The health care system in Pakistan is beset with numerous problems; structural fragmentation, gender insensitivity, resource scarcity, inefficiency and lack of accessibility and utilization. Moreover, Pakistan is faced with a precarious economic situation, burdened by heavy external debt and faltering productivity and growing poverty.

How much to spend on health is a widely debated question with no simple answer. Pakistan has remained a fiscally deficit country for decades and health has never been a priority for any political government due to the budget deficits and a lack of commitment to health sector. Although Pakistan is a signatory to the Millennium Development Goals (MDGs) a recent analysis reveals that Pakistan spends only 2.6 percent of its GDP on health expenditure which is, incidentally, lowest in the South Asian region.

  Major budgetary chunks go to functional heads like General Hospital Services and Administration which constitute more than 85 percent of the total health budget. There is very little left over for spending on other key health interventions like mother and child health, Malaria, TB and immunization coverage. 

A draft National Health Policy remained in discussion for a long time without reaching a consensus for approval and notification which, thus, prevented the health sector from taking a strategic approach. However, the 18th Amendment to the Constitution has transferred full administrative and financial authority to the provinces offering an opportunity to assess the existing publicly funded health care system and introduce far-reaching reforms.

 Decisions in the past were seen to be made mainly on an ad hoc basis and very little, if any, evidence drove policy or decision making. Public finances and donor funding were allocated to projects and programmes but lacked both an exit strategy and the institutional development component, hence sustainability remained the prime stumbling block. We have seen that capacity building has used up major portions of the funding received through both government and Donors in the past. Even though the required trainings were conceived on needs but the lack of an institutional mechanism to retain the capacities as well as the mismatches between skills and the staffing/equipment made these efforts go waste in the long term. The disparities between the allocations to the tertiary and mega hospitals and much lesser focus on the lower down tiers (primary and secondary care facilities) have not only made the tertiary care congested but has also reduced the quality of care required. The hospitals going ghost in the evenings could take up the burden of patients by working round the clock but this has never been given a chance.

Facilities built each year have taken the bulk of the developmental budget without addressing the issue of access. It is quite possible to see a particular area with several facilities while people from an adjacent area need to walk miles before getting a required treatment. The private sector has grown into a giant and requires regulation. As a first step the government needs to step into more and more regulation and leave the service delivery to the private sector. A few models of public private partnership have been tried in Pakistan and outsourcing service delivery is being further considered which is encouraging but needs insights and assessments whether these working arrangements have been as successful as was envisaged. 

These few examples, from an array of issues, underscore the need for innovative health sector reforms while highlighting the complexity of the task involved.

The first and foremost need is the realization that health is a priority, a fact nobody can negate because of its impact on economic development. Institutional capacity of the health sector can be enhanced by developing strategies which are based on evidence from within and on successful experiences of other countries.

Pakistan has just gone through general elections and the commitment that is required from the new government is to take these strategies forward to implementation, in addition to certain other initiatives. The need to establish a sound health delivery system would also require chipping in of capacities from a richly experienced private sector through involving them in service delivery to the masses with embedded safety nets for poor. One of the mechanisms to achieve this is through Social Health Insurance where the rich pay for the poor, healthy pay for the sick and young pay for the old; although this may be true in words but in actual practice everyone pays for himself through pooling money on regular basis. In addition the Social Health Insurance provides the basis for quality assurance since service providers compete for attracting the pool of patients by enriching their services quality and reducing the cost of provision of such services. 

Additionally, targeted initiatives for the poor both in public and private sector are essential to ensure that best services are available to all without any discrimination. Regulation of the private sector in terms of quality and treatment costs is a daunting task requiring governmental focus; quality control of drug manufacturing is vitally important. The establishment of state-of-the-art Drug Testing Laboratories in each province is a must for ensuring drugs which are quality assured and standardized (with preferably an independent management structure).

 It would be pertinent to also mention the scarcity of female service providers in health sector, especially in the rural areas where women seek only female care. Medics, nurses and paramedics can not only be given incentives to take these professions but can also become source of expatriate human resource requirements. Institutionalization of trainings, both pre and in-service, through bringing all trainings under the regional training institutions of the provincial departments of health will not only rationalize trainings but will also ensure sustainability. Strengthening the systems of financial management and monitoring and evaluation within the public health sector and even beyond (private sector) will be able to track the deficiencies and promptly respond to the identified gaps. 

There is neither dearth of implementable strategies nor a lack of people who are able to translate these into actions. We pray that the new government has the strength and commitment to deliver and to come up to the expectations of the people of Pakistan.

 The writer is a Public Health Specialist.