2010年-世界发展银行全球_Delivering_Better_Health_Services_to_Pakistans_Poor_119页_2mb

Summary of "Delivering Better Health Services to Pakistan's Poor"

Core Content

This document provides an in-depth analysis of the health status, performance of the public health service, national health programs, and health financing in Pakistan, with a focus on improving access and outcomes for the poor. It highlights the challenges faced by the health sector and outlines strategic interventions to address them.

Main Topics and Key Points

1. Health Status in Pakistan

• Infant and Child Mortality:

  • Pakistan is not on track to meet MDG4 targets for infant mortality rate (IMR) and under-five mortality rate (U5MR).
  • As of 2006–07, the IMR was 78 and U5MR was 94 per 1,000 live births, significantly above MDG4 targets of 33 and 43.
  • The poorest income quintile has seen no improvement in U5MR over the last 15 years, while the general population has declined slightly.

• Child Nutritional Status:

  • Child malnutrition rates are higher than in sub-Saharan Africa and declining more slowly than in other parts of South Asia.
  • Micronutrient deficiencies are prevalent, and under-five malnutrition remains a significant challenge.

• Maternal Mortality:

  • Maternal mortality is still high, with a 1 in 80 chance of dying during reproductive life.
  • Institutional delivery rates have increased, but maternal mortality remains a critical issue.

• Fertility:

  • Total fertility rate (TFR) is 4.1, higher than neighboring countries and expected to remain so.
  • Fertility decline is slow in rural areas, which is a key barrier to achieving a demographic dividend.

• Burden of Disease:

  • The burden of disease is measured using DALYs and HeaLYs.
  • Leading causes of death include communicable and non-communicable diseases, with a significant impact on the population's health.

2. Performance of the Public Health Service

• Utilization and Coverage:

  • Public health facilities are underutilized due to poor quality of care, low availability of essential drugs and equipment, and high absenteeism among health workers.
  • Only 25% of the poor seek care in public facilities.

• Quality of Care:

  • Many health workers are absent, with high absentee rates in Baluchistan and Sindh.
  • Public facilities lack basic infrastructure like water and toilets.

• Equity and Access:

  • Large disparities exist between the richest and poorest quintiles.
  • Rural-urban and regional differences in access to health services are significant and not solely due to poverty.

3. National Programs

• National Polio Eradication Program:

  • Operational management and coverage have improved, but monitoring and evaluation systems need strengthening.
  • The program has had a positive impact but requires sustained efforts to achieve eradication.

• National Tuberculosis Control Program:

  • Coverage and operational management are limited, and monitoring systems are not robust.
  • The program's impact is mixed, and future directions include better coordination and resource allocation.

• National Lady Health Worker Program:

  • Lady Health Workers (LHWs) and Lady Health Visitors (LHVs) have played a crucial role in improving maternal and child health.
  • The program has had a positive impact, but coverage and monitoring systems require improvement.
  • The program should be expanded to include rural health centers and improve accountability.

4. Health Financing

• Total Health Expenditure:

  • Public spending on health is low, accounting for only 2.6% of GDP in 2005/06, the lowest in South Asia.
  • Out-of-pocket payments are the primary source of health financing, contributing to financial risk and poverty.

• Public-Private Mix:

  • The private sector is increasingly used for health services, especially for maternal and child care.
  • However, public financing is fragmented, with multiple entities responsible for different parts of the system, leading to inefficiencies.

• Cost of Health Shocks:

  • Health shocks can push households into poverty, especially when non-medical costs and lost earnings are significant.
  • Conditional cash transfers and targeted transfers may help reduce financial risk for the poor.

5. Organization and Management of the Public Health System

• Structure and Governance:

  • The public health system is poorly managed, with a lack of clear strategy and coordination.
  • The federal and provincial governments focus more on service delivery than stewardship functions.

• Stewardship Functions:

  • These include setting policy, monitoring and evaluation, regulating, and managing human resources.
  • The government needs to strengthen these functions to improve the system's performance.

• People's Primary Healthcare Initiative (PPHI):

  • A local initiative involving NGOs, which has shown success in improving service utilization and community satisfaction.
  • Recommendations include expanding PPHI to include rural health centers and using third-party evaluations.

6. Concluding Remarks

• Strategic Interventions:

  • The report outlines six key options to improve health outcomes and reduce health-related poverty:
    1. Accelerate child mortality decline through improved maternal care and service access.
    2. Reduce maternal mortality by expanding family planning services and emergency obstetric care.
    3. Intervene to reduce childhood malnutrition through infection control, nutrition education, and community-based management.
    4. Increase contraceptive use by expanding family planning services and promoting social marketing.
    5. Focus on the poor, especially the urban poor, through collaboration with NGOs and targeted deployment of LHWs.
    6. Protect the poor from health shocks by providing a defined package of services and integrating with social protection strategies.

• Need for Investment and Reform:

  • Pakistan needs to increase health spending and improve the efficiency of its use.
  • A coherent strategy is required to improve the management and performance of the health sector.

Key Information

• MDG Targets: Pakistan is not on track to meet most health, nutrition, and population MDGs.
• Health Inequity: Large disparities exist in access to health services, especially between the poor and wealthy, and between rural and urban areas.
• Public Sector Challenges: Poor quality of care, low utilization, and high absenteeism are major issues in public health facilities.
• Private Sector Role: The private sector has played a growing role in health service delivery, particularly for maternal and child care.
• Philanthropic Sector: Philanthropic organizations have shown potential in managing and running health services, especially in rural areas.
• Financing Issues: Out-of-pocket payments are a major contributor to poverty, and public financing is fragmented and inefficient.
• Recommendations: The report suggests a range of interventions, including expanding the PPHI, improving national programs, and increasing public investment in health.

Conclusion

The health sector in Pakistan faces significant challenges in delivering quality services to the poor. Strategic reforms, increased investment, and improved governance are essential to address these issues and achieve better health outcomes. The report provides actionable options to guide the government and its development partners in improving health service delivery and reducing health-related poverty.