Pakistan is not on track to achieve most Millennium development goals (MDGS) related to health, nutrition and population. Given its current rate of progress, in 2015 Pakistan’s infant mortality rate (IMR) will be 65 deaths per 1,000 live births and the under-five mortality rate U5MR will be 78,considerably above the MDG4 targets of 33 and 43 deaths per 1000 births respectively. Pakistan will not achieve the MDG related to nutrition. Childhood malnutrition in Pakistan is higher than in sub-Saharan Africa, and the rate of decline is significantly slower than in the rest of South Asia. In addition, Pakistan’s fertility rate currently at 4.1, although declining, is higher than its neighbors’` and predicted to remain so. While there has been some progress on improving health out comes, the rate of progress is much slower and the poor, in particular, are being left behind.
Though on the decline, child mortality is still high. Currently, the IMR and the U5MR stand at 78 and 94 deaths per 1000 live births, respectively. Comparing the levels with 2001-02, this implies that almost 1 in every 10 children born in Pakistan between 2001-02 and 2006-07 died before reaching five years of age.
Despite a decline among the general population, under-five mortality among the Poorest has made no improvements in the last 15 years. The 1990 and 2006 Pakistan Demographic and Health Surveys indicate that the poorest income quintile has seen almost no change in its U5MR. This is despite a decline in under-five mortality among the general population.
Maternal mortality appears to be declining, but remains high. The rate of Institutional delivery, often used as a proxy for the maternal mortality rate, has increased, mainly due to increased use of private sector facilities. Still women in Pakistan run a 1 in 80 chance of dying of maternal causes during their reproductive life.
Pakistan lags behind its neighbors in immunization coverage and contraceptive prevalence rate. Results from Demographic and Health Surveys conducted between 2005 and 2007 show that India and Pakistan are lagging their neighbors in terms of Vaccination coverage. It is also not clear whether Pakistan is actually making progress in immunizing its children, and there is a debate on whether the decline seen recently is real. The contraceptive prevalence for Pakistan is only 22 percent, less than half that of other South Asian countries.
Pakistan has the potential to generate a demographic dividend by supporting Fertility decline with sound polices. To materialize this potential, Pakistan has to focus on rural areas where the decline in fertility has been slow. Such efforts are required to realize a general decline in fertility, and will results in an increase in the share of the Working age population and the labor force. This generates the first pillar of the demographic dividend, which has to be supported by sound policies to ensure the health Status and capacities of the increased potential labor force.
The gap between the poor and the wealthy and geographic differences in access to health, nutrition and population (HNP) services remain large. The gap in access to services between the poorest income quintile and the wealthiest does not appear to be narrowing. There are also large rural-urban differences in access that are not explained by poverty differentials alone. Similarly, there are large geographical variations in coverage of services. Event within a province, average coverage rates hide very large variations between districts. For example, in Baluchistan immunization coverage between the best and the worst performing districts differs by 69 percentage points.
The quality of care in public facilities is low, resulting in low utilization of public health facilities. Recent health facility surveys in Baluchistan and Sindh indicate that many health workers do not show up regularly to work. In Baluchistan, the absentee rate for all staff was 50 percent, while for doctors it was 58 percent and for female paramedics, 63 percent. The situation was similar in Sindh where 45 percent of the doctors were absent from basic health units (BHUs) and 56 percent were absent from rural health centres (RCHs). These facilities were also poorly equipped and lacked drugs. A 2006 study found that only 46 percent of first level health care facilities had a water supply and only 33 percent had toilets. Only half of the BHUs and RHCs in Sindh had the equipment necessary to carry out proper deliveries. In Baluchistan, contraceptives were available in only 15 percent of BHUs while in Sindh antibiotics were available in only 12 percent of RHCs and 22 percent of BHUs. Oral rehydration salts were available in only one-third of the BHUs and RHCs. As a result, utilization of the public sector, even by the poor, is low; only 25 percent seek care in public facilities.
A large part of total spending in health comes from out-of-pocket payments which drive about 4 percent of the population into poverty every year. Public spending on health represents only a quarter of total expenditure. The largest share of the rest in out-of-pocket payments made by patients at the time of service utilization. Out-of-pocket payments remain large even for those using public facilities. In addition to he income loss associated with being unable to work due to illness, medical costs by themselves can push households into poverty.
Providing protection against the impoverishing impact of ill-health is urgent but requires careful consideration. Designing the mechanism and the benefit package needs to take into account a number of factors. The first consideration is who will be covered, and the number and mix of health service providers in the market. When the majority of the providers are public facilities, an option such as expanding health insurance needs to be accompanied by reforms related to the governing of public facilities. The second consideration is the structure of the cost of health shock. When forgone earnings and non-medical payments constitute the largest share of the cost of health shocks when forgone earnings and non medical payments constitute the largest share of the cost of health shocks, there needs to be provisions in the benefit package that covers such losses if the package is to provide meaningful protection.
The poor in Pakistan might be better protected against the financial risk of health shocks through targeted transfers using tools such as those developed for the Benazir Income Support Program. Direct transfers that are conditioned on health shocks would both protect the poor from the actual cost of treatment and provide partial compensation for foregone earnings. On the other hand, providing insurance coverage to the rural poor without restructuring the existing supply of health-care services would result in limited use and impact of the scheme. Moreover, by paying for insurance premiums which will then cover the cost of services provided by the public sector, the government may end up effectively paying twice for the same services.
Pakistan cannot afford to ignore the HNP sector if it is to realize sustained economic growth. Interventions focused on improving HNP outcomes are necessary for the sector to serve both as a catalyst to growth and as a beneficiary of it. These interventions include the following options for gradual scale-up.
Accelerate the decline in child mortality by (a) addressing neonatal mortality through training lady health workers (LHWs), increasing early post-partum visits, and increasing institutional deliveries; (b) increasing access to effective preventive and curative services, and (c) more regularly tracking the IMR and U5MR and cause of death though demographic surveillance.
Reduce maternal mortality by (a) increasing access to family planning services; (b) increasing the number of skilled providers in rural areas through incentives for doctors, mid-wives, and lady health visitors (LHVs) who work in under-served areas; (c) further expanding 24-hours emergency obstetrical care; (d) improving nutritional status before and during pregnancy (e) providing incentives such as conditional cash transfers for use of prenatal, obstetrical and post-partum care; and (e) providing vouchers for deliveries.
Intervene on a broad scale to reduce childhood malnutrition by (a) controlling childhood infections, possibly through the use of incentives aimed at increasing vaccination coverage and well-child care; (b) promoting early and exclusive breastfeeding and adequate complementary feeding; (c) addressing micronutrient deficiencies; and (d) treating severely malnourished children using “protocolized management” including community-based approaches.
Increase the use of contraceptives to reduce the fertility rate by (a) increasing the focus of LHWs and other rural health workers on providing family planning services and supplies; (b) increasing the number of public facilities that provide a broad menu of family planning methods; (c) broadening social marketing of contraceptives and ensuring results by paying contracts based on performance; and (d) offering supply-side incentives to providers.
Focus particularly on the poor, including the urban poor by (a) engaging more with non-governmental organizations (NGOs) to provide basic preventive and promotive services; and (b) assessing whether the deployment of LHWs can be targeted and deployed in urban areas.
Protect the poor from impoverishing health shocks by ensuring access to a clearly defined package of services and coordination with the social protection strategy to ensure adequate protection.
These interventions require more resources than what Pakistan currently spend on health. Compared to other countries at its level of development, Pakistan spends very little on NHP services. As a proportion of GDP, the Government of Pakistan spent only 2.6 percent in 2005/2006, the lowest in all South Asian countries. Not only is the level of expenditure low, the rate of increase in spending is very low.
In addition to spending more resources, Pakistan also needs to manage the sector better and spend efficiently. Because of the lack of clear strategy, expenditures are volatile. There have been large expenditures on hospitals planned in the Public Sector Development Program (PSDP) that seem at odds with efforts to address the MGDs and improve equity. Further, the public financing system is highly fragmented with various entities being responsible for funding limited components and activities of a program in the health system. Such fragmentation weakens accountability and contributes to the inefficiency of delivery.
Domestic initiatives, such as the People’s Primary Healthcare Initiative (PPHI), offer a means for improving the management of publicly financed services: the PPHI is a locally developed and financed approach to improving publicly financed primary care using NGO management. An evaluation of the initiative in two districts in Punjab showed that utilization of BHU services increased significantly and also community satisfaction of services increased. The PPHI can be further expanded and strengthened by (a) including Rural Health Centres under the responsibility of PPHI and health workers such as lady health workers and vaccinators report to PPHI managers rather than vertically managed by the programs; (b) making the indicators of success explicit and having third party evaluation; and (c) using competitive selection of the NGOs to ensure innovative approaches.
The government could better harness the private sector to attain national health objectives. Much of the improvement in access to prenatal and obstetrical care is due to increased access to and use of the private sector. Taking advantage of private sector growth, even in rural areas, the government could devise alternatives to increase poor people’s access to private providers. It could also consider buying service, such as institutional delivery, from the private sector.
In addition to the for-profit private sector, the government should explore ways to work with the philanthropic sector. This sector is performing well in managing and running hospitals, ambulances, and related health services. The results of half-hearted attempts at giving public hospitals autonomy were modest. A better way of strengthening hospital services, especially for the poor, may be for the government to work with the philanthropic sector. This would involve partnering with philanthropies expand their services. Based on the performance of the philanthropies so far, this approach would appear to have a high likelihood of success.
Improving the HNP outcomes through the above strategies calls for the government to assume a stronger stewardship role in the sector. Because they remain occupied with service delivery, the federal and provincial government devote little time to stewardship functions such as where they have a unique and irreplaceable role to play. This neglect could be partly because of lack of structure, resources, and skilled people to carry out the core stewardship functions both at the federal ministry and in the provincial level. The governments need substantial capacity building to enable them refocus on these core functions.