Health Care Systems in Transition III. Pakistan, Part I. An Overview of The Health Care System in Pakistan

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Journal of Public Health Medicine Vol. 22, No. 1, pp.

38–42
Printed in Great Britain

Health care systems in transition III.


Pakistan, Part I.
An overview of the health care system
in Pakistan
Abdul Ghaffar, Birjees Mazher Kazi and Mohammad Salman

Keywords: system, health, policies, Pakistan sustainable development. The health and population character-
istics in Pakistan are high fertility, low life expectancy, a young
Introduction age structure, high maternal and child mortality, high incidence
of infectious and communicable diseases, and wide prevalence
Pakistan, which occupies the easternmost part of the Gigirist– of malnutrition among children and women.1,2,4 The country is
Euphrates and Indus basin, is a country with strong cultural undergoing a demographic transition, which is characterized by
traditions, going back to the early Indus Valley civilization of a change from high mortality and high fertility to lower
Moen-jo-Daro and the Graeco-Buddhist Gandharan cultures. mortality but still relatively high fertility.
Pakistan became independent in 1947 and occupies an area of
852 392 km2. It is located on the Arabian Sea, bordered by India
to the east and Iran to the southwest, and Afghanistan and China Burden of disease
to the north. Administratively, Pakistan comprises four provinces In Pakistan, pulmonary tuberculosis in adults continues to be a
[Punjab, Sindh, North Western Frontier Province (NWFP) and major pubic health problem, acute respiratory tract infections
Baluchistan], and four federal territories (the Federally are common and malaria remains a potential threat. However,
Administered Tribal Areas, Federally Administered Northern injuries, cardiovascular diseases, cancer and diabetes are
Areas, Islamabad Capital Territory and the state of Azad Jammu emerging as major public health problems. Pakistan is at the
and Kashmir). Each province is divided into districts, which are beginning of an ‘epidemiological transition’, as a result of
the main administrative units. Districts themselves are further which it will need to face not only the challenges generated by
divided into sub-districts, called Tehsils or Talukas. infectious diseases, but also an increasing burden as a result of
After independence, three powerful social factions became non-communicable diseases.4,5
pre-eminent: the military, the civil service and politicians. Over
the last three decades, the country has oscillated between
military governments and democratically elected but fragile Health care provision
civilian governments. As a result, many government policies Under the Pakistani constitution, health is primarily the
have been made by and for the civil servants and politicians, responsibility of the provincial governments, except in the
who are either rich landlords or belong to the small coterie of federally administered territories. The Federal Government is,
rural or urban élites. This has resulted in neglect of the social however, responsible for planning and formulating national
sector of Pakistani society, despite periods of relatively strong
economic growth. Attaining sustainable improvements in health
has proved a difficult goal to achieve, and health and other Department of Community Health and Health Systems, Health Services
social indicators remain low even compared with neighbouring Academy, 12-D West Bewel Plaza, Blue area, Islamabad, Pakistan.
countries with poorer economies than Pakistan (Table 1). Abdul Ghaffar, Head of Department
National AIDS Control Program, NIH, Islamabad, Pakistan.
Birjees Mazher Kazi, National Manager
Health and population characteristics Mohammad Salman, Medical Officer
Pakistan is the seventh most populous country in the world, with Address correspondence to Dr A. Ghaffar, Suite E8011, Division of Com-
munity Health and Health Systems, Department of International Health, Johns
a population of 135 million people.3 It is a nation that has made Hopkins School of Hygiene and Public Health, 615 North Wolfe Street,
economic progress but is struggling to find a road towards Baltimore, MD 21205, USA.

q Faculty of Public Health Medicine 2000


OVERVIE W OF PAKIST AN 39

Table 1 Comparative indicators of health and social development

Variable Pakistan India Bangladesh Nepal Sri Lanka

Infant mortality rate (1996)1 88 65 77 85 15


Maternal mortality ratio (1990–1996)1 340 437 850 1500 30
Total adult literacy rate (%) (1995)2 38 52 38 28 90
GNP per capita (1997)1 490 390 270 210 800
Public expenditure on health (% of GDP)1 0.8 0.7 1.2 1.2 1.5
Population percentage below poverty line ($2 a day)1 57 88.8 – 86.7 41.2
Percentage of total population with access to health services2 55 85 45 48 –
Percentage of total population with access to safe water2 74 81 97 63 57

health policies, although the responsibility for implementation long-term plans, short-term annual development plans (ADP)
rests largely with the provincial governments. The federal and annual recurrent budgets.10 The Federal Ministry of
Ministry of Health is responsible for the implementation of Planning and Development, popularly known as the Planning
some vertical prevention programmes on AIDS and malaria, Commission, is primarily responsible for long-term and
and extended programmes for immunization. strategic planning, and the Ministry of Health and Provincial
Health care provision in Pakistan comprises private and Health Departments design their plans in line with the overall
public services. The private sector serves nearly 70 per cent of policies of the Planning Commission.
the population,6 is primarily a fee-for-service system and Developing appropriate plans that can be implemented
covers the range of health care provision from trained allopathic requires information on health status in conjunction with other
physicians to faith healers operating in the informal private social development indicators, such as literacy and employment
sector. Neither private nor non-government sectors work within rates, housing and basic social security. ‘Needs assessment’ for
a regulatory framework and very little information is available health care programmes in Pakistan is usually based on the size
regarding the extent of the human, physical and financial of the population in an area.11 The specific needs of that area or
resources involved. community are often not taken into account directly, nor are
The public sector comprises more than 10 000 health issues such as access to services (roads, transport, climatic
facilities ranging from Basic Health Units (BHUs) to tertiary conditions) and disease patterns. Similarly, the issue of equity –
referral centres. At present, a BHU covers around 10 000 people, or other broader notions of fairness, a basic principle of the
whereas the larger Rural Health Centres (RHCs) cover around Alma Ata declaration – is usually not considered. To assess
30 000–45 000 people. In Pakistan, Primary Health Care (PHC) levels of equity requires knowledge of the distribution of social
units comprise both BHUs and RHCs. The Tehsil Headquarters indicators and not just their means or aggregates, the form of
Hospital covers the population at sub-district level whereas the most planning information currently available.
District Headquarters Hospital serves a district, as its name Whereas the private sector is primarily a fee-for-service
suggests. Currently there are 22 tertiary care facilities in system, the public health sector at present generates a negligible
Pakistan, which are mostly teaching institutions located in the amount of resources through token user charges.12 The main
major cities.7 source of financing of the public sector is the government.
Less than 30 per cent of the population uses the facilities of Capital investment in the public sector is financed through
the PHC units and some studies indicate that, on average, each Annual Development Plans (ADPs) that also include external
person visits a PHC facility less than once per year.8,9 The funding derived from foreign aid (overseas funding) from both
reasons for their under-utilization, as identified by both bilateral and multilateral organizations. The Federal Govern-
managers and consumers, are the relative lack of health care ment substantially finances provincial development budgets, but
professionals and especially women, high rates of absenteeism, the provinces make independent decisions regarding allocation of
poor quality of services and inconvenient location of PHC funds over various sectors. The provincial non-development
units.7,9 In addition, the Pakistan army, railways, departments budgets are funded from provincial government revenues,
of local government and some autonomous organizations although the Federal Government covers existing deficits
provide health care to their employees, who form a significant through non-obligatory grants. Although public sector spend-
portion of the population.4 ing on health has always remained less than 1 per cent of
GNP,10 per capita health expenditures have increased
enormously in the last 15 years.4 The total percentage of
Health care planning and financing
GNP spent on the health sector in Pakistan ranges between 3
Planning for health care in Pakistan comprises a formal planning and 4 per cent, with 2–3 per cent of GNP spent on private
process, which revolves around the production of 5–15 year health care.
40 JOURNAL OF PUBL IC HEALTH MEDICINE

Table 2 Human resources development in health care, since the provinces, federal areas and donor organizations to bring an
19604,13 accelerated, co-ordinated and concerted improvement in social
Variable 1960 1977 1988 1997
indicators, primarily focusing on four key social sectors: (1)
primary health care; (2) primary education; (3) rural water
Doctor:population ratio 1:7400 1:6916 1:2940 1:1642 supply and sanitation; and (4) population welfare.
Nurse:population ratio 1:32000 1:23376 1:7561 1:5199
Hospital beds:population ratio 1:3200 1:1662 1:1678 1:1610 Prime Minister’s Programme for Family Planning and
Primary Health Care
To improve the use of PHC units and make the system more
Development of human resources efficient and effective, the government launched a community-
Since independence, the Federal Ministry of Health and the based programme in 1994, known as the Prime Minister’s
provincial health departments have been responsible for the Programme for Family Planning and Primary Health Care
planning, production and management of human resources in (PMP). This programme aims to extend outreach services to
the health care sector. At a national level, 12 postgraduate communities, by bringing services to their doorsteps, through
medical colleges, 18 medical colleges, five dental colleges and the appointment of Lady Health Workers (LHWs). These
three nursing colleges now exist.7 Recently, the private sector LHWs are a vital link between the community and health
has also shown a greater interest in the development of human facilities. They provide essential services in the areas of
resources, and eight new undergraduate and two postgraduate reproductive health, mother-and-child health, health education,
medical colleges have been established in the private sector.7 treatment of minor ailments and referral of high-risk patients to
The quality of public and private medical education is similar, health care facilities. Each LHW is a member of the local
despite the fact that the training in the private sector is community and responsible for around 1000 people. The
considerably more expensive. programme currently covers around a third of the population,
The development of human resources has been biased but there are plans to extend it universally after the completion
towards the production of physicians rather than other health of an independent evaluation by the UK Department for
care providers, especially nursing staff. World-wide, the International Development (DFID).
nurse:doctor ratio is generally 3:1; however, in Pakistan the
converse exists and the ratio is 1:3.4 Analysing the increased Health care reforms under consideration
number of medical and nursing personnel and the number of
beds since 1960 (Table 2), one observes a bias towards curative The Government of Pakistan is launching a number of other
care, which further increases the disparity between primary initiatives to improve the health status of the people of Pakistan.
health care facilities and tertiary care institutions. The rationale is to involve all the stakeholders, not only in the
decision-making process, but also in the implementation of any
new programmes. This is to ensure the effectiveness and
Recent initiatives sustainability of the public sector programmes. The following
The relatively poor state of health and social indicators has initiatives are under way.
prompted a rethinking of national health policy guidelines and
the initiation of the Social Action Programme Project (SAPP). District Health Governments (DHGs)
The state of Pakistan’s national finances has always resulted in The government is planning to establish District Health
reduced expenditure on health, particularly on the non-salary Governments to improve the implementation of health care
portion of the budget. This has led to a decline in the quality of provision in the public sector. The philosophy of this initiative
care and service provision, as a result of a reduction in the is a ‘decentralized health system approach with small manage-
development of human resources and non-availability of drugs ment units at the district level’.14 Under this initiative, a District
and supplies. Health Management Team will be set up at district level, headed
by a chief executive, who will be employed on a performance-
Social Action Programme Project (SAPP) based contract. The members of the DHG are to comprise
SAPP is a national programme to improve provision and quality health officials, public representatives, opinion leaders,
of basic social services by addressing issues of access to services, members of local non-governmental organizations (NGOs)
standards, accountability and responsiveness to clients, and and officials of other related departments such as Family
sustainable expenditure. The central focus of SAPP is to Planning and Public Health Engineering. The DHG will have
strengthen the policy-making and management capacity of the full administrative and financial autonomy to hire and fire
the line departments and increase expenditure, especially on the staff and to generate, retain and use allotted funds. The
non-salary portion of the budget. SAPP was launched by the performance of the DHGs will be monitored by independent
Government of Pakistan in 1992–1993 in collaboration with external evaluators.
OVERVIE W OF PAKIST AN 41

Hospital autonomy the required human resources for the social development of the
The government has launched a similar initiative for tertiary nation. Health, education and information technology have been
care hospitals in which an Institutional Management Commit- identified as crucial sectors for future development of the nation.
tee will be set up in each hospital to operate as a board of However, under this programme the health sector continues to
directors under the supervision of a chief executive. The have policy dialogue with different stakeholders to develop
Committee will make decisions about the management of the future strategies.
facility and its finances. The rationale is that ‘managerial and
financial autonomy, coupled with performance agreements and
clearly delineated managerial accountability should improve Conclusions
the quantity and quality of services provided by hospitals’.15 An Creation of an integrated primary health care system, delivering
important feature of this initiative is that the chief executives, essential clinical and minimum public health services, as
both for hospitals and DHGs, would be paid salaries that are suggested by the World Bank16 and advocated by the MOH,
competitive with those in the private sector. should be a key component of health system reforms. The
actual contents of such an essential minimum package should
Public–private partnerships depend on the most urgent health care priorities, and available
financial and human resources. The political and economic
In a recent health policy development, in 1997, the government
situation in Pakistan is such that it is very important to
has allocated some funds to a number of Health Foundations.
implement the planned health care reforms, especially the
These are organizations that give grants to physicians for the
decentralization process being carried out in the Punjab such as
establishment of ‘private’ hospitals in the rural areas. The funds
DHGs, at least partially or in pilot districts, so that their positive
are provided by the government as a loan with minimal interest,
benefits can be established. Health sector reforms should be
which will provide for the establishment of hospitals and clinics
implemented and results obtained urgently before particular
in the private sector, especially in the rural areas.
interest groups and bureaucratic inertia undermine the impetus
The management of non-functional primary health care
for reforms. For successful implementation and continuation of
facilities would be given to the local NGOs or community-
health sector reforms, the concepts of ‘total quality manage-
based organizations (CBOs) under this initiative. This is a
ment’ and ‘good governance’ need to become an integral
separate initiative under which local NGOs and CBOs are asked
component of health system management.
to manage those public sector health care facilities that are
rarely used because of geographical inaccessibility or non-
availability of health staff for whatever reason. The government
provides the allocated budget for these facilities, and the References
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Islamabad: Government of Pakistan, 1995.
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Islamabad: Health Services Academy, 1995–1999.
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Pakistan, report of evaluation study. Islamabad: Government of
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Pakistan, 1993.
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development programme in line with the future needs of the Ad-Ray Publishers, 1996.
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42 JOURNAL OF PUBL IC HEALTH MEDICINE

12 Economic Affairs Division. Economic survey of Pakistan. Islamabad: 15 Department of Health. Punjab hospital autonomy, proposal for project
Government of Pakistan, 1988 and 1999. concept clearance. Lahore: Government of Punjab, 1999.
13 Planning Commission. The third five year plan. Islamabad: Govern- 16 World Bank. World development report. Investing in health. New York:
ment of Pakistan, 1965–1970. Oxford University Press, 1993.
14 Department of Health. District Health Government, concept paper.
Lahore: Government of Punjab, 1999. Accepted on 11 October 1999

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