Healthcare Service Delivery

Challenges & Prospects

 Pakistan Progress on MDGs

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Target
2015

Life Expectancy at birth 64.7 64.9 65.2 65.4 65.6 65.8 66.0 66.1 66.3 66.4 66.6 -
total (year)

Infant Mortality Rate 83.0 81.6 80.1 78.8 77.5 76.1 74.8 73.4 72.1 70.6 69.0 40.0
(Per 1000)

Under 5 Mortality Rate 105.5 103.4 101.4 99.4 97.5 95.6 93.6 91.8 89.9 87.8 85.5 52.0
(Per 1000)

Maternal Mortality - - 230.0 - - - - 190.0 - - 170.0 140.0

Rate Per 100000

Population Growth 1.8 1.8 1.8 1.8 1.9 1.9 1.8 1.8 1.7 1.7 1.9 -
Rate (%)

Source: World Bank – Pakistan Economic Survey 2014-15

 Comparison of Human Development Indicator with regional Countries
Country Life Expectancy Infant Under 5 Maternal Population
2013 Mortality Rate Mortality Rate Mortality Rate Growth Rate
Per 1000 Per 1000 Per 100000 (%)
2013 2013 2013 2013

Pakistan 66.6 69.0 85.5 170.0 1.92

India 66.5 41.4 52.7 190.0 1.24
Bangladesh 70.7 33.2 41.1 170.0 1.22
Sri Lanka 74.2 8.2 9.6 29.0 0.76
Nepal 68.4 32.2 39.7 190.0 1.17
Bhutan 68.3 29.7 36.2 120.0 1.62
China 75.4 10.9 12.7 32.0 0.49
Malaysia 75.0 7.2 8.5 29.0 1.62
Indonesia 70.8 24.5 29.3 190.0 1.21
Philippines 68.7 23.5 29.9 120.0 1.73
Thailand 74.4 11.3 13.1 26.0 0.34
Source: World Bank – Pakistan Economic Survey 2014-15
 Social Determinants of Health

INDICATOR PAKISTAN
Total Per Capita Income (2012) US $ 1046
Total expenditure on health per capita (2012) US $ 91
Total expenditure on health as % of GDP (2012) 3.2%
Literacy rate 57%
Access to piped drinking water 50.4%

Poverty (lowest quintile) 24%

Population Density per Sq. Km 166

Food Security 42%

Source: WB Economic Report 10, WHO, PSLM 2012-13
Childhood Mortality Rates; PDHS 1991 – 2007 - 2013
 1990-91 2006-07 2012-13
64
60
52

37 39

28
23
19
14

ANC 4+ visits SBA TT Shots

Maternal Health Indicators; PDHS 1991 – 2007 - 2013

NCD deaths as % of all deaths (all ages, both sexes) 2014, EMR

Lebanon 85%
Egypt 85%
Tunisia 82%
Saudi Arabia 78%
Libya 78%
Bahrain 78%
Jordan 76%
Iran (Islamic Republic of) 76%
Morocco 75%
Kuwait 73%
Qatar 69%
Oman 68%
United Arab Emirates 65%
Iraq 62%
Pakistan 50%
Syrian Arab Republic 46%
Yemen 39%
Afghanistan 37%
Djibouti 36%
Sudan 34%
Somalia 19%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Source: 2014 WHO estimates (for the year 2012)

 Percentage of deaths attributed to causes
100

80
Percentage

60

40

20

0
1992 1994 1996 1998 2000 2004 2006 2008

Communicable diseases Non-communicable diseases

Maternal illnesses Injuries
Other ill-defined diseases

Adnan Hyder, Burden of disease study Pakistan

 Inequitable Budgetary Allocations

Drugs &
supplies Prevention

Health
promotion

Hospital Rehabilitation
Inequitable Distribution of Health Resources
Population Health
Served Expenditure

1% Tertiary Hospital 40%

9% Secondary Health Care

45%

90% PHC 15%

Inequitable Urban/Rural Distribution of Health Allocations

Population Health Budget

Distribution Distribution

Rural Urban Urban Rural

Population Population Allocation Allocation
Typical BHU Financing
Typical RHC Financing
Source: Social Protection in Pakistan: Managing Household Risks and Vulnerability, World Bank
Lack of PARTNERSHIP FOR Sustainable Health Development

Community Public Sector

NGOs Private Sector

 Issues
• Low coverage; outreach and facility level
• Poor & inequitable access to health services
• Human Resource deficient in number and skill mix
• Population growth
• Low allocations for health
• Weak inter-sectoral interventions and lack of
partnership
• lack of performance linked with accountability &
incentives
Addressing the Inequities
Gender Access Resource Geographic Quality Coverage
Allocations Disparities
Provision of Standardized Services

Informed Planning & Budgeting

Improved Governance & Decentralization

Healthcare Financing

Regulation-Quality Management

Health Systems/Institutional / HR Reforms

Essential Health Services Delivery Package (EHSP)
 3.3
3.2
End epidemics of HIV, TB,
Reduce malaria and NTD, and combat
3.1 hepatitis, water-borne
child and
Reduce neonatal diseases and other
Maternal mortality communicable diseases
Mortality
3.4 Reduce
mortality due
Technology to NCD and
improve
SDG-3 mental health
3.5 Strengthen
TO ENSURE prevention and
treatment of
Time efficiency HEALTHY LIVES substance
abuse
AND PROMOTE (narcotics,
WELLBEING FOR alcohol)

ALL AT ALL AGES 3.6 Reduce

Resource mortality due
constraints to road traffic
injuries
3.7 Universal
access to
sexual and
Flood
reproductive
NFC Award health-care
services
Towards Universal Health Coverage

Ensuring that all people can use the promotive, preventive, curative and
rehabilitative health services they need, of sufficient quality to be effective,
while also ensuring that the use of these services does not expose the user to
financial hardship (WHO)
"We can't solve problems by using the same kind of thinking we used
when we created them" Albert Einstein

Economic
Health
Growth

Reforms

Development
5 Control knobs of Healthcare Reforms

“Fundamental" change implies to establish, set, or adjust one

or more of the five control knobs* .

• Financing
• Organization
• Regulation
• Payment and
• Consumer Behavior

These “control knobs” determine the major processes and

outcomes of health care systems
William Hsiao (2000)