The Series was led by Dr Sania Nishtar, Founder and President of Heartfile, a non-profit health think tank based in Islamabad, Pakistan, and Minister for Education and Training, Science and Technology, Information Technology and Health in Pakistan's pre-election interim government, and Professor Zulfiqar Bhutta, Founding Director of the Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
Series 1 – New analysis reveals that Pakistan's health performance lags behind that of similar countries
In the first Series paper, a group of authors led by Dr Nishtar provides the first ever comprehensive assessment of Pakistan's health systems, measuring progress over the last two decades towards achieving adequate and equitable health for all, fairness in financing, and responsiveness to the health needs of the population. While the authors identify some improvements – rates of maternal mortality and child deaths have fallen, for instance – Pakistan's progress in health in recent decades still falls far short of its peers. With recent provincial devolution of Pakistan's health mandate after the 2010 enactment of the 18th amendment to its constitution, an urgent opportunity has now arisen to reform health, say the authors.
Comparing Pakistan to twelve culturally, geographically, or demographically similar countries [1], the authors identify health financing as one of the key reasons why Pakistan has not kept pace with its peers. Between 1990 and 2010, total health expenditure per person (including public and private expenditure) in Pakistan increased less than the average for all twelve countries included in the analysis. Health expenditure did not keep pace with the country's increasing gross national income per person during this period, with government expenditure on health less than 4% of total government expenditure in 2009, and just half of the average for the peer-country group.
Analysis of thirteen key indicators and determinants of health, including improved sanitation, life expectancy, and attendance of a skilled medical practitioner at birth [2], showed that Pakistan had a below average performance in nearly all areas studied, compared to the twelve peer countries. Between 1990 and 2010, average life expectancy and child mortality rates in Pakistan deteriorated compared to average rates across the twelve peer countries.
Besides health financing issues, the authors point to other deficiencies in Pakistan's current health care systems. Health is one of the most corrupt services in Pakistan, and improving accountability and transparency will be one of the most important priorities to address if Pakistan is to improve its performance in health. Other key factors include providing adequate training for medical personnel – including addressing a severe shortage of nurses and midwives – and improving the collection and analysis of information about health.
According to lead author Dr Nishtar, "Devolution of the health mandate to the provinces of Pakistan represents a great opportunity to reform health systems and address past failures, and we draw attention to key actions that are needed to make the best improvements in Pakistan's health systems. In order to make meaningful strides towards the health systems' goals of fairness in financing, equity in outcomes and responsiveness, the first steps have to be grounded in accountability, transparency, policy consistency and evidence-based decision-making"
NOTES TO EDITORS:
[1] The 12 countries Pakistan is compared to are: Bangladesh, Cambodia, Egypt, India, Indonesia, Iran, Nepal, Philippines, Sri Lanka, Thailand, Uzbekistan, and Vietnam.
[2] The 13 indicators studied were: gross national income per person; adult literacy rate; improved drinking water source; improved sanitation; life expectancy; child mortality; total fertility rate; skilled birth attendance; diphtheria, tetanus, and pertussis [whooping cough] vaccine; tuberculosis treatment success rate; total health expenditure per person; general government expenditure on health as percentage of total government expenditure; and out of pocket expenditure on health as percentage of total health expenditure [see Series paper 1, figure 2, page 5].
Series 2 – Commitment to reducing maternal and child mortality through evidence-based actions could potentially save over 200 000 women's and children's lives in 2015
Globally, Pakistan has the third highest burden of maternal, fetal, and child mortality, yet according to the authors of the second Series paper, a simple set of low-cost, evidence-based interventions could save the lives of over 200 000 women and children in 2015, more than twice the estimated number of lives lost in the devastating 2005 Kashmir earthquake.
According to lead author Professor Bhutta, "The cycle of unfettered population growth and poor health of mothers and their children has impeded Pakistan's progress in health and development in recent decades, and as a result, we now lag behind many similar countries in the region, even those with fewer resources."
The authors identify several reasons for this poor performance, including social determinants of health, such as widespread poverty and poor education among many women in Pakistan; poor coverage of vaccination programmes; and lack of appropriate training for community health workers, despite the successes of Pakistan's pioneering Lady Health Worker Programme [3].
However, the opportunity afforded for health reform as a result of the 18th amendment means that, with political commitment, there is now the potential to vastly improve women's and children's health in Pakistan.
The authors identify seven key intervention packages – all of which are relatively low cost, and have been proven to work in the region – which, if coverage was scaled up to 90% of the population, have the potential to avert over half (58%) of an estimated 367 000 deaths of women and children expected to occur in 2015, amounting to over 200 000 lives saved. The interventions identified involve providing adequate care to mothers throughout, and after, their pregnancy, comprehensive management of childhood illness, and expanding nutrition and vaccination programmes. Many of these interventions can be specifically targeted to reaching the poor and the estimates show that the bulk of lives saved are those in difficult to reach rural populations and urban poor.
"The crisis of governance and poor political ownership of maternal and child health have played the main part in the lack of progress in women and children's health in Pakistan because no political parties have thought that this is a political priority," says Professor Bhutta. "For the situation to change, women and children's health – responsible for far more deaths each year than natural disasters or conflict – must move up the political agenda and receive concerted support from all sections of a male-dominated society. Despite widespread perceptions of a failed state and crisis of governance, we believe that the situation in Pakistan is ready for change."
NOTES TO EDITORS:
[3] In 1994, the Government of Pakistan launched a programme for community health workers known as the National Programme for Family Planning and Primary Health Care. The programme, popularly known as the Lady Health Worker (LHW) Programme, aims to provide community-based preventive services through community engagement and education. Although the programme has received good evaluations in two sequential external reviews, several challenges remain, including poor support from suboptimum functional health facilities, financial constraints, and political interference leading to management issues. The challenges of devolution, poor fiscal support to the provinces, and widespread call for regulation of services threaten the future sustainability of this programme. See Series paper 2, panel 1, page 6 for more information.
Series 3 – Annual cost of deaths due to preventable 'lifestyle diseases' could reach nearly US$300 million in 2025
Pakistan's health systems are completely unprepared for the country's rising burden of non-communicable diseases (NCDs), such as heart disease, cancer, and diabetes, say the authors of the third Series paper. If current trends continue, nearly 4 million (3.87 million) people aged 30 – 69 are predicted to die from cardiovascular disease, cancers, and chronic respiratory disease by 2025.
Recent surveys indicate that nearly a third (29%) of men in Pakistan smoke, as do 4% of women, with tobacco use identified as one of the leading risk factors for death from cardiovascular disease, cancer, or chronic respiratory disease in the country. High blood pressure (hypertension) is also a leading risk factor for these illnesses, with an estimated 40 million (35%) of adults in 2008 thought to have high blood pressure.
Moreover, Pakistan's recent social and political problems – parts of the region have been blighted by conflict for decades – have led to a high prevalence of disability from mental health disorders, which further aggravates the effect of NCDs on the national economy. Injuries, particularly from road accidents, also result in a substantial burden of illness and disease in the country.
Left unaddressed, this disease burden is predicted to cost Pakistan $296 million by 2025, with a cumulative loss of productivity – due to premature death in workers – amounting to $3.5 billion in the same period. However, at least a fifth of these deaths could be avoided by targeting risk factors for disease, such as smoking and obesity say the authors.
The authors emphasise that a 20% reduction in the number of deaths from NCDs expected by 2025 is possible – but that even this modest target will require substantial commitment from not just health policy makers, but across government. Key actions include increasing healthcare spending per head, earmarking funds specifically for preventative services for NCDs (such as stop smoking services, and programmes promoting healthy eating and exercise), better enforcing and strengthening of road safety laws, and improving health workers' training in delivering care to people with NCDs.
However, the highest priority for government and health policy makers needs to be controlling tobacco use, primarily by reducing the number of smokers through an increase in excise duty on cigarettes. Pakistan should aim for a 30% reduction in smoking rates by 2025; if tax on cigarettes was doubled, this could generate $367 million per year in excess of current tax revenues from cigarette sales.
Implementing the full range of interventions recommended by the authors would cost just $2 per person per year, a miniscule amount compared to the estimated costs to Pakistan's productivity and economy if the NCD epidemic is allowed to continue unchecked.
According to lead author Professor Tazeen Jafar, of Duke-NUS Graduate Medical School, in Singapore, "The burden of non-communicable diseases such as heart disease, cancers, and respiratory disease is very high in Pakistan, and is projected to increase. Changing lifestyles and culture in Pakistan has led to a double burden of infectious and non-infectious diseases posing a huge challenge to health systems, which are completely unprepared for this challenge. Immediate interventions are needed urgently, not only from the new government of Pakistan, but also from international donor agencies, who need to reprioritise their portfolios to fund non-communicable diseases and injuries in Pakistan."
Series 4 – Investing in health "might be the key for true national security and Pakistan's survival as a nation state"
In the final paper, the Series authors call for Pakistan's leaders to finally recognise health as a political priority, as the country faces a turning point in health care.
According to Professor Bhutta, "In a rapidly changing environment, rarely have the Pakistani people had the luxury to take stock and generate the political and public support to address the closely intertwined issues of health, human security, and development. We now have the opportunity to undertake an analysis of the past and present, and offer options for the future."
The authors outline six key policy objectives which, if fulfilled, could transform the lives of millions of people in Pakistan. Foremost is the need for Pakistan's leaders to recognise health as a political priority, and increase investment in health care accordingly. Government investment in health should increase to at least 5% of GDP by 2025, say the authors, but even in a constrained fiscal environment, policy makers could get much better value for their health spending by better management of resources.
Health cannot be addressed in isolation from the social and economic problems which usually accompany it, and public health work needs to be carefully integrated with medical care if the health reforms are to be a success.
Many of the actions recommended in the Series – such as increasing tobacco taxes, improving women's education, and improving road safety – need action from outside the health sector, reiterating the authors' appeal for health to become a priority across government. At the same time, a fundamental change introducing a culture of accountability in health systems needs to be introduced if the reforms are to be successful.
According to Dr Nishtar, "The democratic elections in May 2013, and the parliamentary phase commencing after a change of government could be a historic landmark in Pakistan's varied history. After decades of conflict and war on various borders, there is an unprecedented desire for peace and calls for accountability. Investments in population health and human development might be the key for true national security and Pakistan's survival as a nation state."
While welcoming the opportunities that devolution of the health system brings, the authors recommend that a federal institutional system to support the provincial departments of health is set up, to link appropriate ministries and divisions and provide oversight of national health policy aims.
Health reforms following the 18th amendment offer an unprecedented opportunity to improve health, but the authors point out that there is also the risk that devolution of health to the provinces and unconsolidated national health functions would result in fragmented health services. At the time the paper went to press, Pakistan was the only country in the world without a central institution (ministry or department) of health. Since then the interim government has resurrected the health ministry.
According to Dr. Nishtar "The abolition of Pakistan's Ministry of Health after the 18th amendment was clearly a setback. Devolution under the 18th constitutional amendment can augur well for health systems, but an appropriate institutional framework is the first step."
Journal
The Lancet