ZERO DRAFT – 19 Feb 2009
National Health Policy 2009 Stepping Towards Better Health
March 2009
Ministry of Health Government of Pakistan
orward !y the Minister of Health
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"!!reviations AI AIDS BHU BISP BoD CCB C! CP# DA$%s DHDC DHIS DH( D)H D)*s ,m)-C ,PI ,SDP 0A*A 0BS 0$C0 0P 1DP HI2 HIS H# IDUs I-CI I# I*-s $B $H2 $H! 3, CH D1s # -CH )H *B0 *D0 -CD -1) -!0P ))P PHC PHDC PDC P#C
Avian Influenza Acquired Immune Deficiency Syndrome Basic Health Unit Benazir In Income Su Support Pr Programme Burden of Disease Community Citizen Board Community id"ife Contraceptive Pr Prevalence #a #ate Disa&ility Ad'usted $ife %ears District Health Development Center District Health Information System District Head (uarter Department of Health Directly )& )&served *r *reatment + short co course ,mergency )&stetric and -eonatal Care ,.panded Programme on Immunizations ,ssential Service Delivery Pac/age 0ederally Administered *r *ri&al Areas 0ederal Bureau of Statistics 0irst $evel Care 0acility 0amily Planning 1ross Domestic Product Human Immunodeficiency 2irus Health a anagement In Information Sy System Human #esource In'ecting Drug Users Inte ntegrate ated a anage agement of of -e" -e"& &orn orn and and Chil hildhood hood Il Illnes ness Infant ortality #atio Impregnated *reated -ets $ive Births $ady Health 2isitor $ady Health !or/er onitoring and ,valuation aternal and Child Health illennium De Development 1o 1oals aternal o ortality #a #atio aternal4 -e"&orn and Child Health inistry of Health edium *erm Bu Budgetary 0r 0rame"or/ edium *erm Development 0rame"or/ -on5Communica&le Diseases -on 1overnmental )rganization -orth !est !est 0rontier Province )ut of Poc/et Primary Health Care Provincial He Health De Development Ce Center Pa/istan edical and Dental Council Pa/istan e edical an and #e #esearch Co Council
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P-C PPP PP#A P#SP PS$ #HC SA#S SBA S*I *B *H, *H( U8# U!H) !*)
Pa/istan -ursing Council Pu&lic Private Partnership Pu&lic Procurement #egulatory Authority Poverty #eduction Strategy Paper Pa/istan Social and $iving Standard easurement Survey #ural Health Centre Severe Acute #espiratory Infection S/illed Birth Attendance Se.ually *ransmitted Infections *u&erculosis *otal Health ,.penditure 6&oth pu&lic and private7 *ehsil Head (uarter Under five ortality #ate United -ations !orld Health )rganization !orld *rade )rganization
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#ontents
%$&eed for a &ew Health Policy
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The State of Pakistan's Health a% Health System Performance !% Health Sector inancing c% Health Sector Management and Governance d% Monitoring( eval)ation and s)rveillance systems
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"ssessment of progress of implementation of Health policy 200$
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S)mmary of ,ey #hallenges in the Health Sector
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)t)re .irection / Stepping Towards Better Health a% Principles !% ision c% Goal d% Policy 1!ectives e% Strategic Priorities
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4es)lts and indicators of s)ccess
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Translating policy into action
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"nne7)re
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Vision A health system that: is efficient, equitable & effective to ensure acceptable, accessible & affordable health services. It will support people and communities to improve their health status while it will focus on addressing social inequities and inequities in health and is fair, responsive and pro-poor, thereby contributing to poverty reduction .
By considering 2006-07 as the benchmark year for the National Health Policy 2009, the goernment of Pakistan, by 20!", is committed to# ave additional !"",""" lives of children# •
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ave additional $%,""" lives of mothers# &radicate polio# &liminate measles and tetanus# 'revent additional ( million children from becoming malnourished# 'rovide s)illed birth attendance to more than %.* million pregnant women# &nsure provision of family planning services to additional ( million couples. Avert +* million of new - cases# Immunie more than $$ million children against /epatitis - and other vaccine preventable diseases# and 0each %" million poorest people of 'a)istan to ensure provision of essential pac)age of service delivery.
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Draft National Health Policy 2009
Pakistan's &ational Health Policy82009 Stepping Towards Better Health
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&eed for a &ew Health Policy
9: The &ational Health Policy 2009: ;Stepping Towards Better Health; outlines a shared resolve to ensure progress to"ards a healthy Pa/istan in "hich all citizens &enefit from a &etter "or/ing health care delivery system4 particularly the poorest: *he Policy &uilds upon the -ational Health Policy <==9 + *he !ay 0or"ard 5 under "hich modest progress "as made: *here "as a felt need to reset the strategic direction due to> a7 slo" progress in improving health outcomes? &7 inadequate sector performance in improving coverage and access to essential health care services especially for the poor? and? c7 lac/ of synchronization of various policy documents and their lin/ages "ith illennium Development 1oals 6D1s7: *he inistry of Health initiated the process to develop a ne" health policy in <==@ &ut the process remained slo": *he ne" 1overnment as part of its manifesto decided to set a ne" agenda to improve health care: *he process included formulation of a Health Policy *as/ force including si. "or/ing groups "hich too/ stoc/ of the present situation and outlined the future course of action: *he recommendations of the "or/ing groups4 consultation "ith /ey sta/eholders and strategic directions from parliamentarians and top management in inistry and Departments of Health contri&uted significantly to the development of ne" policy:
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The State of Pakistan's Health
<: Human development is the &asic right of every individual and health is a pre5 requisite for the economic development: Health is an entry5point to"ards prosperity and reducing poverty: *he lin/s &et"een ill health and poverty are "ell /no"n: Ill health contri&utes to poverty due to catastrophic costs 9 of illness and reduced earning capacity during illness: Poor people suffer disproportionately from disease and are at higher ris/ of dying from their illness than are &etter off and healthier individuals: !omen and children are particularly vulnera&le: Illness /eeps children a"ay from schools4 decreasing their chances of productive adulthood: : It is4 therefore4 critical to move to"ards a system "hich is a&le to address the challenges and prevents households from falling into poverty: In Pa/istan4 health sector investments are vie"ed as part of the governments poverty alleviation endeavor: *o ma/e progress to"ards achieving the D1s is a national commitment "hich envisages reducing poverty &y <=98: : *he health of the people of Pa/istan has improved since 9EE=? ho"ever the rate of improvement in health outcomes has &een slo" compared to its neigh&oring countries: Pa/istans under5five mortality remains the highest among the South Asian countries: High 9
> An adverse health shoc/ that necessitates 9=F of household income in medical e.penses:
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Draft National Health Policy 2009
maternal mortality 6deaths7 com&ined "ith high fertility results in one out of every GE "omen dying from pregnancy related causes: alnutrition remains "idespread and unaddressed: In addition4 persisting &urden of infectious diseases is no" compounded &y increasing &urden of non5communica&le diseases:
8: Pa/istans population gro"th rate has declined from F in the late 9EG=s to the present estimated level of 9:EF per annum4 &ut it remains unaccepta&ly high: In <==E4 Pa/istan is the si.th most populous country in <==E4 as its population increased from 998 million to over 9= million people in <==E: *he population is pro'ected to &e <9= million in <=<8 and according to a United -ations 6U-7 estimate Pa/istan "ill &ecome the fourth most populous country in the "orld &y the year <=8=4 "hich may lead to increasing scarcity of resources and food: $ife e.pectancy at &irth4 "hich "as years in 9E89 and 8E years in 9EE=4 has increased to @8 years in <==8 "ith no gender disparity: @: High fertility translates into :< million ne" &irths every year i:e: 9948== children are added every day to Pa/istans population: Ho"ever4 a&out E== infants die every day4 of "hich @<8 are less than one month of age and < ne"&orns &a&ies &ecome motherless due to maternal deaths: Compared to 949= children less than 8 years old dying every day in 9EE=4 currently 94=G= children die every day: In addition4 the latest evidence indicates that the poorest population 6quintile7 has seen almost no change in its under58 mortality rate since the early 9EE=s: 1ender does not appear to &e an important determinant of child mortality in Pa/istan: -ational surveys indicate that girls in Pa/istan display the e.pected &iological advantage in infant mortality i:e: G= male infants dying compared to female infants per 9=== live &irths Ho"ever4 gender remains an important determinant in child care e:g: compared to 9== &oys only GG girls are fully immunized: : : aternal mortality and mor&idity is difficult to measure &ut availa&le evidence indicates Pa/istan has made some improvements in recent years: In 9EE=4 8= pregnant "omen died out of E48= "omen giving &irth every day4 ho"ever4 currently4 < pregnant "omen are dying out of 9948== "omen giving &irths every day: S/illed &irth attendance 6SBA7 has improved from 9GF in late 9EE=s to @F in <==@=: 4== out of E48= &irths ta/ing place every day are performed &y s/illed &irth attendants: Institutional deliveries have also increased "ith === &irths ta/e place in a pu&lic or private health facility: Despite improvements4 Pa/istan is still far &ehind from other countries "ith significant variations
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Draft National Health Policy 2009
among provinces and districts4 highlighting the need to rapidly e.pand the use of s/illed &irth attendants and deliveries in health facilities: G: Pa/istan is having the largest ever cohort of the youth population: *he ongoing demographic transition< has provided an opportunity to convert it into a Jdemographic dividend: Ho"ever4 this opportunity "ill &e lost4 if the fertility rate is not &rought do"n at a more rapid pace: Pa/istans contraceptive prevalence rate 6CP#7 has improved since 9EE=4 &ut has stagnated during last fe" years "ith less than one third of couples use contraception "ith only one in five use modern methods: *he unmet demand for family planning persists a&ove =F "ith high rates of a&ortion "ith significant ur&an rural differential: In addition4 high rates of a&ortion imply that "omens lives are at ris/ from unsafe a&ortions: E: Pa/istan has the lo"est prevalence of under5"eight in South Asia "ith the e.ception of Sri $an/a4 ho"ever4 the prevalence has not changed much since 9EE= "ith more than E million malnourished children: It is unli/ely that Pa/istan "ill achieve the D1 target 9B: alnutrition increases the ris/ of dying in childhood &ut also impairs learning a&ilities and in long run decreases the productivity of adult "or/force: *his is further complicated &y "idespread micronutrient deficiencies significantly more prevalent in "omen and the poorest: A&out 9= million of children under58 years4 E:< million of child &earing age "omen suffer from anemia as a result of iron deficiency4 @: million children suffer from reduced gro"th and intellectual capacity as a result of iodine deficiency: In Pa/istan4 9=:8 million children and 98 million child5&earing age "omen have zinc deficiency: : 9=: *he &urden of diseases 6BoD7 is heavily dominated &y communica&le diseases4 reproductive health and malnutrition issues accounting for 8=F of the total &urden of diseases: *his is further complicated &y &urden due to non5communica&le disease group dominated &y cardiovascular diseases4 dia&etes4 in'uries and neuro5psychological diseases: *his dou&le &urden of disease is a ma'or challenge in the health sector of Pa/istan: In <==< ma'or causes of mortality and mor&idity in Pa/istan are summarized in graphs &elo": Ischemic heart disease account for 99F of deaths4 &ut only 8F of years of life lost as many people "ho died of the disease did so at an advanced age: Considering Disa&ilit y ad'usted life years 6DA$%s74 communica&le diseases form the dominant share in the &urden of diseases4 "hich can &e prevented at relatively lo" cost: #espiratory infections and diarrhoeal diseases are still the ma'or /iller diseases in Pa/istan:
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> *he transition in a country from e quili&rium of high fertility and high mortality4 through a period of rapid gro"th4 to a period of declining mortality coe.isting "ith continuing high fertility4 to an ultimate equili&rium of lo" fertility and lo" mortality: > A phenomenon "hich occurs in the last stages of the demographic transition4 "hen changes in the population structure 6decline in dependent population and increased proportion of the "or/ force population7 create a n opportunity for economic &enefits to individuals and the country: > A summary measures that com&ine information on mortality and non5fatal health outcomes to represent the health of a particular population as a single num&er:
Draft National Health Policy 2009
99: Pa/istan is still one of the four remaining countries4 "here polio is endemic and 99G cases have &een reported in <==G: Hepatitis is an endemic disease in the general population "ith a&out 9= million carriers of hepatitis B 3 C in the country: *u&erculosis 6*B7 in Pa/istan ran/s @th amongst the << countries4 "ith high &urden of *B in the "orld: *B is responsi&le for 8:9 percent of the total national disease &urden and there are a&out <8=4===5==4=== ne" cases in the country every year: Pa/istan is a malaria endemic country "ith litt le change in the status over past five years: Pun'a&4 -!0P and Sindh have lo" endemicity of malaria &ut Balochistan and 0A*A are high endemic areas: An emerging communica&le disease challenge is the concentrated epidemic for Human Immunodeficiency 2irus 6HI27 disease among vulnera&le populations particularly among In'ecting Drug Users 6IDUs7: *he evidence indicates increasing prevalence of HI2 among IDUs 6e:g: =:8F in Hydera&ad and <F in Karachi7 and slo"ly increasing prevalence in male se. "or/ers in Karachi 6:9F7 and Hi'ras in $ar/ana 6<:@F7: Halting its spread to &ecome an epidemic in the general population is a ma'or challenge in coming years: In addition4 there are other emerging communica&le diseases 6e:g: avian influenza 6AI74 severe acute respiratory syndrome 6SA#S74 leishmaniasis4 dengue fever4 hemorrhagic fever etc74 "hich off and on pose threat of an epidemic4 highlighting the need to strengthen the capacity for disease surveillance and immediate response system: 9<: Pa/istan is also facing an increasing &urden of non communica&le diseases "ith increasing life e.pectancy and high prevalence of ris/ factors: Share of in'uries accidents is estimated to &e more than 99F of the total &urden of diseases and is li/ely to rise "ith increased traffic4 ur&anization and terrorist activities: Pa/istan is among the top 9= countries in the "orld "ith high dia&etes prevalence4 of a&out :9F: )ne in four adults over the age of = years 6<@:EF7 suffers from coronary artery disease4 due to high prevalence of /no"n ris/ factors4 including smo/ing 69F among men over 9G years of age7? high &lood pressure 6<F in population over 9G years of age74 raised cholesterol 6<=F of people over = years of age74 and over"eight 6
98: !hen Pa/istan came into e.istence in 9E4 the health system "as premature and rudimentary: *he health system has e.panded gradually "ith a large net"or/ of health facility4 "or/force and services across Pa/istan: Progress in health sector is evident from the follo"ing fe" facts> •
In 9E4 there "ere
Draft National Health Policy 2009
&een increased in rural areas "ith more than 88= rural health centers and 84== &asic health units &esides 4@== dispensaries and E== aternal and Child Health 6CH7 centers in ur&an areas: *he information on private sector remains inadequate &ut a rough estimate is that there a&out <=4=== private clinics in the country: •
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Pa/istan had t"o medical colleges in 9E? no" there are 9 medical and dental colleges in the country4 < are in pu&lic sector and E in the private sector: *he num&er of registered doctors has increased e.ponentially from G in 9E to more than 9994@== doctors and G== dentists including <948== specialist doctors and 89 specialist dentists: -ursing profession has also seen gro"th "ith 9=E schools of nursing 6@ in pu&lic and in private sector74 99 schools of mid"ifery4 <@ pu&lic health schools and colleges of nursing: ore than @4=== nurses and 8== $ady Health 2isitors 6$H2s7 are registered "ith Pa/istan -ursing Council 6P-C74 &ac/ed up &y a community &ased "or/force of a&out E84=== lady health "or/ers: Pa/istan has no" initiated a Programme to deploy 9<4=== community mid"ives 6C!7 in the rural areas: $ife e.pectancy has increased from years in 9E to that of @8 years: Infant mortality has reduced from a&out <<= per 9=== live &irths in 9E to G per 9=== live &irths: aternal mortality "as estimated to &e G==59=== per 9==4=== live &irths in late =s? &ut is no" estimated to &e <@ per 9==4=== live &irths: Smallpo. and Dracunculiasis 61uinea "orm7 "ere "ide spread "hen Pa/istan came into e.istence? no" these diseases have &een eradicated: Pa/istan is also very close to the eradication of Polio 6decreasing Polio cases from more than 84=== in 9EE to 99G in <==G7 and the &urden of deaths due to Diarrhea diseases is decreasing? A&out 8<8 pharmaceutical units produce more than 4=== pharmaceutical products and medicines "orth of M9== million are e.ported every year: 0ederal4 provincial and district governments are implementing national health programmes mainly focusing on cost effective interventions: Some of recent successes are as follo"ing> o
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Increase access to CH and 0P services in rural communities through e.pansion of $ady Health !or/ers from G4=== in <==9 to E84=== in <==G? and a&out 84=== community mid"ifes are under training &efore their deployment in their o"n community: Improving immunization coverage 6num&er of children 9<5< months fully immunized7 to @F in <==@5 compared "ith 8F in <==95=
9@: Despite improvements4 Pa/istans health sector continues to face many challenges: *he /ey issue remains slo" progress in ma/ing progress in improving health outcomes and the performance remains inadequate: Poor are not &enefiting from the health system "hereas they &ear ma'or &urden of diseases: ,.panded infrastructure is poorly located4 inadequately equipped and maintained resulting in inadequate coverage and access to essential &asic services: Private health sector continues to e.pand unregulated mainly in ur&an areas: 0actors contri&uting to inadequate performance of health sector are deep rooted including "ea/ management and governance4 partially functional logistics and supply systems? poorly
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Draft National Health Policy 2009
motivated and inadequately compensated staff4 lac/ of adequate supportive supervision4 lac/ of evidence &ased planning and decision ma/ing4 lo" levels of pu&lic sector e.penditures and its inequita&le distri&ution: In addition to factors internal to the sector4 e.ternal factors also contri&ute to poor health outcome including illiteracy4 unemployment4 gender inequality4 social e.clusion4 food insecurity4 ur&anization4 environmental dangers4 lac/ of access to safe drin/ing "ater and inadequate sanitation: Health #are inancing
9: Pa/istan continues to spend less on health than most other countries at the same level of 1ross domestic product 61DP7: )ver the last 98 years pu&lic health e.penditures have increased &y 8=F in nominal terms4 ho"ever ta/ing into account population increase and inflation4 the real e.penditures as percentage of 1DP have stagnated at =:@F: During last five years 6&et"een <==9=< and <==8=@7 pu&lic sector investment increased &y E=F in real terms as compared to &y 8F during the previous 8 years4 &ut this increase also did not meet the targets set under Poverty #eduction Strategy and 0iscal #esponsi&ility Act: ost 68F7 of the health e.penditure is out of poc/et 6))P7: *his com&ined "ith lac/ of social protection mechanism puts large num&er families at ris/ of poverty &ecause of illness: 9G: *he federal and provincial governments have &een a&le to secure internal resources for the health sector in recent years: Ho"ever4 the 1overnment has mo&ilized fe" e.ternal resources for the sector from development partners4 private sector or philanthropic sector: A rough estimate indicates that Pa/istan mo&ilizes only a&out F of total e.penditure from e.ternal sources4 "hen the average for lo" income counties is a&ove 9F and in Bangladesh it is more than <
9E: Pa/istan has a mi.ed health care delivery system including &oth state and non5state providers and for profit and not for profit: *he inistry of Health4 provincial and district health departments4 parastatals4 social security4 non5governmental organizations 6-1)s7 and private sector finance and provide services mostly through vertical mechanisms: <=: *he federal4 provincial and district governments have clear roles and responsi&ilities4 &ut there are overlapping functions in practical terms: *he role of the federal government relates to policy formulation4 provision of technical &ac/stopping4 coordination "ith different partners "ith in and outside the country4 communica&le disease control and financing for health care: Ho"ever an overemphasis of the inistry of Health to"ards national programmes has diminished its ste"ardship roles of policy ma/ing4 regulation4 monitoring 3 evaluation 6including surveillance7 for quality of care and health care financing: Provincial departments of health are responsi&le for translating the national policy into planning and implementing it4 through generating the required human resource4 providing specialized care through its tertiary care hospitals4 &esides overseeing primary and secondary health services provided &y the district governments: <9: *he actual service delivery ta/es place at the district level "here the t"o tiers of primary and secondary health outlets are managed: *he districts also run the federally financed national health programmes that &ring a dichotomy in the management due to its dual command mechanism: All the preventive services are implemented at the district level
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Draft National Health Policy 2009
"here government is more or less the sole provider4 &esides the provision of medico5legal services: <<: Despite devolution of po"ers at the local level4 the health system remains centralized and not a&le to respond to the organizational and governance challenges resulting in ineffective use of already scarce resources and its a&ility to deliver: *he management challenges arise due to multiple supervisors4 lac/ of clear roles and responsi&ilities in three level of government and multiple directions coming from different levels: Devolution remains incomplete "ith "ea/ accounta&ility mechanisms and management capacity at the district level: *he pu&lic health system needs re5organization &ased on management principles4 "ith the federal and provincial governments focusing on its core ste"ardship functions of policy4 regulation4 monitoring and evaluation4 standard setting and moving to"ards quality service delivery &oth &y the pu&lic and private sector: Monitoring(
<: onitoring 3 evaluation and surveillance culture remains "ea/ at all levels due to an a&sence of result &ased culture: Information systems are present in most 0irst level care facilities 60$C0s7 and in national programmes4 so a culture of continuous data reporting e.ists: Currently4 these systems are highly fragmented and often vertical leading to duplication of efforts: Health anagement Information System 6HIS7 developed during early 9EE=s is functional &ut there are significant issues: Data quality4 its accuracy and completeness is compromised and use of information for decision ma/ing is discretely practiced: In addition it failed to evolve to develop other information su& systems initially envisioned e:g: human resource 6H#7 information system: *he pu&lic hospital system in Pa/istan lac/s a standardized information system and most maintain their o"n information system "ithout a regular reporting mechanism: *here is also no system to gather information from large private sector for the state to underta/e its function to protect pu&lic interest: *he a&ove situation of information systems is a direct result of "ea/ institutional mechanism for monitoring and evaluation 63,7 including lac/ of o"nership and organization support for data and information: 0ederal and provincial governments no" focus almost entirely on routine data coming from health management information systems and data from household surveys are not fully used: Pa/istan has not underta/en a national health survey for more than decade: <: onitoring and evaluation are /ey federal and provincial responsi&ilities and careful attention to its operation5a&ility "ill &e critical for enhancing accounta&ility and to ma/e the system result oriented: *he inistry of Health has ta/en steps to strengthen 3, including a detailed assessment of HIS? design and assessment of District Health Information System 6DHIS7 including the hospital sector? DHIS has &een piloted and "or/ is in progress to initiate its implementation across Pa/istan? use of third party to evaluate programmes and a performance assessment of the health sector disaggregated &y provinces and districts to facilitate policy development and informed decision ma/ing: *he performance assessment used analysis of secondary data for intermediate health outcomes generated from Pa/istan Social and $iving Standards easurement 6PS$7 Survey: *hese are steps in the right direction &ut there is more to &e done to generate information to facilitate informed decision ma/ing: <8: A critical aspect under the 3, and ste"ardship function is to ensure having an effective health surveillance system "hich is needed for effective prevention and disease control measures: Pu&lic health surveillance is a recognized pu&lic good and responsi&ility of the state: Ho"ever4 Pa/istan at present has vertically operating multiple small initiatives in surveillance "ithout a system "hich is not in a state to generate good quality information for ma/ing /ey pu&lic health decisions: *he fragmentation is a result of lac/ of organizational unit or structure at the federal provincial and district level responsi&le for surveillance4 lac/ of
Draft National Health Policy 2009
legal frame"or/ for disease reporting and lac/ s/illed manpo"er and resources for this important function: In addition4 no pu&lic health la&oratory net"or/ e.ists e.cept a Pu&lic Health Division $a&oratory in -ational Institute of Health: *he inistry of Health is cognizant of the situation and undertoo/ a detail assessment: A detailed frame"or/ has &een developed &ut not put in place: Some aspects of the plan are &eing implemented e:g: A training programme through 0ul&right fello"ships for researchers4 and communica&le diseases control has &een started to produce s/illed manpo"er for surveillance: *his "ould entail development of a comprehensive system and &uild organizational capacity at federal4 provincial and district levels for its effective functioning: Pharmace)ticals Sector
<@: At the time of independence4 Pa/istan had no pharmaceutical manufacturing unit and pharmaceutical needs "ere met through imports: *he local pharmaceutical industry developed over time responding to indigenous demand gro"ing to a size of a&out #s: GG &illion 69:< &illion M7 "ith e.port of US M 9== million annually 6=:<
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Draft National Health Policy 2009
is also need of rational use of drugs at the service delivery level "hich can only &e ensured through a mechanism of supervision4 availa&ility of treatment protocols and appropriate training: *he procurement of drugs at federal level is &eing no" underta/en according to the Pa/istan Procurement #egulatory Act 6PP#A7: *he procurement process and testing of drug quality is functional &ut the system needs to &e strengthened in terms of its effectiveness and timeliness: In addition4 the process of procurement at all levels has limited internal controls and monitoring mechanism to ensure value for money &eing spent: Medical
<: At the heart of each and every health system4 the "or/force is central to advancing quality of health care: At the time of independence in 9E4 Pa/istan inherited a "ea/ health sector having fe" health esta&lishments and limited avenues for production of doctors and paramedics "ith only t"o medical colleges: Investments during the last three decades have seen considera&le improvement in the production capacity of health care providers: But the focus on human resource development remained un&alanced and lopsided "ith inadequate emphasis on nursing and paramedical education "ith significant negative impact on quality of health care: Pa/istan is among the countries that still has critical shortage of health "or/force: *here is no "ell5defined policy 3 plans for human resource development in the health sector: *he inistry of health and the departments of health lac/ organizational structures responsi&le for human resource development: A num&er of critical issues limit quality of manpo"er produced including> curricula for the health manpo"er do not match local health needs? ,ducational institutions are ill equipped to provide quality education using o&solete traditional instructional methods and curricular formats resulting manpo"er not competent enough to function effectively in primary and secondary levels of health care settings: *here is inadequate emphasis on use of information technology4 in communication methods4 medical ethics4 or the &io5psycho5social model of health: #e5orientation of medical education and curricula to address the a&ove challenges &esides focusing on pu&lic health4 prevention and promotion of health: : *he mechanism for induction courses for different cadres in the health sector is not in place "ith very fe" such activities carried out &y isolated pro'ects: *he in5service training mechanism through Provincial Health Development Centers 6PHDC7 and District Health Development Centers 6DHDCs7 introduced during 9EE=s is partially functional: Similarly there is no formal policy4 national standards or guidelines for structured implementation to update /no"ledge and s/ills of health care providers4 including programmes for continuing medical education and systems of re5accreditation of doctors4 nurses and paramedics: )ther critical areas in "hich there is shortage of s/illed health "or/force include hospital management and management of health systems: Achieving the D1s "ill depend on finding effective human approaches that can &e implemented rapidly: Systematic thin/ing in several areas is required to formulate "ays of recruiting and retaining health "or/ers "ith opportunities for career development:
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Progress of mplementation of Health Policy 200$
: #evie" of the <==9 policy indicates progress has &een made in achieving the targets despite significant challenges: *he revie" of health sector performance in light of D1s or Poverty reduction strategy papers 6P#SP7 monitor5a&le indicators indicates that Pa/istan is moving in the right direction4 even though the pace is slo": *his is evident from declining infant 3 child mortality and fertility etc: Ho"ever4 in depth analysis indicates that this policy is inefficient in terms of resource usage for policy o&'ectives4 ineffective in terms of producing a measura&le impact on intended &eneficiaries and inequita&le in terms of &enefiting relatively more ur&anites and is gender insensitive: *he pu&lic sector services
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Draft National Health Policy 2009
utilization has not changed much: Critical issues related "ith the health policy <==9 are summarized &elo"> i:
*he inter5lin/ages of the health policy <==9 "ith P#SP4 D1s and *D0 are not e.plicitly "ell defined? the policy is not fully synchronized "ith the id *erm Development 0rame"or/ 6*D074 Poverty #eduction Strategies Papers 6P#SP74 illennium Development 1oals 6D1s74 provincial level strategic frame"or/s and medium term &udgetary frame"or/ 6*B07 processes:
ii: -o targeting strategy "as envisaged to ensure pro5poor healthcare interventions? iii: *he policy lac/ed e.plicit monitoring and evaluation frame"or/ to assess results under each goal of the policy: iv: $ittler emphasis on advocacy and orientation for the policy ma/ers in terms of role of health in reducing poverty and producing high quality human capital resulting in lo" financial allocation for health as compared to other sectors: v: *he policy "as almost silent on e.panding and increasing role of the private sector: vi: *o some degree it failed to strategize ho" financial as "ell as non5financial gap "ill &e met and did not envisage alternate healthcare financing sources as option: 8: In summary4 although the health of the population in Pa/istan has improved4 the pace of improvement has not &een satisfactory: *he e.isting health care system has not delivered up to the full e.pectation of the people due to various reasons:
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Draft National Health Policy 2009
%
S)mmary of ,ey #hallenges in the Health Sector:
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In summary4 key challenges in the health sector are> i:
a/ing progress in current health sector programmatic reforms to achieve D1s and tac/ling effectively ne"ly emerging and re5emerging health issues including non5 communica&le diseases and disasters
ii: Improving access of essential and cost effective health services especially for the poor and vulnera&le iii: ,mphasizing more on quality of care and services at all levels iv: Protecting poor from catastrophic health e.penditures v:
Improving the institutional arrangements and management of health care delivery system
vi: Improving the availa&ility 6specially female7 and motivation of health "or/force vii: Aligning outputs of the academic institutes in line "ith the needs of health system and improving the quality of education and training: viii:,ffectively engaging private health sector and civil society organizations to improve health outcomes i.: Developing pharmaceutical sector and ensuring access to quality medicines .: a/ing health system more responsive and accounta&le .i: ,nsuring effective research4 monitoring 3 surveillance system to measure results and evidence &ased decision ma/ing at all levels
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%
)t)re .irection / Stepping Towards Better Health
: Principles: Health is an essential prerequisite "ithout "hich individuals4 families4 communities and nation cannot hope to achieve their social and economic goals: *he ne" policy paradigm is &ased on health as a right as envisioned in the Constitution of Pa/istan and "ill &e driven &y the follo"ing /ey principles> i:
,nsuring universal coverage of an essential pac/age of health interventions "ithout economic4 geographical4 social or cultural &arriers and is responsi&ility of the state?
ii: )vercoming social and economic inequities to improve health outcomes? iii: Promotion of a results &ased culture ensuring a shift from a planning environment concentrated on the reporting of processes and outputs to outcomes? iv: Provision of quality health care and ensuring gender sensitive and patient5centered services? v:
,nsuring good governance4 promotion of meritocracy and transparency in every aspect of health care management? and
vi: Promoting evidence &ased decision ma/ing "hich must prevail at every level of the health system so that policy development and actions deriving from policies are relevant4 feasi&le4 resource appropriate and culturally and socially accepta&le: G: *he principles are envisaged to &e applied to all aspects of health care and "ill &e supported &y emphasis on local 6district7 o"nership and leadership4 strategic coordination4 &uilding local capacity4 and e.panding partnership "ith private sector: E: ision: *he Policy envisages a long term vision to reorient the health system endorsing the concept of health for all strategy al&eit 5 a health system that: is efficient, equitable & effective to ensure acceptable, accessible & affordable health services. It will support people and communities to improve their health status while it will focus on addressing social inequities and inequities in health and is fair, responsive and pro-poor, thereby contributing to poverty reduction . =: Goal> *he overall goal of the policy is to improve health status of the people of Pakistan: 9:
Policy 1!ectives:
-ational Health policy aims to improve health status of people of Pa/istan &y achieving the policy o&'ectives mentioned &elo" and it is envisaged that it "ill also help Pa/istan to ma/e progress to"ards health related D1s: i:
,nhancing coverage and access of essential health services especially for the poor?
ii: easura&le reduction in the &urden of diseases especially among vulnera&le segments of population? iii: Protecting to the poor and under privileged population su&groups against catastrophic health e.penditures and ris/ factors? iv: Strengthening health system "ith focus on resources? v:
Strengthening ste"ardship functions in the sector to ensure service provision4 equita&le financing and promoting accounta&ility?
vi: Improving evidence &ased policy ma/ing and strategic planning in the health sector:
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Strategic priorities
<: Addressing the gaps in the health sector requires a fundamental change in the thin/ing that informs health policy at all levels: *he paradigm shift requires that the o&'ectives of the health policy "ould &e to serve the needs of the people especially poor and vulnera&le: *his implies changes in all health sector parameters> "hat health services to offer? "ho &enefits from health services? "hat programmatic and systems reforms should &e in place? and ho" the resource cost to &e shared: In addition4 it is critical that the federal4 provincialarea and district governments re5affirm achieving health related D1s &y <=98: *o transform this commitment into action4 the federal and provincial area governments "ill develop4 implement and monitor health sector strategic frame"or/s to achieve health related D1s and the follo"ing policy o&'ectives of the -ational Health Policy <==E:
Policy 1!ective $: ,nhancing coverage and access of essential health services especially for the poor
: 1iven the important role of &etter health as a /ey driver of social advancement4 the foremost policy priority is to enhance coverage and access to essential health services and improving the quality of health care services particularly for the poor and vulnera&le especially "omen and children: *he priority policy actions include> Policy "ctions: $%": Primary and Secondary Health #are acilities:
97 ,ssential service delivery pac/age "hich "ill &e a series of specific health services and standards of care and not only a set of physical infrastructure4 staff4 equipment and supplies 6Anne.ure III7: Both pu&lic and private sectors "ill play their role in enhancing coverage of essential health services: Ho"ever4 delivering the essential service delivery pac/age as a pu&lic good to all citizens through its o"n infrastructure "ill &e ensured on priority &asis4 regardless of management arrangements: <7 ,mphasis "ill &e to re5vitalize Primary health care 6PHC7 system "ith a focus on reproductive health and family planning services4 integration of services4 improving quality of care and o"nership of interventions at the local level: 7 Availa&ility of staff 6especially female staff7 for service delivery particularly in primary health care facilities in rural areas "ill &e ensured &y e.ploring differential pac/ages of salaries and performance incentives: 7 A system of supportive supervision and monitoring "ill &e revitalized at the local level along "ith community &ased accounta&ility mechanism: 87 )utreach "or/ers 6vaccinators4 sanitary "or/ers and malaria inspectors etc7 "ill &e converted into multipurpose health care "or/ers4 "ith their line of command at the health facility level: -um&er of posts "ill not &e reduced &ut coverage area "ill &e rationalized for effective delivery of multiple services "ith increase in frequency of visits: @7 ,very district "ill &e attached "ith a teaching institution in the province area and specialists 6initially 1yneo&stetrician4 pediatrician4 surgical and medical specialist7 "or/ing in tertiary and district headquarter hospitals "ill have periodical visits to remote health facilities "ith pu&licized schedule: 7 Considering the issue of ur&anization and ur&an slums4 there "ill &e a revie" and re5 structuring of ur&an primary health care system for provision of essential pac/age of
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health services especially for the poor living in ur&an slums and e.ploring the option of pu&lic private partnership: G7 Productive community involvement at the health facility level "ill &e strengthened to improve responsiveness: E7 A comprehensive referral system &oth for emergencies and normal health care involving all levels of health care "ill &e developed and implemented:
$%B: Primary and Preventive Health #are Programmes:
1) ,ssential health services through the -ational ,.panded Programme on Immunizations 6,PI74 the $ady Health !or/ers 6$H!s7 Programme and the -ational aternal4 -e"&orn and Child Health 6-CH7 Programme "ill &e e.panded "ith ma.imizing synergies &et"een these interlin/ed programmes and further reinforcing lin/ages "ith the -utrition programme: 2) *he health sector "ill specially focus on provision of 0amily planning 60P7 services through the healthcare net"or/ and community &ased lady health "or/ers &y> 6i7 ensuring financing and provision of at least three modern contraceptive methods and s/illed manpo"er in all health outlets of Departments of Health 6DoHs7? 6ii7 strengthening the provision of 0P services and products through the $H!s at the doorstep of community4 and 6iii7 0ostering greater functional integration &et"een the t"o vertical institutional entities4 6Health and Population !elfare7 in order to ma.imize synergies at the service delivery levels: *he main constraint to &e addressed through a&ove measures "ill &e to ensure commodity security and availa&ility of contraceptives in each and every health outlet: 3) In relation to maternal health4 inistry and Departments of Health "ill ensure training and deployment of the ne" cadre of community mid"ives through -ational -CH Programme and strengthening of round the cloc/ comprehensive and &asic ,mergency )&stetrical and -eonatal Care 6,m)-C7 services: 4) Pa/istanNs nutrition outcomes have &een relatively stagnant over the last t"o decades: *he current glo&al increase in food prices4 "hich is affecting Pa/istan as "ell4 is li/ely to compromise these outcomes further: *he inistry and Departments of Health "ill develop a practical programme "ith an o&'ective of improving the nutrition status of "omen of child&earing age and children &elo" years &y improving the coverage of cost effective nutrition interventions: 5) *o address the persistence challenge of child mortality at facility and community level4 the -ational -CH and $ady Health !or/ers 6$H!7 Programmes "ill implement standard protocols for management of common childhood illnesses at facility and community level respectively: 6) Demand side interventions (cash transfer, vouchers scheme etc) will be pilot tested (especially for delivery services and ! treatment) before lar"e scale replication of such interventions#
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Policy 1!ective 2: easura&le reduction in the &urden of diseases especially among vulnera&le segments of population
: Pa/istan &ears a dou&le &urden of diseases? although the &urden of communica&le diseases4 childhood illnesses4 reproductive health pro&lems and malnutrition is high and remains to &e tac/ed4 non5communica&le diseases 6-CDs7 are fast emerging as the ma'or contri&utors of death and disa&ility: *he ma'or &runt of all these diseases are &orne &y the poor O communica&le diseases and malnutrition are commoner amongst the poor and the vulnera&le "hereas -CDs affect the economically productive "or/force4 lead to income losses4 lost productivity and are /no"n to &e the ma'or contri&utors to health shoc/s: *he focus of the health policy "ill therefore &e to address all these disease dimensions through follo"ing policy actions> Policy "ctions:
1) ,.panded Programme on Immunization 6,PI7 "ill respond to the system level challenges &y focusing on lo" performing areas4 attempting to reduce dropouts and improving monitoring and supervision systems: $ady health "or/ers "ill &e involved to deliver routine immunization services in their catchments areas: *he feasi&ility of introducing ne" cost effective vaccines "ill also &e e.plored: 2) Polio eradication "ill remain the priority of the government and efforts "ill &e made to interrupt its transmission &y <=9=: he pro"ramme will attempt to "et around overarchin" issues, such as low covera"e of routine immunisations, security situation in $%&'& and !alochistan and lar"e scale population movements, which are responsible for the increase in the 'olio transmission* there will also be an emphasis on further improvin" the +uality of the campai"n# 3) Interventions to control diseases li/e diarrhea and respiratory infections4 etc "ill &e revie"ed for rapid e.pansion of Integrated management of neonatal and childhood illness 6I-CI7 strategy4 incorporating ne" /no"ledge e:g: use of zinc for the management of diarrhea: 4) he $ational uberculosis (!) ontrol pro"ramme will continue to follow its strate"ic plan with a special emphasis on maintainin" recent successes and e-pandin" uberculosis. Directly /bserved reatment short course (! D/s) strate"y throu"h lar"e networ0 of hospitals and wor0in" with the private sector# he challen"e to ensure uninterrupted availability of D/s medicines will be addressed by stren"thenin" the lo"istics and procurement system with ade+uate nancin"# he pro"rammes strate"ic plan will be updated based on the results of ! prevalence survey and independent third party assessment of the pro"ramme# 5) n response to the endemic alaria burden in 'a0istan, the pro"ramme will continue to implement the oll !ac0 strate"y with eective implementation in hi"h ris0 districts, usin" rapid dia"nostic 0its, e-pandin" the use of impre"nated treated nets ($s) and usin" updated treatment protocols# n addition, a comprehensive strate"y will to be developed to respond to other vector borne diseases especially den"ue fever# 6) he $ational 78 9 D: ontrol 'ro"ramme will rapidly e-pand preventive services for the hi"h ris0 population especially in;ectin" dru" users, se- wor0ers and mi"ratin" population mainly throu"h
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private and $) o address the "rowin" burden and spread of 7epatitis ! 9 , which are mainly transmitted throu"h se- and blood, the $ational 'ro"ramme for 7epatitis ontrol will review its strate"ic plan to focus on primary prevention throu"h e-pandin" immuni?ation for 7epatitis ! in children, vaccination of hi"h@ris0 "roups, ensurin" provision of safe blood# ertiary hospitals will establish screenin" and dia"nostic centres and treatment facilities# A) %hile discoura"in" irrational use of in;ections "ivin" practices, the use of auto destructible syrin"es will be promoted in all health facilities, hospitals and pro"rammes in a phased manner with ban on the use of routine syrin"es# 1B) he "overnment will develop and implement an nte"rated Disease :urveillance :ystem by establishin" operational surveillance units at all levels with s0illed sta and bac0up networ0s of laboratories, ensurin" 'a0istan full the re+uirements in line with international health re"ulations# s the system develops, e-istin" disease specic surveillance activities will be inte"rated alon" with options to include 7 surveillance and $D behaviours# 11) he scope of public health interventions will be broadened to address diseases that have remained ne"lected to date, but which parado-ically are the leadin" causes of death and disability# $on@ communicable diseases, which include in;uries, diseases of the heart, diabetes, cancers and chronic lun" conditions, aect the economically productive wor0force, result in income loss and lost productivity# $D control strate"ies will be implemented focusin" on primary prevention and reducin" ris0y behaviours includin" smo0in", life styles and dietary habits# 12) Cmer"ency response system will be e-panded coverin" all lar"e cities in the initial phase# ll 7 and D7 hospitals will e-pand services to deal with emer"ency and trauma cases# edical emer"ency technician trainin" pro"ramme will be launched#
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Policy 1!ective *: Protecting the poor and under privileged population su&groups against catastrophic health e.penditures and ris/ factors
8: !hether it is glo&al financial crises or increased health e.penditures at household level4 the impact on the poor and near poor is very serious4 as ris/ management options are limited> the poor may need to sell productive assets4 nutritional standards are li/ely to fall and the a&ility to spend on private healthcare "ill fall: n that situation morbidity and mortality rates rose# In countries li/e Pa/istan4 "hen the overall economy comes under pressure4 a common feature is that spending on private healthcare falls as people see/ to shift to pu&lic care: *he demand for pu&lic healthcare rises significantly at precisely the time that governments feel the financial need to cut &ac/: In such situations it is the poor "ho are almost al"ays squeezed out: *herefore4 to protect the poor from catastrophic health e.penditures and ris/s4 the government "ill ta/e follo"ing policy actions> Policy "ctions:
1) *he government "ill "or/ on the concept of a -ational Health Service: *hrough this4 the government "ill ensure the poorest people to access health services and more e.plicitly access to a doctor: *he scheme envisages using the data&ase of Benazir Income Support Programme 6BISP7 and registering the poorest families at the level of the union council or su& district level and issuing a health card "ith &asic health characteristics? the card "ill also entitle citizens to services 6not provided &y the state7 through private providers: *he provider "ill refer cases of critical illness to district level hospitals 6or "hatever higher tier that is required7: *he design4 modalities and strategies "ill &e pilot5tested &efore nation"ide e.pansion: 2) *here "ill &e no user charges at primary level pu&lic health facilities: 0urther emergencies services 6including medicines7 and delivery services in all pu&lic hospitals "ill &e free of cost: #espective governments "ill determine user charges only in referral hospitals to avoid unnecessary load of patients see/ing primary health care: Ho"ever4 those patients referred from primary health care facilities "ill &e e.empted of such user charges: )ther social protection initiatives 6Baat5ul5mal4 a/at etc7 "ill &e made availa&le for the poor: 3) *he government "ill provide free specialized care 6dialysis services4 eye surgery4 treatment of heart diseases and other long term illness and disa&ilities7 to the poorest people "ho are registered "ith BISP: 4) Cash transfer and vouchers schemes "ill &e tested &efore large scale replication to protect poor from catastrophic e.penditures 5) Access to essential drugs "ill &e ensured in all pu&lic health facilities and hospitals: Pharmacy &an/s for the poor "ill &e tested in selected hospitals: 0ree medicines for the treatment of *B4 AIDS and alaria "ill &e made availa&le: 6) o avoid health ris0s and promote better health, inistry and Departments of health will develop comprehensive inte"rated behaviour chan"e communication strate"y, which will focus on the needs of the poor and vulnerable# =) 7ealth insurance models will be piloted to create a mar0et which may later on be e-panded to the poorest se"ments with "overnment ?a0at sharin"#
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Policy 1!ective +: Strengthening health system "ith focus on #esources
@: In health sector4 access to health care provider and access to medicine are the t"o ma'or demands of the people: Health systems ste"ardship functions on human resources and medical products 6including medicines7 "ill &e a priority through follo"ing policy actions: Policy "ctions: +%": Health =orkforce
97 *he government "ill develop a comprehensive health "or/force policy &y <=9=4 &ased on o&'ective assessments of needs: *he government "ill also enact a health "or/force la" encompassing all categories of health care providers4 defining career structures4 laying do"n service4 promotion and recruitment rules and revie"ing cadres to avoid duplication and promoting multipurpose s /illed "or/ers: <7 #ole of health "or/force accreditation &odies + Pa/istan edical 3 Dental Council 6PDC74 Pa/istan -ursing Council 6P-C7 + "ill &e strengthened? "hereas the government "ill revie" the option of esta&lishing a ne" accreditation &ody for health technicians and paramedics: 7 *he government "ill &alance out the mi. of health "or/force considering the needs of the health system: Current shortfall in certain categories e:g: nurses4 mid"ives $ady health visitors 6$H2s74 specialized technicians4 health systems and hospitals managers4 researchers etc4 "ill &e addressed: 7 A separate management cadre 6"ith equal opportunities for females7 at all levels "ill &e developed in the pu&lic sector: 87 Selection and appointment of health "or/force "ill &e &ased on merit and having competencies fit for the post: As system to measure performance and competencies of health "or/force "ill &e developed: @7 Staff vacancies "ill &e filled on priority &asis and the issue of shortage of female health care providers and nursing staff especially in rural areas "ill &e addressed: 7 Staff 6especially in rural areas7 "ill &e employed on terms and conditions that aid recruitment4 equita&le deployment4 retention and high performance: G7 Due attention "ill &e paid to recruit and retain "omen health "or/force &y creating fle.i&ilities and providing opportunities for gro"th: E7 All health departments "ill maintain data&ase of health "or/force appointed in the pu&lic sector: -o posting4 transfer or deputation "ill &e made "ithout feeding the information in the health data&ase: 9=7 Dual 'o& holdings "ill &e discouraged other than institutional practice after "or/ing hours: 997 At least t"o years "or/ing at BUH #HC "ill &e compulsory for post graduation and for appointment as a specialist in the pu&lic sector: 9<7 Competency &ased training "ill &e promoted in all medic and paramedic health institutions: 97 Health institutions "ill esta&lish a mechanism of continued education for all cadres of health "or/force: System of continuing education i:e: Provincial Health Development Centers 6PHDC7 and District Health Development Centers 6DHDC7 "ill &e revitalized: 97 1eneral practitioners "ill &e offered post graduate level training opportunities in family medicine in addition to refresher training courses on technical health issues:
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+%B: Pharmace)ticals and Medical prod)cts
97 inistry of Health "ill announce a ne" prop5poor -ational Drugs Policy: <7 A -ational Drugs #egulatory Authority "ill &e esta&lished that "ill "or/ on the principle of rationalizing rather than directly regulating the entire array of <=== plus drugs registered in the country: *he prices of only essential drugs need to &e regulated4 "hile prices of non5essential medicines should &e monitored: 7 Pharmaceutical product dossier at the time of registration "ill &e simplified and &rought in conformity "ith regional standards: Sta&ility testing procedures "ill also &e standardized on the &asis of &est practices in the region: Cost effectiveness of drugs "ill &e included as a criterion in the process of registration: 7 It is in the interest of registered manufacturers to maintain quality standards if they "ant to capture larger mar/et shares and &rea/ into e.port mar/ets: An institutional mechanism of pu&lic5private partnership for quality chec/s "ill &e devised "here the private sector and civil society "ill also participate in instituting regionally accepta&le quality standards for medicines and other products: 87 -ational #egulatory Authority "ill &e &rought up to the standards of !H)4 so that it may also facilitate production of quality &iological products 6vaccines4 sera and anti5 sna/e venom4 antiviral etc7 in the country: @7 !hile drug inspection is a provincial su&'ect4 high level of variation e.ists in inspections across provinces: Provinces "ill create appropriate protocols for inspection4 in terms of quality and quantity of inspections: $egislation "ill also &e done to give more po"ers to inspectors and for appropriate documentation on inspections and their outcomes: 7 Provincial (uality Control Boards "ill &e esta&lished and strengthened: !hile there "ill &e a need for more la&s in the future4 as a policy4 e.isting quality control la&s "ill &e strengthened and their a&ility to carry out ro&ust chec/s "ill &e ensured: *he quality control la&oratories "ill come up to regional standards for validation: !H) "ill then carry out validation inspections of the la&oratories: )nce the la&s are validated4 the !H) "ill carry out annual audits to ensure quality: G7 )ne mechanism for chec/ing counterfeit and spurious drugs is to &ring in her&al and other alternative medicines under the registration and quality inspection am&it: $egislation in this regard "ill &e put through to the parliament for approval: E7 #ational use of drugs "ill &e promoted: 0or this purpose4 a three pronged approach "ill &e revie"ed> i7 legislation "here&y superfluous or e.cessive use of drugs &y doctors can &e challenged &y the patient4 ii7 appropriate legislation and enforcement mechanism can &e devised to limit over the counter drug availa&ility4 iii7 )ver time the requirement of a qualified chemist at every drug outlet can &e introduced: *his policy action "ill have to &e phased out to ensure that enough pharmacists are produced in the country and present in different parts of the country: Initially this policy can &e introduced and enforced in large ur&an centers of the country: 9=7 *he supply of essential drugs to the appropriate facility "ill &e on the &asis of specific services provided &y the facility as against the present practice of supplying drugs on the &asis of demand from the facility: Drug requirement for each tier of service provision "ill &e determined specifically: 997 *o chec/ against pilferage and "astage4 standard treatment guidelines at different tiers of health facilities "ill &e made operational in the procedure of procurement and dis&ursal of drugs:
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9<7 inistry of Health4 Provincial Health Departments and District Health )ffices "ill follo" a transparent procedure on procurement in line "ith PP#A rules and regulations: 97 ,fficient supply management system "ill &e developed to store and transport medicines at provincial4 district and facility level: 97 *o ensure that drugs manufactured for pu&lic sector facilities do not ma/e their "ay in the mar/et4 they "ill &e pac/aged separately: 987 inistry "ill develop a &aseline position to clearly articulate the Pa/istan specific pu&lic health impact of the !orld *rade )rganization 6!*)7 agreements? and "ill enhance capacity to ta/e advantage to override certain provisions of !*) in the interest of ma/ing lo"5cost high quality drugs "hich are accessi&le to all:
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Policy 1!ective -: Strengthening ste"ardship functions in the sector to ensure service provision4 equita&le financing and promoting accounta&ility
: Strengthening of health systems performance depends upon three vital functions4 i:e: service provision4 financing and promoting accounta&ility: Health System "ill &e strengthened through follo"ing policy actions> Policy "ctions: -%": Service provision !y p)!lic and private sector
97 inistry and Departments of Health "ill e.plore the option of esta&lishing Health services accreditation authority mechanism to ensure implementation and monitoring of essential service delivery pac/ages4 developing policy and legislation on pu&lic private partnerships 6PPP74 regulating partnerships and addressing patient safety issues: <7 In close partnership "ith private sector professional &odies4 provincial governments "ill esta&lish regulatory authorities: 1overnment "ill also focus on formulating minimum standards of quality care and implementing quality assurance mechanism for services &y the private sector: 7 #ole of Health 0oundations "ill &e revie"ed and these foundations "ill &e restructured "ith increased involvement of private sector: *he o&'ective "ould &e to finance private health sector for provision of priority services in the rural areas: 7 Private sector including -1)s "ill &e mainstreamed into the development process and harnessing their potential to deliver services: *he government "ill further promote the role of the private sector in the delivery of health services4 "ith attention to quality and patient safety and safeguarding the interests of the poor and marginalized: 87 !ays and means "ill &e e.plored to integrate the system of traditional medicine into the formal health care delivery system4 ensuring patient safety and quality of care: @7 Pu&lic sector service provision "ill &e improved &y supporting decentralization and devolution of administrative and financial authorities at the local level along "ith community oversight: Q 7 Service delivery system "ill have appropriate chec/s and &alances "ith clear roles of the three tiers of the government4 "ith federal and provincial governments focusing more on ste"ardship functions of policy ma/ing4 strategic planning4 monitoring and evaluation4 standards setting4 quality assurance4 regulations and financing: G7 n public sector, the number of ertiary level hospitals will not be increased* rather focus will be on improvin" +uality of services by developin" and implementin" protocols and standards of care for "eneral care and specialities# E7 1reater autonomy to the pu&lic sector hospitals "ill &e encouraged follo"ing detailed planning4 changes in legislation and contracts and esta&lishing monitoring mechanism and performance assessments: 9=7 *elemedicine "ill &e promoted in the country for transferring health /no"ledge and s/ills from tertiary hospitals to secondary level hospitals: *his "ill also help in esta&lishing lin/ages among international hospitals4 tertiary level hospitals and districts for &etter provision of service delivery:
11) t is important to learn lessons from dierent disasters durin" last few years and establish a well@coordinated response and
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disaster relief eorts# inistry and Departments of 7ealth will ta0e the initiative to build capacity of the health sector for disaster mana"ement, devisin" an institutional arran"ement and implementin" disaster mana"ement protocols* and plan at national, provincial and district levels for an eective emer"ency response# -%B: inancing
97 *he government "ill remove all types of user fees for services at primary health care facilities and community level4 "ith safety nets for the poor see/ing care at referral hospitals: <7 Pu&lic sector health care financing "ill &e scaled up using predominantly ta.5&ased revenues: 7 Pu&lic sector financing "ill &e augmented &y more effective use of development aid and accessing more financial support from glo&al initiatives4 &ilaterals and multilaterals: 7 *he government is committed to reduce out of poc/et e.penditures for health especially &y the poorest: Social Health Insurance may &e an alternative &ut it needs to prove itself as effective4 efficient and equita&le as ta.5&ased financing:
-%#: "cco)nta!ility and 4esponsiveness
97 Pu&lic health sector as a part of the government is ans"era&le to the parliament: inistry of Health "ill regularly give &riefings to the Standing committees on health in Senate and -ational Assem&ly and "ill see/ advice: Same sort of &riefings "ill &e for the health committees of the provincial assem&lies: Pu&lic accounts committee "ill revie" the audit reports of the pu&lic health e.penditures: <7 inister of Health "ill give annual progress report to the Ca&inet in the month of August Septem&er of every year on the status of implementation of -ational Health Policy: 7 Provincial inisters of Health "ill also share annual progress report to the provincial ca&inets the month of August Septem&er of every year on the status of implementation of provincial health sector strategic frame"or/s: 7 At district level4 e.ecutive district officer 6Health7 "ill regularly &rief the district government and assem&ly on the implementation of health schemes and programmes: 87 Annual progress reports "ill &e shared "ith the general population through media: @7 inistry and Departments of Health "ill also &e responsi&le for regular performance audits of service delivery and results disaggregated &y districts: 7 Citizen community &oards 6CCBs7 "ill monitor the progress of health interventions at the community level: Clientpatient satisfaction surveys "ill &e conducted regularly for selected health interventions: G7 Hospitals &oards "ith mem&ers from elected representatives and technocrats "ill &e formed to revie" progress of respective hospitals: Patients satisfaction surveys "ill &e held regularly in selected hospitals:
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Draft National Health Policy 2009
Policy 1!ective 3: Improving evidence &ased policy ma/ing and strategic planning in the health sector:
G: Pu&lic health sectors decision5ma/ing cycle comprises of policy analysis4 goal and target setting4 resource allocation4 "or/ planning4 operational implementation and performance assessment: *he overall purpose of the monitoring and evaluation system "ill &e to provide continuous information and management support to decision5ma/ing processes at each decision5ma/ing levels of the health system: Policy "ctions:
97 -ational Health Information System "ill &e reformed: It "ill &ase on a strategic frame"or/ and "ill consist of four pillars> i7 anagement Information Systems? ii7 Surveillance System? iii7 Health Household Surveys? and iv7 #esearch: <7 *he &ase of anagement Information Systems "ill &e &roadened &y implementing District Health Information System 6DHIS7 in all districts? e.panding it to hospitals and private sector? and aligning it "ith other anagement Information Systems 6IS7 of national programmes: Analysis and use of information "ill &egin at local level "ith feed&ac/ loop and also transmitting information up"ard at district4 provincial and federal level for decision ma/ing process: 7 ,.isting piecemeal infectious surveillance system "ill &e integrated into a comprehensive Disease surveillance system "ith &ac/ up support of diagnostics and immediate response mechanism: Behavioral surveillance and vital registration "ill &e lin/ed at a later stage: Plan of action has already &een developed4 "hich "ill &e operationalised &y esta&lishing a system at district4 provincial and national level: ,pidemiologist "ill &e trained and deployed at all levels for investigative and analytical "or/: 7 Information "ill &e collected through national4 provincial and district level household surveys to measure progress on health outcomes and processes: inistry and Departments of Health "ill coordinate "ith 0ederal Bureau of Statistics and Planning Commission to include relevant health indicators in national and provincial household surveys: 87 Pa/istan edical #esearch Council 6P#C7 "ill draft a five year research strategy in line "ith ne" national health policy: A similar research agenda "ill &e developed and implemented at provincial levels: P#C "ill &e responsi&le to disseminate research results4 ne" discoveries4 etc: to the Policy Units4 parliamentarians and end users of the health care delivery system and the research mar/ets: P#C "ill regulate and coordinate research activities of national and international institutions in the country: P#C "ill also &e responsi&le to ensure availa&ility of financial4 technical and technological resources for health research in the country: #esearch Culture "ill &e developed through reformulated medical education curriculum for undergraduate and postgraduate medical education: @7 All four pillars of Health Information System "ill feed into Health Systems and Policy Unit at federal level and Health Sector #eform Units for policy and strategic frame"or/s development4 implementation and monitoring: All policy and strategic units "ill also &e responsi&le to conduct policy level research4 "hich "ill provide evidence to inform policy and strategic decisions: 7 All spending decisions "ill &e &ased on quantitative information a&out e.pected outputs and outcomes of pu&lic sector interventions: *hrough implementation of edium *erm Budgetary 0rame"or/s4 &udget allocations "ill &e lin/ed "ith policy o&'ectives on one end and interventionprogramme outputs on the other end:
<
Draft National Health Policy 2009
%
4es)lts and indicators of s)ccess
E: *he /ey performance indicators to measure implementation progress against /ey policy o&'ectives are summarized in Anne.ure I: *he inistry of Health "ill "or/ closely "ith the Provincial Departments of Health and 0ederal Bureau of Statistic 60BS7 to ensure collection of the data to tract trends and to disaggregate information &y gender and income quintiles: inistry and Departments of Health "ill regularly monitor progress on "hat is &eing achieved at different levels4 using clearly defined and measura&le output indicators for each heath sector pro'ect: 8=: -ational Health Systems and Policy Unit esta&lished under the inistry of Health and Health Sector #eform and onitoring 3 ,valuation units "ill &e esta&lished strengthened to serve the strategic function of generating evidence4 measuring results4 dissemination and guiding the policy: *hese units "ill &e responsi&le to monitor progress on results and report against indicators &y underta/ing regular health sector performance assessments &y provinces and districts "hich "ill &e disseminated through oHs D)Hs "e&site and via media: *hese assessments "ould &ecome the &asis for federal and provincial dialogue and setting resource priority especially focusing on those districts "hich are performing lo" in district ran/ing:
<
Draft National Health Policy 2009
%
Translating policy into action:
97
Pu&lic sector e.penditure on health "ill &e increased in line "ith 0iscal #esponsi&ility Act <==8: At present4 pu&lic health e.penditures are =:@F of the 1DP: In the first stage efforts "ill &e made to increase pu&lic sector health e.penditures to =:G8F of the 1DP &y <=999< and later on a&ove 9:8F of the 1DP &y <=98:
<7
0ederal4 Provincial Area and District governments re5affirm achieving health related D1s: *o transform this commitment4 federal and provincialarea governments agree to develop costed health sector strategic plans "ith province specific monitoring targets for outcomes and outputs4 to achieve D1s and policy o&'ectives of the -ational Health Policy <==E: Strategic frame"or/s "ill further prioritize policy actions considering availa&le resources: After announcement of -ational Health Policy <==E4 the strategic frame"or/s "ill &e finalized and approved "ithin a time frame of si. months:
7
*he policy and strategic frame"or/s "ill &e disseminated "idely to policy ma/ers4 legislators4 local leaders4 economic and finance e.perts4 media4 development partners and general pu&lic4 &riefing them the important role of health in reducing poverty and producing high quality human capital:
7
-ational Health Systems and Policy Unit at federal level and Health Sector #eform Unitsonitoring and ,valuation units at provincial level "ill regularly revie" and monitor the progress on -ational Health Policy <==E and Strategic 0rame"or/s: *hese units "ill also generate evidence and disseminate that to highlight progress or issues:
87
Detailed roles and responsi&ilities at different levels of the government "ill &e agreed as part of the strategic plans:
@7
All development partners "ill &e as/ed to align their investments in health sector in line "ith strategic plans: onitoring mechanisms "ill &e harmonized so that results are accepta&le to all: Both the government and development partners "ill &e mutually accounta&le: ,ach year4 inistry of Health "ill organize t"o meetings of Health Development Partners 0orum to revie" the reform process and to set agenda for the future:
7
-ational Health Policy5<==E "ill &e aligned "ith other strategic documents i:e: 2ision <==4 *D04 P#SPs4 *B0 and provincial strategic plans etc:
% "nne7)re I> )utcome and )utput targets + &aseline4 &enchmar/s and targets II> 0unctions and #esponsi&ilities III> ,ssential Service Delivery Pac/age
<8
Draft National Health Policy 2009
"nne7)re 8
Health Sector Indicators 6Baseline4 Benchmar/s and *argets7 for -ational Health Policy <==E Policy 1!ective>s
ndicators
Benchmarks and Targets
Baseline 2003805
20098$0
20$08$$
20$$8$2
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aternal mortality ratio 6per 9==4=== l&7 *otal fertility rate
253 +%$
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94<4 94 94<4 9448 9448 94 < <4 < <
F of children 69<5< months7 fully immunized 6Disagregation &y gender and income7 Antenatal care at health facility *etanus *o.oid coverage F of &irths attended &y SBAs F of institutional deliveries Contraceptive prevalence rate 5 F 6Disagregation &y gender and income7 *B 5 Case detection rate 6SS7 5 F *B 5 *reatment success rate 5 F F of families sleeping under insecticide treated nets in high ris/ areas Prevalence of Hepatitis B3C
5
H<"?TH SCST
94<448 94<448
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Draft National Health Policy 2009
H<"?TH SCST
@ @ 94 94
in: govt: e.penditure on health as F of 1DP *otal e.penditure on health per capita 6#s: Per person per yr7 Doctors per 9=== population -urses per 9=== population $H2s per 9=== population $H!s per 9=== population Hospital &eds per 9=== population F of Health facilities "ith stoc/ out of essential 8 medicines
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Draft National Health Policy 2009
"nne7)re 8
Pakistan Health System: #ore )nctions and 4esponsi!ilities #ore )nction S<4#< .
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Draft National Health Policy 2009
"nne7)re 8
*he proposed pac/age of the BHU $evel health facility envisages a facility4 "hich has a catchments area population of around 84===59<4=== and need not necessarily &e staffed &y a full time medical doctor: BHU level health facility comprises not only the physical facility &ut also includes the outreach and community &ased health "or/ers4 as the staff of the BHU level health facility is also responsi&le for monitoring and ensuring the outputs for the population &ase of the 0$C0: *he minimum service pac/age required at this level of care is proposed as follo"s> C)#, Pac/age> •
• • • • • • •
•
•
•
Curative care for common illnesses 6including first aid and provision of essential medicines7 ,PI 6plus7 services Integrated anagement of -eonatal and Childhood Illness -utrition advice services Prenatal and postnatal care Birth preparedness counselling -e"&orn care *reatment of diseases li/e malaria4 tu&erculosis4 hypertension4 dia&etes and s/ins infection etc: 0amily Planning counselling and services including Intra uterine device 6IUD7 insertion and removal services Information and ,ducation for ,mpo"erment and Change 60amily mem&ers4 pregnant "omen4 parents4 traditional care providers etc7 *raining and management support for community &ased lady health "or/ers
Additional )ptional Services> •
• • • •
< Basic ,m)-C services only if transportation and referral to higher level is availa&le and can &e ensured )&stetrical care $a&oratory support for antenatal care Promotion of Iodized salt S*I including HI2AIDS counselling and referral
Draft National Health Policy 2009
•
Psychological reha&ilitation
•
Physical reha&ilitation
!% 4H# ?evel Package:
*his is envisaged as a health facility4 "hich is open < and staffed &y medical doctors: *he envisaged catchments population of this health facility is around 9<4===5=4===: *his facility "ill also provide management support to the attached BHUs: *he minimum service pac/age required at this level of care is proposed as follo"s> C)#, Pac/age> •
• • • • • •
• •
• • •
• • •
•
Curative care for common illnesses 6including first aid and provision of essential medicines7 ,PI 6plus7 services Integrated anagement of -eonatal and Childhood Illness -utrition advice services Prenatal and postnatal care Birth preparedness counselling? < Basic ,m)-C services including handling normal deliveries and availa&ility of interventions for minor complications of delivery post a&ortion care -e"&orn care including resuscitation Comprehensive 0amily Planning counselling and services 6including referral services for surgical contraceptive services7 S*I including HI2AIDS counselling and services < *ransportation 6Am&ulance7 services Diagnostic and *reatment of diseases li/e malaria4 tu&erculosis4 hypertension4 dia&etes and s/ins infection etc: Diagnostic services> la& and radiology Dental care services Information and ,ducation for ,mpo"erment and Change 60amily mem&ers4 pregnant "omen4 parents4 traditional care providers etc7 *raining and management support for community &ased lady health "or/ers
Additional )ptional Services> • • • • • • •
Advanced la&oratory services Blood &an/4 Blood screening and transfusion services Promotion of Iodized salt inor surgical operations ental health services Psychological reha&ilitation Physical reha&ilitation *raining of mid"ives
c% 4eferral Hospital ?evel Package:
*his is envisaged as a hospital4 "hich is open < and staffed &y medical doctors and specialists: *he envisaged catchments population of *H( hospital is around 9==4=== to ==4===4 "hereas for DH( hospital4 the catchments population "ill &e around ==4=== or a&ove: In addition to Core and additional services offered at #HC level facility4 the follo"ing services "ill &e implemented>
=
Draft National Health Policy 2009
•
• • • • •
•
edical4 surgical4 paediatric and gynaecological and anaesthesia 5 specialized services in all *H(H: In addition to specialized services essential for all *H(H4 at least specialized services for ,-*4 ophthalmologic and cardiology "ould &e ensured in all DH(H: Diagnostic services including la& 3 radiology Comprehensive ,m)C services including post5a&ortion care -e"&orn care including incu&ator care *herapeutic feeding centres Comprehensive family planning services including surgical sterilization services for men and "omen *raining of health care providers and paramedics
d% Tertiary #are ?evel Package:
In addition to Core and additional services offered at #eferral level hospital4 the follo"ing services "ill &e implemented> Support 3 delivery of all services offered at DH( and *H( hospital level All types of specialties All diagnostic services *raining of medics and paramedics Physical reha&ilitation services including prosthesis e% #omm)nity level 61rass root level through out5reach services7>
In addition to "hat has &een proposed &y the $H!s Programme4 the follo"ing additional services may also &e provided through $H!s> • • •
,PI services Psychosocial support Provision of clean delivery /its4 -utrition supplementation and 0irst aid 6plus7 etc
*he pac/age of services for community mid"ives "ill &e as prescri&ed &y the -ursing council
9
