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Statecraft and Public Policy

MPP-1001
Lecture. 7
Health Policy of Pakistan

Dr. Kalsoom Sumra


kalsoomsumra@gmail.com
Regulatory bodies& Policies in Pakistan
• Pakistan has a centralized healthcare system and the country
formulates its health policy at federal level. From federal level,
the health policy of Pakistan passes on to the authorities at
provincial level and eventually to the district level. But,
unfortunately provincial and district level’s feedback is neglected
(who have more insight about the people in their area) and hence,
all decisions are made at federal level.
• The federal Ministry of Health is mainly responsible for making
the National Health Policy and legislations including standards
setting for medical education, medical equipment and
manufacturing of pharmaceuticals. Other role s include
coordination with international agencies, management of
federally-run hospitals and planning and management of national
vertical programs like AIDS, malaria, TB-DOTs, family planning
etc.
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• In the public sector health delivery system in Pakistan, health is
considered as provincial subject. The provincial health department
is responsible to make provincial health policy in accordance with
national health policy and to translate it into strategic plans
whereas the primary implementation responsibility lies with
districts within each province. Provinces are responsible for
provision of resources to districts for implementation and also for
supervising their performance.
• The main focus of health policy of Pakistan is empowering the
primary healthcare system that includes dispensaries, mother care
health units and health units. Hospitals at the district level and
institutes for training medical professionals come at the secondary
level when it comes to paying attention to the reforms. Despite all
the corrective measures, the flaws in the healthcare policy of the
country still exist.
Health policy journey in Pakistan
• Though the article 38 of the Constitution of Pakistan (1973)
clearly commits the provision of health care to population, the
first formal health policy in country was announced in 1990.
• Before that, since 1960 health planning was part of the national
Five-Year-Plans. Three health policies have been announced in
Pakistan (1990, 1997, and 2001) and fourth one is of 2009.
• Health Policy 1990: The first National Health Policy of Pakistan
(1990) declared high commitment to health by announcing
intention to increase governmental health expenditures up to 5%
of the GNI. This policy aimed to provide universal health
coverage to the people in accordance with the Health for All
concept (HFA), moreover special attention was given to clean
water, sanitation, housing and family planning to prevent diseases
and to improve health.
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• Health Policy 1997: In 1997, the second National Health Policy was
announced, due to failure of the previous policy to adequately address primary
health care outlined in the vision of HFA. This policy was based on the concept
of health for all, with the aim of making health services more responsive to
current health needs. A special attention was given to HIV/AIDS, cancer,
diabetes, (road traffic) accidents, violence and crime, tuberculosis and mental
health.
• Health Policy 2001 The most recent National Health Policy of 2001 was again
claimed to be based on the HFA approach. It addressed many health issues and
ten key areas were identified as targets to work on. In each of these areas,
strategic objectives have been identified and implementation modalities
determined.
Failure of health policy
• Flaws in the planning process: There is highly centralized policy making
process, which is mainly focused on curative healthcare such as increasing the
number of health facilities, constructing laboratories, ambulances and
providing modern equipments, without assessing how they will be used by the
health professionals, who are not qualified to use the modern equipments,
resulting in loss of resources.
• Interference of the Federal Government in implementation: Though the
implementation of health policies is the responsibility of the district
government, the Federal Government still directly intervenes through its
vertical programs. There are various preventive and promotional health
interventions that include, the National Program for Family Planning and
Primary Healthcare, The Expanded Program of Immunization, The National
AIDs Control Program, Malaria Control Program, National Nutrition Program,
Hepatitis Program and etc. These vertical programs are implemented at the
primary health care facilities, but are directly run by the Federal Government.
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• This creates disharmony at the BHU and district level, resulting in lack of
coordination and integration in health programs and loss of resources, creating a
lot of political and cultural resistance. The local communities and BHU staff
also create hurdles considering them as outside interventions.
• Monitoring and Evaluation: Lack of proper monitoring and evaluation
mechanisms is another gap in health policy. There is no systematic mechanism
to monitor various health projects and the implementation of the programs at the
district level. For evaluation of the health programs, Health Management
Information System (HMIS) and District Health Management Information
System (DHMIS) have been introduced, but they are not properly and
effectively implemented.
• Poor management at the district level: At the district level, the overall system
is suffering from different administrative and managerial flaws. The
administration is on traditional bureaucratic model with little administrative and
financial flexibility, which is not compatible with the emerging needs. The
BHUs and other facilities are not fully functional due to absenteeism, political
interference, and inaccessibility, unavailability of medicine and equipments and
lack of resources.
Options for change and reform
• Option 1: Decentralization of policy: A way forward for Pakistanis to
completely decentralise its health policy process, to the districts. At district
level all the stakeholders and departments like Finance, Environment, Water
and Sanitation etc should directly be involved in the policymaking process.
• Option 2: Improving the existing mechanism: The second option is to
introduce certain reforms in the existing policy process rather than changing it.
Bottom up approach in achieving input and feedback from the communities
through the district governments may be adopted. The district governments
may be mobilised to involve communities, interest groups and NGOs in
assessing whether the programs are targeting the objectives. In this way the
federal government will be able to incorporate social, political and
geographical aspects of each province and the districts while formulating
policies.
Recommendations
 option 1 to be pursued by the government due to the following few reasons.
Firstly, as evident from the literature, environmental and social factors such as
poverty, lack of education, poor sanitation and poor governance, all predict bad
health outcomes. Therefore it would be better for the government to move
away from the traditional curative biomedical model towards more extensive
and holistic approach. The health of people will not improve unless other
factors such as environment, social and cultural aspects are concurrently
addressed.
 Secondly, planning is a two way process where assessment and feedback are
the cornerstone of better outcomes. Therefore it would be highly beneficial, if
the policy making process is decentralized and delegated to the districts, as the
direct health care providers can adopt better and realistic approach for the
problems they encounter on daily basis, knowing the ground realities better.
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• Thirdly, more resources should be put into the capacity building of
government officials and administrators at the district level to better
understand the contemporary health paradigms. As the root causes of many
health problems are not addressed when policies are formulated, due to lack of
knowledge of the concerned places and populations.
• Fourthly, when it comes to implementation phase, independent yet accountable
implementing agencies, with well formulated development strategies should be
brought into play .The communities and networks may be involved and
consulted because such programs should be culturally sensitive in order to be
effective. Federal government involvement should only be to provide the
necessary guidance and expertise along with sufficient funding.
• Lastly, better monitoring and evaluation tools should be constructed and
incorporated in the policy to get an unbiased and valuable feedback to the
policy makers and implementers. At the district and BHU level, management
and infrastructure should be improved in order to provide quality health care to
the masses. All this will be more successful if policy process is also devolved
to the districts.
Conclusion

• The health care system of Pakistan is beset with numerous problems. Pakistan
so far has not been able to come up with a robust health care reform.
• Decentralization, thus, presents an opportunity to bring in fundamental
changes in the primary health care domain in order to make it more efficient
and effective and easily accessible to the masses.
• The goals of health care reform in primary health care sector is to restructure
and reform the existing non efficient system by devolving from the federal to
the district level and removing the ambiguity created by the federal and
provincial governments at different levels, at the same time giving high
priority to preventive health in formulation of effective programs, as well as,
addressing problems such as under utilization, staff absenteeism, lack of
quality services and, scarcity of human, technical and financial resources and
public health measures.