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Summary & Suggestions
Based on several studies, some of which are referred to at the bottom, following are the summary and suggestions. Healthcare system in Pakistan has been improving over time due to policy changes and more budget allocation. However, our rapid population growth defeats all planning quickly. Budget increase, policy changes, MDGs, SDGs, all remain unfinished or without effectiveness which is envisaged during planning. Our promotion of family planning rested entirely on foreign funding and stopped as the funding dried up; population rose rapidly again.
We now look at the good things, the-not-so-good things, challenges, and opportunities. I have taken access to medicines separately because it deserves special attention.
The Good Things – Planning Mostly
- Development of National Health Vision by the Ministry of National Health Services, Regulation and Coordination is slated to help pursue aspirations for better health of the people of the country as a whole. The recent SDG-3 roll out initiative and localization of SDGs by identifying targets per province by the Ministry of NHSR&C is a forward movement for SDG agenda. The structure of NHV is well-thought, although it lacks specific targets and measures.
- Launching of national health insurance schemes in December 2015was expected to reduce out of pocket expenses and provide protection to the population living below poverty line in all districts by 2020. It was later converted to Sehat Sahulat Program which did provide relief to a good number of patients.
- Implementation of family practice approach in 12 model districts will streamline service delivery by the public and private sectors, increase access to comprehensive quality health care services and moving towards universal health coverage.
- Enhanced production of family physicians by launch of the diploma course in KHYBER Medical University through technical support by WHO using the curriculum prepared by the American University of Beirut will ease pressure on the current infrastructure.
- Establishment of Health Planning, Systems Strengthening and Information Analysis Unit by the Ministry of NHSR&C will help in knowledge management hub for producing national level aggregated figures.
- Health information system in Pakistan is being rooted at the district level as “District Health Information System”, with almost 100% reporting with plans to upgrade software to DHIS2
- Elaborate network of over 10,000 public sector primary health care facilities and public sector hospitals that can be effectively used to provide quality health care • Reduction of polio cases from 306 in 2014 to only three cases in 2018.
- Establishment of Drug Regulatory Authority of Pakistan to regulate growing pharmaceutical industry.
- Legislative back up and institutional arrangements put in place in three provinces and federal area to regulate both public and private sectors through health commissions.
- Development and launch of Human Resource for Health Vision 2018-2030.
- Launching of National Hepatitis Strategic Framework and Development of Antimicrobial Resistant (AMR) National Plan.
The execution of above is in various stages with mixed success.
The Not-So-Good Things
- Serious underfunding of the health sector—the public health expenditure was 0.91% of GDP (against the target of 3% of GDP in Pakistan Vision 2025), the government health expenditure per capita is approximately US$ 12.5, and the share of out-of-pocket spending is over 60%.
- Access to the underprivileged areas, and huge semi-urban slums affected coverage of PHC services.
- Large unregulated private health sector comprising general and specialist clinics, pharmacies and diagnostic centres continue to thrive at the expense of patients.
- Shortage in some cadres of Health Workforce such as nurses and paramedical staff and urban/rural unequal distribution of health workforce.
- Unequal distribution of human resources and lack of incentives for staff serving in remote areas
- Dysfunctional/ Absent referral system continues to put the patient load on secondary & tertiary hospitals
- Substandard/spurious/falsely-labelled/falsified/counterfeit medicines remain a tangible public health problem.
What Can Be Done
- Improved coordination among parastatal organizations and non-governmental organizations that are involved in the delivery of health care for their employees.
- Renewed efforts to strengthen district health system that ensures effective health care for the local population through the implementation of innovative approaches such as family practice.
- National health insurance initiative, contracting out with Private sectors, vouchering and cash transfer schemes for improving access and quality of health services are among good practices that can be scaled up
- Increase in the number of medical and allied institutions in the public and private sectors.
- Training and deployment of 100 000 Lady Health Workers has increased access to primary health care services, as planned, and to provide them job and personal security.
- Continued and increasing commitment of development partners and other UN agencies to support the health sector.
- Strengthening of health care commissions for better regulation of the public and private sector
- Complex emergencies impede delivery of priority public health programmes in various parts of the country.
- Very high population growth rate and poor economic situation, leading to negative impact on progress towards universal health coverage.
- Rapid urbanization, epidemiological transition and dual burden of diseases.
- Social Determinants of Health such as high level of illiteracy, unemployment, poverty, access to clean water and sanitation and pervasive inequities.
- Rapid change in management and leadership at the highest levels interrupt continuity of polices
- Health policies, regulations and laws are in abundance but their actual implementation is an issue.
- Ineffective regimes and mechanisms for regulation of the private health sector to control quality and cost of care.
- Variable quality of health professionals, training deployment, fair distribution, skills mix and acute shortages in some cadres.
- High prevalence of HIV/AIDS, TB, Hepatitis and malaria; over 200,000 estimated HIV cases, with only 7% under treatment
- 5th highest burden of tuberculosis with 518,000 new TB cases every year, 27,000 Multi Drug Resistant (MDR) TB Cases per year while 160,000 cases are missed
- Among the highest malaria burden-sharing countries in the EMR with estimated 1.3 million cases per year
What Must Be Done
- Raise health high on social sector agenda of government in order to increase allocations to health and advocate for role of health in economic growth and development.
- Strengthen the stewardship role of Ministry of National Health Services, Regulation and Coordination to effectively undertake federal health functions and improve interprovincial coordination.
- Expand national health insurance scheme, in collaboration between federal and provincial governments, to cover the most vulnerable population groups in country.
- Strengthen the capacity of the provincial health departments, supported by the district health offices, to effectively deliver essential health services to the population through implementation of Family Practice approach.
- Developt/review provincial health strategies in line with the National Health Vision in order to move towards universal health coverage by improving coverage and access to essential health services package and introducing innovative financing schemes.
- Build partnerships with for-profit/non-profit health sector, develop an appropriate regulatory framework, and put in place institutional mechanisms for implementation.
- Improve quality of care at PHC and hospital level through adoption of service standards, investments in health infrastructure and human resources development.
- Enhance production of family physicians and redefine the roles of existing staff towards multi-disciplinary teams.
- Improve health information systems and upgrade software to DHIS2 to ensure timely, accurate and updated information and encourage operational research to support decision-making, planning and monitoring processes.
- Enhance the capacity for disaster preparedness and response and its integration into the health system.
Concerns About Medicines
- Too many registered products and low quality threshold for drug company registration.
- Surveillance of policy, including decentralization, prices, availability, and quality.
- Post devolution need for independent drug regulation authority and greater voice of all stakeholders.
- Best practice lessons learnt from LMICs for pricing policies, particularly controlling availability of ‘orphan drugs’, market price variations and unit cost price estimation.
- Lack of incentives to produce quality drugs.
- Clear cut pricing formula and automatic pricing decisions.
- Operational pilots for improved supply management including new financing mechanisms, medicines information system, and pharmacist’s role in decision making.
- Abolition of flat price control as it is counter productive, resulting in disappearance of low-cost priced drugs.
- Control unnecessary, and often inappropriate prescriptions, by medical practitioners.
- Transparency and availability of information related to medicine use.
- Absence of therapeutic protocols & formularies in health facilities.
- Lack of public sharing of Essential Drugs List, irregular updating and weak linkage with morbidity data.
- Low availability of medicines in public sector at all tiers of health system.
- Inadequate operational budget for medicine in public sector.
- Weak hospital pharmacies across public and private sector.
- Proliferation of shadow pharmacies.
All the above concerns need urgent attention at the federal and provincial level. Implementation of fewer, effective policies is more important than making large number of good-looking ones.
Health is the basic right of all citizens of Pakistan. So far, no government has ensured, provided, and protected this right. It is time to act now, as it is already too late.
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