An overview of the health system in Pakistan over the past 70 years offers evidence of efforts for better service delivery as well as challenges and impediments in this regard. The challenges have spread over a wide area including policy formulation, financing (or lack thereof), coordination of available resources and implementation at the level of end users – the people seeking healthcare. Attempts have been made to fill policy, financing and implementation gaps through different approaches, including participation of donor agencies and private sector. It has been argued that for health reforms to deliver, these must be strategic and outcome- and equity-oriented, with a comprehensive long-term focus on strengthening of health systems because programme-based interventions depend critically on the robustness of the health systems in the first place and are, hence, no alternate to these systems.
The last National Health Policy of Pakistan was approved in 2001. While a draft policy was developed in 2010, it was not approved due to the then ongoing process of devolution. In August 2016, the federal and provincial governments finally agreed on a common National Health Vision (NHV) for the entire country after years of controversies over health issues and disagreements over the regulation of health departments. The document incorporates suggestions from public sector stakeholders, the private sector, UN agencies, donors and academia, and has been endorsed by representatives of all provinces and federating units. NHV aims to bring the country’s health policy frameworks in line with Pakistan Vision 2025 (such as increasing health spending to 3 percent of the GDP), international health priorities and provincial realities within the framework of constitutional roles in the post-18th Amendment scenario.
The NHV notes that donor funding has been minimal in recent years with less than two percent of the total national health expenditure and underscores the need for better alignment and coordination of donor assistance with government’s strategies. Detailed policy options for coherent channeling of donor support for achieving improved outcomes and avoiding wastage of resources, however, have not been outlined.
Multilateral and bilateral donor agencies and development partners, offering financial and technical assistance for improving healthcare delivery in Pakistan include ADB, CIDA, DFAT, DFID, GTZ, IDB, IFRC, JICA, RCS, UNAIDS, UNDP, UNICEF, USAID, WB, WFP and WHO. Foreign aid, as a percentage of total health sector funding, has ranged from 3.5 to 16 percent in different years as shown in able 1.
Support from donors also comes in the form of technical assistance, specifically from UN agencies, and in kind contributions such as mobile health units, drugs, vaccines and diagnostic kits. There are other donors as well, including, for example, the Gulf States, overseas Pakistanis, philanthropists, INGOs and leading private sector entities providing resources to country in social sector areas including health, directly or through corporate social responsibility. Main fields of donor intervention are shown in Figure 1:
To meet the need for healthcare in Pakistan, private sector’s role has increased over the years. In the year 2009-10, it was reported that 87.6% of the population accessed healthcare from the private sector and 12.3% from public sector. In the wake of weak regulations and societal trends, however, the private sector has very few accredited outlets and there has been a mushroom growth of largely unregulated hospitals and small-scale medical units, general practitioners and clinics, homeopaths, Hakeems, Unani (Greco-Arab) healers, herbalists, traditional/spiritual healers, bonesetters and quacks. Some NGOs have been active in the health sector and there are few public-private partnerships (PPPs) and franchising of private health outlets.
PPPs for healthcare in rural areas have been tried but without much evidence-based planning and success. In 2015, Government of the Punjab tried a model of outsourcing health facilities and management of 10 districts but it did not work. In 2016, Punjab again offered health facilities in five low-performing districts to private sector. As per the TORs of this PPP, the private party will be responsible for maintenance of infrastructure, procurement and provision of medical and non-medical, supplies and consumables, enforcement of clinical and hygienic protocols, employing efficient administrative practices that ensure patient satisfaction, hiring of staff against vacant positions, ensuring efficient system for referrals between facilities, efficient management of outreach staff and developing strong linkages between the facility and outreach workers. The government would be responsible for ensuring consistency of supply of funds, providing funds as agreed in the contract, providing initial information on the status of facilities, facilitation and coordination with district officials, guidance and mentoring on quality regimes, ensuring adequate political support, monitoring and providing supplementary grants according to reasonable requirements.
There are gaps in proper utilization of the private sector as well for better healthcare delivery. Private sector is largely unregulated and whatever regulations do exist usually fall victim to weak enforcement mechanism. Apart from unregulated hospitals, the bigger challenge is control and check over quacks and traditional, obsolete healing procedures that can cause serious health problems. No policy tools have so far been formulated to harmonize the private sector with broader perspective of national health objectives and policies.
Donor assistance in the health sector does not come without its own complications and shortcomings. Absence of well-defined national priorities and a health system incapable of optimally absorbing and channeling donor resources, coupled with the fact that donors have their own policies, value and priorities, result in prioritized resource allocation by the donor agencies in specific programme-based areas that offer short-term measurable and tangible outcomes rather than interventions that could bring long-term system strengthening. A major cause of concern is that not only the effectiveness of specific donor projects is undermined due to this lack of coherence, it also has somewhat adverse impacts on existing health systems. It has been documented that continuous influx of donor-driven projects has inculcated a peculiar organizational culture in the public health sector, which influences the long-term sustainability and the effectiveness of these projects. Besides the well-known political interference and bureaucratic barriers, a less tangible and insufficiently recognized phenomenon of “Project Mentality” portrays this transformed culture in the public health sector in Pakistan. Any distorted organizational culture may affect the work environment and hence the ability of the health personnel to practice in a professional manner.
There are structural gaps in the way donor assistance is handled in the country. Foremost is the ownership, or lack thereof, at least in the apparent way things have shaped over the years, taken by the state for sustainability because health is a basic human right and primary responsibility remains with the state, no matter how extensive donor assistance may be. There is no national policy for utilization of donor support due to which international assistance is not properly synchronized with the national policies and becomes a victim of fragmentation within the national system. Lack of proper mechanism for sustainability makes the donor assistance an administrative burden. Weak coordination between the government and donor agencies, lack of clarity in roles and expectations of partners behind national health reform, lack of clear priorities, responsibilities and uniform benchmarks by the government for donors and poor mechanisms for sharing information between the government and donors are also key impediments in effective utilization of donor assistance in the country.
The donors and their development partners/executing agencies also put forth a number of challenges they face while working in Pakistan in general, and in the health sector in particular. To points of general objection, it was pointed out that the governments of the respective donor agencies provide funding out of their taxpayers’ money and according to their foreign policy, therefore, they are bound by certain limitations on what can be done, how and where, and what cannot be done. That’s why funds and interventions are time- and area-barred in many cases. Answering criticism merit and legitimacy of donor-based programmes, it was suggested that end-line surveys and evaluations by third-party evaluators are conducted for most of the projects, donors also have their own research and survey teams, no project is started without defining proper objectives and delivery outcomes, risk-management matrices are made at the start of the project by consulting most of the stakeholders and generally they works. They argue that donor projects do have positive impacts in specific fields of intervention but Pakistan has population explosion which dilutes the impacts or makes them negligible.
It can be concluded that numerous factors contribute to non-optimal utilization of donor assistance for healthcare in Pakistan. There is neither a proactive mechanism for taking need-based proposals to donors for tailor-made projects in the first place nor a clearly-defined policy for integrating donor-initiated projects in the national healthcare objectives by channeling and diverting resources where needed the most. Coordination with donors is lacking from national and provincial levels to district and health facilities levels. Bottom-up approach is totally missing. Starting from disjointed data on health indicators across fields, regions and over time, there is marked absence of field officers’ input not only at the stage of policy formulation but also in signing of agreements with donors. Fragmented databases exist but there is no joint/central health management information system in place that could provide data from across the country. Subsequently there are numerous implementation challenges and outcomes don’t materialize as envisaged, leaving the target population un-served in the real sense. Other problems include lack of sustainability framework on completion of donor projects, lack of incentives in the public setup for skilled health staff to perform, cumbersome procedures and financial management in the public sector and finally absolute mismatch in political priorities of successive governments. Inadequate regulatory framework for private healthcare providers (from full-scale hospitals to presumed healers in streets) and weak enforcement mechanism for regulations that exist have left private sector completely unchecked. PPPs have been tried without proper policy based on ground realities, which resulted in unsuccessful experiments.
- Health is a provincial subject after the 18th Amendment. Health Coordination Committees (HCCs) may be setup under executive orders in the four provinces, AJK and GB, headed by respective Secretary Health and comprising Chief of Section from P&D Departments, DG Health, provincial representatives of donor agencies and UN development partners working in the province. HCCs shall be required to meet every month.
- HCC will co-opt two members – one health expert with vast experience of field work across the province and one head/representative of a well-reputed philanthropic organization in the province. DCs/DCOs and EDOs Health will be called to HCC meetings whenever there is a proposal of their district under consideration.
- HCC will be presented with, to analyze, approve, monitor and evaluate, all donor-assisted programmes/projects, PPPs and philanthropic contributions in the province under the NHV.
- HCC will cause, through DG Health, for a comprehensive provincial health database to be developed, maintained and properly updated for evidence-based decision-making.
- HCC will be required to adopt a proactive approach vis-à-vis donor assistance and PPPs especially in rural areas i.e. based on data, forecast emergency and routine requirements from infrastructure development to availability of vaccines and drugs in the health facilities, prepare short-, medium- and long-term plans/proposals for meeting those requirements and then presenting them in HCC meeting before the donors for their assistance, rather than just relying on donor-initiated proposals which may not be specifically aligned with local needs at times.
- HCC will be required to focus on long-term goals of infrastructure development, improved working conditions for doctors and paramedical staff and better approach to health facilities in far-flung areas, and ensuring appropriate performance of duty by the staff.
- A National Health Coordination Committee (NHCC) may be setup, headed by Secretary MNHSRC and comprising Additional Secretary EAD, national representatives of donor agencies and UN development partners, and HCCs of all provinces. NHCC will be required to meet every three months.
- NHCC will be a coordination and regulation body, aimed at keeping provincial donor-assisted programmes in line with NHV, resolving issues between donors and provinces, if any, and supervising proper maintenance of a national health database by consolidating provincial databases provided by HCCs on monthly basis.
- District Health Coordination Committees (DHCCs) will also be setup, headed by DC/DCO and comprising District Nazim/Chairman, EDO Health, ACs, local representatives of donors/development partners, NGOs, and civil society representatives/community leaders.
- Under HCCs and DHCCs, government can enter into partnership with international donors and local philanthropists (optional) at district level
- Initially, the projects may be started in 5 to 10 districts from all provinces and, if successful, may be replicated in other areas.
- The projects will target preventive as well as curative diseases.
- DC/DCO would proactively identify the problem area for which the project(s) is/are to be initiated.
- Project(s) should be flexible enough to appropriate funds from curative side to preventive side and vice versa on requirement basis, with the approval of the HCC.
- Capacity and performance of District Hospitals, Tehsil Hospitals, RHCs and BHUs should be enhanced such that they serve as filter clinics for the tertiary and teaching hospitals of the respective province.