A CRITICAL REVIEW OF THE UTILIZATION OF

RESIDENTIAL ACCOMMODATIONS IN PUBLIC

SECTOR HEALTH FACILITIES IN
DISTRICT SWABI

Dr. Mohammad Khalid

Session: 2006-2007

Provincial Health Services Academy

Budni Road Duran Pur Peshawar, Pakistan
University of Peshawar
In the name of Allah,
the most merciful and
beneficent
A CRITICAL REVIEW OF THE UTILIZATION OF
RESIDENTIAL ACCOMMODATIONS IN PUBLIC
SECTOR HEALTH FACILITIES IN
DISTRICT SWABI

Dr. Mohammad Khalid

Session: 2006-2007

Provincial Health Services Academy

Budni Road Duran Pur Peshawar, Pakistan
University of Peshawar
 DISSERTATION FORWARDING PERFORMA

No Stage Date Signature

1. Submission of dissertation ________________ _____________________

to supervisor (Dr.Mohammad Khalid)

2. Forwarded by Supervisor ________________ ______________________

to Rector (Dr.Sardar Ahmad)

3. Forwarded by Rector to ________________ _____________________

University (Dr. Mehmood Alam)

4. Defense ________________ _____________________

 i

TABLE OF CONTENTS

Chapter No. Topic Page No.

List of Tables ii

List of Graphs and figures iv

List of Acronyms vi

Dedication viii

Acknowledgements ix

1 Introduction, Aims & Objectives 1

2 Literature Review 5

3 Material and Methods 18

4 Results 26

4.1 General aspects of the study 26

4.2 Reasons for non-occupancy of accommodations 35

4.3 Researcher’s verified status of accommodations 36

4.4 Maintenance and repair of accommodations 39

4.5 Financial aspects of the study 40

5 Discussion 42

6 Conclusion and Recommendations 51

6.1 Conclusion 51

6.2 Recommendations 52

7 Summary 55

References 56

Annexure-1 Questionnaire 61

Annexure-II Epi Info Reports 63

Annexure-III Map of Swabi 76

 ii

LIST OF TABLES

Table Page
Topic
No No
1 List of Public Health Facilities in District Swabi (March, 2007) 18

2 Activity Plan of the Survey in District Swabi 24

3 Occupancy of accommodations in BHUs 33

4 Physical condition of residences 37

5 Electricity of residences 37

6 Water supply of residences 37

7 Security of residences 37

8 Maintenance and Repair of residences 40

9 Total Available Accommodations in All Health Facilities 63

10 Main Accommodation Types Available in Health Facilities 63

11 Distribution of Accommodations in Public Health Facilities 63

12 Type of Facility versus Type of Accommodation 65

13 Accommodation Status as by Services and Works (C&W) Department 65

14 Overall Accommodation Occupancy Rate 65

15 Accommodation Occupancy (According To Type of Health Facility) 66

Accommodation Occupancy in Basic Health Units (Bungalow vs.
16 66
Quarters)

17 Accommodation Occupancy in Civil Hospitals (Bungalow vs. Quarters 67

Accommodation Occupancy in District Head Quarter Hospital

18 67
(Bungalow vs. Quarters)
Accommodation Occupancy in Rural Health Centers (Bungalow vs.
19 67
Quarters)
20 Accommodations Occupancy of Bungalows and Quarters 68
21 Accommodation Occupancy as per Post/Designation 68
 iii

Table Page
Topic
No No
22 Accommodations Designated According to Posts 69

23 Is Designated Person Posted 70

24 Reasons for Non Occupancy: 1. Physically unsuitable 70

25 Reasons for Non Occupancy: 2. Poor security 70

26 Reasons for Non Occupancy: 3. Electricity not present 71

27 Reasons for Non Occupancy: 4. Water supply not functional 71

28 Reasons for Non Occupancy: 5. Own residence nearby 71

29 Reasons for Non Occupancy: 6. Kids’ education 71

30 Reasons for Non Occupancy: 7. Private practice 71

31 Reasons for Non Occupancy: 8. Spouse working elsewhere 72

32 Reasons for Non Occupancy: 9. Post graduation 72

33 Reasons for Non Occupancy: 10. Poor social circumstances 72

34 Reasons for Non Occupancy: 11.Officially working elsewhere 72

35 Reasons for Non Occupancy: 12. Unmarried 72

36 Reasons for Non Occupancy: 13. Other reasons (personal) 73

37 Researcher’s verified Status of accommodations 1. Building 73

38 Researcher’s verified Status of accommodations 2. Electricity status 73

39 Researcher’s verified Status of accommodations 3.Water supply status 73

40 Researcher’s verified Status of accommodations 4. Security 73

41 House Rent Deductions from Salaries of Employees 74

42 Deductions of 5% Maintenance & Repair from Salaries of Employees 74

43 Total Deductions from the salaries of health staff for accommodations 75

44 Maintenance and Repair of Accommodations by Government 75

 iv

LIST OF GRAPHS AND FIGURES

Figure Page
Topic
No No
Total residential accommodations in all public health facilities in
1 26
district Swabi
2 Accommodations as per facility type 27

3 Facility type versus accommodation type 27

4 Serviceable versus non serviceable 28

5 Overall accommodation occupancy 28

6 Occupancy in basic health units 29

7 Occupancy in hospital setup 29

8 Overall occupancy among doctors 30

9 Occupancy of accommodations by doctors in BHUs 30

10 Occupancy of accommodations by doctors in hospital setup 31

Overall occupancy of accommodations among paramedics and

11 31
supporting staff
Occupancy of accommodations by paramedics and supporting staff
12 32
in BHUs
Occupancy of accommodations by paramedic and supporting staff in
13 32
hospital setup

14 Occupancy of accommodations by medical technicians in BHUs 33

15 Occupancy of accommodations by lady health workers in BHUs 33

16 Occupancy of accommodations by chawkidars in BHUs 34

17 Accommodations unoccupied due to vacant posts 34

18 Reasons for non occupancy of accommodations I 35

19 Reasons for non occupancy of accommodations II 36

 v

Figure Page
Topic
No No
20 Building condition of residential accommodations 38

21 Electricity status of residential accommodations 38

22 Water supply status of residential accommodations 39

23 Security status of residential accommodations 39

24 Maintenance and repair of residential accommodations 40

Monthly deductions from salaries of employees for residential

25 41
accommodations

Total monthly deductions of house allowance from different cadres

26 41
of employees
 vi

LIST OF ACRONYMS

AMA Australian Medical Association

BHU Basic Health Unit
BMA British Medical Association
CD Civil Dispensary
CDC Centre for Disease Control (USA)
CH Civil Hospital
DGHS Director General Health Services
DHQ District Head Quarter Hospital
EDO Executive Health Officer
FLCF First Level Care Facility
GNP Gross National Product
GTZ German Assistance Programme
HA House Allowance
HCPs Health Care Providers
HR House Rent
Lab Asstt Laboratory assistant
LHV Lady Health Visitor
LRH Lady Reading Hospital
M&R Maintenance and Repair
MCH Maternal and Child Health
MO Medical Officer
MT Medical Technician
NF Non Functional
NGO Non Governmental Organization
NWFP North West Frontier Province
PGMI Post Graduate Medical Institute
RHC Rural Health Centre
RYK Rahim Yar Khan
SMC Shah Mansoor Complex
UK United Kingdom
 vii

US United States
USA United States of America
WHO World Health Organization
WMO Women Medical Officer
WO Ward Orderly
 viii

DEDICATION

DEDICATEDTO MY
FAMILY
 ix

ACKNOWLEDGEMENTS

To conduct a survey and go through all the stages of data collection, from planning to
analysis and from writing to the printing of final copy was a difficult task that was not
possible without many people.

In this respect I am extremely thankful to my supervisor Dr.Sardar Ahmad,

Coordinator EDO health office Mardan who was very helpful during the whole
process.

I am greatly indebted to Dr. Uma M Irfan whose advice and support was extremely
helpful during the survey and analysis. In this respect her efforts and hard work
especially the Epi Info classes and tutorials are highly commendable which enabled
me to use this software for data entry and analysis by myself.

My sincere thanks to Dr. Sabz Ali Khan EDO health Swabi for his kind permission to
conduct the study in Swabi and the every possible help he and his office extended to
me during the survey. The help of his deputy district health officer Dr. M.Aanwar is
worth mentioning and appreciable.

I would also like to thank Director PHSA Dr. Mehmood Alam, course director Dr.
Zaman Afridi for their kind support and the coordinator MPH course Dr. Ayaz
Mehmood whose dynamism, untiring efforts and dedication made a difficult dream
come true.

Lastly I wish to acknowledge the sacrifices of my family who supported and

encouraged me during the whole MPH course and while preparing this dissertation.

Peshawar Dr.Mohammad Khalid

th
15 April 2007
 1

CHAPTER – 1
INTRODUCTION

Federal and provincial Governments are spending millions of rupees on the construction
of public sector health facilities and residential accommodations for staff and doctors in
these facilities. The sole purpose of this investment is to provide 24 hours health care
services to both the urban and rural populations.

While in the cities these accommodations are hardly being found vacant, most of these
are not used by the designated staff in rural areas. What are the reasons and impacts of
the non-utilization of these accommodations have never being investigated.

There are several aspects of this issue. The public health aspect is the most important one.
Most of the population in rural area is not getting community based, 24 hours health care
coverage from public sector health care facilities and in rural areas the provision of
accommodations to health care providers seems to be wastage of the taxpayer’s money.

Another aspect of the problem is the imposed cutting from the salaries of the designated
employees who have no choice but to pay for the residence whether they occupy the
accommodations or not. Even repair cost (also called house rent) equal to 5% of the basic
pay is deducted from the salaries of the doctors.

The government share of the problem is the lack of maintenance and repair of these
accommodations, resulting in almost total destruction of rural health infrastructure.
Furthermore the ineffective and politically pressurized administration in the province and
districts is unable to solve this problem and has failed to attract doctors to the rural areas.

All this has resulted in a serious public health issue where no body is happy. The public is
dissatisfied over the performance of these facilities. The staff is demoralized over the
cutting of 645 to 3000 thousand rupees from their salaries for these poorly maintained
accommodations and the government itself does not know what to do about this.
 2

A serious thought has never being given to the issue both by the government and the
professional associations of doctors and paramedics and despite the non-utilization of
these accommodations new ones are being constructed and the practice is repeated again
and again.

Another unfortunate aspect of the problem is that researchers hardly address rural health
problems. In primary care medicine this is commonly referred to as the “10/90 gap”
which means that only 10 % of the research in the world is directed at the 90 % of the
health problems that are present in the primary health care sector. (1)

Similarly one can hardly find a study in public health literature, which has addressed the
accommodation problem in public health facilities in detail. So to address the problem in
its entirety this observational study was conducted in district Swabi.

All 252 residential accommodations situated in the 49 public sector health facilities in
district Swabi, ranging from DHQ hospital to basic health units were included and
studied.

The researcher personally visited all the 49 public health facilities that had residential
accommodations. Many aspects of the residential accommodations were checked and the
designated staff was interviewed. The financial, maintenance and repair aspects were also
checked.

In the following chapter a detailed literature review regarding various aspects of the issue
is being given. The chapter has an account of the WHO health perspective followed by
the situation of health delivery and its effectiveness in NWFP and Pakistan. This is
followed by a detailed review of the accommodations and living conditions in Pakistan
and the rest of the world.
 3

The chapter on study design and methodology has a complete section by section detail of
the materials and methods used during the study.. Results of the study, discussion,
conclusion and recommendations, based on the study findings are given at the end
followed by summary. The annexure contain the detailed analysis reports.
 4

OBJECTIVES:
Main Objective:
To review the utilization rate of the available accommodations in public sector
Health facilities in district Swabi
Sub Objectives:
1. To find the reasons for the non-utilization of accommodations in public sector
health facilities in Swabi
2. To assess the condition of residential accommodations in public sector health
facilities in Swabi
3. To estimate the total deductions from the salaries of the employees, who are
being designated these accommodations
 5

CHAPTER – 2
LITERATURE REVIEW

2.1. HEALTH AND HUMAN RESOURCE MANAGEMENT ISSUES:

According to WHO constitution health is the fundamental right of every human being
without distinction of race, religion, political belief, economic and social conditions. A
second opinion considers healthcare as the right rather than health itself. The state has a
responsibility to ensure this, as a part of ensuring social justice. (2)

The provision of healthcare facilities is not an easy task. It is not merely the construction
of healthcare facilities in a country or the provision of medicines, preventive or
diagnostic services in these facilities but also the better if not the best management of
human resource. The availability of human resource 24 hours a day is a major part of this
governmental responsibility.

Competent, motivated staff is at the centre of a high-quality health system. This has been
well illustrated by health system reform efforts of many countries, which have failed to
generate the intended benefits in spite of significant investment in infrastructure and
procedures. (3)

Human resource management issues and staffing of the rural health facilities are the
major hurdles in the provision of effective health services. These issues have affected the
rural healthcare more than the urban. On a global basis the developing world is affected
more than the developed. What are the causes, who are responsible and who are affected?

The health care providers in public service are the most affected from these issues in
most of the developing countries. The poor living conditions and accommodations in the
facilities and their family life have split them between their existence as beings and their
role as care providers. Almost every effort done concentrates on the best utilization of
human resource and facilities but in the process the basic human needs of the health care
providers who are the key elements of the system are ignored.
 6

The World Health Organization (WHO) in a press release has pointed that weak and
inequitable health systems are preventing many Asia-Pacific nations from meeting
international goals set on health and poverty. “The health care systems of many countries
are failing to deliver services of adequate quality, often using resources inefficiently or
inappropriately”, WHO said. (4)

2.2. THE ALMA ATA DECLARATION: WHERE ARE WE TODAY?

The Alma Ata conference in 1978 set the goal of “Health for all by the year 2000”. All
the 134 participating countries signed the declaration and agreed unanimously to
implement and achieve the goal. (5) How many countries have achieved the goal and
where are we? What is the cause of failure to achieve the goal not even in 2007? WHO
has recently urged the nations again to revive their struggle for the Alma Ata goals? (6)

2.3. EFFECTIVENESS OF HEALTH SERVICES IN PAKISTAN:

The first effective public health intervention in Pakistan dates back to 1 st and 2nd health
conferences held in the years 1947 and 1951. Due to these some progress was made in
the health sector and the first 5-year plan had some health improvement objectives. (7)

Prior to independence and until the 1960s the health care delivery system in Pakistan
comprised only of civil hospitals and district council dispensaries. Most of the rural
population had little access to basic health facilities and services. The second five-year
plan (1960-65) sought the establishment of 150 rural health centers (RHCs) in West
Pakistan over a period of five years.

Basic Health Units (BHUs) started in 1980 and during 1985-86 government decided to
establish one BHU in every union council. During 1991-92, government decided to
provide dispensaries in all larger union councils.
 7

Since then a total of 9 health plans have been made for the socioeconomic development
of the country. In all the plans more emphasis was placed on the preventive aspects of
health and the rural healthcare. (8)

What is the reality today? In the words of the minister of health Sindh “The doctors are
reluctant to go to the rural areas. The health system is ineffective and the hospitals
buildings in interior Sindh are occupied by feudal lords. Poor have no access to health
facilities in rural areas”. (9) The cities have large teaching hospitals and Medical
colleges. More emphasis is being placed on curative rather than preventive care. The
budgets of the teaching hospitals are growing day by day and these are drawing most of
the health sector budgets. Even the trend of establishing medical universities has been
introduced in a country where most of the rural population has no access to even the most
basic healthcare.

It is an established fact that most of the developing countries are not spending more than
2% of their gross national product (GNP) on health, resulting in poor coverage of public
health services. The Government of Pakistan spends about 0.8% of GNP on health care,
which is lower than some neighbouring countries such as Bangladesh (1.2%) and Sri
Lanka (1.4%). Our country spends 80% of its meager health budget on tertiary care
services, which are utilized only by 15% of the population. In contrast, only 15% is spent
on primary health care services, used by 80% of the population. (10)

Another interesting fact about healthcare in Pakistan has come from an article “Choosing
interventions that are cost effective (WHO-Choice)”. This article has compared the
relative cost of primary, secondary and tertiary care hospitals. The cost on a bed day in a
primary care hospital is half of the tertiary care hospital. Similarly the cost per outpatient
visit in a tertiary hospital is 2.5 times more as compared to the same in a primary
hospital. (11) This is a good example of cost effective investment in a primary level rural
setup.
 8

Fortunately the media and the higher authorities are beginning to realize that good rural
health is a major support to the country’s economy and that long-term sustainable uplift is
not possible without the improvement in rural health. (12)

2.4. EFFECTIVENESS OF HEALTH SERVICES IN NWFP:

The situation in NWFP is even more alarming. The budget of the province is being
mostly spent on the public sector Medical colleges, the new Medical University and their
teaching hospitals. Most of these (Medical university, the 2 Medical colleges and 3
Teaching hospitals) are situated in the provincial capital. These are providing services to
the elite class at the cost of the rest of the province. The health infrastructure is collapsing
and the repair and maintenance is never done in most of the facilities since their
construction. In the last decade 5 new public sector medical colleges have been opened.

The management of rural health sector has been given to the District Governments and
the posts of doctors have been degraded to the status of contract employment. The
capacity of the district governments to run a technical department like health is limited
and most of the time there is interference in the transfers and postings of the doctors and
paramedical staff. Salary of a contract doctor is less than a Bank guard. No future
planning for the newly graduated doctors is done and they are frustrated and dishearted.
Absenteeism, loss of interest and poor commitment to duties has become the rule and
every body is either trying to go to the cities or abroad.

The health sector reforms unit in NWFP, which is being supported by the German
government, has brought little change in the health care culture of the rural population.
Even more one of the German, working with GTZ Programme has been made the chief
executive of the largest teaching hospital (LRH) thus diverting the health reforms agenda
to the teaching hospitals , ignoring the province as a whole. (13) This shows the poor
commitment of the political leadership towards the improvement of health situation in the
rural areas.
 9

Whenever we in NWFP talk of social injustice and inequity we blame the federal
government for not giving us our share in receipts. What are we doing here? Every
facility and incentive is given to the health care providers in Peshawar. Most of the
offices, medical colleges, major hospitals and educational facilities are concentrated here.
Salaries for doctors are almost 1.5 times more in Peshawar. The rural health care
providers are not only working in the tense politically affected rural areas but also their
working and living conditions are the worst. Is it not a social injustice or inequity? Don’t
we have double standards for the urban and rural populations and health care providers?

2.5. LIVING CONDITIONS AND RESIDENTIAL ACCOMMODATIONS FOR

HEALTH STAFF IN PUBLIC HEALTH FACILITIES IN PAKISTAN:
Why doctors don’t go to the rural areas and why they are reluctant to live in the health
facilities where they are supposed to live. A study in Abbotabad showed that working
conditions in the periphery are poor. Basic facilities like water, electricity and
communication are scarce and social circumstances are unacceptable to doctors and their
families. This study showed that the doctors are neither trained to work in rural setups nor
they are given proper facilities and service structure to work there. They perceive to face
disadvantages affecting their social, professional and family life, if they join in rural
areas. The basic infrastructure and presence of the utilities is important for the retention
of the doctors in the rural health facilities. This study showed that the electricity was
present only in 33.3%, functional toilets in 36.5%, safe water in 20.6% and telephone in
6.3% of the facilities while gas was present in only one of the facilities. (14)

The Ministry of Health and World Health Organization (WHO) conducted a study in
1993 about the utilization of rural health facilities in Pakistan, which showed that out of
58 medical officers (MO) only 64% were present during duty hours, giving an
absenteeism rate of 36%. In only 41% of the facilities, the doctors were residing within
the institutions. Electricity was available in 91% of Rural Health Centers (RHCs) and
55% of Basic Health Units (BHUs), piped water was available in 61% of RHCs and 28%
of BHUs; and telephone was available in 7 out of 23 RHCs and no BHU had this facility.
Although 65% of the RHCs have official accommodations for Women Medical Officer
 10

(WMO), no WMO was utilizing the accommodation facilities. In BHUs utilization of the
official accommodation by the MOs was 18.6%. It was found that electric power,
drinking water and sanitation are the prerequisites in the BHUs and RHCs. (15)

The Punjab government is the pioneer in rural health reforms. It is focusing especially on
the rural and far-flung areas of the province to facilitate masses by the provision of
special job packages to attract doctors to these areas. The Minister health Punjab Dr.
Javed has rightly pointed to this by saying that “If we cannot make it binding on new and
junior doctors to go to rural areas, we shall have to offer them incentives and attractive
packages at least”. (16) The government in this connection has already offered special
incentives including a handsome pay-package to the doctors and para-medical staff
serving in rural areas. (17)

In the famous Rahim Yar Khan Model (RYK Model) doctors are offered better incentives
to work in rural areas. Salaries are 30,000 P.M. Residential accommodations are much
better and both electricity and drinking water are present in all facilities in the project
area. Interest free loans for cars are being offered to doctors. The results are promising.
Before implementation of the project only 9 of the 40 doctors were residing in the
facilities and almost all were involved in private practice. Now all are living in the
facilities and none is practicing privately. In a survey 91% doctors and health staff have
shown confidence in the system. Public satisfaction with system is almost 100% and
more than 83% have acknowledged a positive improvement in the health care. (18) This
is an excellent example of the fact that all the health care providers want to do their duties
provided their human needs are met and well cared for.

Sindh Government is also offering incentives to doctors for keeping them in the rural
areas. It is going to provide loans for cars and increase the house rent allowance under the
Sindh Rural Support Programme. (9)
 11

A study in Pakistan has shown that in addition to others, better human resource
management and availability of staff are the two important factors for health seeking
behaviour in Pakistan. (19)

Unfortunately no incentives are being offered in NWFP and Baluchistan to doctors or

paramedics for going to the rural areas. This is a major issue in the public health services
of these provinces that need urgent attention of the respective provincial governments.
The health care providers in these provinces are reluctant to go to the rural areas. In this
regard female health workers and lady doctors should be offered special incentives as
there is already a shortage of these categories of health employees in the rural sector. A
study in NWFP about the problems and working conditions of female health technician
has rightly suggested special allowances for female health workers to let them work
better in the rural communities. (20) Nurses in NWFP are the only fortunate females
HCPs who are being given higher salary scales.

2.6. LIVING CONDITIONS AND RESIDENTIAL ACCOMMODATIONS OF

HEALTH STAFF ON A GLOBAL BASIS:
Pakistan is not the only country where doctors are unhappy over the poor living
conditions in the public sector. Even the developed countries are having similar
problems. Incentives and special packages are being offered to doctors and other staff in
these countries in order to attract them to rural areas.

2.6.1. UNITED KINGDOM:

Contrary to what doctors associations in the developing countries are doing to solve the
accommodations problem of doctors, the BMA (British Medical Association) has
established clear-cut policies for the provision of standard accommodations for doctors.
The association is trying its best for the implementation of these policies by the
government and various hospitals in UK. (21)

Still things are not as good as they should be. Junior doctors are the worst sufferers of the
accommodation problems. The BBC has reported the problem by saying that “there have
 12

been reports of doctors in some parts of the UK sleeping in insect infested beds and being
forced to use buckets to wash themselves. Doctors at one hospital in Scotland last year
said they were being forced to sleep in cars because hospital accommodation was so
poor. “(22)

An investigation by the BMA's own newspaper, BMA News, revealed that basic living
conditions for some staff were failing to meet standards agreed 11 years ago. (23) There
is no hot and cold water; no beds for on call doctors and poor accommodation facilities
for junior doctors especially in some Scotland hospitals. (24)

The doctor’s accommodations in some places in Scotland are so poor and kilometers
away from the hospitals that the junior doctors are reluctant to serve in these hospitals
especially in the night shifts for security reasons. (25)

To cope with problem and in order to attract doctors to their areas some of the local
health boards in Scotland are investing millions of pounds for the improvement of
doctor’s accommodations in their localities. (26)

2.6.2. UNITED STATES OF AMERICA:

The United States has a health system that is decentralized and locally funded. Private
health insurance schemes are common. The state has only regulatory functions. Still
residents in rural areas suffer a lot due to the lack of funds and the withdrawl of health
management organizations from rural areas because of less profit and shortages of health
care providers. (27)

New York is the standard for modern world but the doctors don’t like to serve in its rural
areas. In Maine, N.Y., located in Broome County, the doctor's office has been vacant for
the last eight years, leaving residents to drive up to 22 miles for care in Binghamton,
N.Y., according to town Supervisor Theodore Woodward. (28) To recruit more doctors to
rural areas, the state has used scholarships and student loan incentives in exchange for
doctors working "a few years in small towns".
 13

In Oklahoma State the residents are said to travel hours to see a doctor in some rural
areas. To solve the problem and to attract doctors to work in the rural communities of
Oklahoma the Oklahoma Senate approved a bill to give tax incentives to doctors. (29)

In Oregon 18 rural health facilities have shortage of doctors. The local authorities are
offering personalized services and incentives to doctors including real estate to attract
them to stay in the rural communities. (30)

Besides governments and local communities the billionaires are also offering incentives
to attract doctors to serve in rural areas. In this regard Senator Jay Rockefeller is offering
20 % bonus to the doctors willing to work in the rural areas of the country. (31) Still
doctors prefer to work in urban communities due to better working conditions and better
residential facilities in the cities.

2.6.3. AUSTRALIA:
The Australians are more concerned about the working conditions of the doctors. In a
position statement the AMA (Australian Medical Association) has described in detail the
required working conditions for doctors.

These include adequate security measures, good workspace on wards, study facilities,
message facilities, dining facilities, child-care facilities, common rooms with full
facilities, on-duty rest rooms, shower facilities and adequate ventilation and thermal
regulation in the workspace. The residential accommodation is a luxury. The statement
has clarified that accommodation should be provided to all those who serve away from
their normal residences and at no cost, in the hospital vicinity. (32)

The suggested specifications of residential accommodations are mentioned here for

comparison with facilities provided in the developing countries. The residences should
have:
 14

1. Secure, clean and well maintained sleeping accommodation that is as close to the
hospital as practicable and separate from accommodation for the relatives of
patients;
2. Windows and doors fitted with security grills and locks as well as external
lighting, fire detectors and extinguishers;
3. Furnishings, facilities and white goods
4. A fully equipped kitchen with a conventional and microwave oven, stove, toaster,
refrigerator, cutlery and crockery;
5. A television, radio, dining table, chairs and beds;
6. A clean and well maintained bathroom;
7. Individual study desk with appropriate lighting (i.e. desk lamp); and
8. Access to on-site car parking.

The AMA has even suggesting to the government to modify the medical education in the
country. They have suggested that training should be funded and bonded to keep the
doctors in the rural areas as the unfunded education don’t bound the doctors for service in
the rural communities. (33)

The Australian government itself is not only spending millions of dollars for the
improvement of doctors accommodations (34, 35), it is also trying to help the community
leaders to attract doctors to their local rural communities. (36)

There have been voices in the parliaments of local legislative assemblies to improve the
health status of rural masses by attracting doctors to theses areas, offering them
incentives and special employment packages. (37)

The New Zealand, a close neighbour is also not behind and the main labour party has
taken a lot of steps and has promised for improvement of rural health. They even have a
separate minister for rural affairs. (38)
 15

This is an example for us, as despite being a rural country Pakistan does not have such a
minister in federal or any of its provincial cabinets.

2.6.4. AFRICA:
Being the poorest continent and with the least health care facilities Africa has some
serious accommodation problems and poor working conditions for the doctors. A report
from Zimbabwe in 2006 has revealed that despite the will to work in their country, the
doctors have been left with no alternative but to migrate to other countries due to the poor
accommodations, broken equipments and transport problems. (39) The government has
been blamed by the Zimbabwe health services board for doctor’s strikes who are
demanding better working conditions including accommodations and house allowance.
(40)

Ghana Medical association is pressing hard for stoppage of the unfair deductions from
salaries of health staff for accommodations as well as other taxes, as by doing so the
government is taking back the incentives and increase in salaries. (41) Doctors are not
happy over the poor working conditions in this African country.

2.6.5. ASIA:
Asia is the most populous continent in the world. Unequal distribution of resources and
high population growth rate are challenges to prosperity. The health infrastructure is
turning into ruble in most countries and rural populations are hardly getting any health
care. Most of the budgets are spent on defense and luxuries in the urban areas. Health is
the least priority and is left mostly to donors who instead of doing anything for health are
promoting their own agendas.

Gulf News has given a beautiful description of a rural Indian hospital, which is being
converted to a tomb. Building, instruments are totally broken down and the doctors
neither have any interest nor any facility to work. (42)
 16

Sri Lanka has been an example of a moderately good economy with better indicators of
health. The working environment is similar to Pakistan in many respects. Doctors in this
country are leaving rural areas not for professional but for family reasons. In the rural
areas there is lack of adequate family accommodations, jobs for HCPs spouses, education
for children and carrier or academic opportunities for doctors. (43)

According to The World Health Organization (WHO) weak and inequitable health
systems are preventing many Asia-Pacific nations from meeting international goals set on
health and poverty. The health care systems of many countries are failing to deliver
services of adequate quality, often using resources inefficiently or inappropriately. (44)

World Bank is helping many countries to develop strategies and incentive packages to
attract doctors serve in rural areas under the research project "Incentives for Doctor
Placement in Rural and Remote Areas". (45)

The importance of keeping doctors in rural areas is so important that even NGOs are
constructing accommodations for doctors and paramedics so that their human needs are
better satisfied and they work better and remain in the projects for a prolonged period of
time. (46)

2.7. EFFECTS AND CONSEQUENCES OF POOR WORKING CONDITIONS:

The effect of poor working conditions on the health workforce is loss of interest,
migration to cities inside the country or migration to developed and Middle Eastern
countries. The genesis of migration is two fold. Pull from west or more prosperous
countries due to globalization and better opportunities is drawing doctors from east to
west and from Europe to America while the push come from internal factors as discussed
above. (47)

In fact, about one-quarter of all licensed physicians in Australia, Canada, the United
Kingdom and the United States are from the developing world, with India, the
Philippines and Pakistan providing most of them. In effect, developing countries are
 17

providing a reverse subsidy, in which the costs of the global mobility of health workers
are being shouldered by poorer source countries, while the benefits are concentrated in
wealthier recipient countries. (48)

In South Africa when the immigrant doctors from two poor countries Angola and Zambia
were asked whether they would like to go back or stay, most were reluctant to go back to
their countries. Even their own governments where there is a serious shortage of skilled
workers were not ready to provide any incentives to them or improve their working
conditions. The push factors, which are compelling the doctors in these countries to go
abroad, are poor salaries, poor accommodations and poor local health infrastructure and
communications. (49)

Thus time has come to act and stop pushing doctors out of the villages and countries as
lot of resources are being spent on the education of doctors. This is our precious human
skilled resource and need to be used here. Rural health care need incentives and better
working conditions for doctors to stay and the governments will have to invest in the
rural health which comprises about 70 % of our human work force.
 18

CHAPTER – 3
MATERIAL AND METHODS
3.1.0. MATERIAL:
3.1.1 (A) SUBJECTS:
The study was conducted in District Swabi. All residential accommodations in public
sector health facilities were the focus of study. District Swabi has a total of 60 health
facilities. The detail is as under:
1. District Head Quarter Hospital 1
2. Shah Mansoor Hospital Complex (Almost complete) 1
3. Civil Hospitals 3
4. Rural Health Centers 2
5. Civil Dispensaries 8
6. Mother Child Health Centers 3
7. Basic Health Units 42
Total: 60
The 3 Mother Child Health Centers and 8 Civil Dispensaries did not have residential
accommodations for the staff so they were excluded from the study. All the rest of 49
health facilities were included in the study. Every residential accommodation in these 49
health facilities was studied and the concerned staff members who were being designated
these accommodations interviewed and questioned. Data regarding cutting from salaries
was collected from EDO Health and District Accounts Offices. Similarly data regarding
the cost of construction and repair was also collected from EDO health and Services and
Works Department.

A list of 49 health facilities that have residential accommodations and the number of
residential accommodations available in each is given in the following table.
Table No: 1 – List of Public Health Facilities in District Swabi, having residential
accommodations (March, 2007)

NO HEALTH FACILITY NAME NO OF ACCOMMODATIONS

1 BHU ADINA 4
 19

2 RHC AMBAR KUNDA 11

3 BHU BACHAIE 4
4 BAHADAR ABAD 4
5 BHU BAJA 4
6 BHU BATAKARHA 4
7 BHU BEKA 4
8 BHU CHECK NODEH 4
9 BHU DAGAI 4
10 BHU DHERI ZAKARIA 4
11 BHU DHOBIAN 4
12 BHU FAZLE ABAD 4
13 BHU GABASNI 4
14 BHU GANDAF 4
15 BHU GANI CHATHRA 4
16 BHU ISMAILA 4
17 BHU JALBAI 4
18 BHU JALSAI 4
19 JEHANGIRA 4
20 BHU JHANDA 4
21 BHU KALABAT 4
22 CH KALU KHAN 10
23 CH KAPGANI 7
24 BHU KOTHA 4
25 BHU LAHOR EAST 4
26 BHU LAHOR WEST 4
27 BHU MAINAI 4
 20

28 BHU MANGAL CHAIE 4

29 BHU MANKAI 4
30 BHU MARGHUZ 4
31 BHU MIAN KALI 4
32 BHU PANJPIR 4
33 BHU QADRA 4
34 BHU SADRE JADEED 4
35 BHU SALIM KHAN 4
36 BHU SARD CHINA 4
37 BHU SHAH MANSOOR 4
38 SHAH MANSOOR
1
COMPLEX
39 BHU SHEIKH JANA 4
40 BHU SHIVA 4
41 DHQ SWABI 29
42 BHU TAND KOHI 4
43 BHU TARAKAI 4
44 BHU THORDHER 4
45 CH TOPI 14
46 BHU YAQOOBI 4
47 RHC YAR HUSSAIN 12
48 BHU ZAIDA 4
49 BHU ZAROOBI 4
TOTAL 49 252
 21

3.1.2. (B) QUESTIONNAIRE:

A questionnaire was made in consultation with the supervisor and teachers of PHSA and
was filled during visits to the concerned facilities. The questionnaire had 5 sections as
given below:
1. Section-I Basic Information of the facility and accommodation
2. Section-II Reasons for Non Occupancy
3. Section-III Accommodation Status as verified by the researcher
4. Section-IV Compulsory Deduction from salaries
5. Section-V Any other incentive the staff wanted to stay in the facility
The questionnaire specimen is given in Annexure I on page – 70.

3.1.3. WORKING DEFINITIONS:

Facility Name: Name of the place where the facility is located
Designated person: The person who is being allotted the accommodation
officially and from whose salary deductions are being
made for the said accommodation whether he or she has
occupied the accommodation or not
Deduction at source: The Allowance is deducted in DAO office before payment
of the salary
Posted: The designated person is drawing salary against the post
Occupied: The designated person is living with or without his family
in the allotted accommodation
Suitable for living: The accommodation building is in reasonable condition to
be used for living
Unsuitable for living The condition of the building is poor with doors, windows,
Bathrooms, kitchen, roof or walls damaged and in poor
condition
Functional: Present and working
Reasonable: Acceptable to the inhabitant
Deduction: Either not given (House Rent) or deducted from salary (5%
of running pay)
 22

Serviceable: Declared fit for living by the Services and works

department and thus the deductions are to be made from
the salary of the designated person
Unserviceable: The accommodation is declared as unfit for living by the
Services and Works department and thus is not allotted
to any person.

3.2.0. METHODS:
3.2.1. VARIABLES:
The variables, which were included and studied in the survey, were:
1. No of Accommodations in public health facilities
2. Types of Accommodations
3. Who were designated these accommodations
4. Occupancy status of the accommodations
5. Reasons for non occupancy of the accommodations
6. Building condition of the accommodations
7. Water supply status of the accommodations
8. Electricity status of the accommodations
9. Security status of the accommodations
10. House rent deductions from salaries for the accommodations
11. 5% maintenance deductions from salaries for the accommodations
12. Incentives asked for by health worker for staying in the facility accommodations

3.2.2. STUDY DESIGN:

This was a Cross sectional study, conducted during the months of March and April in the
year 2007.

3.2.3. STUDY FRAME:

The study included all residential accommodations in public sector health facilities in
district Swabi, NWFP. Every accommodation whether serviceable or not was included in
the study. A total of 48 facilities including BHUs, RHCs, CH, DHQ and even the
 23

completed Shah Mansoor hospital complex were included. The total number of
residential accommodations in these facilities was approximately 252 and all were visited
and included in the study.

3.2.4. SAMPLING METHOD:

The sampling method used was Census. All residential accommodations in public sector
health facilities in district Swabi, NWFP were included in the study.

3.2.5. INCLUSION CRITERIA:

1. Every residential accommodation in a health facility in district Swabi
2. Consent of the health care providers (HCPs) for interviews who were officially
designated the residential accommodations.

3.2.6. EXCLUSION CRITERIA:

1. Those HCPs not giving their consent to be interviewed.

3.2.7. PILOT STUDY:

A pilot study was conducted in 4 facilities, (BHUs Ismaila, Adina, Shiva and Bahader
Abad) covering a total of 16 residential accommodations to check the internal validity of
th
the questionnaire and the study. The pre testing revealed that some questions and the 5
section were needed to be included in the questionnaire to get additional information.
Thus some modification was made in the questionnaire and the strategy for visiting
various facilities was devised. A tentative time schedule was set to visit every facility,
using less time, money and efforts.

3.2.8. THE FIELD SURVEY:

Prior permission was obtained from the EDO Health Swabi for the survey and interviews
of the staff as well as for looking into the records of the Accounts section in connection
with House rent and 5% maintenance and repair cuttings from the salaries of the
concerned staff. The field survey and facilities visits started from 15th March, 2007 and
were completed on 1st April, 2007. For this purpose an operational plan was made
 24

keeping in view the roads and accessibility of the facilities from main Swabi Mardan and
Swabi Jehangira Roads. The Facilities were visited during working hours and the staff,
which was not available, were contacted and interviewed on other days. In this respect a
workshop held in EDO health office was very helpful where many doctors, medical
technicians and LHVs were available and were interviewed with the kind courtesy of the
EDO health.
The outline of the visit plan for survey is given below:
Table: 2 - Activity Plan of the Survey in District Swabi

DATE VISITED FACILITIES

15-03-2007 BHUs ISMAILA, ADINA AND RHC YAR HUSSAIN

16-03-2007 BHUs DHOBIAN , SARD CHINA, YAQOOBI

CH KALU KHAN, BHUs SHIVA, BAHADER ABAD , TARAKAI
17-03-2007
AND DAGAI

BHUs SH.JANA,CH NODEH, SALIM KHAN, MIAN KALI, BACHAI,

20-03-2007
SADRE JADEED AND FAZLE ABAD

BHUs PANJPIR, SHAH MANSOOR D ZAKARIA AND RHC

21-03-2007
AMBAR
22-03-2007 BHUs LAHOR EAST AND WEST,BEKA AND MANKAI

24-03-2007 BHUs JALSI, JALBAI, THORDHER AND MANKAI

26-03-2007 BHUs KOTHA, KALABAT, MARGHUZ, TAND KOHI AND ZAIDA

27-03-2007 BHUs BATAKARA,ZAROOBI,MANAI,JANDA AND CH TOPI

29-03-2007 BHUs GANDAF, MANGAL CHAI AND CH KAPGANI

30-03-2007 BHUs QADRA AND GANI CHATHRA

31-03-2007 BHUs GANI CHATHRA AND GABASNI

01-04-2007 DHQ SWABI

During field survey data regarding all aspects of the residential accommodation like
location, occupancy, serviceability and reasons for non-occupancy was recorded, using
 25

the questionnaire. The researcher himself physically verified the building condition,
water supply, electricity and security status of each residence.

Record of deductions from the salaries of the designated employees, both house
allowance and house rent (5% maintenance and repair) were collected from EDO (H) and
DAO Offices.

Similarly data regarding the repair and maintenance of the accommodations, since their
construction, was also collected from the staff and from the EDO health and / or Services
and Works department Swabi. Cost estimates of construction of a bungalow and a 2-room
quarter was also obtained from the services and works department.

3.2.9. POST SURVEY CHECK:

The questionnaires were checked and the data from other departments, entered where
needed. The incomplete questionnaires were picked and the relevant data entry made
through special visits of the district on 2 consecutive days. The whole data was arranged
in order for entry into the computer.

3.2.10. PROCESSING AND ANALYSIS:

It took 5 days to enter all the 252 questionnaires into the computer. Checking and
corrections took another day. Subsequently the data was processed and analyzed through
the software. The report so made was saved in a separate file in the dissertation folder for
inclusion in the final draft of dissertation.

Epi Info version 3.2.2 was used to analyze the data. First the data was entered into a
preformed database and then it was analyzed through the software, using its analysis
feature. Epi Info was downloaded as a freeware from the CDC website
http://www.cdc.gov/epiinfo/.
 26

CHAPTER - 4
RESULTS

4.1. GENERAL ASPECTS OF THE STUDY:

4.1.1. TOTAL RESIDENTIAL ACCOMMODATIONS:

The study was conducted in the whole district Swabi. A total of 48 health facilities where
residential accommodations are available were included in the study. The total numbers
of residential accommodations were 252 in all these 48 health facilities. Out of 252, 71
were bungalows and 181 were two rooms’ quarters. Further split up in various ways is
given graphically below. (Table 9, p 63)

FIGURE: 1 TOTAL RESIDENTIAL ACCOMMODATION IN ALL PUBLIC

HEALTH FACILITIES IN DISTRICT SWABI

Total: 252

Quarters
181, (72%)

Bungalows
71, (28%)
 27

FIGURE: 2 ACCOMMODATIONS AS PER FACILITY

TYPE

CH
31, (12%)

DHQ
30, (12%)
BHU
168, (67%) RHC
23, (9%)

FIGURE: 3 FACILITY TYPE VERSUS ACCOMMODATION

TYPE

15
RHC 8
Type of Facility

19
DHQ 11 Quarter
21 Bungalow
CH 10

126
BHU 42

0 50 100 150
No of Accommodations
 28

4.1.2. ACCOMMODATION STATUS AS PER SERVICES AND WORKS

DEPARTMENT:
The services and works department classification is for cuttings from the salaries.
Serviceable means the accommodation is fit for use and deductions from salary of the
designated person will be done. Unserviceable means unfit for living. Out of the total 252
233 are serviceable and 19 are unserviceable. (Table 13, p 65)

FIGURE: 4 SERVICEABLE VERSUS NON SERVICEABLE

Servic eable ,
233, (92%)

Unserviceable,
19,(8%)

4.1.3. OVERALL ACCOMMODATION OCCUPANCY:

The overall occupancy of accommodations in all facilities of Swabi was 50 %. (Table 14,
p 65)

FIGURE: 5 OVERALL ACCOMMODATION OCCUPANCY

Occupied
107, (50%)

Unoccupied
106, (50%)
 29

4.1.4. ACCOMMODATIN OCCUPANCY IN BASIC HEALTH UNITS VRSUS

HOSPITAL SETUP:
Although the overall accommodation occupancy rate was 50 % for all facilities, the BHU
accommodation occupancy was 34 % which is much lower than the 92 %
accommodation occupancy rate in the Hospital setup (DHQ, CH, and RHC). Similarly
there were only 5 unoccupied accommodations in hospital setup as compared to 101
unoccupied accommodations in the BHU. (Tables 16, 17, 18, p 66, 67)

FIGURE: 6 OCCUPANCY IN BASIC HEALTH UNIT

Occupied
52, (34%)

Unoccupied
101, (66%)

FIGURE:7 OCCUPANCY IN HOSPITAL SETUP

Occupied
55, (92%)

Unoccupied
5, (8%)
 30

4.1.5. ACCOMMODATION OCCUPANCY AMONG DOCTORS:

There were a total of 72 Category III Bungalows in the district for doctors. 12 posts of
medical officers were vacant. 60 doctors were posted and among them only 30 (50 %)
were living in the remaining 60 bungalows. In BHU setup 42 bungalows were available
but 8 posts of doctors were vacant. In the rest of 34 bungalows only 7 (20.5 %) doctors
were living with families. In hospital setup (RHC, CH and DHQ) 29 bungalows were
available for doctors and 3 posts of doctors were vacant. Out of the rest of 26 bungalows
23 (88.5 %) were occupied. (Table 20, p 68)

FIGURE: 8 OVERALL OCCUPANCY OF

ACCOMMODATION AMONG DOCTORS

Occupied
30, (50%)

Unoccupied
30,(50%)

FIGURE: 9 OCCUPANCY OF ACCOMMODATION BY

DOCTORS IN BHUs

Occupied
7, (20%)

Unoccupied
27,(80%)
 31

FIGURE: 10 OCCUPANCY OF ACCOMMODATION BY

DOCTORS IN HOSPITAL SETUP

Occupied
23, (88%)

Unoccupied
3,(12%)

4.1.6. CCOMMODATION OCCUPANCY AMONG PARAMEDICAL AND

SUPPORTING STAFF:
There were a total of 180 Quarters for the paramedical and supporting staff .77 (50 %) of
the designated 153 Quarters were occupied while 27 were vacant due to the non-
availability of the designated person. In BHU 45 (38 %) out of 119 Quarters were
occupied. In hospital setup 32 (94 %) out of 34 Quarters were occupied.

FIGURE: 11 OVERALL OCCUPANCY OF

ACCOMMODATIONS AMONG PARAMEDICS AND
SUPPORTING STAFF

Occupied
77, (50%)

Unoccupied
76,(50%)
 32

FIGURE: 12 OCCUPANCY OF ACCOMMODATIONS BY

PARAMEDICS AND SUPPORTING STAFF IN BHUs

Occupied
45, (38%)
Unoccupied
74,(62%)

FIGURE: 13 OCCUPANCY OF ACCOMMODATIONS BY

PRAMEDIC AND SUPPORTING STAFF IN HOSPITAL
SETUP
Occupied
32, (94%)

Unoccupied
2,(6%)

4.1.7. OCCPANCY AMONG PARAMEDICS AND OTHERS IN BASIC HEALTH

UNITS:
Occupancy of accommodation by doctors has already been given above under section
5.15 and Figure 9. The occupancy among other cadres of employees in BHUs is given
below:
 33

Table No: 3 - OCCUPANCY OF ACCOMMODATIONS IN BHUs

TOTAL
LIVING IN NOT LIVING IN
CADRE DESIGNATED
FACILITY FACILITY
ACCOMMODATIONS
Medical 10 32 42
Technicians (24 %) (76 %) (100 %)

LHV 14 28 42
33 % 67 % 100.0 %
Chawkidar 24 14 38
63 % 37 % 100.0 %

FIGURE: 14 OCCUPANCY OF ACCOMMODATIONS BY

MEDICAL TECHNICIANS IN BHUs

Occupied
10, (24%)

Unoccupied
32,(76%)

FIGURE: 15 OCCUPANCY OF ACCOMMODATIONS BY

LADY HEALTH WORKERS IN BHUs

Occupied
14, (33%)

Unoccupied
28,(67%)
 34

FIGURE: 16 OCCUPANCY OF ACCOMMODATIONS BY

CHAWKIDARS IN BHUs

Occupied
24, (63%)
Unoccupied
14,(37%)

4.1.8. UNOCCUPIED ACCOMMODATIONS DUE TO VACANT POSTS:

There were a total of 232 serviceable accommodations in the district but only 213 were
designated to staff. The rest were not allotted to anyone due to the designated post being
vacant. (Table 23, p 70)

FIGURE: 17 ACCOMMODATIONS UNOCCUPIED DUE TO

VACANT POSTS

Unoccupied
(Not
dsignated)
19, 8%
Designated
213, 92%
 35

4.2. REASONS FOR NON OCCUPANCY OF RESIDENTIAL

ACCOMMODATIONS:
The reasons given by the health care providers for non-occupancy of accommodations
were grouped in 13 categories. Most common reason was that own accommodation was
available near the place of duty. The rest are being given below in a graphical form.
(Tables 24-36, p 70-73)

FIGURE: 18 REASONS FOR NON OCCUPANCY OF

ACCOMMODATIONS I

60

50
(57) 37 % Own re sidence

40
(21) 12 % Building

(11) 7 % On duty elsewhere

(10) 6.5 % Personal reasons

(13) 9 % No electric ity
(15) 10 % No water
(15) 10 % Security

30
(8) 5 % Private practice

(4) 2.5 % Spouse e lsewhere

(9) 6 % Unmarried

(5) 3 % Kids education

(3) 2 % Postgra dua tion

(2) 1 % Poor sociality

20

10

0
 36

FIGURE: 19 REASONS FOR NON OCCUPANCY OF

ACCOMMODATIONS II
Kids
Physically No electricity
13,( 9%) education Officially
unsuitable
5, (3%) elsewhere
21, (12%)
11,( 7%)

Poor security Personal

15, (10%) reasons
10, (7%)

Unmarried
9, (6%)

Spouse
elsewhere
4, (3%) Own
No Water residence
Private
15, (10%) 57,( 37%)
practice Poor sociality
8, (5%) 2, (1%)
Post
graduation
3, (2%)

4.3. RESEARCHER’S VERIFIED STATUS / CONDITION OF RESIDENTAL

ACCOMMODATIONS:
All the residential accommodations whether occupied or not were examined and checked
from a non-technical, common man’s eye by the researcher himself. 4 aspects of the
accommodations were checked, condition of building, water supply status, electricity
status and security aspects. The findings are summarized below both in tabulated and
graphical forms.
 37

Table No: 4 – Physical Condition (Buildings) of Residences

BUILDING Frequency Percent

REASONABLE 93 37%
POOR CONDITION 159 63%
Total 252 100.0%

Table No: 5 – Electricity of Residences

ELECTRICITY STATUS Frequency Percent

PRESENT / FUNCTIONAL 179 71.0%
NOT PRESENT / POOR WIRING 73 29.0%
Total 252 100.0%

Table No: 6 – Water Supply of Residences

WATER SUPPLY STATUS Frequency Percent

FUNCTIONAL 162 64%
NON FUNCTIONAL 90 36%
Total 252 100.0%

Table No: 7 – Security of Residences

SECURITY Frequency Percent

GOOD 163 65%
POOR 89 35%
Total 252 100.0%
 38

FIGURE: 20 BUILDING CONDITION OF RESIDENTIAL

ACCOMMODATIONS

Poor
conditin
159, (63%)

Reasonable
93, (37%)

FIGURE: 21 ELECTRICITY STATUS OF RESIDENTIAL

ACCOMMODATIONS

Not present /
Poor wiring
73, (29%)

Present /
Functional
179, (71%)
 39

FIGURE: 22 WATER SUPPLY STATUS OF

RESIDENTIAL ACCOMMODATIONS

Poor
conditin
90, (36%)

Reasonable
162, (64%)

FIGURE: 23 SECURITY STATUS OF RESIDENTIAL

ACCOMMODATIONS

Poor
89, (35%)

Good
163, (65%)

MAINTENANCE AND REPAIR OF RESIDENTIAL

ACCOMMODATIONS:
Proper record of previous maintenance and repair of accommodations was not available
in either the EDO health or the Services and Works departments except the record of the
 40

ongoing work in 2007. The data was thus collected from the developmental clerk and
staff of EDO health office as well as from the employees of the facilities themselves. In
this respect the Chawkidars, who are working in the same facilities for the last 10 years
were extremely helpful. The data analysis has revealed that almost 85 % of the
accommodations have never been repaired in the last 10 years or since their construction.
Work for minor repair is in progress in about 8 % accommodations and only 7 % of
accommodations were repaired in the last 5 to 10 years.

Table No: 8 – MAINTENANCE AND REPAIR OF RESIDENCES

Maintenance And Repair Frequency Percent

Less Than 5 Years 14 5.6%
More Than 5 Years 4 1.6%
Never Done 214 84.9%
This Year 20 7.9%
Total 252 100.0%

FIGURE: 24 MAINTENANCE AND REPAIR OF

RESIDENTIAL ACCOMMODATIOS
Never
More than 5
years ago 214, (84%)
4, (2 %)
Less than 5
years ago
14, (6%)

This year
20, (8%)

4.5. FINANCIAL ASPECTS OF THE STUDY:

According to the rules the person who is allotted a government accommodation is not
entitled to get House Allowance (HA). This allowance is deducted at source. A total of
Rs 245166 per month, house allowance is deducted from salaries of all 213 employees
who are being allotted the accommodations. The doctors who reside in bungalows also
 41

pay 5 % of the running basic pay to government. This is called house rent (HR) and is
supposed to be spent on maintenance of the residences. The maintenance and repair
allowance, called house rent is not deducted from those who are allotted two-room
quarters. Monthly deductions of this allowance from all the designated doctors are Rs
33501 per month. (Tables 41-43, p 74-75)

FIGURE: 25 MONTHLY DEDUCTIONS FROM SALARIES

OF EMPLOYEES FOR ACCOMMODATIONS

250000
Rs 245166 Per
200000 month

150000
Rs 33501
100000 Per month

50000
0
House rent 5% M&R

FIGURE: 26 TOTAL MONTHLY DEDUCTIONS OF HOUSE

ALLOWANCE FROM DIFFERENT CADRES OF
EMPLOYEES

100000
Doctors BPS 18
Doctors BPS 17

80000
Chawkidars

Driver / lab asstt

60000
LHV / MT

Nurses

40000
Dais

20000

0
 42

CHAPTER – 5
DISCUSSION
Poor availability of doctors in rural areas is a common phenomenon in Pakistan. Majority
of those who are posted in rural areas do not live in the facility accommodations. The
causes are many and thus the problem is not a simple one.

Many studies in Pakistan by government departments and researchers have revealed that
doctors are reluctant to go to the rural areas commonly known as the periphery. (9, 14)
The important causes are poor working conditions, poor accommodation facilities and no
special incentives.

5.1. TOTAL RESIDENTIAL ACCOMMODATIONS IN PUBLIC SECTOR

HEALTH FACILITIES IN SWABI DISTRICT:
The study, which covered all the accommodations in all health facilities in the district,
revealed some interesting findings. There were a total of 252 residential accommodations
in the whole district. Of the 252, 181 were two rooms’ quarters for paramedical and
supporting staff and 71 were category III bungalows for doctors. Majority (67 %) of the
accommodations were located in purely rural areas and the rest 31 % were in urban areas.

5.2. ACCOMMODATION OCCUPANCY:

The overall accommodation occupancy rate was 50 % by all health care providers. The
occupancy in urban areas was much higher (92 %) as compared to rural areas (34 %).

5.3. ACCOMMODATION OCCUPANCY IN BASIC HEALTH UNITS:

Only 20 % doctors were living in the rural areas (BHUs) as compared to urban areas
where 88 % doctors were using their official accommodations. A survey by ministry of
health in collaboration with WHO has reported the overall accommodation occupancy
rate of 41 % and an occupancy rate of 18.5 % among doctors working in BHUs (14).
These results are approximately similar and the difference may be due to the method of
sampling as all accommodations were included in this study.
 43

Although the overall accommodation occupancy among paramedics and supporting staff
was the same as doctors (50 %) only 38 % of the paramedical staff was residing in the
BHUs. Among them 33 % Lady Health Visitors and 24 % Medical Technicians were
residing in the BHUs. Even 37 % Chawkidars who are supposed to take care of the
government property and assets were not living in the facilities. In urban areas 94 % of
the paramedical and other supporting staff was residing in their accommodations. In the
whole district 19 (8 %) of the accommodations were not used due to non-availability of
the designated staff in the district.

The study has clearly shown that doctors and paramedics both are reluctant to reside in
rural areas for the reasons discussed below. On the contrary a high number (92 %) of
both are utilizing their official accommodations in the urban areas. There are many
reasons for this difference but good working conditions; better schooling, better private
practice and sense of security are obviously the main factors in the urban setup. Another
important factor in rural areas was that most of health employees were from local
community and were living in their own family accommodations near to the health
facilities.

5.4. REASONS FOR NON-OCCUPANCY OF THE RESIDENTIAL

ACCOMMODATIONS:
All those health care providers who were not living in the facilities (106, 50 %) were
asked the reasons for non-occupancy. For some the answer was simple but some give
multiple reasons for not living in the facilities.

Out of 106 respondents, majority (37 %) gave the reason that they were posted near to
their own family accommodations and that due to the joint family system they were not
allowed by their families to live in the facility. This group said that they will not shift to
their official residences, whatever incentives were offered to them .This may be due to
the strong rural socio-cultural values and strong nuclear family system in Swabi.
Although 159 (63 %) residences were in a bad shape only 12 % considered it a reason for
not living in the facilities. Similarly only 10 % each considered poor security
 44

(accommodations near grave yards or away from main population) and non-availability
of water as the reasons for not staying in the facility. Non-availability of electricity was
the reason in 9 % of the cases.

Of the 106 non-occupants 7 % HCPs, mostly doctors were unfortunate because they were
allotted accommodations in one facility from where they were drawing their salaries and
were asked officially to work in another facility. Of them 2 % were working in Peshawar
for post graduation but still they were allotted these accommodations for merely cutting
of allowances and 5 % maintenance and repair charges from their salaries. This group is
unfortunate in the sense that they have been officially working elsewhere and yet are
being charged for accommodations, which they cannot use. The people served by these
facilities are also disadvantaged by the fact that the posts are filled and so no other doctor
can be posted in these facilities to serve them, an example of poor management.

Out of 106 respondents 7 % doctors stated that they had some personal reasons for not
living in the facilities while 6 %, mostly females were not living in the facilities because
they were unmarried and were not allowed by their families to live alone in the facilities.
This also reflects a strong influence of the family on the female health workers. The
families of female health workers often try to post them near to their family
accommodations using the maximum possible political and other pressures on the
administration.

Five percent were of the opinion that private practice was not good in their places of duty
and 3 % each mentioned their spouse jobs or kids education as their reasons for not living
in the facilities. Only one percent of the 106 considered poor sociality as the reason for
not residing in the facilities. The reason for this was that most belonged to the same
district and same social background.

Several studies have been done in Pakistan and abroad to find reasons for unwillingness
to work in the rural areas. Most of them however were done to study the unwillingness or
incentives packages for working in rural areas and most of the respondents were doctors.
 45

Studies focusing mainly on accommodations in public health facilities are hard to find
and the current study is probably the first of its kind in this respect.

A study titled “Doctors perception about staying in or Leaving Rural Health Facilities in
Abbotabad“ was done in 2000. The study focused on willingness to serve in rural areas
and the sample was taken from the doctors in the urban localities. Still there were many
doctors in this study who opted not to go to rural areas because of the poor living
conditions and accommodation related problems (14).

In the performance evaluation of the RYK project in Punjab it was revealed that doctors
are not only living in the facilities but are satisfied and happy with working conditions in
the project area. The reason is simply the fact that they were given good
accommodations, higher salaries and other financial incentives and this made the model a
success story despite the fact that they were not allowed to practice privately. The
outcome and impact analysis has revealed that public satisfaction with the model health
facilities having round the clock health coverage is very high (18)

A similar study in South Africa has shown that doctors considered better accommodation
and financial incentives as the top reasons for staying in the rural areas. (50) Similar
studies in other countries have also considered poor accommodations, lack of incentives
and non payment of house allowance as the main reasons for not working in the rural
areas (45, 49). The non availability of doctors in these countries is responsible for poor
health outcomes and low utilization of health facilities.

In the current study although the main focus was on the accommodations and the reasons
were purely related to the non-utilization of the official accommodations rather than
willingness to work in rural setup still there was a clear-cut difference in the utilization of
health facilities with and without resident health staff. The OPD and preventive health
services were better in those facilities where staff was available at night as reflected in
the HMIS reports of the district.
 46

Reasons for occupying the accommodations were a better social life in urbanized areas,
better security, schooling for kids and also a better private practice. Health impacts are
also obvious in the urban setup as there are better MCH and emergency services in urban
areas as people are confident that there will be doctors and LHV available in the health
facilities if needed. In rural areas the people don’t go to the health facilities at off-duty
hours as they know that facilities with non-resident staff offer no services during these
hours.

Answering to a question as to what incentives would make them stay in the facilities,
most of the doctors did not ask for any special incentives as most were already willingly
working in the rural areas and had their reasons for not staying in the facility. However
few asked for financial incentives, better working conditions and better accommodations
to stay in the facilities. The largest group (37 %), which was not living in the facilities
due to strong nuclear family system absolutely let down the offer and on no account, was
willing to reside in the same locality in a separate house.

5.5.PHYSICAL CONDITION OF THE RESIDENTIAL ACCOMMODATIONS:

In this study 4 aspects of the official residences were also checked from a non-technical,
common man’s perspective.

5.5.1. BUILDING:
The physical examination of the buildings revealed that most were in a very bad shape.
Their doors and windows were damaged; the plaster and interior was in a bad shape, the
roofs were leaky and the whole buildings in most rural facilities were just like ghost
houses. About 159 accommodations were not worth living still the government services
and works department had declared only 19 residences as unfit for living. The rest were
allotted and the designated persons were being charged. This is a disincentive rather than
an incentive for the rural doctors.
 47

Buildings in some BHUs like Shiva, Bahader Abad and Mian Kali were worth seeing as
they were totally irreparable and nothing more than just walls but the doctors and
paramedics in these hard rural areas were still being charged as these accommodations
were serviceable in government papers.

Similarly all Quartes for paramedical staff in CH Kalu Khan were unserviceable and
there was no accommodation for them to stay in the only civil hospital on main Mardan
Swabi road. The accommodations for doctors and paramedics in RHC Yar Hussain were
in a bad shape but still all the designated staff was living in these accommodations. This
is an appreciable act and must be commended. The CH Kapgani is the worst of all as
every building is rubble and the working and living conditions in this so-called CH are
miserable.

There are several other accommodations that do not deserve to be even called
accommodations but still the staff is being punished by cutting of the house allowance
and even the repair and maintenance charges from their salaries for these residences.

Are these incentives or disincentives, is unclear. How can we compel doctors to go to

these facilities and live there? Is it fair to deduct 1000 to 2500 rupees per moth from the
salaries of the posted staff for these ghost houses?

5.5.2. ELECTRICITY:
The second aspect of the accommodations, which was checked, was electricity. Almost
73 (29%) either had no electricity connections or the wiring was dangerous and not
functional. In the ministry of health and WHO study 55 % BHUs had electricity while the
study in Abbotabad showed that 33.3 % rural health facilities had electricity. (14) The
former was done some 14 years ago and the later in 2000 and this study is being done in
2007. This might be the reason for the difference as electrification of the villages has
increased significantly in the last few years.
 48

5.5.3. WATER SUPPLY:

The water supply in health facilities is mostly linked with electricity as no electricity
means no water pump and no piped water supply. A total of 90 (36 %) accommodations
did not have either a piped water supply or the pipes were not functional in the
accommodations. The 1993 government of Pakistan study had shown that 39 % RHCs
and 78 % BHUs did not have water supply. The reason may still be the same as discussed
above. In the study in 2000 in Abbotabad the word “safe water supply” was used with a
percentage availability of 20.6 %.

In one of the BHU named Sard China there was no electricity and no water. The LHV
and Chawkidar were bringing drinking water from outside the facility. A dog in the
process bit the LHV’s younger daughter and she had to spend a lot of money on her
treatment. She and the Chawkidar were the only staff members residing in this almost
th
deserted rural health facility in the light of lanterns in 20 century, without any rewards.
Such workers are in fact the assets of the department and need appreciation and special
incentives rather than punishment for working in the rural areas.

5.5.4. SECURITY:
The security of the accommodations not only includes the location but also a boundary
wall and the presence of a Chawkidar. In total 35 % (89 out of 213) of accommodations
were lacking any one or a combination of the above criteria. Out of the 43 BHUs the post
of Chawkidar was vacant in 5 of the facilities and 16 of the Chawkidars were not living
inside the facilities. More than 5 facilities were situated near the graveyards and 2 were in
the middle of graveyards. One can well imagine the dangers of living with families in
these kinds of situations at the mercy of empty-handed Chawkidars.

5.6. MAINTENANCE AND REPAIR OF THE ACCOMMODATIONS:

There was no proper record of repairs in either the EDO health or the Services and Works
department and the collected data is mostly a memory recall from the staff especially the
Chawkidars and from the available record of the EDO health office. The survey showed
that 84.9 % accommodations were never repaired, 5.6 % had some repair in the last 5
 49

years, 1.6 % residences were repaired some 5 to 10 years ago and in 7.9 % work was in
progress during the survey period.

This reflects a very poor commitment of the government to the rural health service in the
district. The result is rapid loss of precious public property, poor rural health services and
demoralized health staff working in rural areas.

Despite the high occupancy rate, residences in the rural health facilities and civil
hospitals were being in a very bad shape. It was also observed that most of the repair and
maintenance in these accommodations was being done by the staff themselves. They
were spending thousands of rupees from their pockets to make the accommodations fit
for living. In this respect the SMO in charge and WMO in CH Kalu Khan and the WMO
and SMO in charge in RHC Yar Hussain were living in the accommodations repaired by
them. How can we ask WMOs working on contract for years with a salary of 7000 to
9000 rupees to stay in a poorly maintained residence which needs to be repaired from her
own salary and much more when she is even charged 2000 to 2500 rupees for this
accommodation?

5.7. FINANCIAL ASPECTS OF THE STUDY:

The financial aspects of these residential accommodations are important both to the tax
payers and the health staff as the current practice of building new accommodations is still
going on and a number of new BHUs are under construction in public sector where the
above practices will be repeated again. The construction of a single new category III
residence cost approximately 1.5 and a single quarter approximately 0.9 Million rupees to
the taxpayers (S&W Department). This is a big junk from the health budget and needs
proper attention.

The financial loss is also a blow to the health staff. The rules are being made in such a
way that there is maximum benefit to government and maximum loss to staff. The house
allowance is deducted at source by district accounts office and is not given to staff
 50

residing in the facilities while the 5% deductions for maintenance and repair (Known as
house rent) is deducted on the basis of the running pay, giving maximum loss to staff.

In this study all deductions from the salaries of staff for the residential accommodations
were obtained from the accounts section of EDO health office. The total deduction of
house allowance was about 245166 rupees per month or 2941992 rupees per year. The
deduction for maintenance and repair was done from the salaries of doctors only and the
other staff was exempted. Total deductions for maintenance and repair were 33501
rupees per moth or 402012 rupees per year.

The major aspect of the deduction was that every person designated an accommodation
was charged whether he lived in the accommodation or not and whether it was worth
living or not. The assessment for this purpose is done by Services and Works department
on the request of the EDO health. Only 19 accommodations in Swabi were declared unfit
for living and the rest were declared fit, making all the designated staff of these
accommodations liable for deductions of house allowance and house rent.

The study findings in this respect were different and almost 159 of the designated staff
needed relief from deductions due to the poor accommodations facilities. Thus about 140
health employees are being charged for unfit accommodations by the government. Does
this mean that these accommodations were made for income generation from the already
dishearted health staff or for provision of residential facilities to them? In BHUs Mian
Kali, Shiva, Bahader Abad, Sard China, Thordher, Kapgani and some other facilities the
staff is being deprived of a major portion of their salaries for just rubbles in the name of
residential accommodations and yet no body is doing anything for this injustice.

These are major disincentives and the push factors compelling doctors to go to cities and
foreign countries. Whereas other countries are giving incentives to attract doctors to their
countries (39, 43, 45, 47, 48), we are pushing them out of the rural areas and the country.
 51

CHAPTER – 6
CONCLUSION AND RECOMMENDATIONS

6.1. CONCLUSION:
The results and discussion has revealed that there were not enough fit residential
accommodations available in public sector health facilities in rural areas. The
accommodations in the DHQ and Shah Mansoor Complex were also inadequate and more
accommodation facilities were needed for both doctors and paramedical staff in the
district headquarter hospital.

The overall accommodation utilization rate in the district was 50%. The rate was much
higher (92-94%) in the DHQ, CH and RHC for both doctors and other staff as compared
to BHUs, where only 34% staff was residing. Interestingly more (33%) female health
staff (LHVs) was using their accommodations in BHUs than male staff (Doctors 20%,
Paramedics 24%).

The reasons for the non-utilization of accommodations were interesting. Most of the staff
considered posting near their family residence and a strong nuclear family system as the
reasons for the non-utilization of their accommodations. Poor physical condition of the
residence, non-availability of water and electricity and security problems were the
residence related issues raised by the health staff. Unmarried Female staff was reluctant
to live due to social constraints. There were a large number (11%) of doctors who were
officially working in the urban areas but were given accommodations in rural areas due to
their postings. The effect was two fold, non-availability of doctors to the local
community and financial loss to the doctors.

The actual status of accommodations was very bad. No repair was done in most (85%) of
the residences since their construction and the buildings of most (63%) of the residences
were unfit for human use. Few were so bad that these were just walls and rubbles than
accommodations. Basic necessities like water, electricity were not available in nearly
35% of the residences.
 52

An interesting aspect of the study, the financial loss to the government and health staff,
revealed that almost 3.5 Million rupees are being deducted from the salaries of the
designated employees for mere allotment of these accommodations. Keeping the 50%
utilization rate almost half is deducted from the 50% non-resident health staff who have
no alternative but to keep silent over this injustice. The cutting from the salaries is a
major disincentive to rural health care providers and creates a 30 to 40 % difference
between the salaries of the health staff in the urban and rural areas.

6.2. RECOMMENDATIONS:

1. The accommodation issues in the districts may be given a special consideration by

the government and the matter may be discussed with all the stack holders and
solved in the best interest of the community, taxpayers, employees and the
government.

2. The government should allocate enough budget for the repair and maintenance of
the residences to stop their further disintegration and thus loss of the precious
public assets. In this respect the district and local representatives and elected
members should be motivated to allocate funds for the repairs and maintenance of
accommodations in their areas.

3. To solve the problem of low utilization of residences in public sector health

facilities special salary packages, free accommodation facilities, tax credits,
reservation of seats for post graduation in government institutions (PGMI and
PHSA), special seats for the children of rural doctors in educational institutions
and job opportunities and scholarships in foreign countries should be introduced.

4. Electricity, piped water supply and telephone facilities should be provided in all
residences to lessen the problems of the health employees and their families,
working in rural areas.
 53

5. The government should give better grades, service structure and incentives (like
the one given to nurses) to female doctors and female health care providers to
attract them to the rural areas.

6. In the remote and unattractive areas of the province deductions from the salaries
for the use of accommodations should be stopped and free electricity and
telephone facilities should be given to doctors.

7. Construction of new facilities should not be on the basis of political pressure and
availability of donated lands but new facilities should be constructed near to
populations and if possible near to the access roads for their maximum utilization
by the community and health staff.

8. EDO health office should keep a proper record of the residential accommodations,
their occupancy, maintenance and repair, utilization, electricity, water supply,
serviceability etc.

9. Doctors who are officially working in places other than their places of duty
should be exempted from deductions of house allowance and house rent.

10. The EDO health should be provided with all the resources for monitoring visits to
check the staff and their accommodations and to solve the problems of the staff.

11. The procedures for the repairs and maintenance and for the fitness of the
accommodations for living by the Services and Works department should be
made simple so that the unjustifiable deductions from the salaries of health
employees for “unfit for living accommodations” is avoided.

12. The HMIS (Health Management Information System) section in the provincial
health department should have an accommodation section which should have the
 54

accommodation database and should deal all the accommodations problems in the
province.

13. Like other countries research studies are needed to study incentive packages for
doctors, female health workers and other staff for attracting and keeping them in
rural health facilities.

14. The government should also consider the possibility of renting out the unoccupied
accommodations in public health facilities to other government departments like
education for generation of revenue and decreasing financial burden on the health
employees.
 55

CHAPTER – 7
Summary

Millions of rupees are being spent on the construction of residential accommodations for
health staff in public sector health facilities by the government but most of these
accommodations are not utilized by the designated health staff in rural areas.
Unfortunately one can hardly find a study in literature which has addressed this issue in
detail. An effort was made to look into the problem through a cross sectional study
conducted in public sector health facilities in district Swabi. The aim of the study was to
review in detail various aspects of the accommodation problem affecting both public and
the health employees. All available residential accommodations in public sector health
facilities were included in the study. The study found that there is a low (20 to 30 %)
utilization rate of residential accommodations in rural areas both by doctors and
paramedics as compared to the urban areas where the rate was much higher (92-94%).
The main causes of non utilization of residential accommodations were posting near the
family residence, strong nuclear family system in the district and poor living conditions
in rural areas. Poor physical structure of the accommodation’s buildings, non functional
electricity and water supply and poor security in rural areas were additional findings.
Deduction equal to 20-25% of the basic pay from the designated staff for these
accommodations was a major disincentive to the health staff in rural areas. Almost 85 %
of the accommodations were never repaired since their construction by the government
and most were not suitable for living.. The main recommendations were improvement of
the living conditions, offering incentives to staff for staying in the rural health facilities,
provision of free accommodations in hard areas and the appointment of separate
accommodation coordinators in EDO health and DGHS offices for managing
accommodation-related issues.
 56

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2006 [cited 2007 April 6]. http://www.rrh.org.au/articles/subviewafro.asp? Article ID
=581
 61

ANNEXURE - 1

THE QUESTIONNAIRE:

A CRITICAL REVIEW OF THE UTILIZATION OF RESIDENTIAL

ACCOMMODATIONS IN PUBLIC SECTOR HEALTH FACILITIES IN SWABI
No: ______________ Date: ____________________

I: BASIC INFORMATION:
Health Facility Name: ____________________________________________________
Accommodation: Type: __________________Designated to: ___________________
Designated person: Posted_____ Not Posted (post vacant) _____ (If (√) go to section III)
Name of designated person (If posted): _______________________________________
Accommodation Occupancy (If posted): Occupied (living) _____ (If (√) go to section III)
Not Occupied_____ (If (√) go to section II)
II: REASONS FOR NON-OCCUPANCY :( Tick (√) one or more)
REASONS Tick if yes
1: Residence physically unsuitable for living:

2: Situation not suitable (Poor security):

3: Electricity Not Present / unsafe / poor fittings:

4: Water supply Not Present / non functional:

5: Own residence available nearby:

6: Children Education (not available / studying somewhere else) :

7: Private Practice not good :

8: Spouse working elsewhere:

9: Preparing for Post graduation elsewhere:

10: Not willing to work in rural areas (Poor social circumstances):

11: Officially working elsewhere:/On Long Leave Place:

12:Unmarried / single and cannot live alone:
 62

13: Any other reason for non occupancy

III: CHECKED BY RESEARCHER (for all accommodations): (Tick (√))

1: Building condition: Suitable for living: _____ Unsuitable for living: ______
2: Water supply: Functional: ___________ Not Functional: __________
3: Electricity: Present/Functional_____ Not Present/NF: __________
4: Situation / security: Reasonable: __________ Not Reasonable: __________
IV: CUTTING FROM SALARY (of designated person for the accommodation):
(From Salary slip, EDO (H) or District Accounts Office)
House rent: Rs: ____________ 5% (of BP) Maintenance and repair: Rs: __________
V: MAINTENANCE AND REPAIR OF THE ACCOMMODATIONS (By Govt ;):
Last M&R: This year______ <5 years ago______ > 5 years ago_____ Never______
VI: WHAT OTHER INCENTIVES WILL LET YOU STAY IN THE FACILITY?
_____________________________________________________________________
 63

ANNEXURE – 1I

EPI INFO 3.3.2 REPORTS:

Table No: 9 - Total Available Accommodations in All Health Facilities

TYPE Frequency Percent Bungalows Quarters
BHU 168 66.7% 42 126

CH 31 12.3% 10 21
DHQ
30 11.9% 11 19
SMC
RHC 23 9.1% 8 15

Total 252 100.0% 71 181

Table No: 10 - Main Accommodation Types Available In Health Facilities

Accommodation Type Frequency Percent Cum Percent

BUNGALOWS 72 28.6% 28.6%
QUARTERS 180 71.4% 100.0%
Total 252 100.0% 100.0%

Table No: 11 - Distribution of Accommodations in Public Health Facilities

No of Cum
Health Facility Name Percent
Accommodations Percent
ADINA 4 1.6% 1.6%
AMBAR KUNDA 11 4.4% 6.0%
BACHAIE 4 1.6% 7.5%
BAHADAR ABAD 4 1.6% 9.1%
BAJA 4 1.6% 10.7%
BATAKARHA 4 1.6% 12.3%
BEKA 4 1.6% 13.9%
CHECK NODEH 4 1.6% 15.5%
DAGAI 4 1.6% 17.1%
DHERI ZAKARIA 4 1.6% 18.7%
DHOBIAN 4 1.6% 20.2%
FAZLE ABAD 4 1.6% 21.8%
 64

GABASNI 4 1.6% 23.4%

GANDAF 4 1.6% 25.0%
GANI CHATHRA 4 1.6% 26.6%
ISMAILA 4 1.6% 28.2%
JALBAI 4 1.6% 29.8%
JALSAI 4 1.6% 31.3%
JEHANGIRA 4 1.6% 32.9%
JHANDA 4 1.6% 34.5%
KALABAT 4 1.6% 36.1%
KALU KHAN 10 4.0% 40.1%
KAPGANI 7 2.8% 42.9%
KOTHA 4 1.6% 44.4%
LAHOR EAST 4 1.6% 46.0%
LAHOR WEST 4 1.6% 47.6%
MAINAI 4 1.6% 49.2%
MANGAL CHAIE 4 1.6% 50.8%
MANKAI 4 1.6% 52.4%
MARGHUZ 4 1.6% 54.0%
MIAN KALI 4 1.6% 55.6%
PANJPIR 4 1.6% 57.1%
QADRA 4 1.6% 58.7%
SADRE JADEED 4 1.6% 60.3%
SALIM KHAN 4 1.6% 61.9%
SARD CHINA 4 1.6% 63.5%
SHAH MANSOOR 4 1.6% 65.1%
SHAH MANSOOR
1 0.4% 65.5%
COMPLEX
SHEIKH JANA 4 1.6% 67.1%
SHIVA 4 1.6% 68.7%
SWABI 29 11.5% 80.2%
TAND KOHI 4 1.6% 81.7%
TARAKAI 4 1.6% 83.3%
THORDHER 4 1.6% 84.9%
TOPI 14 5.6% 90.5%
YAQOOBI 4 1.6% 92.1%
 65

YAR HUSSAIN 12 4.8% 96.8%

ZAIDA 4 1.6% 98.4%
ZAROOBI 4 1.6% 100.0%
Total 252 100.0% 100.0%

Table No: 12 - Type of Facility versus Type of Accommodation

ACCOMMODATION TYPE
TYPE BUNGALOW QUARTER TOTAL
BHU 42 126 168
Row % 25.0 75.0 100.0
Col % 59.2 69.6 66.7
CH 10 21 31
Row % 32.3 67.7 100.0
Col % 14.1 11.6 12.3
DHQ 11 19 30
Row % 36.7 63.3 100.0
Col % 15.5 10.5 11.9
RHC 8 15 23
Row % 34.8 65.2 100.0
Col % 11.3 8.3 9.1
TOTAL 71 181 252
Row % 28.2 71.8 100.0
Col % 100.0 100.0 100.0

Table No: 13 - Accommodation Status As By Services and Works (C&W)

Department

Accommodation
Frequency Percent Comments
Status
Must be allotted to
Serviceable 233 92.5% someone and are fit to be
used
Unserviceable 19 7.5% Dangerous
Total 252 100.0%

Table No: 14 - Overall Accommodation Occupancy Rate

Accommodation occupied Frequency Percent Cum Percent

Yes 107 50.2% 50.2%
 66

No 106 49.8% 100.0%

Total 213 100.0% 100.0%

Table No: 15 - Accommodation Occupancy

(According To Type of Health Facility)

ACCOMMODATION OCCUPIED
TYPE Yes No TOTAL
BHU 52 101 153
Row % 34.0 66.0 100.0
Col % 48.6 95.3 71.8
CH 15 2 17
Row % 88.2 11.8 100.0
Col % 14.0 1.9 8.0
DHQ 24 0 24
Row % 100.0 0.0 100.0
Col % 22.4 0.0 11.3
RHC 16 3 19
Row % 84.2 15.8 100.0
Col % 15.0 2.8 8.9
TOTAL 107 106 213
Row % 50.2 49.8 100.0
Col % 100.0 100.0 100.0

Table No: 16 - Accommodation Occupancy in Basic Health Units

(Bungalow vs. Quarters)

ACCOMMODATION OCCUPIED
Accommodation Type Yes No TOTAL
BUNGALOW 7 27 34
Row % 20.6 79.4 100.0
Col % 13.5 26.7 22.2
QUARTER 45 74 119
Row % 37.8 62.2 100.0
Col % 86.5 73.3 77.8
TOTAL 52 101 153
Row % 34.0 66.0 100.0
Col % 100.0 100.0 100.0
 67

Table No: 17 - Accommodation Occupancy in Civil Hospitals (Bungalow vs.

Quarters)

ACCOMMODATION OCCUPIED
Accommodation Type Yes No TOTAL
BUNGALOW 7 1 8
Row % 87.5 12.5 100.0
Col % 46.7 50.0 47.1
QUARTER 8 1 9
Row % 88.9 11.1 100.0
Col % 53.3 50.0 52.9
TOTAL 15 2 17
Row % 88.2 11.8 100.0
Col % 100.0 100.0 100.0

Table No: 18 - Accommodation Occupancy in District Head Quarter Hospital

(Bungalow vs. Quarters)

ACCOMMODATION OCCUPIED
Accommodation Type Yes No TOTAL
BUNGALOW 10 0 10
Row % 100.0 0.0 100.0
Col % 41.7 0.0 41.7
QUARTER 14 0 14
Row % 100.0 0.0 100.0
Col % 58.3 0.0 58.3
TOTAL 24 0 24
Row % 100.0 0.0 100.0
Col % 100.0 100.0 100.0

Table No: 19 - Accommodation Occupancy in Rural Health Centers (Bungalow vs.

Quarters)

ACCOMMODATION OCCUPIED
Accommodation Type Yes No TOTAL
BUNGALOW 6 2 8
Row % 75.0 25.0 100.0
Col % 37.5 66.7 42.1
QUARTER 10 1 11
Row % 90.9 9.1 100.0
Col % 62.5 33.3 57.9
 68

TOTAL 16 3 19
Row % 84.2 15.8 100.0
Col % 100.0 100.0 100.0

Table No: 20 – Accommodations Occupancy of Bungalow and Quarters

ACCOMMODATION OCCUPIED
Accommodation Type Yes No TOTAL
BUNGALOW 30 30 60
Row % 50.0 50.0 100.0
Col % 28.0 28.3 28.2
QUARTER 77 76 153
Row % 50.3 49.7 100.0
Col % 72.0 71.7 71.8
TOTAL 107 106 213
Row % 50.2 49.8 100.0
Col % 100.0 100.0 100.0

Table No: 21 – Accommodation Occupancy as per Post / Designation

ACCOMMODATION OCCUPIED
Accommodation Designated to Yes No TOTAL
BEHESHTI 2 0 2
Row % 100.0 0.0 100.0
Col % 1.9 0.0 0.9
CHAWKIDAR 24 14 38
Row % 63.2 36.8 100.0
Col % 22.4 13.2 17.8
DAI 6 0 6
Row % 100.0 0.0 100.0
Col % 5.6 0.0 2.8
DENTAL SURGEON 1 2 3
Row % 33.3 66.7 100.0
Col % 0.9 1.9 1.4
DISPENCER 4 2 6
Row % 66.7 33.3 100.0
Col % 3.7 1.9 2.8
DRIVER 1 0 1
Row % 100.0 0.0 100.0
Col % 0.9 0.0 0.5
LAB ASSTT 1 0 1
 69

Row % 100.0 0.0 100.0

Col % 0.9 0.0 0.5
LABORATORY ATTNDT 1 0 1
Row % 100.0 0.0 100.0
Col % 0.9 0.0 0.5
LHV 14 28 42
Row % 33.3 66.7 100.0
Col % 13.1 26.4 19.7
MO/SMO 22 28 50
Row % 44.0 56.0 100.0
Col % 20.6 26.4 23.5
MT 10 32 42
Row % 23.8 76.2 100.0
Col % 9.3 30.2 19.7
NURSE 8 0 8
Row % 100.0 0.0 100.0
Col % 7.5 0.0 3.8
OTHERS 4 0 4
Row % 100.0 0.0 100.0
Col % 3.7 0.0 1.9
SPECIALIST 7 0 7
Row % 100.0 0.0 100.0
Col % 6.5 0.0 3.3
WO 2 0 2
Row % 100.0 0.0 100.0
Col % 1.9 0.0 0.9
TOTAL 107 106 213
Row % 50.2 49.8 100.0
Col % 100.0 100.0 100.0

Table No: 22 - Accommodations Designated According To Posts

Frequency Percent Cum Percent

Accommodation Designated to
BEHESHTI 2 0.8% 0.8%
CHAWKIDAR 43 17.1% 17.9%
DAI 6 2.4% 20.2%
DENTAL SURGEON 3 1.2% 21.4%
DISPENCER 7 2.8% 24.2%
DRIVER 1 0.4% 24.6%
 70

LAB ASSTT 1 0.4% 25.0%

LABORATORY ATTENDENT 1 0.4% 25.4%
LHV 43 17.1% 42.5%
MO/SMO 58 23.0% 65.5%
MT 43 17.1% 82.5%
NO BODY 20 7.9% 90.5%
NURSE 8 3.2% 93.7%
OTHERS 5 2.0% 95.6%
SPECIALIST 9 3.6% 99.2%
WO 2 0.8% 100.0%
Total 252 100.0% 100.0%

Table No: 23 – Is Designated Person Posted

(Indirectly showing non occupancy due to the post being vacant)

Designated person posted Frequency Percent Cum Percent

Yes 213 91.8% 91.8%
No 19 8.2% 100.0%
Total 232 100.0% 100.0%

Reasons for Non Occupancy of Accommodations

Table No: 24 – 1. Physically unsuitable

Physically unsuitable Frequency Percent Cum Percent

Yes 21 8.3% 8.3%
No 231 91.7% 100.0%
Total 252 100.0% 100.0%

Table No: 25 – 2. Poor security

Poor security Frequency Percent Cum Percent

Yes 15 6.0% 6.0%
No 237 94.0% 100.0%
Total 252 100.0% 100.0%
 71

Table No: 26 – 3. Electricity not present / non functional

Electricity not present Frequency Percent Cum Percent

Yes 13 5.2% 5.2%
No 239 94.8% 100.0%
Total 252 100.0% 100.0%

Table No: 27 – 4. Water supply not functional

Water supply not functional Frequency Percent Cum Percent

Yes 15 6.0% 6.0%
No 237 94.0% 100.0%
Total 252 100.0% 100.0%

Table No: 28 – 5. Own residence nearby

Own residence nearby Frequency Percent Cum Percent

Yes 57 22.6% 22.6%
No 195 77.4% 100.0%
Total 252 100.0% 100.0%

Table No: 29 – 6. Kids’ education

Kids education Frequency Percent Cum Percent

Yes 5 2.0% 2.0%
No 247 98.0% 100.0%
Total 252 100.0% 100.0%

Table No: 30 – 7. Private practice

Private practice Frequency Percent Cum Percent

Yes 8 3.2% 3.2%
No 244 96.8% 100.0%
Total 252 100.0% 100.0%
 72

Table No: 31 – 8. Spouse working elsewhere

Spouse elsewhere working Frequency Percent Cum Percent

Yes 4 1.6% 1.6%
No 248 98.4% 100.0%
Total 252 100.0% 100.0%

Table No: 32 – 9. Post graduation

Post graduation elsewhere Frequency Percent Cum Percent

Yes 3 1.2% 1.2%
No 249 98.8% 100.0%
Total 252 100.0% 100.0%

Table No: 33 – 10. Poor social circumstances

Poor social circumstances Frequency Percent Cum Percent

Yes 2 0.8% 0.8%
No 250 99.2% 100.0%
Total 252 100.0% 100.0%

Table No: 34 – 11. Officially working elsewhere

Officially elsewhere Frequency Percent Cum Percent

Yes 11 4.4% 4.4%
No 241 95.6% 100.0%
Total 252 100.0% 100.0%

Table No: 35 – 12. Unmarried

Unmarried Frequency Percent Cum Percent

Yes 9 3.6% 3.6%
No 243 96.4% 100.0%
Total 252 100.0% 100.0%
 73

Table No: 36 – 13. Other reasons (personal)

Other reasons Frequency Percent Cum Percent

Yes 10 4.0% 4.0%
No 242 96.0% 100.0%
Total 252 100.0% 100.0%

Researcher’s verified Accommodation Status

Table No: 37 – 1. Building

Building Frequency Percent Cum Percent

Not Suitable 159 63.1% 63.1%
Suitable 93 36.9% 100.0%
Total 252 100.0% 100.0%

Table No: 38 – 2. Electricity status

Electricity status Frequency Percent Cum Percent

Not Present/Non functional 73 29.0% 29.0%
Present/Functional 179 71.0% 100.0%
Total 252 100.0% 100.0%

Table No: 39 – 3. Water supply status

Water supply status Frequency Percent Cum Percent

Functional 162 64.3% 64.3%
Non Functional 90 35.7% 100.0%
Total 252 100.0% 100.0%

Table No: 40 – 4. Security

Security Frequency Percent Cum Percent

Good 163 64.7% 64.7%
Poor 89 35.3% 100.0%
Total 252 100.0% 100.0%
 74

Table No: 41 – House Rent Deductions from Salaries of Employees

House rent slab No of Employees Percent Cum Percent

0 52 20.6% 20.6%
645 BPS -1 31 12.3% 32.9%
660 BPS - 2 9 3.6% 36.5%
704 DRIVER 1 0.4% 36.9%
710 LAB AST 3 1.2% 38.1%
831 LHV& MT 89 35.3% 73.4%
1070 NURSE 8 3.2% 76.6%
1662 COUPLE 1 0.4% 77.0%
2142 BPS 17 46 18.3% 95.2%
2807 BPS 18 12 4.8% 100.0%
Total 252 100.0% 100.0%

Table No: 42 – 5% Maintenance and Repair Deductions for the Accommodations,

from Salaries of Employees
Slabs of 5%
No of doctors Percent Cum Percent
Maintenance
0 196 77.8% 77.8%
357 5 2.0% 79.8%
387 1 0.4% 80.2%
410 11 4.4% 84.5%
437 7 2.8% 87.3%
464 4 1.6% 88.9%
491 2 0.8% 89.7%
517 2 0.8% 90.5%
571 1 0.4% 90.9%
598 3 1.2% 92.1%
624 3 1.2% 93.3%
705 2 0.8% 94.0%
758 2 0.8% 94.8%
805 1 0.4% 95.2%
865 1 0.4% 95.6%
873 1 0.4% 96.0%
892 2 0.8% 96.8%
 75

940 1 0.4% 97.2%

974 2 0.8% 98.0%
1041 1 0.4% 98.4%
1075 2 0.8% 99.2%
1143 1 0.4% 99.6%
1176 1 0.4% 100.0%
Total 252 100.0% 100.0%

Table No: 43 –Total Deductions from salaries of health employees for

accommodations

AMOUNT AMOUNT
CUTTINGS Comments
Rs:/month Rs: / year
HOUSE RENT 245166 2941992 From all residents
5% M&R 033501 402012 From resident
doctors only
Both: 278667/month Total: 3344004/year

Amount deducted in the last 10 years for maintenance: 402012 X 10= RS: 4020120

Table No: 44 – Maintenance and Repair of Accommodations by Government

MAINT AND REPAIR Frequency Percent Cum Percent

LESS THAN 5 Y 14 5.6% 5.6%
MORE THAN 5 Y 4 1.6% 7.1%
NEVER DONE 214 84.9% 92.1%
THIS YEAR 20 7.9% 100.0%
Total 252 100.0% 100.0%
 76

ANNEXURE – III

MAP OF DISTRICT SWABI