HEALTH SYSTEMS IN

PAKISTAN
Achievements, Challenges and
the Way forward

Dr Assad Hafeez FCPS, FRCP, PhD

Chief Health systems & Policy Unit
Federal Ministry of Health
Dec 2009
 Contents of the presentation
 Health and poverty
 Resources for health in Pakistan
 Health systems in Pakistan
 Health indicators and targets
 Achievements, Challenges and the Way
forward
 Essential Health Services Package
Health: A basic human right
 Health as a capital
THE VALUE OF HUMAN CAPITAL
WORLD BANK ASSESSMENT ON TOTAL WEALTH OF 192 COUNTRIES

CAPITAL
Human Capital
64% PHYSICAL
65% CAPITAL
15%
ILL HEALTH

Weakened HR capacity
NATURAL CAPITAL
MORE POVERTY 20%

Source: Sustainability and the Wealth of Nations, World Bank 1996

Health ↔ Economic growth
10% increase in 0.4 % increase in
=
life expectancy economic growth

 Effect more pronounced where life expectancies are lower

Source: Commission for Macroeconomics and Health, WHO, 2000

 Total Expenditure on Health
(Federal &Provincial)
Rs in Billions

Year Development Non-development Total Health

Expenditure
as % of GDP
2003-04 8.5 (25.9%) 24.3 (74.0%) 32.8 0.58

2004-05 11.0 (28.9%) 27.0 (71.0%) 38.0 0.57

2005-06 16.0 (40.0%) 24.0 (60.0%) 40.0 0.51

2006-07 20.0 (40.0%) 30.0 (60.0%) 50.0 0.57

2007-08 27.0 (45.0%) 32.0 (53.3%) 60.0 0.57

2008-09 33.0(45.5%) 41.1(54.5%) 74.0 0.55

Source: Economic Surveys of Pakistan

 Financing Health
Pak Afgh India Bangl

Indicator
Year 2006

Total health expenditure (THE) as % of GDP 2.6 9.2 3.6 3.2

General government exp. on health as % of THE 33.6 32.4 25 31.8

Private expenditure on health as % of THE 64.5 67.6 75 68.2

General government expenditure on health as % of total

7.5 6.2 3.4 7
government expenditure

Social Security expenditure on health as % of General

0.3 0 4.9 0
government expenditure on health

Per capita THE (US$) 19.37 27 29 12

Per capita government expend. on health (US$) 6.50 9 7 4

Source: National Health Accounts 2005-6

 Financing Health
Contributions to health care

3%

28%

Tax
Donors
Out of pocket
5%
Others

65%

Source: National Health Accounts 2005-6

 Health Investment by GoP & Partners
GoP (MoH & DoHs)= Rs 45 billions MoPW
Partners= Rs 11 billions 5%

Multilateral
10% Partners
21%

Bilaterals
6%

UN system
5%
MoH & DoHs
74%

Source: Inventory of H & P Investment Pakistan, GoP & WHO 2005

 Health Delivery System
Integrated Rural Health Complex

Health Care Providers Population Served

Specialists, Doctors,
Nurses, Paramedical Tertiary Referral Centers
Staff Hospitals

Specialists, Doctors,
Nurses, Paramedical District 100,000 – 300,000
Headquarters
Staff Hospital

Doctors, Nurses,
Paramedical Staff Rural Health 25,000 – 50, 000
Centers

Paramedical Staff Basic Health 5,000 – 10,000

LHWs Units

© 2006 POPULATION
REFERENCE BUREAU
 Burden of Disease
Mortality (Deaths) by Cause and Gender

Injuries
Females

Other Non-Comm Males

Neoplasms

Neuro-psy

Cardio-vascular
diseases

Diabetes

Nutritional deficiencies

Maternal /Perinatal
cond
Communicable diseases

0 50000 100000 150000 200000 250000 300000 350000

Source: WHO, 2007

 Age Pyramid

35 million 33 million
Ages 15-49 Ages 15-49

12 Current Approach to Reduction of

Maternal and neonatal Mortality
 Age Pyramid

62 million 58 million
Ages 15-49 Ages 15-49

13 Current Approach to Reduction of

Maternal and neonatal Mortality
 Health related MDGs
MDG Baseline Current Targets
indicator 1990 status 2015
Under 5 mortality
140 94 52
IMR
120 78 40
MMR
550 276 140
Births SBAs
18% 39% 90%
HIV prevalence
<0.01 <0.01 <0.01
TB cases detection
rate
- 90% 85%

Source: PDHS 2007

 Progress in IMR
110

78

55

40

1990 2007 2015

Current rate of change= 2.10/yr
Required rate of change=3.40/yr Ref: PDHS 2008.
 Achievements
 Lady Health Worker Program expanded
 National Health Accounts
 New Health Policy 2009
 Hepatitis control program reviewed
 Expansion of infrastructure
 Enhanced financial resources
 Major Challenges
 Low investment in health
 Rapidly increasing population
 Double burden of disease
 Emerging and re emerging diseases
 Absence of social safety nets
 Sub optimal performance of health
systems
 Unregulated private sector
 Way forward
 National Health Policy
 Public private partnership
 Social Security nets for poor
 Universal health coverage
 Essential Health services Package
 Essential Services Package
 Describes and defines functions of different
levels of the health system, as well as
resources and procedures to deliver them
 Functions
 Curative, Preventive, Promotive, Rehabilitative
 Resources
 Workforce, equipment, technology
 Procedures
 Guidelines, SOP, Quality management
 Components of EHP
 Maternal Newborn care
 Family planning
 Child health and immunization
 Non communicable conditions
 Emergency management
 Community outreach and preventive care
 Health education
 Referral linkages
 Management and Health information
 The ESP Matrix
MDG

The Community Health Team

Community
Health Indicators

Community Essential Services Package

Individual
Performance Promotion Prevention Cure Rehabilitation
Indicators Health Team
 Outcomes of successful
implementation of ESP
 Provision of universal access
 Social security net
 Poverty traps reduced
 Equitable health care for all
 Clear resource layout
 Public accountability
 Basis for public private partnership
 Tool for quality control
 BASIS OF NATIONAL HEALTH SERVICE
 HEALTH
A case for increased investment
 Basic services in ESP would require 10-13 $ per
capita government expenditure to ensure
universal coverage
 NHA 2005-06 shows current government
expenditure of 6.5 $ per capita i.e. 0.6% of GDP
 An increase to 1.2 to 1.5 % of GDP in next 5
years will ensure universal coverage of essential
health services to all Pakistanis
 Key to universal access

Information

HRH Technology

Financing ESP Governance

 Summary
 Pakistan has major health problems
contributing to increased poverty
 Financial and non financial constraints are
primary challenges
 Increased investment along with better
health systems performance is required
 ESP implementation has a potential to
achieve the MDG targets by targeting the
poor and provision of universal health
coverage