Building a Dashboard for the Punjab Health Department

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This case was written by Dr Muhammad Ahsan Rana at the Lahore University of Management Sciences to serve as basis for classdiscussion 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

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 theprovinceshealth sector. This was hardly due to inexperiencehe had previously been theSecretary 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. 1Around

68% of its population resided in rural areas and about 56% were children under the age of 15 years. 241% of the

population of 10 years and above could not even read and write.3To 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 wasestimated to provide healthcare to about 30% of the population. 4It fell within DOHs purview to regulate andbroadly 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 GovernmentsRules 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 wasresponsible to the Minister and through him, to the Chief Minister and sthe provincial legislature. A team

1Punjab Bureau of Statistics,Punjab Development Statistics (Lahore: Punjab Bureau of Statistics, Government of Punjab, 2012).2Ibid.3Pakistan Bureau of Statistics, PakistanLabour Force Survey 2010-11(Islamabad: Pakistan Bureau of Statistics, Government of Pakistan,2011).4Government of Punjab, Stocktake of Private Practitioners in Punjab(Government of Punjab, 2008).


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Building a Dashboard for the Punjab Health Department 30-001-2015-1

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composed of senior civil servants and public health specialists assisted him in the discharge of various functions

(see Exhibit 3for 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 bureaucratin 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 periodicinformation 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 variousindicators.

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 forChakwal. 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 Secretarysmeetings 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 thefield was directly recorded in soft form and transmitted to several locations instantaneously. Simple android-

based 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 notalways observations from these visits were recorded as tour notes. Being infrequent and unstructured, thesevisits 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 reportedphysical 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 departmentboth in terms of the people it employed (114,000) and the resources it expendedeach 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.

5 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 ownershipthey were mostly launched on express directivesof the Chief Minister (CM), they had to be accorded priority. Since DOH did not have dedicated staff at boththe 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 leastuntil 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 all-inclusive to be of much help in building a dashboard. The Rules spoke of several things policy, diseasecontrol, 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 Arifwanted 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 reviewedregularly, 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 theCM 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 theweek,if he wanted to keep the job. At the same time, he also appreciated that his real challenge was to improveroutine 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 beimproved, 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. Buthe 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 forcosmetic 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 teammembers 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 areasonable time span to start, said Babar.

As the chief manager, Arifs principal responsibility was to efficiently deploy the DOHshuman, physical andfiscal resources in pursuance of Punjab Governments health policy objectives. Thus, he was routinely makingdecisions 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 o r DGHS, eventually it was the Secretarys responsibility toensure 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 theessential 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 tospecify what to put on the dashboard?

No, replied Arif, we dont have anything specific to my working in this department. A Secretarys duties andfunctions 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 theworking 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, missingfacilities, 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 analy sis 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 tehsilor 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 thesummary 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 apermanent tab on the DOH website. This will help generate public pressure on DOH functionaries to improvetheir 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 outputsor better stilloutcome 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 youapportion 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 areaccounting 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 i nformation in avisually-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 displayeverything 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 theone 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 ITpeople 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 differentindicators:

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 Description Number

Basic Health Units Basic medical/ surgical care and referral 2,456

Rural Health Centres 10-20 inpatient beds for 100,000 people 293

Tehsil Headquarters Hospitals 40-150 beds with nine specialties 89District Headquarter Hospitals >150-400 beds with 18 specialties 36

Teaching/ Tertiary Care Hospitals Large hospitals with multiple specialties 31

Others Dispensaries

TB Clinics and Hospitals

Mother and Child Health Centres (MCHC)

Specialised Hospitals

738

19

329

5

Total 3,996

Source: Department of Health. DH IS Quarterl y Report 4th Quarter 2011. Lahore: Directorate General of

Health Services, Government of Punjab, 2011.

Manpower Employed in the Health Sector (Public and Private)

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

Government of Pakistan, 2011.

27,855

130,220

11,372

76,244

11,51027,153

14,250

52,486

4,602

51,577

10,1487,112

0

20000

40000

60000

80000

100000

120000

140000

Specialists MBBS BDS Nurses LHVs Midwifes

Pakistan

Punjab


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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) Prevention and control of infectious and contagious diseases

(b) Tuberculosis

(c) Eradication / control of malaria

(d) Lepers Act

(e) Treatment of patients bitten by rabid animals

(f) Adulteration of foodstuff through administration of Pure Food

Ordinance, 1960 and the rules framed there-under:

(g) Nutrition surveys

(h) Nutrition and publicity in regard to food

(i) Vaccination and inoculation

(j) Maternity and child welfare

(k) Port quarantine

3. Medical profession:

(a) Regulation of medical and other professional qualifications and standards

(b) Medical practitioners (National Service) Act, 1950

(c) Medical registration including Medical Council

(d) Indigenous system of medicine

(e) Medical attendance of government servants

(f) 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) 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

(b) 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. The Public Health (Emergency Provisions) Ordinance, 1944

ii. Epidemic Diseases Act, 1958


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Exhibit 2: Functions of the Health Department, 2nd

Schedule - Punjab Government

Rules of Business, 2011, Health Department (p2 of 2)

iii. Punjab Vaccination Ordinance, 1958 (W.P Ordinance XXVII of 1958)

iv. Punjab Juvenile Smoking Ordinance, 1959 (W.P. Ordinance XII of

1959)

v. Punjab Prohibition of Smoking in Cinema Houses Ordinance, 1960(W.P. Ordinance IV of 1960)

vi. Eye Surgery (Restriction) Ordinance 1960

vii. Punjab Pure Food Ordinance, 1960 (W.P Ordinance VII of 1960)

viii. Allopathic System (prevention of misuse) Ordinance, 1962

ix. Pakistan Medical and Dental Council Ordinance, 1962

x. Unani, Ayurvedic and Homoeopathic Practitioners Act, 1965

xi. Pharmacy Act, 1967

xii. Drugs Act, 1976

xiii. Medical & Dental Degree Ordinance 1982

xiv. Punjab Health Foundation Act, 1992

xv. Punjab Transfusion of Safe Blood Ordinance 1999

xvi. Mental Health Ordinance for Pakistan 2001

xvii. Protection of Breast Feeding and Child Nutrition Ordinance, 2002xviii. Prohibition of Smoking and Protection of Non-smokers Health

Ordinance, 2002.

xix. Punjab Medical and Health Institutions Act 2003

xx. Injured Persons (Medical Aid Act) 2004

xxi. King Edward Medical University, Lahore Act, 2005.

xxii. Human Organ Transplant Ordinance, 2007.

xxiii. Pakistan College of Physicians and Surgeons Ordinance, 1962.

xxiv. The University of Health Sciences Lahore Ordinance, 2002.

15.

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

District level

MS Medical Superintendent

DHDC District Health Development Centre

CDCO Communicable Disease Control Officer

Source: Developed by author.

Secretary Health

Teaching

Institutions

Tertiary

Care

Hospitals

Director

General HealthServices

36 EDOs

(Health)

Additional

Secretary

(Establishment)

Additional

Secretary

(Development)

Additional

Secretary

(Administration)

Addition

Secretar

(Technica

Special Secretary

Health Program Director,

Punjab Health SectorReforms Program

EDO

(Health)

MS, DHQ Hospital

Principal Nursing

School

MS, THQ

Hospital

Program

Director

DHDC

DO (H)

CDCO, Entomologist,

etc.DDO (H)

(Tehsil)

District

Coordinator

National Programs

District Drug Inspector


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Exhibit 4: DHIS Indicators for PHC and SHC Facilities (p1 of 3)

Sr. No. Indicator PHC SHC

Overall Performance1 Daily OPD attendance

2 Full immunisation coverage

3 Antenatal care coverage 4 Delivery coverage at facility 5 TB-DOTS patients missing more than one week 6 Total visits for FP 7 Obstetrics complications attended 8 C-Sections performed

9 Lab services utilisation

10 Bed occupancy rate

11 LAMA

12 Hospital death rate

13 Monthly report data accuracy

Outpatients Attendance14 New cases

15 Follow up

16 Number of cases of malnutrition < 5 years children

17 Referred attended

Immunisation and TB-DOTS18 Children


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37 1st Postnatal care visit in the facility

38 Normal vaginal delivery in facility

39 Vacuum/ forceps deliveries in facility40 Caesarean Sections

41 Live births in the facility

42 Live births with LBW < 2.5 kg

43 Still births in the facility 44 Neonatal deaths in the facility

Community Data45 Pregnant women newly registered by LHWs 46 Deliveries by skilled persons reported 47 Maternal deaths reported

48 Infant deaths reported

49 Number of modern FP methods users

50


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72 Operations under other type of anaesthesia

Human Resource Data

73 Sanctioned74 Vacant

75 Contract

76 On general duty in facility

77 On general duty out of facility

Revenue Generated and Financial Report78 Total receipts 79 Deposits 80 Total allocation for the fiscal year 81 Total budget released to-date

82 Total expenditure to-date

83 Balance to-date

Others84 LHW pregnancy registering coverage

85 Total Homeo cases

86 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;

Purcheefee 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

Indicator BHU RHC

Cleanliness/general outlook 7 8

Displays 5 8

Availability of utilities 8 4

Functioning of equipment 6 10

Availability of medicines 21 21

Public opinion 10 10Doctors presence 23 21Preventive staff presence 5 5

Administrative staff presence 5 5

Paramedics presence 10 8

Total 100 100

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; andii)

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 CardChakwal

Source: Punjab School Education Department, 2014.

Documents

Building a Dashboard for the Punjab Health Department