Failure analysis of health policy of Pakistan

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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