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HEALTH SYSTEMS IN
PAKISTANAchievements, Challenges and
the Way forward
Dr Assad Hafeez FCPS, FRCP, PhD
Chief Health systems & Policy Unit
Federal Ministry of Health
Dec 2009
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Contents of the presentation
Health and poverty
Resources for health in Pakistan
Health systems in Pakistan Health indicators and targets
Achievements, Challenges and the Way
forward Essential Health Services Package
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Health: A basic human right
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NATURAL CAPITAL
20%
PHYSICALCAPITAL
15%
CAPITAL
64%
Health as a capital
ILL HEALTH
Weakened HR capacity
MORE POVERTY
Human Capital
65%
THE VALUE OF HUMAN CAPITALWORLD BANK ASSESSMENT ON TOTAL WEALTH OF 192 COUNTRIES
Source: Sustainability and the Wealth of Nations, World Bank 1996
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Health Economic growth
10% increase in
life expectancy
Effect more pronounced where life expectancies are lower
0.4 % increase in
economic growth
=
Source: Commission for Macroeconomics and Health, WHO, 2000
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Total Expenditure on Health(Federal &Provincial)
YearDevelopment Non-development Total Health
Expenditure
as % of GDP
2003-04 8.5 (25.9%) 24.3 (74.0%) 32.8 0.58
2004-05 11.0 (28.9%) 27.0 (71.0%) 38.0 0.57
2005-06 16.0 (40.0%) 24.0 (60.0%) 40.0 0.51
2006-07 20.0 (40.0%) 30.0 (60.0%) 50.0 0.57
2007-08 27.0 (45.0%) 32.0 (53.3%) 60.0 0.57
2008-09 33.0(45.5%) 41.1(54.5%) 74.0 0.55
Rs in Billions
Source: Economic Surveys of Pakistan
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Financing Health
Indicator
Pak Afgh India Bangl
Year 2006
Total health expenditure (THE) as % of GDP 2.6 9.2 3.6 3.2
General government exp. on health as % of THE 33.6 32.4 25 31.8
Private expenditure on health as % of THE 64.5 67.6 75 68.2
General government expenditure on health as % of totalgovernment expenditure
7.5 6.2 3.4 7
Social Security expenditure on health as % of Generalgovernment expenditure on health
0.3 0 4.9 0
Per capita THE (US$) 19.37 27 29 12
Per capita government expend. on health (US$) 6.50 9 7 4
Source: National Health Accounts 2005-6
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Financing Health
28%
5%
65%
3%
Contributions to health care
Tax
Donors
Out of pocket
Others
Source: National Health Accounts 2005-6
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Health Investment by GoP & Partners
MoH & DoHs
74%
MoPW5%
UN system
5%
Bilaterals
6%
Multilateral
10%
GoP (MoH & DoHs)= Rs 45 billions
Partners= Rs 11 billions
Partners
21%
Source: Inventory of H & P Investment Pakistan, GoP & WHO 2005
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2006 POPULATIONREFERENCE BUREAU
Health Delivery SystemIntegrated Rural Health Complex
Basic HealthUnits
Rural HealthCenters
DistrictHeadquarters
Hospital
TertiaryHospitals
PopulationServed
Referral Centers
100,000 300,000
25,000 50, 000
5,000 10,000
Health Care Providers
Specialists, Doctors,Nurses, ParamedicalStaff
Specialists, Doctors,Nurses, ParamedicalStaff
Doctors, Nurses,Paramedical Staff
Paramedical StaffLHWs
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Burden of Disease
Mortality (Deaths) by Cause and Gender
0 50000 100000 150000 200000 250000 300000 350000
Communicable diseases
Maternal /Perinatalcond
Nutritional deficiencies
Diabetes
Cardio-vasculardiseases
Neuro-psy
Neoplasms
Other Non-Comm
InjuriesFemales
Males
Source: WHO, 2007
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12 Current Approach to Reduction ofMaternal and neonatal Mortality
Age Pyramid
35 million
Ages 15-49
33 million
Ages 15-49
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13 Current Approach to Reduction ofMaternal and neonatal Mortality
Age Pyramid
62 million
Ages 15-49
58 million
Ages 15-49
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Health related MDGs
MDG
indicator
Baseline
1990
Current
status
Targets
2015
Under 5 mortality 140 94 52
IMR
120 78 40MMR 550 276 140
Births SBAs 18% 39% 90%
HIV prevalence
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1990 2007 2015
Progress in IMR110
78
55
40
Current rate of change= 2.10/yr
Required rate of change=3.40/yr Ref: PDHS 2008.
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Achievements
Lady Health Worker Program expanded
National Health Accounts
New Health Policy 2009 Hepatitis control program reviewed
Expansion of infrastructure
Enhanced financial resources
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Major Challenges
Low investment in health
Rapidly increasing population
Double burden of disease Emerging and re emerging diseases
Absence of social safety nets
Sub optimal performance of healthsystems
Unregulated private sector
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Way forward
National Health Policy
Public private partnership
Social Security nets for poor Universal health coverage
Essential Health services Package
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Essential Services Package
Describes and defines functions of differentlevels of the health system, as well asresources and procedures to deliver them
Functions Curative, Preventive, Promotive, Rehabilitative
Resources Workforce, equipment, technology
Procedures Guidelines, SOP, Quality management
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Components of EHP
Maternal Newborn care
Family planning
Child health and immunization Non communicable conditions
Emergency management
Community outreach and preventive care Health education
Referral linkages
Management and Health information
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The ESP Matrix
MDG
CommunityHealth Indicators
IndividualPerformance
Indicators
The Community Health Team
Community
Health Team
Essential Services Package
Promotion Prevention Cure Rehabilitation
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Outcomes of successful
implementation of ESP Provision of universal access
Social security net
Poverty traps reduced Equitable health care for all
Clear resource layout
Public accountability Basis for public private partnership
Tool for quality control
BASIS OF NATIONAL HEALTH SERVICE
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HEALTH
A case for increased investment
Basic services in ESP would require 10-13 $ percapita government expenditure to ensureuniversal coverage
NHA 2005-06 shows current governmentexpenditure of 6.5 $ per capita i.e. 0.6% of GDP
An increase to 1.2 to 1.5 % of GDP in next 5years will ensure universal coverage of essentialhealth services to all Pakistanis
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Key to universal access
ESPFinancing
HRH
Information
Technology
Governance
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Summary
Pakistan has major health problemscontributing to increased poverty
Financial and non financial constraints areprimary challenges
Increased investment along with betterhealth systems performance is required
ESP implementation has a potential toachieve the MDG targets by targeting thepoor and provision of universal health
coverage
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