, Pakha Ghulam and Lalla Kallay. Repair and maintenance of BHU Pakha Ghulam has also been carried out by the DSM, Health department. Likewise, furniture including chairs, bench, and cupboard is provided to the FWCs by the DPWO office.
Building Human Resources: Male-Female assistants in Latifabad were not posted for many months and the seats continue to be vacant. The DPWO showed immense responsiveness to this issue and ordered immediately transfer of a MFA, instructing the incumbent to report within 15 days. The community also highlighted the absence of Female Field Assistant at FWC Aachar. The DPWO briefed the participants that a case is pending in the Supreme Court of Pakistan against the Population Welfare Department. As this matter is subjugated, no orders can be issued until the resolution. A mapping exercise was conducted by CUP in consultation with LHS to find out the uncovered LHWs areas attached to the selected BHUs. This exercise was shared with the Provincial and District Coordinator-National Programme to take up this matter. Recently, job interviews were conducted at the selected BHUs to fill the vacancies of LHWs.
Provision of Family Planning Equipment: It is highly undesirable that many of the FWCs and BHUs do not have the requisite family planning equipment to serve clients. Each FWC is given only one IUCD kit that is used for the insertion purposes and clients are kept waiting for longer hours until that kit is sterilized. It was resonated during the JCMC meeting that the sterilizer machine must be functioning but unfortunately the sterilizer is worn out and still in use by the staff. DPWO provided additional IUCD kits to all the selected FWCs, however, lamented over low budgetary allocations, which restricted the department to purchase new equipment. He mentioned that his office has to send single facility specific case to the Finance department for purchases and repairs that took longer time. In addition to these, Blood Pressure apparatus, screen, bed, footsteps, baby and adult weighing machines are handed over to FWCs. This has shown encouraging response from the DPW Office. Likewise, the family planning staff housed within BHUs has allowed operating in the labour rooms that has all the requisite IUCD insertion equipment.
Revitalizing Community Outreach: The Community reported that the outreach activities by the field worker such as the LHW and Male/Female Field Assistant are limited in number. It was noted that significant educational and knowledge gaps exist between men and women towards FP services. LHWs are unable to reach out to communities in some areas. Community activists and outreach workers jointly expanded the motivational and educational activities through conduction of “Sukhi Ghar Mehfil” and Support Groups meetings. Population Welfare and Health departments were unable to provide IEC material that could be handed over to participants towards dissemination of information. The DPWO promised that a sizeable budget would be allocated in the coming year to manage the printing of literature, to make information available to maximum population. The National Programme has also appointed additional LHWs in the catchment areas of selected facilities to manage uncovered areas.
Expanding Stakeholders, Strengthening Capacitates and Establishing Referral System: In KP province, population welfare is now a devolved department offering opportunities to work in tandem with the local government representatives. The DPWO and CUP oriented the district leadership on family planning services and CSC for its prioritization and adoption. This is quite dismaying, as the technical staffs have not been trained for the last five years. A five-day training on counselling was arranged at Regional Training Institute, Family Planning Department. 15 staff members from FWCs and BHUs attended the training. Referred clients were not issued any slips for record keeping or tracking the clients for future references. Referral slips has been designed, printed and handed over to DPW office that is further delivered to all 62 FWCs in district Peshawar. DPW office will ensure that these referral slips must be used and accurately recorded.
Monitoring is a decrepit area to be focused while employing citizen engagement mechanisms to ensure community participation and oversight. The DPWO admitted that his office does not have the bandwidth to visit each and every facility in the district, so citizen engagement is a panacea to maintain oversight at the FWC level. He lauded the efforts of community activists who frequently visited FWCs and reported problems for its resolution. The DPWO also shared that the District Mayor has devised a plan to install local level oversight committees comprising of local neighbourhood/village council members to facilitate and monitor the FWCs. The DSM appreciated the efforts of community activists, the increased monitoring visits and prioritized community feedback.
Recommendations for Service Improvements in Family Planning
- Construct standardized family planning service outlets (FWCs and BHUs) with consultation room, insertion room, waiting area, drinking water supply and washrooms.
- Train the staff (LHVs and FWWs) on all the family planning services.
- Print IEC materials for display and use in outreach activities including male and female sessions (Satellite and Sukhi Ghar Mehfil).
- Install public information board displaying information on the family planning methods, its fee, list of sanctioned and appointed staff and methods of grievance redressal.
- Establish a Complaint Management system at the family planning service level duly integrated with the district and provincial redressal portals.
- Increase budgetary allocations to address the core issues of shortage of staff, standardized building, family planning equipment and furniture.
- Increase the monitoring visits of district officials and devise citizen inclusive oversight mechanisms that must ensure community involvement (Women Support Groups and Male Committees).
- Enhance coordination amongst key delivery departments including DPWO, DSM and National Programme for effective service delivery.
- Immediate appointment of LHWs to leverage outreach activities in the uncovered areas, including establishment of committees of men and women.
¹Basic amenities and infrastructure, human resources, behavior of staff to clients, awareness, mobilization, follow ups, monitoring, working hours, referral system, family planning equipment and commodities.
ABOUT AUTHORS
Gulbaz Ali Khan, is the Chief Technical Advisor at Centre for Inclusive Governance (CIG), Pakistan. He holds a masters degree in Economic Development & Policy Analysis from University of Nottingham, UK and is a pioneer Social Accountability Practitioner who successfully tested Citizen Report (CRC), Community Score Card (CSC), Budget Tracking and Public Expenditure Tracking Survey (PETS) in the primary education, basic health, rural drinking water and family planning sectors in Pakistan. He has published a book on “Pro-Poor Growth: Cross Country Analysis Focusing on South Asia.”He conducts trainings, delivers lectures and writes to English daily newspapers in Pakistan on social accountability, budget analysis and transparency and local governance.
Muddassir Ahmad is a Public Health professional with Masters in Public Health and a post graduate diploma in Public Health Management. He has an extensive experience of working on public health issues with national and International Organizations in Pakistan. He has successfully worked with communities and improved human lives in areas of TB ,MNCH, family planning, and primary health care with rigorous applications of gender and social accountability tools. He is also amongst the few public health experts who piloted different social accountability tools in Pakistan.