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