J Ayub Med Coll Abbottabad 2016;28(3)

REVIEW ARTICLE
ANALYSIS OF THE HEALTH CARE SYSTEM OF PAKISTAN: LESSONS
LEARNT AND WAY FORWARD
Zohra Kurji, Zahra Shaheen Premani*, Yasmin Mithani
Aga Khan University School of Nursing and Midwifery, *Catco Kids, Karachi-Pakistan

Background: Pakistani health care system is in progress and since last year, Pakistan has tried to
make much improvement in its health care delivery system and has brought out many reforms.
Methods: A systematic search of national and international literature was looked from peer-
reviewed databases form MEDLINE, CINAHL, and PubMed. Results: There is little strength in
health care delivery system in Pakistan like making health policies, participating in Millennium
Development Goals program, initiating vertical programs and introducing Public Private
Partnership, improving human resource development and infrastructure by making Basic Health
Unit and Rural Health Centres. However, these all programs are very limited in its scope and that
is the reason that Pakistans healthcare system is still not very efficient. There are numerous
weaknesses like poor governance, lack of access and unequal resources, poor quality of Health
Information Management System, corruption in health system, lack of monitoring in health policy
and health planning and lack of trained staff. Conclusion: Pakistan is improving very slowly in
the health sector for the last five decades as is evident by its health indicators and above
mentioned strengths and weaknesses. Therefore, the Government needs to take strong initiatives to
change the current health care system.
Keywords: health care delivery system; Millennium Development Goal; Public Private
Partnership; Basic Health Unit (BHU) and Rural Health Centres (RHC)
J Ayub Med Coll Abbottabad 2016;28(3):6014

INTRODUCTION improved, for example, infant mortality is reduced

from 220 per 1000 live births to 72 per 1000 live
Pakistan is a country which is trying hard to achieve
births, Maternal Mortality Rate again has declined
Millennium Development Goals (MDGs) which are
from 800-1000 per 100,000 live births in late 40s but
set for all developing countries.1 The progress of
now it is 276 per 100,000 live births.5
health sector in Pakistan could not be ignored since
However, these all programs are very
the time of independence. Moreover, it has achieved
limited in its scope and that is the reason that
improvement in social sector, agricultural sector and
Pakistans healthcare system is still not very efficient.
economic sector.2 Pakistani health care system is in
There are numerous weaknesses like poor
progress and since last year, Pakistan has tried to
governance, lack of access and unequal resources,
make much improvement in its health care delivery
poor quality of Health Information Management
system and has brought out many reforms.3 There are
System, corruption in health system, lack of
few strengths in health care delivery system in
monitoring in health policy and health planning and
Pakistan like making health policies, participating in
lack of trained staff. But mainly, I will talk about lack
Millennium Development Goal DG program,
of governance as because of this, the healthcare
initiating vertical programs and introducing Public
system is inefficient. In addition, there is a lot of
Private Partnership (PPP), improving human resource
corruption in health care system due to bureaucrat
development and infrastructure by making Basic
power of the people involved in policy making. As a
Health Unit (BHUs) and Rural Health Centres
result, all people do not have equal access to
(RHCs)4. In my view, the biggest strength of the
healthcare services and healthcare resources are not
system is that it has committed to participate in
divided with equity.
MDGs after re-structuring national health policy in
2001 that included Primary Health Care PHC DISCUSSION
elements in the health policy. Due to these changes,
Government commitment in changes in National
the government started implementation of vertical
health policy:
programs for preventive approaches like Expanded
At the time of independence, Pakistan started its
Program of Immunization for mass population and
journey with limited the focus of National health
strengthening the Maternal and Child Health project
policy on curative services. After the Alma Ata
by training Leady Health Visitors (LHVs) to
Declaration, paradigm of health shifted to primary
improve the health status of the population. Because
health care and for that purpose, Government brought
of these projects, the health indicators have

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about many changes in infrastructure by providing due to increment in their salaries, community
primary health care services. This resulted in satisfaction and physical conditions of BHUs
provision of PHC services in all urban population improved, technical quality of care, cost effective
with 70% of rural population having health facilities interventions improved, better financial management
within 5 kilometres.6 The national policy of health was evident, concept of health promotion and most
was adopted in 1990 in which all aspects of health importantly, issue of staff absenteeism was resolved
like physical, social and mental health were add to by giving health care providers including women
improve quality of life.2 Medical Officers.9
a) Partnership in MDG: c) Government vertical programs:
Pakistan took an initiative by become signatory body Another major initiative taken by Pakistan in the
to achieve the eight Millennium Development Goals health sector is to reduce child and maternal mortality
(MDGs) adopted in 2000 by the United Nation (UN) with the help of foreign aid funds. As a result, the
Members for the improvement of human life and government of Pakistan planned vertical programs
health condition7. These were based on 8 goals, 48 with overseas funds like Maternal and Child Health
indicators and 18 targets, as mentioned in Appendix care, Expanded Program on Immunization,
1.7 Pakistan is fully dedicated to achieving MDGs Information Education and Communication (IEC)
which is reflected by the overall initiatives which campaign for the use of Oral Rehydration Salt
Pakistan has taken in the preceding years. Moreover, packets in case of diarrhoea and Lady Health
Government started working on Term Development Workers program and National Maternal and Child
Framework (MTDF) 200510 and Vision 2030, Health (MCH) Program at all level of health care
which includes seven themes on poverty reduction, system. The prominent attributes of these programs
basic and college education, health and nutrition are to increase inter sectoral collaboration and
interventions, population welfare, water supply & improved community participation.5,7 I will now
sanitation and sustainable development.7 discuss 2 successful vertical programs as below.
b) Partnership of public and private sector: i. Expanded Program of Immunization:
After becoming participatory body in MDGs in Expanded Program on Immunization (EPI) was
2002, the government of Pakistan became pioneer launched in 1978 as low cost intervention to reduce
country in the world to establish a national public and morbidity and mortality caused by preventable
private partnership to struggle towards achieving diseases of children. In Pakistan, EPI focused on six
MDGs. This partnership was between the United diseases in 2001 adding vaccination against Hepatitis
Nations Development Program (UNDP), civil-society B for infants to routine EPI with the assistance of
organizations and private donors, both in Pakistan Global Alliance for Vaccines & Immunization
and abroad. They worked in 53 districts of Pakistan (GAVI).10 Current cost like for the year of 2003 is
in the area of education and health sector also by estimated US $ 31.8 million in which US $ 18.7
improving health care services, particularly for million is shared by Government of Pakistan and the
maternal and child welfare. For example, the Primary rest of it by external partners.10 EPI had positive
Health Care Extension Program trained local health impact on the health outcomes. Due to these
care workers and educated community members at programs, under five mortality rate has decreased
grass root level7. There are many examples in which from 181 to 107.4 from 19702006. By having these
public private partnership was very successful like vaccines, children were protected from preventable
National TB control program, family planning diseases and the immunization coverage has
program and school nutrition program that was improved from 4686% in 2009.10
implemented in 29 of the poorest rural districts. ii. Lady Health Worker training initiative:
Moreover, these entire programs achieved great One of the other accomplishments of the Government
success and the trust of the community people as of Pakistan (GOP) in 19931994 was to commence
well.8 National Program for Family Planning and Primary
One of the result-oriented models is Rahim Healthcare with finance of 9 billion Pakistani rupees.
Yar Khan Model that is an example of successful This is one of the successful Programs of public
healthcare models in Pakistan. In 2003, the Chief health sector in Pakistan. The programs main goal
Minister took lead on implementing primary health was to provide primary health care to the underserved
care and handed over 104 BHUs in Rahim Yar Khan population and mainly women and children and
District, which has a total population of 3.68 million, provide healthcare services such as family planning
to NGOs in contract to overcome the under- services at doorsteps. The biggest strength of this
utilization of services and doctors assigned in program is that the LHWs have played a significant
BHUs.15 The outcomes of the project included 100% role by not only providing PHC services but also by
availability of doctors and medicines at each BHU

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serving as a bridge between the communities and the satisfactory care, therefore, people need to go for
health facilities.2 private facilities which are very expensive and out
Weaknesses of the Pakistani health care system: of reach for the poor people. In addition, as
There are many weaknesses and challenges which are mentioned earlier, the government spent 0.75
currently faced by the Pakistani health care system. percent of GDP on health sector in 200506 in
As evidenced by the literature, health service order to make its population healthier and 76%
facilities in Pakistan have flourished but most of goes out of pocket for health expenditure in
them have poor management, poor quality of health, Pakistan4. Furthermore, because of the shortage of
shortage of resources, dugs, trained staff, finance in Pakistan, poor people face catastrophic
unavailability of female staff, absenteeism of staff, health expenditure and as a result, poor become
most of the assign doctors are busy in their private poorer.13 As a result, the poor has no choice but to
practice because of lack of incentives to improve pay the health cost whether they can afford or not
performance. and this also restricts them to in decision making
1. Lack of Health System Governance: of their own health. In Pakistan, majority of Tehsil
The healthy policy cannot take place without support hospitals are in urban areas and people in remote
of political administration. Pakistan has centralized areas are mainly depend upon BHUs and RHCs
health system in which all major health decisions and but because of absence of health care staff and
power is under control of Federal government. Due to large number of non-functional primary health
this centralization, provincial government has only care facilities, they have no choice but to go for
right to implement policy in their own provinces. private doctors. This increases poor peoples cost
There is no participation of stakeholder, community and make them poorer as they spend huge amount
and individual groups in formulation of heath policies of money to just see the private doctor.3,4,13
and health planning. As a result of this, Besides the unequal resources between different
communication gap is found between federal, income groups, there is also another challenge that
provincial and district levels. Moreover, there is lack health infrastructure is not evenly distributed
of implementation, duplication of resources and among gender as well as different regions within
many programs have no outcome. Although Pakistan. It is very evident in data that public
government acknowledges in National Health Policy health facilities among different provinces of
2001 that good governance is the basic key to achieve Pakistan and that is the reason there is great
quality of care but in real practice, government is not difference among health indicators in all four
providing opportunities for good governance. As a provinces of Pakistan, for example, mortality and
consequence, imbalance of power structure occurs in morbidity indicators between provinces are
unsustainable programs and people do not trust the different.14
system.11 The biggest cause of lack of governance is 3. Physical accessibility and lack of resources in
that people who are involved in policy making are health facilities:
not qualified and even they dont have any qualified Because of poor infrastructure of the BHUs and
and experienced advisory body. Lack of governance RHCs, majority of people are not willing to access
is also responsible for the lack of implementation and healthcare services provided by the public health system
evaluation of health planning and polices and at the and as a result of this, rural people are diverted to the
end, many projects are not analysed and no lessons tertiary care hospitals. The distance to the health
learnt for future direction. At the implementation services and dearth of transportations with poor roads
level, health is managed by doctors but they have no hinder their access to these services.11 Moreover, it is
authority to take action against any type of also found that public sector in Pakistan is underused
corruption. Moreover, majority of people feel that because of weak human resource, lack of health
they feel humiliation at the hands of Executive education, lack of openness and barriers due to language
Director Health Officers (EDHOs) and Nazims and cultural gap. For above mentioned factors for many
because they handle them like their servants15. people, visiting BHUs make the journey not less than a
Because of poor governance, the system is not nightmare.15
efficient and quality is compromised resulting in
decrease in the trust and confidence of the people to CONCLUSION
go for public health providers.12 Pakistan is improving very slowly in the health sector
2. Lack of Health Equity in Pakistan: from the last five decades as it is very evident by its
In Pakistan, there are huge disparities in availability health indicators and above mentioned strengths and
of health services between rich and poor. Majority of weaknesses. Therefore, the Government needs to take
people (around 30%) people live in absolute poverty. strong initiatives to change the current health care
Majority of public health facilities are not providing system.

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 J Ayub Med Coll Abbottabad 2016;28(3)

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Address for Correspondence:

Zohra Kurji, Aga Khan University School of Nursing, Stadium Road, P.O. Box 3500, Karachi-Pakistan
Cell: +92 300 351 7950
Email: zohra.kurji@aku.edu

604 http://www.jamc.ayubmed.edu.pk