Elsevier

The Lancet

Volume 381, Issue 9884, 22–28 June 2013, Pages 2193-2206
The Lancet

Series
Pakistan's health system: performance and prospects after the 18th Constitutional Amendment

https://doi.org/10.1016/S0140-6736(13)60019-7Get rights and content

Summary

Pakistan has undergone massive changes in its federal structure under the 18th Constitutional Amendment. To gain insights that will inform reform plans, we assessed several aspects of health-systems performance in Pakistan. Some improvements were noted in health-systems performance during the past 65 years but key health indicators lag behind those in peer countries. 78·08% of the population pay out of pocket at the point of health care. The private sector provides three-quarters of the health services, and physicians outnumber nurses and midwives by a ratio of about 2:1. Complex governance challenges and underinvestment in health have hampered progress. With devolution of the health mandate, an opportunity has arisen to reform health. The federal government has constitutional responsibility of health information, interprovincial coordination, global health, and health regulation. All other health responsibilities are a provincial mandate. With appropriate policy, institutional, and legislative action within and outside the health system, the existing challenges could be overcome.

Introduction

Pakistan is the sixth most populous country (185 million people) in the world (figure 1);1, 2 64% of its population live in rural areas3 and 43% are illiterate.4 Table 1 summarises the key political and health developments since the country's independence in 1947. Pakistan has been under military rule for 33 years of 65 years.6 The country's geostrategic position in the era of the Cold War and after 9/11 have affected its growth, development, and social structure. Systemic constraints have affected the health system and its performance.7 Recent devolution of power from federal government to the provinces in Pakistan under the 18th Constitutional Amendment has created an expectation and an opportunity to institutionalise reform (panel 1).8 In this report, we analyse the extent to which goals for health systems—adequate and equitable health status, and fairness in financing and responsiveness—have been achieved in the past. We describe challenges in six domains of the health systems (financing, governance, service delivery, human resources, health-information systems, and medicines and technologies) and outline opportunities for improvements.

Section snippets

Data sources and analytical methods

The health-systems performance assessment framework was based on WHO's norms for the building blocks.9 The analyses covered all aspects including inputs (financing, human resources, information, and governance), outputs (service readiness), outcomes (coverage of interventions and prevalence of risk behaviours), and effect. The effect was measured according to WHO's intrinsic goals for the health system—achievement of equity in health outcomes, and fairness in financial contribution and

Health trends

Although some improvements have occurred in the health status over the past 60 years, key health indicators lag behind in relation to international targets.23 Total fertility rate has fallen from 5·4 children per woman in 1990–91 to 3·4 children per woman in 2010, remaining high enough to sustain rapid population growth.24 Mortality in children younger than 5 years has fallen from 124 per 1000 livebirths to 87 per 1000 livebirths during 1990–2011.25 The maternal mortality ratio decreased from

Equity

Substantial differences were noted within Pakistan in most indicators for equity. Rural mortality rates in children younger than 5 years were about a quarter to a third higher than in urban areas in the 2006 PDS and 2006 PDHS, respectively, which is a smaller gap than for instance in India and Indonesia during the same period. Although there has been an increase in the supply of safe drinking water and adequate sanitation during 1991–2010, wide rural–urban differences have not decreased and

Structure and financing of health systems

Pakistan's health delivery system comprises many institutions (figure 3). Three are vertical because they finance and provide services for defined populations (employees and their dependants) and have mutually exclusive service delivery infrastructures, human resources, and governance. The modes of financing vary between institutions. The Armed Forces are financed by revenues covering 6·18 million individuals. In the Fauji Foundation, commercially generated funds sustain a social protection

Health governance

Table 4 summarises the overall challenges for health governance. Health is one of the most corrupt services.50 Health-governance issues are an impediment to leveraging the potential within Pakistan's extensive health infrastructure.51 These issues are compounded by fights over the local government system after a 2001 reform stalled in 2008 with change in government (panel 3). The negative effect of a fully operational local government system became evident during the 2010 and 2011 floods.52

Service delivery

With the exception of a few tertiary hospitals, service delivery was a provincial mandate even before the 18th Constitutional Amendment. The main change after devolution is the handing over of the national public health programmes to the provinces. Also, because population welfare is also devolved and 2740 family welfare clinics have been given to the provinces, an opportunity has arisen to integrate population and health and overcome a longstanding institutional disconnect in Pakistan.63

Human resources

Government functionaries of the now abolished Ministry of Health remained protected by the 18th Constitutional Amendment. The current unrest among doctors and health workers is the result of an inability of the government to deliver in terms of other stated promises, which involve job structures and systems of compensation.75

At the time of Pakistan's creation, there were a few hundred registered doctors. Quantitative progress is evident, with 121 374 doctors currently registered. However, the

Health information

After devolution, Pakistan's health information architecture has been fragmented further. 14 discrete and incomplete information systems for infectious disease are in place and most are donor dependent.87 The country has no integrated disease surveillance system, as drawn attention to by the 2005 earthquake, 2010 floods, and outbreaks of influenza. Under-reporting of influenza A H1N1 in 2009 was evidence of failure to meet the commitments of the International Health Regulations 2005.88

Three

Medicines and technologies

The 18th Constitutional Amendment devolved medicines as a subject but retained the power to create federal regulatory authorities, leading to ambiguity with respect to the drug regulation mandate. After deaths of people from contaminated drugs,92 the matter was settled in favour of the creation of a federal drug regulatory authority. The law creating the new authority also included the regulation of medical devices, which was a welcome step. However, the authority has an uphill task.93 In 2004,

Communication technology

Pakistan has four strengths in terms of information technology for communication and gathering data. It also has a strong telecommunications infrastructure with more than 119 million mobile phone users,99 high broadband penetration, a national data warehouse and acquisition system (National Database Registration Authority), and a national system for validation of poverty (Benazir Income Support Programme). The public sector has not used this enabling infrastructure in the best way for health

Conclusion

In this report, we present the first comprehensive assessment, to the best of our knowledge, of the performance of the health system in Pakistan. The assessment of health-systems performance was hampered by many gaps in availability and quality of the data. Reliable data for levels, trends, and equity for many key indicators were missing. For instance, Pakistan does not have a functioning civil registration and vital statistics system; a health examination survey has not been undertaken for the

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