study on budgetary gap...12 study on budgetary gap analysis of diarrhoea and pneumonia commodities...

Study on Budgetary GapAnalysis of Diarrhoea and

Pneumonia Commodities atProvincial/Region Level

26 November 2017

Coprights © UNICEF PakistanPhoto credits: UNICEF PakistanDesign: Human Design Studios

ContentsAbbreviations ..........................................................................................................................................................9

Acknowledgment .................................................................................................................................................. 10

Executive Summary ............................................................................................................................................. 12

Study Objectives and Methodology ................................................................................................................. 18

2.1. The Current Situation / Context ............................................................................................................................... 18

2.2. Purpose and Objectives of the Study .................................................................................................................. 18

2.3. Scope of the Study ............................................................................................................................................................. 19

2.4. Study Methodology ............................................................................................................................................................. 19

2.5. Sequence of Events ..........................................................................................................................................................20

2.6. Research Ethics ....................................................................................................................................................................20

2.7. Data Collection for Budgetary Gap Analysis ..................................................................................................20

2.8. Key Informant Interviews ...............................................................................................................................................22

2.9. Study of Budget performance and implementation challenges ....................................................22

2.10. Data Caveats..........................................................................................................................................................................23

2.11. Lessons Learnt .......................................................................................................................................................................23

3. Study Findings ............................................................................................................................................. 25

3.1. Estimating the current level of funding commitment by government towards

purchase of commodities for treatment of Pneumonia and Diarrhoea ..................................25

3.2. Funding requirements to purchase essential commodities for treatment of

Pneumonia and Diarrhoea ...........................................................................................................................................27

3.3. Budgetary Gap ......................................................................................................................................................................32

3.4. Out of Pocket Expenditure ...........................................................................................................................................34

3.5. Budget performance and implementation challenges ...........................................................................35

3.6. Use of budget and the system of procurement .........................................................................................38

3.7. Summary Findings ..............................................................................................................................................................39

4. Recommendations and Action Plan ....................................................................................................... 41

4.1. Recommendations ............................................................................................................................................................. 41

4.2. Action Plans and Specific Tasks ...............................................................................................................................44

Annexes ............................................................................................................................................................. 46

List of Tables:

Table 1: Health Facilities Visited ..................................................................................................................................................22

Table 2: Current funding commitments by the Government ...............................................................................26

Table 3: Pakistan’s Population .......................................................................................................................................................27

Table 4: Number of Children Under 5 Years of age with All Diarrhoea (% and Number) .............. 28

Table 5: Number of Children Under 5 Years of age with Bloody Diarrhoea (% and Number) .............29

Table 6: Number of Children Under 5 Years of age with ARI (% and Number) ..................................... 29

Table 7: Number of Morbid Cases - Diarrhoea and Pneumonia .......................................................................30

Table 8: Morbid Population Using Public Health Facilities ......................................................................................... 31

Table 9: Quantitative Requirement for Treatment of Diarrhoea and

Pneumonia in Pakistan ...................................................................................................................................................32

Table 10: Prices of commodities for Treatment of Diarrhoea and Pneumonia ........................................32

Table 11: Budget Required - Assuming the Government provides Treatment to all

Diarrhoea and Pneumonia patients under the age of 5 years - Rs. Millions .......................33

Table 12: Budgetary Gap - Cost of Medicines - Rs. Millions .....................................................................................33

Table 13: Cost requirements including Labour and Overhead Costs - Rs. Millions ................................34

Table 14: Out of Pocket Expenditure - National Health Accounts 2013-14 .................................................34

Table 15: Out of Pocket - Cost of Treatment in Under 5 children - Rs. Millions ........................................35

Table 16: Procurement budget at different tiers of the Government .............................................................38

STUDY ON BUDGETARY GAP ANALYSIS OF DIARRHOEA AND PNEUMONIA COMMODITIES AT PROVINCIAL/REGION LEVEL - NOVEMBER 20178

BUDGETARY GAP ANALYSIS - NOVEMBER 2017

Tables in Annex

Table 20: Sindh Province - Estimated Under 5 Population and Disease Burden ....................................50

Table 21: Sindh Province - Public Expenditure on all types of drugs and medicines ............................ 51

Table 22: Sindh Province - Quantities procured for the treatment of Diarrhoea and

Pneumonia ..............................................................................................................................................................................52

Table 23: Punjab Province - Estimated Under 5 Population and Disease Burden.................................53

Table 24: Punjab Province - Public Expenditure on all types of drugs and medicines and

quantities procured for the treatment of Diarrhoea and Pneumonia .....................................54

Table 25: Balochistan Province - Estimated Under 5 Population and Disease Burden .....................56

Table 26: Balochistan Province - Public Expenditure on all types of drugs and medicines .............58

Table 27: Federal Government - Estimated Under 5 Population and Disease Burden .....................59

Table 28: Federal Government - Public Expenditure on all types of drugs

and medicines ......................................................................................................................................................................59

Table 29: KP Province - Estimated Under 5 Population and Disease Burden ...........................................60

Table 30: KP Province - Public Expenditure on all types of drugs and medicines ................................... 61

Table 31: KP Province - Availability of Medicines for Treatment of Diarrhoea and

Pneumonia - As on July 2017 ..................................................................................................................................62

Table 32: Federally Administered Tribal Areas (FATA) - Estimated Under 5 Population,

Public Expenditure and Procurement of Commodities for treatment of

Diarrhoea and Pneumonia ..........................................................................................................................................63

Annex - Annex Page

Annex 1: Action Plan ..............................................................................................................................................................................46

Annex 2: Sindh Province - Availability of Stocks in Districts visited during the Field Study -

June 2017 ................................................................................................................................................................................ 47

Annex 3: Punjab Province - Availability of Stocks in Districts visited during the Field Study -

June 2017 ................................................................................................................................................................................49

STUDY ON BUDGETARY GAP ANALYSIS OF DIARRHOEA AND PNEUMONIA COMMODITIES AT PROVINCIAL/REGION LEVEL 9


AbbreviationsARI Acute Respiratory Infection

CEO Chief Executive Officer

CMWs Community Midwives

CDD Control Diarrhoea Disease

DDO Drawing and Disbursing Officer

DHIS District Health Information System

DHO District Health Officer

DT Dispersible Tablets

FATA Federally Administered Tribal Areas

IHS Integrated Health Services

KP Khyber Pakhtunkhwa

LHS Lady Health Supervisor

LHW Lady Health Worker

MDG Millennium Development Goals

MICS Multiple Index Cluster Survey

MSD Medical Stores Depot

MNA Member of National Assembly

MNCH Maternal Neonatal and Child Health

MPA Member of Provincial Assembly

OH Overheads

PBS Pakistan Bureau of Statistics

PDHS Pakistan Demographic and Health Survey

PPHI President’s Primary Healthcare Initiative

PSLM Pakistan Social & Living Standard Measurement

RHC Rural Health Centre

THQ Tehsil Headquarter Hospital

WHO World Health Organisation



AcknowledgmentThis report is prepared by Mr. Nohman Ishtiaq1 - budgetary gap analysis consultant. This study would not have been possible without the support of representatives of Departments of Health, Departments of Finance and Departments of Planning and Developments in Punjab, Sindh, Balochistan, KP and FATA. In addition, the researcher would also like to thank representatives of vertical health programmes, outsourced entities including PPHI, IHS, and HANDS. In addition, the researcher acknowledges support of the UNICEF officials who have provided immense support during the study. The researcher also acknowledges the information provided by Micro Nutrient Initiative, WHO, and John Snow Inc.

In particular, the researcher would like to thank Dr. Mohammad Mushtaq Hussain Rana, and Dr. Syed Kamal Asghar of UNICEF, who also reviewed the initial draft of the study and provided feedback.

1 The researcher did not have any conflict of interest to undertake this study

1.Executive Summary



Pakistan2 ranks in the countries with high infant mortality rates. As per the available statistics, each year around 89 children under the age of 5 die in 1,000 livebirths. While there are different causes of high mortality, the two most noticeable reasons are acute respiratory infection (Pneumonia) and Diarrhoea. It was reported3 in 2012-13 that 91,000 children died from Pneumonia and 53,300 children died from Diarrhoea.

As per the Pakistan Demographic and Health Survey (PDHS) of 2012-13, around 23% of children under the age of 5 had Diarrhoea two weeks before the survey, 61% were taken to appropriate health provider, only 38% were provided with oral rehydration salts (ORS), and less than 2% were provided with Zinc supplements. Similarly, 16% of children under the age of 5 had acute respiratory infection (ARI) / Pneumonia two weeks before the survey, and 42% with ARI received antibiotics.

This study is one of the three studies4 commissioned to propose policy recommendations with the aim to reduce child mortality and morbidity caused due to Diarrhoea and Pneumonia. It aims to document existing funding levels for the procurement of commodities for treatment of Diarrhoea and Pneumonia, calculate funding requirements, review methods of forecasting, assess out of pocket expenditure, review budgetary management issues, and provide recommendations. Study objectives and the methodology adopted is provided in Chapter 2. Specific study findings are provided in Chapter 3 while recommendations are provided in Chapter 4.

The study is prepared to provide policy recommendations to the government, parliamentarians and donor coordination group on Diarrhoea and Pneumonia.

The study was carried out in four provinces and the Federal Government. To undertake this study, different types of data was collected from health departments (including vertical health programmes), outsourced health service delivery entities (e.g. PPHI in Sindh), and finance departments of four provinces and the Federal Government (Ref.2.3). In addition, key informant interviews were undertaken through visits made to 44 health facilities and 5 warehouses in 10 districts of Punjab and Sindh (Ref.2.5). Discussions were also held with related health projects, donors, and doctors of private sector clinics.

2 UNICEF. (2015). Committing to Child Survival: A Promise Renewed. Progress Report 2015 - http://www.unicef.org/publications/files/APR_2015_9_Sep_15.pdf3 PDHS 2012-134 The other two studies relate to assessment of supply-chain management system, and landscape analysis

EXECUTIVESUMMARY



KEY STUDYFINDINGS

5 http://www.pbs.gov.pk/node/2047 - The provisional census data is being challenged by different political and is not clear if these numbers will remain same in the future.

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The total number of children under the age of 5 are between 27.8 million (provisional5 population census numbers 2017) and 29.5 million (if growth rates of 1998 population census are undertaken (Table 3). Based on the census 2017 figures, and number of morbid cases report by Pakistan Demographic and Health Survey (PDHS) 2012-13, each year the number of children with Diarrhoea are estimated to be 6.3 million (Table 4) and children with ARI are estimated to be 4.4 million (Table 6).

Based on standard treatment guidelines, and PDHS 2012-13’s estimate of 4 to 6 episodes of Diarrhoea and 1 to 2 episodes of Pneumonia (ARI - Acute Respiratory Infection) each year, the total budget required to treat all the morbid under 5 population of children is estimated to be around Rs.2.3 billion (around $210 million) - Table 13.

At the level of community health workers, primary and secondary healthcare services, the government is estimated to have spent Rs.830 million rupees per year (which includes cost of medicines, labour and overhead cost (Table 12) in 2015-16. This means that the budgetary gap between what is required and what is supplied is a little under 3 times.



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The government procures ORS, Zinc suspension and Amoxicillin syrup at a considerably cheaper rate than what is available in the market (Table 10). Therefore, the out of pocket expenditure - around 60%6 of total health expenditure as per National Health Accounts 2013-14 - is estimated at a high level of Rs.3.1 billion (Table 15).

In 10 districts visited, stocks of ORS, Zinc Sulphate (syrup), Amoxicillin (suspension) and oxygen cylinders with health service providers and warehouses were found to be satisfactory, except:a. RHCs run by IHS in Sindh – IHS officials informed that required budget was not released in 2016-17b. LHWs - both in Punjab and Sindh – a number of LHWs reported having zero stockc. In some cases, stock was not available due to delays on behalf of manufacturers e.g. THQ Rohri, THQ

Kandhkotd. During key informant interviews, the department of health officials in Balochistan, FATA, and KP informed

that out of stocks do occur

Only some DHQs and THQs had Pulse Oximeter and ARI Timers.

Government uses consumption based method of forecasting of medicines and commodities. Actual procurement is undertaken as per budget availability.

Budget for procurement of medicines for the treatment of the two diseases is provided to different centralised and decentralised entities:a. Sindh: Divisional headquarters, vertical health programmes (LHWs, CMWs and Nutrition), outsourced

(PPP) entities, CDD project, and autonomous hospitalsb. Punjab: DDOs, IRMNCH programme, and autonomous hospitals [for 2017-18 to district health authorities,

and health facilities management company will undertake procurement]c. Balochistan: DDOs but re-appropriated during the year to the central medical stores depot, and vertical

health programmesd. Khyber Patkhunkhwa: DDOs, and vertical programmese. FATA: DDOs, and vertical programmes

Budget is generally 10 - 15% lower than the requirements raised by procuring entities. Procuring entities (DDOs / projects) receive their budget information and release of funds communication late which results in delays in procurement processes. Largely procurements take place in quarter 3 and quarter 4 each year. In some cases, manufacturers refused to supply due to delayed work orders resulting in budget lapse. In Balochistan, FD prepares budget on behalf of Health DDOs.

6 As per National Health Accounts 2013-14, 67% of the health expenditures are funded through private sector, out of which 90% is out of pocket (OOP) health expenditures by private households. OOP expenditure is therefore, calculated at 60% of total health expenditure (67% X 90%)



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Central rate contract is generally finalised in the second quarter of a fiscal7 year.

The Federal Cabinet has approved the proposal to gradually reduce funding for provincial vertical health programmes – this raises funding challenge for provinces.

Based on this study the following key recommendations are made:1. Improvement in the method of Forecasting Procurement of Medicines

Currently the forecasting of procurements is based on past consumption patterns. Gradually, this system needs to be modified to procurements based on WHO recommended method (stock adjustment method based on DHIS data, and morbidity based on surveys). Similarly, method of budgeting needs to be improved from incremental and input budgeting to output-based budgeting.

2. Improving efficiency in the use of public funds

Three main areas require consideration:

a. Further clarity need to be communicated to health service providers on standard treatment guidelines in order to promote rational utilisation of medicines

b. Move towards co-packaging, Zinc DT and Amoxicillin DT

c. All public health facilities should be required to use ARI Timers and Pulse Oximeters for improved diagnosis, and

d. Emphasis need to be placed towards prevention / immunization.

3. An early completion of Central Rate Contracts

Central rate contracts in the provinces should be finalised by July or by maximum by August each year. All Drawing and Disbursing Officers (DDOs) should be notified on timely basis (preferably by August end each year) of the budget available to them, and the finalisation of central rate contracts and procurement guidelines.

4. Improvement in procurement and distribution system in case of vertical health programmes

Emphasis will need to be placed on sufficient and timely availability of medicines for Diarrhoea and Pneumonia treatment with the lady health workers.

Three key recommendations are made for vertical health programmes:

a. The provincial governments should review the standard supply of stocks to each lady health worker. The system of procurement - from planning to end usage needs to be reviewed so that sufficient stock availability can be ensured in the communities especially in rural areas.

b. An analysis of budget required by the vertical health programmes and how will the provincial governments take over this responsibility needs to be undertaken.

c. An IT system should be developed through which stock levels with Lady Health Supervisors can be monitored on regular basis.

7July - June



5. An increase of budget on procurement of medicines for treatment of Diarrhoea and Pneumonia

In Balochistan, KP and FATA, there is an immediate need to enhance budget allocation for medicines especially for treatment of Diarrhoea and Pneumonia as discussions with provincial departments of health revealed that stock outs occur. Special emphasis will need to be placed on rural areas and there is a need to increase stock levels and associated budgets by 10% - 15%.

6. Improvement in budget management practices

Discussions will need to take place with Finance Departments to allow one-time release of the budget head ‘procurement of drugs and medicines’ preferably in July/August each year. In addition, every DDO should be notified of his/her budget amounts by 30 August each year. Trainings should be provided to DDOs on procurement. In Punjab rules and regulations and appropriate budgets should be allowed on timely basis for district health authorities and facilities management company. In Sindh, funds release issues should be resolved with the IHS.

7. Development of IT systems

Centralised stocks register - including quantities procured and stored, quantities issued to health service providers, stocks in use, and stock outs, need to be maintained at the central level (departments of health) to enhance efficiency of use and allocations. In addition, the IT systems that have been developed by Punjab government may be demonstrated to other provinces with the aim to replicate such systems.

8. Determination of policy on reduction of out-of-pocket expenditure

Out of pocket expenditure in Pakistan is high8. At times, it results in catastrophic expenditure. If the government intends to provide universal healthcare services, then a policy needs to be formulated on how the out of pocket expenditure will be reduced. This can be achieved through devising a more holistic initiative of community health workers, provision of health insurance, increase in government’s budgetary allocations, etc.

9. Holding of pre-budget consultative sessions / seminars with different stakeholders

It is recommended that for budget 2018-19, for which the budget preparation activities, in the provinces will start from November / December this year, pre-budget consultative workshops should be held with relevant provincial and district officials, local level politicians, and donors. The aim of these workshops will be to apprise various stakeholders of the demographic, disease burden and current levels of health services in the districts and local communities.

10. Promotion of the use of co-packing (ORS and Zinc tablets) for treatment of Diarrhoea and Amoxicillin suspension tablets for treatment of Pneumonia in the private sector

Private sector role in treatment of Diarrhoea and Pneumonia is significant and therefore, the government should, based on WHO’s recommendation, promote use of co-packing (ORS and Zinc DT), Amoxicillin DT, oxygen, ARI Timer and Pulse Oximeter with general physicians.

Details on the recommendations are provided in Chapter 3.7.

8 Source; National Health Survey 2005-06

Study Objectives and Methodology

2.



Study Objectives and Methodology2.1. The Current Situation / Context

Pakistan has one of the highest levels of infant mortality in the world. Around half of mortalities are caused by Diarrhoea, Pneumonia and malaria. As per the Pakistan Health and Demographics Survey of 2012-13, around 23% of children under the age of 5 had Diarrhoea two weeks before the survey, 1 in 9 children suffering from Diarrhoea received no treatment at all, 61% were taken to appropriate health provider, 62% of children did not receive appropriate ORS (Oral Rehydration Solution) treatments, and only 1.5% received Zinc appropriately. Similarly, 16% of children under the age of 5 had acute respiratory infection (ARI) / Pneumonia two weeks before the survey, 59% suffering from Pneumonia receive no treatment, and 42% with ARI received antibiotics While Pakistan has a national immunisation programme, there is currently no vaccine95administered for Diarrhoea and in the country.

As per PDHS, Diarrhoea remains a leading cause of childhood morbidity and mortality in developing countries. Unfortunately, despite simple treatment guidelines, 53,300 children die of Diarrhoea each year, and there was an average of four to six episodes of Diarrhoea per child per year. Diarrhoea is a major cause of mortality and morbidity among Pakistani children despite decades of concerted efforts and special programs’10.6Similarly, around 91,000 children die of Pneumonia each year in Pakistan.

The government spent117between 0.5% to 0.8% of GDP annually on health over the past 10 years. Analysed as proportion of national income (GDP) and per capita investment, this level is on the lower side when compared against other regional economies having similar models of public health care services12.8In addition to inadequacy of public resources, there are questions on the equity, and efficiency on the use of public funds. Around 67% of the health expenditures are funded through private sector out of which 90% is out of pocket (OOP) health expenditures by private households13.9

2.2. Purpose and Objectives of the Study

Overall, the study aims to propose policy recommendations that will lead to reduction of mortality and morbidity in children caused due to Diarrhoea and Pneumonia in Pakistan. More specifically, the study assesses financial resources required vs available at the provincial and area levels for the treatment of the two diseases. In particular, the study;

• Estimates the current level of funding commitment at provincial/regional (i.e. sub-provincial) levels by Government towards purchase of commodities for treatment of Pneumonia and Diarrhoea by using the information provided by the Government.

• Provides a forecasting mechanism to ascertain funding requirements to purchase essential commodities for treatment of Pneumonia and Diarrhoea.

• Uses certain methods to assess the direct costs incurred by the Government (i.e. cost of procurement and cost of transportation) and indirect costs (i.e. manpower cost, overheads, etc.) incurred by the Government.

• Provides a method of calculating the total amount of budget demanded vs allocated and spent on essential commodities for the treatment of Pneumonia and Diarrhoea.

9 As part of the Extended Programme for Immunisation, the province of Punjab is piloting Rota Virus vaccine in 6 districts in Punjab. For this ppose, the Government of Punjab is providing additional budgetary resources10 Pakistan Demographic and Health Survey 2012-1311 Economic Survey 2016-17, Ministry of Finance - 712 WHO benchmark is health spending of 6 percent of GDP. Pakistan’s per capita health spending is US$39.5 which is much below the WHO’s benchmark of US$86 for low-income countries. Source: Economic Survey 216-17, Ministry of Finance - Page 187, and National Health Accounts 2013-1413 National Health Accounts 2013-14



• Discusses the ways to reduce out of pocket expenditure in Pakistan through the review of health treatment offered by the private health facilities vs. the public sector.

• Determines the diversity and depth of the budget performance and implementation challenges.

• Provide recommendations for adequate resource allocation and methods to improve forecasting at the provincial and sub-provincial levels.

2.3. Scope of the Study

The study was carried out for Balochistan, FATA, Federal Government, Khyber Pakhtunkhwa, Punjab and Sindh. This study does not include analysis for Azad Jammu and Kashmir, and Gilgit Baltistan.

In the above geographical locations, the study focuses on public sector health provision for the treatment of Diarrhoea and Pneumonia in children under the age of 5. More specifically the study included costs incurred on treatment of the two diseases by the civil government including:

1. Departments of health and district governments (district health offices / chief executive officers),

2. Vertical health programmes (lady health workers programme, community midwives’ programmes, and Nutrition Programme),

3. Special programmes run by the government (e.g. control of Diarrhoea disease programme in Sindh),

4. Autonomous government hospitals, and

5. Outsourced health provision at the primary level under public-private-partnership model.

The study excludes costs of treatment incurred by the military through the government’s defence budget. The military on average spends around 3%1410of total health expenditure in the country.

The study used data of 132 districts across Pakistan - which includes 6 regions and 7 agencies in FATA. The data was largely collected from provincial authorities.

To review health treatment of the two diseases offered by the private health facilities, discussions were held with 3 private clinics in Punjab.

2.4. Study Methodology

In order to undertake the study, the following methodology was adopted:

• Data collection - data collection exercise was undertaken to determine current level of funding commitment by the government, quantities procured and their unit prices,

• To calculate funding requirements, various types of data including number of children under 5, incidence and prevalence of two diseases, treatments provided, etc. was collected from various types of surveys and studies

• Key informant interviews were carried out in 44 health facilities and 5 warehouses through field visits held in June and July 2017

• In addition, discussions were also held with 5 doctors of private sector clinics to review treatment practices and out of pocket expenditure details, and with donors to ascertain current levels of funding for the treatment of the two diseases.

Based on the above information, this study undertakes specific analysis and proposes recommendations. Further details of the above methodology are provided below (Ref.2.6).

For the management of the study, different roles and responsibilities were as follows:

• Researcher was required to collect information from different information sources

14 Pakistan National Health Accounts 2013-14



• UNICEF representatives in Sindh, Punjab, KP, Balochistan, FATA and Federal Government were requested to arrange meetings and where possible accompany the researcher

• Government representatives were requested to provide data on specific formats. The format was approved as part of the Inception Report of the study

• Data was collected either through manual registers, computerised records, or was provided by various entities.

2.5. Sequence of Events

The following sequence of events was followed to undertake the study:

• Detailed discussion on Terms of Reference of the study with UNICEF officials

• Preparation of inception report - including data collection methods, tools, information requirements, entities to be visited for Key Informant Interviews, etc.

• Presentation of the study objectives, scope, methodology, etc. to key stakeholders in Punjab, Sindh, Federal Government, Balochistan, KP and FATA

• Key Informant Interviews during field visits in June and July 2017

• Collection of data on budgets, procurements, unit costs, etc. in July and August 2017 from provincial health departments, vertical programmes, etc.

• Presentation was made to the project steering committee on the methodology, scope, findings and recommendations of the study

• Comments were obtained from UNICEF officials and the project steering committee members.

2.6. Research Ethics

Research ethics as instructed in the UNICEF procedure for ethical standards in research, evaluation, data collection and analysis and in accordance with the UNICEF strategic guidance note on institutionalizing ethical practice for UNICEF research were followed. In addition, key Informant Interviews (KIIs), and stakeholder group discussions were undertaken with highest levels of professionalism.

2.7. Data Collection for Budgetary Gap Analysis

2.7.1 Current level of funding commitment by the government

To calculate current level of funding on procurement of commodities for treatment of Diarrhoea and Pneumonia, the following data was collected from provincial health departments (including vertical health programmes), outsourced entities, finance departments, and planning and development departments:

• Budget vs expenditure for the past three years on all types of drugs and medicines (the source was the computerised budgeting and accounting system installed at respective Finance Departments and accounting / treasury offices throughout the country), and

• Quantities and unit costs of procurement (ORS, Zinc syrup - 60ml and 90ml, and Amoxicillin syrup - 125mg and 250mg), were collected from:

§ Departments of Health / DHOs / CEOs

§ Vertical Health Programmes (e.g. LHWs, CMWs)

§ Outsourced (PPP) organisations – PPHI, IHS, Hands, etc.

§ Tertiary care hospitals

§ Medicine Stores Depot

§ Projects – e.g. Control of Diarrhoea disease.

Quantitative records have been obtained from either IT systems (including procurement system in place in Government of Punjab) or manual registers.



2.7.2. Determination of forecasting mechanism for ascertaining funding requirements

To forecast estimate funding requirements, the following data were used:

1. Standard treatment guidelines issued by WHO for Pakistan in 2006.

2. Total number of children under the age of 5 in Pakistan were estimated using the population census data and the age cohort data published by the Pakistan bureau of statistics. Two methods were used to estimate the number of under 5 children:

a. Age cohort data of 1998 was applied to the provisional 2017 census numbers, and

b. Population growth rates of 1998 were taken and population estimated for 2016. Age cohort data of 1998 was applied to estimated population of 2016.

Since provisional 2017 census numbers are being challenged by different governments, it is not clear if these numbers will remain the same in the future. Hence, above two methods have been used.

3. To estimate disease burden of Diarrhoea and Pneumonia in under 5 children, data from PDHS 2012-13 was used.

4. The following types of data for children under 5 were used from the above surveys:

a. Diarrhoea:

§ % of children with Diarrhoea incidence

§ % of children with incidence of Diarrhoea with blood

§ % of children sought treatment from public and private health providers

§ % of children who did not receive any treatment

§ % of children who were provided with ORS and Zinc supplements

§ % of children who were provided ORS and Zinc by public sector health providers

b. Pneumonia:

§ % of children with symptoms

§ % of children sought treatment from public and private health providers

§ % of children who were provided with antibiotics

§ % of children who were provided antibiotics by public sector health providers.

2.7.3. Method for calculating direct and indirect costs

Since the government’s budgeting and accounting system does not use the system of apportionment of costs to commodities for treatment of the two diseases, the following method has been used to estimate related labour and overhead costs:

• Average pay and allowances of all government officials working in the health sector (including health departments, and health programmes) were reviewed. In addition, the number of people associated with supply chain activities (e.g. procurement planning, bidding and vendor selection, supply and distribution, storage, etc.) were estimated.

• For the overhead costs, budgets of repairs and maintenance, operating expenditure and depreciation of costs of buildings, and other assets were analysed.

• Based on the above, the following percentages have been used to estimate related labour and overhead costs:

- Labour costs estimated at 3% of the commodity costs

- Overhead costs estimated at 5% of commodity costs.

2.7.4. Method for estimating cost of private sector treatment (out of pocket expenditure)

To estimate out of pocket expenditure incurred on treatment of Diarrhoea and Pneumonia, the following method has been used:



Total quantitative requirement of morbid population X (times) percentage of out of pocket expenditure as provided in National Health Accounts of 2013-14 X (times) cost of commodities and treatment in the private sector.

2.7.5 Commodities Provided by Donors

In addition to expenditure carried out by the public sector (government, public sector enterprises, etc.), the health care services are also provided by the development partners, non-governmental organisations (NGOs), and the private sector in the country.

Since the largest amount of expenditure is carried out by the government, this study will predominately review the government’s budget1511on procurement of drugs and supplies. In addition, efforts will also be made to gather information on procurement of drugs and supplies for Diarrhoea and Pneumonia by the development partners (e.g. USAID, WHO, UNICEF, etc.).

2.8. Key Informant Interviews

Key informant interviews were held with health facilities, warehouses and lady heath workers in 6 districts of Sindh and 4 districts of Punjab. A total of 44 health facilities and 5 warehouses were visited.

Table 1: Health Facilities Visited

The aim of the visits was to:

• Study the system of forecasting of commodities required for treatment of Diarrhoea and Pneumonia,

• Study existing prescription practices,

• Document the budgetary management system in the health facilities - especially budget demands, budget releases, and reporting mechanisms, and

• Understand the system of procurement, management of medicine stock outs, and treatment guidelines and practices.

In addition, discussions were also held with doctors in private clinics to understand treatment offered by the private sector to Pneumonia and Diarrhoea patients, costs of commodities to treat the diseases in the open market, and use of treatment guidelines issued by the WHO.

2.9. Study of Budget performance and implementation challenges

To understand the budget performance and implementation challenges at provincial and sub-provincial levels - key informant interviews were held with 44 health facilities in 10 districts in Punjab and Sindh were undertaken.

15 Including budget spent through vertical health programmes (e.g. Lady Health Workers), budget spent through outsourced service delivery (e.g. Rural Support Programme, People Primary Health Care Initiative, etc.), and sub-provincial levels (e.g. District Health Officers, CEOs in districts in Punjab)

Sindh Punjab

DHQ/Civil Hospitals 4 4

THQ Hospitals 5 3

RHCs * 6 4

BHUs ** 11 7

* Including RHCs managed by IHS and BHUs managed by PPHI in Sindh



In addition, interviews were held with provincial finance departments, departments of health (including vertical health programmes), departments of planning and development in the four provinces to understand methods of budget making, funds releases and expenditure management. Discussions were also held with outsourced entities (e.g. PPHI, and IHS in Sindh).

2.10. Data Caveats

While efforts have been made to collect up-to-date and relevant data, there are however, certain caveats:

1. The PDHS, MICS, PSLM and National Health Accounts surveys were not available for the latest year (2016-17) and hence it was difficult to estimate the exact disease burden of Diarrhoea and Pneumonia to calculate budgetary gap for the current year. Hence, most recent available data sources have been used.

2. While efforts were made to collect district-wise commodities distributed, this data could not be obtained from FATA, KP and Punjab. Hence, data of total commodities procured for the whole of the province was used.

3. The FATA health officials only provided data related to ORS procurements procured using recurrent budget. The data of procurements undertaken through development budgets could not be obtained. Hence, it should be noted that existing levels of procurements for Diarrhoea and Pneumonia commodities may be understated.

4. Data related to autonomous hospitals could not be obtained from Punjab. Therefore, an estimation has been made.

2.11. Lessons Learnt

Four key lessons have been learnt through this study:

1. Data availability - obtaining data on procurements, quantities issued and in stock is a cumbersome process. Data is scattered, largely in manual registers, and not readily available by central health departments (except Balochistan). Increased amount of interaction, regular coordination, and repeated requests are required to be made to obtain required information.

2. Since there are many interlinkages between the financial management, supply chain and the landscape studies, study periods, survey methodologies, and high levels of interactions between teams is a critical factor for building and presenting advocacy tools.

3. Local constituency politics plays a key role in selection and recruitment of personnel at the district and sub-district levels which impacts quality of service delivery.

Study Findings

3.



Study Findings3.1. Estimating the current level of funding commitment by government

3.1.1. Commodities currently used for the treatment

During the visits to 44 health facilities in Sindh and Punjab, it was reported that medical professionals generally prescribe the following commodities:

A For treatment of Diarrhoea:

1. Low-osmolarity Oral Rehydration Salts (LO-RS)

2. Zinc Sulphate (Syrup) - 60ml and 90ml

3. In a few instances, a co-packaged ORS and Zinc (containing 3 sachets of ORS and 1 bottle of Zinc Sulphate syrup)

4. In one health DHQ Zinc dispersible tablets were procured locally from the market

B For treatment of Pneumonia:

1. Amoxicillin Suspension (125mg and 250mg)

2. Any related antibiotic (e.g. Augmentin) in case Amoxicillin is not available at the time of prescription

3. Oxygen in case of acute Pneumonia

4. In some District Headquarters Pulse Oximeter and Oxygen Concentrator are also found to be available.

The WHO, in standard treatment guidelines for Pakistan 2006, prescribes the following:

C For treatment of Diarrhoea:

1. The normal prescription is 1-3 sachets of ORS and a bottle of Zinc enough for 10 - 14 days of intake

2. For Diarrhoea with blood - dysentery - 3-5 sachets of ORS and a bottle of Zinc for more than 2 weeks of intake

D For treatment of Pneumonia:

1. Pneumonia - Amoxicillin anti-biotic syrup - between 125mg and 250mg depending on severity

2. Use of ARI Timer and Pulse Oximeter

3. Oxygen.

The following was observed during key informant interviews with 44 health providers:

1. Not all health providers have clear understanding of standard treatment guidelines,

2. Most of the BHUs and RHCs do not have ARI Timer or Pulse Oximeter,

3. Only PPHI managed BHUs in Sindh had stock of co-packaged ORS and Zinc, and

4. In a number of cases, the health practitioners prescribed an anti-biotic together with ORS for treatment of Diarrhoea.

3.1.2. Stocks of commodities

Interviews and physical checking in 44 health facilities and 5 warehouses (Table 17 and Table 18) in Punjab and Sindh revealed that, with some exceptions, all the health facilities had ORS in stock. During the visits, it was communicated by the representatives of the health facilities that ample stocks were available for the past 2 to 3 years. There were however, certain health facilities where Zinc and Amoxicillin was found to be out of stock.

It was noted both in Sindh and Punjab that in a number of cases the lady health workers (LHWs) did not have stocks of ORS and Zinc for the past few months.



During our interactions with the officials of health departments in Balochistan, Khyber Pakhtunkhwa, and FATA, it was noted that stocks outs do occur in their health facilities of the three commodities - ORS, Zinc and Amoxicillin.

3.1.3. Current funding commitments

As per the data collected from various governments, the total government funding in 2015-16 on purchase of commodities for treatment of Diarrhoea and Pneumonia arrive at Rs. 766 million. Including direct and indirect costs the total funding was Rs.828 million.

Table 2: Current funding commitments by the Government

Geography

Government budget spending - 2016-17 (Excl. Labour and Overhead Costs)

Personnel Costs

Overhead Costs

Govt spending (Incl. Labour and

OH costs)ORS Zinc

Sulphate Amoxicillin Total

Rupees in millions

Balochistan 2.3 24.6 12.7 39.7 1.19 1.98 42.84

FATA 1.9 - - 1.9 0.06 0.10 2.08

Federal 1.3 0.5 3.6 5.4 0.16 0.27 5.87

KP 12.7 7.5 36.0 56.2 1.69 2.81 60.74

Punjab 67.5 155.9 239.3 462.6 13.88 23.13 499.65

Sindh 52.7 23.5 124.2 200.3 6.01 10.02 216.36

Pakistan 138.46 211.93 415.85 766.24 22.99 38.31 827.54

Source: Government budget spending - information provided by different government organisations

3.1.4. Existing budget forecasting method

During key informant interviews with 44 health service providers, it was noted that:

• To demand budget, the consumption basis of forecasting the requirements of commodities is used. A certain percentage is added to the previous year’s consumption quantities to arrive at the next year’s forecast.

• The budget demanded is sent to the provincial departments of health where it is rationalised (often downward revision is applied). In addition, the finance departments also apply downward revision keeping in view resource requirements.

• Generally, DHIS data for morbidity is not used for estimating budget required for the next year.

While collecting data, it was noted that data of procurements was available with different organisations. There was an absence of central register that would specify the following on period basis;

• Total quantities in stock at warehouses and with service providers,

• Total quantities distributed by warehouses to service providers,

• Total quantities procured during the year using the Central Rate Contract,

• Total quantities procured using Local Purchase head of the budget, and

• Quantities procured by autonomous hospitals, and outsourced entities.

Absence of the centralised supply chain data means that the system is prone to inefficiencies.

In our visit to Mithi in District Tharparkar of Sindh, it was noted that the supplies of ORS and Zinc were provided much more than the requirements.



3.1.5 Donor Contribution

In addition to the public sector, private sector, a number of donors - both national and international provide aid in shape of donations to the government of Pakistan.

In addition to the Government, in 2016 the UNICEF supplied the Government of Pakistan with ORS, Zinc and Oxygen Concentrators worth $62,076. In addition, Micro Nutrient Initiative provided 100,000 co-packaged ORS and Zinc syrup in 2016-17 to one district in Punjab.

3.1.6. Budget Demanded Vs Budget Allocated for Public Health Providers

It is learnt from the visits to 11 districts, that the budget for procurement of drugs is generally demands 15 - 20% more than the previous year’s consumption by the DDOs. However, the health departments, based on availability of the budget, and their own understanding of the consumption patterns, reduce the budget demanded. This budget amount is forwarded to the Finance Department for inclusion in the budget. Since the Finance Department does not have sectoral experience, their section officers (in charge of finalising budget demands) further reduce the amount by allocating a certain percentage increase (usually taking into account inflation adjustments) each year.

In some cases, e.g. Balochistan, it is observed that the Finance Department itself prepares the budget of the health department by providing a certain percentage increase each year.

3.2. Funding requirements to purchase essential commodities for treatment of Pneumonia and Diarrhoea

To estimate funding requirements to purchase essential commodities for treatment of Pneumonia and Diarrhoea the following method has been used:

3.2.1. Calculation of population of under 5 children in Pakistan

Provisional estimates12 from the recent population census suggest that Pakistan has a total population of 207.8 million. While demographic statistics of age cohort have not yet been published, using the age cohort of 1998, it is estimated that there are 27.8 million children under the age of 5 years. Based on the above population figures and number of cases, each year the number of children with Diarrhoea are estimated to be 6.3 million, and children with ARI are estimated to be 4.4 million.

Table 3: Pakistan’s Population

Geography

Population (millions) - 2017 Census*

2017 vs 1998 - Population Growth

U5 Children (millions) - 2017 Census

Estimated Population based on 1998 growth rates (millions)**

Urban Rural Total Urban Rural Total Urban Rural TotalPopulation

1998Population

2016U5

Children

13.4% 13.4%

Balochistan 3.4 8.9 12.3 3.5% 3.3% 3.4% 0.5 1.2 1.7 6.6 11.3 1.5

FATA 0.1 4.9 5.0 2.7% 2.4% 2.4% 0.0 0.7 0.7 3.2 5.3 0.7

Federal 1.0 1.0 2.0 3.5% 7.0% 4.9% 0.1 0.1 0.3 0.8 0.8 0.1

KP 5.7 24.8 30.5 3.0% 2.9% 2.9% 0.8 3.3 4.1 17.7 29.7 4.0

Punjab 40.4 69.6 110.0 2.7% 1.8% 2.1% 5.4 9.3 14.7 73.6 117.3 15.7

Sindh 24.9 23.0 47.9 2.5% 2.4% 2.4% 3.3 3.1 6.4 30.4 55.4 7.4

Pakistan 75.6 132.2 207.8 2.7% 2.2% 2.4% 10.1 17.7 27.8 132.4 219.9 29.5

* Provisional results - 6th Population census 2017 (http://www.pbs.gov.pk/node/2047)

** Estimated based on the population growth rates of census 1998

Source: Pakistan Bureau of Statistics, National Institute of Population Studies

16 http://www.pbs.gov.pk/node/2047 - The provisional numbers are being challenged by different political parties and it is not clear whether these numbers will be adjusted in the future



However, since the provisional census numbers have been challenged by different governments in the country, this study also used an alternative method to estimate population. Based on the alternative method, the total population of children is estimated at 29.5 million. The difference between the two methods, in totality, amounts to 2.1 million or around 7%. As per the provisional numbers of population census 2017, the highest amount of population growth rates has been noted in Balochistan, Federal Government, and KP.

For the purposes of this study, census results of 2017 population figures have been used to calculate total morbid population, population using public health facilities, and total value of out of pocket expenditure on treatment of Diarrhoea and Pneumonia.

3.2.2 Estimation of Morbid Population - All types of Diarrhoea in under 5 children

Using the provisional numbers of population census of 2017, age cohort from 1998 population census, and the PDHS 2012-13 statistics, the total number of children with Diarrhoea are estimated to be around 6.3 million in Pakistan:

Table 4: Number of Children Under 5 Years of age with All Diarrhoea (% and Number)

Disease Burden and Treatment - All Diarrhoea (under 5 children) - %

Geography U5 with DiarrhoeaTreatment sought

(public and private) ORS provided Zinc supplements provided

Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total

Balochistan 11.3% 12.2% 12.1% 43.4% 41.5% 0.8%

FATA 21.6% 29.1% 27.9% 23.0% 35.5% 2.3%

Federal 20.5% 66.5% 53.9% 2.5%

KP 21.6% 29.1% 27.9% 23.0% 35.5% 2.3%

Punjab 22.5% 21.6% 21.9% 68.6% 35.2% 1.5%

Sindh 21.9% 23.9% 23.1% 73.0% 45.2% 1.0%

Pakistan 21.9% 22.7% 22.5% 72.3% 56.4% 61.0% 41.5% 36.6% 38.0% 1.5% 1.5% 1.5%

Lowest wealth quantile 22.8% 54.0% 33.6% 2.2%

Source: PDHS 2012-13 - Pakistan Bureau of Statistics

GeographyEstimated U5

Population U5 with Diarrhoea Treatment sought ORS providedZinc supplements

provided

Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total

Balochistan 0.5 1.2 1.7 0.1 0.1 0.2 0.1 0.0 0.0

FATA 0.0 0.7 0.7 0.0 0.2 0.2 0.0 0.0 0.0

Federal 0.1 0.1 0.3 - - 0.1 0.0 0.0 0.0

KP 0.8 3.3 4.1 0.2 1.0 1.1 0.3 0.1 0.0

Punjab 5.4 9.3 14.7 1.2 2.0 3.2 2.2 0.8 0.0

Sindh 3.3 3.1 6.4 0.7 0.7 1.5 1.1 0.5 0.0

Pakistan 10.1 17.7 27.8 2.2 4.0 6.3 7.3 10.0 3.8 4.2 6.5 1.5 0.1 0.1 0.1

Lowest wealth quantile 6.3 3.4 1.2 0.1

Source: Census 2017 - Provisional data and age cohort from 1998 population census. PDHS 2012-13 - Pakistan Bureau of Statistics

Out of 6.3 million children with Diarrhoea (22.5%) - around 3.4 million sought treatment (61%) and 1.2 million children (38%) were provided with ORS, and 0.1 million children (1.5%) were provided with Zinc supplements. As per PDHS around 4 - 6 episodes of Diarrhoea are recorded each year. MICS is currently not available

Disease Burden and Treatment - All Diarrhoea (under 5 children) - Millions of Children



3.2.3 Estimation of Morbid Population - Bloody Diarrhoea in under 5 children

As per PDHS, children with Bloody Diarrhoea are around 0.7 million (2.5% of the population of children under 5).

Table 5: Number of Children Under 5 Years of age with Bloody Diarrhoea (% and Number)

Disease Burden and Treatment - Diarrhoea with blood (under 5 children) - %

Disease Burden - Diarrhoea with blood (under 5 children) - Millions of Children

Geography

U5 with Diarrhoea with blood

Trea

tmen

t so

ught

ORS

pr

ovid

ed

Zinc

pr

ovid

ed

U5 with Diarrhoea with blood

Trea

tmen

t so

ught

ORS

pr

ovid

ed

Zinc

pr

ovid

ed

Urban Rural Total Urban Rural Total

Balochistan 0.9% 1.3% 1.2% 0.0 0.0 0.0

FATA 1.6% 1.9% 1.9% 0.0 0.0 0.0

Federal 0.9% - - 0.0

KP 1.6% 1.9% 1.9% 0.0 0.1 0.1

Punjab 1.8% 2.8% 2.5% 0.1 0.3 0.4

Sindh 1.5% 3.1% 2.5% 0.1 0.1 0.2

Pakistan 1.7% 2.6% 2.3% 71.1% 50.2% 1.0% 0.2 0.5 0.6 0.1 0.2 0.0

Lowest wealth quantile 2.5% 54.0% 33.6% 2.2% 0.7 0.0


3.2.4 Estimation of Morbid Population - Acute Respiratory Infection (ARI) / Pneumonia in under 5 children

Using the provisional numbers of population census of 2017, age cohort from 1998 population census, and the PDHS 2012-13 statistics, the total number of children with ARI / Pneumonia are estimated to be around 4.4 million in Pakistan:

Table 6: Number of Children Under 5 Years of age with ARI (% and Number)

Disease Burden and Treatment - Pneumonia Symptoms - %

GeographyPneumonia Symptoms Treatment sought Anti-biotic received

Urban Rural Total Urban Rural Total Urban Rural Total

Balochistan 12.1% 9.1% 9.7% 77.8% 46.3% 53.5% 38.9% 18.2% 23.0%

FATA 24.9% 23.1% 23.4% 45.5% 25.9% 29.3% 43.9% 46.3% 45.9%

Federal 8.9% 66.9% 32.8%

KP 24.9% 23.1% 23.4% 45.5% 25.9% 29.3% 43.9% 46.3% 45.9%

Punjab 13.5% 16.1% 15.8% 79.3% 69.7% 72.1% 43.9% 44.5% 44.3%

Sindh 14.5% 11.6% 12.8% 80.4% 82.6% 81.6% 28.2% 34.4% 31.6%

Pakistan 16.4% 14.6% 15.9% 75.1% 60.4% 64.4% 38.9% 42.5% 41.5%

Lowest wealth quantile 13.4% 56.6% 41.8%

Source: Pakistan Bureau of Statistics



Disease Burden - Pneumonia Symptoms - Millions of children

Gography

Estimated U5 Population Pneumonia Symptoms Treatment sought Anti-biotic received

Urban Rural Total Urban Rural Total Urban Rural Total Urban Rural Total

Balochistan 0.5 1.2 1.7 0.1 0.1 0.2 0.0 0.1 0.1 0.0 0.0 0.0

FATA 0.0 0.7 0.7 0.0 0.2 0.2 0.0 0.0 0.0 0.0 0.1 0.1

Federal 0.1 0.1 0.3 - - 0.0 - - 0.0 - - 0.0

KP 0.8 3.3 4.1 0.2 0.8 1.0 0.1 0.2 0.3 0.1 0.4 0.4

Punjab 5.4 9.3 14.7 0.7 1.5 2.3 0.6 1.0 1.7 0.3 0.7 1.0

Sindh 3.3 3.1 6.4 0.5 0.4 0.8 0.4 0.3 0.7 0.1 0.1 0.3

Pakistan 10.1 17.7 27.8 1.7 2.6 4.4 1.2 1.6 2.9 0.6 1.1 1.8

Lowest wealth quantile 3.7 2.1 1.6

Out of a total of around 3.7 million children with Pneumonia, around 2.1 million seek treatment and around 1.6 million are provided with an antibiotic.

3.2.5 Number of Diarrhoea and Pneumonia cases in a year

Based on 4 episodes of Diarrhoea13, there are on average 25 million cases of all types of Diarrhoea, and around 2.5 million cases of Bloody Diarrhoea in the country. Based on 6 episodes of Diarrhoea, there are on average 38 million cases of all types of Diarrhoea, and around 3.8 million cases of Bloody Diarrhoea in the country.

Similarly, based on 1 episode of Pneumonia there are 4.4 million cases and around 9 million cases in case of 2 episodes in the country.

For lowest income quantile, the number of Diarrhoea cases can be as high as 38 million and around 4.2 million for Bloody Diarrhoea. Number of cases for lowest income quantile can be as high as 7.5 million cases in case of two episodes of Diarrhoea.

The total number of children with Diarrhoea are around 6.3 million and 4.4 million with Pneumonia.

Table 7: Number of Morbid Cases - Diarrhoea and Pneumonia

Under 5 - Mortality and Morbidity

Geography

U5 Mortality Per 1,000

live births

Data Year

U5 Children

U5 Children with all types of

U5 Children

with Bloody

Diarrhoea

U5 Children

with Pneumonia symptoms

Cases - All Diarrhoea

Cases - Bloody Diarrhoea

Cases - Pneumonia

millions of U5 children

4 episodes

/ year

6 episodes

/ year

4 episodes /

year

6 epsodes

/ year

1 episode /

year

2 episodes

/ year

158 2003-04 1.7 0.20 0.02 0.16 0.80 1.20 0.08 0.12 0.16 0.32

FATA 104 2007-08 0.7 0.19 0.01 0.16 0.75 1.12 0.05 0.08 0.16 0.31

Federal 0.3 0.06 0.00 0.02 0.22 0.33 0.01 0.01 0.02 0.05

KP 75 2006-07 4.1 1.14 0.08 0.96 4.56 6.85 0.31 0.47 0.96 1.91

Punjab 104 2010-11 14.7 3.23 0.37 2.33 12.91 19.37 1.47 2.21 2.33 4.66

Sindh 112 2003-04 6.4 1.48 0.16 0.82 5.93 8.89 0.64 0.96 0.82 1.64

Pakistan 89 2012-13 27.8 6.26 0.64 4.43 25.06 37.59 2.56 3.84 4.43 8.85

Lowest wealth quantile 6.35 0.70 3.73 25.4 38.1 2.78 4.18 3.73 7.46


17 Source: PDHS 2012-13 - on average 4 - 6 episodes of Diarrhoea are reported each year



3.2.6 Morbid population in under 5 years of children using public health facilities

Data of morbid population (in under 5 children) using public health facilities is not available in PDHS 2012-13. The only reliable estimate is available from PLSM 2014-15. The percentage of population using public health facilities is applied to the population census data of 2017.

As per PSLM 2014-15, the morbid population (children under the age of 5 with Diarrhoea and Pneumonia) using public health facilities was around 31%.

This means that out of a total of 6.3 million children with Diarrhoea, around 2 million visited public health facilities out of which 0.7 million received ORS, 0.03 million children received Zinc sulphate syrup. For Pneumonia, out of 4.4 million children with Pneumonia symptoms around 1.1 million visited public health facilities and 0.6 million children received an anti-biotic.

Table 8: Morbid Population Using Public Health Facilities

Morbid population using public sector health facilities

Geography

U5 Children with all types of

Diarrhoea

U5 Children visited public health facility

U5 Children received treatment

ORS provided

Zinc Sulphate provided

U5 Children

with

U5 Children visited public health facility

Anti-biotic

provided

millions % % millions millions millions millions % millions millions

Balochistan 0.20 48.8% 82.4% 0.08 0.07 0.00 0.16 48.8% 0.08 0.02

FATA 0.19 50.6% 85.2% 0.08 0.03 0.00 0.16 50.6% 0.08 0.04

Federal 0.06 24.0% 90.7% 0.01 0.01 0.00 0.02 24.0% 0.01 0.00

KP 1.14 50.6% 85.2% 0.49 0.17 0.01 0.96 50.6% 0.48 0.22

Punjab 3.23 20.5% 89.6% 0.59 0.21 0.01 2.33 20.5% 0.48 0.21

Sindh 1.48 32.3% 92.8% 0.44 0.20 0.00 0.82 32.3% 0.26 0.08

Pakistan 6.26 30.7% 88.5% 1.70 0.65 0.03 4.43 30.7% 1.36 0.56

Lowest wealth quantile 6.35 30.7% 1.72 0.58 0.04 3.73 30.7% 1.1 0.48

Source: PDHS 2012-13 and PSLM 2014-15 - Pakistan Bureau of Statistics

3.2.7 Calculation of total quantities required to treat morbid population in under 5 children

Based on morbid population numbers and the number of episodes of the two diseases (using PDHS 2012-13), the total quantitative requirement of the three commodities (ORS, Zinc Sulphate syrup and Amoxicillin suspension) in a year is calculated as:

1. 4 episodes of Diarrhoea in a year:

a. 100 million sachets of ORS

b. 25 million bottles of Zinc Sulphate (60ml and 90ml)

2. 6 episodes of Diarrhoea in a year:

a. 150 million sachets of ORS

b. 38 million bottles of Zinc Sulphate (60ml and 90ml)

3. 1 episode of Pneumonia in a year:

a. 4.4 million bottles of Amoxicillin (125mg and 250mg)



4. 2 episodes of Pneumonia in a year:

a. 8.9 million bottles of Amoxicillin (125mg and 250mg)

Table 9: Quantitative Requirement for Treatment of Diarrhoea and Pneumonia in Pakistan

Quantities Required for Treatment of Diarrhoea and Pneumonia

Geography Cases - All Diarrhoea

Cases - Bloody Diarrhoea Cases - Pneumonia Diarrhoea Treatment Pneumonia

Treatment

4 episodes

/ year

6 episodes

/ year

4 episodes /

year

6 episodes

/ year

1 episode / year

2 episodes

/ yearORS Zinc Sulphate

(Syrup) Amoxicillin (Syrup)

number of cases 3-5 Sachets 1 Bottle 1 Bottle

4 episodes

/ year

6 episodes /

year

4 episodes

/ year

6 episodes /

year

1 episode / year

2 episodes

/ year

millions

Balochistan 0.80 1.20 0.08 0.12 0.16 0.32 3.20 4.80 0.80 1.20 0.16 0.32

FATA 0.75 1.12 0.05 0.08 0.16 0.31 2.99 4.49 0.75 1.12 0.16 0.31

Federal 0.22 0.33 0.01 0.01 0.02 0.05 0.88 1.32 0.22 0.33 0.02 0.05

KP 4.56 6.85 0.31 0.47 0.96 1.91 18.26 27.39 4.56 6.85 0.96 1.91

Punjab 12.91 19.37 1.47 2.21 2.33 4.66 51.65 77.48 12.91 19.37 2.33 4.66

Sindh 5.93 8.89 0.64 0.96 0.82 1.64 23.72 35.57 5.93 8.89 0.82 1.64

Pakistan 25.06 37.59 2.56 3.84 4.43 8.85 100.23 150.35 25.06 37.59 4.43 8.85

Lowest wealth quantile

25.39 38.09 2.78 4.18 3.73 7.46 101.57 152.35 25.39 38.09 3.73 7.46

Source: PDHS 2012-13 and provisional number of census 2017 - Pakistan Bureau of Statistics

3.2.8. Prices of commodities

Since the government buys in bulk, it is able to gain benefits due to economies of scale. Average prices of commodities are as follows:

Table 10: Prices of commodities for Treatment of Diarrhoea and Pneumonia

Prices of Commodities ORS - Sachet Zinc Sulphate (Syrup) - 60-90 ML Amoxicillin (Syrup) - 125-250mg

Rs. Per scahet Rs. Per bottle Rs. Per bottle

Average Price - Government Procurement 6 25 45

Available in the market:

Price Range 6 - 18 30 - 180 60 - 250

Average 10 80 150

Source: Rate contracts, procurement records of Government

Source: Market pharmaceutical outlet

3.3. Budgetary Gap

Assuming that the government picks up the cost of treatment of all Diarrhoea and Pneumonia morbid population under the age of 5, the total cost requirement arrives at Rs.2.2 billion per year.

The assumptions used in the tables below are based on data collected and analysed in the previous section.



Table 11: Budget Required - Assuming the Government provides Treatment to all Diarrhoea and Pneumonia patients under the age of 5 years - Rs. Millions

Requirement of budget for the Treatment of Diarrheoa and Pneumonia

Geography ORS - Sachet

Zinc Sulphate (Syrup) - 60-90 ML

Amoxicillin (Syrup) -

125-250mgDiarrheoa Treatment Pneumonia Treatment

ORS Zinc Sulphate (Syrup) Amoxicillin (Syrup)

Sachets 1 Bottle 1 Bottle

4 episodes / year

6 episodes / year

4 episodes / year

6 episodes / year

1 episode / year

2 episodes / year

Average cost per unit in Pak Rupees Millions of Rupees

Balochistan 6 25 45 19.2 28.8 20.0 54.0 7.2 14.4

FATA 6 25 45 18.0 26.9 18.7 50.5 7.1 14.1

Federal 6 25 45 5.3 7.9 5.5 14.9 1.1 2.2

KP 6 25 45 109.6 164.3 114.1 308.1 43.1 86.1

Punjab 6 25 45 309.9 464.9 322.8 871.7 104.8 209.6

Sindh 6 25 45 142.3 213.4 148.2 400.2 37.0 73.9

Pakistan 6 25 45 601.4 902.1 626.4 1,691.4 199.2 398.4

Lowest wealth quantile 609.4 914.1 634.8 952.2 167.9 335.8

Source: PDHS 2012-13, population census 2017, average prices from central rate contracts / procurements

Table 12: Budgetary Gap - Cost of Medicines - Rs. Millions

Budgetary Gap - Medicine cost

Geography

Diarrheoa Treatment

Pneumonia Treatment

Total

Government budget spending - 2016-17

Gap

ORS Zinc Sulphate Amoxicillin ORS Zinc

Sulphate Amoxicillin Total

Millions of Rupees

Balochistan 24.0 37.0 10.8 71.9 2.3 24.6 12.7 39.7 32.2

FATA 22.4 34.6 10.6 67.6 1.9 - - 1.9 65.7

Federal 6.6 10.2 1.6 18.4 1.3 0.5 3.6 5.4 13.0

KP 136.9 211.1 64.6 412.7 12.7 7.5 36.0 56.2 356.4

Punjab 387.4 597.3 157.2 1,141.9 67.5 155.9 239.3 462.6 679.2

Sindh 177.9 274.2 55.4 507.5 52.7 23.5 124.2 200.3 307.2

Pakistan 751.7 1,158.9 298.8 2,209.5 138.5 211.9 415.8 766.2 1,443.2

Lowest wealth quantile 761.8 793.5 251.8 1,807.1 1,040.8

Source: Government budget spending - information provided by different government organisations

The government is currently spending Rs.766 million on the commodities for the treatment of Diarrhoea and Pneumonia per year. Adding the labour and overhead costs the total requirement is estimated at around Rs.2.3 billion:



Table 13: Cost requirements including Labour and Overhead Costs - Rs. Millions

Geography

Medicine cost

Estimated Labour Cost

Estimated Overhead Cost Required cost

Rs. Million % of medicine cost

% of medicine cost Rs. Million

Balochistan 71.9 3.0% 5.0% 74.8

FATA 67.6 3.0% 5.0% 70.3

Federal 18.4 3.0% 5.0% 19.2

KP 412.7 3.0% 5.0% 429.2

Punjab 1,141.9 3.0% 5.0% 1,187.6

Sindh 507.5 3.0% 5.0% 527.8

Pakistan 2,209.5 3.0% 5.0% 2,297.8

Lowest wealth quantile 1,807.1 3.0% 5.0% 1,879.4

Based on these calculations the total budgetary gap, if the entire morbid population is treated by the government, comes out to be around Rs.1.5 billion.

3.4. Out of Pocket Expenditure

As per the National Health Accounts of 2013-14 on average around 60 percent of expenditure is incurred out of pocket in Pakistan. Around 80% is incurred through private sector and the remaining 20% is incurred through public sector.

Table 14: Out of Pocket Expenditure - National Health Accounts 2013-14

Rs. Millions

OOP Expenditure - NHA 2013-14

OOP (Excl. Reimbursements)

Total Health Expenditure

OOP as % of Total Health Expenditure

Pakistan 455,760 757,196 60.2%

Punjab 249,328 366,374 68.1%

Sindh 110,604 182,649 60.6%

KP 71,754 111,567 64.3%

Balochistan 23,702 42,148 56.2%

ICT 3,573 4,229 84.5%

Unrecognised (3,201) 50,229

Source: National Health Accounts 2013-14

The out of pocket expenditure is expensive as it attracts three types of costs:

1. Cost of inspection,

2. Cost of treatment, and

3. Cost of travel.

Out of the above three, the cost of treatment is expensive as the average price of commodities for the treatment of Diarrhoea and Pneumonia is higher (Ref. Section 3.3.8) in the market as compared to that incurred by the government.

Based on PDHS survey, and National Health Accounts, population census of 2017, and average prices of



commodities in the market, the out of pocket expenditure on the treatment of Diarrhoea and Pneumonia is estimated to be Rs.3.1 billion in a year.

Table 15: Out of Pocket - Cost of Treatment in Under 5 children - Rs. Millions

There is a need to reduce this level of expenditure especially in the lowest quantile of the population in under 5 years of children.

3.4.9. Role of the private sector

Role of the private sector in health service delivery is significantly large in Pakistan. Discussions with 5 private sector general physicians revealed the following:

§ There is generally lack of awareness of standard treatment guidelines especially use of Zinc sulphate and is often not prescribed

§ Similarly, there is generally lack of awareness of Amoxicillin being the preferred medicine for the treatment of Pneumonia. Use of different anti-biotics for treatment of Pneumonia is in vogue.

3.5. Budget performance and implementation challenges

During key informant interviews with provincial authorities, the following budget performance and implementation challenges were noted across the board:

• Budget demanded by the health service providers is higher than what is normally awarded to them through the budget. A two-staged rationalisation exercise takes place; one at the level of the central departments of health, and second at the level of finance departments.

• Delays occur at the time of budget releases. A number of procurement officials reported to have received substantial portion of budget releases after quarter 2 of a fiscal year. This results in delays in procurements. In some cases, it was noticed that delayed releases resulted in surrender (non-utilisation) of budgeted amounts. It was also reported in some cases that manufacturers refused to

Cost of Private Sector Treatment - Diarrhoea and Pneumonia - under 5 children

Diarrhoea Treatment Pneumonia Treatment

Out of pocket

expenditure on health (%)

Diarrhoea Treatment Pneumonia Treatment

Total average cost Rs. Millions

ORS Zinc Sulphate (Syrup) Amoxicillin (Syrup) ORS Zinc Sulphate

(Syrup) Amoxicillin (Syrup)

3-5 Sachets 1 Bottle 1 Bottle 3-5 Sachets 1 Bottle 1 Bottle

4 episodes

/ year

6 episodes /

year

4 episodes

/ year

6 episodes

/ year

1 episode / year

2 episodes

/ year

4 episodes

/ year

6 episodes

/ year

4 episodes

/ year

6 episodes

/ year

1 episode / year

2 episodes

/ year

millions Cost - Rs. Millions

Balochistan 3.20 4.80 0.80 1.20 0.16 0.32 56.2 18.0 27.0 36.0 54.0 13.5 27.1 87.8

FATA 2.99 4.49 0.75 1.12 0.16 0.31 64.3 19.2 28.9 38.5 57.7 15.1 30.3 94.9

Federal 0.88 1.32 0.22 0.33 0.02 0.05 84.5 7.5 11.2 14.9 22.4 3.0 6.1 32.5

KP 18.26 27.39 4.56 6.85 0.96 1.91 64.3 117.4 176.1 234.9 352.3 92.3 184.7 578.9

Punjab 51.65 77.48 12.91 19.37 2.33 4.66 68.1 351.5 527.3 703.1 1,054.6 237.8 475.5 1,674.9

Sindh 23.72 35.57 5.93 8.89 0.82 1.64 60.6 143.6 215.4 287.2 430.8 74.6 149.2 650.5

Pakistan 100.23 150.35 25.06 37.59 4.43 8.85 657.3 985.9 1,314.5 1,971.8 436.4 872.8 3,119.4

Lowest quantile 101.57 152.35 25.39 38.09 3.73 7.46

Source: PDHS 2012-13, Provisional Population Census 2017, National Health Accounts 2013-14



supply commodities against work orders released in late May or early June.

• Budget for procurement of medicines is funded through recurrent and development budgets. Budgets of DDOs are transparent and the heads of ‘procurement of drugs and medicines’ and ‘procurement of equipment’ are clearly shown. However, information of procurement of the type of drugs and medicines within the budget is not provided. Budget provided to outsourced entities (e.g. PPHI, IHS in Sindh) are provided in a single-line. There is an issue of transparency as it is not clearly how much funds are to be allocated by these outsourced entities on procurement of medicines. Similarly, on the development side, projects also normally include single-line budgets.

• Information on amount that has been allocated and approved as part of the budget is provided roughly 3-4 months after the approval by the Provincial Assembly to the spending units. Secondly, the funds are often reported to have released late resulting in delays in issuance of procurement work orders and subsequent delivery.

• Procurement officials have limited knowledge of alternative forecasting methods that can be used to forecast medicine procurements.

• In 2010 the Council of Common Interest agreed that the Federal Government would provide funding for vertical health programmes till the next National Finance Commission Award. However, in 2017 the Federal Cabinet has decided to gradually reduce funding for vertical health programmes. Going forward, this will raise challenge for the provinces to allocate sufficient funding from their budget.

In addition to the above, the following challenges were noted during key informant interviews:

3.5.1. Sindh Province

1. Recently the Sindh Government has changed the system of allocation of budgets for the ‘procurement of drugs and medicines’. Until 2015-16 the budget under this head was allocated to DDOs and hence it was possible to ascertain how much budget was allocated to each district. From 2016-17 the budget is being allocated to divisional heads. This has reduced visibility and transparency of the budget allocated at the district and sub-district levels.

2. In 2015, a process of district action plans was started in the district government with the help of USAID. The district action plans, prepared with the help of consulting support, formed the basis of allocation of scarce budgetary resources as per the priorities of the districts. It was a system through which incrementalism in the budget was replaced with needs and priority based allocations. This system however, was later discontinued with the completion of the project. The government currently does not have the capability to implement the system of formulation of district action plans on its own.

3. There were budget releases issues encountered by IHS - the organisation that manages Rural Health Centres in Sindh. For this reason, the RHCs visited that were managed by IHS did not have required stocks of medicines available.

3.5.2 Punjab Province

1. The Punjab Government has recently established a Health Facility Management Company to oversee the management of Basic Health Units. Earlier BHUs in a large number of districts were managed by the PRSP (Punjab Rural Support Programme). The PRSP had been operational for the past few years and their budgetary management systems have matured over the years. The creation of a new entity is likely to see disruptions in management of the budget, procurements, and maintenance, due to its recent establishment.

2. Lately, the Punjab Government has established District Health Authorities, that are headed by Chief Executive Officers (CEOs). The budget for procurement is reportedly being provided to these newly created authorities. Separate bank accounts are made operational where initial funds have been transferred by the provincial Finance Department. It has been informed that the provincial government is struggling to appoint relevant personnel in these authorities. Till the full appointment of required staff members, the management of the budget, the procurements, are required reporting is likely to suffer.



3.5.3 Balochistan Province

1. While the budget is allocated to DDOs in the districts, the actual procurement is undertaken by the Medical Stores Depot (MSD). This means that the funds are re-appropriated (the powers of re-appropriation of funds from one entity to another lies with the Finance Department) from all the DDOs to the MSD during the year. Only after this process and the process of funds release, can the MSD undertake procurements. It is reported that normally the first procurement order is made in February / March each year. Since the funds have to be used by 30th June each year, this leaves less time to finalise all processes.

2. The Finance Department compiles the budget (on the recurrent side) on behalf of health department. This means that what is actually required at the district level, their priorities, and the changes to incremental budget, are not accommodated.

3.5.4 Khyber Pakhtunkhwa Province

Information of quantities of procurement are not available with the health department at the time of budget formulation. Hence, largely the incremental budget mechanism is applied to formulate central rate contract.

3.5.5. FATA Secretariat

Federally Administered Tribal Areas (FATA) Secretariat undertakes procurement of medicines through the non-development as well as development budget. There is a project (of Annual Development Programme) through which amounts are spent to procure medicines in the Agencies and Frontier Regions. The funds releases through development budgets are dependent on releases made by the Planning Commission at the Federal level and sub-divided into projects by FATA Secretariat. There are therefore, high chances of delays in budgetary funds releases and procurements.



3.6. Use of budget and the system of procurement

During key informant interviews, it was noted that different types of procurement models are in place in different provinces. The following table summarises the information obtained:

Table 16: Procurement budget at different tiers of the Government

Federal / Provincial

Procurement Authority

Non-Development budget for Procurement of Medicines at primary and secondary level

Sindh Decentral (rates fixed through Central Rate Contract)

From 2016-17 onwards, the budget is made available at the Divisional level

Entity level Where provision of health services is outsourced, each individual entity is authorised to undertake procurements. These entities include; PPHI (President’s Primary Health Care Initiative) - managing the BHUs in Sindh, IHS (Integrated Health Services) - managing certain RHCs in Sindh

Combat Diarrhoea Disease programme

Budget is provided through development budget and the project director is authorised to undertake procurements

Public private partnerships

Public private partnerships are contracts entered by the government with private sector health providers - specific examples include PPHI - President Primary Health Care Initiative managing basic health units, and HIS - Integrated Health Services managing a number of rural health centres. In addition, some Tehsil Headquarter Hospitals are contracted out. In addition, in some districts various level of health facilities have also been contracted out to other private entities like HANDS and Indus Hospital.

Balochistan Central (rates fixed through Central Rate Contract)

Budget is made available at the level of District Health Officers - however, Balochistan follows a central procurement method and hence, during the year, the budget is re-appropriated to the Medical Stores Depot

Punjab Decentral (rates fixed through Central Rate Contract)

From 2016-17, the budget is being made available to the District Health Authorities - who are run by a Chief Executive Officer (CEO). In addition, Punjab Health Facilities Management Company (PHFMC) has been formed which will oversee the management BHUs and RHCs in the province. Budget will be allocated to PHFMC as a single-liner

Khyber Pakhunkhwa (KP)

Decentral (rates fixed through Central Rate Contract)

Budget is made available to DHOs at the district level

Federally Administered Tribal Areas (FATA)

Decentral (rates fixed through Central Rate Contract)

Budget is made available to the DHOs at the Agency and Frontier Regions level.

Procurement Authority

Development Budget for Procurement of Medicines

Provinces, Federal, and FATA

Vertical Programmes The heads of vertical health programmes are authorised to undertake procurement. More specifically, for Diarrhoea and Pneumonia - procurements are undertaken by Lady Health Workers Programme, Maternal Neo-natal and Child Healthcare programme, and Nutrition Programme

FATA Central Procurement through a project is undertaken at the level of DG Health Services



3.7. Summary Findings

The above findings are summarised as follows:

§ Under 5 population between 27.8 (2017 census data) and 29.5 (1998 population growth formula) million.

§ Morbid population in 2017 based on percentages in PDHS 2012-13 survey:

§ Children with all types of Diarrhoea are estimated at 6.3 million

§ Children with Pneumonia symptoms are estimated at 4.4 million

§ As per the existing medicines procured, the number of disease episodes, and rates at which the government procures commodities:

§ The total budgetary requirement to treat morbid population in Pakistan is calculated as Rs.2.2 billion in 2016-17

§ Quantity wise this translates into:

125 million sachets of ORS

31.5 million bottles of Zinc syrup (60ml and 90ml)

6.6 million bottles of Amoxicillin suspension (125mg/5ml and 250mg/5ml)

§ The Government (including outsourced entities) – spent Rs.766 million in 2016-17 on procurement of these commodities.

§ Based on the above calculation – government procured medicines that catered for 35% of the total requirement.

§ Government uses consumption based method of forecasting of medicines. Actual procurement is undertaken as per budget availability.

§ Visits to 44 health facilities revealed that Drawing and Disbursing Officers (DDOs) – generally receive 15% - 20% less budget than demanded.

§ In 10 districts, stocks of ORS, Zinc Sulphate (syrup) and Amoxicillin (suspension) in warehouses and health service providers were satisfactory, except:

§ RHCs run by IHS in Sindh – we were told by IHS that required budget was not released in 2016-17

§ LHWs - both in Punjab and Sindh – a number of LHWs reported having zero stock

§ In some cases – stock was not available due to delays on behalf of manufacturers – e.g. THQ Rohri, THQ Kandh

§ Provincial authorities of Balochistan, KP and FATA informed that stock-outs occur for commodities required for treatment of Diarrhoea and Pneumonia in districts / agencies.

§ The Federal Cabinet has approved the proposal to gradually reduce funding for provincial vertical health programmes – this raises a challenge for provinces.

§ Delayed releases of funds by the Finance Departments to DDOs – result in delayed procurements – in some cases manufacturers refused to supply due to delayed work orders – resulting in budget lapse.

§ Finalisation of Central Rate Contracts took place in quarter 2 of 2016.

§ In Balochistan, FD prepares budget on behalf of Health DDOs.

Recommendations &Action Plan

4.



4.1. Recommendations

Based on the study finding, the following key recommendations are made:

4.1.1 Improvement in forecasting mechanism

At present, the forecasting of medicines procurement is based on method of consumption. This means that a certain percentage is added to prior year’s amounts consumed. The government should build its capacity to gradually move towards WHO recommended forecasting methods. Three methods can be considered by the government:

§ Stock adjustment method - in this method future procurement take into account the situation of functional stock-outs,

§ Morbidity based forecast - this method uses data from surveys to calculate morbid population, percentage of population using health facilities, and forecast quantities required, and

§ Patient load analysis - based on DHIS data, the forecasts of quantities required are undertaken for public health facilities.

However, implementation of the above methods will require capacity enhancement of procurement entities, the departments of health, and departments of finance.

In addition, the government should consider formalising the process of development of ‘district action plans’ as basis of budget allocation. Under this method, each year, the district officials take stock of the following:

• Status of health facilities,

• Current level of stocks of drugs and medicines,

• Disease burden based on a representative sample survey,

• Understanding of out of pocket expenditure,

• Storage capacities,

• Understanding of health service providers - public and private, and

• Budgets made available by the government.

4.1.2. Improving efficiency in the use of government budgets

The gap for treatment between what is currently available and what is required is around 3 times. This means that the government will have to spend 3 times more budget than it is spending currently in order to treat all morbid population under the age of 5.

However, the government can reduce this ratio through a number of mechanisms:

• Increasing efficiency in public health expenditure - more specifically, the government can increase efficiency in expenditure if:

§ The use of co-packing of ORS and Zinc is encouraged

§ The government moves towards the use of dispersible tablets of Zinc and Amoxicillin. Through the use of tablets, the average overhead costs - e.g. transportation, and warehousing - are likely to reduce

Recommendations and Action Plan



§ Use of ARI Timers and Pulse Oximeters are likely to enhance patient diagnosis.

• Government invests funds in prevention of Diarrhoea and Pneumonia through vaccines such as PCV and ROTA virus - however, it is beyond the scope of this study to study the costs and efficiency levels of vaccines.

• Governments investments in education of mothers, water and sanitation to prevent Diarrhoea etc.

4.1.3. An early completion of Central Rate Contracts

During the study visits to 11 districts, it was noted that rate contracts were generally finalised in the months of November and December 2016. For this reason, in many districts the procurement process started late. In some cases, the procurement order was forwarded to the medicine manufacturing companies in the month of May 2017. In such cases, the manufacturing companies refused to supply required medicines by June 2017.

For this reason, it is recommended that the government should aim to complete its central rate contract process ideally by 31st of July and maximum by 31st August of each year. To complete this process, efforts on quantitative procurement requirements, and finalisation of bidding documents will need to be finalised by first week of July each year.

Information of the central rate contracts should be communicated to procurement entities (DDOs) before the end of the first quarter (September) each fiscal year.

4.1.4. Procurement and distribution system in case of vertical health programmes

During the study visits to 10 districts, it was noted that in a number of cases, the lady health workers did not have the required supply of ORS, Zinc sulphate syrup and Amoxicillin suspension. In addition, since the Federal Government is likely to withdraw from its obligation to adequately fund the vertical health programmes, the responsibility would now fall on the provincial governments to appropriately fund these programmes.

The provincial governments have moved towards integrating lady health worker’s programme, community mid-wive’s programme and Nutrition Programme. Where this transition is yet to complete in all provinces, it is recommended that steps should be taken to integrate these programmes.

Three key recommendations are made for vertical health programmes:

1. The provincial governments should review the standard supply of stocks to each Lady Health Worker. The system of procurement - from planning to end usage needs to be reviewed so that sufficient stock availability can be ensured in the communities especially in rural areas. The method of review can include:

a. Situation of stock-outs,

b. Disease burden in districts especially in rural districts (Refer to annexure on district data), and

c. Seasonal pattern of diseases.

2. An analysis of budget required by the vertical health programmes and how will the provincial governments take over this responsibility needs to be undertaken.

3. An IT system should be developed through which stock levels with Lady Health Supervisors can be monitored on regular basis.

4.1.5. An increase of budget on procurement of medicines for treatment of Diarrhoea and Pneumonia

During the study visits to 10 districts, it was noted that the DDOs often request 15 - 20% more budget than what was allocated. These budget requirements are rationalised by the health departments and later by the Finance Departments in the provinces.

Health service providers in the 10 districts noted that increase in supply of medicines, and provision of qualified doctor often leads to improved visiting patients.

For this reason, the health departments and finance departments should be consulted and requested to



provide an increase of 10 - 15% in the budget head ‘A03927’ - procurement of drugs and medicines - more specifically for the procurement of ORS, Zinc syrup, and Amoxicillin syrup. The basis of increase of 10 - 15% is the additional budget that is demanded by the DDOs each year.

In addition, a policy note should be circulated from the Health Department to specify that this increase would be awarded to improve supplies of commodities for treatment of Diarrhoea and Pneumonia in specified health facilities. For this reason, a detailed study should be undertaken on the districts that have high disease prevalence and incidence and the stock availability of the essential commodities for the treatment of the two diseases.

4.1.6. Improvement in budget management practices

Three types of improvements are recommended in the budgetary practices:

1. Each DDO should be communicated with its budget, after approval from the legislative assembly, maximum by 15th August each year. At present a number of DDOs receive this information by October / November.

2. The Finance Departments in the provinces should be requested to amend the funds release policy and allow 100% release of funds preferably on the 1st of July each year for the budget head A03927 titled ‘procurement of drugs and medicines’.

4.1.7. Development of IT systems

Punjab government has developed a number of IT applications that is aiding it in procurements, stock monitoring, and provision and use of medicines at health facilities level.

A seminar should be arranged where Punjab government may be requested to show-case the IT systems to other provinces. A feasibility analysis should be undertaken on adoption of these IT systems in other provinces.

4.1.8. Determination of policy on reduction of out-of-pocket expenditure

The Government should formulate a policy regarding reduction of out-of-pocket expenditure. If the policy is to provide universal healthcare services to all then it should aim to plan for increase of budgetary resources together with supply chain management processes over a specified period of time.

Reduction of out-of-pocket expenditure may require the following types of strategies to be put in place to transition towards universal healthcare coverage:

1. Provision of a more holistic community based health workers,

2. A policy of increase in pre-payment mechanism - this can be done through introduction of health insurance cards for the lowest quantile including their family members. Coverage can also be extended to lower-middle-income quantile by introducing voluntary health insurance,

3. Increase in provincial level taxation in order to allow additional fiscal space for the provision of health care services,

4. Increase in budgetary allocations proportionate to allocations in other sectors,

5. Investments in patient referral system so as to avoid patient congestions at the secondary and tertiary health care facilities.

4.1.9. Holding of pre-budget consultative sessions / seminars with different stakeholders

Pre-budget discussions should be held with different policy stakeholders - including government, donors, parliamentarians, and related reform projects starting from December 2017. While the main theme of pre-budget discussions would seek to influence budget making for the year 2018-19, different types of topics could be discussed with different audience.

1. Government sector - Departments of Health and District Health Officials

a. Review of the system of supply chain of medicines and equipment including system of forecasting of medicines procurement



b. Improvements in budgetary releases to district health organisations, and DDOs

c. Methods to ensure timely submission of procurement work orders by district DDOs and timely supply of medicines by manufacturers

d. Discussions on introduction of co-packing and dispersal tablets for Zinc sulphate and Amoxicillin

e. Discussions on the policy to reduce out of pocket expenditure.

2. Parliamentarians - more specifically the local MPAs and MNAs

f. Key statistics related to health sector in the district / constituency - including state of health facilities, availability of medic and para-medic staff, availability of medicines and equipment, and disease burden related to Diarrhoea and Pneumonia

g. Measures to enhance health service delivery - and policy to treat Diarrhoea and Pneumonia cases

h. Budget provided to and spent by health facilities and providers in the district / constituency.

3. Donor coordination group on reduction of Diarrhoea and Pneumonia

A donor coordination group can be formed to synergise efforts on reduction of Diarrhoea and Pneumonia. The coordination group, on regular basis, can discuss the following:

i. Key initiatives in reduction of mortality and morbidity in under 5 children causes by Diarrhoea and Pneumonia

j. Policy changes implemented and their impacts on mortality and morbidity

k. Evaluations,

l. Aid.

4.1.10 Promotion of the use of co-packaged ORS and Zinc Sulphate for the treatment of Diarrhoea and Amoxicillin suspension for the treatment of Pneumonia amongst private sector general practitioners

Role of the private sector is quite sufficient in Pakistan. The government should therefore, promote the use of standard treatment guidelines, as recommended by WHO, amongst private sector general physicians for the treatment of Diarrhoea and Pneumonia. This would include promotion of co-packaging (ORS and Zinc DT), Amoxicillin DT, Oxygen, ARI Timer and Pulse Oximeter. In this regard, increased government regulations can also play an important role in addition to media campaigns.

4.1.11 Formulation of a comprehensive policy incorporating prevention, treatment and behaviour change elements

While budgetary gap analysis is an important factor to consider for improving service delivery, a more holistic policy definition is suggested to enhance efficiency and effectiveness in the use of public money. Reduction of under 5 mortality and morbidity requires a policy framework taking into account the prevention, treatment and behavioural change aspects. This will ensure a multi-facet approach involving different sectors (e.g. education, hygiene, water and sanitation, health, economic prosperity, etc.) that use public funds.

4.2. Action Plans and Specific Tasks

Based on the report findings, and recommendations, the following Annex (Annex 1) provide detailed activities:

Annexes



Annex 1: Action Plan

Sep Oct Nov Dec Jan Feb Mar Apr May Jun

1. Improvement in the method of Fore-casting Procurement of Medicines

1.1 Trainings on medicines forecasting methods

1.2 Trainings on determination of district action plans and linkage with budgets

2. An early completion of Central Rate Contracts

3. Procurement and distribution system in case of vertical health programmes

3.1 Review of standard supply

3.2Review of procurement and distri-bution system including timelines required

4. An increase of budget on procure-ment of medicines for treatment of Diarrhoea and Pneumonia

4.1

Discussions with health departments and finance departments on increase in budget for commodities for treat-ment of Diarrhoea and Pneumonia

4.2 Discussions on co-packaged (ORS and Zinc) procurements

5. Improvement in budget manage-ment practices

6. Development of IT systems

6.1 Presentation of IT systems of Punjab to other provincial governments

6.2 Discussions with provinces on adop-tion of similar systems

7. Determination of policy on reduction of out-of-pocket expenditure

7.1 Determination of policy on universal health coverage

8. Pre-budget consultative sessions on Diarrhoea and Pneumonia commodities

8.1 With provincial departments of health and district health officials

8.2 With provincial finance departments

8.3 With local parliamentarians



Annex 2: Sindh Province - Availability of Stocks in Districts visited during the Field Study - June 2017

District Health Facility ORS Amoxicillin syrup Zinc Syrup

Sukkur / Sukkur

EDOH stock Available Available Available

MNCH program Stock out since two months

Stock out since two months

Stock out since two months

Civil Hospital Sukkur

Available Stock out since 4 months Available

THQ Rohri Available Available Stock out since 4 months (delay from manufacturer)

RHC Bachal Shah Miani

Available (Before two months stock was out for 2 months)

Stock out

(second line of therapy is in use that is Ampicillin + cloxacillin)

Available

BHU New pind - PPHI

Available Available Available

BHU Thikrato Available Available Available

Kashmore @ Kandhkot

EDOH Available Stock out Available

THQ Hospital Kandkot

Available Stock out Stock out (one month)

RHC Ghouspur Available Stock out since one month

The Health Facility is with Integrated Health System (IHS) and MS told that HIS is struggling to provide medicine due to delay in timely release of budget

Stock out since 4 months

The Health Facility is with Integrated Health System (IHS) and MS told that HIS is struggling to provide medicine due to delay in timely

BHU Dari Available Available Available

BHU Khewaly Available Available Available

Tando Muhammad Khan

EDOH Available Available Available

DHQH TMK Available Available Available

THQH TMK Available Available Available

RHC Rajo Na-zamani


BHU Saeed pur Takara


BHU Sheikh Bhirkyo


Tharparkar / Mithi


DHQ Hospital Available Available Available

THQ Chachro Available Available Available

RHC Islamkot Available Available Available

BHU Kot Arbab Mir Muhammad


BHU Maln Hor Vena




District Health Facility ORS Amoxicillin syrup Zinc Syrup

Karachi / Malir EDOH Available Available Stock out Since 5 months

MNCH (Vertical Health Pro-gramme)

Stock out Stock out Stock out

RHC Old Thano Available Available Available

Sindh Govern-ment Hospital Murad Memon Goth


BHU Jaffer e teyyar

Available Functional stock out

(Physically present but medicines requisition submitted to government with zero stock in-hand report)

Stock out since 3 months

Shaheed Benazirabad

(This district is without PPHI and all BHUs are run by DoH)


DHQ hospital Available Available Available

THQ Hospital Sarkand


RHC Daur Available Available Available

BHU Karam Ali Jamali


BHU Gabhar Lakhair




Annex 3: Punjab Province - Availability of Stocks in Districts visited during the Field Study - June 2017

District Health Provider ORS Amoxicillin syrup Zinc Syrup

Rajanpur

District Warehouse Available Available Available

DHQ Available Available Available

THQ Jampur Available Available Available

RHC Muhammad pur Dewan


BHU Kotla Eisa Available Available Insufficient stock

BHU Saleem Abad available Stock currently present but during one year period 6 days stock was out

Available

IRMNCH & NP Sufficient stock Not available, LHS of Saleem-abad has reported that since last two months Amoxicillin, ORS, and Zinc is out of stock

Muzaffargarh

District Warehouse available available (Amoxicil-lin 250 mg/ 5ml was procured which need more dose accuracy for patient

available


THQ Kot adu Available Available Available

RHC sinawan Available Available Available

BHU jaday wala Available Available Available

BHU Muhammad Kot


IRMNCH & NP Available (stocks for three months has been issued through the couri-er) no demand has been calculated from the field

Available Available

Bahawalnagar

District Warehouse Available Available Available


THQ Chistian Available stock out Available

RHC Madrissa During last one year stock out of ORS occurred

Stock out of Amoxicillin syrup was observed which was solved on Jan 20117

Stock out occurred during last one year

BHU 54/F Available Available Available

BHU 98/F Available stock out Available

IRMNCH & NP Available Available Available

Pakpattan

District Warehouse Currently available but stock out situation observed over the past one year


RHC Bunga Hayat Available Available Available

BHU 28/SP Available Available Available

IRMNCH Insufficient stock Insufficient stock Insufficient stock



Tabl

e 20

: Sin

dh P

rovi

nce

- Est

imat

ed U

nder

5 P

opul

atio

n an

d D

isea

se B

urde

n

Sour

ce: P

akis

tan

Bure

au o

f Sta

tistic

s

Dist

ricts

Pop

ulat

ion

- Cen

sus (

2017

)

Und

er 5

Ch

ildre

n (1

3.4%

of

popu

la-tio

n)

PSLM

201

4-15

PDH

S (2

012-

13)

U

rban

Rura

lTo

tal

Diar

rhoe

a in

last

30

day

s

Trea

tmen

t in

priv

ate

healt

h fa

cility

Trea

tmen

t in

pub

lic

healt

h fa

cility

Whe

re O

RS w

as g

iven

Diar

raho

ea

in U

5 ch

ildre

n - 2

w

eeks

prio

r su

rvey

Diar

rhoe

a w

ith b

lood

Trea

tmen

t so

ught

fro

m h

ealth

fa

cility

pr

ovid

er

ORS

pr

ovid

edZi

nc

prov

ided

Pneu

mon

ia

U5

child

ren

Trea

tmen

t so

ught

fro

m h

ealth

fa

cility

pr

ovid

er

Anti-

biot

ic pr

ovid

ed

% o

f U5

child

ren

Num

ber

of ca

ses

% o

f cas

esN

umbe

r of

case

s%

of U

5 ch

ildre

nN

umbe

r of

child

ren

23%

2.5%

73%

45%

1%13

%82

%32

%

1Ba

din

390

,378

1

,414

,138

1

,804

,516

2

41,8

05

6 1

4,50

8 7

6 3

,482

78

11,

316

55,

857

6,0

45

40,

776

18,

349

408

3

0,95

1 2

5,25

6 7

,981

2Da

du 3

83,1

69

1,1

67,0

97

1,5

50,2

66

207

,736

4

8,3

09

78

1,8

28

96 7

,977

4

7,98

7 5

,193

3

5,03

0 1

5,76

4 3

50

26,

590

21,

698

6,8

56

3G

hotk

i 4

03,5

38

1,2

42,7

80

1,6

46,3

18

220

,607

5

11,

030

63

4,0

81

97 1

0,69

9 5

0,96

0 5

,515

3

7,20

1 1

6,74

0 3

72

28,

238

23,

042

7,2

81

4H

yder

abad

1,8

32,7

55

366

,708

2

,199

,463

2

94,7

28

9 2

6,52

6 9

3 1

,857

79

20,

955

68,

082

7,3

68

49,

700

22,

365

497

3

7,72

5 3

0,78

4 9

,728

5Ja

coba

bad

297

,127

7

09,1

70

1,0

06,2

97

134

,844

23

31,

014

86

4,3

42

100

31,

014

31,

149

3,3

71

22,

739

10,

232

227

1

7,26

0 1

4,08

4 4

,451

6Ja

msh

oro

434

,187

5

58,9

55

993

,142

1

33,0

81

9 1

1,97

7 7

0 3

,593

71

8,5

04

30,

742

3,3

27

22,

441

10,

099

224

1

7,03

4 1

3,90

0 4

,392

7Ka

mba

r Sha

hdad

kot

397

,564

9

43,4

78

1,3

41,0

42

179

,700

5

8,9

85

60

3,5

94

95 8

,536

4

1,51

1 4

,492

3

0,30

3 1

3,63

6 3

03

23,

002

18,

769

5,9

31

8Ka

rach

i14

,910

,352

1

,141

,169

16

,051

,521

2,

150,

904

11 2

36,5

99

85

35,

490

100

236

,599

4

96,8

59

53,

773

362

,707

1

63,2

18

3,6

27

275

,316

2

24,6

58

70,

992

9Ka

shm

ore

@Ka

ndhk

ot 2

53,6

13

835

,556

1

,089

,169

1

45,9

49

6 8

,757

9

0 8

76

91 7

,969

3

3,71

4 3

,649

2

4,61

1 1

1,07

5 2

46

18,

681

15,

244

4,8

17

10Kh

airpu

r 7

75,8

50

1,6

28,4

84

2,4

04,3

34

322

,181

5

16,

109

44

9,0

21

100

16,

109

74,

424

8,0

55

54,

329

24,

448

543

4

1,23

9 3

3,65

1 1

0,63

4

11La

rkan

a 7

01,6

37

822

,754

1

,524

,391

2

04,2

68

21 4

2,89

6 8

6 6

,005

65

27,

883

47,

186

5,1

07

34,

446

15,

501

344

2

6,14

6 2

1,33

5 6

,742

12M

atiar

i 1

82,5

90

586

,759

7

69,3

49

103

,093

6

6,1

86

95

309

89

5,5

05

23,

814

2,5

77

17,

385

7,8

23

174

1

3,19

6 1

0,76

8 3

,403

13M

irpur

khas

425

,752

1

,080

,124

1

,505

,876

2

01,7

87

7 1

4,12

5 4

3 8

,051

96

13,

560

46,

613

5,0

45

34,

027

15,

312

340

2

5,82

9 2

1,07

6 6

,660

14N

aush

ahro

Firo

ze 3

79,8

02

1,2

32,5

71

1,6

12,3

73

216

,058

11

23,

766

67

7,8

43

81 1

9,25

1 4

9,90

9 5

,401

3

6,43

4 1

6,39

5 3

64

27,

655

22,

567

7,1

31

15Sa

ngha

r 5

88,4

05

1,4

68,6

52

2,0

57,0

57

275

,646

17

46,

860

73

12,

652

100

46,

860

63,

674

6,8

91

46,

482

20,

917

465

3

5,28

3 2

8,79

1 9

,098

16Sh

ahee

d Be

na-

zirab

ad 4

89,3

37

1,1

23,5

10

1,6

12,8

47

216

,121

11

23,

773

55

10,

698

95 2

2,58

5 4

9,92

4 5

,403

3

6,44

5 1

6,40

0 3

64

27,

664

22,

573

7,1

33

17Sh

ikarp

ur 3

03,2

49

928

,232

1

,231

,481

1

65,0

18

8 1

3,20

1 7

8 2

,904

97

12,

805

38,

119

4,1

25

27,

827

12,

522

278

2

1,12

2 1

7,23

6 5

,447

18Su

jawal

85,

705

696

,262

7

81,9

67

104

,784

-

38

- -

- 2

4,20

5 2

,620

1

7,67

0 7

,951

1

77

13,

412

10,

944

3,4

58

19Su

kkur

720

,115

7

67,7

88

1,4

87,9

03

199

,379

8

15,

950

87

2,0

74

90 1

4,35

5 4

6,05

7 4

,984

3

3,62

1 1

5,13

0 3

36

25,

521

20,

825

6,5

81

20Ta

ndo

Allah

yar

261

,793

5

75,0

94

836

,887

1

12,1

43

9 1

0,09

3 6

0 4

,037

81

8,1

75

25,

905

2,8

04

18,

911

8,5

10

189

1

4,35

4 1

1,71

3 3

,701

21Ta

ndo

Muh

amm

ad

Khan

142

,050

5

35,1

78

677

,228

9

0,74

9 7

6,3

52

71

1,8

42

74 4

,701

2

0,96

3 2

,269

1

5,30

3 6

,886

1

53

11,

616

9,4

79

2,9

95

22Th

arpa

rkar

132

,071

1

,517

,590

1

,649

,661

2

21,0

55

7 1

5,47

4 4

3 8

,820

97

15,

010

51,

064

5,5

26

37,

276

16,

774

373

2

8,29

5 2

3,08

9 7

,296

23Th

atta

176

,058

8

03,7

59

979

,817

1

31,2

95

9 1

1,81

7 2

4 8

,981

82

9,6

90

30,

329

3,2

82

22,

140

9,9

63

221

1

6,80

6 1

3,71

4 4

,333

24U

mer

kot

243

,361

8

29,7

85

1,0

73,1

46

143

,802

9

12,

942

61

5,0

47

85 1

1,00

1 3

3,21

8 3

,595

2

4,24

9 1

0,91

2 2

42

18,

407

15,

020

4,7

46

24,9

10,4

58

22,9

75,5

93

47,8

86,0

51

6,41

6,73

1 6

17,2

51

147

,428

5

71,0

59

1,4

82,2

65

160

,418

1

,082

,053

4

86,9

24

10,8

21

821

,342

6

70,2

15

211

,788



Tabl

e 21

: Sin

dh P

rovi

nce

- Pub

lic E

xpen

ditu

re o

n al

l typ

es o

f dru

gs a

nd m

edic

ines

Dist

ricts

Publ

ic E

xpen

ditu

re o

n pr

ocur

emen

t of a

ll ty

pes

of d

rugs

and

med

icin

es (R

s.m

illio

n)

2013

-14

2014

-15

2015

-16

Per

capi

ta

(Rup

ees)

2016

-17

2017

-18

Budg

etAc

tual

Budg

etAc

tual

Budg

etAc

tual

Budg

etAc

tual

Budg

et

1Ba

din

103

1

28

128

1

31

160

1

34

74.

2

2Da

du 1

11

145

1

42

144

1

77

177

1

13.9

3G

hotk

i 1

60

177

2

00

153

2

10

179

1

08.9

4H

yder

abad

1,5

13

1,8

93

1,5

85

1,6

94

1,7

25

2,5

68

1,1

67.4

2

,621

3

,129

2

,343

5Ja

coba

bad

20

21

25

26

31

30

29.

7

6Ja

msh

oro

187

2

13

233

2

37

292

2

63

264

.8

7Ka

mba

r Sha

hdad

kot

24

28

30

29

37

27

20.

1

8Ka

rach

i 1

,575

1

,657

2

,640

2

,231

2

,449

2

,250

1

40.2

3

,142

2

,991

3

,370

9Ka

shm

ore

@Ka

ndhk

ot 1

4 1

4 1

7 1

6 2

2 2

2 1

9.8

10Kh

airpu

r 2

49

270

3

06

316

3

21

417

1

73.3

11La

rkan

a 3

98

432

4

98

500

6

22

611

4

00.8

8

35

783

8

32

12M

atiar

i 2

5 3

1 3

1 3

2 3

9 3

6 4

7.3

13M

irpur

khas

54

61

67

74

83

81

53.

9

14N

aush

ahro

Firo

ze 4

6 5

1 5

7 5

8 7

1 7

1 4

4.2

15Sa

ngha

r 3

7 4

6 4

7 5

1 5

8 5

8 2

8.3

16Sh

ahee

d Be

nazir

abad

306

3

70

439

4

41

549

5

18

321

.3

757

7

97

718

17Sh

ikarp

ur 5

7 7

3 7

1 8

6 8

9 8

3 6

7.3

18Su

jawal

-

-

-

-

-

-

-

19Su

kkur

87

109

1

02

124

2

72

263

1

76.5

8

44

882

8

84

20Ta

ndo

Al

lahya

r 3

5 6

5 4

3 7

5 6

4 6

4 7

6.6

21Ta

ndo

Muh

amm

ad

Khan

60

66

75

76

94

74

109

.9

22Th

arpa

rkar

28

36

?

49

44

117

7

1.0

23Th

atta

98

103

1

23

124

1

53

157

1

59.9

24U

mer

kot

110

1

34

144

1

80

184

1

84

171

.1

5,2

97

6,1

23

7,0

05

6,8

47

7,7

47

8,3

83

175

.1

8,1

99

8,5

82

8,1

47

Sour

ce: G

over

nmen

t’s C

ompu

teri

sed

Budg

etin

g an

d Ac

coun

ting

Syst

em -

Fina

nce

Dep

artm

ent a

nd A

ccou

ntin

g O

ffice

s



Tabl

e 22

: Sin

dh P

rovi

nce

- Qua

ntit

ies

proc

ured

for

the

trea

tmen

t of

Dia

rrho

ea a

nd P

neum

onia

Dist

ricts

ORS

(Sac

hett

s)Zn

ic (S

yrup

) - b

ottle

Amox

illin

(Syr

up) -

bot

tle

125m

g an

d 25

0mg

(Ave

rage

)O

RS (S

ache

tts)

Amox

illin

(Syr

up) -

bot

tle

125m

g an

d 25

0mg

(Ave

rage

)Zi

nc (S

yrup

) - b

ottle

sO

RS (S

ache

tts)

ORS

(Sac

hett

s)Zn

ic (S

yrup

) - b

ottle

ORS

(Sac

hett

s)Zn

ic (S

yrup

) - b

ottle

(p

urch

ased

in

2016

-17)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

1Ba

din

200,

000

5.76

1.2

60

000

19.0

1.1

15

0,00

055

.0 8

.3

9,00

06.

6 0

.1

72,

000

39.0

2.8

0

22.0

-

23,

000

6.6

0.2

20

,000

6.6

0.1

2Da

du15

0,00

05.

76 0

.9

6500

019

.0 1

.2

80,0

0055

.0 4

.4

90,0

006.

6 0

.6

72,

000

39.0

2.8

10

0,00

022

.0 2

.2

62,

000

6.6

0.4

6.

6 -

4,

410

22.0

0.1

3G

hotk

i80

,000

5.76

0.5

55

000

19.0

1.0

10

0,00

055

.0 5

.5

100,

000

6.6

0.7

1

00,0

00

39.0

3.9

0

22.0

-

23,

000

6.6

0.2

6.

6 -

2,

450

22.0

0.1

4H

yder

abad

60,0

005.

76 0

.3

5000

019

.0 1

.0

40,0

0055

.0 2

.2

100,

000

6.6

0.7

5

0,00

0 39

.0 2

.0

022

.0 -

1

60,8

00

6.6

1.1

6.

6 -

22

.0 -

5Ja

coba

bad

100,

000

5.76

0.6

25

000

19.0

0.5

72

,000

55.0

4.0

30

,000

6.6

0.2

1

5,00

0 39

.0 0

.6

30,0

0022

.0 0

.7

20,

000

6.6

0.1

20

,000

6.6

0.1

2,

058

22.0

0.0

6Ja

msh

oro

80,0

005.

76 0

.5

4000

019

.0 0

.8

50,0

0055

.0 2

.8

125,

000

6.6

0.8

-

39

.0 -

0

22.0

-

152

,000

6.

6 1

.0

20,0

006.

6 0

.1

22.0

-

7Ka

mba

r Sh

ahda

dkot

72,0

005.

76 0

.4

3000

019

.0 0

.6

40,0

0055

.0 2

.2

06.

6 -

5

0,00

0 39

.0 2

.0

022

.0 -

5

5,40

0 6.

6 0

.4

20,0

006.

6 0

.1

4,41

022

.0 0

.1

8Ka

rach

i5.

76 -

19

.0 -

55

.0 -

0

6.6

-

-

39.0

-

022

.0 -

2

18,0

00

6.6

1.4

6.

6 -

22

.0 -

9Ka

shm

ore

@Ka

ndhk

ot38

200

5.76

0.2

16

000

19.0

0.3

30

,440

55.0

1.7

15

0,00

06.

6 1

.0

50,

000

39.0

2.0

10

0,00

022

.0 2

.2

4,0

00

6.6

0.0

6.

6 -

2,

058

22.0

0.0

10Kh

airpu

r22

4,16

05.

76 1

.3

1220

0019

.0 2

.3

152,

500

55.0

8.4

0

6.6

-

150

,000

39

.0 5

.9

022

.0 -

6

8,20

0 6.

6 0

.5

6.6

-

22.0

-

11La

rkan

a18

0,00

05.

76 1

.0

19.0

-

100,

000

55.0

5.5

12

5,00

06.

6 0

.8

9,0

00

39.0

0.4

0

22.0

-

30,

000

6.6

0.2

20

,000

6.6

0.1

3,

920

22.0

0.1

12M

atiar

i15

,000

5.76

0.1

20

000

19.0

0.4

60

,000

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Sour

ce: P

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Bure

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f Sta

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s



Distr

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Publi

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eDi

strict

Proc

urem

ent -

by C

EOs

2014

-15

2015

-16

2016

-17

Per

capit

a (Ru

pees

)OR

S (Sa

chet

ts)Zn

ic (Sy

rup)

- bot

tleAm

oxilli

n (Sy

rup)

- bot

tle

125m

g and

250m

g (Av

erag

e)OR

S (Sa

chet

ts)Zn

ic (Sy

rup)

- bot

tleAm

oxilli

n (Sy

rup)

- bot

tle

125m

g and

250m

g (Av

erag

e)

Budget

Actual

Budget

Actual

Budget

Actual

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Tota l (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

1At

tock

58

68

78

83

265

132

69.8

2Ba

haw

alnag

ar 21

4 22

9 19

7 23

1 59

0 20

1 67

.3

3Ba

haw

alpur

699

723

990

845

1,54

1 1,

239

337.7

4Ba

kkar

146

132

148

132

244

121

73.1

5Ch

akw

al 31

39

45

89

19

0 11

8 79

.1

6Ch

inio

t 67

65

74

77

17

9 82

59

.8

7De

ra G

hazi

Khan

143

214

163

303

597

475

165.4

8Fa

isalab

ad 65

5 76

3 1,

217

1,39

6 2,

163

1,93

1 24

5.2

9G

ujra

nwala

187

222

265

422

970

596

118.8

10G

ujra

t -

25

86

134

314

245

88.9

11H

afiza

bad

0 0

0 2

83

71

60.9

12Jh

ang

176

185

284

254

524

178

64.9

13Jh

elum

- -

- -

270

151

123.5

14Ka

sur

122

250

71

189

269

172

49.6

15Kh

enaw

al 68

58

11

2 84

29

4 75

25

.8

16Kh

usha

b 82

81

97

10

0 23

1 91

70

.7

17La

hore

6,16

5 6,

230

6,18

3 8,

508

12,51

4 10

,398

934.6

18La

yyah

66

59

64

67

22

6 13

1 72

.0

19Lo

dhra

n 56

49

49

54

21

6 92

53

.9

20M

andi

Bah

audd

in 37

42

58

58

18

0 75

47

.1

21M

ianw

ali 74

51

96

88

27

8 12

4 80

.3

22M

ulta

n 89

3 1,

132

1,59

5 1,

510

2,10

3 1,

666

351.1

23M

uzaff

arga

rh 12

8 16

1 23

6 30

4 55

3 25

0 57

.8

24N

akan

a Sa

hib

116

95

90

111

207

117

86.6

Tab

le 2

4: P

unja

b Pr

ovin

ce - P

ublic

Exp

endi

ture

on

all t

ypes

of d

rugs

and

med

icin

es a

nd q

uant

ities

pro

cure

d fo

r the

trea

tmen

t of D

iarr

hoea

and

Pne

umon

ia



Distr

icts

Publi

c Exp

endit

ure o

n pro

cure

men

t of a

ll typ

es of

drug

s and

med

icine

s (Rs

.milli

on)

IRMNC

H Pr

ogra

mm

eDi

strict

Proc

urem

ent -

by C

EOs

2014

-15

2015

-16

2016

-17

Per

capit

a (Ru

pees

)OR

S (Sa

chet

ts)Zn

ic (Sy

rup)

- bot

tleAm

oxilli

n (Sy

rup)

- bot

tle

125m

g and

250m

g (Av

erag

e)OR

S (Sa

chet

ts)Zn

ic (Sy

rup)

- bot

tleAm

oxilli

n (Sy

rup)

- bot

tle

125m

g and

250m

g (Av

erag

e)

Budget

Actual

Budget

Actual

Budget

Actual

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Tota l (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

Qty

Unit Price

Total (Rs.m)

25N

arow

al 14

6 41

15

1 12

8 35

6 14

8 86

.5

26O

kara

120

40

107

152

377

204

67.2

27Pa

kpat

tan

0 0

0 2

124

94

51.6

28Ra

him

Yar

Kha

n 21

8 21

2 30

9 35

9 67

4 54

7 11

3.6

29Ra

janpu

r 12

2 57

11

3 11

0 17

1 12

4 62

.2

30Ra

walp

indi

1,10

4 1,

267

1,26

5 1,

439

1,72

4 1,

624

300.3

31Sa

hiw

al 55

53

95

10

0 47

5 27

0 10

7.4

32Sa

rgod

ha 13

0 18

5 21

7 34

8 64

0 38

3 10

3.4

33Sh

eikh

upur

a 20

0 10

8 21

7 20

0 54

5 18

5 53

.5

34Si

alkot

35

58

130

144

469

419

107.6

35To

ba T

ek S

ingh

73

20

101

80

237

130

59.3

36Ve

hari

100

58

209

209

410

200

69.0

12,48

7 12

,975

15,11

1 18

,312

31,19

9 23

,057

209.6

5,4

84,00

0 9.3

9 51

.5 3,1

53,00

035

110.4

6,6

66,50

020

133.3

1,

700,0

00

9.39

16.0

1,300

,000

35 45

.5 5,3

00,00

0 20

106.0

Sour

ce: G

over

nmen

t’s C

ompu

teris

ed B

udge

ting

and

Acco

untin

g Sy

stem

- Fi

nanc

e D

epar

tmen

t and

Acc

ount

ing

Offi

ces

and

Dep

artm

ent o

f hea

lth a

nd v

ertic

al h

ealth

pro

gram

mes



Tab

le 2

5: B

aloc

hist

an P

rovi

nce

- Est

imat

ed U

nder

5 P

opul

atio

n an

d D

isea

se B

urde

n

Dist

ricts

Pop

ulat

ion

- Cen

sus (

2017

)

Und

er 5

Ch

ildre

n (1

3.4%

of

popu

la-

tion)

PSLM

201

4-15

PDHS

(201

2-13

)

Ur

ban

Rura

lTo

tal

Diar

rhoe

a in

last

30

day

s

Trea

t -m

ent

in

priva

te

heal

th

facil

ity

Trea

t -m

ent i

n pu

blic

heal

th

facil

ity

Whe

re O

RS w

as

give

n

Diar

raho

ea

in U

5 ch

ildre

n - 2

we

eks p

rior

surv

ey

Diar

-rh

oea

with

bl

ood

Trea

t-m

ent

soug

ht

from

he

alth

fa

cility

pr

ovid

er

ORS

pr

o-vid

ed

Zinc

pr

o-vid

-ed

Pneu

-m

onia

U5

chi

l-dr

en

Trea

tmen

t so

ught

fro

m

heal

th

facil

ity

prov

ider

An-

ti-bi

-ot

ic pr

o-vid

ed

% o

f U5

child

ren

Num

ber

of c

ases

% o

f ca

ses

Num

ber

of c

ases

% o

f U5

chi

l-dr

en

Num

ber

of c

hil -

dren

12%

1.2%

43%

42%

1%10

%54

%23

%

1Aw

aran

34,

244

87,

436

121

,680

1

6,30

5 22

3,5

87

37 2

,260

72

2,5

83

1,9

73

196

8

56

355

7

1

,582

8

46

195

2Ba

rakh

an 1

2,17

6 1

59,3

80

171

,556

2

2,98

9 7

1,6

09

27 1

,175

97

1,5

61

2,7

82

276

1

,207

5

01

10

2,2

30

1,1

93

274

3Ch

agha

i 1

6,31

9 2

09,6

89

226

,008

3

0,28

5 9

2,7

26

15 2

,317

76

2,0

71

3,6

64

363

1

,590

6

60

13

2,9

38

1,5

72

361

4De

ra B

ugti

99,

301

213

,302

3

12,6

03

41,

889

18 7

,540

19

6,1

07

99 7

,465

5

,069

5

03

2,2

00

913

1

8 4

,063

2

,174

5

00

5Ga

wada

r 1

61,5

99

101

,915

2

63,5

14

35,

311

7 2

,472

21

1,9

53

100

2,4

72

4,2

73

424

1

,854

7

70

15

3,4

25

1,8

32

421

6Ha

rnai

24,

554

72,

463

97,

017

13,

000

12 1

,560

59

640

79

1,2

32

1,5

73

156

6

83

283

5

1

,261

6

75

155

7Ja

fara

bad

158

,005

3

55,8

08

513

,813

6

8,85

1 30

20,

655

97 6

20

100

20,

655

8,3

31

826

3

,616

1

,500

2

9 6

,679

3

,573

8

22

8Ka

achi

/Jhal

mag

si 7

,825

1

41,4

00

149

,225

1

9,99

6 10

2,0

00

12 1

,760

94

1,8

80

2,4

20

240

1

,050

4

36

8

1,9

40

1,0

38

239

9Ka

chhi

(Bol

an)

34,

432

202

,598

2

37,0

30

31,

762

17 5

,400

0

5,4

00

100

5,4

00

3,8

43

381

1

,668

6

92

13

3,0

81

1,6

48

379

10Ka

lat

72,

458

339

,774

4

12,2

32

55,

239

20 1

1,04

8 35

7,1

81

86 9

,501

6

,684

6

63

2,9

01

1,2

04

23

5,3

58

2,8

67

659

11Ke

ch (T

urba

t) 3

02,1

36

606

,980

9

09,1

16

121

,822

20

24,

364

50

12,

182

75 1

8,27

3 1

4,74

0 1

,462

6

,397

2

,655

5

1 1

1,81

7 6

,322

1

,454

12Kh

aran

44,

655

111

,497

1

56,1

52

20,

924

6 1

,255

50

628

10

0 1

,255

2

,532

2

51

1,0

99

456

9

2

,030

1

,086

2

50

13Kh

uzda

r 2

77,1

36

525

,071

8

02,2

07

107

,496

20

21,

499

68 6

,880

89

19,

134

13,

007

1,2

90

5,6

45

2,3

43

45

10,

427

5,5

78

1,2

83

14Ki

lla A

bdul

lah

149

,342

6

08,2

36

757

,578

1

01,5

15

8 8

,121

93

568

95

7,7

15

12,

283

1,2

18

5,3

31

2,2

12

43

9,8

47

5,2

68

1,2

12

15Ki

lla S

aifu

llah

62,

743

280

,071

3

42,8

14

45,

937

10 4

,594

93

322

94

4,3

18

5,5

58

551

2

,412

1

,001

1

9 4

,456

2

,384

5

48

16Ko

hlu

17,

426

196

,924

2

14,3

50

28,

723

5 1

,436

78

316

73

1,0

48

3,4

75

345

1

,508

6

26

12

2,7

86

1,4

91

343

17Le

sbel

a 2

79,2

44

295

,048

5

74,2

92

76,

955

7 5

,387

39

3,2

86

96 5

,171

9

,312

9

23

4,0

41

1,6

77

32

7,4

65

3,9

94

919

18Le

hri

16,

608

101

,438

1

18,0

46

15,

818

20 3

,164

5

0 1

,582

75

2,3

73

1,9

14

190

8

31

345

7

1

,534

8

21

189

19Lo

rala

i 6

4,93

8 3

32,4

62

397

,400

5

3,25

2 5

2,6

63

74 6

92

82 2

,183

6

,443

6

39

2,7

96

1,1

61

22

5,1

65

2,7

63

636

20M

astu

ng 3

5,12

9 2

31,3

32

266

,461

3

5,70

6 42

14,

996

41 8

,848

96

14,

397

4,3

20

428

1

,875

7

78

15

3,4

63

1,8

53

426

21M

usak

hel

14,

138

152

,879

1

67,0

17

22,

380

4 8

95

71 2

60

75 6

71

2,7

08

269

1

,175

4

88

9

2,1

71

1,1

61

267

22Na

sirab

ad 9

6,59

1 3

93,9

47

490

,538

6

5,73

2 17

11,

174

95 5

59

100

11,

174

7,9

54

789

3

,452

1

,433

2

8 6

,376

3

,411

7

85



Dist

ricts

Pop

ulat

ion

- Cen

sus (

2017

)

Und

er 5

Ch

ildre

n (1

3.4%

of

popu

la-

tion)

PSLM

201

4-15

PDHS

(201

2-13

)

Ur

ban

Rura

lTo

tal

Diar

rhoe

a in

last

30

day

s

Trea

t -m

ent

in

priva

te

heal

th

facil

ity

Trea

t-m

ent i

n pu

blic

heal

th

facil

ity

Whe

re O

RS w

as

give

n

Diar

raho

ea

in U

5 ch

ildre

n - 2

we

eks p

rior

surv

ey

Diar

-rh

oea

with

bl

ood

Trea

t-m

ent

soug

ht

from

he

alth

fa

cility

pr

ovid

er

ORS

pr

o-vid

ed

Zinc

pr

o-vid

-ed

Pneu

-m

onia

U5

chi

l-dr

en

Trea

tmen

t so

ught

fro

m

heal

th

facil

ity

prov

ider

An-

ti-bi

-ot

ic pr

o-vid

ed

23Nu

shki

46,

386

132

,410

1

78,7

96

23,

959

1 2

40

35 1

56

100

240

2

,899

2

88

1,2

58

522

1

0 2

,324

1

,243

2

86

24Pa

njgu

r 8

0,32

4 2

36,0

61

316

,385

4

2,39

6 20

8,4

79

50

4,2

40

75 6

,359

5

,130

5

09

2,2

26

924

1

8 4

,112

2

,200

5

06

25Pi

shin

143

,142

5

93,3

39

736

,481

9

8,68

8 13

12,

829

81 2

,438

87

11,

162

11,

941

1,1

84

5,1

83

2,1

51

41

9,5

73

5,1

21

1,1

78

26Q

uetta

1,

001,

205

1,2

74,4

94

2,2

75,6

99

304

,944

9

27,

445

66 9

,331

98

26,

896

36,

898

3,6

59

16,

014

6,6

46

128

2

9,58

0 1

5,82

5 3

,640

27Sh

eran

i -

153

,116

1

53,1

16

20,

518

13 2

,667

60

1,0

67

94 2

,507

2

,483

2

46

1,0

77

447

9

1

,990

1

,065

2

45

28Si

bi 6

4,42

7 7

1,14

5 1

35,5

72

18,

167

12 2

,180

10

1,9

62

100

2,1

80

2,1

98

218

9

54

396

8

1

,762

9

43

217

29So

hbat

pur

12,

867

187

,671

2

00,5

38

26,

872

20 5

,374

5

0 2

,687

75

4,0

31

3,2

52

322

1

,411

5

86

11

2,6

07

1,3

95

321

30W

ashu

k 2

1,87

2 1

54,3

34

176

,206

2

3,61

2 16

3,7

78

47 2

,002

82

3,0

98

2,8

57

283

1

,240

5

15

10

2,2

90

1,2

25

282

31Zh

ob 4

6,24

8 2

64,2

96

310

,544

4

1,61

3 9

3,7

45

34 2

,472

74

2,7

71

5,0

35

499

2

,185

9

07

17

4,0

36

2,1

60

497

32Zi

arat

3,4

06

157

,016

1

60,4

22

21,

497

14 3

,010

81

572

94

2,8

29

2,6

01

258

1

,129

4

68

9

2,0

85

1,1

16

257

3,

400,

876

8,9

43,5

32

12,3

44,4

08

1,6

54,1

51

227,8

93

92,

459

204

,607

2

00,1

52

19,85

0 8

6,86

6 36

,049

695

16

0,45

3 8

5,84

2 19

,744

Sour

ce: P

akis

tan

Bure

au o

f Sta

tistic

s



Tabl

e 26

: Bal

ochi

stan

Pro

vinc

e - P

ublic

Exp

endi

ture

on

all t

ypes

of d

rugs

and

med

icin

es

Sour

ce: G

over

nmen

t’s C

ompu

teri

sed

Budg

etin

g an

d Ac

coun

ting

Syst

em -

Fina

nce

Dep

artm

ent a

nd A

ccou

ntin

g O

ffice

s an

d D

epar

tmen

t of h

ealth

and

ver

tical

hea

lth p

rogr

amm

es

Dis

tric

ts

Publ

ic E

xpen

ditu

re o

n pr

ocur

emen

t of a

ll ty

pes

of d

rugs

and

med

icin

es

(Rs.

mill

ion)

Proc

urem

ents

- by

MSD

Proc

urem

ent b

y LH

Ws

2014

-15

2015

-16

2016

-17

Per c

apita

(R

upee

s)O

RS (S

ache

tts)

Znic

(Syr

up) -

bot

tleAm

oxill

in (S

yrup

) - b

ottle

12

5mg

and

250m

g (A

vera

ge)

ORS

(Sac

hett

s)Zn

ic (S

yrup

) - b

ottle

Amox

illin

(Syr

up) -

bot

-tle

125

mg

and

250m

g (A

vera

ge)

Budg

etAc

tual

Budg

etAc

tual

Budg

etAc

tual

Qty

Uni

t Pr

ice

Tota

l (R

s.m

)Q

tyU

nit

Pric

eTo

tal

(Rs.

m)

Qty

Uni

t Pr

ice

Tota

l (R

s.m

)Q

tyU

nit

Pric

eTo

tal

(Rs.

m)

Qty

Uni

t Pr

ice

Tota

l (R

s.m

)Q

tyU

nit

Pric

eTo

tal

(Rs.

m)

Awar

an 1

6 -

21

- 2

1 -

173

.1

Bara

khan

11

- 1

4 -

14

- 8

1.8

Chag

hai

12

- 1

5 -

15

- 6

8.3

Dera

Bug

ti 2

3 -

29

- 2

9 -

94.

3

Gawa

dar

23

- 2

9 -

29

- 1

11.9

Harn

ai 1

9 -

25

- 2

5 -

260

.5

Jafa

raba

d 2

7 -

35

- 3

5 -

68.

3

Kaac

hi/Jh

alm

agsi

23

- 2

9 -

29

- 1

97.6

Kach

hi (B

olan

) 2

5 -

32

- 3

2 -

136

.2

Kala

t 2

7 -

35

- 3

5 -

85.

1

Kech

(Tur

bat)

28

- 3

7 -

37

- 4

0.2

Khar

an 2

6 -

34

1

34

- 2

15.8

Khuz

dar

31

- 4

1 -

41

- 5

0.8

Killa

Abd

ulla

h 2

7 -

35

- 3

5 -

46.

3

Killa

Sai

fulla

h 2

3 -

29

- 2

9 -

86.

0

Kohl

u 2

4 -

31

- 3

1 -

144

.1

Lesb

ela

31

- 4

1 -

41

- 7

0.9

Lehr

i -

- -

- -

- -

Lora

lai

28

- 3

7 -

37

- 9

1.9

Mas

tung

24

- 3

1 -

31

- 1

15.9

Mus

akhe

l 2

2 -

28

- 2

8 -

168

.1

Nasir

abad

28

- 3

7 -

37

- 7

4.4

Nush

ki 2

5 -

32

- 3

2 -

180

.6

Panj

gur

27

- 3

6 -

36

- 1

14.1

Pish

in 2

9 -

38

- 3

8 -

51.

5

Que

tta 5

51

1,2

68

717

1

,443

7

65

1,4

19

336

.0

Sher

ani

5

- 7

-

7

- 4

5.8

Sibi

28

- 3

7 -

37

- 2

69.3

Sohb

atpu

r -

- -

- -

- -



Regi

on P

opul

atio

n - C

ensu

s (2

017)

Und

er 5

Ch

ildre

n (1

3.4%

of

popu

la-

tion)

PSLM

201

4-15

PDH

S (2

012-

13)

U

rban

Rura

lTo

tal

Dia

rrho

ea

in la

st 3

0 da

ys

Trea

t-m

ent i

n pr

ivat

e he

alth

fa

cilit

y

Trea

tmen

t in

publ

ic h

ealth

fa

cilit

yW

here

ORS

w

as g

iven

Dia

rrah

oea

in U

5 ch

ildre

n - 2

w

eeks

prio

r su

rvey

Dia

r-rh

oea

with

bl

ood

Trea

tmen

t so

ught

fr

om

heal

th

faci

lity

prov

ider

ORS

pr

ovid

-ed

Zinc

pr

ovid

edPn

eum

onia

U

5 ch

ildre

n

Trea

tmen

t so

ught

fr

om h

ealth

fa

cilit

y pr

ovid

erAn

ti-bi

otic

pr

ovid

ed

21%

0.9%

67%

54%

3%9%

67%

33%

Isla

mab

ad 1

,014

,825

9

91,7

47

2,0

06,5

72

270

,166

5

13,

508

76

3,2

42

95

12

,833

5

5,38

4 2

,431

3

6,83

0 1

9,85

2 9

21

24,

045

16,

086

5,2

76

Regi

on

Pu

blic

Exp

endi

ture

on

proc

urem

ent o

f all

type

s of

dr

ugs

and

med

icin

es (R

s.m

illio

n)

Pr

ocur

emen

ts -

by D

HO

s an

d Ve

rtic

al H

ealth

Pro

gram

mes

2014

-15

2015

-16

2016

-17

ORS

(Sac

hett

s)Zn

ic (S

yrup

) - b

ottle

Amox

illin

(Syr

up) -

bot

tle 1

25m

g an

d 25

0mg

(Ave

rage

)

Budg

etAc

tual

Budg

etAc

tual

Budg

etAc

tual

Qty

Uni

t Pric

eTo

tal (

Rs.m

)Q

tyU

nit P

rice

Tota

l (Rs

.m)

Qty

Uni

t Pric

eTo

tal (

Rs.m

)

Isla

mab

ad 3

,454

3

,432

2

,426

1

,555

4

,906

7

,541

2

33,4

24

5.5

1.3

2

5,93

6 20

0.5

9

0,77

6 40

3.6

Tabl

e 27

: Fed

eral

Gov

ernm

ent

- Est

imat

ed U

nder

5 P

opul

atio

n an

d D

isea

se B

urde

n

Tabl

e 28

: Fed

eral

Gov

ernm

ent

- Pub

lic E

xpen

ditu

re o

n al

l typ

es o

f dru

gs a

nd m

edic

ines

Sour

ce: G

over

nmen

t’s C

ompu

teri

sed

Budg

etin

g an

d Ac

coun

ting

Syst

em

Sour

ce:a

Pak

ista

n Bu

reau

of S

tatis

tics

Was

huk

8

- 1

0 -

10

- 5

5.8

Zhob

25

- 3

2 -

32

- 1

04.0

Ziar

at 1

9 -

25

- 2

5 -

157

.5

1,2

14

1,2

68

1,5

80

1,4

44

1,6

28

1,4

19

131

.9

267,

348

5.76

1.5

1

01,3

12

24.5

2.5

2

83,2

32

40 1

1.3

115

,000

7

0.8

4

,000

24

.5 0

.1

25,0

00

55.6

1.4

Dis

tric

ts

Publ

ic E

xpen

ditu

re o

n pr

ocur

emen

t of a

ll ty

pes

of d

rugs

and

med

icin

es

(Rs.

mill

ion)

Proc

urem

ents

- by

MSD

Proc

urem

ent b

y LH

Ws

2014

-15

2015

-16

2016

-17

Per c

apita

(R

upee

s)O

RS (S

ache

tts)

Znic

(Syr

up) -

bot

tleAm

oxill

in (S

yrup

) - b

ottle

12

5mg

and

250m

g (A

vera

ge)

ORS

(Sac

hett

s)Zn

ic (S

yrup

) - b

ottle

Amox

illin

(Syr

up) -

bot

-tle

125

mg

and

250m

g (A

vera

ge)

Budg

etAc

tual

Budg

etAc

tual

Budg

etAc

tual

Qty

Uni

t Pr

ice

Tota

l (R

s.m

)Q

tyU

nit

Pric

eTo

tal

(Rs.

m)

Qty

Uni

t Pr

ice

Tota

l (R

s.m

)Q

tyU

nit

Pric

eTo

tal

(Rs.

m)

Qty

Uni

t Pr

ice

Tota

l (R

s.m

)Q

tyU

nit

Pric

eTo

tal

(Rs.

m)



Dis

tric

ts

Pop

ulat

ion

- Cen

sus

(201

7)

Und

er 5

Ch

ildre

n (1

3.4%

of

popu

la-

tion)

PSLM

201

4-15

PDH

S (2

012-

13)

Urb

anRu

ral

Tota

lD

iarr

hoea

in

last

30

days

Trea

t-m

ent

in p

ri-va

te

heal

th

faci

lity

Trea

t-m

ent i

n pu

blic

he

alth

fa

cilit

y

Whe

re O

RS w

as

give

n

Dia

rra-

hoea

in

U5

child

ren

- 2 w

eeks

pr

ior

surv

ey

Dia

r-rh

oea

with

bl

ood

Trea

t-m

ent

soug

ht

from

he

alth

fa

cilit

y pr

ovid

er

ORS

pr

ovid

-ed

Zinc

pr

ovid

-ed

Pneu

-m

onia

U

5 ch

il-dr

en

Trea

t-m

ent

soug

ht

from

he

alth

fa

cilit

y pr

ovid

er

Anti-

bi-

otic

pr

ovid

ed

28%

1.9%

23%

36%

2%23

%29

%46

%

1Ab

bott

abad

293

,137

1

,039

,775

1

,332

,912

1

78,6

10

2

3,5

72

56

1,5

72

85

3,0

36

49,

832

3,3

94

11,

461

4,0

69

264

4

1,79

5 1

2,24

6 5

,621

2Ba

nnu

49,

965

1,1

17,9

27

1,1

67,8

92

156

,498

13

20,

345

43 1

1,59

6 91

18,

514

43,

663

2,9

73

10,

042

3,5

65

231

3

6,62

0 1

0,73

0 4

,925

3Ba

ttag

ram

- 4

76,6

12

476

,612

6

3,86

6 13

8,3

03

40 4

,982

74

6,1

44

17,

819

1,2

13

4,0

98

1,4

55

94

14,

945

4,3

79

2,0

10

4Bu

ner

- 8

97,3

19

897

,319

1

20,2

41

14 1

6,83

4 48

8,7

54

84 1

4,14

0 3

3,54

7 2

,285

7

,716

2

,739

1

77

28,

136

8,2

44

3,7

84

5Ch

arsa

dda

270

,175

1

,346

,023

1

,616

,198

2

16,5

71

15 3

2,48

6 44

18,

192

90 2

9,23

7 6

0,42

3 4

,115

1

3,89

7 4

,934

3

20

50,

678

14,

849

6,8

15

6Ch

itral

49,

794

397

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4

47,3

62

59,

947

2 1

,199

17

995

77

923

1

6,72

5 1

,139

3

,847

1

,366

8

8 1

4,02

7 4

,110

1

,887

7D

.I. K

han

362

,231

1

,264

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1

,627

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2

18,0

36

15 3

2,70

5 70

9,8

12

93 3

0,41

6 6

0,83

2 4

,143

1

3,99

1 4

,967

3

22

51,

020

14,

949

6,8

62

8D

ir (L

ower

) 4

0,37

3 1

,395

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1

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1

92,4

13

4 7

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42

4,4

64

79 6

,080

5

3,68

3 3

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1

2,34

7 4

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2

84

45,

025

13,

192

6,0

55

9D

ir (U

pper

) 4

4,16

5 9

02,2

56

946

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1

26,8

20

7 8

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31

6,1

25

96 8

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3

5,38

3 2

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8

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2

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1

87

29,

676

8,6

95

3,9

91

10H

angu

102

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4

16,3

58

518

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6

9,51

9 10

6,9

52

53 3

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88

6,1

18

19,

396

1,3

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4,4

61

1,5

84

103

1

6,26

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arip

ur 1

26,5

77

876

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1

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1

34,4

06

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rak

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655

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hat

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23,7

28

993

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1

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11 1

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108

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1,57

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8

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3

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1

97

31,

164

9,1

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4,1

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14Ko

hist

an (L

ower

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202

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2

02,9

34

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193

5 1

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43

775

81

1,1

01

7,5

87

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1

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6

19

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hist

an (U

pper

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581

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5

81,7

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77,

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kki M

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876

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7

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101

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275

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1

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1

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at 6

95,9

00

1,6

13,6

70

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09,5

70

309

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6

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569

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4 94

17,

455

86,

346

5,8

80

19,

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7,0

50

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7

2,41

9 2

1,21

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nk 4

7,16

5 3

44,7

20

391

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5

2,51

3 16

8,4

02

75 2

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89

7,4

78

14,

651

998

3

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1

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7

8 1

2,28

8 3

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1

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26To

r Gar

h -

171

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1

71,3

95

22,

967

11 2

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76

606

92

2,3

24

6,4

08

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1

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5

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5,3

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1,5

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723

5,7

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34

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30,

523,

371

4,0

90,1

32

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70

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0,70

6

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1,14

7 7

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3

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93,

175

6,0

37

95

7,09

1 2

80,4

28

128

,716

Sour

ce: P

akis

tan

Bure

au o

f Sta

tistic

s

Tab

le 2

9: K

P Pr

ovin

ce -

Esti

mat

ed U

nder

5 P

opul

atio

n an

d D

isea

se B

urde

n



Dis

tric

ts

Publ

ic E

xpen

ditu

re o

n pr

ocur

emen

t of a

ll ty

pes

of d

rugs

and

med

icin

es (R

s.m

illio

n) -

Curr

ent

budg

et o

nly

Proc

urem

ents

- by

DH

Os

and

Vert

ical

Hea

lth P

rogr

amm

es

2014

-15

2015

-16

2016

-17

Per c

apita

(R

upee

s)O

RS (S

ache

tts)

Znic

(Syr

up) -

bot

tleAm

oxill

in (S

yrup

) - b

ottle

125

mg

and

250m

g (A

vera

ge)

Fina

l Bud

get

Actu

alFi

nal B

udge

tAc

tual

Budg

etAc

tual

Qty

Uni

t Pric

eTo

tal (

Rs.m

)Q

tyU

nit P

rice

Tota

l (Rs

.m)

Qty

Uni

t Pric

eTo

tal (

Rs.m

)

1Ab

bott

abad

74

74

28

59

35

44.

53

2Ba

nnu

- -

- -

- -

3Ba

ttag

ram

32

31

16

11

17

22.

09

4Bu

ner

96

95

72

92

58

102

.93

5Ch

arsa

dda

65

65

19

48

13

29.

70

6Ch

itral

44

44

17

29

20

65.

49

7D

.I. K

han

92

90

54

102

3

4 6

2.57

8D

ir (L

ower

) 2

8 2

6 1

9 3

2 1

4 2

2.16

9D

ir (U

pper

) 5

6 5

5 1

5 3

9 1

5 4

0.97

10H

angu

31

31

24

31

15

59.

02

11H

arip

ur 5

8 5

8 2

9 4

2 2

7 4

1.51

12Ka

rak

51

51

23

32

20

45.

87

13Ko

hat

53

52

33

44

78

44.

12

14Ko

hist

an (L

ower

) 3

3

-

24

- 1

17.5

8

15Ko

hist

an (U

pper

) -

- -

33

- 5

7.53

16La

kki M

arw

at 4

7 4

7 2

2 2

5 2

0 2

8.50

17M

alak

and

48

48

22

45

30

61.

80

18M

anse

hra

73

72

34

38

26

24.

26

19M

arda

n 9

6 9

4 4

6 5

2 4

2 2

1.76

20N

owsh

era

57

57

35

53

16

34.

91

21Pe

shaw

ar 2

21

211

7

6 7

1 1

39

16.

63

22Sh

angl

a 4

1 4

1 1

3 1

5 1

5 1

9.66

23Sw

abi

73

72

24

26

18

16.

04

24Sw

at 1

24

102

6

0 7

8 3

2 3

3.65

25Ta

nk 3

9 3

8 3

5 4

3 3

0 1

10.6

7

26To

r Gar

h 1

0 4

0

2

-

14.

28

1,5

11

1,4

61

715

1

,065

7

15

34.

90

2,1

45,4

60

5.94

12.

7 3

00,0

00

257.

5 9

00,0

00

4036

Tabl

e 30

: KP

Prov

ince

- Pu

blic

Exp

endi

ture

on

all t

ypes

of d

rugs

and

med

icin

es

Sour

ce: G

over

nmen

t’s C

ompu

teri

sed

Budg

etin

g an

d Ac

coun

ting

Syst

em -

Fina

nce

Dep

artm

ent a

nd A

ccou

ntin

g O

ffice

s an

d D

epar

tmen

t of h

ealth

and

ver

tical

hea

lth p

rogr

amm

es



Table 31: KP Province - Availability of Medicines for Treatment of Diarrhoea and Pneumonia - As on July 2017

Source: District Health Information System, Government of Khyber Pakhtunkhwa

District Syp. Amoxicillin/Ampicillin/ Cephradine

Inj. Ampicillin / Amoxicillin / Gentamycin / Ceftriaxone

ORS (Packets)

Abbottabad 40% 36% 92%

Bannu 77% 86% 100%

Battagram 5% 0% 85%

Bunner 75% 88% 69%

Charsadda 42% 88% 78%

Chitral 100% 88% 71%

D.I.Khan 50% 67% 71%

Dir Lower 42% 47% 47%

Dir Upper 0% 47% 94%

Hangu 54% 85% 54%

Haripur 91% 74% 91%

Karak 76% 65% 71%

Kohat 11% 100% 90%

Kohistan 25% 25% 19%

Lakki 100% N/A 100%

Malakand 65% 100% 60%

Mansehra 96% 85% 91%

Mardan 76% 95% 81%

Nowshera 24% 88% 100%

Peshawar 88% 85% 94%

Shangla 35% 90% 59

Swat 40% 28% 90%

Tank 0% 0% 100%

Torghar 89% 0% 100%



Dis

tric

ts P

opul

atio

n - C

ensu

s (2

017)

U

nder

5

Child

ren

(13.

4% o

f po

pula

-ti

on)

Publ

ic E

xpen

ditu

re o

n pr

ocur

emen

t of a

ll ty

pes

of d

rugs

an

d m

edic

ines

(Rs.

mill

ion)

- Cu

rren

t bud

get o

nly

Proc

urem

ents

by

the

DG

O

ffice

Pr

ocur

ed b

y LH

W P

ro-

gram

me

U

rban

Rura

lTo

tal

2014

-15

2015

-16

2016

-17

Per

capi

ta

(Ru-

pees

)

ORS

(Sac

hett

s)O

RS (S

ache

tts)

Bud- ge

tAc

tual

Bud- ge

tAc

tual

Bud- ge

tAc

tual

Qty

Uni

t Pr

ice

Tota

l (R

s.m

)Q

tyU

nit

Pric

eTo

tal

(Rs.

m)

Age

ncie

s

Baja

ur A

genc

y 9

7,54

0 8

89,4

33

986

,973

1

32,2

54

72,

000

6.0

0.4

Khyb

er A

genc

y 3

9,99

7 5

79,5

56

619

,553

8

3,02

0 8

,600

6.

0 0

.1

Kurr

am A

genc

y -

4

66,9

84

466

,984

6

2,57

6 1

5,00

0 6.

0 0

.1

Moh

man

d Ag

ency

4,3

61

538

,893

5

43,2

54

72,

796

4,8

00

6.0

0.0

N.W

azir

ista

n Ag

ency

-

254

,356

2

54,3

56

34,

084

10,

000

6.0

0.1

Ora

kzai

Age

ncy

-

679

,185

6

79,1

85

91,

011

18,

000

6.0

0.1

S.W

azir

stan

Age

cy -

1

,093

,684

1

,093

,684

1

46,5

54

6,5

00

6.0

0.0

141

,898

4,

502,

091

4,6

43,9

89

622

,295

Fron

tier

Reg

ions

FR P

esha

war

-

43,

114

43,

114

5,7

77

13,

000

6.0

0.1

FR K

ohat

-

68,

556

68,

556

9,1

87

FR B

annu

-

118

,578

1

18,5

78

15,

889

5,0

00

6.0

0.0

FR L

akki

Mar

wat

-

26,

359

26,

359

3,5

32

FR T

ank

-

64,

691

64,

691

8,6

69

FR D

.I. K

han

-

36,

389

36,

389

4,8

76

357

,687

3

57,6

87

47,

930

Tota

l 1

41,8

98

4,8

59,7

78

5,0

01,6

76

670

,225

82

.682

.4 8

7.8

86.

2 16

4.7

79.

3 3

2.93

1

52,9

00

0.9

1

68,0

00

6.0

1.0

Tabl

e 32

: Fed

eral

ly A

dmin

iste

red

Trib

al A

reas

(FA

TA) -

Est

imat

ed U

nder

5 P

opul

atio

n, P

ublic

Exp

endi

ture

and

Pro

cure

men

t of

Com

mod

itie

s fo

r tr

eatm

ent

of D

iarr

hoea

and

Pne

umon

ia

Sour

ce: P

akis

tan

Bure

au o

f Sta

tistic

s, G

over

nmen

t Bud

getin

g an

d Ac

coun

ting

Syst

em, a

nd D

epar

tmen

t of H

ealth

study on budgetary gap...12 study on budgetary gap analysis of diarrhoea and pneumonia commodities...

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