Pakistan’s 2005 earthquake, one of the most debilitating natural disasters in their recent history, also damaged the country’s health infrastructure.

On October 8, 2005, a magnitude 7.6 earthquake shook parts of Afghanistan, India, and Pakistan. Losses were most severe in Pakistan, where over 73,000 people died and over 70,000 were injured. The earthquake also damaged Pakistan’s health infrastructure. Approximately 575 health facilities and management offices were partially or fully destroyed by the earthquake, including 75 percent of first level care facilities and all secondary care and smaller health units. The earthquake also destroyed vehicles, drugstores, cold rooms, health staff accommodations and offices, medical equipment, and records.

This disruption of health services left nearly four million Pakistanis without access to primary and secondary healthcare. Restoring this access was a priority, especially because women and children were the heaviest users of the primary healthcare services, representing 60-65 percent of the clients before the earthquake and 70-75 percent of the reported deaths and injuries from the disaster.

International Assistance

International assistance arrived within days of the earthquake. The World Bank, in collaboration with other development partners, undertook an Earthquake Damage and Needs Assessment and assisted Pakistan in mobilizing resources to finance the reconstruction and rehabilitation efforts. The World Bank also provided assistance through the Japan Social Development Fund (JSDF) under the project “Revitalizing and Improving Primary Health Care in Battagram District.” Battagram is an underdeveloped district located in a mountainous setting with land area of 1,300 km2 and an estimated population of 361,000 (2004-05).

The JSDF project aimed to revitalize primary healthcare services in Battagram, strengthen the capacity of district health management and health workers, and contract NGOs to manage primary care services. The project envisaged provision of an essential primary health service package with a focus on maternal/child health including obstetrical and family planning services; diagnosis and treatment of major infectious diseases including tuberculosis; basic curative services; nutritional support including improving micronutrient deficiencies, therapeutic feeding and breastfeeding promotion; and carrying out public health functions including disease surveillance and response to epidemics. The services were expected to be provided through fixed facilities, mobile units, and community-based workers.

Key Features

Through a competitive public tender, the Department of Health contracted out management/delivery of primary healthcare services to Save the Children USA with full administrative control of all health facilities and staff, and full financial powers. The contract specified the roles and responsibilities of both parties with the government’s role being that of financier and stewardship/oversight, and the NGO being responsible for management and implementation of an agreed-upon package of primary care and community-based services. This was appropriate to the needs created by the post-earthquake emergency, as well as to today’s needs in areas where militancy and conflict have disrupted the provision of public services.

Certain characteristics of the contracting out model were critical to its success:

1. The agreement between the Battagram District Government and the NGO gave flexibility to the NGO to manage and to innovate, including the flexibility to introduce performance-based incentives and hire staff at market rates. Specifically, full budgetary, human resource, and administrative control of all district health services were transferred to the NGO. The NGO was responsible for procurement of medicines, supplies and equipment. The motivation of government employees was addressed by the salary supplement provided by the Performance Based Incentive scheme, which reduced the differential in remunerations between government and NGO-recruited employees. This was one of the few contracting
arrangements where salaries of government staff were paid through the NGO, which is likely to have contributed to good management and enhanced managerial authority within the NGO.

2. The project ensured availability and presence of staff in the district, particularly female health providers. With flexibility to use resources across budget lines, the project recruited additional staff (including a 53 percent increase in the number of qualified professionals) with a special focus on female health providers and strengthening community-based outreach to address gender constraints in a traditional society. Staff members were paid market salaries—roughly triple the government rate—and provided security, fully furnished accommodation, and transport.

3. Effective coordination was maintained with the provincial and district governments as well as with community stakeholders. The transfer of execution responsibilities to the NGO allowed the government to focus on its leadership functions. The NGO gained the cooperation of local officials by actively involving them in project activities. The project team also maintained close liaisons with local leaders and influential community members.

4. Alliances within the local community were key as the security situation in the province deteriorated during the project period, and international NGOs were especially targeted. Close ties were established locally, and since many of the managers belonged to the community, project activities continued with minimal disruption.

5. The project adopted a hub approach that decentralized management to the Rural Health Center level. The objective was for the Rural Center to function as a hub for eight to ten Basic Health Units, to provide 24-hour emergency obstetric and neonatal care with a functional ambulance and resident male and female staff, and devolve financial and administrative powers to a Rural Center manager. Most of the medical officers were located at the Rural Centers, and each was staffed with five medical officers, including two female medical officers.

6. The District Health Management Team met regularly to review progress and resolve specific issues. District officials were trained in planning, budgeting, and use of information. Performance-based incentives contributed to the use of data as a management tool.

Delivering Results

Available evidence suggests that the project objectives were met. The data point to substantial improvement in utilization of services, and the findings of the facility survey indicate increased availability of medicines, staff, and equipment, and high levels of patient satisfaction.

The project successfully revitalized primary healthcare service delivery in Battagram, with a substantial increase in utilization of preventive and curative services. The project also helped the provincial government explore options to improve the provision of primary care health services through better management of district-level health systems—mainly by testing out innovative methods through public-private partnerships. The results of the JSDF pilot were disseminated through a workshop to a wider audience of political representatives and government officials at the provincial and district level.

These results have further strengthened ownership and support within the government administration and the provincial leadership to replicate and scale up the initiative, particularly in underserved districts. The World Bank has received a request for the replication of the JSDF pilot model in an additional five districts where health services have been affected by the 2009 militancy and 2010 flood crises.