Public health care in Pakistan has been persistently underfinanced by the three levels of government responsible for it: federal, provincial, and district. Per capita public health expenditure has thus been consistently low. For example, at program appraisal in 2008, health sector spending in the country’s Punjab province averaged 0.5% of gross domestic product and 8% of total public spending. This was insufficient to meet the minimum health services requirements of the population. Both overall and at the district level, recurrent spending, which was largely for salaries, absorbed 80%–90% of funds. Due to a significant resource gap in health care services, key health indicators for the country and for Punjab lagged, particularly in relation to maternal and child health. To improve progress on these two important Millennium Development Goals (MDGs), the provincial government of Punjab (GOP) targeted reducing the infant mortality rate (IMR) from 77 per 1,000 live births in 2000 to 40 by 2015 (MDG 4) and the maternal mortality ratio (MMR) from 300 to 140 per 100,000 live births (MDG 5), over the same period. Significant additional efforts were needed to achieve these targets, within which context, the Asian Development Bank (ADB), responding to government request, designed the Punjab Millennium Development Goal Program as a cluster of three subprograms.
The program was approved in December 2008 together with a loan of 63,730,000 in special drawing rights (SDR) for subprogram 1 (SP1). Subprogram 2 (SP2), financed by a loan of SDR102,318,000, was approved in June 2010. Subprogram 3 (SP3) was not processed due to the termination of an International Monetary Fund standby financing arrangement with Pakistan. The program envisioned contributing to the attainment of MDGs 4 and 5 in Punjab province, as impact. Its intended outcome was improved and more equitable access to quality health services. Delivering health services that met the minimum service delivery standards (MSDSs), especially in maternal, neonatal, and child health (MNCH), was adopted as the core strategy.
At completion, the program fell short of delivering on its planned outputs, which focused on three areas of reforms: (i) improving the availability and quality of primary and secondary health services, (ii) strengthening the management of health service delivery, and (iii) establishing a sustainable pro-poor health financing system. While its design fit ADB and government approaches, its targets and management requirements were beyond reach, with reform activities that were too numerous and quite complex for the executing agency and implementing agencies to implement.
Key factors that barred successful program implementation were lack of institutional and human resource capacity, particularly at the provincial and district levels; frequent changes in key staff; inadequate guidance from ADB; lack of ownership and supervision by senior GOP management; and system inefficiencies in program monitoring. In addition, the GOP had to respond to natural calamities, including repeated floods and a dengue epidemic, which absorbed the provincial health department’s resources and diverted attention from program implementation. The security situation in the province over the implementation period was also challenging.
The program consequently failed to achieve its intended outcome. Of its six outcome targets indicators, only one was met and overachieved—the proportion of women who delivered in health facilities rose from 33% in 2007 to 53.5% in 2010, against a target of 50%. Two were partly achieved—substantial progress was made on the number of antenatal examinations, and the proportion of deliveries attended by skilled birth attendants. The target on the immunization of children was not achieved and no improvements were made on maternal and infant mortality. SP3 was never processed, resulting in a loss of momentum. The level of financial and physical progress achieved in the target districts during the program, as well as the implementation arrangements, were insufficient to produce the desired improvement in the attainment of MDGs 4 and 5.
The GOP’s health department was the executing agency, and all 36 district governments were responsible for the implementation of the program