Link above for actual yearbook
Executive Summary
Government of Khyber Pakhtunkhwa, Department of Health has brought about revolutionary changes and reforms in health sector with a view to improve the health status of people on one hand and achieve Sustainable Development Goals (SDGs) on the other. Institutionalisation and restructuring of health care system have been done to ensure accountable, equitable, efficient and effective service provision to all especially the poorest of the poor. With consensus-oriented governance of the present Government, it has become possible to achieve the vision of inclusive development as envisioned in SDGs.
In order to prioritize health and focussing on strategic direction, Government of Khyber Pakhtunkhwa has worked out a reform agenda. The Department of Health has taken forward this agenda and started practical measures to materialize the required reforms. Senior management of Health Secretariat and Directorate are also committed to work in this direction to achieve the vision of WHO “Health for All.” Similarly, allied departments, programs and projects have worked hard and achieved milestones in health sector reforms with uniformity of vision, direction and efforts.
The 18th Amendment in the Constitution provided opportunity to Khyber Pakhtunkhwa to take health as its responsibility. In order to fulfil this responsibility, Government of Khyber Pakhtunkhwa developed its own evidence-based Health Sector Strategy (2010-17) and implementation plans giving priority to some of the much deserving/neglected areas. In lieu of reform agenda and Health Sector Strategy, the Health Department of KP also underwent restructuring at various levels. After restructuring, it prioritized three key areas of focus i.e. (i) institutional development (ii) provision of optimal health services through adequate human resource, equipment & supplies and (iii) free treatment to the marginalized population. Unlike previous initiatives in Pakistan, the Government of KP has taken ownership of health and initiated practical steps to achieve these three key goals in letter and spirit. In order to promote peoples’ right to health and improve governance in public sector hospitals through autonomy, special emphasis was laid on legislation. Another intention of making legislation was to ensure accountability in public sector hospitals. For this purpose, Independent Monitoring Unit (IMU) was established. Major reforms mentioned in institutional framework were materialized after the legislation of numerous Acts related directly and indirectly to improved health care and patients’ safety.
Keeping in view the importance of investment in health for economic development, the Government of Khyber Pakhtunkhwa increased the budget of health sector from PKR 30.3 billion in 2012-13 to PKR 66.49 billion in 2017-2018 and set precedence in the country. Where Pakistan’s per capita spending in health remains only 1% of the total GDP, share of KP remains 6%. This has increased the per capita spending indicator from USD 6.92 to USD 19.80.
With regards to human resource, positions of doctors have been increased from around 2500 in FY 2012-13 to over 6531 presently. This investment has improved the population per doctor ratio from 6312:1 to 4674:1. However KP is on the way of achieving WHO standard of 1000:1 (population per doctor ratio) in the next five year plan.
Infrastructure investment was also given due consideration along with human resource development. Number of beds in Government hospitals has been increased from 12,114 in 20112-13 to 18,185 in 2016-17 while provision of about 5000 more beds is in pipeline. This has improved the indictor of population per bed from 557 to 485. If this pace of progress continues in future, the international average of 384 persons per beds can be attained in the next phase which will be another milestone in the health sector of Pakistan.
Resource allocation for Minimum Health Services Delivery Package (MHSDP) for Primary and Secondary Health Care is another pro poor initiative of the provincial Government. Besides this, Chief Minister’s Special Initiatives and Flagship Health Services Programmes are the other achievements of the Government to provide adequate health care services to the people of KP.
Yet another pioneer step of the Government is mainstreaming of vertical programmes related to mother and child health i.e. MNCH, EPI, Nutrition and LHWs programmes, under Integrated Health Programme (IHP). IHP is being implemented at primary health care level in all Districts of KP with financial support of DFID. This initiative would improve health indicators particularly related to mother and child health and reduce morbidity & mortality in the distant and vulnerable communities.
In order to make health services financially affordable for the poor and vulnerable people, the Government has started Social Health Protection scheme. In this scheme, health financing is being done through Sehat Insaf Card and Sehat Sahulat Programme in all Districts of the province. It has achieved 60% targets in the first two years of its implementation, now government is extending its coverage up to 69% of the entire population of the province.
Under the present Government, multidimensional reforms, restructuring, regulations, legislations and new initiatives have been introduced at all levels. Furthermore, investments in financial, infrastructure, human resources and medicines have been made along with inductions at all levels of health cadres. In addition to this, up-gradation of health cadres has been done and regulatory and reporting structures have been improved for quality service delivery. The most vulnerable sections of population have been protected with safety net, and long term investment at primary, secondary and tertiary care levels. Now Districts have been mainstreamed and their preventive, promotive, curative and rehabilitative services and processes have visibly improved.
In contrariness to the above situation, key indicators like MMR, IMR, CPR, poliovirus transmission, immunization and malnutrition continue to hamper progress of health sector. Besides this, there is alarming increase in Non-Communicable Diseases and aging population which requires revision in health policy and services. TB control remains successful. However, HIV/AIDs and malaria control demand effective surveillance and monitoring. Along with this, population growth rate needs to be reduced by strengthening family planning services and capacitating LHWs for effective outreach. The role of DHIS and its performance has been remarkable. However, it also has to address gaps in reporting at primary and secondary care levels. Timely and accurate reporting from private sector is yet another challenging task to tackle with.
Despite all challenges, journey towards achievement continues. If developments outlined in reform agenda continue at the same pace for another decade, health profile of the people of KP will visibly improve and it would be at par with that of the developed countries.
Last but not least, donors have made significant contribution in all of the achievements mentioned above. They have provided technical support to bring about reforms and formulate policy documents. In future, they are also required to invest more to bring about new reforms and strategies as required. KP is blessed with dynamic leadership in Health Department. This leadership has played vital role in materializing “Agenda for Change” after forming an inclusive and consensus-oriented structure of governance.
The way forward
Strong Referral System
Despite increase in health budget and reforms in health care system, expected outcomes may not be possible to achieve in the absence of proper referral system. Due to poor referral system, tertiary care facilities are under burden. This affects quality of care being provided there. Moreover, this also hinders the way of tertiary care facilities to become center of excellence in health education and research which is their primary goal. For improving referral system, primary health care system should be strengthened.
Strengthening Department of Public Health
Public Health Department should be strengthened to provide quality health care services. Currently, all health departments work in isolation. These are overworked and understaffed. Capacity building initiatives are not up to the mark. It is the dire need of time to initiate joint ventures through public private partnership. Health Department will explore opportunities for it.
Human resource management
Human Resource is the backbone of any organization. Although recruitment of doctors, dentists, nurses and paramedics has been made in the Province, WHO standard is yet to be achieved. Irrational distribution of human resource, low retention, short attendance of health care staff and low work-place satisfaction still remain issues in the province which result in brain drain.
Quality health care cannot be achieved without sound professional education. It is the dire need of time to synchronise curriculum with modern pedagogic techniques, international standards and local requirements. Similarly, licensing and renewal of licensing of health practitioners needs improvement. It is not linked with qualification, competence, performance and continuous professional development. Both medical and dental curriculum, licensing and renewal of licensing, are the responsibility of Federal Government which needs to be shifted to Provincial Health Departments.
Health Care Financing
Since past decade, KP has been going through security challenges which caused epidemiological transition due to increase in population and increased demand for healthcare. The situation also caused change in disease patterns, increase in health expenditure, population growth and huge rural to urban immigration. Such challenges can only be overcome by diversifying health care financing such as increased tax revenues, community financing, social and private insurance schemes, donors driven projects and philanthropist activities. However, due to inadequate resources, health care financing remains low. Though health budget has been increased, majority of it is consumed by secondary and tertiary care leaving little for preventive and primary health care.
Inter-sectoral Coordination
Inter-sectoral coordination for achieving health care goals was adopted as strategy at international conference on primary health care. Health is a multi-sectoral subject; however, inter-sector collaboration in health sector is weak in the province. At district level, number of programmes such as Malaria Control, LHWs, MCH and Immunization are being implemented. Many of these programmes adopt similar strategies but different implementation styles. It is the dire need of time to adopt inter-sectoral approach in health. Government should strive to develop common vision and one framework & platform to work not only for health but also for education, food security, agriculture & livestock, housing, water & sanitation, local Government, social protection and environment etc. Rapid urbanization, industrialization and population growth is responsible for environmental issues and pollution. Specific environment policy linked with health policy can resolve environmental issue.
In order to achieve SDGs at desired pace and with desired outcome, advocacy, legislation, regulation, planning, behaviour change communication, information exchange, evidence-based decision-making and integration should be promoted. In addition to these, political will, low political interference, accountability, transparency, community involvement, women empowerment, and local/ rural development should also be promoted to enhance the health status of the people of KP.
Leadership and Stewardship in Health
Both public and private stakeholders in health sector need to initiate joint ventures to save time, effort and resources. The role of state as steward and regulator has become critical as we move to new models of financing health and delivering services. Leadership in health department is also essential for continuation and consolidation of current reforms and achievements.
Community Mobilization, Awareness and Ownership
Inadequate contact and lack of trust with the catchment population can lead to the under-utilization of health services. Lack of coordination and community trust is mainly due to absenteeism, unprofessional behavior of medical personnel, lack of quality care, inadequate drugs or medical supplies, poor medical practice and insufficient female health staff. Community involvement and transparent feedback mechanism can enhance public interest in health system.
Health Determinants
Health being a holistic concept is dependent on a number of determinants and inequalities. Some of these determinants include illiteracy, low education, unemployment, gender inequality, social exclusion, rapid urbanization, environmental issues, natural disasters, inadequate resources and population explosion. All of these social determinants need to be addressed to promote health on equitable basis.
Population Control Programme
Conservative social behavior inhibits access of women to health facilities and decision making regarding birth spacing and desired number of children. Thus, a large number of women fall an easy prey to avoidable mortality. Family Planning Association of Pakistan cites 900,000 terminations annually in Pakistan, mostly owing to unsafe abortions. To reduce maternal mortality, it is required to promote sexual and reproductive health including family planning. In communities, where women have no or low access to birth spacing methods, LHWs are working for the same purpose. Counselling of families, and women empowerment, need to be boosted up at primary and secondary levels, to promote the use of birth spacing methods.
The Population Welfare Department of KP is working for family planning. It needs resources and capacity building for delivering productively on reproductive health and rights. Contraceptive Prevalence Rate (CPR) of Pakistan is only 35 % as compared to regional countries. Progress on SDGs related to sexual and reproductive health is also low. Cultural barriers are yet another issue. In order to remove these challenges, strategic awareness raising, adequate resources capacity building and removal of cultural barriers are required. In order to remove social and cultural barriers, media campaigns and public debates involving communities, political representatives and religious scholars can help sensitize communities to great extent.
