ASSESSMENT OF UHC PERFORMANCE MONITORING SYSTEM & UHC BUDGET AND EXPENDITURE ANALYSIS IN PAKISTAN June 2022 1 ACRONYMS AFB Acid-Fast Bacteria LHW Lady Health Worker Accountant General Pakistan MCH Mother and Child Healthcare Center AGPR Revenues Ministry of National Health Services, MONHSR&C ANC Antenatal Care Regulation and Coordination ARI Acute Respiratory Infection NCDs Non-communicable Diseases ASA Advisory Services and Analytics NAM New Accounting Model BEA Budget and Expenditure Analysis NGO Non-governmental Organization BHU Basic Health Unit NHA National Health Accounts CGA Controller General of Accounts OPD Outpatient department CoA Chart of Accounts Program for Advisory Services and PASA COVID-19 Coronavirus Disease-2019 Analytics DAO District Account Offices PFM Public Financial Management DDO Drawing Disbursing Officer Project to Improve Financial PIFRA Reporting and Auditing DHIS District Health Information System PNC Post-natal Care DHQ District Headquarters Hospital PER Public Expenditure Review Diphtheria, Tetanus, Toxoid and DPT3 People’s Primary Healthcare Pertussis PPHI Initiative EPI Expanded Program on Immunization RHC Rural Health Center FP Family Planning Reproductive, Maternal, Newborn Financial Accounting and Budgeting RMNCH FABS and Child Health System SDGs Sustainable Development Goals Global Alliance for Vaccines and GAVI TB Tuberculosis Immunization Government Financial Statistic THQ Tehsil Headquarters Hospital GFSM Manual UHC Universal Health Coverage Health Management Information UN United Nations HMIS System WAN Wide Area Network IT Information Technology WB World Bank KP Khyber Pakhtunkhwa Province WHO World Health Organization 2 ACKNOWLEDGEMENTS The report was prepared as one of the deliverables of the Public Financial Management and Health Financing pillar of the World Bank’s Pakistan Health Support Programmatic Advisory Services and Analytics (ASA) (P175571). This report is led by Qurat ul Ain Hadi (Financial Management Specialist, ESAG1). The report’s development was supported by a World Bank governance and health team including: Hammad Yunus (Public Financial Management [PFM] Consultant) and Tayyeb Masud (Health Specialist Consultant). It was funded by G4GFF, that is, the governance window of the Global Financing Facility and the Global Alliance for Vaccines and Immunization (GAVI) Alliance. The team gratefully acknowledges Najy Benhassine (Country Director for Pakistan), Hisham Waly (Governance Practice Manager, ESAG1) and E. Gail Richardson (Operations Manager, LCC3C). The report also benefited from the valuable inputs provided by Jahanzaib Sohail, (Health Specialist, HSAHP)Raymond Muhula (Senior Governance Specialist, ESAG 1), Aleksandar Kocevski (Senior Operation Officer, ESAG 1) and Akmal Minallah (Senior Financial Management Specialist, ESAG 1) and comments of peer reviewers: Michael Kent Ranson (Senior Health Economist, HHNGE), Timothy Stephen Williamson (Senior Governance and public sector specialist, EPSPF), Richard Anthony Sutherland (Governance Specialist, EPSPF) and Juliette Puret, (Senior Health financing expert GAVI). We also gratefully acknowledge the partnership and support of the Ministry of National Health Services, Regulation and Coordination (MONHSRC), the Finance Division and Provincial Finance Departments, the District Health Offices Primary Health Care Centers, and the Controller General of Accounts (CGA). They helped the Bank team to complete this task by providing useful comments and insights throughout the process. The team would also like to acknowledge the support provided by the staff of the Ministry of National Health Services, Regulation and Coordination (MONHSRC) and the World Bank, in particular Dr. Sabeen Afzal (Deputy Director), who provided guidance and facilitated the whole process, including communications with provincial authorities. We would also like to thank Ms. Lubna Yaqoob, and Dr. Raza Zaidi as well as other key officials at the Ministry of Health, Provincial Departments, United Nations agencies, non-governmental organizations/ international non-governmental organizations (NGOs/INGOs) and other stakeholders. FOREWORD In 2019, the Federal Government of Pakistan enacted a Public Financial Management (PFM) Law. It was subsequently supplemented by the “Financial Management and Power of Principal Accounting Officers Regulation 2021”, the aim of which was to strengthen PFM at the line ministry level. To this end, the PFM Law of 2019 requires each line ministry to have Chief Finance and Accounting Officers and Internal Auditors to improve financial management and the internal control environment. Under the law, all line ministries, including health have been obligated to submit performance-based reports to the Parliament. Each province is also preparing its own PFM law, in fact Balochistan have promulgated their own PFM Act in September 2020 and June 2022, respectively. Health managers have shown a particular interest in the performance evaluation to ensure proper oversight of health performance indicators, particularly the one linked to Universal Health Coverage (UHC) to ensure service access and equity. This report provides information about system challenges that prevent effective oversight and hinder accurate financial and performance reporting for the UHC. The report also suggests ways to improve financial and output health data to enable performance monitoring, as well as to increase the availability of useful information to decision makers. 3 CONTENTS Executive Summary.......................................................................................................................................... 8 1. Introduction.. ................................................................................................................................................ 12 1.1  Universal Health Coverage (UHC)............................................................................................................................................................... 12 1.2  UHC Reporting – Government Accounting System.......................................................................................................................... 13 1.3  Structure of the Report and Relevance................................................................................................................................................... 13 2. UHC Budget and Expenditure Performance Analysis.................................................................................... 14 2.1  Province-level Analysis................................................................................................................................................................................... 14 2.2  Key Findings....................................................................................................................................................................................................... 15 3. Policy Actions/ Recommendations. . ............................................................................................................ 26 Annex 1: Methodology..................................................................................................................................... 27 Limitations................................................................................................................................................................................................................ 28 Annex 2: Provincial UHC Budget and Expenditure Tables - Progress of UHC Indicators Tables......................... 44 Punjab UHC Progress............................................................................................................................................................................................ 44 Sindh UHC Progress..............................................................................................................................................................................................49 Khyber Pakhtunkhwa UHC Progress.............................................................................................................................................................. 54 Baluchistan UHC Progress.................................................................................................................................................................................59 Annex 3 District UHC Budget and Expenditure Table....................................................................................... 64 Punjab District Analysis.......................................................................................................................................................................................64 Sindh District Analysis..........................................................................................................................................................................................78 Khyber Pakhtunkhwa District Analysis........................................................................................................................................................89 Baluchistan District Analysis..........................................................................................................................................................................100 4 BOXES Box 1: What is UHC index?................................................................................................................................................................................................................8 Box 2: Can UHC be Measured?.................................................................................................................................................................................................... 12 Box 3: District Health Information System/ Health Management Information System................................................................... 27 Box 4: FABS........................................................................................................................................................................................................................................... 29 FIGURES Figure 1: UHC performance monitoring............................................................................................................................................................................... 10 Figure 2: Three Dimensions in Moving Toward Universal Health Coverage..................................................................................................12 Figure 3: Punjab - Universal Health Coverage Budget and Expenditure Execution and Performance .................................... 16 Figure 4: Sindh - Universal Health Coverage Budget and Expenditure Execution and Performance ........................................18 Figure 5: Khyber Pakhtunkhwa - Universal Health Coverage Budget and Expenditure Execution and Performance ......................................................................................................................................... 20 Figure 6: Baluchistan - Universal Health Coverage Budget and Expenditure Execution and Performance...........................................................................................................................................22 Figure 7: District-Level per Capita UHC Expenditures (FY 2018-19)................................................................................................................24 Figure 8: Framework for identification of Outputs for UHC...................................................................................................................................32 Figure 9: Punjab districts visits per person ..................................................................................................................................................................... 64 Figure 10: Punjab Districts: Expenditure per capita ................................................................................................................................................. 65 Figure 11: Sindh Districts visits per person....................................................................................................................................................................... 78 Figure 12: Sindh Districts Expenditure per capita........................................................................................................................................................ 79 Figure 13: KPK Districts Visits per person........................................................................................................................................................................ 89 Figure 14: KPK districts expenditure per capita........................................................................................................................................................... 90 Figure 15: Balochistan Districts visits per person..................................................................................................................................................... 100 Figure 16: Balochistan Districts Expenditure per capita....................................................................................................................................... 101 5 TABLES Table 1: Gaps in DHIS and FABS...................................................................................................................................................................................................9 Table 2: UHC Index............................................................................................................................................................................................................................ 30 Table 3: Mapping of UHC monitoring interventions/indicators against DHIS/HMIS data...............................................................33 Table 4: Proposed UHC Index template.............................................................................................................................................................................. 38 Table 5: Mapping of Chart of Account functional Codes......................................................................................................................................... 40 Table 6: Punjab: Budget and Expenditure for three years .......................................................................................................................................44 Table 7: Punjab: Budget and Expenditure for three years, primary and secondary ...............................................................................44 Table 8: Expenditure per facility .............................................................................................................................................................................................. 45 Table 9: UHC Index for Punjab................................................................................................................................................................................................... 45 Table 10: Access to UHC Index.................................................................................................................................................................................................. 46 Table 11: Service Availability Index........................................................................................................................................................................................... 47 Table 12: Service Outcomes Index.......................................................................................................................................................................................... 48 Table 13: Sindh: Budget and Expenditure for three years, primary and secondary............................................................................... 49 Table 14: Sindh: Expenditure per facility............................................................................................................................................................................ 49 Table 15: UHC Index Sindh........................................................................................................................................................................................................... 49 Table 16: Access to UHC Index.................................................................................................................................................................................................. 50 Table 17: Service Availability Index...........................................................................................................................................................................................51 Table 18: Service Outcomes Index...........................................................................................................................................................................................52 Table 19: KP: Budget and Expenditure for three years...............................................................................................................................................53 Table 20: KP: Budget and Expenditure for three years, primary and secondary..................................................................................... 54 Table 21: KPK Expenditure per facility................................................................................................................................................................................. 54 Table 22: UHC Index KPK............................................................................................................................................................................................................. 54 Table 23: Access to UHC Index................................................................................................................................................................................................. 55 Table 24: Service Availability Index........................................................................................................................................................................................ 56 Table 25: Service Outcomes Index.......................................................................................................................................................................................... 57 Table 26: Baluchistan: budget and expenditure for three years......................................................................................................................... 58 Table 27: Balochistan: budget and expenditure for three years, primary and secondary................................................................. 59 Table 28: Baluchistan Expenditure per facility.............................................................................................................................................................. 59 Table 29: UHC Index Baluchistan........................................................................................................................................................................................... 59 Table 30: Access to UHC Index................................................................................................................................................................................................. 60 Table 31: Access to UHC Index................................................................................................................................................................................................... 61 6 Table 32: Service Availability Index........................................................................................................................................................................................ 62 Table 33: Service Outcomes Index ........................................................................................................................................................................................ 63 Table 34: Public health facility.................................................................................................................................................................................................. 64 Table 35: District tables Punjab: Expenditure per capita and visits per person...................................................................................... 66 Table 36: Punjab Health facilities ........................................................................................................................................................................................... 67 Table 37: Punjab Districts Budget Utilization for three years............................................................................................................................. 68 Table 38: Punjab Districts Budget, Expenditure and cost per patient 2016............................................................................................. 69 Table 39: Punjab Districts Budget, Expenditure and cost per patient 2017............................................................................................... 72 Table 40: Punjab Districts Budget, Expenditure and Expenditure per patient 2018............................................................................ 75 Table 41: Sindh: Public Health Facilities............................................................................................................................................................................... 78 Table 42: Sindh: Districts Expenditure per capita and visits per person...................................................................................................... 80 Table 43: Sindh Health Facilities...............................................................................................................................................................................................81 Table 44: Sindh Districts Budget Utilization.................................................................................................................................................................. 82 Table 45: Sindh Districts Budget, Expenditure, and cost per patient 2016............................................................................................... 83 Table 46: Sindh Districts Budgets, Expenditures and Expenditure per patient 2017......................................................................... 85 Table 47: Sindh Districts Budget, Expenditure and Expenditure per patient 2018................................................................................ 87 Table 48: Public Health Facilities: KPK............................................................................................................................................................................... 89 Table 49: KP Districts Expenditure per capita and visits per person............................................................................................................... 91 Table 50: KP Health Facilities.................................................................................................................................................................................................... 92 Table 51: KP districts Budget Utilization........................................................................................................................................................................... 93 Table 52: KP Districts Budget Expenditure and Expenditure per patient 2016...................................................................................... 94 Table 53: KP districts Budget, Expenditure and Expenditure per patient 2017...................................................................................... 96 Table 54: KP Districts Budget Expenditure and Expenditure per patient 2018...................................................................................... 98 Table 55: List of Public Health Facilities Balochistan.............................................................................................................................................. 100 Table 56: Balochistan Districts; Visits per person and Expenditure per capita.................................................................................... 102 Table 57: Baluchistan Districts Budget Utilization.................................................................................................................................................. 103 Table 58: Balochistan Districts Budget Expenditure and Expenditure per patient 2016.............................................................. 104 Table 59: Balochistan Districts Budget Expenditure and Expenditure per patient 2016.............................................................. 105 Table 60: Balochistan Districts, Budget, Expenditure and Expenditure per patient......................................................................... 108 Table 61: Balochistan Districts Budget, Expenditure and Expenditure per patient.............................................................................. 111 7 EXECUTIVE SUMMARY In 2016, Pakistan adopted the Sustainable Development Goals (SDGs) into its national development agenda as part of its commitment to the 2030 Agenda for Universal Health Coverage (UHC). In 2018, the Government of Pakistan designed and approved a National SDGs Framework to prioritize and localize SDGs, which included an accelerated path toward UHC. To measure the global advancement toward UHC, the World Bank and the World Health Organization (WHO) have regularly issued reports concerning how countries were progressing in achieving their goals. However, there is a fundamental challenge in reporting because UHC means different things to different countries, both at the national and sub-national levels. To address this challenge in Pakistan, the Ministry of National Health Services, Regulation and Coordination (MONHSRC) released a report that derives a public health system output referred to as the UHC Index. It uniformly measures the UHC at the sub- national levels. The Index is derived from the 16 clusters1 identified by the WHO to monitor the UHC. To facilitate UHC monitoring, this report evaluates the challenges of measuring UHC performance and develop a contextually relevant reporting template of UHC outputs and financial inputs to enable sub-national monitoring, in this case, district-level monitoring. The data collection effort during measurement and monitoring used the index and template. It brought to light limitations and system gaps of both the routine reporting system and the financial data inputs. The implementation of the proposed suggestions to address these inconsistencies would result in improved UHC performance reporting, thereby also improving budget adequacy, transparency, and accountability in the health care system. These templates and the proposed UHC index will help health officers in data collection effort during measurement and monitoring of UHC performance. This report includes UHC performance reports developed using these templates and UHC index. This kind of work is done for the first time in the country. It brought to light limitations and system gaps of both the routine reporting system and the financial data inputs. The implementation of the proposed suggestions to address these inconsistencies would result in improved UHC performance reporting, thereby also improving budget adequacy, transparency, and accountability in the health care system. Performance accountability underscores the core theme of the PFM act 2019 and Financial Management and Powers of Principal Accounting Officer (PAO) Regulations 2021. It requires each line ministry to prepare performance-based budgets and, at year-end, report on expenditures, outputs, outcomes achieved against Box 1 What is UHC index? There is a fundamental challenge in reporting because UHC means different things to different countries, both at the national and sub-national levels. To address this challenge in Pakistan, the Ministry of National Health Services, Regulation and Coordination (MONHSRC) released a report that derives a public health system output referred to as the UHC Index. It uniformly measures the UHC at the sub-national levels. The Index is derived from the 16 clusters identified by the WHO to monitor the UHC. the agreed performance indicators2 and to formulate and monitor plans, outcomes and outputs and key performance indicators and targets3. However, it is extremely difficult to generate integrated performance reports through Financial Accounting and Budgeting System (FABS). Thus, each line ministry including health must develop its performance benchmarks and have system in place for data collection, measurement of output and reporting of results. From system perspective, the most challenging factor for performance reporting is availability of timely and reliable data. Health departments (federal and provincial) use District Management Information System for reporting on health sector outputs while Financial Accounting and Budgeting system is used for budget and expenditure reporting. Both systems have fall short of in terms of data management. While DHIS has completeness issues, FABS has gaps in budget coding. Some of the key systemic issues in existing performance reporting system are presented below in Table-1. 1 The World Bank and WHO report on Progress toward the UHC uses 16 clusters, which have been adopted by Pakistan. 2 Clause 9 of the PFM Act 2019 3 Clause 7 of the FM and Powers of the PAO Regulation 2019 8 Key Findings Table 1: Gaps in DHIS and FABS District Health Information System (DHIS) Financial Accounting & Budgeting System (FABS) Universal Health Care (UHC) Indicator Data UHC Budget and Expenditure Data The DHIS data lacks inpatient data. Thus, this is an 1.  The FABS current budget coding mechanism is 1.  important missing link in estimating costs. sufficient to account for funds budgeted, allocated, and released, as well as for expenditures. However, given frequent budget coding revisions and a lack of detailed instructions for health budget coding, the mapping of codes by service/UHC indicators is quite difficult. The DHIS data does not provide information about 2.  The existing Chart of Accounts does not support bud- 2.  non-communicable diseases. This would neces- get and expenditure recording with respect to primary, sitate supplementing the data with other regularly secondary, and tertiary health care classifications. The- reported information at the district level to monitor refore, no such report can be generated from FABS. the Non-communicable Disease (NCD) cluster. The DHIS data reporting is not consistent across 3.  The Chart of Accounts coding across provinces 3.  provinces. This issue does not affect the analysis in and across years is not consistent, and items are examining a single district. However, it becomes extre- often coded under one budget line — and then later mely difficult to compare across districts and provinces. expended against other budget lines. Thus, the definitions of data need to be consistent. The DHIS internal verification mechanisms need 4.  There needs to be a clear definition and metho- 4.  to be introduced, and further effort is required to dology for budgeting, accounting, and reporting of ensure data reliability. funds destined for contract facilities. The budgeting mechanism for these transfers is currently not clear, as there are amounts recorded against “Grants to Others” or “Transfers”, some of which appear to be for contracted facilities for primary health care. Tertiary care data is not part of the DHIS sys- 5.  tem. Including this data alongside the outpatient department (OPD) data would greatly improve the understanding of the overall impact of the public sector on UHC. The estimate of visits per person does not consider 6.  multiple visits by the same person. Hence, there is an overestimate of actual population coverage. The UHC analysis brought to light the need for interventions to improve the District Health Information System (DHIS) data quality, as well as steps to improve the Financial Accounting and Budgeting System (FABS) health budget coding (table 1). The DHIS data does not provide information about non- communicable diseases (NCDs). Thus, it needs to be supplemented with other regularly reported information at the district level to monitor the NCD cluster. In addition, the DHIS internal verification mechanisms should be reinstituted, and further effort will be required to ensure data reliability. The reported wide variation in the Expanded Program on Immunization (EPI) indicators is an example of the lack of standardization in the system that should be addressed4. For budgeting and accounting, the Government of Pakistan has the unified Chart of Accounts (CoA). It is implemented at all tiers of government. For a country of its size and diversification, this represents a major feat. Accounting data is reliable, and the financial reports generated are credible. However, the use of the CoA in the health sector is not consistent across provinces, which create difficulties in producing an aggregate view of sector allocations and spending from the FABS5. 4 The figure in the DHIS and with immunization numbers at the provincial EPI information technology (IT) system varies significantly. This wide variation in EPI indicators reported reflects poorly on data reliability. 5 Pakistan uses an integrated financial management information system, which is called Financial Accounting and Budgeting System (FABS), which connects all 140 District Account Offices (DAOs) across the country with centralized data base. It provides such data at the respective provincial headquarters and then with the central server at the federal capital. The DAOs is a network of accounting units of the Controller General Accounts (CGA). It is spread all over the country, with one in each district. 9 UHC Performance Analysis All four provinces show mixed trends in the attainment of UHC indicators over the period under consideration, that is, Fiscal Year (FY) 2016 to 2019. Figure 1 illustrates UHC performance by province, as well as a budget and expenditure execution analysis. Figure 1: UHC performance monitoring Decrease Improvement in the case of UHC indicators, progress variation within the range of + 2.5% is considered static. In case of Static ( “UHC budget utilization”, + 5% on either side of 100 percent is considered static or within the normal range.) Source: Country Financial Management Information System (FABS), the Controller General of Accounts, the Government of Pakistan and the District Health Information System of each respective province and Health Management Information System (HMIS) in the Federal government. Note: Refer to Annex 1 regarding the methodology for developing the proposed UHC index. The infectious disease control cluster implies improvement in service delivery. Thus, an increase in reported cases is considered to be a positive trend. * ** No data for non-communicable disease is available in the DHIS. “UHC budget Utilization”, “Total UHC expenditure per capita” and “Expenditures per facility” values are for FY 2019 with movement (increase/decrease) over the observed period of 2016-2019. ***  Since 2016, there has been an increase in the overall health budget for primary and secondary care in all pro- • vinces, except for Baluchistan, where the budget increase has been insignificant. The UHC index movement is minimal with regard to the “overall” classification; the primary improvements are increases in services provided for antenatal care (ANC) and child immunization. Family planning services show minimal change. For service provision, there has been an overall increase in reported cases of acute respiratory infections (ARIs) for children under the age of five. The budgetary composition remains skewed toward secondary care, especially in the case of the Punjab pro- • vince. Although budget utilization has improved over time, the 100 percent budgetary utilization6 indicates that the budgeting process and allocations may need revision to ensure adequate allocations and consistent use of the Chart of Accounts. Per capita expenditures reveal variations between districts. These should be further explored at the provincial • level to better understand how differences link (or do not link, as the case may be) to health service provision. There does not seem to be a direct relationship between visits per person and per capita expenditures over • time. Further research and statistical analysis will be required to discern which factors affect this relationship. The UHC analysis also shows that a lot of variation exists within provinces, even if the centralized expenditures for preventive programs are excluded. This needs to be further analyzed and addressed. The wide variations in expenditures between expenditures per health facility indicates the need for costing stu- • dies. Such studies would ascertain the costs of indoor service provision, as well as the actual costs of primary care service provision. The broad global estimates do not easily lend themselves to formulating district-level budgets. Conclusion A review of the UHC indexes and disaggregated budgetary analysis shows that there is inconsistent progress against these indicators. Given that the public health institutions do not provide services to most of the popula- tion, this variation shows that even the services provided vary over time. In addition, population service utilization reflects service availability and provision variations. Recommended Policy Actions for Performance Monitoring of UHC The lack of integration of various health sector data sets available within the country undermines effort to utilize routine data to estimate the progress made in public sector health service provision. The absence of a unified out- put database and lack of financial transparency for services and facility level expenditure are the key reasons that a performance (input-output) report for UHC indicators cannot be generated from the existing Chart of Accounts. The proposed National Health Support Program (P172615) has addressed data reliability issues for UHC per- formance reporting through specific Disbursement Linked Indicators (DLI): improving district health information system (DLI-6) and review and updating of government Chart of Account to improve fund tracking and financial reporting of PHC budget and expenditure (DLI-9)7.The important policy aspects to enable UHC performance monitoring are as follows:  or the performance management system to work, the foremost thing is to clearly define Pakistan’s goal 1. F of achieving UHC and everything else flows from there – setting standards, establishing benchmarks and developing performance indicators. It should be widely disseminated, especially at the lower health system levels, to enable monitoring of unified performance indicators. Though, after 18th amendment to the consti- tution, health care is a provincial subject, but Ministry of National Health Services Regulation and Coordina- tion (MoNHSR&C) must take a lead in defining UHC goal in agreement with all provinces and will similar- ly, play an important role in coordinating and setting up uniform performance standards across provinces. n FY 2021, the government launched the health insurance for low-income households. In addition, provin- 2. I cial governments are increasingly using Public-Private-Partnership mode for management of primary and se- condary health facilities. These new initiatives warrant a review of PFM arrangements to support the financial oversight. The absence of monitoring for financial protection needs more attention given the current levels of out-of-pocket expenditures (51.7 percent according to the National Health Accounts (NHA) for 2017-18)  egarding objective accountability and performance measurement, the financial reporting and monitoring of 3. R UHC will need to be strengthened. For this purpose, a review of the CoA is required at the provincial level with respect to health sector functional classification within the existing CoA framework. This is particularly relevant for provincial finance and health departments to present budgets and costs by level of facility (individual facility and cost driver). Further, budget allocations to districts and within districts should be linked to the service out- puts (refer table 4 for proposed template) as opposed to line items.  or credible budgeting the provincial health departments should carry out cost studies for priority services to 4. F deliver UHC at various service delivery level. 6 Instances of greater than 100% budget utilization rate since 2016 include: Punjab: FY 2016-17 (105%); FY 2017-18 (102%) KPK: FY 2017-18 (107%); and Balochistan: FY 2016-17 (105%). 7 Project Appraisal Document National Health Support Program, World Bank, May 2022 11 1. INTRODUCTION Universal Health Coverage is a central goal of the Pakistan health sector. Various interventions have been initiated to address this goal. The question is how to monitor short-term progress toward this goal and link the progress with expenditures to ensure adequacy and continuity of service availability at the grass roots level. The analysis in this paper presents a methodology to monitor financial and performance progress using routine financial and administrative data. 1.1  Universal Health Coverage (UHC) The WHO defines UHC as follows: “[It] means that all people have access to the health services they need, when and where they need them, without financial hardship. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care8.” Three main questions should be addressed: What to cover: The choices and trade-offs policymakers need to make between the dimensions of population coverage, service coverage and financial protection (Box 2). How to pay for UHC: Raising the necessary resources, then allocating and managing these resources efficiently and equitably. How to implement UHC: The issues that need to be addressed to successfully implement UHC reforms. Box 2: Can UHC be Measured? Monitoring progress toward UHC can be measured, and it should focus on two things: The proportion of a population that can access essential quality health services (SDG 3.8.1) • The proportion of the population that spends a large amount of household income on health (SDG 3.8.2). • Measuring equity is also critical to understand who is being left behind—where and why. Source: https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc) Specific policy recommendations in these areas are highly dependent on the context of the country. In particular, the health needs of the population, the level of economic development, and the country’s political environment should be major factors shaping policy responses. Designing and implementing a UHC strategy should therefore not be seen as a one-size-fits-all process. Universal health coverage deals with three major aspects (Figure 2): Services, (What services are available?), Coverage (What proportion of population has access to these services?) and Financial Protection (ensuring that paying for services does not cause financial hardship). Figure 2: Three Dimensions in Moving Toward Universal Health Coverage Reduce cost direct costs Include sharing and proportion other fees of the costs services covered Extend to non- covered Current pool funds Services: which services Population: who is covered? are convered ? Source: World Health Report (2010). 8 Universal Health Coverage Fact Sheet: https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc). Accessed 10 September 2021. 12 1.2  UHC Reporting – Government Accounting System In Pakistan, the attainment of UHC requires coordination within the health and other government sectors, such as population, finance, planning, and so on. They all need to work together and supplement each other’s efforts. Health is also a provincial subject. As such, each province is responsible to its population for ensuring achievement of health sector outcomes. The Health Departments in the provinces and the MONHSR&C at the federal level are primarily responsible for delivering the country’s health mandate. Provincial health departments and the MoNHSR&C are further supported by other ancillary departments. Although they are part of the health department, they are distinct from the parent entity. The UHC is cross-cutting from the health sector perspective, that is, its activities cut across more than one entity and function (within the health sector). Pakistan’s national accounting system has progressed over time. However, as the government endeavors to deliver its mandate, there is a need for an accounting system that can facilitate the realization of its service delivery goals. It should also be fully capable of implementing the PFM Act of 2019, including reporting requirements (reference sections 9, 34 and 35 of the PFM Act of 2019)9. The robustness of the accounting system depends on the architectural strength of the underlying Chart of Accounts. Pakistan has a unified CoA that is applicable at all tiers of government (federal, provincial and district). To inform policy, it is important that the CoA structure should track the cost of services. It should also enable accountability in terms of performance. The existing CoA has all the elements to meet these requirements. However, the functional classification requires reconfiguration to cater to the needs of UHC reporting. At the same time, the CoA’s application also needs improvement to ensure effective reporting because the different implementation arrangements for the various primary health care programs have resulted in inconsistent usage of CoA elements. The need for PFM reforms in the health sector, and especially with respect to UHC performance reporting, has become critical given the fact that the PFM Act of 2019 requires each ministry at the federal level to submit year- end performance reports. These reports then go before the National Assembly for consideration (Section 35, PFM Act of 2019). 1.3  Structure of the Report and Relevance The budget and expenditure analysis of UHC encompasses a period of three years (2016-19). The report presents the findings of the analysis at the provincial and district levels following the methodology, which is outlined in Annex 1. The detail provincial UHC progress over three years have been presented in Annex-2 while Annex-3 has district -wise UHC performance analysis. 9 In accordance with the PFM Act 2019, it is mandatory for each principal accounting officer to submit a medium-term budgetary framework that would include past and current year performance, along with policy goals, indicators and achievements to date. 13 2. UHC BUDGET AND EXPENDITURE PERFORMANCE ANALYSIS This section presents a provincial analysis covering a period of three years (2016-19). It addresses both performance monitoring system gaps and UHC performance analysis based on provincial financial and UHC progress data tables and district-wide results. Performance analysis for each province has two parts, including a financial part using FABS data, as well as progress related to UHC indictors using DHIS/ Health Management Information System (HMIS) data. It should be noted that this study provides a reporting template for UHC integrated reporting, comparing financial and output data. The findings are presented for each province individually; however, there are a few general aspects common across all provinces. a. Budget formulation: The wide variation in utilization over time and within provinces indicates a weakness in the budgeting process. Utilization above 100 percent is problematic. There is always a small portion of the salary budget that is not utilized. As the analysis looks at the original budget versus actual expenditures, it indicates that the preparation of the original budget did not account for policy changes or even focus. Furthermore, even for the same province, the coding of the budget changes from year to year, thus hampering attempts at a more detailed analysis. b. Budget and expenditure codes: The coding issue leads to budget codes having very high expenditures compared to the original budget and vice versa. The salary versus non-salary expenditures and the composition of the budgets at the district level are made problematic, as the codes keep changing between budgets and expenditures. In some cases, items not budgeted for are showing up in the expenditures. All of this is done according to the provision in the rules for supplementary grants, transfers in, transfers out, surrender, release, and the final budget. However, it basically creates an additional workload at the administrative level both for the accounting system, as well as for the management system. A solution needs to be worked out to simplify this process. c. Budget composition: Consistent investment patterns are noted in primary and secondary health care investments over the three-year period. The KPK has increased its investment in PHC in 2019, whereas a significant decline is seen in PHC investment in Baluchistan. d. DHIS data: The standards of reporting vary across districts, and in some there is a consistency in the definitions that appear to have been used, whereas in others this is missing. e. Expenditures per capita: In Rupee terms, expenditures per capita have increased over the three years, except for Baluchistan. However, the increase is more marked in 2016 to 2017. It was quite small in 2018 (see: “District wise per Capita UHC Expenditure FY 2018-19 ”). If it is adjusted against US dollar, the exchange rate remained stable (at around PKR 104-5= 1 USD) in 2016 and 2017. However, in 2018, the Rupee was devalued to around PKR 130-140. Thus, the increase in real terms is very minimal for 2018. 2.1. Province-level Analysis For UHC indicators, no major increase was observed over time, indicating that no targeted interventions were in place. However, a decrease in delivery-related indicators was seen in Punjab, which may show a change of focus with the change of government. The province-level detailed UHC performance and budget and execution analysis is provided in Annex-2, the summarized version is presented below in Figures 3, 4, 5 and 6. 14 2.2. Key Findings The provincial analysis shows that even with the weak HMIS data, some progress can be monitored in UHC-related public health expenditures. Furthermore, the proposed framework can be utilized for monitoring purpose. The present lack of linkages to output can be rectified. However, it would require a serious effort to recode the health data to allow for tracking over time among the different categories. This review also shows that within provinces there also exists a lot of variation, even if the centralized expenditures for health care programs are excluded, as evident from the per capita expenditure analysis (Figure 7). This needs to be addressed. Furthermore, the visits per person when compared to the per capita expenditures over time, do not appear to have any direct relationship. Research and statistical analysis will be required to discern which factors affect this relationship. The proposed UHC index can be used to monitor progress in UHC at the provincial and district levels, keeping the following important weaknesses of the DHIS data in mind: The DHIS data lacks inpatient information; thus, this should be considered when estimating costs. a.  The DHIS data does not provide information about non-communicable diseases (NCDs). This needs to b.  be supplemented with other regularly reported information at the district level to monitor the NCD cluster. The DHIS data reporting is not consistent across provinces, although this issue is resolved when district- c.  level data is analyzed for the district. However, to compare across districts and provinces, the definitions of data will need to be consistent. The internal verification mechanisms of the DHIS need to be reinstituted. Also, further effort is required to d.  ensure the reliability of the data. The wide variation in EPI indicators reported is an indication of the issues to be resolved. Data for tertiary care is not included. Furthermore, even inclusion of the Outdoor Patient Door (OPD) data e.  would greatly improve the understanding of the overall impact of the public sector on UHC. Some costing studies need to be carried out to ascertain the cost of provision of indoor services, as well f.  as the actual cost of the provision of primary care services. The broad global estimates do not easily lend themselves to formulating district level budgets. The per capita expenditures reveal variations among districts. These need to be investigated at the g.  provincial level to understand how they are linked to the provision of services. The estimate of visits per person does not take into consideration multiple visits by the same person. h.  Hence, there is an overestimation of the actual coverage of the population. Regarding the financial data, the issues are more at the provincial level. A better understanding of the allocative efficiencies of the health budget is needed. At the district level, it would be easier to use the data. However, when large-scale comparisons are attempted, the coding issues come to the fore. Some important aspects requiring attention include the following: The use of CoA coding across provinces and across years is not consistent, and items are often coded 1.  under one budget line and then later expended against other budget lines. The object and functional coding for health needs to be further defined to ensure a common understanding 2.  of what is to be coded against which code. This will allow for consistent coding that will lend itself to analysis over time. In Sindh and Baluchistan, the management of PHC facilities is largely contracted-out to PPHI. The PPHI10 is 3.  a public–private partnership (PPP) program of the Governments of Sindh and Baluchistan. PPHI manages 1,140 primary healthcare facilities in Sindh and 653 BHUs/health facilities in Baluchistan through funding provided by the respective provincial governments. These facilities are referred as “contracted-out facilities.” There needs to be a clear definition and methodology of coding the budget destined for contracted facilities. The coding for these transfers is not quite clear. There are also amounts coded against grants to other or transfers to some of which appear to be for contracted facilities. Others are not clearly labeled. Similarly, the differentiation of tertiary and specialized care institutions is not clear in the budget. They 4.  are mostly lumped under general health services or hospital services, which also includes secondary care hospitals. 10  It is a section 42 Company organized by independent private citizens as a Board of Directors. From 2014, PPHI became a registered not-for-profit company. The objective of the organization is to revitalize delivery of health services in the rural areas of Sindh. 15 Figure 3: Punjab - Universal Health Coverage Budget and Expenditure Execution and Performance UHC budget performance UHC output performance Reproductive, Maternal, Neonatal, Child Health UHC Budget & Expenditure and Adolescent Cluster 90% 105% 105% 200 102% Utilization rate Rs. in billions 100% 95% 45% 100 94% 90% 0 85% 0% 2016 2017 2018 2016 2017 2018 Total FP visits Postnatal Care (PNC) UHC Budget UHC Expenditure Utilization Deliveries Normal Deliveries through C-section DPT3 (diphteria, TT & pertussis) Infectious Disease Control UHC per capita exp. & visit per person (Communicable Disease) Cluster 80% 2 000 1,0 Per capita Expenditure in Rs. 0,95 Visit per person per year 0,82 40% 1 000 0,5 0,35 0% 0 2016 2017 2018 2016 2017 2018 Total TB cases including Lab AFB positive cases Expenditure per capita Visits per person per year Total Malaria cases including MP & falciparum positive cases Total Typhoid cases 150% UHC function wise utilization rate Service capacity and access cluster 80% 100% 40% 50% 0% 0% 2016 2017 2018 2016 2017 2018 Primary Secondary Admin Deliveries All Antenatal Care (ANC) visits Measles/Measles 1 Fully Immunized Accute Respiratory Infection (ARI) cases Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan 16 Figure 3 (contd): Punjab - Universal Health Coverage Budget and Expenditure Execution and Performance The budget for primary and secondary health has increased over the three years, and there has been an improvement in the utilization rate of primary health UHC financial mix - Budget & Expenditure care. The increase in primary and secondary care allocation doubled for 2016 and 2017. The increase in primary healthcare is much larger than in secondary care for 2018. There is also an increase in the number of visits (primary and secondary), as well as an increase in the per capita expenditure at the primary and secondary levels. However, the numbers do not Financial Mix Financial Mix show a clear relationship between the two. in Budget 2016 in Expenditure 2016 In 2017, there was an eighty-two percent increase in the budget for primary health care and a one 12% 10% 9% 5% hundred and forty-two percent increase in budget for administration. Budget utilization for primary health care has varied significantly over the years, that is, from fifty to one hundred and nineteen percent. 78% 86% The share of the budget allocated to primary health care and administration has increased relative to Secondary, and the trend has remained same for budget as well as expenditure. Admin has witnessed maximum growth in the expenditure which has doubled since 2016. The UHC index remain static or Financial Mix Financial Mix declining in the three years. One of the major factors in Budget 2017 in Expenditure 2017 appears to be the decrease in service delivery (this may be due to a change of focus after the change of government). The visits per person and expenditures 11% per capita show a positive trend. 19% 13% 20% However, the decrease in primary care indicators requires further in-depth analysis by the Department of Health to understand the issues behind the 70% 67% phenomenon. The UHC index for the RMNCH cluster shows a decrease. Closer examination shows that the DTP3 has decreased over the three years for the service capacity and access cluster. A fall was also evidenced in the reported number of deliveries in 2018. There was also a gradual fall in the immunization Financial Mix Financial Mix indicators. in Budget 2018 in Expenditure 2018 19% 16% 15% 21% 65% 66% Primary Secondary Admin Data Source: District Health Management Information system Punjab. Refer to annexure -1 for methodology for deriving UHC Index 17 Figure 4: Sindh - Universal Health Coverage Budget and Expenditure Execution and Performance UHC budget performance UHC output performance Reproductive, Maternal, Neonatal, Child Health UHC Budget & Expenditure and Adolescent Cluster 120 100% 100 86% 60% 83% 80% 80 60% Utilization rate Rs. in billions 60 58% 30% 40% 40 20% 20 0% 0% 2016 2017 2018 0 2016 2017 2018 Total FP visits Postnatal Care (PNC) Deliveries Normal Deliveries through C-section PHC Budget PHC Expenditure Utilization DPT3 (diphteria, TT & pertussis) UHC per capita exp. & visit per person Infectious Disease Control (Communicable Disease) Cluster 0,94 20% 2 000 0,92 0,92 Per capita Expenditure in Rs. 0,9 Visit per person per year 0,88 0,87 10% 1 000 0,86 0,84 0,84 0,82 0 0% 0,8 2016 2017 2018 2016 2017 2018 Expenditure per capita Visits per person per year Total TB cases including Lab AFB positive cases 2016 2017 2018 Total Malaria cases including MP & falciparum positive cases Total Typhoid cases UHC function wise utilization rate Service capacity and access cluster 120% 60% 50% 40% 60% 30% 20% 10% 0% 0% 2016 2017 2018 2016 2017 2018 Primary Secondary Admin Deliveries All Antenatal Care (ANC) visits Measles/Measles 1 Fully Immunized Accute Respiratory Infection (ARI) cases Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan 18 Figure 4 (contd): Sindh - Universal Health Coverage Budget and Expenditure Execution and Performance There was an increase in the health budget from 2016 to 2017. However, for 2018, the increase is minor. UHC financial mix - Budget & Expenditure Primary care expenditures have increased over the three years, whereas for secondary care, it stagnated in 2017. The overall finance mix remained the same over the observed period. The budget utilization has improved, and the overall distribution of the budget remains stable. Financial Mix Financial Mix However, overall budget utilization is still on the in Budget 2016 in Expenditure 2016 lower side. This requires investigation, except for the secondary health care in FY 2017, where expenditures rose from fifty to one hundred and five 11% 16% percent. Similarly, Hyderabad shows a very high expenditure rate per capita, which is mainly due to 40% 42% programs being financed through the Karachi and Hyderabad Accountant General offices. The visits per person and expenditures per capita show a positive trend. Also, there was an increase in expenditure in 50% 42% 2017, as well as a minor increase in visits per person. However, the increase in expenditures does not show a clear relationship to visits. There is an increase in visits per person over this time. Financial Mix Financial Mix in Budget 2017 in Expenditure 2017 The UHC index also shows a positive trend over the three years. In addition, improvements were seen in access indicators. However, the decrease in primary 13% 10% care indicators requires further in-depth analysis by 40% 33% the Department of Health to understand the issues behind the phenomenon. In the district analysis, Karachi appears to have a very low number of visits per person. This is due to the missing OPD data from 48% 57% tertiary care hospitals. Financial Mix Financial Mix in Budget 2018 in Expenditure 2018 16% 13% 35% 35% 49% 52% Primary Secondary Admin Data Source: District Health Management Information system Sindh. Refer to annexure -1 for methodology for deriving UHC Index 19 Figure 5: Khyber Pakhtunkhwa - Universal Health Coverage Budget and Expenditure Execution and Performance UHC budget performance UHC output performance Reproductive, Maternal, Neonatal, Child Health UHC Budget & Expenditure and Adolescent Cluster 30 150% 80% 107% 70% 20 92% 60% 84% 100% 50% Rs. in billions 40% Utilization 30% 10 50% 20% 10% 0% 0% 2016 2017 2018 0 2016 2017 2018 Total FP visits Postnatal Care (PNC) Deliveries Normal Deliveries through C-section PHC Budget PHC Expenditure Utilization DPT3 (diphteria, TT & pertussis) UHC per capita exp. & visit per person Infectious Disease Control (Communicable Disease) Cluster 10% 1 000 0,90 Per capita Expenditure in Rs. Visit per person per year 0,62 0,63 0,64 0,60 5% 500 0,30 0 0% 0 2016 2017 2018 2016 2017 2018 Expenditure per capita Visits per person per year Total TB cases including Lab AFB positive cases Total Malaria cases including MP & falciparum positive cases Total Typhoid cases UHC function wise utilization rate Service capacity and access cluster 300% 80% 70% 200% 60% 50% 40% 100% 30% 20% 10% 0% 0% 2016 2017 2018 2016 2017 2018 Primary Secondary Admin Deliveries All Antenatal Care (ANC) visits Measles/Measles 1 Fully Immunized Accute Respiratory Infection (ARI) cases Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan 20 Figure 5 (contd): Khyber Pakhtunkhwa - Universal Health Coverage Budget and Expenditure Execution and Performance Regarding the KPK, there was an overall increase of budget and expenditure. There was also an increase UHC financial mix - Budget & Expenditure in the number of visits per person. The budget and expenditure distributions are initially skewed toward secondary care, but in 2017 and 2018, the distribution changed to improve financing for primary care. The sharp increase in “Administration” in the year 2017 is due to the fact that EPI funds were budgeted under the “EPI” (074105) function code, but actual expenditures Financial Share Financial Share were incurred under the “Administration” (076101) in Budget 2016 in Expenditure 2016 function code. In 2018, EPI was budgeted and spent under the “EPI” (074105) function code. The financial share or mix has changed significantly between 15% 9% 18% primary, secondary and administration, reflecting poorly on the use of CoA coding for budgeting, as well 22% as on the subsequent reappropriation process (shifting the budget from one code to the other at the time of expenditure). The UHC index for the KPK remains stable, and it shows minor incremental change. There 63% are some improvements in ANC and immunization 74% indicators over time, whereas the rest show minimal variation. Financial Share Financial Share in Budget 2017 in Expenditure 2017 19% 13% 20% 45% 61% 43% Financial Share Financial Share in Budget 2018 in Expenditure 2018 26% 24% 36% 31% 37% 45% Primary Secondary Admin Data Source: District Health Management Information system KP. Refer to annexure -1 for methodology for deriving UHC Index 21 Figure 6: Baluchistan - Universal Health Coverage Budget and Expenditure Execution and Performance UHC budget performance UHC output performance Reproductive, Maternal, Neonatal, Child Health UHC Budget & Expenditure and Adolescent Cluster 40% 30 150% Rs. in billions 105% 100% 99% Utilization 90% 20 50% 10 0% 0% 2016 2017 2018 2016 2017 2018 Total FP visits Postnatal Care (PNC) UHC Budget UHC Expenditure Utilization Deliveries Normal Deliveries through C-section DPT3 (diphteria, TT & pertussis) Infectious Disease Control UHC per capita exp. & visit per person (Communicable Disease) Cluster 10% 2 000 0,30 Per capita Expenditure in Rs. Visit per person per year 0,22 5% 0,19 0,18 0% 1 500 2016 2017 2018 2016 2017 2018 Total TB cases including Lab AFB positive cases Expenditure per capita Visits per person per year Total Malaria cases including MP & falciparum positive cases Total Typhoid cases 150% UHC function wise utilization rate Service capacity and access cluster 40% 200% 20% 100% 0% 0% 2016 2017 2018 2016 2017 2018 Primary Secondary Admin Deliveries All Antenatal Care (ANC) visits Measles/Measles 1 Fully Immunized Accute Respiratory Infection (ARI) cases Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan 22 Figure 6 (contd): Baluchistan - Universal Health Coverage Budget and Expenditure Execution and Performance Baluchistan has experienced a minimal increase in its health budget over time. However, the number of UHC financial mix - Budget & Expenditure visits per person appears to be declining. The budget and expenditures for primary care show a large decline in 2018. Also, the PHC has a higher financial share in comparison to the other provinces, and it is constant over the observed period. The utilization of the budget remains quite high. The high budget over run indicates a trend in under-budgeting at the Financial Share Financial Share time of budget formulation. This was due to weak in Budget 2016 in Expenditure 2016 planning capacity or wrong use by the CoA. Either way, this needs further investigation as the trend is consistent over the observed period. The effect of 23% health programs being financed through the Quetta 33% 36% AG office becomes pronounced when the expenditure 45% per capita is calculated. Since the major hospitals in Baluchistan are also in Quetta; hence, their budget is also reflected. The UHC index shows minor fluctuations over the three-year period. Post-natal 32% care has shown improvement, and the total FP visits 31% have shown marked improvement. The UHC index dipped in 2017 before rising again in 2018 in relation to 2016. Financial Share Financial Share in Budget 2017 in Expenditure 2017 27% 28% 44% 36% 29% 36% Financial Share Financial Share in Budget 2018 in Expenditure 2018 14% 14% 47% 45% 39% 41% Primary Secondary Admin Data Source: District Health Management Information system Baluchistan. Refer to annexure -1 for methodology for deriving UHC Index 23 Figure 7: (See Next Page) District-Level per Capita UHC Expenditures (FY 2018-19) Data Source: FABS, Controller General of Accounts; Bureau of Statistics, Pakistan Annex-3 provides detailed district-wise UHC progress analysis. Per capita expenditures reveal significant variations between districts. Sindh has the highest variation, whereas the KPK has the lowest. These should be further explored at the provincial level to understand how differences link (or do not link) to health service provision. The practice of block allocations and expenditure booking of primary health care programs at the District Accounting Offices (DAOs) of major cities also distorts per capita expenditures (DAO Hyderabad is a case in point, as most of the PHC programs are booked at Hyderabad with no district-level appropriation available within the FABS). 24 Figure 7 : District-Level per Capita UHC Expenditures (FY 2018-19) Per capita Per capita Per capita Districts Districts Districts exp. (Rs.) exp. (Rs.) exp. (Rs.) Swabi 507 Chakwal 1,200 Karachi 3,040 Swat District 666 Chiniot 734 Kashmore District 408 Tank 717 Dera Ghazi Khan 1,006 Khairpur District 1,758 Torgar 425 Faisalabad 1,246 Larkana 1,920 Awaran District 1,568 Gujranwala 808 Matiari 827 Barkhan District 1,049 Gujrat 957 Mirpur Khas 1,317 Kachhi District 1221 Hafizabad 1,063 Naushahro Feroze 852 Chagai, Pakistan 777 Jhang 981 Nawabshah 1856 Dera Bugti 861 Jhelum 1,395 Sanghar 708 Gwadar District 1,186 Kasur 730 Shikarpur District 894 Harnai District 1,334 Khanewal 758 Sukkur 1,343 Jafarabad 1,067 Khushab 1,197 Tando Allahyar 758 Jhal Magsi 1,057 Lahore 7,188 Tando Muhammad Khan 625 Kalat District 768 Layyah 1,208 Thatta 871 Kharan District 1,762 Lodhran 817 Umerkot 886 Khuzdar District 806 Mandi Bahauddin 1,053 Tharparkar 637 Loralai District 1,345 Mianwali 1,161 Abbottabad 612 Mastung District 1,089 Multan 1,551 Bannu 555 Musakhel Bazar 1,116 Muzaffargarh 761 Battagram 578 Nasirabad 680 Nankana Sahib 1,127 buner 544 Nushki 1,167 Narowal 1,105 Charsadda 433 Panjgur District 1,494 Okara 951 Chitral 1,425 Qilla Saifullah 898 Pakpattan 698 Dera Ismail Khan 677 Sherani 602 Rahim Yar Khan 859 Dir region 481 Sibi District 2,318 Rajanpur 713 Lower Dir 649 Kech District 1,066 Rawalpindi 1,430 Haripur 771 Washuk 973 Sargodha 1,021 Hangu 463 Zhob District 1,314 Sheikhupura 904 Karak 1,165 Ziarat District 1,513 Sahiwal 887 Kohat 449 Qila Abdullah 494 Sialkot 934 Kohistan 214 Quetta 4,786 Toba Tek Singh 862 Lakki marwat 1,022 Lasbela District 1,246 Vehari 719 Malakand 1,126 Kohlu District 1,556 Badin District 672 Mansehra 646 Pishin, Pakistan 644 Dadu District 888 Mardan 521 Sohbatpur 29 Ghotki District 521 Nowshera 694 Attock 968 Hyderabad District 7,176 Peshawar 351 Bahawalnagar 1,031 Jacobabad District 2,320 Shangla 743 Bahawalpur 1,442 Jamshoro 2,320 Bhakkar 1,227 Qambar Shahdadkot 337 25  OLICY ACTIONS/ 3. P RECOMMENDATIONS There is a need to clearly enunciate Pakistan’s goal of achieving UHC. At present. this understanding 1.  is not quite clear at the lower levels of the health system. This policy enunciation would enable health policy makers to clearly define UHC and exactly what it entails. As such, each province should issue a list of interventions and packages for UHC, which can then be monitored to assess coverage. These packages can then be costed to ascertain what financial resources are required to achieve the stated goals and allow for calibration of the interventions to finance to find the most cost-effective route (costing studies). Further, the definition of packages/ interventions will also allow for targeted data collection for UHC and improve the monitoring capacity. The absence of monitoring for financial protection needs more attention. Currently the levels of out-of-pocket 2.  expenditures are quite high (51.7 percent according to the NHA for 2017-18). Further studies will be needed to understand the composition and quality delivered for these expenditures. Although the SEHAT card provides some protection to the lowest socioeconomic tiers of the population, further work needs to be done to ensure coverage for the rest of the population at a reasonable cost. At the same time, it is important to evaluate the existing PFM arrangements for the health sector to ensure that the requisite accounting system is in place for financial reporting and monitoring for the emerging health landscape. Regarding objective accountability and performance measurement, financial reporting and monitoring of 3.  UHC needs to be strengthened. This will require a comprehensive review of the existing CoA with respect to health budget formulation to adequately cater to needs. It will also require a unified output database. For example, the DHIS2 platform has vast potential for integrating reporting (linking output with budget/ expenditures). To meet this potential, the platform may be explored for monitoring purposes. However, this will require that the DHIS be strengthened. Information should also be made available to all tiers of health managers. The report developed the template (refer table 4 Annexure 1) to improve performance reporting by linking service outputs with financial inputs. 26 ANNEX 1: METHODOLOGY This report provides a means to measure progress toward UHC through a better understanding of financial outlays and public system outputs. After addressing system gaps, it can provide decision-makers with timely information about where financing should be increased. In this exercise, the World Bank Public Expenditure Review (PER) methodology is used. A PER is concerned with public-based (but not always government) revenues and expenditures as expressions of public policy and public involvement in the economy. Box 3: District Health Information System/ Health Management Information System The District Health Information System (DHIS) is a mechanism of data collection, transmission, processing, analysis and information feedback to the first-level care facilities and secondary-level health care facilities. The DHIS provides baseline data for district planning implementation and monitoring concerning major indicators of disease patterns, preventive services, and physical resources. The DHIS 2 system (upgrade), unlike the previous system, would gather and collate information from secondary level hospitals (that is, District Headquarter Hospitals (DHQs) and Tehsil Headquarter Hospitals (THQs)). Important Features: • The DHIS is a district-based Routine Health Information System. It responds to the information needs of the district health system’s performance monitoring function, • both at the district and province levels. • The DHIS provides a minimum set of indicators. • It promotes / supports evidence-based decision-making at the local and provincial levels. It caters to the important routine health information needs of the federal and provincial levels for • monitoring policy implementation. • The DHIS is an improved version of the HMIS, as it incorporates many indicators from the HMIS. Source: https://dghs.punjab.gov.pk/district_health World Bank guidance specifies that “Every PER must be selective in what it covers, with the selection of topics based on many factors—what is needed to underpin the country dialogue, what is already known and packaged elsewhere, what is manageable to address given constraints on time, data and funding, etc.” Regarding the PER application in UHC measurement and monitoring, there are a few basic parameters which must be taken into consideration including the time period, level of analysis, and data sources. Parameters: scope, time period: The first question to be addressed concerns the scope of the review. In this case, it is a review of (public) budgets and expenditures related to UHC over a period of three years. Thus, this review will track the fund flow and link these flows with outputs related to UHC over this timeframe. It will also identify limitations, if any. Data sources and disaggregation level: The second issue is the level of disaggregation. Ideally, a PER takes place at the national level; however, in Pakistan, as health is a decentralized area with minimal federal financing and implementation involvement, the review is undertaken at the provincial level. Therefore, the budget expenditure analysis has to be at the provincial level as well. The financial data used in this analysis comes from the FABS. It covers the last three years for which the data is complete and reconciled, that is: 2016-17, 2017-18, and 2018-19. Accounts for 2019-20 are not yet finalized. Furthermore, it is a period with expenditure anomalies (given the COVID-19 pandemic). Hence, it is not an ideal period for comparison. The budget and expenditure data used are at the Drawing Disbursing 27 Officer (DDO) level for provinces. The data is also within the “identified health-related expenditures” category at the district level. Budget and expenditures for both recurrent and development data are used. Outputs related to UHC that are produced by the Health Department were identified as part of the process of developing output data indicators. Given that progress was to be measured over a period of three years, the data needed to be annual and regularly available. The only source for annual output data was the routine HMIS (Box-3). Using this system, the federal and provincial health departments agreed on a set of indicators to be reported regularly for monitoring. This was used as the basis for this analysis. Regarding the budget expenditure analysis, tangible outputs produced by the system are required to link with broader UHC goals. The Ministry of National Health Service, Regulation and Coordination (MONHSRC) currently lists 16 major UHC indicators, of which four relate to vertical programs having stand- alone reporting systems. Four concern non-communicable diseases that do not have any reporting system. The MONHSRC list does not include any financial protection indicators. To address this issue, the team reviewed the literature and data availability and prepared a monitoring list of health sector outputs. This list was discussed with health experts in the MONHSRC and then finalized. It can now be tentatively linked with expenditures. For the purpose of this analysis, specialized and tertiary care outputs were excluded because there were problems with these in terms of coverage identification and output reporting. Thus, for this assignment, UHC budgeting is construed as “budgets for all primary- and secondary- level health care services and related administrative costs, provided by the public sector (including community-level services)”, and outputs are considered as “regularly reported data from services provided by the public sector.” In summary, a UHC output index has been derived linking budgets to public health sector outputs, following a team review of the WHO and World Bank UHC monitoring guidance, as well as a review of indices available in the literature. Limitations Limitations to the data and hence the results produced are discussed here. These should be kept in mind when considering the results. Output data Limitations regarding health output data include the following: The complete DHIS dataset is not used. Instead, data is limited to regular reporting indicators agreed by 1.  the federal and provincial levels. The output data does not include indoor (admissions), which skews the financial numbers, especially for 2.  secondary care. The output data does not comprehensively report on tertiary hospital out-patient departments. 3.  Given that reporting concerning non-communicable disease indicators does not take place, there is no 4.  monitoring in this area. This in turn hampers efforts to focus on long-term diseases. This report uses national-level data, made available by the MoNHSRC, and reported by the provinces. 5.  There are some minor differences when verified with provincial-level data. The quality of reported data has not been verified, and no mechanism exists within departments to syste- 6.  matically cross check and verify this data — except for some simple data entry checks. As the data is not currently used for decision-making, there is little focus on data reliability, even at the 7.  health facility level. Despite these limitations, the regularity of data itself provides an opportunity to ascertain trends in the reported indicators. Although point estimates from data may be quite different from survey data, over time they indicate the direction in which the overall system is moving. Positive or negative trends can be ascertained, and remedial measures can be initiated if the data is plotted for multiple years. 28 Input Data Box 4: FABS The FABS has two components: the New Accounting Model (NAM), and a SAP-Enterprise Resource Planning (ERP) based information technology platform. The NAM was introduced in 2000 through the approval by the Auditor General of Pakistan. Its purpose is to improve the traditional government accounting system by shifting toward modified cash-basis of accounting, double-entry book-keeping, commitment accounting, fixed asset accounting, and a new multi-dimensional Chart of Accounts. The CoA is in compliance with the Manual of Government Statistics (GFSM) for 1986. The FABS objectives include effective budgetary management, financial control, cash forecasting, trend analysis, fiscal administration, and debt management. The SAP-ERP based system is being used at more than 500 sites across the country at the federal, provincial and district levels. The District Account Offices (DAOs) and other district-level offices, as well as provincial line departments, are linked through the Wide Area Network (WAN) to servers at the Accountant General’s Office and the Finance Departments of the respective provinces. All provincial servers are linked through the WAN to the federal server at the office of the Accountant General Pakistan Revenues (AGPR) in Islamabad. This creates a seamless and integrated system capable of providing real-time information about financial transactions taking place in the system across the country at both the national and sub-national levels. Source: About FABS, Office of the Controller General of Accounts: https://fabs.gov.pk/ The input data is from the Financial Accounting and Budgeting System (FABS) implemented under the World Bank-funded Project to Improve Financial Reporting and Auditing (PIFRA) (box 4). The FABS data uses a chart of accounts with function and object (economic) coding. The data is entered ac- cording to the broad categories. However, in the case of health and especially at the provincial level, the budget coding does not follow a uniform method. Although this does not hamper the FABS accounting func- tion as the budget and expenditures can be recorded, it creates problems when trying to compare across provinces and within health expenditures. The limitations and issues regarding the FABS are listed below: For the three years 2016-18, the budget allocation has changed over time. Data for the year 2018 had 1.  distinct district and provincial levels, whereas previous years have no such bifurcation. Each province has variations in how they code the budget. For example, Baluchistan uses the object 2.  category for the DDO level, whereas the other provinces use the function categories. 3. The budget for tertiary care is coded under general hospital services. 4. Similarly, the budget for administration of tertiary care services is coded under general administration. The provinces code their budgets under grants for contracted services. However, these are later reallo- 5.  cated, and expenditures appear against items initially with a zero budget. The budget for salaries is expended under Auditor General Office codes (based on the city where the 6.  office is located). In some cases, they are different from health district names. The inadequate recording of salary expenditures is particularly problematic when analyzing budgets and 7.  expenditures, as the amounts not budgeted under salaries are expended/booked in salaries. This then skews the result. Furthermore, it does not allow for an assessment of the utilization of salary and non-sa- lary budgets. 29 UHC Index The UHC index lacks indicators concerning financial protection, as they are not routinely reported. They are also not part of the equity framework being used by the World Bank and WHO to report UHC. Similarly, the MONHSRC list does not include any financial protection indicators. Further, the non-communicable diseases are not reported through the routine reporting system. Hence, monitoring progress on these diseases is excluded. The factors in the Table-2 below explain the measurement criteria for the UHC indicators. Table 2: UHC index HMIS Data Explanation (Factor) Reproductive, Maternal, Neonatal, Child Health and Adolescent Cluster Total family planning (FP) visits Total FP visits are divided by the number of married women (23 percent). This gives an overestimate of the population serviced. However, over time, it will be reliable in measuring any change. Postnatal Care (PNC) Total pregnancies are taken as 2.5 percent of the population and the PNC is measured against it. Deliveries (normal) Total pregnancies are taken as 2.5 percent of the population. Deliveries (through C-section) C- sections are estimated at 5 percent of total deliveries. DPT3 (diptheria , tetanus toxoid One year cohort of children is taken as 2.5 percent of the population. and pertussis) Infectious Disease Control (Communicable Disease) Clust Total tuberculosis (TB) cases, TB incidence is taken at 250 per 100,000. including Lab Acid-Fast Bacteria (AFB) positive cases Total malaria cases, including Malaria incidence is taken at 30 percent (although it varies widely from 10-37 falciparum positive cases. percent). Total typhoid cases Typhoid incidence is taken at 10 percent. Non-Communicable Disease Control Service Capacity and Access Cluster Deliveries (all) Total pregnancies are taken at 2.5 percent of the population. Antenatal Care (ANC) visits Total pregnancies are taken at 2.5 percent of the population and total ANV visits at 3. Measles/Measles 1 One year cohort of children is taken as 2.5 percent of the population. Fully Immunized One year cohort of children is taken at 2.5 percent of the population. Acute Respiratory Infection The under 5 years of age cohort is estimated at 15 percent of the population (ARI) cases and 2 episodes per child are estimated Source: Pakistan Census (2018), Pakistan Bureau of Statistics, and consultant estimates. 30 The best use of the UHC index is to plot progress over time and see the trends against the indicators. The provinces and districts should feel free to add further indicators which they have access to and are regularly reported to strengthen their monitoring. Parameters: Scope, Time Period: The first question to be addressed is the scope of the review. In this case it is a review of (public) budgets and expenditures related to UHC over a period of three years. Thus, this review will track fund flow and link these flows with outputs related to UHC over this timeframe. Data sources, Disaggregation level: The second issue is the level of disaggregation. Ideally a PER takes place at national level; however, in Pakistan, as health is a decentralized subject with minimal federal financing and implementation involvement, the review is undertaken at provincial level, and therefore the BEA has to be at provincial level too. Functions of the proposed UHC index The proposed UHC index is to enable health managers to monitor progress on UHC at provincial and district levels using available data and is not intended to act as a UHC score which will require further data to encompass all aspects of UHC. The UHC index should allow managers to ascertain progress towards UHC and focus on areas/ districts which require further assistance to move towards UHC. The UHC index also estimates current coverage of the public services and can indicate where the further interventions like expansion of network or inclusion of private/NGO providers into the network is required to attain UHC. The proposed UHC Index is based on the “Towards Universal Health Coverage through Primary Health Care – Pakistan Investment case for 2021-26” published by Ministry of National Health Services, Regulation and Coordination. The above analysis itself is based on the WHO and World Bank framework for measuring equity which has 16 essential health services in 4 categories as indicators of the level and equity of coverage in countries. The aspect of monitoring financial protection is not included in this section of the framework. Data sources Output data Quality of results are dependent on the quality of source data; however, survey or targeted primary data collection is excluded for two reasons, a) the cost of setting up a primary data collection and maintaining it, b) the existence of a data collection system which is already reporting albeit of uncertain quality. This is fur- ther limited by the need for the data to be regularly available. The data is primarily from two official sources: Ministry of National Health Services, Regulation and Coordination, and FABS database from Accountant General Office. Data was cross checked with provincial sources for plausibility. The team used the list of indicators agreed by the by the MONHSRC and the provinces as they are regu- larly reported and compiled. The indicators for monitoring UHC are from the national level indicators and the framework presented in the report “Towards Universal Health Coverage through Primary Health Care – Pakistan Investment case for 2021-26” published by Ministry of National Health Services, Regulation and Coordination. Input data The analysis is based on a review of expenditures as consolidated in FABS/PIFRA System coded under the functions related to health. The financial data covered all public health expenditures (inputs) in health department for the three-year period. Using the system codes in the chart of accounts the expenditure was identified by level of drawing and disbursing officer. The responsibilities of the DDO were categorized by level of service delivery and out of these those directly related to UHC were identified. The expenditures on services related to UHC were then mapped and further disaggregated into three categories; primary including all RHCs, BHUs, MCH centers and smaller health facilities, secondary services above the level of primary care and Admin (DHO) all expenditures related to administration of health services and in some cases health programs not directly identifiable at primary level health facilities. After the categorization the financial data was mapped against the three categories: • Primary (includes BHUs, RHCs, MCH & Dispensaries) • Secondary (includes DHQ, THQ & Hospitals) • DHO (Administration) 31 Data processing & Analysis: The data was checked for consistency and details. For any inconsistency and incomplete data, the providing organization was contacted again for clarifying the inconsistency or providing the missing data. The data was disaggregated by province and then classified into identified categories. An initial tabulation of data was done to ascertain internal consistency and observe variation across categories. For DHIS/HMIS, the data was cross checked with provincial reports. Derivation of (Output) UHC Index The derivation of the output index begins from the UHC cube with its three axis, next we identified the 16 clusters11 against the three axes. The MONHSRC has identified packages of service which would enable the health system to achieve progress against these 16 clusters. The list of indicators proposed by the MON- HSRC was used as a reference to plot the 72 indicators for HMIS. The next step was to plot the HMIS indicators against the service package and cluster. As can be seen in the following tables this results in a such smaller list of indicators which can be regularly monitored, and some service packages have no corresponding measurement tool available within the current HMIS. The long list of DHIS/HMIS indicators does not lend itself to an easy understanding and thus has remained in limited use for decision making. We present the method by which we have derived a UHC index from the routine data which is regularly reported (72 agreed indicators between provinces and federal for reporting on HMIS/DHIS). The analysis done by the MONHRSC on UHC and the derivation of packages of health care for implementation is taken as the base and the reported indicators are aligned to the four clusters and intervention packages. Unfortunately, the routine reporting does not provide information on conditions covered by the Non communicable disease cluster and is therefore limited in regular monitoring of said cluster. There are three main UHC axis (Figure-8), service package, coverage/ access to services, and financial protection, out of these financial protection does not have routine reporting from health facilities and it is left out of consideration for the monitoring through routine data, further the non-communicable disease cluster in the service package also lacks routine reporting and is currently left out. Below in Table-3 is the derivation of the DHIS/HMIS indicators into the four clusters of the service package. Figure 8: Framework for identification of Outputs for UHC Financial • Insurance coverage FINANCIAL protection: • Catatrophic payments Include PROTECTION what do people • Out-of-pocket expenditures Reduce cost other have to pay sharing & fees services out-of-pocket? Extend to Coverage non-convered mechanisms Reproductive, Maternal, Services: Newborn & Child Treatment which services SERVICES • Family Planning Population: who is covered? are covered? • Delivery & Pregnancy care • Child immunization • Child treatment • General category/Others SERVICE COVERAGE Infectious diseases Non-Communicable diseases • Birth delivered in • Tuberculosis treatment a health facility • Prevention of Cardiovascular Disease • HIV treatment • Management of Diabetes • Women receiving any antenatal care (ANC) • Malaria Prevention • Cancer detection & Treatment from a skilled provider • Water sanitation • Tobacco control • General category/Others • General category/Others 11 T  he World Bank and WHO report on Progress towards UHC uses 16 clusters which have been adopted by Pakistan 32 Table 3: Mapping of UHC monitoring interventions/indicators against DHIS/HMIS data Interventions /Packages HMIS Data (Indicators) identified for Pakistan (75) Cluster 1: Reproductive, Maternal, Neonatal, Child Health and Adolescent Cluster  amily 1. F Antenatal and postpartum education on 1.  Total FP visits Planning Family Planning² 2.Insertion/ removal of long-lasting contraceptives (IUPS, Implants)  urgical termination of pregnancy by 3. S manual vacuum aspiration and dilation Tubal ligation 4.  5. Vasectomy  regnancy 2. P •Maternal Deaths reported by Lady Health & Delivery workers (LHW) Care •Infant Deaths reported by Lady Health Workers (LHW) • Live births with Low Birth Weight (LBW) • Postnatal Care (PNC) 6. Basic neonatal resuscitation following • Neonatal Deaths caused by Asphyxia delivery 7. Full supportive care for preterm newborn  anagement of eclampsia with magnesium 8. M • Total admissions of patients with Eclampsia sulphate, including initial stabilization at • Total Deaths of patients caused by Eclampsia health Centre  anagement of labor and delivery in low- 9. M • Deliveries Normal risk women by skilled attendant • Deliveries Assisted Management of labor and delivery in 10.  • Total admissions with maternal complications high-risk women (BEmNOC) including • Total deaths caused by maternal initial treatment of obstetric of delivery complications complications prior to transfer • Total ectopic admissions • Total ectopic deaths • Still Births • Neonatal Deaths • Neonatal Deaths caused by Trauma • Congenital Neonatal Deaths • Premature Neonatal Deaths • Neonatal Deaths caused by Hypothermia  anagement of maternal sepsis, including 11. M • Total admissions with sepsis early detection at health Centre • Total deaths caused by sepsis Management of labor and delivery in high- 12.  • Deliveries through C-section risk women including operative delivery (EmNOC) Management of miscarriage or incomplete 13.  • Total abortion admission abortion and post abortion • Total abortion deaths Management of preterm premature rupture 14.  • Total prolonged labor admissions of membranes, including administration of • Total prolonged labor deaths antibiotics • Total admissions with pre rupture of membranes •Total deaths caused by pre rupture of membranes 15. Pharmacological termination of pregnancy Provision of iron and acid folic 16.  supplementation to pregnant women and provision of food or caloric supplementation to pregnant women in food insecure households 33 Interventions /Packages HMIS Data (Indicators) identified for Pakistan (75)  regnancy 2. P Screening and management of diabetes 17.  & Delivery in pregnancy (gestational diabetes or pre- Care existing type 2 diabetes) Counselling of mothers providing Kangaroo 18.  care of newborn Counselling of mothers on providing 19.  thermal care of preterm newborn delayed bath and skin to skin contact Screening of hypertensive disorders in 20.  pregnancy Child 3.  21. Childhood vaccination series • DPT3 (diphtheria, tetanus toxoid & pertussis) Immunization 22. Pneumococcus vaccination 23. Rotavirus vaccination Tetanus toxoid immunization school 24.  • Tetanus (TT1) & (TT2) doses injected children and among women attending antenatal care  hild 4. C • Diarrhea < 5 years total admissions Treatment • Diarrhea < 5 years total deaths 25. Jaundice management with phototherapy Early detection and treatment of neonatal 26.  • Pneumonia < 5 years total admissions pneumonia with oral antibiotics • Pneumonia < 5 years total deaths Management of neonatal sepsis, 27.  • Neonatal Deaths caused by Sepsis pneumonia and meningitis using injectables and oral antibiotics Management of newborn complications 28.  infections, septicemia, pneumonia, and other profoundly serious infections requiring continuous supportive care (such as IV fluids and oxygen) Vision prescreening by teachers, vision test 29.  and provision of ready Ade glasses on site by eye specialists 10. General Promotion of breast feeding or 30.  Category/ complementary feeding by lay health Others workers Syndromic management of common 31.  sexual and reproductive tract infections (for complete urethral discharge, genital ulcer, and others) according to WHO guidelines Early detection and treatment of early- 32.  stage cervical cancer 33. Education of school children on oral health Education on handwashing and safe 34.  disposal of children’s stools 34 Interventions /Packages HMIS Data (Indicators) identified for Pakistan (75) Cluster 2: Infectious Disease Control (Communicable Disease) Cluster 11. Diagnostic of TB, including assessment of 35.  • Total TB cases including Lab AFB positive cases Tuberculosis rifampicin resistance using rapid molecular • Total pulmonary TB Admissions Treatment diagnostic (ultra-expert), and initiation • Total pulmonary TB Deaths of first line treatment per current WHO • TB-dot patients guidelines for drug susceptible TB referral for confirmation, further assessment of drug resistance Referral of cases of treatment failure for 36.  drug susceptibility testing, enrolment of those with MDR TB treatment per WHO guidelines (either short or long regimen) Systematic identification of individuals with 37.  TB symptoms among high-risk groups and linkage to care (either case finding)  IV 14. H Partner notification and expedited 38.  • HIV AIDS cases Treatment treatment for common STIs including HIV  alaria 15. M Provision of insecticide treated nets to 39.  •Total Malaria cases including MP and Prevention children and pregnant women attending falciparum positive cases health Centre • Total Malaria Admissions • Total Malaria Deaths  ater & 16. W Early detection and treatment of 40.  Sanitation leishmaniasis, dengue, chikungunya, rabies, trachoma, helminthiasis  eneral 17. G • Hepatitis B & C positive cases Category/ • Total Hepatitis A,B,C & E Admissions Others • Total Hepatitis A,B,C & E Deaths • Pneumonia > 5 years total admissions • Pneumonia > 5 years total deaths • Diarrhea > 5 years total admissions • Diarrhea > 5 years total deaths Evaluation and management of fever 41.  • Total Typhoid cases clinically stable individuals using WHO • Total Typhoid admissions and deaths IMAI guidelines with referral of unstable individuals to first level hospital care Evaluation and management of fever in 42.  clinically unstable individuals using WHO IMAI guidelines, including empiric parental antimicrobials and antimalarials and resuscitative measures for septic shock For PLHIV and children under five who 43.  are close contact or household individuals with TB active, perform symptom screening and chest radiography, if there is no active TB, provide isoniazid preventive therapy according to current WHO guidelines Cluster 3: Non-Communicable Disease Control Identify and refer to higher levels of health 44.  care patients with signs of progressive illness In the context of emerging infections 45.  outbreak, provide advice and guidance on how to recognize early symptoms and signs and when to seek medical attention 46. Provision of male circumcision series 35 Interventions /Packages HMIS Data (Indicators) identified for Pakistan (75) Prevention 18.  Long term combination therapy for persons 47.  of Cardio- with multiple CIVD risk factors, including vascular screening for CVD in community sittings Disease non-lab-based tools to access overall CVD risk 48. Medical management of acute heart failure Opportunistic screening of hypertension for 49.  all adults and initiation of treatment among individuals with severe hypertension and or multiple risk factors Provision of aspirin for all cases of 50.  suspected of acute myocardial infarction Secondary prophylaxis with penicillin for 51.  rheumatic fever or established rheumatic heart disease 23.  Manage- Screening of albuminuria kidney disease 52.  • Diabetes cases ment of including targeted screening among people Diabetes with diabetes Cancer 24.  53. Colostomy Detection & Hysterectomy for uterine or intractable 54.  Treatment postpartum hemorrhage 55.  Relief of urinary obstruction by catherization to suprapubic cystostomy 27.  Tobacco Control General 28.  Low dose inhaled corticosteroids and 56.  Category/ bronchodilators for asthma and for selected Others patients with CVD risk 57. Management of bowel obstruction Management of depression and anxiety 58.  disorders with psychological and genetic antidepressant therapy Management of intoxication or poisoning 59.  syndrome 60.  Targeted screening for congenital hearing loss in high-risk children using otoacoustic emission testing Treatment of acute pharyngitis in children 61.  to prevent rheumatic fever Wash behavior change interventions, such 62.  as community led total sanitation 63. Appendectomy Basic management of musculoskeletal and 64.  neurological injuries and disorders, such as prescription of simple exercises and sing or cast provision Compression therapy for amputation, burns 65.  and vascular or lymphatic disorder 66. Dental extraction 67. Drainage of dental abscess 36 Interventions /Packages HMIS Data (Indicators) identified for Pakistan (75)  eneral 28. G 68. Escharotomy or fasciotomy Category/ Others Fracture reduction and placement of 69.  external fixator and use of traction 70. Management of non-displaced fracture Placement of external fixation and use of 71.  traction for traction for fractures Removal of gall bladder including 72.  emergency surgery Repair of perforation 9 e.g, peptic ulcers, 73.  typhoid illegal perforation) 74. Suturing laceration 75. Treatment of caries Cluster 4: Service Capacity and Access Cluster • Deliveries All • Antenatal Care (ANC 1) visits • Measles/Measles 1 • Fully Immunized • Acute Respiratory Infection (ARI) cases In the Infectious Disease cluster, Hepatitis, Pneumonia, Diarrhea and Typhoid lack a corresponding package and are therefore plotted against the general/ others category. Out of this list, five indicators in cluster 1, three indicators in cluster 2 and five indicators in cluster 4 are picked up as main proxy indicators to construct a UHC index which is presented below. Based on population census data 201812 target population was plotted against each indicator to ascertain a level of service coverage. This is then weighted with each indi- cator having an equal weight to derive a final coverage for each cluster. Measles and fully immunized pertain to the same cluster hence only one of them is used to calculate the final coverage for cluster 4. 12 Published by Pakistan Bureau of Statistics 37 Table 4: Proposed UHC Index template Number Coverage HMIS Data Year Year Year Factor Year Year Year Reproductive, Maternal, Neonatal, Child Health and Adolescent Cluster Postnatal Care (PNC) Deliveries Normal Deliveries through C-section DPT3 (diphtheria, TT & pertussis) Weighted average Infectious Disease Control (Communicable Disease) Cluster Total TB cases including Lab AFB positive cases Total Malaria cases including MP and falciparum positive cases Total Typhoid cases Weighted average Non Communicable Disease Control Service Capacity and Access Cluster Deliveries All Antenatal Care (ANC) visits Measles/Measles 1 Fully Immunized Acute Respiratory Infection (ARI) cases Weighted average 38 HMIS Data Explanation (Factor) Reproductive, Maternal, Neonatal, Child Health and Adolescent Cluster Total FP visits Total FP visits are divided by number of married women (23%), this gives an overestimate of the population serviced but over time will be reliable to measure any change Postnatal Care ( PNC) Total pregnancies are taken as 2.5% of the population and PNC is mea- sured against it Deliveries Normal Total pregnancies are taken as 2.5% of the population Deliveries through C-section C- section is estimated at 5% of total deliveries DPT3 ( diptheria , tetanus toxoid & One year cohort of children is taken as 2.5% of population pertussis) Infectious Disease Control (Communicable Disease) Cluster Total TB cases including Lab AFB TB incidence is taken at 250 per 100,000 positive cases Total Malaria cases including MP and Malaria incidence is taken at 30% (although it varies widely from 10-37%) falciparum positive cases Total Typhoid cases Typhoid incidence is taken as 10% Non Communicable Disease Control Service Capacity and Access Cluster Deliveries All Total pregnancies are taken as 2.5% of the population Antenatal Care (ANC) visits Total pregnancies are taken as 2.5% of the population and total ANV visits at 3 Measles/Measles 1 One year cohort of children is taken as 2.5% of population Fully Immunized One year cohort of children is taken as 2.5% of population Acute Respiratory Infection (ARI) Under 5 years cohort is estimated at 15% of population and 2 episodes cases per child are estimated Weighted average is taken Source: Pakistan Census 2018, Pakistan Bureau of statistics and consultant estimates Derivation of Inputs (Financial Index) For the Financial Data we separated out the data by level and divided the data into three levels; • Primary care level includes all RHC, BHU, MCH, dispensaries, etc. • Secondary Care level: includes all DHQ, THQs and Hospitals • Admin: Includes community level programs, administration, etc. Within the codes data related to areas not directly concerned with UHC, (e.g. medicolegal- medical exa- mination for legal purpose like during criminal trial) were removed. The proposed mapping of sub-detailed function codes within Health Function (07) code of country Chart of Accounts13 with Primary, Secondary and Admin are in as follows: 13  ountry COA consists of Entity, Fund, Source, Function, Object segments. Each segment has further 3 to 4 sub-segments, e.g., Function segment of COA C has Major Function > Minor Function > Minor Function > Detailed Function > Sub Detailed Function. 39 Table 5: Mapping of Chart of Account functional Codes Punjab Data Level Codes Original Budget Actual Expenditure Primary 73104 Rural Health Centers   73105 BHU/Dispensaries/Units/Clinics   73301 Maternal & Child Health Total (Primary)     Secondary 73101 General Hospital Services   73102 District Headquarter Hospitals   73103 Tehsil Headquarters Hospitals Total (Secondary)     Admin (Others) 74103 Anti Tuberculosis   74120 Others   76101 Administration Total (Admin)   Source: New Accounting Model (NAM) Chart of Accounts Sindh Data Level Codes Original Budget Actual Expenditure Primary 73104 Rural Health Centers   73105 BHU/Dispensaries/Units/Clinics   73301 Maternal & Child Health Total (Primary)     Secondary 73101 General Hospital Services   73103 Tehsil Headquarters Hospitals   72201 Specialized Medical Services Total (Secondary)     Admin (Others) 74103 Anti Tuberculosis   74101 Others   74120 Administration 76101 Administration 71102 Drug Control Total (Admin)   Source: New Accounting Model (NAM) Chart of Accounts 40 KP Data Level Codes Original Budget Actual Expenditure Primary 73104 Rural Health Centers   73105 BHU/Dispensaries/Units/Clinics   73301 Maternal & Child Health Total (Primary)     Secondary 73101 General Hospital Services   73102 DHQ hospitals   73103 THQ Hospitals Total (Secondary)     Admin (Others) 74105 EPI   74101 Anti Malaria   74120 Others 76101 Administration Total (Admin)   Baluchistan Data Level Codes Level specific Codes Original Budget Actual Expenditure Primary 74120 Total (Primary)     Secondary 73101 AW4028 DHQ Hospital Awaran   BL4042 DHQ Hospital Kachhi DB4034 DHQ Hospital Dera Bugti GR4060 DHQ Hospital Gwadar HI4026 DHQ Hospital Harnai JF4052 DHQ Hospital Jafferabad JH4028 DHQ Hospital Jhal Magsi KL4051 HQ Hospital Kalat KN4047 HQ Hospital Kharan KR4081 HQ Hospital Khuzdar KU4032 DHQ Hospital Kohlu LI4092 DHQ Hospital Loralai 41 Baluchistan MU4054 DHQ Hospital Mastung Data Level Codes Level specific Codes Original Budget Actual Expenditure MK4031 DHQ Hospital Musakhail NB4060 DHQ Hospital Naseerabad NI4038 DHQ Hospital Nushki PJ4052 DHQ Hospital Panjgur PI4050 DHQ Hospital Pishin QS4041 DHQ Hospital Killa Saifullah SI4080 DHQ Hospital Sibi TB4099 DHQ Hospital Kech UL4171 DHQ Hospital Lasbella ZB4048 DHQ Hospital Zhob ZT4033 DHQ Hospital Ziarat QD4037 DHQ Hospital Killa Abdullah Total   (Secondary) Admin (Others) 76101   71102   73101 AW4029 District Health Officer Awaran BE4032 District Health Officer Barkhan BL4044 District Health Officer Kachhi CG4031 District Health Officer Chagai DB4035 District Health Officer Dera Bugti GR4061 District Health Officer Gwadar HI4027 District Health Officer Harnai JF4053 District Health Officer Jafferabad JH4029 District Health Officer Jhal Magsi KL4052 District Health Officer Kalat KN4048 District Health Officer Kharan KR4082 District Health Officer Khuz- dar KU4033 District Health Officer Kohlu LI4093 District Health Officer Loralai MU4055 District Health Officer Mastung MK4032 District Health Officer Musakhail 42 Baluchistan NB4061 District Health Officer Naseerabad NI4039 District Health Officer Nushki PJ4053 District Health Officer Panjgur Data Level Codes Level specific Codes Original Budget Actual Expenditure PI4051 District Health Officer Pishin QS4042 District Health Officer Killa Saifullah SN4022 District Health Officer Sherani SI4081 District Health Officer Sibi SP4081 District Health Officer Sohbat- pur TB4100 District Health Officer Kech. UL4172 District Health Officer Las- bella WS4028 District Health Officer Washuk ZB4049 District Health Officer Zhob ZT4034 District Health Officer Ziarat QD4038 District Health Officer Killa Abdullah SB4006 District Health Officer Shaheed Sikandar Total (Admin)   AW4029 District Health Officer Awaran Source: New Accounting Model (NAM) Chart of Accounts Linking Inputs and Outputs It would have been best if the financial data is linked to the outputs at indicator level. However, with the current reporting and consolidation of financial data which is budgeted and coded by inputs and with limited studies available on the cost of services in Pakistan, linking expenditure to individual indicators at present is not possible. However, to link the two aspects; finances and outputs, the second-best option is to link the costs to a measurable output which is proposed as total OPD for the public facilities. The lack of reported appropriate inpatient data on admissions, length of stay etc, precludes the possibility of further in-depth analysis on this aspect. Thus, we use the widely accepted cost per capita and use a cost per patient. Cost or expenditure per patient is derived by simply dividing total expenditures by number of patients reported. At the primary level, this is simple as mostly the primary facilities focus on outpatient services and even RHCs that provide inpatient services are quite rare. However, at the level of secondary care, lack of inpatient (ad- missions) data results in very high numbers of expenditure per patient. Another parameter used is expenditure per facility; this is arrived at by dividing the overall expenditure for primary or secondary by the number of facilities for that level. A comparison over time indicates whether investment is increasing in primary level or secondary level. 43 ANNEX 2: PROVINCIAL UHC BUDGET AND EXPENDITURE TABLES - PROGRESS OF UHC INDICATORS TABLES Punjab UHC Progress Budget & Expenditure Progress Tables Table 6: Punjab: Budget and Expenditure for three years Total Health Visits Budget for %age Total Expenditure per Year Population Primary, change Utilization Secondary & Expenditure per capita person budget Admin per year 2016 107,649,908 126,486,781,750 133,339,191,444 105% 1,239 0.35 2017 119,989,655 195,183,809,126 199,494,690,514 54% 102% 1,663 0.82 2018 126,045,464 232,132,418,707 217,392,396,634 16% 94% 1,725 0.95 Note: all amounts are in PKR. Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan Table 7: Punjab: Budget and Expenditure for three years, primary and secondary %age change Year 2016 2017 2018 2016- 17 2017-18 Primary Original Budget 12,326,671,296 22,442,868,482 36,003,208,273 82% 61% Actual 6,119,693,217 26,730,373,427 32,105,560,018 337% 2% Expenditure Secondary Original Budget 99,090,848,884 136,199,133,788 152,907,417,647 37% 3% Actual 114,982,940,614 133,271,690,418 140,694,142,148 16% -13% Expenditure Admin Original Budget 15,069,261,570 36,541,806,856 43,221,792,787 142% 21% Actual 12,236,557,613 39,492,626,669 44,592,694,468 223% 12% Expenditure Note: all amounts are in PKR. Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan 44 Table 8: Expenditure per facility Total Exp/facility Facility level # Facility 2016 2017 2018 Primary Facility 3055 2,003,173 8,749,713 10,509,185 Secondary Facility 159 723,163,149 838,186,732 728,000,066 Note: all amounts are in PKR. Data Source: Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan and refer to Tables 29 for facility details Progress of UHC indicators: Table 9: UHC Index for Punjab Punjab Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Reproductive, Maternal, Neonatal, Child Health and Adolescent Cluster Total FP visits 1,972,868 2,170,765 2,043,296 23.00% 7.97% 7.87% 7.05% Postnatal Care ( PNC) 1,034,016 1,172,833 1,090,518 2.50% 38.42% 39.10% 34.61% Deliveries Normal 910,870 1,008,767 946,357 2.50% 33.85% 33.63% 30.03% Deliveries through 46,767 65,722 78,013 5.00% 34.75% 43.82% 49.51% C-section DPT3 (diphtheria, TT & 2,248,453 2,181,920 2,064,533 2.50% 83.55% 72.74% 65.52% pertussis) Weighted average 40% 39% 37% Infectious Disease Control (Communicable Disease) Cluster Total TB cases including 199,485 196,920 195,815 0.25% 74.12% 65.65% 62.14% Lab AFB positive cases Total Malaria cases including MP and 1,437,223 915,158 820,826 30.00% 4.45% 2.54% 2.17% falciparum positive cases Total Typhoid cases 194,753 414,667 565,128 10.00% 1.81% 3.46% 4.48% Weighted average 27% 24% 23% Non-Communicable Disease Control Service Capacity and Access Cluster Deliveries All 958,295 1,074,489 9,205 2.50% 35.61% 35.82% 32.49% Antenatal Care (ANC) 3,314,957 3,991,418 4,024,881 7.50% 41.06% 44.35% 42.58% visits Measles/Measles 1 2,234,631 2,208,942 2,075,628 2.50% 83.03% 73.64% 65.87% Fully Immunized 2,246,122 2,169,275 1,981,150 2.50% 83.46% 72.32% 62.87% Acute Respiratory Infection 14,100,547 16,015,051 17,316,152 30.00% 43.66% 44.49% 45.79% (ARI) cases Weighted average 51% 57% 47% Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 45 Table 10: Access to UHC Index Punjab Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Total FP visits 1,972,868 2,170,765 2,043,296 23.00% 7.97% 7.87% 7.05% Postnatal Care (PNC) 1,034,016 1,172,833 1,090,518 2.50% 38.42% 39.10% 34.61% Deliveries Normal 910,870 1,008,767 946,357 2.50% 33.85% 33.63% 30.03% Antenatal Care (ANC) 3,314,957 3,991,418 4,024,881 7.50% 41.06% 44.35% 42.58% visits DPT3 (diphtheria, TT & 2,248,453 2,181,920 2,064,533 2.50% 83.55% 72.74% 65.52% pertussis) Tetanus (TT1) & (TT2) 1,932,499 1,972,887 1,916,630 2.50% 71.81% 65.77% 60.82% doses injected TB-dot patients 129,504 131,597 131,943 0.25% 48.12% 43.87% 41.87% HIV AIDS cases 455 2,640 4,327 0.10% 0.42% 2.20% 3.43% Total Malaria cases including MP and 1,437,223 915,158 820,826 30.00% 4.45% 2.54% 2.17% falciparum positive cases Hepatitis B & C positive 11,5147 162,443 605,254 10.00% 1.07% 1.35% 4.80% cases Total Typhoid cases 194,753 414,667 565,128 10.00% 1.81% 3.46% 4.48% Deliveries All 958,295 1,074,489 9,205 2.50% 35.61% 35.82% 0.29% Measles/Measles 1 2,234,631 2,208,942 2,075,628 2.50% 83.03% 73.64% 65.87% Fully Immunized 2,246,122 2,169,275 1,981,150 2.50% 83.46% 72.32% 62.87% Acute Respiratory Infection 14,100,547 16,015,051 17,316,152 30.00% 43.66% 44.49% 45.79% (ARI) cases Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index In Service Access we see a gradual decline in all indicators except for ARI cases and ANC cases. 46 Table 11: Service Availability Index Punjab Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Live births with Low Birth 15,585 17,631 17,259 0.50% 2.90% 2.94% 2.74% Weight ( LBW) Total admissions of patients 250 0 0 0.13% 0.19% 0.00% 0.00% with Eclampsia Deliveries Assisted 658 0 0 0.38% 0.16% 0.00% 0.00% Total admissions with 10,278 0 0 0.38% 2.55% 0.00% 0.00% maternal complications Total ectopic admissions 72 0 0 0.02% 0.38% 0.00% 0.00% Total admissions with 47 0 0 0.00% 1.75% 0.00% 0.00% sepsis Deliveries through 46,767 65,722 78,013 0.13% 34.75% 43.82% 49.51% C-section Total abortion admission 1,153 0 0 0.13% 0.86% 0.00% 0.00% Total prolonged labor 611 0 0 0.25% 0.23% 0.00% 0.00% admissions Total admissions with pre 26 0 0 0.00% 0.97% 0.00% 0.00% rupture of membranes Diarrhea < 5 years total 22,4347 25,1626 219,355 6.00% 3.47% 3.50% 2.90% admissions Pneumonia < 5 years total 27,494 37,569 38,671 0.60% 4.26% 5.22% 5.11% admissions Total TB cases including 69,981 65,323 63,872 0.25% 26.00% 21.78% 20.27% Lab AFB positive cases Total pulmonary TB 10,418 11,762 9,599 0.25% 3.87% 3.92% 3.05% Admissions Total Malaria Admissions 16,267 20,507 15,441 30.00% 0.05% 0.06% 0.04% Total Hepatitis A,B,C & E 8,921 13,181 15,265 10.00% 0.08% 0.11% 0.12% Admissions Pneumonia > 5 years total 13,641 21,391 30,608 5.00% 0.25% 0.36% 0.49% admissions Diarrhea > 5 years total 127,799 140,124 139,068 5.00% 2.37% 2.34% 2.21% admissions Total Typhoid admissions 24,233 38,803 42,672 30.00% 0.08% 0.11% 0.11% Diabetes cases 1,305,442 1,759,496 2,256,969 10.00% 12.13% 14.66% 17.91% Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index In the absence of a major push for preventive care, the decrease in numbers is cause for concern. 47 Table 12: Service Outcomes Index Punjab Number Mortality rates HMIS Data 2016 2017 2018 2016 2017 2018 Maternal Deaths reported by Lady 1,734 2,105 992 64.43 70.17 31.48 Health workers (LHW) Infant Deaths reported by Lady Health 22,063 22,400 13,674 8.20 7.47 4.34 Workers (LHW) Neonatal Deaths caused by Asphyxia 662 1,154 1,062 0.25 0.38 0.34 Total Deaths of patients caused by 2 0 0 Eclampsia Total deaths caused by maternal 20 0 0 complications Total ectopic deaths 0 0 0 Still Births 10,657 11,362 16,074 3.96 3.79 5.10 Neonatal Deaths 324 210 161 0.12 0.07 0.05 Neonatal Deaths caused by Trauma 73 89 40 0.03 0.03 0.01 Congenital Neonatal Deaths 103 131 164 0.04 0.04 0.05 Premature Neonatal Deaths 404 734 788 0.15 0.24 0.25 Neonatal Deaths caused by 24 192 148 0.01 0.06 0.05 Hypothermia Total deaths caused by sepsis 0 0 0 0.00 0.00 0.00 Total abortion deaths 0 0 0 0.00 0.00 0.00 Total prolonged labor deaths 1 0 0 0.04 0.00 0.00 Total deaths caused by pre rupture of 1 0 0 0.04 0.00 0.00 membranes Diarrhea < 5 years total deaths 747 339 481 0.05 0.02 0.03 Pneumonia < 5 years total deaths 184 162 305 0.01 0.01 0.02 Neonatal Deaths caused by Sepsis 307 756 449 0.11 0.25 0.14 Total pulmonary TB Deaths 191 222 243 0.18 0.19 0.19 Total Malaria Deaths 2 24 48 0.00 0.02 0.04 Total Hepatitis A,B,C & E Deaths 140 188 147 0.13 0.16 0.12 Pneumonia > 5 years total deaths 56 102 359 0.06 0.10 0.34 Diarrhea > 5 years total deaths 111 92 272 0.12 0.09 0.25 Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 48 Sindh UHC Progress Budget & Expenditure Progress Tables Table 13: Sindh: Budget and Expenditure for three years Visits %age Total Health Total Expenditure per Year Population Budget change Utilization Expenditure per capita person budget per year 2016 44,151,585 81,370,405,021 47,008,141,882 58% 1065 0.84 2017 44,828,777 112,214,614,960 93,183,483,442 38% 83% 2079 0.87 2018 45,451,657 113,897,544,045 97,666,927,078 1% 86% 2149 0.92 Note: all amounts are in PKR. Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan There is an increase in expenditure in 2017 and there is a minor increase in visits per person, however the increase in expenditures does not show a clear relationship to visits. Table 14: Sindh: Budget and Expenditure for three years, primary and secondary %age change Year 2016 2017 2018 2016- 17 2017-18 Primary Original Budget 8,640,736,000 13,195,485,000 19,079,241,910 53% 45% Actual 7,409,796,033 8,658,314,362 13,012,740,923 17% 50% Expenditure Secondary Original Budget 40,280,667,000 48,694,579,900 59,235,129,141 21% 22% Actual 19,967,956,281 50,926,802,448 50,317,804,900 155% -1% Expenditure Admin Original Budget 32,449,002,021 40,490,771,760 42,585,882,194 25% 5% Actual 19,761,117,568 29,445,978,832 34,336,290,255 49% 17% Expenditure Note: all amounts are in PKR. Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan Table 15: Expenditure per facility Total Exp/facility Facility level # Facility 2016 2017 2018 Primary Facility 1,043 7,104,311 8,301,356 12,476,262 Secondary Facility 120 166,399,636 424,390,020 419,315,041 Note: all amounts are in PKR. Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan and refer to annexure 2 Tables 36 for facility details 49 Progress of UHC indicators: Table 16: UHC Index for Sindh Sindh Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Reproductive, Maternal, Neonatal, Child Health and Adolescent Cluster Total FP visits 494,657 494,862 479,837 23.00% 4.87% 4.80% 4.59% Postnatal Care ( PNC) 199,376 245,483 245,487 2.50% 18.06% 21.90% 21.60% Deliveries Normal 170,810 214,022 260,707 2.50% 15.47% 19.10% 22.94% Deliveries through 16,446 17,015 20,779 5.00% 29.80% 30.36% 36.57% C-section DPT3 (diphtheria, TT & 542,116 575,286 616,528 2.50% 49.11% 51.33% 54.26% pertussis) Weighted average 23% 25% 28% Infectious Disease Control (Communicable Disease) Cluster Total TB cases including 19,571 17,473 20,020 0.25% 17.73% 15.59% 17.62% Lab AFB positive cases Total Malaria cases including MP and 1,686,293 1,541,983 798,370 30.00% 12.73% 11.47% 5.86% falciparum positive cases Total Typhoid cases 113,083 136,320 181,326 10.00% 2.56% 3.04% 3.99% Weighted average 11% 10% 9% Non-Communicable Disease Control Service Capacity and Access Cluster Deliveries All 187,811 231,584 281,685 2.50% 17.02% 20.66% 24.79% Antenatal Care (ANC) 856,924 965,637 1,118,641 7.50% 25.88% 28.72% 32.82% visits Measles/Measles 1 539,238 571,032 535,276 2.50% 48.85% 50.95% 47.11% Fully Immunized 484,197 517,027 282,341 2.50% 43.87% 46.13% 24.85% Acute Respiratory Infection 6,224,519 6,310,194 6,388,769 30.00% 46.99% 46.92% 46.85% (ARI) cases Weighted average 35% 37% 38% Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index. 50 Table 17: Access to UHC Index Sindh Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Total FP visits 494,657 494,862 479,837 23.00% 4.87% 4.80% 4.59% Postnatal Care (PNC) 199,376 245,483 245,487 2.50% 18.06% 21.90% 21.60% Deliveries Normal 170,810 214,022 260,707 2.50% 15.47% 19.10% 22.94% Antenatal Care (ANC) 856,924 965,637 1,118,641 7.50% 25.88% 28.72% 32.82% visits DPT3 (diphtheria, TT & 542,116 575,286 616,528 2.50% 49.11% 51.33% 54.26% pertussis) Tetanus (TT1) & (TT2) 377,671 387,152 419,103 2.50% 34.22% 34.54% 36.88% doses injected TB-dot patients 609 524 471 0.25% 0.55% 0.47% 0.41% HIV AIDS cases 26 193 182 0.10% 0.06% 0.43% 0.40% Total Malaria cases including MP and 1,686,293 1,541,983 798,370 30.00% 12.73% 11.47% 5.86% falciparum positive cases Hepatitis B & C positive 80,313 96,065 123,121 10.00% 1.82% 2.14% 2.71% cases Total Typhoid cases 113,083 136,320 181,326 10.00% 2.56% 3.04% 3.99% Deliveries All 187,811 231,584 281,685 2.50% 17.02% 20.66% 24.79% Measles/Measles 1 539,238 571,032 535,276 2.50% 48.85% 50.95% 47.11% Fully Immunized 484,197 517,027 282,341 2.50% 43.87% 46.13% 24.85% Acute Respiratory Infection 6,224,519 6,310,194 6,388,769 30.00% 46.99% 46.92% 46.85% (ARI) cases Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 51 Table 18: Service Availability Index Sindh Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Live births with Low Birth 8,256 12,172 15,652 0.50% 3.74% 5.43% 6.89% Weight ( LBW) Total admissions of patients 0 0 0 0.13% 0.00% 0.00% 0.00% with Eclampsia Deliveries Assisted 555 547 199 0.38% 0.34% 0.33% 0.12% Total admissions with 15,696 17,699 26,956 0.38% 9.48% 10.53% 15.82% maternal complications Total ectopic admissions 0 0 0 0.02% 0.00% 0.00% 0.00% Total admissions with 0 0 0 0.00% 0.00% 0.00% 0.00% sepsis Deliveries through 16,446 17,015 20,779 0.13% 29.80% 30.36% 36.57% C-section Total abortion admission 0 0 0 0.13% 0.00% 0.00% 0.00% Total prolonged labor 0 0 0 0.25% 0.00% 0.00% 0.00% admissions Total admissions with pre 0 0 0 0.00% 0.00% 0.00% 0.00% rupture of membranes Diarrhea < 5 years total 81,315 92,322 69,699 6.00% 3.07% 3.43% 2.56% admissions Pneumonia < 5 years total 24,586 23,063 30,730 0.60% 9.28% 8.57% 11.27% admissions Total TB cases including 19,571 17,473 20,020 0.25% 17.73% 15.59% 17.62% Lab AFB positive cases Total pulmonary TB 2,840 3,816 2,920 0.25% 2.57% 3.40% 2.57% Admissions Total Malaria Admissions 7,954 7,659 10,407 30.00% 0.06% 0.06% 0.08% Total Hepatitis A,B,C & E 3,034 1,915 2,249 10.00% 0.07% 0.04% 0.05% Admissions Pneumonia > 5 years total 7,297 7,768 13,385 5.00% 0.33% 0.35% 0.59% admissions Diarrhea > 5 years total 88,814 98,159 97,894 5.00% 4.02% 4.38% 4.31% admissions Total Typhoid admissions 5,407 7,095 8,127 30.00% 0.04% 0.05% 0.06% Diabetes cases 244,419 280,838 353,037 10.00% 5.54% 6.26% 7.77% Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 52 Table 19: Service Outcomes Index Sindh Number Mortality rates HMIS Data 2016 2017 2018 2016 2017 2018 Maternal Deaths reported by Lady 297 450 201 26.91 40.15 17.69 Health workers (LHW) Infant Deaths reported by Lady Health 3,785 5,248 2,040 3.43 4.68 1.80 Workers (LHW) Neonatal Deaths caused by Asphyxia 578 215 451 0.52 0.19 0.40 Total Deaths of patients caused by 0 0 0 Eclampsia Total deaths caused by maternal 65 51 38 complications Total ectopic deaths 0 0 0 Still Births 2,833 3,581 5,491 2.57 3.20 4.83 Neonatal Deaths 1,276 762 942 1.16 0.68 0.83 Neonatal Deaths caused by Trauma 0 13 2 0.00 0.01 0.00 Congenital Neonatal Deaths 42 64 39 0.04 0.06 0.03 Premature Neonatal Deaths 400 255 189 0.36 0.23 0.17 Neonatal Deaths caused by 33 26 4 0.03 0.02 0.00 Hypothermia Total deaths caused by sepsis 0 0 0 0.00 0.00 0.00 Total abortion deaths 0 0 0 0.00 0.00 0.00 Total prolonged labor deaths 0 0 0 0.00 0.00 0.00 Total deaths caused by pre rupture of 0 0 0 0.00 0.00 0.00 membranes Diarrhea < 5 years total deaths 87 80 184 0.01 0.01 0.03 Pneumonia < 5 years total deaths 267 277 359 0.04 0.04 0.05 Neonatal Deaths caused by Sepsis 186 96 117 0.17 0.09 0.10 Total pulmonary TB Deaths 102 36 38 0.23 0.08 0.08 Total Malaria Deaths 13 6 4 0.03 0.01 0.01 Total Hepatitis A,B,C & E Deaths 82 14 16 0.19 0.03 0.04 Pneumonia > 5 years total deaths 84 50 359 0.22 0.13 0.93 Diarrhea > 5 years total deaths 57 63 35 0.15 0.17 0.09 Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 53 Khyber Pakhtunkhwa UHC Progress Budget & Expenditure Progress Tables Table 20: KPK: Budget and Expenditure for three years Visits %age Total Health Total Expenditure per Year Population Budget change Utilization Expenditure per capita person budget per year 2016 29,630,788 15,246,204,000 14,086,144,978 92% 475 0.62 2017 30,508,920 20,113,990,000 21,455,096,985 31.93% 107% 703 0.63 2018 31,299,988 22,280,058,102 18,811,202,221 10.77% 84% 601 0.64 Note: all amounts are in PKR. Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan Table 21: KPK: Budget and Expenditure for three years, primary and secondary %age change Year 2016 2017 2018 2016- 17 2017-18 Primary Original Budget 2,337,148,000 3,778,102,000 5,879,679,964 62% 56% Actual 2,474,262,023 2,702,833,969 4,566,556,229 9% 69% Expenditure Secondary Original Budget 9,541,364,000 12,367,281,000 8,276,587,776 30% -33% Actual 10,408,145,433 9,155,335,765 8,393,806,088 -12% -8% Expenditure Admin Original Budget 3,367,692,000 3,968,607,000 8,123,790,362 18% 105% Actual 1,203,736,922 9,517,031,403 5,850,839,904 691% -39% Expenditure Note: all amounts are in PKR. Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan Table 22: KPK Expenditure per facility Total Exp/facility Facility level # Facility 2016 2017 2018 Primary Facility 936 2,643,442 2,887,643 4,878,799 Secondary Facility 67 155,345,454 136,646,802 125,280,688 Note: all amounts are in PKR. Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index and refer to annexure 2 Tables 43 for facility details Expenditure per facility witnessed slight drop over the observed period while it doubled for primary health care. 54 Progress of UHC indicators: Table 23: UHC Index for KPK KPK Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Reproductive, Maternal, Neonatal, Child Health and Adolescent Cluster Total FP visits 265,903 284,643 263,643 23.00% 3.90% 4.06% 3.66% Postnatal Care ( PNC) 146,529 151,507 140,609 2.50% 19.78% 19.86% 17.97% Deliveries Normal 138,755 145,181 153,952 2.50% 18.73% 19.03% 19.67% Deliveries through 5,593 9,166 9,813 5.00% 15.10% 24.03% 25.08% C-section DPT3 (diphtheria, TT & 515,584 561,049 554,351 2.50% 69.60% 73.56% 70.84% pertussis) Weighted average 25% 28% 27% Infectious Disease Control (Communicable Disease) Cluster Total TB cases including 5,585 5,118 4,808 0.25% 7.54% 6.71% 6.14% Lab AFB positive cases Total Malaria cases including MP and 381,132 437,734 380,205 30.00% 4.29% 4.78% 4.05% falciparum positive cases Total Typhoid cases 153,994 141,906 161,778 10.00% 5.20% 4.65% 5.17% Weighted average 6% 5% 5% Non-Communicable Disease Control Service Capacity and Access Cluster Deliveries All 146,987 156,253 167,818 2.50% 19.84% 20.49% 21.45% Antenatal Care (ANC) 620,590 753,566 757,568 7.50% 27.93% 32.93% 32.27% visits Measles/Measles 1 484,581 539,155 534,838 2.50% 65.42% 70.69% 68.35% Fully Immunized 410,577 486,813 482,678 2.50% 55.43% 63.83% 61.68% Acute Respiratory Infection 2,781,853 2,593,530 2,609,236 30.00% 31.29% 28.34% 27.79% (ARI) cases Weighted average 36% 38% 37% Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 55 Table 24: Access to UHC Index KPK Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Total FP visits 265,903 284,643 263,643 23.00% 3.90% 4.06% 3.66% Postnatal Care (PNC) 146,529 151,507 140,609 2.50% 19.78% 19.86% 17.97% Deliveries Normal 138,755 145,181 153,952 2.50% 18.73% 19.03% 19.67% Antenatal Care (ANC) 620,590 753,566 757,568 7.50% 27.93% 32.93% 32.27% visits DPT3 (diphtheria, TT & 515,584 561,049 554,351 2.50% 69.60% 73.56% 70.84% pertussis) Tetanus (TT1) & (TT2) 366,690 383,903 395,908 2.50% 49.50% 50.33% 50.60% doses injected TB-dot patients 217 192 191 0.25% 0.29% 0.25% 0.24% HIV AIDS cases 123 118 37 0.10% 0.42% 0.39% 0.12% Total Malaria cases including MP and 381,132 437,734 380,205 30.00% 4.29% 4.78% 4.05% falciparum positive cases Hepatitis B & C positive 18,095 12,016 12,033 10.00% 0.61% 0.39% 0.38% cases Total Typhoid cases 153,994 141,906 161,778 10.00% 5.20% 4.65% 5.17% Deliveries All 146,987 156,253 167,818 2.50% 19.84% 20.49% 21.45% Measles/Measles 1 484,581 539,155 534,838 2.50% 65.42% 70.69% 68.35% Fully Immunized 410,577 486,813 482,678 2.50% 55.43% 63.83% 61.68% Acute Respiratory Infection 2,781,853 2,593,530 2,609,236 30.00% 31.29% 28.34% 27.79% (ARI) cases Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 56 Table 25: Service Availability Index KPK Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Live births with Low Birth 4,362 3,641 2,234 0.50% 2.94% 2.39% 1.43% Weight ( LBW) Total admissions of patients 0 0 0 0.13% 0.00% 0.00% 0.00% with Eclampsia Deliveries Assisted 2,639 1,906 4,053 0.38% 2.38% 1.67% 3.45% Total admissions with 24,080 11,404 7,663 0.38% 21.67% 9.97% 6.53% maternal complications Total ectopic admissions 0 0 0 0.02% 0.00% 0.00% 0.00% Total admissions with 0 0 0 0.00% 0.00% 0.00% 0.00% sepsis Deliveries through 5,593 9,166 9,813 0.13% 15.10% 24.03% 25.08% C-section Total abortion admission 0 0 0 0.13% 0.00% 0.00% 0.00% Total prolonged labor 0 0 0 0.25% 0.00% 0.00% 0.00% admissions Total admissions with pre 0 0 0 0.00% 0.00% 0.00% 0.00% rupture of membranes Diarrhea < 5 years total 42,626 62,107 57,873 6.00% 2.40% 3.39% 3.08% admissions Pneumonia < 5 years total 7,838 8,781 10,309 0.60% 4.41% 4.80% 5.49% admissions Total TB cases including 5,585 5,118 4,808 0.25% 7.54% 6.71% 6.14% Lab AFB positive cases Total pulmonary TB 1,435 1,971 2,356 0.25% 1.94% 2.58% 3.01% Admissions Total Malaria Admissions 6,444 8,178 4,942 30.00% 0.07% 0.09% 0.05% Total Hepatitis A,B,C & E 2,566 2,787 2,799 10.00% 0.09% 0.09% 0.09% Admissions Pneumonia > 5 years total 2,972 4,752 4,602 5.00% 0.20% 0.31% 0.29% admissions Diarrhea > 5 years total 22,987 54,058 30,441 5.00% 1.55% 3.54% 1.95% admissions Total Typhoid admissions 5,915 7,717 6,237 30.00% 0.07% 0.08% 0.07% Diabetes cases 263,596 274,199 319,543 10.00% 8.90% 8.99% 10.21% Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 57 Table 26: Service Outcomes Index KPK Number Mortality rates HMIS Data 2016 2017 2018 2016 2017 2018 Maternal Deaths reported by Lady 221 278 334 29.83 36.45 42.68 Health workers (LHW) Infant Deaths reported by Lady Health 3,389 10,536 7,145 4.57 13.81 9.13 Workers (LHW) Neonatal Deaths caused by Asphyxia 605 633 672 0.82 0.83 0.86 Total Deaths of patients caused by 0 0 0 Eclampsia Total deaths caused by maternal 11 25 1 complications Total ectopic deaths 0 0 0 Still Births 3,170 2,307 1,771 4.28 3.02 2.26 Neonatal Deaths 1,904 2,235 1,924 2.57 2.93 2.46 Neonatal Deaths caused by Trauma 59 49 18 0.08 0.06 0.02 Congenital Neonatal Deaths 155 133 159 0.21 0.17 0.20 Premature Neonatal Deaths 421 478 416 0.57 0.63 0.53 Neonatal Deaths caused by 134 201 153 0.18 0.26 0.20 Hypothermia Total deaths caused by sepsis 0 0 0 0.00 0.00 0.00 Total abortion deaths 0 0 0 0.00 0.00 0.00 Total prolonged labor deaths 0 0 0 0.00 0.00 0.00 Total deaths caused by pre rupture of 0 0 0 0.00 0.00 0.00 membranes Diarrhea < 5 years total deaths 88 116 75 0.02 0.03 0.02 Pneumonia < 5 years total deaths 141 121 106 0.03 0.03 0.02 Neonatal Deaths caused by Sepsis 427 702 473 0.58 0.92 0.60 Total pulmonary TB Deaths 17 37 27 0.06 0.12 0.09 Total Malaria Deaths 12 9 7 0.04 0.03 0.02 Total Hepatitis A,B,C & E Deaths 16 53 22 0.05 0.17 0.07 Pneumonia > 5 years total deaths 13 21 31 0.05 0.08 0.12 Diarrhea > 5 years total deaths 21 25 28 0.08 0.10 0.11 Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 58 Baluchistan UHC Progress Budget & Expenditure Progress Tables Table 27: Baluchistan: Budget and Expenditure for three years Visits %age Total Health Total Expenditure per Year Population Budget change Utilization Expenditure per capita person budget per year 2016 11,822,876 20,561,579,751 21,558,274,375 105% 1823 0.22 2017 12,262,227 23,746,352,300 21,467,015,858 -0.4% 90% 1751 0.19 2018 12,725,086 21,849,906,091 21,710,178,406 1.1% 99% 1706 0.18 Note: all amounts are in PKR. Data Source: Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan Table 28: Baluchistan: Budget and Expenditure for three years, primary and secondary %age change Year 2016 2017 2018 2016- 17 2017-18 Primary Original Budget 4,356,288,951 6,228,978,900 2,988,277,091 35% -50% Actual 6,759,653,972 5,638,025,878 2,888,057,591 -19% -47% Expenditure Secondary Original Budget 6,118,508,000 6,528,197,400 8,647,574,000 6% 8% Actual 6,396,004,893 7,163,051,650 8,326,283,442 14% 13% Expenditure Admin Original Budget 8,672,643,500 10,011,052,000 10,454,969,000 13% 5% Actual 7,481,484,624 7,292,535,027 9,018,542,308 3% 23% Expenditure Note: all amounts are in PKR. Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan Table 29: Baluchistan Expenditure per facility Total Exp/facility Facility level # Facility 2016 2017 2018 Primary Facility 895 7,658,955 6,240,651 3,277,683 Secondary Facility 42 159,143,203 180,882,304 203,997,567 Note: all amounts are in PKR. Data Source: Data Source: Country Integrated Financial Management Information System, Controller General of Accounts, Government of Pakistan and refer to annexure 2 Tables 49 for facility details 59 Progress of UHC indicators: Table 30: UHC Index for Baluchistan Baluchistan Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Reproductive, Maternal, Neonatal, Child Health and Adolescent Cluster Total FP visits 93,412 85,484 139,349 23.00% 3.44% 3.03% 4.76% Postnatal Care ( PNC) 59,156 44,620 90,175 2.50% 20.01% 14.56% 28.35% Deliveries Normal 46,291 43,040 60,186 2.50% 15.66% 14.04% 18.92% Deliveries through 750 712 269 5.00% 5.07% 4.65% 1.69% C-section DPT3 (diphtheria, TT & 73,068 63,990 87,343 2.50% 24.72% 20.87% 27.46% pertussis) Weighted average 14% 11% 16% Infectious Disease Control (Communicable Disease) Cluster Total TB cases including 1,293 1,331 1,370 0.25% 4.37% 4.34% 4.31% Lab AFB positive cases Total Malaria cases including MP and 412,110 300,153 287,744 30.00% 11.62% 8.16% 7.54% falciparum positive cases Total Typhoid cases 74,722 64,300 72,857 10.00% 6.32% 5.24% 5.73% Weighted average 7% 6% 6% Non-Communicable Disease Control Service Capacity and Access Cluster Deliveries All 48,513 45,143 62,259 2.50% 16.41% 14.73% 19.57% Antenatal Care (ANC) 175,852 207,566 238,171 7.50% 19.83% 22.57% 24.96% visits Measles/Measles 1 56,128 53,203 80,166 2.50% 18.99% 17.36% 25.20% Fully Immunized 46,700 42,214 66,311 2.50% 15.80% 13.77% 20.84% Acute Respiratory Infection 1,017,229 905,455 1,023,045 30.00% 28.68% 24.61% 26.80% (ARI) cases Weighted average 21% 20% 24% Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 60 Table 31: Access to UHC Index Baluchistan Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Total FP visits 93,412 85,484 139,349 23.00% 3.44% 3.03% 4.76% Postnatal Care (PNC) 59,156 44,620 90,175 2.50% 20.01% 14.56% 28.35% Deliveries Normal 46,291 43,040 60,186 2.50% 15.66% 14.04% 18.92% Antenatal Care (ANC) 175,852 207,566 238,171 7.50% 19.83% 22.57% 24.96% visits DPT3 (diphtheria, TT & 73,068 63,990 87,343 2.50% 24.72% 20.87% 27.46% pertussis) Tetanus (TT1) & (TT2) 38,793 33,473 51,982 2.50% 13.12% 10.92% 16.34% doses injected TB-dot patients 105 47 33 0.25% 0.36% 0.15% 0.10% HIV AIDS cases 72 7 0 0.10% 0.61% 0.06% 0.00% Total Malaria cases including MP and 412,110 300,153 287,744 30.00% 11.62% 8.16% 7.54% falciparum positive cases Hepatitis B & C positive 3,200 2,589 10,022 10.00% 0.27% 0.21% 0.79% cases Total Typhoid cases 74,722 64,300 72,857 10.00% 6.32% 5.24% 5.73% Deliveries All 48,513 45,143 62,259 2.50% 16.41% 14.73% 19.57% Measles/Measles 1 56,128 53,203 80,166 2.50% 18.99% 17.36% 25.20% Fully Immunized 46,700 42,214 66,311 2.50% 15.80% 13.77% 20.84% Acute Respiratory Infection 1,017,229 905,455 1,023,045 30.00% 28.68% 24.61% 26.80% (ARI) cases Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 61 Table 32: Service Availability Index Baluchistan Number Coverage HMIS Data 2016 2017 2018 Factor 2016 2017 2018 Live births with Low Birth 3,060 3,531 3,335 0.50% 5.18% 5.76% 5.24% Weight ( LBW) Total admissions of patients 0 0 0 0.13% 0.00% 0.00% 0.00% with Eclampsia Deliveries Assisted 1,472 1,391 1,804 0.38% 3.28% 2.99% 3.73% Total admissions with 311 752 1,343 0.38% 0.69% 1.61% 2.78% maternal complications Total ectopic admissions 0 0 0 0.02% 0.00% 0.00% 0.00% Total admissions with 0 0 0 0.00% 0.00% 0.00% 0.00% sepsis Deliveries through 750 712 269 0.13% 5.07% 4.65% 1.69% C-section Total abortion admission 0 0 0 0.13% 0.00% 0.00% 0.00% Total prolonged labor 0 0 0 0.25% 0.00% 0.00% 0.00% admissions Total admissions with pre 0 0 0 0.00% 0.00% 0.00% 0.00% rupture of membranes Diarrhea < 5 years total 2,063 3,094 9,580 6.00% 0.29% 0.42% 1.25% admissions Pneumonia < 5 years total 484 2,097 3,525 0.60% 0.68% 2.85% 4.62% admissions Total TB cases including 1,293 1,331 1,370 0.25% 4.37% 4.34% 4.31% Lab AFB positive cases Total pulmonary TB 37 66 625 0.25% 0.13% 0.22% 1.96% Admissions Total Malaria Admissions 2,369 1,259 3,782 30.00% 0.07% 0.03% 0.10% Total Hepatitis A,B,C & E 57 22 130 10.00% 0.00% 0.00% 0.01% Admissions Pneumonia > 5 years total 131 1,445 2,684 5.00% 0.02% 0.24% 0.42% admissions Diarrhea > 5 years total 852 5,303 14,686 5.00% 0.14% 0.86% 2.31% admissions Total Typhoid admissions 240 775 1,702 30.00% 0.01% 0.02% 0.04% Diabetes cases 32,366 40,915 45,187 10.00% 2.74% 3.34% 3.55% Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 62 Table 33: Service Outcomes Index Baluchistan Number Mortality rates HMIS Data 2016 2017 2018 2016 2017 2018 Maternal Deaths reported by Lady 69 29 18 23.34 10.15 6.77 Health workers (LHW) Infant Deaths reported by Lady Health 70 52 45 0.25 0.21 0.15 Workers (LHW) Neonatal Deaths caused by Asphyxia 48 31 289 0.16 0.11 0.98 Total Deaths of patients caused by 0 0 0 Eclampsia Total deaths caused by maternal 5 0 0 1.69 complications Total ectopic deaths 0 0 0 Still Births 560 598 473 2.11 2.40 1.99 Neonatal Deaths 134 277 365 0.47 0.98 1.34 Neonatal Deaths caused by Trauma 27 50 6 0.09 0.17 0.02 Congenital Neonatal Deaths 4 19 2 0.01 0.07 0.01 Premature Neonatal Deaths 8 98 39 0.03 0.35 0.19 Neonatal Deaths caused by 3 2 8 0.01 0.01 0.05 Hypothermia Total deaths caused by sepsis 0 0 0 0.00 0.00 0.00 Total abortion deaths 0 0 0 0.00 0.00 0.00 Total prolonged labor deaths 0 0 0 0.00 0.00 0.00 Total deaths caused by pre rupture of 0 0 0 0.00 0.00 0.00 membranes Diarrhea < 5 years total deaths 5 8 6 0.02 0.03 0.02 Pneumonia < 5 years total deaths 11 22 24 0.04 0.07 0.08 Neonatal Deaths caused by Sepsis 3 19 0 0.01 0.06 0.00 Total pulmonary TB Deaths 0 0 0 0.00 0.00 0.00 Total Malaria Deaths 0 0 0 0.00 0.00 0.00 Total Hepatitis A,B,C & E Deaths 0 0 0 0.00 0.00 0.00 Pneumonia > 5 years total deaths 1 2 7 0.01 0.22 0.07 Diarrhea > 5 years total deaths 0 3 1 0.00 0.03 0.01 Data Source: Health Management Information System (HMIS)/ District Health Information System (DHIS) and refer to annex-1 for explanation of “Factor” and derivation of output index 63 ANNEX 3: DISTRICT UHC BUDGET AND EXPENDITURE TABLE Punjab Distric Analysis Table 34: Public health facility Level Facility Type Number General Hospitals/Specialized Hospitals 42 Secondary Level DHQ Hospitals 26 THQ Hospitals/Civil Hospitals 124 Primary Level RHCs 310 BHUs 2495 MCH Centres 210 Dispensaries 146 Data Source: Government of Punjab, DHIS Annual Report 2017 Figure 9: Punjab districts visits per person Data Source: Government of Punjab, DHIS Annual Report 2016, 2017 & 2018 64 Figure 10: Punjab Districts: Expenditure per capita Data Source: Government of Punjab, DHIS Annual Report 2016, 2017 & 2018 And IFMIS data from CGA Lahore being provincial capital includes significant health headquarter expenditure and various programs expenditure, which though, spent at district level but booked at Accountant General Lahore. Therefore, for graphical presentation Lahore has not been plotted in above per capita expenditure graph. However, Lahore per capita is presented in the table below on District Expenditure per capita. 65 Table 35: District tables Punjab: Expenditure per capita and visits per person Expenditure Expenditure Expenditure District Visits per Visits per Visits per per capita per capita per capita Name person 2016 person 2017 person 2018 2016 (PKR) 2017 (PKR) 2018 (PKR) Attock 325 766 968 0.57 1.22 1.32 Bhawal Nagar 338 798 1,031 0.52 1.14 1.29 Bhawalpur 1,579 1,739 1,442 0.31 0.83 0.98 Bhukkar 416 906 1,227 0.56 1.23 1.49 Chakwaal 384 815 1,200 0.66 1.31 1.66 Chiniot 240 492 734 0.47 1.1 1.44 D.G Khan 680 1,047 1,006 0.22 0.73 0.83 Faisalabad 1,089 1,383 1,246 0.29 0.73 0.82 Gujranwala 632 831 808 0.27 0.7 0.86 Gujrat 449 891 957 0.36 1.15 1.37 Hafizabad 388 736 1,063 0.59 1.53 1.71 Jhang 313 714 981 0.46 1.1 1.34 Jhelum 477 968 1,395 0.65 1.61 1.83 Kasoor 259 514 730 0.44 0.99 1.25 Khaniwal 176 589 758 0.35 0.94 1.17 Khushab 321 887 1,197 0.53 1.17 1.44 Lahore 7,069 9,425 7,188 0.04 0.24 0.26 Layyah 371 914 1,208 0.52 1.06 1.45 Lodhran 260 593 817 0.47 1.23 1.4 Mandi 294 101 1,053 0.31 0.14 1.22 Bahuddin Mianwali 423 814 1,161 0.71 1.23 1.44 Multan 1,639 2,021 1,551 0.27 0.68 0.73 Muzzafar 250 546 761 0.55 1.16 1.44 Ghar Nankana 320 823 1,127 0.4 1.2 1.55 Sahb Narowwal 420 763 1,105 0.47 1.18 1.6 Okara 314 677 951 0.43 1.04 1.25 Pak Pathan 279 545 698 0.42 1.11 1.36 Rahim Yar 660 1,064 859 0.2 0.84 0.97 Khan RajanPur 320 886 713 0.44 0.93 1.04 Rawalpindi 1,366 1,464 1,430 0.2 0.52 0.6 Sargodha 507 872 1,021 0.38 1.03 1.25 Sheikhupura 285 662 904 0.65 1.18 1.44 Sahiwal 794 918 887 0.15 0.85 1.01 Sialkot 730 886 934 0.3 0.74 0.9 Toba Tek 309 673 862 0.36 1.18 1.42 Singh Vehari 306 595 719 0.44 1.19 1.47 Data Source: CGA, Government of Pakistan, Punjab district budget and expenditure data 2016, 2017 & 2018 downloaded from IFMIS, Pakistan Census data 2018, Pakistan Bureau of Statistics and DHIS Government of Punjab 66 Table 36: Punjab Health facilities Health Facilities - Punjab Sr. District BHU DHQ HOSP MCH RHC THQ Total 1 Bahawalpur 73 0 0 10 12 4 99 2 Jhelum 48 1 0 6 6 2 63 3 Kasur 81 1 0 8 11 4 105 4 Okara 97 2 0 4 10 2 115 5 Pakpattan 55 1 0 2 5 1 64 6 Attock 62 1 0 3 6 5 77 7 Bahawalnagar 103 1 0 7 10 4 125 8 Bhakkar 40 1 0 2 5 3 51 9 Chakwal 64 1 0 2 11 4 82 10 Chiniot 36 1 0 2 3 2 44 11 D.G Khan 53 0 0 5 9 2 69 12 Faisalabad 168 0 0 6 15 6 195 13 Gujranwala 92 0 0 10 12 3 117 14 Gujrat 88 0 4 8 9 6 115 15 Hafizabad 32 1 0 3 7 1 44 16 Jhang 59 1 0 2 10 3 75 17 Khanewal 83 1 0 4 7 3 98 18 Khushab 43 1 0 7 5 4 60 19 Lahore 38 0 4 59 5 7 113 20 Layyah 36 1 0 2 6 6 51 21 Lodhran 48 1 0 1 4 2 56 22 Mandi Bahauddin 48 1 1 5 9 2 66 23 Mianwali 32 1 0 3 8 2 46 24 Multan 82 1 0 16 8 2 109 25 Muzaffargarh 72 1 0 3 13 4 93 26 Nankana Sahib 48 1 0 5 6 2 62 27 Narowal 57 1 0 4 7 1 70 28 Piplan 10 0 0 2 2 1 15 29 Rahimyar Khan 104 0 1 7 19 3 134 30 Rajanpur 32 1 0 1 7 2 43 31 Rawalpindi 98 0 0 6 8 7 119 32 Sahiwal 76 0 0 3 11 1 91 33 Sargodha 131 0 0 8 12 10 161 34 Sheikhupura 80 1 0 4 7 4 96 35 Sialkot 88 0 0 14 6 4 112 36 Toba Tek Singh 70 1 0 2 9 2 84 37 Vehari 74 1 0 4 14 2 95 Total 2501 26 10 240 314 123 3214 Source: Ministry of National Health Services, Regulation & Coordination and Provincial/Area DoH 67 Table 37: Punjab Districts Budget Utilization for three years 2016 2017 2018 District Name Budget Utilization (%) Attock 67 115 111 Bhawal Nagar 19 125 69 Bhawalpur 58 78 100 Bhukkar 50 101 50 Chakwaal 57 94 87 Chiniot 66 92 63 D.G Khan 49 91 89 Faisalabad 39 79 83 Gujranwala 61 77 74 Gujrat 72 141 80 Hafizabad 51 75 102 Jhang 54 103 86 Jhelum 62 96 75 Kasoor 58 69 81 Khaniwal 86 123 95 Khushab 60 361 85 Lahore 38 95 91 Layyah 27 107 72 Lodhran 47 69 71 Mandi Bahuddin 64 150 101 Mianwali 67 53 72 Multan 40 120 80 Muzzafar Ghar 59 94 98 Nankana Sahb 71 109 105 Narowwal 41 97 94 Okara 63 143 90 Pak Pathan 45 73 76 Rahim Yar Khan 63 69 288 RajanPur 53 104 380 Rawalpindi 59 124 109 Sargodha 21 139 80 Sheikhupura 50 95 84 Sahiwal 48 87 86 Sialkot 230 186 95 Toba Tek Singh 64 100 94 Vehari 74 92 88 Data Source: CGA, Government of Pakistan, Punjab district budget and expenditure data 2016, 2017 & 2018 downloaded from IFMIS 68 Table 38: Punjab Districts Budget, Expenditure and cost per patient 2016 Actual Expenditure per District Name Facility Original Budget OPD (Y) Expenditure patient Attock Primary 191,039,494 129,782,986 53,319 2,434 Secondary 228,776,193 149,718,504 1,006,050 149 DHO 140,362,445 93,233,351 Bhawal Nagar Primary 1,176,265,187 225,626,515 167,625 1,346 Secondary 712,211,735 157,955,753 1,344,861 117 DHO 644,982,936 102,515,083 Bhawalpur Primary 353,378,825 205,686,565 173,482 1,186 Secondary 294,059,628 170,897,131 955,645 179 DHO 188,873,442 110,543,819 Bhukkar Primary 168,083,391 86,468,270 65,740 1,315 Secondary 278,651,771 135,075,280 838,797 161 DHO 159,311,600 80,710,686 Chakwaal Primary 279,047,747 147,311,983 50,769 2,902 Secondary 170,012,400 122,913,616 917,759 134 DHO 122,744,774 54,917,284 Chiniot Primary 147,984,971 101,526,569 65,397 1,552 Secondary 43,510,261 31,271,666 566,308 55 DHO 85,086,987 49,112,877 D.G Khan Primary 306,648,685 156,503,065 285,945 547 Secondary 103,077,250 41,298,419 333,503 124 DHO 100,471,709 51,312,900 Faisalabad Primary 543,356,237 341,160,079 337,632 1,010 Secondary 173,941,366 120,676,391 1,892,235 64 DHO 1,138,113,228 253,651,224 Gujranwala Primary 462,559,335 275,309,776 221,201 1,245 Secondary 80,832,882 57,957,066 1,080,932 54 DHO 164,845,390 99,080,284 Gujrat Primary 266,096,000 195,407,334 468,339 417 Secondary 143,224,582 107,846,039 517,887 208 DHO 126,389,624 83,371,433 Hafizabad Primary 155,348,000 94,170,499 95,359 988 Secondary 194,557,000 89,619,914 572,282 157 DHO 123,561,000 57,379,056 Jhang Primary 349,796,067 217,150,082 111,867 1,941 Secondary 261,796,130 167,367,221 1,112,655 150 DHO 224,877,655 63,781,562 69 Actual Expenditure per District Name Facility Original Budget OPD (Y) Expenditure patient Jhelum Primary 209,779,175 134,901,902 125,128 1,078 Secondary 169,284,438 103,073,787 658,946 156 DHO 135,892,045 79,347,796 Kasoor Primary 337,169,834 183,699,389 188,441 975 Secondary 180,725,434 117,205,567 1,309,687 89 DHO 177,360,783 100,072,003 Khaniwal Primary 223,056,957 15,805,6418 93,665 1,687 Secondary 115,682,782 9,550,2003 898,962 106 DHO 57,642,158 86,257,848 Khushab Primary 151,930,804 10,114,3804 46,867 2,158 Secondary 149,390,308 9,381,7851 622,476 151 DHO 120,178,220 58,136,628 Lahore Primary 163,818,599 125,005,883 111,604 1,120 Secondary 345,959,605 219,533,996 341,574 643 DHO 2,047,358,173 637,599,816 Layyah Primary 967,692,800 112,240,053 50,818 2,209 Secondary 269,265,700 185,780,769 867,807 214 DHO 104,536,300 60,160,480 Lodhran Primary 215,080,733 104,268,422 60,612 1,720 Secondary 159,429,395 86,922,663 71,7818 121 DHO 138,425,419 49,186,713 Mandi Bahuddin Primary 193,407,753 127,308,443 36,197 3,517 Secondary 85,237,991 66,780,098 45,7329 146 DHO 110,209,896 55,817,654 Mianwali Primary 171,458,429 135,179,284 82,561 1,637 Secondary 203,407,002 123,869,496 986,647 126 DHO 155,648,693 98,584,321 Multan Primary 537,968,000 229,391,020 162,523 1,411 Secondary 463,177,000 205,115,209 1,071,090 192 DHO 607,765,058 212,654,485 Muzzafar Ghar Primary 443,534,300 293,933,260 384,891 764 Secondary 366,276,100 168,430,508 1,914,627 88 DHO 226,153,700 149,955,298 Nankana Sahb Primary 175,400,041 113,069,143 45,766 2,471 Secondary 97,089,168 74,665,941 49,1164 152 DHO 73,450,723 59,532,585 Narowwal Primary 346,928,993 137,650,869 121,900 1,129 Secondary 113,798,648 77,255,274 676,071 114 70 Actual Expenditure per District Name Facility Original Budget OPD (Y) Expenditure patient DHO 252,711,199 75,349,931 Okara Primary 463,506,471 264,328,531 216,923 1,219 Secondary 210,493,484 144,276,191 1,083,289 133 DHO 136,261,869 98,984,294 Pak Pathan Primary 266,505,510 121,307,767 95,752 1,267 Secondary 114,103,750 59,456,677 648,807 92 DHO 80,980,155 25,846,212 Rahim Yar Khan Primary 422,741,887 254,155,774 198,567 1,280 Secondary 122,875,236 87,378,584 759,354 115 DHO 189,462,696 118,393,906 RajanPur Primary 182,663,100 92,748,140 97,465 952 Secondary 207,977,000 89,902,512 751,508 120 DHO 142,358,786 99,967,869 Rawalpindi Primary 346,955,447 233,841,098 169,782 1,377 Secondary 240,887,209 163,939,009 899,159 182 DHO 689,203,643 361,408,928 Sargodha Primary 657,665,000 27,870,784 329,881 84 Secondary 356,109,000 13,11,233,77 1,038,068 126 DHO 248,908,292 109,492,617 Sheikhupura Primary 3,1072,9461 161,581,779 249,127 649 Secondary 374,078,098 206,112,723 1,948,857 106 DHO 418,779,398 18,0728,396 Shiwal Primary 303,324,420 167,020,967 114,211 1,462 Secondary 54,354,000 34,703,545 251,610 138 DHO 222,271,500 77,505,032 Sialkot Primary 306,420,300 200,532,387 280,620 715 Secondary 110,925,506 10,396,4109 857,467 121 DHO 178,141,750 166,741,011 Toba Tek Singh Primary 235,773,000 132,871,280 79,216 1,677 Secondary 155,200,500 112,116,211 691,110 162 DHO 120,043,448 84,535,323 Vehari Primary 293,556,343 229,685,873 114,196 2,011 Secondary 172,123,832 124,039,119 1,132,481 110 DHO 167,123,876 116,904,859 Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, Punjab district budget and expenditure data 2016 downloaded from IFMIS, Pakistan and DHIS Government of Punjab 71 Table 39: Punjab Districts Budget, Expenditure and cost per patient 2017 Actual Expenditure per District Name Facility Original Budget OPD (Y) Expenditure patient Attock Primary 493,790,138 573,331,076 863,295 664 Secondary 507,941,159 576,269,718 1,431,383 403 DHO 148,365,546 176,614,653 Bhawal Nagar Primary 503,615,248 863,112,153 1,757,842 491 Secondary 635,364,241 616,272,601 1,625,906 379 DHO 540,478,013 618,408,955 Bhawalpur Primary 1,251,317,893 1,178,806,171 1,917,249 615 Secondary 686,778,464 355,600,467 1,110,993 320 DHO 328,184,469 235,302,654 Bhukkar Primary 324422,037 3,08,621,390 898,924 343 Secondary 565,886,803 572,500,651 1,124,103 509 DHO 366,821,241 387,060,144 Chakwaal Primary 526,803,706 345,253,435 884,616 390 Secondary 409,394,929 426,809,624 1,081,784 395 DHO 225,566,018 320,616,396 Chiniot Primary 427,532,894 405,231,056 694,520 583 Secondary 162,598,737 137,792,128 805,679 171 DHO 81,865,208 74,826,716 D.G Khan Primary 527,286,516 469,845,165 1,623,491 289 Secondary 169,703,761 157,807,108 475,777 332 DHO 413,130,762 381,785,258 Faisalabad Primary 1,044,514,527 842,594,340 3,746,715 225 Secondary 731,423,868 557,480,795 2,026,346 275 DHO 1,391,929,564 1,089,725,347 Gujranwala Primary 1,510,814,264 1,252,163,460 2,427,150 516 Secondary 429,523,432 323,512,078 1,090,625 297 DHO 37,783,6051 206,885,977 Gujrat Primary 652,161,180 1,002,454,033 2,243,652 447 Secondary 302,061,460 420,313,393 934,241 450 DHO 188,181,181 187,742,290 Hafizabad Primary 261,146,598 228,089,352 961,288 237 Secondary 32,995,0738 319,982,200 804,607 398 DHO 164,179,535 19,508,394 Jhang Primary 619,426,507 706,662,658 1,561,156 453 Secondary 516,238,422 66,7401,921 1,458,543 458 DHO 624,162,245 444,660,006 Jhelum Primary 356,070,729 386,300,865 1,045,341 370 72 Actual Expenditure per District Name Facility Original Budget OPD (Y) Expenditure patient Secondary 439,809,121 387,463,551 922,835 420 DHO 296,531,356 278,826,020 Kasoor Primary 83,6152,869 556,022,320 2,105,342 264 Secondary 762,626,232 56,427,9104 1,317,345 428 DHO 707,452,908 474,334,958 Khaniwal Primary 745,353,947 946,316,043 1,356,850 697 Secondary 395,985,756 494,847,164 1,395,149 355 DHO 160,282,956 160,567,292 Khushab Primary 48,691,491 323,390,817 670,792 482 Secondary 4,456,000 419,036,606 824,849 508 DHO 223,142,914 256,012,451 Lahore Primary 629,981,634 573,951,075 1,690,099 340 Secondary 552,358,449 492,408,209 970,121 508 DHO 2,160,725,585 2,125,579,220 Layyah Primary 389,726,500 445,593,609 642,550 693 Secondary 637,034,500 726,989,179 1,299,619 559 DHO 322,102,796 268,456,278 Lodhran Primary 287,538,497 228,707,352 1,204,463 190 Secondary 508,665,800 248,719,572 883,919 281 DHO 341,522,558 307,956,580 Mandi Bahuddin Primary 334,095,334 418,412,296 934,668 448 Secondary 237,155,347 317,195,490 681,224 466 DHO 272,264,776 528,959,186 Mianwali Primary 416,540,135 293,230,309 860,424 341 Secondary 454,727,402 44,186,074 1,043,718 42 DHO 428,750,004 349,063,708 Multan Primary 723,326,500 743,133,643 1,959,836 379 Secondary 406,509,600 59,7182,613 1,260,270 474 DHO 657,121,851 801,583,118 Muzzafar Ghar Primary 1,334,659,535 1,269,745,186 2,494,179 509 Secondary 681,696,090 650,832,520 2,528,862 257 DHO 210,253,481 169,673,432 Nankana Sahb Primary 389,984,441 398,269,874 878,425 453 Secondary 206,701,639 335,838,150 747,817 449 DHO 331,674,538 274,649,453 Narowwal Primary 480,576,916 461,473,081 1,148,072 402 Secondary 379,649,971 370,548,592 860,614 431 DHO 375,920,183 360,923,674 73 Actual Expenditure per District Name Facility Original Budget OPD (Y) Expenditure patient Okara Primary 460,114,173 834,458,624 1,652,157 505 Secondary 443,447,368 578,602,853 1511719 383 DHO 390,675,086 440,781,424 Pak Pathan Primary 487,056,783 352,938,031 1218578 290 Secondary 390472,357 252,794,504 810,309 312 DHO 274,200,279 234,326,271 Rahim Yar Khan Primary 1,226,460,154 704,607,853 2,905,891 242 Secondary 392,411,149 333,272,324 1,126,025 296 DHO 754,282,620 600,350,944 RajanPur Primary 369,445,128 384,227,196 923,893 416 Secondary 304,403,224 366,419,673 932,172 393 DHO 159,872,017 114,611,589 Rawalpindi Primary 909,395,711 1,293,539,430 1,650,721 784 Secondary 429,677,000 707,891,152 1,160,293 610 DHO 736,482,952 573,884,791 Sargodha Primary 1,141,534,000 1,482,077,647 2,141,365 692 Secondary 472,852,555 489,654,977 1,667,590 294 DHO 203,990,000 552,761,918 Sheikhupura Primary 617,309,407 581,618,539 1,784,535 326 Secondary 746,118,779 888,759,572 2,292,278 388 DHO 837,882,976 611,814,979 Shiwal Primary 507,940,610 381,581,950 1,779,860 214 Secondary 1,3075,9094 126,234,834 345,629 365 DHO 471,009,683 45,208,3195 Sialkot Primary 538,572,683 736,695,114 1,768,534 417 Secondary 201,446,025 408,259,394 1,106,004 369 DHO 223,831,853 646,143,132 Toba Tek Singh Primary 453,163,270 339,879,866 1,533,732 222 Secondary 404,641,532 510,580,976 1,048,842 487 DHO 448,456,000 453,102,898 Vehari Primary 616,346,527 557,117,056 2,168,370 257 Secondary 505,431,784 506,780,524 1,289,325 393 DHO 523,680,651 448,487,162 Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, Punjab district budget and expenditure data 2017 downloaded from IFMIS and DHIS data, Government of Punjab 74 Table 40: Punjab Districts Budget, Expenditure and Expenditure per patient 2018 Actual Expenditure per District Name Facility Original Budget OPD (Y) Expenditure patient Attock Primary 650,495,615 730,148,434 923,649 791 Secondary 742,827,445 806,338,722 1,625,408 496 DHO 222,986,522 255,406,891 Bhawal Nagar Primary 1,253,984,868 909,785,646 2,115,145 430 Secondary 2,055,842,790 964,567,193 1,809,587 533 DHO 948,061,446 1,055,985,183 Bhawalpur Primary 1,412,816,138 1,327,252,655 2,155,933 616 Secondary 598,213,857 610,588,601 1,536,033 398 DHO 250,006,103 317,093,424 Bhukkar Primary 391,504,293 341,215,677 1,221,119 279 Secondary 1,107,075,148 94,557,216 1,298,734 73 DHO 592,625,740 602,174,064 Chakwaal Primary 485,742,337 398,379,078 1,133,843 351 Secondary 830,496,273 715,523,104 1,388,668 515 DHO 691,772,422 629,888,573 Chiniot Primary 778,665,270 583,682,898 851,993 685 Secondary 654,872,926 293,343,474 1,157,848 253 DHO 116,058,830 102,743,107 D.G Khan Primary 728,874,000 499,760,642 1,727,541 289 Secondary 461,881,000 312,723,160 731,845 427 DHO 614,841,180 789,604,075 Faisalabad Primary 1,004,247,810 899,521,777 4,089,311 220 Secondary 1,021,575,440 898,657,588 2,469,784 364 DHO 2,195,936,100 1,721,853,891 Gujranwala Primary 1,833,385,384 1,674,139,114 3,056,288 548 Secondary 809,142,485 540,881,144 1,355,281 399 DHO 646,169,585 226,056,038 Gujrat Primary 1,271,449,636 1,209,754,950 2,540,488 476 Secondary 1,026,459,330 559,214,906 1,299,554 430 DHO 337,314,168 343,785,669 Hafizabad Primary 342,871,000 266,852,189 1,174,482 227 Secondary 529,092,000 51,358,5301 835,539 615 DHO 287,181,000 402,261,644 Jhang Primary 1,042,391,935 82,5960,462 1,706,843 484 Secondary 1,397,980,730 967,796,419 2,037,848 475 DHO 636,170,242 842,798,985 Jhelum Primary 622,061,208 457,882,053 1,302,317 352 75 Actual Expenditure per District Name Facility Original Budget OPD (Y) Expenditure patient Secondary 1,134,340,330 577,663,866 962,670 600 DHO 465,806,314 636,592,707 Kasoor Primary 1,066,700,531 619,816,797 2,404,457 258 Secondary 1,069,109,728 1,070,193,610 2,001,657 535 DHO 868,285,293 748,302,394 Khaniwal Primary 1,137,228,279 1,255,206,836 1,702,263 737 Secondary 837,487,104 727,899,924 1,786,326 407 DHO 324,830,098 192,272,985 Khushab Primary 423,694,248 389,726,803 859,989 453 Secondary 845,151,957 662,440,952 1,013,044 654 DHO 475,620,540 434,260,092 Lahore Primary 1,139,820,884 881,447,549 1,750,242 504 Secondary 555,689,576 531,649,323 1,222,251 435 DHO 2,338,859,981 2,254,253,065 Layyah Primary 868,898,789 554,025,937 887,637 624 Secondary 1,507,883,974 1,046,787,509 1,825,050 574 DHO 618,201,094 547,860,306 Lodhran Primary 467,062,695 454,131,561 1,314,704 345 Secondary 1,148,047,145 580,355,823 1,109,084 523 DHO 284,098,256 309,120,896 Mandi Bahuddin Primary 744,673,444 520,872,176 1,171,360 445 Secondary 773,255,981 488,503,077 809,424 604 DHO 773,512,878 623,278,690 Mianwali Primary 469,151,502 362,479,192 1,074,706 337 Secondary 1,395,285,263 760,322,830 1,188,332 640 DHO 510,027,634 578,211,053 Multan Primary 976,361,000 872,702,801 2,097,029 416 Secondary 1,195,810,000 841,664,136 1,422,640 592 DHO 1,310,370,000 1,074,463,319 Muzzafar Ghar Primary 1,717,296,399 1,746,691,890 3,383,817 516 Secondary 121,4791,856 1,147,878,672 3,010,694 381 DHO 353,422,727 312,848,120 Nankana Sahb Primary 460,822,080 490,458,110 1,059,163 463 Secondary 545,128,412 584,085,770 1,073,589 544 DHO 394,355,298 392,693,203 Narowwal Primary 625,132,600 586,439,963 1,443,435 406 Secondary 765,178,000 710,580,983 1,330,819 534 76 Actual Expenditure per District Name Facility Original Budget OPD (Y) Expenditure patient DHO 565,870,148 541,378,449 Okara Primary 1,089,817,669 1,009,713,064 1,976,728 511 Secondary 1,265,144,052 1,068,704,651 1,892,169 565 DHO 716,266,697 696,626,517 Pak Pathan Primary 470,703,483 371,551,309 1,507,733 246 Secondary 841,969,424 434,585,330 1,022,866 425 DHO 285,873,178 415,413,180 Rahim Yar Khan Primary 1,586,784,711 823,742,819 3,391,646 243 Secondary 809,114,538 445,023,032 1,352,899 329 DHO 1,279,022,842 937,763,918 RajanPur Primary 579,281,500 497,106,281 975,089 510 Secondary 698,198,000 582,384,185 1,172,361 497 DHO 464,584,356 292,784,756 Rawalpindi Primary 1,356,561,085 1,537,914,543 1,787,823 860 Secondary 806,185,000 867,621,407 1,551,688 559 DHO 644,019,000 641,683,476 Sargodha Primary 1,589,304,510 1,219,890,202 2,661,493 458 Secondary 1,047,316,768 815,605,805 2,043,282 399 DHO 989,206,524 862,382,164 Sheikhupura Primary 712,381,925 672,426,575 1,995,346 337 Secondary 1,839,150,356 1,554,364,323 3,111,143 500 DHO 1,028,860,690 793,859,767 Shiwal Primary 643,954,554 412,700,313 2,174,667 190 Secondary 242,552,437 224,957,045 416,619 540 DHO 625,093,699 661,641,587 Sialkot Primary 935,298,805 905,786,374 2,205,885 411 Secondary 777,889,095 802,573,719 1,369,174 586 DHO 994,305,550 875,419,151 Toba Tek Singh Primary 412,868,000 365,551,683 1,880,965 194 Secondary 831,308,000 745,565,047 1,290,040 578 DHO 646,683,000 6,68,104,397 Vehari Primary 686,734,086 600,349,331 2,455,782 244 Secondary 966,528,510 814,388,519 1,877,951 434 DHO 670,507,316 637,320,295 Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, Punjab district budget and expenditure data 2018 downloaded from IFMIS and DHIS data, Government of Punjab 77 Sindh Distric Analysis Table 41: Sindh: Public Health Facilities Level Facility Type Total Number Tertiary Level General Hospitals/Specialized Hospitals 8 Secondary Level DHQ Hospitals 14 THQ Hospitals/Civil Hospitals 49 Other Hospitals 27 Primary Level RHCs 125 BHUs 757 MCH Centres 67 Dispensaries 792 Data Source: Government of Sindh, Health Profile of Sindh 2017 Figure 11: Sindh Districts visits per person Data Source: DHIS data, Government of Sindh 2016, 2017 & 2018 78 Figure 12: Sindh Districts Expenditure per capita Data Source: DHIS data, Government of Sindh 2016, 2017 & 2018 Data Source: CGA, Government of Pakistan, Sindh district budget and expenditure data 2016, 2017 & 2018 downloaded from IFMIS and Pakistan Census data 2018, Pakistan Bureau of Statistics 79 Table 42: Sindh: Districts Expenditure per capita and visits per person Expenditure Expenditure Expenditure Visits per Visits per Visits per District Name per capita per capita per capita person person person 2016 (PKR) 2017 (PKR) 2018 (PKR) 2016 2017 2018 Badin 454 472 672 1.28 1.34 1.34 Dadu 533 537 888 1.38 1.30 1.34 Ghotki 355 387 521 1.32 1.37 1.30 Hyderabad 3,966 6,399 7,176 1.38 1.44 1.50 Jacobabad 719 1,121 2,320 1.34 1.63 1.61 Jamshoro 1,167 2,405 2,320 1.74 1.86 2.07 Shadad Kot 359 460 337 0.87 0.98 1.22 Karachi 1,016 2,907 3,040 0.01 0.02 0.01 Kashmore 265 290 408 0.51 0.63 0.67 Khairpur 1,370 1,863 1,758 1.26 1.21 1.29 Larkana 1,694 1,794 1,920 0.85 0.98 1.09 Matiari 546 1177 827 1.78 1.81 1.90 Mirpur Khas 691 882 1317 1.35 1.41 1.58 Noushero Feroz 586 663 852 1.46 1.50 1.58 Nawab Shah 1,385 1,676 1,856 1.13 1.16 1.14 Sanghar 485 619 708 1.23 1.28 1.39 Shikarpur 562 688 894 1.13 1.22 1.18 Sukkkar 1,374 1,359 1,343 1.34 0.93 1.01 TandoAllah yar 449 593 758 0.76 0.78 0.85 TandoMuhammad 401 583 625 1.21 1.13 1.11 Khan Thatta 596 712 871 0.65 0.73 0.74 Umerkot 863 837 886 1.65 1.63 1.60 Tharparkar ( Mithi) 662 885 637 0.71 0.74 0.81 Data Source: CGA, Government of Pakistan, Sindh district budget and expenditure data 2016, 2017 & 2018 downloaded from IFMIS, Pakistan Census data 2018, Pakistan Bureau of Statistics and DHIS Government of Sindh 80 Table 43: Sindh Health Facilities Health Facilities - Sindh Sr. District BHU DHQ HOSP MCH RHC THQ Total 1 Jamshoro 18 1 0 2 5 3 29 2 Karachi West 13 0 2 8 4 0 27 3 Tando Muhammad Khan 14 1 0 0 3 1 19 4 Badin 36 1 0 1 11 4 53 5 Dadu 46 1 0 4 3 3 57 6 Ghotki 36 1 0 2 3 4 46 7 Hyderabad 11 0 4 13 3 11 42 8 Jacobabad 26 1 1 3 3 2 36 9 Kamber 28 1 0 2 4 3 38 10 Karachi Central 2 0 6 4 0 0 12 11 Karachi East 7 0 2 5 0 0 14 12 Karachi South 0 0 10 5 0 0 15 13 Kashmore 26 1 0 2 4 1 34 14 Khairpur 71 0 3 21 11 1 107 15 Korangi 10 0 3 6 3 0 22 16 Larkana 29 0 1 3 4 3 40 17 Malir 17 0 3 8 2 0 30 18 Matiari 21 1 1 1 3 2 29 19 Mirpurkhas 38 1 0 11 5 2 57 20 Naushero Feroze 45 1 0 0 13 2 61 21 Sanghar 58 1 0 0 6 4 69 22 Shaheed Benazirabad 37 0 0 14 9 1 61 23 Shikarpur 36 1 2 4 7 1 51 24 Sujawal 29 0 0 0 2 3 34 25 Sukkur 27 0 1 3 3 3 37 26 Tando Allahyar 14 1 0 0 3 0 18 27 Tharparkar 40 1 0 1 2 4 48 28 Thatta 23 1 0 0 6 1 31 29 Umerkot 32 1 2 2 6 3 46 Total 790 17 41 125 128 62 1163 Source: Ministry of National Health Services, Regulation & Coordination and Provincial/Area DoH 81 Table 44: Sindh Districts Budget Utilization 2016 2017 2018 District Name Budget Utilization (%) Badin 77 65 97 Dadu 84 60 98 Ghotki 89 80 98 Hyderabad 120 140 157 Jacubabad 56 76 163 Jamshoro 85 114 95 Shadad Kot 82 73 54 Karachi 36 79 73 Kashmore 84 63 89 Khairpur 94 115 95 Larkana 83 76 88 Matiari 79 138 98 Mirpur Khas 28 77 88 Noushero Feroz 90 79 100 Nawab Shah 82 72 89 Sanghar 87 88 86 Shikarpur 44 77 101 Sukkkar 103 74 79 TandoAllah yar 94 98 28 TandoMuhammad Khan 74 86 86 Thatta 70 23 124 Umerkot 113 92 82 Tharparkar ( Mithi) 137 78 55 Data Source: CGA, Government of Pakistan, Punjab district budget and expenditure data 2016, 2017 & 2018 downloaded from IFMIS 82 Table 45: Sindh Districts Budget, Expenditure, and cost per patient 2016 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Badin Primary 444,486,000 368,272,902 1,379,962 267 Secondary 504,106,000 329,045,833 866,719 380 DHO 89,257,000 99,996,940 Dadu Primary 21,542,000 12,595,470 1,165,014 11 Secondary 839,894,000 721,293,247 979,232 737 DHO 125,347,000 93,910,071 Ghotki Primary 156,429,000 119,589,382 1,037,621 115 Secondary 423,728,000 403,476,024 1,080,170 374 DHO 57,439,000 46,185,407 Hyderabad Primary 94,746,000 75,611,953 892,817 85 Secondary 5,099,027,000 4,209,870,642 2,082,547 2022 DHO 1,942,542,545 4,261,078,047 Jacubabad Primary 190,452,000 14,525,186 682,763 21 Secondary 892,691,000 534,475,518 643,758 830 DHO 183,410,000 163,075,685 Jamshoro Primary 259,251,000 191,858,197 620,796 309 Secondary 972,013,000 778,398,313 1,058,763 735 DHO 97,114,000 156,659,008 Shadad Kot Primary 206,633,000 160,614,876 754,223 213 Secondary 259,085,000 216,722,282 384,395 564 DHO 106,673,000 93,905,958 Karachi Primary 2,522,437,000 2,158,006,481 184,404 11,703 Secondary 18,839,347,000 1,779,588,654 DHO 24,172,982,476 12,373,737,510 Kashmore Primary 130,626,000 107,202,770 419,650 255 Secondary 144,574,000 123,820,788 125,456 987 DHO 61,318,000 50,506,416 Khairpur Primary 896,222,000 778,544,393 2,828,709 275 Secondary 2,249,827,000 2,169,164,144 138,717 15,637 DHO 279,175,000 269,697,794 Larkana Primary 377,881,000 277,262,073 857,658 323 Secondary 2,346,780,000 1,975,856,094 404,845 4,881 DHO 326,651,000 267,746,609 Matiari Primary 190,154,000 141,476,679 885,098 160 Secondary 282,725,000 228,705,508 456,030 502 DHO 50,487,000 40,913,900 83 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Mirpur Khas Primary 380,478,000 303,060,122 1,233,405 246 Secondary 501,227,000 449,778,893 753,968 597 DHO 2,806,210,000 265,269,419 Noushero Feroz Primary 100,818,000 96,754,583 1,659,376 58 Secondary 844,212,000 748,472,023 649,659 1152 DHO 86,101,000 80,257,454 Nawab Shah Primary 492,407,000 443,633,016 1,376,890 322 Secondary 1,585,251,000 1,349,655,196 243,971 5,532 DHO 333,529,000 194,216,171 Sanghar Primary 374,684,000 313,557,107 1,550,113 202 Secondary 651,306,000 578,619,900 917,227 631 DHO 85,057,000 78,229,152 Shikarpur Primary 364,184,000 260,916,089 919,580 284 Secondary 461,035,000 359,593,699 448,283 802 DHO 718,310,000 60,135,842 Sukkkar Primary 87,466,000 81,711,036 1,036,665 79 Secondary 1,305,505,000 1,151,009,405 905,751 1,271 DHO 537,055,000 761,169,805 TandoAllah yar Primary 179,847,000 158,980,773 425,371 374 Secondary 179,112,000 156,001,625 197,762 789 DHO 29,227,000 50,973,921 TandoMuhammad Primary 78,154,000 56,459,477 581,405 97 Khan Secondary 230,988,000 166,068,179 222,210 747 DHO 51,158,000 43,041,848 Thatta Primary 641,232,000 475,569,693 777,251 612 Secondary 659,612,000 394,304,438 361,041 1,092 DHO 203,910,000 178,972,222 Umerkot Primary 94,654,000 133,924,234 1,054,537 127 Secondary 658,790,000 703,291,040 670,621 1,049 DHO 43,497,000 65,566,323 Tharparkar ( Primary 355,953,000 548,941,541 704,020 780 Mithi) Secondary 349,832,000 440,744,836 432,438 1,019 DHO 62,552,000 65,872,066 Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, Sindh district budget and expenditure data 2016 downloaded from IFMIS, Pakistan and DHIS Government of Sindh 84 Table 46: Sindh Districts Budgets, Expenditures and Expenditure per patient 2017 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Badin Primary 410,469,000 338,215,225 1,426,195 237 Secondary 444,570,000 412,831,392 988,607 418 DHO 457,138,000 100,052,568 Dadu Primary 30,479,000 23,676,512 1,017,227 23 Secondary 866,262,000 808,594,065 998,561 810 DHO 482,191,000 Ghotki Primary 322,910,000 150,470,739 1,065,646 141 Secondary 438,903,000 437,673,589 1,256,784 348 DHO 58,356,000 67,842,494 Hyderabad Primary 95,705,000 101,522,662 880,498 115 Secondary 6,297,223,000 5,703,747,769 2,288,922 2,492 DHO 3,660,557,994 8,271,726,821 Jacubabad Primary 338,372,000 155,398,287 812,359 191 Secondary 905,947,000 753,025,792 825,993 912 DHO 228,171,000 215,861,421 Jamshoro Primary 369,905,000 180,140,843 601,000 300 Secondary 1,488,804,000 1,992,742,534 1,248,016 1,597 DHO 233,237,000 217,946,475 Shadad Kot Primary 419,918,000 201,039,193 838,052 240 Secondary 266,763,000 296,994,110 477,801 622 DHO 157,998,000 117,759,659 Karachi Primary 3,145,954,000 2,582,657,090 17,2405 14,980 Secondary 24,815,663,000 26,695,054,884 75,080 355,555 DHO 31,388,155,316 17,379,874,880 Kashmore Primary 269,529,000 116,220,438 498,238 233 Secondary 160,128,000 152,209,848 188,199 809 DHO 70,305,000 48,277,045 Khairpur Primary 1,307,746,000 914,151,486 2,690,575 340 Secondary 2,258,246,000 3,382,624,260 213,486 15,845 DHO 320,544,000 184,550,969 Larkana Primary 639,185,000 339,450,058 939,677 361 Secondary 2,510,851,900 1,966,605,826 546,022 3,602 DHO 440,555,000 423,635,522 Matiari Primary 295,543,000 148,448,846 883,624 168 Secondary 307,479,000 291,364,310 510,858 570 DHO 52,992,000 466,653,140 Mirpur Khas Primary 584,846,000 320,714,874 1,225,297 262 85 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Secondary 580,372,000 548,655,788 895,761 613 DHO 510,081,000 457,730,469 Noushero Feroz Primary 432,068,000 106,543,998 1,696,692 63 Secondary 814,160,000 851,574,706 728,069 1,170 DHO 102,289,000 110,931,739 Nawab Shah Primary 830,314,000 479,054,619 1,478,121 324 Secondary 1,881,063,000 1,810,112,022 213,408 8,482 DHO 683,898,750 163,773,633 Sanghar Primary 648,162,000 326,808,889 1,656,068 197 Secondary 689,137,000 771,249,667 960,177 803 DHO 103,285,000 171,279,768 Shikarpur Primary 563,456,000 335,195,417 1,033,506 324 Secondary 460,841,000 447,965,256 472,579 948 DHO 70,984,000 65,266,707 Sukkkar Primary 471,071,000 95,751,024 993,923 96 Secondary 1,433,547,000 1,406,685,135 384,610 3,657 DHO 814,203,000 520,186,155 TandoAllah yar Primary 291,285,000 208,849,953 470,805 444 Secondary 173,498,000 225,868,444 186,814 1,209 DHO 44,640,000 62,732,573 TandoMuhammad Primary 175,449,000 60,651,219 547,514 111 Khan Secondary 226,939,000 291,257,919 216,246 1,347 DHO 5,5387,000 43,020,800 Thatta Primary 711,884,000 554,406,909 782,580 708 Secondary 4,598,740,000 505,160,542 52,9981 953 DHO 207,839,000 217,446,222 Umerkot Primary 282,683,000 184,515,054 1,081,663 171 Secondary 628,347,000 654,792,348 671,015 976 DHO 66,564,000 58,926,479 Tharparkar ( Primary 992,652,000 734,431,027 722,224 1,017 Mithi) Secondary 585,072,000 610,012,242 494,833 1,233 DHO 279,489,000 113,316,093 Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, Sindh district budget and expenditure data 2017 downloaded from IFMIS, and DHIS Government of Sindh 86 Table 47: Sindh Districts Budget, Expenditure and Expenditure per patient 2018 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Badin Primary 656,614,000 667,743,226 1,448,709 461 Secondary 460,825,000 464,772,951 1,026,388 453 DHO 162,904,619 111,740,595 Dadu Primary 275,138,000 252,433,476 1,025,827 246 Secondary 936,283,000 952,818,019 1,085,502 878 DHO 215,670,000 196,622,573 Ghotki Primary 301,309,000 282,403,341 942,435 300 Secondary 512,812,000 504,890,453 1,259,085 401 DHO 91,140,000 96,347,676 Hyderabad Primary 762,780,830 665,104,321 912,530 729 Secondary 6,843,842,030 6,145,583,698 2,464,976 2,493 DHO 2,667,764,670 9,300,016,707 Jacubabad Primary 306,840,000 143,834,429 692,331 208 Secondary 957,118,200 853,129,635 958,097 890 DHO 189,882,000 137,934,400 Jamshoro Primary 374,834,000 299,249,791 647,829 462 Secondary 1,893,499,000 1,864,234,515 1,472,619 1,266 DHO 238,497,000 20,860,3463 Shadad Kot Primary 364,788,000 35,455,7781 930,086 381 Secondary 358,721,000 50,913,951 740,669 69 DHO 120,076,000 53,773,077 Karachi Primary 1,114,874,000 3,665,261,813 221,100 16,577 Secondary 30,947,049,722 25,434,221,839 DHO 34,447,829,735 19,703,838,675 Kashmore Primary 238,500,000 201,090,793 555,407 362 Secondary 190,171,000 200,560,449 198,695 1,009 DHO 85,872,000 54,290,591 Khairpur Primary 1,366,876,920 1,128,814,009 2,964,619 381 Secondary 2,871,260,000 2,924,753,051 212,178 13,784 DHO 334,927,000 273,328,887 Larkana Primary 38,7191,000 592,171,761 1,042,038 568 Secondary 2,599,163,000 2,100,840,995 657,416 3,196 DHO 398,900,000 294,232,451 Matiari Primary 280,829,000 266,697,204 912,824 292 Secondary 328,123,000 338,019,819 584,709 578 DHO 54,544,000 47,421,130 Mirpur Khas Primary 51,6728,000 439,917,193 1426,822 308 87 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Secondary 609,270,000 623,520,452 993,951 627 DHO 1,177,402,000 960,358,044 Noushero Feroz Primary 387,128,000 373,579,663 1,671,696 223 Secondary 910,797,000 917,352,714 927,929 989 DHO 108,624,000 111,765,800 Nawab Shah Primary 778,079,800 779,332,004 1,362,511 572 Secondary 1,769,212,960 1,651,193,679 332,870 4,960 DHO 570,126,250 341,087,568 Sanghar Primary 629,610,000 542,588,897 1,705,664 318 Secondary 871,951,000 798,037,654 1,216,929 656 DHO 230,045,000 144,989,281 Shikarpur Primary 487,576,000 523,011,517 946,059 553 Secondary 513,772,000 524,287,658 539,077 973 DHO 112,110,000 74,957,586 Sukkkar Primary 422,790,000 196,439,295 940,881 209 Secondary 1,618,759,000 1,430,430,951 603,252 2,371 DHO 557,152,000 422,273,070 TandoAllah yar Primary 342,559,160 374,134,832 526,754 710 Secondary 1,964,011,000 221,835,965 209,378 1,059 DHO 5,1991,000 57,276,176 TandoMuhammad Primary 170,913,000 148,692,457 471,398 315 Khan Secondary 263,679,000 235,572,893 296,794 794 DHO 66,242,000 48,560,558 Thatta Primary 583,391,000 760,876,119 800,892 950 Secondary 423,579,229 579,341,988 550,368 1,053 DHO 284,178,000 254,542,550 Umerkot Primary 350,703,000 233,633,227 1,095,759 213 Secondary 715,366,000 674,733,755 665,538 1,014 DHO 120,923,000 66,798,315 Tharparkar ( Mithi) Primary 976,480,000 121,173,774 856,587 141 Secondary 675,865,000 826,757,816 525,663 1,573 DHO 299,081,920 134,212,482 Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, Sindh district budget and expenditure data 2018 downloaded from IFMIS, Pakistan and DHIS Government of Sindh 88 Khyber Pakhtunkhwa Distric Analysis Table 48: Public Health Facilities: KPK Level Facility Type Total Number Tertiary Level Category -A university Hospitals, 350 beds 8 Secondary Level Category -A hospitals, 350 beds 6 Category -B hospitals, 210 beds 12 Category -C hospitals, 110 beds 28 Category-D hospitals, 42 beds 63 Other hospitals 16 Primary Level RHCs 111 BHUs 769 MCH Centres 33 Dispensaries 436 Data Source: Government of Sindh, Health Profile of Sindh 2017 There are 22 DHQ Hospitals and 18 THQ hospitals in the province. DHQ hospitals are categorized A to D. Most THQ hospitals categorized C and D, while some THQ hospitals are classified as RHC. Figure 13: KPK Districts visits per person Data Source: Government of KP, DHIS Annual Report 2016, 2017 & 2018 89 Figure 14: KPK districts expenditure per capita Data Source: CGA, Government of Pakistan, KP district budget and expenditure data 2016, 2017 & 2018 downloaded from IFMIS and Pakistan Census data 2018, Pakistan Bureau of Statistics 90 Table 49: KPK Districts Expenditure per capita and visits per person Expenditure Expenditure Expenditure Visits per Visits per Visits per District Name per capita per capita per capita person person person 2016 (PKR) 2017 (PKR) 2018 (PKR) 2016 2017 2018 Abbotabad 408 412 612 0.60 0.71 0.83 Bannu 365 325 555 0.54 0.36 0.20 Batgaram 493 507 578 1.04 0.83 0.86 Bunair 388 450 544 0.50 0.60 0.76 Charsadda 445 295 433 0.96 0.92 0.94 Chitral 991 842 1,425 1.21 1.10 0.74 Dera Ismail Khan 504 510 677 0.59 0.47 0.36 Dir ( Upper) 299 264 481 0.74 0.69 0.71 Dir ( Lower) 400 382 649 0.59 0.71 0.76 Haripur 480 482 771 0.72 1.05 1.25 Hungu 374 337 463 0.67 0.89 0.58 Karak 407 460 1,165 0.55 0.62 0.58 Kohat 607 719 449 0.72 0.68 0.59 Kohistan 77 14 214 0.16 0.18 0.12 Lakki 291 275 1,022 0.54 0.58 0.48 Malakand 610 728 1,126 1.44 1.51 1.50 Mansehra 273 302 646 0.77 0.85 0.98 Mardan 413 402 521 0.54 0.55 0.65 Nowshera 496 395 694 0.97 0.75 0.67 Peshawar 980 2,700 351 0.27 0.32 0.39 Shangla 329 403 743 0.45 0.42 0.50 Swabi 556 347 507 0.63 0.70 0.68 Swat 52 62 666 0.48 0.46 0.48 Tank 556 885 717 0.93 0.90 1.12 Tor Ghar 0 170 425 0.31 0.26 0.23 Data Source: CGA, Government of Pakistan, KP district budget and expenditure data 2016, 2017 & 2018 downloaded from IFMIS, Pakistan Census data 2018, Pakistan Bureau of Statistics and DHIS Government of KP 91 Table 50: KPK Health Facilities Health Facilities -Khyber Pakhtunkhwa Sr. District BHU DHQ HOSP MCH RHC THQ Total 1 311 -- Bannu 34 1 3 2 40 2 312 -- D.I. Khan 38 1 7 3 4 53 3 313 -- Lakki Marwat 27 1 2 5 35 4 316 -- Tank 18 1 1 2 22 5 321 -- Abbottabad 53 1 1 7 62 6 322 -- Haripur 74 1 2 9 3 89 7 324 -- Mansehra 51 1 1 3 13 1 70 8 325 -- Battagram 28 1 1 3 33 9 326 -- Toor Ghar 10 10 10 331 -- Karak 19 1 2 4 1 27 11 332 -- Kohat 20 2 2 5 29 12 335 -- Hangu 14 1 1 1 17 13 342 -- Buner 15 2 17 14 343 -- Chitral 19 1 2 6 3 31 15 344 -- Dir Lower 33 1 10 4 6 54 16 345 -- Malakand 20 1 1 5 1 28 17 346 -- Swat 41 1 3 3 2 50 18 347 -- Dir Upper 31 1 4 3 39 19 348 -- Shangla 19 1 2 22 20 351 -- Mardan 47 1 5 2 6 1 62 21 352 -- Swabi 37 1 3 8 1 50 22 361 -- Charsadda 45 1 1 2 2 1 52 23 364 -- Nowshera 32 1 3 4 7 1 48 24 365 -- Peshawar 47 5 5 6 63 Total 772 19 18 57 107 30 1,003 Source: Ministry of National Health Services, Regulation & Coordination and Provincial/Area DoH 92 Table 51: KPK districts Budget Utilization 2016 2017 2018 District Name Budget Utilization (%) Abbotabad 110 87 105 Bannu 109 104 112 Batgaram 78 83 80 Bunair 148 92 106 Charsadda 145 81 22 Chitral 113 77 93 Dera Ismail Khan 129 112 104 Dir ( Upper) 91 73 26 Dir ( Lower) 1265 85 96 Haripur 94 78 93 Hungu 140 8 95 Karak 85 56 105 Kohat 82 76 92 Kohistan 94 6 87 Lakki 90 71 114 Malakand 134 78 222 Mansehra 116 79 85 Mardan 128 106 151 Nowshera 107 160 136 Peshawar 58 167 94 Shangla 86 63 97 Swabi 222 180 81 Swat 136 206 107 Tank 96 129 605 Tor Ghar 91 114 Data Source: CGA, Government of Pakistan, KP district budget and expenditure data 2016, 2017 & 2018 downloaded from IFMIS 93 Table 52: KPK Districts Budget Expenditure and Expenditure per patient 2016 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Abbotabad Primary 366,139 Secondary 488,051,000 505,674,481 429,381 1,178 DHO 3,442,000 37,001,558 Bannu Primary 286,620 0 Secondary 375,616,000 377,338,216 328,563 1,148 DHO 4,722,000 36,355,006 Batgaram Primary 218,734 0 Secondary 292,295,000 228,686,317 264,160 866 DHO 652,829 Bunair Primary 141,463 0 Secondary 227,726,000 33,5712,598 292,447 1,148 DHO 769,696 Charsadda Primary 687,250 0 Secondary 481,977,000 668,535,536 821,395 814 DHO 30,965,434 Chitral Primary 238,037 0 Secondary 386,619,000 433,496,813 294,015 1,474 DHO 2,029,182 Dera Ismail Khan Primary 13,143,177 391,176 34 Secondary 613,695,000 754,900,985 534,499 1,412 DHO 22,492,292 Dir ( Upper) Primary 278,346 0 Secondary 301,236,000 243,758,136 396,603 615 DHO 30,576,219 Dir ( Lower) Primary 152,706 0 Secondary 43,354,000 547,388,301 662,056 827 DHO 1,234,198 Haripur Primary 329,517 0 Secondary 502,280,000 450,108,740 376,799 1,195 DHO 21,580,051 Hungu Primary 94,638 0 Secondary 135,019,000 156,070,720 244,427 639 DHO 32,565,738 Karak Primary 7,336,062 184,966 40 Secondary 32,8019,000 251,230,305 193,635 1,297 DHO 21,192,005 94 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Kohat Primary 288,110 0 Secondary 710,339,000 561354,269 401,227 1,399 DHO 22,496,754 Kohistan Primary 124,395 0 Secondary 62,447,000 58,566,298 DHO 102,000 Lakki Primary 104,622 329,563 0 Secondary 275,829,000 226,005,782 129,896 DHO 21,056,600 Malakand Primary 331,949 0 Secondary 313,385,000 392,856,560 677,881 580 DHO 4,438,000 34,433,332 Mansehra Primary 300,0000 5,516,553 497,074 11 Secondary 355,505,000 377,861,353 665,407 568 DHO 31,534,253 Mardan Primary 35,000,000 4,4785,608 550,155 81 Secondary 7,12,019,000 878,066,094 707,654 1,241 DHO 32,342,696 Nowshera Primary 15,825,000 10,451,165 711,733 15 Secondary 669,720,000 699,625,353 719,774 972 DHO 21378404 Peshawar Primary 2254323000 2369824000 938460 2525 Secondary 1310774500 948117231 156236 6068 DHO 3,355,090,000 688,031,632 Shangla Primary 136,521 0 Secondary 281,184,500 207,494,184 195,273 1,063 DHO 34,908,747 Swabi Primary 27,000,000 22,875,503 646,410 35 Secondary 370,785,000 859,313,033 357,558 2,403 DHO Swat Primary 2000000 668,512 0 Secondary 82,444,000 67,312,098 413,229 163 DHO 47,585,868 Tank Primary 225,933 152,004 1 Secondary 22,1045,000 178,672,030 200,217 892 DHO 32,452,428 Tor Ghar Primary 52,794 Secondary DHO Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, KPK district budget and expenditure data 2016 downloaded from IFMIS, Pakistan and DHIS Government of KPK. 95 Table 53: KPK districts Budget, Expenditure and Expenditure per patient 2017 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Abbotabad Primary 390,954 Secondary 585,548,000 520,420,196 550,599 945 DHO 47,679,000 29,148,768 Bannu Primary 263,587 0 Secondary 324,453,000 348,797,184 161,895 2,154 DHO 39,323,000 30,960,645 Batgaram Primary 175,478 0 Secondary 255,978,000 212,172,391 220,137 964 DHO 33,800,000 29,669,703 Bunair Primary 195,421 0 Secondary 401,849,000 372,846,307 344,532 1,082 DHO 36,000,000 29,891,658 Charsadda Primary 633,285 0 Secondary 549,286,000 452,629,635 854,067 530 DHO 34,914,000 22,431,830 Chitral Primary 191,244 0 Secondary 452,761,000 350,252,973 299,847 1,168 DHO 38,665,000 265,10,466 Dera Ismail Khan Primary 62,216 319,844 0 Secondary 709,550,000 806,041,838 443,276 1,818 DHO 29,499,000 22,376,970 Dir ( Upper) Primary 238,583 0 Secondary 319,162,000 227,362036 419,536 542 DHO 25,819,000 22,904,033 Dir ( Lower) Primary 163,934 0 Secondary 604,469,000 515,996,873 861,539 599 DHO 42,480,000 32,296,169 Haripur Primary 396,744 0 Secondary 603,973,000 472,368,305 651,414 725 DHO 16,416,000 10,058,576 Hungu Primary 149,292 0 Secondary 2,299,540,000 153,360,784 309,928 495 DHO 23,343,000 21,370,503 Karak Primary 1,309,938 173,722 8 Secondary 555,344,000 309,194,522 260,338 1,188 DHO 26,793,000 14,012,686 Kohat Primary 272,041 0 96 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Secondary 912,133,000 689,758,569 406,650 1,696 DHO 29,157,000 23,322,547 Kohistan Primary 144,717 0 Secondary 151,272,000 0 DHO 31,608,000 11,235,113 Lakki Primary 332,027 0 Secondary 325,176,000 228,484,991 172,998 1,321 DHO 16,358,000 12,451,805 Malakand Primary 354,675 0 Secondary 639,371,000 494,160,994 732,687 674 DHO 29,368,000 28,333,428 Mansehra Primary 5,000,000 2,515,000 508,053 5 Secondary 563,684,000 450,809,453 806,995 559 DHO 26,280,000 16,498,110 Mardan Primary 120,525,000 107,716,423 485,049 222 Secondary 751,491,000 820,927,279 827,149 992 DHO 29,821,000 24,647,209 Nowshera Primary 78,275,000 58,476,901 639,801 91 Secondary 276,589,000 531,267,826 495,559 1,072 DHO 20,932,000 10,554,677 Peshawar Primary 3,405,510,000 2,407,510,736 759,028 3,172 Secondary 184,304,000 240,842,660 605,284 398 DHO 3,289,785,000 8,871,765,600 Shangla Primary 99,990,000 61,286,152 117,453 522 Secondary 358,224,000 223,829,292 202,358 1,106 DHO 28,521,000 20,739,574 Swabi Primary 58,802,000 89,014,574 744,132 120 Secondary 255,839,000 475,822,864 391,383 1,216 DHO Swat Primary 10,000,000 63,810,816 615,241 104 Secondary 35,501,000 67,445,000 452,695 149 DHO 24,478,000 12,724,000 Tank Primary 145,787 128,433 1 Secondary 241,784,000 171,425,067 221,706 773 DHO 25,568,000 174,008,607 Tor Ghar Primary 44,498 Secondary 10,000,000 10,000,000 DHO 22,000,000 19,118,726 Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, KPK district budget and expenditure data 2016 downloaded from IFMIS, Pakistan and DHIS Government of KPK 97 Table 54: KPK Districts Budget Expenditure and Expenditure per patient 2018 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Abbotabad Primary 221,338,210 189,549,068 373,487 508 Secondary 315,727,420 288,577,571 751,275 384 DHO 257,981,070 355,641,467 Bannu Primary 351,411,270 194,409,948 170,489 1,140 Secondary 79,304,510 293,644,529 65,270 4,499 DHO 235,686,139 260,662,433 Batgaram Primary 189,732,240 116,773,472 238,322 490 Secondary 78,333,670 78,378,099 181,926 431 DHO 83,425,420 86,765,852 Bunair Primary 5,398,000 188,872,903 248,711 759 Secondary 305,043,000 183,811,362 455,633 403 DHO 160,949,550 129,257,036 Charsadda Primary 302,588,597 287,493,438 741,501 388 Secondary 324,985,355 382,561,952 807,968 473 DHO 2,687,492,236 44,435,815 Chitral Primary 290,377,360 230,974,109 193,955 1,191 Secondary 205,988,040 179,983,226 142,326 1,265 DHO 203,371,570 238,193,379 Dera Ismail Khan Primary 339,688,976 213,025,014 368,957 577 Secondary 373,680,430 563,881,934 235,030 2,399 DHO 378,275,817 361,006,924 Dir ( Upper) Primary 163,706,682 189,924,719 255,170 744 Secondary 1,464,377,730 141,795,562 442,352 321 DHO 155341,200 138,421,328 Dir ( Lower) Primary 276,802,090 232,550,877 165,313 1,407 Secondary 416,536,560 482,884,693 958,400 504 DHO 311,496,240 247,763,939 Haripur Primary 326,032,006 227130,140 376,427 603 Secondary 261,761,052 270,001,461 903,701 299 DHO 256,094,590 29,053,0797 Hungu Primary 61,354,673 43,327,448 139,578 310 Secondary 121,895,827 124,435,793 170,478 730 DHO 77,902,000 79,041,859 Karak Primary 321,651,670 147,985,652 166,413 889 Secondary 310,452,530 412,635,802 252,226 1,636 DHO 195,695,840 215,763,049 Kohat Primary 194,730,260 109,776,950 284,253 386 98 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Secondary 138,014,380 176,950,846 321,606 550 DHO 168,889,640 172,502,581 Kohistan Primary 102,442,500 70,684,358 93,094 759 Secondary 12,385,000 27,120,645 DHO 83,566,400 74,508,820 Lakki Primary 290,259,568 101,720,610 169,816 599 Secondary 331,043,952 706,177,877 265,049 2,664 DHO 189,945,380 114,858,613 Malakand Primary 259,881,850 113,824,519 357,294 319 Secondary 352,015,010 487,188,861 747,863 651 DHO 223,340,640 226,958,515 Mansehra Primary 597,971,960 377,989,666 648,114 583 Secondary 227,565,770 256,923,161 913,202 281 DHO 384,688,520 395,508,258 Mardan Primary 202,876,980 305,468,104 516,441 591 Secondary 425,998,959 497,946,645 1,076,381 463 DHO 209,124,060 464,878,287 Nowshera Primary 189,153,902 168,709,314 572,757 295 Secondary 371,411,307 599,679,809 472,938 1,268 DHO 239,130,648 318,960,112 Peshawar Primary 765,737,330 547,616,221 629,936 869 Secondary 421907,530 537,616,233 1,101,372 488 DHO 474,360,890 472,744,301 Shangla Primary 16,672,689 238,995 70 Secondary 429,312,180 361,858,855 149,310 2,424 DHO 167,511,910 202,341,597 Swabi Primary 3,833,500 32,634,020 720,734 45 secondary 571,998,463 441361,496 415,366 1,063 DHO 469,713,682 369,895,395 Swat Primary 323,824,770 372,597,882 545,995 682 Secondary 670,744,221 697,950,217 555,509 1,256 DHO 421,791,140 450,529,940 Tank Primary 98,885,570 58,298,507 156,124 373 Secondary 52,304,250 116,813,928 292,539 399 DHO 63,336,150 112,380,611 Tor Ghar Primary 28,546,601 39,955 714 Secondary 39,441,170 16,985,410 DHO 24,679,630 27,288,996 Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, KP district budget and expenditure data 2018, downloaded from IFMIS, and DHIS Government of KP 99 Baluchistan Distric Analysis Table 55: List of Public Health Facilities Balochistan Level Facility Type Total Number Tertiary Level General Hospitals/Specialized Hospitals 4 Secondary Level DHQ Hospitals 27 THQ Hospitals/Civil Hospitals 10 Primary Level RHCs 82 BHUs 549 MCH Centres 90 Dispensaries 575 Source: TRF , Health Facility Assessment -Balochistan Provincial Report ( 2012) Figure 15: Balochistan Districts visits per person Data Source: Government of Balochistan, DHIS Annual Report 2016, 2017 & 2018 100 Figure 16: Balochistan Districts Expenditure per capita Data Source: DHIS data, Government of Sindh 2016, 2017 & 2018 Data Source: Government of Balochistan, DHIS Annual Report 2016, 2017 & 2018 and IFMIS data from CGA 101 Table 56: Balochistan Districts; Visits per person and Expenditure per capita Expenditure Expenditure Expenditure Visits per Visits per Visits per District Name per capita per capita per capita person person person 2016 (PKR) 2017 (PKR) 2018 (PKR) 2016 2017 2018 Awaran 0.48 0.47 0.08 1,207 1,536 1,568 Barkhan 0.06 0.00 0.02 939 1,015 1,049 Bolan 0.29 0.23 0.24 1,150 1,076 1,221 Chagai 0.13 0.06 0.10 666 709 777 Dera Bugti 0.28 0.11 0.06 792 962 861 Gawadar 0.77 0.68 0.74 1,057 1,190 1,186 Harnai 0.74 0.69 0.44 808 783 1,334 Jaffarabad 0.19 0.22 0.23 822 929 1,067 Jhal Magsi 0.21 0.23 0.24 1,071 1,166 1,057 Kalat 0.26 0.21 0.23 973 894 768 Kharan 0.29 0.28 0.48 1,176 1,511 1,762 Khuzdar 0.21 0.02 0.16 755 917 806 Loralai 0.40 0.39 0.28 1,134 1,281 1,345 Mastung 0.34 0.27 0.26 803 966 1,089 Musa Khail 0.19 0.02 0.05 1,526 919 1,116 Nasirabad 0.03 0.02 0.03 546 663 680 Nushki 0.43 0.17 0.55 815 924 1,167 Panjgur 0.08 0.02 0.15 1236 898 1,494 Qilla Saif Ullah 0.24 0.12 0.15 655 788 898 Sherani 0.02 0.02 0.02 413 499 602 Sibi 0.65 0.70 0.78 1,894 2,133 2,318 Turbat (Kech) 0.03 0.02 0.04 1,829 1,363 1,066 Washuk 0.05 0.03 0.04 874 929 973 Zhoob 0.64 0.72 0.53 975 1,063 1,314 Ziarat 0.20 0.75 0.50 1,234 1,301 1,513 Qila Abdullah 0.30 0.23 0.08 508 462 494 Quetta 0.01 0.02 0.02 5,950 5,210 4,786 Lesbilla 0.49 0.46 0.49 1,041 1,071 1,246 Kohlu 0.25 0.13 0.23 1,277 1,466 1,556 Pasheen 0.19 0.22 0.08 518 573 644 Sohbatpur 0.49 0.57 0.59 32 79 29 Data Source: CGA, Government of Pakistan, Baluchistan district budget and expenditure data 2016, 2017 & 2018 downloaded from IFMIS and DHIS data, Government of Baluchistan and population data from Pakistan census 2018, Pakistan Bureau of Statistics 102 Table 57: Baluchistan Health Facilities Health Facilities - Balochistan Sr. District BHU DHQ HOSP MCH RHC THQ Total 1 Loralai 38 1 0 4 2 1 46 2 Sibi 15 1 0 4 3 0 23 3 Ziarat 15 1 0 3 5 1 25 4 Awaran 7 1 0 1 2 0 11 5 Barkhan 7 1 0 2 0 0 10 6 Chagai 11 1 0 4 4 1 21 7 Dera Bugti 34 1 1 3 1 0 40 8 Gwadar 22 1 0 3 3 0 29 9 Harnai 7 1 0 1 1 0 10 10 Jaffarabad 41 1 1 7 1 0 51 11 Jhal Magsi 12 1 0 2 3 0 18 12 Kachhi (Bolan) 12 1 0 3 5 0 21 13 Kalat 19 2 0 4 3 0 28 14 Keich (Turbat) 39 1 0 4 13 0 57 15 Kharan 15 1 0 2 0 0 18 16 Khuzdar 43 1 1 1 4 0 50 17 Killa Abdullah 44 1 0 2 6 0 53 18 Killa Saifullah 16 1 0 2 5 1 25 19 Kohlu 36 1 0 1 3 0 41 20 Lasbella 42 1 1 4 4 0 52 21 Mastung 25 1 1 2 5 0 34 22 Musa Khail 20 1 0 2 1 0 24 23 Naseerabad 16 1 0 3 3 0 23 24 Nushki 11 1 0 2 2 0 16 25 Panjgur 30 1 1 4 6 0 42 26 Pishin 32 1 0 4 9 1 47 27 Quetta 38 0 2 14 5 0 59 28 Sherani 8 0 0 1 2 0 11 29 Washuk 25 0 0 0 2 1 28 30 Zhob 17 1 0 2 4 0 24 Total 697 28 8 91 107 6 937 Source: Ministry of National Health Services, Regulation & Coordination and Provincial/Area DoH 103 Table 58: Baluchistan Districts Budget Utilization 2016 2017 2018 District Name Budget Utilization (%) Awaran 74 113 130 Barkhan 107 102 109 Bolan 87 92 100 Chagai 86 102 104 Dera Bugti 84 96 104 Gawadar 85 116 101 Harnai 57 71 96 Jaffarabad 107 108 104 Jhal Magsi 64 86 93 Kalat 100 88 Kharan 97 90 33 Khuzdar 95 110 Loralai 81 103 106 Mastung 73 99 104 Musa Khail 135 91 106 Nasirabad 86 56 101 Nushki 71 88 110 Panjgur 95 77 114 Qilla Saif Ullah 90 105 104 Sherani 80 109 117 Sibi 110 97 111 Turbat (Kech) 168 104 115 Washuk 93 107 103 Zhoob 107 96 115 Ziarat 79 94 107 Qila Abdullah 96 93 27 Quetta 104 83 94 Lesbilla 106 106 107 Kohlu 62 103 102 Pasheen 84 105 121 Sohbatpur 100 117 19 Data Source: CGA, Government of Pakistan, Balochistan district budget and expenditure data 2016, 2017 & 2018 downloaded from IFMIS 104 Table 59: Balochistan Districts Budget Expenditure and Expenditure per patient 2016 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Awaran Primary 6,247 Secondary 67,215,100 29,889,296 51,926 576 DHO 132127,800 116,890,985 Barkhan Primary 24,600,000 20,834,829 206 101,140 Secondary 9,527 0 DHO 122,053,200 135,541,696 Bolan(kachhi) Primary 48,204,000 48,202,616 9,649 4,996 Secondary 74,058,600 29,543,527 57,723 512 DHO 186,213,300 189,552,253 Chagai Primary 6,048,000 5,999,700 5,426 1,106 Secondary 52,983,500 43,567,222 22,090 1,972 DHO 109,661,200 95,061,295 Dera Bugti Primary 23,961,000 23,959,870 16,257 1,474 Secondary 106,997,500 34,570,796 67,651 511 DHO 154,686,200 182,320,068 Gawadar Primary 54,059,000 54,632,235 21,728 2,514 Secondary 87,453,600 55,538,594 177,348 313 DHO 179,544,600 162,035,838 Harnai Primary 10,000,000 10,000,000 1,333 7,502 Secondary 37,231,100 14,497,172 69,226 209 DHO 88,233,200 52,954,702 Jaffarabad Primary 4,500,000 4,499,656 22,775 198 Secondary 89,131,400 78,293,732 73,464 1,066 DHO 290,121,900 326,862,928 Jhal Magsi Primary 17,328,000 17,327,207 5,786 2,995 Secondary 53,760,800 27,701,123 25,242 1,097 DHO 175438100 111,921,462 Kalat Primary 115,399,774 14,735 7,832 Secondary 57,178,647 87,279 655 DHO 216,471,099 Kharan Primary 18,951,000 18,951,000 3,630 5,221 Secondary 69,432,700 40,567,653 41,704 973 DHO 102,992,100 126,570,678 Khuzdar Primary 124,188,853 16,287 7,625 Secondary 95,336,690 142,336 670 DHO 363,001,803 105 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Loralai Primary 56,357,200 58,940,172 11,718 5,030 Secondary 136,749,300 96,418,380 142,946 675 DHO 351,307,100 284,148,979 Mastung Primary 4,896,000 4,718,220 9,889 477 Secondary 75,715,900 39,170,214 76,547 512 DHO 201,693,000 162,838,211 Musa Khail Primary 34,694,000 31,694,000 6,451 4,913 Secondary 46,942,600 29,435,249 24,821 1,186 DHO 105,125,700 191,175,733 Nasirabad Primary 3,700,000 11,623,898 13,788 843 Secondary 97,480,400 69,472,702 DHO 197,524,800 175,511,329 Nushki Primary 500,000 500,000 3,163 158 Secondary 97,610,100 48,539,433 71,785 676 DHO 100,940,000 92,133,150 Panjgur Primary 40,480,000 40,476,995 8,670 4,669 Secondary 134,813,200 106,035,198 17,552 6,041 DHO 229,109,200 237,048,424 Qilla Saif Ullah Primary 14,735,000 14,733,982 7,222 2,040 Secondary 77,171,700 48,912,339 71,277 686 DHO 150,094,700 154,283,525 Sherani Primary 2,502 0 Secondary DHO 76,437,200 61,050,918 Sibi Primary 51,093,500 48,259,801 9,062 5,326 Secondary 93,626,600 93,864,777 105,841 887 DHO 159,730,600 193,326,341 Turbat (Kech) Primary 392,767,000 727,503,054 30,169 24,114 Secondary 160,648,400 139,377,574 DHO 393,971,800 427,084,402 Washuk Primary 16,245,000 30,208,904 7,882 3,833 Secondary DHO 145,289,700 119,529,571 Zhoob Primary 18,300,000 17,300,000 8,291 2,087 Secondary 85,742,900 83,424,012 183,974 453 DHO 171,185,500 194,375,428 106 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Ziarat Primary 8,500,000 6,500,000 6,451 1,008 Seondary 64,117,000 33,203,587 24,821 1,338 DHO 166,867,100 150,548,857 Qila Abdullah Primary 62,725,000 59,533,999 127,757 466 Secondary 111,706,200 78,402,151 91,775 854 DHO 211,644,600 231,611,935 Quetta Primary 3,443,645,251 5,263,665,207 26,669 197,370 Secondary 4,297,919,400 5,023,064,825 DHO 4,470,650,900 2,432,428,208 Lesbilla(Uthal) Primary 66,389,000 59,387,825 13,629 4,357 Secondary 155,652,100 169,656,385 260,635 651 DHO 324,585,400 351,023,412 Kohlu Primary 13,100,000 13,099,500 4,678 2,800 Secondary 76,684,800 51,311,420 46,148 1,112 DHO 331,378,400 197,895,977 Pasheen Primary 16,284,000 16,248,000 23,433 693 Secondary 99,895,900 67,041,847 109,929 610 DHO 323,793,700 284,295,475 Sohabtpur Primary 6,376,000 6,375,851 22,775 280 Secondary 73,464 0 DHO Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, Balochistan district budget and expenditure data 2016, downloaded from IFMIS, and DHIS Government of Balochistanchistan 107 Table 60: Balochistan Districts, Budget, Expenditure and Expenditure per patient Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Awaran Primary 17,250,000 17,169,966 4,136 4,151 Secondary 50,692,000 51,884,474 53,539 969 DHO 97,266,000 118,012,376 Barkhan Primary 19,250,000 18,147,888 837 21,682 Secondary DHO 150,237,000 155,427,287 Bolan(kachhi) Primary 10,872,000 10,871,280 1,174 9,260 Secondary 56,129,000 38,239,259 52,307 731 DHO 210,500,000 205,905,338 Chagai Primary 1,900,000 1,900,000 34,35 553 Secondary 49,547,400 56,339,814 9,074 6,209 DHO 105,746,000 102,400,342 Dera Bugti Primary 98,500,000 97,603,864 17,154 5,690 Secondary 157,193,400 160,640,156 16,623 9,664 DHO 58,053,000 43,020,809 Gawadar Primary 28,822,000 28,793,416 21,663 1,329 Secondary 67,147,000 81,669,579 156,621 521 DHO 172,205,000 201,725,533 Harnai Primary 6,000,000 1,618,757 3,488 464 Secondary 32,123,000 18,179,709 63,365 287 DHO 68,618,000 56,152,840 Jaffarabad Primary 26,211 0 Secondary 99,354,000 95,750,772 88,932 1,077 DHO 343,854,000 381,880,617 Jhal Magsi Primary 20,000,000 19,999,552 4,925 4,061 Secondary 46,706,000 27,630,798 29,249 945 DHO 135,852,000 12,6046,575 Kalat Primary 49,950,000 49,949,952 11,836 4,220 Secondary 73,537,000 65,618,420 73,610 891 DHO 243,303,000 252,984,783 Kharan Primary 48,786,000 48,770,316 3,058 15,948 Secondary 67,721,000 51,124,418 42,122 1,214 DHO 155,351,000 146,081,373 Khuzdar Primary 202,174,000 197,317,001 4,861 40,592 Secondary 161,671,000 138,141,245 9,172 15,061 DHO 407,932,000 396,883,196 Loralai Primary 47,625,000 49,664,875 13,947 3,561 108 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Secondary 136,588,000 124,012,074 141,334 877 DHO 308,279,000 335,538,701 Mastung Primary 5,500,000 5,499,780 10,124 543 Secondary 61,887,000 59,017,545 62,590 943 DHO 191,096,000 192,026,919 Musa Khail Primary 11,100,000 6,100,000 1,007 6,058 Secondary 42,522,000 30,356,540 2,454 12,370 DHO 114,809,000 117,234,501 Nasirabad Primary 27,460,000 27,293,069 10,902 2,503 Secondary 96,549,000 85,029,768 DHO 206,998,000 211,061,095 Nushki Primary 1,648 0 Secondary 76,841,000 52,270,516 28,216 1,853 DHO 111,257,000 113,010,803 Panjgur Primary 7,661 0 Secondary 110,525,000 111,600,786 DHO 25,9041,000 271,714,739 Qilla Saif Ullah Primary 7,250,000 7,249,827 3,660 1,981 Secondary 69,769,000 83,790,719 37,187 2,253 DHO 179,406,000 179,212,052 Sherani Primary 3,022 0 Secondary DHO 70,094,000 76,322,233 Sibi Primary 50,024,000 48,387,201 6,715 7,206 Secondary 127,835,000 106,888,697 119,723 893 DHO 217,877,000 228,153,238 Turbat (Kech) Primary 577,516,700 577,596,170 18,904 30,554 Secondary 157,963,000 169,855,531 DHO 451,105,000 488,886,457 Washuk Primary 18,430,000 13,999,013 5,569 2,514 Secondary 2,427,455 DHO 134,405,000 146,808,827 Zhoob Primary 20,000,000 20,000,000 6,567 3,046 Secondary 105,467,000 96,203,519 217,330 443 DHO 219,104,000 213,737,355 Ziarat Primary 4,055 0 109 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Secondary 53,607,000 41,817,396 115,931 361 DHO 167,163,000 166,435,764 Qila Abdullah Primary 22,500,000 16,624,242 39,867 417 Secondary 108,667,000 91,224,997 134,610 678 DHO 245,302,000 242,157,051 Quetta Primary 4,691,829,200 4,277,718,937 43,553 98,219 Secondary 4,518,156,600 5,423,337,463 DHO 4,986,199,000 2,123,714,223 Lesbilla(Uthal) Primary 11,750,000 11,750,000 13,284 885 Secondary 187,594,000 188,080,260 250,745 750 DHO 380,880,000 417,319,139 Kohlu Primary 16,250,000 16,190,000 2,669 6,066 Secondary 74,226,000 58,500,421 25,496 2,294 DHO 213,398,000 238,900,759 Pasheen Primary 1,600,000 1,592,434 26,309 61 Secondary 94,344,000 87,424,448 138,362 632 DHO 307,587,000 333,473,050 Sohabtpur Primary 13,576,000 13,575,102 26,211 518 Secondary 88,932 0 DHO 0 2,348,462 Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, Balochistan district budget and expenditure data 2017, downloaded from IFMIS, and DHIS Government of Balochistan 110 Table 61: Balochistan Districts Budget, Expenditure and Expenditure per patient Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Awaran Primary 9,839 Secondary 54,485,000 53,176,730 DHO 92,633,000 138,136,034 Barkhan Primary 9,000,000 8,948,118 3,216 2,782 Secondary DHO 159,511,000 175,190,905 Bolan(kachhi) Primary 11,538,000 7,998,000 8,179 978 Secondary 61,998,000 48,120,647 48,656 989 DHO 222,238,000 239,189,882 Chagai Primary 7,501 0 Secondary 64,471,000 56,653,631 16,922 3,348 DHO 112,206,000 126,723,095 Dera Bugti Primary 8,071 0 Secondary 57,130,000 49,392,355 12,396 3,985 DHO 208,416,000 228,043,481 Gawadar Primary 10,000,000 9,532,000 17,446 546 Secondary 92,783,000 82,674,274 180,501 458 DHO 209,680,000 224,659,450 Harnai Primary 31,224,000 31,224,000 2,665 11,716 Secondary 35,218,000 21,650,987 40,739 531 DHO 70,175,000 78,256,861 Jaffarabad Primary 37,500,000 35,998,300 29,937 1,202 Secondary 118,530,000 106,315,223 91,257 1,165 DHO 388,617,000 422,656,438 Jhal Magsi Primary 5,298 0 Secondary 45,148,000 17,739,792 31,674 560 DHO 126,810,000 142,226,428 Kalat Primary 15,000,000 15,000,000 16,493 909 Secondary 88,848,000 80,625,412 82,201 981 DHO 267,888,000 229,903,726 Kharan Primary 50,000,000 49,999,987 4,026 12,419 Secondary 69,586,000 57,096,395 75,877 752 DHO 159,063,000 187,568,325 Khuzdar Primary 38,717,000 40,473,683 2,8371 1,427 Secondary 157,866,000 145,529,630 10,6080 1,372 DHO 407,536,000 479,845,407 Loralai Primary 30,671,000 41,559,905 12,437 3,342 111 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Secondary 145,707,000 128,371,225 101,392 1,266 DHO 342,809,000 377,874,357 Mastung Primary 12,156 0 Secondary 82,380,000 66,513,704 60,019 1,108 DHO 205,379,000 231,748,721 Musa Khail Primary 7,000,000 6,999,280 8,187 855 Secondary 48,693,000 38,370,922 DHO 122,702,000 143,463,327 Nasirabad Primary 6,289,000 4,594,792 12,769 360 Secondary 111,056,000 94,226,217 DHO 221,880,000 245,076,016 Nushki Primary 5,000,000 4,999,343 3,544 1,411 Secondary 76,953,000 72,066,168 98,134 734 DHO 114,284,000 138,456,458 Panjgur Primary 7500,000 11,174 0 Secondary 128,878,000 125,788,348 35,649 3,529 DHO 282,051,000 352,664,122 Qilla Saif Ullah Primary 18,000,000 17,999,963 6,862 2,623 Secondary 100,033,000 83,887,318 47,498 1,766 DHO 187,313,000 215,499,787 Sherani Primary 2,934 0 Secondary DHO 81,111,000 95,148,554 Sibi Primary 31,061,000 28,124,588 7,223 3,894 Secondary 128,758,000 1,155,744,17 134,876 857 DHO 219,840,000 279,089,319 Turbat (Kech) Primary 229,340,000 214,822,367 39,533 5,434 Secondary 186,127,000 209,112,543 DHO 463,466,000 584,138,989 Washuk Primary 53,000 7,364 0 Secondary 13,416,000 2,059,107 DHO 156,022,000 173,110,890 Zhoob Primary 36,950,000 34,789,000 6,990 4,977 Secondary 108,433,000 1,14,207,737 16,1325 708 DHO 216,926,000 268,899,425 Ziarat Primary 2,576,000 2,545,000 4,170 610 Secondary 59,250,000 39,010,609 7,8745 495 DHO 173,564,000 209,450,663 112 Actual Expenditure District Name Facility Original Budget OPD (Y) Expenditure per patient Qila Abdullah Primary 19,250,000 5,042,500 39,146 129 Secondary 115,401,000 98,893,352 21,236 4,657 DHO 248,429,000 285,488,896 Quetta Primary 2,385,608,091 2,327,406,765 45,708 50,919 Secondary 4,831,543,000 6,419,226,699 DHO 4,994,420,000 2,746,032,752 Lesbilla(Uthal) Primary 21,001,000 21,000,000 14,713 1,427 Secondary 241,815,000 205,356,084 276,072 744 DHO 429,201,000 515,324,637 Kohlu Primary 23,469,000 23469,000 4967 4,725 Secondary 75,830,000 68,706,843 45,886 1,497 DHO 244,657,000 257,123,179 Pasheen Primary 1,000,000 1,000,000 28,572 35 Secondary 104,874,000 93,339,797 35,323 2,642 DHO 313,062,000 411,745,140 Sohabtpur Primary 29,937 0 Secondary 91,257 0 DHO 32,190,000 6,018,733 Note: all amounts are in PKR. Data Source: CGA, Government of Pakistan, Balochistan district budget and expenditure data 2018, downloaded from IFMIS, and DHIS Government of Balochistan 113 ASSESSMENT OF UHC PERFORMANCE MONITORING SYSTEM & UHC BUDGET AND EXPENDITURE ANALYSIS IN PAKISTAN June 2022 2022 © GFF/The World Bank Group. Design: Pi COMM. Photo : © adobestock.com / Virgo