There was an overall improvement in utilization of health services from the baseline in the contracted out healthcare facilities. Moreover, improvements were greater in Thatta compared to Sujawal district in all KPIs. An improvement of 33% was observed in out-patient department (OPD) consultations with noticeable progress of 91% in specialist consultations and 106% in accident and emergency consultations from the baseline. General OPD consultations, however, increased only slightly (3%). In-patient admissions also showed upward trend (figure 1). The volume of OPD consultations was inconsistent. A noticeable decline in number of consultations was observed during second quarter of every year (the end of fiscal year).
Facility based deliveries, both vaginal and caesarean section, increased 36% and 49% respectively with an overall improvement of 37%. However, most of the caesarean section were reported from healthcare facilities in Thatta (figure 2). This was consistent with the finding that majority of surgeries both major and minor were also reported from Thatta district (figure 3).
Marked improvement was seen in 1st antenatal care (ANC) visits however there was little improvement in postnatal care (PNC) visits until after two years when PNC visits improved noticeably. There was overall increase of 19% in proportion of pregnant women receiving 2nd tetanus toxoid vaccine dose. However, the increase was prominent in Thatta while it actually showed a decline in Sujawal (figure 4).
Immunization indicators for children under 1 year of age showed decline as number of children fully immunized, immunized for third dose of pentavalent vaccine and 1st dose of measles vaccine indicated inconsistent and downward trend for the contracting out period (figure 5).
Overall, healthcare facilities of district Thatta showed greater improvements in utilization of health services compared to those of Sujawal district. Utilization of services at DHQH Thatta, the only hospital in the two district, showed highest utilization of services including OPD, surgeries, laboratory and diagnostic services and maternal health services. Though there was improvement in most services at THQHs of both the districts, THQHs of Sujawal showed decline in immunization and laboratory services (figure 6).
Almost all RHCs showed improvement in OPD consultations, ANC and PNC, but improvement in institutional deliveries was sluggish and immunization services showed declines at majority of RHCs (figure 7).
For assessing bed capacity, drugs, equipment and supplies and infrastructure, there was no baseline data available and hence these were assessed for adequacy through health facility assessment survey.
RHCs had beds available to cater to in-patient care for cases such as conducting normal vaginal deliveries, treatment pediatric cases for dehydration and cases of accident and trauma. Among the eight RHCs, the average number of bed capacity was 13, with a minimum of 5 and a maximum of 20 beds. Beds to population ratio however was low in most cases.
Among secondary hospitals, those in Thatta had the highest bed strength compared to Sujawal with 242 beds in DHQH in Thatta. In Sajawal, range of beds in THQHs was minimum of 16 to maximum of 98.
Availability of drugs
Though most of the essential drugs were present at majority of the RHCs, essential anticonvulsant and anti-epileptics were found out of stock on all RHCs. Second most important group of drugs found deficient was anti-diabetics. For all the THQHs in both districts, most of the essential drugs were in stock, while antidotes, anti-allergic, respiratory and eye and ear medications were out of stock at the time of the survey.
Availability of equipment and supplies
General medical equipment and supplies were available at most RHCs, but availability of radiology equipment such as x-ray and ultrasound machines were non-existent in some RHCs. Though all secondary hospitals were slightly short on supply of equipment a functional operation theater was available at three of the five hospitals.
There was a need to bring improvements in infrastructure and 9 out of total 13 healthcare facilities were in need of repair. Similar number of facilities had separate latrines for patients but these needed repair. Almost half of healthcare facilities had a proper waste disposal mechanism but an equal number lacked pit incinerators. Non-availability of safe drinking water was a major finding as only 5 of the 13 facilities had potable water available. Unavailability of water also affecting functioning of latrines. Staff housing at all the facilities was in need of repair. DHQH Thatta was the hospital that received most attention in terms of infrastructure improvement.
Situation of health workforce
Overall, staffing situation improved significantly in both the districts. Recruitment for all cadres such as specialists, general doctors, paramedics and support staff were done against vacant positions (figure 8). However, shortage of human resource still persisted at secondary hospital and more so in healthcare facilities of Sujawal district. Similarly, number of vaccinators at all RHCs, though appropriate against sanction positions, was not adequate given low immunization coverage and scattered geography of population.
For all the three fiscal years, not only that there was a delay in release of budget, but the amount of budget released was lower than total of the committed amount. In 2016 – 17, 72% of the committed amount was released. This was even lower in subsequent years i.e. 64% and 58% for 2017 – 18 and 2018 – 19, respectively. When broken down by line items, human resource budget released for each fiscal year was even lower i.e. 34%, 66% and 57% for years 2016 – 17, 2017 – 18 and 2018 – 19, respectively.
Perceptions of program managers regarding contracting out
Delayed and partial release of funds
Delayed and partial release of budget was stated as a major challenge in maintaining day to day operations and paying timely salary to employed staff. This issue that started from day one kept escalating every year and resulted in increased staff turnover. Employees that already were affected by job insecurity due to contractual nature of job were not able to continue given delays in salaries. Thus finding and retaining qualified human resource was constant ordeal.
Fragmented health system
Extensive contracting out of healthcare facilities has led to improved utilisation of health services. But contracting of healthcare facilities to multiple NSPs within the same district has not been accompanied by concurrent measure to ensure coordination. Both in Thatta and Sujawal districts, BHUs were contracted out to one NGO, RHCs and secondary hospitals had been handed over to another NSP and the vertical programs such as immunization and lady health workers (LHW) program fell under the domain of government’s district health office (DHO). While there was no mechanism of reporting between NSPs and DHO office, communication channels between NSPs were also lacking.
Lack of water and electricity
Water and sanitation was a major concern for both the districts in general and also affected the functioning of healthcare facilities. Several of the healthcare facilities were without continuous supply of water also rendering latrines unusable. Unavailability of water also posed threat to health of patients and healthcare staff as maintaining cleanliness through practices such as hand washing was not possible in absence of water. Lack of electricity affected vaccine storage at optimal temperatures and in absence of backup generator led to interruption of services such as operative and trauma care at secondary hospitals.
Remoteness of healthcare facilities
Scattered geography of the region also created difficulties in reaching to some healthcare facilities both for staff to reach on time and for patients to get timely healthcare. One of the healthcare facility located along the main highway received accident and trauma cases. Despite being the only facility in the vicinity, there was no provision for medico-legal officer (MLO), hence it had to turn away the MLO cases to a distant secondary hospital. To add to the misery, weak or absent mobile networks created hurdles in communication from and to these healthcare facilities.
Findings from client exit interviews
More than 60% clients said that they were satisfied with services at these healthcare facilities. About 50% clients said they have seen improvement in services whereas 60% said there have been infrastructure improvements at healthcare facilities in past two years. Availability of medicines at the facilities was a major problem for approximately 64% of clients and about 34% were unhappy with the cleanliness of the facilities. About 96% clients said that they didn’t have to pay for availing services from these healthcare facilities (table 1).