Professional Documents
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10 Afzal and Yousaf
10 Afzal and Yousaf
10 Afzal and Yousaf
Senior Teaching and Research Fellow, Center for Research in Economics and Business (CREB),
Lahore School of Economics, Pakistan.
**
Research Fellow, Graduate Institute of Development Studies (GIDS), Lahore School of
Economics, Pakistan.
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1. Introduction
The Millennium Development Goals (MDGs) provide timebounded objectives to overcome extreme poverty and provide the basic
human rights to health, education, and security that were pledged in the
Universal Declaration of Human Rights and United Nations Millennium
Declaration (Millennium Project, 2006). Two years short of the deadline in
2015, it is useful to see how Pakistan has performed in the health-related
goals that were set in 2000. Health outcomes are useful in gauging a
countrys health performance over past decades and in conducting crosscountry comparisons.
Pakistan is not on track to achieving most health-related MDGs.
While there has been an improvement in the education sector, health
remains on the periphery of the development landscape. With the eighth
highest newborn death rate in the world (Pakistan has the 8th highest,
2010), one in every ten children born in Pakistan during 200107 died
before reaching the age of five years. Women have a 1 in 80 chance of
dying of maternal health causes during their reproductive life (World
Bank, 2010). Pakistan thus faces a daunting challenge in improving health
outcomes for children and adults alike.
In order to achieve substantial improvements in the health sector, it
is imperative to formulate a well-rounded health policy that focuses not
only on short-term health outcomes but also on improving the long-term
health status of the population at large. Given the current level of
government expenditure on health, an improvement in this sector seems
unlikely. The quality of public health services has seen a downturn over
the last few decades, and the rising population is increasing pressure on
state institutions. This has allowed the private sector to bridge the gap
between rising demand and public provision of healthcare. The private
sectors role in the provision of service delivery has increased enormously.
The poor state of public facilities overall has contributed to the diminished
role of public health facilities. Out-of-pocket expenditure as a percentage of
private expenditure on health is about 98 percent, positioning Pakistan
among those countries with the highest share of out-of-pocket payments
relative to total health expenditure (World Health Organization, 2009).
Pakistan is going through an epidemiological transition where it
faces the double burden of communicable diseases combined with
maternal and perinatal conditions, and chronic, noninfectious diseases. The
landscape of public health service delivery presents an uneven distribution
of resources between rural and urban areas. The rural poor are at a clear
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and high fertility rates. What is more alarming is that the rate of skilled
birth attendancea proxy for maternal mortalityhas actually declined
from 48 percent in 200406 to 41 percent in 2008/09 (Pakistan, Planning
Commission, 2010). The situation is even worse in rural areas where the
maternal mortality rate is almost double that of urban areas: 319 per
100,000 in rural areas and 175 per 100,000 in urban areas (Pakistan,
Planning Commission, 2010).
Table 1: Health indicators for South Asia
Pakistan Bangladesh
Health indicators
Infant mortality rate (per 1,000
live births)
India
Sri Lanka
Nepal
1990 2010 1990 2010 1990 2010 1990 2010 1990 2010
95
60
97
39
81
49
24
11
94
41
490
260 800
240
600
200
85
35
770 170
122
74 139
49
114
63
29
13
135
50
54
86
69
95
70
72
86
99
43
82
50
82
65
94
56
74
88
99
57
86
3.4
2.2
2.6
2.3
2.7
65.2
68.6
65.1
74.7
68.4
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Communicable Diseases
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1
2
3
4
5
Rural
88
88
82
68
82
Rajanpur
Hafizabad
Bhakkar
Narowal
54
50
48
35
75
52
57
41
Rural
54
52
49
47
34
Source: Punjab Millennium Development Goals Report (2011); data from Multiple
Indicator Cluster Survey, 2011.
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For more information, on Procter & Gamble Pakistans new partnership to reach 100 primary schools in
Pakistan through a school health project, see http://www.pg.com/en_PK/news/sagfeguard_build_
sanitation_facilities.shtml
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However, this does not shed the public sectors responsibility, which has
the most to contribute in terms of improving the countrys water and
sanitation sector. Public-private partnerships need to be encouraged in
tackling health issues.
Addressing the issue of noncommunicable diseases is equally
important for the adult population. Given the loss of healthy life years
caused by these diseases, the government needs to incorporate programs at
the BHU level to effectively prevent the spread of such diseases. Moreover,
in order to accurately determine and analyze the burden of disease, a
cause-of-death system that collects detailed information on disease
prevalence and mortality should be put in place (Hyder & Morrow, 2000).
The healthcare system must cater to the twin burden of communicable and
noncommunicable diseases simultaneously, which again necessitates
public-private support in health financing.
This leads us to the issue of health expenditure in Pakistan. With
one of the lowest public expenditure shares on health, the government
needs to make an effort to mobilize more resources. While out-of-pocket
expenditure on free health services is growing enormously, approximately
4 percent of the population falls into poverty due to health shocks each
year. This risk is even higher in rural areasthe highest being in KPand
increases with household size and lower income levels (World Bank, 2010).
Improved monitoring and evaluation is also necessary not only to
improve the performance of the health sector but also to enhance existing
programs and reforms. Some instruments, such as the Health Monitoring
Information System developed by the government in 1992 with the help of
USAID, are in place, but the public health surveillance system in Pakistan is
still fragmented and has been unable to generate the data required to make
informed public health decisions.3 Callen, Gulzar, Hasanain, and Khan
(2013) draw on the admirable example of an intervention conducted at the
BHU level to monitor public worker absenteeism. They use smartphone
technology designed to increase inspections at rural clinics, which proved
practical for their purposes. Such studies can be useful in developing
effective means of monitoring and evaluating the health system.
3
In an effort to improve monitoring, the Ministry of Health (prior to the 18th Amendment) designed a
district health information system that covers the hospital sector in addition to primary health facilities.
The Japan International Cooperation Agency (JICA) has provided technical expertise and aid for the
project. The system has already been tested in pilot districts and the plan is to expand it across Pakistan.
This is still an ongoing project (See http://www.jica.go.jp/pakistan/english/activities/activity02_03.html).
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References
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Callen, M., Gulzar, S., Hasanain, A., & Khan, Y. (2013). The political economy
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Unpublished
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Retrieved
from
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