health dept

8/3/2019 Health Dept

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L.S.M.F stands for Licentiate of State Medical Faculty, R.M.P stands for Registered Medical Practitioner,

Health dept. govt of Punjab

http://pportal.punjab.gov.pk/portal/portal/media-

type/html/group/348?page_name=348home&group_type=dept&group_id=348&group_name

=Health&js_pane=P-1004ba76975-10000&pview=true

Outline ofHEALTH CARE SYSTEM IN PAKISTAN

1. Introduction to health care system2. Ministry of health3. Health care structure4. Public health system5. Access to health sector6. Current issues and initiative7. Policies regarding health care system(health care spending and govt exp in pak)8. Strategies to support health system9. Health sector corruption10.Conclusion and recommendation


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INTRODUCTION TO HEALTH CARE SYSTEM

Health care in Pakistan is administered by Ministry of Health. Like other South Asian countries,

health and sanitation infrastructure is adequate in urban areas but is generally poor in rural areas

Brief History of the Health Care System

Pakistan at the time of its independence in 1947 inherited a health care delivery system that

was a legacy of colonial British period. This rudimentary system was in the shape of public

health services and some curative services. It was essentially designed to prevent large scale

epidemics and provide curative services for the population in large and medium sized towns,

many of which were along the lines of communication or political or strategic consequences

During initial phase (1947-1955), most important initial problem was the replenishment of

staff. In addition to other programs, BCG vaccination campaign was launched with the

support of UNICEF and two medical schools were opened in the West Pakistan. From 1955

onwards, developmental activities were affected in phases of five year and each phase was

known as Five Year Plan.

During Five Year Plan (1955-1960)

Six new medical colleges, including one for women were opened in both wings. A nursing

school was attached to each of these medical schools. Postgraduate institutions were

established. A bureau was established to produce vaccines and sera.

During five year plan (1960-1965), under the recommendations of a Medical Reform

Commission, Rural Health Center scheme to cover 50000 populations by each unit, two

Health Technicians Training Institutes were opened, family planning program, and a malaria

eradication program were launched.

Five year plan (1965-1970)

In addition to continuation of the aforementioned initiatives, witnessed launching of

Tuberculosis Control Program and Small pox eradication programs. The major infrastructure
http://en.wikipedia.org/wiki/Pakistanhttp://en.wikipedia.org/wiki/Ministry_of_Health_%28Pakistan%29http://en.wikipedia.org/wiki/South_Asiahttp://en.wikipedia.org/wiki/South_Asiahttp://en.wikipedia.org/wiki/Ministry_of_Health_%28Pakistan%29http://en.wikipedia.org/wiki/Pakistan


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of the public health care system was set up in the 1970s. Pakistan endorsed the "health for all

by 2000" initiative which had been launched by the World Health Organization. Government

launched an extensive infrastructure and policy building initiative. From the villages to the

cities different levels of health care were started like the "Basic health units" for the villages.

The Tehsil headquarter hospital represented secondary health care, and district hospitals and

teaching and referral units represented tertiary care units. Along with this a significant public

health campaign was launched for the first time, keeping in view local needs and WHO

guidelines to meet the target. These were: An expanded program of immunization to

eradicate the prevalent infectious diseases; Malaria control program; Tuberculosis control

program; Family planning program; Diarrhea and pneumonia control programs; and many

others. To monitor all these and to achieve further improvements and make sure the policy

was being applied the national institute of health was created.

During fourth five year plan (1970-1975),

Quota of medicines was substantially increased for major hospitals, a generic name drug

system was introduced to bring down the prices of medicines, eight state-owned fair price

drug shops were opened, six new medical colleges and three new nursing schools, and one

public health school were opened.

The fifth five-year plan (1978-1983) was scheduled for 1975-1980,

But to cover the deficiencies and to make a more realistic plan, the slight shift was made.

Under a process of a Country Health Program (CHP), that aimed at improving planning and

management of health services. Under CHP it was recommended that rural health coverage

be increased at least to 50%, in addition to others, striking the communicable diseases,

combating malnutrition, food adulteration and industrial hygiene were highlighted. During

Sixth five-year plan (1983-1988), government launched extensive rural development

program that provided sound base for Health for all by the year 2000.

Seventh five year plan (1988-1993): Alma Ata declaration of 1978 remained the basis of

all five years plan afterwards. During seventh five-year plan, new health facilities (Basic

Health Units and Rural Health Centers) were established, a female


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Medical technician school was established, and health facilities were provided with

Laboratory facilities. Health facilities were linked with semi-skilled, trained paramedics

termed as community health workers. Third health project was launched aiming at improving

MCH services. Second Family Health Project was started to improve the health of masses in

general and that of women in particular. Minimization of drug abuse, establishment of

national school health services and goiter control were other salient initiatives under this

plan.

In Eighth five year plan (1993-1998), Health management information system (HMIS),

Social action program (SAP), and Prime Minister Program for Family Planning and Primary

Health Care were launched

During Ninth five year plan (1998-2003)

Decentralized Planning, levying user charges for financing, public private partnership and

privatization of health facilities were the areas of programming. The strategy of the plan was

to consider the gains already achieved in the previous plan and to improve the quality of

service by creating a balance of promotive, preventive and curative services and removal of

management weaknesses of the health system.

In 2003-2008 programs the government has aimed to bring about Programmatic and

Organizational and Management Reforms. These are to foster alleviation of poverty agenda

of government, under health sector reforms, devolution has acquired immediate importance

and major impetus is on district health system. At federal level a policy analysis and reform

unit is being established. The new Health Policy 2001 considers health sector investment as

a part of governments Poverty Alleviation Plan. It gives more importance to primary and

secondary health services as opposed to tertiary level health services in the past. Good

governance is seen as a basis of health sector reform to achieve quality health care.


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http://en.wikipedia.org/wiki/Ministry_of_Health_%28Pakistan%29

Ministry of Health: (final)

The Ministry of Health of Pakistan is a government agency responsible for Pakistan's

health system. It is a branch of the Government that is the department for provision of

medical services, responsible to frame the health policies and to enforce the same at a

national level. It is headed by the Health Minister of Pakistan on democratic level. At

bureaucracy level, Federal Secretary (Health) is in-charge who is assisted by Director

General (Health), Chie f (Health), two Joint Secretaries, one looks after finance and

development and the other deals with administration.

Besides the federal health department, each of the four provinces of Pakistan has its

respective health department and Secretariat, under the supervision of a health minister of

that province, controlled by a Secretary, Additional Secretaries, Deputy Secretaries, and a

Director General Health Services, assisted by Director and Deputy Directors. All stand

responsible to control, manage, administer medical service matters to the citizenry of their

jurisdiction and frame and enforce health policies in their respective provinces in line with

that promulgated by the federal health department.

Function of Ministry of Health: (final)

As per Rules of Business, functions of the Ministry of Health are:

National Planning and Coordination in the field of health. Dealings and agreements with other countries and international organizations in the fields

of health, drugs and medicines.

International aspects of medical facilities and public health; International Health andmedical facilities abroad.

Scholarships / fellowships, training courses in health from International Health Agenciessuch as WHO and UNICEF.

Medical, nursing, dental, pharmaceutical and allied subjects: - Maintenance of educational standards.


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Education abroad; and Educational facilities for backward areas and for foreign nationals, except

the nomination of candidates from Federal Administered Tribal Areas for

admission to Medical Colleges.

Standardization and manufacture of biological and pharmaceutical products Vital Health Statistics. Medical and health services for Federal Government employees. National associations in medical and allied fields such as the Red Crescent Society and

T.B Association.

Coordinating medical arrangements and health delivery systems for the Afghan refugees.

Legislation pertaining to drugs and medicines, including narcotics and psychotropic, butexcluding functions assigned to the Pakistan Narcotics Control Board

Administration of Drugs Act.1976 and Poison and dangerous drugs Prevention of the extension from one province to another of infectious and contagious

diseases.

Lunacy and mental deficiency. Administrative control of the Pakistan Medical Research Council, (PMRC), Islamabad. Administrative Control of the National Institute of Handicapped (NIHD), Islamabad.


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Summary

No. of Districts 36

No. of RHCs (in Punjab) 289Tehsil Head Quarters - THQs (Punjab)

Summary

No. of Districts 36

No. of THQs (in Punjab) 80

District Head Quarters - DHQs (Punjab)

Summary

No. of DHQs (in Punjab) 35


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1. Public Health SystemUnder the Pakistani constitution, health is primarily the responsibility of provincial governments,

except in the federally administered territories. The Federal Government is however, responsible

or planning and formulating national health policies, although the responsibility for

implementation rests largely with the provincial governments. The federal Ministry of Health is

responsible for the implementation of some vertical programs on AIDS and malaria, and

extended program of vaccination. Health care provision in Pakistan comprises private and public

services. The private sector serves nearly 70% of the population, is primarily a fee for service

system and covers the range of health care provision from trained allopathic physicians. Neither

private, nor non government sectors work within a regulatory framework and very little

information is available regarding the extent of human, physical, and financial resources

involved.

The public sector comprises more than 10,000 health facilities ranging from Basic Health

Units (BHUs) to tertiary referral canters. At present a BHU covers around 12,000 people Where

as the larger Rural Health Centers (RHCs) cover around 30000-450000 people. In Pakistan,

Primary Health Care (PHC) units comprise both BHUs and RHCs. The Tehsil Headquarters

Hospital covers the population at sub district level whereas the District Headquarters Hospital

serves a district as its name suggests. Currently there are 22 tertiary care facilities in Pakistan,

which are mostly teaching institutions located in the major cities. Less than 30 % of the

population uses the facilities of the PHC units and some studies indicate that, on average, each

person visits a PHC facility less than once a year.

The reasons for their under utilization, are the relative lack of health care professionals and

specially women, high rates of absenteeism, poor quality of services and inconvenient location of

PHC Units. In addition, The Pakistan Army, railways, departments of local government and

autonomous organizations provide healthcare to their employees, who form a significant portion

of the population. Planning for health care in Pakistan comprises a formal planning, whichresolves around the production of 5-15 year long term plans, short-term plans (ADP).

The Federal Ministry of Planning and Development, popularly known as Planning Commission,

is primarily responsible for long term and strategic planning, and the Ministry of Health and

Provincial Health Departments design their plans in line with the overall policies of the Planning

Commission. Developing appropriate plans that can be implemented requires information on


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health status in conjunction with other social development indicators. Needs assessment for

health care programs in Pakistan is usually based on the size of the population in an area. The

specific needs of that area are often not taken into account directly, nor other issues such as

access to services and disease pattern. Where as the private sector is primarily a fee-for-service

system. The public health sector at present generates a negligible amount of resources through

token user charges. The main source of financing of the public sector is the government. Capital

investment in the public sector is financed through Annual Development Plans (ADPs) that also

include external funding derived from foreign aid (overseas funding) from both bilateral and

multilateral organizations. Federal government substantially finances provincial development

budgets, but the provinces make independent regarding allocation of funds over various sectors.

The provincial non Development budgets are funded from provincial government revenues,

although the Federal Government covers existing deficits through non obligatory grants.

Although public sector expenditure on health has remained less than 1% of GNP for a long time,

per capita health expenditures have increased enormously in last decades.


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Access to Health Care Services

In Pakistan, as of 2009-10, the child health care trend shows that 100 children out of every

thousand die before reaching their fifth birthday and 73 infants out of every thousand die before

their first birthday. Figure 1 presents the trends in achieving the child health care targets under

MDGs. It is clear from the graph that there is a desired need to invest in the child care health to

achieve the MDG targets by 2015

.

Thehuman capitalavailable for health care services in Pakistan has gradually improved over the

period of time. There are 163026 doctors and 25633 specialists, registered with the Pakistan

Medical and Dental Council (PMDC). In addition, 10518 general practitioners and 751specialists

registered as dental surgeons .Though there is annual output of around 5,000 medical graduates

from both private and public medical colleges, the current ratio of one doctor per 1222 persons.

According to the WHO international standards, the ratio of doctors to nurses should be 1:3;

however this is reversed in the case of Pakistan, i.e., ratio of doctors to nurses is 3:1 in Pakistan.

Indeed the government of Pakistan is committed to train and provide door-step health care

services through Lady Health Worker (LHW) program however this would only help the poor

and disadvantaged areas in the provision of first aid / primary health care and not the secondary

and/or tertiary health care.


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In the provision of health care services the private sector plays an important role, i.e., private

sector provides almost 80 percent of the outpatient services. According to the PSLM (Pakistan

social and living standard measurement) (2009-10), as many as, 77 percent households consult

the private sector against only 23 percent to the public sector.

These private sector consultants include: private clinics/hospitals, chemist/ medical stores, and/or

pharmaceutical industry are the main service providers in the private sector. Moreover, a large

number of persons consult homeopathic and tabbibs.

Current Issues and Initiatives

Social and economic determinants of health

Macroeconomic situation. The poverty level in Pakistan increased from 26.1 percent in 1996-97

to 39.1 percent in 2009-10. Due to stringent macroeconomic adjustments, better financial and

budget management, remittance from abroad and sustained growth, the macroeconomic situation

of the country has improved since the end of the 90s. The improved level of foreign reserves

along with the increased commitment of donor has increased the fiscal space for the provision of

necessary social investments and for vital infrastructures. The increased fiscal space has led to

some increase in overall expenditure on health but continues to be less than that projected in the

Poverty Reduction Strategy Paper (PRSP).

Social sectors.The population growth is estimated at 3.6% per annum and poses a challenge to

the government to create jobs and to provide health and education services. Pakistan ranks 134 in

the 2009 UNDP HDI (Human Development Index) and most of its social and development

indicators compare poorly with countries of similar level of economic development. UNDP

estimates that in 2004 around 90% of the population had access to improved water sources and

almost 60% had sustainable access to improved sanitation facilities. The latter is a substantial

improvement from 37% in 1990.

Health System Governance

There is an increasing commitment to health development in Pakistan, which is also reflected in

increased amount of resources allocated to the development budget for health at the federal and

provincial levels.In addition, health is considered a priority in the Vision 2030 of the government

for which work has been initiated in the Planning Commission.


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Health system reforms are concurrently being undertaken in the two provinces visited by the

mission. In NWFP, the reforms range from financing of the health sector, contracting out and

improving the quality of health services, and developing a policy on human resource. The reform

process is assisted by the World Bank with technical assistance from the German Agency for

Technical Cooperation and DFID (department for international development).

In Punjab, the reform process is focusing on improving primary health care services by providing

financial incentives and improving salaries of health professionals, creation of positions for

midwives and lady health workers at BHU levels, provision of medicines and continuous

professional development. There is however lack of coordination among the provinces in the

reform process and the federal government has so far not fulfilled its coordination function.

A national health policy unit was established in the federal MOH in 2004 with the technical

assistance of W.H.O and financial support of DFID. The unit is in early phase of development.

Its role within MOH organizational structure needs to be institutionalized and its capacity both in

terms of human and financial resources needs to be strengthened for it to deliver on its mandated

role of furnishing evidence for the much needed health policy and system reforms in the country.

Despite the many constraints, the NHPU was able to constitute a National Health Policy Council,

contribute to the health sector reform agenda for the Pakistan Development Forum 2006, and is

now playing a more proactive role in the formulation of the new national health policy. In

addition, it relationship with provincial DOHs and their health planning and reforms unit needs

to be strengthened. The recruitment of staff in recent months provides some hope but there are

concerns that the project might expire on June 30, 2007 unless the new PC-1 of the NHPU is

approved and funded by government or another development partner.(flash check)

The process of development of the new national health policy has been led by the Pakistan

Health Policy Forum, an NGO-led forum, which brings together the Government, development

partners, and civil society through a consultative process with the provinces and other

stakeholders. Based on discussion with the coordinator of the Forum, it seems that the new

policy has followed a balanced approach to the importance of health systems and programs. It is

critical that the NHPU MOH plays an increasing role in the formulation of the national health

policy as this has indeed to be a government led process. There are indications that the Policy

Unit and the Forum are collaborating and there will be a smooth handing over of the policy

document before it is finalized and announced by the federal MOH.


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Another important initiative is the establishment of a high level National

Commission for Government Reform, which has a sub-committee on health. The committee is

considering several reform initiatives in health that focus on good governance to improve the

quality of essential health services. These reforms are essential and needed to bring rapid

improvements in health services at the point of delivery. At the same time there is a need to

review and reform the organization and functioning of the federal MOH, provincial DOH and

district health offices to address some of the underlying governance issues that are responsible

for the poor health services in the public and the private sector. In this regard essential functions

such as institutional mechanisms for strategic health planning, regulation and standard setting,

health information and its use, and disease surveillance need to be strengthened at all level of the

public health sector.

Several bilateral donors led by the DFID and USAID and multilateral development agencies are

active in the health sector in Pakistan. There is a forum of donors in which all big and small

international health development agencies discuss health issues. However, there is a gap in their

shared understanding of the health system issues in Pakistan and there is a lack of collective

dialogue with the federal and provincial governments on these issues. In recent years there have

been increasing opportunities for a dialogue between the government and its development

partners, however, it needs to be better informed by evidence and be well coordinated. The

government has established a policy coordinating committee with its development partners,

which can play an active role in evolving a unified response to health system development in the

country. WHO can play a catalytic role in helping the government to make this committee more

active in accordance with the Paris agenda on aid effectiveness, as well as, in increasing its

technical capacity to engage in a Dialogue on health system development?

Human Resource Development

There is a lack of clear long-term vision for human resource development and the federal MOH

or provincial DOH does not have a unit, responsible for such an important health system

function. The imbalances in health workforce in terms of cadre, gender and distribution are well

known in Pakistan. The public sector continues to heavily invest its scarce resources in the

development of medical colleges and universities rather than investing in improving quality and

quantity of nursing institutions, public health schools and technicians training institutions.


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Although there is a growing interest to address the identified shortcomings in human resources

including scarcity of nurses, midwives, skilled birth attendants, dentists and pharmacists; future

scenarios for tackling the misdistribution of health professionals and the imbalances in skill mix

across the country have not been developed.

A new national program for the training of community midwives, with considerable resources set

aside for it, has recently been launched to tackle the shortages of personnel in this cadre. In

addition, there have been recent attempts to establish new community midwifery schools and

new nursing schools in some districts and provinces. Some academic institutions are also

providing post graduate training in nursing in order to mitigate the crisis in nursing generated by

limited production and external brain drain.

In the context of health system development, there is a serious shortage of qualified health

system specialists such as health and human resource planners, health economists, health

information experts and health system and hospital managers.

The capacity to train such expertise is limited to non-existent in the country, and there are very

few competitive positions to recruit them in the federal MOH, provincial DOH and district health

offices.

Pre-service training of health professionals follows traditional methods and there is a mismatch

between educational objectives, which focus on hospital based care, instead of addressing the

needs of the communities for promotive, preventive curative and rehabilitative services. Some

attempts to introduce innovative approaches including COME (community oriented medical

education) in medical schools have not been successful for a variety of institutional and

professional reasons such as the lack of involvement of the PM&DC from the beginning, weak

department of public health in medical schools and poor commitment of government and heads

of medical institutions .

The regulatory systems are either weak (for licensing) or non existent (accreditation). The

Pakistan Medical and Dental Council (PM&DC) is responsible for registration, licensing and

evaluation of the medical and dental practitioners, curriculum review, evaluation and approval of

educational institutions in these two categories, and many other regulatory activities. Although

the membership of the council is broad covering most professions and including 52 members

from almost all stakeholders, its coordination capacity to streamline the new policies and

practices and to provide valid evidence on different aspects of human resources production


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seems to be weak. PM&DC has recently been through a period of turmoil and its independent

role has been questioned by the Ministry of Health. How well the PM&DC fulfills its roles and

functions in the new situation is uncertain.

There is a lack of organized continuous professional development (CPD) and there is no

obligation for the health professionals to update their competencies. The attempts made by

PM&DC have not materialized yet. The institutions for health professions education (medical

and nursing schools) lack public health and community orientation in their programs. Graduates,

unlike lady health workers, are not well prepared to practice in a PHC environment while these

needs are most important.

Regulation of private practitioners and different traditional categories of medical practice such as

homeopathic doctors and Yunani Hakims is non-existent. Data on various categories of

professionals are scarce and fragmented. Such situation is affected by the fact that registration is

not updated and in some cases professionals are practicing without being registered. Pakistan is

nevertheless endowed with important training and research institutions and highly qualified

professionals who can contribute in the design and implementation of a well articulated policy

and strategies for human resource development.

Health Care Financing

Estimates by W.H.O and other international development agencies show that the health system

in Pakistan is clearly under funded. Total spending on health as a share of GDP is about 2.4 %,

total MOH expenditure is 2.6 % of total government budget and 70 % of total spending is

coming from out of pocket. The latter is the main reason behind the high level of payment at the

point of service delivery at private facilities or user fee charged at public facilities, both of which

are now well known to put unnecessary burden on the poor and promote inequity. According to

an analysis carried out by the World Bank and the NHPU using data from Household and

Income Expenditure Survey of Federal Bureau of Statistics, private expenditure is increasing in

real terms over time but remains low by international standards. Like the case in many other

countries, households in the lowest income groups tend to spend out of pocket mostly on

medicines. Financial barriers, such as the high cost of health care in the absence of risk pooling1,

explain the forgoing of health care by the lowest income quintiles.

Resources generated by government through budgetary and other means, seem to be mainly

allocated to hospital facilities at the expense of primary health care and preventive services. Also


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there are concerns over the utilization of resources allocated to some federal and provincial

public health programs or to public facilities in general. Such situation may be linked to

weaknesses in financial planning and management at both provincial and district levels, which

result in the lack of understanding of the total resources available, the flow mechanisms, and the

speed with which they flow thereby hampering implementation. In recent years, however, the

major national programs managed by the federal government have had large increase in budgets

and at the same time have shown improved utilization pattern indicating improvement in their

absorptive capacity.

Decision makers at federal and provincial levels seem to be aware about the need to mobilize

more resources for health, particularly through public funding. Efforts are also being made to

improve social protection for which a new national strategy is being developed the emphasis of

which is on conditional cash transfers to poor household in exchange for actions that modifies

their behavior to seek more social services including health. The overall understanding among

public health professionals in the area of social protection in health is limited and the evidence

insufficient. Studies to determine the feasibility of social protection interventions such as the

development of prepayment schemes in the formal and informal sectors of the economy and to

test the effectiveness of conditional cash transfer are essential for informing policy before any

decision to scale up is taken.


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POLICIES EMPHASISING HEALTH CARE SERVICES IN PAKISTAN

Pakistan is in the middle of epidemiological transition where almost 40 percent of total burden of

disease (BOD) is accounted for by infectious/communicable diseases. These include diarrheal

diseases, acute respiratory infections, malaria, tuberculosis, hepatitis B&C, and immunisable

childhood diseases. Another 12 percent is due to reproductive health problems. Nutritional

deficiencies particularly iron deficiency anemia, Vitamin-A deficiency, iodine deficiency

disorders account for further 6 percent of the total BOD. Non-communicable diseases (NCD),

caused by inactive life styles, environmental pollution, unhealthy dietary habits, smoking etc.

including cardio vascular diseases, cerebro-vascular accidents (hemiplegic), diabetes and cancers

account for almost 10 percent of the BOD in Pakistan.

A number of policies emphasize better health care service provision in Pakistan. These include:

Millennium Development Goals; Medium Term Development Framework; National Health

Policy. In the following sub-sections, we shall discuss some salient features of these policy

documents underlining health related strategy.

Health Millennium Development Goals (2015)

For the attainment of eight millennium goals, the UN Millennium Declaration fixed 18 targets

and 48 indicators; of which Pakistan has adopted 16 targets and 37 indicators. Pakistan is a

signatory to the UN Millennium Development Goals (MDG), 2000-2015. Three of the eight

MDGs emphasize directly to health sector with four targets and sixteen indicators. The MDGs

include: Reducing Child Mortality (1 target, 6 indicators); Improving Maternal Health (1 target,

5 indicators) and Combating HIV/AIDS, Malaria and Other Diseases (2 targets, 5 indicators).


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Medium Term Development Framework (2005-10)

The first Medium Term Development Framework (MTDF), 2005-10 provides guidelines to

ensure equitable development in all the regions of Pakistan, having fully integrated economy

with a sense of common and shared Destiny. The MTDF acknowledges the MDG targets and

puts emphasis to continue and strengthen the shift from curative services to preventive,

promotive and primary health care. Moreover, MTDF also addresses the issues of health care

financing, health insurance and employees social security, and public private partnerships in the

health sector. The MTDF also presents the health system in Pakistan at federal, provincial and

district levels (under public health services) and private health services. Ministry of health at the

federal level and health departments at the

Provincial levels are responsible for public health service delivery in Pakistan. The public

provision of medical and health services compromises of primary, secondary and tertiary health

care facilities. Primary health care facilities mainly look after out-door patients. These facilities

include: rural health centers, basic health units, primary health care centers, dispensaries, first aid

posts, mother and child health centers, and lady health workers. Secondary health care services

look after out-door patients as well as in-door patients. District and tehsil headquarter hospitals

are the secondary health care establishments; each district and tehsil must have this facility.


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Tertiary health care facilities are mainly present in major cities only. These facilities are

affiliated with research and teaching organizations. Both the secondary and tertiary health care

services are 24 hours operational.

MTDF highlights following major issues in the health service provision,

Facing Pakistan:

1. Organizational Issues

(a) In-adequacies in Primary/Secondary Health care Services

(b) Urban/rural imbalances

(c) Professional and Managerial deficiencies in District Health System

(d) Gender equity

(e) Unregulated Private Sector

2. Burden of Disease (BOD)

(A) Wide spread prevalence of communicable diseases

(b) Basic nutrition gaps in target population

(c) Addiction and Mental Health

3. Deficient Health Education System

National Health Policy (Health Sector Reform)

The National Health Policy (Ministry of Health, Islamabad), 2001, act as a collective framework

and provides guidelines to the provinces while implementing plans in the health sector in

accordance with their requirements and priorities. The present policy document is a blueprint of

planned improvements in the overall national health scenario. It will require commensurate

investments and interventions by the provincial governments for improving health infrastructure

and healthcare services. The federal government will continue to play a supportive and

coordinative role in key areas like communicable disease control programmes. The strategy of

the health sector reform is to achieve accessible quality health care for all.

The policy document identifies ten key areas:

1. Reducing widespread prevalence of communicable diseases;

2. Addressing inadequacies in primary/secondary health care services;


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3. Removing professional/managerial deficiencies in the district health system;

4. Promoting greater gender equity;

5. Bridging basic nutrition gaps in the target-population;

6. Correcting urban bias in health sector;

7. Introducing required regulation in private medical sector;

8. Creating Mass Awareness in Public Health;

9. Effecting Improvements in the Drug Sector; and

10. Capacity-building for Health Policy Monitoring.

In each of these areas, strategic objectives have been identified and implementation modalities

determined with an appropriate time frame for implementation and indication of targets wherever

possible. The key to success of the health policy lies in its implementation at all levels with the

collaboration of public and private sector, and assistance from international development

partners. Within the public sector collaboration between ministry of health and provincial health

departments and district and local governments would help in effective implementation of the

health policy.

Pakistans health sector: does corruption lurk?Error! Bookmark not defined.

Poor governance, mismanagement, inefficiencies and corruption are often used synonymously in

a health systems context. The connotation of corruption makes it distinctive though as the other

three may be inadvertent and without the intent to benefit whereas the nuance corruption has is

one of deliberate and illegal gains. Notwithstanding the vague separating lines between these

expressions, it is best to address them together in a health systems context as they have complex

interdependencies.

What falls within the ambit of corruption in a health systems context?

Various definitions have been proposed to label corruption. However these suffer from

limitations owing to their lack of ability to encompass every facet of what might be classified

within the purview of corruption. The two most commonly used definitions in the international

literature are:


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Use of public office for private gain, and the sale by government officials of government

property for private gain

However both of these exclude the private sector from the definition and would, by

characterization, exclude for example, the corrupt practices in the domain of pharmaceuticals, to

which the private sector is also a party.

A broader definition of corruption characterizes

it as a pattern which is seen to exist when a power holder, responsible functionary or office

holder is by monetary or other rewards not legally provided for induced to take actions which

favor whoever provides the rewards and thereby does damage to the public and its interests.

Corruption should be classified into two categories; practices which involve measures that

usually lead to monetary gains and others that involve non-monetary forms of corruption

MONETARY GAINS

Financial leakages Siphoning of public fund for private gains Illegal profits Benefits Incentives Pilferage Illegal fees Kickbacks Informal payments Petty corruption-over out allowances Procurement frauds/irregularities Bribe

Nonmonetary corruption:

Failure to base decisions on evidence Deliberate lack of oversight by public officials Deliberate inattention to mechanisms that compel accountability Preferential treatment to well connected individuals Unfair hiring practices


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The different modes of corruption

Corruption at a governance and regulatory level

At a governance level others forms of corruption also exist such as deliberate lack of oversight

by public officials, unfair hiring practices and nepotism, inattention to staff accountably for

misconduct, preferential treatment to well connected individuals, conscious lack of

institutionalizing mechanisms to compel accountability also constitute corruption at a health

systems level.

Corruption in the drug supply and registration system

Corruption in drug supply and registration has a direct bearing on the performance of the health

system and can reduce access to essential medicines, particularly for vulnerable groups. This

practice involves both the regulators and the private sector and may involve any step along the

drug supply chain, starting from registration, licensing and accreditation to the setting of prices,

marketing of drugs and sale and procurements.

In the procurement process, common corrupt practices include collusion among bidders

kickbacks from suppliers and contractors to reduce competition and to influence the selection

process, and bribes to public officials monitoring the winning contractors performance. Corrupt

procurement officers can also purchase sub-standard drugs in place of quality medicines and

pocket the difference in price.

In hospitals, varying quantities of drugs and medical supplies are stolen from central stores and

individual facilities and are diverted for resale for personal gain in private practices or on the

black market.

Corruption at the service delivery level

Staff absenteeism and dual job holding

Staff absenteeism and dual job holding is amongst the most serious issues at a health systems

level in Pakistan; this undermines service delivery and leads to closed/under utilized public

health facilities, which in turn undermines the equity and health objectives of the publicly

financed health care.

Informal Payments


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Informal payments are defined as payments to individual and institutional providers, in kind or in

cash, those are made outside official payment channels or are purchases meant to be covered by

health care systems.

Health care providers behaviors

Under the law of the country, all publicly employed doctors are forbidden from practicing

privately and many of them receive non-practicing allowances as part of their non salary

allowances. That notwithstanding, most of them run lucrative private sector clinics while

working in hospitals and often use the public sector leverage to boost practices in private facility

settings. A number of unethical practices such as refusing to see patients in hospitals and

referring them to private clinics are well established and are almost regarded as a conventional

norm. Provider-driven over-consumption of health services, over-prescription, and over-use of

diagnostics as well as violation of ethical guidelines in clinical practice are well established inPakistan. In terms of the ethics of health care alone, frequent violations of the four basis

principles of: the Right to autonomy, Right to privacy, Right to choose and Right to information

are often seen.

health dept

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