Bahauddin Zakariya University,Multan

Report on Health Policy of Pakistan and its

comparison with America and China

Submitted to: Sir Tariq

Submitted by : Zahid Shafee
Roll No : BPP-16-18
Health policy and its importance
The purpose of healthcare policy and procedures is to provide standardization in daily
operational activities. Through our many years working with policies and procedures it has
become clear to us that they are essential in providing clarity when dealing with issues and
activities that are critical to health and safety, legal liabilities and regulatory
requirements. The importance of healthcare policy and procedures cannot be disputed but the
way they are managed best will vary from one organization to another. As the importance of
policies and procedures manuals may not be as apparent as it should be, we thought it would
be resourceful to share our knowledge on the matter. To our end, we try to develop powerful
solutions, to help manage policies and other documents in order to improve the productivity
and efficiency of a healthcare facility, as well as, ensure it is not breaching any regulations.
With that said, we realize that we may not be every organization’s cup of tea and that another
vendor may offer a better match.
Policy in healthcare is vitally important as it sets a general plan of action used to guide
desired outcomes and is a fundamental guideline to help make decisions. The purpose of
healthcare policy and procedures is to communicate to employees the desired outcomes of the
organization. They help employees understand their roles and responsibilities within the
organization. In the healthcare environment specifically, policy should set the foundation for
the delivery of safe and cost effective quality care.
With the continued increase in new regulations and requirements, such as the Affordable
Care Act, HIPAA, and Meaningful Use, the burden of setting policies and effectively
communicating these to the employees has become burdensome.

Health Policy of Pakistan

Vision Statement

To improve the health of all Pakistanis, particularly women and children, through universal
access, to affordable quality essential health services, and delivered through resilient and
responsive health system, ready to attain Sustainable Development Goals and fulfill its other
global health responsibilities.
HEALTH CARE PROVIDERS IN PAKISTAN:

1) MEDICAL DOCTORS

After the completion of one year residential job the qualified doctor is all set and
suitable for a job or private practice. Family Physicians have the major role in the
deliverance of primary care. They are the first contact of people who not only seek their
help for primary care but also in acute emergencies and accidents. There is no
organized Family Medicine in Pakistan. The Family Physicians work in a random
manner and they have no working relationship with each other. They do not provide
evidence based care to people. Many Family Physicians are involved in taking kick backs
from pharmaceutical companies, pathological laboratories and private hospitals

THE ALTERNATE MEDICAL SERVICES

People do go to Registered Hakims (traditional healers), Registered Homeopaths and

quacks in huge numbers. There is a situation of competition between various types of
primary care providers. The Hakims (traditional healers) and Registered Homeopaths are
free to make any medicine because drug policy does not wrap them and People have a
sturdy faith that these two types of treatment will not cause any harm and more beneficial
than our scientific medicines. There are two very popular misconceptions in Pakistan even
in highly qualified persons and some MBBS doctors as well 1. Sexual problems, Hepatitis A,
B, & C are not curable by any other medication except the Hakims. 2. Homeopathy is very
safe in chronic ailments especially renal stones, arthritis, etc. To become Hakim there is
no need of any basic general education but the famous Hakims are usually Graduates or
Master degree holders in non-medical education. They categorize themselves as A-Class,
B-Class and C-Class. To become a Homeopathic doctor, the candidate must full fill the
following criterion:
 At least ten years of study in school
 Four years course called “DHMS” from any out of hundreds of private
colleges scattered throughout the country
 All who qualify get registered in their counsel. These people use ultra-sound
machines themselves and avail pathology labs and all available diagnostics
including CT-scan and MRI. They buy time on famous private TV channels
and popular FM radios to project themselves and their work. Every such
doctor claims himself to be a new inventor and researcher.

TRADITIONAL QUACKS

They are prevalent in our society. Many efforts have been made to eradicate them but they
are on the mount

RELIGIOUS QUACKS

Traditional Quacks have been a major threat to the health system for quite long but now
a new category of quacks is rising that contain so called religious persons who not only
give blessings but also dispense their own made medicines. They are very famous for
treatment of Hepatitis A, B, & C.

THE PARAMEDICAL STAFF

FEMALE PARAMEDICS:

The following categories which are included under this

term “Nurse” in Pakistan;

CLASSIFIED NURSE:

The female must have passed high school examination in science to get admission into
this course. She takes a four hospital. She does not pay anything for it rather she is given an
attractive monthly helping throughout the course. Despite all these facilities, only girls
from poor background enter these courses. Such nurses are only present in big city
governmental hospitals and very expensive private hospitals. Due to proper education and
training, they work ethically and are aware of the importance of working within their own
limits.
years‟ course in Nursing during which she has to reside in
LADY HEALTH VISITOR (LHV):
The female must have passed high school examination in science to get admission into
this course. She takes a short course of about two years and she is basically trained in
women‟s‟ health and midwifery. They are meant for villages and towns but are rarely found
there. They usually practice
in cities as lady doctors. Most of them exceed their limits and are involved in criminal
abortion.

LOCALLY TRAINED NURSES:

This is the most available variety. Some of them are high school pass but most of them
are usually middle passed or less. They are neither adequately educated nor properly
trained. They are absolutely not aware of their limits. They work in clinics and most of the
private hospitals. Seniors among this category work as lady doctors and are involved
in criminal abortion.

LADY HEALTH WORKER (LHWs)

This type was produced by the government to induce health

education and create awareness about women‟s‟ health.
Females should be only middle pass and a local resident.
Unfortunately, they also forget their limits and start acting as
lady doctors

MIDWIVES OR TRADITIONAL

BIRTH
ATTENDANTS (TBA):

In Pakistan, TBAs are completely uneducated and non-trained. They not only are
unaware of their limits but also do not understand the importance of the referral network.
They are a major cause of maternal mortality and morbidity. They cause damage to mothers
and newborns due to lack of knowledge and skills. They do not understand the
importance of sterilization and use dirty hands on women and on newborns. They cut
umbilical cords with non-sterilized knives and tie it with dirty pieces of cloth or
thread. They insert harmful weeds and their own made medicines in the vagina and
freely inject Oxytocin I/M as a tonic or power injection before delivery.

B) MALE PARAMEDICS

25 % of this group is qualified but 75% are just locally trained in clinics and
pathology labs. We do not have life saving paramedics except in the army. Highly
Trained Mobile Paramedics This is a very recent addition to the system. At the
moment these are only found in Lahore. These are fully qualified.

HEALTH CARE DELIVERY SYSTEM IN PAKISTAN

The government of Pakistan spends 3.1 per cent of its GDP on economic, social and
community services and 43 per cent is spent on debt servicing. About 0.8 per cent is spent
on health care, which is even lower than Bangladesh (1.2 percent) and Sri Lanka (1.4
percent).However, the health status of the population has improved over the past three
decades the rate of immunization of children has more than doubled, and the knowledge of
family planning has increased remarkably and is almost universal. For over half the
population (66 per cent) living in the rural part of the country poverty coupled with
illiteracy, the low status of women and inadequate water and sanitation facilities have
had a deep impact on health indicators. Beside limited knowledge of illness and
wellness, cultural prescriptions, perceptions of a health service and provider and social
lbarriers, cost has been a major barrier to the provision of an effective health service. This
has affected the physical and financial accessibility of the health services. The health care
system in Pakistan comprises the public as well as private health facilities.

PUBLIC SECTOR:

In the public sector, under the Devolution Plan of the Government of Pakistan in
2000,19 the districts have been given comprehensive administrative as well as financial
autonomy in almost all sectors, including health. The districts are now responsible for
developing their own strategies, programs and interventions based on their locally
generated data and needs identified. Following the principles of Alma Alta, the public health
care system is primary care focused. At the community level, the Lady Health Worker
(LHW) program of the Ministry of Health, and the Village Based Family Planning Worker
(VBFPW) program of Ministry of Population Welfare of Government of Pakistan
have been established. These programs gained an international reputation due to their
grass root coverage plans. These workers are supported by an elaborate network
of dispensaries and basic health units (BHU) (serving 10 000–20 000 population) and
rural health centers (RHC) (serving 25 000–50 000 population). The next levels of
referral are the taluka/tehsil hospital (serving 0.5–1 million population), and the tertiary
level hospital (serving 1–2 million people). The nationwide network of medical services
consists of 796 hospitals, 482 RHCs, 4616 BHUs and 4144 dispensaries. However, these
basic level facilities have restricted hours of operation are often located distant from
the population. Manpower is constituted of approximately 90 000 doctors, 3000 dentists, 28
000 nurses, 6000 Lady Health Visitors and 24 000 midwives. Only 25 per cent of the BHUs
and RHCs have qualified female health providers.

PRIVATE SECTOR:

In private sector, there are some ascribed outlets and hospitals but also many
unregulated hospitals, medical general practitioners, homeopaths, Hakeem,
traditional/spiritual healers, Unani (Greco-Arab) healers, herbalists, bonesetters and
quacks. Non-governmental organizations (NGOs) are also active in the health and social
sector. In urban parts of the country, some public–private partnership proposals exist
through franchising of private health outlets. These have been successful to a large extent
in raising the level of awareness of positive health behavior among the people. For instance,
the increasing contraceptive prevalence rate is due to the efforts of NGO sector and the
LHWs of the government. Nevertheless, primary health care activities have not brought about
expected improvements in health practices especially of rural population groups. In
some areas of rural Pakistan, more than 90 per cent of deliveries are performed by
untrained or semi-trained dais or Traditional Birth Attendants (TBAs). Among other diverse
and multi-faceted reasons, a poorly functioning referral system may be partly to blame.
Given the complex nature of the health care delivery system in Pakistan and the limited
resources available to the health care sector, it is essential for the various sectors to plan and
work together to improve the health of Pakistanis. Thus it is important to understand the
health seeking behavior of the population and the factors driving this behavior.

HEALTH AND ECONOMICS OF PAKISTAN

In south Asia, magnitude of household out of pocket expenditure on health is at times

80% of the total amount spent on health care per annum. Economic capability to use
health services has not been very different in Pakistan too. For health expenses in
Pakistan, 76% goes out of pocket. This very factor also decides the measure of ability
of a person or a family as a whole to satisfy their need for health care. The cost has
undoubtedly been a major barrier in seeking appropriate health care in Pakistan. This
complexity is reflected in the health seeking behavior including the use of home
prescriptions and self-medicating with medicine borrowed from a neighbor or purchased
from the chemist shop. In NHS, little difference is observed in terms of health service
utilization by economic status. This insignificant difference in trends of utilization of
health services between rural and urban population does not reflect that both strata of
population enjoy the same health status. Though rural poor have more needs yet they
actually lack quality services and need based treatments. The distance separating patients
from the nearest health facility has been remarked as an important barrier to use, particularly
in rural areas. In NHS, findings reveal that at least 5% go to hakims, homeopaths and
faith healers. This representation looks very diminutive because the traditional beliefs
tend to be intertwined with peculiarities of the illness itself and a variety of
circumstantial, economic and social factors. Nearest and most available health provider in
a rural proximity would be a non-formal practitioner, who would be consulted mainly
because of the low cost incurred. Household economics certainly limit the choice and
opportunity of health seeking

ROLE OF PHARMACIST IN HEALTH CARE SYSTEM OF PAKISTAN

In recent years in most of the public-sector hospitals small numbers of pharmacists were
appointed their role was restricted to drug delivery, procurement and inventory
Control. There was a lack of pharmacy services in hospital and community pharmacies
because of isolation and lack of recognition of pharmacists as health care professionals. The
lack of trained personnel and the resulting lack of contact of pharmacist with the public are
also among the main contributing factors towards the lack of recognition of
Pharmacy profession. In 2003, the doctor of Pharmacy (Pham-d) began to be offered
as a five year profession degree program in Pakistan centered mostly towards the
clinical aspects of the pharmacy profession. The pharmacy council of Pakistan was
establishing under the provision of pharmacy act of 1967. It regulates the practice and
education of Pharmacist in the country. It is also responsible for the registration of
Pharmacy graduates and issuing the license permitting them to practice in the country.
Registration activity is decentralized and the regional pharmacy council (sub bodies)
under the pharmacy council of Pakistan is responsible for controlling and registering
pharmacist in their respective provinces. It has been predicting that among the total number
of pharmacist in Pakistan, approximately 55% are engaged in the production of
Pharmaceuticals – 15% of them working at federal and provisional drug control authority
and hospital pharmacy level –with another 15% in sales and marketing of pharmaceuticals,
10% in community pharmacy, and rest 5% in teaching and research. Although elsewhere in
the world the role of pharmacist is recognized in community pharmacies, hospital and
drug regulatory authority , the health care system of Pakistan has yes to recognized
this role. There are several reasons for the lack of recognition of the pharmacy profession in
Pakistan, such as lack of pharmacist in public health services and the lack of pharmacist in
community pharmacies, which direct to lack of community-pharmacist interaction. The
recognition by other health professionals of the pharmacist‟s
role in the health care system is due to their lack of interaction with pharmacist, as
most of pharmacy institutions in Pakistan exist without an attached hospital where
pharmacy student acquire basic clinical knowledge. Toovercome this problem it has
been proposed that existing pharmacy residency programs or specialized internship in
hospitals after completion of five years course work shouldbe extended from six months to
one year and it should bemade compulsory with a stipend. Besides that final year,
Pharm-d students must be involved in extensive clerkship inthe hospital to improve their
skills as clinical pharmacists, as this will be important to meet the expectations and needs of
society

HEALTH SYSTEM CONSEQUENCES OF THE CURRENT BUDGETING

POLICIES

The insufficiency in health sector budgeting imitates itself in the health and well-being of the
populations. Majority of our population does not utilize the public sector health facilities
because of poor quality and untrustworthy. Due to the insufficiency of the public
sector to provide sufficient, timely as well as suitable health relief to the poor, people
learn to use private health sector far more. The vicious cycle of ill health and poverty
becomes further exacerbated due to poor budgeting and financing of health sector. As a
result, 73.6% people living below poverty line (US$2) are deprived of their fundamental
rights of quality and accessible healthcare. The collision on the overall indicators is huge
as :
a result of this low investment in health. According to the current demographic and health
statistics in Pakistan, most of the indicators have no improved significantly over the past
few years. Total fertility rate increased from 3.9 to 4.1% in 3 years period, whereas the
contraceptive prevalence rate has remained remarkably stagnant (32% in 2003 and 30% in
2006). Infant mortality rate in Pakistan is one of the highest in south Asia (77 per 1000 live
births in demographic and health survey of 2005 and 78 per 1000 live births in 2006

RECOGNITION OF IMPORTANCE AND ROLE OF NGOS IN HEALTH SECTOR

OF PAKISTAN

About 206 public private service organizations and 600 NGOs are involved in health
services provision, research and advocacy. Since many years, the international and local
NGOs have attempted to fill the gaps that have been oft-cited for the public sector in
Pakistan. These are mainly the requirement of physical, financial, social and geographical
access to the health care facilities, poor distribution of resources among various
regions of the country, unavailability of health care providers at the facilities, poor
quality of services at government health facilities and most importantly very little emphasis
on addressing the social determinants of health due to weak inter-sectoral approach.
Working with NGOs besides presenting financial benefits, represents a more attractive
enticement which is the transfer of technical knowledge between partners. Moreover, health
planning becomes far more participatory and consultative with the inputs of all the
stakeholders. Most of the respondents from the government sector and the donor
community emphasized the importance of NGOs at macro and micro levels of the health
systems in Pakistan giving a boost to the public sector while executing with various
government departments.

FACTORS AFFECTING HEALTH SEEKING BEHAVIOR

A variety of factors have been identified as the leading causes of poor utilization of
primary health care services. These factors can be classified as cultural beliefs, socio-
demographic status, women‟s autonomy, economic
conditions, physical and financial accessibility, and disease pattern and health service issues.

CULTURAL AND SOCIO-DEMOGRAPHIC FACTORS

Cultural beliefs and practices often lead to self-care, home remedies and consultation with
traditional healers in rural communities. Advice of the elder women in the house is also very
instrumental and cannot be ignored. These factors result in delay in treatment seeking and are
more common amongst women, not only for their own health but especially for
children‟s illnesses. Family size and parity, educational
status and occupation of the head of the family are also associated with health seeking
behavior besides age, gender and marital status. However, cultural practices and beliefs
have been prevalent regardless of age, socio-economic status of the family and level of
education. They also affect awareness and recognition of severity of illness, gender,
availability of service and acceptability of service. Gender disparity has affected the health
of the women in Pakistan too by putting an un-rewarded reproductive burden on them,
resulting in early and excessive child-bearing. This has led to problems.

„a normal maternity‟ being lumped with diseases and health

WOMEN’S AUTONOMY
Men play a paramount role in determining the health needs of a woman. Since men are
decision makers and in control of all the resources, they decide when and where woman
should seek health care. Women suffering from an illness report less frequently for health
care seeking as compared to men. The low status of women prevents them from
recognizing and voicing their concerns about health needs. Women are usually not
allowed to visit a health facility or health care provider alone or to make the decision to
spend money on health care. Thus women generally cannot access health care in emergency
situations. This certainly has severe repercussions on health in particular and self-
respect in general of the women and their children. Despite the fact that women are often
the primary care givers in the family, they have been deprived of the basic health information
and holistic health services.

ECONOMIC FACTORS

The economic polarization within the society and lack of social security system make
the poor more vulnerable in terms of affordability and choice of health provider. Poverty
not only excludes people from the benefits of health care system but also restricts them
from participating in decisions that affect their health, resulting in greater health
inequalities. Access to a primary health care facility is projected as a basic social right.
Dissatisfaction with primary care services in either sector leads many people to health care
shop or to jump to higher level hospitals for primary care, leading to considerable
inefficiency and loss of control over efficacy and quality of services. In developing countries
including Pakistan, the effect of distance on service use becomes stronger when
combined with the dearth of transportation and with poor roads, which contributes
towards increase costs of visits. Availability of the transport, physical distance of the facility
and time taken to reach the facility undoubtedly influence the health seeking behavior and
health services utilization

HEALTH SERVICES AND DISEASE PATTERN

The under-utilization of the health services in public sector has been almost a universal
phenomenon in developing countries. On the other hand, the private sector has
flourished everywhere because it focuses mainly on „public
health goods‟ such as antenatal care, immunization, family
planning services, treatment for tuberculosis, malaria and sexually transmitted infections.
In Pakistan, the public health sector by and large has been underused due to insufficient
focus on prevention and promotion of health, excessive centralization of management,
political interference, lack of openness, weak human resource development, lack of
integration, and lack of healthy public policy. The low use of MCH centers, dispensaries
and BHUs in Pakistan is discouraging. It may be due to lack of health education, non-
availability of drugs and low literacy rate in rural areas.

DISCUSSION:

To develop balanced policy to offer proficient, successful, suitable, cost-effective,

affordable and accessible services we need to understand the drivers of health seeking
behavior of the population in an increasingly pluralistic health care system. This
correlates both to public as well as private sectors. Increasing the socio-economic status
through multi-
sectoral development activities such as women‟s micro-
credit, life-skill training and non-formal education have been shown to have a positive impact
on health seeking behavior, morbidity and mortality besides the overall empowerment of
women population. Gender sensitive strategies and programs need to be developed. Health
providers also need to be sensitized more towards the needs of the clients especially
the women to improve interpersonal communication. Although there is a fairly large
infrastructure of formal and orthodox institutions for health provision the quality needs to
be improved. Moreover, it is strongly desirable to further nurture critical, creative and
reflective thinking to reorient our health system. Health care providers need to be more
compassionate and caring to the needs of the people they serve. They should acquire
reliability, creativity and sensitivity and be the role model within health care system and in
communities. Introducing a „self care system‟ in the community which includes early
detection of danger signs in diarrhea, malaria, pneumonia and issues like family planning
and personal hygiene could form a package of health education for any community
setting. Public health awareness programs should be organized for mothers as
components of public health efforts intended to help mothers understand the disease
process and difference between favorable and unfavorable health practices. This would
enhance the mothers‟ understanding of disease process and importance of preventive
measures for a better family health With this complex and pervasive picture of health
system utilization and health seeking behavior in Pakistan, it is highly desirable to
reduce the polarization in health system use by introducing more client centered
approach, employing more female health workers, supportive and improved working and
living conditions of health personnel, and a convivial ambiance at health service outlets.

Pakistan’s health policy comparison with China’s health policy

PAKISTAN’S HEALTH CARE DELIVERY SYSTEM

Pakistan was inherited with the health care system initiated by the British government since
1947. The system is mainly responsible for preventing disease and provision of curative
services to its population. In Pakistani constitution, provincial government is
primary responsible for healthcare delivery and its management of the country, and the
implementation of national policies. However, Federal government is responsible for
planning and formulating national policies, research, training, and seeking foreign
assistance (Nishter, 2006). Moreover, in recent times federal domain just looks at the
accessibility of supplies and technology but not focusing on health at all. The healthcare
system in Pakistan has both public and private health facilities, including government
(public) and private hospitals, clinics, homeopaths,
Hakeem’s (Muslim physicians), traditional/spiritual healers, herbalists, bonesetters, and
quacks. Public sector has Primary
Health Care (PHC) facility comprises of Basic Health Units (BHU) and Rural Health
Centers (RHC). Tehsil Headquarters hospitals accommodate population at sub district
level and District Headquarters hospitals cater district population. In addition, tertiary
health care facilities are also available that are mainly located in cities and serves as
teaching hospitals. There are other autonomous organizations such as Pakistan Army,
railways departments of local government, provides healthcare facilities to their employees.
Only 30% of the population utilizes the services of PHC and the reasons are less staff
especially women, poor service quality and inconvenient PHC locations. The public
healthcare sector has multiple problems with inefficiency, unavailability of resources,
poor infrastructures and gender insensitivities (Sheikh, 2010). Public sector is mainly
financed through external or overseas funding. It contributes only 23% of total expenditure
on health. In contrast, private sector contributes 77% of health expenditure. It means that
total 3to 4% of GNP is spend on health, with 2 to 3% of GNP is spend on private

healthcare sectors (Sheikh, 2010).

“Pakistan spends $17 per capithealthcare sectors
(Sheikh, 2010). “Pakistan spends $17 per capitaon health, and $13 of this amount comes
from out-of-pocket
expenses” (Islam, 2002). The government of Pakistan and other
developmental agencies like NGOs always strive for public private partnership but there is no
well defined strategy to regulate both. However, the unregulated private healthcare facilities
have some illegal and unethical issues such as mal practice of healthcare professionals,
over charging patients, unnecessary prescriptions of medications and laboratory test without
any indications and so on. Several studies has concluded that the overall utilization of private
healthcare facility is 80% whereas 20% is from public healthcare facilities by the population.
CHINA’S HEALTH CARE DELIVERY SYSTEM

China’s health care system is managed by ministry of health and

local government that is hospital based delivery system.
Interestingly, china’s inpatient services have largest provision of
health expenditure. In 2003, there was 68.88% health expenditure whereas in 2010, it has
slightly reduced to 61.61%. Previously,
China’s population only had an access to basic healthcare facilities
through cooperative medical schemes (CMS) which was managed by agriculture
communities. The growing urban population had an access to health insurance either by
labor insurance or the Government insurance system (Eggleston, 2012). China’s health
care system has transformed together with china’s society and
economy. Recently, China’s health care system is government
owned and focusing mainly on primary health care system of
“grass root providers” to improve quality and funding for village clinics, township health
centers, and urban community centers
(Eggleston, 2012). China is also facing the issue of inaccessibility of primary healthcare
services and quality of healthcare providers in rural areas by its population but it does not
have any challenge to lack of healthcare providers, absenteeism and disintegrated
infrastructure like other developing countries. The larger share of services is provided by
private sector at the grass root levels including 18.6% of visits to community health
centers and stations.
Since chain’s healthcare system has recently categorized as public
and private therefore, it is difficult to state how much private sectorhas
grown(Eggleston,2012). China was also facing an issue of out of pocket expenditure. To
overcome this issue, in 2009 government of china had announced social health
insurance coverage. This is how china has tried to achieve its five articulated goals of 2009-
2011by extending insurance coverage to 90% of its population, public health service benefit
package, and improving primary care services (Eggleston, 2012).

ORGANIZATIONAL ENVIRONMENT OF BOTH THE HEALTHCARE SYSTEM

GOALS AND EXPECTATIONS.

Pakistan’s healthcare system failed to achieve goals of “Health for
All” in Alma Ata Declaration and thus followed to attain

Millennium Developmental Goals (MDGs) 2015. Some of the targets were focused on
health care such as reducing child mortality rate, improving maternal health, and
combating HIV/AIDS, malaria, and other diseases. Despite having goals and targets,
Pakistan still has showed slow and dissatisfactory progress and it is unlikely that Pakistan
may achieve these deadlines due to scarce resources, structural mismanagement and
inadequate financing (Sheikh, 2012). Similarly, china is also focusing to attain MDGs 2015
for which government of china has reformed its healthcare system and health policies.
China is striving to reduce poverty, child mortality, HIV/AIDS, and other disease,
empowering women, and promoting education like Pakistan. China has targeted its five
major goals in 2009 to 2011 which include 90% of the population has basic health
insurance, public health service packages, primary care is strengthened, development of
essential drug list, and experimenting with reforms of government owned hospitals.

RESOURCES AND TECHNOLOGY.

Pakistan is facing issues in terms of scarce resources, structural mismanagement and
inadequate financing. Government only spends 0.6% GDP on health. National health
policies are formulated based on political inferences rather than evidence of
required need (Shiekh, 2012). Pakistan is in critical stage of workforce deficiency. This
deficiency is stagnant due to lack of financial resources, scarce healthcare professionals,
and migration of skilled workers. Similarly, china is also facing shortage of nurses and
physicians and this scarcity of workforce led poor delivery of health services. Health care
services are well equipped in both countries but, they are underutilized due to untrained
health care professional and the availability of technology is beyond the scope of health care
facility. China has are very limited in numbers of PHC centers and are not well equipped
according to the scope and function of PHC. However, china is striving to advance its
technology and pharmaceutical companies that are the source of earning for china.

–owned hospital (Eggleston, 2012)

POLICY LEVERS

FINANCING
.
Pakistan is the poor country with burden of the debt servicing of 43%. 7% is spent on
defense due to undue tension on border and terrorism. Hence, only 3.1% of GDP is
allocated for economic, social and community services, out of which only 0.8% is spent on
healthcare (Shaikh, 2004). Pakistan spends 85% of its health care budget on tertiary
healthcare that is used by about 15% of the population and leftover 15% is used by
85% of population on primary health care (Islam, 2002). On contrary to this, China
allocates 5.6% to its budget. China spends 35% of its budget on the primary health and 65%
of its budget on the secondary and tertiary health care (Shanlian, 2008). Both the countries
have similar health expenditure and outcome a decade ago. China has felt dearth need to
change its shift of expenditure on primary health after the new china health reforms.

Payment

Payment describes how money, once raised, is spent: who to pay, what to pay for, and
how much to pay (Ma, 2008). Both the countries have less social security system which
makes the poor more vulnerable in terms of affordability and choice of health care
professionals. 76% goes out of pocket cost (OPC) in general population is a certain
barrier in seeking health care (Shaikh, 2004). Transportation to the health facility and
other additional charges spend for the treatment make the consultation more
distressing. Khan (2009) reported that more than 1/3 of women did not know the cause of
their illness, due to lack of exposure to the world outside the home. Lewis (2006) reports
several studies that average payment to hospital visit is US$16-36, with referral it
raises to average US$44. This is roughly 90% of half monthly income. Hence, lack of
insurance coverage of the population has disturbed equity and availability of public health
resources to the population who belong to lower socio-economic status.

MACRO- ORGANIZATION
Organization refers to the broad structure that organizes health care including ownership,
market competition, decentralization (Ma, 2008). In Pakistan the devolution plan of
health came in 1999. According to the plan, the local government is based on the
fundamentals of devolution of political power, decentralization of administrative authority,
and distribution of resources to the district level (Islam, 2002). Despite the
decentralization and authority to local government, health care system has become
worse because of inefficiency of the public health care system. Moreover, private sector
comprises of 72% with the average uptake of the patient more than 70% in routine and
80% of the patients visit first time to the private practitioner on illness because
of inaccessibility of the healthcare professionals and resources in public sector (Uplekar,
2001). In 2000, the central China issued
first regulation concerning non-profit and for-profit health care organizations (Lee, 2012).
Today, although China’s economy as a
whole is dominated by the private sector, the private sector’s role
in health care is still limited. By 2002, there were more than 200,000 private
practitioners, representing about 4% of the total 5.2 million health professionals in China;
most of these private practitioners were located in rural areas and has played the key role
in health improvement (Ma, 2008)

INTERMEDIATE OUTCOMES

ACCESS

Access, here defined as effective availability, measures how easy it

It is for people to overcome barriers e.g., physical, social, and
financial barriers, timing, and service availability obstacles to get care (Ma, 2008). In
Pakistan, dissatisfaction with primary care
services lead many to tertiary care hospitals for primary care hence, considerable
inefficiency and loss of control over efficacy and quality of services occurs (Shaikh, 2004).
China is also facing issue of inaccessibility of primary healthcare services and quality of
healthcare providers in rural areas but not observes challenges in terms of lack of
healthcare providers, absenteeism and disintegrated infrastructure like Pakistan.
QUALITY

Routine evaluation and assessment of quality is an important part of a health system, and
indicators are underuse of public healthservices and supply induced overutilization of
technologies (Ma, 2008). In Pakistan, only 30% of the population utilizes the services of
PHC and reasons are less staff especially women, poor service quality and inconvenient
PHC locations. Moreover, inefficiency, unavailability of resources, poor infrastructures
and gender insensitivities exacerbate the situation (Sheikh, 2010). China has now achieved
universal coverage with 1.295 out of 1.3397 billion people (95% of the population) has
health insurance, and out of pocket spending is 35.5% (Eggleston, 2012). The system
continues to have many weaknesses in providing access to quality services. Thereafter China
is maximally utilizing its resources with the only challenge is to strengthen more its primary
health care.

EFFICIENCY
The efficiency of a health system is determined by the degree to which system maximizes
health-status gain cost effectively. China has developed multiple agencies equivalent to
U.S. Centers for Disease Control and Prevention (CDC). Aiming to improve disease
surveillance incorporated at all levels of governments. Moreover, for further improvement
some local and provincial CDCs have
attempted to establish their own “national” capacity (Ma, 2008).
This enables the government to have synergic implementation at horizontal and vertical
approach in promoting health. Devolution of the federal government, the national level
integration programs had been demolished and come under the provincial government
which has created the discrepancies in many program e.g., immunization and lady
health workers. Moreover, corruption is the root cause of ineffective utilization of money in
Pakistan (Ahmed, 2008).

ULTIMATE ENDS

CONSUMER SATISFACTION AND HEALTH STATUS.

In China patients at public facility are satisfied with hospital environment but
dissatisfied with ability to build relationships whereas, in private facility the high fees
bring dissatisfaction (Eggleston, 2012). Similarly, in Pakistan among patients with
acute illness only 21% seek care at a public sector at first-level, and reason is lack of
quality care. Moreover, private facility has compromised care too thereafter, consumer
dissatisfaction is so high and affecting the health seeking behaviors of the population
(Shaikh, 2008). Consumer satisfaction prospects into health status of the population. For
example, people in China lives longer and healthier than people in Pakistan. In Pakistan,
life expectancy of woman is 67.7 years, whereas in China its 74 years. A man born in
Pakistan has life expectancy of 65.5 years, whereas in China its 70 years. (Lee, 2012)

FINANCIAL RISK PROTECTION

Poor health is associated with worse physical, social and mental well-being. Extensive
research has shown that poor health can also increase poverty and reduce material well-being
through a number of paths including excessive medical expense, impaired labor
market participation, and loss of productivity. In China, 25% of the surveyed households had
to borrow money and that another 6% had to sell their assets to pay for health care (Ma,
2008). Whereas, in Pakistan most common types of shocks are health related which
comprises 55% of the total. These health shocks can be natural disasters or man-made
which take a heavy percentage that shares the household expenditure burden, and in
consequence the populations reports poverty, unemployment, poor health and shelter,
communicable diseases, food shortage, school dropouts, and or child labor (Heltberg,
2009). Hence Pakistani observes more serious health shocks as compared to Chinese.

CONCLUSION
This paper highlighted health care delivery system of Pakistan in comparison to China
followed by organizational structure, analysis of both the healthcare systems, and
recommendations to improve healthcare reform and its utilization. Health cannot
beseparated from political, economic, social and human development contexts. Gaps at
government level, poor system regulation, lack of efficiency and resources, breaks in
social justice cannot be excluded from macroeconomic and social development of
Pakistan. Therefore, Sustainable growth and improvement at the government level need
to be addressed for structural and operational changes in health care system in order to
break the cycle of corruption and underdevelopment

Pakistan’s health policy comparison with America health policy

It is interesting to compare the healthcare systems of Pakistan and the USA, since both
healthcare systems are not welfare oriented. In 2017, the Prime Minister of Pakistan launched
a health insurance scheme which was supposed to provide healthcare coverage to families
earning two dollars a day or less. Serious medical conditions and procedures like cancer,
accident related trauma, burns, diabetes related complication, infection and bypass surgeries.
A family benefiting from this insurance scheme is entitled to an annual treatment costing
$2,600. The project’s goal was to provide health insurance to 23 million families in the
federal capital, FATA and Punjab.

The common perception is that public sector hospitals in Pakistan provide free medical care
to every citizen of the country. If this is the case, then Pakistan is more of a welfare state than
the USA, which spends 8.3 percent of its GDP on healthcare compared to Pakistan’s 0.42
percent. In Pakistan around 78 percent of the population pay for healthcare out of its own
pocket. The private sector provides three quarters of health services in the country, while the
state merely picks up the remaining tab. At present, provincial governments in Pakistan are
the leading institutional entity in terms of expenditure on healthcare (mostly on establishment
costs such as salaries) and allocation has enhanced post devolution from 4-6 percent to 8-11
percent of the budget out of the development outlay.

American healthcare is bankrolled by a complex and uncoordinated amalgam through the

federal, state, and local governments supported by private insurance. Yet, there is no
consolidated system of health insurance. In stark contrast to Pakistan, the prevailing practice
in the USA is insurance coverage for employees managed by their employer with emphasis
on government intervention limited to the most vulnerable segments of society such as the
elderly, disabled and unemployed.

An intriguing aspect of healthcare in the United States is that almost 17 million people were
employed in the health sector or health occupation which means 12 percent of the total US
workforce caters to a population of almost 326 million. The population of Pakistan is around
200 million with a significantly smaller number of persons in the health occupation. In
Pakistan, electronic or tele-medicine, involving basic geographic information systems (GIS),
is spreading as a platform, albeit without any regulatory umbrella. Things are different in the
USA being focused on a formal and conservative prescription approach. Basic medical
diagnostic tests in Pakistan are not so costly as compared to the USA and health tourism is
increasing with Pakistani origin patients coming from the United Kingdom, who find private
medical care such as surgery less costly here, and with the added benefit of a shortened
waiting list.

If a query is raised that in Pakistan is the healthcare provided to those ordinary citizens, not
insured through any organisation whether public or private, adequate and does it ensure the
quality of life then the answer would be a resounding no. There persists a marked and
perceptible difference in treatment being provided in a private hospital and a public hospital.
Technically speaking it may be lack of funding for intestinal staples during surgery, stents for
cardiac procedures, repeated usage of dental equipment instead of disposable dental kits, and
obsolete diagnostic equipment, which ultimately has an impact on quality of life. The waiting
time for surgical intervention in the public sector healthcare environment in the event of
elective, non-malignant diseases including hernias, gall bladder and thyroids may extend
from six months onwards coupled with no choice in selection of surgeon.

The discernible differences in healthcare cannot be easily scoffed as being attributable to the
desire to acquire healthcare in a comfortable or luxurious setting as overcrowded public
sector hospitals have compromised standards of hygiene and quality control and full time
availability of medical personnel and equipment of one’s choice.

In this sense the citizen of Pakistan appears to be in an enviable position compared to the
USA, as every citizen has access to free medical care even if the quality of medical care is
not comparable to that in the private sector whose charges are exorbitant

RECOMMENDATIONS

 Strengthening and empowering the role of state leaders.

 Appropriate utilization of public funds and organization of priority services to be provided

universally.

 Developing substitute service delivery and financing options at the basic healthcare and
hospital levels.

 Granting autonomy at management level and introducing costsharing at the level of

financing.

 Building the capacity and effectively deploying human resource to improve career
structure of all healthcare professional.

 Establishing a rewarding working environment and initiating measures to restore

imbalances with regard to existing staff.

 Building conscious protection in order to balance the risk of creating access and
affordability issues for the poor in new service delivery arrangements.

 Establishing Public-Private partnership in order to foster arrangements that bring

organizations together.

 Establishment of social health insurance as part of a comprehensive social protection.

 Effective management and monitoring of healthcare system should be owned by district

government and thus maintains the standards.
 Government should introduce such environment and policies for research and
development in medical sciences to promote knowledge creation and growth.

 Provision of primary health care is required with cost effective strategies for increasing
population to sustain long term positive impact on health status on the population.

References

 https://dailytimes.com.pk/187286/healthcare-us-pakistan/
 http://aeirc-edu.com/wp-content/uploads/13download-full-paper.pdf
 https://www.researchgate.net/publication/321376296_Health_Care_System_in_P
akistan_A_review