Introduction to Pakistan's Health System PDF

INTRODUCTION TO HEALTH SYSTEM OF PAKISTAN DR. MUHAMMAD WAQAS NISAR AHMED MBBS (Dow), MSPH LEARNING OBJECTIVES By the end of Session, the students will be able to: Differentiate between Health Care System and Health System Describe three main goals of Health System and WHO C...

INTRODUCTION TO HEALTH SYSTEM OF PAKISTAN DR. MUHAMMAD WAQAS NISAR AHMED MBBS (Dow), MSPH LEARNING OBJECTIVES By the end of Session, the students will be able to: Differentiate between Health Care System and Health System Describe three main goals of Health System and WHO Criteria for Assessment of Health System List four main functions of Health system Describe the three tiers of healthcare system in Pakistan Describe the sources of Financing in Pakistan and the existing issues in financing Explain the issues related to healthcare resources in the country Describe the service delivery structure and explain existing issues in the service delivery INTRODUCTION TO HEALTH SYSTEM WHAT IS HEALTH SYSTEM ?? A health system is an organization of people, institutions, and resources that delivers health care services to meet the health needs of target populations. HEALTH SYSTEM: DEFINITION All the activities whose primary aim is to promote, restore and maintain health Includes:  Formal health services  Non-formal services (Health promotion and disease prevention)  Activities whose primary purpose is something other than health (education, industry, agriculture)  HEALTH CARE SYSTEM AND Environment HEALTH SYSTEM Services Norms Improved Economy Health System Beliefs Increased Productivity Infrastructure and Providers Less Burden Consumables Patients on Health Political system Social system DEVELOPMENT STATIC VS DYNAMIC HEALTH SYSTEMS Static health system constantly try to manage emerging issues with old strategies Dynamic health systems evolve and continuously respond to:  Changing demographic and epidemiologic profiles of populations  Rising expectations of a more educated clientele  A fast growing private health sector  Rapid changes in medical technology  W.H.O’S HEALTH SYSTEM PERFORMANCE ASSESSMENT The 3 main goals of health system and their indicators  Goal:1 Health Most important goal of health system Goodness assessed by:  Mortality  Life Expectancy  Disability Adjusted Life Expectancy Fairness assessed by:  Life expectancy in rich and poor  Goal:2 Responsiveness A system’s response to non-health aspects of patients by meeting their legitimate expectations Respect of Patient Client Orientation 1. Dignity 5. Prompt attention  Gentleness Short waiting times  Privacy 6. Access to Social Support: 2. Autonomy  Access to visitors/newspapers  Right to choose what interventions  Being able to observe social & they do and do not receive religious practices during hospital stay 3. Confidentiality 7. Quality of basic amenities:  Adequate space and seating  Personal health information  Access to clean water and fresh air 4. Clear Communication 8. Choice of Provider  Listening to Patient carefully Being able to get to see a health care  Clear explanation of condition provider you are happy with  Giving patients time to ask questions  Responsiveness Assessing goodness: % of people reporting being treated with dignity % of people being provided basic amenities Assessing fairness: % of poor treated with dignity Goal:3 Fairness in Financing Cost of health system is distributed according to ability to pay rather than risk of illness Assessed by:  Out of pocket expenditure  Insurance Contribution in prepayment Fair financing FUNCTIONS OF THE HEALTH SYSTEM  Functions of the Health System FUNCTIONS GOALS / OUTCOMES Stewardship Responsive- (Oversight) ness Resources Service HEALTH Generation Provision Financing (Collecting, Fair Financial Pooling and Purchasing) Contribution  Functions of the Health System 1. STEWARDSHIP Function of a government responsible for welfare of the population and concerned about the trust and legitimacy with which its activities are viewed by citizenry ( includes planners, purchasers and providers) Basic tasks includes:  Formulating health policy  Exerting influence (regulation and oversight)  Collecting and using intelligence Effective Stewardship Policy Vision for future Regulation Implementation Use of information Supporting what is needed  Functions of the Health System 2. FINANCING Three main components of financing – Revenue collection – Fund pooling – Purchasing  Financing Revenue collection Process of receiving money for health – General taxation – Mandatory Social Health Insurance (rated by income) – Voluntary Private Health Insurance (rated by risk) – Out of pocket – From donor agencies (AID)  Financing Fund pooling Accumulation and management of collected revenues for the common advantages of participants to share financial risks like Insurance Cards/cash transfers Can increase the likelihood that patients will be able to afford services by shifting collected funds from  Low risk to high risk-Disease Severity  High income to low income-Ability to Earn  Financing: Purchasing Process through which pooled funds are allocated to institution or individuals provider in order to deliver a specific or unspecific set of intervention What to buy?  Intervention that is needed the most to achieve the goals From whom to buy?  Quality assurance and long term application How to buy?  Avoid micro-purchasing  Design and implement effective contractual, budgeting and payment mechanisms  Functions of the Health System 3. RESOURCE GENERATION What resources are needed? Human resources (doctors, staff) Physical resources (building, equipment) Consumables (medicines, injections, tubes)  Resource generation: Effective utilization of resources HUMAN RESOURCES  Appropriate recruitment (over recruitment and under recruitment)  balance in recruitment (distribution and roles)  Skillful and knowledgeable workforce  a system of refreshing knowledge and skills (CME)  adequate incentives (increases motivation)  Resource generation: Effective utilization of resources PHYSICAL RESOURCES AND CONSUMABLES  Adequacy  Adjusting to new advances(New drugs, equipment)  Functions of the Health System 4. SERVICE PROVISION Combination of input into a production process that takes place in a particular organizational setting and that leads to delivery of a series of intervention Personal health service – Services consumed directly by an individual whether they are preventive diagnostic therapeutic rehabilitative Non personal health service (Community oriented) – Mass health education – Safe water supply/vector control  Functions of the Health System FUNCTIONS GOALS / OUTCOMES Stewardship Responsive- (Oversight) ness Resources Service HEALTH Generation Provision Financing (Collecting, Fair Financial Pooling and Purchasing) Contribution  Delivering services effectively: Choosing right services to provide  Opting for cost effective interventions  Balancing public health and clinical activities (decisions on available data) Organizing services  Having a non-discriminatory attitude  Respecting organizational rules Assure right incentives for providers  autonomy, accountability and monetary incentives BREAK HEALTH SYSTEM OF PAKISTAN  THREE TIERS OF HEALTH SYSTEM OF PAKISTAN 1. FEDERAL 2. PROVINCIAL 3. DISTRICT Federal Level  Tertiary Care Hospitals Primary and Secondary Hospitals Vertical Programs LHW Program Malaria Control Program AIDS Control Program Provincial TB Control Program Maternal Neonatal and Child Health Program Expanded Program on Immunization Food and Nutrition Program  DDO’s Admin+ Finance  Responsibilities Before 18th Amendment Federal Provincial District Generation of Intelligence and Co-ordinate with Federal Management (Recruitment, National Health Policy Government selection, placement, training of staff, Conducting supervisory visits, Management of Vertical Supervise DHS Record Keeping of all stocks and Programs indents of medicines) International coordination with Recruitment, transfer, posting, Planning and Implementation health agencies and donors promotion & disciplinary action (Review of health data/health problems) Regulation (Institutions, Drug Financial distribution Pricing) Developing partnerships (Organization of DHMT) Administration of some hospitals Conducting HSR Disaster preparedness Changed after 18th Amendment  Responsibilities After 18th Amendment Federal Provincial District Generation of Intelligence and Co-ordinate with Federal Management (Recruitment, National Health Policy Government selection, placement, training of staff, Conducting supervisory visits, Management of Vertical Supervise DHS Record Keeping of all stocks and Programs (66% funding) indents of medicines) International coordination with Recruitment, transfer, posting, Planning and Implementation health agencies and donors promotion & disciplinary action (Review of health data/health problems) Regulation (Institutions, Drug Financial distribution Control) Developing partnerships (Organization of DHMT) Administration of some hospitals (20% funding) Conducting HSR Disaster preparedness  CURRENT RESPONSIBILITIES Federal Provincial District Co-ordinate with Federal Management (Recruitment, International coordination with Government selection, placement, training of health agencies and donors staff, Conducting supervisory visits, Supervise DHS Record Keeping of all stocks and Regulation (Institutions, Drug indents of medicines) Pricing) Recruitment, transfer, posting, Planning and Implementation promotion & disciplinary action (Review of health data/health problems) Financial distribution Developing partnerships Generation of Intelligence and (Organization of DHMT) National Health Policy Conducting HSR Management of Vertical Programs Disaster preparedness Administration of some hospitals HEALTHCARE FINANCING IN PAKISTAN SOURCES OF HEALTH FINANCING IN PAKISTAN: National Health Account 2011-12 28% 3%  Health Financing Issues sues Solutions Public Revenues Poor Tax Collection-Low Tax to GDP ratio Inadequate allocation to health-(Conflicts/Business Interests) Development Assistance Not a consistent source Disbursement through Program Assistance Insurances and Safety Nets For Formally employed Sector, employer’s insurance coverage is limited For Informally employed sector, Safety Nets are inadequate Purchasing Allocation not based on burden of diseases/Misalignment in available services and needed services Delays in disbursement Corruption (Leakages/Theft/Clever book keeping) Unsatisfactory incentives to HCW’s RESOURCES OF PAKISTAN HEALTH SYSTEM  Resources Available Economic Survey of Pakistan 2016 Human resources Infrastructure Formal sector 195000 WHOdoctors (1 dr1:1000 standard for 1000) 1142 Hospitals 18000 dentists (1 dentist for 11000) 118041 Hospital Beds (I bed for 1593) 100000 WHOnurses (1: nurse standard for 3 nurses for2000) 1 dr 5374 BHUs 10,000 LHV’s (1 LHV for 20000) 584 RHCs 25000 midwives (1 midwife for 8000) 1000 MCH Centers 100000 LHW’s (1 LHW for 2000) 400 TB Centers Non formal Sector OTHERS 36,488 Tabibs/Hakeems Medicines/Vaccines 21,341 Homeopaths Technology/ Equipment 537 herbalists  Resources Human Resource Issues Inadequacy  70-80% graduates are females among whom half never practice  Almost half of the male doctors leave the country  Shortage of Dentists/Midwives/Nurses/Technicians/pharmacists/biostatisticians/public health experts-Many sanctioned posts remain vacant Unfair distribution  Low incentives in public sector/dual job holding  Poor facilities in rural areas Training and Capacity  Lack of merit  Undergraduate curriculum lack community and health system orientation and exposure to common problems  Unawareness of HCP’s on emerging issues  Resources Drugs, Supplies and Equipment Commissions offered by manufacturers to purchase their drugs/supplies/equipment Leakages-Selling drugs to market Clever Book keeping-Over-invoicing SERVICE DELIVERY IN PAKISTANI HEALTH SYSTEM Service Utilization  Issues Related to Service Delivery 1. Staff absenteeism/Dual Job Holding Availability Ghost worker /LHW/Vaccinator in Primary and Secondary Care Hour shaving in Tertiary Care: Late arrival & early departure 2. Inadequacy of Supplies (sprays sold in the market) 1. Unauthorized charges for consultation/medicines/fake reports Quality 2. Reluctance to see patients in public sector/referral to private clinic 3. Exploitation by private sector-Unnecessary Tests/procedures 4. Quackery Effectiveness 1. Improper Referral 2. Services are not integrated REFERENCES Kielmann AA, Siddiqi S, Mwadime RK. District health planning manual: toolkit for district health managers. Islamabad, Pakistan: Multi-donor Support Unit, Ministry of Health; 2002. Manual of Epidemiology for District Health Management. J. P. Vaughan, R. H. Morrow World Health Organization, 01-Jan-1989Medical198 page Nabeela Ali. District Health Management Team. PAIMAN. Contech International Health Consultants  THANK YOU A PRESENTATION BY DR.MUHAMMAD WAQAS NISAR drwaqasnisar