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The State of the Health Sector in Rural Pakistan.

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It is widely acknowledged that human capital is vital to the growth and development of a nation; the significance of improved health status in this regard has also been well recognised. Therefore keeping the masses healthy is as important as providing them with basic education. The state of people's health in Pakistan is characterised by poor health indicators including high levels of infant child and maternal mortality. There is significant incidence of communicable diseases low life expectancy and a high rate of population growth. Urban-rural disparities further contribute to aggravation of the problems. Poor health status and high fertility rates are believed to be among the major obstacles for poverty eradication. The severity of health poverty in Pakistan becomes more evident when national indicators of health outcomes are compared with other regional countries. As highlighted in Table 5.1 Pakistan lags behind in all indicators when compared to other countries in

South Asia and some other regional countries. Life expectancy at birth in Pakistan is estimated to be 65.7 which is the lowest among the countries in comparison. At the same time infant mortality (59) and mortality under 5 years of age (72) are the highest. A mortality rate of 72 in 2011 implies that 1 in every 14 children born in Pakistan between 2006 and 2011 died before reaching five years of age. According to WHO (2006) the major causes of high rates of child and infant mortality include malnutrition diarrhoea acute respiratory illness and other communicable and vaccine-preventable diseases.

Similarly maternal mortality rate is 260 per 100000. It is disturbing to see that mortality rates in Pakistan are exceptionally high and are above the average in South Asia. Population growth rate is 2.03 which is again highest among the regional countries.

Table 5.1 Regional Health and Population Indicators

###Life###Mortality###Infant###Maternal###Population

###Expectancy###Rate###Mortality###Mortality###Growth

###at Birth###under 5a###Ratea###Rateb###Ratec

###2012###2011###2011###2010###2012

###Pakistan###65.7###72###59###260###2.03

###India###65.8###61###47###200###1.31

###Bangladesh###69.2###46###37###240###1.58

###Sri Lanka###75.1###12###11###35###0.91

###Nepal###69.1###48###39###170###1.77

###Bhutan###68.0###54###42###180###1.18

###China###73.7###15###13###37###0.48

###Malaysia###74.5###7###6###29###1.57

###Indonesia###69.8###32###25###220###1.03

###Philippines###69.0###25###20###99###1.87

###Thailand###74.3###11###12###48###0.54

Prevalence of communicable diseases is also high which accounts for about half the deaths in the country. Pakistan is among 22 countries of the world that have extremely high and endemic burden of tuberculosis (actually it ranks number 10). In 2012 the incidence of tuberculosis (TB) in Pakistan is estimated to be 231 cases per thousand of population per year which is the highest in South Asia and the third highest in Asia only next to Myanmar and Philippines (WHO 2012). A more frightening fact is that the incidence of TB has increased from 177 in 2006 to the current level of 231.

Similarly malaria remains a major public health hazard in the country. The incidence of malaria has risen over the last decade. As shown in Chart 5.1 annual parasite incidence of malaria has increased from 0.77 in 2000 to 1.88 in 2011. Similarly slide positive rate (defined as the number of laboratory-confirmed malaria cases per 100 suspected cases examined) has also increased from 3.06 to 6.98 during the same period. This is despite the fact that not all the cases are recorded in the health system. It is acknowledged by the authorities that not more than 20 percent of the actual number of cases are recorded (WHO 2006).

Table 5.2###Malnutrition in Pakistan [children under 5 years of age]

###2001-02###2010-11

###Total###Urban###Rural

###Underweight###38.0###31.5###26.6###33.3

###Stunted###36.8###43.7###36.9###46.3

Prevalence of hepatitis B and C is high as well. A study conducted by the Pakistan Medical and Research Council (PMRC 2008) found that prevalence of hepatitis B and C was 2.5 percent and 4.9 percent respectively. Overall the positivity was 7.4 percent indicating that almost 12 million people were positive for both viruses in 2008.

STATUS OF HEALTH IN RURAL AREAS

###Table 5.3 Population (in thousands) per Rural Health Facility

###Basic Health Unit###Mother and Child###Rural Health Centres

###(BHU)###Health Centre (MCH)###(RHC)

###1990###18###74###168

###2000###18###109###176

###2013###21###165###174

Health indicators of the rural population are particularly poor. A review of selected national health indicators depicts a gloomy picture of rural areas; urban-rural gaps are significantly wide indicating that the rural population is at a clear disadvantage in terms of access to health services.

The level of malnutrition which is indirectly responsible for 35 percent of childhood deaths is alarmingly high in Pakistan particularly in rural areas (Zaidi 2011). Currently about 32 percent of children are underweight and 44 percent are stunted . Although the ratio of underweight children has shown a slight decline over the last decade the ratio of stunting has actually increased (Table 5.2). The urban-rural divide is also evident where the ratio of underweight children in rural areas is 33 percent as compared to 27 percent in urban areas. Similarly 46 percent of children in rural areas are stunted as opposed to 37 percent in urban areas.

As shown in Chart 5.2 there has been some improvement in the infant mortality rate (IMR) in rural areas since 2005-06. However there exists a very high urban-rural gap as IMR in rural population is 1.6 times greater than that in urban areas. Similarly the Pakistan Demographic and Health Survey 2006-07 reveals a high degree of regional variation in maternal mortality rates 319 in rural areas as compared to 175 in urban areas (Chart 5.3). This is mostly attributed to a high fertility rate low rate of skilled birth attendance illiteracy malnutrition and insufficient access to emergency obstetric care services (WHO 2006).

Expanded immunisation coverage linked with other health services is strongly associated with low infant mortality and low levels of malnutrition. WB (2010) shows estimates that with the full package of interventions the IMR in the country could decline by 35 infant deaths per 1000 live births in five years while the child underweight rate is expected to decline by 16 percentage points.

The Expanded Programme on Immunisation (EPI) in Pakistan was launched more than three decades ago. Some specific objectives of the programme included interruption of polio virus by 2012 elimination of neo-natal tetanus by 2015 elimination of measles by 2015 and reduction of diphtheria and childhood tuberculosis to a minimum level.

However despite continued efforts by the government and support of international partners Pakistan's immunisation indicators have yet to reach the expected benchmarks (WHO 2013). There has been upsurge of polio cases since 2007-08. The number of reported polio cases declined from 119 to 32 between 2001 and 2007 but gradually increased to 197 in 2011 (PILDAT 2012).

As shown in Chart 5.4 not only does the immunisation coverage remain sub-optimal the huge urban-rural gap is also persistent. Overall the immunisation coverage improved sharply from 2001 to 2006 increasing from 27 percent to 49 percent. Improvement was more promising in rural areas where the coverage was doubled. However after 2005-06 the rate of increase remained almost stagnant till 2011 and improved slightly afterwards. Currently 43 percent of the children aged 12-23 months remain out of immunisation coverage.

ISSUES IN HEALTH SERVICE PROVISION

The poor condition of the country's health sector is generally attributed to the ineffective delivery of services as well as to the low level of public spending on health. Pakistan's National Health Accounts for 2007-08 show that out of total health expenditures in the country 25 percent are funded by the government over 70 percent through private sector (mainly out of pocket expenses by households). Development partners/donors organisations have a 3 percent share in total health expenditures. Hence with the private sector being the major service provider most of the burden of health expenditures remains on the households. The role of the private sector is detailed in Box 5.1.

Public Expenditure on Health

Although higher health expenditure does not necessarily lead to better health outcomes the level of public spending reflects the degree of commitment of the government toward improving health conditions of the people.

Chart 5.5 depicts a rather depressing picture of public spending on health in Pakistan where the current level of expenditure is merely 0.35 percent of GDP. More disappointing is the fact that expenditures on health relative to GDP show a declining trend over the past 13 years. They declined from 0.72 in 2000-01 to 0.59 in 2001-02. Since then they ranged between 0.51 and 0.58 till 2009-10 before falling to extremely low level of 0.23 in 2010-11 and improved slightly afterward.

Not only is spending on the health sector low its allocation within the sector is also directed towards curative services with lower priority given to preventive healthcare. Over 80 percent of total government spending is on general hospitals and clinics (GoP 2012).

Coverage of Public Health Facilities

Moreover as asserted by Zaidi (1998) health services in Pakistan are highly inequitable and urban biased. Keeping aside the governance issues related to service delivery coverage of public health facilities in rural areas seems to have deteriorated over the years (Table 5.3). Population per BHU has increased from 18000 to 21000 during 1991 and 2011. Similarly two decades ago there was one MCH centre available for a population of 74000 which now serves 165000 people. Rural Health Centre (RHC) is the highest level of public health facility in rural areas. Population per RHC has increased from 168000 to 174000. In addition to the issue of coverage the quality of service delivery is adversely affected by poor infrastructure and maintenance inadequate supply of equipments and medicines shortage of doctors and paramedics (particularly for retention of female staff) and absenteeism of staff.

One of the most important principles of primary healthcare is people's access to health services. The availability of services is determined by the geographic distribution of healthcare facilities. As shown in Table 5.4 the average distance of a Mouza (village/cluster of villages) from a BHU is 15 kilo metres (km) which is quite a long distance as far as universal coverage and accessibility is concerned. Fairly large disparities exist among the provinces in the geographical accessibility of health service facilities where average distance from a villager's home to a BHU ranges from 8 to 39 km. The situation in the case of MCH centres is even worse.

Table 5.4 Distance of Mouzas from various Types of

###Health Facilities in Rural Areas

###Hospital/###MCH

###Dispensary###RHC###BHU###Cetre

###Overall Mean Distance (Kilometers)

###Punjab###9###9###8###11

###Sindh###12###13###13###16

###Khyber Pakhtukhwa###18###17###16###22

###Balochistan###45###43###39###63

###Pakistan###17###16###15###22

###Percentage distribution of population by distance to BHU

###Less than###50 km

###1 km###1-10 km###11-25 km###and above

###Punjab###13###67###17###3

###Sindh###13###52###27###9

###Khyber Pakhtukhwa###11###54###20###15

###Balochistan###7###24###25###44

###Pakistan###12###56###20###12

Table 5.4 also presents percentage distribution of population by average distance from a BHU. Overall only 12 percent of the rural population is located within 1 km from a BHU. The majority of people (56 percent) have to travel up to 10 km to find a BHU. For a sizable population (12 percent) a BHU is located at a distance of 50 km or more from the settlement.

Utilisation of Public Health Facilities

Due to the factors mentioned above the public health facilities are poorly or sub-optimally utilised in rural areas and people are left with no choice but to consult the private sector providers subject to their affordability. Based on the PSLM data Table 5.5 presents the trend of health seeking behaviour of rural population in terms of consultations with various types of providers for primary health services. The survey data of 2010-11 shows that among the people who consulted any health service provider only 24 percent went to any public hospital BHU or RHC while 67 percent resorted to the private providers. It is important to note that use of public healthcare facilities shows an overall declining trend since 1998-99.

Reasons stated by the respondents of PSLM survey for not consulting government facility first (in the case of treatment for diarrhoea) endorse the issues of governance and accessibility that are believed to be responsible for poor service delivery (Table 5.6). The majority of people (26 percent) have stated that the government facility is too far away to be accessed. Other major reasons include unavailability of doctors shortage of medicines and impolite behaviour of medical staff.

Table 5.5 Health Consultation by Type of Provider in Rural Pakistan [percent of population]

###Private###Public###Others

1998-99###50###29###21

2004-05###64###24###12

2006-07###66###21###13

2008-09###67###23###10

2010-11###67###24###9

Table 5.6 Reasons for not Consulting Government Facility (Rural) [percent of population]

Too far away###26

Doctor not/never available###16

No government facility###18

Not enough medicines###11

Staff not courteous###8

Others###21

Inaccessibility of medical services in rural areas also has serious implications for maternal health of females leading to higher maternal mortality. As shown in Table 5.7 although the proportion of women who receive pre-natal check-up has improved over the past few years consultation made with public sector providers has actually declined during the same period.

In 2005-06 of the total women who received pre-natal consultation 46 percent got their check-up by public health providers. In 2012-13 this proportion is reduced to 43 percent. This decline may be attributed to the accessibility and quality of public health services in rural areas. Similarly the proportion of institutional child delivery (private and public combined) remained fluctuating between 22 and 41 percent. Child delivery at government hospitals/clinics has declined from 15 percent in 2005-06 to 12 percent in 2012-13. The majority of births (59 percent) still take place at home in rural Pakistan. This explains the exceptionally high rate of maternal mortality (319) in rural areas as compared to that in urban areas (175).

Table 5.7 Indicators of Maternal Health (RuralAlternative Delivery Mechanisms

Location of Child Deliverty

###Proportion of###Consultations###Institutional Delivery At Home

###women who###made###Private###Government

###received pre-natal###with public###Hospital/###Hospital/

###check-upa###providersb###Clinic###Clinic

2005-06###42###46###23###15###60

2006-07###45###40###15###7###78

2008-09###50###35###19###9###71

2010-11###57###44###22###9###68

2011-12###62###37###27###11###60

2012-13###63###43###29###12###59

In view of the poor performance of health departments in the delivery of services attempts have been made by governments to introduce alternative service delivery and financing models.

In Punjab the Chief Minister's Initiative for Primary Health Care (CMIPHC) was initiated as a public private partnership (PPP) by the provincial government with the objective to improve the provision of basic health facilities in rural areas. To replicate the successful experiments under CMIPHC the federal government launched a country-wide Programme known as the People's Primary Health Care Initiative (PPHI) to strengthen the services provided in government health facilities. Under PPHI the management and finances of running the Basic Health Units (BHUs) were handed over to the Rural Support Programmes (RSPs) in their respective provinces . The federal government provides financial support for the administrative structure of PPHI in addition to one-time upgrading/rehabilitation of BHUs while the cost of management contracts is borne by the provincial governments. RSPs could hire any staff on contract including medical officers and paramedics. They also have flexibility to incentivise the staff.

According to a third-party evaluation of PPHI conducted in all provinces except Punjab (TRF 2010) PPHI achieved significant improvements in staffing availability of drugs and equipment and physical condition of facilities. Some key findings are listed here:

PPHI has had considerable success in attracting additional Medical Officers (including female MOs) to BHUs. However it was equally successful in attracting Lady Health Visitors (LHVs).

Outpatient attendance increased by 20 percent on average in PPHI districts and fell by about the same in the districts managed by District Department of Health (DDOH) between 2007 and 2010.

Attendance for antenatal and postnatal care services increased in PPHI districts when compared to the starting point. However attendance figures for both PPHI and DDOH districts were found to be quite low when population estimates were used.

In terms of safe delivery a higher percentage of deliveries were performed by BHU staff in PPHI districts (37 percent) than in DDOH districts (18 percent). However most of these deliveries took place at home rather than in BHUs.

Availability of certain diagnostic tests (e.g. Malaria) and treatment for snake and dog bite was found higher in PPHI BHUs. PPHI BHUs had slightly better referral record keeping practices. Consumer satisfaction measured through exit polls revealed that users had selected the BHU because it offered better quality of service than other providers at a rate of 47 percent in PPHI and 36 percent in DDOH BHUs.

Nevertheless there are some areas where improvements and further reforms are needed. Some of the key issues brought forward by TRF (2010) include the following:

Although the coverage has improved as compared to the baseline utilisation of health facilities (in terms of percent of population) still remains very low in both DDOH and PPHI districts. PPHI has not performed so well in terms of family planning services. Contraceptive prevalence rates are found to be a bit higher in DDOH areas (47 percent) than in PPHI areas (40 percent); in the former services are mainly provided by Lady Health Workers (LHWs).

PPHI was established as a time-specific initiative but no exit strategy has been developed. PPHI contracts are not open to competition with other providers. Technical oversight is the missing element in the model. There is no clear role assigned to the health ministry or the provincial health departments in this regard.

Similarly there is an absence of performance monitoring.

Some other issues identified include lack of contract management experience in government conflict resolution and contract weaknesses and lack of the use of arbitration.

Nevertheless despite its limited success and shortcomings in implementation coordination and monitoring mechanisms PPHI seems to have paved the way to adopt innovative approaches for effective delivery of social services.

Vertical Programmes

Following the 18th Amendment to the Constitution the health sector has been devolved to the provinces. Even before the amendment responsibility of health service provision lay mainly with the provincial governments. In order to supplement the efforts of provincial governments the federal government had launched several vertical programmes which include the Programme for Family Planning and Primary Health Care (commonly known as Lady Health Workers Programme); Expanded Programme for Immunisation (EPI); Malaria Control Programme; TB Control Programme; HIV/AIDS Control Programme; Maternal and Child Health Programme (MNCH); Prime Minister's Programme for Prevention and Control of Hepatitis; National Programme for Prevention and Control of Blindness and National Programme for Prevention and Control of Avian Pandemic Influenza.

Table 5.8 Development Allocations to Vertical Programmes

###[Rs in Billions]

###Expenditure###Throw-

###upto###Forward###Allocations

###Cost###June 2014###July 2014###2014-15

###Family Planning and Primary Health Care###53.4###15.6###37.8###11.0

###Population Welfare Programmes###43.4###21.4###21.9###7.8

###(all provinces)

###Maternal Neonatal and Child Health###20.0###3.1###16.9###2.4

###Prevention and Control of Hepatitis###13.9###0.9###13.0###0.7

###Prevention and Control of Blindness###2.8###0.25###2.5###0.25

###Rollback Malaria###0.7###0.2###0.5###0.12

###TB Control###1.2###0.12###1.1###0.12

###Prevention and Control of Avian Influenza###0.3###0.03###0.3###0.04

###Total###22.4

Table 5.8 shows that the total size of allocations to these programmes in the federal Public Sector Development Programme (PSDP) for fiscal year 2013-14 is over Rs 22.4 billion. After the 18th Amendment financing of the vertical programmes emerged as critical issues. The provincial governments were of the view that the 7th NFC Award preceded the 18th Constitutional amendment. Therefore the additional liabilities transferred to the provinces were not coupled with the transfer of additional resources. Hence it would be difficult for the provinces to continue execution of these projects without a meaningful transfer of additional resources at least till the currency of 7th NFC Award. As opposed to this the federal government argued that the provinces are already enjoying enhanced fiscal space under the 7th NFC Award. Therefore they should be able to finance the additional responsibilities which have been constitutionally transferred to them (GoP 2011).

These issues were addressed in the meeting of the Council of Common Interests (on April 28 2011) and it was decided that the federal government would provide financing for vertical programmes of health and population sectors till the next NFC award due in 2014-15.

Some vertical programmes such as the Lady Health Workers Programme have achieved significant success in the provision of health services to communities in rural areas (see Box 5.2). Similarly the EPI programme provides immunisation against the seven vaccine- preventable diseases including childhood tuberculosis poliomyelitis diphtheria pertussis neonatal tetanus measles and hepatitis B.It would be unfortunate if these programmes which confer significant benefits to the people are discontinued by provinces due to insufficiency of resources. Therefore there is need to identify a sustainable exit strategy before the 8th NFC Award so that financing of these programmes is ensured in future once these are transferred to the provinces. EPI has already been transferred to the provinces to a greater extent whereby the federal government took the responsibility of procurements coordination and technical guidance while provincial governments are largely responsible for implementation of the programme.

As far as resource mobilisation is concerned vertical programmes are ideal candidates for mobilising donor support as most of these programmes contribute to the achievement of the MDGs. However effort will be needed to improve their operations and enhance effectiveness. For instance execution of a large number of separate programmes is usually a cause of inefficiencies. Some resources can certainly be spared through administrative integration of some of the vertical programmes. For example Zaidi (2011) has suggested that the 9 vertical programmes may be merged into 3 more substantive vertical programmes in the categories of communicable diseases MaternalNewborn and Child Health and Nutrition and Community. CONCLUSION

The state of the health sector in Pakistan is characterised by poor health indicators low level of public spending and ineffective delivery of service provision. The situation of rural areas is particularly poor. Large disparities exist among urban and rural areas in terms of health outcome indicators such as malnutrition infant mortality maternal mortality and immunisation. Geographic coverage and accessibility of public health services in rural areas is also very poor which has serious implications for people's health. Federal and provincial governments have made attempts to introduce alternate models of service delivery in the form of public private partnerships which have achieved some success. Moreover vertical programmes of the federal government have also played an important role in supplementing the efforts of the provincial government. However the dismal situation of health indicators demands that much more be done possibly in every domain of the health sector.
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Publication:Annual Review Social Development in Pakistan
Article Type:Report
Geographic Code:9PAKI
Date:Dec 31, 2013
Words:3950
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