Health Dept

L.S.M.F stands for Licentiate of State Medical Faculty, R.M.
P stands for Registered Medical Practitioner,
Health dept. govt of Punjab http://pportal.punjab.gov.pk/portal/portal/mediatype/html/group/348?page_name=348home&group_type=dept&group_id=348&group_name =Health&js_pane=P-1004ba76975-10000&pview=true Outline of HEALTH CARE SYSTEM IN PAKISTAN 1. Introduction to health care system 2. Ministry of health 3. Health care structure 4. Public health system 5. Access to health sector 6. Current issues and initiative 7. Policies regarding health care system(health care spending and govt exp in pak) 8. Strategies to support health system 9. Health sector corruption 10. Conclusion and recommendation
L.S.M.F stands for Licentiate of State Medical Faculty, R.M.P stands for Registered Medical Practitioner,
INTRODUCTION TO HEALTH CARE SYSTEM Health care in Pakistan is administered by Ministry of Health. Like other South Asian countries, health and sanitation infrastructure is adequate in urban areas but is generally poor in rural areas Brief History of the Health Care System Pakistan at the time of its independence in 1947 inherited a health care delivery system that was a legacy of colonial British period. This rudimentary system was in the shape of public health services and some curative services. It was essentially designed to prevent large scale epidemics and provide curative services for the population in large and medium sized towns, many of which were along the lines of communication or political or strategic consequences During initial phase (1947-1955), most important initial problem was the replenishment of staff. In addition to other programs, BCG vaccination campaign was launched with the support of UNICEF and two medical schools were opened in the West Pakistan. From 1955 onwards, developmental activities were affected in phases of five year and each phase was known as Five Year Plan. During Five Year Plan (1955-1960) Six new medical colleges, including one for women were opened in both wings. A nursing school was attached to each of these medical schools. Postgraduate institutions were established. A bureau was established to produce vaccines and sera. During five year plan (1960-1965), under the recommendations of a Medical Reform Commission, Rural Health Center scheme to cover 50000 populations by each unit, two Health Technicians Training Institutes were opened, family planning program, and a malaria eradication program were launched. Five year plan (1965-1970) In addition to continuation of the aforementioned initiatives, witnessed launching of Tuberculosis Control Program and Small pox eradication programs. The major infrastructure
of the public health care system was set up in the 1970s. Pakistan endorsed the "health for all by 2000" initiative which had been launched by the World Health Organization. Government launched an extensive infrastructure and policy building initiative. From the villages to the cities different levels of health care were started like the "Basic health units" for the villages. The Tehsil headquarter hospital represented secondary health care, and district hospitals and teaching and referral units represented tertiary care units. Along with this a significant public health campaign was launched for the first time, keeping in view local needs and WHO guidelines to meet the target. These were: An expanded program of immunization to eradicate the prevalent infectious diseases; Malaria control program; Tuberculosis control program; Family planning program; Diarrhea and pneumonia control programs; and many others. To monitor all these and to achieve further improvements and make sure the policy was being applied the national institute of health was created. During fourth five year plan (1970-1975), Quota of medicines was substantially increased for major hospitals, a generic name drug system was introduced to bring down the prices of medicines, eight state-owned fair price drug shops were opened, six new medical colleges and three new nursing schools, and one public health school were opened. The fifth five-year plan (1978-1983) was scheduled for 1975-1980, But to cover the deficiencies and to make a more realistic plan, the slight shift was made. Under a process of a Country Health Program (CHP), that aimed at improving planning and management of health services. Under CHP it was recommended that rural health coverage be increased at least to 50%, in addition to others, striking the communicable diseases, combating malnutrition, food adulteration and industrial hygiene were highlighted. During Sixth five-year plan (1983-1988), government launched extensive rural development program that provided sound base for Health for all by the year 2000. Seventh five year plan (1988-1993): Alma Ata declaration of 1978 remained the basis of all five years plan afterwards. During seventh five-year plan, new health facilities (Basic Health Units and Rural Health Centers) were established, a female
Medical technician school was established, and health facilities were provided with Laboratory facilities. Health facilities were linked with semi-skilled, trained paramedics termed as community health workers. Third health project was launched aiming at improving MCH services. Second Family Health Project was started to improve the health of masses in general and that of women in particular. Minimization of drug abuse, establishment of national school health services and goiter control were other salient initiatives under this plan. In Eighth five year plan (1993-1998), Health management information system (HMIS), Social action program (SAP), and Prime Minister Program for Family Planning and Primary Health Care were launched During Ninth five year plan (1998-2003) Decentralized Planning, levying user charges for financing, public private partnership and privatization of health facilities were the areas of programming. The strategy of the plan was to consider the gains already achieved in the previous plan and to improve the quality of service by creating a balance of promotive, preventive and curative services and removal of management weaknesses of the health system. In 2003-2008 programs the government has aimed to bring about Programmatic and Organizational and Management Reforms. These are to foster alleviation of poverty agenda of government, under health sector reforms, devolution has acquired immediate importance and major impetus is on district health system. At federal level a policy analysis and reform unit is being established. The new Health Policy 2001 considers health sector investment as a part of governments Poverty Alleviation Plan. It gives more importance to primary and secondary health services as opposed to tertiary level health services in the past. Good governance is seen as a basis of health sector reform to achieve quality health care.
http://en.wikipedia.org/wiki/Ministry_of_Health_%28Pakistan%29 Ministry of Health: (final) The Ministry of Health of Pakistan is a government agency responsible for Pakistan's health system. It is a branch of the Government that is the department for provision of medical services, responsible to frame the health policies and to enforce the same at a national level. It is headed by the Health Minister of Pakistan on democratic level. At bureaucracy level, Federal Secretary (Health) is in-charge who is assisted by Director General (Health), Chie f (Health), two Joint Secretaries, one looks after finance and development and the other deals with administration. Besides the federal health department, each of the four provinces of Pakistan has its respective health department and Secretariat, under the supervision of a health minister of that province, controlled by a Secretary, Additional Secretaries, Deputy Secretaries, and a Director General Health Services, assisted by Director and Deputy Directors. All stand responsible to control, manage, administer medical service matters to the citizenry of their jurisdiction and frame and enforce health policies in their respective provinces in line with that promulgated by the federal health department. Function of Ministry of Health: (final) As per Rules of Business, functions of the Ministry of Health are: National Planning and Coordination in the field of health. Dealings and agreements with other countries and international organizations in the fields of health, drugs and medicines. International aspects of medical facilities and public health; International Health and medical facilities abroad. Scholarships / fellowships, training courses in health from International Health Agencies such as WHO and UNICEF. Medical, nursing, dental, pharmaceutical and allied subjects: Maintenance of educational standards.
Education abroad; and Educational facilities for backward areas and for foreign nationals, except the nomination of candidates from Federal Administered Tribal Areas for admission to Medical Colleges.
Standardization and manufacture of biological and pharmaceutical products Vital Health Statistics. Medical and health services for Federal Government employees. National associations in medical and allied fields such as the Red Crescent Society and T.B Association. Coordinating medical arrangements and health delivery systems for the Afghan refugees. Legislation pertaining to drugs and medicines, including narcotics and psychotropic, but excluding functions assigned to the Pakistan Narcotics Control Board Administration of Drugs Act.1976 and Poison and dangerous drugs Prevention of the extension from one province to another of infectious and contagious diseases. Lunacy and mental deficiency. Administrative control of the Pakistan Medical Research Council, (PMRC), Islamabad. Administrative Control of the National Institute of Handicapped (NIHD), Islamabad.
HEALTH (economic survey of Pakistan) At present, there are 972 hospitals, 4842 dispensaries, 5344 basic health units and 909 maternity and Child health centers in Pakistan. With availability of 144,901 doctors, 10,508 dentists, 73,244 nurses and 104,137 hospital beds in the country by 2010-11, the population and health facilities ratio works out at 1222 persons per doctors, 16,854 persons per dentist and 1701 persons per hospital bed which compares well with the other developing countries. During 2010-11, 35 basic health units and 13 rural health centers have been constructed. While 40 rural health centers and 850 basic health units have been upgraded. Some 4500 doctors, 400 dentists, 3200 nurses and 5000 paramedics have completed their academic courses and 4300 new beds have been added in the hospitals. Some 96,000 Lady Health Workers (LHWs) have been trained and deployed mostly in the rural areas. Moreover, some 8 million children have been immunized and 24 million packets of ORS distributed. Various health programmes with a special focus on major public health problems have been carried out. These include cancer treatment, AIDS prevention and Malaria Control Programme. The total outlay of health is budgeted at Rs.42.0 billion (Rs.18.7 billion development and Rs. 23.3 Billion current expenditure) which is equivalent to 0.23 percent of GDP which is 79 billion as compared in 2009-10. Summary No. of Districts No. of BHUs (in Punjab) 36 2456
TOTAL BHUs ARE 2456 BUT 6 BHUs ARE NON-FUNCTIONAL Rural Health Centers - RHCs (Punjab)
Summary No. of Districts No. of RHCs (in Punjab) Tehsil Head Quarters - THQs (Punjab) 36 289
Summary No. of Districts No. of THQs (in Punjab) 36 80
District Head Quarters - DHQs (Punjab)
Summary No. of DHQs (in Punjab) 35
1. Public Health System Under the Pakistani constitution, health is primarily the responsibility of provincial governments, except in the federally administered territories. The Federal Government is however, responsible or planning and formulating national health policies, although the responsibility for implementation rests largely with the provincial governments. The federal Ministry of Health is responsible for the implementation of some vertical programs on AIDS and malaria, and extended program of vaccination. Health care provision in Pakistan comprises private and public services. The private sector serves nearly 70% of the population, is primarily a fee for service system and covers the range of health care provision from trained allopathic physicians. Neither private, nor non government sectors work within a regulatory framework and very little information is available regarding the extent of human, physical, and financial resources involved. The public sector comprises more than 10,000 health facilities ranging from Basic Health Units (BHUs) to tertiary referral canters. At present a BHU covers around 12,000 people Where as the larger Rural Health Centers (RHCs) cover around 30000-450000 people. In Pakistan, Primary Health Care (PHC) units comprise both BHUs and RHCs. The Tehsil Headquarters Hospital covers the population at sub district level whereas the District Headquarters Hospital serves a district as its name suggests. Currently there are 22 tertiary care facilities in Pakistan, which are mostly teaching institutions located in the major cities. Less than 30 % of the population uses the facilities of the PHC units and some studies indicate that, on average, each person visits a PHC facility less than once a year. The reasons for their under utilization, are the relative lack of health care professionals and specially women, high rates of absenteeism, poor quality of services and inconvenient location of PHC Units. In addition, The Pakistan Army, railways, departments of local government and autonomous organizations provide healthcare to their employees, who form a significant portion of the population. Planning for health care in Pakistan comprises a formal planning, which resolves around the production of 5-15 year long term plans, short-term plans (ADP). The Federal Ministry of Planning and Development, popularly known as Planning Commission, is primarily responsible for long term and strategic planning, and the Ministry of Health and Provincial Health Departments design their plans in line with the overall policies of the Planning Commission. Developing appropriate plans that can be implemented requires information on
health status in conjunction with other social development indicators. Needs assessment for health care programs in Pakistan is usually based on the size of the population in an area. The specific needs of that area are often not taken into account directly, nor other issues such as access to services and disease pattern. Where as the private sector is primarily a fee-for-service system. The public health sector at present generates a negligible amount of resources through token user charges. The main source of financing of the public sector is the government. Capital investment in the public sector is financed through Annual Development Plans (ADPs) that also include external funding derived from foreign aid (overseas funding) from both bilateral and multilateral organizations. Federal government substantially finances provincial development budgets, but the provinces make independent regarding allocation of funds over various sectors. The provincial non Development budgets are funded from provincial government revenues, although the Federal Government covers existing deficits through non obligatory grants. Although public sector expenditure on health has remained less than 1% of GNP for a long time, per capita health expenditures have increased enormously in last decades.
Access to Health Care Services In Pakistan, as of 2009-10, the child health care trend shows that 100 children out of every thousand die before reaching their fifth birthday and 73 infants out of every thousand die before their first birthday. Figure 1 presents the trends in achieving the child health care targets under MDGs. It is clear from the graph that there is a desired need to invest in the child care health to achieve the MDG targets by 2015
. The human capital available for health care services in Pakistan has gradually improved over the period of time. There are 163026 doctors and 25633 specialists, registered with the Pakistan Medical and Dental Council (PMDC). In addition, 10518 general practitioners and 751specialists registered as dental surgeons .Though there is annual output of around 5,000 medical graduates from both private and public medical colleges, the current ratio of one doctor per 1222 persons. According to the WHO international standards, the ratio of doctors to nurses should be 1:3; however this is reversed in the case of Pakistan, i.e., ratio of doctors to nurses is 3:1 in Pakistan. Indeed the government of Pakistan is committed to train and provide door-step health care services through Lady Health Worker (LHW) program however this would only help the poor and disadvantaged areas in the provision of first aid / primary health care and not the secondary and/or tertiary health care.
In the provision of health care services the private sector plays an important role, i.e., private sector provides almost 80 percent of the outpatient services. According to the PSLM (Pakistan social and living standard measurement) (2009-10), as many as, 77 percent households consult the private sector against only 23 percent to the public sector. These private sector consultants include: private clinics/hospitals, chemist/ medical stores, and/or pharmaceutical industry are the main service providers in the private sector. Moreover, a large number of persons consult homeopathic and tabbibs.
Current Issues and Initiatives Social and economic determinants of health Macroeconomic situation. The poverty level in Pakistan increased from 26.1 percent in 1996-97 to 39.1 percent in 2009-10. Due to stringent macroeconomic adjustments, better financial and budget management, remittance from abroad and sustained growth, the macroeconomic situation of the country has improved since the end of the 90s. The improved level of foreign reserves along with the increased commitment of donor has increased the fiscal space for the provision of necessary social investments and for vital infrastructures. The increased fiscal space has led to some increase in overall expenditure on health but continues to be less than that projected in the Poverty Reduction Strategy Paper (PRSP). Social sectors. The population growth is estimated at 3.6% per annum and poses a challenge to the government to create jobs and to provide health and education services. Pakistan ranks 134 in the 2009 UNDP HDI (Human Development Index) and most of its social and development indicators compare poorly with countries of similar level of economic development. UNDP estimates that in 2004 around 90% of the population had access to improved water sources and almost 60% had sustainable access to improved sanitation facilities. The latter is a substantial improvement from 37% in 1990. Health System Governance There is an increasing commitment to health development in Pakistan, which is also reflected in increased amount of resources allocated to the development budget for health at the federal and provincial levels.In addition, health is considered a priority in the Vision 2030 of the government for which work has been initiated in the Planning Commission.
Health system reforms are concurrently being undertaken in the two provinces visited by the mission. In NWFP, the reforms range from financing of the health sector, contracting out and improving the quality of health services, and developing a policy on human resource. The reform process is assisted by the World Bank with technical assistance from the German Agency for Technical Cooperation and DFID (department for international development). In Punjab, the reform process is focusing on improving primary health care services by providing financial incentives and improving salaries of health professionals, creation of positions for midwives and lady health workers at BHU levels, provision of medicines and continuous professional development. There is however lack of coordination among the provinces in the reform process and the federal government has so far not fulfilled its coordination function. A national health policy unit was established in the federal MOH in 2004 with the technical assistance of W.H.O and financial support of DFID. The unit is in early phase of development. Its role within MOH organizational structure needs to be institutionalized and its capacity both in terms of human and financial resources needs to be strengthened for it to deliver on its mandated role of furnishing evidence for the much needed health policy and system reforms in the country. Despite the many constraints, the NHPU was able to constitute a National Health Policy Council, contribute to the health sector reform agenda for the Pakistan Development Forum 2006, and is now playing a more proactive role in the formulation of the new national health policy. In addition, it relationship with provincial DOHs and their health planning and reforms unit needs to be strengthened. The recruitment of staff in recent months provides some hope but there are concerns that the project might expire on June 30, 2007 unless the new PC-1 of the NHPU is approved and funded by government or another development partner.(flash check) The process of development of the new national health policy has been led by the Pakistan Health Policy Forum, an NGO-led forum, which brings together the Government, development partners, and civil society through a consultative process with the provinces and other stakeholders. Based on discussion with the coordinator of the Forum, it seems that the new policy has followed a balanced approach to the importance of health systems and programs. It is critical that the NHPU MOH plays an increasing role in the formulation of the national health policy as this has indeed to be a government led process. There are indications that the Policy Unit and the Forum are collaborating and there will be a smooth handing over of the policy document before it is finalized and announced by the federal MOH.
Another important initiative is the establishment of a high level National Commission for Government Reform, which has a sub-committee on health. The committee is considering several reform initiatives in health that focus on good governance to improve the quality of essential health services. These reforms are essential and needed to bring rapid improvements in health services at the point of delivery. At the same time there is a need to review and reform the organization and functioning of the federal MOH, provincial DOH and district health offices to address some of the underlying governance issues that are responsible for the poor health services in the public and the private sector. In this regard essential functions such as institutional mechanisms for strategic health planning, regulation and standard setting, health information and its use, and disease surveillance need to be strengthened at all level of the public health sector. Several bilateral donors led by the DFID and USAID and multilateral development agencies are active in the health sector in Pakistan. There is a forum of donors in which all big and small international health development agencies discuss health issues. However, there is a gap in their shared understanding of the health system issues in Pakistan and there is a lack of collective dialogue with the federal and provincial governments on these issues. In recent years there have been increasing opportunities for a dialogue between the government and its development partners, however, it needs to be better informed by evidence and be well coordinated. The government has established a policy coordinating committee with its development partners, which can play an active role in evolving a unified response to health system development in the country. WHO can play a catalytic role in helping the government to make this committee more active in accordance with the Paris agenda on aid effectiveness, as well as, in increasing its technical capacity to engage in a Dialogue on health system development? Human Resource Development There is a lack of clear long-term vision for human resource development and the federal MOH or provincial DOH does not have a unit, responsible for such an important health system function. The imbalances in health workforce in terms of cadre, gender and distribution are well known in Pakistan. The public sector continues to heavily invest its scarce resources in the development of medical colleges and universities rather than investing in improving quality and quantity of nursing institutions, public health schools and technicians training institutions.
Although there is a growing interest to address the identified shortcomings in human resources including scarcity of nurses, midwives, skilled birth attendants, dentists and pharmacists; future scenarios for tackling the misdistribution of health professionals and the imbalances in skill mix across the country have not been developed. A new national program for the training of community midwives, with considerable resources set aside for it, has recently been launched to tackle the shortages of personnel in this cadre. In addition, there have been recent attempts to establish new community midwifery schools and new nursing schools in some districts and provinces. Some academic institutions are also providing post graduate training in nursing in order to mitigate the crisis in nursing generated by limited production and external brain drain. In the context of health system development, there is a serious shortage of qualified health system specialists such as health and human resource planners, health economists, health information experts and health system and hospital managers. The capacity to train such expertise is limited to non-existent in the country, and there are very few competitive positions to recruit them in the federal MOH, provincial DOH and district health offices. Pre-service training of health professionals follows traditional methods and there is a mismatch between educational objectives, which focus on hospital based care, instead of addressing the needs of the communities for promotive, preventive curative and rehabilitative services. Some attempts to introduce innovative approaches including COME (community oriented medical education) in medical schools have not been successful for a variety of institutional and professional reasons such as the lack of involvement of the PM&DC from the beginning, weak department of public health in medical schools and poor commitment of government and heads of medical institutions . The regulatory systems are either weak (for licensing) or non existent (accreditation). The Pakistan Medical and Dental Council (PM&DC) is responsible for registration, licensing and evaluation of the medical and dental practitioners, curriculum review, evaluation and approval of educational institutions in these two categories, and many other regulatory activities. Although the membership of the council is broad covering most professions and including 52 members from almost all stakeholders, its coordination capacity to streamline the new policies and practices and to provide valid evidence on different aspects of human resources production
seems to be weak. PM&DC has recently been through a period of turmoil and its independent role has been questioned by the Ministry of Health. How well the PM&DC fulfills its roles and functions in the new situation is uncertain. There is a lack of organized continuous professional development (CPD) and there is no obligation for the health professionals to update their competencies. The attempts made by PM&DC have not materialized yet. The institutions for health professions education (medical and nursing schools) lack public health and community orientation in their programs. Graduates, unlike lady health workers, are not well prepared to practice in a PHC environment while these needs are most important. Regulation of private practitioners and different traditional categories of medical practice such as homeopathic doctors and Yunani Hakims is non-existent. Data on various categories of professionals are scarce and fragmented. Such situation is affected by the fact that registration is not updated and in some cases professionals are practicing without being registered. Pakistan is nevertheless endowed with important training and research institutions and highly qualified professionals who can contribute in the design and implementation of a well articulated policy and strategies for human resource development. Health Care Financing Estimates by W.H.O and other international development agencies show that the health system in Pakistan is clearly under funded. Total spending on health as a share of GDP is about 2.4 %, total MOH expenditure is 2.6 % of total government budget and 70 % of total spending is coming from out of pocket. The latter is the main reason behind the high level of payment at the point of service delivery at private facilities or user fee charged at public facilities, both of which are now well known to put unnecessary burden on the poor and promote inequity. According to an analysis carried out by the World Bank and the NHPU using data from Household and Income Expenditure Survey of Federal Bureau of Statistics, private expenditure is increasing in real terms over time but remains low by international standards. Like the case in many other countries, households in the lowest income groups tend to spend out of pocket mostly on medicines. Financial barriers, such as the high cost of health care in the absence of risk pooling1, explain the forgoing of health care by the lowest income quintiles. Resources generated by government through budgetary and other means, seem to be mainly allocated to hospital facilities at the expense of primary health care and preventive services. Also
there are concerns over the utilization of resources allocated to some federal and provincial public health programs or to public facilities in general. Such situation may be linked to weaknesses in financial planning and management at both provincial and district levels, which result in the lack of understanding of the total resources available, the flow mechanisms, and the speed with which they flow thereby hampering implementation. In recent years, however, the major national programs managed by the federal government have had large increase in budgets and at the same time have shown improved utilization pattern indicating improvement in their absorptive capacity. Decision makers at federal and provincial levels seem to be aware about the need to mobilize more resources for health, particularly through public funding. Efforts are also being made to improve social protection for which a new national strategy is being developed the emphasis of which is on conditional cash transfers to poor household in exchange for actions that modifies their behavior to seek more social services including health. The overall understanding among public health professionals in the area of social protection in health is limited and the evidence insufficient. Studies to determine the feasibility of social protection interventions such as the development of prepayment schemes in the formal and informal sectors of the economy and to test the effectiveness of conditional cash transfer are essential for informing policy before any decision to scale up is taken.
POLICIES EMPHASISING HEALTH CARE SERVICES IN PAKISTAN Pakistan is in the middle of epidemiological transition where almost 40 percent of total burden of disease (BOD) is accounted for by infectious/communicable diseases. These include diarrheal diseases, acute respiratory infections, malaria, tuberculosis, hepatitis B&C, and immunisable childhood diseases. Another 12 percent is due to reproductive health problems. Nutritional deficiencies particularly iron deficiency anemia, Vitamin-A deficiency, iodine deficiency disorders account for further 6 percent of the total BOD. Non-communicable diseases (NCD), caused by inactive life styles, environmental pollution, unhealthy dietary habits, smoking etc. including cardio vascular diseases, cerebro-vascular accidents (hemiplegic), diabetes and cancers account for almost 10 percent of the BOD in Pakistan. A number of policies emphasize better health care service provision in Pakistan. These include: Millennium Development Goals; Medium Term Development Framework; National Health Policy. In the following sub-sections, we shall discuss some salient features of these policy documents underlining health related strategy.
Health Millennium Development Goals (2015) For the attainment of eight millennium goals, the UN Millennium Declaration fixed 18 targets and 48 indicators; of which Pakistan has adopted 16 targets and 37 indicators. Pakistan is a signatory to the UN Millennium Development Goals (MDG), 2000-2015. Three of the eight MDGs emphasize directly to health sector with four targets and sixteen indicators. The MDGs include: Reducing Child Mortality (1 target, 6 indicators); Improving Maternal Health (1 target, 5 indicators) and Combating HIV/AIDS, Malaria and Other Diseases (2 targets, 5 indicators).
Medium Term Development Framework (2005-10) The first Medium Term Development Framework (MTDF), 2005-10 provides guidelines to ensure equitable development in all the regions of Pakistan, having fully integrated economy with a sense of common and shared Destiny. The MTDF acknowledges the MDG targets and puts emphasis to continue and strengthen the shift from curative services to preventive, promotive and primary health care. Moreover, MTDF also addresses the issues of health care financing, health insurance and employees social security, and public private partnerships in the health sector. The MTDF also presents the health system in Pakistan at federal, provincial and district levels (under public health services) and private health services. Ministry of health at the federal level and health departments at the Provincial levels are responsible for public health service delivery in Pakistan. The public provision of medical and health services compromises of primary, secondary and tertiary health care facilities. Primary health care facilities mainly look after out-door patients. These facilities include: rural health centers, basic health units, primary health care centers, dispensaries, first aid posts, mother and child health centers, and lady health workers. Secondary health care services look after out-door patients as well as in-door patients. District and tehsil headquarter hospitals are the secondary health care establishments; each district and tehsil must have this facility.
Tertiary health care facilities are mainly present in major cities only. These facilities are affiliated with research and teaching organizations. Both the secondary and tertiary health care services are 24 hours operational.
MTDF highlights following major issues in the health service provision, Facing Pakistan: 1. Organizational Issues (a) In-adequacies in Primary/Secondary Health care Services (b) Urban/rural imbalances (c) Professional and Managerial deficiencies in District Health System (d) Gender equity (e) Unregulated Private Sector 2. Burden of Disease (BOD) (A) Wide spread prevalence of communicable diseases (b) Basic nutrition gaps in target population (c) Addiction and Mental Health 3. Deficient Health Education System
National Health Policy (Health Sector Reform) The National Health Policy (Ministry of Health, Islamabad), 2001, act as a collective framework and provides guidelines to the provinces while implementing plans in the health sector in accordance with their requirements and priorities. The present policy document is a blueprint of planned improvements in the overall national health scenario. It will require commensurate investments and interventions by the provincial governments for improving health infrastructure and healthcare services. The federal government will continue to play a supportive and coordinative role in key areas like communicable disease control programmes. The strategy of the health sector reform is to achieve accessible quality health care for all. The policy document identifies ten key areas: 1. Reducing widespread prevalence of communicable diseases; 2. Addressing inadequacies in primary/secondary health care services;
3. Removing professional/managerial deficiencies in the district health system; 4. Promoting greater gender equity; 5. Bridging basic nutrition gaps in the target-population; 6. Correcting urban bias in health sector; 7. Introducing required regulation in private medical sector; 8. Creating Mass Awareness in Public Health; 9. Effecting Improvements in the Drug Sector; and 10. Capacity-building for Health Policy Monitoring.
In each of these areas, strategic objectives have been identified and implementation modalities determined with an appropriate time frame for implementation and indication of targets wherever possible. The key to success of the health policy lies in its implementation at all levels with the collaboration of public and private sector, and assistance from international development partners. Within the public sector collaboration between ministry of health and provincial health departments and district and local governments would help in effective implementation of the health policy. Pakistans health sector: does corruption lurk? Error! Bookmark not defined. Poor governance, mismanagement, inefficiencies and corruption are often used synonymously in a health systems context. The connotation of corruption makes it distinctive though as the other three may be inadvertent and without the intent to benefit whereas the nuance corruption has is one of deliberate and illegal gains. Notwithstanding the vague separating lines between these expressions, it is best to address them together in a health systems context as they have complex interdependencies. What falls within the ambit of corruption in a health systems context? Various definitions have been proposed to label corruption. However these suffer from limitations owing to their lack of ability to encompass every facet of what might be classified within the purview of corruption. The two most commonly used definitions in the international literature are:
Use of public office for private gain, and the sale by government officials of government property for private gain However both of these exclude the private sector from the definition and would, by characterization, exclude for example, the corrupt practices in the domain of pharmaceuticals, to which the private sector is also a party. A broader definition of corruption characterizes it as a pattern which is seen to exist when a power holder, responsible functionary or office holder is by monetary or other rewards not legally provided for induced to take actions which favor whoever provides the rewards and thereby does damage to the public and its interests. Corruption should be classified into two categories; practices which involve measures that usually lead to monetary gains and others that involve non-monetary forms of corruption MONETARY GAINS Financial leakages Siphoning of public fund for private gains Illegal profits Benefits Incentives Pilferage Illegal fees Kickbacks Informal payments Petty corruption-over out allowances Procurement frauds/irregularities Bribe
Nonmonetary corruption: Failure to base decisions on evidence Deliberate lack of oversight by public officials Deliberate inattention to mechanisms that compel accountability Preferential treatment to well connected individuals Unfair hiring practices
The different modes of corruption Corruption at a governance and regulatory level At a governance level others forms of corruption also exist such as deliberate lack of oversight by public officials, unfair hiring practices and nepotism, inattention to staff accountably for misconduct, preferential treatment to well connected individuals, conscious lack of institutionalizing mechanisms to compel accountability also constitute corruption at a health systems level.
Corruption in the drug supply and registration system Corruption in drug supply and registration has a direct bearing on the performance of the health system and can reduce access to essential medicines, particularly for vulnerable groups. This practice involves both the regulators and the private sector and may involve any step along the drug supply chain, starting from registration, licensing and accreditation to the setting of prices, marketing of drugs and sale and procurements. In the procurement process, common corrupt practices include collusion among bidders kickbacks from suppliers and contractors to reduce competition and to influence the selection process, and bribes to public officials monitoring the winning contractors performance. Corrupt procurement officers can also purchase sub-standard drugs in place of quality medicines and pocket the difference in price. In hospitals, varying quantities of drugs and medical supplies are stolen from central stores and individual facilities and are diverted for resale for personal gain in private practices or on the black market. Corruption at the service delivery level Staff absenteeism and dual job holding Staff absenteeism and dual job holding is amongst the most serious issues at a health systems level in Pakistan; this undermines service delivery and leads to closed/under utilized public health facilities, which in turn undermines the equity and health objectives of the publicly financed health care. Informal Payments
Informal payments are defined as payments to individual and institutional providers, in kind or in cash, those are made outside official payment channels or are purchases meant to be covered by health care systems. Health care providers behaviors Under the law of the country, all publicly employed doctors are forbidden from practicing privately and many of them receive non-practicing allowances as part of their non salary allowances. That notwithstanding, most of them run lucrative private sector clinics while working in hospitals and often use the public sector leverage to boost practices in private facility settings. A number of unethical practices such as refusing to see patients in hospitals and referring them to private clinics are well established and are almost regarded as a conventional norm. Provider-driven over-consumption of health services, over-prescription, and over-use of diagnostics as well as violation of ethical guidelines in clinical practice are well established in Pakistan. In terms of the ethics of health care alone, frequent violations of the four basis principles of: the Right to autonomy, Right to privacy, Right to choose and Right to information are often seen.

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L.S.M.F stands for Licentiate of State Medical Faculty, R.M.

P stands for Registered Medical Practitioner,

Summary No. of Districts No. of THQs (in Punjab) 36 80

District Head Quarters - DHQs (Punjab)

Summary No. of DHQs (in Punjab) 35

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