Health Strategy

PTI’s Reform Unit Health Policy Pakistan Tehreek-e-Insaf Vision

The Health Picture of Pakistan

Status of Health of the People of Pakistan

Status of Health of the People of Pakistan
• Shocking indicators
- Maternal and child health - Double burden of disease, Communicable and Non-communicable

Appallingly wide inequities
- Gender - Income - Rural-urban

• Elite Capture
- Focus on urban tertiary facilities - Neglect of Primary Healthcare

• Preventive care not a priority

Health Status of the Female Population/Mothers of Pakistan

Maternal Health
Maternal Mortality Ratio (per 100,000 live births)
400 350 300 260 250 150 200 150 100 50 0 140 100 48 99 200 170 350 330 250 220 200 240 300 260

50
21 0

37 29 35

2001

2005

2011

MDG 2015 Targets
WHO http://apps.who.int/ghodata/?vid=1320; http://undp.org.pk/goal-5-improve-maternal-health.html

Births Attended by Skilled Staff
Births attended by skilled health staff (%)
100 90 80 70 60 50 40 30 20 10 0 40 41 39 90 Thailand China Sri Lanka Malaysia Iran 99.4 99.3 98.6 98.6 97.3 62.2 52.7 38.8 26.5 18.7 0 20 40 60 80 100 120

Philippines India Pakistan Bangladesh
Nepal

2001

2005

2011

MDG 2015 Targets
WHO http://apps.who.int/ghodata/?vid=1320; http://undp.org.pk/goal-5-improve-maternal-health.html

Population Growth Rate
Population Growth Rate (%)
Pakistan Phillipines Nepal Malaysia Bangladesh India Indonesia Sri Lanka Thailand China 0 0.57 0.49 0.5 1 1.5 2 2.5 0.93 1.07 1.34 1.6 1.58 1.57 1.9

2.03

At this growth rate, 3.6 million children are added each year to the population
Population Council; The Economic Survey of Pakistan 2012

“Women are not dying due to diseases we cannot treat. They are dying because the Government has yet to make a decision that their lives are worth saving”
Mahmoud Fathallah

Status of Health of the Children of Pakistan

Infant Mortality
Infant Mortality Rate (per 1000 live births)
90 80 70 60 50 40 30 20 10 0 2000-01 2004-05 2010-11 Target 2015
WHO http://apps.who.int/ghodata/?vid=1320; http://undp.org.pk/goal-4-reduce-child-mortality.html

80 77 73 70 70 70

60
50 40 40 30 20 11 10 0 5 14 16 22 23 27 38 41 48

Child Mortality
Child Mortality Rate (under 5 per 1000 live births)
120
105 100 100 87 80 100 90

87

80
70 60 48 50 35 26 13 6 17 18 29 63

60

52

50 40

40

30

20

20
10

0 2000-01 2004-05 2010-11 Target 2015

0

4.8 million children died in the last decade

The World Bank; WHO http://apps.who.int/ghodata/?vid=1320; http://undp.org.pk/goal-4-reduce-child-mortality.html

Food Insecurity in Pakistan
• In Pakistan, 58% of the population is food insecure (consuming less than 2,100 kcal per day, year 2011) • 28% of the total population is extremely food insecure (consuming less than 1,700 kcal per day, year 2011)*
Food Insecure population
80% 70% 60% 50% 40% 30% 20% 28% 40% 58% 60% 72% 64% 58% 57%

10%
0%

http://www.wfp.org/food-security http://documents.wfp.org/stellent/groups/public/documents/ena/wfp225636.pdf *National Nutritional Survey, 2011

Stunting Rates
Historic Stunting Rates
50 45 40 35 30 25 20 15 10 41.8 36.3 41.6 43.7 50 45 40 35 30 25 20 15 10 43.7 36.9

National Stunting Rates
46.3

5
0 1985 1990 2001 2011

5
0 National Urban Rural

Stunting: Height-for-age; growth retardation Indicator for long term nutritional deprivation

In Pakistan, almost half of the child population of Pakistan is stunted and a third of the child population is malnourished

Status of Health Risks to general population of Pakistan

Communicable Diseases in Pakistan
Polio Pakistan risks being the last country in the world with endemic polio transmission - In 2010 alone, 192 Polio cases were registered in Pakistan Hepatitis • Pakistan is termed a Cirrhotic state, which indicates high burden of infectious Hepatitis • Nearly 10% of total population is reported to be affected by Hepatitis
– Hepatitis B: 2.4%; Hepatitis C: 4.8%; Hepatitis (A, D, E): 2.5%

Tuberculosis • Poor man’s disease, tied with malnutrition • Pakistan ranked 6th among 22 countries with the highest burden of TB
– 330,000 – 480,000 new TB cases registered each year
http://dawn.com/2011/03/20/10-per-cent-ofpakistans-population-suffering-from-hepatitis/

Non-communicable Diseases in Pakistan
• Pakistan has a double burden of disease issue – In addition to communicable diseases, Pakistan has a high burden of non-communicable diseases • More than 59% of deaths in adults are due to non-communicable diseases such as: – Heart disease, Diabetes, Blood pressure, Cancers etc. • High prevalence of: – Genetic disorders such as Beta Thalassemia – Mental Health problems • Most of them are preventable, but have been out of mainstream planning

Dental Health
• Dental caries (tooth decay) is the single most common chronic childhood disease in the country • More than 90 % of people over 60 have gum disease • Oral health is not integrated with other public health programs • There is no National Oral Health plan

Poor Sanitation
• Inadequate sanitation results in increased risk of disease and mortality leading to losses in education, productivity and time
– Most of existing sewerage systems are dysfunctional – Economic losses totaling $5.7billion (equivalent to 3.9 % of the country’s GDP) each year*

• 100 million people of Pakistan have NO access to sanitation facilities, out of which majority live in the Rural areas
WHO: http://www.who.int/features/factfiles/sanitation/en/index.html; The World Bank http://www.worldbank.org.pk/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/PAKISTANEXTN/0,,contentMDK:23167509~menuPK:293057~pagePK:2865066~piPK:2865 079~theSitePK:293052,00.html

Sanitation facilities in Pakistan
Total population with access to facilities (%)
60 50 40 30 20 10

Rural-Urban Divide
80 70 72

48 37

60 50 40 30 20 10 0 2010 34

0

% of rural population with access
% of urban population with access

Source: Data Bank, The World Bank

250,000 children die each year due to water borne diseases in Pakistan (UNICEF)

The Forgotten Children of Pakistan

Status of Health Governance in Pakistan

Health Allocations have remained static
Six decades of the dip and spike pattern in Pakistan’s Economic Growth Rate

0.8% of GDP (Rs. 165 Bn) allocated for Public Health in 2010-11
Choked Pipes. Oxford University Press, 2010.

Low Health Coverage
The Government provides no Health facilities to 132 million people of Pakistan, who pay for their health

Not provided for, by any means

Choked Pipes. Dr. Sania Nishtar. 2010.

Health Shocks
Health shocks have the most profound affect on household economy
Natural calamities, 7% Health shocks, 54% Economic shocks, 28% Agricultural shocks, 4%

Family matters, 4% Law and order, 3%

Planning commission - Government of Pakistan; 2005

Centralized and Flawed Governance
• Complete disarray of National Health Governance post 18th Amendment • Provinces have not devolved power to Districts • All decision making power concentrated in Provincial Headquarters
– Focus on transfers, postings, based on political and bureaucratic influence

• Absence of professional health management
– Health being managed as simple government line department and not as a ‘sector’

Centralized and Flawed Governance
• Lax regulation of private sector healthcare • Mismanaged public hospitals
– DHQ, THQ Hospitals provide only rudimentary specialist care – Hospital facilities grossly underutilized as they provide no value to the people – Specialist care focused at hospitals in a few large cities

• Prevention completely ignored by the entire Health system

Systemic Collusion
• There are 624 Rural Health Centers in Pakistan
– Rs. 78 Bn of Pakistani tax payer money has been sunk in establishing these RHCs – Approx. Rs. 7 Bn is budgeted annually for recurring expenses

• There are about 5,000 Basic Health Units in Pakistan
– Rs. 37 Bn sunk in establishing these BHUs – Rs. 15 Bn is budgeted annually for recurring expenses

• Without impacting the Health profile of the Rural Poor

Workforce and Health Facilities Shortfall
Pakistan remains critically short of Health workforce required to serve the people • The shortage is especially acute in numbers of
– Nurses, LHVs and Midwives and Paramedics – Pharmacists and Technicians – Dentists and Other Specialists (especially Eye)

• Population per hospital bed ratio of approx. 1600 has worsened for over 20 years

Stagnant growth in PHC Facilities
1200
1991

6000
2001

1000
2001

5000 4000
2001

2002

800 600 400
2001

3000 2000 1000 0

200 0
1947 1951 1961 1971 1981 1991 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

MCH

RHCs

TB Centers

1947 1951 1961 1971 1981 1991 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Dispensaries

BHUs

Economic Survey of Pakistan, 2011

The Health System of Pakistan

A system by the elite, for the elite, with the people missing from the equation

Health Strategy

PTI’s Health System – Policy Reform Unit The Way Forward Pakistan Tehreek-e-Insaf

The Way Forward
• In order to provide ‘Insaf’ in the delivery of Healthcare to the poor of Pakistan, the entire Health sector needs to be re-oriented and reengineered • This can only be done by a Government which has the:
– Vision to know what to do – Political Will to change the status quo – Ability to get it done

PTI’s Health System Vision
Improve Environment & other External Factors
Emergency
Water & Sanitation

Reform of health Governance System

Foster correct Behavioral / Individual Choices Emergency
Awareness of health hazards Healthy Diet

Federal - National Health Objectives

Food Adulteration • • • • Provincial Health Policy Health Workforce District Monitoring Research Institutions District – Operationalizing Health Service Delivery

Pollution

Healthy Lifestyle

Social Determinants

Financing

PTI’s 5 Point Health Plan
1. Paradigm shift towards Preventive Healthcare through action and Awareness on
– – – Water and sanitation crisis; Food and Drug adulteration Polio / Hepatitis / TB Healthy Diet and Lifestyle

2.

Complete decentralization and de-politicization of Health governance
– – Supported by a motivated and need-based Health workforce With the community at the center of Health governance and Health delivery

3.

Prioritize Primary Healthcare with special focus on
– – Mother and Child care School Health program

4.

Develop a thoroughly reliable and integrated Health Information System for evidence based planning and decision making

5.

Increase public Health funding from 0.8% to 2.6% of GDP
– From Rs. 165 bn today to Rs. 1,260 bn in Year 5

Agenda # 1
Paradigm shift towards Preventive Healthcare

1. Public Health – Prevention is better than Cure
• Sustained Awareness and Prevention programs will be launched to
– Control the spread of Communicable diseases
• Hepatitis, Tuberculosis, HIV

– Control spread of Non-Communicable Diseases
• Deterrence campaign against tobacco use and other addictive products • Prevention of common Genetic disorders • Promote a program of healthy diet and lifestyle

– Improve environment and external factors
• Vector control • Social determinants

1. Public Health – Prevention is better than Cure Improved sanitation and access to safe drinking water will be a high priority action of the PTI government to prevent waterborne diseases

• A community based mega sanitation and safe water program will be initiated
– Creation of specific funds at the District Level – Communities to implement and manage sanitation schemes
• Both Urban and Rural components

1. Public Health - Food and Drug Regulation
• Review and update Food and Drug regulation and legislation to prevent adulteration of Food and prevent the production of spurious drugs

• Ensuring uniform implementation of Food and Drug Policies through Transparency in governance and public awareness
• Setting up of internationally accredited Food and Drug testing laboratories

Agenda # 2 Complete decentralization and depoliticization of Health governance

2. Re-engineered Health Governance
• Create a Health Division at the Federal level with responsibility for National Health objectives
– International health commitments – National Health regulation

• Re-configure the role of the Province towards
– Health Policy formulation – Health Workforce capacity and quality – District monitoring and oversight – Research and in-service training Institutes

2. Re-engineered Health Governance
PTI is resolved to make the District a hub of provision of healthcare to the people of Pakistan • Creation of financially and managerially empowered District Health Boards
– CEO to be chosen by an open competitive manner

• Similar Boards to run DHQ / THQ hospitals with complete financial and managerial autonomy
– Upgrade to provide higher level of Tertiary / Specialist care – Create Forensic departments at every DHQ hospital

• Replace current antiquated management system with modern IT based MIS

2. Health Governance - Tertiary Care
• Upgrade THQ / DHQ Hospitals to provide a higher level of Tertiary / Specialist care at grassroots level • All Tertiary care hospitals will have to play a proactive role in connectivity with Districts • Upgrade all major Teaching hospitals to provide a wider range of specialist services of international levels
– Reducing the need of going abroad for treatment

2. Health Governance - Workforce
Develop a Health workforce appropriate to the needs of the country’s re-engineered Health system
• Update, modify and improve service rules / structures • Priority on training Nurses, LHVs, Midwives and other Paramedics to meet shortfall • Connecting selected DHQs to Public sector Teaching hospitals to deal with key shortages of workforce, particularly specialists • Developing Public-Private Partnerships of Private Medical colleges with selected DHQs for Tertiary care

2. Health Governance - Workforce
Raising standards of medical education • Upgrade the quality of medical education in public and private medical colleges
– Strengthen and depoliticize Statutory bodies of Doctors and Paramedics

• Continuous Medical Education Program to create incentives for quality
– Service structure will be directly linked to continuous medical education

• Develop Health Management as a specialization
– In the modern world, health management is one of the keys of health service delivery

• Upgrade the skills of Paramedic staff to free the Doctors from tasks which they are over-qualified to perform

Agenda # 3 Focus on Primary Healthcare

3. Primary Healthcare
• The Rural Health Center (RHC) to be the fulcrum of Primary Healthcare in its area
– RHC to oversee all BHUs and dispensaries in their catchment – BHUs to integrate the delivery of all preventive and curative services to its catchment area

• Elected Village Councils (under PTI LG Plan) to be integrated with the management of the RHCs and BHUs

3. Primary Healthcare
Mother and Child Health • At least half of all BHUs will have 24/7 Mother and Child Health Services equipped with fully functioning labor/delivery facilities • Reproductive Health including birth spacing • Immunization programs • School health services to
– reduce prevalence of malnutrition and stunting – Promote hygiene (including oro-dental)

3. Primary Healthcare
• Upgrade selected RHCs along major roads for Accident and Emergency
• Connect RHCs to BHUs with an ambulance service network

• Foster Public-Private partnerships to provide services where public sector infrastructure is insufficient • Initiate a program for deploying Dentists and Dental Technicians in all RHCs • Focus on controlling and preventing oral diseases through primary health care approach with community participation

3. Primary Healthcare
An RHC, which is a referral point for BHU’s, has the following functions:
EMOC Services X-ray, lab, ultrasound facilities Ambulance Facilities

Surgical Facilities

Blood Bank

20 Bed Medical Ward

RHC

HMIS

3. Primary Healthcare
Health Education
Communicable disease Screening and Control EPI

Nutrition Support

Vector Control

HMIS

Rehabilitatio n Services

Transportation and referral system

MNCH and FP and Out reach services

BHU

Resuscitation of emergencies

3. Primary Healthcare
Capacity building of each district to establish, develop and run its own primary, secondary and tertiary facilities to provide complete healthcare coverage to the residents. Primary Secondary Tertiary

Agenda # 4 Health Information System

4. Health Information System
• The 18th Amendment has resulted in the Federal government not being responsible any longer, while the Provinces have not built the capacity • PTI views this as a matter of urgent national security and will urgently
– Strengthen the institutional pillars of the National Health Information System – Build and consolidate various STREAMS of the health information system

6. Health Information System
Integration
– Health Management Information System
• • • • • Patient Management System Clinical Information Systems Administrative Systems Financial Systems Ancillary Services
RHC Center

DHQHs

THQHs

RHC

– Referral System

BHU

BHU

Out Reach Services

Out Reach Services

Data Transfer

4. Technology in Health
• Our approach to technology as a principle rather than strategy; areas of focus:
– Capitalizing on telecommunications to promote evidence-based, demand-driven, sustainable, and standards compliant e-health. – Enacting legislation, defining e-health standards – Linking all hospitals through the District Health Information System – Use of GPRS enabled Smartphone’s track workers locations for accountability

Agenda # 5 Public Health Funding

5. Public Health Expenditure
Year 2013 PTI Year 1 PTI Year 2 PTI Year 3 PTI Year 4 PTI Year 5 Health Budget (% GDP) 0.8 1 1.5 2 2.3 2.6%

In PTI Year 5, 2.6% of GDP equals Rs. 1,260 billion whereas at 0.8% of GDP, Health expenditure would have been Rs. 388 billion

Faced with illness, the poor become indebted, sell their assets or simply forego treatment

5. Protecting the Poor from Health Shocks
• PTI will create a Health Equity Fund to pay for the treatment of catastrophic illness of the Poorest of the Poor
– Using innovative IT based technology for registered hospitals to process funding requests – Using an automatic interface with NADRA database – Institute safe guards for validation of eligibility

– Technology will ensure the entire cycle from request to funding is completed within the shortest time frame
– Eligibility criteria will begin from the poorest of the poor

5. Health Insurance
• Create an enabling environment for private health insurance • Incentivize private sector employers to offer health insurance to all employees, not only those covered by Government Social Security network • Give private employers the choice of opting out of Social Security by registering in Government approved health insurance schemes

PTI’s Commitment in Health to the People of Pakistan

Deliverables in a PTI 5 Year Tenure
• PTI shall ensure that in 5 years there will be a 100% improvement in the existing coverage by the public sector • Sustained Preventive programs will have reduced the burden of Communicable and Non-Communicable Diseases • PTI will achieve all Health related MDGs related to Maternal, Neonatal, Infant and Child Mortality • A fully devolved national Health governance system with solid links to the community will be firmly in place

Deliverables in a PTI 5 Year Tenure
• PTI will sustain a robust Primary Healthcare network in the rural areas to ensure Health of the people of Pakistan at grassroot level • PTI will ensure the availability of safe drinking water and sanitation facilities across rural and urban Pakistan • National programs on Prevention of Blindness, prevention of Genetic disorders and Oro-dental diseases will be initiated • PTI will develop a need based workforce of Health in its tenure

In a 5 year PTI government, the Health profile of the people of Pakistan will dramatically change A healthy population across Rural and Urban areas will be contributing towards the building of a new Pakistan

Acknowledgements to the Health Advisory team
Dr. Fazl-e-Hadi Dr. Saeed Akhtar Dr. Mubashar Dr. Saleem and special thanks to PMA and Heartfile

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