Table 5.

Facilitators, barriers and recommendation affecting health system in conflict areas of Pakistan

	Facilitators	Barriers	Recommendations
Health Workforce	- Hiring of qualified local people along with incentives for retention	- Lack of female health workers	- Hire more female staff and reduce gender imbalance
		- Absenteeism and lack of capacity of healthcare staff
		- Workers hired from outside face language and cultural issues	- Send female staff on rotation basis to conflict areas
		- Political influence and favoritism	- Hire local people and provide adequate training
		- Security threats	- Provide housing and basic necessities
		- Low salaries	- Merit based hiring
		- Absence of accommodation and basic facilities for doctors	- Doctors or staff to provide replacements when going on leave
		- Quacks are preferred by people over doctors
Service Delivery	- Secondary facilities relatively well maintained	- Non-functional healthcare facilities	- SOPs should be implemented
	- Establishment of various new primary and secondary healthcare facilities	- Poor infrastructure	- Work on infrastructure for the uptake of health care intervention
		- Political influence
	- Ambulatory service with staff care	- Quality of care compromised	- Stringent monitoring mechanisms using technology
	- Midwives and lady health workers visit homes	- Unavailability of transport for staff
	- Service of institutional deliveries in presence of skilled birth attendant	- Changing demographic pattern	- Improve community awareness and mobilization activities
		- No arrangements for transport of complicated cases
	- Social mobilization activities		- Improving LHWs functionality
Supplies and Commodities	- Different donors provide different supplies and services	- Curfews during the conflict blocked supplies to the facilities	- Procurement decisions at the district level
			- Procurement systems to simplified and made efficient
	- Enough supplies were provided	- Insufficient supply for commonly used drugs
		- Delay in supplies from government	- Strict monitoring
		- Supplements sold in open market
		- Allocation of budget for medicines not revised according to present needs
		- Absence of diagnostic facilities
Monitoring and Reporting	- Before and after surveys sometimes conducted	- Poor quality of data	- Promote E-Health
	- Internal monitoring was done	- No record of training or equipment distribution	- Improve quality of data
	- Third party monitoring on monthly basis for Polio	- Preference of manual work over computer use	- Do situational analysis before implementation
	- DHIS system for reporting	- Data not used for decision making	- Data to be used for decision
Finances	- Funding is done by donors and the government	- Delay in release of funds from the donors	- To ensure sustainability of funding for existing programs
Cluster meetings	- Seminars held for coordination	- Not regularly held for most programs	- Regular cluster meetings for all issues
	- Regular meetings held for Polio at district and provincial level		- Improve communication between center and district
Natural Disaster	- Disaster management authority present at provincial level		- Improve the functionality
	- Nutrition plan for emergency situations present
Epidemics	- Disease Surveillance and Response Unit in FATA		- Proper forecasting and pre-emptive measures

LHW, Lady Health Workers, SOPs Standard Operating Procedure, MnE Monitoring and Evaluation, DHIS District Health Information System