NEWSLETTER

HEALTH CARE COMMISSION

---------------------------------------------------------------------------------------------------------

Government of Khyber Pakhtunkhwa

July 2022 - June 2023
 TABLE
NEWSLETTER OF
CONTENTS
About the Commission 1

Messages 2

Organizational Restructuring 3

Staff Motivation 4

Minimum Service Delivery Standards 5

Trainings of HCEs 6

Supportive Supervision 7

Online Registration 8

Provisional Licensing 9

Independent Assessors 10

Award of Full Licence 11

 TABLE
NEWSLETTER OF
CONTENTS
Quackery Eradication 12

Geo-Tagging of HCEs 13

Complaints Management 14

Legal Framework 15

Digitization 16

Support to Sehat Card Plus Program 17-18

COVID-19 Control Measures at Airport 19

Aesthetic & Rehab Centers 20

Awareness of Citizens 21

Federal & Provincial Consultations 22

 1 July 2022 to June 2023
T h e K hy b e r Pa k h t u n k hw a H e a l t h C a re
Co m m i s s i o n i s a n a u t o n o m o u s b o d y,
established and governed by the K hyber
Pakhtunkhwa Health Care Commission Act, 2015.
The Act envisages regulation of both public and
private Health Care Establishments in the province
to improve quality of care. The Commission is
ABOUT
legally mandated to ensure right of citizens to safe
and good quality healthcare through eradication of
quackery and other malpractices, as well as setting
THE
standards for all types of medical practice,
including but not limited to allopathic and
alternative medicines. The Commission carries out
COMMISSION
this function through registration and licensing of
the Health Care Establishments, and complaints
management of patients and health care providers.
The Khyber Pakhtunkhwa Health Care commission
operates through a two tier management hierarchy
i.e. the Board and the executive. The Board consists
of 10 members, three are representatives of the
government departments while seven are selected
from the private sector. The Board is policy making
body. The executive, consisting of the CEO,
directors and staff members, is responsible for
implementation and performing the core functions
of the Commission.
The Board is highly vibrant, committed and expert
and has taken charge of office, with a pledge to
uplift the Commission and healthcare standards in
the province. Commitment of the board can be
realized from the fact that despite statutory
requirement of only one meeting per quarter, the
Board had seven meetings in the rst nine months
and many important policy decisions were taken.
 2
July 2022 to June 2023 2

Message from the Chairman Message from the CEO

I am happy to note that health sector in

the province of Khyber Pakhtunkhwa
has witnessed historic reforms in the
I t has been a terri c year of effort,
hard work and success in multiple
directions and we have tried to
recent past, and the establishment of achieve many of the milestones for
K hyber Pak htunk hwa Health Care securing excellence in the health care
Commission in the 2015 is one of those system in the province, that were
outstanding accomplishments. During planned years before but could not be
the last one year in particular, the initiated due to numerous
Commission ensured and facilitated organisational challenges, including
notable improvements in health care the in-house technical capacity,
infrastructure and quality of care, use of nancial constraints, lack of assistance
medical technology, increased access to from development partners and
health care services and bridging the resistance to change due the culture of
health care gaps by providing easy option status quo that remained a rule for
of registration and licensing to new HCEs. quite long. I am, however, highly
The Commission has also engaged the grateful for the support through
stakeholders through continuous timely and intelligent decisions of the
training sessions and the citizens through Board and efficient assistance by the
a robust grievance redressal mechanism. senior management and staff of the
My sincere thanks are due to the hon'ble Commission in meeting the targets set
Board Members for their dedication, for the year. I am also thankful to the
professionalism and wholehearted Health Department, Government of
support to the cause of Health care Khyber Pakhtunkhwa for the valuable
Commission. I congratulate the entire support. Moreover, the role of all the
management and staff of the stakeholders remained commendable
Commission for fast track in the implementation of service
implementation and remarkable delivery standards and I foresee the
achievements, despite many challenges. I same level of cooperation in future
look forward to an increased level of also.
commitment during the days to follow.
 3 July 2022 to June 2023
NEWSLETTER
T he Board along with the senior management assessed the existing
organizational structure and the main functions of the Commission. It
was realized that restructuring is required. The whole structure was

“
revamped and five directorates were formed, i.e., Quality, Licensing, Legal
Affairs, Operations, and Finance. This way the organization was
restructured according to its core functions.

The Commission The restructuring helped in improving performance and fast track
implementation was carried out; however, the Commission faced several
challenges during the year.

was Restructured
According to Fast track implementation and
its Core remarkable achievements
despite serious challenges:
Functions
” Ÿ Lack of human resource
Ÿ Non-availability of development
partners assistance
Ÿ No release of funds by Government
 July 2022 to June 2023 4

“Sta
NEWSLETTER
Motivation:
Employee of the
Quarter, and
Appreciation T he Commission believes in team work and
always appreciates and motivates its staff
members. For that matter, the Commission grants
Certificates quarterly awards to employee/s of the quarter and
also awarded certi cates of appreciation to the staff

” members for their contribution in development of

MSDS.
 5 July 2022 to June 2023

I
“11Manuals
n order to ensure quality of service, and bring uniformity
NEWSLETTER in healthcare system, throughout the province, the
Commission developed Minimum Service Delivery
Standards for various categories of Health Care
Establishments (HCEs) and services. The Commission has
Reference
developed 11 Reference Manuals of standards for various
c a t e g o r i e s o f H C E s a n d n o t i e d t h e s a m e fo r
implementation by the care providers. The MSDS de nes a
of
set of benchmarks for a minimum level of quality of
services that a health care establishment is responsible to
Standards
achieve and patients have a right to expect.
All the reference manuals of Minimum Service Delivery Developed &
Standards, were developed by the staff of the Commission,
without any external assistance from development partner
or hiring of consultant.
Notified
”
Minimum Service
Delivery Standards (MSDS)
July 2022 to June 2023 6

WSLETTER
T
“303110Sta
he Commission has also undertaken the responsibility to
guide the HCE's on how to implement the MSDS and for that

of matter regular trainings and orientation sessions of the health

care managers, both formal and informal, are conducted. During
the last one year the commission conducted 16 training sessions

HCEs for different categories, such as the managers, clinicians,

pharmacists, nurses, biomedical engineers and pathologists etc.
and trained a total of 303 staff of 110 hospitals/HCEs from across

Trained on the province.

MSDS Training

Quality Number of Sessions

16
Number of Hospitals

110
Number of staff

303

Standards The Commission signed an MoU with the Project Management

Implementation Unit, which is a project of the health

” department for revamping of Secondary Care Hospitals. The

purpose of MOU was to facilitate trainings of staff of the Public
Hospitals in the province, on quality and standards of health
services.

Trainings of HCEs
 7 July 2022 to June 2023
NEWSLETTER
“Hospitals
were Assisted
During
Implementation B esides training, the Commission also provided supportive
super vision and handholding to the health care
establishments. The hospitals were assisted and on- eld

of guidance was provided through meetings, orientation sessions,

target setting and inspections by the staff of the Commission. In
order to prepare the hospitals for nal assessment by
Standards independent assessors, mock assessments were arranged for
them. This helped them in understanding the process of

” assessment and expectations of assessors. This way the hospitals

were helped in the implementation of the minimum service
delivery standards for grant of Full Licence by the Health Care
Commission.
Supportive Supervision
 July 2022 to June 2023 8

WSLETTER
R egistration and licensing is an essential and primary
function of the Health Care Commission and under the
Act, it is mandatory for all the private Health Care
Establishments to get registered and for all the Health care
establishments to get licensed by the Health Care Commission
subject to compliance of the Minimum Service Delivery
Standards. The directorate of licensing worked hard and
during one year, a total of 6,860 new HCEs were registered.
HCEs Registered
Total HCEs Registered Total during last one year

14,888 6,860 Total HCEs

Registered - 14,888
“Registration
is Online
Number Doubled
in
One Year
”
 9 July 2022 to June 2023
NEWSLETTER
A fter nalization of Minimum Services Delivery
Standards for Category 1 HCEs, the Commission
initiated the process of licensing of the health care

“
establishments. In September 2022, the Commission
awarded provisional licence to 25 HCEs (10 hospitals and
15 labs) in a ceremony graced by the then Provincial
Minister for Health, Mr. Taimur Saleem Khan Jhagra. During
the last one year, the Commission, on successful
110 HCEs
completion of training, awarded provisional licences to 110
health care establishments in the province. Provisionally
Licensed
”
 July 2022 to June 2023 10

WSLETTER
I n order to ensure transparency in the
process of licensing, the commission
“Assessment
established a pool of independent assessors,
trainers and experts, consisting of quali ed
through
and senior professionals from various
specialties of medical services, including
c l i n i c i a n s, h e a l t h m a n a g e r s, n u r s e s,
Independent
pharmacists, and electro-medical engineers.
Assessors
Pool of Assessors
and Trainers
”
 11 July 2022 to June 2023
NEWSLETTER
18 Hospitals
“Full
6 Awarded
Licence
Assessed
T ”
he Commission assessed 18 provisionally
licensed hospitals through independent
assessors. Criteria for assessments was based on
the standards and indicators provided in the
minimum service delivery standards. After
detailed assessment, six category 1 hospitals of
district Peshawar were found eligible and they
were awarded full licence during a ceremony on
June 26, 2023. Award of full licence was an
acknowledgment of their compliance with the
minimum service delivery standards and it has
been the rst ever event in the province that any
hospital was awarded a full licence. The licences
were awarded by the Chairman K hyber
Pakhtunkhwa Health Care Commission, subject
to renewal after three years.
 July 2022 to June 2023 12

WSLETTER
Q uackery is one of the major problems of the health
care sector in the province and the Khyber
Pakhtunkhwa Health Care Commission is determined to
eradicate quackery from the entire province. The
Commission has prepared a comprehensive plan and
adopted multi-pronged strategy, i.e., excluding quacks
through registration and licensing of quali ed
healthcare professionals; conducting regular anti-
quackery campaigns; online and manual complaint
management system; imposition of nes and
permanent sealing of the establishments and public
awareness to join hands with the Commission for
eradication of the menace of quackery and ensuring
6,971 HCEs Inspected
safety of patients.
The Commission on one hand facilitated the quali ed
health care providers to register themselves through a
1,569 Notices Issued
very easy online registration system and isolating the
non-quali ed ones and on the other hand launched
serious quackery eradication campaigns throughout the
777 Sealed
province. In addition to the routine inspections, the
Commission also conducted sweeping anti-quackery
campaign in several districts. The Commission also
extended its operations to the merged tribal districts.

Quackery Eradication
13 July 2022 to June 2023

I n order to secure complete information

about the health care establishments in the
“Third Party
province, the Commission has launched a
project to develop a comprehensive database
and GIS map of all the HCEs in the province.
Registration and
The exercise will not only identify and tag the
HCEs but will also facilitate the unregistered
Geo-Tagging
HCEs to apply for registration on the spot.
Moreover, the quacks will be identi ed for
further necessary legal action. The project is
in Progress
assisted by the World Bank and implemented
by an independent third party.
”
 July 2022 to June 2023 14

WSLETTER
Complaints Management

“Complaint Management
System for Right
I n order to maintain transparency and accountability in
the health care system, it is vital to have an effective and
responsive complaints management system. The
Commission has established a robust mechanism for
complaints management and grievance redressal of the

Protection patients as well as service providers. The Commission

accepts complaints regarding medical negligence,

”
maladministration, malpractice or failure in provision of
the health care services according to quality standards
through the Pakistan Citizens' Portal, KP HCC Online
Complaints Portal, and manually submitted to the
Commission. During the last one year the commission has
received 1,642 complaints on various forums and
resolved 1,470.

1,642 Complaints Received,

90% Resolved
 15 July 2022 to June 2023

6 Manuals of Regulations
“
Amendments to Act and
Licensing Rules Submitted
Drafted and Approved
by the Board
to Government

T
”
he Khyber Pakhtunkhwa Health Care Commission was established
through Act No. V of 2015, followed by the Conduct of Business
Regulations 2016. However, in order to align the existing legal framework
with the contemporary healthcare standards and regulations, the
Commission approved certain essential amendments to the Act of 2015,
and the Licensing Rules, 2022 which were submitted to the Government of
Khyber Pakhtunkhwa. The Commission has also developed and approved
the Human resource M anagement, Financial M anagement,
Establishment, Anti-quackery, Registration and Licensing, and Complaints
Management Regulations, 2022 for conduct of its day to day business.

Legal Framework
July 2022 to June 2023 16

A utomation and digitization increases efficiency,

improves transparency and reduces over-
reliance on human interaction. The Commission has
developed a state of the art website and provided
online Complaint Management, Quackery Reporting
and Registration Systems, thereby facilitating the

“Online Portals
stakeholders to have easy remote access to the
Commission. This, however, is just the beginning and
the Commission has started work on further
digitization of the processes and establishment of
online data bases.

Digitization
Developed for
Registration
Complaints Management
Quackery Reporting

”
NEWSLETTER 17 July 2022 to June 2023

“37 Sehat Card

Hospitals Assessed T he Khyber Pakhtunkhwa Health Care

”
Commission believes in team work and
working in harmony with the partners in
health care system. On the Directives of the
Hon'ble Peshawar High Court, the Secretary
Health Government of Khyber Pakhtunkhwa
established a Grievance Redressal Committee
(GRC) for the health insurance programme in
the province, which is headed by the Chief
Executive O fficer of the Health Care
Commission. Under the auspices of the GRC,
the commission trained 40 assessors on the
empanelment criteria under the Sehat Card
Plus Programme and conducted assessment
of 37 Sehat Card Plus empaneled hospitals.

Support to Sehat Card Plus

Programme
NEWSLETTER July 2022 to June 2023 18

“
Assistance to
Sehat Card Plus
for Standards
Development
T he Commission inked a tripar tite

” Memorandum of Understanding with

Sehat Card Plus Programme and State Life
Insurance Corporation, for review of
assessment criteria for empanelment of
secondary care hospitals, development of
assessment criteria for tertiary care hospitals,
establishment of a joint pool of assessors and
a s s e s s m e nt s o f ve S e h at Ca rd Pl u s
empaneled tertiary care hospitals. Services of
a third party consultancy rm have been hired
for the purpose and the project will be
completed soon.

Tripartite MoU between the

KP HCC, Sehat Card Plus
and State Life
 19 July 2022 to June 2023

“Covid-19 Control
Measures Assessed
at Bacha Khan
International
Airport
”
D ue to surge in the Covid-19 cases in the
country, and in order to follow the measures
being taken by the Federal Government for
mitigation and control of the virus transmission,
the Khyber Pakhtunkhwa Health Care Commission
took active part in the activity and conducted
assessment of disease control measures at Bacha
Khan International Airport, Peshawar. The report,
containing recommendations, was submitted to
the Ministr y of National Health Ser vices,
Regulations and Coordination.
July 2022 to June 2023 20

WSLETTER
“Rehabilitation
Aesthetic and

Centres
Brought under
Regulatory Net
T
”
he K hyber Pak htunk hwa Health Care
Commission conducted thorough consultation
on the services provided by the beauty salons and
rehabilitation centers. It was realized that they
provided services which are infact medical services
and therefore, steps were taken to bring them under
the regulatory net of the Commission. Awareness
campaigns were conducted through social, print
and electronic media. This was followed by eld visits
and registration of these centres.

Aesthetic and
Rehabilitation Centers
21 July 2022 to June 2023

“Awareness is Integral Part

of Strategy to Improve
Quality of Health Care
and Curb Quackery

C
”
itizens being the major stakeholders of the Health Care System, the Khyber
Pakhtunkhwa Health Care Commission prioritized the right to information and
awareness of the citizens and took various initiatives for educating them regarding their
rights and the relevant regulatory frameworks in vogue from time to time. For this
purpose the Commission used the available forums of print and electronic media, social
media and dissemination of information through door to door campaigns. Besides
regular dissemination through social media and newspapers, the Commission also
broadcasted awareness messages through various TV Channels and the senior officers
attended live awareness shows on national television.
 July 2022 to June 2023 22

WSLETTER
“Participation in
Federal and
Provincial
Consultations
K
”
P HCC is part of the various Federal level Committees of
the Federal Ministry of Health Services and actively
engages in consultative dialogue. It is contributing to the
policy discourse and is part of the Technical Working Group on
Hospital Sector Vision, National Price Fixation Committee for
Life Saving Medical Devices, National Consultations on
Maternal and Perinatal Death Surveillance and Response,
Patient Safety Committee on Development of National safety
Standards for Hospitals, and Medical Tourism. KP HCC is also
part of the consultative dialogue with UNODC on National
Standards and Protocols for the Treatment of Drug Use
Disorder.
In order to ensure uniformity in the policies and standards of
health care, the Chief Executive Officer, Khyber Pakhtunkhwa
Health Care Commission held various consultative meetings
with the Health Regulatory Authorities of the other provinces
and shared the experiences and adopted best practices from
the other provinces.
 KHYBER PAKHTUNKHWA
HEALTH CARE COMMISSION
Phase-V, Hayatabad, Khyber Pakhtunkhwa, Peshawar, Pakistan

+92 91 9217791 www.hcc.kp.gov.pk