District Health Profile Dera Ghazi Khan 2005
District Health Profile – Dera Ghazi Khan
Preface There has never been a more opportune time to work on improving maternal and newborn health in Pakistan. The country has an extensive health service network in place yet mortality and morbidity rates for mothers and newborn babies remain disturbingly high. Each year some 4.5 million women give birth and as many as 30,000 die of pregnancy-related causes. In response to this, USAID has launched the Pakistan Initiative for Mothers and Newborns, a five-year project to implement a full range of health interventions. The task has been entrusted to John Snow Inc. and partners. Adding further impetus, the Government of Pakistan has made public its support in providing quality health services to mothers and their newborns and its commitment to achieving the Millennium Development Goals which call for a reduction in the maternal mortality ratio by three quarters by 2015. Devolution of the health sector means that the District health system now has a vital part to play and responsibility to assume. As part of the preparation for district level planning, JSI has worked with District Health officials in compiling a series of district profiles. For successful future planning, it is vital that information is gathered at the district level. I would like to acknowledge CONTECH International Health Consultants, one of our partners, for taking the lead in preparing the district profiles. These profiles take a vital step closer to achieving all our aims.
Dr. Nabeela Ali Chief of Party Pakistan Initiative for Mothers and Newborns (PAIMAN)
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District Health Profile – Dera Ghazi Khan
Foreword The District Health Department of District D.G. Khan welcomes this initiative by PAIMAN. Devolution has brought with it many challenges to improve maternal and newborn health in Pakistan. Chief among them is the realization that health professionals working in the districts must take responsibility for their own planning and improvement of services. Vital in upgrading and coordinating services is data gathered using special indicators specific to districts. As such the production of health profiles at district level provides an invaluable tool for future planning. The District welcomes PAIMAN’s invitation to work with it in improving maternal health for all women and newborns. It is only through partnership at every level of the public and private sector that successes will be achieved.
Executive District Officer – Health District Dera Ghazi Khan
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District Health Profile – Dera Ghazi Khan
ACRONYMS
ADB
Asian Development Bank
ARI
Acute Respiratory Infections
AJK
Azad Jammu and Kashmir
ASV
Assistant Superintendent of Vaccination
BCG
Bacillus Calmette-Guérin
BHUs
Basic Health Units
CIA
Central Investigation Agency
CDC
Communicable Disease Control
CDD
Communication Disease Department
CDCO
Communicable Disease Control Officer
DCO
District Coordination Officer
DDO
Deputy District Officer
DDHO D.G. Khan
Deputy District Health Officer Dera Ghazi Khan
DHDC
District Health Development Center
DHEO
District Health Education Officer
DHMT
District Health Management Teams
DHQ
District Headquarter Hospital
DOH
District Officer Health
DMS
Deputy Medical Superintendent
DPT
Diphtheria-Tetanus-Pertussis vaccine
DTPS
District Team Problem Solving
DSV
District Superintendent of Vaccination
EDO
Executive District Officer
EmOC
Emergency Obstetric Care
EPI
Expanded Program on Immunization
FHT
Female Health Technician
FP
Family Planning
FANA
Federally Administered Northern Areas
FATA
Federally Administered Tribal Areas
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District Health Profile – Dera Ghazi Khan GNI
Gross National Income
GPs
General Practitioners
HMIS HIV/AIDS
Health Management Information System Human Immune Deficiency Virus/Acquired Immunodeficiency Syndrome
I/C
In-charge
IPC
Inter-Personal Communication
JSI
John Snow Inc.
LHV
Lady Health Visitor
LHWs
Lady Health Workers
MCEB
Mean Children Ever Born
MCH
Maternal and Child Health
MCHCs
Maternal and Child Health Centers
MNCH
Maternal, Neonatal and Child Health
MO MREO MS
Medical Officer Monitoring, Research and Evaluation Officer Medical Superintendent
NGO
Non Governmental Organization
NWFP
North West Frontier Province
PAIMAN PHC PMDC
Pakistan Initiative for Mothers and Newborns Primary Health Care Pakistan Medical and Dental Council
OBSI
Optimum Birth Spacing Initiative
OPV
Oral Polio Vaccine
OTA
Operation Theater Assistant
RHC
Rural Health Centers
RHSC-A
Reproductive Health Services Center -A
SMO
Senior Medical Officer
SNL
Saving Newborn Lives
TB
Tuberculosis
TB DOTS
Tuberculosis Directly Observed Treatment Short Strategy
TBA
Traditional Birth Attendant
TFR
Total Fertility Rate
THQ
Tehsil Headquarter Hospital
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District Health Profile – Dera Ghazi Khan TT UNICEF
Tetanus Toxoid United Nation’s International Children Fund
UNDP
United Nations Development Program
USAID
United States Agency for International Development
WMO
Woman Medical Officer
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District Health Profile – Dera Ghazi Khan
Preface Foreword Acronyms Table of Contents
Table of contents
I II III VI
Section 1 – Context
1
1.1 Introduction and Background 1.2 Pakistan Initiative for Mothers and Newborns (PAIMAN) 1.3 District Health Profiles
2 2 4
Section 2 – Introduction
5
2.1 District D.G. Khan at a Glance 2.2 District Health System (DHS)
6 7
Section 3 – Health System in District Dera Ghazi Khan
10
3.1 District Health Department 3.2 District Health Management Team (DHMT) 3.3 Demographic Information 3.4 Fertility Behavior 3.5 Health Indicators 3.6 Socio-economic Indicators 3.7 Health Facilities 3.8 Public Sector Health Manpower 3.9 District Health Development Center (DHDC) 3.10 Other Health Initiatives including Public Private Partnership 3.11 Population Welfare Department 3.12 Private clinics and hospitals 3.13 Non-Governmental Organizations (NGO)s
11 11 12 13 14 15 15 19 19 19 20 21 21
Section 4 – Budget Allocation and Utilization
22
Data Set 1 2 3 4
26 27 28 29 30
– List of Table Population structure of District D. G. Khan Demographic information on D.G. Khan, Punjab and Pakistan Comparison on indicators of Women and Fertility Behavior Comparison between basic indicators of D.G. Khan, Punjab and Pakistan 5 Comparison between health and nutrition indicators of D.G. Khan, Punjab and Pakistan
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31
District Health Profile – Dera Ghazi Khan 6
Comparison between social indicators of D.G. Khan, Punjab and Pakistan 7 Human Resource Position a. Human Resource Position at BHUs b. Human Resource Position at RHCs c. Human Resource Position at MCHCs d. Human Resource Position at THQ Taunsa 8 Public Health Sector Manpower 9 Training Profile of DHDC D.G. Khan for the year 2004 10 List of private sector health care providers 11 List of NGOs working in D.G. Khan 12 Budget Allocation for the DHD of D. G. Khan
32 33 33 33 34 35 37 40 41 50 56
List of Figures 1 PAIMAN districts 2 Three main determinants of DHS 3 Organizational Structure – District Health Department 4 Sex-wise population distribution 5 Urban-Rural population distribution 6 CPR and TFR comparison 7 Infant mortality rate comparison 8 Under 5 mortality rate 9 Staff Positions at BHUs 10 Comparison of district total budget with health sector budget 11 Category-wise health sector budget break-up 12 Percentage budget utilization (year-wise)
3 7 11 12 13 13 14 14 16 23 23 24
Annexures Annexure – A (TORs of DHMT) Annexure – B (Map of health facilities in District D.G. Khan) References
57 58 59 60
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District Health Profile – Dera Ghazi Khan
Section 1 – Context • •
Pakistan Initiative for Mothers and Newborns (PAIMAN) District Health Profiles
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District Health Profile – Dera Ghazi Khan
1. CONTEXT 1.1.
Introduction and Background Pakistan is the 6th most populous country in the world with a population of over 1541 million people. There is an alarmingly high Maternal Mortality Ratio of 350-4002 accompanied with a high infant mortality rate of 77/10001 and an under-five mortality
rate
of
101/1000
live
births3.
The
estimated
population growth rate is 1.9 % per annum , which projects that 2
Pakistan’s population would increase to 226 million by year 2025. The Total Fertility Rate (TFR) is 4.01 which ranks amongst the highest in the world and the second highest in the region.
1.2.
Pakistan Initiative for Mothers and Newborns (PAIMAN) The Pakistan Initiative for Mothers and Newborns (PAIMAN) is a five-year project funded by the United States Agency for International Development (USAID). The goal of the PAIMAN project is to reduce maternal, newborn, and child mortality in Pakistan, through viable and demonstrable initiatives in 10 districts of Pakistan.
The project is working on capacity
building of public and private health care providers and structures within health systems and communities. This strategy will ensure improvements and supportive linkages in the continuum of health care for women from the home to the hospital. The key partners in the implementation of PAIMAN are the Ministry of Health, the Ministry of Population Welfare, the Provincial
Health
Departments,
the
private
sector
and
consortium partners.
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District Health Profile – Dera Ghazi Khan
Strategic Objectives The project is based on the “Pathway to Care and Survival” framework. The five major strategic objectives are as follows: •
Increase awareness and promote positive maternal and neonatal health behaviours;
•
Increase access to and increase community involvement in maternal and child health services (including essential obstetric care) and ensure services are delivered through health and ancillary health services;
•
Improve service quality in both the public and private sectors, particularly related to management of obstetrical complications;
•
Increase capacity of MNH managers and care providers; and
•
Improve management and integration of health services at all levels.
The PAIMAN consortium is lead by John Snow Inc. (JSI), a USbased public health organization. JSI is joined by a number of international
and
local
organizations
to
form
a
strong,
professional team for implementing this project. PAIMAN
is
implemented districts
of
being in
10
Pakistan.
These
include
Rawalpindi,
Jhelum,
D.G.
Khan,
Figure 1: PAIMAN Districts
Khanewal
(Punjab); Sukkur, Dadu (Sindh);
Jaffarabad,
Lasbella
(Balochistan);
and Upper Dir, Buner (NWFP) refer in Figure 1.
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District Health Profile – Dera Ghazi Khan 1.3.
District Health Profiles The PAIMAN project has prepared district health profiles which contain relevant basic information for each of the program district. The purpose of preparing district profiles is to have a comprehensive document which can be used by District Health Management
Teams
(DHMT),
international
and
national
stakeholders and the PAIMAN team as a ready reference. Data collection instruments were developed by a team of eminent public health experts. Teams for data collection were trained for two days at the Contech International Head Office in Lahore. Data was collected, tabulated and analyzed by the Contech team.
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District Health Profile – Dera Ghazi Khan
Section 2 ‐ Introduction • District Dera Ghazi Khan at a Glance •
District Health System
page | 5
District Health Profile – Dera Ghazi Khan 2. INTRODUCTION 2.1.
District Dera Ghazi Khan at a Glance Dera Ghazi Khan Town was founded by Haji Khan, after the name of his son Ghazi Khan. In 1849, on the conclusion of the second Sikh War, the British Government declared it as a district. This district is situated in the southwestern part of Pakistan. The district consists of two major towns, i.e. DG Khan and Taunsa. The district is bounded on the north by the District Dera Ismail Khan (NWFP) and its adjoining area; on the east by Muzaffargarh and Layyah separating these two districts by river Indus; on the south by Rajanpur: and on the west by Musa Khail and Barkhan districts of Balochistan Province. The total area of the district is 119224 square kilometers. Geographically, District DG Khan is divided into two regions i.e. one is the mountainous area and the other is plane in the east. The western half of the district is covered by the hills of the Suleman Mountains. The mountains are formed of sandstone with occasional autocross of limestone. The plane area of the district can be subdivided into three natural tracts, namely, piedmont area, canal-well irrigated plane area and riverine area. The piedmont area stretches along base of hills. The cultivation in area depends upon flow of hill torrents. Canal-well irrigated plane area forms the intermediate zone between the piedmont area and riverine area. The cultivation of these areas depends upon the spills of the river Indus. The district headquarter D.G. Khan is connected with metalled roads to its Tehsil headquarters. A metalled road also connects this district with Musa Kheail, Barkhan, Loralai and other districts.
The district is served by railway line from Taunsa
Barrage to Rajanpur District across which it leads to Jacobbabad page | 6
District Health Profile – Dera Ghazi Khan District of Sindh.
DG Khan is linked with Lahore, Rawalpindi,
Karachi, Quetta and Peshawar through rail. There is also an airport, 26 kilometers away from the main DG Khan city. The annual mean minimum and maximum temperatures remain around 4.5ºC in January and above 42ºC in June respectively. The cultivation and livestock breeding are the main pursuits and the means of the livelihood of the rural and urban population. The other subsidiary means of occupation of the rural population is basket making, mat and shoe making. For administration of health services, District D. G. Khan is divided into two tehsils, i.e. D. G. Khan and Taunsa, and one tribal area. There are 59 union councils comprising of 51 rural and 8 urban. Their elected representatives formulate the Zilla (District) and Tehsil (Town) councils. Political constituencies include 2 national seats and 4 provincial seats in the legislative assemblies. 2.2.
District Health System (DHS) A
DHS
includes
the
Figure 2: Three main determinants of DHS
interrelated elements in the
district
that
contribute to health in homes,
educational
institutions, workplaces,
public
places
and
communities, as well as in
the
physical
and
psychosocial environment. based
on
A
DHS
Primary
Health Care (PHC) is a self-contained segment of the national
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District Health Profile – Dera Ghazi Khan health system. It includes all the relevant health care activities in the area, whether governmental or otherwise. It includes selfcare and all health care personnel and facilities, whether governmental or non-governmental, up to and including the hospital at the first referral level and the appropriate support services (laboratory, diagnostic and logistic support). As the decentralized part of the national health system, the DHS represents a manageable unit, which can integrate health programs by allowing top-down and bottom-up planning and is capable of coordinating government and private sector efforts. Following are the three main criteria for defining a DHS unit:
A clearly defined area with local administration and representation of different sectors and departments;
An area which can serve as a unit for decentralized intersectoral planning of health care; and
A network of health facilities with referral support.
The district is the basic administrative unit in Pakistan. The presence of district managers and supervisors led by the Executive District Officer (EDO) Health offers the opportunity to function
as
an
representatives
effective of
other
team
with
support
departments,
from
the
Non-Government
Organization (NGOs), private sector as well as the community. In any health system, there are three important elements that are highly interdependent, namely: the community, the health service delivery system and the environment where the first two elements operate. Figure 2 illustrates the interdependence of these elements.
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District Health Profile – Dera Ghazi Khan Environment This, for example, could be the context in which the health service delivery system operates. The contextual environment could
be
the
political
system,
health-care
policies
and
development policies. It could also include the socio-economic status or the physical environment, e.g. climatic conditions. All these elements have a bearing on the health status of the individual and the community, as well as the functioning of the health service delivery system. Health Service Delivery System This depicts how health facilities are distributed in the community, which could also have a bearing on coverage. Similarly, health services could be viewed in terms of their affordability and responsiveness to equity which contribute to the health status of the community. Community The characteristics of the society, such as culture, gender, beliefs
and
health-seeking
behavior,
together
with
the
environment and health service delivery system, determine the health status. It is worth mentioning that information included in district health profiles takes into account the broader perspective of district
health
system
conceptualized
in
the
preceding
paragraphs.
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District Health Profile – Dera Ghazi Khan
Section 3 – Health System in District Dera Ghazi Khan • • • • • • • • • • • • •
District Health Department
District Health Management Team (DHMT) Demographic Information Fertility Behavior Health Indicators Socio-economic Indicators Health Facilities Public Sector Health Manpower District Health Development Center Other Health Initiatives including Public Private Partnership (PPP) Population Welfare Department Private Clinics and Hospitals Non Governmental Organizations (NGOs)
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District Health Profile – Dera Ghazi Khan 3. Health System in District Dera Ghazi Khan 3.1.
District Health Department The health care delivery network is headed by Executive District Officer Health. He is assisted by the District Officer Health (DOH),
the
Medical
Headquarter
(DHQ)
Superintendent Hospital
and
(MS)
the
of
Tehsil
the
District
Headquarter
Hospitals (THQ), and the Program Director of the District Health Development Center (DHDC). There is an operational District Health
Management
Team
(DHMT)
in
the
district.
The
organizational structure of district health department is given below: Figure 3: Organizational structure district health department
Executive District Officer (Health)
M.S THQ Hospitals
Program Director DHDC
District Sanitary Inspector
3.2.
Assistant Entomologist
MS DHQ Hospital
District Superintendent Vaccination
District Officer (Health)
DDHOs
Principal Nursing School
District Coordinator NP for FP & PHC
Nursing Superintendant
AIHS
District Sanitary Vaccination
District Coordinator Women Health Project
District Health Management Team (DHMT) DHMT is part of the overall health sector reforms and decentralization of health services at the district level. The concept of DHMT allows efficient management of health facilities and services in the district for the promotion and support
for
the
preventative,
educative,
curative
and
rehabilitative health services in the district.
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District Health Profile – Dera Ghazi Khan On the recommendation of Project Director, Women Health Project Punjab and Secretary, Government of the Punjab, Health Department,
the
Development
Punjab
issued
a
Local
Government
notification
in
and
June
Rural
2005
for
establishment of DHMTs in all districts of Punjab. The composition of DHMT as was notified is given under 1:
1 2 3 4 5 6 7 8 9
3.3.
Composition of DHMT Executive District Officer-Health District Officer( Health) Deputy District Health Officer(Headquarter) Executive District Officer( Community Development) Executive District Officer (Education) District Officer Coordination as representative of District Coordination Officer Two nominees of District Nazim (One Nazim Union Council and one lady member of Zila Assembly) One representative of reputable NGO working in respective district Two co-opted members if required
Chairman Member Secretary Member Member Member Member Member Member
Demographic Information The current population of District D.G. Khan is 2,018,0005
with
Figure 4: Sex-wise Population Distribution 48%
52%
males and 48% females
Males
as shown in Figure 4. The
estimated
annual
population growth rate is 3.42%.
Overall
Females
52%
Literacy
rate is 36%6. Population density is 1457 persons per square kilometre. The average household size is 6.96.
1
Terms of Reference of this DHMT is annexed as annexure A.
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District Health Profile – Dera Ghazi Khan The percentage break-up
Figure 5: Rural Urban Population Distribution
of the rural and urban
14%
population is 86 and 145 respectively
showing
that most of the district
Rural
population lives in rural
Urban
areas as shown in Figure 5.
The
break
up
of
population may also be
86%
seen in Table 1. The crude death rate is 9 per 1000, which is higher than the national figure of 83 per 1000. The crude birth rate in D. G. Khan is 42.59 per 1000 as compared to 31 per 10003 at national level.
Table 2 gives more information on
demographic indicators.
3.4.
Fertility Behaviour In D. G. Khan, like the rest of the country, community social structures and belief systems are defined and dominated by men, which perpetuate gender imbalances and contribute to outcomes
in
40
behavior
and
reproductive Thus,
the
30
36
CPR
20
TFR
15 10 5
use remains low
0
although
27
25
contraceptive (27%)
36
35
fertility
health.
Figure 6: CPR and TFR Comparison
poor
6
Dera Ghazi Khan
4.7
Punjab
4
Pakistan
knowledge about contraceptives is high (76%)6 as shown in Figure 6. A considerable unmet need for family planning services exists, which has not been converted into effective page | 13
District Health Profile – Dera Ghazi Khan contraceptive usage; partly because of family dynamics of a male dominated society. Mean Children Ever Born (MCEB) to married women aged 15-49 are 3.11 in District D. G. Khan as compared to 2.32 in Punjab8. The Total Fertility Rate is 69 as compared to 4.78 in the province and 4.01 in the country as a whole. There is a growing commitment by both the provincial and district governments to review and reform the equity of service delivery.
Comparison of indicators on women and
fertility behaviours is given in Table 3. 3.5.
Health Indicators People, in general, are poor and experience high levels of mortality, morbidity and disability. An appropriately defined and maintained set of health
Figure 7: Infant Mortality Rate
indicators
provides
information
for
the
88
elaboration
of
a
86
relevant profile of the
84
population’s
health
82
situation. In District
80
D. G. Khan, 77% of the
population
access
to
has safe
87
IMR 77
78 76 74 72 Dera Ghazi Khan
drinking water while the sanitation of
population.
120
The infant mortality
100
has
been
80
estimated to be 87
60
per
thousand
live
40
which
is
20
births8
Pakistan
facilities 140
rate
Punjab
Figure 8: Under five mortality rate
are available to 33% the
77
128 112 101
U5MR
0 Dera Ghazi Khan
Punjab
Pakistan
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District Health Profile – Dera Ghazi Khan higher than provincial and national figure as shown in Figure 7. Under 5 mortality rate is 128 which is again higher than the provincial figure of 1128. The prevalence of underweight in children under five years of age is 45%. Twenty-five percent of children (< 6-9 months) are breastfed with complementary food as compared to 44% in Punjab8 and 31%3 in Pakistan. The percentage of children under 5 years of age receiving Vitamin A supplementation is 80 against 87 in Punjab. 7% of the population is currently using iodized salt as compared to 8% in Punjab8. The comparison of Health indicators may be seen in Table 4 and 5. 3.6.
Socio-economic Indicators The literacy rate of 36%6 is lower than the rest of the country (49%)3. Similarly, primary school enrolment rate is very low (34); i.e. 38 for males and 29% for females. Poverty remains a serious concern in Pakistan. With a per capita gross national income (GNI) of $7362, poverty rates had fallen substantially in the 1980s and early 1990s, started to rise again towards the end of the decade. In 2004-05, 33% of the population was living below the poverty line. In District Dera Ghazi Khan, poverty is significantly high as 60% of the population earns below Rs. 878 per month. The above picture depicts the need of renewed and additional efforts within the district in order to meet the vision embraced in the Millennium Development Goals by 2015. Comparison of social-economic indicators of D. G. Khan with Punjab and Pakistan may be seen in Table 6.
3.7. Health Facilities The health care delivery system of the district health department of D.G. Khan comprises of one DHQ, one THQ and two Civil
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District Health Profile – Dera Ghazi Khan Hospitals. In addition there are 9 Rural Health Centers, 53 Basic Health Units, 5 MCH centers and 29 Dispensaries. The following facilities are currently providing services in the district: Basic Health Units (BHUs) The BHUs have been established at the union council level that normally provides primary health care services, which include11 provision of static and out reach services, MCH, FP, EPI and advice on food and nutrition, logistics and management support to LHWs and TBAs and provision of first-level referral services for patients referred by LHWs. Fifty-three BHUs are functional in District D. G. Khan. Overall human resource except doctors in BHUs of District D. G. Khan needs improvement as can be seen in Figure 9. For the 53 BHUs in the district, there are 53
Figure 9: Staff Position at BHUs
sanctioned positions of
60
doctors.
50
Three
posts,
are
lying
however, vacant.
There
sanctioned
are
posts
53 50
40
50 for
31 30 Sanctioned
LHVs, out of which 19
20
are vacant and out of 10
10
posts for Female Health
0
Technician (FHT), 5 posts
50
Filled 10 5
Doctors
LHVs
Female Health Technician
lying vacant as depicted in Figure 9. There are 52 sanctioned posts of dispensers against a requirement of 53, out of which 6 are vacant. There are 47 sanctioned posts for Health Technicians against the requirement of 53, out of which 11 are lying vacant. The Human Resource position at BHU D. G. Khan can be seen in Table 7a.
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District Health Profile – Dera Ghazi Khan Rural Health Centers (RHC) RHCs
are
small
rural
hospitals
located
at
the
town
committee/markaz level. The role of the RHCs11 includes
the
provision of primary level curative care; static and out-reach services like MCH, FP, EPI and advice on food and nutrition; sanitation, health education; CDC, ARI and acting as a referral link for patients referred by LHWs, TBAs and BHUs. RHCs are first-level care facilities where medico-legal duties are also performed. They serve a catchment population of about 25,000–50,000 people, with about 30 staff including 3-4 doctors and a number of paramedics. They have 10-20 beds, x-ray machine, laboratory and minor surgery facilities. It is mandatory for male and female medical officers, LHV and support staff to reside at the premises so as to ensure their presence round the clock. Nine RHCs are functioning in District D. G. Khan. Out of 30 posts of doctors, 12 are lying vacant. The details of Human Resource position at RHCs D. G. Khan can be seen in Table 7b. Maternal & Child Health Centers (MCHC) MCH centers have been established in rural and peri-urban areas. Activities at MCHCs include antenatal, natal and postnatal care. Growth
monitoring,
health
education
and
family
planning
advice/services are also provided. Presently 5 MCH Centers are established and providing services in the district. All the MCH Centers are fully staffed except for one center where the post of Dai is lying vacant. Moreover, the posts of the Chauwkidars are not sanctioned, which are necessary for the security purposes. The Human Resource position at MCHCs can be seen in Table 7c.
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District Health Profile – Dera Ghazi Khan Tehsil Headquarter (THQ) Hospitals The THQ Hospital is serving as a first-level referral hospital, which receives health care users from the catchment area and referrals from RHCs and BHUs within the tehsil. The THQ Hospital provides specialist support and expertise of clinicians and offers basic inpatient services as well as out-patient services. This serves a catchment population of about 100,000 to 300,000 people; and typically has 40-90 beds and appropriate support services including x-ray, laboratory and surgical facilities. Its staff may include specialists such as a general surgeon, obstetrician & gynaecologist, ophthalmologist, and occasionally supported by an anaesthetist. One THQ Hospital at Taunsa is functioning in District D. G. Khan. The positions of Gynecologist and Dental Surgeon are not filled at the THQ Hospital Taunsa. Moreover, the position of the Medical Specialist and Anesthesiologist is not sanctioned. The Human Resource position at THQH D. G. Khan can be seen in Table 7d. District Headquarter (DHQ) Hospital DHQ Hospitals also provide secondary care with additional specialties as compared to THQ Hospitals. DHQ Hospitals receive health care users from lower level health facilities including THQ Hospitals, RHCs and BHUs and provide services in all major specialties including general surgery & medicine, ENT, pediatrics, ophthalmology,
pathology,
chest
diseases,
cardiology,
and
gynecology. Preventive care is also provided such as health education, immunization and antenatal care. In D. G. Khan, a 150-bedded hospital which receives health care users directly and from lower level health facilities including the THQ Hospital provides specialist care.
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District Health Profile – Dera Ghazi Khan 3.8.
Public Sector Health Manpower Out of 1204 sanctioned positions in District D. G. Khan, 80% are filled. Among the management cadre, only the position of one Deputy Medical Superintendent is lying vacant. Out of 143 positions of doctors, 47 are lying vacant and among the paramedical staff, 17 positions of LHVs, 10 positions of health technicians, 5 positions of female health technicians and 7 positions of dispensers are lying vacant. The reason generally mentioned for unfilled positions is a continued ban on staff recruitment.
Vacancies
were filled
whenever the ban was lifted for brief periods. It is pertinent to note that there is no significant improvement in the situation following devolution. Other reasons quoted for the inability to fill the vacant positions include a policy to hire staff on a contract basis rather than by recruitment through the Public Service Commission on permanent basis. The details of positions are mentioned in Table 8. 3.9.
District Health Development Centre (DHDC) DHDC D. G. Khan was established in 1998 under the World Bankassisted Second Family Health Project to provide pre/in-service trainings and other research and development activities. The mission of the DHDCs is to support district health services through training, as well as developmental and operational research activities. The details of the training profile of the DHDC for the year 2004 are given in Table 9.
3.10. Other Health Initiatives including Public Private Partnership There are a number of initiatives being implemented in D. G. Khan, both in the public sector as well as the private/NGO sector. Among the government initiatives there are the EPI, the National Program for Family Planning and Primary Health Care, and the T.B. DOTS program. page | 19
District Health Profile – Dera Ghazi Khan i.
Expanded Program on Immunization (EPI): The District Superintendent of Vaccination (DSV) under the supervision of the DOH and the EDO (H) manages the EPI in the district. The DSV is supposed to coordinate and supervise the activities of the EPI at all fixed centers and outreach teams. EPI coverage of district has been 37%.
ii.
The National Program for Family Planning & Primary Health Care: The National Program for Family Planning and Primary Health Care provides the missing link between health care outlets and users of health services. The link is provided through a network of Lady Health Workers (LHWs), especially trained in PHC, family
planning
and
community
organization.
At
present, the number of LHWs is 1000 in the district, with almost 50% population coverage. iii.
Optimal
Birth
Spacing
Initiative:
This
project
launched in January, 2005. Under this initiative, training on Optimal Birth Spacing Initiative (OBSI) was given to 60 Master Trainers and 678 LHWs. iv.
T.B. DOTS Program: The T.B. DOTS program was started in April, 2004. The training of doctors has been completed whereas only 50% of the paramedics and microscopists have been trained.
3.11.
Population Welfare Department
Major services offered by the District Population Welfare Office include Family Planning, Maternal Care, Child Care and General Health Care Services. These services in District D. G. Khan are offered through one RHSCA, one RHSC-B, 2 mobile service units and 31 family welfare centers. However, as decided in the meeting of the Central Working Development Party in January 2005, all the Family Welfare Center page | 20
District Health Profile – Dera Ghazi Khan Staff was to be stationed in the nearest Basic Health Unit from July 1, 2005. 3.12.
Private Clinics and Hospitals
There has been rapid growth in the number of private clinics and hospitals in the recent past. Health care being provided by the private sector is preferred by the community if they can afford it. People are also attracted by the innumerable, “less expensive” quacks. All efforts to enlist them have failed in the past. There are 146 general medical practitioners and 45 hospitals working in the private sector located in major towns of the district. Different strategies need to be adopted in order to mainstream the private
sector
standardization
including of
private
public practice,
private provision
partnerships, of
training
opportunities and inclusion in the social marketing of health. A list of private clinics and hospitals operating in D. G. Khan may be seen in Table 10. 3.13.
Non Governmental Organizations (NGO)s
The Social Welfare Department of the district is headed by the Executive
District
Officer
for
Community
Development
and
supported by the Deputy District Officer. The department was devolved after the promulgation of the Punjab Local Government Ordinance 2001 and has been a district government subject since then. There is a strategic, as well as an annual operational plan for the district social welfare office. It is mandatory for all NGOs to register with the Social Welfare Department. There are 82 registered NGO’s in District Dera Ghazi Khan with a breakup of 50 for Tehsil D. G. Khan and 32 for Tehsil Taunsa Sharif. The main focus of these organizations is on the health and education of women and children in particular. A list of some significant NGOs working in District D. G. Khan may be seen in Table 11.
page | 21
District Health Profile – Dera Ghazi Khan
Section 4 – Budget Allocation and Utilization
page | 22
District Health Profile – Dera Ghazi Khan 4. Budget Allocations and Utilization D. G. Khan District witnessed a gradual rise in budgetary allocations each year since 200102.
The
allocation 2004-5
Figure 10: Comparison of Total with Health Sector Budget (Rs. In million)
budgetary for is
the
Rs.
year
1457.6
million as compared to Rs. 1295.3
million
1,200 1,000 800
represents an increase as
600
reflected in Figure 10. On
400
the contrary, the district
200
budgetary
-
allocation
1,295 1,157
which
year,
1,458
1,400
the
preceding
of
1,600
894 Total District Budget Health Sector Budget
199
159
Y2001-2
shows a declining trend
Y2002-3
186
163
Y2003-4
Y2004-5
for health sector allocation reducing its share from 17% in 2002-03 to 12.7% in 2003-04 and 12.5% in 2004-05. In real terms, the budgetary allocations for health have not registered any increase in the past two years.
Figure 11: Category wise Health Sector Budget Breakup
The allocations for the DHQ
Hospital
in
the
100% 90%
current year 2004-5 grew
80%
considerably
70%
12%.
Comparatively, allocations for THQ hospitals were also
increased
only
by
12% during this period. Budgetary allocations for RHCs
and
BHUs
48%
60%
46%
51%
Non-development
60%
Development
50% 40%
24%
22%
17%
18%
Non salary Salary
30% 20%
28%
44%
33%
44%
Y2002-3
Y2003-4
Y2004-5
10% 0% Y2001-2
were
decreased by 9% during same period as is shown in Figure 11.. It has been observed that the gap between allocations to secondary and primary care has narrowed with a leaning towards enhanced allocations towards DHQ hospital. Comparing the development and
page | 23
District Health Profile – Dera Ghazi Khan non-development
budget,
it
may
be
observed
that
the
non-
development budgetary allocations have increased slightly in the last four years, whereas the development budgetary allocations were made only in 2003-04 (Rs. 11 million) and the current year (Rs. 19 million). The main reasons may include the following: 1. The health sector has to compete with other sectors for the budget under the newly established district government system, where a block allocation goes to the district; 2. Health teams in the district may have limited capacity to plan and advocate for enhanced allocations; and 3. The priority of the political leaders/District Nazim may be in other sectors, such as pavement of roads, provision of street lighting, etc. as opposed to health services.
Figure 12: Percentage Budget Utilization (Year wise)
92
Y2004-5
8
84
Y2003-4
Utilized
16
Ununtilized
76
Y2002-3
0
20
40
24
60
80
100
It has also been observed that all allocated funds may not be spent in any given year. The percentage of unutilized funds, however, has decreased over the past two years. District D. G. Khan was able to spend 76%, 84% and 92% of the allocated budget in the fiscal year 2002-3, 2003-4 and 2004-5 respectively as is shown in Figure 12.
page | 24
District Health Profile – Dera Ghazi Khan The details of budgetary allocation for the District Health Department of District D.G. Khan may also be seen in Table 12.
page | 25
District Health Profile – Dera Ghazi Khan
Data Set • • • • • • • • • • • • • • •
Table 1: Population structure of district D.G. Khan Table 2: Demographic information on D.G Khan , Punjab and Pakistan Table 3: Comparison of indicators on women and fertility behaviors Table 4: Comparison between basic indicators of D.G Khan, Punjab and Pakistan Table 5: Comparison between health and nutrition indicators of D.G. Khan, Punjab and Pakistan Table 6: Comparison between social indicators of D.G Khan, Punjab and Pakistan Table 7a: Human resource position at BHUs Table 7b: Human resource position at RHCs Table 7c: Human Resource Position at MCH Centers Table 7d: Human resource position at THQ Table 8: Public health sector manpower Table 9: Training profile of DHDC D.G. Khan Table 10: List of private sector health care providers Table 11: List of Non-Governmental Organizations working in D.G Khan Table 12: Budget allocation for the District Health Department D.G. Khan
page | 26
District Health Profile – Dera Ghazi Khan Table 1: Population Structure of District D.G. Khan Population Groups
Less than 1 year Less than 5 years
Standard Demographic Percentages 2.54 17.51
Estimated Population (2005) 41,659 287,730
49.07 22
806,353 358,951
16 4.5
261,055 73,422
Less than 15 years Women in child bearing age (1549 years) Married Child bearing age Pregnant Women
Sources: 1. District Population Profile Punjab, MSU, 2002
page | 27
District Health Profile – Dera Ghazi Khan Table 2: Demographic Information of D.G. Khan, Punjab and Pakistan Demographics Population (thousands) under age of 15 years Population (thousands) under age of 5 years Population annual growth rate (%)
DG Khan
Punjab
Pakistan
806
31304
70150
287
10481
20922
3.42
1.9
1.9
Crude death rate,
9
12.5
8
Crude birth rate,
42.5
33.8
31
Life expectancy,
61
64
63
Total fertility rate,
6.0
4.7
4.0
% of urban population,
14
32
34
Sources: 1. 2. 3. 4.
Punjab Development Statistics 2004. Pakistan Economic Survey 2004-5. Multiple Indicators Clusters Survey (MICS) Punjab 2003-4. UNICEF [Cited 2005 Sep 3] Available from: URL: http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html 5. District Population Profile MSU Islamabad 2002.
page | 28
District Health Profile – Dera Ghazi Khan Table 3: Comparison of Indicators on Women and Fertility Behaviors Women & fertility behavior
DG Khan
Punjab
Pakistan
Total fertility rate
6.0
4.7
4.0
Contraceptive Prevalence (any method)
27
36
36
Antenatal care coverage by any attendant (%)
75
77
43
Antenatal care coverage by skilled attendant (%)
47
44
35
Birth Care by skilled attendant
26
33
20
Birth Care by any attendant
99
99
99
Post-birth Care by skilled attendant
19
30
24
Post-birth Care by any attendant
93
90
67
Mean Children Ever Born Married Women 15-49
3.11
2.32
2.7
Sources: 1. Multiple Indicators Clusters Survey Punjab 2003-4. 2. UNICEF [Cited 2005 Sep 3] Available from: URL: http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html 3. District Population Profile MSU Islamabad 2002.
page | 29
District Health Profile – Dera Ghazi Khan Table 4: Comparison between basic indicators of D.G Khan, Punjab and Pakistan.
Basic Indicators
DG Khan
Punjab
Pakistan
2018
84562
154000
205345
796096
14/86
31/69
34/66
108
107
108
Population density
145
359
166
Population growth rate
3.42
1.9
2.3
Total population (thousands) Area in sq. km Population urban/rural
11922
ratio Sex ratio ( number of males over 100
females) at birth (person per square km)
Sources: 1. 2. 3. 4. 5.
Punjab Development Statistics 2004. Pakistan Economic Survey 2004-5. Multiple Indicators Clusters Survey (MICS) Punjab 2003-4. District Population Profile MSU Islamabad 2002. UNICEF [Cited 2005 Sep 3] Available from: URL: http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html_ page | 30
District Health Profile – Dera Ghazi Khan Table 5: Comparison between Health and Nutrition indicators of D.G. Khan, Punjab and Pakistan. Health and Nutrition
DG Khan
Punjab
Pakistan
128
112
101
Infant mortality rate (under 1)
87
77
77
% of total population using safe drinking water sources
77
92
90
% of total population using adequate sanitation facilities
33
58
54
% of one-year-olds fully immunized against measles
37
66
67
% of pregnant women immunized for tetanus
36
63
45
% of under-five years suffering from underweight (moderate & severe) % of children who are breastfed with complementary food (
