Reforms in health system

Dr Abdul Wali Khan
DEVELOPMENT in health sector is linked with the development in the other sectors particularly the social sector e.g. quality of life, literacy, poverty etc. Due to the multifarious nature, any intervention in health sector needs a holistic approach. Globally, health has remained on top, as priority area for political governments. However, the pace of development in health sector remained varied irrespective of allocated resources and investment in it. Learning from experience of others while keeping the socio-cultural and other contextual has been found quite successful e.g. Thailand (6.5% GDP)’s community health initiatives. As a whole, allocation of GDP for health reflects the commitment to and priority of health in national policy. Notwithstanding, it is not the mere allocation of GDP spent on health but rather importantly is the wise distribution and expenditure of the resources. The United States is spending almost 17% of the GDP but still far behind from other countries and was ranked 37th in terms of quality and fairness by WHO and Pakistan (2.6% GDP) was ranked 122 out of 199 countries.
In the second half of 20th Century, a new concept of Primary Health Care (PHC) emerged out of necessity with the idea of preventing a disease was more yielding than curing. The Declaration of Alma-Ata(1978) and Ottawa Charter (1986) emphasizing on PHC are worth-mentioning events. To address the issue of PHC, the expansion of Basic Health Units (BHUs)/Dispensaries at Union Council level in Pakistan and Lady Health Workers Program (LHWs) are remarkable initiatives taken by Government of Pakistan. With 18th Constitutional Amendment, with the idea to provide healthcare at door-steps, devolution of health to provinces was done. However, without proper prior planning and ground-work including enhancing the technical capacity of provincial health departments, the consequence was a disaster as a whole. At federal level, the health sector remained fragmented under different ministries/divisions. In public sector, there is high urban bias of existing health providing facilities but majority of population are rural. Due to lack of proper referral system these health facilities in urban areas are overcrowded, thus compromising the quality. In order to achieve an optimal healthcare system, which is cost-effective and efficient, it is imperative to steadily incorporate initiatives based on evidence and experience. Some of the reforms that need to be taken are following: Any incumbent government needs to take health sector as a top priority area and to put it on national agenda.
Pakistan has miniscule health insurance coverage, predominantly provided by some private companies. Proper health insurance will be a step in the right direction. However, this will require a long time. Private sector may be invited to fill the vacuum till a proper public sector insurance system. After devolution, provinces may be authorized to devise their own respective provincial insurance system. To address the issue of equity, the government needs to emphasize on rural areas keeping the demography and geographical access to health facilities. Screening for chronic diseases in community at door step can reduce the burden of particularly non-communicable diseases. LHWs may play a pivotal role. Furthermore, some new concepts e.g. community nurses, community health volunteers etc. can be applied. We may learn from the experienc of Thailand, where community nurses have been playing pivotal role in diagnosis and timely prevention of chronic diseases e.g. screening for diabetes, hypertension, breast-cancer. Existing health care system need to have room for alternative medicines i.e. as pluralistic system e.g. acupuncture, homeopathy, Unani/Tibb and traditional medicine. But these sectors also need to be properly regulated with trained professionals.
Proper regulation of the private sector in addition to the stewardship of public sector is imperative. Moreover, legislation may be needed at national level and also at provincial level to enact relevant laws/regulations and also establishing regulatory bodies/authorities not only to regulate but to monitor the quality and standards. This will also help reduce quackery and contain the price of diagnostic and intervention facilities. Japan has maintained affordability and easy accessibility through annual pricing mechanism. In order to prevent leakage/corruption and to ensure transparency through the mechanism of social accountability is needed to be incorporated in the healthcare system. There is also need of shifting from bureaucratic structure to technocratic and additional ways to minimize the administrative expenditure will be the ways forward. Low administrative cost is an internationally agreed yardstick index of a successful healthcare delivery system. To the irony, with such gigantic administrative expenditure, the health personnel in Pakistan as deliverers are still remuneratively considered to be the marginalized and underpaid segment of society.
Our healthcare system need to be economically sustainable and self-sufficient with less dependency on donors. This will also help us to be independent in decision-making and to be free from influence of donors. There is no perfect healthcare system, and there is always room for improvement based on new innovations and increasing demand. A good health system is affordable and is performing efficiently on the principal of equity and universal coverage with in existing resources. It is responsive to the legitimate expectation of consumers. Success of any health care system is determined by the accomplishment of short-term and long-term goals, manifested by the improvement in morbidity and mortality indicators.
— The writer is Assistant Executive Director, Federal Govt Polyclinic, Islamabad,

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