TA Title: E4H Punjab TA: Refinement and Operationalisation of the Healthcare Quality Index (HQI) for Punjab Health Care Commission (PHCC)

Programme

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 and also to the Federal and Khyber Pakhtunkhwa (KP) governments. The Punjab component is being implemented by Palladium along with Oxford Policy Management (OPM).

Through its flexible, embedded, and demand-driven model, E4H Punjab will support the government to achieve a resilient health system that is prepared for health emergencies, responsive to the latest evidence, and delivers equitable, quality, and efficient healthcare services. Specifically, E4H will deliver TA across three outputs:

Output 1: Strengthened integrated health security, with a focus on preparing and responding to health emergencies, including pandemics.

Output 2: Strengthened evidence-based decision-making to drive health sector performance and accountability.

Output 3: Improved implementation of Universal Health Coverage, with a focus on ending preventable deaths.

E4H-Punjab works in partnership with the Punjab Department of Health (DOH).

Terms of reference

Background

• The Punjab Healthcare Commission (PHCC) regulates healthcare establishments across the province through licensing, inspection, enforcement, and implementation of Minimum Service Delivery Standards (MSDS). The MSDS framework provides the minimum regulatory requirements that healthcare establishments must meet to operate safely and appropriately.
• Under previous E4H technical assistance, PHCC’s MSDS framework was assessed across Category I and II healthcare establishments to understand how effectively minimum standards are being implemented and whether they are contributing to improved quality of care. As part of this assessment, a Healthcare Quality Index (HQI) was developed and tested in 59 facilities to complement MSDS compliance assessment. The HQI drew on internationally recognised healthcare quality dimensions (WHO, OECD) including safety, effectiveness, efficiency, patient-centredness, and equity, and was contextualised using PHCC’s regulatory framework, MSDS requirements, facility assessment findings, and available service delivery data.
• The assessment confirmed that MSDS remains an essential regulatory tool focused on assessing operational and process-related aspects of service delivery, but also showed that compliance with minimum standards does not always provide a complete picture of quality. Importantly, the relationship between MSDS compliance and HQI performance was found to be positive but not linear. Facilities with higher MSDS compliance generally performed better on HQI; however, some facilities achieved relatively strong outcome performance despite partial compliance, while others with high compliance did not consistently demonstrate equivalent outcome-level performance. The assessment therefore recommended that PHCC consider using a structured, outcome-based quality  measurement approach alongside MSDS to support more nuanced facility performance review, benchmarking, and quality improvement.

Problem Statement

While PHCC has an established mechanism to assess minimum compliance through MSDS, it does not yet have an institutionalised approach to measure, compare, and track broader quality performance across public and private healthcare establishments. This limits its ability to identify variation in quality, prioritise regulatory follow-up based on risk and performance, and provide structured feedback to facilities for improvement beyond minimum standards.

A refined and operationalised HQI  is therefore needed to translate selected quality indicators into a practical scoring and benchmarking tool that can support PHCC’s regulatory decision-making, facility quality improvement, and, over time, greater transparency for patients and providers.

Goal and Objectives

The overall objective of this TA is to refine, standardise and validate the HQI, building on its initial development and pilot application under the MSDS Impact Assessment, to strengthen PHC’s capacity for performance-based monitoring and decision-making.

Objectives

1. To refine the existing HQI approach by building on the previous MSDS assessment, PHCC’s regulatory mandate, recognised quality-of-care dimensions, and lessons from initial application of the HQI in Category I and II healthcare establishments.
2. To strengthen PHCC’s capacity to assess quality beyond minimum compliance by developing a feasible approach for measuring, scoring, and comparing broader dimensions of healthcare quality, including safety, effectiveness, efficiency, patient-centredness, and equity.
3. To test the practical use of the HQI within PHCC’s regulatory and quality improvement functions through a limited pilot that assesses feasibility, data availability, usability, and relevance for decision-making.
4. To recommend future institutionalisation and scale-up of the HQI by developing a practical roadmap that sets out how it may be used, maintained, reviewed, and progressively integrated into PHCC’s existing systems, subject to PHCC priorities, capacity, and decision-making.

Strategic Approach

Contributions to Health Systems Strengthening

This TA aims to strengthen healthcare regulation and quality improvement in Punjab by supporting PHCC to move beyond minimum compliance monitoring towards a more performance-based approach to assessing healthcare quality. HQI will complement MSDS rather than replace it. The HQI will support evidence-based regulatory decision-making, risk-informed follow-up, facility feedback, benchmarking, and continuous quality improvement across private and public Category I and II healthcare establishments. Over time, it may also support hospital rating or public-facing quality information, contributing to greater transparency, patient choice, and healthy competition among providers.

Alignment with Other E4H TAs / Investments

This TA builds directly on the previous E4H-supported MSDS Impact Assessment conducted with PHCC, which tested an initial HQI model and recommended that PHCC complement MSDS compliance assessment with a broader quality measurement approach. The proposed TA therefore represents the next phase of support: moving from assessment and initial testing towards refinement, validation, operationalisation planning, and a practical pathway for institutional uptake of the HQI. The assignment also aligns with E4H’s broader support to quality of care, evidence-based decision-making, health systems governance, and UHC by strengthening PHCC’s ability to use regulatory and facility-level data for performance monitoring and quality improvement.

Scope of Work and Methodology

The TA will support PHCC to refine, validate, and prepare the HQI for practical application within PHCC’s regulatory and quality improvement functions.

Phase 1: Inception, Review and Agreement on Practical Application

• Conduct a rapid review of the previous MSDS Impact Assessment, the HQI model developed, PHCC’s MSDS tools, inspection processes, data systems, and relevant quality monitoring standards and practices.
• Agree with PHCC on the scope, workplan, timelines, roles, coordination arrangements, and PHCC focal points.
• Agree with PHCC on the intended institutional application and feasible use of the HQI, including its use for internal regulatory planning, facility performance review, targeted inspections, structured feedback to healthcare establishments, quality improvement, and potential future hospital rating or public-facing quality information.
• Confirm pilot scope, facility categories, sampling principles, data sources, validation approach, dashboard expectations, and institutionalisation requirements.
• Ensure the approach is agreed with PHCC from the outset and reflected in the Inception Report.

Phase 2:  Refinement of HQI Framework, Indicators, Scoring, and Benchmarking Approach

• Review and refine the HQI framework developed under the previous MSDS assessment, including quality domains, indicators, scoring logic, weighting, data requirements, and feasibility for routine use.
• Ensure the refined HQI reflects recognised quality dimensions and is aligned with international best practice, while remaining aligned with PHCC’s MSDS framework and regulatory mandate.
• Review indicators for relevance, measurability, data availability, reliability, and usefulness for PHCC decision-making.
• Develop a practical scoring and benchmarking approach using MSDS requirements, previous assessment findings, facility category/type, available data, and feasible performance thresholds.
• Submit and validate the draft HQI framework, indicator matrix, scoring methodology, and benchmarking approach from PHCC.

Phase 3: Limited Pilot Testing and Validation

• Pilot the refined HQI in selected Category I and II healthcare establishments, with the sample and selection criteria agreed with PHCC during inception.
• Test indicator feasibility, measurability, data availability, data verification requirements, scoring practicality, dashboard usability, and relevance for PHCC decision-making.
• Assess how the HQI can complement MSDS inspections and PHCC’s existing regulatory processes without adding unnecessary burden to PHCC staff or healthcare establishments.
• Gather feedback from PHCC teams and participating facilities on usability, interpretation, and practical value of HQI outputs.
• Refine the indicator set, scoring approach, data requirements, dashboard structure, and implementation guidance based on pilot findings.

Phase 4: Development of HQI Manual, User Guidance and Dashboard Prototype

• Co-develop and finalse a practical HQI package for PHCC, including the HQI manual, indicator definitions, scoring and aggregation rules, data source requirements, quality assurance checks, reporting formats, and user guidance.
• Develop a simple dashboard prototype, in line with the approach agreed during inception.
• Ensure the dashboard can present facility-level scores, domain-level performance, comparison across relevant facility categories, and priority areas for improvement.
• Develop the dashboard as a practical, non-system-dependent tool or prototype for immediate use and future digital integration decisions.

Phase 5: Finalisation and Integration Planning

• Work with PHCC to define how the HQI can be progressively integrated into existing regulatory, inspection, monitoring, and quality improvement processes.
• Request PHCC to share HQI with health care commissions in other provinces as well as the Islamabad Healthcare Regulatory Authority (IHRA) in close coordination with the TWG at the federal level responsible for regular coordination of HCCs.
• Develop an implementation roadmap setting out rollout steps, roles and responsibilities, PHCC ownership arrangements, review and update frequency, data management requirements, and facility feedback mechanisms.
• Identify options for future use of HQI results, including internal regulatory planning, hospital rating, and public-facing quality information, subject to PHCC decision-making.
• Define practical requirements for sustaining the HQI beyond the TA period, including staff capacity, governance arrangements, dashboard maintenance, future refinement of indicators, and alignment with PHCC systems.
• Conduct a structured validation, orientation, and handover session with PHCC to support support future uptake and informed decision-making on continued use.

Sustainability and Institutionalisation

Sustainability and institutionalization considerations will be built into the TA from inception.

• PHCC focal points and responsible units will be identified during inception to guide the refinement, piloting, validation, and institutionalisation of the HQI. The intended institutional use of the HQI, approval pathway, and integration into PHCC processes will also be agreed at this stage.
• The HQI framework, indicator set, scoring methodology, benchmarking approach, dashboard prototype, manual, and implementation roadmap will be developed jointly with PHCC to ensure technical relevance, ownership, and feasibility for routine use.
• The TA will move from TA-led technical refinement during early stages, to co-led piloting and validation, and finally to PHCC-led application and review with TA backstopping. This phased approach will help ensure that PHCC staff are able to understand, apply, interpret, and update the HQI subject to PHCC’s future adoption and resourcing decisions.
• Orientation and hands-on support will be provided to relevant PHCC staff on HQI indicators, scoring, data requirements, dashboard use, interpretation of results, and facility feedback processes. The final roadmap will also identify any further training needs required for wider rollout.
• The TA will define how the HQI can be progressively integrated into PHCC’s existing inspection, licensing, monitoring, quality assurance, facility feedback, and performance review processes, rather than creating a parallel quality monitoring mechanism.
• The final stage will include structured handover of the HQI manual, indicator dictionary, scoring methodology, dashboard prototype, user guidance, and implementation roadmap. The roadmap will set out recommended rollout steps, timelines, responsible units, review frequency, dissemination approach, and options for future use of HQI results, including facility feedback, hospital rating, and public-facing quality information.
• The HQI will be designed as a living tool that can be reviewed and refined over time based on PHCC experience, data availability, facility feedback, and evolving regulatory priorities. This will provide the foundation for progressive institutionalisation and potential long-term use beyond E4H technical assistance.

Deliverables

The tentative timeline to implement all phases of the are 8 months. The deliverable requirements from consultants are as follows:

1. Inception Slide Deck and Work Plan: Agreed scope, methodology, workplan, pilot approach, PHCC focal points, agreed use of HQI, data sources, dashboard expectations and institutionalisation pathway
2. Draft HQI Framework: Refined quality domains, indicator definitions and matrix, data sources, scoring/weighting methodology, benchmarking approach, and proposed dashboard structure.
3. Pilot Validation Report: Findings documented on feasibility, data availability, scoring practicality, usability, dashboard relevance, and PHCC/facility feedback. Revised HQI framework, indicators, scoring approach, and dashboard structure updated based on pilot findings.
4. HQI Manual, User Guide and Dashboard Design: Including indicator dictionary, scoring and benchmarking, user guidance, data quality checks, and dashboard prototype
5. Final Report and Implementation Roadmap: Roadmap to include rollout and institutionalisation steps, PHCC ownership arrangements, responsible units, review frequency, training needs, dissemination approach, approval pathways, and sustainability measures and requirements for conintinued use.