E4H Punjab TA: Technical Assistance for Centralized Pay-for-Performance Monitoring of Outsourced Health Facilities

Programme Overview

Evidence for Health (E4H) is a Foreign, Commonwealth & Development Office (FCDO)-funded programme aimed at strengthening Pakistan's healthcare system, thereby decreasing the burden of illness and saving lives. E4H (2023–2027) provides technical assistance (TA) to Punjab, Federal, and KP governments, implemented by Palladium in partnership with Oxford Policy Management (OPM).

Through its flexible, embedded, and demand-driven model, E4H supports governments to achieve a resilient health system that is prepared for emergencies, responsive to evidence, and delivers equitable, quality, and efficient healthcare services.

Background and Problem Statement

Background

The Government of Punjab is committed to advancing Universal Health Coverage (UHC) in line with Sustainable Development Goal (SDG) 3.8, with a focus on equitable access to quality health services. While Pakistan’s UHC Service Coverage Index has increased from 39.7 in 2015 to 52.7 in 2022, and Punjab slightly exceeds the national average at 53.8, progress remains limited by gaps in governance, accountability, and data use for decision-making.

As part of the Chief Minister’s Health Sector Reform Plan (2024–29), Punjab has expanded the outsourcing of primary healthcare facilities under a Pay-for-Performance (P4P) model. This model currently covers more than 2,500 Basic Health Units and over 60 Rural Health Centres, intending to improve service utilisation, quality of care, and patient experience by linking payments to predefined performance indicators. To safeguard public funds and ensure value for money, the credibility of this approach depends on robust, standardised, and transparent verification of reported performance.

To support this, the Health & Population Department (H&PD) has initiated the development of the Centralised Outsourced Facilities Management and Verification System (COFMVS) as a core accountability mechanism. COFMVS is intended to consolidate performance data from multiple sources, support independent verification, and enable evidence-based P4P payments. However, as the system moves from concept to operational use at scale, targeted technical assistance (TA) is required to refine its design, governance, and institutional use so that it can function as a reliable, department-owned tool for performance oversight and decision-making.

Problem Statement

The COFMVS, in its current design and operationalisation, has weaknesses that limit its credibility as an effective P4P mechanism. Fragmented processes, unclear or inconsistently applied business rules, and gaps in verification and data validation reduce confidence in performance results and increase risks of inefficiency, disputes, and misuse. Stronger design coherence, standardised verification workflows, and clear governance arrangements are therefore needed to ensure COFMVS produces reliable, transparent, and auditable evidence for payment decisions and routine performance oversight at scale.

Goals and Objectives

Overall Goal

To strengthen the institutional capacity of the H&PD to credibly manage, verify, and govern P4P arrangements for outsourced health facilities by refining and standardising the design, governance, and operational use of the existing COFMVS, ensuring transparent, evidence-based, and performance-linked decision-making under full government ownership.

Objectives

1. Clarify and standardise how COFMVS measures performance and calculates P4P payments, using clear, H&PD-owned KPIs and rules.
2. Put in place a transparent verification and quality assurance process—defining roles and responsibilities, process, and evidence required (audit officers, third-party assessors, and government teams).
3. Strengthen governance and rollout readiness by establishing clear workflows, escalation steps, training, standard operating procedures (SOPs), and a handover package, so H&PD/HISDU/PIU can run COFMVS sustainably.

Strategic Approach

Contribution to health systems strengthening:

By strengthening and operationalising the existing COFMVS, the department will shift from manual, discretionary reporting towards a transparent, rules-based verification system that supports a results-focused performance culture towards outsourced facilities. This TA directly underpins Punjab’s strategic purchasing reforms and complements the Community Health Inspector (CHI) initiative, ensuring that performance data are systematically analysed and used for evidence-based decision-making within H&PD. In doing so, the TA strengthens wider information and data governance arrangements, particularly by reinforcing functional linkages with the Health Information and Service Delivery Unit (HISDU), thereby improving value for money and sustainability of reforms.

Alignment with other E4H TAs/investments:

This TA complements ongoing advisory support provided for EMR/HMIS optimisation and CHI implementation. It works with the department to ensure that the processes, data-use protocols, and verification logic within COFMVS are aligned with the broader health information ecosystem overseen by HISDU—without creating or modifying any digital tools. The Maryam Nawaz Health Clinics (MNHCs) Project Implementation Unit (PIU) will draw on strengthened analytical outputs from improved COFMVS processes to inform evidence-based policy decisions.

Alignment with other partners:

This TA complements the WHO’s health system strengthening support, the World Bank–financed NHSP focus on PHC performance and data use, and FCDO’s broader emphasis on UHC and evidence-driven decision-making. By refining the institutional processes surrounding COFMVS, the TA provides a unifying accountability layer that supports partner investments in PPP oversight without involvement in digital system development or procurement.

Scope of Work and Methodology

This TA will support the H&PD in strengthening and institutionalising the existing COFMVS to make it a credible, transparent, and usable mechanism for verifying performance and calculating Pay-for-Performance (P4P) payments for outsourced facilities. The TA is advisory and process focused. It will not develop software or procure digital tools. Instead, it will help H&PD, HISDU, and the PIU to simplify and standardise business processes, improve how performance is verified (so payments are evidence-based and auditable), and strengthen governance, roles, SOPs, and capacity, enabling the system to be managed sustainably by the government. All recommendations will align with existing government systems, standards, and reform priorities, with HISDU/PIU retaining full ownership.

Phase 1 — Inception

Objective: Establish a shared understanding of the current COFMVS landscape, confirm the advisory scope, and agree on governance, planning, and delivery arrangements.

Key Activities:

• Conduct consultations with H&PD, HISDU, PIU, district authorities, and private operators (for BHUs: individual doctors (stated as health managers in the new contract arrangements); for RHCs: a panel/set of doctors).
• Review the Punjab Primary and Secondary Healthcare Act 2025 (re: outsourcing), and all relevant supporting documents, including P4P contracts, SOPs, existing MNHCs PIU documentation, preliminary COFMVS materials, KPIs, verification rules, payment triggers, and quality scoring criteria.
• Map the end-to-end P4P payment process, including verification of patient data and services/medicines delivered; consolidation of data across sources; dispute resolution; validation and approval workflows; and payment release mechanisms.
• Assess current governance and coordination arrangements (roles, reporting lines, decision rights, and coordination mechanisms across H&PD/HISDU/PIU and districts).
• Identify key gaps and risks (e.g., unclear rules, weak verification, inconsistent data use, bottlenecks, and potential points of dispute).
• Develop a detailed workplan, monitoring approach, and risk mitigation strategy based on inception findings.

Outputs:

• Inception Report and Slide Deck (capturing all findings, decisions, and agreed next steps from the inception phase).

Phase 2 — Functional Design and Governance Blueprint

Objective: Produce a clear, department-owned blueprint that enables consistent implementation of COFMVS and guides government teams on system use and enhancement.

Key Activities:

• Refine and standardise KPIs, scoring methods, and payment rules, including thresholds, weighting, deduction/penalty rules, and minimum evidence requirements for payment.
• Define verification and quality assurance standards, including what must be checked, how discrepancies/exceptions are handled, how findings are validated, and principles for sampling and supervision.
• Establish data governance and audit requirements aligned with HISDU standards (data ownership, access controls, audit trails, privacy safeguards, and reporting standards).
• Provide advisory input on how existing Electronic Medical Records (EMR) systems that link outsourced BHUs and RHCs can be effectively integrated into COFMVS and governed appropriately.

Outputs:

• Functional Design and Governance Document (including system-use recommendations).

Phase 3 — Module Logic Refinement & Workflow Configuration (Advisory Only)

Objective: Provide advisory guidance to refine operational workflows and business rules to support government-led system development and configuration.

Key Modules Supported Through Advisory Work:

1. Staff & HR Management Logic
• Define clear rules for validating staff attendance.
• Specify red flags and escalation triggers for HR-related non-compliance.
2. Service Utilisation Data Verification Logic
• Define and optimise methods to verify the utilisation of OPD and IPD services and facility-based births, using modalities such as data review, call verification, and field verification.
• Clarify how discrepancies are identified, categorised, resolved, or escalated before services are accepted for payment or any deductions.
3. Rules-Based Payment & Deduction Framework
• Refine payment calculation rules, deduction mechanisms, transparency standards, and financial audit requirements.

Outputs:

• Workflow maps and recommended module configurations for H&PD IT teams.

Phase 4 — Handholding Support for Roll-Out (Advisory Role)

Objective: Support H&PD in optimising COFMVS during phased roll-out by strengthening institutional capacity and readiness.

Key Activities:

• Provide advisory input on phased rollout planning and develop an operational readiness checklist.
• Deliver orientation and training for relevant government teams on governance roles, verification processes, and the use of COFMVS outputs for decision-making.
• Finalise SOPs for facility engagement and verification processes, including clear escalation pathways.

Outputs:

• Final Advisory and Handover Report, including standardised SOPs, training materials, rollout guidance, and sustainability recommendations.

Sustainability, Institutionalisation & Transition Planning

The TA’s focal point will be the MNHC PIU. The TA will ensure long-term institutional ownership, governance clarity, and continuous improvement mechanisms for COFMVS by;

• Providing post-roll-out advisory support for refinement of workflows, governance structures, and data protocols.
• Formalising system governance arrangements, verification standards, and audit trail procedures.
• Support the transition of complete operational control to HISDU and PIU.

Deliverables

Expected deliverables are:

1. Inception Report and Slide Deck: Including stakeholder engagement plan, governance and coordination structure, detailed workplan, M&E and risk management plan, and inception presentation.
2. System Design & Architecture Blueprint & Advisory Document: Functional design document, refined business process maps, KPI validation and payment rules, verification workflows, recommended interoperability logic, data governance and cybersecurity protocols aligned with government standards.
3. COFMVS Module & Workflow Configuration Guidance: Advisory documentation outlining recommended configurations, rule sets, user flows, exception-handling logic, quality assurance protocols, and integration considerations for: Staff & HR Management: [Service Data Verification; Attendance & surveillance validation; Rules-based payment and deduction methodology]
4. COFMVS Institutionalisation & Roll-out Support Package (Non-Digital Deliverables Only): [Final Advisory Report for COFMVS operationalisation; Capacity-building completion report, and audit protocols, updated SOPs, training materials, and sustainability roadmap; Handover package containing design documentation, governance guidance, and future enhancement pathways]

Health Systems & PPP Specialist (TA Team Lead) – Senior National

LOE: 80 days (subject to change)
Period: (as per TA schedule; aligned to deliverables timeline)

Role Requirements

• Provide overall leadership, quality assurance, and strategic direction for the COFMVS TA.

• Lead coordination with H&PD, HISDU, PIU, and development partners.

• Oversee design and refinement of P4P rules, governance arrangements, QA and accountability frameworks.

• Guide development of sustainability roadmap, institutionalisation plan, and audit/compliance protocols (non-digital).

Technical Expertise
Master’s degree in Public Health, Health Policy, Economics, Public Administration, Social Sciences, or a related/relevant discipline. Minimum 15 years of overall professional experience, including experience in health systems, PPPs, or P4P reforms. Demonstrated leadership in multi-stakeholder coordination and system strengthening initiatives. Experience working with government and donor-funded programmes.

Core Competencies
PPP governance and verification systems; leadership and negotiation; high-quality technical writing (frameworks/SOPs); political economy awareness; ability to navigate provincial bureaucracies; results orientation.

Deliverables
Same as above.