Developing A Health Sector Strategy For Pakistan

Abstract

The health of the population in Pakistan has improved in the past three decades, but the pace of improvement has not been satisfactory. Today, Pakistan lags well behind the averages for low-income countries in key indicators, including infant and child mortality and the total fertility rate. Poor health status is in part explained by poverty, low levels of education (especially for women), low status of women in large segments of society, and inadequate sanitation and potable water facilities. But it is also related to serious deficiencies in health services, both public and private. There is a broad consensus in Pakistan that the health sector is in need of fundamental reform in order to achieve a better impact on the health status of the population. The present dissertation has been prepared as a contribution to the national -debate on health sector reform. The research focuses on three key broad areas of public policy in the health sector: the setting of priorities for the use of public revenues; management problems in the government health services and possible reforms; and weaknesses in private health services and suggestions for improving the beneficial effects of these services. Priorities among health services financed with public revenues should take account of what the private health sector is doing and could do in the short to medium term. Generally, government health services should seek to avoid "crowding out" private services, provided that the latter are supplied by providers with the requisite training. Such providers are not available in many rural areas of the country. The dissertation recommends that top priority should be given to health education, in such areas as nutrition, creating greater awareness of the health benefits of adequate birth spacing, and stressing the importance of immunization and other preventive interventions; control of communicable infectious diseases; and maternal and child health services including family planning, pre- and post-natal care, deliveries by trained personnel, and management of the sick child, especially for diarrhea, acute respiratory infections and malnutrition. Most of these top priority services could be delivered through first-level health care facilities linked to community-based health workers and backed by referral services in secondary hospitals at the Tehsil and District levels. The top priority services generally merit subsidization from public revenues. However, except for health education and certain types of communicable disease control interventions, the subsidy need not be equal to the cost of production. But the issue of what constitutes a suitable cost recovery policy in the health sector is a complex one. If charges were increased, there would be a risk of displacing poor patients towards untrained practitioners or self-care, and discrimination against women/girls in households' health care expenditure could increase. The latter effect would moreover tend to be more pronounced among poor households. Thus any new system of increased user charges would need to incorporate safeguards to protect the poor, and be piloted before its widespread application. Enhanced cost recovery would increase the resources available to the government health services, provided that steps are taken to ensure that revenues accrue to the collecting facilities and are truly incremental to their budgets. But there is also much scope for improving the efficiency of resource use and achieving a greater impact with existing resources. This could be achieved through reforms such as setting better priorities among types of inputs; undertaking periodic in-depth budget 4 reviews of both the development and the current budgets; deepening decentralization of management in the Provinces; establishing Health Boards at the district level; involving communities in supporting government health care providers and helping to increase their accountability; contracting out some services to NGOs and others in the private sector; and placing a greater emphasis on staff development. At the same time that a concerted effort is made within the government health sector to improve efficiency, responsiveness and impact, the public sector also needs to work with private health care providers and their representatives to effect a parallel improvement in private health services. The public policy goal should be to achieve an optimal division of labor between the public and private health sectors. Attention to private health services is crucial because surveys show that in Pakistan the great majority of the populations seek the care of private providers when they fall ill --in many cases providers with little or no medical training. The dissertation suggests several types of partnerships between the public and the private sectors in order to improve private services. Partnerships could aim at encouraging continuing education of private providers; empowering professional associations to manage a system of certification and licensing of providers; introducing a voluntary accreditation system for private clinics and hospitals; enhancing attention to preventive interventions; fostering consumer education in the health area; and facilitating the development of health insurance.