Healthcare System in Pakistan

Healthcare System In Pakistan an overview. Prepared by Elsa Ali Student BBA (1st Year)

Contents

S#	Topic	Page #
1.	Introduction	1
2.	Healthcare an overview	1
3.	Health expenditure	1-2
4.	Pakistan Healthcare system Primary Health care secondary health care tertiary health care private Health Sector	2-4
5.	Major health programs in Pakistan	5
6.	Human Resources Situation in Pakistan healthcare  System	6-7
7.	Health Situation of Pakistan	7
8.	Disease burden in Pakistan	8
9.	Factors causing poor health in Pakistan	8
10.	Challenges of Pakistan health care system	9
11.	Problems in the health sector of Pakistan	9-13
12.	Recommendations	14-15
13.	Conclusion	16

 

Introduction

The World Health Organization defines a health system as “all the organizations, institutions, and resources that are devoted to producing health actions.” The health sector can be described as the sum of all the activities involved in dealing with health issues. Health is one of the major issues with the human being as it is obvious that there are people they will come across the health issues. The main objectives of the health system are to improve the health of the population, fairness in financing and risk distribution, and responsiveness to the non-medical needs of the population. Health sector can be figure out as:

Healthcare an overview

As per the Economic Survey, there are currently 233,261 doctors in the country, up from 220,829 in 2018. Separately, there were 112,123 nurses in 2019, up from 108,474 the previous year. Till last year there were 1,279 hospitals in the country, according to the Pakistan Bureau of Statistics. No new hospitals were added in the year 2018-2019. There are currently 132, 227 hospital beds in Pakistan, which means that for 1,608 persons one bed is available. The number remains unchanged from 2018. It is important to note that the 2018-2019 Economic Survey had stated the doctor population ratio in the country. According to the previous report, one doctor was available for 963 people. However, the new survey does not include this figure.

Health expenditure

In terms of total health expenditure as a percentage of the GDP in 2018-2019, the spending was 1.1%. The figure has reduced from 1.2% in 2017-2018. The survey notes that Punjab has 32 District headquarter Hospitals (DHQs), 9,126 Tehsil Headquarter Hospitals (THQs), 10,316 RHCs, and 2,506 BHUs. In the financial year 2020, it allocated a budget of Rs 64,891.26 million for development projects in the health sector. While Sindh allocated Rs 114.14 billion for the health sector in the budget for FY2020.Pakistan has a high total fertility rate of 3.8%, and the current modern Contraceptive Prevalence Rate is only 26%. · Pakistan became the first country in the world to include the Typhoid Conjugate Vaccine (TCV) into its routine immunization program in Sindh from November 2019. Almost 40 million children, including 6.8 million children at schools designated fixed points, were vaccinated for polio during December 2019. The number of children missed during the last campaign in April 2019 decreased from 1.8 million children to 0.5 million children in December 2019.

Pakistan Healthcare system

Pakistan is a lower-middle-income country and the 5^th most populous country with an estimated 220.89 million. Pakistan as a developing country and rich in population has a big challenge to deal with Health. In spite of limited resources, Pakistan has a defined health sector which can be divided as:

• Government operated
  • Federally operated
  • Provincial operated
• Private operated

The health services provided by the government of Pakistan have 3 layers.

1. Primary Health Care
2. Secondary health care
3. Tertiary health care

1. Primary Health care (PHC):

This is the first level of Healthcare, where patients have their initial interaction with the system and it provides curative and preventive Healthcare Services. Primary healthcare is the first contact a person has with the health system when they have a health problem. It refers to a broad range of health services provided by medical professionals in the community. Pakistan has a relatively large primary health care infrastructure. This includes

• 5000 basic health units,
• 600 rural health centers,
• 7500 other first-level care facilities
• Over 100,000 lady health workers providing services across Pakistan (WHO). These primary health care services are supported by a network of 989 secondary care hospitals, at tehsil and district levels, for referrals.

A primary health care approach includes three components:

• Meeting people’s health needs throughout their lives.
• Addressing the broader determinants of health through multispectral policy and action.
• Empowering individuals, families, and communities to take charge of their own health

 In Pakistan primary healthcare is provided in the following centers:

• Basic Health Units
• Rural Health centers
• Dispensaries

(Along with these centers Pakistan government is running the Lady Health workers program vigorously.)

In Primary Care following facilities is provided:

• Preventive care.
• Vaccination
• Breast cancer awareness
• Dengue prevention

Secondary Healthcare

It is an intermediate level of Healthcare that is concerned with the provision of technical, therapeutic, and diagnostic services. It is the first referral level serving at district and tehsil. Specialist consultation and hospital admissions fall into this category.

Secondary health care system is provided by the following centers:

1. Tehsil Headquarters (THQ)
2. District Headquarters (DHQ)

Tehsil Head Quarters (THQs) serve a population of 0.5 to 1 Million peoples. Most of THQs have 40-60 beds. THQs are supposed to provide basic and comprehensive Emergency, Obstetrics, and newborn care. Provide referral care to those referred by RHCs, BHU, and Lady Health Workers. District Head Quarters (DHQs) are located at the district level and serves 1-3 million population. DHQs provide primitive, preventive, curative, diagnostics, inpatient, and referral services. All DHQs provide referral care to patients referred by BHUs, RHCs, and Tehsil Head Quarters.

Tertiary Healthcare

Tertiary Healthcare hospitals are for more specialized inpatient care. Specialized Healthcare services usually for inpatients and on referrals from primary or secondary health professionals.

Tertiary healthcare services are provided in the following institutions:

1. Teaching Hospitals
2. Specific hospitals for specific patients like cancer etc.

Tertiary healthcare provides the following services:

• Curative services
• Specialized healthcare
• Teaching facilities
• Rehabilitation
• Major surgeries.

Private health sector in Pakistan

The private health sector operates through a fee-for-service system of unregulated hospitals, medical general practitioners, homeopathic doctors, hakeems, and other spiritual healers. The private health care system is providing comparatively perceived as quality service than the government healthcare system. The services are prompt and well equipped than the Government sector. People who can effort prefer to go to private hospitals, clinics, etc. although it is very costly.

Studies have shown that Pakistan’s private sector healthcare system is outperforming the public sector healthcare system in terms of service quality and patient satisfaction, with 70% of the population being served by the private health sector. (Akbari, Ather (Summer 2009). “Demand for Public Health Care in Pakistan”. The Pakistan Development Review. 48 (2): 141–153. doi:10.30541/v48i2pp.141-153.)

Major health programs in Pakistan

In Pakistan, there are many health programs running for the betterment of public health most of the programs are government-operated and funded and some programs are with foreign, and WHO cooperation. Some of the major healthcare programs are:

• Expanded program in immunization (EPI).
• National Aid Control Program (NACP).
• Malaria Control Program (MCP).
• National T.B. Control Program (NTCP).
• National program for prevention and control of blindness
• National program for family planning and primary health care
• National maternal newborn and child health program (MNCH Program)
• Cancer treatment program
• Drug abuse control

 

Human Resources Situation in Pakistan Healthcare System

Pakistan has an estimated 0.82 physicians, 0.57 nurses and midwives, and 0.06 community health workers per 1000 population (Figure 2). There continues to be an inverse ratio of doctors to nurses, with fewer nurses produced than doctors, as a result of high out-migration of the former. There is also a shortage of allied health professionals with 0.9 pharmacists/10, 0000 population, which is far below the WHO recommended ratio of 1 pharmacist per 2000 population. Policy emphasis continues to focus on the expansion of medical colleges and the number has grown exponentially with 2 in 1947 to 144 in 2019. As of January 2019, there are a total of 114 medical colleges in Pakistan, 44 of which are public and 70 private. Pakistan is also producing certified family physicians, although these are mostly destined for private practice in urban areas because the government has not yet established a cadre to absorb family physicians in the public sector infrastructure. There are also notable urban-rural discrepancies in human resources, particularly for doctors. An estimated 14.5 physicians per 10, 000 population in urban areas is contrasted with 3.6 per 10, 000 population in rural areas. There is a smaller but nevertheless significant discrepancy in the distribution of nurses and midwives, with a higher urban concentration of 7.6 midwives compared to 2.9 per 10, 000 population in rural areas (see Figure 3).

 

Figure 2 Human resources for health in Pakistan

Source: World development indicators: Health systems. Washington DC: World Bank Group: 2008–2014. Available at: http://wdi.worldbank.org/table/2.15

Ghaffar A et al (2013). Medical education and research in Pakistan. The Lancet, 381: 2193, p 2234-2236.

Figure 3 Urban–rural distribution of human resources for health in Pakistan

Source: World Health Organization

Health Situation of Pakistan

Pakistan is facing a double burden of diseases (BoD)

• Hepatitis B and C with 7.6 % affected individuals.
• 5^th highest Tuberculosis burden in the world.
• HIV prevalence (20000 new cases per annum as per WHO).
• High rates of unscreened blood transfusion.
• Pakistan is ranked 10^th in Diabetes prevalence.
• One in fourth adults over 18 is hypertensive.
• The infant mortality rate for Pakistan in 2020 was 59.109 deaths per 1000 live births.
• The prevalence of anemia among ever-married women aged 15 to 44 is reported to be 26% in urban areas and 47% in rural areas.

Disease burden in Pakistan

Factors causing poor health in Pakistan

1. Poverty
2. Lack of medical research
3. Pollution
4. Illiteracy
5. Health policies
6. Lack of awareness
7. Unhygienic conditions (water etc.)
8. Inadequate medical facilities
9. Urbanization
10. Poor sanitation and sewerage.
11. Communicable diseases are the major reasons for death
12. Inadequate vaccinations

CHALLENGES OF PAKISTAN HEALTH CARE SYSTEM

Pakistan’s healthcare system is loaded with a number of challenges. Since the division in rural and urban areas, non-uniform facilities are available. Pakistan’s major population is in rural areas while most of the facilities are available in urban areas moreover urbanization is increasing day by day which is also causing problems in urban areas. This situation is also negatively supported by the healthcare staff who are reluctant to work in rural areas due to lack of facilities and lack of infrastructure.

Major challenges in Pakistan healthcare can be pointed as:

1. Lack of awareness amongst people of Pakistan towards a healthy lifestyle.
2. Low Economy.
3. Lack of funds.
4. Lack of research.
5. Low Literacy ratio.
6. Malnutrition.
7. Poverty.
8. Poor sanitization
9. Fake healthcare service providers like unqualified doctors, Hakeems, etc.
10. Self-medication.
11. Net medication.
12. Chachi’s treatment.
13. Weakness in health policies of Pakistan
14. Corruption

Problems in the health sector of Pakistan

The Healthcare system in Pakistan faces a number of problems due to several controllable and uncontrollable factors. We can talk about controllable factors which by good management and by filling up the gaps can be overcome to resolve problems. The basic is the direction by the policymakers which directs the healthcare system towards providing services. Below is the policy of the government of Pakistan which sets the direction of the healthcare system:

RESPONSIBILITY OF PROVINCIAL AND FEDERAL GOVERNMENT (ARTICLE 38d):

According to the constitution, article 38d provide necessities of life such as food, clothing, housing, education, and medical relief, for all such citizens, irrespective of caste, creed, or race, as are permanently or temporarily unable to earn their livelihood on account of infirmity, sickness or unemployment. Health care is mainly the responsibility of provincial governments, except in the territories administered by the federal government. The planning and formulation of health policies are dealt with by the federal government and the provincial government has the responsibility to ensure the proper implementation of those policies. The responsibility of implementing some vertical programs on AIDS and malaria and the extended program of immunization rests largely with the federal ministry of health.

As per the article illustrated above the provincial government has all the authorities in respective provinces Federal government can’t interfere in their problems that is causing a conflict between the two bodies Federal Government want to interfere but the provincial government does not allow them moreover the provincial government regularly complains about the release of funds from Federal government. Federal and provincial governments lack coordination as well political interest which is, in the end, damaging the people of Pakistan.

Some of the major problems in Pakistan healthcare system are illustrated as:

1. LACK OF RESEARCH IN HEALTH SECTOR:

Lack of research, interest, and orientation in the field of medical research is a major issue in the health sector of Pakistan. Research can provide information about the spreading diseases, risk factors, symptoms, outcomes of treatments, and health care costs. Clinical trials provide information about the adverse effects of medical inventions by controlling factors that can affect the results of the study.

• LACK OF HEALTH AND INSURANCE CARDS:

KPK government has issued a health card system, positive thing is that this health card system is also been introduced to other areas of Pakistan. Previously this facility was not available, these cards are adding positively towards providing healthcare facilities to the general public. The major problem is utilizing these cards and available to every needy person in Pakistan. 

• NO PROPER  DOCUMENTATION:

There is no proper documentation in the health sector of Pakistan. Documentation includes the number of visits made by doctors, the dates, various reports of patients. The absence of proper documentation leads to errors as proper follow-up is necessary and if the hospital would not keep a record of this, then effective treatment can be difficult.

• MISDIAGNOSIS:

In Pakistan the normal practice is empirical therapy means therapy without proper lab diagnostics as it is not freely available, it is costly and there are quality issues with lab diagnosis as well, therefore there is an issue of misdiagnosis, administration of a wrong drug, the improper dose of a given medication, and wrong route of administration retained surgical instruments.

• CORRUPTION IN HEALTH SECTOR:

Pakistan’s health care sector is considered as the most corrupted sector. General surveys suggest that the majority of Pakistanis are unhappy with the health services they are offered. Corruption in the health sector causes a decline in economic growth and reduces private sector investment.

The medical staff involved in such deceiving jobs is not only challenging the integrity of such a respected and trustworthy profession but also making it impossible for a low-income person to seek medical help when needed. The conventional ways medical staff adopt to get extra money include, asking for bribes from patients for the queue jump, increase their bills making them stay unnecessarily long in the hospital, or misguide them to consult a specialist that takes high fees for a checkup.

• MEDICATION ERRORS BY DOCTORS:

Wrong prescriptions, an overdose of medicines, and adverse side effects of drugs topped such errors that took human lives. According to an estimate, 400,000 -500,000 people die in Pakistan as well owing to wrong administration of drugs and other lethal errors in medication. (The Daily Dawn). this is a highly alarming situation meriting the immediate attention of authorities and pharmacists.

• LACK OF FACILITIES TO PATIENTS:

In Pakistan, the health sector is under considerable stress because of its low spending, inability to meet per capita requirements of doctors and allied medical staff, and suffers from “workforce crisis” (WHO 2006). There is only one bed for 1600 patients, one nurse for 1600 patients. According to international standards, there is a need to have two physicians one dentist for a population of 1000, 4 nurses to one doctor.

• NON-SERIOUS DOCTORS/ JOB PERFORMANCE AMONG HOSPITALS:

In Pakistan, health workers in general and physicians, in particular, are not satisfied with the current jobs and they tend to perform poorly due to a lot of problems. In general, Pakistan has struggled to counter the scarcity of resources along with under productivity, maldistribution, migration, and social threats to health workers and despite giving much attention to increasing the number of doctors and medical schools it still falls well short of international recommendations (Abdullah et al, 2014).

• FAKE DOCTORS:

In September 2018, (Reported by The Daily Dawn) a fake doctor was caught at PIMS where he had been practicing for six months. During the initial investigation, it was transpired that two postgraduates had hired the individual, who was basically a vendor of medicines and instruments as their proxy and were paying him.

Patients by the hundreds, young and old visit suck fake clinics and hospitals every day thinking they are being treated by real doctors. Every hour the receptionist’s hands over a stack of one thousand rupee notes to the quacks owner and together this team of planned killers continue to feast in broad daylight.

In rural and remote areas of Pakistan, a quack is often the first point of medical contact. Having inadequate medical powers in diagnosing and treating diseases, infection control, and sterilization, these quacks unnecessarily medicate patients with antibiotics and steroids leading to further deterioration of patients’ conditions.

1. POOR MEDICAL EDUCATION SYSTEM:

The economic crisis in the last few years has reduced the role of government in social development and transferred it to the private sector. These changes have affected medical education too. Lack of resources has created a situation where outdated knowledge, skills, and attitudes. Students are understandably frustrated when they discover that their long journey through medical school has yielded knowledge that does not match the requirements of their profession. The government is investing its limited resources in the development of medical colleges and universities rather than investing in improving the quality of healthcare by training medical professionals by introducing public health schools and techniques training institutions.

1. UNAVAILABILITY OF SKILLED LABOR:

The issue of medical health concerning health professionals and their abilities in countries is still unclear. The government is still unable to pinpoint the major areas of the problem. In the framework of health system development, there is an alarming shortage of skilled and qualified healthcare experts like Human Resource planners in the health system, health information experts, health care system managers, and healthcare economists. The government’s ability to train the staff member is unable to fully train the medical staff and is still playing with people’s lives.

1. LACK OF INFORMATION TO GENERAL PEOPLE:

The lack of information is one factor that hinders poor people’s use of health services. Poor access to social people’s use of health services. Poor access to social networks, inadequate services, and inability to pay are some of the other factors. Due to poverty and lack of awareness, the power income group of society is compelled to adopt inappropriate health-seeking behaviors such as selecting a low standard hospital, untrained health care provider, self-medication or even discontinuing the treatment because of their low salaries and shortage of money. These actions worsen the financial and health status of the patient, thus creating a vicious cycle.

1. POPULATION ACCESS TO HEALTHCARE:

According to the study, less than 30% of the population has access to the facilities of the PHC units, and on average, every person visits a PHC facility less than once a year. The reason for their underutilization, as recognized by both the managers and consumers, is the lack of health care professionals and especially women, poor quality of services, and inconvenient location of PHC units. There are many organizations like the Pakistan Army, railways, departments of local government, and many other independent organizations that are providing health care facilities to their employees, and those employees form a major portion of the population.

1. DISCRIMINATION IN HIRING NURSES:

There is gender discrimination in the health sector. Females are given priority when it comes to nursing. We hardly see male nurses. The government is investing its limited resources in the development of medical colleges and universities rather than investing in improving the quality of health care by training medical professionals by introducing public health schools and technicians training institutions.

1. CONTINUOUS PROFESSIONAL DEVELOPMENT:

There is no structured continuous professional development system, and there is no way a medical professional is held responsible for its incompetence. Although the PMDC has made some attempts, they have not been materialized yet. There is a shortage of public health and community direction in the programs of medical and nursing schools. Graduates of these schools are not well prepared to practice in a public health care atmosphere while these needs are important.

1. WEAKNESS IN HEALTH POLICIES OF PAKISTAN:

Health policies mainly focus on curative healthcare such as increasing number of health facilities, laboratories, ambulances, and modern equipment without assessment of how health professionals will use them, who are not trained for modern technology. While formulating the policies, insight is taken from success stories of developed countries without considering ground realities, religious, cultural values, a social dimension, and paying less attention to economic differences. Contents of health policies show the same traditional biomedical model dealing with the treatment of disease rather than covering cultural and environmental determinants to prevent diseases. All vertical programs are implemented at primary healthcare facilities but are administered and run by the federal government. This creates disharmony at BHU and district levels because they are not involved in the planning of programs. Monitoring and evaluation is another gap in health policies. No system to compile, evaluate and use data for assessment and policy reforms at the district level. As a result, data is not presented to the federal ministry for feedback and evaluation of the vertical program.

1. BRAIN DRAIN OF MEDICAL GRADUATES:

1700 physicians per year are lost from the pool of practicing physicians because of lack of security, poor remuneration, and limited resources of professional development, and overall discouragement of the health professionals in Pakistan.

1. INADEQUATE FUNDING:

Pakistan spends less than 1% of its GDP on the health sector which is one of the lowest in the world. Resulting in limited allocations for personnel equipment and infrastructure in the health sector.

RECOMMENDATIONS

• It would be better to move away from the curative biomedical model towards a more extensive and holistic approach. Other factors such as environmental, social, and cultural aspects need to be concurrently addressed to improve the health of people.
• It would be highly beneficial if policymaking is decentralized and delegated to districts because they can adopt a better and realistic approach to the problems they encounter on daily basis.
•  More resources should be kept into capacity building of the administrators at the district level to understand contemporary health issues, because the root causes of problems are not addressed while formulating policies, due to lack of knowledge about the concerned place and population.
•  Better monitoring and evaluation tools should be constructed to get valuable and unbiased feedback to policymakers and implementers.
• Other key measures can be taken to improve the Healthcare sector of Pakistan; control population growth, increase literacy rate, increase health budget, control corruption in public health projects, regionalization of Healthcare services, and promote health education, proper check on quackery, and exchange of human resource and knowledge with developed countries.
• The health care system should analyze both patient population and organizational operations to identify areas for improvement.
• Having access to care is the single most important factor for improving quality healthcare and patient outcomes. Patients must have access to the right care at the right time in order to get the right results. Patients can be the best advocates for their own health, but first, they have to be engaged and taught to be proactive healthcare consumers.
• For true engagement in healthcare, primary care providers should think more holistically and find effective ways to connect and encourage communication between families, physicians, other care providers, insurance providers, and social services throughout the patient’s entire healthcare journey.
• Basic nutrition gaps should be bridged in the target population.
• There should be mass awareness in public health.
• There should be improvements in the drug sector.
• There should be the correction of urban bias in the health sector.
• There should be capacity building for health policy monitoring.
• Promotion of healthy communities and healthy behavior.
• A poverty reduction strategy should be made.
• The widespread prevalence of communicable diseases should be reduced.
• Make National Health Policy (Health Sector Reform)
• Greater gender equity should be promoted.
• The deficiency of the health education system should be reduced.
• The private sector should be regulated.
• The government should invest in nursing colleges to overcome the limited human capital in the health sector.
• There should be an increase in budget spending on health.
• There should be a public-private partnership of the provision of medical facilities.
• Encourage medical research and development at a public and private levels.
• Bring health reforms and ensure their successful implementation.

 

CONCLUSION

Health care system of Pakistan is facing numerous problems. Pakistan’s health sector is inadequate, underfunded. With the rapid population growth, the facilities are not expanding proportionally and as desired. We have a poorly organized health structure. We need to clearly define the four-tier healthcare system.  The private sector is playing a vital role in the health care service delivery in Pakistan. However, this sector needs to be regulated and monitored. The health care situation in Pakistan is alarming. The main reason is the poverty of course and the other is unawareness about health care issues. Health needs devotion at both government and public level. A single-sided attempt by the government is not adequate until the people themselves do not have awareness regarding the significance and value of health.