I am thrilled to share that JSI’s work to improve health financing in Pakistan’s second-largest province, Sindh, was found to improve health service delivery. As many of us who work in public health know, measuring the effects of HSS efforts, such as health financing, is not easy.
In Pakistan, JSI implemented the Health Systems Strengthening Component of USAID’s Maternal and Child Health Program from 2013 to 2018. JSI worked intensively with all 44 districts in Sindh Province to improve not only their planning and budgeting processes, but also their advocacy capacity. As a result of this work, described below, the overall funding for health in Sindh increased by 137 percent.
JSI’s approach to health systems strengthening is based on the WHO’s six building blocks. It’s important to note that JSI incorporated a holistic approach to HSS, and success in health financing could not have occurred without concurrent project activities that improved human resources for health, access to essential medicines, health information systems, leadership and governance, and service delivery.
When the HSS Component began, districts did not do any planning and received their budgets from the Sindh provincial government. The budgets were uniformly disbursed across all districts, and increased annually at a flat percentage. There was no consideration of district-level demographics, epidemiological burden, or priorities in determining district budgets.
The HSS Component started with a health facility assessment followed by technical support to health departments to develop district health profiles that identified specific health needs and gaps. The project helped the districts use information from their profiles to identify priorities and develop three-year rolling district action plans (DAPs) and budgets using the medium-term budgetary framework (MTBF). The DAPs included cross-cutting activities that affect service delivery such as training, monitoring and supervision, repair and maintenance, and community mobilization. From the three-year DAPs, the districts developed costed annual operational plans.
The HSS Component helped districts use their costed annual operational plans to advocate for increased funding to policy- and other decision-makers in the Sindh departments of health, finance, and planning and development. JSI also worked to develop mechanisms to ascertain if districts were disbursing funds according to their costed plans. As a result of these efforts, the government of Sindh allocated an additional PKR 330.8 million—an increase of 137 percent over the previous year—based on districts’ specific needs.
When a third-party evaluation team asked if the DAP and MTBF process had improved service delivery, Sindh provincial and district health managers said that, “the DAP and MTBF strengthened planning processes, created new budget lines, informed decision making, and supported needs-based budgeting and activity-based costing. The DAP process was based on the needs identified in the health facility assessment and district health profiles. Resource allocation decisions were based on confirmed needs.”
The evaluation went on to conclude that “[the HSS Component] demonstrated the efficacy of a systems approach…modeled on WHO’s health system building blocks. Evidence from multiple sources suggests that this approach yielded benefits in the form of strengthened coordination between and across departments as well as between districts and the province, increased district health financing, improved health facility reporting, increased use of information for decision making, and improved service delivery.”
One important lesson we learned, however, is that the effectiveness of the DAP process depends on the timely release of allocated budgets. In Sindh, the funds were released late, which hindered improvements in service delivery. The Sindh Department of Health must be more engaged in anticipating barriers to releasing budget funds on time, and be willing to work with the provincial finance department to streamline budget-releasing processes. Strengthening mechanisms to ensure transparency and accountability in the disbursement and use of funds is one way to do this. In fact, JSI recommended that the Sindh Department of Health establish a MTBF oversight committee for this very purpose.
JSI has been awarded a new USAID-supported project that will continue to provide technical assistance to Sindh to ensure the sustainability of HSS interventions. The new project will work in Khyber Pakhtunkhwa Province, where JSI will apply best practices and lessons from Sindh to strengthen the health system and service delivery.
*For more information, listen to Voices of Public Health Podcast with Dr. Nabeela Ali: How Does Strengthening a Health System Save Lives?