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BUILDING A DASHBOARD FOR THE PUNJAB HEALTH DEPARTMENT

April 2013: Arif Nadeem felt overwhelmed. He had been working as the Secretary of the Punjab Department of
Health (DOH) for almost a year and was still finding it difficult to keep track of what was happening in the
department and the provinces health sector. This was hardly due to inexperience he had previously been the
Secretary in two other departments and was well versed in the technique and practice of management. However,
he did not feel on top of things. Although DOH regularly collected and passed on to him substantial volumes of
information on a range of indicators, there was hardly a system that could filter information to suit his decision
needs. No wonder, he felt under-informed and over-informed at the same time. He realised that he needed a
dashboard that presented updated information on key indicators to suit his everyday information needs.
Working of the Health Department
Punjab was a large province spread over 205,345 square kilometres, with a population of 96.7 million.1 Around
68% of its population resided in rural areas and about 56% were children under the age of 15 years.2 41% of the
population of 10 years and above could not even read and write.3 To provide healthcare to this large, youthful,
largely rural and uneducated population, DOH maintained an extensive network of about 4,000 primary,
secondary and tertiary healthcare facilities (Exhibit 1). Primary Healthcare (PHC) facilities comprised Basic
Health Units (BHUs) and Rural Health Centres (RHCs). These provided basic healthcare as well as outreach
and community-based activities focusing on immunisation, sanitation, malaria control, maternal and child
health, and family planning services. Secondary Healthcare (SHC) facilities comprised Tehsil Headquarter
(THQ) Hospitals and District Headquarter (DHQ) Hospitals. These provided inpatient and outpatient care in a
variety of sub-disciplines. Tertiary care facilities were located in major cities and provided specialised treatment
and care.
In addition, there was a large private sector comprising 11,125 private hospitals and clinics, which was
estimated to provide healthcare to about 30% of the population.4 It fell within DOHs purview to regulate and
broadly oversee the working of private health facilities in the province.
DOH was also responsible for performing a range of related functions as specified in the Punjab Governments
Rules of Business, 2011 (Exhibit 2). These included inter alia provision of policy input, planning and
management of health services, management of health professionals, collection of health-related statistics,
control of epidemics, drug control, and implementation of various laws. This was a very broad mandate and
DOH often struggled to discharge it effectively.
To manage its health facilities and perform other functions listed in the Rules of Business, 2011, DOH
employed a large workforce comprising more than 114,000 technical and non-technical employees. The
Secretary was the Chief Executive Officer of the Department and was responsible for providing
superintendence, oversight and guidance to the entire workforce in the discharge of their duties. He was
responsible to the Minister and through him, to the Chief Minister and sthe provincial legislature. A team
1

Punjab Bureau of Statistics, Punjab Development Statistics (Lahore: Punjab Bureau of Statistics, Government of Punjab, 2012).
Ibid.
Pakistan Bureau of Statistics, Pakistan Labour Force Survey 2010-11(Islamabad: Pakistan Bureau of Statistics, Government of Pakistan,
2011).
4
Government of Punjab, Stocktake of Private Practitioners in Punjab (Government of Punjab, 2008).
2
3

This case was written by Dr Muhammad Ahsan Rana at the Lahore University of Management Sciences to serve as basis for class
discussion rather than to illustrate either effective or ineffective handling of an administrative situation. This material may not be quoted,
photocopied or reproduced in any form without the prior written consent of the Lahore University of Management Sciences. This research
was made possible through support provided by the United States Agency for International Development. The opinions expressed herein are
those of the author and do not necessarily reflect the views of the US Agency for International Development or the US Government.

2015 Suleman Dawood School of Business, Lahore University of Management Sciences

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composed of senior civil servants and public health specialists assisted him in the discharge of various functions
(see Exhibit 3 for organogram).
The first two tiers of service delivery, viz. PHC and SHC facilities, were under the supervision and control of
District Governments, which maintained an elaborate hierarchy of officials to discharge functions necessary for
the efficient working of these facilities. An Executive District Officer (EDO) was the officer in charge of the
health department at the district level and managed human and fiscal resources on behalf of the District
Government and the DOH. The EDO reported to the District Coordination Officer (DCO) the chief bureaucrat
in the district. He was assisted by a number of officials, such as District Officers (DOs), Deputy District
Officers (DDOs), Assistant District Officers (ADOs) and Medical Superintendents of various THQ and DHQ
hospitals (Exhibit 3).
Data Collection and Analysis
DOH had multiple streams to regularly collect data on a range of indictors. These included the following: 1)
data provided by PHC and SHC facilities for the District Health Information System (DHIS); 2) data collected
by Monitoring and Evaluation Assistants (MEAs) through field inspections; 3) inspection reports of DOH field
officers and 4) progress updates on development schemes. In addition to these four main data streams,
information also reached the Secretary from other sources. Tertiary healthcare facilities reported on various
aspects of their functioning on need basis i.e. as and when so required by the Department. Newspapers,
nongovernment organisations and various interest groups (such as pharmaceuticals) provided periodic
information on various aspects of health provision in the province. DOH also compiled data on its human and
financial resources, and regarding special campaigns that it launched from time to time to meet health-related
exigencies.
DHIS
DHIS was by far the most comprehensive data collection system in the Department. It was launched in 2006,
initially in a few districts but it extended to the entire province by 2009. It was based on data reported by the
staff of PHC and SHC facilities on various aspects of functioning of their facilities. This data covered 79 and 83
clinical and non-clinical indicators for PHC and SHC facilities respectively. Clinical indicators covered 43
communicable and non-communicable diseases, whereas non-clinical indicators covered vacancies, presence of
staff, utilisation of facilities, patients treated, availability of medicine, budget, etc. (see Exhibit 4 for DHIS
indicators).
PHC and SHC facilities initiated monthly reports on separate pro forma. The information was derived from 24
registers maintained by concerned officials in the facility. The whole system was paper-based. Although it was
the responsibility of the facility in-charge to ensure that reporting was accurate, in practice he/she neither had
the time nor incentive to carefully check what was being reported. To minimise the possibility of misreporting,
DOH introduced Lot Quality Assurance Sampling (LQAS) as a quality assurance mechanism. LQAS involved
drawing samples in each district and cross checking data through field visits. In practice, however, LQAS
testing did not become a regular feature of data collection at DOH.
DHIS data were consolidated in the District DHIS Cell each month. The District Cell converted the data into
soft form and generated district reports for the benefit of EDO, DCO and other managers at the district level.
These reports were also circulated to in-charges of PHC and SHC facilities in the district. Shortly thereafter, the
EDO held his monthly meeting with his district-based and field teams to review current progress on various
indicators.
The District DHIS Coordinators sent a copy to the Directorate General of Health Services (DGHS), where the
Director (MIS) consolidated district reports into a provincial DHIS report. DGHS published quarterly and
annual reports, which were widely shared with a range of stakeholders including the Secretary, other senior
DOH managers, EDOs, heads of teaching institutions, various project managers and international aid agencies.
Potentially, DHIS reports contained useful information that could inform management decisions. For example,
the annual reports for 2011 showed that per capita attendance at the outpatient departments in PHC and SHC
facilities was only 0.90 for Punjab i.e. on average, staff comprising 100 persons was serving around 90 patients
per unit of time. These reports also showed wide variation among districts 0.31 for Lahore and 1.41 for
Chakwal. These were useful information bits for the Secretary and other managers when they had to make
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decisions and policies regarding allocation of human and financial resources. Whether or not this actually
happened was a different question.
Data Collected by MEAs
MEAs were initially fielded by the Punjab Education Department in 2004 to collect data on government schools
in the province. In 2006, DOH asked MEAs to also inspect health facilities while they were out in the field
visiting government schools. DOH prepared separate pro forma for PHC and SHC facilities covering 14
indicators (Exhibit 5). These indicators pertained to various aspects of the functioning of the health facility,
such as general upkeep, staff attendance and vacancy, availability of medicine and use of outdoor and indoor
facilities. Several of these indicators were already part of DHIS, but DOH commissioned MEA inspections to
crosscheck the DHIS data.
Data collected by MEAs was consolidated into a district report at the district level. This report was shared with
the DCO, the EDO and other health managers to help them take appropriate actions regarding staff absenteeism
or medicine stock out. The Punjab Health Sector Reforms Program (PHSRP) a policy think tank of DOH
consolidated district reports at the provincial level and prepared a monthly ranking of districts on selected
indicators. District ranking was based on a formula that assigned specific weightage to various indicators
(Exhibit 6).The score of each district was determined based on its monthly performance on various indicators
and weights assigned to it. PHSRP sent the district ranking report to the Secretary on monthly basis and also
placed the report on its website.
During 2006-08, PHSRP used to present the district rankings in its periodic meetings with the Chief Secretary
the chief bureaucrat in the province. Senior DOH managers and all DCOs attended these meetings. A low
ranking put health managers and the DCO concerned in an embarrassing position before their peers. Gradually,
however, health managers and DCOs started objecting to the mechanical nature of these district rankings. They
pointed out that a district might perform low due to factors completely or partially out of its control, such as the
availability of medicine and staff vacancy. They argued that since medicine was supplied by DGHS and senior
positions were filled by DOH, it was unfair to penalise a district for being lacking in one of these. Although
PHSRP continued to rank districts on these indicators, it did not present these rankings in Chief Secretarys
meetings after 2008.
Inspection Reports of DOH Officials
Being supervisory officers, EDOs, DOs, DDOs and ADOs were supposed to regularly visit PHC and SHC
facilities in their respective areas of jurisdiction to get first-hand information on the status of services provided
by these facilities. Each official was assigned a specific percentage of facilities for inspection, which ranged
from 100% for ADOs to 5% for a districts EDO. During the field visit, these officials checked staff attendance,
medicine availability, general upkeep of the facility, number of patients, maintenance of records, progress of
development schemes, etc. There was no specific format to record this information and a report was made
usually when an aberration was found, but not otherwise. Mostly verbal feedback was provided in monthly
meetings of EDOs with facility in-charges. In case of a serious observation, a written report was made to the
DCO and the DOH, which could initiate appropriate action thereupon. These reports were rarely sent for the
Secretarys perusal.
To facilitate reporting from field inspections, DOH introduced smartphone based data reporting in February
2011. The new regime differed from DHIS and MEA data collection streams to the extent that data from the
field was directly recorded in soft form and transmitted to several locations instantaneously. Simple androidbased applications were specifically developed for this purpose and installed on smartphones provided to field
officials. The new system was introduced in 18 districts in the province and 392 smartphones were provided.
Each time a supervisory official visited a health facility, he recorded observations in the smartphone. Date, time
and location were electronically stamped on the reports, which were instantaneously fed into a central backend
system at PHSRP. Pictures could also be uploaded to ward off the possibility of fake reporting. So a visiting
official could simply have himself photographed with the facility staff and send the group photograph to the
data repository as proof of his visit as well as staff attendance.
A set of 12 indicators was used for data collection (Exhibit 7). These related to staff attendance, medicine stock
out, number of outpatient visits and deliveries, functionality of equipment and general upkeep of the facility.
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Data received from the field was not aggregated at the provincial level. Similarly, time-series analyses were not
carried out to see long-term trends.
Occasionally, DOH sent its senior managers to tour health facilities in various districts. Sometimes but not
always observations from these visits were recorded as tour notes. Being infrequent and unstructured, these
visits did not produce data that could be regularly and reliably used in decision-making.
Progress Update on Development Schemes
DOH had a large portfolio of development projects. In 2011-12, out of a total allocation of Rs. 64.7 billion,
allocation for development schemes stood at Rs. 12.3 billion. 5 This allocation was for various schemes of
construction of new buildings, purchase of equipment and repair and maintenance of facilities in the province.
Like other departments, DOH had an elaborate system of tracking progress on these schemes and for keeping
accounts thereof.
Two pro forma were used for reporting progress on development schemes. These were Planning Commissions
(PC) pro forma III (A) and III (B). These were prepared by concerned wings/projects in the department that
were undertaking a development scheme. PC III (A) was prepared at the beginning of the financial year and
contained an annual work plan. Based on the annual work plan, quarterly work plans and financial requirements
were worked out. The purpose was to work out in advance the funds requirement against each scheme and
milestones against which disbursements could be made. PC III (B) was prepared on monthly basis. It reported
physical progress of the scheme, procurement and fund utilisation during the preceding month. This information
was consolidated at the provincial level and was sent to the Secretary and other senior managers each month.
Human Resources and Financial Management
DOH was a large department both in terms of the people it employed (114,000) and the resources it expended
each year (Rs. 64.7 billion in 2011-12). DGHS, Additional Secretary (Establishment) and EDOs (Health) in the
districts maintained category-wise data on staff employed in various wings/facilities. These officials were
responsible for recruitment, posting, transfer and other service matters of DOH employees according to a
hierarchical system of exercise of authority. Service matters of employees up to Basic Pay Scale 16 were mostly
dealt with by the respective EDOs, and service matters of employees from Basic Pay Scale 17 and above were
dealt with by DGHS. There was no comprehensive database on employees listing their professional
qualifications and experience, service history, special skills, salary, performance against targets, complaints, etc.
In the absence of such a database, it was difficult for the Secretary to plan an effective deployment of this large
workforce. Information on the human resource was presented to the Secretary as and when desired by him.
The DOH budget was consumed at two levels: 50-60% was consumed at the provincial level and the remaining
was spent at the district level. In 2011-12, salaries comprised about 25% of the total current expenditure and
utilities consumed 44% of the total budget. Record of receipts and expenditure was kept at the district and
provincial levels. Monthly reports were sent to the Deputy Secretary (Budget), who consolidated these into a
single statement for the perusal of the Secretary outlining total budget allocation under various heads and
expenditures so far. Since most of the budget was committed upfront for salaries, utilities, maintenance,
development, etc., there was little discretion to be exercised by the Secretary. Nevertheless, it was possible for
the Secretary to make minor adjustments here and there during a fiscal year to accommodate exigencies or
political priorities. A slightly larger opportunity to do so presented itself at the time of budget making when
resource allocations for the next fiscal were being finalised.

World Bank, Punjab Performance Expenditure Review (Islamabad: World Bank, 2013).

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Data on Special Campaigns


In addition to managing health facilities, purchasing medicines, etc., DOH often launched special campaigns to
respond to epidemics and other health exigencies. The most recent example was the dengue control campaign.
Since these campaigns often had explicit political ownership they were mostly launched on express directives
of the Chief Minister (CM) , they had to be accorded priority. Since DOH did not have dedicated staff at both
the Secretariat level and in the field to plan, design, implement and monitor these special campaigns, it had to
assign additional responsibilities to existing staff. Being high visibility activities, the Secretary and other senior
managers were deeply involved in various stages. They tried to keep them updated on the progress at least
until political ownership was intact. It was usual for the Secretary to designate a key staff member as the focal
person for a special campaign. It was the responsibility of the focal person to collect data on a set of indicators
on daily/weekly basis and to consolidate these into a statement for the Secretary.
Challenges in Building a Dashboard
As Arif started thinking about building a dashboard, he realised that it was quite a challenge for a variety of
reasons. Firstly, DOH did not have a clearly defined set of strategic objectives that it pursued in a given
timeframe. Its mandate, as defined by the Punjab Governments Rules of Business 2011, was too broad and allinclusive to be of much help in building a dashboard. The Rules spoke of several things policy, disease
control, regulation of health professionals and education, development schemes and implementation of laws.
These were all individually important and worthy candidates for tracking progress on regular basis, but Arif
wanted to focus on a few of these items, at least initially. However, he was far from clear regarding which items
these could be. He realised that selection must be done carefully, as this would effectively set priorities for
health professionals in the public sector. Once they knew which indicators progress would be reviewed
regularly, health practitioners would have limited incentive to excel on other indicators.
Secondly, Arif often found himself and his team caught between the priority of the week as determined by the
CM and regular work of the department. The CM frequently shifted from one priority to another in response to
media reports, judicial activism and his own caprice or political expediency. It was, therefore, not uncommon
for the department to pursue as the top priority, say, dengue control in one week and disposal of hospital waste
in the next. Arif had learnt during the previous year that he had to be very up-to-date on the priority of the
week, if he wanted to keep the job. At the same time, he also appreciated that his real challenge was to improve
routine functioning of his department. It was the everyday interface of the common citizen with an official in
the EDOs office or in the Secretariat, or with a health professional at a typical facility, that needed to be
improved, simply because this constituted the point of interaction between the department and its clients.
Balancing these competing information needs was a challenge.
Thirdly, there was some tension between the frontend and the backend work that the DOH performed. The
former comprised treating patients, conducting procedures, implementing development projects, etc. These
were more visible and usually concrete. The latter included mundane and relatively lacklustre tasks, such as
maintaining databases and keeping inventories. But could the former be accomplished without attending to the
latter? Arif tended to answer in the negative, which meant he had to devote some space in the dashboard to
measuring progress on the backend work.
Lastly, the dashboard had to satisfy information needs of a set of stakeholders. If it were just him who was the
primary user, the task would have been easy. He could select a few indicators of his choice that directly
contributed to achievement of priority policy objectives and monitor progress on these indicators regularly. But
he was only one user of the dashboard. Others included senior managers in the department, such as the DGHS,
Program Director PHSRP, Additional Secretaries, and EDOs et al. in the field. These users had different
information needs. For example, while DGHS was interested in child immunisation and disease outbreaks, the
Additional Secretary (Establishment) was keen to know how many posts were vacant and how many
disciplinary proceedings were pending at various levels. In order to be useful for a variety of users, the
dashboard had to present information on several groups of indicators and some opportunity for customisation.
Arif also realised that managers and field officials needed different levels of detail. Therefore, the dashboard
had to be capable of presenting summary information for one group of users (viz. managers) and detailed
information for another group of users (viz. field officials).

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The Dashboard Structure


Arif fully appreciated these challenges. He assembled the following senior managers of the DOH to develop the
broad contours of a dashboard:

Babar Hayat Tarar, Special Secretary, DOH

Dr. Anwar Janjua, Additional Secretary (Technical), DOH

Dr. Zahid Pervaiz, DGHS

Farasat Iqbal, Program Director, PHSRP

Dr. Beena Malik, Public Health Specialist

Asim Kabeer, Punjab Information Technology Board

Arif explained his reasons for wanting to develop the dashboard:


I am a manager. I need a dashboard to better manage my department. I dont need it for
cosmetic or academic purposes. So we should try to develop something that is practically
useful for me in making decisions. I want the dashboard to contain at least the following: key
summary statistics on departments resources and facilities, activities of various team
members and what is being accomplished, i.e. health outcomes.
Babar said that a useful starting point could be to identify the decisions that Arif made on daily, weekly or
monthly basis. The next step could be to identify the information that could inform these decisions. From this
list could be filtered the most vital statistics to include in the dashboard. Perhaps a month would be a
reasonable time span to start, said Babar.
As the chief manager, Arifs principal responsibility was to efficiently deploy the DOHs human, physical and
fiscal resources in pursuance of Punjab Governments health policy objectives. Thus, he was routinely making
decisions in these two broad areas. As for the human resource (HR), his decisions related to staff recruitment,
promotion, transfer, seniority, leave, professional development, disciplinary proceedings and complaints.
Although most HR issues were dealt with by EDOs or DGHS, eventually it was the Secretarys responsibility to
ensure that the DOH personnel were efficiently utilised and that rules and regulations were followed.
Furthermore, he was the supervising officer for a small number of senior managers. Summary statistics on
category-wise number of posts, vacancies, staff presence, qualification, length of experience, place of posting,
training, special skills, etc. were relevant for decision making in this area.
Similarly, Arif made decisions regarding allocation of financial resources to various facilities and projects.
Mainly, this was done at the time of budget making, but progress had to be monitored on regular basis.
Additionally, there was some space for reallocation of budget from one project to another and from one head to
another. Often, service provision at a facility would suffer because it could not incur an unanticipated expense
on, say, the repair of a particular equipment or purchase of medicine. DHIS provided detailed data on these
aspects regularly, but Arif did not receive summary statistics on e.g. the X-ray machines not working or the
essential medicines being out of stock. Similarly, the PC III reported monthly progress on each project, but Arif
wanted a summary instead. The following information was relevant: budget allocation and utilisation in various
heads and for various facilities, physical and financial progress of development projects, equipment
functionality and number of tests carried out, medicine stock out, physical condition of the DOH buildings, etc.
Beena suggested expanding this list to include those items that Arif was required to do but was unable to attend
to for any reason whatsoever:
There are several items in the Rules of Business, which Arif does not seem to be very
bothered about in his routine functioning. Should we continue to ignore them? If we do not
include them in the dashboard, they are likely to remain ignored. If items such as juvenile
smoking, nutrition, collection of data on the state of health in the province, etc. are still
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important for the DOH, these should be put on the dashboard. Otherwise, they should be
removed from the Rules of Business.
She also asked Arif, Do you have a Terms of Reference (TOR) or a Charter of Duties that we can use to
specify what to put on the dashboard?
No, replied Arif, we dont have anything specific to my working in this department. A Secretarys duties and
functions are given in the Rules of Business (Exhibit 8), but they are generic.
Anwar suggested, Perhaps we can have several sections and each section can focus on one aspect of the
working of the department as specified in the Rules of Business. This way, we will cover both what we are
currently doing and what we should be doing but are not.
Asim, who had previously worked with the School Education Department to develop a District Report Card,
shared a sample of the Report Card (Exhibit 9). The Report Card contained summary statistics on staff strength
and vacancies, teachers attendance, student enrolment and attendance, students exam performance, missing
facilities, budget allocation and utilisation, and inspection visits by supervisory authorities. He highlighted four
aspects of the Report Card. Firstly, it showed trends by comparing data across several months. Secondly, it
presented data for the entire district as well as for constituent tehsils. Thirdly, data was gender segregated for
some indicators. Lastly, several data items were ratios, which provided a relational analysis of variables. Can
we develop something on these lines? he asked.
Zahid suggested that the dashboard should have layers. It should provide summary statistics for the entire
province, but should also support deeper exploration, if one so wished. For example, it should be possible to
also view district (or tehsil or facility) level statistics for the current year as well as for previous years. This
would make it useful for several tiers of functionaries. The same dashboard could be used by the Minister and
senior managers as well as by EDOs.
Arif liked the idea. We can give different access rights to various users. Can we make at least a portion of the
summary statistics available for viewing by the general public as well? he asked.
Beena wondered why that should be a problem. She was of the view that other than information on individuals,
the entire information on working of various facilities, resources at their disposal, budget allocation and
utilisation and targets achieved should be available to the public at large. The dashboard should have a
permanent tab on the DOH website. This will help generate public pressure on DOH functionaries to improve
their performance, she opined.
Farasat shared a few dashboard samples. He highlighted that these sample dashboards presented data on output
and outcome level indicators. He said:
We receive a lot of data every month on dozens of indicators, but except for a handful, all of
these indicators either relate to inputs or to activities. So we end up measuring how many
officials we have posted, how much money we have allocated and which equipment or
building we have provided. At best, we measure whether or not the doctors et al. are present
in the health facility. But we hardly make any effort to measure what we are achieving. For
this we shall have to focus on outputs or better still outcome level indicators.

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He proposed that the dashboard should have data on the following indicators:

Facility utilisation i.e. patients per staff member;

Doctor/ patient ratio; paramedic/ doctor ratio;

Population per doctor or per hospital bed;

Infant and maternal mortality rates;

District-wise proportion of children immunised;

Proportion of deliveries at health facilities or by trained birth attendants;

Number of drug samples taken and proportion found spurious;

Number of tests/ X-ray /MRI /CT scans conducted;

Polio/ dengue cases detected and treated;

Cost per patient or per procedure; cost comparison across facilities/districts

Arif wondered if it was possible to calculate cost per patient or per procedure. He asked, How will you
apportion cost of the District Offices and of the support provided by DGHS?
Farasat responded in these words: Yes, this is tricky. But there must be a way to do this. I am sure there are
accounting conventions to handle such apportionment. The private health facilities do it on regular basis. Let us
ask them to help us with this.
Farasat further emphasised that by focusing on outputs and outcome level indicators, the dashboard could
become an important instrument of assigning targets to health facilities and districts. It would also enable a
performance comparison across districts. Beena proposed that at least some indicators on preventive healthcare
should also be included in the dashboard. She complained that the DOH was very indifferent to this aspect of
healthcare, and consequently ended up spending substantial sums on ailments that could have been prevented at
a fraction of the cost.
Arif asked how health awareness would be measured. After all, raising awareness was also an important
function of the department and a key component of preventive healthcare. Farasat said that surveys could be
designed to measure awareness among the public at large.
Asim cautioned against putting too much into one dashboard:
In your efforts to make it comprehensive, you will make the dashboard unwieldy and
complex. Then you wouldnt look at it. The whole point is to present key information in a
visually-friendly manner. Also, this dashboard will not be the only thing the Secretary will
look at. It is just one of the several data sources at his disposal.
Arif then asked if having a layered structure would solve this problem. He stated, We do not have to display
everything on one screen. Instead, we can have links to lead the interested viewer to more detailed information.
Thats true, replied Farasat, but we have to be careful in choosing what goes in the first screen thats the
one most looked at.
Arif asked if anyone had an idea of how much resource it would take to build a dashboard. Asim suggested that
it should not cost much, given that most of the data was already being collected by DGHS and/or PHSRP. He
said, It is just a question of deciding which data you want and in what form. Once that has been done, your IT
people should be able to do it for you.

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How frequently will we need to update it? asked Arif. Farasat replied that it would vary for different
indicators:
Some values change daily e.g. outpatient or medicine stock out. But some values change over
a long time e.g. population per hospital bed or proportion of children immunised. Then there
are variables whose values change over a very long time e.g. infant mortality rate. We collect
data on these indicators accordingly. We will update the dashboard as and when new data is
available for an indicator. So some indicators will be updated daily, while others will be
updated monthly and some annually.
Beena enquired about those indicators for which data was not readily available, such as juvenile smoking or
nutrition. Farasat replied that PHSRP could conduct surveys and update the dashboard as soon as results from a
survey were available.
Moving Forward
The meeting was inconclusive. Even after two hours of discussion, Arif and his team did not agree regarding the
choice of indicators. Farasat proposed the following eight sections for the dashboard:

HR management;

Physical assets and financial resources;

Key activities, outputs and outcomes;

Development schemes;

Medical education;

Implementation of laws;

Findings from various periodic surveys;

Emergent issues

He wanted the aggregate statistics in these eight areas to fit on one screen, which Arif could quickly glance
through and see how things were. He proposed that most of these statistics should be shown in a graphic, rather
than a tabular form. He also wanted each section to lead to detailed district-wise or facility-wise information.
Such detailed information would be available on a click to different users, who would have variable access
levels.
Arif spent the next few days pondering about the appropriateness of the above eight sections. He did not want to
put too much on the dashboard, but neither did he want to miss important indicators that ought to be included.
He was also thinking about how he could use the dashboard to improve his management in particular and the
effectiveness and efficiency of healthcare provision in general.

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Exhibit 1:

Health Facilities and Practitioners in Punjab- Number of Public Sector


Health Facilities in Various Categories

Category
Basic Health Units
Rural Health Centres
Tehsil Headquarters Hospitals
District Headquarter Hospitals
Teaching/ Tertiary Care Hospitals
Others

Description
Basic medical/ surgical care and referral
10-20 inpatient beds for 100,000 people
40-150 beds with nine specialties
>150-400 beds with 18 specialties
Large hospitals with multiple specialties
Dispensaries
TB Clinics and Hospitals
Mother and Child Health Centres (MCHC)
Specialised Hospitals

Number
2,456
293
89
36
31
738
19
329
5
3,996

Total

Source: Department of Health. DHIS Quarterly Report 4th Quarter 2011. Lahore: Directorate General of
Health Services, Government of Punjab, 2011.

Manpower Employed in the Health Sector (Public and Private)

130,220

140000

Pakistan

120000
100000

Punjab
76,244

80000
52,486

60000
40000
20000

51,577

27,855
14,250

11,372

11,510
4,602

27,153
10,148

7,112

0
Specialists

MBBS

BDS

Nurses

LHVs

Midwifes

Source: Ministry of Finance. Pakistan Economic Survey 2011-12. Islamabad: Ministry of Finance,
Government of Pakistan, 2011.

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Exhibit 2:

Functions of the Health Department, 2nd Schedule - Punjab Government


Rules of Business, 2011, Health Department (p1 of 2)

1.

Health management, planning and policy

2.

Policy matters relating to guidelines regarding:


(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)

3.

Prevention and control of infectious and contagious diseases


Tuberculosis
Eradication / control of malaria
Lepers Act
Treatment of patients bitten by rabid animals
Adulteration of foodstuff through administration of Pure Food
Ordinance, 1960 and the rules framed there-under:
Nutrition surveys
Nutrition and publicity in regard to food
Vaccination and inoculation
Maternity and child welfare
Port quarantine

Medical profession:
(a)
(b)
(c)
(d)
(e)
(f)

Regulation of medical and other professional qualifications and standards


Medical practitioners (National Service) Act, 1950
Medical registration including Medical Council
Indigenous system of medicine
Medical attendance of government servants
Guidelines regarding levy of fee by medical officers

4.

Medical and Nursing Council

5.

Medical education including Medical Schools and Colleges and institution of Dentistry

6.

Control of medicinal drugs, poisons and dangerous drugs (Drugs Act and Rules)

7.

Medical institutions, chemical examination laboratories and Blood Transfusion services in the
province including Blood Bank

8.

Collection, compilation, registration and analysis of vital health statistics and estimation of population
for future projections

9.

Matters relating to Nursing:


(a)
(b)

Administrative control of the entire nursing cadre in the Province in respect of those working
under the provincial Health department or in the teaching hospitals
Education (local and foreign) service and pay structure of nursing cadre

10.

Preparation of development schemes, budget, schedule of new expenditure and ADP proposals

11.

Budget, accounts and audit matters

12.

Purchase of stores and capital goods for the department

13.

Service matters except those entrusted to Services and General Administration Department

14.

Administration of the following laws and the rules framed there-under:


i.
ii.

The Public Health (Emergency Provisions) Ordinance, 1944


Epidemic Diseases Act, 1958
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Exhibit 2:
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
xiv.
xv.
xvi.
xvii.
xviii.
xix.
xx.
xxi.
xxii.
xxiii.
xxiv.
15.

Functions of the Health Department, 2nd Schedule - Punjab Government


Rules of Business, 2011, Health Department (p2 of 2)
Punjab Vaccination Ordinance, 1958 (W.P Ordinance XXVII of 1958)
Punjab Juvenile Smoking Ordinance, 1959 (W.P. Ordinance XII of
1959)
Punjab Prohibition of Smoking in Cinema Houses Ordinance, 1960
(W.P. Ordinance IV of 1960)
Eye Surgery (Restriction) Ordinance 1960
Punjab Pure Food Ordinance, 1960 (W.P Ordinance VII of 1960)
Allopathic System (prevention of misuse) Ordinance, 1962
Pakistan Medical and Dental Council Ordinance, 1962
Unani, Ayurvedic and Homoeopathic Practitioners Act, 1965
Pharmacy Act, 1967
Drugs Act, 1976
Medical & Dental Degree Ordinance 1982
Punjab Health Foundation Act, 1992
Punjab Transfusion of Safe Blood Ordinance 1999
Mental Health Ordinance for Pakistan 2001
Protection of Breast Feeding and Child Nutrition Ordinance, 2002
Prohibition of Smoking and Protection of Non-smokers Health
Ordinance, 2002.
Punjab Medical and Health Institutions Act 2003
Injured Persons (Medical Aid Act) 2004
King Edward Medical University, Lahore Act, 2005.
Human Organ Transplant Ordinance, 2007.
Pakistan College of Physicians and Surgeons Ordinance, 1962.
The University of Health Sciences Lahore Ordinance, 2002.

Matters incidental and ancillary to the above subjects.

Source: Punjab Government Rules of Business, 2011.

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Exhibit 3:

Organogram of Provincial Secretariat


Secretary Health
Special Secretary
Health

Teaching
Institutions

Tertiary
Care
Hospitals

Program Director,
Punjab Health Sector
Reforms Program

Additional
Secretary
(Establishment)

Director
General Health
Services

Additional
Secretary
(Development)

Additional
Secretary
(Administration)

Additional
Secretary
(Technical)

36 EDOs
(Health)

District level
EDO
(Health)

MS, DHQ Hospital

Principal Nursing
School

MS, THQ
Hospital

Program
Director
DHDC

CDCO, Entomologist,
etc.

MS
Medical Superintendent
DHDC District Health Development Centre
CDCO Communicable Disease Control Officer
Source: Developed by author.

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DO (H)

DDO (H)
(Tehsil)

District Drug Inspector


District
Coordinator
National Programs

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Exhibit 4:
Sr. No.

DHIS Indicators for PHC and SHC Facilities (p1 of 3)

1
2
3
4
5
6
7
8
9
10
11
12
13

Indicator
Overall Performance
Daily OPD attendance
Full immunisation coverage
Antenatal care coverage
Delivery coverage at facility
TB-DOTS patients missing more than one week
Total visits for FP
Obstetrics complications attended
C-Sections performed
Lab services utilisation
Bed occupancy rate
LAMA
Hospital death rate
Monthly report data accuracy

14
15
16
17

Outpatients Attendance
New cases
Follow up
Number of cases of malnutrition < 5 years children
Referred attended

18
19
20
21
22
23

Immunisation and TB-DOTS


Children <12 months received 3rd Pentavalent vaccine
Children <12 received 1st Measles vaccine
Children <12 months fully immunised
Pregnant women received TT-2 vaccine
Intensive phase TB-DOTS patients
Intensive phase TB-DOTS patients missing treatment > 1 week

24
25
26
27
28
29
30
31
32
33

Family Planning Services


Total FP visits
COC cycles
POP cycles
DMPA Inj.
Net-En Inj.
Condom Pieces
IUCD
Tubal Ligation
Vasectomy
Implants

34
35
36

Maternal and New-born Health


1st Antenatal Care visits (ANC-1)
ANC-1 women with Hb < 10g/dl
Antenatal care revisit in the facility

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PHC

SHC

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Exhibit 4:

DHIS Indicators for PHC and SHC Facilities (p2 of 3)

Community Data
Pregnant women newly registered by LHWs
Deliveries by skilled persons reported
Maternal deaths reported
Infant deaths reported
Number of modern FP methods users
<5 years diarrhoea cases reported
<5 years ARI cases reported

52
53

Community Meetings
Number of community meetings
Number of participants

54
55
56
57

Diagnostic Services
Total lab investigations
Total X-Rays
Total ultra sonographics
Total ECGs

58

Stock out
Stock out of drugs/vaccines

59
60
61
62
63
64
65
66
67
68

Indoor Services
Allocated beds
Admissions
Discharged not on same day of admission
Discharged on same day of admission
LAMA
Referred
Deaths
Total of daily patient count
Bed occupancy
Average length of stay

69
70
71

Procedures
Operations under general anaesthesia
Operations under spinal anaesthesia
Operations under local anaesthesia

37
38
39
40
41
42
43
44

1st Postnatal care visit in the facility


Normal vaginal delivery in facility
Vacuum/ forceps deliveries in facility
Caesarean Sections
Live births in the facility
Live births with LBW < 2.5 kg
Still births in the facility
Neonatal deaths in the facility

45
46
47
48
49
50
51

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Exhibit 4:

DHIS Indicators for PHC and SHC Facilities (p3 of 3)

72

Operations under other type of anaesthesia

73
74
75
76
77

Human Resource Data


Sanctioned
Vacant
Contract
On general duty in facility
On general duty out of facility

78
79
80
81
82
83

Revenue Generated and Financial Report


Total receipts
Deposits
Total allocation for the fiscal year
Total budget released to-date
Total expenditure to-date
Balance to-date

84
85
86

Others
LHW pregnancy registering coverage
Total Homeo cases
Total Tibbi/Unani cases

Source: DHGS Records, 2014.

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Exhibit 5:

Indicators used by MEAs

Cleanliness and general outlook of the facility;

Display of signboard/direction board, organogram, maps, etc.;

Availability and functionality of utilities;

Disposal of hospital waste;

Purchee fee deposited and OPD visits during last month;

Attendance of doctors;

Details of absent staff other than doctors;

Vacant posts;

Inspection of the facility by District Government officers;

Availability of medicines;

Indoor patients and availability of MO and Nurses in evening and night shifts;

Public opinion regarding the following: presence of doctors, attitude of doctors towards patients,
waiting time, free availability of medicines;

Progress of development schemes/ provision of missing facilities;

Availability and functionality of equipment

Note: Sr. No. 11 above was not applicable to BHUs.


Source: DGHS Records, 2014.

Exhibit 6:

BHU/RHC Ranking Criteria and Weights Assigned


Weightage
BHU
RHC
7
8
5
8
8
4
6
10
21
21
10
10
23
21
5
5
5
5
10
8
100
100

Indicator
Cleanliness/general outlook
Displays
Availability of utilities
Functioning of equipment
Availability of medicines
Public opinion
Doctors presence
Preventive staff presence
Administrative staff presence
Paramedics presence
Total
Source: PHSRP Records, 2014.

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Exhibit 7:

Indicators used in Smartphone based Data Collection

Medical Officer present/absent or other staff absent

Tablets out of stock

Injections out of stock

Syrups out of stock

Other medicine out of stock

Non-functional equipment

OPD cases per day

Deliveries per month

Outlook

Display of maps, organogram, etc.

Outreach

Source: PHSRP Records, 2014.

Exhibit 8:

Duties and Functions of Secretary, Punjab Rules of Business, 2011

10. Functions of the Secretary.(1) A Secretary shall:


a)

be the official head of the Department and be responsible for its efficient administration and discipline,
for the conduct of business assigned to the Department and for the observance of laws and rules,
including these rules, in the Department;
b) be responsible to the Minister for the business of the Department and keep him informed about the
working of the Department, and of important cases disposed of without reference to the Minister;
c) assist the Minister in the formulation of policy and bring to the notice of the Minister cases required to
be submitted to the Chief Minister under the rules;
d) execute the sanctioned policy;
e) submit, with the approval of the Minister, proposals for legislation to the Cabinet;
f) keep the Chief Secretary informed of important cases disposed of in the Department;
g) issue, subject to any general or special orders of the Government:
i) standing orders specifying the cases or class of cases which may be disposed of by an officer
subordinate to the Secretary; and
ii)specific orders and instructions to its officers for the conduct of the business assigned to a District
Government.
(2) While submitting a case for the orders of the Minister, the Secretary shall suggest a definite line of
action.
(3) Where the Ministers orders appear to contravene any law, rules, regulations or Government policy,
the Secretary shall resubmit the case to the Minister inviting his attention to the relevant law, rules,
regulations or Government policy, and if the Minister disagrees with the Secretary, the Minister may
refer the case to the Chief Minister for orders.
Source: Punjab Rules of Business, 2011
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Exhibit 9:

District Report Card Chakwal

Source: Punjab School Education Department, 2014.

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