In the remote village of Gabral, nestled amidst the snowclad mountains of Swat, stands Basic Health Unit (BHU), Gabral. Perched atop a hill overlooking the sprawling valley below, the clinic serves as a lifeline for the local community, providing essential medical services to residents who would otherwise have to travel long and treacherous distances for basic health needs. It is one of the hundreds of primary care facilities providing healthcare services to the people of KP across a difficult terrain.

Up until recently, these facilities were run down, lacking even the basics like boundary walls, sitting areas, working lights and sometimes even running water. On top of this, critical service delivery equipment and emergency medicines rarely met the required levels. That changed with the introduction of Primary Care Management Committees (PCMCs) in Khyber Pakhtunkhwa, a move to transfer funds and decision-making to the grassroots level, empowering primary care facilities to cater to their own unique needs without waiting for higher tiers of bureaucratic wheels to turn.

A similar concept had existed in the education sector as far back as three decades ago. In the 1990s, Khyber Pakhtunkhwa experimented with the idea of decentralizing decision-making at schools through the introduction of Parent-Teacher Councils (PTCs). The PTCs gave community members, especially parents, the power to be involved in the educational progress of their children at the grassroots level through financial and administrative powers of the councils to spend funds on a need basis. According to the Annual Statistical Report of Government Schools, more than 95% of all Primary and Secondary public schools have a functional PTC. The initiative proved its efficacy throughout the past three decades, paving the way for a similar approach in Health.

Despite the inherent challenges of delivering healthcare across Khyber Pakhtunkhwa’s vast geography, where 83.5% of the population resides in rural areas, a particularly concerning obstacle emerges. Primary healthcare facility administrators face an onerous bureaucratic burden, requiring them to navigate a complex approval process for even minor expenses, such as replacing a lightbulb. This stifles their ability to address even the most basic needs and hinders the smooth operation of these crucial facilities.

Having PTCs as inspiration which addressed similar challenges in education, the Government of KP green-lit the formation of Primary Care Management Committees (PCMCs) in Basic Health Units (BHUs), Rural Health Centers (RHCs) and select Civil Dispensaries (CDs) and Hospital Management Committees (HMCs) in secondary hospitals in 2020. Since then, PCMCs have been made functional in more than 80% of BHUs and RHCs in the province. The committees have their own bank accounts to receive funds from the government, and donations from donors and philanthropists and retain 90% of the user fee revenue.

The Committee is empowered to spend funds on repair and maintenance, supplies, service delivery, and overall management of facilities. It can undertake maintenance work through local expertise instead of waiting for the Communication & Works (C&W) Department to go through a long tendering process to get basic repairs done. They can also hire temporary workers, undertake outreach activities, and procure a limited quantity of life-saving drugs.

While primary care facilities are provided with in-kind medicine and supplies through the District Health Officer (DHO), recurring fiscal crunches like the one during the interim government in KP mean fund flow could dry up to the bottom level very quickly. Facility in-charges believe the decision to let PCMCs retain the little revenue they generate allowed them to function during the interim government when there was no operational budget from the provincial government. Experts believe limiting PCMCs to purchase of essential life-saving medicine only may be counterproductive since they could purchase other medicine as needed by each individual facility.

So far, PCMCs have spent the majority of funds received from the provincial government on infrastructural development. This, however, is by design since the primary care facilities in KP were in particularly bad shape before the revamp. As a next step, the expenditure priorities should naturally shift away from infrastructure to medicine and equipment. That is, if the PCMC reform is owned by the current government and a steady flow of funds through the current budget is ensured. Looking at budget data from the interim government, ensuring the release and allocation for PCMCs will be a shift from last year.

The new Khyber Pakhtunkhwa (KP) government’s early focus on healthcare is encouraging. Their prior success in health reforms during their previous terms likely contributed to their recent electoral victory. Now, a crucial opportunity exists to maximize returns by prioritizing investments and reforms at the foundation of the healthcare system: primary care.

Strengthening PCMCs offers significant improvements with minimal additional resources. By prioritizing the needs of local communities, the government can lay the groundwork for substantial improvements in health outcomes. Policymakers must recognize the critical role of PCMCs and prioritize their strengthening to fully capitalize on this promising reform initiative.

Mir Sana Ullah Khan
The writer is a Fulbright Scholar, holding a Master’s degree from Columbia University, and is currently working in the development sector. His X handle is @MirSanaullah