The lack of well-trained human resources is the biggest constraint in implementing Minimum Service Delivery Standards (MSDS) in Punjab.
To implement the Maternal, Neonatal, And Child Health (MNCH) related MSDS successfully, it is critical to have adequate and well-qualified and skilled Women Medical Officers (WMOs), midwives, nurses, female health visitors, and paramedics.
Currently, Asian Development Bank (ADB) report of Punjab Health Services revealed, about 22 percent of the approved posts for various health workers at Basic Health Units (BHUs) and (RHCs) in Punjab are vacant. Among the medical staff, the highest (32 percent) proportion of vacant posts is for the WMO. Similarly, 37 percent of the approved posts for nurses at BHUs and RHCs are currently vacant. At DHQs, almost one third of the approved posts of gynecologists and anesthetists are vacant. The situation is even worse at THQs, where 48 percent of the approved posts of gynecologists and 59 percent of anesthetists' posts are vacant.
To implement MNCH-related MSDS effectively, ADB report observed that about 14,000 new posts need to be approved and filled. They include about 660 specialists (primarily gynecologists, obstetricians, anesthetists, and pediatricians); about 1,550 medical officers (including WMOs); about 5,000 nurses; 3,000 each of lady health visitors and midwives; and 1,000 paramedics. The shortage is especially pronounced among paramedics and nurses. Against this requirement, Punjab produces about 1,400-1,600 nurses and 350 lady health visitors per year.
In addition, 39,000 nurses have been registered until 2006. Therefore, once posts are approved, a substantial part of them are expected to be filled in the next 2 years. For some posts, however, additional measures may be necessary for attracting health workers to the posts. For example, Punjab produces a large number of doctors-including female doctors-in relation to nurses, but the availability of WMOs (particularly in rural areas) is a challenge as many female doctors leave the profession or opt to practice in urban areas, ADB report disclosed.
Punjab government has introduced incentives for doctors posted at BHUs. As a result, their vacancies at BHUs have significantly reduced for the last 2 years.
Apart from the quantitative challenge, there are serious quality concerns in the health profession. Some of the medical training institutions in Punjab do not appear to apply any stringent quality standards. In addition, there is no continuous education system to enable doctors to update their knowledge and skills regularly. Further, the quality of paramedics is not up to required standards.
For instance, the entrance requirement for dispensers is only 10 years of schooling. Since 1947, only about 35,000 dispensers have been qualified out of 1.2 million who appeared for the exam after a year of training. The quality of training offered is very low mainly because of lack of qualified trainers. Consequently, the quality of the paramedics is low and they are ill-prepared to offer quality care, ADB pinpointed. The Health Sector Reform Programme (HSRP) has made substantial headway in closing gaps in physical infrastructure and staff requirements.
Vacant positions at RHCs and BHUs are being filled through monetary incentives for doctors. Absenteeism is actively checked. Correspondingly, the utilisation rates of RHCs and BHUs are increasing, albeit slowly. The federal MNCH program also plans to upgrade the maternal wards and delivery rooms of DHQs, THQs, and RHCs. The federal government's plan to increase coverage of lady health workers who provide preventive health care and health education in the community is expected to improve people's health-seeking behaviour.
It is critical that the Punjab Millennium Development Goals Programme (PMDGP) help Punjab sustain reforms and investments, and ensure staff retention to improve the quality of health care provision for Maternal, Neonatal, And Child Health (MNCH).
The demand for, and spending on, private health care is higher because the public perceive the quality of private health care to be better than that at public health facilities. Low quality, lack of standardised provision of health services within and across health facilities, lack of adequate human resources, and lack of drugs and medical supplies have been the main impediments resulting in the low utilisation of BHUs and RHCs.
The public either chooses to use unqualified health care providers or home treatment, or go to hospitals even for minor illnesses. This has resulted in delays in seeking appropriate health care when needed as well as over crowded hospitals.
Both the federal and provincial governments are allowed to set health sector policies. Although the Punjab government does not have a health sector policy specific to Punjab, the National Health Policy gives a reasonable vision, focusing on (i) poverty alleviation, (ii) primary and secondary health care, and (iii) good governance. However, it does not specify the steps and outputs required for realising the vision or MDGs. Without specifying what services are provided at which level of healthcare by whom, and the minimum acceptable quality for different types of services to achieve the goals, it has been impossible to translate the policy and the MDG commitment of Punjab into investments and action plans, ADB report mentioned.
ADB report pointed out that the MSDS notified in Punjab in December 2007 have filled this crucial gap. They were developed through consultations involving provincial and district health officials and public health specialists, based on reviews of service delivery standards in other South Asian countries (Bangladesh, India, and Sri Lanka); the international evidence-based standards set by the World Health Organisation (WHO) for developing countries; and existing services in Punjab.
The MSDS define the minimum package of services that the public is entitled to, a set of performance indicators and minimum acceptable levels of performance by service providers at each level of health care, and the required physical and human resource requirements.
To facilitate the implementation of MSDS, Punjab government has also developed comprehensive referral guidelines, standard operating procedures (SOPs), and standard medical protocols (SMPs). MSDS, Standard Operating Procedure (SOPs), and Standard Medical Protocol (SMPs) together have well-defined accountability parameters at each level of health care, for different health professionals, and benchmarks against which performance of the health system as a whole and that of each worker will be monitored and evaluated.
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