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Health Strategy
Policy Reform UnitPakistan Tehreek-e-Insaf
PTI’s Health Vision
The Health Picture of PakistanStatus 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
WHO http://apps.who.int/ghodata/?vid=1320;http://undp.org.pk/goal-5-improve-maternal-health.html
Iran
Malaysia
Sri Lanka
China
Thailand
Phillipines
NepalIndia
Indonesia
Bangladesh
Pakistan
0
50
100
150
200
250
300
21 29 35 3748
99
170
200220
240260
0
50
100
150
200
250
300
350
400
350330
260
140
2001 20052011 MDG 2015 Targets
Maternal Mortality Ratio (per 100,000 live births)
Births Attended by Skilled Staff
Nepal
Bangladesh
Pakistan
India
Philippines
Iran
Malaysia
Sri Lanka
China
Thailand
0 20 40 60 80 100 120
18.7
26.5
38.8
52.7
62.2
97.3
98.6
98.6
99.3
99.4
0
10
20
30
40
50
60
70
80
90
100
40 41 39
90
2001 2005 2011 MDG 2015 TargetsWHO http://apps.who.int/ghodata/?vid=1320;
http://undp.org.pk/goal-5-improve-maternal-health.html
Births attended by skilled health staff (%)
Population Growth Rate
China
Thailand
Sri Lanka
Indonesia
India
Bangladesh
Malaysia
Nepal
Phillipines
Pakistan
0 0.5 1 1.5 2 2.5
0.49
0.57
0.93
1.07
1.34
1.57
1.58
1.6
1.9
2.03
Population Growth Rate (%)
Population Council; The Economic Survey of Pakistan 2012
At this growth rate, 3.6 million children are added each year to the population
“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
WHO http://apps.who.int/ghodata/?vid=1320; http://undp.org.pk/goal-4-reduce-child-mortality.html
0
10
20
30
40
50
60
70
80
90
7773
70
40
2000-01 2004-052010-11 Target 2015
Malaysia
Thailand
Sri Lanka
ChinaIra
n
Phillipines
Indonesia
BangladeshNepal
India
Pakistan
0
10
20
30
40
50
60
70
80
511
14 1622 23
27
3841
48
70
Infant Mortality Rate (per 1000 live births)
Child Mortality
The World Bank;WHO http://apps.who.int/ghodata/?vid=1320;
http://undp.org.pk/goal-4-reduce-child-mortality.html
0
20
40
60
80
100
120
105100
87
52
2000-01 2004-052010-11 Target 2015
Malaysia
Thailand
Sri Lanka
ChinaIra
n
Phillipines
Indonesia
BangladeshNepal
India
Pakistan
0
10
20
30
40
50
60
70
80
90
100
613
17 18
2629
35
48 50
63
87
4.8 million children died in the last decade
Child Mortality Rate (under 5 per 1000 live births)
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)*
http://www.wfp.org/food-securityhttp://documents.wfp.org/stellent/groups/public/documents/ena/wfp225636.pdf
*National Nutritional Survey, 2011
National
PunjabSindh
KPK
Balochist
anFATA AJK GB
0%
10%
20%
30%
40%
50%
60%
70%
80%
58% 60%
72%
28%
64%58% 57%
40%
Food Insecure population
Stunting Rates
0
5
10
15
20
25
30
35
40
45
50
41.8
36.3
41.643.7
Historic Stunting Rates
1985 1990 2001 2011
0
5
10
15
20
25
30
35
40
45
50
43.7
36.9
46.3
National Stunting Rates
National Urban Rural
Stunting: Height-for-age; growth retardationIndicator 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
PolioPakistan 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 yearhttp://dawn.com/2011/03/20/10-per-cent-of-pakistans-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:2865079~theSitePK:293052,00.html
Sanitation facilities in Pakistan
20002001
20022003
20042005
20062007
20082009
20100
10
20
30
40
50
60
37
48
Total population with access to facilities (%)
Source: Data Bank, The World Bank
20100
10
20
30
40
50
60
70
80
34
72
Rural-Urban Divide
% of rural population with access% of urban population with access
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
Choked Pipes. Oxford University Press, 2010.
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. Dr. Sania Nishtar. 2010.
Low Health Coverage
Not provided for, by any means
The Government provides no Health facilitiesto 132 million people of Pakistan, who pay for their health
Health Shocks
Natural calamities; 7%
Agricul-tural
shocks; 4%
Eco-nomic
shocks; 28%
Law and
order; 3%
Family matters; 4%
Health shocks;
54%
Health shocks have the most profound affect on household economy
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
Economic Survey of Pakistan, 2011
19471961
19812001
20032005
20072009
20110
200
400
600
800
1000
1200
1991
2001
2001
2001
MCH RHCsTB Centers
19471961
19812001
20032005
20072009
20110
1000
2000
3000
4000
5000
6000
2002
2001
Dispensaries BHUs
The Health System of Pakistan
A system by the elite, for the elite,
with the people missing from the equation
Health Strategy
Policy Reform UnitPakistan Tehreek-e-Insaf
PTI’s Health System – The Way Forward
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 re-engineered
• 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
Reform of health Governance System
Foster correct Behavioral /
Individual Choices
Federal - National Health Objectives
Provincial • Health Policy• Health Workforce• District Monitoring• Research Institutions
District – Operationalizing Health
Service Delivery
Food Adulteration
Water & Sanitation
Pollution
Emer
genc
y
Financing
Emergency
Awareness of health hazards
Healthy Diet
Healthy Lifestyle
Social Determinants
PTI’s 5 Point Health Plan1. 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 # 1Paradigm shift towards Preventive
Healthcare
• 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
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 # 2Complete decentralization and de-politicization 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 - WorkforceDevelop 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 - WorkforceRaising 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 # 3Focus 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
RHC20 Bed
Medical Ward
Surgical Facilities
EMOC Services
X-ray, lab, ultrasound
facilities Ambulance Facilities
Blood Bank
HMIS
An RHC, which is a referral point for BHU’s, has the following functions:
3. Primary Healthcare
BHUMNCH and FP and Out
reach services
Rehabilitation Services
Vector Control
Health Education
Communicable disease
Screening and Control
EPI
Nutrition Support
HMIS
Transportation and referral
system
Resuscitation of
emergencies
Primary
Secondary
Tertiary
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.
3. Primary Healthcare
Agenda # 4Health 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
Data Transfer
Integration– Health Management Information System
• Patient Management System• Clinical Information Systems • Administrative Systems• Financial Systems• Ancillary Services
– Referral System
Center
DHQHs
THQHs
RHC
BHU
Out Reach Services
RHC
BHU
Out Reach Services
6. Health Information System
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 # 5Public Health Funding
5. Public Health Expenditure
Year Health Budget (% GDP)
2013 0.8
PTI Year 1 1
PTI Year 2 1.5
PTI Year 3 2
PTI Year 4 2.3
PTI Year 5 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 assetsor 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. MubasharDr. Saleem
and special thanks to PMA and Heartfile