Implementing The District Health System

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Implementing the district health system in the

framework of primary health care in Pakistan: can
the evolving reforms enhance the pace towards the
Millennium Development Goals?
F. Sabih,1 K. M. Bile,1 W. Buehler,2 A. Hafeez,3 S. Nishtar4 and S. Siddiqi5
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ABSTRACT There is growing renewed trust in primary health care as the best approach for ensuring equity in the
delivery of essential health services. However, Pakistan with one of the most widely spread district health system
networks in the region, has not delivered at the expected capacity. A series of health system reform agendas are
now stipulated which include the promulgation of an essential health service package, public private partnerships
and a people-centred focus. Nevertheless, success of these reforms will hinge on the ability of the three tiers of
the government and other stakeholders to work together to improve the overall performance of the district
health system. This paper provides an overview of the district health system infrastructure and organization
of primary health care services in Pakistan, the evolving governance pattern and the operational significance and
merit of health system pillars for effective service implementation.
Intégration du système de santé de district dans le cadre des soins de santé primaires au Pakistan : les réformes
évolutives peuvent-elles accélérer la réalisation des objectifs du Millénaire pour le développement ?
RÉSUMÉ On observe une confiance renouvelée croissante dans les soins de santé primaires en tant que
meilleure approche pour garantir l’équité dans la fourniture de services de soins de santé essentiels. Cependant,
le Pakistan, dont le réseau de systèmes de santé de district est l’un des plus étendus de la région, n’a pas été
en mesure d’assurer ces services au niveau attendu. Une série de calendriers de réformes du système de santé
a maintenant été définie. Elle comprend notamment l’annonce d’un ensemble de services de soins de santé
essentiels, des partenariats public/privé et une attention centrée sur l’individu. Mais le succès de ces réformes
dépendra de la capacité de l’ensemble du gouvernement et des autres parties prenantes à travailler de concert
pour améliorer les performances globales du système de santé de district. Cet article donne un aperçu des
infrastructures de ce système et de l’organisation des services de soins de santé primaires au Pakistan, du mode
de gouvernance évolutif et de l’importance opérationnelle des piliers du système de santé ainsi que de leur
valeur pour l’intégration efficace des services.
1
World Health Organization, Country Office, Islamabad, Pakistan (Correspondence to F. Sabih: sabihf@pak.emro.who.int)
2
Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva
3
National Health Services Academy, Ministry of Health, Islamabad, Pakistan
4
Heartfile (health sector nongovernment organization), Islamabad, Pakistan
5
World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt.
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Table1 Types and numbers of health facilities in Pakistan
Province/ Regions Districts Urban/ Hospitals (district Rural health Basic health Other first–level care facilities Health Housea
Rural headquarter centres units Dispensaries TB centres Maternal and Subhealth
hospital/ tehsil child health centres
headquarter centres
hospital)
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Islamabad Capital Urban 7 – – 40 – 4 –

Territory 1 Rural – 3 14 1 – – – 346
Punjab 35 Urban 284 63 – 531 54 425 77
Rural 23 228 2452 977 – 90 493 50 361
Sindh 23 Urban 328 46 34 1001 150 113 –
Rural 6 59 736 1112 36 38 2 22 054
Khyber Pakhtunkhwa 23 Urban 95 4 4 106 20 30 –
Rural 107 88 938 459 10 115 31 13 983
Balochistan 30 Urban 96 7 25 34 23 43 9
Rural 2 63 495 533 – 50 – 6 437
Total 112 Urban 810 120 63 1712 247 615 86
Rural 138 441 4635 3082 46 293 526
Urban 948 561 4698 4794 293 908 612 93 181
Azad Jammu and Rural 14 – 6 13 19 23 2
Kashmir 7 Urban 2 33 188 87 48 154 270 3 133
Gilgit Baltistan 6 Rural 6 – – – – – –
Urban 19 2 18 113 21 5 133 1 293
Federally administered
tribal areas 7 Rural – – – – – – – 1 490
Grand total 113 137 132 Urban 830 120 69 1,725 266 638 88
Rural 159 476 4841 3282 115 502 929
Total 989 596 4910 5007 381 1140 1017 99 097
Source: Health Management Information System, 2008; aLady Health Workers Management Information System, 2009.
Note: The recent administrative rearrangement has increased the total number of districts to 136 shortly being reflected in the reporting system.
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Table 2 Types of service available in first-level care facilities (basic health units and rural health centres)
Types of service Service availability
Basic health unit Rural health centre
1. Maternal and newborn health
Prenatal and postnatal care
Antenatal, normal delivery and postpartum care + +
Laboratory support for antenatal care
Diagnosis of pregnancy/anaemia + +
Newborn care
Antenatal, newborn and postpartum care + +
Newborn resuscitation − +
24/7 Basic emergency obstetric and neonatal care
Normal deliveries and obstetric first aid + +
Complicated deliveries − +
Post-abortion care − +
Family planning counselling and provision of contraceptives
Family planning counselling and provision of contraceptives + +
Intrauterine device (IUD) services − +
2. Child health and development
Immunization services (static facilities) + +
Management of major childhood illnesses + +
3. Nutrition
Nutrition advice, breastfeeding promotion and support, growth monitoring + +
4 and 5. Communicable and noncommunicable diseases
Counselling and curative care
+ +
Control of tuberculosis, malaria
+ +
Detect, manage and refer common communicable illnesses and
+ +
noncommunicable diseases
6. Basic diagnostic services
Laboratory and X-Ray services
Laboratory diagnostic facilities + +
Routine examinations/X-rays − +
7. Drugs dispensing/management
Dispensing, storage and record-keeping + +
8. Minor surgical services
Minor surgical operations and stabilization of emergencies (trauma and
− +
accidents)
9. Basic emergency/first aid
Stabilize/refer minor injuries, insect/snake bites + +
Poisoning, shock and minor surgical operations − +
10. Allied services
Administrative activities + +
Reception/registration, record-keeping + +
Maintenance of drugs/store-keeping + +
Sanitation + +
Training activities/meeting of Lady Health Workers + +
11. Selective outreach services
Immunization outreach and monitoring and supervision of Lady Health
+ +
Workers and community midwives
12. Dental care
Dental caries filling and dental surgery − +
Sources: Training 2000, Punjab; Essential Health Services Package for First Level Care Facilities, 2009.
+ Service available; −Service not available.
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DBSFGBDJMJUJFT UIFJSVUJMJ[BUJPOSBUFCZ 3PMM#BDL.BMBSJB OBUJPOBMUVCFSDVMP- OBUJPOXJEFUPBDUBTSFTPVSDFUSBJOJOH
UIFDBUDINFOUBSFBQPQVMBUJPOJTMPX TJTDPOUSPMOVUSJUJPOQSFWFOUJPOBOE DFOUSFTGPSDBQBDJUZCVJMEJOH)PXFWFS
XJUIMFTTUIBOPOF
QBUJFOUWJTJU DPOUSPMPGCMJOEOFTTDPOUSPMPGIFQB- UIFTFJOTUJUVUJPOTIBWFOPUSFDFJWFEBE-
QFSTPOZFBS UJUJTWJSBMJOGFDUJPOTBOEUIFFYQBOEFE FRVBUFTVQQPSUUPPQFSBUFFĎFDUJWFMZ
S136
;nüÐØ{_UÐ
Table 3 Types of service available in secondary-level care facilities (tehsil headquarter hospital and district headquarter hospitals)
Types of service Service availability
Tehsil District
headquarter headquarter
hospital hospital
Preventive services
Basic maternal care
Antenatal, natal , complicated deliveries and post partum care, perinatal and maternal
mortality reviews, family planning services, prevention and management of sexually
transmitted illnesses and reproductive tract infections + +
Immunization
Measles, diphtheria, tetanus, polio, pertussis, tuberculosis, hepatitis B and vitamin A
supplementation + +
Mental health
Identification, diagnosis, counselling and management and rehabilitation + +
Major micronutrient supplementation
Iron , folic acid, iodine, vitamin A and vitamin D supplementation + +
Screening for common health problems
Hypertension, diabetes mellitus, anaemia, malnutrition, obesity, visual acuity + +
Outreach and community services
Health education and promotion on maternal, neonatal and child health issues + +
Promotive services
Health education and promotion
Creation of awareness and demand for immunization, prenatal, natal and post natal care,
family planning, good nutrition and hygiene practices, healthy life style, environmental and
gender health, health seeking behaviour + +
Curative services
24/7 Basic emergency obstetric and neonatal care
Normal deliveries and obstetric first aid, newborn care and resuscitation, complicated
deliveries, post abortion care + +
Comprehensive emergency obstetric and neonatal
Caesarean section, blood transfusion, incubator, advanced resuscitation support & paediatric
nursery + +
Child health care (integrated management of neonatal and childhood illnesses)
Malaria, measles, ENT, tetanus neonatorum, malnutrition, anaemia, childhood TB & deworming + +
Medical outpatient department and indoor services
Basic medical care including communicable and noncommunicable diseases + +
Specialist medical care + +
Surgical outpatient department and indoor services
Basic surgical care (incision and drainage, splints and control of haemorrhage) + +
Specialist surgical care + +
Mortality reviews (hospital death reviews by a designated team) + +
Emergency services
24-hour basic medical, surgical and other emergency services + +
Trauma care (trauma centres) + +
Burns (established burn units) − +
Blood transfusion services
Blood grouping, cross matching, screening for malaria, hepatitis B and C and HIV/AIDS + +
Diagnostic services
Basic diagnostics (urine routine, urine sugar, blood routine and malarial parasite)
Routine diagnostics (blood and urine complete examination , X-ray and ultrasound) + +
Advanced diagnostics (histopathology, microbiology, biochemical, renal and lipid profile, + +
gastroscopy, endoscopy) + +
CT scan − +
Rehabilitative services
Physiotherapy, psychiatric, psychological, social and palliative + +
Surgical − +
Source: Minimum Service Delivery Standards for Primary and Secondary Health Care in Punjab by the Punjab Devolved Social Security Program, 2008.
Tehsil headquarter hospital sanctioned specialists include surgeon (general and orthopaedic), anaesthetist, physician, gynaecologist, radiologist, pathologist,
ophthalmologist and paediatrician. District headquarter hospital sanctioned specialists additionally include urologist, cardiologist, neurosurgeon, psychiatrist,
pulmonologist, dermatologist and paediatric surgeon.
+ Service available; − Service not available.
S137
Health information QVCMJDTFDUPSQSPDVSFNFOUSFHVMBUPSZ Health financing

ĉFOBUJPOBMIFBMUIJOGPSNBUJPOTZTUFN BVUIPSJUZ BOBVUPOPNPVTCPEZXJUIUIF )FBMUIėOBODJOHJOUIFQVCMJDTFDUPSIBT
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IFBMUIFWFOUT XIJDIBMPOHXJUINBMOV- ESVHMJTUUIBUDPOTJTUTPGNFEJDJOFT MJOF CVEHFU QPPMu BMMPĨFE UP MJOF
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BDIJFWFNFOUT BOESFDPNNFOEBUJPOT BSFHFOFSJDTĉFQBDLBHFPGFTTFOUJBM BMMPDBUFE GPS TBMBSJFT BOE PQFSBUJPOBM
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OFUXPSL*OUIFQBTUGFXZFBST FĎPSUT DVSFNFOUPGNFEJDJOFTBOEFRVJQNFOU
GBDJMJUJFT QSFTDSJCF GSFFMZ QSPWJEFE
IBWFCFFONBEFUPFYQBOEUIFTDPQF NBZSFBDIPGUIFCVEHFUPGUIFTF
NFEJDJOFT XIFO BWBJMBCMF IPXFWFS
PGUIFIFBMUIJOGPSNBUJPOTZTUFNUPJO- JOTUJUVUJPOT"MUIPVHIUIFGPSNBMTFDUPS
NPTUQVCMJDTFDUPSGBDJMJUJFTTVĎFSGSPN JTDPWFSFECZEJĎFSFOUGPSNTPGTPDJBM
DPSQPSBUF JOGPSNBUJPO GSPN IPTQJUBM
GSFRVFOUTUPDLPVUTUIBUGPSDFQBUJFOUT IFBMUI JOTVSBODF UIF JOGPSNBM TFDUPS
JOQBUJFOUTBOEUIFQSJWBUFTFDUPSĉF
BOEGBNJMJFTUPQSPDVSFESVHTPOUIFJS IBTMJĨMFPSOPTPDJBMQSPUFDUJPO NBLJOH
FOIBODFE IFBMUI JOGPSNBUJPO TZTUFN
JNQMFNFOUBUJPOIBTTPGBSDPWFSFEBCPVU PXO UIFSJTLPGPVUPGQPDLFUDBUBTUSPQIJD
EJTUSJDUTPGUIFDPVOUSZĉFSFJTDVS- 5BCMFEFQJDUTUIFBWFSBHFOVNCFS FYQFOEJUVSFTNPSFMJLFMZUPPDDVS
SFOUMZ IPXFWFS OPQSPWJTJPOJOFJUIFSPG PGEBZTQFSNPOUIUIBUFTTFOUJBMESVHT 5BCMFJMMVTUSBUFTUIFDMBTTJėDBUJPO
UIFTZTUFNTUPDPMMFDUBOEJODPSQPSBUF SFNBJOFE PVUPGTUPDL JOWBSJPVT EJT- PG UIF EJTUSJDU IFBMUI TZTUFN CVEHFU-
JOGPSNBUJPOGSPNUIFUFSUJBSZDBSFQVCMJD USJDUIFBMUITZTUFNPVUMFUT0OUIFPUIFS BSZBMMPDBUJPOTFBSNBSLFEGPSEJĎFSFOU
IPTQJUBMTBOEUIFQSJWBUFIFBMUITFDUPS IBOE QSPDVSFNFOUPGNFEJDJOFTBOE IFBMUI GBDJMJUJFT ĉF ZFBSMZ VOJUDPTUT
PGBCBTJDIFBMUIVOJUBOEBSVSBMIFBMUI
PUIFSTVQQMJFT FRVJQNFOUBOESFMBUFE
Medical products and DFOUSFWBSZCFUXFFOQSPWJODFT SBOH-
technologies UFDIOPMPHJFTEPFTOPUQVSTVFOBUJPO-
JOHGSPN64UP64
ĉFQVCMJDTFDUPSQSPDVSFNFOUGVOD- BMMZTFUUFDIOJDBMHVJEFMJOFT-JLFXJTF
XJUISVSBMIFBMUIDFOUSFBMMPDB-
UJPOTPGUIFEJTUSJDU JODMVEJOHQSPDVSF- UIFSF BSF OP QPMJDJFT UP SFQMBDF VTFE UJPOTCFJOHUPUJNFTIJHIFSUIBO
NFOUPGNFEJDJOFT BSFNBOBHFECZB FRVJQNFOUBěFSDPNQMFUJOHBEFėOFE UIF CVEHFU BMMPDBUFEGPS CBTJD IFBMUI
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Table 4 Essential drugs—days out of stock (mean number of days per month)
Essential drug Hospital Rural health Basic health Dispensary Maternal and TB centre SSC SHC
centre unit child health
centre
Oral rehydration salts 5 7 8 7 9 13 8 7
Co-trimoxazole tablets 5 6 6 7 8 8 7 3
Chloroquine tablets 9 8 9 9 9 12 9 3
Folate tablets 9 10 12 11 10 13 9 13
Iron tablets 8 9 11 10 10 11 9 10
Source: National Health Management Information System Data 2005–2008.
TB = tuberculosis; SSC = social security centre; SHC = subhealth centre.
S138
;nüÐØ{_UÐ
JODMVEJOH TUJQFOE USBJOJOH QSPDVSFE
Suspected Malnutrition Rate of commonly

Table 5 Common diseases and conditions diagnosed in district headquarter hospital/tehsil headquarter hospitals and first-level care facilities in Pakistan (summarized from 480.50
NFEJDJOFTBOEFRVJQNFOUBOEUIFFY-
18 diseases/
conditionsc
diagnosed
QFOEJUVSFJODVSSFEPONPOJUPSJOHBOE
68
65
63
63
70
74
73
%
TVQFSWJTJPO
'JHVSFTIPXTUIFUSFOEJOBMMPDB-
UJPOTGSPNmUPmBUUIF
GFEFSBM BOE QSPWJODJBM MFWFMT 'FEFSBM
IFBMUI BMMPDBUJPOT JODSFBTFE PWFS UIF
20
22
33
18
21
21
%
3
ZFBST CVU EFDSFBTFE JO m EVF
UPUIFSFWJTFE/BUJPOBM'JOBODF$PN-
NJTTJPO BXBSE EJTUSJCVUJPO XIFSFBT
Includes measles, neonatal tetanus, diphtheria, whooping cough, meningitis; bIncludes dog bites, snake bites; cReported in HMIS (except AIDS) along with malnutrition in children less than 3 years.
cholera
0.00
0.00
0.00
0.02
0.01
0.01
0.01
QSPWJODJBMTIBSFTGSPNUIFEJWJTJCMFQPPM
%
XFSFFOIBODFETJHOJėDBOUMZ1SPWJODJBM
TIBSFTIBWFJODSFBTFEGSPNUIFQSFTFOU
Animal
bitesb
0.00
UP JO UIF ėSTU ZFBS PG UIF
0.06
0.07
0.04
0.04
0.24
0.18
%
/BUJPOBM'JOBODF$PNNJTTJPO m

BOEUPJOUIFSFNBJOJOHZFBST
hepatitis
0.07
Viral
0.03
0.03
0.03
0.03
PGUIFBXBSE)PXFWFS QSPWJODFTXJMM
0.01
0.14
%
IBWFUPXPSLUPNBLFUIFUBSHFUJOHPG
UIFTFBEEJUJPOBMSFTPVSDFTUSBOTQBSFOU
Goitre
0.02
0.02
0.02
0.03
0.03
0.03
0.01
BOEFĎFDUJWF
%
Organization and
preventable suspected TB
management
Cough
0.84
0.56
0.38
0.54
0.17
1.26
27
%
ĉF QSJNBSZIFBMUIDBSFTFSWJDFTJOB
EJTUSJDU BSF NBOBHFE CZ BO FYFDVUJWF
EJTUSJDU PđDFS PWFSTFFJOH UIF EJTUSJDU
diseasesa
Vaccine
IFBMUI TZTUFN OFUXPSL PQFSBUJPOT

0.04
0.04
0.04
0.02
0.02
0.03
0.01
%
XIJMFUIFEJTUSJDUIFBERVBSUFSIPTQJUBM
JTSVOCZBNFEJDBMTVQFSJOUFOEFOU#PUI
UIFNFEJDBMTVQFSJOUFOEFOUBOEFYFDV-
Diarrhoea Fever Dysentery Scabies
2.50
UJWFEJTUSJDUPđDFSSFQPSUUPUIF%JTUSJDU
%
5
3
$PPSEJOBUJPO 0đDFS QSPWJODJBM

EJSFDUPSHFOFSBMGPSIFBMUITFSWJDFTBOE
0.41
3.55
UIF SFDFOUMZ SFFTUBCMJTIFE EJWJTJPOBM

%
3
4
Source: Health Management Information System Aggregated Data 2001-2009.
EJSFDUPST ĉF DPPSEJOBUJPO CFUXFFO

UIFFYFDVUJWFEJTUSJDUPđDFSBOENFEJDBM
TVQFSJOUFOEFOUJTPěFOXFBLBOEEF-
10
10
12
13
%
11
6
QFOETUPBHSFBUFYUFOUPOUIFJSFĎPSUTUP
HFOFSBUFQBSUOFSTIJQTBOEDPPQFSBUJPO
7.04
%
5PJNQSPWFUIFRVBMJUZPGTFSWJDF
million patient visits during 2001–09)
ARI = acute respiratory infection; TB = tuberculosis.
QSPWJTJPOJOSVSBMTFĨJOHT UIFGFEFSBM
BOEQSPWJODJBMHPWFSONFOUTPQUFEUP
ARI
36
22
23
19
19
18
15
%
PVUTPVSDFBMBSHFOVNCFSPGCBTJDIFBMUI
VOJUTPOBOBUJPOXJEFCBTJTUPBOPO-
Maternal and child health
HPWFSONFOUBMPSHBOJ[BUJPO UIF1FPQMFT
(total patient visits in
1SJNBSZ)FBMUIDBSF*OJUJBUJWF 11)*

Rural health centres
Health institution
Basic health units
JOUSPEVDJOHTVCTUBOUJWFDIBOHFTJOUIF
Dispensaries
NBOBHFNFOU PG UIFTF GBDJMJUJFT ĉF

(198.3)
Hospitals
millions)
TDIFNFXBTJOJUBJMMZMBVODIFEJO
(136.1)
(76.6)
(16.0)
(45.3)
TB clinic
centres
(7.0)
Others
(1.2)
VOEFSUIFHPWFSONFOUTOFXJOJUJBUJWF
TQPOTPSFECZUIF.JOJTUSZPG*OEVTUSJFT
a
S139
BOE 4QFDJBM *OJUJBUJWFT BOE DVSSFOUMZ
Source: i) Compiled by the Planning Commission of Pakistan from Pakistan Punjab Economic Report towards Medium Term Development Strategy 2005 and Treatment Cost at the Basic Health Unit in North West Frontier Province and Federally
Workers programme
0.0001
Administered Tribal Areas 2005; ii) District Health Information System, Punjab Report Nov 2009 (Hospitals); and iii) Planning Commission Document 1 (2009-10) National Program for Family Planning and Primary Health Care (Lady Health
0.8102
total
% of
DPPSEJOBUFECZUIF$BCJOFU%JWJTJPOPG
0.08
22.04
iii) Lady Health
2.05
67.49
6.37
1.16
100
UIF'FEFSBM(PWFSONFOU
Allocation 11)* BTVCTJEJBSZPGUIFQSPWJODJBM
59,050
87 500
700.23
19 288
c
b
5 560
SVSBM TVQQPSU QSPHSBNNFT JO BHSFF-
1 790
US$
1 010
0.13
60
NFOU XJUI UIF GFEFSBM BOE QSPWJODJBM
HPWFSONFOU OFHPUJBUFTDPOUSBDUTXJUI
UIFEJTUSJDUBVUIPSJUJFTGPSNBOBHFNFOU
ii) Hospitals (tehsil &
district headquarter
total
% of
5.84
25.38
29.77
1.37
4.72
17.81
15.11
PGCBTJDIFBMUIVOJUTBOEUIFJSTFSWJDF
100
NA
hospitals)
EFMJWFSZĉFQSPWJODJBMIFBMUIEFQBSU-
Allocation
NA NFOUTUSBOTGFSBMMUIFZFBSMZCVEHFUFE
6 130
3 650
330
1 140
1 410
24 150
4 300
7 190
US$
GVOETGPSUIFTFGBDJMJUJFTUP11)* XIJDI
BSFNBOBHFEJOEFQFOEFOUMZCZGFEFSBM
Includes Rural Health Centers and Basic Health Units only; bIncludes training of Lady Health Workers only; c Includes pay and allowances of other staff, pension and physical assets etc.
QSPWJODJBM BOE EJTUSJDU 11)* TVQQPSU
VOJUT
total
% of
0.62
3.38
3.38
9.54
6.77
1.54
1.23
73.23
Balochistan
100
.FEJDBMPđDFSTJOUIFCBTJDIFBMUI
VOJUTVOEFS11)*BSFHJWFODPOUSBDUT
Allocation
XJUIBIJHIFSTBMBSZQBDLBHFBOENPCJM-
23.80
0.20
0.40
0.50
32.50
2.20
US$
3.10
1.10
1.10
JUZJODFOUJWFT$VSSFOUMZ UIFQSPWJTJPO
PGCBTJDDVSBUJWFDBSFSFNBJOTUIFNBJO
i) First-level care facilitya (unit cost per annum only)
GPDVT PG 11)*NBOBHFE CBTJD IFBMUI

Khyber Pakhtunkhwa
total
% of
2.98
9.79
1.28
0.43
74.47
2.13
5.11
VOJUTXJUIDPNNVOJUZTVQQPSUBDUJWJ-
3.4
100
UJFTSFDFOUMZUBLFOVQUISPVHITPDJBMPS-
HBOJ[FSTBOETVQQPSUHSPVQT
Allocation
0.80
0.70
1.20
0.50
0.30
17.50
23.50
2.30
US$
0.10
Community-based initiatives
and social determinants of
health
Table 6 Budget allocation by type of health facility in US$ in thousands (US$ 1 = Rs 80)
total
% of
73.90
1.99
2.99
9.76
1.59
1.39
5.18
3.19
ĉF JNQMFNFOUBUJPO PG DPNNVOJUZ

100
CBTFEJOJUJBUJWFTJTMFECZUIFJOUFHSBUFE
Sindh
Allocation
BOEDPNNVOJUZDFOUSFE#BTJD%FWFM-
1.00
0.80
1.60
2.60
50.20
4.90
0.70
1.50
US$
37.10
PQNFOU/FFETBQQSPBDI JOUSPEVDFE
POL = Petrol, oil and lubricants; BCC = behaviour change communication; NA = not applicable.
JOTFMFDUFEEJTUSJDUTPG1BLJTUBOBMPOH
XJUIPUIFS.FNCFS4UBUFTPGUIF8PSME
8.62
5.85
2.92
2.92
76.92
1.23
1.23
)FBMUI0SHBOJ[BUJPOT 8)0
&BTU-
total
0.31
% of
100
FSO .FEJUFSSBOFBO 3FHJPO UISPVHI

Punjab
8)0 UFDIOJDBM TVQQPSU ĉF #BTJD

Allocation
%FWFMPQNFOU /FFET BQQSPBDI IBT

50.00
65.00
5.60
0.80
0.80
3.80
1.90
1.90
0.20
US$
SFWJUBMJ[FE UIF GVOEBNFOUBM QSJODJQMF

PGDPNNVOJUZPSHBOJ[BUJPO NPCJMJ[B-
UJPOBOEQBSUJDJQBUJPOJOQSJNBSZIFBMUI
ransport/furniture-building department
DBSFJNQMFNFOUBUJPO DSFBUJOHBEJSFDU
Maintenance and Repair equipment/
Salary and allowances (establishment
DPOOFDUJPO CFUXFFO QSJNBSZ IFBMUI

transportation, advertising/BBC
Non-salary (operating expenses)
POL, printing, communication,
DBSFBOETPDJBMEFUFSNJOBOUTPGIFBMUI
BOEUSJHHFSJOHIFBMUIDFOUSFEJOUFHSBUFE
DPNNVOJUZBDUJPOPOXBUFSBOETBOJUB-
Drugs and medicine
UJPO CBTJDQSJNBSZFEVDBUJPO GFNBMF

Heads of Account
MJUFSBDZBOEQBSUJDJQBUJPOBOEJODPNF
General stores
Workers Program)
HFOFSBUJOHMJWFMJIPPEBDUJWJUJFTMFBEJOH
charges)
UP B TJHOJėDBOU JNQSPWFNFOU JO NB-

Utilities
Others
UFSOBMBOEDIJMETVSWJWBMBOEOVUSJUJPO
Total
IFBMUIPVUDPNFT
a
S140
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BEESFTTUIFDPNNVOJUZIFBMUIBHFOEB
BOEFOHBHFJOTUSBUFHJDQMBOOJOHUPQSP-
WJEFBDPIFSFOUBSSBZPGQSJNBSZIFBMUI
DBSFTFSWJDFTĉFHPWFSONFOUTIPVME
FYQBOE UIF EFQMPZNFOU PG EJTUSJDU
IFBMUIUFBNTCZFOIBODJOHUIFTUSFOHUI
PG-BEZ)FBMUI8PSLFST WBDDJOBUPST
BOEDPNNVOJUZNJEXJWFTJOBMMSVSBM
BOEVSCBOTMVNTFĨJOHT XIJMFJOCBTJD
IFBMUIVOJUTBOESVSBMIFBMUIDFOUSFT UIF
OFDFTTBSZGFNBMFXPSLGPSDFTIPVMECF
HVBSBOUFFEJOPSEFSUPJNQSPWFTPDJBM
BDDFQUBCJMJUZBOEBDDFTTUPUIFFTTFOUJBM
IFBMUI TFSWJDF QBDLBHF <> 1SJNBSZ
Figure 1 Federal and provincial health budgetary allocation trends (2005–06 to IFBMUIDBSFUFBNTIBWFUPNPCJMJ[FBO
2010–11) (KPK = Khyber Pakhtunkhwa)
BDUJWFOFUXPSLPGDPNNVOJUZQBSUJDJQB-
UJPOJOIFBMUIQSPNPUJPOBOEEJTFBTF
QSFWFOUJPO BDUJWJUJFT XJUI QSPWJTJPO
PG OFDFTTBSZ FNFSHFODZ SFGFSSBM TVQ-
Discussion mSFMBUFE EJTFBTFT DPOUJOVF UP QPTF
QPSU 'VSUIFSNPSF RVBMJUZ BTTVSBODF
TFSJPVTCVSEFOT EFTQJUFUIFVOJWFSTBM
JOXPSLGPSDFQFSGPSNBODFOFFETUPCF
1BLJTUBO IBT B XJEFMZ TQSFBE EJTUSJDU JNQMFNFOUBUJPOPGOVNFSPVTDPNNV-
TVTUBJOFEUISPVHIDPOUJOVJOHQSPGFT-
IFBMUITZTUFNOFUXPSL XIFSFUIFIJ- OJDBCMFEJTFBTFDPOUSPMJOUFSWFOUJPOTJO
TJPOBMEFWFMPQNFOUBMPOHXJUIIPTQJUBM
FSBSDIJDBMMZ PSHBOJ[FE ėSTUMFWFM DBSF FWFSZEJTUSJDU
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Implementing The District Health System

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Implementing the district health system in the

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Islamabad Capital Urban 7 – – 40 – 4 –

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Suspected Malnutrition Rate of commonly

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ARI = acute respiratory infection; TB = tuberculosis.

Basic health units

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