This paper will be helpful for the researchers and students of Public Health and Public Policy.It will also be helpful in health policy formulation for the provinces in Pakistan, including Balochistan in the aftermath of 18th Amendment. This is my own point of view, which may never be referred or quoted as an official/public document. (By Abdullah Khan Noorzai,Ex-Regional Program Director, Peoples Primary Healthcare Initiative(PPHI), Balochistan - Pakistan)
Introduction
Pakistan
has a centralized healthcare system. The government takes the responsibility to
provide free heath care services to the citizens across the country. The policy
is set at the Federal level, which flows down to the Provincial government and
is further delivered to the district government, which is responsible for implementation.
The districts do not have any role in the policy making process. There are two
major problems associated with health sector in Pakistan. First, the policy
process happens at the federal level without involving the provincial and
district governments. Second, it is mainly based on bio medical model, which
puts emphasis on clinical treatments or curative healthcare (Khan 2006 pp.
97-100 and Khan 2009, p. 7).
This
paper will analyse flaws in the health policy process and implementation of
programs at primary healthcare level and will state the reasons, why primary
healthcare is not efficiently and effectively addressing health issues. It will
then propose recommendations for making health policy geared towards preventive
care, devolving policy making process to the districts along with its impacts and
improving and integrating health program management at the primary healthcare level.
Contextualization of the policy problem
Pakistan
health policies were formulated in 1990 and 1997 respectively, which were aimed
at addressing the basic health sector problems particularly strengthening of
the poor primary healthcare system. There are three levels of healthcare
facilities: First, the primary healthcare that include the Basic Health Units
(BHUs), Mother and Child Healthcare Centres and in some areas the Civil dispensaries.
The second level of healthcare called secondary healthcare facilities are the
district headquarter hospitals, and third are Tertiary level healthcare
facilities such as federal and provincial teaching hospitals which are meant
for preparing medical professionals and research (Khan 2009, pp. 12-13).
The
main focus of health policy, in Pakistan over the years, has been the
restoration of Primary Healthcare System, as an essential instrument, to combat
core health issues. But despite reforms, it has not been able to deflect from
the biomedical model of curative health. The major flaws in the health policy
making process have been the highly centralized policy making process and the large
gap between theory and practice (Khan 2006 and Khan 2009).Subsequently, in 2001,
new healthcare reforms were introduced to address long standing health issues.
Being committed to Millennium Development Goals, Government of Pakistan
reiterated the need to focus more on prevention and control of diseases,
reproductive health, child health and malnutrition, rather than focusing on the
curative aspect. It was decided to gear the thrust of public expenditures
towards primary healthcare tier for achieving the health goals. But the issue
of involving the districts and the provinces in the policy making process was
once again ignored. Even the medicine and equipments lists are not finalized by
the districts, which undermines the socio-cultural and environmental aspects of
medication varying from district to district.
In
short, the federal ministry of health along with its Planning and Development
Unit formulates policies, which are mainly focused on clinical healthcare,
paying less attention to other determinants of health and diseases lying
outside the Biomedical model of health (Ali 2000 and Green et al 1997).The role
of the provincial government is to pass down the policies to the district
governments, which implement them. Another problem with the whole process is
lack of monitoring and evaluation mechanism to assess whether the targets set
are being achieved or not. The tool of monitoring and evaluation for any
program is indispensible, which primary healthcare sector lacks in Pakistan (Khan
2009, pp. 7-10).
Critical Analysis of the issue
Reforms to the health policy, introduced in
2001, highlighted the importance of preventive health care model, but
everything happened in documentation only. Practically, the focus is still on
curative side, emphasizing the need to increase hospitals and to increase
expenditure on purchase of modern technology and equipments, drawing very less attention
towards multidimensional health issues such as public health. The content of
the 2001 policy shows that the policies and instruments adopted in the document
are in line with the same traditional Biomedical model dealing with treatment
of the diseases rather than preventing diseases and covering cultural and
environmental determinants, to cover health and wellbeing as a whole, in
accordance with the modern paradigms. In addition, it also lacks proper strategies
and instruments for the implementation of different programs (Siddiqui et al
2004 and Khan 2006, pp. 98-99).
Health
indicators show that Pakistan lags behind in achieving its targets. Its
Maternal Mortality Rate and Infant Mortality Rates are high, almost 280 per 100,000
deaths and 71 per 1000 live births, respectively. About 19% of the whole population
and 30% of children less than five years are malnourished. Hepatitis B and C
are rampant with almost 3 million cases in the country. Leading causes of
morbidity and mortality includes gastroenteritis, respiratory infections,
typhoid fever and malaria. Malaria and Poliomyelitis, which have been wiped
from almost all other countries of the world, have not yet been eradicated.
Therefore, as evidence suggests, the cost of treating these diseases is many
times more than preventing them (Khan 2009, p.5).
The
2001 health policy asserts that the main issues can be addressed at the primary
health care level using the primary healthcare institutions as instruments. For
the 66% of the rural population of Pakistan, it is a good idea to prioritize
and bring in robust reforms at the basic healthcare facility level, as this
population is the most disadvantaged as far as basic healthcare is concerned.
Primary healthcare is an intervention at the village and Union Council level: a
grass root level mechanism. The net of Basic Health Units and other primary
level facilities is spread over the country; present in almost every Union Council
(Khan 2009, p. 5 and Nishtar 2007, pp. 203-205).But these primary care
facilities only provide delivery of curative services, completely ignoring the
preventive side .
There
are certain factors behind the failure of health policy in addressing health
problems at the primary care level. The main flaws are categorically analysed
as under:
Flaws in the planning process
There
is highly centralized policy making process, which is mainly focused on
curative healthcare such as increasing the number of health facilities,
constructing laboratories, ambulances and providing modern equipments, without
assessing how they will be used by the health professionals, who are not
qualified to use the modern equipments, resulting in loss of resources (Khan
2006).Another problem is that while formulating these policies, insight is taken from the success stories of other
developed countries, without considering the ground realities, social dimensions,
religious and cultural values, paying
insufficient attention to the differences between the economic, political and
ideological contexts in the transferring country and the borrowing
country(Dolowitz and Marsh 2000, pp. 5-21; Khan 2009, pp. 19-20).This is what
happened, when family planning and population planning programs were being
implemented, the religious groups opposed it on the ground that it was contrary
to Islamic values, which resulted in failure of the programs. Conflict of values
occurs in terms of cultural and local morals, in implementing policy
interventions. The communities find these health initiatives and interventions
culturally incompetent and in conflict with their values due to lack of information
and wrong perceptions(Khan 2009, p. 32; Lee et al 1998;Thatcher and Rein 2004,
pp. 457-481).
Interference of the Federal Government in implementation
Though
the implementation of health policies is the responsibility of the district
government, the Federal Government still directly intervenes through its
vertical programs. There are various preventive and promotional health interventions
that include, the National Program for Family Planning and Primary Healthcare,
The Expanded Program of Immunization, The National AIDs Control Program,
Malaria Control Program, National Nutrition Program, Hepatitis Program and etc.
These vertical programs are implemented at the primary health care facilities,
but are directly run by the Federal Government (Nishtar 2007, pp. 63-73).This creates
disharmony at the BHU and district level, resulting in lack of coordination and
integration in health programs and loss of resources, creating a lot of political
and cultural resistance. The local communities and BHU staff also create
hurdles considering them as outside interventions (Khan 2006, pp. 101-104).
Monitoring and Evaluation
Lack
of proper monitoring and evaluation mechanisms is another gap in health policy.
There is no systematic mechanism to monitor various health projects and the
implementation of the programs at the district level (Bhutta et al 2003). For
evaluation of the health programs, Health Management Information System (HMIS)
and District Health Management Information System (DHMIS) have been introduced,
but they are not properly and effectively implemented. Over and above, there is
no system at the districts to compile, evaluate and use the data for policy
reform and assessment. As a result no data is transmitted to the Federal
Ministry of Health for feedback and evaluation (Khan 2009; Khan 2006 and Lee et
al 1998).
Poor management at the district level
At
the district level, the overall system is suffering from different
administrative and managerial flaws. The administration is on traditional
bureaucratic model with little administrative and financial flexibility, which
is not compatible with the emerging needs (Bjorkman 1986 and Hughes 2003). The
BHUs and other facilities are not fully functional due to absenteeism,
political interference, and inaccessibility, unavailability of medicine and
equipments and lack of resources. Each BHU has a residential quarter for the
doctor and the LHV, but since the BHUs are situated in villages, where the staffs
do not live due to lack of facilities, they prefer to travel from cities to
their duty places and in majority of the cases, they remain absent. (Khan 2009,
pp. 13-17). There is lack of coordination among different health programs, the
BHU staff and the communities. The BHUs mainly function as an inpatient clinic,
without health education which is the main component of contemporary public
health agenda , environmental, religious
and cultural predictors of health and wellbeing.
Options for change and reform:
Option 1: Decentralisation of policy
A
way forward for Pakistanis to completely decentralise its health policy process,
to the districts. At district level all the stakeholders and departments like
Finance, Environment, Water and Sanitation etc should directly be involved in the
policymaking process. In addition, communities, NGOs and other civil society groups
should also be involved in terms of their input and feedback. Like in Indian
state of Kerala, through decentralisation and involvement of the local
governments, NGOs and community groups, primary health care program was
successfully implemented, achieving high targets. Similarly in Bangladesh,
positive results were observed in controlling Tuberculosis (Varatharajan et al
2004; Zafarullah et al 2006 and Siddiqui et al 2004). Moreover, all the
vertical programs of the federal government should be delegated to the district
governments, which will not only increase efficiency, but will also, integrate
all the programs. For monitoring and evaluation, the Provincial HMIS should be
replaced by the DHIS and the district government should be assisted to
establish an evaluation cell with all necessary equipments and human resource.
The district health should be allowed administrative and financial authority in
accordance with the Governance model. However, certain necessary measures
should be adopted to ensure accountability. In this way, the districts will
make policies in accordance with their own social, economic, political and
environmental needs and will be in a better position to achieve better goals.
There
will be some financial and political hurdles for the district government in policy
making and implementation from bureaucracy, politicians and other interest
groups, for which the Federal government should provide due assistance.. Decentralization
of policy will require legislation, which may face political resistance.
Option 2: Improving the existing mechanism
The
second option is to introduce certain reforms in the existing policy process
rather than changing it. Bottom up approach in achieving input and feedback
from the communities through the district governments may be adopted. The
district governments may be mobilised to involve communities, interest groups
and NGOs in assessing whether the programs are targeting the objectives. In
this way the federal government will be able to incorporate social, political
and geographical aspects of each province and the districts while formulating policies.
Similarly at the district levels, mechanisms for monitoring and evaluation
should be strengthened .Evaluation is the part of policy process, which is
highly ignored. It is an indispensible tool for feedback, learning and improvement
(Bovens et al 2006 andKhan 2006).
Much
more importance should be given to prevention of diseases, health education,
clean environment and reproductive health services. It is much easier and cost
efficient to formulate a uniform, but comprehensive policy for the whole country
and allowing the districts to implement. Administratively all the vertical
programs should be brought under the district health department. At the BHU level,
the medical in charge may be delegated powers and authorities; both administrative
and financial to supervise and manage all the health initiatives.
In
short, the policy making should rest with the federal government with more
focus on preventive and promotional health services and in addition more
effective administrative and managerial reforms should be introduced at the
district level to make primary healthcare more effective.
This
option has is not cost effective and more administratively inefficient as
compared the first one.
Recommendations
In
light of the above analysis and discussion, I recommend option 1 to be pursued
by the government due to the following few reasons. Firstly, as evident from
the literature, environmental and social factors such as poverty, lack of education,
poor sanitation and poor governance, all predict bad health outcomes. Therefore
it would be better for the government to move away from the traditional
curative biomedical model towards more extensive and holistic approach. The
health of people will not improve unless other factors such as environment,
social and cultural aspects are concurrently addressed. Secondly, planning is a
two way process where assessment and feedback are the cornerstone of better
outcomes. Therefore it would be highly beneficial, if the policy making process
is decentralized and delegated to the districts, as the direct health care providers
can adopt better and realistic approach for the problems they encounter on
daily basis, knowing the ground realities better. One such example is the
Peoples Primary Healthcare Initiative introduced in few districts of Pakistan,
in accordance with the New Public Management and Governance model. Planning,
administrative and financial authority was delegated to the district managers
with the flexibility to manage the Basic Health Units. The main approach was
bottom-up-approach to involve communities in health initiatives and programs.
This program showed positive results (Khan 2009, pp. 22-24).Thirdly, more
resources should be put into the capacity building of government officials and
administrators at the district level to better understand the contemporary
health paradigms. As the root causes of many health problems are not addressed when
policies are formulated, due to lack of knowledge of the concerned places and
populations. Fourthly, when it comes to implementation phase, independent yet
accountable implementing agencies, with well formulated development strategies
should be brought into play .The communities and networks may be involved and
consulted because such programs should be culturally sensitive in order to be effective.
Federal government involvement should only be to provide the necessary guidance
and expertise along with sufficient funding. Lastly, better monitoring and
evaluation tools should be constructed and incorporated in the policy to get an
unbiased and valuable feedback to the policy makers and implementers. At the
district and BHU level, management and infrastructure should be improved in
order to provide quality health care to the masses. All this will be more
successful if policy process is also devolved to the districts.
Conclusion:
The
health care system of Pakistan is beset with numerous problems. Pakistan so far
has not been able to come up with a robust health care reform.
Decentralization, thus, presents an opportunity to bring in fundamental changes
in the primary health care domain in order to make it more efficient and
effective and easily accessible to the masses. The goals of health care reform
in primary health care sector is to restructure and reform the existing non
efficient system by devolving from the federal to the district level and
removing the ambiguity created by the federal and provincial governments at
different levels, at the same time giving high priority to preventive health in
formulation of effective programs, as well as, addressing problems such as
under utilization, staff absenteeism, lack of quality services and, scarcity of
human, technical and financial resources and public health measures.
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