International Development Partners and

Health Sector in Punjab from 1999-2006

Robina Yasmin

Punjab is striving hard to catch up health standard as defined in

the Millennium Development Goals (MDGs) milestones. The
international development partners have also joined hands with
the Punjab government in its efforts to bring about improvement in
the health status of the people of Punjab. This article presents an
analysis of the issues in the health sector of the Punjab province
and the subsequent efforts of the government to take on these
challenges and their effects on the society in the said period.
Status of the millennium development goals has also been
discussed in with special reference to the health indicators in the
Punjab.

Key Words: Health Sector, International Development Partners, MDGs

Background

The significance of sound health for the advancement of society and

the economy cannot be overstated. In societies, where health is suboptimal,
there is a corresponding reduction in an individual's productivity and
income. An analysis of the health and medical records provide noteworthy
insights into the state of health and healthcare systems in the Indian
subcontinent throughout the reigns of the Delhi Sultanate (1206-1526),
Mughals (1526-1857), and the British Raj (1858-1947). Several
international visitors observed the exceptional state of health among the
indigenous inhabitants. Fryer's observations on the mortality rates of the
English in Bombay and its environs revealed that the rural population
exhibited a tendency to live to an advanced age. This phenomenon was
attributed to their moderate lifestyle.”1 Bernier speaks about the "common
habits of moderation among the people,"2Exceptions were made for a few
people in the top class and the royal family.
International Development Partners and Health Sector in Punjab from 1999-2006 39

In Muslim India, the provision of public hospitals can be traced back

to the Firuz Tughluq’s era (1351–1388). According to Jahangir's
autobiography, upon ascending to the throne, he issued a decree to establish
government-funded hospitals in major cities. 3
There was a limited availability of local physicians, and considering
the requirement for European physicians, especially surgeons, it seems that
the local physicians were unable to meet all the requirements. Nevertheless,
the overall health of the residents implies that the health services were not
entirely insufficient, and the local doctors were capable of handling typical
issues. According to a narrative in Iqbal Nama, a book written during
Jahangir's period, when a plague outbreak was imminent, mice would
behave erratically, rushing out of their holes and frantically hitting
themselves against doors and walls before eventually dying. 4As noted by
contemporary researchers, this observation encompasses two pieces of
information regarding the plague, which have been supported by modern
scientific findings: the connection between rodent deaths and the disease,
and the importance of evacuating infected areas. According to the account,
if the inhabitants promptly left their houses and sought refuge in the jungle
upon witnessing this sign, their lives would be spared. However, failing to
do so would result in the villager’s falling victim to death's grasp. 5

The Health System since 1947

From the previous British colonial rule, Pakistan inherited a health

care system that was heavily centralized. The government of Pakistan held
the responsibility of offering free national health care services to every
citizen, which included cost-free hospital care. While these services were
not particularly satisfactory, they were available in nearly all cities and
towns. In the area of health, human resources include people like doctors,
nurses, pharmacists, dentists, environmentalists, social scientists, public
health experts, and people who work hard to improve people's overall
health. 6
The health policies in Pakistan were shaped by the influence of its
colonial history, particularly by the health reports of the British. In October
1943, in India the British Government set up a "Health Survey and
Development Committee." This group came up with some important ideas
for how health services should change in the future. One of these ideas said
that no one should have to go without good medical care because they can't
pay for it. The committee suggested that health consultants be given the lab
and hospital tools they need to make sure that all patients are properly
40 Pakistan Vision Vol. 24 No.1, Jan.-June 2023

diagnosed and treated. The committee also talked about how important
preventive steps are. It said that medicine and preventive health care
services should be set up close to the people. Following Pakistan's
independence, the newly established government adopted most of the
committee's proposals, including the provision of free medical treatment for
all individuals in need and a strong focus on disease prevention. 7
In subsequent years, various commissions and panels of experts
conducted assessments of the development of the health sector in Pakistan.
One such commission was the Medical Reforms Commission, established
on November 24, 1959, which issued multiple reports between January and
April of 1960. These reports proposed the takeover of municipal hospitals
and envisioned a district-based model for health services, with a
hierarchical structure extending from districts to sub-districts and
dispensaries. In 1961, the Rural Health Centers (RHC) scheme was
introduced to provide fundamental healthcare services and a classified
system of medical care in rural areas of Pakistan. After many years, on June
twenty four, 1969, a new Health Study Group was appointed, and their
report was published in March 1970.8
The government started the "People's Health Scheme" in March
1972. It was aimed at preventing illness and improving health care in rural
areas. In October 1973, the Planning Commission came up with a set of
national rules that were in line with the scheme's goals. With the goal of
making health planning easier, the government and the World Health
Organisation worked together to make these standards even better. Then, in
1978, Pakistan officially accepted the "Health for All (HFA) by the Year
2000" plan of the World Health Organisation. The government's first plan
for a national health policy was presented in January 1990.9According to
the 1990 National Health Policy (NHP), the people of Pakistan suffer
greatly from diseases, many of which could have been easily prevented. The
policy emphasized the necessity of enhancements in essential areas such as
clean water, sanitation, housing, and birth control in order to address these
challenges.10
The subsequent National Health Policy in 1997 expressed its
objective to revitalize and enhance health policies in alignment with
contemporary health paradigms. It acknowledged that the former health
policy had not sufficiently addressed all aspects of primary healthcare
(PHC) and the Health for All (HFA) strategy. The policy sought to enhance
the responsiveness of healthcare services to current health demands in
accordance with the HFA principles. Additionally, It named HIV/AIDS,
International Development Partners and Health Sector in Punjab from 1999-2006 41

cancer, diabetes, road traffic crashes, violence and crime, mental health, and
tuberculosis as some of the new health problems.11

National Health Policy: (NHP2001) and Health Indicators (1999-2006)

The 2001 health policy NHP endeavors to revamp the healthcare

sector with the objectives of disease prevention, health promotion, and
enhancing the general health condition of the populace, aligning with the
principles of Health For All(HFA).12

In Pakistan, particularly in Punjab province, the overall health

condition is characterized by disparities based on rural-urban divide,
income levels, and gender. The gender ratio between males and females was
one hundred and seven in urban areas and one hundred and five in rural
areas. 88 babies died for every 1,000 live births in rural areas, while only 65
babies died for every 1,000 live births in urban areas. In urban places,
female babies died at a rate of 70 deaths per 1,000 live births, while male
babies died at a rate of 60 deaths per 1,000 live births. Also, babies born to
mothers who didn't go to school had a higher death rate (89 deaths per 1,000
live births) than babies born to mothers who went to school for more than
10 years (49 deaths per 1,000 live births).
The overall childhood immunization rate in Pakistan was 53%, but
Punjab province fared slightly better at 57%, while Balochistan lagged
behind at only 24%. Income-based discrepancies were evident in childhood
immunization, as the poorest quintile in Punjab province had coverage rates
50% lower than the richest quintile. Malnutrition played a significant role in
maternal and infant deaths. Communicable diseases accounted for almost
40% of the disease burden, reproductive health issues contributed to 12%,
and nutritional deficiencies accounted for 6%. Punjab province seems to be
in the early stages of the epidemiological transition, where preventable or
easily treatable diseases that primarily affect young children and women are
responsible for a significant portion of morbidity and premature mortality.13
In Punjab, only 40% of women seek prenatal consultations at
healthcare facilities, while the national average for Pakistan is 35%. Out of
these women, 42% choose to visit a government hospital or clinic. Prenatal
consultations are particularly low in rural areas, with only 31% of women
receiving them compared to sixty four% in the cities of Punjab.
Additionally, only forty three% of pregnant women are getting a single
tetanus injection, with the national figure for Pakistan being 38%. In rural
areas, the percentage of women receiving a tetanus injection drops to 37%,
42 Pakistan Vision Vol. 24 No.1, Jan.-June 2023

while it rises to 63% in urban areas. The rate of institutional deliveries

among pregnant women is quite low, with only 20% delivering in
healthcare institutions. Out of these, 12% opt for private facilities, while 8%
choose government facilities. In cities, the institutional deliveries is merely
thirteen %, contrasting with forty four % in urban areas.14

The objective of the Health Department is to deliver high-quality

healthcare services to the people by establishing an accessible, equitable,
culturally acceptable, affordable, and sustainable service delivery system.
Health reforms should focus on transforming healthcare delivery and
shifting from supply-driven to demand-based interventions. To enhance
public health, it is crucial for public health specialists to transition from an
academic approach to a more practical one.

Despite substantial investments made between 1999 and 2006 to

expand the healthcare service delivery network, there has been limited
improvement in the health status of impoverished individuals. The
implementation of reform measures occurred rapidly and extensively,
resulting in various imbalances and mismatches within the sector, mainly
due to the public sector's inability to effectively manage and sustain the
reform process.
While there has been a significant increase in the availability of
resources in the health sector and a commendable level of locative
efficiency has been achieved, these developments were not based on a
comprehensive approach, leading to the emergence of new imbalances.
Although primary healthcare received better financial support than ever
before, its underutilization remains a significant concern.
Preventive programs face ongoing challenges in integrating into the
mainstream health delivery system, despite their growing significance
within the sector. While the decentralization initiative has resolved some
immediate issues, it still needs fine-tuning to address local needs and
requires significant capacity to effectively manage devolved service
delivery.15
Having adequate medical equipment is crucial for providing quality
health services. Unfortunately, our public sector facilities face challenges in
this regard. They either lack essential equipment, have equipment that is in
disrepair or outdated, or even underutilized. The absence of manuals or non-
compliance with them contributes to the underutilization of these critical
pieces of equipment.
International Development Partners and Health Sector in Punjab from 1999-2006 43

From the viewpoint of the economically disadvantaged, the most

pressing issue is the shortage and absenteeism of nurses and paramedics,
particularly noticeable in rural areas. Despite the fact that the majority of
users of public healthcare facilities are from the lower-income segments,
there is no mechanism in place to ensure adherence to established standards
and procedures. Overall, the health system exhibits a bias toward tertiary
and urban healthcare, neglecting the needs of the underprivileged. 16
The lack of sufficient funding and planning capacity has led to an
unfair distribution of public sector health services, resulting in significant
challenges related to the quality and accessibility of healthcare. Health
facilities in rural and remote areas, which are often understaffed and
inadequately financed, struggle to provide the necessary level of healthcare
services to the local population. Moreover, the absence of incentivized
salary packages further hinders healthcare staff from serving in these
challenging and isolated areas, where a large portion of the poor and
vulnerable groups reside. 17
PFIS reports that low utilization of health facilities particularly by
poor, women and children confirm that existing service provisions don’t go
with the local needs. 1819

Primary Health Care in Punjab

The primary healthcare (PHC) network in Punjab is composed of

Basic Health Units (BHUs) and Rural Health Centers (RHCs) located at the
union council and Markaz levels, respectively. At the district and Tehsil
levels, Tehsil and District Headquarters Hospitals provide essential
specialized services. These hospitals are responsible for addressing the
majority of medical and surgical needs, as well as emergency healthcare
services. In certain larger towns, specialist clinics and teaching hospitals are
also present.
The primary healthcare systems in Punjab have a number of
problems that make them less effective. A thorough analysis shows that
some of the biggest problems are Staff absence, low use of services, poor
standard of care, limited planning, lack of ownership, and a lack of strong
referral links between Primary Health Care and Rural Health Centres are all
problems. 20

The primary health care facilities face a significant issue of staff

absenteeism, which can be attributed to disappointingly low salaries, the
absence of residences and transportation for health service providers, and
44 Pakistan Vision Vol. 24 No.1, Jan.-June 2023

other related factors. Also, chronic absenteeism at the basic health care level
is caused by poor internal management that lacks monitoring and evaluation
tools, as well as a lack of effective external checks and community
involvement. Staff at Basic Health Units (BHUs) and Rural Health Centres
(RHCs) are also less likely to do their jobs well if they don't have enough
medical equipment and important drugs.21
At the basic health care level, low use of health care facilities is
another very important problem. PHC facilities aren't used as well as they
could be because of things like bad locations, infrastructure that is falling
apart or is missing, staff absences, drug shortages, and a lack of medical
tools.
Planning that is limited and one-size-fits-all, along with a lack of
ownership, hurts the way basic health care services are given. The planning
horizon is limited by the fact that planning is uniform and based on projects.
Also, vertical programmes with narrow provincial and district roles make it
hard for high-poverty places to be targeted in an effective way. This shows
how important industry planning is?
Because there aren't good links between basic health care (PHC) and
secondary health care (SHC), the quality of services at the BHU and RHC
levels is very low. Lack of proper guidance and health education for
illiterate and poor rural people, lack of information about services available
at PHC outlets in rural communities, complicated patient enrollment
procedures, and lack of transportation and ambulance services all contribute
to the disconnect and lack of referral links between primary and secondary
health care tiers. 22
Regrettably, the public sector fail to meet the needs of susceptible
sectors of society, particularly the poor, children and women. The Poverty
Focused Investment Strategy prepared under the PRMP highlights that the
public health sector primarily concentrates its investments in secondary and
places where most tertiary health care institutions are found in larger
cities.23 This trend results in inefficient allocation of public resources and
misaligned priorities within the health sector.

Infrastructure and Facilities

Pakistan's public health system is made up of four different levels of

care. First of all, Lady Health Workers offer services in the community for
mother and child health, family planning, immunisation, and malaria.
Second, there are 2,489 Basic Health Units (BHUs) and 301 Rural Health
Centres (RHCs) that provide basic care. These places offer preventive care
International Development Partners and Health Sector in Punjab from 1999-2006 45

and only a small amount of treatment. A BHU usually has four pros
working there. On a higher level, Rural Health Centres (RHCs) are basic
care facilities with 20 beds and a staff of about eight professionals,
including four medics. There are 77 Tehsil Headquarters Hospitals. They
offer inpatient and outpatient care, have 40–60 beds, and are run by 3–5
experts. District Headquarters Hospitals have anywhere from 80 to 250 beds
and provide second-line care for people who need it. Last but not least,
there are 17 teaching hospitals in big towns. These hospitals offer
specialized care and are connected to medical schools for training at both
the bachelor and graduate levels. 24

Millennium Development Goals (MDGs)

MDGs number 4, 5 and 6 specifically relate to the health sector

which have been discussed in this part of the paper.
Most people agree that the Millennium progress Goals (MDGs) are
a good way to measure how far progress has come. They include many
important health goals, such as reducing the death rate among children,
improving the health of mothers, and dealing with HIV/AIDS, malaria,
tuberculosis (TB), and other infectious diseases. They also stress the
importance of gender equality in reaching these goals. However, during the
period of 1999 to 2006, the health sector faced significant challenges that
hindered the effective targeting of the MDGs at the primary health care
(PHC) level. These challenges included an urban elite bias, which resulted
in a disproportionate allocation of resources towards tertiary-level care, and
a fragmented approach to preventive health measures. These obstacles
severely undermined the efforts and initiatives of the health sector in
striving to achieve the MDGs.”25

A) Reduce Child Mortality

Child mortality played a significant role in the overall mortality rate

within the province, particularly among children under the age of 5. The
primary reasons of child death included pneumonia, diarrhea, malaria,
measles, and malnutrition. Notably, there was a considerable disparity in the
Infant Mortality Rate (IMR) and mortality rates for children under the age
of 5 across different districts of the province. 26
46 Pakistan Vision Vol. 24 No.1, Jan.-June 2023

B) Improve Maternal Health

The Pakistan Reproductive Health and Family Planning Survey

from 2000-01 found that the maternal mortality rate (MMR) was shockingly
high at 533 deaths per 100,000 live births. But the numbers ranged from
260 to 300 per 100,000 live births in the region of Punjab.27
The Maternal Mortality Ratio (MMR) remained worryingly high,
ranging from 670 to 4,472 per 100,000 live births. What's more concerning
is that there was no significant decrease in these rates over the past various
years. The administration of Rural Health Center (RHC) services exhibited
fragmentation, with services being delivered at four different levels without
proper management-level coordination. These levels include community-
level services provided by Lady Health Workers (LHWs), primary
healthcare level services delivered through District Governments, services
provided at referral hospitals, and initiatives funded by the Annual
Development Program (ADP) limited to specific geographical areas. 28
Most maternal deaths were attributed to direct obstetric causes that
could have been prevented. The primary causes, both in the public and
hospitals, included blood loss, eclampsia, sepsis, obstructed labor, and
abortion. Several clinical factors contributed significantly to this situation,
including:

1. Insufficient presence of skilled professionals during childbirth

2. Inadequate provision of immediate postnatal care
3. Insufficiency in the availability of essential medications and medical
supplies
4. Limited access to basic emergency obstetric care
5. Inadequate availability of comprehensive emergency obstetric care
6. Insufficient provision of post-abortion care29
An additional objective should focus on increasing access to
information, building capacity, and expanding the availability of various
contraceptive methods to promote family planning and enhance maternal
and child health. While current efforts to educate people about
contraception have led to a widespread awareness of contraceptive use and
a subsequent reduction in fertility rates, there is a lack of knowledge
regarding alternative contraceptive methods. It is crucial, therefore, to raise
awareness among individuals about the advantages and disadvantages of all
available methods, particularly emphasizing the risks associated with
frequent and closely spaced pregnancies.30
International Development Partners and Health Sector in Punjab from 1999-2006 47

C) Combat HIV/AIDS, Malaria and Other Diseases

Communicable diseases are a significant public health issue, causing

a heavy disease burden. In Pakistan, the HIV/AIDS pandemic has had a
lasting impact since 1987. Unfortunately, routine HIV screening for
pregnant women during antenatal examinations was disregarded and not
prioritized within the country's socio-cultural framework. In the 1980s and
1990s, there was an increase in HIV infections among mainly men who
lived or traveled abroad. As a result, some of these men passed on the
infection to their wives, who, in certain cases, transmitted it to their
children..31
In the 1990s, incidents of HIV and AIDS were documented within
several vulnerable populations, including sex workers, injecting drug users,
long-haul truck drivers, and individuals in correctional facilities. 32
HIV infections and AIDS cases have been consistently increasing
throughout the province in all regions. According to the WHO/UNAIDS
forecast model, the estimated number of cases represents approximately
0.1% of the adult population. In Pakistan, the primary modes of HIV/AIDS
transmission are heterosexual contact (51.4%) and the use of contaminated
blood or blood products (12.5%). Additional modes of transmission include
injecting drug use (2.2%), homosexual or bisexual activity (4.2%), and
mother-to-child transmission (2.4%). There is a significant gender disparity
in reported cases, with a maletofemale ratio of 7:1 for HIV-positive cases
and 8:1 for AIDS cases.33
The reported cases only scratch the surface, and the actual number
of cases could be significantly higher. Partial research findings suggest that
HIV prevalence among vulnerable or high-risk populations ranged from one
percent to two percent.”34
48 Pakistan Vision Vol. 24 No.1, Jan.-June 2023

Other Major Programs under MDGs

Besides the curative health care, the major programs / project of

health department contributing to the achievement of MDGs

a) National Program for Primary Health Care & Family Planning and
Nutrition.
b) Control of Diarrheal Diseases
c) Enhanced HIV/AIDS Control Programme (2003- 08)
d) Malaria Control Programme (MCP)
e) T B DOT35

a) National Program for Primary Health Care & Family Planning

The National Program for Primary Healthcare (PHC) and Family Planning
(FP) plays a vital role in reducing childhood malnutrition through the
following actions:
1. Monitoring the growth of all children under the age of three.
2. Promoting exclusive breastfeeding for the first six months.
3. Enhancing appropriate weaning practices.
4. Providing supplements such as multivitamin syrup for children and
iron-folate supplements to pregnant and lactating mothers.
Until 2006, insufficient attention was given to promoting child nutrition,
including addressing protein-calorie and micronutrient deficiencies.
The main objective of the National Programme for Primary Health Care and
Family Planning is to target rural communities, with a particular focus on
women of reproductive age and children under five years old. Presently, the
program has a workforce of 38,015 Lady Health Workers (LHWs), and an
additional 5,738 LHWs are undergoing training. The program has also
broadened its reach to offer essential healthcare services to economically
disadvantaged households in both urban and rural settings.
However, the program faces several challenges, including:
1. Understaffing at primary healthcare outlets, particularly at Rural
Health Centers (RHCs) and Basic Health Units (BHUs), which
hampers the provision of technical support, backup assistance, and
referral services.
2. Constraints arising from the part-time nature of service provision,
affecting the timing and accessibility of first-level care facilities.
International Development Partners and Health Sector in Punjab from 1999-2006 49

3. The absence of full-time job positions for District Coordinators,

impacting their ability to effectively carry out their responsibilities.
4. The program faces competition with other preventive programs in
the districts, with Executive District Officers (EDOs) ranking the
program as low priority due to its federal nature.
5. Inadequate skill mix among management staff, potentially limiting
their ability to address programmatic challenges effectively.
6. Low motivation and commitment among staff, posing challenges to
the program's overall effectiveness.
7. Feedback on monitoring processes is insufficient, hindering the
program's ability to track and evaluate its progress effectively.
8. Concerns regarding sustainability arise after the withdrawal of
federal support, raising questions about the program's long-term
viability. 36
Reforms in this domain should prioritize institutional innovations,
encompassing both internal improvements and the establishment of public-
private partnerships. It is essential to foster sustainability and enhance
supervision by fully devolving responsibilities to district governments,
while the provincial government assumes the role of capacity development
and outcome monitoring. This approach aims to drive effective change and
ensure long-term success in the healthcare sector.

b) Control of Diarrheal Diseases

Diarrhea remains a significant cause of illness and death among

children under the age of five. In the year 2004, there were a total of 84,548
reported episodes of diarrhea, with 14% of cases progressing to moderate or
severe dehydration. The majority of diarrhea cases, over 90%, were
attributed to the ROTA virus. To address this problem, the most effective
approach was to replace fluid and electrolyte losses, and oral rehydration
therapy (ORT) emerged as the most efficient method for achieving this
goal. ORT plays a crucial role in combating diarrhea by restoring the lost
fluids and electrolytes in affected children.”37Oral rehydration solution
(ORS) was very important to the community, and the Lady Health Workers
(LHWs) in the National Programme for Primary Health Care and Family
Planning were a big part of that. Also, ORS was made available at all public
health centres. The WHO/UNICEF-led Control of Diarrheal Diseases
(CDD) programme helped bring more attention to oral rehydration. But this
50 Pakistan Vision Vol. 24 No.1, Jan.-June 2023

project was stopped because other things became more important. To bring
the project back to life, the following steps must be taken:
1. Revitalize the CDD program to address the control of diarrheal
diseases effectively.
2. Establish ORT corners in all health facilities to ensure access to
oral rehydration therapy.
3. Conduct a public awareness campaign to educate the community
about the prevention and appropriate management of diarrhea.
4. Provide training to healthcare professionals and paramedics in
oral rehydration therapy (ORT) techniques. 38
c) Enhanced HIV/AIDS Control Programme (2003- 08)

The plan targeted this goal in Punjab was “Enhanced HIV/AIDS

Control Programme (2003- 08).39The programme aimed to HIV/AIDS
below 1 percent of all adults. There are problems with the programme
because different parts of society are against it, and the law makes it hard to
help disadvantaged groups. In the middle term, the program's main goals are
to provide targeted services for vulnerable subgroups of the population,
make it easier for the general population to avoid HIV, and stop HIV/STIs
from spreading through blood transfusions. The comprehensive range of
services aimed at sub-groups of vulnerable populations encompasses
activities such as monitoring and coordinating at-risk groups within the
project area, implementing a Behavior Change Communication (BCC)
strategy, providing education and facilitating access to suitable and
culturally appropriate services for sexually transmitted diseases and primary
healthcare, delivering voluntary counselling and testing (VCT) services,
dispensing condoms alongside educational materials, and fostering a
supportive environment.40
The program's objective is to prevent HIV transmission through
Behavior Change & Communication, which entails enhancing the general
public's knowledge and adoption of preventive measures for HIV, including
the utilization of high-quality STI services. Advocacy efforts aim to create
an enabling environment for the involvement of various stakeholders in
HIV/AIDS prevention, while also increasing public awareness through the
dissemination of accurate information via electronic and print media.
Skill development of healthcare workers is another key target,
utilizing existing networks of healthcare services to disseminate HIV/AIDS
information and prevention materials effectively. Additionally, the program
International Development Partners and Health Sector in Punjab from 1999-2006 51

emphasizes infection control by developing, distributing, and promoting

adherence to national guidelines and policies on infection control measures.

Lastly, the program recognizes specific vulnerable groups that may

not necessarily be high transmitters of infection but are at increased risk due
to unique exposure and vulnerabilities. These groups are given specific
attention and targeted interventions to address their HIV/AIDS-related
concerns.

d) Malaria Control Programme (MCP)

Malaria has reemerged as a notable infectious ailment and has

assumed the position of being the foremost tropical malady of interest for
the World Health Organisation (WHO). It holds the third position among
the primary causes of mortality resulting from infectious ailments,
following Pneumococcal Acute Respiratory Infections and Tuberculosis.
Malaria continues to be a significant public health concern in Pakistan,
persistently endangering the lives of millions of individuals. The task of
malaria management has become progressively challenging due to
alterations in environmental conditions caused by both natural and human
factors, significant population migrations to regions where the disease is
prevalent, escalating concerns regarding the resistance of parasites to drugs,
and restricted financial means. The available data from the provincial
Malaria Control Programme (MCP) suggests that the prevalence of malaria
in Punjab is comparatively low, thereby not meeting the criteria for being
classified as a significant public health concern. The Annual Parasite
Incidence (API) is the metric used to quantify this phenomenon.41
The Malaria Control Programme (MCP) says that it is very
important to keep effective control measures in place to make sure that the
Annual Parasite Incidence (API) does not go above 0.5 cases per 1000
people. As a partner in the global Roll Back Malaria (RBM) effort, the
MCP puts a lot of focus on reducing the morbidity and mortality caused by
malaria. This is done by catching problems early and treating them right
away. Also, in places where there is a lot of malaria, steps are taken to get
rid of vectors, like spraying indoors to kill mosquitoes. The goal of these
activities is to target and reduce the number of vectors that spread malaria in
homes. By using all of these tactics together, the MCP tries to control
malaria and lessen its effects on the people who are affected.42
In its attempts to stop malaria, the MCP got help from the NP for
PHC & FP. As part of this partnership, LHWs were taught how to help
52 Pakistan Vision Vol. 24 No.1, Jan.-June 2023

people who might have malaria before they were sure they did. But there
have been some problems that have slowed down the programme. There
isn't a clear strategy framework, the monitoring system isn't very good,
there are a lot of empty positions, the service structure isn't very appealing,
and the people at the district level don't seem to care or take ownership.
These problems need to be solved if successful malaria control is to be
achieved and the programme is to be a success. 43
The Malaria Control Programme had a mission to significantly
reduce the malaria burden by 50% within the next 10 years. This objective
was to be achieved by implementing effective strategies aligned with the
Roll Back Malaria (RBM) initiative, utilizing interventions tailored to local
needs, fostering strong partnerships across multiple sectors, and
strengthening the health sector as a whole. The proposed five-year plan
represented a crucial step in attaining the global RBM target set by the
World Health Organization (WHO) of reducing the malaria burden by 50%
by the year 2010. The overarching goal of the project was to coordinate
nationwide efforts for the successful implementation of the RBM initiative
in Pakistan, with the targeted timeline for completion set as the year 2006.44
1. The primary means of achieving malaria control involves enhancing
the preventive, diagnostic, therapeutic, and surveillance services of
the health systems, particularly in the context of decentralizing
health services.
2. The implementation of an Integrated Vector Control Programme
that involves the collaboration of both public and private sectors, as
well as community participation, is necessary to ensure the
sustainability of control measures.
3. The implementation of effective elements of health education can
enhance community awareness.
4. The Rolling Back Malaria initiative's approach is founded upon
several fundamental components:
5. Effective methodologies and procedures, such as oversight,
surveillance, and other related measures.
6. Prompt identification and swift intervention.
7. The prompt discusses the timely detection and management of
outbreaks of infectious diseases.
International Development Partners and Health Sector in Punjab from 1999-2006 53

8. There are various strategies for prevention.

9. The concept of conducting focused operational research is being
considered.
10. The establishment of sustainable collaborations with governmental
and non-governmental entities, both domestically and abroad.45
e) T B Control

According to the World Health Organisation (WHO), the estimated

incidence of all types of Tuberculosis (TB) in Punjab was 177 cases per
100,000 population. The target demographic for tuberculosis (TB) control
encompassed the entirety of the populace inhabiting the region of Punjab,
which was estimated to be around 83.9 million individuals. The DOTS
strategy, also known as Directly Observed Treatment, Short-Course,
achieved a coverage rate of 85% among the population. Nonetheless, the
rate of identifying cases for tuberculosis in the population covered by
Directly Observed Treatment, Short-Course (DOTS) was only 47%, which
did not meet the intended goal of 70%. The rate of success in treatment was
74%, which fell short of the anticipated target of 85%.
The programme has effectively initiated the implementation of DOTS in
twenty four districts, with the remaining ten districts currently undergoing
training and logistical preparations. As of June 2005, the Directly Observed
Treatment, Short-Course (DOTS) programme had undergone expansion
across the Punjab region. The programme has successfully established 210
diagnostic centres and more than 200 treatment centres throughout the
province. The Directly Observed Treatment Short-Course (DOTS)
programme has recorded the registration of over 60,000 patients afflicted
with tuberculosis. Of these patients, 50% have successfully concluded their
treatment. The Punjab Tuberculosis Programme (PTP) has implemented a
range of inventive strategies, including:
1. Workshops on quarterly surveillance across districts.
2. The implementation of an electronic reporting system has been
proposed as a means to enhance surveillance capabilities.
3. Inter-sector collaboration with the Punjab Employees Social
Security Institutions is a crucial aspect to consider in the pursuit of
effective and efficient service delivery.
4. The collaboration between the Aga Khan Health Services and
Pakistan Anti-TB Association Pakistan is a mix of public and
private sectors.46
54 Pakistan Vision Vol. 24 No.1, Jan.-June 2023

The programme had to deal with a number of problems, such as the

need to create a model for urban DOTS implementation, get tertiary care
hospitals involved, encourage the use of fixed-dose combinations of Anti-
Tuberculosis Treatment (ATT) medicines, set up a Quality Assurance
model for sputum smear microscopy, help TB patients and their families get
better, and deal with the social stigma that comes with TB. To get rid of TB,
a long-term sickness, will take planning and work over a long period of
time.
To make the programme work better, we need to come up with more
Public-Private Partnership (PPP) ideas for working together. Setting up a
method to send TB patients from teaching hospitals to the closest facilities
is important to make sure care stays consistent and transitions go smoothly.
Also, there should be more community involvement by getting councillors,
teachers, religious leaders, and other community volunteers involved. Their
participation can help raise knowledge, get rid of negative stereotypes, and
build stronger support networks for TB patients and their families. 47

Conclusion

This study examines poverty alleviation in Punjab from 1999 to

2006 and the role of International Development Partners like the IMF and
World Bank. There are two schools of thought on poverty reduction in
Pakistan, particularly in Punjab. One group believes poverty has decreased
due to government and international efforts, while the other group argues
that the natural resources of developing countries are being destroyed, and
heavy investments from international financial institutions have not
effectively reduced poverty.
The study suggests that there has been a clear reduction in poverty in
Punjab, but isolating the impact of international assistance is challenging
without comprehensive data. Various factors, along with foreign assistance,
have contributed to the social and economic improvement in Punjab.The
World Bank defines poverty as hunger, lack of shelter, limited access to
healthcare and education, unemployment, powerlessness, and lack of
representation and freedom. International partners have played a significant
role in poverty reduction in Punjab by providing resources and expertise. To
strengthen the health system, the study recommends the preparation of an
Operational Manual, improved management procedures, capacity building,
and incentivized attitudinal change. It also emphasizes the importance of
creating a new cadre of public health professionals and involving
communities to enhance health service delivery in the province.
International Development Partners and Health Sector in Punjab from 1999-2006 55

Notes and References

1
John Fryer, A New Account of East India and Persia, ed. by William Crooke (3 vols.;
London, 1909–1915); Edward F. Oaten, European Travelers’ in India (London, 1909).

2
François Bernier, Travels in the Mogul Empire, A.D. 1656-1658, trans. by A. Constable
(London, 1914),439. The European travelers found that the people had less energy than in
colder areas, but they enjoyed their health more. From what they said, it sounds like even
the weather was good. People who come to the country with any of these diseases are soon
completely cured. The general level of health also went up because the Mughals put a lot of
stress on physical fitness and pushed men to play manly games outside. The goal was to
teach everyone to be a soldier, a good rider, a good shikari (hunter), and able to stand out in
games. At Surat, the English were "much less active and athletic than the Indians. It's
possible that the Europeans' drinking habits made them more likely to get sick in the
tropics.

3
Parmatma Saran, The Provincial Governments of the Mughals (Allahabad, 1941), 419–40.
4
Mutamid Khan, Iqbal Nama, quoted in Edwards and Garrett, 279
5
Modern scholars have pointed out that this finding is based on two facts about the plague
that have been confirmed by modern science: the link between the disease and the death of
rodents and the need to leave the infected area.Ibid.
6
Khan, M.M., &Vanden Heuvel, W. (2005) , The Impact of Political Context upon Health
Policy Process in Pakistan. Public Health, Accepted pending revisions.
7
Ibid.
8
Khan, M.M., & Van den Heuvel, W. (2005b). Description and Content Analysis of the
National Health Policy of Pakistan. Asia Pacific Journal of Public Health, Accepted
pending revisions
9
Ali, S.ZHealth for All in Pakistan: Achievements, Strategies and Challenges. Eastern
Mediterranean Health Journal. 6(4),(2000),832-7.
10
National Health Policy 1990. Islamabad. Government of Pakistan, Ministry of Health.
11
National Health Policy 1997. Islamabad. Government of Pakistan, Ministry of Health.
12
Nina Gera.Social Sector Expenditures and Outcomes, A Case Study of the Punjab in
1990s,Pakistan Economic and Social Review,vol,45,Number 1.Summer(2007).50-52.
13
State of Human Rights in Pakistan in 2006(MaktabJadeed Press: Lahore,2006),274.
14
Ibid
15
Punjab Devolved Social Services Delivery programmes (2005) ADB.
16
Human Rights Commission Report (2006).
17
Ibid.
18
Poverty Focused Investment Strategy Papers, (2005).
19
Health Sector Reform Framework, jointly developed by Punjab Resource Management
Programme Planning and Development Department Government of the Punjab and Health
Department Government of the Punjab,2006.
20
State of Human Rights in Pakistan,(2006)
21
Ibid
22
Ibid
23
Ibid
24
Muhammad Aslam, G R Pasha and CH Muhammad Azam, “Reproductive Health Status
of Women in Pakistan: A Case Study of Multan District”, Biannual Journal of Gender and
56 Pakistan Vision Vol. 24 No.1, Jan.-June 2023

Social Issues, Spring/Summer 2005, Vol. 4, Number 1-2, Fatima Jinnah Women
University, Rawalpindi, 64.
25
Pakistan Millennium Development Report,2004,26
26
Ibid
27
State of Human Rights (2006)
28
PFIS (2005)
29
Scoping study on social exclusion in Pakistan, 2003.
http://www.dfid.gov.uk/Pubs/files/pakistan-social-exclusion.pdf
30
PDSSP (2005)
http://www.pdssp.gop.pk/downloads/documents/rrpr-post-1-4-25-Nov.pdf
31
Dawn,5 January,2006,p6
32
Health Department Punjab / P&D Department / PFIS (2005)
33
PFIS (2005)
34
HRCP
35
Punjab devolved social services programme report (2005)
http://www.pdssp.gop.pk/downloads/documents/rrpr-post-1-4-25-Nov.pdf retrieved on 24
may 2008, 3-45 pm.
36
PDSSP (2004) http://www.pdssp.gop.pk/downloads/documents/rrpr-post-1-4-25-
Nov.pdfretrieved on 23 August 08 2-45 pm.
37
Health Department/ P&D Department, Punjab
http://www.pndpunjab.gov.pk/user_files/File/PunjabEconomicReport2007-08.pdf retrieved
on 23 September,08, 01-35 pm.
38
PFIS report (2005)
39
The News,25February,2003,3.
40
P&D Department, Punjab. Health Department/ P&D Department, Punjab
http://www.pndpunjab.gov.pk/user_files/File/PunjabEconomicReport2007-08.pdf retrieved
on 11 September ,08,2-25 pm.
41
Health Department/ P&D Department, Punjab
http://www.pndpunjab.gov.pk/user_files/File/PunjabEconomicReport2007-08.pdf
42
Ibid
43
Ibid
44
PFIS (2005)
45
The News,24 July,2004,3.
46
PFIS (2005)http://www.punjab-prmp.gov.pk/pfis/retrieved on 23 may 2008 12 -35 pm .
47
The News, 24 July, 2004, 3.