Khyber Pakhtunkhwa is an extremely challenging environment for public development
“In Khyber Pakhtunkhwa there was a plethora of plans and strategies, however, the implementation of these plans was poor due to lack of structure. The interactions with mid-level managers responsible for implementation of provincial plans were mostly ad-hoc and infrequent meetings at district level resulted in poor communication with facility staff.”
Khyber Pakhtunkhwa is a province in the North West of Pakistan, sharing a border with Afghanistan. The province has a turbulent political history and fractured leadership record. Health outcomes in Khyber Pakhtunkhwa are poor, in 2015 just one in two children were receiving their routine vaccinations. Additionally, independent data showed that more than half of all primary healthcare facilities failed to stock critical medicines.
Until recently, health reform implementation in Khyber Pakhtunkhwa has been haphazard. Previous reform attempts have lacked organisation; a seven-year long KP health sector strategy was approved in 2010 but showed little impact on the services provided to the citizen. Staff turnover had been high; limiting the transfer of knowledge, slowing progress and contributing to poor communication between provincial, district and facility levels.
Implementing routines to support improvements
Since 2015, Acasus has been supporting the Government of Khyber Pakhtunkhwa to implement ambitious health reforms aimed at ensuring critical medicines are available, front line health staff are present and children are receiving life-saving immunisations. As part of this a series of monthly and quarterly routines were established.
| Routine | Frequency | Level | Agenda |
|---|---|---|---|
| Stocktake | Quarterly | Provincial | Review progress of reforms with political leadership |
| Pre-stocktake | Monthly | Provincial | Review progress with Secretary Health and department |
| District health office meetings | Monthly | Provincial | Review progress with official from districts |
| Provincial review of the expanded programme on immunisation (EPI) | Quarterly | Provincial | Review progress of EPI with focal person for implementation at district level |
| Monthly review of EPI | Monthly | District | Review progress of EPI in district with all service providers in district |
Establishing routines has had a dramatic effect on implementation in Khyber Pakhtunkhwa
These routines are used to:
- Provide a forum for setting direction and targets
- Check and hold leaders accountable for progress
- Learn what is working and use collective knowledge to solve problems
Prior to routines, ad-hoc and lockdown meetings were common yet ineffective at holding stakeholders accountable. Now, routines provide a structured forum where stakeholders are properly held accountable. This includes both singling out poor performance and recognising and sharing top performance, incentivising managers to deliver.
Additionally Khyber Pakhtunkhwa now benefits from structured communication channels and knowledge sharing. As in most systems, Khyber Pakhtunkhwa has pockets of good performance. Routines provide an opportunity to mine these pockets for useful insights and share them amongst all districts.
These initiatives have contributed to rapid improvements in Khyber Pakhtunkhwa. Medicine availability has risen to 67%, it’s well on the way to meeting the target of 90%. 50 facilities now operate around the clock, ready and able to deliver babies 24/7. In February 2018, these facilities delivered 677 more babies compared with September (a 72% increase), when the facilities had limited opening hours. Additionally, these initiatives have helped foster new energy and enthusiasm amongst those involved in improving the system.
Characteristics of effective routines
In order to be effective, routines should aim to be:
- Well-led: The leader of the routine should be motivated, respected, accountable and in a position to make rapid decisions
- Regular: Routines should be on a fixed basis
- Focused: Routines should focus on prioritized objectives
- Action oriented: Routines should clarify and set tasks going forward
- Consistent: Routines should examine the same set of relevant indicators to determine whether actions are improving the prioritized objectives over time
- Collaborative: Attendees of routines should aim to learn from pockets of high performance, share best practices and address areas of low performance
About the Authors
Syed Akbar is a consultant at Acasus. He is currently working in public sector development in Pakistan to bring fast improvements through building reliable data systems, implementing performance management frameworks and routines to drive progress. Will Anderson is the lead researcher for public-sector projects at Acasus.