Consultative Workshop

Towards Quality Health Care Services in Khyber Pakhtunkhwa

February 13−14, 2018
PC Hotel, Peshawar

Background

1. Recent economic and social performance. Pakistan achieved considerable economic

growth in the last 2 decades and the country has recently been classified as a lower middle-
income country with a gross domestic product (GDP) of $1,500 (2015). However, these economic
successes did not translate into better health outcomes. Pakistan was not able to achieve the
Millennium Development Goals and is also lagging in progress towards the Sustainable
Development Goals. Pakistan’s health profile is still characterized by a high infant mortality rate
(66 per 1,000 live births), high maternal mortality ratio (178 per 100,000 live births)1 and a dual
burden of communicable and non-communicable diseases.2 In Khyber Pakhtunkhwa (KP), these
health indicators are lower than the national average. The explosive growth of population over
200 million, estimated to double in the next 30 years, will add further burden on the already
overloaded social systems, including health.

2. Health sector constraints. With the devolution in the wake of the 18th Constitutional
Amendment in 2011, health care became a responsibility and accountability of the province. Using
the World Health Organization (WHO) framework3 on assessing health systems, the health sector
is characterized by the following key constraints: (i) poor health services delivery and utilization,4
(ii) insufficient and ineffective health financing, and (iii) weak governance and public financial
management.

3. Health service delivery: At the core of problems related to health services delivery is the
lack of access to quality health care services of the population. Indeed, quality improvement is
singled out as one of the major objectives of the Department of Health-KP (DoH-KP) strategy.
While preparatory work has been done for most of the interventions, such as developing a
Minimum Service Delivery Standards and the Essential Health Service Packages for the Primary
and Secondary Healthcare, the concept of integrated quality management and the structural,
process, outcome dimension of quality in health care and the concept of Continuous Quality
Improvement are yet to become part of the political debate and the sector policy/strategy
framework for quality in the health sector. Among the issues that lead to poor quality of health
care services are:

4. Poor referral systems, with tertiary-level institutions attracting huge crowds while
primary care facilities and secondary hospitals are underutilized. The health sector in KP is

1 Pakistan Demographic and Health Survey.

2 Institute for Health Metrics and Evaluation. http://ghdx.healthdata.org/gbd-results-tool (accessed 11 December
2017).
3 World Health Organization. 2007. Everybody’s business: Strengthening health systems to improve health outcomes.
WHO’s framework for action. Geneva: World Health Organization
http://www.who.int/healthsystems/strategy/everybodys_business.pdf
4 Asian Development Bank. 2015. Country Partnership Strategy 2015−2019. Manila : ADB
https://www.adb.org/sites/default/files/institutional-document/171824/cps-pak-2015-2019.pdf.
composed of public sector, and private sector. Altogether, the public sector has 11 tertiary
hospitals and 24 specialized hospitals, 190 secondary hospitals and 1,290 primary health care
(PHC) facilities. Despite having a considerable size of health service delivery outlets and
government’s efforts to provide quality care to citizens, PHC facilities and secondary hospitals are
often underutilized, mainly because of dearth of health care professionals and especially female
professionals, weak governance, substandard quality of services, but also lack of a functioning
referral system.

5. Standard Operating Procedures (Guidelines, Clinical Pathways) to avoid arbitrary

decision making are missing thus compromising effectiveness and efficiency of care.
In a rapid quality audit conducted in selected hospitals, key issues having an impact on quality
have been repeatedly found in almost all facilities. Clinical knowledge on diagnostic and
therapeutic procedures for the most frequent diseases is rather good but documentation of
symptoms at admission, clinical examination results, therapy plan, and follow-up is insufficient
and there is no standard template for a patient record to be used by all secondary level hospitals
which is supposed to provide relevant information for peer review and quality monitoring and
control.

6. Unregulated private sector. In addition, while private provision of healthcare is

widespread,5 information on the capacity, workforce strength and service provision of this
significant player remains elusive. Early attempts of regulation of the private sector through the
Healthcare Commission have begun, but resistance from private providers have impeded the
activity to initially register all private health care providers across the Province, and subsequent
objectives to minimize malpractice, over-provision and prescription of care and medicine, and
negligent behavior. Leaving the private sector to continue practicing and providing care in an
unfettered manner puts the population of the province at risk, with the delivery of care from
unregistered practitioners, otherwise known as “quacks”.

7. Minimum service delivery standards for secondary care has been developed but
not implemented. Operation of health facilities, medicine and supplies availability and the
functionality of equipment have traditionally been quite poor. In addition, operating conditions vary
widely across districts and individual facilities. To tackle these problems, DOH-KP initiated
development of minimum service delivery standards for both primary and secondary health
facilities. Explicit packaging of health services at various levels of care ensures the availability of
required services for a particular level, which also specifies the infrastructure, human resource,
medicines, supplies and equipment necessary to deliver the services.6 With the support of
Department of International Development (DFID), the minimum package for PHC has been rolled
out. Implementation of the package for secondary facilities is yet to happen due to financing
constraints and the need to operationalize its implementation roll-out.

8. No coherent and systematic process exists to formulate projects and develop

business cases for investment. Health facilities, beds and equipment are not equitably
distributed across districts. Almost all tertiary and specialized hospitals are concentrated in
Peshawar. This is because capital outlay submissions, business cases and feasibility studies are
informed by subjective and ad-hoc end-user requirements, as well as because of political
pressures, which often take precedence over projects generated from end-users.

5 Evidenced through household surveys of providers choice and out-of-pocket expenditures by provider type from the
National Health Accounts of Pakistan. http://www.pbs.gov.pk/content/national-health-accounts (accessed 11
December 2017).
6 I. Thaver and M.Khalid. 2016. Secondary Level Minimum Health Service Delivery Package for Secondary Hospitals.
Peshawar.

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9. Poor health knowledge of the population and providers. Low level of health education
of the population as well as inadequate implementation and understanding of behavior change
communication at the provider side lead to uninformed health-seeking behaviors of the
population. There is lack of behavior change communication activities (BCC) at the facility level,
resulting from lack of training on undergraduate level, lack of systematic continuous medical
education on BCC, lack of advocacy for BCC within policies, and lack of time within daily routines
of doctors.

10. Health Financing. Facilities will be unable to pursue quality enhancement measures with
limited resources available to them. The following bottlenecks contribute to limited financing and
inefficient use of existing resources:

11. Predominance of out-of-pocket payments in health financing. Like many Asian

developing countries, households´ Out-of-Pocket payments (OOP) constitute the largest source
of funding for the health sector in Pakistan at 56%. In KP, OOP account for 68% while public
sources contribute less than 21%. The proportion of Government Health Expenditure (GHE) over
Total Health Expenditure (THE) has increased between 2005 and 2014, but stabilized since then;
the proportion of OOP spending has evolved in the opposite direction. Contributing to this tight
fiscal space is the meager tax collection which is only 10% of GDP. Countries of similar income
level collect on average 22% of GDP. DoH KP has made the most challenging intervention and
crucial step towards achieving Universal Health Care (UHC) and reducing OOPs with the
introduction of a social health insurance program. This program was first piloted with KfW
financing in 4 districts of KP end of December 2015 and further extended with DoH’s own funds
to all districts of KP end of 2016 while also increasing the number of beneficiaries from 21% to
69% of the population in 2017. Being the first province of Pakistan launching a provincial wide
health insurance scheme, the GoKP has demonstrated its strong commitment to improve access
to health services for the poor and to achieve UHC.

12. Lack of comprehensive analysis of the financial sustainability of some of the

reforms. Uncoordinated budgeting for project development through the Annual Development
Program (ADP), and for operational expenditures through the recurrent budget, leads to
inefficiencies in the long-term financial planning. Moreover, due to political decisions and the
absence of a clear financial masterplan with earmarked budgets, many projects are delayed as
funds in subsequent years are reduced. This has resulted in the resources allocated to the ADP
for health becoming increasingly insufficient to meet funding requirements of all approved
projects. Furthermore, a long-term health financing sustainability analysis between projected
revenues and financing needs is currently not available.

13. Governance and Public Financial Management. It is not enough that facilities are
allocated resources, the facilities should be allowed to use those resources to pursue quality
enhancing activities. In exchange for this autonomy is that facilities should be accountable in
delivering quality services. The following issues hamper autonomy and accountability:

14. Limited management capacity. Most health facilities have limited managerial
autonomy, and depend heavily on decisions made at the central level (district or provincial).
However, different facilities may exercise varying degrees of autonomy resulting to wide variation
in management and operation practices and processes across the system. In addition,
management capacity is limited especially at the facility level. Pervasive political interferences in
appointment of managers and daily facility operations greatly reduce the ability of facility
managers to manage and take responsibility. On average, even though Medical Superintendents
(MS) are appointed for a 3-year mandate, they stay only 7 months in the same position.
Second, managers are usually doctors with no training in or experience in management. As a

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result, MSs often know little of the problems and workings of the facility they are supposed to
manage, and have no incentive to invest their efforts in it.

15. Authority and roles are fragmented between levels of government and
governmental agencies, contributing to the blurring of authority and accountability lines.
Responsibility for PHC services delivery has been decentralized to district authorities, while the
DOH manages secondary and tertiary care facilities with no systematic mechanisms in place for
coordinated planning at the district level.

16. Although the IMU and DHIS are commendable, the monitoring and assessment of
the various reform initiatives have not been well documented nor fully used for decision
making. Although a District Health Information Software (DHIS) is available, information is
fragmented, not compiled, and although capacity is available, current analysis is superficial and
merely descriptive. The focus is also mostly on inputs used rather than outcomes and
performance. As such, accountability mechanisms are non-functional, and enforcement of
policies and rules is weak.

17. Addressing these challenges implies the need for not only increasing resource allocation
to health, but also substantially improving the effectiveness of the health system through policy
implementation and coordination. These will require comprehensive reforms which the GoKP has
started to initiate at all levels of its health care system. Health policy in KP is informed mostly by
the National Health Vision 2016-2025 and the Khyber Pakhtunkhwa Health Sector Strategy 2010-
2017. The provincial Health Sector Strategy 2010-2017 is extended until June 2018 to provide
sufficient time for review of outcomes achieved and for the development of a new updated and
consolidated Health Sector Strategy.

Objectives

18. The objective of this workshop is to present the results of the assessment that examined
delivery of health services particularly quality of care, governance of the health sector, planning
and financial sustainability, and health seeking behavior of the population. With all the ongoing
initiatives in KP, there is a need for a consistent policy framework to coordinate and align all the
reform initiatives and prevent system fragmentation by reforms implemented in silos. It is
envisioned that the sector assessment will inform the new Health Strategy for the province.

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 Attachment 1

Challenges and Solutions for better Quality of (Hospital) Care

I. Challenges

Challenges identified during the assessment mission (site visits and document review) can be
categorized in those related to structural elements (staff, infrastructure and equipment), those
related to processes (the way care is being provided), and those related to outcomes of clinical
care.

A. Structural Elements (Infrastructure, Equipment, and Supplies)

• Inappropriate infrastructure (both buildings and installations)

 Inappropriate design, not fit for health care delivery (lack of space, dysfunctional location
of services and support units / organization of patient- and work-flows / issues regarding
hygiene and patient privacy);
 Discontinued supply / availability of utilities and support services (power and water,
sanitary installations, sewage and solid waste management systems);
 Lack of both preventive and curative maintenance;
• Lack of (functional) medical equipment for diagnostic procedures (imaging, laboratory,
clinical tests), sterilization, operation theater instruments, ICU monitors and anesthesia
machines;
• Lack of qualified staff, specifically of qualified nursing staff;
• Insufficient supply of (essential) drugs and medical consumables with frequent stock-outs.

B. Processes

• Secondary and tertiary level (referral) hospitals are overcrowded with patients bypassing the
PHC system, thus compromising the quality of care;
• Recording of patient data, anamnesis, diagnostic measures and treatment plans including
information on the implementation of the plan is often incomplete; standard record forms not
systematically available;
• Standard protocols / clinical pathways for diagnostic and therapeutic procedures are not
available;
• Quality Management (QM) tools and instruments (e.g. quality circles or committees to
monitor and review key performance and quality indicators) do not exist.

C. Outcomes
• Data and indicators on outcomes of clinical care are not systematically analyzed and
evaluated, e.g.:
 Inpatient morbidity and mortality directly or indirectly related to the medical intervention,
e.g. hospital acquired infections;
 Maternal mortality if a case of maternal mortality has been observed

II. Solutions for discussion

Results of the assessment were supposed to provide information and evidence for specific
measures to improve quality of hospital care provided to the population of KP. Proposed
interventions can be classified accordingly
A. Structural Elements (Infrastructure, Equipment, and Supplies)

• Systematically assess gaps regarding infrastructure and equipment of secondary level

hospitals using the following documents as reference
 Secondary Health Care Standards for Quality Health Services Volumes I-IV, developed
in the framework of a GIZ Technical Assistance Project and published in 2007, and the
 Secondary Level Minimum Health Services Delivery Package for Secondary Care
Hospitals (MHSDP), published in November 2016
• Establish a master plan for the development of the hospital infrastructure at provincial level
(consider PPPs to implement the master plan);
• Establish a system to assure continuous maintenance of buildings and equipment;
• Allow for decentralized management of drugs and consumables supply.

B. Processes

• Systematically develop and introduce Standard Operating Procedures (Guidelines / Clinical

Pathways / Protocols) for Medical Care – start with the most frequent diseases / medical
conditions requiring inpatient care;
• Introduce QM Tools and Instruments like e.g. QM Committees, Hygiene Committees, Drug
Committees, Mortality Conferences, etc. discussing and monitoring quality related issues;
• Develop and implement a program for Continued Medical Education (CME) for both doctors
and nurses to support the introduction of the above-mentioned tools and assure state of the
art knowledge and skills of all medical and paramedical staff;
• Consider using Electronic Patient Records (EPR) for both data and information management
to monitor and to steer (standardization) clinical care.

C. Outcomes

• Establish a regulatory and operational framework for Continuous Quality Improvement (CQI)
including both internal (at facility / service level) and external (at provincial level) QM
systems based on continuous monitoring and evaluation of service performance and quality
indicators;
• Introduce risk management measures to improve patient and staff safety (hospital hygiene,
prevention of clinical complications, systematic analysis and evaluation of inpatient
mortality);
• Assure follow-up on patient outcomes (survival rates, readmission rates, patient satisfaction,
etc.);
• Elaborate regular (annual) quality reports for each hospital (compiled quality report could
then be established at provincial level analyzing the range of quality indicators observed and
establishing benchmarks for Continuous Quality Improvement.

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 Attachment 2

Governance Issues and Policy Options

I. Issues

• Fragmented sector governance (and unclear authority lines): This decentralized system is
fragmented along subsectors (public, private and donors-funded NGOs), government
levels (provincial, district and community), and institutions (several departments are
involved in decision-making and resource allocation in health).
• Varying managerial autonomy at facility level: Heath facilities enjoy variable levels of
autonomy: they are responsible for their own procurement, but district-level facilities
(including secondary hospitals) have no authority for reallocating the line-item budget.
Medical Teaching Institutions (the large teaching hospitals) have been given broad
managerial autonomy, including the ability to set their own user fees.
• Limited managerial capacity: Facility managers are, in most cases, physicians who spend
some of their time caring for the management of the facility or take a leave from their
physician duties. They are not trained or familiarized with management objectives,
principles or tools.
• Institutional weakness and political interference: Interference from local politicians or
interest groups (such as political parties) on staff appointment and day-to-day operations
is a constant practice, and prevents effective management. On average managers spend
around 7 months in their management position before being replaced.
• Incomplete reforms and organizational innovations: DOH has sought to contract out facility
management and operation to private organizations, through a variety of organizational
arrangements akin to PPPs (Public-Private Partnerships) or through making selected
hospitals more autonomous. Limited evidence is available on the impact of these
innovative models. Few rigorous evaluations of these experiences have been done. They
have been challenged on various grounds, and some of them have been discontinued
without a clear rationale for discontinuation.

II. Policy options for discussion

• Develop a clear vision and roadmap for the future, clarifying the role of PPPs, facility
autonomy and other reforms
• Clarify sector governance and roles and strengthen district-level coordination
• Devise a new approach and policy on health facilities autonomy (based on
performance contracting)
• Design and adopt a stronger contracting framework and tool, apply first to MTAs
• Reorient information systems toward performance Monitoring and Evaluation (M&E)
• Reduce political interference thru enforcement of regulations, PPPs and other
approaches
• Train facility managers & develop management tools
• Others

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 Attachment 3

Healthcare Masterplan and Healthcare Financing: Issues and Options

I. Issues
• Quality and reliability of data on: demographic statistics, formal and informal workforce,
size and services provided by the private healthcare sector, cost of infrastructure (i.e.
construction costs)
• Planning for new healthcare infrastructure seems to be underfunded and on ad hoc
basis without a strategic long-term planning
• KP’s health budget is fragmented between development budget and current budget
(operational budget) and between the Provincial level and the District levels
• Budget expenditures show an underfunding of preventive and corrective maintenance of
healthcare infrastructure and equipment, leading to shortened economic lifespans
• Current social health insurance SHPI only provides partial cover for healthcare (i.e.
inpatient care) while outpatient care concerns the largest share of health expenditures
for the population
• Current KP funding for healthcare is insufficient to provide a more comprehensive cover,
for instance including outpatient care at the primary health care level

II. Options for discussion

• Develop a Masterplan to guide needs-based planning
o Healthcare needs in terms of services, infrastructure and HR
• Expanding coverage: how to cover the remaining 31% non-covered population
o Towards Universal Health Coverage: should there be a deepening of the
benefits package of SHPI:
▪ To include outpatient services?
▪ More catastrophic illnesses?
▪ Chronic conditions?
o What are the financial implications for KP?
▪ Long-term strategy to address financing gaps in health: moving from
out-of-pocket to pre-payment systems
▪ A financial analysis of policy options
• Improving efficiencies by moving from input-based financing (i.e. line items) to output-
based financing and mixed-models
• Others

Workshop Set-Up
During the workshop the participants will be presented both (1) a Masterplan to plan the further
development of the (public and private) healthcare sector, and (2) an Actuarial model to assess
and make projections of the healthcare costs of various options. The assumptions for the
Masterplan and Actuarial model will then be discussed and updated in an interactive workshop

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 Attachment 4

Challenges & Solutions for Behavioral Change Communication in the field of MNCH
within Secondary Care Facilities

I. Issues
• Demand Side:
- Insufficient knowledge about the right level of care for MNCH services
- Insufficient knowledge about the right medical attention at health facilities during delivery
and in general
- Insufficient knowledge about the right antenatal, delivery care and postnatal care
practices (according to the Minimum Care Standards for Primary and Secondary Care
Facilities in KP)

• Supply Side:
- Insufficient communication of community based MNCH providers (especially LHWs)
about the right MNCH practices and the right level of care
- Insufficient knowledge of health professionals working in secondary care facilities (and
beyond) about the concept of Behavioral Change Communication/health communication
and its importance
- Insufficient implementation of already existing BCC strategies for secondary care
facilities (i. e. mentioned within the Minimum Health Services Delivery Package for
Secondary Care in KP)
- Insufficient monitoring of existing BCC strategies
- Lack of a mainstream MNCH BCC strategy that is applicable to all levels of care (Most of
the existing strategies focus on primary care interventions)

• Cross cutting:
- Insufficient knowledge of district, provincial and federal bureaucrats about Behavioral
Change Communication; lack of advocacy for BCC within all policies

II. Strategies and Solutions for Discussion

• Demand side:

- Design and conduct formative research to identify contextualized BCC messages

(around MNCH) focusing on secondary level care interventions
- Design BCC messages around utilization of MNCH services focusing on secondary level
care
- Offer special discounts to pregnant women for accessing healthcare at the right time and
level of care
- Strengthen the cooperation and communication between primary and secondary care
facilities

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• Supply side (short-term):

- Create and ensure that there are BCC focal persons at all levels of the health care
structure (from provincial directorate of health to DHQ/THQ); establish positions at each
level and deploy qualified personnel, select ten districts in KP as a starting point and
select one DHQ or THQ from each district as a model hospital
- The BCC focal persons at the hospitals identifies needs of the target group, educates
accordingly and organizes health education sessions, he coordinates with the respective
MNCH professionals/departments in DHQ/THQ (gynecology and Obstetrics, Pediatrics
et al)
- The BCC focal persons at DHO/EDO office monitors and supervises BCC personnel at
the DHQ/THQ level, provides on-going continuous education to them, collates monthly
reports et al
- The BCC focal persons at provincial directorate office level prepares policies and
projects around BCC/IEC, coordinates with all stakeholders such as PMDC, PNC,
selected agencies, national and international BCC experts and Public Health
Department of KP, ensures distribution and use of BCC/IEC materials to all relevant
healthcare centers/hospitals
- Establish a forum of health providers (composed of all assigned focal persons for BCC)
from all levels which gets together and exchanges BCC experiences; DOH in KP must
make sure that meetings are obligatory

• Supply Side (medium-term):

- Implement the concept of Behavioral Change Communication into the curriculum of

undergraduates, post-graduates and continuing education for all health professionals by
the Higher Education Commission (HEC)
• Cross cutting/district, provincial and federal bureaucrats:
- Identify key people from within the district hospitals (starting with the model districts),
provincial governments and federal who are responsible for Education and
Communication and sensitize and prepare them as advocates of BCC/IEC
- Create a forum comprising of provincial health department, directorate of health,
registrar PMDC, PNC, Medical Directorate et al
• Cross Cutting/Media:
- Research on TV Channels and their outreach; select certain channels
- Identify an agency for preparing a targeted communication agenda
- Develop a media campaign strategy in cooperation with the agenda
- Assure that the selected channels cover MNCH news on a regular basis
- Monitor the media campaign by conducting surveys within the community

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 Profile of Speakers

Muhammad Abid Majeed is currently heading the Department

of Health KP as Secretary to Government of Khyber
Pakhtunkhwa. He has graduated from University of Peshawar
in 1991. He joined the Provincial Civil Service (PCS) in
1993−94 after passing the competitive examination. He has
participated in the 14th Senior Management Course at National
Management College, Lahore. In addition to position of
Secretary Health, he has also remained as Secretary to
Governor, Secretary Administration FATA & Secretary
Information.

Ms. Rie Hiraoka joined the Asian Development Bank (ADB) in

2001 and currently the Director of Social Sector Division for
Central and West Asia Department. In 2011–2016, she was
the Country Director in Kyrgyz Resident Mission. Ms. Hiraoka
holds a PhD in Development (Faculties: Economics and
Regional Science) from the Cornell University, and a
Bachelor’s degree in Earth and Planetary Science from Tokyo
University. She has over 25 years of experience in
international development in strategy and evidence—based
policy development, public sector management, public
finance, and service delivery. She has also worked with the
World Bank, and UNICEF.

Rouselle F. Lavado is a Health Specialist in the Social Sector

Division, Central and West Asia Department of the Asian
Development Bank. Prior to joining ADB, she was a Health
Economist at the World Bank Headquarters, working as a Task
Team Leader and team member for several health projects
and analytical products at the Europe and Central Asia
Region. She was also a Senior Fellow at the Institute for Health
Metrics and Evaluation at the University of Washington and
was in-charge of the research team that estimated
expenditures by diseases and meta-analysis of household
surveys and national health accounts. She has a PhD in
Economics from Hitotsubashi University, Tokyo, Japan, and a
post-doctoral degree in health metrics and evaluation from the
University of Washington, Seattle, USA.

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 Andrea Godon holds a Master degree in agriculture economics
from the Technical University Berlin and a postgraduate
degree in health economics from the European Business
School (EBS). The completed a post graduate program in
international development and economics at the German
Development Institute (DIE) in Berlin. As principal project
manager she has been with KfW Development Bank,
Frankfurt, for almost 20 years, including a 3 years secondment
to the European Bank for Reconstruction and Development
(EBRD), London, and was in charge of projects in various
sectors in Asian countries. The last 8 years the she was
responsible for all KfW financed projects in the health sector in
Pakistan, including the health insurance program in Khyber
Pakhtunkhwa. Since September 2017 she is working as
secondee from KfW in the Social Sector division of the Central
and West Asia department in ADB headquarter, Manila.

Dr. Eduardo Banzon is a Senior Health Specialist in the Asian

Development Bank. He champions universal health coverage
(UHC) and has long provided technical support to countries in
Asia and the Pacific. He was President and Chief Executive
Officer of the Philippine Health Insurance Corporation
(PhilHealth), World Health Organization (WHO) regional
adviser for health financing in the Eastern Mediterranean
region, World Bank senior health specialist, WHO health
economist, PhilHealth Vice President for Health Finance
Policy and Services sector, and a faculty of the University of
the Philippines College of Medicine and Ateneo de Manila
University Graduate School of Business.

Dr. Bernard Couttolenc has a PhD in health economics from

the Johns Hopkins University, and is an international
consultant for the World Bank, the Asian Development Bank
and the World Health Organization. He was for ten years a
professor and researcher at the University of Sao Paulo and in
recent years has been a director at the Performa Institute, a
think tank based in Sao Paulo. He has over twenty years of
experience in health sector reform projects in more than
twenty developing countries of Latin America, Africa and Asia,
with a special focus on health financing and payment
mechanisms, hospital management and governance, and
performance evaluation at the level of health providers and
health systems.

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Dr. Hiddo Arnold Huitzing (Hiddo) is an international consultant
specialized in health financing, both for health infrastructure
development projects as well as for health insurances. Hiddo
has worked and lived in Middle East, Asian, Pacific Island and
African countries and is fluent in French, English, Dutch and
Indonesian. Hiddo started his career in 1999 at the University
of Groningen, The Netherlands, and worked at an international
actuarial firm in The Netherlands. Since 2006, Hiddo has been
active in emerging markets, with in-country experience in over
two dozen countries. For health insurances, Hiddo has
developed internationally validated models for use in data-
poor and resource-poor settings. Hiddo holds a PhD in
Behavioral Sciences, a MSc in Econometrics (both University
of Groningen, The Netherlands), and a diploma in Actuarial
Sciences (Royal Dutch Actuarial Association, The
Netherlands), and certifications in Micro-insurance and Micro-
finance (Frankfurt School of Finance & Management,
Germany).

Dr. Nasir Idrees is a Health Systems, Policy & Governance

Specialist, having experience of working in development
sector for over 27 years. His work includes areas of policy,
strategy, strategic and operational planning, health sector
reforms, governance reforms, health system strengthening,
development of projects and programs, among others. He has
worked for the Government, Development Partners/Donors
(DFID, GIZ, USAID, UNDP, World Bank, Asian Development
Bank and DFAT), implementing partners (MMP, HLSP, OPM,
JSI etc.). He is a technical member of the National Health Task
Force, National Commission on Government Reforms; and
Provincial Reform Program (PRP) of Khyber Pakhtunkhwa
Province.

Faraz Khalid is a health financing specialist with over eleven

years of experience in social health protection in the Eastern
Mediterranean Region. He has been recently consulting with
World Health Organization and United Nations International
Children Emergency Fund for health financing assignments in
Pakistan, Lebanon, Jordan, and Morocco. As a health
financing technical analyst, he has reviewed health social
protection models of lesser developed countries, analyzed
health financing data from equity and efficiency perspectives,
assessed health systems performance, synthesized baseline
survey reports, and have assessed political, institutional,
cultural, and historical bottlenecks for Universal Health
Coverage (UHC) reforms. In addition to his medical training,
he completed his PhD in Global Health Policy and
Management on Fulbright Scholarship from Tulane School of
Public Health and Tropical Medicine, USA and Masters in
Public Health from London School of Hygiene and Tropical
Medicine. He was an “Emerging Voice for Global Health in

13
 2016” and has been recently awarded “Dean’s Scholastic
Award” and “Best Doctoral Dissertation Award for 2017”.

Martina Merten has been working as an international

consultant focusing on healthcare systems in developing
countries and emerging nations since 2009. She also works as
an instructor for global health and comparative healthcare
systems at various national and international universities.
Before she started her career as a consultant, she worked from
2005-2009 as an editor for social and health policy in the
correspondent office of the German Medical Journal – the
largest specialized medical journal in Germany. She has
worked as a health consultant and done on the ground
research on global health in more than 16 countries –among
others in China, the Philippines, Vietnam, Thailand, India,
Pakistan and the United States of America. She has received
numerous grants for international reporting and was recently
awarded by the Bill and Melinda Gates Foundation for global
health reporting. Merten holds a Master in political science,
constitutional-, social- and economic history and in public
international law from Friedrich-Wilhelms University, Bonn.

Frances Ng is an experienced specialist health strategy and

planning manager, providing advisory services to Government
authorities, public sector hospital providers, private investors
and private operators in the areas of strategy and capacity
planning, health service demand modelling and projections,
feasibility testing, market assessment and monitoring,
resource planning, commissioning and development of models
of care and patient flows for health system and facility
developments. She has more than ten years of global
experience in health systems, predominantly within Australia,
the Pacific and the Middle East. Her areas of expertise include
capacity planning, hospital and health system planning, health
services demand modelling, resource assessment and
planning, and development of system-wide, hospital or
service-oriented models of care. She is highly capable in
coordination and management of complex specialized health
planning projects and most recently was the Project Lead for
the feasibility study, including service planning and financial
modelling, for a comprehensive cancer center in Muscat,
Oman, home health business model in Riyadh, KSA and a
350-bed private hospital in Kampar, Malaysia.

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Michael Niechzial is a Medical Doctor specialized in Surgery
and holding a Master Degree in Public Health. In 2016 he
became Professor for Health Care Management at the
Accadis University in Germany. During more than 25 years in
international health he has been involved as expert, team
leader and back stopper in several health sector reform
projects and programs in different countries in Asia and Africa,
all of them aiming at health systems strengthening in general
and at improved access to quality health services. Michael has
strong expertise in project design, operational planning, and
monitoring and evaluation. His research and teaching activities
focus on Health Care Markets, Stakeholders in Health Care
Systems and Health Technology Assessment (HTA).

Dr. Zahra Ladhani is a national consultant specialized in

behavior change communication, health systems, capacity
building and training of health care personnel. She has worked
and lived in Karachi and Islamabad, Pakistan and in USA as
well as has worked on numerous short-term assignments on
many projects all over Pakistan and in Afghanistan. For more
than 15 years now, she has worked in various capacities in
health systems including teaching and supervising
undergraduate & graduate students and health professionals
as part of in-service training. She holds a PhD in Health
Professions Education from Maastricht University in
Netherlands, Masters in public health from University of
Minnesota USA, BSc in nursing from Aga Khan University and
a fellowship in developmental sciences from Harvard
University and another one in medical education and research
from Philadelphia, USA.

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