HHealthealth SSectorector RReformseforms

To Support RBM Implementation in To Support RBM Implementation in Health Sector, PakistanHealth Sector, Pakistan

Outline of PresentationOutline of Presentation

Defining health sector reforms, current interest and Defining health sector reforms, current interest and significance for developing countriessignificance for developing countries

Scope, objectives and guiding principles for HSR Scope, objectives and guiding principles for HSR Actions needed to achieve “Result-based Actions needed to achieve “Result-based

Management” through HSRManagement” through HSR Proposed HSR Agenda for PakistanProposed HSR Agenda for Pakistan Broad Strategies to implement HSR Agenda in Broad Strategies to implement HSR Agenda in

PakistanPakistan Conclusion Conclusion

What is HSR ?What is HSR ?

Reform means positive change, Reform means positive change, HSR implies “sustained, purposeful and HSR implies “sustained, purposeful and fundamental change”–to address the needs of fundamental change”–to address the needs of the communities for provision of equitable the communities for provision of equitable healthcare healthcare services.(Berman, 1995). services.(Berman, 1995).

SustainedSustained PurposefulPurposefulFundamental Fundamental

ChangeChange

Definition of Health Sector ReformDefinition of Health Sector Reform

Health sector reform is “a fundamental rather Health sector reform is “a fundamental rather than an incremental change, which is than an incremental change, which is sustained rather than one-off, [and] purposive sustained rather than one-off, [and] purposive in nature” (Cassels:1997).in nature” (Cassels:1997).

According to Cassels, health sector reform According to Cassels, health sector reform includes:includes:• Improving the performance of civil servicesImproving the performance of civil services• Decentralizations of power and resourcesDecentralizations of power and resources• Improving functions of national health ministriesImproving functions of national health ministries• Broadening health financing mechanismsBroadening health financing mechanisms• Introducing managed competitionIntroducing managed competition• PrivatizationPrivatization

Current interest in HSRCurrent interest in HSR

D EE CV OE NL OP MI IN EG S

IncreasingPoverty

VolatileSocio-economic

Brittle Governance

PopulationGrowth

Unemployment

InequitableHealthcare

access

Lack ofSocial

Protection

Overall HSR ObjectivesOverall HSR Objectives

The overall objectives is: “to improve the The overall objectives is: “to improve the health status of the population through health status of the population through provision of equitable, affordable and provision of equitable, affordable and efficient quality health care services”efficient quality health care services”

Equity

Quality Assurance

Efficiency

Good Governance

Sustainability

Community Participation

HSR for fairness:HSR for fairness: Connecting equity, accountability, Connecting equity, accountability, and efficiency and efficiency

Equity in services, and financingEquity in services, and financing:: requirement of requirement of social justice, and fairnesssocial justice, and fairness

AccountabilityAccountability:: requirement of justice because we have requirement of justice because we have fundamental interest in fundamental interest in fairfair governance,governance, also instrumentally also instrumentally important to efficient, equitable delivery of servicesimportant to efficient, equitable delivery of services

EfficiencyEfficiency:: efficient systems can get better value for efficient systems can get better value for money in meeting needs under resource limits; requires money in meeting needs under resource limits; requires integrated focus on equity, so goals work together.integrated focus on equity, so goals work together.

Scope and Guiding Principles for HSR in Scope and Guiding Principles for HSR in support of RBMsupport of RBM

Bridging the gap between health policy Bridging the gap between health policy and implementationand implementation

Evidence-based decision-making through Evidence-based decision-making through decentralized health managementdecentralized health management

Provision of cost-effective and affordable Provision of cost-effective and affordable quality healthcare servicesquality healthcare services

Improving equitable access and coverageImproving equitable access and coverageAddressing local needs and solutions Addressing local needs and solutions

through community participation through community participation Achieving improved health statusAchieving improved health status

Health Sector Reforms in PakistanHealth Sector Reforms in Pakistan

Pakistan is an important strategically located Pakistan is an important strategically located country in South East Asia, ranking country in South East Asia, ranking 66thth in terms of in terms of population. population.

Total Population—Total Population—150 million150 million (double in 2040 with (double in 2040 with current current growth rategrowth rate of 1.9%), of 1.9%),

35% of population live below 35% of population live below poverty-linepoverty-line Total Health Expenditures—Total Health Expenditures—US$ 16 per capitaUS$ 16 per capita Nine times increase in Nine times increase in UNEMPLOYMENTUNEMPLOYMENT since since

19711971 Only Only 20% population20% population utilizes public health facilities utilizes public health facilities

and 80% goes to private for profitand 80% goes to private for profit The financial allocation for health is The financial allocation for health is 0.88% of GDP0.88% of GDP

IndicatorsIndicators Current Current StatusStatus

MDGsMDGs20152015

Infant Mortality Rate per 1000 Live Births Infant Mortality Rate per 1000 Live Births 8282 4040

Under 5 Mortality Rate per 1000 Live BirthsUnder 5 Mortality Rate per 1000 Live Births 104104 4747

Coverage for Prenatal CareCoverage for Prenatal Care 3535 7070

Contraceptive Prevalence Rate (CPR)Contraceptive Prevalence Rate (CPR) 30 %30 % 60 %60 %

Maternal Mortality Rate per 100,000 Live Maternal Mortality Rate per 100,000 Live BirthsBirths

400400 140140

Percentage of births attended by SBAPercentage of births attended by SBA 2020 9090

Percentage of fully immunized childrenPercentage of fully immunized children 50%50% 90%90%

Vision for HEALTH INDICATORS in PakistanVision for HEALTH INDICATORS in Pakistan

Issues and Problems of Health Sector in Pakistan Issues and Problems of Health Sector in Pakistan

HSR HSR ObjectivesObjectives

AchievementsAchievements Issues/GapsIssues/Gaps

Equitable health Equitable health care servicescare services

WHO specified health WHO specified health care infrastructure— care infrastructure— BHU, RHC, hospitals BHU, RHC, hospitals etcetc

Disproportionate distribution of Disproportionate distribution of resources for preventive and resources for preventive and curative servicescurative services

Mal-distribution of staff in urban Mal-distribution of staff in urban and rural health facilitiesand rural health facilities

High IMR and MMRHigh IMR and MMR

Good Governance Good Governance District Governments District Governments thru devolution—thru devolution—health is now devolved health is now devolved subjectsubject

Effective implementation of Effective implementation of devolution policydevolution policy

Lack of clarity of roles, Lack of clarity of roles, responsibilities and authority responsibilities and authority linkageslinkages

Limited capacity of staff to cope Limited capacity of staff to cope with the changewith the change

Issues and Problems of Health Sector in Pakistan Issues and Problems of Health Sector in Pakistan

ObjectivesObjectives AchievementsAchievements Issues/GapsIssues/Gaps

Improving Health Improving Health Sector FinancingSector Financing

Resource allocation Resource allocation increased from 0.72% increased from 0.72% to 0.88% of GDPto 0.88% of GDP

Committed to raise up Committed to raise up to 2% of GDP by 2010to 2% of GDP by 2010

Expansion of Private Expansion of Private Health Sector Health Sector

Still Total Health Expenditures are Still Total Health Expenditures are US$ 16 per capita as compare to US$ 16 per capita as compare to US$ 34 proposed by WHO US$ 34 proposed by WHO

Out-of Pocket spending on health is Out-of Pocket spending on health is US$ 12 per capitaUS$ 12 per capita

Major chunk to tertiary health Major chunk to tertiary health care, while 1% population has care, while 1% population has accessaccess

Improving Improving Regulation of Regulation of Health Sector Health Sector

Health Regulatory Health Regulatory Authorities established Authorities established in two Provincesin two Provinces

Provincial Blood Provincial Blood Transfusion Transfusion Authorities in place Authorities in place

Lack of effective implementation of Lack of effective implementation of HRA—operation policesHRA—operation polices

Limited laws and regulations on Limited laws and regulations on accreditation of private healthcare accreditation of private healthcare institutionsinstitutions

Resistance from stakeholdersResistance from stakeholdersStandardization of servicesStandardization of services

HSR Agenda for PakistanHSR Agenda for Pakistan Strengthening of devolved District health System (DHS) to address Strengthening of devolved District health System (DHS) to address

inadequacies in healthcare servicesinadequacies in healthcare services• Removal of professional and managerial deficienciesRemoval of professional and managerial deficiencies

• Correction of urban biased healthcare servicesCorrection of urban biased healthcare services• Promotion of greater equity in health sectorPromotion of greater equity in health sector

Improving governance in MoH, DHS, and healthcare provider Improving governance in MoH, DHS, and healthcare provider organizationsorganizations

• Introduction of operational policies for management developmentIntroduction of operational policies for management development• Strengthening of M & E for performance improvement/appraisalStrengthening of M & E for performance improvement/appraisal• Regulatory and legal framework for performance management & Regulatory and legal framework for performance management &

accountabilityaccountability Alternative funding strategies for healthAlternative funding strategies for health

• Cost-recovery and cost-sharing mechanismsCost-recovery and cost-sharing mechanisms Strengthen the government’s approaches to Private healthcare sector Strengthen the government’s approaches to Private healthcare sector

regulationregulation• Regulation and accreditation of private health sectorRegulation and accreditation of private health sector

• StandardizationStandardization

Proposed HSR Agenda—Proposed HSR Agenda— Strengthening of DHSStrengthening of DHS

Strategy Strategy One—ESTABLISH through DevolutionOne—ESTABLISH through Devolution

• District Health Management TeamDistrict Health Management Team Capacity building of the district staff to handle the Capacity building of the district staff to handle the

decentralized health systemdecentralized health system Explicit Clarification of roles and responsibilities of Explicit Clarification of roles and responsibilities of

different components of decentralized District Health different components of decentralized District Health System (DHSSystem (DHS))

• District Health Planning SystemDistrict Health Planning System Provide support to develop District Health Plan (DHP)Provide support to develop District Health Plan (DHP) Develop necessary tools and instruments for planning Develop necessary tools and instruments for planning

functions by the districtfunctions by the district

Devolution:Devolution:• The most popular reform defined as The most popular reform defined as

“transfer of resources, functions and “transfer of resources, functions and authority from the center to the authority from the center to the geographically defined periphery”.geographically defined periphery”.

• The devolution is said to support local The devolution is said to support local bureaucracies to better adapt to local bureaucracies to better adapt to local needs and demands.needs and demands.

• Thus improving efficiency, quality and Thus improving efficiency, quality and utilization of servicesutilization of services

Proposed HSR AgendaProposed HSR Agenda—— Strengthening of DHSStrengthening of DHS

StrategyStrategy Two—ENSURE Two—ENSURE

• Strengthening the capacity of District Health DepartmentStrengthening the capacity of District Health Department

Managing Change through innovation, learning Managing Change through innovation, learning experiences, research & developmentexperiences, research & development

Re-designation and creation of new cadres appropriate Re-designation and creation of new cadres appropriate for decentralized district health systemfor decentralized district health system

Regulatory and legislatory supportRegulatory and legislatory support

• Linkages among all DHSs through explicit mechanismLinkages among all DHSs through explicit mechanism For sharing information, knowledge and skills for For sharing information, knowledge and skills for

public health practicespublic health practices

Proposed HSR AgendaProposed HSR Agenda—— Strengthening of DHSStrengthening of DHS

StrategyStrategy Three—PROMOTE Three—PROMOTE

• Introduction of ‘Purchase-Provider Split’ between Introduction of ‘Purchase-Provider Split’ between DHD and District Health InstitutionsDHD and District Health Institutions

DOH, DHQ and THQ Hospitals for delivery of cost-DOH, DHQ and THQ Hospitals for delivery of cost-effective healthcare serviceseffective healthcare services

• Options for public-private partnerships in the Options for public-private partnerships in the districtdistrict

Explore new avenues for PPPs e.g. NGO run HospitalsExplore new avenues for PPPs e.g. NGO run Hospitals

• Quality Assurance Systems (QAS) at all tiers of Quality Assurance Systems (QAS) at all tiers of healthcare systemhealthcare system

Proposed HSR AgendaProposed HSR Agenda—— Strengthening of DHSStrengthening of DHS

StrategyStrategy Four—DEFINE Four—DEFINE

• Strengthened referral system within the districtStrengthened referral system within the district Develop referral guidelinesDevelop referral guidelines

• Health services packages for all tiers of delivery Health services packages for all tiers of delivery system system

Developing necessary manuals and guidelines Developing necessary manuals and guidelines for successful implementationfor successful implementation

Steering Role of Provincial Health Department Steering Role of Provincial Health Department

(PHD)(PHD)

PHDRegulating

Technical Support

CapacityBuilding

National Programs

Policy into Planning Guidelines

Coordinating Healthcare

DeliveryMonitoring

Proposed HSR AgendaProposed HSR Agenda—— Good GovernanceGood Governance

Develop operational policies for different management Develop operational policies for different management componentscomponents

HRM & DHRM & DReview of job descriptions & CadresReview of job descriptions & CadresReview of remuneration packagesReview of remuneration packagesPerformance-linked contractsPerformance-linked contractsTrainings & training needs assessmentTrainings & training needs assessmentCareer mobility & developmentCareer mobility & development

Procurement & suppliesProcurement & suppliesReview of current procedures & practicesReview of current procedures & practicesCriteria, standardization, selection and Criteria, standardization, selection and

specificationspecification Regulatory mechanismsRegulatory mechanisms

Proposed HSR AgendaProposed HSR Agenda— — Good GovernanceGood Governance

Cont:Cont: Develop operational policiesDevelop operational policies Financial managementFinancial management

Financial Manuals for devolved DHSFinancial Manuals for devolved DHS Review of procedures & practicesReview of procedures & practices Accountability Accountability

Assets & LogisticsAssets & Logistics Manuals and guidelines for devolved DHSManuals and guidelines for devolved DHS Review of procedures & practicesReview of procedures & practices Health Institution Database (HID)Health Institution Database (HID)

Service deliveryService delivery Review of existing models of service-deliveryReview of existing models of service-delivery Institutional guidelines & manualsInstitutional guidelines & manuals

HSR Agenda—HSR Agenda—Good GovernanceGood Governance

PerformancePerformance DHS performanceDHS performance

Establish benchmarks for every DHD—District Profile Establish benchmarks for every DHD—District Profile Evaluating against the preset targets through uniform Evaluating against the preset targets through uniform

criteria & standardcriteria & standard

Institutional performanceInstitutional performance Institutional guidelines & manuals Institutional guidelines & manuals Evaluating against the preset targets through uniform Evaluating against the preset targets through uniform

criteria & standardcriteria & standard

Individual performanceIndividual performance Review of existing systems—ACRsReview of existing systems—ACRs Linking performance with career mobility & developmentLinking performance with career mobility & development

HSR Agenda—HSR Agenda— Alternative Funding Strategies for HealthAlternative Funding Strategies for Health

Strategy One—COST-SHARINGStrategy One—COST-SHARING

Strengthen existing finance generation schemes in Strengthen existing finance generation schemes in the districtthe district

Extension & Expansion of “User-Charges”Extension & Expansion of “User-Charges” Cost-sharing for drugsCost-sharing for drugs Public-Private PartnershipsPublic-Private Partnerships Prepayment SchemesPrepayment Schemes Hotel ServicesHotel Services

Provide necessary support to implement and Provide necessary support to implement and testing the interventionstesting the interventions

Proposed HSR AgendaProposed HSR Agenda —— Alternative Funding Alternative Funding Strategies for HealthStrategies for Health

StrategyStrategy Two-COST-RECOVERYTwo-COST-RECOVERY

Grant fiscal autonomy to Tertiary/DHQ Hospitals through Grant fiscal autonomy to Tertiary/DHQ Hospitals through phased approach with gradual reduction of public subsidyphased approach with gradual reduction of public subsidy

Expand hospital financing by linking with “HI Expand hospital financing by linking with “HI Schemes”, “Purchaser-Provider Split” and other Schemes”, “Purchaser-Provider Split” and other Cost-recovery mechanismsCost-recovery mechanisms

Strengthen DHQ Hospitals to become END-Strengthen DHQ Hospitals to become END-REFERRAL CentersREFERRAL Centers

Provide necessary support to implement and testing the Provide necessary support to implement and testing the interventionsinterventions

HSR Agenda—HSR Agenda— Alternative Funding Strategies for HealthAlternative Funding Strategies for Health

StrategyStrategy Three—COST-POOLINGThree—COST-POOLING

Health insurance SchemesHealth insurance Schemes

Introduction of Community-based Health Insurance Introduction of Community-based Health Insurance Schemes (CBHI)Schemes (CBHI)

Introduction of Health Insurance Schemes for Introduction of Health Insurance Schemes for Public Sector EmployeesPublic Sector Employees

Social Health InsuranceSocial Health Insurance Provide necessary support to implement and Provide necessary support to implement and

testing the interventionstesting the interventions

Proposed HSR AgendaProposed HSR Agenda—— Regulation Regulation

Provide regulatory and legislative support for Provide regulatory and legislative support for public and private health sector regulationpublic and private health sector regulation

Identify and address the gaps in public and Identify and address the gaps in public and private health systems regulationprivate health systems regulation

Develop consensus and implement legislation Develop consensus and implement legislation

Proposed HSR AgendaProposed HSR Agenda—— Regulation Regulation

Strengthen the capacity of MoH, DHD and Strengthen the capacity of MoH, DHD and DHS to enforce the legal mandates in public DHS to enforce the legal mandates in public health practiceshealth practices

• Develop new tools and instruments for Food, Develop new tools and instruments for Food, Drugs, Standardization, Licensing and quality Drugs, Standardization, Licensing and quality assurance regulationassurance regulation

• Strengthen the laboratories and equipment used Strengthen the laboratories and equipment used for regulation and QA (DTL, Chemical Examiner for regulation and QA (DTL, Chemical Examiner etc.)etc.)

ConclusionsConclusions

HSR should be sustained and evolve HSR should be sustained and evolve through continuous processthrough continuous process

Institutional development and Institutional development and capacity building is key to successcapacity building is key to success

More resources should be made More resources should be made available for reformsavailable for reforms

Reform strategies should be Reform strategies should be regularly reviewed and adjusted regularly reviewed and adjusted according to country context. according to country context.

THANK YOUTHANK YOU