Contracting-in management to strengthen publicly financed primary health services--the experience of Punjab, Pakistan.

OBJECTIVES: In response to low utilization of primary health services in rural areas, the Government of Punjab contracted with a local non-governmental organization (NGO) to manage the basic health units in one district. METHODS: To evaluate the performance of the contractor, health facility surveys, household surveys, and routinely collected information were used to compare the experimental district (Rahim Yar Khan, RYK) with a contiguous and equally poor district (Bahawalpur, BWP). RESULTS: The evaluation found that contracting led to more than a 50% increase in out-patient visits in RYK compared to BWP. There was also increased satisfaction of the community with health services. Technical quality of care was equally poor in both districts and contracting also had little effect on the coverage of preventive services. The latter was likely the result of the NGO not being given managerial responsibility over vaccinators and other community health workers. CONCLUSIONS: Despite methodological limitations, this study found that contracting in management achieved important goals at the same cost to the Government, implying a large increase in efficiency. Contracting in management worked reasonably well in this context and has now been significantly expanded. The approach provides a plausible means for large-scale improvements of poorly performing primary health care systems.

She may reach a facility but will still die! An analysis of quality of public sector maternal health services, District Multan, Pakistan.

OBJECTIVE: To assess the availability, utilization and functional capacity of the public health delivery system in terms of human resources, equipment, supplies and health provider knowledge regarding management of obstetric complications. METHODS: A cross-sectional study was conducted in March 2003 for Multan's public health delivery system. A complete inventory of equipment, supplies, drugs, staff availability and knowledge of obstetric complications management were assessed. RESULTS: The number and distribution of public sector facilities serving a population of 3.2 million was well beyond the minimum requirement for basic obstetric care but fell short for comprehensive Emergency Obstetrical Care (EmOC). Utilization patterns were skewed to the tertiary facility for normal and complicated deliveries. Partograms were not available, magnesium sulphate was only available at the tertiary facility, while basic supplies like iron and folate tablets, broad spectrum antibiotics, oxytocics, gloves and sutures were not available at primary or secondary facilities. Knowledge scores regarding management of obstetric complications were less than average, especially among nurses at basic or comprehensive EmOC facilities. Intensity of labour pains (nurses 59%) at basic EmOC facility and cervical dilatation by doctors at basic and comprehensive facilities were the most frequent responses for monitoring in labour. CONCLUSION: Strengthening the four interlinked health system elements--human resources, access to, use and quality of services is essential though not sufficient.