While reporting a substantial expansion in the National Programme for Family Planning and Primary Health Care between December 2007 and November 2009 compared with 2003 despite facing the decentralisation-triggered challenges, a latest external evaluation of the Health Ministry’s initiative launched in 2000 says the programme has penetrated into more rural and less advantaged areas though it is still not reaching the most disadvantaged areas.

“Coverage rates, work levels, knowledge and delivery of services have generally improved. Overall, the programme has expanded substantially,” say the findings of the evaluation done by Oxford Policy Management (OPM), UK. The Canadian International Development Agency (CIDA) had provided funding for the evaluation through the World Bank Trust Fund.

However, despite this significant progress, the evaluation points out failure of the full implementation of the Programme’s strategic plan and PC-1, and introduction of the systems development initiatives.

“The governance arrangements generally failed to deliver on performance reporting and ensuring accountability, and many issues identified in the Management Review may have been addressed if a stronger governance arrangement had been in place.

Some of other issues that were not addressed are options for decentralisation, non-compliance with residency criteria in Sindh, issues of integration with basic health units (BHUs) that have been contracted out to non-governmental organisations, and further expansion in urban areas at the expense of development of the programme into poorer rural areas. These are issues that needed to be exposed by the National Coordinator of the Programme, addressed through the governance committees, and on which decisions needed to be taken to resolve the issues by the secretary of health and the central agencies,” say the evaluation findings released here during a function where Advisor to the prime minister on Social Development Shahnaz Wazir Ali was the chief guest.

The evaluation was done to explore whether the programme had provided the services planned from July 2003 to June 2008 to the accepted quality standards; to the agreed level of coverage; with an impact on the health system; and at a reasonable cost.

With a nationally representative sample, the survey covered 5,752 households and 554 lady health workers (LHWs) — in 60 districts of the Punjab, Sindh, NWFP, Balochistan, Azad Jammu and Kashmir, and Federally Administered Northern Areas (Fana).

Separate interviews were conducted with 298 Lady Health Supervisors (LHSs), selected medical staff at 335 health facilities (FLCFs), 572 community groups and the District Programme Implementation Units, which managed the selected LHWs.

According to the OPM evaluation, the Programme is contributing a lot to the provision of preventive, promoting and basic curative care to the people in their communities, besides along with a link to link to emergency and referral care. However, it has no intended impact on areas including hygiene and sanitation behaviour, breastfeeding, growth monitoring and attendance at deliveries.

Additional attention by the programme to the performance of LHWs might bring substantial health benefits in these areas. It also said the Programme has improved supervision and has increased average levels of knowledge. The level of service delivery has increased. However, there remain a group of under performing LHWs whose working practices must be improved, and gaps in LHWs’ knowledge. There remain significant failures in supply systems, both in medicines and equipment. These are issues that must still be addressed going forwards.

While highlighting the Programme’s positive effects on the well-being and empowerment of women it employs, the OPM evaluation said LHWs were relatively more empowered compared with other working women. “The explicit focus on training, the visible nature of the work, and the high degree of mobility and self-confidence that this interaction with the community requires all serve to empower women in ways that other work does not,” it said.

As for management and control of the programme’s systems, they have coped with the large expansion of the Programme from 40,000 LHWs in 2000 to almost 90,000 LHWs in 2008.

According to the study, the systems have operated to: recruit LHWs and LHSs (although there was a failure to recruit drivers); provide training, including continuing training at the health facility and refresher training courses; improve the level of supplies to LHWs (although there are still problems); improve the payment of salaries (although, again, there are still unacceptable delays); and increase the level of supervision of LHWs.

“The core design of the systems appears robust, and has been sustained over the 15 years of the life of the programme. Poor systems performance occurs most often when there is a shortage of inputs, or non-compliance with the systems standards. For example, there was insufficient procurement of supplies for the LHWs (logistics system); non-compliance with residency criteria in Sindh (selection and recruitment system); and lack of funds for salary payments was evidenced at the time of the Quantitative Survey,” it said.

However, it suggested these problems were management and governance problems, not systems problems. Highlighting three areas of non-performance in systems, the OPM evaluation of the programme said that the system for dealing with non-performance of LHWs required improvement so that, where there is evidence of non-performance and a non-willingness to work, the LHW can be terminated efficiently. It said the process for condemnation of vehicles was also not operating; while the procurement process conducted by the Health Ministry and the FPIU had experienced problems resulting in long delays in purchasing.

“Systems need to undergo continuous improvement (not necessarily be radically changed), and planned systems developments were generally not implemented. This cannot be attributed to lack of funding neither can this be due to the tensions of rapid expansion, as most of the expansion of the Programme had occurred by 2003.

Our conclusion is that there is a lack of management attention focused on systems improvements: attention is absorbed by operational concerns. It is also difficult to build up the necessary experience to deal with systems development when there are frequent changes in senior management in the Programme and in the Ministry of Health (see also Management Review). There is also a lack of accountability to the Ministry of Health for developments budgeted for and approved in the Strategic Plan and PC-1,” the evaluation said.

As for the programme’s budgets and expenditure per LHW, according to the study, they have increased since 2002. It said the Programme was not under funded, as sufficient funds were provided to expand from approximately 70,000 to 100,000 LHWs (if donor contributions are included). It declared the cost structure of the PC-1 (2003-08) appropriate for future budgeting.

The LHW supervision and performance management, and effective district-level management were suggested as the Programme’s key short and medium-term measures.

“The programme’s impact can be increased further by increasing rate of LHW service provision, LHW knowledge levels, and expansion into poor and un-served areas. And this can be ensured through LHW recruitment and retention, LHW supervision and performance management, training regimes (core & refresher), and district-level management,” the OPM study said.