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Healthcare Service Delivery

Kazi, S., Haq, I. U., Laviolette, L., &Kostermans, K. (2013). Expanding Quality Health, Population, and Nutrition Services. Pakistan policy note no. 10. World Bank.
According to this policy note by the World Bank, health and population outcomes in Pakistan have improved over the last decade but at a slower rate than in most other South Asian countries. This is due to key issues that the health sector faces. This includes the low budgetary allocation to this sector and the fact that the public sector provides only a fifth of curative services, even for the poor and rural population. Furthermore, the policy note contributes poor health performance mainly to weak management and governance, including wide- spread staff absenteeism, centralized management, and weak stewardship. Thus, according to the note, in terms of reforms special attention will be required to ensure appropriate institutional arrangements to house federal functions, a clear delineation of responsibilities, and the building of capacities and structures at all levels. Actions to improve health sector performance should include improving health services targeting the poor; increasing health spending; strengthening health sector management and accountability with a greater focus on monitoring and information (in a context of devolution and contracting). Only then will Pakistan be able to catch up to the regional and global indicator averages.

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Punjab Health Sector Strategy 2012-2020. (2012). Punjab Health Sector Reforms Programme.Government of Punjab.
Punjab Health Sector Strategy is designed to support the Department of Health (DoH) to progress further after the 18thConstitutional Amendment decentralization, with a sense of direction, by prioritizing policy related interventions consistent with availability of financial resources. The strategy initially discusses the various challenges that Punjab faces in this sector. It identifies how limited access to essential health services is mainly affecting the population residing in rural areas due to persistent urban-rural bias. It also questions the quality of health care both of public and private health facilities. In terms of governance, it is pointed out that the health department is overstretched and there is a serious lack of capacity to produce nurses and allied health professionals which further aggravates the poor availability of skilled human resource in difficult areas. Exacerbating these issues, is the low government funding. Thus, in order to overcome these challenges, this strategy focuses on improving access and quality of healthcare, ensuring an efficient system of health sector governance, accountability and regulation, creating a management system that provides incentives for performance and ensures accountability and enhancing public sector financing. Furthermore, it outlines the need for continuous monitoring for successful implementation of the strategy.

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Sindh Health Sector Strategy 2012-2020. (2012). Government of Sindh.
The document provides the strategic framework for 2012-2020 and serves as an over-arching umbrella to guide the operational plans of medium and long term programs and projects. It also provides estimates of resource envelopes, for the total budgetary outlays as well as costs of specific strategies requiring assistance. The document also specifies strategic directions for resource mobilization from the stakeholders including the public sector, international donors, corporate sector and philanthropic organizations. It stipulates that District Health Systems need strengthening more particularly in lower performing districts. Furthermore, human resource deployment, retention and capacity are sub-optimal in rural areas particularly for female staff. There is also lack of regulation despite highest private health sector concentration in Sindh. Therefore, the strategy suggestsimplementing an Urban PHC system built on public private partnerships andaddressing contextual needs of low-income urban population. It also recommends enhancing coverage and technical supervision of LHWs, and deploying community male and female volunteers in under-coveredremote areas using a modified package of services, as well as developing a trained administrative cadre to improve efficiency of health administration at district and provincial level.

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Jooma, R., Khan, A., & Khan, A. A. (2012). Protecting Pakistan’s health during the global economic crisis. Eastern Mediterranean Health Journal, 18(3).
This paper explores the reduction in health spending due to the global economic turndown and its impact on the health of Pakistan’s population. According to the paper, the economic crisis has affected the health sector through a reduction in the government spending as well as donor funding, which constrains investment by limiting allocations for personnel, equipment and infrastructure that are crucial for health care provision, controlling preventable diseases and life-saving interventions. It also decreases the ability of the public to access health care. An impact through the food crisis is also seen as people may decide to shift to consumption of cheaper foods of lower nutritional value that compromise their health, eventually placing a greater burden on the health care system. Thus, the paper recommends strategies that minimize these adverse affects. It suggests carrying an updated assessment of the burden of disease so that few selected interventions must be adequately funded on priority diseases, rather than spreading the available funds across many interventions. It also suggests priority prevention efforts that foster behaviours that reduce or better manage diarrhoeal or respiratory infections. Optimizing human resources is also recommended through training and monitoring as well as providing social security safety nets.

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K, Ayesha and K, Adnan. (2012). Health Systems Governance Challenges and Opportunities after Devolution.Research and Development Solutions, Policy Brief Series, 29.
This brief assesses the initial experience of health following devolution and proposes suggestions to build on this opportunity. After the devolution, the experience of Health and Population Welfare Departments has varied in different provinces. Some have allocated sufficient funds to them, while others have struggled. The main issue is of lack of feedback from district level or point of service and the lack of involvement of beneficiaries or district authorities in decision-making remains nearly unchanged even after devolution. This connects to the fact that programs are based on inputs (and some outputs), with little connection to health outcomes, therefore they ultimately don’t respond to the needs of target beneficiaries or deliver low results. Furthermore, there is political interference, corruption and weak monitoring to modify the program based on evaluations. In order for any reforms to succeed, a departure from the past is needed. Thus, the brief recommends measuring results not fund utilization. It also suggests involving communities in oversight over local health facilities by using community scorecardsand use of the results to determine funding levels of facilities and to reward or promote personnel. Electronic reporting can also be useful to make the system more transparent.

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Bossert, T. J., & Mitchell, A. D. (2011). Health sector decentralization and local decision-making: Decision space, institutional capacities and accountability in Pakistan. Social Science & Medicine, 72(1), 39-48.
This study analyzes relationships between three dimensions of decentralization: decentralized authority (referred to as “decision space”), institutional capacities, and accountability to local officials. Based on an analytic framework that includes these dimensions, this article assesses the degree of variation in actual decision-making exercised by local officials within the legally defined range of choice granted to officials, and relates those choices to concomitant institutional capacities and mechanisms of accountability. The study finds that districts in Pakistan are indeed at different stages of the decentralization process and district officials exercise varying degrees of decision space within a formal civil service structure that is highly bureaucratic and traditionally rule-oriented organizational culture. Thus, the paper raises important policy questions about relationships between decentralization and system-wide performance. Respondents from the economically and developmentally less well-off provinces of Balochistan and NWFP tended to be less likely to use the full extent of their decision space on the dimensions of decentralization analyzed, while those in better-off Sindh and Punjab reported relatively high levels.While the study could not assess the reasons for these differences, it does suggests that policymakers in Pakistan should be concerned about whether decentralization may be perpetuating inequities in the sector.

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Khan, M. M., & Van den Heuvel, W. (2007). The impact of political context upon the health policy process in Pakistan.Public Health, 121(4), 278-286.
In many developing countries, the impact of the political context upon the health system and the health of people is ignored when health policies are analysed.This paper attempts to fill the gap for Pakistan, and presents an analysis of the political context in which the health policy is embedded. Using a qualitative method, it finds that political instability and frequent changes in regimes resulting in changes in health policies have resulted in not enough time being allowed for any health policy to be properly implemented. Moreover, the content of these health policies does not vary much in essence as considerable attention is still given to the delivery of healthcare services rather than to disease prevention and health promotion. Frequent changes of governments have also removed the political energy that is needed for the effective implementation of health policies and resulted in the wasting of resources. According to the paper, these political factors have undermined the effectiveness of the health sector. Thus, it suggests that Pakistan needs to develop a continuous democratic political system that can ensure sustainable health policies. A regular bottom-up communication, and its careful consideration at provincial and federal level, can make the health policy process flexible, participative, collaborative and effective.

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Country Cooperation Strategy for WHO and Pakistan 2005–2009. (2006). World Health Organization.
This Country Cooperation Strategy (CCS) reflects a medium-term (6 year) vision and a strategic framework for WHO technical cooperation with Pakistan. It serves as a medium-term basis for key periodic planning and also aims at improving WHO’s support to Pakistan for achieving the Millennium Development Goals (MDGs). According to the report, with devolution being the main focus of governance, the most critical challenge is building the capacity of the health sector at all levels to respond to the requirements of a devolved health system. This would include improving the policy-making basis and governance, developing and managing human resources for health, improving service delivery, access and equity, and improving health financing. The other priority challenges are control of communicable diseases not just through eradication but also through immunization and disease early warning system, improving child and maternal health, and prevention and control of non-communicable diseases. The report also points to the importance of emergency preparedness and response by strengthening the role of the Federal Ministry of Health in the Country Disaster Management Team and in provincial units of States and Frontier Regions.

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Health and Human Security Chapter 4. (2005). Human Development in South Asia: Human Security in South Asia.MahbubulHaq Human Development Centre.
According to the report, security encompasses more than protection from external threats; it also means human security, which includes health security. Health deprivation is measured by using the lack of access to safe water and malnourishment as indicators of poor health. The brunt of it is borne by women and children. Furthermore, the poor environmental conditions that result from widespread poverty in South Asia are responsible for a large burden of preventable diseases. According to the report, the primary cause of the large burden of disease and mortality in South Asia is the lack of government commitment to provide adequate and quality healthcare for the poor. Government expenditure on public health remains low and inadequate. Also, the focus of government expenditure on health is on urban and tertiary level care, and not on rural and primary healthcare. Furthermore, whatever little is spent is often wasted through a lack of adequate monitoring and delivery system. Thus, the report recommends improving the access, equity and quality of health services by focusing on the poor as well as on preventative health rather than curative. It also suggests improving public sector management and creating public-private partnerships.

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Shaikh, B. T., & Hatcher, J. (2005). Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers. Journal of Public Health, 27(1), 49-54.
This paper reviews the relationship of factors affecting health seekingbehaviour on use of health services in the developing world including Pakistan, encompassing public as well as private sector. The paper classifies these factors into categories such as cultural and socio-demographic factors in which case women are usually not allowed to visit a health facility or health care provider alone or to make the decision to spend money on health care. It also looks at factors economic in nature, which also affects the opportunity of health seeking since cost is undoubtedly a major barrier. The public health sector by and large has been underused due to insufficient focus on prevention and promotion of health, excessive centralization of management, political interference, and weak human resource development. Thus, the paper suggests undertaking measures such as raising the socio-economic status through multi-sectoral development activities such as women’s micro-credit, life-skill training and non-formal education which have been shown to have a positive impact on health seeking behaviour, morbidity and mortality. It also recommends introducing a ‘self care system’ in the community which includes early detection of danger signs in diarrhoea, malaria, pneumonia and where issues like family planning and personal hygiene could form a package of health education for any community setting.

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Mumtaz, Z., Salway, S., Waseem, M., &Umer, N. (2003). Gender-based barriers to primary health care provision in Pakistan: the experience of female providers. Health policy and planning, 18(3), 261-269.
This paper highlights an important issue regarding the constraints faced by female health care providers. The findings of this paper highlight the fact that female health workers must operate within the same gender systems that necessitate their appointment in the first place. Thus, female workers in South Asia, like the women they seek to serve, are likely to be marginalized and disadvantaged by the male- dominated context within which they live and work. The survey conducted amongst female health workers demonstrated that respondents found the management structure and style of the public sector system to be unsupportive and complained of oppressive use of power. A particularly serious problem was sexual harassment, which was widespread, with serious effects on motivation. Distant placements and restricted mobility also led to high absenteeism and the fact that there was little career advancement meant low job satisfaction. Thus, the paper emphasizes on the need to encourage female employees to exercise ‘voice’, that is to individually and collectively challenge the existing system and to co-opt men in senior positions to support them. However, it must be considered these findings are based on opinions of current female workers and not ex-workers or men. Thus, it can bias the sample.

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