Development in the health sector is linked with the development in 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 experiences of others has been found quite successful, e.g., Thailand’s (6.5 per cent GDP) 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, rather it is the wise distribution and expenditure of the resources. United States is spending almost 17 per cent 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 per cent GDP) was ranked 122nd out of 199 countries.
Due to newer innovations and advanced treatment option, the percentage of health budget steadily increased worldwide. In Asia, Hong Kong (5.7 per cent), Malaysia (4.2 per cent GDP) and Singapore (4.9 per cent) have efficient and successful publicly-run healthcare systems. In South Asia, Sri Lanka (3.5 per cent), India (4.7 per cent) and Bangladesh have improved morbidity and mortality indicators and are ahead of Pakistan.
Finance is a vital component of healthcare system. The first step in healthcare financing is to invest in health. There is always a price for any health activity. The ways of payment are either from government levied taxes, e.g., in UK, Canada, Pakistan, etc., or from premium based pre-payment — Germany, Austria and others.
The concept of premium for health emerged in the 20th century. From this pooling of resources, budgetary allocation and capitation are made. The aim of pooling of resources for health/insurance is to secure the health of all citizens in case of any uncertainty due to diseases and other morbid health conditions and to secure the financial impact. In most countries, the responsibility was taken by the public sector as a formal organiser and regulator (stewardship).
In the second half of the 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) emphasising 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 Programme (LHWs) are remarkable initiatives taken by the government of Pakistan. However, these initiatives needed to be improved and strengthened.
Health sector remained highly unorganised and largely remained dependent on the informal sector/private sector. In spite of a vast network of health facilities, health sector of Pakistan still has major flaws and needs reforms — as evident by the fact that we do not have a consistent evidence-based comprehensive and pragmatic national health policy. Multiple health policies in 1990, 1997, 2001 and 2010 did not achieve the desired goals. Health remained a low priority area for any government.
With the 18th Constitutional Amendment, health sector was devolved to provinces without proper prior planning and groundwork including enhancing the technical capacity of provincial health departments. At the federal level, health sector remained fragmented under different ministries/divisions. In the public sector, there is high urban bias of existing health facilities, but majority of population lives in rural areas. Due to lack of proper referral system these health facilities in urban areas are overcrowded, thus compromising 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 experiences.
The government needs to make health sector as top priority area and put it on national agenda. For this, the government has to increase the allocated GDP on health. Moreover, there is need of a national homogenous and uniform health policy clearly identifying the broader areas, inter-sectorial and departmental coordination and liaison with private sector. At federal level, the fragmented health sector after devolution needs to be placed under one administrative control of a ministry/authority.
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. In Germany, it took almost a century to devise an efficient premium based health insurance system. It is pertinent to mention the pooling of resources and subsequent execution/management of the money by a government designated agency or by some other company. Lessons may be learned from the experiences of Public Trust of Britain, Sickness Funds of Germany, National Health Security of Thailand and from the option of multiple insurers of Japan. Private sector may be invited to fill the vacuum till a proper public sector insurance system is evolved. After devolution, provinces may be authorised to devise their own respective provincial insurance system.
To address the issue of equity, the government needs to emphasise on rural areas keeping the demography and geographical access to health facilities. To overcome the issue of human resource scarcity, the government needs to start different special projects e.g. special package/allowances for rural areas, incentives during trainings with surety bond to serve in rural areas after completion etc. The existing health facilities need to be strengthened and this will reduce the burden on secondary and tertiary healthcare facilities in urban areas. Proper referral system and shifting from manual entry of data to electronic data will be needed. Community trust needs to be restored and community participation in health activities will be the hallmark of success.
Screening for chronic diseases in community at doorstep 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 experiences 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 healthcare system needs 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 and provincial level to enact relevant laws/regulations and establish 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 ensure transparency, a 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 minimise the administrative expenditures 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 expenditures, the health personnel in Pakistan as deliverers are still remuneratively considered to be the 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 newer innovations and increasing demand. A good health system is affordable and is performing efficiently on the principal of equity and universal coverage within existing resources. It is responsive to the legitimate expectation of consumers. Success of any healthcare system is determined by the accomplishment of short-term and long-term goals, manifested by the improvement in morbidity and mortality indicators.