Case

Building a Dashboard for the Asian Journal of Management Cases

12(2) 128147
Punjab Health Department 2015 Lahore University of
Management Sciences
SAGE Publications
sagepub.in/home.nav
DOI: 10.1177/0972820115592210
http://ajc.sagepub.com
M. Ahsan Rana1

Abstract
This case is about monitoring and evaluation (M&E) challenges in the Punjab Department of Health
(DOH). Despite his substantial experience of working in senior managerial positions, Arif Nadeem, the
department secretary, finds himself somewhat lost in the numerous department related reports and
data sheets that keep on coming from various quarters. He feels under-informed and over-informed
at the same time.
DOH regularly collects data on a range of indicators and there are multiple systems in place to
collect the data from various health facilities. The following four systems are important. First, the
District Health Information System (DHIS) collects data on around eighty indicators covering treatment
and spread of communicable and non-communicable diseases, human resources, facility utilization, etc.
Second, the M&E assistants (MEAs) inspect primary health care facilities and report on fourteen indica-
tors covering the number of patients attended, staff presence, medicine availability, public opinion, etc.
Third, the DOH field operatives visit health facilities and report on various aspects of functioning in
monthly meetings of officials at the district level. Since 2011, they have been using simple smartphone
based applications to enter data on site and transmit it to the points of analyses instantaneously. Fourth,
progress on development projects is reported every month on prescribed pro forma covering physical
progress as well as the amount spent. In addition, tertiary care hospitals report on various aspects of
their functioning on need basis and receipt/expense statements are regularly prepared by the budget
and accounts section in the department.
Often there is too much information to absorb. There is no effective system of filtering and
processing information according to the needs of various managerial tiers. Arif realizes that he needs
a dashboard that can provide just enough detail to various users. Arif and his team deliberate on the
choice of indicators for the dashboard. There is substantial disagreement on what to include and what
to leave. The disagreement partly emanates from a lack of clarity on the mandate of the department
and its senior management. Farasat, a key team member, proposes eight key areas for the dashboard.
He suggests displaying these eight areas on the main screen and creating links to detailed district,
tehsil and facility-wise data on selected indicators.

Keywords
Public sector governance, performance dashboard, monitoring and evaluation, collecting and managing
performance data

1
Suleman Dawood School of Business, Lahore University of Management Sciences, Pakistan

Corresponding author:
M. Ahsan Rana, Suleman Dawood School of Business, Lahore University of Management Sciences, Pakistan.
E-mail: ahsan.rana@lums.edu.pk

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Rana 129

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 the provinces health sector. This was hardly due to inexperience.
He had previously been the secretary 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 realized 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
(Punjab Bureau of Statistics, 2012). Around 68 per cent of its population resided in rural areas and about
56 per cent were children under the age of 15 years (ibid). Forty-one per cent of the population over the
age of 10 and above could not even read and write (Punjab Bureau of Statistics, 2011). To provide health
care to this large, youthful, largely rural and uneducated population, DOH maintained an extensive
network of about 4,000 primary, secondary and tertiary health care facilities (Exhibit I). Primary health
care (PHC) facilities comprised basic health units (BHUs) and rural health centres (RHCs). These
provided basic health care as well as outreach and community-based activities focusing on immuniza-
tion, sanitation, malaria control, maternal and child health, and family planning services. Secondary
health care (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 specialized treatment and care.
In addition, there was a large private sector comprising 11,125 private hospitals and clinics, which
was estimated to provide health care to about 30 per cent of the population (Government of Punjab,
2008). It fell within DOHs purview to regulate and broadly 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
Governments Rules of Business, 2011 (Exhibit II). 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 nontechnical employees. The
secretary was the chief executive officer of the department and was responsible for providing super-
intendence, oversight and guidance to the entire workforce in the discharge of their duties. He was
responsible to the minister and through him, to the chief minister and the provincial legislature. A team
composed of senior civil servants and public health specialists assisted him in the discharge of various
functions (Exhibit III for 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

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130 Asian Journal of Management Cases 12(2)

coordination officer (DCO)the chief bureaucrat in 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 III).

Data Collection and Analysis

DOH had multiple streams to regularly collect data on a range of indictors. These included the follow-
ing: (a) data provided by PHC and SHC facilities for the District Health Information System (DHIS);
(b) data collected by monitoring and evaluation assistants (MEAs) through field inspections; (c) inspection
reports of DOH field officers; and (d) progress updates on development schemes. In addition to these
four main data streams, information also reached the secretary from other sources. Tertiary health care
facilities reported on various aspects of their functioning on need basis, that is, as and when so required
by the department. Newspapers, nongovernment organizations and various interest groups (such as
pharmaceuticals) provided periodic information 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 was 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 seventy-nine and eighty-three clinical and nonclinical indicators for PHC and SHC
facilities, respectively. Clinical indicators covered forty-three communicable and noncommunicable
diseases, whereas nonclinical indicators covered vacancies, presence of staff, utilization of facilities,
patients treated, availability of medicine, budget, etc. (Exhibit IV for DHIS indicators).
PHC and SHC facilities initiated monthly reports on separate pro forma. The information was derived
from twenty-four registers maintained by concerned officials in the facility. The whole system was
paper-based. Although it was the responsibility of the facility incharge to ensure that reporting was accu-
rate, in practice he/she neither had the time nor incentive to carefully check what was being reported.
To minimize 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 was 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 incharges 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 various indicators.
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.

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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, that is, on average, staff comprising 100 persons
was serving around ninety patients per unit of time. These reports also showed wide variation among
districts0.31 for Lahore and 1.41 for Chakwal. These were useful information bits for the secretary
and other managers when they had to make decisions and policies regarding allocation of human and
financial resources. Whether or not this actually happened was a different question altogether.

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 V). 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 regard-
ing staff absenteeism or medicine stock out. The Punjab Health Sector Reforms Program (PHSRP)a
policy think tank of DOHconsolidated 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 VI). 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 20062008, PHSRP used to present the district rankings in its periodic meetings with the
chief secretarythe 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 penalize 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 the chief secretarys meetings 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 per cent for ADOs to 5 per cent 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

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132 Asian Journal of Management Cases 12(2)

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 incharges.
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 the field was directly recorded in soft form and transmitted to several locations instanta-
neously. Simple android-based applications were specifically developed for this purpose and installed
on smartphones provided to field officials. The new system was introduced in eighteen 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 twelve indicators was used for data collection (Exhibit VII). These related to staff attendance,
medicine stock out, number of outpatient visits and deliveries, functionality of equipment and general
upkeep of the facility. 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 not always, observations from these visits were recorded as tour notes. Being infrequent and unstruc-
tured, these visits 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 20112012, out of a total allocation of
`64.7 billion, allocation for development schemes stood at `12.3 billion (World Bank, 2013). 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 the concerned wings/projects
in the department that were undertaking a development scheme. PC III (A) was prepared at the beginn-
ing 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 reported physical progress of the scheme, procure-
ment and fund utilization 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 expended each year (`64.7 billion in 20112012). DGHS, additional secretary (establishment) and

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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 comprehen-
sive 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: 5060 per cent was consumed at the provincial level
and the remaining was spent at the district level. In 20112012, salaries comprised about 25 per cent of
the total current expenditure and utilities consumed 44 per cent 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 out-
lining 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 year were being finalized.

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 ownership, they were
mostly launched on the express directives of the chief minister (CM) and had to be accorded priority.
Since DOH did not have dedicated staff at both the 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 themselves updated on the progressat least until 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 realized that it was quite a challenge for
a variety of reasons. First, 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
thingspolicy, disease control, regulation of health professionals and education, development schemes
and implementation of laws. These were all individually important and worthy candidates for tracking

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134 Asian Journal of Management Cases 12(2)

progress on regular basis, but Arif wanted to focus on a few of these items, at least initially. However,
he was far from clear regarding which items these could be. He realized 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 reviewed regularly, health practitioners would have
limited incentive to excel on other indicators.
Second, Arif often found himself and his team caught between the priority of the week as deter-
mined by the CM 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 one
week and disposal of hospital waste in the next one. Arif had learnt during the previous year that he had
to be very up to date on the priority of the week if he wanted to keep the job. At the same time, he
also appreciated that his real challenge was to improve routine 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 be improved, simply because this consti-
tuted the point of interaction between the department and its clients. Balancing these competing informa-
tion needs was a challenge.
Third, 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.
Last, 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. But he was only one user of the dashboard. Others included senior managers in
the department, such as the DGHS, programme 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 immunization 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 customization. Arif also realized 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).

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:

1. Babar Hayat Tarar, special secretary, DOH

2. Dr Anwar Janjua, additional secretary (technical), DOH
3. Dr Zahid Pervaiz, DGHS

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4. Farasat Iqbal, program director, PHSRP

5. Dr Beena Malik, public health specialist
6. 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 for cosmetic 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 team members 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 a reasonable time span to start, said Babar.
As the chief manager, Arifs principal responsibility was to efficiently deploy the DOHs human, physi-
cal and fiscal resources in pursuance of Punjab Governments health policy objectives. Thus, he was
routinely making decisions in these two broad areas. As for the human resource (HR), his decisions related
to staff recruitment, promotion, transfer, seniority, leave, professional development, disciplinary proceed-
ings and complaints. Although most HR issues were dealt with by EDOs or DGHS, eventually it was
the secretarys responsibility to ensure that the DOH personnel were efficiently utilized 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. This was mainly 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, for
example, the X-ray machines not working or the essential 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 utilization 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 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 to
specify what to put on the dashboard?
No, replied Arif, we dont have anything specific to my working in this department. A Secretarys
duties and functions are given in the Rules of Business (Exhibit VIII), but they are generic.

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136 Asian Journal of Management Cases 12(2)

Anwar suggested, Perhaps we can have several sections and each section can focus on one aspect of
the working 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 IX). The report card contained summary statistics on
staff strength and vacancies, teachers attendance, student enrolment and attendance, students exam
performance, missing facilities, budget allocation and utilization, and inspection visits by supervisory
authorities. He highlighted four aspects of the report card. First, it showed trends by comparing data
across several months. Second, it presented data for the entire district as well as for constituent tehsils.
Third, data was gender segregated for some indicators. Lastly, several data items were ratios, which
provided a relational analysis 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 view district (or tehsil or 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 the summary 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 utilization and targets achieved should be available to the public at large. The dashboard
should have a permanent tab on the DOH website. This will help generate public pressure on DOH func-
tionaries to improve their 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.

He proposed that the dashboard should have data on the following indicators:

1. Facility utilization, that is, patients per staff member

2. Doctor/patient ratio; paramedic/doctor ratio
3. Population per doctor or per hospital bed
4. Infant and maternal mortality rates
5. District-wise proportion of children immunized
6. Proportion of deliveries at health facilities or by trained birth attendants
7. Number of drug samples taken and proportion found spurious
8. Number of tests/X-ray/MRI/CT scans conducted
9. Polio/dengue cases detected and treated
10. 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
you apportion cost of the District Offices and of the support provided by DGHS?

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Rana 137

Farasat responded in these words: Yes, this is tricky. But there must be a way to do this. I am sure
there are accounting 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 emphasized 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 health care should also be included in the dashboard. She complained that the DOH was
very indifferent to this aspect of health care, 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 impor-
tant function of the department and a key component of preventive health care. 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 information in a visually-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 display everything 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 the one 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 IT people should be able to do it for you.
How frequently will we need to update it? asked Arif. Farasat replied that it would vary for different
indicators:
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:

1. HR management
2. Physical assets and financial resources
3. Key activities, outputs and outcomes

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138 Asian Journal of Management Cases 12(2)

4. Development schemes
5. Medical education
6. Implementation of laws
7. Findings from various periodic surveys
8. 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 man-
agement in particular and the effectiveness and efficiency of health care provision in general.

Exhibit I. Health Facilities and Practitioners in PunjabNumber 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 1020 inpatient beds for 100,000 people 293
Tehsil headquarters hospitals 40150 beds with nine specialties 89
District headquarter hospitals >150400 beds with 18 specialties 36
Teaching/tertiary care hospitals Large hospitals with multiple specialties 31
Others Dispensaries 738
TB clinics and hospitals 19
Mother and child health centres (MCHC) 329
Specialized hospitals 5
Total 3,996
Source: Government of Punjab (2011).

Source: Ministry of Finance (2011).

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Rana 139

Exhibit II. Functions of the Health Department, 2nd SchedulePunjab Government Rules of
Business, 2011, Health Department

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 thereunder
(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 thereunder:
i. The Public Health (Emergency Provisions) Ordinance, 1944
ii. Epidemic Diseases Act, 1958
iii. Punjab Vaccination Ordinance, 1958 (W.P. Ordinance XXVII of 1958)

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140 Asian Journal of Management Cases 12(2)

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, 2002
xviii. 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.

Exhibit III. Organogram of Provincial Secretariat

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Rana 141

Source: Developed by author.

Exhibit IV. DHIS Indicators for PHC and SHC Facilities (p1 of 3)

Sr. No. Indicator PHC SHC

Overall Performance
1 Daily OPD attendance : :
2 Full immunization 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 utilization :
10 Bed occupancy rate :
11 LAMA :
12 Hospital death rate :
13 Monthly report data accuracy : :
Outpatients Attendance
14 New cases : :
15 Follow up : :
16 Number of cases of malnutrition < 5 years children : :
17 Referred attended : :
Immunization and TB-DOTS
18 Children <12 months received 3rd Pentavalent vaccine : :
19 Children <12 received 1st Measles vaccine : :

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142 Asian Journal of Management Cases 12(2)

Sr. No. Indicator PHC SHC

20 Children <12 months fully immunized : :
21 Pregnant women received TT-2 vaccine : :
22 Intensive phase TB-DOTS patients : :
23 Intensive phase TB-DOTS patients missing treatment > 1 : :
week
Family Planning Services
24 Total FP visits : :
25 COC cycles : :
26 POP cycles : :
27 DMPA Inj. : :
28 Net-En Inj. : :
29 Condom pieces : :
30 IUCD : :
31 Tubal ligation : :
32 Vasectomy : :
33 Implants : :
Maternal and New-born Health
34 1st antenatal care visits (ANC-1) : :
35 ANC-1 women with Hb < 10g/dl : :
36 Antenatal care revisit in the facility : :

37 1st postnatal care visit in the facility : :

38 Normal vaginal delivery in facility : :
39 Vacuum/forceps deliveries in facility : :
40 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 Data
45 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 < 5 years diarrhoea cases reported : :
51 < 5 years ARI cases reported : :
(Exhibit IV continued)

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Rana 143

(Exhibit IV continued)
Sr. No. Indicator PHC SHC
Community Meetings
52 Number of community meetings : :
53 Number of participants : :
Diagnostic Services
54 Total lab investigations : :
55 Total X-rays : :
56 Total ultra sonographics : :
57 Total ECGs
Stock out : :
58 Stock out of drugs/vaccines : :
Indoor Services
59 Allocated beds : :
60 Admissions : :
61 Discharged not on same day of admission : :
62 Discharged on same day of admission : :
63 LAMA : :
64 Referred : :
65 Deaths : :
66 Total of daily patient count : :
67 Bed occupancy : :
68 Average length of stay : :
Procedures
69 Operations under general anaesthesia : :
70 Operations under spinal anaesthesia : :
71 Operations under local anaesthesia : :
72 Operations under other type of anaesthesia : :
Human Resource Data
73 Sanctioned : :
74 Vacant : :
75 Contract : :
76 On general duty in facility : :
77 On general duty out of facility : :
Revenue Generated and Financial Report
78 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 : :

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144 Asian Journal of Management Cases 12(2)

Sr. No. Indicator PHC SHC

Others
84 LHW pregnancy registering coverage :
85 Total Homeo cases :
86 Total Tibbi/Unani cases :
Source: DHGS Records, 2014.

Exhibit V. 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
Purchee fee 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
Source: DGHS Records, 2014.
Note: Sr. No. 11 above was not applicable to BHUs.

Exhibit VI. 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 10
Doctors presence 23 21
Preventive staff presence 5 5
Administrative staff presence 5 5
Paramedics presence 10 8
Total 100 100
Source: PHSRP Records, 2014.

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Rana 145

Exhibit VII. 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 VIII. 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; and
ii)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 IX. District Report CardChakwal

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Source: Punjab School Education Department, 2014.
Rana 147

References
Government of Punjab (2008). Stocktake of private practitioners in Punjab. Punjab: Government of Punjab.
. (2011). Punjab Government Rules of Business. Punjab: Government of Punjab.
Department of Health. (2011). DHIS quarterly report 4th Quarter 2011. Lahore: Directorate General of Health
Services. Punjab: Government of Punjab.
. (2014). Lahore: Directorate of General Health Services (DGHS). Punjab: Government of Punjab.
Ministry of Finance (2011). Pakistan Economic Survey 201112. Islamabad: Ministry of Finance, Government of
Pakistan.
Pakistan Bureau of Statistics (2011). Pakistan Labour Force Survey 201011. Islamabad: Pakistan Bureau of
Statistics, Government of Pakistan.
. (2012). Punjab development statistics. Lahore: Punjab Bureau of Statistics, Government of Punjab.
Punjab Health Sector Reforms Programmes (2014). Lahore: Punjab Health Sector Reforms Programmes. Punjab:
Government of Punjab.
Punjab School Education Department (2014). Lahore: Punjab School Education Department. Punjab: Government
of Punjab.
World Bank (2013). Punjab performance expenditure review. Islamabad: World Bank.

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