Introduction
Recent decentralization in Pakistan has opened up new avenues for developing a rational district health system. Non-functionality of health facilities at different tiers in districts has been strongly felt for quite a long period and lots of concerns have been shown in respect of the health of common people. Specifically, a large number of Basic Health Units (BHUs) have been abandoned due to non-availability of doctor and other staff; medicines and supplies; lack of quality care; and most of those situated at remotest of the remote areas which limits the access.
National Health Policy has spelled out with significance the primary and secondary components of healthcare among its key features. Besides, two other key features of the policy have stated the need to link health sector investments with poverty alleviation and ensuring quality of care. The policy document has explicitly envisioned ‘Health for All’ approach with a focus on equity, efficiency and effectiveness in health sector. In order to materialize these key elements of the policy, at least three key areas out of ten, directly aim at transforming the district health system for the betterment of the population. These key areas include:
Key area 2: Addressing inadequacies in primary/secondary health care services
Key area 3: Removing professional/managerial deficiencies in the District Health System
Key area 6: Correcting urban bias in health sector
Improvements in health system may also be seen in the context of poverty reduction efforts – PRSP, Millennium Development Goals (MDGs), recent initiatives of Medium Term Budgetary Framework (MTBF) and MTDF. These are some of the potential opportunities that require - as a prerequisite - a level of functionality of health system at various tiers: district health system being one of those.
A functional level of health system has been stressed in various studies and reports with a view to achieve effectiveness of over all health system. A working group of UN Millennium Project that oversees the implementation of Millennium Development Goals (MDGs) has come up with the observation that present health system in developing countries has three major flaws that would hamper progress towards achieving MDGs. These flaws include:
Availability, accessibility and utilization of key health interventions are impossible through existing fragile and fragmented system
Catastrophic costs of seeking care are further deepening poverty
Failing to become a core social institution, the health system intensifies exclusion, reduction in citizens’ voice and inequity
Furthermore, a working group on MCH related to UN Millennium Project has emphasized that to reduce maternal mortality - one of the eight Millennium Development Goals – a functional district health system is pre-requisite. The report suggested that for each 500, 000 population segment, there should be one Comprehensive Emergency Obstetric Care (EmoC) facility and four Basic Emergency Obstetric Care facilities along with a functional referral system. This discussion points out the need of building a functional district health system on priority basis so as to improve health status of the population over time.
Conceptual Framework
A conceptual framework (see Annex I) has been developed as the basis of district health model. The framework has been developed on the basis of observations in literature. It draws its conclusions from concepts discussed in the following documents:
National Health Policy 2001
District Health Planning Manual: Toolkit for District Health Managers, MoH, 2002
Public-Private Partnership in Health Study, 1997
Devolution in Pakistan, DFID, WB, 2005
The conceptual framework provides the basis of a district health model to be implemented through newly devolved structure. According to District Health Planning Manual, each district is required to prepare its District Health Plan drawn primarily from Provincial Operational Plan. The broader policy objectives that need to be achieved must reflect appropriately in the district plan with a view to attain the improvement in the health status as a final outcome of the plan. However, plan should also encompass the goals of a health system. Any health system should have following goals[1]:
Improving health status
Financial Risk Pooling
Public Satisfaction
In the context of these goals a district plan would comprise of two components i.e. district heath system and district health organization.
According to the proposal District Health Organization should focus on stewardship role under the overall guidance of EDO (H). However, information gathered suggests that under decentralized office, EDO (H) has no sufficient power to control and manage the district system. An EDO (H) is appointed by the provincial health department while he has to report to DCO; he has no transfer powers beyond grade 10. He/she can make appointments from grade 4 to 15. In case of Punjab there are two positions in the upper hierarchy of districts that are EDO (H) and DHO. However, there is lack of clear distinction in their roles and responsibilities regarding both the positions. Therefore, it is important that an EDO (H) is provided with sufficient control over human resource management[2] with a view to ensure positive outcomes. Regarding transparent procedures, community involvement, monitoring and quality assurance[3] he/she would be supported by health managers; District Health Management Committee – an advisory body; Citizens Community Boards; and Village Health Committees. EDO (H) will ensure monitoring and evaluation of the district health organization and its plan. M&E team should have sufficient powers and authority to oversee the functioning. Monitoring and evaluation exercise will also guide in developing future health plan.
Second component is health system. Three goals of the health system have been identified in the framework. The goal of ‘health status’ has been further divided into public-private-community action in the form of health promotion, social mobilization. At this level a suggestion is forwarded that pertains to the merging of unqualified practitioners into health care system. It is suggested that such practitioners would be provided training for about 6 to 9 months at District Center for Health Development (DCHD). This suggestion is in line with the suggestion from study on public-private partnership conducted by Futures Group. The trained private practitioners would be merged into mainstream and they would be providing preventive and curative care at a prescribed standard evolved by district health system or guided by provincial authorities. They would be provided with a medical contract with a specific number of clients for immunization, nutrition, tuberculosis, MCH, FP and other services. A detailed mechanism may be chalked out.
National Health Policy 2001 has made commitment towards affordability and equity in health. In this regard two innovative ideas are being proposed. First, an endowment fund regarding provision of essential medicines may be created at BHU level. Second, a community financing scheme may be introduced in order to make utilization of BHUs at appropriate level. In this regard a Health Card Scheme is suggested which is being practiced in Thailand and Vietnam quite successfully. The study on PPP had also suggested such scheme.
Public satisfaction being an important factor could be ensured through access, efficiency and effectiveness of the district health system. However, that may be achieved only through a set of interventions. These include incentives to Medical Officer, BHU, a functional referral system and a Village Health Committee to oversee the functioning of the BHU as well as to mobilize people to adopt health seeking behavior. MO, BHU would be provided extra Rs. 5000 along with pay and he/she would get admission for post graduation on priority basis in case he/she continuously serves at BHU for two year.
Costing of the proposal would be conducted after gathering required data from all the provinces. In this regard contacts have been made with relevant officials.
Package of Interventions
EDO (H) would be provided sufficient authority to control and manage the healthcare system.
Endowment fund for BHU
Incentives for MO, BHU
Health Card Scheme
Referral system
Training of un-qualified practitioners to merge them into mainstream
CCBs and Village Health Committees
[1]Mobilizing Domestic Resources. Commission on Macroeconomics and Health, Working Group 3
[2] Public-Private Partnership in Health Study, 1997, The Futures Group International
[3] ibid
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