Health Sector Reforms
To Support RBM Implementation in
Health Sector, Pakistan
Outline of Presentation
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Defining health sector reforms, current interest and
significance for developing countries
Scope, objectives and guiding principles for HSR
Actions needed to achieve “Result-based
Management” through HSR
Proposed HSR Agenda for Pakistan
Broad Strategies to implement HSR Agenda in
Pakistan
Conclusion
What is HSR ?
Reform means positive change,
 HSR implies “sustained, purposeful and
fundamental change”–to address the needs of
the communities for provision of equitable
healthcare services.(Berman, 1995).
Sustained
Purposeful
Fundamental
Change
Definition of Health Sector Reform
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Health sector reform is “a fundamental rather
than an incremental change, which is
sustained rather than one-off, [and] purposive
in nature” (Cassels:1997).
According to Cassels, health sector reform
includes:
• Improving the performance of civil services
• Decentralizations of power and resources
• Improving functions of national health ministries
• Broadening health financing mechanisms
• Introducing managed competition
• Privatization
Current interest in HSR
D
E
V
E
L
P
I
N
G
E
C
O
N
O
M
I
E
S
Population
Growth
Increasing
Poverty
Inequitable
Healthcare
access
Unemployment
Volatile
Socio-economic
Brittle
Governance
Lack of
Social
Protection
Overall HSR Objectives
The overall objectives is: “to improve the
health status of the population through
provision of
equitable, affordable
and
efficient quality health care services”
Equity
Sustainability
Good
Governance
Quality
Assurance
Community
Participation
Efficiency
HSR for fairness:

Connecting equity, accountability,
and efficiency
Equity in services, and financing: requirement of
social justice, and fairness
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Accountability: requirement of justice because we have
fundamental interest in fair governance, also instrumentally
important to efficient, equitable delivery of services
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Efficiency: efficient systems can get better value for
money in meeting needs under resource limits; requires
integrated focus on equity, so goals work together.
Scope and Guiding Principles for HSR in
support of RBM
Bridging the gap between health policy
and
implementation
Evidence-based decision-making through
decentralized health management
Provision of cost-effective and affordable
quality healthcare services
Improving equitable access and coverage
Addressing local needs and solutions
through community participation
Achieving improved health status
Health Sector Reforms in Pakistan
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Pakistan is an important strategically located
country in South East Asia, ranking 6th in terms of
population.
Total Population—150 million (double in 2040 with
current growth rate of 1.9%),
35% of population live below poverty-line
Total Health Expenditures—US$ 16 per capita
Nine times increase in UNEMPLOYMENT since
1971
Only 20% population utilizes public health
facilities and 80% goes to private for profit
The financial allocation for health is 0.88% of GDP
Vision for HEALTH INDICATORS in Pakistan
Indicators
Current
Status
MDGs
2015
82
40
104
47
35
70
30 %
60 %
Maternal Mortality Rate per 100,000 Live
Births
Percentage of births attended by SBA
400
140
20
90
Percentage of fully immunized children
50%
90%
Infant Mortality Rate per 1000 Live Births
Under 5 Mortality Rate per 1000 Live Births
Coverage for Prenatal Care
Contraceptive Prevalence Rate (CPR)
Issues and Problems of Health Sector in Pakistan
HSR
Objectives
Achievements
Issues/Gaps
Equitable
health
care services

WHO specified health
care infrastructure—
BHU, RHC, hospitals
etc

Good Governance

District Governments
thru
devolution—
health is now devolved
subject
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Disproportionate distribution of
resources for preventive and
curative services
Mal-distribution of staff in urban
and rural health facilities
High IMR and MMR
Effective implementation of
devolution policy
Lack of clarity of roles,
responsibilities and authority
linkages
 Limited capacity of staff to cope
with the change
Issues and Problems of Health Sector in Pakistan
Objectives
Achievements
Issues/Gaps
Improving Health
Sector Financing

Resource
allocation
increased from 0.72%
to 0.88% of GDP
 Committed to raise up
to 2% of GDP by 2010
 Expansion of Private
Health Sector

Improving
Regulation of
Health Sector

Health Regulatory
Authorities established
in two Provinces
 Provincial Blood
Transfusion
Authorities in place

Still Total Health Expenditures are
US$ 16 per capita as compare to
US$ 34 proposed by WHO
Out-of Pocket spending on health is
US$ 12 per capita
Major chunk to tertiary health
care, while 1% population has
access
Lack of effective implementation of
HRA—operation polices
 Limited laws and regulations on
accreditation of private healthcare
institutions
Resistance from stakeholders
Standardization of services
HSR Agenda for Pakistan
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Strengthening of devolved District health System (DHS) to address
inadequacies in healthcare services
• Removal of professional and managerial deficiencies
• Correction of urban biased healthcare services
• Promotion of greater equity in health sector
Improving governance in MoH, DHS, and healthcare provider
organizations
• Introduction of operational policies for management development
• Strengthening of M & E for performance improvement/appraisal
• Regulatory and legal framework for performance management &
accountability
Alternative funding strategies for health
• Cost-recovery and cost-sharing mechanisms
Strengthen the government’s approaches to
Private healthcare sector
regulation
• Regulation and accreditation of private health sector
• Standardization
Proposed HSR Agenda— Strengthening
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of DHS
Strategy One—ESTABLISH through Devolution
• District Health Management Team
Devolution:
 Capacity building of the district staff to handle the
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•
• The health
most system
popular reform defined as
decentralized
“transfer of resources,
functions
and
Explicit Clarification
of roles and
responsibilities
of
authority
from
the
center
to
the
different components of decentralized District Health
geographically
defined periphery”.
System (DHS
)
• The devolution is said to support local
bureaucracies to better adapt to local
District Health
Planning
System
needs and demands.
 Provide support to develop District Health Plan (DHP)
• Thus improving efficiency, quality and
 Develop necessary tools and instruments for planning
utilization of services
functions by the district
Proposed HSR Agenda—
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Strategy
Strengthening of DHS
Two—ENSURE
• Strengthening the capacity of District Health Department
 Managing
Change through innovation, learning
experiences, research & development
 Re-designation and creation of new cadres appropriate
for decentralized district health system
 Regulatory and legislatory support
• Linkages among all DHSs through explicit mechanism
 For sharing information, knowledge and skills for
public health practices
Proposed HSR Agenda—
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Strategy
Strengthening of DHS
Three—PROMOTE
• Introduction of ‘Purchase-Provider Split’ between
DHD and District Health Institutions
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DOH, DHQ and THQ Hospitals for delivery of costeffective healthcare services
• Options for public-private partnerships in the
district
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Explore new avenues for PPPs e.g. NGO run Hospitals
• Quality Assurance Systems (QAS) at all tiers of
healthcare system
Proposed HSR Agenda—

Strategy
Strengthening of DHS
Four—DEFINE
• Strengthened referral system within the district
 Develop referral guidelines
• Health services packages for all tiers of delivery
system
 Developing necessary manuals and guidelines
for successful implementation
Steering Role of Provincial Health Department
(PHD)
Capacity
Building
Monitoring
Regulating
Technical
Support
PHD
National
Programs
Coordinating
Healthcare
Delivery
Policy into
Planning
Guidelines
Proposed HSR Agenda—
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Good Governance
Develop operational policies for different management
components
 HRM & D
Review of job descriptions & Cadres
Review of remuneration packages
Performance-linked contracts
Trainings & training needs assessment
Career mobility & development
 Procurement & supplies
Review of current procedures & practices
Criteria,
standardization,
selection
specification
Regulatory mechanisms
and
Proposed HSR Agenda—
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Cont:
Good Governance
Develop operational policies
 Financial management
 Financial Manuals for devolved DHS
 Review of procedures & practices
 Accountability
 Assets & Logistics
 Manuals and guidelines for devolved DHS
 Review of procedures & practices
 Health Institution Database (HID)
 Service delivery
 Review of existing models of service-delivery
 Institutional guidelines & manuals
Good Governance
HSR Agenda—
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Performance
 DHS performance
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Establish benchmarks for every DHD—District Profile
Evaluating against the preset targets through uniform
criteria & standard
 Institutional performance
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Institutional guidelines & manuals
Evaluating against the preset targets through uniform
criteria & standard
 Individual performance
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Review of existing systems—ACRs
Linking performance with career mobility & development
HSR Agenda—
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Strategy
Alternative Funding Strategies for Health
One—COST-SHARING
 Strengthen existing finance generation schemes in
the district
 Extension & Expansion of “User-Charges”
 Cost-sharing for drugs
 Public-Private Partnerships
 Prepayment Schemes
 Hotel Services
 Provide necessary support to implement and
testing the interventions
Proposed HSR Agenda —
Alternative Funding
Strategies for Health
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Strategy
Two-COST-RECOVERY
 Grant fiscal autonomy to Tertiary/DHQ Hospitals through
phased approach with gradual reduction of public subsidy
 Expand hospital financing by linking with “HI
Schemes”, “Purchaser-Provider Split” and other
Cost-recovery mechanisms
 Strengthen
DHQ Hospitals to become ENDREFERRAL Centers
 Provide necessary support to implement and testing the
interventions
HSR Agenda—

Strategy
Alternative Funding Strategies for Health
Three—COST-POOLING
 Health insurance Schemes
 Introduction of Community-based Health Insurance
Schemes (CBHI)
 Introduction of Health Insurance Schemes for
Public Sector Employees
 Social Health Insurance
 Provide necessary support to implement and
testing the interventions
Proposed HSR Agenda—
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Regulation
Provide regulatory and legislative support for
public and private health sector regulation
 Identify and address the gaps in public and
private health systems regulation
 Develop consensus and implement legislation
Proposed HSR Agenda—
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Regulation
Strengthen the capacity of MoH, DHD and
DHS to enforce the legal mandates in public
health practices
• Develop new tools and instruments for Food,
Drugs, Standardization, Licensing and quality
assurance regulation
• Strengthen the laboratories and equipment used
for regulation and QA (DTL, Chemical Examiner
etc.)
Conclusions
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HSR should be sustained and evolve
through continuous process
Institutional
development
and
capacity building is key to success
More resources should be made
available for reforms
Reform strategies should be regularly
reviewed and adjusted according to
country context.
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