Report On Health Conditions of Pakistan

HEALTH CONDITIONS OF PAKISTAN
Report on Health Conditions of Pakistan A Descriptive Study
Submitted to, Dr. A.R Jafri Submitted by, Aamir Shehzad MPhil-Mgt-002 Institute of Administrative Sciences, University of the Punjab Lahore
Table of Contents List of Acronyms List of Tables Abstract Introduction Health Indicators . 5 . 7 8 9 11 17 19 20 20 24 26 29 30 31 33 36 37 38 40 47 50
Comparison of Health Conditions in South Asia
The Five-Year Health Plans The First Five-Year Plan (1955-1960) The Second Five-Year Plan (1960-1965) The Third Five-Year Plan (1965-1970) The Fourth Five-Year Plan (1970-1975) The Fifth Five-Year Plan (1978-1983) The Sixth Five-Year Plan (1983-1988) The Seventh Five-Year Plan (1988-93) The Eighth Five-Year Plan (1993-98) The Ninth Five-Year Plan (1998-2003)
Three-Year Development Program (2001-2004)
Medium Term Development Framework (2005-10) Current Situation of the Health Sector
Current Weaknesses in Public Health Services Factors Responsible for Poor Health
Current Health-Related Issues in Pakistan
51 51 53 56 56 58 59 60 61 62 63 65 67
Taliban Banned on Polio Vaccination
Young Doctors and Paramedics Strikes in Punjab Suggestions to improve Health Conditions in Pakistan
Paradigm shift: from providing health care to producing health Regionalization of Health Care Services Elimination of Structural Fragmentation Establishing Functional Specificity Public-Private Partnership Healthy Public Policy
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Promoting Gender Equity in the Health Care System Good Governance, Freedom and Development References
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Acronyms ACSM ADB AIDS BCG BHU CIA DHDC DHO DHQ DOTS EmONC EPI FATA GAVI GDP GNP HALE HIV JICA LHWs MCH Advocacy Communication and Social Mobilization Asian Development Bank Acquired Immune Deficiency Syndrome Bacillus Calmette-Gurin Basic Health Unit Central Intelligence Agency District Human Development Centers District Health Officer District Headquarter Directly Observed Treatment System Emergency Obstetric and Neonatal Care Expanded Program on Immunization Federally Administrated Tribal Areas Global Alliance for Vaccination & Immunization Gross Domestic Product Gross National Product Healthy life expectancy Human Immunodeficiency Virus Japan International Cooperation Agency Lady Health Workers Maternal and Child Health
MDGs MMR MoU NFC NIDs NIH NTP ORS PAEC PHDC PMA PSDP RHU TBAs THQ UNDP UNICEF USAID VBFPWs WHO YDA
Millennium Development Goals Maternal Mortality Ratio Memorandum of Understanding National Finance Commission National Immunization Days National Institute for Health National TB Program Oral Rehydration Salt Pakistan Atomic Energy Commission Provincial Human Development Centers Pakistan Medical Association Public Sector Development Programs Rural Health Unit Traditional Birth Attendants Tehsil Headquarter United Nations Development Programme United Nations Children's Fund United States Agency for International Development Village Based Family Planning Workers World Health Organization Young Doctors Association
List of Tables
Table 1: Regional Human Development Indicators
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Table 2: Health Facilities and Health Indices of Pakistan: 1965 Table 3: Targets and Achievements of the Third Plan
. 25 . 27 30
Table 4: Development and Recurring Expenditures on Health Table 5: Targets and Achievements of the Fifth Plan (1978-83)
Table 6: Targets and achievements of the Seventh Plan (1988-93) . 32 Table 7: Selected Demographic Indicators for the Seventh Plan . 33 35
Table 8: Budget Allocation and Revised Estimates for 1994-95 and 1995-96 Table 9: Expenditure for the three year period during 2001-04 Table 10: Budget Allocations for 2011-12 and 2012-13
. 38
. 41 . 44
Table 11: Physical Target/Achievement 2011-12 and 2012-13 Table 12: Health Affairs and Services (Rs. In Million)
. 46 47
Table 13: Health & Nutrition Expenditures (2000-01 to 2011-12) (Rs. Billion)
Abstract Healthcare needs to be seen in an inter-related perspective of economy, nutritional status and environment. Health is one of the very basic human needs but in Pakistan state has failed drastically to provide a good health system for the welfare of its people. The condition of health services in this country has remained below par throughout the history. The extreme of this sorry state is that still there are no serious considerations towards improving it. Moreover a wave of strikes by the young doctors and paramedical staff in the Punjab has created dangerous healthcare issues for the needy patients in the public hospitals. The healthcare problems in Pakistan may be positively addressed by shifting paradigm from provision of health services to producing health, regionalization of health services, elimination of structural fragmentation, establishing functional specificity, public-private partnership, healthy public policy, promoting gender equity and adopting good governance, freedom and development. Key Words: health, medical, Pakistan, WHO, hospitals, public, government
Report on Health Conditions of Pakistan A Descriptive Study The most important resource of any nation is its people and it is states foremost responsibility to take care of them in the best possible way. The primary obligation of a state towards its people is to ensure provision of all basic needs to them so that people may make struggles for the higher needs and as a result they can provide a real wealth of knowledge and research to the nation. In this knowledge based world now it is the key to success and advancement. Therefore a responsible nation needs to develop a welfare system of governance which can provide freedom to the people from the worries for basic facilities of health, education, food, and housing. The World Health Organization defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO, Constitution of the World Health Organization, 1946). Health is also defined as the extent to which an individual or a group is able to realize aspirations and satisfy needs, and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources as well as physical capabilities (WHO, Health Promotion: A Discussion Document, 1984). It is a state characterized by anatomic, physiologic and psychological integrity; ability to perform personally valued family, work and community roles; ability to deal with physical, biologic, psychological and social stress a feeling of well-being; and freedom from the risk of disease and untimely death (Stokes, 1982). A state of equilibrium between humans and the physical, biologic and social environment, compatible with full functional activity (Last, 1998). However sociologists believe that it is not just a personal
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choice, nor it is only a biological issue; patterns of well-being and illness are rooted in the organization of society (Macionis, 2005). Healthcare refers to the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. It is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers. Moreover it includes the work done in providing primary care, secondary care and tertiary care, as well as in public health. Healthcare needs to be seen in an inter-related perspective of economy, nutritional status and environment. It is also important to consider the historical perspective of healthcare in Pakistan. The social, cultural, economic and political changes that followed the introduction of British rule in India dealt an almost fatal blow to the practice of the Indian system of medicine. Almost every facet of life, including the medical and public health services, were subordinated to the commercial, political, and administrative interests of the imperial government in London. The impetus to make change in the Indian medical system of that time was justified by the rapid advances in western medicine during the nineteenth and twentieth centuries. As a result, the Indian system of medicine stated to fall out of favor, subsequently leading to its decline. In comparison, the Western system flourished as it gained favor with the educated classes. This change resulted in a skewed system of medical services of rife with all the problem caused by colonization. At the time of independence in 1947, the British left a healthcare system for a small section of population. They built hospitals in large cities and indoor and outdoor facilities on a varying scale in small cities and towns. The system primarily provided free health services to officials of the colonial government and their families, although its doors were not closed to
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citizen in general. A very large section of the population in the rural areas was without any curative healthcare. The British also established a department of health in every province with a health officer in each district, whose main task was to prevent large scale epidemics through immunization and other sanitary measures. All these activities were confined to the urban areas. At this time only the ruling class of civil and military officers, subordinate government employees and the affluent sections of the civil society received medical services. Of the remaining 90 per cent of the population, only a small fraction could get some form of medical care in hospitals and dispensaries run by the government agencies, missionaries, philanthropic institutions and by the few private practitioners. Similarly, only a big few cities had health services, which were but a form of environmental sanitation. The rest received some public health services only when there was an outbreak of massive epidemics, such as plague, cholera and smallpox. Vigorous efforts were made to segregate the valuable population, around the military establishments and cantonments (Hasan, 1997). After independence, the health system of Pakistan was expanded more or less according to the lines laid down by the British rulers. The public healthcare infrastructure remained inadequate, unable to meet the demands of the country. There is a great disparity in healthcare between the urban and rural areas, where most of Pakistans population lives. Doctors are concentrated in the urban areas, further augmenting the severe shortage of any trained health human resource in the rural areas. The doctor to population ratio is nearly two times greater than the ratio of nurse to population (Aksari, 2012). Poor access to health services results in a scenario which is both bleak as well as disappointing. The government remains a silent observer. The upper government hierarchy (mostly the elite of the society) and the department heads have made neither concentrated efforts
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nor consistent policies to address this issue. Mostly at the whim of the donors, successive national government have experimented with no less than one dozen different primary healthcare models all embedded in the same inefficient and unwieldy system run by incompetent and corrupt officials. Even though some initiatives were good, for instance, family planning, they did not work well because of immense corruption in the government healthcare and family planning services. Health is one of the very basic human needs but in Pakistan state has failed drastically to provide a good health system for the welfare of its people. The condition of health services in this country has remained below par throughout the history. The extreme of this sorry state is that still there is no serious consideration towards improving it. Health Indicators The conditions of health of a nation are measured by different health indicators defined as characteristics of an individual, population, or environment which are subject to measurement (directly or indirectly) and can be used to describe one or more aspects of the health of an individual or population (quality, quantity and time) (WHP, 2012). The significant health indicators are as follow; Life expectancy at birth This indicator indicates average number of years that a newborn is expected to live if current mortality rates continue to apply (WHO, 2006). It reflects the overall mortality level of a population. It summarizes the mortality pattern that prevails across all age groups - children and adolescents, adults and the elderly.
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Healthy life expectancy (HALE) Healthy life expectancy indicates average number of years that a person can expect to live in "full health" by taking into account years lived in less than full health due to disease and/or injury (WHO, World Health Report 2004: Changing History, 2004). Substantial resources are devoted to reducing the incidence, duration and severity of major diseases that cause morbidity but not mortality and to reducing their impact on peoples lives. It is important to capture both fatal and non-fatal health outcomes in a summary measure of average levels of population health. Healthy life expectancy (HALE) at birth adds up expectation of life for different health states, adjusted for severity distribution making it sensitive to changes over time or differences between countries in the severity distribution of health states. Adult Mortality Rate Adult mortality rate means Probability that a 15 year old person will die before reaching his/her 60th birthday (Division, 2002). Disease burden from non-communicable diseases among adults, the most economically productive age span, is rapidly increasing in developing countries due to ageing and health transitions. Therefore, the level of adult mortality is becoming an important indicator for the comprehensive assessment of the mortality pattern in a population of a particular country. Under-Five Mortality Rate and Infant Mortality Rate The indicator of under-five mortality rate shows probability of a child born in a specific year or period dying before reaching the age of five, if subject to age-specific mortality rates of that period. Moreover infant mortality rate is the probability of a child born in a specific year or period dying before reaching the age of one, if subject to age-specific mortality rates of that period (Hill Kenneth, 1999). Under-five mortality rate and infant mortality rate are leading
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indicators of the level of child health and overall development in countries. They are also MDG indicators (UNICEF, 2005). Neonatal Mortality Rate Neonatal mortality rate is defined as the number of deaths during the first 28 completed days of life per 1,000 live births in a given year or period. Furthermore neonatal deaths may be subdivided into early neonatal deaths, occurring during the first seven days of life, and late neonatal deaths, occurring after the seventh day but before the 28 completed days of life (WHO, Perinatal and neonatal mortality: In preparation, 2005). The neonatal deaths account for a large proportion of child deaths. Moreover mortality during neonatal period is considered a useful indicator of both maternal and newborn health and care. Maternal Mortality Ratio It is defined as number of maternal deaths per 100 000 live births during a specified time period, usually one year (WHO, Maternal Mortality Estimates developed by WHO, UNICEF and UNFPA, 2000). Complications during pregnancy and childbirth are leading causes of death and disability among women of reproductive age in developing countries. Maternal mortality ratio (MMR) represents the risk associated with each pregnancy, i.e. the obstetric risk. It is also an MDG indicator for monitoring goal 5 of improving maternal health (WHO, International Classification of Diseases, 10th Revision, 2004). Estimated Rate of Adults (15 Years and Older) Dying of HIV/AIDS (Per 1000) and Estimated Rate of Children below 15 Years of Age Dying of HIV/AIDS (Per 1000) Estimated mortality due to HIV/AIDS is the number of adults and children that have died in a specific year based in the modeling of HIV surveillance data using standard and appropriate tools (UNAIDS, 2004). Adult and children below 15 mortality rate are leading indicators of the
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level of impact of HIV/AIDS epidemic and impact of interventions specially scale up of treatment and prevention to mother to child transmission in countries (Helen Ward, 2004). Tuberculosis mortality Tuberculosis mortality is estimated number of deaths due to TB per 100,000 population per year. This indicator includes deaths from all forms of TB, and deaths from TB in people with HIV (Christopher Dye, 1999). Number of Hospital Beds per 100,000 Population It measures the number of in-patient beds per 100,000 population. Hospital beds include in-patient and maternity beds. Maternity beds are included while cots and delivery beds are excluded (WHO, South-East Asia Region: Basic Indicators 2004, 2004). Other Indicators Defined By WHO The other health indicators defined and measured by the World Health Organization (WHO) are as follow; Coverage of vital registration of deaths - General government expenditure on health as percentage of total expenditure on health - General government expenditure on health as percentage of total government expenditure - External resources for health as percentage of total expenditure on health - Social security expenditure on health as percentage of general government expenditure on health - Out-of-pocket expenditure as percentage of private expenditure on health - Private prepaid plans as percentage of private expenditure on health - Per capita total expenditure on health at average exchange rate (US$)
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- Per capita government expenditure on health at average exchange rate (US$) - Per capita government expenditure on health at international dollar rate - Total expenditure on health as percentage of GDP - General government expenditure on health as percentage of total general government expenditure - Per capita total expenditure on health at international dollar rate Number of -physicians per 1 000 population -nurses per 1 000 population -midwives per 1 000 population -dentist per 1 000 population -pharmacists per 1 000 population -public and environmental health workers per 1 000 population -community health workers per 1 000 population -laboratory health workers per 1 000 population -other health workers per 1 000 population -health management and support workers per 1 000 population Prevalence of current (daily or occasional) tobacco smoking among adults (15 years and older) (%) Prevalence of current tobacco use in adolescents (13-15 years of age) Population using solid fuels (%) Population with -sustainable access to an improved water source (%)
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-access to improved sanitation (%) Prevalence of adults (15 years and older) who are obese (%) Newborns with low birth weight (%) Children under five years of age - stunted for age (percentage) - underweight for age (percentage) - overweight for age (percentage) Births by caesarean section (%) Children 6-59 month of age who received vitamin A supplementation Children under five years of age with fever who received treatment with any anti-malarial (%) Comparison of Health Conditions in South Asia While discussing healthcare conditions in Pakistan, it is important to keep in perspective the comparative developments and status of healthcare in other countries of South Asia. Although Pakistan has a reasonably high gross national product per capita, it falls far behind the average in health indicators for low income (infant mortality, malnutrition, etc.) in comparison with countries such as Sri Lanka and Bangladesh, which have improved their healthcare programs and reduced their infant and child mortality rates, or Bangladesh and Maldives, which have the highest literacy rates. The health of the population in Pakistan has improved in the last three decades, but the pace of improvement has not been satisfactory. Poor health status is in part explained by poverty, low level of education (especially for women), the low status of women in large segments of
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society as well as inadequate sanitation and potable water facilities. It is also related to serious deficiencies in health services, both public and private. Although Pakistan produces doctors at an alarmingly high and unregulated rate, most look towards the lucrative private sector; finding health professionals, especially women, to work in rural areas is difficult. The inadequacies of the public sector service mean that the private sector is heavily used. In this respect some surveys suggest that it is used by 80 per cent of the population, even by the very poor, who are barely able to afford the fees (Abbasi, 1999). Nonetheless, the sheer size of the population and the extent of need ensure that public facilities remain overcrowded. The government health sector is further compounded by inadequate and ineffective health standards and policies, and with frequent changes in government this results in further hampering effective changes in healthcare management. A report of Economic Survey of Pakistan 2011-12 has stated that the most recent data on health performance of other South Asian countries suggest that Pakistan lags behind in infant mortality rate (at 63 per 1000 live births) and the under 5 years mortality rate (at 86.5 per 1000 live births). The report maintains that these indicators continue to remain high mainly on account of unhealthy dietary habits, water borne diseases, malnutrition and rapid population growth (Aksari, 2012). However, the average life expectancy at 66 years compares well with India, Nepal and Bangladesh. Pakistan is committed towards achieving the MDGs. The MDGs 4, 5 and 6 are related to child mortality, maternal health and combating HIV and Aids, Malaria and other diseases. Considerable efforts and immense resources are required to achieve the desired health outcomes.
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It pertinent to mention here that the previous report of Economic Survey of Pakistan (2010-11) had declared that Pakistan still suffered from a high infant and maternal mortality, a double burden of diseases, and inadequate health care facilities with high population growth, despite the fact that Pakistan has made progress during last couple of years towards achieving these health targets yet the pace has been sluggish. The mortality, morbidity and slow progress of indicators in the maternal and child health are major concerns in the progress towards achieving Millennium Development Goals; Pakistan is lagging behind from other developing countries in these indicators. Table 1 Regional Human Development Indicators
Country Pakistan India China Bangladesh Sri Lanka Nepal Life Expectancy 2011 65.99 66.80 74.68 69.75 75.73 66.16 Mortality Rate under 5 per 1000 2010 86.5 62.7 18.4 47.8 16.5 49.5 Infant Mortality Rate per 1000 2011 63.26 47.57 16.06 50.73 9.70 44.54 Population Growth Rate (%) 2011 2.03 1.34 0.49 1.57 0.93 1.60
Source: World Development Report 2011 The Five-Year Health Plans: 1955-2010 and the Current Situation Health is both a means of achieving development and one of the principal goals of development itself. The aim of integrated social and economic development is to improve the general level of living of the people. Thus the health standards of a country are both a reflection and a cause of prevailing economic conditions. The important role that human capital plays in development is now universally recognized. Health is one of the major factors determining the quantity and quality of the output
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of this capital. Investment in health pays rich dividends both in the form of improved human welfare and increased productivity. This emphasizes the importance of improved health standards for economic development, and accounts for the fact that health programs have formed an increasingly important part of national development plans in Pakistan. The chapter describes the review and development of health plans in Pakistan since from 1955, the year when a formal First Five-Year Plan was formulated. The First Five-Year Plan (1955-1960) This contained a very modest program for the health sector, but the implementation of even this program was quite unsatisfactory. Only about 50 per cent of the total Plan allocation of Rs. 287 million was utilized. The utilization of the funds allocated for preventive services was even lower, i.e. about 25 per cent, although the plan had placed greater emphasis on such services. The main reasons for this serious shortfall were lack of qualified and trained personnel for implementation and delays in the commitment of funds. The Second Five-Year Plan (1960-1965) This plan witnessed a vastly improved performance in the field of healthcare. The pace of implementation improved substantially and it was estimated that actual expenditure would exceed the plan allocation of Rs.370 million by approximately Rs.50 million. Three medical colleges were set up each at Dhaka, Sylhet and Mymensingh. The number of doctors was expected to rise to 15,600 by the end of the plan. A systematic program to provide medical coverage to rural population was ushered in and nearly 200 Rural Health Centers were set up by the end of 1964-1965. A long-range program for the eradication of malaria was also launched. The entire population of Pakistan was vaccinated against small pox resulting in decrease from about 79,000 cases in 1958 to about 50 cases in 1964. The number of hospital
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beds increased from 28,000 in 1960-61 to 35,000 beds in 1964-1965. There was an all-round improvement in training facilities for medical and paramedical personnel, although personnel in the latter category were still scarce. General improvement also took place in the organizational and administrative set up for the implementation of development programs. In short, achievements during the Second FiveYear Plan period helped to provide a base over which, an adequate structure of health services could be built for the future and hence provided a base for the enabled the inclusion of health programs in the Third Plan. The achievements at the end of the Second Five-Year Plan appear in the table below; Table 2 Health Facilities and Health Indices of Pakistan: 1965 Pakistan (1965)
Doctors to population ratio Nurses to population ratio Hospital Beds to population ratio Lady Health Visitors to population ratio T.B. Beds to population ratio Crude Death Rate Crude Birth Rate Infant Mortality Rate Mortality Rate Per 100,000 Population due to; a) Malaria b) Diarrhea Dysentery c) Tuberculosis 1:7400 1:32000 1:3200 1:115000 1:50 Fatal Cases 29 per 1000 55 per 1000 155 per 1000 100 320 100-150
Source: The Third Five-Year Plan 1965-1970, Planning Commission and Government of Pakistan
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The above table points to a number of problem areas. They showed that the chief causes of both morbidity and mortality were largely preventable and originated from low standards of living and lack of properly developed health services. They also indicated that there were too few doctors, nurses and trained health personnel to look after the health of the masses. They also pointed to a number of problems, some of which are the following. Statistical Deficiencies. An accurate quantitative assessment of the countrys health problems was not possible for want of statistically reliable data. Vital statistics were infrequently recorded, morbidity data were far from complete and even registered causes of mortality and morbidity were unreliable. However, some numerical data could be arrived at from returns of government health institutions and a number of surveys conducted by various organizations. Lack of Proper Environmental Sanitation. It was estimated that in Pakistan, nearly 50 per cent of all illness were attributable to gastrointestinal disorders like diarrhea, dysentery, worm infections, enteric fever and cholera, all of which thrive only in unhygienic conditions. Protection against some of these diseases can be provided by inoculation but permanent eradication requires arrangements for proper disposal of sewage and provision of safe drinking water. While financial provision for these items were made under the Physical Planning and Housing Sector, promotion of environmental sanitation was one of the principal functions of the health personnel, especially of those working in the rural areas. Low Nutritional Standard. The low state of nutrition makes the population more vulnerable to diseases. One of the surveys conducted in Pakistan indicated that the caloric intake of a majority of the population was below minimum standards recommended by the Food and Agriculture Organization. The nutritional problem was the result not only due to low per capita income but also because of general unawareness of dietary deficiencies and their correctives.
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Malaria. A serious problem was posed by the high incidence of malaria, which claimed approximately 100,000 lives every year. It was largely prevalent in the rural areas and affected the population during the peak seasons of activity, leading to both human and economic losses. Tuberculosis. Tuberculosis was claiming around 150,000 lives every year. A tuberculosis survey conducted in Pakistan revealed that one in every 22 persons suffered from pulmonary tuberculosis. The incidence was higher in the male population and majority fell in the category of ages between age 20 and 40, i.e. the prime age of working life. The first two plan emphasized BCG vaccination campaign and the establishment of hospitals and dispensaries. The Third Plan contemplated a shift from the provision of hospital beds to the establishment of network of clinics that were designed to facilitate earlier diagnosis and domiciliary treatment. Child and Maternal Mortality. It was seen that half of all recorded deaths were of children below the age of ten. Of these, about half of the children were less than one year old. Maternal mortality was also very high; almost five times that of some of other developing country. Paucity of Trained Personnel. Of major obstacles some were the scarcity of trained personnel, particularly the paramedical staff. During 1964-1965, East Pakistan had as many as 6700 doctors but only about 550 nurses and 147 health visitors. The situation in West Pakistan was slightly but not very much better. Rapid Growth of Population. The rapid rate of population growth was swallowing up the progress in living standards achieved through development plans. Population in both parts of Pakistan great at an alarming rate and was a major cause of distress for development planners but nothing practical was done until the Third Five-Year Plan.
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The Third Five-Year Plan (1965-1970) The Third Five-Year Plan allocated a budget to Family Planning Program that was nine times that of the Second Five-Year Plan. Allocating for the health sector rose from the Rs.287 million in the First Five-Year Plan to Rs.1370 million in the Third Plan. The Third Plan provided Rs.901 million (Rs629 million for General Health and Rs.272 million for Malaria Eradication Program) for the general health sector (excluding family planning). Major sub sectors for which this allocation was earmarked included the Malaria Eradication Program, hospital beds, rural health centers, tuberculosis control and medical education and training. It was estimated that approximately 45 per cent of this allocation would be utilized by the end of the plan period (excluding the Malaria Eradication Program). Considerable shortfalls were expected in the physical targets envisaged for the Third Plan in the health sector. The position with regards to the targets and achievements of the Third Plan is given in the following table: Table 3 Targets and Achievements of the Third Plan
Item Doctors Nurses Lady Health Visitors Hospital beds Rural Health Sectors Sanitary Inspectors Para-medicals Plan Target 4,800 1,800 1,700 12,800 547 Achievements 5,000 1,660 950 3,650 230 700 1,500 Percentage Increase 104 98 56 30 34 -
Source: The Fourth Five-Year Plan 1970-1975, Planning Commission, and Government of Pakistan
The most disappointing feature of the Third Five-Year Plan was the failure in the implementation of the rural health program. It was estimated that by the end of the Third Plan
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860 rural health centers and 2,400 sub-centers would be functioning, but only 230 rural health centers were commissioned and a few more were under construction. In East Pakistan, only the rural health centers carried over from the Second Plan could be completed and no new scheme was started. In West Pakistan, the rural health centers almost remained at a standstill. This state resulted from delay in the allocation of funds and some controversy regarding the conceptual pattern of the rural health program. No headway could be made under the program for hospital beds. In the first place, the figures given as benchmark for hospital beds in the Third Plan were inflated. Secondly, the beds to be provided under the rural health program and medical colleges were also added to the overall target for hospital beds. Due to unsatisfactory progress of the rural health programs and delay in the completion of medical colleges, the target for hospital beds could not be reached. The number of beds added during the Plan were 3,650 against the plan target of 12,800. The position with regard to tuberculosis control was also not very encouraging. In East Pakistan, only 22 TB clinics carried over from the Second Plan were completed, whereas in West Pakistan hardly eight clinics out of the planned 445 were set up. Under medical education, work continued on medical colleges at Sylhet and Mymensingh and work started at Barisol and Rangpur. Work on these colleges was carried over into the Fourth Plan. Facilities for postgraduate medical education could not be augmented. Work on schools for Tropical Medicine at Dhaka had started but the postgraduate medical institute in East Pakistan had not yet been started by at the end of the Third Plan. The Fourth Five-Year Plan (1970-1975) An amount of Rs.2.4 billion was allocated for health in the Fourth Plan but this was not implemented due to political reasons and the separation of East from West Pakistan and the creation of Bangladesh. Only yearly plans were prepared from 1971. The eight years from 1970,
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that is from 1970-1978, fell into two phases. The first phase was from 1970-1972 when developmental expenditure fell to Rs.59 million per annum and many health programs came to a virtual standstill. In the second phase, that is from 1977-1978, investment in health rose nearly to a level of Rs.684.34 million by 1977-1978. Substantial progress was made in the expansion of health facilities and significant initiatives were undertaken in several health related fields. The per capita expenditure increased (Mahmud, H. et al. 1990) in current prices from Rs.3.52 (0.41 per cent of GNP) in 1970-1971 to Rs.16.18 (0.62 per cent of GNP) in 1977-78. This had been steadily increasing from one year to another. Table 4 Development and Recurring Expenditures on Health (Excluding Population Planning)
Year 1970-71 1971-72 1972-73 1973-74 1974-75 1975-76 1976-77 1977-78 Development (Million Rupees) 61.700 57.620 95.550 157.670 309.000 629.099 539.800 684.340 Non-Development (Million Rupees) 157.700 141.100 171.900 210.100 278.000 360.640 439.200 558.600 Total (Million Rupees) 213.400 198.720 267.450 367.770 587.000 989.739 979.000 1242.940 % of GNP .47 .40 .44 .46 .59 .92 .65 .62 Per Capita Expenditure 3.52 3.13 4.10 5.47 8.48 14.08 13.23 16.18 Index 1970-71 100 890 116 155 241 400 376 460
Source: The Fifth Five-Year Plan 1978-83, Planning Commission, and Government of Pakistan.
The six years had been marked by a comprehensive review and an extensive debate over all aspects of health policy. As a result of these deliberations, a new health policy emerged which represented a significance shift from the earlier strategies. The principal impact of new policy was felt during the Fifth Plan period (1978-1983). Rs.4.58 billion or 3.7 per cent were allocated for the health sector, but only 55 per cent of this was utilized over the plan period.
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In the field of prevention, the Malaria Control Program was revived to meet the threat posed by resurgence of the disease. Spraying which had come to virtual halt was resumed in June 1975. Along with the revival of the program, integration of the Malaria Program with health services was introduced. Measures to combat tuberculosis were intensified. The scale of effort on the preventive side however remained inadequate. Pakistan was declared free from small pox on 18th December 1976. In the rural health services, some progress was made in implementing the old scheme for rural health centers though actual achievement remained below target. The number of rural health centers increased from 86 to 289. A significant development in the sphere of rural health services was the experiment of community health workers (Health Guards) in the Northern areas of Pakistan. The number of hospital beds increased from 32,063 in 1969-70 to 46,092 in 1977-78. The achievement was close to target for these years. It is evident that the scale on which health services were available for the population of the rural areas was comparatively poorer than the urban areas, even if allowance was made for the fact that many hospitals and other institutions located in the urban sites, served people living in rural areas as well. The most striking development of this period was the rapid expansion in facilities from higher medical education. The number of medical colleges went up from six to fifteen, and enrolment capacity rose from 900 to 4000 per annum. However the development of training facilities for paramedical and auxiliaries did not keep pace with the expansion in the output of doctors. The number of nurses increased from 5,400 to 9,711, and of lady health visitors from 1,881 to 3,250. Measures had also been initiated for the training of paramedics.
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The Generic Drug Scheme enforced in1972 was modified to a considerable extent by the comprehensive Drug Act 1976, which provides for drug manufacturing licenses through a Central Licensing Board consisting of representatives of the federal and provincial governments. A system of registration of drug, whether imported or locally manufactured was introduced to ensure supply of drugs of required efficacy and quality. A national formulary comprising drugs allowed to be imported, manufactured and sold in the country, was published. The Act also provided for control on advertisement of drugs and publicity of unscientific remedies. Funds embarked for the preventive measures during the period of 1970-78 were relatively inadequate. The bias in the health program had been towards provision of curative services. Furthermore, availability of foreign aid and other considerations tended to favor vertical programs for combating particular diseases at the expense of strengthening the general health services. While success had been achieved in controlling major epidemic diseases, the overall incidence of communicable and preventable diseases remained very high. The concurrent operation of several separate programs not only proved expensive but also prevented co-ordination and effective supervision. Lack of integration of health programs thus prevented optimal utilization of personnel and facilities. Another difficulty facing the health service was availability of sufficient funds to meet the recurrent expenditures. In many cases the infrastructure was available but could not be utilized in full because of shortage of funds for personnel, drugs and maintenance. Special programs for vulnerable people were developed to some extent but they were never adequate in relation to requirements. School health services were at a rudimentary stage. Maternity and Child Health Services extended to only a small part of the population. In the
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absence of an integrated health service and inadequate outreach, community health programs were slow to develop. Progress with health education had also been insignificant. Style and method of management at federal and provincial levels have a direct bearing on the management of services. Although there have been some improvements over a period of time, but the existing organization and management systems were not conducive to a responsive development oriented health delivery system. It was too centralized, fragmented and weak. The government realized that there was a need for managerial change. This recognition was a major step towards hopes of improvement. The Fifth Five-Year Plan (1978-1983) The Fifth Five-Year Plan had the following objectives: 1. To provide modern health coverage within 2-4 miles for the entire population. 2. To reduce the crude death rate from 14 per thousand to about 10.2 per thousand. 3. To reduce infant mortality rate from 105 per thousand to 79 per thousand live births. 4. To increase the life expectancy from 54 years for men to 60 years, and from 53 to 59 years for women. All this was to be achieved at an estimated cost of Rs.6.6 billion at 1978 prices. The expenditure incurred during the Fifth Plan, at current (1983) prices was Rs.4,584 million. Discounting for inflation, the amount allocated for the health sector added up to Rs.3,615 million at 1978 prices or 55 per cent of the envisaged allocation during the plan period. Taking into account the budgetary cuts, the allocation had not been more than 50 per cent of the estimated cost of the plan requirement. The achievement in term of vital health indices was as follows:
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Table 5 Targets and Achievements of the Fifth Plan (1978-83)

Index Crude Death Rate Infant Mortality Maternal Mortality Ratio Life Expectancy at Birth a) b) Male Female 54 Years 53 Years 60 Years 59 Years 55 Years 54 Years 1978 14 105 600-800 Fifth Plan Targets for 1982-1983 10.2 79 Achievements up to June 1983 12 100 600-800
Source: The Sixth Five-Year Plan 1983-88, Planning Commission, and Government of Pakistan.
The Sixth Five-Year Plan (1983-1988) During the Sixth Five-Year Plan, the Crude Death Rate declined from 12 per thousand to about 11 per thousand; maternal mortality was 2-4 per thousand; infant mortality decreased from 98.5 per thousand to 80 per thousand live births, and life expectancy increased to 61 years. During the Sixth Plan 85 per cent of the Union Councils were provided a BHU or an RHC; some Union Councils were provided more than one facility. Nearly all the children up to five years were fully immunized which save an estimated 100,000 children from dying and another 45,000 from getting disabled. The training of dais (Traditional Birth Attendants or TBA) was satisfactory and the target of 30,000 was fully met although the disposal is not uniform. Treatment of diarrhea by oral rehydration salts made satisfactory progress. However, the Sixth Plan made slow progress in combating third degree malnutrition and providing for the care of the disabled. Other areas where the Sixth Plan did not met its goals include creation of a cadre of health managers, introduction of user charges, patronage to traditional medicine and expansion of private sector due to lack of proper incentives.
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The unemployment of doctors was solved to some extent by special measures. About 18,000 doctors graduated out of which 13,000 were employed by the private sector. Credit facilities for doctors to establish their own clinics were improved. The target laid down for various categories of health manpower were almost achieved except those of paramedics where only about 75 per cent of the target was met mainly due to the slow expansion of the training institutions for paramedics. In 1988, there was only one doctor for 2,920 persons, one dentist for 61,760 persons, one primary healthcare facility for 11,230 persons and one hospital bed for 1,650 persons. Primary healthcare facilities were offered by 3,496 BHUs, 492 RHCs, and 6,050 other health outlets, i.e. dispensaries, maternity child health centers and sub-centers. The Seventh Five-Year Plan (1988-93) This provided Rs.13.2 billion development expenditure to be incurred for health sector at 1988 prices. This was 3.8 per cent of the total public sector development outlay. Of this 43 per cent was earmarked for the rural health program, 24 per cent for hospitals, 16 per cent for human resource development and eight per cent for other preventive programs. Most of the allocation earmarked for rural health programs was used for bricks and mortar rather than provision of actual health services. The expenditure was nearly Rs.11 billion at current prices. The utilization was 84 per cent of the allocations. The non-development expenditure was projected to be Rs.36 billion but only Rs.21 billion were spent which is 58.3 per cent of the allocation, and that too at current prices. Targets and achievements of the Seventh Five Year Plan appear in the following table;
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Table 6 Targets and achievements of the Seventh Plan (1988-93) Sub-sector Health Facilities
Basic Health Unit (BHUs) Rural Health Centers (RHCs) Urban Health Centers Hospital Beds
1,913 133 227 19,871 1,950 130 50 18,000 102 97 22 90
Target
Achievement
% Achievement
Human Resources
Doctors Dentists Nurses Paramedics TBAs
15,700 800 10,000 68,650 20,000 16,500 775 9,500 26,000 21,000 105 97 95 37 105
Process Indicators
Immunization (Million Children) ORS (Million Packets)
19.3 46 18.3 34.1 93 74
Source: Planning and Development Division, Government of Pakistan, Islamabad
It is apparent that neither the development nor the non-development budgets were protected. The expenditure had gone down in nominal terms and the shortfalls would be much greater in constant prices. To control goiter, cretinism, still births and abortions, an iodized oil program was started in 1989 in the remote hilly areas of the country which was complemented by salt iodization program from July 1988. The private sector made satisfactory progress by establishing new medical college, other training institutions and hospitals. This provided employment and services but mainly in urban areas. The selected demographic indicators achieved during the Seventh Plan appear in the following table;
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Table 7 Selected Demographic Indicators for the Seventh Plan

1987-88 (Benchmark) Mid-Year Population (Millions) Birth Rate (Per 1000 Population) Death Rate (per 1000 population) Rate of Growth Number of Births Averted 105.7 42.3 11.1 3.1 0.3 1988-89 109.0 42.0 10.8 3.1 0.4 1989-90 112.4 41.2 10.4 3.1 0.5 1990-91 115.9 40.8 10.0 3.1 0.6 1991-92 119.4 40.2 9.6 3.1 0.7 1992-93 123.0 39.6 9.2 3.0 0.8
Source: The Seventh Five-Year Plan 1988-93, Planning Commission, Government of Pakistan.
The Eighth Five-Year Plan (1993-98) The main emphasis during this plan was to consolidate the gains already achieved in the health sector. Efforts were made to improve the quality of services by creating a balance of promotive, preventive and curative care and by the removal of inequities. Imbalances in the health manpower were aimed to be reduced and management weaknesses of health system were to be addressed. It was planned to decentralize the public health sector. Villages which remained without the facility un-served were to be provided reasonable outreach services by training Lady Health Workers (LHWs). An area of importance for this plan was provision of adequate maternal and child health (MCH) services. To improve referral care and bring services closer to villages, it was planned to upgrade and make more functional more than 5,000 health facilities in the rural areas. The upgrading involved making staff available, improving their skills and provision of equipment and transport. It was planned to upgrade the rural health system and improve the quality of care to the extent that the RHCs would in take cases of Pregnant women with life threatening conditions, Critically sick children, and
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Trauma/burns cases.
Some of other measures proposed included: 1. Introduction of user charges and/or payment for services, 2. A package of incentives to be introduced to encourage the private sector to extend services to rural and semi-rural areas, 3. Traditional system of medicine to be developed within its own fundamental principles, 4. Family planning services to be provided at all health outlets, and 5. Planning of human resources for health to be institutionalized at both the federal and provincial levels. The Eighth Plan was successful in decentralizing primary and secondary health care and providing services at the community level through LHWs and the Village Based Family Planning Workers (VBFPWs). The former belonged to the Ministry of the Health while the latter belonged to the Ministry of Population Welfare. User charges were introduced in most of the public sector tertiary care institutions. No package of incentives for the private sector was prepared to encourage it to provide services in the rural and semi-urban areas. However, the private sector expanded tertiary care facilities, training of doctors, and diagnostic services as required by the market forces. The private sector still remained unguided with no regulatory mechanism. Family planning services could not be provided from all health outlets. No headway was made in institutionalizing planning of human resources for health, and the central theme of provision of providing MCH remained a distant dream. No upgrading of health facilities was undertaken with the result that RHCs could not provide emergency basic emergency obstetric care. Little progress was made on the development of traditional medicine.
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The total expenditure during the Eighth Plan improved from a base of 0.63 per cent of GNP in 1982-83 to a little over 1.01 per cent of GNP during 1987-88. This was the only year when public health sector expenditure crossed 1.00 per cent of GNP (Planning Commission. 1992). The budget allocations and revised estimates for the two middle years of the Eighth FiveYear Plan appear in the table below; Table 8 Budget Allocation and Revised Estimates for 1994-95 and 1995-96
Budget Allocation 1994-95 Health Division Medical Services Public Health Total 54.734 756.008 75.007 885.749 Revised Estimates 1994-95 54.281 897.543 73.128 1024.952 Budget Allocation 1995-96 53.904 898.573 66.622 1019.099
Source: Annual Plan 1995-96, Planning Commission of Pakistan.
The Ninth Five-Year Plan (1998-2003) The Ninth Plan started on schedule. A working group in health, nutrition and narcotics prepared a report for preparation of a chapter on the health sector but the Government decided not to approve a five year plan. Hence there is no Ninth Five-Year Plan. The military took control of the countrys government on 12th October 1999. This de facto government prepared a three year plan for 2001-2004. During the interim period the main emphasis was to consolidate the gains already achieved in the health sector. The main efforts under this plan included;
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1. Improving the quality of services by creating a balance of promotive, preventive and curative care and removal of inequalities 2. Reducing imbalances in the human resources for health and management weaknesses of the health system, and 3. Providing reasonable outreach services to villages, which still remained without unserved. Implementation status During the interim period 1998-2000 period outreach services were extended by training more LHWs. No progress was made in removing imbalances in human resources for health and in decreasing management weaknesses. Though MCH was the central theme of the Eighth Plan progress and was followed during the interim period, but progress remained unsatisfactory as female staff was not available. Three-Year Development Program (2001-2004) In the absence of the Ninth Plan, the government prepared a three year development program. This program was based on the National Health Policy of 2001. The goals of this policy included 1. Reducing widespread prevalence of communicable diseases, 2. Addressing adequacies in primary/secondary healthcare services, 3. Removing professional and managerial deficiencies in the District Health System 4. Promoting greater gender equity, 5. Bridging basic nutrition gaps in the regulation in the target population, 6. Correcting urban bias in the health sector, 7. Introducing required regulations in the private medical sector,
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8. Creating mass awareness in public health matters, 9. Affecting improvements in the drug (pharmaceutical) sector, and 10. Capacity-building for health policy monitoring. Financial An amount of Rs.87 billion was the estimated expenditure on health in the public sector during 2001-04. This included Rs.21.8 billion as development and Rs.65 billion as nondevelopment expenditure. The development expenditure on federal projects was Rs.11.5 billion which is fifty per cent of the total development expenditure during this three year period. However, the non-development expenditure of the Federal Ministry of Health was Rs.6 billion or ten per cent of the total non-development expenditure in the public health sector. The provincial governments spending is mainly on the non-development side, almost 70 per cent of which is for salaries. The utilization has remained around 80 per cent. Summary of the expenditure for the three year period during 2001-04 appears in the following table;
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Table 9 Expenditure for the three year period during 2001-04

The Project
National Program for Family Planning and Primary Healthcare ( LHWs Program) Expanded Program on Immunization Enhanced HIV/AIDS Control Program Pakistan High Risk Area Approach for Neonatal Tentanus at NIH, Islamabad (JICA) Women Health Project, ADB Reproductive Health Project Improvement of Nutrition through Primary Healthcare & Nutrition Education/ Public Awareness Roll Back Malaria Control Enhanced HIV/AIDS Control Program Pakistan Strengthening of EPI Services through GAVI Grant Assistance National Tuberculosis Control Program Total Preventive Other (Curative etc.) Grand Total
Cost
21533.502 5366.30 2858 856.60 795.528 631.752 302.70
Financial Aid
0.00 0.0 966.80 856.00 630.40 476.10 0.0
Allocation 2001-04
5611 1400 515 335 372 40 110.713
Utilization 2001-04
3900 1320 458 300 269 14.55 105.713
% of Utilization 2001-04
70 94 89 89 72 36 95
273.30 267 158.5 33043.182 3790 36833
0.0 2.8 0.0 2932 467.5 3947
100 48 54 8586 1608 10194
93 48 36 6544 1492 8036
93 100 76 76 93 76
Source: Draft Medium Term Plan 2005-10, Planning Commission, Government of Pakistan
Abbreviations: NIH( National Institute for Health), ADB (Asian Development Bank), EPI (Expanded Program on Immunization), GAVI (The Global Alliance for Vaccination & Immunization), JICA (Japan International Cooperation Agency) Medium Term Development Framework (2005-10) The vision for 2005-2010 was a healthy population with a sound health care system practicing healthy life style, in partnership with private sector including civil society, which is effective, efficient and responsive to the health needs of low socio-economic groups especially women in the reproductive age. The following were the objectives for the framework; to provide quality care to reduce infant, child and maternal mortality
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to improve nutritional status of children less than five years
The suggested strategy was to make the paradigm shift in the policy from curative services to preventive, promotive and primary health care in the following way; Primary Health Care will be strengthened with necessary back up support in rural areas where all the outlets will function as focal points for PHC and Family Planning Services round the clock. Centers will be established to cover the underserved areas in the urban slums. Training and re-training of Medical Staff at all levels will be improved by further supporting the Provincial Human Development Centers (PHDCs) District Human Development Centers (DHDCs). The system of cost recovery for the services rendered and subsidization for the poor segments of target population and regulation of private sector will be addressed by health sector reforms. Hospital management will be improved through establishment of health boards under the devolution. The programs of T.B./Malaria Control with new strategies of DOTS/Roll back malaria will appreciably help to address re-emerging issue of communicable diseases affecting mainly the productive age group. To enhance Health Education through skill development of health staff in communication techniques at all levels. Master Plan for Substance Abuse developed by Narcotic Control Division, shall be vigorously followed.
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In order to adopt /implement the above strategies Ministry of Health has to play its role of stewardship and improve the Health System as an overall development strategy. Current Situation of the Health Sector Although Pakistan is making progress in the healthcare services but it is still far behind
other South Asian countries in this regard. Though on decline, child mortality, under-five mortality and maternal mortality are still unacceptably very high. Under-five mortality among the poorest has modestly improved in the last 15 years. . Pakistan lags behind its neighbors on immunization coverage. Gap between access to health services for the poor and the affluent and geographic differences are large. The quality of care in public facilities is low resulting in low utilization of public health facilities. Moreover, slow progress in achieving maternal and child health and reduction in their morbidity and mortality are major concerns in the progress towards achieving Millennium Development Goals (MDGs). In pursuance to 18th Amendment to the Constitution, health sector has been devolved to the provinces with absolute administrative and financial autonomy. Accordingly Ministry of Health was abolished on 30th June 2011. The following residual functions have been spread to various Ministries/Divisions including Planning & Development Division, Cabinet Division, Inter-Provincial Coordination Division, Capital Administration & Development Division, Economic Affairs Division and Interior Division. The health functions retained at the federal level are: National Planning Coordination (with provinces and international development partners) Funding of Vertical Programs in Health Sector Regulation of Pharmaceutical Sector
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International Health Regulations Dealing with International Agreements and MoUs Training Abroad
Although vertical Programs in health sector have been devolved to the provinces, however, upon their request and in pursuance to the decision of CCI, funding for these vertical Programs during the 7th NFC Award shall be catered to by Federal Government. An amount of Rs.14.3 billion was provided in Federal PSDP 2011-12 against which utilization by end of March 2012 stands at Rs.9.7 billion as appears in the following table; Table 10 Budget Allocations for 2011-12 and 2012-13
Vertical Programs National Program for Family Planning and Primary Health Care Expanded Program of Immunization Enhanced HIV/AIDS Control NIH Islamabad National T.B. Control Program Roll Back Malaria Control Program National Program for Prevention and control of Blindness, NIH, Islamabad. Prime Ministers Program for Prevention & Control of Hepatitis, NIH, Islamabad National Maternal Neonatal and Child Health Program, Islamabad. National Program for Prevention and Control of Avian Pandemic influenza, NIH, Islamabad. Total Total Cost 77,101 24,983 1,931 1,184 659 2,776 13,904 19,995 331 2011-12 Allocation 8,000 2,716 247 124 124 247 600 2,281 37 2012-13 Allocation 11,000 2,793 247 124 124 247 684 2,366 37 17,622
142,864 14,375 Source: Annual Plan 2012-2013, Planning Commission of Pakistan.
The program for Family Planning and Primary Health Care has recruited about 110,000 Lady Health Workers (LHWs) to date. More than 60% of total population and 76% of target population stands covered by LHWs. Out of 30 million children, about 16 million are immunized by LHWs during National Immunization Days (NIDs). Similarly in high risk districts out of 5
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million target women, 4.5 million are vaccinated by LHWs. Their role in improving mother and child health is by now well recognized. Malaria is the second most prevalent and devastating disease in the country and has been a major cause of morbidity in Pakistan. More than 90% of disease burden in the country is shared by 56 highly endemic districts, mostly located in Balochistan (17 out of 29 districts), FATA (7 agencies), Sindh (12 districts) and Khyber Pakhtunkhwa (12 districts). Most of the reported cases from these districts are due to falciparum malaria which is more dangerous form of malaria. Federally Administrated Tribal Areas (FATA) is the second highest malaria affected belt of the country which accounts for 12-15% of the total case load of the country. Pakistan is 6th amongst 22 high disease burden countries. TB Control Program has achieved 100% Directly Observed Treatment System(DOTS) coverage in public sector and in the last five years the Program has provided care to more than half a million TB patients in Pakistan. The Program is moving steadily to achieve the global targets of 70% case detection. There are areas where NTP has to improve each as suspect management, contact management, quality bacteriology services, engaging all care providers through public private partnership and inter-sectoral collaboration, monitoring and supervision, research for evidence based planning and advocacy communication and social mobilization (ACSM). Till date 4,500 HIV positive cases have been reported to the AIDS Control Programs at federal and provincial levels .It includes 2,700 full blown AIDS cases. Around 1030 are receiving free treatment through 12 AIDS Treatment Centers. Maternal & Child Health Program has been launched by the government in order to improve Maternal and Neonatal Health services for all particularly the poor and the disadvantaged at all levels of health care delivery system. It aims to provide improved access to
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high quality Mother and Child Health and Family Planning services, train 10,000 community midwives, comprehensive Emergency Obstetric and Neonatal Care (EmONC) services in 275 hospitals/health facilities, basic EmONC services in 550 health facilities, and family planning services in all health outlets. During the year 2010-11, 7 million children of 0-11 months and 6.5 million pregnant women were immunized against 7 deadly diseases and tetanus oxide respectively. 19 million packets of ORS were distributed. Under the preventive program, about 8.5 million children will be immunized and 25 million packets of Oral Rehydration Salt (ORS) will be distributed during 2011-12. Routine coverage is regarded as the basis of child protection. Pakistan Atomic Energy Commissions (PAEC) 13 Cancer Hospitals in four provinces are providing diagnosis and treatment facilities to cancer patients. Moreover another nine new cancer hospitals are in the process of construction. Breast care clinics have been established at all the nuclear medical centers. In addition to the above discussed major health programs, progress on some other health activities are presented as under: Establishment of 7 Rural Health Centers (RHCs) 30 Basic Health Units (BHUs) up gradation of 15 existing RHCs and 35 BHUs. Addition of 4000 new doctors, 450 dentists, 3000 Nurses, 4500 paramedics and 500 Traditional Birth Attendants. Under the preventive program, about 7 million children were targeted to be immunized and 19 million packets of ORS are likely to be distributed during 2011-12. 4500 HIV positive cases have been reported to the National and Provincial AIDS Control Programs .It includes 2700 full blown AIDS. Around 1030 patients are receiving free treatment through 12 AIDS Treatment Centers.
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Table 11 Physical Target/Achievement 2011-12 and 2012-13

Sub Sector Targets A. Rural Health Program New BHUs New RHCs Strengthening/Improvement of BHUs Strengthening/Improvement of RHCs. B. Hospital Beds C. Health Manpower Doctors Dentists Nurses Paramedics TBAs Training of LHWs D. Preventive Program Immunization (Million NOs) Oral Rehydration Salt (ORS) (Million Packets) 50 10 50 20 5,000 5,000 500 4,000 5,000 550 10,000 7.5 22 2011-12 Achievements 30 7 35 15 4,000 4,300 450 3,000 4,500 500 9,500 7 20 Targets 2012-13 40 10 45 15 5,000 5,000 500 4,500 5,500 500 10,000 8 23
(%) 60 70 70 75 80 86 90 75 90 91 95 93 91
Source: Annual Plan 2012-2013, Planning Commission of Pakistan.
Highlighting the health facilities, the current survey (2011-12) says that the health facilities and health related manpower have expanded substantially due to the greater focus on health sector programs over the last three decades. This has resulted in the setup of a large network of health facilities with 108,137 hospital beds, 149,201 doctors, 10,958 dentist and 76,244 nurses by 2011. Insufficient health spending and rapid population growth have contributed to continuing low facilities to population ratios particularly in the case of dentists, nurses and hospital beds. The potential payoff of investing in and improving the overall health services is enormous. The health care system in Pakistan comprises both public and private health facilities. The public sector until recently was under the domain of the Ministry of Health. However, under the 18th amendment of the constitution of
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Pakistan, the Ministry of Health has been devolved in June 2011 and the functions of the ministry have been transferred to provincial health departments. The provinces are now responsible for developing their own strategies, programs and interventions based on their local needs. The health expenditure of 0.5 per cent of GDP in public sector is extremely low. The foreign funded projects are working in different parts of country but their effectiveness is only dependent on good progress in other sectors of life. Mass education, political stability, economic growth and total eradication of corruption are required for a modern health care system in the country. The main highlights of the health care conditions are as follow (Khan, 2012); At present, there are 972 hospitals, 4,842 dispensaries, 5,374 basic health units and 909 maternity and child health centers in Pakistan. With availability of 149,201 doctors, 10,958 dentists, 76,244 nurses and 108,137 hospital beds in the country during 2011-12 compared to 144,901 doctors, 10,508 dentists, 73,244 nurses and 104,137 hospital beds last year, the population and health facilities ratio worked out 1,206 persons per doctors, 16,426 persons per dentist and 1,665 persons per hospital bed. During 2011-12, thirty basic health units and seven rural health centers have been constructed, while fifteen rural health centers and thirty five basic health units have been upgraded. 4,300 doctors, 450 dentists, 3,000 nurses and 4,500 paramedics have completed their academic courses and 4,000 new beds have been added in the hospitals.
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9,500 Lady Health Workers (LHWs) have been trained and deployed mostly in the rural areas. Moreover, some seven million children have been immunized and twenty million packets of ORS have been distributed.
In addition to ongoing various health programs such as cancer treatment, AIDS prevention, Malaria Control Program, this year special focus was given by Federal as well as Provincial Government to Dengue Epidemic Control Program.
Under the head of Health Affairs and Services, a total allocation of Rs7,845 million has been made in the budget estimates 2012-13, which is higher by 196.5% and 18.0% when compared with budget and revised estimates 2011-12 (Pakistan, 2012). Details are given in the following table: Table 12 Health Affairs and Services (Rs. In Million)
Classification Health Affairs and Services Medical Products, Appliances and Equipment Hospitals Services Public Health Services R & D Health Health Administration Budget 2011-12 2,646 2,435 140 70 Revised Budget 2011-12 6,651 100 5,712 696 1 143 Budget 2012-13 7,845 132 6,609 845 259
Source: Annual Budget Statement 2012-2013, Government of Pakistan Finance Division Islamabad
To maintain the expansion of health facilities, the financial allocation for the health sector has been increasing steadily. However, the massive floods of 2010 caused a significant downwards rationalization of health and nutrition expenditures which had to be diverted to the relief and rehabilitation effort (Khan, 2012). Total health expenditures (federal and provincial) declined from Rs. 79 billion in 2009-10 to Rs. 42 billion in 2010-11. For 2011-12 these have been increased to Rs. 55.12 billion; comprising Rs. 26.25 billion as development expenditure and
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Rs. 28.87 billion as non-development (current) expenditure. Rs. 15.72 billion have been provided in the federal PSDP for 2011-12. Table 13 Health & Nutrition Expenditures (2000-01 to 2011-12) (Rs. Billion)
Fiscal Years Public Sector Expenditure (Federal and Provincial) Total Health Expenditures 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 24.28 25.41 28.81 32.81 38.00 40.00 50.00 60.00 74.00 79.00 42.00 55.12 Development Expenditure 5.94 6.69 6.61 8.50 11.00 16.00 20.00 27.22 33.00 38.00 19.00 26.25 Current Expenditure 18.34 18.72 22.21 24.31 27.00 24.00 30.00 32.67 41.10 41.00 23.00 28.87 9.9 4.7 13.4 13.8 15.8 5.3 25.0 20.0 23.0 7.0 (-)47 31.24 Percentage Change Health Expenditure as % of GDP 0.72 0.59 0.58 0.57 0.57 0.51 0.57 0.57 0.56 0.54 0.23 0.27
Source: Economic Survey of Pakistan 2011-12, Ministry of Finance Islamabad.
Current Weaknesses in Public Health Services Public health services in Pakistan suffer from many weaknesses that impair their quality and effectiveness. The most important of them are as follow; Insufficient Focus on Preventive Interventions Government health services have traditionally had a curative orientation. Health staff has tended to passively wait for the sick people to come to their facilities for treatment. The pattern of disease in Pakistan, however, calls for a greater emphasis on preventive interventions. Such emphasis also requires health staff to be more proactive and seek to educate the neighboring
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communities on how to take better care of their health. The inadequate emphasis on preventive interventions is reflected in the unsatisfactory coverage of immunization, maternal and child health, and family planning programs. Health education programs are also poorly developed and that is why they cannot deliver desired outcomes to uplift health conditions of the country. Gender Imbalances The government health services are predominately male, both front-line staff as well as the managers. While programs in recruiting front-line female staff have been made in recent years under the Social Action Program, large gaps still remain intact. Excessive Centralization of Management The management of provincial/area government health services is very centralized in all of its phases, i.e. planning, implementation and monitoring. In this regard, most peripheral managers are ineffective. Moreover control of resources and real management decision making is far away from the delivery of services. Negative Staff Attitude and Absenteeism While difficult to document, there is a widespread impression in Pakistan that the attitude of government health staff towards the public is often negative and unfriendly. Along with this attitude problem, absenteeism is also acknowledged to be a significant problem. Political Interference Political interference with the management of government health services is widespread in the country. This results in demoralization of managers and distorts a range of decisions related to personnel recruitment, postings, transfers, disciplinary actions, reducing shedding excess or redundant staff and location of facilities.
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Lack of Openness Government health services have little interaction with community bodies, professional associations, NGOs and the private health services. The absence of meaningful interaction with these other segments of civil society weakens accountability and the impetus for reforms. Weak Human Resource Development Human resource development in the government health service has been deficient in its three dimensions: planning, production and personnel management. The planning of human resources has been incomplete and intermittent. Personal management has been largely limited to personnel actions including i.e. recruitment, promotions, transfers, etc. rather than the detriment of other functions such as setting performance standards and carrying out performance assessment against these standards. There is a lack of forward planning, career advancement and utilization of new technologies. Personnel management has also suffered from executive centralization and political interference. Insufficient Non-Salary Budgets The government health services have also suffered from insufficient budget allocations to fund current expenses other than staff salaries. This include expenses for drugs, diagnostics (laboratory tests, X-rays, etc.), repair and maintenance of facilities, replacement of equipment, utilities and in-service training expenses. At the same time government health services may be over staffed in certain categories, such as general medical officers and non-technical support staff. Under the Social Action Program, there were attempts to raise the proportion of the nonsalary budget to total current budget but the results were mixed.
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Factors Responsible for Poor Health The most important factors responsible for poor health as described by the World Bank in its Health Sector Strategy Note are the following; Poverty Poverty negatively affects health status through constraining the ability of household to purchase various health-related services and goods. Due to unprecedented inflation in the country the proportion of the population living under the poverty line is increasing rapidly. The poverty trends are so higher that now an alarming 60.2 per cent of the total population is earning less than 2 dollars a day. Moreover according to the World Bank report 33 per cent people of Pakistan are living under the poverty line (Bank, 2012). Lack of Awareness and Education Pakistan has lagged behind badly in terms of educating its population, particularly women. In this respect, lack of education results in poorly educated consumers of health services and as a result it constraints the adoption of key disease-prevention behavior. Pakistan is now making a major effort to upgrade the educational status of its population, especially women, under the Social Action Program. However a lot of serious actions are required at the end of government to make health conditions really better in the country. Low Status of Women In addition to their low levels of education, women in Pakistan are constrained in seeking health care for themselves and their children on account of their restricted mobility. In many rural areas, women are not permitted to leave the house or village and are subject to severe restrictions in their interactions with any males outside their immediate family and communities.
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In recent years, under the Social Action Program, the government has started to address this program through the development of community based health care services with female workers. Inadequate Sanitation and Water Supply The large burden of infectious diseases in Pakistan is closely related to lack of adequate sanitation facilities and safe resources of potable water for many households. It is estimated that only 55 per cent of rural households have access to safe water and about one fourth have sanitation facilities. Improving access to safe water and sanitation facilities is another area of focus under the Social Action Program. Poor Quality of Health Services Both government and private health services suffer from serious quality deficiencies. In this regard low allocation/expenditure of government for public sector health program makes it impossible to make improvements in the health services. Pakistan is spending only 0.27 per cent of its GDP on health which is among the lowest in the world, so it is next to impossible to give a better shape to the healthcare infrastructure of the country. Donor Driven Programs/Strategies Donors have ruined Pakistans health sector as they have advocated what was reflected in their beliefs but which was not consistent with the plans/policies of the country. Generally they have opposed the integration of vertical disease control programs for example, the integration of population program into the health sector. Current Health Related Issues Taliban Banned Polio Vaccination Taliban commander has banned polio vaccinations in North Waziristan in the tribal belt, days before 161,000 children were due to be vaccinated. He linked the ban to American drone
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strikes and fears that the CIA could use the polio campaign as cover for espionage, much as it did with Dr. Shakil Afridi, the Pakistani doctor who helped track Osama bin Laden. The commander, Hafiz Gul Bahadur, said that polio vaccinations would be banned until the CIA stopped its drone campaign, which has been largely focused on North Waziristan. Bahadur said the decision had been taken by the shura-e-mujahedeen, a council that unites the myriad jihadi factions in the area, including the Taliban, Al Qaeda and Punjabi extremists. According to a report in the New York Times, the announcement is a blow to polio vaccination efforts in Pakistan, which is one of just three countries where the disease is still endemic and which accounted for 198 new cases last year the highest rate in the world. The tribal belt, which has suffered decades of poverty and conflict, is the largest reservoir of the disease. A UNICEF spokesman said health workers had intended to target 161,000 children under the age of 5 in a vaccination drive scheduled to begin on June 20, 2012. That operation is now likely to be canceled. So far this year, Pakistan has recorded 22 new polio cases, compared with 52 in the same period last year. The Taliban announcement will also likely rekindle controversy surrounding Dr. Afridi, who was recently convicted by a tribal court and sentenced to 33 years in prison. In March and April 2011, Dr. Afridi ran a vaccination campaign in Abbottabad that was designed to covertly determine whether Bin Laden lived in a house in the city. Dr. Afridi failed to obtain a DNA sample, a senior American official said, but did help establish that Bin Ladens local protector, known as the courier, was inside the Bin Laden compound in Abbottabad. Dr. Afridi was arrested three weeks after American Navy SEALs raided the house on May 2, 2011, and killed the Al Qaeda leader. But the Abbottabad operation was not his only vaccination campaign. American officials say Dr. Afridi had been working with the C.I.A. for several years, at a time
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when he was leading polio vaccination efforts in Khyber Agency, a corner of the tribal belt that harbors a rare strain of the disease. Western aid workers have sharply criticized the C.I.A. for recruiting medical personnel and have complained of harsh restrictions on their work imposed by suspicious Pakistani authorities. American officials say Dr. Afridi was targeting a mutual enemy of Pakistan and the United States. The Taliban statement suggests that suspicion about health workers has spread to militant groups, which are prepared to use the issue for propaganda purposes (Polio vaccination efforts suffer blow after Taliban ban, 2012). Young Doctors and Paramedics Strikes in Punjab A number of new issues have emerged with the ongoing strikes by the medical personnel in the province of Punjab. The duty of people in medical profession is to serve, save lives and put the needs of the patients above themselves. How then can they ignore their duty and breach their oath by denying a bleeding patient treatment? A one-day strike alone causes thousands of patients to suffer, they are forced to go back home holding on to their stomachs and burning fever, the burden of which comes heavily on the poor class. Contrary to popular belief, Dr Izhar Ahmed Chaudhry, general secretary of Pakistan Medical Association highlights that the doctors strike is not a treachery against the people but rather the last avenue of frustrated doctors that have been denied the respect and economic standing that they have so rightfully earned after 18 long years of education. Doctors have to complete a five year MBBS and then complete a one year mandatory house job which gives them the license to become doctors. Dr Chaudhry says that doctors today really are the cream of the cream as out of 38000 applicants in the Punjab alone only 3000 MBBS and BBS students were enrolled in government
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medical colleges, and that the last merit position was at an astounding 82.6 percent. These doctors have filtered and passed through a rigorous system that qualifies them to become doctors. To then disregard their level of qualification and knowledge, and to put them at the same pay scale as government officials that have lesser qualification and lesser work hours is absurd and unacceptable to them. A doctor gets Rs 18,000 monthly pay during house job while salaries of drivers employed in the judiciary alone may go up to that level, says PMA secretary. The young doctors who are at the disposal of the patients 24/7 and in general have 80 working hours a week, which comes to 15 hours a day, demand a pay that is acceptable and enough for them to feed their families. Doctors have been swallowing the bitter pill of low pays but the increasing lack of respect on the part of the government has made the situation more unacceptable, says Dr Chaudhry. Dr Nasir Bokhari, the spokesperson for YDA Punjab recalls the YDA was created on the April 4 in 2008. It has gone on eleven strikes in the last four years. One of their demands has been of job security. Dr Bokhari explains that many doctors even after 30 years of service have no idea what the process of their promotions is. He says that the promotion of doctors takes place on a pick and choose basis and there is a dire need for a fair and transparent system. The promotion of juniors before seniors has agitated senior doctors that have then encouraged the younger doctors to protest. The Punjab Health Secretary, Arif Nadeem, however, claims the government has been addressing the needs of doctors who do have a proper four tier service structure with its ratios for doctors of every grade. Over the past few years the government has inducted 400 new doctors, teachers and specialists in the primary and secondary care levels and has also regularised all doctors that were on contract, he says.
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Again Dr Bokhari of YDA points out that the regularisation of doctors only took place in March 2009 after a strike of the doctors against the government policy that doctor be employed on a contractual basis allowing for MS to dismiss and terminate doctors without inquiry. It was also after the doctors 4-5 day strike in 2009 that 20 per cent of the doctors that were working without pay in the Punjab were catered to, and still 500 doctors are working without pay in the Punjab. The health secretary claims the government is trying its level best to increase the number of promotions and has given more promotions in the last six months than ever before. He points out that Pakistan has heavily subsidised its medical education, and spends 4 to 5 billion on medical colleges alone, while everywhere else in the world medical students are burdened with heavy tuition fees. Given that the countrys growth rate is 2 to 3 per cent and that the government spends about 700 billion rupees mainly on the salaries of government officials and running costs, it is nearly impossible for the government to further increase salaries, especially those of house doctors that have had their pay increased to Rs18,000 and that of post graduate registrars (PGRs) to Rs42,500, which is 30 to 40 per cent more than what an equally capable engineer gets in the country. The government has spent a total of 5.5 billion in raising the salaries of the doctors alone, he says. Dr Bokhari points out that the pay increase has only applied to the 6500 house officers and PGRs and not for the remaining 17,000 medical officers and doctors that have a pay ranging from 10 to 15,000. A senior YDA member says the government is quick to change its calculations and that its recent bid to build hospitals in areas like Bahawalpur shows that there is no shortage of funds, but it is only a matter of priority. The Health Secretary Arif Nadeem says that the government, at present, is more inclined to developing new infrastructure and hospitals so that the investment may both boost the
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economy and provide better healthcare. Secretary Nadeem urged that the doctors should resort to avenues other than strikes. He proposes that the media and judiciary are avenues that could help resolve the doctors problems. He urges that doctors should look at their problems in a broader context and not isolate themselves from the civil society (Rahman, 2012). There is no doubt that the medical professionals and staff have valid demands but at the same time they have to realize the sensitivity of their jobs. Their apathy towards the needy patients is not only against the spirit of their profession rather it is inhumane thing to penalize an innocent group for the fulfillment of their demands. In order to achieve their demands they can adopt other ways of protest in which no harm to the needy patients. However talk tables always have a solution for such complex issues. Therefore medical professionals and the government should settle the issue with negotiations in order to facilitate general public of the province. Suggestions to Improve Health Conditions in Pakistan The healthcare conditions in Pakistan are so devastating that there is no other way to escape from it except to take concrete measures to address the basic problems present in the existing healthcare system. In this regard, there are following few suggestions to improve the health conditions of the country; Paradigm shift: from providing health care to producing health In order to improve health conditions, Pakistan needs a drastic change in its basic approach to healthcare. The healthcare needs a paradigm shift from providing healthcare to producing health. Pakistan, like many other countries, has traditionally emphasized the provision of health care services. Consequently, the focus is on curative care, both at the tertiary level and at the domain of primary health care. Not surprisingly, according to some estimates, Pakistan spends 85 percent of its health care budget on tertiary health care that is used by about 15 percent
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of the population. On the other hand, only 15 percent of the health care budget is spent on primary health care services that are used by 85 percent of the population (World Bank. Pakistan - towards a health sector strategy, 1997). Most of the primary health care funds are also earmarked for the provision of curative care through beds at the Rural Health Centers and/or Tehsil Headquarter Hospitals. Illness prevention and/or health promotion services, such as, antenatal care, immunization, and health education receive scant attention or funds. In short, the focus is on the provision of health care services. Since 1970s, there is a growing recognition that a signification proportion of disease and illness that afflicts us is a consequence of conscious behavioral choices that we make. The Lalonde Report in Canada, published in early 1970s, is perhaps the best example of a public study that eloquently emphasized this point. The Report, therefore, advocated shifting of resources from curative care to health promotion (Lalonde, 1974). Smoking and drug use, for example, are conscious behavioral choices that have serious health consequences. Likewise, from obesity to cardiovascular diseases and diabetes - a number of health problems could be traced back to lack of physical exercise. Physical exercise, needless to say, is a behavior over which we have or could have complete control. Personal hygiene, to a great extent, is also a product of our behavioral choice. A health care system, to be efficient and effective, must place significant emphasis on influencing and positively changing these individual behavioral choices. At the same time, emphasis must be placed on the provision of sanitation, safe drinking water, and healthy environment. These two sets of factors, behavioral changes and safer environment, create a foundation for better health. In other words, the health sector in Pakistan is in need of a fundamental paradigm shift - from the provision of health care services to producing health.
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Regionalization of Health Care Services A health care system must be sustainable financially and organizationally within a geographically specified region. It also must encompass a spectrum of services that meets the essential health care needs of the population. In short, with an emphasis on primary health care, the system must include appropriate secondary and tertiary levels of care. While the province must retain the overall responsibility for health services to its people, it should establish regions to decentralize the health care system. A region may consist of a number of districts with a population large enough to sustain an integrated health care system. A region shall contain a spectrum of health services, programs and facilities that are symbiotically and functionally related to form a rather independent system. Given the fact that the existing districts in Pakistan were created by the British colonial power as administrative units, they are unlikely to serve as regions as conceived here. While the province would provide the broad policy guidelines, independent health boards should be responsible for the provision and management of health services within the regions. Initially, the provincial government could form the Regional Health Boards, composed of community leaders as well as professionals. In the long run, the people could democratically elect the members of these boards. Through legislation, the composition of the regional boards could be regulated to ensure representation from different segments of the population. The creation of regions with a relatively large population base would make it possible to develop a sustainable integrated health care system encompassing the entire spectrum of services. On the other hand, the creation of regional health boards would make the health care system independent of the government and bureaucratic inefficiency. While the regional health boards would receive public funds (from the provincial and federal governments) on the basis of a
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composite population-based formula, they should have the freedom, within broad policy guidelines, to generate new resources for health care, including user fees. Regions could also introduce appropriate social insurance schemes. While Canada (most provinces) and most of the Western European countries provide examples of successful regionalization of health care services, a large number of developing countries in Asia, Africa, and Latin America are also moving in this direction through a process of decentralization (Health Sector Reform in Asia and the Pacific: Options for Developing Countries, 1999). Elimination of Structural Fragmentation The public health care system in Pakistan currently suffers from serious structural ambiguity. For example, while provision of health care is primarily a provincial responsibility, the federal Ministry of Health administers the National Program on Family Planning and Primary Health Care. At the district level, the District Health Officer (DHO) represents the provincial government and provides leadership to the publicly funded healthcare system. On the other hand, a separate federal officer, the District Coordinator, looks after the National Program. The National Program, it should be emphasized, provides vital primary health care and family planning services at the village level Lady Health Workers (LHW). In other words, the DHO enjoys no control over the provision of primary health care and family planning services. This structural fragmentation makes it difficult to coordinate health care services at the district level. It also frustrates the development of an integrated referral system encompassing all levels of service. This structural fragmentation needs to be eliminated. A single office at the district level should exercise direct supervisory control over all types of primary health care and family planning services. Within the framework of the existing system, such a controlling office must be
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part of the provincial bureaucracy. Pakistan must also address this structural fragmentation and bring all health care services under the supervision of the DHO who is part of the provincial bureaucratic setup. Establishing Functional Specificity Functional specificity of different service providers backed by an integrated and effective referral system is essential for system efficiency. For example, a hospital should provide secondary level care; it should not become a center for primary health care services. Quite often, due to the inefficiency or inaccessibility of other elements of the health care system, people use the hospital for primary health care services. Lack of an effective referral system could also lead to such use (rather misuse) of different elements of the health care system. Such use, on the one hand, promotes inefficiency and, on the other, hinders the maturity of the underutilized part of the system. In Pakistan, Basic Health Units (BHU) and Rural Health Clinics (RHC) are designed to provide a comprehensive array of primary health care services, including health protection and promotion services. The National Health Policy as well as other official proclamations emphasized the centrality of BHU and RHC in the provision of primary health care services throughout the country (Pakistan National Health Policy, 2009). However, as the World Banks and other reports indicate, BHUs and RHCs remain underutilized (Family health project assessment report , 2010), while people line up in secondary hospitals for basic primary health care services (these are also underutilized). Pakistan must make a concerted effort to improve the basic institutions for primary health care services. Appropriate (and adequate) human resources with a gender balance are perhaps the most important issue that needs to be addressed. Available facilities must also reflect the
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expressed health care needs of the population at large. Similarly, services and facilities at the secondary level hospitals (Tehsil Headquarter and District Headquarter Hospitals - THQs and DHQs) must also be improved so that they can perform their specific functions effectively. Restoring functional specificity to different levels of the health care system, therefore, should be part of the health sector reform strategy in Pakistan. Public-Private Partnership The private health care sector in Pakistan is composed of physician-practitioners, maternity homes, dispensaries, diagnostic laboratories, and for-profit hospitals (usually of small size). There are also some large tertiary hospitals in the private sector, concentrated mostly in big cities. Numerous non-government organizations, funded through philanthropy or donor agencies, also provide various types of health care services. Pharmacies or other outlets selling drugs overthe-counter also form part of the private sector. The private sector in Pakistan is largely unregulated in terms of standards of practice and quality of service. Most dangerous is perhaps the lack of regulations governing the qualifications of physicians that made it possible for anyone with rudimentary knowledge on medicine (working as an assistant in a clinic for a few years, for example) to practice medicine. Another serious problem is the lack of regulations governing over-the-counter sell of drugs. Any credible health sector reform must address these fundamental issues. Regulations and their strict enforcement are required. Similarly, there is a need to renew the legal framework guiding the traditional systems of medicine (primarily, the Unani system). In Pakistan, little attempt has ever been made to introduce social insurance for health care. Social insurance is limited to employees of the government, semiautonomous organizations, and members of the armed forces. There is no social insurance scheme in which
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people at large can participate. The amount of out-of-pocket money being spent on health clearly indicates that there is a strong possibility of successfully introducing social insurance in Pakistan. It will require a strong partnership with the private sector. In this respect, Pakistan, as part of its health sector reform strategy, should introduce a Health Card scheme that covers essential primary health care services and secondary level hospital care. The private sector, especially NGOs could play a leading role in this regard. The Regional Health Boards, suggested earlier, could also manage such a voluntary insurance scheme. Healthy Public Policy Usually health is defined narrowly and, consequently, health related policies and programs are assumed to be the exclusive domain of the Ministry of Health. In recent decades, scholars have emphasized the inter-sectoral nature of health and the need for healthy public policies. It has been pointed out that policies in agriculture (e.g. on the use of fertilizers or pesticides), or in transportation (e.g. on the use of seat belt), or in housing, education, or industry have significant implications for human health. All policies, therefore, must take into account their impact on human health. Accountability for health, thus, is a prerequisite for any public policy across all sectors. In short, the goal is not simply policies for health, but for healthy public policy. Healthy public policy is the policy challenge set by a new vision of public health. It refers to policy decisions in any sector or level of government that are characterized by an explicit concern for health and an accountability for health impact (Second Conference on Health Promotion, 1986). Pakistan is yet to adopt such a holistic approach to health and healthy public policy. However, such an approach must be part of the overall health sector reform strategy. All departments at different levels of government must coordinate their policies in the context of
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their potential impact on human health. An explicit concern for health and accountability for health impact must become the essential foundation for all public policies in Pakistan. An interdepartmental committee could be formed for this purpose. It would be the task of the interdepartmental committee to review and assess public policies prior to their implementation. Promoting Gender Equity in the Health Care System The strong patriarchal nature of the Pakistani society is reflected in the womens health status. Womens health status in Pakistan is arguably worse than that of men. It has one of the highest maternal mortality rate among the countries with a similar per capital income. More women suffer from malnutrition than men do. Female literacy rate in Pakistan is one of the lowest in the world, showing a disastrously 16 per cent in most of Baluchistan - the most underdeveloped province in the country (Multiple Indicator Cluster Survey Balochistan 2009-10, 2010). Violence against women, along with the practice of honor killing is widespread. The health care system in Pakistan has so far failed to effectively address these problems. In short, the gender bias of the health care system is painfully evident. Few managers or health policy makers are women; and appropriate and adequate services for women are painfully absent. Women have little participation in the decision making process involving the health care system. The low socioeconomic status of women and the overall conservative feudal character of the broader society reinforce the gender bias of the health care system. No health sector reform in Pakistan would succeed without addressing this critical gender bias of the system. A four-pronged approach needs to be adopted to effectively address this critical issue. First, concerted efforts should be made to recruit more women managers, administrators, and policy makers. A target should be set to have women occupy at least 40 per cent of the top positions within the health care system in the next ten years and reaching parity by the year 2025.
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Second, appropriate facilities and professional staff should be made available in all health centers. Priority should be placed on having emergency obstetric services available in all Rural Health Centers. Third, the two WHO/World Bank/UNDP developed training tools should be adopted to make all levels of health care providers sensitive to womens issues, on the one hand, and on the other, making women aware of their health needs and rights so that they could actively participate at the grass root level in articulating their demands. The two tools are the Health Workers for Change, and the Healthy Women Counseling Guide (Health Workers for Change; and Healthy Women Counseling Guide, 1995). All professional, paramedic and frontline staff working within the health sector must undergo training using the tool Health Workers for Change. This will make them and the healthcare system more sensitive to womens health issues, and improve the client-service provider relationship. This tool is geared towards making the service providers better understand the inherent gender bias of the system and in making them respect and appropriately respond to womens health needs. The Healthy Women Counseling Guide is an excellent tool that can be used to train underprivileged women better understand their health care needs and articulate them in order to demand better services from the healthcare system. Training in this tool raises the awareness of women and helps them participate in decisions affecting their lives. In other words, while the former tool makes the service providers better understand womens health needs, the latter makes women better articulate their demands and participate in the decision-making process. These two tools, in short, would engender the health care system in Pakistan. Massive training using these tools should be an essential part of any health sector reform effort. Lastly, Pakistan must abolish all laws patently discriminatory to women and start strictly enforcing laws that could protect women against violence.
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Good Governance, Freedom and Development No reform strategy could avoid the issue of good governance, which is perhaps, the biggest challenge facing Pakistan. Good governance is at the core of development and permeates all sectors of the social, economic, and political system. It involves, on the one hand, creating a system of governance that is efficient, transparent, and accountable, and on the other, democratic, giving people the freedom to participate in the political process. Transparency and accountability are essential ingredients of good governance as they are instrumental in preventing corruption - the anathema to good governance. Good governance, as the World Bank has emphasized, is central to sustainable and equitable development (Governance and Development, 1992). Defining corruption as the abuse of public office for private gain, the World Bank also emphasized the critical need to create a corruption free society so as to ensure development (Helping countries combat corruption: The Role of the World Bank, 1997). Pakistan, historically speaking, failed to eliminate corruption or to introduce good governance. Corruption, for example, had been the root cause of failure and fall of successive governments in Pakistan since late 1960s. However, their removal did not end corruption or created conditions for good governance. Corruption and poor governance continue to take a heavy toll. The states failure in all areas associated with good governance, sometime spectacularly, is at the heart of Pakistans continued dismal record in terms of key development indicators across all sectors education, social services, health, economic growth, and political freedom (Burki, 1999) (Haq, 1999). Pakistanis require political freedoms, economic facilities, social opportunities, transparency guarantees, and protective security to break this cycle of corruption and underdevelopment. Political freedoms include the right to determine who should govern and on what principles, freedom of the press, and freedom of association, and of expressing dissent.
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Economic facilities refer to the opportunities that individuals respectively enjoy to utilize economic resources for the purpose of consumption, or production, or exchange. Social Opportunities refer to the arrangements that society makes for education, health care, and so on, which influence the individuals substantive freedom to live better. Transparency guarantees deal with the need for openness that people can expect: the freedom to deal with one another under guarantees of disclosure and lucidity. Transparency is instrumental in preventing corruption, financial irresponsibility and underhand dealings. Protective security refers to the social safety net provided by the society that prevents the affected population from being reduced to abject misery, and in some cases even starvation and death. The domain of protective security includes fixed institutional arrangements such as unemployment benefits and statutory income supplements to the indigent as well as ad hoc arrangements such as famine relief or emergency public employment to generate income for destitute (Sen, 1999). Unadulterated democracy coupled with a credible investment in the social sector - in education, health, and the environment - are essential steps that Pakistan must follow. While democracy would provide the freedom of participation in the decision-making processes for the people at large, access to basic education and health care would provide them with the capability to participate in the economy as productive members of the society. In the context of Pakistan, human capability expansion would also mean the abolishment of all forms of bonded labor, along with societal guarantees of access to basic education and health care. In a comprehensive sense, good governance must incorporate these fundamental elements. Health sector reform or any other reform would fail to realize its full potential without a commitment to, and concrete actions toward, ensuring freedoms to citizens in all aspects. In this respect, Pakistan must rise to this challenge.
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Report On Health Conditions of Pakistan

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Report On Health Conditions of Pakistan

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HEALTH CONDITIONS OF PAKISTAN