Kielmann Model
Healthcare Delivery System – District
level
Elements of PHC
E – Health Education about prevailing health problems
L – Prevention & Control of Locally endemic diseases
E – Provision of Essential drugs (EDL)
M – MCH care (Maternal & Child health) incl Family Planning
E – (EPI) Immunization against infectious diseases
N – Proper Nutrition and food supplies
T – Treatment of common diseases & injuries (Primary care)
S – Adequate Safe water supply & Sanitation
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Kielmann model
• A health management manual for districts was
developed by multi donor support team headed
by Dr Arnfried Kielmann, a Public Health Specialist
• The aim of the manual was to build capacity of the
District Health Managers and the District Health
Management Teams in the area of planning for
health services in the districts, post devolution
(LGO 2001)
Why the need for it?
• The Health Policy 2001 had identified two key areas:
– Addressing inadequacies in primary healthcare/secondary health
care services
– Removing professional/managerial deficiencies in the District
Health System
• District managers are now expected to play a more proactive
role in the development of a district
• Managers would be expected to plan, budget, implement, and
monitor activities that have a direct or indirect bearing on
health in their respective districts
• District Health Plans should be based on an appropriate
Situation Analysis of the District Health System
The purpose of the model
• To correctly identify community health needs and priorities
• Systematically assess the health care delivery system
• Define appropriate interventions based on identified
problems
• Ensure equity in the distribution of services among the
population
• Coordinate on-going health care activities, including
‘priority’ programs at the district level
• Determine resource requirements with respect to various
plan components, and make efficient use of new and
available resources.
The building blocks, functions & goals of HS
6 Building Blocks, 4 Functions & 3 Goals
Kielmann Model
• It is a system approach to DHS which comprises of three highly
interdependent elements:
• Ecosystem - socio-cultural, demographic, economic
and political surroundings
The environment in which the system operates
• Health Care Delivery System – based on health
problems and needs, it is comprised of health inputs,
distribution, output, utilization and outcomes.
Good management & organization and support system plays vital
role
• Community Involvement – organization, awareness, contribution and
utilization
• The Health Care Delivery System (HCDS) will optimally serve the
community, but there must be a close ‘fit’ between these three
elements
The eco system
• The environment in which the community lives and the Health
System operates
• It exerts a major influence on the nature, volume and quality of
health service availability
• Socio - cultural environment and its influences
• Economic conditions of the country, province and the district
• Political system and its local effects
• Literacy level, social and cultural acceptability of proposed
services
• Demography; population, urban – rural ratio, male-female
ratio, children under 5, educational status, growth rate etc
• Climatic conditions
Health problems and Needs
• The environment largely determines the nature of Health
Problems and Health Needs, as well as the ways and means
the community deals with them.
• They form, the basis of any health care delivery system
• Health Problems are objectively verifiable conditions;
Mortality & Morbidity patterns; IMR, MMR, TB, HCV, NCDs
etc
• Health Needs are problems identified and verbalized by
health professionals and by the community.
– Health needs encompass the broader set of factors and resources
necessary to achieve and maintain overall health and well-being;
access, gaps in service delivery, community involvement etc
Healthcare delivery system
• Service Inputs
– Man, Money & Material
• Availability of trained Manpower
– Availability and functionality of health facilities
– Infrastructure
• Hospitals – DHQ, THQs, Hospital beds, Services etc
• No of BHUs & RHCs
– Services like:
• Reproductive Health
• EPI Programme
• Communicable Disease control Programme
• NCDs
• MNCH
…the delivery system
• Input/Service Distribution
• It refers both to accessibility of the essential services and
their availability;
– Outreach services - LHWs
– Outdoor services – BHUs, Dispensaries etc
– Hospital services
– Paramedics services
– Timings of services
• Vaccination
• Family Planning days
• The services offered must adhere to standards of quality, i.e.
be functional, to exert the desired effect
…service distribution
• How the services are distributed area wise?
• The existence of regional inequalities in health care services is
common phenomena
• Developed vs less developed districts
– HR availability and Capacity issues
– Accessibility & Structural issues
• Urban vs Rural area distribution:
– 85% doctor and 90% beds are held in urban areas
• The existence of strong District Health Team results in an
effective input distribution and service delivery system at
district level
– This is how you see certain districts out-performing others
Management & Organization
• The aim of good management is to provide health services
to the community in an appropriate, efficient, equitable,
and sustainable manner – as per appropriate
Management Plan
• Managers need to have the knowledge, skills and
understanding of the role, tasks and purpose of the
services they deliver
• They will ensure that key resources for service provision,
including human resources, finances, hardware and
process aspects of care delivery are brought together at
the point of service delivery and are carefully synchronized
Support system
• It includes all those management and support structures
and systems that are essential for health services to be
established and to become functional
• These systems are the transport, management
information, repair and maintenance, drug and
contraceptive supply, finance and budgeting, in-service
training, and other important and necessary sub-systems
• In the health systems model, these support systems
closely relate to health service Inputs, as their
functionality is essential to make health services
accessible and of acceptable quality.
Pakistan
• Pakistan is the 5th most populous country in the world with
approximately 248 million population
• Current population growth rate is estimated at 2.1%, it was 3.42 in
1983
– Fertility rate of Pakistan fell gradually from 6.6 births per woman in 1971
to 3.4 births per woman in 2020
• 62% of the population lives in the rural areas
• Per capita income is an indicator of economic wellbeing and has
increased from US$ 586 in 2002-03 to US$ 1562.6 in 2021 – this
places Pakistan in a Lower Middle Income country, category
• Health is not a human right as per constitution of Pakistan
• GoP is spending around 1.2% of GDP on health against
recommended 6% by WHO
• Literacy level 10 years and older is stagnant at 60 percent
Major Health problems & Health indicators
• As of 2023, poverty is expected to reach 37.2 percent ($3.65 /day) – (the
world bank)
• Pakistan has double burden of diseases; had traditionally been a hub of
communicable diseases, how ever recently the NCDs have a share of 60%
of the mortality
• Infant Mortality Rate & Maternal Mortality Ratio are one of the highest
in the region
• It is the most unsafe country in the world to be born in – due to highest
neonatal mortality
• Over 40 percent of Pakistan's under-five children are stunted, as
compared to the South Asian average of 31 percent
• Looking at the United Nations Sustainable Development Goals for 188
countries and the chance of achieving them by 2030, Pakistan is ranked
164th
• (The Lancet: Pakistan faces double burden of communicable, non-communicable diseases, and persistent inequities,
Published January 18, 2023)
Health system - Governance
• GoP is responsible for providing strategic direction to the
healthcare
• Under the constitution (after 18th amendment), health is the
responsibility of the provincial governments
• The Federal government is responsible for vision, budgetary
allocation, international coordination, vertical programs and the
healthcare delivery in the federally administrated area (ICT)
• The health planning at Federal level is done in the Planning
commission of Pakistan, which has a Chief of Health section which
coordinate with the planning cell of MoH
• At Provincial level; Planning & Development Departments under
CM which is linked with the respective planning section of
Department of Health.
• At District level: EDO Health
The Healthcare Delivery
• Pakistan has a mixed public & private healthcare delivery system
• The state provides healthcare through a three-tiered public
healthcare delivery system and a range of public health
interventions – vertical programs
• Health care delivery is the responsibility of the provinces, with
districts mainly responsible for implementation
• The devolution has increased budgetary allocations to health and
improved healthcare delivery
• The public sector is composed of 7 autonomous systems (federal,
4 provincial & 2 sp areas), all organized around the similar
principles of providing free to affordable care to the population
through preventive, curative and rehabilitative services.
• It is well integrated and work as one system- Public system
The Public Healthcare Facilities
• National health infrastructure comprises of
• BHUs 5,558
• Dispensaries 5,808
• Maternity & Child Health Centers 780
• TB centers 416
• RHCs 636
• Hospitals 1276
• Total availability of beds in these health facilities is
estimated at 146,043
• Pakistan economic survey 2022-23
Private Sector
• Private sector is a market driven system, working on the demand and
supply model
• It is a larger partner but is diverse, and not integrated, operating mainly
as independent units – catering for 70% of patient encounters
• It is divided into formal & non-formal, it is generally unregulated, bulk
comprise of private practitioners, maternity homes, diagnostic centres,
pharmacies and small hospitals
• It includes both for profit and philanthropic run health systems
• Some of the best hospitals like Agha Khan, Shaukat Khanum, Indus,
RMI, Shifa international etc are in private sector
• The non-formal sector includes Hakims, Homeopaths and traditional
quacks like spiritual healers, bone-setters etc
– Some Homeopaths & Hakims are part of formal system
• Unlike public system, it’s ownership is in multiple hands & it works on
fee for service basis.
Total beds:
20,000
National Digital Health Framework 2022-2030
The Health HR Pakistan
• The total Health HR available:
• Registered doctors: 282,383
• Registered dentists: 33,156
• Registered nurses: 127,855 (include LHVs)
• Registered Pharmacists: 36,000
• LHW: 96,000?
• Due to non availability of formal Councils or
Associations, data of trained Paramedics is not
available.
• Pakistan economic survey 2022-23
Healthcare System
- Pakistan
Public Sector
Private Sector
Federal Govt Provincial
Govt
MoD NHSRC Parastatals Employee Fauji
Social Foundation
Security Ministry of
Health Health system
Institute
Institutes Hospitals
Military , Clinics of GPs
Hospitals Hospitals Primary & Surgeries
& PIA Secondary
Cantt
Vertical Railways Medical Maternity
General care Homes
Hospitals Programs Colleges &
Pak Steel District
ICT HCDS Mills Tertiary care Healthcare Diagnostic labs
hospitals/Instit Dental
WAPDA utes system
Surgeries
NESCOM
Pharmacies
POF
NGO’s run
FC/Rangers facilities
PTV/Radio Philanthropy
Pak etc run institutions
Hakims
Homeopath
Quacks
Healthcare Delivery at District level
• There are 160 districts in Pakistan including the Capital
Territory, the erstwhile FATA districts and the districts of
AJK & GB
• District level health system is a sort of self contained unit to plan
and execute health care activities; under EDO Health/DHO/CEO
Health
• The district government is responsible to provide a package of
health services including Public Health, Nutritional interventions,
Child & Woman Health, Vaccination, Family Planning, and
curative services through Dispensaries, Basic Health Units, Rural
Health Centers, THQ and certain DHQs
– The districts have their own facilities for Nursing &
Paramedics Training
DHS
• A manageable unit, which can integrate health programs by
adopting top-down and bottom-up planning, and is capable
of coordinating government and private sector efforts
• The districts are uniquely placed at a level where they are
in a position to maintain a vertical relationship with higher
management levels, horizontal relationship with other local
departments and an external relationship with the
communities and organizations they serve
• The EDO has two lines of reporting: to DGHS & DC of the
district
• After full implementation of the DHA, the CEO will be
responsible to the board
Deputy
Commissioner
Delivery of Public Health services
• The public sector health delivery system is composed of
Three tiers;
– 1st tier: It is the 1st point of contact with the community
– It focuses mainly on out patient management and basic inpatient
care
– It also focuses on PHC (Primary Health Care); immunization,
sanitation, control of endemic diseases, maternal and child health,
nutrition and family planning etc
– Consists of Outreach and community-based services, LHW –
Health Homes
– Basic Health Units (BHUs) are the mainstay of Primary Health
Care & this tier. Some of the Rural Health centres (RHCs) are
also part of it.
The next two!
• tier: The Secondary health care facilities which
2rd
include some RHCs, Tehsil Headquarters Hospital
(THQH) and some District Headquarters Hospital
(DHQH) for out patient, inpatient and also specialist care
• 3rd tier: Some DHQ Hospitals work as Tertiary care
hospitals, others are the Teaching Hospitals &
Specialized hospitals/Centres located in the District
Headquarter and major cities for more specialized
inpatient care.
– This tier includes teaching hospitals and other specialized
institutes
Lady Health Worker
• The LHWs work like a bridge between the formal health system and their
community.
• Health Houses: The Lady Health Workers’ programme is the largest public
sector community health initiative in the region, covering most of the rural
and selected peri-urban population of the country with a workforce of
96,000
• It is the hub from where LHW (training of 15 months) carries out daily field
visits to her catchment area population of 1000-1500
• A lady health supervisor (LHS) oversees the work of 20–25 LHWs on a routine
basis, with her office typically located within a Basic Health Unit (BHU)
• As a standard, an LHW is assigned to visit 07 household per day, which
requires about 245 min. LHWs carry out:
– Health and nutrition promotion & interventions
– Maternal and child healthcare
• providing antenatal, natal, and postnatal care (PTO)
…Role of LHW
– Family Planning & counselling
• Distribution of products
– Preventing and treating common ailments
– Help in other programmes like vaccination
– Referrals to BHU
– Record Keeping
• However, in recent years, the Government capped this
program and banned new recruitment of LHWs. This
decision may pose a potential challenge to the LHW
program’s ability to provide effective services to the
community
Basic Health Unit
• On an average, a basic health unit serves a population of around
10,000 –25,000, providing a range of primary health care
services along with referral support for major health problems
• Staffed by 14 members including Medical Officer, Nutrition
supervisor, LHV, vaccinator, health technician, dispenser,
sanitary inspector, midwife and other support staff, the BHU is
capable of providing the components of PHC.
• The BHU also provides clinical, logistical and managerial support
to the LHWs
– Outreach/ community based services
• Clustering of BHUs and 24/7 service with ambulance for
transferring of patients – 1234 BHUs providing 24 hours EmONC
services
Other health outlets & National
programmes
• Civil dispensaries; established in urban areas at the bottom of health
pyramid. Two types; one manned by a dispenser and the other by a
doctor
• MCH Centres: These facilities provide maternal, neonatal and child
health services including reproductive health and family planning;
and are often located in urban and large rural areas. Maternal and
child health centres are managed by Lady Health Visitors assisted by
TBAs
• TB Centres: These centres detect and manage tuberculosis patients.
The TB/DOTS Programme currently is also implemented by most first-
level care facilities
• RHCs
• THQs
• DHQs
The Tehsil Level
• Each tehsil usually has 10 to 40 BHUs, 3 to 6 RHCs and 1 THQ
to be monitored and managed by the DDO
• The DDO (ADHO) is the main officer responsible for running
the health system at the tehsil level.
– The proactive DDOs ensure that the Health Plans of the district cater
for the health needs of their tehsils. They however do not prepare
separate health plans
• They implement the district health plan for their tehsils,
supervise and monitor the service provision
• The DDO is responsible that staff are attending to their duties,
that there are sufficient medical supplies, and that the
facilities are functional, staffed, and well equipped
National priority programmes
• The district health system hosts and supports the implementation of
numerous federally funded national programmes, that include:
– The Lady Health Workers’ programme;
– Maternal, neonatal and child health;
– National AIDS control & Roll Back Malaria;
– National tuberculosis control;
– Nutrition;
– Prevention and control of blindness;
– Control of hepatitis viral infections;
– Expanded programme on immunization, closely interfacing with the primary
health care services at district level
• Many of these programmes have a dedicated workforce at district level
with varying degrees of functional integration with the district health
system; the federal and provincial management units of all these
programmes providing the necessary technical and logistics back-up
support for effective service delivery.
Family Planning
• The Ministry of Population Welfare operates a
network of around 3000 facilities for the delivery
of reproductive health and family planning services
ranging from reproductive health centres
embedded in the tehsil headquarter hospital and
district headquarter hospital service delivery
domains and family welfare centres located at
Union Council settings as well as mobile service
units and community based outreach services
through Lady Health workers
How the DHS is organized
• Service Outputs; Outputs are usually measured in
terms of quantity, quality, timeliness and cost
• They are immediate results of health inputs &
distribution and it is in numbers;
– Number of patients attended
– Frequency of patients
– How many tests performed
– How many children vaccinated
– Number of TBA trained
– Number of deliveries attended by SBA
Outcomes leading to Impact
• Service Outcomes; they are the measure of performance,
but in order to achieve the expected outcomes the
appropriate outputs need to be produced first
• They designate intermediate results short of reaching
the main, or principal objective;
– Covering 85% of women with reproductive health services
– 90% coverage of above 15 women with tetanus immunization
• By end of certain time the outcomes become ‘The
Service Impact’ when you see change in the health status
of a community:
– Polio free community
– Reduced MMR & IMR
Community Participation
• Community Participation is at the centre of this model
• Community participation is part of “people centered”
or “human centric” principles; the idea is that citizens
should have some powers over the decisions that
affect their lives.
• It helps decision makers to take into account the
problems of the community and develope
programmes as per their needs
• The participation should be meaningful & without it,
services will not reach their full potential
Community Participation – Kielmann Model
• Community Organization: This is the 1st level, where
community has a formal organization to cater for the
health needs. Support groups in a community will
play important role
• Community Voice: the community must express its
health needs through regular meetings.
• Community Contribution: Community contributes in
improving the services through mobilization
• Service utilization: Utilization rates are important in
determining the trust community has in the HCD
Rounding it up
• Service inputs, its support systems, input distribution
and service outputs together with health service
Management and Organization make up the Health
Care Delivery System (HCDS)
• Appropriateness (to health needs) and quality of the
HCDS influence Service Outcome
• Service outcomes are the desired effects, which have
major influence on the final result, the Impact
• The surrounding Ecosystem influences all components
of this "Wheel of Events".
Health Planning
• The Strategic planning at the National level, is done by
Health Section in the Planning and Development Division –
Planning Commission (headed by a Senior Chief)
– A small independent Planning Cell in the MoNHSRC liaise with &
supports P&D Division
• In provinces, strategic planning is done by P&D departments
under the Chief Ministers, headed by ACS, which work
closely with Health Department which has it’s own Planning
& Development Cell, usually headed by Additional Secretary
– Punjab & Sind have Planning Boards
• EDO Health is responsible for the operational planning and
it’s implementation at the district level
Health Planning
• Health Planning is the identification and elaboration (within existing
resources) of means and methods for providing effective health care
relevant to identified health needs for a defined population
• Districts have been passive recipients of earmarked resources, and
planning at the district levels has largely been restricted to
preparation of annual budgets
• Not every EDO Health will be involved in the formal health planning
– More important is his duty to implement and monitor the existing plans
• However, proactive EDOs prepare district health plans that
incorporate developmental as well as recurring ongoing activities,
and complement each other.
• The principal instrument for the former has been the PC-1 Proforma
and for the latter, the Annual recurring Budget.
Various Plans at District level
• Project Plan – Plan focusing on time related activities to meet
specific project objectives, often through an independent
implementation unit
• Program Plan – Plan focusing on a specific health program such
as FP, EPI, Nutrition as an integral part of the regular health
care activities
• Capital Plan – Plan focusing on the capital development of an
organization such building a new facility
• Service Plan – Plan focusing on the services to be provided. In
many ways, a Service Plan is similar to a program plan
• Annual Plan: prepared by line orgainzations for the recurring
budget usually
The Planning Cycle
Situation
Analysis
Evaluation
Target setting-
Evaluation
Goals
Implementation
& Monitoring Option
Appraisal
Programming
Challenges of District Health System
• There are a range of governance challenges impeding the
organization, implementation and management of essential health
services; poorly supported by weak strategic and operational
planning, irregular monitoring and supervision, an inadequate
accountability system and insufficient community participation
• Private sector comprise of formal, informal, for profit and non profit
HCFs, more than 60% health coverage is by private sector which is
not under control of EDO Health
• Vertical programmes though integrated with the DHS, have their
own line of reporting and accountability
• Besides regular Health care workers, there are categories of
contract workers; creating an atmosphere of conflict & hostility
• Presence of Tertiary care institutes in the district though beneficial
can be a threat to the EDOs
Challenges
• Healthcare commission is to regulate healthcare delivery
system; its safety & quality. However, due to severe HR shortage,
HC is unable to implement the standards at the District level
– For over 100,000 HCFs, HC Punjab has only 26 manpower in the anti
quackery unit
• HC does not have any establishment at district level
• Drug inspector of the districts have their own reporting system
and they seldom interact with EDO Health
• Change in focus due to change in the government and it’s
policies
• There is inadequate health infrastructure which is further
accentuated by inequitable distribution of the healthcare
facilities
Challenges…
• Lack of integrated approach by the District management in service
and input distribution
– Dental surgeon posted but no dental chair and vice versa
– Surgeons & Gynecologist posted but no anesthetist
– Many districts with out a Radiologist
• Extremely low health budget where the district health system
struggles to obtain a fair share
– Excluding the salary component, these funds are short of satisfying the
minimum service delivery package necessary for PHC and acute care
• Many health interventions need intersectoral integrations, but
they are not appropriately done as many EDOs shy away from
approaching their counterparts in other departments
• Political interference is more easily done at District level; EDOs
feel the heat of the political pressure not infrequently
