Health Care Service Delivery

Hammer, J. S. (2013). Balancing Market and Government Failure in Service Delivery. Lahore Journal of Economics, 18.
This paper argues that the design and implementation of effective policies in social sectors requires facing hard realities of the constraints under which governments operate. These constraints are not solely and not primarily, limited funds. The government is further hampered by endemic problems of governance when the stage of implementation is reached. Ignoring this fact has led to enormous sums of wasted money. It uses the example of the health sector in Pakistan particularly to illustrate the fact that the real, practical, problem that governments face is how to improve welfare given that both “unfettered private enterprise” (the market) and“public authority” (the government) have their shortcomings. According to the paper, for pure public health, the market failure is clear, the benefits to the poor are clear and (arguably) there are tried and true policies that are well within a government’s capacity to implement. Thus, the benefits to the poor depend entirely on how the policy is implemented (and the track record is not good), and the decision must be based on which modality is easier to implement. Hence, governments should learn to pick their targets carefully, understanding what the alternatives to public provision are and honestly assessing their own capacity to improve the status quo. vol 18 se/01 Hammer.pdf

Callen, M., Gulzar, S., Hasanain, A., Khan, A. R., Khan, Y., &Mehmood, M. Z. (2013). Improving Public Health Delivery in Punjab, Pakistan: Issues and Opportunities. Lahore Journal of Economics, 18.
This paper presents a detailed qualitative and quantitative look at the institutional context in which such an intervention in the public health sector in Punjab would be trialed. It identifies important lessons for Punjab’s health sector managers. It postulates that facilities are distributed unevenly compared to the population catchment area, and need to be relocated. This means there are more doctors per facility in some areas at the expense of others, it also means that the administrative (monitoring) workload of district officers is uneven.Furthermore, facility attendance of health workers is extremely weak, and vacant positions are left unfilled on a very large scale. There is also widespread demand for the availability of medicines in the province and, more generally, the department must focus on supply chain improvements, adding new services, and improving management. Thus the paper suggests that these problems stem from managerial, not financial, constraints. Thus, one promising development, in the case for resolving absenteeism particularly, is the introduction of ICT. It could be the catalyst for necessary reforms in the public health sector. vol 18 se/11 Callen, Gulzar, Hasanain, Khan, Khan, and Mehmood.pdf

Afzal, U., & Yusuf, A. (2013). The State of Health in Pakistan: An Overview. Lahore Journal of Economics, 18.
This paper provides an overview on the health sector and its outcomes. It postulates that 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. The landscape of public health service delivery presents an uneven distribution of resources between rural and urban areas.This has allowed the private sector to bridge the gap between rising demand and public provision of healthcare. The private sector’s role in the provision of service delivery has increased enormously. The paper also points out that 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. Given the increasing burden of communicable disease, the budgetary share of preventive measure programs should also increase. In order to improve the current situation, the paper suggests aggressive intervention to strengthen the network of health services, expand the outreach of health programs, and introduce technologies to better monitor and strengthen the health programs in place. Furthermore, social protection in the form of health insurance could also play a critical role in protecting against health shocks. vol 18 se/10 Afzal and Yousaf.pdf

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.

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.

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.

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.

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.

The Punjab ANC Services Assessment Study. (2011). Research Society, AllamaIqbal Medical College.
This research study evaluates the provision and quality of antenatal care (ANC) services provided at primary healthcare level in Punjab. Quantitative assessment was carried out to measure the institutional capacity in terms of quality of service and facility performance for ANC. Furthermore, qualitative study was conducted to explore the factors that influence the ANC services delivery service. The findings of the study suggest that there is little coverage and low quality of services provided which leads first time users to not follow up on their visits. The reasons associated with these issues are shortage of supplies like laboratory equipment, its non-functionality and human resource mismanagement. There is also weak target setting and it’s monitoring which leads to lack of accountability amongst the healthcare management. These issues are compounded by the fact that there is very little awareness for the need for ANC. Thus, there is need to not only raise client awareness but improve accessibility and capacity of the current facilities through training providers and addressing deficiency of resources. Summary Report.pdf

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.

Tarin, E., Green, A., Omar, M., & Shaw, J. (2009). Policy process for health sector reforms: a case study of Punjab Province (Pakistan). The International journal of health planning and management, 24(4), 306-325.
This study is unique because no previous study reports on the policy process in the Punjab health sector. A stream of reforms was introduced in the Punjab health sector during the 1990s. This study investigates examples of a de-concentrated district health system and determines the causes of their failure. It attributes failure to firstly the roles and interests of the different groups and secondly the structural deficiencies in the government policy processes. The culture of policy making in Punjab leads to a very narrow involvement of stakeholders with policy-making being viewed in government as the sole domain of the cabinet, senior politicians and departmental officers. However, since different stages of the policy process require different types of input, from political leadership over principles to field and professional input on detailed implementation design, it leads to policy failure. Thus, this study provides insights into a country where policy process is thought to follow systematic bureaucratic procedures but which in practice are affected by a variety of factors including interests of key actor groups.

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.

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.

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.

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.

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.