KP Health Sector

Assessment

13-14 February 2018

 WHY KP?
Health Context
Health Expenditure is Low
 UHC Tracer Indicators:
Preventive and Promotion, 2005-2014
Country/ Contraceptive Skilled Birth DPT3 Non-
Region prevalence ANC Attendant Coverage tobacco use Water Sanitation
Afghanistan 21% 73% 36% 78% 55% 32%
Armenia 55% 99% 100% 93% 72% 93% 89%
Georgia 53% 98% 100% 91% 68% 89% 96%
Kazakhstan 51% 98% 100% 95% 72% 94% 97%
Kyrgyz Republic 36% 98% 98% 96% 73% 78% 92%
Pakistan 35% 46% 52% 72% 77% 91% 64%
Tajikistan 28% 79% 87% 97% 84% 60% 90%
Turkmenistan 48% 99% 80% 62%
Uzbekistan 65% 99% 100% 99% 86% 89% 91%
Low-middle
income countries 46% 86% 75% 85% 77% 75% 51%
Source: World Development Indicators
 KP Health Indicators Lower Than Pakistan Average
Antenatal Tetanus Facility- Children with Acute Children with
care (%) Toxoid based all basic respiratory diarrhea with
injections delivery (%) vaccinations infection treatment (%)
(%) (%) treatment (%)

Pakistan 73.1 58.6 48.2 53.8 41.5 61.0

Regions
Khyber 60.5 51.0 40.5 52.7 29.3 23.0
Pakhtunkhwa
Punjab 77.8 67.9 48.5 65.6 72.1 68.6
Sindh 78.2 48.4 58.6 29.1 81.6 73.0
Balochistan 30.6 20.9 15.8 16.4 53.5 43.4
ICT Islamabad 94.3 75.4 86.4 73.9 66.9 66.5

Gilgit Baltistan 64.0 45.3 42.6 47.0 81.5 69.5

Source: Pakistan Demographic and Health Survey

7
Universal Health Coverage Tracer Indictors in Pakistan –
Differences between provinces
KP
Punjab
Improved
sanitation Improved
100 sanitation
% with no 80 DPT3 100
impoverishment 60 % with no 80 DPT3
40 impoverishment 60
20 40
Pre-natal
% with no CHE 0 20
cosnultation Pre-natal
% with no CHE 0
cosnultation
Dairrhea Post-natal
treatment with… consultation Dairrhea Post-natal
Skilled birth treatment with… consultation
attendance Skilled birth
attendance

Sindh Balochistan

Improved Improved
sanitation sanitation facilities
100 100
% with no 80 % with no 80
DPT3 DPT3
impoverishment 60 impoverishing… 60
40 40
20 20
Pre-natal % with no Pre-natal
% with no CHE 0 0
cosnultation catastrophic… cosnultation

Dairrhea Post-natal Dairrhea Post-natal

treatment with… consultation treatment with… consultation
Skilled birth Skilled birth
attendance attendance

Indicators and estimations were made using PSLM 2014

UHC Tracer Indicators-Inequities within the KP
KP-Poorest KP-Richest
Improved Improved
sanitation sanitation
100 100
% with no 80 % with no 80
DPT3 DPT3
impoverishment 60 impoverishment 60
40 40
20 Pre-natal 20 Pre-natal
% with no CHE 0 cosnultation
% with no CHE 0 cosnultation

Dairrhea Post-natal Dairrhea Post-natal

treatment with… consultation treatment with… consultation
Skilled birth Skilled birth
attendance attendance

KP-Rural
KP-Urban
Improved
sanitation Improved
100 sanitation
% with no 80 DPT3 100
impoverishment % with no 80
60 impoverishment
DPT3
40 60
40
20 Pre-natal 20 Pre-natal
% with no CHE 0 cosnultation % with no CHE 0 cosnultation

Dairrhea Post-natal
Dairrhea Post-natal
treatment with… consultation
treatment with… consultation
Skilled birth
Skilled birth attendance
attendance

Indicators and estimations were made using PSLM 2014

KP- Inequities in progress of UHC tracer indicators (2001-14)

Residential location dimension

120

100

80

60

40

20

0
Rural Urban Rural Urban
2001-02 2013-14
% population with improved sanitation % children received DPT3 vaccine
% visited health facility for prenatal consultation % received post-natal consultation
% deliverd by skilled provider % diarrhea cases where ORS was given
% households with no CHE due to OOP % households not impoverished due to OOP

Indicators and estimations were made using PSLM

KP- Inequities in progress of UHC tracer indicators (2001-14)
Economic status dimension
120

100

80

60

40

20

0
Poorest Richest Poorest Richest
2001-02 2013-14
% population with improved sanitation % children received DPT3 vaccine
% visited health facility for prenatal consultation % received post-natal consultation
% deliverd by skilled provider % diarrhea cases where ORS was given
% households with no CHE due to OOP % households not impoverished due to OOP

Indicators and estimations were made using PSLM

 WHY KP?
The Government Strategy
Health sector – a priority for KP Govt
• In the backdrop of all the challenges stated, KP government has
undertaken an ambitious agenda to reform the health sector
• The strategies employed are both legal and programmatic
• Legal: Over 23 acts/ordinances/amendments pertaining to health sector
have been passed since 2011
• Programmatic: Programs aimed at increasing the scope of services and
improving quality have been initiated ( for instance: SHPI, Independent
Monitoring Unit, Healthcare Commission)
• Significant increase has been made in budget for the health sector
• These initiatives signify a great deal of vigilance and effort on part of the
KP government thereby indicating a great opportunity for ADB to engage
with the province’s health sector
ADB’s role in Pakistan’s Health Sector: Historical Context

• Women’s Health Project (1999-2006)

• Reproductive Health Project (2001-2008)
• Balochistan Devolved Social Services Program (2005-2009)
• Sindh Devolved Social Services Program (2003—2008)
• Punjab Devolved Social Services Program (2004-2008)
• Improving access of poor women and children to better health services (2003-2008)
• Iron & Folic Acid Fortification in small scale milling to improve lives of poor (2006-2009)
• Project for providing grants to NGO initiatives to prevent HIV/AIDS (2006-2008)
• Multisectoral Rehabilitation and Improvement for AJK (2004-2009)
• Earthquake Emergency Assistance Project for AJK (2006-2009)
• Punjab MDG Program (2008-2011)
KP Health Sector Assessment
 KP Health Sector Assessment

• Objectives:
• To identify bottlenecks and opportunities within the KP health sector
• To lay the foundation for a masterplan for the health sector
• Using WHO’s framework for health systems assessment, challenges and
opportunities were reviewed in detail for the following areas:
• Physical and Human Resources
• Quality of Health Services
• Behaviour Change Communication
• Governance, particularly hospital autonomy and contracting
• Public Financial Management
• Financial planning (projections) for the ongoing social health protection reforms
Assessment Methodology
• Review of current documents and data available with the Department of
Health and allied offices
• Quantitiave survey conducted in 30 secondary care hospitals with the
support of Khyber Medical University
• On-site visits to 6 secondary care hospitals
• Two missions had detailed discussions with relevant stakeholders in DOH,
allied offices, and government hospitals
• The missions comprised of international experts in Health Facility
Planning, Health Financing, Behavior change communication,
Governance, and Quality
Key Health System Areas for Intervention
• The assessment has concluded that health sector is facing challenges in
three key dimensions of health systems with access and quality being
cross-cutting themes:

• Service Delivery and Utilization

• Governance
• Financing (including Public Financial Management)

• Corresponding strategies within each area have been developed

KP Health Sector Assessment
Service Delivery and Utilization
Service Delivery and Utilization
• Burgeoning demand for health service delivery (inpatient and outpatient)
and human resource for health
• Inadequate Infrastructure
• Outdated Facilities
• Inadequate and outdated equipments
• Only essential medicines available through Medical Supply Department
• SOPs, basic guidelines and clinical pathways are missing
• No strategy for Behaviour Change Communication is present
• The private sector in KP remains elusive due to inadequate data and lack
of cooperation
 Gap Analysis for Service Delivery: Admitted
Hospital Care
4,000,000

3,000,000 2,835,151
2,327,793
1,887,971
2,000,000

Admitted patients
1,526,878
1,215,481
1,000,000 784,330

Estimated and projected gaps -431,151

-1,000,000 -742,548
between supply and demand of
-1,103,641
admitted hospital care in KP for -1,543,463
-2,000,000
years 2015, 2020, 2025, 2030 -2,050,821
to 2035
-3,000,000
2015 2020 2025 2030 2035
Estimated Supply Demand Gap
 Gap Analysis for Service Delivery: Out-patient
care
500,000,000

400,000,000 370,502,422
319,380,672
300,000,000 274,320,803
Outpatient consultation 233,159,170
195,728,240
200,000,000
106,389,200
100,000,000

0
Estimated and
projected gaps -100,000,000
between supply and -89,339,040
-126,769,970
demand of outpatient -200,000,000 -167,931,603
hospital care in KP for -212,991,472
-300,000,000 -264,113,222
years 2015, 2020, 2015 2020 2025 2030 2035
2025, 2030 to 2035
Estimated Supply Demand Gap
 Quality of Hospital Services
• Infrastructure and Equipment
• Inadequate space (too little in most cases but in some cases too much)
• Relevant services not adjacent to each other
• Reports of inadequate basic installations (water, power, sewage & solid waste management)
• Insufficient medical equipment-from basic to more sophisticated machines
• Process Management and Clinical Outcomes
• Lack of written protocols for diagnostic or therapeutic procedures
• No quality circles of committees
• No monitoring/review or feedback mechanism
• Lack of analysis of clinical outcomes and their relationship with the care given
• Overburdened Secondary Care Hospitals
• Most patients bypass PHC facilities and hence there is overcrowding at the secondary care level
• Around 80% of patients at the secondary care facilities only required PHC level care
Human Resource for Health - Government’s
Initiatives
• The government of KP has made concerted efforts to bolster its
Human Resource for Health
• Examples:
• Incentive structures have been improved to get doctors to hard to reach areas
• In recent past there has been the number of doctors have increased in the
province
• Independent Monitoring Unit
• Capacity building is one of the functions mandated to Healthcare Commission
• To build on this momentum in a systematic fashion it is important to
review the current situation methodically with an eye on future needs
 Gap Analysis for Human Resource: Doctors
80,000

60,000 56,328

39,800
40,000

Medical practitioners
26,500
20,000 15,879
Supply, demand and gap of 8,71611,185
medical practitioners, KP, 2017 to 0
2035 -2,469
-7,163
-20,000
-17,784

-40,000 -31,084

-47,612
-60,000
2017 2020 2025 2030 2035

Estimated Supply Demand Gap

Gap Analysis for Human Resource: Nurses
200,000 176,340

150,000
119,321

100,000 77,214

Nursing personnel
45,910
50,000 32,371
18,314
Supply, demand and gap of
0
nursing staff, KP, 2017 to
-14,057
2035 -50,000 -27,596
-58,900
-100,000
-101,007
-150,000
-158,026
-200,000
2017 2020 2025 2030 2035

Estimated Supply Demand Gap

Behavior Change Communication - Challenges
• Health seeking behavior in KP is primarily influenced by:
• High out-of-pocket payments
• Lack of transportation
• Patriarchal norms
• Lack of education.
• There is lack of Behaviour Change Communication (BCC) strategy
• Doctors/nurses not being trained in BCC at the undergraduate level
• Lack of continouous medical education
• Little to no time for the relevant human resource to conduct BCC
related interventions
KP Health Sector Assessment
Governance
Government’s Achievements
• A number of governance related initiatives have been undertaken by the
government of KP
• Following is a non-exhaustive list of these initiatives
• Multiple laws have been passed to bolster the governance function of the
government. Some of the critical laws include:
• Khyber Pakhtunkhwa Healthcare Commission Act 2015
• Khyber Pakhtunkhwa Public Health (Surveillance and Response)
Ordinance 2017
• Khyber Pakhtunkhwa Medical Teaching Institutions Reforms Act,
2015
• Formation of Healthcare Commission for better regulation of the sector
• Local Government Reforms and their implementation has given greater
autonomy to grassroots in the decision-making process
• Contract Management Unit has been formed which will ensure effective
private sector engagement
Challenges
• The decentralized system is fragmented along sub-sectors
• Management at facility level is being run by physicians who do not have
managerial training
• Without the stewardship of DoH and district authorities, there is little
process standardization, guidance, or supervision for a number of facilities
• Institutional weakness and political interference
• There is varying managerial autonomy at facility level
• Limited contract management capacity. No holistic assessment of the
effectiveness of Public Private Partnerships has been undertaken
KP Health Sector Assessment
Health Financing
Government’s Achievements
• The Government of KP is committed to achieving the goal of UHC and has
made some notable achievements
• Overall, the sectoral share of public health has doubled between FY
2013-14 and FY 2017-18
• Social Health Protection Initiative (by the completion of third phase) will
cover 69% of population
• Establishment of Financial Management Cell: Health Sector has started
preparing its own budget
• Given the ambitious undertaking of SHPI and increase in allocation
towards health, it is critical to review financing as it relates to KP’s overall
health system
 Challenges
• Public Financial Management:
• Department of Health has neither an adequately trained budget staff nor does
it have the institutional memory of developing budgets
• Internal controls for Public Financial Management are inadequate
• Inadequate funding for maintenance of equipment/infrastructure
• Amount of out-of-pocket spending in KP per household is higher than all other
provinces
• Incomplete implementation and variable interpretation of the notification for
income retention by the public hospitals through SHPI
• Benefit package for the population currently covered/entitled:
• Primary health/out-patient care is not being covered by SHPI for the 69% of
population
• There is great deal of variation in what is covered through the various
models-details in the table to follow
Consolidated Allocations by Major Line Items – PKR (billion)
Major line items FY 2016- FY 2017-
17 18
Employee related expenses 27.65 36.07
Operating expenses 19.51 20.15
Grants1 1.52 1.85
Transfers2 1.45 3.04
Physical assets 0.07 2.00
Civil works 4.68 2.85
Repairs and maintenance 0.06 0.06
Total 54.94 66.02
Expenditure mix – salary and non-salary
(secondary health care facilities)

24% 26% 24% 23%

35%

Non-salary
Salary
76% 74% 76% 77%
65%

2012-13 2013-14 2014-15 2015-16 2016-17

Insurance reimbursements as % of non-salary
budgets to secondary public hospitals
Chart Title
18% 17%
16%

14%

12% 11%
10% 9%
8%

6%
4%
4% 3%
2%
2% 1% 0.20%
0%

Lakki Malakand Kohat Abbottabad Charsada Chitral Mardan Swabi

Segments of the population receiving
partial/comprehensive financial coverage for Health in KP*
Informally employed sector
Formally employed sector Total
Federal Provincial Military Cantonmen Autonomous Private Employees Sehat Baitul-Mal Zakat Other
govt. govt. t Boards bodies (both health Social Sahulat (NGOs,
federal and insurance Security Program foundation)
provincial) Institution (social
health
protection
initiative)
Total number of
beneficiaries/em
ployees and
their dependents 0.99 3.05 2.04 0.23 0.85 0.10 0.58 19.20 0.0023 0.030 0.09
covered (in 27.18
millions)
% of total
KP's
population 3.2 10.0 6.7 0.8 2.8 0.3 1.9 69.00 0.01 0.10 0.30 95.15
covered
Services covered Both Both Both Both Both Usually, no Both Inpatient (all Mostly Mostly A broad
outpatient outpatient outpatient outpatient outpatient and outpatient outpatient illnesses inpatient illnesses variation in
and and inpatient, and inpatient. and inpatient. inpatient. but service is and inpatient requiring (illnesses requiring the set of
inpatient, but there is but there is but there is there is no covered. services, hospitalizatio requiring admissions services
but there is no explicit no explicit no explicit explicit There is a and there is n in hospitalizatio in secondary supported by
no explicit package for package for package for package for financial cap a financial secondary n in hospitals different
package for inpatient inpatient inpatient inpatient on the cap on the hospitals, secondary and low cost organization
inpatient services services services services covered latter and selected hospitals and diagnostics s
services inpatient treatments in tertiary
services tertiary hospitals)
hospitals and high cost
diagnostics
*Estimations made with Chief Statistician, National Health Accounts, Pakistan Bureau of Statistics for KP Health Sector Assessment
Key messages
1. KP has done great strides in its pursuit of Universal
Health Coverage
2. Key challenges remain: quality of care, governance,
health financing, health knowledge of the
population, planning towards sustainability of
reforms
3. With all the ongoing initiatives in KP-health, there is
a need to for a consistent policy framework to
coordinate and align all these reform initiatives
 Thank you

rlavado@adb.org